Phase II Study of Metastatic Melanoma With Lymphodepleting Conditioning and Infusion of Anti-MART-1 F5 TCR-Gene-Engineered Lymphocytes

Background:

• We have engineered human TIL (tumor infiltrating lymphocytes) and peripheral blood lymphocytes (PBLs) to express an anti-MART-1 T-cell receptor that recognizes an HLA-A*0201 restricted epitope derived from the TIL clone DMF5.
• We constructed a single retroviral vector that contains both alpha and beta chains and can mediate genetic transfer of this TCR with high efficiency without the need to perform any selection.
• In co-cultures with HLA-A*0201 positive melanoma, anti-MART-1 F5 TCR transduced T cells secreted significant amount of interferon (IFN)-gamma (but no significant secretion was observed in control co-cultures with cell lines.
• The anti-MART-1 F5 TCR transduced T-cells could efficiently kill HLA-A*0201 positive tumors. There was little or no recognition of normal fibroblasts cells.
• This TCR is over 10 times more reactive with melanoma cells than the MART-1 TCR that mediated tumor regression in two patients with metastatic melanoma.

Objectives:

Primary objectives:

-Determine if the administration of anti-MART-1 F5 TCR -engineered peripheral blood lymphocytes (PBL) or tumor infiltrating lymphocytes (TIL) and aldesleukin to patients following a nonmyeloablative but lymphoid depleting preparative regimen will result in clinical tumor regression in patients with metastatic melanoma.

Secondary objectives:

• Determine the in vivo survival of TCR gene-engineered cells.
• Determine the toxicity profile of this treatment regimen.

Eligibility:

Patients who are HLA-A 0201 positive and 18 years of age or older must have:

• metastatic melanoma;
• previously received and have been a non-responder to or recurred after aldesleukin;
• normal values for basic laboratory values.

Patients may not have:

• concurrent major medical illnesses;
• any form of primary or secondary immunodeficiency;
• severe hypersensitivity to any of the agents used in this study;
• contraindications for high dose aldesleukin administration.

Design:

• If TIL can be obtained and grown, but are non-reactive, patients will be assigned to receive TIL transduced with the anti-MART-1 F5 TCR retroviral vector. If TIL cannot be obtained, PBMC will be obtained by leukapheresis (approximately 5 X 10(9) cells) and cultured in the presence of anti-CD3 (OKT3) and aldesleukin and transduced with the anti-MART-1 F5 TCR retroviral vector. If TIL cells are reactive to autologous tumor or major histocompatibility complex (MHC)-matched tumor cells or PBL cannot be grown, patients will not be treated on this protocol.
• Transduction is initiated by exposure of approximately 10(8) to 5 times 10(8) cells to retroviral vector supernatant containing the anti-MART-1 F5 TCR genes. These transduced cells will be expanded and tested for their anti-tumor activity.
• Once engineered lymphocytes are demonstrated to be biologically active according to the strict criteria outlined in the Certificate of Analysis, patients will receive a nonmyeloablative but lymphocyte depleting preparative regimen consisting of cyclophosphamide and fludarabine followed by intravenous infusion of ex vivo tumor reactive, TCR gene transduced cells plus IV aldesleukin (720,000 IU/kg q8h for a maximum of 15 doses).
• Patients will undergo complete evaluation of tumor with physical examination, CT of the chest, abdomen and pelvis and clinical laboratory evaluation four to six weeks after treatment and then monthly for approximately 3 to 4 months or until off study criteria are met.
• The study will be conducted using a phase II optimal design where initially 21 evaluable patients will be enrolled into each of two cohorts. If 0 or 1 of the 21 patients per cohort experiences a clinical response, then no further patients will be enrolled but if 2 or more of the first 21 evaluable patients enrolled in that cohort have a clinical response, then accrual to that cohort will continue until a total of 41 evaluable patients have been enrolled in that cohort.
• The objective will be to determine in two cohorts if the combination of high dose aldesleukin, lymphocyte depleting chemotherapy, and anti-MART-1 F5 TCR-gene engineered lymphocytes (TIL and PBL) is able to be associated with a clinical response rate that can rule out 5% (p0=0.05) in favor of a modest 20% PR (partial response) + CR (complete response) rate (p1=0.20).

• INCLUSION CRITERIA:

• Metastatic melanoma with measurable disease
• Previously received high dose IL-2 (aldesleukin) and have been either non-responders (progressive disease) or have recurred.
• Positive for MART-1 by immunohistochemistry (IHC)
• Greater than or equal to 18 years of age.
• Willing to sign a durable power of attorney
• Able to understand and sign the Informed Consent Document
• Clinical performance status of Eastern Cooperative Oncology Group (ECOG) 0 or 1.
• Life expectancy of greater than three months.
• Patients of both genders must be willing to practice birth control for four months after receiving the preparative regimen.
• Patients must be human leukocyte antigen (HLA-A)*0201 positive
• Serology:

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• Seronegative for human immunodeficiency virus (HIV) antibody. (The experimental treatment being evaluated in this protocol depends on an intact immune system. Patients who are HIV seropositive can have decreased immune -competence and thus be less responsive to the experimental treatment and more susceptible to its toxicities.)
• Seronegative for hepatitis B antigen and hepatitis C antibody unless antigen negative.
• Women of child-bearing potential must have a negative pregnancy test because of the potentially dangerous effects of the preparative chemotherapy on the fetus.

l. Hematology:

• Absolute neutrophil count greater than 1000/mm^3 without the support of filgrastim.
• White blood cell (WBC) (greater than 3000/mm^3).
• Platelet count greater than 100,000/ mm^3.
• Hemoglobin greater than 8.0 g/dl.

m. Chemistry:

• Serum alanine aminotransferase (ALT)/aspartate aminotransferase (AST) less or equal to 2.5 times the upper limit of normal.
• Serum creatinine less than or equal to 1.6 mg/dl.
• Total bilirubin less than or equal to 1.5 mg/dl, except in patients with Gilbert's Syndrome who must have a total bilirubin less than 3.0 mg/dl.

n. More than four weeks must have elapsed since any prior systemic therapy at the time the patient receives the preparative regimen, and patients' toxicities must have recovered to a grade 1 or less (except for toxicities such as alopecia or vitiligo).

o. Six weeks must have elapsed since prior anti-CTLA4 antibody therapy to allow antibody levels to decline.

p. Patients who have previously received anti-CTLA4 antibody must have a normal colonoscopy with normal colonic biopsies.

Exclusion criteria

• Patients with reactive TIL (IFN-gamma release greater than 200 pg/mL) available based on overnight co-culture assay with autologous tumor or MHC-matched tumor cells.
• Women of child-bearing potential who are pregnant or breastfeeding because of the potentially dangerous effects of the preparative chemotherapy on the fetus or infant.
• Active systemic infections, coagulation disorders or other major medical illnesses of the cardiovascular, respiratory or immune system, myocardial infarction, cardiac arrhythmias, obstructive or restrictive pulmonary disease.
• Any form of primary immunodeficiency (such as Severe Combined Immunodeficiency Disease).
• Opportunistic infections (The experimental treatment being evaluated in this protocol depends on an intact immune system. Patients who have decreased immune competence may be less responsive to the experimental treatment and more susceptible to its toxicities).
• Systemic steroid therapy.
• History of severe immediate hypersensitivity reaction to any of the agents used in this study.
• History of coronary revascularization or ischemic symptoms.
• Any patient known to have an left ventricular ejection fraction (LVEF) less than or equal to 45 percent.
• Documented LVEF of less than or equal to 45 percent tested in patients with:

• Clinically significant atrial and/or ventricular arrhythmias including but not limited to: atrial fibrillation, ventricular tachycardia, second or third degree heart block.
• Age greater than or equal to 60 years old.
• Documented forced expiratory volume 1 (FEV1) less than or equal to 60 percent predicted tested in patients with:

• A prolonged history of cigarette smoking (20 pk/yrs of smoking).
• Symptoms of respiratory dysfunction.