Tumor-Infiltrating Lymphocytes After Combination Chemotherapy in Treating Patients With Metastatic Melanoma

OUTLINE:

Patients receive cyclophosphamide intravenously (IV) on days -7 to -6 and fludarabine phosphate IV on days -5 to -1. Patients undergo TIL infusion over 30-60 minutes on day 0 and receive aldesleukin IV every 8 hours on days 1-5 for up to a maximum of 14 doses.

After completion of study treatment, patients are followed up at 6, 12, and 24 weeks.

Inclusion criteria

Step I Inclusion Criteria:

• Stage IV melanoma or stage III melanoma that is unlikely to be cured by surgery
• Able to tolerate high-dose cyclophosphamide, fludarabine and high-dose IL-2
• Eastern Cooperative Oncology Group (ECOG) performance status of 0-1
• Patients must have a magnetic resonance imaging (MRI), computed tomography (CT), or positron emission tomography (PET) of the brain within 2 months before consenting if known history of brain metastasis or if clinically indicated; if new lesions are present, principal investigator (PI) or designee should make final determination regarding enrollment
• Patients must have a site of metastatic disease that can be safely resected or biopsied for tissue sufficient for TIL harvest

Step II Inclusion Criteria:

• Patients must have measurable metastatic melanoma
• Able to tolerate high-dose cyclophosphamide, fludarabine, and high-dose IL-2
• ECOG performance status of 0-1
• Patients must have brain imaging by MRI, CT or PET within 30 days prior to lymphodepletion; patients may have asymptomatic brain lesions that are =< 1 cm each, lesions that are > 1 cm that have been irradiated and in the opinion of the investigator no longer represents active disease will also be allowed
• A functional cardiac test (e.g., stress treadmill, stress thallium, multigated acquisition scan (MUGA), dobutamine echocardiogram) to rule out cardiac ischemia within 4 months prior to lymphodepletion is required for all patients
• Pulmonary function tests (PFTs) are required of all patients within 4 months prior to lymphodepletion; forced expiratory volume (FEV)1 and forced vital capacity (FVC) must be >= 65% predicted and diffusion lung capacity for carbon monoxide (DLCO) must be >= 50% predicted
• Patients must have their tumor sent for v-Raf murine sarcoma viral oncogene homolog B1(BRAF) mutational analysis
• Patients must have adequate TIL (at least 40 x 10^6 cells at the pre-expansion stage)

Exclusion criteria

Step I Exclusion Criteria:

• Men or women of reproductive ability who are unwilling to use effective contraception or abstinence for 4 months after treatment
• Calculated creatinine clearance (estimated glomerular filtration rate [eGFR]) < 60 ml/min; EGFR values can be determined by either Modification of Diet in Renal Disease (MDRD) or Cockcroft-Gault equation based on the investigator's discretion
• Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) > 3 x upper limit of normal
• Total bilirubin > 2.0 mg/dl, except in patients with Gilbert's syndrome whose total bilirubin must not exceed 3.0 mg/dl) deemed by investigator to be irreversible
• FEV1 < 65% predicted, FVC < 65% of predicted, DLCO (corrected for hemoglobin [Hgb]) < 50% predicted); pulmonary function tests (PFTs) within 4 months prior to consent for Step I will be required for patients with underlying risk factors such as smoking history > 10 pack years, or a history of pre-existing symptomatic lung disease (not including melanoma metastases to the lung)
• Pre-existing known cardiovascular abnormalities as defined by any one of the following:

• Congestive heart failure
• Clinically significant hypotension
• Cardiac ischemia, or symptoms of coronary artery disease
• Presence of cardiac arrhythmias on electrocardiogram (EKG) requiring drug therapy
• Ejection fraction < 45% (echocardiogram or MUGA), although any patient with an ejection fraction between 45-49% must receive clearance by a cardiologist to be eligible for Step II of the trial
• Clinically significant autoimmune disorders or conditions of immunosuppression; patients with acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV)-1 associated complex or known to be HIV antibody seropositive or known to be recently polymerase chain reaction (PCR)+ for hepatitis B or C are not eligible for this study; the severely depressed or altered immune system found in these patients and the possibility of premature death would compromise study objectives
• Patients with active systemic infection requiring intravenous antibiotics
• Clinically significant psychiatric disease which, in the opinion of the PI or sub-investigator (I), would render immunotherapy and its potential sequelae unsafe or compliance with procedural requirements unlikely

Step II Exclusion Criteria:

• Pregnant women, nursing mothers, men or women of reproductive ability who are unwilling to use effective contraception or abstinence; women of childbearing potential must have a negative pregnancy test within 14 days prior to entry; patients of both genders must practice birth control during treatment and for four months after treatment
• Calculated creatinine clearance (eGFR) < 60 ml/min; EGFR values can be determined by either MDRD or Cockcroft-Gault equation based on the investigator's discretion
• AST/ALT > 3 x upper limit of normal
• Total bilirubin > 2.0 mg/dl, except in patients with Gilbert's syndrome whose total bilirubin must not exceed 3.0 mg/dl)
• Clinically significant pulmonary dysfunction (FEV1 < 65% predicted or FVC < 65% of predicted, DLCO (corrected for Hgb) < 50% predicted)
• Pre-existing known cardiovascular abnormalities as defined by any one of the following:

• Congestive heart failure
• Clinically significant hypotension
• Cardiac ischemia, or symptoms of coronary artery disease
• Presence of cardiac arrhythmias on EKG requiring drug therapy
• Ejection fraction < 45%, although any patient with an ejection fraction between 45-49% must receive clearance by a cardiologist to be eligible for Step II of this trial
• Absolute neutrophil count less than 1000/mm^3
• Platelet count less than 100,000/mm^3
• Hemoglobin less than 10.0 g/dl
• Untreated central nervous system metastases that are either symptomatic or greater than 1 cm at time of therapy; lesions that are > 1cm that have been irradiated and in the opinion of the PI or sub-I no longer represent active disease may be allowed
• Patients with systemic infections requiring active therapy within 72 hours of lymphodepletion
• Systemic cancer therapy (standard or experimental), including cytotoxic chemotherapy or IL-2, received less than 4 weeks or checkpoint blocking agents (e.g., cytotoxic T-lymphocyte protein [CTLA]-4 or programmed cell death protein [PD]1/PD-ligand [L]1 inhibitors) received less than 6 weeks prior to lymphodepletion, with the exception of targeted therapies
• Commercially available, molecularly targeted therapies (e.g., dabrafenib, trametinib, vemurafenib, imatinib) taken within 7 days prior to lymphodepletion
• Clinically significant autoimmune disorders or conditions of immunosuppression; patients with AIDS or HIV-1 associated complex or known to HIV antibody seropositive or known to be recently PCR+ for hepatitis B or C virus are not eligible for this study; virology testing will be done within 6 months of T cell infusion; the severely depressed or altered immune system found in these patients and the possibility of premature death would compromise study objectives
• Prior treatment with systemic steroids within 4 weeks prior to lymphodepletion (except for physiologic replacement doses for adrenal insufficiency, premedication for contrast allergies for scans, and for drug fever related to targeted therapy)
• Any other significant medical or psychological conditions that would make the patient unsuitable candidate for cell therapy at the discretion of the PI