Randomized phase II study using a non-myeloablative lymphocyte depleting regimen of chemotherapy followed by infusion of tumor infiltrating lymphocytes and interleukin-2 in metastatic melanoma

The five-year survival of patients with metastatic melanoma is approximately
5%. Combination chemotherapy can induce objective regressions of melanoma but
median response durations are short, and this treatment is rarely, if ever,
curative. Approximately 15% of melanoma patients treated with high-dose
interleukin-2 (Proleukin) experience objective regressions, with approximately
a third of these responses being complete and durable. No other standard
therapies are available for patients who do not respond to or relapse after
chemotherapy or interleukin-2 (standard treatment in the USA).
Prior preclinical and clinical studies have shown that tumors from patients
with advanced melanoma contain tumor-infiltrating lymphocytes (TIL) with
anti-tumor reactivity targeting a variety of melanoma-associated antigens.
Prior clinical trials have shown that these TIL can be expanded in vitro using
interleukin-2 with OKT-3 antibody stimulation and can cause regression of
melanoma when adoptively transferred back to the patient.
Preclinical mouse models and clinical studies have shown that host
immunosuppression prior to the adoptive transfer of tumor-reactive lymphocytes
greatly enhances their anti-tumor effect.
Using a preparative non-myeloablative regimen of cyclophosphamide and
fludarabine, a single institution phase II study in 43 patients showed a 51%
objective response rate to TIL and interleukin-2, with complete and durable
partial responses in a patient population that was heavily pretreated. Thus, in
this trial we will investigate whether TIL treatment improves progression free
survival in randomized phase II study compared to the current standard of care
(dacarbazine chemotherapy). If PFS is indeed significantly broader application
of this approach for patients with advanced melanoma should pursuit.

A pilot feasibility study (n=5) will be performed to evaluate the feasibility
(logistics, timing) and safety of administering autologous tumor infiltrating
lymphocytes (TIL) generated at the NKI-AVL infused in conjunction with systemic
high-dose interleukin-2 after non-myeloablative chemotherapy in patients with
metastatic melanoma.
After this the randomized controlled phase II study will follow to evaluate
whether this treatment can result in tripling the median PFS when randomly
compared to *standard dacarbazine chemotherapy* in stage IV melanoma patients,
to evaluate whether this treatment can cause consistent and durable objective
responses in stage IV melanoma patients and a constructive technology
assessment will be performed to evaluate the impact of the TIL treatment on
patients and organizational processes.

Part I: Pilot study (5 patients)

Patients will undergo surgical resection of a melanoma metastasis of 3 cm (dm)
to grow TIL in vitro. Once TIL have been generated from these cultures, cells
will be rapidly expanded for adoptive transfer. Patients will undergo
leukapheresis to obtain *feeder cells* for rapid expansion protocol.
Patients will receive a non-myeloablative lymphocyte-depleting preparative
regimen consisting of cyclophosphamide (60 mg/kg/day X 2 days i.v.) and
fludarabine (25 mg/m2/day IV X 5 days). Following this regimen, patients will
receive an intravenous adoptive transfer of at least 5 x 10^9 TIL followed by
high-dose intravenous interleukin-2 (Proleukin) (600.000 IU/kg/dose every 8
hours for up to 15 doses).
Supportive care consisting of blood or platelet transfusions is given until
spontaneous hematopoietic recovery occurs. A complete assessment of evaluable
lesions will be conducted 6 weeks after cell infusion and periodically after
that to obtain best objective response by RECIST.
During this pilot study, special focus will be on logistics and timing: waiting
time for metastasectomy, planning of leukapheresis, admission to the hospital
for start of chemotherapy. Timing of TIL infusion and start of high-dose IL-2.
Release from hospital.

Part II: Randomized controlled phase II study

Patients with metastatic (stage IV) melanoma, not previously treated
systemically for stage IV disease will be randomized to either treatment arm A
or treatment arm B.

Arm A: standard Dacarbazine chemotherapy (800 mg/m2 x 1 day i.v., q 3 weeks).
Arm B: fThe experimental TIL treatment. First the patients will undergo
resection of one metastasis of 3 cm (dm). Once TIL can be grown from this
tumor, the patient need to undergo leukapheresis to gain T-cells for the
expansion of TIL. Before they are given the T cell infusion, the patients will
be treated with non-myeloablative chemotherapy (cyclophosphamide 60 mg/kg/day x
2 days i.v., fludarabine 25 mg/m2/day x 5 days i.v.) followed by intravenous
adoptive transfer of at least 5 x 10^9 TIL followed by high dose interleukin-2
(Proleukin) (600.000 IU/kg/dose every 8 hours for up to 15 doses).

Pilot study:
Patients need to undergo surgery to obtain a metastasis of 3 cm (dm) that will
be used to culture TIL. Only when these cells can be cultured in vitro,
patients will be hospitalized for leukapheresis, non-myeloablative
chemotherapy, and intravenous infusion of in vitro expanded TIL followed by
high dose bolus interleukin-2 treatment.

Randomized phase II study:
Patients will be randomized for either standard treatment with dacarbazine or
the experimental TIL treatment. Patients randomized for standard treatment will
receive dacarbazine 800 mg/m2 x 1 day i.v. q 3 weeks. Patients randomized for
TIL treatment first need to undergo surgery to obtain a metastasis of 3 cm (dm)
that will be used to culture TIL. When generation of TIL is successful,
patients will undergo interventions as described above in Study design. The
patients for whom no TIL can be generated, will be taken off study. They will
be treated with dacarbazine according to the standard chemotherapy arm.

The TIL treatment will involve surgery of one melanoma metastase of 3 cm (dm),
leukapheresis, in-hospital non-myeloablative chemotherapy, infusion of TIL, an
intravenous high dose bolus IL-2 treatment and 2 biopsies will be taken after
treatment. Although this treatment and toxicity has been demonstrated to be
well manageable, common toxicities from non-myeloablative chemotherapy
(transient bone marrow suppression requiring red cell and platelet support,
increased chance of bacterial, viral and fungal infections, requiring
antibiotics) and high dose IL-2 (high fever, rash, low blood pressure and
decreased urinary output, edema requiring saline infusion support) may or will
occur. Due to the infusion of TIL, patients may develop signs of melanoma
associated autoimmune diseases such as vitiligo and uveitis. The latter, which
is the more serious side effect, has been shown to respond promptly to topical
corticosteroid treatment. However, the fact that these patients may have a high
chance of durable objective responses, which otherwise would occur, justifies
for the burden and possible toxicities.