Clinical trial NCT04611126
Conditions: Metastatic Ovarian Cancer Metastatic Fallopian Tube Cancer Peritoneal Cancer
Keywords: Adoptive Cell Therapy Immune Therapy Tumor Infiltrating Lymphocytes
Sponsor: Inge Marie Svane
Start date: 2021-04-22; Completion date: 2024-03-03
Enrollment: 6 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
Although immunotherapy has revolutionized the treatment of many cancers, ovarian cancer patients have not yet benefitted from the advances.

In two consecutive pilot trials at National Center for Cancer Immune Therapy (CCIT-DK), is has been have shown that adoptive cell therapy (ACT) with TILs for patients with advanced ovarian cancer (OC) is feasible and tolerable. In the most recent of these trials ACT was combined with a CTLA-4 inhibitor, Ipilimumab and a PD1-inhibitor, Nivolumab. Only transient clinical responses where observed.

Between 90-100 % of infused T-cells in our previous ovarian cancer ACT trial expressed LAG-3. The interaction between LAG-3 on T-cells and MHC-II on tumor cells inhibits T-cell function.

In this study adding the LAG-3 antibody Relatlimab to the ACT-regimen described above may therefore well unleash T-cell antitumor efficacy by blocking the known LAG-3-MHC-II interaction.

With this study the aim is to demonstrate that adding the lag-3-inhibitor Relatlimab to the above treatment regimen is feasible and tolerable. The study will elucidate whether the combination Relatlimab-Nivolumab leads to objective responses and improves progression free survival (PFS).

Detailed description:
Rationale T-cell therapy is an experimental personalized immunotherapy where TILs are isolated from the patient's own tumor tissue, expanded in vitro to billions of cells and then administered to the individual patient with the purpose of eliminating the remaining cancer cells. Lymphodepleting chemotherapy with cyclophosphamide and fludarabine phosphate is administered to the patient before TIL infusion to reduce the number of irrelevant immune cells.

In two consecutive pilot trials at National Center for Cancer Immune Therapy (CCIT-DK), it has been shown that adoptive cell therapy (ACT) with TILs for patients with advanced ovarian cancer (OC) is feasible and tolerable. In the most recent of these trials ACT was combined with a CTLA-4 inhibitor, Ipilimumab and a PD1-inhibitor, Nivolumab.

Between 90-100% of infused T-cells in these previous ovarian cancer ACT trial expressed LAG-3. The interaction between LAG-3 on T-cells and MHC-II on tumor cells inhibits T-cell function.

In this phase I/II study 18 patients with advanced ovarian -, fallopian tube-, and primary peritoneal cancer will be included. Included patients undergo surgical removal of tumor tissue for tumor-infiltrating lymphocyte (TIL) manufacturing. Lymphodepleting chemotherapy is administered prior to TIL infusion. Hereafter the patients are treated with the programmed cell death protein 1 (PD-1) antibody Nivolumab and the anti-lymphocyte activation gene 3 (anti-LAG-3) antibody Relatlimab. The study will be divided into 3 steps.

* Step One (6 subjects): Patients are treated without prior administration of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibody Ipilimumab pre-tumor harvest.
* Step Two (6 subjects): If Step One proves feasible and tolerable patients in Step Two will receive one dose of Ipilimumab pre-tumor harvest.
* Step Three (6 subjects): Patients are treated either with or without prior Ipilimumab pre-tumor harvest depending on the tolerability data from Step Two.

All patients are treated with lymphodepleting chemotherapy for 7 days followed by infusion of TILs. For safety reasons no IL-2- will be administered in this study

The aim of this study is to demonstrate that ACT and a combination of Relatlimab-Nivolumab does not increase the toxicity compared to the same treatment regimen including Nivolumab monotherapy. The study will elucidate whether the combination Relatlimab-Nivolumab lead to objective responses and improves progression free survival (PFS). It is anticipated that combining Relatlimab and Nivolumab with Adoptive T cell therapy (ACT) for advanced OC is safe and feasible. Further, it is hypothesized that the combination will lead to improved immunity in tumor and blood as well as improved antitumor efficacy.

Objectives

* To evaluate the tolerability and safety of the treatment
* To characterize antitumor immune responses and clinical efficacy

Arms: arm 1: At Step 1, 6 patients will be treated without Ipilimumab pre tumor harvest. If feasible and tolerable, as defined by no additional SAE/SAR compared to the previously completed pilot studies at CCIT-DK, the trial will move to Step 2.

Depending on the safety and feasibility on step 2, 6 more patients can be included at step 1. arm 2: At Step 2, 6 patients will be included. Ipilimumab 3 mg/kg will be administered 2-6 weeks pre tumor harvest.

If no additional SAE/SAR compared to the previous completed pilot study at CCIT-DK is observed additional 6 patients can be included at Step 2. If on the other hand Step 2is not found safe additional 6 patients can be included at Step 1
Interventions: intervention 1: Ipilimumab intervention 2: Cyclophosphamid intervention 3: Fludarabine Phosphate intervention 4: Tumor Infiltrating Lymphocytes infusion intervention 5: Nivolumab intervention 6: Relatlimab
Intervention descriptions: intervention 1: Ipilimumab 3 mg/kg is administered 2-6 weeks before surgical removement of the tumor. The medicine is administered i.v. over 30 minutes. intervention 2: Cyclophosphamide 60 mg/kg is administered i.v. on day -7 and day -6. intervention 3: Fludarabine 25 mg/m2 is administered on day -5 to day -1. intervention 4: Tumor-infiltrating lymphocytes grown ex-vivo from resected from cancer tissue and reapplied to the patient via an intravenous infusion. The maximum number of expanded TILs are infused over 30-45 minutes on day 0. intervention 5: Nivolumab 240 mg i.v. is administered on day -2 and every 2 weeks for a total of 4 doses. The medicine is administered over 30 minutes. intervention 6: Relatlimab 80 mg i.v. is administered on day -2 and every 2 weeks for a total of 4 doses. The medicine is administered over 60 minutes.

Protocol documents:
Prot_SAP_000.pdf: 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
 
T-cell Therapy in Combination with Nivolumab, 
Relatlimab and Ipilimumab for Patients with 
Advanced Ovarian-, Fallopian Tube- and 
Primary Peritoneal Cancer 
 
A phase I/II study 
 
 
EudraCT nr: 2020-002738-34 
Intern protocol nr: GY2028 
BMS-986213 
 
The study will be conducted as described in this protocol and according to Good Clinical 
Practice (GCP) guidelines and regulatory requirements. The investigator allows direct access 
to data sources/documents (including patient charts) for monitoring, audit and/or inspection 
from the Danish Medicines Agency, GCP-units or other national health authorities. 
 
 
Sponsor 
 
Inge Marie Svane, professor, M.D., ph.d. 
 
Head of National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
Date: ____________________________________________ 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 21 31 
 
 
 
Inge Marie Svane: ______________________________ 
 
 
Principal Investigator 
Tine Juul Monberg, M.D., Clinical Assistant 
 
National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
Date: ______________________________________________ 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 29 83 
 
 
 
Tine Juul Monberg: ______________________________ 
 
 
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
2
Project Managers 
 
Sponsor 
Inge Marie Svane, professor, M.D., ph.d. 
 
Head of National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 21 31 
 
 
 
 
 
Principal Investigator 
Tine Juul Monberg, M.D., Clinical Assistant 
National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 29 83 
 
 
 
Sub-investigators 
Marco Donia, M.D., PhD 
National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 14 56 
 
Additional collaborators 
Ôzcan Met, MSc., PhD 
National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 92 29 
 
Marie Christine Wulff Westergaard, MSc., PhD 
National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 91 83 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
3
 
Trine Zeeberg Iversen, M.D., PhD 
Department of Oncology (54B1) 
Herlev Hospital, University of Copenhagen 
 
Borgmester Ib Juuls Vej 25C, 5th floor 
Phone: 38 68 89 20 
 
 
Monitoring 
GCP unit 
GCP-unit at University of Copenhagen 
Bispebjerg Hospital, Bygning 51, 3.sal 
Bispebjerg Bakke 23 
2400 København NV 
Phone: 35 31 38 90 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
4
Table of Contents 
 
PROJECT MANAGERS ...................................................................................................................................................................... 2 
MONITORING .................................................................................................................................................................................... 3 
TABLE OF CONTENTS ..................................................................................................................................................................... 4 
LIST OF ABBREVIATIONS ............................................................................................................................................................. 7 
SYNOPSIS ............................................................................................................................................................................................ 9 
INDICATION AND TREATMENT .............................................................................................................................................................................. 9 
RATIONALE .............................................................................................................................................................................................................. 9 
PURPOSE ................................................................................................................................................................................................................ 10 
STUDY DESIGN ...................................................................................................................................................................................................... 11 
POPULATION ......................................................................................................................................................................................................... 12 
TOXICITY ............................................................................................................................................................................................................... 12 
EVALUATION OF CLINICAL RESPONSE ............................................................................................................................................................... 13 
IMMUNOLOGICAL RESPONSE EVALUATION ...................................................................................................................................................... 13 
INTRODUCTION AND RATIONALE .......................................................................................................................................... 14 
OVARIAN CANCER ................................................................................................................................................................................................ 14 
TUMOR IMMUNOLOGY ......................................................................................................................................................................................... 14 
TUMOR INFILTRATING LYMPHOCYTES (TILS) ................................................................................................................................................ 14 
T-CELL THERAPY .................................................................................................................................................................................................. 14 
CHECKPOINT INHIBITION .................................................................................................................................................................................... 17 
CCIT-DKS EXPERIENCE WITH T-CELL THERAPY ........................................................................................................................................... 18 
Clinical trials ................................................................................................................................................................................................ 18 
Translational research ............................................................................................................................................................................ 19 
THE RATIONALE OF THE DRUGS USED IN THE STUDY ..................................................................................................................................... 20 
Lymphocyte depleting chemotherapy ................................................................................................................................................ 20 
Cyclophosphamide ..................................................................................................................................................................................... 20 
Fludarabine phosphate ............................................................................................................................................................................ 21 
Checkpoint inhibition in combination with T-cell therapy ........................................................................................................ 21 
Ipilimumab ................................................................................................................................................................................................... 22 
Nivolumab ..................................................................................................................................................................................................... 22 
Relatlimab-Nivolumab combination .................................................................................................................................................. 22 
THE RATIONALE OF THE TREATMENT REGIMEN USED IN THE STUDY ......................................................................................................... 23 
PURPOSE AND HYPOTESES ....................................................................................................................................................... 23 
PRIMARY................................................................................................................................................................................................................ 23 
SECONDARY........................................................................................................................................................................................................... 23 
STUDY DESIGN ............................................................................................................................................................................... 23 
STUDY POPULATION ................................................................................................................................................................... 26 
CRITERIA OF IN- AND EXCLUSION ...................................................................................................................................................................... 26 
Criteria of inclusion ................................................................................................................................................................................... 26 
Criteria of exclusion .................................................................................................................................................................................. 27 
EVALUATION BEFORE INCLUSION ...................................................................................................................................................................... 28 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
5
TREATMENT PLAN ............................................................................................................................................................................................... 29 
EXAMINATION PLAN DURING TREATMENT ...................................................................................................................................................... 30 
MEDICINAL PRODUCTS USED IN THE STUDY .................................................................................................................................................... 31 
Ipilimumab ................................................................................................................................................................................................... 32 
Cyclophosphamide ..................................................................................................................................................................................... 32 
Fludarabine phosphate ............................................................................................................................................................................ 32 
Nivolumab ..................................................................................................................................................................................................... 32 
Relatlimab ..................................................................................................................................................................................................... 32 
TILs .................................................................................................................................................................................................................. 32 
Pegfilgratim ................................................................................................................................................................................................. 32 
RELATLIMAB-NIVOLUMAB ADMINISTRATION ................................................................................................................................................. 33 
DOSAGE MODIFICATION ..................................................................................................................................................................................... 33 
DOSE DELAY CRITERIA ....................................................................................................................................................................................... 33 
CRITERIA TO RESUME TREATMENT .................................................................................................................................................................. 34 
GUIDELINES FOR CONCOMITANT TREATMENT ................................................................................................................................................ 34 
END OF TREATMENT ............................................................................................................................................................................................ 36 
Normal end of treatment including follow-up ................................................................................................................................ 36 
Follow-up schedule .................................................................................................................................................................................... 36 
Early termination of treatment ............................................................................................................................................................ 37 
Subsequent treatment .............................................................................................................................................................................. 37 
PRODUCTION OF TILS ................................................................................................................................................................. 38 
ACQUISITION OF TUMOR TISSUE ........................................................................................................................................................................ 38 
ESTABLISHMENT OF ”YOUNG TIL” CULTURES ................................................................................................................................................ 38 
RAPID EXPANSION PROTOCOL (REP) ............................................................................................................................................................. 38 
HANDLING AND TRANSPORTATION OF THE INFUSION PRODUCT ................................................................................................................. 38 
PHENOTYPE- AND CLONOTYPE DETERMINATION ........................................................................................................................................... 39 
ADVERSE EVENTS, POTENTIAL RISKS AND PRECAUTIONS .......................................................................................... 39 
ADVERSE EVENTS ................................................................................................................................................................................................ 39 
Grading of Adverse Events ...................................................................................................................................................................... 39 
Serious Adverse Events ............................................................................................................................................................................ 40 
GUIDELINES FOR ADVERSE EVENTS POSSIBLE RELATION TO THE TREATMENT ......................................................................................... 40 
Adverse Reactions ...................................................................................................................................................................................... 40 
Reporting of Adverse Events and Adverse Reactions ................................................................................................................... 41 
KNOWN ADVERSE REACTIONS .......................................................................................................................................................................... 42 
Chemotherapy ............................................................................................................................................................................................. 42 
Cyclophosphamide ..................................................................................................................................................................................... 42 
Fludarabine phosphate ............................................................................................................................................................................ 42 
Checkpoint inhibition and irAEs .......................................................................................................................................................... 43 
Ipilimumab ................................................................................................................................................................................................... 43 
Nivolumab ..................................................................................................................................................................................................... 43 
Relatlimab ..................................................................................................................................................................................................... 43 
TILs .................................................................................................................................................................................................................. 43 
RISKS AND DISADVANTAGES REGARDING SURGERY AND TEST SAMPLING .................................................................................................. 44 
Risks associated with removing tumor tissue ................................................................................................................................. 44 
Risks associated with biopsies ............................................................................................................................................................... 44 
Risks associated with blood tests ......................................................................................................................................................... 44 
MONITORING AND PRECAUTIONS ...................................................................................................................................................................... 44 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
6
Hematological parameters .................................................................................................................................................................... 44 
Kidney- and urine infections .................................................................................................................................................................. 44 
Cardiotoxicity .............................................................................................................................................................................................. 44 
Immune-related toxicity .......................................................................................................................................................................... 45 
Infertility........................................................................................................................................................................................................ 45 
Live vaccines ................................................................................................................................................................................................ 45 
Interactions .................................................................................................................................................................................................. 45 
EFFECT EVALUATION, DATA PROCESSING AND MONITORING ................................................................................... 45 
EFFECT EVALUATION ........................................................................................................................................................................................... 45 
Primary effect parameter ....................................................................................................................................................................... 45 
Secondary effect parameters ................................................................................................................................................................. 46 
RESPONSE CRITERIA ........................................................................................................................................................................................... 46 
RECIST ............................................................................................................................................................................................................ 46 
IMMUNOLOGICAL MONITORING ......................................................................................................................................................................... 46 
Blood samples for immunological monitoring ............................................................................................................................... 46 
Tumor biopsies ............................................................................................................................................................................................ 47 
Specimens for Future Biomedical Research .................................................................................................................................... 47 
ADDITIONAL RESEARCH ANALYSES ................................................................................................................................................................... 47 
Isolation of tumor cells ............................................................................................................................................................................ 47 
Tumor-associated lymphocytes (TALs) and chemokines ........................................................................................................... 48 
Cytokine Release Assay ............................................................................................................................................................................ 48 
Gene-based arrays ..................................................................................................................................................................................... 48 
Cell lines and cell cultures ....................................................................................................................................................................... 49 
STATISTICS ............................................................................................................................................................................................................ 50 
DATA REGISTRATION AND -ANALYSIS ............................................................................................................................................................... 50 
END OF STUDY REPORT ....................................................................................................................................................................................... 51 
AMENDMENTS ...................................................................................................................................................................................................... 51 
ETHICAL ASPECTS ........................................................................................................................................................................ 51 
RECRUITMENT OF STUDY PATIENTS AND INFORMED CONSENT ................................................................................................................... 51 
INSURANCE ............................................................................................................................................................................................................ 51 
ETHICAL ASPECTS ................................................................................................................................................................................................ 52 
RESEARCH BIOBANK, INCLUDING FUTURE BIOMEDICAL RESEARCH BIOBANK ......................................................................................... 52 
REPORTING TO THE RESEARCH ETHICS COMMITTEE .................................................................................................................................... 53 
ADMINISTRATIVE ASPECTS AND PUBLICATION ............................................................................................................... 53 
PATIENT IDENTIFICATION .................................................................................................................................................................................. 53 
PUBLICATIONS ...................................................................................................................................................................................................... 53 
ECONOMY .............................................................................................................................................................................................................. 54 
REFERENCE LIST ........................................................................................................................................................................... 55 
APPENDIX ........................................................................................................................................................................................ 60 
MANAGEMENT OF IR MYOCARDITIS ................................................................................................................................................................. 60 
 
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
7
List of Abbreviations 
ACT = Adoptive Cell Therapy 
AE = Adverse Event 
ALAT = Alanine-Aminotransferase  
AR = Adverse Reaction 
ASAT = Aspartaet-Aminotransferase 
BP = Blood Pressure 
CA 125 = Cancer Antigen 125 
CCIT-DK = National Center for Cancer Immune Therapy 
CD3 = Cluster of differentiation 3 
CD4+ Cells = Helper T cells 
CD8+ Cells = Cytotoxic T cells 
CR = Complete Response 
CRP = C-Reactive Protein 
CTC = Common Toxicity Criteria 
CTCAE = Common Terminology Criteria for Adverse Events 
CTLA-4 = Cytotoxic T-lymphocyte-assosiated antigen 4 
Cy = Cyclophosphamide 
DMSO = DiMethyl SulfOxide 
eCRF = Elektronic Case Report Form 
ELISA = Enzyme-Linked ImmunoSorbent Assay 
ELISpot = Enzyme-Linked ImmunoSpot 
EMA = European Medicines Agency 
GM-CSF = Granulocyte-macrophage colony stimulating factor 
HLA = Human Leukocyte Antigen 
IFN-γ = Interferon-gamma 
IMPD = Investigational Medical Product Dossier 
IL-2 = Interleukin-2 
irAE = Immune related adverse events 
KFE = Klinisk forskningsenhed / Clinical Research Unit  
LAG-3 = lymphocyte activation gene 3 
LDH = Lactate dehydrogenase 
MM = Malignant melanoma = skin cancer 
NSCLC = Non small cell lung cancer 
OC = Ovarian cancer 
ORR = Overall Response Rate 
P = Pulse 
PD = Progressive Disease 
PD-1 = Programmed cell death protein 1 
PD-L1 = Programmed cell death-ligand 1 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
8
PD-L2 = Programmed cell death-ligand 2 
PET =Positron Emission Tomography  
PR = Partial Response 
PS = Performance status, ECOG scale 0-4 
RECIST = Response Evaluation Criteria In Solid Tumours 
REP = Rapid Expansion Protocol 
SAE = Serious Adverse Event 
SAR = Serious Adverse Reaction 
SCLC = Small cell lung cancer 
SD = Stable Disease 
SUSAR = Suspected Unexpected Serious Adverse Reaction 
TAA = Tumor Associated Antigens 
TAL = Tumor Associated Lymphocytes 
TIL = Tumor Infiltrating Lymphocytes 
TNF = Tumor Necrosis Factor 
TNI= Troponin I  
TNT= Troponin T 
VEK = Videnskabsetisk Komité / Health Research Ethics Committee 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
9
Synopsis 
Indication and treatment 
There are limited treatment options for patients with advanced ovarian cancer (OC). Although 
immunotherapy has revolutionized the treatment of many cancers, OC patients have not yet 
benefited from the advances. Why this patient group do not respond to immunotherapy is still 
partly unknown. Therefore, revealing the mechanisms behind immunotherapy resistance is 
very important; not only for the development of effective treatments for advanced OC but also 
for the whole field of immunotherapy as it is likely that the mechanisms are shared across 
cancer types. 
 
In this phase I/II study we will treat 18 patients with advanced ovarian -, fallopian tube-, and 
primary peritoneal cancer. Included patients undergo surgical removal of tumor tissue for 
tumor-infiltrating lymphocyte (TIL) manufacturing. Lymphodepleting chemotherapy is 
administered prior to TIL infusion. Hereafter the patients are treated with the programmed 
cell death protein 1 (PD-1) antibody Nivolumab and the anti-lymphocyte activation gene 3 
(anti-LAG-3) antibody Relatlimab. The study will be devided into 3 steps.  
Step One: patients are treated without prior administration of cytotoxic T-lymphocyte-
associated antigen 4 (CTLA-4) antibody Ipilimumab pre-tumor harvest.  
Step Two: if Step One proves feasible and tolerable patients in Step Two will receive one dose 
of Ipilimumab pre-tumor harvest.  
Step Three: Patients are treated either with or without prior Ipilimumab pre-tumor harvest 
depending on the tolerability data from Step Two.  
All patients are treated with lymphodepleting chemotherapy followed by infusion of TILs.  
 
Rationale 
T-cell therapy is an experimental personalized immunotherapy where TILs are isolated from 
the patient’s own tumor tissue, expanded in vitro to billions of cells and then administered to 
the individual patient with the purpose of eliminating the remaining cancer cells. 
Lymphodepleting chemotherapy with cyclophosphamide and fludarabine phosphate is 
administered to the patient before TIL infusion to reduce the number of irrelevant immune 
cells- as well as regulatory T cells known to inhibit T-cell mediated cancer cell killing.  
 
In two consecutive pilot trials at National Center for Cancer Immune Therapy (CCIT), we have 
shown that adoptive cell therapy (ACT) with TILs for patients with advanced ovarian cancer 
(OC) is feasible and tolerable1 (ref. Kverneland et al, manuscript in preparation).  
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
10 
In the most recent study, NCT03287674 clinicaltrials.gov, ACT was combined with a CTLA-4 
inhibitor, Ipilimumab, administret once pre-tumor havest and a PD1-inhibitor, Nivolumab, 
administered during the ACT treatment at specific time points. 6 patients were treated. The 
treatment combination was safe and feasible and the unpublished data show that 1 patient 
obtained PR, while 1 had unconfirmed PR. The remaining patients had SD, with one having 
long-lasting SD, mPFS 86 days (ref. Kverneland et al, manuscript in preparation). 
CTLA-4 is involved in the regulation of the early stages of T-cell activation while PD-1 
predominantly potentiates the effector functions of T cells at the tumor site. It is therefore 
hypothesized that targeting both these two receptors will lead to a positive and synergistic 
effect on the efficacy of TILs2 
 
Between 90-100% of infused T-cells in our previous ovarian cancer ACT trial expressed LAG-
3. Moreover, a high MHC-II tumor expression was found in the majority of patients1. The 
interaction between LAG-3 on T-cells and MHC-II on tumor cells inhibits T-cell function. 
Adding the anti-LAG-3 antibody Relatlimab to the ACT-regimen described above may 
therefore well unleash T-cell antitumor efficacy by blocking the known LAG-3-MHC-II 
interaction.  
 
With this study we aim to demonstrate that ACT and a combination of Relatlimab-Nivolumab 
does not increase the toxicity compared to the same treatment regimen including Nivolumab 
monotherapy. The study will elucidate whether the combination Relatlimab-Nivolumab lead 
to objective responses and improves progression free survival (PFS). This will be compared to 
our previous pilot study with ACT and Nivolumab as monotherapy. To reduce risk of side 
effect no IL-2 post TIL infusion will be administered. 
 
Finally, the study will provide a unique possibility to compare results with immune data from 
the previous CCIT-DK pilot studies in order to dissect Relatlimab-specific changes. 
Specifically, we can establish paired tumor cell lines and TILs from the patients before and 
during therapy. Based on this material we will be able to address changes in functional 
aspects of TILs such as tumor reactivity and specificity under influence of Relatlimab.  
 
We anticipate that combining Relatlimab and Nivolumab with Adoptive T celle therapy (ACT) 
for advanced OC is safe and feasible. Further, we hypothesize that the combination will lead to 
improved immunity in tumor and blood as well as improved antitumor efficacy. 
 
Purpose 
The primary objective of this study is to evaluate the tolerability and safety of the treatment. 
The secondary objective is to characterize antitumor immune responses (immune 
monitoring) as well as to assess the clinical effect of the treatment by use of the objective 
response rate (using RECIST 1.1). Also, Cancer antigen 125 (CA-125) measurements will be 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
11 
done. Assessment with PERCIST and irRC will be done exploratively. In addition, overall 
survival (OS) and progression-free survival (PFS) will be described, but not included as 
endpoints. 
 
Study design 
The trial is an open label phase I/phase II study. Patients will be included and treated at the 
Department of Oncology at Herlev Hospital. Patients can be referred from other oncology or 
gynecology centers. 
 
A stepwise approach will be applied for safety reasons. Step One is a safety run without 
Ipilimumab pre-tumor harvest and will include 6 patients. If feasible and tolerable, as defined 
by no additional SAE/SAR compared to the previously completed pilot study NCT02482090 
clinicaltrials.gov and the ongoing study NCT03287674 clinicaltrials.gov the trial will move to 
Step Two with addition of Ipilimumab pre-tumor harvest and will include 6 patients. Since 
our previous study, NCT03287674 clinicaltrials.gov, similarly administered Ipilimumab, TILs 
and Nivolumab, the observed SAE/SAR in step two will be compared with this study.  
Step Three: If no additional SAE/SAR is observed when compared to the 6 patients treated in 
the study NCT03287674 clinicaltrials.gov additional 6 patients will be included at Step Two. If 
on the other hand Step Two is not found safe additional 6 patients will be included at Step 
One.  
In Step Two, all eligible patients will be treated in the outpatient clinic with one dose of 
Ipilimumab, 2-6 weeks before surgical removal of tumor tissue for TIL manufacturing.  
In both Step One and Step Two, TIL administration and the start of Nivolumab and Relatlimab 
treatment will take place during hospital admission. It is anticipated that it will take 
approximately 4-6 weeks from the tumor tissue is removed for TIL manufacturing to the start 
of treatment. Hospitalization and treatment will span approximately 3 weeks with Nivolumab 
and Relatlimab treatment continuing after discharge in the outpatient clinic for a total of 4 
series. T-cell therapy will be administered only once. 
In some cases, TILs will be isolated from tumor tissue in advance and cryo-preserved for later 
treatment. After the end of treatment, the patients will be followed with clinical- and imaging 
controls for up to 5 years in a specialized immunotherapy unit at the Department of Oncology, 
Herlev Hospital. Patients will be excluded upon clinical or radiological progression.  
The inclusion period is expected to be approximately 2 year, starting from august 2020. We 
expect all patients to be treated and have finished the 6 months follow-up within three years. 
The study will be monitored by the Good Clinical Practice (GCP)-unit, and reported to the 
Danish Medicines Agency, the Research Ethics Committee and the Danish Data Protection 
Agency. 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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Population 
Patients with histologically verified advanced ovarian-, fallopian tube-, and primary 
peritoneal cancer will be eligible for treatment if they meet the criteria of inclusion, including 
an acceptable performance status, acceptable kidney- and liver function, and the absence of 
major co-morbidities. Eighteen patients will be included and treated in a stepwise approach 
as described above. The treatment will only be completed in patients with successful 
manufacturing of TILs.  
Prior clinical trials have shown that the success rate of TIL manufacturing from metastatic 
melanoma exceeds 90% 3. To date, we have successfully generated viable TIL cultures from 34 
out of 34 samples (100%) from patients with OC who have undergone debulking surgery (our 
internal observation). In our clinical pilot study, we managed to grow TIL cultures from 9 out 
of 10 OC tumor samples (90%)1. 
The actual success rate of TIL manufacturing in this trial depend on additional factors e.g. 
previous chemotherapy regimens that the patients have received before enrolment, but any 
major difficulties in manufacturing TILs from most patients are not anticipated.  
Toxicity 
So far, twelve OC patients have undergone ACT treatment in CCIT-DK initiated trials.  The first 
six patient were treated with ACT therapy and IL-2 according to the decrescendo regimen. 
Only expected and manageable toxicities was observed.1  The next six patients had ACT 
treatment in combination with Ipilimumab, Nivolumab, and low-dose IL-2, NCT03287674 
clinicaltrials.gov No unacceptable toxicity has been registered (ref. Kverneland et al, 
manuscript in preparation). 
 
The toxicities associated with Ipilimumab are well-described4. Two clinical studies by the 
same group have treated patients with OC with a vaccine and subsequent CTLA-4 blockade. 
Initially, 2 OC patients were treated with Ipilimumab several years after the vaccine5 and in 
the continued study 9 additional OC patients were treated with Ipilimumab between 1-4 
months after vaccination6. No serious toxicity was seen in the first study, while 2 patients 
experienced grade 3 gastrointestinal toxicities, which resolved after oral corticosteroid 
administration, in the second study. A low level of toxicity is anticipated in this study since the 
patients will only receive 1 dose of Ipilimumab. 
 
The toxicities associated with Nivolumab are also well-described, and are in general milder 
and less frequent than with Ipilimumab7. A clinical study treating 20 patients with OC with 
Nivolumab has shown acceptable toxicity in a phase II trial8. 
Moreover, 6 patients with OC have been treated a combination of low-dose IL-2, Nivolumab 
and Ipilimumab in the ongoing phase 1 study , NCT03287674 clinicaltrials.gov. No 
unacceptable toxicity has been registered, (ref. Kverneland et al, manuscript in preparation) 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
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The toxicities associated with a Nivolumab-Relatlimab combination therapy was assessed as 
of the clinical data cutoff date October 30, 2019. At that time, 78 patients had been treated in 
the study CA224020 with Relatlimab 160 mg + Nivolumab 480 mg every four weeks (BMS-
986213).  “Of the 78 patients treated, 75 patients (96.2%) experienced at least 1 adverse event 
(AE). Drug-related AEs were reported in 54 (69.2%) of subjects. Grade 5 non-drug related events 
were reported in 11 subjects: including disease progression (3 subjects, 3.8%), malignant 
neoplasm (7 subjects, 9.0%), and respiratory failure (1 subject, 1.3%).” All grade 5 AEs were 
non-drug related and no subjects experienced a drug-related life-threatening and/or fatal 
unexpected serious adverse reaction. 
Two other patient cohorts are being treated in the study CA224020. One cohort is treated 
with 80 mg Relatlimab + 240 mg Nivolumab in separate solutions every second week. The 
other is treated with 160 mg Relatlimab + 480 mg Nivolumab in separate solution every 
fourth week. As of October 30, 2019, the primary endpoint of the last two mentioned patient 
cohorts has not been met and the efficacy data are not yet available. (ref. INVESTIGATOR 
BROCHURE, Relatlimab-Nivolumab FDC. BMS-986213) 
 
Patients in this study will be treated with 80 mg Relatlimab IV and 240 mg Nivolumab IV as 
this dose was proven safe in the CA224020 study where 30 patients have been enrolled and 
treated at Herlev hospital so far. 
Evaluation of clinical response 
The patients will be clinically evaluated 6 and 12 weeks after treatment with TILs and every 3 
months hereafter. Evaluation by diagnostic imaging will take place before the treatment, 
before discharge following TIL treatment, and in connection with the clinical evaluations 
starting from 6 weeks after TIL treatment. 
Immunological response evaluation 
Blood samples of 109 ml will be collected at the time of surgery (step 1) or before treatment 
with Ipilimumab (step 2), before TIL infusion, before the second treatment with 
Nivolumab/Relatlimab  and in connection with the clinical evaluations. Blood samples (15 ml 
blood samples) will be collected during hospitalization at day 0 before TIL infusion, 2 hours 
after TIL infusion, on day 1 and 2 and before the second treatment with 
Nivolumab/Relatlimab. Immune cells will be isolated from the collected blood samples by 
standard gradient centrifugation and cryo-preserved for later analysis. Flow-cytometric 
analyses will be used to assess the quantity and function of different immune cell subsets (e.g. 
CD4+, CD8+) before and after treatment at several time points. 
 
 
 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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Introduction and rationale 
Ovarian cancer 
Approximately 1900 women are diagnosed with a gynecological malignancy annualy in 
Denmark. Of these, approximately 450 have ovarian-, fallopian tube- and primary peritoneal 
cancer. 70-80% have local- or advanced disease at the time of diagnosis and it is the 4th most 
common cause of cancer death among women in Denmark9. Inoperable patients are treated 
with combinational chemotherapy (carboplatine in a combination with a taxan or a 
topoisomerase inhibitor). In patients with advanced stages of OC an addition of Bevacizumab 
has proven to increase PFS.  Recently, the PARP-inhibitor Olaparib was approved for some 
BRCA-positive patients with relaps10.  Despite recent progress in treatment strategies, 
patients with advanced disease still have dismal survival rates11.  
Tumor immunology 
Remarkable progress has been made in the understanding of the reactions of the immune 
system against cancer in recent years. It has become clear that the immune system reacts 
against certain tumors in vivo and that immunological response against cancer cells are 
associated with a better prognosis12,13. In addition, it has been shown that a small percentage 
of patients with widely metastatic cancers can be cured with a variety of immune-activating 
approaches, including transfer of T cells14.  
T-cell therapy in patients with OC has only been investigated scarcely and most of the existing 
studies were conducted more than 15 years ago. Importantly, none of the studies used current 
protocols of TIL manufacturing or preparative chemotherapy regimens. These studies are 
described in detail below (section “T-cell therapy”). 
Immune checkpoint inhibition in patients with OC has been investigated more recently and in 
several trials. The clinical trials with CTLA-4-, PD-1-, PD-L1- and LAG-3 antibodies are 
described in more details below (section “Checkpoint inhibition”). 
Tumor infiltrating lymphocytes (TILs) 
Tumors are often infiltrated by large amounts of T-cells (TILs) that specifically recognize 
tumor antigens but typically are inactive, or not sufficiently active, in the tumor 
microenvironment. The inactive state of the T cells in the tumor tissue is characterized by 
abnormal intracellular signaling, apoptosis and reduced proliferative capability, which are 
probably caused by various immune inhibiting factors in the tumor environment15,16. 
However, it is possible to amplify and reactivate such TILs for tumor cell killing in vitro by use 
of activating factors like IL-217,18.  
 
T-cell therapy 
T-cell therapy, which is also called” Adoptive T-cell Therapy” (ATC), is an immunotherapeutic 
cancer treatment that has shown very promising results, especially in metastatic MM. This 


 
 
 
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treatment, which uses the patient’s own T cells for tumor cell killing, was developed at the 
American National Institute of Health and in recent years several studies from research 
centers in other countries in both USA and Europe have been published with more than 500 
patients having received the treatment in total19–24.  
 
The treatment is defined as the infusion of T cells isolated from the patient’s own  
tumor tissue after ex vivo activation and several rounds of expansion, and takes advantage of 
the high number of tumor reactive T cells in tumor tissue compared to peripheral blood25. 
 
Briefly, tumor-infiltrating T-lymphocytes are harvested from freshly resected tumor material 
from an individual patient and initially expanded ex vivo over a period of 2-4 weeks by 
growing T cells in high concentrations of the T-cell growth factor IL-2. Upon TIL isolation and 
initial growth, cells are further expanded to around 5x1010 cells in a standard 14 days rapid 
expansion protocol (REP), where TILs are cultured in the presence of allogeneic or autologous 
irradiated peripheral mononuclear blood cells (PBMCs, “feeder cells”), soluble anti-CD3 
antibodies and IL-2. Prior to infusion of the TIL product, patients receive in-hospital 
lymphodepleting chemotherapy for 7 days as a conditioning treatment. This last step has no 
direct impact on tumor growth but is crucial for subsequent in vivo TIL persistence and 
expansion. The patients remain in hospital for a total of 14-21 days (see Figure 1 for an 
overview of the procedure). When an autologous and polyclonal tumor specific T-cell 
population is infused under these conditions, migration of anticancer T cells to the tumor site 
leads to a broad and patient-specific recognition of both defined and undefined antigens 
expressed on tumor cells leading to tumor cell killing and, eventually, tumor regression.  
 
This makes T-cell therapy a highly specialized and individualized form of cancer immune 
therapy. 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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Figure 1: Course of treatment with T-cell therapy 
Tumor tissue for manufacturing of the T-cell infusion product is removed immediately after 
inclusion. Treatment with Cyclophosphamide (C) and fludarabine phosphate (F) is commenced a 
week before the T cells are ready for infusion and are followed by infusion of the T cells. 
 
T-cell therapy has shown very promising results in metastatic MM with overall response rates 
(ORR) around 50%, which has been confirmed in several phase I/II “single institution” 
studies20–22,26,27.  Complete response (CR) has been observed in about 20% of the treated 
patients of which most CR are of long duration and with patients being free of disease more 
than 7 years after the treatment19. Thus, TIL based T-cell therapy seems to have the potential 
of curing a significant number of the treated patients with metastatic MM. 
 
Previous experiences with more than 500 patients with metastatic MM treated with T-cell 
therapy has shown that the treatment is safe to administer to patients in a good performance 
status and adequate organ function, despite considerable - but temporary - toxicity. The 
observed side effects are reversible and acute and consist of known and expected side effects 
to lymphodepleting chemotherapy and high dose IL-2. 
Of the older studies investigating T-cell therapy for OC, one study administered TILs in the 
peritoneal cavity with a low dosage of IL-2 and found manageable toxicity but no measurable 
response28. Two studies administered TILs without simultaneous IL-2 administration. One of 
the studies administered 1 series of cyclophosphamide or cisplatine-based chemotherapy 
followed by administration of TILs and found CR in 14,3% and 70%, respectively, while 
finding partial response (PR) in 57,1% and 20%, respectively, in very small patient groups (7 
and 10 patients)29. The other study was performed in an adjuvant setting following primary 
operation and adjuvant chemotherapy. Thirteen patients were treated with 5-floururacile and 
cyclophosphamide or cyclophosphamide and Adriamycin followed by TILs randomized 
against chemotherapy alone for 11 patients. They found 100% and 67,5% 3 years overall 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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survival rate and 82,1% and 54,5% 3 years disease-free survival rate, both significant 
results30. More recently, a pilot study using gene-modified T cells with PBMCs derived from 
leukapheresis were tested for treatment of patients with recurrent epithelial OC. The 
treatment was shown to be safe, but no clinical responses were observed31.  
Two recent studies administering T-cell therapy to patients with metastatic OC has been 
performed here at CCIT-DK and is mentioned in detail below (see “Clinical trials”). 
Checkpoint inhibition 
Immune checkpoint therapy targets regulatory pathways in T cells with the purpose of 
enhancing antitumor immune responses. The regulatory pathways of interest to this study are 
described briefly in the following.  
MHC-molecule presentation of tumor antigen in the context of B7 co-stimulation by 
professional antigen-presenting cells is necessary for priming of tumor-specific T cells. This 
priming leads to activation, acquisition of effector functions and infiltration of tumor sites. 
Upon T-cell activation, an induction of  CTLA-4 expression leads to an accumulation of CTLA-4 
on the surface of the activated T cells that, at a certain level, can block B7 co-stimulation and 
thereby subsequently suppress T-cell activation32–34. The majority of Activated T cells that 
infiltrates the tumor microenvironment express PD-1 on their cell surface and many types of 
cancer express its inhibitory ligands, PD-L1 and PD-L2, thus inhibiting local anti-tumor 
responses in the T cells effector phase32,34,35.  
Two clinical studies have investigated CTLA-4 blockade in patients with OC. In one study 9 
previously vaccinated cancer patients were treated with the CTLA-4 antibody Ipilimumab (3 
mg/kg). Two of these patients had OC. The vaccine consisted of irradiated, autologous tumor 
cells engineered to secrete GM-CSF. No serious toxicities directly related to the antibody were 
observed and the two OC patients experienced a brief reduction in CA-125 values followed by 
stabilization (total 4 months) and a stabilization (1 month), respectively5. The other study 
from the same group continued treating previously vaccinated cancer patients with the 
difference that CTLA-4 blockade (Ipilimumab 3 mg/kg with subsequent treatments at 2-3 
months intervals as clinically indicated, range 1-16) was given between 1 and 4 months after 
vaccination instead of after several years, as in their earlier study. The same vaccine was used. 
Nine additional OC patients were treated. Two patients experienced grade 3 gastrointestinal 
toxicities which resolved after the administration of oral corticosteroids. One of the two also 
manifested Sweet’s syndrome. The remaining 7 patients only experiences minor 
inflammatory toxicities. Three patients achieved stable disease (SD) (2,4,6+ months) and one 
patients achieved a partial response (PR) (35+ months)6. 
One clinical study has investigated anti-PD-1 antibodies in patients with OC. They treated 20 
patients with platinum-resistant OC with the PD-1 antibody Nivolumab (two 10-patient 
cohorts, the first treated with 1 mg/kg, the second with 3 mg/kg, treatment every 2 weeks for 
up to six cycles with four doses per cycle). Eight of 20 patients (40%) experienced grade 3- or 
4 treatment-related toxicities. Two patients experienced severe adverse events. Six patients 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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achieved SD (4 in the 1 mg/kg group), one achieved PR (in the 1 mg/kg group) and two 
achieved CR (both in the 3 mg/kg group)8.  
One clinical study investigated anti-PD-L1 antibodies in patients with OC. They treated a total 
of 207 patients with the anti-PD-L1 antibody BMS-936559 (escalating doses from 0.3 to 10 
mg/kg every 14 days in 6-week cycles for up to 16 cycles). Seventeen of these patients had OC. 
Treatment-related grade 3 or 4 adverse events were observed in 19 of 207 (9%) and serious 
adverse events in 11 of 207 patients (5%). No information about these events was available 
based on the different cancer types. Of the 17 OC patients, 1 achieved PR and 3 achieved SD 
for at least 24 weeks. All were in the 10-mg dose group36.  
Several other trials are currently enrolling patients, but results are so far unknown (source 
clinicaltrials.gov). 
CCIT-DKs experience with T-cell therapy 
Clinical trials 
The complicated methods of manufacturing TILs has been established at the National Center 
for Cancer Immune Therapy (CCIT-DK), Herlev Hospital, as one of the few places in the 
world37. CCIT-DK and the Department of Oncology at Herlev Hospital have several years of 
experience in treating cancer patients with T-cell therapy and different regimens of IL-2. 
All patients have been treated with classic lymphodepleting chemotherapy with 
cyclophosphamide and fludarabine phosphate followed by TIL infusion and subsequent 
administration of IL-2. 
In the original “T-cell regimen” described by Dudley et al very high dosages of IL-2 (720.000 
IU/kg i.v.) where given as bolus injection every 8 hours until treatment limiting toxicity. It is 
unknown how high a dosage of IL-2 is necessary to maintain T-cell expansion, and 
consequently CCIT-DK has tested the treatment with low and intermediate doses of IL-2 to 
investigate whether clinical efficacy can be maintained while toxicity is decreased. 
Initially, low dosage subcutaneous IL-2 was given to 6 patients in a pilot study initiated in the 
summer of 2009 and the results are now published20.  Two of the six treated patients achieved 
CR and are presently without evidence of disease (NED). 
To achieve a higher response rate (RR), the dosage of IL-2 was then increased to an 
intermediary dosage and administered after the decrescendo-regimen equal to the 
decrescendo regimen used in Denmark as standard treatment of metastatic MM. 
Additionally, 25 patients have been treated after the increase in IL-2 dosage. Of the 31 treated 
patients, five achieved CR (48 (NED), 13 (NED), 38+, 22+ and 11+ months) and 7 patients 
achieved partial PR (35+ (NED), 12, 18+, 25+ (NED), 11, 8 and 6+), of which 7 are having 
ongoing responses varying from 6-38 months. Thirteen patients had stable disease (SD) for 4-
6 months and 5 patients progressed immediately after treatment. An ORR of 39% has been 
observed, which is comparable to other studies administering high dosage of IL-2. The 
lymphodepleting chemotherapy induced, as anticipated, myelosuppression with anemia, 
leucopenia and thrombocytopenia and all patients received prophylactic antibiotics and blood 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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transfusions. All patients experienced transient grade III-IV toxicities during the 3 weeks of 
hospitalization but recovered quickly after the treatment. The above mentioned results have 
recently been published38. Markedly reduced toxicities have been observed with the low- to 
intermediary dosage of IL-2 and the treatment has shown to be manageable at a regular 
Department of Oncology with limited need for intervention from an Intensive care unit. 
Recently, an international phase III study treating patients with metastatic MM with TILs and 
a high dosage bolus IL-2 regimen (600.000 IU/kg) was initiated at the Department of 
Oncology, Herlev Hospital. So far, toxicity has been acceptable. 
A previous pilot study conducted at the CCIT-DK with 6 patients has shown that it is feasible 
and safe to treat patients with metastatic OC with T-cell therapy and IL-2 according to the 
decrescendo regimen. Only expected and manageable toxicities have been observed and all 
patients’ hematopoietic system recovered without the need for stem cell support. Four 
patients experienced SD for 3 months and the last two patients had SD for 5 months1  
 
In a prior clinical trial (NCT03287674 clinicaltrials.gov ) at CCIT-DK 6 patients with OC have 
been treated with Ipilimumab, T-cell therapy, Nivolumab, and low dose IL-2. The unpublished 
data show that one patient obtained PR, one unconfirmed PR, mPFS 3 months. The treatment 
has been feasible and only anticipated and manageable toxicities was observed. ref. 
Kverneland et al, manuscript in preparation) 
Translational research 
Further development of T-cell therapy with optimizing and expansion to other cancer forms 
has a high priority at CCIT-DK. Our already established platform for T-cell therapy for MM 
gives us a unique opportunity to study the interactions between tumor and immune system 
and thereby identify possible methods for optimization of T-cell therapy, as well as extension 
to other tumor histologies.  
 
Several studies has shown that the following T-cell characteristics are important for achieving 
a clinical response after T-cell therapy: long telomeres, short time spent in culture, a favorable 
T-cell phenotype (CD27+, CD28+), a high absolute number of T cells and a high number of 
cytotoxic  tumor-reactive T cells in the infusion product39 as well as an increased persistence 
of T-cell in the peripheral blood after infusion19,37,40. AT CCIT-DK, we have modified the 
original T-cell expansion method from” Standard TIL expansion” to” Young TIL expansion” 
based on these characteristics and leading to a reduction of the length of cell manufacturing 
from 4-7 weeks to 2-4 weeks. A decreased amount of time in culture (Young TIL) provides the 
TILs with longer telomere sequences and more favorable phenotypes (CD27+, CD28+) with 
the ability of increased proliferation, an increased persistence in vivo and a higher antitumor 
activity, all of which are correlated to an increased clinical response19,37. This optimization of 
TIL production has made it possible to produce clinically usable TIL infusion products from 
more than 90% of the patients41–44. Furthermore, during the final expansion phase, the Rapid 
Expansion Protocol (REP), we have introduced the use of the Wave® bioreactor45, which 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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optimizes the conditions of proliferation of T cells and has made it possible to achieve a higher 
total number of cells as well as tumor reactive T cells in the TIL infusion product. We have 
standardized and harmonized TIL production methods between 3 European cancer research 
centers based on these TIL production protocols developed at CCIT-DK and have initiated a 
randomized, multicenter TIL-based phase III trial with T-cell therapy versus standard 
immunotherapy (clinicaltrials.gov identifier: NCT02278887) with the purpose of the approval 
of T-cell therapy as standard treatment for patients with MM.  
 
Recent studies suggest that TIL based ACT potentially can be used with success in other 
cancer forms including colon, breast, head and neck, kidney, sarcoma and OC46–51. It has been 
shown that a high intratumoral presence of T cells is correlated with longer survival and 
functional analysis has shown that tumor infiltrating T cells show in vitro anti-tumor activity 
similar to that seen in MM. In a preclinical study, we have successfully manufactured TILs 
from 34/34 samples obtained with primary debulking surgery from patients with OC. Tumor 
cell lines have been established from 14/33 tumor samples and we have been able to detect 
an anti-tumor response (either CD8+ or CD4+ T cells) in 19 of 31 patients tested against 
either tumor cell line or tumor digest (Westergaard MCW et al., ESMO IO 2014).  
Subsequently, in our aforementioned pilot study with T-cell therapy in OC, we were able to 
manufacture TILs from 9/10 patients, establish tumor cell lines from 5/10 tumor samples, 
and detect anti-tumor responses (either CD8+ or CD4+ T cells) in 5/6 of the treated patients 
tested against either tumor cell line or tumor digest1. 
The rationale of the drugs used in the study 
Lymphocyte depleting chemotherapy 
Activating cytokines (the signal molecules IL-2, IL-7, IL-15, IL-21 etc.) need to be available for 
the tumor specific T cells to sustain an immunological response against tumor tissue. Many 
“irrelevant” T cells will decrease the availability of these cytokines for the relevant T cells 
through competition. Thus, a high number of tumor specific T cells with a high specificity as 
well as a reduction of irrelevant T cells and regulatory T cells (Tregs) are needed to create an 
environment that facilitates the T-cell mediated antitumor response. 
This study will use combination chemotherapy with two days treatment with 
cyclophosphamide and 5 days with fludarabine phosphate to create such an environment. 
This combination has been chosen based on earlier studies where it was shown safe and 
effective52,53. 
Cyclophosphamide 
Cyclophosphamide is an alkylating drug that works by creating covalent bindings with 
biologically important macromolecules. Of special interest is the creation of a binding and 
linkage to DNA. Cell division can be prevented if the linkage is not canceled by the cells repair 
systems. The binding to important proteins in the cell can damage important cellular 


 
 
 
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functions and lead to cell death. Cyclophosphamide is among others used to treat breast 
cancer and in the treatment of hematological diseases as myelomatosis54.  
Fludarabine phosphate 
Fludarabine phosphate is a pro-drug that is converted to the active triphosphate 2-fluoro-ara-
ATP. It is an anti-metabolite which inhibits DNA synthesis while simultaneously reducing RNA 
and protein synthesis. Fludarabine phosphate is used in the treatment hematological diseases 
as CLL among others55.  
Checkpoint inhibition in combination with T-cell therapy 
As mentioned earlier, a high absolute number of T cells and a high number of cytotoxic tumor-
reactive T cells in the infusion product is important for achieving a clinical response after T-
cell therapy39. Furthermore, CTLA-4 is involved in the regulation of the early stages of T-cell 
activation while PD-1 predominantly regulates T-cell effector functions in the periphery and it 
is therefore hypothesized that targeting these two receptors will lead to a positive and 
synergistic effect on the TILs2. 
One study has shown an increased intratumoral infiltration with CD8+ cells in posttreatment 
biopsies when treating patients with metastatic malignant melanoma (MM) with a CTLA-4 
antibody56. Another study investigated 40 patients with metastatic MM treated with the 
CTLA-4 antibody Ipilimumab and found that clinical response was associated with an increase 
in absolute lymphocyte count (p = 0.008), absolute T-cell count (p = 0.02) and the absolute 
number of activated T cells in peripheral blood (p = 0.003) after 1 series of treatment57. Other 
recent studies from our laboratory and others have shown that blockade with a CTLA-4 
antibody broadens the intratumor and peripheral T-cell repertoires58 (Bjørn J et al., 
Oncotarget 2017 in press). Our laboratory has also shown that in vitro stimulation of TIL 
cultures from OC patients with a CTLA-4 antibody increases the frequency of CD8+ T cells. We 
were able to generate TIL cultures in 5/5 cultures stimulated with Ipilimumab vs. 3/5 and 4/5 
cultures not stimulated with Ipilimumab. The Ipilimumab stimulated cultures contained an 
increased number of TILs per fragment in 4/5 cultures and an increased amount of CD8+ TILs 
in 5/5 cultures compared to the unstimulated ones. 
Thus, pretreating the patient with a CTLA-4 antibody before tumor harvest may lead to 
increased quality of the TIL product and in vitro stimulation with a CTLA-4 antibody may 
increase the quality of the TIL product even further. 
Studies investigating the expression of programmed cell death-ligand 1 (PD-L1) in OC has 
shown an uncertain correlation to prognosis59,60, but also that a high intratumoral amount of 
CD3+ T cells is positively correlated to prognosis. It is hypothesized that PD-L1 expression is 
upregulated in tumor tissue as a compensatory reaction to an immune response against 
tumor cells and suppresses antitumor CD8+ T cells59–61. 
In addition, we have shown that a significant fraction of tumor-reactive TILs in the infusion 
product express an increased level of PD-1 and that in vitro addition of anti-PD1 leads to 
increased tumor killing by these TILs (unpublished data).   


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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Therefore, clinical targeting of the PD-1 receptor could potentially decrease the suppression 
of the infused tumor reactive CD8+ T cells.  
Ipilimumab 
Ipilimumab is an anti-CTLA-4 antibody that inhibits a decrease in the activation and 
proliferation of T cells when presented to tumor antigens by professional antigen presenting 
cells in the priming phase, as mentioned earlier. Ipilimumab is approved by the European 
Medicines Agency (EMA) for the treatment of metastatic malignant melanoma and is 
undergoing clinical trials in combination with PD-1/PD-L1 inhibitors in non-small cell lung 
carcinoma (NSCLC), small cell lung cancer (SCLC), bladder cancer and metastatic hormone-
refractory prostate cancer62. 
Ipilimumab will be administered to patients in Step Two in the approved dosage of 3 mg/kg 
for 1 dose 2-6 weeks before surgical removal of tumor tissue for TIL production. 
Nivolumab 
Nivolumab is an anti-PD-1 antibody that inhibits suppression of the activated T cells in 
performing their effector functions in targeting the tumor cells in the tumor 
microenvironment in the effector phase, as mentioned earlier. Nivolumab is approved by the 
EMA for the treatment metastatic malignant melanoma, NSCLC, renal cell carcinoma, 
Hodgkin’s lymphoma, head and neck cancer63.  
Nivolumab will be administered in the approved dosage of 240 mg starting 2 days before T-
cell therapy and every 2nd week continuing after discharge in the outpatient clinic for a total of 
4 series. 
 
Relatlimab 
Relatlimab is an anti-LAG-3 antibody that inhibits activated T-cells from interacting with 
MHC-II on the tumor cells. Relatlimab thereby inhibits the inactivation signals to the T-cells. 
This could lead to sustained anti-tumor activity of infused T-cells and increased anti-tumor 
efficacy. Relatlimab will be administered in the dose 80 mg and is given in combination with 
Nivolumab starting 2 days before T-cell therapy and every 2nd week. The therapy continues 
after discharge in the outpatient clinic for a total of 4 series. 
Relatlimab-Nivolumab combination 
Relatlimab is an anti-LAG-3 antibody that inhibits activated T-cells from interacting with 
MHC-II on the tumor cells. Relatlimab in combination with Nivolumab is currently tested in 
the open-label Phase I/II study CA224020 assessing the pharmacokinetics, clinical efficacy, 
and safety of Relatlimab in subjects with advanced solid tumors. (ref. INVESTIGATOR 
BROCHURE Relatlimab-Nivolumab FDC. BMS-986213). Relatlimab will be administered in the 
dose 80 mg and is given in combination with 240 mg Nivolumab starting 2 days before T-cell 
therapy and every 2nd week. The therapy continues after discharge in the outpatient clinic for 
a total of 4 series. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
23 
 
The rationale of the treatment regimen used in the study 
The ACT regimen has been determined according to our previous study carried out in MM3 
and OC1  
Purpose and hypoteses 
Primary 
1) To assess tolerability and feasibility of the treatment. 
Secondary 
1) To clarify whether T-cell therapy in combination with three different checkpoint 
inhibitors for patients with advanced ovarian-, fallopian tube- and primary peritoneal 
cancer can induce a measurable immune response against tumor cells. 
2) To describe objective responses using RECIST 1.1. Furthermore, overall survival (OS) 
and progression-free survival (PFS) will be described. 
Study design 
The study is an open label phase I/phase II study for patients with advanced ovarian-, 
fallopian tube- and primary peritoneal cancer. All patients will be included and treated at the 
Department of Oncology, Herlev Hospital. Patients can be referred to treatment from other 
centers in Denmark. 
 
We expect to include and treat 18 patients in total. 
In Step One 6 patients will be treated without Ipilimumab. If feasible and tolerable, as defined 
by no additional SAE/SAR compared to the previously completed pilot studies, the trial will 
move to Step Two with addition of Ipilimumab pre-tumor harvest and will include 6 patients. 
If no additional SAE/SAR compared to Step One is observed additional 6 patients can be 
included at Step Two. If on the other hand Step Two are not found safe additional 6 patients 
can be included at Step One. 
We expect to have completed initial patient enrolment and treatment within 2 years and 6 
months follow-up within 3 years.  
 
The course of treatment consists of 3 steps followed by clinical controls and evaluation-scans 
as follow-up. 
 
- 
Step One: 6 patients.  Screening, inclusion, surgical removal of tumor material followed 
by production and growth of TILs in the laboratory. Treatment during hospitalization 
includes chemotherapy, Nivolumab, Relatlimab, and TIL. Finally, continued treatment 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
24 
with Nivolumab and Relatlimab every 2nd week in the outpatient clinic for a total of 4 
series. 
If feasible and tolerable, as defined by no additional SAE/SAR compared to the 
previously completed pilot studies, the trial will move to Step Two.  
 
- 
Step Two:  6 patients. Screening, inclusion, Ipilimumab treatment, surgical removal of 
tumor material followed by production and growth of TILs in the laboratory. 
Treatment during hospitalization includes chemotherapy, Nivolumab, Relatlimab, and 
TIL. Finally, continued treatment with Nivolumab and Relatlimab every 2nd week in the 
outpatient clinic for a total of 4 series. 
 
- 
Step Three: If no additional SAE/SAR is observed in Step Two when compared to the 6 
patients treated in the trial: NCT03287674 clinicaltrials.gov , additional 6 patients will 
be included in Step Two. If on the other hand the Step Two treatment is not found safe, 
additional 6 patients will be included at Step One (figure 2). 
 
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
25 
 
Figure 2 Schematic presentation of the course of treatment. In Step One, 6 patients are treated 
without Ipilimumab. In Step Two, one dose of Ipilimumab (3 mg/kg) is administered 2-6 weeks 
before tumor resection. Tumor tissue (metastasis or primary tumor) of minimum 1 cm3 is 
surgically removed from the patient and transported to the laboratory under sterile conditions 
where the tumor is separated into suitable fragments of 1-3 mm3 and placed in growth wells 
with a growth media and IL-2. TILs are then initially grown for 2-4 weeks until a cell-number of 
minimum 50 x 106. At this point the cells can be cryo-preserved for later use or pass on to the 
Rapid Expansion Protocol (REP) in which the T cells for 2 weeks are stimulated with anti-CD 3 
antibody, allogeneic, radiated PBMC (peripheral mononuclear blood cells), feeder cells and IL-2. 
After stimulation, the expanded TILs (now billions) are then washed, pooled and re-infused 
intravenously back into the patient.  Prior TIL infusion,  seven days of lymphodepleting 
chemotherapy with cyclophosphamide (C) on day -7 to day -6 and Fludarabine (F) on day -5 to 
day -1 is given to the patient with the purpose of removing all existing lymphocytes to make 
room for the infused TILs and remove regulatory T cells (Tregs). Nivolumab (240 mg) and 
Relatlimab (80 mg) is administered 2 days before TIL infusion to boost the activity of the 
reinfused TILs. Nivolumab and Relatlimab is continued in the outpatient clinic for a total of 4 
series. In step 2 Ipilimumab (3 mg/kg) is administered once 2-6 weeks before tumor havest. 
Depending on tolerability and feasability Step 3 will be similar to either step 1 or step 2.  
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
26 
Study population 
Patients with histological verified advanced ovarian-, fallopian tube- or primary peritoneal 
cancer will be candidates for this study. The patients need to have an acceptable performance 
status, no major co morbidities and acceptable organ functions. 
Only patients in which it is possible to grown T cells from their tumor tissue will be offered 
treatment with T cells in the study and only patients receiving treatment will be included in 
the final study population. 
Criteria of in- and exclusion 
Criteria of inclusion 
All the criteria listed in the following need to be met before patient inclusion. 
 
1. Histological proven advanced ovarian-, fallopian tube or primary peritoneal cancer 
with the possibility of surgical removal of tumor tissue of > 1 cm3. All histologies can be 
included. 
2. Progressive or recurrent resistant disease after platin-based chemotherapy (platinum 
resistant) or progressive or recurrent disease after second line or additional 
chemotherapy. 
3. Age: 18 – 75 years. 
4. ECOG performance status of ≤1 (Appendix 2). 
5. Life expectancy of > 6 months. 
6. At least one measurable parameter in accordance with RECIST 1.1 –criteria. 
7. LVEF assessment with documented LVEF ≥50% by either TTE or MUGA (TTE preferred 
test) within 6 months from first study drug administration 
8. No significant toxicities or side effects (CTC ≤ 1) from previous treatments, except 
sensory- and motoric neuropathy (CTC ≤ 2) and/or alopecia (CTC ≤ 2).  
9. Sufficient organ function, including:  
o Absolute neutrophil count (ANC) ≥ 1.500 /µl 
o Leucocyte count ≥  lower normal limit 
o Platelets ≥ 100.000 /µl and <700.000 /µl 
o Hemoglobin ≥ 6,0 mmol/l (regardless of prior transfusion) 
o S-creatinine < 140 
o S-bilirubin ≤ 1,5 times upper normal limit 
o ASAT/ALAT ≤ 2,5 times upper normal limit 
o Alkaline phosphatase ≤ 5 times upper normal limit 
o Lactate dehydrogenase ≤ 5 times upper normal limit 
o Sufficient coagulation: APPT<40 and INR<1,5 
10. Signed statement of consent after receiving oral and written study information 
11. Willingness to participate in the planned controls and capable of handling toxicities. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
27 
12. Age and Reproductive Status: Females, ages ≥18 years, inclusive  
• Women of childbearing potential (WOCBP) must have a negative serum or urine 
pregnancy test (minimum sensitivity 25 IU/L or equivalent units of human 
chorionic gonadotropin [hCG]) within 24 hours prior to the start of study 
treatment.Women of childbearing potential (WOCBP) must agree to follow 
instructions for method(s) of contraception. This applies from inclusion in the 
study and for the duration of treatment with Ipilimumab, Relatlimab and 
Nivolumab plus 5 half-lives of study treatment plus 30 days (duration of ovulatory 
cycle) for a total of 24 weeks post-treatment completion. The following are 
considered safe methods of contraception: 
- 
Hormonal anticonception (birth control pills, spiral, depot injection with 
gestagen, subdermal implantation, hormonal vaginal ring and transdermal 
depot patch) 
- 
Intrauterine device 
- 
Surgical sterilization 
- 
Surgical sterilization of male partner with verification of no sperm after the 
procedure 
- 
Menopause (for more than 12 months) 
Criteria of exclusion 
Patients will be excluded if they meet one of the criteria’s listed below 
 
1. A history of prior malignancies. Patients treated for another malignancy can 
participate if they are without signs of disease for a minimum of 3 years after 
treatment. 
2. Known hypersensitivity to one of the active drugs or one or more of the excipients. 
3. Severe medical conditions, such as severe asthma/COLD, significant cardiac disease, 
poorly regulated insulin dependent diabetes mellitus among others. 
4. Creatinine clearence < 70 ml/min*. 
5. Acute/chronic infection with HIV, hepatitis, syphilis among others. 
6. Severe allergies or previous anaphylactic reactions. 
7. Active autoimmune disease, such as autoimmune neutropenia/thrombocytopenia or 
hemolytic anemia, systemic lupus erythematosis, Sjögren’s syndrome, sclerodermia, 
myasthenia gravis, Goodpasteur’s disease, Addison’s disease, Hashimotos thyroiditis, 
active Graves disease. 
8. Subjects with history of myocarditis, regardless of etiology 
9. Troponin T (TnT) or I (TnI) > 2x institutional upper limit of normal (ULN) is excluded. 
ii) between > 1 to 2 x ULN will be permitted if a repeat assessment remains ≤ 2 x ULN 
and participant undergoes a cardiac evaluation and is cleared by a cardiologist or 
cardio-oncologist 
10. Prior treatment with LAG-3 targeted agents. 
11. Pregnant women and women breastfeeding. 
12. Simultaneous treatment with systemic immunosuppressive drugs (including 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
28 
prednisolone, methotrexate among others)**. 
13. Simultaneous treatment with other experimental drugs. Based on clinical judgement 
antihormonal treatment can be accepted.  
14. Simultaneous treatment with other systemic anti-cancer treatments. 
15. Patients with active and uncontrollable hypercalcemia 
 
* In selected cases it can be decided to include a patient with a GFR < 70 ml/min with the use 
of a reduced dose of chemotherapy. 
** In selected cases a systemic dose of ≤10 mg prednisolone or a transient planned treatment 
that can be stopped before TIL therapy can be tolerated. 
Evaluation before inclusion 
The following need to be carried out before the start of treatment: 
- 
Medical history and clinical examination 
- 
Performance status in accordance to the ECOG-scale 
- 
Electrocardiogram 
- 
Echocardiogram (ECHO) 
- 
Cr-EDTA clearance 
- 
Urine sample 
- 
Screening blood tests:  
o Hematology: Hemoglobin, leukocytes with diff-count and platelets 
o Liver: ASAT, ALAT, albumin, alkaline phosphatase, bilirubin, LDH, total protein, 
INR, APPT. 
o Kidney: sodium, potassium, creatinine, carbamide, magnesium, bicarbonate, 
phosphate, Ca-ion. 
o Cardiac: Troponin T (TnT) or I (TnI) 
o Other: Glucose, CRP. 
o Chronic infections: HIV, Hepatitis B surface antigen, Hepatitis B surface 
antibody, Hepatitis B core antibody, Hepatitis C antibody, HTLV IgG, EBV, 
Trepone. 
o Endocrine: TSH, T3, T4. 
o Female specific: Estradiol, prolactin. 
o Ovarian Specific: CA-125 
- 
Pregnancy test: Women in the fertile age must take a pregnancy test. This includes 
women who are not surgically sterilized, who are not postmenopausal and who have 
not used safe contraception’s regularly within the last 6 months.  
- 
Baseline tumor evaluation: CT, MR or PET-CT scans can be used. A PET/CT scan is 
preferred.  
- 
Reviewing the checklist for inclusion/exclusion for treatment. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
29 
Treatment plan 
The course of treatment can vary between patients depending on the time period from 
surgery to treatment. In most cases (e.g. TILs undergoing massive expansion and infusion 
without cryopreservation of intermediate products), the patients will receive treatment 
approximately 4-6 weeks after the operation and in these cases the course of treatment from 
Ipilimumab treatment before surgery until the first evaluation with diagnostic imaging (6 
weeks after treatment) will span across approximately 3-4 months. 
 
Surgical removal of tumor tissue for TIL expansion can be repeated if not possible to grow TIL 
after initial surgery if additional accessible tumor tissue is present and based on an individual 
clinical assessment. Presurgical treatment with Ipilimumab is to be administered 2-6 weeks 
prior to surgery and is to be repeated if more than 6 weeks has passed since the initial 
Ipilimumab treatment. 
 
Stem cell harvest by leukapheresis will not be performed since we and others have observed 
that the patients’ hematopoietic system recovers after the lymphodepleting chemotherapy 
without the need for stem cell support64–67 (unpublished data). 
 
Treatment plan step 1 
Location 
Hospital 
Outpatient 
Week 
-2 
-1 
1-2 
4 
6 
Day 
-8 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
0 
1-11 
12 
13 
26 
40 
Pt. is admitted 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cyclophosphamide (60 mg/kg) iv 
 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
Fludarabine (25 mg/m2) iv 
 
 
 
x 
x 
x 
x 
x 
 
 
 
 
 
 
Nivolumab (240 mg) iv and 
Relatlimab (80 mg) iv 
 
 
 
 
 
 
x 
 
 
 
x 
 
x 
x 
TILs iv 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
Pegfilgrastime (6 mg) sc 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
Treament plan step 2 
Location 
 
Hospital 
Outpatient 
Week 
* 
-2 
-1 
1-2 
4 
6 
Day 
* 
-8 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
0 
1-11 
12 
13 
26 
40 
Ipilimumab (3 mg/kg) iv 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pt. is admitted 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cyclophosphamide (60 mg/kg) iv 
 
 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
Fludarabine (25 mg/m2) iv 
 
 
 
 
x 
x 
x 
x 
x 
 
 
 
 
 
 
Nivolumab (240 mg) iv and 
Relatlimab (80 mg) iv 
 
 
 
 
 
 
 
x 
 
 
 
x 
 
x 
x 
TILs iv 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
Pegfilgrastime (6 mg) sc 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
30 
* Ipilimumab is administered 2-6 weeks before surgery 
 
Step 3 will be identical with either step 1 or step 2 depending on feaseablity and tolerability.  
Examination plan during treatment 
The patients are continuously monitored on several parameters before, during and after TIL 
infusion. 
 
Blood samples will be collected before, during and after hospitalizing. After ended treatment, 
the patients will be evaluated for up 5 years at the unit of experimental cancer treatment 
(EFEK) at the Department of Oncology, Herlev Hospital. Patients will be excluded upon clinical 
or radiological progression. 
 
Time point 
Screening 
Before Ipilimumab 
Tumor tissue removal 
<14 days to admission 
At admission 
Daily during hospitalization 
Before Nivolumab and 
Relatlimabb, 1st of 4 
At TIL infusion 
At discharge 
Before Nivolumab and 
Relatlimab 2nd of 4 
Before Nivolumab and 
Relatlimab, 3rd of 4 
Before Nivolumab and 
Relatlimab, 4th of 4 
After Nivolumab and 
Relatlimab, 4th of 4 
Week 
 
a 
b 
-4 → -2 
-2 
-1→c 
-1 
0 
c 
2 
4 
6 
8 
Day 
 
a** 
b 
-22→-9 
-8 
-7→c 
-2 
0 
c 
12 
26 
40 
54 
Performance Status 
x 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
 
Clinical examination 
x 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
 
Weight, BP, P, Temp. 
x 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
 
Toxicity assessment 
(CTC) 
x 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
 
Screening blood 
tests 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Research blood tests 
 
x 
 
 
x 
x* 
 
x 
 
x 
 
 
 
Standard blood tests 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
 
T (cTnt) or I (cTnI) 
x 
 
 
 
 
 
x 
 
 
x 
x 
x 
x*** 
Immunological blood 
tests 
x 
 
 
 
x 
 
x 
 
 
x 
x 
x 
 
Ovarian specific 
blood tests 
x 
x 
 
 
x 
 
 
 
 
x 
 
 
 
ECG 
x 
 
 
 
x 
 
x 
 
 
x 
x 
x 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
31 
Cr EDTA 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Urine sample 
 
 
 
 
x 
 
 
 
 
 
 
 
 
Urine or blood hCG  
x 
 
 
 
 
 
x 
 
 
 
x 
 
x**** 
Biopsy 
 
 
x 
 
 
 
 
 
 
 
 
 
 
Tumor Evaluation 
x 
 
 
x 
 
 
 
 
 
 
 
 
 
a: At least 14 days before tumor tissue removal (b) 
b: Day of tumor tissue removal. 
C: Depends on recovery period after TIL infusion, approximately at day 7. 
* Daily on day 0,1 and 2 
** Examination and blood tests will only be repeated if clinically indicated or >2 weeks from 
screening 
*** ± 5 days 
**** ± 7 days 
 
Overlapping samples are only taken once. 
 
Screening blood tests: Se previous section “Evaluation before inclusion”. 
 
Research blood tests: See section “Blood samples for immunological monitoring” under the 
section “Immunological Monitoring”. 
 
Standard blood tests: Hemoglobin, platelets, leukocytes with differential-count, creatinine, 
sodium, potassium, magnesium, phosphate, ASAT, ALAT, bilirubin, alkaline phosphatase, Ca-
ion, CRP, INR, APPT, Tnt or TnI.  
 
Immunological blood tests: Hemoglobin, platelets, leukocytes with differential-count, 
creatinine, sodium, potassium, carbamide, bicarbonate, albumin, urate, ALAT, ASAT, LDH, 
alkaline phosphatase, bilirubin, amylase, glucose, TSH, T4, Ca-ion, cortisol, prolactin, Estradiol. 
 
Ovarian specific blood tests: CA-125. 
 
Tumor evaluation: CT, MR, PET-CT or a PET-MR scan can be used. Before inclusion a current 
scan needs to be available for review. A PET/CT scan is preferred. Before hospital admission a 
baseline scan has to be performed. 
Medicinal products used in the study 
The medicinal products used in this study are Ipilimumab, Nivolumab, Relatlimab, 
cyclophosphamide, and fludarabine phosphate. Mixing and storage of the products is carried 
out according to existing standard guidelines at the Department of Oncology. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
32 
Ipilimumab 
Ipilimumab is an antibody targeting the CTLA-4 receptor on T cells. The antibody functions as 
a negative regulator by blocking of the suppressive signaling through the receptor and 
thereby potentiating T-cell activity.  
In Step Two Ipilimumab is administered in the outpatient clinic 2-6 weeks before surgical 
removal of tumor tissue for TIL production as an intravenous infusion. The dosage is 3 mg/kg 
body weight and administration takes 30 minutes.  
Cyclophosphamide 
Cyclophosphamide is given as an intravenous infusion for two consecutive days in a dosage of 
60 mg per kg of body weight. The treatment takes place during hospital admission and with 
supplementary hydration and Mesna injections.  
Fludarabine phosphate 
Fludarabine phosphate is given as an intravenous infusion for 5 consecutive days in a dosage 
of 25 mg per m2 body surface (starting the day after the last dosage of cyclophosphamide). 
The treatment takes place during hospital admission.  
Nivolumab 
Nivolumab is an antibody targeting the PD-1 receptor which is expressed on activated T-
lymphocytes. By blocking this receptor, Nivolumab prevents inhibition of T-lymphocyte 
activity through binding of the receptor ligands, PD-L1 and PD-L2.  
Nivolumab is administered 2 days before TIL administration as an intravenous infusion over 
30 minutes in a dosage of 240 mg and every 2 weeks for a total of 4 doses. 
Relatlimab 
Relatlimab is an anti-LAG-3 antibody that inhibits activated T-cells from interacting with 
MHC-II on the tumor cells.  Relatlimab is administered after Nivolumab 2 days before TIL 
administration as an intravenous infusion over 60 minutes in a dosage of 80 mg and every 2 
weeks for a total of 4 doses (ref. INVESTIGATOR BROCHURE Relatlimab-Nivolumab FDC. BMS-986213). 
TILs 
The tumor specific T cells are infused intravenously back into the patient during 
hospitalization on the day after the last dosage of fludarabine phosphate (day 0). The number 
of T cells in the product depends on the possible in vitro degree of expansion and is therefore 
variable but will normally consist of approximately 1010 cells. See the Investigational Product 
Medicinal Dossier (IMPD) for more information. 
Pegfilgratim 
Is an analog of human granulocyte colony stimulatory factor (G-CSF). It works by stimulating 
the bone marrow into producing white blood cells and increasing the peripheral blood count. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
33 
It is usually given to cancer patients who suffer from low blood counts following 
chemotherapy68.  
Pegfilgrastim is administered as a single dose of 6 mg s.c. at 2 hours after TIL infusion to help 
patients recover from the lymphodepleting chemotherapy.  
 
Relatlimab-Nivolumab administration 
Relatlimab and Nivolumab are administered sequentially. 
The administration steps are as follows: 
 
- 
250 ml NaCl (flush) 
- 
Nivolumab 240 mg IV infusion over 30 minutes  
- 
250 ml NaCl (flush) 
- 
BMS-986016 Relatlimab 80 mg IV infusion over 60 minutes  
- 
250 ml NaCl (flush) 
 
Dosage Modification 
No dose modification for Nivolumab and Reltalimab is permitted. 
 
Dose Delay Criteria 
Study treatment administration should be delayed for the following: 
-Grade 2 non-skin, drug-related adverse event with the exception of fatigue, nausea, vomiting 
and anemia 
-Grade 2 drug-related creatinine, ASAT, ALAT and/or total bilirubin abnormalities 
-Grade 3 skin, drug-related adverse event 
-Grade 3 drug-related fatigue, nausea, vomiting, and anemia 
-Grade 3 drug-related laboratory abnormality, with the following exceptions: 
-Grade 3 lymphopenia or asymptomatic amylase or lipase elevations do not 
require dose delay 
   
-Grade 3: ASAT, ALAT, total bilirubin will require dose discontinuation.   
-All troponin elevations require a dose delay to allow for prompt cardiac evaluation 
-Any adverse event, laboratory abnormality, or intercurrent illness which, in the judgment of 
the investigator, warrants delaying the dose of study medication 
 
If dosing is resumed after a delay, study treatment may be resumed as soon as possible after 
the criteria to resume treatment are met. 
Participants who require delay of any study treatment should be re-evaluated weekly or more 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
34 
frequently if clinically indicated, and resume dosing when criteria to resume treatment are 
met. 
 
Criteria to Resume Treatment 
Participants may resume study treatment when the drug-related AE(s) resolve to Grade ≤ 1 or 
baseline value, with the following exceptions: 
-Participants may resume treatment in the presence of Grade 2 fatigue. 
-Participants who have not experienced a Grade 3 drug-related skin AE may resume 
treatment in the presence of Grade 2 skin toxicity. 
-For participants with Grade 2 ASAT, ALAT, and/or total bilirubin abnormalities, dosing may 
resume when laboratory values return to baseline and management with corticosteroids, if 
needed, is complete. 
- Participants with combined Grade 2 ASAT/ALAT AND total bilirubin values meeting 
discontinuation parameters must discontinue treatment permanently. 
-Drug-related pulmonary toxicity, diarrhea, or colitis must have resolved to baseline before 
treatment is resumed. Participants with persistent Grade 1 pneumonitis after completion of a 
steroid taper over at least 1 month may be eligible for retreatment if discussed with and 
approved by sponsor. 
-Participants with drug-related endocrinopathies adequately controlled with only physiologic 
hormone replacement may resume treatment after consultation with sponsor. Adrenal 
insufficiency ≥ Grade 3 requires discontinuation regardless of control with hormone 
replacement. 
-Troponin elevations will require the participant to undergo a cardiac evaluation. Following 
this evaluation, determination of further treatment will be based on the discussion with the 
sponsor. 
 
Guidelines for concomitant treatment 
Supportive treatment is given on ordinary medical indications estimated by the physician 
responsible for the treatment. Any measures should be specified in the patient chart and flow 
sheet. The following is meant as guidance and other medications can be administered as it is 
seen fit. One exception is systemic corticosteroid which can be administered du to immune 
related adverse events (irAEs) in relation to the treatment with checkpoint inhibitors. 
During lymphodepleting chemotherapy: 
In order to protect the mucosa of the bladder the following is administered: 
• Supplementary fluid therapy during cyclophosphamide treatment. 
• Inj. Mesna (25% of the cyclophosphamide dosage i.v. x 4 daily on day -7 and -6).  


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
35 
In order to prevent and relieve nausea during chemotherapy (day -7 to -1) the following is 
administered:  
• Inj. Aloxi 250 μg i.v. on day -7 and -5. 
• Tabl. Emend 125 mg on day -7, 80 mg on day -6, 80 mg on day -5. 
• Tabl. Motilium 20 mg x 3. 
• Tabl. Temesta 1-2 mg max x 4 if needed. 
• Tabl. Pantoloc 40 mg x 1-2 daily. 
 
After TIL infusion: 
• Inj. Pegfilgrastime, 6 mg x 1 s.c. on day 0, two hours after TIL infusion. 
• Tbl. Pethidine, 25 mg max x 4, if needed. 
• Oxygen on nasal catheter if needed. 
 
To prevent opportunistic infections:  
• Tabl. Sulfamethizole with Trimethoprime, 400/80 mg, 1 tabl. Daily on day -7 and 6 months 
ahead. 
• Tabl. Aciclovir, 400 mg x 2 daily on day 0 and 6 months ahead. 
• Tabl. Diflucan, 100 mg daily on day 0 and until the neutrophile count is > 1000/µl. 
 
In case of fever: 
If simultaneous neutropenia and fever occurs, it will be treated in accordance with local 
guidelines described in appendix 4. 
 
In case of diarrhea: 
• Patients are treated according to local guidelines that include loperamide and fecal 
samples. 
• Loss of fluid and electrolytes are evaluated daily and corrected orally or intravenously. 
 
Immune related adverse events (irAEs) to checkpoint inhibitors:  
• irAEs are to be managed in accordance with local guidelines described in appendix 5.  
 
In case of anemia and thrombocytopenia:  
• Transfusions with blood should be administered if hgb ≤ 6.0 mmol/L or if it is otherwise 
clinically indicated.  
• Transfusion with platelets is indicated if platelets <20/μl or if it is otherwise clinically 
indicated. 
• Radiated and filtered blood is to be administered from day -7 and 6 months ahead if 
indicated. 
 
Others: 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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36 
In some cases, e.g. localized bone pain, local radiotherapy can be prescribed.  
o Radiotherapy is preferably to be avoided within the 3 weeks period of hospitalization  
o Radiated areas cannot be used as parameters in the assessment of treatment response.  
o If possible, not all evaluable areas should be included in the radiated area. If all 
evaluable areas are treated, the patient is withdrawn from the study to ensure correct 
evaluation. 
End of treatment 
Normal end of treatment including follow-up 
Patients who finish the treatment course will be followed with clinical controls and diagnostic 
imaging before hospital discharge following TIL treatment, at 6 and 12 weeks after treatment 
and every 3 months hereafter. After 2 years the controls will change to every 6 months for a 
total of up to 5 years or until progression.  
 
A clinical examination, blood tests and diagnostic imaging will be performed in connection 
with every evaluation. At the first three evaluations the blood tests will include immunological 
parameters and a toxicity assessment (any late onset adverse events will be registered 
throughput the entire follow-up period). If tumor tissue is accessible, a tumor biopsy will be 
performed at the first evaluation and/or after progression. 
 
End of study is defined as 6 months after the last patients’ treatment or after progression. OS 
and PFS will subsequently be followed for up to 5 years. 
Follow-up schedule 
Evaluation, month 
1,5 
3 
6 
9 
12 
15 
18 
21 
24 
30 
36 
42 
48 
54 
60 
BP, P, PS 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
ECG 
x 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Toxicity assessment 
(CTC) 
x 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
Research blood tests 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Evaluation blood 
tests 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Ovarian specific 
blood tests 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Tumor evaluation 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Tumor biopsy* 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*If possible, a biopsy is also performed at the time of progression. 
 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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Research blood tests: See section “Blood samples for immunological monitoring” under the 
section “Immunological Monitoring”. 
 
Evaluation blood test: Hemoglobin, platelets, leukocytes with differential-count, creatinine, 
sodium, potassium, magnesium, phosphate, Ca-ion, ASAT, ALAT, bilirubin, alkaline 
phosphatase, albumin, amylase, TSH, LDH, CRP, INR, APTT, TSH, T4, cortisol, prolactin, 
Estradiol. 
 
Ovarian specific blood tests: CA-125. 
 
Tumor evaluation: CT, MR, PET-CT or a PET-MR scan can be used. A PET/CT scan is preferred. 
 
Tumor biopsy: A tumor biopsy is carried out at 6 weeks evaluation and in case of progression 
if it is accessible and safe to perform. This is further explained in the “Tumor biopsies” section. 
Early termination of treatment 
Several reasons can lead to early termination of the planned treatment course: 
 
Not possible to grow TILs: The patient cannot be offered treatment if it is not possible to grow 
TILs. 
 
Patients own wish: The treatment can be stopped at any time the patient wishes so.  
 
Medical decision: The treatment can be stopped because of medical conditions at any time the 
investigator finds it in the patients’ best interest. 
 
Other treatment: Patients will be excluded at any time a new treatment with an experimental 
drug or other systemic anticancer treatment is initiated after inclusion in this protocol. The 
patient will be excluded if systemic treatment with corticosteroids is initiated unless it is on 
vital indication an in agreement with the physician responsible for the protocol. 
 
Adverse events: Treatment is terminated if adverse events of a degree that makes completion 
of the study impossible do occur. 
 
If a patient is excluded before infusion of TILs a replacement subject will be found. They will 
be followed until end of adverse events caused by the treatment but will not be followed with 
subsequent controls. 
Subsequent treatment 
Patients that are excluded from the study can receive other treatment freely. If patients 
progress, they can receive other treatment. 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
38 
Production of TILs 
Acquisition of tumor tissue 
The patients will receive oral and written information as described elsewhere and a written 
consent will be obtained before surgery. A tumor biopsy will be performed after sufficient 
tissue material for pathological examination has been removed. The biopsy will be labeled 
with date and patient code, placed in a sterile container and transported to the GMP facilities 
54J7 or 54I6 at Herlev Hospital for further processing. See the IMPD for more details. 
If present, ascites fluid will be collected during surgery, if possible to do so without increased 
risk to the patient. Ascites fluid will be labeled and transported in the same way as the biopsy, 
Acquisition and examination of ascites fluid will be for research purposes only. See the section 
‘Immunological monitoring’ and ‘Additional research analyses’ for more details. 
Establishment of ”Young TIL” cultures 
T cells are expanded using a recently established method for ”Young TILs”37. The tumor mass 
will be isolated with a scalpel and cut into small 1-3 mm3 fragments. Fragments (typically 
from 24 to 72 fragments in total) will be placed separately in the wells of a 24 well/plate. A 
TIL culture is established from each fragment by passive migration of T cells from tumor 
tissue in the IL-2 based media. IL-2 belongs to the group of homeostatic cytokines which are 
characterized by having a positive effect on the activation of tumor specific T-cell and thereby 
tumor cell killing. T-cell density is kept at about 1x106 cells/ml growth media containing the 
immune stimulating cytokine IL-2. Cell cultures from the different fragments are pooled to a 
single cell culture. T-cell expansion is performed unselected to produce a polyclonal TIL 
repertoire targeted against multiple epitopes to potentially achieve more effective tumor cell 
destruction in vivo. The establishment of” Young TIL” cultures usually takes 2-4 weeks with a 
rate of success more than 90%. See the IMPD for more details. 
Rapid Expansion Protocol (REP) 
When the TIL cultures are expanded to approximately 5x107 cells they are either frozen for 
later use or transferred directly for further expansion by use of the Rapid Expansion Protocol 
(REP) in which TIL are grown with radiated (40 Gy) allogeneic PBMCs (peripheral blood 
mononuclear cells) that work as “feeder cells”, IL-2 and anti-CD3 antibody that activates the 
TILs. In this way it is possible to reach a large number of activated tumor specific T-cell with a 
high level of activity against tumor associated antigens (TAA) and tumor in 14 days. 
Ultimately, the autologous T cells are concentrated in a 400 ml infusion bag for intravenous 
infusion. See the IMPD for further details. 
Handling and transportation of the infusion product 
The infusion bag is labeled with patient ID and a patient specific transport schedule is filled 
out and both are then placed in a secure hatch. A trained physician controls the information 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
39 
on the infusion product and transport schedule, signs the latter and transports the infusion 
product to the patient. Before administration, the infusion product is controlled again by the 
treatment staff and matched to the ID of the patient through patient identification. 
Phenotype- and clonotype determination 
The prevalence of T-cell types (e.g. CD4+ and CD8+) as well as characterization of T-cell stages 
in both Young TILs and REP TILs will be determined by use of flow cytometric analysis. See 
the IMPD for more details. 
 
Adverse events, potential risks and precautions 
Adverse Events 
Adverse events (AE) are defined as any undesirable experience occurring to a subject during a 
clinical trial, whether considered related to the investigational treatment. All AEs reported 
spontaneously by the subject or observed by the investigator or his staff will be recorded and 
described in the patient chart and the electronic Case Report Form (eCRF). The severity and 
consequences will be recorded for each AE. The severity and relation to the study medication 
will be assessed in accordance with the guidelines described in the following. 
The investigator must attempt to identify all clinical and objective events from patients 
receiving treatment and determine their relation to the study medication. The investigator 
determines the relationship between AEs and treatment using the following guidelines: 
Grading of Adverse Events 
The severity of an AE refers to the intensity of the reaction. 
 
Events are graded using CTCAE version 4.0 (appendix 3)69. The following scale can be used if 
this grading is not applicable:  
 
1 = light 
2 = moderate 
3 = severe 
4 = life threatening 
5 = lethal 
 
Patients experiencing AEs will be monitored with the relevant clinical evaluations and 
laboratory investigations assessed by the attending physician. All AEs must be monitored 
until satisfactory restitution or stabilization. Results of the monitoring must be recorded in 
the patient chart and eCRF. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
40 
Abnormal laboratory tests are not to be recorded in the eCRF unless they have caused a 
clinical event, resulted in termination of the treatment or otherwise meet the criteria of a 
serious adverse event (see the following). 
Serious Adverse Events 
A serious adverse event (SAE) is to be reported to sponsor within 24 hours. It is defined as 
any medical occurrence or effect that, at any dose from the signed ICF and until 100 days after 
the last study drug dose: 
 
- 
results in death; 
- 
is life threatening (at the time of the event); 
- 
requires hospitalization or prolongation of existing patients’ hospitalization; 
- 
results in persistent or significant disability or incapacity; 
- 
leads to a congenital anomaly or birth defect; 
- 
is a significant medical event. An example of such an event include potential drug 
induced liver injury (DILI) 
- 
results in the transmission of an infectious agent 
- 
pregnancy must follow the same transmission timing and process used for SAEs.  
Guidelines for adverse events possible relation to the treatment 
0  
No relation– no temporal relation, other etiologies very likely the cause 
 
1  
Possible relation – less clear temporal relation, other etiologies likely the cause 
 
2  
Probably related – clear temporal relation with recovery at termination of treatment, and not 
reasonably explained by the patient’s known clinical condition 
 
3 
Related – clear temporal relation with laboratory confirmation or a positive retreatment test 
 
If the event is assessed as being caused by the investigational treatment it is classified as an 
adverse reaction (AR) or a serious adverse reaction (SAR). 
Adverse Reactions 
An adverse reaction (AR) can be expected if it is described in the IMPD or the relevant product 
summary, or unexpected if the grade or severity does not correlate with the product 
information in the before mentioned documents. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
41 
If the AR is unexpected, meets the criteria of a serious adverse reaction (SAR) and is found 
related to the investigational treatment it is classified as a suspected unexpected serious 
adverse reaction (SUSAR). The section describing known side effects and their frequencies in 
the product resumé (section 4.8) for Nivolumab, Ipilimumab, Cyclophosphamide and 
Fludarabine phosphate will be used as reference for classifying an AE as unexpected. Side 
effects from Relatlimab and the combination of Relatlimab-Nivolumab will be classified as 
either expected or unexpected using the investigator brochures (ref. INVESTIGATOR 
BROCHURE Relatlimab. BMS-986016 and INVESTIGATOR BROCHURE Relatlimab-Nivolumab 
FDC. BMS-986213)) as a reference. Side effects from the production of TIL will be classified as 
unexpected using the “Reference Safety Information” in the IMPD. 
Reporting of Adverse Events and Adverse Reactions 
Investigator reports SAEs, SARs and SUSARs to sponsor within 24 hours. Sponsor judges 
whether a SAR fulfills the criteria of being a SUSAR and reports SUSARs to the Danish 
Medicines Agency within 7 days if considered life threatening or fatal, and otherwise within 
15 days. Consequences for the study must be reported. Sponsor submits a yearly list that 
summarizes any SARs (including  SUSARs) as well as a report regarding the study patients’ 
safety to the Danish Medicines Agency and the Research Ethics Committee (investigator can 
report to the Research Ethics Committee as well). 
Sponsor submits a final report to the Danish Medicines Agency at the end of the study, with a 
description of all SAEs, SARs and SUSARs. 
SAEs, SARs and SUSARs related to the study drug Relatlimab will be reported to the 
biopharmaceutical company Bristol-Myers Squibb, which provides the drug for free in this 
protocol (for further information see the section “Economy”, p. 55) 
 
The following is not to be reported: 
- 
deaths caused by the malignant disease or progression 
- 
Planed hospitalization before ICF signature 
- 
hospitalizations or prolongation of current hospitalization caused by the malignant 
disease: 
o weight loss 
o fatigue 
o electrolyte derangement 
o pain management 
o anxiety 
o Social reaseon 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
42 
o palliative hospitalization 
o stay at hospice or terminal care 
o progression of the underlying disease 
- 
hospitalizations or prolongation of current hospitalization if the sole reason for 
hospitalization or prolongation is: 
o fluid treatment or treatment of nausea 
o blood transfusion 
o platelet transfusion 
o febrile leucopenia/neutropenia 
o administration of investigational procedures 
o placement of a permanent intravenous catheter 
These events are to be registered in the eCRF. 
Known Adverse Reactions 
Chemotherapy 
The adverse reactions to chemotherapy described in the following are all general adverse 
reactions seen when the drugs are given as the primary treatment for oncological and 
hematological diseases. 
In these cases, the treatment is often given over several series. In this study, the treatment 
will be given over a few days, why we expect a milder adverse reactions profile. 
Cyclophosphamide 
The dose limiting toxicities in patients’ receiving treatment with cyclophosphamide are 
myelosuppression (neutropenia, thrombocytopenia and anemia) and urotoxicity (cystitis, 
haematuria and hemorrhagic cystitis). Sufficient treatment with Mesna alongside rehydration 
markedly reduces the frequency and severity of the urotoxicity. 
Other common adverse reactions are alopecia, nausea and vomiting. 
Patients receiving treatment with Cyclophosphamide can experience the following adverse 
reactions described in the product resumé54 found at www.laegemiddelstyrelsen.dk. 
Fludarabine phosphate 
The adverse reactions are myelosuppression (neutropenia, thrombocytopenia and anemia), 
infection including pneumonia, coughing, fatigue, limpness, nausea, vomiting and diarrhea. 
Other common adverse reactions are shivering, edema, malaise, peripheral neuropathy, visual 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
43 
disturbances, anorexia, mucositis, stomatitis and rash. Severe opportunistic infections have 
occurred in patients receiving treatment with fludarabine phosphate. Deaths have been 
recorded as a cause of severe adverse reactions. 
Patients receiving treatment with fludarabine phosphate can experience the following 
adverse reactions described in the product resumé55 found at www.laegemiddelstyrelsen.dk. 
Checkpoint inhibition and irAEs 
The antibodies used in this study targets activated T cells in the immune system by blocking 3 
natural brakes in T-cell activation (CTLA-4, PD-1, and LAG-3) which allows a potential 
immunological reaction against tumor cells. Due to these mechanisms of action, immune 
related adverse events (irAE) can occur, which are often mild, but can aggravate and require 
treatment. 
Immune related adverse events include skin toxicities (erythema, exema or exanthema with 
generalized itching and urticarial, as well as possible worsening of existing autoimmune skin 
disorders (such as psoriasis and roseaca), gastrointestinal toxicities (diarrhea/colitis), 
endokrinopathias (hypophycitis, hypothyriosis, hyperthyriosis), hepatotoxicity, pulmonary 
toxicity (pneumonitis), ocular toxicity, myocarditis, neuropathia and immune related 
nephrotoxicity.   
Patients can experience irAEs from multiple organ systems and irAEs can also occur late 
during or after the course of treatment.  
See appendix 5 for details regarding handling of irAEs. 
Ipilimumab 
Patients receiving treatment with the CTLA-4 antibody Ipilimumab can experience adverse 
reactions as described above and in the product resumé62 found at www.ema.europa.eu. 
Nivolumab 
Patients receiving treatment with the PD-1 antibody Nivolumab can experience adverse 
reactions as described above and in the product resumé63 found at www.ema.europa.eu. 
Relatlimab 
Patients receiving treatment with the LAG-3 antibody Relatlimab can experience adverse 
reactions as described above and in the investigator brochure (ref. INVESTIGATOR BROCHURE 
Relatlimab-Nivolumab FDC. BMS-986213) 
TILs 
No SARs are expected due to TIL infusion. The patients might experience transient fever, 
shivering and mild dyspnea with a few cases of an observed light decrease in saturation.  
There is a theoretical risk of the development of allergic reactions/anaphylactic shock. This 
has not yet been observed according to literature.  
See the IMPD for more details on previous human exposure and anticipated risks. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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Risks and disadvantages regarding surgery and test sampling 
Risks associated with removing tumor tissue 
Prior to inclusion it will be assessed whether it is possible to remove some of the patients own 
tumor tissue in a minor operative procedure. Surgery will mainly be performed by physicians 
at the Gynecological Department at Herlev Hospital or by physicians from other specialties if 
necessary. The patient will not be able to participate in the study if no tumor tissue is 
available for removal or if removal will put the patient at a too large risk.  
Risks associated with biopsies 
There is a slight risk of infection and/or bleeding when performing a biopsy. Pain and 
bruising might also occur in the area. 
Risks associated with blood tests 
Pain and bruising can occur in the area. Blood testing will involve frequent hospital visits.  
Monitoring and precautions 
Hematological parameters 
Careful hematological monitoring of blood counts is indicated for all patients during 
treatment. Leukocyte count, platelet count, and hemoglobin values will be controlled at fixed 
intervals. Measurements will be made before start of chemotherapy and daily during 
treatment until neutrophile counts is > 500/μl and leukocyte count is > 1000/μl. 
Chemotherapy will not be given to patients with a leukocyte count < 500/μl and/or platelet 
number < 50.000/ μl before the start of chemotherapy. 
Kidney- and urine infections 
Any obstruction of the efferent urinary tracts, cystitis or infection will be resolved before start 
of treatment. Patients will be treated with Mesna and fluid therapy to decrease the frequency 
and severity of bladder toxicity. Treatment will be terminated if cystitis associated with 
micro- or macroscopic haematuria occurs during treatment with Cyclophosphamide. The 
patients’ urine will be controlled for the presence of microscopic haematuria before start of 
treatment with Cyclophosphamide. 
Cardiotoxicity 
Cardiotoxicity is especially seen when administrating high doses of Cyclophosphamide (120-
240 mg/kg body weight). An electrocardiogram will be performed before the start of 
treatment. Patients with known heart disease will not be included in the study. Necessary 
investigational procedures will be performed if the patient’s experiences symptoms from the 
cardiovascular system (e.g. chest pains, shortness of breath). Myocarditis has been described 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
45 
following combination therapy with Nivolumab and Relatlimab. If suspected CKMB, TPN, ECG 
and cardiology consult should be performed. 
Immune-related toxicity 
Is monitored and handled as described in appendix 5. 
Infertility 
Patients receiving chemotherapeutic treatment have a risk of affecting their fertility in the 
future. It is not known whether T-cell therapy increases the risk of cross reaction from T cells 
to normal ovarian tissue. 
Live vaccines 
Vaccination with live vaccines is to be avoided prior to- and immediately after treatment with 
chemotherapy because of the immunosuppressive effect. 
Interactions 
Cyclophosphamide inhibits cholinesterase activity which increases the effect of depolarizing 
muscle relaxants such as Suxamethoniumchloride. This can result in prolonged apnea when 
anesthetized. The anesthesiologist is to be informed if the patient has received treatment with 
Cyclophosphamide within 10 days before treatment with Suxamethoniumchloride. The 
combination should be avoided.  
 
The patient is to avoid eating grapefruit or drinking grapefruit juice since grapefruit contains 
a substance that can impair the activation of Cyclophosphamide and thereby its effect. 
 
Transfusion related graft-versus-host reactions have been observed in patients receiving 
treatment with fludarabine phosphate after transfusion with non-radiated/non-filtered blood. 
Patients requiring blood transfusion within ½ a year from treatment with fludarabine 
phosphate is therefore to receive only radiated and filtered blood. An agreement with the 
blood bank at Herlev Hospital has been made so that there will be ordered radiated blood 
only for these patients for ½ a year after treatment. All blood in the Capital Region is filtered. 
 
Effect evaluation, data processing and monitoring 
Effect evaluation 
Primary effect parameter 
Safety and toxicity:  
Registration of all AEs and unexpected events that occur in relation to the treatment will be 
done in accordance with the CTCAE v.4 criteria (appendix 3). 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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Secondary effect parameters 
Immune monitoring:  
Patients will be followed continually with in vitro analysis of the specific T-cell reactivity 
against tumor antigens to evaluate the immunological effect of treatment. The immunological 
response against tumor antigens before and after treatment will be compared. These analyses 
will be done on blood samples and tumor biopsies. 
Clinical evaluation:  
The clinical effect of treatment will be rated using the objective response rate in accordance 
with RECIST 1.1 and overall survival (OS) and progression-free survival (PFS) will be 
described. Furthermore, PERCIST70 and irRC71 will be used exploratively.  
Response Criteria 
RECIST 
Clinical evaluation will be done in accordance with RECIST 1.1 Guidelines72:  
 
Complete response (CR): All lesions disappear. 
Partial response (PR): Defined as a ≥ 30 % reduction in the sum of all measurable parameters 
longest diameter. 
Stabile disease (SD): Defined as a < 30 % reduction in the sum of all measurable parameters 
longest diameter or a < 20 % increase in the sum of all measurable parameters longest 
diameter. 
Progression (PD): Defined as a > 20 % increase in the sum of all measurable parameters 
longest diameter or the appearance of new lesions. 
 
Complete and partial response is to be verified by examination at a minimum of 4 weeks after 
documentation of the response at the earliest. 
Immunological monitoring 
Blood samples for immunological monitoring 
Blood samples with 100 ml heparinized blood for immunological monitoring and 9 ml blood 
in a gel glass for freezing of serum are taken: before operation (step 1) or before treatment 
with Ipilimumab (step 2), before start of treatment (at ”baseline”), before second treatment 
with Nivolumab/Relatlimab (day 12) and 6 and 12 weeks after T-cell infusion (see the 
examination plan and follow-up schedule). Blood samples will be taken for immunological 
monitoring every 3rd month at evaluation hereafter until the patient is withdrawn from the 
study. In addition, blood samples (15 ml blood sample) will be taken at day 0 before TIL 
infusion, 2 hours after TIL infusion, on day 1 and 2 during hospital admission and before the 
second treatment with Nivolumab/Relatlimab   


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
47 
A total of 500 ml of blood will be collected for research purposes in the period from time of 
surgery until the patient meet for the first evaluation after treatment. These blood samples 
are taken to assess the effect of treatment on the immune system for research purposes. The 
amount of blood taken during the course of the study does not exceed what the body itself is 
capable of producing between each test. Blood samples for research purposes will not be 
taken if the blood count is not acceptable (> 6 mmol/l). 
 
Mononuclear cells from the peripheral blood (PBMCs) are isolated using 
Lymfoprep/Leucosep density gradient technique. The mononuclear cells are washed and 
resuspended in a freezing media consisting of 90% heat inactivated humane AB serum and 10 
% DMSO. The cells are frozen at -150°C until analysis. A panel of relevant immunological 
assays for testing of antigen specific immune reactivity will be applied, including 
measurements of cytokine production (multimeric fluorescence coloring, ELISpot and ELISA), 
proliferative- and cytotoxic potential. 
Tumor biopsies 
Biopsies are sought taken from accessible tumor lesions or involved lymph nodes depending 
on localization and accessibility. Biopsies are preferred at evaluation 6 weeks after treatment 
and at progression if possible (see the examination plan and follow-up schedule).  
Biopsies will be performed guided by ultrasound and under sterile conditions by the 
Ultrasound Department, Herlev Hospital, if the involved areas are not directly accessible. The 
procedure will be performed in the outpatient clinic and the size will be approximately 5 mm3. 
 
Biopsies will be examined for the concentration of immune cells. Furthermore, TILs will be 
isolated from the lesions and analyzed for clonotype and specificity. 
Specimens for Future Biomedical Research 
Only leftovers from analyses specifically described in the protocol will be transferred to the 
biobank for future biomedical research, as described on page 53 “Research biobank including 
Future Biomedical Research Biobank”. There will be no extra samples to be obtained during 
this study. These specimens may be used to study various causes for how subjects may 
respond to the immunotherapy. These specimens will be stored to provide a resource for 
future trials conducted by CCIT-DK focused on the study of biomarkers responsible for how 
immunotherapy works, other pathways immunotherapy may interact with, or other aspects 
of disease. 
Additional research analyses 
Isolation of tumor cells 
Tumor cells are isolated from the tumor fragments or ascites fluid using enzymatic processing 
or seeding of cells from the tumor fragments or ascites fluid and are then frozen for later use 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
48 
in determining T-cell anti-tumor activity. This exploratory analysis will not influence any 
prior or subsequent surgical decisions or medical treatment of the patients enrolled. 
Tumor-associated lymphocytes (TALs) and chemokines 
Lymphocytes found in ascites will be isolated with gradient centrifugation. A portion will be 
frozen and stored for additional immunological analyses, while a portion will be cultured 
immediately by using the exact methods used with TILs. Remaining ascites fluid will be 
centrifuged, and supernatants will be collected and frozen to study which cytokines present in 
the fluids can influence the activity of TALs. 
Cytokine Release Assay 
TIL cultures is screened for activity against TAA and autologous tumor by determining their 
production of the activating cytokines (INF-γ + TNF-α). The production of the activating 
cytokines is quantified by use of ELISpot technique and intracellular flow cytometric analysis. 
Gene-based arrays 
The aim of the planned gene analyses is to learn more about; 
1. Differences among patients in expression level of a panel of relevant normal genes in 
the tumor microenvironment which could influence the chance of benefit from 
treatment 
2. Expression of tumor/patient specific mutated genes which could influence the chance 
of benefit from treatment 
Analysis for identifying specific tumor gene expression signatures73 and mutations in the 
tumor cells, leading to patient-specific neo-antigens derived from these mutations74, will be 
performed.  
These analyses will contribute to the identification of patients that are most likely to respond 
to treatment as well as contribute to the optimization of T-cell therapy based on the selection 
of neo-antigen specific T cells. These analyses will not benefit the patients included in this 
study but might benefit future patients. 
Methods: 
Tumor tissue gene expression profiles will be analyzed on FFPE tumor tissue. Using Illumina 
targeted RNA sequencing applicable to degraded RNA we will retrieve gene expression data 
on approximately 500 cancer/immunity related genes. 
Next Generation Sequencing (NGS) of tumors and normal cells of the individual patient will be 
used to obtain information on tumor-specific mutations. Gene sequencing will be performed 
on tumor cells (tumor gene profile) and leukocytes (normal gene profile). Tumor specific gene 
expression (neo antigens) will be performed by subtracting the two gene profiles from each 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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other. Data regarding potential disease-causing genes will be generated as a byproduct of this 
analysis, but this data will not be used or explored further upon, since only data regarding 
tumor specific genes will be processed more closely. Therefore, we do not expect to obtain 
explicit knowledge regarding disease causing genes. Furthermore, ‘Targeted sequencing’ on a 
limited number of defined genes will be performed on the tumor tissue to obtain a ‘immune 
profile’ to determine which genes- and consequently which proteins- are expressed in the 
tumor tissue. Data will be handled according to national laws.  
Patients will have the option of being referred to comprehensive genetic counseling prior to 
giving their consent. If by chance these analyses will discover known mutations with potential 
significant impact on patient’s health, the case will be discussed with the Clinical Genetics 
Department, Rigshospitalet, unless the patient has chosen not to be informed as stated in the 
patient information. The following criteria will determine if further actions are indicated. 
• there is a reasonable degree of possibility that a genetic disposition is present, 
• there is solid documentation of a link between the genetic disposition and the 
development of disease, 
• the tests used to determine the genetic disposition are well established, 
• the disease in question can be prevented or treated, and 
• the link between the genetic disposition and the development of disease has 
considerable importance for the patient. 
If indicated, the patient will be contacted and asked for permission to referral to such 
Department for additional information and testing. 
In case that a patient dies/is dead, or do not want information regarding significant health 
issues, a medical assessment, using the 5 above mentioned criteria, will determine whether 
relatives to the patient is to be informed, in accordance with Danish law (sundhedslovens § 
43, stk. 2, nr.2.). 
Cell lines and cell cultures  
Establishment of autologous short term in vitro cultured tumor cell lines (as in ref. 37and75, or 
equivalent methods) and lymphocyte cultures (as in ref. 76or equivalent methods) will be 
attempted using these samples. These cultures will be primarily used to perform correlates of 
tumor-recognition in vitro (as in ref.76) with immune parameters and clinical outcomes 
following therapy on an exploratory basis. The informed consent sheet will contain 
information about the possibility to generate cell lines and cell cultures, that under 
pseudonymized or anonymized form can be used for health research purposes in multiple 
countries, according to the Danish National Ethics Committee guidelines 


 
 
 
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Statistics  
The study is non-blinded and non-comparative. Descriptive statistics will be used to estimate 
the immunological- and clinical response rate. Descriptive statistics will also be used to sum 
up the duration of response and patient characteristics. The study is designed as a phase I/ 
phase II study and the primary aim is to determine safety and toxicity to the treatment. A 
required sample size that allows determination of primary- as well as secondary- and tertiary 
end points can therefore not formally be calculated.  
Data registration and -analysis 
The patients are given a patient number at inclusion in the study to secure patient anonymity. 
Clinical personnel and selected persons in the laboratory will have access to patient 
information to secure proper treatment. 
The principal investigator has access to patient charts to obtain information regarding the 
cancer disease to be able to compare this information with the project specific analysis 
performed on cancer tissue and blood tests.  
 
All relevant data is registered in the eCRF (electronic Case Report Form) developed in 
cooperation with the clinical research unit, KFE. The principal investigator has the 
responsibility of manufacturing the eCRF and subsequent recording of data when the 
investigational treatment is finished and eCRFs are reported to sponsor. Sponsor and 
principal investigator are responsible for data analysis on all included patients. Patient data 
and eCRF will be stored for 5 years in accordance with current guidelines for storage of 
personal information. Drafting of a final report will be conducted in collaboration between the 
members of the study group. 
 
Analyses will include: 
• Toxicity (CTC registration) 
• Immunological response  
• Clinical effect parameters 
 
Personal data and remaining tests will be coded at the end of the study. All patients receiving 
T-cell therapy will be included in the statistical analyses. Patients excluded for one of the 
following reasons will not be included in the statistical analyses: 
• Not enough tissue to produce tumor TIL 
• Unable to produce TILs in the laboratory  
• Withdrawal of consent 
• Started other treatment 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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End of study report 
Sponsor will inform the Danish Medicines Agency and Research Ethics Committee within 90 
days of study completion. The definition of study completion is 6 months after the last 
patients’ treatment or after exclusion due to progression whereafter the patient will be 
transferred to standard care/follow up. In addition, patients will be followed for PFS and OS 
for up to 5 years. If the study is prematurely terminated, the Danish Medicines Agency and the 
Research Ethics Committee will be informed of the reason(s) for the termination. As soon as 
possible and no later than a year after the trial has ended, the trial results must be entered in 
EudraCT. Subsequently, data will be published on www.clinicaltrialsregister.eu. Sponsor will 
submit a final study report to the Research Ethics Committee with the study results including 
publications based on the study within a year of study completion. 
Amendments 
An application to the Danish Medicines Agency and the Research Ethics Committee will be 
made if substantial changes to the protocol are to be made. These can be implemented when 
approved. Changes to the protocol are considered substantial in accordance with ‘Vejledning 
om anmeldelse, indberetningspligt m.v. (sundhedsvidenskabelige forskningsprojekter)’, 
paragraph 6.0. on www.dnvk.dk and the schedule ’Skema om ændringer (ammendmendts) til 
kliniske forsøg’ on sundhedsstyrelsen.dk.  
 
Ethical aspects 
Recruitment of study patients and informed consent 
Eligible patients with advanced OC will be referred from the Oncological Department at 
Herlev Hospital or other Oncological centers in Denmark treating patients with these cancers. 
Information about the study will be given at scientific meetings for physicians at the relevant 
departments. 
Referral of patients is to be made to the uro-gynecological (UG team) visitation office, 
Department of Oncology, Herlev Hospital. 
Contact to eligible patients will be done in accordance with the Danish Health Act, § 46, 
paragraph 3. 
 
All patients will be informed about the study according to appendix 1. 
Insurance 
Patients’ participation in the study will be covered by “Patienterstatningen”. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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Ethical aspects 
Despite advances in the chemotherapeutic treatment of patients with relapse of OC the 
prognosis is still poor and many of the women are still young and in a good general condition, 
why the need for new effective treatments is great11. The purpose of this study is to improve 
survival for patients with relapse of OC. Based on the current knowledge and the lack of 
treatment options, the risks and downsides associated with this study are assessed to be 
acceptable.  
Participation is voluntary and is preceded by oral and written information and the treatment 
will be stopped in case of unacceptable adverse reactions or if the patient wishes so at any 
time. 
The patient will receive treatment after the current guidelines at the department if she does 
not wish treatment according to the protocol. The study is therefore assessed as ethical 
proper.  
 
The study follows the Helsinki agreement and the principal investigator is to obtain 
permission from the Danish Medicines Agency and the Research Ethics Committee. 
 
For future biomedical research, risks to the subject have been minimized. Risks include those 
associated with venipuncture to obtain the whole blood specimen. This specimen will be 
obtained at the time of routine blood specimens drawn in the main trial. 
Research biobank, including Future Biomedical Research Biobank 
In connection with the current study, blood samples (110 ml/blood sample) and tumor 
biopsies will be stored in coded form at -150 °C in a research biobank at the CCIT-DK in room 
PA102 until all analysis concerning the study is performed. Samples that are not used in the 
study will be transferred to a biobank at CCIT-DK for future biomedical research as described 
below (p. 53). 
 
Analyses will be primarily performed at CCIT-DK. However, some special analyses on tumor 
tissue or blood test samples may be performed at a partner institution after establishing a 
specific written agreement. The Research Ethics Committee will be informed if any such 
agreement is to be established. All patient relevant information will be sent in a coded way. In 
case the patient’s cells will be sent to partner institutions located abroad, these will be 
handled according to national laws and regulations of the specific nation where these have 
been sent. In such a case, all patient information will be communicated in coded form. A 
written data processing agreement will be signed between the data controllers and the data 
processors abroad. If any gene analysis are to be performed abroad, the data processing 
agreement will include the 5 criteria (p. 50) regarding the discovery of known mutations with 
potential significant impact on patient’s health, as well as the requirement, that the partner 
abroad reports back to the primary project managers in Denmark so that relevant actions can 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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be taken as described on p. 50. If data processing is to be performed in a third-country, 
permission will be applied for at the Danish Data Protection Agency, or one of the agencies 
standard contracts will be used. 
 
Samples that are not used in the study will be transferred to a biobank at CCIT-DK for future 
biomedical research for up to 15 years and is accepted by the Danish Data Protection Agency. 
If additional studies in other research areas are to be performed on any samples obtained 
during the conduct of this study/samples that are transferred to a new biobank, a request to 
do so will be submitted to the Research Ethics Committee as per the ‘Act of Processing of 
Personal Data’ §§ 5 and § 10, paragraph 2 and 3. After 15 years, any remaining tissue samples 
will be disposed of according to the local guidelines for destruction of biohazardous waste. 
If a patient withdraws his/her informed consent, all biological material is to be destroyed if 
the patient wishes so.  
Reporting to the Research Ethics Committee 
The study is reported to the Research Ethics Committee. The law dealing with personal data 
will be respected. Information concerning study patients is protected according to the law 
concerning personal data and the Act on Research Ethics Review of Health Research Projects.  
 
Administrative aspects and publication 
Patient identification 
Patients will be given a number after enrollment in the study. This number will be used to 
identify the patient and will be used in the Case Report Forms (eCRFs). Data and patient 
materials will be treated in code and confidentially. The number is given sequentially after 
enrollment in the study and is not based on the patients’ initials or birthday.   
Publications 
The primary project managers are Inge Marie Svane and Tine Juuk Monberg. The members of 
the project group have joint copyright of the obtained results, given that the Vancouver rules 
are met. Positive results, inconclusive results as well as negative results will be published in 
international journals. Manuscripts will be produced in cooperation with the project 
managers and other members of the study group, with the project managers as primarily 
responsible for the preparation. The project managers are co-authors on publications made 
based on this study. Author succession will be determined based on the individual 
contributions. Use of study data, oral as well as written, at congresses, teaching or the likes, is 
only to take place if accepted by the project managers. The project managers are obliged to 
publish results from the study and are naturally interested in the propagation and 
implementation of the results in clinic. Publications are expected to be completed in 2024. 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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Economy 
The study is initiated by CCIT-DK in cooperation with the Department of Oncology, Herlev 
Hospital, and is partially financed by these two departments. Additional expences will be 
covered from a research grant of 1,9 mio. DKK from the private funding organization OvaCure.  
In addition, operational- and salary funding is applied for ongoing.  
 
A contract has been concluded between CCIT-DK and the biopharmaceutical company Bristol-
Myers Squibb (BMS). This contract states that BMS will provide the study drug Relatlimab 
produced by BMS for free, and the agreement has been approved by the Hospital Director at 
Herlev Hospital and the lawyers of the Capital Region of Denmark.  The role of BMS in this 
study is therefore limited to the supply of Relatlimab, which is a medical drug not yet 
marketed and therefore exclusively available from BMS. The ownership of the data belongs to 
the project group at CCIT-DK, but CCIT-DK is committed to report pseudo anonymized SAEs, 
SARs and SUSARs related to the study drug Relatlimab to  BMS (see “Reporting of Adverse 
Events and Adverse Reactions”, p. 42) 
 
The Research Ethics Committees will be informed if/when new funds support is obtained. 
None of the physicians involved in the study have any economic interests in the study and 
there is no potential economic gain for the departments or of personnel in connection with 
the study. There are no economic attachments between the financial supporters and the 
project managers. 
The study is part of the principal investigator Tine Juul Monberg’s PhD project. 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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Reference list 
1. 
Pedersen, M. et al. Adoptive cell therapy with tumor-infiltrating lymphocytes in patients with 
metastatic ovarian cancer: a pilot study. Oncoimmunology 7, (2018). 
2. 
Eskander, T. C. L. and R. N. Immune Checkpoint Inhibition: Therapeutic Implications in 
Epithelial Ovarian Cancer. Recent Pat. Anticancer. Drug Discov. 10, 133–144 (2015). 
3. 
Andersen, R. et al. Adoptive cell therapy with tumor infiltrating lymphocytes and 
intermediate dose IL-2 for metastatic melanoma. J. Immunother. Cancer 2, P1 (2014). 
4. 
Weber, J. S., Kähler, K. C. & Hauschild, A. Management of immune-related adverse events 
and kinetics of response with ipilimumab. J. Clin. Oncol. 30, 2691–2697 (2012). 
5. 
Hodi, F. S. et al. Biologic activity of cytotoxic T lymphocyte-associated antigen 4 antibody 
blockade in previously vaccinated metastatic melanoma and ovarian carcinoma patients. 
Pnas 100, 4712–7 (2003). 
6. 
Hodi, F. S. et al. Immunologic and clinical effects of antibody blockade of cytotoxic T 
lymphocyte-associated antigen 4 in previously vaccinated cancer patients. Proc. Natl. Acad. 
Sci. U. S. A. 105, 3005–3010 (2008). 
7. 
Weber, J. S., Yang, J. C., Atkins, M. B. & Disis, M. L. Toxicities of immunotherapy for the 
practitioner. J. Clin. Oncol. 33, 2092–2099 (2015). 
8. 
Hamanishi, J., Mandai, M., Ikeda, T., Minami, M. & Kawaguchi, A. Safety and Antitumor 
Activity of Anti – PD-1 Antibody , Nivolumab , in Patients With Platinum-Resistant Ovarian 
Cancer. 33, 11–13 (2016). 
9. 
Dansk Gynækologisk Cancer Gruppe. Retningslinier for visitation , diagnostik og kontrol af 
epitelial ovarie- , tuba- og primær peritonealcancer samt borderline tumorer. 5. udgave. Dgcg 
1–10 (2016). 
10. 
DGCG. 5. Ikke-kirurgisk behandling af epiteliale tumorer. 1–25 (2016). 
11. 
Coleman, R. L., Monk, B. J., Sood, A. K. & Herzog, T. J. Latest research and treatment of 
advanced-stage epithelial ovarian cancer. Nat. Rev. Clin. Oncol. 10, 211–24 (2013). 
12. 
Klebanoff, C. a, Khong, H. T., Antony, P. a, Palmer, D. C. & Restifo, N. P. Sinks, 
suppressors and antigen presenters: how lymphodepletion enhances T cell-mediated tumor 
immunotherapy. Trends Immunol. 26, 111–7 (2005). 
13. 
Overwijk, W. W. Breaking tolerance in cancer immunotherapy: time to ACT. Curr. Opin. 
Immunol. 17, 187–94 (2005). 
14. 
Dudley, M. E. et al. A phase I study of nonmyeloablative chemotherapy and adoptive 
transfer of autologous tumor antigen-specific T lymphocytes in patients with metastatic 
melanoma. J. Immunother. 25, 243–51 (2002). 
15. 
Reichert, T. E., Strauss, L., Wagner, E. M., Gooding, W. & Whiteside, T. L. Signaling 
Abnormalities , Apoptosis , and Reduced Proliferation of Circulating and Tumor-infiltrating 
Lymphocytes in Patients with Oral Carcinoma. Clin. cancer Res. 3137–3145 (2002). 
16. 
Yamamoto, T., Kimura, T., Ueta, E., Tatemoto, Y. & Osaki, T. Characteristic Cytokine 
Generation Patterns in Cancer Cells and Infiltrating Lymphocytes in Oral Squamous Cell 
Carcinomas and the Influence of Chemoradiation Combined with Immunotherapy on These 
Patterns. Oncology 64, 407–415 (2003). 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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17. 
Hald, J., Rasmussen, N. & Claesson, M. H. Tumour-infiltrating lymphocytes mediate lysis of 
autologous squamous cell carcinomas of the head and neck. Cancer Immunol. Immunother. 
41, 243–50 (1995). 
18. 
Dudley, M. E. et al. Adoptive transfer of cloned melanoma-reactive T lymphocytes for the 
treatment of patients with metastatic melanoma. J. Immunother. 24, 363–73 (2001). 
19. 
Rosenberg, S. a et al. Durable complete responses in heavily pretreated patients with 
metastatic melanoma using T-cell transfer immunotherapy. Clin. cancer Res. 17, 4550–7 
(2011). 
20. 
Ellebaek, E. et al. Adoptive cell therapy with autologous tumor infiltrating lymphocytes and 
low-dose Interleukin-2 in metastatic melanoma patients. J. Transl. Med. 10, 169 (2012). 
21. 
Pilon-Thomas, S. et al. Efficacy of adoptive cell transfer of tumor-infiltrating lymphocytes 
after lymphopenia induction for metastatic melanoma. J. Immunother. 35, 615–20 (2012). 
22. 
Radvanyi, L. G. et al. Specific lymphocyte subsets predict response to adoptive cell therapy 
using expanded autologous tumor-infiltrating lymphocytes in metastatic melanoma patients. 
Clin. cancer Res. 18, 6758–6770 (2012). 
23. 
Besser, M. J. et al. Adoptive Transfer of Tumor Infiltrating Lymphocytes in Metastatic 
Melanoma Patients: Intent-to-Treat Analysis and Efficacy after Failure to Prior 
Immunotherapies. Clin. cancer Res. (2013) doi:10.1158/1078-0432.CCR-13-0380. 
24. 
Dudley, M. E. et al. Randomized selection design trial evaluating CD8+-enriched versus 
unselected tumor-infiltrating lymphocytes for adoptive cell therapy for patients with 
melanoma. J. Clin. Oncol. 31, 2152–9 (2013). 
25. 
Rosenberg, S. A., Spiess, P. & Lafreniere, R. A new approach to the adoptive 
immunotherapy of cancer with tumor-infiltrating lymphocytes. Science (80-. ). 233, 1318–21 
(1986). 
26. 
Besser, M. J. et al. Clinical responses in a phase II study using adoptive transfer of short-
term cultured tumor infiltration lymphocytes in metastatic melanoma patients. Clin. cancer 
Res. 16, 2646–55 (2010). 
27. 
Dudley, M. E. et al. Adoptive cell therapy for patients with metastatic melanoma: evaluation 
of intensive myeloablative chemoradiation preparative regimens. J. Clin. Oncol.  26, 5233–9 
(2008). 
28. 
Freedman, R. S. et al. Intraperitoneal adoptive immunotherapy of ovarian carcinoma with 
tumor-infiltrating lymphocytes and low-dose recombinant interleukin-2: a pilot trial. J. 
Immunother. Emphasis Tumor Immunol. 16, 198–210 (1994). 
29. 
Aoki, Y. et al. Use of Adoptive Transfer of Tumor-infiltrating Lymphocytes Alone or in 
Combination with Cisplatin-containing Chemotherapy in Patients with Epithelial Ovarian 
Cancer. 1934–1939 (1991). 
30. 
Fujita, K. et al. Prolonged disease-free period in patients with advanced epithelial ovarian 
cancer after adoptive transfer of tumor-infiltrating lymphocytes. Clin. Cancer Res. 1, 501–7 
(1995). 
31. 
Kershaw, M. H. et al. A phase I study on adoptive immunotherapy using gene-modified T 
cells for ovarian cancer. Clin. Cancer Res. 12, 6106–15 (2006). 
32. 
Topalian, S., Drake, C. & Pardoll, D. Targeting the PD-1/B7-H1 (PD-L1) pathway to 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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activate anti-tumor immunity. Curr. Opin. Immunol. 24, 207–212 (2012). 
33. 
Sharma, P. & Allison, J. P. The future of immune checkpoint therapy. Science 348, 56–61 
(2015). 
34. 
Postow, M. A., Callahan, M. K. & Wolchok, J. D. Immune Checkpoint Blockade in Cancer 
Therapy. J. Clin. Oncol. 33, JCO.2014.59.4358- (2015). 
35. 
Dong, H. et al. Tumor-associated B7-H1 promotes T-cell apoptosis: a potential mechanism 
of immune evasion. Nat. Med. 8, 793–800 (2002). 
36. 
Brahmer, J. R. et al. Safety and activity of anti-PD-L1 antibody in patients with advanced 
cancer. N. Engl. J. Med. 366, 2455–65 (2012). 
37. 
Donia, M. et al. Characterization and comparison of ‘standard’ and ‘young’ tumour-
infiltrating lymphocytes for adoptive cell therapy at a danish translational research 
institution. Scand. J. Immunol. 75, 157–167 (2012). 
38. 
Andersen, R. et al. Long-Lasting Complete Responses in Patients with Metastatic Melanoma 
after Adoptive Cell Therapy with Tumor-In fi ltrating Lymphocytes and an Attenuated IL2 
Regimen. Clin. Cancer Res. 1–12 (2016) doi:10.1158/1078-0432.CCR-15-1879. 
39. 
Donia, M. et al. Methods to Improve Adoptive T-Cell Therapy for Melanoma: IFN-γ 
Enhances Anticancer Responses of Cell Products for Infusion. J. Invest. Dermatol. (2012) 
doi:10.1038/jid.2012.336. 
40. 
Tran, K. Q. et al. Minimally cultured tumor-infiltrating lymphocytes display optimal 
characteristics for adoptive cell therapy. J. Immunother. 31, 742–51 (2008). 
41. 
Besser, M. J. et al. Minimally cultured or selected autologous tumor-infiltrating lymphocytes 
after a lympho-depleting chemotherapy regimen in metastatic melanoma patients. J. 
Immunother. 32, 415–23 (2009). 
42. 
Dudley, M. E. et al. CD8+ enriched ‘young’ tumor infiltrating lymphocytes can mediate 
regression of metastatic melanoma. Clin. cancer Res. 16, 6122–31 (2010). 
43. 
Goff, S. L. et al. Tumor infiltrating lymphocyte therapy for metastatic melanoma: analysis of 
tumors resected for TIL. J. Immunother. 33, 840–7 (2010). 
44. 
Joseph, R. W. et al. Impact of clinical and pathologic features on tumor-infiltrating 
lymphocyte expansion from surgically excised melanoma metastases for adoptive T-cell 
therapy. Clin. cancer Res. 17, 4882–91 (2011). 
45. 
Somerville, R. P. T., Devillier, L., Parkhurst, M. R., Rosenberg, S. a & Dudley, M. E. 
Clinical scale rapid expansion of lymphocytes for adoptive cell transfer therapy in the 
WAVE® bioreactor. J. Transl. Med. 10, 69 (2012). 
46. 
Turcotte, S. et al. Tumor-reactive CD8+ T cells in metastatic gastrointestinal cancer 
refractory to chemotherapy. Clin. Cancer Res. 20, 331–43 (2014). 
47. 
Mahmoud, S. M. a et al. Tumor-infiltrating CD8+ lymphocytes predict clinical outcome in 
breast cancer. J. Clin. Oncol. 29, 1949–55 (2011). 
48. 
Junker, N. et al. Bimodal ex vivo expansion of T cells from patients with head and neck 
squamous cell carcinoma: a prerequisite for adoptive cell transfer. Cytotherapy 13, 822–34 
(2011). 
49. 
Markel, G. et al. Preclinical evaluation of adoptive cell therapy for patients with metastatic 


 
 
 
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with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
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renal cell carcinoma. Anticancer Res. 29, 145–54 (2009). 
50. 
Robbins, P. F. et al. Tumor regression in patients with metastatic synovial cell sarcoma and 
melanoma using genetically engineered lymphocytes reactive with NY-ESO-1. J. Clin. 
Oncol. 29, 917–24 (2011). 
51. 
Zhang, L. et al. Intratumoral T cells, recurrence, and survival in epithelial ovarian cancer. N. 
Engl. J. Med. 348, 203–13 (2003). 
52. 
Gattinoni, L. et al. Removal of homeostatic cytokine sinks by lymphodepletion enhances the 
efficacy of adoptively transferred tumor-specific CD8+ T cells. J. Exp. Med. 202, 907–12 
(2005). 
53. 
Antony, P. a et al. CD8+ T cell immunity against a tumor/self-antigen is augmented by 
CD4+ T helper cells and hindered by naturally occurring T regulatory cells. J. Immunol. 174, 
2591–601 (2005). 
54. 
Lægemiddelstyrelsen. Produktresumé Cyclophosphamid. (2016). 
55. 
Sundhedsstyrelsen. Produktresumé Fludarabinphosphat. (2013). 
56. 
Huang, R. R. et al. CTLA4 blockade induces frequent tumor infiltration by activated 
lymphocytes regardless of clinical responses in humans. Clin. Cancer Res. 17, 4101–4109 
(2011). 
57. 
Bjoern, J. et al. Immunological correlates of treatment and response in stage IV malignant 
melanoma patients treated with Ipilimumab. Oncoimmunology 5, e1100788 (2016). 
58. 
Kvistborg, P. et al. Anti-CTLA-4 therapy broadens the melanoma-reactive CD8+ T cell 
response. Sci Transl Med 6, 254ra128 (2014). 
59. 
Hamanishi, J. et al. Programmed cell death 1 ligand 1 and tumor- infiltrating CD8 ؉ T 
lymphocytes are prognostic factors of human ovarian cancer. 104, (2007). 
60. 
Darb-esfahani, S. et al. Prognostic impact of programmed cell death-1 ( PD-1 ) and PD-
ligand 1 ( PD-L1 ) expression in cancer cells and tumor- infiltrating lymphocytes in ovarian 
high grade serous carcinoma. 1, (2015). 
61. 
Webb, J. R., Milne, K. & Nelson, B. H. PD-1 and CD103 Are Widely Coexpressed on 
Prognostically Favorable Intraepithelial CD8 T Cells in Human Ovarian Cancer. Cancer 
Immunol. Res. 3, 926–35 (2015). 
62. 
EMA - European Medicines Agency. Produktresume Ipilimumab. 
63. 
EMA - European Medicines Agency. Produktresume Nivolumab. 
64. 
Stevanović, S. et al. Complete regression of metastatic cervical cancer after treatment with 
human papillomavirus-targeted tumor-infiltrating T cells. J. Clin. Oncol. 33, 1543–50 
(2015). 
65. 
Dudley, M. E. et al. Adoptive cell transfer therapy following non-myeloablative but 
lymphodepleting chemotherapy for the treatment of patients with refractory metastatic 
melanoma. J. Clin. Oncol. 23, 2346–2357 (2005). 
66. 
Robbins, P. F. et al. A pilot trial using lymphocytes genetically engineered with an NY-ESO-
1-reactive T cell receptor: Long term follow up and correlates with response. Clin. Cancer 
Res. 21, 1019–1027 (2015). 
67. 
Secondino, S. et al. T-cell therapy for EBV-associated nasopharyngeal carcinoma: 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
59 
Preparative lymphodepleting chemotherapy does not improve clinical results. Ann. Oncol. 
23, 435–441 (2012). 
68. 
European Medicines Agency. EPAR summary Neulasta. (2011). 
69. 
National Institute of Cancer. Common Terminology Criteria for Adverse Events ( CTCAE ). 
NIH Publ. 2009, 0–71 (2010). 
70. 
Wahl, R. L., Jacene, H., Kasamon, Y. & Lodge, M. A. From RECIST to PERCIST: Evolving 
Considerations for PET response criteria in solid tumors. J. Nucl. Med. 50 Suppl 1, 122S–
50S (2009). 
71. 
Wolchok, J. D. et al. Guidelines for the evaluation of immune therapy activity in solid 
tumors: Immune-related response criteria. Clin. Cancer Res. 15, 7412–7420 (2009). 
72. 
Eisenhauer, E. A. et al. New response evaluation criteria in solid tumours: Revised RECIST 
guideline (version 1.1). Eur. J. Cancer 45, 228–247 (2009). 
73. 
Jönsson, G. et al. Gene expression profiling-based identification of molecular subtypes in 
stage IV melanomas with different clinical outcome. Clin. cancer Res. 16, 3356–67 (2010). 
74. 
Robbins, P. F. et al. Mining exomic sequencing data to identify mutated antigens recognized 
by adoptively transferred tumor-reactive T cells. Nat. Med. 19, 747–52 (2013). 
75. 
Dijkstra KK, Cattaneo CM, W. F. et al. Generation of Tumor-Reactive T Cells by Co-culture 
of Peripheral Blood Lymphocytes and Tumor Organoids. Cell 174, 1586-1598 e1512 (2018). 
76. 
Andersen R, Borch TH, D. A. et al. T cells isolated from patients with checkpoint inhibitor 
resistant-melanoma are functional and can mediate tumor regression. Ann Oncol (2018). 
 
 
 
 
 
 
 


 
 
 
Protocol GY2028: T cell Therapy in Combination with Nivolumab, Relatlimab and Ipilimumab for Patients 
with Advanced Ovarian-, Fallopian Tube- and Primary Peritoneal Cancer. Version 3.3 Date: 02-11-2020. 
EudraCT nr. 2020-002738-34. 
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Appendix  
Management of IR myocarditis