Conditions: Non-Small Cell Lung Cancer Metastatic Non-small Cell Lung Cancer Squamous Cell Carcinoma Advanced NSCLC Adenosquamous Carcinoma Adenocarcinomas
Keywords: Stage IV NSCLC Recurrent TIL Tumor-infiltrating Lymphocyte Therapy (TIL)
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 20
Healthy volunteers: no

Brief summary:
Investigators plan to study the safety, side effects, and benefits of tumor-infiltrating lymphocytes (TILs) when they are given with the drug nivolumab. Nivolumab is a type of immunotherapy - a drug that is used to boost the ability of the immune system to fight cancer, infection, and other diseases.

Detailed description:
In this study, these special immune T-cells will be taken from a sample of the participant's tumor tissue that will be surgically removed. Certain parts of these cells will be multiplied, or grown, in the laboratory, using the drug interleukin-2 (IL-2) during part of the process. They will then be given back to the participant by an infusion in their veins. These cells are called tumor- infiltrating lymphocytes (TILs). The use of TILs involves a combination of drugs, including the following:

* Fludarabine and cyclophosphamide - two types of chemotherapy drugs. These drugs will be used for what is called lymphodepletion. The purpose of lymphodepletion in this study is to temporarily reduce the number of normal lymphocytes circulating in the participant's body before they are given the TILs that were grown in the lab. This is so that there will be more "space" for the lymphocytes (TILs) that will be infused in their veins.
* Interleukin-2 (IL-2) - a drug used to help the body's response to treatment on the immune system. A high dose regimen of IL-2 will be given after the participant receives the infusion of the T-cells.

Arms:
arm 1: Tumor-infiltrating Lymphocyte Therapy (TIL) + Nivolumab Treatment Plan: Tumor harvest, Tumor-infiltrating Lymphocytes growth, 4 cycles of nivolumab, cytoreductive chemotherapy with cyclophosphamide and fludarabine, TIL infusion, Interleukin-2 treatment.

Interventions: intervention 1: Tumor-infiltrating Lymphocytes (TIL) intervention 2: Nivolumab intervention 3: Cyclophosphamide intervention 4: Fludarabine intervention 5: Tumor-infiltrating Lymphocyte Therapy intervention 6: Interleukin-2 (IL2)
Intervention descriptions: intervention 1: Tumor harvest for TIL growth in the lab: A sample of the participant's tumor will be collected and sent to the lab for TIL growth. TIL will be prepared and cryopreserved. intervention 2: Nivolumab will be administered intravenously at a fixed dose of 240 mg for 4 doses every 2 weeks prior to TIL. Nivolumab dose will be fixed at 480 mg every 4 weeks up to 12 months after TIL. intervention 3: Cyclophosphamide will be administered at 60 mg/kg/day IV in 250 mL normal saline (NS) over approximately 2 hours. Cyclophosphamide will be initiated seven days prior to the anticipated TIL transfer, and the precise timing will depend on the rate of in vitro TIL growth. The dose will be based on the patient's body weight, but to prevent undue toxicity, it will not exceed a dose greater than 140% of the maximum ideal body weight per Metropolitan Life Insurance Company, Height and Weight Table. intervention 4: After administration of Cyclophosphamide, Fludarabine will then be infused at 25 mg/m\^2 intravenous piggyback (IVPB) daily over approximately 30 minutes starting 5 days prior to TIL transfer. To prevent undue toxicity with fludarabine, the dose will be based on body surface area (BSA), but will not exceed a dose calculated on surface areas based on body weights greater than 140% of the maximum ideal body weight per Metropolitan Life Insurance Company Height and Weight Tables. intervention 5: On day 0, all patients will receive TIL administered according to the current Moffitt Cell Therapy TIL Standard Operating Procedure (SOP). Eight (8) to twelve (12) hours after completing the TIL infusion, all participants will begin intermediate-dose decrescendo interleukin-2 (IL-2). intervention 6: Interleukin-2 (IL-2) - a drug used to help the body's response to treatment on the immune system. A high dose regimen of IL-2 will be given after the infusion of the T-cells.

Protocol document:
Prot_SAP_000.pdf: 
 
 
A Phase I Clinical Trial Combining Nivolumab and Tumor Infiltrating 
Lymphocytes (TIL) for Patients with Advanced Non-Small Cell Lung Cancer 
 
 
 
NCT03215810 
 
Version 1.6 
September 2, 2020 


September 02, 2020 
Page 1 
 
 
 
 
 
A Phase I Clinical Trial Combining Nivolumab and Tumor Infiltrating 
Lymphocytes (TIL) for Patients with Advanced Non-Small Cell Lung 
Cancer 
 
 
 
PROTOCOL VERSION: 1.6 
VERSION DATE: September 2, 2020 
 
PROTOCOL NUMBERS: 
 
CA209-9JA, MCC 19122 
 
 
SPONSOR: 
H. Lee Moffitt Cancer Center & Research Institute, Inc. 
(Moffitt Cancer Center) 
 
FUNDING: Stand Up to Cancer (SU2C) 
 
 
PRINCIPAL INVESTIGATOR: 
Ben Creelan, MD MS 
Moffitt Cancer Center 
Phone number:  (813) 745-7640 
 
 
STATISTICIAN: 
Dung-Tsa Chen, PhD 
Moffitt Cancer Center 
 
Participating Sites: 
University of Florida 
 


September 02, 2020 
Page 2 
 
PROTOCOL SYNOPSIS 
Clinical Protocol CA209-9JA 
Study Title:  A Phase I Clinical Trial Combining Nivolumab and Tumor Infiltrating Lymphocytes (TIL)  for 
Patients with Advanced Non-Small Cell Lung Cancer 
Protocol Number:  MCC 19122, CA209-9JA 
Clinical Phase:  Phase I 
Study Duration:  30 months 
Investigational Product(s) and Reference Therapy: 
Adoptive cell transfer with autologous tumor-infiltrating-lymphocyte will be supplied as a cellular product. 
Primary Objectives:  
• To evaluate the safety and tolerability of TIL administered following initial progression on nivolumab therapy 
in combination with nivolumab in subjects with advanced non-small cell lung cancer (NSCLC).  
 
Secondary Objectives:  
• To evaluate the efficacy of TIL administered in combination with nivolumab in subjects with NSCLC by 
assessing the objective response rate (ORR) per RECIST v1.1  
• To evaluate the efficacy of TIL administered in combination with nivolumab in subjects with NSCLC by 
assessing duration of response .  
• To evaluate the T-cell persistence following TIL and nivolumab when administered in combination.  
 
Exploratory Objectives:  
• To characterize the pharmacodynamics and evaluate biomarkers of TIL and nivolumab from tumor tissue and 
peripheral blood.  
• To explore the antitumor activity of nivolumab in combination with TIL based on immune-related response 
criteria (irRC).  
• To evaluate the overall survival (OS) of subjects with select advanced solid tumors treated with TIL 
administered in combination with nivolumab. 
• To explore the proportion of reactivity of autologous T cells to tumor-specific antigens in subjects with NSCLC 
by assessing the correlation with response and survival. 
Study Design: 
This is a phase I open label clinical trial of TIL administered in combination with nivolumab in subjects with 
advanced NSCLC. Upon enrollment, subjects undergo tumor harvest for TIL. TIL is prepared and 
cryopreserved. Patients then receive 4 cycles of nivolumab. CT scans are performed after 2 and 4 cycles, and 
the patients with initial response to nivolumab continue to receive drug for up to 1 year. The TIL for patients 
without radiographic response to nivolumab will undergo rapid expansion protocol (REP) after completion of a 
pre-REP checklist. Prior to receiving TIL, patients will undergo cytoreductive chemotherapy with 
cyclophosphamide (60 mg/kg/day) on Day -7 and Day -6 with fludarabine (25 mg/m2 IV over 30 minutes) on 
Days -7 to -3.  The TIL cell product is an intravenous (IV) infusion on Day 0. Subjects then receive IV 
intermediate-dose decrescendo IL-2 on Days +1 to +6 during an inpatient hospital stay. Patients receive a CT 
at Day 28, then every 6 weeks (+/- 7 days) for one year from the date of initial TIL infusion. 
Patients will have clinic visits as outlined in the study calendar. Tumor biopsies will be taken at progression of 
disease, if accessible tumor is amenable to biopsy. Long term follow-up (LTFU) with the patient occurs after 
the patient has been confirmed to have progression of disease or discontinues from the study prior to 
progression.  
Patients who have initial response to nivolumab and subsequently progress may be eligible for TIL treatment, 
if they meet eligibility requirements. 
Number of Centers: 2. Sites: Moffitt Cancer Center, University of Florida 


September 02, 2020 
Page 3 
 
Number of Subjects: 
The target enrollment for this trial is approximately 20 patients with the expectation of 14 evaluable subjects. In 
order to be considered evaluable, a patient must receive lymphodepletion/TIL and complete at least 70% of 
planned visits during the toxicity evaluation window.  Unevaluable patients may be replaced. 
Study Population: 
Advanced non-small cell lung cancer 
Investigational Product(s), Dose and Mode of Administration: 
Nivolumab, 240 mg, IV infusion every 2 weeks for 8 weeks prior to TIL infusion, and then after TIL infusion 480 
mg every 4 weeks for up to 12 months 
 
Adoptive cell transfer with NSCLC TIL 
 
IV decrescendo dose interleukin-2 (per Andersen CCR, 2016 22(15):3734-45) 
 


September 02, 2020 
Page 4 
Table of Contents: 
 
PROTOCOL SYNOPSIS ...................................................................................................................... 2 
Table of Contents: ................................................................................................................................. 4 
List of Abbreviations .............................................................................................................................. 6 
Study Schema ..................................................................................................................................... 9 
Study Calendar   *,** ALL +/- 3 DAYS *; precise start for D0 will depend on rate of TIL growth and 
patient’s clinical status. ....................................................................................................................... 10 
Footnotes to the Study Calendar ..................................................................................................... 11 
1.0 
Significance and Background ............................................................................................... 13 
1.1 
Non-small cell lung cancer as an immune target and non-small cell lung cancer 
differentiation antigens ......................................................................................................... 13 
1.2  
Adoptive cell therapy induces durable remissions for a subset of cancer patients: .............. 13 
1.3 
Lung cancer: a prime target for adoptive cell transfer: ......................................................... 14 
1.4  
Initial studies of adoptive T cell transfer for the treatment of human cancer......................... 14 
1.5 
Addition of non-myeloablative lymphodepletion to adoptive cell transfer ............................. 15 
1.6  
Intermediate (decrescendo) dose IL-2 as an alternative to high-dose IL-2:.......................... 17 
1.7  
Anti-PD-1/L1 priming enhances TIL reactivity in vitro and in vivo: ........................................ 17 
1.8 
Anti-PD-1 blocking antibody (nivolumab) as an agent to combine with adoptive cell therapy
 ............................................................................................................................................. 18 
1.9 
Specifications of Nivolumab ................................................................................................. 19 
2.0 
Hypotheses and Objectives .................................................................................................. 21 
3.0 
Clinical Pharmacology ........................................................................................................... 22 
3.1 
Interleukin-2 (Aldesleukin, Proleukin) ................................................................................... 22 
3.2 
Fludarabine/Cyclophosphamide Conditioning Regimen ....................................................... 23 
3.3 
Mesna (Sodium 2-mercaptoethanesulfonate, Mesnum, Mesnex, NSC-113891) .................. 25 
3.4 
Granulocyte-Colony Stimulating Factor (G-CSF, Filgrastim, tbo-filgrastrim) ........................ 26 
3.5 
Levofloxacin (Levaquin) and Trimethoprim and Sulfamethoxazole double strength (TMP / 
SMX DS, Bactrim) ................................................................................................................ 26 
3.6 
Acyclovir (Zovirax) and Valacyclovir Hydrochloride (Valtrex) ............................................... 27 
3.7 
Fluconazole (Diflucan).......................................................................................................... 27 
3.8 
Ondansetron hydrochloride (Zofran) .................................................................................... 27 
3.9 
Furosemide (Lasix) .............................................................................................................. 27 
3.10 
Nivolumab ............................................................................................................................ 28 
3.11 
TIL Cell Preparation ............................................................................................................. 28 
4.0 
Eligibility Assessment and Enrollment ................................................................................ 29 
4.1 
Screening, Initiation of Nivolumab, and TIL Expansion ........................................................ 29 
4.2 
Adoptive Cell Treatment – Chemotherapy/TIL Infusion ........................................................ 31 
5.0 
Treatment Plan ....................................................................................................................... 32 
5.1 
Treatment Outline ................................................................................................................ 32 
5.2 
Prophylaxis ........................................................................................................................... 35 
5.3 
Apheresis ............................................................................................................................. 36 
5.4 
TIL Harvest ........................................................................................................................... 36 
5.5 
Definition of Dose-Limiting Toxicity (DLT) ............................................................................ 36 
6.0 
Evaluation during Study ........................................................................................................ 39 
7.0 
Evaluation of Toxicity ............................................................................................................ 42 
7.1 
Toxicity Monitoring ............................................................................................................... 42 
7.2 
Immune-Related Adverse Events and Other Possible Toxicities Attributable to Nivolumab 43 
7.3 
Management of Toxicity Due to Nivolumab and/or TIL therapy ............................................ 45 


September 02, 2020 
Page 5 
7.4 
Criteria that Require Permanent Discontinuation of Nivolumab and other study protocol 
treatment that are not related to DLT ................................................................................... 45 
7.5 
Criteria that Require Permanent Discontinuation of Nivolumab and other study protocol 
treatment that are not related to DLT ................................................................................... 47 
7.6 
Nivolumab-related non-neurological adverse events that require permanent discontinuation 
and result in a nivolumab-related DLT ................................................................................. 47 
7.7 
Nivolumab-related neurological adverse events that require permanent discontinuation of 
the trial protocol and result in a nivolumab-related DLT ....................................................... 47 
7.8 
Exceptions to Permanent Discontinuation of Nivolumab due to Toxicity: ............................. 48 
7.9 
Management of gastrointestinal irAEs (diarrhea and colitis) ................................................ 48 
7.10 
Non-DLT nivolumab-related Grade 3 IRAEs ........................................................................ 48 
7.11 
Infusion Reactions Related to Nivolumab............................................................................. 49 
7.12 
Adverse Event Reporting to the FDA ................................................................................... 49 
7.13 
Adverse Event Reporting ..................................................................................................... 50 
8.0 
Criteria for Stopping the Trial Due to Toxicity ..................................................................... 56 
9.0 
Criteria for Response ............................................................................................................. 56 
9.1 
Evaluation of target lesions
1 ................................................................................................. 57 
9.2 
Evaluation of non-target lesions
2 .......................................................................................... 57 
9.3 
Evaluation of best overall response ..................................................................................... 58 
10.0 
Criteria for Removal from the Study ..................................................................................... 58 
11.0 
Statistical Considerations and Data Analysis ..................................................................... 58 
11.1 
Overview .............................................................................................................................. 58 
11.2 
Trial Design .......................................................................................................................... 59 
11.3  Accrual ................................................................................................................................. 59 
11.4  Sample Size Justification and Stopping Rules ..................................................................... 59 
11.5 
Outcomes and Data Analysis ............................................................................................... 61 
12.0 
Biological sampling procedures ........................................................................................... 62 
 
Blood flow cytometry and nucleic acid sequencing .............................................................. 62 
. 
62 
 
Tumor nucleic acid sequencing and Proteonomics .............................................................. 62 
 
Handling, storage and destruction of biological samples...................................................... 63 
13.0 
Data Safety Monitoring Plan .................................................................................................. 63 
13.1 
Recruitment and Informed Consent ..................................................................................... 63 
13.2 
Protection Against Risk ........................................................................................................ 64 
13.3 
Importance of the Knowledge to be Gained ......................................................................... 64 
13.4 
Data Safety and Monitoring Plan .......................................................................................... 64 
13.5 
Scientific Review Committee (SRC) ..................................................................................... 65 
13.6 
PI Responsibility ................................................................................................................... 65 
13.7 
The Protocol Monitoring Committee (PMC) .......................................................................... 65 
13.8 
Suspension/Termination....................................................................................................... 65 
13.9 
Trial Discontinuation ............................................................................................................. 66 
13.10  Monitoring of the Study and Regulatory Compliance .......................................................... 66 
13.11  Internal Monitoring Plan ...................................................................................................... 67 
13.12  Protocol Modifications ......................................................................................................... 67 
13.13  The Institutional Review Board (IRB) .................................................................................. 67 
13.14  Patient Privacy .................................................................................................................... 68 
13.15  Records Retention .............................................................................................................. 68 
13.16  Compliance with Trial Registration and Results Posting Requirements .............................. 68 
14 
REFERENCES ......................................................................................................................... 69 


September 02, 2020 
Page 6 
List of Abbreviations 
 
ABBREVIATION 
Term 
α 
 
 
anti 
ab 
 
 
antibody 
ACT 
 
 
Adoptive Cell Therapy 
AE 
 
 
Adverse Event  
ALK 
 
 
Anaplastic Lymphoma Kinase 
ALT 
 
 
Alanine Aminotransferase 
ANC 
 
 
Absolute Neutrophil Count 
AST 
 
 
Aspartate Aminotransferase 
ATAC  
 
Assay for Transposase-Accessible Chromatin 
BID 
 
 
Twice per Day (bis in die) 
BMS 
 
 
Bristol Myers Squibb 
BP 
 
 
Blood Pressure 
BSA 
 
 
Body Surface Area 
BUN 
 
 
Blood Urea Nitrogen 
C 
 
 
Celsius 
CBC 
 
 
Complete Blood Count 
CD 
 
 
Cluster of Differentiation 
CEA 
 
 
Carcinoembryonic Antigen 
CEF 
 
 
Cytomegalovirus, Epstein-barr virus and influenza virus peptide 
cm 
 
 
centimeter 
CMP 
 
 
Comprehensive Metabolic Panel 
CMV 
 
 
Cytomegalovirus 
CNS 
 
 
Central Nervous System 
CO2 
 
 
Carbon Dioxide 
CR 
 
 
Complete Response 
CRF 
 
 
Case Report Form 
CT 
 
 
Computed Tomography 
CTCAE v 
 
Common Terminology Criteria for Adverse Events version 
CTO 
 
 
Clinical Trials Office 
CLTA  
 
Cytotoxic T-Lymphocyte Associated Antigen 
D 
 
 
Day 
D5W 
 
 
5% Dextrose in Water solution 
DC 
 
 
Dendritic Cell 
dL 
 
 
Deciliter 
DLCO  
 
Diffusion Lung Capacity for Carbon Monoxide 
DLT 
 
 
Dose-Limiting Toxicity 
DNA 
 
 
Deoxyribonucleic Acid 
DS 
 
 
Double Strength 
DSMP  
 
Data Safety & Monitoring Plan 
EBV 
 
 
Epstein Barr Virus 
ECOG  
 
Eastern Cooperative Oncology Group 
EEG 
 
 
Electroencephalogram 
EGFR  
 
Epidermal Growth Factor Receptor 
EKG 
 
 
Electrocardiogram 
ELISA  
 
Enzyme-Linked Immunosorbent Assay 
ELISpot 
 
Enzyme-linked Immune Absorbent Spot 
EOP 
 
 
Extended Outpatient 
FACS  
 
Fluorescence-Activated Cell Sorting 
FDA 
 
 
Food and Drug Administration 
FEV1 
 
 
Forced Expiratory Volume in 1 Second 
FNA 
 
 
Fine Needle Aspiration 
FTA 
 
 
Fluorescent Treponemal Antibody 
G-CSF  
 
Granulocyte Colony Stimulating Factor 
GI 
 
 
Gastrointestinal 
gm 
 
 
gram 
HD 
 
 
High Dose 


September 02, 2020 
Page 7 
HIV 
 
 
Human Immunodeficiency Virus 
HLA 
 
 
Human Leukocyte Antigen 
hr 
 
 
hour 
HSV 
 
 
Human Simplex Virus 
ICH 
 
 
International Conference on Harmonisation 
IFN 
 
 
Interferon 
IL 
 
 
Interleukin 
IM 
 
 
Intramuscular 
IND 
 
 
Investigational New Drug 
irAE 
 
 
immune-related Adverse Event 
irRC 
 
 
immune-related Response Criteria 
IRB 
 
 
Institutional Review Board 
IU 
 
 
International Units 
IULN 
 
 
Institutional Upper Limit of Normal 
IV 
 
 
Intravenous 
IVPB 
 
 
Intravenous Piggyback 
kg 
 
 
kilogram 
L 
 
 
liter 
LD 
 
 
Longest Diameter 
CEA 
 
 
Carcinoembryonic antigen 
LFT 
 
 
Liver Function Test 
LTFU 
 
 
Long Term Follow-Up 
m2 
 
 
Square Meter 
mAb 
 
 
Monoclonal Antibody 
MAGE  
 
Melanoma Associated Gene 
MCC 
 
 
Moffitt Cancer Center 
mcg 
 
 
microgram 
mcL 
 
 
microliter 
mg 
 
 
milligram 
MIU 
 
 
Million International Units 
MHC 
 
 
Major Histocompatibility Complex 
mL 
 
 
milliliter 
mm 
 
 
millimeter 
MRI 
 
 
Magnetic Resonance Imaging 
MSKCC 
 
Memorial Sloan Kettering 
MUGA  
 
Multigated Acquisition Scan 
NCI 
 
 
National Cancer Institute 
NIH 
 
 
National Institutes of Health 
NK 
 
 
Natural Killer 
NS 
 
 
Normal Saline 
NSCLC  
 
Non-Small Cell Lung Cancer 
OKT3  
 
Muromonab-CD3  
ORR 
 
 
Overall Response Rate 
OS 
 
 
Overall Survival 
PBL 
 
 
Peripheral Blood Lymphocytes 
PBMC  
 
Peripheral Blood Mononuclear Cell 
PA 
 
 
Posteroanterior 
PCP 
 
 
Pneumocystis carinii Pneumonia 
PD 
 
 
Progressive Disease 
PD-1 
 
 
Programmed Cell Death Protein-1 
PD-L 
 
 
Programmed Death-Ligand 
PFS 
 
 
Progression-Free Survival 
PFT 
 
 
Pulmonary Function Testing 
PI 
 
 
Principal Investigator 
PK 
 
 
Pharmacokinetics 
PMC 
 
 
Protocol Monitoring Committee 
PO 
 
 
By Mouth (per os) 
PR 
 
 
Partial Response 
PRBC  
 
Packed Red Blood Cell 
PT 
 
 
Prothrombin Time 


September 02, 2020 
Page 8 
PTT 
 
 
Partial Thromboplastin Time 
q 
 
 
Every  
 
 
Q2W 
 
 
Every 2 weeks 
QD 
 
 
Once per Day (quaque die) 
QTc 
 
 
QT interval corrected for heart rate 
RECIST 
 
Response Evaluation Criteria in Solid Tumors 
REP 
 
 
Rapid Expansion Protocol 
RPR 
 
 
Rapid Plasma Reagin 
SAE 
 
 
Serious Adverse Event 
SC 
 
 
Subcutaneous 
SD 
 
 
Stable Disease 
SMX 
 
 
Sulfamethoxazole 
SOP 
 
 
Standard Operating Procedure 
SpO2  
 
Peripheral Capillary Oxygen Saturation 
SRC 
 
 
Scientific Review Committee 
SST 
 
 
Serum Separator Tube 
SU2C  
 
Stand Up to Cancer 
T3 
 
 
Triiodothyronine 
T4 
 
 
Thyroxine 
TCR 
 
 
T Cell Receptor 
TRVB  
 
T Cell Receptor Variable Beta chain 
TID 
 
 
Three Times per Day (ter in die) 
TIL 
 
 
Tumor-infiltrating lymphocytes 
TKI 
 
 
Tyrosine Kinase Inhibitor 
TMP 
 
 
Trimethoprim 
TNF 
 
 
Tumor Necrosis Factor 
TSH 
 
 
Thyroid-Stimulating Hormone 
PBMC  
 
Peripheral blood mononuclear cells 
ULN 
 
 
Upper Limit of Normal 
USP 
 
 
United States Pharmacopeia 
VATS  
 
Video-Assisted Thoracoscopic Surgery 
VZV 
 
 
Varicella Zoster Virus 
WBC 
 
 
White Blood Cell Count 
 
 


September 02, 2020 
Page 9 
 
Study Schema 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
-8   -7 -6 -5 -4 -3 -2 -1     0     
   -67     -63    -49   -35    -21 
Apheresis for PBMC 
NIVO 
Decrescendo
IL-2 IV 
Tumor 
Harvest 
TIL 
Infusion 
REP 
Cy / Flu 
Select TIL 
& Freeze 
Screening 
1→ 6  
14    28          56 
Q4w x 1 yr
Nivo 
Q4w
If progression -> treat with TIL 
Nivolumab Responders Group 
Nivo 
PR/CR 
PD/SD 
Nivo 
Pre-chemo 
checklist 
Eligibility 
checklist 
PR/CR 
Q6w x 1 yr
56  
TIL 
REP 


September 02, 2020 
Page 10 
Study Calendar  
*,** ALL +/- 3 DAYS *; precise start for D0 will depend on rate of TIL growth and patient’s clinical status. 
Footnote 
 
 
 
 
 
 
 
Window 
(18) 
 
 
 
  
 
 
IL2(12) 
Week 
(19) 
 
(20) 
Days post-EOT(21) 
Day 
Screening -67 -63 -49 -35 -21 -8 ±7(8, 13) -7  
-6 
-5 -4 -3 -2 
-1 0 (TIL) 
1 - 6 
1 
2 
4 
Q4w 
Q6w 
PD 
0 
+30 
+90 
Informed Consent 
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Medical history 
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REP Eligibility Checklist 
 
 
 
 
 
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Chemotherapy Checklist 
 
 
 
 
 
 
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Cardiac Stress test (2) 
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PFTs, MUGA (3) 
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EKG 
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Blood Tests  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CBC, CMP  
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PT/PTT 
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HLA sequencing  
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EBV ab 
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Hepatitis B and C 
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HIV, RPR (FTA if necessary) (4) 
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Thyroid Tests (T4, TSH) (5) 
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Blood Pregnancy Test (6) 
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Peripheral Blood Draw for Correlatives (7) 
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Brain imaging (9) 
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Chest X-Ray PA/lateral  
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Tumor surgical biopsy for TIL (10) 
 
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Tumor biopsy (Core/FNA biopsy) (10) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Adverse Event Assessment (11) 
 
 
 
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Urinalysis 
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Nivolumab  
 
 
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Lymphodepletion: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cyclophosphamide (Daily x 2) 
 
 
 
 
 
 
 
 
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Fludarabine (Daily x 5)  
 
 
 
 
 
 
 
 
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Adoptive Transfer of TIL  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• 
 
 
 
 
 
 
 
 
 
 
Intermediate dose IL-2 (12)   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• 
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Preferred antibiotic (14) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Fluconazole (15) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Preferred antiviral (16) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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September 02, 2020 
Page 11 
Footnotes to the Study Calendar  
1. Subjects will have their blood pressure and pulse measured before each nivolumab infusion. 
Subjects will have their vital signs measured during TIL infusion per section 5.1. Vital signs during 
IL-2 are recommended q4 hours or per institutional standard. 
2. Cardiac stress test can be omitted if previously been done within 6 months of screening. 
3. MUGA and PFTs can be omitted if previously done within 4 months of screening. Echocardiogram 
or stress echocardiogram is acceptable alternative for MUGA. 
4. FTA only if RPR is positive per section 4.1.2 #8  
5. If T4 and TSH are clinically significantly abnormal, thyroid or autoimmune workup will be done per 
family practice guidelines, Am Fam Physician. 2012 Aug 1; 86(3): 244. 
6. Serum pregnancy test will be performed on women of child-bearing potential, and must be negative, 
within 7 days of screening, within 7 days prior to each dose of nivolumab, and within 14 days prior 
to chemotherapy. 
7. Venipuncture for peripheral blood mononuclear cells (PBMCs) will be performed at day -63, -35, -8, 
+7, +14, then every 6 weeks +/- 7 days.  PBMCs will be obtained by leukapheresis on day 28.  If 
leukapheresis is not feasible at day 28, then PBMCs must be collected by peripheral blood draw. 
Samples will be used for immune monitoring purposes and will not be used for patient therapy. 
Blood draws will be omitted for patients with symptomatic anemia or deemed not clinically feasible 
by the PI or treating co-investigator. 
8. A +/- 7 day window is included to account for variable preparation time for TIL and rapid expansion. 
Patients who achieve a PR/CR by day -8 will remain on nivolumab following q4w and q6w visits.  
For patients who experience clinical decline in ECOG PS due to cancer during Cycle 1-4 of 
nivolumab may elect to stop subsequent nivolumab and instead receive bridging systemic therapy if 
judged in the best patient interest by the treating clinical investigator. This bridging therapy group is 
described below. 
9. CT Scans with IV contrast at screening, following 2 and 4 cycles of nivolumab, 6 weeks +/- 7 days 
after adoptive TIL transfer, then every 6 weeks (+/- 7 days) for 1 year, then every 12 weeks (+/- 14 
days) for 3 years, then every six months (+/- 21 days) thereafter. CT pelvis after baseline may be 
omitted if patients do not have lesions identified in the pelvis.  
For brain imaging, MRI of the Brain with and without contrast is required for those patients with no 
contraindications; A CT of head with and without IV contrast (if not allergic) can be substituted for 
brain MRI at discretion of the PI. For patients with CT IV contrast allergy, appropriate premedication 
is preferred, and use of MRI or CT without IV contrast may be undertaken only at the discretion of 
the PI.  
The q6 week brain imaging should be omitted for patients without any lesions identified on brain 
imaging at screening and day -8 evaluation. 
10. Tumor fragments from the harvest will be plated in the Cellular Therapies Core lab for TIL growth. 
At disease progression, a tumor core needle biopsy will be obtained. An FNA is an acceptable 
alternative to core biopsy only after discussion with the PI. 
11. Adverse events will be collected until 30 days after both of the following conditions are met: 
progression of disease (PD) and end of treatment (EOT +0) has occurred. This is expected to 
correspond to the EOT +30 visit. 
12. Inpatient stay for intermediate-dose IL-2. Patients are expected to be inpatient for TIL infusion (day 
0) which will be followed within 12 hours by continuous IL-2 infusion administered in a decrescendo 
regimen (18 MIU/m2 over 6, 12, and 24 hours followed by 4.5 MIU/m2 over 24 hours for up to 3 days 
depending on tolerance)  
13. For nivolumab responders, if  subsequent disease recurrence is suspected, then the patient will be 
set up with Day -21 clinic visit, and then complete pre-REP eligibility checklist and procedures per 
Section 5.9, in preparation for subsequent Cy/Flu/TIL. 


September 02, 2020 
Page 12 
14. Daily oral TMP/SMX single-strength (SS) prescription is preferred. Alternative schedule, dose, or 
alternative antibiotics for pneumocystis prophylaxis are permitted at the discretion of the 
investigator. Preferred to continue for at least six (6) months or until CD4 > 200/mm3 
15. Continue until ANC > 1000/mm3 
16. Daily oral valcyclovir is preferred. Begins one day after Day 0. Alternative acyclovir prescription is 
permitted, or omission for patients with intolerance/allergy. Continue until 1 year or CD4 > 200/mm3 
17. Placeholder. 
18. Lymphodepletion chemotherapy administered in inpatient or outpatient setting. 
19. Follow-up visits will be conducted per study calendar after TIL infusion, then every 4 weeks (+/- 7 
days) for 1 year (while on nivolumab therapy), then after nivolumab, every 12 weeks (+/- 14 days) 
for 3 years, then every six months (+/- 14 days) thereafter or until disease progression, withdrawal 
of consent, or death. The q4w and q6w calendar visit procedures are intended to overlap for 
patients who are receiving nivolumab treatment. For post-TIL non-treatment visits of patients facing 
transportation hardship, a virtual visit may be conducted as an alternative. 
Patients who have discontinued nivolumab for reasons other than confirmed progression of disease 
remain on regular trial schedule. These patients may forego q4w calendar visits after 6 weeks have 
elapsed from drug discontinuation. They will continue the q6w calendar visits. 
20. PD: Progression of disease. Percutaneous biopsy after radiologic progression for subjects who 
have not suffered decline in performance status. This is further defined in Section 5, PD. 
21. End of Treatment (EOT) procedures to take place within +0, +30 days and +90 days after the last 
regular study visit; including patients who go on to receive non-study therapies.  EOT does not 
apply to patients who remain on-study follow-up after completing 1-year of nivolumab or require 
cessation of nivolumab for reasons other than progressive disease (see Footnote 19). These EOT 
visits are to continue to assess safety (including exam, CBC, CMP) as well as peripheral blood 
draw for PBMC collection. The EOT visits are further defined in Section 5, EOT. 


September 02, 2020 
Page 13 
1.0 
Significance and Background 
1.1  Non-small cell lung cancer as an immune target and non-small cell lung cancer 
differentiation antigens 
Patients with stage IV metastatic non-small cell lung cancer have a five-year survival rate of less 
than 5% according to most published clinical series.  While chemotherapy regimens have been 
shown to induce objective regressions in 10-40% of non-small cell lung cancer patients, anti-tumor 
responses are generally short-lived and rarely result in complete clinical responses.  Over the past 
five years, immunotherapy has become a viable alternative to chemotherapy for the treatment of 
metastatic non-small cell lung cancer, largely because, like melanoma, non-small cell lung cancer is 
one of the most immunogenic of known human epithelial cancers (1-3).  
 
 
The first indication that immune responses could alter the clinical course of established, invasive 
human cancers came from studies of the administration of interleukin-2 (IL-2) to patients with 
metastatic melanoma (4).  While IL-2 has no direct impact on the growth of cancer cells, it does 
have a number of immune regulatory effects, including the expansion of T lymphocytes following 
activation by specific antigen and NK cells (5, 6).  Approximately 15% of melanoma patients treated 
with IL-2 experience objective regressions, a portion of which are long-lasting and potentially 
curative (7, 8).  This result suggested that activation of T lymphocytes with anti-tumor activity was 
responsible for the induction of tumor regressions (9). 
 
Subsequent studies in both humans and in animal models have borne out these predictions and 
have allowed for the elucidation of the mechanisms behind the immune recognition of tumor cells at 
the molecular level.  T cells specifically recognize antigens presented as small peptides in 
association with surface human leukocyte antigen (HLA) molecules (10, 11).  Peptide antigens 
expressed on the surface of cancer cells have been demonstrated in multiple studies to induce T 
cell recognition leading to tumor cell killing and/or the release of helper and other cytokines.  In the 
case of non-small cell lung cancer, a number of antigens have now been identified that can be 
recognized by both CD8+ cytotoxic T cells and CD4+ T-helper cells, including mesothelin, MAGE-
A3, and NY-ESO-1 (11 -13).  
1.2 Adoptive cell therapy induces durable remissions for a subset of cancer patients:  
Despite progress in T-cell immune checkpoint inhibitors for NSCLC, these agents fail to cause 
complete cancer remission for the majority of patients (14, 15).  Further treatments which employ 
the exquisite specificity of memory T-cells are still needed for this pervasive cancer. Adoptive cell 
therapy (ACT) with tumor-infiltrating lymphocytes (TIL) is a promising T-cell-based immunotherapy 
that has evolved over the past sixty years into a tenable treatment for select solid tumors, 
particularly melanoma (16). In this process, TIL are first propagated from explanted minced tumor 
fragments and cultured with interleukin-2 (IL-2) to a target goal of >30 million cells. These TIL then 
undergo rapid clonal expansion (REP) by incubation with anti-CD3 monoclonal antibody (mAb), 
resulting in >500-fold expansion. Upon adequate TIL generation, the patients receive 
lymphodepleting chemotherapy prior to infusion of the TIL product and administration of IL-2. The 
National Cancer Institute has pioneered this treatment and reported response rates of 50% or more 
in metastatic melanoma; with 22% of patients achieving durable complete responses, many more 
than 9 years (1). The impressive durability of responses to ACT is a hallmark of this treatment. Our 
center at Moffitt has shown that ACT for metastatic melanoma is feasible and effective, with over 50 
patients treated to date (17) Since TIL are derived from native genetically unmodified cells, 
complications due to engagement of normal host cells is uncommon. Durable regressions with TIL 
have previously been reported in a variety of epithelial malignancies, including cholangiocarcinoma, 
cervical, and colorectal cancer. 


September 02, 2020 
Page 14 
1.3 Lung cancer: a prime target for adoptive cell transfer:  
Like melanoma, NSCLC arises from extreme environmental mutagenesis and therefore presents a 
rich array of tumor neoantigens for adaptive immunity. Once explanted, lung TIL are bereft of their 
suppressive tumoral mileu and may be free to recover antitumor capacity (18). A prior non-
randomized trial of 131 patients with Stage I-III NSCLC yielded successful ACT in 86% of case, with 
a median of 20 x 109 cells infused and this product displayed autologous reactivity (19). However, 
because these were resections for curative intent, the subjects were not evaluable for response 
rate. TIL phenotype does not vary among histologies or metastastic location (20). Since metastatic 
deposits contain even richer amounts of TIL than primary lung tumors, metastatectomy samples 
may be expected to provide a reliable TIL source for NSCLC patients. Along these lines, a trial of 
ACT in metastatic NSCLC followed by high dose (HD) IL-2 has activated at NCI [NCT02133196]. 
Our center at Moffitt has shown that lung TIL has high proliferative capacity with a median of 1.9 x 
109 CD3+ cells after REP. In our protocol, small pieces (~2mm x 2mm) of freshly resected tumor 
are aseptically cultured on separate wells of a 24 well plate containing 2 mL TIL media and 
6000IU/mL of rhIL-2.  Once ~5x107 TIL are propagated, cells are clonally expanded in IL-2 and 
30ng/mL activating anti-CD3 mAb (OKT3) with irradiated feeder PBMCs at 200:1. Expansion is 
successful in over 75% of attempts (n=13) and these CD3+ cells displayed a predominantly CD8 
phenotype [Figure 1A]. Moreover, these cells demonstrated moderate autologous tumor specificity 
which was enhanced in the presence of IL-2 [Figure 1C].  
 
 
1.4 Initial studies of adoptive T cell transfer for the treatment of human cancer 
The identification of T cells with the ability to specifically recognize epithelial cancer antigens, along 
with the technological capability to expand these tumor-reactive T cells to large numbers in the 
laboratory, has led to the development of adoptive transfer protocols for patients with metastatic 
epithelial cancers.  Tumor-infiltrating lymphocytes (TIL) derived from resected tumors that were 
CD4 
CD8 
87.51% 
9.18% 
T IL
T IL  +  P M A /I
T m
T IL  +  T m
T IL  +  T m  +  P D L 1
T IL  +  T m  +  IL 2
T IL  +  T m  +  IL 2  +  P D L 1
0
5 0 0
1 0 0 0
1 5 0 0
2 0 0 0
    *
    *
B 
A 
C 
D 
 
IF N g  (p g /m l)


September 02, 2020 
Page 15 
expanded in vitro were shown to be capable of specifically recognizing tumor antigens, such as 
carcinoembryonic antigen (CEA), in over two-thirds of cancer patients (21, 22).   
 
TIL growth requires two phases. In the first phase, called pre-rapid expansion, individual cancer 
tumor fragments (1-3 mm3) are explanted in vitro in media containing interleukin-2. After 4-6 weeks, 
TIL propagated from fragments successfully yielding 30-60 million cells in total are pooled and used 
in the second phase, called rapid expansion. During rapid expansion, OKT and IL-2 as well as 
irradiated feeder cells result in 500-1000 fold proliferation. When TIL are expanded to large 
numbers (greater than 20 billion) and adoptively transferred intravenously to patients along with IL-
2, objective response rates of 35-50% have been observed (23).  This response rate is nearly twice 
that observed with IL-2 alone and was also seen in patients that were refractory to IL-2 treatment.  
However, most of the initial responses were transient and limited tumor reactivity and persistence of 
the transferred cells was observed, and TIL preparation typically required 6-8 weeks (24). Improving 
tumor reactivity, TIL persistence and reducing the time required for preparation can enhance patient 
outcomes. 
 
1.5 
Addition of non-myeloablative lymphodepletion to adoptive cell transfer 
Mounting evidence suggests that the host immune environment can significantly impact the efficacy 
of adoptive cell transfer therapy.  Data from mouse tumor models have demonstrated that sublethal 
doses of irradiation prior to adoptive transfer of tumor antigen-specific lymphocytes substantially 
increases the persistence and anti-tumor activity of the transferred cells (25).  While the 
mechanisms leading to this enhanced T cell activity have not been precisely delineated, two non-
mutually exclusive hypotheses may provide an explanation.  A subset of CD4+ T cells, expressing 
high levels of CD25 and the molecule FoxP3 and known as regulatory or suppressor T cells, is 
thought to have a negative impact on the activity of cytotoxic T cells in vivo (26, 27).  It has been 
hypothesized that increased numbers of suppressor T cells in cancer patients may correlate with an 
unfavorable prognosis and that elimination of these cells may result in an improved efficacy of 
adoptive immunotherapy (28-31).  Alternatively, prior depletion of lymphocytes may create ‘space’ 
for the adoptively transferred cells within the lymphocyte compartment (32).  Under this model, 
homeostatic lymphocyte survival may result in increased proliferation and enhanced survival of 
transferred T cells, perhaps through a mechanism involving increased access to endogenous 
cytokines like IL-7 and IL-15 (33). 
 
In a prior published protocol, patients with metastatic melanoma received a single dose of 
cyclophosphamide (Cytoxan) at 25 mg/kg prior to the administration of autologous TIL cells.  Traffic 
of TIL to tumor sites was evaluated by labeling TIL with Indium-111 and performing sequential 
radionuclide scans.  Of 26 patients that received cyclophosphamide, TIL trafficking to tumor was 
seen in 21 patients (81%) compared to TIL trafficking to tumor in 42% of patients that did not 
receive cyclophosphamide (p=0.026).  No difference was seen in tumor regression rates.  Thus, 
even with a mild and very transient leukopenia (about 5 days), evidence of increased lymphocyte 
trafficking to tumor was observed (34). 
 
The animal and clinical studies cited above strongly suggest that the clinical effectiveness of these 
cells and their ability to survive and repopulate the host would be enhanced if patients were 
significantly immunosuppressed by the depletion of lymphocytes prior to the adoptive transfer of 
lymphocytes.   
 
A recent clinical trial investigated the addition of a lymphodepleting conditioning regimen to adoptive 
cell transfer therapy in patients with metastatic melanoma. Patients received a lymphodepleting 


September 02, 2020 
Page 16 
chemotherapy regimen consisting of high dose cyclophosphamide and standard doses of 
fludarabine before administration of highly selected, expanded, tumor-reactive TIL and IL-2 (35, 36). 
The lymphodepletion step resulted in a transient myelosuppression and the elimination of all 
circulating lymphocytes for approximately one week, after which time patients recovered 
endogenous marrow function and reconstituted their lymphocyte compartments towards normal 
levels within two to three weeks (37).  
 
 
Because of the immunosuppression of fludarabine, one of the patients who had clonal repopulation 
from infused TIL cells and a complete response of metastatic melanoma, developed Epstein-Barr 
virus (EBV) - associated B cell lymphoma.  This patient was EBV-naïve prior to the treatments.  The 
potential source of EBV was thought to be multiple blood product transfusions after chemotherapy.  
The patient later died of complications from the treatment of his lymphoma.  Another patient 
developed polyneuropathy manifested by vision blindness, motor and sensory defects, 
approximately 2 months after chemotherapy.  The etiology of this complication is unknown, but was 
possibly related to the fludarabine (35).  
 
In a prior publication in Science, six patients of thirteen demonstrated objective tumor regression 
and four additional patients showed mixed responses with substantial shrinkage of some lesions 
after lymphoid depletion and adoptive transfer of highly selected, expanded, tumor-reactive TIL and 
IL-2.  Significant levels of tumor regression were observed in metastatic deposits in the liver, lungs, 
cutaneous and subcutaneous tissues, and lymph nodes.  One patient had dramatic regression of 
axillary, pelvic and intraabdominal metastases, on-going at 17 months and was rendered free of 
disease by a surgical removal of one residual intraperitoneal lesion. Two other patients had marked, 
persistent lymphocytosis up to 3 weeks after the TIL infusion. Molecular and immunological 
analyses confirmed that these lymphocytes from their peripheral blood were the progeny of the 
infused TIL (23).  In particular, in one patient, it was shown that one specific clone repopulated this 
patient’s peripheral blood lymphocytes (PBL) up to 2 months after infusion.  Immunohistochemistry 
studies revealed that specific clones from infused bulk oligoclonal TIL cells infiltrated the regressing 
tumor nodules.  Although the mechanism for the continued proliferation in vivo of these rapidly 
expanded (REPed) bulk TIL cells and their anti-tumor effects remain to be determined, it appears 
that some cells in the REPed bulk TIL might have provided necessary cytokines (such as IL-2) for 
cytotoxic T lymphocytes to persist and survive in vivo and eventually kill the tumor.  Alternatively, 
the chemotherapy regimen used in this protocol might have depleted endogenous suppressive 
lymphocytes.  Seven of these 13 patients received a second cycle of treatment with the same 
chemotherapy regimen plus bulk TIL and high dose IL-2.  All seven patients recovered from a 
second cycle (35).  Four out of the 13 patients developed vitiligo and one patient developed uveitis, 
which did not interfere with vision and reversed after steroid therapy (35).  
 
More recent experience with lymphoid depletion, TIL and IL-2 at the Moffitt Cancer Center, MD 
Anderson Cancer Center, Sheba Medical Center in Israel and the National Cancer Institute suggest 
that so-called “young” TIL that are not selected for tumor reactivity but are grown from tumor 
fragments in IL-2 and pooled without an intermediate step to assay their tumor specific release of 
cytokine can be successfully used to treat patients. In a presentation at the American Society for 
Clinical Oncology annual meeting in June 2011, Shapira-Frommer et al described their experience 
with 42 patients treated with “young” TIL at the Sheba Medical Center, demonstrating a 40% ORR 
and significant regression of tumor in patients with extensive metastatic disease.  At the MD 
Anderson Cancer Center, 35 patients have been treated with Cytoxan-Fludarabine followed by TIL 
and high-dose IL-2, with a 50% ORR.  Tumor regression was associated with larger number of CD8 
T cells administered (36, 37).  However, the results were not reported on an intention-to-treat basis 
and would be significantly lower if the drop-out rate was taken into consideration.  
 


September 02, 2020 
Page 17 
Finally, the National Cancer Institute, which has pioneered TIL therapy for cancer, has described 
their long-term experience with up to 5-year follow-up in 93 patients treated with TIL that have had 
lymphoid depletion using the current Cytoxan-Fludarabine regimen, or using that regimen with 200 
or 1200 rad of total lymphoid irradiation.  They documented that 22% of their patients had complete 
responses, and that 93% of those patients were alive at 5 years, free of disease.  Again, the results 
were not reported on an intention-to-treat basis. In the NCI experience, the level of anti-tumor 
response was associated with selection of tumor fragments plated in 24 well plates by their 
recognition of fresh tumor cells measured by gamma interferon release, with patients receiving so-
called unselected “young TIL” having a lower response rate and fewer sustained complete 
responses. At Moffitt Cancer Center, in an ongoing adoptive cell therapy trial, we have successfully 
treated 10 patients (59%) of 17 patients with cytoxan-fludarabine followed by TIL with IL-2. Of 
these, we have observed 5 partial responses and two patients with stable disease (1), all with 
selected TIL. 
 
The collective results suggest that the non-myeloablative lymphodepleting chemo-preparative 
regimen identical to the above regimen proposed in this current study can be tolerated and is 
potentially efficacious for the treatment of advanced metastatic disease.  This may be due to the 
homeostatic pressure created by the chemotherapy regimen.  After ablation of the endogenous 
lymphocyte compartment, the infused TIL cells may expand better in vivo without competition from 
endogenous lymphocytes.  At the NIH, marked proliferation of the transferred TIL cells was not 
observed without this course of chemotherapy. To further optimize adoptive cell therapy in the 
proposed study, the plan is to administer nivolumab (PD-1 blocking antibody) as described below in 
order to enhance resulting TIL reactivity and persistence.  
1.6 Intermediate (decrescendo) dose IL-2 as an alternative to high-dose IL-2: 
The primary toxicities resulting from typical adoptive cell therapy regimens are related to high-dose 
IL-2 administered after cell transfer. IL-2 is administered to support in vivo proliferation and 
persistence of the infused cell product.  In order to reduce this toxicity and maintain efficacy and 
persistence of the cell product, alternative IL-2 dosing regimens have been explored.  One such 
regimen which has demonstrated efficacy in a melanoma population receiving TIL ACT product is 
an intermediate-dose decrescendo IL-2 infusion, as previously described by Keilholz et al. (38) and 
Andersen et al (39). 
 
On day 0, patients receive a bolus infusion of TIL followed by a continuous IL-2 infusion 
administered in a decrescendo regimen (18 MIU/m2 over 6, 12, and 24 hours followed by 4.5 
MIU/m2 over 24 hours for 3 days). IL-2 infusion is started within 12 hours after the TIL infusion. 
Maximum total dose of IL-2 administered is limited to 135 MIU, corresponding to a body surface 
area of 2 m2. All patients receive prophylactic antibiotics and antiemetics. To reduce the 
neutropenic period and time in hospital a single subcutaneous injection of granulocyte colony-
stimulating factor (G-CSF) is administered after the TIL infusion. 
 
1.7 Anti-PD-1/L1 priming enhances TIL reactivity in vitro and in vivo:  
ACT depends upon infiltration of T-cells into the tumor margin prior to harvest, and potent anti-
tumor effector function after transfer.  Lung tumors contain large numbers of regulatory T-cells and 
mediate potent inhibition of autologous T-cells (46). Aberrant expression of suppressive ligands 
such as PD-L1 may mediate failure of adoptive cell therapy. Specifically, PD-1 is upregulated on 
activated and exhausted T-cells. In an NCI study of CD8+ TIL from 6 melanoma patients, 
expression of PD-1 identified the autologous tumor-reactive repertoire, including mutated 
neoantigen-specific CD8+ cells, and TCRβ sequencing detected oligoclonal expansion of specific 


September 02, 2020 
Page 18 
TCRβ clonotypes which was only in PD-1+CD8+ TIL populations (47). Our group isolated TIL from 
disaggregated primary human NSCLC tumors (n =14) and performed flow cytometry (FACS) 
[Figure 1B], which demonstrated high PD-1 co-expression compared to other checkpoints. After 
clonal expansion, addition of 10 mcg/mL α-PD-L1 in vitro augmented TIL reactivity to autologous 
tumor and was synergistic with addition of IL-2 at 6,000 IU/mL [Figure 1C].  
 
We have also shown that αPD-1 treatment prior to tumor resection improved the yield of TIL in a 
B16 murine melanoma model [Figure 1D]. Mice (n=3 per group) were injected subcutaneously with 
105 B16 cells. Mice with established tumors received 30 mg/kg of αPD-1 or isotype control. Tumors 
and spleens were collected on day 24 and phenotyped for CD8+ T cells. αPD-1 caused a significant 
increase in CD8+ T cells infiltrating into the tumors and higher CD8+ counts in the spleen. These 
cultured TIL also had higher reactivity to B16 compared to isotype control [Figure 1D].  
 
Since CD8+ T cells are thought to be the predominant mediator of anti-tumor function of TIL, we 
expect the addition of PD-1/PD-L1 blockade prior to tumor harvest will result in enhanced infiltration 
by anti-tumor effector T cells. This effect is expected to be durable in humans, as a single dose of 
αPD1 results in a mean occupancy of >70% of PD-1 co-receptors on circulating T-cells for more 
than two months after a single dose. Notably, post-treatment biopsies in humans with either αPD-1 
or αPD-L1 show an significant increase in peritumoral T-cell infiltrate, substantiating its potential 
role as a partner with ACT. 
 
1.8 Anti-PD-1 blocking antibody (nivolumab) as an agent to combine with adoptive cell 
therapy  
Programmed death 1 (PD-1) is an immune checkpoint receptor expressed by activated T cells.  
Interaction between PD-1 and its ligand PD-L1 in peripheral tissues such as tumors and stromal 
cells leads to the immunosuppression of T cells (Dong, H Nat Med 2002; Topalian, S Curr Opin 
Immul 2012; Freeman, GL J Exp Med 1999).  In murine models, blockade of PD-1/PD-L1 
interactions results in enhanced T cell proliferation, persistence and anti-tumor activity (Pilon-
Thomas, S JI 2010; Iwai, Y PNAS 2002).  In recent Phase I clinical trials, treatment patients with 
anti-PD-1 or anti-PD-L1 antibodies led to an overall clinical response rates betweem 20 - 28% in 
patients with melanoma and 15 - 20% in non-small cell lung cancer (Topalian et al.  NEJM 2012).   
Of note, a single dose of PD-1 antibody resulted in a mean occupancy of >70% of PD-1 co-
receptors on circulating T cells for ≥ 2 months after a single dose (Brahmer et al. JCO 2010).  
 
Published work in a murine model has shown that anti-PD-1 or anti-PD-L1 antibody treatment 
augments the infiltration of T cells within the tumor (Peng, Q Cancer Res 2012). Murine work has 
also demonstrated that pre-treatment of harvested B16 melanoma and other tumors with anti-PD-
L1 antibody increases the likelihood that T cells with anti-tumor reactivity can be propagated from 
treated tumors (unpublished data). In the current trial, we will attempt to increase T cell trafficking to 
tumor by using anti-PD-L1 antibody prior to surgical resection of tumor and growth of TIL. The 
safety and feasibility of this approach will also be evaluated in the current trial.      
 
To date, few investigators have examined ACT with autologous TIL for patients with advanced 
NSCLC. Moreover, the combination of aPD-1 mAb with ACT has not been reported in NSCLC. 
These drugs have a favorable side effect profile, and may re-activate the host’s natural immune 
system to eliminate tumor cells. Thus, this project is original and significant, has intellectual merit, 
and has potential for broad impact in the field of immunotherapy.  


September 02, 2020 
Page 19 
1.9 
Specifications of Nivolumab 
Pharmacodynamics  
Nivolumab binds with high affinity and specificity to human PD-1 and blocks its interaction with PD-
L1 and PD-L2. In vitro studies demonstrate that nivolumab antagonizes the inhibitory effect of PD-
L1 on primary human T cells, resulting in their restored proliferation and release of interferon 
gamma (IFN-γ). Additionally, nivolumab demonstrated a lack of antibody-dependent cell-mediated 
cytotoxicity and complement-dependent cytotoxicity in cell-based functional assays. In vivo studies 
show that nivolumab inhibits tumor growth in a xenograft model via a T lymphocyte (T-cell) 
dependent mechanism. Moreover, an anti-mouse PD-L1 antibody demonstrated improved survival 
in a syngeneic tumor model when given as monotherapy and resulted in complete tumor regression 
in > 50% of treated mice when given in combination with chemotherapy. Combination therapy (dual 
targeting of PD-L1 and cytotoxic T-lymphocyte-associated antigen 4 [CTLA-4]) resulted in tumor 
regression in a mouse model of colorectal cancer.  
 
Cynomolgus monkeys were selected as the only relevant species for evaluation of the 
pharmacokinetics (PK)/pharmacodynamics and potential toxicity of nivolumab. Following 
intravenous (IV) administration, the PK of nivolumab in cynomolgus monkeys was nonlinear. 
Systemic clearance (CL) decreased and concentration half-life (t1/2) increased with increasing 
doses, suggesting saturable target binding-mediated clearance of nivolumab. No apparent gender 
differences in PK profiles were observed for nivolumab.  
 
In general, treatment of cynomolgus monkeys with nivolumab was not associated with any 
nivolumab-related adverse effects that were considered to be of relevance to humans. Adverse 
findings in the non-Good Laboratory Practice (GLP) PK/pharmacodynamics and dose range-finding 
study, and a GLP 4-week repeat-dose toxicity study were consistent with antidrug antibody (ADA)-
associated morbidity and mortality in individual animals. The death of a single animal in the non-
GLP, PK/pharmacodynamics, and dose range-finding study was consistent with an ADA-associated 
acute anaphylactic reaction. The spectrum of findings, especially the clinical signs and microscopic 
pathology, in a single animal in the GLP, 4-week, repeat-dose study was also consistent with ADA 
immune complex deposition, and ADA:nivolumab immune complexes were identified in a 
subsequent non-GLP, investigative immunohistochemistry study. Similar observations were 
reported in cynomolgus monkeys administered human mAbs unrelated to nivolumab. Given that 
immunogenicity of human mAbs in nonclinical species is generally not predictive of responses in 
humans, the ADA-associated morbidity and mortality were not considered for the determination of 
the no-observed-adverse-effect level (NOAEL) of nivolumab.  
 
Finally, data from the pivotal 3-month GLP toxicity study with nivolumab in cynomolgus monkeys 
showed that subchronic dosing of nivolumab was not associated with any adverse effects. 
Therefore, the NOAEL of nivolumab in all the general toxicity studies was considered to be 100 
mg/kg, the highest dose tested in these studies. In addition to the in vivo toxicology data, no 
unexpected membrane binding of nivolumab to human or cynomolgus monkey tissues was 
observed in GLP tissue cross-reactivity studies using normal human and cynomolgus monkey 
tissues. 
 
Clinical experience with nivolumab is fully described in the current version of the Nivolumab 
Investigator’s Brochure and drug package insert.  
 
Pharmacokinetics and Product Metabolism  
Nivolumab monotherapy exhibited nonlinear (dose-dependent) PK. The area under the 
concentration-time curve from 0 to 14 days (AUC0-14) increased in a greater than dose-


September 02, 2020 
Page 20 
proportional manner over the dose range of 0.1 to 15 mg/kg and approached linearity at ≥ 3 mg/kg, 
suggesting that the nonlinear PK of nivolumab is likely due to saturable target-mediated clearance. 
Exposures following multiple doses (currently up to a maximum of 26 doses) demonstrated 
accumulation consistent with PK parameters estimated from the first dose.  
 
Suppression of free soluble PD-L1 (sPD-L1) was correlated with nivolumab PK concentrations. 
Following administration of nivolumab monotherapy, free sPD-L1 levels were below the lower limit 
of quantitation (LLOQ) in the majority of subjects with available data (n = 38) at all timepoints 
following IV doses ≥ 1 mg/kg every 2 weeks (Q2W). Subsequent data has shown suppression of 
free sPD-L1 at higher doses using flat-dosing of 480 mg q4 weeks leading to FDA approval of this 
newer schedule for oncologic indications beginning in March 2018. 
 
Overall, a low incidence of ADA was observed. Of the 220 subjects who received nivolumab 
monotherapy and for whom PK/ADA data were available, 5 were detected ADA positive, with an 
impact on PK/pharmacodynamics reported in 1 subject.  
Safety  
Based upon the package insert, important potential risks of nivolumab and its related molecules 
include immune-mediated reactions such as enterocolitis, dermatitis, hepatitis/hepatotoxicity, 
endocrinopathy, pneumonitis, and neuropathy. Additional important potential risks include infusion-
related reactions, hypersensitivity, serious allergic reactions, serious infections, and immune 
complex disease.  
The majority of the safety data are from the monotherapy study, CD-ON-nivolumab-1108, 
specifically the 10 mg/kg Q2W cohort (N = 393). In this cohort, the most frequently reported (≥ 10% 
of subjects) adverse events (AEs; all grades, regardless of causality) were fatigue (29.8%), nausea 
(20.1%), dyspnea (19.6%), decreased appetite (19.1%), constipation (14.0%), diarrhea and 
vomiting (12.5% each), cough (11.5%), pyrexia and back pain (10.4% each), and rash (10.2%). In 
approximately half of the subjects, the highest AE severity was Grade 1 (25.2% of subjects) or 
Grade 2 (22.9% of subjects). Most of these events were managed clinically without the need for 
dose modifications or delays. Grade 3 or higher AEs that occurred in > 1% of subjects were 
dyspnea (5.1%), increased gamma-glutamyltransferase (3.3%), fatigue, general physical health 
deterioration, increased aspartate aminotransferase, and back pain (2.3% each), anemia and 
dehydration (1.8% each), and abdominal pain, vomiting, sepsis, syncope, and hypotension (1.3% 
each). Treatment-related Grade 3 AEs in 2 or more subjects were fatigue (4 subjects), increased 
gamma-glutamyltransferase (3 subjects), and vomiting, increased alanine aminotransferase, 
increased aspartate aminotransferase, and arthralgia (2 subjects each). There were 2 subjects with 
treatment-related Grade 4 events (hypercalcemia, fatigue) and 1 subject with a treatment-related 
Grade 5 event (angiopathy). In general, Grade 3 or higher AEs were manageable and reversible 
with standard toxicity management guidelines.  
 
Serious adverse events (SAEs) and other significant AEs occurred in less than one-third of subjects 
treated with nivolumab 10 mg/kg Q2W in Study CD-ON-nivolumab-1108. The most frequently 
reported SAEs (regardless of causality; > 5 subjects) were dyspnea (15 subjects), general physical 
health deterioration (9 subjects), pyrexia (8 subjects), back pain and abdominal pain (7 subjects 
each), and dehydration and pleural effusion (6 subjects each). One subject (with Stage IV lung 
cancer and a history of cardiac disease) died due to angiopathy considered by the investigator as 
related to nivolumab. Adverse events that resulted in permanent discontinuation of nivolumab in ≥ 2 
subjects were dyspnea (7 subjects), general physical health deterioration (5 subjects), and death, 
increased transaminases, pulmonary embolism, and respiratory failure (2 subjects each).  
No dose-limiting toxicities (DLTs) were reported in the dose-escalation cohorts of the monotherapy 
studies. Overall, the AE profile of nivolumab was consistent with the pharmacology of the target.  
 


September 02, 2020 
Page 21 
Efficacy  
Nivolumab is FDA approved for multiple indications, including the second-line treatment of 
Metastatic Squamous and Non-squamous NSCLC. CHECKMATE-017 (NCT01642004) was a 
randomized (1:1), open-label study enrolling 272   patients   with   metastatic   squamous   NSCLC   
who   had   experienced   disease    progression during or after one prior platinum doublet-based 
chemotherapy regimen. Patients received 3 mg/kg of OPDIVO (n=135) by intravenous infusion 
every 2 weeks  or  docetaxel  (n=137)  administered  intravenously  at  75  mg/m2  every  3  weeks.  
The  trial  demonstrated  a  statistically  significant  improvement  in  OS  for  patients  randomized 
to OPDIVO as compared with docetaxel at the prespecified interim analysis  when  199  events  
were  observed  (86%  of  the  planned  number  of  events  for  final  analysis). The Overall 
Response Rate (ORR) was 20% (95% CI 14-28) in the nivolumab arm compared to 9% (95% CI 5-
15%) in the docetaxel arm, p value = 0.0083.  
Nivolumab is also FDA approved for first-line treatment of Stage 4 metastatic NSCLC in 
combination with ipilimumab for patients with PD-L1 expression of 1% or higher (CHECKMATE-
227). Nivolumab is also FDA approved for first-line treatment of Stage 4 NSCLC patients in 
combination with platinum-based chemotherapy and ipilimumab (CHECKMATE 9-LA) based upon 
superior overall survival (OS) compared to platinum doublet chemotherapy.  
 
Nivolumab also has comparable, but not superior efficacy, to standard platinium-based 
chemotherapy in the first-line setting in patients. For example, the Phase III CHECKMATE-026 
randomized patients (1:1) with NSCLC tumors with PD-L1 expression ≥1% of cells in an open-label 
to either nivolumab 3 mg/kg IV q2 weeks or control platinum-based chemotherapy of investigator’s 
choice. In the primary intent-to-treat (ITT) population, the median PFS was 4.2 months with Opdivo 
and 5.9 months with platinum-based doublet chemotherapy (stratified hazard ratio [HR]=1.15 [95% 
CI: 0.91, 1.45, p=0.25]). Objective responses occurred in 26.1% of nivolumab patients and 33.5% of 
chemotherapy-treated patients. Overall survival was 14.4 months for Opdivo versus 13.2 months for 
chemotherapy (HR=1.02 [95% CI: 0.80, 1.30]). Eligible patients had stage IV or recurrent NSCLC 
and had received no prior systemic therapy for advanced disease and had no EGFR or ALK 
mutations sensitive to available targeted therapies. The trial was limited to patients whose tumors 
had ≥1% PD-L1 expression. The primary analysis did not show nivolumab superiority. The total rate 
of crossover at progression was 43.6% in the nivolumab arm and 64.2% in the chemotherapy arm. 
In the nivolumab arm, 1.4% of patients crossed over to other immunotherapy, as compared with 
60.4%. At the end of the trial, 18.7% of treated patients remained on randomized therapy in the 
nivolumab group versus 5.3% of the chemotherapy arm. 
 
 
2.0 
Hypotheses and Objectives 
 
The primary objective of this study will be to demonstrate that treatment with nivolumab in patients 
undergoing lymphodepletion/TIL/IL2 therapy is safe with a continuous Pocock-type stopping boundary 
for serious toxicity of < 17%, with safety reported based upon CTCAE version 4.0 criteria. 
 
Primary Hypothesis: The combination of TIL therapy and nivolumab for NSCLC patients will be 
feasible and achieve an acceptable toxicity profile.  
 
Primary endpoint: To determine if serious toxicity rate (rate of DLT, defined in section 5.5) exceeds 
17% 
 
 
The secondary objectives of this study will be: 
1.  To determine the best objective response rate (BORR) associated with the treatment regimen 


September 02, 2020 
Page 22 
 
2.  To determine the overall survival associated with the treatment regimen 
 
Exploratory Hypothesis: The combination of TIL therapy with nivolumab for NSCLC will produce 
observed responses in a population of patients who are refractory to or progress on nivolumab 
monotherapy alone. 
 
Secondary endpoint: Determine if the treatment produces a best overall radiologic response rate in 
radiographically evaluable patients who progress on nivolumab monotherapy in unselected NSCLC of 
20% or more.  
 
 
3.0 
Clinical Pharmacology  
3.1 
Interleukin-2 (Aldesleukin, Proleukin)  
Interleukin-2 (IL-2) is manufactured and supplied for in vitro use, and will be supplied for clinical use 
(aldesleukin). IL-2 is a 133 amino acid protein primarily secreted by T-cells in response to various 
antigenic stimuli.  The cytokine acts through a specific IL-2 receptor consisting of α, β, γ subunits.  In 
addition to T-cell proliferation, IL-2 leads to activation and proliferation of natural killer (NK) cells, 
increasing their tumoricidal activity.  Other actions of IL-2 include augmentation of B-cell growth and 
immunoglobulin production, enhancement of interferon (IFN)-γ and tumor necrosis factor (TNF)-α 
production from T-cells, IL-6 production by monocytes, modulation of histamine release by basophils, 
and upregulation of IL-2 receptors.  This triggers the release of various other cytokines leading to the 
total immune/ inflammatory reaction and resultant toxicity.   
 
On day 0, following the infusion of TIL, IL-2 is administered as a continuous infusion in a decrescendo 
regimen (18 MIU/m2 over 6 hours, then 18 MIU/m2 over 12 hours, then 18 MIU/m2 over 24 hours, 
followed by 4.5 MIU/m2 over 24 hours daily for 3 days). IL-2 infusion is started within 12 hours after the 
TIL infusion. Maximum total dose of IL-2 administered is limited to 135 MIU, corresponding to a body 
surface area of 2.0 m2.  
 
Adverse events common to IL-2 include diarrhea, nausea, vomiting, hypotension, skin changes, 
anorexia, mucositis, dysphagia, constitutional symptoms, and laboratory changes.  IL-2 administration 
has been associated with capillary leak syndrome (CLS) which is characterized by a loss of vascular 
tone and extravasation of plasma proteins and fluid into the extravascular space. CLS results in 
hypotension and reduced organ perfusion which may be severe and can result in death. CLS may be 
associated with cardiac arrhythmias (supraventricular and ventricular), angina, myocardial infarction, 
respiratory insufficiency requiring intubation, gastrointestinal bleeding or infarction, renal insufficiency, 
edema, and mental status changes.  
 
IL-2 treatment is also associated with impaired neutrophil function (reduced chemotaxis) and with an 
increased risk of disseminated infection, including sepsis and bacterial endocarditis. Consequently, 
preexisting bacterial infections should be adequately treated prior to initiation of IL-2 therapy. Patients 
with indwelling central lines are particularly at risk for infection with gram positive microorganisms. 
Antibiotic prophylaxis with oxacillin, nafcillin, ciprofloxacin, or vancomycin has been associated with a 
reduced incidence of staphylococcal infections. IL-2 administration should be withheld in patients 
developing moderate to severe lethargy or somnolence; continued administration may result in coma. 
 
The standard approach to the administration of high-dose IL-2 in all studies is to continue dosing until 
grade 3 or 4 events occur. The most commonly seen grade 4 events are pulmonary and renal 


September 02, 2020 
Page 23 
impairment, and mental status changes. These toxicities may sometimes require intubation for 
protection of the patient’s airway. It is important to note that although these patients require significant 
supportive measures during this period, all toxicities are reversible and the overwhelming majority of 
patients have suffered no long term sequelae following this treatment regimen. However, fatal 
complications are possible and it is therefore only appropriate to carry out this experimental treatment 
in the context of life threatening metastatic cancer. Within this trial, IL-2 is given as a continuous 
infusion, which may partially abrogate the adverse effects due to high Cmax of bolus dosing, while 
maintaining biologically relevant concentrations within the tissue and plasma compartments. 
 
 
3.2 
Fludarabine/Cyclophosphamide Conditioning Regimen 
The animal and clinical studies cited above (section 1.5) strongly suggest that the clinical effectiveness 
of TIL and their ability to survive and repopulate the host would be enhanced if patients were 
significantly immunosuppressed by the depletion of lymphocytes prior to the adoptive transfer of 
lymphocytes.  Based on this data, a non-myeloablative lymphodepleting chemo-preparative regimen 
consisting of fludarabine/cyclophosphamide, as proposed in this current study, is selected as it has 
been demonstrated it can be tolerated and can be efficacious for the adoptive cell therapy of advanced 
metastatic disease. 
 
Cyclophosphamide will be administered at 60 mg/kg/day IV in 250 mL NS over approximately 2 hours.  
Cyclophosphamide will be initiated seven days prior to the anticipated TIL transfer, and the precise 
timing will depend on the rate of in vitro TIL growth.  If a patient is obese (BMI >35), drug dosage will be 
calculated using practical weight as indicated below. Infusions may be slowed as medically indicated.  
Fludarabine will then be infused at 25 mg/m2 IVPB daily over approximately 30 minutes starting 5 days 
prior to TIL transfer (Day -7 -6 -5, -4, -3).  If a patient is obese (BMI >35), drug dosage will be calculated 
using practical weight. Infusions may be slowed as medically indicated.   
 
 
Body Weight Determination 
 
Actual body weight is used for dose calculations of study treatments (ie, cyclophosphamide, 
fludarabine, TIL, IL-2). 
In subjects who are determined to be obese (BMI > 35), the practical body weight (see item 3 below) 
will be used. 
1. BMI Determination: 
 
• 
BMI = weight (kg) / [height (m)]2 
 
2. Calculation of ideal body weight: 
o Male = 50 kg + 2.3 (number of inches over 60 inches) 
 
Example: ideal body weight of 5’10” male: 50 + 2.3 (10) = 73 kg 
 
o Female = 45.5 kg + 2.3 (number of inches over 60 inches) 


September 02, 2020 
Page 24 
 
Example: ideal body weight of a 5’3” female: 45.5 + 2.3 (3) = 57kg 
 
3. Calculation of “practical weight”: Calculate the average of the actual and the ideal body 
weights. 
 
3.2.1 
Fludarabine (Fludara) 
Fludarabine phosphate is a fluorinated nucleotide analog of the antiviral agent vidarabine, 9-β-D-
arabinofuranosyladenine (ara-A) that is relatively resistant to deamination.   Fludarabine is a purine 
antagonist antimetabolite.  Fludarabine phosphate is rapidly dephosphorylated to 2-fluoro-ara-A and 
then phosphorylated intracellularly by deoxycytidine kinase to the active triphosphate, 2-fluoro-ara-ATP.  
This metabolite appears to act by inhibiting DNA polymerase alpha, ribonucleotide reductase and DNA 
primase, thus inhibiting DNA synthesis.  The mechanism of action of this antimetabolite is not 
completely characterized and may be multi-faceted.  
 
Fludarabine will be purchased from commercial sources as a powder in the form of a white, lyophilized 
solid cake.  The fludarabine powder is stable for at least 18 months at 2 – 8 degrees C; when 
reconstituted, fludarabine is stable for at least 16 days at room temperature.  Specialized references 
should be consulted for specific compatibility information.  Fludarabine is dephosphorylated in serum, 
transported intracellularly and converted to the nucleotide fludarabine triphosphate; this 2-fluoro-ara-
ATP molecule is thought to be required for the drug’s cytotoxic effects.  Fludarabine inhibits DNA 
polymerase, ribonucleotide reductase, DNA primase, and may interfere with chain elongation, and RNA 
and protein synthesis. 
 
Fludarabine is administered as an IV infusion in 100 mL 0.9% sodium chloride, USP over approximately 
15 to 30 minutes.  At doses of 25 mg/m2/day for 5 days, the primary side effect is myelosuppression.  
However, thrombocytopenia is responsible for most cases of severe and life-threatening hematologic 
toxicity.  Hemolytic anemia has been reported after one or more courses of fludarabine with or without a 
prior history of a positive Coomb’s test; fatal hemolytic anemia has been reported.  In addition, bone 
marrow fibrosis has been observed after fludarabine therapy.  Other common adverse effects include 
malaise, fatigue, anorexia, and weakness.  Irreversible and potentially fatal central nervous system 
toxicity in the form of progressive encephalopathy, blindness, and coma is rare at the currently 
administered doses.  More common neurologic side effects at the current doses of fludarabine include 
weakness, pain, malaise, fatigue, paresthesias, visual or hearing disturbances, and sleep disorders.  
Adverse respiratory effects of fludarabine include cough, dyspnea, and allergic or idiopathic interstitial 
pneumonitis. Tumor lysis syndrome has been rarely observed in fludarabine treatment of chronic 
lymphocytic leukemia. 
 
3.2.2 
Cyclophosphamide (Cytoxan) 
Cyclophosphamide is a synthetic anti-neoplastic drug chemically related to the nitrogen mustards.  It is 
biotransformed principally in the liver to active alkylating metabolites by a mixed function microsomal 
oxidase system.  These metabolites interfere with the growth of susceptible rapidly proliferating 
malignant cells.  The mechanism of action is thought to involve cross-linking of tumor cell DNA.   
 
Cyclophosphamide is well absorbed after oral administration with a bioavailability greater than 75%.  
The unchanged drug has an elimination half-life of 3 to 12 hours.  It is eliminated primarily in the form of 
metabolites, but from 5% to 25% of the dose is excreted in urine as unchanged drug.  Several cytotoxic 
and non-cytotoxic metabolites have been identified in urine and in plasma.  Concentrations of 
metabolites reach a maximum in plasma 2 to 3 hours after an IV dose.  Plasma protein binding of 


September 02, 2020 
Page 25 
unchanged drug is low but some metabolites are bound to an extent greater than 60%.  It has not been 
demonstrated than any single metabolite is responsible for either the therapeutic or toxic effects of 
cyclophosphamide.  Although elevated levels of metabolites of cyclophosphamide have been observed 
in patients with renal failure, increased clinical toxicity in such patients has not been demonstrated. 
 
Following conversion to active metabolites in the liver, cyclophosphamide functions as an alkylating 
agent and possesses potent immunosuppressive activity.   The serum half-life after intravenous 
administration ranges from 3 to 12 hours; the drug and/or its metabolites can be detected in the serum 
for up to 72 hours after administration. 
     
Cyclophosphamide will be obtained from commercially available sources. It will be diluted in 250 mL NS 
and infused over approximately two hours.  The dose will be based on the patient’s body weight. 
Hematologic 
toxicity 
occurring 
with 
cyclophosphamide 
usually 
includes 
leukopenia 
and 
thrombocytopenia.  Anorexia, nausea, and vomiting may occur, especially after high-doses.  Diarrhea, 
hemorrhagic colitis, and mucosal and oral ulceration have been reported in patients.  Sterile 
hemorrhagic cystitis occurs in about 20% of patients; severity can range from microscopic hematuria to 
extensive cystitis with bladder fibrosis.  Although the incidence of hemorrhagic cystitis associated with 
cyclophosphamide appears to be lower than that associated with ifosfamide, mesna (sodium 2-
mercaptoethanesulfonate) has been used prophylactically as an uroprotective agent   Mesna may not 
be effective in all patients.  Patients who receive high dose cyclophosphamide may develop interstitial 
pulmonary fibrosis, which can be fatal.  Hyperuricemia due to rapid cellular destruction may occur, 
particularly in patients with hematologic malignancy.  Hyperuricemia may be minimized by adequate 
hydration, alkalinization of the urine, and/or administration of allopurinol.  If allopurinol is administered, 
patients should be watched closely for cyclophosphamide toxicity due to allopurinol induction of hepatic 
microsomal enzymes.  At high doses, cyclophosphamide can also result in a syndrome of inappropriate 
antidiuretic hormone secretion; hyponatremia with progressive weight gain occurs.  Cardiotoxicity has 
been observed at high doses of cyclophophamide.  Deaths have occurred from diffuse hemorrhagic 
myocardial necrosis and from acute myopericarditis; in such cases, congestive heart failure may occur 
within a few days of the first dose.  Other consequences of cyclophosphamide cardiotoxicity include 
arrhythmias, potentially irreversible cardiomyopathy, and pericarditis.  Other reported adverse effects of 
cyclophosphamide include headache, dizziness, and myxedema; faintness, facial flushing, and 
diaphoresis. Patients may require loop diuretics such as furosemide as-needed during 
cyclophosphamide treatment for treatment of edema. 
  
3.3 
Mesna (Sodium 2-mercaptoethanesulfonate, Mesnum, Mesnex, NSC-113891) 
Mesna (sodium 2-mercaptoethanesulphonate; given by IV injection) is a synthetic sulfhydryl compound 
that can chemically interact with urotoxic metabolites of cyclophosphamide (acrolein and 4-
hydroxycyclophosphamide) to decrease the incidence and severity of hemorrhagic cystitis.   
 
Mesna was developed as a prophylactic agent to reduce the risk of hemorrhagic cystitis.  Analogous to 
the physiological cysteine-cystine, mesna is rapidly oxidized to its major metabolite, mesna disulfide 
(dimesna).  Mesna disulfide remains in the intravascular compartment and is rapidly eliminated by the 
kidneys.  In the kidney, the mesna disulfide is reduced to the free thiol compound, mesna, which reacts 
chemically with the urotoxic metabolites, resulting in their detoxification.   
 
Mesna will be obtained commercially and is supplied as a 100 mg/mL solution.  Intact ampules are 
stored at room temperature.  Diluted solutions (1 to 20 mg/dL) are physically and chemically stable for 
at least 24 hours under refrigeration.  Mesna is chemically stable at room temperature for 48-72 hours 
in D5W, 48-72 hour in D5W/0.45% normal saline, or 24 hours in normal saline.  It will be diluted up to 


September 02, 2020 
Page 26 
20 mg Mesna/mL fluid in D5W or normal saline and will be administered intravenously as a continuous 
infusion.  Toxicities include nausea, vomiting and diarrhea.  
 
3.4 
Granulocyte-Colony Stimulating Factor (G-CSF, Filgrastim, tbo-filgrastrim) 
Filgrastim is a human granulocyte colony-stimulating factor (G-CSF)‚ produced by recombinant DNA 
technology. Filgrastim‚ which has been selected as the name for recombinant methionyl human 
granulocyte colony-stimulating factor (r-metHuG-CSF). Biological equivalents, such as tbo-filgrastim or 
peg-filgrastim, are considered acceptable alternatives. 
 
Filgrastim is a 175 amino acid protein manufactured by recombinant DNA technology, produced by 
Escherichia coli (E coli) bacteria into which has been inserted the human granulocyte colony-
stimulating factor gene. Filgastrim is a sterile‚ clear‚ colorless‚ preservative-free liquid for parenteral 
administration. The product is available in single use vials and prefilled syringes. The single use vials or 
prefilled syringes contain either 300 mcg or 480 mcg Filgrastim. 
 
The starting dose of Filgastrim is approximately 5 mcg/kg/day, usually rounded to either 300 mcg or 
480 mcg prefilled syringes‚ administered as a single daily injection by SC injection. A CBC and platelet 
count should be obtained before instituting Filgastrim therapy‚ and monitored twice weekly during 
therapy. Doses may be increased‚ according to the duration and severity of the ANC nadir. 
 
Filgastrim should only be administered if required based upon treating clinician discretion. Common 
reasons which may prompt initiation of filgrastrim include refractory infection, evidence of sepsis, or 
persistence of febrile neutropenia despite optimal supportive care. Filgrastrim should not be given 
earlier than 24 hours after the administration of cytotoxic chemotherapy. Filgastrim should not be 
administered in the period 24 hours before the administration of chemotherapy. Filgastrim can be 
administered daily for up to 2 weeks‚ until the ANC has reached 1‚000/mm3 following the expected 
chemotherapy-induced neutrophil nadir. The duration of Filgastrim therapy needed to attenuate 
chemotherapy-induced neutropenia may be dependent on the myelosuppressive potential of the 
chemotherapy regimen employed. Filgastrim therapy should be discontinued if the ANC surpasses 
1‚000/mm3 after the expected chemotherapy-induced neutrophil nadir.  
3.5 
Levofloxacin (Levaquin) and Trimethoprim and Sulfamethoxazole double strength (TMP / 
SMX DS, Bactrim) 
Levofloxacin is used to prevent infections caused by bacteria.  It is a synthetic broad spectrum 
antibacterial agent.  The mechanism of action of Levofloxacin involves inhibition of bacterial 
topoisomerase IV and DNA gyrase, enzymes required for DNA replication, transcription, repair, and 
recombination.  An alternative antibiotic by mouth for patients who are allergic to Levofloxacin will be 
Keflex.  
 
TMP/SMX SS will be obtained by from commercial sources.  It will be used for the prevention of 
Pneumocystis carinii Pneumonia (PCP).  The standard oral dose is 1 tablet PO SS daily, or DS tablet 
three times a week. Like other sulfa drugs, Bactrim (sulfamethoxazole-trimethoprim) can cause 
allergies, fever, nausea, and vomiting. Allergies typically develop as a widespread itchy red rash with 
fever eight to fourteen days after beginning the standard dose. Neutropenia, a reduction in the number 
of neutrophils, can also occur.   
 


September 02, 2020 
Page 27 
3.6 
Acyclovir (Zovirax) and Valacyclovir Hydrochloride (Valtrex) 
Valacyclovir or acyclovir will be obtained by from commercial sources.   
 
Valtrex is the hydrochloride salt of L-valyl ester of acyclovir.  It is rapidly converted to acyclovir, which 
has demonstrated antiviral activity against herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) and 
varicella-zoster virus (VZV).  The inhibitory activity of acyclovir is highly selective due to its affinity for 
the enzyme thymidine kinase (TK) encoded by HSV and VZV.  This viral enzyme converts acyclovir into 
acyclovir monophosphate, a nucleotide analogue.  The monophosphate is further converted into 
diphosphate by cellular guanylate kinase and into triphosphate by a number of cellular enzymes.  
Acyclovir triphosphate stops replication of herpes viral DNA. 
 
Valtrex (valacyclovir) is the preferred antiviral to be used to prevent the occurrence of herpes virus 
infections.  Acyclovir is an acceptable alternative. It is supplied as oral tablets of 200 and 800 mg.  
Reversible renal insufficiency has been reported with intravenous but not oral acyclovir.  Neurologic 
toxicity including delirium, tremors, coma, acute psychiatric disturbances, and abnormal EEGs has 
been reported with higher doses of acyclovir.  Should this occur, a dosage adjustment will be made, or 
the drug should be discontinued.  Stomach upset, headache, nausea, rash, hives, diaphoresis, 
hematuria; hypotension, and thrombocytosis have been reported.  Hair loss from prolonged use has 
also been documented. Acyclovir will not be used concomitantly with other nucleoside analogs that 
interfere with DNA synthesis, e.g. ganciclovir.  In renal disease, the dose is adjusted as per product 
labeling.  
 
3.7 
Fluconazole (Diflucan) 
Fluconazole will be obtained by from commercial sources.  It will be used for prophylaxis against fungal 
infections.  It is available in 200 mg tablets.  It can cause headache, nausea, vomiting, diarrhea or 
abdominal pain, and liver damage that may be irreversible.  It can cause rashes and itching, which in 
rare cases has caused Stevens Johnson Syndrome. It has several significant drug interactions.  
Voriconazole is a alternative for patients at very high risk for opportunistic fungal infections, especially 
those receiving prolonged courses of oral corticosteroids.  
 
3.8 
Ondansetron hydrochloride (Zofran) 
Ondansetron hydrochloride will be obtained from commercial sources.  It will be used to control nausea 
and vomiting during the chemotherapy preparative regimen.  It can cause headache, dizziness, 
myalgias, drowsiness, malaise, and weakness.  Less common side effects include chest pain, 
hypotension, pruritis, constipation and urinary retention.  Consult the package insert for a complete list 
of side effects and specific dose instructions. 
 
3.9 
Furosemide (Lasix) 
Furosemide, a loop diuretic, will be obtained from commercial sources.  It will be used to enhance urine 
output during the chemotherapy preparative regimen with cyclophosphamide. Adverse effects include 
dizziness, vertigo, paresthesias, weakness, orthostatic hypotension, photosensitivity, rash and pruritis.  
Consult the package insert for a complete list of side effects and specific dose instructions. 
 


September 02, 2020 
Page 28 
3.10 
Nivolumab 
3.10.1 Identification 
Nivolumab is available in concentrations of 100 mg/10mL. The sterile solution in the vial is clear and 
colorless. Nivolumab is administered via intravenous infusion only.  
PRODUCT INFORMATION TABLE:  
 
 
 
 
 
 
 
 
 
 
 
 
3.10.2 Packaging and Labeling 
Bristol Myers Squibb (BMS) will provide nivolumab antibody at no cost for this study.  Nivolumab will be 
provided in open-label 10 mL vials containers at a concentration of 10 mg/mL. The labels will contain 
the protocol prefix, batch number, content, storage conditions, and dispensing instructions along with 
the Investigational New Drug (IND) caution statement.  
 
3.10.3 Storage 
Nivolumab must be stored in a secure area according to local regulations. The investigator must ensure 
that it is stored at a temperature ≥ 2°C and ≤ 8°C. 
 
3.10.4 Handling and Disposal 
As with all injectable drugs, care should be taken when handling and preparing Nivolumab. Whenever 
possible, Nivolumab should be prepared in a laminar flow hood or safety cabinet using standard 
precautions for the safe handling of intravenous agents applying aseptic technique. Latex gloves are 
required. If Nivolumab concentrate or solution comes in contact with skin or mucosa, immediately and 
thoroughly wash with soap and water. After final drug reconciliation, unused Nivolumab solution should 
be disposed at the site following procedures for the disposal of anticancer drugs. 
3.11 
TIL Cell Preparation   
 
Product Description:  (Nivolumab, Other names = MDX-1106, ONO-4538, anti-PD-1) 
Product 
Description 
and Dosage 
Form 
Potency 
Primary 
Packaging 
(Volume)/ 
Label Type 
Secondary 
Packaging 
(Qty) 
/Label 
Type 
Appearance 
Storage 
Conditions 
(per label) 
Nivolumab 
(BMS-
936558-01)* 
Injection drug 
product is a 
sterile, non-
pyrogenic, 
single-use, 
isotonic 
aqueous 
solution  
100 
mg/Vial 
(10 
mg/mL). 
Carton of 5 or 
10 vials 
10-mL Type 
1 flint glass 
vials 
stoppered 
with butyl 
stoppers and 
sealed with 
aluminum 
seals. 
Clear to 
opalescent, 
colorless to 
pale yellow 
liquid.  May 
contain 
particles 
BMS-936558-01 
Injection must be 
stored at 2 to 8 
degrees C (36 to 
46 degrees F) 
and protected 
from light and 
freezing. 
 


September 02, 2020 
Page 29 
The procedures and reagents for expanding human TIL cells will be followed according to Moffitt Cell 
Growth Facility SOPs. Briefly, TIL from the patient tumor biopsy are cultured and expanded in IL-2 
(6000IU/ml) for an average of 21 days in 24 well culture plates. Briefly, patient tumor biopsies are 
dissected and 3mm tumor fragments were each cultured in separate wells of a 24 well culture plate with 
in RPMI media supplemented with 10% Human AB serum and 600IU/mL of IL-2. Each well is assessed 
every 2 to 3 days for TIL. TIL were fed every 2 to 3 days by removing half volume of media and 
replacing half volume of fresh media. Wells are split when TIL reach approximately >80% confluence. 
TIL cultures are tested by ELISA for tumor specific interferon-gamma (INF-γ) production after 24 hour 
stimulation with either tumor digest or CD3/CD28 beads.  TIL are selected and pooled based on  
growth and IFN-γ production. Timing for patient dosing is facilitated by cryopreservation of the pooled 
TIL. When patients were ready for dosing, TIL are thawed and rapidly expanded in IL-2 (300IU/ml) and 
anti-CD3 (30ng/ml) with a layer of feeder cells in large flasks and incubated for approximately 14 days. 
Upon harvest, TIL product undergoes Quality Control testing  and release testing.  
 
Plastic adherence method is used to generate dendritic cells. Autologous PBMCs or apheresis samples 
are thawed and resuspended, incubated at 37°C, 5% CO2. After 90 minutes, non-adherent cells are 
collected and washed with media, then cultured over 7-10 days in media containing IL-4 and GM-CSF, 
then frozen in 10% DMSO for correlative assays.  
 
4.0 
Eligibility Assessment and Enrollment 
 
 
Patient evaluation for eligibility and registration will occur utilizing a two-step design (at screening prior 
to tumor harvest and prior to lymphodepletion with chemotherapy). Patients with antibiotic allergies per 
se are not excluded; although the production of TIL for adoptive transfer includes antibiotics, extensive 
washing after harvest will minimize systemic exposure to antibiotics. 
 
4.1 
Screening, Initiation of Nivolumab, and TIL Expansion  
 
Patients must fulfill all of the following screening criteria to be eligible for the study.  
 
4.1.1 Screening Inclusion Criteria 
1. Age greater than or equal to 18 years  
2. Able to understand and give written informed consent. 
3. Confirmed or suspected diagnosis of stage IV or recurrent non-small cell lung cancer (NSCLC). 
For suspected NSCLC, diagnosis must be histologically or cytologically confirmed prior to start 
of nivolumab treatment.  Neuroendocrine cancers, or mixed neuroendocrine features in >10% of 
tumor cells, are excluded. 
4. Tumor deemed accessible by metastatectomy (TIL harvest) which expects to yield >1.5 cm3 of 
resectable tumor amount. 
5. Measurable disease, even after resection of applicable lesion for TIL harvest. Defined as ≥1 
lesion that is ≥10 mm in one dimension by CT scan, MRI, or calipers on clinical exam.  
6. ECOG performance status of 0 or 1 
7. Expected survival > 6 months 
8. Patients with activating EGFR mutation or ALK rearrangement which is expected to be 
responsive to available tyrosine kinase inhibitor therapy, must have been previously treated with 
an applicable tyrosine kinase inhibitor.   
9. Adequate normal organ and marrow function in an assessment performed within 7 days (+ 3 
day window) of enrollment as defined below:  
• 
Hemoglobin ≥ 9.0 g/dL 


September 02, 2020 
Page 30 
• 
Absolute neutrophil count (ANC) ≥ 1.0 x 109/L (> 1000 per mm3) 
• 
Platelet count ≥ 100 x 109/L (>100,000 per mm3) 
• 
PT and PTT ≤ 1.5x the institutional upper limit of normal (ULN), (This will not apply to subjects with 
confirmed Factor XII deficiency.) 
• 
Serum bilirubin ≤ 1.5x the institutional ULN, or ≤ 3x ULN if confirmed Gilbert’s syndrome (persistent or 
recurrent hyperbilirubinemia that is predominantly unconjugated in the absence of hemolysis or hepatic 
pathology) 
• 
AST (SGOT)/ALT (SGPT) ≤ 2.5x institutional ULN unless liver metastases are present, in which case it 
must be ≤ 5x ULN 
• 
Serum creatinine of ≤ 1.5x institutional ULN. 
• 
Albumin ≥ 2.5 g/dl. 
10. Positive screening EBV IgG antibody titer on screening test. 
11. Cardiac stress test within past 6 months without evidence of reversible ischemia. 
12. Cardiac echocardiogram, stress test, or MUGA within past 6 months with demonstrated LVEF > 
50% 
13. Pulmonary function tests within past 6 months showing DLCO >50% of predicted. Adjusted 
DLCO based on hemoglobin concentration should be used, if available. 
 
4.1.2 Screening Exclusion Criteria 
1. More than 5 lines of prior systemic therapy in the preceding three years. 
2. Any previous treatment with a PD-1 or PD-L1 inhibitor, including but not limited to: nivolumab, 
atezolizumab, pembrolizumab, avelumab, or durvalumab.  
3. Current or prior use of any immunosuppressive medications, such as corticosteroids, within 14 
days before enrollment.  
a. Oral hydrocortisone, only for the purposes of a documented and confirmed adrenal 
insufficiency diagnosis, is permitted if ≤ 25 mg daily total dose.  
b. Inhaled, intranasal, or topical corticosteroids are permitted. 
4. Patients with untreated brain metastases. Treated brain metastases with radiation or surgery 
are allowed if: ≤ 3 cm in size AND ≤ 4 in number AND there is no evidence of progressive 
disease, on brain imaging ≥ 21 days after last day of CNS treatment.  
5. History of leptomeningeal metastases. 
6. Current or prior use of anticancer therapy before TIL collection: 
a. Chemotherapy within the past 4 weeks; 
b. Tyrosine kinase inhibitor (TKI) within the past 1 week; 
c. Investigational therapy within the past 4 weeks or 4 half-lives, whichever is shorter.  
7. Uncontrolled intercurrent illness including, but not limited to, symptomatic congestive heart 
failure, unstable angina pectoris, cardiac arrhythmia (other than stable atrial fibrillation), and 
significant carotid artery stenosis. 
8. Patients known to be HIV positive, hepatitis B or C positive, or both RPR and FTA positive. 
(Hepatitis B surface or core antibody alone is not indicative of HBV infection).  
9. Patients with rapidly progressing tumors, as judged by the investigator. 
10. Mean QT interval corrected for heart rate (QTc) ≥470 ms calculated from electrocardiograms 
(ECGs) using Bazett’s Correction  
11. Known history of previous tuberculosis  
12. Receipt of live attenuated vaccination within 30 days prior to first anticipated dose of nivolumab.  
13. History of allogeneic organ transplant  
14. History of primary immunodeficiency  
15. History of severe hypersensitivity to nivolumab, cyclophosphamide, fludarabine, interleukin-2, or 
any excipient  
16. Any condition that, in the opinion of the investigator, would interfere with evaluation of study 
treatment or interpretation of patient safety or study results  


September 02, 2020 
Page 31 
17. Patients with active systemic infections requiring intravenous antibiotics within 1 week prior to 
enrollment 
18. Any unresolved toxicity (>CTCAE v4 grade 2) from previous anti-cancer therapy. Subjects with 
irreversible toxicity that is not reasonably expected to be exacerbated by the investigational 
product may be included (e.g., hearing loss, peripheral neuropathy).  
19. History of pneumonitis or drug-related inflammatory lung disease  
20. Patients who have a significant history of pulmonary disease that necessitates the use of 
supplemental oxygen, and patients with resting pulse oximetry <92% on room air.  
21. Active or prior documented autoimmune disease within the past 2 years. NOTE: Subjects with 
vitiligo, Grave’s disease, limited site eczema, or limited site plaque psoriasis not requiring 
systemic treatment (within the past 2 years), or other autoimmune conditions which are not 
expected to recur, are allowed after approval from the medical monitor or PI.  
22. Patients with other prior malignancies must have had a ≥ 2-year disease-free interval, except 
for: in situ carcinoma of the cervix, in situ ductal carcinoma of the breast, in situ prostate cancer, 
in situ bladder cancer. These must have been deemed stable and not expected to relapse. In 
addition, early stage skin cancers, including basal, squamous cell cutaneous carcinoma, and 
melanoma, are permitted if previously treated with curative intent and not expected to relapse.  
23. Women who are pregnant or lactating. 
24. Women of childbearing potential and fertile men unwilling to use effective contraception during 
study until 4 months after conclusion of the treatment period. 
 
 
4.1.3 Screening Procedures 
 
All patients must sign an informed consent form and a negative pregnancy test (serum) must be 
documented for women of childbearing potential at screening and within 7 days before starting 
nivolumab. Screening procedures are outlined in the study calendar. If patients have had redundant 
laboratory screening studies performed for another reason within 14 days of enrollment, they need not 
be repeated, with the exception of pregnancy testing. If patients have had redundant imaging screening 
studies, such as CT scan or MRI, within 30 days of enrollment, then these need not be repeated. If a 
cardiac stress test is required and was done within the previous 6 months, the test will not be repeated 
unless in the judgment of the investigator at the time of screening, there has been a significant interval 
change in the patient’s clinical status. 
 
For patients who have a suspected but not confirmed diagnosis of metastatic NSCLC, the diagnosis 
must be confirmed cytologically or histologically prior to nivolumab treatment. This permits biopsy of 
patients for both histology confirmation and TIL harvest in a single procedure.  
 
4.2 
Adoptive Cell Treatment – Chemotherapy/TIL Infusion 
 
4.2.1 Testing prior to Adoptive cell therapy  
Patients must fulfill all of the following criteria to be eligible for the adoptive cell treatment phase. 
Laboratory testing must be complete and satisfactory within 14 days of initiation of chemotherapy. 
Imaging tests must be complete and satisfactory within 14 days of initiation of chemotherapy, and the 
identical criteria and management will be followed as discussed in section 4.1.1. 
 
4.2.2 REP Eligibility Checklist 
On Day -21, investigator will complete an eligibility checklist to confirm that it is appropriate to initiate 
the TIL REP by Cell Therapies Core. 


September 02, 2020 
Page 32 
 
1. Clinical performance status equivalent to ECOG 0-1 at the last calendar clinical visit.  
2. Does not currently have a partial or complete response to nivolumab treatment 
3. Absolute neutrophil count greater than or equal to 1000/mcL. 
4. Platelet count greater than or equal to 100,000/mcL. 
5. Hemoglobin greater than or equal to 8.0 g/dL(Note that this threshold is slightly lower than the 
initial trial screening parameter since most subjects will require blood transfusion at some point 
during the protocol treatment, and the established threshold for transfusion is 8 gm/dL). 
6. Serum ALT and AST less than three times the institutional upper limit of normal. 
7. Serum creatinine of ≤ 1.5x institutional ULN 
8. Total bilirubin less than or equal to 2.0 mg/dL, except in patients with Gilbert’s Syndrome who 
must have a total bilirubin less than 3.0 mg/dL 
9. Patient has central IV access or request for central IV access submitted.  
 
4.2.3 Chemotherapy/Cell Infusion Eligibility Checklist  
On Day -8 (or within 7 days prior to Day -7), investigator must complete an eligibility checklist attesting 
that subject is fit to proceed with lymphodepletion and adoptive cell transfer.  
 
1. Patients must have adequate TIL available as per Moffitt Cell Therapies current SOP. 
2. Male patients with female partners of childbearing potential and female patients of childbearing 
potential must agree to use contraception for six months after receiving the preparative regimen  
3. For women of child-bearing potential, a negative serum pregnancy testing will be verified within 
7 days prior to treatment. 
4. Clinical performance status equivalent to ECOG 0-1 at the clinical visit prior to lymphodepletion.  
5. Absolute neutrophil count greater than or equal to 1000/mcL. 
6. Platelet count greater than or equal to 100,000/mcL. 
7. Hemoglobin greater than or equal to 8.0 g/dL(Note that this threshold is slightly lower than the 
initial trial screening parameter since most subjects will require blood transfusion at some point 
during the protocol treatment, and the established threshold for transfusion is 8 gm/dL). 
8. Serum ALT and AST less than three times the institutional upper limit of normal. 
9. Serum creatinine less than or equal to 1.7 mg/dL. 
10. Total bilirubin less than or equal to 2.0 mg/dL, except in patients with Gilbert’s Syndrome who 
must have a total bilirubin less than 3.0 mg/dL. 
11. PT and PTT less than or equal to 1.5 times the institutional upper limit of normal 
12. Patients with EKG within 14 days of initiation of chemotherapy demonstrating no new significant 
rhythm, axis or ST segment changes will be included. If clinically significant, new EKG changes 
are present, patients may be included if cardiac stress test indicates no reversible cardiac 
ischemia.  
13. Urinalysis within 14 days demonstrating that no urinary tract infection is present.   
14. Compete history and physical examination will be required within 2 weeks prior to initiation of 
chemotherapy.   
 
5.0 
Treatment Plan 
5.1 
Treatment Outline   
TIL will be expanded in a state-of-the-art Good Medical Practices-certified cell growth facility at Moffitt 
Cancer Center that will allow compliance with all FDA regulations regarding investigational cell transfer 
products.  The Moffitt adoptive cell therapy laboratory has demonstrated consistent TIL expansions of 
greater than 400 fold, which is ideal to treat patients with cell numbers consistent with earlier clinical 


September 02, 2020 
Page 33 
experiences at the National Cancer Institute (NCI), Moffitt Cancer Center and MD Anderson Cancer 
Center.  TIL expansion will occur per Moffitt Cancer Center Cell therapy Standard Operating 
Procedures. 
 
Venipuncture to obtain blood for correlative immunologic assays will be performed at screening. 
Nivolumab will be administered intravenously at a fixed dose of 240 mg for four doses beginning after 
tumor harvest (+/- 7 days). Patients will have a history and physical examination, vital signs and 
complete blood count and comprehensive metabolic panel prior to nivolumab. Women of child-bearing 
potential will have a confirmed negative serum pregnancy test prior to each nivolumab therapy. If 
patients are hospitalized for unanticipated reasons such as an adverse event, then patients are 
permitted to omit one nivolumab infusion (eg Day -49, Day -35, or Day -21) in order to remain on the 
calendar schedule. 
 
Cyclophosphamide will be administered at 60 mg/kg/day IV in 250 mL NS over approximately 2 hours.  
Cyclophosphamide will be initiated seven days prior to the anticipated TIL transfer, and the precise 
timing will depend on the rate of in vitro TIL growth.  The dose will be based on the patient’s body 
weight.  Fludarabine will then be infused at 25 mg/m2 IVPB daily over approximately 30 minutes starting 
7 days prior to TIL transfer.  On day 0, all patients will receive TIL administered according to the current 
Moffitt Cell Therapy TIL SOP. Eight (8) to twelve (12) hours after completing the TIL infusion, all 
patients will begin intermediate-dose decrescendo interleukin-2 (IL-2).  Doses will be skipped if patients 
reach Grade III or IV toxicity including diarrhea, nausea, vomiting, hypotension, skin changes, anorexia, 
mucositis, dysphagia, or constitutional symptoms and laboratory changes (i.e. platelets, creatinine, total 
bilirubin).  If the toxicity is easily reversed by supportive measures, then additional doses may be 
continued.  There will be no dose modification for IL-2, although dose holds are permitted as outlined in 
IL-2 section. Patients will discontinue IL-2 treatment for altered mental status, supra-ventricular 
arrhythmias that require medication, evidence of myocarditis, uncontrolled hypotension, urine output 
less than 600 mL per 24 hours and/or creatinine of ≥3.5 gm/dL in spite of maximal supportive 
measures, bilirubin of ≥8 gm/dL, positive blood culture, or evidence of infection. IL-2 will be 
permanently discontinued in patients who develop a life-threatening ventricular arrhythmia, life-
threatening infection, myocardial infarction, or persistently altered mental status.  
 
 
 
 
Of note, in a previous Moffitt trial, there were no DLTs related to adoptive cell therapy in melanoma (as 
defined in 34 days after TIL infusion; this time point was chosen as based on our previous experience 
as a majority of significant toxicity occurs within 2 weeks of the adoptive cell therapy. Therefore 3 – 4 
weeks is a reasonable point to determine toxicity for safety assessment purposes). The dose of 
nivolumab will be fixed at 240 mg. Since nivolumab is FDA-approved at a fixed dose of 240 mg q2 
weeks or 480 mg q4 weeks, there is no anticipated requirement to escalate the dosing of nivolumab.  If 
at any point on the trial, toxicity probability is concluded to exceed 17% on the stopping boundary as 
defined in Section 8.0, the trial will stop accrual. In order to be evaluable for safety, patients must have 
received Cy/Flu chemotherapy and completed ≥70% of planned visits due the DLT evaluation period. 
Up to 20 subjects will be enrolled, with the goal of having 14 evaluable patients. Additional subjects 
may be replaced. No more than 4 subjects will be allowed into the DLT evaluation period at any given 
time.  
 
 
Treatment: 


September 02, 2020 
Page 34 
Timing is based on days after day of TIL administration, defined as day 0. Note due to the variable time 
required to prepare TIL, the precise days that some of the treatment events will occur after the TIL 
transfer will be variable. 
Nivolumab dose will be fixed at 240 mg for 4 doses every 2 weeks prior to TIL.  
Nivolumab dose will be fixed at 480 mg every 4 weeks up to 12 months after TIL. 
Nivolumab dose will be fixed at 480 mg every 4 weeks until progression for patients who have 
achieved PR/CR after their initial 4 doses. Reference Section 5.10 
Nivolumab infusion rate will be infused over 30 minutes (or 60 minutes, per institutional standard). 
 
The following is an outline intended to elaborate upon select procedures, in accordance with 
the study calendar. The study calendar is intended to serve as the primary management 
guide. 
 
Day -67: Tumor harvest for TIL. 
 
Day -63:  Venipuncture for baseline sample to be used in correlative assays. First intravenous dose 
of nivolumab. 
 
Day -49: Intravenous dose of nivolumab. 
 
Day -35: Intravenous dose of nivolumab. Venipuncture for correlative assays (post 2 dose of 
nivolumab). Restaging scans will be done (and only those patients without PR/CR will proceed to 
have TIL expanded, those with PR/CR will continue nivolumab q4 weeks until progression, at which 
point they may then proceed to ACT after applicable checklist assessment) 
 
Day -21: Intravenous dose of nivolumab. Completion of REP eligibility checklist prior to REP for 
eligible patients. 
 
Day -8: Venipuncture for correlative assays (post 4 doses of nivolumab). Restaging scans will be 
done (and only those patients without PR/CR will proceed to TIL infusion, those with PR/CR will 
continue nivolumab q4 weeks until progression, at which point they may then proceed to TIL 
infusion).  Completion of REP eligibility checklist (for those patients who had not previously 
undergone at day –21), as well as chemotherapy checklist assessment (for all patients receiving 
TIL infusion) prior to proceeding to conditioning chemotherapy (within 10 days of anticipated start of 
lymphodepletion). 
 
Day -7 and -6 (timing will depend on rate of TIL growth): 
Cyclophosphamide 60 mg/kg/day IV in 250 mL NS over approximately 2 hrs x 2 days. Mesna 20 
mg/kg with D5W or NS at 125 mL/hr infused intravenously over 24 hours after each 
cyclophosphamide dose. Venipuncture for correlative assays (pre-lymphodepletion). Extended 
outpatient hospital stay. 
 
Day -7 to Day -3 (timing will depend on rate of TIL growth): 
Fludarabine 25 mg/m2 IVPB daily over approximately 30 minutes for 5 days.   
 
Day 0 (timing will depend on rate of TIL growth): 


September 02, 2020 
Page 35 
Venipuncture (10 mL only to confirm lymphodepletion). TIL infusion will be administered according 
to the Moffitt Cell Therapy TIL SOP. Vital signs (temperature, blood pressure, pulse and respiratory 
rate) and pulse oximetry will be monitored every 15 minutes during the TIL infusion, every 30 
minutes for 1 hour after TIL infusion, and hourly thereafter for a total of 4 hours after completion of 
the infusion.  G-CSF will be administered per protocol until ANC >1000/mcL or clinician discretion. 
 
Day 0 - 10 (timing will depend on rate of TIL growth): Intermediate-dose decrescendo IL-2 will 
begin 8-12 hours after TIL infusion, and continue as per decrescendo regimen outlined in section 
3.1 (18 MIU/m2 over 6, 12, and 24 hours followed by 4.5 MIU/m2 over 24 hours for up to 3 days 
depending on tolerance).  Patients will receive IL-2 as part of an inpatient hospitalization starting 
Day 0 which is anticipated to be for approximately 7-10 days.  
 
Day 14: (approximate; precise days will depend on rate of TIL growth): Toxicity assessment 
and PBMCs for correlatives.  
 
Day 28 (approximate; precise days will depend on rate of TIL growth):       
Toxicity assessment and assessment for response (restaging scans).Venipuncture (post TIL 
therapy). Apheresis catheter, if necessary, will be placed and up to 5 L of blood volume for 
apheresis product.  
Day 28 (approximate) and onward: Patient proceed to receive nivolumab 480 mg IV every 4 
weeks for up to one year. 
 
 
5.2 
Prophylaxis 
 
5.2.1 Infection Prevention and Pneumocystis carinii Pneumonia (PCP) Prophylaxis 
Patients will receive ciprofloxacin at 500 mg daily (or other preferred antibiotic if allergic to 
fluoroquinolone) until ANC recovers to greater than 1000/mcL and the fixed combination of 
trimethoprim (TMP) and sulfamethoxazole (SMX) as single strength (SS) tablet [SS tabs = TMP 80 
mg/tab and SMX 400 mg/tab] po daily.  TMP/SMX-SS will be taken by patients beginning on Day +28 
and continuing until six months or CD4 count is >200 cells/mcL.  Patients with sulfa allergies will 
receive aerosolized Pentamidine 300 mg per nebulizer within one week prior to admission and 
continued monthly for the same duration. 
 
In addition to ANC specification above, patients will take ciprofloxacin (or preferred antibiotic) during 
intermediate dose IL-2 therapy. 
 
5.2.2 Herpes Virus Prophylaxis 
Within one day after TIL infusion, patients will be administered valacyclovir 500 mg po daily or acyclovir 
800 mg twice daily, if patient is able to take oral medications, which is continued for one year for HSV 
prophylaxis. Acyclovir 5 mg/kg IVPB every 8 hours is given if patient needs intravenous medications. 
Reversible renal insufficiency has been reported with IV administered acyclovir but not with oral 
acyclovir.  Neurologic toxicity including delirium, tremors, coma, acute psychiatric disturbances, and 
abnormal EEGs has been reported with higher doses of acyclovir.  If symptoms occur, a dosage 
adjustment will be made or the drug be discontinued.  Valacyclovir or acyclovir will not be used 
concomitantly with other nucleoside analogs (e.g. ganciclovir), which interfere with DNA synthesis. In 
patients with renal disease, the dose is adjusted as per product labeling. 
 


September 02, 2020 
Page 36 
5.2.3 Fungal Prophylaxis  
Patients will begin fluconazole 200 mg po daily within one day after the TIL infusion (Day +1) and 
continue until the absolute neutrophil count is >1000/mcL or clinician discretion. 
 
5.2.4 Empiric Antibiotics  
If fever, patients will be admitted as inpatient status and start on broad-spectrum antibiotics, either a 3rd 
or 4th generation cephalsosporin or a fluoroquinolone for fevers ≥38.5 oC with an ANC less than 
500/mcL.  Aminoglycosides should be avoided unless there is evidence of sepsis. Infectious disease 
consultation will be obtained for patients when deemed appropriate by the treating attending physician. 
 
5.2.5 Blood Product Support  
Using daily CBC’s as a guide, the patient will also receive platelets and packed red blood cells 
(PRBC’s) as needed.  Attempts will be made to keep Hemoglobin >8.0 gm/dL, and platelets 
>20,000/mcL. Leukocyte reduction protocols or filters will be utilized for all blood and platelet 
transfusions to decrease sensitization to transfused WBC’s and decrease the risk of CMV infection.  
Irradiated blood and blood products should be used. 
5.3 
Apheresis 
Blood leukapheresis will take place at designated days as described in the study calendar. If required, 
apheresis catheters will be placed in interventional radiology on the designated day and removed after 
collection at the designated cell therapies apheresis suite by the designated nurse practitioner or 
physician. If site is incapable of performing an apheresis, then PBMC kit will be obtained instead. 
 
5.4 
TIL Harvest 
Accessible tumors deemed safely accessible by a surgeon will be reviewed for eligibility. Tumor 
procedure must be expected to yield at least 1.5 cm 3 of tumor tissue. Tumor tissue will be collected by 
the cellular therapies core, selected, and expanded accordingly to their previously established TIL 
protocols.  
Examples of potential sites for NSCLC TIL biopsy procedures include excisional supraclavicular or 
axillary lymph node biopsies, excisional biopsy of subcutaneous metastasis, cervical mediastinoscopy, 
or pleural biopsy via video-assisted thoracoscopic surgery (VATS).  
 
5.5 
Despite evidence of a metastasis on cross-section imaging, it is conceivable that initial 
TIL harvest obtained by excisional biopsy could yield no tumor tissue (negative biopsy). 
In this case, it is preferred that the TIL will be discarded and not used for manufacturing. 
Instead a second excisional biopsy of a different metastastic site may be arranged. This 
repeat 
biopsy 
is 
permitted 
to 
be 
obtained 
up 
until 
Day 
-35 
of 
trial. 
 
Definition of Dose-Limiting Toxicity (DLT) 
Toxicity will be assessed using Common Terminology Criteria for Adverse Events version 4.0 (CTCAE 
v4). Dose-limiting toxicity will be assessed separately for nivolumab treatment and adoptive cell therapy 
(comprised of lymphodepletion, TIL transfer and intermediate dose IL-2).  
 
DLT related to nivolumab will be defined as any grade ≥3 immune-related adverse event definitely 
attributable to nivolumab.  


September 02, 2020 
Page 37 
 
DLT related to adoptive cell therapy will be defined as: 
• 
any grade 3 toxicity lasting more than 7 days, occurring upon or after the start of 
chemotherapy, that is not related to non-small cell lung cancer or other pre-existing condition, 
or  
• 
any grade ≥ 4 toxicity, regardless of duration, occurring upon or after the start of chemotherapy, 
that is not related to non-small cell lung cancer or other pre-existing condition 
With the following exceptions: 
• 
Myelosuppression (includes bleeding in the setting of platelet count less than 50 x109/L and 
documented bacterial infections in the setting of neutropenia), defined as lymphopenia, 
neutropenia, decreased hemoglobin, and thrombocytopenia (since these are expected due to 
the chemotherapy preparative regimen)  
• 
Immediate hypersensitivity reactions (excluding symptomatic bronchospasm and grade 4 
hypotension) occurring within 2 hours of TIL infusion that are reversible to a ≤ grade 2 within 24 
hours of TIL administration with standard therapy  
• 
Grade 3 or 4 fever  
• 
Tumor lysis syndrome (TLS) including associated manifestations attributable to TLS (eg, 
electrolyte abnormalities, renal function, hyperuricemia)  
• 
Grade 3 transaminase, alkaline phosphatase, bilirubin or other liver function test elevation, 
provided there is resolution to ≤ grade 2 within 14 days  
• 
Grade 4 transient serum hepatic enzyme abnormalities provided there is resolution to ≤ grade 3 
within < 72 hours and ≤ grade 2 within 14 days  
• 
Grade 3 cardiac adverse events (eg, arrhythmia, ventricular dysfunction) must resolve to grade 
2 or better within 48 hours 
 
5.6 
Progressive disease (PD) procedures. 
All patients with the occurrence of progressive disease after Day 0, including non-target lesions, must 
undergo a percutaneous core tumor biopsy. This biopsy should be performed within 14 days of the first 
occurrence of progression. An EUS, EBUS, FNA if an acceptable alternative only for patients whose 
lesion is not accessible to core biopsy. This tumor biopsy may be deferred for safety reasons only after 
documented discussion with the PI. 
Before Day 0, patients with progressive disease who are changing treatment should also undergo a 
percutaneous core tumor biopsy. This tumor biopsy may be deferred for safety reasons only after 
documented discussion with the PI. Note that patients with symptomatic progressive disease prior to 
Day 0 are permitted to remain on study with expectation of receiving bridging therapy are not required 
to receive a PD biopsy at that timepoint, per Section 5.10 below.  
 
 
5.7 
Confirmation of progression (PD).  
Patients with the occurrence progressive disease after Day 0 who are not experiencing symptoms of 
clinical deterioration may be permitted to continue on nivolumab treatment at the discretion of the 
investigator. A PD CRF and biopsy is still required in this instance. Tumor imaging should be repeated 
within a 4 to 6 week interval, and if additional increase in target lesions by >10% or unequivocal non-
target progression is present, then the patient must discontinue treatment. If a diagnostic biopsy reveals 
only benign tissue in the radiographically progressing lesion(s), then the subject is also permitted to 
remain on nivolumab. 


September 02, 2020 
Page 38 
 
5.8 
End of Treatment (EOT) procedures. 
All patients who experience confirmed disease progression (PD) will enter into the EOT treatment 
phase. A +0 EOT should be completed at the time the patient is permanently discontinued from regular 
study follow-up. This  +0 EOT is not applicable if a regular study visit, including PBMC blood draw, was 
performed within 3 days of the time that the subject was permanently discontinued from the study 
study. The +0 EOT can be combined with the PD procedure visit if clinically practical. After EOT +90, 
patients may occasionally be contacted by telephone for survival follow-up for up to five years.  
 
The EOT visits do not apply to patients who have permanently stopped nivolumab for toxicity or drug 
intolerance. These patients must continue to receive scheduled imaging visits until confirmed disease 
progression is observed per the study calendar and footnotes. 
  
5.9 
Criteria for treatment with TIL after initial response to nivolumab. 
 
Patients who experience initial response (PR/CR) with nivolumab and then have the occurrence of 
disease progression may be eligible to subsequently receive the TIL product.  This eligibility is 
contingent upon an attestation from Cell Therapies Core that sufficient frozen pre-REP cell product 
remains available for the TIL manufacture, and that the patient meets the REP eligibility checklist as 
outlined. The investigator will also need to provide an attestation that the patient continues to meet 
eligibility requirements as outlined in 4.1, with the exception of items: 4.1.1 #4, 5, 9, 10, 11, 12, 13; and 
4.1.2 #1, 2, 21. These patients will follow study procedures beginning on Day -21. 
 
Patients who have achieved a response to initial nivolumab (PR/CR) may voluntarily elect to forego 
their subsequent trial-related visits and procedures at the study site if it imposes undue hardship. The 
rationale for this is that regular indefinite q28d nivolumab visits may result in cumulative burden for 
patients traveling from long distances, such as >300 miles. These patients are permitted to be seen 
and treated at the discretion of their local oncology team.  If disease recurrence is suspected, then the 
patient will be set up with Day -21 clinic visit, and then complete pre-REP eligibility checklist and 
procedures per Section, in preparation for subsequent Cy/Flu/TIL. 
 
5.10 
Bridging therapy and criteria for TIL treatment 
Patients who receive at least one dose of nivolumab, but experience clinical decline in ECOG PS 
attributable to cancer, as judged by the investigator, are eligible to stop nivolumab and instead receive 
bridging therapy with standard-of-care (SOC) systemic therapy. If the patients have improvement in 
ECOG PS and then have evidence of progression (PD) on subsequent CT scans, then these patients 
are then eligible to receive subsequent TIL product. This eligibility is contingent upon an attestation 
from Cell Therapies Core that sufficient frozen pre-REP cell product is available for a TIL manufacture, 
and that the patient meets the REP eligibility checklist as outlined. The investigator will also need to 
provide an attestation that the patient continues to meet eligibility requirements as outlined in 4.1, with 
the exception of items: 4.1.1 #4, 5, 9, 10, 11, 12, 13; and 4.1.2 #1, 2, 21. These bridging therapy 
patients will then follow study procedures beginning on Day -21. 
 
1. Current or prior use of anticancer therapy before TIL collection: 
a. Chemotherapy within the past 4 weeks; 
b. Tyrosine kinase inhibitor (TKI) within the past 1 week; 
c. Investigational therapy within the past 4 weeks or 4 half-lives, whichever is shorter.  
Patients who are started upon bridging therapy will follow the following study calendar: 


September 02, 2020 
Page 39 
 
Study Calendar during Bridging   
*,** ALL +/- 3 DAYS *** 
 
Bridging 
 
 
Window  
Procedures after 
Day 
Therapy 
-21 -8 
±7 (8, 17) -7 (18) 
Day -7 follow main 
Medical history 
- 
• 
• 
 
• 
calendar. Pg 11 
Current medications 
− 
• 
• 
 
• 
 
Physical Exam 
- 
• 
• 
 
• 
 
Vital Signs including SpO2 (1) 
- 
• 
• 
 
• 
 
Performance Status 
- 
• 
• 
 
• 
 
REP Eligibility Checklist 
 
• 
 
 
 
 
Chemotherapy Checklist 
 
 
• 
 
 
 
EKG 
− 
• 
• 
 
 
 
Blood Tests  
 
 
 
 
 
 
CBC, CMP  
- 
• 
• 
 
• 
 
CEA  
− 
• 
• 
 
• 
 
PT/PTT 
− 
 
• 
 
 
 
Thyroid Tests (T4, TSH) (5) 
− 
• 
 
 
• 
 
Blood Pregnancy Test (6) 
-- 
• 
• 
 
 
 
Peripheral Blood Draw for Correlatives (7) 
 
 
• 
 
 
 
CT Chest-Abdomen-Pelvis (8)(9) 
− 
• 
 
 
 
 
Brain imaging (9) 
− 
• 
 
 
 
 
Chest X-Ray PA/lateral  
 
 
• 
 
 
 
Adverse Event Assessment (11) 
 
-- 
• 
• 
 
• 
 
Urinalysis 
 
 
• 
 
 
 
Lymphodepletion: 
 
 
 
 
• 
 
Cyclophosphamide, Fludarabine 
 
 
 
 
• 
 
5.11 
Failure to manufacture TIL 
In some cases, it is possible that insufficient tumor is harvested for TIL, or insufficient TIL is able to be 
grown to manufacture the final TIL product. In these instances, the patient may continue to receive 
nivolumab at the discretion of their treating physician. However, if progression becomes evident while 
receiving nivolumab, the patient will discontinue trial treatment and receive appropriate therapy at the 
discretion of their treating physician. 
 
Patients with initial response to nivolumab who subsequently progress on TIL are described in Section 
5.9.  
 
6.0 
Evaluation during Study 
 
During the preparative cyclophosphamide-fludarabine regimen therapy, patients will have a complete 
blood count (CBC) and comprehensive metabolic profile every 1 to 2 days of treatment.  On the day of 
TIL infusion, patients will be monitored with vital signs at baseline and after cell infusion as described in 
section 5.1.  Venipuncture will be performed at screening and on days as listed in the study calendar. In 
addition, apheresis will be performed on day 28 (+/- 7 days). These samples will be used to evaluate T 
cell persistence by comparing TCR clonotyping to the products of TIL infusion. Serum may be used to 
determine anti-tumor antibody formation using autologous tumor targets from excess, unused tumor 
obtained at the time of tumor harvest for TIL. 
 
Clinical evaluation for tumor response with physical examinations and appropriate CT scans (routine 
chest, abdomen and pelvis, as well as any additional areas deemed appropriate by the study physician) 
and brain MRI will be performed pre nivolumab treatment, prior to lymphodepletion and 6 weeks 
following the adoptive TIL transfer.  Then patients will have restaging CT scans with follow-up visits as 


September 02, 2020 
Page 40 
outlined in the study calendar.   For patients with CT IV contrast allergy, appropriate premedication, use 
of MRI or CT without IV contrast will be undertaken at the discretion and judgment of the PI. Note CT of 
the head without and with IV contrast (if not allergic) will be substituted for brain MRI in cases of 
existing MRI contraindication. These follow-up assessments will be performed for all patients on the 
study until disease progression, withdrawal of consent, loss to follow-up or death.  
 
 
Descriptive correlative laboratory studies: 
Recovered circulating T cells will be assessed for TIL persistence by Vβ clonotyping T cell receptor. 
The TCR of the cells from PBMC collections will also be derived by sequencing. Persistence of TIL will 
be determined by comparing the clonotyping results of the TIL to the post-infusion blood samples. 
Persistence will be correlated to clinical outcome.  
The generation of specific effector T cell activity in TIL capable of recognizing HLA-matched tumor cells 
will be assessed by the use of a TIL-target co-culture assay for 24 hours followed by an ELISA for 
gamma interferon as has been described previously (1).  Successfully generated TIL from each 
discrete tumor fragment will be tested. TIL will be co-incubated with HLA-matched or autologous tumor 
targets at a ~2:1 ratio for a 24-hour period, and supernatants will be removed. Aliquots will be used for 
a gamma interferon ELISA assay, as well as multiplex cytokine bead array assay. Controls will include 
no effector and no target samples, as well as an HLA-mismatched target control. Assays will be 
performed in triplicate. Observation of more than 200 picograms per mL of gamma interferon and/or a 
statistically significant increase in pro-inflammatory cytokine release over the controls is desired for an 
assay to be declared positive at a given time point.  
At the time of tumor harvest for TIL, a core or core-equivalent biopsy after tumor extirpation will be 
obtained. Immunohistochemistry will be performed to assay CD3, CD4, CD8 as well as T cell immune 
checkpoint expression. In addition, TCR sequencing will be performed on the TIL product and 
applicable PBMC samples, and whole-exome sequencing will be performed on the biopsy of harvested 
tumor. Due to the small sample size of this study, results will be reported descriptively.  If sufficient 
material is available, peptide sequencing of the tumor will be performed by the Moffitt Proteomic Core. 
If sufficient material is available, single-cell RNA sequencing and/or bulk RNA sequencing of the tumor 
harvest sample or progressive biopsy will be performed. Tumor antigens will be predicted using existing 
MCC bioinformatics pipeline. Predicted peptides may be synthesized and tested for autologous 
reactivity with either cultured T cells or fresh T cells.  
 
 Collaborative laboratory studies  
• 
Multi-color serial flow cytometry of PBMCs and TIL will be performed, including CD3, CD8, CD4, 
CD25, and T cell immune checkpoint markers to assess change in phenotype before/after TIL. 
For available research tumor samples, MultiOmyx, a multi-parameter immunohistochemistry, 
will be performed to assess for T cell subsets and activation status. This includes measurement 
of expression levels and spatial distribution and will utilize a finalized material transfer 
agreement. One to two unstained 5 um de-identified FFPE slides from each tumor will be sent 
externally to the vendor for this. Unused slides will be returned.  
• 
In addition, some functional testing of T cells using de-identified samples may be performed at 
Fred Hutchison Cancer Center with the Riddell Lab, using a finalized material transfer 
agreement. Correlative analysis of circulating factors, such as Bioplex 27 platform, will be 
performed on serial serum samples to assess changes in cytokine production before/after TIL. 


September 02, 2020 
Page 41 
Single-cell cytokine profiling will be performing on CD8+ cells using Isolight ® to assess for 
change in polyfunctional T cells before/after TIL.  
• 
Some de-identified PBMC samples may also be released to Pilon-Thomas laboratory for testing 
of MDSC phenotype.  
• 
Additional in vitro testing will be performed to validate predicted antigens on correlative 
samples. Depending on HLA status, NFAT-GFP engineered Jurkat cells (NFAT-GFP-Jurkat) will 
be transfected with DNA encoding predicted epitopes together with the relevant HLA allele and 
the intracellular CD3/CD28 signaling domain. When recognized and bound with the epitope-
specific TCR on T cells, HLA-epitope complex on NFAT-GFP-Jurkat cells are expected to 
transmit activation signals through CD3/CD28 intracellular domain to NFAT, which in turn 
causes the expression of GFP. Using this technique, the GFP+Jurkat cells will be sorted for 
sequencing of the epitope portion and antigen epitope sequence derived. These experiments 
will be performed through an academic collaboration which Dr Creelan has with Dr Xi Chen, 
PhD at Root Path Genomics in Cambridge MA. For an appropriate sample, Moffitt would 
provide 1 TIL sample, 1 vial of PBMCs, and information on the identified neoantigen to his 
laboratory. Moffitt will receive all the results from the experiments derived from these de-
identified samples. Drs. Wang and Dr. Creelan, of Moffitt will supervise these projects and retain 
primary roles in the intellectual direction, interpretation and reporting, including writing  
academic papers or presentations. 
• 
Dr Creelan is working with Dr Klebanoff to specifically explore KRAS mutations as an effective 
neoantigen. Moffitt may transfer one (1) vial of pre-TIL PBMC, one (1) vial of post-TIL PBMC, 
one (1) vial of random TIL fragment culture, and one (1) vial of post-REP TIL to Dr. Chris 
Klebanoff's laboratory at Memorial Sloan Kettering Cancer center. The team’s hypothesis is that 
several TCRs which Dr Klebanoff has already experience and identified in others patients a set 
of TCR alpha beta chains which may interact with KRAS. The analysis plan is to perform 
functional validation using the peptides and pMHC tetramer/pentamers that he has synthesized 
on the cells. He will incubate the peptide or pMHC and test for activation marker display by flow 
cytometry. He may sort cells based on memory or activation markers to determine if the specific 
TCR of interest is present before or after peptide stimulation in TIL and PBMCs. He may also 
perform paired single-cell VDJ seq on the cultured TIL, PBMCs, or uncultured tumor suspension 
immune cells. Moffitt will receive all the results from the experiments derived from these de-
identified samples. This includes raw data and downstream interpretation files such as UMAP 
plots, tsne plots, volcano plots. Drs. Wang and Dr. Creelan, of Moffitt, expect to be maintained 
in an academic role and retain active collaborative roles in the intellectual direction, 
interpretation and reporting of the data, including citation as authors in academic papers or 
presentations. 
• 
Dr Creelan works closely with Dr Antonia for this trial. Moffitt may transfer TIL samples to Dr 
Scott Antonia at Duke Cancer Institute for ATAC seq single-cell analysis to determine potential 
causes of resistance to adoptive cell transfer. This research is exploratory, and intended to 
identify signatures related to exhaustion of TIL or what phenotype may constitute an effective 
TIL product. Drs. Wang and Dr. Creelan, of Moffitt, expect to be maintained in an academic role 
for any projects involving this patient's data. They retain active collaborative roles in the 


September 02, 2020 
Page 42 
intellectual direction, interpretation and reporting of the data, including citation as authors in 
academic papers or presentations. 
• 
Moffitt may transfer raw RNA-Seq or exome .bam or .vcf files through a collaboration with Dr 
Rabadan in bioinformatics at Columbia University. Dr Rabadan is the Gerald and Janet Carrus 
Professor in Systems Biology, Biomedical Informatics and Surgery at Columbia University. Dr 
Rabadan’s group is experienced in detecting tumor allelic HLA loss of hetereozygosity and this 
is a hypothesized exploratory resistance mechanism for TIL. Dr Creelan is working with Dr 
Rabadan, to explore HLA mutation, down-regulation, or LOH as a mechanism of resistance for 
TIL treatment. Moffitt will receive all the results from the experiments derived from these de-
identified samples. This includes downstream interpretation files such as plots, tsne plots, 
volcano plots. Drs. Wang and Dr. Creelan, of Moffitt, expect to be maintained in an academic 
role for any projects derived from this. They retain active collaborative roles in the intellectual 
direction, interpretation and reporting of the data, including citation as authors in academic 
papers or presentations. 
 
7.0 
Evaluation of Toxicity 
7.1 
Toxicity Monitoring 
An Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of a pre-
existing medical condition in a patient or clinical investigation subject administered an investigational 
(medicinal) product and that does not necessarily have a causal relationship with this treatment. An AE 
can therefore be any unfavorable and unintended sign, symptom, or disease temporally associated with 
the use of investigational product, whether or not considered related to the investigational product. 
Adverse events can be spontaneously reported or elicited during open-ended questioning, examination, 
or evaluation of a subject. (In order to prevent reporting bias, subjects should not be questioned 
regarding the specific occurrence of one or more AEs.) 
This study will utilize the National Cancer Institute Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 for toxicity and Adverse Event reporting.  A copy of the CTCAE version 4.0 can be 
found online at the NCI website.  Careful evaluation to ascertain the toxicity and immunologic effects 
and anti-tumor efficacy of nivolumab and the cell infusion will be performed.  Toxicities will be 
monitored and documented beginning at ~day -63 (nivolumab infusion) and continuing at regular 
intervals as outlined in the study calendar. Patients with treatment-limiting toxicity will continue to be 
followed as outlined in the study calendar, footnote 19. Dose limiting toxicity is defined above. 
 
The sponsor, Moffitt Cancer Center, with the cooperation of the principal investigator, will monitor the 
data and toxicities to identify trends.  The principal investigator will be responsible for revising the 
protocol as needed to maintain safety.  The sponsor’s contact for transmission of material to the FDA at 
Moffitt is: 
 
Carrie Thomas 
Moffitt Cancer Center 
Ph 813 745 3467 
FAX 813 745 3933  
 


September 02, 2020 
Page 43 
The principal investigator will also review serious adverse events and evaluate trends.  Whenever a 
trend is identified, the sponsor, in cooperation with the principal investigator will determine an 
appropriate follow-up plan. 
 
The use of nivolumab as well as the non-myeloablative chemotherapy regimen in this protocol entail 
serious potential discomforts and hazards for the patient.  Although it is anticipated that this protocol is 
relatively safe because of the expected recovery of the patients’ bone marrow within 2 to 4 weeks, fatal 
complications are possible.  It is therefore only appropriate to carry out this experimental procedure in 
the context of life-threatening advanced cancer.  The major hazards are infection, immune-related 
adverse events and disease progression.  The major discomforts are nausea, mucositis, anorexia, 
diarrhea, fever and malaise.   
 
Select side effects of common drugs used in this non-myeloablative regimen include, but are not limited 
to: 
 
Cyclophosphamide: Marrow suppression, nausea, mucositis, rash, hemorrhagic cystitis, myocardial 
damage, alopecia, infertility, nausea and vomiting, and syndrome of inappropriate antidiuretic hormone 
(SIADH).  
  
Fludarabine: Myelosuppression, fever and chills, nausea and vomiting, malaise, fatigue, anorexia, 
weakness, neurologic toxicity, and interstitial pneumonitis.  Serious opportunistic infections have 
occurred in chronic lymphocytic leukemia (CLL) patients treated with fludarabine. 
 
Antimicrobials in general: Allergic reactions, renal impairment, nausea, vomiting, hepatic damage, 
marrow suppression.  
 
Intermediate-dose IL-2:  A variety of side effects have been associated with intermediate-dose IL-2. 
Intermediate dose IL-2 is thought to have reduced toxicity profile as compared to high dose IL-2.  
 
Adoptive cell therapy with TIL: a variety of side effects that potentially overlap with IL2 have been 
associated with adoptive cell therapy in our experience and at the NCI. Possible long-term side effects 
include: vitiligo, high frequency hearing loss and uveitis. 
 
 
7.2 
Immune-Related Adverse Events and Other Possible Toxicities Attributable to Nivolumab  
Definition of immune-related adverse events (irAEs): Blocking PD-1 function may permit the emergence 
of autoreactive T cells and result in autoimmunity. Nivolumab can result in severe and even fatal 
immune-mediated reactions due to T-cell activation and proliferation. 
For this proposal, an irAE is defined as a clinically significant (i.e requiring intervention) adverse event 
of any organ that is probably associated with nivolumab drug exposure, and is clinically consistent with 
an immune-mediated phenomenon. Serological, immunological, histological (biopsy) data where 
available as well as patient history and physical examination findings should be used to support an irAE 
diagnosis. Additionally the event should be of significant duration (e.g. ≥ 7 days) and/or grade to make 
it unlikely to be caused by non-autoimmune factors. Appropriate efforts should be made to rule out 
neoplastic, infectious, metabolic, toxin or other etiologic causes of the adverse event when clinically 
relevant. Patients will be carefully monitored for evidence of clinically significant systemic irAEs (e.g., 
symptoms associated with systemic lupus erythematosus-like diseases) or organ-specific irAEs (e.g., 
rash, colitis, uveitis, hepatitis or thyroid disease, see below).  


September 02, 2020 
Page 44 
Immune-related Pulmonary Toxicity 
Nivolumab has been reported to cause an immune-mediated pneumonitis. Clinical manifestations 
include acute shortness of breath, chest pain, and increased work of breathing/supplemental oxygen 
requirement. Patients with a previous history of pulmonary disease that require supplemental oxygen or 
more than weekly inhaler therapy will be required to undergo pulmonary function tests at screening. If 
patients on this trial develop acute shortness of breath, a prompt clinical workup will ensue that may 
include CT scan of the chest if clinically warranted. If there is no clinical evidence of non-immune-
mediated pulmonary disease (i.e. pneumonia, pulmonary embolus, or myocardial ischemia), patients 
will be considered for prompt corticosteroid treatment. 
Immune-related Gastrointestinal Events 
The clinical presentation of GI immune-related AEs included diarrhea, increase in the frequency of 
bowel movements, abdominal pain, or hematochezia. Patients will be carefully monitored for GI 
symptoms that may be indicative of immune-related colitis, diarrhea, or GI perforation. Diarrhea or 
colitis occurring after initiation of nivolumab therapy should be evaluated to exclude infectious and 
alternative etiologies. In clinical trials of other similar immunotherapies, immune-related colitis was 
associated with evidence of mucosal inflammation, with or without ulcerations, and lymphocytic 
infiltration. 
Immune-related Hepatotoxicity 
In previous trials of nivolumab, hepatic immune-related AEs were mostly clinically silent and manifested 
as transaminase or bilirubin laboratory abnormalities. Serum transaminase and bilirubin levels will be 
evaluated before dosing of nivolumab as early laboratory changes may be indicative of emerging 
immune-related hepatitis. Elevations in liver function tests (LFTs) may develop in the absence of clinical 
symptoms. Increase in LFTs or total bilirubin will be evaluated to exclude other causes of hepatic injury, 
including infections, disease progression, or medications, and laboratory abnormalities will be 
monitored until resolution. In trials of other similar immunotherapy, liver biopsies from patients who had 
immune-related hepatotoxicity showed evidence of acute inflammation (neutrophils, lymphocytes, and 
macrophages). 
Immune-related Skin Toxicity 
Skin immune-related AEs may present as a rash and/or pruritus. Some subjects reported vitiligo 
associated with nivolumab administration in previous trials. Pruritus can often be managed with oral 
antihistamines. 
Immune-related Endocrinopathy 
Nivolumab may cause inflammation of the endocrine system organs, specifically hypophysitis, 
hypopituitarism, and adrenal insufficiency. Patients may present with nonspecific symptoms, which may 
resemble other causes such as brain metastasis or underlying disease. The most common clinical 
presentation of immune-mediated endocrinopathy includes headache and fatigue. Symptoms may also 
include visual field defects, behavioral changes, electrolyte disturbances, and hypotension. Adrenal 
crisis as a cause of the patient’s symptoms should be excluded. Based on the available data with 
known outcome, most of the subjects symptomatically improved with hormone replacement therapy. It 
is possible that longterm hormone replacement therapy will be required for subjects developing 
hypophysitis/hypopituitarism after treatment with nivolumab. 
Immune-related Neurological Events 
Neurological manifestations from nivolumab may include muscle weakness and sensory neuropathy. 
Fatal Guillan-Barré syndrome has been reported in clinical trials of immunotherapy agents similar to 
nivolumab. Patients may present with muscle weakness. Sensory neuropathy may also occur. 
Unexplained motor neuropathy, muscle weakness, or sensory neuropathy lasting more than 4 days will 


September 02, 2020 
Page 45 
be evaluated and non-inflammatory causes such as disease progression, infections, metabolic 
syndromes, and medications should be excluded. 
Other Immune-related AEs 
Other possible immune-related adverse events associated with nivolumab include ocular inflammation, 
manifesting as episcleritis or uveitis. Other presumed immune-related AEs reported include, but are not 
limited to, arthritis/arthralgias, pneumonitis, pancreatitis, autoimmune (aseptic) meningitis, autoimmune 
nephritis, pure red cell aplasia, noninfective myocarditis, polymyositis, and myasthenia gravis, of which 
have been individually reported for < 1% of subjects.  
It is expected that some subjects may develop infusion-related reactions secondary to nivolumab, 
including diaphoresis, nausea, headache, or hypotension. Low-grade constitutional symptoms such as 
fever and fatigue, as well as headache, allergic rhinitis, nasal stuffiness, arthralgia, myalgia, and cough 
have occurred in prior clinical trials. Other low-grade adverse events include flushing, leukopenia, 
nausea, vomiting, thrombocytopenia, abdominal pain or cramping, anemia, pruritus, rash/ 
desquamation, vitiligo, and diarrhea.  
7.3 
Management of Toxicity Due to Nivolumab and/or TIL therapy 
If an irAE is noted, appropriate workup (including biopsy if possible) should be considered, and steroid 
therapy may be considered if clinically necessary. It is unknown if systemic corticosteroid therapy will 
have an attenuating effect on nivolumab activity, and may attenuate the effects of IL-2 and TIL. 
However, clinical antitumor responses have been maintained in subjects with autoimmunity treated with 
corticosteroids and by discontinuing the immunotherapy, including nivolumab as monotherapy. In our 
recent experience with adoptive cell therapy, one patient required systemic corticosteroids for uveitis 
and still maintained a near complete response 12 months after being weaned from systemic steroids. If 
utilized, corticosteroid therapy should be individualized for each subject. Recommended dosing is 1 
mg/kg of oral prednisone or intravenous methylprednisolone (as clinically warranted) followed by a 
taper over 4-6 weeks. Prior experience suggests that colitis manifested as a Grade 3 diarrhea requires 
systemic corticosteroid treatment.  
 
7.4 
Criteria that Require Permanent Discontinuation of Nivolumab and other study protocol 
treatment that are not related to DLT 
 
7.4.1  
Dose Delay Criteria for Nivolumab 
Because of the potential for clinically meaningful nivolumab-related AEs requiring early recognition and 
prompt intervention, management algorithms have been developed for suspected AEs of selected 
categories. Please see current Investigator Brochure for Nivolumab for citation examples. 
Dose delay criteria for nivolumab apply for all drug-related adverse events (regardless of whether or not 
the event is attributed to nivolumab).  
Subjects may resume treatment with nivolumab when the drug-related AE(s) resolve to Grade ≤ 1 or 
baseline value, with the following exceptions: 
• 
Drug-related grade 2 fatigue, vitiligo, or arthropathy 
• 
Subjects who have not experienced a Grade 3 drug-related skin AE may resume treatment in 
the presence of Grade 2 skin adverse event. 


September 02, 2020 
Page 46 
• 
Subjects with baseline Grade 1 AST/ALT or total bilirubin who require dose delays for reasons 
other than a 2-grade shift in AST/ALT or total bilirubin may resume treatment in the presence of 
Grade 2 AST/ALT OR total bilirubin 
• 
Drug-related combined Grade 2 AST/ALT AND total bilirubin values meeting discontinuation 
parameters should have treatment permanently discontinued 
• 
Drug-related endocrinopathies adequately controlled with physiologic hormone replacement 
may resume treatment 
• 
Drug-related asymptomatic amylase or lipase elevations without clinical evidence of pancreatitis 
may continue drug treatment. 
• 
Other conditions which, after discussion with PI, are not expected to recur, recrudesce, or 
worsen in the presence of additional nivolumab. 
 
If the criteria to resume treatment are met, the subject should restart treatment at the next scheduled 
timepoint per protocol. However, if the treatment is delayed past the next scheduled timepoint per 
protocol, the next scheduled timepoint will be delayed until dosing resumes. 
If treatment is delayed > 10 weeks, the subject must be permanently discontinued from study therapy, 
except as specified below. 
 
7.4.2   
Criteria to Resume Treatment 
Subjects may resume treatment with study drug when the drug-related AE(s) resolve to Grade ≤1 or 
baseline value, with the following exceptions: 
• 
Drug-related grade 2 fatigue, vitiligo, or arthropathy 
• 
Subjects who have not experienced a Grade 3 drug-related skin AE may resume treatment in 
the presence of Grade 2 skin adverse event. 
• 
Subjects with baseline Grade 1 AST/ALT or total bilirubin who require dose delays for reasons 
other than a 2-grade shift in AST/ALT or total bilirubin may resume treatment in the presence of 
Grade 2 AST/ALT OR total bilirubin 
• 
Drug-related combined Grade 2 AST/ALT AND total bilirubin values meeting discontinuation 
parameters should have treatment permanently discontinued 
• 
Drug-related endocrinopathies adequately controlled with physiologic hormone replacement 
may resume treatment 
• 
Drug-related asymptomatic amylase or lipase elevations without clinical evidence of pancreatitis 
may continue drug treatment. 
• 
Other conditions which, after discussion with PI, are not expected to recur, recrudesce, or 
worsen in the presence of additional nivolumab. 


September 02, 2020 
Page 47 
If the criteria to resume treatment are met, the subject should restart treatment at the next scheduled 
timepoint per protocol. However, if the treatment is delayed past the next scheduled timepoint per 
protocol, the next scheduled timepoint will be delayed until dosing resumes. 
If treatment is delayed > 10 weeks, the subject must be permanently discontinued from study therapy, 
except as specified in discontinuation section. 
 
 
7.5 
Criteria that Require Permanent Discontinuation of Nivolumab and other study protocol 
treatment that are not related to DLT 
Subjects MUST discontinue study protocol treatment for any of the following reasons that are not 
related to an immune-related adverse event/DLT:  
• Withdrawal of informed consent (subject’s decision to withdraw for any reason) 
• Pregnancy (see Section 7.13.11)  
• Loss of ability to freely provide consent through imprisonment or involuntary incarceration for 
treatment of either a psychiatric or physical (eg, infectious disease) illness. 
• The development of unequivocal progressive disease accompanied by severe clinical deterioration of 
subject’s condition such that a change of therapy to a different active therapy is immediately required. 
Investigators are permitted to continue treatment if pseudo-progression is suspected. 
 
7.6 
Nivolumab-related 
non-neurological 
adverse 
events 
that 
require 
permanent 
discontinuation and result in a nivolumab-related DLT 
• Any Grade 3 or higher bronchospasm or other Grade 3 or higher hypersensitivity reaction will result in 
nivolumab-related DLT . 
• Any other Grade 3 non-skin related adverse event will result in nivolumab-related DLT with the 
exception of laboratory abnormalities or events listed under “Exceptions to Permanent Discontinuation” 
(section 7.8). 
• Any Grade 4 laboratory abnormalities, except abnormalities of amylase, lipase, AST, ALT, or Total 
Bilirubin will have different parameters that result in nivolumab-related DLT (see immediately below).  
• AST or ALT > 8 x IULN will result in nivolumab-related DLT. 
• Total Bilirubin > 5 x IULN will result in nivolumab-related DLT. 
• Concurrent ALT > 4 X IULN AND total bilirubin > 2 X IULN will result in nivolumab-related DLT. 
•  Grade 4 elevation in amylase and lipase will not result in nivolumab-related DLT if the abnormality 
resolves to grade 1 or less within 2 weeks and if the subject is off steroids >10 mg of prednisone daily . 
• Any other Grade 4 adverse event (including skin-related adverse events) will result in nivoluamab-
related DLT. 
• Any adverse event, laboratory abnormality or intercurrent illness that, in the judgment of the 
investigator, presents a substantial clinical risk to the subject with continued nivolumab dosing will 
result in nivolumab-related DLT. 
 
7.7 
Nivolumab-related neurological adverse events that require permanent discontinuation 
of the trial protocol and result in a nivolumab-related DLT 
• Any Grade 2 eye pain or reduction of visual acuity that does not respond to topical therapy and does 
not improve to Grade 1 severity within 2 weeks of starting therapy or requires systemic treatment  
• Any motor neurologic toxicity >/= Grade 3 regardless of causality 


September 02, 2020 
Page 48 
• Any>/= Grade 3 treatment-related sensory neurologic toxicity. Please refer to the Investigator 
Brochure for nivolumab for specific treatment algorithms. 
 
7.8 
Exceptions to Permanent Discontinuation of Nivolumab due to Toxicity:  
• Potentially reversible inflammation (< Grade 4), attributable to a local antitumor reaction and a 
potential therapeutic response. This includes inflammatory reactions at sites of tumor resections or in 
draining lymph nodes, or at sites suspicious for, but not diagnostic of metastasis 
• Hematologic and non-hematologic toxicities not felt due to an irAE and managed as above 
• Hospitalization for Grade 2 adverse events where the primary reason for hospitalization is to expedite 
the clinical work-up 
• Subjects with the following conditions where in the investigator’s opinion continuing study drug 
administration is justified:  
 
Ocular toxicity that has responded to topical therapy  
Endocrinopathies where clinical symptoms are controlled with appropriate hormone replacement 
therapy. 
 
Note: Nivolumab may not be restarted while the subject is being treated with systemic corticosteroids 
except for subjects on stable doses of physiologic/homeostatic hormone replacement therapy such as 
prednisone 10 mg daily or equivalent steroid dosing. All subjects who discontinue treatment 
prematurely due to a protocol treatment-related AE or symptomatic progression prior to disease 
assessment 12 weeks following adoptive TIL transfer will be asked to return for the applicable PD visit 
and series of EOT visits at 0, 30 and 90 days. 
 
7.9 
Management of gastrointestinal irAEs (diarrhea and colitis) 
Patients with grade 1 diarrhea without blood may be managed symptomatically with loperamide, one 
tablet after each loose bowel movement up to 7 tablets in 24 hours or diphenoxylate/atropine four times 
a day until diarrhea subsides. For those with grade 2 diarrhea, or grade 1 diarrhea with blood, 
Budesonide may be added to the regimen for 14 days. If grade 3 diarrhea occurs, patients will be 
started on budesonide and tapering doses of prednisone over at least 30 days at the discretion of the 
treating physician. If there is bloody grade 3 diarrhea, intravenous methylprednisolone will be 
administered. For grade 4 diarrhea or any clinical concern for hemodynamic instability, patients will be 
hospitalized and given intravenous methylprednisolone, made NPO, and hydrated intravenously as 
clinically indicated. For all patients with grade 2 diarrhea or more, flexible sigmoidoscopy or 
colonoscopy will be performed with at least three random biopsies if normal appearing, and three or 
more directed biopsies if abnormal.  
 
7.10 
Non-DLT nivolumab-related Grade 3 IRAEs 
For the purposes of this trial, non-DLT nivolumab drug-related irAEs are skin-related immune-mediated 
adverse events of Grade 3 or less and potentially reversible inflammation <Grade 4 that can be 
attributable to a local antitumor reaction that could potentially be a therapeutic response as judged by 
treating Moffitt physician will be considered an non-dose limiting irAE related to nivolumab. Grade IV 
elevations in amylase and/or lipase that resolve to grade 1 within 2 weeks, and if the subject is off 
steroids >10 mg of prednisone daily within 2 weeks will not result in nivolumab-related DLT.  
 


September 02, 2020 
Page 49 
7.11 
Infusion Reactions Related to Nivolumab 
Since nivolumab contains only human protein sequences, it is unlikely that any allergic reaction will be 
seen in subjects. However, it is possible that the infusion will induce a cytokine release syndrome that 
could be evidenced by fever, chills, rigors, rash, pruritus, hypo- or hypertension, bronchospasm, or 
other symptoms. No prophylactic premedication will be given unless indicated by previous experience 
in an individual subject (detailed below). Infusion reactions should be treated based upon the following 
recommendations: 
 
For mild symptoms: (Localized cutaneous reactions such as mild pruritus, flushing, rash) the rate of 
infusion will be decreased until recovery from symptoms, then the infusion may be completed at the 
initial planned rate. Diphenhydramine 50 mg (or equivalent medication) and/or acetaminophen 325-
1000 mg, may be administered at least 30 minutes before administration of nivolumab, at the discretion 
of the health care provider.  
 
For moderate symptoms: For any symptom not listed above (mild symptoms) or below (severe 
symptoms) such as generalized pruritus, flushing, rash, dyspnea, hypotension with systolic BP >80 mm 
Hg, the infusion will be interrupted, the patient will receive diphenhydramine 50 mg IV (or equivalent 
medication) and/or acetaminophen 325-1000 mg, and the subject will be monitored until resolution of 
symptoms. Corticosteroid treatment may be authorized at the discretion of the treating physician. The 
infusion may be resumed after recovery of symptoms at the discretion of the treating physician. The 
infusion may be resumed at one-half the initial infusion rate, then increased incrementally to the initial 
infusion rate if no further complications ensue after 30 minutes. If symptoms develop after resumption 
of the infusion, the infusion should be discontinued and no additional treatment should be administered 
within 7 days. If clinical recovery after 7 days is complete, an additional attempt at treatment may be 
undertaken with monitoring, following the same treatment guidelines outline above. At the discretion of 
the treating physician, additional oral or IV diphenhydramine 50 mg (or equivalent medication) and/or 
acetaminophen 325-1000 mg ay be administered. 
 
For severe symptoms: For any reaction such as bronchospasm, generalized urticaria, systolic blood 
pressure <80 mm Hg, mental status change, or angioedema, nivolumab infusion will be immediately 
discontinued. The treating physician will consider bronchodilators, epinephrine 1 mg IV or IM and/or 
diphenhydramine 50 mg IV with solumedrol as needed. Subjects will be monitored until complete 
resolution of symptoms or will be admitted to the hospital if the symptoms have not resolved after 6 
hours or upon closure of the outpatient facility. Nivolumab will be permanently discontinued for severe 
symptoms. 
 
In the case of late-occurring hypersensitivity symptoms (e.g. appearance within one week after 
treatment of a localized or generalized pruritus), symptomatic treatment may be given (e.g., oral 
antihistamine or corticosteroids). 
 
7.12 
Adverse Event Reporting to the FDA 
All adverse events will be reported to the FDA in the annual report according to this table: 
 
Attribution 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Unrelated 
 
 
X 
X 
X 
Unlikely 
 
 
X 
X 
X 
Possible 
X 
X 
X 
X 
X 


September 02, 2020 
Page 50 
Probable 
X 
X 
X 
X 
X 
Definitive 
X 
X 
X 
X 
X 
 
 
Exceptions to this rule will include events and laboratory abnormalities that represent common 
symptoms and abnormalities of non-small cell lung cancer and chemotherapy and/or have no clinical 
significance: 
 
• 
Abnormalities in hematologic parameters due to myelosuppressive therapeutic effect: 
i. 
Anemia, neutropenia, lymphopenia, thrombocytopenia 
ii. 
Epistaxis or bleeding except for catastrophic CNS or pulmonary hemorrhage 
• 
Common symptoms of cancer (unless grade >/= 3) including: 
i. 
Fatigue 
ii. 
Weakness 
iii. 
Bone, joint or muscle pain 
iv. 
Alopecia 
v. 
Loss of appetite, nausea, vomiting 
vi. 
Chemistry abnormalities (phosphorus, calcium, glucose) 
vii. 
Coagulation abnormalities (shortened PT, PTT, increased fibrinogen) 
• 
Laboratory abnormalities: 
i. 
CEA (increased or decreased) 
ii. 
Alkaline phosphatase (increased or decreased) 
iii. 
Low levels of the following: AST, ALT, creatinine, BUN, uric acid, bilirubin, albumin, total 
protein 
iv. 
Electrolyte abnormalities (sodium, potassium, bicarbonate, CO2, magnesium 
• 
General therapy related events: 
i. 
Catheter related events 
ii. 
Rash related to antibiotic use 
 
7.13 
ADVERSE EVENT REPORTING  
7.13.1 Serious Adverse Events 
A Serious AE (SAE) is any untoward medical occurrence that at any dose:  
• 
results in death 
• 
is life-threatening (defined as an event in which the subject was at risk of death at the time of the 
event; it does not refer to an event which hypothetically might have caused death if it were more 
severe) 
• 
requires inpatient hospitalization or causes prolongation of existing hospitalization (see NOTE 
below)      
• 
results in persistent or significant disability/incapacity 
• 
results in a congenital anomaly/birth defect  
• 
is an important medical event (defined as a medical event(s) that may not be immediately life-
threatening or result in death or hospitalization but, based upon appropriate medical and scientific 
judgment, may jeopardize the subject or may require intervention [eg, medical, surgical] to prevent 
one of the other serious outcomes listed in the definition above.) Examples of such events include, 
but are not limited to: intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization.)   


September 02, 2020 
Page 51 
• 
Suspected transmission of an infectious agent (eg, any organism, virus or infectious particle, 
pathogenic or non-pathogenic) via the study drug is an SAE. 
Although pregnancy, overdose, cancer are not always serious by regulatory definition, these events 
must be handled as SAEs.   
NOTE: The following hospitalizations are not considered SAEs: 
• 
a visit to the emergency room or other hospital department lasting less than 24 hours that does not 
result in admission (unless considered an “important medical event” or a life-threatening event) 
• 
elective surgery planned before signing consent 
• 
admissions as per protocol for a planned medical/surgical procedure 
• 
routine health assessment requiring admission for baseline/trending of health status (eg, routine 
colonoscopy) 
• 
medical/surgical admission for purpose other than remedying ill health state that was planned 
before study entry. Appropriate documentation is required in these cases. 
• 
Admission encountered for another life circumstance that carries no bearing on health status and 
requires no medical/surgical intervention (eg, lack of housing, economic inadequacy, caregiver 
respite, family circumstances, administrative). 
 
7.13.2 Collection and Reporting 
Adverse events can be spontaneously reported or elicited during open-ended questioning, examination, 
or evaluation of a subject. (In order to prevent reporting bias, subjects should not be questioned 
regarding the specific occurrence of one or more AEs.) 
The following categories and definitions of causal relationship to investigational product as determined 
by a physician should be used: 
• 
Related: There is a reasonable causal relationship to investigational product administration and the 
adverse event. 
• 
Not Related: There is not a reasonable causal relationship to investigational product administration 
and the adverse event. 
The expression “reasonable causal relationship” is meant to convey in general that there are facts (eg, 
evidence such as dechallenge/rechallenge) or other arguments to suggest a positive causal 
relationship. 
 
If known, the diagnosis of the underlying illness or disorder should be recorded, rather than its 
individual symptoms. The following information should be captured for all AEs: onset, duration, 
intensity, seriousness, relationship to investigational product, action taken, and treatment required. If 
treatment for the AE was administered, it should be recorded in the medical record. 
The investigator shall supply the sponsor and Ethics Committee with any additional requested 
information, notably for reported deaths of subjects. 
 
7.13.3 Serious Adverse Events 
Following the subject’s written consent to participate in the study, all SAEs must be collected, including 
those thought to be associated with protocol-specified procedures. All SAEs must be collected that 
occur within 30 days of discontinuation of dosing of the investigational product. This 30-day period also 


September 02, 2020 
Page 52 
applies to subjects receiving bridging therapy as outlined in Section 5.10. Subsequent adverse events 
are not collected for patients receiving standard-of-care bridging therapy, until resumption of study 
procedures at Day 21 as specified in the calendar in Section 5.10. If applicable, SAEs must be 
collected that relate to any later protocol-specified procedure (eg, a follow-up skin biopsy). The 
investigator should notify the Sponsor of any SAE occurring after this time period that is believed to be 
related to the investigational product or protocol-specified procedure. 
All SAEs whether related or unrelated to the trial treatment, must be immediately reported to the 
Sponsor (by the investigator or designee) within 24 hours of becoming aware of the event. If only 
limited information is initially available, follow-up reports are required. The original SAE form must be 
kept on file at the study site. Report SAEs by completing an SAE report in OnCore, the electronic data 
capture system. The SAE must be reported by email (affiliate.research@moffitt.org) to the External Site 
Coordination (ESC) office within 2 working days. If applicable, the site should also follow protocol 
guidelines for additional reporting to government agencies. 
 
If a non-serious AE becomes serious, this and other relevant follow-up information must also be 
provided to the Sponsor and the FDA. 
Serious adverse events that do not require expedited reporting to the FDA still need to be reported to 
the Sponsor preferably using the MedDRA coding language for serious adverse events.  This 
information should be reported on a monthly basis and under no circumstance less frequently than 
quarterly. 
 
For studies conducted under an Investigator IND, any drug-related event that is both serious and 
unexpected must be reported to the FDA as soon as possible and, in no event, later than 7 days (death 
or life-threatening event) or 15 days (all other SAEs) after the investigator’s or institution’s initial receipt 
of the information. SAEs should be reported on the MedWatch Form 3500A, which can be accessed at: 
http://www.accessdata.fda.gov/scripts/medwatch/. 
MedWatch SAE forms should be sent to the FDA at: 
MEDWATCH 
5600 Fishers Lane 
Rockville, MD 20852-9787 
Fax: 1-800-FDA-0178 (1-800-332-0178) 
http://www.accessdata.fda.gov/scripts/medwatch/ 
Any adverse event for which there is a reasonable possibility that the drug caused the adverse event, 
must be recorded on the SAE page and reported expeditiously to comply with regulatory requirements. 
An SAE report should be completed for any event where doubt exists regarding its status of 
seriousness.  
All drug-related SAEs must be immediately reported by confirmed facsimile transmission (fax) and 
mailing of the completed SAE page. In some instances where a facsimile machine is not available, 
overnight express mail may be used. If only limited information is initially available, follow-up reports are 
required. (Note: Follow-up SAE reports should include the same investigator term(s) initially reported.) 
In selected circumstances, the protocol may specify conditions that require additional telephone 
reporting.  
If the investigator believes that an SAE is not related to the investigational product, but is potentially 
related to the conditions of the study (such as withdrawal of previous therapy, or a complication of a 
study procedure), the relationship should be specified in the narrative section of the SAE page. 


September 02, 2020 
Page 53 
If an ongoing SAE changes in its intensity or relationship to the investigational product, a follow-up SAE 
report should be sent immediately to the sponsor. As follow-up information becomes available it should 
be sent immediately using the same procedure used for transmitting the initial SAE report. All SAEs 
should be followed to resolution or stabilization. 
7.13.4 Handling of Expedited Safety Reports 
In accordance with local regulations, the drug manufacturer will periodically notify investigators of all 
SAEs that are suspected (related to the investigational product) and unexpected (ie, not previously 
described in the Investigator Brochure) for nivolumab, (aka SUSARS).  
Other important findings which may be reported by the sponsor as an expedited safety report include: 
increased frequency of a clinically significant expected SAE, an SAE considered associated with study 
procedures that could modify the conduct of the study, lack of efficacy that poses significant hazard to 
study subjects, important safety recommendations from a study data monitoring committee, or sponsor 
decision to end or temporarily halt a clinical study for safety reasons. 
 
7.13.5 Nonserious Adverse Events 
A nonserious adverse event is an AE not classified as serious. 
The collection of non-serious AE information should begin at initiation of investigational product.  
If an ongoing nonserious AE worsens in its intensity, or if its relationship to the investigational product 
changes, a new nonserious AE entry for the event should be completed. Nonserious AEs should be 
followed to resolution or stabilization, or reported as SAEs if they become serious. Follow-up is also 
required for nonserious AEs that cause interruption or discontinuation of investigational product, or 
those that are present at the end of study participation. Subjects with nonserious AEs at study 
completion should receive post-treatment follow-up as appropriate. 
All identified nonserious AEs must be recorded and described in the medical record. 
 
7.13.6 Reporting of deaths 
All deaths that occur during the study, or within the protocol defined 30-day post last dose of nivolumab 
safety follow-up period must be reported as follows: 
Death that is clearly the result of disease progression should be documented but should not be 
reported as an SAE. 
Where death is not due (or not clearly due) to progression of the disease under study, the AE causing 
the death must be reported to the Sponsor as a SAE within 24 hours.  The report should contain a 
comment regarding the co-involvement of progression of disease, if appropriate, and should assign 
main and contributory causes of death.   
Deaths with an unknown cause should always be reported as a SAE.  A post mortem maybe helpful in 
the assessment of the cause of death, and if performed a copy of the post-mortem results should be 
forwarded to the Sponsor within the usual timeframes. 
Deaths that occur following the protocol-defined 30-day post-last-dose of nivolumab safety follow-up 
period will be documented as events for survival analysis, but will not be reported as an SAE 
 
7.13.7 Overdose 
 


September 02, 2020 
Page 54 
1. An overdose is defined asf a subject receiving a dose of nivolumab in excess of that specified in 
the Investigator’s Brochure, unless otherwise specified in this protocol. 
2. Any overdose of a study subject with nivolumab, with or without associated AEs/SAEs, is 
required to be reported within 24 hours of knowledge of the event to the Sponsor or designee . If 
the overdose results in an AE, the AE must also be recorded as an AE. Overdose does not 
automatically make an AE serious, but if the consequences of the overdose are serious, for 
example death or hospitalization, the event is serious and must be recorded and reported as an 
SAE. There is currently no specific treatment in the event of an overdose of nivolumab.  
3. The investigator will use clinical judgment to treat any overdose. 
 
7.13.8 Hepatic function abnormality 
1. Hepatic function abnormality in a study subject, with or without associated clinical 
manifestations, is required to be reported as “hepatic function abnormal” within 24 hours of 
knowledge of the event to the Sponsor or designee, unless a definitive underlying 
diagnosis for the abnormality (e.g., cholelithiasis or bile duct obstruction) that is unrelated to 
investigational product has been confirmed. 
2. If the definitive underlying diagnosis for the abnormality has been established and is 
unrelated to investigational product, the decision to continue dosing of the study subject will 
be based on the clinical judgment of the investigator. 
3. If no definitive underlying diagnosis for the abnormality is established, dosing of the study 
subject must be interrupted immediately. Follow-up investigations and inquiries must be 
initiated by the investigational site without delay. 
4. Each reported event of hepatic function abnormality will be followed by the investigator and 
evaluated by the Sponsor.  
 
7.13.9 Pregnancy 
Pregnancy itself, or pregnancy of a subject’s partner, is not regarded as an adverse event unless there 
is a suspicion that the investigational product under study may have interfered with the effectiveness of 
a contraceptive medication. Congenital abnormalities/birth defects and spontaneous miscarriages 
should be reported and handled as SAEs. Elective abortions without complications should not be 
handled as AEs. The outcome of any conception occurring from the date of the first dose until 90 days 
after the last dose (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth or 
congenital abnormality) should be followed up and documented even if the subject was withdrawn from 
the study.  
1. Pregnancy in a female subject who has received investigational product is required to be 
reported within 24 hours of knowledge of the event to the Sponsor or designee. 
2. Subjects who become pregnant during the study period must not receive additional doses of 
investigational product but will not be withdrawn from the study. The pregnancy will be followed 
for outcome of the mother and child (including any premature terminations) and should be 
reported to the Sponsor or designee after outcome. 
3. Male subjects should refrain from fathering a child or donating sperm during the study and for 3 
months following the last dose.   
4. Should the investigator become aware of a pregnancy in the partner of a male study subject 
who has received investigational product this should be reported within 24 hours of 


September 02, 2020 
Page 55 
knowledge of the event to the Sponsor or designee. The sponsor will endeavor to collect 
follow-up information on such pregnancies provided the partner of the study subject provides 
consent. 
 
7.13.10 
Other Safety Considerations 
Any significant worsening noted during interim or final physical examinations, electrocardiograms, x-
rays, and any other potential safety assessments, whether or not these procedures are required by the 
protocol, should also be recorded in the medical record. 
 
7.13.11 
Contraception 
Females of childbearing potential who are sexually active with a nonsterilised male partner must use 2 
methods of effective contraception from screening, and must agree to continue using such precautions 
for 90 days after the final dose of investigational product; cessation of birth control after this point 
should be discussed with a responsible physician.  Periodic abstinence, the rhythm method, and the 
withdrawal method are not acceptable methods of birth control. 
• 
Females of childbearing potential are defined as those who are not surgically sterile (i.e., bilateral 
tubal ligation, bilateral oophorectomy, or complete hysterectomy) or postmenopausal (defined as 12 
months with no menses without an alternative medical cause). 
• 
Subjects must use 2 acceptable methods of effective contraception as described in Table 1. 
• 
Nonsterilised males who are sexually active with a female partner of childbearing potential must use 
2 acceptable methods of effective contraception (see Table 1) from Day 1 and for 90 days after 
receipt of the final dose of investigational product. 
Table  
Effective methods of contraception (two methods must be used) 
Barrier Methods 
Intrauterine Device Methods 
Hormonal 
Methods 
Male condom plus spermicide 
Copper T 
Implants 
Cap plus spermicide 
Progesterone Ta 
Hormone shot or 
injection 
Diaphragm plus spermicide 
Levonorgestrel-releasing 
intrauterine system (e.g., Mirena®)a 
Combined pill 
Minipill 
Patch 
a 
This is also considered a hormonal method. 
 
7.13.12 
Blood donation 
Subjects should not donate blood while participating in this study 


September 02, 2020 
Page 56 
7.13.13 
Permitted Concomitant Medications 
Investigators may prescribe concomitant medications or treatments (e.g., acetaminophen, 
diphenhydramine) deemed necessary to provide adequate prophylactic or supportive care except for 
those medications identified as “excluded”. 
7.13.14 
Excluded Concomitant Medications 
The following medications are considered exclusionary during the study.  
1. Any investigational anticancer therapy <<other than the protocol specified therapies>> 
2. Any concurrent chemotherapy, radiotherapy (except palliative radiotherapy), immunotherapy, 
biologic or hormonal therapy for lung cancer treatment, <<other than any stated comparator or 
combination regimens.>> Concurrent use of hormones for noncancer-related conditions (e.g., 
insulin for diabetes and hormone replacement therapy) is acceptable.  <<NOTE: Local 
treatment of isolated lesions for palliative intent is acceptable (e.g., by local surgery or 
radiotherapy)>> 
3. Immunosuppressive medications including, but not limited to systemic corticosteroids. 
Supplemental hydrocortisone or prednisone at doses not exceeding 10 mg/day of prednisone or 
equivalent are permitted for physiologic adrenal insufficiency only. Other excluded 
immunosuppressives include, but are not limited to, methotrexate, azathioprine, and TNF-α 
blockers. Use of immunosuppressive medications for the management of investigational 
product-related AEs or in subjects with contrast allergies is acceptable. In addition, use of 
inhaled and intranasal corticosteroids is permitted. A temporary period of steroids will be 
allowed for different indications, at the discretion of the principal investigator (e.g., chronic 
obstructive pulmonary disease, radiation, nausea, etc). This must be previously approved by the 
PI.    
4. Live attenuated vaccines within 30 days of nivolumab dosing (ie, 30 days prior to the first dose, 
during treatment with nivolumab and for 30 days post discontinuation of nivolumab).  Inactivated 
viruses, such as those in the influenza vaccine, are permitted. 
 
8.0 
Criteria for Stopping the Trial Due to Toxicity 
 
The trial will be stopped early due to toxicity if a TIL-treated patient experiences a grade 5 event (i.e. 
death) that is reasonably attributable to the adoptive cell transfer (TIL) treatment. The trial will stopped 
due to toxicity if it crosses the Pocock boundary for toxicity as enumerated in Section 11.4 Table A1.   
 
 
9.0 
Criteria for Response  
The initial disease assessment performed prior to TIL will be subsequently confirmed at the 
assessment immediately prior to TIL per the study calendar.  Following TIL, subsequent disease 
assessments will occur regularly (+/- 7 days) for trial duration per Study Calendar. Following TIL, the 
interpretation of response will be based upon the baseline measurements obtained most proximal prior 
to administration of TIL. For example, a subject who received TIL will have their Day -8 CT scan 


September 02, 2020 
Page 57 
measurements serve as baseline for subsequent tumor worksheets and interpretation of subsequent 
CT scans. 
For external sites. All tumor-specific imaging and reports performed for trial purposes, including CT 
scans, MRIs, and other relevant images, will be shipped to study coordinator and securely stored 
electronically for independent review by a designated Moffitt radiologists as applicable.  
If, during trial treatment, subjects receive standard-of-care CT/MRI imaging that includes their tumor(s) 
at other centers or hospitals, then both the imaging report and imaging should be obtained. In this 
instance, RECIST measurements should be calculated and tumor worksheet completed, if applicable. .  
 
9.1 
Evaluation of target lesions
1 
 
 
Complete Response (CR): 
 Disappearance of all target lesions 
 
Partial Response (PR):  At least a 30% decrease in the sum of the longest diameter (LD) of target 
lesions taking as reference the baseline sum LD. 
 
Progression (PD):  At least a 20% increase in the sum of LD of target lesions taking as reference the 
smallest sum LD recorded since the treatment started or the appearance of one or more new lesions. 
 
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for 
PD taking as references the smallest sum LD. 
 
1All measurable lesions up to a maximum of 5 lesions representative of all involved organs should 
be identified as target lesions and recorded and measured at baseline.  Mediastinal and 
abdominal lymphadenopathy should be considered as separate organ sites, since these receive 
different (regional v. metastatic) classifications in AJCC lung cancer staging. Target lesions should 
be selected on the basis of their size (lesions with the longest diameter) and their suitability for 
accurate repetitive measurements (either by imaging techniques or clinically).  A sum of the longest 
diameter (LD) for all target lesions will be calculated and reported as the baseline sum LD.  The 
baseline sum LD will be used as reference to further characterize the objective tumor response of 
the measurable dimension of the disease. At least one lesion defined radiologically must be 
present. RECIST Version 1.1 will be referenced for determination of response. 
 
9.2 
Evaluation of non-target lesions
2 
 
 
Complete Response (CR):  Disappearance of all non-target lesions and normalization of tumor marker 
level. 
 
Non-Complete Response:  Persistence of one or more non-target lesions. 
 
Progression (PD):  Appearance of one or more new lesions. Unequivocal progression of existing non-
target lesions. 
 
2All other lesions (or sites of disease) should be identified as non-target lesions and should also 
be recorded at baseline.  Measurements are not required, and these lesions should be followed as 
“present” or “absent.” 


September 02, 2020 
Page 58 
 
9.3 
Evaluation of best overall response 
 
The best overall response is the best response recorded from the start of the adoptive cell transfer 
(TIL) treatment until disease progression/recurrence (taking as reference for progressive disease 
the smallest measurements recorded since the treatment started).  The patient's best response 
assignment will depend on the achievement of both measurement and confirmation criteria. 
 
Target Lesions 
Non-Target Lesions 
New Lesions 
Overall Response 
CR 
CR 
No 
CR 
CR 
Non-CR/Non-PD 
No 
PR 
PR 
Non-PD 
No 
PR 
SD 
Non-PD 
No 
SD 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
 
10.0 
Criteria for Removal from the Study 
 
Patients will be taken off the regular study schedule if:  (a) the patient voluntarily withdraws, (b) there is 
significant noncompliance, (c) there is progression of disease (PD) by RECIST 1.1 criteria that occurs 
after adoptive TIL transfer, or (d) death. These patients who are removed from the regular study should 
be scheduled for progression of disease (PD) assessments as outlined in the Study Calendar and 
followed according to the EOT schedule. 
 
11.0 
Statistical Considerations and Data Analysis 
11.1 
Overview 
 This is a phase I clinical trial that is designed to prospectively evaluate the safety and the feasibility of 
including nivolumab in the regimen of TIL administered after lymphodepletion and followed by a cycle of 
intermediate-dose decrescendo IL-2 (one dose cohort: TIL+ intermediate-dose IL-2).  The primary 
objectives of this study will be: 1) to demonstrate that the combination of nivolumab with TIL therapy in 
patients with advanced NSCLC is safe, with a report of toxicity assessed by CTCAE v4 definitely 
attributed to the treatment regimen, and 2) to establish the feasibility of the combination treatment, as 
shown by the ability to successfully perform the TIL adoptive cell transfer in at least 67% of all patients 
accrued to this trial protocol.   There is no dose escalation for the infused TIL cell product. 
We will accrue up to 20 patients with the goal of having 14 patients who are evaluable (i.e., who receive 
lymphodepletion/TIL and complete at least 80% of planned visits during the toxicity evaluation window).  
The primary endpoints of the trial will be the safety and feasibility of administering nivolumab with TIL 
therapy.  
 


September 02, 2020 
Page 59 
11.2 
Trial Design 
The purpose of the study is evaluate the safety of the combination of TIL and IL-2 by employing the 
continuous monitoring method for toxicity using a Pocock-type stopping boundary. That is, each patient 
will be monitored to see any occurrence of DLT. If excessive numbers of patients with toxicity are seen, 
the trial will be stopped. 
 
DLT related to nivolumab will be defined as any grade ≥3 immune-related adverse event 
definitely attributable to nivolumab. DLT related to adoptive cell therapy will be defined as a 
non-hematologic grade 4 or higher adverse event that is immediately life-threatening occurring 
upon or after the start of therapy that is immediately life-threatening and not related to non-
small cell lung cancer or other pre-existing condition. For the purposes of safety assessment, 
toxicity will be assessed within 4 weeks of the adoptive TIL transfer. 
 
11.3 Accrual  
We anticipate that a maximum of 20 patients will be enrolled to obtain 14 evaluable patients for the 
safety assessment of the study. Being evaluable is defined as patients that receive lymphodepletion/TIL 
and complete at least 70% of planned visits during the toxicity evaluation window. Time from accrual to 
response confirmation is 4 months. Anticipated accrual rate is 2 patients per 3 months. We plan to have 
30 months for accrual. This will result in a total of 20 patients (2/3*30=20) for enrollment. We expect a 
30% of non-evaluable rate for toxicity and/or response. This will lead to an expected total of 14 
evaluable patients for the study.  
 
Accrual Estimate 
months 
3 6 9 12 15 18 21 24 27 
total number of expected patients accrued  
2 4 6 
8 10 12 14 16 18 
 
11.4 Sample Size Justification and Stopping Rules  
We expect a total of 14 evaluable patients for the study. Sample size justification is based on 
continuous monitoring for toxicity using a Pocock-type stopping boundary. We consider the maximum-
tolerated toxicity is 17%. We also consider the probability of early stopping to be at most 10%. With 14 
patients, these settings result in a Pocock-type stopping boundary (Table A1). The accrual will be 
halted if excessive numbers of patients with toxicity are seen. For example, if there are 5 or more out of 
10 patients (full follow-up) with toxicity, the trial will be stopped. This boundary is equivalent to testing 
the null hypothesis, after each patient, that the maximum-tolerated toxicity rate is equal to 17%, using a 
one-sided level 0.053 test. In sensitivity analysis (Table A2), if the true toxicity rate is 17%, the 
probability to stop the trial is 9% with about 13 expected patients (SD=2.59) for full follow-up and 2.25 
patient with toxicity (SD=1.24). If the true toxicity rate is 50%, the chance to close the trial increases to 
87%.  For futility, we consider a response rate less than 5% as ineffective. A Bayesian approach is 
used to continuously monitor each patient for futility with a non-informative beta prior, beta(1,1), for 
response rate. If the posterior probability of response rate less than 5% is greater than 0.5, we will 
conclude the treatment is ineffective. This design converts into a stopping rule for futility: if there is no 
response in the first 13 patients or in all the 14 patients, we consider the treatment is ineffective and will 
not move forward the study. By simulation, the sensitivity analysis (Figure A1) shows if the true 
response rate is 1%, the chance as an ineffective treatment is 88%. For a true response rate of 5% and 
20%, the probability as an ineffective treatment decreases to 51% and 6%, respectively.    
      


September 02, 2020 
Page 60 
 
Table A1: 
 
 
Table A2: 
 
θ 
φ* 
E[Y] 
SD[Y] 
E[N] 
SD[N] 
E[Y/N] 
SD[Y/N] 
0.17 
0.0933 
2.25 
1.24 
13.24 
2.59 
0.20 
0.19 
0.20 
0.1445 
2.57 
1.24 
12.87 
3.07 
0.24 
0.21 
0.30 
0.3909 
3.32 
1.14 
11.08 
4.27 
0.39 
0.25 
0.40 
0.6696 
3.54 
1.08 
8.84 
4.61 
0.53 
0.26 
0.50 
0.8721 
3.35 
1.06 
6.70 
4.15 
0.64 
0.24 
0.60 
0.9681 
3.01 
0.96 
5.02 
3.25 
0.73 
0.22 
0.70 
0.9958 
2.68 
0.78 
3.83 
2.34 
0.81 
0.20 
0.80 
0.9998 
2.42 
0.60 
3.02 
1.58 
0.88 
0.17 
0.90 
1.0000 
2.20 
0.42 
2.44 
0.97 
0.95 
0.12 
1.00 
1.0000 
2.00 
0.00 
2.00 
0.00 
1.00 
0.00 
 
Definitions: 
Y = the number of patients with toxicity 
N = the number of patients, random, between 1 and K 
φ* = the actual probability of early stopping (hitting the boundary) 
E[ ] denotes the expected value (mean) 
SD[ ] denotes the standard deviation 
 
 


September 02, 2020 
Page 61 
Figure A1 
 
11.5 
Outcomes and Data Analysis 
The data analysis will mainly be descriptive, with inferential statistics provided for the primary and 
secondary endpoints. Summary statistics for adverse events, including the proportions of each 
preferred adverse event type will be tabulated and assembled into Tables. Adverse events will be 
categorized by Grade. Survival will be reported as a time-to-event outcome. All correlative study results 
will be treated as exploratory in nature due to the pilot status and sample size of the trial. The intention-
to-treat approach will be used for data analysis of this trial. That means all patients who undergo tumor 
harvest will be included in the interim and final data analyses. Patients who are lost to follow-up or drop 
out of the study prior to their scheduled  evaluation time due to any reason will be included for feasibility 
determination and censored for any time-to-event type of endpoints at the time of their last 
assessment/follow-up if no relevant event has occurred by then.  
Safety will be determined by an assessment of all patients who initiate nivolumab infusion based upon 
CTCAE v4.  It will be reported using both a point estimate and its exact confidence interval based on 
the binomial distribution. The rate of nivolumab dose-limiting toxicity will be reported similarly.  
Overall response (OR) is assessed based upon timepoints after the adoptive TIL transfer, and the 
tumor size evaluated using the RECIST 1.1 criteria including a complete response (CR) or partial 
response (PR). Evaluations will be made for patients by CT scan approximately 4 weeks after the cell 
infusion, and by clinical evaluation during this time. The best overall response (CR+PR) (BORR) rate 
will be summarized using both a point estimate and its exact 95% confidence interval based on the 
binomial distribution.  
 
Baseline characteristics including patient age, histology, gender, tumor PD-L1 status, and tumor-
mutation burden will be summarized in a descriptive table including relevant average. Prior lines of 
systemic therapy will be listed. Survival will be plotted on a Kaplan-Meier curve. Confidence intervals 
for the median and survival rates at different time points will be constructed if needed and appropriate. 
This secondary endpoint will be reported descriptively. BORR will be plotted on applicable ‘Waterfall’ 
0.05
0.10
0.15
0.20
0.0
0.2
0.4
0.6
0.8
1.0
Sensitivity Analysis
true response rate
probability of stopping the trial
0.88
0.51
0.26
0.12
0.0
0.01


September 02, 2020 
Page 62 
plots using percent change from nadir = (total length – nadir in total length) / (nadir in total length) x 
100%. Depth of response will be recorded over time using applicable “Spider” plots showing the change 
in size of lesions at a given visit after nivolumab and after TIL.  
For correlative analysis, we will explore the extent to which changes between pre- and post-treatment 
levels correlate with response,.  This will be done on the percent change from the pre-treatment values 
for the biomarkers using the paired tests at α = .05, reported only for exploratory testing. 
 
12.0 
Biological sampling procedures 
Blood flow cytometry and nucleic acid sequencing  
Peripheral blood will be collected at visits as specified in the Study Calendar. The collection kits consist 
of four-green top (sodium heparin) tubes, one tiger-top (SST) tube and one lavender-top (citrate) tube 
at each time-point. These tubes will be used for multi-color flow cytometry, nucleic acid sequencing, 
and cytokine profiling, respectively. The screening blood draw will also include two yellow-top (acid 
dextrose-citrate) tubes for HLA Class I & II sequencing.  
Tumor nucleic acid sequencing and Proteomics 
In summary, residual tumor specimen that is not used for TIL will be processed for DNA, RNA, and 
proteomic sequencing, including whole-exome sequencing (WES). These samples will be used to 
evaluate potentially predictive biomarkers and complete other correlative studies. Approximately 50 g of 
tumor sample is required for this purpose, snap frozen and stored in liquid nitrogen. In addition, post-
treatment tumor biopsies will be obtained on at least 7-10 total patients during the study. The biopsies 
may be performed under image guidance (including but not limited to CT or ultrasound-guided core 
biopsies) as determined by the location of tumor and risks associated with each procedure.  
 
The tumor collected through these methods will be analyzed to explore whether positive vs. negative 
biomarkers could predict response and resistance to the nivolumab-TIL combination. More specifically 
for the fresh tumor biopsies, on-site evaluations for tissue quality will be performed by the 
cytotechnologist to ensure viable tissue and for collection of adequate tumor sample. 
  
Immunohistochemistry will be used to assess the levels of the proposed molecules in histological tumor 
collected before and after therapy where appropriate. Additional biomarkers may be explored including 
but not limited to other immune checkpoint molecule expression. We will utilize advanced NGS DNA 
analyses to test and identify putative mutational load of tumors (tumor mutation burden, TMB) and 
candidate neoantigens.  Further, exploratory correlative studies may be completed based on the 
additional data obtained from phenotypic characterization of the manufactured TIL product and the 
patients’ peripheral blood over time. The collection and interpretation of additional data has the 
potential to help address some of the critical barriers for effective personalized treatment. We will also 
use mRNA sequencing to verify expression of relevant genes. 
 
The results from DNA sequencing do not get returned to patients or their medical files. Assays are for 
research purposes with coded samples, not diagnostic purposes. Not defined as an investigational 
device.  This follows ICH E15 and Pharmacogenetics Working Group (PWG) recommendations, and 
thus genetic counseling for patients on study will not be required. 
 
Polyfunctional Strength Index 
PSI measures the ability of single CD8+ cells to secrete multiple different cytokines after stimulation. 
CD8+ T cells are sorted from TIL and peripheral blood, and stimulated with CD28 and CD3 antibody. 


September 02, 2020 
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Testing is performed using the Isoplexis IsoCode chip using the 32 human cytokine single-cell 
proteome panel. Pre- and post- infusion timepoints will be compared using a mixed-effects model 
(REML) with stacked matching with Geisser-Greenhouse correction, in an exploratory comparison. 
Multiplicity adjusted p value using Dunnett’s control.  
 
Screening T cells for reactivity to neoantigens using the ELISpot assay  
Effector T cells will be co-cultured with autologous DCs cells loading 1-10 μg/mL tumor antigen 
peptides. CEF peptides and/or plate-bound OKT3 (1 μg/mL) will be used as positive controls. Effector T 
cells only and/or effector T cells co-cultured with unloaded DCs are used as negative controls. After 
antibody staining, plates are scanned and auto-counted using an ImmunoSpot ELISpot plate reader 
(Cellular Technologies, Ltd).    
 
 
Molecular Statistical Analyses 
Molecular testing is considered exploratory for the interpretation of tumor biomarkers. Where 
applicable, biomarkers will be tested separately and considered significant if P <0.05. Analysis will be 
carried out using either SAS statistical software (SAS, Inc, Cary, NC) or Prism.  
   
Handling, storage and destruction of biological samples 
The handling of the tissue samples will be per the laboratory manual. 
 
 
13.0 
Data Safety Monitoring Plan 
13.1 Recruitment and Informed Consent 
Patients who present with advanced NSCLC may be offered participation in the clinical trial described 
in this proposal. The trial is explained in detail to the patients by one of the investigators on the trial.  
The patients are given the opportunity to read the informed consent document and are given a chance 
to ask questions.  If they wish to participate the patient will then sign the informed consent document in 
the presence of a witness. The study team member who participates in the informed consent process 
also documents, in a clinic note, the nature of the consent process that occurred.  
 
All non-Moffitt subjects must be registered with the External Site Coordination (ESC) office to be 
able to participate in the trial. The participating site must fax or email the completed study 
specific eligibility checklist and registration forms, supporting documents and signed informed 
consent to the Coordinating Center. Unsigned or incomplete forms will be returned to the site. 
Once documents are received, the ESC Research Coordinator will review them to confirm eligibility 
and to complete the registration process. If eligibility cannot be confirmed, the research 
coordinator will query the site for clarification or additional documents as needed. Subjects failing 
to meet all study eligibility requirements will not be registered and will be unable to participate in 
the trial. 
 
Upon completion of registration, the ESC Research Coordinator will provide the participating site with 
the study sequence number and randomization information, if indicated. Within 24-48 hours after 
registration, it is the site’s responsibility to: 
• 
Enter the demographic and on-study patient information into the Oncore database 
• 
Order investigational agent(s) if indicated per protocol 


September 02, 2020 
Page 64 
 
 
It is the responsibility of the participating Investigator or designee to inform the subject of the 
research treatment plan and to conduct the study in compliance with the protocol as agreed upon 
with Moffitt Cancer Center and approved by the site’s IRB. 
 
To register a patient send the completed signed eligibility checklist along with supporting 
documentation to the ESC via email at affiliate.research@moffitt.org or via fax at 813-745-5666, 
Monday through Friday between 8:00AM and 5:00PM (EST). 
 
 
13.2 Protection Against Risk 
To protect participants from excess risk, the above-mentioned study procedures were instituted. 
Additional protection is provided through the data safety and monitoring plan described below. The 
complete care of each patient, including the clinical management of all toxicities, is provided to the 
patient by their physicians. The clinical data are kept in the patient's individual electronic hospital 
record. Research study documentation charts are kept in a locked secure room with limited access and 
through Oncore (a Web-based, password-protected database), with privacy protected to the full extent 
of the law. Authorized research investigators, the Department of Health and Human Services, and the 
Institutional Review Board may inspect the records. Final protocol and ICF approvals are to be obtained 
from the IRB. 
Additional protection is provided through the data safety and monitoring plan described below.  
 
13.3 
Importance of the Knowledge to be Gained 
The development of a well-tolerated and effective regimen in a disease could potentially at worst add to 
the armamentarium of available regimens and at best change standard of care. Specific strategies to 
improve the care of patients relapsing following chemotherapy for lung cancer are direly needed.  
 
13.4 Data Safety and Monitoring Plan 
The Data Safety & Monitoring Plan (DSMP) will ensure that this trial is well designed, responsibly 
managed, appropriately reported, and that it protects the rights and welfare of patients.  The following 
internal and external review and monitoring processes provide oversight and active monitoring of this 
trial: 
• 
The Principal Investigators (PI) 
• 
The Clinical Trials Office (CTO) 
• 
The Scientific Review Committee (SRC) 
• 
The Protocol Monitoring Committee (PMC); 
• 
The Research Compliance Division (RCD) of the Cancer Center's Compliance Office; 
• 
Institutional Review Board (IRB). 
 
The protocol includes a section that specifies the following with respect to Adverse Event reporting: 
what constitutes an adverse event (versus what is a serious adverse event), the entities to which 
adverse events should be reported, the timing of this reporting, and the person or persons responsible 
for reporting.  This includes prompt (within one day of knowledge of the event) reporting to the IRB for 
unanticipated risks to subjects and reporting in writing within five working days to the IRB and sponsor.  
 


September 02, 2020 
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13.5 Scientific Review Committee (SRC) 
Each SRC conducts a formal internal peer review of all clinical protocols and general scientific 
oversight of interventional clinical research. Protocols are reviewed for scientific merit, adequate study 
design, safety, availability of targeted study population, and feasibility of timely completion of all 
proposed research projects to be conducted by its assigned programs at each Cancer Center.  The 
SRC is responsible for evaluating the risk/benefit assessment and corresponding data and safety 
monitoring plan as part of the scientific review and approval process.   
 
13.6 PI Responsibility 
The PI of each study is ultimately responsible for every aspect of the design, conduct and actions of all 
members of the research team.  This includes the final analysis of the protocol.   
 
All protocols include a DSMP and procedures for its implementation commensurate with the risk and 
complexity of the study.  The DSMP must include a structured adverse event determination, monitoring 
and reporting system, including standardized forms and procedures for referring and/or treating 
subjects experiencing adverse events.  The plan must include data and safety-monitoring procedures 
for subjects enrolled who may be receiving a part of their protocol-required treatment at community 
sites. 
 
In all cases, the PI of the study will have primary responsibility for ensuring that the protocol is 
conducted as approved by the SRC and IRB.  The PI will ensure that the monitoring plan is followed, 
that all data required for oversight of monitoring are accurately reported to a DSMB and/or to the PMC 
and IRB as required, that all adverse events are reported according to protocol guidelines, and that any 
adverse actions reflecting patient safety concerns are appropriately reported. 
 
13.7 The Protocol Monitoring Committee (PMC) 
The PMC reviews and evaluates safety and/or efficacy data for all physician authored clinical 
intervention trials. The PMC ensures the safety of patients and the validity and integrity of data. PMC 
reviews SAEs, deviations, Interim analysis, interim and final reports from the external Data Monitoring 
Committee (DMC) as well as audits both internally and externally. The PMC can make the following 
determinations, Accepted, Acceptable with Corrective Action and Tabled.    
 
Investigators of studies, which are designated to be reviewed by the PMC for data and safety 
monitoring, shall provide an interim analysis report of the study’s progress and summary of adverse 
events and deviations based on the phase of the study and the associated risk of the study or more 
often if applicable.  The external DSMB (if applicable) shall forward its report for high-risk studies 
designated for external review at least annually or more often if applicable. 
 
13.8 Suspension/Termination 
The PMC and/or the IRB may vote to suspend or terminate approval of a research study not being 
conducted in accordance with the IRB, the Cancer Center and/or regulatory requirements or that has 
been associated with unexpected problems or serious harm to subjects.  The PMC/IRB will notify the PI 
in writing of such suspension or terminations.  It is the responsibility of the PMC/IRB Chairperson to 
ensure prompt written notification of any suspensions or terminations of PMC/IRB approval to the 


September 02, 2020 
Page 66 
relevant Federal Agencies, including OHRP, FDA, the study sponsor/funding source and if applicable, 
the Affiliate Program. 
 
13.9 Trial Discontinuation 
For reasonable cause the Investigator and/or sponsor may terminate this study prematurely. Conditions 
that may warrant termination include, but are not limited to: the discovery of an unexpected, significant, 
or unacceptable risk to the patients enrolled in the study or if the accrual goals are met. A written 
notification of termination will be issued. 
 
13.10  Monitoring of the Study and Regulatory Compliance 
The Principal Investigator and the Clinical Research Coordinator assigned to the case will be primarily 
responsible for maintaining all study related documents including the clinical research forms.  Oncore is 
the database of record for all CRF entries and will be verified with source documentation. The review of 
medical records within PowerChart will be done in a manner to assure that patient confidentiality is 
maintained. 
 
Monitoring will be performed regularly to verify data is accurate, complete, and verifiable from source 
documents; and the conduct of the trial is in compliance with the currently approved 
protocol/amendments, Good Clinical Practice (GCP), and applicable regulatory requirements. 
 
To obtain access to OnCore, the External Site Coordination (ESC) office Coordinator will supply 
forms required to be completed by the external site staff. Once the completed forms are received, the 
site coordinator will receive DUO access, logon/password, and information on how to access 
OnCore. The ESC office will provide OnCore training to the site once initial access is granted and on 
an ongoing basis, as needed.  
 
Required Documentation 
Before the study can be initiated at any site, the site will be required to provide regulatory 
documentation to the External Site Coordination (ESC) office at Moffitt Cancer Center. Sites must 
provide a copy of their informed consent to the ESC office for review and approval prior to 
submission of any documents to the site’s IRB. Any changes requested by the site’s IRB must be 
provided to the ESC staff for review and approval prior to resubmission to the IRB. 
 
The ESC office must receive the following trial specific documents either by hardcopy, fax, or email 
before a site can be activated for any trial: 
 
1. IRB Approval Letter that includes the protocol version and date 
2. FDA Related Forms 1572/1571/310 as appropriate 
3. Signed Protocol Title Page 
4. IRB Approved Consent Form 
5. Site Delegation of Authority Log 
6. Signed Financial Interest Disclosure Forms (principal and sub investigators) 
7. Updated Investigator/Personnel documents (CVs, licenses GCP and HSP training 
certificates, etc.) as needed 
8. Updated Laboratory Documents (certifications, normal ranges, etc.) as needed  


September 02, 2020 
Page 67 
9. Signed protocol specific Task Order 
 
A study initiation teleconference will be held prior to the start of any study related activity at the site. 
Attendance is required for:  
• 
The site PI and appropriate research staff 
• 
Moffitt PI and ESC research coordinator 
 
The requirements of the protocol and all associated procedures and processes will be reviewed and 
agreed upon prior to the activation of the study. The ESC utilizes the EDC system, OnCore. OnCore 
training will be scheduled, if indicated, with the appropriate staff from the site.  
 
 
 
13.11  Internal Monitoring Plan 
Data will be captured in Oncore.  
Regulatory documents and case report forms will be reviewed routinely by the MCC Clinical Research 
Monitoring Core for accuracy, completeness and source verification of data entry, validation of 
appropriate informed consent process, adherence to study procedures, and reporting of SAEs and 
protocol deviations according to MCC Monitoring Policies.  
 
Regulatory documents and case report forms will be monitored internally according to Moffitt Cancer 
Center Monitoring Policies. Both internal and external site monitoring will be performed regularly by the 
MCC Clinical Monitoring Core for accuracy, completeness, and source verification of data entry, 
validation of appropriate informed consent process, reporting of SAEs, and adherence to the protocol, 
Good Clinical Practice (GCP) guidelines, and applicable regulatory requirements. 
 
13.12  Protocol Modifications 
No modifications will be made to the protocol without the agreement of the investigators. Changes that 
significantly affect the safety of the patients, the scope of the investigation, or the scientific quality of the 
study will require Scientific Review Committee and Institutional Review Board approval prior to 
implementation, except where the modification is necessary to eliminate apparent immediate hazard to 
human subjects.  Any departures from the protocol must be fully documented in the case report form 
and the source documentation. 
 
13.13  The Institutional Review Board (IRB) 
The trial will not be initiated without approval of the appropriate Institutional Review Board (IRB).  All 
administrative requirements of the governing body of the institution will be fully complied with.  This 
protocol, consent procedures, and any amendments must be approved by the IRB in compliance with 
current regulations of the Food and Drug Administration.  A letter of approval will be sent to the 
institution(s) funding the study prior to initiation of the study and when any subsequent modifications 
are made.  The IRB will be kept informed by the investigator as to the progress of the study as well as 
to any serious or unusual adverse events. 
 


September 02, 2020 
Page 68 
13.14  Patient Privacy 
In order to maintain patient confidentiality, all case report forms, study reports and communications 
relating to the study will identify patients by initials and assigned patient numbers.  The US Food and 
Drug Administration (FDA) may also request access to all study records, including source 
documentation for inspection. 
 
13.15  Records Retention 
U.S. FDA regulations (21 CFR §312.62[c]) require that records and documents pertaining to the 
conduct of this study and the distribution of investigational drug, including CRFs, consent forms, 
laboratory test results, and medication inventory records, must be retained by the Principal Investigator 
for 2 years after marketing application approval.  If no application is filed, these records must be kept 2 
years after the study is discontinued and the U.S. FDA and the applicable national and local health 
authorities are notified. 
 
13.16  Compliance with Trial Registration and Results Posting Requirements 
Under the terms of the Food and Drug Administration Modernization Act (FDAMA) and the Food and 
Drug Administration Amendments Act (FDAAA), the Sponsor of the trial is solely responsible for 
determining whether the trial and its results are subject to the requirements for submission to the 
Clinical Trials Data Bank, http://www.clinicaltrials.gov.  Information posted will allow subjects to identify 
potentially appropriate trials for their disease conditions and pursue participation by calling a central 
contact number for further information on appropriate trial locations and trial site contact information.     


September 02, 2020 
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