Conditions: Metastatic Melanoma Stage IV Cutaneous Melanoma AJCC v6 and v7
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 16
Healthy volunteers: no

Brief summary:
This phase II trial studies the side effects and how well white blood cells taken from person's own (autologous) cluster of differentiation (CD)8+ antigen-specific T cells, cyclophosphamide, aldesleukin, and ipilimumab work in treating patients with melanoma that has spread to another place in the body. Autologous CD8+ antigen-specific T cells are white blood cells that are designed in the laboratory to find melanoma cells and may kill them. Biological therapies, such as aldesleukin, use substances made from living organisms that may stimulate the immune system in different ways and stop tumor cells from growing. Immunotherapy with monoclonal antibodies, such as ipilimumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Drugs used in chemotherapy, such as cyclophosphamide, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving autologous CD8+ antigen-specific T cells with cyclophosphamide, aldesleukin, and ipilimumab may be an effective treatment for patients with metastatic melanoma.

Detailed description:
PRIMARY OBJECTIVE:

I. Evaluate the safety and efficacy of adoptively transferred cytotoxic T-lymphocytes (CTL) targeting melanoma tumors combined with anti-CTLA4.

SECONDARY OBJECTIVES:

I. Evaluate the influence of anti-CTLA4 on the duration of in vivo persistence and anti-tumor efficacy achieved following adoptive transfer of antigen-specific CTL.

II. Evaluate the influence of anti-CTLA4 on the induction of T cells to non-targeted tumor-associated antigens (antigen-spreading) following adoptive transfer antigen-specific CTL, and the correlation of these responses with clinical outcome.

OUTLINE:

Beginning 48 to 72 hours prior to T cell infusion, patients receive cyclophosphamide intravenously (IV) over 30-60 minutes. Patients then receive autologous CD8+ melanoma-specific T cells IV over 30-60 minutes on day 0, aldesleukin subcutaneously (SC) twice daily (BID) on days 0-13 and ipilimumab IV over 90 minutes on days 1, 22, 43, and 64 in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months for up to 5 years.

Arms:
arm 1: Beginning 48 to 72 hours prior to T cell infusion, patients receive cyclophosphamide IV over 30-60 minutes. Patients then receive autologous CD8+ melanoma-specific T cells IV over 30-60 minutes on day 0, aldesleukin SC BID on days 0-13 and ipilimumab IV over 90 minutes on days 1, 22, 43, and 64 in the absence of disease progression or unacceptable toxicity.

Interventions: intervention 1: Aldesleukin intervention 2: Autologous CD8+ Melanoma Specific T Cells intervention 3: Cyclophosphamide intervention 4: Ipilimumab intervention 5: Laboratory Biomarker Analysis
Intervention descriptions: intervention 1: Given SC intervention 2: Given IV intervention 3: Given IV intervention 4: Given IV intervention 5: Correlative studies

Protocol document:
Prot_SAP_000.pdf: 
CD8+ T Cell and Ipilimumab   
M.D. ANDERSON CANCER CENTER
 HOUSTON, TX 
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PHASE II STUDY OF CELLULAR ADOPTIVE 
IMMUNOTHERAPY USING AUTOLOGOUS CD8+ 
ANTIGEN-SPECIFIC T CELLS AND ANTI-CTLA4 FOR 
PATIENTS WITH METASTATIC MELANOMA 
PRINCIPAL INVESTIGATOR 
Adi Diab, MD 
CO-INVESTIGATORS 
Elizabeth Shpall MD 
Katy Rezvani MD 
COLLABORATORS 
Patrick Hwu, MD, Chair and Professor 
Sapna Patel, MD 
Michael Davies, MD, PhD 
Wen-Jen Hwu, MD, PhD 
Rodabe Amaria, MD 
Cassian Yee, MD 
Isabelle Glitza, MD 
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Date 4/8/2016


CD8+ T Cell and Ipilimumab    
 
       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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2. 
INTRODUCTION ................................................................................4 
2.1  Immunotherapy of Malignant Melanoma ..........................................4 
2.2 Adoptive T Cell Therapy ......................................................................5 
2.3  Antigen-loss variants and antigen-spreading .....................................6 
2.4    Anti-CTLA4 Therapy for Cancer .......................................................7 
2.5  Cyclophosphamide as an Immunopotentiator ...................................7 
2.6  Regulatory T Cells ................................................................................8 
2.7 Interleukin-2 ..........................................................................................8 
2.8 Potential toxicities associated with CD8+ CTLs .................................9 
2.9  Rationale and Proposed Study of Adoptive T Cell Therapy for 
the Treatment of Patients with Metastatic Melanoma ........... 10 
3. 
OBJECTIVES .................................................................................... 10 
3.1  Primary Objectives ............................................................................ 10 
3.2  Secondary Objectives ........................................................................ 10 
4. 
STUDY DESIGN................................................................................ 11 
5. 
PATIENT ELIGIBILITY ................................................................. 11 
5.1  Eligibility for enrollment ................................................................... 11 
5.2  Exclusion for enrollment ................................................................... 12 
5.3 Eligibility for Treatment (Includes Cyclophosphamide, T cell, 
anti-CTLA4 infusions and s.c. IL-2) ......................................... 13 
5.4 Exclusion Criteria for Treatment .................................................... 13 
6. 
STUDY AGENTS .............................................................................. 14 
6.1 Antigen-specific CD8+ T cells ............................................................ 14 
6.2  Cyclophosphamide ............................................................................. 14 
6.3 Anti-CTLA4 / Ipilimumab ................................................................ 14 
7.     PLAN OF TREATMENT .................................................................. 15 
 
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8.      SCHEDULE OF EVALUATIONS .................................................. 20 
9. 
MANAGEMENT OF TOXICITIES AND COMPLICATIONS .. 23 
10. REPORTING ADVERSE EVENTS ................................................ 28 
11. DATA ENTRY AND PROTOCOL MANAGEMENT .................. 31 
12 
STATISTICALCONSIDERATIONS .............................................. 31 
13. ADMINISTRATIVE CONSIDERATIONS .................................... 36 
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2. 
INTRODUCTION 
 
Adoptive T cell therapy represents a promising strategy for the treatment of patients with 
cancer. Phase I and II studies using adoptively transferred antigen-specific T cells have led to 
the conclusion that its effectiveness may be enhanced by extending the in vivo persistence of 
transferred T cells and broadening the repertoire of immune responses to limit the outgrowth 
of antigen-loss tumor variants.   
 
CTLA4 is a molecule that is up-regulated on activated T cells and functions as an inhibitory 
receptor. When engaged to its B7-ligand, CTLA4 delivers inhibitory signals that impede TCR 
signaling, IL-2 transcription, and T cell proliferation (1). The use of anti-CTLA4 antibody to 
counteract this effect can lead to an enhanced T cell response and the induction of a broadened 
T cell response to antigens released by killed tumor cells.  
 
We propose a combined biologic strategy involving the use of adoptively transferred antigen-
specific CD8+ CTL and the concomitant administration of anti-CTLA4 as a means of 
enhancing the transferred T cell response and promoting the generation of endogenous T cell 
responses against a broader panel of tumor-associated antigens that are released in a pro-
inflammatory environment following lysis of melanoma tumors by transferred CTL.   
 
 
 
 
 
 
 
 
 
 
We will evaluate, in a Phase II study of adoptive cellular therapy, up to 20 patients with 
metastatic melanoma to evaluate the influence of anti-CTLA4 administration on the duration 
of in vivo persistence of transferred antigen-specific CTL and the induction of a multivalent 
T cell response against non-targeted epitopes. Results will be correlated to clinical responses 
and/or the outgrowth of antigen-loss tumor variants if this last event occurs. Patients will 
receive an infusion of antigen-specific CTL (1010 cells/m2) preceded by low-dose cytoxan 
(300 mg/m2). They will receive in addition to low-dose IL-2, one dose of anti-CTLA4 3mg/kg 
the day after the CTL infusion followed by anti-CTLA4 for a total of 3 successive doses at 
3mg/kg every 3 weeks thereafter. 
 
2.1  
Immunotherapy of Malignant Melanoma 
The incidence of malignant melanoma has steadily doubled since 1975 to reach 20 new cases 
per 100’000 inhabitants per year in 2004. Unlike the trend for other common cancers, the 
death rate for invasive forms at time of diagnosis has not decreased and has remained steady 
since 1991, suggesting very little improvement in the 5-year survival rate for the past 15 years 
(2). The median age of patients with melanoma is 45 years and thus, the loss of productive 
years is one of the most significant among cancers (2). Chemotherapy and radiation therapy 
represent the standard treatment for patients with extensive disease at presentation or with 
recurrent disease after surgical resection, but response rates are low and the responses are not 
usually durable. As a result many patients are treated in a palliative way or are enrolled in 
investigational studies (3). 
 
In recent years, the identification of immunogenic targets in melanoma and other 
malignancies and the development of novel technologies to elicit effector cells in vivo and ex 
vivo have led to clinical trials of adoptive cellular therapy and vaccination studies. Evidence 
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of tumor regression and measurable responses in patients with progressive metastatic disease 
who were otherwise refractory to conventional therapy has heralded a renewed interest in 
antigen-specific cellular immunotherapy. 
 
2.2 
Adoptive T Cell Therapy 
Significant advances in understanding and 
manipulating the tumor immune response over 
the last decade have shown that tumor-
associated antigens can be identified that can 
elicit a robust T cell response in patients and, 
thus, strategies to isolate and expand such T 
cells ex vivo would allow the adoptive transfer 
of anti-tumor immunity to the treated patient. 
This concept is the basis for adoptive cellular 
therapy 
(ACT), 
which 
is 
a 
form 
of 
immunotherapy that involves the ex vivo 
isolation and expansion of antigen-specific T 
cells for infusion, with the expectation that this bolus of tumor-reactive, effector cells can 
traffic to tumor sites, mediate regression, and maintain a durable response.  In general, there 
are three sources of T cells for ACT (Fig. 1): (1) tumor infiltrating lymphocytes (TIL), 
comprised of an IL-2-expanded population of tumor-derived T cells; (2) chimeric antigen 
receptor (CAR) or T cell receptor (TCR) engineered lymphocytes, genetically modified to 
redirect specificity to tumor-associated target antigens; and (3) endogenous T cells (ETC) 
isolated from peripheral blood, which, by various enabling technologies, can be selected on 
the basis of antigen-specificity and expanded ex vivo for adoptive transfer. Since circulating 
tumor-reactive, antigen-specific T cells are typically present in patients at very low 
frequencies, ETC represents a technically challenging strategy, but allows for greatest 
flexibility for targeting tumors and rapid deployment into the clinical arena.1 
Endogenous T Cell (ETC) Therapy 
In the last decade, the identification of an increasing number of tumor-associated antigens 
that are capable of eliciting an antigen-specific immune response (i.e., an immunogenic 
target) has heralded the development of antigen-specific immunotherapy, and led to 
strategies to either isolate such rare antigen-specific T cells from the peripheral blood (ETC) 
or to present a means to engineer T cells to express the cognate TCR of interest. Engineered 
TCR and CAR T cell therapies have recently demonstrated remarkable success, in particular 
for studies using CAR T cells targeting CD19 for the treatment of refractory B cell leukemias 
and lymphomas. This approach represents an attractive ‘off-the-shelf’ strategy; however, it 
is encumbered with its unique set of regulatory constraints and both scientific and technical 
hurdles.2, 3  Over the last 18 years, we have taken another approach to the generation of 
antigen-specific T cells and pioneered ETC as a novel form of adoptive cellular therapy.1, 4, 5 
Unlike TIL therapy, which is constrained by accessibility to tumor of sufficient size and a 
tumor type known to harbor infiltrating lymphocytes, ETC therapy requires only access to 
peripheral blood and thus provides a broader, unskewed T cell repertoire. Based on the 
premise that tumor-reactive T cells can be found in this extant circulating T cell repertoire,6 
we have developed enabling technology to isolate rare antigen-specific T cells present at 
very low frequency (< 1: 100,000) in the peripheral blood, aided by tetramer-guided cell 
sorting,7, 8 and to expand these T cells to a cell dose of > 1010/ m2 for adoptive transfer.  
Furthermore, we demonstrated for the first time that exposure of peripheral blood T cells to 
Fig. 1. Sources of Effector Cells for Adoptive Cell 
Therapy 
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IL-21 during in vitro antigen priming leads to the generation of a unique population of central 
memory type CD8 T cells (TCM) characterized by high surface expression of CD28 and 
CD127 (IL-7 receptor).9, 10 CD28 signaling is directly linked to the antigen-driven autocrine 
production of IL-2, and gives rise to the helper-independent properties of these long-lasting 
central memory type CD8 T cells. Further, the intrinsic properties of T cells grown in this 
manner allow for a gentler pre- and post-infusion regimen; thus, ETC therapy is not 
encumbered 
by 
the 
intensive 
hospital 
monitoring 
associated 
with 
high–dose 
lymphodepletion, and post-infusion high dose IL-2. 11   
Using this approach, we have successfully generated antigen-specific T cells 
targeting virus-associated antigens (polyoma T antigen )12 differentiation antigens (MART-1, 
gp100),4, 13-15 self-antigens (WT1)16 and cancer testis antigens (NY-ESO1)17 for use in several 
first-in-human clinical trials for the treatment of patients with leukemia, sarcoma, melanoma, 
breast cancer, pancreatic cancer and Merkel cell carcinoma.  
 
2.3  
Target antigens 
2.3.1 MART-1/ MelanA antigen 
MART-1 also known as melanoma antigen recognized by T cells, and MelanA was 
identified as a tumor-associated antigen by Kawakami et al and Coulie et al, respectively in 
1994. This antigen is broadly expressed in cutaneous melanoma (upwards of 90%) but 
following treatiment with immune checkpoint therapy, has been found less frequently. For 
this reason, we are also proposing to target a CT antigen, PRAME; the CT antigens are 
believed to be upregulated following epithelial mesenchymal transformation and immune 
resistance that may occur after immune checkpoint therapy failure.  
 
2.3.2  PRAME antigen 
PRAME, also known as preferentially expressed antigen in melanoma, is a germinal tissue-
specific gene expressed in placenta and endometrium, and both hematological and solid tumor 
malignancies. Several HLA-A*0201 restricted epitopes have been identified, one of which, 
PRAME-004, has been shown to be presented in melanoma with high immunogenicity and 
prevalence33. This epitope has been found only on tumor samples, and not normal tissues. In 
the TCGA database, it is expressed at very high levels in melanoma, ovarian and 
uterine/endometrial cancers (> 40 RPKM) with no expression in normal tissues except at very 
low levels in adrenal gland. Its prevalence of expression in melanoma is > 80%. 
 
 
 
2.4 
Antigen-loss variants and antigen-spreading 
Following in vivo targeting of a single antigen with a T cell clone, we and others have shown 
that antigen-loss tumor variants can appear. In these cases, effective induction of an 
endogenous multivalent response through antigen-spreading (i.e. the induction and/or 
expansion of pre-existing host T cell responses to non-targeted antigens) clearly did not occur. 
There is accumulating evidence that such antigen-spreading can occur and be of therapeutic 
benefit. Both murine and human studies have demonstrated tumor regression following 
immunologic targeting of only a single antigen or epitope in settings in which the antigen is 
known to be heterogeneously expressed (6, 12-16). In a vaccine study of melanoma patients, 
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anti-tumor CTL recognizing non-targeted antigens MAGE-C2 and gp100 expanded several-
fold in vivo after MAGE-3 vaccination, exceeded the frequency of anti-MAGE-3 CTL, and 
were associated with complete tumor regression.  In our own studies using CD4+ T cell clones 
to the single tumor-associated antigen, NY-ESO-1, we demonstrated the induction of a 
broader multivalent response appearing in a patient who developed a complete regression of 
his tumor (17).  
 
2.4   
Anti-CTLA4 Therapy for Cancer 
CD28 and CTLA4 represent counter-receptors to the T cell co-stimulator ligands B7-1 and 
B7-2 that regulate T cell activation. Whereas CD28 is constitutively expressed and provides 
positive co-stimulatory signals during the early phase of T cell activation, CTLA4 is 
upregulated following activation and provides an inhibitory effect on T cell activation, 
attenuating the magnitude of the T cell response. CTLA4 localizes to the immunologic 
synapse in direct proportion to the TCR signal strength, leading to inhibition of IL-2 
production and cell cycle progression (18-20); hence strategies that abrogate CTLA4 
engagement may lead to enhanced T cell responses. Murine studies demonstrate that CTLA4 
blockade alone can promote rejection of immunogenic tumors, and, if combined with 
vaccination or CD25 depletion, can also promote eradication of established poorly 
immunogenic tumors such as B16 melanoma (21). Since CTLA4 blockade can promote 
expansion of not only effector, but also of regulatory T cell populations (with the ratio of 
effector to regulator cells being a major determinant of anti-tumor efficacy) (22), anti-CTLA4 
therapy would likely be most effective in a setting in which the regulatory T cell population 
has been reduced with methods such as CD25 depletion or low-dose cyclophosphamide 
administration (21).  
The treatment of melanoma and ovarian cancer patients with a combination of GM-CSF-
transduced autologous tumor cell vaccine and anti-CTLA4 led to extensive tumor necrosis 
and CD8+ T cell infiltrates in 3 of 9 patients, and reduction or stabilization of disease in 2 
others (23). At this time, a number of studies have used the anti-CTLA-4 antibody 
(ipilimumab) in monotherapy for melanoma and patterns of tumor response observed vary 
from a classic tumor response in baseline lesions, a slow and steady decline in tumor mass, 
response after initial increase in tumor burden and a response in tumor burden in the presence 
of new lesion. These patterns of response are thought to derive from the fact that immune 
activation precedes tumor shrinkage from weeks to and have been defined as immune-related 
responses (24).  
In this study, the doses of ipilimumab will consist of the standard approved dosage of 3mg/kg, 
cyclophosphamide and T cell infusions. 
 
 
 
2.5  
Cyclophosphamide as an Immunopotentiator 
The effectiveness of immunotherapy may be enhanced when combined with conventional 
cytotoxic agents, cyclophosphamide being the most extensively studied drug (26). Since the 
original observation almost 40 years ago that CY could augment immune responses (27), this 
effect has been evaluated in experimental animals and clinical studies at doses ranging from 
40 to >6000 mg/m2 (28-32). In human studies, CY potentiated delayed type hypersensitivity 
(DTH) responses to a vaccine in patients with metastatic cancer at doses as low as 300 mg/m2 
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(33-36). Studies have suggested that low doses of CY (200-400 mg/m2) can selectively deplete 
suppressor activity whereas higher doses (1000-4000 mg/m2) induced a more global lympho-
depletion but may have had a beneficial ‘bystander’ effect promoting preferential homeostatic 
expansion of responding T cells in lymphodepleted hosts (31, 35). 
 
2.6  
Regulatory T Cells 
CD4+ regulatory T cells (Treg) comprise 5-10% of CD4+ cells in human peripheral blood and 
have been phenotypically characterized as CD4+ cells constitutively expressing surface CD25. 
Treg CD4+ cells, in contrast to recently activated CD4+ T cells that are CD25med or resting 
CD4+ T cells that are CD25lo, can be isolated based on being phenotypically CD25hi, and 
further distinguished by expression of the forkhead transcription factor, Foxp3. 
Cyclophosphamide has been shown to deplete Treg cells, and in murine studies 
cyclophosphamide-mediated Treg depletion enhanced anti-tumor immunity (21, 37-39), 
suggesting this may in part be the basis for the immuno-potentiating effect of 
cyclophosphamide in tumor therapy models. In patients, circumstantial evidence suggests that 
the levels of Treg cells may correlate with disease stage and prognosis (40), and selective 
depletion of CD25+ cells using an IL-2-diphtheria-toxin conjugate is the subject of several 
ongoing clinical trials (25, 41).  
 
2.7 
Interleukin-2  
 
The Use of IL-2 in Patients with Metastatic Melanoma 
IL-2 promotes the proliferation of immune effector cells such as T cells and NK cells by 
binding to high and intermediate affinity surface receptors.  Initial studies using high dose IL-
2 for the treatment of metastatic melanoma and renal cell carcinoma have demonstrated 
responses in 3 - 24% of patients with rare durable remissions.  These doses, in the range of 
18-28 x 106 U/m2 every 8 hours resulted in significant morbidity as a result of capillary leak 
syndromes and occasional mortality (43). In contrast, patients receiving low-dose 
recombinant IL-2 at doses up to 3 x 106 U/m2 for periods of 1 month or more do not experience 
significant toxicity (WHO classification, Grade III or IV) (44-46). While such doses have 
seldom resulted in clinical response, doses as low as 100,000 U have been demonstrated to 
induce cellular immunologic effects in vivo while doses greater than 106 U/m2 were associated 
with systemic symptoms of malaise and myalgias. Following subcutaneous (s.c.) 
administration, IL-2 exhibits a half-life of between 3 to 12 hours, sustained serum levels of 
10- 25 U/ml, and receptor saturating serum concentrations of 22 pM after an injection of 
250,000 U/m2 (47-50). Administration of 3 x 106 U/m2 of IL-2 for up to 21 days for the 
treatment of melanoma results in response rates of 0 to 9% (51). Therefore, patients receiving 
low-dose IL-2 in this trial, (250,000 U s.c twice daily), are unlikely to receive significant 
benefit from the IL-2 alone, rather, the IL-2 is administered  in a manner designed to promote 
persistence of infused T cells in vivo. 
High-dose IL-2 (600,000 U/kg three times daily) is the U.S. FDA-approved dose and schedule 
for the treatment of patients with metastatic melanoma or renal cell cancer and has a 
demonstrated response rate in patients with melanoma of 15% and a complete remission (CR) 
rate of 6-8%; however most patients experiencing a CR go on to enjoy a long term durable 
remission. The toxicities associated with high-dose IL-2, in particular the vascular leak 
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syndrome secondary to cytokine-mediated permeability of capillary vessels leads to 
interstitial edema, hypotension, fever and oliguria.  IL-2 associated toxicities are reversed in 
most cases upon cessation of IL-2 therapy and go on to complete an average of 10-12 doses 
of IL-2 with the first course.  
 
2.7.1  The Use of Interleukin-2 in Adoptive T Cell Therapy 
In our clinical studies, adoptively transferred CTL clones had a median survival of 6.6 +/- 0.8 
days in the absence of IL-2. The addition of a 14-day course of low-dose IL-2 (250,000 U/m2 
twice daily) following T cell infusion significantly prolonged median CTL survival to 16.8 
+/- 1.6 days without associated toxicity (6). The frequency of transferred CTL in vivo began 
to fall before the end of the 14-day course, suggesting limited benefit might be expected with 
continued administration of IL-2 at this dose beyond 14 days.  
High-dose IL-2 (720,000 U/kg three times daily) has been administered following adoptive 
transfer of CD8+ T cells (7, 8). In one study, clonal T cells were promulgated to very high 
numbers and clinical responses were observed; however, due to the design of the study, no 
conclusions could be drawn as to whether high-dose IL-2 was required for the in vivo survival 
or expansion of transferred T cells.  In addition to a direct effect on T cell expansion, it could 
be speculated that increase vascular permeability induced by high-dose IL-2 provides 
improved tissue access to tumor sites. Additionally, our own studies and that of others (42) 
have shown that exposure to high-dose IL-2 (1000 U/ml) leads to rapid, antigen-independent 
expansion of CTL clones in vitro (in a manner similar to IL-15) while exposure to low-dose 
IL-2 had little effect.  Of note, responses to high-dose IL-2 were only observed with antigen-
specific CTL clones generated by cyclical re-stimulation using PBMCs of vaccine-naïve 
donors. CTL clones generated from G209M-vaccinated donors and exposed to high doses of 
IL-2 in vitro failed to respond to either high-dose IL-2 or IL-15, thus concurring with the 
hypothesis that the manner and source from which T cells are generated can influence their in 
vivo behavior.   
 
  
2.8 
Potential toxicities associated with CD8+ CTLs  
The infusion of large numbers of antigen-specific ex vivo derived CD8+ T cells may 
potentially lead to recognition by the same T cells of antigen expressed in normal tissue. 
Furthermore, tissue-specific toxicities associated with T cells targeting cancer-testis antigens 
have not been observed with vaccine (52) or adoptive therapy studies (17). However, if 
antigen spreading occurs and the patient develops a de novo response to his own melanoma 
cells, recognition of normal tissue may occur. Melanoma antigen is expressed in cells derived 
from the neural crest such as melanocytes of the skin and choroid and retinal cells.  The 
pigmented tissues of the eye may be protected from potential toxicity since the sub-retinal 
space and vitreous cavity are considered immunologically privileged sites, like the testis, by 
virtue of physical barriers and immunosuppressive factors such as TGF-beta, alpha-MSH and 
other low molecular weight proteins present in these sites (53-55).  
 
In humans, there have been reports of patients treated with immunomodulators such 
as gamma-interferon or IL-2 in whom the appearance of vitiligo parallels their response to 
therapy (56).  Patients with metastatic melanoma have also been treated with infusions of 
large numbers of (up to 1011) CD8+ TIL cells that were subsequently shown to be reactive to 
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antigens (gp100, Melan-A and antigen) shared by melanomas and normal melanocytes. 
Although vitiligo was observed in a small proportion of these patients, there was no evidence 
of visual or neurologic toxicity (57). More recently, we reported on the development of a 
targetoid rash surrounding normal pigmented skin cells on a patient who received MART-1 
specific CD8+ T cells. The infused T cell clone was retrieved from these sites of inflammation 
(9).  The rash resolved without sequelae, and the patient did not develop evidence of ocular 
or neurologic toxicity.  There have been no toxicities associated with the infusion of PRAME-
specific CTL.  
 
  
2.9  
Rationale and Proposed Study of Adoptive T Cell Therapy for the Treatment of Patients 
with Metastatic Melanoma 
In this study we propose to examine the benefits of a combined biologic approach: adoptive 
transfer of antigen-specific CTLs together with anti-CTLA4. CTLA4 functions as an 
inhibitory receptor for B7 ligands and is upregulated in T cells proportionally to the strength 
of the TCR signal from antigen recognition. The higher affinity for binding to B7 of CTLA4 
compared to CD28 permits disruption of co-stimulatory signals from CD28 as well as 
delivery of inhibitory signals that impede TCR signaling, IL-2 transcription, and T cell 
proliferation(1). Although CTLA4 was initially shown to play a role during primary 
induction of antigen-specific T cells, it is also believed to contribute to secondary T cell 
responses (58).  We postulate that administration of anti-CTLA4 may not only enhance the 
adoptively transferred T cell response, but also promote the generation of additional T cell 
responses against a broader panel of tumor-associated antigens that are released in a pro-
inflammatory environment following lysis of tumors by antigen-specific CTL. 
 
Antigen Specificity and Patient Treatment 
 
Disease Diagnosis & Staining Outcome 
Antigen-Specific CTL 
Pt. tests for HLA-A*0201, MART1 + 
MART 1 cells (1010 cells/m2) 
Pt. tests for HLA-A*0201, PRAME + 
PRAME cells (1010 cells/m2) 
Pt. tests for HLA-A*0201, MART1 + and 
PRAME+ 
MART1 cells and PRAME cells (1010 
cells/m2  total, with no fewer than 29 
cells/m2 of each) 
 
 
3. 
OBJECTIVES 
 
3.1  
Primary Objectives 
 
1. Evaluate the safety and efficacy of adoptively transferred CTL targeting melanoma 
tumors combined with anti-CTLA4 
 
3.2  
Secondary Objectives 
 
1. Evaluate the influence of anti-CTLA4 on the duration of in vivo persistence and anti-
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tumor efficacy achieved following adoptive transfer of antigen-specific CTL. 
 
2. Evaluate the influence of anti-CTLA4 on the induction of T cells to non-targeted 
tumor-associated antigens (antigen-spreading) following adoptive transfer antigen-
specific CTL, and the correlation of these responses with clinical outcome. 
 
4. 
STUDY DESIGN 
 
The proposed study is a Phase II trial aimed at treating up to 20 HLA-A*0201+ individuals 
with metastatic melanoma. Patients will first receive a lympho-depleting conditioning 
regimen comprised of a single dose of cytoxan at 300mg/m2 on day -2. On day 0, patients will 
receive an infusion of 1010  T cells/m2, followed by a 14-day course of low-dose s.c. IL-2. 
Anti-CTLA4 will be administered at a dose of 3 mg/kg intravenously over ~90 minutes 24 
hours after the T cell infusion. Thereafter anti-CTLA4 will be given every 3 weeks at a dose 
of 3mg/kg intravenously for a combined total of 4 doses. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
For the purposes of registration, the CORe system will be employed.  All patients will be registered 
in CORe before any study specific tests are performed.  
This protocol is designed to treat metastatic melanoma patients with measurable residual 
disease and no CNS metastasis.  
Based on the entry criteria requiring a performance status of >70% (85% of total patients, 
n=119) and HLA-A2 expression (40% of these patients), an average of 45 patients/year will 
be eligible for this study.  
 
5. 
PATIENT ELIGIBILITY 
 
5.1  
Eligibility for Enrollment 
a 
Histopathologic documentation of melanoma concurrent with the current or prior 
diagnosis of metastatic disease or in-transit disease  
b 
Male or female subjects ≥18 years of age. 
c 
Expression of HLA-A2. 
Anti-CTLA4  
(Day 1) 
CY 
(Day  -2) 
CTL Infusion 
 (Day 0) 
Low-dose IL-2 (14 days) 
Monitoring and  
Staging Evaluations 
(12 weeks) 
Anti-CTLA4  
(Day 22) 
Anti-CTLA4  
(Day 43) 
Anti-CTLA4  
(Day 64) 
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d 
ECOG/ Zubrod performance status of ‘0-1’ at screening visit  
e 
Women of childbearing potential (WOCBP) must be using an adequate method of 
contraception to avoid pregnancy throughout the study in such a manner that the risk 
of pregnancy is minimized.  Suggested precautions should be used to minimize the 
risk or pregnancy for at least 1 month before start of therapy, and while women are 
on study for up to 3 months after T cell infusion, and at least 8 weeks after the study 
drug is stopped. WOCBP include any female who has experienced menarche and who 
has not undergone successful surgical sterilization (hysterectomy, bilateral tubal 
ligation or bilateral oophorectomy) or is not postmenopausal  
f 
Men must be willing and able to use an acceptable method of birth control, during 
and for at least 3 months after completion of the study, if their sexual partners are 
WOCBP. 
g 
Willing and able to give informed consent. 
h 
Adequate venous access- consider PICC or central line. 
i 
Evaluation of BRAFV600 mutation status.   
j 
Measurable tumor (by RECIST criteria).  
k 
MART 1 or PRAME (+) assay results.  (If patients have not had staining test in the 
past, the test will be run after patient consent is obtained, but before enrollment).   
5.2  
Exclusion for Enrollment 
a 
Any other malignancy from which the patient has been disease-free for less than 5 
years, with the exception of adequately treated and cured basal or squamous cell skin 
cancer, superficial bladder cancer, carcinoma in situ of the cervix. 
 
b 
Pregnant women, nursing mothers, men or women of reproductive ability who are 
unwilling to use effective contraception. Women of childbearing potential with a 
positive pregnancy test within 3 days prior to entry. 
 
c 
Active and untreated central nervous system (CNS) metastasis (including metastasis 
identified during screening MRI or contrast CT): 
• No signs or symptoms of CNS mets within the last 30 days (from enrollment 
evaluation). 
• No single lesion larger than 1cm 
• No more than 5 lesions 
 
 
d 
Autoimmune disease: Patients with a history of Inflammatory Bowel Disease are 
excluded from this study, as are patients with a history of autoimmune disease  (e.g. 
Systemic Lupus Erythematosus, vasculitis, infiltrating lung disease) whose possible 
progression during treatment would be considered by the Investigator to be 
unacceptable.  
 
e 
Any underlying medical or psychiatric condition, which in the opinion of the 
Investigator, will make the administration of study drug hazardous or obscure the 
interpretation of adverse events, such as a condition associated with frequent diarrhea. 
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f 
Positive screening tests for HIV, Hep B, and Hep C (referencing blood draw at 
leukapheresis screening). If positive results are not indicative of true active or chronic 
infection, the patient can be treated. 
 
5.3 
Eligibility for Treatment (Includes Cyclophosphamide, T cell, anti-CTLA4 infusions 
and s.c. IL-2) 
a 
ECOG/Zubrod performance status of ‘0-1’  
b 
At least 4 Weeks must have elapsed since the last chemotherapy, radiotherapy or major 
surgery. At least 6 Weeks for nitrosoureas, mitomycin C and liposomal doxorubicin. 
If started before T-cell administration, Ipilimumab infusions must be least 21 
days apart. 
c 
Toxicity related to prior therapy must either have returned to ≤ grade 1, baseline, or 
been deemed irreversible.  
d 
Persons of reproductive potential must agree to use and utilize an adequate method 
of contraception throughout treatment and for at least 8 weeks after study drug is 
stopped. 
e 
Willing and able to give informed consent.  
 
5.4 
Exclusion Criteria for Treatment  
 
a 
CBC and Chemistry profile prior to cyclophosphamide and T cell infusions: 
 
• WBC ≤ 1000/uL 
• Hct ≤ 24% or Hemoglobin ≤ 8 g/dL 
• ANC ≤ 500 
• Platelets ≤ 50,000 
• Creatinine ≥ 3.0 x ULN 
• AST/ALT ≥ 2.5 x ULN 
• Bilirubin ≥ 3 x ULN 
 
b 
Pregnant women, nursing mothers, men or women of reproductive ability who are 
unwilling to use effective contraception. Women of childbearing potential with a 
positive pregnancy test within 3 days prior to entry. 
 
c 
Steroids are not permitted 3 days prior to T cell infusion and concurrently during 
therapy.  
 
d 
Any non-oncology vaccine therapy used for the prevention of infectious disease 
within 1 month before or after any ipilimimab dose.  
 
e 
Patients may not be on any other treatments for their cancer aside from those included 
in the protocol. Patients may not undergo another form of treatment concurrently with 
this study. 
 
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f         Active and untreated central nervous system (CNS) metastasis (including metastasis            
          identified during screening MRI or contrast CT): 
• No signs or symptoms of CNS mets within the last 30 days (from enrollment 
evaluation). 
• No single lesion larger than 1cm 
• No more than 5 lesions 
 
 
 
 6. 
STUDY AGENTS 
 
6.1 
Antigen-specific CD8+ T cells 
All T cells administered will be T cells derived from the peripheral blood lymphocytes of 
metastatic melanoma patients.  Briefly, T cells demonstrating antigen-specific cytolytic 
function will be tested for: 
• CD3+, 8+ surface phenotype 
• Class I MHC restricted lysis of antigen-expressing target cells 
• Mycoplasma, fungal and bacterial sterility 
T cells will be infused intravenously at a rate of not more than 500cc/hour through a 
peripheral vein or central catheter. The infusion bag will be gently mixed every 5 minutes 
during the infusion. 
6.2  
Cyclophosphamide 
Cyclophosphamide at 300 mg/m2 will be administered intravenously. Standard Practice 
Policy guidelines will be followed and its administration will be completed at least 48 hours 
prior to the T cell infusion.  
 
6.3 
Anti-CTLA4 / Ipilimumab 
Ipilimumab (Yervoy™) is a human cytotoxic T-lymphocyte antigen 4 (CTLA-4) blocking 
antibody indicated for the treatment of unresectable or metatstatic melanoma. Ipilimumab 
will be purchased by M.D. Anderson Pharmacy from commercial sources. Ipilimumab 
administration will be initiated approximately 24 hours after the T cell infusion at a dose of 
3mg/kg over approximately 90 minutes intravenously.  
 
6.4 
Interleukin-2  
Low-dose s.c IL-2 will be initiated within 6 hours of T cell infusion. 
Low-dose IL-2 will be administered at 250,000 U/m2 s.c. twice daily x 14 days. The patient 
or their caregiver will be instructed on s.c. self-administration. 
 
7. 
PLAN OF TREATMENT/STUDY SCHEDULE (Appendix A) 
 
The timing of visits and procedures after T cell infusion are expected to occur +/- 3 days of 
the designated date.   
 
7.1  
Screening visit/Consent visit 
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• Patients will be screened for their eligibility on the study based on eligibility for 
enrollment inclusion/exclusion criteria.  
• Patients will be screened for Hepatitis B Surface Antigen, Hepatitis B Core Antibody, 
Hepatitis C Virus Antibody, and HIV 1/HIV 2 Antibody within 7 days of 
leukapheresis.   
• EKG performed prior to enrollment (within the last 6 months).  
• Patients may be consented.  
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, baseline Thyroid Function Testing, Liver function tests and 
LDH (including TSH, free T4, T3, AST, ALT, alkaline phosphatase, total bilirubin, 
and direct bilirubin); Complete blood count and differential, platelets (see Appendix 
A, Schedule of treatment and evaluation).  
• Leukapheresis visit may be scheduled. 
 
7.2 
Tumor Biopsy (Optional) 
• Patients undergoing surgery to remove or biopsy tumor as part of the usual 
management of their disease will be asked to consent to the use of a non-diagnostic 
portion of their tumor for research purposes (including measurement of antigen and 
MHC expression). 
• Patients may be asked to consent to an optional tumor biopsy should the tumor be 
measureable and accessible (e.g. skin or subcutaneous site) and risks, in the opinion 
of the surgeon, are minimal. 
 
7.3  
 Leukapheresis Visit 
• 
Leukapheresis is scheduled at a time prior to anticipated interval systemic therapy or, 
if the patient is receiving treatment, at a time at least two weeks from last treatment 
cycle and when blood counts satisfy criteria for leukapheresis (see section 5.4). 
Peripheral blood mononuclear cells (PBMC’s) will be used for the generation of 
antigen-specific T cells in the lab. Patients ineligible for leukapheresis because of 
poor venous access or patients who elect not to undergo leukapheresis but still wish 
to remain on the study may undergo a maximum of four weekly phlebotomies to 
obtain PBMC’s necessary to establish T cell cultures. On each of these blood draws, 
50 – 100 cc of blood will be obtained. 
 
• 
Leukapheresis may be deferred for patients with active infections or oral temperature 
> 38.2 C within 72 hours prior to planned Leukapheresis.  
 
• 
Leukapheresis may be deferred for patients with Hct < 30%, WBC <2500/uL and 
platelets <50,000 immediately prior to Leukapheresis.   
 
Typically, a leukapheresis procedure will collect at least 1 billion white blood cells from 
which we generate the T cells for the clinical trial.  If more than 1 billion cells are collected, 
then we may use some portion of the unused white blood cell collection to perform 
laboratory research studies that will improve the ability to grow these cells and improve 
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their function for future clinical trials.  The excess cells will be used for laboratory research 
only at the discretion of the principal investigator.   
 
7.4  
Pre-Infusion Visit (Week -4 to -2) 
• Patients for whom antigen-specific CTL have been generated will be evaluated prior 
to the anticipated treatment date.  
• At this visit, eligibility criteria for treatment will be assessed (refer to section 5.3 and 
5.4). 
• If patient has not had in the last seven (7) days, perform perform: physical exam; vital 
signs; comprehensive chemistry panel to include electrolytes, BUN, Cr, Liver 
function tests and LDH; Complete blood count and differential, platelets; collect 
research blood samples (see Appendix A, Schedule of treatment and evaluation) 
• Patients will be excluded from treatment if CBC and Chemistry profile prior to 
cyclophosphamide and T cell infusion is: 
• 
WBC ≤ 2000/uL 
• 
Hct ≤ 24% or Hemoglobin ≤ 8 g/dL 
• 
ANC ≤ 1000  
• 
Platelets ≤ 50,000 
• 
Creatinine ≥ 3.0 x ULN 
• 
AST/ALT ≥ 2.5 x ULN 
• 
Bilirubin ≥ 3 x ULN 
• Staging for measurable disease: Patients must have bi-dimensional measureable 
disease by palpation on clinical exam or radiographic imaging (CT scan). 
• At least 4 Weeks must have elapsed since the last chemotherapy, radiotherapy or 
major surgery. At least 6 Weeks for nitrosoureas, mitomycin C and liposomal 
doxorubicin. If started before T-cell administration, Ipilimumab infusions must 
be least 21 days apart. 
• Steroids are not permitted 3 days prior to T cell infusion and concurrently during 
therapy. 
• Patients may not be on any other treatments for their cancer aside from those included 
in the protocol. Patients may not undergo another form of treatment concurrently with 
this study. 
• Bi-dimensionally measurable disease by palpation on clinical exam, or radiographic 
imaging (CT scan). 
• If patients agree to proceed with T cell therapy and all criteria are met, then a 
cyclophosphamide infusion visit (outpatient) and T cell infusion visit (inpatient) 
appointment will be scheduled 
7.5  
Cyclophosphamide Infusion visit (Day -2) 
• If patient has not had in the last seven (7) days, perform: physical exam; vital signs; 
comprehensive chemistry panel to include electrolytes, BUN, Cr, Liver function tests 
and LDH; Complete blood count and differential, platelets (see Appendix A, 
Schedule of treatment and evaluation). 
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• Cyclophosphamide will be administered at 300 mg/m2 intravenously 48 to 72 hours 
prior to T cell infusion as an outpatient procedure. For women of child-bearing 
potential, the confirmation of the absence of pregnancy will be required prior to 
infusion. 
 
7.6  
T Cell Infusion Visit (Day 0) 
 
• Prior to infusion perform: physical exam; vital signs; comprehensive chemistry panel 
to include electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood 
count and differential, platelets; collect research blood samples (see Appendix A, 
Schedule of treatment and evaluation). 
• Administer T cells at a dose of 1010 cells/m2. T cells from in vitro cultures will be 
washed three times with RPMI-Hepes solution and re-suspended in 250-500 ml of 
0.9% NaCl in preparation for infusion. 
• Patients will have vital signs and oxygen saturation measured by pulse oximetry pre-
infusion, approximately every 15 minutes for the first hour, then approximately every 
30 minutes for the next two hours followed by approximately every 6 hours overnight.  
 
7.7  
Interleukin-2 Administration (Day 0 to Day +14) 
• Low-dose IL-2 (250,000 U/m2 s.c. q12h) will begin within 6 hours of T cell infusion 
and continue for a total of 14 days (28 doses). 
 
7.8  
Anti-CTLA4 (Ipilimumab) Administration (Day +1 to Day +64) 
• Ipilimumab will be administered ~24 hours after the T cell infusion at a dose of 
3mg/kg over ~90 minutes intravenously. Subsequent infusions will be administered 
on days +22, +43 and +64 (+/- 1 day) at a dose of 3mg/kg.   
 
7.9 
Follow Up: (Day +3): 
• 
Perform: comprehensive chemistry panel to include electrolytes, BUN, Cr, Liver 
function tests and LDH; Complete blood count and differential, platelets; collect 
research blood samples (see Appendix A, Schedule of treatment and evaluation). 
7.10  
Follow Up: (Day +7): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation) 
7.11  
Follow Up: (Day +14): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation. 
• End Low dose IL-2 (Day 13). 
 
7.12  
Follow Up: (Day +22): 
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• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, baseline Thyroid Function Testing, Liver function tests and 
LDH (including TSH, free T4, T3, AST, alkaline phosphatase, total bilirubin, and 
direct bilirubin); Complete blood count and differential, platelets; collect research 
blood samples (see Appendix A, Schedule of treatment and evaluation. 
• 2nd dose of Ipilimumab will be administered at a dose of 3mg/kg over ~90 minutes 
intravenously. 
7.13  
Follow Up: (Day +28): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation. 
7.14  
Follow Up: (Day +35): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation). 
• Perform staging for measurable disease (Day +35 to +42) 
7.15  
Follow Up: (Day +43/6 weeks): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, baseline Thyroid Function Testing, Liver function tests and 
LDH (including TSH, free T4, T3, AST, alkaline phosphatase, total bilirubin, and 
direct bilirubin); Complete blood count and differential, platelets; collect research 
blood samples (see Appendix A, Schedule of treatment and evaluation. 
• 3nd dose of Ipilimumab will be administered at a dose of 3mg/kg over ~90 minutes 
intravenously. 
7.16  
Follow Up: (Day +49): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation. 
7.17  
Follow Up: (Day +56): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation). 
7.18  
Follow Up: (Day +64): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, baseline Thyroid Function Testing, Liver function tests and 
LDH (including TSH, free T4, T3, AST, alkaline phosphatase, total bilirubin, and 
direct bilirubin); Complete blood count and differential, platelets; collect research 
blood samples (see Appendix A, Schedule of treatment and evaluation). 
• 4nd dose of Ipilimumab will be administered at a dose of 3mg/kg over 90 minutes 
intravenously. 
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7.19  
Follow Up: (Day +70): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation). 
7.20  
Follow Up: (Day +77): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation). 
• Perform staging for measurable disease (Day +77 to +84) 
 
7.21  
Follow Up: (Day +84/12 weeks): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, baseline Thyroid Function Testing, Liver function tests and 
LDH (including TSH, free T4, T3, AST, alkaline phosphatase, total bilirubin, and 
direct bilirubin); Complete blood count and differential, platelets; collect research 
blood samples (see Appendix A, Schedule of treatment and evaluation). 
7.22  
Follow Up: (Day +112): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation). 
7.23  
Follow Up: (Day +140): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, Liver function tests and LDH; Complete blood count and 
differential, platelets; collect research blood samples (see Appendix A, Schedule of 
treatment and evaluation). 
7.24  
Follow Up/End of Study: (Day +168): 
• Perform: physical exam; vital signs; comprehensive chemistry panel to include 
electrolytes, BUN, Cr, baseline Thyroid Function Testing, Liver function tests and 
LDH (including TSH, free T4, T3, AST, alkaline phosphatase, total bilirubin, and 
direct bilirubin); Complete blood count and differential, platelets; collect research 
blood samples (see Appendix A, Schedule of treatment and evaluation). 
 
Follow up visits that do not require the patient to return to MD Anderson, may be performed 
by the patients’ local oncologist/doctor. The collection of data and blood samples will be 
coordinated by the assigned MD Anderson Study Coordinator. All outside labs will need to 
be reviewed, signed and dated by the Principal Investigator or treating physician prior to 
submission to the electronic medical record.  The PI or treating physician should appraise 
abnormal lab results and determine/document clinical significance.  
 
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Retreatment may be considered if no serious unexpected adverse toxicities were experienced 
with the initial treatment and any adverse toxicities from the initial treatment (including those 
related to ipilimumab administration) have resolved to Grade I or lower prior to re-treatment. 
 
7.25  End of Patient Monitoring 
The end of patient monitoring is planned for 6 months after the T cell infusion. Patients who 
have detectable transferred cells >0.5% of CD8+ T cells at the end of monitoring, show tumor 
response (refer to section 8.2 for definitions) or show antigen spreading, will continue to be 
monitored on study with visits every 4-6 weeks or as often as clinically indicated.  MD 
Anderson Immune Monitoring Core Facility will perform the analysis using tetramer staining 
and/or ELISPOT analysis. 
 
7.26  Outside Physician Participation During Treatment 
 
• MDACC Physician communication with the outside physician is required prior to 
the patient returning to the local physician. (This will be documented in the patient 
record). 
• A letter to the local physician outlining the patient's participation in a clinical trial 
will request local physician agreement to supervise the patient's care (Appendix M). 
• Protocol required evaluations outside MDACC will be documented by telephone, fax 
or e-mail.  Fax and/or e-mail will be dated and signed by the MDACC physician, 
indicating that they have reviewed it. 
• Changes in drug dose and/or schedule must be discussed with and approved by the 
MDACC physician investigator, or their representative prior to initiation, and will be 
documented in the patient record. 
• A copy of the informed consent, protocol abstract, treatment schema and evaluation 
during treatment will be provided to the local physician. 
• Documentation to be provided by the local physician will include drug 
administration records, progress notes, reports of protocol required laboratory and 
diagnostic studies and documentation of any hospitalizations. 
• The home physician will be requested to report to the MDACC physician 
investigator all life threatening events within 24 hours of documented occurrence. 
• Patients will return to MDACC at time-points (D+35 to D+42) and (D+77 to D+84)  
months for evaluation (staging for measurable disease). 
• Collection of data and blood samples will be coordinated by the assigned MD 
Anderson Study Coordinator. 
 
 
8.      SCHEDULE OF EVALUATIONS  
 
8.1 
General Toxicity Assessment  
 
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8.1.1 Vital signs (temperature, pulse, breathing, blood pressure), Physical exams, oxygen 
saturation, Comprehensive chemistry panel, Complete blood counts, differentials and platelet 
counts will be completed according to the schedule as outlined in Appendix A.  
Of note, the dates listed on the study calendar are approximate as many patients reside out of 
the area and cannot always follow the time points as dictated by the protocol.  
8.1.2 All adverse events will be recorded and graded according to the NCI CTCAE v4.1 and 
the table in section 10.10.  The Investigator or physician designee is responsible for verifying 
and providing source documentation for all adverse events and assigning the attribution for 
each event for all subjects enrolled on the trial. 
 
8.2 
Efficacy Assessment 
8.2.1 Clinical Response 
Radiographic imaging and clinical assessment of residual disease will be compared with pre-
infusion assessment. A complete response (CR) will be defined as total regression of all 
tumor, a partial response (PR) as 30% or greater decrease in the sum of the longest diameter 
of target lesions and progressive disease (PD) as 20% increase in the sum of the longest 
diameter of target lesions (RECIST criteria) This assessment will be performed 12 weeks 
following T cell infusion and then every 3 months until disease progression or intervening 
therapy.  The overall response rate (OR) will be after 1 cycle (12) weeks.  
 
8.2.2 Delayed Response Endpoints   
Ipilimumab is expected to trigger immune-mediated responses, which require activation of 
the immune system prior to the observation of clinical responses. Such immune activation 
may take weeks to months. Some patients with advanced melanoma may have objective 
volume increase of tumor lesions within 12 weeks after inclusion in the study.   Such patients 
may not have had sufficient time to develop the required immune activation or, in some 
patients, tumor volume increases may represent infiltration of lymphocytes into the original 
tumor. In conventional studies, such tumor volume increases during the first 12 weeks of the 
study would constitute PD and lead to discontinuation of imaging to detect response, thus 
disregarding the potential for subsequent immune-mediated clinical response. Therefore, in 
this study, patients with tumor volume increase detected prior to Week 12, but without rapid 
clinical deterioration, will continue to be treated with ipilimumab and clinically observed 
with a stringent imaging schedule to allow detection of a subsequent tumor response. Such 
assessments will be using identical criteria considering index and non-index lesions. Best 
overall response assessments will therefore include responses occurring at any time before 
disease progression and after early progression, within the first twelve weeks of the study. 
This will improve the overall assessment of the clinical activity of ipilimumab and more 
likely capture its true potential to induce clinical responses.   
 
8.2.3 Best Overall Response Rate (BORR)   
BORR is defined as the total number of patients whose BOR is CR or PR, divided by the 
total number of patients.   
 
8.2.4  Duration of Response   
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A patient’s Duration of Response is defined as the time between the date measurement 
criteria are first met for subsequently-confirmed OR of PR or CR (whichever status is 
recorded first) and the date of disease progression or death. Duration of Response will be 
calculated for all patients with CR or PR using the Kaplan-Meier product limit method.  For 
patients who undergo tumor resection on study, Duration of Response will be censored on 
the date of last tumor assessment prior to resection. For those patients who remain alive and 
have not progressed, Duration of Response will be censored on the date of last tumor 
assessment.  The subset of patients whose Duration of Response (CR or PR) is ≥ 24 weeks 
will also be captured. This is referred to as Major Durable Response (MDR). The Major 
Durable Response Rate (MDRR) is defined as the total number of patients with MDR divided 
by the total number of patients.   
 
8.2.5  Time to Response   
A patient’s Time to Response is defined as the time from the first dose of study therapy until 
measurement criteria are first met for subsequently confirmed OR of PR or CR  (whichever 
status is recorded first). Every confirmed CR or PR, whether occurring before or after 
progression of disease, is included in this assessment. Descriptive statistics on Time to 
Response will be computed, as treated, for all treated patients whose BOR is PR or CR. Time 
to Response will also be analyzed for all treated patients, as treated, using the Kaplan-Meier 
product limit method.  In this case, for patients who do not have BOR of CR or PR, Time to 
Response will be censored on the date of last tumor assessment. For patients undergoing 
tumor resection before a confirmed PR or CR is observed, Time to Response will be censored 
on the date of the last tumor assessment prior to resection.   
 
8.2.6 Progression Free Survival (PFS)   
PFS is defined as the time between infusion date and the date of progression or death. A 
patient who dies without reported prior progression will be considered to have progressed on 
the date of death. For a patient who undergoes tumor resection on study, PFS will be censored 
on the date of the last tumor assessment prior to resection. For those who remain alive and 
have not progressed, PFS will be censored on the date of last tumor assessment. For patients 
who have PD prior to Week 12 and a subsequent assessment of SD, PR or CR, the date of 
PD following response (where available) will be used in the analysis of PFS; otherwise these 
patients will be censored on the date of their last tumor assessment. PFS is estimated using 
the Kaplan-Meier product limit method.   
 
8.2.7 Progression Free Survival (PFS) Rate at Week 12  
PFS Rate at Week 12 is defined as the probability that a patient survives and is progression 
free at Week 12 following infusion date.  It is estimated using the Kaplan-Meier product limit 
method. PFS Rate at Week 12 will also be evaluated as a proportion, calculated as the total 
number of patients who have an OR assessment of SD, PR or CR at the Week 12 assessment, 
divided by the total number of patients. Patients who have PD prior to the Week 12 
assessment and a subsequent assessment of SD, PR or CR at Week 12 will be analyzed as 
having SD, PR or CR, respectively, at the Week 12 assessment. 
 
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       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
- - 23 - - 
8.3 
Immune Monitoring 
Patients will have 60 mls of heparinized blood (green top tube) drawn at the pre-infusion visit, 
immediately prior to the CD8+ T cell infusion, and on days +1, +3 and +7 and then weekly 
thereafter for 12 weeks, followed by every 4 weeks until 6 months post-infusion, 
corresponding to the discontinuation of patient monitoring. 
  
Patients will also have 5ml gray top tube drawn at the pre-infusion visit, immediately prior to 
the CD8+ T cell infusion, and on day +1, +7, +14, +28, +43, +56, +84, +112, +140 and +168 
after the T cell infusion.   
 
Samples will be used to evaluate the duration of in vivo persistence and function of infused T 
cells as well as antigen spreading. 
 
Immune monitoring will be carried out in the PI research laboratory, with the support of the 
Core Immune Monitoring Lab. 
 
Primary endpoint:  
The numeric and functional persistence of transferred CTL will be performed on peripheral 
blood obtained from patients prior to T cell infusion (baseline sample), on Days +1, +3, +7, and 
weekly thereafter. To prevent inter-test bias, all samples will be cryo-preserved, and then 
thawed and assayed simultaneously. The numeric frequency of transferred T cells will be 
determined using peptide MHC-tetramer analysis or specific CDR3 TCR quantitative PCR of 
transferred CTL if necessary. The function of transferred CTL will be determined by 
intracellular cytokine staining of tetramer+ CD8+ cells following in vitro stimulation as 
previously described.  
 
Secondary endpoint: 
Responses to non-targeted antigens will be evaluated for evidence of “antigen-spreading”.  
Blood samples taken pre-infusion and at 1 month, 3 months, and every 3 months up to one 
year following T cell infusion and/or at the time of observed partial or complete clinical 
response, will be analyzed for the induction of non-targeted T cell responses. Two approaches 
will be used – tetramer analysis and ELISPOT assay: 
 
a 
Tetramer analysis. Since all patients on study will be HLA-A2+, the use of tetramers 
to track several well-characterized tumor-associated HLA-A2-restricted responses 
will be feasible. These include responses to several melanosomal antigens: 
(tyrosinase, MART-1/MelanA, gp100, SLC45A2) and CT antigens: (PRAME, 
MAGE-A1, MAGE-A10). Flow-based tetramer staining permits multiparametric 
analysis such that surface markers of differentiation (CD62L, CCR7, CD27, CD28) 
can be used to further characterize the effector, effector memory or central memory 
phenotype of the induced population of antigen-specific T cells. 
b 
ELISPOT analysis. The use of RNA-transfected autologous APCs as stimulator cells 
will provide a more comprehensive analysis of induced responses by detecting 
responses regardless of the HLA-restricting element, as well as identifying CD4+ T 
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       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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cell responses to tumor-associated antigens (we have demonstrated the feasibility of 
this assay in ongoing adoptive therapy trials). 
 
8.4   
Tumor Immunophenotyping 
In the absence of complete regression, immunophenotype analysis of the tumor pre-infusion 
will be compared with persistent tumor nodules or new tumor nodules post-infusion to 
evaluate for the outgrowth of antigen-loss tumor variants.  New nodules will be sampled 
when they arise. Persistent disease will be sampled 2 weeks following the T cell infusion. 
Immunophenotyping will evaluate the expression of targeted antigen as well as other 
melanoma antigens. The level of expression will be scored by the pathologist in ‘blinded’ 
samples, as 0-4+ with a score of 0 being no expression, 1+, 25% of cells positive; 2+, 50% of 
cells, 3+, 75% of cells, 4+ 100% of cells. Antigen loss will be defined as the absence of 
expression of targeted antigens or a significant decrease in expression (defined as a ≥ 2 level 
decrease in score) in post-infusion sample as compared with the pre-infusion sample.. 
Persistent expression of non-targeted antigen, e.g. gp100, in the post-infusion tumor sample 
in the presence of antigen-loss as defined above will be considered evidence of outgrowth of 
antigen-loss variants as a result of immune targeting. Where possible, single cell suspensions 
of tumor samples will be stained with anti-Class-I and anti-HLA-A2 antibodies in order to 
evaluate HLA allele loss as a possible alternative mechanism of immune evasion.  
 
8.5   
T cell Localization to Disease Sites 
Localization of transferred antigen-specific CTL to tumor sites will be evaluated in selected 
patients with surgically accessible disease (disease that is accessible by needle or core biopsy, 
or that can be excised). Single cell suspensions will be prepared and stained to identify 
antigen-specific CTL by tetramer analysis. Tetramer positive cells will be sorted and 
analyzed for identity to the original infused CTL by PCR of a cell-specific CDR3 region of 
the T cell receptor. Where possible, these results will be compared with a pre-infusion tumor 
sample and the peripheral blood. A T cell frequency at least five-fold higher than that found 
in the peripheral blood or pre-infusion sample will be considered evidence of T cell 
localization/accumulation in disease sites.  
 
 
9 
MANAGEMENT OF TOXICITIES AND COMPLICATIONS 
 
9.1  
Dose Limiting Toxicity (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 ≥ Grade 3 bronchospasm or other hypersensitivity reaction; 
• Any adverse event, laboratory abnormality or inter current illness which, in the 
judgment of the Investigator, presents a substantial clinical risk to the patient with 
continued dosing 
• Any other ≥ Grade 3 non-skin related adverse event that does not return to baseline 
levels within 7 days, with the exception of events listed below: 
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       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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9.2  
Exceptions 
• Cytokine Release Syndrome (CRS) that, in the opinion of the investigators, is 
attributable to T cell infusions: Including but not limited to asthemia, flu-like 
symptoms, myalgia, lymphopenia, neutropenia that returns to a Grade 2 toxicity on 7 
days from day of onset. 
• Skin rash/Erythroderma (grade 2 toxicity) lasting for ≤7 days 
• Reversible inflammation (< Grade 4), potentially attributable to a local anti-tumor 
reaction and therapeutic response. This includes inflammatory reactions at sites of 
tumor resections or draining lymph nodes, at sites suspicious for, but not diagnostic 
of metastasis.  
• Hospitalization for ≤ Grade 2 adverse events where the primary reason for 
hospitalization is to expedite the clinical work-up. 
• Patients 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: ipilimumab may not be restarted while 
the patient is being treated with systemic corticosteroids except for patients on 
stable doses of hormone replacement therapy such as hydrocortisone. 
• Fever > 40C for less than 24 hours. 
• WBC < 1000 for less than 7 days. 
• Platelets < 50,000 for less than 7 days. 
• ANC < 500 for less than 7 days. 
 
 
 
9.3 
Criteria for Discontinuation of Therapy 
• Permanent discontinuation of ipilimumab, T cell infusion and IL-2 will be required 
for any patient experiencing a dose-limiting toxicity (9.1) with exceptions as noted in 
9.2. 
• Withdrawal of informed consent (subject’s decision to withdraw from the study for 
any reason). 
• Any clinical adverse event, laboratory abnormality or intercurrent illness which, in 
the opinion of the Investigator, indicates that continued treatment with study therapy 
is not in the best interest of the subject. 
• Pregnancy: all WOCBP should be instructed to contact the Investigator immediately 
if they suspect they might be pregnant (e.g., missed or late menstrual period) at any 
time during study participation and therapy will be discontinued.  
• Imprisonment or the compulsory detention for treatment of either a psychiatric or 
physical (e.g., infectious disease) illness.  
 
9.4 
Management of Symptoms during T Cell Infusion 
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CD8+ T Cell and Ipilimumab    
 
       M.D. ANDERSON CANCER CENTER 
 
             
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Mild transient symptoms have been observed with tumor infiltrating lymphocytes (TIL), 
lymphokine activated killer (LAK) therapy and antigen-specific T cell infusions.  The 
management of these symptoms is outlined below: 
• Fever, chills and temperature elevations > 101°F will be managed with 
acetaminophen 650 mg p.o. q 4-6 hrs.  All subjects that develop fever or chills will 
have a blood culture drawn. Naproxen 250 mg po q 12 hours prior to and during high-
dose IL-2 will be administered prophylactically per standard practice guidelines for 
IL-2 administration.  
• Headaches may be managed with acetaminophen following a neurologic 
examination. 
• Nausea, vomiting will be treated with a non-steroidal anti-emetic of choice.  
• Hypotension will initially be managed by intravenous fluid administration and further 
measures as dictated by standard medical practice. 
• Hypoxemia will initially be managed with supplemental oxygen and further measures as 
dictated by standard medical practice. 
 
9.5 
Toxicities Warranting Ablation of Adoptively Transferred T Cells 
Severe toxicity occurring after CD8+ T cell infusions and, in the best judgment of the 
investigator, are related to CD8+ T cells toxicity as opposed to a transient albeit severe 
cytokine release syndrome, may warrant ablation. Patients that receive ablation must be 
discontinued from the study. 
Examples of such scenarios include: 
• Hypotension (systolic BP <90 mmHg and > 20 mmHg below baseline), tachycardia 
(HR > 130), tachypnea (RR > 32) and/or hypoxemia (arterial O2 saturation < 90%), 
not responsive to supportive care. 
• Grade 2 or greater allergic reaction, consisting of bronchospasm or generalized 
urticaria.  
• Grade 3 or greater toxicity occurring in any other organ system following 
administration of antigen-specific cytotoxic T cells, and not attributable to a different 
cause.  Exceptions to this are: 
• 
Fever of >40˚C which lasts less than 48 hours following infusions  
• 
Lymphopenia of Grade 3 that does not revert to Grade 2 within 96 hours 
Patients will receive corticosteroids if treatment-related toxicity warranting ablation of T cells 
is observed and the following dose schedule is suggested:  
 
Day 1 Intravenous Solu-Medrol at 2 mg/kg   
Day 2 Intravenous Solu-Medrol at 2 mg/kg  
Day 3-4 Prednisone at 30 mg po b.i.d.  
Day 5-6 Prednisone at 15 mg po b.i.d.  
Day 7-8 Prednisone at 10 mg po b.i.d.  
Day 9-10 Prednisone at 10 mg po q.d  
Day11-12 Prednisone at 5  mg po q.d.  
 
9.6 
Management of Symptoms During Ipilimumab Administration 
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CD8+ T Cell and Ipilimumab    
 
       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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Since ipilimumab contains only human protein sequences, it is less likely that any allergic 
reaction will be seen in patients.  However, it is possible that infusion of ipilimumab 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 
pre-medication will be given unless indicated by previous experience in an individual patient.  
 
Reactions will be treated based upon the following recommendations:  
 
For mild symptoms (e.g., localized cutaneous reactions such as mild pruritus, flushing, rash): 
• Decrease the rate of infusion until recovery from symptoms, remain at bedside and 
monitor patient; 
• Complete the ipilimumab infusion at the initial planned rate ; 
• Diphenhydramine 50 mg IV may be administered at the discretion of the treating 
physician and patients may receive additional doses with close monitoring; 
• Premedication with diphenhydramine may be given at the discretion of the 
Investigator for subsequent doses of ipilimumab. 
 
For moderate symptoms (any symptom not listed above [mild symptoms] or below [severe 
symptoms] such as generalized pruritus, flushing, rash, dyspnea, hypotension with systolic 
BP >80 mmHg): 
• Interrupt ipilimumab; 
• Administer diphenhydramine 50 mg IV;  
• Monitor patient closely until resolution of symptoms; 
• Corticosteroids may abrogate any beneficial immunologic effect, but may be 
administered at the discretion of the treating physician; 
• Resume ipilimumab infusion after recovery of symptoms; 
• At the discretion of the treating physician, ipilimumab infusion may be resumed at one 
half the initial infusion rate, then increased incrementally to the initial infusion rate.  
• If symptoms develop after resumption of the infusion, the infusion should be 
discontinued and no additional ipilimumab should be administered that day; 
• The next dose of ipilimumab will be administered at its next scheduled time and may 
be given with pre-medication (diphenhydramine and acetaminophen) and careful 
monitoring, following the same treatment guidelines outlined above;  
• At the discretion of the treating physician additional oral or IV antihistamine may be 
administered prior to dosing with ipilimumab. 
 
For severe symptoms (e.g., any reaction such as bronchospasm, generalized urticaria, systolic 
blood pressure <80 mm Hg, or angioedema): 
• Immediately discontinue infusion of ipilimumab, and disconnect infusion tubing from 
the subject; 
• Consider bronchodilators, epinephrine 1 mg IV or subcutaneously, and/or 
diphenhydramine 50 mg IV, with solumedrol 100 mg IV, as needed. 
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       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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• Patients should be monitored until the Investigator is comfortable that the symptoms 
will not recur; 
• No further ipilimumab will be administered; 
 
In 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). 
 
Treatment of Ipilimumab Related Isolated Drug Fever 
• In the event of isolated drug fever, the Investigator must use clinical judgment to 
determine if the fever is related to the ipilimumab or to an infectious etiology. 
• If a patient experiences isolated drug fever, for the next dose, pre-treatment with 
acetaminophen or non-steroidal anti-inflammatory agent (Investigator discretion) 
should be instituted and a repeated antipyretic dose at 6 and 12 hours after ipilimumab 
infusion, should be administered. The infusion rate will remain unchanged for future 
doses. 
• If a patient experiences recurrent isolated drug fever following premedication and post 
dosing with an appropriate antipyretic, the infusion rate for subsequent dosing should 
be decreased to 50% of the previous rate. If fever recurs following infusion rate 
change, the Investigator should assess the patient’s level of discomfort with the event 
and use clinical judgment to determine if the patient should receive further 
ipilimumab. 
 
9.7 
Concomitant Therapy 
• Active infections occurring after initiating the study should be treated according to 
the standard of care. 
• Patients may not be on any other treatments for their cancer aside from those included 
in the protocol. Patients may not undergo another form of treatment concurrently with 
this study. 
• The following agents are not allowed while on study:  
• 
Systemic   corticosteroids (except as outlined for management of transferred 
T cell toxicity in section 9.6), 
• 
Immunotherapy (for example, interleukins, interferons, melanoma vaccines, 
intravenous immunoglobulin, expanded polyclonal TIL or LAK therapy) 
• 
Pentoxifylline 
• 
Other investigational agents. 
 
9.8 
Premature Discontinuation 
Subjects who do not complete the study medication will be considered to have prematurely 
discontinued the study.  The reasons for premature discontinuation (for example, voluntary 
withdrawal, toxicity, death) must be recorded on the case report form. If possible, final study 
evaluations should be completed at the time of discontinuation.   
 
Potential reasons for premature discontinuation include: 
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       M.D. ANDERSON CANCER CENTER 
 
             
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• Patients who are enrolled but do not meet treatment eligibility criteria. 
• Development of a life-threatening infection. 
• Judgment by the principal investigator that the patient is too ill to continue. 
• Patient noncompliance with study therapy and/or clinic appointments. 
• Pregnancy. 
• Voluntary withdrawal; a patient may remove himself/herself from the study at any 
time without prejudice. 
•  Significant and rapid progression of melanoma requiring alternative   medical or 
surgical intervention including, but not limited to, the development of CNS metastasis. 
• Grade III or IV toxicity judged to be possibly or probably related to study therapy 
according to criteria and exceptions as described above. 
• Initiation of any additional non-study cancer treatment regardless of the reason 
• Termination of the study by the principal investigator, the DSMB, Institutional 
Review Office or the Food and Drug Administration. 
 
10. 
REPORTING ADVERSE EVENTS  
 
10.1 
An adverse event or suspected adverse reaction is considered “serious” if, in the view of either 
the investigator or the sponsor, it results in any of the following outcomes: 
10.1.1 Death 
10.1.2 A life-threatening adverse drug experience – any adverse experience that places the 
patient, in the view of the initial reporter, at immediate risk of death from the adverse 
experience as it occurred. It does not include an adverse experience that, had it 
occurred in a more severe form, might have caused death. 
10.1.3 Inpatient hospitalization or prolongation of existing hospitalization. 
10.1.4 A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions. 
10.1.5 A congenital anomaly/birth defect. 
 
10.2 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
Examples of such medical events include allergic bronchospasm requiring intensive treatment 
in an emergency room or at home, blood dyscrasias or convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse (21 CFR 
312.32). 
 
10.3 
Important medical events as defined above, may also be considered serious adverse events. 
Any important medical event can and should be reported as an SAE if deemed appropriate by 
the Principal Investigator or the IND Sponsor, IND Office. 
 
10.4 
All events occurring during the conduct of a protocol and meeting the definition of a SAE 
must be reported to the IRB in accordance with the timeframes and procedures outlined in 
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       M.D. ANDERSON CANCER CENTER 
 
             
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“The University of Texas M. D. Anderson Cancer Center Institutional Review Board Policy  
for Investigators on Reporting Unanticipated Adverse Events for Drugs and Devices”.  Unless 
stated otherwise in the protocol, all SAEs, expected or unexpected, must be reported to the 
IND Office, regardless of attribution (within 5 working days of knowledge of the event). 
 
10.5 
All life-threatening or fatal events, that are unexpected, and related to the study drug, must 
have a written report submitted within 24 hours (next working day) of knowledge of the event 
to the Safety Project Manager in the IND Office. 
 
10.6 
Unless otherwise noted, the electronic SAE application (eSAE) will be utilized for safety 
reporting to the IND Office and MDACC IRB.   
 
10.7 
Serious adverse events will be captured from the time of the first protocol-specific 
intervention until 30 days after the last study treatment/intervention, unless the participant 
withdraws consent. Serious adverse events must be followed until clinical recovery is 
complete and laboratory tests have returned to baseline, progression of the event has 
stabilized, or there has been acceptable resolution of the event.  Adverse events occurring one 
week after pheresis prior to cytoxan infusion (Day-2) will not be recorded in the CRF.   
 
10.8 
Additionally, any serious adverse events that occur after the 30 day time period that are related 
to the study treatment must be reported to the IND Office.  This may include development of 
a secondary malignancy.   
 
10.9 
Reporting to the FDA 
 
10.9.1 Serious adverse events will be forwarded to the FDA by the IND sponsor (Safety 
Project Manager IND Office) according to 21 CFR 321.32 
 
10.10 It is the responsibility of the PI and the research team to ensure serious adverse events 
are reported according to the Code of Federal Regulations, Good Clinical Practices, the 
protocol guidelines, the sponsor’s guidelines and Institutional Review Board policy. 
 
10.11 All Adverse Events will be recorded according to the table below. Adverse events will be 
captured from the time of T-cell infusion until 30 days after the last dose of study drug. 
 
 
Recommended Adverse Event Recording Guidelines  
Attribution 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
  
  
  
  
  
  
Unrelated 
Phase I 
Phase I 
Phase I           
Phase II   
  
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
Unlikely 
Phase I 
Phase I 
Phase I           
Phase II   
  
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
Possible 
  
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       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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Phase I            
Phase II 
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
Probable 
Phase I            
Phase II 
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
  
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
Definitive 
Phase I            
Phase II 
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
  
Phase I           
Phase II  
Phase III 
Phase I           
Phase II  
Phase III 
 
11. 
DATA ENTRY AND PROTOCOL MANAGEMENT  
 
For the purposes of this study at M. D. Anderson Cancer Center, the Protocol Data 
Management System (PDMS) will be employed.  All patients will be registered in CORe 
before any study specific tests are performed 
 
12. 
STATISTICALCONSIDERATIONS 
 
This is a single-arm, open-label, phase II clinical trial to evaluate the efficacy and safety of 
autologous CD8+ antigen-specific T cells and anti-CTLA4 treating patients with metastatic 
melanoma. The regimen will be considered successful if it elicits a higher overall response 
rate and no higher toxicity rate in this patient population than Ipilimumab (standard of care).  
The primary endpoint for evaluating efficacy will be the overall response rate (OR = 
complete or partial response) at 12 weeks after T cell infusion and subsequently every 3 
months until disease progression.  Toxicities are defined as serious adverse events as noted 
in Section 9.1.  Expected accrual is 1 to 2 patients per month.  A maximum of 30 patients 
will be enrolled in this study on an intent-to-treat basis, and MDACC will enroll 20 patients.  
Data from an additional patients is available through data sharing on patients enrolled at 
Fred Hutch Institute. 
 
12.1 
SAMPLE SIZE AND ENDPOINT MONITORING 
 
Overall response and toxicity will be monitored simultaneously using the Bayesian 
approach of Thall, Simon, Estey (1995, 1996) and the extension by Thall and Sung 
(1998).  The OR rate of Ipilimumab is less than 20%.  A serious toxicity rate of 30% 
or less is considered acceptable in this patient population.  Using this information, we 
constructed the Dirichlet parameters for the joint prior distribution of efficacy and 
toxicity for the standard of care: 
 
Table 1.  Dirichlet parameters for the joint prior distribution of 
overall response and serious toxicity assuming information on 100 
patients and independence among response and adverse events. 
 
Objective Response 
Others 
Toxicity 
6 
24 
No Toxicity 
14 
56 
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Patients will be considered non-responders after 1 cycle (12 weeks). 
 
A flat Dirichlet prior distribution for the study regimen was chosen reflective of 
information from the equivalent of 2 patients with the same marginal distributions in 
table 1 (i.e., OR rate of 20% and serious adverse event rate of 30%). 
 
This new regimen will be considered worthy of further investigation if it elicits a 10% 
increase in overall response to 30% with acceptable toxicity.  Thus, interim monitoring 
rules, assuming the prior distributions above, were constructed that meet the following 
two conditions, 
 
1) Pr(θE, Tox > θS,Tox| data) > 0.90 and, 
2) Pr(θE, Resp > θS,Resp + 0.1| data) < 0.01 
 
θE,Resp and θS,Resp are the OR rates for the study treatment and Ipilimumab, respectively.  
Similarly, θE,Tox and θS,Tox are the serious adverse event rates for study treatment  and 
Ipilimumab, respectively.  The first rule provides for stopping the study if the serious 
adverse event rate with new treatment exceeds that of Ipilimumab with high 
probability (i.e., probability > 90%).  The second condition will stop the study early 
for futility, i.e., if the data suggest that it is unlikely the OR response rate with this 
new treatment is better than Ipilimumab (probability < 1%).    
 
The continuous monitoring rule for serious adverse events, based on these assumptions 
and monitoring conditions is found in table 2.  Both toxicity and futility monitoring 
will start after 10 patients have been enrolled. For example, accrual will cease if 6 
patients experience serious AE among the first 10-11 patients treated. 
 
Table 2.  Stop accrual if the number of serious adverse events is equal to or greater than 
indicated (i.e., # Serious AE’s) among the number of patients accrued (i.e., # Patients). 
# Serious AE’s 
6 
7 
8 
9 
10 
11 
12 
13 
# Patients 
10-11 
12-13 
14-16 
17-19 
20-21 
22-24 
25-26 
27-29 
 
Overall response will be monitored according to the rule listed in Table 3.  Again, 
monitoring rule will be implemented after 10 patients enrolled. For example, accrual 
will cease if no patient experience OR in the first 10-16 patients treated. 
 
Table 3.  Stop accrual if the number patients with an overall response is less than or 
equal to that indicated (i.e., # OR’s) in the number of patients accrued (i.e., # Patients). 
# OR’s 
0 
1 
2 
3 
# Patients 
10-16 
17-22 
23-27 
28-29 
 
Simulation (10,000 replicates) was used to evaluate the performance of these stopping 
rules on the conduct of the study (Table 4).  The probability of stopping the study early 
if the objective response rate of the new regimen was not better than Ipilimumab was 
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37% given low toxicity and 90% given high toxicity.  This study design was carried 
out using Multc99 version 2.1. 
 
Table 4.  Operating characteristics, based on 10,000 simulations per scenario, of 
simultaneous monitoring of overall response and serious adverse event rates for patients 
treated with study treatment. 
Response/Serious 
AE Relationship 
True Response and 
Seriou AE Rates 
Probability of 
Stopping Early 
Achieved Sample Size 
Quartiles 
25th 
50th 
75th 
Low / Low 
20%/30% 
0.37 
17 
30 
30 
Low / High 
20%/50% 
0.90 
9 
11 
19 
High / Low 
30%/30% 
0.17 
30 
30 
30 
High / High 
30%/50% 
0.86 
9 
11 
21 
 
ANALYSIS PLAN 
 
Continuous variables (e.g., age, etc.) will be summarized using the mean (SD) or median 
(range).  Frequency tables will be used to summarize categorical variables.  Logistic 
regression will be used to assess the impact of patient characteristics on the overall response 
rate.  The distribution of time-to-event endpoints (e.g., CR duration, overall survival) will be 
estimated using the method of Kaplan and Meier.  Comparison of time-to-event endpoints by 
important subgroups of patients will be made using the log-rank test.  Cox (proportional 
hazards) regression will be used to evaluate multivariable predictive models of time-to-event 
outcomes. 
 
12.2 
Projected targeted accrual 
Neither gender nor ethnicity is criteria for enrollment on this study. Since melanoma afflicts 
primarily (> 95%) a Caucasian population, we do not expect to see significant minority 
representation. It is anticipated that CTL may not be derived for some enrolled patients and 
some patients may opt not to receive the study treatment.  A maximum of 30 patients will 
be enrolled in this study on an intent-to-treat basis, and MDACC will enroll 20 
patients.  Data from additional 10 patients is available through data sharing on patients 
enrolled at Fred Hutch. 
 
Toxicities are defined as serious adverse events as 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 >/= Grade 
3 bronchospasm or other hypersensitivity reaction; any adverse event, laboratory 
abnormality or inter current illness which, in the judgment of the Investigator, presents a 
substantial clinical risk to the patient with continued dosing; any other >/= Grade 3 non-skin 
related adverse event that does not return to baseline levels within 7 days, with the exception 
of events listed below: 
 
Exceptions 
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·           Cytokine Release Syndrome (CRS) that, in the opinion of the investigators, is 
attributable to T cell infusions: Including but not limited to asthemia, flu-like symptoms, 
myalgia, lymphopenia, neutropenia that returns to a Grade 2 toxicity on 7 days from day of 
onset. 
·           Skin rash/Erythroderma (grade 2 toxicity) lasting for ≤7 days 
·           Reversible inflammation (< Grade 4), potentially attributable to a local anti-tumor 
reaction and therapeutic response. This includes inflammatory reactions at sites of tumor 
resections or draining lymph nodes, at sites suspicious for, but not diagnostic of metastasis. 
·           Hospitalization for ≤ Grade 2 adverse events where the primary reason for 
hospitalization is to expedite the clinical work-up. 
  
Patients 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: ipilimumab may not be restarted while the patient is being 
treated with systemic corticosteroids except for patients on stable doses of hormone 
replacement therapy such as hydrocortisone. 
  
·           Fever > 40C for less than 24 hours. 
·           WBC < 1000 for less than 7 days. 
·           Platelets < 50,000 for less than 7 days. 
·         ANC < 500 for less than 7 days 
 
 
 
TARGETED/PLANNED ENROLLMENT:  Number of Subjects 
 
ETHNIC CATEGORY 
 
 
 
Sex/Gender 
 
Females 
Males 
Total 
Hispanic or Latino 
0 
0 
0 
Not Hispanic or Latino 
5 
5 
10 
Ethnic Category Total of All Subjects* 
5 
5 
10 
 
                  Racial Categories 
American Indian/Alaska Native 
0 
0 
0 
Asian 
0 
0 
0 
Native Hawaiian or Other Pacific Islander 
0 
0 
0 
Black or African American 
0 
0 
0 
White 
5 
5 
10 
Racial Categories: Total of All Subjects * 
5 
5 
10 
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CD8+ T Cell and Ipilimumab    
 
       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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CD8+ T Cell and Ipilimumab    
 
       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
- - 36 - - 
13. 
ADMINISTRATIVE CONSIDERATIONS 
 
13.1  PROTOCOL MONITORING  
 
The study will be monitored by the M.D. Anderson IND office and a protocol specific 
monitoring plan will be followed. 
 
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 
MD Anderson IRB will review serious adverse events as they are submitted.  Serious adverse 
events will be submitted to the FDA by the IND Sponsor (Safety Project Manager, IND 
Office).  The principal investigator will also review serious adverse events and evaluate 
trends.  Whenever a trend is identified, the principal investigator will determine an appropriate 
follow up plan. 
 
 
Changes to the Protocol: 
Any change or addition to this protocol requires a written protocol amendment that must be 
approved by the IND Office and the IRB. A copy of the written approval of the IRB must be 
received  by the IND Office and the principal investigator before implementation of any 
changes.  The IRB must review and approve all amendments to the protocol. 
 
 
Ethics and Good Clinical Practice: 
This study must be carried out in compliance with the protocol and Good Clinical 
Practice, as described in:  
 
ICH Harmonized Tripartite Guidelines for Good Clinical Practice   1996. 
 
US 21 Code of Federal Regulations dealing with clinical studies    
(including parts 50 and 56 concerning informed consent and IRB regulations). 
 
Declaration of Helsinki, concerning medical research in humans  
(Recommendations Guiding Physicians in Biomedical Research Involving 
Human Subjects, Helsinki 1964, amended Tokyo 1975, Venice 1983, Hong 
Kong 1989, Somerset West 1996). 
 
The investigator agrees, when signing the protocol, to adhere to the instructions and 
procedures described in it and thereby to adhere to the principles of Good Clinical 
Practice 
 
 
13.2 
Institutional Review Board 
In accordance with federal regulations (21 CFR 312.66), an Institutional Review Board (IRB) 
that complies with regulations in 21 CFR 56 must review and approve this protocol and the 
informed consent form prior to initiation of the study. 
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       M.D. ANDERSON CANCER CENTER 
 
             
 HOUSTON, TX 
 
 
 
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13.3 
Consent 
The Principal Investigator or designee must explain verbally and in writing the nature, 
duration, and purpose of the study and possible consequences of treatment.  Patients must 
also be informed that they may withdraw from the study at any time and for any reason 
without jeopardizing their future treatment.  In accordance with federal regulations (21 CFR 
312), all patients must sign the IRB-approved consent form in the presence of a witness.   
 
 
 
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