Conditions: Metastatic Melanoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 13
Healthy volunteers: no

Brief summary:
Background:

Adoptive T cell therapy with tumor infiltrating lymphocytes (TILs) has been reported to induce durable clinical responses in patients with metastatic melanoma. From patients own tumor material T cells are extracted, expanded and activated in vitro in a 4-6 weeks culture period. Before TIL infusion patients are preconditioned with a lymphodepleting chemotherapeutic regimen. After TIL infusion, patients are treated with IL-2 to support T cell activation and expansion in vivo.

The BRAF inhibitor is an approved treatment of metastatic melanoma and functions by selectively inhibiting the BRAF mutated enzyme, consequently halting the proliferation of tumor cells. Furthermore, in vitro tests have shown that vemurafenib has immunomodulatory effects that are hypothesized to synergize with TIL therapy, which has been confirmed in animal studies.

Objectives:

* To evaluate safety and feasibility when combining vemurafenib and ACT with TILs.
* To evaluate treatment related immune responses
* To evaluate clinical efficacy

Design:

* Patients will be screened with a physical exam, medical history, blood samples and ECG.
* Patients will start vemurafenib 960 mg BID and will continue during TIL preparation.
* 7 days after start of vemurafenib, patients will undergo surgery to harvest tumor material for TIL production.
* Patient stops vemurafenib and is admitted day -8 in order to undergo lymphodepleting chemotherapy with cyclophosphamide and fludara starting day -7.
* On day 0 patients receive TIL infusion and shortly after starts IL-2 infusion continually following the decrescendo regimen.
* The patients will followed until progression or up to 5 years.

Detailed description:

Arms:
arm 1: 7 days before tumor harvest, patients will begin taking vemurafenib until admission for lymphodepleting chemotherapy regimen of cyclophosphamide and fludarabine, followed by TIL infusion and interleukin-2.

Interventions: intervention 1: Vemurafenib intervention 2: Lymphodepleting chemotherapy intervention 3: TIL infusion intervention 4: Interleukin-2
Intervention descriptions: intervention 1: Vemurafenib is used to treat patients with BRAF mutated metastatic melanoma. Patients will start treatment in a dose of 960 BID 7 days before tumor harvest and ends at the day of admission (day -8). intervention 2: First patients undergo lymphodepleting chemotherapy regimen consisting of cyclophosphamide 60 mg/kg for 2 days and fludarabine 25 mg/m2 for 5 days (constitutes day -7 to -1 of admission). intervention 3: 7 days after start of vemurafenib treatment, patients undergo surgery to removal of a tumor in order to isolate, activate and expand tumor infiltrating lymphocytes (TIL) to high numbers. In vitro preparation usually takes 4-6 weeks using the young TIL method.

On day 0 patients receive an infusion of TIL (1x10e9-2x10e11 cells). intervention 4: After infusion of TILs, patients will receive interleukin-2 infusions according to the decrescendo regimen (18 MIU/m2 for 6 hours, 18 MIU/m2 for 12 hours, 18 MIU/m2 for 24 hours followed by 4,5 MIU/m2 for another 3 x 24 hours)

Protocol document:
Prot_SAP_000.pdf: 
 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
1
 
 
T-cell therapy in combination with vemurafenib  
for patients with BRAF mutated  
metastatic malignant melanoma 
 
 
 
 
A pilot study 
 
 
EudraCT no.: 2014-001419-38 
 
 
 
 
The clinical trial will be performed according to the present protocol, current Good Clinical Practice 
(GCP) guidelines and requirements from the authorities. The investigator allows direct access to 
source data/documents (including patient records) in the event of monitoring, auditing, and/or 
inspection from the Danish Medicines Agency, the GCP units, or from the health authorities of 
other countries, respectively. 
 
 
Sponsor 
 
Inge Marie Svane, Professor, Chief Physician, PhD 
Date: _______________________________ 
Director of the National Center for Cancer Immune Therapy 
Department of Oncology and Department of Hematology 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 25C, 5th floor, 2730 Herlev 
Phone: +45 38 68 21 31 
 
 
Inge Marie Svane: ____________________ 
 
 
Primary investigator 
Troels Holz Borch, physician, PhD student 
Date: _______________________________ 
National Center for Cancer Immune Therapy (CCIT-DK) 
Department of Oncology R 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 25C, 5th floor, 2730 Herlev 
Phone: +45 38 68 17 56 
 
 
Troels Holz Borch:____________________ 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
2
Protocol responsible parties 
 
Sponsor 
Inge Marie Svane, Professor, Chief Physician, PhD 
 
Director of the National Center for Cancer Immune Therapy  
Department of Oncology and Hematology 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 25C, 5th floor, 2730 Herlev, Denmark 
Phone: +45 38 68 21 31 
 
 
 
Primary investigator 
Troels Holz Borch, physician, PhD student 
 
CCIT-DK, Department of Oncology 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 25C, 5th floor, 2730 Herlev, Denmark 
Phone: +45 38 68 17 56 
 
 
 
Sub-investigators 
Rikke Andersen, physician, PhD student 
CCIT-DK, Department of Oncology 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 25C, 5th floor, 2730 Herlev, Denmark 
Phone: +45 38 68 93 57 
 
Marco Donia, physician, PhD 
CCIT-DK, Department of Oncology and Hematology  
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 25C, 5th floor, 2730 Herlev, Denmark 
Phone: +45 38 68 14 56  
 
Collaborators and involved departments 
Per thor Straten and Mads Hald Andersen 
Center management, National Center for Cancer Immune Therapy (CCIT-DK) 
Hematology Laboratory 54P4 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 25C, 5th floor, 2730 Herlev, Denmark 
Phone: +45 38 68 38 68 
 
Department of Oncology 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 7, 2730 Herlev, Denmark 
Phone: +45 38 68 38 68 
 
Hanne Marie Michelsen 
Clinical Research Unit, Department of Oncology  
Copenhagen University Hospital Herlev 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
3
Borgmester Ib Juuls Vej 9, 5th floor, 2730 Herlev, Denmark 
Phone: +45 38 68 38 68 
 
Lisbet Rosenkrantz Hölmich 
Department of Plastic Surgery 
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 5, 2730 Herlev, Denmark 
Phone: +45 36 68 38 68 
 
Helle Westergren Hendel 
Department of Clinical Physiology and Nuclear Medicine  
Copenhagen University Hospital Herlev 
Borgmester Ib Juuls Vej 71, 4th floor, 2730 Herlev, Denmark 
Phone: +45 36 68 38 68 
 
Monitoring 
 
GCP unit 
GCP unit at Copenhagen University Hospital 
Bispebjerg Hospital, Building 51, 3rd floor 
Bispebjerg Bakke 23 
2400 København NV 
Denmark 
Phone: +45 35 31 38 90 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
4
Table of contents 
 
PROTOCOL RESPONSIBLE PARTIES ................................................................................................................. 2 
MONITORING ......................................................................................................................................................... 3 
TABLE OF CONTENTS ......................................................................................................................................... .4 
ABBREVIATIONS ................................................................................................................................................... 7 
SYNOPSIS .................................................................................................................................................................... 8 
INDICATION AND TREATMENT ................................................................................................................................................ 8 
RATIONALE ........................................................................................................................................................................ 8 
PURPOSE ........................................................................................................................... ERROR! BOOKMARK NOT DEFINED.8 
STUDY DESIGN .................................................................................................................................................................... 8 
POPULATION ...................................................................................................................................................................... 9 
TOXICITY ........................................................................................................................................................................... 9 
CLINICAL RESPONSE EVALUATION ............................................................................................................................................ 9 
IMMUNOLOGICAL RESPONSE EVALUATION ................................................................................................................................ 9 
INTRODUCTION AND RATIONALE ............................................................................................................................... 9 
MALIGNANT MELANOMA ...................................................................................................................................................... 9 
TUMOR IMMUNOLOGY ....................................................................................................................................................... 10 
TUMOR INFILTRATING LYMPHOCYTES (TILS) ........................................................................................................................... 10 
T-CELL THERAPY ................................................................................................................................................................ 11 
CCIT-DK experiences with T-cell therapy ................................................................................................................. 12 
CLINICAL TRIAL .................................................................................................................. ERROR! BOOKMARK NOT DEFINED.12 
TRANSLATIONAL RESEARCH ................................................................................................................................................. 12 
Rationale behind the substances used in the clinical trial ....................................................................................... 13 
LYMPHOCYTE-DEPLETING CHEMOTHERAPY ............................................................................................................................. 13 
CYCLOPHOSPHAMIDE ......................................................................................................................................................... 13 
FLUDARABINE PHOSPHATE .................................................................................................................................................. 14 
INTERLEUKIN-2 ................................................................................................................................................................. 14 
OPTIMIZING T-CELL THERAPY WITH VEMURAFENIB ................................................................................................................... 14 
Rationale behind the treatment regime used in the clinical trial ............................................................................ 14 
PURPOSE AND HYPOTHESES ......................................................................................................................................15 
PRIMARY ......................................................................................................................................................................... 15 
SECONDARY ..................................................................................................................................................................... 15 
STUDY DESIGN ...........................................................................................................................................................15 
STUDY POPULATION ..................................................................................................................................................15 
CRITERIA FOR INCLUSION AND EXCLUSION .............................................................................................................................. 16 
Inclusion criteria ...................................................................................................................................................... 16 
Exclusion criteria ..................................................................................................................................................... 17 
EVALUATION BEFORE INCLUSION IN THE CLINICAL TRIAL ............................................................................................................. 17 
Examination plan associated with the treatment ................................................................................................... 18 
TREATMENT STRATEGY .............................................................................................................................................19 
SUBSTANCES IN THE CLINICAL TRIAL ....................................................................................................................................... 21 
Vemurafenib ............................................................................................................................................................ 21 
Cyclophosphamide .................................................................................................................................................. 21 
Fludarabine phosphate ........................................................................................................................................... 21 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
5
Interleukin-2 ............................................................................................................................................................ 21 
TILs .......................................................................................................................................................................... 22 
TREATMENT PLAN DURING HOSPITALIZATION .......................................................................................................................... 22 
SIMULTANEOUS TREATMENT ............................................................................................................................................... 22 
Guidelines for supportive care and treatment ........................................................................................................ 22 
Prophylactic treatment ........................................................................................................................................... 23 
Supportive treatment .............................................................................................................................................. 23 
Local radiotherapy .................................................................................................................................................. 24 
TREATMENT DISCONTINUATION ................................................................................................ ERROR! BOOKMARK NOT DEFINED. 
Normal discontinuation ........................................................................................................................................... 24 
Follow-up ................................................................................................................................................................. 24 
Early discontinuation of treatment ......................................................................................................................... 25 
Subsequent treatment ............................................................................................................................................. 26 
PRODUCTION OF TILS ................................................................................................................................................26 
REQUISITION OF TUMOR TISSUE ........................................................................................................................................... 26 
ESTABLISHING ”YOUNG TIL” CULTURES ................................................................................................................................. 26 
RAPID EXPANSION PROTOCOL (REP) .................................................................................................................................... 26 
ISOLATION OF TUMOR CELLS ................................................................................................................................................ 27 
PHENOTYPE AND CLONOTYPE DETERMINATION ........................................................................................................................ 27 
CYTOKINE RELEASE ASSAY .................................................................................................................................................. 27 
GENE-BASED ARRAYS ......................................................................................................................................................... 27 
ADVERSE EVENTS, POTENTIAL RISKS, AND PRECAUTIONS .........................................................................................27 
ADVERSE EVENTS (ADVERSE EVENT = AE) .............................................................................................................................. 27 
GRADUATION OF ADVERSE EVENTS ....................................................................................................................................... 27 
SERIOUS ADVERSE EVENT (SERIOUS ADVERSE EVENT = SAE) ..................................................................................................... 28 
GUIDELINE FOR POSSIBLE RELATIONSHIPS BETWEEN ADVERSE EVENTS AND TREATMENT  .................................................................. 28 
SIDE EFFECTS .................................................................................................................................................................... 28 
REPORTING OF EVENTS AND SIDE EFFECTS .............................................................................................................................. 29 
KNOWN SIDE EFFECTS ........................................................................................................................................................ 30 
Vemurafenib ............................................................................................................................................................ 30 
Chemotherapy ......................................................................................................................................................... 31 
Cyclophosphamide .................................................................................................................................................. 32 
Fludarabine phosphate ........................................................................................................................................... 37 
TILs .......................................................................................................................................................................... 39 
Interleukin-2 ............................................................................................................................................................ 39 
Risks and disadvantages associated with surgery and sample collection ............................................................... 45 
Risks associated with removal of tumor tissue .................................................................................................. 45 
Risks associated with biopsy collection  ............................................................................................................. 45 
Risks associated with blood sampling ................................................................................................................ 45 
MONITORING AND PRECAUTIONS ......................................................................................................................................... 46 
Hematological parameters ................................................................................................................................. 46 
Kidney and urinary tract function....................................................................................................................... 45 
Cardiotoxicity...................................................................................................................................................... 46 
Infertility ............................................................................................................................................................. 46 
Live vaccines ....................................................................................................................................................... 46 
Interactions ........................................................................................................................................................ 47 
EFFECT EVALUATION,  DATA ANALYSIS, AND MONITORING ......................................................................................47 
EFFECT EVALUATION .......................................................................................................................................................... 47 
Primary effect parameter ........................................................................................................................................ 47 
Secondary effect parameter .................................................................................................................................... 47 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
6
RESPONSE CRITERIA ........................................................................................................................................................... 47 
RECIST ...................................................................................................................................................................... 47 
IMMUNOLOGICAL MONITORING ........................................................................................................................................... 48 
Blood samples for immunological monitoring ........................................................................................................ 48 
Tumor biopsies ........................................................................................................................................................ 48 
STATISTICS ....................................................................................................................................................................... 49 
DATA REGISTRATION AND ANALYSIS ...................................................................................................................................... 49 
END OF STUDY REPORT ....................................................................................................................................................... 49 
AMENDMENTS ................................................................................................................................................................. 50 
ETHICAL CONSIDERATIONS ........................................................................................................................................50 
RECRUITMENT OF STUDY PARTICIPANTS AND INFORMED CONSENT .............................................................................................. 50 
INSURANCE ...................................................................................................................................................................... 50 
ETHICAL ASPECTS .............................................................................................................................................................. 51 
RESEARCH BIOBANK ........................................................................................................................................................... 51 
REPORTING TO THE DANISH DATA PROTECTION AGENCY .......................................................................................................... 52 
ADMINISTRATIVE ASPECTS AND PUBLICATION ..........................................................................................................52 
PATIENT IDENTIFICATION .................................................................................................................................................... 52 
PUBLICATIONS .................................................................................................................................................................. 52 
ECONOMY ....................................................................................................................................................................... 51 
REFERENCES ..............................................................................................................................................................53 
APPENDIX 1: GUIDELINE FOR PROVIDING VERBAL PARTICIPANT INFORMATION ..............................57 
APPENDIX 2: PATIENT CHARACTERISTICS AND CLINICAL RESULTS .......................................................59 
APPENDIX 3: ANTI-TUMOR RESPONSE IN THE TIL INFUSION PRODUCT ..................................................60 
APPENDIX 4: CD8+ TIL CYTOKINE PRODUCTION IS INCREASED BY STIMULATION WITH 
AUTOLOGOUS TUMOR PRETREATED WITH VEMURAFENIB. ..................................................................61 
APPENDIX 5: ECOG-FUNCTION STATUS/PERFORMANCE STATUS ..............................................................62 
APPENDIX 6: COMMON TERMINOLOGY CRITERIA FOR ADVERSE EVENTS (CTCAE) VERSION 4.0 ...63 
APPENDIX 7: GUIDELINES FOR MONITORING, DOSE MODIFICATIONS, AND SUPPORTIVE 
TREATMENT DURING INFUSION OF INTERLEUKIN-2 (DECRESCENDO REGIME) ASSOCIATED 
WITH T-CELL THERAPY .....................................................................................................................................64 
APPENDIX 8: FEBRILE NEUTROPENIA DURING T-CELL THERAPY .............................................................82 
APPENDIX 9: GUIDELINE FOR DOSE MODIFICATION OF VEMURAFENIB .................................................84 
APPENDIX 10: THE MOST FREQUENT RELEVANT DRUG-INTERACTIONS WITH VEMURAFENIB .......86 
APPENDIX 11: SKIN DIAGRAM FOR OBSERVATION OF SKIN CHANGES ASSOCIATED WITH 
VEMURAFENIB TREATMENT.  ..........................................................................................................................89 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
7
Abbreviations 
AE = Adverse Event 
ALAT = Alanine Aminotransferase  
AR = Adverse Reaction 
ASAT = Aspartate Aminotransferase 
CCIT-DK = National Center for Cancer Immune Therapy 
CD4+ Cells = Helper T cells 
CD8+ Cells = Cytotoxic T cells 
CR = Complete Response 
CTC = Common Toxicity Criteria 
CTCAE = Common Terminology Criteria for Adverse Events 
CTL = Cytotoxic T lymphocytes 
Cy = Cyclophosphamide 
DMSO = Dimethyl Sulfoxide 
eCRF = electronic Case Report Form 
Flu = Fludarabine phosphate 
GGT = Gamma-glutamyltransferase 
GM-CSF = granulocyte-macrophage colony-stimulating factor 
IFN-γ = Interferon-gamma 
IL-2 = Interleukin-2 
IMPD = Investigational Medical Product Dossier 
KFE = Klinisk Forsknings Enhed (Clinical Research Unit) 
 
LDH = Lactate dehydrogenase 
MM = malignant melanoma  
ORR = Overall response rate 
PD = Progressive Disease 
PFS = Progression-free survival 
PET = Positron Emission Tomography 
PR = Partial Response 
PS = Performance status, ECOG scale 0-4 
RECIST = Response Evaluation Criteria In Solid Tumours 
REP = Rapid Expansion Protocol 
SAE = Serious Adverse Event 
SAR = Serious Adverse Reaction 
SCC = Squamous Cell Carcinoma 
SD = Stable Disease 
SUSAR = Suspected Unexpected Serious Adverse Reaction 
TAA = tumor associated antigens 
TIL = Tumor Infiltrating Lymphocytes 
TREG = Regulatory T cells 
VEK = Videnskabsetisk Komité (The National Committee on Health Research Ethics) 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
8
Synopsis 
 
Indication and treatment 
In this pilot study patients with BRAF-mutated metastatic malignant melanoma (MM) are treated 
with T-cell therapy in combination with vemurafenib. The treatment includes treatment with 
vemurafenib (vem), high-dose chemotherapy, infusion of tumor-infiltrating lymphocytes (TILs) 
isolated from the patient’s own tumor tissue, and administration of the immune-stimulating cytokine 
interleukin-2 (IL-2). 
 
Rationale 
T-cell therapy is an experimental immuno-therapeutic treatment, where TILs are isolated from the 
patient’s own tumor tissue, expanded ex vivo into billions of cells and infused into the patient with 
the intention to eliminate the cancer cells. Before tumor excision the patient is treated with 
vemurafenib to improve the TIL product by increasing the T cell infiltration of the tumor, increase 
expression of tumor antigens, and making the tumor cells more sensitive to immune-mediated tumor 
cell killing. Vemurafenib treatment is continued until one week before TIL infusion, where 
lymphodepleting chemotherapy, cyclophosphamide, and fludarabine phosphate is initiated with the 
purpose to reduce irrelevant T cells and eliminate the regulatory T cells, which are known to be able 
to inhibit T-cell mediated tumor cell killing. After TIL infusion IL-2 is administered to activate and 
stimulate further proliferation of the infused T cells.   
 
Purpose 
The primary purpose is to evaluate tolerability and safety of the treatment. The secondary aims are to 
characterize the immune response against tumor cells in the tumor as well as in the blood and to 
evaluate the clinical effect of the treatment, determined by the objective response rate (assessed 
according to RECIST 1.1). In addition, survival and progression-free survival is described. 
 
 
Study design 
The clinical trial is a pilot study. All patients are included and treated at the Department of Oncology, 
Herlev Hospital. The patients are referred to treatment from oncology departments at Copenhagen 
University Hospital Herlev, Aarhus University Hospital, and Odense University Hospital. All suitable 
patients will be treated with vemurafenib in an outpatient setting from one week before the patient 
has tissue removed until one week after the TIL infusion. From the removal of tissue from the patient 
for TIL production until T cells are infused it will typically take 4-6 weeks. After treatment the 
patients will be followed by an immunotherapeutic team with outpatient control visits. In the case of 
progression, patients will be excluded from the study. The inclusion period for the clinical trial is 
expected to last approximately 2 years. The inclusion period is expected to last from June 2014 until 
December 31, 2018. The clinical trial will be reported to the GCP unit, the Danish Medicines Agency, 
the National Committee on Health Research Ethics, and the Danish Data Protection Agency. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
9
Population 
Patients with histopathologically verified BRAF-mutated malignant melanoma, which has 
metastasized, will be candidates for the treatment. The patients, who are included in this clinical trial, 
must have an acceptable functional status, acceptable kidney and liver function, and be free from 
serious competing conditions. The clinical trial will include 12 patients in total. Only the patients, for 
whom it is possible to grow T cells from the tumor tissue (approximately 90 % of the patients), will 
be offered treatment.  
 
Toxicity 
We have already in an ongoing phase II study shown that T-cell based immunotherapy with 
lymphodepleting chemotherapy, TIL infusion, and intermediary dose IL-2 has acceptable toxicity and 
can be administered safely in an oncological setting. Vemurafenib is approved as standard treatment, 
and the side effects are known and manageable.  
 
Clinical response evaluation 
Patients are evaluated clinically through outpatient attendance six and 12 weeks after treatment with 
T cells and thereafter every 3rd month. In addition, imaging-based evaluation (CT, MR, PET-CT, or 
PET-MR) will be performed before tumor collection, during the week before admission, and 
thereafter in connection with clinical evaluations starting from 6 weeks after treatment with T cells.  
Before treatment start CT/MR scans of the cerebrum will be performed to rule out CNS metastases. 
 
Immunological response evaluation 
Project blood samples of 110 ml will be taken at surgery, before TIL infusion, at discharge 
(approximately 10 days after TIL infusion), and thereafter in connection with clinical evaluation after 
the treatment. During hospitalization blood serum samples (10 ml blood sample) are taken on day 0 
before TIL infusion, two hours after TIL infusion, and thereafter every second day until discharge. 
Immune cells are isolated from the collected blood samples using the LymphoPrepTM technique and 
are stored frozen until analysis. Flow cytometry analyses are performed to assess different immune 
cells (e.g. CD4+ and CD8+ T cells) before treatment start and during the course of treatment.  
In addition, a tissue sample from the tumor will be taken from the patients before starting 
vemurafenib, in connection with tumor collection, 6 weeks after TIL infusion, and in the case of 
progression.  
 
Introduction and rationale 
Malignant melanoma 
In Denmark, approximately 2,100 new cases of malignant melanoma (MM) are diagnosed annually 
(2011)1, and the incidence is increasing with approximately 5 % per year. Approximately 5 - 10 % 
of patients have metastases at the time of diagnosis, and an additional approximately 10 – 15 % 
develop metastases later in the course of illness2. Thus, approximately 350-400 new cases of 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
10
metastasizing malignant melanoma can be expected per year in Denmark. MM is a very aggressive 
cancer, and once the disease has metastasized the five-year survival has so far been below 10 %3.  
  
In Denmark, four treatments for metastatic MM are currently approved: temodal, interleukin-2 (IL-
2), ipilimumab, and vemurafenib. Temodal is a chemotherapeutic, which has been shown to have an 
objective response rate (ORR) of 10-15 % but no effect on survival4. IL-2 is an immune-stimulating 
cytokine, which is used for patients in good general condition younger than 70 years, and has shown 
an ORR of 15 % with complete response (CR) among less than 5 %5, but there seems to be a 
positive effect on survival. Ipilimumab is one of the new compounds, which in 2012 was approved 
in Denmark for use after first line treatment of metastatic MM. It is a human monoclonal antibody, 
which works by blocking the T-cell surface receptor CTLA4 (Cytotoxic T-Lymphocyte Antigen 4), 
which works like a natural break in the immune system. In a large phase III study with ipilimumab 
an ORR of approximately 10 % was found, as well as a CR in 0.6 %, but approximately 20 % 
achieve stable disease (SD) with significant effect on survival6,50. In 2012, Vemurafenib was also 
approved in Denmark for the approximately 50 % of MM patients, which have an activating 
mutation in the BRAF-gene. Approximately 50 % of the treated patients have an objective response 
to Vemurafenib. In addition, up to 30 % have stable disease (stable disease: SD) but the disease 
recurs within a median of seven months and the effect on long-term survival and recovery is 
unknown, as long-term follow-up has not been completed yet. The effect of Vemurafenib is 
typically fast-acting but most patients will unfortunately only experience short-lasting effects of the 
treatment7.  
There is therefore still a large need for the development of new and more effective treatments for 
metastatic MM. 
 
Tumor immunology  
In the recent years remarkable progress in the understanding of the immune system reaction against 
cancer has been made. Thus, it is today clarified that the immune system reacts against certain 
tumors in vivo, and that an immunological response against cancer cells in some cases is associated 
with a better prognosis8,9. Likewise, it has been shown that a patient’s immune response against 
tumor cells can be reinforced by treatment with different immune-stimulating therapies, which in 
some cases appear to be curative10. 
 
Tumor-infiltrating lymphocytes (TILs) 
Tumors are often infiltrated by large numbers of T cells (TILs), which specifically recognizes tumor 
antigens but typically are inactive. The T cells include both cytotoxic T cells (CD8+ T cells), helper 
T cells (CD4+ T cells), and regulatory T cells (Tregs), where the latter inhibit tumor cell killing. The 
T cells consist of different clones with varying degrees of specificity towards tumor antigens, where 
only few clones have a particularly high specificity. The inactive state of T cells in the tumor tissue 
is characterized by abnormal intracellular signaling, apoptosis, and a decreased proliferative ability, 
presumably caused by different immune-suppressing factors in the tumor environment11,12. 
However, it is possible in vitro to multiply and reactivate such TILs for tumor cell killing using 
activating factors such as IL-213,14.  
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
11
T-cell therapy 
T-cell therapy, also called ”Adoptive T cell Therapy” is an immunotherapeutic cancer treatment, 
which has shown very promising results in particular for malignant melanoma. This type of 
treatment, which uses the patient’s own T cells for tumor cell killing, was developed by the 
American National Institutes of Health (NIH), and in the more recent years several studies have 
been published from other cancer research centers in the US and Europe, where more than 300 
patients have received the treatment so far15–20.  
 
TIL-based T-cell therapy uses the fact that there is a high number of tumor reactive T cells in the 
tumor tissue compared to peripheral blood21. TILs are isolated from the patient’s own tumor tissue 
(metastasis or primary tumor) and expanded in vitro for 4-6 weeks into billions of T cells, which are 
given back into the patient with the purpose to eliminate the cancer cells. This makes T-cell therapy 
a highly specialized and individualized type of cancer immunotherapy. 
 
The actual treatment consists of an initial week of lymphodepleting chemotherapy (cyclophos-
phamide and fludarabine phosphate) with the purpose of eliminating existing regulatory T-cells 
(Tregs) in the patient and reducing the number of irrelevant T cells. After a week of chemotherapy 
T cells (TILs) are infused intravenously and shortly thereafter, the patient receives high-dose IL-2 
to increase activation and expansion of the infused T cells.  
 
 
 
Figure 1: Treatment course for T-cell therapy 
Shortly after inclusion of the patient, tumor tissue for production of the T-cell infusion product is 
removed. The week before the T cells are ready for infusion, treatment with cyclophosphamide (Cy) 
and fludarabine phosphate (Flu) is started, followed by T-cell infusion and treatment with IL-2.  
The duration and dosing of the IL-2 treatment varies in different protocols. 
 
T-cell therapy has shown very promising results for metastatic MM, where an ORR of 
approximately 50 % has been observed, which has been confirmed in several phase I/II “single-
institution” studies16-18,22–23. In addition, CR has been observed in 20 % of the treated patients, of 
which most are lasting, and the patients remain disease-free for more than seven years after the 
treatment15. TIL-based T-cell therapy thereby appears to have the potential to cure a significant 
proportion of patients with metastatic MM. 
 
Experiences from previous clinical trials with more than 300 treated patients have shown that T-cell 
therapy despite considerable toxicity is safe for use in patients in good general condition with 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
12
sufficient organ function. The described side effects are reversible, acute side effects consisting of 
known and expected side effects of lymphodepleting chemotherapy and high-dose interleukin-2. 
CCIT-DK experiences with T-cell therapy 
Clinical trial 
As one of the few places in the world the complicated methods for producing TILs are established 
at the National Center for Cancer Immune Therapy (CCIT-DK), Herlev Hospital25 and has been 
translated into a clinical trial (clinicaltrials.gov identifier: NCT00937625), where we so far have 
treated 26 patients with metastatic MM. All patients were treated with classical lymphodepleting 
chemotherapy with cyclophosphamide and fludarabine phosphate followed by TIL infusion with 
approximately 100x109 cells and subsequent administration of IL-2 (see appendix 2). 
 
In the original “T-cell regime” described by Dudley et al.15 very high doses of IL-2 (720,000 IU/kg 
IV) are given as bolus injections every eighth hours until treatment-limiting toxicity. Since it is 
unknown, whether these very high doses of IL-2 are necessary to maintain T-cell expansion, we 
have at CCIT-DK, Herlev Hospital tested treatment with low to intermediary doses of IL-2 to 
determine, whether the response rates can be maintained, while the toxicity is reduced. 
 
A pilot study where six patients were treated with low-dose IL-2 SC was initiated in the summer of 
2009, and the results of this are now published16. Of the six treated patients, two patients achieved 
CR. 
 
To achieve a higher RR, the IL-2 dose was thereafter increased to an intermediary dose, where IL-2 
is administered after a decrescendo regimen27, which is equal to the IL-2 decrescendo regimen, 
which in Denmark is used as standard treatment of metastatic MM. 
 
After increasing the dose of IL-2 we have treated an additional 20 patients, of which 18 have 
currently been evaluated with imaging. In total (n = 26), we have seen an ORR of 46 %, which is 
comparable with what has been achieved in other studies with high-dose IL-2. Three patients 
achieved complete response (CR; 49, 13, 27+ months), and eight patients achieved a partial 
response (PR), of which six are still followed with responses lasting from 2-25 months. Five 
patients had stable disease (SD) for 2-4 months, and three patients progressed shortly after the 
treatment. 
 
Further, clearly reduced toxicity has been observed at low to intermediary dose IL-2, and the 
treatment has shown to be manageable in an ordinary oncology department without the need for 
intervention from an intensive care unit. 
 
Translational research 
Further development of the T-cell therapy in the form of optimization and expansion to other kinds 
of cancer is a highly prioritized research area at CCIT-DK. Our already established platform for T-
cell therapy for MM has given us a unique opportunity to study interactions between tumors and the 
immune system, and thereby to clarify possible methods for optimization of the T-cell therapy. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
13
Several studies have shown that the following characteristics for T cells are important in order to 
achieve a clinical response from T cell therapy: long telomeric length, short expansion time, a 
favorable phenotype of T cells (CD27+, CD28+), a high absolute number of T cells and a high 
number of cytotoxic tumor-reactive T cells in the infusion product28, and increased persistence of 
the T cells in the peripheral blood after infusion15,25,29. On the basis of this we have at CCIT-DK 
changed the primary expansion method from “traditional expansion” to “Young TIL” expansion, 
whereby the first expansion period is shortened from 4-7 weeks to 2-4 weeks. Shorter time in 
culture gives TILs with a longer telomeric length and more favorable phenotypes (CD27+, CD28+) 
with characteristics such as increased proliferation, increased persistence in vivo, 
and higher antitumor activity, which as mentioned is correlated with an increased clinical 
response15,25. By decreasing the time-span during which the T cells are grown in culture, a simpler 
and faster method for production of the TIL infusion product has been achieved and testing of the 
TIL specificity is no longer necessary. This optimization of the TIL production has made it possible 
to produce clinically applicable TIL infusion products from more than 90 % of the patients30–33. 
Further, we have during the final expansion phase, the Rapid Expansion Protocol (REP), introduced 
the use of the Wave® bioreactor34, which optimizes the proliferation conditions and has made it 
possible to achieve a higher absolute cell number, as well as a higher number of tumor-reactive T 
cells in the TIL infusion product. Based on these TIL production protocols, developed at CCIT-DK,  
we have standardized and harmonized TIL production methods among three European cancer 
research centers, and a randomized, multicenter TIL-based T-cell therapy phase III clinical trial 
aiming at approval of T-cell therapy as standard treatment for patients with malignant melanoma is 
planned. 
 
Rationale behind the substances used in the clinical trial 
Lymphocyte-depleting chemotherapy 
To maintain an immunological response against the tumor, activating cytokines (the signaling 
molecules IL-2, IL-7, IL-15, IL-21 etc.) must be available for the tumor-specific T cells. Many 
“irrelevant” T cells will competitively reduce the availability of these cytokines for the relevant T 
cells. To create an environment, which facilitates a T-cell mediated anti-tumor response, there must 
in addition to the presence of many tumor-specific T cells with high specificity be made a reduction 
of irrelevant T cells, as well as an elimination of Tregs. To create such an environment, a 
combination of two days of cyclophosphamide and five days of fludarabine phosphate will be used 
in the present study. A combination chosen on the basis of experiences from previous studies35,36.  
 
Cyclophosphamide 
Cyclophosphamide is an alkylating compound, which works by forming covalent bonds with 
biologically important macromolecules. In particular, bonds are formed with the DNA and in some 
cases cross-binding of the DNA takes place. If the cross-binding is not removed by the cell repair 
systems, the cell division can be prevented. The binding to important proteins in the cell may harm 
important functions and lead to cell death. Cyclophosphamide is used in oncology for e.g. breast 
cancer and in malignant hematological diseases such as myelomatosis37.  
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
14
Fludarabine phosphate 
Fludarabine phosphate is a prodrug, which is changed into the active triphosphate, 2-fluoro-ara-
ATP. The compound is part of the group of anti-metabolites, which inhibits the DNA synthesis, 
and at the same time leads to a reduction of the RNA and protein synthesis. Fludarabine phosphate 
is used for the treatment of malignant hematological diseases e.g. CLL38.  
 
Interleukin-2  
Interleukin-2 (IL-2) after the decrescendo regimen27 is used in Denmark as a standard first-line 
treatment for suitable patients with metastatic malignant melanoma. Low-dose IL-2 is also used for 
treatment of metastatic kidney cancer. IL-2 is normally produced by activated T-lymphocytes and 
stimulates through specific receptors both the antigen specific and the unspecific immune defense39.  
IL-2 will in this experiment be given according to the decrescendo regimen, which is used for 
standard IL-2 treatment of disseminated malignant melanoma. 
 
Optimization of T-cell therapy with vemurafenib 
Vemurafenib is an approved standard treatment for patients with malignant melanoma with mutated 
BRAF status. Vemurafenib has in several studies been shown to have several positive qualities in 
addition to the specific inhibition of the mutated BRAF enzyme. Primarily, it has been shown to 
change the tumor microenvironment in a favorable direction, so that the infiltration of immune cells 
is increased. Of primary importance, the number of CD8+ T cells is increased, while the number of 
regulatory T cells is reduced40,41,42. Through this a better starting point for the cultivation of T cells 
in vitro is created. 
In addition, in vitro experiments indicate that the treatment of tumor with vemurafenib increases the 
number of tumor-reactive CD8+ T cells (see appendix 4), which has been shown to correlate 
positively with clinical response (see appendix 3), and that these cells react to a broader selection of 
antigens43.  
Other centers have started clinical trials, which combine vemurafenib with T-cell therapy 
(ClinicalTrials.gov Identifier: NCT01659151 and NCT01585415), but in these trials the patients do 
not start vemurafenib until after surgery, and thus does not benefit from the increased T cell 
infiltration. The last-mentioned trial has treated 6 patients without signs of increased toxicity44. 
 
Rationale behind the treatment regime used in the clinical trial 
The T-cell therapy regime is structured according to guidelines described by Dudley et al.15. A few 
approaches, however, differ from this regime, and these deviations are described below. 
 
As it is unknown, whether high-dose IL-2 is necessary to maintain the T-cell expansion after 
infusion, we have chosen to treat the patients with intermediary dose IL-2 (decrescendo regimen) 
instead of high-dose bolus infusions, which have been used in earlier studies, and which are 
considerably more toxic15. Our results indicate that it is possible to achieve a response rate of 
approximately 50 % with intermediary dose IL-2, which is comparable with earlier studies, which 
have used high-dose bolus IL-2 (see page 12 and appendix 1). 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
15
By pretreating with vemurafenib from one week before the removal of tumor tissue, we hope to be 
able to exploit the positive qualities described above to improve the TIL product and in this way 
achieve even higher treatment response. Contrary to the other centers, which study the combination 
of T-cell therapy and vemurafenib, we have chosen to stop the treatment with vemurafenib, when 
the patient starts chemotherapy to avoid unnecessary toxicity and resistance development. Thereby 
the patients will not be excluded from receiving renewed treatment with BRAF inhibitors, if they 
progress after T-cell therapy. 
 
Purpose and hypotheses 
Primary 
1) To evaluate tolerability and feasibility of the treatment.  
 
Secondary 
1) To determine whether T-cell therapy in combination with vemurafenib in patients with MM 
can induce a measurable immune response against tumor cells.  
 
2) To describe an objective response using RECIST 1.1. 
 
3) To describe survival and progression-free survival (PFS). 
 
Study design 
The clinical trial is a pilot study for patients with metastatic (inoperable stage III or stage IV) 
malignant melanoma. All patients are included and treated at the Department of Oncology, Herlev 
Hospital. The patients are referred for treatment from oncology departments at Copenhagen 
University Hospital Herlev, Aarhus University Hospital, and Odense University Hospital. 
 
We will include and treat 12 patients and expect that this can be done within two years. We expect 
that the patients can finish the treatment and the first six months of follow-up within approximately 
three years. The patients will be evaluated for objective response six and 12 weeks after infusion of 
T cells, and thereafter every third month. 
 
The inclusion period is expected to begin in June 2014, and the clinical trial is expected to end by 
December 31, 2018. The actual treatment course can vary from patient to patient depending on the 
time-span between surgery and treatment. In most cases the patient may receive treatment 
approximately 4-6 weeks after surgery, and in this case the treatment course from surgery until the 
first imaging-based evaluation (six weeks after treatment) will last approximately 4-5 months. 
 
Study population 
Patients with histopathologically verified metastatic or locally advanced malignant melanoma will 
be candidates for this clinical trial, except for patients, whom have previously been treated with T-


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
16
cell therapy and/or BRAF inhibitors. As is evident from the exclusion criteria below, the patients 
must be in good general condition, be free of serious competing conditions, and have acceptable 
organ function. Only the patients, where it is possible to grow T cells from the tumor tissue 
(approximately 90 % of the patients), will be offered treatment with T cells. 
 
Criteria for inclusion and exclusion 
Inclusion criteria 
All criteria listed below must be fulfilled in order for patients to be included: 
 
1. Histologically verified progressing metastatic or locally advanced malignant melanoma, 
where surgical removal of tumor tissue is feasible. 
2. Pathologically verified BRAF mutation. 
3. Age: 18 – 70 years. 
4. ECOG Performance Status of ≤1 (see appendix 5). 
5. Life expectancy > 3 months. 
6. At least one measurable parameter according to RECIST criteria. 
7. No significant toxicity or side effects (CTC ≤ 1) from any previous treatment. 
8. Sufficient organ function, including:  
System 
Laboratory values 
Hematology 
 
ANC (Absolute Neutrophil Count) 
≥ 1,500/µl 
Leukocytes 
≥ normal range 
Thrombocytes 
≥ 100,000/µl and < 700,000/µl 
Hemoglobin 
> 6.0 mmol/l (e.g. after blood transfusion) 
Kidney 
 
S-creatinine  
< 140 mol/l 
Liver 
 
Total serum bilirubin 
≤ 1.5 times the upper normal limit 
ASAT/ALAT 
≤ 2.5 times the upper normal limit  
Alkaline phosphatase 
≤ 5 times the upper normal limit 
LDH 
≤ 5 times the upper normal limit  
Coagulation 
 
PP 
> 40, unless the patient receives therapeutic 
anticoagulation. 
INR 
< 1.5, unless the patient receives therapeutic 
anticoagulation. 
9. Women of child-bearing potential must use safe means of birth control. Likewise, men who 
participate in the clinical trial or female partners of men, who participate in the clinical trial 
must use safe anticonception. This goes from the inclusion until six months after the last 
dose of study drug.  


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
17
Oral contraceptive pills, intrauterine device (IUD), depot injection of progestogen, sub-
dermal implantation, hormonal vaginal rings, and transdermal patches are considered safe 
contraceptive methods. 
10. Signed informed consent form after oral as well as written information. 
11. Prepared to meet up at the planned control visits and capable of handling toxicity. 
Exclusion criteria 
Patients should be excluded, if they meet just one of the criteria listed below: 
 
1. Other malignant tumors in the anamnesis with the exception of basal cell carcinoma and 
adequately treated carcinoma in situ colli uteri. Patients treated for other malignant 
conditions can participate, if the patient is without signs of illness for at least five years after 
ended treatment. 
2. Patients with cerebral metastases. Patients with solitary cerebral metastases can be included 
after radical surgery or stereotaxic radiotherapy, if the patient at least 1 month later is 
without signs of cerebral disease activity, clinically as well as by MR scanning. Patients 
with non-previously treated asymptomatic cerebral metastases can be included according to 
the investigator’s discretion. 
3. Patients with ocular malignant melanoma. 
4. Patients who have previously been treated with a BRAF inhibitor. 
5. In the case of confirmed sensitivity to one of the active compounds or one or more of the 
adjuvant substances. 
6. Serious medical or psychiatric condition e.g. serious asthma/COLD, badly regulated 
coronary disease, Morbus cordis, long QT syndrome, insulin-demanding diabetes mellitus. 
7. Corrected QT (QTc) interval ≥450 msec at baseline. 
8. Creatinine clearance < 70 ml/min. In selected cases it can be decided to include despite a 
GFR < 70 ml/min with the use of reduced chemotherapy dosing. 
9. Acute/chronic infection with e.g. HIV, hepatitis, tuberculosis. 
10. Serious allergy or previous anaphylactic reactions. 
11. Active autoimmune disease e.g. autoimmune neutropenia/thrombocytopenia or hemolytic 
anemia, systemic lupus erythematosus, Sjögren’s syndrome, scleroderma, myasthenia 
gravis, Goodpasture syndrome, Addison’s disease, Hashimoto’s thyroiditis, Grave’s disease. 
12. Pregnant and breast-feeding women. 
13. Concurrent treatment with systemic immunosuppressive medication (including 
prednisolone, methotrexate etc.) excluding planned shorter-lasting treatment, which 
according to the study responsible physician’s assessment can be discontinued before 
planned treatment with T-cell therapy. 
14. Concurrent treatment with other experimental drugs. 
15. Patients with active uncontrolled hypercalcemia. 
16. Patients may not have received chemotherapy, immunotherapy, biologically targeted 
treatment or radiotherapy (apart from locally) within the past 28 days. 
 
Evaluation before inclusion in the clinical trial 
The following tests must be performed within one month prior to treatment start (laboratory tests, 
however, within one week): 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
18
- 
Anamnesis and objective examination 
- 
Performance Status according to the ECOG Scale 
- 
Electrocardiogram 
- 
Cr-EDTA clearance 
- 
Urine analysis test 
- 
Laboratory tests:  
A) Hematology: hemoglobin, leukocytes, granulocytes, and thrombocytes 
B) Blood chemistry tests: Sodium, potassium, creatinine, LDH, alkaline phosphatase, 
ASAT, ALAT, bilirubin, ionized calcium, CRP, TSH, Calcium ion, INR, PP 
C) Infections: Hepatitis B, Hepatitis C (IgG), HIV, HTLV-1(IgG), EBV 
- 
Pregnancy test: Women of child-bearing potential must do a pregnancy test. This means 
women, who are not surgically sterilized, post-menopausal, or have used safe birth-control 
for more than 6 months. 
- 
Baseline tumor evaluation: CT, MRI, PET-CT, or PET-MRI scans can be used. Use of 
PET/CT scan is advised. 
- 
Revision of check-list for inclusion/exclusion for treatment. 
Examination plan associated with the treatment 
 
Inclusion 
 
Vemurafenib 
start1 
Surgery Vemurafenib 
control2 
Before 
chemotherapy 
T-cell 
infusion 
Before 
discharge 
Day 
 
-49 to -35 
-42 to -
28 
-21 to -8 
-8 
0 
App. +10 
Performance 
Status 
x 
x 
 
x 
x 
x 
x 
Objective 
examination 
x 
x 
 
x 
x 
 
x 
Weight 
x 
x 
 
x 
x 
x 
x 
Side effects 
(CTC) 
 
x 
 
x 
x 
x 
x 
Miscellaneous 
blood samplesa 
 
x 
 
x 
x 
x 
x 
Screening 
blood samplesb 
x 
 
 
 
 
 
 
Immunological 
blood samplesc 
 
 
x 
 
x 
 
x 
EKG 
x 
 
 
x 
 
 
 
Dermatological 
assessmentd 
 
x 
 
x 
 
 
 
Tissue (test 
BRAF V600 
mutation) 
x 
 
 
 
 
 
 
Biopsye 
x 
 
x 
 
 
 
 
Tumor 
evaluationf 
x 
 
 
 
x 
 
 
Examination plan 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
19
1: 
Vemurafenib is initiated 7 days before surgery. 
2: 
Vemurafenib control 28 days after initiation or at the latest at admission for treatment 
(in the table marked as ”Before chemotherapy”). 
a:  
Miscellaneous blood samples: Hemoglobin, leukocytes, differential counts, 
thrombocytes, creatinin, sodium, potassium, LDH, ASAT, ALAT, bilirubin, alkaline 
phosphatase, albumin, ionized calcium, TSH, CRP, INR, PP.  
b: 
Screening blood samples: T-cell screening (Labka blood sample package): 
hemoglobin, thrombocytes, leukocytes, differential counts, sodium, potassium, 
creatinine, ALAT, ASAT, alkaline phosphatase, bilirubin, LDH, INR, APTT, PP, 
ionized calcium, CRP, TSH, calcium-ion free, Hepatitis B virus s antigen (HBVSAG), 
Hepatitis C virus antibody (HCVAB), Human immunodeficiency virus type 1 and 2 
antibody and antigen (HIVABAG)), HTLV type I antibody + HTLV type II antibody 
(IgG) (HTLVIGG), Ebstein-Barr virus antibody (EBV), P-Treponema pallidum-
antibody (TREPONE) 
c: 
Immunological blood samples (HEREKS11): See the section on “Immunological 
monitoring, blood samples”. 
d: 
Separate schedule to be completed, in particular be attentive of SCC, see appendix 11. 
e: 
If possible, and depending on localization and accessibility, excision-, punch- 
(“stanse“), crude needle-, or fine needle biopsy is taken.  
f: 
CT, MRI, PET-CT, or PET-MRI scans can be used. Use of PET/CT scan is advised. 
Scans before chemotherapy should be performed in the week before admission.  
 
Treatment strategy 
The treatment course consists of two treatment steps and a subsequent control course.   
 
Step 1: Treatment with vemurafenib one week before surgical removal of tumor material with 
subsequent preparation and expansion of TIL cultures in the laboratory. Vemurafenib is continued 
until admission.  
 
Step 2: Treatment during admission with chemotherapy, TIL infusion, and IL-2.  
 
Control course: Evaluation of treatment effect and follow-up.  
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
20
 
Figure 2: The figure shows a schematic presentation of pretreatment with vemurafenib, TIL 
isolation and expansion, and T-cell therapy. 
 
The patient is pretreated with vemurafenib with the purpose of increasing the T-cell infiltration of 
the tumor and to increase the tumor reactivity of the infiltrating T cells, where after the patient has 
tumor tissue removed (metastasis or primary tumor) of a size of minimum 1 cm3, and the tumor 
tissue is brought to the laboratory under sterile conditions, where it is cut into suitable fragments of 
1-3 mm3 and placed in cultivation wells with growth medium and IL-2. TILs are initially grown for 
2-4 weeks, until a cell number of a minimum of 50 x 106 is reached. At this time the Rapid 
Expansion Protocol (REP) is started, where the T cells are stimulated with anti-CD3 antibody, 
allogeneic irradiated PBMC (peripheral blood mononuclear cells) feeder cells, and IL-2 for two 
weeks. The expanded TILs (now billions of cells) are washed, pooled, and re-infused intravenously 
into the patient.  
 
Before TIL infusion one week of lymphodepleting chemotherapy consisting of cyclophosphamide 
(C) day -7 to day -6 and fludarabine phosphate (F) day -5 to day -1 is given in order to remove 
existing lymphocytes in the patient to make room for the infused TILs and remove regulatory T 
cells (Treg). After the TIL infusion, continuous IL-2 is given from day 0 to day 5 to activate and 
stimulate the infused T cells into further expansion in the patient. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
21
Substances in the clinical trial 
The substances, which are included in the clinical trial, are vemurafenib, cyclophosphamide, 
fludarabine phosphate, and interleukin-2. Mixing and storage of the substances is performed 
according to existing standard guidelines in the department. 
Vemurafenib 
Vemurafenib is given daily as tablet 960 mg (4 tablets) twice daily from 7 days before removal of 
tumor tissue and until commencing chemotherapy. Vemurafenib therapy is labelled according to the 
existing Annex 13 in the GMP rules.  
 
Example of label: 
 
 
Cyclophosphamide 
Cyclophosphamide is given as an intravenous infusion for two consecutive days in a dose 
corresponding to 60 mg per kg body weight. The treatment will take place during hospitalization 
and with supplemental hydration and mesna injections. 
 
Fludarabine phosphate 
Fludarabine phosphate is given as an intravenous infusion in a dose corresponding to 25 mg per m2 
body surface given daily for five consecutive days (the day after the last dose of 
cyclophosphamide). The treatment will take place during hospitalization. 
 
Interleukin-2 
After one week of chemotherapy and infusion of T cells on day 0, treatment with interleukin-2 is 
started as a continuous intravenous infusion on day 0-4: 18 MU/m2 for 6 hours, 18 MU/m2 for 12 
hours, 18 MU/m2 for 24 hours followed by 4.5 MU/m2 for 24 hours for 3 days. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
22
TILs 
The tumor-specific T cells are infused intravenously on the day after the last dose of fludarabine 
phosphate (day 0). The number of T cells in the product is dependent on the feasible degree of 
expansion in vitro and is therefore variable but an infusion will normally consist of a minimum of 
approximately 1010 cells. The treatment will take place during hospitalization. 
 
Treatment plan during hospitalization 
Year:          Date: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Week 
-7 to -3 
-2 
-1 
0 
+1 
Treatment day 
-49 to -9 -8 
-7 
-6 
-5 
-4 
-3 
-2 
-1 
0 
1 
2 
3 
4 
9 
Treatment time point 
(indicative time 
points) 
12:
00  
14:
00 
18:
00 
24:
00 
12:
00 
12:
00 
12:
00 
12:
00 
Vemurafenib tablet 
960 mg x 2 daily 
x1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient is admitted 1) 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cyclophosphamide  
60 mg/kg IV 
 
 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fludarabine 
phosphate 
25 mg/m2 IV 
 
 
 
 
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
 
 
TIL IV 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
Pegfilgrastim 
 6 mg SC*  
 
 
 
 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
IL-2 18 MIU/m2 IV 
continuously for 6, 
12, and 24 hours 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
 
 
 
IL-2 4.5 MIU/m2 IV 
continuously for 24 
hours 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
Treatment plan 
1 Is given from 7 days before surgery and until admission, and treatment length is therefore 
dependent on the in vitro cultivation time of the T cells.  
* See the section ”supportive treatment” 
 
Simultaneous treatment 
Guidelines for supportive care and treatment  
Is given on standard medical indication according to the assessment of the treatment responsible 
physician and must be specified in the medical record and flow sheets. The following are 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
23
guidelines, and other drugs may be used at your discretion. However, the patient may not receive 
simultaneous systemic adrenocortical hormone.  
 
Prophylactic treatment 
Prophylactic treatment includes fluid therapy during cyclophosphamide treatment as well as 
supportive treatment with mesna (25 % of cyclophosphamide dose IV 4 times daily on day -7 and -
6) in order to protect the bladder mucosa. During IL-2 treatment fluid therapy is also given in order 
to prevent electrolyte derangement as well as too low blood pressure, cf. appendix 7. 
 
In order to prevent opportunistic infections, the following is given: 
• Tabl. Sulfamethizole with trimethoprim, 400/80 mg, 1 tabl. daily, day -7 and 6 mo. on. 
• Tabl. Aciclovir, 400 mg x 2 daily. Day 0 and 6 mo. on. 
• Tabl. Diflucan, 100 mg daily. Day 0 and until the neutrophilocyte number is > 1000/µl. 
 
In order to prevent and relieve nausea during chemotherapy (day -7 to -1), the following is given: 
• Inj. Aloxi 250 μg IV day -7 and -5 
• Tabl. Emend 125 mg day -7, 80 mg day -6, 80 mg day -5 
• Tabl. Motilium 20 mg x 4 
• Tabl. Temesta 1-2 mg max x 4 as needed. 
• Tabl. Pantoloc 40 mg x 1-2 daily. 
 
In order to prevent and relieve nausea during IL-2 (day 0 to 5), the following is given: 
• Tabl. Motilium 20 mg x 4 
• Ondansetron 8 mg x 1 as needed max x 2. 
• Imolope 2 mg as needed max x 8 
 
In order to reduce the duration of neutropenia, pegfilgrastim, which is a human granulocyte-
stimulating factor (G-CSF) is given, 6 mg SC day 0 after TIL infusion (at 14:00). 
 
Supportive treatment 
During infusion with T cells, the patient may experience chills, which can be relieved with injection 
of Petidin 25 mg subcutaneously as needed max x 4. 
Similarly, light difficulties breathing, possibly with a drop in the oxygen saturation, may be seen, 
which is treated with oxygen through a nasal catheter. 
 
Neutropenia: 
In the case of simultaneous neutropenia and fever will be treated according to the instruction (see 
appendix 8) for “Febrile neutropenia during T-cell therapy”. 
 
Diarré:  
Diarrhea will immediately be treated with appropriate supportive care and treatment, including 
Loperamide. Loperamide must be discontinued, if there is blood or slime in the feces related to the 
diarrhea. In these circumstances appropriate diagnostic microbiological samples should be collected 
in order to exclude an infectious etiology. The patients should also be instructed in drinking plenty 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
24
of clear fluids to prevent dehydration due to the diarrhea. 
 
Anemia:  
Blood transfusion is given if Hgb ≤ 6,0 mmol/L, or if clinically indicated. Irradiated and filtered 
blood from day -7 and 6 mo. on will be used. 
 
Thrombocytopenia:  
Thrombocyte transfusion is given to patients with thrombocyte numbers < 20/μl, or if clinically 
indicated. 
 
Local radiotherapy 
Local radiotherapy can be prescribed against bone pain, wounds, or other indication. Out of 
consideration for the patient radiotherapy should be avoided during the 3-week period, where the 
actual treatment will take place, and treatment with vemurafenib should be paused 7 days before 
radiotherapy, and not be resumed until 7 days after radiotherapy. Irradiated areas cannot be used as 
a parameter to evaluate response. If possible, all target lesions should not be included in the 
irradiated area. If this cannot be accomplished, the patient is considered non-evaluable for response 
and is excluded from the trial. 
 
Treatment discontinuation 
Normal discontinuation 
The patients will only receive one treatment series consisting of 4-6 weeks of vemurafenib, one 
week of chemotherapy, a single infusion of T cells, and 5 days of IL-2 according to the decrescendo 
regimen. The patients will after the conclusion of the clinical trial be followed by the immune team. 
 
Follow-up 
After the treatment the patients will be followed with outpatient control visits at 6 and 12 weeks 
after the treatment and thereafter every third month. The patients will after conclusion of the clinical 
trial be followed by the immunotherapeutic team. Follow-up by the immunotherapy team proceeds 
according to the same guidelines as described below, except that blood samples will not be taken 
for research, and that the scanning interval may be adjusted according to individual needs.  
 
At each outpatient control visit, an objective examination, toxicity assessment, blood samples 
including immunological blood samples, as well as PET/CT scan will be performed. If the patients 
have accessible remaining tumor tissue, tumor biopsies will also be taken at the first outpatient 
attendance. 
 
Follow-up schedule 
Year:          
Date: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Week no. 
6 
 
12 
 
24 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
25
Month no. 
1,5 
 
3 
 
6 
 
9 
 
12 
 
15 
 
18 
 
21 
 
24 
Objective 
examination 
and subjective 
complaints 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
Toxicity 
assessment 
0 
 
0 
 
0 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
0 
 
0 
 
0 
 
 
 
 
 
 
 
 
 
 
 
 
PS 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
Blood samples:  
T-cell follow-
up1) 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
Dermatological 
assessment2) 
0 
 
0 
 
0 
 
 
 
 
 
 
 
 
 
 
 
 
Biopsy 2) 
0 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor-
evaluation 3) 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
 
0 
1) Blood samples (T-cell follow-up): hemoglobin, thrombocytes, leukocytes, differential count, 
sodium, potassium, creatinine, ALAT, ASAT, alkaline phosphatase, bilirubin, LDH, INR, APTT, PP, 
ionized calcium, CRP, TSH, calcium-ion free, immunological blood samples – HEREKS11 (See the 
section on “Immunological monitoring, blood samples”) 
2) Separate schedule to be completed, in particular be attentive of SCC, see appendix 11. 
3) See the section on ”Immunological monitoring, tumor biopsy”.  
4) CT, MRI, PET-CT, or PET-MRI scan can be used. Use of PET-CT is recommended. 
 
Early discontinuation of treatment 
Not possible to grow TIL: If it is not possible to grow TILs, the patient cannot be offered treatment. 
Criteria for this include that >50x106 cells can be produced by in vitro cultivation within 35 days 
after surgery.  
 
The patient’s preference: The treatment can be stopped at any time, if the patient wants it. 
 
Medical decision: The treatment can at any time be stopped, if the investigator, for medical reasons, 
finds it to be in the patient’s best interest. 
 
Other treatment: The patients will leave the study, if treatment with other experimental drugs or 
other systemic anticancer treatment is started after the patient has been included for T-cell therapy. 
The patient will leave the study, if treatment with adrenocortical hormone is started, unless it is 
based on a vital indication as agreed with the protocol responsible physician. 
 
Side effects: If side effects arise in a patient in relation to the treatment to such a degree that the 
study cannot be completed, the treatment is aborted. 
 
Patients, who have stopped with IL-2 treatment early, will still be followed according to the 
protocol. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
26
Patients, who have left the protocol before infusion of tumor-specific T cells, will be replaced by 
new study subjects. They will be followed until cessation of side effects of the received treatment 
but will not be followed with further controls after that. 
 
Subsequent treatment 
If the patients leave the clinical trial or develop progressive disease, they can freely receive other 
treatment. 
 
Production of TILs 
Requisition of tumor tissue  
Before the patients are operated, they will be informed verbally, and written consent will be 
collected according to procedures described elsewhere. When sufficient tissue has been obtained for 
a possible pathological examination, a biopsy of at least 1 cm3 will be taken from the tumor tissue.  
The biopsy is labelled with date and patient code number, placed in a sterile container, and 
transported to the GMP laboratory 54J7, Herlev Hospital, where the further processing takes place. 
 
Establishing ”Young TIL” cultures 
The T cells are expanded by our newly established method for “Young TILs”25. The tumor tissue is 
cut into fragments of 1-3 mm3 and placed in a culture plate with 24 wells. From each fragment a 
TIL culture is established by either migration of T cells from the tumor tissue or by enzymatic 
processing. The cell density is maintained at approximately 1x106 cells/ml growth medium, where 
the immunostimulatory cytokine IL-2 has been added. IL-2 belongs to the group of homeostatic 
cytokines, characterized by having a beneficial effect on the activation of tumor-specific T cells and 
thereby on tumor cell killing. The cell cultures from the different fragments are pooled into a 
combined cell culture. The T cell expansion proceeds in an unselected manner, as a polyclonal TIL 
repertoire directed against multiple epitopes is desired in order to potentially obtain a more efficient 
destruction of the tumor cells in vivo. The establishment of “Young TIL” cultures typically takes 2-
4 weeks with a success rate of more than 90 %.  
For any further inquiries, please refer to the Investigational Medicinal Product Dossier (IMPD). 
 
Rapid Expansion Protocol (REP)  
When the TIL cultures have been expanded to approximately 5 x 107 cells, they are transferred to 
further expansion through the Rapid Expansion Protocol (REP), where TILs are grown together 
with irradiated (40 Gy) allogenic PBMCs (peripheral blood mononuclear cells), which serve as 
“feeder cells”, and IL-2 and anti-CD3 antibody, which activate the TILs. A very high number of 
activated tumor-specific T cells with a high activity towards tumor associated antigens (TAA) and 
tumor can be obtained in the course of 14 days. In the end the autologous T cells are concentrated in 
a 400 ml infusion bag for the purpose of intravenous infusion.  
For any further inquiries, please refer to the IMPD. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
27
Isolation of tumor cells  
Tumor cells are isolated from tumor fragments by enzymatic processing or seeding from the tumor 
fragments and frozen for the purpose of later use for determination of anti-tumor T-cell activity. 
 
Phenotype and clonotype determination  
In both Young TIL and REP TIL cultures the prevalence of T cell types (e.g. CD4+ and CD8+) and 
T cell stages are characterized (naïve and activated T cells) through flow cytometry. 
 
Cytokine Release Assay  
The TIL cultures are screened for activity towards TAA and autologous tumor by determining the 
production of activating cytokines (INF-γ + TNF-α). The production of activating cytokines is 
quantified using the ELISPOT method, flow cytometry, and combinatorial coding flow cytometry. 
 
Gene-based arrays 
Analyses will be performed in order to identify specific tumor gene expression signatures51 and 
mutations in the tumor cells, which lead to the identification of patient-specific neo-antigens derived 
from these mutations52. These analyses can contribute to the identification of patients, whom are more 
likely to respond to the treatment, and further it may contribute to optimization of the T-cell therapy 
based on the selection of neo-antigen specific T cells. 
 
Adverse Events, potential risks, and precautions 
Adverse events (Adverse Event = AE) 
Adverse events are unwanted signs, symptoms, or events, which occur during participation in the 
study, regardless of whether they are causally linked to the treatment or not. All adverse events 
must be described in the patient’s medical record and in the electronic Case Report Form (eCRF). 
The severity and effects after the treatment should be recorded for each adverse event. The severity 
of the adverse event and relationship with the administered treatment must be evaluated in 
accordance with the guidelines described below.   
The medical investigator should try to find all clinical and objective reactions from patients in 
treatment and determine their relationship with the experimental drugs. The investigator evaluates 
the relationship between adverse event and treatment using the following guidelines: 
 
Graduation of adverse events 
Severity refers to the intensity of a reaction.  
 
Events are graded according to CTCAE version 4.0 (see appendix 6)46. If this cannot be used, use 
the following scale: 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
28
1 = light 
2 = moderate 
3 = severe 
4 = life-threatening 
5 = lethal 
 
Patients, who experience adverse events, will be monitored with relevant clinical assessments and 
laboratory testing according to the recommendations by the treatment responsible physician. All 
adverse events must be followed until satisfactory restitution or stabilization. Results from the 
follow-up must be recorded in the patient’s medical record and in the eCRF. 
Abnormal laboratory test results should not be recorded in the eCRF, unless these events either 
caused a clinical event, led to the discontinuation of the treatment, or fulfill the criteria for an SAE 
(see below). 
 
Serious adverse event (Serious Adverse Event = SAE) 
A serious adverse event must be reported to the sponsor within 24 hours and is defined as an event, 
which indicates a significant risk, contraindication, side effect, or precaution, and includes events, 
which: 
- result in death or are life-threatening 
- lead to hospitalization or prolong existing hospitalization 
- result in considerable or continuing disability or incapacity for work 
- lead to an inborn anomaly or malformation 
- is a significant medical event. 
 
Guideline for possible relationships between adverse events and treatment 
0  
Not related – no temporal relationship, other etiologies very likely to be the cause. 
 
1  
Possibly related – less evident temporal relationship, other etiologies are also possible.  
 
2  
Probably related – clear temporal relationship with improvement upon discontinuation of 
treatment, and not reasonably explained by the patient’s known clinical condition. 
 
3 
Related – clear temporal relationship with laboratory confirmation or a positive re-treatment 
test. 
 
If the event is determined to be causally related to the experimental treatment, it is classified as a 
side effect (Adverse Reaction = AR) or as a serious side effect (Serious Adverse Reaction – SAR). 
 
Side effects 
A side effect may be expected, if it is described in the IMPD (appendix 12) or relevant “Summary 
of Product Characteristics” (SPC), or unexpected, if character or seriousness does not agree with the 
product information in these documents. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
29
If the side effect is unexpected, fulfill the criteria for an SAE, and is determined to be related to the 
experimental treatment, it is classified as a serious unexpected side effect (Suspected Unexpected 
Serious Adverse Reaction = SUSAR).  
 
Reporting of events and side effects 
The investigator reports SAEs, SARs, and SUSARs to the sponsor within 24 hours. 
The sponsor reports SUSARs to the Danish Medicines Agency within 7 days, if they are deemed 
life-threatening or are fatal, and otherwise within 15 days. Consequences for the study must be 
reported. 
The sponsor submits a list annually, which sums up possible SARs and SUSARs, as well as a report 
of the safety of the study subjects to the Danish Medicines Agency and the National Committee on 
Health Research Ethics (NVEK) (reporting to the NVEK can also be done by the investigator). 
 
At the conclusion of the study, the sponsor submits a final report to the Danish Medicines Agency, 
where all events and side effects (SAEs, SARs, SUSARs) will be described. 
 
The following should not be reported: 
- deaths where the death is due to progression of the malignant disease  
- hospitalizations or prolongation of existing hospitalization, which are caused by the 
cancer: 
▪ weight loss 
▪ fatigue 
▪ electrolyte disturbances 
▪ pain management 
▪ anxiety 
▪ admission for palliative care 
▪ hospice stay or terminal care 
▪ progression of the basic disease 
- hospitalizations or prolongation of existing hospitalizations, if the only reason for the 
hospitalization or the prolongation is the following: 
▪ fluid or nausea treatment 
▪ blood transfusion 
▪ thrombocyte transfusion 
▪ hospitalization due to febrile leukopenia/neutropenia 
▪ administration of examination procedure 
▪ insertion of a permanent intravenous catheter. 
 
These events should be recorded in the eCRF. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
30
Known side effects 
Vemurafenib 
Patients, who receive vemurafenib, may experience the following side effects: 
Examinations   
Very common (≥1/10) 
 
Common (≥1/100 to <1/10) 
 
 
 
Uncommon (≥1/1,000 to <1/100) 
 
Increase in GGT. 
 
Increase in ALAT, increase in alkaline 
phosphatase, increase in bilirubin, weight 
loss, QT prolongation. 
 
Increase in ASAT. 
The nervous system   
Very common (≥1/10) 
 
Common (≥1/100 to <1/10) 
 
 
Uncommon (≥1/1,000 to <1/100) 
 
Headache, dysguesia. 
 
Paralysis of the 7th cranial nerve (nervus 
facialis), dizziness. 
 
Peripheral neuropathy. 
Eyes 
Common (≥1/100 to <1/10) 
 
Uncommon (≥1/1,000 to <1/100) 
 
Uveitis. 
 
Retinal vein occlusion. 
Airways, thorax, and mediastinum   
Very common (≥1/10) 
 
Cough. 
Gastrointestinal tract   
Very common (≥1/10) 
 
Diarrhea, vomiting, nausea, constipation. 
Skin and subcutaneous tissue 
Very common (≥1/10) 
 
 
 
Common (≥1/100 to <1/10) 
 
 
 
Uncommon (≥1/1,000 to <1/100) 
Photosensitivity reaction, actinic keratosis, 
rash, maculopapular rash, pruritus, 
hyperkeratosis, erythema, alopecia, dry 
skin, sunburn. 
 
Palmar-plantar erythrodysesthesia 
syndrome, erythema nodosum, keratosis 
pilaris. 
 
Toxic epidermal necrolysis, Stevens-
Johnson syndrome. 
Bones, joints, muscles, and connective tissue  
Very common (≥1/10) 
 
 
 
Common (≥1/100 to <1/10) 
 
Arthralgia, myalgia, pain in the 
extremities, musculoskeletal pain, back 
pain. 
 
Arthritis. 
Metabolism and nutrition   
Very common (≥1/10) 
 
Decreased appetite. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
31
Source: The European Medicines Agency (EMA) SPC, vemurafenib45. 
The text is abbreviated compared to the approved SPC. The full SPC is available at the EMA home page 
www.ema.europa.eu/ 
 
As treatment with vemurafenib leads to an increased risk of skin tumors, monitoring for skin lesions 
must be performed. Most often these tumors can be handled by simple excision without dose 
adjustment.  
Dose limiting toxicity should be handled according to the guidelines described in appendix 9, 
‘Guidelines for dose modification of vemurafenib’. 
 
Vemurafenib can increase the plasma exposure of drugs, which are mainly metabolized by 
CYP1A2, and reduce the plasma exposure of drugs, which are mainly metabolized by CYP3A4, 
including oral contraceptives. Dose adjustments for drugs, which are mainly metabolized through 
CYP1A2 or CYP3A4 should be considered, based on their therapeutic windows, before 
simultaneous treatment with vemurafenib. In addition, some inhibition of CYP2C9 and in vitro 
CYP2C8, as well as an induction of CYP2B6 has been found, of which the clinical significance of 
the latter two effects is unknown. See appendix 10 for a list of the most frequent relevant 
interactions.  
 
Chemotherapy 
The side effects of chemotherapy described below are all general side effects of the two drugs, 
which are seen, when the drugs are given as primary treatment for oncological and hematological 
diseases. For such indications the treatment will often be given as multiple treatment series. In this 
clinical trial, the treatment will only be given in one session, and a milder side effect profile is 
therefore expected. 
 
Infections and parasitic diseases   
Common (≥1/100 to <1/10) 
 
Folliculitis. 
Benign, malignant, and unspecified tumors (incl. 
cysts and polyps)   
Very common (≥1/10) 
 
 
Common (≥1/100 to <1/10) 
 
Uncommon (≥1/1,000 to <1/100) 
 
 
SCC of the skin, seborrheic keratosis, skin 
papilloma. 
 
Basal cell carcinoma, new primary 
melanoma. 
 
Non-cuSCC. 
Vascular diseases    
Uncommon (≥1/1,000 to <1/100) 
 
Vasculitis. 
General symptoms and reactions at the 
administration site    
Very common (≥1/10) 
 
 
Inertness, pyrexia, peripheral edema, 
asthenia. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
32
Cyclophosphamide 
In patients, who receive cyclophosphamide, the dose-limiting toxicities consist of myelosuppression 
(neutropenia, thrombocytopenia, and anemia) and urotoxicity (cystitis, hematuria, and hemorrhagic 
cystitis). Sufficient treatment with mesna and hydration can markedly reduce the frequency and 
severity of bladder toxicity. 
Other commonly presenting side effects are alopecia, nausea, and vomiting.  
 
Patients, who receive cyclophosphamide treatment, may experience the following side effects: 
Infections and parasitic diseases 
Common (   1/100 to <1/10)  
   
Uncommon (   1/1,000 to <1/100)  
   
Very rare (<1/10,000)  
   
Infections  
   
Pneumonia, sepsis  
   
Septic shock  
Benign, malignant, and unspecified tumors (incl. 
cysts and polyps)  
Rare (   1/10,000 to <1/1,000)  
   
   
   
Very rare (<1/10,000)  
   
Unknown (cannot be estimated based on available 
data)  
   
   
   
Secondary tumors, bladder cancer, 
myelodysplastic changes, urinary tract 
cancer, acute leukemia.  
   
Tumor lysis syndrome.  
   
Lymphoma, sarcoma, kidney carcinoma, 
renal pelvic cancer, thyroid cancer, 
carcinogenic effect in offspring, 
progression of underlying malignancy.  
Blood and lymphatic system  
Very common (   1/10)  
   
 
Common (   1/100 to <1/10)  
   
Uncommon (   1/1,000 to <1/100)  
   
Very rare (<1/10,000)  
   
   
Unknown (cannot be estimated based on available 
data)  
   
   
Myelosuppression, leukopenia, 
neutropenia.  
   
Neutropenic fever.  
   
Thrombocytopenia, anemia.  
   
Hemolytic uremic syndrome, disseminated 
intravascular coagulation.  
   
Pancytopenia, agranulocytosis, 
granulocytopenia, lymphopenia, reduced 
hemoglobin.  
Immune system  
Very common (   1/10)  
   
Uncommon (   1/1,000 to <1/100)  
   
   
Immunosuppression.  
   
Anaphylactic reactions, hypersensitivity 
reactions.  
   


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
33
   
Very rare (<1/10,000)   
 
Anaphylactic shock.  
The endocrine system  
Very rare (<1/10,000)  
   
   
Unknown (cannot be estimated based on available 
data) 
   
Vasopressin hypersecretion 
(SIADH/Schwartz-Bartter syndrome).  
   
Water intoxication.  
Metabolism and nutrition  
Uncommon (   1/1,000 to <1/100)  
   
Rare (   1/10,000 to <1/1,000)  
   
Very rare (<1/10,000)  
   
Unknown (cannot be estimated based on available 
data) 
 
   
Anorexia.  
   
Dehydration.  
   
Water retention, hyponatremia.  
   
Increased blood glucose, decreased blood 
glucose.  
Mental disturbances  
Very rare (<1/10,000)  
 
   
Confusion.  
Nervous system  
Uncommon (   1/1,000 to <1/100)  
   
 
Rare (   1/10,000 to <1/1,000)  
   
Very rare (<1/10,000)  
   
   
Unknown (cannot be estimated based on available 
data) 
   
Peripheral neuropathy, polyneuropathy, 
neuralgia.  
   
Dizziness.  
   
Cramps, paresthesia, taste disturbances, 
hepatic encephalopathy.  
   
Encephalopathy, posterior reversible 
leukoencephalopathy syndrome, 
myelopathy, dysesthesia, hypoesthesia, 
tremor, hypogeusia, parosmia.  
Eyes  
Rare (   1/10,000 to <1/1,000)  
   
Very rare (<1/10,000)  
   
   
   
Unknown (cannot be estimated based on available 
data) 
   
Blurred vision.  
   
Visual disturbances, conjunctivitis and 
*eye edema in connection with 
hypersensitivity.  
   
Increased lacrimation.  
Ear and labyrinth  
Uncommon (   1/1,000 to <1/100)  
   
Deafness.  


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
34
   
Unknown (cannot be estimated based on available 
data) 
   
Hearing impairment, tinnitus.  
Heart 
Uncommon (   1/1,000 to <1/100)  
   
   
Rare (   1/10,000 to <1/1,000)  
   
   
Very rare (<1/10,000)  
   
   
   
Unknown (cannot be estimated based on available 
data)   
   
Cardiomyopathy, **heart failure, 
tachycardia, myocarditis.  
   
Arrhythmia (e.g. ventricular arrhythmia, 
supraventricular arrhythmia).  
   
Atrial fibrillation, ventricular fibrillation, 
angina pectoris, myocardial infarction, 
**cardiac arrest, pericarditis.  
  
Ventricular tachycardia, cardiogenic shock, 
pericardial effusion, hemorrhagic 
myocardium, left-sided ventricular failure, 
bradycardia, palpitation, EKG QT 
prolongation, reduced ejection fraction. 
Vascular diseases  
Rare (   1/10,000 to <1/1,000)  
   
Very rare (<1/10,000)  
   
   
Unknown (cannot be estimated based on available 
data)  
 
   
Hemorrhage.  
   
Thromboembolia, hypertension, 
hypotension.  
   
Pulmonary embolism, venous thrombosis, 
vasculitis, peripheral ischemia, flushing.  
Airways, thorax, and mediastinum  
Very rare (<1/10,000)  
   
   
   
   
Unknown (cannot be estimated based on available 
data)  
   
Bronchospasm, dyspnea, cough, interstitial 
pneumonia, chronic interstitial pulmonary 
fibrosis, pulmonary edema, pleural 
exudate, shock lung (ARDS), hypoxia.  
   
Pulmonary veno-occlusive disease, 
obliterative bronchiolitis, interstitial 
pneumonia, allergic alveolar diseases, 
pneumonia, unspecified lung diseases, 
nasal congestion, nasal discomfort, pain in 
the throat, rhinitis, sneezing.   
Gastrointestinal tract  
Very rare (<1/10,000)  
   
   
   
 
   
Ascites, hemorrhagic enterocolitis, acute 
pancreatitis, mucosal ulcerations, 
stomatitis, diarrhea, vomiting, congestion, 
nausea.  
  


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
35
 
Unknown (cannot be estimated based on available 
data)  
   
Gastrointestinal bleeding, abdominal pain, 
abdominal discomfort, colitis, enteritis, 
cecitis, inflammation of the parotid gland. 
Liver and biliary tract  
Rare (   1/10,000 to <1/1,000)  
   
Very rare (<1/10,000)  
   
   
Unknown (cannot be estimated based on available 
data)    
   
   
Liver function disturbances, hepatitis.  
   
Hepatic veno-occlusive disease, enlarged 
liver, icterus, activation of viral hepatitis. 
   
Cholestatic hepatitis, cytolytic hepatitis, 
cholestasis, liver toxicity with liver failure, 
increased bilirubin in the blood, abnormal 
liver function, increase in liver enzymes 
(ALAT, ASAT, alkaline phosphatase, and 
gamma-glutamyl transferase). 
Skin and subcutaneous tissue  
Very common (   1/10)  
   
Uncommon (   1/1,000 to <1/100)  
   
Rare (   1/10,000 to <1/1,000)  
   
Very rare (<1/10,000)  
   
     
     
   
 
Unknown (cannot be estimated based on available 
data) 
   
 
Alopecia.  
   
Total alopecia.  
   
Exanthem, dermatitis  
   
Stevens-Johnson syndrome, toxic 
epidermal necrolysis, pruritus, erythema of 
the irradiated area, serious skin reactions, 
discoloration of palms, finger nails, and 
soles of the feet, toxic skin inflammation.    
 
Palmar-plantar erythrodysesthesia (hand-
foot syndrome), erythema multiforme, 
urticaria, blisters, erythema, swelling of the 
face, hyperhidrosis. 
Bones, joints, muscles, and connective tissue  
Very rare (<1/10,000)  
   
Unknown (cannot be estimated based on available 
data) 
 
   
Rhabdomyolysis, cramps.  
   
Scleroderma, muscle cramps, myalgia, 
arthralgia.  
Kidneys and urinary tracts  
Very common (   1/10)  
   
Common (  1/100 to <1/10)  
   
Very rare (<1/10,000)  
   
   
Cystitis, microhematuria.  
   
Hemorrhagic cystitis, macrohematuria.  
   
Suburethral bleeding, edema of the bladder 
wall, kidney failure, reduced kidney 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
36
   
   
 
 
Unknown (cannot be estimated based on available 
data) 
   
function. Interstitial inflammation, fibrosis, 
and sclerosis of the bladder. Increased 
creatinine in the blood.  
   
Tubular necrosis, tubular disturbances, 
toxic nephropathy, hemorrhagic urethritis, 
ulcerative cystitis, bladder contractions, 
nephrogenic diabetes insipidus, atypical 
epithelial cells in the urinary bladder, 
increased urea in the blood.  
Pregnancy, puerperium, and the perinatal 
period  
Unknown (cannot be estimated based on available 
data) 
   
   
Premature birth  
The reproductive system and breast  
Common (  1/100 to <1/10)  
   
Uncommon (  1/1,000 to <1/100)  
   
   
Rare (  1/10,000 to <1/1.000)  
   
   
 
Unknown (cannot be estimated based on available 
data) 
 
   
Reduced spermatogenesis.  
   
Ovulation disturbances, reduced levels of 
female sex hormones. 
   
Oligospermia***, azoospermia***, 
irreversible ovulation disturbances, 
amenorrhea***.  
  
Infertility, ovarian failure, oligomenorrhea, 
testicular atrophy, reduced estrogen in the 
blood, increased gonadotropin in the blood. 
Inborn, familial, and genetic diseases 
 
Unknown (cannot be estimated based on available 
data)  
 
   
 
Fetal death, fetal malformation, delayed 
fetal development, fetal toxicity. 
General symptoms and reactions at the 
administration site  
Very common (  1/10)  
   
Common (  1/100 to <1/10)  
   
   
Rare (  1/10,000 to <1/1,000)  
   
Very rare (<1/10,000)  
   
   
   
   
   
   
Fever.  
   
Chills, asthenic conditions (e.g. fatigue, 
weakness, discomfort), mucositis.  
   
Chest pain.  
   
Multiple organ failure, headache, pain. 
Reactions at the administration site, e.g. 
phlebitis, thrombosis, necrosis, pain, 
swelling, erythema.  
   


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
37
Source: The Danish Medicines Agency SPC, cyclophosphamide37 
The text is abbreviated compared to the approved SPC. The full SPC is available at www.produktresume.dk. 
 
Cyclophosphamide inhibits the cholinesterase activity and thereby enhances the effect of 
depolarizing muscle relaxants, such as suxamethonium chloride. This can result in long-lasting 
apnea during anesthesia. The anesthesiologist must be informed, if a patient has received treatment 
with cyclophosphamide within 10 days prior to treatment with suxamethonium chloride. The 
combination should be avoided.  
 
Patients should not eat grapefruit or drink grapefruit juice, as grapefruit contains a substance, which 
can impair the activation of cyclophosphamide and thereby its effects.  
 
Fludarabine phosphate 
The most frequent side effects are myelosuppression (neutropenia, thrombocytopenia, and anemia),  
infections including pneumonia, cough, fever, fatigue, malaise, nausea, vomiting, and diarrhea. 
Other commonly presenting side effects are chills, edemas, discomfort, peripheral neuropathy, 
visual disturbances, anorexia, mucositis, stomatitis, and skin rash. Serious opportunistic infections 
have arisen among patients treated with fludarabine phosphate. Deaths caused by serious side 
effects have been reported. 
 
Patients, who receive fludarabine phosphate, may experience the following side effects: 
Unknown (cannot be estimated based on available 
data)  
   
Pyrexia, edema, influenza-like illness.   
Examinations  
Uncommon (  1/1,000 to <1/100)  
   
   
   
Very rare (<1/10,000)  
   
ECG changes, reduced left ventricle 
ejection fraction (LVEF), increased LD, 
increased C-reactive protein.  
   
Weight increase. 
Infections and parasitic diseases 
Very common (  1/10)  
 
 
 
 
 
 
Rare (  1/10,000 to <1/1,000)  
 
 
Infections/opportunistic infections (as 
latent virus reactivation, such as e.g. 
progressive multifocal leukoencephalo-
pathy, Herpes zoster virus, Epstein-Barr-
virus) 
Pneumonia 
 
Lymphoproliferative diseases (EBV-
associated) 
 
Benign, malignant, and unspecified tumors (incl. 
cysts and polyps)  
Common (  1/100 to <1/10)  
 
 
 
Myelodysplastic syndrome and acute 
myeloid leukemia (mainly associated with 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
38
previous, concurrent, or later treatment 
with alkylating compounds, 
topoisomerase-inhibitors, or radiotherapy) 
 
Blood and lymphatic system 
Very common (  1/10)  
 
Common (  1/100 to <1/10)  
 
 
Neutropenia, anemia, thrombocytopenia 
 
Myelosuppression 
 
The immune system 
Uncommon (  1/1,000 to <1/100)  
 
 
Autoimmune diseases (including 
autoimmune hemolytic anemia, Evans 
syndrome, thrombocytopenic purpura, 
acquired hemophilia, pemphigus) 
 
Metabolism and nutrition 
Common (  1/100 to <1/10)  
 
Uncommon (  1/1,000 to <1/100)  
 
 
Anorexia 
 
Tumor lysis syndrome (including kidney 
failure, metabolic acidosis, hyperkalemia, 
hypocalcemia, hyperuricemia, hematuria, 
urinary stones, hyperphosphatemia) 
 
The nervous system 
Common (  1/100 to <1/10)  
 
Uncommon (  1/1,000 to <1/100)  
 
Rare (  1/10,000 to <1/1,000)  
 
Unknown 
 
Peripheral neuropathy 
 
Confusion 
 
Coma, seizures, agitation 
 
Cerebral bleeding 
 
Eyes 
Common (  1/100 to <1/10)  
 
Rare (  1/10,000 to <1/1,000)  
 
 
Visual disturbances 
 
Blindness, optic neuritis, optic neuropathy 
Heart  
Rare (  1/10,000 to <1/1,000)  
 
 
Cardiac arrest, arrhythmia 
 
Airways, thorax, and mediastinum  
Very common (  1/10)  
 
Uncommon (  1/1,000 to <1/100)  
 
 
Cough 
 
Pulmonary toxicity (including pulmonary 
fibrosis, pneumonitis, dyspnea) 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
39
Source: The Danish Medicines Agency SPC, fludarabine phosphate38 
The text is abbreviated compared to the approved SPC. The full SPC is available at www.produktresume.dk. 
 
TILs 
No serious side effects of TIL infusion are expected. The patients can briefly experience fever, 
chills, and light dyspnea, and a small drop in saturation has been observed a few times. In addition, 
autoimmune reactions, including vitiligo and uveitis47, can be seen. 
Theoretically, there is a risk for the development of allergic reactions/anaphylactic shock. 
According to the literature this has not been seen yet. 
 
Interleukin-2 
Frequency and severity of side effects associated with interleukin-2 have in general proven to be 
dependent on route of administration, dose, and dosing interval. Most side effects are self-limiting and 
will go away within 1-2 days of treatment discontinuation. 
 
 
Unknown 
 
 
Pulmonary bleeding 
 
Gastrointestinal tract 
Very common (  1/10)  
 
Common (  1/100 to <1/10)  
 
Uncommon (  1/1,000 to <1/100)  
 
 
Vomiting, diarrhea, nausea 
 
Stomatitis 
 
Gastrointestinal bleeding, abnormal 
pancreatic enzymes 
Liver and biliary tract 
Uncommon (  1/1,000 to <1/100)  
 
 
Abnormal liver enzymes 
Skin and subcutaneous tissues 
Common (  1/100 to <1/10)  
 
Rare (  1/10,000 to <1/1,000)  
 
 
Rash 
 
Skin cancer, toxic epidermal necrolysis, 
(Lyell-type), Stevens-Johnson-syndrome 
Kidneys and urinary tract 
Unknown 
 
 
Hemorrhagic cystitis 
General symptoms and reactions at the 
administration site 
Very common (  1/10)  
 
Common (  1/100 to <1/10)  
 
 
 
Fever, fatigue, lethargy 
 
Edema, mucositis, chills, discomfort 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
40
See also the enclosed ”Vejledning til monitorering, dosismodifikationer og understøttende 
behandling under infusion af høj-dosis Interleukin-2” (”Guidelines for monitoring, dose 
modifications, and supportive treatment during infusion of high-dose interleukin-2”) (appendix 7) 
 
The following side effects were reported from clinical studies and from post-marketing experience with 
interleukin-2:  


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
41
Infections and parasitic diseases 
Common (≥1/100 to <1/10) 
 
 
Respiratory infection. 
 
Blood and lymphatic system (see further 
information below the table) 
Very common (≥1/10) 
 
Common (≥1/100 to <1/10) 
 
 
Uncommon (≥1/1,000 to <1/100) 
 
 
Rare (≥1/10,000 to <1/1,000) 
 
 
 
Anemia, thrombocytopenia. 
 
Leukopenia, coagulopathy including 
disseminated intravascular coagulation, 
eosinophilia. 
 
Neutropenia  
 
Agranulocytosis, aplastic anemia, 
hemolytic anemia, neutropenic fever. 
The immune system  
Uncommon (≥1/1,000 to <1/100) 
 
Rare (≥1/10,000 to <1/1,000) 
 
Hypersensitivity reactions. 
Anaphylaxis. 
The endocrine system  
Very common (≥1/10) 
 
Common (≥1/100 to <1/10) 
 
 
Hypothyroidism 
 
Hyperthyroidism. 
Metabolism and nutrition   
Very common (≥1/10) 
 
Common (≥1/100 to <1/10) 
 
 
 
Uncommon (≥1/1,000 to <1/100) 
 
Rare (≥1/10,000 to <1/1,000) 
 
Anorexia. 
 
Acidosis, hyperglycemia, hypocalcemia, 
hypercalcemia, hyperkalemia, 
dehydration. 
 
Hypoglycemia. 
 
Diabetes mellitus 
 
Mental disturbances 
Very common (≥1/10) 
 
Common (≥1/100 to <1/10): 
 
Anxiety, confusion, depression, insomnia. 
 
Irritability, agitation, hallucinations. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
42
The nervous system  
Very common (≥1/10) 
 
 
Common (≥1/100 to <1/10) 
 
 
 
Uncommon (≥1/1,000 to <1/100) 
 
 
Unknown (cannot be estimated based on available 
data) 
 
Dizziness, headache, paresthesia, 
somnolence. 
 
Neuropathy, syncope, speech 
disturbances, lost sense of taste, 
drowsiness. 
 
Coma, cramps, paralysis, muscle 
weakness 
 
Intracranial/cerebral bleeding, 
cerebrovascular event, leukoencephalo-
pathy (see further information below the 
table). 
Eyes 
Common (≥1/100 to <1/10) 
 
Rare (≥1/10,000 to <1/1,000) 
 
 
Conjunctivitis. 
 
Optic nerve disease including optic 
neuritis. 
Heart  
Very common (≥1/10) 
 
 
Common (≥1/100 to <1/10) 
 
 
 
 
 
Uncommon (≥1/1,000 to <1/100) 
 
 
Rare (≥1/10,000 to <1/1,000) 
 
Unknown 
 
 
Tachycardia, arrhythmia, chest pain. 
Arrhythmia, cyanosis. 
 
Cyanosis, transient ECG changes, 
myocardial ischemia, palpitations, 
cardiovascular disease including heart 
failure. 
Ventricular hypokinesis. 
 
Myocarditis, cardiomyopathy, cardiac 
arrest, pericardial exudate.   
 
Ventricular hypokinesis. 
 
Cardiac tamponade 
 
Vascular diseases  
Very common (≥1/10) 
 
Common (≥1/100 to <1/10) 
 
Uncommon (≥1/1,000 to <1/100) 
 
 
Hypotension. 
 
Phlebitis, hypertension. 
 
Thrombosis, thrombophlebitis, bleeding. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
43
Airways, thorax, and mediastinum   
Very common (≥1/10) 
 
Common (≥1/100 to <1/10) 
 
 
 
Rare (≥1/10,000 to <1/1,000) 
 
Dyspnea, cough. 
 
Pulmonary edema, pleural exudate, 
hypoxia, hemoptysis, epistaxis, nasal 
congestion. rhinitis. 
 
Pulmonary embolism, adult respiratory 
distress syndrome. 
Gastrointestinal tract   
Very common (≥1/10) 
 
 
Common (≥1/100 to <1/10) 
 
 
 
 
Uncommon (≥1/1,000 to <1/100) 
 
 
 
Rare (≥1/10,000 to <1/1,000) 
 
 
Nausea with or without vomiting, diarrhea, 
stomatitis. 
 
Dysphagia, dyspepsia, constipation, 
gastrointestinal bleeding including rectal 
bleeding, hematemesis, ascites, cheilitis, 
gastritis. 
 
Pancreatitis, intestinal obstruction, 
gastrointestinal perforation including 
necrosis/gangrene. 
 
Activation of latent Crohn’s disease, 
pancreatitis, intestinal obstruction. 
Liver and biliary tract  
Common (≥1/100 to <1/10) 
 
 
 
 
Rare (≥1/10,000 to <1/1,000) 
 
Elevation of liver transaminases, increase 
in alkaline phosphatase, increase in lactate 
dehydrogenase, hyperbilirubinemia, 
hepatomegaly or hepatosplenomegaly. 
 
Cholecystitis, liver failure with lethal 
outcome. 
 
Skin and subcutaneous tissues  
Very common (≥1/10) 
 
 
Common (≥1/100 to <1/10) 
 
Uncommon (≥1/1,000 to <1/100) 
 
Rare (≥1/10,000 to <1/1,000) 
 
 
Erythema/rash, skin exfoliation, pruritus, 
sweating. 
 
Alopecia, urticaria. 
 
Vitiligo, Quincke’s Edema. 
 
Vesiculobullous rash, Stevens-Johnson’s 
syndrome. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
44
Bones, joints, muscles, and connective tissue  
Common (≥1/100 to <1/10) 
 
Uncommon (≥1/1,000 to <1/100) 
 
 
Myalgia, arthralgia. 
 
Myopathy, myositis. 
Kidneys and urinary tract  
Very common (≥1/10) 
 
 
Common (≥1/100 to <1/10) 
 
 
Oliguria, increased serum urea, increased 
serum creatinine. 
 
Hematuria, kidney failure, anuria. 
General symptoms and reactions at the 
administration site  
Very common (≥1/10) 
 
 
 
 
 
 
Common (≥1/100 to <1/10) 
 
 
Rare (≥1/10,000 to <1/1,000) 
 
 
 
Reaction at the injection site*, pain at the 
injection site*, inflammation at the 
injection site*, fever with or without 
chills, discomfort and fatigue, pain, 
edema, weight increase, weight loss  
Necrosis at the injection site. 
 
Mucositis, lump at the injection site, 
hypothermia. 
 
Necrosis at the injection site. 
Source: The Danish Medicines Agency SPC, interleukin-248  
The text is abbreviated compared to the approved SPC. The complete SPC is available at www.produktresume.dk. 
 
Comments: 
* The frequency of reactions, pain, and inflammation at the injection site is lower than what is seen 
with continuous intravenous infusion.  
 
Leukoencephalopathy 
In the literature rare cases of leukoencephalopathy in connection with Proleukin have been reported, 
in particular among patients treated for HIV infection. In some cases, other risk factors such as 
opportunistic infections, co-administration of interferons, as well as several series of chemotherapy, 
which may predispose the patients to leukoencephalopathy, were present. 
 
Capillary leak syndrome 
Cardiac arrhythmia (supraventricular and ventricular), angina pectoris, myocardial infarction, 
respiratory insufficiency demanding intubation, gastrointestinal bleeding or infarction, renal 
insufficiency, edema, and mental state changes can be linked with capillary “leak” syndrome. The 
frequency and severity of the capillary “leak” syndrome is lower after subcutaneous administration 
than for continuous intravenous infusion. 
 
Serious manifestations of eosinophilia 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
45
During treatment most patients develop lymphocytopenia and eosinophilia with reactive 
lymphocytosis within 24-48 hours after cessation of treatment. These conditions are not considered 
side effects and may be attributed to the mechanism of the inflammatory activity of interleukin-2. 
 
Cerebral vasculitis 
Cerebral vasculitis, both isolated and in combination with other manifestations, has been reported. 
Cutaneous and leukocytoclastic hypersensitivity vasculitis have been reported. Some of these cases 
respond to treatment with corticosteroids. 
 
Side effects associated with concurrent treatment with interferon alfa 
The following side effects have been reported as rare with respect to parallel treatment with 
interferon alfa: Extracapillary IgA glomerulonephritis, oculo-bulbar myasthenia gravis, 
inflammatory arthritis, thyroiditis, bullous pemphigoid, rhabdomyolysis, as well as Stevens-
Johnson’s syndrome. Serious rhabdomyolysis and myocardial damage, including myocardial 
infarction, myocarditis, and ventricular hypokinesis, appear to be increased among patients treated 
with Proleukin (intravenously) and interferon alfa simultaneously. 
 
Bacterial infection 
Bacterial infection or worsening of bacterial infection, including septicemia, bacterial endocarditis, 
septic thrombophlebitis, peritonitis, pneumonia, and local infection surrounding the catheter site has 
been reported, mainly in association with intravenous administration. 
 
Risks and disadvantages associated with surgery and sample collection 
Risks associated with removal of tumor tissue 
Prior to inclusion it will be assessed, whether it is possible to remove part of the patient’s own 
tumor tissue, either from the primary tumor or from a metastasis, through a minor surgical 
procedure. The operation will predominantly be performed by physicians at the Department of 
Plastic Surgery at Herlev Hospital, or by physicians from other surgical specialties, if necessary. 
Use of subcutaneous/cutaneous metastases or lymph nodes is prioritized. If there is no readily 
available tumor tissue, or if removal is associated with serious risks for the patient, the patient 
cannot be included in the clinical trial. 
 
Risks associated with biopsy collection 
Associated with biopsy collection there will be a small risk of infection and/or bleeding. Also, there 
may be discomfort such as pain or ecchymosis in the biopsy area.  
 
Risks associated with blood sampling 
Associated with blood sampling the patient may experience discomfort such as pain or ecchymosis 
at the puncture site. The blood samples will also be associated with frequent visits at the hospital. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
46
Monitoring and precautions 
Hematological parameters 
Close hematological surveillance of blood counts is indicated for all patients during treatment. 
Leukocyte count, thrombocyte count, and hemoglobin values will be controlled at fixed intervals, 
cf. Examination plan associated with the treatment (p. 18) and Follow-up schedule (p. 24). 
Measurements will be made prior to commencing vemurafenib, during vemurafenib treatment, 
before starting chemotherapy, and daily during chemotherapy treatment, and until the 
neutrophilocyte number is > 500/l and the leukocyte number is > 1000/l. Chemotherapy will not 
be administered to patients with leukocyte numbers below 500/l and/or a thrombocyte number 
below 50,000/l before starting chemotherapy. 
 
Kidney and urinary tract function 
Before treatment start any obstruction of the efferent urinary tract, cystitis, or infection will be 
resolved. The patients will be treated with mesna and plenty of fluids to reduce the frequency and 
severity of bladder toxicity. If, during the treatment with cyclophosphamide, cystitis associated with 
micro- or macrohematuria is detected, the treatment will be stopped. The urine will be controlled 
for the presence of microscopic hematuria with a urine analysis test prior to commencing treatment 
with cyclophosphamide.   
 
Cardiotoxicity 
Cardiotoxicity is especially seen in association with administration of high doses of 
cyclophosphamide (120-240 mg/kg body weight). Associated with vemurafenib treatment a 
prolongation of the QT interval has been seen. An electrocardiogram will be recorded prior to 
treatment. Patients with known heart disease cannot be included in the clinical trial. If the patient 
experiences symptoms from the coronary circulation (e.g. chest pain, shortness of breath), the 
necessary examination-procedures will be performed. 
 
Infertility 
Treatment of men can increase the risk of irreversible infertility, and they will therefore be informed 
about the possibility of freezing down semen before treatment start. There is also a risk of fertility 
problems among women. 
 
Live vaccines 
Vaccination with live vaccines must be avoided during and immediately after treatment with 
chemotherapy due to the immunosuppressive effect. 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
47
Interactions 
Cyclophosphamide inhibits the cholinesterase activity and thereby reinforces the effect of 
depolarizing muscle relaxants, such as suxamethoniumchloride. This may result in longer-lasting 
apnea in association with anesthesia. The anesthesiologist must be informed, if a patient has 
received treatment with cyclophosphamide within 10 days prior to treatment with 
suxamethoniumchloride. The combination should be avoided. 
 
Patients should not eat grapefruit or drink grapefruit juice, as grapefruit contains a substance, which 
may impair the activation of cyclophosphamide and thereby its effects. 
 
Transfusion-related graft-versus-host reactions have been observed among patients treated with 
fludarabine phosphate after transfusion with non-irradiated/non-filtered blood. Therefore, patients 
who require blood transfusion and whom receive or have received treatment with fludarabine 
phosphate within ½ a year, may only receive irradiated or filtered blood. An agreement has been 
made with Blodbanken (the “blood bank”) at Herlev Hospital, that only irradiated blood will be 
ordered for these patients for half a year after treatment. All blood within the Capital Region of 
Denmark is filtered.  
 
 
Effect evaluation, data analysis, and monitoring 
Effect evaluation 
Primary effect parameter 
Paraclinical evaluation: to evaluate the immunological effects of the treatment, the patients will be 
followed by continuous in vitro analyses of the specific T-cell reactivity against tumor antigens. 
The immunological response towards tumor antigens before and after the treatment will be 
compared. These analyses will be performed on blood samples and tumor biopsies. 
 
Secondary effect parameter  
Clinical evaluation: The clinical effects of the treatment will be assessed using the objective 
response rate according to RECIST 1.1, survival, and progression-free survival. 
 
Response criteria 
RECIST 
Clinical evaluation will be made according to the RECIST 1.1 Guidelines49:  
 
Complete response (CR): All lesions disappear. 
Partial response (PR): Defined as ≥ 30 % reduction of the sum of all measurable lesions’ longest 
diameter. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
48
Stable disease (SD): Defined as < 30 % reduction of the sum of all measurable lesions’ longest 
diameter, or < 20 % increase in the sum of all measurable lesions’ longest diameters. 
Progressive Disease (PD): Defined as > 20 % increase in the sum of all measurable lesions’ longest 
diameter or the presence of new lesions. 
 
Complete and partial response must be verified by examination at the earliest 4 weeks after the 
response has been documented. 
 
Immunological monitoring 
Blood samples for immunological monitoring 
Blood samples of 100 ml heparinized blood are taken for immunological monitoring, as well as 10 
ml blood in dry glasses to freeze down serum; at surgery, before treatment start (at “baseline”), at 
discharge (approximately 1 week after T-cell infusion), and thereafter 6 and 12 weeks after infusion 
of T cells (see schedule for examination plan and for follow-up). Thereafter, blood samples for 
immunological monitoring will be taken, when the patients show up for evaluation every third 
month, and until the patient leaves the study. Further, additional serum samples (10 ml blood 
sample) are taken on day 0 before TIL-infusion, 2 hours after TIL-infusion, and then every second 
day until discharge. From the time of surgery until the first outpatient visit approximately 500 ml 
blood is taken for research. The volume of blood, which will be taken for the clinical trial, does not 
surpass, what the body itself can produce between each sampling. Research blood samples will not 
be taken, if the patient’s hemoglobin is below 6 mmol/l.  
 
Mononuclear cells from peripheral blood (PBMCs) are isolated using Lymphoprep/Leucosep 
density gradient technique. The mononuclear cells are washed and resuspended in a freezing 
medium consisting of 90 % heat inactivated human AB serum and 10 % DMSO. The cells are 
frozen at -150 oC until analysis. A panel of relevant immunological assays for testing of antigen-
specific immune reactivity will be applied, including measurement of cytokine production 
(multimer fluorescence staining, ELISPOT, ELISA), and proliferative and cytotoxic potential. 
 
Tumor biopsies 
Biopsy sampling from available tumor lesions or involved lymph nodes is planned. Depending on 
the localization and availability, excision-, punch-, crude needle-, or fine needle biopsies are taken. 
The biopsies are requested before starting vemurafenib, at tumor sampling, 6 weeks after TIL-
infusion, and in the case of progression, if possible (see schedule for examination plan and schedule 
for follow-up). If the implicated areas are not readily available, the biopsy sampling will, if 
possible, take place under the guidance of ultrasound in sterile conditions at the ultrasound 
department at Herlev Hospital. The biopsy sampling will take place on an outpatient basis, and the 
biopsy size will here be approximately 5 mm3.  
 
Biopsies are examined for their content of immune cells. Further, TILs will be isolated from the 
lesions and analyzed for clonotype and specificity. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
49
Statistics 
This is a non-blinded, non-comparative study. Only descriptive statistics will be used, where the 
immunological and clinical response rate will be determined. Descriptive statistics will also be used 
to sum up response duration and patient characteristics. The study is designed as a pilot study and 
primarily aims at determining the safety and toxicity of the treatment. It is therefore not possible to 
formally determine a required sample size, which will allow determination of primary as well as 
secondary and tertiary end points. Based on experiences from previous clinical trials, inclusion of 
12 patients26 is deemed appropriate.  
 
Data registration and analysis 
The patient receives a patient number upon entry in the study in order to ensure patient anonymity. 
However, clinical personnel and selected individuals in the laboratory will be granted access to 
personal information, as this information is necessary to make sure the patient receives the correct 
treatment. The study responsible physician has access to the patient medical records to be able to 
request information about your illness, as this information shall be compared with the project 
specific analyses, which are made on cancerous tissue and blood samples. 
 
All relevant data are registered in an eCRF (electronic Case Report Form), which is created together 
with the KFE. The principal investigator is responsible for eCRF creation and typing of data into 
the eCRF, when the study treatment has been completed. The eCRFs will be reported to the 
sponsor. Sponsor and principal investigator are responsible for data analysis for all included 
patients. Patient data and eCRF will be stored for 5 years according to existing guidelines for the 
storage of person sensitive information. A final report is compiled in collaboration between the 
members of the project group. 
 
The analysis will include overviews of: 
• Toxicity (side effect registration) 
• Immunological response  
• Clinical effect parameters 
 
Upon termination of the study, person-referable data and any remaining samples will be coded. 
 
All patients, who receive T-cell infusion, will be included in the statistical analysis. Patients, who 
due to one of the following causes are excluded, will not be included in the statistical analysis:  
• Does not have enough tissue to produce TILs 
• Where TILs cannot be produced in the laboratory 
• Withdraw their consent 
• Has started another treatment 
 
End of study report 
Sponsor will inform the Danish Medicines Agency that the study has been concluded within 90 
days. The study is deemed finalized at the last visit of the last patient. If the study is finished 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
50
prematurely, the Danish Medicines Agency will also be informed with an explanation of the early 
ending. 
 
Within one year of the conclusion of the study, sponsor will submit a final study report with the 
study results including publications based on the study to the Danish Medicines Agency and the 
National Committee on Health Research Ethics. 
 
Amendments 
Permission to make substantial changes to the protocol should be applied for from the Danish 
Medicines Agency and the National Committee on Health Research Ethics, and these changes 
cannot be implemented until approval has been received.  
Changes in the protocol are considered substantial (substantial amendments), when they relate to 
• The safety of the study participants 
• The interpretation of the scientific documentation  
• The completion or management of the study 
• Quality and safety of the study drugs 
• Other substantial changes. 
 
In the case of changes relating to  
• extension relative to the date stated in the original approval 
• new centers/changing of centers 
• changing of principal investigator or sponsor 
• when the study ends 
• other small changes apart from typographical errors 
the Danish Medicines Agency and the National Committee on Health Research Ethics will be 
informed, even though these authorities do not have to approve these changes. 
 
Ethical considerations 
Recruitment of study participants and informed consent 
Patients with metastatic or locally advanced MM will be referred to the clinical trial from the 
oncology or plastic surgery department at Herlev Hospital or from one of the other oncological 
centers in Denmark, which treat patients with MM (Odense University Hospital, Aarhus University 
Hospital). Information about the study will be provided at scientific meetings for physicians at the 
involved departments. Referral of patients for the study is directed to the urogynecological (UG-
team) visitation office, Department of Oncology at Herlev Hospital. 
 
All patients will be informed about the study cf. appendix 1. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
51
Insurance 
The patients, who participate in the study, are covered by the hospital liability insurance. 
 
Ethical aspects 
Malignant melanoma has through several years shown increasing incidence and has a bad 
prognosis, when the illness is disseminated. Metastasizing MM can rarely be cured by either 
surgery, radiotherapy, chemotherapy, or immunotherapy, and the need for new treatment modalities 
is therefore considerable. 
The purpose of this study is to improve the survival of patients with MM in the long term. Based on 
the current knowledge and the lack of treatment alternatives, there are no unacceptable risks or 
disadvantages associated with this study. 
 
Participation is voluntary and preceded by both verbal as well as written information, and the 
treatment will be stopped in the event of unacceptable side effects, or at any time point if the patient 
so wishes. If the patient does not want treatment according to the protocol, the patient will receive 
treatment according to the usual guidelines of the department. The study is therefore deemed 
ethically sound. 
 
The study follows the guidelines of the Declaration of Helsinki, and the study responsible physician 
will obtain permission from the National Committee on Health Research Ethics and the Danish 
Medicines Agency. 
 
Research biobank 
In relation to the present study, blood samples (110 ml/blood sample) and tumor biopsies will be 
taken and stored coded at -150 oC in a research biobank at CCIT in room PA102, until all analyses 
linked to the study have been made or for a maximum of 15 years, after which any remaining 
material will be safely destroyed. 
The samples may only be used for other research studies within other areas of research, if approved 
following a new application to the National Committee on Health Research Ethics. The National 
Committee on Health Research Ethics may according to the circumstances waive the requirement 
for consent in such future research projects. 
 
The analyses will primarily be performed at CCIT, Department of Oncology, Herlev Hospital. 
Some special analyses of tumor tissue and blood samples may be performed at a foreign research 
institution, which we will make a specific collaboration with, and an independent Data Processor 
Agreement will be made. All patient information will in such cases be provided in coded form. If 
tissue and blood samples are sent abroad, they will be covered by the national legislation of the 
country, they are sent to.  
If the patient withdraws his or her informed consent, the biological material will be destroyed, if the 
patient does not want the material to be used. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
52
Reporting to the Danish Data Protection Agency 
The clinical trial is reported to the Danish Data Protection Agency. The law on treatment of 
personal data will be followed. Data pertaining to study subjects will be protected according to the 
law on treatment of personal data and the Health Act Section 3 regarding the legal position of 
patients. 
 
Administrative aspects and publication 
Patient identification 
After entry into the study the patient will receive a number. This number will be used to identify the 
patient and will be used on electronic Case Report Forms (eCRFs). Data and patient material will be 
handled in a coded form and confidentially. The number will be awarded sequentially according to 
entry in the protocol and is not based on the patient’s initials or birthdate. 
 
Publications 
The investigators are Troels Holz Borch, Inge Marie Svane, Rikke Andersen, and Marco Donia.  
Provided that the Vancouver rules, moreover, are fulfilled, the members of the project group will 
have shared copyright for the obtained results. All positive, negative, and inconclusive results will 
be published in international scientific journals. Manuscripts will be prepared in collaboration 
between the investigators and the other members of the project group, with the investigators being 
primarily responsible for the preparation. The investigators will be co-authors on publications based 
on this study.  
The order of authors will be determined according to the contribution of each author. The use of 
data from the study, both written and verbal, such as for e.g. conference participation, teaching, or 
the like, can only take place after approval from the investigators. The investigators are obliged to 
publish results from the study and are naturally also interested in the results being disseminated and 
implemented in the everyday clinical practice. Publication is expected to be completed during 2019. 
 
Economy 
The study is initiated by the National Center for Cancer Immune Therapy (CCIT-DK) in 
collaboration with the Department of Oncology, Herlev Hospital, and is financed in part by these 
two departments, by the Capital Region of Denmark’s research fund, and through operating and 
salary funds from private research foundations, which we continuously apply for. 
The Committees on Health Research Ethics will be informed, if/when further funding is obtained. 
None of the physicians at the participating departments have any financial interest in the study, and 
there are no financial gains related to the study for the departments or their personnel. There are no 
financial connections between the funding bodies and the investigators. 
The clinical trial is part of the study responsible physician Troels Holz Borch’s PhD project. 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
53
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Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
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Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
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Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
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Robbins PF, Lu Y-C, El-Gamil M, Li YF, Gross C, Gartner J, et al. Mining exomic 
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reactive T cells. Nat Med 19(6):747–52 (2013). 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
57
Appendix 1: Guideline for providing verbal participant information  
The verbal information regarding the project ”T-celle terapi i kombination med vemurafenib til 
patienter med BRAF muteret metastaseret malignt melanom” (“T cell therapy in combination with 
vemurafenib for patients with BRAF mutated metastasized malignant melanoma”) will be provided 
at the Department of Oncology, Herlev Hospital. The information session will be carried out by 
physicians associated with the study. In connection with the verbal information, written information 
material will be handed out. The session will take place in compliance with the guidelines from the 
Committee on Health Research Ethics: 
 
Before the information session 
• a time and a place for the session must be booked 
• it should be stated that it constitutes an invitation to participate in a health science research 
project 
• the right to take time to consider the information and the possibility to bring an assessor to 
the session should be stated 
The information session 
• must be carefully planned 
• must take place in an undisturbed setting and without interruptions 
• the participant must be given sufficient time to read the written information, listen to the 
verbal information, and ask questions 
• must include an understandable presentation of the research study without the use of 
technical or emotionally charged terms, and be provided in a considerate manner, adapted to 
the recipient’s individual preconditions regarding age, maturity, experience etc.  
• must contain information about possible predictable risks, side effects, complications, and 
disadvantages, as well as the fact that there may be unpredictable risks and burdens 
associated with participation in a health science research project. 
• must contain information about other treatment options 
• must contain information about the fact that information about health conditions, strictly 
private circumstances, and other confidential information may be passed on to and be 
handled by individuals, who have to carry out a legally required quality control of the study. 
• must contain information about the participants’ rights to renounce knowledge regarding 
their own health  
• the information is provided by the study responsible physician or by the thereto authorized 
person associated with the study 
 
Period of reflection and obtaining consent 
• The period of reflection depends on the nature of the study. As a rule, the period of 
reflection should be at least 24 hours. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
58
• There should be a clear relationship between information and consent. This entails that the 
consent to study participation as a rule is given soon after the information has been 
provided, yet still taking into consideration the necessary period of reflection. 
 
After the information session, the study subject will be informed, 
• If during the study new information about effect, risks, side effects, complications, or 
disadvantages should arise. 
• If the research project’s experimental design should change considerably with respect to the 
safety of the study subject (pertains to study subjects who actively participate in the study). 
• If, during the completion of the research study, significant information about the health of 
the study subject should arise, unless the study subject unequivocally has expressed that he 
or she does not want this. 
• About the achieved results, as well as about possible consequences for the individual 
participant. This requires, that it is practically possible, and that the study subject wants this. 
• If the study is discontinued, the study subject should be informed about the cause of this. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
59
Appendix 2: Patient characteristics and clinical results  
 
 
Patient characteristics and clinical results (unpublished) from clinical trial with TIL-based T-cell 
therapy at CCIT-DK/Department of Oncology, Herlev Hospital (clinicaltrials.gov identifier: 
NCT00937625). CR: complete response, PR: partial response, SD: stable disease, PD: progressive 
disease. Ellebaek E. et al, Journal of translational medicine 2012 and CCIT unpublished. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient ID
Age
Sex
AJCC 
stage
Previous 
Treatments
Infused Cells 
(x109)
CD8%
CD4%
gd%
Infused CD8 
(x109)
IL-2
Response
Survival
Responders (n=11)
MM909.01
60
F
M1c
1 (IL2)
28,7
78,1
19,5
0,03
22,4
Low
CR (49 mo) NED
53 mo+
MM909.11
41
M
M1a
3 (IL2, Ipi, DC)
74,7
97
2,4
0,01
72,5
Low
CR (13 mo) NED
32 mo+
MM909.15
48
F
M1b
1 (IL2)
85,7
31,3
54,9
10,7
26,8
Intermediate
CR (27 mo+)
27 mo+
MM909.17
49
M
M1c
2 (IL2, Ipi)
142,5
24,5
72
2,5
34,9
Intermediate
PR (25 mo+) NED
25 mo+
MM909.20
65
F
M1c
3 (IL2, Ipi, Tem)
82
88,5
10,5
0,04
92,7
Intermediate
PR (12 mo)
19 mo+
MM909.24
56
M
M1a
3 (Ipi, IL2, Vem)
110
67
20
0,05
73,7
Intermediate
PR (15 mo+)
15 mo+
MM909.26
46
M
M1c
1 (Ipi)
131,2
93
5
0,05
122,0
Intermediate
PR (13 mo+)
13 mo+
MM909.31
65
M
M1c
2 (IL2, Ipi)
117
53
47
0,22
62,0
Intermediate
PR (11 mo)
12 mo+
MM909.22
60
F
M1c
2 (IL2, Ipi)
123
21,6
78,1
0,02
26,6
Intermediate
PR (8 mo+)
8 mo+
MM909.36
40
F
M1c
3 (IL2, Ipi, Vem)
120
54,7
43,8
0,6
65,6
Intermediate
PR (7 mo+)
7 mo+
MM909.42
68
F
M1c
2 (IL2, Ipi)
83
8,2
91
0
6,8
Intermediate
PR (2 mo+)
2 mo+
54 ± 4
2,1 ± 0,8
100 ± 33
56 ± 31
40 ± 31
1,3 ± 3
55 ± 35
Non Responders (n=13)
MM909.07
61
M
M1c
3 (IL2, CD137, DC)
12,7
89,2
9,8
0,17
11,3
Low
SD (5mo)
11 mo
MM909.03
62
M
M1c
2 (IL2, DC)
20
91,8
6,9
0,12
18,4
Low
SD (4mo)
11.5 mo
MM909.06
36
M
M1c
1 (IL2)
3,4
52,5
46,8
0,31
1,8
Low
PD
4.6 mo
MM909.02
47
M
M1b
2 (IL2, DC)
17,7
95,2
3,2
0,84
16,9
Low
PD
7 mo
MM909.16
60
M
M1c
2 (IL2, Ipi)
61,5
87,5
11,3
0,17
53,8
Intermediate
SD (4 mo)
25 mo+
MM909.18
51
M
M1c
2 (IL2, Ipi)
199,5
86,2
8,6
3,6
172,0
Intermediate
SD (4 mo)
5.4 mo
MM909.25
25
M
M1b
3 (Ipi, Il2, Ipi)
127
55
35
9,7
69,9
Intermediate
SD (4 mo)
5.5 mo
MM909.34
46
F
M1c
2 (IL2, Ipi)
110
92,2
4
0,93
101,4
Intermediate
SD (4 mo)
5 mo
MM909.37
36
F
M1c
2 (IL2, Ipi)
125
49,9
28,9
16,9
62,4
Intermediate
SD (3 mo)
6 mo+
MM909.40
53
M
M1c
3 (Ipi, IL2, Ipi)
78
27,7
57,8
9,53
21,6
Intermediate
SD (2 mo+)
2 mo+
MM909.14
43
F
M1c
4 (IL2, Ipi, Tem, DC)
85,7
17,3
82,1
0,25
14,8
Intermediate
PD
3 mo
MM909.29
52
F
M1c
4 (IL2, DC, Ipi, Vem)
81,6
37,3
10,1
51
30,4
Intermediate
PD
6 mo
MM909.27
62
F
M1b
3 (Ipi, IL2, Vem)
98
47,5
51,8
0,20
46,6
Intermediate
PD
4 mo
48 ± 8
2,5 ± 0,9
78 ± 56
64 ± 28
27 ± 25
7 ± 14
48 ± 47
Not Evaluated (n=2)
MM909.43
48
F
M1c
2 (IL2, Tem)
99
31,9
67,1
0,17
31,6
Intermediate
MM909.46
50
F
M1c
2 (IL2, Ipi)
75
31
54
13,5
23,3
Intermediate
Patient Characteristics
Treatment Characteristics
Clinical Outcome


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
60
Appendix 3: Anti-tumor response in the TIL infusion product 
 
 
The TIL infusion product is incubated with autologous (open circles) or allogeneic tumor cell lines 
(closed circles), after which the number of interferon (IFN)-γ and tumor necrosis factor (TNF)-α 
producing T cells are determined using intracellular cytokine staining. The number of reactive T 
cells, which are infused into the patient is significantly correlated with clinical response. The 
reactivity of the infusion product has so far been analyzed for 21 patients. Donia M. et al, J. Invest 
Dermatol 2013 and CCIT, unpublished. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
61
Appendix 4: CD8+ TIL cytokine production is increased by stimulation with 
autologous tumor pretreated with vemurafenib. 
 
 
 
CD8+ TILs stimulated with autologous tumor release TNF- α and IFN-γ (A), and in additino also 
CD107a (B), as a surrogate marker for activated status and cytotoxic activity, respectively. The 
frequency of cytokine-producing CD8+ TILs increase after pretreatment of the tumor with 
vemurafenib. Donia M et al., J Invest Dermatol 201343. 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
62
Appendix 5: ECOG-function status/Performance status 
 
ECOG PERFORMANCE STATUS* 
Grade 
ECOG 
0 
Fully active, no negative effects on activities of daily living (ADL). 
1 
Limited physically strenuous activity, but ambulatory and capable of performing 
light or sedentary work, e.g. light housework, office work. 
2 
Ambulatory and capable of taking care of him-/herself, but unable to do any 
kind of work. Ambulatory more than 50 % of waking hours. 
3 
Capable of taking care of him-/herself to a limited extent, bedridden or sitting 
more than 50 % of waking hours. 
4 
Completely disabled. Unable to take care of him-/herself. Always bedridden or 
sitting in a chair. 
5 
Dead 
* Published in Am. J. Clin. Oncol.: 
Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: 
Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 
5:649-655, 1982.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
63
Appendix 6: Common Terminology Criteria for Adverse Events (CTCAE) version 
4.0 
 
CTCAE46 is a descriptive terminology, which can be used when reporting side effects. The adverse 
events (AEs) are graded according to the following: 
 
• Grade 1: Mild AE 
• Grade 2: Moderate AE 
• Grade 3: Severe AE 
• Grade 4: Life-threatening AE or AE leading to disability  
• Grade 5: Death related to an AE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
64
Appendix 7:  Guidelines for monitoring, dose modifications, and supportive 
treatment during infusion of interleukin-2 (decrescendo-regime) associated 
with T-cell therapy 
 
 
 
 
 
 
 
 
 
 
 
 
 
Guidelines for protocol MM1414:  
T-cell therapy in combination with vemurafenib for patients with BRAF mutated metastatic 
malignant melanoma 
 
 
 
 
 
 
 
Clinically responsible: 
Physician, PhD student Rikke Andersen 
Physician, PhD student Troels Holz Borch 
Professor, Chief Physician Inge Marie Svane 
 
Department of Oncology R 
Herlev Hospital 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
65
Table of contents 
 
TABLE OF CONTENTS ...................................................................................................................................... 64 
BACKGROUND AND RATIONALE ..................................................................................................................... 66 
TREATMENT.................................................................................................................................................... 65 
DOSE MODIFICATION ..................................................................................................................................... 66 
MONITORING DURING IL-2 TREATMENT ........................................................................................................ 67 
GUIDELINES FOR SUPPORTIVE TREATMENT .................................................................................................... 68 
INFLUENZA-LIKE SYMPTOMS ..................................................................................................................................... 68 
NAUSEA ............................................................................................................................................................... 67 
FLUID BALANCE/HYPOTENSION ................................................................................................................................. 69 
HEMATOPOIESIS .................................................................................................................................................... 71 
COAGULATION....................................................................................................................................................... 72 
SKIN .................................................................................................................................................................... 72 
DERMATOLOGICAL LONG-TERM SIDE EFFECTS .............................................................................................................. 74 
THE CENTRAL NERVOUS SYSTEM ................................................................................................................................ 75 
LUNGS ................................................................................................................................................................. 76 
LIVER ................................................................................................................................................................... 77 
HEART ................................................................................................................................................................. 77 
GASTROINTESTINAL TRACT ....................................................................................................................................... 78 
CHRONIC TOXICITY ................................................................................................................................................. 79 
THYROID GLAND ........................................................................................................ ERROR! BOOKMARK NOT DEFINED. 
LYMPHADENOPATHY ............................................................................................................................................... 80 
JOINT PAIN ............................................................................................................... ERROR! BOOKMARK NOT DEFINED. 
OTHER AUTOIMMUNE DISORDERS ............................................................................................................................. 80 
CONCOMITANT MEDICATION .................................................................................................................................... 80 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
66
Background and rationale 
T-cell based immunotherapy is an experimental treatment regime with tumor-specific T cells, which 
ex vivo have been activated to show a specific reaction towards the cancer cells. This experimental 
type of treatment has been tested on patients with advanced malignant melanoma, and in this setting 
both complete and partial disease regression has been registered, where 50 % of the patients 
achieved measurable disease reduction. 
Tumors are often infiltrated by large amounts of T cells (tumor-infiltrating lymphocytes), which 
specifically recognize tumor antigens but typically are inactive. It is possible in the laboratory to 
expand and reactivate such cytotoxic T cells for tumor cell killing. The patients’ own tumor tissue is 
prepared in the laboratory, so that the cytotoxic T cells with the largest activity towards autologous 
tumor cells are activated and expanded in vitro. To maintain an immunological response towards 
the tumor, activating cytokines must be available to the specific T cells. Many “irrelevant” T cells 
will competitively reduce the availability of these cytokines to the T cells in question. To create an 
environment, which facilitates a T-cell mediated anti-tumor response, it is necessary, in addition to 
the presence of many tumor-specific T cells, to reduce irrelevant T cells and eliminate regulatory T 
cells. 
 
Treatment 
The treatment consists of one week of lymphocyte-depleting chemotherapy with two days of 
cyclophosphamide (60 mg/kg IV) and five days of fludarabine phosphate (25 mg/m2 IV) followed 
by one infusion of tumor-infiltrating lymphocytes (TILs) (approximately 109-1010 cells). 
After one week of chemotherapy and infusion of T cells on day 0, treatment with interleukin 2 is 
commenced, consisting of a continuous intravenous infusion on day 0-2: 18 MU/m2 for 6 hours, 18 
MU/m2 for 12 hours, 18 MU/m2 for 24 hours, followed by 4.5 MU/m2 for 24 hours for 3 days. 
 
Dose modification 
The following treatment guideline only applies to IL-2. 
The listed toxicity gradings are based on CTC criteria (version 4.0). 
 
IL-2 is paused at the following toxicities: 
• Hypotension according to the instructions of this guideline 
• Newly arisen cardial arrhythmia, other than sinus tachycardia.  
• Suspicion of or verified AMI. 
• Agitation or persisting confusion. 
• Bilirubin increase grade III/IV. 
• Sepsis. 
• Resting dyspnea. 
• In the case of coagulation disturbances, defined as PP < 0.2.  
 
In the case of pausing of IL-2, the patient should be reassessed every second hour, and the treatment 
cannot be resumed, until the toxicity is reduced to grade 0/1. When the IL-2 infusion is resumed, the 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
67
planned dose is administered, so that the time of treatment is prolonged corresponding to the 
treatment pause. If the pause exceeds 24 hours, the treatment is shortened with this exceedance, so 
that the treatment is maximally prolonged with 24 hours. 
 
Dose modification of IL-2 is primarily done with pausing. In the case of the following toxicities, IL-
2 can be resumed at 50 % dose. IL-2 cannot be resumed until the toxicity is reduced to grade 0 or 1. 
• In the case of an increase in creatinine grade III/IV 
• In the case of grade II or III cerebral toxicity. 
 
Contraindications for continued IL-2 treatment: 
• Documented myocardial ischemia or infarction. 
• Grade IV CNS toxicity.  
 
Monitoring during IL-2 treatment 
(Please refer to the relevant sections in the guidelines for supportive treatment) 
• Vital functions: 
• Pulse/BP every fourth hour. 
• Temperature every eighth hour. 
• Diuresis every 12 hours. 
• Lung stethoscopy every 24 hours. 
• Weight every 24 hours. 
After treatment cessation, pulse/BP is measured for the last time after 4 hours, however BP is 
followed until normalization. 
  
Monitoring of patients with systolic BP below 80 mm Hg, who are not responding to volume 
treatment are followed with: 
• Pulse/BP every second hour. 
• Diuresis every second hour.  
• Lung stethoscopy every second hour. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
68
Guidelines for supportive treatment 
 
Influenza-like symptoms 
During treatment with cytokines, the so called ”Flu-like Syndrome” usually arises, that is influenza-
like symptoms such as fatigue, joint pain, fever, and chills. These constitutional symptoms are 
triggered by IL-2 and Interferon through a number of secondary cytokines, in particular TNF and 
IL-1. The degree of these constitutional symptoms varies a lot from person to person. This may be 
due to genetic causes, as the TNF production is determined by a genetic polymorphism in the 
HLA region. 
 
The clinical picture 
The degree of influenza-like symptoms varies a lot. Frequently, pronounced fatigue presents, as 
well as routinely fever, where the maximal increase in temperature varies but where the temperature 
may be between 38 and 41 oC. In the case of a rapid increase in temperature, chills usually present. 
These side effects are usually not critical but can, however, be perceived by patients as burdensome. 
 
Treatment principles 
The fever is perceived as an effect and not a side effect of the treatment and therefore shall not be 
treated with antipyretic drugs such as paracetamol and NSAIDs. Only if the temperature surpasses 
41 oC, should treatment with paracetamol be initiated. It is of paramount importance, that the 
patients prior to the treatment are advised about these things, and that the fever is considered an 
important part of the treatment. It should be noted that opioids also have an antipyretic effect, and 
that their use therefore should be carefully considered. 
 
References 
• 
Blay, J.Y et al: Correlation between clinical response to interleukin 2 therapy and sustained production of 
tumor necrosis factor. Cancer Res. 1990. 
• 
Economou, J.S et al: Production of tumor necrosis factor α and interferon γ in interleukin-2-treated melanoma 
patients: correlation with clinical toxicity. Cancer Immunol. Immunother. 1991. 
• 
Edwards, M.J et al: Passive immunization against tumor necrosis factor inhibits interleukin-2-induced 
microvaascular alterations and reduces toxicity. Surg. 1992. 
• 
Hobohm U: Fever therapy revisited. British Journal of Cancer 2005. 
• 
Hoption Cann S.A: Dr William Coley and tumour regression: a place in history or in the future. Postgrad Med 
J 2003. 
 
Nausea 
The pathogenesis for IL-2 triggered nausea is unknown. 
 
The clinical picture 
Nausea and vomiting can arise during IL-2 treatment. It can vary from single bouts of vomiting 
without nausea to nearly permanent severe nausea with frequent vomiting. On the contrary, loss of 
appetite is seen in nearly all patients. 
 
Treatment principles 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
69
General guidelines cannot be given, as there are large individual differences in the occurrence of 
nausea and vomiting. Both centrally as well as peripherally acting antiemetics can be used. 
 
Treatment guideline 
The following drugs can be used in the case of nausea, administered either perorally or IV. 
Prednisolone may not be used due to its immunosuppressive effects. Vogalene should be avoided 
due to the risk of orthostatic hypotension. 
 
• Emend (Aprepitan)  
 
125 mg on day 1, 80 mg on day 2 and 3 
• Motilium (Domperidon) 
 
20 mg up to 4 times pr. day 
• Zofran (Ondansetron) 
 
16 mg for 24 hours 
• Kytril (Granisetron) 
 
1-2 mg/24 hours 
• Temesta (Lorazepam) 
 
1-2 mg  
 
References 
• 
Siegel, J.P et al: Interleukin-2 toxicity. J. Clin. Oncol. 1991 
 
Fluid balance/hypotension 
Interleukin-2 usually leads to fluid retention. In the majority of the older studies with high-dose 
intravenous infusion, the most frequent dose-limiting side effect was a complex disturbance in the 
fluid balance. Interleukin-2 affects the regulation of the fluid balance through the so-called 
“capillary leak syndrome” and through a direct effect on the kidney function. 
 
Reduced renal perfusion 
Independently of the capillary-leak associated hypovolemia, oliguria is seen upon infusion of IL-2.  
It is evoked by an effect on the renal perfusion. IL-2 leads via leukotrienes to a disturbed renal 
vasoregulation. The large preglomerular vessels respond with pronounced vasoconstriction and 
subsequent reduction of the glomerular perfusion. This effect counteracts the physiological 
renovascular autoregulation, which in the case of a reduction in the glomerular flow actually was 
supposed to lead to a dilation of the preglomerular vessels. The pronounced reduction in the 
glomerular flow leads to a reduced function of the glomeruli and thereby oliguria, increasing to 
anuria. 
 
Capillary leak syndrome 
The underlying pathophysiology of the capillary leak syndrome is an increased permeability of the 
capillaries. There are several molecular mechanisms involved in this: in part an activation of 
endothelial cells via secondary cytokines, and in part a direct toxic effect of activated mononuclear 
cells, in particular on activated endothelial cells. The result is an increased permeability of the 
capillaries and an outflow of liquid and low molecular weight substances into the extravasal space. 
Hereby, interstitial edemas arise in nearly all organs, as well as an intravasal hypovolemia. 
 
The clinical picture 
The symptoms of the affected regulation of the fluid balance is complex. On one hand the capillary 
leak syndrome causes interstitial edemas and intravasal hypovolemia with subsequent arterial 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
70
hypotonia. On the other hand, the rapidly developing renovascular autoregulatory disturbance leads 
to oliguria, fluid retention, and intravasal hypervolemia. Therefore, during infusion with IL-2 a 
reduced renal perfusion with oliguria and intravasal hypervolemia will occur. Later, as a 
consequence of the capillary leakage, an outflow of liquid to the extracellular space, edemas, and 
intravasal hypovolemia with consequent arterial hypotonia will occur (see below).  
 
The following is a schematic attempt to describe interleukin-2’s effect on the fluid balance: 
 
Reduced renal perfusion 
1) Reduced glomerular perfusion 
2) Oliguria 
3) Fluid retention 
4) Intravasal hypervolemia 
5) Edemas 
 
Capillary leak syndrome 
1) Increased capillary permeability 
2) Outflow of water, electrolytes, and albumin 
3) Interstitial edemas 
4) Intravasal hypovolemia 
5) Arterial hypotonia 
 
Edemas can arise in all organs and are partly the cause of some of the organ side effects mentioned 
below. Interstitial pulmonary edema may be particularly problematic. This, however, should not 
arise during adequate treatment. The disturbances in the fluid balance frequently become more 
complicated due to fever, peripheral vasodilation, and diarrhea. 
 
Treatment principles 
To avoid intravasal hypovolemia, sufficient fluids should be administered. Large fluid infusions 
over a short time should, however, be avoided, as a pulmonary edema may arise. A fluid retention 
of approximately 5-10 % of the body weight may be necessary during a five-day IL-2 infusion to 
prevent intravasal hypovolemia and thereby arterial hypotonia. 
In the case of oliguria, dopamine or loop diuretics, which increase the glomerular perfusion, may be 
used. Both substances should be dosed correctly to maintain an adequate diuresis and may not be 
overdosed, as a too strong diuresis leads to volume depletion and thereby arterial hypotonia. 
NSAID drugs cannot be used simultaneously with the IL-2 treatment due to a risk of aggravation of 
renal insufficiency. 
 
Treatment guideline  
• Concurrent with the IL-2 treatment, infusion of potassium-sodium-glucose infusion fluid at 
100 ml/hour is administered for the entire IL-2 treatment period. 
• In the case of a drop in systolic blood pressure of more than 30 mm Hg or to below 90 mm 
Hg, the infusion speed of potassium-sodium-glucose infusion fluid is increased to 125 
ml/hour. 
• At systolic blood pressure < 80 mm Hg or a clinically affected patient, 2 x 1000 ml NaCl 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
71
infusion is given within 2 hours. 
• If the blood pressure is not restored after the above, the IL-2 infusion is paused, and the 
patient is reassessed again after 2 hours with the aim to resume the IL-2 infusion. 
• If the systolic blood pressure continues to drop, and the patient is clinically shocked, the 
patient should be transferred to the intensive care unit for treatment with pressors. 
 
It is important, that the primary blood pressure, which is measured, and which forms the 
basis for assessment of blood pressure drop during treatment, is measured resting and 
without stress. 
 
Voluven or HES infusion fluid is not used anymore, after two large studies have indicated a 
negative effect on renal function, and the Danish study showed an increased mortality in the HES 
treatment group. 
 
In the case of hyponatremia below 130 mmol/L, NaCl is used instead of KNAG infusion in the 
same volumes. Hypokalemia can be compensated as usual according to the departmental 
instructions. 
 
At diuresis below 360 ml/12 hours, furosemide is administered as a continuous infusion at 120 
mg/24 hours. The infusion product is produced as two times furosemide 60 mg in 250 ml NaCl for 
infusion over 12 hours. The infusion is administered over a minimum of 24 hours and can be 
continued for as long as requested. Intravenous bolus infusion or tablet furosemide cannot be used. 
 
References 
• 
Cotran, R.S et al: Endothelial activation during interleukin-2 immunotherarpy. A possible mechanismen for the 
vascular leak syndrome. J. Immunol. 1987. 
• 
Keilholz, U.et al: Mechanism and clinical managemant of interleukin-2 indced renal toxicity and fluid 
retention. Int.J. Immunophath. Pharmaol. 1993. 
• 
Ognibene, F.P et al: Interleukin-2 administration causes reversible hemodynamic changes and left ventricular 
dysfunction similar to those seen in septic shock. Chest 1988. 
 
Hematopoiesis 
During treatment with IL-2, a drop in all hematopoietic cell lines (granulocytes, thrombocytes, and 
erythrocytes) in the peripheral blood can be seen. It is not caused by, as in chemotherapy, a toxic 
effect on the hematopoiesis. The bone marrow is not hypoplastic, and nadir is seen already at 1-2 
days after cessation of the IL-2 infusion. The mechanism behind the hematopoietic toxicity is today 
not fully understood, probably it relates to an inhibition of the last steps of differentiation and an 
inhibited release of hematopoietic cells from the bone marrow through secondary cytokines. Unlike 
this, the lymphopenia, which usually presents after a few hours of IL-2 infusion, is a physiological 
reaction, as IL-2 activated lymphocytes in the peripheral blood express several adhesion antigens, 
which lead to adhesion to the capillary endothelium and subsequent extravasation. Upon cessation 
of IL-2 treatment the lymphopenia is reversible and is usually followed by lymphocytosis. These 
lymphocytes correspond to morphologically highly activated lymphatic cells, which can be 
confused with immature cells. After IL-2 infusion a pronounced eosinophilia is often seen, triggered 
by IL-5. The eosinophilia may in extreme cases constitute 50 % of the leukocytes. This 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
72
phenomenon is not completely understood and has according to current knowledge no therapeutic 
or pathophysiological importance. 
 
The clinical picture 
As described above, a pronounced lymphopenia is seen during IL-2 infusion followed by 
lymphocytosis 1-2 days after cessation of treatment. Whether this has a clinical significance is not 
known. Anemia, thrombocytopenia, and granulocytopenia may occur, and among 10-20 % of 
patients, infusion of blood or thrombocytes is indicated. The hematological toxicity is reversible 
within a couple of days after cessation of IL-2 infusion. The granulocytopenia is very rarely serious 
but a functional disturbance of the granulocyte ability for chemotaxis may appear. This may lead to 
a reduced ability to fight bacterial infections, which predominantly is seen among patients with an 
intravenous catheter. 
 
Treatment principles 
Erythrocytes and thrombocytes may be substituted according to standard guidelines. Lympho- and 
granulocytopenia does not require treatment and does not warrant prophylactic antibiotics. All 
clinically uncharacteristic treatment courses should, however, lead to the consideration of bacterial 
infection. 
Upon suspicion of bacterial infection (e.g. unusually high fever, unusually pronounced tachycardia, 
disturbances in coagulation, or affected general condition) the patient should be treated as for a 
bacteremia. This is important, as many of the side effects of IL-2 are similar to a bacteremia. If a 
patient is still having a high fever 3 hours after pausing of IL-2, the patient should be treated as 
having a bacteremia. Nephrotoxic antibiotics should be avoided due to the simultaneous 
nephrotoxicity.  
  
Treatment guideline 
Upon suspicion of bacterial infection: 
• Follow the usual procedures of the department 
• Nephrotoxic antibiotics should be avoided 
  
References 
• 
Clerigue, M et al: Effects of interleukin-2 and interleukin-2-activated cells on in vitro myelopoiesis. Clin. Exp. 
Immunol. 1990. 
• 
Huang, C.M et al: Changes in laboratory results for cancer patients treated with interleukin-2. Clin. Chem. , 
1990. 
• 
Klempner, M.S et al: An acquired chemotactic defect in neutrophils from patients receiving interleukin-2 
immunotherapy. N. Engl. J. Med. 1990. 
• 
Wanebeo, H.J et al: Production of and response to interleukin-2 in peripheral blood lymphocytes of cancer 
patients. Cancer. 1986. 
 
Coagulation 
Activated monocytes and endothelial cells can produce and release coagulation promoting 
substances. Of central pathogenetic importance is here the induction of Factor 3, which activates the 
exogenous coagulation cascade. The coagulation disturbance can be even more complex, as the 
malignant condition in itself can lead to hypercoagulopathy. Finally, the synthesis of coagulation 
factors in the liver may be reduced by IL-2. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
73
 
The clinical picture  
During IL-2 treatment a drop in coagulation factor 2,7,10 (PP) may be seen. Clinically relevant 
coagulation disturbances, such as disseminated intravascular coagulation (DIC) or thromboembolic 
complications, are, however, only seen rarely. In the case of severe coagulation disturbances, the 
possibility of sepsis should always be considered, and the treatment adapted accordingly.  
  
Treatment principles 
To avoid disruption of IL-2 infusion, K-vitamin should be given intravenously at the following PP 
values. 
• At PP < 0.30 10 mg Konakion IV is given, this can be repeated until PP is above 0.30. 
• At PP < 0.20 Interleukin-2 treatment in paused. Konakion 10 mg IV is given, whereafter a new 
blood sample is taken after 2 hours, the injection can be repeated. The Interleukin-2 treatment 
can be resumed at 100 % dose, when PP is above 0.30.  
• In the case of abnormal bleeding tendency, which can be related to abnormal coagulation 
factors, fresh, frozen plasma (type-specific) may be given, contact e.g. the coagulation 
laboratory. 
  
Patients treated with blood thinner will continue this treatment during the immunotherapy, and 
intervention is only needed, if PP falls below 0.20. In this case IL-2 is paused, and Konakion 1 mg IV 
may be used until PP is above 0.20, whereafter IL-2 can be resumed.  
 
References 
• 
Andreesen, R et al.: A new approach to adoptive immunotherapy of cancer using tumorcytotoxic macrophages 
grown from peripheral blood monocytes. Cancer Res. 1991. 
• 
Birchfiel, G.R et al: Hypoprothombinemia associates with interleukin-2 therapy; correction with vitamin K. J. 
Immunother. 1992. 
• 
Fleischmann, J.D et al: Fibrinolysis, thrombocytopenia, and coagulation abnormalities complicating high-dose 
interleukin-2 immonotherapy. J. Lab. Clin. Med. 1991. 
 
Skin 
Several of the secondary cytokines, which are induced by IL-2, lead to a generalized dilatation of 
the peripheral vessels, in particular in the skin and mucosa. Histologically numerous activated T 
lymphocytes are found underneath the basement membrane. It is unclear, if these cells represent a 
proliferation of already present subcutaneous lymphocytes, or if they are extravasated from the 
dilated capillaries in the skin. In the skin these activated T cells release additional cytokines, which 
enhance the inflammatory reaction. 
 
The clinical picture 
The most distinctive clinical manifestation is a pronounced erythema, which is seen in nearly all 
patients, who receive high-dose IL-2. The erythema, however, has no clinical significance. 
Inflammatory skin conditions with generalized pruritus and hives can develop. Further, it is known 
that autoimmune skin conditions, in particular psoriasis, are worsened during IL-2 treatment. 
Essential fatty acids to relieve skin problems 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
74
Good symptomatic effects on skin dryness and pruritus has been found with plant oil based dietary 
supplements with the essential fatty acids omega-3, omega-6, and omega-9. This should be 
recommended to the patient as basis treatment alongside of skin lotion. The dietary supplements 
described below can be purchased in health food stores and other products can probably be used; 
however, types which contain the three mentioned types of essential fatty acids are recommended. 
The following products have so far been used by patients: “Perfect balance” or “Livets olie” 
(“Life’s oil”). The recommended daily dose is listed on the product. The ingestion of the oil is 
easiest if used together with beverages e.g. juice. For skin areas with annoying itching, the oil can 
additionally be applied directly to the skin a couple of times per day. 
  
Treatment principles 
The generalized erythema does not require treatment. In the case of pruritus and hives, systemic 
antihistamine products may be effective. Drug-induced exanthems, which may go unnoticed during 
IL-2 treatment, pose a particular problem. The same may be the case for reactions to radiocontrast 
agent. Drug-induced exanthems may necessitate cessation of further IL-2 treatment. A few cases of 
severe exfoliative reactions have been described. It should here be noted that glucocorticoids block 
both side effects, as well as the antitumoral effect. In severe allergic reactions, local glucocorticoids 
can be used, while systemic treatment is only considered if vitally indicated, simultaneously with 
cessation of the IL-2 treatment.  
 
Treatment guideline 
Dietary supplements with essential fatty acids should be used as basis treatment along with skin 
lotion, following the above guidelines. In the absence of effect hereof, the following may be used: 
• Itching: Tablet Atarax 25 mg as needed for maximally 5 days. In the absence of effect tablet 
Tavegyl or Zyrtec may be used. 
• Severe itching: Local glucocorticoid creams. 
• Systemic glucocorticoids may only be used if vitally indicated!  
 
References 
• 
Dummer, R et al: The skin: An immunoreactive target organ during interleukin-2 administration? 
Dermatologica  1991. 
• 
Gaspari, A.A et al: Dermatologic changes associated with interleukin-2 administration. JAMA 1987. 
• 
Staunton, M.R et al: Life-threatening bullous skin eruptions during interleukin-2 therapy. J. Nat. Canc.Inst. 
1991. 
 
Dermatological long-term side effects 
Dermatological long-term side effects are common. Most frequently they consist of dryness and 
itching of the skin, which may persist for months after treatment. Drug-induced exanthems, caused 
by the supportive medication, may be particularly long-lasting and annoying. Pre-existing 
autoimmune skin disorders are usually worsened. This is seen, in particular, for psoriasis and can 
develop into a psoriatic arthritis. One death has been reported of a patient with pemphigus, who 
shortly after IL-2 treatment had a lethal worsening of his/her skin condition. Of particular interest is 
the manifestation of vitiligo among melanoma patients. Vitiligo is an immunological reaction 
directed towards normal melanocytes but also towards melanoma cells due to a large shared antigen 
pool. Vitiligo is not seen during IL-2 treatment of patients with other tumors and is in melanoma 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
75
patients associated with the effects of the immune therapy. Serious skin conditions such as 
pemphigus, lupus, and dermatomyositis are contraindications for IL-2 treatment.  
 
Good symptomatic effects on skin dryness and itching by plant oil-based dietary supplements with 
the essential fatty acids omega-3, omega-6, and omega-9 has been found. This should be 
recommended for patients as a basis treatment, alongside of moisturizing cream. The recommended 
daily dose is listed on the product. The ingestion of the oil is easiest if used together with beverages 
e.g. juice. For skin areas with annoying itching, the oil can additionally be applied directly to the 
skin a couple of times per day. 
 
Treatment guideline 
• Skin dryness, itching: Symptomatic treatment (oil baths, moisturizing cream, essential fatty 
acid dietary supplements).  
• Psoriasis: confer with the department of dermatology, treatment with local glucocorticoids is 
permitted.  
 
References 
• 
Richards, J.M. et al: Sequential chemoimmunotherapie in the treatment of metastic melanoma. J. Clin. Oncol.,  
1992. 
• 
Staunton, M.R.et al: Life-threatening bullous skin eruptions during interleukin-2-therapy. J. Nat. Canc. Inst., 
1990. 
 
The central nervous system 
Effects on the central nervous system during high-dose IL-2 treatment are frequent and caused by 
several mechanisms. An interstitial edema may arise as a consequence of the disturbances in the 
fluid balance. Secondary cytokines have a direct as well as an indirect toxic effect on the CNS. The 
mechanism behind this is only partially known. Probably these compounds exert their effects 
through the central neurotransmitter system. Brain metastases represent a special problem, as the 
IL-2 mediated inflammation of brain metastases can lead to a peritumoral edema. This reaction, 
which in peripheral metastases only rarely give rise to problems, can in the brain lead to generalized 
seizures and in rare cases incarceration. 
 
The clinical picture 
Studies have shown that up to 40 % of the patients in high-dose IL-2 treatment have mental side 
effects. Clinically significant side effects, however, are rare but include the full spectrum of 
psychiatric disorders such as depression, hallucinatory psychoses, schizoaffective psychoses, and 
comatose conditions. Most frequent are sleep disturbances.  
 
Treatment principles 
Mild mental changes should not be treated but observed. More severe psychiatric conditions should 
lead to pausing, treatment with systemic glucocorticoids, and usually discontinuation of the 
treatment. It can be difficult to discern an IL-2 triggered depression from the reactive depression, 
which may arise due to the processing of the disease. In case of doubt, a psychiatric consultation 
may be necessary. The patient should prior to the treatment be informed that the treatment may 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
76
trigger a depression, and that a previous endogenous depression may predispose to this. Patients 
with a clinically significant psychiatric condition cannot be offered treatment with IL-2.  
 
Treatment guideline 
In the case of lasting confusion, coma/cramps, severe motor weakness, or focal neurological 
deficits, the treatment is discontinued. Glucocorticoid treatment with Solumedrol 80 mg IV daily is 
initiated immediately and until the symptoms have disappeared. Additional cerebral CT/MRI-
imaging to check for cerebral metastases should be performed, if the symptoms do not decrease 
within a couple of days. At degree II and III CNS toxicity, treatment can after consultation with the 
treatment responsible physicians and careful information of the patient be resumed at 50 % dose. At 
degree IV CNS toxicity, the treatment is discontinued.  
  
References 
• 
Denicoff, K.D et al: The neuropsychiatric effects of treatment with interleukin-2 and lymphokine-activated 
killer cells. Ann. Intern. Med. , 1987. 
• 
Denicoff, K.D et al: The neuroendocrine effects of interleukin-2 treatment. J. Clin. Endocrin. Metab. , 1989. 
 
Lungs 
An interstitial pulmonary edema may develop due to disturbances in the fluid balance. However, 
only rarely does it develop into a fulminant pulmonary edema. The cause is, as in a toxin provoked 
pulmonary edema, an increased capillary permeability. Therefore, no increase in pulmonary or 
central venous pressure is seen. The IL-2 provoked pulmonary edema can appear despite of 
hypovolemia. Unlike a cardiogenic pulmonary edema, the alveolar fluid is rich in albumin, and 
protein-rich pleural exudates may also appear.  
 
The clinical picture 
At high-dose IL-2 the clinical symptoms usually develop in the following order: 
• Clear respiratory sound 
• Light tachypnea increasing to hyperventilation (low pCO2, normal pO2) 
• Moist respiratory sounds 
• Respiratory insufficiency (drop in pO2) 
Existing lung conditions such as asthma bronchiale, chronic obstructive pulmonary disease, and 
restrictive lung disease can make the clinical picture very complex. Patients with these diseases 
should therefore not be treated with high-dose IL-2, and all patients with known lung disease or a 
smoking anamnesis should prior to treatment perform a pulmonary function test and have a forced 
expiratory volume for 1 second (FEV1) > 70 %. 
  
Treatment principles 
In the case of a mild pulmonary edema, the IL-2 infusion can be continued, if the diuresis can be 
increased, i.e. if there is no intravasal hypovolemia present. In this situation the mild pulmonary 
edema can be treated rapidly. A simultaneous intravasal hypovolemia is, however, an indicator for a 
considerable capillary leak syndrome and should lead to a pausing of the IL-2 infusion. In the case 
of resting dyspnea, the IL-2 infusion should be paused.  
 
Treatment guideline 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
77
In the case of resting dyspnea, the following is done: 
• IL-2 injection is paused, and nasal oxygen is administered. 
• If the above is without effect, furosemide, 10-20 mg intravenously, is given. Coincidence of 
dyspnea and hypotension should be expected, and the attention should therefore be directed 
towards simultaneous treatment thereof.  
• Depending on arterial puncture and clinical condition, high-pressure ventilation may be 
considered. If high-pressure ventilation is indicated, injection of Solumedrol 80 mg IV should 
be tried first, and may be repeated. 
• In the case of need for respiratory treatment/steroid the current treatment series is stopped, and 
the patient is reassessed after 2 weeks. 
 
References 
• 
Keilholz, U et al: Mechanismen and clinical management of interleukin-2 induced renal toxicity and fluid 
retention. Int. J. Immunopath. Pharmacol. , 1993. 
• 
Ognibene, F.P et al: Interleukin-2 administration causes reversible hemodynamic changes and left ventricular 
dysfunction similar to those seen in septic shock. Chest, 1988. 
 
Liver 
Interstitial edema and secondary cytokines probably play a role here, as well as hepatitis-like 
changes due to activated inflammatory cells, endothelium, and Kupffer cells.  
 
The clinical picture 
Frequently, during IL-2 treatment an increase in transaminases without a concurrent drop in liver 
function is seen. Simultaneously, an increase in alkaline phosphatase is seen. A mild liver synthesis 
disturbance is seen among 5-30 % of the patients. In particular, the synthesis of coagulation factors 
and albumin is of clinical importance. In the case of severely reduced liver function, a bacterial 
infection should always be considered. Further, see the section on coagulation. 
 
References 
• 
Fischer, B et al: Interleukin-2 induces profound reversible cholestasis: a detailed analysis in treated cancer 
patients. J. Clin. Oncol., 1989. 
• 
Huang, C.M et al.: Changes in laboratory results for cancer patients reated with interleukin-2. Clin. Chem. 
1990. 
 
Heart 
Arrythmia and myocardial infarction is described but the exact mechanism is unclear. Secondary 
mediators, as well as the interstitial edema in association with fever, may cause arrythmia. The 
triggering factors for acute myocardial infarction are probably pre-existing arteriosclerosis in 
connection with fever, endothelial activation through secondary cytokines, and possibly activation 
of the coagulation system. In addition, an IL-2 triggered myocarditis probably plays a role for the 
development of arrythmia and myocardial infarction (AMI). 
 
The clinical picture 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
78
All types of arrythmia may occur, including the febrile sinus tachycardia. In refractory sinus 
tachycardia and atrial flutter, hyperthyreosis should be considered in differential diagnostics. It may 
be triggered by an iodine-containing radiocontrast agent or be due to an IL-2 triggered thyroiditis. 
 
Treatment principles 
In clinically significant arrythmia or myocardial ischemia, the IL-2 infusion should be paused until 
restitution from the toxicity, and until the cardiac toxicity is clarified.  
 
Treatment guideline 
Upon suspicion of AMI, IL-2 treatment is stopped, and the treatment is paused, until AMI is 
confirmed or denied. Upon suspicion of AMI, ECG and cardiac enzymes are evaluated. The patient 
is moved to the coronary unit for continuous monitoring with scope. In the case of evidence of 
morbus ischaemicus cordis, the treatment is discontinued. Arrythmias are treated as usual.  
 
References 
• 
Goel, M et al: Reversible cardiomyopathy after high-dose interleukin-2 therapy. J. Immunol.1992 
• 
Kragel, A.H et al.: Myocarditis or acute myocardial infection associated with interleukin-2 therapy for cancer. 
Cancer , 1990 
• 
Lee, R.E. et al.: Cardiorespiratory effects of immunotherapy with interleukin-2. J. Clin.Oncol. , 1989 
• 
Nora, R et al.: Myocardial toxic effects during recombinant interleukin-2 therapy. J.Nat.Canc.Inst., 1989 
• 
Ravaud, A et al.: Cardiomyopathy after acute myocardial infarction after therapy with interleukin-2 and 
tumour infiltrating lymphocytes. Eur. J. Canc. , 1992 
• 
Shulman, K.L et al: Adverse reactions to intravenous contrast media in patients treated with interleukin-2. J. 
Immunother. 1993 
 
Gastrointestinal tract 
Three factors play a role in the gastrointestinal toxicity: Mucosal edema, motility disturbances, and 
a general stress impact. 
The clinical picture 
The most frequently affected organs are the ventricle and the colon. Gastritis and ventricular ulcers, 
which may lead to strong bleeding, have been described. Mucosal edemas of the colon prevent 
reabsorption of fluids, and a characteristic diarrhea presents: watery diarrhea, one to five times a 
day. A few cases of ventricular and colon perforation during IL-2 treatment have been described. 
The pathophysiology behind these very rare side effects is unknown. 
 
Treatment principles 
The treatment is in all cases symptomatic. Prophylactic treatment with antacids and H2 blockers is 
not recommended but can be used in ulcer anamnesis or in treatment-induced dyspepsia. The 
diarrhea is difficult to treat. Loperamide may give slower peristalsis, and the fluid reabsorption in 
the colon may be improved to some degree. If larger losses of fluid occur from the gastrointestinal 
tract, these must be equalized in order to avoid intravasal hypovolemia and arterial hypotonia.   
 
Treatment guideline 
In the case of clinical suspicion of fungus, treatment is initiated according to the usual guidelines of 
the department. Also, general good oral hygiene. In the case of diarrhea, more than 3-4 loose stools, 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
79
tablet Imodium 4 mg is administered, followed by Imodium 2 mg at each loose stool. In the case of 
gastritis, treatment with proton-pump inhibitors is used.  
 
References 
• 
Rahman, R et al: Unusual gastrointestinal complications of interleukin-2 therapy. J. Immunother. , 1991. 
• 
Schwartzentruber, D et al: Colonic perforation: An unusual complication of therapy with high-dose 
interleukin-2. Cancer, , 1988. 
• 
Sparano, J.A et al: Symptomatic exacerbation of Crohn disease after treatment with high-dose interleukin-2. 
Ann. Med., 1993. 
 
Chronic toxicity 
Unlike the acute IL-2 toxicity, which disappears shortly after discontinuation of the infusion, a 
number of side effects, which may last from weeks to months, and which may be worsened by 
continued immunotherapy, appear. These side effects consist mainly of autoimmune reactions, 
which are more frequent among patients, who respond to the treatment. It is possible, that this 
association is seen, because the immune system of these patients is more easily “stimulated”. More 
likely, however, it is that these autoimmune phenomena more frequently appear in responding 
patients, because these patients receive a longer-lasting treatment with IL-2. All chronic side effects 
usually disappear by themselves, and they respond well to glucocorticoid treatment. Treatment with 
glucocorticoids, however, should only be used on vital indication, as the effects on the tumor are 
also inhibited.  
 
Thyroid gland 
Autoimmune disorders in the thyroid gland are frequent, and subclinical conditions often become 
clinically manifest during IL-2 treatment. This is more common upon subcutaneous administration 
than by infusion. In a few studies of long-term treatment up to 50 % of participants show thyroid 
function disturbances, both hyper- and hypothyreosis. This, however, is significantly less frequent 
in high-dose IL-2 infusion and presents in between 1 and 20 %. Before, during, and after the 
treatment, thyroid parameters should be controlled (TSH, T3, and T4).  
 
Treatment guideline 
In the case of clinical disturbances in thyroid function, the endocrinology department should be 
consulted but the treatment may continue.  
 
References 
• 
Atkins, M.B et al: Hypothyroidism after treatment with interleukin-2 and lymphokine-activated killer cells. N. 
Eng. J. Med. , 1988. 
• 
Reid, I et al.: Thyroid dysfunction can predict response to immunotherapy with interleukin-2 and interferon-
2α.. 
• 
Sauter, N.P et al: Transient thyrotoxicosis and persistent hypothyroidism due to acute autoimmune thyroiditis 
after interleukin-2 and interferon-α therapy for metastatic carcinoma: A case report. Am. J. Med., 1992. 
• 
Wejl, N. I. et al: Hypothyroidism during immunotherapy with interleukin-2 is associated with antithyroid 
antibodies and response to treatment. J. Clin. Oncol. , 1993. 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
80
Lymphadenopathy 
During IL-2 treatment a generalized lymphadenopathy with lymph nodes up to 4 cm in diameter is 
frequently seen. These reactive lymph node changes may be misinterpreted as tumor progression. 
Typically, the peripheral lymph nodes are not tender upon pressure. Lymphadenopathy may also be 
seen in a few locations and typically disappears after a couple of weeks.  
 
Treatment suggestions 
No treatment is necessary. The differential diagnosis between lymphadenopathy and progression 
may be difficult but by having a pause of at least 2 weeks between the last treatment and the 
evaluation, misinterpretation is avoided. 
 
Joint pain 
Transient joint pain is seen as a result of unspecific inflammatory reactions. Actual rheumatological 
joint disorders have so far only been observed among patients, who have been treated for a long 
time. Newly arised conditions, as well as exacerbations of existing conditions such as spondylosis, 
psoriatic arthropathy, and rheumatoid arthritis, have been observed. Usually the symptoms decrease 
for weeks to months after treatment discontinuation.  
 
References 
• 
Baron, N.W et al: Scintigraphic findings in patients with shoulder pain caused by interleukin-2. AJT, 1990. 
• 
Scheibenbogen, C et al: Rheumatic disease following immunotherapy. Ann. Rheum. Dis,. 1993. 
 
Other autoimmune disorders 
In principle, all clinically relevant autoimmune disorders may be induced or worsened by IL-2 
treatment. In animal experimental studies, severe conditions such as rheumatoid arthritis, lupus 
erythematosus, myositis, nephrotic syndrome, and many others can be seen during long-term IL-2 
treatment. Autoantibodies are frequent, but do not all have clinical relevance. Further, potentially 
life-threatening autoimmune conditions represent a contraindication for IL-2 treatment.  
All autoimmune phenomena during IL-2 treatment can be treated with high-dose glucocorticoids 
but at the same time as this the potential therapeutic effect is abolished.  
 
Accompanying medication 
 
Pain treatment 
During the treatment with IL-2 and interferon, analgesics with antipyretic effect should as far as 
possible be avoided, cf. section on influenza-like symptoms. Opioids have, like paracetamol and 
NSAIDs, an antipyretic effect, and use during the immunotherapy should therefore be carefully 
considered.  
Treatment with NSAID simultaneously with IL-2 is contraindicated due to an increased risk of renal 
insufficiency. 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
81
Tapering off of antihypertensive medication 
As IL-2 may lead to a considerable drop in blood pressure, in particular in patients in anti-
hypertensive therapy, a tapering off of all antihypertensive medication before treatment initiation is 
recommended. Antihypertensive medication is paused for as long as the treatment lasts. Most 
antihypertensive medications can be readily discontinued but one should pay attention to 2 groups 
of drugs: 
• Beta blockers. Fast tapering may lead to tachycardia and angina pectoris, why tapering 
should be done over 14 days. 
• ACE inhibitors/Angiotensin II-antagonists. May often be readily discontinued. If the 
indication is cardiac insufficiency, the patient should be referred to a cardiologist and the 
ejection fraction should be evaluated, as this should be normal.   
One may prior to treatment ask one’s own general practitioner to supervise the tapering and 
subsequent resumption of the treatment. 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
82
Appendix 8: Febrile neutropenia during T-cell therapy 
There is indication to initiate empirical antibiotic treatment in severely granulocytopenic (< 0.5 
bn/l) patients with fever (≥ 38.5 °C or ≥ 38.0 °C for ≥ 1 hour). 
Examinations at fever onset:  
• 
Culture for bacteria and fungi from:  
o blood (sterile glass vials) 
o urine for D+R 
o throat  
o potential foci of infection (e.g. wounds)  
• 
C-reactive protein, hematology, fluid numbers (in blood) 
• 
X-ray of thorax  
 
Treatment 
Initially  
o Piperacillin/Tazobactam (Tazocin) dose: 4 g/0.5 g every eighth hours IV.  
o Penicillin allergy: Ceftazidim (Fortum) (dose: 2 g / eighth hours IV).  
Initially, Gentamicin is not used in febrile neutropenia during T cell therapy, as the combination of 
gentamicin and IL-2 can exacerbate the nephrotoxicity. In the case of an aggravation of the clinical 
condition, supplemental Gentamicin can be used, however, at maximally 3 doses. 
 
In the case of positive cultures, possibly adjustment of the initial treatment.  
 
Evaluation on day 3  
Temperature dropping, clinical response:  
As a rule, the treatment is continued unchanged for at least another 4 days corresponding to 
a total of 7 days of treatment; however, so that the patient must have been afebrile for at 
least 2 days before discontinuation. In cases of continued signs of infection and in all cases 
of septicemia with Pseudomonas aeruginosa antibiotic treatment, however, is continued 
until the granulocyte number is > 0.5 bn/l. 
 
Temperature unchanged/increasing, clinical condition unchanged/aggravated:  
Repetition of initial examinations, supplemented with culturing for Aspergillus spp. from the 
nasal vestibules. 
 
Necessary considerations: 
• Lung infiltrates: Bronchoalveolar lavage (BAL) with adjustment of treatment 
depending on findings. Possibly ordering of expectorate testing for Legionella-PCR, 
"atypical pneumonia titers" (LAT (Legionella antibody test), MPT (Mycoplasma 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
83
pneumoniae test), and CKT (Chlamydia complement fixation test)), LUT 
(Legionella-antigen urine test), and CT scan of the thorax.  
• Signs of IV catheter infection: Addition of Vancomycin dose: 1 g/twelfth hour IV 
(dose reduction in case of renal insufficiency) 
• Signs of oral candidiasis: At this time decision should be made about indication to 
add empirical systemic antifungal therapy with Amphotericin B-dose or 
Caspofungin-dose: 70 mg IV day 1, thereafter 50 mg IV daily (dose reduction in 
liver insufficiency). 
 
No objective findings: Change of initial treatment to Meropenem-dose: 1 g/eighth hour IV. 
 
Evaluation on day 8 
In the case of continued fever, the examinations from day 3 are repeated, supplemented with: 
 
• Aspergillus galactomannan-antigen  
• CMV-antigen in blood (PCR-method)  
• CT scan of liver and spleen (chronic disseminated candidiasis):  
• Consider systemic antifungal therapy with Amphotericin B as monotherapy or in case of 
simultaneous suspicion of infection with Aspergillus spp.: Caspofungin-dose: 70 mg IV 
day 1, hereafter 50 mg IV daily (dose reduction in liver insufficiency).  
 
Switching from intravenous to peroral antibacterial therapy 
Can be considered in cases, where the granulocyte number is increasing, and the patient has become 
afebrile.  
The treatment is changed to: Penicillin 1 MIU x 3 perorally + Ciprofloxacin-dose: 500 mg x 2 
perorally. 
In the case of penicillin allergy, penicillin is replaced by Roxithromycin-dose: 150 mg x 2 perorally. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
84
Appendix 9: Guideline for dose modification of vemurafenib 
Toxicity grade (CTC-
4.0) 
Dose changes in the present 
treatment period 
Dose adjustments for resumption 
of treatment 
Grade 1 and tolerable grade 2 toxicities 
No dose changes (100% of starting dose) 
Grade 2 (intolerable toxicities) 
First occurrence 
Seponate, until resolution 
(Grade 0-1) 
720 mg twice daily (75 %) of 
starting dose) 
Second occurrence 
Seponate, until resolution 
(Grade 0-1) 
480 mg twice daily (50 %) of 
starting dose 
Third occurence 
Seponate permanently 
 
Grade 3 
First occurrence 
Seponate, until resolution 
(Grade 0-1) 
720 mg twice daily (75 %) of 
starting dose 
Second occurrence 
Seponate, until resolution  
(Grade 0-1) 
480 mg twice daily (50 %) of 
starting dose 
Third occurence 
Seponate permanently 
 
Grade 4 
Begin symptomatic treatment, when possible 
First occurrence 
Seponate permanently or 
discontinue until resolution 
(Grade 0-1) 
Reduce to 50 % 
 
Tablet treatment 
The patients must be informed that they should take their dose every twelfth hour, 1 hour before a 
meal or 2 hours after a meal. If the patient forgets a dose, the dose can be taken for up to 4 hours 
before the next dose in order to comply with the daily regime of two doses daily. If the patient 
vomits during the treatment course, the patient may not be redosed before the next planned dose. 
 
New malignant cutaneous lesions 
Patients, who develop cutaneous squamous cell carcinoma, new cutaneous melanoma, or other skin 
lesions, may continue in treatment. They are referred to the Department of Plastic Surgery at Herlev 
Hospital for surgical excision. 
 
QTc increase 
If QTc surpasses 500 ms or the changes from baseline are larger than 60 ms, vemurafenib treatment 
must be aborted temporarily. The QTc interval should be monitored weekly, until it is below 500 
ms. 
Appropriate electrolyte evaluation (K+, Mg++, Ca++) must be performed, and all necessary 
corrections and risk factors for heart attacks (e.g. congestive heart failure, bradyarrhytmia) must be 
controlled. 
When the QTc drops to below 500 ms, resumption of the treatment can be done at a reduced dosing 
level from 960 mg b.i.d. to 720 mg b.i.d. If a subsequent increase in QTc to >500 ms or a change 
from baseline larger than 60 ms is observed, vemurafenib may be reduced to 480 mg twice daily. 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
85
Permanent discontinuation of the treatment with vemurafenib is recommended, if the QTc increase 
fulfills both criteria of >500 ms and >60 ms change from pretreatment values, or if QTc > 500 ms 
or the change from baseline of > 60 ms is observed in 2 separate previous cases. 
 
Treatment pause 
Treatment with vemurafenib among patients, who have to undergo tumor surgery, radiotherapy, or 
other procedures, must be paused 7 days before and resumed 7 days after the procedure. For 
stereotaxic radiotherapy, however, vemurafenib may be resumed 1 day after treatment. 
 
 
Side effect 
Management 
Arthralgia 
NSAIDs, steroids in low dose, pausing of 
medication 
Rash 
Steroid cream (e.g. Kenalog), antihistamine, 
pausing of medication and dose reduction 
KA/SCC/ new MM 
Simple excision 
Photosensitivity 
Sun block (≥SPF 30) 
Palmar-plantar 
erythrodysesthesia 
Strongly acting steroid cream (e.g. 
Dermovat) 
Keratosis pilaris exfoliants 
(10 % salicyl-vaseline) 
Hepatotoxicity 
Pausing of medication and dose reduction 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
86
Appendix 10: The most frequent relevant drug-interactions with vemurafenib 
Drugs, which inhibit the P450 enzyme system, so that the concentration of vemurafenib in the blood is 
increased. 
CYP1A2 
CYP2B6 
CYP2C8 
CYP2C9 
CYP2C19 
CYP2D6 
CYP2E1 
CYP3A4,5,7 
fluvoxamine1 
ciprofloxacin1 
cimetidine3 
amiodarone 
fluoroquinolones 
furafylline 
interferon 
methoxsalen 
mibefradil 
ticlopidine 
thiotepa 
ticlopidine 
gemfibrozil1 
trimethoprim2 
glitazones 
montelukast 
quercetin 
fluconazole1 
amiodarone 
fenofibrate 
fluvastatin 
fluvoxamine 
isoniazid 
lovastatin 
phenylbutazone 
probenicid 
sertraline 
sulfamethoxazole 
sulfaphenazole 
teniposide 
voriconazole 
zafirlukast 
PPIs: 
esomeprazole 
lansoprazole 
omeprazole 
pantoprazole 
rabeprazole 
Other: 
chloramphenicol 
cimetidine 
felbamate 
fluoxetine 
fluvoxamine 
indomethacin 
ketoconazole 
modafinil 
oxcarbazepine 
probenicid 
ticlopidine 
topiramate 
bupropion1 
cinacalcet1 
fluoxetine1 
paroxetine1 
quinidine1 
duloxetine2 
sertraline2 
terbinafine2 
amiodarone3 
cimetidine3 
celecoxib 
chlorpheniramine 
chlorpromazine 
citalopram 
clemastine 
clomipramine 
cocaine 
diphenhydramine 
doxepin 
doxorubicin 
escitalopram 
halofantrine 
histamine H1 
receptor antagonists 
hydroxyzine 
levomepromazine 
methadone 
metoclopramide 
mibefradil 
midodrine 
moclobemide 
perphenazine 
ranitidine 
reduced-haloperidol 
ritonavir 
ticlopidine 
tripelennamine 
diethyl-dithiocarbamate 
disulfiram 
HIV Antivirals: 
indinavir1 
nelfinavir1 
ritonavir1 
clarithromycin1 
itraconazole1 
ketoconazole1 
nefazodone1 
saquinavir1 
suboxone1 
telithromycin1 
aprepitant2 
erythromycin2 
fluconazole2 
grapefruit juice2 
verapamil2 
diltiazem2 
cimetidine3 
amiodarone 
NOT azithromycin 
chloramphenicol 
boceprevir 
ciprofloxacin 
delaviridine 
diethyldithiocarbamate 
fluvoxamine 
gestodene 
imatinib 
mibefradil 
mifepristone 
norfloxacin 
norfluoxetine 
starfruit 
telaprevir 
voriconazole 
 
1) A strong inhibitor, which can result in >5 times increase in plasma AUC values or more than 80 % less clearance. 
2) A moderate inhibitor, which can result in >2 times increase in plasma AUC values or 50-80 % less clearance. 
3) A weak inhibitor, which can result in >1.5 times but <2 times increase in plasma AUC values or 20-50 % less clearance. 
Source: http://medicine.iupui.edu/clinpharm/ddis/main-table/ 
 
 
Drugs, which induce the P450 enzyme system, so that the concentration of vemurafenib in the blood is 
reduced. 
CYP1A2 
CYP2B6 
CYP2C8 
CYP2C9 
CYP2C19 
CYP2D6 
CYP2E1 
CYP3A4,5,7 
broccoli 
brussel sprouts 
char-grilled meat 
insulin 
methylcholanth-rene 
modafinil 
nafcillin 
beta-naphthoflavone 
omeprazole 
tobacco 
phenobarbital 
phenytoin 
rifampin 
rifampin 
rifampin 
secobarbital 
carbamazepine 
norethindrone 
NOT pento-barbital 
prednisone 
rifampicin 
dexamethasone 
rifampin 
ethanol 
isoniazid 
HIV Antivirals: 
efavirenz 
nevirapine 
barbiturates 
carbamazepine 
glucocorticoids 
modafinil 
oxcarbazepine 
phenobarbital 
phenytoin 
pioglitazone 
rifabutin 
rifampin 
St. John's wort 
troglitazone 
Source: http://medicine.iupui.edu/clinpharm/ddis/main-table/ 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
87
Substrates for the relevant P450 enzyme systems 
CYP1A2 
CYP2B6 
CYP2C
8 
CYP2C9 
CYP2C19 
CYP2D6 
CYP2E1 
CYP3A4,5,7 
amitriptyline 
caffeine 
clomipramine 
clozapine 
cyclobenzaprine 
estradiol 
fluvoxamine 
haloperidol 
imipramine N-
DeMe 
mexiletine 
naproxen 
olanzapine 
ondansetron 
phenacetin 
acetaminophen -> 
NAPQI 
propranolol 
riluzole 
ropivacaine 
tacrine 
theophylline 
tizanidine 
verapamil 
R-warfarin 
zileuton 
zolmitriptan 
bupropion 
cyclophosphamide 
efavirenz 
ifosphamide 
methadone 
sorafenib 
amodiaquine 
cerivastatin 
paclitaxel 
repaglinide 
sorafenib 
torsemide 
NSAIDs: 
diclofenac1 
ibuprofen 
lornoxicam 
meloxicam 
S-naproxen_Nor 
piroxicam 
suprofen 
 
Oral 
Hypoglycemic 
Agents: 
tolbutamide1 
glipizide 
 
Angiotensin II 
Blockers: 
losartan 
irbesartan 
 
Sulfonylureas: 
glyburide 
glibenclamide 
glipizide 
glimepiride 
tolbutamide 
amitriptyline 
celecoxib 
fluoxetine 
fluvastatin 
glyburide 
nateglinide 
phenytoin-4-OH2 
rosiglitazone 
tamoxifen 
torsemide 
S-warfarin 
PPIs: 
lansoprazole 
omeprazole2 
pantoprazole 
rabeprazole 
 
Anti-epileptics: 
Diazepam -> Nor 
phenytoin(O) 
S-mephenytoin 
Phenobarbitone 
amitriptyline 
carisoprodol 
citalopram 
chloramphenicol 
clomipramine 
clopidogrel 
cyclophosphamide 
hexobarbital 
imipramine 
N-DeME 
indomethacin 
R-mephobarbital 
moclobemide 
nelfinavir 
nilutamide 
primidone 
progesterone 
proguanil 
propranolol 
teniposide 
R-warfarin -> 8-OH 
 
Tamoxifen 
Beta Blockers: 
carvedilol 
S-metoprolol 
propafenone 
timolol 
 
Antidepressants: 
amitriptyline 
clomipramine 
desipramine 
fluoxetine 
imipramine 
paroxetine 
venlafaxine 
 
Antipsychotics: 
haloperidol 
perphenazine 
risperidone->9-OH 
thioridazine 
zuclopenthixol 
alprenolol 
amphetamine 
aripiprazole 
atomoxetine 
bufuralol 
chlorpheniramine 
chlorpromazine 
clonidine 
codeine (-> O-desMe) 
debrisoquine 
dexfenfluramine 
dextromethorphan 
donepezil 
duloxetine 
encainide 
flecainide 
fluvoxamine 
lidocaine 
metoclopramide 
methoxyamphetamine 
mexiletine 
minaprine 
nebivolol 
nortriptyline 
ondansetron 
oxycodone 
perhexiline 
phenacetin 
phenformin 
promethazine 
propranolol 
sparteine 
tramado 
Anesthetics: 
enflurane 
halothane 
isoflurane 
methoxyflurane 
sevoflurane 
acetaminophen-
>NAPQI 
aniline 
benzene 
chlorzoxazone 
ethanol 
N,N-
dimethylformamide 
Theophylline->8-OH 
Macrolide 
antibiotics: 
clarithromycin 
erythromycin (not 
3A5) 
NOT azithromycin 
Telithromycin 
 
Anti-arrhythmics: 
Quinidine->3-OH 
(not 3A5) 
 
Benzodiazepines: 
alprazolam 
diazepam->3OH 
midazolam 
triazolam 
 
Immune 
Modulators: 
cyclosporine 
tacrolimus 
(FK506) 
 
HIV Antivirals: 
indinavir 
nelfinavir 
ritonavir 
saquinavir 
 
Prokinetic: 
Cisapride 
 
Antihistamines: 
astemizole 
chlorpheniramine 
terfenadine 
 
Calcium Channel 
Blockers: 
amlodipine 
diltiazem 
felodipine 
lercanidipine 
nifedipine 
nisoldipine 
nitrendipine 
verapamil 
HMG CoA 
Reductase 
Inhibitors: 
atorvastatin 
cerivastatin 
lovastatin 
NOT pravastatin 
NOT rosuvastatin 
simvastatin 
 
Steroid 
6beta-OH: 
estradiol 
hydrocortisone 
progesterone 
testosterone 
 
Miscellaneous: 
alfentanil 
aprepitant 
aripiprazole 
boceprevir 
buspirone 
cafergot 
caffeine->TMU 
cilostazol 
cocaine 
codeine- 
N-demethylation 
dapsone 
dexamethasone 
dextromethorphan 
docetaxel 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
88
domperidone 
eplerenone 
fentanyl 
finasteride 
gleevec 
haloperidol 
irinotecan 
LAAM 
lidocaine 
methadone 
nateglinide 
ondansetron 
pimozide 
propranolol 
quetiapine 
quinine 
risperidone 
romidepsin 
salmeterol 
sildenafil 
sirolimus 
sorafenib 
sunitinib 
tamoxifen 
taxol 
telaprevir 
terfenadine 
torisel 
trazodone 
vemurafenib 
vincristine 
zaleplon 
ziprasidone 
zolpidem 
Source: http://medicine.iupui.edu/clinpharm/ddis/main-table/ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
Protocol: T-cell therapy in combination with vemurafenib for patients with BRAF mutated 
metastatic malignant melanoma. EudraCT no. 2014-001419-38. Version 1.4. 24.02.2019. The 
National Committee on Health Research Ethics, case no. 1402192/1609377. Danish Medicines 
Agency, journal no. 2014041619. 
 
89
Appendix 11: Skin diagram for observation of skin changes associated with 
vemurafenib treatment. 
 
 
 
Avatar for registration of skin elements in relation to vemurafenib 
 
 
Yes 
No 
Commens 
Skin examination 
Spinocellular carcinoma present? 
Mark with 1 
 
 
 
Basocellular carcinoma present? 
Mark with 2 
 
 
 
Actinic keratosis present? 
Mark with 3 
 
 
 
Keratoacanthoma present? 
Mark with 4 
 
 
 
New primary skin element? 
Mark with 5 
 
 
 
If yes, biopsy to confirm diagnosis and localization is noted on the avatar.