Inclusion Criteria:
1. Histologically confirmed inoperable or metastatic melanoma (stage IIIc or IV).
2. Progressive disease after standard treatment with anti-PD-1 check-point inhibition
or combination of aforementioned with anti-CTLA-4 check-point inhibition.
3. Age: 18
- - 75 years at the time of signed Informed consent.
4. ECOG performance status of ≤1 (Appendix 2).
5. Is fit for tumor resection and has at least one lesion (> 1 cm3) available for
surgical resection for manufacture of TIL. (Unless TILs are already available
through metastasectomy prior to enrollment in this study, as described in step one
under study design)
6. At least one measurable parameter in accordance with RECIST 1.1 -criteria (excluding
the lesion to be resected).
7. LVEF assessment with documented LVEF ≥50% by either TTE or MUGA.
8. Sufficient organ function, including:
- - Absolute neutrophil count (ANC) ≥ 1.500 /μl.
- - Leucocyte count ≥ lower normal limit.
- - Platelets ≥ 100.000 /μl and <700.000 /μl.
- - Hemoglobin ≥ 6.0 mmol/l.
- - S-bilirubin ≤ 1.5 times upper normal limit (Exception: Subjects with liver
metastasis ≤ 2.5 × ULN)
- ASAT/ALAT ≤ 2.5 times upper normal limit (Exception: Subjects with liver
metastasis ≤ 5.0 × ULN)
- Alkaline phosphatase ≤ 5 times upper normal limit.
- - Lactate dehydrogenase ≤ 5 times the upper normal limit.
- - Sufficient coagulation: APPT<40 and INR<1.5.
9. Signed statement of consent after receiving oral and written study information. 10. Willingness to participate in the planned controls and capable of handling
toxicities.
11. Subject must receive CRISPR-TIL as the next therapy following tumor resection unless
bridging therapy is administered:
- - Bridging therapy is discouraged.
However, if in the opinion of the
Investigator, the subject requires immediate therapy after tumor resection, the
subject may receive bridging therapy for the period during which the subject is
awaiting the manufacture of TIL-infusion product. Bridging therapy may be a
continuation of the therapy the subject was receiving prior to tumor resection
or may be a new therapy.
- - Following this bridging therapy, the subject must adhere to the mandatory
washout periods (described in exclusion criterion 1) and must continue to have
measurable disease prior to receiving CRISPR-TIL.
12. Age and Reproductive Status:
- - Women of childbearing potential (WOCBP) must have a negative urine or serum
pregnancy test AND must agree to use an effective method of contraception
starting at the first dose of chemotherapy for at least 12.
WOCB must also
agree to refrain from egg donation, storage, or banking during these same time
periods. The following are considered safe methods of contraception:
- - Hormonal anticonception (birth control pills, spiral, depot injection with
gestagen, subdermal implantation, hormonal vaginal ring, and transdermal
depot patch)
- Intrauterine device.
- - Surgical sterilization.
- - Surgical sterilization of male partner with verification of no sperm after
the procedure.
- - Menopause (for more than 12 months)
- Male subjects must be surgically sterile or agree to use a double-barrier
contraception method or abstain from sexual activity with an WOCBP starting at
the first dose of chemotherapy and for 6 months thereafter.
Male subjects must
also agree to refrain from sperm donation, storage, or banking.
Exclusion Criteria:
1. Subject has received or plans to receive the following therapy/treatment prior to
tumor resection (TR) or lymphodepleting chemotherapy (LDC):
- - Cytotoxic chemotherapy: Washout period 3 weeks before TR and LDC.
- - Small molecules/TKI: Washout period 1 week before TR and LDC.
- - Immune therapy (monoclonal AB therapy, CPI, and biologics): 2 weeks before TR
and LDC.
- - Prior T-cell therapy, including gene therapy using an integrating vector.
- - Corticosteroids at dose equivalent > 10 mg prednisone or any other
immunosuppressive therapy.
2 weeks before TR and LDC. Note: Use of topical
steroids is not an exclusion.
- - Investigational treatment: 4 weeks or 5 half-lives, whichever is shorter before
TR and LDC.
- - Radiation to the pelvis and/or multiple bones containing ≥ 25% of bone marrow:
4 weeks before TR and LDC.
- - Whole brain radiotherapy or brain stereotactic radiosurgery: 4 weeks before TR
and LDC.
- - Radiotherapy to the target lesions: 3 months prior to TIL infusion.
A lesion
with unequivocal progression post-radiotherapy may be considered a target
lesion.
2. A history of prior malignancies. Patients treated for another malignancy can
participate if they are without signs of disease for a minimum of 2 years after
treatment. Subjects with curatively treated ductal carcinoma in situ (DCIS or LCIS)
breast cancer for which they are taking hormonal therapy is acceptable. Resectable
squamous or basal cell carcinoma of the skin is acceptable.
3. Patients with metastatic ocular/mucosal or other non-cutaneous melanoma. Unknown
primary melanoma is eligible.
4. Toxicity from previous anti-cancer therapy must have resolved to ≤ Grade 1 or
baseline prior to enrollment (except for non-clinically significant toxicities e.g.,
alopecia, vitiligo). Subjects with Grade 2 toxicities who are deemed stable or
irreversible (e.g., peripheral neuropathy) can be enrolled.
5. Patients who have more than 2 CNS metastases or who have any CNS lesion that is
symptomatic, greater than 1 cm in diameter, or show significant surrounding edema on
MRI scan will not be eligible until they have been treated and demonstrated no
clinical or radiologic CNS progression for at least 2 months.
6. The following patients will be excluded because of their inability to receive
high-dose interleukin-2 (See appendix 5):
- - History of coronary revascularization.
- - Documented LVEF of less than 45% in patients with clinically significant atrial
and/or ventricular arrhythmias including but not limited to atrial
fibrillation, ventricular tachycardia, 2o or 3o heart block.
- - Documented FEV-1 less than or equal to 60% predicted value for patients with: A
prolonged history of cigarette smoking (greater than 20 pack years), large
tumor burden in the lungs, or Symptoms of respiratory distress.
7. Known hypersensitivity to one of the active drugs or one or more of the excipients.
8. Severe medical conditions, such as severe asthma/COLD, significant cardiac disease,
and poorly regulated insulin-dependent diabetes mellitus among others.
9. Creatinine clearance (eGFR) < 70 ml/min*.
10. Acute/chronic infection with HIV, hepatitis, and syphilis among others.
11. Severe allergies or previous anaphylactic reactions.
12. Active autoimmune or immune-mediated disease that has not yet resolved. Subjects
with the following will be eligible:
- - Immune-mediated AEs secondary to immunotherapy which have resolved to ≤ Grade 1
without steroids;
- Hypothyroidism, Type I diabetes, adrenal insufficiency, or pituitary
insufficiency that are stable on replacement therapy;
- Disorders such as asthma, vitiligo, psoriasis, or atopic dermatitis that are
well-controlled without requiring systemic immunosuppression;
- Other stable immune conditions that do not require prednisone higher than 10
mg/day or their equivalent dose for other corticosteroid agents may be
acceptable with the agreement of the Sponsor.
13. Pregnant women and women breastfeeding.
14. Subjects deemed unlikely to fully comply with protocol requirements by the study
investigator.
- - In selected cases it can be decided to include a patient with a eGFR < 70
ml/min with the use of a reduced dose of chemotherapy.
