Adoptive cell transfer therapy following non-myeloablative but lymphodepleting chemotherapy for the treatment of patients with refractory metastatic melanoma

Abstract

Purpose: We investigated the combination of lymphodepleting chemotherapy followed by the adoptive transfer of autologous tumor reactive lymphocytes for the treatment of patients with refractory metastatic melanoma.

Patients and methods: Thirty-five patients with metastatic melanoma, all but one with disease refractory to treatment with high-dose interleukin (IL) -2 and many with progressive disease after chemotherapy, underwent lymphodepleting conditioning with two days of cyclophosphamide (60 mg/kg) followed by five days of fludarabine (25 mg/m(2)). On the day following the final dose of fludarabine, all patients received cell infusion with autologous tumor-reactive, rapidly expanded tumor infiltrating lymphocyte cultures and high-dose IL-2 therapy.

Results: Eighteen (51%) of 35 treated patients experienced objective clinical responses including three ongoing complete responses and 15 partial responses with a mean duration of 11.5 +/- 2.2 months. Sites of regression included metastases to lung, liver, lymph nodes, brain, and cutaneous and subcutaneous tissues. Toxicities of treatment included the expected hematologic toxicities of chemotherapy including neutropenia, thrombocytopenia, and lymphopenia, the transient toxicities of high-dose IL-2 therapy, two patients who developed Pneumocystis pneumonia and one patient who developed an Epstein-Barr virus-related lymphoproliferation.

Conclusion: Lymphodepleting chemotherapy followed by the transfer of highly avid antitumor lymphocytes can mediate significant tumor regression in heavily pretreated patients with IL-2 refractory metastatic melanoma.

Fig 1

Lymphodepletion and adoptive cell transfer-induced regression of metastatic disease in diverse anatomic sites. (A) Axillary, pelvic and intraperitoneal metastases (patient 1); (B) extensive liver disease (patient 31); (C) brain and recurrent axillary metastases (patient 28); (D) multiple lung and pelvic metastases (patient 6); (E) lung and subcutaneous disease (patient 21). Pre, pretreatment.

Fig 1

Lymphodepletion and adoptive cell transfer-induced regression of metastatic disease in diverse anatomic sites. (A) Axillary, pelvic and intraperitoneal metastases (patient 1); (B) extensive liver disease (patient 31); (C) brain and recurrent axillary metastases (patient 28); (D) multiple lung and pelvic metastases (patient 6); (E) lung and subcutaneous disease (patient 21). Pre, pretreatment.

Fig 2

Loss of antigen expression in post-treatment lesions. Tumor cells in pretreatement samples expressed all antigens; however, individual antigens were lost from recurrent lesions. A) MART-1 antigen expression was lost in a recurrent lesion from patient 10. B) HLA-A2 antigen was lost in the recurrent tumor from patient 28. mθ, macrophage.

Fig 3

Granulocyte colony-stimulating factor (G-CSF) administration significantly improved the time to neutrophil recovery (two-tailed P < .03). The percentage of patients who had recovered neutrophil counts above 500/ mm³is graphed. ANC, absolute neutrophil count

Fig 4

Absolute lymphocyte count (ALC) increased transiently in some patients after adoptive cell transfer. The maximum ALC for each patient within the first 8 days after cell transfer is plotted for all nonresponding patients (NR) and objective responders (OR) who had peak ALC values above a relatively high, arbitrarily chosen value of 1,000 lymphocytes/mm³.

Fig 5

CD8⁺lymphocyte counts recovered more rapidly than CD4⁺lymphocytes. Each symbol represents an individual patient. All available data is included, but measurements were not available for all patients at each time increment. Open symbols represent five patients who were treated with a prior course of lymphodepleting chemotherapy. Horizontal lines indicate normal limits. A) Recovery of CD4⁺cells. B) Recovery of CD8⁺cells. Bars represent mean values of all patients.

Fig 6

Transferred cells persisted for extended time in responding patients. Each tumor-infiltrating lymphocyte administered on day 0 contained a tumor reactive clone with the indicated T-cell receptor beta chain variable region (Vβ) expression or HLA-A2/MART-1-26-35 (27L) tetrameter (A2/MART-1)-binding. The percentage of CD8+ cells recognized by the indicated reagent is indicated. Pre, pretreatment peripheral blood lymphocytes (PBL). Post, PBL on the day indicated after cell transfer.