Overview of Immune

Therapeutic Strategies

Marcus Butler, MD

Personalized Cancer Medicine

February 11, 2014

Disclosures

Advisory boards for

Bristol-Myers Squib

Merck & Co.

Novartis Pharmaceuticals

Patent (co-inventor)

artificial antigen presenting cell

Immune Therapy Principles

• Tumors evolve in the context of the

immune system

• Specificity

• Aims to manipulate non-malignant

processes

• Responses may be delayed

• Holds the promise of long-term benefit

and immunologic memory

Pathways of Tumor Immunity

Mellman, Coukos, Dranoff. Nature 2011;480:480-489

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.

Abbas, Lichtman, and Pillai. Cellular and Molecular Immunology, 7th edition. Copyright © 2012 by Saunders, an imprint of Elsevier Inc.

Lymphocytic Inflammation in Tumors

Ovarian Cancer TIL

Zhang et al., N Engl J Med. 2003 Jan 16;348(3):203-

13. 186 patients

TIL and Ovarian Cancer Zhang L et al. Intratumoral T cells, recurrence, and survival in epithelial

ovarian cancer. N Engl J Med 348, 203-213 (2003).

Sato E et al. Intraepithelial CD8+ tumor-infiltrating lymphocytes and a high

CD8+/regulatory T cell ratio are associated with favorable prognosis in

ovarian cancer. Proc Natl Acad Sci U S A 102, 18538-18543 (2005).

Tomsova M et al. Prognostic significance of CD3+ tumor-infiltrating

lymphocytes in ovarian carcinoma. Gynecol Oncol 108, 415-420 (2008).

Wolf D et al. The expression of the regulatory T cell-specific forkhead box

transcription factor foxp3 is associated with poor prognosis in ovarian

cancer. Clin Cancer Res 11, 8326-8331 (2005).

Hamanishi J et al. Programmed cell death 1 ligand 1 and tumor-infiltrating

CD8+ T lymphocytes are prognostic factors of human ovarian cancer.

Proc Natl Acad Sci U S A 104, 3360-3365 (2007).

Immunotherapy Balance

• Anti-Cancer

– Dendritic cells

– Lymphocytes

(CD8 T cells)

– Cytokines (IL2,

IFN-g)

• Tumor Promoting

– Suppressive

macrophage

– Lymphocytes (T reg)

– Cytokines (TGF-beta,

IL-10, IDO)

Specificity

Tumor Associated Antigens

Tissue associated • MART1, gp100, PSA, CEA, Mesothelin,

CA125, folate receptor-a, HER2/neu

Abnormally expressed • p53, MUC1

Paraneoplastic • cerebellar degeneration-related protein cdr2

Cancer-testis • NY-ESO-1, MAGE family members

Universal • Survivin, hTERT

MS Lawrence et al. Nature 000, 1-5 (2013) doi:10.1038/nature12213

Somatic mutation frequencies observed in exomes from 3,083 tumor-normal pairs.

Tumor Derived Neoantigens

Pathways of Antigen Processing

T cell Recognition of Peptide-MHC

Goal of Immune Therapy:

Manipulation of Host Response

Therapeutic Strategies

• Induction of new responses

• Vaccination

• Oncolytic virus/epitope spreading

• Adoptive therapy

• Augmentation of pre-existing responses

• Checkpoint blockade

• TIL therapy

• Immune modulation, cytokines

Vaccination

Mellman, Coukos, Dranoff. Nature 2011;480:480-489

Whole tumor cell vaccines

Peptide vaccines

Dendritic cell vaccines

Targeting with oncolytic virus

Sharma P et al. Nat Rev Ca 2011;11:805-812

Clinical Breakthroughs:

Immune Checkpoints, CTLA-4 & PD1/PDL1

Ipilimumab (Anti-CTLA-4)

Stage IV or

Unresectable Stage III

Melanoma

Pathways of Tumor Immunity

Mellman, Coukos, Dranoff. Nature 2011;480:480-489

Adoptive Cell Therapy

Mellman, Coukos, Dranoff. Nature 2011;480:480-489

Gattinoni et al. Nature Reviews Immunology 6: 383–393, 2006.

Adoptive Cell Therapy (ACT) with TIL

NCI Experience •Highly selected TIL

•Rapid expansion protocol

•Lymphodepletion

-Increase IL2, IL7, IL15

-Reduce regulatory T cells

•High dose IL-2

22

Adoptive Immunotherapy with TIL

20+ Years of ACT at the NIH

(All receive High Dose IL-2)

Regimen Cells Response Rate Toxicity

No lymphodepletion (1980’s)

LAK Melanoma: 22% (6/27) All enrolled: 28% (24/85)

↑↑

No lymphodepletion (1988-1992)

TIL 34% (29/86) ↑↑

•Cytoxan: 60 mg/kg/d x 2

•Fludarabine: 25 mg/m2/d x 5

Selected

TIL 49% (21/43) ↑↑↑

•Cytoxan: 60 mg/kg/d x 2

•Fludarabine: 25 mg/m2/d x 5

•TBI: 2-12 Gy

Selected

TIL

2 Gy: 52% (13/25) 12 Gy: 72%(18/25)

↑↑↑↑

Rosenberg, S.A. et al. JNCI; 86: 1159-66, 1994.

Dudley, M. E. et al. J Clin Oncol; 26: 5233-9, 2008.

Rosenberg, S.A. et al. JNCI; 85: 622-32, 1993.

Adapted from Restifo, Dudley and Rosenberg, Nature Reviews Immunology 2012

4) Cyclophosphamide, fludarabine ->

TILs ->

LOWER DOSE IL-2 therapy

Adoptive Cell Therapy with

Tumor infiltrating lymphocytes (TILs)

1) Tumor sample

2) Initial expansion of TILs

(+ interleukin-2)

3) Rapid expansion of TILs

(OKT3, feeder cells, IL-2 (LOWER DOSE)

Pretreatment 2 Months

PR (78% decrease in hilar nodule @ 2 months)

Princess Margaret TIL Patient #1

Non-measurable non-index lesions @ 2 months:

Pulmonary nodules - stable

Right hilar nodes – absent

Subcutaneous lesion - absent

Immune Therapy:

Delayed and Repeated Responses

Screening

Week 96: Durable & ongoing response

without signs of IRAEs

Harmankaya K, et al: Presented at EADO 7th World Congress of Melanoma 2009, Vienna, Austria

Delayed responses to ipilimumab;

paradoxical interim increases

Week 12:

Initial increase in

total tumor burden

(mWHO PD)

Week 16:

Responding

Metastatic cancer lesions are made up mainly of cancer cells and stromal cells, with a very limited immune and inflammatory infiltrate by lymphocytes and macrophages.

Ribas A et al. Clin Cancer Res 2009;15:7116-7118 ©2009 by American Association for Cancer Research

Ovarian Cancer Response Associated with

Anti-NY-ESO-1 Immunity

Ipilimumab

Hodi FS, Butler MO et al. PNAS; 105, 3005-10, 2008.

OV65 (82 yo): Autologous Ovarian

GVAX Followed by Ipilimumab

GVAX

Maintenance on ipilimumab:

8 years

CA

12

5

Long-term Disease Control and

Memory

Ipilimumab Can Produce Durable Benefit

Stage IV or

Unresectable Stage III

Melanoma

Pooled OS Analysis Including EAP Data: 4846 Patients

Patients at Risk

Ipilimumab 4846 1786 612 392 200 170 120 26 15 5 0

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 12 24 36 48 60 72 84 96 108 120

Ipilimumab

CENSORED

Median OS, months (95% CI): 9.5 (9.0–10.0)

3-year OS rate, % (95% CI): 21 (20–22)

Pro

po

rtio

n A

live

Months

Schadendorf, Hodi FS, Robert et al. ESMO 2013

Adoptive Transfer of T Cells

Kandalaft L E et al. JCO 2011;29:925-933

©2011 by American Society of Clinical Oncology

aAPC

• K562 erythroleukemia cell line

• Engineered to express CD80, CD83, HLA-A2

• Able to present peptide

• CTL generated from purified CD8

• Low dose IL-2 and IL-15

• No feeder cells

Artificial APC for the Generation of

CTL for Adoptive Immunotherapy

TCR/CD3

CD28/CTLA-4 CD80

CD83

HLA-A2

LFA-3

ICAM-1

IL-2

IL-15

K562-based

Artificial

APC

CD8+

T Cell

CD2

LFA-1

CD83L

CD8

• Target: MART1/Melan-A, a melanoma-associated antigen

• No lymphodepletion, IL-2, anti-CTLA-4, or vaccine

• 35 day cycles with 2 CTL infusions

A Pilot Study of the Adoptive Transfer of MART1/Melan-

A CTL for Metastatic Melanoma

Leukapheresis 1 Infusion 1

CTL Generation 1 CTL Generation 2

Day -21 Day 0 Day 14 Day 35 Day 70

Infusion 2 Leukapheresis 2 Leukapheresis 3

Day -21 0 14 35 70

Anti-Tumor Activity of Infused MART1 CTL

Patient 5:

complete

response

54+

months

Patient 3:

mixed

response

Pre-Infusion Post-Infusion

day 67 day 107

day 74 day 140

CTL Induce Anti-tumor Immune Response

(Patient 5 Tumor Biopsy)

Pre-infusion

Post-infusion day 5

CD8

Foxp3 CD4

Long-term Persistence of Infused MART1 T Cells

MA

RT

1 p

en

tam

er+

T c

ell

s

(% C

D8)

MA

RT

1 p

en

tam

er+

T c

ell

s

(fo

ld i

ncre

ase i

n %

CD

8)

Day 56

(n=9)

Days 102-358

(n=6)

Patient #

Pre-

infusion

Day

14

Day

49

Patient 7

Butler MO et al. Sci Trans Med 3: 80ra34, 2011.

No. Age/

sex Stage

Notable Comorbid

Conditions

Best

Response

Overall

Time to

next therapy

1 74M

M1c:

liver, adrenal,

spleen, lung, skin

high blood pressure, history of

bowel obstruction

Died on

day 51 --

2 69M M1b:

lung, skin

deep vein thrombosis, on

warfarin

Progressive

disease Day 103

3 49F M1c:

lung, adrenal -

Mixed

response Day 146

4 68M

M1c:

muscle, lung,

mediastinum, cardiac

asbestosis, cardiac metastasis Stable Day 140

5 66M

M1a:

multiple

lymph nodes

diabetes, high blood pressure,

coronary artery disease (MI) Complete Response 54+ months

6 55M M1b:

lung high blood pressure Stable Day 287

7 70F M1b:

lung, skin

diabetes, coronary artery

disease (MI)

Progressive

disease Day 335

8 80M

M1b:

lung,

mediastinal nodes

coronary artery disease (MI),

s/p CABG, pacemaker Stable Day 372

9 64M

M1b:

lung,

mediastinal nodes

High blood pressure Progressive

disease Day 146

Patient Status

CTLA-4 Blockade: MART1 T Cells with Memory

Phenotype Expand (Patient 2)

α-CTLA-4

Pre-Infusion Post-Infusion

day 74 day 167 day 224 day 537

Anti-CTLA-4

No. Age/

sex

Time to

further

therapy

CTLA-4

Blockade Outcome

Duration of

response

(months)

Survival

(months)

2 69M Day 103 Ipilimumab

(10 mg/kg)

Partial

response 16 18

3 49F Day 146 Ipilimumab

(10 mg/kg)

Partial

response 60+ 60+

7 70F Day 335 Ipilimumab

(3 mg/kg) Stable 6 14

8 80M Day 372 Ipilimumab

(3 mg/kg) Stable 5 13

9 64M Day 146

Ipilimumab

(10 mg/kg)

+ bevacizumab

Partial

response 42+ 42+

Patient Response to Subsequent Ipilimumab

Conclusion

• Tumors develop in immune context

• Goal of immunotherapy

• Modulate individual immune reactivity

• Induction of tumor-specific response

• Vaccination (direct or indirect)

• Adoptive transfer

• Induce long-term responses,

immunologic memory, and cures

Acknowledgements

DFCI Protocols

Philip Friedlander, MD, PhD

F. Stephen Hodi, MD

Linda Drury, PA

Martin Mihm, MD

Lisa Brennan, RN

Kristen Stevenson

Donna Neuberg, PhD

Lee M. Nadler, MD

Naoto Hirano, MD, PhD

Princess Margaret

Anthony Joshua, BSc(Med),

MBBS, PhD, FRACP

David Hogg, MD, FRCPC

Leila Khoja, MBChB, PhD

Bianzheng Zhang, RN

Pamela Ohashi, PhD

Linh Nguyen, PhD

DFCI Cell Manipulation

Heather Daley

Jeffrey Cram

Sharon Helm

Darlys Schott

Myriam Armant, PhD

Grace Kao, MD

Olive Sturtevant

Leslie Silberstein, MD

Jerome Ritz, MD

Princess Margaret

Shlomit Boguslavsky, PhD

Shinya Tanaka, PhD

Diana Gray

Valentin Sotov

Naoto Hirano, MD, PhD

Support

S. Craig Lindner Fund for

Cancer Research

Rudolf E. Rupert Foundation for

Cancer Research

Cancer Research Institute

TAKARA

Madeleine Franchi Ovarian

Cancer Research Fund

Center for Human Cell Therapy,

Boston

NIH/NCI

Dana-Farber Cancer Institute