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Adoptive cell therapy
John B.A.G. Haanen MD, PhD
ESMO I-O preceptorship Zürich November 2017
Disclosures
• I have provided consultation, attended advisory boards, and/or
provided lectures for: Pfizer, MSD, BMS, IPSEN,
Roche/Genentech, NEON Therapeutics, Novartis for which NKI
received honoraria
• Through my work NKI received grant support from BMS, MSD,
Novartis
• I declare no conflict of interest
Patient case
• Mr. X
– 48 years
– Aside obesitas no other comorbidities
– 2007: superficial spreading melanoma of the right
upper leg: resected
– 2010: Inguinal node metastasis: IND
– 2010: pulmonary metastases en in-transit in the
right upper leg
Patient case
• BRAF V600E mutation present
– Started treatment with vemurafenib
– Resolution of pulmonary metastases
– Disease progression after 6 months
• Started dacarbazine chemotherapy
– After 2 courses progressive disease (PD)
• Started anti-CTLA4 (ipilimumab)
– After 4 courses PD
Patient case
• No treatment options
– Participated in experimental trial with TIL
– One in-transit metastasis was removed from right
leg and TIL were isolated and cultured for 5 weeks
– He received TIL infusion in Oct 2012 preceded by
non-myeloablative chemotherapy and followed by
HD IL-2
Days -7 to -1: Nonmyeloablative chemotherapy with Cyclophosphamide and fludarabin
Day 0: 2 x 1011 TIL (unselected ‘young’ TIL)
Days 0 – 3: high dose bolus IL-2 (4 in total)
Tumor-infiltrating lymphocyte (TIL) therapy of melanoma
Prior to TIL 3 wks after TIL 20 wks after TIL8 wks after TIL
Clinical data N10TIL003 patient: CR at 20 weeks
Overview of presentation
• Adoptive cellular immunotherapy
– TILs
– TCR/CAR gene therapy
Immunosuppressive tumor microenvironment
Kerkar S P , Restifo N P Cancer Res 2012
TILs in melanoma
Taube et al. Science Transl Med 2012
Scheme for TIL therapy
Rosenberg & Restifo Science 2015
Scheme for ‘young’ TIL therapy
Rosenberg & Restifo Science 2015
Tumor digest
Rosenberg & Restifo Science 2015
Goff et al., J Clin Oncol 2016
Goff et al., J Clin Oncol 2016
Patient characteristics
Overall Survival
Goff et al., J Clin Oncol 2016
Progression Free Survival
Survival of patients receiving TIL treatment
Response to TIL treatment
24% of patients developed a CR, only 1 of these progressed. Median FU 40.9 months
NMA TIL NMA + 1200cGy TIL
Goff et al., J Clin Oncol 2016
• International, multicentre, open-label, randomized controlled phase III study
• Patients with unresectable stage IIIc/IV melanoma
• Zero to one prior treatment (now virtually always anti-PD-1)
• Health technology assessment
M14TIL (NCT02278887)
168 patients
84 TIL 84 ipilimumab
Herlev Hospital,Copenhagen
NKI-AvL, Amsterdam
Inclusions since start (2015)
Centre TIL Ipilimumab Screening Total
NKI 16 14 2 30
Herlev 7 6 - 13
Total 23 20 - 43
24 mm
14 mm
13 mm
16-9-15 28-12-15
Patient treated in the RCT with TIL after failure to pembrolizumab
Prior to TIL 3 months after TIL
- Strong correlation between immune cell infiltrates and various types of cancer
Rationale to develop adoptive T cell therapy:
Fridman et al., Nat Rev Canc 2012
• Strong correlation between immune cell infiltrates and various types of cancer
• Approaches to ‘non-specifically’ mobilize endogenous anti-tumor immune responses show clear efficacy• Anti-CTLA4• Anti-PD1/PD-L1• Combination I-O therapies
• With currently available technologies ACT is feasible at a large(r) scale
Rationale to develop adoptive T cell therapy:
TIL therapy: How does it work?
Patient pretreated withlymphodepletingchemotherapy
TIL are grown from melanoma
tumors
Infusion of TIL + IL-2
Rapid Expansion
Immunotherapy of melanoma: TIL therapy
TIL are grown from melanoma
tumors Rapid Expansion
1x1011 T cellsA few million T cells
Which (cytotoxic) T cells mediate cancer regression?
?
Patient pretreated withlymphodepletingchemotherapy
TIL are grown from melanoma
tumors
Infusion of TIL + IL-2
Rapid Expansion
TIL therapy: Key question
What could tumor-specific cytotoxic T cells detect on tumor cells?
1. Self antigens (to which tolerance is incomplete)
2. ‘Neo-antigens’, epitopes that are truly foreign
What could tumor-specific cytotoxic T cells detect on tumor cells?
1. Self antigens (to which tolerance is incomplete)
2. ‘Neo-antigens’, epitopes that are truly foreign
Three subclasses:
a). Melanocyte differentiation antigens (e.g. Mart-I)b). Cancer-Germline antigens (e.g. NY-ESO-1)c). Overexpressed antigens
What could tumor-specific cytotoxic T cells detect on tumor cells?
1. Self antigens (to which tolerance is incomplete)
2. ‘Neo-antigens’, epitopes that are the result of carcinogen (UV or smoking) induced DNA damage. These are most often patient specific and truly foreign to the immune system
Both types of antigens comprise 100-1000 of potential epitopes
Peptide 1 Peptide 2 Peptide 3
Disintegration
Rescue Peptides
Toebes et al. Nat. Med. 2006Bakker et al. PNAS 2008
Generation of pMHC multimers by UV-induced peptide exchange
Tools for high-throughput analysis of tumor-antigen specific CD8 T cell responses:
Allows analysis of T cell responses against 100s-1000s of (predicted) antigens
Generate fluorochrome conjugated MHC multimers
Mix to create a collectionof differentially encoded MHC multimers
Assembly of combinatorial codes on T cell surfaces
Analysis by flow cytometry
T cell T cell T cell
Self-assembling molecular codes
Allows detection of 47 T cell responses in parallel
Hadrup et al, Nat Methods 2009, Andersen et al, Nat Prot 2012.
Summary of analysis of T cell responses against self antigens in clinically infused TIL products
• TIL infusion products very often comprise self-antigen specific CD8 T cells
• MDA
• C/T
• Overexpressed antigens
• These self-Ag specific T cells make up only a small minority of tumor-reactive
T cells (1% or less) with the TIL product
• TIL therapy leads to a significant increase in the number of tumor-reactive T
cell responses against the group of self antigens: broadens the tumor-reactive
immune response
What are we missing?
Analysis of T cell responses against self antigens in clinically effective TIL products
� TIL therapy leads to a significant increase in the number of tumor-reactive T
cell responses against the group of self antigens
� These T cell responses are however of a surprisingly low magnitude
Explanation A). Few cells suffice (and things may even get better when we
induce stronger T cell responses against these antigens)
Explanation B). We may not be looking at (all) the right antigens: recognition
of mutated peptides (neo-antigens) may be much more important
Generate map of tumor-specific mutations (DNASeq: exome, whole genome)
Determine which mutatedgenes are expressed (RNASeq)
Predict epitopes for each mutation per HLA-allele in silico = ‘antigenome’
Screen for T cell recognitionof mutated epitope
MDLVLNELVISLIVESKLLEHLA-A2HLA-B7HLA-C2
T cell
Developing a strategy for analysis of neo-antigen-specific T cell responses
Analyzing the neo-antigen-specific T cell repertoire in human cancer?
Excise tumor
Isolate tumor cells Isolate tumor-infiltrating T cells
Identify tumor-specific mutations
Predict potential T cell epitopes
Screen for T cell reactivity
Pt 010: complete response upon TIL therapy
480 1 2 3.5 5 6 7 8 9 10 11 12 13 14 150
50
100
Months post infusion of TIL
Red
uct
ion
in tu
mo
r b
urd
en
Months post infusion of TIL
Tum
or
bu
rden
Strong neo-antigen specific T cell responses in the infusion product
TIL infusion productVARST>M MYLKG>V WDR1N>K LRP3T>S RBM12S>L
0.096 1.03 1.242 0.290 29
Strong neo-antigen specific T cell responses in the infusion product
TIL infusion productVARST>M MYLKG>V WDR1N>K LRP3T>S RBM12S>L
0.096 1.03 1.242 0.290 29
Profound effect of TIL therapy on the neo-antigen specific T cell pool
TIL infusion product
2 months
4.45
Pre therapy
0.02
6 months
15.06
34 months
2.20
12 months
8.78
VARST>M MYLKG>V WDR1N>K LRP3T>S RBM12S>L
0.096 1.03 1.242 0.290 29
>450 fold increase in neo-antigen specific T cell reactivity upon TIL therapy
Peripheral blood
Summary of neo-antigen analysis in CD8 T cells
12 patients analyzed, neo-antigen specific reactivity in 10
(Not all alleles covered, exome coverage incomplete, epitope predictions
imperfect)
Percentage neo-antigen reactivity in general higher than shared
antigens
CD8 neoantigen-specific T cells have cytolytic activity against
autologous melanoma in vivo (PDX model) and may be superior
over C/T specific T cells
CD8+ T cells frequently respond to the consequence of DNA
damage in human melanoma
Neo-antigen reactive CD4+ cells also detected (5 out of 6 patients)
Possible advantages:No requirement for in vitro expansion of autologous tumor-specific T cells
One set of ”good” TCRs could serve many
Alternatives to adoptive T cell therapy: transferring TCRs rather than T cells
Possible advantages:No requirement for in vitro expansion of autologous tumor-specific T cells
One set of ”good” TCRs could serve many
Alternatives to adoptive T cell therapy: transferring TCRs rather than T cells
Cancer patient
Removal of peripheralblood lymphocytes
Infusion of autologous TCR gene modified T cells
Ex vivo transduction process
Infusion of gene-modified T cells
Kershaw et al. Nat Rev Cancer 2013
Genetically modified peripheral blood lymphocytes
Mouse transgenic for human TCR gene locus and MHC cl I
Modified from: Restifo et al., Nature Rev Immunol (2012)
Leukapheresis Start chemotherapy:Cyclophosphamide + fludarabin for total of 7 days
-7 0
Infusion of transduced T cells
High dose IL-2
Monitoring response and survival
mnd 1, 2, 3, 6Patient:
Informed consent + screening
Preparation of gene modified T cells
Schedule of treatment
On-target toxicity of MART-1-specific TCR gene therapy
CT scan of liver metastasis in patienttreated with TCR-modified T cells
Feasibility of TCR gene transfer in the clinic
Clinical data with TCRs specific for melanocyte differentiation antigens(expression on melanoma and healthy melanocytes)
Clinical responses but also (acceptable) on-target toxicity
Feasibility of TCR gene transfer in the clinic
Clinical data with TCRs specific for melanocyte differentiation antigens(expression on melanoma and healthy melanocytes)
Clinical responses but also (acceptable) on-target toxicity
Pre 5 months
Feasibility of TCR gene transfer in the clinic
Clinical data with TCR specific for carcinoembryonic antigen(expression on colorectal cancer and healthy colonic epithelium)
Modest clinical responses with substantial on-target toxicity
Feasibility of TCR gene transfer in the clinic
Clinical data with TCR specific for NY-ESO-1(expression on cancer cells and -MHC-negative- spermatocytes)
Clear clinical responses (both melanoma and synovial sarcoma. No detectable toxicity
Platforms for gene modified T cells
Fesnak et al. Nat Rev Cancer 2016
CAR T cell concept
Ramos et al. Ann Rev Immunol 2016
CD19 CAR development and beyond
Fesnak et al. Nat Rev Cancer 2016
Success rate of CD19 CAR therapy in refractory ALL
Brentjens et al., Sci Transl Med 2013; Grupp et al., NEJM 2013; Davila et al., Sci Transl Med 2014; Maude et al., NEJM 2014; Lee et al., Lancet 2015; Frey et al., ASH 2014; Park et al., ASH 2014
Sadelain J Clin Invest 2015
Survival of refractory ALL patients treatedwith CD19 CAR T cells
Lee et al., Lancet 2015
Emily Whitehead story
• 2010: at 5 years: pre-B acute lymphoblasticleukemia: treated with standard chemotherapy (for6 months): CR
• 2011: at 6 years: recurrence of ALL: again treatedwith chemotherapy and scheduled for bonemarrow transplant in 2012
• 2012: at 7 years: before BMT, recurrence.• 2012: at 7 years: first child to receive CD19 CAR T
cells: developed CR.
Emily Whitehead story
Future of infusion of gene modified T cells
• CD19 CAR T cell therapy has now been approved in 2017 for refractory ALL and B-NHL
• Further development of CARs (3rd and 4th generation) with more potent efficacy (less toxicity?)
• Combination therapy a.o. with immune checkpoint blockade
• More CAR T cells targets for solid cancers– CEA, PSMA, HER2, GD2, MUC1, EGFRvIII, mesothelin
• Targets for TCR gene therapy: neo-antigens
• T cell responses against self antigens are enhanced by these T cell products but are nevertheless oftentimes weak
• It is now possible to also evaluate the contribution of T cell responsesagainst patient-specific neo-antigens
- We need to find out which T cells matter most
• Adoptive T cell therapy with patient-derived T cells can mediate cancer regression in melanoma patients
• Genetic engineering of tumor-specific T cell responses is feasible- Makes adoptive T cell therapy feasible for the (many) tumor types for which TIL can not be grown
- Early clinical data demonstrate feasibility and clinical potential- Antigen choice is critical- More advanced engineering strategies are in development- Will allow the design of T cells that carry out desired functions on command
Adoptive immunotherapy of cancer