NHL immunotherapy

Immunotherapy for Lymphoma:

Finally?

F B Hagemeister, MDProfessor of Medicine

Department of Lymphoma and MyelomaM D Anderson Cancer Center

Bangkok 29 August 2015

Chimeric Antigen Receptor-T Cell Therapy for Lymphomas

• Development of CAR-Ts• Studies in Adults with B-Cell

Lymphomas• Identification and Management of

Toxicities

ASCT for Relapsed DLBCL: Pre-Rituximab Era (PARMA study)

7 year EFS was 41% vs 13% in for ASCT vs the chemo alone arm

EFS (months)

Surv

ival

(%)

DHAP x 6(n = 54)

DHAP x2 + ASCT (BEAC)(n = 55)

p = 0.002

41%

13%

100908070605040302010

00 30 60 90 120 150

Results are only for those in PR/CR after 2 DHAP Only CRs to initial chemotherapy were enrolled

EFS (induction ITT) OS (induction ITT)

R-ICE/ASCT vs R-DHAP/ASCT for Rel/Ref DLBCL: EFS and OS by Induction

Surv

ival

pro

babi

lity

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60 72OS (months)

Surv

ival

pro

babi

lity

EFS (months)

0.0

0.2

0.4

0.6

0.8

1.0

0 12 24 36 48 60 72

p = 0.2672 p = 0.3380

R-ICER-DHAP

R-ICER-DHAP

Gisselbrecht et al. JCO 28:4184–4190, 2010.Includes all patients! Note: Not much improvement in 20 years of research!

The Limited Benefit of ASCT for Relapsed DLBCL

300 patientsDLBCL

200 Cured with RCHOP

100 RelapseOr refractory

50 Transplantcandidate

50 Transplantineligible

25 Chemo-refractory

25 Respond and ASCT

Friedberg 2011 ASH Educational Session

210 Cured

90 receive Palliation. Most likely die from DLBCL

15 patients relapse

10 Cured after ASCT

Mechanisms of T-Cell Anergy in Therapy of Cancer

• T-cell response to antigens requires:– Recognition of antigen– Activation of the T cell– Persistence of T-cell function

• T-cell anergy is caused by:– Inhibition or lack of activating signals– Loss of antigen presentation– Activation of suppressive cells– Presence of suppressive ligands

Gotsman et al Circulation Res 109: 1220-1231, 2008. Scott et al. Nature Rev Cancer 14: 517-534, 2014.

Design of CAR-T Cells for Cancer Immunotherapy

• Basic Design: Two Fundamental Domains– Antigen binding portion• A single chain variable fragment (scFv)

derived from a monoclonal antibody– One or more intracellular T-cell signaling

domains• CAR-Ts must expand, persist, exhibit enduring

antitumor cytotoxicity, withstand an immunosuppressive microenvironment, and overcome tumor antigen escape

CAR-T Cells Recognize Antigen But Must Be Activated and Persist

• The tumor specific portion recognizing the tumor antigen can come from two sources – A T cell that is naturally occurring or from a

transgenic mouse– A tumor specific antibody found on normal B cells

• Activation requires modification of the T cell by adding a naturally occurring protein (CD3zeta, 1st generation)

• Persistence induced by stimulation via other proteins (CD28, 2nd generation) or costimulants (4-1BB or OX40 or other, 3rd generation)

Kershaw et al. Nature Rev Cancer 13: 525-541, 2013. Cassuri et al. J Cancer 2: 378-382, 2011>

Development of CARs for Therapy of Cancer

Components of an Artificial TCR

1st, 2nd, and 3rd Generation CARs

Resultant CAR can be inserted into T Cells by transfection with viruses of other means

CD19 as an Antigenic Target in Lymphoma and Myeloma

An Ideal Antigen? Lymphoma MyelomaExpressed on Most Tumor Cells

Yes No

Expressed on Cell Surface

Yes Yes

Essential for Tumor Growth

Unknown Unknown

Expressed on Clonogenic Cells

Probably Unknown

Not Expressed on Normal Cells or Target Toxicity Acceptable

B-Cell Depletion Acceptable

B-Cell depletion Acceptable

Kochenderfer er al. Blood 119: 2709-2720, 2014.

Importance of the Microenvironment in Limitation of CAR-T Effectiveness

• Endogenous immunosuppressive cells– CD4 regulatory T cells– Myeloid-derived suppressor cells– Plasmacytoid dendritic cells– Tumor-associated macrophages

• Immune checkpoint inhibitors• Immunosuppressive soluble ligands and

cytokines– Interleukin (IL)-10– Transforming growth factor (TGF)-beta

Variables Potentially Affecting Results in CAR-T Trials

Variables ImplicationsAntigen Efficacy

Safety (Off Tumor/On Target Toxicity)

CAR Construct Type CD28 (MSKCC) 4-BB (U Penn)

Comparisons of Efficacy and Persistence Unknown

Delivery Vector Lentivirus, Other Retrovirus CD3 Beads, Cytokines

EfficiencyUnknown Effect on Efficacy

T Cells (Bulk vs Subsets)Lymphodepleting Therapy Impact Always Significant

Control of Immune FunctionTumor Volume May Be Important




Adverse Events

Phase I 19-28z CAR-T After ASCT for Rel/Ref Aggressive B-NHL

• 11 patients with disease chemosensitive to relapse therapy

• Eligibility– PET positive disease after > 2 cycles of relapse

therapy, but PR by other criteria– Marrow involvement at time of relapse or

refractory disease and not an allo candidate• Phase I Study: Generate CAR using CD28 for

persistence, attached to activated scFv-C3zeta chain (19-28z CAR)

• Retrovirus used to insert CAR into T cell

Sauter et al. ASCO 2015, Abst 8515.

Potential Advantages of 19-28z CAR-T Cells Post-Ablative Chemotherapy and ASCT• After expansion of resultant CAR-Ts (weeks), cells

are infused following AutoSCT into eligible patients

• Potential advantages of this sequence– Modulation of a hostile immunosuppressive

tumor microenvironment• Elimination of regulatory T cells• Elimination of myeloid suppressor cells

– Elimination of cytokine “sinks” for optimized proliferative expansion of 19-28z CAR-T cells


Phase I 19-28z CAR-T After ASCT for Rel/Ref Aggressive B-NHL


Salvage Chemo Leukapheresis Generation of CAR-Ts

-7 -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +10

Hospital

BEAM

Pegfilgrastim

ASCT

Infusion 19-28z CAR-Ts

Anticipated Engraftment

Dose Levels-1 2 x 106

+ 1 5 x 106

+2 1 x 107

+ 3 2 x 107

Phase I CAR-Ts After ASCT for Rel/Ref Agg B-NHL: Patients and Results

• 11 patients enrolled, med age: 61 (34-75 years)• Pathology: DLBCL-5; tFL/MZL/CLL-4; BL-1; Blastoid

MCL-1.• Status prior to ASCT: 10 PR (2 with BM involved), 1

PET CR but with leukemic phase• Median prior therapies: 2 (range 2-4)• CAR-T doses: 10 receive 5 x 106 /kg, 1 receives 10/kg• Toxicity: 7/11 have CRS/CNS toxicity, 1 dies at 1 mo• Response (10 eval): CR – 6 patients; 2 CRs have PD• PFS: 10 eval, 4 CRs still in CR at 13, 15, 20, 21 mo


CAR-T Cells for Relapsed/Refractory CD19 Positive NHLs

• CTL019 engineered T cells contain:• Chimeric antigen receptor (CAR) specific

for CD19. • Activation and signaling via a CD3-zeta

domain.• Costimulatory signaling via a CD137 (4-

1BB) domain. • Other chimeric antigen receptor-modified T

cell therapy against CD19 has been effective in treating relapsed and refractory ALL and CLL.

Maude et al. N Engl J Med 2014; 371:1507-17.Grupp et al. N Engl J Med 2013; 368:1509-18.Porter et al. N Engl J Med 2011; 365:725-33.

Chimeric Antigen Receptor

(CAR)

CD19

CD3-ζ

Schuster et al. ASCO 2015, Abst 8516.

CAR-T Cells for Relapsed/Refractory CD19 Positive NHLs: Criteria for Entry

DLBCL• Progression after ASCT or ineligible for ASCT • Transformation from CLL/SLL or FL allowed

FL• > 2 prior regimens • Progression < 2 years after last therapy

MCL• Progression after ASCT • Any relapse or progression and ineligible for

ASCT or AlloSCT


Month +3 response assessment

CAR-T Cells for Rel/Ref CD19 Positive NHLs: Treatment Schema

CD19+ Lymphoma•Eligibility determination•Enrollment

Apheresis•Baseline immune assays

Restaging and Lymphodepleting ChemotherapyCT Scans and Bone Marrow. Therapy Physician Choice.

Ends 1-4 Days before CTL019 infusion

CTL019 Infusion, Monitoring and Response Assessments

Day 0

Month +1

Month +2 and +3evaluations

Quarterly f/u x 2 yr F/U 15 years

Adverse event monitoring

CTL019 infusion

= Clinical evaluation; immune/CTL019 assays

Day -1


CAR-T Cells for Rel/Ref CD19 Positive NHLs: Patient Features

Feature DLBCL (N=19) FL (N=8) MCL (N=3)

Med age, Yr (range) 56 (25 - 77) 61 (43-71) 55

Med # prior Txs (range) 4 (1 - 8) 6 (4-8) 4 (3-6)

Prior SCT, N (%) 7 (37) 2 (25) 1 (33)

Stage III-IV, N (%) 12 (63) 7 (88) 3 (100)

High LDH, N (%) 14 (74) 5 (63) 2 (66)

> 1 ENS, N (%) 6 (32) 1 (13) 3 (100)

Med PS (range) 1 (0 - 1) 0 (0-1) 1 (0-1)


DLBCL: ORR at 3 Mo 50% (N = 13) Best Response 50% (N = 13) - CR: 2- PR: 4- PD: 6- Response not yet assessed: 1

- CR: 5- PR: 1- PD: 6- Response not yet assessed: 1

• 3 PR at 3 mo converted to CR at 6; 1 PR at 3 mo had PD at 6

CAR-T Cells for CD19 Positive NHLs: Response Rates for DLBCL and FL

FL: ORR at 3 Mo 100% (N = 7) Best Response 100% (N = 7)

- CR: 3- PR: 4

- CR: 6- PR: 1

• 3 PR at 3 mo converted to CR by 6 mo; 1 PR at 9 mo had PD at 12


CAR-T Cells for Rel/Rel CD19 Positive NHLs: PFS Results for DLBCLs

N = 13Median PFS 90 days

1.00

0.75

0.50

0.25

0.000 100 200 300 400

Days


CAR-T Cells for Rel/Ref CD19 Positive NHLs: PFS Results for FLs

N = 7Median not reachedMedian follow-up 290 days

1.00

0.75

0.50

0.25

0.000 100 200 300 400

Days


AE G3 G4 AE G3 G4

Renal 2 Infections 2

Anemia 1 Hypophosphatemia 3 1

CRS 1 1 Hypotension 1 1

Delirium 1 Leukopenia 3 2

Fever 1 Lymphopenia 10 8

Hypertension 2 Neutropenia 3 6

Hypocalcemia 1 Thrombocytopenia 1

Hypokalemia 1 Transaminitis 1

Hyponatremia 1

CAR-Ts for Rel/Ref NHLs: Grade 3-4 AEs in > 2 Patients Regardless of Cause


Current CAR Studies for Lymphomas or Myelomas (2015)

• Seven centers have trials targeting CD19– NCI (Bethesda)– MSKCC (New York)– Fred Hutchinson (Seattle)– U Penn (Philadelphia)– City of Hope (Los Angeles)– Baylor (Houston)– MDACC (Houston)

• Multicenter Trials– Kite– Novartis

• One study targeting CD22 at NCI




Adverse Events

Classic Toxicity Associated with CAR-T Cell Therapy

• Cytokine Release Syndrome (CRS)– High fevers, hypotension, hypoxia– Mild Coagulopathy (Elevated D-Dimer, Low

Fibrinogen, C-Reactive Protein)– Hepatosplenomegaly, mild transaminitis– Elevated cytokines: IL-6, TNF

• Macrophase Activation Syndrome– High Ferritin levels– Moderate marrow hemophagocytosis (HLH)

Neurologic Symptoms Observed in CD19 CAR-T Trials

• Mental status changes associated with hypotension and fevers– Classically confusion; obtundation when severe – Occasionally mild, with focal neurologic changes,

including aphasia and myoclonus– Easiest identification: handwriting– Most resolve in days to weeks

• Exact cause unknown– Associated with larger tumor burden, marrow

involvement– Also thought to be off target toxicity, CARs found in

CSF

Unmet Needs in CAR-T Research• Improve Efficacy– Improve antigens or combinations– Improve CAR-T effector function and persistence.– Decrease immunosuppression in microenvironment

(better conditioning, humanization of scFv)• Improve Safety– Better understand causes/prevention of CRS and

neurotoxicity– Include safeguards (suicide genes) in next CAR-Ts

• Integrate into Standard Care and Improve Feasibility– Develop combination therapies– Study applicability beyond specialized centers




Adverse Events

Immunotherapy for Lymphoma: Finally?

F B Hagemeister, MDProfessor of Medicine

Department of Lymphoma and MyelomaM D Anderson Cancer Center

Bangkok 29 August 2015