CAR T-Cell Therapy:Efficacy, Treatment, Access

Michael I. Nishimura, Ph.D.Professor of Surgery and Vice Chair for Surgery Research

Stritch School of Medicine

Tumor Immunology & Immunotherapy ProgramCardinal Bernardin Cancer Center

Loyola University Chicago

Disclosures Basic, Translational, Pre-clinical and Clinical

studies supported in total or in part by following NIH grants: R01 CA90873 (MN, inactive) R01 CA102280 (MN, inactive) R01 CA107947 (MN, inactive) R01 CA107947 S1, ARRA Supplement (MN, inactive) P01 CA154778 (MN, inactive) R21 CA153789 (MN, inactive) R21 AR056624 (SM, inactive) R01 CA138930 (SM, inactive) R01 AR054749 (ICL, inactive) R01 AR057643 (ICL, inactive) R01 AI129563 (BB & MN MPI, active)

Lentivirus vector development studies supported by subcontracts from the Lentigen Corp. R43 CA126461 (BD, inactive) R44 CA126461 (BD, inactive)

CD19 CAR studies supported by a generous gift from the Leukemia Research Foundation

Basic, Translational and Pre-clinical studies supported in part by the following Department of Defense grant: Idea Development Award 110036 - W81XWH-

12-1-0185 (ICL, inactive)

Pre-clinical studies supported in part by a grant from the Falk Foundation: Catalyst Research Program Award (MN,

inactive) Transformtional Research Award (MN, active)

rhIL-15 and other cytokines for the preclinical studies and clinical trials generously provided by the Biological Resources Branch, DCTD, NCI

Conflict of Interest Consulted for Sanofi S.A. Chair SAB for T-Cure SAB for Moderna Therapeutics SAB for Anocca, AB

Acknowledgements

Med. Univ. South CarolinaShikhar Mehrotra

Amir Al KhamiNavtej Kaur

Pravin KesarwaniOsama Naga

Shahid HussainKeisuke Shirai

Elizabeth Garrett-Mayer

Nishimura LabGlenda Callender

Timothy ClayDavid Cole

Mary CusterAnnika DalheimMatthew DeJongTelma da Palma

Erica Fleming-TrujilloKendra Foley

Elizabeth GrindstaffElizabeth He Wood

Barbara KaplanAaron Lesher

Mingli LiGretchen Lyons

Mark McKeeTamson MooreKelly MoxleyDavid MurrayHakan Norell

Jeffrey RoszkowskiPablo Sanez-Lopez Larrocha

Gina ScurtiThomas SmithTimothy SpearNatalie Spivey

Mallory ThomasDavid Yu

Siao-Yi Wang

NHLBI, NIHRichard ChildsAdriana Byrnes

Elena CherkasovaRosa Nadal Rios

BRB, NCI, NIHJason Yovandich

Stephen Creekmore

Loyola UniversityMedical Center

Jose GeuvaraPhong Le

Clinical TeamJoseph Clark

Constantine GodellasNasheed HossainKelli HutchensAnn Lau ClarkKaren PilmanDiane Palmer

Mala ParthasarathyCourtney Wagner

Jodi SeiserPatrick Stiff

Univ. Colorado DenverHugo Rosen

Lucy Golden-MasonRachel Leistikow

Rachel H. McMahan

University of Notre DameBrian Baker

Fernando HuykeLance HellmanNishant Singh

Yuan Wang

Lentigen CorporationBoro Dropulic

Heather EmbreeRimas Orentas

University of UtahBrian Evavold

Elizabeth Motunrayo Kolawole

Northwestern University

I. Caroline Le PooleEmilia Dellacecca

Jonathan EbyJared Klarquist

Jeffrey Mosenson

Earle Chile Research Institute

Brendan CurtiChristopher Fountain

Bernard FoxTarsem Moudgil

Walter Urba

Karolinska InstituteRolf KiesslingYuneng Mao

Eiji Miyahara

Objectives 1) Brief History and Rationale for Adoptive T-Cell Therapy for Cancer

1. Overview of Cancer Immunotherapy2. Adoptive Cell Transfer Therapy

a) Stem Cell Transplantationb) Tumor Infiltrating Lymphocytes (TIL)

3. Lymphodepletion2) Reasons for Using Genetically Modifying T Cells

1. Altering Antigen Specificitya) Types of receptors used for gene therapyb) Chimeric Antigen Receptors

i. Evolution/Generations of CARii. Targets for CAR Therapyiii. Why CD19?iv. Clinical Outcomes

c) T Cell Receptorsi. Targetsii. Clinical Outcomes

3) Gene Modified T Cells – Loyola Experience1) Manufacture, purification, and tracking of transduced T cells in humans2) Clinical trial Design3) TCR gene modified T cell clinical trial results

– The immune system has evolved to enable us to fight various pathogens (virus, bacteria, fungus, etc.)

– The immune system must first know what is “normal self” before it can know what should be attacked

– Since cancer is derived from normal cells, with few exceptions, the immune system is not very efficient at recognizing and eliminating cancer cells naturally.

Immunotherapy For Cancer

Goal:To boost the host anti-tumor immune response leading to regression of widely disseminated disease and prevention of recurrent disease.

Approaches:1) Cytokines (IL-2, IFN-g, GM-CSF, and others)2) Vaccines (Peptide, recombinant protein, whole cell, cell extract,

dendritic cell, recombinant virus, and others)3) Monoclonal antibodies

a) Therapeuticb) Blocking

4) Adoptive cell transfer1) LAK2) T cells3) NK cells4) Stem cell transplantation (autologous, allogeneic, cord blood)

Immunotherapy For Cancer

Immunotherapy For Cancer

Allogeneic Stem Cell Transplant

Rezvani et al. Bone Marrow Transplant. 2015From Winthrop P. Rockefeller Cancer Institute Web Site

TIL Therapy

Rosenberg et. al., J Natl Cancer Inst ;85:622-632, 1993

Tumor Infiltrating Lymphocytes:– T cells are chemotactic and can

migrate to sources of antigen– Tumor-reactive T cells can

accumulate in tumor lesions– TIL cultures can recognize many

HLA matched tumors or only the autologous tumor

– TIL can be expanded from some tumors to therapeutic numbers

Total number Objective response rateTreatment of patients CR PR CR + PR

IL-2 134 9 14 23 (17%)

TIL + IL-2 86 5 24 29 (34%)Prior IL-2 28 1 8 9 (32%)No prior IL-2 58 4 16 20 (34%)

Rosenberg et al., JNCI 86:1159-1166, 1994

TIL Therapy

Lymphodepletion/Homeostatic Proliferation

Homeostasis:1) The hematopoietic system regulates the number of each cell

type in the blood, lymphoid organs, and bone marrow. 2) Depletion of one or more of these hematopoietic cell types

leads to mobilization of the progenitors to restore the population to normal.

Lymphodepletion:1) Chemotherapy and/or total body irradiation can destroy the

hematopoietic system leading to homeostatic proliferation of the depleted cell types.

Lymphodepletion Prior to T Cell Infusion

Advantages:1) The cytokines and other factors that drive the hematopoietic

system to regenerate also favor the expansion of the adoptively transferred T cells, both normal and gene modified.

2) Suppressor cells derived from the hematopoietic system (Treg, myeloid derived suppressor cells, etc.) are eliminated.

Disadvantages:1) Chemotherapy and/or total body irradiation leads to immune

suppression.2) Chemotherapy and/or total body irradiation has toxicities.

Rosenberg et al, Clin Can Res, 2011

Rx CRNMA 21/43 (49%)+2Gy 13/25 (52%)

+12 Gy 18/25 (72%)

Adoptive Cell TherapyTIL with Prior Lymphodepletion

Common Hurdle for Adoptive Cell Therapy

Facts:1) Tumor reactive T cells can be difficult to obtain from all patients. 2) TIL therapy requires a resectable tumor.3) Expansion of T cells to therapeutic numbers takes time. 4) Many cancers progress rapidly such that in many cases the

patient can be too sick for adoptive T cell therapy.

Conclusions:1) Despite the effectiveness of adoptive T cell transfer, this

approach is only practical for some patients.

Gene Modified T Cell TherapyAltering Antigen Specificity

Tumor cell

Antigenic Peptide

MHC Class Iβ2M Surface Antigen

T-cell

CD3TCRα β

Gene Modified T Cell TherapyAltering Antigen Specificity

Gene Modified T Cell TherapyAltering Antigen Specificity – The Receptors

V

C

HL

Immunoglobulin Chimeric Single ChainAntibody Receptor

scFv-Fcg scFv-CD3z

T Cell Receptor

a b

zged ze

CD3

ChimericActivatingReceptor

NKG2D-CD3z

ChimericLigand

Receptor

IL-13-CD3z

Advantages1) CAR T cells can be generated for

any patient that has T cells in a short period of time (~10-20 days)

2) Recognizes antigens in an MHC-unrestricted fashion

3) Supersensitive, requires very low antigen expression

4) Can target non-protein antigens 5) Can engineer functional CD4+ and

CD8+ T cells and non-T cells.

Disadvantages

1) CAR T cells can only recognize antigens expressed on the target cell surface

2) Associated with serious side effects, such as targeting normal cells expressing the target antigen

3) Risk of Cytokine Release Syndrome (CRS)

Gene Modified T Cell TherapyAdvantages and Disadvantages of CAR Therapy

Gene Modified T Cell TherapyAltering Antigen Specificity - CAR

T-cell

CD3TCRα β

pA

LTR

y+

LTR VL VH CD3ζ

Linker

CD3ζ

VL VH

CAR

Gene Modified T Cell TherapyAltering Antigen Specificity - CAR

Tumor cell

Antigenic Peptide

MHC Class Iβ2M Surface Antigen

T-cell

CD3TCRα β

CAR

Gene Modified T Cell TherapyAltering Antigen Specificity - CAR

Tumor cell

Antigenic Peptide

MHC Class Iβ2M Surface Antigen

T-cell

CD3TCRα β

Gene Modified Cell TherapyEvolution of CAR

T-cell

CD3TCRα β

First generation CAR

z chain

Second generation CAR

z chain

z chain

CD28

Third generation CAR

OX40CD284-1BBICOS OX40

4-1BBICOS

Gene Modified T Cell TherapyCAR Targets

BCMA Multiple MyelomaCAIX Renal CellCD19 Diffuse large B-cell lymphoma (DLBCL), Acute Lymphoblastic Leukemia (ALL)CD20 DLBCL, ALL, Mantle Cell Lymphoma (MCL)CD22 DLBCL, ALL, MCL, chronic lymphocytic leukemia (CLL)CD30 Hodgkins Lymphoma, Non-Hodgkin LymphomaCD70 Pancreatic/Renal Cell/Breast/Ovarian/MelanomaCD171 NeuroblastomaCEA ColonGD2 NeuroblastomaGPC3 Hepatocellular CarcinomaHer-2 Breast/OvarianLewis-Y Acute Myeloid Leukemia (AML)Mesothelin MesotheliomaPSCA ProstateROR1 CLL, MCL, ALL, Non-small Cell Lung Cancer, Triple Negative Breast Cancer

BCMA Multiple MyelomaCAIX Renal CellCD19 Diffuse large B-cell lymphoma (DLBCL), Acute Lymphoblastic Leukemia (ALL)CD20 DLBCL, ALL, Mantle Cell Lymphoma (MCL)CD22 DLBCL, ALL, MCL, chronic lymphocytic leukemia (CLL)CD30 Hodgkins Lymphoma, Non-Hodgkin LymphomaCD70 Pancreatic/Renal Cell/Breast/Ovarian/MelanomaCD171 NeuroblastomaCEA ColonGD2 NeuroblastomaGPC3 Hepatocellular CarcinomaHer-2 Breast/OvarianLewis-Y Acute Myeloid Leukemia (AML)Mesothelin MesotheliomaPSCA ProstateROR1 CLL, MCL, ALL, Non-small Cell Lung Cancer, Triple Negative Breast Cancer

Gene Modified T Cell TherapyCAR Targets

Gene Modified T Cell TherapyWhy CD19 as a CAR Target?

Frey, et al., Oncology, Vol 30, p.880-8, 890, 2016

Gene Modified T Cell TherapyCD19 CAR - Clinical Trial Outcomes

Clinical Responses1) Large numbers of objective

clinical responses2) Many responses are durable (CR)3) Clinical responses found in most

types of B cell malignancies4) Clinical responses found in both

adult and pediatric patients

Frey, et al., Oncology, Vol 30, p.880-8, 890, 2016

Gene Modified T Cell TherapyCD19 CAR - Clinical Trial Outcomes

Serious Adverse Events1) Cytokine release syndrome in all

or most patients2) Tumor lysis syndrome in some

patients3) Neurologic toxicity in some

patients4) Chronic B cell lymphopenia

Gene Modified T Cell TherapyCD19 CAR – Commercial Trial Outcomes

Maude et al., N Engl J Med, 2018

• B cell ALL– Results from multi-centered trials of centrally manufactured anti-CD19

CAR T cells have demonstrated a 70-93% completed response (CR) in relapsed or refractory B cell ALL.

– In Aug 30, 2017, FDA approved Tisagenlecleucel for treatment of relapsed or refractory B cell ALL in patients up to 25 years of age.

– Available follow-up data demonstrated that only 50% of patients remained in remission at one year.

Gene Modified T Cell TherapyCD19 CAR – Commercial Trial Outcomes

• Large B cell lymphomas– Results from multi-centered trials of centrally manufactured anti-CD19

CAR T cells have demonstrated 59-83% overall response rate (ORR) and 40-58% complete response (CR) in relapsed or refractory B cell lymphomas.

– In Oct 18, 2017, FDA approved Axicabtagene ciloleucel for relapsed or refractory large B cell lymphomas.

– In May 1, 2018, FDA expanded Tisagenlecleucel to include relapsed or refractory B cell lymphomas.

– In a large trial, at median follow-up duration of 27.1 months, only 62% of patients remained in a CR and the majority of patients achieving partial responses had progressed.

Locke et al., Lancet Onc, 2019

Gene Modified T Cell TherapyAltering Antigen Specificity – The Receptors

V

C

HL

Immunoglobulin Chimeric Single ChainAntibody Receptor

scFv-Fcg scFv-CD3z

T Cell Receptor

a b

zged ze

CD3

ChimericActivatingReceptor

NKG2D-CD3z

ChimericLigand

Receptor

IL-13-CD3z

TCR α TCR β

pA

LTR

ψ+

LTR TCRβTCRα2A

Gene Modified T Cell TherapyAltering Antigen Specificity - TCR

T-cell

CD3

EndogenousTCRα β

Introduced TCR

Mixed TCR

Gene Modified T Cell TherapyAltering Antigen Specificity - TCR

Tumor cell

Antigenic Peptide

MHC Class Iβ2M Surface Antigen

T-cell

CD3TCRα β

Gene Modified T Cell TherapyAltering Antigen Specificity - TCR

Tumor cell

Antigenic Peptide

MHC Class Iβ2M Surface Antigen

T-cell

CD3

EndogenousTCRα β

Introduced TCR

Mixed TCRCD34t

Gene Modified Cell TherapyTCR Targets

CEA Colongp100 MelanomaHer-2 Breast, ovarian, colon, lungHERV-E RenalhTERT Many human tumorsMART-1 MelanomaMAGE-3 Melanoma and othersMAGE-A4 EsophagealNY-ESO-1 Sarcoma, melanomap53 Many human tumorsPRAME Melanoma, AML, MDS, MMTyrosinase MelanomaWT-1 ALL, AML, MDS

Group Target Disease Objective Response RateAarhus, Denmark MART-1 melanoma 1/15 (7%)Duval et al, 2006

NIH/NCI MART-1 melanoma 2/15 (13%)Morgan et al, 2006

NIH/NCI MART-1 melanoma 6/20 (30%)Johnson et al, 2009 gp100 melanoma 3/16 (19%)

NIH/NCI CEA Colorectal 1/3 (33%)*

Parkhurst et al, 2011

NIH/NCI MAGE-A3 melanoma 5/9 (56%)*

Morgan et al, 2013

U Penn/Adaptimmune MAGE-A3 myeloma and melanoma 0/2 (0%)*

Linette et al, 2013; Cameron et al, 2013

NIH/NCI NY-ESO-1 synovial cell sarcoma 11/18 (61%)Robbins at al, 2015 melanoma 11/20 (55%)

Mie, Japan MAGE-A4 esophageal 0/10 (3 with SD)Kageyama et al, 2015

Gene Modified Cell TherapyTCR Clinical Trial Results

1) Unique Feature of our Clinical trials1) Marker genes allow for purifying and tracking transduced T cells2) Fresh cell products3) Altered cytokines (growth factors)4) Exact dosing of transduced T cells (CD34t expressing T cells per kg)5) Deliver specific T cell subsets6) Reduced Cost to the Patient

2) Two Phase I clinical trials have been initiated treating patient at three sites1) HLA-A2 restricted, tyrosinase reactive TCR for melanoma patients at Loyola and Portland

Providence2) HLA-A11 restricted, HERV-E reactive TCR for renal cell carcinoma patients at the NHLBI/NIH

3) Three more Phase I Trials are near starting or in process1) Various CD19 CAR constructs for B cell lymphomas2) IL-13 CAR for glioblastoma3) HLA-A2 restricted, hTERT reactive TCR for pancreatic cancer and other solid tumors

Gene Modified Cell TherapyLoyola Experience

T-cell

CD3TCRα β

TCR α TCR βpA

LTR

ψ+

LTR TCRβ CD34tTCRα2A 2A

CD34t

Gene Modified Cell TherapyAltering Antigen Specificity TCR

CD34tCD3ζ

VL VH

CAR

Ψ+

LTR VL VH CD3ζ

pA

LTRCD34t2A

TCR α TCR βpA

LTR

ψ+

LTR TCRβ CD34tTCRα2A 2A

CD34t

Gene Modified Cell TherapyAltering Antigen Specificity TCR

CD34tCD3ζ

VL VH

CAR

Ψ+

LTR VL VH CD3ζ

pA

LTRCD34t2A

T-cell

CD3

EndogenousTCRα β

Introduced TCR

Mixed TCR

CD34t

Gene Modified Cell TherapyEnriching for TCR Transduced T Cells

CD34Vβ12

TRP-1

mergeDAPI

CD3

biopsy. biopsy.

Moore et al, Cancer Immunol. Immunother, 2018

Gene Modified Cell TherapyDose Level I – Patient 2&3

0.01

0.1

1

10

100

0 10 20 30 40

0.01

0.1

1

10

100

0 10 20 30 40

0.01

0.1

1

10

100

45 145 245 345 445 545

0.01

0.1

1

10

100

45 145 245 345 445 545

%C

D34

+C

ells

Days Post-infusion

Dose Level TIL 1383I TCR HERV-E TCR CD19 CAR

I 2.5x106 T cells/kg 1.0x106 T cells/kg 0.5x106 T cells/kg*II 7.5x106 T cells/kg 5.0x106 T cells/kg 1.0x106 T cells/kgIII 25.0x106 T cells/kg 10.0x106 T cells/kg 1.5x106 T cells/kgIV 75.0x106 T cells/kg 50.0x106 T cells/kg 2.0x106 T cells/kgV 3.0x106 T cells/kg

Gene Modified Cell TherapyPhase I Clinical Trial Doses

Patient TIL 1383I HERV-E1 2.0x108/CD34+ T cells - NR 1.06x108/CD34+CD8+ T cells - SD2 2.86x108/CD34+ T cells - PR* 8.25x107/CD34+CD8+ T cells - SD 3 2.06x108/CD34+ T cells - MR* 7.58x107/CD34+CD8+ T cells - PD4 5.79108/CD34+ T cells - NR5 8.42x108/CD34+ T cells - NR6 5.90x108/CD34+ T cells - NR7 1.76x109/CD34+ T cells - NR

Gene Modified Cell TherapyPhase I Clinical Trial Outcomes

R Axillary LNApril 2, 2014

Day -15May 15, 2014

Day +28

Moore et al, Cancer Immunol. Immunother, 2018

Gene Modified Cell TherapyDose Level I – Patient 2

R Apical Lung NoduleApril 2, 2014

Day -15May 15, 2014

Day +28

Moore et al, Cancer Immunol. Immunother, 2018

Gene Modified Cell TherapyDose Level I – Patient 2

R Minor Fissure Lung NoduleApril 2, 2014

Day -15May 15, 2014

Day +28

Moore et al, Cancer Immunol. Immunother, 2018

Gene Modified Cell TherapyDose Level I – Patient 2

L Chest Subcutaneous NodulesApril 2, 2014

Day -15May 15, 2014

Day +28

Moore et al, Cancer Immunol. Immunother, 2018

Gene Modified Cell TherapyDose Level I – Patient 2

Gene Modified Cell TherapyDose Level I – Patient 2

Pre-treatment baseline Day 60 post HERV-E T-cell treatment

Clinical Resolution of Chest painDecreased rib metastasis SUV

Gene Modified Cell TherapySummary

1) Gene modified cells are here to stay2) The process of genetically modifying T cells leads to a safe and

effective product3) T cells can be genetically modified to recognize almost any target4) Adoptive transfer of CAR and TCR transduced T cells can lead to

objective clinical responses5) Adoptive transfer of CAR and TCR transduced T cells6) Strategies are being developed to better predict if a CAR or TCR

will target normal cells and use questionable ones more safely