Adoptive cellular therapies

Carl H. June, MDRichard W. Vague Professor in ImmunotherapyDepartment of Pathology and Laboratory Medicine Director, Center for Cellular Immunotherapies Director, Parker Institute for Cancer ImmunotherapyUniversity of Pennsylvania Perelman School of MedicinePhiladelphia, PA

IMMUNOTHERAPY: TRANSFORMATION OF THERAPIES FOR BLOOD CANCER

Disclosures§ I disclose the following relationships

§ Novartis: Grants/Research Support§ Novartis: Royalty Recipient§ Tmunity: stockholder

§ I will discuss investigational use in my presentation:§ CTL019, CART-BCMA

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IMMUNOTHERAPY: TRANSFORMATION OF THERAPIES FOR BLOOD CANCER

Goals

§ The purpose of this presentation is to§ Provide update on states of adoptive cell therapy

§ After this session, learners should be better able to§ Understand toxicities from CD19 directed CAR T cells§ Manage cytokine release syndrome§ Awareness of need for immunoglobulin replacement therapy in

patients with persistent B cell aplasias

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Deep Pipeline of Cancer Immunotherapies

(multiple)

Nature Reviews Drug Discovery (2016) doi:10.1038/nrd.2015.35

Adoptive Cell Therapy: 3 Approaches in Advanced Development

Science Trans Med, 2015

Other Investigational Adoptive Cellular Therapies in Hematologic Malignancies*

Agent Sponsor Phase Cancer Type Trial ID

KTE-C19 Kite2 NHL ZUMA-1

1/2 ALL ZUMA-3

JCAR014

Juno

1/2 CLL, ALL, NHL NCT01865617

JCAR015 2 ALL ROCKET

JTCR016 1/2 AML NCT01640301

NY-ESO TCR Adaptimmune 1/2 MM NCT01352286

BB2121 Bluebird Bio 1 MM NCT02658929

*Clinicaltrials.gov

Design of CAR T Cells

Using Synthetic Biology to Overcome ToleranceCreation of Bi-specific CAR T cells

Extracellular

Intracellular

First GenerationCD4 / CD8z CARs

VH

VLV

L

VHVH

VLV

L

VH

First GenerationscFv CARs

VH

VLV

L

VHVH

VLV

L

VH

Second GenerationscFv BBz CARs

4-1BB

Finney, 2003Imai, 2004Milone, 2009Carpenito, 2009

CD28

VH

VLV

L

VHVH

VLV

L

VH

Second GenerationscFv CD28z CARs

Roberts, 1995Finney, 1998Maher, 2002

CD27ICOS

VH

VLV

L

VHVH

VLV

L

VH

Second GenerationscFv CD27z CARsscFv ICOSz CARs

Song, 2012Guedan, 2014Duong, 2013

Kuwana, 1987Eshhar, 1993

Irving & Weiss, 1991Letourneur, 1991Romeo, 1991

Essential factors for augmenting adoptive immunotherapy

Which LymphocyteSubset?

Optimize Ex Vivo Expansion

Synthetic Biology: Genetic Reprogram

The cell culture technology and lymphocyte subset may be more important than signaling domains for CAR T persistence!

Cumulative Patient Safety: Exposure to Genetically Modified T cellsUniversity of Pennsylvania (as of May 2016)

Pharmacovigilance

Trial EngineeredTCell #PatientsInfused Safety(Patient-Years)CD4zCAR(HIV) RetroviralCAR 44 745.6SangamoZFNCCR5(HIV) Ad5/35zincfingernuclease 12 65.0SB-728mRCCR5ZFN CCR5ZFN 7 3.1MAZ-Takara(HIV) RetroviralMazF 10 14.1VirxSysVRX496(HIV) LentiviralantisenseHIVenv 20 186.9Adaptimmune(HIV) LentiviralgagTCR 2 9.1AdaptimmuneNY-ESO-1 LentiviralNY-ESO1TCR 21 79.3NovartisCTL019(tisagenlecleucel-T) Lentiviral19:BBzCAR 224 335.5UPCC19214CART-MESO-19 CART-MESO-19 3 2.1UPCC31213 CART-MESO 15 16.6

Total 368 1457

CART19 (tisagenlecleucel-T ): Overview

Patient DonatesCells

Genetic engineeringExpand T cells

T cell transfusion

Porter, 2011Grupp, 2013Maude, 2014Garfall, 2015

July 31, 20101st CART19 Infusion

SyntheticBiology

PediatricOncology:

ALL

Adult Oncology:ALL, CLL, DLBCL,

MCL, Myeloma

CVPF

Cytokine Release Syndrome

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CTL019 Phase I Trial for r/r CLL: 5 yr follow upSummary of patient baseline characteristics

N= 14 patients, protocol 04409 (NCT01029366)

§ Overall response rate: 57%

§ CR 4/14 (28%)

§ PR 4/14 (28%)

§ NR 6/14 (43%)

Characteristics Statistics, N(%)N 14Age at infusion in years

Mean (SD)Median (range)

66.9 (8.1)66 (51-78)

GenderMaleFemale

12 (85%)2 (14%)

Number of prior therapiesMean (SD)Median (range)

5.3 (2.8)5 (1-11)

P53 or 17p deletionNoYes

8 (57%)6 (43%)

IGHV mutationNo YesUnknown

9 (64%)4 (29%)1 (7%) Porter et al, Science Trans Med 2015

Long term persistence and expression of CTL019 is associated with durable remission in leukemia: Predictive Biomarker

CAR T Persistence for first year after infusion

copi

es /

mcg

gDNA

1e+1

1e+2

1e+3

1e+4

1e+5

1e+6

01-CR

ggD

NA

1e+1

1e+2

1e+3

1e+4

1e+5

1e+6

03-PR

ggD

NA

1e+1

1e+2

1e+3

1e+4

1e+5

1e+6

06-NR 07-NR

05-PR

Months (post infusion)0 2 4 6 8 10 12

25-NR

10 120 2 4 6 8

ggD

NA

1e+1

1e+2

1e+3

1e+4

1e+5

1e+6

18-NR

Months (post infusion)

02-CR 09-CR 10-CR

12-PR 22-PR

Months (post infusion)

0 2 4 6 8 10 12

17-NR

Months (post infusion)

0 2 4 6 8 10 12

14-NR

copi

es /

mc

copi

es /

mc

copi

es /

mc

Porter et al, Science Trans Med 2015

HighResponseRateinRefractory ALL

Youngadult/pediatricphase1:

• 93%CR(57/60pts)

• 22%earlyBcellrecovery(<6months)

• 15%CD19+relapse

DurationofBCellAplasiaisaPredictiveBiomarkerinALL

Mechanisms of Resistance to CD19 CAR T cells

§ Loss of CAR T engraftmentØ Immunogenicity of CAR transgeneØ Exhaustion of CAR T cellsØ Manifest by loss of B cell aplasia

§ Target lossØ CD19 escape Ø Observed in ALL but not CLLØ Prevented by combinatorial targeting?

§ CAR B Cells

Mechanism of resistance in ALL: CD19 escape

Grupp,etal.NEJM2013.Sotilloetal. CancerDiscovery 2015

By flow cytometry, the CD19escape variants lack the epitope recognized by theCAR T cell

PREDICTED PROTEIN PRODUCTS FOR ISOFORMS• CD19 escape is a

combination ofmutations andshifts in splic ingthat favor retainingsome CD19 protein

• DNA mutations canbe subclona l, andmay include splicefactors sites

CART19 Toxicities - I

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§ B cell aplasiaØ observed in all responding patients to dateØ long-lived plasma cells may survive

Ø managed with IVIG replacement therapy

§ Tumor lysis syndrome (TLS)Ø may be delayed for 20 to 50 days post infusion

§ Macrophage activation syndrome (HLH / MAS)Ø elevated serum ferritin (>500,000 ng/ml), CRP, D-dimer, IL-6, IFN-gamma

§ Cerebral edema: JCAR15 ?

A B

DC

Anti-Streptococcus pneumoniae IgG

0

20

40

60

80

100200250

10

0 90 180

UPCC04409-2UPCC04409-3UPCC04409-5UPCC04409-26UPCC04409-27UPCC04409-31

Day post-CTL019

mg/

L

Anti-Tetanus Toxoid IgG

0

1

2

3

4

0.010 90 180

UPCC04409-2UPCC04409-3UPCC04409-5UPCC04409-26UPCC04409-27UPCC04409-31

Day post-CTL019

mg/

L

Anti-Measles IgG

0 90 180120

UPCC04409-2UPCC04409-3UPCC04409-5UPCC04409-26UPCC04409-27UPCC04409-31

1000

2000

3000

Day post-CTL019

mIU

/mL

Anti-HSV1/2 IgA

0 100 200 300 4000

50

100

150 UPCC04409-27UPCC04409-31CHP959-107CHP959-115CHP959-125

CHP959-115IVIg Monthly

CHP959-107IVIg Monthly

Day pre/post-CTL019

U/m

l

30

CART19 Toxicities – IICD19 Independent Long-lived Plasma Cells

• Patients with persistent B cell aplasia

• Antigen-specific antibody titers at baseline and after CTL019 infusion

• Adults may not require IVIG?

VG Bhoj et al, Blood 2016

CART19 Toxicities - III

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§ Cytokine release syndrome (CRS)Ø Reversible, on-target toxicityØ Severity related to tumor burden: Treat MRD as outpatient?Ø Cytokine blockade: Therapeutic tocilizumab or pre-emptive tocilizumabØ Role for Jakinibs: RuxolitinibØ Source of IL-6

CART19: ALL Patient #1

Day (post infusions)

0 5 10 15 20 25 30

Seru

m C

ytok

ine

(fold

cha

nge

from

bas

elin

e)

10-1

100

101

102

103

IL-2 IL-6 IFN-g IL-2Ra TNF-a

CHP #100

Grupp et al NEJM 2013 May 2016

April 2012

CART19 Toxicities: Dermatologic

Rubin, C. B., et al. "Evaluating the skin in patients undergoing chimeric antigen receptor modified T-cell therapy." J Am Acad Dermatol 75(5): 1054-1057, 2016.20

§ “Eruption of lymphocyte recovery”

International Phase II Trial to Determine Efficacy and Safety of CTL019 in Relapsed and Refractory B-cell ALL (ELIANA)

US sites• Children’s Hospital of Philadelphia• Cincinnati Children’s Hospital• University of Wisconsin• Children’s Medical Center of

Dallas/UTSW• Children’s Mercy Kansas University• Oregon Heath & Science University• Stanford University• University of Minnesota• Children’s Hospital Los Angeles• University of Michigan• Duke University Clinicaltrials.gov NCT02435849

Protocol closed to enrollmentNovartis

Ex- US(Canada, Australia, EU, Japan)• Royal Children’s Hospital (Australia)• Hospital St. Justine (Canada)• Ghent University (Belgium)• Oslo Univ. Hospital (Norway)• Kyoto (Japan)

Moving beyond leukemia: CAR T for myeloma*

* clinicaltrials.gov

Institution CAR Protocol TitleNCT02135406UPENN

CART19 Pilot Study of Redirected Autologous T Cells Engineered To Contain Anti-CD19 Attached To TCRζ And 4-1BB Signaling Domains Coupled With Salvage Autologous Stem-Cell Transplantation (ASCT) In Multiple Myeloma Patients With Early Relapse/Progression After Initial ASCT

NCT02215967NCI

CART BCMA A Phase I Clinical Trial of T-Cells Targeting B-Cell Maturation Antigen for Previously Treated Multiple Myeloma

NCT02546167UPENN

CART BCMA Pilot Study of Redirected Autologous T Cells Engineered To Contain an Anti-BCMA scFv Coupled To TCRζ And 4-1BB Signaling Domains in Patients With Relapsed and/or Refractory Multiple Myeloma

NCT02658929NCI / Bluebird Bio

CART BCMA A Phase 1 Study of bb2121 in BCMA-Expressing Multiple Myeloma

NCT01886976Chinese PLA General Hospital

CART 138 Clinical Study of Chimeric CD138 Antigen Receptor-modified T Cells in Relapsed and/or Chemotherapy Refractory Multiple Myelomas

BCMA (B-cell maturation antigen)

Maus and June, Clin Cancer Res 2013

CART-BCMA Cells for Multiple Myelomaclinicaltrials.gov NCT02546167

§ Pilot, first-in-human, 3+3 dose-escalation study

§ n=12-18 rel/ref MM patients (≥ 3 priors)

§ Primary obj: Safety

VH Linker VL CD8aHinge and TM 4-1BB CD3zSignal

seq.

Anti-BCMA scFv

Adam Cohen Michael Milone

CART-BCMA Cells for Multiple MyelomaSubject #1

Interim results

§ Grade 3 CRSà responded to tocilizumab

§ Robust CART-BCMA expansion and persistence: similar to CART19

§ Ongoing sCR (6+ months)

CD8

BC

MA

-CA

R

Pre-tx Day 7

PB CART cells

Day

Seru

m M

-spi

ke

(g/d

L)

IgG

(mg/

dL)

Summary§ As few as one CD19 CAR T cell can eliminate leukemia and lymphoma

§ CAR T directed to CD19 and BCMA have potent activity in myeloma

Challenges and Opportunities: Cell Transfer § In 2017, FDA approval expected for CD19 CAR T cells for

numerous indications: =>challenging logistics of implementing personalized cellulartherapy for widespread application (lessons from Sipuleucel-T)

§Universal “3rd Party” Cells: can off the shelf cells have effects in blood cancers?

§Scale-out issues for manufacturing gene modified autologous T cells:ÞTime frame for fully automated and robotic manufacturing?

Colleagues and Patients: Thank you!PENNMedicineDavidPorterNoelleFreyLynnSchuchter

GillLabSaarGillMarcoRuellaOlgaShestova

LymphomaTeamEliseChongSunita NastaJakubSvobodaMariuszWasikDanLandsburgAnthonyMatoStephenSchuster

CenterforCellularImmunotherapiesAnneChewReginaYoungDanaHammillKatieMarcucciOmkarKawalekarAveryPoseyJohnSchollerShannonMcGettighanBiliangHuAnthonyLinMauroCastellarinGabrielaPlesa

TCellEngineeringYangbingZhaoJiangtaoRenChongyun FangXiaojunLiuShuguangJiang

MiloneLabMichaelMiloneRoddyO’ConnorSabaGhassemiSeleneNunez-Cruz

MyelomaTeamAdamCohenAlGarfallMichaelMiloneEdwardStadtmauer

CVPFBruceLevineDonSiegelSuzetteArosteguiTheresaColligonClareTaylorAnneLamontagneAlexMalykhinMattO’Rourke

PDCSJosMelenhorstSimonLaceyJosephFraietta

JohnsonLabLauraJohnsonAlexCogdillAlinaBoesteanu

CHOPStephanGruppDavidBarrettShannonMaude

NovartisUsmanAzamCelesteRichardsonJensHasskarlReshmaSinghKeithMansfieldJenniferBrogdonGlennDranoffBillSellersJayBradner