Paola Neri, MD, PhD

Associate Professor of Medicine

University of Calgary

Arnie Charbonneau Cancer Institute

How to optimize immunotherapy

approaches in Myeloma

Paola Neri MD, PhD

• Grants/research support: MMRF, CIHR, LLS

• Speakers bureau/honoraria: Amgen, Celgene, Janssen, Takeda

• Consulting fees: Celgene, Janssen, Takeda

Disclosures

Immune deregulation in multiple myeloma

➢ Disease progression from MGUS to Myeloma

➢ Response to immune-based therapeutics:

✓ anti-CD38 monoclonal antibodies

✓ checkpoint inhibitors

✓ CAR-T cell therapies

Strategies to reverse immune tolerance / deregulation in

myeloma

Outline

Mechanisms of Tumor Escape in Myeloma

• ⇣⇣⇣ expression tumor antigens

• ⇣⇣⇣ expression of HLA

costimulatory molecules

• Shedding of MHC class I chain-

related protein A (MICA)

• ⇡⇡⇡ surface inhibitory ligands

Inadequate T-cell stimulation

and Impaired cytotoxicity

• ⇣⇣⇣ CD4:CD8 ratio

• ⇣⇣⇣ of stem-like (Tscm) and effector

memory (TEM) T cells

•

• ⇡⇡⇡ in terminal effector T cells

• T-cell exhaustion /senescence

• ⇡⇡⇡ Th17

• Recruitment of IS cells (T-regs, MDSCs,

pDCs)

Induce Tumor escape

BM Milieu MM cells

Kumar S et al, Nature Reviews 2017

MGUS is genetically similar to Myeloma with an overall lower levels of genetic abnormalities

Mikulasova A et al, Haematologica 2017

Mutational load does not vary significantly

in the transition from MGUS to MM

Hierarchical model of human T cell differentiation

Gattinoni L et al Nature Med 2016

Decreased memory T cells and increased terminal effectors in

MGUS & MM compared to healthy donors

Bailur J et al, JCI Insight 2019

Expression of TCF1 is increased among memory T cells in the MGUS cohort

Decreased memory T cells stemness

in the transition from MGUS to MM

Bailur J et al, JCI Insight 2019

Depletion of Tscm and increase in TEF/TE correlates

with progression from MGUS to MM

Bailur J et al, JCI Insight 2019

T cells stemness is essential to repress clonal escape & sustain

effective anti-tumoral immune response

Gattinoni L, et al. Nature Reviews Cancer. 2012

Mechanisms of resistance to anti-CD38 monoclonal antibodies:

Role of T cells

Krejick J et al Blood. 2016

Krejick J et al Blood. 2017

Caseneuf T Blood Advances 2017

Nijhof R Clin Canc Res 2014

Daratumumab resistance in MM

Role of CD38 expression ?

Nihjov I et al Blood 2016, 128:959-970

Horenstein AL et al. Cells. 2015;4:520-537

Krejcik J et al. Clin Cancer Res; 2017; 23; 1–14

Higher CD38 expression (MFI) on myeloma cells was associated with better response ( ≳ PR) in daratumumab treated patients.

CD38 expression cannot be used as a predictor of depth or duration of response to daratumumab due to:

• overlap in CD38 expression between responders and non-responders.

• Rapid depletion in CD38 expression post daratumumab therapy in all patients.

How does anti-CD38 therapy affect the myeloma BM Immunome?

• Serial BM aspirates (n=16) from lenalidomide refractory /relapsed patients treated with daratumumab + Pomalidomide

(MM014 trial) prior to initiation of therapy, C3D1 and at relapse.

• Paired-end sequencing; median 97,237 reads /per cell & 2599 cells per sample

• Cell Ranger Single and Seurat were used for sample de-multiplexing, barcode processing, single-cell 3′ gene counting and data

analysis. Monocle and Velocyto were applied for trajectory analysis and cell diffusion.

CD 138+ cells

CD 138 - cells

Bone Marrow

Ficoll

gradient

separation

Mononuclear

Fraction

Single-cell RNA-seq

Single-cell RNA-seq

CD3 + cellsTCR Single-cell RNA-seq

10X GemCode system

Single-cell ATAC-seq

Single-cell CNV

Single-cell ATAC-seq

Tirosh I et al Science 2016;352:189-96

Neri P, Alberge JB, Bahlis N. Unpublished work

Daratumumab resistance & T cellsT cells subsets

Daratumumab resistance & T cells

Neri P, Alberge JB, Maity R, Bahlis N. Unpublished work

CD27pos SELLneg Effector Memory T cells are significantly more expanded in sensitive patients

T cells checkpoint inhibitors expression

LAG3 > TIGIT > PDCD1 > HAVCR2

Neri P, Alberge JB, Maity R, Bahlis N. Unpublished work

Daratumumab resistance & T cell exhaustion

Neri P, Alberge JB, Maity R, Bahlis N. Unpublished work

T cells in Daratumumab and IMiDs refractory patients are largely exhausted (loss of CD28 and high expression of LAG3)

TFs mediating exhaustion in T cells: TBX21high EOMEShigh TCF7low

Neri P, Alberge JB, Maity R, Bahlis N. Unpublished work

Cohen A et al, JCI 2019

T-cells subsets and CART-BCMA therapy

Phase I study of autologous T cells lentivirally transduced with a fully human,

BCMA-specific CAR containing CD3ζ and 4-1BB signaling domains

Cohen A et al, JCI 2019

CAR-T associated with

expansion and response:

1. higher CD4/CD8 T ratio

2. higher % of

CD27+CD45RO- CD8+

cell (naïve/stem cell)

Patients with higher number of naïve and stem cell memory T cells have a

robust in vivo CAR-T expansion and clinical response

Antigen escape as mechanism of relapse

Majzer R et al, Cancer Discovery 2018

Antigen drifting / editing and immune escape

Brudno J et al, JCO 2018

Strategies to reverse T cells

tolerance / deregulation in multiple myeloma

LAG3 Blockade promotes T cell activation in

an autologous myeloma and T cell co-culture systemControl Ab LAG3 blocking Ab

Neri P, Alberge JB, Maity R, Bahlis N. Unpublished work

Miller B et al, Nature Immunology 2019

Progenitor (but not terminally) exhausted CD8+ T cells

are associated with response to checkpoint inhibitors

Pro

port

ion

of

cyto

toxic

CD

8 T

cells

p = 0.025

GZMB expressing cytotoxic T cells

Terminally exhausted cytotoxic T cells are expanded in

Daratumumab resistant (but not sensitive) patients

Neri P, Alberge JB, Maity R, Bahlis N. Unpublished work

TGFβ attenuates tumor response to PD-L1 blockade by contributing to exclusion of T cells

Mariathasan S et al, Nature 2018

Anti-TGFβ and anti-PD-L1 treatment promote tumor regression

- human antigen-recognition domains to reduce immunogenicity

- bb21217 cultured with PI3 kinase inhibitor, bb007, to enrich for T cells displaying a memory-like phenotype

- TET2 modification can improve T cell stemness and persistence

Modifying manufacturing techniques to generate more phenotypically favorable

CAR-T cell

Fraietta J et al, Nature 2018

Open clinical questions

More effective clinical responses to IOs in subjects with a less differentiated, more stem-like

rather than terminal effector T cells

o Immune modifying strategies should be applied early at diagnosis or even pre-MM

transition?

o Consider harvesting and storage of T cells early in the disease course for later use

in CAR T manufacturing?

o Continue to investigate checkpoint inhibitors in MM? appropriate selection of

checkpoint inhibitor and better predictive tools of responders.

Acknowledgments

Collaborators

Stephane Minivielle (Nantes)

Philippe Moreau (Nantes)

Lawrence Boise (Emory)

Benjamin Barwick (Emory)

Anjan Thakurta PhD (Celgene)

Christopher Chiu PhD (Janssen)

Our Patients

Multiple Myeloma Research Foundation

Canadian Institute of Health and Research (CIHR)

Southern Alberta Multiple Myeloma Society

Funding Agencies

Dr Ranjan Maity, PhDDr Nizar Bahlis, MD Jean Baptiste Alberge, MSc