melanoma, o status da imunoterapia e o futuro...

III International Symposium on Immuno-Oncology

Saturday, October 7th 9:30 – 10:00 am

Melanoma, o status da imunoterapia

e o futuro próximo

Antoni Ribas, M.D., Ph.D.

Professor of Medicine, Surgery, Molecular and Medical Pharmacology

Director, Tumor Immunology Program, Jonsson Comprehensive Cancer Center (JCCC)

Director, Parker Institute for Cancer Immunotherapy (PICI) Center at UCLA

University of California Los Angeles (UCLA)

Chair, Melanoma Committee at SWOG

Overall Survival: Metastatic Melanoma

Phase III Studies

1. M. Middleton Ann Oncol 2007;18:1691. 2. Hodi FS et al NEJM 2010;363:711. 3. Schadendorf D et al JCO 2015:33:1889. 4. Robert C et al NEJM 2011;364:2517. 5. Maio M et al. JCO 2015; 33:1191. 6. Chapman PB et al Poster presentation SMR 2015. 7. Hauschild A et al Poster presentation ESMO 2014. Abstract 1092. 8. Atkinson V et al Poster presentation SMR 2015. 9. Hodi FS et al Oral presentation AACR 2016. Abstract CT001. 10. Carlino M et al Oral presentation AACR 2016. Abstract CT004. 11. Long GV Lancet Oncol 2016. 12. Ascierto PA et al Lancet Oncol 2016:17:1248. 13. Larkin J et al AACR 2017:1558. 14. Schachter J et al Oral presentation ASCO 2016. Abstract 9504. 15. Flaherty K et al Oral presentation ASCO 2016. Abstract 9502.16. MacArthur GA et al. Poster presentation SMR 2016

25–35%156%

670%7

2012 2013

46%2 47%4

2010 2011

71%8

2014

71%10 Pembrolizumab

74%11 Dab + tramd

75%12 Vem + cobi

2015

24%2 29%4 Ipi 45%715%1 53%11 Dab + tram2-year OS

55%14 Pembrolizumab

58% Nivo8

48%12 Vem + cobi

3-year OS

2017

5-year OS

73%13 Nivo + ipi

22%3

1990

35%9 Nivo (ph I)

44%15 Dab + tram

64%13 Nivo + ipi

1-year OS

18%5 Ipi

30%6

©Georgina V Long, MIA

2016

37%16 Vem + cobi

Dabrafenib + trametinib1 (n = 352)

Vemurafenib + cobimetinib5 (n= 247)

Nivolumab2 (n = 210)

Nivolumab3 (n = 316)

aPembrolizumab4 (n = 279)

1. Robert C Oral ESMO 2016. 2. Atkinson et al Poster SMR 2015. 3. Larkin J et al Oral AACR 2017.

4. Schachter J et al Oral ASCO 2016. 5. Ascierto PA et al Lancet Onc 2016.

PF

S, pro

babili

ty

Time from randomisation, months

Nivo + ipi3 (n = 314)

0.0

1.0

0.8

0.6

0.4

0.2

0 6 12 3018 24 36 42 48

45-50%

40-45%

50%

30%

39%

43%

24%

High LDHHigh tumour volume More metastatic sitesBrain metastasesPD-L1 negative/lack of immune signature

Normal LDHLow tumour volume Fewer metastatic sitesCR to treatment

©Georgina V Long, MIA

CTLA-4 and PD-1 Checkpoint Blockade

Abril-Rodriguez and Ribas, Snapshot, Cancer Cell 2017

Checkmate 067: Progression-Free Survival

50%

43%

18%

43%

37%

12%

Perc

en

tag

e o

f P

FS

Months

0

10

20

30

40

50

60

70

80

90

100

0 3 6 9 12 15 18 363024 332721

0IPI

NIVO+IPI (N=314) NIVO (N=316) IPI (N=315)

Median PFS, mo (95% CI)11.7

(8.9–21.9)6.9

(4.3–9.5)2.9

(2.8–3.2)

HR (95% CI) vs. IPI0.42

(0.34–0.51)0.54

(0.45–0.66)--

HR (95% CI) vs. NIVO0.76

(0.62–0.94)-- --

Pro

gre

ssio

n-f

ree S

urv

ival (%

)

5162730333543465877136315

Patients at risk:

0NIVO 16628897103107112120132151178316

0NIVO+ IPI 1671104110118125132137156176218314

NIVO+IPI

NIVO

IPI

Database lock: Sept 13, 2016, minimum f/u of 28 monthsLarkin et al. AACR 2017, Wolchok et al. NEJM 2017

Grade 3/4 tox:

59%

21%

28%

Checkmate 067: Overall Survival

MonthsPatients at risk:

73%

74%

67%

64%

59%

45%

Perc

en

tag

e o

f P

FS

0

10

20

30

40

50

60

70

80

90

100

0 3 6 9 12 15 18 393024 332721

Ove

rall

Su

rviv

al (%

)

36

0IPI 34104129136149164182205228254285315 4

0NIVO 55157175181191201213230244265292316 3

0NIVO+IPI 49170192198200209221226247265292314 7

*P<0.0001

NIVO+IPI (N=314) NIVO (N=316) IPI (N=315)

Median OS, mo (95% CI) NRNR

(29.1–NR)20.0

(17.1–24.6)

HR (98% CI) vs. IPI0.55

(0.42–0.72)*0.63

(0.48–0.81)*--

HR (95% CI) vs. NIVO0.88

(0.69–1.12)-- --

NIVO+IPI

NIVO

IPI

Database lock: Sept 13, 2016, minimum f/u of 28 monthsLarkin et al. AACR 2017, Wolchok et al. NEJM 2017

CTLA-4 and PD-1 Checkpoint Blockade

Abril-Rodriguez and Ribas, Snapshot, Cancer Cell 2017

Tumeh et al., Nature 2014

PD1/PDL1

PD1/PDL1Melanoma cell or

tumor macrophage

IFN-g

Anti-PD-1

Anti-PD-L1

Melanoma response to PD-1 blockade is mediated by pre-existing

infiltrates of CD8s inhibited by reactively expressed PD-L1

PD-1 blockade induces responses

by inhibiting adaptive immune resistance

Melanoma cell

or tumor macrophage

Hypothesis formulated

based on quantitative

IHC analyses of 46

cases from UCLA

Response Progression

CD

8P

D-1

PD

-L1

Melanoma cell

or tumor macrophage

Interferon gamma

Adapted from Tumeh et al. Nature 2014

Patient #1 Patient #2

Pembrolizumab Keynote 001 trial. Central radiology review by RECIST v1.1 Ribas et al. JAMA 2016

ORR: 33%

ORR in previously untreated: 45%

What differentiates anti-PD-1-responsive

from non-responding melanomas?




Ayers et al, JCI 2017




Le et al, NEJM 2015Rizvi et al, Science 2015

Mutational load and

response to anti-PD-1

in NSCLC

Mutational load and


in MSI high colon

cancer

Mutational load and


in melanoma

Hugo et al, Cell 2016

McGranahan et al. Science 2016

IPRES (Innate anti-PD-1 Resistance) signature

Roger S. Lo,

MD, PhD

Willy Hugo,

PhD

Jesse Zaretsky

Hugo, Zaretsky et al. Cell 2016




Tumor foreignness

Mutational load

General immune status

Lymphocyte count

Immune cell

infiltration

Intratumoral T cells

Absence of Checkpoints

PD-L1Absence of soluble inhibitors

IL6->CRP/ESR

Tumor sensitivity to

immune effectors

MHC expression

IFN-g sensitivity

Absence of inhibitory

tumor metabolism

LDH, glucose utilization

Blank, Haanen, Ribas, Schumacher. Science 2016

The Cancer Immunogram

anti-PD-1/L1

A rare subtype of melanoma (less than 4%)

A dense fibrous reaction

A known relationship to UV light damage

High NF1 mutation rate and no known

actionable genes for targeted therapies.

Zeynep Eroglu

Siwen Hu-Lieskovan

Jesse Zaretsky

(submitted)

b)

c)

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e

Baseline 2-3 months later

CA

SE

1C

AS

E 2

CA

SE

3

a)

b)

c)

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e


CA

SE

1C

AS

E 2

CA

SE

3

a)

Desmoplastic melanoma: Defined by a dense collagenous fibrous tissue

Baseline

Collagen

(Trichrome)

Tumor

(S100)

blue collagenous stroma, red cytoplasm and brown nucleus

2-3 months after

anti-PD1 therapyb)

c)

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e

DM1 DM2 CM1 CM2

S1

00

Tri

ch

rom

e


CA

SE

1C

AS

E 2

CA

SE

3

a)

0 1 0 2 0 3 0 4 0 5 0 6 0 7 0

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

T im e S in c e F irs t d o s e (M o n th s )

Es

tim

ate

d O

ve

ra

ll

Su

rv

iva

l (%

)

B)

0 1 0 2 0 3 0 4 0 5 0 6 0

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

T im e S in c e F irs t d o s e (M o n th s )

Pro

gre

ss

ion

Fre

e

Su

rv

iva

l (%

)

A)

Extended Data Figure 1

70% overall response rate

18% complete response rate

High response rate and high mutational load in Desmoplastic melanoma

n=57 (out of

1054 cases

Reviewed*)1 sIIIc

3 M1a

20 M1b

35 M1c

= Progressive Disease

= Response (RECIST1.1)

Non-Desmoplastic

Melanoma

Desmoplastic

Melanoma

*Retrospective Review

% Overall survival (OS), median not reached

Estimated 2 year OS 73% (CI 62-88).

Time (months)

Zeynep Eroglu

Siwen Hu-Lieskovan

Jesse Zaretsky

(submitted)

Primary and Acquired Resistance to PD-1 Blockade

Ribas et al. JAMA 2016

0 4 12 16 20 24 28 32

10

30

40

50

60

70

80

90

100

Re

sp

on

se

, %

8 36

0

20

Time, months

233 220 199 175 160 136 118 78 24 0

No. at risk

46 42 32 29 25 23 19 13 3 0

Pembrolizumab

Ipilimumab

Robert et al. ASCO 2017

Waterfall plot of RECIST responses in 510 patients

treated with pembrolizumab in the Keynote 001 trial

KM of duration of response in patients treated with

pembrolizumab or ipilimumab in the Keynote 006 trial

Primary

resistance

Acquired

resistance

How does the cancer sense IFN-gamma

and reactively expresses PD-L1?

Tumeh et al., Nature 2014

PD1/PDL1

PD1/PDL1

Melanoma cell

or tumor macrophage

Interferon gamma

Interferon gamma receptor pathway regulating

reactive PD-L1 expression

Adapted from Shin et al. Cancer Discovery 2017 and Garcia-Diaz et al. Cell Reports 2017

IRF-1

PD-L1 PDL1

Promoter

Melanoma

cell

Primary resistance to PD-1 blockade by

disabling PD-L1 adaptive expression

Melanoma

cell

Would be useless to try to inhibit PD-1:PD-L1

Adapted from Shin et al. Cancer Discovery 2017 and Garcia-Diaz et al. Cell Reports 2017

IRF-1

PD-L1 PDL1

Promoter

Is JAK loss associated with primary resistance to PD-1 blockade?

JAK1 homozygous

1/23 melanoma cases with

high-allele frequency JAK1 mutation

1/16 colorectal cases with

high-allele frequency JAK1 mutation

Shin et al, Cancer Discovery 2017

JAK1 homozygous

Responders Non-Responders

data from Le DT et al. NEJM 2015

all heterozygous

0 200 400 600 800

0

500

1000

1500

Days on Therapy

Lesio

n S

ize

(mm

2)

*

CN Total

0 1/2 3 4 5/6 >6

Non-Synonymous Mutations

Baseline CNV

Relapse CNV

CN Minor Allele

0 1(LOH)

Baseline (M420)

Relapse (Tumor)

Relapse (M464)

JAK2 F547_splice

Case #2

0 200 400

0

2000

4000

6000

Days on Therapy

Lesio

n S

ize

(mm

2)

0 1 2 3 >=4

Non-Synonymous Mutations

Baseline CNV

Relapse CNV

0

*

CN Total

CN Minor Allele

(LOH)

Baseline

Relapse

JAK1 Q503*

Case #1

Baseline Relapse

*

New mutation

Jesse Zaretsky

UCLA MSTP

PD-L1

JAKs

Melanoma

cell

APM

Growth inh/apoptosis

Acquired

Resistance

Interferon-gamma Sensitivity Model: • Initially, benefits of PD-L1 suppression outweigh immune sensitizing effects.

• PD-L1 expression is of no benefit after PD-1/L1 blockade; selective pressure is

flipped.

• The cancer has an incentive to lose INF-γ sensitivity, avoid apoptosis, enhanced

antigen presentation.

Adapted from Zaretsky et al. NEJM 2016

In 8 additional paired biopsies:

• One additional B2M LoF mutation

• No additional JAK1/2, IFNGR, IRF1 or STAT1/3/5 LoF mutations

How prevalent are JAK and B2M loss-of-function mutations?

Neither

IFNGR, JAK/STAT pathwaymutations

B2M mutations

n=12

2

2

8

Jesse Zaretsky, Antoni Ribas (unpublished)

0 5 10 150

200

400

600

800

MC38 wild-type

days after tumor injection

tum

or

vo

lum

e (

mm

3)

MC38 WT untreated

MC38 WT aPD-1

0 5 10 15 200

200

400

600

800


tum

or

vo

lum

e (

mm

3)

MC38 B2M knockout

B2M untreatedB2M aPD-1

0 10 20 300

100

200

300

400

500

MC38 JAK2 knockout


tum

or

vo

lum

e (

mm

3)

JAK2 untreated

JAK2 aPD-1

Confirmation of B2M and JAK as genetic mechanisms of resistance

to anti-PD-1 using CRISPR/Cas9 knock out sublines

Davis Torrejon, Gabriel Abril Rodriguez, Siwen Hu-Lieskovan (unpublished)

Defects in the IFNγ pathway induce resistance

Loss of Ptpn2 increases IFNγ sensing by tumour cells

Genome-wide CRISPR mutagenesis reveals essential

genes for the effector function of T cells in a target cell.

Functional loss of APLNR reduces efficacy of cancer

Immunotherapy, which IPs with JAK1

Conclusions

• Inhibiting adaptive immune resistance is the mechanistic basis of the antitumor activity of PD-1 blockade therapies

• Combination therapies aimed at increasing T cell infiltration in tumors may improve the antitumor activity of PD-1 blockade

• Loss of function mutations in IFN-gamma receptor signaling or antigen presenting machinery mediate some cases of primary resistance and acquired resistance to PD-1 blockade therapy

Intervalo

III International Symposium on Immuno-Oncology

Saturday, October 7th 10:30 – 10:50 am

Combinação em Imunoterapia:

Deve ser o standard?

Qual o melhor parceiro para

combinar com imunoterapia?

Antoni Ribas, M.D., Ph.D.

Professor of Medicine, Surgery, Molecular and Medical Pharmacology

Director, Tumor Immunology Program, Jonsson Comprehensive Cancer Center (JCCC)

Director, Parker Institute for Cancer Immunotherapy (PICI) Center at UCLA

University of California Los Angeles (UCLA)

Chair, Melanoma Committee at SWOG

Teng, Ngiow, Ribas, Smyth. Cancer Research, 2015

Intrinsic or primary resistance to immune checkpoint

therapies- cellular microenvironment

Alternate immune suppressive mechanisms?

Cold tumors- induce TILs?

Teng et al., Can Res, 2015; Taube et al., Sci Trans Med, 2012

45%41%

2%12%

Intrinsic or primary resistance to immune checkpoint

therapies- cellular microenvironment

PD-L1 baseline surface expression

2 out of 48 melanoma cell lines had JAK1/2 LOF mutations and did not respond to IFN-gamma by expressing PD-L1

Shin et al. Cancer Discovery 2017, 7, 188-201Daniel Shin, MD

M368 : JAK2 chr9:5055668 G>A, Exon 8 D313_Splice

0 200 400 600 800 1000 1132 aa

0

5

# M

uta

tio

ns

JAK2

D313_splice

SH2 Pkinase_Tyr Pkinase_Tyr

M395: JAK1chr1:65309827C>T, Exon 17 D775N

0 200 400 600 800 1000 1154 aa

0

5

# M

uta

tio

ns

JAK1

D775N

Pkinase_Tyr Pkinase_Tyr

Management of cancer in the

anti-PD-1/L1 era

Anti-PD-1/anti-PD-L1

Generate T cells:

+ anti-CTLA4

+ immune activating antibodies

or cytokines

+ TLR agonists or oncolytic

viruses

+ IDO or macrophage inhibitors

+ targeted therapies

Bring T cells

into tumors:

Vaccines

TCR engineered ACT

CAR engineered ACT

Modified from Ribas, Cancer Discovery 2016

Tumorcell

INFγ

PD-1 / PD-L1 and IDO in the T cell inflamed phenotype

T cell mediated INFγ release triggers both

• PD-L1 expression

• IDO expression

in tumor cells and in the µ-environment

STAT

INFγ

TCR

T cell

MHC

PD-1

Tryptophan

Kynurenine

+

-

PD-L1

- IDO

Efficacy data: ECHO-202, Keynote-006, Checkmate 067

ResponseECHO-202

Epacadostat + Pembro1

PD-1 single agentCheckmate 067 2 /

Keynote-006 3

Ipi + NivoCheckmate 067 2

ORR (CR+PR) 56% 44% / 42% 58%

CR 14% 16% / 13% 19%

PR 41% 30% / 29% 42%

SD 16% 10% / 21% 11%

PD 29% 38.6 / 29% 23.6

Not evaluable 3% 7% / - 6%

Median PFS 12.4 months 6.9 / 8.3 months 11.5 months

PFS @ 18 months 52% 43% / - 50%

Grade 3/4 toxicity 20% 21% / 17.5% 59%

1 Hamid, ESMO 2017; 2 Larkin, AACR 2017 and Wolchok, NEJM 2017; 3 Robert, ASCO 2017 (2 pembro arms pooled). Note: data not randomized head to head, comparison only for indication

Double immune checkpoint

inhibition: PD-1 plus LAG-3

TCR

Dendritic

cell

MHC

CD28

B7 CTLA-4

- - -

B7+++

+++

CTLA-4 Blockade

anti-CTLA-4

T cell

T cellTumor cell

MHCTCR

PD1 PD-L1

- - -

PD-1 Blockade +LAG-3 Blockade

anti-PD1

++ +

LAG3

MHC c IIanti-LAG-3

- - -

ASCO 2017-Ascierto et al

Nivolumab + BMS-986016 (anti-LAG3)Patients refractory or resistant to anti-PD-1

• LAG-3 expression enriched for responses in IO-experienced patients

• Nearly a 3-fold increase in ORR was observed in patients with LAG-3 ≥1% vs LAG-3 <1% (20% vs 7.1%)

• Overall response rate was 13%

DCR, disease control rate; ORR, objective response rate.aLAG-3 expression (percent of positive cells within invasive margin, tumor, and stroma) evaluated using immunohistochemistry (IHC) assays on formalin-fixed, paraffin-embedded tumor sections.

Immune cell LAG-3 expression (≥1% or <1%) determined using mouse antibody clone 17B4. bResponse-evaluable patients (n = 48; all progressed on prior anti–PD-1/PD-L1 therapy).

Six patients had clinical progression prior to their first scan and are not included in the plot. One patient with best change from baseline >30% had an unconfirmed best response of SD.

LAG-3 <1%a

n = 12

ORR, 7.1%

LAG-3 ≥1%a

n = 22

ORR, 20%

LAG-3 Unknownn = 8

ORR, 0B

est P

erc

ent C

hange in S

um

of T

arg

et Lesio

n D

iam

ete

rs F

rom

Baselin

eb

‒100

‒80

‒60

‒40

100

80

60

40

‒20

20

0

‒100

‒80

‒60

‒40

100

80

60

40

‒20

20

0

‒100

‒80

‒60

‒40

100

80

60

40

‒20

20

0

Metastatic Melanoma with Prior-IO Cohort

6 PRs: 2 prior PD; 3 prior PR; 1 unk

Ascierto et al. ASCO 2017

Adding intralesional therapies

to anti-PD-1/L1


IT injection oncolytic virus

TLR agonist

STING agonist

Then the benefit should only be in the

patients who were unlikely to respond

to anti-PD-1/L1 alone because their T

cells were not in the tumor

+ Anti-PD-1/anti-PD-L1

MASTERKEY-265: T-Vec + pembrolizumab

Ribas et al. Cell 2017

Baseline (Week -5) Week 0 Week 12

Pa

tie

nt 2

–100

–75

–50

–25

0

25

50

75

100

Stage IV M1c (N = 8)Stage IV M1b (N = 4)Stage IV M1a (N = 2)Stage IIIC (N = 6)Stage IIIB (N = 1)N = 21

Perc

enta

ge C

hange fro

m B

aselin

ePembrolizumab

6

T-VEC Intralesional

1 30Wk:

PFS

21 16 14 14 13 13 1

0 3 6 9 12 15 18

Study Month

0

20

40

60

80

100

T-VEC plus pembrolizumab (N = 21)

Median (95% CI)

Number of Patients at Risk:

|| | |||||||||| || | |||||||||| |

Kapla

n-M

eie

r P

erc

ent

Study Month

21 20 20 20 20 17 6

0 3 6 9 12 15 18

0

20

40

60

80

100| | ||| | | |||||| || | || || | ||| | | |||||| || | || |

Number of Patients at Risk:

Kapla

n-M

eie

r P

erc

ent

T-VEC plus pembrolizumab(N = 21)

Median (95% CI)

OS62% objective response rate

33% complete response rate

T-VEC increases tumor CD8 and PD-L1 in patients

responding to combination with pembrolizumab

T-VEC T-VEC+ pembro

CD8 antibody with red chromogen

Pt

#1

Pt

#2

Baseline Week 6 Week 30

T-VEC T-VEC+ pembro

Adding BRAF targeted therapies

to anti-PD-1/L1


BRAFi+MEKi

BRAFi+MEKi

+ anti-PD-1/L1

Wilmott et al. CCR 2013

Frederick et al. CCR 2013

Combination of BRAFi+MEKi+Anti-PD-1

NIH Director’s Blog*Knocking Out Melanoma: Does This Triple Combo Have What It Takes?Posted on March 31, 2015 by Dr. Francis Collins Comment on: Hu-Lieskovan S, et al. Sci Transl Med. 2015;7:279ra41.

*Available at: https://directorsblog.nih.gov/2015/03/31/knocking-out-melanoma-does-this-triple-combo-have-what-it-takes/. Accessed on August 18, 2016.

Hu-Lieskovan et al. Sci Transl Med. 2015 Mar 18;7(279):279ra41

Clinical trials combining BRAFi+MEKi+anti-PD-1/L1

dabrafenib+trametinib

+durvalumab

Ribas et al. J Clin Oncol 33, 2015

(suppl, abstr 3003 ASCO)Ribas et al. ESMO, 2017

dabrafenib+trametinib

+pembrolizumabvemurafenib+cobimetinib

+atezolizumab

Hwu et al. Annals of Oncology 27; 2016

(supp 6; abstr 1109PD ESMO)

** *

**

*

0 4 8 12 16 20 24

-100

-80

-60

-40

-20

0

20

40

60

80

100

Time, months

Ch

an

ge f

rom

Bas

eli

ne

, %

*

*0 4 8 12 16 20 24

Time, months

4

Conclusions

• Inhibiting adaptive immune resistance is the mechanistic basis of the antitumor activity of PD-1 blockade therapies

• Combination therapies aimed at increasing T cell infiltration in tumors may improve the antitumor activity of PD-1 blockade

• Loss of function mutations in IFN-gamma receptor signaling or antigen presenting machinery mediate some cases of primary resistance and acquired resistance to PD-1 blockade therapy

melanoma, o status da imunoterapia e o futuro...

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