ACTAUNIVERSITATIS

UPSALIENSISUPPSALA

2017

Digital Comprehensive Summaries of Uppsala Dissertationsfrom the Faculty of Medicine 1379

Preclinical evaluation ofimmunostimulatory gene therapyfor pancreatic cancer

EMMA ERIKSSON

ISSN 1651-6206ISBN 978-91-513-0102-0urn:nbn:se:uu:diva-330189

Dissertation presented at Uppsala University to be publicly examined in Fåhræussalen,Rudbecklaboratoriet, Dag Hammarskjölds väg 20, Uppsala, Friday, 1 December 2017 at09:15 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will beconducted in English. Faculty examiner: Professor Tanja de Gruijl (Department of MedicalOncology, VU University Medical Center, Amsterdam, The Netherlands.).

AbstractEriksson, E. 2017. Preclinical evaluation of immunostimulatory gene therapy for pancreaticcancer. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty ofMedicine 1379. 66 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-513-0102-0.

Pancreatic cancer is characterized by its desmoplastic tumor microenvironment and theinfiltration of immunosuppressive cells. It is a devastating disease where most patients arediagnosed at a late stage and the treatment options are few. The development of new treatmentsis surly needed. One treatment option explored is the use of immunotherapy with the intent toactivate the immune system and change the balance from pro-tumor to anti-tumor. This thesispresents the idea of using oncolytic adenoviruses called LOAd-viruses that are armed withimmunostimulatory- and microenvironment-modulating transgenes. For effective treatment ofpancreatic cancer, the virus needs to be able to be given in addition to standard therapy,the chemotherapy gemcitabine. In paper I, the immunomodulatory effect of gemcitabine wasevaluated in blood from pancreatic cancer patients receiving their first 28-day cycle of treatmentwith infusions day 1, 8 and 15 followed by a resting period. Gemcitabine reduced the level ofimmunosup-pressive cells and molecules but the effect did not last throughout the resting period.On the other hand, gemcitabine did not affect the level or proliferative function of effector Tcells indicating that gemcitabine could be combined with immunotherapy.

The LOAd700 virus expresses a novel membrane-bound trimerized form of CD40L (TMZ-CD40L). In paper II, LOAd700 showed to be oncolytic in pancreatic cancer cell lines aswell as being immunostimulatory as shown by its capacity to activate dendritic cells (DCs),myeloid cells, endothelium, and to promote expansion of antigen-specific T cells. In paperIII, LOAd703 armed with both 4-1BBL and TMZ-CD40L was evaluated. LOAd703 gave amore profound effect than LOAd700 on activation of DCs and the virus was also capableof reducing factors in stellate cells connected to the desmo-plastic and immunosuppressivemicroenvironment. In paper IV, LOAd713 armed with TMZ-CD40L in combination with asingle-chain variable fragment against IL-6R was evaluated. The virus could kill pancreaticcancer cells lines through oncolysis and could also reduce factors involved in desmoplasia instellate cells. Most interestingly, LOAd713 could reduce the up-regulation of PD-1/PD-L1 inDCs after CD40 activation. Taken together, LOAd703 and LOAd713 seem to have interestingfeatures with their combination of immunostimulation and microenvironment modulation. Atpresent, LOAd703 is evaluated in a clinical trial for pancreatic cancer (NCT02705196).

Keywords: Pancreatic cancer, immunotherapy, oncolytic viruses, adenoviruses, CD40L,4-1BBL, IL-6, tumor microenvironment

Emma Eriksson, Department of Immunology, Genetics and Pathology, Rudbecklaboratoriet,Uppsala University, SE-751 85 Uppsala, Sweden.

© Emma Eriksson 2017

ISSN 1651-6206ISBN 978-91-513-0102-0urn:nbn:se:uu:diva-330189 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-330189)

Things are only impossible until they’re not Jean-Luc Picard

Till min familj

List of Papers

This thesis is based on the following papers, which are referred to in the text by their Roman numerals.

I Eriksson, E*., Wenthe, J*., Irenaeus, S., Loskog, A., Ullenhag,

G. (2016) Gemcitabine reduces MDSCs, tregs and TGFβ-1 while restoring the teff/treg ratio in patients with pancreatic cancer. Journal of Translational Medicine, 14:282

II Eriksson, E., Moreno, R., Milenova, I., Liljenfeldt, L., Dieth-erich, LC., Christiansson, L., Karlsson, H., Ullenhag, G., Mangsbo, SM., Dimberg, A., Alemany, R., Loskog, A. (2017) Activation of myeloid and endothelial cells by CD40L gene therapy supports T-cell expansion and migration into the tumor microenvironment. Gene Therapy, 24(2):92-103

III Eriksson, E*., Milenova, I*., Wenthe, J., Ståhle, M., Leja-Jarblad, J., Ullenhag, G., Dimberg, A., Moreno, R., Alemany, R., Loskog, A. (2017) Shaping the tumor stroma and sparking immune activation by CD40 and 4-1BB signaling induced by an armed oncolytic virus. Clinical Cancer Research, 23(19):5846-5857

IV Eriksson, E., Milenova, I., Wenthe, J., Moreno, R., Alemany, R., Loskog, A. (2017) An oncolytic virus for pancreatic cancer targeting interleukin-6 signaling and driving CD40-mediated immune activation. Submitted manuscript.

*Authors contributed equally to the work

Reprints were made with permission from the respective publishers.

Contents

Introduction ................................................................................................... 11 Tumor Immunology ................................................................................. 11

Cancer initiation .................................................................................. 11 Cancer recognition and elimination ..................................................... 11 Immune escape mechanisms ................................................................ 13

Immunotherapy ........................................................................................ 16 TILs ..................................................................................................... 17 Chimeric antigen receptor (CAR) T cells ............................................ 18 Immune checkpoint inhibitors ............................................................. 19 Immunostimulating agents ................................................................... 20 Virotherapy .......................................................................................... 20

Pancreatic cancer ...................................................................................... 23 Diagnosis and incidence ...................................................................... 23 Biology ................................................................................................ 23 Treatment and prognosis ...................................................................... 24 Tumor microenvironment .................................................................... 26 Immunotherapy for pancreatic cancer ................................................. 27

The LOAd-virus platform ........................................................................ 29 Adenoviruses ....................................................................................... 29 LOAd backbone ................................................................................... 31 Transgenes ........................................................................................... 32

Aim of thesis ................................................................................................. 36 Specific Aims ........................................................................................... 36

Paper I .................................................................................................. 36 Paper II ................................................................................................ 36 Paper III ............................................................................................... 36 Paper IV ............................................................................................... 36

Results and Discussions ................................................................................ 37 Paper I ...................................................................................................... 37 Paper II ..................................................................................................... 37 Paper III .................................................................................................... 38 Paper IV ................................................................................................... 39

Conclusions ................................................................................................... 41 Paper I ...................................................................................................... 41

Paper II ..................................................................................................... 41 Paper III .................................................................................................... 41 Paper IV ................................................................................................... 42

Future Perspectives ....................................................................................... 43 Clinical trials ............................................................................................ 43

LOAd703 Oncolytic Virus Therapy for Pancreatic Cancer ................. 43 LOAd703 Oncolytic Virus Therapy for Solid Tumors ........................ 43

Combination therapy ................................................................................ 44 Immunotherapy/immunotherapy ......................................................... 44 Immunotherapy/angiogenesis inhibitors .............................................. 44

Populärvetenskaplig sammanfattning ........................................................... 46

Acknowledgments......................................................................................... 49

References ..................................................................................................... 51

Abbreviations

5-FU 5-fluorouracil α-SMA Alpha-smooth muscle actin Δ24 24 base-pair deletion in the adenovi-

ral gene E1A Ad5 Adenovirus serotype 5 APC Antigen presenting cell ATPs Adenosine triphosphates CAR Chimeric antigen receptor CAR Coxsackie- and adenovirus receptor CD Cluster of differentiation CD40L CD40 ligand CMV Cytomegalovirus CRS Cytokine release syndrome CTL Cytotoxic T lymphocyte CTLA-4 Cytotoxic T lymphocyte antigen-4 DAMPs Danger-associated molecular pat-

terns DCs Dendritic cells DNA Deoxyribonucleic acid ECM Extracellular matrix EMA European Medicines Agency EMT Epithelial to mesenchymal transition Fas L Fas ligand FDA Food and Drug Administration FGF Fibroblast growth factor Gal-3 Galactin-3 GITR Glucocorticoid-induced TNFR GemCap Gemcitabine + capecitabine GM-CSF Granulocyte-macrophage colony-

stimulating factor HGF Hepatocyte growth factor HLA Human leukocyte antigen HMGB1 High mobility group box 1 ICD Immunogenic cell death IFN Interferon IL Interleukin

IL-6R IL-6 receptor KIR Killer cell immunoglobulin-like

receptor LAG-3 Lymphocyte activating gene-3 MDSCs Myeloid-derived suppressor cells MHC Major histocompatibility complex MMR-d Miss-match repair deficiency MSI-H Microsatellite instability high NK Natural killer NKT NK T cells NOS2 Nitric oxide synthase 2 PanINs Pancreatic intraepithelial neoplasia PBMC Peripheral blood mononuclear cells PD-1 Programed death-1 PD-L1 Programed death-ligand 1 PDGF Platelet-derived growth factor PGE2 Prostaglandin E2 PSCs Pancreatic stellate cells pRb Retinoblastoma protein ROS Reactive oxygen species scFv Single chain variable fragment scFv-aIL-6R scFv against IL-6R STAT Signal transducer and activator of

transcription TAAs Tumor-associated antigens TAMs Tumor-associated macrophages TCR T cell receptor TGF Transforming growth factor Th T helper TILs Tumor-infiltrating lymphocytes TIM-3 T cell immunoglobulin and mucin-

domain containing-3 TMZ Trimerized membrane-bound iso-

leucine zipper TNF Tumor necrosis factor TRAIL TNF-related apoptosis-inducing

ligand Tregs T regulatory cells TWEAK TNF-like weak inducer of apoptosis VEGF Vascular endothelial growth factor

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Introduction

Tumor Immunology The complex interaction between the immune system and tumor cells is con-sidered a hallmark of cancer (1). On the one hand, immune cells can recog-nize cancer cells and eliminate them in the same ways as virus-infected cells are eliminated, and on the other hand there is a link between chronic in-flammation and the initiation and progression of cancer.

Cancer initiation Healthy cells transform to cancer cells by gaining genetic mutations and epigenetic alterations that leads to uncontrolled proliferation and dysregulat-ed homeostasis (2). Genetic alterations can be caused by extrinsic factor like carcinogens or radiation that causes mutations in the deoxyribonucleic acid (DNA). However, inflammatory responses to autoimmune diseases or infec-tions can also contribute to the initiation of cancer by leading to DNA dam-age and chromosomal instability due to the production of inflammatory fac-tors including reactive oxygen species (ROS), cytokines, chemokines, pros-taglandins and nitric oxide (3, 4). Chronic infections and inflammation in-crease the risk of cancer as seen in hepatocellular carcinoma (virus), colon cancer (autoimmune disease), stomach cancer (bacteria) and pancreatic can-cer (chronic inflammation). It is estimated that chronic inflammation con-tributes to approximately 20% of all cancer-related deaths (3, 5).

Cancer recognition and elimination Cancer cells have acquired mutations and genetic alternations that give rise to expression of neoantigens and cancer testis antigens. Together with differ-entiation antigens these antigens can be presented on their surface on major histocompatibility complex (MHC) class I molecules. Dendritic cells (DCs) that reside in the tumor microenvironment will take up tumor-antigens by engulfing cell debris or apoptotic cells. DCs will then process the tumor-antigens and present them on their MHC class I and II molecules to naïve cluster of differentiation (CD)4+ and CD8+ T cells in the lymph nodes. An-tigen presentation by DCs is known as signal 1 in the activation of T cells. For the induction of an effector T cell response against the tumor-antigens

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the DCs must be activated (matured). Activation signals can come from cel-lular stress or from danger signals including type-1 interferons (IFNs), heat shock proteins, toll-like receptor ligands, or CD40 ligand (CD40L) (6). Acti-vated DCs upregulate their expression of MHC molecules and co-stimulatory molecules including CD80 and CD86 (signal 2) which bind to CD28 on T cells. They also start to secrete immunostimulatory cytokines such as interleukin (IL)-12 (signal 3) needed for the induction of a T helper (Th)1 response with cytotoxic T cells (CTLs) and natural killer (NK) cells as effector cells (7). The activated effector T cells can then traffic to the tumor and infiltrate into the microenvironment where they recognize the tumor cells that express the same antigen that was presented to them via DCs. Up-on recognition, the T cell kills the tumor via apoptosis induction leading to release of new tumor-antigens to DCs. The immune response will continue until there are no more antigens presented in the context of danger. When inactivated (immature) DCs present antigens to T cells the stimulation in-stead leads to anergy (unresponsiveness) or apoptosis (8). Chen and Mell-man described this as the cancer-immunity cycle. The cycle is divided into sevens steps (Figure 1) were the initiation of an anti-tumor response is rein-forced but also can fail at any of the given steps (9). Failure of the anti-tumor response will be discussed under immune escape mechanisms below.

Figure 1: The initiation and amplification of the anti-tumor response as described by Chen and Mellman in the cancer immunity cycle (9). Re-printed with approval from publisher.

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Effector cells The anti-tumor response consists of a large variety of cells from the innate and adaptive immune system including macrophages, neutrophils, NK cells and T cells. The two major effector cell types of the response are the CTLs and the NK cells. CTLs are activated CD8+ T cells that are primed against an antigen. Fully-functional long-term surviving CTLs must be licensed by DCs that have interacted with CD4+ Th 1 cells through CD40:CD40L inter-actions (10). They will recognize and eliminate tumor cells that present the same antigen on their MHC class I molecules that was previously presented to them by DCs as described above. CTLs kill target cells by releasing per-forin and granzymes. Perforin polymerizes and inserts itself into the mem-brane to create channels aiding transport of granzymes into the cytosol. Granzymes cleave caspases which initiate cell death via apoptosis. CTLs also express death receptor ligands such as Fas ligand (FasL; CD95L), tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) and TNFα. Engagement of their counterpart receptor on the target cell initiates a signal-ing cascade leading to caspase cleaving and cell death by apoptosis (11, 12).

NK cells are cytotoxic cells of the innate immune system that do not re-quire priming to kill, even if activation via cytokines like IL-12 and IFNγ can generate expansion and enhanced responses. NK cells express both co-stimulatory and co-inhibitory receptors and when binding to a cell it is the sum of the stimulatory and inhibitory signals that will decide the faith of that cell. For example, the inhibitory killer cell immunoglobulin-like receptor (KIR) recognizes self-expressed MHC molecules meaning that NK cells will not kill normal cells. However, it can kill tumor cells with down-regulated or mutated MHC (13). Like CTLs, NK cells kill tumor cells by releasing per-forin and granzymes or by death receptor ligands such as FasL (14, 15). Infiltration of CD8+ T cell and/or NK cells in the tumor microenvironment is associated with a favorable outcome in cancer patients (16-18).

Immune escape mechanisms The immune system holds an immunogenic pressure on the tumor. As the tumor progresses, tumor clones will arise that can escape the attack from the immune system by 1) evading recognition, 2) becoming insensitive to effec-tor mechanisms and/or 3) inducing an immunosuppressive microenviron-ment (19).

Evading recognition Tumor cells can avoid recognition by the immune system by down-regulation or loss of expression of MHC class I molecules on the cell surface (20-22). The lack of recognition by CTLs can also be due to mutations in the antigen-processing machinery or loss of antigen expression (23-25). Further,

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tumors can evade NK cells by loss of co-stimulatory receptors needed for NK-mediated killing or by expressing protective MHC-like molecules such as human leukocyte antigen (HLA)-G (26, 27).

Insensitivity to effector mechanisms Tumor cells can become insensitive to killing by CTLs and NK cells through the upregulation of anti-apoptotic proteins that will lead to inhibition of the death signals, or through mutations that lead to expression of inactive forms of the death receptors (28, 29).

Immunosuppression Tumor cells and supportive stroma cells produce factors including vascular endothelial growth factor (VEGF), prostaglandin E2 (PGE2), transforming growth factor β (TGFβ) and granulocyte-macrophage colony-stimulating factor (GM-CSF) that attract myeloid cells including myeloid-derived sup-pressor cells (MDSCs) and tumor-associated macrophages (TAMs) (30-34). These factors and cells constitute the tumor microenvironment and contrib-ute to cancer progression by supporting the growth and metastases of the tumor and by directly suppressing anti-tumor immune reactions as well as promoting differentiation of naïve immune cells into immunosuppressive cells.

MDSCs Immature CD11b+ myeloid cells that lack expression of maturation markers such as HLA-DR and Lin (linage markers) are collectively called MDSCs. Based on their expression of CD14 they can be divided into monocytic MDSC (CD14+) or granulocytic MDSCs (CD14-) (35). MDSCs affect the anti-tumor response negatively by suppressing the function of T cells. Mon-ocytic MDSCs are regarded as more efficient suppressors than the granulo-cytic counterpart. They produce nitric oxide synthase 2 (NOS2) and arginase 1 which both deplete the amino acid L-arginine from the microenvironment. This leads to impaired T cell function and proliferation since T cells depend on L-arginine. Granulocytic MDSCs suppress T cells in an antigen-dependent manner by binding to T cells and releasing ROS which leads to downregulation of the signaling domain in the T cell receptor (TCR) com-plex or by inhibiting the binding to MHC molecules (36-38). MDSCs can also induce differentiation of T regulatory cells (Tregs) from naïve CD4 T cells and is involved in cross-talk with TAMs to generate an immunosup-pressive environment (39, 40). MDSCs not only play a central role in im-mune suppression but are also involved in remodeling of the tumor microen-vironment by secretion of VEGF which leads to angiogenesis, establishment of pre-metastatic niches, and initiating epithelial to mesenchymal transition (EMT) (41). MDSCs infiltrate into the tumor but they are also present in high level in the blood of cancer patients leading to a general immunosup-

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pression, while few are detected in the blood of healthy individuals. The level of MDSCs in the circulation is directly associated with tumor load and, hence, with progression and poor survival in many cancers (42).

TAMs Macrophages can roughly be divided accordingly to their polarization into pro-inflammatory M1 macrophages with anti-tumor properties and anti-inflammatory M2 macrophages with pro-tumor properties. However, the classification is more complex with a gradient of activated states between the two extremes (43). TAMs display a typical M2 phenotype due to the pres-ence of factors like IL-10, PGE2 and TGFβ in the tumor microenvironment that drives the M2 polarization (44). TAMs reside inside the tumor microen-vironment where they contribute to the progression of the tumor by promot-ing angiogenesis, invasion, migration and suppression of immune effector cells. Immune suppression by TAMs is executed due to their production of the immunosuppressive cytokines IL-10 and TGFβ and from their expression of the inhibitory programed death ligand 1 (PD-L1) (45). TAMs can also recruit, or induce differentiation of Tregs in the tumor (46, 47). A high den-sity of infiltrating TAMs is correlated to a poor clinical outcome in variety of cancers (48).

Tregs Tregs are CD4+ T cells that express a high level of CD25 (IL-2 receptor α) and the transcription factor FoxP3, but lack CD127 (IL-7 receptor α) (49). In healthy individuals, Tregs are involved in peripheral tolerance and immune homeostasis but in cancer patients they contribute to inhibition of the anti-tumor immune response (50). Tregs can be recruited to the tumor microenvi-ronment by the production of CCL2 by tumor cells or TAMs (47). They can also be induced from naive CD4+ T cells in the tumor microenvironment in response to TGFβ (51). Tregs inhibit the anti-tumor response by binding and killing CTLs by releasing perforin and granzyme A or by ligation of FasL to Fas (52, 53). Tregs also secrets the cytokines IL-10 and TGFβ, that contrib-utes to immunosuppression by inhibiting the function of DCs and effector T cells (54, 55). The high expression of CD25 by Tregs leads to consumption of IL-2 in the microenvironment which can lead to cytokine deprivation-induced apoptosis in effector cells (56). A high number of Tregs are associ-ated with a worse prognosis in many non-hematopoietic cancers (47, 57, 58).

Immune checkpoint molecules Immune checkpoint molecules normally function as a negative feedback loop in T cells where they constrict the immune response. When effector cells become activated they up-regulate expression of co-inhibitory receptors where cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and pro-gramed death-1 (PD-1) (CD279) are the most explored. CTLA-4 competes

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with CD28 in binding to CD80/CD86 on antigen presenting cells (APCs) in the lymph node. Due to its higher affinity, CTLA-4 outcompetes CD28 lead-ing to inhibition of T cell activation (59). CTLA-4 is also constitutively ex-pressed on Tregs and plays an important role in their function since it occu-pies the CD80/86 molecules and restricts APCs (60, 61). The central role of CTLA-4 in controlling T cells can been seen in the double knock-out Ctla4-/- mice that die 3-4 weeks after birth due to lymphoproliferative disorder (62). PD-1 seems to be more involved in controlling peripheral primed anti-gen-specific T cells since PD-1 deficiency gives rise to organ-specific auto-immunity rather than uncontrolled proliferation of any T cell (63, 64). Liga-tion of PD-1 to its main ligand PD-L1 (CD274) leads to inhibition of cyto-kine production, proliferation, and effector function in T cells (65, 66). PD-1 signaling is also involved in survival of T cells since it inhibits anti-apoptotic molecules (67). Thus, the outcome of PD-L1:PD-1 signaling in T cells can be apoptosis or anergy and this contributes to the tumor’s escape from im-mune attack since the tumor or stroma cells often express PD-L1 (68, 69). The level of PD-L1 expression is associated to a poorer prognosis in many cancers. (70-73). PD-1 also has a second ligand known as PD-L2 (CD273). As with PD-L1, the ligation with PD-L2 will lead to inhibition of T cell acti-vation (74). PD-L2 is expressed on APCs and can be induced on a variety of other immune cells and nonimmune cells including cancer-associated fibro-blasts. Unlike PD-L1, PD-L2 is not as strongly correlated to a worse survival in cancer patients (75).

Immunotherapy Immunotherapy aims at activating, or re-activating, the immune system to generate a potent anti-tumor response with long lasting tumor-specific CD8+ T cells. For example, this can be achieved by stimulating the T cells in vivo with injections of tumor-antigen loaded DCs, by giving tumor-peptide vac-cinations to load DCs in situ, to perform ex vivo expansion of tumor infiltrat-ing lymphocytes (TILs) prior reinfusion, by infusing ex vivo generated gene-engineering tumor-targeting T cells, or by injecting immune checkpoint in-hibitors to prevent T cell anergy in the patient (Figure 2). It is a clinical bal-ance act to activate immunity and overcome the immune escape mechanisms without unleashing a too strong response causing serious autoimmunity in-stead. Below, find a selection of the most promising strategies.

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Figure 2. Different types of immunotherapy. Re-printed with permission from pub-lisher (76).

TILs Adoptive cell therapy aims at expanding patients own immune cells ex vivo and reinfusing the cells back into the patient. One form of adoptive cell ther-apy is TIL therapy. In TIL therapy, lymphocytes are cultured and expanded from the patient’s tumor material. The final TIL product will vary between trial centers since some only use the fast-growing crude T cell product and some use TILs that have shown tumor-selectivity against the patient´s own tumor or tumor cell lines. The treatment is initiated by lymphodepletion in the form of chemotherapy, with or without total body irradiation, before infusion of the TIL product. To sustain TIL survival, the patient is treated with supportive high dosage IL-2 infusions (77). Most patients treated so far have had advanced stage, treatment refractory malignant melanoma. About 50% of the patients had a clinical response of which 20% remain in a dura-ble complete remission 10 years after therapy (78). Today no results exist from a phase III study but there are trials ongoing in malignant melanoma (NCT00200577, NCT02278887).

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Patients given TIL therapy can experience severe adverse events due to the lymphodepletion regime and the infusion of high dosage IL-2. However, the T cells themselves do not seem to induce severe adverse reactions (77). Better protocols to manufacture TILs are needed since a lack of expansion of lymphocytes from some patients has been noted. Further, there is a low per-sistence of TILs after infusion including problems of homing of the TILs to the tumor which is likely due to the immunosuppressive tumor microenvi-ronment. Also some TIL cultures show only T cells with low affinity to tu-mor antigens (79, 80). Increasing the efficacy of TIL therapy by combining it with infusion of immune checkpoint inhibitors will certainly be an interest-ing possibility.

Chimeric antigen receptor (CAR) T cells T cells can be genetically engineered to express a chimeric antigen receptor (CAR). The CAR molecule consists of the antigen-binding part of an anti-body, a single chain variable fragment (scFv), fused to the signaling domain of the TCR, and one or two co-stimulatory molecules (e.g CD28, 4-1BB or OX40). The CAR allows for recognition of antigens in a MHC-independent manner (81). The most successful CAR T cells so far, are the CD19-targeting CARs for treatment of B-cell malignancies with an overall re-sponse rate of around 48%, with 24% being complete responses (82). The highest success rate in this group has been seen in patients with acute lym-phocytic leukemia, were complete response rates ranging from 50-90% have been reported in previously treatment refectory patients (83, 84). In solid tumors the success is still to come. It is more difficult to generate safe CARs for solid tumors because of the lack of tumor-specific cell surface antigens. Further, the effect is less prominent in a solid tumor due to the difficulties for T cells to traffic into the tumor microenvironment, and/or the immuno-suppressive environment they will encounter within the tumor lesion (85). CAR therapy is associated with immune-mediated adverse events such as cytokine release syndrome (CRS). This is due to the massive activation of CAR T cells which can occur after antigen-binding, and which leads to re-lease of inflammatory cytokines by the CAR T cells, the B cell tumor cells or other immune cells such as macrophages that are affected by the CARs (86). Other types of toxicity that can occur after CAR therapy are neurologi-cal toxicities and so called on-target/off-tumor effect which is dependent on the specificity of the CAR. For example, in B-cell malignancies all B-cells can be killed by CARs since they all express CD19 regardless of their ma-lignant status (87, 88). In solid malignancy, on-target/off-tumor is a problem since there are few promising tumor markers to target that do not occur also on healthy cells.

Two CD19-targeting CAR therapies have been approved by the Food and Drug Administration (FDA) in the United States, tisagenlecleucel for the

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treatment of children and young adults with acute B cell leukemia and axi-cabtagene ciloleucel for the treatment of adults with relapsed or refractory large B-cell lymphoma.

Immune checkpoint inhibitors Monoclonal antibodies have been developed that bind to the co-inhibitory receptors, or their ligands, to release the brake that exists on CTLs in cancer patients. The first approved was an αCTLA-4 antibody (ipilimumab) that in a phase III clinical trial for advanced malignant melanoma showed a signifi-cant survival benefit compared to a gp100 peptide vaccination (10.1 months vs 6.4 months) (89). It is suggested that αCTLA-4 acts in the lymph nodes where it inhibits the binding of CTLA-4 to CD80/CD86 during the priming of T cells. This leads to activation and proliferation of effector T cells re-gardless if they are tumor-specific or not. The antibody also targets Tregs to release their suppressive hold on effector T cells (90). Blocking of PD-L1:PD-1 signaling is done with either αPD-1 (nivolumab, pembrolizumab) or αPD-L1 (atezolizumab, durvalumab, avelumab) antibodies. These anti-bodies act on already primed CTLs (91). Treatment with immune checkpoint inhibitors is associated with adverse events connected to the immune system including autoimmune-mediated toxicity of the skin, gastrointestinal tract and endocrine organs. As expected from its unspecific mode of action, αCT-LA-4 is known to cause the most severe reactions (92, 93). Several immune checkpoint inhibitors are approved by FDA and the European Medicine Agency (EMA) for a large variety of solid tumors ranging from first-line treatment to last. Treatment with αPD-1 of patients with advanced or refrac-tory solid tumors gives an overall response rate of up to 26-27% where the best responses have been seen in melanoma, lung cancer, and renal cancer (94). A cancer form that stands out is Hodgkin’s lymphoma were overall response rates above 60% have been reported (95). When dividing patients based on the PD-L1 expression in the tumor, the response rate is 48% for PD-L1+ compared to 15% for PD-L1- (96). Responsiveness to αPD-1 thera-py is also improved in patients with miss-match repair deficiency (MMR-d), a state known for causing a high frequency of mutations and hence, a higher likelihood of antigens that T cells react to (97). Today, the αPD-1 antibody pembrolizumab is approved for patients with MMR-d and/or high microsat-ellite instability (MSI-H) independent of tumor origin.

Monoclonal antibodies against other immune checkpoint pathways are being tested including lymphocyte activating gene-3 (LAG-3) and T cell immunoglobulin and mucin-domain containing-3 (TIM-3) on T cells and KIR on NK cells (93). Clinical trials are also ongoing to demonstrate safety and effect of combination treatment of two different checkpoint inhibitors, or a checkpoint inhibitor with for example TIL therapy, or immune activating

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therapies including the immunostimulating antibodies or oncolytic virother-apy (clinicaltrials.gov).

Immunostimulating agents Stimulation of an immune response by the interaction of co-stimulatory mol-ecules on DCs with counteracting receptors on T cells or NK cells can be mimicked in vivo by agonistic antibodies or soluble recombinant im-munostimulatory ligands. As mentation above, CD40:CD40L interactions play a central role in the generation of a robust effector response since it promotes DCs activation and priming of tumor-specific CTLs (98). CD40L is provided by CD4+ T helper cells when they become activated. To bypass the need of CD4+ T cell help, soluble recombinant CD40L can be adminis-tered. However, the natural interaction between the ligand and the receptor can also be mimicked by monoclonal αCD40 antibodies. Both substitutes have been tested in clinical trials. The response rate has been approximately 20% across trials and with a mild toxicity profile that includes elevated liver enzymes, decreased level of platelets and inflammatory reactions at the infu-sion site (99). In addition to αCD40 antibodies and recombinant CD40L, CD40L gene therapy has been tested by us and others, and will be further discussed below with a focus on local delivery to the tumor microenviron-ment using a virus vector (100-103). Immune stimulating antibodies have also been developed against other co-stimulatory molecules on T cells in-cluding 4-1BB, OX40 and glucocorticoid-induced TNFR (GITR) (104-106).

Virotherapy Viruses can be utilized to transfer immunostimulatory genes into the tumor or for their oncolytic capacity. In parallel with testing viruses as gene deliv-ery vehicles to cancer lesions, viruses were being explored for their capacity to induce cell death via oncolysis. Oncolytic viruses can infect and selective-ly replicate inside tumor cells due to the natural preference of the virus or due to genetic modifications of the virus genome. Oncolytic viruses used in pre-clinical evaluations or clinical trials are many and include measles virus, herpes virus, polio virus, vaccinia virus and adenovirus (107). The effect of oncolytic viruses was believed to be a consequence only of the virus capabil-ity to replicate in tumor cells thereby causing cell death by oncolysis and the subsequent release of new virions. The oncolytic virus would then spread and infect metastasis throughout the body leading to tumor eradication. To-day, oncolytic viruses are considered as a form of immunotherapy since the oncolysis of tumor cells leads to release of tumor antigens at the same time as the virus per se is immunogenic (108). Further, oncolysis is considered as an immunogenic cells death (ICD), meaning that it is a type of cell death which leads to activation of the immune system. Killed cells will release

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danger-associated molecular patterns (DAMPs) including high mobility group box 1 (HMGB1), heat shock proteins, and adenosine phosphates (ATPs) that can activate DCs. The virus itself will also activate the immune system since the viral capsid and DNA are recognized by toll-like receptors on DCs. Further, the virus infection of tumor cells in the immune suppres-sive microenvironment can lead to a shift towards a more pro-inflammatory state where the infected cells produce cytokines such as IL-6, IL-8, IL-12 and IFNγ that will attract more effector immune cells (109, 110) (Figure 3).

Figure 3. A schematic view of the effects of oncolytic virus therapy on the immune system (111). Re-printed with permission from publisher.

Since viruses are human pathogens there is a concern that the immune sys-tem will be alerted and drive an anti-viral response instead of an anti-tumor response, a concept known as immunodominance, which could limit the efficacy of the therapy (112, 113). There is also a concern that previous in-fections with wild-type viruses will limit the efficacy. For example, most humans have circulating neutralizing antibodies and reactive CD8+ T cells against adenoviruses which makes systemic delivery problematic (114). Nevertheless, oncolytic viruses have advantages over other type of cancer therapies with their tumor selectivity, modest toxicity profile, low resistance

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mechanisms, replication capacity and that they can act in synergy with con-ventional therapy (115-117).

ONYX-015 was the first genetically engineered oncolytic adenovirus vi-rus evaluated in clinical trials. Patients with head and neck cancer were treated with intratumoral injections and the virus was well tolerated with 14% of patients reported to have a complete or partial response and 41% stable disease (118, 119). ONYX-015 have also been tried for other indica-tions including gastric cancers, pancreatic cancer and colorectal cancer both as single agent and as combination treatment with chemotherapy (120). In a phase I/II trial NV1020, a herpes simplex virus, was evaluated for treatment of metastatic colorectal cancer. The virus was well tolerated and one patient had a partial response and 14 had stable disease of the 32 patients treated (121). In another phase I/II clinical trial, Reolysin, a reovirus, was tested for the treatment of advanced malignancies in combination with the chemother-apeutic drugs paclitaxel and carboplatin. The virus treatment was well toler-ated and one patient had a complete response, six patients had partial re-sponse and nine patients had stable disease of the 31 patients treated (122).

Oncolytic viruses can also be armed with transgenes including modulators of the immune system or the tumor microenvironment converting them to potent immunostimulating agents (123). Hence, most virotherapies are now-adays combining the oncolytic capacity with its function as a gene delivery vehicle. A virus that has showed promising clinical results is JX-594 (Pexa-Vec), a vaccinia virus armed with the human immunostimulatory gene GM-CSF for the intratumoral treatment of advanced hepatocellular carcinoma. In a dose-finding phase II trial results showed that the median survival of the patients was related to the dose of the virus, with 6.7 months for the low dose compared to 14.1 months for the high dose. Replication of the virus and expression of GM-CSF was detected as well as induction of anti-tumor im-munity (124). Currently, a phase III trial of JX-594 in combination with so-rafenib, a tyrosine kinase inhibitor, compared to sorafenib alone is ongoing (PHOCUS, NCT02562755). CG0070, an oncolytic adenovirus of serotype 5 (Ad5), also armed with GM-CSF is in clinical trials for non-muscle-invasive bladder cancer that has failed previous treatment with BCG and refused cys-tectomy. In the interim analysis during phase II, the therapy showed to an acceptable toxicity profile and 47% of the patients had a complete response at six months after treatment (BOND2, NCT02365818) (125). Arming of viruses with other types of immunostimulatory genes have also been tested in clinical trials, for example nine patients with advanced solid tumors were treated with an oncolytic adenovirus carrying CD40L (CGTG-401). The treatment was well tolerated and 83% of the patients had disease control at three months (126).

Currently, there are two approved oncolytic viruses for treatment of can-cer. Talimogene laherparepvec (T-VEC), a genetically modified herpes sim-plex virus type 1 that encodes for GM-CSF is approved for treatment of ad-

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vanced melanoma in the US, Europe and Australia. T-VEC was approved after a phase III randomized trial in which intratumoral injections of T-VEC increased both the durable and objective response compared to subcutane-ously GM-CSF administrations (127). Clinical studies of combination treat-ment of T-VEC with checkpoint inhibitors for advance melanoma or treat-ment of new indications are ongoing with promising results (128, 129). In China, a genetically modified adenovirus, H101 is approved for the treat-ment of late stage cancer in combination with chemotherapy (130).

Pancreatic cancer Diagnosis and incidence Pancreatic ductal adenocarcinoma, herein named as pancreatic cancer, is the most common form of cancer that originates from the pancreas, contributing to 95% of all cases (131). The median age of diagnosis is around 71 years of age and there is shewing towards more men getting the disease (132). The incidence is 1 to 10 per 100 000 in the world and pancreatic cancer is only the 9th most common cancer in the western world, but due to the aggressive-ness of the tumor it is ranked as the 4th cause of cancer-related deaths (133, 134). Projections of the coming years show that by 2030, pancreatic cancer will be the 2nd cause of cancer-related deaths (135). Risk factors include smoking, diabetes, obesity, alcohol consumption and chronic pancreatitis (136, 137). Genetic risk factors with a familiar history of pancreatic cancer account for 10% of all the cases (138). Pancreatic cancer is divided into three stages; resectable, locally advanced, and metastatic disease. Patients are usually diagnosed at a late stage due to vague early symptoms. More than 80% of diagnosed patients have unresctable disease (locally advanced or metastatic). At a late stage, the symptoms include weight loss, loss of appetite, jaundice, back pain and abdominal pain (131).

Biology Pancreatic cancer arises from the exocrine part of the pancreas, in the ductal cells. Like most cancers, pancreatic cancer has pre-stages known as pancre-atic intraepithelial neoplasia (PanINs). As the disease progresses, the neo-plasms acquire more mutations and develop into full-blown malignancy which is finally leading to metastatic disease. However, unlike most cancers, pancreatic cancer can form metastases before the radiological appearance of a malignant tumor since metastatic capacity seems to be acquired at early malignant development (139). The most common mutation seen in up to 90% of all patients is mutated KRAS which has been linked initiation and progression of the disease (140). KRAS mutation is followed by loss of activ-

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ity or deletion in tumor suppression genes including p53 (>50% of all pa-tients), p16/CDKN2A (85-90% of patients), and SMAD4 (30% of all pa-tients) (138). Even though about 97% of all patients with pancreatic cancer have genetic mutations the frequency of somatic mutations seen in each pa-tient is lower than that of patients with malignant melanoma and lung cancer, two cancer forms known to respond well to immune checkpoint inhibitors (141).

Treatment and prognosis The only curative treatment for pancreatic cancer is surgery but only 10-20% of patients diagnosed are eligible. Sadly, most patients will relapse and the overall survival is only 17-20 months post-surgery (142). Surgery is there-fore combined with adjuvant chemotherapy. In Sweden, the standard is gem-citabine in combination with capecitabine (GemCap), a prodrug to 5-fluorouracil (5-FU). The addition of GemCap given for six cycles to surgery has in a clinical trial showed improved overall survival, 28 months compared to 25.5 months with gemcitabine alone (143).

For the rest of the patients (locally advanced and metastatic disease) treatment with chemotherapeutic drugs are standard. The first-line treatment is based on the deoxycytidine analog gemcitabine that when taken up by cells are converted to its active metabolites that inhibit DNA synthesis (144). For patients with metastatic disease, treatment with gemcitabine has a mod-est effect on survival compared to treatment with 5-FU (5.56 vs 4.41 months) but it generally has a good effect on symptom relief and quality of life (145). Gemcitabine has been tested in many different combinations and has been most successful in combination with nab-paclitaxel, a chemothera-peutic drug that inhibits the normal break-down of the microtubule. Treat-ment of metastatic pancreatic cancer increases survival with two months compared to gemcitabine alone (8.7 vs 6.6 months) but at the same time there is an increase in side-effects making the combination only evaluable to patients with acceptable performance status. The combination of gemcita-bine and nab-paclitaxel is approved as first-line treatment both in the U.S and in Europe (146). The best effect of chemotherapy has been seen with the non-gemcitabine–based combination treatment FOLFIRINOX (oxaliplatin, irinotecan, leucovorin and 5-FU) that in a phase III study gave a significant survival-benefit compared to gemcitabine (11.1 vs 6.8 months). FOLFIRNOX is a harsh treatment and can only be given to patients with a good performance status (147). Recently treatment with liposomal irinotecan has been approved by EMA. In a phase III study with patients that previous have been given gemcitabine-based therapy the combination of liposomal irinotecan, 5-FU and folic acid improved the overall survival compared to liposomal irinotecan alone or 5-FU and folic acid (6.1 vs 4.9 vs 4.2 months) (148).

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Gemcitabine’s effect on the immune system Chemotherapeutic drugs are not specific in their targeting of tumor cells but will affect all dividing cells in the body including cells of the immune sys-tem. The capacity of chemotherapy to affect immunosuppressive cell popu-lations is explored to support the effect of immunotherapy. Hence, chemo-therapy can be given as an immune-conditioning treatment during (metro-nomic conditioning) or prior immunotherapy (pre-conditioning) (149-151). The most commonly used method is pre-conditioning using cyclophospha-mide and fludarabine the days prior to immunotherapy. However, even if such treatment can remove suppressive cells, they rapidly expand thereafter. Continuous, high dose, cyclophosphamide is toxic and may reduce the ca-pacity of lymphocytes which is not a desirable feature of metronomic condi-tioning (150). Hence, there may be more efficient methods to reduce immu-nosuppression at the same time as leaving the T cell population intact.

Gemcitabine is a known suppressor of the myeloid cells compartment. About 26% of all patients treated will become neutropenic (145). Since im-mature myeloid suppressor cells are directly connected to poor prognosis and immunosuppression, targeting this population may be beneficial during immunotherapy. Studies investigating gemcitabine´s broader effect on the immune system are few and there is a lack of consistency in the results due to differences in study design regarding both sample collection and combina-tion treatments. Nevertheless, Annels et al reported that eight of 19 patients treated with GemCap had a reduction of MDSCs (defined as CD11b+Lin-HLA DR-). However, this did not reach significance when comparing pre and post treatment sample for the entire population (152). Vizio et al report-ed a significant decrease in the level of Tregs after treatment which is sup-ported by two other studies (153-155). On the other hand, Plate et al could not see any effect on the levels of Tregs (156). No negative effects where noted on CD4+ effector cells when investigated, which can be due to the enhanced proliferation of Tregs compared to CD4+ effector cells. Gemcita-bine targets all dividing cells making the proliferating Tregs a greater target for the drug (154). A restoration of the levels of CD8+, CD4+, NK, natural killer T cells (NKT) and DCs after treatment with gemcitabine and cisplatin has been noted in a study be Bang et al. Further, they concluded that T cells had a retained proliferation capacity and NK cells had still good killing ca-pacity post treatment (157). Soeda et al also reported a positive effect of gemcitabine on the immune system with an increased absolute number and percentage of monocytes and CD11c+ DCs (158). Taken together, it seems like gemcitabine affects the immunosuppressive populations but spares the effector populations.

In paper I, we investigated the effects of gemcitabine with a focus on treatment naïve patients receiving their first cycle of chemotherapy. Samples were collected throughout a 28-day cycle with treatments given at day 1, 8,

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and 15 aiming to clarify how the immune cell populations are affected over time and if a favorable immune milieu is established during gemcitabine therapy.

Tumor microenvironment Only about 10% of the volume in the pancreatic tumor mass consists of ma-lignant cells. Instead, the tumor mass consists of a high infiltration of stroma cells, suppressive immune cells, and a large deposit of extra cellular matrix (ECM) which together forms the characteristic dense stroma known as desmoplasia. The ECM consists of collagen, fibronectin, proteoglycan, hya-luronic acid, enzymes and proteinases (159, 160). The dense stroma destroys the normal structure of the pancreas and compresses the vasculature and lymphatic vessels contributing to treatment resistance by increasing the in-terstitial pressure and reducing the perfusion (161, 162). There are some key players in the pancreatic tumor microenvironment. Their link to progression of the disease will be discussed below.

Pancreatic stellate cells Pancreatic stellate cells (PSC) constitute about 4-7% of the normal paren-chymal cells and are quiescent fat-storing cells containing vitamin A (163, 164). When PSCs become activated they change their morphology into myo-fibroblast-like cells expressing alpha smooth muscle actin (αSMA). In the normal pancreas, activated PSCs function as regulators of ECM protein syn-thesis and are involved in wound healing by stimulating fibrosis before re-turning to their quiescent state (165). In pancreatic cancer, PSCs remain in an activated state and are involved in a complexed cross-talk between tumor cells, immune cells and other cells present in the tumor microenvironment. Tumor cells produce growth factors including TGFβ, platelet-derived growth factor (PDGF) and fibroblast growth factor (FGF) that stimulates prolifera-tion of PSCs and their production of collagen. PSCs are they major source of fibrous proteins, like collagen, and are central in the generation of fibrosis seen in pancreatic cancer (166-168). In turn, PSCs stimulate the proliferation of tumor cells and at the same time they induce apoptosis resistance in the tumor cells (169). PSCs also contribute to progression of pancreatic cancer by being involved in invasion and metastasis. For example, PSCs can induce EMT and produce metalloproteinases that lead to degradation of the sur-rounding tissue (170, 171). The hypoxic nature of the microenvironment stimulates production of VEGF by PSCs leading to angiogenesis (172, 173). Moreover, PSCs are involved in the recruitment and differentiation of MDSCs and contribute to the lack of an anti-tumor response by inhibiting T cell infiltration and inducing apoptosis of T cells (174-176). Hence, the PSCs play a central role to maintain and progress pancreatic cancer.

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Immune cells The tumor microenvironment in pancreatic cancer is immunosuppressive with a high infiltration of TAMs, as well as MDSCs, and Tregs. The effector T cells are rarely present in the tumor (177-179). Infiltration of immune sup-pressive cells is linked to a negative impact on survival. For example, high infiltration of TAMs and Tregs are associated to a worse prognosis (57, 180). Expression of PD-L1 on pancreatic cancer cells is negatively correlat-ed to infiltration of CD8+ T cells and associated to a poorer prognosis (73). Similar to other cancer indications, an infiltration of both CD4+ and CD8+ cells in the tumor mass is associated to a better outcome (181). In a study by Ino et al, high infiltration of CD4+ and CD8+ cells in a combination with low infiltration of Tregs or a high infiltration of M1 macrophages in combi-nation with a low level of M2 macrophages had the most favorable impact on survival (182). Hence, despite the low mutational load, the immune sys-tem clearly has an impact in pancreatic cancer and there may be means to promote anti-tumor immunity to enhance patient survival.

Immunotherapy for pancreatic cancer Many different strategies have been tested or are currently in clinical trials for pancreatic cancer including checkpoint inhibitors, adoptive cell therapy, immune modulation, vaccination, and virotherapy.

Immune checkpoint inhibitors In a phase II trial invesigating αCTLA-4 (ipilimumab) for the treatment of advanced pancreatic cancer there was no responders as evaluated by RE-CIST, even if a patient showed delayed progression (183). Similarly, in a phase I study evaluating αPD-L1 (BMS-956559) treatment for advanced solid tumors no responders were seen among the patients with pancreatic cancer (184). This might be due to the immune suppressive tumor microen-vironment in pancreatic cancer which inhibits the formation of the anti-tumor response, and to the low frequency of somatic mutations that can give rise to neoantigens needed for the response. Patients with advanced pancreat-ic cancers have usually very low number of TILs (185). Only 13-17.4% of all patients with pancreatic cancer have MMR-d. In an ongoing clinical trial with pembrolizumab which included four pancreatic cancer patients with MMR-d, one had a partial response and three had stable disease (NCT01876511) (186).

Several clinical trials are recruiting pancreatic cancer patients to single agent studies with the checkpoint inhibitors αPD-L1 and αPD-1, including dose-escalation studies and studies with resectable patients. Combinations studies are also ongoing not only of αCTLA-4 with αPD-1/αPD-L1 but also

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combinations of the different immune checkpoint inhibitors with vaccina-tion, chemotherapy and tyrosine kinase inhibitors (187).

Adoptive cell transfer Several studies are ongoing with adoptive cell therapy including TIL–based therapy, TCR-modified T cells and CAR therapy (187). Even though TILs are uncommon in pancreatic cancer it is possible to expand them ex vivo. These expanded T cells are reactive against tumor-associated antigens (TAAs) expressed by pancreatic cancer e.g mesothelin and survivin and can kill autologous tumor cells in vitro (188). In the field of CAR therapy a clin-ical trial is ongoing, enrolling patients with pancreatic cancer for the treat-ment with CAR T cells directed against mesothelin (NCT01583686). In a case report, the treatment of two patients led to an initial anti-tumor response but both patients progressed thereafter. The CARs were only short term ex-pressed in this protocol since mRNA gene transfer was used (189).

Immunostimulation αCD40 antibody (CP-780,893) treatment in combination with gemcitabine has been tested for advanced pancreatic cancer. Four of the 22 patients treat-ed had a partial response and additional trials are ongoing (187, 190). Unlike other solid tumors where the effect of αCD40 therapy is dependent on T cells the effect in pancreatic cancer seems to be based on depletion of stroma by CD40-stimulated macrophages (191). Interestingly, in experimental mod-els of pancreatic cancer the addition of αCD40 to immune checkpoint inhibi-tors demonstrated that resistance to the checkpoint inhibitors was broken (192, 193).

Another form of immunostimulation that have been tested in pancreatic cancer is the use of whole-cell vaccination known as GVAX. GVAX is based on allogenic irradiated pancreatic cancer cells that are transfected to express GM-CSF (187). In clinical trials GVAX has been evaluated as single therapy or as combination therapy with chemotherapy or with a Listeria vac-cine, CRS-207, expressing mesothelin for metastatic pancreatic cancer. When evaluated in combination with cyclophosphamide no significant dif-ferent were seen compared to GVAX alone in regards to overall survival but the combination group had a higher induction of mesothelin-specific T cells (194). In the trial with GVAX/cyclophosphamide and CRS-207, an effect on overall survival could be seen compared to GVAX/cyclophosphamide (6.1 vs 3.9 months) and the effect was most noticeable when comparing the pa-tients that got three vaccinations (9.7 vs 4.6 months) (195). Today GVAX is evaluated in clinical trials as combination treatment with αPD-1 (NCT02451982 and NCT02648282) or as combination treatment with CRS-207, and αPD-1 (NCT02243371).

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Oncolytic virus therapy Several oncolytic viruses are explored for treatment of pancreatic cancer. An oncolytic adenovirus, ONYX-015, was tested in two clinical trials for locally advanced pancreatic cancer. Patients were treated with local injections into the tumor. The treatment was well tolerated but without any objective re-sponses (196). When ONYX-015 was combined with gemcitabine, two of 21 patients had a partial response (197). A HSV called HF10 was evaluated in another clinical trial. Partial response was seen in one of six treated patients (198). The oncolytic reovirus Reolysin that causes lysis of tumors with acti-vated KRAS has also been tested in clinical trial for pancreatic cancer. The virus was evaluated in combination with paclitaxel and carboplatin com-pared to paclitaxel and carboplatin alone. The combination was safe but no effect could be seen on progression-free survival (199).

There are some ongoing clinical trials with oncolytic viruses for pancreat-ic cancer, a combination study of HF10 with chemotherapy (NCT03252808), two dose-escalation studies of a genetically modified adenovirus encoding human PH20 hyaluronidase, called VCN-01 in combination with chemother-apy (NCT02045602 and NCT02045589), an oncolytic parvovirus (ParvOryx 02) (NCT02653313), and our oncolytic adenovirus virus LOAd703 (NCT02705196). Detailed information of the LOAd-virus platform includ-ing LOAd703 will now follow.

The LOAd-virus platform LOAd-viruses are oncolytic adenoviruses that encode human immunostimu-latory transgenes (Table 1). In paper II-IV the function of the first LOAd-viruses and their transgenes was evaluated using in vitro and in vivo experi-mental models of pancreatic cancer.

Table 1. LOAd-virus platform

Virus Transgene/s

LOAd(-) - LOAd700 TMZ-CD40L LOAd703 TMZ-CD40L, 4-1BBL LOAd713 TMZ-CD40L, scFv-aIL-6R

Adenoviruses Adenoviruses are non-enveloped double stranded DNA-viruses that cause infection of the respiratory and gastrointestinal tract in humans. The viruses have an icosahedral capsid made up by hexon proteins which give the shape of the virus. At the 12 vertices of the virus the penton bases and the trimer-

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ized fiber proteins are positioned (200). Packed inside the capsid is the ade-noviral genome (Figure 4).

Figure 4. A simplified schematic picture of the adenoviral structure.

The genome is divided into three different classes of genes, the early genes (E1A, E1B, E2A, E2B, E3 and E4), the delayed-early genes and the late genes (L1-5). The early genes are non-structural and are involved in the rep-lication of the virus and the escape from immune recognition. The late genes encode the structural proteins and other proteins needed for the creation of new virus particles. Human adenoviruses are divided into serotypes (total of 57) based on their sensitivity to neutralizing antibodies and then further sub-classified into 7 species (A-G) based on their hemagglutination profile (201). The adenoviral life cycle (Figure 5) starts with infection of human cells through the binding of the virus to its primary attachment protein, different serotypes of adenoviruses uses different entry molecules. Most adenoviruses including Ad5 bind to the coxsackie- and adenovirus receptor (CAR) with the knob domain followed by interactions between the penton base and cell surface integrins (202, 203). The interactions between the virus and the cell lead to clathrin-mediated endocytosis. The virus escapes the endosome due to a pH drop and is transported to the cell nucleus on microtubules due to binding of the hexons to dyneins. Once at the nucleus the adenoviral genome is injected into the core (204). Cellular proteins then bind to the E1A gene to initiate expression. E1A binds to the retinoblastoma protein (pRb) and re-leases E2F which is needed to push the cell cycle into S-phase. E1A also binds and activates the transcription of the other early genes which leads to replication of the virus genome. Once replication is started the late genes are expressed from the major late transcription unit. The proteins are transported to the nucleus and the new virus particles are assembled (205). Cell death is initiated through the expression of the adenovirus death protein (206).

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Figure 5. The adenoviral life cycle starting with the binding of the adenovirus to its main entry receptor e.g. CAR for Ad5 and ending with the release of new virus par-ticles and the lysis of the cells.

Adenoviruses have been used in gene therapy both as oncolytic viruses and as non-replication competent viruses for the delivery of transgenes into cells. Non-replication competent viruses are made through the deletion of viral genes needed for replications. The advantages of using adenoviruses as the chosen vector for therapy include that they are non-enveloped viruses which means that they can be stably packed as lyophilized preparations, the virus genome does not integrate into the cell genome, they are easy to produce, have a low cytotoxicity, large cloning capacity, and genes can be transferred to non-dividing cells (207). The disadvantage of using adenoviruses is that they are human pathogens and most humans have preexisting immunity against the viruses in the form of memory T cells and neutralizing antibodies (208-210).

LOAd backbone LOAd-viruses are chimeric viruses based on serotype 5 but with a serotype 35 fiber. Ad5 infects cells as mention above by binding to CAR but the sero-type 35-fiber instead binds to CD46. CD46 is abundantly expressed through-out the body on both healthy and transformed cells unlike CAR which is often downregulated on cancer cells (211, 212). The LOAd adenoviral back-bone has been further modified by a 24 base-pair deletion (Δ24) in the ade-noviral gene E1A and by a deletion of 6.7K/gp19K in the E3 gene region. The E1AΔ24 in the LOAd genome blocks replication of the virus due to its inability to bind to pRb. By introducing E2F binding site upstream of E1A LOAd viruses can replicate in cells with continuously free E2F which occurs in cells with hyper-phosphorylated pRb or dysregulated pRb (213). Most tumors have mutations in the pRb pathway due to its central role in control-

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ling proliferation, making the E1AΔ24 good strategy for restricting the repli-cation to tumor cells (214). When free E2F binds to the E2F binding sites, expression of the E1A gene is initiated and this activates transcription of other early genes. The adenoviral gene E4-6/7 forms complexes with E2F which further enhances expression of the E1A gene. In normal cells E2F bound to pRb will bind to the E2F binding sites which leads to docking of histone deacetylases and inhibition of E1A transcription which would limit the liver toxicity that is associated to free E1A in mice models (215-217). The deletion in E3 inhibits the virus evasion of immune recognition by CTLs since the 6.7K protein otherwise reduces the expression of TRAIL receptors on the surface of infected cells and the gp19K proteins traps MHC class I molecules inside the endoplasmic reticulum (218). The transgene cassette is placed after the L5 gene and the transgenes are controlled by a cytomegalovirus (CMV) promotor, enabling expression of the transgenes in any cell infected with LOAd viruses regardless if replication occurs (Figure 6).

Figure 6. The LOAd-virus back bone.

Transgenes TMZ-CD40L Trimerized membrane-bound isoleucine zipper CD40L (TMZ-CD40L) is based on the human wild-type CD40L but lacks the intracellular domain. Instead the extracellular and the transmembrane region is connected by a linker to an oligomerization domain know as an isoleucine zipper (219) (Figure 7). Natural occurring human CD40L is expressed by activated T cells, B cells, NK cells and platelets. It exists both as a transmembrane pro-tein and as a soluble protein (sCD40L) (220).

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Figure 7. Schematic view of TMZ-CD40L and wild-type CD40L (paper II). Re-published with permission from publisher.

The receptor CD40 is more abundantly expressed through the body and can be found on DCs, monocytes, macrophages, myofibroblasts, fibroblasts, epithelial and endothelial cells (221). CD40 can also be expressed by tumor cells and is expressed in pancreatic cancer. A high expression level of CD40 is associated with TNM stage and lymph node metastasis (222). The most potent signaling occurs when trimerized CD40L binds to trimerized CD40. The signaling outcome is dependent on the type of cells it occurs in (223). In B cells, CD40 signaling leads to proliferation, survival, class-switch of the B cell receptor, to formation of germinal centers and creation of a humoral response (220). CD40 signaling plays a central role in cell-mediated re-sponses where it is needed for activation of DCs that in turn activates the adaptive responses with focus on T-cell meditated immunity (10). Interest-ingly, ligation to CD40 expressed by tumor cells lead to apoptosis even though the receptor itself lacks deaths domains. Apoptosis-induction might be due to up-regulation of FasL and TRAIL on tumor cells, or due to the redox state of the tumors which leads to Ask-1 phosphorylation and activa-tion of the mitochondrial apoptosis pathway after CD40 engagement (224, 225).

We have previously evaluated a replication-deficient adenovirus encoding for wild-type CD40L, AdCD40L for its anti-tumor activity upon local deliv-

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ery into the tumor. We have shown immunostimulatory effects and tumor regression post treatment of mice (226-228), dogs (229, 230) and humans (100, 101, 231). In a clinical trial for bladder cancer the virus was delivered into the bladder cavity, whereupon increased TILs and IFNγ was detected in the tumor while decreased circulating Tregs were noted (100). In a clinical trial for malignant melanoma an increased T effector to Treg ratio, and in-creased expression of death receptors in the tumor lesion could be seen (231). Systemic exposure of CD40L recombinant protein causes dose-limiting liver toxicity but no severe toxicities have been reported in our trials with local CD40L gene delivery (232).

In paper II, the immunodulatory effects of the novel oncolytic virus LOAd700 encoding for TMZ-CD40L is presented.

4-1BBL 4-1BBL (CD137L) is expressed on activated professional APCs and can be induced by CD40 signaling in B cells and DCs (233-235). The receptor, 4-1BB (CD137), is expressed on a variety of immune cells including T cells, Tregs, DCs, myeloid cells, activated NK and NKT cells (236-239). Signaling in the 4-1BB:4-1BBL system is reciprocal, hence, reverse signaling into the ligand-expressing cells have also been reported. The reverse signaling in monocytes leads to activation, proliferation and survival (240). 4-1BB is induced on T cells after antigen recognition and the signaling is involved in proliferation, effector functions and survival due to up-regulation of anti-apoptotic proteins. Proliferation signaling is preferential seen in the CD8+ T cells (241, 242). Studies in mice have shown that 4-1BB signaling is CD28-independent in regard to survival and function of T cells (235, 243). Moreo-ver, signaling with 4-1BBL enhances the generation of memory T cells and can also induce a significant expansion of NK cells (244, 245).

Immunotherapy based on monoclonal antibodies against 4-1BB have been tested in clinical trials. (105). The systemic delivery of one of the mon-oclonal antibodies (urelumab) is associated with dose-limiting toxicity in the liver (246).

LOAd703 is encoding both 4-1BBL and TMZ-CD40L. Simultaneous ac-tivation of the CD40 and 4-1BB pathways in the tumor microenvironment may lead to stimulation of naïve tumor-reactive T cells via maturation of antigen-loaded DCs, but also to reactivation and expansion of already pre-sent effector cells including CTLs but also NK cells and macrophages. Since LOAd-viruses are administrated by local intratumoral injections the toxici-ties associated with systemic CD40 and 4-1BB activation will hopefully be avoided. In paper III, we present the function of the oncolytic virus LOAd703 in models of pancreatic cancer.

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scFv-aIL-6R Targeting of the IL-6 pathway is an interesting concept explored for cancer therapy. IL-6 signals through binding to its receptor, IL-6R (CD126) which exists as both a membrane-bound and soluble protein. For signaling, the IL-6R forms dimers with the ubiquitously expressed co-receptor gp130. Mem-brane-bound IL-6R is only expressed by hepatocytes, neutrophils, mono-cytes/macrophages and some lymphocytes but since gp130 is expressed by all cells, IL-6 signaling can occur in all cells due to the soluble form of the receptor (247). IL-6 signaling leads to phosphorylation of signal transducer and activator of transcription (STAT)3 that controls genes involved in pro-liferation, survival, angiogenesis, and immunosuppression (248). IL-6 is elevated in pancreatic cancer patients and is connected to a poorer prognosis but also to a poorer health status in general since IL-6 is related to cachexia and depression (249-251). IL-6 plays a central role in the progression of pancreatic cancer due to the IL-6-mediated STAT3 signaling that drives proliferation of the tumor cells (252). Further, IL-6 signaling can induce resistance to apoptosis (253). IL-6 signaling also triggers expression of TGFβ-1 that leads to collagen production and fibrosis of the pancreas (254). Moreover, IL-6 is involved in suppression of the immune system by inhibit-ing activation of dendritic cells, initiating differentiation of MDSCs and stimulating the production of Th2 cytokines (176, 255, 256). The major source of IL-6 in pancreatic cancer is TAMs, but IL-6 is also produced by other cells, including the previous mentioned PSCs (176, 252). IL-6R block-ade using the humanized monoclonal antibody tocilizumab is being evaluat-ed for treatment of cancer. Pre-clinical studies have shown that tocilizumab can inhibit cell growth of renal carcinoma, inhibit angiogenesis in oral squamous cell carcinoma and sensitizes chronic lymphatic leukemia cells to chemotherapy (257-259). Serval clinical trials are ongoing (clinicaltri-als.gov; NCT02767557, NCT01637532, NCT03135171).

In paper IV, we present LOAd713, an oncolytic virus expressing TMZ-CD40L in combination with a single chain variable fragment that blocks the IL-6R (scFv-aIL-6R).

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Aim of thesis

The overall aim of this thesis was to preclinically evaluate the immunostimu-latory viruses within the LOAd platform and to select the best candidate for clinical investigation.

Specific Aims Paper I To investigate the effect of gemcitabine, the standard treatment for pancreat-ic cancer, on the immune system and to evaluate if it is a suitable metro-nomic conditioning for LOAd immunotherapy.

Paper II To investigate the effect of an adenovirus encoding for CD40L or TMZ-CD40L on immune cells in vitro and in vivo.

Paper III To evaluate the novel oncolytic virus LOAd703’s capacity to kill pancreatic cancer cell but sparing normal cells, to activate human immune cells, and if gemcitabine will enhance or prevent the oncolytic capacity of the virus in vitro and in vivo.

Paper IV To evaluate the novel oncolytic virus LOAd713’s effect on blocking IL-6/IL-6R signaling in combination with CD40 stimulation on tumor cells, stellate cells and immune cells.

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Results and Discussions

Paper I Blood samples from 10 pancreatic cancer patients were collected during the first 28-day treatment cycle in which gemcitabine is administrated at day 1, 8, and 15. Samples were collected at day 1, day 8, day 15 and 29. The level of immunosuppressive cells such as Tregs, granulocytic MDSCs and mono-cytic MDSCs were elevated in the treatment naive patients compared to healthy controls. Gemcitabine is a known suppressor of myeloid cells and the level of granulocytic MDSCs decreased during the treatment cycle. In-terestingly, so did the levels of Tregs. However, for both granulocytic MDSCs and Tregs the effect was lost during the resting week and levels were normalized to that of the starting level indicating the need for continu-ous conditioning to have a sustained effect. The immunosuppressive cyto-kine TGFβ-1 was significantly decreased by gemcitabine treatment during the cycle but after the resting week this effect was also lost. The decrease of TGFβ-1 probably explains the effect seen on the lymphocyte population since only the Tregs were negatively affected. The patients had equal levels of CD3+ cells throughout the gemcitabine cycle. Stimulation of the patients’ peripheral blood mononuclear cells (PBMCs) with anti-CD3 and IL-2 gave the same strong proliferative response as PBMCs from healthy controls.

Paper II LOAd700, an oncolytic adenovirus expressing TMZ-CD40L was evaluated for its capability to kill pancreatic tumor cell lines and stimulate immune cells after infection. Expression analysis showed that TMZ-CD40L was re-tained on the surface of infected cells, indicating that treatment with LOAd700 would reduce the possibility of systemic toxicity seen in patients treated with recombinant sCD40L. Infection of four different pancreatic cell lines in vitro led to a decreased viability after 48 hours compared to unin-fected cells, or cells infected with a replication-deficient virus. The decrease in cell viability was equal to that of cells infected with LOAd(-), a virus without transgenes, showing that the addition of the transgene did not affect the oncolytic capability of the virus. Treatment of tumor-bearing mice in a xenograft model with LOAd700 or LOAd(-) led to a decreased tumor growth

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compared to PBS. No difference could be noted between LOAd700 and LOAd(-) due to the lack of cross-reactivity between human CD40L and mu-rine CD40. When evaluating the immunomodulatory effect of the virus, an-imals treated with a murine version of LOAd700 had an increased ratio of M1/M2 macrophages compared to PBS-treated animals. LOAd700-infection of human monocyte-derived DCs resulted in an increased expression of mat-uration markers like CD83, CD86 and CD70, and an enhanced production of cytokines including IL-12(p70), IFNγ and TNFα compared to LOAd(-) in-fected DCs. Hence, the virus alone is not enough for full activation of DCs even if the stimulation of toll-like receptors by the virus back bone can also trigger some degree of activation. LOAd700-infected DCs could also expand antigen-specific T cells reactive to CMV-antigen pp65 to a higher extent than LOAd(-)-infected DCs. For an efficient immunotherapy it is not enough to expand antigen-specific T cells, the T cells also has to be able to move into the tumor microenvironment from the vessels. Since endothelial cells express CD40, the effect of LOAd700 was investigated on human endotheli-al cells. Interestingly, LOAd700-infected endothelial cells upregulated markers needed for attachment and transmigration. To investigate if lym-phocytes are indeed migrating to the tumor after CD40 stimulation in vivo, an Ad5 virus expressing murine CD40L was used, mAdCD40L, due to the lack of entry receptor for LOAd-viruses on murine cells. mAdCD40L treat-ment of the B16 tumor model prior to infusion of tumor-specific T cells in-creased the infiltration of T cells into the tumor compared to animals only treated with the T cells indicating that CD40L can enhance the migration of T cells into the tumor. This might be due to the activation of the endothelium and/or the possible modulation of the microenvironment to produce factors such as chemokines needed for T cell migration.

Paper III LOAd703, an oncolytic adenovirus encoding TMZ-CD40L in combination with 4-1BBL was preclinically evaluated. Similarly to LOAd700, LOAd703 could kill pancreatic cancer cell lines in vitro and control tumor growth in vivo in a xenograft model. The addition of gemcitabine to the treatment in vitro or in vivo did not hamper the effect of the virus indicating that it is pos-sible to combined the two for treatment of pancreatic cancer. To check the specificity of the virus, human pancreatic exocrine cells were infected with the virus. No difference in viability could be seen between LOAd703-infected cells and cells infected with a replication-deficient virus. Infection of tumor cells will not only lead to oncolysis but also to expression of the transgenes that could modulate the expression of tumor-promoting proteins. LOAd703 infection led to a significant down-regulation of CXCL16 a pro-tein that promotes invasiveness and at the same time upregulated the T cell

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chemoattractant CXCL10. This however was not seen in tumor cells infected by LOAd700 indicating an added effect of combining TMZ-CD40L with 41-BBL. Local injection of LOAd703 into the tumor will not only lead to infec-tion of tumor cells but also infection of stroma cells and infiltrating immune cells. LOAd703-infection and LOAd700-infection of PSCs led to a de-creased level of tumor-promoting factors like galactin-3 (Gal-3) and FGF5 but also to a decrease of LAP-TGF that is involved not only in immunosup-pression but also in the formation of the desmoplastic stroma seen in pancre-atic cancer. Infection of human endothelial (HUVC) cells led to upregulation of factors involved in lymphocyte attachment and transmigration. Infection of DCs with LOAd700 and LOAd703 resulted in an upregulation of matura-tion markers including CD83, CD86, and CD70, and to production of cyto-kines including IL-12(p70) and IFNγ. The effect on DCs were must pro-nounce in LOAd703 and a more detailed look at the markers produced by these cells reveled a significant upregulation of chemokines, cytokines and co-stimulatory molecules compared to LOAd700. The matured DCs could expand antigen-specific T cells in a CMV model system. LOAd703 expand-ed the highest number of total cells without given rise to significantly more CMV-specific T cells. In depth analysis revealed that LOAd703 also ex-panded NK cells.

Paper IV LOAd713, an oncolytic virus encoding TMZ-CD40L and a scFv-aIL-6R were preclinically evaluated. The addition of the two transgenes into the virus did not negatively affect the oncolytic capability of the virus since LOAd713-infected pancreatic cancer cell line showed an equal decrease in viability as LOAd(-)-infected cells. The presence of scFv-aIL-6R in superna-tant from LOAd713-infected cells reduced the level of IL-6-induced STAT3 phosphorylation in pancreatic tumor cells. Pancreatic cancer is defined by its desmoplastic stroma where stellate cells produce factor involved in prolifera-tion, immunosuppression, invasion, and remodeling of the cellular matrix. Infection of human PSCs led to a reduction of LAP-TGF and the TGFβ-induced protein collagen type I that are involved in the fibrotic transfor-mation of the pancreas. Moreover, LOAd713-infection also reduced factors connected to tumor progression and suppression of anti-tumor responses like FGF5, hepatocyte growth factor (HGF) and TWEAK and at the same time upregulated the production of CCL20 that supports T lymphocyte infiltra-tion. This indicates that LOAd713 can modulate stellates cells in beneficial way. Pancreatic cancer is defined by its immunosuppressive tumor microen-vironment with infiltration of MDSCs. Culturing of PBMCs with condition-ing medium containing IL-6/GM-CSF leads to differentiation of MDSCs. Supernatants from LOAd-virus-infected cells were added to the cultures,

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which led to a block in differentiation. However, no difference could be seen between the different virus groups indicating that the block in differentiation is not related to the transgenes but to the inflammatory response to the virus itself. The addition of scFv-aIL-6R did not affect TMZ-CD40L capability to induce maturation of DCs. Interestingly, LOAd713-infected DCs had re-duced upregulation of the immunosuppressive molecules PD-L1 and PD-1 compared to LOAd700-infected cells.

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Conclusions

Paper I Gemcitabine can reduce immunosuppressive cells and the immunosuppres-sive molecule TGFβ while sparing the effector T cells indicating that condi-tioning treatment with gemcitabine before immunotherapy is a possibility for pancreatic cancer. However, the effect is lost during the 14 days after the final dose. We therefore conclude that gemcitabine should be given as met-ronomic conditioning of patients during LOAd immunotherapy.

Paper II TMZ-CD40L is an oligomerized molecule that is retained in the cell mem-brane compared to wild type CD40L that is also shed from the cells. LOAd700, encoding TMZ-CD40L is capable of killing pancreatic cell lines by oncolysis while TMZ-CD40L expression can drive an anti-tumor re-sponse through the activation of the endothelium, stimulation of myeloid cells, maturation of DCs, and expansion of antigen-specific T cells. We con-clude that CD40 stimulation is an interesting cancer therapeutic option and that TMZ-CD40L is better retained on the cell surface than wildtype CD40L. Therefore, a novel therapeutic agent would likely benefit from encoding TMZ-CD40L.

Paper III LOAd703 is capable of killing pancreatic tumor cells by oncolysis in vitro and in vivo, even in the presence of gemcitabine. It is a more potent immune activator than LOAd700 due to the combination of TMZ-CD40L and 4-1BBL. LOAd703 can also change two of the characteristic of pancreatic cancer, the desmoplastic stroma and the immunosuppressive microenviron-ment. We conclude that LOAd703 is a strong immune enhancer and a prom-ising clinical candidate.

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Paper IV LOAd713 can target pancreatic cancer by killing tumor cells through oncol-ysis, by activating the immune system and by reducing factors involved in desmoplasia. IL-6R signaling blockade could prevent DC upregulation of the PD-L1/PD-1 receptors after CD40-mediated activation. We conclude that LOAd713 is an interesting candidate for IL-6-driven tumors.

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Future Perspectives

Clinical trials LOAd703 has shown to be the best immune stimulator in our investigations even if LOAd713 also have many interesting features. One clinical trial is initiated in Houston, TX and another will hopefully begin soon in Sweden, both sponsored by Lokon Pharma AB.

LOAd703 Oncolytic Virus Therapy for Pancreatic Cancer Patients diagnosed with low tumor burden, locally advanced or metastatic pancreatic cancer not eligible for surgery are included into a phase I/IIa clin-ical trial (NCT02705196) at Baylor College of Medicine and Baylor St. Luke’s Medical Center, Houston, TX. The patients will receive image-guided intratumoral injections of LOAd703 during their standard-of-care treatment with gemcitabine and nab-paclitaxel. Primary outcome of the trial is to evaluate the safety of the virus administration. Secondary outcomes are to investigate the presence of virus over time and immunomodulatory effect of the virus in blood samples as well as effect on tumor size and patient sur-vival.

LOAd703 Oncolytic Virus Therapy for Solid Tumors Patients diagnosed with different kinds of solid tumors (pancreatic, colorec-tal, biliary, and ovarian) will be included into a clinical trial at Uppsala Uni-versity Hospital. The patients will receive image-guided intratumoral injec-tion of LOAd703 into tumor lesions as an add-on therapy to their standard-of-care chemotherapy, or together with gemcitabine metronomic condition-ing if there are no standard-of-care options available (e.g. last line). The study will be a phase I/IIa trial with safety as the primary endpoint. Second-ary outcomes are to investigate the presence of virus over time and im-munomodulatory effects of the virus in blood samples as well as effect on tumor size and patient survival.

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Combination therapy An interesting concept is the combination of different type of therapies for treatment of cancer. In the first clinical trial the combination of immunother-apy and chemotherapy is tested in the form of LOAd703 given together with gemcitabine and nab-paclitaxel.

Immunotherapy/immunotherapy LOAd-viruses could be combined with anti-PD-1/PD-L1 therapy where the killing of tumor cells by the virus would lead to release of tumor antigens that could be taken up by DCs in the tumor microenvironment. The addition of the immunostimulatory transgenes in the virus would potentiate the virus-induced immune activation. Activated T cells produce IFNγ which could lead to upregulation of PD-L1 on tumor cells and immune cells which would then lead to an inhibition of the response (260). Combination of the LOAd therapy with antibodies against immune checkpoint molecules could release this negative effect on T cells and lead to a more potent and long lasting response. As mentation above, immune checkpoint inhibitors have shown little effect in pancreatic cancer but in animal models the addition of αCD40 to the therapy can increase the effect (192, 193). Since our viruses also are immunostimulators it is not unlikely that they would contribute to the thera-py in a similar fashion.

A negative aspect of this type of combination therapy is the fear that the release of the break on T cells would not mainly affect the T cells primed against tumor antigens but those primed against viral antigens. This would then hamper the anti-tumor response and lead to a more effective clearing of the virus. The combination of LOAd-viruses with anti-PD-1/PD-L1 needs to be investigated in animal models prior to clinical use. We are therefore de-veloping a model with murine tumor cells expressing human CD46 to allow LOAd infection. Another interesting combination is LOAd703 together with tocilizumab to see if the promising features of LOAd703 and LOAd713 can be combined. Another possibility would be to combine LOAd703 therapy with TIL or CAR therapy were the virus capacity to create a favorable mi-croenvironment inside the tumor could lead to stimulation and attraction of T cells (and NK cells). At present, we are collecting preclinical data with the incucyte technology prior to in vivo models. This could open up for a treat-ment combination for lymphoma patients since we already have a CAR trial ongoing for those patients.

Immunotherapy/angiogenesis inhibitors Another interesting combination strategy is the possibility of combining LOAd-viruses with angiogenesis inhibitors. Solid cancers have an abnormal

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vasculature with immature vessels and a loss of structure which leads to low perfusion and leaky vessels. The microenvironment in pancreatic cancer has high levels of pro-angiogenesis factors like VEGF and FGF that could be targeted. For example, anti-VEGF therapy would lead to a break in the mas-sive angiogenesis signaling which would ultimately lead to normalization of the vasculature and better access for infiltrating immune cells that could be activated by the LOAd-viruses. However, patients receiving anti-angiogenic therapy has an increased bleeding risk which may not allow for intratumoral injection techniques.

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Populärvetenskaplig sammanfattning

Pankreascancer (bukspottkörtelcancer) är en aggressiv cancerform där medelöverlevanden efter diagnos är under ett år. Runt 20% av alla patienter kan genomgå kirurgi i syfte att bota patienten men för de flesta så leder detta inte till en friskförklaring. Resterande patienter får cellgifter i syfte att för-länga liv och minska symptom. Nya behandlingsalternativ för patienter med pankreascancer måste utvecklas. En typ av behandling som utforskas är im-munterapi. Immunterapi bygger på idén att vårt immunförsvar kan känna igen och döda cancerceller precis på samma sätt som det gör med virus efter en infektion. Så varför finns då cancer om vårt immunförsvar har denna otro-liga förmåga? När cancer uppstår i kroppen så kommer immunförsvaret att försöka ta död på alla cancerceller genom att skapa ett så kallat antitumör-försvar. Antitumörförsvaret genereras genom att immunceller kallade dend-ritiska celler tar upp delar av tumören och visar upp dessa för effektorceller-na, som också kallas T-mördarceller. Dessa T-mördarceller blir då aktive-rade till att känna igen och döda cancercellerna i tumören. Cancercellerna kan undkomma T-mördarcellernas försök till att avlägsna tumören genom att på olika sätt maskera sig så att T-mördarcellerna inte längre känner igen dem. Cancerceller och deras stödjeceller inuti tumören kan också tillverka immunhämmande proteiner som ser till att miljön i tumören påverkar im-munceller inkl T-mördarceller så att de inte längre kan fungera. Detta kallas för immunhämning. Med immunterapi vill man hjälpa immunförsvaret ge-nom att tillföra extra aktivering och motverka immunhämningen. Man kan då få immunförsvaret att känna igen cancercellerna på nytt.

I denna avhandling presenteras en typ av immunterapi som bygger på onkolytiska virus tänkt som behandling för pankreascancer. För att immunte-rapi effektivt ska kunna ges till patienter så måste det kunna kombineras med den standardterapin som finns i dag. För majoriteten av pankreaspatienter är det cellgiftet gemcitabin. Gemcitabin dödar cancerceller genom att hindra dem ifrån att dela sig. Det negativa med detta ur ett immunterapiperspektiv är att gemcitabin inte är selektivt utan kan hindra alla celler i kroppen från att dela sig, inklusive immuncellerna som utgör antitumörförsvaret. I artikel I så utvärderades gemcitabins påverkan på immunförsvaret. Blod samlades in ifrån patienter precis innan och under det att fick sin första behandling med cellgiftet. Utvärderingen visade att gemcitabin har en förmåga att minska andelen immunhämmande celler, alltså de celler som bidrar till att hämma antitumörförsvart, i blod. Gemcitabinbehandling minskade även

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nivån av immunhämmande proteiner. Både de immunhämmande cellerna och proteinerna återställdes till sina ursprungliga nivåer när gemcitabin inte gavs under en period. Gemcitabin hade däremot ingen negativ påverkan på nivån T-mördarceller eller deras funktion vilket tyder på att man kan kombi-nera gemcitabin och immunterapi.

Onkolytiska virus är cancerdödande virus genom att de infekterar och förökar sig i cancerceller vilket leder till att cellerna sprängs (lyseras) när nya virus frisätts. Onkolytiska virus kan ej föröka sig i friska celler och kan därför inte skada kroppens vanliga celler och vävnader. Denna avhandling fokuserar på vad vi kallar LOAd-virus. LOAd-virus har sitt ursprung från adenovirus som normalt sett orsaker infektioner i luftvägarna hos människor (eg vanlig förkylning). De är genetiskt modifierade virus, vilket betyder att man har förändrat virusets DNA på ett sådant sätt att det bara kan föröka sig i cancerceller och inte i friska celler dvs de har blivit onkolytiska. Förutom att vara onkolytiska så bär även LOAd-virusen på olika mänskliga gener, så kallade transgener. Dessa transgener har förmågan att stimulera immunför-svaret till att bli aktivt och/eller påverka miljön i tumören på att sådant sätt att det gynnar antitumörförsvaret. I artikel II så utvärderades det virus som kallas för LOAd700 som bär på en ny form av CD40L. CD40L har en cen-tral roll i immunförsvaret genom att den är nödvändig för aktiveringen av dendritiska celler. Dendritiska celler är, som har nämnts tidigare, nödvändiga för att aktivera T-mördarcellerna i antitumörförsvaret. I artikel II fokuserade vi på hur man kan använda ett onkolytiskt virus för att få in CD40L i tumö-rer. Resultatet visade att LOAd700 kan döda (onkolys) pankreascancerceller och aktivera dendritiska celler. Dessa aktiverade dendritiska celler kunde i sin tur aktivera T-mördarceller. Förutom detta ledde även infektion av en-dotelceller, cellerna som bygger upp blodådrorna i kroppen, till aktivering av dessa. Denna aktivering kan hjälpa T-mördarcellerna att ta sig ifrån blodet in till tumören.

I artikel III och IV utvärderades två olika LOAd-virus som båda bär på CD40L i kombination med andra gener. Artikel III handlar om LOAd703 som i kombination med CD40L uttrycker en annan immunstimulerande gen som heter 4-1BBL. I likhet med LOAd700 så ledde LOAd703-infektion till onkolys av pankreascancerceller och när virusets selektivitet utvärderades kunde ingen onkolys uppmätas i frisk vävnad. Kombinationen av CD40L och 4-1BBL i LOAd703 ledde till ännu bättre aktivering av dendritiska cel-ler än om CD40L var ensam (LOAd700). Stödjecellerna i pankreascancer bidrar till att förstöra den normala vävnaden genom att skapa fibros och även till att hämma immunförsvaret. Infektion av dessa stödjeceller med LOAd703 ledde till att de började producera mindre av de negativa faktorer som annars leder till fibros och hämning av immunförsvaret.

I artikel IV presenteras arbetet med LOAd713 som i kombination med CD40L bär på en blockeringsmolekyl som stoppar signaler mellan interleu-kin-6 och dess receptor. Interleukin-6 är ett av de proteiner som orsakar

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fibros och immunhämningen i pankreascancer. Om man blockerar interleu-kin-6 kan man därför motverka fibros och immunhämning. I likhet med de tidigare virusen så kunde LOAd713 döda pankreascancerceller via onkolys och aktivera dendritiska celler. En viktig observation var att när LOAd713 användes för att aktivera dendritiska celler så ledde detta till en minskad produktion av två faktorer som är centrala i hämningen av immunförsvaret, PD-1 och PD-L1. LOAd713 kunde också påverka stödjecellerna på ett posi-tivt sätt genom att motverka interleukin-6 signalering.

Resultatet av forskningen i denna avhandling har lett till en klinisk studie där LOAd703 utvärderas i kombination med cellgifter för behandling av pankreascancer. Studien pågår just nu på Baylor College of Medicine och Baylor St. Luke’s Medical Center i Houston, USA. En studie i Sverige för-väntas starta snart.

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Acknowledgments

This thesis was performed at the Department of Immunology, Genetics and Pathology (IGP), Rudbeck Laboratory, Uppsala University. The work was possible by funding from The Swedish Research Council, The Swedish Can-cer Society, Swedish State Support for Clinical Research (ALF), and by a research contract agreement with Lokon Pharma AB. Jag vill först tacka mina handledare under denna doktorandtid, min huvud-handledare Angelica och mina bihandledare Gustav och Lena. Angelica, tack för att jag fick chansen att jobba med detta projekt, att få vara delaktig i något med det ultimata målet att nå kliniken är fantastiskt. Du är verkligen en sann inspirationskälla med all din kunskap och ditt arbete för att kunna hjälpa patienterna. Gustav, tack för all din kunskap och värdefulla kommen-tarer om pankreascancer och för att jag har fått följa med på auskultering hos dig. Lena, du är en inspirationskälla och tack för alla givande kommentarer rörande mitt arbete. Jag skulle också vilja tacka Sara och Magnus för alla givande kommentarer och kluriga frågor när jag har presenterat mina pro-jekt. Sara, tack också för alla trevliga cykelrundor som slutade med en fan-tastisk tjejvättern. Tack till Christina och Helene på administrationen, ni har varit gulvärda under denna doktorandtid.

I would also like thank all the patients that donated blood in paper I, without their contribution the paper would not have been a possibility.

Big thanks to all the co-authors of the three papers and the one manuscript in my thesis. A special thanks to Rafael Moreno and Ramon Alemany for expanding my knowledge of oncolytic viruses. Erika, hur kan jag med ord beskriva vad det har betytt för mig att vi har följts åt på denna resa, från våra mastersprojekt till våra disputationer. Allt som har hänt under denna tid, ifrån träningssektioner och tjejklassikern till trevliga lunchträffar under mammaledigheten, det har varit superkul att ha någon att dela allt detta med. Lotta, hur skulle vi klara oss utan dig. Jag äls-kar din förmåga att kunna ta en diskussion bara så där lite för långt. Jessica, I am so happy that you decided to join the LOAd-virus project. Thanks for a

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great collaboration on paper I, for wonderful company at conferences and all the good times in the lab and lunch room. Tanja, jag är superglad att du började jobba hos oss. Våra nördiga diskussioner vad det nu än handlar om förgyller verkligen dagen. Sedi, det är så kul när nya personer kommer in i projektet. Ett stort tack för att du även har öppnat mina ögon för de godast kakor som finns. Ioanna, thanks for all your help with the LOAd-virus pro-ject and for your contributions to paper II-IV. Justyna, tack för all hjälp och även kommande. Din kunskap rörande allt du håller på med är verkligen beundransvärd. Pella och Berith, labbet är inte sig likt utan er. Berith, jag saknar våra diskussioner i viruslabbet tidigt på morgonen, nu är jag oftast själv där inne så tidigt. Tack för all hjälp med virusproduktioner. Jag hoppas du njuter av din pension. Pella, jag saknar att labba ihop med dig. Du är all-tid så glad och omtänksam. Frida och Gunilla det är alltid lika roligt när ni tittar förbi. Vem ska jag diskutera feminism med när du inte är här, Frida. Tina tack för alla spännanade samtalsämnen och för alla böcker som jag har fått låna av dig. Jag hoppas bara att vi inte skrämmer dig allt för mycket. Di, thanks for always taking the time to answer all of my questions. Chuan, Kiki, Jing, Mohan, Miika, Minttu-Maria, Kim, Iliana, Mohamed and Luuk thank you for making this to one of the best working environments. Lisa, Lina, Linda, Camilla, Joachim och Hannah, ni är saknade! Sofie, Victoria, Ingrid, Hanna och Bejan, tack för alla middags-dejter och soffhäng där inget ämne är för litet eller för galet att diskuteras. Astrid, Karro, Matilda, Aleks, Maria och Sara, tack för att ni alltid finns där oavsett hur lång tid som har gått sedan vi sist sågs. Margaretha och Lars, tack för att ni har välkomnat mig in i familjen Eriks-son. Mamma, pappa, Linus och mormor, tack för alla stöttning och för att ni alltid finns där för mig. Visst är det ändå inte lite konstigt att jag snart har uppfyllt min barndomsdröm! Henrik och Viggo vad vore livet utan er, ni som är mina största stöttepelare. Jag vet inte hur jag skulle ha klarat denna tid utan er och jag ser med spän-ning fram emot nästa del av våra liv. Älskar er♥

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Acta Universitatis UpsaliensisDigital Comprehensive Summaries of Uppsala Dissertationsfrom the Faculty of Medicine 1379

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A doctoral dissertation from the Faculty of Medicine, UppsalaUniversity, is usually a summary of a number of papers. A fewcopies of the complete dissertation are kept at major Swedishresearch libraries, while the summary alone is distributedinternationally through the series Digital ComprehensiveSummaries of Uppsala Dissertations from the Faculty ofMedicine. (Prior to January, 2005, the series was publishedunder the title “Comprehensive Summaries of UppsalaDissertations from the Faculty of Medicine”.)

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