FC21-NK-cell adoptive immunotherapy in patients with ...€¦ · FC21-NK infusions were performed...
Transcript of FC21-NK-cell adoptive immunotherapy in patients with ...€¦ · FC21-NK infusions were performed...
Presented at the 56th American Society of Clinical Oncology (ASCO) Virtual Annual Meeting, May 29–31, 2020, Chicago, IL, United States
CD56bright/CD16bright FC21-NK-cell adoptive immunotherapy in patients with concurrent CNS disease and relapsed or refractory (R/R) AML
LUCIA SILLA,1 ALESSANDRA PAZ,2 NELSON HAMERSCHLAK,3 ROSANE BITTENCOURT,2 DEAN A LEE4
1Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; 2Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; 3Hospital Albert Einstein, São Paulo, SP, Brazil; 4Nationwide Children’s Hospital, Columbus, OH, [email protected]
• Patients with relapsed or refractory acute myeloid leukemia (R/R AML)and concurrent central nervous system (CNS) disease rarely respond tochemotherapy and have a dismal prognosis1
• Adoptive immunotherapy with haploidentical ex vivo-activated/expandednatural killer (NK) cells shows promise in refractory AML2–4
• However, it is unknown whether the blood–brain barrier (BBB) represents anobstacle to this approach in patients with R/R AML and CNS disease
• Double-bright (CD56bright/CD16bright; DB) NK cells are generated fromperipheral blood using transfected feeder cells expressing membrane-boundinterleukin-21 (mbIL-21) and 4-1BB ligand (FC21)5
• FC21-derived NK cells present a unique DB phenotype and expresshyperfunctional characteristics with high levels of cytolytic activity5
• In a phase I study (NCT02809092), we investigated multiple doses of DB FC21-NK cells following standard fludarabine, cytarabine, and granulocyte-colonystimulating factor (FLAG) induction in patients with R/R AML
INTRODUCTION
• To investigate preliminary safety and efficacy data in a subgroup of patientswith R/R AML and concurrent CNS disease from this phase I study
OBJECTIVE
METHODS• This open-label, phase I study was performed in patients treated at a single
center in Brazil• Eligible patients were ≥2 years old, with R/R AML; a Karnofsky or Lansky
performance status score of ≥70; and adequate renal, liver, andpulmonary function
• Eligible donors were a human leukocyte antigen-haploidentical relativeselected for best NK alloreactivity
• Cytogenetic risk was determined according to European LeukemiaNet(ELN) guidelines6
• FC21 cells were expanded from donors on FC21 feeder cells aspreviously described5
• The treatment schema is shown in Figure 1
Figure 1: Treatment schema
FC21-NK infusions were performed 2–14 days after FLAG chemotherapy.*Up to 28 days for some cultures.ANC, absolute neutrophil count; G-CSF, granulocyte-colony stimulating factor.
Day -30
Cryopreservation
-7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7
(Continues thrice weeklyfor 6 IV infusions in total)
G-CSF 5 µg/kg dailyfrom day -7 untilpost-nadir ANC ≥1000
Fludarabine(30 mg/m2 daily × 5)
Cytarabine(2 g/m2 daily × 5,4 hours after fludarabine)
Donor blood obtained
FC21-NK infusion Treatment day
NK-cell expansionon FC21 × 14 days*
FC21-NK infusions were performed 2–14 days after FLAG chemotherapy.*Up to 28 days for some cultures.ANC, absolute neutrophil count; G-CSF, granulocyte-colony stimulating factor.
• This post hoc analysis assessed the following outcomes in a subgroup ofpatients with concurrent CNS disease:– Overall response; assessed at day 28 using the International Working
Group (IWG) response criteria7
– CNS responses; assessed at day 30 using the Response Assessment inNeuro-Oncology (RANO) criteria8
– Adverse events (AEs); reported from day 0 up to day 56 and gradedaccording to the Common Terminology Criteria for Adverse Events(CTCAE) version 4
• Gene expression profiling was performed by next-generation sequencingon mRNA libraries (TruSeq RNA Sample Preparation Kit. Illumina Inc., SanDiego, CA) made from total RNA extracted from NK cells prior to and aftermbIL-21 expansion
Patient characteristics• Of 13 patients treated with FLAG chemotherapy followed by FC21-NK,
4 patients had concurrent CNS disease and were included in this analysis• Characteristics of patients with CNS disease are summarized in Table 1
– All 4 patients had received a prior stem cell transplant and were heavilypretreated, and 1 patient had primary refractory disease
– Two patients were treated under compassionate use
Table 1: Patient characteristicsCharacteristic Patient 1 Patient 4 Patient 5* Patient 6*
Sex Female Male Male Female
Age, years 48 31 22 1.6
CNS involvement Mycetoma‡ Bone and nerve root
Uncus/brain stem Chloromas
Cytogenetic risk‡ Favorable Favorable Adverse Intermediate
Chromosomal aberrations
inv(16)(p13;q22)
t(8;21)(q22;q22)
t(6;9)(p22;q34) DEK/NUP214 Normal
Prior treatments, n 6 4 7 5
Prior SCT Autologous Allogeneic Allogeneic Haploidentical
Relapse, n or refractory 4 2 3 Refractory
*Patient treated under compassionate use;†Diagnosed during treatment. SCT, stem cell transplant;‡Patients were wild-type for FLT-3 internal tandem repeat mutations.
Treatment exposure and safety• Treatment exposure is shown in Table 2; all patients completed ≥6 IV infusions
of FC21-NKTable 2: Treatment exposureCharacteristic Patient 1* Patient 4 Patient 5 Patient 6
Cell dose per infusion 1 × 106/kg 5.5 × 106/kg 8.3 × 106/kg 6.6 × 106/kg
Number of infusions 11 6 6 6
*Patient 1 completed 2 FC21-NK treatments: the first treatment comprised 6 infusions of FC21-NK only; the secondcomprised 5 infusions of FC21-NK following FLAG chemotherapy (6th infusion discarded due to contamination of the infusion sample).
• All patients experienced grade 4 febrile neutropenia attributed to hematologictoxicity secondary to FLAG
• AEs considered to be related to treatment are shown in Table 3; all weremanageable
• No FC21-NK cell infusion-related toxicities or cytokine storm syndromewere reported
• Patient 5 experienced graft-versus-host disease (GVHD):– Grade 1 acute GVHD occurred 2 days after the last FC21-NK infusion and
was managed with tacrolimus and high-dose steroids– Re-activation of chronic liver GVHD was suspected at day 38; this resolved
after removal of hepatotoxic medications including tacrolimus
Table 3: Adverse events considered to be related to FC21-NK cell treatment
Adverse event Grade Description
Patient 1*
Worsening of pulmonary symptoms 3
Pre-existing invasive pulmonary aspergillosis, managed
with voriconazole
Probable CNS aspergillosis 2 Resolved without medication
CNS hypertension 2 Transient, secondary to CNS inflammation
Patient 4 Anemia 4 Resolved with high-dose dexamethasone
Patient 5 CNS hypertension 4Transient, secondary to CNS inflammation. Resolved with high dose dexamethasone
*AEs experienced by patient 1 occurred during the first treatment.
Treatment outcome• All four patients showed a response (Table 4)
Table 4: Outcome after treatment with FC21-NK following FLAG chemotherapyCharacteristic Patient 1 Patient 4 Patient 5 Patient 6
Response CR CRi CR PR
Duration of response*, days 151 31 168 90
Time to patient death†, days 344 176 505 224
*Time from first reporting of response to relapse; †Time from start of the protocol (from the first FC21-NK infusion in the caseof patient 1 who did not receive FLAG in her first treatment).
Responses were durable, lasting up to 5.5 months (Figure 2)• CNS responses as indicated by cellular infiltration or the resolution of CNS
lesions, was observed in all four patients with nervous system lesions (includingprobable aspergilloma), shown in Figure 3:– Complete resolution of CNS lesions were documented in patients 1
and 5, and patient 1 also experienced no relapse of pulmonary or CNSaspergillosis
– Almost complete resolution of bone and nerve root leukemic infiltrationwas observed in patient 4, and patient 6 experienced a 50% reduction ofCNS chloromas
Figure 2: Swimmer plot showing the course of patients with R/R AML and CNS involvement
0 90 180 270 360 450
PR PD PD/Other TxCR ProtocolCRi
R D1
D4
R
R
5
6
Days
R
D
R relapse DeathD
#Patie
nt
Swimmer plot of patient courses, indicating duration of protocol therapy, remission, relapse or persistent disease, additional therapy, and death. CR complete response; CRi, complete response with incomplete hematologic recovery; D, death; PD, progressive disease; PR, partial response; R, relapse; Tx, treatment.
Figure 3: CNS responses in patients treated with FC21-NK after FLAG chemotherapy
Head MRI of patient #1, showing parenchymal mycetoma obtained (left), and resolution at day 28 (right).
Spine MRI of patient #4 showing sacral leukemic infiltration with soft tissue and probable cauda equina involvement (left) and resolution at day 28 (right).
T1, axial, and diffusion-weighted head MRI of patient #6 showing chloromas non-responsive to prior treatment (top row), and 2 months after treatment showing resolution (bottom row).
Head MRI axial FLAIR of patient #5 showing signal intensity consistent with refractory AML in both unci and brainstem (left), five days post last NK cell infusion showing extension of signal to anteromedial temporal lobes and optic chiasm, optic nerves, and ventral striatum (not shown) consistent with inflammatory response (middle), and 6 months post treatment showing normalization of the signal in unci with evolution to cavitary lesions bordered by low signal rim (consistent with hemosiderin; right).
A
C
B
D
Gene expression profiles in FC21-NK cells• Expression profiles of genes related to adhesion and cell trafficking are shown
in Figure 4• Notably, CNS and inflammation-homing addressins ALCAM,9 CCR2, CCR5
and CXCR3,10,11 ICAM-2,12 ITGB213 (CD18/LFA-1), and NCAM1 (CD56) were allsignificantly increased with FC21-NK
Figure 4: Gene expression profiling in FC21-NK10
8
6
4
2
0
-2
-4
Fold
cha
nge
(log2
)
Gene Gene
Rela
tive
expr
essio
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ALCAM
CCR1CCR2
CCR5CCR7
CCRL2CXCR1
CXCR2CXCR3
CXCR4CXCR6
ICAM2ICAM3
ITGA1ITGA2
ITGA3ITGA4
ITGA6ITGA9
ITGADITGB2
ITGB3BPITGB7
L1CAMNCAM1
NECTIN1
NECTIN3
SMAGP
ITGB1BP1100
1000
10000
ALCAM
CCR1CCR2
CCR5CCR7
CCRL2CXCR1
CXCR2CXCR3
CXCR4CXCR6
ICAM2
ICAM3ITGA1
ITGA2ITGA3
ITGA4ITGA6
ITGA9ITGAD
ITGB1BP1ITGB2
ITGB3BPITGB7
L1CAM
NCAM1
NECTIN1
NECTIN3
SMAGP
BA
A Relative mRNA expression levels. B Fold change in mRNA expression of mbIL-21-expanded FC21-NK cells compared with freshly isolated peripheral blood NK cells. Shown are genes related to cell adhesion and trafficking with DESeqScore ≥ 1.5 or ≤ -1.5. Figures show mean ± standard deviation..
• Multiple IV infusions of ex vivo-expanded FC21-NK cells were welltolerated and demonstrated unprecedented CNS responses inpatients with R/R AML
• These data demonstrate the potential of FC21-NK to traverse the BBBand mediate therapeutic anti-leukemic effect
• Receptors for CNS homing that are upregulated on FC21-NK cellsmay influence their migration into the CNS
• The role of ex vivo-expanded FC21-NK cells for use in therapeuticapplications for CNS malignancies warrants further investigation
CONCLUSIONS
REFERENCES1. Rozovski U, et al. Leuk Lymphoma 2015;56:1392–7;2. Miller JS, et al. Blood 2005;105:3051–7;3. Romee R, et al. Sci Transl Med 2016;8:357ra123;4. Vela M, et al. Cancer Lett 2018;422:107–17;5. Denman CJ, et al. PLoS One 2012;7:e30264;6. Döhner H, et al. Blood 2017;129:424–47;7. Cheson BD, et al. J Clin Oncol 2003;21:4642–9;8. Chukwueke UN and Wen PY. CNS Oncol 2019;8:CNS28;9. Cayrol R, et al. Nat Immunol 2008;9:137–45;10. Keawvichit R, et al. Immunology 2018;153:455–65.11. Sørensen TL, et al. J Clin Invest 1999;103:807–15.12. Haghayegh Jahromi N, et al. Front Immunol 2020;10:3056.13. Schwab N, Schneider-Hohendorf T, Wiendl H. Oncotarget 2015;6:17863–4.
DISCLOSURESSilla: Nothing to disclosePaz: Nothing to discloseHamerschlak: Nothing to discloseBittencourt: Nothing to discloseLee: CytoSen Therapeutics, leadership role & consultancy; Kiadis Pharma, stock ownership, consultancy, research funding, & patents/royalties; Caribou Biosciences, consultancy; Courier Therapeutics, consultancy
ACKNOWLEDGMENTSThis study was supported by a grant to LS from a Consortium formed by the MCTI/CNPQ/MS-SCTIE - DECIT # 401193/2013-6; MS/DECIT/MCTI/FINEP # 01.08.0630.01; MEC/CAPES/PRODOC # 23038.004681/2014-17; CGSAU 2012 (APQ) # 404896/2012-0; GESCON # 375/2013; MS/FNS/MCTI/CNPQ # 455405/2014-0; MEC/MCTI/CAPES/CNPQ/FAPS # 401086/2014-3; FIPE – HCPA # 10-0457, which supported the installation of a GMP facility at our Institution, acquisition of related equipment and material, validation of NK cell manufacturing processes, and this clinical trial. Hospitalization costs for patients were supported by the Brazilian National System of Health Care (SUS – Sistema Unico de Saude) or by private health insurance (some had support through UNIMED). Paul Hoban, a medical writer supported by funding from Kiadis Pharma, provided drafts and editorial assistance to the authors during preparation of this poster.
RESULTS
Abstract 3025