transgeneL’immunothérapie appliquéeau traitement des cancerset des maladies infectieuses

Immunotherapy to fight cancerand infectious diseases

G Inchauspé

Combining immunotherapy and vaccination to treat chronic infections,

June 15- 17, 2009

Immunotherapy and vaccine against HBV and HCV

transgene

There is no therapeutic vaccines on the market today, neither

in the cancer field nor in the infectious diseases field

�Why do we think therapeutic vaccines represent one of

« tomorrow’s » most promising therapeutics ?

�Why do we think therapeutic vaccines can work ?

�What would they bring to the patient ?

�What are the encouraging signs ?

The HCV/HBV examples

Therapeutic vaccination today

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FiveFive major cancersmajor cancers((worldwideworldwide): ): liverliver fithfith

Lung(1.239.000)

Breast(1.050.000)

Colo-rectum(943.000)

Stomach(875.000)

Liver(566.000)

[Parkin et al., Int J Cancer 2001]

VHB(53%)

VHC(25%)

Autres(22%)

Current medical need

HBV + HCV = 75% HBV + HCV = 75% ofofAll All liverliver cancerscancers

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HCV HBV

HBV and HCV: therapies

Cure obtained in 45% but Life-long therapy

toxicity (IFN-aplha, ribavirin), (no toxicity),

cost, adherence

Moving towards multiple- Idem therapy (moving to bi-

drug regimen (tri-therapy) therapy). Cost issues

Cost issues, side effects ?

Genotype-dependance of Resistance

new therapies ? still an issue ?

…………………………… …Not Optimal…………………………………….

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� Need for improved therapies to:

• cure infection in most/all cases

• slow down disease progression

avoid transition from « healthy » to « diseased » carrier stage

• Provide patients a « break » from SOC, to shorten duration of SOC

� Need to bring in therapeutics with different mode of action than

those already exploited by small molecules

• small molecules = direct effect on virus or bateria

effect on replication

• therapeutic vaccines = effect on host immune system

effect on cells from immune system

Therapeutic vaccination

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CD8+ priming: the «importance of the « where »

�The site of viral infection and of antigenic expression plays a

critical role in the quality of induced T cell responses (Bowen et

al., 2004):

In transgenic mice expressing transgenes both in the liver and

periphery:

• Naïve CD8+ T cells activated within liver exhibit defective cytotoxic

function and shortened half-life

•Naïve CD8+ T cells activated within lymph nodes are fully activated

and capable of lytic activity

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The different ways leading to HCV-specific CD8+ CTL priming

according to the site of viral entry (Racanelli et al., 2007)

PREFERED SITE OF

EXPRESSION

FOLLOWING VACCINE

ADMINISTRATION

Activation of T cells in

lymph nodes = effective

LIVER = PREFERED INFECTION AND EXPRESSION SITE

Activation of T cells in the liver = impaired

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SpontaneousClearance

(1% ??)

PrimaryInfection

SpontaneousClearance

(15-30%)

Chronic CarrierState

(70-85%)

Chronic LiverInflammationFibrosis, Cirrhosis, Hepatocellular Carcinoma

(5- 70%) Healthy Carriers(30 %) +/- Antiviral Therapies

+/- Immune modulatorsAcute phase (< 6 months)

Chronic phase (>6 months)

HCV: course of infection and therapeutic vaccine options

Therapeutic vaccination

Before disease During disease

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Kinetics of virus replication and HCV-specific CD8+ T cell responses

early after infection and associated with clearance

Weeks after infectionWeeks after infection

HCVHCV

2 4 6 8 10 12 14 16 2 4 6 8 10 12 14 16 18 18

Active Active replicationreplication

T cell T cell inductioninduction

66--8 weeks8 weeks

11

1010

100100

Vir

ion

sV

irio

ns

101066

/ ml

/ ml

Sustained Adaptive Sustained Adaptive responsesresponses

HCVHCV %%tettet .+.+

CD8+ T cellsCD8+ T cells

11

1010

100100V

irio

ns

Vir

ion

s1010

66/ m

l/ m

l

0.40.4

0.80.8 % H

CV

te t.+ /CD

8%

HC

V te t.+ /C

D8

Weeks after infectionWeeks after infection2 4 6 8 10 12 14 16 18 202 4 6 8 10 12 14 16 18 20

% IFN% IFNγγγγγγγγ+/CD8+/CD8HCVHCV--RNARNA

Weeks after infectionWeeks after infection

11

1010

100100

Vir

ion

sV

irio

ns

101044

/ ml

/ ml

200200

300300

100100

00

IFN

IFN

−− −−−− −− γγ γγγγ γγE

LIS

PO

TE

LIS

PO

T

CHIMPANZEE CHIMPANZEE INFECTIONINFECTION

HUMAN INFECTIONHUMAN INFECTION

0 0 8 16 24 32 408 16 24 32 40

Thimme, R. et al, J Exp Med 2001 Shoukry, N. et al, J Exp Med 2003

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HCV therapeutic vaccines: first and second generation

Company Vaccine

Innogenetics INNO10101 (E1) HCV +

Intercell IC41-102 (5 HCV peptides) HCV +

GlobeImmune GI-5005 (Yeast - NS3/Core) HCV +

Novartis/CSL ISCOMATRIX (Core) HCV -

Novartis HCV-MF59 (E1E2) HCV -

Kurume Univ. ND (4 peptides) HCV +

Tripep/Inovio ChronVac-C® (NS3NS4A) HCV +

Transgene TG4040 (MVA-NS345B) HCV+

Target populations Preclinical Phase I Phase II Phase III

Safety +

Lack of efficacySTOPPED

Safety + lack of

efficacy ?

Safety + efficacy ?

Safety

Safety

Safety + efficacy ?

Safety + early efficacy

Safety + early efficacy

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� T cell-based therapeutic vaccine including three HCV antigens (Fournillier et al., Vaccine 2007) :

Derived from Modified Vaccinia Ankara (MVA) poxvirus strain, a highly attenuated strain of vaccinia virus, non-integrative and non-proliferativeExpressing non-structural proteins (NS3, NS4a+b & NS5b) of HCV (genotype 1b)

Shown in mice to produce double (IFN-γ/TNFα, 3-8%, CD8+)and triple IFN-γ/TNFα/Il2, 03-0.5%, CD4+) producing cells Shown in mice to induce in vivo CTL capable to migrate to livers of animals displaying hepatic expression of HCV antigens and control this expression (recListeria assay)

TG4040 Vaccine (TRANSGENE)

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Open-label, dose-escalating, phase I study of TG4040 (MVA-HCV) in (1) treatment-naïve patients chronically infected with hepatitis C virus (HCV genotype 1). FRANCE.

(2) patients relapsers to therapy. CANADA.

Primary Objective:Determination of the tolerance of sub cutaneous injections of TG4040 in non cirrhotic patients

Secondary Objectives:Determination of the biological activity of TG4040:

• Viral load• Cellular and humoral immune response• Identification of molecular biomarkers

TG4040 clinical studies

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TG4040.01 (naïve patients): Study Design

8 12 16 20 40 44 4828 32 360

TG4040 TG4040 (cohort 3)

weeks4 24

Viral load

Immunology

Collected samples for:

Transcriptomic■

Cohort 1: 3 injections of 106 pfu at D1, D8 and D15 in 3 patients

Cohort 2: 3 injections of 107 pfu at D1, D8 and D15 in 3 patients

Cohort 3: 3 injections of 108 pfu at D1, D8 and D15 in 9 patients + 1 boost injection at M6

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Results on Primary end -point: Safety

69 Adverse Events (AE) reported in 14 patients

43/69 AEs related to study drug with no grade 3, 4 or 5 and no SAE:

12 patients (80%) had injection site reactions (26 events)

2 patients (13%) had influenza like illness (5 events)

1 patient had fatigue (3 events)

1 patient had metrorrhagia (3 events)

Other events (once): ALT increased, AST increased, lymphadenopathy, nausea, pyrexia, arthralgia

Safety of TG4040 so far established: no exacerbation of liver disease

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Preliminary results on secondary end-point: Viral Load

Changes (change of RNA from baseline) TG4040.01 study

D22 D37 M2 M3 M4 M5 M6 M6+8 M6+22 M9D15D8D1

TG4040 injections

1,0

0,5

0,0

- 0,5

- 1,0

Cha

nge

in H

CV

RN

A (

log1

0)

106 pfu

107 pfu

108 pfu

� No significant effect on viral load over time at 108 pfu

� VL decrease seen 1 week after last vaccination

� Sustained reduction in viral load from day 37 to month 6 at 106 pfu

Boost (only 10 8 pfu)

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-1,6-1,4-1,2

-1-0,8-0,6-0,4-0,2

00,20,40,60,8

1

Cha

nge

in H

CV

RN

A (

log1

0 IU

/ml)

D22 D37 M2 M3

Mean +/- SD

Mean Viral Load Changes from D22 to M3 (All Cohorts)

D0-15

- Nadir Viral load decrease at D 37

injections

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Viral Load Cohort 1 (10 6 pfu )

Change in HCV RNA from baseline (D1) 01/B-C02/C-N03/J-K

� Window of decrease: Viral load decrease observed betw een D22 and M3

-1,6

-1,4

-1,2

-1,0

-0,8

-0,6

-0,4

-0,2

0,0

0,2

0,4

D1 D8 D15

D22

D37

M2

M3 M4

M5

M6

Visits

Cha

nge

in H

CV

RN

A (

Log1

0 IU

/ml)

TG4040 delivery

transgene

Vir

al lo

ad F

old

ch

ang

e/b

asel

ine

(lo

g10

)D

elta-Sp

ots (S

pecific –

bkg

dsp

ots)

-2 0

Pt 02

-1

-0,5

0

0,5

1

0

100

200

250

28

BL

D22

M6

D37

0-1

-0,5

0

0,5

1

100

200

250

28ND

Pt 01

BL D22

M6D37

M2

NS4B NS5/1 NS5/2NS3/1 NS3/2 VL

TG4040.01: 106 pfu - in Tx-naive patients -

neg

neg

neg

Pt 031

-1,5

-1

-0,5

0

0,5BL

D22 M6

2850

100

150

200

250

ND ND

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TG4040.01: conlusions, next steps

� Primary en-point met (safety), secondary end-points (effect on VL and induction of specific T – cell immunity) met in part

� Most significant VL decreases observed when most significant vaccine-specific T cells could be detected

� Need to increase, broaden and maintain such effective responsesIncrease priming, work on booster vaccinations, memory..

� Initiation of Phase II in combination with SOC planned (2010). Two schedules tested + 2 timings of administration (vaccine added before or after SOC)

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interaction

Virion

Nucleus

Hepatocyte

translation

encapsidationreverse transcription

pgRNADNA (-)

cccDNAamplification

transcription

mRNA

pgRNAAAAAAAAAAAAAcccDNAcccDNA

cccDNA formation

RC DNA

entrypolymerase

DNA (+)

(+) strandsynthesis

virion secretion

ER

HBeAg

HBsAg

receptor ?

ER

viral proteinssecretion

Zoulim et al Future Virology 2006

Nucleoside

analogs

No action/ do not know how to

prevent cccDNA formation

HBV life cycle: limitation of current antiviral dru gs

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Prime/ boost T cell responses in particular those susceptible to lyse

infected cells and help the infected host to get rid-off pools of cccDNA

Break the cylcle of production of new progeny viruses

Use vaccine as an add-on therapy to existing antivirals

In HBV infection (contrasting with HCV infection), there is a much

tighter relationship between Viral Load and Disease progression but

also Viral Load and Vigour of specific T-cell responses (“threshold

notion”)

Specific goals of HBV therapeutic vaccination

22transgene

Phase I Phase II Phase III # viral

vectored

vaccines

HBV 6 3 0 4

(2x MVA, 1 Ad5

1 fowlpox)

NumberNumber ofof HBV HBV therapeutictherapeutic candidate vaccines in candidate vaccines in clinicalclinical developmentdevelopment

� Most therapeutic vaccines are limited to one single immunogen (HBsAg)

� Two candidates only are polyantigenic/ polyepitopic :

- Dong-A Pharma: 5 plasmids (Core, HBsAg, X, polymerase, IL-12)

- Innogenetics: DNA/MVA string-of-beads epitopes (40, from all HBV antigens)

HBV therapeutic vaccines: landscape

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Yang et al., Gene Therapy 2006 (Dong A Pharma)

- 12 HBV caucasian chronic carriers

- Treatment naïve (i.e. Lamuvidine – naïve) volunteers

- Non-controlled trial (1 arm= Lamuvidine + treatment)

- Primary end -point: time to VL rebound at end of treatment

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ELISPOT analysis: correlation with sustained control of viremiaEx-vivo ELISPOT assay (24 hrs), overlapping peptides or cultured ELISPOT (10 days)

50% Virol.

Responders

Versus 19%

historical cont.

LAM alone

(follow-up 52

Weeks)

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Immuno-monitoringT, NK cellsELIspot, ICS

AgHBe/a-HBe

Vaccine

Group A: anti-viral Tx + DNA vaccine (n=35)

ALT

Group B: anti-viral Tx (n=35)

Vir

al lo

ad H

BV

DN

A

Restoration of T cell response ?

Anti-viral drugs STOP Anti-viral drugs

M-3 M0 M2 M4 M10-11 M12 M18

Group B

Group A

?

Group B

Is vaccine-induced HBV-specific T cell response associated with suppression of viral rebound ?

Clinical trial in progress (ANRS HB02): DNA vacccin e expressing S2S + SOC (phase II)

Vaccination starts once patients have responded to SOC (decrease VL)

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Key conclusions on current ststus with HCV/HBV therapeutic vaccination

Growing acknowledgement by the medical community that it “makes sense” to try and recruit active contribution of host immune system to 1) increase clearance rate (HCV and HBV); 2) give patients a therapy-break (HBV); 3) slow down disease progression (HBV and HCV ?)

Mounting evidence on “safety” of these vaccines (in particular T cell – based ones)

Growing acknowledgement that therapeutic vaccines will most likely need “companion” molecules (antivirals, inhibitors of negative signals, enhancers of priming, …)

Most potent T-cell vaccines (vector – based) just entering the clinics

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MEASURE OF POTENCY IS AS CRITICAL AS MAKINGTHE VACCINE

« IF YOU DO NOT LIKE THE RESULTS, BLAME THE ASSAYS »

Transversal issue: testing of vaccine potency ?

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Tg4040 birth(CNRS-BioMérieux,Lyon)

Paris

Lyon

Tg4040 production(Transgene, Strasbourg)

Tg4040 Clin. Trials France(Lyon, Grenoble, Strasbourg)

Tg4040 Clin. Trials.(Canada)

THANK YOU

Emilie Jacquier D Smichdt

Guillaume Bach Nathalie Sylvestre

Estelle Gérosier Jean Marc Balloul

Alexei Evlachev Isabelle Didillon

Perrine Martin Catherine Mathis

Anne Fournillier ClémentineSpring-

Giusti

Delphine Agathon

Delphine Olivier Géraldine Honnet

Laure Veron Jean Marc Limacher

Christine Bain Jean Yves Bonnefoy

Transgene Lyon Transgene Strasbourg