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Not Only Chemotherapy Anti-Tumor Vaccines for Tumor Eradication Irit Avivi Department of Hematology...
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Transcript of Not Only Chemotherapy Anti-Tumor Vaccines for Tumor Eradication Irit Avivi Department of Hematology...
Not Only ChemotherapyNot Only Chemotherapy
Anti-Tumor Vaccines for Tumor Anti-Tumor Vaccines for Tumor EradicationEradication
Irit AviviIrit Avivi
Department of Hematology and BMTDepartment of Hematology and BMT
Rambam Medical Health Care CampusRambam Medical Health Care Campus
Haifa Haifa
Talk PlanTalk Plan The immune system in the healthy personThe immune system in the healthy person Why does the immune system fail to eradicate Why does the immune system fail to eradicate
cancer ?cancer ? Strategies to overcome this immunological Strategies to overcome this immunological
impairmentimpairment Vaccine studies in MyelomaVaccine studies in Myeloma Future directionsFuture directions
Current Approach to CancerCurrent Approach to Cancer Targeting tumor cellsTargeting tumor cells
chemotherapy – attacking divided cellschemotherapy – attacking divided cells
The tumor is a foreign entity
Is their any evidence for anti-tumor response?
Evidence for the Role of the Immune Evidence for the Role of the Immune System on Cancer GrowthSystem on Cancer Growth
Allogeneic stem cell transplantation Allogeneic stem cell transplantation
recipient donor
Evidence for the Role of the Immune Evidence for the Role of the Immune System on Cancer GrowthSystem on Cancer Growth
Allogeneic stem cell transplantation Allogeneic stem cell transplantation
recipient donor
• Graft-vs-host disease is associated with graft vs tumor effect•
More Evidence for the Role of the More Evidence for the Role of the Immune System on Cancer GrowthImmune System on Cancer Growth
T cells & Antibodies directed against tumor cellsT cells & Antibodies directed against tumor cells
exist in the circulationexist in the circulation
HoweverHowever
Immune responses are ineffective in Immune responses are ineffective in
preventing disease establishment and progressionpreventing disease establishment and progression
Dendritic Cells- The most Dendritic Cells- The most important Antigen Presenting Cells important Antigen Presenting Cells
T
T
T
T
DC maturation
iDC Monocytes mDC
How does the Tumor Escape the Immune System?How does the Tumor Escape the Immune System?
DCDC
DC
T
TT
T
Tumor Tumor
ActivationAnergy
VEGF IL6
How does the Tumor Escape the Immune System?How does the Tumor Escape the Immune System?
DCDC
DC
T
TT
T
Tumor Tumor
Activation Anergy
VEGF IL6
CTLA-4
Trg
PDL1
PD1
PDL1
PD1
TT
How Does the Tumor Escape How Does the Tumor Escape the Immune System?the Immune System?
The tumor expresses Host AgsThe tumor expresses Host Ags
It impairs DC maturation and functionIt impairs DC maturation and function
Interferes with Antigen presentationInterferes with Antigen presentation
The tumor interacts with T cells AnergyThe tumor interacts with T cells Anergy
The tumor express inhibitory moleculesThe tumor express inhibitory molecules
The tumor induces accumulation of regulatory T cellsThe tumor induces accumulation of regulatory T cells
Strategies to Overcome Strategies to Overcome Tumor-Induced Immunological Defects Tumor-Induced Immunological Defects
Tumor escape OvercomingTumor escape Overcoming Host Ags Host Ags Tumor specific AgsTumor specific Ags
Immunogenic stimulatorsImmunogenic stimulators
Impaired DCs Maturation Impaired DCs Maturation Ex vivo DCs maturation Ex vivo DCs maturation
T cell Anergy T cell Anergy Interfere with Interfere with
mechanisms involvedmechanisms involved
in anergyin anergy
Ex vivo DC Maturation Results in Potent Mature DCs
DC
DC
DC
DC
T T
T
Ex vivo In Vivo= with Tumor
T
DC maturation
Strategies to Load Tumor Antigens onto DC
Tumor cell fusion
Loading of Tumor lysate
Loading of Tumor peptides
Individual Ag Whole Cell
Vaccination with Individual AntigensVaccination with Individual Antigens AdvantagesAdvantages
Tumor specificityTumor specificity FeasibilityFeasibility Monitoring response against defined AgMonitoring response against defined Ag Lower risk for autoimmunityLower risk for autoimmunity
DisadvantagesDisadvantages Limited number of antigensLimited number of antigens HLA restrictionHLA restriction Tumor evasion through down regulation of antigen Tumor evasion through down regulation of antigen
expressionexpression
Vaccination with Whole Cell Derived AntigensVaccination with Whole Cell Derived Antigens AdvantagesAdvantages
Broad response limits risk of tumor evasionBroad response limits risk of tumor evasion Presentation of unidentified & patient’s -tumor Presentation of unidentified & patient’s -tumor
specific Agsspecific Ags Presence of helper (DC4) and CTL (CD8) Presence of helper (DC4) and CTL (CD8)
response crucial for maintenance of long term response crucial for maintenance of long term immune responseimmune response
DisadvantagesDisadvantages Technical challenge of manipulating whole cells for Technical challenge of manipulating whole cells for
multi-center settingmulti-center setting Risk of auto-immunityRisk of auto-immunity
Why did we Choose Myeloma?Why did we Choose Myeloma?
7 year survival Relapse rate
Khaled Y et al, BMT 44:325, 2009
Vaccination with DC/MM Fusions: Vaccination with DC/MM Fusions: Trial DesignTrial Design
Phase I dose escalation trialPhase I dose escalation trial
EligibilityEligibility Patients with advanced stage myelomaPatients with advanced stage myeloma Presence of measurable diseasePresence of measurable disease > 20% plasma cells in bone marrow for > 20% plasma cells in bone marrow for
vaccine generationvaccine generation
Vaccination Schedule: Vaccination Schedule: 3 subcutaneous vaccinations in conjunction 3 subcutaneous vaccinations in conjunction
with GM-CSF administered every 3 weekswith GM-CSF administered every 3 weeks
Adherent PBMCs cultured for 5-7 days with GM-CSF & IL-4; TNF- added for 48-72 hours
Myeloma cells isolated
DCs assessed for DC & tumor specific markers
Myeloma cells assessed for tumor & DC specific markers
DC & myeloma fused with 50% PEG at DC: tumor, 3:1 to 10:1
Fusion cells quantified by measuring dual expression ofunique DC & tumor markers
Doses prepared & frozen microbiology testing sent
Leukapharesis
Bone marrow
aspiration
CD38
MUC1
DR
CD86
CD86
CD38
CD40
CD83
CD80
CD138
CD138
GM-CSF 100ugat vaccine site for 4 days
Monocytesn=18
Myeloma Cells CD-38 Dendritic Cells CD86
Vaccine CharacterizationVaccine Characterization
Fusion cell
Adverse EventsAdverse Events Treatment associated events, transient grade I-II:Treatment associated events, transient grade I-II:
Injection site reactions 37Injection site reactions 37 Edema 6Edema 6 Muscle Aches 5Muscle Aches 5 Fatigue 2Fatigue 2 Fever 1Fever 1 Chills/sweats 2Chills/sweats 2 Diarrhea 1Diarrhea 1 Pruritis 1Pruritis 1 Rash 2Rash 2 Anorexia 1Anorexia 1 No Autoimmune disordersNo Autoimmune disorders
Episode of DVT/PE with antecedent history of DVT Episode of DVT/PE with antecedent history of DVT
Immunological Response: Vaccine Site Reaction Recruitment of “ attacking” CD8 T cells
Recruitment of antigen- presenting DCs (CD1a)
0
10
20
30
40
50
60
DCs
Tumor
Fusions
Stim
ulat
ion
Inde
x (S
I)
(n=16) (n=16)(n=16)
Fusion Cells Stimulate Fusion Cells Stimulate Allo – CD8 +T cellAllo – CD8 +T cell
Tumor Lysate Induced Tumor Lysate Induced
IFNIFNγγ Expression by CD8+ T cells Expression by CD8+ T cells
100 101 102 103 104
FL1-H
Pre-vaccination#3
55.8
10.8
100 101 102 103 104
FL1-H
1 month postvaccination
57
4.5
100 101 102 103 104
FL1-H
Pre-mobilization
51
1.78
100 101 102 103 104
FL1-H
Post-transplantation
72
4.1
IFN
CD8 FITC
Vaccination Induced Immune Response
Persistent Response against Persistent Response against Tumor Specific Antigen Tumor Specific Antigen
0
1
2
3
4
5
6
% MUC1 CD8
Pre vaccine 1 month post 3 months post
Immunologic response associated with disease stabilization
Vaccination with DC/Myeloma Fusions: Vaccination with DC/Myeloma Fusions: Conclusions Conclusions
Vaccination is feasible and well toleratedVaccination is feasible and well tolerated Majority of patients show immunologic Majority of patients show immunologic
responseresponse Disease stabilization in a majority of patientsDisease stabilization in a majority of patients
How to Improve the Efficacy of How to Improve the Efficacy of Fusion Vaccines?Fusion Vaccines?
Administer to patients with Administer to patients with
minimal residual disease minimal residual disease
Administer after eliminating Regulatory T cellsAdminister after eliminating Regulatory T cells
High Dose Therapy (HDT)High Dose Therapy (HDT)
Provides minimal residual disease Provides minimal residual disease
Induces a significant reduction in Induces a significant reduction in
suppressive regulatory T cellssuppressive regulatory T cells
“ A vaccine supportive environment ”
Study UpdateStudy Update
41 patients enrolled to date41 patients enrolled to dateAll underwent successful vaccine generationAll underwent successful vaccine generation
21 - completed vaccinations, Med FU21 - completed vaccinations, Med FU
22 - ongoing study22 - ongoing study
Vaccine details:Vaccine details:
Mean percent of fusion: 40%; Fusion viability: 78%Mean percent of fusion: 40%; Fusion viability: 78%
Mean dose: 3.9 x 10Mean dose: 3.9 x 1066 fusion cells fusion cells
Safety: unchanged. 2 ANA without symptomsSafety: unchanged. 2 ANA without symptoms
Perc
enta
ge o
f CD
4+ T
cel
ls
expr
essi
ng IF
N
Perc
enta
ge o
f CD
8+ T
cel
ls e
xpre
ssin
g IF
N
Mean Percentage of Tumor Reactive T Cells
Pre Tx Post Tx Peak PostVaccine
Peak PostVaccine
Post TxPre Tx
CD4 CD8
Immunological Response to Vaccine
Clinical Response Clinical Response
Transplant VaccinationPost-tx 1 month
Post-tx4 months
Post-tx9 months
CR/nCR 67%
Response RateResponse RatePercentage of Patients Achieving CR Over Time Percentage of Patients Achieving CR Over Time
68% -complete response or very good partial response >>>> 40% with HDT only
Vaccination with DC/MM Fusions Following SCTVaccination with DC/MM Fusions Following SCT
Conclusions Conclusions
Feasible & well toleratedFeasible & well tolerated
Induces a significant anti-myeloma Induces a significant anti-myeloma immune responseimmune response
Results in a high response rateResults in a high response rate
Strong correlation between immunological Strong correlation between immunological and clinical responsesand clinical responses
How does the Tumor Escape the Immune System?How does the Tumor Escape the Immune System?
DCDC
DC
T
TT
T
Tumor Tumor
Activation Anergy
VEGF IL6
CTLA-4
Trg
PDL1
PD1
PDL1
PD1
TT
PD-L1/PD-1 Pathway•PD-L1 -an inhibitory ligand expressed by APCs •Signals via the costimulatory complex
•promotes
•Induces apoptosis of memory effector cells & disrupts CTL mediated lysis
•Inhibits T cell activation
PDL-1 Expressed by Tumor PDL-1 Expressed by Tumor is Associated with Toleranceis Associated with Tolerance
Shin & Rehermann Nature Medicine 2006
100 101 102 103 104
FL2-H100 101 102 103 104
FL2-H
IgG PDL1
100 101 102 103 104
FL2-H100 101 102 103 104
FL2-H
DC
MM
PDL-1 is Expressed by DCs and Myeloma Cells
100 101 102 103 104
FL1-H
100 101 102 103 104
FL1-H
100 101 102 103 104
FL1-H
100 101 102 103 104
FL1-H
17.3%4.8%
Control Myeloma PatientsIg
G
IgG
PD
-1
PD
-1
CD 4
PD-1 Expression on T cells
p=0.004
Mean PD-1 Expression on CD4 T cells : Increase with Advanced Disease
% E
xpre
ssio
n (
CD
4 T
Cel
ls)
CD4 T cell expressing PD-1 Increase Following Fusion Stimulation
% E
xpre
ssio
n of
P
D-1
(C
D 4
T c
ells
)
100 101 102 103 104
FL1-H
100 101 102 103 104
FL2-H
PDL-1 Expression on DC/Myeloma Fusions
CD
86
CD 38
PDL-1
PD-1 BlockadePD-1 Blockade CT-011: clinical humanized PD1 antibodyCT-011: clinical humanized PD1 antibody
Binds effector memory Tcs, resulting in their activation Binds effector memory Tcs, resulting in their activation and inhibition of apoptosis and inhibition of apoptosis
In animal models, administration induced anti-tumor In animal models, administration induced anti-tumor immune responses & tumor regressionimmune responses & tumor regression
Clinical Trials:Clinical Trials: Phase I trial : tolerated with evidence of clinical benefitPhase I trial : tolerated with evidence of clinical benefit Administration post ASCT results in increased CD4+ Administration post ASCT results in increased CD4+
effector memory T cells effector memory T cells (Rotem-Yehudar et al., A1216; Ash 2009)(Rotem-Yehudar et al., A1216; Ash 2009)
% E
xpre
ssio
n
of
PD
-1 (
CD
4 T
cel
ls)
PD-1 Blockade Results in Downregulation of PD-1Expression on CD 4 T Cells following Fusion Stimulation
p=0.048
% E
xp
ress
ion
of
IFN
γ (
CD
4 T
ce
lls)
PD-1 Blockade Results in Increased Interferon-gamma Following Fusion Stimulation
100 101 102 103 104
FL1-H100 101 102 103 104
FL1-H100 101 102 103 104
FL1-H
0.210.03 0.55
2.510.90.01
CD8/IFNgCD8/IgG CD8/IFNg
In Vivo Vaccine Primed Tumor Reactive T cells are Increased in the Presence of Ex-vivo PD-1 Blockade
)
Pre-Vaccine #1
1 month post vaccines
100 101 102 103 104
FL1-H100 101 102 103 104
FL1-H100 101 102 103 104
FL1-H
0.03 0.21 0.55
CD8 CD8 INFG CD8INFG + AntiPD1
PD-1 Blockade Results in Increased Lysis of Autologous Tumor by Fusion Stimulated T Cells
Granzyme
Tu
mo
r
+ Anti-PD-1 Control
100 101 102 103 104
FL1-H100 101 102 103 104
FL1-H
23% 32%
PD1-PDL1 pathway in MyelomaPD1-PDL1 pathway in Myeloma Strong in vitro data supporting the potential role Strong in vitro data supporting the potential role
of PD1-PDL1 pathway in myelomaof PD1-PDL1 pathway in myeloma
- High expression of PDL1 on DCs & MM cells- High expression of PDL1 on DCs & MM cells
- High expression of PDL on T cells- High expression of PDL on T cells PD1-PDL1 blockade improved anti-tumor PD1-PDL1 blockade improved anti-tumor
response in vitroresponse in vitro The in vitro data provide strong platform for The in vitro data provide strong platform for
combining anti PD1-PDL1 hrapy with combining anti PD1-PDL1 hrapy with
DirectionsDirections
Choose the right tumor: Choose the right tumor:
Immunogenic vs “Non Immunogenic?Immunogenic vs “Non Immunogenic?
Improve the immunogenic target: Improve the immunogenic target:
specific peptides vs whole tumor ?specific peptides vs whole tumor ?
Control the inhibitory environment Control the inhibitory environment
Potential ApproachesPotential Approaches
DCDC
DC
T
TT
T
Tumor Tumor
Activation Anergy
VEGF IL6
CTLA-4
Trg
PDL1
PD1
PDL1
PD1
TT
The Rambam- Harvard Vaccine Program The Rambam- Harvard Vaccine Program
DC/MM – anti PD1L Myeloma vaccine studyDC/MM – anti PD1L Myeloma vaccine study DC/MM- immuno-mudulatory drug studyDC/MM- immuno-mudulatory drug study DC/AML- anti PD1L Myeloma vaccine study DC/AML- anti PD1L Myeloma vaccine study DC/RCC – Sunitinib StudyDC/RCC – Sunitinib Study
Sunitinib -kinase inhibitor of Flt3, Kit, VEGFSunitinib -kinase inhibitor of Flt3, Kit, VEGF
and PDGF receptors and PDGF receptors Pre-clinical study for vaccination for CLL Pre-clinical study for vaccination for CLL
AcknowledgmentsAcknowledgments
Hematology Department, RMC Hematology Department, RMC
Tami Katz, Tami Katz,
Lina Bisharat, Lina Bisharat,
Jacob M RoweJacob M Rowe
Hematology Department, BIDMCHematology Department, BIDMC
Jacalyn Rosenblat Jacalyn Rosenblat
David AviganDavid Avigan