Tumor Antigen Specific mAb Immunotherapy

and Combinations for Head and Neck Cancer

Robert L. Ferris, MD, PhD

Professor of Otolaryngology, of Radiation Oncology and of Immunology Chief, Division of Head and Neck Surgery

Associate Director for Translational Research

Co-Leader, Cancer Immunology Program University of Pittsburgh Cancer Institute

Disclosures

Amgen: Clinical trial/research funding

Bristol-Myers Squibb: Advisory board, Clinical trial/research funding VentiRx

Pharmaceuticals: research funding

“Heal with Steel”

Two distinct diseases comprise HNC

pRB

E7 p16

HPV

p53

E6

p53 mut

p16

3p, 4q, 5q, 8p,

13q del

Escalating Chemoradiation Morbidity

Trotti A et al. Lancet Oncol 2007;8:6713-24.

Convergence of “targeted therapy” with “immunotherapy”

The promise of tumor-targeted biological agents

Agents that do not directly attack DNA

Directed against important biological/molecular

targets – sparing the normal cells (bone marrow)

Well-tolerated drugs that can be combined

safely with cytotoxics

EGFR - Human SCCHN (+ in 80-100%)

Ang et al. Cancer Research 2002

Grandis, et al. JNCI 1998

Cetuximab + RT in Locally

Advanced SCCHN: Locoregional

Control

p = 0.02

Months

0

RT RT+C

(n=213) (n=211)

Events 106 90

Median (mos) 19 36

RT + cetuximab

RT

Bonner, NEJM, 2006

RTOG 1016: A Randomized Phase III Trial of

Chemoradiotherapy With Cisplatinum or Cetuximab in

P16+ Oropharynx Cancer

R

A

N

D

O

M

IZ

E

IMRT

70Gy/35 fxs

Cetuximab

400/250

mg/m2 qwk

Cisplatin

100 mg/m2/q21d

Stratify: HPV, smoking, stage

Cetuximab loading dose = 400 mg/m2 on Day 1 of Cycle1 with induction

ELIGIBILITY

Stage

III, IVA, B

Resectable

P16+

Oropharynx

Cancer

IMRT 70Gy/35 fxs

IMRT = intensity-modulated radiation therapy.

ClinicalTrials.gov.

EGFR Inhibition – immune mechanism of action?

Proliferation Survival

Angiogenesis

Signaling

cascades

Adaptor

proteins

Nucleus

PLC GRB2

Gene activation

Cell cycle progression M G1

S G2

MYC FOS

JUN

P P

Antibody (cetuximab, panitumumab)

Tyrosine kinase

inhibitor

(erlotinib, gefitinib)

Cetuximab

anti-EGFR monoclonal Ab

• IgG1 (chimeric mAb)

• High-affinity and prevents ligand binding to

EGFR

• apoptosis angiogenesis

• Clinical anti-tumor activity in 20% (Bonner,

Vermorken), not correlated with level of EGFR

expression or gene copy number

Fc Portion

Constant portion

(changes depending on the isotype)

Variable Portion

F(ab): epitope specific

In chimeric mAb this

portion is murine

Structure of a mAb

EGFR mAb therapy in SCCHN: inhibition of

phosphorylation or immunotherapy?

0%

10%

20%

30%

40%

50%

60%

0 0.001 0.01 0.1 1 10Lys

is/a

po

pto

sis

mAb concentration mg/ml

cetuximab

isotype

0

0.0

01

0.0

1

0.1

1

10

cetuximab mg/ml

pEGFR

EGFR

b-actin

Cetuximab blocks EGFR

activation but does not kill HNC cells

Lopez-Albaitero 2007

Antibody dependent cell cytotoxicity

(ADCC)

Polymerized mAb complexes trigger responses in

macrophages and NK cells through the FcgR

receptors

There are several types of FcgR on effector cells,

these variations influence the response against a

mAb depending on its isotype.

EGFR

cetuximab

FcgR

cytolysis

Potential immune effect of mAb for cancer

therapy – explanation for variability in responses

Modified from Adams et al Nature Biotechnology 23, 1147 - 1157 (2005)

lysis

Tumor cell

C

% lysis

A

0

25

50

75 p<0.0001

0

25

50

75

25:1 12:1 6:1 3:1

NK

NK cell depleted%

lysis

E:T ratio

PBMC

Cetuximab mediated ADCC correlates with FcgR genotype

Lopez-Albaitero CII 2009

0

25

50

VVVFFF

cetuximab+3G8 mAb

cetuximab

B

% lysis

Copyright © American Society of Clinical Oncology

Bibeau, F. et al. J Clin Oncol; 27:1122-1129 2009

Progression-free survival for patients with metastatic colorectal cancer (mCRC) according to the presence or absence of (A) KRAS mutation and to the (B) Fc{gamma}R polymorphisms combination

Is cetuximab activity immune

mediated?

Months

N=104 patients

Disease-Specific Survival by FCgamma RIIIa

Time

Pro

po

rtio

n S

urv

ivin

g

0.0

0.2

0.4

0.6

0.8

1.0

VVVFFF

p = 0.6833

0 6 12 18 24 30 36 42 48

Srivastava, Clin Can Res 2013 Results confirmed with RTOG 0522 trial

0

25

50

VVFF

0

7

14

VVFF

0

60

120

VVFF

0

170

340

VVFF

0

80

160

VVFF

0

5

10

VVFF

IFN-g p<0.05

TNF-a p<0.05

IL-8 p<0.05

MIP-1b p<0.05

MIP-1a p<0.05

RANTES p<0.05

pg/m

l

pg/m

l

pg/m

l

pg/m

l

pg/m

l

pg/m

l

Cetuximab activated NK cells secrete cytokines and chemokines

associated with recruitment of T cells and dendritic cells –

bridging a network of antitumor lymphocyte activation?

effector cell

cetuximab Fc

F(ab)

tumor cell cytolysis

T cell

stimulation

and expansion

Dendritic cell

Internalization of

Ab-coated

EGFR and cross

presentation to

T cells

ADCC Cross-presentation of

tumor antigens by DC Cetuximab

coated EGFR

p<0.001

Pedro Andrade, MD

Athanassios Argiris, MD

Michael Gibson, MD

James Ohr, MD

Cetuximab naïve

HNC patient

EG

FR

853-8

61 t

etr

am

er

CD3+CD8+ cells

Cetuximab treated

HNC patient

EGFR-specific tetramer+ T cell frequencies are elevatedin cetuximab treated HNC patients compared cetuximab naïve HNC patients

Cetuximab treated Cetuximab naïve HLA-A2- HIV tetramer0

50

100

150

200

250 Cetuximab treated (n=17)

Cetuximab naïve (n=39)

HLA-A2- (n=21)

HIV tetramer (n=37)

Tetr

am

er+

cell

s/

10,0

00 C

D8+

/CD

3+

cell

s

Cetuximab treated Cetuximab naïve HLA-A2- HIV tetramer

Srivastava,

Clin Cancer Res, 2013

Neoadjuvant Cetuximab

Followed by Surgery/CRT and adjuvant Cetuximab

(UPCI Protocol #08-013)

B

I

O

P

S

y

HNSCC

Stage II-IV

Resectable

OC, OP,

HP, L

Endpoints:

Modulation of biomarkers, 2-yr DFS

Sample size N=33/40 PI - Ferris

Cetuximab

x 4 wk

S

U

R

G

E

R

Y

Standard

Postop Chemo-Radiation

+ cetuximab

R01 DE 19727

P50 CA097190

B

I

O

P

S

y

HNSCC

Stage II-IV

Resectable

OC, OP,

HP, L

Endpoints:

Modulation of immune biomarkers, 2-yr PFS

ACCRUAL 33/40

Cetuximab

x 4 wk

S

U

R

G

E

R

Y

Standard

Postop Chemo-Radiation

+ cetuximab

Neoadjuvant Cetuximab

Followed by Surgery and adjuvant Cetuximab

(UPCI Protocol #08-013)

Respo

nd

er

Nonre

sponder

James Mountz, MD, PhD

Exhausted CD8+ T cells express PD-1 and Tim-3 during chronic antigen stimulation

Trends in Immunology August 2011, Vol. 32, No. 8

Blocking inhibitory receptors to reactivate exhausted T cells

CTLA-4 (CD152)

Modified from Annu. Rev. Immunol. 2008. 26:677–704

(* PD-Ligand expressed on cancer cells)

*

Anti-PD-1 mAb

Anti-CTLA-4 mAb

New immunotherapeutic targets: CTLA-4 and PD-1 (Programmed death 1)

PBL

TIL

13.03 56.72

19.50 10.75

2.68 4.87

30.06 62.39

HPV-Negative Patient

12.91 1.60

83.75 1.75

0.52 1.45

95.81 2.22

2.71 2.71

81.63 12.94

17.40 11.0

67.20 4.4

HPV-Positive Patient

9.12 1.11

84.31 5.47

1.18 1.60

89.45 7.78

TIM-3, PD-1, and LAG-3 Expression by CD8+ TIL and PBL (HPV+ vs HPV-)

0.12 1.16 (*91%)

28.53 70.19

0.42 0.76 (*64%)

55.15 43.68

Checkpoint Receptors on HPV E7-Tetramer+ TIL (HPV+ Patient 11-6369)

0.59 0.17 (*22.4%)

88.48 10.75

analysis

HPV+ sample contains higher proportion of PD-1+/TIM-3+ cells on HPV E7-tetramer+ TIL than PBL

2.0 0.2 (*10.0%)

95.88 2.76

1.72 0.13 (*7.0%)

92.33 5.81

2.10 0.38 (*15.3%)

88.25 9.27

* % in tetramer + Cells

TIL

PBL

APC Anti-

tumor

T cell

CD4+ T cell APC Tumor

cell

B7 CD28

CD8+ T cell - -

+ +

Blocking

Anti-PD-1 mAb

MHC TCR

MHC TCR

TCR MHC

Blocking

Anti-PD-L1 mAb

Ferris, RL, Cancer , 2012

Topalian, NEJM, 2012 Brahmer, NEJM, 2012

Targeting the PD-1/PD-L1 pathway

CA209-141: Randomized Phase II/III Trial of Nivolumab vs Cetuximab

in Recurrent or Metastatic Platinum-refractory HNSCC

Cetuximab

Immune Responses induced by cetuximab treatment

Treg

CTL

TGF-b, CD39, CTLA-4?

p = 0.004 p = 0.014*

* paired Wilcoxon Sign test

(n = 40) (n = 22) (n = 22)

Cetuximab induces suppressor/regulatory T cells in treated HNSCC patients

A

Cetuximab induces CTLA-4+ Treg cells in treated HNSCC patients

Treg suppression of cetuximab mediated antitumor activity Is mediated by TGF-β and correlates with clinical response

p = 0.015 (n = 20)

CD4+CD39+CD25+ Treg before cetuximab treatment: > 6% < 6%

Phase Ib Trial of Concurrent Cetuximab/IMRT with

Ipilimumab, Plus Biomarker Correlatives, in Locally

Advanced, High Risk Oropharynx Cancer

Stage

III-IVA OPSCC

(HPV-

HPV+ smokers,

N2b)

p16 IHC

Tumor/

Blood collection

Cetuximab/Radiotherapy Plus Ipilimumab

RT 66 Gy with 200 cGy daily fractions in 6.5 weeks

Cetuximab weekly at 250 mg/m2 during radiation*

Ipilimumab 3, 10 mg/kg q21 days, starting week 4

SCHEMA

*after loading dose of 400 mg/m2 on cycle 1, day 1

Ipilimumab will be continued at indicated dose for additional 2 cycles.

Ferris and Bauman

Summary • Cellular immunity (antitumor NK and T cells) are

induced by cetuximab

• Suppressive mechanisms include regulatory T

cells (Treg) and checkpoint receptors

(CTLA-4, PD-1, etc)

• But what else is clinically available for immuno-

therapy of HNC? -> Toll Like Receptor Adjuvants

• TLR3 – poly IC:LC – plans for clinical trial

• Active8: EXTREME +/- TLR8 agonist trial

Human TLR Family and Known Ligands

The Nobel Prize in Physiology or Medicine 2011

© 2011 The Nobel Committee for Physiology or Medicine. The Nobel Prize® and the Nobel Prize® medal design mark are registered trademarks of the Nobel Foundation.

The 2011 Nobel Prize in Physiology or Medicine - Press Release". Nobelprize.org. 11 Oct 2011 http://www.nobelprize.org/nobel_prizes/medicine/laureates/2011/press.html

Toll-like Receptor 8 (TLR8) Pathway is Important

in Human Immune Responses

• Activation induces potent Th1 immune response

• Expressed on myeloid dendritic cells (CD11c+), monocytes

(CD14+), and natural killer cells (CD56+) in humans

• Induces significant IL-12 production in humans

• Can be activated by small molecule agonists

TLR8 TLR7 TLR9

Expression Myeloid DC,

Monocytes

Plasmacytoid DC

Plasmacytoid DC,

B-cells

Natural Ligand ssRNA ssRNA Bacterial DNA

Small Molecule Agonist Yes Yes No

IL-12 induction Yes No No

TNFα induction Yes No No

IFNα induction No Yes Yes

TLR8 – expression and function

Antibody-Dependent Cell-Mediated Cytotoxicity (ADCC)

Can Augment Tumor Cell Killing

Representative Flow Cytometry Data

Day 1 Day 15

t=0 hr

t=24 hr

105

104

103

102

0

<F

ITC

-A>

: C

D3

0 102 103 104 105

<APC-A>: CD56

82.56 79.2

1.63 16.6

105

104

103

102

0 <

FIT

C-A

>:

CD

3

0 102 103 104 105

<APC-A>: CD56

18.9 23.5

5.12 52.5

105

104

103

102

0

<F

ITC

-A>

: C

D3

0 102 103 104 105

<APC-A>: CD56

87.8 2.2 85.6

2.7 9.55

105

104

103

102

0

<F

ITC

-A>

: C

D3

0 102 103 104 105

<APC-A>: CD56

37.4 19.8 17.6

3.73 58.9

Phase 1b Head & Neck Trial: VTX-2337 + cetuximab

First-line therapy in locally advanced and metastatic

head and neck cancer

SOC: platinum, 5-FU, cetuximab

477 patients cisplatin (approx 60%) or carboplatin

Primary Tumor sites:

– oropharynx

– hypopharynx

– larynx

– oral cavity

Targeting EXTREME Patient Population

NEJM 2008:359:1116

PF + cetux PF

OS 10.1 m 7.4 m

PFS 5.6 m 3.3 m

ORR 36% 20%

Disease Control 81% 60%

1.0

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0

0 3 6 9 12 15 18 21 24 Pro

ba

bil

ity o

f O

ve

rall

Su

rviv

al

Months

Chemotherapy (N=220)

Chemotherapy plus

cetuximab (N=222)

Hazard ratio (95% CI): 0.80 (0.64‒0.99)

P=0.04

No. at Risk Chemotherapy

Chemotherapy

plus cetuximab

220

222

173

184

127

153

83

118

65

82

47

57

19

30

8

15

1

3

1.0

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0

0 3 6 9 12 24 Pro

ba

bil

ity o

f O

ve

rall

Su

rviv

al

Months

Chemotherapy (N=220)

Chemotherapy plus

cetuximab (N=222)

Hazard ratio (95% CI): 0.54 (0.43‒0.67)

P<0.001

No. at Risk Chemotherapy

Chemotherapy

plus cetuximab

220

222

103

138

29

72

8

29

3

12

1

7

Kaplan-Meier Estimates of Overall Survival and

Progression-free Survival According to

the Treatment Group

VTX-2337 enhanced cetuximab-dependent degranulation of NK cells

No Antibody

Cetuximab

Untreated Untreated VTX 250nM VTX 500nM IL-2

80

70

60

50

40

30

20

10

0

%C

D1

07

a+

NK

cells

**

effector cell

cetuximab Fc

F(ab)

EGFR+

tumor cell

cytolysis

T cell

stimulation

and expansion

TLR8+ myeloid

Dendritic Cell

Internalization of

Ab-coated TA and cross

presentation to T cells

ADCC Cross-presentation of

tumor antigens by DC

Cetuximab

coated EGFR

TLR8 stimulation (VTX-2337) May Enhance

T cell priming Effects of mAb Response

In vitro stimulation of EGFR-specific T cells is enhanced

by VTX-2337 stimulated, cetuximab-treated NK:DC

Day 0

Day 7

Day 14

125

100

75

50

25

0

Untreated VTX-2337 Cetuximab Cetuximab+VTX-2337

EG

FR

-sp

ecif

ic

CD

8 T

cells/1

0,0

00

^

* **

Active-8 trial: TLR8 adjuvant to enhance

Cetuximab-based immunotherapy

Screening

Randomization

Cisplatin/Carboplatin,

5-FU, and Cetuximab

+

VTX-2337

Cisplatin/Carboplatin,

5-FU, and Cetuximab

+

Placebo

Cetuximab

+

VTX-2337

Cetuximab

+

Placebo

Disease

Progression

Survival

Follow Up

Follow Up

Subsequent

Treatment

7+ Cycles

Initial Treatment

6 Cycles (18 Weeks)

Screening

≤ 14 days

Standard of care consists of platinum chemotherapy

(cisplatin or carboplatin), 5-FU, and cetuximab

PI’s- Cohen and Ferris

RANTES &

IP10

chemokine

secretion

T cell DC

TA processing

HLA class I antigen

presentation Tumor cell death

Targeting model to

restore type 1

microenvironment -

reversal of tumor

immune escape

and CTL

recognition of HNC Chemoattraction into TME

Tumor

cell

Reprogramming of

anti-tumor CTL to

reverse inhibitory

signals

T cell

anti-CTLA4

anti-PD1

OHNS

Jonas T. Johnson, MD

Eugene N. Myers, MD

Carl H. Snyderman, MD

David Eibling, MD

Jennifer Grandis, MD

Steve Kim, MD

Uma Duvvuri, MD, PhD

Radiation Oncology

Dwight Heron, MD

Andy Clump, MD

Medical Oncology

Julie Bauman, MD, MPH

James Ohr, DO

R01 DE019727-01, R01

CA115902-05,

Bristol Myers-Squibb

NCI P50 CA097190-06,

FAMRI, PGxH biosciences,

VentiRx Biosciences