Advanced Course in Basic & Clinical Immunology
February 21, 2018
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Immunotherapy
Mark S. Anderson UCSF
FOCiS
Disclosures
• Own stock in Medtronic
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Advanced Course in Basic & Clinical Immunology
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Lecture outline
• Biotherapeutics
• Challenges
• Where the field is going
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Biopharmaceutical Market Sector• Biopharmaceuticals are recombinant proteins,
Mabs, or nucleic acid based products• The annual global market for
biopharmaceuticals is >$100 billion USD• 2003 >140 biopharmaceuticals were approved
>500 were in clinical evaluation• 2010 ~50% of drugs in development are
biopharmaceuticals
Genentech Confidential - do not copy, distribute or use without prior written consent.
Evolution of Top Ten Selling Pharmaceuticals
2005
Product Company TA
Lipitor Pfizer CV
Advair GSK IMM-RESP
Norvasc Pfizer CV
Nexium AZ GI
Zocor Merck CV
Zyprexa Eli Lilly NEURO-PSYCH
Plavix BMS CV
Diovan Novartis CV
Effexor Wyeth NEURO-PSYCH
Rituxan Roche ONC
2015
Product Company TA
Humira AbbVie IMM
Harvoni Gilead ID
Rituxan Roche ONC-IMM
Lantus Sanofi MET
Avastin Roche ONC
Herceptin Roche ONC
Prevnar Pfizer ID
Revlimid Celgene ONC
Remicade JNJ IMM
Advair GSK IMM-RESP
Worldwide sales: source Evaluate Pharma
Small molecule
Large molecule
Vaccine
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Why Antibodies as Therapeutics?
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- High affinity and specificity
- Low immunogenicity, predictable pharmacokinetics
- Can harness host immune effector functions
- Developed production and regulatory systems
Advantages of Recombinant MAbTherapeutics
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Strategies to Generate Therapeutic Abs
• Mouse hybridoma technology
• Humanized mouse hybridoma technology
• Mouse B cell cloning technologies
• Phage display technologies
• Human B cell cloning technologies
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Mouse Ab
Splenic Cells Myeloma Fusion partner
Mouse Ab
Mouse Hybridoma Technology
1984
.. ‘ Cesar MilsteinGeorges Kohler
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Humanized Rodent Technologies
VL JL C
VH DH JH C
VL JL C
VH DH JH C
Human IgH
Human IgL
Mouse IgH
Mouse IgL
VL JL C
VH DH JH C
Human IgH
Human IgL
HIg
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Naïve B cells
Amplified natural
repertoires
Immune
VL2 JL2
VH1 DH3 JH2
T
T
T
T
T
T
T
T
T
G
G
T
G
T
T
T
T
T
CG
G
G
T
T
G
C
C
G
Trp
Cys
Phe
Leu
T
SyntheticCDR
diversity
DNA Synthesis
Synthetic
VL1 JL4
VH8 DH6 JH4
E. Coli expressing Fabs
Phage Display Technologies
Phage Library
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3
4
5
Phage Binds to TargetWash Away
Unbound PhageElute Bound
Phage
12
3
4
5
3
3
Phage diversity library ~1010
Propagate Phage in E. Coli
SequenceDNA
IgH
IgL
Clone 3
VL JL
VH DH JH
Human antibody(Clone 3)
Phage Display Technologies
Natural Ab repertoire >1012
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Therapeutic Abs Directly from Humans
Vaccinated, infected, or recovered human
Monoclonal Ab(e.g., pavilizumab)
Polyclonal antiserum(e.g., IVIG, CMV immune globulin)
Single B cell cloning VL1 JL1
VL2 JL2
VL3 JL3
B CA
Ig cloning
Ig expression
Screening for activity
A B C
Act
ivity
Human antibody(Clone A)
Antibody-Drug Conjugates
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emtansine
Toxin
Non-cleavableLinker
-N-H
Ag Ag
MCC
CancerTargeting Ab
(Bouchard et al, Bioorg & Med Chem Lett, 24:5357, 2014)
Endocytosis
Lysosome degradation(drug release)
Endosomeformation
Lysosome trafficking
Lysosome
Drug binding to target
Antigen binding
mAb-Linker-Drug(ADC)
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Laptatinib-Capecitabine 25.1 182T-DM1 30.9 149
(Stratified HR 0.68 (95% CI, 0.55-0.85, P < 0.001)
Median survival (mo) No. of events
Verma et al (EMILIA), NEJM 367:1783, 2012
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Kadcyla for Her2+ MBC
emtansine
Toxin
Non-cleavableLinker
-N-H
Her2 Her2
MCC
CancerTargeting Ab
Transtuzumab
Antibody-Drug Conjugates for Her2+ Breast CA
Activation of T and/or B cells results in increased
immune response
Trafficking of leukocytes, which are capable of cytokine production
Secretion of cytokines and other products from
activated immune cells tissue injury
Failure to downregulate
If you were to design a therapy for immune-mediated diseases, which pathway(s) should you
target?
Chronic Inflammation
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RORtCD4+
TCR
AntigenPresenting Cell
MHCII
Ag
StimulusTLR
p40p35
IL‐12
IL‐23
p40p19
IL‐17(Th17)
IL‐23R IL‐12R1
Interleukin-23 is a Th17 survival factor by sustaining RORgt and IL-17
expression
Comparison of ustekinumab (anti-p40) and etanercept for moderate-
to-severe psoriasis
Griffiths et al. N Engl J Med; 362:118-28.
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Rich P, et al. Britich Journal of Dermatology. 2012; DOI: 10.1111/bjd.12070
Secukinumab (anti-IL17a) for induction and maintenance therapy in moderate to severe
plaque psoriasis
Hueber W, et al. Gut. 2012; 61:1693-1700.
Crohn’s disease: Primary endpoint at week 6 shows no treatment benefit of
secukinumab
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Why do some fail and some succeed?
• No better data then that directly in humans
• Need to learn better from negative results
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Target Validation
Drug Discovery
IND FilingPhase 1 Phase 2 Phase 3
Regulatory Review Phase 4Discovery
Phase 4
Efficacy
Safety
Drug development 101‐ A quick overview
Phase 1
Safety and Tolerability
Pharmacodynamic markers
Pharmacokinetics
Phase 2
Proof of Clinical Activity
Dose finding
Safety
Phase 3
Demonstration of Benefit
Safety
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• INCREASING COSTS
• DECREASING SUCCESS RATES
1987 2001 2003 2005 2016
Fully burdened costs
$318M $802M $897M $1,200M > $2,600M
Tufts CSDD study of biopharmaceutical development details R&D costs, 2006Adams and Brantner, Health Economics, 19:130-141, 2010
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1996-1998
1999-2001 2002-2004
2005-2007
2008-2010
Phase 1 to launch 17.6% 12.9% 8.8% 10.5% 7.0%
Drug development costs and success rates worsening
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Reasons for high failure rates of clinical studies (a partial list)
Pre-clinical models are poor models of human disease
Lack of understanding of human disease
Lack of understanding of mechanisms of therapeutic candidates
Little learned from negative clinical trials
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Dunn, Mertsching, Peach, Kehry (Biogen-IDEC)
Martin, Gong, Lee (GNE)
Mouse collagen-induced arthritis (intervention)
Challenge 1: Selection of pre-clinical modelsImmunization(100ug CII/CFA)
Immunization(100ug CII/IFA)
Day 021
70
Terminate study
0
2
4
6
8
10
12
20 30 40 50 60 70Study days
Mea
n ar
thri
tis
scor
e
Control
Anti-CD20
TNFRII-Fc+ methotrexate
Treatment beginsDay 24
18
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12
0
10
20
30
40
50
60
ACR20 ACR50 ACR70%
Pa
tien
ts
Placebo (N=201)
Rituximab (N=298)
p < 0.0001
p < 0.0001
p < 0.0001
Anti-TNF failures
REFLEX Study
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Joint transcriptome of mouse collagen induced arthritis is different than human RA
-3 +3
CD90
CD14
CD8
CD8
CD19
CD22
IL-1
IL-6
LT-
LT-
TNF-
BAFF
(Flavius Martin and colleagues)
Mouse CIA jointHuman RA synovium
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Which pre-clinical model?Model Spontaneous
(S) or Inducible (I)
H-2 haplotype
Unique characteristics Autoantibodies
Collagen-induced arthritis
I q or r Anti-collagen II AbsAnti-CCP Abs
Autoantibody-induced arthritis
I all
Pristane-induced arthritis
I d or q Rheumatoid nodules Rheumatoid factorAnti-collagen II AbsAnti-HSP Abs
Proteoglycan-induced arthritis
I d or k Ankylosing spondylitis Anti-PG Abs
Chronic antigen-induced arthritis
I b Lymphoid aggregates
D1CC (rCII promoter/enhancer-hCIITA)
I (hCII) q Rheumatoid nodulesInterstitial pneumonitis
Anti-cII Abs Anti-CCP Abs
K/B X N S I
I-Ag7 all
Anti-GPI Abs
SKG S and I d or b/d Skin inflammationInterstitial pneumonitis
Rheumatoid factor 31
Challenge : Co-medications and active comparators
How do we control in pre-clinical models the potpourri effects of co-administration of SOC medications?
• RA: NSAIDs, Plaquenil, Sulfasalazine, Methotrexate• SLE: Steroids, Imuran, Methotrexate, Cellcept
Active comparator to demonstrate superiority
• Importance of specific biological pathways can be under-and over-estimated in specific pre-clinical models (e.g., IL1 pathway and LFA-1 biology in collagen-induced arthritis) 32
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Clinical Symptom C
Clinical Symptom D
Clinical Symptom E
Clinical Symptom A
Clinical Symptom B
Molecular PathwayDysregulation
Therapy A
Adenosine deaminase deficiencyFabry’s disease (-galactosidase)Factor VIII & IX deficiencyPompe disease (-glucosidase)
Monogenic diseases with a single disease pathogenic mechanism have high drug discovery success rates
Therapy A
Therapy B
Therapy C
Developing “targeted” therapies AND ability to identify the “right” patient for a drug will increase success and provide greater patient benefit
Molecular Pathway 1
Molecular Pathway 2
Molecular Pathway 3
CDx
CDx
CDx
34Identifying patient subsets driven by dominant molecular pathways to increase drug discovery/development success
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Predictive Diagnostics to find the right therapy for the right patient
67% responders
3% responders missed
= Responder
= Non-responder
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20.3 mo
25.4 mo (25% )
RR = 0.76p = .025
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The right therapy for the right patient
3% responders missed
67% responders= Responder
= Non-responder
5 months
(22.7%)
Actual Benefit(All Patients)
5 mos (22.7%)
Expected Benefit Target PrevalenceRequired Sample Size
and Study Duration
1250 52 mo100%
1.25 mos (5.7%) 11000 349 mo25%37 v
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A Phase III in which 25% of patients show a treatment effect.
Without patient selection, a potentially beneficial therapy would have been missed
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Disease Molecular Pathway Incidence Targeted Therapy Approval(with Dx)
Breast Estrogen receptor 70% tamoxifen (Nolvadex)faslodex (Fulvestrant)anastrozole (Arimidex)
197720022005
Breast Her2/Neu/Erb2 overexpression
25% trastuzumab (Herceptin)pertuzumab (Perjeta)
19982013
CML Bcr-Abl fusion 90% imatinib (Gleevac)nilotinib (Tasigna)dasatinib (Sprycel)bosutinib (Bosulif)ponatinib (Iclusig)
20012010201320132016
Colorectal cancer
K-ras mutations (codons 12 and 13)
40% Contraindicated:cetuximab (Erbitux)
pantimumab (Vectibix)
2009
NSCLC Nucleophosmin-anaplastic lymphoma
kinase (NPM/ALK)
3% crizotinib (Xalkori)alectinib (Alecensa)
20112016
Melanoma Raf (V600E) mutation 50% vemurafenib (Zelboraf)dabrafenib (Tafinlar)
20112016
Transforming clinical into molecular oncology39
Anti-PDL1 mAb: Releasing a T cell checkpoint
SS
Dendritic Cell/tumor
Stimulation
CD28TCR
B7‐1
HLA
T cell SS
Dendritic cell/tumor
Stimulation
CD28PD‐1
Inhibition
TCR
PD‐L1B7‐1
HLA PD‐L2
T cell
Exhaustion
Anti-PD1/L1 mAb
RejuvenationImmune Activation
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PD-L1 Is Broadly Expressed in Human Cancer
Tumor Type Estimated PD‐L1 Prevalence (≈ %)*
NSCLC (SCC) 50
NSCLC (adeno) 45
Colon 45
Melanoma 40
Renal 20
* Staining of archival tumor tissue (GNE); Brown chromogen: PDL1; Blue: hematoxylin counterstain
PD-L1
Garon, AACR 2015
PDL1 staining: < 1% 1 - 49% > 50%
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Obj
ecti
ve R
espo
nse
Rat
e (%
)
KEYNOTE 001 KEYNOTE 010
PD-L1 Score
8.1%
12.9%
19.4%
29.6%
45.4%
10.0%
30.0%
(Grigg and Rizvi, J Immunother CA 4:48, 2016)
<1% 1-24% 25-49% 50-74% 75-100% 1-49% >50%
Prevalence (%) 39.2 31.0 6.7 8.6 14.6 37.9 28.4
50
40
30
20
10
0
PD-L1+ in advanced NSCLC enriches for benefit with pembrolizumab (anti-PD1 mAb)
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Breast CA Colon CA Melanoma Lung CA
Estrogen R
Her 2
EGFR Raf K-ras
PDL1PI3K/PTEN loss
Unknown
Redefining clinical phenotypes into molecular mechanisms 43
Identifying patient subsets driven by dominant molecular pathways may increase drug discovery/development success
Therapy A
Therapy B
Therapy C
Developing “targeted” therapies AND ability to identify the “right” patient for a drug will increase probability of success and provide greater patient benefit
CancersAsthma
Rheumatoid ArthritisSystemic Lupus ErythematosusInflammatory Bowel Disease
….
Molecular Pathway 1
Molecular Pathway 2
Molecular Pathway 3
Polygenic diseases have multiple pathogenic molecular/cellular pathways that contribute to disease
Biomarker
Biomarker
Biomarker
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Rheumatoid Arthritis: synovial heterogeneity
Synovium
FACS profile
Histology
Transcriptome Sorted Cells
Histology scores
Total Synovial Transcriptome
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“Lymphoid”(33%)
“Myeloid”(33%)
“Fibroid”(33%)
Synovial Gene Expression Clusters have Differential Representation of Biological Pathways
Dennis et al, Arthritis Research and Therapy 2014, 16:R90.
• Training cohort of active RA patients (n=69) on standard of care therapies
• >3 years of disease
• Majority Rheumatoid Factor positive
• Synovial tissue from involved joints (small and large) undergoing orthopedic surgery to correct deformity or for joint replacement
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“Lymphoid”(33%)
“Myeloid”(33%)
“Fibroid”(33%)
Synovial Gene Expression Clusters have Differential Representation of Biological Pathways and Histologies
Dennis et al, Arthritis Research and Therapy 2014, 16:R90.
Lymphoid gene score
Monocyte/M1 macrophage gene score
Lower serum C reactive protein
CD3 CD20
Minimal inflammation
CD3 CD20
~25% have GC-like structures
CD3 CD20
>80% have GC-like structures
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Baseline Synovial Myeloid Gene Score Predicts EULAR ‘GOOD’ Infliximab (anti-TNF) Response
Myeloid
Interrogation of pre-treatment synovial tissue GEO data set
p=N.S. p=N.S.
Lymphoid Fibroid
p<0.05
*
Data shown as median/IQR(p values derived from t-statistic of EULAR Good vs. Moderate vs Poor clinical response at 16 weeks)
(Dennis et al, Arthritis Research and Therapy 2014, 16:R90; Lindberg et al, PloS One 5:e11310) 2010)
ICAM1hi CXCL13lo ICAMllo CXCL13hi ICAM1lo CXCL13loSerum:
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Serum ICAM1 and CXCL13 levels can differentially enrich anti-TNF vs. anti-IL6R responders
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(Dennis et al, Arthritis Research and Therapy 2014, 16:R90)
Working Model for RA Heterogeneity and Drug Response Groups
Chondrocytes
Jointcellularity(Early & Late
Disease)Lymphocytes
Fibroblasts
Macrophages
‘Lymphoid’Axis ‘Myeloid’Axis ‘Fibroid’ Axis
Patients
CXCL13SystemicBiomarkers
sICAM CRP, ESR, Antibodies
Anti-TNF
Poor anti-inflammatory drug response (methotrexate,
Rituxan)
Anti-IL-6RDrug
ResponseAnti-CD20
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ER/PR Her 2 PI3K Ras Raf?? PDL1
Molecular Medicine- 2017 and beyondBreast CA Lung CAMelanomaColon CA
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Lupus Geographic atrophy
Ulcerative colitis
Asthma
IFN BAFF IL13 7 TNF fD
Biomarker development to decrease disease heterogeneity!
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Immunotherapy
• Many pathways/targets now developed
• Cancer Immunotherapy: very exciting developments
• How does it work???
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Acknowledgements
• Scott Plevy
• Andy Chan