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
Top Related