Primer on Adoptive T cell Therapy. Saar Gill, MD, PhD University of Pennsylvania

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2 Primer on Adoptive T cell Therapy Saar Gill, MD, PhD University of Pennsylvania

3 Presenter Disclosure Information Saar Gill The following relationships exist related to this presentation: Novartis, Research funding

4 Learning Objectives Describe the key requirements for successful adoptive T cell therapy Describe the different types of T cell-based immunotherapy

5 Why T cells? Increased relapses in leukemia patients given T cell depleted bone marrow transplants BMT from syngeneic donors have more relapses than BMT from Allogeneic donors Immunodeficiency-associated malignancies If T cell depletion decreases the anti-tumor effect, does T cell supplementation increase the anti-tumor effect? Marmontet al. Blood 1991

6 What is required for successful adoptive T cell therapy?

7 Forms of ACT Allogeneic hematopoietic cell transplantation (HCT) and donor lymphocyte infusion Tumor-specific T cells (tumor infiltrating, TIL; or circulating anti-tumor T cells) TCR transgenic T cells Engineering / Synthetic biology Chimeric antigen receptor T cells

8 Forms of ACT: allogeneic hematopoietic cell transplantation

9 Forms of ACT: allogeneic hematopoietic cell transplantation

10 Forms of ACT: allogeneic hematopoietic cell transplantation Survival after HLA-matched sibling donor transplants for AML

11 Forms of ACT: allogeneic hematopoietic cell transplantation Donor lymphocyte infusion is effective, but only in low disease burden DLI associated with significant incidence of GVHD AlloHCT(and DLI) not effective in solid tumors Schmidet al, J ClinOncol2007

12 Forms of ACT: tumor-infiltrating lymphocytes (TILs)

13 Forms of ACT: tumor-infiltrating lymphocytes (TILs) 1. Tumor-specificTcells can befoundinatumor biopsy Tranetal Science Tumor-specificTcells can befoundinthe blood-cohen et al, J Clin Invest 2015

14 Smart TILs: successful adoptive T cell therapy based on mutation-specific T cells Tran et al, Science 2014;344:641

15 Smart TILs: successful adoptive T cell therapy based on mutation-specific T cells c Tran et al, Science 2014;344:641

16 Smart TILs: successful adoptive T cell therapy based on mutation-specific T cells Tran et al, Science 2014;344:641

17 Smart TILs: successful adoptive T cell therapy based on mutation-specific T cells Tran et al, Science 2014;344:641

18 Forms of ACT: T cell receptor (TCR) transgenics Restifo etal, Nat Rev Immunol2012

19 (TCR) transgenics: affinity engineering can impart viral-like affinity to cancer-specific TCRs values (Bioacore) Affinity engineering Lietal.,Nat. Biotech 2005 TCRKd Strong T cell potency- ability to be triggered by lower numbers of MHC: peptide complexes Weak Affinity-enhanced MAGE a3atcr MAGE-A3 TCR

20 (TCR) transgenics: NY-ESO1

21 (TCR) transgenics: NY-ESO1

22 (TCR) transgenics: MAGE-A3 Melphalan 200 mg/m 2 ASCT 5x % transduced T cell infusion Diarrhea, C.diff+ Fever, neutropenia T 102.4; Afib with RVR Hypotension, hypoxia, MS; STE ICU; intubation; 100 mg hydrocortisone, levophed TTE: large pericardial effusion, bradycardia Cath lab: no tamponade CRRT 1 gm solu-medrol Trop 1.2->13.75 TTE: new low EF Cath lab: IABP Acidosis, MSOF Death Linette et al, Blood year old man with multiple myeloma Prior treatments: Radiation, lenalidomide, bortezomib, dexamethasone, D-PACE PMH: rate-controlled Afib, hypertrophic CM without outflow obstruction, normal stress test

23 (TCR) transgenics: MAGE-A3 Cells/ l of Blood copies/ g genomic DNA Days post T cell infusion Total WBC/ul blood Copies/ g DNA in PBMC Marked cells/ul blood Copies/ g DNA PBMC fold from baseline (blood) Fold from baseline 10 4 VEGF IL-1 G-CSF Hours post infusion HGF FGF-Basic IL-6 IL-15 IL-17 GM-CSF MCP-1 IL-5 IFN- IL-1R IP-10 IL-2R MIG IL-8 Blood Pericardial fluid

24 (TCR) transgenics: MAGE-A3 myocardium 100x 400x H&E CD3 IHC

25 (TCR) transgenics: MAGE-A3 Titin cross-reactivity Expressed in striated muscle Mutations are a/w cardiomyopathy Low/undetectable in most cultured cells Mouse titin no homology with human MAGE-A3 specific T cells killhla-a1 + beating, ipsc- derived cardiomyocytes icells alone icells + untransduced T cells icells + MAGE a3a-tcr- T cells Cameron et al. Science Translational Medicine 5:197ra103, 2013

26 (TCR) transgenics: MAGE-A3 First example of off-target effects with TCR-engineered T cells Affinity enhanced TCR engineered T cell therapy at risk for cross-reactivity Biologically relevant preclinical screening of new TCRs is critical Dose reduction maynotameliorate riskand mayonlydelayonsetof toxicity(duetoinvivotcellexpansion) Toxicity management: corticosteroids did not ablate. Would suicide systems or other forms abort toxicity? NY-ESO-1 TCRs are safe with encouraging clinical results to date

27 Forms of ACT: chimeric antigen receptor (CAR) T cells

28 Chimeric antigen receptor (CAR) T cells Redirected T cell concept pioneered in vitro by Eshhar et al (PNAS, 1989) Anti-CD19 CAR Study Year Jensen, BBMT 2010 Porter, NEJM 2011 Kalos, STM 2011 Brentjens, Blood 2011 Kochenderfer, Blood 2011 Kochenderfer, Blood 2012 Cruz, Blood 2013 Despite strong pre-clinical rationale, technical difficulties prevented clinical translation until recently: o o Efficient T cell culture systems Efficient gene transfer systems Early trials showed some promise but ultimately disappointing, due to poor T cell persistence Brentjens, STM 2013 Grupp, NEJM 2013 Kochenderfer, Blood 2013 Davila, STM 2014 Maude, NEJM 2014 Lee, Lancet 2015 Kochenderfer, JCO 2015

29 Chimeric antigen receptor (CAR) T cells CD19 is a prototypic antigen Pre B-ALL B cell lymphomas and leukemias myelomas Stem Cell pro B pre B immature B mature B plasma cell CD19 CD22 CD20 Brentjens and Sadelain

30 CAR T cells: what have we learned? Concept Selected Reference Co-stimulation is important Savoldo 2011 Lymphodepletion is important Brentjens 2011 Persistence is important Kalos 2011 Establishment of memory Kalos 2011 Disease kinetics not important many No dose-response (probably) unpublished Antigen-loss(immunosurveillance) Grupp 2013 Cytokine release/ Macrophage activation Grupp 2013 CRS correlates with antigen burden Maude 2014 Trafficking to immunoprivileged sites Grupp 2013 Encephalopathy Davila 2014

31 CAR T cells: open questions in 2016 Concept T cell manufacturing optimal method? Optimal for what / who? Gene transfer LV, RV, mrna, transposon, other Which co-stimulatory molecule? (efficacy, toxicity) Beyond 2 nd generation? Solid tumors trafficking, other CLL -?immunosuppression What to dowhen CART fail to persist? CRS prophylaxis or treatment?

32 1 st Generation CAR 2 nd Generation CAR 3 rd Generation CAR T cell VH scfv scfv hinge hinge hinge VH VH scfv T cell TM Collected from patients via apheresis a b T cell c CD3ζ CD28 or 41BB CD3ζ >2 Domains CD28 41BB ICOS CD27 OX40 CD3ζ CD3/CD28 beads e Proliferation LV vector CD19 Granzymes Cytokines IL-2 support TCR CD28 d Degranulation Cytokine Release CD19+ Tumor Tumor Death CAR TM cell Infusion back into patients

33 CART-19 trial overview FDA Approved Therapy Monitor for recurrence CART Infusion Infusions Day 0,1,2 (split dose) Day 11 (full dose if available) CD19+ve Heme Malignancy Observation Monthly observation / monitoring / monitoring 6 months 6 months post post infusion infusion Quarterly Lentiviral observation/monitoring vector safety to assessments year annually 2 Roll over to destination protocol for 15 year f/u for monitoring for delayed AEs related to gene transfer PBMC Baseline Assays Wk - 4 Assess Response PBMC Endpoint Assays Wk + 4 Eligibility Tumor Restaging Apheresis #1 ( L) CART-19 T Cells Manufacture / Cryopreservation ChemoRx ~d -2 Apheresis #2 (2L) Incurable with standard therapies

34 CART-19 in CLL

35 CART-19 in CLL

36 CART-19 in CLL

37 CART-19 in CLL

38 CART-19 in CLL

39 CART-19 in CLL Proof of concept 47% ORR in heavily pre-treated patients Cause of poorer-than-expected response rates? Immunosuppression in CLL Combination with other agents Immunotherapy vs small molecules, esp ABT-199

40 CART-19 in ALL N=30 (evaluable) 25 pediatric and 5 adult patients 40% female, 60% male Median age 14 (5-61) Disease status Primary refractory 10% 1 st relapse 17% >2 nd relapse 73%

41 CART-19 in ALL day +6 day +23 Marrow T Cells Blasts (ALL) Deep remission induced in 23 days Status: CR (11+) MRD <0.01% cells Gruppet al, NEJM 2013

42 CART-19 in ALL d-23 d8 d12 d92 d176 CD8 + CART19 + cells CD4 + CART19 + T-cells Tnv Tscm Tcm Ttm Tem Tte Persisting cells remain functional CD107a

43 CART-19 in ALL Morphology of CARs In Vivo Blood CHOP-100 CHOP-101 1% marking copies/ µg gdna Blood Day Daysafter Infusion CSF copies/ µg gdna CSF Day Daysafter Infusion

44 CART-19 in ALL Response N=30 % Complete Response 27/30 90% No response 3/30 10% Not evaluable (extramedullarydz(1) and short f/u (4) 5

45 CART-19 in ALL

46 CART-19 in ALL Event free Survival Probability month EFS: 66% (95% CI: 49,87) N: Days since infusion

47 CART-19 in ALL Overall Survival month OS: 78% (95% CI: 64,95) Probability N: Days since infusion

48 CART-19 in ALL

49 CART-19 in ALL

50 CART-19 in ALL Patient Tissue timepoint Cell equivalents total productive reads Total unique sequences Total tumor reads tumor clone frequency UPN01 Blood , , , , , , Marrow , , , , UPN02 Blood -1 61,270 1,385,340 4,534 1,231, , , Marrow , , CHP Blood , , , , Marrow ,460 59, , , , , CHP Blood ,584 38, , , Marrow ,730 68, , ,067 1, , , ,

51 CART-19 in ALL CHOP 101 Baseline CHOP 101 Day < CHOP 101 Day CD CD19 SSC CD45

52 CART-19 in ALL Sotillo E., Cancer Discovery 2015 Grupp SA, NEJM, 2013 Convergence of acquired mutations and alternative splicing of CD19 enables resistance to CART-19 immunotherapy

53 What is required for successful adoptive T cell therapy?

54 ACT: conclusions T cells may be the most potent immune cells Early studies suffered from lack of specificity (toxicity and lack of activity) TIL therapy is elegant but resource-intensive Genetic engineering by TCR or CAR gene transfer confers specificity Co-stimulatory molecule engineering leads to enhanced T cell function By successively addressing the requirements for ACT, it is likely that we will gradually develop a robust, predictable platform for cancer immunotherapy