Preclinical Modeling of CART Cell and combination Immunotherapies

Transcription

1 Preclinical Modeling of CART Cell and combination Immunotherapies Saad S. Kenderian, MD Assistant Professor of Medicine, Immunology and Oncology Mayo Clinic College of Medicine July 19, MFMER slide-1

2 Disclosures Novartis: patents and potential royalties, inventor IP is managed according to an agreement between Mayo Clinic, University of Pennsylvania and Novartis 2015 MFMER slide-2

3 Chimeric Antigen Receptor Monoclonal Antibody γ ε α β ε δ ζ ζ v H v L TCR complex CAR scfv Intracytoplasmic 2015 MFMER slide-3

4 Chimeric Antigen Receptors Pioneered by Eshhar et al MFMER slide-4

5 CD19: An Ideal Tumor Target in B-Cell Malignancies CD19 expression is generally restricted to B cells and B cell precursors 1: CD19 is not expressed on hematopoietic stem cells CD19 is expressed by most B-cell malignancies: CLL, B-ALL, DLBCL, FL, MCL preb-all B cell lymphomas and leukemias CD19 expression Hematopoietic stem cell Pro-B Pre-B Immature Mature Activated (IgM) (IgM, IgD) B cell Memory B cell (IgG, IgA) Plasma cell (IgG) Image adapted from Janeway CA, Travers P, Walport M, et al. Immunobiology. 5th ed. New York, NY: Garland Science; 2001: ; Scheuermann RH, et al. Leuk Lymphoma. 1995;18: ; and Feldman M, Marini JC. Cell cooperation in the antibody response. In: Roitt I, Brostoff J, Male D, eds. Immunology. 6th ed. Maryland Heights, Missouri: Mosby;2001: MFMER slide-5

6 CART19 for B cell malignancies Maude et al, NEJM 2014 Lee et al, Lancet MFMER slide-6

7 Serum Cytokine (fold change from baseline) Cytokine Release Syndrome Serum Cytokine (fold change from baseline) High fevers, myalgia, nausea, CHOP 100 hypotension, hypoxia, shock Very high levels of IL6; IFN-g, 100 modest TNF-a; Mild increases in IL-2 10 Severe CRS is reported in up to 60% 1 of patients CHOP 101 IL-1b IL-6 IFN-g TNF-a IL-2R IL-2 IL-10 IL-1RA Almost all responding Day after Infusion patients developed a CRS Day after Infusion Deaths are reported 2015 MFMER slide-7

8 CAR T cell Toxicity: Cytokine Release Syndrome Ref T cell Engager Anti-CD19 CAR T cells Population Response CRS Maude et al. NEJM 2014 Anti-CD19 CART 4-1BB N=30 Peds&Adults CR=90% 100% CRS 27% Severe Davila et al. SciTrMed 2014 Anti-CD19 CART CD28 N=16 Adults CR=88% 43% Severe Lee et al. Lancet 2015 Anti-CD19 CART CD28 N=21 Peds&AYA CR=67% 76% CRS 28% Severe Turtle et al. JCI 2016 Anti-CD19 CART 4-1BB N=30 Adults CR=93% 83%CRS 2015 MFMER slide-8

9 CRS is Correlated with Disease Burden, IL-6 Levels, CRP Lee et al, Lancet 2015 Maude et al, NEJM MFMER slide-9

10 Treatment of CRS Supportive care (often in ICU) Steroids: Effective Tocilizumab IL-6 receptor antagonist blocks IL-6 mediated effects rapidly reversed CRS administered on day 2 to MFMER slide-10

11 Temperature Response to Tocilizumab F Temperature (F) Tocilizumab , 6a 1, 12p 1, 6p 2. 12a 2. 6a 2. 12p 2, 6p 3, 12a 3. 6a 3. 12p 3. 6p 4, 12a 4. 6a 4. 12p 4. 6p 5, 12a 5. 6a 5. 12p 5. 6p 6, 12a 6. 6a 2015 MFMER slide-11

12 ng/ml Macrophage-activation syndrome CRS associated with HLH/MAS: hemophagocytosis, ferritin >500,000, hemolysis, DIC, altered mental status Ferritin Tocilizumab MFMER slide-12

13 Grading and Management Algorithm for CRS Concerns with early intervention after CART cell therapy 2015 MFMER slide-13

14 Grading and Management Algorithm for CRS Lee et al, Blood 2014 Porter et al, ASH abstract # MFMER slide-14

15 Develop a preclinical model for CRS after human CART cell therapy Strategies to prevent CRS in high risk patients 2015 MFMER slide-15

16 Model for human CRS PBMCs AML Blasts 3x10 6 NSGS mice Bleeding Engraftment 2 4 weeks CART123 (1x10 6 ) High Burden Weight Survival Cytokines T cell Kinetics AML count Kenderian et al. ASH 2016 Weakness Emaciation Hunched bodies Withdrawal Poor motor response Death within one week 2015 MFMER slide-16

17 Model for human CRS One week after CART 2015 MFMER slide-17

18 Ruxolitinib JAK/STAT inhibitor, approved in MF and PV Mascarenhas et al, 2012 Can ruxolitinib affect cytokine profile after CART cell therapy? 2015 MFMER slide-18

19 Ruxolitinib does not impair CART cell effector functions Killing of Targets by CART123 cells Direct Killing of CART cells by Ruxolitinib Kenderian et al. ASH MFMER slide-19

20 Ruxolitinib slows CART proliferation but does not impair their effector functions RUX 0ug/ml RUX 0.1ug/ml RUX 1ug/ml CART123 + CD123 positive primary AML 2015 MFMER slide-20

21 Ruxolitinib prevents CRS in preclinical models 5 days vehicle Ruxolitinib 30 mg/kg PO BID Ruxolitinib 60 mg/kg PO BID Ruxolitinib 90 mg/kg PO BID NSGS mice CART123 1x10(6) 3x10 6 Bleeding Bleedings Engraftment Weights Clinical status Tumor burden 2 weeks 4 weeks Survival AML Blasts 2015 MFMER slide-21

22 Ruxolitinib ameliorates cytokine production without impairing anti-tumor effect CD33 Day70 CD3 ** 2015 MFMER slide-22

23 Ruxolitinib ameliorates cytokine production without impairing anti-tumor effect 10 days after CART injection 2015 MFMER slide-23

24 Ruxolitinib ameliorates cytokine production without impairing anti-tumor effect 2015 MFMER slide-24

25 Combination of CART19 and BTK inhibition - First in class BTK inhibitor - Approved in multiple hematological malignancies Inhibits ITK and drives Th1 differentiation Can Ibrutinib synergize with CART19 in B cell malignancies? Dubovsky et al, blood 2015 Ruella* and Kenderian* et al, Clinical Cancer Research MFMER slide-25

26 B L I ( p / s e c ) Combination of CART19 and ibrutinib is synergistic C D 3 + /u l C A R T 1 9 C A R T IB R U T IN IB 6 M C L B L I 4 2 T -c e lls N O T R E A T + V E H I C L E I B R U T I N I B m g / K g / d a y C A R T E 6 + V E H I C L E C A R T E 6 + I B R U T I N I B m g / K g / M C L -R L -L u c D a y s T - c e l l s / I b r u D a y s R L - L U C Ruella* and Kenderian* et al, Clincal Cancer Research MFMER slide-26

27 CRS model with CART MFMER slide-27

28 Ibrutinib prevents the development of CRS Ruella* and Kenderian* et al. Leukemia MFMER slide-28

29 Conclusions CRS is the most serious and dose limiting toxicity after CART cell therapy Xenograft model for the development of human CRS Combination CART/small molecules prevents the development of human CRS One modality to be investigated in patients at high risk for the development of severe CRS 2015 MFMER slide-29

30 Acknowledgments Kenderian Lab Cynthia Forsman Leo Sakemura Baustin Welch William Gerdon Genome Engineering Stephen Ekker Karl Clark William Gerdon Mayo BMT Mark Litzow William Hogan Mrinal Patnaik Shahrukh Hashmi MCCC Aminah Jatoi Robert Diasio IMPACT lab Dennis Gastineau Al Dietz Martha Lacy Yi Lin CIM Keith Stewart Scott Beck Penn TRP/CCI Carl June Saar Gill David Porter Olga Sheshtova Marco Ruella Miriam Kim Michael Klichinsky Regina Young Mayo Hematology Tait Shanafelt Neil Kay Stephen Russell Greg Nowakowaski Alex Wolanshyj Immunology Diane Jelinek Dan Billadeeau Larry Pease Predolin Foundation MFMER slide-30

31 Questions Comments 2015 MFMER slide-31