Development of Recombinant Vaccines for the Therapy of Carcinomas

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1 Development of Recombinant Vaccines for the Therapy of Carcinomas Monotherapy and Combination Therapy Jeffrey Schlom, Ph.D. Laboratory of Tumor Immunology and Biology Center for Cancer Research National Cancer Institute, NIH

2 STRATEGIC PLAN Cancer Vaccine Developme nt: Focus on human carcinoma Focus on development of vaccines that can be widely evaluated Ultimate Use: Early in disease process/low tumor burden Survival as the endpoint Minimal toxicity Immunologic Platform: Combination immune therapies immune stimulation strategies reduction of immune inhibitory entities Combination Therapies: Vaccine plus: conventional therapies conventional therapies in novel strategies other experimental therapies

3 Translational Research Programmatic Effort PRECLINICAL STUDIES: CLINICAL STUDIES: Laboratory of Tumor Immunology and Biology (LTIB) James Hodge Al Tsang Claudia Palena Jack Greiner Connie Rogers Benedetto Farsaci Sofia Gameiro Matteo Vergati Mary Litzinger Ken Hance Laboratory of Molecular Biology Ira Pastan Vaccine Branch Jay Berzofsky LTIB/Medical Oncology Branch James Gulley Philip Arlen Ravi Madan Mary Pazdur Medical Oncology Branch William Dahut Tito Fojo William Figg Radiation Oncology Kevin Camphausen Urologic Oncology Marston Linehan Peter Pinto Biostatistics and Data Management Section Seth Steinberg NIH Nuclear Medicine Jorge Carrasquillo C.H. Park

4 Translational Research Programmatic Effort CLINICAL STUDIES EXTRAMURAL: Georgetown John Marshall Dana Farber Cancer Center Donald Kufe, Paul Eder, Philip Kantoff Columbia Howard Kaufman Cancer Institute of New Jersey Edward Lattime, Robert DiPaola Ohio State William Carson Eastern Cooperative Oncology Group (ECOG) Robert DiPaola, Howard Kaufman, Louis Weiner CANCER THERAPY EVALUATION PROGRAM (CTEP): Howard Streicher Jan Casadei PRIVATE SECTOR: GlobeImmune Alex Franzusoff, David Apelian BN ImmunoTherapeutics Wayne Godfrey, Reiner Laus NCI Technology Transfer Center: Kevin Brand, Karen Maurey NIH Office of Technology Transfer: Mojdeh Bahar

5 Strategies to Enhance Vaccine Potency 1. Mode of Delivery of the Vaccine place the gene for the tumor antigen into a vector 2. Diversified Vaccine Prime and Boost 3. T-cell Costimulation these molecules are essential for vigorous T-cell activation place costimulatory molecule into vaccine vector 4. Alter the a.a. sequence of the tumor antigen to enhance the immune response epitope enhancement 5. Combination therapies

6 Vaccine Platforms Recombinant poxviruses vaccinia; (MVA) fowlpox Recombinant saccharomyces (yeast) Chitosan / nanoparticles

7 Recombinant Vaccine Vectors Pox vectors Vaccinia (rv-) elicits a strong immune response host induced immunity limits its continuous use MVA (replication defective) Avipox (fowlpox rf-, ALVAC) derived from avian species safe; does not replicate can be used repeatedly with little if any host neutralizing immunity Can insert multiple transgenes Do not integrate into host DNA Efficiently infect antigen presenting cells including dendritic cells

8 Costimulatory Molecule Candidates: Major Costimulatory Effect must be on the T-cell No Overlap of T-cell Ligands No Redundancy of Costimulatory Mechanisms APC MHC + Peptide Costimulatory Molecule B7-1 (CD80) ICAM-1 (CD54) TCR Ligand CD28 CTLA-4 LFA-1 T-Cell Costimulatory Mechanism IL-2-R upregulation, IL-2 secretion Tyrosine Kinase, Phospholipase C T-cell Activation (CPM x 10 5 ) LFA-3 (CD58) CD2 (Region 1) Tyrosine Kinase, Ca 2+ Mobilization camp Production None LFA-3 ICAM-1 B7-1 TRICOM Costimulatory Molecule

10 TRICOM TRIad of COstimulatory Molecules Costimulatory Molecule Ligand on T cell B7-1 (CD80) CD28/CTLA-4 ICAM-1 (CD54) LFA-1 LFA-3 (CD58) CD2 TRICOM = B7-1/ICAM-1/LFA-3 CEA/TRICOM = CEA/B7-1/ICAM-1/LFA-3 CEA/MUC-1/TRICOM = CEA/MUC-1/B7-1/ICAM-1/LFA-3 (PANVAC) PSA/TRICOM = PSA/B7-1/ICAM-1/LFA-3 (PROSTVAC) All vaccines contain: rv- as a prime vaccine avipox (fowlpox, rf-) as multiple booster vaccines CEA, MUC-1, and PSA transgenes all contain enhancer agonist epitopes

11 CEA-specific Lymphoproliferation of T Cells from CEA-Tg Mice Vaccinated with TRICOM Vectors 8000 Con-A Ovalbumin Proliferation (CPM) CEA/TRICOM CEA/B7-1 CEA VAAA Regimen CEA CEA/B7-1 CEA/TRICOM TRICOM 2000 TRICOM All groups with GM-CSF and low dose IL None [CEA], ( g/ml) Aarts WM, Schlom J, Hodge JW. Cancer Res. 62:5770-7, 2002

12 Therapy of 14-Day Established CEA + Experimental Metastases in CEA-Tg Mice Using CEA/TRICOM Vectors % Survival CEA/TRICOM (P<0.02 vs CEA) VAAA Regimen CEA CEA/TRICOM All groups with GM-CSF and low dose IL-2 20 CEA 10 Buffer Control Weeks Post Tumor Transplant Tumor Vaccine Aarts WM, Schlom J, Hodge JW. Cancer Res. 62:5770-7, 2002

13 The Next Frontier: Combinatorial Therapies The use of cancer vaccines in combination with conventional therapies Chemotherapy Hormone therapy Local radiotherapy of tumor Small molecule targeted therapeutics

14 Vaccine Combination Therapies 1. Vaccines Induce Minimal Toxicity can act independently of concomitant therapy 2. Do NOT confuse multiple therapies used prior to vaccine vs. therapies used with vaccine or following vaccine

15 Vaccine Combination Therapies 3. The vaccine induction of a dynamic host immune response can be boosted by concomitant or subsequent therapies (a) can alter the phenotype of tumor cells, rendering them more susceptible to T-cell killing (b) can lyse populations of tumor cells which, in turn, act as a booster for tumor-specific immune cells (c) can kill or inhibit regulatory T cells and thus boost the immune response

16 Potential Multiple Effects of Local Irradiation of Tumors Hodge et al, Oncology

17 . Combination Therapy: Vaccine + External Beam Radiation Tumor (MC38- CEA + SQ) V1 8 Gy (2 Gy x 4) V2 V3 V4 Day rv-cea/tricom rf-gm-csf rf-cea/tricom rf-gm-csf Tumor volume (mm 3 ) No Treatment Vaccine Irradiation Vaccine + Irradiation n=12 12 (36) n=13 11 (41) n=12 66 (435) n=9 54 (415) % Fas + n=0 n=0 n=0 n= Days Post Tumor Transplant Chakraborty M, Abrams SI,, Schlom J, Hodge JW. Cancer Res. 15: , 2004

18 Radiation-Enhanced Antigen-Specific Lysis of Tumor Cells Radiation CD8 + T-cell Target Cell FAS-L FAS

Persistence of Fas Upregulation on MC38-CEA + Tumors After External-Beam Irradiation 10 4 10 3 0 5 5 87 Time Post Tumor Irradiation (8 Gy) 0 Day 2 Day 4 Day 7 Day 11 Day 0 15 0 60 0 89 0 88 5 80

19 Persistence of Fas Upregulation on MC38-CEA + Tumors After External-Beam Irradiation Time Post Tumor Irradiation (8 Gy) 0 Day 2 Day 4 Day 7 Day 11 Day Fas-PE CEA-FITC H&E Histochemistry Isotype Fas

It preferentially binds to osteoblastic metastatic tumor deposits in

20 QUADRAMET is a therapeutic agent consisting of radioactive samarium ( 153 Sm) and chelator. It preferentially binds to osteoblastic metastatic tumor deposits in bone. 153 Sm is currently FDA approved and clinically utilized for palliation of bone metastasis in multiple tumor histologies.

21 Low Dose Radiation (25 Gy) of LnCaP Human Prostate Cell Line Treatment of LnCaP prostate cancer cells with low dose radiation results in the upregulation of MHC and Fas Cell Number 25 gy 0 Gy 0 Gy 25 gy 25 gy 0 Gy FAS MHC-I Gene Expression in LnCaP cells RT-PCR Tumor Antigen Genes 0 Gy 25 Gy PSA PSMA PAP CEA MUC MFI

22 Treatment of LnCaP Prostate Cells with Palliative Levels of 153 Sm (Quadramet) Modulates Phenotype, Upregulates TAA, and Increases Sensitivity to Antigen-specific CTL Killing Treatment of LnCaP prostate cancer cells with Palliative doses of 153 Sm results in the upregulation of MHC class I and Fas Treatment of LnCaP prostate cancer cells with Palliative doses of 153 Sm results in the upregulation of TAAs CTL: PSA-Specific p<0.001 p<0.001 Cell Number 25 gy 0 Gy 0 Gy 25 gy 25 gy 0 Gy FAS MHC-I. Gene Expression in LNCaP cells after Sm-153 treatment Accessory Genes 0 Gy 25 Gy Fas ICAM Tumor Antigen Genes 0 Gy 25 Gy PSA MUC % Lysis (Mock) Day 4 Sm-153 delivered Dose (Gy) CTL: MUC-1-Specific p< MFI Treatment of LnCaP prostate cancer cells with Palliative doses of 153 Sm results in increased sensitivity to multiple CTLs % Lysis Chakraborty, Wansley Schlom, Hodge, NCI, Clin Cancer Res., Collaboration with Nuclear Medicine Branch. 0 0 (Mock) Day 4 Sm-153 delivered D ose (Gy)

23 PSA-TRICOM Sm Patient Population: Metastatic Androgen Independent Prostate Cancer R A N D O M I Z E Arm A: PSA-TRICOM Sm (n=34) Arm B: 153 Sm (n=34) Vaccine: rv-psa/tricom s.c. d 1 rf-psa/tricom s.c. d 15, 29, q 4 wks All vaccines given with GM-CSF 100μg s.c. x 4 d 153 Sm: 1 mci/kg d 8, may be repeated q 12 wks upon hematologic recovery. PI Gulley NCI# 7678

24 Effect of the pan Bcl-2 Inhibitor GX on the Immune System: Preclinical Studies

25 Activated mature CD8 T lymphocytes are more resistant to GX than very early activated Very early activated CD8 T lymphocytes A 24h 72h B 24h 72h Densitometry IP: MC L1 IB: BAK IP: MC L1 IB: MC L1 C GX µm 0 1 Activated mature CD8 T lymphocytes D 24h 72h E 24h 72h Densitometry IP: MCL1 IB: BAK F IP: MC L1 IB: MC L1 GX µm 0 1 1/29/2009 Benedetto Farsaci 25

-NON SELF-CEA LUNG TUMOR MODEL (C57BL/6 MICE) - SELF-CEA LUNG TUMOR MODEL (CEA-TG MICE) Experimental setup Mice: C57BL/6 or CEA-Tg, female Tumor cells: LL2-CEA 3x10 5 cells/muse (i.v.

26 -NON SELF-CEA LUNG TUMOR MODEL (C57BL/6 MICE) - SELF-CEA LUNG TUMOR MODEL (CEA-TG MICE) Experimental setup Mice: C57BL/6 or CEA-Tg, female Tumor cells: LL2-CEA 3x10 5 cells/muse (i.v.) Type of tumor model: Pulmonary tumor nodules Vaccine prime: PFU 1x10 8 rvcea-tricom + PFU 1x10 7 rf GM-CSF / mouse (s.c.) Vaccine boost: PFU 1x10 8 rf CEA-TRICOM + PFU 1x10 7 rf GM-CSF / mouse (s.c.) Inhibitor: GX or 2 mg/kg/mouse (i.v.) Groups (6 mice/group): 1. No treatment 2. GX alone 3. Vaccine alone 4. Vaccine + GX Assays IFN- production from splenocyte bulk cultures Pulmonary tumor nodules count Tumor cell injection GX GX Day 0 Day 5 Vaccine prime Day 12 Vaccine boost Day 19 Day 23 Day 35 Sacrific e 1/29/2009 Benedetto Farsaci 26

27 Pulmonary tumor meta-analysis P = P = 0.027* P < 0.001* P = 0.044* P < 0.001* P = 0.030* n = 13 n = 20 n = 12 n = 21 Vaccine No treatment GX alone alone Vaccine + GX Closed symbols: CEA-Tg mice. Open symbols: C57BL/6 mice. * = Statistical significance from two-tailed Mann-Whitney test, 95% confidence interval. 1/29/2009 Benedetto Farsaci 27

28 GX inhibits Treg function p = NP68 µg/ml CD8:Treg ratio :1 p = :2 p = :1 p = :2 CD8 alone CD8 + Untreated Tregs CD8 + GX-treated Tregs 1/29/

29 Ability of Docetaxel to Alter Tumor-Cell Phenotype: Enhanced Sensitivity to Antigen-Specific T-Cell Lysis No treatment Taxotere M % (37) M % (196) 90% 80% 70% Tumor cell (MC38) Lysis by CEA-Specific T Cells 0 ng/ml Tax 2.5 ng/ml Tax 25 ng/ml Tax 250 ng/ml Tax 60% Fas-PE Fas-PE Fas-PE % Lysis 50% 40% M % (117) 67.68% (721) M1 30% 20% 10% Db-PE MHC 1-PE Db-PE 0% 100:1 Media E:T Garnett, Schlom, Hodge, Clin Cancer Res., 2008

30 Docetaxel +/- PANVAC Patient Population: Metastatic Breast Cancer (Docetaxel Naïve) n=48 R A N D O M I Z E Arm A: Weekly Docetaxel + PANVAC (rv, rf-cea-muc-1-tricom) Arm B: Docetaxel alone Primary endpoint: TTP Preliminary Data: 14 patients enrolled Arm A Arm B Median TTP 10.5 months 2 months # on >6 months 5/6 (1 too early) 1/7

31 Prostate Cancer Vaccine Program

32 Prostate Cancer and Vaccine Therapy Long interval from primary diagnosis to metastatic disease Serum PSA (doubling time/velocity) as a surrogate for therapeutic benefit or disease recurrence Nomogram (Halabi) at metastatic disease can predict more indolent vs more aggressive disease

Vaccine/Androgen Receptor Antagonist Therapy Patient Population: Androgen Independent Prostate Cancer with Rising PSA and No Radiographic Evidence of Disease (D = 0.

33 Vaccine/Androgen Receptor Antagonist Therapy Patient Population: Androgen Independent Prostate Cancer with Rising PSA and No Radiographic Evidence of Disease (D = 0.5) R A N D O M I Z E Arm A: Vaccine* (n=21) rv-psa + rv-b7-1 prime, rf-psa boosts monthly IL-2 low dose x 5 days, recombinant GM-CSF x 4 days Arm B: Nilutamide* (n=21) (Androgen Receptor Antagonist) *If patient progressed by PSA but still NED radiographically, they could add in the therapy of the other arm Arlen et al. J. Urol. 174:539-46, 2005

34 Time to Treatment Failure Regimen n Median time to treatment failure Vaccine months Nilutamide months Time to Treatment Failure After Cross-Over Regimen n Median time to treatment failure Vaccine Vaccine + nilutamide months (after cross-over)* 25.9 months (from initiation of therapy) Nilutamide Nilutamide + vaccine months (after cross-over) 15.5 months (from initiation of therapy) * Median time to cross over was 12.0 months

35 Overall Survival: Randomized Trial in Patients with Nonmetastatic HRPC Receiving Vaccine (rv-psa/b7.1, rf-psa) vs. Androgen Receptor Antagonist (Nilutamide) with Crossover at Progression 100 % Survival Vaccine +/ Nilutamide (n = 21) Nilutamide +/ Vaccine (n = 21) 0 At progression, patients continued initial therapy and crossed over to also receive other therapy. Five-Year Overall Survival: 38%: Nilutamide first 59%: Vaccine first Months (from diagnosis date) Madan, Gulley, Schlom et al. Clin. Cancer Res. 14: , 2008

36 Randomized Multicenter Placebo-controlled Vaccine Therapy Trial in Castrate-resistant Metastatic Prostate Cancer Patients Patients (n = 125) Metastatic prostate cancer (CT or bone scan +) Gleason score 7; no visceral disease Chemotherapy naïve Vaccine: rv, rf-psa-tricom (PROSTVAC) + GM-CSF Control arm: empty vector Randomization: 2:1 (double blind) P.I.: P. Kantoff, Dana-Farber Cancer Center Analyses: W. Godfrey, BNIT B. Blumenstein, statistician

37 0.006 Kantoff PW, Schuetz TJ, Blumenstein BA, Glode LM, Billhartz DL, Gulley JL, Schlom J, Laus R, Godfrey WR. Overall survival (OS) analysis of a phase II randomized controlled trial (RCT) of a poxviral-based PSA targeted immunotherapy in metastatic castration-resistant prostate cancer (mcrpc) ASCO Annual Meeting, Orlando, FL, May 29-June 2, 2009.

38 Randomized Multicenter Placebo-controlled Vaccine Therapy Trial in Castrate-resistant Metastatic Prostate Cancer Patients Observations: A. Time to Progression: no difference in arms B. Median survival at 4 years Placebo: 16.6 months Vaccine: 25.1 months (p=0.006) C. 40% reduction in death rate in vaccine arm Phase III Trial Planned

39 Overall survival analysis of a Phase II study of PSA-TRICOM in the treatment of metastatic, castrate-resistant prostate cancer Ravi A. Madan 1, James L. Gulley 1, William L. Dahut 2, Kwong Y. Tsang 1, Seth M. Steinberg 3, Jeffrey Schlom 1 and Philip M. Arlen 1 1 Laboratory of Tumor Immunology and Biology, 2 Medical Oncology Branch, and 3 Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland

40 Predicted vs. Actual Survival of PSA-TRICOM Patients Patient Number Updated with March 10, 2008 data n=17 Halabi Predicted Survival Survival less than Predicted Survival greaterthan Predicted StillAlive n=15 Halabi Predicted Survival of < 18 Months Halabi Predicted Survival of 18 Months Months From On-Study Date

41 PERCENT SURVIVAL Actual survival Halabi predicted survival Actual survival (*) compared with the Halabi predicted survival (o).

42 Phase II/III Trials: Metastatic Prostate Cancer Phase III Median Overall Survival Mitoxantrone 16.4 mo Docetaxel (weekly) 17.3 mo Δ 0.9 mo Docetaxel (3 weekly) 18.9 mo Δ 2.5 mo NCI Phase II Docetaxel (HPS 16.5 mo) 15.5 mo (Δ 1.0 mo) Randomized Phase II Vector control 16.3 mo PSA-TRICOM (p = 0.006) 24.4 mo Δ 8.1 mo (HR = 0.6) NCI Phase II PSA-TRICOM (HPS 17.4 mo) 26.6 mo Δ 9.2 mo (ave HPS 12.3 mo) 14.6 mo Δ 2.2 mo (ave HPS 20.9 mo) 37.3 mo Δ 16.4 mo

43 Vaccine Combination Therapies The vaccine induction of a dynamic host immune response can be boosted by concomitant or subsequent therapies (a) can alter the phenotype of tumor cells, rendering them more susceptible to T-cell killing (b) can lyse populations of tumor cells which, in turn, act as a booster for tumor-specific immune cells (c) can kill or inhibit regulatory T cells and thus boost the immune response

Development of Recombinant Vaccines for the Therapy of Carcinomas Monotherapy and Combination Therapy

Development of Recombinant Vaccines for the Therapy of Carcinomas Monotherapy and Combination Therapy Jeffrey Schlom, Ph.D. Laboratory of Tumor Immunology and Biology (LTIB) Center for Cancer Research