Antiviral Adoptive Immunotherapy for Primary Immunodeficiency Disorders. Speaker Disclosures

Transcription

1 3/27/218 Antiviral Adoptive Immunotherapy for Primary Immunodeficiency Disorders Michael Keller, MD Program for Cell Enhancement & Technologies for Immunotherapy (CETI) Director: Dr. Catherine Bollard Children s National Medical Center Speaker Disclosures Funding: K23 (NHLBI) Jeffrey Modell Foundation CIRM CLIN II grant No other financial interests to disclose. 1

2 Adv PCR (blood) 3/27/218 7 m/o DGS and Adenoviremia Complete Digeorge syndrome Dx via NBS absent TRECS, absent T-cells Maintained on IVIG, bactrim, fluconazole Admitted due to vomiting, congestion, dehydration Diagnosed with adenovirus infection 1.E+9 1.E+8 1.E+7 1.E+6 1.E+5 1.E+4 Cidofovir Days of Treatment 7 m/o DGS and Adenoviremia What to do? Continue Cidofovir and await thymic transplant? Donor lymphocyte infusion? Matched sibling marrow infusion? 2

3 3/27/218 Viral Infections are Deadly in PID Viral infections account for up to 4% of pre and post-hsct mortality in Primary Immunodeficiency patients SY Pai et al. NEJM 214 Adoptive Immunotherapy restores antiviral immunity Transfer of virus-specific T-cells (VST) from a donor to recipient Utilizes selection or ex vivo expansion Highly successful in post- HSCT period >4 patients treated internationally Minimal risk of GVHD 3

4 3/27/218 Methods of VST production PBMC Cell Selection Ex vivo Expansion Viral peptides ~1 day Virus-specific T-cells Evolution of VST Production Year Study Targeted virus(es) Viral antigen source Production time 1995 Walter EA et al, NEJM CMV CMV-infected fibroblasts >28 days 1998 Rooney CM et al, Blood EBV EBV-Lymphoblastoid cell lines (EBV-LCL) 28-4 days 26 Leen AM et al., Nat Med CMV/EBVAd5f35pp65-transduced EBV- /Adv LCL 28-4 days 21 Uhlin M et al., Cancer Immunoth EBV Multimer selection 1 day 21 Feuchtinger T et al., Blood CMV Selection by IFN-g capture following peptide stimulation 1 day 212 Gerdemann U et al., Mol Ther. Overlapping 15-mer peptide CMV/EBV pools encompassing viral /Adv epitopes (pepmix) 1-12 days 4

5 IFN-g IFNg SFC/1x1E5 cells CMV pp65/a24 3/27/218 Measuring VST specificity MHC Multimer staining Intracellular cytokine staining CD8 +CMV pp65/ie1 +EBV EBNA1/LMP2 +Adv Hexon/Penton CD4 Measuring VST specificity Interferon-g ELISpot

6 3/27/218 Are Virus-specific T-cells safe? VST have Minimal Related Toxicity Source Peripheral Blood VST Donor/Recipient Matching # of Patients Acute GvHD Haplo 14 None MUD 6 1 Grade I MRD 1 1 Grade I Cord Blood VST CBT: 5/6 6 None CBT: 6/6 4 None Melenhorst et al, Blood 21 6

7 % Specific lysis 3/27/218 VST are Non-Alloreactive 51 Cr release assay: VSTs (effectors) & PHA blasts (targets) 45% 4% 35% 3% 25% 2% 15% 1% 5% % Effector: Target Ratio Allogeneic PHA blasts Allo PHA +pp65/ie1 Allo PHA +EBNA1/LMP2 Allo PHA +Hexon/Penton Autologous PHA blasts Auto PHA+pp65/IE1 Auto PHA+EBNA1/LMP2 Auto PHA+Hexon/Penton Are Virus-specific T-cells efficacious? 7

8 CMV copy number (blood) IFN-g SPW IFN-g SPW EBV copy number 3/27/ E+6 1.2E+6 1.E+6 8.E+5 6.E+5 4.E+5 2.E+5.E+ VST can control CMV Infection CNMC P1: Resolution of CMV after T-cell therapy in SCID patient VST, 5 x 1 6 /m 2 x 2 doses Cidofovir CMV viral count Anti-pp65 T-cells Anti-IE1 T-cells Days post first CTL Infusion VST restore immunity to EBV CNMC P8: EBV in a WAS patient 1 month post-mud HSCT VST, 2x1 7 /m 2 (Targeting LMP2 and EBNA1) Rituximab EBV T cells EBV Viral Load day -16 Day -13 day -1 Day -3 Day Day 4 Day 7 Day 14 Day 21 Days post VST 2.5E+5 2.E+5 1.5E+5 1.E+5 5.E+4.E+ 8

9 % Responses 3/27/218 Prior Use of VST in PID Patients To date, 67 PID patients at 1 institutions received VSTs MHC II, CTPS 2 1, 2 CGD, 2 Diagnoses HIGM, 3 IL1R LAD, 1 GATA2, def, 1 MALT1 Digeorge, 1 1 ALPS, 1, 1 WAS, 5 CID, 7 SCAEBV, 4 XLP, 8 SCID, 17 FHLH, 11 VST Source Third party, 19 HSCT donor, 5 Viral targets HHV6, 1 BKV, 2 Adv, 1 EBV, 27 CMV, 18 VST have antiviral activity in vivo 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % VST Antiviral Efficacy by Targeted Virus N=15/18 N=19/27 N=9/9 N=1/1 N=1/2 CMV EBV Adv HHV6 BKV Complete Response (CR) = resolution of viremia Partial Response (PR) = >1 log decrease in viremia 9

10 3/27/218 Survival and AEs Survival: 55/67 (82%) Deaths: EBV-PTLD (6) Relapsed T-cell lymphoma (1) CMV (3) Fungal pneumonia (1) GVHD in 4 patients All low grade (I-II) Custom VST products have limitations Requires an available donor 2% cord blood fraction often unavailable for VST manufacturing. Time requirement 2 weeks for virus-exposed donors 6-8+ weeks for virus-naïve donors 1

11 3/27/218 Third-party VST provide off the shelf therapy for viral infections Antiviral Rx VST infusion Optional doses HSCT Viral infection Resolution Weeks post VST infusion HLA-A HLA-B HLA-C DRB1 DQB1 68:3, 35:43, 3:3, 4:7, Patient 68:5 52:1 52:2 4:11 2, 3 VST: B35, P15D A11 52:1 4, 12 11, 16 2, 5 Partially matched VST (antiviral activity through B52:1) Recipient Prior Studies of Third-Party VST Support Safety Study Target n Serious adverse events Clinical Results Haque, 27 EBV 33 None 52% CR/ PR Barker, 21; Doubrovina, 212 EBV 5 None 4 / 5 CR s CR after 2 Uhlin, 21 EBV 1 None VST doses Leen, 213 Tzannou, 217 CMV, EBV, Adv 5 CMV, EBV, Adv, BK, HHV cases GvHD (2 de novo) 74% CR/PR 2 cases of de novo GVHD (gr I) 92% CR/PR 11

12 3/27/218 Small VST banks with HLA diversity can provide for many referrals Leen et al Blood (213) 74/82 patients (9%) had partially matched VST options from 32 products Tzannou et al JCO (217) 54/56 patients (97%) had partially matched VST from 56 products CETI experience: 4 VST products >9% availability for referrals Third-party or HSCT donor VST are comparably effective % CR/ PR Responses CR/PR by VST VST donor Source % 71% Responses by Virus 1% 83% 6% 5 1 Days post-vst infusion HSCT donor (n=1) Third Party (n=7) 12

13 IFN-g SFC EBV PCR (log) Adenoviiral copy number (log) IFNg SFC / 1x1E5 cells 3/27/218 Third party VSTs provide rescue therapy 4 year old IL-1R deficient patient, s/p MMRD HSCT Third-party VST (5/1 match, activity against Adv through HLA-DR7) Cidofovir Days post HSCT Anti- Hexon T- cells Anti- Penton T- cells 25 year old with severe aplastic anemia, s/p haplo HSCT Third party VSTs provide rescue therapy Rituximab EBV-CTL, Dose 1 Obinutuzimab EBV-CTL, Dose Days post-hsct Days post-hsct EBV PCR, blood EBV PCR, CSF Anti EBV- LMP2 T-cells Anti EBV- EBNA1 T-cells 13

14 3/27/218 Third party VSTs provide rescue therapy EBV-specific VST permit clearance of CNS PTLD Pre-VST therapy (following steroids,xrt 1 month post VST dose 1 2 months post VST dose 2 Can Third party VST be used before transplant for PID patients with viral infections? 14

15 Adv PCR (blood) 3/27/218 Third party VSTs may be effective pre-hsct Three PID patients treated in the pre-hsct period to date Dx Virus Dose Infusions HSCT Outcome ADA SCID EBV 5x1 6 /m 2 1 dose N/A (ERT) Died, PTLD RAG1 SCID Adenovirus 2x1 7 /m 2 2 doses MRD CR, 2 years CDGS Adenovirus 2x1 7 /m 2 2 doses MRD CR, 1 months Complete DGS with Adenovirus Given two doses of third-party VST 5/1 and 4/1 HLA matched, class-i restricted Received MSD marrow infusion (unconditioned) Hepatitis immediately post HSCT (viral vs GVHD) VST D1 VST D2 MRD marrow 1.E+9 1.E+8 1.E+7 1.E+6 1.E+5 1.E+4 1.E+3 1.E+2 1.E+1 1.E Days post HSCT 15

16 % of Adv-specific T-cells Adenovirus PCR (log) % TCRb repertoire IFN-g - PE 3/27/218 Third party VSTs may be effective pre-hsct 5 month old RAG1 SCID w/ disseminated Adv pre-hsct /17/15 9/16/15 1/16/15 11/15/15 12/15/15 1/14/16 3% 2% 1% VST dose 1 VST dose 2 MUD BMT(uncond.) BRINCID CID CID BRINCID % 8/17/15 9/16/15 1/16/15 11/15/15 12/15/15 1/14/16 Plasma Stool Urine CD4+ ADV-specific T-cells (%) CD8+ ADV-specific T-cells (%) VST can be traced by TCRb deep sequencing VST products sorted by IFN-g capture following adenoviral peptide stimulation.2%.15%.1% VST doses CD4 - FITC Detection of Adenovirus-specific TCRb clonotypes VST Product 1 VST Product 2.5%.% Days Post Marrow Infusion 16

17 TCR Frequency TCR Frequency 3/27/218 VST Infusions Aid Immune Recovery Day -36, pre-marrow infusion Timeline 6% 5% 4% 3% 2% 1% % TCRBJ2-7 TCRBJ2-6 TCRBJ2-5 TCRBJ2-4 TCRBJ2-3 TCRBJ2-2 TCRBJ2-1 TCRBJ1-6 TCRBJ1-5 TCRBJ1-4 J gene Vb gene %-1% 1%-2% 2%-3% 3%-4% 4%-5% 5%-6% TCRBJ1-3 TCRBJ1-2 TCRBJ1-1 VST Infusions Aid Immune Recovery Timeline Day -21 pre-marrow infusion VST dose 1 4% 3% 2% 1% % J gene TCRBJ2-7 TCRBJ2-6 TCRBJ2-5 TCRBJ2-4 TCRBJ2-3 TCRBJ2-2 TCRBJ2-1 TCRBJ1-6 TCRBJ1-5 TCRBJ1-4 TCRBJ1-3 TCRBJ1-2 TCRBJ1-1 Vb gene %-1% 1%-2% 2%-3% 3%-4% 17

18 TCR Frequency TCR Frequency 3/27/218 VST Infusions Aid Immune Recovery Timeline Day +6 post-marrow infusion VST dose 1 VST dose 2 MUD BM infusion 5% 4% 3% 2% 1% % J gene Vb gene %-1% 1%-2% 2%-3% 3%-4% 4%-5% TCRBJ2-7 TCRBJ2-6 TCRBJ2-5 TCRBJ2-4 TCRBJ2-3 TCRBJ2-2 TCRBJ2-1 TCRBJ1-6 TCRBJ1-5 TCRBJ1-4 TCRBJ1-3 TCRBJ1-2 TCRBJ1-1 VST Infusions Aid Immune Recovery Timeline Day +84 post-marrow infusion VST dose 1 VST dose 2 MUD BM infusion 5% 4% 3% 2% 1% % J gene Vb gene %-1% 1%-2% 2%-3% 3%-4% 4%-5% 18

19 TCR Frequency 3/27/218 VST Infusions Aid Immune Recovery Timeline 1 year post-marrow infusion VST dose 1 VST dose 2 MUD BM infusion 5% 4% 3% 2% 1% % J gene Vb gene %-1% 1%-2% 2%-3% 3%-4% 4%-5% Challenges for Third party VST therapy Ideal targets unclear for many viruses Viral epitope mutations could allow viral evasion. Best methods of partial HLA matching are unclear Limited number of known HLA restrictions for many viral epitopes VSTs are inactivated by immunosuppression Limits usage with GVHD or in the setting of inflammatory disorders 19

20 3/27/218 Extending Third-party VST therapy Antiviral Cellular Therapy for Enhancing T-cell Reconstitution Before or After Hematopoietic Stem Cell Transplantation (ACES) Arm A Arm B Viral infections following Stem Cell Transplantation Viral infections in PID patients before Transplantation Banked, partially HLA matched VSTs Broadening Targets for VST Therapy Human Parainfluenza Virus Leading cause of viral pneumonia in immunocompromised patients No available vaccines or treatments 2

21 3/27/218 VST can simultaneously target 6 viruses IFNy SFC/1x1 5 cells Medium Actin pp65 IE1 EBNA1 LMP2 Hexon Controls CMV EBV Adv HHV6 BKV HPIV3 Penton HHV6 U54 HHV6 U9 LgT VP1 HPIV3-NP HPIV3-Fus Donor 1 Donor 2 Donor 3 Donor 4 Donor 5 Donor 6 Donor 7 Donor 8 Donor 9 NATS Trial: Hexaviral VSTs Novel Antigens Targeted by ex vivo Expanded T- Lymphocytes following Hematopoietic Stem Cell Transplantation (NATS) Targeting 6 viruses after HSCT: CMV EBV Adenovirus HHV6 BK virus Human Parainfluenza Virus 3 Patient #1 3 weeks post infusion for BKV 21

22 3/27/218 NATS Results to Date P# Dx BMT donor 1 MDS MMRD BK 2 AML MMUD 3 HbSS MRD 4 DLBCL MMRD Preinfusion Viral Infection Antiviral s Rx Cidofovir (stopped dt toxicity) BK, CMV BK, CMV BK, CMV Cidofovir (stopped dt toxicity) Ganciclovir (stopped), cidofovir (stopped) Cidofovir (stopped dt toxicity) Dose 1x1E7/ m 2 Post-infusion Viral Reactivations 1x1E7/ Adv (12/15/17, m 2 <1 copies) 2x1E7/ m 2 2x1E7/ m 2 Antiviral response(s) No BK detection No further BK/CMV detection. Adv clearance CMV <3 log at 1 month; BKV load stable but asymptomatic CMV/BK <3 log, BK symptoms improving Future directions Improving classification of immune reconstitution Ultradeep TCRb sequencing Immunomagnetic flow sorting Upcoming targets for VST therapy Mycobacteria HPV Norovirus 22

23 IFNg SPW, 1 5 cells/well IFNg SPW (day 1) 3/27/218 Rapid ex vivo expansion of Mycobacteria-specific T-cells (MSTs) PBMC Mycobacterial peptide libraries* * Antigens: AG85B PPE68 ESAT6 CFP1 ADK IL-4, IL-7 G-Rex days Mycobacteria specific T-cells Mycobacteria-specific T-cells can be Generated by Ex Vivo Expansion Day 1 IFNg ELISpot BCG immunized healthy donors BCG non-immunized healthy donors Donor 1 Donor 2 Donor 3 Donor 4 Donor 1 Donor 2 Donor 3 Donor 4 23

24 IFNg SPW (day 1) 3/27/218 PID patients with MAC lack responses to most TB antigens Day 1 IFNg ELISpot CTL only SEB Actin AG85B PPE68 ESAT6 ESXB ADK IL12RB NFKB1 haploinsuff. GATA2 CID, undefined IFNGR def CID, undefined Kabuki IFNg AutoAb IFNg AutoAb Moving MSTs to the Bedside MSTs derived from third-party donors MST infusion Optional doses MAC Antibiotic Rx Resolution 24

25 3/27/218 CETI and Collaborators Acknowledgements 25