GRAFT VS. HOST DISEASE AND CELLULAR THERAPEUTICS

Transcription

1 GRAFT VS. HOST DISEASE AND CELLULAR THERAPEUTICS Sunil Abhyankar, MD Professor Medicine, Medical Director, Pheresis and Cell Processing University of Kansas Medical Center Blood & Marrow Transplant Program April 27, 2013 GRAFT VS HOST DISEASE (GVHD) Definition: A syndrome resulting from allo-reactive donor T cells attacking host organ systems Setting: (Billingham s Postulates) Immunocompromised patients (Impaired T cell function) Immunocompetent donor T cells Histoincompatibility between donor and host (major or minor histoincompatibility) 2 1

2 GVHD Syndrome After AlloHCT Acute GVHD: rash, GI, liver Chronic GVHD: skin, eyes, mouth, GI liver, musculoskeletal, lungs, GU Alloreactivity Autoimmunity Classic acute Late acute Classic chronic Chronic overlap Day y 2 y 3 y 5 y Activity Damage (inflammation) in j u r y r e p a i r (fibrosis) 3 Causes of Death after Allogeneic Transplantation performed in Primary Disease (37%) Unrelated Donor New Malignancy (1%) GVHD (18%) HLA-identical Sibling Primary Disease (49%) New Malignancy (1%) GVHD (16%) Other (18%) Infection (18%) Infection (13%) Organ Failure (8%) Other (16%) Organ Failure (5%) 4 2

3 Pathophysiology of GVHD Afferent Phase Conditioning Regimen Interleukin-1 Interleukin-2 APC T cell Interleukin-2 receptor 1. Antigen presentation 2. Activation of individual T-cells Efferent Phase Ferrara and Deeg, NEJM, 1991 NK cell CTL Lymphokine dysregulation Macrophage 3. Clonal proliferation Target cell death 5 Step 1: Priming of the immune response Socié G, and Blazar B R Blood 2009;114: by American Society of Hematology 6 3

4 Step 2: T-cell activation and co-stimulation Socié G, and Blazar B R Blood 2009;114: by American Society of Hematology 7 Step 3: Regulation of acute GVHD by T-cell subpopulations Socié G, and Blazar B R Blood 2009;114: by American Society of Hematology 8 4

5 Step 4: T-cell trafficking Socié G, and Blazar B R Blood 2009;114: by American Society of Hematology 9 Step 5: Effector phase Socié G, and Blazar B R Blood 2009;114: by American Society of Hematology 10 5

6 Acute GVHD 11 Consensus conference on acute GVHD grading Przepiorka

7 Influence of agvhd on survival 13 Chronic Graft-versus-Host Disease A multi-system chronic alloimmune and autoimmune disorder that occurs later after allogeneic hematopoietic stem cell transplantation, featured by: Immunosuppression Immune dysregulation Decreased organ function Impaired survival 14 7

8 Dry eyes Bronchiolitis obliterans Oral lesions Loss of bile ducts Nail dystrophy Fasciitis Skin sclerosis Deep sclerosis Autoantibodies M-skeletal Infections Endocrine Metabolism Nutrition Pain Quality of life Disability Skin ulcers Spectrum of Manifestations in cgvhd - 15% Life Threatening cgvhd Pathogenesis Poorly Understood Theories Alloreactive T-cells, aberrant thymopoiesis Altered APC function T-cell imbalance o Th2 cells in murine models, Th1/Th2 imbalance o TREGs in donor/recipient early= cgvhd o Cytokine dysregulation High IL1-β, IL-6, INFγ, TNF-α, TGF-β Low IL-10 o Antibody mediated 16 8

9 Donor Allo T-Cells Antibody Production T-B epitope spreading Y Y Y Y Y Radiation Cyclosporine Steroids Thymus B cell Activation Donor Th2-Cells Donor HSC -Thymus Damage -Impaired Negative Selection -?Impaired T-cell Development Donor Auto T-Cells Donor APC Cytokines/ Costimulation Chronic GVHD Disease of Immune Dysregulation T-reg Deficiency Dysfunction -Tissue Damage -Lymphopenia -Immunodeficiency -IL-13, TGF-β -Fibroblasts -Collagen synthesis cgvhd Poor Prognostic Factors Thrombocytopenia (platelets < 100K) Progressive onset Generalized skin involvement Hyperbilirubenemia, cirrhosis Low Karnofsky score Recurrent infections GI involvement (diarrhea, weight loss) Steroid refractory disease 18 9

10 Organ sites involved by Chronic GVHD Flowers M. et al, Blood 2002 (100): Complications of cgvhd Not mutually exclusive 20 10

11 Approach to GVHD Prevention Prevention Prevention Prevention 21 GVHD Prevention Targeting Deacetylases SW Choi et al, Univ of Michigan. ABSTRACT #2 HDAC inhibitors Reduce pro-inflammatory cytokines Modulate APC function through IDO (STAT-3 dependent mechanism) Increase T-reg numbers Have been shown to decrease GVHD in a murine model (Reddy et al) 22 11

12 GVHD Prevention Targeting Deacetylases Phase I/II study SW Choi et al, Univ of Michigan. ABSTRACT #2 45 pts undergoing RIC MRD transplant (Flu-Bu) Vorinostat 100mg bid added to Tac MMF Blood obtained pre study, day 1, day 30 and day100 Vorinostat was well tolerated, no DLTs and all engrafted, with 95%, 97% and 100% chimersim at day 30, 100 and 365 Increased H4 acetylation at day 30, enhanced IDO expression and decreased TNF and IL-6 at day 30 in PBMC 23 GVHD Prevention Targeting Deacetylases Phase I/II study SW Choi et al, Univ of Michigan. ABSTRACT #2 Study pts showed increased T-regs (CD4+CD25+CD127-) and Foxp3 by qpcr Incidence of gr II IV agvhd at day 100 was 22% and 4% gr IV. Relapse rate 17% at 1 year Vorinostsat needs further study in phase III 24 12

13 Tacrolimus-Sirolimus vs. Tacrolimus-Methotrexate GVHD Prophylaxis (739) Background Standard of care for GVHD prevention = calcineurin inhibitor + methotrexate Stage II-IV acute GVHD rates ~30-50% Sirolimus has demonstrated promising results Cutler C, et al. Blood. 2012;120(21): Abstract Tacrolimus-Sirolimus vs. Tacrolimus-Methotrexate GVHD Prophylaxis (739) Design o Randomized, open label, multicenter trial Primary Endpoint o Day 114 Grade II-IV acute GVHD-Free Survival Randomization o Sirolimus/Tacrolimus: Tacrolimus/Methotrexate 1 : 1 Stratification & Accrual o Transplant Center o 312 transplant recipients Power o 80% to detect at 15% difference (60? 75%), α= Enrollment & Analysis o November 2006 to October 2011 o November 1, 2012 Cutler C, et al. Blood. 2012;120(21): Abstract

14 Tacrolimus-Sirolimus vs. Tacrolimus-Methotrexate GVHD Prophylaxis (739) Eligibility AML/ALL in CR, CML CP/AP, MDS KPS 70% Age 2-60 years No prior transplant or uncontrolled infection Adequate organ function Conditioning Cyclophosphamide or etoposide + TBI (>12 Gy) Supportive Care No planned G-CSF unless clinically indicated Cutler C, et al. Blood. 2012;120(21): Abstract Tacrolimus-Sirolimus vs. Tacrolimus-Methotrexate GVHD Prophylaxis (739) B Cutler C, et al. Blood. 2012;120(21): Abstract

15 Tacrolimus-Sirolimus vs. Tacrolimus-Methotrexate GVHD Prophylaxis (739) Conclusions No difference in 114- day acute GVHD-free survival seen between treatment arms When compared with tacrolimus + methotrexate in the setting of MRD HSCT, tacrolimus + sirolimus is associated with More rapid engraftment Less severe acute GVHD Less severe oral mucositis More chronic GVHD More endothelial injury syndromes Similar long-term outcomes Sirolimus-tacrolimus is an acceptable alternative to tacrolimusmethotrexate in the prevention of GVHD in MRD HSCT 29 Cutler C, et al. Blood. 2012;120(21): Abstract 739 Acute graft-versus-host disease biomarkers measured during therapy can predict treatment outcomes: a Blood and Marrow Transplant Clinical Trials Network study 6 previously validated diagnostic biomarkers of GVHD (IL-2 receptor-α; tumor necrosis factor receptor-1; hepatocyte growth factor; IL-8; elafin, a skin-specific marker; and regenerating islet derived 3-α, a gastrointestinal tract specific marker) could discriminate between therapy responsive and nonresponsive patients and predict survival in patients receiving GVHD therapy 112 patients participating in CTN agvhd study, had samples collected GVHD biomarker concentrations were measured from samples prospectively obtained at the initiation of treatment, day 14, and day 28, on a multicenter, randomized, 4-arm phase 2 clinical trial for newly diagnosed acute GVHD. Levine J E et al. Blood 2012;119:

16 Biomarker concentrations at study entry (day 0) according to day 180 survival status Biomarker concentrations at study entry (day 0) according to day 180 survival status. The boxplots show the range, median, and mean (diamond) graphed on a log-scale for each of the 6 biomarkers measured on day 0 according to the day 180 survival status (alive or dead). P values are shown for the comparison of median concentrations for each biomarker. Levine J E et al. Blood 2012;119: Survival from study entry stratified by day 0 biomarker panel Survival from study entry stratified by day 0 biomarker panel. The optimized threshold for the biomarker panel measured at study entry was used to define a high versus low panel result. Patients with a high panel (dashed line, N = 32) were much more likely to die by day 180 compared with patients with a low panel Levine J E et al. Blood 2012;119:

17 Survival from study entry stratified by day 28 biomarker panel Survival from study entry stratified by day 28 biomarker panel. The optimized threshold for the biomarker panel measured at day 28 of GVHD treatment was used to define a high versus low panel result. Patients with a high panel (dashed line, N = 41) were much more likely to die by day 180 compared with patients with a low panel (solid line, N = 63; P <.001). Levine J E et al. Blood 2012;119: Conclusions At each of 3 time points, GVHD onset, 2 weeks into treatment, and 4 weeks into treatment, a 6-protein biomarker panel predicted for clinical outcomes of day 28 post therapy nonresponse and mortality at day 180 from onset. GVHD biomarker panels can be used for early identification of patients at high or low risk for treatment non-responsiveness or death, They may provide opportunities for early intervention and improved survival after hematopoietic cell transplantation

18 Assorted abstracts for GVHD #51: Atorvastatin given to donors and patients in MRD HPCT. 30 pts and donors, agvhd gr 3 4, 3.7% (!), cgvhd 26%, 68% 1 yr PFS #55: Steroids + Ritxuan upfront Rx for cgvhd. 35 pts, 48% PR+CR #62: Lower uric acid at time of Allo-HPCT prevents GVHD 35 MSCs to treat SR-aGVHD (#47,63) 48 and 50 pts respectively adults and peds MSCs from healthy volunteer BM, expanded with platelet lysate Up to 3 infusions 63% and 50% respectively had response, CRs 36% and 56% 36 18

19 Alemtuzumab Dosing for Chronic GVHD (744) Dose-escalation study establishing an MTD for alemtuzumab of 3 mg x 1, then 10 mg x 5 doses over a 4 week period (N=13) Significant rates of infectious complications Occurring early in the course of therapy, despite prolonged lymphopenia, and in a dose-dependent manner Observed response rate of 70% (CR 30%) in 10 evaluable patients Predominantly skin and joint/fascia/muscle 4 of 10 patients reduced steroids or discontinued immunosuppression at 12 weeks Efficacy for alemtuzumab in the treatment of steriodrefractory chronic GVHD in patients who have failed multiple therapies Use of alemtuzumab in this context deserves study in larger phase II trials Nikiforow S, et al. Blood. 2012;120(21): Abstract Bronchiolitis Obliterans Syndrome A progressive, insidious lung disease occurring in a subset of patients after lung transplantation and allogeneic HSCT Progressive circumferential fibrosis of the small terminal airways Manifests as new fixed airflow obstruction Occurs in 2 3% of all HSCT recipients 6% of those with chronic GVHD 80% of cases occur within 18 months of transplantation Median time to diagnosis = 439 days Williams KM, Chien JW, Gladwin MT, et al. Bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation. JAMA 2009;302:

20 Bronchiolitis Obliterans Syndrome - Diagnosis Williams KM, Chien JW, Gladwin MT, et al. Bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation. JAMA 2009;302: Fluticasone-Montelukast-Azithromycin A series of 8 patients treated with FAM + steroids were compared to 14 historical controls treated with steroids alone No difference in spirometry between groups Norma BS, Jacobsohn D, Williams KM, et al. Fluticasone, azithromycin, and montelukast (FAM) therapy in reducing steroid exposure in bronchiolitis obliterans syndrome after allogeneic hematopoetic stem cell transplant (HCT)- a case series of 8 patients. Bone Marrow Transpl 2010;16:s

21 ECP Machines THERAKOS UVAR (1 st Generation) THERAKOS UVAR XTS (2 nd Generation) THERAKOS CELLEX (3 rd Generation) ECP Uses: 1) CTCL (FDA-approved) ; 2) cgvhd; 3) Organ transplant BMT Photopheresis Volume ( 27.0%) ( 41.2%) 1,915 ( 7.8%) 1,508 ( 82.8%) 991 1,068 ( 224.5%) CY07 CY08 CY09 CY10 CY11 CY

22 Clinical Studies in BOS Montelukast NCI Inhaled Cyclosporine NHLBI Azithromycin Asan Med Center FAM NCI Bortezomib Northwestern ECP KUMC 43 Mechanism of Action of ECP 1 + Methoxsalen UV radiation Leukocytes 2 Apoptosis 3 Phagocytosis Anti-inflammatory cytokines (eg, IL-10, TGF-ß) Proinflammatory cytokines (eg, IL-12, IFNγ) Stimulation T effector cells 5 Treg Tr Tr Tr Tr Tr Tr 4 Tolerogenic DC/APC Cross-linked DNA Receptor-mediated signaling 44 22

23 ECP GVHD Research at KUMC Project: ECP to prevent GVHD Single institution research project 21 patient phase II study to use ECP pre and post allo transplant to ameliorate GVHD 14 patients enrolled to date Clinical end points acute and chronic GVHD, survival and relapse 45 Prophylactic ECP study for the Prevention of GVHD - University of Kansas Hospital ECP BuCy / TBICy ECP 21 patient pilot study. To date 14 patients enrolled Immunological assessments at baseline and day

24 Prophylactic ECP Study Patient 1 Patient 2 Patient 4 Patient 5 Patient 7 Patient 8 Patient 9 Age Sex M M F M M M F Diagnosis AML AML AML AML AML AML AML Donor Type Acute GVHD Acute GVHD response Chronic GVHD Survival MUD MUD MUD MSD MUD MSD MUD No No Yes Grade II Yes Grade III Yes Grade IV Yes Yes Yes --- Yes No Yes No No No Yes No 14 months (currently alive) 14 months (currently alive) 11 months (currently alive) 4 months (deceased, relapse) 9 months (currently alive) No 8 months (currently alive) Yes Grade II 7 months (currently alive) 47 Cellular Therapeutics Applications: Cancer therapy with T cells, T reg cells, NK cells, dendritic cells peptide pulsed, tumor lysate pulsed Cytotoxic T cells directed against multi-viral target (EBV, CMV, BK) Chimeric Antigen receptor modified T cells Mesenchymal cells Wharton s jelly Umbilical cord blood expansion Tissue regeneration 48 24

25 Cellular therapies including MSC, Treg, NKTand B cell targeting The left panel highlights the central role of various cell types including B and NKT cells for effector T-cell activation during GVHD. In this GVHD favoring scenario NKT-cell derived IFN-γ and B cells function as T-cell activators, while Treg expansion is suppressed. The right panel depicts potential strategies how this processes can be manipulated to favor a more tolerogenic environment. Adoptive transfer of in vitro generated or donor-derived Treg, MSC or NKT cells either directly inhibits effector T-cell activation and expansion, or indirectly tips the balance toward a tolerogenic milieu by inducing Treg expansion by American Society of Hematology 49 Wolf D et al. Blood 2012;119:16-25 Mechanisms of MSC Suppression Rasmusson I, Exp Cell Ther

26 Contemplating your Umbilicus Cord Blood: Mesenchymal Stromal Cells (MSCs) USSCs *** BioE s cells VSEL Umbilical Vein: Endothelial cells MSCs Wharton s Jelly: Umbilical cord matrix cells Perivascular cells Amnion (and amniotic fluid) Placenta and Decidua 51 TESTING WJCs in rat GVHD model Positive control GVHD + no cells GVHD + WJC day 2 GVHD + WJC day 0 Neg 52 26

27 Driving CARS to the Clinic 53 The New York Times- Health. March 20,

28 TUMOR CELL Other targets (tumor associated antigens) are still present, though! Genetically Modify T cells to express chimeric antigen receptors specific for different TAA s How Do Tumors Escape Cellular Immunity? Withdrawing HLA molecules renders them invisible to our T cells T CELL 55 X TUMOR CELL T CELL T CELL Can we give new eyes to our T cells? Chimeric Antigen Receptors (CAR) are not HLA restricted! 28

29 CAR technology evolution through the generation of more potent CARs. First-generation CARs classically contain only one signaling domain, typically the cytoplasmic signaling domain of the CD3 TCRζ chain 2012 by American Society of Hematology Brentjens R J, and Curran K J Hematology 2012;2012: Many variables exist in the design of an optimized clinical protocol using autologous CAR-modified tumor-targeted T cells in the treatment of cancer Many variables exist in the design of an optimized clinical protocol using autologous CAR-modified tumor-targeted T cells in the treatment of cancer. Patients undergo an initial leukapheresis to isolate autologous T cells. 1. CAR gene transfer of T cells may variably be achieved through retroviral-, lentiviral-, or transposon-mediated technology, 2. Optimal CAR design currently remains unclear although previously published data support a second- or third-generation CAR design over a first-generation CAR. 3. Conditioning therapy favors T-cell persistence and an improved antitumor response. 4. The role of postinfusion exogenous cytokine support in obtaining an optimal antitumor response requires additional clinical study 58 Brentjens R J Blood 2012;119:

30 Clinical Trials of CAR at CMH and KUMC Doug Myers, MD STALLO/STALLONe STALLO: Reduced intensity, mismatched related donor transplant with CD34+ selected stem cell product Feasible? Safe? Good platform for immunotherapy? Tumor response? STALLONe: Donor-derived tri-virus specific T-lymphocytes redirected to GD2 with a chimeric antigen receptor for infusion in patients with relapsed/refractory neuroblastoma after allogeneic transplant Feasible? Safe? Tumor Response? MARVSmALo Autologous, vaccine-enriched, T-lymphocytes redirected to GD2 for infusion in patients with relapsed/refractory melanoma Do pre-harvest and post-infusion vaccination with common vaccines help gene-modified T-lymphocytes expand and kill tumor safely in these patients? Is this a model for improving expansion of tumor redirected T-lymphocytes? EBV latent life cycle 2009 by American Society of Hematology Heslop H E Blood 2009;114:

31 Classical versus rapid Epstein-Barr virus (EBV) specific CTL production. Bollard C M JCO 2013;31: Safety and Clinical Efficacy of Rapidly-Generated Trivirus Directed T Cells After Allogeneic HSCT To date we have administered these lines to 10 allogeneic HSCT recipients at doses ranging from 0.5-2x10 7 /m 2 as treatment for: CMV (n=3) Adv (n=2) EBV (n=2) EBV+Adv (n=1) CMV+Adv (n=2). One patient developed a skin rash 2 weeks post-rctls, but no other toxicity have been observed. Eight treated patients, including one with a biopsy-proven EBV lymphoma and the 3 patients with double reactivations, had complete clinical responses to rctl, which corresponded with an increase in the frequency of virus-specific T-cells detected in peripheral blood. rctls have been safe & effective in 80% of patients and have the potential to increase the availability of cell products for HSCT recipients. Gerdemann et al. Biol Blood Marrow Transplant. 19 (2013) S111. Abstract

32 Infarct Repair with Bone Marrow Cells Nature Apr 5;410(6829): Lin-/c-kit+ BMCs 63 Adult Stem Cells for Heart Repair Bone marrow mononuclear cells Mesenchymal stem cells (MSCs) Circulating progenitor cells (CPCs) Numerous clinical trials - completed and ongoing Very small embryonic-like stem cells (VSELs)- 1 clinical trial Cardiac stem cells- Adipose stem cells- Skeletal myoblasts- 2 clinical trials ongoing 2 clinical trials ongoing Several Clinical trails completed 64 32

33 Potential Targets for Stem Cell Therapy Heart attack, heart failure, heart block Stroke, spinal cord injury, neuropathy Critical limb ischemia Curative bone marrow transplant (e.g., for myeloma, HIV-related lymphoma) Graft failure, GVHD Joint diseases Cornea repair Autoimmune diseases (ulcerative colitis, etc.) 65 Center for Advanced Biologics & Immunotherapeutics Purpose Statement (Goals) To develop a Cellular therapy center to advance novel personalized cancer treatments. The center will link basic, translational and clinical investigators to advance therapy in targeted individualized cancer treatment and in hematopoietic stem cell transplantation 66 33

34 GMP Units Will be located in the basement of the KUMC Lied building Provided by AES A team of KU administrators are involved in the planning and implementation Potential expansion in the future to add cell modification capabilities, flow cytometry 67 Components of Stem Cell Operations Modular GMP units for processing of stem cells from adult patients following Good Manufacturing Practice (GMP) standards for FDA approval Personnel for cell processing, modification, expansion, and research Personnel for the conduct of clinical trials 68 34

35 viral ctl GMP Lab DC CARs Regulatory GMP Lab Cardiac and Regenerative Medicine Grants and Contracts Translational Laboratories 69 Thank You Contact: (913) (913)