In Vivo Lung Perfusion (IVLP) for Cancer Therapy and Gene Therapy of the Lung

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1 In Vivo Lung Perfusion (IVLP) for Cancer Therapy and Gene Therapy of the Lung Marcelo Cypel MD, MSc, FRCSC Canada Research Chair in Lung Transplantation Surgical Director ECLS Program UHN Associate Professor of Surgery Division of Thoracic Surgery University of Toronto

2 The Problem The lung is a very common site for metastatic disease Often is the only site of spread Recurrence after initial surgical resection is exceedingly high: - Colorectal 50% - Sarcoma 70% - Melanoma 88% World J Surg Jun;37(6): Ann Surg Oncol Oct;14(10):

3 Prognostic Groups MST (mos.) group I single and DFI > 35 mos. 61 II single or DFI > 35 mos. 34 III multiple, DFI < 36 mos. 24 IV incomplete resection 14 J Thorac Cardiovasc Surg 1997; 113:37-49

4 Toronto data More than 3 lesions or < 1 year DFI = no survivors at 5 years (osteosarcoma) Annals of Oncology 20: ,

5 Current Limitations 5 years survival after surgery is only 15-45% (Including recent series with modern chemotherapy and targeted therapies) Median disease free survival is short (12-18mos) Reoperations are feasible, but often patients become inoperable Systemic therapy with variable grades of response and excessive toxicity

6 Micrometastases J Vis Exp Aug 21; 6

7 How about giving anti-cancer treatment only to the lung?

8 In Vivo Lung Perfusion (IVLP) Thoracic Surgery Latner Labs

9 TORONTO EX VIVO LUNG PERFUSION (EVLP) SYSTEM Perfusion : 40% CO Ventilation: 7cc/kg, 7BPM, PEEP 5, FiO 2 = 21% Cypel/Keshavjee J Heart Lung Transplant 2008; 27(12): Cypel/Keshavjee NEJM 2011; 14;364(15):

10 NEJM 2011

11 J Thorac Cardiovasc Surg

12 Dose escalation study 75mg/m2 well tolerated 150mg/m2 moderate injury 225mg/m2 severe injury leading to animal death Annals of Thoracic Surgery

13 Doxorubicin 75 mg/m 2 Pre IVLP Post Reperf 200x 200x

14 IVLP clinical trial 1) To determine the safety of IVLP with Dox. 2) To determine the maximal tolerated dose by using a titration design. 3) To determine the time from treatment to recurrence in the ipsilateral treated lung versus the non - IVLP treated contralateral lung.

15 15 IVLP

16 Recent Patient: DC home in 6 days

17 Dox concentration Pt02 Sample Doxorubicin (ng/assay) serum T3 IVLPO2 T3S (200 µl) ND serum T4 IVLPO2 T4S (200 µl) ND POD1 IVLPO2 POD1 (200 µl) ND POD2 IVLPO2 POD2 (200 µl) ND POD3 IVLPO2 POD3 (200 µl) ND POD4 IVLPO2 POD4 (200 µl) ND POD5 IVLPO2POD5 (200 µl) ND T0.5 IVLPO2 T0.5 perfusate (20 µl) T1 IVLPO2 T1 perfusate (20 µl) 76.4 T2 IVLPO2 T2 perfusate (20 µl) 31.8 T3 IVLPO2 T3 perfusate (20 µl) 20.2 T4 IVLPO2 T4 lung (15 mg) 104.9

18 18 Evaluating Efficacy of Novel Treatments

19 Establishment of colorectal and sarcoma lung metastases model Sarcoma model (Day 28) Micrometastases (Day 4) Day 0 Day 4 Injection Sarcoma cells (5 x 10^6 cells) Colorectal cells (2.5 x 10^6 cells) Day 28 Evaluation Colorectal ca model (Day 28)

20 Establishment of colorectal and sarcoma lung metastases model Sarcoma model (Day 28) Micrometastases (Day 4) Treatment IV or IVLP Day 0 Day 4 Injection Sarcoma cells (5 x 10^6 cells) Colorectal cells (2.5 x 10^6 cells) Day 28 Evaluation Colorectal ca model (Day 28)

21 Sarcoma model IVLP only IV (Dox) IVLP (Dox)

22 Left lung weights at day 25 mg * * Kruskal-Wallis statistic (p = ) (Non-parametric ) and Dunn's Multiple Comparison Test

23 Colorectal model IVLP only IV FOLFOX IVLP with FOLFOX

24 24 Lung-specific gene delivery to treat/prevent pulmonary metastases recurrences

25 Lentivirus-Luciferase Distribution Day 8

26 Day 28

27 Left IVLP (4 weeks) lung at sacrifice Right lung Left lung Heart Liver Spleen kidney

28 Targeted gene: Interleukin 12 (Localized immunetherapy)

29 DAY 0 N=5 for each group Fischer F g Injection Cells RCN9 colorectal cancer cell line Left Jugular vein DAY 7 Control Group (Sham group) Group 1: IT LV-IL12 (LD) Group 2: IT LV-IL12 (HD) Group 3: IV Oxaliplatin Group 4: IV Oxaliplatin + IT LV-IL12 (LD) Group 5: IV Oxaliplatin + IT LV-IL12 (HD) DAY 28 Sacrifice: Histological analysis + Analysis of the number of nodules (Weksler Technique) + Measurement of IL12 INF-γ TNF-α

30 Assessment of LV-IL12 efficiency India ink staining + Fekete s Solution Slides with H&E staining

31 IL-12 Lung expression At Day 28

32 Efficiency of LV-IL12 Number of lung nodules/slides One way Anova p< * Mann-Whitney test p<0.05

33 IT IL-12 group Control

34 Combination treatment increased lung NK cell content

35 Combination treatment increased IFNγ + and polyfunctional CD4 + T cells

36 Conclusions IVLP is a new platform for treatment of pulmonary metastases Phase I clinical trial IVLP Dox for sarcoma is underway (starting oxaloplatin for colorectal ca in 2018) Preliminary studies in small animals have shown localized IL-12 gene therapy to be effective Future directions:complete the small animals studies combining IVLP and IL-12. Localized IL-12 delivery in large animals (safety studies).

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