CliniMACS Technology in stem cell transplantation

Advancing clinical applications CliniMACS Technology in stem cell transplantation Graft manipulation T cell and B cell depletion Balance of GvT versus GvHD Fighting infections

CliniMACS Technology in stem cell transplantation Advancing clinical applications Graft engineering Hematopoietic stem cell transplantation (HSCT) is a well known therapeutic option for the treatment of distinct hematological malignancies and a number of non-malignant diseases. The stem cell graft may be engineered before transplantation. Miltenyi Biotec has developed several strategies for graft engineering, based on clinical grade antibodies for different epitopes. The CliniMACS CD34 Separation System was CE-marked in December 1997. A number of publications substantiate the reliable performance of the CliniMACS Technology.¹ ¹² CD34 + enrichment effective passive T and B cell depletion Allogeneic stem cell transplantation for a number of patients with distinct malignant and non-malignant diseases is considered the only curative approach.¹ However, this therapeutic option bears the risk of transplant-related mortality. Graft-versus-host disease (GvHD) is a complication after allogeneic transplantation that can occur despite immunosuppressive prophylaxis even when the donor is a matched sibling.¹³ In vitro CD34 + cell enrichment of stem cell grafts is a very potent technology for an effective T cell depletion, and results in a 104 to 105-fold depletion of T cells from the graft. A high ex vivo T cell depletion enables effective prevention of GvHD.¹⁴ ¹⁷ CD34 enrichment is widely used in haploidentical transplantations, but it has been used even in the matched related setting, namely for AML patients with intermediate or unfavorable cytogenetic profiles. As published, in this study no post-transplantation GvHD prophylaxis was given because of an extensive T cell depletion using CliniMACS CD34 selection (median CD3 + T cell dose: 0.07 105/kg). These patients were compared to a similar cohort of AML patients enrolled in a study which utilized non-manipulated allogeneic grafts followed by post-transplant pharmacologic immune suppression. Recipients of T cell-depleted grafts experienced lower rates of acute and chronic GvHD, whereas rates of relapse, transplant-related mortality, disease-free survival, and overall survival were similar at at follow-up one year after transplantation. ¹⁸, ¹⁹ In the autologous setting, CD34 + cell enrichment has been used for the depletion of tumor cells from the graft.²⁰ CD3/CD19 depletion active T and B cell depletion In contrast to CD34 + cell enrichment, the graft after T and B cell depletion contains CD34 + stem cells, CD34 stem cells, other progenitor cells and natural killer (NK) cells, monocytes, and dendritic cells, which might have engraftment facilitating effects.⁷ The depletion strategy is currently being used in combination with reduced intensity conditioning.⁷, ¹⁰, ²¹ Active depletion TCRα/β depletion Another possibility for active T cell depletion is the CliniMACS TCR (T cell receptor) α/β depletion system. If the presence of TCRγ/δ T cells within the cellular product is of potential therapeutic value, a depletion of TCRα/β + T cells may be performed. This approach maintains the stem cells and immune effector cells, such as NK cells and TCRγ/δ + T cells, in the cellular product. The CliniMACS TCRα/β product line can also be used in combination with the CliniMACS CD19 Reagent to additionally remove the CD19 + B cells from the graft. NK cells and TCRγ/δ T cells are reported to induce GvL/T (graft-versusleukemia/tumor) effects, while the potential risk of inducing GvHD may be reduced.²² Stem cell, CD34 Lymphoid progenitor Progenitor phases, CD34 + Myeloid progenitor B lymphocyte T lymphocyte NK cell Dendritic cell Macrophage Neutrophil Eosinophil Mast cell Platelets Red blood cells Figure 1: Schematic view of the hematopoietic system in humans

Donor Lymphocyte Infusion Tailoring Donor lymphocyte infusion (DLI) means the adoptive transfer of specific immune cells during or after stem cell transplantation for the prevention and treatment of: Relapse GvHD Infection Graft rejection In this context, Miltenyi Biotec has developed CliniMACS Products for the clinical grade separation of different cell types, based on antibodies for CD3, CD4, CD8, CD14, CD19, CD25, and CD56 epitopes. TCRα/β depletion This technical option allows the enrichment of cell populations of the innate immune system, such as NK cell subpopulations and TCRγ/δ T cells within a DILI (donor innate lymphocyte infusion) product. Both cell populations are reported to induce GvL/T effects, while the potential risk of inducing GvHD may be reduced.²² Depletion of naïve T cells CD45RA depletion CD45RA depletion for DLI tailoring results in a cellular product enriched for effector cells, while naïve T cells, potentially inducing GvHD, are depleted (mouse model).²³ Natural killer cells NK cells (CD56 enrichment/cd3 depletion) and NKT cells (CD56 enrichment) may be a perfect tool to exert GvT effects in the transplant as well as in the non-transplant setting, since they have not been observed to induce GvH reactions. NK cell DLIs have been infused in non-transplant, and in haploidentical and unrelated donor PBSC (peripheral blood stem cells) transplantation settings in order to explore GvT effects. Furthermore, the capacity to reduce risk of GvHD and early relapse of hematological malignant diseases (e.g., AML, CML), and the potential to emend an unstable donor chimerism after HSCT, are under clinical investigation.²⁴ ⁴¹ NK cell DLI may also be used in a non-transplant setting. As published in 2010, 10 pediatric patients in first complete remission received low-dose immunosuppression followed by donor-recipient inhibitory KIR-HLA mismatched NK cells. As stated, engraftment occurred in all patients for a median of 10 days without GvHD, and in vivo expansion of NK cells could be demonstrated. All patients remained in remission after a median follow-up time of 964 days.²⁴ KIR-mismatch situation/nk cell therapy allogeneic NK cell target cell Inhibitory KIR KIR: killer cell immunoglobulinlike receptor Activating NK cell receptor MHC class Ligand for activating NK cell receptor Figure 2: If a malignant or infected target cell expresses a sufficient spectrum of ligands that trigger activating NK cell receptors, while inhibitory signalling is blocked due to the KIR mismatch, the allogeneic NK cells are activated to kill the target cell.

CD8 + and CD4 + T cells When GvHD-mediating CD8 + T cells are depleted from the cellular product, CD4 + T cells, the majority of NK cells, and accessory cells, like antigen-presenting T cell populations, are preserved within the cellular product to potentially mediate GvT effects. This treatment option may also be applied in order to amend an unstable donor chimerism after HSCT. 42-49 In the allogeneic transplantation setting, CD4 + T cells in donor lymphocyte infusions (DLI) may be capable of mounting GvT responses, concomitantly reducing the risk of GvHD⁵⁰,⁵¹ and reconstituting the recipient s immune system.⁵² Additionally, Tн2 cells have been successfully used to support stem cell grafts.⁵³ Regulatory T cells (Treg cells CD25 + ) The primary rationale of applying Treg cell DLI is to induce immune suppression. In allogeneic HSCT, two concepts of administration of Treg cell DLI are in early clinical development: Co-infusion of Tregs in close temporal sequence with the stem cell graft. Treg cell DLI applied in combination with an effector cell DLI post-hsct. In both cases the rationale is to reduce risk of GvHD and to provide a platform which allows for lower dosing of immunosuppressive drugs.⁵⁴-⁵⁷ Antigen specific T cells Viral or fungal infections are a major cause of morbidity and mortality in the period of immune recovery after HSCT. In many cases, viral infections result from reactivation of latent viruses such as Cytomegalovirus (HCMV), Adenovirus (AdV), and Epstein-Barr virus (EBV). Antigen-specific CD4 + and CD8 + T cells can be enriched using the CliniMACS Cytokine Capture System (IFN-gamma).⁶¹ A successful enrichment of T cells with the specificity for HCMV⁶², AdV⁶³, EBV⁶⁴, and Aspergillus⁶⁵, as well as leukemia-reactive T cells⁶⁶, has been demonstrated. Adoptively transferred antigen-specific T cells have been shown to restore protective immunity and control established AdV⁶⁷, HCMV⁶⁸, and EBV⁶⁹ infections after HSCT. Figure 4: Subsequent steps in the restimulation of antigen-specific CD4 + and CD8 + T cells, leading to the secretion of IFN-gamma. secretion Activated CD4 + and CD8 + T cells secrete the cytokine IFN-gamma, which enables CD8 CD4 their concomitant enrichment with the CliniMACS Cytokine Capture System (IFN-gamma). Figure 3: Cytokine Capture System Monocyte (CD14 + ) derived Dendritic cells (DCs) DCs have a pivotal role in bridging innate and adaptive immunity. As professional antigen-presenting cells, they have a unique role in initiating and modulating naïve and memory cells. The safety and feasibility of a monocyte-derived DC vaccine, and the induction of T and B cell responses, has 58-60 been demonstrated in leukemia patients. Figure 4: CD8 positive T cell

CliniMACS Technology Key features of the CliniMACS System Clinical-scale cell separation Automated procedure Compatible for use in a GMP setting Functionally closed, CE-marked system Enrichment or depletion of target cell populations Reproducible high purity and excellent yield Cell Preparation Bag Magnet and Separation Column Figure 5: The CliniMACS Plus Instrument with an installed CliniMACS Tubing Set. Enrichment of cells Depletion of cells Modular platform Variable cell source Variable target cell type Focused separation strategies Figure 6: Key features of CliniMACS Technology NK cells CD3/CD19 depletion CD3 depletion, CD56 enrichment strengthen GvT GvHD prophylaxis T cell depletion of the graft CD34 + cell selection CD3/CD19 depletion TCRα/β depletion CD45RA depletion Tailored DLI CD45RA depletion CD8 depletion TCRα/β depletion strengthen GvT CD4 enrichment DC vaccination Regulatory T cells CD25 enrichment control of GvHD prevent GvHD Virus-specific T cells Cytokine Capture system increase immune response Figure 7: Possible implications of CliniMACS Products

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