S. Khleif - Ovarian cancer - General lecture on vaccine
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The document discusses the current state of cancer vaccines, focusing on HPV vaccines. It outlines the types of vaccines as prophylactic, preventive, or therapeutic. HPV vaccines have proven highly effective as prophylactic vaccines in preventing cervical cancer. Clinical trials demonstrated up to 100% efficacy of the HPV vaccines Gardasil and Cervarix in preventing precancerous lesions. However, challenges remain regarding cross-protection against other HPV types, long-term duration of protection, and reducing production costs to increase global access.
S. Khleif - Ovarian cancer - General lecture on vaccine
- 1. Cancer Vaccine- What is the Current State of the Art? Samir N. Khleif Chief, Cancer Vaccine Section, NCI Professor of Medicine, Uniformed Services University for Health Sciences
- 2. Vaccines Prophylactic Therapeutic preventive Treatment
- 3. Vaccines Prophylactic Therapeutic preventive Treatment
- 4. Vaccines Prophylactic Therapeutic preventive Treatment
- 5. Cancer Vaccines • Prophylactic: prevention or elimination of the causative agents • Preventive: elimination of premalignant lesion or prevention of recurrence • Treatment: established tumor
- 6. Vaccines Prophylactic Therapeutic HPV preventive Treatment Provenge
- 7. Prophylactic
- 8. Infectious agents and Cancer • HPV • HBV • HCV • EBV • HIV • HHV8 • HTLV1 • Helicobactore
- 9. Infectious agents and Cancer • HPV • HBV • HCV • EBV • HIV • HHV8 • HTLV1 • Helicobactore
- 10. Cervical Cancer • 2nd most common cancer worldwide • ~ 510,000 new cases / year • ~ 274,000 deaths / year • Most common cancer in the developing world
- 11. What is HPV? • Small DNA Tumor Virus • 55 nm in diameter • 8000-base double stranded circular DNA • Causes an array of benign and malignant pathology
- 13. L1/2 E5/2/4 E1 E6/7
- 14. L1/2 E5/2/4 E1 E6/7
- 15. L1/2 E5/2/4 E1 E6/7
- 16. Woodman et al. Nature Reviews Cancer 7, 11–22 (January 2007) | doi:10.1038/nrc2050
- 17. HPV Infection Transient Persistent Infection Infection • 1 year Low Grade Dysplasia CIN 1 • 5 years High Grade Dysplasia CIN 2/3 • Decades Invasive Cancer
- 18. HPV Infection Transient Persistent Infection Infection Low Grade Dysplasia CIN 1 High Grade Dysplasia CIN 2/3 Invasive Cancer
- 19. HPV Infection Transient Persistent Infection Infection Low Grade Dysplasia CIN 1 Integration High Grade Dysplasia CIN 2/3 Invasive Cancer
- 20. HPV Infection Transient Persistent Infection Infection Low Grade Dysplasia CIN 1 Integration High Grade Dysplasia CIN 2/3 Invasive Cancer
- 21. HPV Infection Transient Persistent Infection Infection Low Grade Dysplasia CIN 1 Integration High Grade Dysplasia CIN 2/3 Invasive Cancer
- 22. Viral Proteins Expressed HPV Infection L1, L2 Transient Persistent Infection Infection Low Grade Dysplasia CIN 1 Integration High Grade Dysplasia CIN 2/3 Invasive Cancer
- 23. L1/2 E5/2/4 E1 E6/7
- 24. Humoral Vaccines • Killed virus (influenza) • Live attenuated (MMR) • Sub-units
- 25. Humoral Vaccines • Killed virus (influenza) • Live attenuated (MMR) • Sub-units
- 26. Live Attenuated/killed Viruses Are Not Suitable For an HPV Prophylactic Vaccine • Papillomavirus cannot be efficiently grown in cultured cells • The viral genomes contain oncogenes
- 27. Humoral Vaccines • Killed virus (influenza) • Live attenuated (MMR) • Sub-units
- 28. L1/2 E5/2/4 E1 E6/7
- 29. L1/2 E5/2/4 E1 E6/7
- 30. HPV L1 VLP Vaccine Synthesis L1 gene Empty viral on HPV capsids DNA Yeast cell DNA Transcription L1 gene inserted Capsid proteins into genome of mRNA yeast cell tRNA Translation rRNA Yeast Cell
- 31. HPV L1 VLP Vaccine Synthesis L1 gene Empty viral on HPV capsids DNA Elicits immune response in host Yeast cell DNA Transcription L1 gene inserted Capsid proteins into genome of mRNA yeast cell tRNA Translation rRNA Yeast Cell
- 32. Vaccine Available companyName Vaccine Type Merck: Gardasil Quadrivalent (yeast) FDA Approved 2006 GSK: Cervarix Bivalent (baculovirus) FDA Approved 2009
- 33. Clinical Trials: HPV Prophylactic Vaccine Study Vaccine No of Subjects End points Efficacy Vaccine Control % (confidence limits) Koutsky Gardasil 6087 6080 CIN 2/3 AIS 98 (86-100) Garland Gardasil 2241 2258 CIN 2/3 AIS 100 (94-100) 2261 2279 GW VIN 100 (94-100) VAIN Joura Gardasil 7811 7785 VIN 2/3 100 (72-100) VAIN 2/3 Harper Cervarix 481 470 CIN 100 (42-100) CIN 2/3 Paavonen Cervarix 7788 7838 CIN 2/3 90 (53-99) MITT Analysis
- 34. Duration of Follow up in Phase II Studies Harper DM, Expert Rev Vaccines. 2009
- 35. Reduction in LEEP for CIN 2/3 Harper DM, Expert Rev Vaccines. 2009
- 37. US Recommendations • FDA approved the vaccine for girls and women ages 9 to 26 for the prevention of Cervical, Vulvar and vaginal cancers and precancerous lesions • FDA approved the vaccine for men and women ages 9 to 26 for the prevention of anal cancers and precancerous lesions • FDA approved the vaccine for boys and men ages 9 to 26 to prevent genital warts • Federal Advisory Committee on Immunization Practices recommends that girls routinely receive the vaccine between the ages of 11 and 12. • The HPV vaccine is most effective when administered to girls and women before the onset of sexual activity. Vaccination is also recommended for women up to age 26, regardless of sexual activity.
- 38. Incidence of Cervical cancer/ 100,000 cases • US : 7 • Jordan 2.6 • Egypt 2.7 • Israel (Arabs) 2.5 • Israel (Jews) 5.3 • Cyprus 3.7 • Turkey 4.76 Komodiki et al, MECC Monograph Hatipoglu/Ozgul, MOH Turkey
- 39. Issues to be addressed • Cross sub-types protection • Duration of protection • Production cost • Time frame for public health impact
- 44. Normal Cancer
- 45. Normal Cell Tumor Cell
- 48. Tumor Cell
- 49. 1 2 1
- 59. Normal Cell KILL
- 60. L1/2 E5/2/4 E1 E6/7
- 61. Viral Proteins Expressed HPV Infection L1, L2 Transient Persistent Infection Infection E1, E2, L1, L2 Low Grade E1, E2 Dysplasia CIN 1 Integration High Grade Dysplasia CIN 2/3 Invasive Cancer
- 64. • Prevention of HPV infection Viral Proteins Expressed • Elimination of HPV infection HPV Infection L1, L2 Transient Persistent Infection Infection E1, E2, L1, L2 Low Grade • Elimination of low grade dysplasia E1, E2/ E6, E7 Dysplasia CIN 1 Integration High Grade High Grade E6, E7/ E1, E2 • Elimination of high grade dysplasia Dysplasia CIN 2/3 CIN 3 • Preventions of recurrence Invasive E6, E7 Cancer Treatment of invasive disease
- 65. •Prevention of HPV infection Viral Proteins Expressed •Elimination of HPV infection HPV Infection L1, L2 Transient Persistent Infection Infection E1, E2, L1, L2 Low Grade •Elimination of low grade dysplasia E1, E2/ E6, E7 Dysplasia CIN 1 Integration High Grade High Grade E6, E7/ E1, E2 •Elimination of high grade dysplasia Dysplasia CIN 2/3 CIN 3 •Preventions of recurrence Invasive E6, E7 Cancer Treatment of invasive disease
- 66. •Prevention of HPV infection Viral Proteins Expressed •Elimination of HPV infection HPV Infection L1, L2 Transient Persistent Infection Infection E1, E2, L1, L2 Low Grade •Elimination of low grade dysplasia E1, E2/ E6, E7 Dysplasia CIN 1 Integration High Grade High Grade E6, E7/ E1, E2 •Elimination of high grade dysplasia Dysplasia CIN 2/3 CIN 3 •Preventions of recurrence Invasive E6, E7 Cancer Treatment of invasive disease
- 70. Clinical Trials: Preventive Vaccine for CIN Vaccine Type Phase Antigen Lesion Patient Number Immunologic Clinical response Authors response Protein-based II Fusion protein CIN 3 58 Increased 13/58 CR Einstein 2007 HPV-16 E7- inflammation in 32/58 PR HSP65 responders 11/58 SD 2/58 PD II Fusion protein High grade CIN 21 9/17 7/20 CR Roman 2007 HPV-16 E7- 1/20 PR HSP65 11/20 SD 1/20 PD Viral vector- I/II MVA E2 CIN 1, 2 and 3 36 100% Ab 34/36 CR Gutierez 2004 based particles induction 2/36 PR 100% CTL II MVA E2 CIN 2 or 3 34 100% Ab 19/34 CR Garcia- particles induction 15/34 PR Hernandez CTL response 2006 (data not shown) II Recombinant Anogenital (non- 29 NA 1/29 CR Fiander 2006 HPV-16 E6E7L2 cervical) 5/29 PR protein (TA- neoplasia 3 CIN) and TA- (AGIN 3) HPV Chimeric virus- I/II HPV-16L1E7 CIN 2 or 3 39 100% Ab 9/23 PR Kaufmann like particle induction (p>0.05) 2007 5/23 E7-specific T cells DNA I Plasmid CIN 2 or 3 15 Low immune 3/9 PR Trimble 2009 expressing a Sig- response (p>0.05) E7(detox)-HSP 70 fusion protein
- 71. Preventive HPV E7 Vaccine / VIN Kenter GG et al. NEJM 2009
- 72. Preventive HPV E7 Vaccine / VIN Kenter GG et al. NEJM 2009
- 73. A combined prophylactic therapeutic vaccines
- 74. L1/2 E5/2/4 E1 E6/7
- 75. Targeting HPV16 E2 Using Chimeric VLPs and E2 Peptides Chimeric VLP: HPV16 VLP-E7E2 L2 L1 E7 E2 HPV16 L1/L2-E7-E2 Chimeric VLP
- 76. Conclusion • E2 vaccine induce CTL that lyse the tumor cell line expressing HPV 16 E2. • Modified E2 sequence showed higher binding affinity , elicited strong IFN- production and can, also, induce CTL to lyse B16-AAD-E2. • Combination with VLP priming enhances the E2 CTL • E2 vaccine has a potential for the treatment of CINs.
- 78. Prostate antigen: PAP 48 hours incubation with GM
- 79. Disease Behavior Kantoff PW, N Engl J Med. 2010 Jul 29;363(5):411-22
- 80. Sipuleucel-T (Provenge) • Sipuleucel-T (Provenge) is an autologous, dendritic cell- based vaccine (CD541) that is pulsed with a selective prostate antigen: prostatic acid phosphatase. • the FDA has recently approved sipuleucel-T in patients with asymptomatic or minimally symptomatic metastatic hormone-refractory prostate cancer. • Side effects include chills, fatigue, fever, and joint aches.
- 81. Framing the Problem Fact I • Cancer Vaccine article
- 82. Framing the Problem Fact I • Cancer Vaccine article 18,543
- 83. Framing the Problem Fact I • Cancer Vaccine article 18,543 • Drug Approved 1
- 84. Fact II • Most of the people who received cancer the Vaccine did not benefit
- 85. Effectors vs. Suppressors Tumor Vaccine CD8+ CTL CTL CTL CTL CTL APC CD4+
- 86. Ideal Antigenic target • Expressed uniquely in cancer cells • Important for the maintenance of the malignant phenotype • Immunogenic
- 87. Mutant Ras
- 88. Solid tumor with Ras mutation Sequencing Ras Mutant Ras peptide Toubaji et al, 2008
- 90. Post 3 vax.
- 91. Post 3 vax.
- 93. Effectors vs. Suppressors Tumor Vaccine CD8+ CTL CTL CTL CTL CTL APC CD4+
- 94. Tumor Immune Modulation Network (TIMN) Co-inhibitory-Ligands Tumor CD8+ CTL CTL CTL Cytokines/factors APC CTL CTL Treg Treg Treg CD4+ Treg MDSC Other inhibitory mechanism TAM
- 95. PD-1/PD-L1/PD-L2 Blank, Cancer Immunol Immunother, 2005
- 96. PD-1/PD-L1 Engagement Suppresses Effector T cells PD-L1 PD-1 Tumor cell MDSC Suppressed/Apoptotic Activated T cell CD28 B7 TCR MHC/ APC Treg peptide
- 97. PD-1/PD-L1 Engagement Suppresses Effector T cells PD-L1 PD-1 Tumor cell MDSC Activated T cell CD28 B7 Anti-PD-1 TCR MHC/ APC Treg peptide
- 98. Effectors vs. Suppressors CTLA4 CTL Tumor CD8+ CTL CTL Cytokines APC Treg Treg CTLA4 CTL Treg CD4+ Treg CTL MDSC Other inhibitory mechanism TAM
- 99. Improved Overall Survival in a Phase II Randomized Controlled Trial of a Poxviral-Based PSA-Targeted Immunotherapy in Metastatic Castration-Resistant Prostate Cancer Kantoff, et al. JCO, 2010
- 100. Effectors vs. Suppressors PD1-PDL1 CTL Tumor CD8+ CTL CTL Cytokines APC Treg Treg PD1-PDL1 CTL Treg CD4+ Treg CTL MDSC Other inhibitory mechanism TAM
- 101. Humanized mAb PD-L1 PD-L2 to PD-1 PD-1 tumor DCs Activated T cells anti-PD-1 antiboby
- 102. Evaluation of therapeutic efficacy of vaccine in combination with anti-PD1 Days 0 7 8 15 22 Monitoring of tumor growth and survival TC-1 E7+aPD1 E7+aPD1 E7+aPD1 Day 7 after implantation of 50,000 TC-1 cell
- 103. 1.5 1.5 1.5 Tumor Growth 1.2 1.2 1.2 0.9 0.9 0.9 0.6 0.6 0.6 0.3 0.3 0.3 Non-immunized E7 a-PD1 0 0 0 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 1.5 1.5 1.5 E7+CPM 1.2 1.2 1.2 0.9 0.9 0.9 0.6 0.6 0.6 0.3 0.3 0.3 CPM a-PD1 +CPM 0 0 0 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 1.5 1.5 E7+aPD1 1.2 1.2 0.9 0.6 0.9 Tumor Volume, cm3 0.3 0.6 E7+CPM+aPD1 0 5 8 15 22 26 29 31 35 38 0.3 0 5 8 15 22 26 29 31 35 38 Days after tumor implantation
- 104. Enhancing T cell Enhancing Memory response response Enhancing Ag presentation + + Long Lasting Ag I. R. I. R. Effective I. R.
- 105. Enhancing T cell Enhancing Memory response response Enhancing Ag presentation + + Long Lasting Ag I. R. I. R. _ Better Targets Inhibiting negative Effective regulators I. R.
- 106. A Pilot Study of CT-011+ Provenge (Sipuleucel- T)+ Cyclophosphamide in Patients with Metastatic Castrate Resistant Prostate Cancer
- 107. Study Design Part 1, Run In phase, up to 12 patients CPM 250 mg/m2 (Day -1 only) + Sipuleucel –T (Day 0) >>> Q 2 wk X 3 CPM 125 mg/m2 Part 2, Randomized, total 45 patients • Sipuleucel-T Q 2 wk X 3 • Sipuleucel-T Day 0 + CT-011 (3 mg/kg Day 2) • CPM (Day -1 only) + Sipuleucel-T Day 0 + CT-011 (3 mg/kg Day 2) CPM = Low Dose Cyclophosphamide Apheresis 2-3 days prior to each dose of Sipuleucel-T for cell generation
- 108. Objectives Primary endpoint Secondary endpoint • Feasibility Provenge™+ • Progression-free CPM survival • Immune efficacy on • Overall survival PA2024-specific IFN-γ • Toxicity
- 109. Inclusion Criteria • mCRPC with progression, testosterone < 50 ng/dL. • PSA over nadir at least 2X, 3 weeks apart. • No prior chemotherapy.
- 110. Disease Behavior
- 111. A Pilot Study to of Gemcitabine and CT-011 in Resected Pancreatic Cancer
- 112. Phase I trial of escalating doses of CT-011 in combination with p53 vaccine in adults with advanced solid tumors
- 113. Effectors vs. Suppressors CTLA4 CTL Tumor CD8+ CTL CTL Cytokines APC Treg Treg CTLA4 CTL Treg CD4+ Treg CTL MDSC Other inhibitory mechanism TAM
- 114. PD-1 and CTLA-4 combination blockade expands infiltrating T cells and reduces regulatory T and myeloid cells (Curran MA et al, PNAS 2010)
- 115. Tumor Growth Pattern with Chemotherapy and Vaccines Fojo et.al. Clin Cancer Res, 2010
- 116. treatment Fojo et.al. Clin Cancer Res, 2010
- 117. treatment Chemotherapy Fojo et.al. Clin Cancer Res, 2010
- 118. treatment Chemotherapy Vaccines Fojo et.al. Clin Cancer Res, 2010
- 119. Disease Behavior
- 120. Disease Behavior
- 121. Pt Age Cancer Pathology Mutation Pre-vaccination Stage on Disease extension Arm A Patient Profile: Il-2 Therapy Enrollment on enrollment Liver, Lung, Para- 1A 56 Colon Adenocarcinoma ASP Sx1, Cx3 4 aortic LN 2A 57 Colon Adenocarcinoma ASP Sx2, Cx2 4 Lung 3A 62 Colon Adenocarcinoma ASP Sx1, Cx3, Rx1 4 Lung Pancreas, Liver, Adrenals, Omentum, 4A Peritoneum, Infradiaphragmati 50 Pancreatic Adenocarcinoma ASP Sx1, Cx2 4 c LN 5A 60 Lung Adenocarcinoma VAL Cx2, Rx1 4 Chest Wall 6A 59 Colon Adenocarcinoma VAL Cx2 4 Liver 7A 52 Colon Adenocarcinoma CYS Sx2, Cx2 NED NED Lung, Hilar 8A 68 Lung NSCLC CYS Sx1, Cx5, Rx2 4 Adenopathy 9A 56 Colon Adenocarcinoma ASP Sx2, Cx3, Rx2 NED NED 10A 63 Colon Adenocarcinoma ASP Sx3, Cx3 4 Liver, Lung 11A 42 Pancreatic Adenocarcinoma ASP Sx2, Cx1 NED NED 12A 39 Colon Adenocarcinoma ASP Sx1, Cx1 NED NED 13A 67 Colon Adenocarcinoma CYS Sx1, Cx2 4 Liver 14A 51 Colon Adenocarcinoma ASP Sx2, Cx1 NED NED 15A 60 Pancreatic Adenocarcinoma VAL Sx1, Cx4, Rx1 4 Liver 16A
- 122. # Of Off-study reason/Disease Pt Cycles A Clinical Outcome:PFS (ms)# Arm Status Il-2 OS (ms)* 1A 2 PD 0.5 5.5 2A 3 PD 3.9 16.8 3A 3 PD 5.8 21.5 4A 3 PD 3.6 6.2 5A 1 PD 1 2.8 6A 3 PD 3.5 8.9 7A 11 Completed 129+ 129+ 8A 3 PD 3.6 13.1 9A 10 PPS 15.4 37.2 10A 3 PD 3.3 19.9 11A 6 PD 7.5 24.1 12A 3 PD 6.2 23 13A 3 PD 3.5 4.8 14A 3 PD 7.1 41.3 PPS/Lost to Follow- 15A 3 Up 2.7+ 5.3
- 124. Study Design Re-staging -7 1 8 15 22 1 8 15 22 1 For 6 cycles or Days until disease progression or SE
- 125. Objectives Primary endpoint Secondary endpoint • Feasibility and safety • Clinical response
- 126. Inclusion Criteria • Resectable pancreatic CA • Eligible for Gemcitabine • No previous treatment
- 127. Schema • •Staging •Staging •Staging evaluation •evaluatio •evaluatio n n 1(0) 2 (3) 3 (6) 4 (9) 5 (12) 6 (15) 7 (18) Until Cycles (Weeks) disease p53 (264-272) progression or CT-011 toxicity
- 128. Schema • Dose Escalation Schedule Dose Level Dose of CT-011^ Level 1 0.3 mg/kg every 3 weeks X 2 * Level 2 1.5 mg/kg every 3 weeks X 2 * Level 3 3 mg/kg every 3 weeks X 2 * Level 4 6 mg/kg every 3 weeks X 2 * ^Evaluation of toxicity to define DLT will be performed 3 weeks after the 1st dose (cycle 1). *Evaluation of clinical status and tumor response will be performed after 2 cycles
- 129. Improved Overall Survival in a Phase II Randomized Controlled Trial of a Poxviral-Based PSA-Targeted Immunotherapy in Metastatic Castration-Resistant Prostate Cancer Kantoff, et al. JCO, 2010
- 130. Disease Behavior
- 131. Disease Behavior Show the difference in vaccine vehcle and then Here add the understanding of the TIRN and Then show CTLA and potentially PD1 for use together
- 132. T regs in colon cancer patients p<0.05 * 12 11 %CD4+CD25+FOXP3+ 10 9 8 %CD4+CD25+FOXP3+ 7 6 5 4 3 2 1 0 Normal NORMAL Colon Cancer COLON CANCER COLON CANCER WIT H RAS MUT AT ION WIT HOUT RAS MUT AT Ion
- 133. Successful cancer immunotherapy requires simultaneous targeting of both arms of immune system Induction of immune Inhibition of response suppression Bhardwaj et al. 2007
- 134. Successful cancer immunotherapy requires simultaneous targeting of both arms of immune system Induction of immune Inhibition of response suppression Bhardwaj et al. 2007
- 135. Successful cancer immunotherapy requires simultaneous targeting of both arms of immune system Induction of immune Inhibition of response suppression Bhardwaj et al. 2007
- 136. Effectors vs. Suppressors Tumor Vaccine CD8+ CTL CTL CTL CTL CTL APC CD4+
- 137. Long Lasting Ag I. R. I. R. Effective I. R.
- 138. Enhancing T cell Enhancing Memory response response Enhancing Ag presentation + + Long Lasting Ag I. R. I. R. Effective I. R.
- 140. SC Low dose IL-2 and Vaccines
- 142. Enhancing effector Enhancing memory T cell response response Enhancing Ag presentation + + Long Lasting Ag I. R. I. R. Effective I. R.
- 143. Enhancing effector Enhancing memory T cell response response Enhancing Ag presentation + + Long Lasting Ag I. R. I. R. _ Immune Evasion Immune Negative Effective regulation I. R.
- 144. Enhancing T cell Enhancing Memory response response Enhancing Ag presentation + + Long Lasting Ag I. R. I. R. _ Better Targets Inhibiting negative Effective regulators I. R.
- 145. Combination Immune Therapy • Immune Enhancing • Immune Modulating • Targeting inhibitory cells • Blocking inhibitory cytokines/factors (anti- IL10, TGFb etc) • Blocking co-inhibitory molecules (anti-PD1, CTLA-4 etc)
- 146. Immune Combination Therapy • Vaccine • Immune modulating and enhancing agents • Antibodies • Targeted Therapy • Chemotherapy • Radiotherapy
- 147. Evaluation of therapeutic efficacy of vaccine in combination with anti-PD1 Days 0 8 15 22 Monitoring of tumor growth and survival TC-1 E7+aPD1 E7+aPD1 E7+aPD1 Tumor Volume, cm3 Non-treated E7 n=10 n=9 E7+ aPD1 aPD1 n=10 n=8 Days after tumor implantation
- 148. Evaluation of therapeutic efficacy of vaccine/CT-011 combination in TC-1 mouse model Days 0 8 15 22 Monitoring of tumor growth and survival TC-1 E7+aPD1 E7+aPD1 E7+aPD1 120 100 Percent Survival 80 Tumor Volume, cm3 Non-treated E7 n=10 n=9 60 40 20 0 E7+ CT-011 CT-011 10 15 20 25 30 35 40 45 n=10 n=8 Days after tumor implantation Days after tumor implantation
- 149. Treg cell inhibitor-cyclophosphamide (CPM) Low Dose CPM selectively targets Treg cells, leaving other T cell populations intact (Lutsiak et al, Blood, 2005; Ikezawa et al, J Dermatol Sci, 2005).
- 150. Effectors vs. Suppressors PD-1 PD-L1 CTL Tumor CD8+ CTL CTL Cytokines APC Treg PD-1 PD-L1 Treg CTL Treg CD4+ Treg CTL MDSC Other inhibitory mechanism TAM
- 151. Therapeutic efficacy of vaccine in combination with anti-PD1 and CPM CPM Days 0 7 8 15 22 Monitoring of tumor growth and survival TC-1 E7+aPD1 E7+aPD1 E7+aPD1 Day 7 after implantation of 50,000 TC-1 cell
- 152. 1.5 1.5 1.5 Tumor Growth 1.2 1.2 1.2 0.9 0.9 0.9 0.6 0.6 0.6 0.3 0.3 0.3 Non-immunized E7 aPD1 0 0 0 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 1.5 E7+CPM 1.2 0.9 0.6 0.3 CPM 0 5 8 15 22 26 29 31 35 38 E7+CT-011
- 153. 1.5 1.5 1.5 Tumor Growth 1.2 1.2 1.2 0.9 0.9 0.9 0.6 0.6 0.6 0.3 0.3 0.3 Non-immunized E7 aPD1 0 0 0 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 1.5 1.5 1.5 E7+CPM 1.2 1.2 1.2 0.9 0.9 0.9 0.6 0.6 0.6 0.3 0.3 0.3 CPM aPD1+CPM 0 0 0 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 5 8 15 22 26 29 31 35 38 1.5 E7+aPD1 1.2 0.9 0.6 0.3 0 5 8 15 22 26 29 31 35 38
- 154. Vaccine in combination with anti-PD1 and CPM Synergize in tumor rejection Non-treated (n=15) E7 (n=14) a-PD1 (n=15) CPM (n=15) E7+ a-PD1(n=15) E7+CPM (n=14) a-PD1 +CPM (n=15) 100 E7 + a-PD1 + CPM (n=20) 80 Percent Survival 60 40 20 0 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 Days after tumor implantation
- 155. Vaccine in combination with anti-PD1 and CPM induces potent antigen-specific immune responses in tumor bearing mice Days 0 7 8 15 21 TC-1 tumor CPM E7+a-PD1 TERMINATION 140 *** Number of IFN spots per 106 *** R2=0.8106 120 *** Number of IFN spots per 106 120 P<0.001 100 splenocytes splenocytes 80 80 60 40 40 20 0 0 E7 E7 E7 E7 a-PD1 NT 0.0 0.3 0.6 0.9 1.2 1.5 a-PD1 +CPM a-PD1 +CPM Tumor volume, cm3 ***P<0.001 +CPM
- 156. Vaccine in combination with anti-PD1 and CPM increases the levels of tumor-infiltrated CD8+ T cells 9.E+03 8.E+03 *** CD8+ cells *** * Absolute numbers per 7.E+03 10e6 tumor cells 6.E+03 5.E+03 4.E+03 3.E+03 2.E+03 1.E+03 0.E+00 E7 E7 E7 E7+ a-PD1 NT +CPM a-PD1 a-PD1 +CPM +CPM 12 *** * *** 10 * * CD8+/Treg Ratio 8 6 4 2 0 E7 E7 E7 E7+ a-PD1 NT +CPM a-PD1 a-PD1 +CPM +CPM *P<0.05, **P<0.01 and ***P<0.001
- 157. Anti-PD1 partially overcomes tumor-induced suppression of stimulated Tconv cell proliferation in vitro Isotype control anti-PD-L1 100 25 *** 25 Percent of maximum *** 20 15 10 5 0 +TC-1 Tconv# +TC-1 +TC-1 +TC-1 +Irr Ab + a-PD1 +PD-L1 ***P<0.001
- 158. Anti-PD1 and CPM synergize to decrease the level splenic and tumor infiltrated Treg cells ** Day 21 40 * Treg - % of CD4+ cells 35 30 25 20 15 10 5 2.5E+03 0 ** Treg cells E7 E7 E7 E7 CT-011 NT * + a-PD1 +CPM +a-PD1 +CPM 2.0E+03 ** +CPM Absolute numbers per * * 10e6 tumor cells 1.5E+03 ** 1.0E+03 5.0E+02 *P<0.05 and **P<0.01 0.0E+00 E7 E7 E7 E7+ aPD1 NT +CPM + a-PD1 a-PD1 +CPM +CPM
- 159. Anti-PD1/CPM synergize to decrease and maintain low level of Tregs in periphery 25 % of Tregs within CD4+T cell population 20 NT CPM a-PD1 15 a-PD1 +CPM NS NS 10 * * ** 5 ** ** 0 Tumor (days) 7 8 11 14 18 21 26 CPM (days) 0 +1 +4 +7 +11 +14 +19
- 160. T cell subsets involved in tumor protection after Combination of Vaccine with anti-PD1/CPM Anti-CD8 Anti-CD8 400ug i.p. 400ug i.p. TC-1 Days 0 5 7 8 15 17 22 24 Monitoring of tumor growth and survival Anti-CD4 Vaccine + Vaccine + Anti-CD4 Vaccine + 300ug i.p. a-PD1 a-PD1 300ug i.p. a-PD1 CPM 100 No treatment Percent Survival 80 E7+a-PD1+CPM E7+a-PD1+CPM+anti-CD8 60 E7+a-PD1+CPM+anti-CD4 /anti-CD8 40 E7+a-PD1+CPM+anti-CD4 20 0 8 13 18 23 28 33 38 43 48 53 58 63 68 73 78 Days after tumor implantation
- 161. Vaccine/anti-PD1/CPM: Mechanism of Action PD-1 PD-L1 CTL Tumor CD8+ CTL CTL CTL CTLCTL TGF APC Treg CD4+ PD-1 PD-L1 Treg Treg CD4+ CTL CD4+ Treg PD-1 PD-L1
- 162. Summary • Combination of anti-PD1 with Treg cell inhibition (CPM) and vaccine is a feasible strategy that results in tumor eradication under challenging conditions • Anit-PD1 enhances CD8+ tumor infiltration when combined with vaccine and CPM • Anti-PD1 synergize with CPM to decrease both peripheral and tumor-infiltrated Treg cells
- 163. Current Clinical Trials • A Pilot Study to of Gemcitabine and CT-011 in Resected Pancreatic Cancer • Phase I trial of escalating doses of CT-011 in combination with p53 vaccine in adults with advanced solid tumors • A Pilot Study of CT-011 and Provenge (Sipuleucel-T) in combination with low dose Cyclophosphamide in Patients with Metastatic Castrate Resistant Prostate Cancer
- 164. B7-DC-Ig PD-L1 PD-L2 PD-1 Chimera of ECD of murine PD-L2 and Fc portion of IgG tumor DCs Activated T cells
- 165. Vaccine in combinations with B7-DC-Ig and CPM induce potent antigen-specific immune responses in tumor bearing mice Number of IFN spots per 10e6 splenocytes *** E7 E7 E7 E7 B7DCIg NT +AMP-224 +CPM +B7DCIg +CPM +CPM *P<0.05, ***P<0.001
- 166. Vaccine in combinations with B7-DC-Ig and CPM induce potent antigen-specific immune responses in tumor bearing mice Number of IFN spots per 10e6 splenocytes *** 30 Percent of apoptotic TC-1 cells E:T=10:1 25 *** *** E:T=25:1 * E:T=50:1 20 15 10 5 E7 E7 E7 E7 AMP-224 NT 0 E7 E7/ E7/ E7/ CPM/ NT + B7DCIg +CPM + B7DCIg +CPM B7DCIg CPM CPM/ AMP-224 +CPM B7DCIg *P<0.05, ***P<0.001
- 167. Vaccine in combinations with B7-DC-Ig and CPM induce potent antigen-specific immune responses in tumor bearing mice 120 100 Non-treated (n=15) Percent Survival B7DCIg (n=15) 80 E7 (n=15) E7+ B7DCIg (n=13) 60 B7DCIg +CPM (n=15) 40 E7+CPM (n=15) CPM (n=15) 20 E7 + AMP-224 + CPM (n=15) 0 10 15 20 25 30 35 40 45 50 55 60 65 70 Days after tumor implantation
- 168. Vaccine in combinations with B7-DC-Ig and CPM induce potent antigen-specific immune responses in tumor bearing mice 120 100 Non-treated (n=15) Percent Survival B7DCIg (n=15) 80 E7 (n=15) E7+ B7DCIg (n=13) 60 B7DCIg +CPM (n=15) 40 E7+CPM (n=15) CPM (n=15) 20 E7 + AMP-224 + CPM (n=15) 0 10 15 20 25 30 35 40 45 50 55 60 65 70 Days after tumor implantation 100 No treatment E7+B7DCIg+CPM Percent Survival 80 E7+B7DCIg+CPM+anti-CD8 60 40 20 0 8 13 18 23 28 33 38 43 48 53 58 63 68 73 78 Days after tumor implantation
- 169. T regulatory Cells Treg Anti-PD1 ** Treg cells Nnumbers per 10e6 tumor * ** * * ** cells E7 E7 E7 E7+ +aPD1 NT +CPM +aPD1 +aPD1 +CPM +CPM *P<0.05, **P<0.01, ***P<0.001
- 170. T regulatory Cells Treg Anti-PD1 B7-DC-Ig ** Treg cells *** Treg cells Nnumbers per 10e6 tumor * ** ** ** * * * ** ** ** cells ** E7 E7 E7 E7+ +aPD1 NT E7 E7+ E7+ E7+ B7DCIg + NT +CPM +aPD1 +aPD1 +CPM CPM B7DCIg CPM+ CPM +CPM B7DCIg *P<0.05, **P<0.01, ***P<0.001
- 171. T Conventional Cells Tconv Anti-PD1 Numbers per 10e6 tumor cells 3500 * 3000 2500 2000 * 1500 1000 500 0 E7 E7 E7 E7+ aPD1 NT +CPM +aPD1 aPD1 +CPM +CPM *P<0.05, ***P<0.001
- 172. T Conventional Cells Tconv Anti-PD1 B7-DC-Ig Numbers per 10e6 tumor cells 3500 3500 * *** 3000 3000 2500 2500 2000 * 2000 1500 1500 1000 1000 500 500 0 E7 E7 E7 E7+ aPD1 0 E7 E7+ E7+ E7+ CPM+ NT NT +CPM +aPD1 aPD1 +CPM CPM B7DCIg CPM/ B7DCIg +CPM B7DCIg *P<0.05, ***P<0.001
- 173. CD8+ T Cells CD8 Anti-PD1 AMP-224 *** CD8+ cells * CD8+ cells *** Numbers per 10e6 tumor * NS *** cells E7 E7+ E7+ E7+ AMP + NT E7 E7 E7 E7+ aPD1 NT +CPM +aPD1 aPD1 CPM AMP CPM+ CPM +CPM +CPM AMP *P<0.05, ***P<0.001
- 174. CD8+ T Cells CD8 Anti-PD1 B7-DC-Ig *** CD8+ cells * CD8+ cells *** Numbers per 10e6 tumor * NS *** cells E7 E7+ E7+ E7+ B7DCIg NT E7 E7 E7 E7+ aPD1 NT +CPM +aPD1 aPD1 CPM B7DCIg CPM+ CPM +CPM +CPM B7DCIg *P<0.05, ***P<0.001
- 175. B7-DC-Ig decreases the level of tumor infiltrated PD-1high CD8+T cells 5000 Numbers per 10e6 tumor cells 4500 * 4000 NS *** 3500 3000 2500 2000 1500 1000 500 0 E7 E7+ E7+ E7+ CPM B7DCIg B7DCIg + CPM
- 176. B7-DC-Ig decreases the level of tumor infiltrated PD-1high CD8+T cells 5000 TI CD8+ PD-1high cells and CD8+ PD-1low cells Numbers per 10e6 tumor cells 4500 5000 * 4000 NS 4500 *** 3500 4000 3000 3500 2500 3000 2000 2500 1500 2000 1000 1500 500 1000 0 500 E7 E7+ E7+ E7+ 0 CPM B7DCIg B7DCIg E7 E7+ E7+ E7+ + CPM CPM B7DCIg B7DCIg CPM GATED ON CD8+ PD-1high PD-1high 53.81% 25.75% GATED ON CD8+ PD-1high PD-1high 67.82% 23.36%
- 177. B7-DC-Ig decreases the level of tumor infiltrated PD-1high CD8+T cells 5000 TI CD8+ PD-1high cells and CD8+ PD-1low cells Numbers per 10e6 tumor cells 4500 5000 * 4000 NS 4500 *** 3500 4000 3000 3500 2500 3000 2000 2500 1500 2000 1000 1500 500 1000 0 500 E7 E7+ E7+ E7+ 0 CPM B7DCIg B7DCIg E7 E7+ E7+ E7+ TI CD8+ PD-1low cells + CPM 4000 CPM B7DCIg B7DCIg Numbers per 10e6 tumor cells 3500 CPM * GATED ON CD8+ * PD-1high PD-1high 3000 * 2500 53.81% 25.75% 2000 1500 1000 500 GATED ON CD8+ PD-1high PD-1high 0 E7 E7+ E7+ E7+ 67.82% 23.36% CPM B7DCIg B7DCIg + CPM
- 178. In contrast to anti-PD1, B7DCIg doesn’t overcome tumor-induced suppression of stimulated Tconv cell proliferation Percent of maximum *** *** *** Tconv +TC-1 +TC-1 +TC-1 +TC-1 +Irr Ab +CT-011 +AMP-224
- 179. Immune Modulating Agents • Does it act as we want it to ? • What else would it do within the context of TIMN ?
- 180. Final Rankings of Agents with High Potential for Use in Treating Cancer NCI Immunotherapy Agent Workshop, 2007
- 181. Houot R and Levy R, Blood, 2011 Combinations of anti- OX40, CTLA4, GITR, and 4 (FR4)) with Intratumoral CpG Houot R and Levy R, Blood, 2011 Houot R and Levy R, Blood, 2011
- 182. Vaccine and Anti-Transforming Growth Factor-β Anti–TGF-β (1D11) synergistically enhanced the efficacy of a CTL- inducing peptide tumor vaccine consisting of HPV16 E749-57 peptide, emulsified in incomplete Freund's adjuvant together with Terabe M et al, Clin Can Res 2009
- 183. Synergistic antitumor effect of anti-GITR and anti-CTLA4 DTA-1 is an anti-GITR mAb, 4F10 is an anti-CTLA4 mAb Ko et al, JEM, 2005
- 184. What did we learn? • Lack of understanding of simple biology--- Simplistic approach, “single agent approach” • Difference in tumor behavior--- “wrong monitoring” • Clinical trial design--- chemotherapy based approach
- 186. Immune Combination Therapy • Science
- 187. Immune Combination Therapy • Science • Toxicity
- 188. Immune Combination Therapy • Science • Toxicity • Regulatory/ Clinical Trial Design
- 189. Immune Combination Therapy • Science • Toxicity • Regulatory/ Clinical Trial Design • Business/IP and Data Sharing
- 190. Immune Combination Therapy • Combination • Should understand the agent • Regulatory/ Clinical Trial Design • Business/IP and Data Sharing
- 191. What did we learn? • Lack of understanding of simple biology--- Simplistic approach, “single agent approach” • Difference in tumor behavior--- “wrong monitoring” • Clinical trial design--- chemotherapy based approach
- 192. Improved Overall Survival in a Phase II Randomized Controlled Trial of a Poxviral-Based PSA-Targeted Immunotherapy in Metastatic Castration-Resistant Prostate Cancer Kantoff, et al. JCO, 2010
- 193. Improved Overall Survival in a Phase II Randomized Controlled Trial of a Poxviral-Based PSA-Targeted Immunotherapy in Metastatic Castration-Resistant Prostate Cancer Kantoff, et al. JCO, 2010
- 194. What did we learn? • Lack of understanding of simple biology--- Simplistic approach, “single agent approach” • Difference in tumor behavior--- “wrong monitoring” • Clinical trial design--- chemotherapy based approach
- 195. Dose determination and Phase I need?
- 196. Clinical Trial Design 1. Do cancer vaccines have significant toxicity? 2. Does dose escalation effect toxicity? 3. Does dose escalation effect response and how is it measured?
- 197. Phase 1 for Cancer Therapy • 3+3 Cohort Expansion with Dose escalation • Patients with Late Stage Disease • Determine DLT and MTD • Cancer vaccines – Vaccines are inherently safe, if have toxicity seen in long term – Patients will have weak immune response b/c of advanced disease
- 198. Do phase 1 trials for cancer vaccines have significant toxicity? • Reviewed phase 1 trials for therapeutic cancer vaccines – 1990/2011 – 241 studies, 4,952 patients – Excluding all combination therapies
- 199. Do phase 1 trials for cancer vaccines have significant toxicity? Toxicity vs. patient number # of Trials Patients Grade 3/4 rxns Percentage Related (%) Autologous 88 1692 37 2.19% 1.36% DC 58 922 9 0.98% 0.33% Tumor 30 770 28 3.64% 2.60% Allogeneic Cells 17 407 22 5.41% 1.23% Synthetic 136 2853 108 3.79% 1.23% Peptide 68 1333 40 3.00% 0.83% DNA 17 311 1 0.32% 0.32% RNA 2 36 0 0% 0% Virus/Bacteria 36 761 50 6.57% 2.63% Anti-idiotypic 10 362 15 4.14% 0% Liposomal 3 45 2 4.44% 4.44% TOTAL 241 4952 167 3.37% 1.25%
- 200. Do phase 1 trials for cancer vaccines have significant toxicity? Toxicity vs Vaccine number # of Trials Patients Vaccines Grade 3/4 rxns Percentage Related (%) Autologous 73 1301 5722 20 0.35% 0.14% DC 51 796 3424 9 0.26% 0.09% Tumor 22 505 2298 11 0.48% 0.22% Allogenic Cells 16 347 1874 22 1.17% 0.26% Synthetic 117 2376 14239 78 0.55% 0.21% Peptide 61 1183 7637 37 0.48% 0.12% DNA 15 259 1388 1 0.07% 0.07% RNA 2 36 335 0 0% 0% Virus/Bacteria 30 594 2714 31 1.14% 0.66% Anti-idiotypic 7 266 1938 7 0.36% 0% Liposomal 2 38 227 2 0.88% 0.88% TOTAL 206 4024 21835 120 0.55% 0.20%
- 201. Does dose escalation effect toxicity? • Correlation between dose and toxicity • Dose escalation trials – 127 trials – Grade 3/4 Toxicities # of Trials Patients Grade 3/4 rxns Trials w/DLT Autologous 40 847 11 0 DC 27 466 0 0 Tumor 13 381 11 0 Allogenic Cells 5 130 20 1 Synthetic 83 2008 67 2 Peptide 36 852 10 0 DNA 12 208 1 0 Virus/Bacteria 26 592 47 2 Anti-idiotypic 8 339 7 0 Liposomal 1 17 2 0 TOTAL 127 2985 98 3
- 202. Does dose escalation effect response and how is it measured? • Trials that looked at dose immune response relationship – Phase 1 and non-phase 1 trials Dose Related Immune Response Vaccine trials # of Trials Statistically Total Our Analysis Study Analysis Significant Autologous 32 7 3 4 0 Allogenic 4 3 2 1 0 Synthetic 70 19 13 5 1 Phase II trials 10 7 2 4 1 TOTAL 116 36 20 14 2 31.03%
- 203. What did we learn? • Lack of understanding of simple biology--- Simplistic approach, “single agent approach” • Difference in tumor behavior--- “wrong monitoring” • Clinical trial design--- chemotherapy based approach
- 205. Acknowledgment Khleif’s Lab • Margaret Wojtowitz Collaborators: • Laurent Ozborn • Sarah Bernstein • Jay Berzofsky • Tammie Brent-Steel • • Osama Rahma Masaki Terabe • Cathy Maruffi • Mikayel Mkritchian • Frank Grollman • Phil Dennis • Namju Chong • Rajif Shanker • Michael Hamilton • Callie Raulfs • Steve Rucker • Barrie Gause • Stephanie Zdanov • Margaret Edison • John Schiller • Marie Rice • Geoffray Guittard • Bernie Fox • Mercedes Giliom • Zhison Chen • Sandy Chatfield • Theressa Whiteside • Omar Dakheel • Hong Yang • Albert Dileo • Anat Ohali • Magis Madapathil • Toni Toubaji • Raed Samara • Ramy Ibrahim • Maher Abdallah • Robert Behrens CureTech • Yana Najjar • Vincent Herrin • Mike Schinkler • Orna Nitzan • Ed Ashtar • Rinat Rotem AmplImmune • Sol Langerman
- 206. In contrast to CT-011, AMP-224 doesn’t overcome tumor-induced suppression of stimulated Tconv cell proliferation Percent of maximum *** *** *** No blocking of PD- 1/PD-L1 interaction. Due to low affinity of AMP-224 binding to Tconv +TC-1 +TC-1 +TC-1 +TC-1 PD-1 +Irr Ab +CT-011 +AMP-224
- 207. Differential effect of AMP-224 on proliferation of different T cell subsets Tconv Treg Percent of Proliferating cells * ** ** ** Tconv DMSO AMP AMP AMP IgG IgG IgG Treg DMSO AMP AMP AMP IgG IgG IgG 10ug 20ug 40ug 10ug 20ug 40ug 10ug 20ug 40ug 10ug 20ug 40ug CD8 Percent of Proliferating cells CD8 DMSO AMP AMP AMP IgG IgG IgG 10ug 20ug 40ug 10ug 20ug 40ug
- 208. Surface PD-1 expression on different T cell subsets at non-stimulated stage 300 Isotype ctr 250 PD-1 expression NS * MFI 200 150 100 50 0 CD8 Tconv Treg
- 209. Number of surface PD-1 molecules on different T cell subsets at different time-points after stimulation 1.2E+05 Tconv Number of surface PD-1 1.0E+05 Treg 8.0E+04 CD8 receptors 6.0E+04 4.0E+04 2.0E+04 0.0E+00 NS 24h 48h 72h 105 phosphoS6 48h 100 Percent change 95 AMP-224 90 effect zone 85 >80,000 80 75 PD-1 level NT Tconv Treg CD8 +AMP +AMP +AMP
- 210. Periphery Tumor-infiltration Naive Activated No direct Maximal Tconv effect of depletion or AMP-224 inhibition No direct Minimal CD8 effect of effect AMP-224 No direct Maximal Treg effect of depletion or AMP-224 inhibition AMP-224 effect zone >80,000 PD-1 level
- 211. Anti-PD1 binding affinity, a determinant in therapeutic strategy design due to the difference of PD-1 expression levels on different T cell subsets.
Editor's Notes
- #198: Vaccines based on DNA constructs, viral vectors, cytokines…etc …already proven safe
- #200: Related % = all g3/4 toxicities possibly/probably/defiantly related to vaccine except for local reactions, constitutional symptoms, and adjuvant related events
- #201: Related % = all g3/4 toxicities possibly/probably/defiantly related to vaccine except for local reactions, constitutional symptoms, and adjuvant related events
- #203: Autologous – Stated by us (3), stated by them (4), statistically significant (1)Allogeneic – stated by us (2), stated by them (1)Synthetic – stated by us (13), stated by them (5), statistically significant (1), unknown (1)Non phase 1 – stated by us (2), stated by them (4), statistically significant (1)