Download The blockade of immune checkpoints in cancer

Immunotherapy in Multiple
Myeloma: where do we go ?
Paul Moss
Birmingham, UK
Outline
• Introduction to immunotherapy
• Immunotherapy in the setting of Myeloma
• Cellular therapy
• Future application
History of Cancer Therapy
• Surgery
– 1000s of years
• Radiotherapy
– 100+ years
• Chemotherapy
– 70+ years
• Immunotherapy
William Coley (1862-1932)
• Sarcoma surgeon
• Noticed that a patient with
severe skin infection
developed a long term
remission from disease
• Developed live and killed
extracts of Streptococcus and
Serratia and treated 1000+
cancer patients
Treatment was controversial at
the time
The idea
Tumour
cell
T cell or NK cell
recognises and
kills tumour cell
Evidence for importance of immune system in
control of cancer
• Cancer creates an Immunosuppressive microenvironment
• Tumour cells often lose expression of HLA molecules that cells use to
‘present’ antigen to the immune system
– They are ‘escaping’ immune recognition
– 50% of Diffuse Large B cell Lymphomas have lost HLA
• Tumour infiltrating lymphocytes (TIL) are associated with regression of
tumours
• Il-2 can sometimes have anti-tumour effects
Is there evidence that patients make an
immune response to myeloma ?
• Spontaneous clinical remissions are very rare
• No strong evidence for HLA class I downregulation
• Il-2 is not effective
– So not encouraging ?
Patients with MGUS make T cell immune
responses to tumour that are lost in MM
Dhodapkar et al
2004
Perhaps immunotherapy underlies current
management of myeloma ?
•
•
•
•
•
ImiDs
Monoclonal antibodies
Chemotherapy ?
Autograft
Allograft
Autograft
• Clinical outcomes are better in patients who exhibit increased
lymphocyte response in the early post-transplant period
• Rarely curative
– Does this indicate complete lack of MM-specific immune
response or
– is this response suppressed in MM patients ?
• (this question can now be addressed through checkpoint
blockade)
Allograft
• Potentially curative but remains associated with considerable
morbidity and mortality
• Remissions are often associated with considerable graft
versus host disease
• This may suggest that the specificity of the immune response
is alloreactive
Comparison of alloreactive and tumourspecific immune response
P
D
D
1. Alloreactive
P
T cell response
D
2. Tumour-specific
P
D
T cell response
Tumour cell
Minor histocompatibility antigens
HLA Class I
D
R
Syngeneic (identical) twins are generally not good
donors for allografts
• Genetically the same
• There cannot be a significant minor
histocompatibility antigen-specific responses
• Presumably this stops the graft versus leukaemia
response ….?
Syngeneic transplantation in multiple myeloma
• 25 cases
– 17 entered complete remission
• 4 cases of GvHD
• Comparable results to HLA-identical sibling
Gharton et al, 1999
Does this give us hope ?
• Perhaps patients with paraproteinaemia DO make an
immune response to the tumour
• This helps to keep the disease in check
• However, when there is loss of immune control, any
form of current conventional (autologous) therapy
cannot overcome this
• Perhaps the immune response of another person can
still gain control (an allograft)
How can we improve immunotherapy
in MM ?
Broad approaches to immunotherapy
• Cell therapy
• Checkpoint blockade
• Vaccination
• Others
– Reversal of immune suppressive micro-environment
– Antibodies to retarget T cells to tumours (BiTe)
Cell therapy in Myeloma
• Expanding autologous T cells in the laboratory and
re-infusing them
• Redirecting these T cells to see an ‘antigen’ on the
myeloma cells
– Neoantigen
– Cancer Testis Antigen
• Chimeric antigen receptor therapy
Infusion of bone marrow derived T cells
• Isolate 200ml bone marrow
• Use mitogenic beads to expand marrow infiltrating
lymphocytes (MIL)
• Achieved 109 T cells within 1 week
• Infuse these at day 3 after melphalan-conditioned CD34+
selected autograft
• Noonan et al. Sci Tsl Med. 2015
Conclusions
• Marrow infiltrating T cells can be expanded in
virtually all patients
• No significant side effects
• Some encouraging signs of efficacy
It would be much better if we knew what our
target was
”Ehrlich- On Immunity with Special Reference to Cell Life”
Royal Society 1900
Tumour
cell
T cell or NK cell
Tumour
cell
T cell or NK cell
What are the antigens that are recognised in a
myeloma-specific immune response ?
• Neo-epitopes
– Peptides that are derived from mutations in the cancer
clone
• Cancer Testis Antigens
– Proteins that are expressed only in fetal cells and then
again in tumour cells
• Idiotype
– The unique immunoglobulin on the tumour cell
• Proteins in plasma cells
– that are expressed relatively specifically on plasma cells
Neo-antigens
• The concept..
– tumours acquire mutations
– These code for the synthesis of proteins that contain
mutated amino acids
– these are presented by HLA molecules
• The immune can recognise these can kill the
cancer cell
This is currently believed to be the major
mechasism by which checkpoint blockade works
Indeed, tumours with lots of mutations appear to
respond well to immunotherapy
Kandoth et al. Nature 2013
Neo-antigens in myeloma
• Poorly characterised
• These may emerge from the current studies of
checkpoint blockade to ‘boost’ endogenous
immune responses
Cancer Testis Antigens
• These are proteins that are expressed in germ
cells but not in adult cells
• They are re-expressed in tumours
Why ?
A bit of evolution..
3,500 MYA
700 MYA
The germ cell and the soma
Germ cell
The body (Soma)
Germ cell
Cancer occurs when the soma loses control
of growth
Germ cell
The cancer cells express proteins expressed
in the germ cells
This allows the immune system to recognise
that ‘something is wrong’
MAGE-1 immunohistochemistry stain of
human testis – Old LJ (2003)
Cancer testis antigens are expressed in germ
cells and tumours
testis
trophoblast
ovary
Bladder
cancer
Cancer testis antigens are important in Melanoma
(A)
(B)
(C)
Evolution of skin metastases on the leg of patient EB81
during treatment.
(A) Before vaccination
(B) After four vaccinations with ALVAC (after 3 months)
(C) After 10 months
van Baren N et al 2005
T cells against CTAg are indeed present in patients with
multiple myeloma
Oliver Goodyear et al. Blood 2005;106:4217-4224
They kill tumour cells
However, these CD8+ immune responses may
not be protective
T cell therapy against cancer testis antigens in
patients with myeloma
• T cell therapy was used after autograft
• Autologous T cells were transduced with a high affinity T cell
receptor against an NY-ESO peptide presented by HLA-A2
• Average 2 billion T cells were infused at day 2
Tumour
cell
• Rapoport, Nat Med, 2015
T cell or NK cell
20 patients treated
PFS 19 months
16 responses
- CR/nCR in 14
- VGPR in 2
Antigen escape seen in 2
1% T cells present at 180
days
Persistence of T cells was
negatively correlated with
NY-ESO in marrow
Targeting cancer testis antigens in myeloma
• Rather weak immune responses so difficult to
study
• Gene transfer technology may allow more
effective targeting
What peptides are actually expression on the
surface of myeloma cells ?
Tumour
cell
• It is now possible to:
– isolate tumour cells
– Purify HLA molecules
– Pull out the peptides and sequence them
Two arms to embrace the oncopeptidome.
Jacques Neefjes Blood 2015;126:1154-1156
HLA expression is high on myeloma cells
Simon Walz et al. Blood 2015;126:1203-1213
©2015 by American Society of Hematology
A wide range of myeloma-associated peptides were found
Simon Walz et al. Blood 2015;126:1203-1213
T cell responses against these peptides were found in the
patients
Simon Walz et al. Blood 2015;126:1203-1213
Conclusions
• There was no evidence of mutated peptides on the surface of
myeloma cells
• Cancer testis antigen peptides were present
• Majority of MM-associated peptide were normal somatic cell
proteins
• The immune response was responding to these
– More hope for checkpoint blockade..
Chimeric antigen receptors
Tumour has lost HLA or
proteins that had been
seen by immune system
But, still
expresses
e.g. CD19
Chimeric antigen receptors
Tumour has lost HLA or
proteins that had been
seen by immune system
But, still
expresses
CD19
“CD19”
killing
Acute leukaemia expresses CD19
“CAR” T cells
Emily Whitehead - “The girl that lived”
Third generation CARs have transformed clinical
outcomes
Rotolo et al. 2016
Clinical success of CAR therapy
• Excellent results through targeting of CD19
–
–
–
–
treatment of relapsed acute lymphoblastic leukaemia
89% CR, within 3 weeks, not related to tumour burden
Excellent in primary refractory disease – all 9 CRs
Somewhat less effective in lymphoma
Challenges of CAR therapy
• Personalised cell therapy
– Expensive and challenging
• Relapse can occur due to loss of target molecule
– e.g. CD19-negative ALL
• May need lymphodepletion
– e.g. fludarabine/cyclophosphamide conditioning
• Toxicity
– Neutotoxicity
– Off-target recognition
Targets for CAR therapy in myeloma
• BCMA
• CD19
• CD138
– N=5, low dose, 3 SD ? escape
• CD44v6
• CD38
• CD56
BCMA
• B cell maturation antigen
– TNFRSF17
• Provides survival signal to plasma cell
• Present on plasma cells and some B cells
• Also plasmacytoid dendritic cells
• Antibodies to BCMA have been seen in patients achieving CR
after allo transplant
CAR against BCMA
in patients with myeloma
• 12 patients treated
• Conditioning
300mg/m2 cyclophosphamide for 3 days (900mg)
30mg/m2 of fludarabine for 3 days
0.3 x 106/Kg escalating to 1, 3 and 9
-gave T cells 3 days after conditioning
Around 67% if T cells expressed CAR at infusion
CAR-BCMA T cells specifically recognized BCMA in vitro and exhibited antimyeloma activity
in humans.
Syed Abbas Ali et al. Blood 2016;128:1688-1700
©2016 by American Society of Hematology
Patient 10 entered a stringent complete remission.
+4 weeks
+8 weeks
Syed Abbas Ali et al. Blood 2016;128:1688-1700
©2016 by American Society of Hematology
MM was eliminated from the bone marrow of patient 11 after CAR-BCMA infusion.
Syed Abbas Ali et al. Blood 2016;128:1688-1700
©2016 by American Society of Hematology
Patients with the most impressive antimyeloma responses had the highest levels of blood
CAR-BCMA+ cells.
Syed Abbas Ali et al. Blood 2016;128:1688-1700
©2016 by American Society of Hematology
Review of BCMA-specific CAR
• Responses were not durable
– 2 x VGPR
– 1 x CR which lasted for 17 weeks
– Low level expression of BCMA
– Soluble BCMA
• Significant toxicity
• Short term (3 month) persistence of CAR T cells
Enormous potential for immunotherapy
Lots more targets in the
immuno-suppressive
microenvironment
Summary
• Weak evidence of cancer-specific immunity in MM
• Peptide targets are being identified
• These can now be targeted with cell therapy or
vaccination
• Combination with immuno-modulatory drugs is likely
to be very powerful
Future role of cell therapy in
management of myeloma
• We are moving to a ‘chemotherapy-free’ world in cancer
treatment
– when not if
• Combinations of:
– Checkpoint blockade
– Vaccines or CAR
– Immune modulators
Haabeth, 2014
Functional analysis of short-term T-cell cultures.
Oliver Goodyear et al. Blood 2005;106:4217-4224
©2005 by American Society of Hematology
Serial analysis of CGAg-specific CD8+ T-cell responses in 11 patients with multiple myeloma.
Oliver Goodyear et al. Blood 2005;106:4217-4224
©2005 by American Society of Hematology
Event-free survival in 30 children and adults treated with CTL019 therapy. Of this group, 5 patients who entered a CR
went on to further therapy, 3 of whom received an allogeneic bone marrow transplant. The fourth had refractory Tcell ALL aberrantly expressing CD19, entered remission after CTL019, and subsequently underwent donor
lymphocyte infusion. She remains in remission >1 year later. The fifth patient developed myelodysplastic syndrome
and received therapy for this condition (this was scored as an event, but she did receive further therapy in ALL
remission and was counted among the 5). The rest have not received further therapy to consolidate their remissions.
EFS, event-free survival. Figure adapted from Maude et al26 with permission
Nonchemotherapeutic agents in the treatment of indolent lymphoma. mAbs can be directed
against B-cell surface antigens such as CD20, which is expressed by tumor cells and
mediates complement, antibody-dependent cell-mediated cytotoxicity or direct cell deat...
Emmanuel Bachy, and Gilles Salles Clin Cancer Res
2014;20:5226-5239
©2014 by American Association for Cancer Research
PD-1 and PD-L expression
• PD-1 expressed during thymic development and induced in a variety of
haemopoietic cells in the periphery through antigen receptor signaling
and cytokines
• PD-L1 and PD-L2 are ligands of PD-1.
• PD-L2 expression limited to DCs, macrophages, peritoneal B cells, memory
B cells
• PD-L1 is broadly distributed on both haemopoietic and non-haemopoietic
cells
• Constitutively expressed on lymphoid and myeloid cells and further
upregulated upon activation.
• PD-L1 can be expressed on a wide range of non-haemopoietic cells in
epithelial, vascular endothelial, pancreatic, and immune-privileged sites,
such as the eye and placenta
• Expression of PD-L1 and PD-L2 can be regulated by inflammatory milieu.
Cytokines are potent stimulators
Mechanism of action of Elotuzumab
Weisel K et al. 2015
Interactions between multiple myeloma (MM) cells and the bone marrow (BM) niche. Adhesion of MM cells to BM stromal cells is
mediated by cell-adhesion molecules including vascular cell adhesion molecule-1 (VCAM-1) and integrin α-4 (VLA-4). This adhesion
triggers secretion of cytokines, such as VEGF and IL-6, from both MM cells and BM stromal cells. Both of these cytokines stimulate the
growth of MM cells and development of the neo-vasculature. Endothelial cells, in turn, secrete more VEGF, IL-6, and IGF-1, further
enhancing growth and survival of MM cells. Furthermore, receptor activator of NFκB ligand (RANKL) is produced by BM stromal cells and
stimulates osteoclastogenesis. In contrast, osteoblast differentiation is inhibited by Dickkopf-1 (DKK-1), which is produced by MM cells.
MM cells also secrete metalloproteases, such as MMP-2, resulting in degradation of the BM niche. While inhibition of
osteoblastogenesis promotes osteolysis, degradation of the BM environment further enhances homing of the MM cells
Al-Hudaily et al, 2016
Chimeric Antigen Receptor (CAR) therapy for multiple myeloma
British Journal of Haematology
Volume 172, Issue 5, pages 685-698, 20 JAN 2016 DOI: 10.1111/bjh.13889
http://onlinelibrary.wiley.com/doi/10.1111/bjh.13889/full#bjh13889-fig-0002
Identification of T cell responses against cancer
• Boon et al analysed anti-tumoral T cell responses in patients
with a melanoma that was undergoing regression
• Identified T cell clones that could kill tumour
• Frequencies of antitumor T cells ranging from 3 × 10− 5 to
10−3 of CD8 T cells were observed in a group of six patients.
• What did the T cells recognise ?
Functional analysis of short-term T-cell cultures.
Oliver Goodyear et al. Blood 2005;106:4217-4224
©2005 by American Society of Hematology
Comparative HLA ligandome profiling and identification of myeloma-associated antigens.
Simon Walz et al. Blood 2015;126:1203-1213
©2015 by American Society of Hematology
Identification of synergistic HLA class II–restricted myeloma-associated antigens.
Simon Walz et al. Blood 2015;126:1203-1213
©2015 by American Society of Hematology
Perhaps it has always been about
immunotherapy ?
• When we cure patients with acute leukaemia
with the use of chemotherapy…
– Can we really kill off 100,000,000,000 cells with 4
courses of chemotherapy ?
• Perhaps chemotherapy just resets the
immune system..
59 yo female with lung adenocarcinoma.
LUL lobectomy November 2012 ; then adjuvant chemotherapy till April 2013, then
pleural effusion September 2013
December 2013
February 2014
Neo-antigens in myeloma
• Poorly characterised
• These may emerge from the current studies of
checkpoint blockade to ‘boost’ endogenous
immune responses
CAR-BCMA T cells became more differentiated after infusion.
Syed Abbas Ali et al. Blood 2016;128:1688-1700
©2016 by American Society of Hematology