Desarrollo de terapias celulares T dirigidas frente a

Desarrollo de terapias celulares T dirigidas frente a una mutación tumoral Enrique González Billalabeitia S. Hematología y Oncología Médica Hospital G. U. Morales Meseguer 1

Regulation of the Immune response Padmana Sharma. AACR 2019 2

T-Cell is the soldier Padmana Sharma. AACR 2019 3

Strategies to improve Immune Response Padmana Sharma. AACR 2019 4

T-Cell therapies for Cancer Therapy Donor Lymphocyte Infusion (DLI) Tumor Infiltrating Lymphocytes (TILs + IL 2) T-Cell Receptor (TCR) Modifications HLA restricted Chimeric Antigen Receptor (CAR) T-Cell Not HLA restricted 5

Cancer Antigens • Mutations -> IL 2, CTLA 4, TILs – Somatic, intracellular and Unique (Most) – Driver, shared mutations • KRAS, TP 53 • Cell surface proteins (non mutated, not esential for patient survival, recognized by antibodies or ligands) -> Abs, Bispecifics, CAR-Ts – CD-19 (Ab, CAR-T. . ), CD 22, G 2… 6

Adoptive Cell Therapy Using Tumor Infiltrating-Lymphocytes (TIL) Steven A. Rosenberg @ NCI AACR 72019

The Process of Antigen Presenting For a mutation to be a cancer antigen it needs to: 1. Be processed intracellularly into a 9 -11 amino acid peptide 2. Needs to feet in the groove and be presented by the MHC molecules CD 8/4 8 Steven A. Rosenberg. AACR 2019

Immunogenic mutations in Tumors and Perypheral Blood (CD 8+) Melanoma Solid tumors Gastrointestinal Tumors P. Blood CD 8+ selection All neoantigen were unique except for 2 KRAS mut. 9 Steven A. Rosenberg. AACR 2019

Responses are also observed in a variety of solid tumors Heavily pre-treated Breast Cancer Zacharachis. Nat Med 2018 Pre-treated 14 m 10

Library Preparations for “hot spot” antigenic Driver Mutations KRAS neoantigenes Top TP 53 neoantigenes 11

Chimeric Antigen Receptor (CAR) T-Cell therapy ASCO 2018 Advance of the Year 12

Engineered T-Cells: The promise Fresnak A, June C, Levine J. Nat Rev Cancer 2016 13

Fresnak A, June C, Levine J. Nat Rev Cancer 2016 14

Enginered CAR T-Cells 15 (2018) June et al. , Science 359, 1361– 1365

CAR T-cells are “Autologous live therapies” Mikkilineni N & Kochenderfer JN. Blood 2017 16

Rational for anti-CD 19 therapies Blanc V. Clin Cancer Res 2011 17

First reports of Clinical Activity were in a FL and CLL Follicular lymphoma CLL Kochenderfer JN …. Rosemberg SA. Blood 2010 Surgery Branch. NCI. Porter DL. . . June JC. N Engl J Med 2011 University of Pensylvania 18

Relapsed or refractory ALL 19 Kenderian SJ. AACR 2019

Efficacy of CD 19 CAR-Ts in B-ALL Pediatric ALL (& young adults) 4 -1 BB Maude SL. N Engl J Med 2018 Adults ALL CD 28 Park JH. N Engl J Med 2018 20

Refractory Diffuse Large B Cell Lymphomas 21

Outstanding results in Relapsed/refractory Diffuse Large B Cell Lymphomas Axicabatagene ciloleucel (CD 28) Axi-Cel. RV-CART 19 YESCARTA® ZUMA-1 Locke. Lancet Oncol 2018 Tisagenlecleucel (4 -1 BB) Tisa-Cel LV-CART 19 KYMRIAH® JULIET Schuster. NEJM 2019 22

Limitations of CAR T-Cell therapies On Target (Ej. CD 19) Off-target (CRS, CRES, HLH) Shah NN and Fry TJ. Nat Rev Clin Oncol 2017 23

Cytokine Release Syndrome (CRS) Fever 24 (2018) June et al. , Science 359, 1361– 1365

Cytokine Release Syndrome (CRS) Tocilizumab Supportive therapy (ICU) -Hydratation -Vasoactive drugs -Anti-IL 6 -Esteroid (¿? ) 25 (2018) June et al. , Science 359, 1361– 1365

Macrophage Activating Syndrome (HLH/MAS) Ferritin High Haemophagocytosis 26 June et al. , Science 359, 1361– 1365 (2018)

CAR related Encephalopatic Syndrome (CRES) Haemophagocitic syndrome 27 (2018) June et al. , Science 359, 1361– 1365

CAR-T Toxicities are transient Stimated time course CRS and CRES are correlated Santomasso et al. Cancer Discovery 2018 Kenderian. AACR 2019 28

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Kenderian. AACR 2019 30

31 Kenderian. AACR 2019

Kenderian. AACR 2019 32

33 Kenderian. AACR 2019

Acute Lymphoblastic Leucemia (ALL) Diffuse Large B Cell Lymphoma (DLBCL) Most Frequent CD 19 negative relapse (Most) CD 19 positive relapse (Most) Others Mechanims of Resistance CD 19 positive (Poor CART expansion) Selection of CD 19 - clones Due to Loss or poor expansion of CAR-T cells (T-Cell problem) CD 19 negative (Poor CART expansion or loss) 34

Mechanism for CD 19 negative relapses Mut/Alt Splicing Grupp. N Engl J Med 2013 Shah N. Frontiers Oncol 2019 35 Jacoby. Nat Comm 2016

CAR-T Factors In vivo expansion is very important Functionality is associated with response 36

Intrinsic fitness of the T cell is critical Fraietta JA. Nature 2018 37

Learning from outliers. A late responder with disruption of TET with enhanced efficacy Fraietta JA. Nature 2018 38

Most Frequent Mechanims of Resistance Acute Lymphoblastic Leucemia (ALL) Diffuse Large B Cell Lymphoma (DLBCL) CD 19 negative relapse (Most) CD 19 positive relapse (Most) Selection of CD 19 - clones Multitarget CAR-T Due to Loss or poor expansion of CAR-T cells (T-Cell problem) Improved CAR-T selection, stimulation and exhaustion prevention Sinergy with PD 1/PDL 1 inh 39

Multitargeted CAR-T Cells Shah N. Frontiers Oncol 2019 40

Choosing another target (CD 22) can rescue CD 19 negative relapses Bi-specific CARTs Phase I trial • 21 patients treated (17 after CD 19 CART) • CR 73% (including 5 CD 19 -) Fry TJ Nat Med 2018 41

CAR-T Clinical trials including with multiple targets Shah N. Frontiers Oncol 2019 42

43 Fresnak A, June C, Levine J. Nat Rev Cancer 2016

44 KT. Roybal. Cell 2016

Multiantigen Tumor discrimination 45

Cho et al. , 2018, Cell 173, 46 1426– 1438

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Solid tumor targets for CAR-T cells 50 Li et al. Journal of Hematology & Oncology (2018) 11: 22

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Might have advantages! 52

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Systemic Anti-GD 2 CAR-T cells in H 3 K 27 M+ difuse midline glioma showed promising activity in orthotopic models 55 Mount CW. Nat Med. 2018 May ; 24(5): 572– 579.

Clinical trials recruiting in Paediatric Tumors (Paediatric Dream Team) Park J. AACR 562019

MSLN as a target for therapy -Cell-surface antigen -Binds CD 125/MUC 16 -Promotes metastasis and associates aggresiveness Morello A, et al. Cancer Discovery 2016 57 Adusumilli. AACR 2019

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61 J. Hartman et al. EMBO Molecular Medicine 2017

20 19 >300 4 152 30 1 4 179 8 5 62 Updated from J. Hartman et al. EMBO 2017

63 Schultz and Mackall, Sci. Transl. Med. 11, eaaw 2127 (2019)

Centros acreditados SNS para CAR-T en LNHBDCG y LLA Adultos: • H. Clínic • H. Vall d’Hebron • H. de la Santa Creu i Sant Pau. • ICO (H. Duran i Reynals y H. Germans Trias i Pujol) (Reserva) Adultos • Complejo Asistencial de Salamanca Adultos H. U. Gregorio Marañón (Madrid) Pediatría H. del Niño Jesús (Madrid) H. La Paz (Madrid)(Reserva) Niños: • H. Sant Joan de Deu • H. Vall d’Hebron Adultos • H. U. i Politècnic La Fe • H. Clínico U. de Valencia Adultos • H. U. Virgen del Rocío, (Sevilla) Adultos • H. U. de Gran Canaria Doctor Negrín 64

Summary • Adoptive therapy is very promising • CAR-T cell therapies are already approved in ALL and DLBCL • Several issues need to be fixed in solid tumors: – Immuno suppresive microenviroment – Antigeneicity – On-target toxicities • New engineered CAR-Ts might be helpful 65