1. No category

CCIT
DENMARK
Kræft Immunologi
‐ Kunsten at hæmme immunhæmmere
Mads Hald Andersen, professor
Sundhedsstyrelsens specialespecifikke kursus: Teoretisk Immunologi, 13.‐16. april 2015 OUH, Odense
Forskning ved CCIT, Herlev Hospital, Dk
Management: Inge Marie Svane, Per thor Straten and Mads Hald Andersen
Basal immunforskning
Immunmålinger
Klinisk immunforskning
2
Dagens program
Baggrund
Introduktion til immunforsvaret og Immunforsvarets genkendelse af kræft
Immunhæmning – betydning i klinikken Fra laboratoriet til klinikken
Konklusioner
Kræft immunologiens historie
Immunterapi imod kræft – store gennembrud
Approvals of Dendreons Prostate Cancer Vaccine (provenge),
Ipilimumab antibody for melanoma
September 2014: anti‐PD‐1 mAb, Pembrolizumab and December 2014: Nivolumab FDA approvals
Cytokines
Antibodies
Immunterapi imod kræft
Adoptive T cell transfer
Vaccines
6
Innate and adaptive immune responses
* Innate immune responses :
Response
: Fast
Cell types
: Dendritiske celler (DCs), Mø,
Recognizes antigen by germline encoded receptors
* Adaptive immune responses :
Response
: Slow
Cell types
: B- and T cells
Recognizes antigen by unique receptors generated by
somatic gene rearrangent
Aktivering af T‐celler
Bacterie,
Virus, kræftcelle protein, ect
T‐celle
Den aktiverede T‐celle deler sig……!
Cirkulerer via blodet til infektions‐
stedet – eller kræftknuden
illustreret videnskab nr. 12/2009
T‐celle aktivers
Pardoll D. PNAS 2002;99:15840-15842
©2002 by National Academy of Sciences
”Den gode cirkel”
Behandlende vaccine
cancer celler
Dendritiske celler
optager protein
fra cancer celler
Infiltration og
drab af cancer
celler
Lymfe knude
Aktivering af
T-celler
cell
What is recognized by the immune system...
Cancer cells: genetic and epigenetic changes
X
Mutation
Deletion
Methylation
1
5’
2
1
5’
3
2
4
3
6
6
7
3’
7
CH3 CH3 CH3
1
5’
2
3
4
Gene A
Translocation5’
5
1
2
5
6
7
Gene B
3
3
4
5
3’
3’
T‐cells recognizing cancer cells
Cancer antigen
tumor‐specific T cells
Normal celle
Kræftcelle
Normal celle
T-celle
Normal celle
T-celle
Kræftcelle
Kræftcelle
Død kræftcelle
”Live and let Die”
”Live and let Die”
Tumor antigens that are recognized by T-cells
Group I. Viral antigens, e.g. HPV
Group II. Broadly expressed mutated antigens, e.g. ras, braf
Group III. Patient specific mutated antigens
Group IV. differentiation antigens, e.g. MART-1, gp100, PAP
Group V. Cancer-testis antigens, e.g. MAGE
Group VI. Overexpressed (including universal) tumor antigens,
e.g. telomerase, survivin
Vævstype‐molekyler (HLA) præsenterer cellens indhold på overfladen
Peptide/HLA restriction
…..LTLAKHTISSDYVIPIGTYGQMK……EKCDICTDEYMGGQHPTN….
TLEGFASPLTGIADASQSSMHNALHIYMNGTMSQVQGSAND………
…VLTALLAGLVSLLCRHKRK…
HLA‐A1
HLA‐A2
HLA‐A3
50 % of Caucasian population
Spontan immunreaktion imod kræftproteiner (antigener) i en
patient med modermærkekræft
kræft patient
kontrol
gp100
Survivin
TRP-2
Mage-3
Rask kontrol
….so what’s the problem?
© Gary Larsson
….so what’s the problem?
”Immune escape”
Loss of Hla/antigen
No danger ‐> no activation of T‐cells
Immune suppresive molecules – and cells
‐ Direct immune suppressive actions ‐ By induction or attraction of regulatory cell types
Suppressive mechanisms that have been identified in human melanoma metastases and
validated mechanistically in preclinical studies.
Gajewski T F Clin Cancer Res 2007;13:5256-5261
©2007 by American Association for Cancer Research
Cancer Cell
Tumor‐specific
T‐cell
Cancer Cell
Tumor‐
specific
T‐cell
Antibodies
Ipilimumab = anti‐CTLA‐4
Ipilimumab extend survival in metastatic melanoma patients in phase 3.
Translational research at CCIT
Mads Hjortsø
Shamaila Munir Ahmad
Merete Jonassen
Stine Kiær Larsen
With support from:
The Novo Nordisk Foundation, The Danish Cancer Society, Danish Medical Research Council, The John and Birthe 33
Meyer Foundation, and Herlev Hospital.
Suppressive mechanisms that have been identified in human melanoma metastases and validated mechanistically in preclinical studies.
IDO
Gajewski T F Clin Cancer Res 2007;13:5256‐5261
©2007 by American Association for Cancer Research
Can IDO be used as at vaccine target?
35
IDE: Kan immunforsvarets effektorceller genkende immunhæmmende celler (som udtrykker unormale mængder af visse proteiner, f.eks. IDO
IDO+ tumor
IDO+ APC
IDO reagerende T-celler?
T
36
IDO – a T‐cell target?
IDO protein
IDO-specific T cells
37
Analyse af immunreaktioner
Immun-reaktion:
Kontrol
kræftprotein
Ingen Immun-reaktion
Patient prøve
Isolering af
blodceller
Forsøg
Kontrol
kræftprotein
Elispot
T celler som reagerer imod det immunhæmmende protein IDO findes i kræftpatienter
Uden IDO
Med IDO IDO specific cells per 4 x 10^5 cells
Eksempel
400
300
200
100
0
HD
BC
MM
RCC
-100
Blod fra kræftpatiener
T-celler dyrkes i laboratoriet og undersøges
T celler
T
Drab af både kræftceller og
immunhæmmende celler
T
Kræftceller immunhæmmende celler
Ca
Cancer cells
nc
( ID
O
Sh
N
RN
hR
g)
b)
A)
A)
ne
A
lls
id
e
T2
ce
pt
m
O
lS
(ID
tro
lls
on
lls
(c
ce
lls
er
ce
ce
A
er
pe
nc
HL
Ca
ID
O
(+
+
lls
er
ce
nc
er
Ca
nc
er
Ca
nc
Ca
T2
Lysis (%)
IDO‐specifike T‐celler dræber IDO+ cancer celler
80
60
40
20
0
41
IDO‐specifike T‐celler dræber IDO+ immunceller
60,0
60,0
50,0
50,0
40,0
40,0
Lysis (%)
Lysis (%)
Δ In vitro immatured autologous DC
▀ In vitro matured autologous DC
30,0
Δ In vitro immatured allogeneic DC
▀ In vitro matured allogeneic DC
30,0
20,0
20,0
10,0
10,0
0,0
0,0
15:1
5:1
1.7:1
15:1
0.6:1
5:1
1.7:1
E:T ratio
E:T ratio
In vitro immatured DC
In vitro matured DC
MFI
428
1,438
IDO
0.6:1
HIV‐ Tetramer
Tetramer‐PE
0.21%
0.10%
CMV‐Tetramer
19.29%
88.09%
Tetramer‐APC
IDO‐specifikke T‐celler øger immunforsvarets øvrige reaktioner
Leukemia 2013
IDO‐expression in antigen presenting cells
Modified from 45
Wing et al. Nature Immunology, 2010:11; 7–13
Summary
• IDO‐specifikke T‐celler findes spontant i kræftpatienter
• IDO‐specifikke T‐celler kan dræbe kræftceller og immunhæmmende celler
• Ido‐specifikke T‐celler kan øge immunforsvarets øvrige reaktioner imod kræft
46
Sørensen et al. Blood, 2011, Vaccination kan blive måden at ramme immunhæmning
+
Vaccination
IDO vaccine
T
T
T
Kræftceller T
T
T
Dræber T‐celler
Immunhæmmende celler
Target identification
Pre‐clinical evaluation
From lab to bench
Tox test
Patents?
Clinical testing
48
Meget papir‐arbejde……
Udarbejdelse af protokol m.m.m.
GCP‐enhed
Videnskabsetisk Komité
Datatilsynet
Lægemiddelstyrelsen
From bench to clinic
HLA‐A2‐restricted IDO peptide/montanide
vaccination in 14 NSCLC patients
IDO5 No peptide
Trine Zeeberg Iversen
From June 2012:
Phase I/II clinical trials with IDO and survivin peptide vaccination with montanide and GM‐CSF in melanoma patients in combination with temozolomide.
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IDO ‐ Nyt antigen for vaccine terapi
– Fase I studie til metastatisk, stadie III‐IV lunge cancer patienter
– “First in man” study opstartet i Juni 2010
– www.clinicaltrial.gov. NCT01219348
– Studiet lukket, 15 HLA‐A2 NSCLC patienter inkluderet
– Primært endepunkt: Toxicitet
– Sekundært endepunkt: Klinisk effekt
– Tertiært endepunkt: Induktion af immunrespons
– Vaccinen er opfundet og patenteret af CCIT – IDO aminosyre sekvens (HLA‐A2: ALLEIASCL)
– Første peptidvacccine forsøg I Danmark
Dias 51
Vaccine behandling
Imiquimod (TLR 7)
IDO peptide mix med Vaccine injektion
på vaccine site
Montanide
subcutant
Innate immunsystem
Adaptive immunsystem
Dias 52
%
C
h
a
n
g
e
sinta
r
g
e
tle
s
io
n
s
Kliniske resultater
Re sponse to IDO v accine tre atme nt
(N=15)
40
30
20
Pt#03
--------------------------------------------- PD
10
0
Blue: New lesion
Red: >20% PD
Orange: On study
- 10
- 20
- 30 ---------------------------------------------- PR
- 40
Pt#18
0
2.5 5.5 8.5
12
15
18
21
24
Months
Target
Lesion
(Pt#18)
Baseline
March
2012
1st Eval
July
2012
2nd Eval
Oct
2012
3rd Eval
Dec
2012
4th Eval
March
2013
5th Eval
June
2013
A (liver)
2.9
2.8
2.5
2.6
2.2
2.2
B (liver)
2.7
2.5
2.1
1.6
1.8
1.8
C (liver)
1.8
1.8
1.8
1.8
1.1
1.1
Sum
(cm)
7.4
7.3
6.4
6.0
5.1
5.1
Dias 53
Overlevelsesanalyser
Overall survival (N=25)
N=15 HLA-A2 pos. (+vacc.)
Median OS=25.9 months
80
N=10 HLA-A2 neg. (-vacc.)
Median OS=7.7 months
Percent survival
100
60
40
20
0
0
P=0.03
500
1000
Days
Dias 54
Immunanalyser ‐ IDO specifikke CD8+ T celler
Dias 55
Flow cytometry analyser – immunceller
Dias 56
CONCLUSIONS
• No severe toxicity induced
• IDO vaccine safe and well tolerated
• Partial response in one patient with liver metastases
• Sustained disease stabilization in around half of the patients
•Significant better OS in HLA‐A2 positive (vaccine treated) vs. HLA‐A2
negative (non‐treated) patienter
• Demonstration of IDO specific T cells in most of the patients, ex vivo killing
of cancer cells
•Pre‐response towards IDO correlated with clinical benefit
• Phase II IDO vaccine trial www.clinicaltrials.gov (NCT 01543464)
Iversen et al. , Clinical Cancer Research, In press
IDO – et eksempel på ”Translational Research”
‐IDO identificeret som antigen for cytotoksiske T‐celler
‐IDO‐specifikke T‐celler kan genkende og slå kræftceller og immunhæmmende celler ihjel
‐ IDO vaccination virker som en lovende ny vaccine‐strategi imod kræft
‐Kan med fordel benyttes i kombination med anden terapi
58
Selv‐reactive, regulatory T‐cell antigens
* Heme Oxygenase‐1 specific CD8 T cells are present in high frequencies in cancer patients – seem to have a regulatory function
Andersen et al. J. Clin. Invest. 119, 2009 • IDO‐2 specific cytotoxic T‐cells are present in healthy individuals as well as cancer patients. Such T‐cells are able to kill IDO2 expressing breast cancer as well as colon cancer cells. Sorensen et al. Cancer Resarch 71(6), 2011
•
FoxP3 can be recognized by cytotoxic T‐cells and specific CD8 T‐cells enhaunces tumor immunity Nair et al. Cancer Resarch 67(1), 2007
Larsen et. al, Leukemia 2013
• PD‐L1 specific cytotoxic T‐cells are present in healthy individuals as well as Munir et al. Cancer Research, 2013
cancer patients
Munir et al. Leukemia 2013
Ahmad et al. Leukemia 2013
• IDO plays a vital role in inflammation and cancer. Specific T cells identified in melanoma patients Sørensen et al PlosOne 2009, Blood 2011, Munir et al, PlosOne 2012
• Additional similar novel targets: FoxO3, TDO…..
59
Tumour cells Chemotherapy +
Vaccination
Vaccination
Treg
Treg
Treg
Treg
Treg
MDSC T
T
T
T
T
MDSC MDSC IDO+ DC T
T
– immunreaktionen mod kræft er der, men den er svag…..
………………men den kan styrkes gennem immunterapi!
”It is a mistake to try to look too far ahead. The chain of destiny can only be grasped one link at a time.”
Sir Winston Churchill