1. No category

CARs and armored CARs
Lymphoma and Myeloma 2014
New York NY
October 23, 2014
Renier Brentjens MD PhD
Associate Member
Leukemia Service
Chief, Cellular Therapeutics Center
Department of Medicine
Memorial Sloan Kettering Cancer Center
Conflict of Interest Disclosure
Renier Brentjens MD PhD
•Stockholder: Juno Therapeutics (scientific cofounder)
•Royalties: Juno Therapeutics
•Honoraria: none
•Reserch Funding: Juno Therapeutics
•Consultant fees: Juno Therapeutics
•Discussion of off-label drug use: Tocilizumab
Generation of a tumor targeted chimeric antigen
receptor (CAR)
α-TAA mAb
TCR complex
α-TAA scFv—CD8-ζ
ψ
5’ LTR
SD
α-tumor scFv
VH
VL
CD8 ζ chain
SA
CAR retroviral vector
3’ LTR
Generation of TAA-targeted
T cells for treatment of Cancer
TAA CAR
Native TCR
αTAA scFv
CD8
1. Construct a
chimeric antigen
receptor (CAR)
CD3 ζ
3. Transduce and
expand patient T
cells ex vivo
TAA CAR
4. Infuse transduced
T cells to eradicate
TAA+ tumor cells
2. Subclone CAR
gene into a retroviral
vector (SFG)
ψ
5’ LTR
SD
αTAA scFv
VH
VL
SA
SFG-CAR
CD8
ζ chain
3’ LTR
TAA
Advantages of CAR T cell therapy
• HLA-independent antigen recognition, therefore
universal application
• Active in both CD4+ and CD8+ T cells
• Target antigens include proteins, carbohydrates
and glycolipids
• Rapid generation of tumor specific T cells
• Minimal risk of autoimmunity or GvHD
• A living drug, single infusion
Expression of CD19 and other B cell
markers on B lineage cells
B cell lymphomas and
leukemias
preB-ALL
Stem Cell
pro B
pre B
CD19
CD22
CD20
immature B
mature B
myelomas
plasma cell
Evolution in CAR design
Clinical trials using CD19 targeted T
cells in relapsed or refractory B-ALL
Patient characteristics and treatment
outcomes
Sci Transl Med. 2013 Mar 20;5(177):177ra38
Clinical Efficacy Outcomes
(n=22)
Characteristics
No. of Patients
Overall Complete Response to
8
salvage chemotherapy
%
36
Overall Complete Response
to 19-28z CAR T cells (n=21)
18
86
10
83
Complete Remission
(CR)
14
64
Complete Remission with
incomplete count recovery
(CRi)
4
18
Molecular Complete
Remission (CRm) (n=21)*
15
72
In patients with morphologic
residual leukemia (n=12)
Time to CR/CRi (days)
Post CAR T Allo-SCT**
(n=12 eligible patients)
22.1
8
67
* mCR or MRD- as determined by flow cytometry and/or deep sequencing for
the index IgH clonotype and/or qPCR for the bcr-abl transcript
** Four patients had medical contraindication to allo-SCT, two patients
in CR have declined potential allo-SCT, one is inevaluable and one is being
evaluated for an allo-SCT
UPenn studies of relapsed B-ALL
• 25 pediatric and 5 adult relapsed or refractory
B-ALL patients treated
• 19-4-1BBz CAR design
• 90% CR
• 6 month EFS 67%
• 6 month OSR 78%
Maude et al N Engl J Med. 2014, 371:1507-17
NCI studies of relapsed B-ALL
• 20 pediatric and young adult relapsed or
refractory B-ALL patients treated.
• 19-28z CAR design
• 70% CR (14/20)
• 60% MRD- CR
• 5 month EFS 78% in MRD- patients
Lee et al Lancet. Published online October 13, 2014
The Problem
Clinical trials using CD19 targeted T
cells in low grade B cell malignancies
UPenn clinical trial results
Patient
Prior Chemotherapy
Conditioning
Chemotherapy
Response
1
Fludarabine, Rituximab,
Alemtuzumab, R-CVP,
Lenolidomide, PCR
Bendamustine
CR (3+
years)
2
Alemtuzumab
Bendamustine/Rituximab
PR (7
months)
3
Rituximab/Fludarabine,
Rituximab/Bendamustine.
Alemtuzumab
Pentostatin/
Cyclophosphamide
CR (3+
years)
Kalos et al Sci Trans Med 2011
Updated UPenn Trials in CLL
(ASH 2013)
• Abstract 4162
– CD19 CAR T cells treating relapsed/refractory CLL
• Utilizing a 4-1BBz CAR construct, 14 CLL patients treated
• 3/14 patients obtained CR (21%), 5/14 patients obtained PR (36%), 6/14 patients
with no response (43%)
• 6/14 patients with persistent detectable CAR T cells (5-35 months)
• No CR patients with reported relapsed disease
• No dose response reported
• Abstract 873
– Dose randomized dose optimization trial of CLL patients with either high or
low dose CAR T cell infusions
• Utilizing a 4-1BBz CAR construct, 27 CLL patients treated
• Patients randomized to either low dose (5 x 107 CAR T cells) or high dose (5 x 108
CAR T cells)
• No dose response benefit seen in these treated patients
• Overall response rate (CR + PR) was 40%
• No correlation with CRS and RR was observed
MSKCC clinical trial results: CLL
No
Cyclophosphamide
Cyclophosphamide
Brentjens et al Blood. 2011 Nov 3;118(18):4817-28
CAR questions
• What is the etiology of differential responses
by CAR T cell therapy to relapsed B-ALL versus
CLL?
• What is the role of bulky disease and CAR T
cell anti-tumor efficacy?
• The role of the hostile tumor microenvironment and CAR T cell function
• How to build a better T cell?
The hostile tumor microenvironment
The tumor microenvironment contains multiple
inhibitory factors designed to potentially suppress
effector T cells.
–
–
–
–
–
CD4+ CD25hi FoxP3+ regulatory T cells (Tregs)
MDSCs
TAMs
Expression of inhibitory ligands by tumor (PD-L1)
Tumor secretion of T cell suppressive cytokines (TGF-β and
IL-10)
The solution?
Armored CAR T cells
Moving Forward: Armored CARs
IL-12
• A heterodimeric cytokine secreted by activated APCs,
neutrophils and macrophages.
• Induces Th1 CD4+ T cell response enhancing IL-2 and
IFN-γ secretion
• Enhances T cell clonal expansion and effector function in
concert with TCR signaling (signal 1) and CD28 costimulation (signal 2), serving as a signal 3.
• Avoids/reverses T cell anergy
• May overcome Treg mediated effector T cell inhibition
• Recruits and activates NK cells
• Clinical trials in cancer using systemic IL-12 therapy has
been limited by severe inflammatory side effects
Syngeneic EL4(hCD19) tumor model
EL4(hCD19)
53%
IV injection
Assess T cell
eradication of
tumor
mCD19-/- hCD19+/IV injection
Assess T cell
homing to tumor
Assess longterm survival
of T cells
Assess memory T
cell response
to rechallenge
with tumor
Assess T cell
proliferation
Harvest
splenocytes
in vivo
Assess the efficacy
of suicide vectors
Determine the side
effects of therapy
mCD19-/- hCD19+/Retroviral
transduction
with
chimeric receptor
Lymphodepletion enhances anti-tumor
efficacy of 19z1+ T cells
6Élive cells
80
10
3
2.07
10
2
10
1
97.6
10
Cytoxan + 19z1
No Cytoxan + 19z1
Cytoxan Pz1
60
1Élive cells
40
10
4
10
3
20
24.3
10
2
10
1
0.11
24.3%
75.5
100
10
0
0.063
10
1
2
10
10
FL1-H: FL1-Height
3
10
4
0
0
10
20
30
Time (d)
40
50
Days since tumor cell injection
60
0.02
2.07%
100
FL2-H: hCD19 PE
% Survival
4
FL2-H: hCD19
100
Percent Survival
10
0
0.29
10
1
2
10
FL1-H: mCD19
10
3
10
4
19z1IRESIL-12 modified T cells secrete biologically active IL-12 and
exhibit enhanced targeted cytotoxic function and resistance to Tregs
A
B
C
D
Specific Lysis (%)
40
30
*
*
20
10
*
*
19mzIRESIL-12
19mz
0
1:1
2.5:1
5:1
E:T ratio
10:1
Pegram et al Blood 2012
Syngeneic IL-12 secreting CD19 targeted
T cells induce B cell aplasias and tumor
eradication
A
B
Pegram et al Blood 2012
IL-12 secreting CAR T cells in vivo efficacy
IL-12 genetically modified T cells: Armored
CAR T cells
NK cell
NK cell
Recruitment
and activation
Targeted tumor
cytotoxicity
Tumor cell
IL-12 secretion
Targeted tumor
cytotoxicity
CAR-IRES
IL-12
IL-12 secretion
Targeted tumor
cytotoxicity
Activated
TIL
Reversal of
anergy
Anergic
TIL
IL-12 secretion
Enhanced CM
phenotype, enhanced
cytotoxicity,
enhanced persistence
Resistance to Treg
and TGFβ inhibition
Conclusions
• Autologous CD19 targeted CAR modified T cells have demonstrated very
promising anti-tumor efficacy in B cell ALL with more modest responses in
patients with low grade B cell malignancies.
• Etiologies of CAR T cell resistance may be related to the hostile tumor
microenvironment.
• Application of CAR T cell therapy for low grade B cell malignancies as well as
moving forward towards application to solid tumor malignancies requires
“armored” CAR T cells designed to both overcome the hostile tumor
microenvironment and exhibit enhanced anti-tumor efficacy and long term
persistence.
• “Armored” CAR T cells appear to have enhanced anti-tumor efficacy based on
pre-clinical tumor models.
• Future studies using “armored” CAR T cell technology will focus on
translation of these armored CAR T cells to the clinical setting both in the
context hematological as well as solid tumor malignancies.
Renier Brentjens
Hollie Pegram
Mythili Koneru
Sarwish Rafiq
Swati Pendharkar
Eric Smith
James Lee
Yan Nikhamin
Jae Park
Kevin Curran
Peter Chang
Cell Therapy and Cell
Engineering Facility
(Isabelle Riviere, Director)
Michel Sadelain
Marco Davila
Michael Gong
Jean Baptiste Latouche
QA/QC
Shirley Bartido
Yongzeng Wang
(Mark Przybylowski)
James Hosey
Domenick Pirraglia
(Vanessa Capacio)
Leukemia Service
David Scheinberg
Jae Park
Martin Tallman
Mark Frattini
Peter Maslak
Mark Heaney
Joe Jurcic
Nicole Lamanna
Marco Davila
Dan Douer
R&D, Manufacturing
Xiuyan Wang
Jolanta Stefanski
Malgorzata Olszewska
Oriana Borquez-Ojeda
Teresa Wasielewska
Jinrong Qu
Clinical Research
Yvette Bernal
Lymphoma Service
Craig Moskowitz
Ariela Noy
GYN service
Samith Sandadi
Roisin O’Clearbhail
Adult BMT Service
Sergio Geralt
Craig Sauter
Department of Clinical
Laboratories
Lillian Reich
David Wuest
Kathy Smith
Biostatistics
Glenn Heller
Funding
CA59350 (MS) ; P30 CA-008748 (CT); 3RO1CA138738-02S1(RJB); Alliance for Cancer Gene Therapy ; Terry Fox Run for Cancer Research; William H. Goodwin and Alice
Goodwin, and the Commonwealth Cancer Foundation for Research and the ETC of MSKCC; Damon Runyon Clinical Investigator Award (RJB); William Lawrence &
Blanche Hughes Foundation (RJB); CLL-Global Research Foundation (RJB)
Brentjens’ Lab Members