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CIT: from translational research to clinical application
John Haanen
ESMO I-O preceptorship Zürich 2018
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My disclosures
• I have provided consultation, attended advisory boards, and/or provided lectures for: Pfizer, Bayer, MSD, BMS, IPSEN, Novartis, Roche/Genentech, Neon Therapeutics, Celsius Therapeutics, Gadeta BV, Immunocore, Seattle genetics for which NKI received honoraria
• Through my work NKI received grant support from BMS, MSD, Novartis and Neon Therapeutics
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Cancer Immunotherapy
…fighting cancer but ignoring the tumor…
unleashing the immune system or
harnessing the immune system
to combat cancer
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2013 2014 2015
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What is the science behind CIT?
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van Elsas et al., J Exp Med 1999
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van Elsas et al., J Exp Med 1999
Prevention of outgrowth and rejection of aggressive B16 melanoma using CLTA-4 blockade and vaccine
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Combination of anti-CTLA-4 + vaccine leads to rejectionof pulmonary metastases and immune infiltrates
van Elsas et al., J Exp Med 1999
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Melanoma bearing mice successfully treated withanti-CTLA4 and vaccine develop vitiligo
van Elsas et al., J Exp Med 1999
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Cancer immunity cycle
Chen & Mellman Immunity 2013
CTLA4
PD1/PDL1CTLA4
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T cell signaling
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T cell activating and inhibiting molecules and signals
Melero, Haanen. Nat Rev Cancer 2015
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Checkpoint molecule CTLA4
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CTLA4 plays a role during T cell priming
Ribas. N Engl J Med 2012
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Human CTLA4 blockade
• Ipilimumab, IgG1 human mAb, selected for its lack of ADCC/CDC activity– Administered every 3 weeks x 4, 3 mg/kg– Showed improvement in mOS of 4 months in
metastatic melanoma– Approved in 2011
• Tremelimumab, IgG2 human mAb– Administered every 3 months, 15 mg/kg– Failed to show improvement in mOS
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Efficacy of ipilimumab as first line treatment
Robert et al., NEJM 2015
ORR: 11.9%
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CTLA-4 blockade (ipilimumab) can induce long-term survival (pooled overall survival analysis including Expanded Access Program data from 4846 patients)
4846 1786 612 392 200 170 120 26 15 5 0
Median OS (95% CI): 9.5 months (9.0–10.0)
3-year OS rate (95% CI): 21% (20%–22%)
Pro
port
ion
Aliv
e
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Months0 12 24 36 48 60 72 84 96 108 120
Ipilimumab
CENSORED
Patients at RiskIpilimumab
Schadendorf D, et al. J Clin Oncol 2015
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Treatment with anti-CTLA-4 mAb
Maker et al., Ann Surg Oncol 2005
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Auto-immune uveitis afteranti-CTLA-4 treatment
Aftertreatment
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Immune related adverse events upon anti-CTLA-4 mAb treatment
colitis hypophysitis
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How does CTLA4 blockade lead to anti-tumor immune responses?
Two not mutually exclusive mechanisms have been proposed:1. Priming of tumor-reactive T cells
– Against shared tumor associated antigens– Against mutated (neo) antigens
2. Depletion of regulatory FoxP3+ T cells from the tumor microenvironment
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1. Self antigens (to which tolerance is incomplete)Shared between patients
2. ‘Neo-antigens’, epitopes that arise as a consequence of tumor-specific mutationsIn large part patient-specific, hence generallyignored
What could tumor-specific cytotoxic T cells detect on human cancer?
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Kvistborg et al., Science Transl Med 2014
Two models proposed
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Analysis of PBMC from 40 ipilimumab treated melanoma patients for 75 tumor associated
antigens
Kvistborg et al., Science Transl Med 2014
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Generation of pMHC multimers by UV-induced peptide ex change
Peptide 1 Peptide 2 Peptide 3
Disintegration
Rescue Peptides
Toebes et al. Nat. Med. 2006Bakker et al. PNAS 2008
Allows generation of 1000s of pMHC in parallel
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Generate fluorochromeconjugated MHC multimers
Mix to create a collectionof differentially encodedMHC multimers
Assembly of combinatorialcodes on T cell surfaces
Analysis by flow cytometry
T cell T cell T cell
Self-assembling molecular codes
Allows detection of 47 T cell responses in parallel
Hadrup et al, Nat Methods 2009, Andersen et al, Nat Prot 2012.
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Flow results…
Kvistborg et al., Science Transl Med 2014
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Ipilimumab treatment leads to broadening of the anti cancer IR
Kvistborg et al., Science Transl Med 2014
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Kvistborg et al., Science Transl Med 2014
T cell responses against shared tumor antigens
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1. Self antigens (to which tolerance is incomplete)Shared between patients
2. ‘Neo-antigens’, epitopes that arise as a consequence of tumor-specific mutationsIn large part patient-specific, hence generallyignored
What could tumor-specific cytotoxic T cells detect on human cancer?
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Generate map of tumor-specific mutations (ExomeSeq)
Determine which mutatedgenes are expressed (RNASeq)
Predict epitopes for each mutation/ each HLA-allele in silico
Screen for T cell recognitionof mutated epitopes
MDLVLNELVISLIVESKLLEHLA-A2HLA-B7HLA-C2
T cell
Analyzing the neo-antigen-specific T cell repertoire in human cancer?
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Pt 002: Partial response upon anti-CTLA4 treatment
pre-treatment post-treatment
Van Rooij et al., J Clin Oncol 2013
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Analyzing the neo-antigen-specific T cell repertoire in human cancer?
T >
A / A
> T
T >
G / A
> C
T >
C / A
> G
C >
A / G
> T
C >
G / G
> C
C >
T / G
> A
0
20
40
60
80
100
Mutation Type%
of
No
n-S
yno
nym
ou
s m
uta
tio
ns
(n=1036)Resected tumor material
Isolate tumor cells
Identify tumor-specific mutations
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Analyzing the neo-antigen-specific T cell repertoire in human cancer?
Screen with MHC multimer technology
Resected tumor material
Isolate tumor cells Isolate tumor-infiltrating T cells
Identify tumor-specific mutations
Predict potential epitopes
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pMHC PE-Cy7 (ATRS>L)
pMH
CQ
D 6
25 (
AT
RS
>L)
3.3%
Strong T cell response against an ATRS>L neo-epitope within the tumor
Screen with MHC multimer technology
Resected tumor material
Isolate tumor cells Isolate tumor-infiltrating T cells
Identify tumor-specific mutations
Predict potential epitopes
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Increased magnitude of neo-antigen-specific T cell response under anti-CTLA4
pMHC PE-Cy7 (ATRS>L)
pMH
CQ
D 6
25 (
AT
RS
>L)
3.3%
van Rooij, van Buuren JCO 2013
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Cancer exome-guided immunomonitoring
� Exome-based analysis of neo-antigen specific T cell responses in human
cancer is feasible
- Dissect the role of neo-antigen specific T cell reactivity in melanoma
immunotherapy (TIL therapy, anti-CTLA4, anti-PD1 etc.)
� The T cell based immune system commonly interacts with the consequences
of DNA damage in human melanoma
in 10 out of 12 pts CD8 neo-ag spec TIL
in 5 out of 6 CD4 neo-ag spec TIL
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Snyder et al. NEJM 2014
Mutational load and outcome to ipi
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How does CTLA4 blockade lead to anti-tumor immune responses?
Two not mutually exclusive mechanisms have been proposed:1. Priming of tumor-reactive T cells
– Against shared tumor associated antigens– Against mutated (neo) antigens
2. Depletion of regulatory FoxP3+ T cells from the tumor microenvironment
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Vargas et al. Cancer Cell 2018
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CD16 snp plus inflamed tumor associated with better outcome on ipilimumab in melanoma
Vargas et al. Cancer Cell 2018
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Freeman & Sharpe. Nat Immunol 2013
PD1 and PD-L1 checkpoint
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Programmed Death-1 receptor (PD1)
• Discovered in 1992 by Honjo and coworkers– Upregulated gene in relation to apoptosis
• Member of the Ig superfamily• Cytoplasmic domains with ITIM and ITSM
– Recruites phosphatases– Inhibits PI3K and AKT activity
• Inducibly expressed by CD4 and CD8 T cells, NKT cells, B cells, monocytes and subtypes of DC
• Expressed by both effector and regulatory T cells• PD1/PD-L1 interaction involved in tolerance and chronic
inflammation• PD1/PD-L1 contributes to functional T cell exhaustion during
chronic infection and cancer
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Nishimura et al. Immunity 1999; Nishimura et al., Science 2001
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Freeman et al., J Exp Med 2000
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Adoptive cell transfer of tumor-specific TCR transgenic 2C PD-1-/- T cells rejected tumor cells
Blank et al., Cancer Res 2004
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PD-1 pathway inhibits T cell response directlydownstream of the TCR
Freeman PNAS 2008
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PD1/PD-L1 play a role at the tumor/effector phase
Ribas. N Engl J Med 2012
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Checkpoint molecules PD-1/PD-L1
• Nivolumab: anti-PD-1• Pembrolizumab: anti-PD-1• Cemiplimab: anti-PD-1• Spartalizumab: anti-PD-1
• Atezolizumab: anti-PD-L1• Durvalumab: anti-PD-L1• Avelumab: anti-PD-L1
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Expression of PD1 ligands
PD-L1 (B7-H1) PD-L2 (B7-DC)
Hematopoietic cells DC, macrophages, B cells, T cells, BM-derivedmast cells
DC, macrophages, B cells, Th2 cells, BM-derived mast cells
Non-hematopoietic cells Vascular endothelium, epithelia, muscle, liver, pancreatic islets, placenta, eye
Few, airway epithelia
Stimuli Interferons (α, β, γ) IL-4 + GM-CSGBinding partners PD1, B7.1 PD1
Expression by tumors Melanoma, RCC, HNSCC, ovary, NSCLC
Expression also found on tumors
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PD-L1 on human tumor cells mediatesT cell inhibition
Pardoll DM, Nat Rev Cancer 2012
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Expression of PD-L1 co -localizes withTILs
Taube et al. Science Transl Med 2012
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PembrolizumabBaseline: April 13, 2012
Images courtesy of A. Ribas, UCLA.72-year-old male with symptomatic progression after bio-chemotherapy, HD IL-2, and ipilimumab
April 9, 2013
Ribas A ASCO 2013
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Design of CheckMate 066
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Results of the CheckMate 066
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Nivolumab improves PFS and OS compared to dacarbazine
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Are there any predictive markers for PD1/PDL1 blockade?
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Evolution of CD8+ T-cells, according to treatment outcome
IHC Analysis of CD8+ T-cells in samples obtained before and during anti-PD1 treatment
Tumeh et al. Nature 2014
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PD-L1 expression and response in melanoma
Pembrolizumab
ORR – “PDL1+”1% cut-off: 49%
10% cut-off: 52%
ORR – PDL1-1% cut-off: 13%
10% cut-off: 23%
Melanoma
Daud, AACR 2014Ghandi, AACR 2014
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OS in Checkmate-066 according to PDL1 expression
Atkinson et al. abstract 3774 SMR 2015
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Correlation of PD-L1 Expression and Efficacy
Borghaei H, ASCO 2016; Rittmeyer A, Lancet 2016; Herbst R, Lancet 2015
66
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Mutational burden and clinical benefit from anti-PD1 in NSCLC
Rizvi et al., Science 2015
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A neo-antigen specific T cell response induced during anti-PD1 treatment
Rizvi et al., Science 2015
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Anti-PD1 in mismatch repair deficient tumors
Le et al., NEJM 2015
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A neo-antigen repertoire may only be frequent in so me human cancers
Formation of neo-antigens
Generally
Regularly
Occasionally
Caveat: It is possible that a ‘neglected’ repertoire of neo-antigens existsWe may be underestimating…
Schumacher and Schreiber Science 2015
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Checkpoint blockade
Paradigm shift: Cancer immunotherapy can be applied broadly
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Ayers et al. JCI 2017
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Ayers et al. JCI 2017
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Requirement for effective CIT
• High mutation burden increases chance for neo-antigen specific T cell response
• T cell infiltrate in tumor or invasive margin– CD4 and/or CD8
• PD-L1 expression (indicative of T cell-tumor interrogation) favors response
• IFN-γ gene signature favors response to CIT
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Target cancer immunity cycle obstructions
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Selection and optimization of immunotherapy-based combinations
Zappasodi et al. Cancer Cell 2018
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Marit van Buuren
Sander Kelderman
Carsten Linneman
Laura Bies
Daisy Philips
Mireille Toebes
Pia Kvistborg
Maarten Slagter
Joost Beltman
Clinical translation
Nienke van Rooij
Bianca Heemskerk
Raquel Gomez
Joost van den Berg
Maaike van Zon
Noor Bakker
Christian Blank
Chemical Biology
Huib Ovaa
PDX models
Kristel Kemper
Daniel Peeper
Sanger Institute
Sam Behjati
Mike Stratton
AIMM Therapeutics
Remko Schotte
Hergen Spits
LUMC
Els Verdegaal
Sjoerd van der Burg
Cancer Immunotherapy Dream Team
MSKCC
Naiyer Rizvi
Matt Hellman
Alexandra Snyder
Vlad Makarov
Jonathan Havel
Taha Merghoub
Jedd Wolchok
Tim Chan
Utrecht University
Can Keşmir
MD Anderson
Laszlo Radvanyi
Chantale Bernatchez
Patrick Hwu