Chimeric Antigen Receptor T-cell therapy for CD19+ Maligancies

(1)

Chimeric Antigen Receptor T-cell therapy for

CD19+ Maligancies

Noelle Frey, MD, MSCE

Assistant Professor of Medicine

Associate Director, Blood and Marrow Transplantation

University of Pennsylvania Medical Center

(2)

Disclosures

• Novartis: Research Funding

• Amgen: Consultant

(3)

Targeted Cellular Therapy: Rationale

• Targeted cellular immunotherapy could

overcome limitations of conventional

chemotherapy and immunotherapy.

• Genetically modified, autologous T cells with

redirected specificity to tumor antigens may

combine advantages of:

• Antibody therapy (specificity).

• Cellular therapy (amplified response)

• Vaccine therapy (memory activity)

(4)

CD19: An ideal tumor target

•

CD19 is expressed on the surface of most B cell malignancies

•

Antibodies against CD19 inhibit growth of tumor cells

•

CD19 expression is restricted to B cells and their precursors

•

CD19 is not expressed on pluripotent bone marrow stem cells

•

On target expected SE is B cell aplasia

preB-ALL

B cell lymphomas and

leukemias myelomas

Stem Cell pro B pre B immature B mature B plasma cell

CD19

CD22 CD20

1. Scheuermann RH, et al. Leuk Lymphoma. 1995;18:385-397

Image adapted from Janeway CA, Travers P, Walport M, et al. Immunobiology. 5th ed. New York, NY: Garland Science; 2001:221-293; Scheuermann RH, et al. Leuk Lymphoma. 1995;18:385-397; and Feldman M, Marini JC. Cell cooperation in the antibody response. In: Roitt I, Brostoff J, Male D, eds. Immunology. 6th ed. Maryland Heights, Missouri: Mosby;2001:131-146.

(5)

Optimizing the CAR Signaling Domain

• Gene transfer technology is used

to stably express CARs on T

cells, conferring novel antigen

specificity

• CARs combine Antigen

recognition domain (Anti-CD19)

with intracellular signaling domain

• Intracellular signaling domain:

–

CD3-

ζ

chain: same functionality as

endogenous T cells

–

4-1BB (CD137-TNF family):

Co-stimulatory endodomain mediates potent

antileukemia effects & promotes

persistence

(Anti-CD19)

Milone, et al. Mol Ther 2009 Carpenito, et al. PNAS 2009

(6)

Redirecting the Specificity of T cells to Target CD19

•

Gene transfer technology (UPENN=

lentiviral vector) is used to stably

express CARs on T cells, conferring

novel antigen specificity (CD19)

•

CTL019 cells can thus be directed

against any tumor cell that expresses

CD19

•

CTLO19 therapy takes advantage of

the cytotoxic potential of T cells

thereby killing tumor cells in an

antigen-dependent manner

•

Persistent CTL019 cells consist of

both effector (cytotoxic) and central

memory T cells

1. Milone MC, et al. Mol Ther. 2009;17:1453-1464. 2. Kalos M, et al. Sci Transl Med. 2011;3:95ra73. 3. Hollyman D, et al. J Immunother. 2009;32:169-180.

T cell CD19 Native TCR Tumor cell CTL019 cell

Dead tumor cell

Anti-CD19 CAR construct

(7)

Therapeutic Overview

Gene transfer 10-12 days 4. Infuse transduced T cells to eradicate CD19+ tumor CD19 Native TCR 19z1 CAR Lymphodepleting chemotherapy

1

2

3

4

5

(8)

CARs Meet Leukemia

100+ CART19 Recipients

• ALL:

– 30+ kids

– 21 adults

• CLL:

– 42 adults

• NHL:

– 18 adults

• MM

– 5 adults

(9)

ALL: Rationale for Novel Therapies

• Prognosis for relapsed/refractory ALL poor

• Median survival < 1yr

• 3 yr OS <25%

• Cure with allogeneic SCT in >CR 2 is 20-40%

•

Probability of CR2 30-40%, CR 3, ~20%

(10)

Outcomes for Adults with 1

st

Relapse ALL

Fielding A K et al. Blood 2007;109:944-950. ECOG 2993

Male vs Female

Age <20, 20-34, 35-49, 50+

Time to relapse >6 mo, 6-12 mo,

1-2 yr, >2 yr

+/- Extramedullary disease

(11)

CART19 in Adult & Pediatric ALL

• N=30 (evaluable)

1

• 25 pediatric and 5 adult patients

• 40% female, 60% male

• Median age 14 (5-61)

• Disease status

• Primary refractory

10%

• 1

st

relapse

17%

• >2

nd

relapse

73%

(12)

ALL: Overall Response to CART19

Response

N=30

%

Complete Response

27/30

90%

No response

3/30

10%

Not evaluable

(extramedullary dz

(1) and short f/u (4)

5

(13)

CART19 for Rel/Ref ALL: Survival

(14)

CART-19 Persistence and B cell Aplasia

month 18

month 15

month 12

CART19

B cells

14.6% 3.4% CD2 0 CD19 Year 3

(15)

Chronic Lymphocytic Leukemia (CLL)

• Average age at diagnosis is 65

• 120,000 adults living with the disease

• Incurable without bone marrow transplant

• Affects patients differently: Survival 2-20 yrs

• Indolent course: long windows between

treatments

• Aggressive course: Becomes refractory to

chemotherapy, patients die from disease

(16)

CLL Pilot Study: Demographics

• N=14

• 12 men, 2 women

• Median Age: 66 (51-78)

• Median Prior Therapies: 4 (1-10)

• P53 deletion: 6/10

• Lymphodepleting chemotherapy:

• Bendamustine (6)

•

PC (5)

(17)

Clinical Response

(CLL Pilot Study: n=14)

UPN Blood Marrow Nodes Expansion Comments Max Resp

01 NED NED NED >3 log MRD* neg CR 39 mo+ 02 NED NED NED >3 log MRD* neg CR 38 mo+

03 PR PR PR 2 log PR 4 mo

06 NR NR NR <2 log NR

09 NED NED NED >3 log MRD* neg CR 18 mo+ 10 NED NED PR 2 log Bulky nodes CR 15 mo +

12 NED NED PR 2 log Bulky nodes PR 6 mo +

14 NR NR NR - NR (10 mo)

18 NR NR NR min NR at 8 wk NR (7 mo)

22 NED NED PR >2 log Bulky nodes PR 9 mo +

(18)

Clinical Response:

(CLL Pilot Study: N=14)

UPN Blood Marrow Nodes Expansion Comments Max Resp

09 NED NED NED >3 log MRD* neg CR 18 mo+ 10 NED NED NED 2 log Bulky nodes CR 15 mo +

(19)

Clinical Response:

(CLL Pilot Study: N=14)

UPN Blood Marrow Nodes Expansion Comments Max Resp

(20)

Clinical Response: (

CLL Pilot Study: N=14)

UPN Blood Marrow Nodes Expansion Comments Max Resp

06 NR NR NR <2 log _NR

07 NR NR NR <2 log _NR

14 NR NR NR - _{NR (10 mo)}

17 NR NR NR - _{NR (8 mo)}

(21)

UPN Resp Age P53- # prior Rx Dose CART10*8

CRS

01 CR 65 N 7 1.100 Y Median age 66

02 CR 64 Y 4 0.140 Y Median prior therapies 4

03 PR 78 Y 3 5.900 Y P53 del, 3/8

05 PR 66 N 2 3.9 N? Med CAR dose 1.45

09 CR 59 N 10 1.700 Y Expansion >3 logs

10 CR 78 N 5 3.700 Y

12 PR+ 66 N 5 1.2 Y

22 PR+ 60 Y 3 0.86 Y

06 NR 63 N 4 0.650 N Median age 67

07 NR 51 Y 5 0.170 N Median prior therapies 4

14 NR 70 N 4 1.6 N P53 del, 3/6

17 NR 78 N 8 1.15 N Med CAR dose 1.3

18 NR 64 Y 3 2.8 N Expansion < 3 logs

25 NR 75 Y 7 2.7 N

(22)

CLL: CART19 Dose Optimization Trial:

• What is the optimal dose of CTL019 cells for future study?

Randomized phase 2 trial (NCT01747486)

CLL:

Advanced,

relapsed/refractory

Arm A 1-5 x 107_{CTL019 cells} n=12

Primary Endpoint:

CR at 3 months

Arm B

1-5 x 108_{CTL019 cells}

n=12

Define optimal dose and enroll additional

(23)

Overall Response to CTL019 in CLL

Response

N

%

Complete Response

7/32

22

Partial Response

8/32

25

Overall Response

15/32

47%

(24)

UPN02 Marrow Response by Day 31

Pre-infusions marrow:

>50% involved by CLL

(40x)

Day 31

No evidence CLL and negative by

flow cytometry, cytogenetics, FISH

or deep sequencing

(25)

Baseline

10 prior therapies, transformed CLL,

del(17p), ibrutinib resistant, XRT resistant

Month 2

BM and blood NED

Month 3

BM and blood NED

(26)

(27)

Successes of CART19 Therapy

Ref Program/

CAR

Population Response

Acute Lymphoblastic Leukemia

Maude et al. NEJM 2014 PENN 4-1BB N=30(ALL) Peds&Adults CR=90% Davila et al. SciTrMed 2014 MSK CD28 N=16 (ALL) Adults CR=88% Lee et al. Lancet 2015 NCI CD28 N=21 (ALL) Peds&AYA CR=67% Intent to Treat

Non-Hodgkins Lymphoma & Chronic Lymphocytic Leukemia

Kochenderfer JCO 2015 NCI CD28 N=15 (NHL/CLL) CR=53% PR=27% Porter et al. SciTrMed2014 PENN 4-1BB N=14(CLL) CR=29% PR=29%

(28)

Complications of CAR T cell Therapy

• Cytokine Release Syndrome

• Neurologic Toxicity

(29)

Cytokine Release Syndrome

•

Correlates with:

•

CART19 activation & expansion

•

Dramatic cytokine elevations (IL6, IL10,

IFNɤ, CRP, ferritin)

•

Clinical Syndrome:

•

Onset 1-14 days after infusion (ALL)

•

Duration 1-10 days

•

Fevers come first and get very high (105)

•

Myalgias, fatigue, anorexia

•

Capillary leak, hypoxia and hypotension

•

Similarities MAS/HLH

(30)

CRS with CART19 Therapy

Ref Program/

CAR

Population Response CRS

Acute Lymphoblastic Leukemia

Maude et al. NEJM 2014 PENN 4-1BB N=30(ALL) Peds&Adults CR=90% 100% CRS 27% Severe Davila et al. SciTrMed 2014 MSK CD28 N=16 (ALL) Adults CR=88% 43% Severe Lee et al. Lancet 2015 NCI CD28 N=21 (ALL) Peds&AYA CR=67% Intent to Treat 76% CRS 28% Severe

Kochenderfer JCO 2015 NCI CD28 N=15 (NHL/CLL) CR=53% PR=27% 27% Severe Porter et al. ASH 2014 PENN 4-1BB N=14(CLL) CR=29% PR=29% 42% Severe

(31)

CRS: Cytokine Profiles

•

Clinical Laboratory Correlates:

•

Ferritin and CRP

• Investigational Correlates: Direct Impact on Care

1

!

•

Cytokine Profiles:

IFNɤ,

IL6

,

IL2R, IL10

(32)

CRS: Anti-cytokine Management

•

Tocilizumab:

•

Humanized monoclonal antibody to IL6-R

•

FDA approved adult RA, JIA

•

Limited inherent toxicity

•

Tocilizumab for CRS

•

Adopted by most Programs

•

Effective!

•

?Toxicity management without large efficacy impact?

-Improvement over high dose steroids

•

Further Studies needed to optimize tx

-Current approach: Treat at severe CRS

-Prophylactic/Pre-emptive approach better?

(33)

CRS: Clinical Response to Tocilizumab

Tocilizumab

95 96 97 98 99 100 101 102 103 104 0 1, 6a 1,

12p 1, 6p 2.12a 2. 6a 2.12p 2, 6p 3,12a 3. 6a 3.12p 3. 6p 4,12a 4. 6a 4.12p 4. 6p 5,12a 5. 6a 5.12p 5. 6p 6,12a 6. 6a

Temp

(34)

CRS: Ferritin Response to Tocilizumab

Tocilizumab: d10

CRS, Pt 04409-09

0 100000 200000 300000 400000 500000 600000 700000 -11 -5 -4 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

F

e

rr

it

in

(35)

CRS: Predictors of Severity

Disease Characteristics:

•

Underlying Disease (ALL>NHL/CLL)

1

•

Disease Burden (ALL)

2,3

Therapeutic Characteristics

•

Infusional Dose

4

•

Product variance

•

LD chemotherapy

Correlates with Severe Course

•

Cytokine and CRP, earlier clinical manifestations

• Concurrent infectious illness

1_{Frey et al. ASH 2014} 2_{Maude et al. NEJM 2014} 3_{Davila et al. SciTranMed 2014} 4_{Lee et al. TheLancet 2015}

(36)

Neurologic Toxicity

•

Real: Independent of Delirium of Fever

•

PENN: 30 Ped/Adult ALL

1

•

13/30 patients with neurologic events

•

encephalopathy, aphasia, seizure(1)

•

6 with onset post systemic CRS resolution

•

Resolution to baseline in all cases

•

Mechanism of Toxicity Unclear

•

T cell vs Cytokine Mediated??

•

CAR T cells are seen in the CSF

1-4 1Maude et al. NEJM 2014

2Davila et al. SciTranMed 2014 3Lee et al. TheLancet 2015 4Kochendorfet al. JCO 2015

(37)

Neuro Toxicity of CART19 Therapy

Ref Program/

CAR

Population Response CRS Neuro Toxicity

Acute Lymphoblastic Leukemia

Maude et al. NEJM 2014 PENN 4-1BB N=30(ALL) Peds&Adults CR=90% 100% CRS 27% Severe 43% Total Encephalopathy Aphasia Seizure (1) Davila et al. SciTrMed 2014 MSK CD28 N=16 (ALL) Adults CR=88% 43% Severe 25% Gr3-4 Encephalopathy Seizure Lee et al. Lancet 2015 NCI CD28 N=21 (ALL) Peds&AYA CR=67% Intent to Treat 76% CRS 28% Severe 29% Total hallucinations Dysphasia encephalopathy

Kochenderfer JCO 2015 NCI CD28 N=15 (NHL/CLL) CR=53% PR=27% 27% Severe 40% Total Encephalopathy Aphasia R facial par Monoclonus Ataxia Porter et al. ASH 2014 PENN 4-1BB N=14(CLL) CR=29% PR=29% 42% Severe NR

(38)

Blinatumomab

• Bispecific Antibody:

– antiCD3 & antiCD19 arms

– FDA approved for Rel/Ref B cell ALL

• Toxicities:

– Cytokine Release Syndrome

• Correlation CRS & Disease Burden

• Tumor reduction lead in strategy with steroids

– Neurotoxity

1

Topp et al. TheLancet 2015

(39)

CRS From Blinatumomab:

Reversed with Tocilizumab

(40)

Summary: CART19 in CD19+ Disease

• 80-90% CR rate in rel/ref ALL & 50% ORR in CLL

– MRD negative

– Successful bridge to ALLO SCT

– Some pts with prolonged remissions from CART19 alone

• CAR T cells can persist for >48 months (Penn experience)

– Cells remain functional

– Correlates with remission & B cell aplasia (IVIG replacement)

• CRS is most significant toxicity:

– Responsive to supportive care and anti-cytokine therapy

• Relapses:

– CD19 negative: combination strategies/baseline predictors?

– CD19 positive: loss of persistence

(41)

CAR T-Cell Therapy: Future Directions

• CART-19:

• Larger Multicenter Studies (Expand beyond a few specialized

centers?)

• Larger cohorts NHL, CLL, ALL, MM

• New Targets

• CART-22 (B cell malignancies)

• Solid tumors, AML

• Next Generation CARs

• Off the Shelf CAR T cells

• CRISPR technology

(42)

(43)

Colleagues and collaborators

(too many to list)

TCSL

Jos Melanhorst

Simon Lacy

Minnal Gupta

Irina Kulikovskaya

Jeff Finklestein

Frazana Nazimuddin

Vanessa Gonzalez

Saar Gill

CVPF

Bruce Levine

Andrea Brennan

Anne Chew

Ashley Vogel

Zoe Zheng

Study

Participants

Path./Lab. Med.

Adam Bagg

Pediatrics

Stephan Grupp

Shannon Maude

David Barrett

ACC Translational Research

Carl June

Carmine Carpenito

Michael Milone

Gwendolyn Binder-Scholl

Lester Lledo

Elizabeth Veloso

Joan Gilmore

DSMC Members

Univ Penn Clinical Group

David Porter

Alison Loren

Ed Stadtmauer

Selina Luger

Steve Schuster

Elizabeth Hexner

Ran Reshef

Sunita Nasta

Saar Gill

Jacob Svoboda