Marcela V. Maus

Assistant Professor, Harvard Medical School

Director of Cellular Immunotherapy, Cancer

Center, Massachusetts General Hospital

Boston, USA

Next Generation of Engineered T

cells for Immunotherapy

Marcela V. Maus, MD, PhD

Cancer Crosslinks, Oslo Cancer Cluster, Oslo, Norway

January 18, 2018

Disclosure InformationMarcela V. Maus, MD, PhD

Consultant for: Adaptimmune, Adaptive Biotechnologies, agenus, Bluebird Bio, Cell Design Labs, Cellectis (SAB), CRISPR therapeutics, Kite Pharma, Neon, Obsidian, Unum, TCR2 (SAB) and WindMIL(SAB)

Speaker’s Bureau for: none

Grant/Research support from: agenus, CRISPR therapeutics, kyn, TCR2, Unum

Stockholder in: none

Employee of: Mass. General Hospital

I may discuss the following off label use and/or investigational use in my presentation: T cell therapies

(CTL019, JCAR015, JCAR017, KTE19, bb2121)

Disclosure

• Any recruiting efforts that I may make for Norwegian students or postdocs in my lab are completely independent from Donald Trump’s request to increase immigration from Norway

Pipeline of Immune-oncology Drugs in the Modern Era

5Axel Hoos, Nature Reviews Drug Discovery (2016)

Overview of T cell Therapy

Maus and June, CCR 2016

To engineer a T cell, you need…

4-1BB 4-1BB

A gene delivery

system

(lentiviral vector)

An antigen receptor

(natural ligand,

TCR or CAR)

Ex vivo culture

system (anti-

CD3/28 beads)

Antigen recognition: TCR vs CAR

Cancer cell

ch

ain

4-I

BB

CD

28

VH V2

CAR T cell

V2VH

CAR

Surface protein

Target protein

Lentivirus

CARs are not MHC restricted but only see see surface proteins

HLA-peptide complex

Processing

TCR T cell

chain

ε

ε

δ

δ

TCR

Lentivirus

Potentially 100% of proteins are presented by HLA

Human CD19 Expression by Hematopoietic Cells

Immature

B

Naïve

B

Germinal

Center B

Memory

B

Plasma

CellNormal: Pre-B

Immature

Chronic

Lymphocytic

Leukemia

(mutated)

Acute Lymphoblastic Leukemia (ALL)

Chronic

Lymphocytic

Leukemia (CLL)

(unmutated)

Malignant:

Mantle Cell Lymphoma MultipleMyeloma

(MM)

FollicularLymphoma

Diffuse Large B-Cell Lymphoma

Waldenstrom’sMacroglobulinemia

Pro-B

Adapted From: J Rubenstein, M.D., Ph.D.

T cells require multiple signals for optimal function

Comparing CD19 CARs for Leukemia

Davila et al,

Oncoimmunol 2012

KTE-C19

(NCI)

Novartis CTL019

JCAR 017 (Seattle)JCAR 015

(MSKCC)

Vector Retroviral1 Retroviral2 Lentiviral3

Expression ~30 Days ~30-60 Days >4 years

1Brentjens Blood 2011 and Science Trans Med, 2014

2Kochenderfer Blood 2012; Kochenderfer JCO 2014; Lee, Lancet Oncology 2015

3Porter NEJM 2011; Science Trans Med, 2011 , 2015

Examples of Clinical Responses

Day -21UPN 01

Day 177

R/B R/B B

CARs

Days from Infusion

-80 -40 120 160 200

Cells

(x10

-3/m

m3)

0

10

20

30

40

50

60

70

80WBC

ALC

Corticosteroidsstarted

80400

UPN 03

UPN 02

Pre-Therapy 3 Months

3 month Tx

Porter NEJM 2011Kalos STM 2011

Pharmacokinetics of CAR T cells

A CART19:Blood

Day (post infusion)

cop

ies

/mg

gD

NA

0 20 40 60 80 100 120 140 160 180

1

10

100

1000

10000

100000

UPN 03

UPN 01UPN 02

CART19 cells proliferate

2 to 4 log10 in all patients in vivo

1. Sustained antibody

delivery with a single

infusion of engineered

T cells!

2. CARs expressed for

at least 3 years

10 102

103

104

105

103

104

105

CD8

Day 56

210

27.2

64.3

Grupp, ASH 2016

Grupp, ASH 2016

July 12, 2017: ODAC vote for tisagenlecleucel for patients

age 3-25 with r/r B-cell acute lymphoblastic leukemia

Blinatumomab in r/r ped ALL

(N=70, Phase 1/2 trial):

Median OS: 7.5 mos

Von Stackelberg, JCO, 2016

Clofarabine + etoposide

and cytoxan in r/r ped ALL

(N=25, Phase 2 trial):

Median OS: 2.5 mos

Hijiya, Blood, 2011

Global registration trial of CTL019 in r/r pediatric ALL;

presented by Stephan Grupp, ASH 2016

August 30, 2017: FDA approves tisagenlecleucel

(Novartis product) for pediatric r/r ALL

$475,000*

* paid only if patient in CR at 1 month

Novartis Phase 2 trial in Diffuse Large B Cell Lymphoma

59% ORR43% CR

3 month CR: 37%

Nov 2017: Novartis filed for both indications in Europe

6-month OS Rate 80% in ZUMA-1 vs. 55% in SCHOLAR-1

1. Crump et al. ASCO 2016. NR, not reached; OS, overall survival. 21

Median OS (95% CI), mo

ZUMA-1 NR (10.5-NR)

SCHOLAR-11

6.6 (6.1-7.5)

bORR 76%CR 47%

YESCARTA approved Oct 18, 2017Filed in Europe Aug 1, 217

Axicabtagene ciloleucel

Common toxicities with CAR 19

• Cytokine release syndrome

– Characterized clinically by fever, hypotension, sepsis-like picture

– Clinical lab elevations in C-reactive protein, ferritin, may have other lab evidence of organ damage (DIC, transaminitis, AKI, etc.)

– Severe CRS is very similar to HLH/MAS

– Mechanism related to high levels of circulating IL-6, IFN gamma

– Managed primarily with anti-cytokine therapy

• Neurological toxicity

• B cell aplasia – on-target effect

94

95

96

97

98

99

100

101

102

103

104

7.12a

7,6a

7.12p

7.6p

8.12a

8,6a

8.12p

8.6p

9.12a

9,6a

9.12p

9.6p

10.12a

10,6a

10.12p

10,6p

11.12a

11,6a

11.12p

11,6p

12.12a

12,6a

12.12p

12,6p

13.12a

136a

13.12p

13,6p

14.12a

14,6a

14.12p

14,6p

Temp(degF)

CLLPt04409-09DavidPorter,MD

Tocilizumab,d10

Cytokine release syndrome and neurologic toxicity in DLBCL

Grade ≥3 Adverse Events, total N = 93 treated

n (%)

Cytokine release syndrome 12 (13)Neurologic event 27 (29)Fatal events (excluding PD) 3 (3)

Kite

26%

13%

ALL: Mechanisms of Resistance to CART-19

• In pediatric and adult ALL, there is a >90% CR at 1 month

• ~ 30% relapse rate of ALL after CART19:

• Of these, ~33% are early and associated with loss of B

cell aplasia

• Late relapses (~66%) are associated with target loss

(CD19 negative leukemia)

• Also cases of reversion to

Myeloid phenotype (Gardner et al, Blood, 2016)

Grupp, et al. NEJM 2013.Maude, et al. NEJM 2014.

Elena Sotillo et al. Cancer Discov 2015;5:1282-1295

In vivo efficacy of CAR-37 in a Mantle Cell Lymphoma model

CA

R-3

7 H

-LC

AR

-19

UT

D

DAY14 DAY21

UT

DC

D3

7H

-LC

D1

9b

bz

DAY7DAY0 DAY28 DAY35

BLI

D-7 D0

UTD/CART i.v.

2e6 cells

D7 D14 D21

-1h

Jeko-1 i.v.

1e6 cells

D28 D35

BLI

NOD/SCID

flow qPCR

0 7 14 21 28 35

103

104

105

106

107

108

109

DAYS

Flu

x

UTD

CAR-37 H-L

CAR-19

***

2 normal donors, N=10

Irene Scarfo

B Cell Maturation Antigen (BCMA) Target

▪ TNF receptor superfamily

▪ Binds B Cell Activating Factor (BAFF) and A Proliferation-inducing Ligand (APRIL)

▪ Selective expression profile▪ Plasma cells and some

mature B cells▪ Surface of malignant

plasma cells

▪ BCMA-deficient mice are healthy▪ Have normal B cell counts▪ Reduced survival of plasma

cells

BCMA is an attractive target for multiple myeloma

Maus et al. Clin. Cancer Res., 2013

Bluebird Bio: All Patients in Active Dose Cohorts Achieved an Objective Response, Duration up to 54 Weeks

*High tumor burden

(>50% bone marrow

involvement)

Includes unscheduled

assessments.ASCO 2017

Summary of BCMA-directed CAR T cell trials to dateBluebird Bio Novartis Legend

Abstract ASCO 2017 #3010 ASH 2016#1147

ASCO 2017LBA 3001

Construct Lenti/mscFv-41BB-z Lenti/hscFv-4-1BB-z Lenti/nano-4-1BB-z

Sites Multi, US Single, Penn Multi, China

Antigen cutoff 50% None 50%

Prior lines [median]

≥3 (2 if double refractory) [7]

≥3 (2 if double refractory), [9]

>3 [4]

Conditioning Flu/cy None or Cy Flu/cy

Responses ORR 100%, n=6 2 sCRs ORR 44%, n=91 sCR

ORR 100%, n=1914 sCR

Avoiding antigen escape and lower affinity

extracellular domain in one:

natural ligand CAR based on APRIL

APRIL CD8α 4-1BB CD3ζ T2A mCHERRYLTR LTRΨ Ψ

1 1860

1

APRIL 4-1BB 4-1BB CD3ζ T2A mCHERRYLTR LTRΨ Ψ

1815

CD8α 4-1BB CD3ζ T2A mCHERRYLTR LTRΨ Ψ

VH VL

21991

α-BCMA scFv

α-BCMACAR

APRIL CD8

4-1BBζ CAR

APRIL4-1-BBζ

CAR

APRIL4-1-BBθ

CAR

0

20

40

60

80

100

% C

AR

+

Transduction

Maria Ormhoj

APRIL-based CARs but not BCMA-CAR

is able to kill TACI+ target cells

1:3 1:1 3:1 10:10

20

40

60

E:T (K562TACI)

% S

pecif

ic lysis

**** ***

1:3 1:1 3:1 10:10

20

40

60

E:T (K562BCMA)

% S

pecif

ic lysis

***

UTD BCMA-CAR APRIL-CD8-CAR APRIL-4-1-BB-CAR

Maria Ormhoj

Liquid to Solid

32

Antigens for CAR T cells in solid tumors

• What is on the surface? (not HLA restricted)

– Her2, CAIX, IL13Ra2, PSMA, EGFRvIII, GD2, mesothelin…

– Most are heterogeneous

– None are systematically characterized/validated/part of diagnostic

workflow

• Avoiding on-target, off-tumor effects

– What’s a dispensable cell or tissue? Most are lineage/tissue

dependent

Rationale for EGFRvIII as therapeutic target in GBM

EGFRvIII:

♦ In-frame deletion of exons 2-7 and generation of novel glycine residue at the

junction

♦ Constitutively active, oncogenic mutation

♦ Not expressed in normal tissues

♦ Expressed in ~30% of GBM cases (but heterogeneous)

Gan et al., J Clin Neurosci, 2009.

35

25

A. B.

C.

D.

Figure 6

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

2173 CAR T cells

3C10 CAR T cells

CD19 CAR T cells

tumor cell sq injection

T cell iv injection

Tumorspalpable

Tu

mo

r si

zeL

x W

x H

(cm

3) ±

SEM +

****

*** p<0.005 Kruskal –Wallis

+ all mice euthanized

* p<0.05 Kruskal –Wallis

PBS UTD 2173Saline Untransduced T cells h3C10-BBz CAR T cells

Day 11 after T cells,

Day 18 after U87 cells

Targeting a single (heterogeneous) antigen is not enough

Adaptive immunosuppressive response/tumor

microenvironment

O’Rourke, STM, 2017

U87 tumor greenIrrelevant (19) CAR red

U87 tumor green EGFR-CAR red

U87 tumor greenEGFR CAR redactivated Treg

Modeling effect of Tregs on CAR T

Svetlana Markova, Ana Castano, Angela Boroughs

Before After

IL13Rα2-BBz

CARs targeting solid tumors can induce regression:

may require multiple doses and local administration;

relapse with antigen loss can still occur

Many ways to address current limitations are in development

• Multiple specificities

– Address tumor heterogeneity

• Drug controlled expression of CAR/other genes

– Salvage non-ideal targets?

• CAR secreting cytokines or antibodies

– Modify tumor microenvironment; heterogeneity

• Gene-edited T cells

– Universal donor; resistant to exhaustion

• Cells other than T cells (NK, NKT, Treg, iPS-T, iPS)

– Better homing?

• Combinations with checkpoint antibodies and/or small molecule drugs

– Modify environment, resist exhaustion, liberate epitopes?

AcknowledgementsMaus Lab

MGH CIPMadison HebertGlenn SiegmannTim GraubertRob MakarYi-Bin ChenAmir FathiJeremy AbramsonNoopur RajeJustin GainorWill CurryTracy Batchelor

DF/HCC Jerry RitzSarah NikiforowArlene SharpeGordon FreemanGeorge DemetriJennifer BrownNikhil MunshiDavid WeinstockHidde Ploegh

MIT Darrell Irvine

MGH Mark CobboldDaniel IrimiaLarry TurkaMark Poznansky

Broad InstituteAviv RegevOrit Rozenblatt-Rosen

Irene Scarfo, Lauren Riley, Madison Hebert, MattFriguault, Maria Ormhoj, Selena Lorrey, Ana Castano, Bryan Choi, Angela Boroughs, Amanda Bouffard, Svetlana Markova, Felipe Bedoya, Andrea Schmidts, Allison Taylor, Becca Larson

One approach to tumor heterogeneity: target 2 antigens

2016

One approach to tumor microenvironment: CARs can secrete

immunomodulatory cytokines; can synergize with checkpoint

blockade

Sci Reports 2017

Some small molecule drugs can enhance CAR T cell function

Nalm6/

ALL

OSU-

CLL

Blood, 2016