CARs and armored CARs

Lymphoma and Myeloma 2014New York NY

October 23, 2014

Renier Brentjens MD PhDAssociate MemberLeukemia Service

Chief, Cellular Therapeutics CenterDepartment of Medicine

Memorial Sloan Kettering Cancer Center

Renier Brentjens MD PhD

•Stockholder: Juno Therapeutics (scientific co-founder)•Royalties: Juno Therapeutics•Honoraria: none•Reserch Funding: Juno Therapeutics•Consultant fees: Juno Therapeutics•Discussion of off-label drug use: Tocilizumab

Conflict of Interest Disclosure

Generation of a tumor targeted chimeric antigen receptor (CAR)

VH VL5’ LTR

α-tumor scFv

CD8 ζ chain 3’ LTRψ

SD SA

α-TAA mAb

TCR complex

CAR retroviral vector

α-TAA scFv—CD8-ζ

TAA CAR

VH VL5’ LTR

αTAA scFv

CD8 ζ chain 3’ LTRψ

SD SA

Generation of TAA-targetedT cells for treatment of Cancer

αTAA scFv

CD8

CD3 ζ

1. Construct a chimeric antigen receptor (CAR)

SFG-CAR

2. Subclone CAR gene into a retroviral vector (SFG)

3. Transduce and expand patient T cells ex vivo

4. Infuse transduced T cells to eradicate TAA+ tumor cells

TAA

Native TCR

TAA CAR

• 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

Advantages of CAR T cell therapy

Expression of CD19 and other B cell markers on B lineage cells

Y Y

Y

Y

Y

Y

Y

Y

YY

YY

YY

Y Y

Y Y

preB-ALLB cell lymphomas and

leukemias myelomas

Stem Cell pre B immature B mature B plasma cellpro B

CD19

CD22

CD20

Evolution in CAR design

Clinical trials using CD19 targeted T cells in relapsed or refractory B-ALL

Sci Transl Med. 2013 Mar 20;5(177):177ra38

Patient characteristics and treatment outcomes

Maude et al N Engl J Med. 2014, 371:1507-17

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%

Lee et al Lancet. Published online October 13, 2014

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

The Problem

Clinical trials using CD19 targeted T cells in low grade B cell malignancies

Kalos et al Sci Trans Med 2011

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)

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

Cyclophosphamide

No 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 micro-environment 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 co-stimulation (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

mCD19-/- hCD19+/-

mCD19-/- hCD19+/-

IV injection

EL4(hCD19)

Harvest splenocytes

IV injection

Retroviraltransduction

with chimeric receptor

Assess T cell homing to tumor

Assess T cell eradication of

tumor

Assess T cell proliferation

in vivo

Assess long-term survival

of T cells

Assess the efficacyof suicide vectors

Assess memory T cell response to rechallenge

with tumor

53%

Determine the sideeffects of therapy

Per

cent

Sur

viva

l

Days since tumor cell injection

Lymphodepletion enhances anti-tumor efficacy of 19z1+ T cells

100 101 102 103 104100

101

102

103

104

1Élive cells

FL1-H: FL1-HeightF

L2

-H: h

CD

19

PE

24.3 0.11

0.06375.5

24.3%

hC

D19

100 101 102 103 104

100

101

102

103

104

6Élive cells

FL1-H: mCD19

FL

2-H

: hC

D1

9

2.07 0.02

0.2997.6

2.07%

hC

D19

19z1IRESIL-12 modified T cells secrete biologically active IL-12 and exhibit enhanced targeted cytotoxic function and resistance to Tregs

1:1 2.5:1 5:1 10:1

***

*

A

B

C D

Pegram et al Blood 2012

A B

Syngeneic IL-12 secreting CD19 targeted T cells induce B cell aplasias and tumor eradication

Pegram et al Blood 2012

IL-12 secreting CAR T cells in vivo efficacy

Enhanced CMphenotype, enhanced

cytotoxicity, enhanced persistence

Resistance to Treg and TGFβ inhibition

NK cell Recruitment

and activation

IL-12 secretion

IL-12 secretion

Targeted tumor cytotoxicity

Targeted tumor cytotoxicity

Targeted tumor cytotoxicity

Tumor cell

NK cell

ActivatedTIL

AnergicTIL

IL-12 secretion

Reversal of anergy

CAR-IRES IL-12

IL-12 genetically modified T cells: Armored CAR T cells

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 BrentjensHollie PegramMythili KoneruSarwish RafiqSwati PendharkarEric SmithJames LeeYan NikhaminJae ParkKevin CurranPeter Chang

Michel SadelainMarco DavilaMichael GongJean Baptiste Latouche

Leukemia ServiceDavid ScheinbergJae ParkMartin TallmanMark FrattiniPeter MaslakMark HeaneyJoe JurcicNicole LamannaMarco DavilaDan Douer

Cell Therapy and Cell Engineering Facility(Isabelle Riviere, Director)

R&D, ManufacturingXiuyan WangJolanta StefanskiMalgorzata OlszewskaOriana Borquez-OjedaTeresa WasielewskaJinrong Qu

QA/QCShirley BartidoYongzeng Wang(Mark Przybylowski)James HoseyDomenick Pirraglia(Vanessa Capacio)

Clinical ResearchYvette Bernal

FundingCA59350 (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)

Lymphoma ServiceCraig MoskowitzAriela Noy

GYN serviceSamith SandadiRoisin O’Clearbhail

Adult BMT ServiceSergio GeraltCraig Sauter

Department of ClinicalLaboratoriesLillian ReichDavid WuestKathy Smith

BiostatisticsGlenn Heller

Brentjens’ Lab Members