CAR-T Matteo G Carrabba IRCCS Ospedale San Raffaele, Milano UO - - PowerPoint PPT Presentation

▶
car t
SMART_READER_LITE
LIVE PREVIEW

CAR-T Matteo G Carrabba IRCCS Ospedale San Raffaele, Milano UO - - PowerPoint PPT Presentation

Oct 20, 2023 300 likes •653 views

IMMUNOTHERAPY IN HEMATOLOGICAL MALIGNANCIES, 17-19 May 2018, Cuneo CAR-T Matteo G Carrabba IRCCS Ospedale San Raffaele, Milano UO Ematologia-Trapianto Midollo Osseo Unit di Fase I Ematologia Confidential, OSR 1 Key Points of This Talk

slide-1
SLIDE 1

Confidential, OSR

CAR-T

Matteo G Carrabba IRCCS Ospedale San Raffaele, Milano UO Ematologia-Trapianto Midollo Osseo Unità di Fase I Ematologia

1

IMMUNOTHERAPY IN HEMATOLOGICAL MALIGNANCIES, 17-19 May 2018, Cuneo

slide-2
SLIDE 2

Confidential, OSR

Key Points of This Talk

  • CAR-T growing interest
  • CAR-T anti CD19 overview
  • CAR-T Toxicities: Can Murine Models Help to Improve

Their Management ?

  • CAR-T 2.0
  • CAR-T CD44v6

Innovative Immunotherapies Unit 2

slide-3
SLIDE 3

Confidential, OSR

CAR generations

3 Innovative Immunotherapies Unit

slide-4
SLIDE 4

Confidential, OSR

CAR-T GROWING NUMBERS OF TRIALS

Innovative Immunotherapies Unit 4

Hartmann et al, EMBO Mol Med 2017

slide-5
SLIDE 5

Confidential, OSR

TARGETS SELECTED FOR TRIALS

Innovative Immunotherapies Unit 5

Hartmann et al, EMBO Mol Med 2017

slide-6
SLIDE 6

Confidential, OSR

TARGETS AND OUTCOME (2017)

Innovative Immunotherapies Unit 6

Hartmann et al, EMBO Mol Med 2017

slide-7
SLIDE 7

Confidential, OSR

Key Points of This Talk

  • CAR-T growing N° Trials and Targets, Interest also in

solid tumors

  • CAR-T anti CD19 overview
  • CAR-T Toxicities: Can Murine Models Help to Improve

Their Management ?

  • CAR-T 2.0
  • CAR-T CD44v6

Innovative Immunotherapies Unit 7

slide-8
SLIDE 8

Confidential, OSR

Chimeric Antigen Receptor T-Cell Therapy (CAR-T) anti CD19

(Tran E et al. NEJM Dec 2017)

  • Feasible, highly effective in r/r

ALL and DLBCL

  • Toxicity (CRS and

encephalopathy) severe but manageable

  • High CR rates in advanced

ALL and DLBCL/FL patients

slide-9
SLIDE 9

Confidential, OSR

CD28 versus 41BB

9 Innovative Immunotherapies Unit

Davis, Blood Advances 2016

2G (CD28) 2G (41BB)

slide-10
SLIDE 10

Confidential, OSR

ALL

10 Innovative Immunotherapies Unit

48% Overall Survival (12m) Median OS: 12,9 76% Overall Survival (12m) Median OS: 19,1 m

Maude, NEJM 2018 (Upenn, 41BB) Park, NEJM 2018 (MSKCC, CD28)

52% Overall Survival (12m)

Lee, Lancet 2016 (NCI, CD28)

slide-11
SLIDE 11

Confidential, OSR

ALL

11 Innovative Immunotherapies Unit

35% Event-free Survival Median EFS: 6.1 50% Event-free Survival (12m) Median EFS: Not reached

Maude, NEJM 2018 (Upenn) Park, NEJM 2018 (MSKCC)

Cytokine Releasing Syndrome (CRS) G 3 or more

  • Neurotox. G3 or more

Cytokine Releasing Syndrome (CRS) G 3 or more

  • Neurotox. G3 or more

46% 13% 26% 42%

slide-12
SLIDE 12

Confidential, OSR

Among 38 patients with refractory diffuse large B-cell lymphoma or follicular lymphoma:

  • 28 were able to receive CAR T cells;
  • 16 had complete remission;
  • none of those who had had a complete

response at 6 months had a relapse at 28 months of follow-up; Schuster SJ et al. N Engl J Med ;377:2545-2554

Schuster SJ et al. N Engl J Med ;377:2545-2554

Original Article

Chimeric Antigen Receptor T Cells in Refractory B-Cell Lymphomas

18 % CRS G3 or more 11 % Neurotox G3 or more 42 % CR rate

slide-13
SLIDE 13

Confidential, OSR

In 101 (111 enrolled) patients with refractory large B- cell lymphoma, anti-CD19 chimeric antigen receptor (CAR) T-cell therapy (axicabtagene ciloleucel) resulted in an overall response rate of 82%, with a 52% survival at 18 months, despite serious toxic effects.

Schuster SJ et al. N Engl J Med ;377:2545-2554

Original Article

Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma

Neelapu SS et al. N Engl J Med ; 2531-2544

13% CRS G3 or more 28% Neurotox G3 or more 51 % CR rate

slide-14
SLIDE 14

Confidential, OSR

Key Points of This Talk

  • CAR-T growing number of trials, multiple targets, interest in

solid tumors

  • CAR-T anti CD19 -> Breakthrough (R/R ALL, DLBCL FL),

waiting for long term data

  • CAR-T Toxicities: Can Murine Models Help to Improve Their

Management ?

  • CAR-T 2.0
  • CAR-T CD44v6

Innovative Immunotherapies Unit 14

slide-15
SLIDE 15

Confidential, OSR

Cytokine release syndrome

15 Innovative Immunotherapies Unit

  • Rapid inflammatory reaction (within the first 2 weeks)
  • High fever, hypotension, hypoxia and multi-organ toxicity
  • Potentially life-threatening
  • C-reactive protein (CRP) and IL-6 elevations
  • Ameliorated by tocilizumab (anti-IL-6R mAb)
  • More frequent in patients with an high tumor burden
slide-16
SLIDE 16

Confidential, OSR

Cytokine release syndrome

16 Innovative Immunotherapies Unit

slide-17
SLIDE 17

Confidential, OSR

  • Long-term Efficacy
  • CAR-related Toxicities: Cytokine Release Syndrome

Neurotoxicity On-target off-tumor toxicity (hematologic)

Humanized model for CAR-T

17 Innovative Immunotherapies Unit

HSCs NSG-SGM3 mice Long-term follow-up Malignant hematopoiesis Normal hematopoiesis (mono, B, T) Leukemia CAR-T Norelli M, Nat Med in press

slide-18
SLIDE 18

Confidential, OSR

In vivo modeling of CRS

18 Innovative Immunotherapies Unit

Adapted from Norelli M, Nat Med in press

CD19 CAR-T cells

7 14 21 28 70 80 90 100 110

Days from CAR-T Weight (% from initial) NSG-SGM3 humanized NSG-SGM3

7 14 21 28

  • 1

1 2 3 4 5

Days from CAR-T Fever (Δ°C)

7 14 21 28 5,000 10,000 15,000

Days from CAR-T IL-6 [pg/ml]

14 28 4242 168 25 50 75 100

Days from CAR-T CRS mortality (%)

slide-19
SLIDE 19

Confidential, OSR

Role of monocytes in CRS

19 Innovative Immunotherapies Unit

Adapted from Norelli M, Nat Med in press

IL-6 sources Monocyte’s ablation

7 14 21 28

  • 1

1 2 3 4 5

Days from CAR-T Fever (Δ°C) humanized NSG-SGM3 humanized NSG-SGM3 + LC

slide-20
SLIDE 20

Confidential, OSR

IL-1 is upstream IL-6

20 Innovative Immunotherapies Unit

Adapted from Norelli M, Nat Med in press

7 14 21 20 40 60 80 100

Days from CRS Positivity (%)

IL-1 IL-6 IL-1/IL-6

Monocytes (in vivo) IL-1 sources

slide-21
SLIDE 21

Confidential, OSR

Tocilizumab and Anakinra

21 Innovative Immunotherapies Unit

Tocilizumab: inhibits IL-6 pathway (CAN’T cross the BBB) Anakinra: Inhibits IL-1 pathway (CAN cross the BBB)

Adapted from Norelli M, Nat Med in press

slide-22
SLIDE 22

Confidential, OSR

Key Points of This Talk

  • CAR-T growing number of trials, multiple targets, interest in

solid tumors

  • CAR-T anti CD19 -> Breakthrough (R/R ALL, DLBCL FL),

waiting for long term data

  • CAR-T Toxicities: Murine Models shows a role of Monocytes

in CAR-T Tox and provide a rationale for IL-1 targeting

  • CAR-T 2.0
  • CAR-T CD44v6

Innovative Immunotherapies Unit 22

slide-23
SLIDE 23

Confidential, OSR Innovative Immunotherapies Unit 23

Hartmann et al, EMBO Mol Med 2017

CART EVOLUTION ONGOING

slide-24
SLIDE 24

Confidential, OSR

4th generation CARs

24 Innovative Immunotherapies Unit

Chmielewski, Cell reports 2018

slide-25
SLIDE 25

Confidential, OSR

CAR targeting to the TCR locus

25 Innovative Immunotherapies Unit

CAR expression Efficacy Expansion Exhaustion

Eyquem J ,Nature 2017

slide-26
SLIDE 26

Confidential, OSR

Key Points of This Talk

  • CAR-T growing number of trials, multiple targets, interest in solid

tumors

  • CAR-T anti CD19 -> Breakthrough (R/R ALL, DLBCL FL), waiting

for long term data

  • CAR-T Toxicities: Murine Models shows a role of Monocytes in

CAR-T Tox and provide a rationale for IL-1 targeting

  • CAR-T 2.0: multiple strategies under evaluation -> opportunity but

also issue for clinical research

  • CAR-T CD44v6

Innovative Immunotherapies Unit 26

slide-27
SLIDE 27

Confidential, OSR

CD44v6 CAR-based strategy

27 Innovative Immunotherapies Unit

  • CD44v6
  • oncogenic antigen
  • expressed on AML, MM and epithelial cancers
  • expressed on circulating monocytes and keratinocytes
  • CD44v6 CAR-T
  • Potent anti-leukemia/myeloma activity
  • Monocytopenia (on-target, off-tumor toxicity)
  • Co-expression with suicide genes
  • Keratinocyte resistance to killing (in vitro)

Casucci M, Blood 2013

slide-28
SLIDE 28

Confidential, OSR

7 14 21 28 35 42 49 20 40 60 80 100

Days from CAR-T Survival (%) CTRL 44v6.28Z ***

NGFR-spaced CARs

28 Innovative Immunotherapies Unit

Bondanza A, Casucci M, Bonini C, WO 2016/042461 Casucci M, Front Immunol in press

TNFR-Cys2 TNFR-Cys4 TNFR-Cys3 TNFR-Cys1 Serine/Threonine rich stalk

NGFR

Anti-NGFR antibody

IgG1

CH2CH3

Selection Tracking

35.3 95.8

NGFR NGFR NGFR CD3 CD45 CD3

2.59 2.46

slide-29
SLIDE 29

Confidential, OSR * * *

1 2 3 4 5 0.0 0.4 0.8 1.2 1.6 time (weeks) circulating leukemic blasts (%) CTR.CAR28z CD44v6.CAR28z T cells 2 4 6 8 10 12 15 17 19 5 10 15 20 25 30 time (weeks) circulating leukemic blasts (%) T cells CD44v6.CAR28z CTR.CAR28z

CD44v6 ¡is ¡a ¡redox ¡rheostat ¡ Anti-tumor efficacy

  • +

20 40 60 80 100

** CD44v6 elimination (%)

  • +

20 40 60 80 100

** CD44v6 elimination (%) Casucci et al. Blood, 2013

pAMLs pMMs

Confidential, OSR, Dec 2017

In vitro In vivo

29

slide-30
SLIDE 30

Confidential, OSR 30 Casucci M et al, Blood, 2013

CD44v6 in healthy tissues

Non-haematopoietic Keratinocytes Haematopoietic Circulating monocytes

!"! !"# !"$ !"% !"& '"! '"# '"% ()*+,

  • ,.)/

0+12)1 3)4/+5 64,+/.7897./4 :+;)/.78<+1=)=7+1 :2>;.=? @+.,2 <+/.8A.*. :B7++/ C.;;.,5897./4 D.2 E)2F)2.,5 G+2)/.

  • C

H,+2+, A>7>/ I*F4F=2 I*.,5 IB2)=8J+,*+ H,)/.,58-7.44+, KF>4+F; L/2+12)/8M:;.77N :B)/.78A>,4 0?5,>)4 L2,.=,./).786,2+,5 (5;B?8J>4+ E+,)=.,4)F; <.O)/. E7.=+/2. G+=2F; 0,.=?+. E+/)1 (F/O CF1=7+ 0>/1)7 E./=,+.1 E,>12.2+ P1>B?.OF1 H2+,F1 A+,*)Q J.1.78CF=>1. :R)/ 0>F/O+ H*F7. S' S# ST S'& S'# !"# 3+,.2)/>=52+1 AK$$*%8;GJ68M,+7.2)*+8+QB,+11)>/N !"! !"# !"$ !"% !"& '"! ()*$+ ,' ,#

  • ./0,'&

1203454 ()$$6%0378-09:;<=>?6;0;@A:;BB?45C !"#$%&''$ #('$ #&'$ &)'$ *&'$ !"#$%&''$ #&'$%&)'$ *&'$ +,-, +,-, ./0122$ 3/0122$ &&/0122$ 4&(/0122$ 5 6 7 8 9 5: ;7

#3 3& '3 <=+,>

#?@@AB/CDEFG HH

Confidential, OSR, Dec 2017

slide-31
SLIDE 31

Confidential, OSR

Keratinocyte resistance

31 Innovative Immunotherapies Unit

In vivo skin xenograft

In collaboration with MolMed hCD3 IHC EGFR CD44v6 N i h i l 4 4 v 6 . 2 8 z E G F R . 2 8 z 1 9 . 2 8 z

10 20 30 40

CD3+ cells (#) *** ** **** (#) *** ** **** Nihil 44v6.28z EGFR.28z 19.28z

1 2 3

Dermal CD3+ cells (score) * ** EGFR CD44v6 hCD3 IHC

Ex vivo skin explant

In collaboration with Antonella Monno Greco B, Poster #305, room Carlo 3

slide-32
SLIDE 32

Confidential, OSR

CD44v6 CAR clinical trial

32 Innovative Immunotherapies Unit

Main objective: to conduct a multicentre, first- in-man Phase I/IIa clinical trial to evaluate the safety and the efficacy of CD44v6 CAR-T cells in refractory AML and MM Proof-of-principle for future applications in solid tumors

slide-33
SLIDE 33

Confidential, OSR

Key Points of This Talk

  • CAR-T growing number of trials, multiple targets, interest in solid tumors
  • CAR-T anti CD19 -> Breakthrough (R/R ALL, DLBCL FL), waiting for

long term data

  • CAR-T Toxicities: Murine Models shows a role of Monocytes in CAR-T

Tox and provide a rationale for IL-1 targeting

  • CAR-T 2.0: multiple strategies under evaluation -> issue for clinical

research

  • CAR-T CD44v6: phase 1 clinical trial protocol submission to HA is

expected in the next months

Innovative Immunotherapies Unit 33

slide-34
SLIDE 34

Confidential, OSR

Aknowledgments

Innovative Immunotherapies Unit 34

Fabio Ciceri and all Staff, Hematology and Bone Marrow Transplantation Unit, San Raffaele Hospital Scientific Institute, Milan Attilio Bondanza, Novartis Institutes for Biomedical Research, Basel Monica Casucci and Margherita Norelli Innovative Immunotherapies Unit, San Raffaele Scientific Institute, Milan

EURE-CART* Group Members (www.eure-cart.eu)

*This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 733297