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
Disclosures Novartis: Research Funding Amgen: Consultant
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)
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.
Optimizing the CAR Signaling Domain Gene transfer technology is used to stably express CARs on T cells, conferring novel antigen specificity (Anti-CD19) 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): Costimulatory endodomain mediates potent antileukemia effects & promotes persistence Milone, et al. Mol Ther 2009 Carpenito, et al. PNAS 2009
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 Native TCR T cell CTL019 cell CD19 Dead tumor cell Anti-CD19 CAR construct 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. Tumor cell
Therapeutic Overview 1 5 19z1 CAR Native TCR Gene transfer 4 Lymphodepleting chemotherapy 4. Infuse transduced T cells to eradicate CD19 + tumor CD19 2 10-12 days 3
CARs Meet Leukemia 100+ CART19 Recipients ALL: 30+ kids 21 adults CLL: 42 adults NHL: 18 adults MM 5 adults
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% Allogeneic SCT for ref ALL largely ineffective
Outcomes for Adults with 1 st Relapse ALL 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 Relapse after chemo, auto, allo Fielding A K et al. Blood 2007;109:944-950. ECOG 2993
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% 1 Maude SL, Frey N. et al. N Engl J Med 2014;371:1507-1517.
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 Maude SL, Frey N. et al. N Engl J Med 2014;371:1507-1517.
CART19 for Rel/Ref ALL: Survival Maude, Frey et al. NEJM 2014;371:1507-1517.
CART-19 Persistence and B cell Aplasia CART19 month 12 month 15 month 18 Year 3 14.6% 3.4% B cells CD20 CD19
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
N=14 CLL Pilot Study: Demographics 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) FC (3)
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 05 PR PR PR 2 log PR 4 mo 06 NR NR NR <2 log NR 07 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) 17 NR NR NR - NR (8 mo) 18 NR NR NR min NR at 8 wk NR (7 mo) 22 NED NED PR >2 log Bulky nodes PR 9 mo + 25 NR NR NR NR (8 mo)
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 05 PR PR PR 2 log PR 4 mo 06 NR NR NR <2 log NR 07 NR NR NR <2 log NR 09 NED NED NED >3 log MRD* neg CR 18 mo+ 10 NED NED NED 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) 17 NR NR NR - NR (8 mo) 18 NR NR NR min NR at 8 wk NR (7 mo) 22 NED NED PR >2 log Bulky nodes PR 9 mo + 25 NR NR NR NR (8 mo)
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 05 PR PR PR 2 log PR 4 mo 06 NR NR NR <2 log NR 07 NR NR NR <2 log NR 09 NED NED NED >3 log MRD* neg CR 18 mo+ 10 NED NED NED 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) 17 NR NR NR - NR (8 mo) 18 NR NR NR min NR at 8 wk NR (7 mo) 22 NED NED PR >2 log Bulky nodes PR 9 mo + 25 NR NR NR NR (8 mo)
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 05 PR PR PR 2 log PR 4 mo 06 NR NR NR <2 log NR 07 NR NR NR <2 log NR 09 NED NED NED >3 log MRD* neg CR 18 mo+ 10 NED NED NED 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) 17 NR NR NR - NR (8 mo) 18 NR NR NR min NR at 8 wk NR (7 mo) 22 NED NED PR >2 log Bulky nodes PR 9 mo + 25 NR NR NR - NR (8 mo)
Clinical Response: (CLL Pilot Study: N=14) 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
CLL: CART19 Dose Optimization Trial: What is the optimal dose of CTL019 cells for future study? Randomized phase 2 trial (NCT01747486) Arm A CLL: Advanced, relapsed/refractory 1-5 x 10 7 CTL019 cells n=12 Arm B 1-5 x 10 8 CTL019 cells n=12 Define optimal dose and enroll additional 8 patients Primary Endpoint: CR at 3 months
Overall Response to CTL019 in CLL Response N % Complete Response 7/32 22 Partial Response 8/32 25 Overall Response 15/32 47% Heme Malignancy Update 2-7-14
UPN02 Marrow Response by Day 31 Pre-infusions marrow: >50% involved by CLL (40x) Porter et al. NEJM, 2011 Day 31 No evidence CLL and negative by flow cytometry, cytogenetics, FISH or deep sequencing
Ongoing and Delayed Response Baseline Month 2 BM and blood NED Month 3 BM and blood NED 10 prior therapies, transformed CLL, del(17p), ibrutinib resistant, XRT resistant
Ibrutinib
Successes of CART19 Therapy Ref Program/ CAR Acute Lymphoblastic Leukemia Population Response 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 Porter et al. SciTrMed2014 NCI CD28 PENN 4-1BB N=15 (NHL/CLL) CR=53% PR=27% N=14(CLL) CR=29% PR=29%
Complications of CAR T cell Therapy Cytokine Release Syndrome Neurologic Toxicity Off Tumor On Target: B cell Aplasia
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 Self Limited or Anti-cytokine Intervention
CRS with CART19 Therapy Ref Program/ CAR Acute Lymphoblastic Leukemia Population Response CRS 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 Non-Hodgkins Lymphoma & Chronic Lymphocytic Leukemia 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
CRS: Cytokine Profiles Clinical Laboratory Correlates: Ferritin and CRP Investigational Correlates: Direct Impact on Care 1! Cytokine Profiles: IFNɤ, IL6, IL2R, IL10 1 Grupp et al. NEJM 2013
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? Other Cytokine Targets..
CRS: Clinical Response to Tocilizumab 104 103 Temp 102 101 100 99 98 Temp 97 96 Tocilizumab 95 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
CRS: Ferritin Response to Tocilizumab 700000 600000 Tocilizumab: d10 500000 Ferritin 400000 300000 200000 100000 0-11 -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 CRS, Pt 04409-09
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 1 Frey et al. ASH 2014 2 Maude et al. NEJM 2014 3 Davila et al. SciTranMed 2014 4 Lee et al. TheLancet 2015 Cytokine and CRP, earlier clinical manifestations Concurrent infectious illness
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
Neuro Toxicity of CART19 Therapy Ref Program/ CAR Acute Lymphoblastic Leukemia Maude et al. NEJM 2014 Davila et al. SciTrMed 2014 Lee et al. Lancet 2015 PENN 4-1BB MSK CD28 NCI CD28 Population Response CRS Neuro Toxicity N=30(ALL) Peds&Adults N=16 (ALL) Adults N=21 (ALL) Peds&AYA CR=90% 100% CRS 27% Severe 43% Total Encephalopathy Aphasia Seizure (1) CR=88% 43% Severe 25% Gr3-4 Encephalopathy Seizure CR=67% Intent to Treat 76% CRS 28% Severe Non-Hodgkins Lymphoma & Chronic Lymphocytic Leukemia Kochenderfer JCO 2015 Porter et al. ASH 2014 NCI CD28 PENN 4-1BB N=15 (NHL/CLL) CR=53% PR=27% N=14(CLL) CR=29% PR=29% 29% Total hallucinations Dysphasia encephalopathy 27% Severe 40% Total Encephalopathy Aphasia R facial par Monoclonus Ataxia 42% Severe NR
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
CRS From Blinatumomab: Reversed with Tocilizumab Teachey, Grupp. Blood, 2013
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 1. Porter D, et al. ASH 2013; Abstracts 873 and 4162.
CART-19: CAR T-Cell Therapy: Future Directions 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 1. Porter D, et al. ASH 2013; Abstract 873 and 4162.
Colleagues and collaborators (too many to list) ACC Translational Research Carl June Carmine Carpenito Michael Milone Gwendolyn Binder-Scholl Lester Lledo Elizabeth Veloso Joan Gilmore Univ Penn Clinical Group David Porter Alison Loren Ed Stadtmauer Selina Luger Steve Schuster Elizabeth Hexner Ran Reshef Sunita Nasta Saar Gill Jacob Svoboda CVPF Bruce Levine Andrea Brennan Anne Chew Ashley Vogel Zoe Zheng Study Participants DSMC Members TCSL Jos Melanhorst Simon Lacy Minnal Gupta Irina Kulikovskaya Jeff Finklestein Frazana Nazimuddin Vanessa Gonzalez Saar Gill Path./Lab. Med. Adam Bagg Pediatrics Stephan Grupp Shannon Maude David Barrett