Kræft Immunologi Kunsten at hæmme immunhæmmere

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1 CCIT DENMARK Kræft Immunologi Kunsten at hæmme immunhæmmere Mads Hald Andersen, professor Sundhedsstyrelsens specialespecifikke kursus: Teoretisk Immunologi, april 2015 OUH, Odense

2 Forskning ved CCIT, Herlev Hospital, Dk Management: Inge Marie Svane, Per thor Straten and Mads Hald Andersen Basal immunforskning Immunmålinger Klinisk immunforskning 2

3 Dagens program Baggrund Introduktion til immunforsvaret og Immunforsvarets genkendelse af kræft Immunhæmning betydning i klinikken Fra laboratoriet til klinikken Konklusioner

4 Kræft immunologiens historie

5 Immunterapi imod kræft store gennembrud Approvals of Dendreons Prostate Cancer Vaccine (provenge), Ipilimumab antibody for melanoma September 2014: anti PD 1 mab, Pembrolizumab and December 2014: Nivolumab FDA approvals

6 Cytokines Antibodies Immunterapi imod kræft Adoptive T cell transfer Vaccines 6

7 Innate and adaptive immune responses * Innate immune responses : Response : Fast Cell types : Dendritiske celler (DCs), Mø, Recognizes antigen by germline encoded receptors * Adaptive immune responses : Response : Slow Cell types : B- and T cells Recognizes antigen by unique receptors generated by somatic gene rearrangent

8 Aktivering af T celler Bacterie, Virus, kræftcelle protein, ect T celle

9 Den aktiverede T celle deler sig! Cirkulerer via blodet til infektionsstedet eller kræftknuden

10 illustreret videnskab nr. 12/2009

11 T celle aktivers Pardoll D. PNAS 2002;99: by National Academy of Sciences

12 Den gode cirkel cancer celler Lymfe knude Behandlende vaccine Dendritiske celler optager protein fra cancer celler Aktivering af T-celler cell Infiltration og drab af cancer celler

13 What is recognized by the immune system... Cancer cells: genetic and epigenetic changes X Mutation Deletion CH 3 CH 3 CH 3 Methylation Translocation Gene A Gene B

14 T cells recognizing cancer cells Cancer antigen tumor specific T cells

15 Normal celle Kræftcelle

16 Normal celle T-celle

17 Normal celle T-celle

18 Kræftcelle

19 Kræftcelle

20 Død kræftcelle

21 Live and let Die

22 Live and let Die

23 Tumor antigens that are recognized by T-cells Group I. Viral antigens, e.g. HPV Group II. Broadly expressed mutated antigens, e.g. ras, braf Group III. Patient specific mutated antigens Group IV. differentiation antigens, e.g. MART-1, gp100, PAP Group V. Cancer-testis antigens, e.g. MAGE Group VI. Overexpressed (including universal) tumor antigens, e.g. telomerase, survivin

24 Vævstype molekyler (HLA) præsenterer cellens indhold på overfladen

25 Peptide/HLA restriction..ltlakhtissdyvipigtygqmk EKCDICTDEYMGGQHPTN. TLEGFASPLTGIADASQSSMHNALHIYMNGTMSQVQGSAND VLTALLAGLVSLLCRHKRK HLA A1 HLA A2 HLA A3 50 % of Caucasian population

26 Spontan immunreaktion imod kræftproteiner (antigener) i en patient med modermærkekræft kræft patient Rask kontrol kontrol gp100 Survivin TRP-2 Mage-3

27 .so what s the problem? Gary Larsson

28 .so what s the problem? Immune escape Loss of Hla/antigen No danger > no activation of T cells Immune suppresive molecules and cells Direct immune suppressive actions By induction or attraction of regulatory cell types

29 Suppressive mechanisms that have been identified in human melanoma metastases and validated mechanistically in preclinical studies. Gajewski T F Clin Cancer Res 2007;13: by American Association for Cancer Research

30 Cancer Cell Tumor specific T cell

31 Cancer Cell Tumorspecific T cell

32 Antibodies Ipilimumab = anti CTLA 4 Ipilimumab extend survival in metastatic melanoma patients in phase 3.

33 Translational research at CCIT Mads Hjortsø Merete Jonassen Shamaila Munir Ahmad Stine Kiær Larsen With support from: The Novo Nordisk Foundation, The Danish Cancer Society, Danish Medical Research Council, The John and Birthe 33 Meyer Foundation, and Herlev Hospital.

34 Suppressive mechanisms that have been identified in human melanoma metastases and validated mechanistically in preclinical studies. IDO Gajewski T F Clin Cancer Res 2007;13: by American Association for Cancer Research

35 Can IDO be used as at vaccine target? 35

36 IDE: Kan immunforsvarets effektorceller genkende immunhæmmende celler (som udtrykker unormale mængder af visse proteiner, f.eks. IDO IDO + tumor IDO + APC IDO reagerende T-celler? T 36

37 IDO a T cell target? IDO protein IDO-specific T cells 37

38 Analyse af immunreaktioner Immun-reaktion: Kontrol kræftprotein Ingen Immun-reaktion Patient prøve Isolering af blodceller Forsøg Kontrol kræftprotein Elispot

39 T celler som reagerer imod det immunhæmmende protein IDO findes i kræftpatienter Eksempel Uden IDO Med IDO IDO specific cells per 4 x 10^5 cells HD BC MM RCC Blod fra kræftpatiener

40 T-celler dyrkes i laboratoriet og undersøges T celler T Drab af både kræftceller og immunhæmmende celler T Kræftceller immunhæmmende celler

41 IDO specifike T celler dræber IDO + cancer celler Lysis (%) 20 0 T2 T2 + IDO peptide Cancer cells Cancer cells (+ HLA mab) Cancer cells (IDO neg) Cancer cells (control ShRNA) Cancer cells (IDO ShRNA) Cancer cells

42 IDO specifike T celler dræber IDO + immunceller 60,0 Δ In vitro immatured autologous DC In vitro matured autologous DC 60,0 Δ In vitro immatured allogeneic DC In vitro matured allogeneic DC 50,0 50,0 Lysis (%) 40,0 30,0 20,0 Lysis (%) 40,0 30,0 20,0 10,0 10,0 0,0 15:1 5:1 1.7:1 0.6:1 E:T ratio 0,0 15:1 5:1 1.7:1 0.6:1 E:T ratio In vitro immatured DC In vitro matured DC MFI 428 1,438 IDO

43 HIV Tetramer CMV Tetramer 0.21% 19.29% Tetramer PE 0.10% 88.09% Tetramer APC

44 IDO specifikke T celler øger immunforsvarets øvrige reaktioner Leukemia 2013

45 IDO expression in antigen presenting cells Modified from 45 Wing et al. Nature Immunology, 2010:11; 7 13

46 Summary IDO specifikke T celler findes spontant i kræftpatienter IDO specifikke T celler kan dræbe kræftceller og immunhæmmende celler Ido specifikke T celler kan øge immunforsvarets øvrige reaktioner imod kræft 46 Sørensen et al. Blood, 2011,

47 Vaccination kan blive måden at ramme immunhæmning + Vaccination IDO vaccine T Kræftceller T T T T T Dræber T celler Immunhæmmende celler

48 Target identification From lab to bench Pre clinical evaluation Tox test Clinical testing Patents? 48

49 Meget papir arbejde Udarbejdelse af protokol m.m.m. GCP enhed Videnskabsetisk Komité Datatilsynet Lægemiddelstyrelsen

50 From bench to clinic HLA A2 restricted IDO peptide/montanide vaccination in 14 NSCLC patients IDO5 No peptide Trine Zeeberg Iversen From June 2012: Phase I/II clinical trials with IDO and survivin peptide vaccination with montanide and GM CSF in melanoma patients in combination with temozolomide. 50

51 IDO Nyt antigen for vaccine terapi Fase I studie til metastatisk, stadie III IV lunge cancer patienter First in man study opstartet i Juni NCT Studiet lukket, 15 HLA A2 NSCLC patienter inkluderet Primært endepunkt: Toxicitet Sekundært endepunkt: Klinisk effekt Tertiært endepunkt: Induktion af immunrespons Vaccinen er opfundet og patenteret af CCIT IDO aminosyre sekvens (HLA A2: ALLEIASCL) Første peptidvacccine forsøg I Danmark Dias 51

52 Vaccine behandling Imiquimod (TLR 7) på vaccine site IDO peptide mix med Montanide Vaccine injektion subcutant Innate immunsystem Adaptive immunsystem Dias 52

53 Kliniske resultater %Changesintarget lesions Response to IDO vaccine treatment (N=15) Pt# PD Blue: New lesion Red: >20% PD Orange: On study PR Pt# Months Target Lesion (Pt#18) Baseline March st Eval July nd Eval Oct rd Eval Dec th Eval March 2013 A (liver) B (liver) C (liver) th Eval June 2013 Sum (cm) Dias 53

54 Overlevelsesanalyser Overall survival (N=25) 100 N=15 HLA-A2 pos. (+vacc.) Median OS=25.9 months Percent survival N=10 HLA-A2 neg. (-vacc.) Median OS=7.7 months P= Days Dias 54

55 Immunanalyser IDO specifikke CD8+ T celler Dias 55

56 Flow cytometry analyser immunceller Dias 56

57 CONCLUSIONS No severe toxicity induced IDO vaccine safe and well tolerated Partial response in one patient with liver metastases Sustained disease stabilization in around half of the patients Significant better OS in HLA A2 positive (vaccine treated) vs. HLA A2 negative (non treated) patienter Demonstration of IDO specific T cells in most of the patients, ex vivo killing of cancer cells Pre response towards IDO correlated with clinical benefit Phase II IDO vaccine trial (NCT ) Iversen et al., Clinical Cancer Research, In press

58 IDO et eksempel på Translational Research IDO identificeret som antigen for cytotoksiske T celler IDO specifikke T celler kan genkende og slå kræftceller og immunhæmmende celler ihjel IDO vaccination virker som en lovende ny vaccine strategi imod kræft Kan med fordel benyttes i kombination med anden terapi 58

59 Selv reactive, regulatory T cell antigens * Heme Oxygenase 1 specific CD8 T cells are present in high frequencies in cancer patients seem to have a regulatory function Andersen et al. J. Clin. Invest. 119, 2009 IDO 2 specific cytotoxic T cells are present in healthy individuals as well as cancer patients. Such T cells are able to kill IDO2 expressing breast cancer as well as colon cancer cells. FoxP3 can be recognized by cytotoxic T cells and specific CD8 T cells enhaunces tumor immunity Nair et al. Cancer Resarch 67(1), 2007 Sorensen et al. Cancer Resarch 71(6), 2011 Larsen et. al, Leukemia 2013 PD L1 specific cytotoxic T cells are present in healthy individuals as well as cancer patients Munir et al. Cancer Research, 2013 Munir et al. Leukemia 2013 Ahmad et al. Leukemia 2013 IDO plays a vital role in inflammation and cancer. Specific T cells identified in melanoma patients Sørensen et al PlosOne 2009, Blood 2011, Munir et al, PlosOne 2012 Additional similar novel targets: FoxO3, TDO.. 59

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61 Tumour cells Chemotherapy + Vaccination Treg Treg Treg Treg Treg T T T T T T T MDSC MDSC MDSC IDO+ DC

62 immunreaktionen mod kræft er der, men den er svag.. men den kan styrkes gennem immunterapi!

63 It is a mistake to try to look too far ahead. The chain of destiny can only be grasped one link at a time. Sir Winston Churchill