Cellular Immunotherapy

BMedSC
Frederick Chen
Consultant Haematologist
NHSBT & Cancer Sciences

Father of Modern Immunotherapy:

Immunisation against cow pox

Picture 18. A painting showing Jenner

vaccinating James Phipps.
Wellcome Library, London.

Enhancing immunity

Active immunisation:

Preventative Vaccines

Therapeutic vaccines
Dendritic Cell vaccine
Ralph Steinman

Immunotherapy

E. Donnall Thomas

Passive immunisation:

Haemopoietic Stem Cell Transplant

Adoptive T cellular therapy

Donor Lymphocytes Infusion

Hans-Jochen Kolb

Enhancing immunity:
from infections to cancer, from prevention to therapy
Cancer Vaccines
Preventative Vaccines
Hepatitis B
HPV

Therapeutic vaccines: Cancer Vaccines

DC vaccine: eg. melanoma
Prostate
HCC
BCG for Bladder Ca
Peptide vaccines eg. AML

 Hep B vaccine prevents hepatocellular carcinoma:

450 million carriers of Hep B worldwide
1/2million new cases of HCC/year
Reduction in HCC incidence by 50%
in Taiwan since 1980s (MH Chang 1997, NEJM
1997)
HPV vaccine for prevention of Cervical Carcinoma
million new cases / year
Vaccination programme for teenage girls

Dendritic cell Cancer vaccine

PROVENGE by Dendreon
1st FDA approved DC cancer vaccine
For advanced prostate cancer
Extends life by 3 months for $90,000
Share price

FDA approval

Enhancing immunity: from infections to cancer, from prevention to therapy

Adoptive Cellular Immunotherapy

Replacement ACT
HSCT
Solid Organ Transplantation

Cancer ACT

virus-associated malignancies

Non-viral

CMV disease
EBV-assocaited Post-Transplant
Lymphoproliferative Disease (PTLD)

EBV-associated primary tumours eg.:

PTLD
Nasopharyngeal carcinoma
NK T-cell Lymphoma
Hodgkins disease

Melanoma

CLL
Synovial cell sarcoma

Leukapheresis

COBE Spectra
cell processor

Conditioning

Chemotherapy
+/- radiotherapy

Patient with leukaemia

Post transplant

Patient with leukaemia

Immune Reconstitution mimicks anti-viral

response

Read months for post-transplant reconstitution

From google search

Causes of death
Post-allogeneic Haemopoietic Stem Cell Transplant
(over 1000 performed / year in UK)
Leukaemia
Relapse
50%
Infections
25%

GvHD
25%

Immunotherapeutic solutions for HSCT

Anti-leukaemia Immunotherapy
non-specific/target unknown?

DLI

Chemotherapy
+/- radiotherapy

Relapsed
leukaemia

Patient with leukaemia

Post transplant

Patient with leukaemia

Adoptive Immunotherapy: DLI

No. of patients
Diagnosis

Studied

Evaluable*

Complete remission (%)

CML
Cytogenetic relapse

57

50

40 (80)

Hematologic relapse

124

114

88 (77)

Transformed phase

42

36

13 (36)

Polycythemia vera/MPS

AML/MDS

97

58

15 (26)

ALL

55

20

3 (15)

MMY

25

17

5 (29)

EBMT-95 survey

Targeted Immunotherapy

Immune response
INNATE IMMUNITY

ADAPTIVE IMMUNITY

Non-specific but immediate

Specific, has memory, amplifies

and rapid

skin, mucosal linings, saliva, gastric juices

Complement system

Inflammatory mediators eg. cytokines

Neutrophils, Macrophages

NK cells

Toll-like receptors

T lymphocytes
(cellular immunity)
CD8 (cytotoxic)
CD4 (Th1, Th2)
Regulatory CD4
B cells and antibodies
(Humoral Immunity)

Key to recognition of antigen by cytotoxic T cell

-basis of Tissue Matching in TransplantationCytotoxic T-lymphocytes

Infected Cell

(MHC I)

Nanomer peptide
(9 amino acids)

Birds eye view

1. Birmingham: CMV infection as

model for antigen-specific
immunotherapy
using HLA tetramers

Scale of the problem

Prior to use of ganciclovir, CMV Pneumonitis post
BMT was associated with 70% mortality
(GM Schmidt et al, NEJM:325: 1005, 1991)

1.

Diagnostic HLA Tetramers

(HLA-Tetramers- J Altman, P Moss, Science 1996)

C
D
8

Using HLA-Tetramers for immunotherapy

PE

TetramerCMV

Biotin

2. HLA tetramers for immunomagnetic

isolation

Avidin-PE

PE-Tetramer-bound CMV-specific CTL can be selected

with anti-PE magnetic beads

(M Cobbold, P Moss JEM 2005)

HL A-T etCMV

Magne tic column

T Cell
PE

Selecte d CMV-spec ific

CD8+ T c ells

Anti-PE mAb bound to

magnet ic MACS microbeads

Discard non -spe cific T cells

The cliniMacs machine can be used to select T

cells to clinical grade

99% purity

12% CD8s

Tetramer

99% CD8s

CD8

Positive selection

Targeted Adoptive Immunotherapy:

Direct transfer of CMV-specific DLI
Phase I/II trial

250mls PB
or PBSC

Radiotherapy

immunosuppressed

CMV INFECTION

Outcome of Phase 1 Trial

CMV-specific T cells expand in vivo following
transfer
9

8000

7000

6000

Viral Load

5000

0.5x106
T cells
Infused

5
4

CMV-specific cells

4000
3000

3
2000

1000

1
0
0

20

40

60

80

100

120

140

160

180

0
200

Day Post Transplant

In 8/9 (89%) viraemia resolved completely

Very few cells were needed (mean 0.5 x 10^6 CTL)

Use of Ganciclovir reduced by 48%

250x fold expansion in vivo

No Adverse side effects. No GVHD

Up to 99% purity with HLA tetramers

CMV TRIALS
Proof of principle trial

Phase I Trial

Randomised Controlled Trials

IMPACT- Sib
Phase II / III
Cell Medica/NHSBT
(NHSBT logistical support)
2008

(UoB/NHSBT - R&D)
2001
ACE-ASPECT - MUD
Phase II trial
UoB/NHSBT/Cell Medica
(UoB/NHSBT - R&D)
2010

Clinical Practice

Adoption by
clinicians ?

ACE-ASPECT

Collaboration with Industry: Cell Medica

Funding from LLR
Multi-centre trial: 10 UK SCT centres

Selection from unrelated stem cell harvest

minimises risk and inconvenience to donors
off- the shelf cryopreserved cells

CMV specific CD8 T cell reconstitution in ACE Trial 08/2

BC 4 Strept-select 25.11.08.001

R2

c e ll n u m b e r /m l

610 0 5

410 0 5

VTE

210 0 5

NLV
VLE
10 0

10 1

10 2
CD8 FITC

10 3

10 4

Single reagent Streptamers can be dissociated from bound cells

Patient Recruitment

50

100

150

Days post HSCT

200

250

2. EBV

Epstein Barr Virus (EBV)

EBV INFECTION SYNDROMES
Asymptomatic or mild symptoms
Glandular Fever (infectious Mononucleosis)
Chronic active EBV infection
Fulminant infections

EBV-ASSOCIATED TUMORS
Burkitts lymphoma (endemic variant)
Hodgkins lymphoma
Nasopharyngeal carcinoma
Nasal NK T cell lymphoma

EBV is cancerogenic

Diffuse large B cell lymphoma of the elderly

Diffuse large B cell lymphoma of CNS in HIV
Post-transplant lymphoproliferative disorder (PTLD)

Post-Transplant Lymphoproliferative
Disease

EBV-driven

Epidemiology
Post HSCT : 1-5% ??
Post Solid Organ Transplant 5-10%??
Post Cord Blood transplant: <10% ??

Standard treatment:
Reduction in immunosuppression
Rituximab +/- CHOP chemotherapy 60-70% response
Need for novel treatment eg. Immunotherapy

Post-Transplant Lymphoproliferative disease

The Lancet
Volume 345, Issue 8941, Pages 9-13, 1995

Use of gene-modified virus-specific T lymphocytes to control Epstein-Barr-virus-related

lymphoproliferation
C.M Rooney, C.Y.C Ng, S Loftin, C.A Smith, C Li, R.A Krance, M.K Brenner, H.E Heslop, C.M Rooney, M.K Brenner
Department of Virology and Molecular Biology, St Jude Children's Research Hospital, Memphis, TN 38105

Ten years follow-up of adoptive immunotherapy with EBV-specific CTL in HSCT

(1993- 2005; Heslop et al. Blood 2010)

No CTL prophylaxis:
11% of transplants
developed PTLD

Prophylaxis:
12 developed EBV
reactivation but no
PTLD

3rd party EBV-CTL for post-SOT PTLD

(T.Haque, D.Crawford, Blood 2007)

Review of EBV targeted cellular immunotherapy

(using in vitro expanded EBV CTL)

Cancer Immunotherapy
40%

Transplant immunotherapy
60%

A. Merlo et al. Haematologica 2010

Outcome of EBV-targeted cellular immunotherapy

Ex vivo selection
HLA-multimers

8 hrs

Cytokine Capture

<36 hrs

Rapid selection from HSCT donors

IFNCytokine Capture System + CliniMACS (Miltenyi)
Pool of 23 EBV peptides

Blood, April 2010

6 patients treated
50% CR (3/6)
Early PTLD responded
3 Patients with late PTLD
with multi-organ failure died

Engineered T cell
Immunoreceptors

THE CONTEXT

T cell engineering
Retroviral TCR or CAR Transduction into T Lymphocytes for
immunotherapy
Gene encoding
tumour-specific
TCR
Autologous
or donor
lymphocytes

TCR-td Adult PB CD8 T cells

TCR or CAR
modified T cell

Cancer patient

P
Gene
transfer

Infuse cancerspecific T cells

16th October 2014

CAR-19 therapy
Phase I/IIa Trial

30 B-ALL (25 children & young adults, 5 older patients)

18 were post-HSCT relapses

26 in 1st to 4th relapse,

3 primary refractory,
1 relapsed T-ALL (CD19+)
hopeless cases

Outcome

90% CR ; 78% OS 6mo

7 relapses

19 patients had sustained remissions

3 no response

(Standard salvage therapy 40% CR)

Toxicity & Complications

No GVHD or off-target reactivities
Cytokine release syndrome
30% severe ITU
IL6 blocker Tocilizumab
Absence of B cells CR
Return of B cells relapse (MRD monitoring)
Patients need i.v. Immunoglobulin replacement therapy

Immunotherapeutic solutions for HSCT

Graft-Versus-Host Disease
(GVHD)

Acute GVHD

Lichenoid Lesions of Chronic Graft-versus-Host Disease

Antin J. N Engl J Med 2002;347:36-42

Measures against GVHD

Prevention
donor selection, HLA matching
T cell Depletion: Campath. ATG
Cyclosporin + Methotrexate

1st line treatment

steroids

2nd line treatment

Tacrolimus, Mycophenolate Mofetil (MMF)
Campath, ATG
anti-TNF, anti-CD25
PUVA
Photopheresis
Mesenchymal Stem Cells

Mesenchymal Stem Cells as

Immunosuppressive therapy

- Originally found in marrow cultures, but can be isolated from

virtually all tissues and expanded up to large numbers.

- MSC inhibit many immune responses, probably through

a variety of secreted and cell surface factors.

Mesenchymal Stromal Cells (MSC)

MSC differentiate into bone, fat and cartilage. In vivo, MSC also probably develop into stromal elements of
bone marrow and lymph nodes, and provide trophic support for HSC and lymphocytes

Bone

Fat

Cartilage
Images:JG, edc2, sciweb, MMG

Immunological Properties of MSC

Do not provoke a strong alloresponse
Are immunosuppressive

Nauta & Fibbe

Blood 110:3499

Treatment of severe acute graft-versus-host

disease with third party haploidentical mesenchymal
stem cells Le Blanc et al Lancet.2004May1;363(9419):143941

Liver
GvHD
marker

Gut
GvHD
marker

Days after HSCT

Cell Therapy approaches

In vitro expansion culture 2-3 months

EBV /CMV CTL

TIL
CIK
MSC
T Reg

Ex vivo selection
Antigen-specific T cells
HLA-multimers
Cytokine Capture

8 hrs
<36 hrs

T-Reg rapid selection

Engineered T cells
4 days
T Cell Receptor transduced lymphocytes
Chimeric Antigen Receptor transduced lymphocytes

Factors that determine the Efficacy of targeted

immunotherapy
Target Antigen
Cancer-specific
Self antigens eg. cancer testis
TCR/CAR quality
specificity
Affinity
avidity
T-cell biology
Exhausted T cells
Young T cells
Immunomodulation
Checkpoint inhibitors: CTLA4 & PD1 inhibitors

Lymphodepletion

10 10

10 7-8

10 8

10 5-6

P.Moss & A. Rickinson, Nature Reviews Immunology 2005