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Present and future of oncolytic virus therapies
 

Present and future of oncolytic virus therapies

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Description of oncolytic adenoviruses by Oncos Therapeutics and Cancer Gene Therapy Group

Description of oncolytic adenoviruses by Oncos Therapeutics and Cancer Gene Therapy Group

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    Present and future of oncolytic virus therapies Present and future of oncolytic virus therapies Presentation Transcript

    • Onkolyyttiset virushoidot:  vaikutusmekanismit,, prekliiniset tutkimukset,  kokemukset potilailla, kokemukset potilailla, tulevaisuuden näkymät Akseli Hemminki, MD, PhD Specialist in Oncology  Specialist in Oncology K. Albin Johansson Research Professor,  Finnish Cancer Institute Cancer Gene Therapy Group Molecular Cancer Biology Program &  Transplantation Laboratory &  Haartman Institute & FIMM University of Helsinki and  Disclaimer: AH is co‐founder and shareholder of  Disclaimer AH is co founder and shareholder of Oncos Therapeutics Inc., a company founded for  Helsinki Univ. Central Hospital facilitating clinical trials with oncolytic viruses
    • Cancer is not a beaten  disease CANCER > 1/2 of people alive today will get cancer*  • 1/3 of us will die of cancer • disseminated solid tumors cannot usually be cured  with currently available treatments Novel treatments are needed! * Jemal CA Cancer J Clin 2005 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2
    • Bert Vogelstein, ASCO 2009: Cancer  therapeutics after the cancer genome  therapeutics after the cancer genome project (http://cgap.nci.nih.gov/) Sequencing of complete genomes of tumors has revealed hundreds of  mutations in each tumor (Wood Science 2007, Parsons Science 2008) However, the combination of mutations is different in each tumor  , ‐> Each tumor is an individual  ‐> Difficult to use small molecular inhibitors because a different  combination of inhibitors would have to be used for each tumor  combination of inhibitors would have to be used for each tumor (Wood Science 2007, Parsons Science 2008).  ‐> For long term efficacy, each patient would have to be treated with  hundreds of inhibitors (impossible because of side effects) hundreds of inhibitors (impossible because of side effects) However, all of these mutations seem to fall in 12 pathways (Jones  Science 2008).   Therefore, better to use pathway selective drugs (Vogelstein ASCO  Th f b h l i d (V l i ASCO 2009).  For example, p16/Rb pathway selective oncolytic virus A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3
    • Deletion mutant oncolytic adenoviruses: ∆24 d i ∆24 Fueyo Oncogene 2000 Heise Nature Med 2000 E2F • S-phase E2F Rb • Virus replication • normal cell • wt Ad Rb E1A & cell lysis E1A 24 bp deletion in Rb binding site of E1A • normal cell E2F Rb E2F Rb • No S phase entry S-phase • ∆24 • No virus replication • Replication in cells ∆24-E1A ∆24-E1A mutant in Rb-p16 Rb p16 pathway E2F E2F • cancer cell E2FE2F E2FE2F • S-phase • ∆24 • Virus replication • Includes all human ∆24 E1A ∆24-E1A ∆24-E1A ∆24 E1A & cell lysis cancers (Sherr Science 1996) A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4
    • How Far is Clinical Gene Therapy ? Phase I: Safety and toxicity ? Phase II: Any evidence of efficacy ? Phase II: Any evidence of efficacy ? Phase III: Proof of efficacy  (randomization) N= 1579 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    5
    • Mutation compensation Randomized trial: head and neck cancer ‐ Ad p53 + radiation vs radiation alone Ad‐p53 + radiation vs. radiation alone ‐ 67% vs. 24% CR (N= 82, P<0.01) ‐ Pan J Clin Oncol 2008 ‐ Gendicine® for sale in China ‐ More than 10 000 patients treated Promoter p53 gene p53 gene pA Press release 23 Jul 2008: Ad Press release 23 Jul of cells p53 (Advexin )  Infection 2008: Ad‐p53 (Advexin®) Infection of cells Cancer cells phase III SCCHN trial positive in US: not  Normal cells with p53 mutation approved by FDA with healthy p53  Approved by EMEA for Li‐Fraumeni syndrome  Cell death, also sensitation to  (orphan drug) ( h d ) chemotherapy and radiation h h d di i No cell death A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    6
    • Prodrug converting enzymes (suicide gene therapy) with Ad‐TK  (suicide gene therapy) with Ad TK and GCV Ad coding for  TK Advantage vs.  thymidine kinase  mutation  mutation (TK) compensation:  bystander effect  via gap junctions Non‐toxic pro drug pro‐drug GCV Activated  Activated toxin Cell death A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    7
    • Adjuvant Ad‐TK/GCV CHALLENGE: even with bystander Randomized phase 2b for glioma (N=36). effect, canA. Mol Ther 2004 penetration Randomized phase 2b for glioma (N 36). Immonen A. Mol Ther 2004 p Immonen we get effective , g Patients resected and randomized:  into established tumors ? 1. follow‐up +/‐ XRT (= standard) SOLUTIONS: locally amplifying systems 2. Standard + Ad‐TK into resection margins, ganciclovir for 14d 2 Standard + Ad TK into resection margins ganciclovir for 14d Median survival 39.0 wk. vs. 70.6 wk. (p<0.0095) No increase in toxicity Similar results in hepatocellular ca. adjuvant trial (Li Clin Cancer Res 2007) d ) Si il lt i h t ll l Ph Phase dj results 22 O t 2009 (ASPECT study): III t lt i l (Li Cli C t Oct R 2007) t • Cerepro vs standard care: 1.43 HR (p=0.02) = positive primary end-point • About 40d increase in median survival • More temozolomide use in control group due g p to non-blinded Cerepro -> dilution of results • EMEA did not approve because non-standard end point end-point (time to re-intervention or death) re intervention • Appeal ongoing A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    8
    • Oncolytic viruses • Replication of virus  p causes oncolytic death  of cells • Normal cells‐ no  replication A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    9
    • Short history of oncolytic viruses 1896. 1st report of response to oncolytic virus ( influenza Dock Am J Med 1896. 1st report of response to oncolytic virus (”influenza” Dock Am J Med  Sci 1904) 1940s. 1st systematic trials with oncolytic viruses (”Egypt 101”, Hoster  Cancer Res 1949) 1950s. Adenovirus used for treatment of cervical cancer patients (Smith  Cancer 1956) ¬ Various serotypes, intratumoral, intravenous and intra‐arterial delivery ¬ Poorly characterized preparations: titers unknown ¬ Treatment with and without immune suppression ¬ Good safety, similar side effects to modern trials ¬ Frequent responses ¬ Approach was abandoned: relapses, advent of chemotherapeutics 1960s & 1970s. Rational development of oncolytic viruses in test animals,  further trials (Asada Cancer 1974) f th t i l (A d C 1974) 1991 & 1996. Utilization of molecular features for making viruses selective  for tumor cells (Martuza Science 1991, Bischoff Science 1996) 2004. First phase III trial with oncolytic virus completed (”H101”, Yu Curr  2004 First phase III trial with oncolytic virus completed (”H101” Yu Curr Cancer Drug Targets 2007) A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 0
    • H101 (Oncorine®) phase III trial in  advanced head and neck cancer  d dh d d k H101 is almost identical to dl1520 (=ONYX‐015)  descibed earlier in the US Randomized phase III trial (N=105) H101 + cisplatin + 5‐FU vs. cisplatin + 5‐FU H101 + cisplatin + 5 FU vs cisplatin + 5 FU CR+PR = 79% vs. 38%, P<0.0001  Mild tox: flu‐like symptoms, injection site pain p More than 800 patients now enrolled H101 approved in China Yu Curr Cancer Drug Targets 2007 Yu Curr Cancer Drug Targets 2007 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 1
    • Cancer Gene Therapy is maturing  as a treatment approach h Safety has been good – over 15 000 pts treated with both repli‐ cation deficient and replication competent (oncolytic) viruses  Recent  randomized trials (N=5) have confirmed efficacy of even  early generation approaches* early generation approaches* No patients w/ metastatic cancer cured: much work remains TUMOR PENETRATION NEEDS IMPROVEMENT Replication competent oncolytic viruses Replication competent oncolytic viruses Transcriptional tumor targeting (activation only in tumor) Transductional tumor targeting (gene delivery only to tumor) g g (g y y ) Armed oncolytic viruses * Immonen Mol Ther 2004, Li Clin Cancer Res 2007, Yu Curr Cancer Drug  Targets 2007, Pan J Clin Oncol 2008, Ylä‐Herttuala ESGCT 2008,  A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 2
    • Our own experience with oncolytic  adenovirus (update 5 Feb 2010) adenovirus (update 5 Feb 2010) • 171 patients since Nov 07. 8 different viruses • All had metastatic solid tumors progressing after routine  All had metastatic solid tumors progressing after routine treatments (chemo, radiation, etc) • Written informed consent. Full GCP implemented. • Side effects: gr. 1‐2 flu‐like symptoms, fever, fatigue, pain in all pt Side effects: gr 1 2 flu like symptoms fever fatigue pain in all pt • SAE in < 5% (eg. pain, embolus, thrombosis, cholecystitis) • No treatment related deaths so far (compare to chemo, surgery) • Clinical benefit (imaging CR, PR, SD): 61% overall, 76% best virus • Some patients have benefited for > 2 years (= length of follow‐up) • Additive/synergistic benefits from 2nd ‐ 10th treatments Additive/synergistic benefits from 2 treatments  • Long term (>500 d) survival in 48% with best virus A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 3
    • Inclusion and exclusion criteria for  oncolytic virus treatment oncolytic virus treatment Inclusion criteria  Exclusion criteria Solid tumor (not leukemia or  confirmed brain metastases or glioma lymphoma) organ transplant, HIV Refractory disease = previously  severe cardiovascular, metabolic or  d l b l treated with oncology treatments for  pulmonary disease which there is strong scientific  Other diseases that prevent oncolytic  evidence* virus treatment i t t t Good performance status: WHO  0‐2.  Elevated serum bilirubin ( (WHO 3 is safe but less efficacy) y) Serum AST or ALT > 3 x upper limit of  Written informed consent  normal No major organ function deficiencies Thrombocytes  < 75.   * In most cases this means 1st line chemotherapy for metastatic  disease, and in some cases several lines of chemotherapy (eg.  di di l li f h th ( breast, ovarian and colorectal cancer) In practice, the median number of prior chemo regimens is 3 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 4
    • Findings possible only in pts: Mechanisms of anti‐ tumor efficacy y inflammation 3. Induction of  cytotoxic T‐cells  1. Killing of differentiated tumor cells 1 Killing of differentiated tumor cells against tumors against tumors 6 CD8+ 5 vitiligo E+8 4 10E 3 2 0 17 41 48 2. Killing of tumor initiating ”stem” cells 4. Induction of specific immunity against tumor epitope (survivin) Cerullo Cancer Res in press 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 5 Eriksson Mol Ther 2007, Bauerschmitz Cancer Res 2008
    • Case: Systemic efficacy of Ad5/3‐Cox2L‐D24 in  chemo refractory neuroblastoma chemo refractory neuroblastoma • Ad5/3‐Cox2L‐D24 replicates in cells overexpressing Cox2 and  defective in the Rb/p16 pathway Previous  Previous treatments:  • 6 yr old boy, WHO 1 Vincristine +  • Progressive disease in bone marrow, left kidney, lymph nodes.  cis/carboplatin • Single oncolytic adenovirus treatment: i v intratumoral cis/carboplatin  Single oncolytic adenovirus treatment: i.v., intratumoral. + etoposide +  • Gr. 1 stomach pain, diarrhea, flu‐like symptoms, liver enzymes cyclophospham • 4 wk later: complete response in bone marrow, partial  ide response in primary  i i Doxorubicin +  etoposide +  iphosphamide;  iphosphamide; Intensive chemo  and autologous  stem cell  stem cell transplant; Oral 13‐cis‐retinoic  acid A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 6
    • Ad5/3‐ Cox2L‐D24  in neuro‐ blastoma → CD56 staining (brown) for  tumor cells in bone  marrow → Imaging of primary before  and after treatment → Increase in cytotoxic T‐cells →→ Increase in virus  neutralizing antibodies →→→ Extended presence of  virus in blood 0 →→→→ Cox2 expression in  6540 tumor (reason for  ( f 500 selectivity and efficacy) Pesonen Submitted 2008|    1 7 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    Pesonen Acta Oncol 2010
    • Higher efficacy with a second round of  treatment • Metastatic pancreatic ca. WHO 2 • Prior gemcitabine and gemcitabine chemoradiation • Second round of treatment with Ad5‐24‐RGD (Bauerschmitz  Cancer Res 2002) produced response A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 8 Pesonen in preparation
    • Higher efficacy with retreatment Adenovirus replication is  very immunogenic Second round of injection  results in enhanced  immune attack on tumor ? i tt k t ? Immunity against  adenovirus or also tumor ? adenovirus or also tumor ? Cytotoxic  Cytotoxic lymphocytes  in pt treated  with Ad5/3‐ with Ad5/3 Cox2L‐D24 Cytotoxic T‐lymphocytes approaching  tumor cells (pic from Natl Geographic) A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    1 9
    • Improving antitumor immunity: oncolytic  adenoviruses coding for GM‐CSF  adenoviruses coding for GM CSF Cerullo Mol Ther ASGT suppl 2009 GM‐CSF • GM‐CSF is the most potent inducer of anti‐ GM-CSF GM CSF anti G CS tumor immunity (Dranoff Immunol Rev 2002) GM-CSF • GM‐CSF in E3: expression starts at 8h ⇒ GM‐CSF expressed only in cells that allow replication of the virus • Hi h expression at tumor, l systemic High i low i GM CSF GM-CSF GM-CSF Cerullo Cancer Res in press 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 0
    • GM‐CSF can enhance antigen presentation  and induce NK and cytotoxic T cells and induce NK and cytotoxic T‐cells Tumor cells killed with 3 mechanisms: - Oncolytic effect of virus replication - NK cell mediated direct cell killing - DCs mediated tumor specific immunity NK NK CD8+ CD8+ CD8+ NK NK CD8+ CD8+ CD8+ NK CD8+ CD8+ NK = personalized NK Ca Ca cancer vaccine GM-CSF Ca Ca Ca Ca C DC Ca Ca Ca GM-CSF A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 1
    • Cerullo Cancer Res in press 2010 Treatments A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 2
    • Syrian hamsters cured of HapT1 tumors  with Ad5D24 GMCSF: protection from  with Ad5D24‐GMCSF: protection from HapT1 challenge N=5 ** *** *** N=5 * N=5 Cerullo Cancer Res in press 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 3
    • Syrian hamsters cured of HapT1 tumors  with Ad5D24‐GMCSF: no protection  with Ad5D24 GMCSF: no protection from HaK challenge A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 4 Cerullo Cancer Res in press 2010
    • Efficacy Ad5‐D24‐GMCSF: Single round of treatment Neutralizing Antibody Titer g y Virus Load in Serum Response p Patient Dosea Primary Week post-treatment Days post-treatment code (VP) Tumor RECISTa 0 1 2 4 0 1 2 3-7 8-12 21-40 Density/o Marker Survival ther C3 8x109 Jejunum ca 0 1024 16834 0 0 <500 <500 0 MR 120 M3 1 1010 1x10 HCC 0 16384 4096 0 0 4896 0 0 0 SD (+5.2%) ( 5 2%) 548b O12 3.6x1010 Ovarian ca 0 16384 16384 0 0 0 0 0 SD (+7.7.%) SD 106 O14 1x1011 Ovarian ca 64 64 0 0 0 <500 0 0 CR (-100%) CR 528b G15 1x1011 Gastric ca 1024 16384 16384 0 0 565 <500 0 0 -4.6% 308b K18 2x1011 NSCLC 16384 16384 16384 0 <500 0 0 856 PD (+15%) 59 T19 2x1011 Thyroid ca 0 16384 0 765 <500 <500 0 0 SD (-8.9%) MR 490b U89 2x1011 Renal ca 64 16384 0 0 0 PD (+13%) 144 S100 2x1011 Leiomyosar 0 0 16384 0 <500 <500 PD (+39%) 121 c S108 2x1011 Synovial 0 0 256 0 <500 <500 0 PD (+59%) 74 sarc M50 2.5x1011 Mesothelio 256 16384 0 0 <500 0 SD (-5.7%) 403b ma R8 3x1011 Breast ca 64 16384 0 <500 <500 0 CR (-100%) PR 447b M32 3x1011 Mesothelio 0 256 16384 0 0 0 0 PDc 125 ma X49 3x1011 Cervical ca 16 4096 1024 0 4290 1211 PD (+55%) -27% 92 I52 3x1011 Melanoma 0 256 256 0 576 PD (+25%) 112 I78 3x1011 Choroideal 0 64 0 44876 <500 63 mel C58 4x1011 Colon ca 256 16384 16384 0 1978 4236 PD (+37%) 118 R73 4x1011 Breast ca 0 256 1024 0 <500 25787 SD (-3.6%) 245b O88 4 1011 4x10 Ovarian O i ca 0 1024 0 <500 yesd PR 126 O9e 2x1011 Ovarian ca 16384 16384 0 2133f MR (-20%) 142 Overall efficacy (radiology) Summary of side effects - CR 2/16 - All pts: gr 1-2 flu-like symptoms, fatigue, fever - MR 1/16 - One gr 3 ileus (OvCa pt w similar previous episodes) - SD 5/16 Cerullo Cancer Res in press 2010 - Lab: gr 1-2 AST/ALT, hypo-K+,mgrk1-3   hypo-Na+   |    2 5 A k s e l i   H e m i n i       |   2 3  F e b  2 0 1 0 - PD 8/16
    • Efficacy of Ad5‐D24‐GMCSF in injected and  non injected tumors: mesothelioma patient non‐injected tumors: mesothelioma patient • 60 yr old man, asbestos exposure • Prior treatment with cisplatin+pemetrexed Prior treatment with cisplatin+pemetrexed • WHO 1 • Single intrapleural and i.v. injection  • More prominent reduction of non‐injected tumor than  More prominent reduction of non injected tumor than injected tumor A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 6 Cerullo Cancer Res in press 2010
    • Complete response in OvCa pt  with small disease burden ith ll di b d Metastatic ovarian ca. 2002 M t t ti i 2002 Operation, adjuvant CEF x6, taxol+carbo x6, docetaxel,  bevacizumab, topotecan, erlotinib, aromatase inhibitor Progressive disease, WHO 1 Single intraperitoneal treatment Complete response (CT, markers) for 9 mo  Cerullo Cancer  Cerullo Cancer Res in press  2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 7
    • Rapid response upon re‐treatment with  GM CSF coding oncolytic GM‐CSF coding oncolytic adenovirus • Peritoneally metastatic ovarian cancer since 2005.  • 5 lines of chemo (paclitaxel‐carbo, liposomal doxorubicine,  gemcitabine+carbo, gemcitabine, topotecan) • Progressive disease, WHO 1 • 52.5% tumor size reduction in 17 days after 2nd treatment y A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 8 Cerullo Cancer Res in press 2010
    • Long term survival in 1/3 of patients  treated with Ad5 D24 GMCSF treated with Ad5‐D24‐GMCSF A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    2 9 Cerullo Cancer Res in press 2010
    • Immunological response to GM‐CSF  coding oncolytic adenovirus coding oncolytic adenovirus Adenovirus: T cell response  towards adenovirus  towards adenovirus components (Hexon, Penton,  Fiber etc.)  ) Tumor: T cell response to  tumor specific epitopes tumor specific epitopes 6 CD8+ 5 10E+8 8 4 3 2 0 17 41 48 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 0
    • CT guided injection displays  immunological response to adenovirus immunological response to adenovirus 3 h before oncolytic virus.     10 min after CT guided  3 h before oncolytic virus. 10 min after CT guided injection (3 ml) A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 1
    • eceptor king of T‐Cell re Block Ad5 (hexon) Specific  Immunity Cerullo Cancer Res in press 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 2
    • eceptor king of T‐Cell re Block Tumor‐specific  Immunity y (Survivin) Cerullo Cancer Res in press 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 3
    • Inflammation due to virus and/or GM‐ CSF can falsely increase tumor markers  CSF can falsely increase tumor markers and enlarge tumors  Virus replication  • 59 old man with esophageal cancer  59 old man with esophageal cancer activates tumor  cell metabolism • Prior chemo: oxaliplatin+capesitabine,  oxaliplatin, docetaxel, irinotecan‐ paclitaxel, cyklo‐doxo‐cisplatin, oxali‐ irino‐cetuximab, capecitabine • Progressive disease WHO 1 • Intratumoral and i.v. virus injection Necrosis A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 4
    • Baseline                 3 months              6 months Senzer J Clin Oncol 2009 Effects of  Effects of oncolytic inflammation  inflammation on tumor size Reid Cancer Res 2002 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 5
    • PET‐CT more useful for oncolytic viruses ? Park Lancet Oncol 2008 Senzer J Clin Oncol 2009 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 6
    • Improving transduction to  improve oncolysis i l i Coxsackie‐ LOW CAR  ‐ LOW CAR ‐ adenovirus  receptor (CAR):  key to Ad entry key to Ad entry LOW GENE  DELIVERY ! CAR IS AN  CAR IS AN ADHESION  MOLECULE ‐ LOW  LOW EXPRESSION  IN TUMORS  A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 7
    • Increasing infectivity of target cells:  transductional targeting Non-targeted Targeted T t d adenovirus adenovirus Adenovirus receptor CAR High Low transduction Benign cell transduction Tumor associated receptor p Low High transduction Cancer cell transduction A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 8
    • Serotype chimerism for tumor targeting  120 Ad5 CAR 100 3x 1x108 VP i.p. Ad3 receptor 80 % Survival Negative  M1 60 40 Kanerva Mol Ther 2003 20 0 15 25 35 45 55 65 75 85 95 105 115 125 135 Day Kanerva Clin Cancer Res 2002 1,E+06 Biodistribution Ad3 receptor CAR 1,E+05 RLU / mg protein 1,E+04 1,E+03 Ad5/3  1,E+02 , with knob domain  1,E+01 * from Ad3 1,E+00 Kanerva Mol Ther 2002 s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    3 9 Ak
    • Cancer stem cell (CSC) hypothesis CSC Committed progenitors cells: Rapid replication PCa Limited lifespan Self-renewal: fibro CSC Slow replication other Unlimited lifespan inflam vasc Ca Ca Most ca. treatments select target Ca cells based on higher replication Ca Ca Ca Ca Ca stem cells may not actively y y replicate: not killed Ca C Ca Ca Differentiated Ca Ion transporters remove drugs ca. cells from cells: not killed CSC Ca Tumors T mors are mixed mi ed Clinical research may have missed populations of cells CSC specific agents A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 0
    • Cancer stem cells can be killed with  oncolytic adenoviruses oncolytic adenoviruses Eriksson Mol Ther 2007 Bauerschmitz Cancer Res 2008 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 1
    • Ad5/3‐D24‐GMCSF Fiber chimerism for enhanced  transduction of cancer cells Replication  in cells mutant in Rb‐p16  NK NK CD8+ pathy CD8+ CD8+ NK CD8+ CD8+ Includes most human cancers NK CD8+ CD8+ CD8+ NK NK GM‐CSF  can enhance antigen  NK Ca Ca presentation and induce NK and  GM-CSF Ca cytotoxic CD8+ T‐cells Ca Ca DC Ca Expressed under the control of E3 Ca Ca Starts at 8h Ca = personalized Expression coupled to virus  GM-CSF cancer vaccine replication p Koski  Submitted 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 2
    • Ad5/3‐D24‐GMCSF effective in vitro MDA-MB-436 A549 A549 As effective as wild type GMCSF secretion verified GMCSF secretion verified Koski  Submitted 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 3
    • Benefits of treatment (single injection  of Ad5/3 D24 GMCSF) of Ad5/3‐D24‐GMCSF) Objective benefit in Computer Scans (RECIST 1.1): Objective benefit in Computer Scans (RECIST 1 1): Minor Response (MR) 17% (best ‐15%) Long term survival of  Stable Disease (SD) 50% y >250 days in circa 40%    Progressive Disease (PD) 33% Clinical benefit (imaging): 67% (ongoing) Other benefits: Other benefits: Adverse events d e se e e ts CR: ascites and pleural effusion Monitored for 4 weeks CR: pleural effusion  No grade 4‐5 events CR: non‐injected liver metastasis CR i j d li i One grade 3 cholecystitis 1% reduction in injected tumor Mild to moderate flu‐like  Injected tumor 6% smaller j symptoms, fever, fatigue,  symptoms fever fatigue Overall biological activity injection site pain common (intent to treat population): 13/21= 62% No elevations in cytokine  levels  l l Koski  Submitted 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 4
    • Examples of Ad5/3‐D24‐GMCSF  nt Before treatmen t efficacy in patients K75 NSCLC: CR in O129 ovarian cancer: I98 melanoma: - 39% (v/v) p pleural eff. & ascites -17% (v/v) (v/v) ) eatment 2 mo. after tre Koski  Submitted 2010    2 3  F e b  2 0 1 0    |    4 5 Akseli Hemminki   |
    • Pretreatment prediction of CGTG‐102  efficacy 2,5E+07 , V136 1,6E+05 K75 Pleural effusion cells *** *** sion (RLU) 1,4E+05 Ascites cells ene expression (RLU) 2,0E+07 1,2E+05 1,0E+05 gene express 1,5E+07 8,0E+04 1,0E+07 6,0E+04 Transge 4,0E+04 4 0E+04 Transg 5,0E+06 2,0E+04 0,0E+00 0,0E+00 Ad5luc1 Ad5/3luc1 Ad5luc1 Ad5/3luc1 / Ad/3luc1 ***p<0.005 against Ad5luc1 Pre‐treatments samples of malignant pleural effusion and ascites Pre‐treatments samples of malignant pleural effusion and ascites Luciferase expression of cells infected with 5000 vp/cell V136: SD in CT scan, liver metastasis disappeared K75: CR in ascites formation  K75: CR in ascites formation Koski  Submitted 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 6
    • Ad5/3‐D24‐GMCSF is able to kill  pleural effusion cells pleural effusion cells 200 250 V136 M137 180 160 200 140 bility of (%) ) 120 150 ability (%) 100 80 100 *** Via 60 Viab 40 50 *** 20 0 0 Uninfected Ad5luc1 Ad5/3-d24- Uninfected Ad5luc1 Ad5/3-d24- cells GMCSF cells GMCSF ***p<0.005 against uninfected cells Pre‐treatment samples of malignant pleural effusions Pre‐treatment samples of malignant pleural effusions Cells from sample infected with 100 vp/cell V136: SD in CT scan, liver metastasis disappeared M137: SD in CT scan, CR in pleural effusion formation M137: SD in CT scan CR in pleural effusion formation Koski  Submitted 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 7
    • Higher amounts of virus at the tumor than  in blood  8000 6851 7000 Serum 6000 Ascites Virus in ascites sample  r  (vp / ml) 5000 able to produce  bl d cytopathic effect in 70%  4000 of wells in cell culture  (293 cells) (293 ll ) Titer 3000 2000 Functional virus present 1000 <500 0 0 NA NA 0 Day 0 1 Day 1 Week Patient (O82) had MR in tumor marker  levels during follow up Koski  Submitted 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 8
    • Induction of anti‐adenoviral and anti‐ tumoral immunity in blood tumoral immunity in blood ELISPOT- patient I80 (had vitiligo) Increase of CD8+ T lymphocytes after of CD8+ T lymphocytes treatment in 10/14 patients an SFC per million  cells 120 Adenovirus Average CD8+ cell count increases 100 1,60 80 CD cells x10e10/l 1,40 60 1,20 40 1,00 N 10 N=10 20 x Mea 0,80 0 0,60 0 35 0,40 Days (post‐treatment) D8+ Mean SFC per million  cells 0,20 60 0,00 Survivin Pre-treatment After treatment 50 40 30 Analysis of T cells specific for of T cells for   20 adenovirus and tumor epitopes with 10 0 interferon gamma ELISPOT 0 35 Days (post‐treatment) Koski  Submitted 2010 A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    4 9
    • Summary Overall survival w/ CGTG‐102 50% survival = 315d Survival at 200d = 75% Survival at 500d = 48% N=25 Clinical proof‐of‐principle available  for many ca. gene therapy approaches y g py pp Safety has generally been excellent Effective gene delivery continues to be key to efficacy Oncolytic viruses amplify and help in tumor penetration  Anti‐viral and anti‐tumoral immunity key in efficacy Multiple injections more effective than single Multiple injections more effective than single Overall clinical benefit 76% in 110 treatments with our best  virus CGTG‐102 (now being tested in a clinical trial) 48% overall survival at 500d with CGTG‐102 Earlier treatment and smaller tumor load increase benefits Formal clinical trials are needed ! (€€€)  Formal clinical trials are needed ! (€€€) A k s e l i   H e m m i n k i       |     2 3  F e b  2 0 1 0    |    5 0