Cancer Gene Therapy
                                               h


Akseli Hemminki, MD, PhD

Specialist in Oncology an...
How Far is Clinical Gene Therapy ?



                   Phase I: Safety and toxicity ?
                   Phase II: Any e...
Mutation compensation

                             Randomized trial: head and neck cancer
                             ‐ ...
Prodrug converting enzymes
             (suicide gene therapy) with Ad‐TK 
             (suicide gene therapy) with Ad TK
...
Adjuvant Ad‐TK/GCV
                                           CHALLENGE: even with bystander
Randomized phase 2b for gliom...
Oncolytic viruses

• Replication of virus 
     p
causes oncolytic death 
of cells




                   • Normal cells‐ ...
H101 (Oncorine®) phase III trial in 
        advanced head and neck cancer 
         d     dh d d         k

H101 is almos...
Gene therapy of hematological 
                  cancers

Promising Phase 1 and 2 data in cutaneous B‐ and T 
cell lymphom...
Adenoviral Gene Therapy 
                Strategies for Cancer
                           f
  Safety has been good – over ...
Increasing infectivity of target cells: 
       transductional targeting

       Non-targeted               Targeted
     ...
Serotype chimerism for tumor 
          targeting 
 Ad5                                                     107 SKOV3.ip1 ...
Cancer stem cells can be killed with 
     oncolytic adenoviruses
     oncolytic adenoviruses




  Eriksson Mol Ther
  20...
Compassionate treatment of refractory 
solid tumors with oncolytic adenovirus 
solid tumors with oncolytic adenovirus
   •...
Findings possible only in pts: Mechanisms of anti‐
                     tumor efficacy of oncolytic adenovirus
           ...
Case: Systemic efficacy of Ad5/3‐Cox2L‐D24 in 
                          chemo refractory neuroblastoma
                  ...
Ad5/3‐
              Cox2L‐D24 
               in neuro‐
               blastoma
→ CD56 staining (brown) for 
  Oncolytic ...
Improving antitumor immunity: oncolytic 
                     adenoviruses coding for GM‐CSF 
                     adenovi...
GM‐CSF can enhance antigen presentation 
           and induce NK and cytotoxic T cells
           and induce NK and cytot...
Schematic of Oncolytic Virus Treatment




                                                                               ...
Efficacy and virus replication




                                                                           SD




Overa...
GM‐CSF coding oncolytic adenovirus 
                    in a mesothelioma patient
                    in a mesothelioma pa...
Complete response in OvCa pt 
                 with small disease burden
                  ith    ll di      b d
Metastati...
Inflammation due to virus and/or GM‐
CSF can falsely increase tumor markers 
CSF can falsely increase tumor markers
      ...
dl1520, CoCa liver mets
 • Patients failed all available chemo
 • Reid T Cancer Res 2002




                             ...
Rapid response upon re‐treatment with 
 GM CSF coding oncolytic
 GM‐CSF coding oncolytic adenovirus
 •   Peritoneally meta...
Immunological response to GM‐CSF 
                                coding oncolytic adenovirus
                            ...
Ad5(hexon)‐Specific Immunity
                       1000                                                                10...
Tumor‐specific Immunity (pentamer staining 
                                  for survivin)
                              ...
Summary


1.
1    Initial clinical proof‐of‐principle is available for many cancer gene 
     Initial clinical proof of pr...
Acknowledgements




Akseli Hemminki      Marko Ahonen             Maria Rajecki         Transgene         Univ. Helsinki ...
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Oncolytic viruses (Nordic Hematology Conference 2009)

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Professor Akseli Hemminki's presentation at Nordic Hematology Conference, Tampere, Finland (May 7, 2009)

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Oncolytic viruses (Nordic Hematology Conference 2009)

  1. 1. Cancer Gene Therapy h Akseli Hemminki, MD, PhD Specialist in Oncology and Radiotherapy Specialist in Oncology and Radiotherapy K. Albin Johansson Research Professor,  Finnish Cancer Institute Cancer Gene Therapy Group Molecular Cancer Biology Program &  Transplantation Laboratory & Haartman Institute & Finnish Inst. for Mol. Medicine University of Helsinki and  Helsinki Univ. Central Hospital
  2. 2. 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) A k s e l i   H e m m i n k i       |     7  M a y   2 0 0 9    |     2
  3. 3. 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 phase III SCCHN trial positive in US Cancer cells Normal cells with healthy p53  with p53 mutation Already approved by EMEA for treatment of  Li‐Fraumeni syndrome Cell death, also sensitation to  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       |     7  M a y   2 0 0 9    |     3
  4. 4. Prodrug converting enzymes (suicide gene therapy) with Ad‐TK  (suicide gene therapy) with Ad TK and GCV Ad coding for  Advantage vs.  thymidine kinase  TK 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       |     7  M a y   2 0 0 9    |     4
  5. 5. 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) Si il lt i h t ll l dj t t i l (Li Cli C R 2007) Phase III results 30 Jul 2008 ( Ph lt J l (press release): l ) Cerepro® w/ & w/o temozolomide vs controls w/ & w/o temozolomide: 42 d improvement in median survival (310 d vs 268 d, p , p<0.032). ) Orphan drug status alreadyi   H e m m i n k i    by M a y   2 0 0 9    |     5 A k s e l given   |     7 EMEA
  6. 6. 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       |     7  M a y   2 0 0 9    |     6
  7. 7. H101 (Oncorine®) phase III trial in  advanced head and neck cancer  d dh d d k H101 is almost identical to dl1520 (=ONYX‐015) i H101 now entering  H101 descibed earlier in the US phase 3 trials in 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       |     7  M a y   2 0 0 9    |     7
  8. 8. Gene therapy of hematological  cancers Promising Phase 1 and 2 data in cutaneous B‐ and T  cell lymphomas with Ad‐IFN‐gamma: 56% responses  y p g p (Dummer Blood 2004) Oncolytic measles virus for multiple myeloma  Oncolytic measles virus for multiple myeloma (unpublished) Several trials evaluating mdr transfer to  Several trials evaluating mdr transfer to hematopoietic stem cells Several trials of HSV‐TK transfer to donor cells  S l t i l f HSV TK t f t d ll (modulation of graft‐vs‐leukemia) A k s e l i   H e m m i n k i       |     7  M a y   2 0 0 9    |     8
  9. 9. Adenoviral Gene Therapy  Strategies for Cancer f Safety has been good – over 15 000 pts treated with both repli‐ S f t h b d 15 000 t t t d ith b th li cation deficient and replication competent (oncolytic) viruses  Recent  randomized trials (N 5) have confirmed efficacy of even  Recent randomized trials (N=5) have confirmed efficacy of even early generation approaches No patients w/ metastatic cancer cured: much work remains TUMOR PENETRATION NEEDS IMPROVEMENT Replication competent oncolytic viruses Transcriptional tumor targeting (activation only in tumor) Transductional tumor targeting (gene delivery only to tumor) d i l i ( d li l ) Armed oncolytic viruses Oncolytic replication is not enough to cure advanced tumors O l ti li ti i t ht d dt A k s e l i   H e m m i n k i       |     7  M a y   2 0 0 9    |     9
  10. 10. 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       |     7  M a y   2 0 0 9    |     1 0
  11. 11. Serotype chimerism for tumor  targeting  Ad5 107 SKOV3.ip1 cells intraperitoneally (i.p.)  10 days later 10 days later CAR 3x1x108 VP i.p. Follow survival Ad3 receptor 120 100 3x 1x108 VP i p 3x 1x10 VP i.p. 80 urvival Ad5/3  60 % Su with knob  40 domain  20 from Ad3 0 15 25 35 45 55 65 75 85 95 105 115 125 135 Kanerva Clin Cancer Res 2002 Kanerva Mol Ther 2003s e l i   HDay i n k i       |     7  M a y   2 0 0 9    |     1 1 Ak emm
  12. 12. 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       |     7  M a y   2 0 0 9    |     1 2
  13. 13. Compassionate treatment of refractory  solid tumors with oncolytic adenovirus  solid tumors with oncolytic adenovirus • 115 patients and 202 treatments since Nov 07. 6 different viruses  • All had metastatic solid tumors progressing after routine  treatments (chemo, radiation, etc) • Side effects: gr. 1‐2 flu‐like symptoms, fever, fatigue, pain in all pt • SAE in < 4% of patients (abd. pain, constipation, embolus, venous  SAE in < 4% of patients (abd. pain, constipation, embolus, venous thrombosis, cholecystitis). • No treatment related deaths (compare to chemotherapy). • Objective benefit including tumor marker data ( biological  Objective benefit including tumor marker data (“biological activity”): 69% all viruses, 75% best virus • Clinical benefit (imaging CR, PR, SD): 41% overall, 67% best virus • Benefit lost in a few months in most patients • Many patients benefited (even more) from 2nd ‐ 6th treatment  A k s e l i   H e m m i n k i       |     7  M a y   2 0 0 9    |     1 3
  14. 14. Findings possible only in pts: Mechanisms of anti‐ tumor efficacy of oncolytic adenovirus y y inflammation 3. Induction of  1. Killing of differentiated tumor cells 1 Killing of differentiated tumor cells cytotoxic T cells  cytotoxic T‐cells against tumors 6 CD8+ 5 vitiligo 10E+8 4 3 2 0 17 41 48 2. Killing of tumor initiating ”stem” cells 4. Induction of specific immunity  against tumor epitope (survivin) against tumor epitope (survivin) CD8+ cells 4 4 0 0 Before virus 0.46% 10 before virus0.46 0 3 wk after 4.09% after virus 4.09 03 10 3 Survivin specific C FL2-H 2 2 0 10 n 01 10 1 0 0 99.5 0 95.9 0 k0 A10s e l i   H e m m i n k i       |     7  M a y   2 0 0 9    |     1 4 10 0 10 1 10 2 10 3 10 4 10 0 10 1 10 2 10 3 10 4 Eriksson Mol Ther 2007, Bauerschmitz Cancer Res 2008 FL1-H FL1-H
  15. 15. 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       |     7  M a y   2 0 0 9    |     1 5
  16. 16. Ad5/3‐ Cox2L‐D24  in neuro‐ blastoma → CD56 staining (brown) for  Oncolytic replication alone is usually  tumor cells in bone  marrow not enough to cure advanced tumors not enough to cure advanced tumors → 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 6 A k s e l i   H e m m i n k i       |     7  M a y   2 0 0 9   
  17. 17. Improving antitumor immunity: oncolytic  adenoviruses coding for GM‐CSF  adenoviruses coding for GM CSF GM‐CSF • Tumor selectivity: Rb binding site deletion restricts replication to Rb/p16 mutant cells p /p G CS GM-CSF •GM‐CSF is a potent inducer of antitumor GM-CSF immunity (Dranoff G Immunol Rev 2002) • GM‐CSF under control of the endogenous Ad E3 gene expression system: expression starts 8h after infection ⇒ GM‐CSF expressed only in cells that allow replication of the virus p GM CSF GM-CSF GM-CSF • High expression at tumor, low systemic A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    1 7 exposure
  18. 18. 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 NK Ca Ca 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       |     8  O c t   2 0 0 8    |    1 8
  19. 19. Schematic of Oncolytic Virus Treatment 60 A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    1 9
  20. 20. Efficacy and virus replication SD Overall efficacy (RECIST 1.1) single injection: * Indicates patients still CR 2/14 alive at the time of cutoff. li t th ti f t ff SD 5/14 A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    2 0 PD 7/14
  21. 21. GM‐CSF coding oncolytic adenovirus  in a mesothelioma patient in a mesothelioma patient • 60 yr old man, asbestos exposure 60 yr old man asbestos exposure • Prior treatment with cisplatin+pemetrexed • WHO 1 • Single intrapleural and i.v. injection  l l l d A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    2 1
  22. 22. 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  A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    2 2
  23. 23. 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       |     8  O c t   2 0 0 8    |    2 3
  24. 24. dl1520, CoCa liver mets • Patients failed all available chemo • Reid T Cancer Res 2002 A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    2 4
  25. 25. 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       |     8  O c t   2 0 0 8    |    2 5
  26. 26. Immunological response to GM‐CSF  coding oncolytic adenovirus coding oncolytic adenovirus Adenovirus: T cell response  p towards adenovirus  components (Hexon, Penton,  Fiber etc.)  b ) Tumor: T cell response to  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       |     8  O c t   2 0 0 8    |    2 6
  27. 27. Ad5(hexon)‐Specific Immunity 1000 10 4 10 4 0 0.21 0 21 0.21 0 21 Ad5Hex) 800 3 3 10 10 tter 600 CD3 3 FSC-H Size Scat Before B FL2-H H FL3-H H ramer (A 2 2 10 10 400 48.4 61.7 1 1 10 10 200 Tetr 0 0 0.085 99.7 0 10 10 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 FL3-H FL1-H FL1-H CD3 CD8 CD8 1000 10 4 10 4 0 2.72 2.72 Hex) 800 10 3 3 Tetramer (Ad5H 10 e Scatter After 600 CD3 FL2-H FSC-H FL3-H 2 2 10 10 400 47.8 Size 68.8 68 8 1 10 10 1 200 0 0.68 96.6 0 10 0 10 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 FL1-H FL3-H FL3 H FL1-H FL1 H CD3 CD8 CD8 Data confirmed in ELISPOT assay A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    2 7
  28. 28. Tumor‐specific Immunity (pentamer staining  for survivin) o su ) Before virus: R73 3 weeks after virus: R73 104 104 0 0.46 0.46 0 4.09 4.09 Pentamer 103 103 ↓ ↓ All analyzed patients y p r‐specific P FL2-H FL2-H 102 102 Tumor 1 1 10 10 0 99.5 0 95.9 100 100 4 100 101 102 103 104 100 101 102 103 104 FL1-H FL1-H CD8 ↑ Patient Code: R73 ↑ Patient Code: R73 A k s e l i   H e m m i n k i       |     8  O c t   2 0 0 8    |    2 8
  29. 29. Summary 1. 1 Initial clinical proof‐of‐principle is available for many cancer gene  Initial clinical proof of principle is available for many cancer gene therapy approaches 2. Safety has generally been excellent 3. Effective gene delivery continues to be key to efficacy ff d l b k ff 4. Oncolytic viruses amplify local dose and help in tumor  penetration  5. More than 50% of our patients have obtained benefit from  treatment with oncolytic adenovirus 6. Patient data has revealed central role of immune reponse in  Patient data has revealed central role of immune reponse in patient benefit 7. Immune response toward both adenovirus and tumor epitopes 8. 8 Clinical trials are needed to confirm promising preliminary results Clinical trials are needed to confirm promising preliminary results 9. Current regulations make translational work difficult A k s e l i   H e m m i n k i       |     7  M a y   2 0 0 9    |     2 9
  30. 30. Acknowledgements Akseli Hemminki Marko Ahonen Maria Rajecki Transgene Univ. Helsinki & HUCH: Monika Lusky Martti Ala‐Opas Sari Pesonen Iulia Diaconu Mari Raki Henrik Alfthan Laura Ahtiainen La ra Ahtiainen João Dias João Dias Tuuli Ranki T li Ranki Delsitech D li h Petri Bono Petri Bono Sophie Escutenaire Kilian Guse Marta Sloniecka Mika Koskinen Maija Harrela Mika Jalonen Pekka Häyry Vincenzo Cerullo Theresia Gutmann Merja Särkioja Krister Höckerstedt Anna Kanerva Otto Hemminki Matteo Ugolini Helena Isoniemi Institut Catala Kalevi Kairemo Camilla Ribacka Camilla Ribacka Lotta Kangasniemi Lotta Kangasniemi d Oncologica: d’Oncologica: Tuula Kiviluoto Minna Oksanen Anniina Koski Päivi Hannuksela Ramon Alemany Jorma Paavonen Elina Haavisto Sergio Lavilla‐Alonso Kikka Holm Ari Ristimäki Ilkka Liikanen Aila Karioja‐Kallio Univ. Glasgow Mirja Ruutu Laura Denby Jarmo Salo Petri Nokisalmi Eerika Karli Andy Baker Andy Baker Ulf Håkan Stenman Ulf‐Håkan Stenman Maija Tarkkanen The Patients Salk Institute Mikko Tenhunen Matt Weitzman Pekka Virkkunen Timo Joensuu Grant support: Grant support: Saila Eksymä‐ ERC Sillman EU FP6 APOTHERAPY Mauri Kouri EU FP6 THERADPOX Jenni Kylä‐Kause HUCH Research Funds (EVO) Leena Laasonen Pekka Simula Academy of Finland y Satu Nikander S Nik d Finnish Cancer Organizations Marina Rosliakova Biocentrum Helsinki Katri Silosuo Sigrid Juselius Foundation Arja Vilkko  National Cancer Institute (USA) Heini Välijeesiö

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