Professor Akseli Hemminki presents on gene therapy and oncolytic viruses

Treatment of human cancer with oncolytic adenoviruses: an example of personalized therapy of personalized therapy Akseli Hemminki, MD, PhD 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 & FIMM University of Helsinki f l k Disclaimer: AH is co‐founder and shareholder of Disclaimer AH is co founder and shareholder of Oncos Therapeutics Inc., a company founded for facilitating clinical trials with oncolytic viruses

Overview of presentation Why new treatments ? Gene therapy of cancer: what is the clinical evidence ? Gene therapy of cancer: what is the clinical evidence ? Oncolytic adenoviruses in our own patients Importance of immune response in determining I t fi i d t i i efficacy: the next generation of oncolytic agents Tumor targeting: the next generation of oncolytic agents Personalization of treatment for each patient Questions A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 2

Cancer is not a beaten disease CANCER > 1/2 of people alive today will get cancer* • 1/3 of us will die of cancer • few disseminated solid tumors can 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 8 O c t 2 0 1 0 | 3

Bert Vogelstein: Cancer Cancer therapeutics after the cancer ft th genome project (ASCO 2009) ( ) Sequencing of tumor genomes revealed hundreds of mutations in each (Wood S i ft l dh d d f t ti i h (W d Science 2007, Parsons Science 2008) Combination different in each tumor ‐> Each tumor is an individual ‐> Each tumor would require a different combination of inhibitors ‐> For long term efficacy, each pt would have to be treated with hundreds of inhibitors ‐ > Impossible because of side effects > Impossible because of side effects All of these mutations seem to fall in 12 pathways (Jones Science 2008). ‐ > Use pathway selective drugs (Vogelstein ASCO 2009) For example, p16/Rb pathway selective oncolytic virus http://cgap.nci.nih.gov/ A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4

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 8 O c t 2 0 1 0 | 5

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 8 O c t 2 0 1 0 | 6

Mutation compensation Randomized ph. III trial: head & neck ca. ‐ 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 Infection of cells Infection of cells Normal cells Cancer cells Press release 23 Jul 2008: Ad‐p53 (Advexin®) with p53 mutation with healthy p53 phase III SCCHN trial positive in US: not approved by FDA 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 | 2 8 O c t 2 0 1 0 | 7

Prodrug converting enzymes Randomized Phase III trial for glioma (ASPECT): • Ad-TK + standard care vs. standard care: 1.43 HR (p=0.02) (p ) Ad coding for Ad di f • 40d increase in median survival thymidine TK • More temozolomide use in control group due to kinase (TK) non blinded non-blinded gene therapy-> dilution of results therapy > • EMEA did not approve because non-standard end-point (time to re-intervention or death) o to c p od ug Non‐toxic prodrug Advantage vs. Ad t = ganciclovir mutation compensation: bystander effect via gap Activated Activated junctions CHALLENGE: even with bystander toxin Cell death effect, can we get effective penetration into established tumors ? SOLUTIONS: locally amplifying systems A k s e l i H e m m i n k i | 2 8 O c t 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 8 O c t 2 0 1 0 | 9

Phase 3 trials with oncolytic viruses Oncolytic adenovirus H101 (OncorineR ≈ ONYX 015) Oncolytic adenovirus H101 (Oncorine ONYX‐015) ¬ Not armed, not very potent ¬ Randomized phase III trial (N=105) ¬ Intratumoral H101 + cisplatin + 5‐FU vs. cisplatin + 5‐FU ¬ CR+PR = 79% vs. 38%, P<0.0001 ¬ Mild tox: flu‐like symptoms, injection site pain Mild t fl lik t i j ti it i ¬ Approved in China in 2006 (Yu Curr Cancer Drug Targets 2007) OncovexGMCSF ¬ Oncolytic herpes virus armed with GMCSF ¬ Previous phase 2: advanced melanoma, intratumoral injection p , j ¬ N = 50. CR = 8 (+5), PR = 5, SD = 10. Disease control = 23/50 (46%). Survival 58% @ 1yr, 52% @ 2yr. ¬ Ph Phase 3 finished early 2011 3 fi i h d l 2011 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 1 0

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 Seminal phase 3 trials ongoing (Oncovex, Jennerex) * 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 8 O c t 2 0 1 0 | 1 1

Personalized oncolytic adenovirus treatments in the Advanced Therapy Access Program in the Advanced Therapy Access Program • 210 pts since Nov 2007. 10 different viruses • All had metastatic solid tumors progressing after routine treatments (chemo, radiation, etc) • Written informed consent. Full GCP. Direct regulation by FIMEA • 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): 48% overall, 77% b t i Cli i l b fit (i i CR PR SD) 48% ll 77% best virus • Some patients have benefited for 3 years (= length of follow‐up) • Additive/synergistic benefits from 2nd ‐ 17th treatments • Long term (>300 d) survival in 50% with best virus, best schedule A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 1 2

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 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 1 3 Eriksson Mol Ther 2007, Bauerschmitz Cancer Res 2008

Ad5/3‐Cox2L‐D24 in chemotherapy refractory OvCa refractory OvCa • 53 yr old woman, WHO 1. Stage 3 ovarian cancer • Progressive disease after 62 rounds of prior chemo, Progressive disease after 6 rounds of prior chemo, including paclitaxel, paclitaxel+carbo, carbo, liposomal doxorubicine, etoposide ... • single intraperitoneal injection of 2x10e11 VP single intraperitoneal injection of 2x10e11 VP Oncolytic replication alone is usually Oncolytic replication alone is usually not enough to cure advanced tumors Pesonen Gene Ther 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 1 4

Higher efficacy with a second round of treatment: role of immune response ? treatment: role of immune response ? • 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 8 O c t 2 0 1 0 | 1 5 Kanerva in preparation

Improving antitumor immunity: oncolytic adenoviruses coding for GM‐CSF adenoviruses coding for GM CSF Cerullo Mol Ther ASGT suppl 2009 GM‐CSF Cerullo Cancer Res 2010 • 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 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 1 6

GMCSF based approach validated 29 Apr 2010: Provenge (Sipuleucel T) Apr 2010: Provenge (Sipuleucel‐T) Hormone Hormone refactory prostate cancer Collection of Collection of white blood cells Incubation w/ PAP & GMCSF to activate antigen presenting cells Return cells into patient ti t First immunotherapy product ! product ! PAP = prostatic acid phosphatase GMCSF = granulocyte macrophage colony stimulating factor i l i f A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 1 7 www.provenge.com

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 8 O c t 2 0 1 0 | 1 8

Cerullo Cancer Res 2010 Treatments A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 1 9

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 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 2 0

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 8 O c t 2 0 1 0 | 2 1 Cerullo Cancer Res 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 2010 - Lab: gr 1-2 AST/ALT, hypo-K+,m i n k1-3 hypo-Na+ | 2 2 A k s e l i H e m gr i | 2 8 O c t 2 0 1 0 - PD 8/16

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 8 O c t 2 0 1 0 | 2 3 Cerullo Cancer Res 2010

Systemic efficacy of Ad5‐D24‐GMCSF in injected and non injected tumors: virus injected and non‐injected tumors: virus circulation, immune response • 60 yr mesothelioma patient, asbestos exposure 60 yr mesothelioma patient asbestos exposure • Prior treatment with cisplatin+pemetrexed • WHO 1 • Single intrapleural and i.v. injection Single intrapleural and i v injection • 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 8 O c t 2 0 1 0 | 2 4 Cerullo Cancer Res 2010

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 8 O c t 2 0 1 0 | 2 5

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 8 O c t 2 0 1 0 | 2 6

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 8 O c t 2 0 1 0 | 2 7 Ak

Ad5/3‐D24‐GMCSF = CGTG‐102 Fiber chimerism for enhanced transduction of cancer cells CGTG‐102: 76% clinical NK Replication in cells mutant in Rb‐p16 pathy benefit in advanced ca. pts benefit in advanced ca pts NK NK CD8+ CD8+ CD8+ CD8+ NK CD8+ Includes most human cancers 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 Mol Ther 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 2 8

50% survival = 320 days Overall survival of Survival at 200 days = 66% Survival at 300 days = 55% patients treated patients treated N= 19 with CGTG‐102 (Ad5/3 D24 (Ad5/3‐D24‐ GMCSF) 50% survival = 177 days Survival at 200 days = 47% Overall survival Survival at 300 days = 37% All treatments Survival at 500 days = 22% N= 155 50% survival = 157 days Survival at 300 days = 34% All patients were chemo refractory and All patients were chemo refractory and N= 144 progressing at treatment Overall clinical benefit in imaging = 76% Criteria: death due to any cause Censoring: alive at last follow‐up Median overall survival of chemotherapy resistant patients 30‐115 days (eg. Vigano Palliat Med 2000 Llobera Eur J of Med 2000, Llobera J of Cancer 2000) A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 2 9

50% survival Effect of serial 277 d treatment on treatment on 112 d 109 d overall survival 300 day survival y of CGTG 102 of CGTG‐102 48 % patients 33 % 7 % 7% Violet= CGTG‐102 serial treatment (Kanerva, Nokisalmi in rols preparation) Green = CGTG‐102 Green = CGTG‐102 al contr single treatment (Koski Mol Ther 2010) Blue = our first ATAP Historica virus (Pesonen Gene i (P G Ther 2010) Non‐randomised series but inclusion criteria and patient 30 115 characteristics are identical Survival rates between 30‐115 d have been reported for this patient population in historical control series (Vigano Palliat Med 2000, Llobera Eur J of Cancer 2000) A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 0

Inclusion and exclusion criteria, personalization of oncolytic virus treatment personalization of oncolytic virus treatment Inclusion criteria c us o c te a Exclusion criteria c us o c te a Refractory solid tumor confirmed brain met. or glioma Failed treatments for which there is organ transplant, HIV strong scientific evidence* severe comorbidity severe comorbidity Good performance status: WHO 0‐ Elevated serum bilirubin 2. (WHO 3‐4 safe but less efficacy) ( y) Serum AST or ALT > 3 x normal Written informed consent Thrombocytes < 75. Personalization: Personalization: Selection of virus (out of 10): existing preclinical data on capsids, promoters, arming, pretreatment efficacy prediction Dose: tumor burden, comorbidities Route: i.t (ultrasound or CT‐guided), intraperitoneal, intrapleural, i.v. * In most cases this means 1st line chemotherapy Virus sensitizers: T‐Reg, autophagy, TH2‐>TH1 Vi iti TR t h TH2 >TH1 for metastatic disease, and in some cases several f t t ti di di lines of chemotherapy (eg. breast, ovarian and l colorectal cancer) Seroswitching when intravenous efficacy sought In practice, the median number of prior chemo 3 1 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | regimens is 4 –> heavily pretreated

Systemic efficacy of Ad5/3‐Cox2L‐D24 in chemo refractory neuroblastoma y • 6 yr old boy, WHO 1 • Heavily pretreated: 5 lines of chemo, stem cell transplant h t ll t l t • Metastases in bone marrow and near kidney •Ti l Triple‐modified virus was difi d i selected for intravenous efficacy • Cox2 expression confirmed in bone marrow biopsy bone marrow biopsy • Gr. 1 stomach pain, diarrhea, flu‐like symptoms, liver enzymes 0 • 4 wk later: complete response 4 wk later: complete response 6540 in bone marrow, partial 500 response in primary A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 2 Pesonen Acta Oncol 2010

Preclinical data suggests correlation between gene delivery and oncolytic potency: Archival receptor levels did not predict efficacy h l l l dd d ff CAR staining – to +++ CAR ++ , CEA MR CAR ++, CT SD Archival tumors are typically operated primaries They may be quite different from CAR+, CT SD CAR negative, CT CR CAR+, Choi resp. CAR+ CT SD CAR negative CT CR CAR+ Choi resp metastatic and relapsing tumors treated with many y different therapies Eg CAR level is known to correlate known to correlate CAR+, CT CR CAR ++ CT PD CAR‐, CT MR CAR CT CR CAR CT PD CAR CT MR with tumor aggressiveness ‐> change in CAR h i CAR Haavisto et al. unpublished A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 3

Tumor biopsies may be able to measure gene delivery to relevant tumor substrates gene delivery to relevant tumor substrates ← Pre‐treatment biopsies infected with virus with same capsid as oncolytic O12 C3 virus Biopsy Biopsy • O12: SD in imaging and markers k • C3: MR in markers • Cerullo Cancer Res 2010 V136 ← Malignant pleural 2,5E+07 2 5E+07 Pleural effusion cells 1,6E+05 1 6E 05 K75 effusion and ascites ff i d i ression (RLU) Ascites cells ssion (RLU) 1,4E+05 2,0E+07 • V136: SD in imaging, CR 1,2E+05 in non‐injected liver 1,5E+07 , 1,0E+05 metastasis nsgene expres ransgene expr 8,0E+04 1,0E+07 6,0E+04 • K75: CR in ascites 4,0E+04 formation 5,0E+06 • Koski Mol Ther 2010 Koski Mol Ther 2010 Tran 2,0E+04 2 0E+04 Tr 0,0E+00 0,0E+00 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 4 Ad5luc1 Ad5/3luc1 Ad5luc1 Ad/3luc1

Pre‐treatment prediction of Ad5/3‐D24‐GMCSF efficacy: killing of pleural effusion cells efficacy: killing of pleural effusion cells 200 250 V136 - SD in CT scan M137 180 - SD in CT scan 160 - CR in liver 200 - CR in pleural p metastasis t t i effusion 140 - Survival > 700d Viability of (%) 120 150 Viabilit (%) (ongoing) 100 ty y 80 100 *** 60 *** 40 50 20 0 0 Uninfected Ad5luc1 Ad5/3-d24- Uninfected Ad5luc1 Ad5/3-d24- cells GMCSF cells GMCSF Koski Mol Ther 2010 R73 - SD i CT scan in - Survival >800d (ongoing) Cerullo Cancer Res 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 5

Virus circulates for extended times in extended times in Last d38 Last d28 most patients – no correlation to correlation to efficacy or adverse events Last d40 Last d63 Last d64 Escutenaire Ann Med in Last d52 Last d52 press, Cerullo Cancer Res ll 2010, Nokisalmi CCR 2010, Koski Mol Ther 2010, Pesonen Gene Ther 2010, Pesonen Gene Ther 2010, Pesonen submitted A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 6

Neutralizing antibodies are present in some patients before treatment. They are induced rapidly p y p y in most patients – neither correlates with efficacy Intriguing case with no NAb induction • Heavily pre‐treated 9yr old Wilms tumor patient: Heavily pre treated 9yr old Wilms tumor patient: Multiple operations, 6 lines of chemotherapy, radiation 16 384 • Progressive disease in several abdominal locations • ICOVIR‐7 1x10e11 VP; 80% i.t.,20% i.v. 4 096 • gr 2 stomach pain, fatigue, fever. gr 1 AST, nausea gr 2 stomach pain fatigue fever gr 1 AST nausea 1 024 • Pre‐treat Nab titer 4, no increase in 4 weeks 256 Before oncolytic virus Partial response 36d after er Nab tite 64 16 4 1 0 Koski Mol Ther 2010 0 0 1 2 3‐4 > 4 Time (weeks) Y62 H64 C66 S67 S70 P74 K75 O79 I80 O82 H83 I87 C95 H96 I98 N110 O113 S119 X122 O129 V136 M137 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 7 Nokisalmi Clin Cancer Res 2010

Anti‐adenoviral and anti‐tumor immunity are induced in most patients: no are induced in most patients: no correlation to efficacy. Decrease might also relate to efficacy ? Decrease might also relate to efficacy ? Anti‐Ad Anti‐Survivin Koski Mol Ther 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 8

Tumor specific T‐cell responses might require HLA. However, HLA staining of archival HLA However HLA staining of archival specimens does not predict efficacy HLA staining (scale – t ++) t i i ( l to G15 + R8 negative R73 + Efficacy -Choi response, - CR in imaging, markers - SD in CT scan - Survival > 400d - Survival > 1000d, ongoing - Survival >800d(ongoing) Diaconu, Cerullo, unpublished A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 3 9

Metronomic cyclophosphamide for down‐ regulation of T Reg regulation of T‐Reg Background: T‐Regs g g TReg inhibit NK and cytotoxic T‐cells CD8+ NK Ca C Ca C Ca Ca C Ca Ca Ca Ca Ca A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4 0

Cyclophosphamide for reducing T‐Regs and enhancing the effect of oncolytic enhancing the effect of oncolytic virotherapy TReg Cyclophosphamide CD8+ NK Ca C Ca C Ca Ca C Ca Ca Ca Ca Ca A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4 1

GM‐CSF can enhance antigen presentation and induce NK and cytotoxic T cells and induce NK and cytotoxic T‐cells TReg TReg TReg NK CD8+ NK CD8+ CD8+ CD8+ NK NK 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 | 2 8 O c t 2 0 1 0 | 4 2

Cyclophosphamide can enhance the effect of GM CSF induced NK and cytotoxic T cells GM‐CSF induced NK and cytotoxic T‐cells TReg TReg Cyclophosphamide CD8+ Cyclophosphamide C clophosphamide NK NK CD8+ CD8+ CD8+ NK NK CD8+ CD8+ NK CD8+ CD8+ NK NK Ca GM-CSF Dying tumor cells Ca DC Ca Ca Ca GM-CSF A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4 3

Oral or intravenous low‐dose cyclophosphamide or both ? l h h id b th ? Metronomic cyclophosphamide useful for reducing T‐Reg I.v. low dose bolus cyclo useful for Th2‐>Th1 switch Combination useful for both ? Combination useful for both ? Cyclo also synergistic for oncolytic cell killing High doses could be antagonistic for anti‐tumor immune responses Hypothesis: medium dose i.v.+p.o. optimal for oncolytic Ad treatment ? A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4 4 Cerullo Submitted

Low dose cyclophosphamide reduces T‐reg in most but not all patients. Most effective in most but not all patients Most effective in patients with high T‐Reg counts? Cerullo Submitted A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4 5

Possible clinical predictors of benefit from oncolytic Ad: tumor benefit from oncolytic Ad: tumor burden, performance score, age 57 yr old woman with Stage 4 ovarian cancer 57 yr old woman with Stage 4 ovarian cancer Operation, adjuvant CEF x6, taxol+carbo x6, docetaxel, bevacizumab, topotecan, erlotinib, aromatase inhib. WHO 1. Progressive disease, but low tumor burden WHO 1 Progressive disease but low tumor burden Single intraperitoneal treatment Ad5‐D24‐GMCSF Complete response (CT, markers) for 9 mo. Survival >1000d (ongoing) Immunotherapy works best in good perf. score patients, as seen for ipilimumab Immunotherapy works best in good perf score patients as seen for ipilimumab (Hodi NEJM 2010), sipuleucel‐T (Kantoff NEJM 2010) Cerullo Cancer Res 2010 WHO performance score: score: 0 no symptoms 1 symptoms 2 needs rest <50% 3 needs rest >50% 3 d t >50% 4 needs rest 100% 5 dead A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4 8

Summary Clinical proof‐of‐principle available for oncolytic viruses p p p y Anti‐viral and anti‐tumoral immunity key in efficacy Clinical benefit 76% (radiology) with CGTG‐102 (N=110) 50% overall survival at 300d with CGTG 102 (serial treatments) 50% overall survival at 300d with CGTG‐102 (serial treatments) CGTG‐102 now being tested in clinical trial (Oncos Therapeutics) Clinical trials very expensive (3.5 mil€ for phase 1‐2 with 40 pts) For personalization archival specimens not useful. Fresh biopsies, For personalization archival specimens not useful Fresh biopsies effusion or ascites seem more promising Virus replication, antibodies or T‐cells do not seem to predict efficacy T‐Reg modulation and autophagy induction can be tailored modulation and autophagy induction can be tailored Some clinical parameters seem to predict efficacy Personalized therapy in an advanced therapy access program can give patients not eligible for trials access to therapy patients not eligible for trials access to therapy Personalized therapy can help answer scientific questions pave the way for trials, which are ultimately needed (and help design succesful trials) Every patient and tumor is different > therapy should also be Every patient and tumor is different ‐ > therapy should also be A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 4 9

Acknowledgements Akseli Hemminki Marko Ahonen Suvi Parviainen Institut Catala Univ. Helsinki & HUCH: d’Oncologica: Petteri Arstila Sari Pesonen Karoliina Autio Maria Rajecki Pekka Häyry Sophie Escutenaire Sophie Esc tenaire Iulia Diaconu I lia Diacon Noora Rouvinen Noora Ro inen Ramon Alemany a o e a y Krister Höckerstedt Ki Hö k d Vincenzo Cerullo João Dias U. Washington Helena Isoniemi Anna Kanerva Otto Hemminki Kikka Holm Andre Lieber Tuula Kiviluoto Jorma Paavonen Minna Oksanen Mari Hirvinen Eerika Karli Risto Renkonen Anniina Koski Anniina Koski Saila Pesonen Saila Pesonen U. Ottawa John Bell Ari Ristimäki Ari Ristimäki Ilkka Liikanen Mirja Ruutu Petri Nokisalmi Jarmo Salo Kalle Saksela Ulf‐Håkan Stenman Mikko Tenhunen Mikko Tenhunen Pekka Virkkunen The Patients Pekka Simula Timo Joensuu Timo Ahopelto Tuomo Alanko Tuomo Alanko Charlotta Backman Charlotta Backman Grant support: Grant support: Saila Eksymä‐Sillman Elina Haavisto ERC Kalevi Kairemo Lotta Kangasniemi Academy of Finland Jenni Kylä‐Kause Aila Karioja‐Kallio ASCO Leena Laasonen Biocentrum Helsinki Heli Nyrhinen Satu Kauppinen Satu Kauppinen Biocenter Fi l d Bi t Finland Tuuli Ranki Kaarina Partanen Sigrid Juselius Foundation Marina Rosliakova Maija Salo University of Helsinki Mikko Salo HUCH Research Funds (EVO) Antti Vuolanto

Immunological response to GM‐CSF coding oncolytic adenovirus: against virus or tumor? oncolytic adenovirus: against virus or tumor? 3 h before CT guided injection (3ml 10 min after 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 8 O c t 2 0 1 0 | 5 1

king of MHC I Block Ad5 (hexon) Specific Immunity Cerullo Cancer Res 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 5 2

king of MHC I Block Tumor‐specific Immunity y (Survivin) Cerullo Cancer Res 2010 A k s e l i H e m m i n k i | 2 8 O c t 2 0 1 0 | 5 3

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 8 O c t 2 0 1 0 | 5 4

Breast cancer stem cells can be killed with oncolytic adenoviruses killed with 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 8 O c t 2 0 1 0 | 5 5

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Professor Akseli Hemminki presents on gene therapy and oncolytic viruses

by Oncos Therapeutics on Nov 09, 2010

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Professor Akseli Hemminki presents on gene therapy and oncolytic viruses — Presentation Transcript