Professor Akseli Hemminki presents on gene therapy and oncolytic viruses

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Presentation held on October 28, 2010, at Institute for Molecular Medicine for Finland (FIMM). The presentation includes information on a newest theory on immune response against the cancer tumor, mediated by oncolytic viruses

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Professor Akseli Hemminki presents on gene therapy and oncolytic viruses

  1. 1. Treatment of human cancer with  oncolytic adenoviruses: an example  of personalized therapyof 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 f l k Disclaimer AH is co founder and shareholder ofUniversity of Helsinki Disclaimer: AH is co‐founder and shareholder of  Oncos Therapeutics Inc., a company founded for  facilitating clinical trials with oncolytic viruses
  2. 2. 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 I t f i i d t i iImportance of immune response in determining  efficacy: the next generation of oncolytic agents Tumor targeting: the next generation of oncolytic  agents Personalization of treatment for each patient Questions Akseli Hemminki   |  28 Oct 2010  |  2 Questions
  3. 3. Cancer is not a beaten  diseasedisease 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! Akseli Hemminki   |  28 Oct 2010  |  3* Jemal CA Cancer J Clin 2005
  4. 4. Bert Vogelstein:  CancerCancer  therapeutics  ft thafter the cancer  genome project  ( )(ASCO 2009) S i f t l d h d d f t ti i h (W dSequencing of tumor genomes revealed hundreds of mutations in each (Wood  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) Akseli Hemminki   |  28 Oct 2010  |  4 For example, p16/Rb pathway selective oncolytic virus http://cgap.nci.nih.gov/
  5. 5. Deletion mutant oncolytic d i ∆24adenoviruses: ∆24 Fueyo Oncogene 2000 Heise Nature Med 2000 • S-phase • Virus replication & cell lysis E2F Rb E1A E2F Rb • normal cell • wt Ad 24 bp deletion in Rb binding site of E1A • No S phase entryE2F Rb E1A E2F Rb• normal cell wt Ad • Replication in cells mutant in Rb-p16 • No S-phase entry • No virus replication ∆24-E1A E2F Rb ∆24-E1A E2F Rb• normal cell • ∆24 mutant in Rb p16 pathway • Includes all human • S-phase • Virus replication & cell lysis∆24-E1A ∆24 E1A • cancer cell • ∆24 E2F E2F E2F E2F E2F E2F Akseli Hemminki   |  28 Oct 2010  |  5 cancers (Sherr Science 1996) & cell lysis∆24 E1A ∆24-E1A
  6. 6. 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 Akseli Hemminki   |  28 Oct 2010  |  6
  7. 7. 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 Promoter p53 gene pA ‐ Gendicine® for sale in China ‐ More than 10 000 patients treated Infection of cells Promoter p53 gene pA Infection of cells Normal cells with healthy p53  Cancer cells with p53 mutation Press release 23 Jul 2008: Ad‐p53 (Advexin®)  Cell death, also sensitation to  h h d di i phase III SCCHN trial positive in US: not  approved by FDA Akseli Hemminki   |  28 Oct 2010  |  7 chemotherapy and radiation No cell death
  8. 8. Prodrug converting enzymes Ad di f Randomized Phase III trial for glioma (ASPECT): • Ad-TK + standard care vs. standard care: 1.43 HR (p=0.02) Ad coding for  thymidine kinase (TK) TK (p ) • 40d increase in median survival • More temozolomide use in control group due to non-blinded gene therapy-> dilution of results Ad t non blinded gene therapy > dilution of results • EMEA did not approve because non-standard end-point (time to re-intervention or death) Non‐toxic prodrug Advantage vs.  mutation  compensation:  o to c p od ug = ganciclovir Activated bystander  effect via gap  junctionsActivated  toxin Cell death CHALLENGE: even with bystander effect, can we get effective penetration into established tumors ? Akseli Hemminki   |  28 Oct 2010  |  8 SOLUTIONS: locally amplifying systems
  9. 9. Oncolytic viruses • Replication of virus p causes oncolytic death  of cells • Normal cells‐ no  Akseli Hemminki   |  28 Oct 2010  |  9 replication
  10. 10. 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 t fl lik t i j ti it i¬ Mild tox: flu‐like symptoms, injection site pain ¬ Approved in China in 2006 (Yu Curr Cancer Drug Targets 2007) OncovexGMCSFOncovex ¬ Oncolytic herpes virus armed with GMCSF ¬ Previous phase 2: advanced melanoma, intratumoral injectionp , j ¬ N = 50. CR = 8 (+5), PR = 5, SD = 10. Disease control = 23/50 (46%).  Survival 58% @ 1yr, 52% @ 2yr.  Ph 3 fi i h d l 2011 Akseli Hemminki   |  28 Oct 2010  |  10 ¬ Phase 3 finished early 2011
  11. 11. Cancer Gene Therapy is maturing  has a treatment approach 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 Replication competent oncolytic viruses TUMOR PENETRATION NEEDS IMPROVEMENT 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) Akseli Hemminki   |  28 Oct 2010  |  11 * Immonen Mol Ther 2004, Li Clin Cancer Res 2007, Yu Curr Cancer Drug  Targets 2007, Pan J Clin Oncol 2008, Ylä‐Herttuala ESGCT 2008, 
  12. 12. Personalized oncolytic adenovirus treatments  in the Advanced Therapy Access Programin 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 ptSide 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) Cli i l b fit (i i CR PR SD) 48% ll 77% b t i• Clinical benefit (imaging CR, PR, SD): 48% overall, 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 Akseli Hemminki   |  28 Oct 2010  |  12
  13. 13. Findings possible only in pts: Mechanisms of anti‐ tumor efficacy inflammationinflammationy 1 Killing of differentiated tumor cells 3. Induction of  cytotoxic T‐cells  against tumors1. Killing of differentiated tumor cells CD8+ 4 5 6 E+8 against tumors vitiligovitiligo 2 3 4 0 17 41 48 10E 2. Killing of tumor initiating ”stem” cells 4. Induction of specific immunity against tumor epitope (survivin) Akseli Hemminki   |  28 Oct 2010  |  13 Eriksson Mol Ther 2007, Bauerschmitz Cancer Res 2008 Cerullo Cancer Res 2010
  14. 14. Ad5/3‐Cox2L‐D24 in chemotherapy  refractory OvCarefractory 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 usuallyOncolytic replication alone is usually  not enough to cure advanced tumors Pesonen Gene Ther  2010 Akseli Hemminki   |  28 Oct 2010  |  14 2010
  15. 15. 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 Akseli Hemminki   |  28 Oct 2010  |  15 Kanerva in preparation
  16. 16. Improving antitumor immunity: oncolytic  adenoviruses coding for GM CSFadenoviruses coding for GM‐CSF  Cerullo Mol Ther ASGT suppl 2009 GM‐CSF • GM‐CSF is the most potent inducer of anti‐ GM-CSF Cerullo Cancer Res 2010 • GM CSF is the most potent inducer of anti tumor immunity (Dranoff Immunol Rev 2002) • GM‐CSF in E3: expression starts at 8h G CS GM-CSF ⇒ GM‐CSF expressed only in cells that allow replication of the virus Hi h i l i• High expression at tumor, low systemic GM-CSF Akseli Hemminki   |  28 Oct 2010  |  16 GM CSF GM-CSF
  17. 17. GMCSF based approach validated 29  Apr 2010: Provenge (Sipuleucel‐T)Apr 2010: Provenge (Sipuleucel T) HormoneHormone  refactory prostate  cancer Collection ofCollection of  white blood cells Incubation w/ PAP  & GMCSF to  activate antigen  presenting cells Return cells into  ti tpatient First  immunotherapy  product !product ! PAP = prostatic acid  phosphatase  GMCSF = granulocyte  macrophage colony  i l i f Akseli Hemminki   |  28 Oct 2010  |  17 stimulating factor www.provenge.com
  18. 18. GM‐CSF can enhance antigen presentation  and induce NK and cytotoxic T‐cellsand induce NK and cytotoxic T cells Tumor cells killed with 3 mechanisms: - Oncolytic effect of virus replicationOncolytic effect of virus replication - NK cell mediated direct cell killing - DCs mediated tumor specific immunity CD8+ CD8+CD8+CD8+ CD8+ NK NK NK CD8+ NK CD8+ CD8+ CD8+ CD8+ NK NK NK CaCa Ca C NK NK GM-CSF = personalized cancer vaccine Ca Ca CaCa CaCa DC Akseli Hemminki   |  28 Oct 2010  |  18 GM-CSF
  19. 19. Cerullo Cancer Res 2010 Akseli Hemminki   |  28 Oct 2010  |  19Treatments
  20. 20. Syrian hamsters cured of HapT1 tumors  with Ad5D24‐GMCSF: protection fromwith Ad5D24 GMCSF: protection from  HapT1 challenge N=5 ** *** N=5 *** N=5 * Akseli Hemminki   |  28 Oct 2010  |  20Cerullo Cancer Res 2010
  21. 21. Syrian hamsters cured of HapT1 tumors  with Ad5D24 GMCSF: no protectionwith Ad5D24‐GMCSF: no protection  from HaK challenge Akseli Hemminki   |  28 Oct 2010  |  21 Cerullo Cancer Res 2010
  22. 22. Efficacy Ad5‐D24‐GMCSF: Single round of treatment Neutralizing Antibody Titer Virus Load in Serum Responseg y p Patient code Dosea (VP) Primary Tumor Week post-treatment Days post-treatment 0 1 2 4 0 1 2 3-7 8-12 21-40 RECISTa Density/o ther Marker Survival C3 8x109 Jejunum ca 0 1024 16834 0 0 <500 <500 0 MR 120 M3 1 1010 HCC 0 16384 4096 0 0 4896 0 0 0 SD ( 5 2%) 548bM3 1x1010 HCC 0 16384 4096 0 0 4896 0 0 0 SD (+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 c 0 0 16384 0 <500 <500 PD (+39%) 121 S108 2x1011 Synovial sarc 0 0 256 0 <500 <500 0 PD (+59%) 74 M50 2.5x1011 Mesothelio ma 256 16384 0 0 <500 0 SD (-5.7%) 403b R8 3x1011 Breast ca 64 16384 0 <500 <500 0 CR (-100%) PR 447b M32 3x1011 Mesothelio ma 0 256 16384 0 0 0 0 PDc 125 X49 3x1011 Cervical ca 16 4096 1024 0 4290 1211 PD (+55%) -27% 92X49 3x10 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 mel 0 64 0 44876 <500 63 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 O i 0 1024 0 <500 d PR 126 Overall efficacy (radiology) - CR 2/16 O88 4x1011 Ovarian ca 0 1024 0 <500 yesd PR 126 O9e 2x1011 Ovarian ca 16384 16384 0 2133f MR (-20%) 142 Summary of side effects Akseli Hemminki   |  28 Oct 2010  |  22 CR 2/16 - MR 1/16 - SD 5/16 - PD 8/16 Cerullo Cancer Res 2010 - All pts: gr 1-2 flu-like symptoms, fatigue, fever - One gr 3 ileus (OvCa pt w similar previous episodes) - Lab: gr 1-2 AST/ALT, hypo-K+, gr 1-3 hypo-Na+
  23. 23. Long term survival in 1/3 of patients  treated with Ad5‐D24‐GMCSFtreated with Ad5 D24 GMCSF Akseli Hemminki   |  28 Oct 2010  |  23 Cerullo Cancer Res 2010
  24. 24. Systemic efficacy of Ad5‐D24‐GMCSF in  injected and non‐injected tumors: virusinjected 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 injectionSingle intrapleural and i.v. injection  • More prominent reduction of non‐injected tumor than injected tumor Akseli Hemminki   |  28 Oct 2010  |  24 Cerullo Cancer Res 2010
  25. 25. Improving transduction to  i l iimprove oncolysis LOW CAR ‐LOW CAR  ‐ LOW GENE  Coxsackie‐ adenovirus  receptor (CAR):  key to Ad entry DELIVERY ! CAR IS AN key to Ad entry CAR IS AN  ADHESION  MOLECULE ‐ LOWLOW  EXPRESSION  Akseli Hemminki   |  28 Oct 2010  |  25 IN TUMORS 
  26. 26. Increasing infectivity of target cells:  transductional targetingtransductional targeting T t dNon-targeted adenovirus Targeted adenovirus Adenovirus receptor CAR Benign cell High transduction Low transduction receptor CAR Tumor associated receptor Cancer cell Low transduction High transduction p Akseli Hemminki   |  28 Oct 2010  |  26
  27. 27. Serotype chimerism for tumor targeting  Ad5 80 100 120 3x 1x108 VP i.p.CAR Ad3 receptor 40 60 80 %Survival Kanerva Mol Ther 2003 M1 Negative  0 20 15 25 35 45 55 65 75 85 95 105 115 125 135 CAR Kanerva Clin Cancer Res 2002 Day Ad3 receptor 1,E+05 1,E+06 Biodistribution Ad5/3  1,E+02 1,E+03 1,E+04 / mg proteinwith knob domain  from Ad3 1,E+00 1,E+01 , RLU  * Akseli Hemminki   |  28 Oct 2010  |  27Kanerva Mol Ther 2002
  28. 28. Ad5/3‐D24‐GMCSF = CGTG‐102 Fiber chimerism for enhanced  transduction of cancer cells Replication  in cells mutant in Rb‐p16  CD8+ NK NK CGTG‐102: 76% clinical  benefit in advanced ca ptspathy Includes most human cancers CD8+ NK CD8+ CD8+ CD8+ CD8+ CD8+ CD8+ CD8+ NK NK NK benefit in advanced ca. pts GM‐CSF  can enhance antigen  presentation and induce NK and  cytotoxic CD8+ T‐cells CaCa Ca Ca NK Ca Ca DC NK GM-CSF Expressed under the control of E3 Starts at 8h Expression coupled to virus  replication Ca Ca Ca Ca GM-CSF = personalized cancer vaccine Akseli Hemminki   |  28 Oct 2010  |  28 p Koski Mol Ther 2010
  29. 29. Overall survival of  patients treated 50% survival =  320 days Survival at 200 days = 66% Survival at 300 days = 55% patients treated  with CGTG‐102  (Ad5/3‐D24‐ N= 19 (Ad5/3 D24 GMCSF) Overall survival 50% survival = 177 days Survival at 200 days = 47% Survival at 300 days = 37% All patients were chemo refractory and All treatments 50% survival = 157 days Survival at 300 days = 34% Survival at 500 days = 22% N= 155 All patients were chemo refractory and  progressing at treatment Overall clinical benefit  in imaging = 76% Criteria: death due to any cause N= 144 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 Akseli Hemminki   |  28 Oct 2010  |  29 Vigano Palliat Med 2000, Llobera Eur J of  Cancer 2000)
  30. 30. Effect of serial  treatment on 50% survival 277 d treatment on  overall survival  of CGTG‐102 112 d 109 d 300 day survival of CGTG 102  patients Violet= CGTG‐102 serial  y 48 % 33 % 7 % treatment  (Kanerva,  Nokisalmi in  preparation)  Green = CGTG‐102 7 % rols Green = CGTG‐102  single treatment  (Koski  Mol Ther 2010) Blue = our first ATAP  i (P G al contr virus (Pesonen Gene  Ther 2010) Non‐randomised  istorica series but inclusion  criteria and patient  characteristics are  identical  30    115 H Akseli Hemminki   |  28 Oct 2010  |  30 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)
  31. 31. Inclusion and exclusion criteria,  personalization of oncolytic virus treatmentpersonalization of oncolytic virus treatment Inclusion criteria  Exclusion criteriac us o c te a Refractory solid tumor Failed treatments for which there is  c us o c te a confirmed brain met. or glioma organ transplant, HIV severe comorbiditystrong scientific evidence* Good performance status: WHO  0‐ 2. (WHO 3‐4 safe but less efficacy) severe comorbidity Elevated serum bilirubin Serum AST or ALT > 3 x normal Personalization: ( y) Written informed consent  Thrombocytes  < 75.   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. Vi iti T R t h TH2 >TH1 * In most cases this means 1st line chemotherapy  f t t ti di d i l Akseli Hemminki   |  28 Oct 2010  |  31 Virus sensitizers: T‐Reg, autophagy, TH2‐>TH1 Seroswitching when intravenous efficacy sought for metastatic disease, and in some cases several  lines of chemotherapy (eg. breast, ovarian and  colorectal cancer) In practice, the median number of prior chemo  regimens is 4 –> heavily pretreated
  32. 32. Systemic efficacy of Ad5/3‐Cox2L‐D24  in chemo refractory neuroblastomay • 6 yr old boy, WHO 1 • Heavily pretreated: 5 lines of  h t ll t l tchemo, stem cell transplant • Metastases in bone marrow  and near kidney T i l difi d i• Triple‐modified virus was  selected for intravenous efficacy • Cox2 expression confirmed  in  bone marrow biopsy 0 bone marrow  biopsy • Gr. 1 stomach pain, diarrhea,  flu‐like symptoms, liver enzymes • 4 wk later: complete response Akseli Hemminki   |  28 Oct 2010  |  32 6540 500 • 4 wk later: complete response  in bone marrow, partial  response in primary  Pesonen Acta Oncol 2010
  33. 33. Preclinical data suggests correlation between  gene delivery and oncolytic potency:  h l l l d d d ffArchival receptor levels did not predict efficacy CAR staining – to +++                                                          CAR ++ , CEA MR               CAR ++, CT SD Archival tumors are  typically operated  primariesprimaries They may be quite  different from  CAR+ CT SD CAR negative CT CR CAR+ Choi resp metastatic and   relapsing tumors  treated with many  CAR+, CT SD                    CAR negative, CT CR          CAR+, Choi resp. y different therapies Eg CAR level is  known to correlate CAR CT CR CAR CT PD CAR CT MRknown to correlate  with tumor  aggressiveness ‐>  h i CAR CAR+, CT CR                       CAR ++ CT PD                   CAR‐, CT MR Akseli Hemminki   |  28 Oct 2010  |  33 change in CAR Haavisto  et al. unpublished
  34. 34. Tumor biopsies may be able to measure  gene delivery to relevant tumor substrates ←   Pre‐treatment biopsies  infected with virus with  gene delivery to relevant tumor substrates same capsid as oncolytic  virus • O12: SD in imaging and  k O12 Biopsy C3 Biopsy markers • C3: MR in markers • Cerullo Cancer Res 2010 ←    Malignant pleural  ff i d i2 5E+07 V136 1 6E 05 K75 effusion and ascites • V136: SD in imaging, CR  in non‐injected liver  metastasis1,5E+07 2,0E+07 2,5E+07 ssion(RLU) Pleural effusion cells 1,0E+05 1,2E+05 1,4E+05 1,6E+05 ression(RLU) K75 Ascites cells metastasis • K75: CR in ascites  formation  • Koski Mol Ther 20105,0E+06 1,0E+07 , nsgene expres 2 0E+04 4,0E+04 6,0E+04 8,0E+04 ransgene expr Akseli Hemminki   |  28 Oct 2010  |  34 Koski Mol Ther 2010 0,0E+00 Ad5luc1 Ad5/3luc1 Tran 0,0E+00 2,0E+04 Ad5luc1 Ad/3luc1 Tr
  35. 35. Pre‐treatment prediction of Ad5/3‐D24‐GMCSF  efficacy: killing of pleural effusion cells 160 180 200 V136 200 250 M137 efficacy: killing of pleural effusion cells - SD in CT scan - CR in liver t t i - SD in CT scan - CR in pleural 100 120 140 yof(%) 150 ty(%) metastasis p effusion - Survival > 700d (ongoing) 20 40 60 80 Viability 50 100 Viabilit *** *** 0 20 Uninfected cells Ad5luc1 Ad5/3-d24- GMCSF 0 Uninfected cells Ad5luc1 Ad5/3-d24- GMCSF Koski Mol Ther 2010 R73 SD i CT- SD in CT scan - Survival >800d (ongoing) Akseli Hemminki   |  28 Oct 2010  |  35 Cerullo Cancer  Res 2010
  36. 36. Virus circulates for  extended times inextended times in  most patients – no  correlation to Last d38 Last d28 correlation to  efficacy or adverse  events Last d40 Last d63 Escutenaire Ann Med in  ll Last d52 Last d64 press, Cerullo Cancer Res  2010, Nokisalmi CCR 2010,  Koski Mol Ther 2010,  Pesonen Gene Ther 2010, Last d52 Akseli Hemminki   |  28 Oct 2010  |  36 Pesonen Gene Ther 2010,  Pesonen submitted
  37. 37. 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: 4 096 16 384 • Heavily pre‐treated  9yr old Wilms tumor patient:  Multiple operations, 6 lines of chemotherapy, radiation • Progressive disease in several abdominal locations • ICOVIR‐7 1x10e11 VP; 80% i.t.,20% i.v. • gr 2 stomach pain fatigue fever gr 1 AST nausea 256 1 024 er • gr 2 stomach pain, fatigue, fever. gr 1 AST, nausea • Pre‐treat Nab titer 4, no increase in 4 weeks Before oncolytic virus         Partial response 36d after 4 16 64 Nab tite 0 1 Koski  Mol Ther 2010 0 0 1 2 3‐4 > 4 Time (weeks) Akseli Hemminki   |  28 Oct 2010  |  37 Y62 H64 C66 S67 S70 P74 K75 O79 I80 O82 H83 I87 C95 H96 I98 N110 O113 S119 X122 O129 V136 M137 Nokisalmi Clin Cancer Res 2010
  38. 38. Anti‐adenoviral and anti‐tumor immunity  are induced in most patients: noare induced in most patients: no  correlation to efficacy.  Decrease might also relate to efficacy ?Decrease might also relate to efficacy ?  Anti‐Ad Anti‐Survivin Akseli Hemminki   |  28 Oct 2010  |  38Koski  Mol Ther 2010
  39. 39. Tumor specific T‐cell responses might require  HLA However HLA staining of archivalHLA. However, HLA staining of archival  specimens does not predict efficacy HLA t i i ( l t ++)HLA staining (scale – to ++) G15 + R8 negative R73 + Efficacy -Choi response, - CR in imaging, markers - SD in CT scan - Survival > 400d - Survival > 1000d, ongoing - Survival >800d(ongoing) Akseli Hemminki   |  28 Oct 2010  |  39Diaconu, Cerullo, unpublished
  40. 40. Metronomic cyclophosphamide for down‐ regulation of T‐Regregulation of T Reg Background: T‐Regs  TReg g g inhibit NK and cytotoxic  T‐cells CC CD8+ NK CaCa Ca Ca CCa Ca Ca Ca CaCa Akseli Hemminki   |  28 Oct 2010  |  40
  41. 41. Cyclophosphamide for reducing T‐Regs and  enhancing the effect of oncolyticenhancing the effect of oncolytic  virotherapy TReg Cyclophosphamide CC CD8+ NK CaCa Ca Ca CCa Ca Ca Ca CaCa Akseli Hemminki   |  28 Oct 2010  |  41
  42. 42. GM‐CSF can enhance antigen presentation  and induce NK and cytotoxic T‐cellsand induce NK and cytotoxic T cells TReg TReg TRegTReg TReg TReg CD8+ CD8+CD8+CD8+ CD8+ NK NK NK CD8+ NK CD8+ CD8+ CD8+ NK NK NK CaCa Ca C NK NK GM-CSF Ca Ca CaCa CaCa DC Akseli Hemminki   |  28 Oct 2010  |  42 GM-CSF
  43. 43. Cyclophosphamide can enhance the effect of  GM‐CSF induced NK and cytotoxic T‐cellsGM CSF induced NK and cytotoxic T cells TReg TRegTReg TReg C clophosphamide Cyclophosphamide CD8+ CD8+CD8+CD8+ CD8+ NK NK NK Cyclophosphamide CD8+ NK CD8+ CD8+ CD8+ NK NK NK Ca NK NK GM-CSF Dying tumor cells Ca CaCa Ca DCtumor cells Akseli Hemminki   |  28 Oct 2010  |  43 GM-CSF
  44. 44. Oral or intravenous low‐dose  l h h id b th ?cyclophosphamide or both ?  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 ? Akseli Hemminki   |  28 Oct 2010  |  44 Cerullo Submitted
  45. 45. Low dose cyclophosphamide reduces T‐reg in  most but not all patients Most effective inmost but not all patients. Most effective in  patients with high T‐Reg counts? Akseli Hemminki   |  28 Oct 2010  |  45Cerullo Submitted
  46. 46. Possible clinical predictors of  benefit from oncolytic Ad: tumorbenefit from oncolytic Ad: tumor  burden, performance score, age 57 yr old woman with Stage 4 ovarian cancer57 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 burdenWHO 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 (HodiImmunotherapy 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 d t >50% Akseli Hemminki   |  28 Oct 2010  |  48 3 needs rest >50% 4 needs rest 100% 5 dead
  47. 47. Summary Clinical proof‐of‐principle available for oncolytic virusesp 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 biopsiesFor 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 tailoredT‐Reg 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 therapypatients 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 Akseli Hemminki   |  28 Oct 2010  |  49 Every patient and tumor is different  > therapy should also be
  48. 48. Acknowledgements Akseli Hemminki Sari Pesonen Sophie Esc tenaire Marko Ahonen Karoliina Autio I lia Diacon Institut Catala d’Oncologica: Ramon Alemany Univ. Helsinki & HUCH: Petteri Arstila Pekka Häyry K i Hö k d Suvi Parviainen Maria Rajecki Noora Ro inenSophie Escutenaire Vincenzo Cerullo Anna Kanerva Minna Oksanen Iulia Diaconu João Dias Otto Hemminki Mari Hirvinen Anniina Koski a o e a y U. Washington Andre Lieber U. Ottawa Krister Höckerstedt Helena Isoniemi Tuula Kiviluoto Jorma Paavonen Risto Renkonen Ari Ristimäki Noora Rouvinen Kikka Holm Eerika Karli Saila PesonenAnniina Koski Ilkka Liikanen Petri Nokisalmi John Bell Ari Ristimäki Mirja Ruutu Jarmo Salo Kalle Saksela Ulf‐Håkan Stenman Mikko Tenhunen Saila Pesonen Mikko Tenhunen Pekka Virkkunen Grant support: Timo Joensuu Tuomo Alanko Pekka Simula Timo Ahopelto Charlotta Backman The Patients Grant support: ERC Academy of Finland ASCO Biocentrum Helsinki Bi t Fi l d Tuomo Alanko Saila Eksymä‐Sillman Kalevi Kairemo Jenni Kylä‐Kause Leena Laasonen Satu Kauppinen Charlotta Backman Elina Haavisto Lotta Kangasniemi Aila Karioja‐Kallio Heli Nyrhinen Biocenter Finland Sigrid Juselius Foundation University of Helsinki HUCH Research Funds (EVO) Satu Kauppinen Kaarina Partanen Marina Rosliakova Tuuli Ranki Maija Salo Mikko Salo Antti Vuolanto
  49. 49. 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 CD8+ 5 6 8 2 3 4 10E+8 Akseli Hemminki   |  28 Oct 2010  |  51 2 0 17 41 48
  50. 50. king of MHC I Ad5 (hexon) Specific  Immunity Block Akseli Hemminki   |  28 Oct 2010  |  52Cerullo Cancer Res 2010
  51. 51. king of MHC I Tumor‐specific  Immunity  Block y (Survivin) Akseli Hemminki   |  28 Oct 2010  |  53Cerullo Cancer Res 2010
  52. 52. Cancer stem cell (CSC) hypothesis CSCCSC Committed progenitors cells: PCa CSCCSC Committed progenitors cells: Rapid replication Limited lifespan CSCCSC Self-renewal: Slow replication other fibro CSCCSC CaCa Slow replication Unlimited lifespan othervascinflam Ca Ca C Ca Ca Most ca. treatments select target cells based on higher replication Ca stem cells may not actively CaCa Ca CaCa Ca CSCCSC T mors are mi ed y y replicate: not killed Ion transporters remove drugs from cells: not killed CaDifferentiated ca. cells Akseli Hemminki   |  28 Oct 2010  |  54 CaTumors are mixed populations of cellsClinical research may have missed CSC specific agents
  53. 53. Breast cancer stem cells can be  killed with oncolytic adenoviruseskilled with oncolytic adenoviruses Eriksson Mol Ther Akseli Hemminki   |  28 Oct 2010  |  55 Eriksson Mol Ther 2007 Bauerschmitz Cancer Res 2008

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