Immunotherapy-for-Merkel- CellCancer SLIDES.pdfboomers-age-in-to-MCC-risk-groups 4 9 4 9 4 9 4 9 4 9 4 9 4 85+ 0 2 4 6 8 10 Age at Diagnosis (Years) Annual Incidence Rate Adjusted)

Immunotherapy for Merkel Cell Cancer

Kelly Paulson, MD, PhD

Oncology Fellow, FHCRC/UW Combined Program Dr. Aude Chapuis Lab

[email protected]

WSMOS MeeGng 13 October 2017

Outline

• Merkel cell cancer: presentaGon, impact, pathogenesis • Adjuvant therapy: + radiaGon, -‐ chemotherapy, ADAM clinical trial • Monitoring for recurrence: serology assay • Advanced MCC: Checkpoint inhibitors in 1st line per 2018 NCCN •  T cell therapies for MCC

•  Current trials: endogenous T cell therapy •  Sharing cures: transgenic T cell therapy

• QuesGons

Outline

• Merkel cell cancer: presenta.on, impact, pathogenesis • Adjuvant therapy: + radiaGon, -‐ chemotherapy, ADAM clinical trial • Monitoring for recurrence: serology assay • Advanced MCC: Checkpoint inhibitors in 1st line per 2018 NCCN •  T cell therapies for MCC


• QuesGons

Merkel cell carcinoma •  Aggressive neuroendocrine skin cancer

•  Typically presents as a red or purple, rapidly growing nodule1

•  Incidence increased 3-‐10 fold in immunosuppressed populaGons, & outcomes worse in these populaGons2

•  HOWEVER 90% of cases diagnosed in immunocompetent

Images: Paul Nghiem 1. Heath et al JAAD 2008 2. Paulson et al JID 2013

MCC Incidence Increasing: 2500 cases/year in USA

2000 2005 2010100

150

200

Year

Case

s Re

porte

d to

SEE

R-18

(%

cas

es in

yea

r 200

0)

MCC

All Solid Tumors

Melanoma

B.

+15%

+57%

+95%

SEER database

MCC incidence will conCnue to grow as baby boomers age in to MCC risk groups

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84 85

+0

2

4

6

8

10

Age at Diagnosis (Years)

US A

nnua

l Inc

iden

ce R

ate

(Sex

Adj

uste

d)

Melanoma(per 6.7K)

MCC(per 100K)

A.

Baby boomers 2015

Baby boomers 2025

2000 2005 2010 2015 2020 20250

1000

2000

3000

4000

Year

MCC

Incid

ence

in U

S (#

Cas

es)

Calculated from Observed SEER-18 Incidence RatesProjected based on US Census Data

B.

Paulson et al, JAAD, in revision

MCC risk factors

• Age • Male sex • UV exposure •  Immune suppression • Merkel cell polyomavirus – 80% of cases

Feng et al – Science 2008

Discovered in 2008 by Patrick Moore and Yuan Chang at U. Pia (who also discovered KSHV)

MCPyV – a common virus that breaks in a rare and special way to cause MCC

Virus associated MCCs are addicted to oncoprotein

expression

The virus in MCC tumors is broken and no longer

contagious

MCC Staging: Stage IIIB “unknown primary”

•  Up to 50% of paGents presenGng with stage IIIB (palpable nodal, no distant) MCC have no idenGfiable skin primary

•  These paGents are thought to have had an immune response leading to regression of a small skin primary

•  Consistent with this, outcomes are beaer in this group

Chen et al, Am J Surgery 2013

Outline

• Merkel cell cancer: presentaGon, impact, pathogenesis • Adjuvant therapy: + radia.on, -‐ chemotherapy, ADAM clinical trial • Monitoring for recurrence: serology assay • Advanced MCC: Checkpoint inhibitors in 1st line per 2018 NCCN •  T cell therapies for MCC


• QuesGons

Risk of MCC recurrence is high! This is true even for early stage disease….

Nghiem et al, merkelcell.org Paul Nghiem, MD

Adjuvant radiaCon typically indicated: improved RFS and OS

BhaGa S et al, JNCI, 2016

*non-‐randomized data – randomized studies unlikely to be performed due to clear local control benefit

Adjuvant chemotherapy does not help and may hurt

• No clear survival benefit in any of the studies that have looked at adjuvant chemotherapy for MCC, even when straGfying to stage III disease (eg. BhaGa S et al, JNCI 2016)

• Based on emerging data, chemotherapy may reduce responsiveness to subsequent immunotherapy should recurrence develop….

Adjuvant immunotherapy is being tested

• ADAM trial: •  Stage IIIB (palpable nodal) disease, within 4 months of surgical excision •  +/-‐ radiaGon therapy OK •  100 paGents, randomized 1:1 placebo vs. avelumab (PD-‐L1 blockade)

•  2 years treatment -‐> 3 years follow-‐up •  14 US sites, being led by SCCA •  Opens soon – we appreciate your kind referral of potenGally eligible stage IIIB paGents as we try to accrue for this rare disease!

Shailender BhaGa, MD

Outline



• QuesGons

Biomarkers for recurrence •  Immunotherapy works beaer at lower burdens: raGonale for early detecGon of recurrent disease

• Good biomarkers amplify underlying cancer signal to help differenGate signal to noise

•  The immune system is a great amplifier • Virus posiGve MCCs have a shared anGgen (viral oncoprotein)

Serologic assay for MCC (“AMERK”) •  At presentaGon, ~50% of paGents have circulaGng anGbodies to Merkel cell polyomavirus oncoproteins (T AnGgens)

•  <1% of healthy individuals have these anGbodies

•  SeronegaGve paGents have a high recurrence risk •  Mixed group of virus negaGve paGents and poor immune response to MCC paGents

•  For seroposiGve paGents, serial anGbody Gters can be used to detect recurrence

Paulson, Carter et al, Cancer Res 2010 Paulson et al, Cancer, 2017

Denise Galloway, PhD

Example paCents

NED

Recurrence

AMERK is clinically available (UW labmed) & listed as an opCon in 2018 NCCN guideline •  If tesGng:

•  Check iniGal level within 90 days of diagnosis – levels fall fast •  Only check serial levels if iniGally seroposiGve •  Validated only for detecGon of first recurrence, not for monitoring response to immunotherapy or detecGng subsequent recurrences

Conflict of interest statement: I was involved in the development of this assay. I have no personal financial interest in this assay.

Ordering: hMp://www.merkelcell.org/sero

Outline



• QuesGons

Durability of chemotherapy response historically poor: addiConal treatment opCons needed

Iyer et al 2016

All MCC is immunogenic

•  80% (MCPyV+): Addicted to immunogenic viral oncoproteins •  20% (MCPyV-‐): Higher mutaGonal burden than any cancer type in TCGA (Goh et al, 2016)

MCC outcome, whereas peritumoral lymphocytes are not. This is alsotrue for other cancers, such as ovarian cancer and colon cancer.27,34

Second, immunohistochemical CD8! evaluation may be more sen-sitive and specific for identification of TILs than routine histology.This is because T cells can sometimes be indistinguishable from MCCtumor cells using hematoxylin and eosin staining.

This study has several limitations despite the fact that it is both thelargest molecular and immunohistochemical examination of MCCyet reported, to our knowledge. The median age of the patient popu-lation (66 years) was younger than that for MCC nationally (76years).3,11 This may in part reflect the fact that patients in this cohortwere ascertained because they sought specialty care or information/

A

C

B

0 1 2 3 4 5 6 7 8 9 10

TILs present (n = 86)* TILs absent (n = 44)M

CC-S

peci

fic S

urvi

val (

%)

Time Since Diagnosis (years)

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


Local Regional Metastatic

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


25

50

75

100

CD8+ brisk (IT, n = 26)†

CD8+ sparse (IT, n = 120)

CD8+ brisk (IT, n = 18)CD8+ sparse (IT, n = 60)



Fig 3. T-cell infiltration and Merkel cell carcinoma (MCC)–specific survival in an independent set of 146 patients. (A) Tumor infiltrating lymphocytes (TILs) analysis byroutine histology among 129 patients. (*) TILs were prognostically significant on univariate (P " .03) but not multivariate (P " .12) analysis. (B) Intratumoral (IT) CD8!lymphocyte infiltration. Brisk CD8s were defined as an intratumoral CD8 score of 3 to 5 (corresponding to approximately 60 or more CD8s per typical 40# high powerfield), sparse as 0 to 2. (†) IT CD8 infiltration was a statistically significant predictor of outcome on univariate (P $ .01) and multivariate (P " .01) regression analyses(Table 3). (C) Subgroup breakdown of (B), by extent of disease at presentation (as indicated). Extent of disease at presentation was not known for two patients.Statistical analysis was not performed on subgroups; instead, multivariate Cox regression is listed in Table 3.

Table 3. Multivariate Cox Regression Analysis Demonstrates Intratumoral CD8 Score Is an Independent Predictor of Merkel Cell Carcinoma Outcome

Characteristic

Univariate Multivariate

HR 95% CI P HR 95% CI P

StageII v I 0.8 0.1 to 5.0 .86 1.1 0.2 to 6.6 .92III v I 6.5 1.9 to 22.6 $ .01 5.5 1.4 to 21.2 .02IV v I 18.8 3.4 to 104.5 $ .01 31.5 6.8 to 147.0 $ .01

Female sex 0.4 0.1 to 1.0 .06 0.6 0.2 to 1.7 .31Age at diagnosis ! 65 years 1.1 0.5 to 2.3 .87 0.8 0.4 to 1.8 .62CD8, per increase on 0 to 5 scale

Peritumoral 0.8 0.6 to 1.0 .06 0.9 0.6 to 1.4 .79Intratumoral 0.5 0.5 to 0.7 $ .01 0.5 0.3 to 0.9 .01

NOTE. CD8! scoring scale is described in Methods and in the scoring guide provided as a Data Supplement. All variables listed in this table were included in themultivariate analysis.

Abbreviation: HR, hazard ratio.

Paulson et al

1544 © 2011 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY

Downloaded from ascopubs.org by Fred Hutchinson Cancer Research Center on August 9, 2017 from 140.107.061.185Copyright © 2017 American Society of Clinical Oncology. All rights reserved.

Brisk intratumoral T cell response

Sparse intratumoral T cell response

Paulson et al, JCO 2011

Checkpoint inhibitors are effecCve in advanced MCC • Pembrolizumab (1st line)

•  PD-‐1 inhibitor, q3 weeks, under FDA review for this indicaGon

•  RR 56%

• Avelumab (2nd line) •  PD-‐L1 inhibitor, FDA-‐indicated , q2 weeks

•  RR 32%

Nghiem et al NEJM 2016

Kaufman et al Lancet Oncol 2016

ToxiciCes of checkpoint inhibitors are similar in MCC as to other cancers: faCgue, iRAEs including rare severe autoimmune reacCons

Checkpoint inhibitors are now first line in 2018 NCCN guideline

NCCN.org

Great progress, but we can do even beaer….

Time à

Pro

gres

sion

-Fre

e S

urvi

val

Primary refractory (never responded)

Acquired resistance (lost response) Long-term response

(immunologic cure

Types of clinical responses to checkpoint blockade….

Reprising a previous slide

Poor T cell infiltrate (n=120)

Strong T cell infiltrate (n=26)

no T cells

T cells at edge

MCC outcome, whereas peritumoral lymphocytes are not. This is alsotrue for other cancers, such as ovarian cancer and colon cancer.27,34

Second, immunohistochemical CD8! evaluation may be more sen-sitive and specific for identification of TILs than routine histology.This is because T cells can sometimes be indistinguishable from MCCtumor cells using hematoxylin and eosin staining.

This study has several limitations despite the fact that it is both thelargest molecular and immunohistochemical examination of MCCyet reported, to our knowledge. The median age of the patient popu-lation (66 years) was younger than that for MCC nationally (76years).3,11 This may in part reflect the fact that patients in this cohortwere ascertained because they sought specialty care or information/

A

C

B

0 1 2 3 4 5 6 7 8 9 10

TILs present (n = 86)* TILs absent (n = 44)M

CC-S

peci

fic S

urvi

val (

%)


25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


Local Regional Metastatic

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


25

50

75

100

0 1 2 3 4 5 6 7 8 9 10

MCC

-Spe

cific

Sur

viva

l (%

)


25

50

75

100

CD8+ brisk (IT, n = 26)†

CD8+ sparse (IT, n = 120)




Fig 3. T-cell infiltration and Merkel cell carcinoma (MCC)–specific survival in an independent set of 146 patients. (A) Tumor infiltrating lymphocytes (TILs) analysis byroutine histology among 129 patients. (*) TILs were prognostically significant on univariate (P " .03) but not multivariate (P " .12) analysis. (B) Intratumoral (IT) CD8!lymphocyte infiltration. Brisk CD8s were defined as an intratumoral CD8 score of 3 to 5 (corresponding to approximately 60 or more CD8s per typical 40# high powerfield), sparse as 0 to 2. (†) IT CD8 infiltration was a statistically significant predictor of outcome on univariate (P $ .01) and multivariate (P " .01) regression analyses(Table 3). (C) Subgroup breakdown of (B), by extent of disease at presentation (as indicated). Extent of disease at presentation was not known for two patients.Statistical analysis was not performed on subgroups; instead, multivariate Cox regression is listed in Table 3.

Table 3. Multivariate Cox Regression Analysis Demonstrates Intratumoral CD8 Score Is an Independent Predictor of Merkel Cell Carcinoma Outcome

Characteristic

Univariate Multivariate

HR 95% CI P HR 95% CI P

StageII v I 0.8 0.1 to 5.0 .86 1.1 0.2 to 6.6 .92III v I 6.5 1.9 to 22.6 $ .01 5.5 1.4 to 21.2 .02IV v I 18.8 3.4 to 104.5 $ .01 31.5 6.8 to 147.0 $ .01

Female sex 0.4 0.1 to 1.0 .06 0.6 0.2 to 1.7 .31Age at diagnosis ! 65 years 1.1 0.5 to 2.3 .87 0.8 0.4 to 1.8 .62CD8, per increase on 0 to 5 scale

Peritumoral 0.8 0.6 to 1.0 .06 0.9 0.6 to 1.4 .79Intratumoral 0.5 0.5 to 0.7 $ .01 0.5 0.3 to 0.9 .01

NOTE. CD8! scoring scale is described in Methods and in the scoring guide provided as a Data Supplement. All variables listed in this table were included in themultivariate analysis.

Abbreviation: HR, hazard ratio.

Paulson et al

1544 © 2011 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY

Downloaded from ascopubs.org by Fred Hutchinson Cancer Research Center on August 9, 2017 from 140.107.061.185Copyright © 2017 American Society of Clinical Oncology. All rights reserved.

These individuals never need

immunotherapy

These individuals o3en respond to

checkpoint blockade

These individuals typically do not respond to checkpoint

blockade (primary refractory)

Outline



• QuesGons

Endogenous Cellular Therapy TargeCng MCPyV

Patient

Leukapheresis

Enrich with peptide-pulsed dendritic cells

Peptide = small piece of target antigen (MCPyV)

Total production time: ~4-6 weeks

T cells (autologous/self) ‘Outgrowth’ of antigen-specific T cells

GMP flow sorting

Expansion Dr. Aude Chapuis

ΜΗΧ-πεπτιδε

Τετραµερ

Infuse virus-‐specific, highly expanded T cells back into paCent (1010 per m2)

How CD8+ T cells (“cytotoxic T lymphocytes”) work

(CTL)

(HLA)

i.e. T-‐cell receptor

Signal 1 = Trigger

Signal 2 = Safety

Target T cell PDL1 PD1

OFF – NO KILLING

Target T cell PD1

ON – KILLING

CombinaCon immunotherapy for advanced MCC

(CTL)

(HLA)

i.e. T-‐cell receptor

Signal 1 = Trigger

Signal 2 = Safety

Target T cell PDL1 PD1

OFF – NO KILLING

Our current T cell therapy trials have three parts (triple therapy): 1) CD8+ T cells (virus specific) 2) Class I MHC upregulaGon 3) Checkpoint inhibiGon

Infused T cells Persist and Function

Grey lines: with PD1 axis blockade Black lines: without PD1 axis blockade

Infused MCPyV T cells preferenCally localize to tumor

0

5

10Nu

mbe

r Inf

used

TC

R Cl

ones

Det

ecta

ble

Number of Infused Top 20 Clones Detectable

Peripheral BloodMCC Tumor Tissue

Pre-Treatment <1 month ~6 months post Post-Treatment Treatment (in CR)

2

0 01

5

90.001

0.01

0.1

1

Perce

nt TC

R Se

quen

ces

Corre

spon

ding t

o Top

20

Infus

ed S

eque

nces

Percent TCR Sequences Corresponding to Infused Product



Tumor burden: +++ ++ 0

# detected infused clonotypes

% detected infused clonotypes 1

2

34567891011121314151617181920Remainder

Infusion product

Infused T cells trigger epitope spreading

34

Patient HLA-upreg

TargetedMCPyVepitope

Grade3/4AEs

BestResponse(RECIST)

9245-157y/oF

XRT HLA-A24“EWW”/B07 “APN”

Lymphopenia

CR(ongoing@

14mo)

9245-256y/oM

IFN HLA-A02“KLL” Lymphopenia

CR(ongoing@

15mo)

9245-360y/oM

IFN+XRT HLA-A02”KLL”/B35“FPW”

Lymphopenia,CRS

CR(ongoing@

12mo)

9245-564 y/oM

XRT HLA-A02“KLL” Lymphopenia

PR(progressed@

3mo)

9245-6<30y/o F

IFN HLA-A02“KLL” Lymphopenia

PD

Encouraging responses to endogenous cell therapy

Complete regressions in 3 pa.ents that had persistence of the infused T cells – all ongoing at > 1 year

In paGents who the T cells did not persist, outcomes were worse

Paulson et al, ASCO 2017

Now 21 mo

Now 21 mo

Now 18 mo

Responses by iRRC

1 2 3 4 5 6 7 8 9 10 11 12

-100-75-50-25

0255075

Time from Treatment Initiation(Months)

Chan

ge in

Tu

mor

Bur

den

(%)

9245-19245-29245-39245-49245-59245-6

Response in Tumor Burden (irRC)

Closed Symbols=Received T cells

Stable Disease

Pre-treatment

Pre-treatment 9 months later

Radiated lesion à

•  Patient with ongoing CR 21 months after Triple Therapy •  Tolerated all study infusions without toxicity

Non-radiated lesion à

T cells plus avelumab plus single fracGon radiaGon to one lesion confirmed CR at all cancer sites

LimitaCons of endogenous cell therapy

•  Slow •  Expensive • Difficult to deliver intended doses…. • Dependent on the paGent’s underlying immune response

•  PaGent may have poor avidity or absence of underlying T cell responses

Transgenic T cell Therapy

Patient

Leukapheresis

Total production time: ~3 weeks

T cells (autologous/self)

GMP flow sorting

Non-specific expansion

TCR transduce (lentivirus)

TCR

Dr. Aude Chapuis

What TCR do you want? Sharing Cures

0

5

10

Num

ber I

nfus

ed

TCR

Clon

es D

etec

table

Number of Infused Top 20 Clones Detectable



2

0 01

5

90.001

0.01

0.1

1

Perce

nt TC

R Se

quen

ces

Corre

spon

ding t

o Top

20

Infus

ed S

eque

nces

Percent TCR Sequences Corresponding to Infused Product



Tumor burden: +++ ++ 0

# detected infused clonotypes

% detected infused clonotypes 1

2

34567891011121314151617181920Remainder

Infusion product

PaCent 9245-‐3 In pathologic CR 18

months aker therapy start

Problem: TCR alpha and beta on different chromosomes SoluCon: Single Cell RNA sequencing

Gel bead emulsions made on the bench top in a toaster sized machine

ATTACk-‐MCC Regimen: In development, anCcipaCng enrollment in 2018

•  16 paGents over 2 years • Autologous •  Transgenic T cells • Avelumab • Class I MHC upregulaGon

Dr. Aude Chapuis Fred Hutch Dr Megan McAfee Dr Maurizio Perdicchio Felecia Wagener Daniel Hunter Marcus Lindberg Dr Paul Nghiem Fred Hutch/UW Dr Jayasri Iyer Natalie Vandeven Dr Candice Church Dr Rima Kulikauskas Dr Aric Colunga Hannah Thomas Dr Shailender Bhatia UW

Thank you!!!! Dr Jason Bielas Fred Hutch BJ Valente Dr Raphael Gottardo Fred Hutch Dr Valentin Voillet Dr Cassian Yee MD Anderson Dr Philip Greenberg Fred Hutch/UW 9245: EMD Serono Zhen Su MD, PhD Kevin Chin MD

Patients and their families Funding: NIH Bezos Family Foundation FHCRC EMD Serono (9245) MCC Gift Fund at University of Washington WSMOS

Dr Robert Pierce FHCRC Jean Campbell Kimberly Smythe Kim Melton FHCRC Genomics Core Andy Marty, PhD Dr. David Koelle Clinical Team Kieu-Thu Bui Judy Delismon Cari Morin Susan Lemmon Ana Radu Melanoma/Renal RNs Skin Oncology RNs

Documents

Immunotherapy-for-Merkel- CellCancer SLIDES.pdfboomers-age-in-to-MCC-risk-groups 4 9 4 9 4 9 4 9 4 9 4 9 4 85+ 0 2 4 6 8 10 Age at Diagnosis (Years) Annual Incidence Rate Adjusted)