Multiple MyelomaAntineoplastic Combined Chemotherapy Protocols

Leukemia, Myeloid, AcuteAntineoplastic Agents

Dexamethasone

Hematopoietic Stem Cell Transplantation

Antibodies, Monoclonal

Drug Resistance, Neoplasm

Stem Cell Transplantation

Thalidomide

Chromosome Aberrations

Neoplasm Recurrence, LocalPolymorphism, Single Nucleotide

Bortezomib

Genes, p53

Aza CompoundsBiomarkers, Tumor

Boron CompoundsBoronic Acids

Bridged Bicyclo Compounds, HeterocyclicDNA Methylation

fms-Like Tyrosine Kinase 3

Glycine

Immunosuppressive Agents

Killer Cells, Natural

Leukemia, Myeloid

Leukemia, Plasma Cell

Lymphohistiocytosis, Hemophagocytic

Mutation Proteasome Inhibitors

Pyrazines

5'-Nucleotidase

Adjuvants, Immunologic

ADP-ribosyl Cyclase 1

Age Factors

Alleles

Amyloid Neuropathies, Familial

Angiogenesis Inhibitors

Antibiotics, Antineoplastic

Antigens, Neoplasm

Antimetabolites, Antineoplastic

Apoptosis

ATP-Binding Cassette, Sub-Family B, Member 1

Betamethasone

Bone Marrow Transplantation

Bone Neoplasms

Burkitt Lymphoma

Cardiomyopathies

Cell Culture Techniques

Cell Separation

Central Nervous System Neoplasms

Chromatin

Chromosome Deletion

Chromosome Inversion

Chromosomes, Human, Pair 1

Chromosomes, Human, Pair 13

Chromosomes, Human, Pair 17

Chromosomes, Human, Pair 3

Chromosomes, Human, Pair 9Consolidation Chemotherapy

Cost-Benefit Analysis

Cyclophosphamide

Cytarabine

Cytidine Deaminase

DNA-Binding Proteins

DNA Topoisomerases, Type IIEnhancer of Zeste Homolog 2 Protein

Founder Effect

Gene Deletion

Gene Expression Regulation, Leukemic

Acknowledgments

Multiple MyelomaRisk Factors and prognosis studies though different databases

Outcome and survival of myeloma patients diagnosed 2008-2015. Real-world data on 4904 patients from the Swedish Myeloma Registry.

Incidence, characteristics, and outcome of solitary plasmacytoma and plasma cell leukemia. Population-based data from the Swedish Myeloma Register.

Propensity score matching analysis to evaluate the comparative effectiveness of daratumumab versus real-world standard of care therapies for patients with heavily pretreated and refractory multiple myeloma.

Natural history of relapsed myeloma, refractory to immunomodulatory drugs and proteasome inhibitors: a multicenter IMWG study.

IMWG consensus on risk stratification in multiple myeloma.

Regional differences in the survival of patients with MM in Sweden.

15 different articles

Multiple Myeloma Chromosomal aberrations

2009 The prognostic significance of 8p21 deletion in multiple myeloma.

2010 Impact of chromosome 13 deletion and plasma cell load on long-term survival of patients with multiple myeloma undergoing autologous transplantation

2011 Clinical impact of chromosomal aberrations in multiple myeloma

2013 In search of the molecular consequences of 8p21 deletion in multiple myeloma: commentary on Gmidéne et al.

2016 Proteasome inhibitors and IMiDs can overcome some high-risk cytogenetics in multiple myeloma but not gain 1q21.

2015 Deletion of Chromosomal Region 8p21 Confers Resistance to Bortezomib and Is Associated with Upregulated Decoy TRAIL Receptor Expression in Patients with Multiple Myeloma.

Variants in ELL2 influencing immunoglobulin levels associate with multiple myeloma.

Genome-wide association study identifies multiple susceptibility loci for multiple myeloma.

The multiple myeloma risk allele at 5q15 lowers ELL2 expression and increases ribosomal gene expression

Multiple Myeloma

Gene regulation, Epigenetic and Genetics

translocation probe, t(4;14)

§ WGS: Mutation identification in coding and non-coding regions§ ATACseq: DNA accessibility assay. Identify open chromatin regions§ ChIP-seq: Mapping chromatin modifications and regulatory elements genome wide.

H3K27ac (active enhancers, promoters)§ RNA-seq: Gene expression

WGS ATAC-seq ChIP-seqH3K27Ac

RNA-seq

Modified from the ENCODE project

2019-02-18Robert Mansson-Hareth Nahi 13

The Multiple Myeloma PhenotypeA combination of genetics, epigenetics and gene regulation

2019-02-18 14

Wide-spread de-compaction of chromatinA novel myeloma specific feature

Robert Mansson- Hareth Nahi

Figure 4

ChromHMM State

1 Active Promoter2 Weak Promoter3 Poised Promoter4 Strong Enhancer5 Strong Enhancer6 Weak Enhancer7 Weak Enhancer8 Insulator9 Transcription Transition10 Transcription Elongation11 Weak Transcription12 Repressed13 Heterochromatin/lo14 Repetitive/CNV15 Repetitive/CNV

A.

0 2 4 6 8 10

02

46

810

cor=0.72

2 4 6 8

02

46

8

8 Insulatorcor=0.28

0 2 4 6 8 10

02

46

8

13 Heterochromatincor=0.60

All (excluding insulator)

log2

(H3K

27Ac

sig

nal)

log2(ATAC-seq signal)

B.

avg.MM avg.Norm

Fraction of ATAC-seq peaks

010k20k30k40k

Number of ATAC-seq peaks

MM23MM21MM20MM18MM17MM15MM14MM13MM12MM11MM10MM9MM8MM7MM6MM5MM4MM3MM2MM1

PC.D3PC.D2PC.D1PB.D3PB.D2PB.D1

memB.D3memB.D2memB.D1

0.00 0.25 0.50 0.75 1.00

Yi et al., Blood 2018

2019-02-18 15Robert Mansson- Hareth Nahi

The Core Gene regulatory Network Super-enhancer regulated transcription factors underpin myeloma gene regulation

Yi et al., Blood 2018

Future plans

• Replace FISH analysis with phased WGS (10x Genomics Chromium).

• Investigate epigenetic subgroups of MM to identify specific gene regulatory

patterns and features.

• Investigate genetic and epigenetic changes connected to relapse and disease

progression.

2019-02-18 16Robert Mansson Hareth Nahi

History + future of drugs in Multiple Myeloma

NK-cellsCAR-TBiTe

CAR-NK

Ixazomib(Ninlaro)

Monoclonals

2017 2018 2019

Cancer Immunotherapy

Innate ImmunityT-Cell Immunity

T-Cell Redirecting mABs

B-Cell Immunity

Checkpoint modulators

Cytokines

Adjuvants

Oncolytic Viruses

Antigen Specific Cellular Immunotherapy

Adoptive T-Cell Therapy

T-cell Checkpoint Modulators

T-reg Therapies

NK Cell Therapies

Cell Therapy Innovators Have Access To Capital for Go To Market Strategy

Bloomberg.com

0

2 000

4 000

6 000

8 000

10 000

12 000

14 000

16 000

18 000

20 000

Bi-specific CAR T TCR CTL Other T celltherapy

TIL

Mar

ket C

ap ($

M)

Market Cap of Leading Biotechsin T-Cell Space by Technology (2014)

ZioPharmTakara BioSangamo BiosciencesMolMedMacroGenicsLion BiotechnologyKite PharmaJuno TherapeuticsEmergent BiosolutionsCellular Biomedicine GrpCellectisBluebird BioBellicumAtara BiotherapeuticsAffimed Therapeutics$2.3B

$17B

$8.6B

$1.2B $797M $536M

Immunotherapies – Hype or Hope?

• Immunotherapies can be a better way of treating cancer.

– The immune system is specific. It can learn and adapt.

– Chemotherapy can be toxic and affect the whole body.

Antibodies-Antikroppar

Multiple MyelomaAntineoplastic Combined Chemotherapy Protocols

Antibodies, Monoclonal

Targeting CD38 with Daratumumab Monotherapy in Multiple Myeloma.Dratumumab, Lenalidomide, and Dexamethasone for Multiple Myeloma.

Oral Ixazomib, Lenalidomide, and Dexamethasone for Multiple MyelomaCarfilzomib, lenalidomide, and dexamethasone for relapsed multiple myeloma.

Lenalidomide and dexamethasone in transplant-ineligible patients with myeloma.

18 February 2019 23

• Dara treatment leads to reduced CD38 levels solely during treatments rechallenging ispossible

CD38 expression after Dara treatment

18 February 2019 24

• Numbers of circulating NK cells drop after Dara treatment• Percentage of CD16+ NK cells are stable • Decrease in CD4+/CD8+ T cells

T and NK cells decrease immediately at Dara infusion

Figure 1A, response to treatment, PD=progressive disease, SD=stable disease, MR=minimal response, PR=partial remission, VGPR=very good partial remission and CR=complete remission.

-100.00

-75.00

-50.00

-25.00

0.00

25.00

50.00

75.00

% R

edu

ctio

n/i

ncr

ease

in

m-

pro

tein

≥MR=16 (70%)

≥PR=14 (61%)

≥VGPR=7 (30%) SD=5 (22%)

PD=2 (8%)

CR=4 (17%)

Patient parameters and outcome

18 February 2019 25

n or mean (% or range)

Total number of patients

23 (100)

Age, mean 63 (34-82)Gender, female 6 (29)

Viral reactivation 7 (30)

Natural Killer (NK) cells

Natural Killer cells

NK cell abnormalities in cancer: Born or licensed to kill?

Abnormality DiseaseDecreased cytotoxic activity NSC lung Ca

HCCCRCH&N CaBreast CaSquam. cell CaBronchogenic Ca

Cervical CaOvarian CaAMLALLB-CLLCMLMM

Defective expression of activating receptors

HCCM. melanoma

AMLMM

Defective proliferation Renal CaNeuroblastoma

Nasopharyn. CaCML

Increased number of CD56bright

H&N Ca Breast Ca

Defective expression of signalling molecules

Cervical CaCRCOvarian Ca

Prostate CaAMLCML

Decreased NK cell counts Nasopharyngeal CaNeuroblastoma

CMLALL (Pediatric)

Defective cytokine production

AMLALL

CML

The expansion process developed at KI

Day 20

Day 0CellGro SCGM5% Human AB

serumIL-2 (500 U/ml)

OKT3 (10 ng/ml)

Every 2-3 daysAdditional medium with IL-2, without

OKT3

Detailed phenotypic characterization of NK cells

Degranulation and cytotoxicity assays

13.6 1.48

66.718.2

15.6 2.91

64.117.4

39.6 14.7

43.32.36

72.4 6.58

19.61.37

53.7 19.7

26.20.39

CD3

CD

56

Day 0 Day 5 Day 10 Day 15 Day 20

How large?

Different strategies for scaling up

cGMP certified expansion process

ACP-001

• First-in-man, Phase I• Open, single arm study• Primary objective:

– Safety and tolerability• Secondary objective:

– Effect on serum Ig levels • Inclusion:

– 20 MM patients eligible for ASCT

• 3 escalating infusions/patient (Weekly)– 106, 5X107 and 108 cells/kg

• Evaluation: – 4 weeks after infusion,– 6 months follow up.

18/02/2019 Hareth Nahi-Evren Alici 33

Chimeric Antigen Receptors (CARs)

Hareth Nahi

Tumor Infiltrating

Lymphocytes (TILs)

Chimeric Antigen

Receptors (CARs)

T-Cell Receptors

(TCRs)

IMPROVING LENTIVIRAL AND RETROVIRAL GENE DELIVERY TO NK CELLS

CAR NK cells

CD3ξ

4-1BB

CD28

NSA

NSC

Chimeric Antigen Receptors

1st 2nd 3rd Generation CAR-T cell constructs

1st Generation CAR-NK cell construct

CAR-NK cell

CAR-T cell

NK-92 and clinical approaches

18 February 2019 Michael Chrobok 38

B-cell maturation antigen (BCMA)

Durable clinical responses in heavily pretreated patients with relapsed/refractory multiple myeloma: Updated results from a multicenter study of bb2121 anti-BCMA

CAR T cell therapy

Jesus Berdeja MD1, Yi Lin, MD, PhD2, Noopur Raje, MD3, Nikhil Munshi, MD4, David Siegel, MD, PhD5, Michaela Liedtke, MD6, Sundar Jagannath, MD7, Marcela Maus, MD,

PhD3, Ashley Turka8, Lyh Ping Lam, PharmD8, Kristen Hege, MD9, Richard A. Morgan, PhD8, M. Travis

Quigley8, and James N. Kochenderfer, MD10

1- Sarah Cannon Research Institute and Tennessee Oncology, Nashville, TN, 2- Mayo Clinic, Rochester, MN, 3- Massachusetts General Hospital Cancer Center, Boston, MA, 4- Dana Farber Cancer Institute, Boston, MA, 5-

Hackensack University Medical Center, Hackensack, NJ, 6- Stanford University Medical Center, Palo Alto, CA, 7- Mount Sinai Medical Center, New York, NY, 8- bluebird bio, Inc., Cambridge, MA, 9- Celgene Corporation, San Francisco, CA,

10- Experimental Transplantation and Immunology Branch, National Cancer Institute/National Institutes of Health, Bethesda, MD

CRB-401 Study Design and Status

Expansion Cohort Initiated in August 2017• 12 additional patients have been collected and dosed in the Expansion Cohort as of 02

Nov 2017

3 + 3 Dose Escalation of CAR+ T Cells

*1200 x 106 dose cohort no longer planned

Manufacturing success rate of 100%

Study Status(Escalation

Phase)Cells Collected N=24

DosedN=21

Evaluable for ResponseN=21

Leukapheresis

Screening

bb2121manufacturing

Manufacturing (10 days) + release

bb2121 infusion

1st ResponseAssessment (Wk 4)

BM BX (Wk 4)

BM BX (Wk 2)

Day 0

Clinical deterioration prior to infusion n=3

Clinical Response: Deepening of Response over Time

276

47

33

27

56

0

20

40

60

80

100

04 MAY 2017 (N=15) 02 OCT 2017 (N=18)

Objective Response RateSubjects Treated in Escalation – Cohorts ≥150 × 106

CR/sCR

VGPR

PR

ORR=94%ORR=100%

Note: Objective Response defined as attaining Stringent Complete Response, Complete Response, Very Good Partial Response, or Partial Response. Including unconfirmed responses.

Efficacy Parameter Statistic Result

Time (months) to First Response Median (min, max) 1.02 (0.5, 3.0)

Time (months) to Best Response Median (min, max) 3.74 (0.5, 13.7)

Time (months) to Complete Response

Median (min, max) 3.84 (0.5, 13.7)

Duration of Response Median (min, max) NR

Progression free survival Median (min, max) NR

Progression free survival rate @ 6 mos

% 81%

Progression free survival rate @ 9 mos

% 71%

≥CR27%

≥CR56%

≥VGPR89%

≥VGPR74%

Dose Escalation: Cohorts ≥150 × 106 CAR+ T Cells (N=18)

Median duration of follow up 40 weeks (min, max: 6.6, 69.1)

NR, not reached

First-in-class anti-BCMA agent withmultiple modes of actionFirst-in-class anti-BCMA agent

with multiple modes of action

10

ADC, antibody-drug conjugate; ADCC, antibody-dependent cell-mediated cytotoxicity; BCMA, B-cell maturation antigen; MMAF, monomethyl auristatin-F

Four mechanisms of action:1. ADC mechanism2. ADCC mechanism3. BCMA receptor signaling inhibition4. Immunogenic cell death

1

4

3

1

BCMA

Effector Cell

x

BCMA

BCMA

BCMA

Lysosome

FcReceptor

ADCC

ADC

Cell death

MalignantPlasma

Cell

23

4

The agent

The target

Key attributes

– GSK’916 is a humanised IgG1 antibody targeting BCMA (B-cell maturation antigen)

– Linked to the anti-mitotic agent MMAF– Afucosylated to enhance ADCC

– BCMA plays a key role in plasma cell survival – It is found on the surfaces of plasma cells and is

overexpressed on malignant plasma cells– Not expressed in healthy tissues

– New modality in multiple myeloma: first ADC– Easy and convenient to administer: 1h infusion q3w– No pre-medication for infusion reactions

– Pre-medication with steroid eye drops– New MoA enabling diverse combinations

Phase 3 Randomized Study of Daratumumab Plus Lenalidomide and Dexamethasone (D-Rd) Versus Lenalidomide and Dexamethasone (Rd) in Patients With Newly Diagnosed Multiple

Myeloma (NDMM) Ineligible for Transplant (MAIA)*

Thierry Facon,1 Shaji Kumar,2 Torben Plesner,3 Robert Z. Orlowski,4 Philippe Moreau,5 Nizar Bahlis,6 Supratik Basu,7 Hareth Nahi,8Cyrille Hulin,9 Hang Quach,10 Hartmut Goldschmidt,11 Michael O’Dwyer,12 Aurore Perrot,13 Christopher P. Venner,14 Katja Weisel,15

Joseph R. Mace,16 Tahamtan Ahmadi,17 Christopher Chiu,18 Jianping Wang,19 Rian Van Rampelbergh,20 Clarissa M. Uhlar,18

Rachel Kobos,19 Ming Qi,18 Saad Z. Usmani21

1Service des Maladies du Sang, Hôpital Claude Huriez, Lille, France; 2Department of Hematology, Mayo Clinic Rochester, Rochester, MN, USA; 3Vejle Hospital and University of Southern Denmark, Vejle, Denmark; 4Department of Lymphoma-Myeloma, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA; 5Hematology, University Hospital Hôtel-Dieu, Nantes, France; 6University of Calgary, Arnie Charbonneau Cancer Institute, Calgary, AB, Canada; 7Royal

Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom; 8Karolinska Institute, Department of Medicine, Division of Hematology, Karolinska University Hospital at Huddinge, Stockholm, Sweden; 9Department of Hematology, Hospital Haut Leveque, University Hospital, Pessac, France; 10St. Vincent's Hospital, University of Melbourne, Melbourne, Australia; 11University Hospital Heidelberg and National Center of Tumor Diseases (NCT), Heidelberg, Germany; 12Dept. of Medicine/Haematology, NUI, Galway, Republic of Ireland; 13Hematology Department, University Hospital, Vandoeuvre Les Nancy, France; 14Division of Medical Oncology University of Alberta, Edmonton, AB, Canada; 15Universitaetsklinikum Tuebingen der Eberhard-Karls-Universitaet, Abteilung fuer Innere Medizin II, Tuebingen, Germany; 16Florida Cancer Specialists & Research Institute, St. Petersburg, FL, USA; 17Genmab US, Inc., Princeton, NJ, USA; 18Janssen Research &

Development, Spring House, PA, USA; 19Janssen Research & Development, Raritan, NJ, USA; 20Janssen Research & Development, Beerse, Belgium; 21Levine Cancer Institute/Atrium Health, Charlotte, NC, USA.

*ClinicalTrials.gov Identif ier: NCT02252172

BiSpecific Antibodies (BiTe)