Principles of Tumour Immunology

Principles of tumour immunology

Michele Teng Nov 20th 2017, Singapore

Cancer Immunoregulation and Immunotherapy Laboratory QIMR Berghofer MRI Brisbane, Australia [email protected] Disclosure Slide

• I have received speakers bureau honoria from Merck Sharp & Dohme. Talk Outline 1. Hallmarks of Cancer 2. Cells of the Immune system 3. The Cancer Immunity Cycle - Tumor-associated antigens (TAA), Cellular and Humoral responses to TAA 4. Conceptual developments in the field of tumour immunology - Immunosurveillance and role of innate immunity, immune balance against cancer Sources of slide

• Charles Janeway’s Immunobiology text book • Peer-reviewed articles (Pubmed) • Online slides ( URL listed) Cancer Hallmarks of Cancer (2000)

Hanahan and Weinberg, Cell 2000 Emerging Hallmarks and Enabling Characteristics

Hanahan and Weinberg, Cell 2011 Hallmarks of Cancer (2017)

In Vitrogen Immunology (Study of the immune system) Cells of the immune system

ILCs –innate lymphoid cells MAITs –Mucosal associated invariant T cells

gd T cells – gamma delta T cells

(ILCs) (gd, MAIT) Cancer Immunology (Study of the response of the immune system to cancer) The Cancer-Immunity Cycle – Steps to generate an effective anti-tumour response

Chen and Mellman Immunity 2013 Not all cell deaths are equal (at priming an immune response) Cells can die in different ways

DAMPs Tumour fragments

Immunogenic Cell Death (ICD) DAMPs – Damage (Adjuvanticity, Antigenicity) associated molecular patterns Differential requirements for the immunogenicity of cell death

TLR4

Nat Rev Immunol. 2017 Feb;17(2):97-111. doi: 10.1038/nri.2016.107. The Cancer-Immunity Cycle

Immunity. 2013 Jul 25;39(1):1-10. doi: 10.1016/j.immuni.2013.07.012. Types of professional Antigen Presenting Cells (APCs)

Nat Rev Immunol. 2014 Nov;14(11):719-30. doi: 10.1038/nri3754. Activation of tumour-specific T cells by APCs

TCR with the right specificity Tumor-specific and tumor-associated antigens

(Neoantigens)

TAA – therapeutic targets? Cell-mediated and humoral immune responses to tumour Requirements for effective priming of T cells

Front. Oncol., 10 April 2014 | https://doi.org/10.3389/fonc.2014.00077 The many flavours of CD4+ T cells

Th22 Cell-mediated and humoral immune responses to tumour T cell-independent and T cell-dependent B cell activation Antibody mechanism of action

IgG1

FcgRIIIa -activating receptor

NK cells Antibody mechanism of action

Activate cellular effector function

Antibody-Dependent Antibody-Dependent Cell-Mediated Cytotoxicity Cellular Phagocytosis

Biolegend ADCC - the underlying mechanism for the clinical efficacy of therapeutic anti-cancer antibodies.

Biolegend Effector responses of NK cells are regulated by inhibitory and activatory receptors

Release of Cytokines

Cytolysis

Trends in Immunology 2011 32, 364-372DOI: (10.1016/j.it.2011.06.001) Major inhibitory and activating receptors on NK cells and their cognate ligands on targets

NKp30 isoforms predict clinical outcome of GIST, neuroblastoma

Chan et al., 2014 Cell Death Differentiation The Cancer-Immunity Cycle

Immunity. 2013 Jul 25;39(1):1-10. doi: 10.1016/j.immuni.2013.07.012. When the Cancer Immunity Cycle is successfully completed…… Cancer Immunology (pre 2000) Reason for failures

Cancer Immunology (2000-2017) - What went right.... Conceptual Developments in Cancer Immunology

1Cancer 2Tumour immunoediting Neoantigen

4Combination mAb-based therapy 3Immune Reaction

5Tumour induced Immune suppression 1 3Es

KILL BATTLE LOSE

Smyth et al. JEM 2000, Shankaran et al. Nature 2001 Swann et al. J. Clin. Invest. 2007, Koebel et al. Nature 2007 Teng et al., JLB 2008; Schreiber..Smyth. Science 2011 Teng et al., Cancer© ResQIMR 2012,Berghofer Teng Medical et al.,Research JCI 2015Institute | 36 2Mutational load correlates with frequency of tumour neoantigens... & response

Estimate of the neoantigen repertoire in human cancer MHC

Synder A et al., NEJM 2014 Ton N. Schumacher, and Robert D. Schreiber Quality van Allen et al., Science , 2015, Hugo W et al., Cell 2016 Science 2015;348:69-74 3 Immune contexture correlates with clinical outcome

NKT Stroma

Neutrophil B cells Immune contexture Mast cell Location, density, functional associated with good orientation of cells prognosis in CRC Blood Eosinophil vesse Macrophage Chemokine l Immature NK CTL ↑CXCL9 ↑CX3CL1 DC ↑ CXCL10 ↑ CCL2 T 17 ↑ CCL5 ↑ CXCL13 Tumor H γδT core MDSC Adhesion ↑MADCAM1 ↑ ICAM1 Treg ↑ VCAM1 DC TFH Cytotoxic F-DC ↑ Granzymes TH1 Invasive ↑ Perforin Lymphaic margin ↑ Granulysin vessel

TH1 TH1 TH1 ↑T-bet ↑ IL-12 Epithelial/smooth ↑ IRF1 ↑ IFN-γ TLS muscle layer ↑ STAT1 ↑IL-15

B TFH ↑ IL21 cells

Tumor margin ↑ CD3+, CD8+, Immunoscore CD45RO+ T cells Galon et al., 2006 Science, Pages et al., 2005 NEJM, Fridman et al., 2012 NRC, Bindea el al., 2013 Immunity Mechanism of Treg mediated immunosuppression

Worman C et al., Cell Mol Life Sci 2009 Mechanism of MDSC mediated immunosuppression

Dmitry I. Gabrilovich Cancer Immunol Res 2017;5:3-8 4

(trimAb)

trimAb anti-DR5 (immunogenic cell death) anti-CD40 (activate APC) anti-CD137 (enhance effector T cell function and survival)

MCA induced fibrosarcoma model

MCA Detect sarcoma 50-180 d Measure growth Commence treatment

WT or KO mouse Rejection of carcinogen-induced established tumors by trimAb

Uno et al. Nature Medicine, 2006 4 The four nodes to target for inducing maximal anti-tumour immunity

Smyth et al., NRCO 2016 5 Engagement of checkpoint receptors represents a major mechanism of tumour-induced immunosuppression

Checkpoint receptors: Brakes to limit overzealous T cell activation

About 20 interactions regulate T cell immune response

Melero I et al. APC/Tumour T cell Nat Rev Cancer 2015 Checkpoint blockade can unleash endogenous anti-tumour response

ORR – 10% 2010

ORR – 31% 2012

ORR – 53% 2013

ORR – 61% 2015 Anti-PD-1 to be used as standard of care and in combination immunotherapies

ORR – 2015 33.7% vs 11.9%

ORR – 2015 31.7% vs 10.6%

ORR – 20% vs 9% 2015

ORR – 2016 44.8% vs 27.8% Cancer immunotherapy-based combination studies underway in 2016

Chen & Mellman Nature 2017 Tumour microenvironment can be stratified into 4 types based on TILs and PD-L1 expression in tumours

Teng et al., 2015 Cancer Res Summary

• Anti-PD-1/PD-L1 - will become the immunotherapeutic backbone of future cancer treatments

• Cancers can be divided into four type – absence or presence of TILs and PD-L1 expression

• Efficient anti-tumour strategies must focus on hitting different targets concurrently

• Key nodes to target in combination treatment – abrogating immune suppression – inducing immunogenic cancer-cell death, – enhancing antigen presentation/adjuvanticity – inducing activation and survival of immune-effector cells Summary

• Exome-sequencing data can be mined to – identify unique neoantigen profile of tumours – guide future personalized vaccine design for use in combination treatments

• A large proportion of patients have ‘immune ignorant’ (cold) tumours, – predicted to have a poor prognosis regardless of any current intervention – novel therapies have to be developed (Oncolytic virus, STING agonist, CAR-T). Moving Forward… Key issues in cancer immunotherapy

1) Identifying biomarkers to predict what cancers and pts will respond to anti-PD-1/PD-L1 2) How do we increase the proportion of patients who respond to anti-PD-1/PD-L1? 3) What therapies do we use to treat cancers with microenvironments that are resistant to anti-PD-1/PD- L1 monotherapy? 4) What do we do for patients who develop acquired resistance to anti-PD-1 therapies? 5) What is the optimal scheduling for administration of combination immunotherapy? 6) How to assess the therapeutic index (anti-tumour efficacy/irAEs) of combination immunotherapies?

Improving the tail of the curve.... Overall Survival Overall

Time Thank You www.qimrberghofer.edu.au Identifying biomarkers to predict patients who will respond to anti-PD-1/PD-L1 Tumour microenvironment can be stratified into 4 types based on TILs and PD-L1 expression in tumours

TIL+ TIL- PD-L1+ PD-L1- (38%) (41%) Type I Type II

Melanoma Type IV Type III TIL+ TIL- PD-L1- PD-L1+ (20%) (1%)

Taube et al. Sci Transl Med 2012, CCR 2014 Association of anti-PD-L1 response and tumour-infiltrating immune cell PD-L1 expression

Nature, 2014 Cancers with type I TME containing CD8+ T cells and PD-L1 most likely to respond to anti-PD-1/PD-L1

Level of PD-1 expression Ngiow et al., Cancer Res 2015

PDL2 expression?

Tumeh et al. Nature (2014) © QIMR Berghofer Medical Research Institute | 59 Factors that influence the cancer–immune set point Biomarkers of response to PD-1/PDL1 blockade

Density, Location PD-1 expression level Other checkpoint Angiogenesis receptors Epigenetics Other immune cells

CD8+ T cell Tumor/Immune Microbiome MMR-deficient/MSI-H cells Somatic vs Driver IFN gene signature mutations (early on txt) (e.g BrafV600) Mutational PD-L1 Burden expressio n Tumor load Genetics Age External factors Prior therapy Time

Durability of Response From bed-side To bed-side

Clinical research

Ex vivo/ Experimental In vitro research Mouse research To bench From bench

Melero I et al., Abstract presented at: 2017 Gastrointestinal Cancers Symposium; January 19-21, 2017; San Francisco, CA. Atezolizumab (anti-PD-L1) – Tecentriq, approved for treatment of bladder cancer Adaptive immune gene signature in early-on- treatment samples best predict responders

Chen, P, Cancer Discov, 2016

• EDT – median 1.4 months (0.7-26 months) • Vilain et al EJC 2015; EDT (within 2 months of treatment) increase in intratumoral CD3+, CD8+, CD68+ in responders • Non-responders – increased VEGFA

Checkpoint immunotherapy: picking a winner Teng et al., Cancer Discovery 2016 in press How do we increase the proportion of patients who respond to anti-PD-1/PD-L1? Can we improve above the 50% ORR induced by anti-CTLA-4 & anti-PD-1?*

*Without the toxicity Combination of anti-PD-1 or anti-CTLA-4 with IDO inhibitors (Indoximod) in melanoma

Abstract #3075 ASCO 2016, Yousef Zakharia.. Mhd Milhem IDO - Indoleamine 2,3-dioxygenase, an immune suppressor

Abstract #3075 ASCO 2016, Yousef Zakharia.. Mhd Milhem ORR 53% No increase in toxicity Phase II trial ongoing – 64 pts

Questions 1) PFS? 2) Durability 3) Other cancers? What therapies do we use to treat cancers with TME that are resistant to anti-PD-1/PD-L1 monotherapy? • T-VEC + anti-CTLA-4 • Chemotherapy or targeted therapy + anti-PD-1 • Radiotherapy + anti-CTLA-4 + anti- • PD-1(Twyman-Saint Victor et al., Nature 2015) • Type I IFN (poly-ic) + anti-PD-1 (Bald et al. Cancer Discovery 2014) • Microbiota (Zitvogel L et al, Gajewski T el, Science 2015) • Engineering FcR engaging variants of IgG (Ravetch Cancer Cell 2016) • Scheduling (Neoadjuvant/adjuvant) • CAR-T + anti-PD-1

anti-CD40 + anti-IL-23 anti-CD40 + anti-CSFR1 What other cancers should we treat with anti-PD-1/PD-L1? PD-1 & PD-L1 expression in various types of solid tumours PD-1+ TILs expression correlates with increasing mutational load Le et al., NEJM, 2015; Maby et al., Cancer Res, 2015

Gut bacteria affect immunotherapy effectiveness

Sivan A et al., Science 2015 Vétizou M et al., Science 2015

The composition of intestinal microbiota affects checkpoint blockade efficacy and can be manipulated to improve responses.

Alexandra Snyder et al. Science 2015;350:1031-1032 Neoantigen presentation in the tumour microenvironment

Khalil, D. N. et al. (2016) Nat. Rev. Clin. Oncol. T-cell inflamed phenotype gene expression signatures to predict clinical benefit from pembrolizumab across 5 cancer types Biomarkers and response to pembrolizumab (pembro) in recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC) What do we do for patients who develop acquired resistance to anti-PD-1 therapies? Jesse Zaretsky.. Antoni Ribas NEJM 2016

Mean time to relapse 624 days (range, 419 to 888) Mechanisms of resistance

• Whole-exome sequencing of biopsy samples fomr paired baseline and relapsing lesions in 4 pts

• 2 pts; IFNgR associated JAK1/JAK2 mutations  loss of ability to respond to IFNg

• 1 pt; b2m mutation  loss of surface MHC I expression

• 1 pt; - no defined genetic alterations to explain acquired resistance (no PDL1 on tumors pre/post txt) Genomic and Transcriptomic Features of Response to Anti-PD-1 Therapy in Metastatic Melanoma

Hugo W, ….. Ribas A, Lo R Cell 2016 Association of PD-L2 expression in human tumors with atezolizumab activity.

© QIMR Berghofer Medical Research Institute | 85 © QIMR Berghofer Medical Research Institute | 86 © QIMR Berghofer Medical Research Institute | 87 © QIMR Berghofer Medical Research Institute | 88 Evidence for immunoediting in human tumours

• Analysis of 18 TCGA tumour types shows genomic correlates of immune cytolytic activity

• Multiple tumour types demonstrate strong link between mutation load and local immunity

• Number of predicted MHC Class I- associated neoantigens correlated with cytolytic activity. Lower than expected in colorectal and other tumours, suggesting immune-mediated elimination

• Infiltrated tumours are enriched for Rooney et al., Cell 2015 probable escape lesions affecting CASP8, HLA, B2M Integrative Analyses of Colorectal Cancer Show Immunoscore Is a Stronger Predictor of Patient Survival Than Microsatellite Instability

• MSI and a subgroup of MSS patients have high intratumoral adaptive immune gene expression

• Functional effector anti-frameshift mutation CTLs kill tumor cells in MSI patients

• Genetic evidence of immunoediting in human CRC, in particular for MSI patients

• Immunoscore gives an indicator of tumor recurrence and survival beyond MSI staging Mlecnik et al., Immunity 2016 © QIMR Berghofer Medical Research Institute | 91 Tumor associated antigens and tumor specific antigens

https://www.slideshare.net/csbrprasad/neoplasia-robbins-path-13540987 ecancer 8 441 / https://doi.org/10.3332/ecancer.2014.441 Activation of tumor specific T cells by Antigen Presenting Cells (APCs) Antibody mechanism of action

Targeting CTLA-4 and PD-1 to release the brakes on T cells

Lymph Node "inflammatory site” (tumor)

Ribas A NEJM 2012 The Immune System Delves P and Roitt I, NEJM 2000 Targeting NK cells in cancer immunotherapy

Guillerey C et al., Nat Immunol 2016