Tumor Immunity Immunotherapy of Cancer

TUMOR IMMUNITY IMMUNOTHERAPY OF CANCER

WHAT IS IT?

HOW DOES IT WORK?

CAN WE USE IT TO PREVENT AND/OR CURE CANCER?

WORK IN PROGRESS AMAZING ADVANCES AFTER YEARS OF GO AND STOP

IMMUNITY – IMMUNITAS (Latin); ☺EXEMPTION FROM OBLIGATION, DUTY OR LIABILITY SUCH AS MILITARY SERVICE ☺RESISTANTCE TO A PARTICULAR DISEASE DISCLAIMERS

1. I am not a clinical oncologist. For specific treatment options consult your physician.

2. Treatments are presented to illustrate specific points and are not necessarily those recommended or undergoing clinical trials now.

3. I have no conflicts of interest with any of the material presented. BREAST CANCER

BREAST CANCER 400 BC Greece CANCER=CRAB Estimated deaths 630,000 +/-2Million

COVID -19 20 MILLION CASES - 500,000 DEATHS 2020 DEATH RATE DOWN BUT DEATH TOTAL UP BACKGROUND INFORMATION

CLINICAL TRIALS

NANOPARTICLE DELIVERY PRECLINICAL TESTING - ANIMAL MODELS CLINICAL TRIALS HUMAN

PHASE I DOSE TOXICITY TITRATION STUDIES TO DETERMINE MAXIMUM SAFELY TOLERATED DOSE

PHASE II DETERMINATION OF MOST EFFECTIVE ANTI-TUMOR ACTIVITY AT DOSES CHOSEN FROM PHASE I TRIALS. SELECTION OF DOSE AND TIMING RELATIONSHIPS FOR PHASE III

PHASE III COMPARISON OF TREATMENT PROTOCOLS WITH NEW AGENT TO EFFECTS OF STANDARD TREATMENT

PHASE IV APPLICATION OF EFFECTIVE NEW THERAPY PROTOCOL INTO GENERAL ONCOLOGY PRACTICE: INTEGRATION INTO MULTI-MODALITY REGIMENS CLINICAL TRAILS

COMPLETE RESPONSE: DISAPPEARANCE OF ALL CLINICAL, RADIOLOGICAL AND MARKER EVIDENCE OF TUMOR DISEASE; NOT NECESSARILY CURE

PARTIAL RESPONSE: DECREASE OF AT LEAST 50% IN THE PRODUCT OF TWO PERPENDICULAR DIAMETERS OF ALL MEASURABLE DISEASE MANIFESTATIONS (USUALLY RADIOLOGICAL) AND >50% DECREASE IN SERUM CONCENTRATIONS OF A TUMOR MARKER (APF, CEA, CA19-9, CA-50, PSA, ETC.) KAPLAN-MEIER SURVIVAL PLOT END POINT – 50% survival

CENSORED NANOPARTICLE DELIVERY

NANOPARTICLES NANO - DWARF Riley RS, June CH, Langer R, Mitchell MJ. Delivery technologies for cancer immunotherapy. Natur Rev. Drug Discovery. 18:175-196, 2019 ANTIBODY FabF a n

LOCALLIZATION OF NANOPARTICLES IN TUMOR MOUSE MODEL OF BREAST CANCER MMTV-PyMT TRANSGENIC MICE – PRIMARY BREAST CANCERS FEMALES – 8-12 WEEKS MALES – 5-6 MONTHS MEDULLARY GLANDUALR FEMALE 12 WEEKS

DUCTAL LUNG METASTASIS ANTI-CD49f/Cy-7 NANOPARTICLE

Anti-CD49 Binds to cancer cells

Cy-7 Fluorescent compound Nanoparticle I.P. injections and IVIS fluorescent images

Before Immediately After 1 hr

Void NP

Control

CD49f

Void NP

Control

CD49f

cy7

cy7 cy7

Arrow: Site of tumor Control Void NP-cy7 NP-CD49f-cy7

After 2 hr After 3 hr After 4 hr

Void NP

Control

CD49f

Control

CD49f

Void NP

Control

CD49f

cy7

cy7 cy7

After 24 h

Void NP

Control

CD49f

cy7 cy7

Cy-7 (Cyanine 7) – FLUORESCENT COMPOUND DETECTED BY IN VIVO IMAGING SYSTEM ANTI-CD49f/PTC-209

Anti-CD49 Binds to cancer cells

PTC-209 Inhibits cancer cells Anti CD49f NANOPARTICLES CONTAINING PTC 209 INHIBIT GROWING TUMORS

FMMC 41911

FVB female mouse

UNTREATED ANTI-CD49f-PTC 209

NP ONLY ANTI-CD49f-PTC 209 NANOPARTICLES USED TO DELIVER DRUGS, ETC.TO CANCER CELLS MAJOR IMMUNE EFFECTOR MECHANISMS IN TUMOR IMMUNITY

-NON-SPECIFIC

- INNATE IMMUNITY

-SPECIFIC

- CELL MEDIATED

- ANTIBODY MEDIATED

-REGULATORY

- REMOVE BLOCK TO TUMOR IMMUNITY THERAPEUTIC APPROACHES IN HUMAN TUMOR IMMUNITY i. NON-SPECIFIC IMMUNITY COLEY’S TOXINS (1890-1926) CYTOKINES TOXIC 1970 INTERLEUKINS AND NANOPARTICLES 2020

ii. SPECIFIC PASSIVE IMMUNITY (CELLULAR) TILS – ADOPTIVE TRANSFER 1980s- CAR (CHIMARIC ANTIGEN RECEPTOR) T-CELLS 2010-

iii. SPECIFIC PASSIVE IMMUNITY (HUMORAL) MONOCLONAL ANTIBODIES 1980s- HERCEPTIN – ANTI-EGF RECEPTOR RITUXIMAB – ANTI-CD20 (B-CELL MARKER) BISPECIFIC ANTIBODY

iv. SPECIFIC ACTIVE IMMUNITY - VACCINATION VIRAL ANTIGENS (HPV, HEPATITIS B) MELANOMA TCTL PEPTIDES 1980s NANOPARTICLE mRNA PERSONALIZED VACCINES (2020s)

v. CHECK POINT INHIBITORS 2000s CTL-4 PD-1

vi. COMBINATORIAL IMMUNOTHERAPY Infection INNATE “NATURAL” IMMUNITY

Microbial toxins γδT CELLS Necrotic tissue MACROPHAGES NK CELLS

Attract and Activate Inflammatory Cells PMNs/MAST CELLS

INTERLEUKINS DEGRANULATION Attract and Activate Macrophages CYTOKINES Microbiocidal enzymes (cathepsins, peroxidase, protease, etc) Attract and Activate Oxygen radicals Lymphocytes and Macrophages Collagenase, Gelatinase, Elastase COLEY’S TOXIN

STEPHEN S. HALL

A COMMOTION IN THE BLOOD

HENRY HOLT & CO. NEW YORK

1997 CYTOKINE STORM Coley‘s Experiments - The Occasional Miracle

1889 - Dr. Coley obtains medical license

1890 - Elazabeth Dashiell dies from Round Cell Sarcoma of bone “Ewing’s Sarcoma” (arm). JD Rockefeller funds program

1891 - Coley reviews the case of Fred K Stein. 11 years earlier Stein had inoperable cancer, developed erysipelas infection (S. pyogenes) and cancer went away

1891 - A patient of Dr. Coley, Mr. Zola, has a large inoperable neck tumor. Coley intentionally repeatedly infects Mr. Zola with S. pyogenes. After severe life-threatening infections, Zola recovers and tumor goes away

1891-1893 - Coley intentionally infects 12 more patients. 4 have severe infections, 2 die and 2 appear cured of tumor 8 do not get severe infections and are not cured. 1890’s WILLIAM COLEY

JOHN D. ROCKEFELLER ELIZABETH DASHIELL

WILLIAM COLEY 1892 SIGNOR ZOLA

TREATED 1891 BY INFECTION WITH S. PYOGENES

AFTER LIFE THREATENING INFECTION, TUMORS GO AWAY! Coley‘s Toxin

1893 - Coley produces Coley's toxin - extract of cultures of S. Pyogenes and B prodigiosus (endotoxin producer) 1893 - Coley treats John Ficken, 13 year old boy with inoperable metastatic tumors by direct injection of toxin into tumors, severe fever and chills, tumors go away 1913 - Coley has treated over 500 patients, claims many remissions. However, others not successful. considerable controversy. 1926 - Some anecdotal cases of remission still reported.

Dr. Coley's experience with occasional incredible cures, lack of consistency and failure of others to duplicate results haunts cancer immunotherapy to this day. In 1920's Coley's toxins not accepted for cancer therapy as radiation therapy becomes in vogue. ENTHUSIASM INDEX CASES ANECDOTAL COLEY’S TOXINS HISTORYOF CLINICAL TRIALS IMMUNOTHERAPYCANCER TRIALS CLINICAL SMALL EARLY TIME TRIALS CLINICAL LARGER APPLICATION CLINICAL FINAL

A COMMOTION IN THE BLOOD - CYTOKINE STORM

PRODUCED BY: T-CELLS MACROPHAGES

IL-2 T-CELL PROLIFERATION IL-1 T-CELL ACTIVATION IL-3 STIMULATES HEMATOPOIESIS IL-12 ACTIVATES NK CELLS IL-4 STIMULATES B-CELLS (IgE, IgA) Th1 DIFFERENTIATION IL-5 EOSINOPHIL DIFFERENTIATION IL-18 STIMULATES INF-γ IL 6 T- AND B-CELL GROWTH Th1 DIFFRENTIATION IL-8 ATTRACTS/ACTIVATES PMNs TGF-β INHIBITS CELL GROWTH IL-9 ACTIVATES MAST CELLS INF-α INCREASES MHC I EXPRESSION IL-10 SUPRESSES MACROPHAGES TNF-α ACTIVATES ENDOTHLIAL CELLS IL-13 Th2 DIFFERENTIATION (CACHEXIN) TUMOR NECROSIS IL-15 ACTIVATES NK CELLS IL-16 ATTRACTS CD4+T-CELLS INF-γ ACTIVATES MACROPHAGES TNF-β KILLS CELLSPRODUCE IF CYTOKINE STORM IS TOO TOXIC, HOW ABOUT INDIVIDUAL CYTOKINES? INDIVIDUAL CYTOKINES

TUMOR NECROSIS FACTOR

INTERFERON

IL-2

IL-12 TNF - TUMOR NECROSIS FACTOR

1957 - Old and Carswell discover a factor in serum of mice after treatemet with BCG and endotoxin which kills tumor cells.

1970's-80's - clinical trails show little or no effect on tumors and severe toxic side effects including fatal shock.

1988 - Ferdy Lejeune infused 10X MTD of TNF into isolated limb of patients with mutiple melanoma lesions. Obtains remarkable remissions. Effect enhanced by adding low dose INF-γ and mephalan (Triple Therapy) .

YOU CAN CURE THE LIMB, BUT YOU CANNOT CURE THE PATIENT

Not approved INTERFERON

1956-58 Lindeman and Isaacs - Interferance in viral infections found to be due to soluble factor 1962 Packer and Cantrell - INF affects cell growth in vitro 1966 Gresser - INF inhibits growth of transplanted tumors 1970 Cantrell - Sets up high production lab for Interferon

1970's Interferon-alpha used to treat many different kinds of cancers. At first many remissions, but not consistent and not reprorducable in large trials.

1984 Interferon alpha approved for clinical use for hairy cell Leukemia and Sezary Syndrome.

NOW IN LIMITED USE IN COMBINATION THERAPY about 30% of cases Sezary Syndrome. INTERLEUKIN - 2

1960'2 - Cultures of activated lymphocytes produce factors which act on other white cells. Later known as "Interluekins". 1974 - Morgan and Ruscetti identify factor in culture of PHA stimulated lymphocytes which stimulates growth of T-cells. Named LAF or TCGF; later termed "Interleukin - 2". 1980 - Rosenberg attempts to treat cancer with IL-2. At first reports remission rate of up to 50%. Not reproducible and very toxin side effects.

1980 - Elizebeth Grimm shows that IL-2 will activate NK cells to be more active. LAKs - Lymphokine activated killer cells.

1984 - Rosenberg treats 75 patients with IL-2 and LAK, by taking cells from patients and culturing them with IL-2. Claims 45% response rate. Not reproducible

1985 - Hyperbole in Press, Rosenberg - Man of the Year

1996 - IL-2 not approved by FDA, only used in experimental centers. IL - 12

1990's - Trinchieri - IL-12 activates NK cells Gately - IL-12 activates Th1 helpers and stimulates DTH. Blocks angiogenesis Cures human tumors in nude mice

1995 - Phase I clinical trails - patients "primed with IL-12 at low dose, wait 2 weeks give high dose , little or no side effects. Phase II trials - omit priming dose.

All 15 patients become severely ill and 2 die.

PRESENT – RARELY USED AS LOCAL INJECTION DUE TO HIGH TOXICITY

Lasek W, Radoslaw, Z, Jakovisiak M. Interluekin 12: still a promising candidate for tumor innumotherapy? Cancer Immunol Immunother. 63: 419-435, 2014 TOXICITY REBIRTH - NANOPARTICLE DELIVERY OF INTERLEUKIN mRNA GREATLY DECREASES TOXICITY MODERNA NANOPARTICLES DELIVERS SELECTED CYTOKINES

TREATMENT OF TRANSPLANTABLE TUMOR IN MICE

TREATMENTS THAT WORK IN MOUSE TUMOR TRANSPLANT MODELS OFTEN DON’T WORK ON HUMANS ANTI-Covid -19/CYTOKINE NANOPARTICLE

Anti- Covid-19 Binds to virus Cytokine/ Redemsivir

WOULD IT WORK FOR COVID-19 TREATMENT? ENTHUSIASM INDEX CASES ANECDOTAL INTERLEUKINS, INTERLEUKINS, CYTOKINES,ETC. NON TRIALS CLINICAL SMALL EARLY - SPECIFIC SPECIFIC IMMUNOTHERAPY TIME TRIALS CLINICAL STAGE3 APPLICATION CLINICAL FINAL ? MAJOR IMMUNE EFFECTER MECHANISMS IN TUMOR IMMUNITY

-NON-SPECIFIC

- INNATE IMMUNITY

-SPECIFIC

- CELL MEDIATED

- ANTIBODY MEDIATED

-REGULATORY

- REMOVE BLOCK TO TUMOR IMMUNITY INDISCRIMANENT OVERKILL TARGETED

THERAPEUTIC APPROACHES IN HUMAN TUMOR IMMUNITY i. NON-SPECIFIC IMMUNITY COLEY’S TOXINS (1890-1926) CYTOKINES TOXIC 1970 INTERLEUKINS AND NANOPARTICLES 2020

ii. SPECIFIC PASSIVE IMMUNITY (CELLULAR) TILS – ADOPTIVE TRANSFER 1980s- CAR (CHIMARIC ANTIGEN RECEPTOR) T-CELLS 2010-

iii. SPECIFIC PASSIVE IMMUNITY (HUMORAL) MONOCLONAL ANTIBODIES 1980s- HERCEPTIN – ANTI-EGF RECEPTOR RITUXIMAB – ANTI-CD20 (B-CELL MARKER) BISPECIFIC ANTIBODY

iv. SPECIFIC ACTIVE IMMUNITY - VACCINATION VIRAL ANTIGENS (HPV, HEPATITIS B) MELANOMA TCTL PEPTIDES 1980s NANOPARTICLE mRNA PERSONALIZED VACCINES (2020s)

v. CHECK POINT INHIBITORS 2000s CTL-4 PD-1

vi. COMBINATORIAL IMMUNOTHERAPY CD 8 KILLER T-CELL MUTIPLE SOLID TUMORS

PROTECTIVE REACTIONS KILLING OF VIRUS INFECTED CELLS DESTRUCTIVE REACTIONS DESTROY NORMAL TISSUE CELLS CROHN’S DISEASE STEVE ROSENBERG

NIH

IL-2 IL-12 NK cells

TILs Engineered CAR T-cells INTERLEUKIN 2 ALSO ACTIVATES CYTOTOXIC T-CELLS TUMOR INFILTRATING LYMPHOCYTES (TILS) THERE ARE TWO SIDES TO EVERY STORY ESPECIALLY IN IMMUNOLOGY 1898 HALSTED CANCERS WITH LYMPHOCYTIC INFILTRATE (TUMOR INFILTRATING LYMPHOCYTES, TILS) HAVE BETTER PROGNOSIS THAN TUMORS WITHOUT LYMPHOCYTES

BUT KALISS 1965 AND PREHN 1977 IMMUNOSTIMULATION – THE REASON THAT TUMORS WITH LYMPHOCYTIC INFILTRATE HAVE BETTER PROGNOSIS IS THAT THEY ARE DEPENDENT ON STIMULATION FROM LYMPHOCYTES AND LESS AUTONOMOUS. TILS TUMOR INFILTRATING LYMPHOCYTES (? CYTOTOXIC T-CELLS)

FROM HALSTED’S HYPOTHESIS LYMPHOCYTES IN TUMORS SHOULD HAVE INCREASED POTENTIAL FOR KILLING TUMOR CELLS.

REMOVE PRIMARY TUMOR EXTRACT LYPHOCYTES (CULTURE OR TREAT TILS IN VITRO) INJECT BACK INTO PATIENT FOLLOW DEVELOPMENT OF METASTASES

VERY DIFFICULT TO GET TILs - TUMOR INFILTRATING LYMPHOCYTES

1983 - McAllester and Knuth extract lymphocytes from a tumor, culture them with IL-2 and show increased lysis of tumor cells.

1986 – Steve Rosenberg begins treating patients with TILs after culture with IL-2, claims "substantial remission" in 8/9 patients with melanoma. Then, with more patients 55%PR.

Then with further trials MUCH lower response rate.

Approach, which is quite complicated and costly, is not practical and now modified by inserting chimeric receptors

CAR T-CELLS CHIMERIC ANTIGEN RECEPTOR

CAR T-CELLS CHIMERIC ANTIGEN RECEPTOR ADD SIGNALLING DOMAINS CARs to CD19, an antigen expressed in B-cell–related blood cancers

Acute and Chronic lymphoytic leukemia, B-CELL LYMPHOMA

CD - CLUSTERS OF DIFFERENTIATION Chimeric antigen receptor (CAR)-modified T-cell therapy has revolutionized the care of patients with relapsed and refractory B-cell acute lymphoblastic leukemia (B-ALL). Results from clinical trials across multiple institutions report remarkable remission rates with CD19-directed CAR-modified T-cell therapy. These remissions are also proving to be durable in many patients with a relapse-free survival (RFS) of approximately 50% to 60% at 1 year across several trials and institutions in this population that has been historically very difficult to treat..

DiNoffa AM, et al. Chimeric antigen receptor T-cell therapy clinical trial: Results in pediatric and young adult B-cell ALL. HemaSphere. 3:279, 2019 KYMRIAH CAR T-CELLS CD 19 NOVARTIS

DIFFUSE LARGE B-CELL LYMPHOMA CAR CLINICAL TRIALS

CAR T-CELLS CLINICAL TRIALS

SCHAFT N.

The landscape Of CAR-T cell Clinical trials against solid tumors-A Comprehensive overview.

Cancers 12: 2020

NANOPARTICLE ACTIVATION OF CAR T-CELLS ENTHUSIASM INDEX CASES ANECDOTAL ADOPTIVECELL TRANSFER CANCERIMMUNOTHERAPY TRIALS CLINICAL SMALL EARLY TIME ? THERAPEUTIC APPROACHES IN HUMAN TUMOR IMMUNITY i. NON-SPECIFIC ACTIVE IMMUNITY COLEY’S TOXINS (1890-1926) CYTOKINES TOXIC 1970 INTERLEUKINS AND NANOPARTICLES 2020

ii. SPECIFIC PASSIVE IMMUNITY (CELLULAR) TILS – ADOPTIVE TRANSFER 1980s- CAR (CHIMARIC ANTIGEN RECEPTOR) T-CELLS 2010-

iii. SPECIFIC PASSIVE IMMUNITY (HUMORAL) MONOCLONAL ANTIBODIES 1980s- HERCEPTIN – ANTI-EGF RECEPTOR RITUXIMAB – ANTI-CD20 (B-CELL MARKER) BISPECIFIC ANTIBODY

iv. SPECIFIC ACTIVE IMMUNITY - VACCINATION VIRAL ANTIGENS (HPV, HEPATITIS B) MELANOMA T-CTL PEPTIDES 1980s

v. CHECK POINT INHIBITORS 2000s CTL-4 PD-1

vi. COMBINATORIAL ANTIBODY DIRECTED THERAPY

PAUL EHRLICH

1897

PROPOSED ANTIBODY RESPONSE TO CANCERS

MAGIC BULLET

NOBEL PRIZE 1908 ANTIBODY MEDIATED MECHANISMS

NEUTRALIZATION / INACTIVATION

CELL LYSIS

DRUG DELIVERY

WILL PRESENT EXAMPLES OF EACH NEUTRALIZATION/INACTIVATION REACTIONS

HORMONE DEPENDENT CANCERS

PROTECTIVE REACTIONS NEUTRALIZATION OF TOXINS; BLOCKING OF VIRUS RECEPTORS DESTRUCTIVE REACTIONS INACTIVATION OF CELLS - HYPOTHYROIDISM, ACQUIRED HEMOPHILIA ANTIBODY MEDIATED CYTOLYTIC REACTIONS LYSIS

OPSONIZATION ANTIBODY MEDIATED DRUG DELIVERY MONOCLONAL ANTIBODIES NEILS JERNE GEORGES KOHLER CESAR MILSTEIN

The Nobel Prize in Physiology or Medicine 1984 was awarded jointly to Niels K. Jerne, Georges J.F. Köhler and César Milstein "for theories concerning the specificity in development and control of the immune system and the discovery of the principle for production of monoclonal antibodies.

“HUMANIZED” MONOCLONAL ANTIBODIES

GENE CLONING

Production of enginered monoclonal antibodies is accomplished using recombinant DNA to create constructs[3] capable of expression in mammalian cell culture.

Gene segments capable of producing antibodies are isolated and cloned into cells that can be grown in a bioreactor such that antibody proteins produced from the DNA of the cloned genes can be harvested en masse. CONSTANT AG REGIONS HUMAN

VARIABLE REGIONS MOUSE

HEAVY CHAIN AG LIGHT CHAIN

CHIMERIC MOUSE –HUMAN ANTIBODY MONOCLONAL ANTIBODY SUFFEXES

-OMAB -XIMAB -ZUMAB -UMAB

CANNOT BE USED IN HUMANS SERUM SICKNESS ANTIBODY RESPONSE TO FOREIGN PROTEINS

VASCULITIS CAUSED BY DEPOSITION OF SOLUBLE ANTIBODY ANTIGEN COMPLEXES IN VESSEL WALLS FULLY HUMANIZED MONOCLONAL ANTIBODIES DERIVED FROM HUMAN B-CELLS

PATIENT MAKING DESIRED ANTIBODY EFFECT OF ANTI-EGF RECEPTOR (HER2) ON GROWTH OF HUMAN CANCER CELLS IN ATHYMIC MICE PRECLINICAL

JOHN MENDELSOHN

Masui H, Kawamoto T, Sato JD, Wold B, Sato G, Mendelsohn J. Growth inhibition of human tumor cells in anthymic mice by anti-epidermal growth factor receptor monoclonal antibodies. Cancer Res. 64:1003-1007, 1984 HERCEPTIN® WHAT IS IT? A HUMANIZED MOUSE INACTIVATION MONOCLONAL ANTIBODY TO HER2.

TRASTUZUMAB

WHAT IS HER2? HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR. IT IS PRESENT ON 25 TO 30% OF HUMAN BREAST CANCERS.

HOW IS IT USED? IN ADDITION TO STANDARD CHEMOTHERAPY; MULTIPLE INJECTIONS.

WHAT IS STANDARD CHEMOTHERAPY? ANTRACYCLINE AND CYCLOPHOSPHAMIDE OR PACITAXEL

WHAT IS EFFECT? INCREASES SURVIVAL TIME BY 5-6 MONTHS. Slaman, DJ, et al, NEJM. 11:783-792, 2001 HERCEPTIN TREATMENT OF BREAST CANCER ANTIBODY MEDIATED CYTOXICITY RITUXIMAB RITUXAN®

WHAT IS IT? CHIMARIC MOUSE MONOCLONAL ANTIBODY TO CD20, A PAN B-CELL DEVELOPMENTAL MARKER PRESENT ON 90% OF HUMAN B-CELL LYMPHOMAS

HOW HUMANIZED? MOUSE VARIABLE Ig DOMAINS; HUMAN CONSTANT DOMAINS

HOW USED? AS ADDITION TO CHOP CHEMOTHERAPY

WHAT IS CHOP CHEMOTHERAPY? CYCLOPHOSPHAMIDE, DOXERUBICIN, VINCRISTINE, PREGNASONE (HIGH DOSES FOR 14 DAYS

WHAT IS EFFECT? RITUXIMAB INCREASES SURVIVAL (18 MONTHS) BY 20% BETTER THAN CHOP ALONE

HOW DOES IT WORK? ? Complement mediated lysis; ADCC CARs to CD20, an antigen expressed in B-cell–related blood cancers

Acute and Chronic lymphoytic leukemia, B-CELL LYMPHOMA

CD - CLUSTERS OF DIFFERENTIATION RETUXIMAB TREATENT OF B-CELL LYMPHOMA

Retuximab

Observation

Jaeger, U, et al, Rituximab maintenance for patients with aaggressive B-cell lymphoma in first remission: results of the randomized NJL13 clinical reial, Hematologica 100:, 2015

Ponziani et al, Antibody-drug conjugates: The new frontier of chemotherapy. Int.J Mol Sci. 15:5510, 2020 ANTIBODY-DRUG CONJUGATES APPROVED FOR CLINICAL USE Type of Cancer Name Antigen Target Linker Type Status Target Cleavable linker Mylotarg® (Gemtuz Myeloid leukemia CD33 (hydrazone acetyl marketed umab ozogamicin) B-cell lymphoma butyrate)

Cleavable linker Besponsa® (Inotuz Lymphoblastic B CD22 (hydrazone acetyl marketed umab ozogamicin) leukemia butyrate)

Protease- Adcetris® (Brentuxi Hodgkin’s CD-30 cleavable mc-VC marketed mab vedotin) lymphoma PABC Kadcyla® (Trastuzu HER2+ Breast Non cleavable HER-2 marketed mab emtansine) cancer thioether linker

Polivy® (Polatuzum Large B Cell Protease- CD79B marketed ab vedotin) lymphoma cleavable

Lumoxiti® (Moxetu Recombinant Refractory hairy momab CD22 covalently fused marketed cell leukemia pasudotox) (linkerless)

Ponziani et al, Antibody-drug conjugates: The new frontier of chemotherapy. Int.J Mol Sci. 15:5510, 2020 SOME MONOCLONAL ANTIBODY MECHANISMS

INACTIVATION Cetuximab (Erbitux) Colon, head and neck Cell receptors for epidermal growth factor

Bevaxizumab (Avastin) Multiple Vascular-endothelial growth factor

CELL LYSIS Alemtuzumab (CD52 antigen) CLL ADCC

DRUG DELIVERY Ibritumomab ( Zevalin) Non-Hodgkin’s lymphoma (CD20) Delivers radiation (yttrium-90)

Ado-trastuzumab emtansine Breast Cancer (HER-2 receptor) Delivers chemotherapy (maytansinoid cytotoxin)

Brentuximab vedotin (Adcetris®) Hodgkin lymphoma (CD30 antigen) Delivers toxic chemical (monomethyl auristatin E) Large cell lymphoma

BISPECIFIC ANTIBODY TREATMENT OF MALIGNANT ASCITES EPITHELIAL CANCERS

Heiss MM, et al, The role of relative lymhocyte count as a biomarker for the effect of Catumaxomab on survival in malignant ascites patients: Rewults from a phase II/III study. Clinical Cancer Research.20, 2014 ENTHUSIASM INDEX CASES ANECDOTAL MONOCLONAL ANTIBODIES CANCERIMMUNOTHERAPY TRIALS CLINICAL SMALL EARLY TIME TRIALS CLINICAL STAGE3 APPLICATION CLINICAL FINAL INTERMISSION THERAPEUTIC APPROACHES IN HUMAN TUMOR IMMUNITY i. NON-SPECIFIC IMMUNITY COLEY’S TOXINS (1890-1926) CYTOKINES TOXIC 1970 INTERLEUKINS AND NANOPARTICLES 2020

ii. SPECIFIC PASSIVE IMMUNITY (CELLULAR) TILS – ADOPTIVE TRANSFER 1980s- CAR (CHIMARIC ANTIGEN RECEPTOR) T-CELLS 2010-

iii. SPECIFIC PASSIVE IMMUNITY (HUMORAL) MONOCLONAL ANTIBODIES 1980s- HERCEPTIN – ANTI-EGF RECEPTOR RITUXIMAB – ANTI-CD20 (B-CELL MARKER) BISPECIFIC ANTIBODY

iv. SPECIFIC ACTIVE IMMUNITY - VACCINATION VIRAL ANTIGENS (HPV, HEPATITIS B) MELANOMA T-CTL PEPTIDES 1980s NANOPARTICLE mRNA PERSONALIZED VACCINES (2020s)

v. CHECK POINT INHIBITORS 2000s CTL-4 PD-1

vi. COMBINATORIAL IMMUNOTHERAPY VIRAL CANCER VACCINES

Cornelis JM, et al Therapeutic cancer vaccines. JCI. 125:3401-3412, 2015

EFFECT OF HPV VACCINATION ON INCIDENCE OF CERVICAL CANCER

HBV vaccination programs are a key HCC prevention strategy. The 30-year report on the neonatal HBV vaccination effort in Taiwan noted that HCC incidence declined 80% and mortality declined 92% in cohorts born after the vaccination program began (22). Many other countries that implemented programs in the 1980s, such as China, Singapore, and Spain are seeing reductions similar to those of Taiwan in the prevalence of HBV in vaccinated cohorts (10).

McGlynn KA, et al, Epidemiology of hepatocellular carcinoma. Hepatology. 73. Suppl 1 4-13, 2021 VIRAL CANCER VACCINES

Cornelis JM, et al Therapeutic cancer vaccines. JCI. 125:3401-3412, 2015 TUMOR VACCINES

DO TUMORS EXPRESS ANTIGENS LIKE INFECTIOUS AGENTS?

CAN WE IMMUNIZE WITH THESE ANTIGENS AND INDUCE A PROTECTIVE OR PREVENTATIVE IMMUNE RESPONSE? AUTOCHTHONOUS TUMOR ANTIGENS

SELF HEALING MALIGNANT MELANOMA

MELANOMA

MACROPHAGES WITH LYMPHOCYTES MELANIN TUMOR IMMUNITY CONCEPTS

IMMUNOSURVEILLANCE

IMMUNOEDITING

CONCOMITANT IMMUNITY IMMUNOSURVEILLANCE DEVELOPING TUMORS ARE RECOGNIZED AND DESTROYED OR HELD IN CHECK BY IMMUNE MECHANISMS

LEWIS THOMAS, NYU 1959 MACFARLAND BURNETT, HALL INSTITUTE, AUSTRALIA NOBEL PRIZE 1960

BUT NO TUMORS IN IMMUNODEFICIENT MICE OSIAS STUTMAN, SLOAN KETTERING IMMUNOEDITING

(PREVIOUSLY KNOWN AS IMMUNOSELECTION)

IMMUNE SYSTEM WEEDS OUT IMMUNOGENIC TUMOR CELLS

OBSERVATION:

TUMORS ARISING IN THE PRESENCE OF A FULLY FUNCTIONING IMMUNE SYSTEM ARE LESS IMMUNOGENIC THAT THOSE THAT DEVELOP IN THE ABSENCE OF IMMUNITY

Cell lines from tumors that arise in WT mice will grow in syngeneic WT and SCID mice Only half of cell lines from tumors arising in SCID mice will grow in syngeneic WT mice

Bui JD, Schreiber RD. Cancer immunosurveillance, immunoediting and inflammation: independent or interdependent processes? Current Opinion Immunology. 19:203-208, 2007 CONCOMITANT IMMUNITY

TUMOR BEARING INDIVIDUAL IS IMMUNE TO HIS/HER OWN TUMOR CELLS TUMOR CELLS TAKEN FROM AN INDIVIDUALS OWN TUMOR WILL BE REJECTED IF INJECTED INTO ANOTHER SITE

AUTOCHTHONOUS TUMOR IMMUNITY

MANY ATTEMPTS TO IMMUNIZE HUMANS WITH THEIR OWN TUMOR CELLS WITH AND WITHOUT ADJUVANTS A FEW POSITIVE RESULTS HUMAN TUMOR ANTIGENS/CANCER VACCINES

PROBLEMS:

1. IDENTIFICATION OF HUMAN TUMOR ANTIGENS

2. DEVELOPMENT OF IMMUNIZATION PROTOCOLS

3. PRODUCE EFFECTIVE IMMUNE RESPONSE NOT SUPPRESSIVE FOR T-CELLS MICE VACCINES TO CANCER ASSOCIATED ANTIGENS

Some Tumor Vaccines in Mice (Preclinical)

Antigen Adjuvants Effect MUC-1 (mucin) “Naked” DNA Inhibition of growth of transplanted tumor Vaccinia vectored DNA CEA “Naked” DNA Induction of antibody and T-cell response CEA Vaccinia vectored Ab, CMI and inhibition of tumor growth Modified MHC class I Transfected tumor cells Change Th2 to Th1 type response Mutated p53 Anti-idiotype (PAb240) Resist growth of transplanted tumor cells Wild type p53 Complete Freund’s adj Decreased chemical carcinogenesis Anti-B cell idiotype ” DNA Antibody mediated tumor inhibition E1A peptide Anti-CD40 Primes for TCTL Neu Plasmid Immunity to Neu expressing tumor ErbB-2 Linked to superantigen gene Regression of tumor growth ErbB-2 (breast CA) “Naked” DNA Inhibit tumor growth Tumor cells (breast) MHC class II, B7.1 transfect. Reduces metastases, does not affect primary Myeloma cells Il-2-IgG transfect. tumor rejection, immunity to re- challenge sLeX (Lewis antigen) Anti-idiotype Slowed tumor growth CHO peptide mimes QS-21 adjuvant Slowed tumor growth Tn (CHO) antigen linked to CD4 epitope Slowed tumor growth SOME APPROACHES TO HUMAN CANCER VACCINES

Human Melanoma Adjuvant Rwsponse Polyvalent melanoma none At 12 years 17% response rate; 17% CR BCG Some bladder cancers Melanoma lysate lipid A, mycobacterial cell Phase III trial negative (Melacine) walls, cyclophosphamide Melanoma lysate Vaccinia Phase III trial negative Polyvalent melanoma Alum Preliminary results positive (shed culture medium) gp100 peptide IL-2 Preliminary evidence of partial regression GM2 ganglioside BCG, cyclophosphamide Trials negative (melanoma) KLH conjugation Trials underway Irradiated melanoma GM-CSF transfection Lymphocyte infiltration of tumors seen Irradiated melanoma IL-2 transfected cells Induction of TCTL, no clinical response Melanoma antigens Anti-idiotype (melimmune) Ab and CMI induced to melanoma antigens

Human Other PSA-liposome BCG, GM-CSF, Induce Ab and CMI, Clinical trials Prostate peptides Dendritic cells 30% responders in phase II trial (ONCO-VAX) cyclophosphosphamide underway (prostate cancer) HPV (E6 and E7) peptides; DNA+cytokines Approved for human use. Hepatitis Antigens peptides Effective in preventing Hepatitis Sialyl-Tn (STn) KLH conjugate Antibody and CMI induced to Stn CEA canarypox vectored Induce TCTL, safe in phase I trial Colon CA cell lines DETOX, IL1-α Some side effects in Phase I trial. HER-2/neu peptides GM-CSF Antibody and CMI induced EFFECT OF “VACCINES” ON OVERALL SURVIVAL OF PATIENTS WITH METASTATIC CASTRATE-REISITANT PROSTATE CANCER

OS ADVANTAGE 4.1 MOS. OS ADVANTAGE 8.5 MOS.

APCs FROM PERIPHERAL BLOOD MONOCYTES RECOMBINANT VACCINIA VIRUS CONTAINING INCUBATED WITH PROSTATIC ACID TRANSGENES FOR PSA, B7.1, ICA-3 AND LFA-3. PHSPHATASEAP FUSED TO GM-CSF) PSA-TRICOM

Schlom J. Therapeutic cancer vaccins: currest status and moving forward. JNCI reviews 104:599-613, 2012 TUMOR ANTIGENS IDENTIFIED BY TCTL-CELLS

1981 ALEXANDER KNUTH IN GERMANY TAKES MELANOMA CELLS FROM A PATIENT TO THEIRY BOON IN BELGIUM. BOON TREATS CANCER CELLS WITH MUTAGENS. AFTER IRRADIATION, THE NON-VIABLE CANCER CELLS ARE INJECTED BACK INTO THE PATIENT, WHO HAD MULTIPLE METASTASES AND DEBILITATED

AFTER THREE INJECTIONS OVER THREE MONTHS, TUMORS WENT AWAY AND WITH REPEATED INJECTIONS DID NOT RECUR

LYMPHOCYTES FROM PATIENT KILLED TUMOR CELLS IN VITRO.

USING IL-2 CLONED A T-CELL LINE (TCTL) FROM THE PATIENT

IDENTIFIED A 9 AMINO ACID PEPTIDE PRESENTED BY CLASS I MHC

MAGE-1 SOME TCTL DEFINED TUMOR ANTIGENS MAGE-1,2,3,ETC MELANOMA, LUNG VACCINE TRIALS

TYROSINASE MELANOMA *MELANOSOMAL PROTEIN

MUC1 PANCREAS, BREAST MUCIN ANTIGEN NOT MHC RESTRICTED

CAGE-1,2 MELANOMA *MHC RESTRICTED

CAGE 3 MELANOMA, BREAST NON-MHC RESTRICTED

MELAN-A/ MART-1 MELANOMA *ALSO ON RETINA

MSHR MELANOMA HORMONE RECEPTOR

TRP-1/2 MELANOMA DIFFERENTIATION AG

PMEL17 GP-100 MELANOMA IN CLINICAL TRIALS INCONSISTANT RESULTS MAJOR PROBLEMS

● IMMUNOGENIC TUMOR ANTIGENS POORLY DEFINED

● OPTIMAL ADJUVANT (DANGER SIGNAL) OR ANTIGEN PRESENTATION METHOD NOT KNOWN

● CANCER PRODUCES IMMUNOSUPPRESSION – (T-regs; MYELOID DERIVED SUPPRESSOR CELLS)

TUMOR SPECIFIC TRANSPLANTATION ANTIGENS EXERIMENTAL TUMOR TRANSPLANTATION HOST/GRAFT RELATIONSHIP

TUMOR GROWTH

AUTOLOGOUS SAME INDIVIDUAL (GRAFT) AUTOCHTHONOUS (TUMOR)

SYNGENEIC GENETICALLY IDENTICAL TWINS, INBRED STRAINS

TUMOR REJECTED

ALLOGENEIC DIFFERENT INDIVIDUAL SAME SPECIES

XENOGENEIC DIFFERENT SPECIES PIG TO HUMAN DEMONSTRATION OF TUMOR SPECIFIC TRANSPLANTATION IMMUNITY

George Klein 1960 PRIMARY METHYCHOLANTHERE INDUCED TUMOR IN MOUSE A

GROWTH IN SYNGENEIC NO GROWTH PRIMARY TUMOR FROM MOUSE RECIPIENT MOUSE B IN MOUSE A C GROWS IN MOUSE A

MODERNA mRNA-4157 VACCINE

KETRUDA ANTI-PD1 more to come

ModernaTX, Inc.'s mRNA personalized cancer vaccine (PCV) mRNA-4157 is a therapeutic cancer vaccine candidate that is a combination of validated defined neoantigens, predicted neoepitopes, and mutations in driver genes into a single mRNA concatemer (mRNA-4650). ENTHUSIASM INDEX CANCER VACCINESCANCER CANCERIMMUNOTHERAPY TIME ? THERAPEUTIC APPROACHES IN HUMAN TUMOR IMMUNITY i. NON-SPECIFIC ACTIVE IMMUNITY COLEY’S TOXINS (1890-1926) CYTOKINES TOXIC 1970 INTERLEUKINS AND NANOPARTICLES 2020

ii. SPECIFIC PASSIVE IMMUNITY (CELLULAR) TILS – ADOPTIVE TRANSFER 1980s- CAR (CHIMARIC ANTIGEN RECPTOR) T-CELLS 2010-

iii. SPECIFIC PASSIVE IMMUNITY (HUMORAL) MONOCLONAL ANTIBODIES 1980s- ANTI-CD4 SEZARY’S SYNDROME (10% EFFECTIVE) HERCEPTIN – ANTI-EGF RECEPTOR RITUXIMAB – ANTI-CD20 (B-CELL MARKER) BISPECIFIC ANTIBODY

iv. SPECIFIC ACTIVE IMMUNITY - VACCINATION VIRAL ANTIGENS (HPV, HEPATITIS B) MELANOMA T-CTL PEPTIDES 1980s TUMOR SPECIFIC TRANSPLANTATION ANTIGENS

v. CHECK POINT REGULATOR INHIBITORS 2000s CTL-4 PD-1

vi. COMBINATIORIAL CHECK POINT REGULATOR INHIBITORS

DECEMBER 2013 APRIL 2016 PROTEINS ON SURFACE OF T-KILLER CELLS

PD1 - PROGRAMMED CELL DEATH PROTEIN 1

CTLA 4 - CYTOTOXIC T-LYMPHOCYTE ASSOCIATED PROTEIN 4

ACTIVATION LEADS TO DEATH OF T-KILLER CELLS

ACTIVATING LIGANDS

PD1-L ON TUMOR CELLS

CTLA 4 LIGAND (B7.1/2) ON ANTIGEN PROCESSING CELLS

ANTIBODIES TO PD1 OR CTLA 4 BLOCK LIGAND REACTION AND PREVENT DEATH OF T-CELLS ACTIVATION OF PD-1 AND CTLA-4 LEADS TO LOSS OF KILLER T-CELLS ACTIVATION BLOCKED BY ANTIBODY ANTI CTLA-4 INHIBITS GROWTH OF TRANSPLANTED COLON CARCINOMA CELLS IN MICE

Leach DR, Krummel F, Allison J. Enhancement of antitumor immunity by James P. Allison CTLA-4 Blockade. Science 271:1734-1736, 1996 NOBEL PRIZE 2018

A. 4 x 106 CELLS B. 2 x 106 CELLS C. 4 INDIVIDUAL MICE

Protected against subsequent challenge with WT tumor cells ANTI-CTLA-4 THERAPY CTLA4 blocks tumor immunity (CHECK POINT REGULATOR) Reversal by treatment with anti-CTLA-4 antibody. IPILIMUMAB

a. Specific T-cells are activated by tumor specific antigen peptides presented by dendritic cells to the TCR and through co-stimulation Through B7 and CD28

b. CTLA 4 is then upregulated, displaces CD28 and attenuates X the T-cell response.

c. Treatment with anti-CTLA-4 blocks CTLA4 activity and allows re-establishment of T-cell activation

d. Activated T-cells can now effect tumor cell death.

I Mellman et al. Nature 480, 480-489 (2011) doi:10.1038/nature10673 Durable benefit and the potential for long-term survival with immunotherapy in advanced melanoma IPILMUMAB - ANTI-CTLA-4

10 % response

22 months

Gp100 – melanoma peptide vaccine

Fig. 2. Kaplan–Meier analysis of overall survival in study MDX010-20. A separation in the Kaplan–Meier curves between the ipilimumab arms and the control arm is observed after 3 months of treatment. A plateau in the Kaplan–Meier curves for the ipilimumab arms ...

David McDermott, Celeste Lebbé, F. Stephen Hodi, Michele Maio, Jeffrey S. Weber, Jedd D. Wolchok, John A. Thompson, Charles M. Balch Cancer Treatment Reviews, Volume 40, Issue 9, 2014, 1056–1064 http://dx.doi.org/10.1016/j.ctrv.2014.06.012

Glycoprotein 100, gp100 or Melanocyte protein PMEL is 661 amino acids long and is a type I transmembrane glycoprotein enriched in melanosomes, which are the melanin-producing organelles in melanocytes. The gp100 protein is a melanoma antigen i.e. a tumor-associated antigen. Short fragments of it have been used to develop the gp100 cancer vaccine which is or contains gp100:209-217(210M Anti-PD-1 Therapy

TSUKU HONJO NOBEL 2018 KEYTRUDA ANTI-PD 1 NON-SMALL CELL LUNG CANCER

Selected Safety information: Pneumonitis (12); Colitis (4); Hepatitis (2); Hypophysitis (2); Nephritis (3); Hyperthyroidism (5); dermatitis; uveitis; arthritis myositis; pancreatitis; seizures; adrenal insufficiency; myasthenia syndrome; optic neuritis; and rhabdomyolysis (Less than 1%). Discontinued 1n 9% of patients. From The New England Journal of Medicine, Reck M, Rodríguez-Abreu D, et al, for the KEYNOTE- 024 Investigators, Pembrolizumab versus chemotherapy for PD-L1–positive non–small-cell lung cancer, 2016 Oct 8. [Epub ahead of print]. doi:10.1056/NEJMoa1606774. Accessed 25 October 2016. Copyright © 2016 Massachusetts Medical Society. PD-L1 EXPRESSION IN NON-SMALL-CELL LUNG CANCERS PREDICTS CLINICAL RESPONSE

LESS THAN 1% 1 to 49% > 50%

NO. PATIENTS 76 161 119

Garon EB, et al. Pembrolizumab for the treatment of non-small-cell lung ccancer. New Eng. J Med. 372:2018, 2015 EFFECT OF PD-L1 EXPRESSION ON SURVIVAL PEMBROLIZUMAB TREATMENT OF LUNG CANCER

KEYTRUDA (Pembralizmab) ANTI-PD-1 MERCK YEROV IPILIMUAB ANTI-CTLA 4 BRISTOL MYERS The first and only anti–PD-1 to achieve superior overall survival— 31% reduction in the risk of death with KEYTRUDA 10 mg/kg Q3W vs ipilimumab in KEYNOTE-006

ADVANCED MELANOMA

From The New England Journal of Medicine, Robert C, Schachter J, Long GV, et al, for the KEYNOTE-006 investigators, Pembrolizumab versus ipilimumab in advanced melanoma, Vol 372, Pages 2521–2532. Copyright © 2015 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society UNTOWARD EFFECTS OF CHECK POINT INHIBITOR THERAPY ENTHUSIASM INDEX CASES ANECDOTAL CHECK POINT POINT CHECKREGULATOR INHIBITORS CANCERIMMUNOTHERAPY TRIALS CLINICAL SMALL EARLY TIME TRIALS CLINICAL STAGE3 APPLICATION CLINICAL FINAL? COMBINATORIAL THERAPY

COMBINE

TWO DIFFERENT IMMUNOTHERAPIES (ANTI-CTLA-4 + ANTI-PD-1)

TARGETED THERAPY AND IMMUNOTHTHERAPY

Ledford, H. The perfect blend: The next frontier in cancer immunotherapy lies in combining it with other treatments. Scientists are trying to get the mix just right. Nature 532:162-164 April 14, 2016 YEROV ANTI-CTLA-4 OPDIVO ANTI-PD-1 COMBINATION MONOCLONAL AB IMMUNOTHERAPY CHECK POINT INHIBITORS VS CHEMOTHERAPY

OVERALL SURVIVAL COMBINATORIAL TREATMENT OF B-CELL LYMPHOMA WITH ANTI-B-CELL DRUG CONJUGATES

Polatuzumab is a CD79b targeted antibody drug conjugate delivering monomethyl auristatin E (microtubule inhibitor blocks proliferation of B cells).

Bendamustine – alkylating agent blocks DNA synthesis, Rituximab - anti CD20

Sehn LH, Polatuzuab Vedotin in relapsed or refractory diffuse large B-cell lymphoma. J Clin Oncol 38:155-165, 2020. KINASE INHIBITORS BLOCK CELL PROLIFERATION BLUE LINE - CONTROL (DECARBIZINE) ORANGE LINE ANTI-CTLA4 OR COMBINATION WITH BRAF INHIBITOR Tomei S, et l. Non-BRAF-targeted therapy, immunotherapy and combination for melanoma Expet Opinion on Biol Therapy. 14:2014 KEY CLINICAL TRIALS WITH COMBINATION THERAPIES Agents Indication Regimen or design n Overall response (CR Survival Refs and PR) Ipilimumab and Advanced- Nivolumab or ipilimumab 945 -44 % nivolumab Median PFS: [98] nivolumab stage alone versus nivolumab -19 % ipilimumab -2.9 months for ipilimumab* † untreated plus ipilimumab -58 % ipilimumab plus -6.9 months for nivolumab melanoma nivolumab -11.5 months for nivolumab plus ,† ipilimumab* Ipilimumab and Advanced- Concurrent or sequential 53 42 % OS rate: [146] nivolumab stage combination with dose (concurrent -85 % 1-year melanoma escalation combination) -79 % 2-year Ipilimumab and Advanced- Ipilimumab alone versus 142 -11 % ipilimumab* Median PFS: [147] nivolumab stage Ipilimumab plus -61 % ipilimumab plus -4.4 months for ipilimumab untreated nivolumab nivolumab* -Not reached for ipilimumab plus melanoma nivolumab Ipilimumab and Previously Ipilimumab or vaccine 676 -10.9 % ipilimumab Median OS: [13] GP100 vaccine treated alone versus ipilimumab alone* -10.1 months for ipilimumab alone † advanced- plus vaccine -1.5 % vaccine alone -6.4 months for vaccine alone* stage -5.7 % ipilimumab with -10.0 months for ipilimumab plus ,† melanoma vaccine* vaccine* Ipilimumab and Advanced- Dacarbazine alone versus 502 -10.3 % dacarbazine Median OS: [79] dacarbazine stage Ipilimumab plus alone -9.1 months for dacarbazine alone* untreated dacarbazine -15.2 % ipilimumab -11.2 months for ipilimumab plus melanoma with dacarbazine dacarbazine* Ipilimumab and Post- Radiotherapy followed by 799 NA Median OS: [149] radiotherapy docetaxel placebo versus -10.0 months for radiotherapy followed CRPC radiotherapy followed by by placebo ipilimumab -11.2 months for radiotherapy followed by ipilimumab Carboplatin plus NSCLC Placebo control versus 204 -18 % chemotherapy Median irPFS: [150] paclitaxel with phased or concurrent control -4.6 months chemotherapy control* placebo or schedule -32 % irBORR -5.7 months for phased ipilimumab* ipilimumab ipilimumab Carboplatin plus ED-SCLC Placebo control versus 130 -53 % chemotherapy Median irPFS: [151] paclitaxel with phased or concurrent control -5.3 months chemotherapy control* placebo or schedule -71 % irBORR -6.4 months for phased ipilimumab* ipilimumab ipilimumab

THERAPEUTIC APPROACHES IN HUMAN TUMOR IMMUNITY i. NON-SPECIFIC ACTIVE IMMUNITY COLEY’S TOXINS (1890-1926) CYTOKINES TOXIC 1970 INTERLEUKINS AND NANOPARTICLES 2020

ii. SPECIFIC PASSIVE IMMUNITY (CELLULAR) IMMUNE RNA 1970s TILS – ADOPTIVE TRANSFER 1980s- CAR (CHIMARIC ANTIGEN RECPTOR) T-CELLS 2010-

iii. SPECIFIC PASSIVE IMMUNITY (HUMORAL) MONOCLONAL ANTIBODIES 1980s- HERCEPTIN – ANTI-EGF RECEPTOR RITUXIMAB – ANTI-CD20 (B-CELL MARKER)

iv. SPECIFIC ACTIVE IMMUNITY - VACCINATION VIRAL ANTIGENS (HPV, HEPATITIS B) MELANOMA T-CTL PEPTIDES 1980s

v. CHECK POINT INHIBITORS 2000s CTL-4 PD-1

vi. COMBINITORIAL ENTHUSIASM INDEX CASES ANECDOTAL CANCERIMMUNOTHERAPY TRIALS CLINICAL SMALL EARLY TIME ? MONOCLONAL ANTIBODY IMMUNOTHERAPY

Pembralizumab SELL FAMILY W&M GRADUATES

STEW, PAT, SHERRI, BUD,SEAN, STEPH, SAMANTHA, ALLY

DELAYED HYPERSENSITVITY

SPECIFIC ANTIGEN RECOGNITION BY T-CELL ACTIVATES MACROPHAGE LINE 1 TUMOR BCG INJECTION

NO TUMOR LYMPH IN NODE NODE METASTASIS

SKIN LYMPHOCYTES TUMOR

IMMUNE CELLS TUMOR CELLS APOPTOSIS 1960s HERB RAPP AND TIBOR BORSOS NIH BCG TREATMENT OF METASTATIC CARCINOMA IN THE SKIN

BEFORE AFTER

ONCOLYTIC VIRUS IMMUNOTHERAPY In October 2015, the US FDA approved the injectable formulation of T-VEC, with the brand name Imlygic, for the treatment of melanoma in patients with inoperable tumors. Mechanism of action T-VEC was engineered from herpes simplex virus 1 (HSV-1), a relatively innocuous VIRUS that normally causes cold sores. A number of genetic modifications were made to:

•Attenuate the virus (so it could no longer cause herpes) •Increase selectivity for cancer cells (so it destroys cancer cells while leaving healthy cells unharmed) •Secrete the cytokine GM-CSF (a protein naturally secreted in the body to initiate an immune response)

IN PHASE 2 CLINICAL TRIALS TUMOR MICROENVIRONMENT

TUMOR SUPPORTING CELLS

TISSUE STROMA (including blood supply)

TUMOR INFILTRATING MACROPHAGES (TIMs)

CANCER ASSOCIATED FIBROBLASTS (CAFs)

MYELOID-DERIVED SUPPRESSOR CELLS (MDSCs) THERAPY DIRECTED TO BONE MARROW NICHE FOR MUTIPLE MYELOMA STEM CELLS

KEN ANDERSON

Hideshima, T. et al. Blood 2004;104:607-618 BORTEZAMIB - PROTEOSOME INHIBITOR Inhibits breakdown of proapopotic proteins, increases programmed cell death

Harausseau J-L, et al Bortezomib plus dexamethasone is superior to vincristine plus doxorubicin plus dexamethasone as induction treatment prior to autologous stem-cell transplantation in newly diagnosed multiple myeloma “ results of the IRM 2005-01 phase III trial. J. Clin. Oncol. 28:4621-4609, 2011

Comparison of CyBorD response rates to other treatment regimens for newly diagnosed multiple myeloma Regimen Thal- Dex Len– Dex Bor– Dex MPT VTD Bor–MP CyBorD CR/nCR 8% N/A 22% 16% 36% 33% 39% VGPR 43% 44% 47% 29% 60% 41% 61% Abbreviations: CR, complete response; nCR, near complete response, VGPR, very good partial response; MM, multiple myeloma; Thal–Dex, thalidomide–dexamethasone; Len–Dex, lenalidomide–dexamethasone; Bor–Dex, bortezomib– dexamethasone; MPT, melphalan, prednisone and thalidomide; VTD, velcade, thalidomide and dexamethasone; Bor–MP, bortezomib, melphalan and prednisone. CyBorD, cyclophosphamide, bortezomib and dexamethasone.

Reeder CR, et al. Cyclophosphamide, bortezomib and dexamethasone induction for newly diagnosed multiple myeloma: high response rates in a phase II clinical trial. Leukemia 23:1337-1341, 2009. Elotuzamab is a humanized monoclonal antibody to the SLAMF7 receptor (signalling –lymphocyte activation molecule) 1. ADCC

Fc receptor

2. Blocks adhesion

Dual Mechanism – 1. Binds to Fc receptor (CD-16) and activates NK cells ADCC of myeloma cells 2. Blocks interaction between SLAMF7 on MM and stromal cells. Magen, H, Muchtar E. Elotuzumab: the first approved monoclonal antibody for multiple meloma treatment. Ther Adv Hematol. 2016 August;7(4):187-195