Analysis of ROR1 Protein Expression in Human Cancer and Normal Tissues Ashwini Balakrishnan1, Tracy Goodpaster2, Julie Randolph-Habecker2, Benjamin G

Published OnlineFirst November 16, 2016; DOI: 10.1158/1078-0432.CCR-16-2083

Cancer Therapy: Preclinical Clinical Cancer Research Analysis of ROR1 Protein Expression in Human Cancer and Normal Tissues Ashwini Balakrishnan1, Tracy Goodpaster2, Julie Randolph-Habecker2, Benjamin G. Hoffstrom3, Florencia G. Jalikis4, Lisa K. Koch4, Carolina Berger1,5, Paula L. Kosasih1, Anusha Rajan1, Daniel Sommermeyer1, Peggy L. Porter6, and Stanley R. Riddell1,5,7

Abstract

Purpose: This study examines cell surface ROR1 expression in homogenously expressed on a subset of ovarian cancer, triple- human tumors and normal tissues. ROR1 is considered a prom- negative breast cancer, and lung adenocarcinomas. Contrary to ising target for cancer therapy due to putative tumor-specific previous findings, we found ROR1 is expressed on several expression, and multiple groups are developing antibodies normal tissues, including parathyroid; pancreatic islets; and and/or chimeric antigen receptor–modified T cells to target ROR1. regions of the esophagus, stomach, and duodenum. The 6D4 On-target, off-tumor toxicity is a challenge for most nonmutated mAb recognizes rhesus ROR1, and ROR1 expression was sim- tumor antigens; however, prior studies suggest that ROR1 is ilar in human and macaque tissues, suggesting that the absent on most normal tissues. macaque is a suitable model to evaluate safety of ROR1-tar- Experimental Design: Our studies show that published anti- geted therapies. bodies lack sensitivity to detect endogenous levels of cell surface Conclusions: ROR1 is a promising immunotherapeutic target ROR1 by immunohistochemistry (IHC) in formalin-fixed, paraf- in many epithelial tumors; however, high cell surface ROR1 fin-embedded tissues. We developed a ROR1-specific monoclonal expression in multiple normal tissues raises concerns for on- antibody (mAb) targeting the carboxy-terminus of ROR1 and target off-tumor toxicities. Clinical translation of ROR1-targeted evaluated its specificity and sensitivity in IHC. therapies warrants careful monitoring of toxicities to normal Results: The 6D4 mAb is a sensitive and specificreagentto organs and may require strategies to ensure patient safety. detect cell surface ROR1 by IHC. The data show that ROR1 is Clin Cancer Res; 1–11. 2016 AACR.

Introduction secreted variant 3 (v3; UniProt IDQ01973-3) putatively encodes the amino-terminal 393 aa (12, 13). The receptor tyrosine kinase ROR1 serves as a Wnt5a receptor Ror1 expression has mainly been evaluated by transcriptional and is widely expressed in embryonic development and multiple analysis of normal tissue and tumor biopsy specimens. Micro- human cancers (1–11). There are 3 described splice variants of array studies comparing gene expression in B-cell chronic lym- Ror1: variant 1 (v1; UniProt IDQ01973-1) encodes a transmem- phocytic leukemia (B-CLL) and normal mature B cells first iden- brane protein consisting of 934 amino acids (aa) expressed on the tified Ror1 as a signature gene in B-CLL (14, 15). Many human cell surface; intracellular variant 2 (v2; UniProt IDQ01973-2) solid tumors, including breast, ovarian, and lung cancers, have lacks the amino-terminal 549 aa of ROR1; and intracellular/ also been shown to express Ror1 by RNA analysis (6, 7, 9, 10, 16, 17). Multiple groups have demonstrated protein and cell surface expression of ROR1 in B-CLL, mantle cell lymphoma (MCL), and a subset of B-cell acute lymphoblastic leukemia (ALL) using flow 1Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, 2 cytometry (2, 5, 12, 18). Immunohistochemistry (IHC) of both Washington. Experimental Histopathology Shared Resource, Fred Hutchinson fi fi Cancer Research Center, Seattle Washington. 3Antibody Development Shared frozen and formalin- xed, paraf n-embedded (FFPE) tumor Resource, Fred Hutchinson Cancer Research Center, Seattle Washington. samples using antibodies targeting the N-terminal region of ROR1 4Department of Pathology, University of Washington School of Medicine, detected ROR1 in many solid tumors; however, many studies Seattle, Washington. 5Department of Medicine, University of Washington, described mainly cytoplasmic staining, not the expected cell Seattle, Washington. 6Department of Pathology, Fred Hutchinson Cancer 7 surface expression of ROR1-v1 (3, 4, 6, 7, 10, 11). ROR1 expres- Research Center, Seattle, Washington. Institute for Advanced Study, Technical sion has also been characterized in normal human tissues by University of Munich, Munich, Germany. transcriptomics, immunoblot, and IHC. Ror1 transcripts were Note: Supplementary data for this article are available at Clinical Cancer evaluated in cDNA pools from normal adult tissues and identified Research Online (http://clincancerres.aacrjournals.org/). in adipose tissue and pancreas at higher levels than other normal Corresponding Author: Stanley R. Riddell, Fred Hutchinson Cancer Research tissues (5, 19). Using flow cytometry, we showed cell surface Center, 1100 Fairview Avenue North, P.O. Box 19024, D3-100, Seattle, WA 98109. ROR1 was present on adipocytes differentiated in vitro from Phone: 206-667-5249; Fax: 206-667-7983; E-mail: [email protected] precursor cells and on normal immature B cells in the bone doi: 10.1158/1078-0432.CCR-16-2083 marrow (5). A variety of ROR1-specific antibodies have been 2016 American Association for Cancer Research. used to detect ROR1 in normal tissues by immunoblot or IHC

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Translational Relevance Materials and Methods Procurement of tissues Multiple groups are investigating the cell surface receptor Protocols for procurement of human and rhesus tissues were tyrosine kinase ROR1 as a target in solid tumors for mono- approved by the Institutional Review Board of the Fred Hutch- clonal antibodies or chimeric antigen receptor–modified inson Cancer Research Center (FHCRC; Seattle, WA) and T cells because of its reported high expression in tumors and the Institutional Animal Care and Use Committee (IUCAC) of low expression in normal tissues. We developed a sensitive the University of Washington and FHCRC or obtained as ROR1-specific monoclonal antibody and characterized cell tissue microarrays (TMA) from US Biomax (Ov208, BR- surface ROR1 expression in tumors and normal tissues. We 1503d, BC-04115c, HLug-Ade090Lym-01, PA1001a, FDA999g show that ROR1 is frequently expressed homogenously in and RhFDA1) and Cooperative Human Tissue Network multiple types of ovarian cancer, triple-negative breast cancer, (CHTN_OvCa-1 and CHTN_Norm2 and flash-frozen normal and lung adenocarcinomas. Contrary to previous reports, we tissues). Thirty-eight FFPE TNBC samples were from a popu- also found that ROR1 is highly expressed in the parathyroid, lation-based study of women with a first diagnosis of invasive pancreatic islets, and several regions in the gut, raising con- breast cancer. Rhesus T cells were isolated, retrovirally trans- cerns for potential off-tumor toxicity. Clinical testing of ROR1- duced to express rhesus ROR1 (XP_014996735) using targeted therapies in patients with solid tumors will require described methods (19), and immunomagnetically selected careful monitoring of normal tissue toxicities or additional for ROR1 positivity. strategies, such as combinatorial circuits to improve tumor- specific targeting. Plasmid vectors, cell lines, and antibodies Open reading frames of human ROR1-v1 (NP_005003.2) and ROR2 (pDOMR223-ROR2-Addgene) were cloned into a retrovi- (2, 12, 20). These studies have shown variable results but con- ral vector (35). The lentiviral construct expressing the ROR1- fi cluded that ROR1-v1 is selectively expressed on tumor cells and speci c R12scFv CAR has been described (29). K562, JeKo-1, not on normal tissues. MDA-MB-231, NCI-H1975, and 293T cell lines were obtained The tumor-selective expression has made ROR1 a potential from ATCC. K562 cells were transduced with retroviral vectors target for therapy. Targeting ROR1 is attractive, as its expression expressing human ROR1-v1, human ROR2, and rhesus ROR1-v1. has been shown to enhance tumor cell growth and survival and Commercial antibodies against ROR1 were from R&D Biosystems promote epithelial–mesenchymal transitionandmetastasis(7, (AF2000), Cell Signaling (4102), and Abcam (ab135669). The 10, 11, 21). ROR1 cooperates in prosurvival pathways such as ROR1 antibody 4A5 was a kind gift from Thomas Kipps (UCSD). PI3K/AKT, EGFR signaling, and the p38/MAPK pathway (7, 10, Flow staining was performed with anti-ROR1 (Clone 2A2-Milte- 22–24). Consistent with a role of ROR1 in tumor cell survival nyi) and anti-ROR2 (R&D Biosystems-FAB20641G) or isotypes as and metastasis, high ROR1 expression has correlated with previously described (19). shorter overall and metastasis-free survival in triple-negative fi breast cancer (TNBC), lung adenocarcinoma, and ovarian can- Generation of ROR1-speci c monoclonal antibody 6D4 cer (4, 6, 11, 17). Monoclonal antibodies or antibody–drug Female BALB/c and CD1 mice were immunized with a fi conjugates targeting cell surface ROR1 are being evaluated in cocktail of 4 synthetic peptides (CHI Scienti c) coupled to – KLH. Polyclonal sera were screened by immunoblotting against preclinical studies in multiple settings (9, 25 27), and cirmtu- þ zumab, a humanized monoclonal antibody, is currently being ROR1 CLL and K562 ROR1 cell lysates using the WES tested in patients with relapsed or refractory CLL (28). Our immunoblot device (ProteinSimple, Bio-Techne). Hybridomas laboratory has developed T cells engineered with chimeric were picked and ranked for peptide binding using a cytometric þ bead array carrying the peptide cocktail. Clones were screened antigen receptors (CAR) targeting ROR1 that lyse ROR1 tumor þ þ cells in vitro and eliminate ROR1 human tumor xenografts in by IHC against ROR1 cell lines, CLL lymph nodes, and / multiple normal tonsil tissues. Hybridoma 6D4 underwent 2 NOD/SCID/gc mice (5, 29). In both monoclonal antibody and CAR T-cell therapies, subsequent rounds of subcloning with repeated validation for toxicity to normal tissues expressing the target molecule is a peptide binding. potential side effect, and strategies that enhance safety may need to be developed (30–33). Moreover, escape of tumor cells IHC protocols lacking the target can be a mechanism of relapse (34). Thus, it For the 6D4 mAb, 4-mm sections were cut and stained with the is important to rigorously analyze expression in normal tissues Leica Bond Rx (Leica Biosystems). Slides were pretreated with H2 to identify organs at risk of toxicity and to evaluate the buffer (20 minutes), blocked with 3% hydrogen peroxide (5 uniformity of ROR1 expression in tumors to identify patients minutes) and protein block (10 minutes: 15% goat serum, 5% that might derive greatest benefit from ROR1-targeted immu- human serum in antibody diluent) followed by the 6D4 mAb notherapies. We developed a murine monoclonal antibody (1:50 dilution) for 30 minutes and detected using Leica Power (mAb) that is specific for a peptide in the carboxy-terminus Vision HRP mouse specific polymer (PV6110–12 minutes). IHC present in full-length ROR1 that can be used in IHC to char- staining with commercially available ROR1-specific antibodies acterize the expression of cell surface ROR1 on solid tumors used published protocols or those provided by the investigator and normal tissues. Here, we report an in-depth analysis of cell (4A5 monoclonal mAb; refs. 6, 8, 10, 12). For the 4A5 antibody, surface ROR1 expression in a subset of common epithelial antigen retrieval (Trilogy-30 minutes, high salt buffer-30 min- tumors and normal human tissues using this novel ROR1- utes) was followed by primary antibody (8 mg/mL) overnight and specificmAb. either CSA amplification (investigator protocol) or anti-mouse

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polymer. The staining for all antibodies was visualized with 3,30- selected 4 peptides of 19 to 29 aa in length corresponding to diaminobenzidine (DAB). regions with maximal aa differences between human and mouse Tumor tissues were scored for cell surface ROR1 by 2 inde- ROR1 and had minimal homology to other sequences in the pendent board-certified pathologists (F.G. Jalikis and L.K. human proteome (Supplementary Fig. S2A). Polyclonal sera from Koch) and the scores averaged. Tissues were scored as 0 (neg- immunized mice were screened by immunoblot against lysates þ ative), 1 (low antibody staining), 2 or 3 (high membrane from primary CLL (ROR1 ) cells and ROR1 K562 cells to staining with antibody). Homogenous and focal staining were identify sera that detected the 130-kDa band of full-length ROR1 defined as staining on greater than 50% and less than 30% of (Supplementary Fig. S2B). Hybridoma clones were generated tumor cells, respectively. from splenocytes of mice with high anti-ROR1 titers, and 1222 clones were selected on the basis of binding to fluorescently Immunblotting and PCR labeled target antigen. Supernatants from individual clones were Immunoblotting of ROR1 with 6D4 mAb and AF2000 (R&D ranked on the basis of binding to a cytometric bead array con- Biosystems) was performed as described (12) and visualized with jugated to the ROR1 peptide cocktail, and supernatants from the anti-mouse-HRP and anti-goat-HRP, respectively. Real-time PCR top 103 clones were tested in IHC of FFPE K562/ROR1, K562 cells, was performed using primers and protocols from previous studies CLL lymph nodes, and normal tonsil. Similar to commercial (19). reagents, supernatants from many of the clones stained K562 cells that overexpressed ROR1 but failed to detect endogenous ROR1 in FFPE CLL lymph node. However, supernatant from clone Primary and T-cell cultures 6D4 specific for peptide NPRYPNYMFPSQGITPQGQIAGFIGP- Primary adipocytes were differentiated from human white PIP stained both K562/ROR1 and primary CLL with high sensi- preadipocytes (Promo Cell; ref. 5). Two thousand islets equiva- tivity and specificity and was selected for validation (Supplemen- lent of primary human islets, acinar cells, and media for islet tary Fig. S2C). culture were procured from Prodo Labs. Human T cells were transduced with the ROR1 CAR lentivirus as described (29). Primary adipocytes, islets, and acinar cells were cocultured at a Validation of 6D4 anti-ROR1 monoclonal antibody þ T cell:target ratio of 2:1 with untransduced and ROR1 CAR T cells Purified 6D4 mAb was further evaluated by staining ROR1 prepared from 2 independent donors. Supernatants were har- cell lines and primary tumors. 6D4 stained K562/ROR1 with vested after 24 hours coculture and cytokine production assayed minimal background against untransduced K562 cells or K562 by multiplex immunoassay (Luminex). Target killing was per- expressing human ROR2 and stained hematopoietic and epi- formed at T cell:target ratio of 5:1 using carboxyfluorescein thelial tumor cell lines, including JeKo1, MDA-MB-231, and diacetate succinimidyl ester (CFSE) to label target cells and NCI-H1975, which also show cell surface ROR1 staining by propidium iodide (PI) to score percentage of dead target cells flow cytometry using the well-characterized clone 2A2 (Fig. after 24 hours of incubation (36). 1A). We re-tested purified 6D4 for staining CLL and MCL lymph nodes and peripheral blood mononuclear cells and observed Results uniform membrane staining with minimal background on normal human tonsil (Fig. 1B and Supplementary Fig. S2D). Development of a ROR1-specific antibody for IHC þ Immunoblot of lysates from K562/ROR1, ROR1 tumor lines, Tumor biopsies and archival samples are typically formalin- primary CLL, and MCL cells with 6D4 detected a 130-kDa fixed, which can mask epitopes and require antigen retrieval for band consistent with ROR1-v1 (Fig. 1C). These results dem- IHC. A sufficient level of target epitope needs to be unmasked for onstrated that the 6D4 mAb specifically detects endogenously sensitive detection of most proteins by IHC without nonspecific expressed cell surface ROR1 on primary tumors with greater antibody cross-reactivity. We evaluated previously tested ROR1- sensitivity than previous reagents and without cross-reactivity specific antibodies using published protocols for staining on FFPE against ROR2. K562 cells transduced to express high levels of ROR1 (K562/ ROR1high) and nontransduced K562 cells (ROR1neg; refs. 6, 8, 10, 12). In addition, we tested these ROR1 antibodies for IHC of FFPE ROR1 expression in epithelial cancers lymph nodes from patients with CLL, as CLL uniformly expresses Ovarian cancer. Previous studies analyzed ROR1 expression in high cell surface ROR1 by flow cytometry, and FFPE normal ovarian cancer using transcriptional profiling and IHC (6, 8, 9). human tonsil, which lacks ROR1. We found that most ROR1 Approximately 50% of ovarian cancers were found to express Ror1 antibodies stained transduced cells that overexpressed ROR1 but transcripts, and patients with tumors who had high Ror1 tran- not FFPE CLL lymph nodes (Supplementary Fig. S1). We tested a script levels had an unfavorable disease-free and metastases-free variety of antigen retrieval and staining conditions but were survival (6). However, the IHC analysis of ROR1 localized the unable to find conditions for reproducible detection of ROR1 in staining primarily to the tumor cell cytoplasm and nucleus, which CLL lymph nodes with minimal background on normal tonsil was distinct from the cell surface expression of ROR1-v1 on tumor (data not shown). cell lines, and contrary to our data showing clear membrane The poor sensitivity of available ROR1-specific antibodies for expression with the 6D4 mAb in CLL and MCL lymph nodes detecting endogenously expressed ROR1 on FFPE tissues (6, 8). We therefore examined 2 tissue microarrays composed of prompted us to develop a mouse anti-human ROR1 mAb target- 159 ovarian cancers of a variety of histologies using the 6D4 mAb ing the intracellular carboxy-terminal region of ROR1, which is in IHC. We found that 50% of the ovarian cancers showed present in the cell surface ROR1-v1 but may be less subject to predominantly membrane and cytoplasmic stainings with 6D4 epitope loss following formalin fixation. Because human ROR1 is (Fig. 2A). In 92% of tumors, ROR1 was expressed homogeneous- highly conserved with 97% aa homology with mouse ROR1, we ly, defined as definite membranous staining of more than 50% of

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Figure 1. IHC staining of FFPE ROR1þ cells with the 6D4 mAb. A, IHC staining of ROR1-transfected and control cell lines (left) and ROR1þ tumor cell lines (right). Paired ﬂow cytometric staining with anti-ROR1 (blue), anti-ROR2 (red), and isotype (gray) antibodies. B, 6D4 staining of FFPE tonsil tissue and CLL and MCL lymph nodes. C, þ Immunoblot analysis of ROR1 and ROR1 cell lines with the 6D4 mAb. ROR1-v1 is expressed as a 130-kDa protein. Scale bars represent 50 mm.

þ cells, and the staining intensity in positive tumors could be found that 22% were ROR1 and these patients had a shorter classiﬁed as high or low based on the intensity of cell surface disease-free survival (4). We examined 24 estrogen receptor (ER)/ þ þ staining (Supplementary Fig. S3). When grouped into histologic progesterone receptor (PR) , 12 Her2 , and 60 TNBC samples for subtypes, approximately 90% of endometrioid adenocarcinomas ROR1 using the 6D4 mAb (Fig. 3A–C). We found low ROR1 þ þ þ were ROR1 and 60% of positive tumors were ROR1high, 74% staining in a small percentage of the ER/PR (12% ROR1 ) and þ þ of serous papillary carcinomas were ROR1 with 50% graded no ROR1 expression in HER2 tumors. However, ROR1 was þ þ ROR1high, 44% of mucinous adenocarcinomas were ROR1 highly expressed in TNBC where 57% of samples were ROR1 (31% ROR1high); and 37% of serous adenocarcinomas were with 56% graded as ROR1high and 74% showing homogenous þ ROR1 (50% ROR1high; Fig. 2B and C). Cell surface ROR1 was staining (Fig. 3B and C). low or absent in certain subtypes of ovarian cancer such as clear cell carcinomas and mucinous papillary adenocarcinoma. We Lung cancer. Ror1 transcripts were identiﬁed in non–small cell also examined a small number of metastatic samples (1 clear lung cancer by microarray and PCR (10, 17). IHC with different cell, 4 serous papillary, and 7 serous adenocarcinomas) and found polyclonal and monoclonal antibodies reported ROR1 staining in that 75% of the metastatic serous papillary and 40% of the serous 24% to 90% of lung adenocarcinomas, which constitute 40% of þ adenocarcinomas were ROR1 . These results demonstrate that all lung cancers (8, 10, 11). ROR1 expression in other lung cancer the 6D4 mAb detects cell surface ROR1 in a large fraction of subtypes has not been well characterized. We examined 137 ovarian cancers and will be useful both to determine prognostic primary lung cancers of different histologic types using the implications of ROR1 expression and to identify patients eligible 6D4 mAb. ROR1 expression was most frequent in lung adeno- þ for ROR1-targeted therapies. carcinomas (42% were ROR1 with 38% graded ROR1high) with a þ minority (12%) of squamous cell carcinomas staining ROR1 Breast cancer. ROR1 gene expression was previously examined in (Fig. 4A–C). We also observed ROR1 staining in adenosquamous breast cancer using publically available GEO datasets, and high carcinomas, large cell carcinomas, small cell carcinomas, and ROR1 expression correlated with an epithelial–mesenchymal atypical carcinoid tumors, although too few of these tumors were transition (EMT) gene signature and lower metastasis-free survival examined for an accurate estimate of the frequency of positivity þ (7, 21). One report found ROR1 protein expression in 70% of (Fig. 4B and C). All ROR1 lung tumors exhibited homogeneous primary cancers by IHC (75% of lobular breast and 70% of ductal staining. þ breast were ROR1 ), although staining with the reagent used in Because ROR1 has been reported to play a role in EMT and that study was localized to the nucleus and cytoplasm, suggesting tumor migration, we examined whether ROR1 expression in the protein detected may not be the cell surface variant of ROR1 primary tumors was maintained in matched metastatic lesions. (7). An independent group examined ROR1 by IHC in TNBC and We examined 30 primary and matched metastatic lymph nodes

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Figure 2. Membrane ROR1 staining in ovarian cancer using the 6D4 mAb. A, Representative IHC images of subtypes of ovarian cancer samples stained with the 6D4 mAb. þ Scale bar represents 100 mm. Regions in squares in middle are magniﬁed 10 in bottom panels. B, Percentage of ROR1 tumors in different subtypes of ovarian cancer. C, Percentage of ROR1high and ROR1low tumors in the ROR1þ ovarian cancer subset.

from patients with lung adenocarcinoma, 50% of whom had are necessary to determine whether ROR1 expression correlates þ þ ROR1 tumors. In patients with ROR1 primary tumors, 60% of with a distinct clinical behavior. þ the matched metastatic lymph nodes remained ROR1 and 40% were ROR1 (Fig. 4D). In 2 patients, the primary tumor was ROR1 expression in normal human tissues þ ROR1 but the metastatic lymph nodes were ROR1 . These A concern for antibody or adoptive T-cell therapies targeting results suggest there may not be a direct correlation between ROR1 is the potential for on-target, off-tumor toxicities due to increased ROR1 expression and metastatic potential in lung expression of ROR1 on normal tissues (33, 37, 38). Prior adenocarcinomas or that maintenance of ROR1 expression is not studies that have analyzed ROR1 expression in normal tissues required for tumor growth at a distant metastatic site. However, a by real-time PCR or immunoblot of whole tissue lysates found larger number of paired primary and metastatic samples in that ROR1 is absent or expressed at low levels in most normal multiple tumor settings will need to be examined for cell surface tissues(2,5,12,20).WholetissuecDNApoolsorlysatesare ROR1 expression to determine whether ROR1 is a driver of an important firststeptodetectROR1butcanfailtodetect metastasis. expression if it is localized to a minority of cells or a region of the tissue. We previously used flow cytometry to show that cell Pancreatic cancer. We also examined cell surface ROR1 expression surface ROR1 is present on adipocytes differentiated from in 38 cases of pancreatic adenocarcinoma, which was reported in adipocyte precursors in vitro and at an early stage of normal one study to frequently (83%) express ROR1 (8). Surprisingly, we B-cell differentiation in the bone marrow (5). Several studies found ROR1 expressed at low levels in a small fraction of tumors have examined ROR1 expression in normal tissues using IHC (15%; Supplementary Fig. S4). with previously available antibody reagents but have not In summary, our analysis of common epithelial cancers shows reported cell surface ROR1 in normal tissues, except for adi- that high levels of cell surface ROR1 are present in a significant pocytes (12, 28). fraction of ovarian cancers, TNBC, and lung adenocarcinomas. The6D4mAbissensitiveandspecific for ROR1 and might ROR1 staining is typically homogeneous; suggesting that the vast detect ROR1 on normal tissues that were previously thought majority of tumor cells may be susceptible to ROR1-targeted to be negative. Therefore, we examined ROR1 expression by therapies. ROR1 expression does not appear to be required for IHC using 2 human multi-organ normal tissue microarray metastases in lung adenocarcinomas; however, additional studies panels. ROR1 was absent in brain, heart, lung, liver, but we

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Figure 3. Membrane ROR1 staining in breast cancer using the 6D4 mAb. A, Representative IHC images of subtypes of breast cancer tissue samples stained with the 6D4 mAb. Scale bar represents 100 mm. Regions in squares in middle are magniﬁed 10 in bottom panels. B, Percentage of ROR1þ tumors in different subtypes of breast cancer. C, Percentage of ROR1high and ROR1low tumors in the ROR1þ breast cancer subset.

detected significant cell surface staining of normal parathy- lysates from tissues such as the parathyroid than in CLL pos- roid, pancreatic islet cells, and in multiple regions of the sibly due to differences in posttranslational modifications such gastrointestinal tract (Fig. 5A and B; Supplementary Fig. S5). as N-linked glycosylation (Fig. 5C). On treating the lysates with We performed a more extensive analysis in different regions PNGaseF which removes N-linked glycosylation, a deglycosy- of the gastrointestinal tract and found that cell surface ROR1 lated ROR1 protein band of 100 kDa was detected in positive was expressed in basal epithelial lining of the esophagus, in tissues as previously reported (Supplementary Fig. S6A; ref. 39). the surface and foveolar epithelial cells of the gastric antral We also measured transcripts of Ror1-v1 in human gut tissues mucosa, and in the duodenal mucosa (absorptive cells, goblet by real-time PCR and found significant Ror1 transcripts in cells, and crypt epithelium; Fig. 5B). ROR1 expression on gut stomach and adipocytes, although transcript levels of these mucosa appeared to be higher on luminal epithelium and tissues were lower than in peripheral blood samples from between cell–cell junctions (Fig. 5B). Cell surface ROR1 was patients with CLL (Supplementary Fig. S7). not seen in the jejunum or ileum, and low levels were To determine whether the levels of ROR1 detected by the observed in the surface and crypt epithelium of the ascending 6D4 mAb are sufficient for recognition by T cells that express a and descending colon (Fig. 5B). ROR1-specific CAR, we cocultured primary human differenti- Because prior studies had not detected ROR1 in normal ated adipocytes, pancreatic islet cells, and acinar cells with tissues by IHC, it was important to ensure that the cell surface ROR1-CAR T cells and measured cytokines in the culture staining observed with 6D4 did not reflect cross-reactivity with supernatant. We found that ROR1 CAR T cells secreted IFNg, another protein. Thus, we procured flash-frozen samples of the granulocyte macrophage colony-stimulating factor (GM-CSF), positive tissues and prepared cell lysates for immunoblot and IL2 when incubated with primary adipocytes, islet cells but analysis with 6D4 and the previously published polyclonal not mock T cells from the same donors (Fig. 5E; Supplementary goat anti-ROR1 antibody (12). We also prepared cDNA for Fig. S6B and S6C). The levels of cytokine secretion during in real-time PCR with primers specificforRor1-v1 (19). A band vitro culture were proportional to ROR1 expression on targets. þ consistent with the 130-kDa full-length ROR1 protein was In addition, ROR1 CAR T cells lysed ROR1 K562/ROR1 cells detected by immunoblot using both 6D4 and the polyclonal and differentiated adipocytes but not K562 cells (Supplemen- goat anti-ROR1 antibody in lysates from CLL cells and in lysates tary Fig. S6D). These studies confirmed that, contrary to prior from parathyroid, pancreatic islets, stomach antrum, and gas- reports, cell surface ROR1 is expressed in many normal adult tric body, esophagus, duodenum, and colon (Fig. 5C and D). tissues including adipocytes, parathyroid, pancreatic islets, and TheROR1bandhadaslightlyhighermolecularweightin regions of the gastrointestinal tract.

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Figure 4. Membrane ROR1 staining in lung cancer using the 6D4 mAb. A, Representative IHC images of ROR1 expression in subtypes of lung cancer samples stained with the 6D4 mAb. Scale bar represents 100 mm. Regions in squares in middle are magniﬁed 10 in bottom panels. B, Percentage of ROR1þ tumors in different subtypes of lung cancer. C, Percentage of ROR1high and ROR1low tumors in the ROR1þ lung cancer subset. D, Representative IHC images of ROR1 expression in primary þ and matched metastatic lymph nodes of ROR1 lung adenocarcinomas. Scale bar represents 50 mm.

ROR1 expression in rhesus tissues Discussion Our group has previously demonstrated the safety of ROR1 ROR1 is expressed on many human cancers and is a candidate CAR T cells in a preclinical rhesus macaque (Macaca mulatta) for monoclonal antibodies or ROR1 CAR T-cell therapy (5, 26, 28, model, which was felt to be suitable because the epitope recog- 29, 40). Our understanding of the role of ROR1 in human nized by the ROR1 CAR is conserved, and normal macaque tissues malignancy and normal tissues, and the potential to target this expressed similar levels of Ror1 transcripts (19). No toxicities molecule therapeutically has been hampered by the lack of were seen in macaques even with infusion of very high doses of effective reagents for detecting its expression by IHC. Most prior functional CAR T cells (19). To evaluate whether ROR1 protein studies have concluded that ROR1 is expressed in a subset of is expressed in the same normal tissues in macaques as in epithelial cancers but not in normal tissues, suggesting that humans, we first tested whether the 6D4 mAb recognized targeting ROR1 will be safe (2, 12, 28). However, our studies rhesus ROR1, whose epitope differs by 1 aa with human ROR1 show that previously available reagents only detect cells expres- (Supplementary Fig. S6E). We transduced K562 and macaque T sing high levels of ROR1 and lack sensitivity and specificity for cellswithrhesusROR1andstained these cells with the 6D4 staining endogenous ROR1 in FFPE tumor and tissue samples, mAb (Fig. 6A). We then performed IHC on a normal rhesus including lymph nodes from patients with B-CLL that uniformly tissue panel and found cell surface ROR1 in the same tissues expresses ROR1. Furthermore, prior IHC studies reported mainly as in humans including parathyroid, pancreatic islets, and cytoplasmic staining in FFPE tissues even though the antibodies gastrointestinal tract including basal esophagus epithelium, target the N-terminal extracellular domain of ROR1-v1 (6, 8, 24). foveolar epithelial cells of the stomach antral mucosa, and the We developed a novel murine mAb specific for a carboxy-terminal intestinal glands of the duodenal mucosa (Fig. 6B and C). epitope of ROR1 and show that 6D4 detects membrane staining ROR1 was not detected in the rhesus colon in contrast to the of endogenously expressed ROR1-v1 in IHC and does not cross- low levels detected in human colon. These results indicate the react with ROR2. The 6D4 mAb has markedly greater sensitivity expression pattern of ROR1 is highly similar in rhesus and for detecting endogenous ROR1 on CLL and MCL lymph nodes human tissues. The lack of clinical, biochemical, or histologic and localizes ROR1 to the cell surface and cytoplasm in solid evidence of toxicity after infusing ROR1 CAR T cells in tumors. In addition to the ROR1-v1, 6D4mAb could potentially macaques observed in our prior study (19) suggests insuffi- recognize intracellular ROR1-v2, which is reported to have cient trafficking of ROR1 CAR T cells to uninflamed normal restricted transcript expression in fetal and adult central nervous tissues or levels of antigen that are insufficient for CAR T-cell system, neuroectoderm-derived cancers, and lymphoma/ recognition in vivo.

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Figure 5. ROR1 expression in normal human tissues. A, Membrane ROR1 staining in human parathyroid and pancreatic islets with the 6D4 mAb. B, ROR1 expression in different regions of the human gastrointestinal tract. Scale bar represents 100 mminA and B. Regions in squares in middle are magniﬁed 10 in bottom panels in A and B. C, Immunoblot analysis of ROR1 in normal tissues using 6D4 mAb. D, Immunoblot analysis of ROR1high normal tissues using polyclonal anti-ROR1. E, Cytokine production (IFNg, GM-CSF, and IL2) by ROR1 CAR T cells or mock-transduced T cells after 24 hours of culture with different target cells at a T-cell:target ratio of 2:1 (data are average of 2 independent experiments).

þ þ leukemia cell lines (41, 42). Immunoblot staining of ROR1 tumors were ROR1 , which may reflect the lack of specificity of the primary CLL, MCL, tumor cell lines, and normal human tissues reagent under the staining conditions used in that study (8). We confirms the specificity of 6D4 mAb for the 130-kDa cell surface found that ROR1 staining with the 6D4 mAb was mainly localized isoform of ROR1, although a faint 60-kDa band consistent with to the membrane and cytoplasm in tumors. Previous studies ROR1-v2 was observed in the stomach antrum and gastric body found that only heavily glycosylated ROR1 (130 kDa) is expressed (data not shown). Thus, unlike most commercially available on the cell membrane and inhibition of glycosylation reduces cell ROR1-specific antibodies that lack sensitivity for detecting ROR1 surface ROR1 (39). Cytoplasmic expression detected by the in FFPE samples, the 6D4 mAb provides specific detection of low 6D4mAb could be residual 130-kDa ROR1, partially or unglyco- levels of endogenous cell surface ROR1. sylated forms of ROR1, or ROR1-v2 (39, 42). It is important to þ We used the 6D4 mAb to assess ROR1 surface staining on a note that among ROR1 tumors, 56% of TNBCs, 38% of lung variety of common human epithelial tumors where Ror1 has adenocarcinomas, and 30% to 50% of ovarian cancers have high been previously reported to be expressed by transcriptomic anal- levels of membrane ROR1. This patient cohort would be ideal ysis and to negatively impact overall survival (6, 7, 10). We candidates to initially test ROR1 CAR T cells or monoclonal examined TMAs of tumor samples from patients with ovarian, antibodies, as patient tumors that homogenously express high breast, lung, and pancreatic cancer. We found that ROR1 was levels of ROR1 are most likely to receive clinical benefit from typically membranous, and homogenously expressed in the ROR1-targeted therapies. tumor, and was more prevalent in certain types of ovarian cancer, A second objective of our study was to determine the expression TNBC, and lung adenocarcinomas. In ovarian cancer, ROR1 was on normal tissues to provide insight into potential side effects of detected in a high percentage of endometrioid adenocarcinomas, targeting ROR1. We did not observe cell surface ROR1 expression serous papillary carcinoma, mucinous adenocarcinomas, and on vital tissues including brain, heart, lung, or liver. However, serous adenocarcinomas and was low in clear cell carcinomas. cell surface ROR1 was observed in the parathyroid, pancreatic Contrary to previous studies, we found ROR1 expressed primarily islets, and several regions of the human gut, with particularly high þ þ in TNBC and rarely in ER/PR or HER2 carcinomas (7). We were levels in the stomach antrum and gastric body. Previous studies surprised to find that only 15% of pancreatic adenocarcinomas reported a total lack of staining in normal postpartum tissues or þ were ROR1 , as previous studies had reported 80% of pancreatic observed cytoplasmic staining in several tissues including the

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Figure 6. ROR1 expression in normal rhesus tissues by IHC. A, Staining of ROR1 K562 and rhesus T cells and K562 and rhesus T cells transfected with rhesus ROR1 with the 6D4 mAb. Scale bar represents 50 mm. B, ROR1 staining in rhesus parathyroid and pancreatic islets. C, Representative IHC images of ROR1 staining in different regions of the macaque gastrointestinal tract. Scale bar represents 100 mm. Regions in squares in middle panels are magniﬁed 10 in right panels in B and bottom panels in C.

þ brain, heart, lung, liver, and various regions of the gut, possibly with ROR1 differentiated human adipocytes and primary islet due to lower sensitivity or cross-reactivity with the reagents used cells, they secreted cytokines indicating sufficient ROR1 was (12, 28). Previous immunoblot studies of normal tissues also presentontargetcellsforT-cellactivation.Thelackofin vivo did not report a protein band consistent with the 130-kDa ROR1- toxicity could be due to poor trafficking of CAR T cells to v1 in normal tissues including stomach, but detected a strong 50- normal tissues in the absence of inciting inflammation. Traf- kDa band in most normal tissues postulated to be ROR1-v3 ficking of T cells to nonlymphoid tissues involves interactions (UniProt ID Q01973-3), which could potentially explain the with tissue-derived dendritic cells leading to upregulation to cytoplasmic staining observed by IHC (2, 12, 20). Because specific chemokine receptors and adhesion molecules resulting most of the published antibodies target epitopes in the extra- in selective migration of the T cells to inflamed or infected cellular domain of ROR1, high expression of ROR1-v3 could tissue (43, 44). For example, homing to the gut has been interfere with detection of the cell surface cell surface variant. By associated with T-cell expression of a4b7 integrin and chemo- sampling multiple regions of the gut and specifically testing kine receptor CCR9, whose ligand is expressed specifically on pancreatic islets instead of whole pancreas by immunoblot, we the high endothelial venules of mesenteric lymph node and show that the 6D4 mAb and a polyclonal goat anti-ROR1 venules of the intestine (45). In the absence of dendritic cell– detects the 130-kDa ROR1-v1 in these normal tissues, validat- derived interactions; it is unclear whether in vitro derived CAR T ing the results obtained by IHC with 6D4. cells exit the blood and lymphoid compartments efficiently and The presence of ROR1 in many normal tissues is concerning traffic to normal tissues where ROR1 is expressed. Our findings for off-tumor, on-target toxicity of ROR1-targeted therapies. We are consistent with data from a study of CAR-T cells targeting previously tested the safety of ROR1 CAR T cells in a macaque mesothelin, which showed antitumor activity in patients with- model and observed no clinical or biochemical evidence of out evidence of toxicity to normal pleura observed with anti- toxicity to normal tissues (19). Cell surface ROR1 is similar in body–drug conjugates targeting mesothelin (46). However, human and rhesus tissues with high expression in the parathy- CARs targeting carboxyanhydrase IX (CAIX) in metastatic renal roid, pancreatic islets, antral, and duodenal mucosa. However, cell carcinoma or ERBB2 in patients with colon cancer had off- glucose levels remained within normal limits and weight loss or tumor, on-target liver and lung toxicity, respectively, potential- adipose tissue inflammation was not observed in macaques ly because these organs are more accessible to T cells (33, 37). treated with ROR1 CAR T cells, indicating that ROR1 CAR T Engineering T cells with specific chemokine receptors may help cells did not damage these normal tissues despite cell surface T cells access solid tumor environments while limiting migra- ROR1 expression. When ROR1 CAR T cells were cocultured tion to normal tissues (47, 48).

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Balakrishnan et al.

A challenge for T-cell therapy of solid tumors is that few Authors' Contributions antigens are truly tumor-specific, and our ability to target them Conception and design: A. Balakrishnan, T. Goodpaster, J. Randolph- successfully may depend on developing approaches that mini- Habecker, P.L. Porter, S.R. Riddell mize recognition of normal tissues that express the antigen. Development of methodology: A. Balakrishnan, T. Goodpaster, J. Randolph- Habecker, B.G. Hoffstrom, S.R. Riddell Effective therapy of certain solid tumors such as glioblastoma Acquisition of data (provided animals, acquired and managed patients, may be achievable by regional delivery of CAR T cells (49). A more provided facilities, etc.): A. Balakrishnan, T. Goodpaster, C. Berger, D. Som- widely applicable approach would be to incorporate combina- mermeyer, P.L. Porter torial circuits that require more than one antigen for optimal CAR Analysis and interpretation of data (e.g., statistical analysis, biostatistics, function or where CAR expression is driven by an independent computational analysis): A. Balakrishnan, T. Goodpaster, J. Randolph- antigen expressed on the tumor (30, 31, 50). The safety of ROR1 Habecker, F.G. Jalikis, L.K. Koch, D. Sommermeyer, P.L. Porter, S.R. Riddell Writing, review, and/or revision of the manuscript: A. Balakrishnan, T. Good- CAR T cells at high doses in the macaque model warrants the high paster, J. Randolph-Habecker, F.G. Jalikis, L.K. Koch, P.L. Porter, S.R. Riddell careful clinical testing of the ROR1 CAR in ROR1 tumors such Administrative, technical, or material support (i.e., reporting or organizing as TNBC, lung adenocarcinomas, and ovarian cancer. However, data, constructing databases): A. Balakrishnan, P.L. Kosasih, A. Rajan our findings suggest that additional engineering approaches may Study supervision: S.R. Riddell be necessary to mitigate normal tissue toxicity for the successful clinical translation of ROR1 CAR T cells. Grant Support This work was supported by NIH grants CA114536 (S.R. Riddell), RR00166 Disclosure of Potential Conflicts of Interest (WaNPRC), NIH/NCI P50 CA138293 (P.L. Porter), W81XWH-12-1-0079 A. Balakrishnan, J. Randolph-Habecker, B.G. Hoffstrom, and S.R. Riddell DOD, and a generous gift from the Lembersky family. A. Balakrishnan was are co-inventors of patents for ROR1-specific binding proteins and uses thereof supported by the Walker Immunotherapy Research fellowship. (US Serial # 62/290,337) and anti-ROR1 antibodies and uses thereof (US Serial The costs of publication of this article were defrayed in part by the payment of advertisement # 62/324,876), which are owned by Fred Hutchinson Cancer Research Center page charges. This article must therefore be hereby marked in and licensed to Juno Therapeutics. S.R. Riddell reports receiving commercial accordance with 18 U.S.C. Section 1734 solely to indicate this fact. research grants from and is a consultant/advisory board member for Juno Therapeutics. No potential conflicts of interest were disclosed by the other Received August 25, 2016; revised October 31, 2016; accepted November 2, authors. 2016; published OnlineFirst November 16, 2016.

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Analysis of ROR1 Protein Expression in Human Cancer and Normal Tissues

Ashwini Balakrishnan, Tracy Goodpaster, Julie Randolph-Habecker, et al.

Clin Cancer Res Published OnlineFirst November 16, 2016.

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