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IMMUNOTHERAPY
Vanesa Gregorc MD
IRCCS San Raffaele, Milano
LUNG CANCER AS AN IMMUNOLOGICMEDIATED DISEASE AND TARGET FOR
IMMUNOTHERAPY
Although many immunotherapies are being
investigated in NSCLC, currently
none have been FDA approved, as
vaccines and other immune-modulators have
yet to demonstrate considerable
improvements inOS in phase III clinical
trials
NOVEL ASPECTS
Immune-related response criteria
Endpoints
The immune-related toxicities
All differ considerably
from conventional
cytotoxic agents and
targeted therapies
RESPONSE EVALUATION FOR
IMMUNOTHERAPY
•Permissive not restrictive
•RECIST/mWHO modified by
immunological criteria
•First radiological examination
the most critical (pseudoprogressions)
•irResponders with new lesions
also but decrease in baseline
lesions
•PD should be confirmed after 4 w
Wolchok JD, et al Clin Cancer Res
2009; 15:7412-7420.
NSCLC IMMUNOTHERAPY
IMMUNOMODULATORS
ANTI PD1-PDL1
ANTI CTLA4
VACCINES
MAGE A3
MUC1
BELAGEN-PUMATUCEL L
Tumor/T cells
Mechanism of action
IMMUNOMODULATORS
PROGRAMMED DEATH-1 IMMUNE
CHECKPONT (PD-1)
PD-1 (cell receptor) is overexpressed on NSCLCinfiltrating T cells and these are functionally
exhausted cells
Ligands: PDL-1 and PDL-2 (tumor cell /APC)
Higher tumoral PDL-1 expression correlates with
decreased OS
RATIONALE
Blocking the PD-1 or PDL-1 pathway would
restore/promote the function of chronically
exhausted tumor-specific T cells and decrease
tumor-induced immune suppression
Zhang Y et al. Cell Mol Immunol. 2010;7:389- 395.
OF T CELL
OF TUMOR CELL
CLINICAL DEVELOPMENT OF INHIBITORS OF PD-1
IMMUNE CHECKPOINT
Inhibitors of PD-1 – Phase I trial
CT-O11
CT-O11
(0.26.0mg/kg
N=17
0.2-6.0 mg/kg IV
1YEAR SURVIVAL=42%, 2 YEAR SURVIVAL 24%
Lambrolizumab in NSCLC
Garon E. et al Abstract
MO18.02 IALS 2013
INHIBITORS OF PDL1- phase I
trial
Inhibitors of PD-L1-Activity in
NSCLC
PD L1 Expression
Pd-L1 Is broadly expressed in NSCLC
UPDATE
UPDATE
EGFR STATUS AND IMMUNOTHERAPY
EGFR wild type has higher PD-L1
expression vs EGFRm
MO18.01 EGFR status and MPDL3280A Activity in NSCLC Horn et al.
IPILIMUMAB
Co-stimulation via CD28: CTLA-4 blocks co-stimulation: Ipilimumab blocks CTLA-4:
T-cell activation
No T-cell activation
T-cell activation
T cell
T cell
T cell
CTLA4
CTLA4
TCR
CD28
APC
CD28
CD28
B7
MHC
TCR
TCR
MHC
APC
B7
MHC
ipilimumab
B7
APC
Adapted from Lebbé et al. ESMO 2008
APC, antigen-presenting cell; CTLA-4, cytotoxic T-lymphocyte antigen-4; MHC, major histocompatibility complex; TCR, T-cell receptor.
Adapted from DoomC. 2012 PILC
RANDOMIZED PHASE II STUDY OF
IPILIMUMAB AND CT IN ADVANCED NSCLC
[TITLE]
Lynch TJ, et al. phase II study. J Clin Oncol. 2012;30:2046-2054.
Adapted by J. Brahmer, 2013 ASCO Annual Meeting
RESULTS
RANDOMIZED PHASE II STUDY OF
IPILIMUMAB AND CT IN ADVANCED NSCLC
[TITLE]
Lynch TJ, et al. phase II study. J Clin Oncol. 2012;30:2046-2054.
Adapted by J. Brahmer, 2013 ASCO Annual Meeting
OUTCOME BY HISTOLOGY
OS IN SQUAMOUS
ONGOING PHASE III OF IPILIMUMAB IN
SQUAMOUS CELL LUNG CANCER
Carbo –
paclitaxel placebo
R
Carbo AUC 6
Paclitaxel 175 mg/mq
Ipilimumab 10 mg/kg q3w
Carbo –
paclitaxel ipilimumab
Double blind
Primary endpoint: OS
Secondary: OS in patients who receive one dose of ipi/placebo, PFS, RR
Adapted by J. Brahmer, 2013 ASCO Annual Meeting
LUNG CANCER VACCINATION. NSCLC
ONGOING PH 3 TRIALS
setting
Phase III
Early stage
Post surgery
MAGE-A3
MAGRIT Target 2270
recruited
Loc.adv. Stage
L-BLP25
START target 1300
Reported ASCO 2013
Post chemorad
>
8000
Advanced
In combo with chemo
Belagenpumatucel-L
STOP target 700
Reported ESMO2013
rEGF target 1000
ongoing
TG4010
TIME target 1000
ongoing
1E10 Target 1082
ongoing
L-BLP25
MUC1 is a mucinous glycoprotein that is overexpressed and aberrantly
glycosylated in many human malignancies. BLP25 is a synthetic, liposomal
cancer vaccine that targets the extracellular tandem repeat sequences of
Butts ASCO2013
the MUC1 tumour-associated antigen.
START TRIAL – STUDY DESIGN stage IIIA/B
post CT/RT (DC)
[TITLE]
START TRIAL – PRIMARY ENDPOINT OS
START TRIAL – SECONDARY ENDPOUINT
TIME TO PROGRESSION
START TRIAL – OS SUBGROUP ANALYSES BY
RANDOMIZATION DATA
STOP TRIAL
stage III/IV in DC after 1° line
belagenpumatucel-L
Primary endpoint: OS
Other endpoints: PFS, RR, QoL, CNS metastases, safety
Belagenpumatucel-L(Lucanix®) uses genetically modified whole tumour cells to
stimulate the patient's own immune system to attack the tumour. It is comprised
of 4 transforming growth factor (TGF)-ß2 antisense gene-modified,
Giaccone et al.ESMO 2013
irradiated, allogeneic NSCLC cell lines.
STOP TRIAL did not meet predefined
end point-OS
BUT: Significantly prolonged overall survival in
patients who began belagenpumatucel-L within
12 weeks of the completion of front-line
chemotherapy or RT in Sq and Non-Sq
conclusions
Immunotherapy has promising anti-tumor activity
in NSCLC and an unique set of side effects
consistent with the immune mechanism of action
Patient selection (biomarker) might be the key to
further development as a single agent and in
combination with other therapies
Phase III trials are ongoing in order to make
immunotherapy a reality for the treatment of
NSCLC