09,00 - 09,45

I Sessione“La rinascita di un antico sogno”

Moderatori:

Roberto Labianca - Giorgio Parmiani

09,30 - 09,45

Altre formedi immunoterapia

convenzionale

Ruggero Ridolfi

1° SessioneLA RINASCITA DI

UN ANTICO SOGNO

“ALTRE FORME DI IMMUNO-

TERAPIA CONVENZIONALE”

Ruggero RidolfiGià Direttore UO Immunoterapia e

Terapia Cellulare SomaticaIRST – IRCCS Meldola

Forlì-Cesena

LAK TIL

ASPORTAZIONE CHIRURGICA DIUNAMASSERELLA TUMORALE

SOSPENSIONE DI SINGOLE CELLULE INCUBATE CON IL-2

TIL CHEPROLIFERANO

IMMUNOTERAPIARAZIONALE(anni1980-90)

ADOPTIVEIMMUNOTHERAPYWITHIL-2± LAKINMELANOMAROSENBERG'93PHASEIIITRIALIL-2+LAK OR (%) 22.2%IL-2 alone OR (%) 27.2%

ADOPTIVEIMMUNOTHERAPYWITHTIL+IL-2INMELANOMA

ROSENBERG '94 OR 34%OVERALLSURVIVALIN22PTSSTAGEIIIANDIV

RESECTEDMELANOMA(L.Ridolfi J.Immunother.26(2)156;2003 )

3Years OS=0,45(0,21-0,68)

Should High-Dose Interleukin-2 still be the Preferred Treatment for Patients with Metastatic Renal Cell Cancer?Robert O. Dillman, Neil M. Barth, Louis A. VanderMolen, Warren H. Fong, Khosrow K. Mahdavi, and Stephanie E. McClure

CANCERBIOTHERAPYANDRADIOPHARMACEUTICALS;

Volume26,Number3,2011

IL-2altedosi:melanomaoca.renalemetastatico

Disegnodellostudio:ProgettopilotadifaseIIinaperto.

IL2:18MIU/m2/die in500ccininfusionecontinuaper72ore.IltrattamentoconIL-2èsomministratoogni3settimaneper4cicli,poiogni3-4settimaneperaltri2cicli.Iltrattamentovieneeseguitoconmoderatedosidicortisonici

2cicliIL2

3ggboost RT(dalgg -5al-3)

2-4cicliIL2

Follow-up

Radioterapia comestimoloimmunologicoinpazienticonmelanomaocarcinomarenalemetastaticotrattaticon altedosidiINTERLEUCHINA-2ininfusionecontinua(72h):studiodellarispostaimmuneedeimarcatoribiologicipotenzialmentepredittividirispostaclinica.

3ggboost RT(dalgg -5al-3)

Primitivo età N° Ter.pre SedeRT N° CicliIL-2 DoseIL-2/dieMUI

OR Dur.resp OS

1 rene 55 4 Bone 6 33840 SD 6 14

2 rene 39 0 1node 6 35460 CR 33+ 36+

3 Mel. 48 2 Skin groin 2 35820 PD - 54 Mel.uveal 35 3 neck 2 34200 PD - 2

5 Mel.mucosal 39 3 Lung1met. 2 30600 PD 12

6 rene 72 3 BoneL1 1 34200 NV - 4

7 Mel.mucosal 37 3 Linf mediastino 2 36000 PD - 4

8 Mel. 40 1 liver 3 25200 PD - 59 Rene 68 2 Lung 2 35460 PD - 9

10 rene 60 3 skin 6 36000 PR 11 16+

11 rene 61 3 lung,linf.paracardiaco

2 32000 PD - 7+

12 rene 61 4 Linf.add emed 6 32400 SD 5 7+

13 Mel.uveale 63 3 Node,liver 6 32000 SD 4+ 6+

14 Mel.uveale 43 3 liver 6 33600 SD 3+ 5+

15 Mel.uveale 66 3 liver 6 36000 SD 4+ 6+

16 rene 72 2 nodes 4 32400 SD 2 4+

Dic 2015

Radiotherapy as an immunological booster in patients with metastatic melanoma or renal cell carcinoma treated with High-dose Interleukin-2: evaluation of biomarkers of immunologic and therapeutic response

Protocol Code: IRST172.03 Eudract number: 2012-001786-32

xxxxxxxxxxxxxxxxxxxxxx

PazBLdianni38AffettodaCaRenaleditipopapillareLuglio2012:Nefrectomizzatodexconmalattiaavanzataaddominaleeperitoneale

THEPIVOTALROLEOF

DENDRITICCELLS

Nakai N. 2010 - DC Vaccination for melanoma:Reviewof54Clinical Trials

antigen processingand

CROSS PRESENTATION

Class IClass II

IMMATURE DC

ANTIGEN

CD 40 R

B7

Class I

Class IIT-cell CD4+

T-cell CD8+

MATURE DC

Migration

Cytokine production

Th2Th1IFNγTNFα

IL-5,IL-10…

CD 40 LIL-12 IL-4 ?

CYTOTOXIC T-CELL CD 8+

MEMORY CELL CD 4+Central memory CCR7+

Effector memory CCR7-

TOLEROGENIC WAY

ROLE OF DENDRITIC CELLS IN T-CELL REGULATION

DANGER-SIGNAL DC LAMP

OX 40L

CCR7

OX40

+

ITALIANHEALTHMINISTRY:Autorization N800/IIA.48.3/2099JUNE28°,2001

DENDRITICCELLVACCINATIONPULSEDWITHAUTOLOGOUSTUMORLYSATE

INADVANCEDMELANOMAPATIENTS:APILOTPHASEI-IISTUDYPRINCIPAL INVESTIGATOR :RUGGERORIDOLFIMD

MEDICAL ONCOLOGY – FORLI’HOSPITAL

ROMAGNACANCERCENTERIRSTMELDOLA,FORLI’ITALY

October1st,2007CELLFACTORYIRSTMeldola,FORLI’

2001/20/CE

EMEADIRECTIVE

Cellular Therapy =

Drug Delivery

Italian implementation

DL 219April 24°,2006

NomeDitta:IRSTSrlDataIspezione:07-10novembre2011

Pagine:1di12

VerbaleSito/iispezionato/i:IstitutoScientificoRomagnoloperloStudioela

CuradeiTumori(IRST)ViaPieroMaroncelli 40,47014Meldola (FC)

Sedelegale:ViaPieroMaroncelli 40,47014Meldola (FC)–CodiceFiscale:03154520401

27/04/2012 Autorizzazione AIFA alla produzione di terapiecellulari N° aM-55/2012

AutorizzazioneAIFA studio ABSIDE30/05/2013

14

3b

3a

4a

4b

FLUSSIDIPRODUZIONEDELVACCINO

StudyPhase 1-2 study 27 (35.1%)Vaccine plus low-dose temozolomide 18 (23.3%)Compassionate use 32 (41.6%)AgeMedian 51Range 18 – 78GenderMale 49 (63.6%)Female 28 (36.4%)Disease stageIIIc 5 (6.5%)IV M1a 23 (29.9%)IV M1b 16 (20.8%)IV M1c 33 (42.8%)Primary melanoma siteCutaneous 59 (76.6%)Mucosal 3 (3.9%)Uveal 4 (5.2%)Unknown primary 11 (14.3%)

77patientstreatedwithDendritic CellVaccinationforMetastaticMelanoma:a14-yearMonoinstitutional Experience.

PATIENTS’CHARACTERISTICS(1)

77patientstreatedwithDendritic CellVaccinationforMetastaticMelanoma:a14-yearMonoinstitutional Experience.

PATIENTS’CHARACTERISTICS(2)Number of previous lines of systemic therapyNone 24 (31.2%)1 24 (31.2%)2 or more 29 (37.6%)Previous treatments for unresectable diseaseChemotherapy 37 (48.1%)Bio-chemotherapy 26 (33.8%)Cytokines 8 (10.4%)Ipilimumab 5 (6.5%)BRAF inhibitors 0 Other 3 (3.9%)Treatments received after vaccineNone 28 (36.4%)Chemotherapy 16 (20.8%)Bio-chemotherapy 5 (6.5%)Cytokines 6 (7.8%)Ipilimumab 16 (20.8%)BRAF inhibitors 5 (6.5%)Other 3 (3.9%)

77patientstreatedwithDendritic CellVaccinationforMetastaticMelanoma:

a14-yearMonoinstitutional Experience.

• 68ptsevaluableforRESPONSE.• Intention-to-treat:• 2CR(2,6%)2PR(2,6%)23SD(29,9%) and41PD• OverallClinicalBenefitRate35.1%• Medianfollow-up47months.• MedianOverallSurvival10.2months(95%confidence

interval7.0- 15.1months);• Theprobabilitiesofsurvivalafter12and24monthssincetreatmentstartare64.9%and6.5%respectively.

Follow up mediano = 47 mesi - 5 Pazienti tuttora viventi e liberi da malattiaSopravvivenzamedianainmesicalcolataapartiredall’iniziodelvaccino[95%CI]=10.2[7.0- 15.1]

MOS 10.2months(95% confidenceinterval7.0- 15.1months);

Event Grade 1-2 Grade 3-4

ANAEMIA 1 (1.3%) 3 (3.9%)

ASTHENIA 4 (5.2%)

FATIGUE 3 (3.9%)

FEVER 10 (13.0%) 3 (3.9%)

FLU-LIKE SYNDROME 3 (3.9%)

GASTROESOPHAGEAL REFLUX 2 (2.6%)

INJECTION SITE REACTION 21 (27.3%)

NAUSEA 3 (3.9%)

PAIN 3 (3.9%)

PLEURAL EFFUSION 2 (2.6%)

PRURITUS 4 (5.2%)

SKIN RASH 3 (3.9%)

THROMBOEMBOLISM 2 (2.6%) 3 (3.9%)

URTICARIA 5 (6.5%)

ADVERSEEVENTS

Hazard ratio(95% CI)

p-value

Sex

Female 1

Male 0.95 (0.59-1.54) 0.834

Age 1.00 (0.98-1.02) 0.864

Immunological responsePositive 1

Negative 0.49 (0.29-0.82) 0.006Antigen format

Autologous tumour lysate 1

Autoogous tumour homogenate 0.83 (0.51-1.35) 0.451

Metastatic sites

Skin, subacutis, lymph nodes 1

Visceral 1.54 (0.94-2.52) 0.088

Number of metastatic sites

1 1

>1 1.90 (1.16-3.11) 0.011

Univariateanalysis of prognostic factors for overall survival. 95% CI:confidence intervalat the 95% level.

23/09/2010

28/07/2010

20/05/2010

MJ

PET 02/09/2005

MJ

PET 27/02/2007

MJPET 30/03/2009 e 15/05/12

Tuttora

vivente e libera da malattia

ABSIDE(ABScopal effect, Interferon-a, DEndritic cells)

Eudract: 2012-001410-41

VaccinationwithAutologous Dendritic CellsloadedwithAutologous TumorLysate orHomogenatecombinedwith

immunomodulating RADIOTHERAPY and/orPRELEUKAPHERESISIFN-a inpatientswithmetastaticmelanoma:

ARANDOMIZED“PROOF-OF-PRINCIPLE”PHASEIISTUDYRAZIONALE

• La radioterapia induce risposte immunitarie cellulari anche a distanza dall’irradiazone (ABSCOPAL EFFECT) soprattutto in corso di stimolazione del sistema immunitario

• L’IFN-alfa per via sistemica (sottocute) prima della Leucaferesi può migliorare l’accrual dei Precursori DC e la loro efficienza maturativa.

RANDOMIZED SELECTION DESIGN

(Simon,Clinical Cancer Res 2005)

After completion of all Screening Phase evaluations, each patient will be assigned to one

of the following treatment arm:

1) three single boosts of RT at 8 up to 12 Gy delivered to one non-index metastatic fieldat week 2

2) daily 3 MU subcutaneous IFN-a for 7 days before leukapheresis (day -15 to -9, or 7days before any additional leukapheresis if required);

3) both 1 and 2 external immunostimulant conditions;

4) neither 1 or 2 external immunostimulant conditions.

Fase II Randomizzato

IFN-α

TCT

6 sì no 6

sì + + + -

no - + - -

6 6

Pt.ID Sesso/età Braccio/N°vaccini

DTH

BestResponse

L/HKLH

CLINICALRESPONSE

RESPONSEDURATION

(months)

OS

(Months)

1 M/67 vax/6 - + PD - 9+

2 F/68 IFN/5 - +++ PD - 11

3 M/72 IFN/5 - ++ PD - 8

4 F/72 IFN/6 . ++ PD - ND

5 F/74Vax/5+

Incorso++++ ++++ PR 1+ 3+

6 M/56Vax/6+

Incorso- +++ PR 2+ 5+

7 M/49 RT/14 - ++++ PR 21+ 23+

8 F/77 RT/5 - - PD - 3

Ott 2015M.E F Screening failureV.M. F Screening FailureMi.Er F Screening Failure

Vaccination withautologous dendritic cells loaded with autologous tumor lysate orhomogenate combined with immunomodulatingradiotherapy and/or preleukapheresis IFN-a inpatients with metastaticmelanoma: arandomized “proof-of-principle” phase IIstudy

ABSIDEProtocol Code: IRST172.02 Eudract number: 2012-001410-41

STUDIO APERTOACDC: Complementary Vaccination with DendriticCells pulsed with autologous tumor lysate in

RESECTED STAGE III AND IV melanoma patients: A PHASE II RANDOMIZED TRIAL

(ACDC: ADJUVANT TRIAL).•Occorre recuperare il materiale quando si opera il paziente, •Il paziente viene randomizzato a vaccino o osservazione. •Nel braccio vaccino si erogano sei vaccinazioni totali (ogni quattro settimane).•Il materiale dei pazienti del braccio osservazione viene comunque conservato e potrebbe essere usato in futuro.

STUDI SOTTOPOSTI AD AIFA COREVAX-1: Vaccination with autologous dendritic cells loaded with

autologous tumour lysate or homogenate after curative resection for stage IV COLORECTAL CANCER: a phase II study.

RENALVAX-2: Vaccination with dendritic cells pulsed with autologous tumor homogenate in combination with HD-IL2 and immunomodulating RADIOTHERAPY in

METASTATIC RCC: a phase II trial

GRAZIE!!

Published clinical studies on DC vaccination in from Noerregaard LE. 2008

PigmentCellMelanomaRes.2010Oct;23(5):607-19.Epub 2010Jul27.Dendritic cellvaccinationinhumanmelanoma:

relationshipsbetweenclinicaleffectsandvaccineparameters.

Nakai N,Hartmann G,Kishimoto S,Katoh N.

•Reviewof54trials:Significantdifferenceswerefoundbetween:Ø immatureandmatureDCswithregardtoprogressivedisease(PD),ØstageIIIandIVforclinicalresponse,Øuseandnon-useofadjuvants intreat.withtumorlysate-pulsedDCs,Øpositiveandnegativedelayed-typehypersensitivity(DTH) forPD,ØIncreasedinterferon(IFN)-γ-secretingTcellsforclinicalresponse.

DCvaccination….neededtoenhanceantigen-specificcytotoxic Tcellsanddecrease

immunosuppression.

JImmunother. 2012Oct;35(8):641-9.Tumor Stem Cell Antigensas ConsolidativeActive Specific Immunotherapy:

ARandomized Phase IITrialofDendritic Cells VersusTumor Cells inPatientsWithMetastaticMelanoma.

Dillman RO,Cornforth AN,Depriest C,McClay EF,Amatruda TT, deLeonC,Ellis RE,Mayorga C,Carbonell D,Cubellis JM.

• 42Ptz wererandomizedtoreceive1. irradiatedautologous proliferatingtumorcellsor2. autologous Dendritic Cellsloadedwithantigensfromsuchcells

• survivalissuperiorintheDCarm(hazardratio,0.27;95%confidenceinterval,0.098-0.729)

• mediansurvivalnotreachedversus15.9months,

• 2-yearsurvivalratesof

§72%versus31%(P=0.007)

MONTHLY VACCINATIONS

-X 0 1 2 3 4 5 6 7 8 9 10 11 WEEKS

APHERESISSURGERY THAWING OUT

VACCINE

BLOODSAMPLE

FREEZINGCELLS

DTH

FUNCTIONALTESTS

FLOWCYTOMETRY

CLIN. EVAL.

1° 2° 3° 4°

TREATMENTFLOWCHART

STERILITY TEST

Dendritic Cell Vaccination in metastatic melanoma patients: A TWELVE-YEAR monoinstitutional experience.

a safety and efficacy data for all the 82 patients December 31, 2012 82 advanced cancer patients (71 melanomas; 11RCC) a total of 749 vaccines.Adverse events (AEs) in 39/82 (47.6%) pts;none led to treatment discontinuation.Local Reactions to the vaccine (10/82; 12.2%) Fever after adjuvant IL-2 (12/82; 14.6%). TWO G4 Aes non-symptomatic subsegmentary pulmonary embolism not likely related to study treatment. 1 case of moderate-severe autoimmune myositis

Responses 71/82 evaluable patients who received at least four vaccine doses were as follows: CR 2 (2.4%) PR 2 (2.4%) SD 31 (37.8%) PD 36 (43.9%) Clinical Benefit 42.6%. Median OS 12.01 months.

immunoresponsive patients 22.76 vs 8.06 mths; (p=0.0036)Median Follow-up 71 months

0

5

10

15

20

25

30

35

Patient LC

surv

tyr

gp100

NY-ESO

MAGEA3

MART-1

024681012141618

PatientGGsurv

tyr

gp100

NY-ESO

MAGEA3

MART-1

ENHANCEMENT OF ANTIGEN SPECIFIC IFN-γ SPOT-FORMING CELLS (SFCS) IN BLOOD SAMPLES OF MELANOMA PATIENTS DURING THERAPY

IFN

-γSF

Cs/

4x10

5ce

lls

Baseline after 3 cycle Baseline after 3 cycle

Fig.2Circulating immune effectors specific for a selected panel of TAA known to be expressed in MM patientsassessed by IFN-γ ELISPOT assay ((interferon-γ-Enzyme Linked Immunosorbent Spot). All tests were performed using PBMC from whole bloodsamples. The number (enumerated as SFCs, spot forming cells) of TAA-specific circulating T cells was investigated during therapy.

Should High-Dose Interleukin-2 still be the Preferred Treatment for Patients with Metastatic Renal Cell Cancer?

Robert O. Dillman, Neil M. Barth, Louis A. VanderMolen, Warren H. Fong, Khosrow K. Mahdavi, and Stephanie E. McClure

CANCERBIOTHERAPY ANDRADIOPHARMACEUTICALS; Volume26,Number 3,2011

• High-dose IL-2is associated witha5-yearsurvivalratethatisHIGHERTHANOBJECTIVERESPONSERATES,suggestingadelayedimmunotherapybenefitforsomepatients.

• TheuseofintensiveIL-2hasdeclineddramaticallyinrecentyears,butunlessalongterm survivalbenefitcanbeshownforthesenewtargetedproductswefeelthatcliniciansshouldcontinuetoconsiderIL-2astheINITIALTHERAPYinanypatientswithmetastaticclearcellrenalcellcancerwhoaremedicallyFITFORSUCHTHERAPY.

• PatientswhoreceiveHIGH-DOSEBOLUSIL-2afterprevioustreatmentwithsorafenib,sunitinib,orbevacizumab mayhaveanunacceptablyHIGHRATEOFCARDIACCOMPLICATIONSduring subsequent IL-2treatment

0

50

100

150

200

250

300

350

400

Patient BL

surv

CAIX

5T4

NY-ESO

MAGEA3

EGFR

0

20

40

60

80

100

120

140

160

180

Patient RF

surv

CAIX

5T4

NY-ESO

MAGEA3

EGFR

0

50

100

150

200

250

300

350

400

Patient AG

surv

CAIX

5T4

NY-ESO

MAGEA3

EGFR

0

10

20

30

40

50

60

70

80

Patient GGi

surv

CAIX

5T4

NY-ESO

MAGEA3

EGFR

ENHANCEMENT OF ANTIGEN SPECIFIC IFN-γ SPOT-FORMING CELLS (SFCS) IN BLOOD SAMPLES OF RENAL CANCER PATIENTS DURING THERAPY

IFN

-γSF

Cs/4

x105

cells

Baseline after 6° cycle Baseline after 2 cycle

Baseline after 2 cycle Baseline after 4 cycle

Fig.3 Circulating immune effectors specific for a selected panel of tumor antigens known to be expressed in RCC patients assessed by IFN-γELISPOT assay (interferon-γ-Enzyme Linked Immunosorbent Spot). All tests were performed using PBMC from whole blood samples. The number(enumerated as SFCs, spot forming cells) of TAA-specific circulating T cells was investigated during therapy.

Hazard ratio(95% CI)

P-value

DTH

Negative 1

Positive 0.42 (0.25-0.72) 0.002

Disease site

Skin, subcutis, lymph nodes 1

Visceral 1.83 (1.10-3.06) 0.021

DTH

Negative 1

Positive 0.41 (0.24-0.71) 0.002

Number of metastatic sites

1 1

2 or more 2.21 (1.32-3.17) 0.003

MULTIVARIATEANALYSIS two multivariate Cox models demonstrating a high prognostic value for DTH skin test positivizationafter treatment.