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.