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Dado el carácter y la finalidad exclusivamente docente y eminentemente ilustrativa de las explicaciones en la clase de esta presentación, el autor se acoge al artículo 32 de la Ley de la propiedad intelectual vigente respecto al uso parcial de obras ajnas com imágenes, gráficos u otro material contenidas en las distintas diapositivas.

Todas las imágenes presentadas se incluyen como citas necesarias para ilustrar las explicaciones de esta clase.

•  No conflict with commercial interests or companies, except in what corresponds to educational talks sponsored by some companies and recent participation (S-5) as member of an Oncology Advisory Board of Grifols.

•  Investigator of the CART19-BE-01 trial, evaluating the role of ARI-0001 cells in patients with B-cell malignancies. Approval dossier in preparation, but I do not benefit personally (or economically) from it.

Conflicts of interest

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Emerging Immunotherapies in Cancer

- TABLE III: IMMUNO ONCOLOGY THERAPEUTIC STRATEGY–

Future Directions for CAR-T Therapy

Manel Juan MD, PhD. Head of Immunotherapy Section Servei Immunologia - CDB Hospital Clínic de Barcelona / H Sant Joan de Déu / BST Thursday, Sept 26th 2019 (12:15 – 12:35) Casa de Convalescència,

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scFv

Signaling Domains

TM

T-cell

?

Concept Product = Drug

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Possible “future directions” for CARs

1. As a immunotherapeutic tool:

2.  As a product - drug.

3. As “a health concept”

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Cytotoxic lymphocyte

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T-cell Cytoxicity: TA recognition & more

Ag

TcR

1 3

2

HLA

T-cell Cytoxicity: TA recognition & more

Ag TcR 1

3

2

HLA

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T-cell Cytoxicity: TA recognition & more

Ag TcR 1

3

2 HLA

Cytotoxicity

Proliferation/ Cytokines

Survival

Tumor Cell 1.- C

ytolyti

c Effe

ct

2.- Proliferation / Production of Cytokines

3.- Survival

Cytotoxic T-cells

Esquema del autor

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Ag receptors for cytotoxic lymphocytes

Humphries C, Nature 504, S13-S15 2013

CAR = Chimeric Antigen Receptor

Sònia Guedán Carrió & Anna Boronat Barado Chapter 6. Monografías SEI – Elsevier. “Inmunoterapia antitumoral con linfocitos genéticamente modificados (CAR): una realidad con futuro”

Antibody TcR Complex

1ª description “T-bodies” by Prof Zelig Eshhar (1995), Weizmann Institute of Science, Israel.

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scFv

Transducting Domains

(CD3ζ, CD28, …)

TM

CARs in T-cells = CARTs

T-cell “Cytotoxic”

14 Movieprovided by Dr. Beatriz Martin

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Tisa-cel (Kymriah) & axi-cel (Yescarta): Results in LDCGB R/R

Schusteretal.NEJM2018Zuma1

•  Phase 2, JULIET & ZUMA-1.

Lockeetal.LancetOncology2018

Juliet

FDA / EMA approval of CART19 treatment (T-cell with anti-CD19 CAR):

August-October 2017 / July 2018

USA: Novartis ALL & DLBL <25 y: 475,000 $ / patient response ) NICE = £282,000 per patient (Sep 5, 2018) 320 m€ Spain : 320 m€ (160 + 160) It is anticipated that soon for adult ALL

Kite NHL DLBCL: USA 373,000 $ / patient Spain: 320m€ (140 + 140)

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18 FULL OF LIFE v, 66 yo (2011), in his RV parked at his home in New Jersey

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CODING SEQUENCE OF CAR ANTI-CD19

CGCCTTTT………… ……. ...TGTCGTGA

ATGG…. ...GGCCG

CACTCCCA.…Gly+Ser... Gly+Ser……. GAGCTGA

CACCACG……….. ……..……TTTACTGC

AAACGGGG……….. ……AAGGAGGA

AGAGTGAA…

…CTCGCTAA

V L

V H

CD8a (hinge +

transmembrane)

scFv (A3B1) CD137 / 4-1BB (Signaling domain)

CD3ζ (Signalling domain)

CD8a (signal

peptide)

LENTIVIRAL SEQUENCES

LENTIVIRAL SEQUENCE

S

EF-1 PROMOTER

gDNA / lentivirus

mRNA

CAR Protein (transmembrane)

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Possible”future directions” of CARs 1. As a immunotherapeutic tool:

-  Different structures: (a) scFv - Affinities - Specificities (b) Signaling (increase function vs reduce SAE)

(c) Combinations: Dual, iCAR, 4G, ... -  Cells:

(i) CART: total T-cells, subpopulations, ... (ii) CAR-NK (iii) CAR-?

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Basado en: Sònia Guedán Carrió y Anna Boronat Barado Capítulo 6. Monografías SEI – Elsevier. “Inmunoterapia antitumoral con linfocitos genéticamente modificados (CAR): una realidad con futuro”

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CAR evolution

Casucci & Bondanza (2011). J Cancer 2011; 2:378-382

Cytotoxicity

1G

Cytotoxicity

Proliferation/ cytokine production

2G

Survival

3G

Classic CARs Current CARs Prototype CARs

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CAR evolution

TRUCKs

T cells Redirected for Universal Cytokine Killing

4G (armored CARs)

Based on Casucci & Bondanza (2011). J Cancer 2011; 2:378-382

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CARs: 4th GENERATION (II) DUAL CARs COMBINATED

THERAPY (MoAb) ARMORED CARs

iCARs

Cho et al., 2018, Cell 173, 1–13

Possible “future directions” for CARs

2.  As a product ‒ drug: -  Criopreserved vs fresh product. -  Autologous (including iPSC) vs allogenic

(UCART) -  Lentivirus, gene editing (SB, TALENs,

CRISPR, …) -  Several growing protocols defining cell

profiles of cells.

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From TILs to T-cell modified therapy

PATIENT

LYMPHOCYTES

Blood

Leukoapheresis T-cell expansion by CD3 + CD28 beads

lymphocytes against tumor

Monitoring

Lymphocyte transduction

* *

UNDER GMP CONDITIONS

T-cell infusion Cryopreservation

Cell expansion

UCARs: 4th GENERATION (III)

UCART

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Tumor cell

TAA (TSA) 1.- C

ytolyti

c effe

ct

2.- Proliferation / Cytokine 3.- Survival

1st signal

2n & 3rd signal Cytotoxic T-cell

scFv

CD3ζ

CD137 (4-1BB)

CD8hinge & TM

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CELL CANCER IMMUNOTHERAPY

CARTs

&

“CELLbots” (engineered

T-cells)

Knowledge + Infrastructures (Clean Rooms) + Rules/Quality

Figure made by author

NK

TA

Vaccines

TcR

SCT/ DLIs Allo-

recognition

TILs

DCs

Celltherapy=>A

dvancedtherapy

product=“Drug

“

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Possible “future directions” for CARs

3.  As “health concept”: -  Drug vs transplantation (or different

equivalent process) -  Commercial vs Academic -  From the bench the bedside vs

centralized centers for production of Infusion

Scheme adapted by author fom the list of

Diamonds 50,000 €

5

Californium 252 30,000,000 €

3

CART19 1,000,000,000 € (3000 patients?)

2 1

Antimatter 60,000,000,000,000 €

Plutonium 4,000 €

7

Gold 34 €

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Rhino horn 110 €

13

Anti-C5 20,000 €

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How much is 1 g?

“Bussiness insider”, September 2014

The “most expensive” things in our world.

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Pharma(vsAcademic)CARTs(SWOTanalysis)

•  Distancebetweenhospitalandmanufacturingcenter.

•  HighPrice/patient.

•  Afterapprovalproductmaintainedwithoutchanges:slowimprovements.

•  AcademicCARTproposals.

•  Newproductsbyevolutionoftheknowledge.

•  Justfewindications.

•  Accreditation:“Pharma”decidesinsomeway???!!!

•  Centralizedapproval(FDA,EMA,…):responsibleofhomogeneityofproduct.

•  Specificityanddocumentationinindication

•  Easytobeacceptedbythepatient/family.

•  “Hierarchical”structureoftheteam

•  Presentlimitationsofothercancertherapies.

•  Todefineallogenicproducts(universalCARTs).

•  Tostabilizetheoptionofcellularimmunotherapy.

W

T

S

O

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Overallresponse

ALL CLL NHL

81%/76%

50%/26%

40%/19%

SchubertML/SchmittMHumGeneTher.2016Jul31

SuccessofCARs:Patientsnnearto1000

Commertialdevelopment Academicdevelopment

“Take home messages” and discussion Academic Cell Immunotherapy approaches are options of treatment for patients (?): •  By now “Hospital exemption” is the only way to use them

(otherwise, cost for approval is beyond “academic” economical options). Medical laboratories as “producers”.

•  Academic proposals should allow a faster evolution of treatments (lower global budgets, no need of “profits” and “returns of inversion”, … ).

•  Direct relation and “internal consistency” between “public research grants” and “public health system”.

•  Loss of the conditionings of the “pharma lobbies”: rules for autologous cell treatments nearer to SCT than to drugs, ...

•  Production can be done near to the patient!!!

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Academic CART products are possible!!! • And maybe the main option for treating “rare”

tumours (paediatric) and make them accessible for our “European Health Systems”

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CELL CANCER IMMUNOTHERAPY

CARTs

&

“CELLbots” (engineered

T-cells)

Knowledge + Infrastructures (Clean Rooms) + Rules/Quality

Figure made by author

NK

TA

Vaccines

TcR

SCT/ DLIs Allo-

recognition

TILs

DCs

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Thank you! Any question? mjuan@clinic.ub.es