Tumour Immunotherapy:

Harnessing Immune Responses to Cancer

Dr Alasdair Fraser
Sylvia Aitken Research Fellow Section of Experimental Haematology, Glasgow Royal Infirmary

Tumour Immunotherapy: possible?

It would be as difficult to reject the right ear and leave the left ear intact, as it is to immunize against cancer.
W.H.Woglom, Cancer Research (1929)

Tumour Immunotherapy: questions

Can immune stimulators combat cancer? Which forms of immunotherapy can be used?

Is vaccination effective against established tumours?

Can anti-tumour responses be generated in vitro? Can in vitro responses translate into in vivo effects?

What barriers are there to development of effective IT?

How can we harness the immune response?

Tumour cell present

Ab / ADCC / cytokine attack

Th

Th cells educate other T/B cells

CTL CTL

Broken up to release antigens

APC recruits T cells able to recognise tumour antigens

CTL recognise and destroy other tumour cells

APC

Passive immunotherapy

Adminstration of monoclonal antibodies which

target either tumour-specific or over-expressed antigens.

Kill tumour cells in a variety of ways:

M NK

Apoptosis induction

Complementmediated cytotoxicity

ADCC

Conjugated to toxin / isotope

Antibody-based immunotherapy
Name
Rituxan Herceptin Campath Erbitux Avastin

Malignancy
B cell lymphoma Breast, lymphoma B-CLL Colo-rectal Colo-rectal

Target CD20 Her-2/neu CD52 EGFR VEGF Target CD33

(calicheamicin)

Name
Mylotarg Bexxar

Malignancy
AML B cell lymphoma

CD20
(131In / 90Y)

Effects of antibody therapy

Rituxan and Campath often used to control disease with fewer side-effects than chemotherapy. Herceptin is the only monoclonal which is effective against solid tumours.

Immunotoxins still not commonly used due to problems with penetration and specificity. Bexxar trial in 2005 reported 59% of BCL diseasefree 5 years after a single treatment.

Active immunotherapies

Cytokines-

IL-2 / IFNs / TNF

Vaccination strategies-

single peptide multiple peptides HSP complexes whole tumour cells

Cell-based therapies -

tumour-specific CTL tumour-derived APC DC priming

Effective therapies
Complete regression of a large liver metastasis from kidney cancer in a patient treated with IL-2.

Regression is ongoing seven years later

Rosenberg (2001) Nature, 411;381-4

Other Immunostimulants

BCG (bacterial preparation) injected intra-tumourCan be effective for early-stage bladder cancer. IFN was gold standard for CML until recent introduction of Gleevec (imatinib) affects MHC Class I expression and cell division. TNF effective in vitro, but too toxic to use in patients (pyrexia / -algias).

Peptide vaccines

Single peptides:
Melanoma most thoroughly covered (Phase III).
bcr-abl fusion peptide trial underway. Naked DNA prime-boost also trialled.

Tumour escape through selection of nonantigen variants selected.

Multiple peptide vaccines

Microarray data identified new candidate Ags. Breadth of IR correlates with improved survival.

Peptide vaccination

Improved effects of vaccination when given with adjuvants (eg CpG). Immunostimulators also accentuate response (GM-CSF, IL-2, IL-12).

Alternatively, can target inhibitory receptors to increase anti-tumour responses (CTLA4).

Effectiveness of multiple antigen vaccines

Patient with multiple metastatic melanomas treated with tyrosinase / gp100 / MART vaccine

Heat Shock Proteins for Therapy

HSPs protect the delicate functions of the cell.

Heat Shock Proteins (HSP70)

NH4

COOH

ATPase

peptide-binding domain

tumour peptide sequence

How is the anti-tumour effect produced?

Hsp70 or gp96 / peptide complex

CTL

NK
tumour peptides presented to CTL / NK cells via HLA Class I

TAP system
CD91
endocytosis receptor
Transporter Associated with Peptide processing

APC

Survival rates in a model of lymphoma

Immunized with PBS () 40 g HSP70 from liver () 20 g HSP70 A20 cells () 40 g HSP70 A20 cells ()

Vaccination using HSP complexes

Peripheral blood from CML patient

Isolate HSP complexes from tumour cells

Develop DC

Load mdDC with HSP complexes in vitro

Co-culture with patient T cells and expand effectors for infusion into patient

Immunize patient directly with tumour antigenprimed mdDC

Using whole cells for immunization

Killed tumour cells effective vaccinating agents in mouse

models- not effective in humans.

Novel methods can enhance immunogenicity of tumour cells.

CTL CTL

CTL
CTL

CTL

CTL

tumour

tumour

tumour tumour

tumour

tumour

Allogeneic TransplantThe Original Immunotherapy.

Allogeneic bone marrow or stem cells

repopulate patient with entirely new immune system (matched to donor closely)

Relatively crude- associated with significant

morbidity / mortality

Modification using T cell depletion or RISCT

Quiescent tumour stem cell Proliferating tumour cells

relapse Development of resistance to therapy

Tumour therapy
Diagnosis No Donor Available

MRD established

Matched allodonor

peptide vaccine (single Ag) HSP vaccine (multiple Ag) Ag-specific CTL leukaemic DCs ex-vivo Ag-primed DC IFN/ IL-2

Myeloablative alloSCT or RISCT + DLI

Lasting remission / cure

Copland et al (2005) Cancer Immunol. Immunother. 54:297

Dendritic cell therapy

Dendritic cells are key components of

the adaptive immune response

APC function with ability to direct IR

(activation/tolerance)

Present in peripheral blood as

circulating subtypes (<0.4% TWC)

Dendritic cell sources for therapy

Haemopoietic Stem Cell Common Myeloid Progenitor Circulating Myeloid DC

Monocyte CD34+ Stem Cell

Ex vivo GM-CSF + Flt-3 + TNF Ex vivo GM-CSF + IL-4

Immature mdDC
Maturation factors

Mature mdDC

CD34+ DC
Copland et al (2005) Cancer Immunol. Immunother. 54:297

DC-based therapy
DC developed from patient monocytes Pulsed with target antigens
Currently in Phase II and Phase III trials for melanoma, prostatic carcinoma and lymphoma.

Stimulated to maturation and inoculated back into patient

Tumour-specific immune responses measured

Results of current clinical trials

Wide variation in markers of response:

Evidence of IR through dth, CD4 prolifn., isolation of tumourspecific CTL in periphery and detection of TIL.

How do these reflect true responses to therapy?

Peptide vaccine trials
175 patients total 7 patients responded

Tumour vaccine trials

142 patients total 6 patients responded

DC vaccine trials
257 patients total 16 patients responded

(4.0%)

(4.2%)

(6.2%)

Total for all cancer vaccine studies = 3.8%

Immunotherapy of cancer in action

PTLD- Post-transplant lymphoproliferative

disease

Caused by EBV recrudescence during immunosuppression.

Current chemotherapy toxic. Novel immunotherapy approach appliedBank of EBV-specific T cell clones collected from dozens of blood donors, expanded and stored (currently covers ~95% of all UK MHC haplotypes)

Effects of matched EBV-specific CTL therapy

Haque et al. J Immunol (1998). 160, 6204-6209

EBV Copy Number/Million Cells

1600000 1400000 1200000 1000000 800000 600000 400000 200000 0

Pre 1 st Post 1st nd Pre 2 Post Pre 3 2nd rd post 3rd 1 wk/ 4 mn 5 mn 8 mn 4th th/ 4t h th/ 4t h th/ 4t h

EBV load after allogeneic CTL infusions

Sample Timepoint

Defining whether malignancies are suitable for Immunotherapy

Chronic Myeloid Leukaemia Multiple Myeloma

High tumour burden Effective therapy (IM) Intact immune response Several candidate antigens
identified

Low tumour burden Adequate therapies Impaired immune response Few candidate antigens
identified

Strong potential for IT

approaches

Many factors (eg. age)

reduce effectiveness of IT.