Immunomodulation in lymphomas

1. Sattva S. Neelapu, M.D. Department of Lymphoma and Myeloma UT MD Anderson Cancer Center Houston, TX Texas Fresh AIR October 23-24, 2014 Immunomodulation in lymphomas

2. Naked monoclonal Abs Radio-immunotherapy Target tumor Ab-drug conjugates Immunotoxins Lymphoma immunotherapy Vaccines Checkpoint antagonists Activate immune cells Stimulatory agonists CAR T-cell therapy

3. Why active immunotherapy for lymphoma? Results after non-myeloablative SCT OS PFS OS PFS Median F/U – 5 yrs Median F/U – 8 yrs Khouri et al, Blood 2008 Khouri et al, Blood 2012 Chemosensitive Chemorefractory PFS Khouri et al, Blood 2012

4. Tumor-infiltrating T-cells recognize autologous tumor cells in follicular lymphoma (FL) CD4 vs CD8 T cells CD3/CD20 Bulk tumor cells 12% 67% CD3 CD4 33% 10x CD3 CD20 After in vitrostimulation and expansion with tumor CD4 + Tumor CD4 alone 0.2% 42% GM-CSF IFN- TNF- TNF- pg / ml CD69 CD69 Tum T+Tum Tum T+Tum T T

5. FL1 - Peripheral blood and intratumoral T cells recognized mutated neo-antigens in FL FL – PB T cells at Dx 16 peptide screen FL – TIL at Dx HLA Restriction FL – TIL at Dx Mutated vs. Wild type

6. FL2 - Peripheral blood and intratumoral T cells recognized mutated neo-antigens in FL FL4 – PB T cells at Dx 20 peptide screen FL4 – PB T cells in remission FL4 – TIL at Dx P17 – MUC6 Q1821H HLA-DRB10701 Wt affinity (TATSFQTTTTYPT ) – 9.3 nM Mt affinity (TATSFHTTTTYPT) – 14.6 nM

7. FL3 - Peripheral blood and intratumoral T cells recognized mutated neo-antigens in FL FL5 – PB T cells at Dx 29 peptide screen FL5 – PB T cells in remission FL5 – TIL at Dx

8. Coinhibitory molecules on intratumoral T cells in FL

9. 3.50 17.30 65.82 PD-1 PD-1 CD4 CD8 PD-1+ CD4 & CD8 T cells are increased in the peripheral blood and tumor of FL 4.35 17.64 42.09

10. PD-1 expression in other lymphomas ** ** ** ** ** CD4 Tumor PBMC CD8

11. Pidilizumab + rituximab in relapsed FL patients Days 17 24 31 38 Rituximab If SD/PR/CR continue 8 more infusions every 4 wks Pidilizumab 1 2 3 4 n = 30 Days 1 29 57 85 113 CT/PET/BM 0 57 113 q3mo Core Bx0 14 113 Blood/PBMC 1,2 14 • Pidilizumab– iv infusion at 3.0 mg/kg/cycle q 4 weeks for up to 12 cycles • Rituximab- iv infusion at a dose of 375 mg/m2 weekly for 4 weeks

12. Pidilizumab + Rituximab in relapsed FL 66% ORR 52% CR rate 86% • ORR did not correlate with FLIPI1 or FLIPI2 score, amount of prior rituximab, prior chemotherapy, or duration of prior response (p>0.05) Westin, et al [Neelapu], Lancet Oncol, 2014

13. Time to response and duration of response Median time to response was 88 days Westin, et al [Neelapu], Lancet Oncol, 2014

14. Biomarker of response after pidilizumab and rituximab therapy in FL

15. PD-L1 status vs response to nivolumab in melanoma Topalian et al, N Engl J Med, 2012

16. PD-L1 expression on lymphoma tumors Brown et al, J Immunol 2003; Marzec et al, PNAS, 2008; Xerri et al, Hum Pathol, 2008; Andorsky et al, Clin Cancer Res, 2011; Chen et al, Clin Cancer Res, 2013

17. CD4+PD-1+ T cell subsets in FL Bcl6 - Tfh IL-21 - Tfh Relative mRNA level IL-4 - Tfh T-bet – Th1 IFN-g - Th1 GATA3 – Th2 RORc – Th17 Tfh – protumor Th1 - antitumor

18. Impact of PD-1+ T-cell subsets in FL αPD-1 Ab Tfh (PD-1hi) Tumor regression Th1 (PD-1int/lo) αPD-1 Ab Th1 (PD-1int/lo) No response or Tumor progression Tfh (PD-1hi) Neelapu, Oncoimmunol, 2014

19. CD4+ T-cell subsets in FL tumors (Tfh) (Th1) Westin et al, [Neelapu], Lancet Oncol, 2014

20. Teff-gene signature correlated with PFS after pidilizumab + rituximab therapy 41-gene signature in pretreatment tumors Signature average Dichotomization PFS according to 41-gene signature P=0.004 N = 18 patients Westin et al, [Neelapu], Lancet Oncol, 2014

21. Does the Teff-gene signature predict outcome after chemotherapy?

22. Teff-gene signature did not correlate with survival in FL patients treated with chemotherapy 41-gene signature in Dave et al study OS according to 41-gene signature Signature average Dichotomization P=0.139 N = 191 Dave et al, N Engl J Med 2004; 351:2109 Westin et al, [Neelapu], Lancet Oncol, 2014

23. Summary – Pidilizumab + rituximab in FL • Highly effective in relapsed follicular lymphoma with an ORR of 66% and CR of 52% • Compares favorably to previous rituximab retreatment data - ORR of 40% & CR of 11% - Davis et al, J Clin Oncol 2000 • High Teff-gene signature may suggest more Th1 vs. Tfh in the tumor and therefore, a pre-existing antitumor immune response and may be predictive of outcome after anti-PD-1 Ab therapy • Needs to be confirmed in larger trials • Teff-gene signature may also serve as a predictive biomarker for other immunotherapy agents Westin et al, [Neelapu], Lancet Oncol, 2014

24. T-cell dysregulation in FL Altered numbers T-cell dysregulation Th1/Tc1 (Exhaustion / Synapse) Teffs Tfh (Increased IL-4) Tregs Altered function / differentiation Tregs (Induction/Recruitment) Teff:Treg

25. Increased Treg recruitment in FLCross talk between Tumor, FDC, Tfh, Tregs Treg Treg CCL17 CCL22 Tum Tum Tum Tfh Tum Tfh IL-4 LT-a Tfh BAFF Tfh Tum Tum Treg CD40 – CD40L Tum Treg FDC Tfh Treg CXCL13 Follicle HEV Rawal et al [Neelapu], J Immunol 2013

26. Differentiation and effects of macrophages in FL Monocytes Blood vessel Lymph node Th1/Tc1 Tumor IFN-g Induction Tregs IL-10/TGF-b Tregs Suppression Macrophages Th1/Tc1 IL-4/IL-21 Angiogenesis Tfh Apoptosis Survival Growth Chemoprotection Genomic instability Tumor

27. CD8+T CAR T cells CD4+T • PD-1 Antibody • CTLA-4 Ab • LAG3 Ab M MΦ / MDSC M Tumor Tumor Tregs Combination immunotherapy for lymphomas • Co-inhibitory receptors / ligands • Vaccines • Novel immune stimulants • eg: 4-1BB Ab, OX-40 Ab • Rituximab • Ab-drug conjugates • Targeted therapies • OX-40 Antibody • TLR ligands Combination immunotherapy • CSF-1R Ab • S100A9 Ab

28. Reprogram the tumor microenvironment in follicular lymphoma?

29. Rituximab + Lenalidomide in frontline indolent NHL • Rituximab was administered once per cycle • Lenalidomide was administered for 21 / 28 days per cycle Fowler et al, [Neelapu] Lancet Oncol, 2014

30. Increased activated T-cell infiltration into tumorsRituximab + lenalidomide in FL CD4 CD8 PD-1 Pre On therapy Fowler et al, [Neelapu] Lancet Oncol, 2014

31. Activated T cells in peripheral blood in FL on lenalidomide PD-1+ CD4+ and CD8+ T cells Memory CD4+ and CD8+ T cells ? Compartmental shift due to altered chemokine gradients in tumor, improved immunogenicity of tumor, and better immune synapse formation On therapy Pre CD80 Fowler et al [Neelapu], Lancet Oncol, 2014

32. Acknowledgements Neelapu Laboratory Fuliang Chu Xiaoyun Cheng Elena Percivalle AnupamaGopisetty Seung Tae Lee Rakesh Sharma Former members MyriamFoglietta David Delgado SeemaRawal Department of Lymphoma, MDACC R. Eric Davis Jason Westin Luis Fayad Larry Kwak Nathan Fowler Jorge Romaguera Frederick Hagemeister Michelle Fanale Felipe Samaniego Rochelle Allen Min Zhang • Collaborators, MDACC • Department of Immunology • Chen Dong • TomohideYamazaki • Natalia Orozco • Luis Vence • Department of Biostatistics • Lei Feng • Veera Baladandayuthapani • Funding agencies • NIH (R01CA155143; R21CA143785) • Leukemia Lymphoma Society

34. Immunotherapy + Chemotherapy Combination in Aggressive LymphomasWindow design Tumor reduction Immunotherapy Chemo Immunotherapy with chemo-free window 1-2 cycles No tumor reduction Alternative Rx Chemo Neo-adjuvant Rx Assess response Induction Consolidation -Imaging - IgVH sequencing • Determine efficacy of immunotherapy alone • Study novel agents in front-line setting • Pre-selection of patients that will benefit from consolidation

35. Anti-PD-1 Ab monotherapy trials in NHL

36. Pidilizumab after auto-SCT in DLCL – Phase II • N = 66 • 3 doses of pidilizumab at 1.5 mg/kg Q 6 wks starting 1-3 months after SCT • ORR of 51% in patients with measurable disease after SCT • PFS of 72% and OS of 85% at 16 months Armand, et al, J ClinOncol, 2013