Human Programmed Cell Death-1 Research Articles

Abstract 5045: Pharmacokinetics and pharmacodynamics of MEDI0680, a fully human anti-PD1 monoclonal antibody, in patients with advanced malignancies

Abstract Background: MEDI0680 (AMP-514) is a humanized immunoglobulin gamma 4, kappa (IgG4κ) monoclonal antibody (mAb) specific for human programmed cell death-1 (PD-1), developed for the treatment of cancer. The primary objectives of this analysis were to (a) describe the pharmacokinetics (PK) of MEDI0680 and quantitate the impact of patient/disease characteristics on PK variability (b) to compare body weight (WT)-based and fixed dosing regimens of MEDI0680 and (c) to characterize PK-pharmacodynamic (receptor occupancy) relationship. Methods: A total of 905 serum concentration records from 58 patients in Phase 1 study (D6020C00002) designed to evaluate safety, tolerability and PK following 0.1, 0.5, 2.5, 10, and 20 mg/kg every 3 weeks (Q3W), every 2 weeks (Q2W) or weekly doses (QW) as intravenous (IV) infusion of MEDI0680 were included in this analysis. The population PK analysis was performed using a non-linear mixed effects modeling approach in NONMEM (version 7.2) software. Impact of patient demographics, clinical indices and biomarkers on PK parameters were explored. The appropriateness of the final model was tested using visual predictive check (VPC). A sequential PK-PD analysis was performed using receptor occupancy (RO) data from 35 subjects. Results: MEDI0680 PK profiles were best described using a 2-compartment model with linear clearance. The clearance (CL), volume of distribution (Vc) were 0.27 L/day, 5.07 L with a modest between-subject variability of 30% and 19%, respectively. None of the evaluated covariates showed any impact on PK parameters except a minor (not clinically relevant) impact of body weight on volume of distribution. VPC results demonstrated good predictability of the final population PK model. A direct Emax model described the PK-PD relationship of MEDI0680. The estimate of EC50 was approximately 9.3 µg/mL. PK/PD simulations indicate that following 20 mg/kg Q2W dose, >90% receptor occupancy can be maintained in all subjects. Based on preclinical/clinical PK, PD, and safety data, a dose of 20 mg/kg Q2W was selected for phase 2 studies. Conclusions: A population PK model of MEDI0680 was developed and validated. Modeling results indicate no need for dose adjustment based on patient/disease characteristics. Similar PK is expected following both WT-based and fixed dosing regimens. PK/PD findings support the dose of 20 mg/kg Q2W. Clinical studies are ongoing in various tumor types. Citation Format: Xuyang Song, Xizhe Gao, Bo Zheng, Chelsea Black, Matthew Gribbin, Joyson Karakunnel, Lorin Roskos, Rajesh Narwal. Pharmacokinetics and pharmacodynamics of MEDI0680, a fully human anti-PD1 monoclonal antibody, in patients with advanced malignancies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5045. doi:10.1158/1538-7445.AM2017-5045

Structure-guided development of a high-affinity human Programmed Cell Death-1: Implications for tumor immunotherapy

Programmed Cell Death-1 (PD-1) is an inhibitory immune receptor, which plays critical roles in T cell co-inhibition and exhaustion upon binding to its ligands PD-L1 and PD-L2. We report the crystal structure of the human PD-1 ectodomain and the mapping of the PD-1 binding interface. Mutagenesis studies confirmed the crystallographic interface, and resulted in mutant PD-1 receptors with altered affinity and ligand-specificity. In particular, a high-affinity mutant PD-1 (HA PD-1) exhibited 45 and 30-fold increase in binding to PD-L1 and PD-L2, respectively, due to slower dissociation rates. This mutant (A132L) was used to engineer a soluble chimeric Ig fusion protein for cell-based and in vivo studies. HA PD-1 Ig showed enhanced binding to human dendritic cells, and increased T cell proliferation and cytokine production in a mixed lymphocyte reaction (MLR) assay. Moreover, in an experimental model of murine Lewis lung carcinoma, HA PD-1 Ig treatment synergized with radiation therapy to decrease local and metastatic tumor burden, as well as in the establishment of immunological memory responses. Our studies highlight the value of structural considerations in guiding the design of a high-affinity chimeric PD-1 Ig fusion protein with robust immune modulatory properties, and underscore the power of combination therapies to selectively manipulate the PD-1 pathway for tumor immunotherapy.

Nivolumab (ONO-4538/BMS-936558) as salvage treatment after second or later-line chemotherapy for advanced gastric or gastro-esophageal junction cancer (AGC): A double-blinded, randomized, phase III trial.

2 Background: Recent clinical trials have established 1st and 2nd line chemotherapy as the standard treatment for advanced gastric or gastro-esophageal junction cancer (AGC). However, prognosis of AGC is still poor. Nivolumab (ONO-4538/BMS-936558) is a human monoclonal IgG4 antibody which blocks the human programmed cell death-1 (PD-1) receptor. We evaluated the efficacy and safety of nivolumab as salvage treatment after failure of the standard chemotherapy for AGC. Methods: 493 patients aged ≥ 20 years with ECOG PS 0-1 and unresectable advanced or recurrent AGC who had failed two or more previous chemotherapy regimens were randomized in a 2:1 ratio to receive 3 mg/kg nivolumab (N=330) or placebo ( N=163) every 2 weeks until unacceptable toxicity or disease progression. Primary endpoint was overall survival (OS) in Intention-to-Treat population. This trial is registered in ClinicalTrials.gov (NCT02267343). Results: As of the data cut-off on Aug 13th2016, 5.6 months after last patient randomized, median OS was 5.32 months with nivolumab versus 4.14 months with placebo (hazard ratio [HR], 0.63; 95% confidence interval [CI], 0.50-0.78; p<0.0001), and OS rates at 6 and 12 month were 46.4% versus 34.7% and 26.6% versus 10.9%, respectively. The overall response rate (ORR) was 11.2% (95% CI, 7.7-15.6) with nivolumab versus 0% (95% CI, 0.0-2.8) with placebo (p<0.0001). Median progression-free survival (PFS) was 1.61 months with nivolumab versus 1.45 months with placebo (HR, 0.60; 95% CI, 0.49-0.75; p<0.0001). Grade ≥ 3 drug-related adverse events (AEs) occurred in 11.5 % of nivolumab and 5.5 % of placebo; 2.7% and 2.5%, respectively, discontinued of study treatment due to drug-related AEs (any grade). Conclusions: Nivolumab was effective as the salvage treatment for pretreated AGC with significantly improved OS, PFS and ORR compared to placebo. Funding:Ono Pharmaceutical Co., Ltd. and Bristol-Myers Squibb. Clinical trial information: NCT02267343.

High-resolution crystal structure of the therapeutic antibody pembrolizumab bound to the human PD-1.

Pembrolizumab is an FDA-approved therapeutic antibody that targets the programmed cell death-1 (PD-1) to block the immune checkpoint pathway for the treatment of various types of cancer. It receives remarkable attention due to the high degree of efficacy. Very recently, the crystal structure of the Fab fragment of pembrolizumab (PemFab) in complex with the extracellular domain of human PD-1 (PD-1ECD) was reported at a resolution of 2.9 Å. However, this relatively low-resolution structural data fails to provide sufficient information on interfacial water molecules at the binding interface that substantially contribute to affinity and specificity between the therapeutic antibody and target. Here, we present the independently determined crystal structure of the Fv fragment of pembrolizumab (PemFv) in complex with the PD-1ECD at a resolution of 2.15 Å. This high-resolution structure allows the accurate mapping of the interaction including water-mediated hydrogen bonds and provides, for the first time, a coherent explanation of PD-1 antagonism by pembrolizumab. Our structural data also provides new insights into the rational design of improved anti-PD-1 therapeutics.

1072P - A Phase 1 first-in-human study of MEDI0680, an anti-PD-1 monoclonal antibody (mAb) in adult patients (pts) with advanced tumors

Programmed cell death-1 (PD-1) inhibits T-cell activation. Blocking the PD-1/programmed cell death ligand 1/2 (PD-L1/2) axis has an acceptable safety profile, induces antitumor responses, and provides clinical benefit across tumors. MEDI0680 is a humanized IgG4&kgr; mAb specific for human PD-1 that blocks interaction with PD-L1/2. This is an ongoing Phase 1, multicenter, open-label, first-in-human, dose-escalation and expansion study of single-agent MEDI0680 in immunotherapy-naïve pts with advanced solid tumors. Primary objectives are safety/tolerability and maximum tolerated dose (MTD). Secondary objectives include pharmacokinetics (PK), pharmacodynamics (PD) and antitumor activity (modified RECIST v1.1). As of 2 Nov 2015, 58 pts have enrolled across 9 cohorts (0.1–20 mg/kg given Q3W, Q2W, QWx2 then Q2W, or QWx4 then Q2W). MTD was not reached. Treatment-related AEs occurred in 46 pts; most common (>10%) were fatigue (21%), nausea (14%) and arthralgia (14%). Related Grade 3/4 AEs occurred in 10 pts; most common (>1 pt) were anemia, arthralgia and increased AST (3% each). 2 pts discontinued due to related AEs: pyrexia in 1 pt; and increased AST, myasthenia gravis and myositis in 1 pt. There were no Grade 5 related AEs. MEDI0680 had a linear PK profile with dose-proportional increases in peak serum concentration. Median PD-1 receptor occupancy on CD3+ T cells was ≥70% after 1 cycle of 10 or 20 mg/kg Q2W. Increased percentages of Ki67 + , ICOS+ and HLA-DR+ T cells; increased levels of plasma IFNγ; and enhanced intra-tumor gene expression for these factors were seen after treatment, demonstrating biological activity of MEDI0680. Of 51 evaluable pts, 9 (18%) had an objective response (8 had renal cancer or melanoma), including 1 (2%) complete response (renal cancer). 14 (28%) pts had stable disease as their best response. The recommended dose is 20 mg/kg Q2W, based on PK, PD, safety and efficacy. MEDI0680 has an acceptable safety profile, with preliminary signs of efficacy. A Phase 1 combination study with durvalumab to test the concept of complete PD-1/PD-L1 axis blockade is ongoing in advanced solid tumors.

Abstract 1484: Combined treatment with anti-LAG-3 and anti-PD-1 fully human monoclonal antibodies inhibits tumor growth in immunocompetent double-humanized LAG-3/PD-1 mice

Abstract Lymphocyte-activation gene 3 (LAG-3) receptor is expressed on activated CD4 and CD8 T cells, γδ T cells, Treg, NK, NKT, B and plasmacytoid dendritic cells. LAG-3 binds to major histocompatibility complex class II (MHC II) and delivers inhibitory signals that regulate T cell proliferation and cytokine production. LAG-3 blockade augments T cell proliferation and activation. Programmed cell death 1 (PD-1) receptor upon binding to its ligands PD-L1 (B7-H1; CD274) and PD-L2 (B7-DC; CD273) also delivers an inhibitory checkpoint signal that is critical for the establishment and maintenance of peripheral T cell tolerance. PD-1 signaling plays a critical role in the tumor microenvironment by allowing tumors to escape immune surveillance. We tested in vivo activity of anti-mouse PD-1 and anti-mouse LAG-3 antibodies in several preclinical syngeneic tumor models and showed that combination treatment with both antibodies resulted in an additive anti-tumor effect compared to either single antibody treatment. TaqMan analysis in the MC38 tumor model demonstrated CD8+ T cell expansion in both the draining lymph nodes and spleens of mice in the combination treatment group. Anti-human LAG-3 antibody is a fully human monoclonal antibody developed for cancer immunotherapy. It binds with high affinity to human LAG-3 and blocks LAG-3/MHC II interaction. Fully human monoclonal antibody REGN2810 binds with high affinity to human PD-1 and blocks PD-1 interaction with PD-L1 and PD-L2. Double humanized LAG-3/PD-1 mice were engineered using VelociGene® technology to replace the extracellular domains of mouse Pdcd1 and Lag3 genes with the corresponding regions of human PD-1 and human LAG-3 genes. To validate humanized protein expression, we examined PD-1 and LAG-3 protein expression on T cells after anti-CD3/anti-CD28 antibody stimulation. We confirmed binding of human LAG-3 and PD-1 to the corresponding mouse ligands by cell adhesion assay for human LAG-3 and mouse MHC II interactions and by SPR-Biacore for human PD-1 and mouse PD-L1 interactions, respectively. Combination of REGN2810 and anti-hLAG-3 antibodies in MC38.ova tumor model in double humanized LAG-3/PD-1 mice, which allows testing of clinical antibodies that do not cross to mouse receptors, demonstrated improved efficacy, including reduced tumor growth and improved survival, compared to REGN2810 and anti-hLAG-3 monotherapies. Robust anti-tumor efficacy of REGN2810 and anti-hLAG-3 combination in preclinical setting supports their clinical development as a combination cancer immunotherapy. Citation Format: Elena Burova, Omaira Allbritton, Chandrika Taduriyasas, Venus Lai, William Poueymirou, Nicholas Papadopoulos, Douglas MacDonald, William Olson, Markus Mohrs, Ella Ioffe, Gavin Thurston. Combined treatment with anti-LAG-3 and anti-PD-1 fully human monoclonal antibodies inhibits tumor growth in immunocompetent double-humanized LAG-3/PD-1 mice. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1484.

The Long PD-1 Receptor Binding Kinetics of Nivolumab May Increase Efficacy of Subsequent Therapy in Relapsed and Refractory Multiple Myeloma Patients

Introduction: Programmed cell death-1 (PD-1) signaling suppresses the antigen driven activation of T cells upon interaction with its ligands PD-L1 and PD-L2. The PD-1/PD-L1 axis is thought to mediate the resistance of multiple myeloma to conventional therapy (Tamura 2013; Paiva 2015). Nivolumab, a fully human IgG4 monoclonal PD-1 receptor-blocking antibody, has shown clinical activity in a variety of tumor types. Nivolumab has demonstrated a prolonged receptor binding kinetic lasting >100 days that may lead to an efficacy or toxicity signal in the post-treatment period. We therefore evaluated the response of patients with relapsed or refractory multiple myeloma to additional myeloma therapy received within 3 months of the end of nivolumab administration.Methods: The preliminary results of an open-label study that treated patients with relapsed or refractory multiple myeloma using a dose escalation design (1 mg/kg and 3 mg/kg) of nivolumab administered every 2 weeks have been reported previously (NCT01592370, Lesokhin et al., ASH 2014). Here we will report responses and safety data using standard criteria to the next line of therapy received immediately after nivolumab.Results: 8 patients with multiple myeloma from the original open label study were treated at Memorial Sloan Kettering Cancer Center. The disease characteristics and efficacy results are shown in the table. 1 of 8 patients (12.5%) experienced progression while on therapy manifested by development of an isolated plasmacytoma. The patient received radiation and then resumed and completed 97 weeks of therapy with nivolumab. He is currently off therapy without any evidence of disease at 48 weeks after cessation of nivolumab. 3 of 8 patients (37.5%) achieved a partial response to the next line of treatment after nivolumab. 2 of 8 patients (25%) who were exposed and refractory to immunomodulatory drugs (IMiDs) received single-agent, low-dose lenalidomide as the next line of therapy and achieved stable disease lasting approximately 100 days after cessation of nivolumab followed by disease progression. 1 of 8 patients (12.5%) experienced progressive disease despite the next line of therapy, and 1 of 8 patients (12.5%) received an experimental treatment as the next line of therapy and was therefore not evaluable. No new drug-related adverse events occurred in the 3 months after completing treatment with nivolumab. Overall, 6 out of 8 patients derived clinical benefit from post-nivolumab therapy, an unusually high response rate for this population.Conclusions: In a small cohort of patients with relapsed and refractory multiple myeloma, evaluation of response kinetics after cessation of nivolumab supports the notion that long PD-1 receptor binding kinetics may increase the efficacy of subsequent therapy without added toxicity. Larger studies are needed to confirm and expand our findings.TablePatient Characteristics and EfficacyAgeSexISSCytogeneticsPrior LinesASCTIMiD EIMiD RProt EProt RBest Response to NivolumabNext Line of Standard TherapyBest Response to Next Line52M1S3YYYYYSDCarfilzomib, Cyclophosphamide, DexamethasonePR32M1S3YYYYYSDNone*N/A80F1S1NYNNNSDLenalidomidePR52F1I3YYYYNSDLenalidomideSD62M1H1YYNYNPDCyclophosphamide, Bortezomib, DexamethasonePR58M2S5YYYYYPDLenalidomideSD57F1S3YYNYYPDNone^N/A59F1S3YYYYYPDLenalidomide, Bortezomib, DexamethasonePDISS=international staging system; S=standard cytogenetics; I=intermediate cytogenetics; H=high risk cytogenetics; ASCT=autologous stem cell transplant; IMiD E=IMiD exposed; IMiD R=IMiD refractory; Prot E=proteosome exposed; Prot R=proteosome refractory; PD=progressive disease; SD=stable disease; PR=partial response*Patient completed 97 weeks of nivolumab and continues untreated without any evidence of disease at 48 weeks after cessation of therapy^Patient received treatment on an experimental protocol DisclosuresFunt:Kite Pharma: Equity Ownership. Off Label Use: Nivolumab is FDA approved for use in patients with metastatic melanoma but not in patients with multiple myeloma. . Page:Celgene: Consultancy. Landgren:Bristol-Myers Squibb: Honoraria; Celgene: Consultancy; BMJ Publishing: Consultancy; Bristol-Myers Squibb: Consultancy; BMJ Publishing: Honoraria; Medscape: Consultancy; Medscape: Honoraria; Celgene: Honoraria; International Myeloma Foundation: Research Funding; Onyx: Honoraria; Onyx: Research Funding; Onyx: Consultancy. Borrello:Celgene: Research Funding. Lesokhin:Bristol Myers Squibb: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Aduro: Consultancy; Genentech: Research Funding; Efranat: Consultancy.

Presence of PD-1 Expressing T Cells Predicts for Inferior Overall Survival in Newly Diagnosed Multiple Myeloma

Background: Programmed cell death 1 (PD-1) protein downregulates T cell activation and is related to immune tolerance. PDL1 up regulation, T cell infiltration, and T cell exhaustion are features, which suggest susceptibility to PD-1 blockade antibodies. Blockade of PD-1 or its ligand PD-L1 has shown promising responses in several malignancies. Although little clinical activity has been seen in patients with relapsed multiple myeloma (MM), the role of the PD-1 pathway and T cell exhaustion in newly diagnosed MM has not been explored.Objective: To determine whether T-cell infiltrate or expression of PD-1 correlates with clinical features and prognosis among patients with newly diagnosed multiple myeloma.Methods: We screened a clinically annotated database of 341 patients seen at MSKCC between 1998 and 2012 that had Multiple Myeloma, received a bone marrow transplant and were consented to a biospecimen research protocol for availability of pre-treatment bone marrow specimens. A total of 64 bone marrow biopsy specimens were identified. Immunohistochemistry (IHC) was performed in formalin-fixed paraffin-embedded specimens using an anti human CD3 monoclonal antibody (mAb) (Dako, Clone F7.2.38) and an anti human PD-1 mAb (Cell Marque, catalog #315M-95). CD3 and PD1 IHC staining were graded as negative (<5% for CD3, < 1% for PD1), or positive (≥5% for CD3, ≥1% for PD1). Correlative analyses were performed between CD3/PD1 expression and clinical outcome using the following parameters: International Staging System (ISS), cytogenetic risk, progression free survival (PFS), overall survival (OS), and response to treatment. Groups were compared by Fisher's exact test. OS and PFS were assessed by Cox regression and estimated by Kaplan-Meier methods.Results: 23 specimens (36%) were CD3 positive and 10 specimens (16%) were PD-1 positive. All PD-1 positive specimens were CD3 positive. 41 specimens (64%) were CD3 negative (<5%) and PD1 negative (<1%). Based on these results, specimens were divided into three groups: Exhausted T-cell infiltrate (CD3+/PD1+), non exhausted T-cell infiltrate (CD3+/PD1-) and no T-Cell infiltrate (CD3-/PD1-). In the exhausted T-cell infiltrate group 30% of patients had ISS stage 3 and 40% had high risk cytogenetics. In the non-exhausted T-cell group 15% of patients had ISS stage 3 and 15% high cytogenetic risk. In the no T-cell infiltrate group 10% had ISS stage 3 disease and 22% high cytogenetic risk. These proportions were not significantly different across the 3 groups. Median OS from 1st auto infusion was 7 years while median PFS was 2.3 years. On univariate analysis, there was no significant difference in PFS between the 3 groups. The presence of CD3 and PD1 T-cells were significantly associated with OS (p-value = 0.04). Median OS from 1st auto infusion was 43 months for the exhausted T-Cell infiltrate group followed by 83 months for the no T-Cell infiltrate group. The non exhausted T-cell group had the highest OS, median not reached; OS by 7-years was 75%. Cytogenetic risk at diagnosis was significantly associated with OS (p-value = 0.03). In a multivariable model, CD3/PD1 staining continued to trend toward an association with OS (p-value = 0.08) and cytogenetic risk remained significant (p-value = 0.05).Conclusions: The presence of T-cells with PD-1 expression was not associated with higher risk disease at MM diagnosis based on cytogenetics and ISS stage. The presence of PD-1 expressing CD3+ T cells trends toward an association with poorer overall survival in newly diagnosed MM, especially compared to non exhausted T-cell infiltrate, suggesting the possibility that T cell exhaustion represents a novel high risk disease characteristic. Further investigation is necessary to assess if the presence of CD3+PD-1+ T cells is an independent prognostic feature in newly diagnosed MM. [Display omitted] DisclosuresGiralt:JAZZ: Consultancy, Honoraria, Research Funding, Speakers Bureau; TAKEDA: Consultancy, Honoraria, Research Funding; CELGENE: Consultancy, Honoraria, Research Funding; AMGEN: Consultancy, Research Funding; SANOFI: Consultancy, Honoraria, Research Funding. Landgren:International Myeloma Foundation: Research Funding; Onyx: Consultancy; Bristol-Myers Squibb: Consultancy; Celgene: Consultancy; Medscape: Honoraria; Bristol-Myers Squibb: Honoraria; Medscape: Consultancy; BMJ Publishing: Consultancy; Celgene: Honoraria; Onyx: Honoraria; BMJ Publishing: Honoraria; Onyx: Research Funding. Hassoun:Novartis: Consultancy; Takeda: Research Funding; Celgene: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees. Lesokhin:Genentech: Research Funding; Aduro: Consultancy; Janssen: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; Efranat: Consultancy.

Clinical Scale Zinc Finger Nuclease-mediated Gene Editing of PD-1 in Tumor Infiltrating Lymphocytes for the Treatment of Metastatic Melanoma

Programmed cell death-1 (PD-1) is expressed on activated T cells and represents an attractive target for gene-editing of tumor targeted T cells prior to adoptive cell transfer (ACT). We used zinc finger nucleases (ZFNs) directed against the gene encoding human PD-1 (PDCD-1) to gene-edit melanoma tumor infiltrating lymphocytes (TIL). We show that our clinical scale TIL production process yielded efficient modification of the PD-1 gene locus, with an average modification frequency of 74.8% (n = 3, range 69.9-84.1%) of the alleles in a bulk TIL population, which resulted in a 76% reduction in PD-1 surface-expression. Forty to 48% of PD-1 gene-edited cells had biallelic PD-1 modification. Importantly, the PD-1 gene-edited TIL product showed improved in vitro effector function and a significantly increased polyfunctional cytokine profile (TNFα, GM-CSF, and IFNγ) compared to unmodified TIL in two of the three donors tested. In addition, all donor cells displayed an effector memory phenotype and expanded approximately 500-2,000-fold in vitro. Thus, further study to determine the efficiency and safety of adoptive cell transfer using PD-1 gene-edited TIL for the treatment of metastatic melanoma is warranted.

Nivolumab in Patients with Relapsed or Refractory Hodgkin Lymphoma - Preliminary Safety, Efficacy and Biomarker Results of a Phase I Study

Introduction: Classical Hodgkin lymphoma (cHL) is characterized by Reed Sternberg (RS) cells surrounded by an extensive but ineffective inflammatory/immune cell infiltrate. Recent studies suggest that Hodgkin RS cells have developed mechanisms that exploit the programmed cell death-1 (PD-1) pathway to evade immune detection. In cHL, chromosome 9p24.1 gain is a frequent structural alteration that increases the gene dosage of the PD-1 ligands, PD-L1 and PD-L2, and their induction via JAK/STAT signaling. Epstein-Barr Virus (EBV) infection also increases the expression of the PD-1 ligands in EBV-positive cHL. Ligand binding to PD-1 receptor-positive activated T cells induces “T cell exhaustion,” a reversible inhibition of T cell activation and proliferation.Nivolumab (BMS-936558, Bristol-Myers Squibb) is a fully human IgG4 monoclonal PD-1 blocking antibody that potentiates anti-tumor T cell activity, and exhibits clinical efficacy in several solid tumors. We hypothesized that nivolumab may augment anti-tumor activity in patients with relapsed or refractory (R/R) cHL, including those who had failed brentuximab vedotin (BV), and evaluated the PD-1 blocking antibody. These are the first analyses being reported with PD-1 antibody for the treatment of cHL.Methods: Patients with R/R cHL were included as an independent cohort in a dose escalation and cohort expansion phase I study of nivolumab in lymphoma and multiple myeloma (MM). Results for patients with non-Hodgkin lymphoma and MM are reported separately. Patients with cHL received nivolumab 3 mg/kg every 2 weeks until confirmed tumor progression or excessive toxicity. Responses were evaluated using standard criteria. The primary endpoint was safety; key secondary endpoints included anti-tumor activity and expression of immunomodulatory proteins in tumor biopsies.Results: Twenty-three patients were enrolled with R/R cHL. Patients were heavily pre-treated, 87% had received ≥ 3 prior treatment regimens, 78% had prior autologous stem cell transplant (ASCT), and 78% had prior BV treatment. Drug-related adverse events (AEs) of any grade occurred in 78% of patients, the most common of which were rash (22%), decreased platelet count (17%), diarrhea, nausea, pruritus, fatigue, and pyrexia (each at 13%). Drug-related grade 3/4 AEs occurred in 22% of patients. Three patients experienced 1 serious AE each (grade 3 myelodysplastic syndrome [MDS], grade 3 pancreatitis, and grade 2 lymph node pain).The objective response rate (ORR) was 87% (20/23), with 4 patients (17%) achieving a complete response (CR) and 16 (70%) obtaining a partial response (PR). The remaining 3 patients (13%) had stable disease (SD). All 23 patients had a reduction in tumor burden at 1 or more efficacy assessments during treatment with nivolumab (Figure). Among the 18 patients who had previously failed BV, the ORR was 89% (16/18), with 6% (1/18) achieving CR and 83% (15/18) PR. Progression-free survival (PFS) rate at 24 weeks was 86% (95% CI, 62-95%). The median overall survival (OS) has not been reached (range, 21+ to 75+ weeks). Six of 23 patients elected to discontinue study treatment to undergo stem cell transplantation, 2 patients discontinued due to toxicities (MDS and thrombocytopenia in 1 patient; pancreatitis in 1 patient), 4 patients discontinued due to disease progression, and 11 patients continue on study as of June 16, 2014.In a subset of study patients (10/23), PD-L1 and PD-L2 copy numbers in RS cells were assessed using fixed tumor biopsy specimens and a 3-probe fluorescence in situ assay (PD-L1,PD-L2, and control centromeric probe). In all tumors, RS cells had copy gains of PD-L1 and PD-L2, as a result of either polysomy or amplification; these tumors also exhibited increased protein expression of PD-L1. RS cells were also largely positive for pSTAT3, indicative of active JAK/STAT signaling.Conclusions In patients with R/R cHL, nivolumab-mediated PD-1 blockade is safe and tolerable with a safety profile similar to that in solid tumors. The frequent and long-lasting responses in heavily pretreated, R/R patients, including those who have failed BV, highlight the importance of the PD-1 pathway in cHL, and the genetically defined sensitivity to PD-1 blockade in this disease. Based on these results, the FDA granted nivolumab breakthrough status in relapsed cHL and a large, multinational, phase II trial of this therapy is underway. [Display omitted] DisclosuresArmand:Merck: Consultancy. Off Label Use: Nivolumab was tested for the treatment of hematologic malignancies.. Ansell:Bristol-Myers Squibb: Research Funding. Lesokhin:Bristol-Myers Squibb: Consultancy, Research Funding. Timmerman:Bristol-Myers Squibb: Research Funding. Borrello:Bristol-Myers Squibb: Research Funding. Rodig:Bristol-Myers Squibb: Research Funding. Zhu:Bristol-Myers Squibb: Employment. Grosso:Bristol-Myers Squibb: Employment, Equity Ownership. Kim:Bristol-Myers Squibb: Employment. Shipp:Merck: Membership on an entity’s Board of Directors or advisory committees; Pharmacyclics: Membership on an entity’s Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Membership on an entity’s Board of Directors or advisory committees; Bayer: Membership on an entity’s Board of Directors or advisory committees; Sanofi: Research Funding; Janssen R&D: Membership on an entity’s Board of Directors or advisory committees.

Preliminary Results of a Phase I Study of Nivolumab (BMS-936558) in Patients with Relapsed or Refractory Lymphoid Malignancies

Introduction Programmed cell death-1 (PD-1) is an immune checkpoint receptor that inhibits T cell activation upon interaction with its ligands PD-L1 or PD-L2. Increased PD-L1 expression has been reported in various lymphoid malignancies, and may allow these tumors to circumvent host anti-tumor immunity. Nivolumab, a fully human IgG4 monoclonal PD-1 receptor blocking antibody, potentiates T cell activity, and has clinical efficacy in various solid tumors. We hypothesized that nivolumab might also have clinically important anti-tumor activity in patients with lymphoid malignancies.Methods This open-label study enrolled patients with relapsed or refractory lymphoid malignancies including B-cell non-Hodgkin lymphoma (B-NHL), T-cell NHL (T-NHL), multiple myeloma (MM), and classical Hodgkin lymphoma (cHL). Patients were treated using a dose escalation design (1 mg/kg and 3 mg/kg) of nivolumab administered every two weeks for up to two years. Responses were assessed using standard criteria. The primary endpoint was safety; key secondary endpoints included anti-tumor activity and expression of immunomodulatory proteins in tumor biopsies. The preliminary results for the cHL patients will be reported separately.Results Twenty-nine patients with B-NHL, 2 patients with primary mediastinal B-cell lymphoma; 23 patients with T-NHL; 27 patients with MM; and 1 with chronic myelogenous leukemia were enrolled. Patients were heavily pretreated with 67%, 69%, and 78% of MM, B-NHL, and T-NHL patients, respectively, having received ≥ 3 prior treatment regimens. Previous autologous stem cell transplantation was reported for 56% of MM, 14% of B-NHL, and 9% of T-NHL patients. Prior brentuximab treatment was reported in 7% of B-NHL and 26% of T-NHL patients. When this pre-planned interim analysis was performed, six patients had been treated at the 1 mg/kg dose with 2 dose-limiting toxicities (DLTs) occurring in the same patient: grade 3 pneumonia and pneumonitis. At the 3mg/kg dose, seven patients were treated with one patient experiencing two DLTs: grade 3 eosinophilia and diplopia. Additional patients were enrolled in the cohort expansion at 3 mg/kg.Drug-related adverse events (AEs) occurred in 72%, 65%, and 52% of B-NHL, T-NHL, and MM patients, respectively. Serious AEs in B-NHL patients were pneumonitis (7%), acute respiratory distress syndrome, dermatitis, diplopia, enteritis, eosinophilia, mucosal inflammation, pyrexia and vomiting, each occurring in 3%. In the T-NHL patients, serious AEs were pneumonitis, rash, and sepsis, each occurring in 4%, and in MM patients, serious AEs were pneumonitis, myositis, and increased creatine phosphokinase, each occurring in 4%. The incidence and severity of drug related AEs were similar across tumor types. Efficacy results are shown for each tumor type in the table. The overall response rate (ORR) and complete response (CR) rate in patients with B-NHL were 28% and 7%, respectively, including an ORR of 36% in patients with diffuse large B-cell lymphoma (DLBCL), and 40% in patients with follicular lymphoma (FL). In patients with T-NHL, ORR was 17% (no CR), including an ORR of 40% in the 5 patients with peripheral T cell lymphoma. No objective responses were observed in MM. Analysis of PD-L1 expression and correlation to clinical outcome is being performed and will be presented.Conclusions Nivolumab administered at a dose of 3 mg/kg every two weeks was tolerable and the safety profile was similar to that of the agent in solid tumors. Objective responses were observed in DLBCL, FL, mycosis fungoides (MF), and peripheral T cell lymphoma (PTCL). Durable stable disease was observed in relapsed MM. The results of this phase 1 study have led to phase 2 studies in DLBCL and FL, which are ongoing.Table:Efficacy ResultsTumorNComplete Responsen (%)Partial Responsen (%)Stable Disease (SD)n (%)Progression Free Survival Rate at 24 Weeks (%)Diffuse Large B Cell Lymphoma (DLBCL)111 (9)3 (27)3 (27)(24)Follicular Lymphoma (FL)101 (10)3 (30)6 (60)(68)Other B Cell Lymphoma8005 (63)(38)Primary Mediastinal B Cell Lymphoma2002 (100)(0)Mycosis Fungoides (MF)1302 (15)9 (69)(39)Peripheral T Cell Lymphoma (PTCL)502 (40)0(30)Other T Cell Lymphoma5001 (20)(0)Multiple Myeloma (MM)270018 (67)(15)Chronic Myelogenous Leukemia1001 (100)(100) DisclosuresLesokhin:Bristol-Myers Squibb: Consultancy, Research Funding. Ansell:Bristol-Myers Sqibb: Research Funding. Armand:Merck: Consultancy. Cohen:Celgene: Member, Independent Response Adjudication Committee Other; Onyx: Advisory Board, Advisory Board Other; Bristol-Myers Squibb: Advisory Board, Advisory Board Other, Research Funding; Janssen: Advisory Board, Advisory Board Other. Lebovic:Genentech, Allos, Celgene, Onyx, Millennium: Consultancy, Research Funding, Speakers Bureau. Rodig:Bristol-Myers Squibb: Research Funding. Zhu:Bristol-Myers Squibb: Employment. Grosso:Bristol-Myers Squibb: Employment, Equity Ownership. Kim:Bristol-Myers Squibb: Employment. Shipp:Merck: Membership on an entity’s Board of Directors or advisory committees; Pharmacyclics: Membership on an entity’s Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Membership on an entity’s Board of Directors or advisory committees; Bayer: Membership on an entity’s Board of Directors or advisory committees; Sanofi: Research Funding; Janssen R&D: Membership on an entity’s Board of Directors or advisory committees. Borrello:Bristol-Myers Squibb: Research Funding. Timmerman:Bristol-Myers Squibb: Research Funding.

O1-21-4 - Phase I Study of Anti-Pd-1 Antibody Ono-4538 and Chemotherapy in Patients with Advanced Non-Small-Cell Lung Cancer

Background: ONO-4538 (BMS-936558, nivolumab) is a fully human monoclonal antibody targeting PD-1 (programmed cell death 1) and enhances antitumor activity by blocking PD-1 / PD-L1 (programmed cell death 1 ligand 1) binding that down-regulates T-cell co-stimulatory signal. This phase I study investigated the tolerability, safety and pharmacokinetics of ONO-4538 in combination with chemotherapy in Japanese patients with advanced non-small-cell lung cancer (NSCLC).Methods: Patients who have stage IIIB without indication for definitive radiotherapy, stage IV, or recurrent NSCLC were eligible. ONO-4538 (10 mg/kg, day 1) and chemotherapy [Arm A: cisplatin (80 mg/m2, day 1) / gemcitabine (1250 mg/m2, day 1 and 8), Arm B: cisplatin (75 mg/m2, day 1) / pemetrexed (500 mg/m2, day 1), Arm C: carboplatin (AUC 6, day 1) / paclitaxel (200 mg/m2, day 1) / bevacizumab (15 mg/kg, day 1), Arm D: docetaxel (75 mg/m2, day 1)] were administered every three weeks. Arm A and B were administrated for four cycles and Arm C was for six cycles as first-line chemotherapy. After that, ONO-4538 in Arm A, ONO-4538 / pemetrexed in Arm B, and ONO-4538 / bevacizumab in Arm C were continued every three weeks as maintenance therapy until disease progression. Arm D were administrated until disease progression as second-line chemotherapy. Dose limiting toxicity was evaluated during the first treatment cycle.Results: As of September 30, 2013, 14 patients (Arm A / B / C / D: 3 / 6 / 3 / 2 patients) were enrolled. There were no dose limiting toxicities during the evaluation periods. A severe infusion reaction (CTCAE version 4.0 grade 3) was observed in a patient receiving the third cycle treatment of Arm D.Conclusions: ONO-4538 10 mg/kg was tolerable in combination with chemotherapy in Japanese patients with advanced NSCLC.

Mechanisms of costimulation

The immune system has the remarkable ability to defend against a diversity of microbial pathogens, yet not respond to self. The discovery of the T-cell antigen receptor (TCR) provided an explanation for the specificity and diversity of T-cell responses. Yet, functional studies of Lafferty and colleagues (1) suggested that antigen alone was not sufficient to drive the activation of naive T cells and led to the two signal concept of T-cell activation. According to this model, productive T-cell activation requires a first signal provided by the interaction of antigenic peptide/major histocompatibility complex (MHC) with the TCR and a second, antigen-independent co-signal, the ‘costimulatory signal’. In addition, seminal studies of Jenkins and Schwartz (2, 3) demonstrated that TCR-mediated activation of T cells in the absence of costimulation resulted in antigen-specific unresponsiveness (termed T-cell anergy), rendering the T cells unable to respond to subsequent exposure to antigen. Thus, costimulation was postulated to have a pivotal role in determining whether the outcome of T-cell encounter with antigen would be activation or anergy. The critical role of costimulation in regulating the immune response has given impetus to the study of costimulation and resulted in incredible growth of this field, since an understanding of costimulation is of fundamental and therapeutic interest. Early studies defined the function of the CD28 receptor as a stimulatory receptor for the activation of naive T cells (2), and identified the B7 family members, B7-1 (CD80) and B7-2 (CD86) as its ligands (5–7). The interaction between CD28 and B7-1/B7-2 fulfilled many of the requirements for the costimulatory signal postulated by Lafferty, Schwarz, and colleagues (1). The CD28 homolog cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) (3) was found to be a higher affinity binding partner for B7-1 and B7-2, as compared to CD28 (4). It was presumed that CTLA-4 would also be a stimulatory receptor; however, the dramatic fatal inflammatory phenotype of CTLA-4 deficient (−/−) mice revealed the critical inhibitory function of CTLA-4 (10, 11). Furthermore, the phenotype of CTLA-4−/− mice demonstrated that T-cell costimulatory receptors could deliver inhibitory, as well as stimulatory, second signals for T-cell responses, and provided the first indication that inhibitory second signals (co-inhibitory) could regulate T-cell tolerance. While the B7-1/B7-2:CD28/CTLA-4 pathway is the best characterized T-cell costimulatory pathway, there are now many additional costimulatory pathways. These pathways fall into two major families: the immunoglobulin (Ig) superfamily, which includes the B7/CD28, CD2, and T-cell Ig and mucin domain (TIM) families, and the tumor necrosis family (TNF)/TNF receptor (TNFR) family. Reviews in this issue of Immunol Rev discuss the functions of pathways within all of these families. These articles not only review the current understanding of costimulation on the fundamental level, but also the therapeutic opportunities and challenges of targeting costimulatory pathways for treating autoimmunity, graft rejection, cancer and infectious diseases. In this introduction, I provide perspectives on key functions of costimulatory pathways, highlighting recent advances, and discuss how this progress is changing our view of the functions of T-cell costimulation.

PD-1/PD-L pathway and autoimmunity

Programmed cell death 1 (PD-1) was isolated in 1992 by subtractive-hybridization technique, as a molecule whose expression is enhanced by apoptotic stimuli. Since then we have been analyzing the function of PD-1 in the regulation of immune responses. Generation of PD-1 deficient mice, pathophysiological analyses of autoimmune diseases in PD-1 deficient mice, identification of two ligands, and analyses of downstream events of PD-1 revealed that PD-1 prevents autoimmunity by inhibiting activation of self-reactive lymphocytes. These findings were further applied on human autoimmune diseases and single nucleotide polymorphisms (SNPs) on human PD-1 gene have been reported to link with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and type I diabetes.