1. ©2015 MFMER | slide-1 Introduction to Immuno-Oncology Keith L. Knutson, Ph.D. Professor of Immunology Community Oncology Conference 2.0 April 23-24, 2015

2. ©2015 MFMER | slide-2 Cells of the immune system All cellular elements of the blood are derived from a single pluripotent hematopoietic stem cell

3. ©2015 MFMER | slide-3 Phagocytes Monocytes DCP

4. ©2015 MFMER | slide-4 Polymorpho- nuclear leukocytes All (except maybe mast cells) are derived from the common myeloid precursor

5. ©2015 MFMER | slide-5 Natural Killer Cells INNATE Both are derived from the common lymphoid precursor Lymphocytes Antigen-Specific Lymphocytes ADAPTIVE

6. ©2015 MFMER | slide-6 Schematic Structure of Antigen Receptors

7. ©2015 MFMER | slide-7 Antigens are recognized by the immune response while epitopes are sites within antigens

8. ©2015 MFMER | slide-8 Antibodies and T cell receptors recognize antigen by different mechanisms

9. ©2015 MFMER | slide-9 Antibody dependent cellular cytotoxicity

10. ©2015 MFMER | slide-10

11. ©2015 MFMER | slide-11 Oncogenesis proto-oncogenes tumor suppressor genes oncogenes Carcinogen results in mutation dysfunctional tumor suppressor genes inherited defect increased GF increased GF receptors exaggerated response to GF loss of ability to repair damaged cells or induce apoptosis Increased growth Virus introduces oncogenes

12. ©2015 MFMER | slide-12 Tumor Antigen Classifications Tumor-specific antigens –Ras –p53 –BCR-Abl –Viral antigens –Mis-splice variants Cancer-Testis antigen –MAGE (1 st cloned tumor antigen) –NY-ESO Differentiation antigens –Tyrosinase –MART-1 Overexpressed antigens –HER-2/neu –hTERT

13. ©2015 MFMER | slide-13 Paradoxical roles of the immune system in cancer development 1.The key functions of the mammalian immune system: (1) Protect from infectious pathogens (2) Monitor tissue homeostasis => Eliminate damaged cells (e.g. tumor cells) and induce wound healing. 2.Mechanisms against cancer development: (1) Cellular immunity- T, NK, & Other innate immune cells (2) Humoral immunity- Cytokines, Abs, etc. 3.Mechanisms promoting cancer development: (1) Inflammation => Angiogenesis & Tissue remodeling (2) Enhance survival pathways (NF-kB activation) (3) Suppression of anti-tumor immune responses

14. ©2015 MFMER | slide-14 The complex relationship between the immune system and cancers 1.Adaptive and innate immune cells regulate tissue homeostasis and efficient wound healing 2.Altered interactions between adaptive and innate immune cells can lead to “chronic inflammatory disorders”. 3.Chronic inflammatory conditions enhance a predisposition to cancer development. 4.In cancers, an abundance of infiltrating innate immune cells (e.g. macrophages, mast cells, and neutrophils) correlates with increased angiogenesis and/or poor prognosis.

15. ©2015 MFMER | slide-15 Association of inflammation with cancers

16. ©2015 MFMER | slide-16 Acute vs. Chronic Inflammation: Role in Cancer Pathology

17. ©2015 MFMER | slide-17 Inflammation causes genomic damage through reactive oxygen and nitrogen

18. ©2015 MFMER | slide-18 Inflammation elevates cytokines that activate transcription factors which promote tumor formation and progression.

19. ©2015 MFMER | slide-19 Inflammation induces immune suppressive cells which prevent adaptive cellular immunity

20. ©2015 MFMER | slide-20 Science 2013;339:286-291 Malignant cells foster development of wound healing responses

21. ©2015 MFMER | slide-21 Preventing Tumor-inducing Inflammation Life style changes: lose weight, quit smoking, quit drinking. Non-steroidal anti- inflammatories: colorectal, bladder, ovarian. Vaccination: HBV, MUC1 Phytochemicals: Variety of inhibitors (Natural Cox and Stat3 inhibitors). Gut 2010;59:1670-1679

22. ©2015 MFMER | slide-22 Science 2013;339:286-291 Converting chronic to acute inflammation

23. ©2015 MFMER | slide-23 Science 2013;339:286-291 Reversing Tumor-Associated Chronic Inflammation Adoptive Therapies T cells Cytokines Vaccines Combination approaches Viruses to induce acute inflammation Checkpoint blockade

24. ©2015 MFMER | slide-24 Reconstituting humoral immunity Humanization of mouse monoclonals Mechanisms of action ADCC Complement Signal enhancer/inhibitor Enhances acute immunity Monoclonal antibody therapy

25. ©2015 MFMER | slide-25 Mocellin et al, Cochrane Database of Systemic Reviews 2013;DOI10.1002/14651858 Meta-analysis of interferon impact on overall survival

26. ©2015 MFMER | slide-26 Humanizing monoclonal antibodies Monoclonal antibody therapy

27. ©2015 MFMER | slide-27 MAb NameTrade NameUsed to Treat:Target RituximabRituxan Non-Hodgkin lymphoma CD20 TrastuzumabHerceptinBreast cancerHER-2/neu Gemtuzumab ozogamicin* Mylotarg Acute Myelogenous leukemia (AML) CD33 AlemtuzumabCampath Chronic Lymphocytic leukemia (CLL) CD52 Ibritumomab tiuxetan* Zevalin Non-Hodgkin lymphoma CD20 Tositumomab*Bexxar Non-Hodgkin lymphoma CD20 CetuximabErbituxColorectal cancerEGFR BevacizumabAvastinColorectal cancerVEGF FDA-Approved antibodies

28. ©2015 MFMER | slide-28 HER2+ Breast Cancer Management 1 st -line: chemo + trastuzumab Metastatic Disease Response 50-80% Time to disease progression ~ 11-14 mo Adjuvant Setting ~50% reduction in relapse Best if used concurrently with chemo.

29. ©2015 MFMER | slide-29 Therapeutic Efficacy of Herceptin New England Journal of Medicine

30. ©2015 MFMER | slide-30 TIL Therapy

31. ©2015 MFMER | slide-31 Current Opinion in Immunology Tumor regression following T cell infusion

32. ©2015 MFMER | slide-32 Current Opinion in Immunology Survival of Patients Treated with TIL and IL-2

33. ©2015 MFMER | slide-33 Uveitis Vitiligo Autoimmunity Following Cell therapy

34. ©2015 MFMER | slide-34 Target suppressive molecules: anti-IL-10 antibodies Block key immune regulatory loops Anti-CTLA-4 (checkpoint blockade) Block systemic and infiltrating regulatory T cells IL-2 immunotoxin Anti-CD25 antibody Blocking immune suppression

35. ©2015 MFMER | slide-35 Checkpoint Blockade

36. ©2015 MFMER | slide-36

37. ©2015 MFMER | slide-37 Anti-CTLA-4 causes regressions of melanoma metastases Klein O et al. Clin Cancer Res 2009;15:2507-2513 Lung met Lymph node met Chest wall met

38. ©2015 MFMER | slide-38 Anti-PD-1 causes regressions of melanoma metastases New England Journal of Medicine

39. ©2015 MFMER | slide-39 Chimeric Antigen Receptor T cell Therapy