Professor Akseli Hemminki's presentation at Nordic Hematology Conference, Tampere, Finland (May 7, 2009)

1. Cancer Gene Therapy
h
Akseli Hemminki, MD, PhD
Specialist in Oncology and Radiotherapy
Specialist in Oncology and Radiotherapy
K. Albin Johansson Research Professor,
Finnish Cancer Institute
Cancer Gene Therapy Group
Molecular Cancer Biology Program &
Transplantation Laboratory & Haartman
Institute & Finnish Inst. for Mol. Medicine
University of Helsinki and
Helsinki Univ. Central Hospital

2. How Far is Clinical Gene Therapy ?
Phase I: Safety and toxicity ?
Phase II: Any evidence of efficacy ?
Phase II: Any evidence of efficacy ?
Phase III: Proof of efficacy
(randomization)
A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 2

3. Mutation compensation
Randomized trial: head and neck cancer
‐ Ad p53 + radiation vs radiation alone
Ad‐p53 + radiation vs. radiation alone
‐ 67% vs. 24% CR (N= 82, P<0.01)
‐ Pan J Clin Oncol 2008
‐ Gendicine® for sale in China
‐ More than 10 000 patients treated
Promoter p53 gene
p53 gene pA
Press release 23 Jul 2008: Ad
Press release 23 Jul of cells p53 (Advexin )
Infection 2008: Ad‐p53 (Advexin®)
Infection of cells
phase III SCCHN trial positive in US Cancer cells
Normal cells
with healthy p53 with p53 mutation
Already approved by EMEA for treatment of
Li‐Fraumeni syndrome Cell death, also sensitation to
chemotherapy and radiation
h h d di i
No cell death
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4. Prodrug converting enzymes
(suicide gene therapy) with Ad‐TK
(suicide gene therapy) with Ad TK
and GCV
Ad coding for Advantage vs.
thymidine kinase TK mutation
mutation
(TK) compensation:
bystander effect
via gap junctions
Non‐toxic
pro drug
pro‐drug
GCV
Activated
Activated
toxin
Cell death
A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 4

5. Adjuvant Ad‐TK/GCV
CHALLENGE: even with bystander
Randomized phase 2b for glioma (N=36). effect, canA. Mol Ther 2004 penetration
Randomized phase 2b for glioma (N 36). Immonen A. Mol Ther 2004 p
Immonen we get effective
, g
Patients resected and randomized: into established tumors ?
1. follow‐up +/‐ XRT (= standard) SOLUTIONS: locally amplifying
systems
2. Standard + Ad‐TK into resection margins, ganciclovir for 14d
2 Standard + Ad TK into resection margins ganciclovir for 14d
Median survival 39.0 wk. vs. 70.6 wk. (p<0.0095)
No increase in toxicity
Similar results in hepatocellular ca. adjuvant trial (Li Clin Cancer Res 2007)
Si il lt i h t ll l dj t t i l (Li Cli C R 2007)
Phase III results 30 Jul 2008 (
Ph lt J l (press release):
l )
Cerepro® w/ & w/o temozolomide vs
controls w/ & w/o temozolomide: 42 d
improvement in median survival (310 d vs
268 d, p
, p<0.032).
)
Orphan drug status alreadyi H e m m i n k i by M a y 2 0 0 9 | 5
A k s e l given | 7 EMEA

6. Oncolytic viruses
• Replication of virus
p
causes oncolytic death
of cells
• Normal cells‐ no
replication
A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 6

7. H101 (Oncorine®) phase III trial in
advanced head and neck cancer
d dh d d k
H101 is almost identical to dl1520 (=ONYX‐015) i
H101 now entering
H101
descibed earlier in the US phase 3 trials in US
Randomized phase III trial (N=105)
H101 + cisplatin + 5‐FU vs. cisplatin + 5‐FU
H101 + cisplatin + 5 FU vs cisplatin + 5 FU
CR+PR = 79% vs. 38%, P<0.0001
Mild tox: flu‐like symptoms, injection site pain
p
More than 800 patients now enrolled
H101 approved in China
Yu Curr Cancer Drug Targets 2007
Yu Curr Cancer Drug Targets 2007
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8. Gene therapy of hematological
cancers
Promising Phase 1 and 2 data in cutaneous B‐ and T
cell lymphomas with Ad‐IFN‐gamma: 56% responses
y p g p
(Dummer Blood 2004)
Oncolytic measles virus for multiple myeloma
Oncolytic measles virus for multiple myeloma
(unpublished)
Several trials evaluating mdr transfer to
Several trials evaluating mdr transfer to
hematopoietic stem cells
Several trials of HSV‐TK transfer to donor cells
S l t i l f HSV TK t f t d ll
(modulation of graft‐vs‐leukemia)
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9. Adenoviral Gene Therapy
Strategies for Cancer
f
Safety has been good – over 15 000 pts treated with both repli‐
S f t h b d 15 000 t t t d ith b th li
cation deficient and replication competent (oncolytic) viruses
Recent randomized trials (N 5) have confirmed efficacy of even
Recent randomized trials (N=5) have confirmed efficacy of even
early generation approaches
No patients w/ metastatic cancer cured: much work remains
TUMOR PENETRATION NEEDS IMPROVEMENT
Replication competent oncolytic viruses
Transcriptional tumor targeting (activation only in tumor)
Transductional tumor targeting (gene delivery only to tumor)
d i l i ( d li l )
Armed oncolytic viruses
Oncolytic replication is not enough to cure advanced tumors
O l ti li ti i t ht d dt
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10. Increasing infectivity of target cells:
transductional targeting
Non-targeted Targeted
T t d
adenovirus adenovirus
Adenovirus
receptor CAR
High Low
transduction Benign cell transduction
Tumor associated
receptor
p
Low High
transduction Cancer cell transduction
A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 1 0

11. Serotype chimerism for tumor
targeting
Ad5 107 SKOV3.ip1 cells
intraperitoneally (i.p.)
10 days later
10 days later
CAR
3x1x108 VP i.p.
Follow survival
Ad3 receptor
120
100
3x 1x108 VP i p
3x 1x10 VP i.p.
80
urvival
Ad5/3 60
% Su
with knob 40
domain
20
from Ad3
0
15 25 35 45 55 65 75 85 95 105 115 125 135
Kanerva Clin Cancer Res 2002 Kanerva Mol Ther 2003s e l i HDay i n k i | 7 M a y 2 0 0 9 | 1 1
Ak emm

12. Cancer stem cells can be killed with
oncolytic adenoviruses
oncolytic adenoviruses
Eriksson Mol Ther
2007
Bauerschmitz
Cancer Res 2008 A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 1 2

13. Compassionate treatment of refractory
solid tumors with oncolytic adenovirus
solid tumors with oncolytic adenovirus
• 115 patients and 202 treatments since Nov 07. 6 different viruses
• All had metastatic solid tumors progressing after routine
treatments (chemo, radiation, etc)
• Side effects: gr. 1‐2 flu‐like symptoms, fever, fatigue, pain in all pt
• SAE in < 4% of patients (abd. pain, constipation, embolus, venous
SAE in < 4% of patients (abd. pain, constipation, embolus, venous
thrombosis, cholecystitis).
• No treatment related deaths (compare to chemotherapy).
• Objective benefit including tumor marker data ( biological
Objective benefit including tumor marker data (“biological
activity”): 69% all viruses, 75% best virus
• Clinical benefit (imaging CR, PR, SD): 41% overall, 67% best virus
• Benefit lost in a few months in most patients
• Many patients benefited (even more) from 2nd ‐ 6th treatment
A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 1 3

14. Findings possible only in pts: Mechanisms of anti‐
tumor efficacy of oncolytic adenovirus
y y
inflammation
3. Induction of
1. Killing of differentiated tumor cells
1 Killing of differentiated tumor cells cytotoxic T cells
cytotoxic T‐cells
against tumors
6 CD8+
5
vitiligo
10E+8
4
3
2
0 17 41 48
2. Killing of tumor initiating ”stem” cells 4. Induction of specific immunity
against tumor epitope (survivin)
against tumor epitope (survivin)
CD8+ cells
4 4
0
0 Before virus 0.46% 10
before virus0.46 0 3 wk after 4.09%
after virus 4.09
03 10 3
Survivin specific C
FL2-H
2 2
0 10
n
01 10 1
0 0 99.5 0 95.9
0 k0
A10s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 1 4
10 0 10 1 10 2 10 3 10 4 10 0 10 1 10 2 10 3 10 4
Eriksson Mol Ther 2007, Bauerschmitz Cancer Res 2008 FL1-H FL1-H

15. Case: Systemic efficacy of Ad5/3‐Cox2L‐D24 in
chemo refractory neuroblastoma
chemo refractory neuroblastoma
• Ad5/3‐Cox2L‐D24 replicates in cells overexpressing Cox2 and
defective in the Rb/p16 pathway
Previous
Previous
treatments: • 6 yr old boy, WHO 1
Vincristine + • Progressive disease in bone marrow, left kidney, lymph nodes.
cis/carboplatin • Single oncolytic adenovirus treatment: i v intratumoral
cis/carboplatin Single oncolytic adenovirus treatment: i.v., intratumoral.
+ etoposide + • Gr. 1 stomach pain, diarrhea, flu‐like symptoms, liver enzymes
cyclophospham • 4 wk later: complete response in bone marrow, partial
ide response in primary
i i
Doxorubicin +
etoposide +
iphosphamide;
iphosphamide;
Intensive chemo
and autologous
stem cell
stem cell
transplant;
Oral 13‐cis‐retinoic
acid
A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 1 5

16. Ad5/3‐
Cox2L‐D24
in neuro‐
blastoma
→ CD56 staining (brown) for
Oncolytic replication alone is usually
tumor cells in bone
marrow
not enough to cure advanced tumors
not enough to cure advanced tumors
→ Imaging of primary before
and after treatment
→ Increase in cytotoxic T‐cells
→→ Increase in virus
neutralizing antibodies
→→→ Extended presence of
virus in blood
0
→→→→ Cox2 expression in
6540
tumor (reason for
( f
500
selectivity and efficacy)
Pesonen Submitted 2008| 1 6
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17. Improving antitumor immunity: oncolytic
adenoviruses coding for GM‐CSF
adenoviruses coding for GM CSF
GM‐CSF
• Tumor selectivity: Rb binding site deletion
restricts replication to Rb/p16 mutant cells
p /p G CS
GM-CSF
•GM‐CSF is a potent inducer of antitumor
GM-CSF
immunity (Dranoff G Immunol Rev 2002)
• GM‐CSF under control of the endogenous
Ad E3 gene expression system: expression
starts 8h after infection
⇒ GM‐CSF expressed only in cells that allow
replication of the virus
p GM CSF
GM-CSF
GM-CSF
• High expression at tumor, low systemic
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 1 7
exposure

18. GM‐CSF can enhance antigen presentation
and induce NK and cytotoxic T cells
and induce NK and cytotoxic T‐cells
Tumor cells killed with 3 mechanisms:
- Oncolytic effect of virus replication
- NK cell mediated direct cell killing
- DCs mediated tumor specific immunity
NK NK CD8+ CD8+ CD8+
NK NK CD8+ CD8+
CD8+
NK CD8+ CD8+
NK
NK Ca Ca
GM-CSF Ca
Ca Ca Ca
C DC
Ca Ca Ca
GM-CSF A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 1 8

19. Schematic of Oncolytic Virus Treatment
60
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20. Efficacy and virus replication
SD
Overall efficacy (RECIST 1.1) single injection:
* Indicates patients still
CR 2/14 alive at the time of cutoff.
li t th ti f t ff
SD 5/14
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 0
PD 7/14

21. GM‐CSF coding oncolytic adenovirus
in a mesothelioma patient
in a mesothelioma patient
• 60 yr old man, asbestos exposure
60 yr old man asbestos exposure
• Prior treatment with cisplatin+pemetrexed
• WHO 1
• Single intrapleural and i.v. injection
l l l d
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22. Complete response in OvCa pt
with small disease burden
ith ll di b d
Metastatic ovarian ca. 2002
M t t ti i 2002
Operation, adjuvant CEF x6, taxol+carbo x6, docetaxel,
bevacizumab, topotecan, erlotinib, aromatase inhibitor
Progressive disease, WHO 1
Single intraperitoneal treatment
Complete response (CT, markers) for 9 mo
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 2

23. Inflammation due to virus and/or GM‐
CSF can falsely increase tumor markers
CSF can falsely increase tumor markers
and enlarge tumors
Virus replication • 59 old man with esophageal cancer
59 old man with esophageal cancer
activates tumor
cell metabolism • Prior chemo: oxaliplatin+capesitabine,
oxaliplatin, docetaxel, irinotecan‐
paclitaxel, cyklo‐doxo‐cisplatin, oxali‐
irino‐cetuximab, capecitabine
• Progressive disease WHO 1
• Intratumoral and i.v. virus injection
Necrosis
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 3

24. dl1520, CoCa liver mets
• Patients failed all available chemo
• Reid T Cancer Res 2002
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 4

25. Rapid response upon re‐treatment with
GM CSF coding oncolytic
GM‐CSF coding oncolytic adenovirus
• Peritoneally metastatic ovarian cancer since 2005.
• 5 lines of chemo (paclitaxel‐carbo, liposomal doxorubicine,
gemcitabine+carbo, gemcitabine, topotecan)
• Progressive disease, WHO 1
• 52.5% tumor size reduction in 17 days after 2nd treatment
y
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 5

26. Immunological response to GM‐CSF
coding oncolytic adenovirus
coding oncolytic adenovirus
Adenovirus: T cell response
p
towards adenovirus
components (Hexon, Penton,
Fiber etc.)
b )
Tumor: T cell response to
tumor specific epitopes
6 CD8+
5
10E+8
8
4
3
2
0 17 41 48
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 6

27. Ad5(hexon)‐Specific Immunity
1000 10
4 10
4
0
0.21
0 21 0.21
0 21
Ad5Hex)
800
3 3
10 10
tter
600
CD3
3
FSC-H
Size Scat
Before
B
FL2-H
H
FL3-H
H
ramer (A
2 2
10 10
400
48.4
61.7
1 1
10 10
200
Tetr
0 0 0.085 99.7
0 10 10
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4
10 10 10 10 10 10 10 10 10 10 10 10 10 10 10
FL3-H FL1-H FL1-H
CD3 CD8 CD8
1000 10
4 10
4
0 2.72 2.72
Hex)
800 10
3
3
Tetramer (Ad5H
10
e Scatter
After
600
CD3
FL2-H
FSC-H
FL3-H
2
2 10
10
400 47.8
Size
68.8
68 8 1
10
10 1
200
0 0.68 96.6
0 10
0 10
0 1 2 3 4
0 1 2 3 4 0 1 2 3 4 10 10 10 10 10
10 10 10 10 10 10 10 10 10 10
FL1-H
FL3-H
FL3 H FL1-H
FL1 H
CD3 CD8 CD8
Data confirmed in ELISPOT assay A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 7

28. Tumor‐specific Immunity (pentamer staining
for survivin)
o su )
Before virus: R73 3 weeks after virus: R73
104 104
0
0.46 0.46 0
4.09 4.09
Pentamer
103 103
↓
↓ All analyzed patients
y p
r‐specific P
FL2-H
FL2-H
102 102
Tumor
1 1
10 10
0 99.5 0 95.9
100 100
4
100 101 102 103 104 100 101 102 103 104
FL1-H FL1-H
CD8
↑ Patient Code: R73
↑ Patient Code: R73
A k s e l i H e m m i n k i | 8 O c t 2 0 0 8 | 2 8

29. Summary
1.
1 Initial clinical proof‐of‐principle is available for many cancer gene
Initial clinical proof of principle is available for many cancer gene
therapy approaches
2. Safety has generally been excellent
3. Effective gene delivery continues to be key to efficacy
ff d l b k ff
4. Oncolytic viruses amplify local dose and help in tumor
penetration
5. More than 50% of our patients have obtained benefit from
treatment with oncolytic adenovirus
6. Patient data has revealed central role of immune reponse in
Patient data has revealed central role of immune reponse in
patient benefit
7. Immune response toward both adenovirus and tumor epitopes
8.
8 Clinical trials are needed to confirm promising preliminary results
Clinical trials are needed to confirm promising preliminary results
9. Current regulations make translational work difficult
A k s e l i H e m m i n k i | 7 M a y 2 0 0 9 | 2 9

30. Acknowledgements
Akseli Hemminki Marko Ahonen Maria Rajecki Transgene Univ. Helsinki & HUCH:
Monika Lusky Martti Ala‐Opas
Sari Pesonen Iulia Diaconu Mari Raki Henrik Alfthan
Laura Ahtiainen
La ra Ahtiainen João Dias
João Dias Tuuli Ranki
T li Ranki Delsitech
D li h Petri Bono
Petri Bono
Sophie Escutenaire Kilian Guse Marta Sloniecka Mika Koskinen Maija Harrela
Mika Jalonen Pekka Häyry
Vincenzo Cerullo Theresia Gutmann Merja Särkioja Krister Höckerstedt
Anna Kanerva Otto Hemminki Matteo Ugolini Helena Isoniemi
Institut Catala Kalevi Kairemo
Camilla Ribacka
Camilla Ribacka Lotta Kangasniemi
Lotta Kangasniemi d Oncologica:
d’Oncologica: Tuula Kiviluoto
Minna Oksanen Anniina Koski Päivi Hannuksela Ramon Alemany Jorma Paavonen
Elina Haavisto Sergio Lavilla‐Alonso Kikka Holm Ari Ristimäki
Ilkka Liikanen Aila Karioja‐Kallio Univ. Glasgow Mirja Ruutu
Laura Denby Jarmo Salo
Petri Nokisalmi Eerika Karli Andy Baker
Andy Baker Ulf Håkan Stenman
Ulf‐Håkan Stenman
Maija Tarkkanen
The Patients Salk Institute Mikko Tenhunen
Matt Weitzman Pekka Virkkunen
Timo Joensuu Grant support:
Grant support:
Saila Eksymä‐ ERC
Sillman EU FP6 APOTHERAPY
Mauri Kouri EU FP6 THERADPOX
Jenni Kylä‐Kause HUCH Research Funds (EVO)
Leena Laasonen Pekka Simula Academy of Finland
y
Satu Nikander
S Nik d Finnish Cancer Organizations
Marina Rosliakova Biocentrum Helsinki
Katri Silosuo Sigrid Juselius Foundation
Arja Vilkko
National Cancer Institute (USA)
Heini Välijeesiö