This document summarizes advances in cancer immunotherapy for lymphomas and myelomas. It describes positive phase III clinical trials of cancer vaccines for prostate cancer, melanoma, and lymphoma that were FDA approved. It then focuses on the development of an idiotype vaccine for B-cell lymphomas from an academic laboratory through preclinical and clinical trials, including a positive phase III trial showing improved disease-free survival. Future directions discussed include combining the idiotype vaccine with other therapies like anti-CD20 antibodies or adoptive T-cell therapies. The development of second-generation DNA vaccines that could reduce manufacturing time is also discussed.

1. Advances in immunotherapy
for lymphomas and
myelomas
Larry W. Kwak, M.D., Ph.D.
Chairman, Department of Lymphoma/Myeloma
Justin Distinguished Chair in Leukemia Research
Co-Director, Center for Cancer Immunology Research
MD Anderson Cancer Center

2. CME Disclosures
• Biovest International (consultant)
• Xeme Biopharma, Inc. (equity)
• Celgene (research support)
• Celltrion (consultant)
• OncoPep (consultant)

3. Positive controlled Phase III cancer
vaccine/immunotherapy clinical trials
• Sipuleucel-T (prostate cancer) *
NEJM July 2010
• Ipilimumab (melanoma) *
NEJM August 2010
• gp100 peptide (melanoma)
NEJM June 2011
• B-cell idiotype protein (lymphoma)
J Clin Oncol July 2011
* FDA approved

4. Bench-to-bedside development of a homegrown
therapeutic agent from an academic laboratory
CD4+
• Addition of GM-CSF Adjuvant improves
vaccine potency
CD8+
cytokines
Lymphoma
Tumor
Y
(Kwak et al. PNAS 1996)
Phase I/II Clinical Trial
(Nature Med 1999):
•Vaccine induces
molecular remissions
•
Tumor
protein
Phase III Controlled Clinical Trial
(J Clin Oncol 2011)
• Vaccine prolongs DFS in patients in a chemotherapy-
induced remission (n=117, p=0.045)
Preclinical
Isolate
antigen
Package in
Delivery system

5. Idiotype: A clonal marker and model tumor
antigen
Mature B cells
Lymphoma*
= malignant transformation
*
Idio-:
Defn: Ancient Greek ἴδιος
(“own, personal, distinct”)

6. Personalized Human Vaccine Production
Tumor
biopsy
Fusion and Id sequence
determination
Hybridoma
scale-up
Affinity
purification
Id protein matches
each patient’s tumor
(automated)

7. Vaccine components
• Idiotype of the Ig antigen of a B-
cell lymphoma can be used as a
tumor-specific immunogen
• Keyhole lympet hemocyanin
(KLH) carrier serves as an
immune stimulant
• GM-CSF administered
concurrently at site of injection
as an adjuvant
KLHGM-CSF

8. Types of vaccines
• Therapeutic
• Secondary prevention
• Prevention (e.g. infectious diseases)

9. NCI/Biovest Phase III Trial: 2-Stage Study Design
LN
Bx
Assign CR
Stratify for IPI1, cycles of PACE2
2:1 Randomization
Chemo
• 2 prospective efficacy analyses
• Primary endpoint: disease-free survival
• 14 sites enrolled patients from 2000-2007
1low, low-intermediate or high-
intermediate, high groups
2 < 8 or > 8 cycles
6 - 12 months 6 months6 - 8 months
(Id Vaccine)
(Control)
ITT mITT

10. Disease Free Survival from Randomization (mITT)
log-rank
p=0.045
Median Follow-up
56.6 mo (range 12.6 – 89.3)
Median DFS
Id vaccine = 44.2 mo
Control vaccine = 30.6 mo
Events
Id vaccine = 44
Control vaccine = 29
Cox PH Model
HR = 0.62; [95% CI: 0.39,0.99]
(p=0.047)
Control vaccine (n=41)
Id vaccine( n=76)
Schuster , Neelapu et al. (Kwak) J Clin Oncol 29:2787, 2011

11. 52nd ASH Annual Meeting, Orlando, FL
Disease Free Survival for Patients with IgM-isotype
lymphomas: a potential predictive biomarker
Median Follow-up
56.6 mo (range 12.6 – 89.3)
N = 60
IgM-Id vaccine N = 35
Control N = 25
Median DFS
IgM-Id vaccine = 52.9 mo
[95% CI:40.2,NA]
Control = 28.7 mo
[95% CI:21.0,39.8]
Events
IgM-Id vaccine = 17
Control = 20
Schuster , Neelapu et al. (Kwak) J Clin Oncol 29:2787, 2011

12. Positive Phase III trial: Potential
challenges to “Delivery”
• Patient accrual stopped early/treatment effect
apparent only in modified ITT
• requirement for biopsy and personalized
manufacture (“high commercial risk”)
• optimal treatment requires sustained complete
remission

13. Future directions
• Excisional biopsies serve as a rich source of residual
tumor on all patients for genomic profiling/biomarkers
• Additional clinical trials combining this vaccine with anti-
CD20 mAb (rituximab)-containing chemotherapy
regimens
• Making further improvements in the vaccine product (e.g.
2nd generation DNA fusion vaccines)

14. 2nd generation DNA Vaccine Strategy
• Maintain or improve efficacy
• Reduce Manufacturing Time
– For Protein Vaccines: 3-6 months
– For DNA Vaccines: 4-5 weeks

16. Biragyn et al. [Kwak] Nature Biotech 1999 and Science 2002
Next generation vaccine development: genetic fusions
Antigen Presenting Cell (APC) Receptor Targeting

17. Phase I Study of an Active Immunotherapy for
Asymptomatic Phase Lymphoplasmacytic Lymphoma with
DNA Vaccines Encoding Antigen-Chemokine Fusion (RAC
# 1007-1050 Sept. 2010)
• Formulation and Administration:
– 0.5ml intramuscular injection rotated between thighs
• Dosing Cohorts:
– Cohort 1: 500 g
– Cohort 2: 2500 g
• Schedule of Administration:
Wk 4 Wk 8Wk 0
RP100457, Cancer Prevention & Research Institute of Texas (CPRIT; Kwak)
Multiple Myeloma SPORE, Project 2 (Thomas/Neelapu)

18. J Immunol 1997; 159: 5921
Science 1997; 276: 273
Immunol. Rev. 1997; 160: 43
Mol. Ther. 2004; 9; 902
Exp. Opin. Biol. Ther. 2008; 8: 475
Anti-CD3 Anti-CD28
Artificial APC: Bead
Signal 1
Growth
CD28 CTLA4TcR/CD4
Signal 2
Activated T Cell Production with Artificial APCs
Cellular and Vaccine Production Facility CVPF

19. Activated T Cell Production Ex Vivo
1. Leukapheresis, enrich, deplete,
or isolate cells of interest
3. Large scale cell expansion
Reinfuse
cells
4. Remove beads, wash
and concentrate cells
2. Stimulate cells with
aAPC
5. Quality Control

20. 100
10
1
0.1
0.01
T cell
expansion
ex vivo
Cancer
Vaccine
“Threshold
for cure”% Tumor
specific
T cells in
vivo
Hypothesis
Combining Active and Passive
Immunotherapy

21. Central Hypothesis
• Idiotype (Id-KLH) vaccine + the vaccine-primed adoptive
T cell transfer will result in a robust Id-specific humoral
and cellular response, compared to a control vaccine
(KLH only)

22. Objectives
• Primary
– Whether infusions of Id-KLH primed CD3/CD28 activated
autologous lymphocytes mediate a more intense Id-specific
immunity than KLH-primed CD3/CD28 activated autologous
lymphocytes
• Secondary
– To demonstrate that Id-KLH primed CD3/CD28 autologous
lymphocytes can be infused safely and effectively in more than
80% of eligible patients
– To determine whether Id-KLH primed CD3/CD28 activated
autologous lymphocytes are as safe and as well tolerated as the
KLH-primed primed CD3/CD28 activated autologous
lymphocytes
– To determine if the presence of Id-specific immunity correlates
with disease response

23. Overview of the Clinical Trial
Figure D1. Schematic overview of the clinical protocol.
Immunoassessment
R
Id-KLH/GM-CSF
Priming vs
Placebo vaccine
Id-KLH/GM-CSF
Booster
Vaccines /
Placebo
T cell
Transfer
Lymphodepletion
Chemotherapy
Day 0 Day 2Day -14
Apheresis
T cell expansion
B
A
Plasma-
pheresis
Eligibility
TumorRestaging
Multiple Myeloma SPORE, Project 1 (Qazilbash/Kwak)

24. Conclusions
• Lymphoma vaccination improves disease-free survival
following chemotherapy in patients already in complete
remission at time of vaccination (secondary prevention)
• The clinical effect of the vaccine is validated by the
subgroup analysis of patients expressing the IgM
isotype
• Long-term clinical experience with the vaccine
demonstrates low toxicity, making it ideal for
consolidation or maintenance therapy (standard of care)
• Future cancer vaccine strategies should feature
combinations with adoptive T-cell therapy or
immunologic checkpoint blockade

25. Acknowledgements
Center for Cancer
Kwak Laboratory Immunology Research
• Soung-chul Cha Sapna Parshottam
• Hong Qin Sattva Neelapu
• Sheetal Rao Sheeba Thomas
• Daniel Paick Dept. of SCTCT
• Ippei Sakamaki Richard Champlin
• Flavio Baio Muzaffar Qazilbash
• James Weng EJ Shpall/Ian McNiece
• Beata Lerman
• Guowei Wei
• Kunhwa Kim
• Sung Doo Kim
Grant support
• Leukemia & Lymphoma Society SCOR
(7262-08)
• Myeloma SPORE (NCI P50 CA142509)
• DoD CDMRP (W81XWH-07-1-0345)
• CPRIT (RP100457)