CellGene Therapy by Jeff Sheehy the California Institute for Regenerative Medicine CIRM Jerome Zack UCLA HansPeter Kiem The Fred Hutchinson Cancer Research Center Jessica Handibode ID: 776655
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Slide1
Cell/gene therapy
HIV Cure Research Training Curriculum
Cell/Gene Therapy by:
Jeff Sheehy, the California Institute for Regenerative Medicine (CIRM)
Jerome Zack, UCLA
Hans-Peter
Kiem
, The Fred Hutchinson Cancer Research Center
Jessica
Handibode
,
AVAC
July, 2015
The HIV CURE training curriculum is a collaborative project aimed at making HIV cure research science accessible to the community and the HIV research field.
Slide2Session Goals/Objectives
Learn about how therapies that insert genes and use cells is on the brink of transforming medicine and curing disease.
Learn how Gene/Cell therapies fit into HIV cure efforts
Learn the targets, techniques, and cell types used in HIV Gene/Cell Therapy
Understand the risks associated with Gene/Cell therapy clinical trials
Slide3Timothy Brown Road to a Cure for HIV
HIV+ Acute Myeloid Leukemia Patient
Identification of HLA-identical, CCR5Δ32 homozygous bone marrow donor
Chemo- and Radiotherapy Conditioning
Allogeneic stem cell transplant
6 years later: remains cured
Slide4GOOD MORNING AMERICAUCLA Researchers Announce Gene Therapy Cure for 18 ‘Bubble Baby’ Patients Nov 18, 201418 patients with Severe Combined Immunodeficiency Disease (SCID) ranging in age from 3 months to 4 years at the time of treatment.Their blood stem cells (hematopoietic stem cells) were removed from their bone marrow and genetically modified to correct the gene defect that had left the children without a working immune system.The children were cured without any side effects.
New York TimesIn Girl’s Last Hope, Altered Immune Cells Beat LeukemiaDecember 9, 2012Juno Therapeutics, the company developing the therapy, in a study found an 89 percent remission rate among 27 adults with acute lymphoblastic leukemia no longer responding to other treatments.Doctors remove millions of the patient’s T-cells and insert new genes that enable the T-cells to kill cancer cells.The new genes program the T-cells to attack B-cells, a normal part of the immune system that turn malignant in this leukemia.The altered T-cells — called chimeric antigen receptor cells — are then dripped back into the patient’s veins, and if all goes well they multiply and start destroying the cancer.
Regenerative Medicine
/
Cell
-
Gene Therapy Maturing
Gene
modification of
patients’ own
immune cells returned to patients is saving lives.
Slide5What is Cell/Gene Therapy
A branch of
Regenerative Medicine
, an emerging field that involves
the "process of replacing, engineering or regenerating human cells, tissues or organs to restore or establish normal
function”.
Gene therapy
is
the the
delivery
of therapeutic gene into
a patient's
cells to treat disease.
Cell therapy
is the delivery of intact, living cells into a patient to treat disease.
Combination
Cell/Gene
Therapy
approaches that seek to insert genes into a patients’ own cells to control or kill HIV are in clinical trials now.
Slide6Ex vivo gene therapy - Usually with blood cells (lymphocytes or blood stem cells) for diseases affecting the hematopoietic systemIn vivo gene therapy -Oncolytic adenoviruses for the treatment of cancerAdeno-associated vectors for the treatment of Duchenne muscular dystrophy or hemophiliaNon-viral for cancer
Different Routes of Gene Therapy
Slide7Sterilizing Curecomplete eradication of all replication competent forms of HIV. The reservoir is gone.Timothy Brown received a sterilizing cure.
Functional CureLife-long control of virus in the absence of antiretroviral therapy, but without achieving complete eradication of HIV.Virus remains in reservoirs in the body.
Sterilizing vs functional cure
Slide8Gene Therapy in Blood Cells
Slide9Therapeutic HIV protection gene
Gene Therapy in Blood Cells
Slide10Gene Therapy in Blood Cells
Slide11Gene Therapy in Blood Cells
Slide12Therapeutic HIV protection gene
Gene Therapy in Blood Cells
Slide13Some targets for gene therapy
Slide14Some targets for gene therapy
Slide15Some targets for gene therapy
Slide16Some targets for gene therapy
Slide17Some targets for gene therapy
Slide18Gene Therapy- Vectors to deliver anti-HIV genes
LV- Lentivirus vectors RV- gammaretroviral vectors, AAV – adeno-associated vectors Adenovirus vectorsVectors are replication defective – so they cannot replicate and spread once they are inside the cells and after delivering the anti-HIV genes
Slide19Patient
Ex Vivo Gene Therapy: Putting Functional Genes Into Marrow Stem Cells or T cells Outside of the Body
Slide20Patient
Ex Vivo Gene Therapy: Putting Functional Genes Into Marrow Stem Cells or T cells Outside of the Body
Mobilization
Leukapheresis
OR
Bone Marrow Harvest
Slide21Patient
Ex Vivo Gene Therapy: Putting Functional Genes Into Marrow Stem Cells or T cells Outside of the Body
Virus-Mediated Transfer of
Therapeutic Gene
GOAL: Gene modified cells engraft and correct or treat the disease
- Cancer
- Genetic disease
- Infectious disease
Slide22Patient
Ex Vivo Gene Therapy: Putting Functional Genes Into Marrow Stem Cells or T cells Outside of the Body
Reinfusion
Slide23Next GenerationTechnology
Genome editingZinc finger TAL Effector NucleaseCRISPR/Cas9MegaTals
NH2
COOH
Zinc finger
TAL Effector Nuclease
CRISPR
/Cas9
megaTAL
Slide24HIV target gene eg CCR5
Thanks to Barry Stoddard
Site-Specific Gene
Targeting / Engineering
Slide25Scarless
Repair Of Genetic Defect or
Targeted Insertion Of New Genetic Material
Slide26Scarless
Repair Of Genetic Defect or
Targeted Insertion Of New Genetic Material
Slide27Scarless
Repair Of Genetic Defect or
Targeted Insertion Of New Genetic Material
Slide28Scarless
Repair Of Genetic Defect or
Targeted Insertion Of New Genetic Material
Slide29Kiem et al. Cell Stem Cell 2012 (modified)
Patient
Hematopoietic Stem Cell Modification and
Transplantation to Cure HIV/AIDS
Slide30Collection HSCs
Kiem et al. Cell Stem Cell 2012 (modified)
Patient
Hematopoietic Stem Cell Modification and
Transplantation to Cure HIV/AIDS
Slide31Collection HSCs
Kiem et al. Cell Stem Cell 2012 (modified)
Vector mediated gene transfer of HIV resistance genes
Nucleases for CCR5 disruption
Nucleases to eliminate integrated Virus
Patient
Hematopoietic Stem Cell Modification and
Transplantation to Cure HIV/AIDS
Slide32Expanding gene-edited and corrected
HSCs
Collection HSCs
Kiem et al. Cell Stem Cell 2012 (modified)
Vector mediated gene transfer of HIV resistance genes
Nucleases for CCR5 disruption
Nucleases to eliminate integrated Virus
Patient
Hematopoietic Stem Cell Modification and
Transplantation to Cure HIV/AIDS
Slide33Expanding gene-edited and corrected
HSCs
Development of novel
conditioning
regimens for efficient engraftment
Generation of HIV protected blood and immune system inside the patientIIn vivo selection
Collection HSCs
Kiem et al. Cell Stem Cell 2012 (modified)
Vector mediated gene transfer of HIV resistance genes
Nucleases for CCR5 disruption
Nucleases to eliminate integrated Virus
Patient
Patient
Hematopoietic Stem Cell Modification and
Transplantation to Cure HIV/AIDS
Slide34Current Clinical Approaches
Slide35Timothy Brown--cured of HIV through a transplant of hematopoietic stem cells with a natural mutation that largely prevents HIV infection. This mutation can be replicated via gene therapy.Timothy received the stem cells from a donor and the resulting graft vs host disease was likely a factor in his cure. Attempts to replicate have failed in 6 patients due to the severity of their cancer.Matt Sharp took part in a clinical trial in which his own T-cells were removed from whole blood via apheresis and then gene modified and returned into his body. The Phase I trial recruited immunologic non-responders and Matt experienced a rise in his T-cell count. Sangamo, the sponsor, reported Phase II trial results in late 2014, that a “single infusion” of modified T cells “resulted in sustained reduction and control of viral load in the absence of antiretroviral drugs in several subjects..” and “a decrease in the size of the HIV reservoir.”
Cell/Gene Therapy—Why?One cure, human trials underway
Slide36Current Clinical Trials
MazF
-T
Redirected
MazF
- CD4 autologous T-cells
Phase 1
Study Completion: 2016
SB728-mR-T +
cyclophosphamid
Phase 1/II
Study Completion: 2018
Genetically modified periphal blood stem cell transplant in treating patients with HIV-associated non-Hodgkin’s lymphoma or Hodgkin lymphomaStudy Completion: 2019
VRX- 496University of PennsylvaniaPase I/IIStudy Completion: 2020
www.treatmentactiongroup.org/cure/trials
Slide37Clinical trials—blood cancer patients
Many trials recruit lymphoma or leukemia patients who need a transplant
Undergo conditioning to eliminate current immune system to create space for a new system
The HSCs used in these trials are autologous, meaning that they are taken from the patients
not
from a donor
.
Their HSCs are gene modified to resist HIV, and are then transplanted back into the participant in a mix of modified and unmodified cells.
Slide38Clinical trials-other patient populations
Other trials propose going into healthier patients—currently, either immunologic non-responders or patients who have quit taking ART (treatment fatigue) as participants.
Some of these trials include conditioning regimens which present toxicity issues
Slide39Clinical Trial Issue
CCR5
deletion is
unlikely to be sufficient by itself in many patients.
Mutated HIV
that uses the CXCR4 receptor to infect cells
is a potential complication
Gene therapy that blocks HIV in multiple ways will be needed.
Slide40Clinical Trial Issue
During
cell modification, the percentage of cells modified varies, and
a low yield
of modified cells is a barrier
.
Enough cells must be modified to achieve a therapeutic effect.
Hematopoietic cells are stimulated in a patient using drugs prior to apheresis to increase their number and percentage in the blood and enable more cells to be modified and returned.
Slide41Gene therapy clinical trial concerns
Gene therapy trials involve different gene editing/modifying techniques. Precision is key, a serious concern is “off target” editing. If the genes other than those targeted are modified (off target editing), the potential for serious adverse events exist, including cancer.
Slide42Treatment Interruptions
Seen as essential to allow modified cells to engraft and increase as a proportion of the cell population and to allow HIV to kill unprotected cells, and thus select for modified cells.
This process carries potential risks like
treatment regimen resistance
Slide43Basic Science Approaches- Improving the Technology and Engineering Possible Solutions
Slide44Patient
Expansion
of
gene-edited and
HIV protected HSCs
Collaboration Dr. Sauvageau (new UM171 molecule Fares et al Science 2014)
Development of novel conditioning
regimens, treosulfan,Astatine-211-based RIT, CAR-T cells
Generation of genetically modified HIV protected blood and immune system inside the patientin vivo selection
HSC Collection
Kiem et al. Cell Stem Cell 2012 (modified)
Vector mediated
gene therapy
Nuclease-mediated
protection from HIV
Nuclease-mediated disruption of integrated HIV
Patient
Hematopoietic Stem
Cell Gene Therapy / Editing for HIV
Slide45O6BG/BCNU
% Gene Marking
Days After Transplantation
Gene Marking
Therapeutic Threshold
In vivo
Selection to increase the Percent HIV-protected cells
Slide46Macrophage Activation
B-Cell function
CD8
+
T-Cell function
Cytolytic Activity
Long-term protection
Dampening of IR
Peripheral Tolerance
Maintenance of Lymphoid Tissue
Maintenance of SHIV-Specific CD4
+
T-Cells
Resistance to Direct Infection
R5- tropic
X4- tropic
Dual-tropic
Development of Gene Modified, Infection Resistant CD4
+
T-cells
Decreased Viremia
HSC M
odification Results in the Development of Infection Resistant Immune Cell Populations and an Enhanced Immune Response
Younan…Kiem Blood 2013
Slide47Other Gene/Cell therapy approaches
T cells are taken from the peripheral blood of patients suppressed on antiretroviral therapy and presented with multiple HIV antigens before expansionCells are functional and have broadly specific and potent HIV infected cell killing ability and the ability to suppress HIV replication Can be used with latency reversing agents as a “kill” strategy
HIV: Shock and Kill. Steven G
Deeks
.
Nature
487, 439-440 (26 July 2012)
Slide48Chimeric antigen receptor (CAR)
Antigen binding componentExpressed on outside of cell;This can be part of an antibody, or other molecule Usually binds HIV envelope on infected cellsHLA independent; Signaling ComponentSends signal into the cellDirects the cell to kill HIV infected target
CD3
ζ
Binds
Viral
protein
Slide49CD4-zeta CAR Vector For Introduction into Stem Cells
UbC
H1
CCR5
sh1005
Δ
LTR
5’ LTR
EGFP
CD4-zeta
7SK
sh516
2A
D1
D2
D3
D4
CD4-Tm
Zeta
CD4 extracellular Domain
Anti-HIV protective genes
Signaling Domain
Slide50Other approaches:
Chimeric antigen receptor T cells (CAR T cells)
Engineering hematopoietic and T stem cells that attack and kill cells infected with HIV. Provides a self-renewing population of both CD8+ and CD4+ HIV-targeted T-cells resistant to direct HIV infectionAlso used in cancer
Jacobson, Caron A., and Jerome Ritz. "Clinical Trials Time to Put the CAR-T before the Horse."
Blood Journal
.
American Society
of Hematology, 3 Nov. 2011.
Slide51New avenues: In vivo gene modification
A new class of genetic engineering tools called targeted nucleases make genetic engineering of stem cells much more precise and therefore saferDeliver these reagents directly to the stem cells in the body, Uses a viral vector that specifically targets hematopoietic cells in vivo.
HSC
T cells
Slide52Conclusions
Regenerative Medicine/Cell-Gene Therapy is a rapidly maturing field offering potential for cures and therapies in several diseases and conditions
Clinical trials in HIV are underway or planned
A functional cure may result, but clinical benefit such as increased T cells for immunological non-responders would also help some patients greatly. And cell/gene therapy could provide the “kill” in “kick and kill”. It doesn’t have to lead to a cure by itself.
Slide53Conclusions
Current approaches in trial are very complex, but as the technologies develop, easier to administer and cheaper therapies will be available.
Risks, such as off-target effects and the need for treatment interruptions, are high in early trials and participants should carefully consider all risks before entering a trial.
Slide54Acknowledgements