Robert P. Edwards, MD, Chair of OB/GYN/RS, Co-Director of Women's Cancer Program at University of Pittsburgh, offers information about the current state of immunotherapy for recurrent ovarian cancer patients.

1. IMMUNOTHERAPY AND
RECURRENT OVARIAN CANCER:
TIME FOR NEW PARADIGMS!
ROBERT P. EDWARDS MD
CHAIR OF OB/GYN/RS
CO-DIRECTOR WOMEN’S CANCER PROGRAM
UNVERSITY OF PITTSBURGH
MWRI AND UPCI
DIRECTOR WOMEN’S HEALTH SERVICE LINE
OF UPMC

2. IMMUNOTHERAPY FOR
RECURRENT OVARIAN CANCER
• Introduction
• Inflammation and
Cancer
• Historical Vaccine
Experience
• New Paradigms
• The Promise of
Checkpoints

3. Ovarian Cancer:
Highest Mortality of All Gynecologic Malignancies

4. BALANCE OF INFLAMMATION AND
DEATH
ZOU, 2004

5. Inflammation
• Inflammation is integral
to most carcinogenesis
• Most tumors induce
measurable immunity
during carcinogenesis
• “Bad” inflammation is
there from the beginning

6. Healthy
Individuals
Premalignancy Cancer
Diagnosis
Treatment Survivorship
Improved early detection and prevention
…through better understanding of ovarian cancer precursors
Endometriosis is a chronic inflammatory disease that
increases the risk for ovarian cancer
Endometriosis
Atypical
Endometriosis
Endometriosis-
Associated Ovarian
Cancer (EAOC)

7. Atypical Endometriosis Transitions to Ovarian Cancer
Clear
Cell
Tumor
Atypical
Cells
normal
cancer
Atypical transition
Inflammation drives ovarian cancer
development
Stromal
inflammation

8. T CELLS INFILTRATES
ZHANG, 02

9. 0 20 40 60 80 100 120 140
Overall Survival (Months)
0.0
0.2
0.4
0.6
0.8
1.0
CumulativeSurvival
Intraepithelial CD8+ TIL
lowest tertile
all others
Log Rank test
P=0.009
Median survival: 55 Vs 26 months
Hazard ratio: 0.33 (p = 0.0003)Sato et al, PNAS. 2005, 102:18538
Evolution of the RPCI-UPCI Ovarian SPORE: High
Intraepithelial CD8+ TILs is associated with
improved survival

10. Clinical Course Overview
Disease
Burden
Low
NED
High
Time (months)
0 1 7 19 31 60
CA125  35
Death
CA125 >35
“Watchful waiting”
Surgery
Chemotherapy
(platinum/taxol)
Clinical Recurrence
“Watchful
Waiting”
“Recurrent
Disease”
06/07
15
10
08
12

11. Galluzzi et al, Oncotarget, 5 (24) 2015
Ovarian Cancer
Immunotherapy
Budiu, Edwards,
Vlad et al,
Cancer Imm
Immunother
2011, 2012
IP IL-2
Budiu,
Kalinski,
Edwards, et
al,
Oncogene
2013
MUC1
Mony, Vlad,
Edwards et al,
Cancer Immunol
Immunother 2015
aPD-L1
SPORE:
EDWARDS/
KALINKSI
IDO,
CHEMOTHERAPY

12. CANCER VACCINES
• Prophylactic
• Therapeutic
o Peptides and proteins
• Free peptide*
• HSP-peptide
• Dendritic cell-loaded peptides
o Antibodies
• Anti-idiotype
• Hybrid engineering
o Whole tumor

13. Antigens
(rank/reference
number and
name)
Cumulati
ve score
Therapeutic
function
(0.32)
Immunogen
icity (0.17)
Oncogenicity
(0.15)
Specificit
y (0.15)
Expression
level and %
positive cells
(0.07)
Stem cell
expression
(0.05)
No. patients
with antigen-
positive
cancers
(0.04)
No.
epitopes
(0.04)
Cellular location of
expression (0.02)
1. WT1 0.81 0.75 (fair) 1.0 (trials) 1.0 (o) 0.54 (o) 0.37 (hm) 1.0 (st) 1.0 (mphl) 1.0 (mu) 0.95 (iMHC)
2. MUC1 0.79 0.75 (fair) 1.0 (trials) 1.0 (o)
0.23
(posttransl
ational
changes) 1.0 (ha) 1.0 (st) 1.0 (mphl) 1.0 (mu) 0.25 (sc)
3. LMP2 0.78 0.75 (fair) 1.0 (trials) 0.34 (pv) 1.0 (ab) 0.37 (hm) 1.0 (st) 1.0 (mphl) 1.0 (mu) 0.95 (iMHC)
4. HPV E6 E7 0.77 0.89 (mixed) 1.0 (trials) 0.34 (pv) 1.0 (ab) 0.23 (la)
0.73 (all
stages, 11;
stem cells, 3) 0.16 (mpll) 1.0 (mu) 0.95 (iMHC)
5. EGFRvIII 0.76 0.76 (mixed) 1.0 (trials)
0.62 (o), 8;
uncertain but
decreased
survival, 7) 1.0 (ab) 0.37 (hm) 1.0 (st)
0.11 (high level,
small subset) 0.13 (s) 1 (slc MHC)
6. HER-2/neu 0.75 0.85 (adequate) 1.0 (trials) 1.0 (o) 0.35 (oe) 0.37 (hm) 0.66 (al)
0.11 (high level,
small subset) 1.0 (mu) 0.25 (sc)
7. Idiotype 0.75 0.76 (mixed) 1.0 (trials) 0.12 (d) 1.0 (ab) 1.0 (ha) 0.66 (al) 0.14 (unique) 1.0 (mu) 1.0 (slc MHC)
8. MAGE A3 0.71 0.79 (mixed) 1.0 (trials) 0.25 (ubds) 0.54 (of) 0.37 (hm) 1.0 (st) 1.0 (mphl) 1.0 (mu) 0.95 (iMHC)
9. p53 nonmutant 0.67 0.42 (mixed) 1.0 (trials) 1.0 (o) 0.35 (oe) 0.37 (hm) 1.0 (st) 1.0 (mphl) 1.0 (mu) 0.95 (internal MHC)
10. NY-ESO-1 0.66 0.75 (fair) 1.0 (trials) 0.25 (ubds) 0.54 (of) 0.37 (hm) 1.0 (st)
0.11.0 (high
level, small
subset) 1.0 (mu) 0.95 (iMHC)
The Prioritization of Cancer Antigens: A National Cancer Institute Pilot
Project for the Acceleration of Translational Research
Clin Cancer Res 2009; 15 (1N=75

14. REVIEW OVARIAN CANCER
THERAPEUTIC VACCINES
• 36 English language trials most uncontrolled phase I/II
o 3 Randomized placebo-controlled trials
(oregovamab trials)
o 6 randomized allocation studies
o Median patient number (2 to 371)
• Outcome measures highly variable (2010)
o Immunologic response endpoints 34
o Clinical response measures 21
o Survival 25
o Toxicity 28
• Current Trials Open (Clinical Trials.gov)
o 23 Trials nation-wide involving a vaccine or
immunotherapy
LEFFLER, 2010

15. CANCER VACCINES
• Prophylactic Vaccines
o Peptide
o VLP
• Therapeutic Vaccines
o Peptide and DC/cytokine
o VLP
o Antibodies
• Immune Adjuvants
o Co-stimulatory molecules
o Cytokines
o Anti T Regulatory/Myeloid Suppressor strategies

16. TARGET ANTIGENS
• Monoclonal antibody
o CA125
o EpCAM
o Membrane folate receptor
o MUC1
o Her2/neu

17. PEPTIDE-BASED
• P53
• NY-EOS-1
• HER2/NEU
• CEA
• MUC-1

18. OVARIAN CANCER
REMISSION
• Is this the right setting for vaccination?
o Prior chemotherapy induced involution
o No primary cytotoxic or biologic therapy has
been shown to extend overall survival in this
cohort
o Expensive trials to demonstrate efficacy (RCT
require 300 to 400 subject

19. Oregovomab (OvaRex®)
• Oregovomab forms xenotypic
complexes with CA125 in
circulation
• Immune complexes are taken
up by antigen-presenting cells
• Oregovomab enhances the
activation of T cells by:
– Increasing uptake
– Cross-presenting on HLA
Class I and II
– Activating T helper cells
and CTL
– Stimulating immune
function by exposure to
foreign antibody
CA-125-specific monoclonal antibody to induce anti-tumor immunity
1 Gordon et al. Gynecol Oncol 2004;94(2):340-351.

20. OvaRex® Clinical Trial Overview
Disease
Burden
Low
NED
High
Time (months)
0 1 7 19 31 60
CA125  35
Death
CA125 >35
“Watchful waiting”
Surgery
Chemotherapy
(platinum/taxol)
Clinical Recurrence
“Watchful
Waiting”
“Recurrent
Disease”
06/07
15
10
08
12

21. ADJUVANT TRIAL DESIGN
Berek, JCO. 2008

22. RESULTS OF
OREGOVOMAB TRIALS
o Consolidation
• Phase III Trial with
2:1Randomization
• Double-blinded
• Placebo-controlled
• 373 subjects
• Unither stops development

23. Adapted from Cancer Genome Atlas Research Network. "Integrated genomic analyses of
ovarian carcinoma." Nature 474.7353 (2011): 609-615.
No survival difference for any of the
transcriptional subtypes
The Cancer Genome Atlas (TCGA)
Identification of an “immunoreactive” group
in high grade serous ovarian cancer

24. Immune Profiling the OVCA TCGA Dataset
• N=327 genes with known immune functions, mostly associated with T cell (also
B and NK cell) immunity
• N=92 (28%) - immune effector/cytotoxic genes
• N=123 (38%)- immune regulation
• N=10 (3%) immune checkpoint
Cytotoxicity
T cell migration
Immune
checkpoint
Immune
suppression

25. OVARIAN CANCER
Effector and Inhibitory Molecules show positive
correlation in the tumor microenvironment
CD3
CD4
IFNG
TBX21
EOMES
CXCL9
CXCL10
FASLG
PRF1
GZMA
GZMB
LAG3
TIM3
PD1
PDL1
George Tseng, Ph
Charles Ma

26. OVARIAN BREAST KIDNEY GLIOBLASTOMA
Supervised Clustering Identifies Patients with Decreased Survival

27. Hemorrhagic
ascites
Injected
ovary
Diaphragm
implants
Uninjected
ovary (control)
A C DB
Ovarian
tumor

28. Normal Ovaries
OSE
Serous Clear CellEndometrioid
MUC1
More than 80% of epithelial ovarian tumors overe
MUC1-C acts and oncogen
D. W Kufe Cancer Biology & Therapy 8:13, 1197-1203; 1 July 2009
MUC1: Well defined tumor associated antigen, oncoprotein and vaccine candidate
Mucinous

29. Ovarian Cancer Standard of Care:
Surgery + Platinum/Taxane Chemotherapy
Combination Chemo-Immuno Therapy

30. CHEMOIMMUNOTHERAPY
• Debulking tumor burden also debulks stromal support
cells and consequently fascilitating inflammation
• T regulatory cells suppress in the existing new T cell
activation at tumor sites
• “ Wiping the slate clean with surgery and chemotherapy
allows naïve T cell recruitment as the tumor dies
• Synergy with chemotherapy and immunotherapy is
counter-intuitive but many groups are now adopting

31. Cisplatin Upregulates Human Tumor PD-L1 Expression
in vitro
OVCA420
(Resistant)
OVCA432
(Sensitive)

32. Cisplatin Upregulates Murine Tumor PD-L1 Expression
PD-L1
5.87%
PD-L1
14.2%
PD-L1
9.33%
PD-L1
20.2%
2F8 Ctrl 2F8 Cisplatin 2F8Cis Ctrl 2F8Cis
Cisplatin
2F8 PD-
L1
10X
40X
2F8Cis PD-
L1
10X
40X
2F8 2F8cis

33. Cisplatin Increases T Cell Infiltration in vivo
3684T(Anti-PD-L1) CD3
3797T(Anti-PD-L1) CD3
3874T(Cisplatin) CD3
3873T(Cisplatin)
CD3
3906T(Cis/Anti-PD-L1) CD3
3905T(Cis/Anti-PD-L1)
CD3
10X
10X10X 10X
10X 10X
40X
40X40X40X
40X40X
Grabosch et al, In prepa

34. Celecoxib Improves Overall Survival in
Combination with Cisplatin and Anti-PD-L1
• Cyclooxygenase-2 (COX-2)
o Proinflammatory enzyme expressed by ovarian cancer
o Poor prognostic marker
o Product prostaglandin E2 (PGE-2) associated with invasion
• Celecoxib
o Selective COX-2 Inhibitor
0 1 0 2 0 3 0 4 0 5 0
0
5 0
1 0 0
S u rv iv a l p ro p o rtio n s : C o n tro l v s C is p la tin /C e le c o x ib /A n ti-P D -L 1
T im e
Percentsurvival
C o n tro l
C is /C e le /P D -L 1p = 0 .0 0 2 7 *

35. Roswell Park Cancer
Institute
University of Pittsburgh
Cancer Institute
PD-L1 is present in areas of T cell infiltration
PD-L1
CD8
DAPI
Frances Zeng

36. Acknowledgments
Shannon Grabosch, MD
Jyothi Mony, PhD
Frances Zhang
Lixin Zhang, MD PhD
Joan Brozick, MHA
Mirna Bulatovic, PhD
•Tianzhou Ma, MS-University of Pittsburgh, Dept of Statistics
•George Tseng PhD- University of Pittsburgh, Dept of Statistics
•Esther Elishaev, MD- Magee-Womens Hospital
NIH R01 CA163462
NIH P50 RPCI-UPCI SPORE
DOD Ovarian Cancer Academy – OC093429
Developmental Research Project- UPCI/RPCI Ovarian Cancer SPORE
Anda Vlad , MD, PhD
Pawel Kalinski, MD PhD