Abstract LB-140: Phase 1b/2 study of an intratumoral TLR9 agonist spherical nucleic acid (AST-008) and pembrolizumab: Evidence of immune activation
Authors: Milhem Mohammed M. , Perez Cesar A. , Hanna Glenn J. , Wise-Draper Trisha M. , Bhatia Shailender , Bexon Alice S. , Daniel Weston L. , O'Day Steven J. 
Published: September 2020

Abstract
Background: AST-008 is a novel spherical nucleic acid configuration of a toll-like receptor 9 (TLR9) agonist oligonucleotide, designed to trigger anti-tumor immune responses. Here we focus on immune activation upon AST-008 injection in the phase 1b/2 study in patients with advanced solid tumors (NCT03684785). Materials and Methods: AST-008 was injected intratumorally (IT) into one or more tumors QW for 8 doses, then Q3W thereafter, at doses from 2 to 32 mg. Starting at week 3, pembrolizumab was administered per label until toxicity or progression. Peripheral blood immune cell profiling and cytokine/chemokine analyses were performed before and 24 hours after both the first AST-008 dose (week 1) and the first combination dose (week 3). Serial tumor biopsies of lesions were collected from both AST-008-injected lesions and non-injected (“witness”) lesions at baseline, after IT AST-008 monotherapy, and after combination therapy. Results: Seventeen patients have been enrolled in the dose escalation cohort: median age 66 [range: 30-86], 82% male, median ECOG 1 [0-1]. Dose dependent lymphocyte activation was observed after IT AST-008. AST-008 dosing alone (16 mg cohort, n = 3) increased activated fractions of CD4+ (33%) and CD8+ T cells (64%), monocytes (97%) and NK cells (94%), compared to baseline (15%, 22%, 4%, and 37%, respectively). At AST-008 doses of 8 and 16 mg, the cell activation response within a dose level was generally similar in the presence or absence of pembrolizumab. In addition, the cytokines/chemokines IL-12p40, IL-1RA, IP-10, and MCP-1 were induced in a dose-proportional manner after IT AST-008 mono- or combination therapy. IT AST-008 resulted in average fold increase of 5, 12, and 16 for doses of 2, 4, and 8 mg dose cohorts, respectively, in IP-10 concentration from baseline (n = 11). Generally, combination therapy with pembrolizumab and AST-008 at doses of 2 and 4 mg produced a cytokine/chemokine response that was smaller than AST-008 alone (n = 5), but 8 mg dose responses were similar after monotherapy or combination therapy (n = 3). Preliminary analysis of serial biopsies by Nanostring revealed increased T cells and cytotoxic cells in the injected lesion after AST-008 dosing (n = 4) and in the non-injected witness lesion after combination therapy (n = 6). Combination therapy produced increases in B cells, T cells, cytotoxic cells and macrophages the AST-008 injected lesions (n = 6). Further PD data are being collected. The emerging safety profile consists mostly of grade (G) 1 and 2 injection site reactions and flu-like symptoms, reflecting local and systemic immune activation. One G3 lymphocytopenia has been observed, with no clinical consequences. No AST-008-related serious AEs or DLTs have been reported. Conclusions: IT AST-008 is well tolerated at the doses administered and is associated with dose-proportional systemic immune activation. Gene expression analysis suggests increased lymphocytes in the injected tumor after IT AST-008 and in both injected and witness tumors after combination therapy.
Citation Format: Mohammed M. Milhem, Cesar A. Perez, Glenn J. Hanna, Trisha M. Wise-Draper, Shailender Bhatia, Alice S. Bexon, Weston L. Daniel, Steven J. O'Day. Phase 1b/2 study of an intratumoral TLR9 agonist spherical nucleic acid (AST-008) and pembrolizumab: Evidence of immune activation [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-140.