Lirilumab Enhances Anti-Tumor Efficacy of Elotuzumab
Authors: Sola Caroline , Blery Mathieu , Bonnafous Cécile , Bonnet Elodie , Fuseri Nicolas , Graziano Robert F , Morel Yannis , André Pascale 
Published: October 2019

Abstract
Tumor cells that express reduced levels of Major Histocompatibility Complex (MHC) class I molecules may be recognized and killed by Natural Killer cells (NK cells), through a process known as “missing self” recognition. In humans, this is controlled by inhibitory receptors such as Killer Immunoglobulin-like Receptors (KIR) that recognize Human Leukocyte Antigen (HLA)-A, -B or –C. Engagement of KIR by HLA molecules results in inhibitory signaling that reduces NK cell-mediated natural killing and antibody-dependent cellular cytotoxicity (ADCC). Hence, antibodies that block interactions between inhibitory KIR and their HLA ligands are being evaluated as an anti-cancer therapeutic strategy. The anti-KIR2DL1/2/3-specific monoclonal antibody, lirilumab (BMS-986015 / IPH2102), is a fully human IgG4 that blocks binding of KIR to HLA-C, and is being developed for treating hematologic malignancies and solid tumors.
Elotuzumab (BMS901608 / HuLuc63) is a humanized IgG1 anti-SLAMF7 (signaling lymphocyte activation molecule family member 7, CS-1) being developed for the treatment of Multiple Myeloma (MM). SLAMF7 is a cell surface glycoprotein highly expressed in myelomatous cells and only at low levels on normal cells. NK cell-mediated ADCC is one of the main mechanisms of action of elotuzumab, but ADCC is negatively regulated by KIR checkpoint receptors. Thus a combination of lirilumab and elotuzumab has strong scientific rationale. The aim of the present study was to assess whether lirilumab would enhance elotuzumab anti-MM activity in vitro with human peripheral blood NK cells and MM cell lines, and in vivo in a newly developed xenogenic mouse model.
Two MM cell lines (OPM-2 and U266B1) were identified that express both HLA-C and SLAMF7. These MM cells were capable of activating peripheral blood NK cells from healthy donors in vitro, as assessed by three different endpoints (CD107 mobilization on NK cells surface and intracellular production of the cytokines IFN-g and TNF- a); each of these responses were significantly enhanced, in a dose-dependent manner, by both lirilumab and elotuzumab independently. Moreover, the elotuzumab-mediated functional activation of KIR2D+ NK cells could be further enhanced by the addition of increasing doses of lirilumab. The best combinatorial effect was observed in response to MM cells expressing low densities of SLAMF7. These data suggest that lirilumab treatment may increase the therapeutic efficacy of elotuzumab, particularly in MM patients with low SLAMF7 expression. In these experiments, it was not possible to clearly identify the impact of Fc receptor genotype or HLA-C genotype on the NK cell responses.
To assess the therapeutic efficacy of lirilumab and elotuzumab in vivo, we generated a novel strain of double-transgenic mice expressing human KIR2DL3 as well as its ligand, HLA-cw3, on a Rag1-/- background (KIR-cw3-tgRAG mice), to allow engraftment of human MM tumor cells expressing SLAMF7. The OPM-2 MM cell line was subcutaneously engrafted in these mice and when high tumor volumes were reached, mice were treated with lirilumab, elotuzumab or a combination of both. As monotherapy, each of monoclonal antibody had some therapeutic effect while the combination of both resulted in a significantly stronger anti-tumor effect and increased survival of the mice. Median survival of mice treated with huIgG control was 38 days, 41 days with lirilumab, 42 days with elotuzumab and 51 days with both mAbs in combination (10 mice per group). In conclusion, we demonstrate that blockade of KIR checkpoint receptors with lirilumab was able to augment elotuzumab mediated ADCC in vitro and synergized with elotuzumab to mediate potent anti-MM activity in vivo. Taken together, these data provide a rationale for clinical trials to test combination treatment of lirilumab and elotuzumab in MM patients.

Disclosures
Sola: InnatePharma: Employment, Equity Ownership. Blery:Innate Pharma: Employment, Equity Ownership. Bonnafous:Innate Pharma: Employment, Equity Ownership. Bonnet:Innate Pharma: Employment, Equity Ownership. Fuseri:Innate Pharma: Employment, Equity Ownership. Graziano:Bristol-Myers Squibb: Employment; Bristol-Myers Squibb: Equity Ownership. Morel:Innate Pharma: Employment, Equity Ownership. André:Innate Pharma: Employment, Equity Ownership.