1. Cord Blood Natural Killer Cells for
Immunotherapy
Nina Shah, M.D.
Assistant Professor
Department of Stem Cell Transplantation and Cellular Therapy
M.D. Anderson Cancer Center
Houston, TX

2. OBJECTIVES
• NK cell tumor immunity
• Generation of CB NK cells
• Modulating the NK response
• Clinical implications

3. BACKGROUND: NATURAL KILLER (NK)
CELLS
• Non T/B cytotoxic lymphocytes
• CD56+/CD3-
• Mechanisms of action
• ADCC
• Killer Immunoglobulin-like
Receptor (KIR)-MHC Class I
mismatch

4. NCRs +
±
+
KIRs, CD94
2B4, NTBA
NKG2D
?
HLA I
CD48?
MICA, MICB, ULBPs
KIR-HLA I MISMATCH: “MISSING SELF”
HYPOTHESIS1
1. Moretta et al, Nature Immunology, 2002
NK Cell Target Cell

5. Donor KIR Type (HLA type) Recipient HLA Type
2DL2/3 (C1) C2 homozygous
2DL1 (C2) C1 homozygous
2DL2/3 + 2DL1 (C1 + C2) C1 or C2 homozygous
3DL1 (Bw4) Bw4 negative
ALLOREACTIVE DONOR KIR-RECIPIENT HLA I
COMBINATIONS

6. NK CELLS AND ALLOREACTIVITY
• Allo-reactive NK cells predict better outcome in
haplo-SCT’s for AML1
• Lower relapse rate in patients transplanted in CR
• Better EFS in patients transplanted in relapse or remission
• Reduced risk of relapse or death
• KIR-ligand incompatibility associated with improved
outcome after UCBT for acute leukemia
• Improved LFS, OS
• Decreased relapse rate
• Results more evident for AML
1. Ruggeri et al, Blood 2007
2. Willemze et all, Leukemia, 2009

7. WHY DON’T NK CELLS PROMOTE GVHD?
Ruggeri et al, Blood, Cells, Mol and Dis, 2004
GVL
GVHD
Ruggeri et al, Blood, Cells, Mol and Dis, 2004

8. ARE ALLOGENEIC NK CELLS SAFE?
• Haplo-identical NK cell infusion well-tolerated without
evidence of GVHD and some transient CR’s1
• MDACC protocol 2005-0508 and 2010-0099:
• AML/MDS, CML pts (15 +5 so far)
• Up to 8.24 x 106 CD56+ cells/kg have been infused
• No infusional toxicities, grade 3 GVH or delayed engraftment thus far
• U of AK experience2: Relapsed/refractory myeloma
• N=10
• Haplo-identical KIR-mismatched NK cells with auto-HCT
• No GVH
• No autograft rejection
• 50% nCR +CR; PFS 0-533 days
1. Miller, Blood 2005
2. Shi, Br J Haematol, 2008

9. WHY DON’T AUTOLOGOUS NK CELLS WORK?
• Altered balance of inhibitory and activating receptors on
autologous NK cells1
• Altered ligands on tumor cells - requiring more active NK
cells than at baseline2
• Change in distribution of NK cell subpopulations (LN, PB) 3
• Direct immunosuppression by tumor cell –produced
soluble factors (cytokines, ligands) 1, 4
• NK cells from MM patients express PD-15
• Increased Class I on MM cells in advanced disease6
1. Lion, Leukemia, 2012
2. Veuillen, JCI, 2012
3. Gibson, Hum Pathol, 2011
4. Reiners, Blood, 2013
5. Benson, Blood, 2010
6. Carbone, Blood, 2005

10. CORD BLOOD AS A SOURCE OF NK
CELLS
• Peripheral blood (PB)
• Requires collection
• (Mis)-Matching
• Cord blood (CB)
• Immediate availability
• More flexibility in matching
• More naïve T cell repertoire

11. CB NK CELLS: CHALLENGES
• Ability to expand CB NK cells
• Expanded CB NK cells have appropriate
phenotype
• CB NK cells are as active as PB NK cells
• Must use frozen cord blood units

12. TECHNIQUES OF CB NK CELL EXPANSION

13. CB NK CELL EXPANSION: TECHNIQUES
• CD56 selection + IL-2
• Feeder cells: K562 antigen-presenting
cells expressing Fc-IL-21 or IL-15 +IL-2
• Gas permeable culture system

14. IL-21
CD86
4-1BBL
CD19
FcγRI
IL-15 4-1BBL
K562-cl9-mIL21 K562-mb-IL15-
41BBL
ARTIFICIAL APC’S
Courtesy of Dr. L Cooper Courtesy of Dr. D. Campana

15. GAS PERMEABLE EXPANSION FLASKS

16. GAS PERMEABLE EXPANSION FLASKS
Gas permeable
membrane allows
for more efficient
gas exchange for
cells
Media
automatically
feeds cells by
convection
and diffusion

17. Frozen cord
Blood unit
Ficoll
MNC
Culture condition:
2(γ-irradiated)APC : 1 cord MNC
IL-2 100u/ml
GP500 bioreactor
Day 7
CD3 depletion (CliniMACS)
CD3-depleted NK cells
Culture condition:
2(γ-irradiated)APC : 1 CD3 - cell
IL-2 100u/ml
For another 7 days
Day 14
CD3 depletion (CliniMACS)
CD3-depleted NK cells
CD3+ cells
CD3+ cells
Flow cytometry
on day7 & 14
CD56
CD16
CD3
CD19
CD14
CD45
Clinical NK Expansion From Cryopreserved Umbilical Cord Blood
Thaw
Day 0

18. 1
10
100
1000
10000
Fresh + IL-2 Fresh + APC Frozen + APC
FoldExpansionofNKCells
A
0.1
1
10
100
1000
10000
0 7 14
NKCellExpansion,x106
Days
Fresh + IL-2
Fresh + APC
B
0.1
1
10
100
1000
10000
Fold NK increase # NK Cells
Produced (x 10e6)
# CD3+ Cells (x
10e6)
IL-15
IL-21
C
*
*
*
n=3 n=10 n=7
P <0.01
P <0.01
* P <0.01
P <0.01
APC CB-NK expansion from fresh or cryopreserved CB units yields
significantly greater fold expansion of NK cells than expansion of
CD56+ cells with IL-2 alone
Fold NK
increase
Absolute NK
(x 10e6)
Absolute CD3
(x 10e6)
IL-15 2659.5 883.1333333 0.872
IL-21
4093.66
6667 1471 4.495666667

19. 10
0
101
102
103
10
4
FL2 H CD(16 56) PE
10
0
10
1
102
10
3
10
4
FL4-H:CD3APC
39.3 0.22
7.5253
10
0
10
1
10
2
10
3
10
4
FL2 H CD(16 56) PE
10
0
101
10
2
103
10
4
FL4-H:CD3APC
0.22 0.39
77.521.9
10
0
10
1
10
2
10
3
10
4
FL2 H CD(16 56) PE
10
0
101
102
10
3
104
FL4-H:CD3APC
0.032 0.15
96.43.43
0 200 400 600 800 1000
0
200
400
600
800
1000
SSC-H:SideScatter
93.6
0 200 400 600 800 1000
0
200
400
600
800
1000
SSC-H:SideScatter
78.6
0 200 400 600 800 1000
0
200
400
600
800
1000
SSC-H:SideScatter
74.8
Day 0 Day 14Day 7
CD3SSC
FSC
A
CD56
aAPC
Eomes T-bet
B
C CD16 NKp30 NKp46 NKp44 KIR2DL1/DS1 KIR2DL2/DL3 KIR3DL
1
NKG2A CD94NKG2C
IL-2 alone

20. AFTER EXPANSION, CB NK CELLS ARE
AS ACTIVE AS PB NK CELLS
Pre-Expansion Post-Expansion
Xing et al, J of Immunotherapy, 2010

21. K562 RPMI 8226 Primary CD138+
cells
U266ARP-1
A
CD138+ CD138-
B
APC-expanded NK cells synapse with tumor targets.
0
10
20
30
40
50
60
%NK:TargetSynapseFormation

22. A
C
-10
0
10
20
30
40
50
60
70
80
10:1 1:1 0.1:1
%Cytotoxicity
Effecto:Target Ratio
K562
RPMI 8226
ARP-1
U266
Autologous
0
5
10
15
20
25
10:1 1:1 0.1:1
%Cytotoxicity
Effector:Target Ratio
CD138+
B
0
10
20
30
40
50
60
70
80
10:1 1:1 0.1:1
%Cytotoxicity
Effector: Target Ratio
IL-2
APC
APC-expanded NK cells are cytotoxic to various
myeloma targets

23. 0
5000
10000
15000
20000
25000
30000
35000
40000
8 15 22
ARP-1
ARP-1+ NK
Days after ARP-1 injection
LuminescenceinROI,p/s
0
500000000
1E+09
1.5E+09
2E+09
2.5E+09
3E+09
3.5E+09
4E+09
4 8 11 15 18 22
ARP-1
ARP-1 + NK
P <0.05 at each time point
Days after ARP-1 injection
Serumkappa,ng/mL
d.4
d.8
d.11
d.15
d.18
d.22
ARP-1 ARP-1 +NK
P <0.01 at each time point
CB-NK cells delay development of
myeloma in a NSG murine model

24. -8 -7 -5 0
Lenalidomide 10 mg daily
High dose
melphalan, 200
mg/m2
CB NK cells
Autologous
graft
PHASE I/II STUDY OF UMBILICAL CORD BLOOD-DERIVED
NATURAL KILLER CELLS IN CONJUNCTION WITH HIGH
DOSE CHEMOTHERAPY AND AUTOLOGOUS STEM CELL
TRANSPLANT FOR PATIENTS WITH MULTIPLE MYELOMA
-2

25. EXPANDED CB NK CELLS ARE ACTIVE
AGAINST CLL
EX CB NK
CLL-B
EX CB NK
CLL-B
EX CB NK
CLL-B
EX CB NK
CLL-B

26. Day -8 to -2: lenalidomide 10 mg PO daily
Day -7 to -4: Fludarabine 40 mg/m2 IV daily
Day -4: Melphalan 140 mg/m2 IV x1
Day -16 to -2
Identify 2 CB units
Use 20% fraction of
one unit to generate
NK cells
-16 -2 0
Ex vivo NK generation from 20%
fraction
Day 0
Infuse unmanipulated CB
units
100% CB# 1
80% CB# 2
Day -2
Infuse
expanded NK
cells
Protocol 2011-0493: Pilot study of double cord blood transplantation with ex-
vivo expanded cord blood derived natural killer cells to enhance the graft-versus-
leukemia effect in patients with relapsed/refractory lymphoid malignancies.
NK cell dose: 3- 7 x108 (can be obtained from the 20% fraction of the CB unit)
Principal Investigator: Chitra Hosing

27. ENHANCING CB NK ACTIVITY: LENALIDOMIDE

28. LENALIDOMIDE
• Immunomodulatory agent
• First-line novel agent in myeloma
• Direct anti-tumor effects via apopotosis
• Disrupts tumor microenvironment (anti-angiogenic
and anti-osteoclastic effects)
• Immunomodulatory effects, possibly on NK cells

29. Chromium Cytotoxicity
Assay
Treatment of target myeloma cells with
lenalidomide enhances CB NK cytotoxicity

30. TREATMENT OF EFFECTOR AND TARGET WITH
LENALIDOMIDE ENHANCES CELL KILLING OF PRIMARY
CLL
0
10
20
30
40
50
60
70
10:1 1:1 0.1:1
No Revlimid
Plus Revlimid
p < 0.001 at 1:1 and 10:1
E:T Ratio
PercentSpecificLysis

31. CAN LENALIDOMIDE REVERSE NK
DYSFUNCTION?
…Can lenalidomide enhance normal NK function?
Ramsay, Blood, 2012

32. CB NK CELL -PROJECTS IN DEVELOPMENT

33. FUCOSYLATION OF NK CELLS TO IMPROVE HOMING
TO BM
√
P-, L- & E-
Selectin?
BM endothelial cell
A
*
*
* *
*
*
*
*
*
*
*
*
*
*
CD34+
CB NK

34. NK
MM
FcR
Elotuzumab
NK CAR
Potential Targets for MM
• CS1
• Kappa/ lambda light chain
• CD38

35. CONCLUSIONS
• NK cells are a potential therapy for hematologic
malignancies
• Autologous NK cells do not provide sufficient anto-
tumor activity
• CB NK cells may be a safe and effective allogeneic
option to shift balance towards GVL and away from
GVH
• CB NK cells can be expanded to clinical scale
• CB NK cells have activity against myeloma and CLL
(and other hematologic malignancies)

36. ACKNOWLEDGEMENTS
Cell Therapy Laboratory
Elizabeth J. Shpall
Katy Rezvani
Ian McNeice
Beatriz Martin Antonio
Simon Robinson
Hong Yang
Eric Yvon
Amer Najjar
Simrit Parmar
Michael Thomas
Xiaoying Liu
Sufang Li
Junjun Lu
Van Nguyen
Indreshpal Kaur
Baylor College of Medicine-
Center for Cell and Gene Therapy
Catherine Bollard
Stephanie Ku, Benjamin Tzou
Department of Stem Cell Transplantation and Cellular Therapy
Richard Champlin
Chitra Hosing
Muzaffar Qazilbash
Department of Pediatrics
Laurence Cooper
Dean Lee
Department of Lymphoma/Myeloma
Robert Orlowski
Michael Wang
Qing Yi
Celgene Corporation

37. THANK YOU!