U.S. patent application number 14/911160 was filed with the patent office on 2016-06-30 for combination therapy for the treatment of cancer.
This patent application is currently assigned to Novartis AG. The applicant listed for this patent is Yan Chen, Xizhong Huang, Sunkyu Kim. Invention is credited to Yan Chen, Xizhong Huang, Sunkyu Kim.
Application Number | 20160184311 14/911160 |
Document ID | / |
Family ID | 51355593 |
Filed Date | 2016-06-30 |
United States Patent
Application |
20160184311 |
Kind Code |
A1 |
Chen; Yan ; et al. |
June 30, 2016 |
Combination Therapy for the Treatment of Cancer
Abstract
The present disclosure relates to a pharmaceutical combination
comprising (1) a first agent which is a CDK inhibitor or a
pharmaceutically acceptable salt thereof and (2) a second agent
which is an anti-hormonal agent or a pharmaceutically acceptable
salt thereof. The present disclosure also relates to a
pharmaceutical combination comprising (1) a first agent which is a
CDK inhibitor or a pharmaceutically acceptable salt thereof, (2) a
second agent which is an anti-hormonal agent or a pharmaceutically
acceptable salt thereof, and (3) a third agent which is an agent
that regulates the PI3K/Akt/mTOR pathway or a pharmaceutically
acceptable salt thereof.
Inventors: |
Chen; Yan; (Cambridge,
MA) ; Huang; Xizhong; (Cambridge, MA) ; Kim;
Sunkyu; (Cambridge, MA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Chen; Yan
Huang; Xizhong
Kim; Sunkyu |
Cambridge
Cambridge
Cambridge |
MA
MA
MA |
US
US
US |
|
|
Assignee: |
Novartis AG
Basel
CH
|
Family ID: |
51355593 |
Appl. No.: |
14/911160 |
Filed: |
August 7, 2014 |
PCT Filed: |
August 7, 2014 |
PCT NO: |
PCT/IB2014/063782 |
371 Date: |
February 9, 2016 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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61865804 |
Aug 14, 2013 |
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61894029 |
Oct 22, 2013 |
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Current U.S.
Class: |
514/171 ;
514/221; 514/232.2; 514/252.16 |
Current CPC
Class: |
A61P 5/32 20180101; A61K
31/5377 20130101; A61K 31/4439 20130101; A61P 43/00 20180101; A61K
31/551 20130101; A61K 31/436 20130101; A61K 31/565 20130101; A61P
35/00 20180101; A61K 31/5685 20130101; A61P 5/00 20180101; A61K
31/5513 20130101; A61K 31/138 20130101; A61K 31/519 20130101; A61K
31/4196 20130101; A61K 45/06 20130101; A61P 35/02 20180101; A61K
31/519 20130101; A61K 2300/00 20130101; A61K 31/5513 20130101; A61K
2300/00 20130101; A61K 31/4439 20130101; A61K 2300/00 20130101;
A61K 31/5377 20130101; A61K 2300/00 20130101 |
International
Class: |
A61K 31/519 20060101
A61K031/519; A61K 31/4439 20060101 A61K031/4439; A61K 31/5377
20060101 A61K031/5377; A61K 31/138 20060101 A61K031/138; A61K
31/565 20060101 A61K031/565; A61K 31/5685 20060101 A61K031/5685;
A61K 31/551 20060101 A61K031/551; A61K 31/4196 20060101
A61K031/4196; A61K 31/436 20060101 A61K031/436 |
Claims
1. A pharmaceutical combination comprising (1) a first agent which
is a CDK inhibitor or a pharmaceutically acceptable salt thereof
and (2) a second agent which is an anti-hormonal agent or a
pharmaceutically acceptable salt thereof.
2. A pharmaceutical combination comprising (1) a first agent which
is a CDK inhibitor or a pharmaceutically acceptable salt thereof,
(2) a second agent which is an anti-hormonal agent or a
pharmaceutically acceptable salt thereof, and (3) a third agent
which is an agent that regulates the PI3K/Akt/mTOR pathway or a
pharmaceutically acceptable salt thereof.
3. The combination of claim 1, wherein the agents are administered
simultaneously, separately or sequentially.
4. The combination of claim 1, wherein the CDK inhibitor is CDK4/6
inhibitor.
5. The combination of claim 4, wherein the CDK4/6 inhibitor is
Compound A1, described by Formula A1 below: ##STR00032##
6. The combination of claim 4, wherein the CDK4/6 inhibitor is
Compound A2, described by Formula A2 below: ##STR00033##
7. The combination of claim 4, wherein the CDK4/6 inhibitor is
palbociclib.
8. The combination of claim 1 or 2, wherein the anti-hormonal agent
is an aromatase inhibitor.
9. The combination of claim 8, wherein the aromatase inhibitor is
non-steroidal.
10. The combination of claim 8, wherein the aromatase inhibitor is
steroidal.
11. The combination is of claim 8, wherein the aromatase inhibitor
is letrozole.
12. The combination is of claim 8, wherein the aromatase inhibitor
is exemestane.
13. The combination of claim 1, wherein the anti-hormonal agent is
an estrogen receptor antagonist.
14. The combination of claim 13, wherein the estrogen receptor
antagonist is fulvestrant.
15. The combination of claim 1, wherein the anti-hormonal agent is
a selective estrogen receptor modulator.
16. The combination of claim 15, wherein the selective estrogen
receptor modulator is tamoxifen.
17. The combination of claim 2, wherein the agent that regulates
the PI3K/Akt/mTOR pathway is a PI3K inhibitor.
18. The combination of claim 17, wherein the PI3K inhibitor is
Compound C1, described by Formula C1 below: ##STR00034##
19. The combination of claim 17, wherein the PI3K inhibitor is
Compound C2, described by Formula C2 below: ##STR00035##
20. The combination of claim 2, wherein the agent that regulates
the PI3K/Akt/mTOR pathway is an mTOR inhibitor.
21. The combination of claim 20 wherein the mTOR inhibitor is
everolimus.
22. A method of treating cancer comprising administering to a
subject the pharmaceutical combination of claim 1.
23. The method of claim 22, wherein the cancer is selected from the
group consisting of sarcoma, lymphomas, cancer of the lung,
bronchus, prostate, breast, pancreas, gastrointestine, colon,
rectum, colon, colorectal adenoma, thyroid, liver, intrahepatic
bile duct, hepatocellular, adrenal gland, stomach, gastric, glioma,
glioblastoma, endometrial, melanoma, kidney, renal pelvis, urinary
bladder, uterine corpus, uterine cervix, vagina, ovary, multiple
myeloma, esophagus, a leukaemia, acute myelogenous leukemia,
chronic myelogenous leukemia, lymphocytic leukemia, myeloid
leukemia, brain, a carcinoma of the brain, oral cavity and pharynx,
larynx, small intestine, non-Hodgkin lymphoma, melanoma, villous
colon adenoma, a neoplasia, a neoplasia of epithelial character, a
mammary carcinoma, basal cell carcinoma, squamous cell carcinoma,
actinic keratosis, tumor diseases, a tumor of the neck or head,
polycythemia vera, essential thrombocythemia, myelofibrosis with
myeloid metaplasia, and Waldenstroem disease.
24. The method of claim 23, wherein the cancer is breast
cancer.
25. The method of claim 22, wherein the cancer is an estrogen
receptor positive cancer.
26. The method of claim 23, wherein the breast cancer is estrogen
receptor positive breast cancer.
27. A pharmaceutical combination comprising (1) a first agent which
is Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00036## and (2) a second agent which
is letrozole.
28. A pharmaceutical combination comprising (1) a first agent which
is Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00037## (2) a second agent which is
letrozole, and (3) a third agent which is Compound C1, described by
Formula C1 below or a pharmaceutically acceptable salt thereof:
##STR00038##
29. A pharmaceutical combination comprising (1) a first agent which
is Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00039## (2) a second agent which is
letrozole, and (3) a third agent which is Compound C2, described by
Formula C2 below or a pharmaceutically acceptable salt thereof:
##STR00040##
30. A pharmaceutical combination comprising (1) a first agent which
is Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00041## and (2) a second agent which
is fulvestrant.
31. A pharmaceutical combination comprising (1) a first agent which
is Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00042## (2) a second agent which is
fulvestrant, and (3) a third agent which is Compound C1, described
by Formula C1 below or a pharmaceutically acceptable salt thereof:
##STR00043##
32. A pharmaceutical combination comprising (1) a first agent which
is Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00044## (2) a second agent which is
fulvestrant, and (3) a third agent which is Compound C2, described
by Formula C2 below or a pharmaceutically acceptable salt thereof:
##STR00045##
33. A pharmaceutical combination comprising (1) a first agent which
is Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00046## (2) a second agent which is
everolimus, and (3) a third agent which is exemestane.
34. A method of treating breast cancer comprising administering to
a subject the pharmaceutical combination of claim 27.
35. A method of treating HR+, HER2- breast cancer comprising
administering to a subject a pharmaceutical combination comprising
(1) a first agent which is Compound A1 described by Formula A1
below or a pharmaceutically acceptable salt thereof: ##STR00047##
and (2) a second agent which is letrozole.
36. A method of treating ER+, HER2- advanced breast cancer
comprising administering to a subject a pharmaceutical combination
comprising (1) a first agent which is Compound A1 described by
Formula A1 below or a pharmaceutically acceptable salt thereof:
##STR00048## and (2) a second agent which is letrozole.
37. A method of treating ER+ advanced breast cancer comprising
administering to a subject a pharmaceutical combination comprising
(1) a first agent which is Compound A1 described by Formula A1
below or a pharmaceutically acceptable salt thereof: ##STR00049##
(2) a second agent which is letrozole, and (3) a third agent which
is Compound C1, described by Formula C1 below or a pharmaceutically
acceptable salt thereof: ##STR00050##
38. A method of treating ER+ advanced breast cancer comprising
administering to a subject a pharmaceutical combination comprising
(1) a first agent which is Compound A1 described by Formula A1
below or a pharmaceutically acceptable salt thereof: ##STR00051##
(2) a second agent which is letrozole, and (3) a third agent which
is Compound C2, described by Formula C2 below or a pharmaceutically
acceptable salt thereof: ##STR00052##
39. A method of treating postmenopausal woman with ER+, HER2-
breast cancer comprising administering to a subject a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00053## and (2) a second agent which
is fulvestrant.
40. A method of treating postmenopausal woman with ER+, HER2-
breast cancer comprising administering to a subject a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00054## (2) a second agent which is
fulvestrant, and (3) a third agent which is Compound C1, described
by Formula C1 below or a pharmaceutically acceptable salt thereof:
##STR00055##
41. A method of treating postmenopausal woman with ER+, HER2-
breast cancer comprising administering to a subject a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof: ##STR00056## (2) a second agent which is
fulvestrant, and (3) a third agent which is Compound C2, described
by Formula C2 below or a pharmaceutically acceptable salt thereof:
##STR00057##
42. A method of treating ER+ breast cancer comprising administering
to a subject a pharmaceutical combination comprising (1) a first
agent which is Compound A1 described by Formula A1 below or a
pharmaceutically acceptable salt thereof: ##STR00058## (2) a second
agent which is everolimus, and (3) a third agent which is
exemestane.
Description
FIELD OF THE DISCLOSURE
[0001] The present disclosure relates to a pharmaceutical
combination comprising a CDK inhibitor and an anti-hormonal agent
for the treatment of cancer; the uses of such combinations in the
treatment of cancer; and to a method of treating warm-blooded
animals including humans suffering cancer comprising administering
to said animal in need of such treatment an effective dose of a CDK
inhibitor and an anti-hormonal agent. In addition, the combination
can optionally include an agent that regulates the PI3K/Akt/mTOR
pathway.
BACKGROUND OF THE DISCLOSURE
CDK Inhibitors
[0002] Tumor development is closely associated with genetic
alteration and deregulation of CDKs and their regulators,
suggesting that inhibitors of CDKs may be useful anti-cancer
therapeutics. Indeed, early results suggest that transformed and
normal cells differ in their requirement for, e.g., cyclin D/CDK4/6
and that it may be possible to develop novel antineoplastic agents
devoid of the general host toxicity observed with conventional
cytotoxic and cytostatic drugs.
[0003] The function of CDKs is to phosphorylate and thus activate
or deactivate certain proteins, including e.g. retinoblastoma
proteins, lamins, histone H1, and components of the mitotic
spindle. The catalytic step mediated by CDKs involves a
phospho-transfer reaction from ATP to the macromolecular enzyme
substrate. Several groups of compounds (reviewed in e.g. Fischer,
P. M. Curr. Opin. Drug Discovery Dev. 2001, 4, 623-634) have been
found to possess anti-proliferative properties by virtue of
CDK-specific ATP antagonism.
[0004] At a molecular level mediation of CDK/cyclin complex
activity requires a series of stimulatory and inhibitory
phosphorylation, or dephosphorylation, events. CDK phosphorylation
is performed by a group of CDK activating kinases (CAKs) and/or
kinases such as wee1, Myt1 and Mik1. Dephosphorylation is performed
by phosphatases such as cdc25(a & c), pp2a, or KAP.
[0005] CDK/cyclin complex activity may be further regulated by two
families of endogenous cellular proteinaceous inhibitors: the
Kip/Cip family, or the INK family. The INK proteins specifically
bind CDK4 and CDK6. p16ink4 (also known as MTS1) is a potential
tumour suppressor gene that is mutated, or deleted, in a large
number of primary cancers. The Kip/Cip family contains proteins
such as p21Cip1, Waf1, p27Kip1 and p57kip2, where p21 is induced by
p53 and is able to inactivate the CDK2/cyclin(E/A) complex.
Atypically low levels of p27 expression have been observed in
breast, colon and prostate cancers. Conversely over expression of
cyclin E in solid tumours has been shown to correlate with poor
patient prognosis. Over expression of cyclin D1 has been associated
with oesophageal, breast, squamous, and non-small cell lung
carcinomas.
[0006] The pivotal roles of CDKs, and their associated proteins, in
co-ordinating and driving the cell cycle in proliferating cells
have been outlined above. Some of the biochemical pathways in which
CDKs play a key role have also been described. The development of
monotherapies for the treatment of proliferative disorders, such as
cancers, using therapeutics targeted generically at CDKs, or at
specific CDKs, is therefore potentially highly desirable. Thus,
there is a continued need to find new therapeutic agents to treat
human diseases.
Anti-Hormonal Agent
[0007] Anti-hormonal agent works in two ways: (1) by lowering the
amount of the hormone in the body or (2) by blocking the action of
hormone on cells.
[0008] Various types of anti-hormonal agents are known.
[0009] One type of anti-hormonal agents is known as aromatase
inhibitors. Aromatase inhibitors work by inhibiting the action of
the enzyme aromatase, which converts androgens into estrogens by a
process called aromatization. As breast tissue is stimulated by
estrogens, decreasing their production is a way of suppressing
recurrence of the breast tumor tissue. The main source of estrogen
is the ovaries in premenopausal women, while in post-menopausal
women most of the body's estrogen is produced in peripheral tissues
(outside the CNS), and also a few CNS sites in various regions
within the brain. Estrogen is produced and acts locally in these
tissues, but any circulating estrogen, which exerts systemic
estrogenic effects in men and women, is the result of estrogen
escaping local metabolism and spreading to the circulatory system.
There are two types of aromatase inhibitors: (1) steroidal
inhibitors, such as exemestane (Aromasin) which forms a permanent
and deactivating bond with the aromatase enzyme; and (2)
non-steroidal inhibitors, such as anastrozole (Arimidex) or
Letrozole (Femara) which inhibit the synthesis of estrogen via
reversible competition for the aromatase enzyme.
[0010] Another type of anti-hormonal agent is estrogen receptor
antagonist. An example of an estrogen receptor antagonist is
fulvestrant (Faslodex). Estrogen receptors are found in and on
breast cells. Estrogen binds to estrogen receptors, like a key
fitting into a lock. This can activate the receptor and cause
hormone receptor-positive tumors to grow. Fulvestrant binds to and
blocks estrogen receptors and reduces the number of estrogen
receptors in breast cells.
[0011] Another type of anti-hormonal agent is selective estrogen
receptor modulators (SERMs) are a class of compounds that act on
the estrogen receptor. A characteristic that distinguishes these
substances from pure receptor agonists and antagonists is that
their action is different in various tissues, thereby granting the
possibility to selectively inhibit or stimulate estrogen-like
action in various tissues An example of a SERM is tamoxifen.
Tamoxifen is an estrogen receptor agonist at bone and uterus, but
an antagonist at breast.
Agent that Regulates the PI3K/Akt/mTOR Pathway
[0012] The PI3K/Akt/mTOR pathway is an important, tightly regulated
survival pathway for the normal cell. Phosphatidylinositol
3-kinases (PI3Ks) are widely expressed lipid kinases that catalyze
the transfer of phosphate to the D-3' position of inositol lipids
to produce phosphoinositol-3-phosphate (PIP),
phosphoinositol-3,4-diphosphate (PIP.sub.2) and
phosphoinositol-3,4,5-triphosphate (PIP.sub.3). These products of
the PI3K-catalyzed reactions act as second messengers and have
central roles in key cellular processes, including cell growth,
differentiation, mobility, proliferation and survival.
[0013] Of the two Class 1 PI3Ks, Class 1A PI3Ks are heterodimers
composed of a catalytic p110 subunit (.alpha., .beta., .delta.
isoforms) constitutively associated with a regulatory subunit that
can be p85.alpha., p55.alpha., p50.alpha., p85.beta. or p55.gamma..
The Class 1B sub-class has one family member, a heterodimer
composed of a catalytic p110.gamma. subunit associated with one of
two regulatory subunits, p101 or p84 (Fruman et al., Annu Rev.
Biochem. 67:481 (1998); Suire et al., Curr. Biol. 15:566
(2005)).
[0014] In many cases, PIP2 and PIP3 recruit AKT to the plasma
membrane where it acts as a nodal point for many intracellular
signaling pathways important for growth and survival (Fant) et al.,
Cell 69:413-423(1992); Bader et al., Nature Rev. Cancer 5:921
(2005); Vivanco and Sawyer, Nature Rev. Cancer 2:489 (2002)).
Aberrant regulation of PI3K, which often increases survival through
AKT activation, is one of the most prevalent events in human cancer
and has been shown to occur at multiple levels. The tumor
suppressor gene PTEN, which dephosphorylates phosphoinositides at
the 3' position of the inositol ring and in so doing antagonizes
PI3K activity, is functionally deleted in a variety of tumors. In
other tumors, the genes for the p110.alpha. isoform, PIK3CA, and
for AKT are amplified and increased protein expression of their
gene products has been demonstrated in several human cancers.
Further, somatic missense mutations in PIK3CA that activate
downstream signaling pathways have been described at significant
frequencies in a wide diversity of human cancers (Kang at el.,
Proc. Natl. Acad. Sci. USA 102:802 (2005); Samuels et al., Science
304:554 (2004); Samuels et al., Cancer Cell 7:561-573 (2005)).
Thus, inhibitors of PI3K alpha are known to be of particular value
in the treatment of cancer and other disorders.
[0015] mTOR is a kinase protein predominantly found in the
cytoplasm of the cell. It acts as a central regulator of many
biological processes related to cell proliferation, angiogenesis,
and cell metabolism. mTOR exerts its effects primarily by turning
on and off the cell's translational machinery, which includes the
ribosomes, and is responsible for protein synthesis. mTOR is a key
intracellular point of convergence for a number of cellular
signaling pathways. mTOR performs its regulatory function in
response to activating or inhibitory signals transmitted through
these pathways, which are located upstream from mTOR in the cell.
These diverse signaling pathways are activated by a variety of
growth factors (including vascular endothelial growth factors
(VEGFs), platelet-derived growth factor (PDGF), epidermal growth
factor (EGF), insulin-like growth factor 1 (IGF-1)), hormones
(estrogen, progesterone), and the presence or absence of nutrients
(glucose, amino acids) or oxygen. One or more of these signaling
pathways may be abnormally activated in patients with many
different types of cancer, resulting in deregulated cell
proliferation, tumor angiogenesis, and abnormal cell
metabolism.
[0016] In spite of numerous treatment options for cancer patients,
there remains a need for effective and safe therapeutic agents and
a need for their preferential use in combination therapy.
SUMMARY OF THE DISCLOSURE
[0017] The present disclosure relates to a pharmaceutical
combination comprising (1) a first agent which is a CDK inhibitor
or a pharmaceutically acceptable salt thereof and (2) a second
agent which is an anti-hormonal agent or a pharmaceutically
acceptable salt thereof.
[0018] The present disclosure also relates to a pharmaceutical
combination comprising (1) a first agent which is a CDK inhibitor
or a pharmaceutically acceptable salt thereof, (2) a second agent
which is an anti-hormonal agent or a pharmaceutically acceptable
salt thereof, and (3) a third agent which is an agent that
regulates the PI3K/Akt/mTOR pathway or a pharmaceutically
acceptable salt thereof.
[0019] Such combination may be for simultaneous, separate or
sequential use for the treatment of a cancer.
[0020] In one embodiment, the CDK inhibitor is CDK4/6
inhibitor.
[0021] The CDK4/6 inhibitor can be, for example,
[0022] Compound A1, described by Formula A1 below:
##STR00001##
or,
[0023] Compound A2, described by Formula A2 below:
##STR00002##
or,
[0024] palbociclib (hereinafter referred as Compound A3, also known
as PD-0332991).
[0025] Compound A1 is also described by the chemical name
7-Cyclopentyl-2-(5-piperazin-1-yl-pyridin-2-ylamino)-7H-pyrrolo[2,3-d]pyr-
imidine-6-carboxylic acid dimethylamide.
[0026] Compound A2 is also described by the chemical name
7-cyclopentyl-N,N-dimethyl-2-(5-((1R,6S)-9-methyl-4-oxo-3,9-diazabicyclo[-
4.2.1]nonan-3-yl)pyridin-2-ylamino)-7H-pyrrolo[2,3-d]pyrimidine-6-carboxam-
ide.
[0027] Compound A3 is also described by the chemical name
6-Acetyl-8-cyclopentyl-5-methyl-2-{[5-(1-piperazinyl)-2-pyridinyl]amino}p-
yrido[2,3-d]pyrimidin-7(8H)-one.
[0028] In one embodiment, the anti-hormonal agent is an aromatase
inhibitor. Such aromatase inhibitor can be either a non-steroidal
aromatase inhibitor or a steroidal aromatase inhibitor.
[0029] Letrozole (hereinafter referred as Compound B1) is an
example of a non-steroidal aromatase inhibitor.
[0030] Exemestane (hereinafter referred as Compound B2) is an
example of a steroidal aromatase inhibitor.
[0031] In another embodiment, the anti-hormonal agent is an
estrogen receptor antagonist.
[0032] Fulvestrant (hereinafter referred as Compound B3) is an
example of an estrogen receptor antagonist.
[0033] In yet another embodiment, the anti-hormonal agent is a
selective estrogen receptor modulator.
[0034] Tamoxifen (hereinafter referred as Compound B4) is an
example of a selective estrogen receptor modulator.
[0035] In one embodiment, the agent that regulates the
PI3K/Akt/mTOR pathway is a PI3K inhibitor.
[0036] The PI3K inhibitor can be, for example,
[0037] Compound C1, described by Formula C1 below:
##STR00003##
or,
[0038] Compound C2, described by Formula C2 below:
##STR00004##
[0039] Compound C1 is also described by the chemical name
(S)-Pyrrolidine-1,2-dicarboxylic acid 2-amide
1-({4-methyl-5-[2-(2,2,2-trifluoro-1,1-dimethyl-ethyl)-pyridin-4-yl]-thia-
zol-2-yl}-amide).
[0040] Compound C2 is also described by the chemical name
5-(2,6-di-4-morpholinyl-4-pyrimidinyl)-4-(trifluoromethyl)-2-pyrimidinami-
ne.
[0041] In another embodiment, the agent that regulates the
PI3K/Akt/mTOR pathway is a mTOR inhibitor.
[0042] Everolimus (hereinafter referred as Compound C3) is an
example of a mTOR inhibitor.
[0043] The present disclosure further relates to the above
pharmaceutical combination(s) for use in the treatment of a
cancer.
[0044] The present disclosure further relates to a method for the
treatment of a cancer comprising administering the above
pharmaceutical combination(s) in jointly therapeutically effective
amount, to a warm-blooded animal, preferably a human, in need
thereof.
[0045] In accordance with the present disclosure, the compounds in
the pharmaceutical combination(s) may be administered either as a
single pharmaceutical composition, as separate compositions, or
sequentially.
[0046] In a specific embodiment, the disclosure relates to a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof:
##STR00005##
[0047] and (2) a second agent which is letrozole.
[0048] In another specific embodiment, the disclosure relates to a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof:
##STR00006## [0049] (2) a second agent which is letrozole, and
[0050] (3) a third agent which is Compound C1, described by Formula
C1 below or a pharmaceutically acceptable salt thereof:
##STR00007##
[0051] In another specific embodiment, the disclosure relates to a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof:
##STR00008## [0052] (2) a second agent which is letrozole, and
[0053] (3) a third agent which is Compound C2, described by Formula
C2 below or a pharmaceutically acceptable salt thereof:
##STR00009##
[0054] In another specific embodiment, the disclosure relates to a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof:
##STR00010##
[0055] and (2) a second agent which is fulvestrant.
[0056] In another specific embodiment, the disclosure relates to a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof:
##STR00011## [0057] (2) a second agent which is fulvestrant, and
[0058] (3) a third agent which is Compound C1, described by Formula
C1 below or a pharmaceutically acceptable salt thereof:
##STR00012##
[0059] In another specific embodiment, the disclosure relates to a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof:
##STR00013## [0060] (2) a second agent which is fulvestrant, and
[0061] (3) a third agent which is Compound C2, described by Formula
C2 below or a pharmaceutically acceptable salt thereof:
##STR00014##
[0062] In another specific embodiment, the disclosure relates to a
pharmaceutical combination comprising (1) a first agent which is
Compound A1 described by Formula A1 below or a pharmaceutically
acceptable salt thereof:
##STR00015## [0063] (2) a second agent which is everolimus, and
[0064] (3) a third agent which is exemestane.
[0065] In another specific embodiment, the disclosure relates to a
method of treating HR+, HER2- breast cancer comprising
administering to a subject a pharmaceutical combination comprising
(1) a first agent which is Compound A1 described by Formula A1
below or a pharmaceutically acceptable salt thereof:
##STR00016##
[0066] and (2) a second agent which is letrozole.
[0067] In another specific embodiment, the disclosure relates to a
method of treating ER+, HER2- advanced breast cancer comprising
administering to a subject a pharmaceutical combination comprising
(1) a first agent which is Compound A1 described by Formula A1
below or a pharmaceutically acceptable salt thereof:
##STR00017##
[0068] and (2) a second agent which is letrozole.
[0069] In another specific embodiment, the disclosure relates to a
method of treating ER+ advanced breast cancer comprising
administering to a subject a pharmaceutical combination comprising
(1) a first agent which is Compound A1 described by Formula A1
below or a pharmaceutically acceptable salt thereof:
##STR00018## [0070] (2) a second agent which is letrozole, and
[0071] (3) a third agent which is Compound C1, described by Formula
C1 below or a pharmaceutically acceptable salt thereof:
##STR00019##
[0072] In another specific embodiment, the disclosure relates to a
method of treating ER+ advanced breast cancer comprising
administering to a subject a pharmaceutical combination comprising
(1) a first agent which is Compound A1 described by Formula A1
below or a pharmaceutically acceptable salt thereof:
##STR00020## [0073] (2) a second agent which is letrozole, and
[0074] (3) a third agent which is Compound C2, described by Formula
C2 below or a pharmaceutically acceptable salt thereof:
##STR00021##
[0075] In another specific embodiment, the disclosure relates to a
method of treating postmenopausal woman with ER+, HER2- breast
cancer comprising administering to a subject a pharmaceutical
combination comprising (1) a first agent which is Compound A1
described by Formula A1 below or a pharmaceutically acceptable salt
thereof:
##STR00022## [0076] and (2) a second agent which is
fulvestrant.
[0077] In another specific embodiment, the disclosure relates to a
method of treating postmenopausal woman with ER+, HER2- breast
cancer comprising administering to a subject a pharmaceutical
combination comprising (1) a first agent which is Compound A1
described by Formula A1 below or a pharmaceutically acceptable salt
thereof:
##STR00023## [0078] (2) a second agent which is fulvestrant, and
[0079] (3) a third agent which is Compound C1, described by Formula
C1 below or a pharmaceutically acceptable salt thereof:
##STR00024##
[0080] In another specific embodiment, the disclosure relates to a
method of treating postmenopausal woman with ER+, HER2- breast
cancer comprising administering to a subject a pharmaceutical
combination comprising (1) a first agent which is Compound A1
described by Formula A1 below or a pharmaceutically acceptable salt
thereof:
##STR00025## [0081] (2) a second agent which is fulvestrant, and
[0082] (3) a third agent which is Compound C2, described by Formula
C2 below or a pharmaceutically acceptable salt thereof:
##STR00026##
[0083] In another specific embodiment, the disclosure relates to a
method of treating ER+ breast cancer comprising administering to a
subject a pharmaceutical combination comprising (1) a first agent
which is Compound A1 described by Formula A1 below or a
pharmaceutically acceptable salt thereof:
##STR00027## [0084] (2) a second agent which is everolimus, and
[0085] (3) a third agent which is exemestane.
[0086] The present disclosure further relates to a kit comprising
the pharmaceutical combination.
DETAILED DESCRIPTION OF THE FIGURES
[0087] FIG. 1 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A1 and Compound B1
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0088] FIG. 2 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A1 and Compound B2
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0089] FIG. 3 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A1 and Compound B3
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0090] FIG. 4 shows an extended dose matrix demonstrating the
effects of combining Compound A1 and Compound B1 with or without
the presence of Compound C1, Compound C2 or Compound C3 on
proliferation of MCF7/ARO human breast carcinoma cells with
.DELTA.4A.
[0091] FIG. 5 shows an extended dose matrix demonstrating the
effects of combining Compound A1 and Compound B2 with or without
the presence of Compound C1, Compound C2 or Compound C3 on
proliferation of MCF7/ARO human breast carcinoma cells with
.DELTA.4A.
[0092] FIG. 6 shows an extended dose matrix demonstrating the
effects of combining Compound A1 and Compound B3 with or without
the presence of Compound C1, Compound C2 or Compound C3 on
proliferation of MCF7/ARO human breast carcinoma cells with
.DELTA.4A.
[0093] FIG. 7 shows the MCF7/Aro Cell Growth for 6 Days w .DELTA.4A
with the CTG Assay.
[0094] FIG. 8 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A3 and Compound B1
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0095] FIG. 9 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A2 and Compound B1
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0096] FIG. 10 shows an extended dose matrix demonstrating the
effects of combining Compound A3 and Compound B1 with or without
the presence of Compound C1 or Compound C3 on proliferation of
MCF7/ARO human breast carcinoma cells with .DELTA.4A.
[0097] FIG. 11 shows an extended dose matrix demonstrating the
effects of combining Compound A2 and Compound B1 with or without
the presence of Compound C1 or Compound C3 on proliferation of
MCF7/ARO human breast carcinoma cells with .DELTA.4A.
[0098] FIG. 12 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A3 and Compound B2
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0099] FIG. 13 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A2 and Compound B2
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0100] FIG. 14 shows an extended dose matrix demonstrating the
effects of combining Compound A3 and Compound B2 with or without
the presence of Compound C1 or Compound C3 on proliferation of
MCF7/ARO human breast carcinoma cells with .DELTA.4A.
[0101] FIG. 15 shows an extended dose matrix demonstrating the
effects of combining Compound A2 and Compound B2 with or without
the presence of Compound C1 or Compound C3 on proliferation of
MCF7/ARO human breast carcinoma cells with .DELTA.4A.
[0102] FIG. 16 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A3 and Compound B3
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0103] FIG. 17 shows an extended dose matrix and isobologram
demonstrating the effects of combining Compound A2 and Compound B3
doses on proliferation of MCF7/ARO human breast carcinoma cells
with .DELTA.4A.
[0104] FIG. 18 shows an extended dose matrix demonstrating the
effects of combining Compound A3 and Compound B3 with or without
the presence of Compound C1 or Compound C3 on proliferation of
MCF7/ARO human breast carcinoma cells with .DELTA.4A.
[0105] FIG. 19 shows an extended dose matrix demonstrating the
effects of combining Compound A2 and Compound B3 with or without
the presence of Compound C1 or Compound C3 on proliferation of
MCF7/ARO human breast carcinoma cells with .DELTA.4A.
[0106] FIGS. 20-22 show antitumor efficacy of various compounds
used as single agent, in double or in triple combination in the
HBCx-34 human breast patient-derived xenograft model.
[0107] FIG. 23 illustrates the study design of clinical trial
described in Example 3.
[0108] FIGS. 24 and 25 show the duration of exposure to treatment
in ARM1 and ARM2 of the clinical trial described in Example 3
(interim results).
[0109] FIG. 26 shows the partial response observed for patient with
metastatic breast carcinoma treated with Compound A1 and
Letrozole.
[0110] FIG. 27 illustrates the study design of clinical trial
described in Example 5.
[0111] FIGS. 28 and 29 show the Mean plasma concentration-time
profiles for Compound A1 and EVE in patients treated with Compound
A1+EVE+EXE on C1 D15.
[0112] FIG. 30 shows the duration of exposure to treatment of the
clinical trial described in Example 5 (interim results).
[0113] FIG. 31 shows improvement in soft tissue metastases in a
patient with lymph node, plura, lung, and soft tissue metastases
who had received 1 prior line of anastrozole and 1 prior line of
fulvestrant in the advanced/metastatic setting.
DETAILED DESCRIPTION OF THE DISCLOSURE
[0114] The following general definitions are provided to better
understand the disclosure:
[0115] "Aromatase inhibitor" used herein relates to compounds which
inhibit the estrogen production, i.e. the conversion of the
substrates androstenedione and testosterone to estrone and
estradiol, respectively. Such compounds will be referred to as
"aromatase inhibitors".
[0116] "Selective estrogen receptor modulator (SERM)" refers to
compound(s) that act on the estrogen receptor. A characteristic
that distinguishes SERMs from pure receptor agonists and
antagonists is that their action is different in various tissues,
thereby granting the possibility to selectively inhibit or
stimulate estrogen-like action in various tissues.
[0117] "PI3K inhibitor" is defined herein to refer to a compound
which targets, decreases or inhibits phosphatidylinositol 3-kinase.
Phosphatidylinositol 3-kinase activity has been shown to increase
in response to a number of hormonal and growth factor stimuli,
including insulin, platelet-derived growth factor, insulin-like
growth factor, epidermal growth factor, colony-stimulating factor,
and hepatocyte growth factor, and has been implicated in processes
related to cellular growth and transformation.
[0118] "Combination" refers to either a fixed combination in one
dosage unit form, or a non-fixed combination (or kit of parts) for
the combined administration where a compound and a combination
partner (e.g. another drug as explained below, also referred to as
"therapeutic agent" or "co-agent") may be administered
independently at the same time or separately within time intervals,
especially where these time intervals allow that the combination
partners show a cooperative, e.g. synergistic effect. The term
"combined administration" or the like as utilized herein are meant
to encompass administration of the selected combination partner to
a single subject in need thereof (e.g. a patient), and are intended
to include treatment regimens in which the agents are not
necessarily administered by the same route of administration or at
the same time. The term "fixed combination" means that the active
ingredients, e.g. a compound of formula A1 and a combination
partner, are both administered to a patient simultaneously in the
form of a single entity or dosage. The terms "non-fixed
combination" or "kit of parts" mean that the active ingredients,
e.g. a compound of formula A1 and a combination partner, are both
administered to a patient as separate entities either
simultaneously, concurrently or sequentially with no specific time
limits, wherein such administration provides therapeutically
effective levels of the two compounds in the body of the
patient.
[0119] "Treatment" includes prophylactic and therapeutic treatment
(including but not limited to palliative, curing,
symptom-alleviating, symptom-reducing) as well as the delay of
progression of a cancer disease or disorder. The term
"prophylactic" means the prevention of the onset or recurrence of a
cancer. The term "delay of progression" as used herein means
administration of the combination to patients being in a pre-stage
or in an early phase of the cancer to be treated, a pre-form of the
corresponding cancer is diagnosed and/or in a patient diagnosed
with a condition under which it is likely that a corresponding
cancer will develop.
[0120] "Pharmaceutical preparation" or "pharmaceutical composition"
refers to a mixture or solution containing at least one therapeutic
agent to be administered to a warm-bloodeded, e.g., a human.
[0121] "Co-administer", "co-administration" or "combined
administration" or the like are meant to encompass administration
of the selected therapeutic agents to a single patient, and are
intended to include treatment regimens in which the agents are not
necessarily administered by the same route of administration or at
the same time.
[0122] "Pharmaceutically acceptable" refers to those compounds,
materials, compositions and/or dosage forms, which are, within the
scope of sound medical judgment, suitable for contact with the
tissues of mammals, especially humans, without excessive toxicity,
irritation, allergic response and other problem complications
commensurate with a reasonable benefit/risk ratio.
[0123] "Therapeutically effective" preferably relates to an amount
of a therapeutic agent that is therapeutically or in a broader
sense also prophylactically effective against the progression of a
cancer.
[0124] "Jointly therapeutically effective" means that the
therapeutic agents may be given separately (in a chronologically
staggered manner, especially a sequence-specific manner) in such
time intervals that they prefer, in the warm-blooded animal,
especially human, to be treated, still show a (preferably
synergistic) interaction. Whether this is the case can, inter alia,
be determined by following the blood levels, showing that both
compounds are present in the blood of the human to be treated at
least during certain time intervals.
[0125] "Single pharmaceutical composition" refers to a single
carrier or vehicle formulated to deliver effective amounts of both
therapeutic agents to a patient. The single vehicle is designed to
deliver an effective amount of each of the agents, along with any
pharmaceutically acceptable carriers or excipients. In some
embodiments, the vehicle is a tablet, capsule, pill, or a patch. In
other embodiments, the vehicle is a solution or a suspension.
[0126] "Dose range" refers to an upper and a lower limit of an
acceptable variation of the amount of therapeutic agent specified.
Typically, a dose of the agent in any amount within the specified
range can be administered to patients undergoing treatment.
[0127] "Subject", "patient", or "warm-blooded animal" is intended
to include animals. Examples of subjects include mammals, e.g.,
humans, dogs, cows, horses, pigs, sheep, goats, cats, mice,
rabbits, rats, and transgenic non-human animals. In certain
embodiments, the subject is a human, e.g., a human suffering from,
at risk of suffering from, or potentially capable of suffering from
a brain tumor disease. Particularly preferred, the subject or
warm-blooded animal is human.
[0128] The terms "about" or "approximately" usually means within
20%, more preferably within 10%, and most preferably still within
5% of a given value or range. Alternatively, especially in
biological systems, the term "about" means within about a log
(i.e., an order of magnitude) preferably within a factor of two of
a given value.
[0129] The present disclosure relates to a pharmaceutical
combination comprising (1) a CDK inhibitor or a pharmaceutically
acceptable salt thereof and (2) an anti-hormonal agent or a
pharmaceutically acceptable salt thereof.
[0130] The present disclosure also relates to a pharmaceutical
combination comprising (1) a CDK inhibitor or a pharmaceutically
acceptable salt thereof, (2) an anti-hormonal agent or a
pharmaceutically acceptable salt thereof, and (3) an agent that
regulates the PI3K/Akt/mTOR pathway or a pharmaceutically
acceptable salt thereof.
[0131] Such combination may be for simultaneous, separate or
sequential use for the treatment of a cancer.
[0132] In one embodiment, the CDK inhibitor is CDK4/6
inhibitor.
[0133] The CDK4/6 inhibitor can be, for example,
[0134] Compound A1, described by Formula A1 below:
##STR00028##
or,
[0135] Compound A2, described by Formula A2 below:
##STR00029##
or,
[0136] palbociclib (hereinafter referred as Compound A3, also known
as PD-0332991).
[0137] Compound A1 is also described by the chemical name
7-Cyclopentyl-2-(5-piperazin-1-yl-pyridin-2-ylamino)-7H-pyrrolo[2,3-d]pyr-
imidine-6-carboxylic acid dimethylamide.
[0138] Compound A2 is also described by the chemical name
7-cyclopentyl-N,N-dimethyl-2-(5-((1R,6S)-9-methyl-4-oxo-3,9-diazabicyclo[-
4.2.1]nonan-3-yOpyridin-2-ylamino)-7H-pyrrolo[2,3-d]pyrimidine-6-carboxami-
de.
[0139] Compound A3 is also described by the chemical name
6-Acetyl-8-cyclopentyl-5-methyl-2-{[5-(1-piperazinyl)-2-pyridinyl]amino}p-
yrido[2,3-d]pyrimidin-7(8H)-one.
[0140] In one embodiment, the anti-hormonal agent is an aromatase
inhibitor. Such aromatase inhibitor can be either a non-steroidal
aromatase inhibitor or a steroidal aromatase inhibitor.
[0141] Letrozole (hereinafter referred as Compound B1) is an
example of a non-steroidal aromatase inhibitor.
[0142] Exemestane (hereinafter referred as Compound B2) is an
example of a steroidal aromatase inhibitor.
[0143] In another embodiment, the anti-hormonal agent is an
estrogen receptor antagonist.
[0144] Fulvestrant (hereinafter referred as Compound B3) is an
example of an estrogen receptor antagonist.
[0145] In yet another embodiment, the anti-hormonal agent is a
selective estrogen receptor modulator.
[0146] Tamoxifen (hereinafter referred as Compound B4) is an
example of a selective estrogen receptor modulator.
[0147] In one embodiment, the agent that regulates the
PI3K/Akt/mTOR pathway is a PI3K inhibitor.
[0148] The PI3K inhibitor can be, for example,
[0149] Compound C1, described by Formula C1 below:
##STR00030##
or,
[0150] Compound C2, described by Formula C2 below:
##STR00031##
[0151] Compound C1 is also described by the chemical name
(S)-Pyrrolidine-1,2-dicarboxylic acid 2-amide
1-({4-methyl-5-[2-(2,2,2-trifluoro-1,1-dimethyl-ethyl)-pyridin-4-yl]-thia-
zol-2-yl}-amide).
[0152] Compound C2 is also described by the chemical name
5-(2,6-di-4-morpholinyl-4-pyrimidinyl)-4-(trifluoromethyl)-2-pyrimidinami-
ne.
[0153] In another embodiment, the agent that regulates the
PI3K/Akt/mTOR pathway is a mTOR inhibitor.
[0154] Everolimus (hereinafter referred as Compound C3) is an
example of a mTOR inhibitor.
[0155] Specific embodiments of the present disclosure include the
following:
[0156] (1) Combination comprising Compound A1 and Compound B1;
[0157] (2) Combination comprising Compound A1 and Compound B2;
[0158] (3) Combination comprising Compound A1 and Compound B3;
[0159] (4) Combination comprising Compound A1 and Compound B4;
[0160] (5) Combination comprising Compound A2 and Compound B1;
[0161] (6) Combination comprising Compound A2 and Compound B2;
[0162] (7) Combination comprising Compound A2 and Compound B3;
[0163] (8) Combination comprising Compound A2 and Compound B4;
[0164] (9) Combination comprising Compound A3 and Compound B1;
[0165] (10) Combination comprising Compound A3 and Compound B2;
[0166] (11) Combination comprising Compound A3 and Compound B3;
[0167] (12) Combination comprising Compound A3 and Compound B4;
[0168] (13) Combination comprising Compound A1, Compound B1 and
Compound C1;
[0169] (14) Combination comprising Compound A1, Compound B1 and
Compound C2;
[0170] (15) Combination comprising Compound A1, Compound B1 and
Compound C3;
[0171] (16) Combination comprising Compound A1, Compound B2 and
Compound C1;
[0172] (17) Combination comprising Compound A1, Compound B2 and
Compound C2;
[0173] (18) Combination comprising Compound A1, Compound B2 and
Compound C3;
[0174] (19) Combination comprising Compound A1, Compound B3 and
Compound C1;
[0175] (20) Combination comprising Compound A1, Compound B3 and
Compound C2;
[0176] (21) Combination comprising Compound A1, Compound B3 and
Compound C3;
[0177] (22) Combination comprising Compound A1, Compound B4 and
Compound C1;
[0178] (23) Combination comprising Compound A1, Compound B4 and
Compound C2;
[0179] (24) Combination comprising Compound A1, Compound B4 and
Compound C3;
[0180] (25) Combination comprising Compound A2, Compound B1 and
Compound C1;
[0181] (26) Combination comprising Compound A2, Compound B1 and
Compound C2;
[0182] (27) Combination comprising Compound A2, Compound B1 and
Compound C3;
[0183] (28) Combination comprising Compound A2, Compound B2 and
Compound C1;
[0184] (29) Combination comprising Compound A2, Compound B2 and
Compound C2;
[0185] (30) Combination comprising Compound A2, Compound B2 and
Compound C3;
[0186] (31) Combination comprising Compound A2, Compound B3 and
Compound C1;
[0187] (32) Combination comprising Compound A2, Compound B3 and
Compound C2;
[0188] (33) Combination comprising Compound A2, Compound B3 and
Compound C3;
[0189] (34) Combination comprising Compound A2, Compound B4 and
Compound C1;
[0190] (35) Combination comprising Compound A2, Compound B4 and
Compound C2;
[0191] (36) Combination comprising Compound A2, Compound B4 and
Compound C3;
[0192] (37) Combination comprising Compound A3, Compound B1 and
Compound C1;
[0193] (38) Combination comprising Compound A3, Compound B1 and
Compound C2;
[0194] (39) Combination comprising Compound A3, Compound B1 and
Compound C3;
[0195] (40) Combination comprising Compound A3, Compound B2 and
Compound C1;
[0196] (41) Combination comprising Compound A3, Compound B2 and
Compound C2;
[0197] (42) Combination comprising Compound A3, Compound B2 and
Compound C3;
[0198] (43) Combination comprising Compound A3, Compound B3 and
Compound C1;
[0199] (44) Combination comprising Compound A3, Compound B3 and
Compound C2;
[0200] (45) Combination comprising Compound A3, Compound B3 and
Compound C3;
[0201] (46) Combination comprising Compound A3, Compound B4 and
Compound C1;
[0202] (47) Combination comprising Compound A3, Compound B4 and
Compound C2; and
[0203] (48) Combination comprising Compound A3, Compound B4 and
Compound C3.
[0204] The present disclosure further relates to the above
pharmaceutical combination(s) for use in the treatment of a
cancer.
[0205] The present disclosure further relates to a method for the
treatment of a cancer comprising administering the above
pharmaceutical combination(s) in jointly therapeutically effective
amount, to a warm-blooded animal, preferably a human, in need
thereof.
[0206] In accordance with the present disclosure, the compounds in
the pharmaceutical combination(s) may be administered either as a
single pharmaceutical composition, as separate compositions, or
sequentially.
[0207] The present disclosure further relates to a kit comprising
the pharmaceutical combination.
[0208] The Compounds A1-A3, B1-B4, C1-C3 may be incorporated in the
combination of the present disclosure in either the form of its
free base or any salt thereof. Salts can be present alone or in
mixture with free compound, e.g. the compound of the formula A1,
and are preferably pharmaceutically acceptable salts. Such salts of
the compounds of formula A1 are formed, for example, as acid
addition salts, preferably with organic or inorganic acids, from
compounds of formula A1 with a basic nitrogen atom. Suitable
inorganic acids are, for example, halogen acids, such as
hydrochloric acid, sulfuric acid, or phosphoric acid. Suitable
organic acids are, e.g., succinic acid, carboxylic acids or
sulfonic acids, such as fumaric acid or methansulfonic acid. For
isolation or purification purposes it is also possible to use
pharmaceutically unacceptable salts, for example picrates or
perchlorates. For therapeutic use, only pharmaceutically acceptable
salts or free compounds are employed (where applicable in the form
of pharmaceutical preparations), and these are therefore
preferred.
[0209] The Compounds A1-A3, B1-B4, C1-C3 can be synthesized by one
skilled in the art. Specifically, Compound A1 is disclosed as
Example 74 of WO2010/020675; Compound A2 is disclosed in
WO2011/101409; Compound C1 is disclosed as Example 15 of
WO2010/029082; and Compound C2 is disclosed as Example 10 of
WO2007/084786.
[0210] Suitable aromatase inhibitors include, but are not limited
to, [0211] (a) steroids, such as exemestane and formestane; and
[0212] (b) non-steroids, such as aminoglutethimide, vorozole,
fadrozole, anastrozole and, especially, letrozole. Exemestane can
be administered, e.g., in the form as it is marketed, e.g. under
the trademark AROMASIN.RTM.. Formestane can be administered, e.g.,
in the form as it is marketed, e.g. under the trademark
LENTARON.RTM.. Fadrozole can be administered, e.g., in the form as
it is marketed, e.g. under the trademark AFEMA.RTM.. Anastrozole
can be administered, e.g., in the form as it is marketed, e.g.
under the trademark ARIMIDEX.RTM.. Letrozole can be administered,
e.g., in the form as it is marketed, e.g. under the trademark
FEMARA.RTM. or FEMAR.RTM.. Letrozole has been specifically
described in the European patent No. 0 236 940 published on Sep.
16, 1987, as well as in U.S. Pat. No. 4,978,672 published on Dec.
18, 1990, and Japanese Patent No. 2018112 all in the name of the
applicant. Aminoglutethimide can be administered, e.g., in the form
as it is marketed, e.g. under the trademark ORIMETEN.RTM..
[0213] The structure of the active agents identified by code nos.,
generic or trade names may be taken from the actual edition of the
standard compendium "The Merck Index" or from databases, e.g.,
Patents International (e.g., IMS World Publications). The
corresponding content thereof is hereby incorporated by
reference.
[0214] Comprised are likewise the pharmaceutically acceptable salts
thereof, the corresponding racemates, diastereoisomers,
enantiomers, tautomers, as well as the corresponding crystal
modifications of above disclosed compounds where present, e.g.
solvates, hydrates and polymorphs, which are disclosed therein. The
compounds used as active ingredients in the combinations of the
present disclosure can be prepared and administered as described in
the cited documents, respectively. Also within the scope of this
disclosure is the combination of more than two separate active
ingredients as set forth above, i.e., a pharmaceutical combination
within the scope of this disclosure could include three active
ingredients or more.
[0215] It is believed that the combination(s) of the present
disclosure possesses beneficial therapeutic properties, e.g.
synergistic interaction, strong in vitro or in vivo
anti-proliferative activity and/or strong in vitro or in vivo
antitumor response, which render it particularly useful for the
treatment of cancer.
[0216] Suitable cancers that can be treated with the combination of
the present disclosure include, but are not limited to, sarcoma,
lymphomas, cancer of the lung, bronchus, prostate, breast
(including sporadic breast cancers and sufferers of Cowden
disease), pancreas, gastrointestine, colon, rectum, colon,
colorectal adenoma, thyroid, liver, intrahepatic bile duct,
hepatocellular, adrenal gland, stomach, gastric, glioma,
glioblastoma, endometrial, melanoma, kidney, renal pelvis, urinary
bladder, uterine corpus, cervix, vagina, ovary, multiple myeloma,
esophagus, a leukaemia, acute myelogenous leukemia, chronic
myelogenous leukemia, lymphocytic leukemia, myeloid leukemia,
brain, a carcinoma of the brain, oral cavity and pharynx, larynx,
small intestine, non-Hodgkin lymphoma, melanoma, villous colon
adenoma, a neoplasia, a neoplasia of epithelial character, a
mammary carcinoma, basal cell carcinoma, squamous cell carcinoma,
actinic keratosis, tumor diseases (including solid tumors), a tumor
of the neck or head, polycythemia vera, essential thrombocythemia,
myelofibrosis with myeloid metaplasia, and Waldenstroem disease.
Where a cancer, a tumor, a tumor disease, sarcoma, or a cancer are
mentioned, also metastasis in the original organ or tissue and/or
in any other location are implied alternatively or in addition,
whatever the location of the tumor and/or metastasis.
[0217] The combination of the present disclosure is particularly
useful for the treatment of a cancer mediated by
phosphatidylinositol 3-kinase (PI3K), particularly the
alpha-subunit of PI3K. Proliferative diseases may include those
showing overexpression or amplification of PI3K alpha, somatic
mutation of PIK3CA or germline mutations or somatic mutation of
PTEN or mutations and translocation of p85.alpha. that serve to
up-regulate the p85-p110 complex. In a preferred embodiment, the
cancer is a tumor and/or cancerous growth mediated by the alpha
isoform of PI3K. Disease may include those showing overexpression
or amplification of the alpha-isoform of PI3K and/or somatic
mutation of PIK3CA.
[0218] The combination of the present disclosure is also
particularly useful for the treatment of a hormone sensitive and/or
hormone receptor positive cancers. Hormone sensitive cancers may
include, but are not limited to, breast cancer, endometrial cancer,
ovarian cancer, and/or cervical cancer. Hormone-receptor positive
cancers may include estrogen receptor positive cancers (i.e.,
cancer that grows in response to the hormone estrogen) or
progesterone receptor positive cancers (ie., cancer that grows in
response to the hormone progesterone. Preferably, the hormone
receptor positive cancer is estrogen receptor positive breast
cancer.
[0219] In one embodiment, the cancer is a solid tumor.
[0220] In a further embodiment, the cancer is selected from the
group consisting of cancer of the breast, endometrial, ovary and
cervix.
[0221] In a further embodiment, the cancer is a cancer showing both
(a) overexpression or amplification of the alpha-isoform of PI3K
and/or somatic mutation of PIK3CA, and (b) hormone receptor
positive status.
[0222] In a further embodiment, the cancer is breast cancer.
Preferably, the cancer is a breast cancer having either hormone
receptor positive, a mutation in the PIK3CA, or a combination
thereof. More preferably, the cancer is estrogen receptor positive
(+) breast cancer.
[0223] In a further embodiment, the cancer is a hormone receptor
positive (+) breast cancer resistant to treatment with hormone
therapy (e.g., estrogen or progesterone). A cancer "resistant to
treatment with hormone therapy" refers to a cancer or tumor that
either fails to respond favorably to treatment with prior hormone
therapy, or alternatively, recurs or relapses after responding
favorably to hormone therapy. Said hormone therapy is understood to
be in the absence of a PI3K inhibitor. The cancer or tumor may be
resistant or refractory at the beginning of treatment or it may
become resistant or refractory during treatment.
[0224] It is one objective of this disclosure to provide a
pharmaceutical composition comprising a quantity, which is jointly
therapeutically effective at targeting or preventing a cancer, of
each therapeutic agent of the disclosure.
[0225] In accordance with the present disclosure, agents in the
composition of the present disclosure may be administered together
in a single pharmaceutical composition, separately in two or more
separate unit dosage forms, or sequentially. The unit dosage form
may also be a fixed combination.
[0226] The pharmaceutical compositions for separate administration
of agents or for the administration in a fixed combination (i.e., a
single galenical composition comprising at least two therapeutic
agents according to the disclosure may be prepared in a manner
known per se and are those suitable for enteral, such as oral or
rectal, topical, and parenteral administration to subjects,
including mammals (warm-blooded animals) such as humans, comprising
a therapeutically effective amount of at least one
pharmacologically active combination partner alone, e.g., as
indicated above, or in combination with one or more
pharmaceutically acceptable carriers or diluents, especially
suitable for enteral or parenteral application. Suitable
pharmaceutical compositions contain, e.g., from about 0.1% to about
99.9%, preferably from about 1% to about 60%, of the active
ingredient(s).
[0227] Pharmaceutical compositions for the combination therapy for
enteral or parenteral administration are, e.g., those in unit
dosage forms, such as sugar-coated tablets, tablets, capsules or
suppositories, ampoules, injectable solutions or injectable
suspensions. Topical administration is e.g. to the skin or the eye,
e.g. in the form of lotions, gels, ointments or creams, or in a
nasal or a suppository form. If not indicated otherwise, these are
prepared in a manner known per se, e.g., by means of conventional
mixing, granulating, sugar-coating, dissolving or lyophilizing
processes. It will be appreciated that the unit content of each
agent contained in an individual dose of each dosage form need not
in itself constitute an effective amount since the necessary
effective amount can be reached by administration of a plurality of
dosage units.
[0228] Pharmaceutical compositions may comprise one or more
pharmaceutical acceptable carriers or diluents and may be
manufactured in conventional manner by mixing one or both
combination partners with a pharmaceutically acceptable carrier or
diluent. Examples of pharmaceutically acceptable diluents include,
but are not limited to, lactose, dextrose, mannitol, and/or
glycerol, and/or lubricants and/or polyethylene glycol. Examples of
pharmaceutically acceptable acceptable binders include, but are not
limited to, magnesium aluminum silicate, starches, such as corn,
wheat or rice starch, gelatin, methylcellulose, sodium
carboxymethylcellulose and/or polyvinylpyrrolidone, and, if
desired, pharmaceutically acceptable disintegrators include, but
are not limited to, starches, agar, alginic acid or a salt thereof,
such as sodium alginate, and/or effervescent mixtures, or
adsorbents, dyes, flavorings and sweeteners. It is also possible to
use the compounds of the present disclosure in the form of
parenterally administrable compositions or in the form of infusion
solutions. The pharmaceutical compositions may be sterilized and/or
may comprise excipients, for example preservatives, stabilizers,
wetting compounds and/or emulsifiers, solubilisers, salts for
regulating the osmotic pressure and/or buffers.
[0229] In particular, a therapeutically effective amount of each of
the combination partner of the combination of the disclosure may be
administered simultaneously or sequentially and in any order, and
the components may be administered separately or as a fixed
combination. For example, the method of preventing or treating a
cancer according to the disclosure may comprise: (i) administration
of the first agent in free or pharmaceutically acceptable salt
form; and (ii) administration of a second agent in free or
pharmaceutically acceptable salt form, simultaneously or
sequentially in any order, in jointly therapeutically effective
amounts, preferably in synergistically effective amounts, e.g., in
daily or intermittently dosages corresponding to the amounts
described herein. The individual combination partners of the
combination of the disclosure may be administered separately at
different times during the course of therapy or concurrently in
divided or single combination forms. Furthermore, the term
administering also encompasses the use of a pro-drug of a
combination partner that convert in vivo to the combination partner
as such. The instant disclosure is therefore to be understood as
embracing all such regimens of simultaneous or alternating
treatment and the term "administering" is to be interpreted
accordingly.
[0230] The effective dosage of each of combination partner agents
employed in the combination of the disclosure may vary depending on
the particular compound or pharmaceutical composition employed, the
mode of administration, the condition being treated, the severity
of the condition being treated. Thus, the dosage regimen of the
combination of the disclosure is selected in accordance with a
variety of factors including type, species, age, weight, sex and
medical condition of the patient; the severity of the condition to
be treated; the route of administration; the renal and hepatic
function of the patient; and the particular compound employed. A
physician, clinician or veterinarian of ordinary skill can readily
determine and prescribe the effective amount of the drug required
to prevent, counter or arrest the progress of the condition.
Optimal precision in achieving concentration of drug within the
range that yields efficacy requires a regimen based on the kinetics
of the drug's availability to target sites. This involves a
consideration of the distribution, equilibrium, and elimination of
a drug.
[0231] A further benefit is that lower doses of the active
ingredients of the combination of the disclosure can be used, e.g.,
that the dosages need not only often be smaller but are also
applied less frequently, or can be used in order to diminish the
incidence of side effects. This is in accordance with the desires
and requirements of the patients to be treated.
[0232] The combination of the agents can be combined in the same
pharmaceutical preparation or in the form of combined preparations
"kit of parts" in the sense that the combination partners can be
dosed independently or by use of different fixed combinations with
distinguished amounts of the combination partners, i.e.,
simultaneously or at different time points. The parts of the kit of
parts can then, e.g., be administered simultaneously or
chronologically staggered, that is at different time points and
with equal or different time intervals for any part of the kit of
parts.
[0233] The present disclosure further relates to a kit comprising a
first compound selected from the group consisting of Compounds
A1-A3 or pharmaceutically acceptable salts thereof, a second
compound selected from the group consisting of Compounds B1-B4 or
pharmaceutically acceptable salts thereof, and a package insert or
other labeling including directions for treating a cancer.
[0234] The present disclosure further relates to a kit comprising a
first compound selected from the group consisting of Compounds
A1-A3 or pharmaceutically acceptable salts thereof, a second
compound selected from the group consisting of Compounds B1-B4 or
pharmaceutically acceptable salts thereof, a third compound
selected from the group consisting of Compounds C1-C3 or
pharmaceutically acceptable salts thereof, and a package insert or
other labeling including directions for treating a cancer.
[0235] The following Examples illustrate the disclosure described
above; they are not, however, intended to limit the scope of the
disclosure in any way. The beneficial effects of the pharmaceutical
combination of the present disclosure can also be determined by
other test models known as such to the person skilled in the
pertinent art.
Example 1
[0236] The following experimental procedure is performed to
demonstrate the efficacy and anti-proliferative activity of
Compound A1 in double or triple combination in the treatment of
breast cancer:
Preparation of Compounds/Reagent Solutions
[0237] Compound A1 (a CDK4/6 inhibitor, 10 mM), Compound B1
(Letrozole, Sigma, 10 mM), Compound B3 (Fulvestrant, Sigma, 10 mM),
Compound B2 (Exemestane, Sigma, 10 mM), Compound C1 (a PI3K
inhibitor, 10 mM), Compound C3 (an mTor inhibitor, 10 mM) and
Compound C2 (a PI3K inhibitor, 10 mM) were dissolved in DMSO.
.DELTA.4A (the precursor androstenedione 10 mM) were dissolved in
ethanol. All these reagents were stored in aliquots at -20.degree.
C.
Cell Culture
[0238] MCF7 human breast carcinoma cells were provided by Dr. Chen
Shivan (City of Hope National Medical Center, CA, USA), which were
stably transfected with the aromatase expression vector bearing the
neomycin (G418) resistance gene (also named MCF7/Aro). Aromatase
converts the precursor androstenedione (.DELTA.4A) into
17.beta.-estradiol (E2), which is required for the proliferation of
the host cell line. Unless otherwise mentioned, all cell culture
reagents were obtained from Invitrogen. Cells were maintained in
MEM (#11095-080) supplemented with 10% v/v fetal bovine serum (FBS,
#10099-141), 1 mM sodium pyruvate (#11360-070), 1% v/v
non-essential amino acids (#11140-050) and G418 (geneticin, #10131)
in a humidified incubator at 37.degree. C. in 5% CO2. The cells
were passaged twice a week and the medium was changed every 2 to 3
days. To assess estrogen driven cell proliferation, it was
necessary to deplete the medium of steroids. To do so, the
steroid-depleted (SD) medium, MEM (#51200-038, no phenol red &
no glutamine) supplemented with charcoal stripped FBS (#12676-029)
and Glutamax (#35050-061) was used. Medium without phenol red (pH
indicator) was required since it is a structural homologue of
estrogen. Moreover, normal FBS need to be replaced by
charcoal-stripped FBS in order to remove steroids. TryPLE Express
(12604-013, no phenal red) was used for cell dissociation during SD
treatment.
Cell Viability Assay and Cell Proliferation Assay
[0239] MCF7/Aro cells were steroid deprived for 3 days before
trypsinized using TryPLE Express (#12604-013, without phenol red)
and 1500 cells/well were plated on clear-bottom 384-well black
plates (Greiner, #781091) in triplicates with 30 .mu.l/well growth
media, cells were allowed to attach overnight and were followed by
6 days of incubation with 10 nM of .DELTA.4A and various
concentrations of drugs or drug combinations (10 .mu.l/well). Cell
viability was determined by measuring cellular ATP content using
the CellTiter-Glo.RTM. (CTG) luminescent cell viability assay
(Promega). Each single agent and combination treatment of cells was
compared to controls (cells treated with an equivalent volume of
medium). 30 .mu.l/well of the CTG reagents was added to each well
at the end of the compound treatment and luminescence was recorded
on an Envision plate reader (Perkin Elmer). Reduced and enhanced
luminescent signal values (responses) were calculated relative to
untreated (control) cells.
Combinations Tested
[0240] The following combinations were tested:
[0241] (a) Compound A1/Compound B1 (Letrozole);
[0242] (b) Compound A1/Compound B1 (Letrozole)/Compound C1 (1 uM or
500 nM);
[0243] (c) Compound A1/Compound B1 (Letrozole)/Compound C3 (20 nM
or 2 nM);
[0244] (d) Compound A1/Compound B1 (Letrozole)/Compound C2 (333
nM);
[0245] (e) Compound A1/Compound B3 (Fulvestrant);
[0246] (f) Compound A1/Compound B3 (Fulvestrant)/Compound C1 (1 uM
or 500 nM);
[0247] (g) Compound A1/Compound B3 (Fulvestrant)/Compound C3 (20 nM
or 2 nM);
[0248] (h) Compound A1/Compound B3 (Fulvestrant)/Compound C2 (333
nM);
[0249] (i) Compound A1/Compound B2 (Exemestane);
[0250] (j) Compound A1/Compound B2 (Exemestane)/Compound C1 (1 uM
or 500 nM);
[0251] (k) Compound A1/Compound B2 (Exemestane)/Compound C3 (20 nM
or 2 nM); and
[0252] (l) Compound A1/Compound B2 (Exemestane)/Compound C2 (333
nM).
[0253] Compound A1, Compound B1 (Letrozole), Compound B2
(Exemestane) and Compound B3 (Fulvestant) were in multiple doses,
and Compound C1, Compound C2 and Compound C3 were in a single dose
as a background compounds (doses as labeled above) in all the
triple combinations.
[0254] To evaluate the anti-proliferative activity of all the
combinations in a non-bias way, as well as to identify synergistic
effect at all possible concentrations, the studies were conducted
with a "dose matrix." This utilized all possible permutations of
serially-diluted Compound A1/Compound B1 (Letrozole), Compound
A1/Compound B3 (Fulvestant) and Compound A1/Compound B2
(Exemestane) (with a single dose background compound). In all
combination assays, agents were applied simultaneously.
[0255] The "dose matrix, Compound A1/Compound B1, Compound
A1/Compound B3 and Compound A1/Compound B2" were consisted of the
followings: [0256] (a) Compound A1 (in the combination of Compound
A1/Compound B1 and Compound A1/Compound B2), which was subjected to
a 6 dose 3.times. serial dilution with a high dose of 10 uM and a
low dose of approximately 41 nM [0257] (b) Compound A1 (in the
combination of Compound A1/Compound B3), which was subjected to a 5
or 6 dose 3.times. serial dilution with a high dose of 1 or 3 uM
and a low dose of approximately 12 nM [0258] (c) Compound B1, which
was subjected to a 7 dose 3.times. serial dilution with a high dose
of 5 uM and a low dose of approximately 7 nM [0259] (d) Compound
B3, which was subjected to a 6 dose 3.times. serial dilution with a
high dose of 800 nM and a low dose of approximately 3 nM [0260] (e)
Compound B2, which was subjected to a 7 dose 3.times. serial
dilution with a high dose of 10 uM and a low dose of approximately
14 nM.
Calculating the Effect of Combinations:
[0261] The synergistic interaction (analyzed using Chalice software
[CombinatoRx, Cambridge Mass.]) was calculated by comparing the
response from a combination to the response of the agent acting
alone, against the drug-with-itself dose-additive reference model.
Deviations from dose additives can be assessed numerically with a
Combination Index (CI), which quantifies the overall strength of
combination effect. This calculation (esentially a volume score) is
as follows: V.sub.HSA=.SIGMA..sub.X,YInfX InfY
(I.sub.data-I.sub.HSA). Additionally, CI is calculated between the
data and the highest single-agent surface, normalized for single
agent dilution factors (Lehar et al, 2009):
Data Analysis
[0262] Data evaluation and graph generation were performed using
Microsoft Excel software, and Chalice software.
Results
[0263] To investigate the activity of double or triple combinations
of Compound A1 with antiestrogen therapeutics such as fulvestrant
(Compound B3), letrozole (Compound B1) and exemestane (Compound
B2), with or without PI3K or mTOR inhibitor Compound C1, Compound
C2 or Compound C3 on cell proliferation, various combos as
described in the method section were tested in androstenedione
driven, aromatase overexpressing MCF7 cells. Synergy was observed
between Compound A1 and all three antihormonal therapies in a
7.times.8 dose matrix combination setting, with synergy score each
at 4.12, 2.41 and 1.43, for letrozole (Compound B1), exemestane
(Compound B2) and fulvestrant (Compound B3), respectively. Various
does of PI3K and mTOR inhibitor was also added to the same
7.times.8 does matrix setting as a background compounds to test the
efficacy of triple combinations, in all cases, the triple combo
significantly enhanced the maximum level of inhibition achieved by
single or double reagents, and greatly reduced the doses needed for
achieving the same levels of inhibition. Those results solidly
support the concept of combining two or three reagents targeting
cell cycle, mTOR/PI3K and estrogen pathway in ER positive breast
cancer.
[0264] The results from Example 1 are shown in FIGS. 1-7.
Example 2
[0265] The following experimental procedure is performed to
demonstrate the efficacy and anti-proliferative activity of
Compound A2 or Compound A3 in double or triple combination in the
treatment of breast cancer:
Preparation of Compounds/Reagent Solutions
[0266] Compound A2 (a CDK4/6 inhibitotor, 10 mM), Compound A3 (a
CDK4/6 inhibitor, 10 mM), Compound B1 (Letrozole, Sigma, 10 mM),
Compound B3 (Fulvestrant, Sigma, 10 mM), Compound B2 (Exemestane,
Sigma, 10 mM), Compound C1 (a PI3K inhibitor, 10 mM), and Compound
C3 (an mTor inhibitor, 10 mM) were dissolved in DMSO. .DELTA.4A
(the precursor androstenedione, 10 mM) were dissolved in ethanol.
All these reagents were stored in aliquots at -20.degree. C.
Cell Culture
[0267] MCF7 human breast carcinoma cells were provided by Dr. Chen
Shivan (City of Hope National Medical Center, CA, USA), which were
stably transfected with the aromatase expression vector bearing the
neomycin (G418) resistance gene (also named MCF7/Aro). Aromatase
converts the precursor androstenedione (.DELTA.4A) into
17.beta.-estradiol (E2), which is required for the proliferation of
the host cell line. Unless otherwise mentioned, all cell culture
reagents were obtained from Invitrogen. Cells were maintained in
MEM (#11095-080) supplemented with 10% v/v fetal bovine serum (FBS,
#10099-141), 1 mM sodium pyruvate (#11360-070), 1% v/v
non-essential amino acids (#11140-050) and G418 (geneticin, #10131)
in a humidified incubator at 37.degree. C. in 5% CO2. The cells
were passaged twice a week and the medium was changed every 2 to 3
days. To assess estrogen driven cell proliferation, it was
necessary to deplete the medium of steroids. To do so, the
steroid-depleted (SD) medium, MEM (#51200-038, no phenol red &
no glutamine) supplemented with charcoal stripped FBS (#12676-029)
and Glutamax (#35050-061) was used. Medium without phenol red (pH
indicator) was required since it is a structural homologue of
estrogen. Moreover, normal FBS need to be replaced by
charcoal-stripped FBS in order to remove steroids. TryPLE Express
(12604-013, no phenal red) was used for cell dissociation during SD
treatment.
Cell Viability Assay and Cell Proliferation Assay
[0268] MCF7/Aro cells were steroid deprived for 3 days before
trypsinized using TryPLE Express (#12604-013, without phenol red)
and 1500 cells/well were plated on clear-bottom 384-well black
plates (Greiner, #781091) in triplicates with 30 .mu.l/well growth
media, cells were allowed to attach overnight and were followed by
6 days of incubation with 10 nM of A4A and various concentrations
of drugs or drug combinations (10 .mu.l/well). Cell viability was
determined by measuring cellular ATP content using the
CellTiter-Glo.RTM. (CTG) luminescent cell viability assay
(Promega). Each single agent and combination treatment of cells was
compared to controls (cells treated with an equivalent volume of
medium). 30 .mu.l/well of the CTG reagents was added to each well
at the end of the compound treatment and luminescence was recorded
on an Envision plate reader (Perkin Elmer). Reduced and enhanced
luminescent signal values (responses) were calculated relative to
untreated (control) cells.
Combinations Tested
[0269] The following combinations were tested:
[0270] (a) Compound A2/Compound B1 (Letrozole);
[0271] (b) Compound A2/Compound B1 (Letrozole)/Compound C1;
[0272] (c) Compound A2/Compound B1 (Letrozole)/Compound C3;
[0273] (d) Compound A2/Compound B3 (Fulvestrant);
[0274] (e) Compound A2/Compound B3 (Fulvestrant)/Compound C1;
[0275] (f) Compound A2/Compound B3 (Fulvestrant)/Compound C3;
[0276] (g) Compound A2/Compound B3 (Exemestane);
[0277] (h) Compound A2/Compound B3 (Exemestane)/Compound C1;
[0278] (i) Compound A2/Compound B3 (Exemestane)/Compound C3;
[0279] (j) Compound A3/Compound B1 (Letrozole);
[0280] (k) Compound A3/Compound B1 (Letrozole)/Compound C1;
[0281] (l) Compound A3/Compound B1 (Letrozole)/Compound C3;
[0282] (m) Compound A3/Compound B3 (Fulvestrant);
[0283] (n) Compound A3/Compound B3 (Fulvestrant)/Compound C1;
[0284] (o) Compound A3/Compound B3 (Fulvestrant)/Compound C3;
[0285] (p) Compound A3/Compound B3 (Exemestane);
[0286] (q) Compound A3/Compound B3 (Exemestane)/Compound C1;
and
[0287] (r) Compound A3/Compound B3 (Exemestane)/Compound C3.
[0288] Compound A2, Compound A3, Letrozole (Compound B1),
Exemestane (Compound B2) and Fulvestant (Compound B3) were in
multiple doses, and Compound C1 (1 uM) and Compound C2 (20 nM) were
in a single dose as a background in all the triple
combinations.
[0289] To evaluate the anti-proliferative activity of all the
combinations in a non-bias way, as well as to identify synergistic
effect at all possible concentrations, the studies were conducted
with a "dose matrix." This utilized all possible permutations of
serially-diluted Compound A2/Compound B1 (Letrozole), Compound
A2/Compound B3 (Fulvestant), Compound A2/Compound B2 (Exemestane),
Compound A3/Compound B1 (Letrozole), Compound A3/Compound B3
(Fulvestant) and Compound A3/Compound B2 (Exemestane) (with a
single dose background compound). In all combination assays, agents
were applied simultaneously.
[0290] The "dose matrix, Compound A2/Compound B1, Compound
A2/Compound B3, Compound A2/Compound B2, Compound A3/Compound B1,
Compound A3/Compound B3 and Compound A3/Compound B2" were consisted
of the followings: [0291] (a) Compound A2, which was subjected to a
7 dose 3.times. serial dilution with a high dose of 3 uM and a low
dose of approximately 4.1 nM [0292] (b) Compound A3, which was
subjected to a 7 dose 3.times. serial dilution with a high dose of
3 uM and a low dose of approximately 4.1 nM [0293] (c) Compound B1,
which was subjected to a 6 dose 3.times. serial dilution with a
high dose of 5 uM and a low dose of approximately 20.6 nM [0294]
(d) Compound B3, which was subjected to a 6 dose 3.times. serial
dilution with a high dose of 100 nM and a low dose of approximately
0.4 nM [0295] (e) Compound B2, which was subjected to a 6 dose
3.times. serial dilution with a high dose of 10 uM and a low dose
of approximately 41.2 nM
Calculating the Effect of Combinations
[0296] The synergistic interaction (analyzed using Chalice software
[CombinatoRx, Cambridge Mass.]) was calculated by comparing the
response from a combination to the response of the agent acting
alone, against the drug-with-itself dose-additive reference model.
Deviations from dose additives can be assessed numerically with a
Combination Index (CI), which quantifies the overall strength of
combination effect. This calculation (esentially a volume score) is
as follows: V.sub.HsA=.SIGMA..sub.X,YInfX InfY
(I.sub.data-I.sub.HSA). Additionally, CI is calculated between the
data and the highest single-agent surface, normalized for single
agent dilution factors (Lehar et al, 2009):
Data Analysis
[0297] Data evaluation and graph generation were performed using
Microsoft Excel software, and Chalice software.
Results
[0298] To investigate the activity of double or triple combinations
of Compound A2 and Compound A3 with antiestrogen therapeutics such
as fulvestrant (Compound B3), letrozole (Compound B1) and
exemestane (Compound B2), with or without PI3K or mTOR inhibitor
Compound C1 or Compound C3 on cell proliferation, various combos as
described in the method section were tested in androstenedione
driven, aromatase overexpressing MCF7 cells. Synergy was observed
between Compound A3 and all three antihormonal therapies in a
7.times.8 dose matrix combination setting, with score each at 3.7,
1.2 and 1.7 for letrozole, exemestane and fulvestrant respectively.
And synergy was also observed in Compound A2/Letrozole and Compound
A2/Fulvestrant combinations with score each at 3.2 and 1.4. Single
dose of PI3K and mTOR inhibitor was also added to the same
7.times.8 does matrix setting as a background compounds to test the
efficacy of triple combinations, in all cases, the triple combo
significantly enhanced the maximum level of inhibition achieved by
single or double reagents, and greatly reduced the doses needed for
achieving the same levels of inhibition. Those results solidly
support the concept of combining two or three reagents targeting
cell cycle, mTOR/PI3K and estrogen pathway in ER positive breast
cancer.
[0299] The results from Example 2 are shown in FIGS. 8-19.
[0300] The Table below summerizes the synergy score of the various
combinations tested in Example 2.
TABLE-US-00001 Combo synergy score Compound A3/Compound B1 3.7
Compound A3/Compound B1/Compound C1 1.7 Compound A3/Compound
B1/Compound C3 4.5 Compound A3/Compound B2 1.2 Compound A3/Compound
B2/Compound C1 1.5 Compound A3/Compound B2/Compound C3 2.8 Compound
A3/Compound B3 1.7 Compound A3/Compound B3/Compound C1 3.0 Compound
A3/Compound B3/Compound C3 1.7 Compound A2/Compound B1 3.2 Compound
A2/Compound B1/Compound C1 1.9 Compound A2/Compound B1/Compound C3
4.4 Compound A2/Compound B2 0.8 Compound A2/Compound B2/Compound C1
1.3 Compound A2/Compound B2/Compound C3 2.4 Compound A2/Compound B3
1.4 Compound A2/Compound B3/Compound C1 3.2 Compound A2/Compound
B3/Compound C3 1.5
Example 3
[0301] A clinical trial is currently on going to further the
clinical development of the two investigational agents in ER+
breast cancer, Compound A1 (CDK4/6 inhibitor) and Compound C1 (PI3K
inhibitor). This is a multi-center, open-label, dose finding Phase
Ib/II trial. The Phase Ib part is a three-part dose escalation
study to estimate the MTD and/or RP2D for two double combinations:
Compound A1 with letrozole and Compound C1 with letrozole followed
by estimation of the MTD and/or RP2D of the triple combination of
Compound A1+Compound C1 with letrozole.
[0302] The three-part Phase Ib will be followed by a randomized
Phase II study to assess the preliminary anti-tumor activity of the
two double combination regimens (Compound A1+letrozole and Compound
C1+letrozole) versus the triple combination (Compound A1+Compound
C1 with letrozole) and to further evaluate their safety in patients
with ER+/HER2- locally advanced or metastatic breast cancer.
[0303] Approximately 290 adult women with ER+/HER2- locally
advanced or metastatic breast cancer will be enrolled.
[0304] The starting dose for the study drug combination doublets
and triplet are described below. The standard dose of letrozole
will be used throughout this study (2.5 mg/day).
Starting Doses for Each Arm:
TABLE-US-00002 [0305] Compound A1 (3 weeks followed by a one week
Compound C1 Letrozole Arm break) (QD) (QD) Compound A1 and 600 mg
-- 2.5 mg Letrozole Compound C1 and -- 300 mg 2.5 mg Letrozole
Compound A1 and 400 mg 100 mg 2.5 mg Compound C1 and Letrozole
The objectives of the Phase Ib portion of the study are:
Primary Objectives
[0306] To estimate the maximum tolerated dose (MTD) and/or
recommended Phase II dose (RP2D) of the following combinations:
[0307] Arm 1: Compound A1+letrozole (2.5 mg) [0308] Arm 2: Compound
C1+letrozole (2.5 mg) [0309] Arm 3: Compound A1+Compound
C1+letrozole (2.5 mg).
Secondary Objectives
[0310] To characterize the pharmacokinetic (PK) profiles of
Compound A1, Compound C1, and letrozole when used in
combination.
[0311] To characterize the safety and tolerability in Arms 1, 2,
and 3.
[0312] To assess preliminary clinical antitumor activity in Arms 1,
2, and 3.
Study Design (FIG. 23)
[0313] In the Phase Ib portion of this multicenter, open-label
study, postmenopausal women with ER+/human epidermal growth factor
receptor negative (HER2-) advanced BC are being treated with
once-daily doses of Compound A1 (3-weeks-on/1-week-off)+letrozole
(2.5 mg) or Compound C1+letrozole (2.5 mg).
[0314] Dose escalation is guided by the adaptive Bayesian Logistic
Regression Model (BLRM) along with the Escalation With Overdose
Control principle.
[0315] PK assessments were conducted prior to dose-escalation
decisions during the study to monitor exposure and evaluate
possibility of cytochrome P450-mediated drug-drug interactions.
[0316] Upon determination of the MTD/RP2D in Arms 1 and 2, the BLRM
will be updated with the most recent data from the dose-escalation
in Arms 1 and 2, and this will be used to determine the starting
dose for Arm 3.
Key Inclusion Criteria
[0317] Postmenopausal women with metastatic or locally advanced
ER+/HER2- BC.
[0318] Any number of prior lines of endocrine therapy.
[0319] Up to 1 prior cytotoxic regimen in the metastatic or locally
advanced setting.
[0320] Representative tumor specimen (archival or new) available
for molecular testing (unless otherwise agreed).
[0321] Newly obtained, matched pre- and on-therapy tumor samples
are mandatory in the Phase Ib dose-escalation part of the
study.
Key Exclusion Criteria
[0322] Prior treatment with a CDK4/6, AKT, mTOR, or PI3K inhibitor
and failure to benefit.
[0323] Current symptomatic brain metastases.
[0324] Clinically manifest diabetes mellitus, history of
gestational diabetes mellitus, or documented steroid-induced
diabetes mellitus.
[0325] QT corrected with Fridericia's formula (QTcF) >470
ms.
Assessments
[0326] Routine safety assessments conducted at baseline and at
regular intervals throughout the study, and adverse events (AEs)
assessed continuously according to Common Terminology Criteria for
Adverse Events v4.03.
[0327] Tumor response evaluated locally by the investigator, using
computerized tomography and magnetic resonance imaging, based on
Response Evaluation Criteria In Solid Tumors v1.1. Evaluations
conducted at baseline, every 8 weeks through to Cycle 6, every 12
weeks thereafter (or sooner if there is clinical evidence of
disease progression), and at end of treatment.
[0328] Samples for PK evaluations collected on Days 1, 2, 8, 15,
21, and 22 of Cycle 1 and on Day 15 of Cycles 2-6. Real-time PK
assessments were conducted to guide dose escalation (in addition to
BLRM).
Interim Results
Patient Characteristics and Disposition
[0329] 10 patients have been treated with Compound A1 and letrozole
(Arm 1), and 7 patients have been treated with Compound C1 and
letrozole (Arm 2). The patients details are shown in Table 1.
TABLE-US-00003 TABLE 1 Patient Characteristics and Disposition Arm
1: Compound Arm 2: Compound A1 600 mg + C1 300 mg + All subjects
Characteristic letrozole (n = 10) letrozole (n = 7) (N = 17) Median
age, years (range) 59 (45-67) 61 (51-72) 60 (45-72) WHO performance
status, n (%) 0 5 (50) 4 (57) 9 (53) 1 5 (50) 3 (43) 8 (47) Median
time since initial 123 (9-173) 49 (2-295) 104 (2-295) diagnosis to
first dose of treatment, months (range) Pts who received prior 10
(100) 7 (100) 17 (100) antineoplastic regimens, n (%) Number of
regimens, n (%) 1 2 (20) 3 (43) 5 (29) 2 1 (10) 2 (29) 3 (18) 4 0 1
(14) 1 (6) 5 2 (20) 0 2 (12) >5 5 (50) 1 (14) 6 (35) Prior
therapies received in the advanced/metastatic setting, n (%)
Chemotherapy 4 (40) 0 4 (24) Anastrozole 4 (40) 3 (43) 7 (41)
Fulvestrant 6 (60) 2 (29) 8 (47) Letrozole 4 (40) 3 (43) 7 (41)
Tamoxifen 1 (10) 0 1 (6) Exemestane 3 (30) 2 (29) 5 (29)
PI3K/AKT/mTOR 5 (50) 1 (14) 6 (35) inhibitors Other 7 (70) 2 (29) 9
(53) Number of pts who received 9 (90) 7 (100) 16 (94) prior
surgery, n (%) Number of pts who received 8 (80) 4 (57) 12 (71)
prior radiotherapy, n (%) mTOR, mammalian target of rapamycin;
PI3K, phosphatidylinositol 3-kinase; pts, patients; WHO, World
Health Organization.
[0330] At the time of study entry, all patients had stage IV
ER+/HER2- BC.
[0331] Treatment has been discontinued in 2 (20%) patients in Arm 1
due to disease progression. At the cut-off date, treatment was
ongoing for all 7 (100%) patients in Arm 2.
Safety
[0332] Of 12 patients evaluable as part of the dose-determining set
(6 in each arm), 3 dose-limiting toxicities (DLTs) were observed: 1
Grade 4 neutropenia in Arm 1 and 2 Grade 2 hyperglycemia in Arm
2.
[0333] The most common (>30% patients) all-grade adverse events
suspected to be study drug-related were (see Table 2):
[0334] Arm 1: neutropenia (90%) and nausea (40%)
[0335] Arm 2: hyperglycemia (57%), nausea (43%), decreased appetite
(43%), and diarrhea (43%).
TABLE-US-00004 TABLE 2 All Grades .gtoreq.10% and All Grade 3/4
Adverse Events Arm 1 Compound A1 Arm 2: Compound C1 600 mg +
letrozole 300 mg + letrozole All subjects (n = 10) (n = 7) (N = 17)
All Grade All Grade All Grade Adverse grades, 3/4, grades, 3/4,
grades, 3/4, event n (%) n (%) n (%) n (%) n (%) n (%) Hematologic
adverse events Neutropenia 9 (90) 5 (50) 0 0 9 (53) 5 (29)
Leukopenia 2 (20) 0 0 0 2 (12) 0 Lymphopenia 0 0 1 (14) 1 (14) 1
(6) 1 (6) Non-hematologic adverse events Nausea 4 (40) 0 3 (43) 0 7
(41) 0 Fatigue 3 (30) 0 2 (29) 1 (14) 5 (29) 1 (6) Decreased 1 (10)
0 3 (43) 0 4 (24) 0 appetite Diarrhea 1 (10) 0 3 (43) 0 4 (24) 0
Hyperglycemia 0 0 4 (57) 1 (14) 4 (24) 1 (6) Weight 1 (10) 0 2 (29)
0 3 (18) 0 decreased Dysgeusia 0 0 2 (29) 0 2 (12) 0
[0336] QTcF prolongation (>470 ms) was not observed in Arm
1.
[0337] Grade 3/4 adverse events suspected to be study drug related
included (Table 2): [0338] Arm 1: neutropenia (50%) [0339] Arm 2:
lymphopenia (14%), fatigue (14%), and hyperglycemia (14%).
[0340] Dose reductions occurred in 5 patients: 1 patient in Arm 1
and 4 patients in Arm 2.
Pharmacokinetics
[0341] Preliminary PK data for Compound A1, Compound C1, and
letrozole are as follows (Table 3): [0342] PK for Compound A1 and
Compound C1 on Days 1 and 21 are comparable with historic
single-agent data. [0343] PK for letrozole on Day 1 are comparable
with those observed in single-agent studies. [0344] Additional data
are being gathered from patients currently enrolled in the trial to
further evaluate letrozole PK in combination with Compound A1.
TABLE-US-00005 [0344] TABLE 3 Pharmacokinetic Parameters of
Compound A1, Compound C1 and Letrozole AUC all (h*ng/ml), C.sub.max
(ng/ml), T.sub.max (h), Analyte n mean (SD) mean (SD) median
(range) Arm 1, C1D1 Compound A1 6 13072 (9458) 1320 (859) 3.0
(1.9-4.2) Letrozole 6 421 (115) 25 (4) 2.0 Arm 1, C1D21 Compound A1
3 32038 (16586) 2780 (767) 4.0 (1.9-4.0) Letrozole 3 1364 (785) 79
(12) 4.0 (4.0-7.5) Arm 2, C1D1 Compound C1 5 29102 (8251) 2480
(922) 3.8 (1.2-4.1) Letrozole 5 330 (115) 27 (13) 2.0 (1.2-4.0) Arm
2, C1D21 Compound C1 3 40358 (6329) 3167 (314) 2.0 (2.0-3.8)
Letrozole 3 2412 (189) 118 (9) 2.0 (1.9-2.0) AUC, area under the
curve; C, cycle; Cmax, maximum concentration; D, day; Tmax, time to
reach maximum concentration.
Clinical Activity
[0345] Duration of exposure to treatment is shown in FIGS. 24 and
25.
[0346] In Arm 1, there was 1 patient with a confirmed partial
response (FIG. 26), 2 patients with stable disease (SD), and 1
patient without measurable disease had neither complete response
nor progressive disease (NCRNPD; FIG. 24).
[0347] In Arm 2, there were 2 patients with SD and 3 patients had
NCRNPD (FIG. 25).
Conclusion (Based on Interim Results)
[0348] Both arms of the study have demonstrated an acceptable
safety profile and preliminary signs of clinical activity in
postmenopausal women with ER+/HER2- advanced BC.
[0349] Neutropenia is an anticipated side effect of Compound A1,
potentially due to inhibition of proliferation via CDK4/6
inhibition.
[0350] Hyperglycemia observed in Arm 2 (Compound C1+letrozole) may
be an on-target effect of PI3K inhibition.
[0351] Dose escalation continues to determine the MTD/RP2D.
[0352] Upon determination of the MTD/RP2D in Arms 1 and 2,
enrollment into Arm 3 will commence. Following the Phase Ib portion
of the study a randomized Phase II portion will compare Compound
A1+letrozole and Compound C1+letrozole with Compound A1+Compound
C1+letrozole.
Example 4
[0353] A multi-center, pre-surgical, randomized, phase II study is
planned, to assess the biological activity of Compound A1, 400 mg
or 600 mg daily, in combination with letrozole 2.5 mg daily, as
compared to single agent letrozole daily in postmenopausal patients
with newly diagnosed HR+, HER2-negative, early breast cancer. A
total of approximately 120 patients will be randomized. Patients
will receive trial therapy for 14 days (.+-.3 days) and then
undergo surgery. Patients will be randomly assigned to treatment
with:
[0354] a. Letrozole (2.5 mg once daily); OR
[0355] b. Letrozole (2.5 mg once daily)+Compound A1 400 mg daily;
OR
[0356] c. Letrozole (2.5 mg once daily)+Compound A1 600 mg
daily
[0357] The primary objective of the study is to assess the cell
cycle response rate defined as the percentage of patients who
achieve a reduction in Ki67 expression to natural logarithm of
percentage positive Ki67 of less than 1 (Baselga 2009). Although
the trial is designed as open label, all pharmacodynamics and
clinical pharmacology endpoints will be assessed by experts who are
blinded to randomized treatment.
Example 5
[0358] A Phase Ib/II Trial of Compound A1 with everolimus and
exemestane in the treatment of ER+Her2- Advanced Breast Cancer is
on-going. The purpose of the trial is to estimate the MTD(s) and/or
RP2D of Compound A1 in combination with everolimus+exemestane, and
Compound A1 in combination with exemestane, and to characterize the
safety and tolerability of the combinations of
everolimus+exemestane.+-.Compound A1 and Compound A1+exemestane in
patients with ER+HER2- advanced breast cancer. The study consists
of 3 arms:
TABLE-US-00006 Arms Assigned Interventions Compound A1 + everolimus
+ Compound A1 is taken orally once per exemestane triple
combination day for 21 days of each 28 day cycle. Exemestane is
taken orally once per day. Everolimus is taken orally once per day.
Compound A1 + exemestane Compound A1 is taken orally once per
double combination day for 21 days of each 28 day cycle Exemestane
is taken orally once per day. everolimus + exemestane Exemestane is
taken orally once per day. double combination Everolimus is taken
orally once per day.
Compound A1 comes in 50 mg and 200 mg capsules. Exemestane comes in
25 mg tablets. Everolimus comes in 2.5 mg, 5 mg, and 7.5 mg
tablets. The objectives of the Phase Ib portion of this study
are:
Primary Objective
[0359] Determine the maximum tolerated dose (MTD)/recommended Phase
II dose (RP2D) of Compound A1+everolimus (EVE)+exemestane (EXE) in
patients with ER+/human epidermal growth factor receptor 2-negative
(HER2-) advanced BC.
Secondary Objectives
[0360] Determine the safety and tolerability of Compound A1+EVE+EXE
and Compound A1+EXE.
[0361] Characterize the pharmacokinetics (PK) of Compound A1 and/or
EVE when administered in combination with EXE.
[0362] Assess preliminary antitumor activity of Compound A1+EVE+EXE
and Compound A1+EXE.
[0363] Evaluate the relationship between antitumor activity and
molecular aberrations in the cyclin D-CDK4/6-INK-Rb, PI3K/AKT/mTOR,
and other cancer-related pathways.
Study Design:
[0364] In the Phase Ib portion of this Phase Ib/II multicenter,
open-label study, postmenopausal women with ER+/HER2- advanced BC,
resistant to letrozole or anastrozole, are being treated with
escalating doses of Compound A1+EVE+EXE (25 mg/day) or a safety
run-in of Compound A1 (600 mg/day)+EXE (25 mg/day; FIG. 27).
[0365] Dose escalation is being guided by the adaptive Bayesian
Logistic Regression Model along with the Escalation with Overdose
Control principle and PK was assessed prior to dose-escalation
decisions.
[0366] Upon determination of the MTD/RP2D, the Phase II portion of
the study will compare Compound A1+EVE+EXE triplet) and Compound
A1+EXE (doublet) with EVE+EXE.
Key Inclusion Criteria:
[0367] Postmenopausal women with ER+/HER2- locally advanced or
metastatic BC.
[0368] Recurrence while on, or within 12 months of end of, adjuvant
treatment with letrozole or anastrozole OR progression while on, or
within 1 month of end of, treatment with letrozole or anastrozole
treatment for locally advanced or metastatic BC. Letrozole or
anastrozole need not be the last treatment prior to study
start.
[0369] Previous treatment with a CDK4/6 inhibitor, EXE, or mTOR
inhibitor allowed (for Phase Ib but not Phase II).
[0370] Representative tumor specimen (archival or new) available
for molecular testing.
Key Exclusion Criteria:
[0371] >2 chemotherapy lines for advanced BC.
[0372] Absolute neutrophil count .ltoreq.1.5.times.109/L.
[0373] QT corrected with Fridericia's formula >470 ms.
Assessments:
[0374] Routine safety assessments conducted at baseline and at
regular intervals throughout the study. Adverse events (AEs) are
being assessed continuously according to Common Terminology
Criteria for Adverse Events v4.03.
[0375] Tumor response assessed locally by the investigator using
computerized tomography or magnetic resonance imaging according to
Response Evaluation Criteria In Solid Tumors v1.1 at baseline and
on Day (D) 1 of Cycles (C) 3, 5, and 7, on D1 of every 4th
subsequent cycle (or sooner if clinically indicated), and at the
end of treatment.
[0376] PK evaluations for Compound A1 and EVE performed in patients
treated with Compound A1+EVE+EXE during C1 on D1, 2, 8, 15, 16, and
21, and D1 of each subsequent cycle up to and including C6.
[0377] Tumor samples analyzed by next-generation sequencing to
determine any alterations in genes of interest.
Interim Results:
Patient Characteristics and Disposition:
[0378] As of the interim report cut of date, 16 patients have been
treated: 3 patients with Compound A1 600 mg+EXE 25 mg and 13
patients with Compound A1 (200 mg [6 patients]; 300 mg [6
patients]; 250 mg [1 patient])+EVE 2.5 mg+EXE 25 mg.
[0379] Treatment has been discontinued in 5 (31%) patients. The
primary reasons for discontinuation were: disease progression (4
patients) and death (1 patient).
[0380] In the advanced/metastatic setting, previous treatment with
letrozole or anastrozole was reported in 10 (63%) and 5 (31%)
patients, respectively, while 6 (38%) and 3 (19%) patients had
received prior EXE and EVE, respectively (Table 4).
TABLE-US-00007 TABLE 4 Patient and Disease Characteristics
Characteristic All (N = 16) Median age, years (range) 57 (41-84) 57
(41-84) Time since initial diagnosis of primary site 83 (8-355) to
first dose of drug (months), median (range) Site of metastases, n
(%) Bone (no visceral disease) 3 (25) Bone and visceral 9 (50)
Visceral (no bone disease) 4 (25) Others 9 (56) Setting at last
medication, n (%) Adjuvant 2 (13) Neoadjuvant 1 (6)
Advanced/metastatic disease 14 (88) Number of prior regimens in the
advanced/metastatic setting, n (%) 0 2 (13) 1-2 5 (31) 3-4 7 (44)
>4 2 (13) Number of prior chemotherapy regimens in the
advanced/metastatic setting, n (%) 0 10 (63) 1 2 (13) 2 4 (25)
Prior therapies received in the advanced/metastatic setting, n (%)
Letrozole 10 (63) Anastrozole 5 (31) Fulvestrant 11 (69)
Chemotherapy 6 (38) Exemestane 6 (38) Everolimus 3 (19) Other
PI3K/AKT/mTOR pathway inhibitors 4 (25) Tamoxifen 2 (13) Others 5
(31) PI3K, phosphatidylinositol 3-kinase; mTOR, mammalian target of
rapamycin.
Safety:
[0381] Among 13 patients evaluable for dose-limiting toxicities
(DLTs), 3 DLTs were observed, all with Compound A1 300 mg+EVE 2.5
mg+EXE 25 mg: 1 Grade 3 febrile neutropenia and 2 Grade 3 alanine
aminotransferase (ALT) elevation.
[0382] Hematologic AEs were the most common toxicity across all
cohorts (Table 5).
[0383] The most common (.gtoreq.10%) Grade 3/4 study drug-related
AEs were neutropenia (50%), leukopenia (31%), ALT increased (13%),
and hypophosphatemia (13%).
TABLE-US-00008 TABLE 5 Adverse Events (All Grade >15% in All
Pts) Suspected to be Treatment Related Comp A1 Comp A1 Comp A1 All
pts Comp A1 (200 mg) + (250 mg) + (300 mg) + treated with (600 mg)
+ EVE (2.5 mg) + EVE (2.5 mg) + EVE (2.5 mg) + Comp A1 + EXE (25
mg) EXE (25 mg) EXE (25 mg) EXE (25 mg) EVE + EXE All pts Adverse
Event n = 3 n = 6 n = 1 n = 6 n = 13 N = 16 Hematologic toxicities
Neutropenia All 3 (100) 4 (67) 0 5 (83) 9 (69) 12 (75) G3/4 2 (67)
3 (33) 0 4 (67)* 6 (46) 8 (50) Thrombocytopenia All 3 (100) 3 (50)
0 5 (83) 8 (62) 11 (69) G3/4 0 1 (17) 0 0 1 (8) 1 (6) Anemia All 3
(100) 2 (33) 0 5 (83) 7 (54) 10 (63) G3/4 0 0 0 0 0 0 Leukopenia
All 3 (100) 1 (17) 1 (100) 5 (83) 7 (54) 10 (63) G3/4 2 (67) 1 (17)
0 2 (33) 3 (23) 5 (31) Lymphopenia All 0 3 (50) 0 2 (33) 5 (39) 5
(31) G3/4 0 1 (17) 0 0 1 (8) 1 (6) Hypophosphatemia All 0 1 (17) 1
(100) 1 (17) 3 (23) 3 (19) G3/4 0 0 1 (100) 1 (17) 2 (15) 2 (13)
Non-hematologic toxicities ALT increased All 1 (33) 2 (33) 0 4 (67)
6 (46) 7 (44) G3/4 0 0 0 2 (33)* 2 (15) 2 (13) AST increased All 1
(33) 1 (17) 0 4 (67) 5 (39) 6 (38) G3/4 0 0 0 1 (17) 1 (8) 1 (6)
Stomatitis All 2 (67) 3 (50) 0 1 (17) 4 (31) 6 (38) G3/4 0 0 0 0 0
0 Blood alkaline All 0 2 (33) 0 2 (33) 4 (31) 4 (25) phosphatase
G3/4 0 0 0 0 0 0 increased Diarrhea All 2 (67) 1 (17) 0 1 (17) 2
(15) 4 (25) G3/4 0 0 0 0 0 0 Nausea All 1 (33) 1 (17) 0 2 (33) 3
(23) 4 (25) G3/4 0 0 0 0 0 0 Fatigue All 0 0 0 3 (50) 3 (23) 3 (19)
G3/4 0 0 0 1 (17) 1 (8) 1 (6) Headache All 1 (33) 1 (17) 0 1 (17) 2
(15) 3 (19) G3/4 0 0 0 0 0 0 ALT, alanine aminotransferase; AST,
aspartate aminotransferase; EVE, everolimus; EXE, exemestane; pt,
patient; Comp A1, Compound A1. *Dose-limiting toxicities included 1
Grade 3 febrile neutropenia and 2 Grade 3 ALT elevations.
Pharmacokinetics:
[0384] Mean plasma concentration-time profiles for Compound A1 and
EVE in patients treated with Compound A1+EVE+EXE on C1 D15 are
shown in FIGS. 28 and 29.
[0385] Both Compound A1 and EVE were rapidly absorbed at steady
state (C1D15); median Tmax of Compound A1 and EVE was 2 and 1
hours, respectively, across dose ranges.
[0386] At steady state, treatment with Compound A1 (200 and 300
mg)+EVE 2.5 mg+EXE 25 mg resulted in Compound A1 exposure similar
to that of single-agent Compound A1, while EVE exposure was
approximately 1.5- to 2-fold and 2- to 3-fold higher than
historical single-agent data when administered with Compound A1 200
and 300 mg, respectively.
Clinical Activity:
[0387] Of 13 patients evaluable for response, 1 patient had a
confirmed partial response (Compound A1 300 mg+EVE 2.5 mg+EXE 25
mg), 7 patients had stable disease (SD; Compound A1 600 mg+EXE 25
mg: 1 patient; Compound A1 200 mg+EVE 2.5 mg+EXE 25 mg: 2 patients;
Compound A1 300 mg+EVE 2.5 mg+EXE 25 mg: 4 patients), and 1 patient
had neither complete response nor progressive disease (Compound A1
300 mg+EVE 2.5 mg+EXE 25 mg; FIG. 30 and FIG. 31).
[0388] One patient with a p16 (CDKN2A) deletion, and cyclin D1
(CCND1) and insulin-like growth factor receptor 1 (IGFR1)
amplification treated with Compound A1 200 mg+EVE 2.5 mg+EXE had SD
>6 months (FIG. 30).
CONCLUSIONS (Based on Interim Result)
[0389] Preliminary data suggest that the combinations of Compound
A1+EXE and Compound A1+EVE+EXE are feasible, and clinical signs of
activity have been observed in both arms of the study.
[0390] Preliminary PK analysis suggests that the 300-mg dose of
Compound A1 resulted in increased EVE exposure at steady state, but
EVE does not affect Compound A1 exposure.
[0391] The most common AEs were hematologic as anticipated with
CDK4/6 inhibitors, and were mild to moderate.
Example 6
[0392] A Phase Ib/II trial is planned. The trial will have 3 arms
as described below:
TABLE-US-00009 Arm Assigned Interventions Compound A1 Compound A1:
600 mg each day, 21 days on, and 7 days off; Fulvestrant
Fulvestrant: 500 mg IM Day 1 and 15, followed by Q month Compound
A1 Compound A1: 400 mg each day, and 21 days on, 7 days off;
Compound C2 Compound C2: 20 mg each day continuous; and Fulvestrant
Fulvestrant: 500 mg IM Day 1 and 15, followed by Q month Compound
A1 Compound A1: 400 mg each day, 21 days on, and 7 days off;
Compound C1 Compound C1: 100 mg each day continuous; and
Fulvestrant Fulvestrant: 500 mg IM Day 1 and 15, followed by Q
month
Example 7
[0393] This on-going study aims at determining antitumor efficacy
of various compounds used as single agent, in double or in triple
combination in the HBCx-34 human breast patient-derived xenograft
model.
[0394] The xenograft model proposed in this study is HBCx-34.
HBCx-34 is a ductal carcinoma with wild type P53, no HER2
overexpression and PR and ER.alpha. overexpression. The tumor is
highly responsive to adriamycine/cyclophosphamide and responsive to
docetaxel and capecitabine. HBCx-34 has got no cachexia properties,
but no body weight gain is observed for HBCx-34 bearing mice.
[0395] HBCx-34 breast tumor-bearing mice will receive estrogen
diluted in drinking water (R-oestradiol, 8.5 mg/I), from the date
of tumor implant to the date of inclusion. No estrogen will be
added during the rest of the study.
[0396] Female athymic nude mice (Hsd:Athymic Nude-Fox1nu), 6- to
9-week-old at the beginning of the experimental phase, will be
obtained from Harlan Laboratories (Gannat, France). Animals will be
maintained in specific pathogen-free animal housing at the Center
for Exploration and Experimental Functional Research (CERFE, Evry,
France) animal facility. Animals will be delivered to the
laboratory at least 7 days before the experiments during which time
they are acclimatized to laboratory conditions. Mice will be housed
in groups of a maximum of 7 animals during acclimation period and 5
animals during experimental phase. Mice will be housed inside
individually ventilated cages (IVC) of Polysulfone (PSU) plastic
(mm 213 W.times.362 D.times.185 H, Allentown, USA) with sterilized
and dust-free bedding cobs. Food and water will be sterilized.
Animals will be housed under a light-dark cycle (14-hour circadian
cycle of artificial light) and controlled room temperature and
humidity.
Compound A1: 75 mg/kg free base, p.o. Volume of administration: 5
ml/kg (i.e. 125 .mu.l for a 25 g mouse) Route of administration:
p.o. Form: solution Vehicle: 0.5% Methylcellulose in water
Concentration: 15 mg/ml free base Compound C2: 30 and 20 mg/kg free
base, p.o. [0397] Volume of administration: 5 ml/kg (i.e. 125 .mu.l
for a 25 g mouse) [0398] Route of administration: p.o. [0399] Form:
solution [0400] Vehicle: 10% NMP/90% PEG300 [0401] Concentration: 6
mg/ml free base=6.534 mg/ml salt base [0402] 4 mg/ml free
base=4.356 mg/ml salt base Compound C1: 35 mg/kg, p.o. Volume of
administration: 5 ml/kg (i.e. 125 .mu.l for a 25 g mouse) Route of
administration: p.o. Form: suspension Vehicle: 0.5% Methylcellulose
in water Concentration: 7 mg/ml
Vehicle: NaCl 0.9%
[0403] Volume of administration: 5 ml/kg (i.e. 125 .mu.l for a 25 g
mouse) Route of administration: p.o.
Comparison Compounds: Standards of Care
[0404] Letrozole (Compound B1) 2.5 mg/kg (Femara.RTM., Novartis)
Volume of administration: 5 ml/kg (i.e. 125 .mu.l for a 25 g mouse)
Route of administration: p.o.
Form: Suspension
Vehicle: 0.9% NaCl
[0405] Concentration: 0.5 mg/ml Exemestane 25 mg/kg (Compound B2,
Aromasine.RTM., Pharmacia) Dose: 25 mg/kg Volume of administration:
5 ml/kg (i.e. 125 .mu.l for a 25 g mouse) Route of administration:
p.o.
Form: Suspension
Vehicle: 0.9% NaCl
[0406] Concentration: 5 mg/ml
Study Groups and Regimen
TABLE-US-00010 [0407] 1 Drug/Testing Agent 2 Drug/Testing Agent 3
Drug/Testing Agent Gr. N Agent mg/kg Route Schedule Agent mg/kg
Route Schedule Agent mg/kg Route Schedule 1 10 Vehicle -- PO qd
.times. 56* -- -- -- -- -- -- -- -- 2 10 Letrozole 2.5 PO qd
.times. 56* -- -- -- -- -- -- -- -- (Compound B1) 3 10 -- -- -- --
Compound 75 PO qd .times. 56* -- -- -- -- A1 4 10 -- -- -- -- -- --
-- -- Compound 30-20 PO qd .times. 26-30** C2 5 10 -- -- -- -- --
-- -- -- Compound 35 PO qd .times. 56* C1 6 10 Letrozole 2.5 PO qd
.times. 56* Compound 75 PO qd .times. 56* -- -- -- -- (Compound A1
B1) 7 10 Letrozole 2.5 PO qd .times. 56* -- -- -- -- Compound 30-20
PO qd .times. 26-30** (Compound C2 B1) 8 10 Letrozole 2.5 PO qd
.times. 56* -- -- -- -- Compound 35 PO qd .times. 56* (Compound C1
B1) 9 10 Letrozole 2.5 PO qd .times. 56* Compound 75 PO qd .times.
56* Compound 30-20 PO qd .times. 26-30** (Compound A1 C2 B1) 10 10
Letrozole 2.5 PO qd .times. 56* Compound 75 PO qd .times. 56*
Compound 35 PO qd .times. 56* (Compound A1 C1 B1) *qd .times. 56:
from D0 to D55 **qd .times. 26-30: from D0 to D25 at 30 mg/kg then
from D26 to D56 at 20 mg/kg In combination groups, the 2 or 3
compounds will be administered without delay.
Dosing volume will be individually adjusted to the body weight. In
each experimental group, the mentioned dose will be applied for all
mice.
[0408] Tumorgraft Model Induction
[0409] Tumors of the same passage will be transplanted
subcutaneously onto 5-10 mice (donor mice, passage (n-1)). When
these tumors reach 1000 to 2000 mm.sup.3, donor mice will be
sacrificed by cervical dislocation, tumors will be aseptically
excised and dissected. After removing necrotic areas, tumors will
be cut into fragments measuring approximately 20 mm.sup.3 and
transferred in culture medium before grafting.
[0410] Mice will be anaesthetized with ketamine/xylazine, and then
skin will be aseptized with a chlorhexidine solution, incised at
the level of the interscapular region, and a 20 mm.sup.3 tumor
fragment will be placed in the subcutaneous tissue. Skin will be
closed with clips.
[0411] All mice from the same experiment will be implanted on the
same day.
[0412] Inclusion Criteria
[0413] Healthy mice aged 6 to 9 weeks and weighing at least 20 g
will be included in the study. Mice will be allocated to different
groups according to their tumor volume to give homogenous mean and
median tumor volume in each treatment arms. Treatments will be
randomly attributed to cages housing up to 5 mice.
[0414] For each group, 10 mice with established tumors and average
tumor volume ranging 108 (6.times.6) to 288 (9.times.8) mm.sup.3
will be included in the study. In the case that tumor growth is
heterogeneous, group size may be reduced (up to 8 mice/group)
and/or inclusion may be staggered.
[0415] Animals Observations
[0416] From grafting day to study termination, animals will be
observed every day, for physical appearance, behavior and clinical
changes.
[0417] Tumor Measurements and Body Weight Monitoring
[0418] Tumor volume will be evaluated by measuring tumor diameters,
with a calliper, biweekly during the treatment period and once a
week during the follow-up period. The formula TV (mm.sup.3)=[length
(mm).times.width (mm).sup.2]/2 will be used, where the length and
the width are the longest and the shortest diameters of the tumor,
respectively.
[0419] Tumors will not be weighed at the end of experimental
phase.
[0420] All animals will be weighted biweekly during the treatment
period and once a week during the follow-up period.
[0421] Unless specified otherwise by the Sponsor, in case that body
weight loss reaches 15% compared to the 1.sup.st day of treatment,
DietGel Recovery will be given for the entire group in which the
body weight loss is observed.
[0422] Criteria for Ethical Sacrifice
[0423] Each animal will be sacrificed if one of the following
conditions is met: [0424] Body weight loss (BWL) .gtoreq.20%
compared to the 1st day of treatment for 3 consecutive measurements
(2 days or 48 hours). [0425] General alteration of behaviour or
clinical signs. [0426] Tumor volume .gtoreq.2000 mm.sup.3.
[0427] Unless specified otherwise, no necropsy will be performed at
sacrifice.
[0428] End Points (Whichever Comes First)
[0429] Each group of animals will be sacrificed if the two
following conditions are met: [0430] A tumor volume of 2000
mm.sup.3 is reached for at least one animal [0431] And the initial
median tumor volume has been increased by 3 to 5-fold.
[0432] The endpoints for the experiment are: [0433] a treatment
phase of 8 weeks* (*) Treatment phase could be extended by 2 or 3
weeks if no toxicity is observed and if required according to
"Tumorgraft model induction". [0434] and a follow-up phase of 57
days.
[0435] Data Analysis
[0436] Day 0 will be always considered the first day of treatment.
The days of the experiment will be subsequently numbered according
to this definition. Recordings will be expressed as mean+/-standard
error of the mean (mean+/-sem) and median+/-interquartile
(median+/-IQR).
[0437] Statistical analysis will be done for each measurement by
Mann-Whitney non parametric comparison test using GraphPad Prism
software. Each treated group will be compared with control
group.
[0438] FIGS. 20-22 illustrates some results of this study.
* * * * *