U.S. patent application number 15/593897 was filed with the patent office on 2017-11-16 for combination of anti-pd-1 antibodies and radiation to treat cancer.
The applicant listed for this patent is Regeneron Pharmaceuticals, Inc.. Invention is credited to Israel LOWY, Dimitris SKOKOS.
Application Number | 20170327567 15/593897 |
Document ID | / |
Family ID | 58800911 |
Filed Date | 2017-11-16 |
United States Patent
Application |
20170327567 |
Kind Code |
A1 |
SKOKOS; Dimitris ; et
al. |
November 16, 2017 |
COMBINATION OF ANTI-PD-1 ANTIBODIES AND RADIATION TO TREAT
CANCER
Abstract
The present invention provides methods for treating, reducing
the severity, or inhibiting the growth of cancer (e.g., solid
tumors). The methods of the present invention comprise
administering to a subject in need thereof a therapeutically
effective amount of a programmed death 1 (PD-1) antagonist (e.g.,
an anti-PD-1 antibody), optionally, in combination with radiation
therapy. In certain embodiments, the methods comprise administering
hypo-fractionated radiation in combination with an anti-PD-1
antibody or a fragment thereof to achieve a prolonged abscopal
effect in tumor inhibition.
Inventors: |
SKOKOS; Dimitris; (New York,
NY) ; LOWY; Israel; (Dobbs Ferry, NY) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Regeneron Pharmaceuticals, Inc. |
Tarrytown |
NY |
US |
|
|
Family ID: |
58800911 |
Appl. No.: |
15/593897 |
Filed: |
May 12, 2017 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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62335743 |
May 13, 2016 |
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62340142 |
May 23, 2016 |
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62348546 |
Jun 10, 2016 |
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62350305 |
Jun 15, 2016 |
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62364920 |
Jul 21, 2016 |
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62374020 |
Aug 12, 2016 |
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62451274 |
Jan 27, 2017 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 39/395 20130101;
C07K 2317/76 20130101; C07K 2317/73 20130101; A61P 35/00 20180101;
A61K 47/6849 20170801; A61N 2005/0604 20130101; A61N 5/0603
20130101; C07K 16/28 20130101; A61N 2005/0608 20130101; A61P 35/04
20180101; A61K 39/39575 20130101; A61K 2039/545 20130101; A61N
2005/0607 20130101; A61N 5/06 20130101; A61N 2005/0605 20130101;
A61N 2005/0606 20130101; A61N 2005/0609 20130101; A61K 39/39541
20130101; A61N 2005/061 20130101; C07K 16/18 20130101; C07K 16/3053
20130101; A61K 2039/505 20130101; A61N 2005/1098 20130101; A61K
39/39558 20130101; A61K 51/1045 20130101; C07K 16/2818 20130101;
C07K 16/2878 20130101; A61K 2300/00 20130101; C07K 16/2803
20130101; C07K 2317/21 20130101; A61N 2005/0611 20130101; A61K
2039/507 20130101; A61K 39/39541 20130101; A61K 2300/00
20130101 |
International
Class: |
C07K 16/18 20060101
C07K016/18; A61K 39/395 20060101 A61K039/395; A61N 5/06 20060101
A61N005/06; C07K 16/28 20060101 C07K016/28; A61K 51/10 20060101
A61K051/10 |
Claims
1. A method of treating or inhibiting the growth of a tumor in a
subject comprising: (a) selecting a subject with a cancer; and (b)
administering to the subject in need thereof one or more doses of
radiation therapy in combination with one or more doses of a
therapeutically effective amount of an antibody or antigen-binding
fragment thereof that specifically binds programmed death 1 (PD-1),
wherein the anti-PD-1 antibody or antigen-binding fragment thereof
comprises the heavy chain complementarity determining regions
(HCDR1, HCDR2 and HCDR3) of a heavy chain variable region (HCVR)
comprising the amino acid sequence of SEQ ID NO: 1 and three light
chain complementarity determining regions (LCDR1, LCDR2 and LCDR3)
of a light chain variable region (LCVR) comprising the amino acid
sequence of SEQ ID NO: 2.
2. The method of claim 1, wherein each dose of the anti-PD-1
antibody comprises between 0.1-20 mg/kg of the subject's body
weight.
3. The method of claim 2, wherein each dose of the anti-PD-1
antibody comprises 0.3, 1, 3, 5 or 10 mg/kg of the subject's body
weight.
4. The method of claim 1, wherein each dose comprises 20-600 mg of
the anti-PD-1 antibody.
5. The method of claim 2, wherein each dose of radiation comprises
2-80 Gray (Gy).
6. The method of claim 5, wherein each dose of the anti-PD-1
antibody comprises 1, 3, or 10 mg/kg of the subject's body weight
and each dose of radiation therapy comprises 20-50 Gy.
7. The method of claim 6, wherein the radiation therapy is
fractionated radiation therapy.
8. The method of claim 7, wherein the fractionated radiation
therapy comprises 2-10 fractions.
9. The method of claim 8, wherein the fractionated radiation
therapy comprises 30 Gy in 5 fractions.
10. The method of claim 8, wherein the fractionated radiation
therapy comprises 27 Gy in 3 fractions.
11. The method of claim 2, wherein each dose of the anti-PD-1
antibody is administered 0.5-4 weeks after the immediately
preceding dose.
12. The method of claim 11, wherein each dose of the anti-PD-1
antibody is administered 2 weeks after the immediately preceding
dose.
13. The method of claim 7, wherein each dose of the anti-PD-1
antibody is administered 0.5-4 weeks after the immediately
preceding dose.
14. The method of claim 1, wherein the anti-PD-1 antibody is
administered prior to, concurrent with or after the radiation
therapy.
15. The method of claim 14, wherein the anti-PD-1 antibody is
administered prior to the radiation therapy.
16. The method of claim 1, wherein the administration of the
combination results in enhanced therapeutic efficacy as compared to
administration of the antibody or radiation alone.
17. The method of claim 16, wherein enhanced therapeutic efficacy
comprises an effect selected from the group consisting of tumor
regression, abscopal effect, inhibition of tumor metastasis,
reduction in metastatic lesions over time, reduced use of
chemotherapeutic or cytotoxic agents, reduction in tumor burden,
increase in progression-free survival, increase in overall
survival, complete response, partial response, and stable
disease.
18. The method of claim 17, wherein enhanced therapeutic efficacy
comprises tumor regression in a tumor distal to an irradiated
tumor.
19. The method of claim 17, wherein the tumor growth is inhibited
by at least 50% as compared to a subject administered with either
antibody or radiation alone.
20. The method of claim 17, wherein the tumor growth is inhibited
by at least 50% as compared to a subject administered a dose of
radiation prior to an anti-PD-1 antibody.
21. The method of claim 1, wherein the subject is resistant or
inadequately responsive to, or relapsed after prior therapy.
22. The method of claim 1, wherein the cancer is recurrent or
metastatic cancer.
23. The method of claim 1 further comprising administering to the
subject an additional therapeutic agent or therapy, wherein the
additional therapeutic agent or therapy is selected from the group
consisting of surgery, a chemotherapeutic agent, a cancer vaccine,
a programmed death ligand 1 (PD-L1) inhibitor, a lymphocyte
activation gene 3 (LAG3) inhibitor, a cytotoxic
T-lymphocyte-associated protein 4 (CTLA-4) inhibitor, a
glucocorticoid-induced tumor necrosis factor receptor (GITR)
inhibitor, a T-cell immunoglobulin and mucin-domain containing-3
(TIM3) inhibitor, a B- and T-lymphocyte attenuator (BTLA)
inhibitor, a T cell immunoreceptor with Ig and ITIM domains (TIGIT)
inhibitor, a CD47 inhibitor, an indoleamine-2,3-dioxygenase (IDO)
inhibitor, a bispecific anti-CD3/anti-CD20 antibody, a vascular
endothelial growth factor (VEGF) antagonist, an angiopoietin-2
(Ang2) inhibitor, a transforming growth factor beta (TGF.beta.)
inhibitor, a CD38 inhibitor, an epidermal growth factor receptor
(EGFR) inhibitor, granulocyte-macrophage colony-stimulating factor
(GM-CSF), cyclophosphamide, an antibody to a tumor-specific
antigen, Bacillus Calmette-Guerin vaccine, a cytotoxin, an
interleukin 6 receptor (IL-6R) inhibitor, an interleukin 4 receptor
(IL-4R) inhibitor, an IL-10 inhibitor, IL-2, IL-7, IL-21, IL-15, an
antibody-drug conjugate, an anti-inflammatory drug, and a dietary
supplement.
24. The method of claim 23, wherein the additional therapeutic
agent is an anti-GITR antibody.
25. The method of claim 23, wherein the additional therapeutic
agent is cyclophosphamide.
26. The method of claim 23, wherein the additional therapeutic
agent is GM-CSF.
27. The method of claim 23, wherein the additional therapeutic
agent is selected from the group consisting of docetaxel,
carboplatin, paclitaxel, cisplatin, gemcitabine, and
pemetrexed.
28. The method of claim 1, wherein the anti-PD-1 antibody is
administered intravenously, subcutaneously, or
intraperitoneally.
29. The method of claim 1, wherein the cancer comprises a solid
tumor.
30. The method of claim 29, wherein the solid tumor is selected
from the group consisting of colorectal cancer, ovarian cancer,
prostate cancer, breast cancer, brain cancer, cervical cancer,
bladder cancer, anal cancer, uterine cancer, colon cancer, liver
cancer, pancreatic cancer, lung cancer, endometrial cancer, bone
cancer, testicular cancer, skin cancer, kidney cancer, stomach
cancer, esophageal cancer, head and neck cancer, salivary gland
cancer, and myeloma.
31. The method of claim 29, wherein the solid tumor is selected
from the group consisting of hepatocellular carcinoma, non-small
cell lung cancer, head and neck squamous cell cancer, basal cell
carcinoma, breast carcinoma, cutaneous squamous cell carcinoma,
chondrosarcoma, angiosarcoma, cholangiocarcinoma, soft tissue
sarcoma, colorectal cancer, melanoma, Merkel cell carcinoma, and
glioblastoma multiforme.
32. The method of claim 1, wherein the anti-PD-1 antibody or
antigen-binding fragment thereof comprises three HCDRs (HCDR1,
HCDR2 and HCDR3) and three LCDRs (LCDR1, LCDR2 and LCDR3), wherein
HCDR1 comprises the amino acid sequence of SEQ ID NO: 3; HCDR2
comprises the amino acid sequence of SEQ ID NO: 4; HCDR3 comprises
the amino acid sequence of SEQ ID NO: 5; LCDR1 comprises the amino
acid sequence of SEQ ID NO: 6; LCDR2 comprises the amino acid
sequence of SEQ ID NO: 7; and LCDR3 comprises the amino acid
sequence of SEQ ID NO: 8.
33. The method of claim 32, wherein the HCVR comprises the amino
acid sequence of SEQ ID NO: 1 and the LCVR comprises the amino acid
sequence of SEQ ID NO: 2.
34. The method of claim 1, wherein the anti-PD-1 antibody comprises
a HCVR with 90% sequence identity to SEQ ID NO: 1.
35. The method of claim 1, wherein the anti-PD-1 antibody comprises
a LCVR with 90% sequence identity to SEQ ID NO: 2.
36. The method of claim 1, wherein the anti-PD-1 antibody comprises
a HCVR with 90% sequence identity to SEQ ID NO: 1 and a LCVR with
90% sequence identity to SEQ ID NO: 2.
37. The method of claim 1, wherein the anti-PD-1 antibody comprises
a heavy chain comprising the amino acid sequence of SEQ ID NO: 9
and a light chain comprising the amino acid sequence of SEQ ID NO:
10.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims the benefit under 35 U.S.C.
.sctn.119(e) of US provisional application Nos. 62/335,743, filed
on May 13, 2016; 62/340,142, filed on May 23, 2016; 62/348,546,
filed on Jun. 10, 2016; 62/350,305, filed on Jun. 15, 2016;
62/364,920, filed on Jul. 21, 2016; 62/374,020, filed on Aug. 12,
2016; and 62/451,274, filed on Jan. 27, 2017, the disclosures of
each herein incorporated by reference in their entireties.
FIELD OF THE INVENTION
[0002] The present invention relates to methods for treating cancer
comprising administering to a subject in need thereof a
therapeutically effective amount of an antibody that specifically
binds to programmed death 1 (PD-1) receptor in combination with
radiation therapy.
BACKGROUND OF THE INVENTION
[0003] Radiation therapy utilizes the DNA-damaging properties of
ionizing radiation to control tumor growth and/or kill tumor cells
and has been used extensively in the past six decades for localized
tumor therapy. Radiation therapy can promote stimulatory effects on
the immune system, for example, due to release of tumor antigens.
However, radiation can also lead to immune-suppressive effects,
e.g., stimulation of inhibitory immune cells such as regulatory T
cells (Le et al 2015, Clin. Cancer Res. 21: 3393-3401).
[0004] The development of immune checkpoint inhibitors for cancer
therapy has led to interest in combining them with radiation
therapy (Tang et al 2014, Cancer Immunol. Res. 2: 831-838; Teng et
al 2015, Cancer Lett. 365: 23-29). One such immune checkpoint
inhibitor is programmed death 1 (PD-1). PD-1 receptor signaling in
the tumor microenvironment plays a key role in allowing tumor cells
to escape immune surveillance by the host immune system. Blockade
of the PD-1/PD-L1 T-cell checkpoint pathway is an effective and
well tolerated approach to stimulating the immune response, and has
achieved significant objective responses in advanced melanoma,
renal cell cancer (RCC), and non-small cell lung cancer (NSCLC)
(Topalian et al 2012, New Engl. J. Med. 366: 2443-2454). However,
optimal therapy will likely require combining anti-PD-1 monoclonal
antibody treatment with conventional therapies and novel
immunotherapy approaches. Combinatorial approaches to stimulate
convergent aspects of host immunity by employing complementary
immune modulators as well as immune-stimulatory aspects of
conventional modalities such as radiation and chemotherapy may
result in the development of more effective cancer therapies.
BRIEF SUMMARY OF THE INVENTION
[0005] According to certain embodiments, the present invention
provides methods for treating or ameliorating at least one symptom
or indication, or inhibiting the growth of cancer in a subject. The
methods according to this aspect of the invention comprise
administering to a subject in need thereof a therapeutically
effective amount of an antibody or antigen-binding fragment thereof
that specifically binds to programmed death 1 (PD-1), optionally,
in combination with radiation therapy.
[0006] According to certain embodiments, the present invention
includes methods to treat cancer including a solid tumor, the
methods comprising selecting a subject with a cancer and
administering one or more doses of an anti-PD-1 antibody in
combination with one or more doses of radiation therapy. In certain
embodiments, administration of the combination results in enhanced
therapeutic efficacy or anti-tumor efficacy as compared to
administration of either the antibody or radiation alone.
[0007] In certain embodiments of the present invention, methods are
provided for treating or ameliorating at least one symptom or
indication, or inhibiting the growth of cancer in a subject. In
certain embodiments of the present invention, methods are provided
for delaying the growth of a tumor or preventing tumor recurrence.
In certain embodiments of the present invention, methods are
provided for increasing the overall or progression-free survival of
a patient with cancer. The methods, according to this aspect of the
invention, comprise sequentially administering one or more doses of
a therapeutically effective amount of an antibody or
antigen-binding fragment thereof that specifically binds to PD-1.
In one embodiment, the anti-PD-1 antibody is administered in
combination with radiation therapy.
[0008] In certain embodiments, the cancer or tumor is a solid tumor
or malignancy. In certain embodiments, the solid tumor is selected
from the group consisting of colorectal cancer, ovarian cancer,
prostate cancer, breast cancer, brain cancer, cervical cancer,
bladder cancer, anal cancer, uterine cancer, colon cancer, liver
cancer, pancreatic cancer, lung cancer, endometrial cancer, bone
cancer, testicular cancer, skin cancer, kidney cancer, stomach
cancer, esophageal cancer, head and neck cancer, salivary gland
cancer, and myeloma.
[0009] In certain embodiments, the anti-PD-1 antibody is
administered as a `first-line` treatment to a patient with cancer,
wherein the patient has not received prior systemic treatment for
the cancer. In certain embodiments, the anti-PD-1 antibody is
administered as `second-line` treatment to a patient with cancer
(e.g., metastatic cancer), wherein the patient has been previously
treated with `standard-of-care` therapy including, but not limited
to chemotherapy, surgery and radiation.
[0010] One embodiment of the invention pertains to an anti-PD-1
antibody for use in the treatment of skin cancer. In certain
embodiments, the skin cancer is a non-melanoma skin cancer
including, but not limited to, cutaneous squamous cell carcinoma
and basal cell carcinoma. The anti-PD-1 antibody may be
administered, as described herein, to a patient with metastatic or
locally advanced cutaneous squamous cell carcinoma. In certain
embodiments, the anti-PD-1 antibody is administered, as described
herein, to a patient with advanced basal cell carcinoma, wherein
the patient is intolerant to a Hedgehog pathway inhibitor (e.g.,
vismodegib, sonedegib) or has been treated with a Hedgehog pathway
inhibitor and shows progressive disease.
[0011] In certain embodiments, each dose of anti-PD-1 antibody
comprises 0.1-20 mg/kg of the subject's body weight. In certain
embodiments, each dose of anti-PD-1 antibody comprises 0.3, 1, 3,
5, or 10 mg/kg of the subject's body weight. In certain
embodiments, each dose of the anti-PD-1 antibody comprises 20-600
mg. In one embodiment, each dose of the anti-PD-1 antibody
comprises about 200 mg. In one embodiment, each dose of the
anti-PD-1 antibody comprises about 250 mg. In one embodiment, each
dose of the anti-PD-1 antibody comprises about 350 mg.
[0012] In certain embodiments, the radiation therapy is
administered in one or more doses. In certain embodiments, each
dose of radiation therapy comprises 2-100 Gray (Gy). In certain
embodiments, the radiation therapy is hypofractionated radiation
therapy. In certain embodiments, the radiation therapy comprises
2-12 fractions.
[0013] In certain embodiments, the methods of the present invention
comprise administering a therapeutically effective amount of an
anti-PD-1 antibody prior to, concurrent with, or subsequent to
radiation therapy. In one embodiment, the methods of the present
invention comprise administering an anti-PD-1 antibody prior to a
dose of radiation therapy.
[0014] In certain embodiments, the methods of the present invention
comprise administering 0-50 therapeutic doses each of an anti-PD-1
antibody, wherein each dose is administered 0.5-12 weeks after the
immediately preceding dose. In one embodiment, each dose is
administered 1 week after the immediately preceding dose. In one
embodiment, each dose is administered 2 weeks after the immediately
preceding dose. In one embodiment, each dose is administered 3
weeks after the immediately preceding dose.
[0015] In certain embodiments, the one or more doses of anti-PD-1
antibody and optionally radiation therapy are comprised in a
treatment cycle. The methods, according to this aspect of the
invention, comprise administering to a subject in need thereof at
least one treatment cycle wherein the at least one treatment cycle
comprises one or more doses of an anti-PD-1 antibody. In certain
embodiments, up to 12 treatment cycles are administered to a
subject in need thereof. In certain embodiments, at least one
treatment cycle further comprises one or more doses of radiation
therapy. In certain embodiments, radiation therapy is administered
in only one treatment cycle. In certain embodiments, the radiation
therapy is hypofractionated radiation therapy. In certain
embodiments, the anti-PD-1 antibody is administered before
radiation therapy.
[0016] In certain embodiments, the anti-PD-1 antibody and the
radiation therapy are administered in combination with an
additional therapeutic agent or therapy (e.g., cyclophosphamide, or
any agent or therapy disclosed herein).
[0017] In certain embodiments, the treatment produces one or more
therapeutic effects selected from the group consisting of tumor
regression, abscopal effect inhibition of tumor metastasis,
reduction in metastatic lesions over time, reduced use of
chemotherapeutic or cytotoxic agents, reduction in tumor burden,
increase in progression-free survival, increase in overall
survival, complete response, partial response, and stable
disease.
[0018] According to certain embodiments, the anti-PD-1 antibody or
antigen-binding protein comprises the heavy chain complementarity
determining regions (HCDRs) of a heavy chain variable region (HCVR)
comprising the amino acid sequence of SEQ ID NO: 1 and the light
chain CDRs of a light chain variable region (LCVR) comprising the
amino acid sequence of SEQ ID NO: 2. One such type of
antigen-binding protein that can be used in the context of the
methods of the present invention is an anti-PD-1 antibody such as
REGN2810.
[0019] In certain embodiments, the present invention provides use
of an anti-PD-1 antibody or antigen-binding fragment thereof in the
manufacture of a medicament to treat or inhibit the growth of
cancer in a subject, including humans. In certain embodiments, the
cancer is a solid tumor. In certain embodiments, the cancer is
colorectal cancer, ovarian cancer, prostate cancer, breast cancer,
brain cancer, cervical cancer, bladder cancer, anal cancer, uterine
cancer, colon cancer, liver cancer, pancreatic cancer, lung cancer,
endometrial cancer, bone cancer, testicular cancer, skin cancer,
kidney cancer, stomach cancer, esophageal cancer, head and neck
cancer, salivary gland cancer, or myeloma.
[0020] In certain embodiments, the present invention provides use
of an anti-PD-1 antibody or antigen-binding fragment thereof in the
manufacture of a medicament in combination with radiation therapy
to treat or inhibit the growth of cancer in a subject, including
humans. In certain embodiments, the cancer is a solid tumor. In
certain embodiments, the cancer is colorectal cancer, ovarian
cancer, prostate cancer, breast cancer, brain cancer, cervical
cancer, bladder cancer, anal cancer, uterine cancer, colon cancer,
liver cancer, pancreatic cancer, lung cancer, endometrial cancer,
bone cancer, testicular cancer, skin cancer, kidney cancer, stomach
cancer, esophageal cancer, head and neck cancer, salivary gland
cancer, or myeloma.
[0021] In one aspect, the present invention provides a kit for
treating a subject afflicted with a cancer, the kit comprising: (a)
a dosage of an antibody or an antigen-binding portion thereof that
specifically binds to and inhibits PD-1; and (b) instructions for
using the anti-PD-1 antibody for treating the subject according to
the methods disclosed herein. In certain embodiments, the cancer is
selected from the group consisting of colorectal cancer, ovarian
cancer, prostate cancer, breast cancer, brain cancer, cervical
cancer, bladder cancer, anal cancer, uterine cancer, colon cancer,
liver cancer, pancreatic cancer, lung cancer, endometrial cancer,
bone cancer, testicular cancer, skin cancer, kidney cancer, stomach
cancer, esophageal cancer, head and neck cancer, salivary gland
cancer, and myeloma.
[0022] Other embodiments of the present invention will become
apparent from a review of the ensuing detailed description.
BRIEF DESCRIPTION OF THE FIGURES
[0023] FIG. 1 shows the study design including dosing of an
anti-PD-1 antibody and radiation (XRT) in mice implanted with MC38
tumors (study described in Example 1 herein).
[0024] FIG. 2 shows the average tumor growth in mice treated with
isotype control antibody ( ), anti-PD-1 antibody (.box-solid.),
isotype control+radiation (XRT) (.tangle-solidup.), or anti-PD-1
antibody+XRT () in the study described in Example 1 herein.
[0025] FIG. 3 shows the overall survival of mice treated with
isotype control antibody ( ), anti-PD-1 antibody (.box-solid.),
isotype control+radiation (XRT) (.tangle-solidup.), or anti-PD-1
antibody+XRT () in the study described in Example 1 herein.
[0026] FIG. 4 shows the study design including dosing of an
anti-PD-1 antibody and radiation (XRT) in mice implanted with
B16F10.9 tumors (study described in Example 2 herein).
[0027] FIG. 5 shows the average tumor growth in mice treated with
isotype control antibody ( ), anti-PD-1 antibody (.box-solid.),
isotype control+radiation (XRT) (.diamond-solid.), or anti-PD-1
antibody+XRT (.largecircle.) in the study described in Example 2
herein.
[0028] FIG. 6 shows the overall survival of mice treated with
isotype control antibody ( ), anti-PD-1 antibody (.box-solid.),
isotype control+radiation (XRT) (.diamond-solid.), or anti-PD-1
antibody+XRT (.largecircle.) in the study described in Example 2
herein.
[0029] FIG. 7 shows the study design including dosing of an
anti-PD-1 antibody and radiation (XRT) in mice implanted with MC38
tumors (study described in Example 4 herein)
[0030] FIG. 8 shows average primary tumor growth in mice treated
with isotype control antibody ( ), anti-PD-1 antibody
(.box-solid.), isotype control+radiation (XRT) (.tangle-solidup.),
or anti-PD-1 antibody+XRT () in the study described in Example 4
herein.
[0031] FIG. 9 shows overall survival of mice treated with isotype
control antibody ( ), anti-PD-1 antibody (.box-solid.), isotype
control+radiation (XRT) (.tangle-solidup.), or anti-PD-1
antibody+XRT () in the study described in Example 4 herein.
[0032] FIG. 10 shows secondary tumor growth in mice treated with
isotype control antibody ( ), anti-PD-1 antibody (.box-solid.),
isotype control+radiation (XRT) (.tangle-solidup.), or anti-PD-1
antibody+XRT () in the study described in Example 4 herein.
[0033] FIG. 11 shows the study design including dosing of an
anti-PD-1 antibody, an anti-GITR antibody, and radiation (XRT) in
mice implanted with MC38 tumors (study described in Example 5
herein).
[0034] FIG. 12 shows the average tumor growth in mice treated with
isotype control antibody ( ), anti-PD-1 antibody (.box-solid.),
anti-GITR antibody (.tangle-solidup.), combination of anti-PD-1
antibody and anti-GITR antibody (), isotype control+radiation (XRT)
(.diamond-solid.),anti-PD-1 antibody+XRT (.largecircle.), anti-GITR
antibody+XRT (.quadrature.), or combination of anti-PD-1 antibody,
anti-GITR antibody+XRT (.DELTA.) in the study described in Example
5 herein.
[0035] FIG. 13 shows the overall survival of mice treated with
isotype control antibody ( ), anti-PD-1 antibody (.box-solid.),
anti-GITR antibody (.tangle-solidup.), combination of anti-PD-1
antibody and anti-GITR antibody (), isotype control+radiation (XRT)
(.diamond-solid.),anti-PD-1 antibody+XRT (.largecircle.), anti-GITR
antibody+XRT (.quadrature.), or combination of anti-PD-1 antibody,
anti-GITR antibody+XRT (.DELTA.) in the study described in Example
5 herein.
[0036] FIG. 14A shows a radiographic image of lung metastases in a
basal cell carcinoma (BCC) patient indicated by arrows at baseline,
left, and at Week 24, right.
[0037] FIG. 14B shows a radiographic image of neck mass in a
cutaneous squamous cell carcinoma (CSCC) patient at baseline, left,
and at Week 16, right.
DETAILED DESCRIPTION
[0038] Before the present invention is described, it is to be
understood that this invention is not limited to particular methods
and experimental conditions described, as such methods and
conditions may vary. It is also to be understood that the
terminology used herein is for the purpose of describing particular
embodiments only, and is not intended to be limiting, since the
scope of the present invention will be limited only by the appended
claims.
[0039] Unless defined otherwise, all technical and scientific terms
used herein have the same meaning as commonly understood by one of
ordinary skill in the art to which this invention belongs. As used
herein, the term "about," when used in reference to a particular
recited numerical value, means that the value may vary from the
recited value by no more than 1%. For example, as used herein, the
expression "about 100" includes 99 and 101 and all values in
between (e.g., 99.1, 99.2, 99.3, 99.4, etc.).
[0040] Although any methods and materials similar or equivalent to
those described herein can be used in the practice of the present
invention, the preferred methods and materials are now described.
All publications mentioned herein are incorporated herein by
reference to describe in their entirety.
Methods of Treating or Inhibiting Growth of Cancer
[0041] The present invention includes methods for treating,
ameliorating or reducing the severity of at least one symptom or
indication, or inhibiting the growth of a cancer in a subject. The
methods according to this aspect of the invention comprise
administering to a subject in need thereof a therapeutically
effective amount of an antibody or antigen-binding fragment thereof
that specifically binds PD-1. In certain embodiments, the anti-PD-1
antibody is administered in combination with an anti-tumor therapy
(described elsewhere herein). In one embodiment, the anti-tumor
therapy is radiation therapy. As used herein, the terms "treat",
"treating", or the like, mean to alleviate symptoms, eliminate the
causation of symptoms either on a temporary or permanent basis, to
delay or inhibit tumor growth, to reduce tumor cell load or tumor
burden, to promote tumor regression, to cause tumor shrinkage,
necrosis and/or disappearance, to prevent tumor recurrence, to
prevent or inhibit metastasis, to inhibit metastatic tumor growth,
and/or to increase duration of survival of the subject.
[0042] As used herein, the expression "a subject in need thereof"
means a human or non-human mammal that exhibits one or more
symptoms or indications of cancer, and/or who has been diagnosed
with cancer, including a solid tumor and who needs treatment for
the same. In many embodiments, the term "subject" may be
interchangeably used with the term "patient". For example, a human
subject may be diagnosed with a primary or a metastatic tumor
and/or with one or more symptoms or indications including, but not
limited to, unexplained weight loss, general weakness, persistent
fatigue, loss of appetite, fever, night sweats, bone pain,
shortness of breath, swollen abdomen, chest pain/pressure,
enlargement of spleen, and elevation in the level of a
cancer-related biomarker (e.g., CA125). The expression includes
subjects with primary or established tumors. In specific
embodiments, the expression includes human subjects that have
and/or need treatment for a solid tumor, e.g., colon cancer, breast
cancer, lung cancer, prostate cancer, skin cancer, liver cancer,
bone cancer, ovarian cancer, cervical cancer, pancreatic cancer,
head and neck cancer, and brain cancer. The term includes subjects
with primary or metastatic tumors (advanced malignancies). In
certain embodiments, the expression "a subject in need thereof"
includes patients with a solid tumor that is resistant to or
refractory to or is inadequately controlled by prior therapy (e.g.,
treatment with an anti-cancer agent). For example, the expression
includes subjects who have been treated with one or more lines of
prior therapy such as treatment with chemotherapy (e.g.,
carboplatin or docetaxel). In certain embodiments, the expression
"a subject in need thereof" includes patients with a solid tumor
which has been treated with one or more lines of prior therapy but
which has subsequently relapsed or metastasized. For example,
patients with a solid tumor that may have received treatment with
one or more anti-cancer agents leading to tumor regression;
however, subsequently have relapsed with cancer resistant to the
one or more anti-cancer agents (e.g., chemotherapy-resistant
cancer) are treated with the methods of the present invention. The
expression also includes subjects with a solid tumor for which
conventional anti-cancer therapy is inadvisable, for example, due
to toxic side effects. For example, the expression includes
patients who have received one or more cycles of chemotherapy with
toxic side effects.
[0043] In certain embodiments, the methods of the present invention
may be used to treat patients that show elevated levels of one or
more cancer-associated biomarkers [e.g., programmed death ligand 1
(PD-L1), CA125, CA19-9, prostate-specific antigen (PSA), lactate
dehydrogenase, KIT, carcinoembryonic antigen, epidermal growth
factor receptor (EGFR), ALK gene rearrangement]. For example, the
methods of the present invention comprise administering a
therapeutically effective amount of an anti-PD-1 antibody in
combination with radiation therapy to a patient with an elevated
level of PD-L1 and/or EGFR. In a preferred embodiment, the methods
of the present invention are used in patients with cancer that are
selected on the basis of PD-L1 expression in cancer tissue. In
certain embodiments, the methods of the present invention are used
to treat patients with a cancer wherein the patients are selected
on the basis of at least 1%, at least 2%, at least 5%, at least
10%, at least 20%, at least 30%, at least 40% or at least 50% PD-L1
expression in cancer tissue and/or immune cells. Methods to
determine PD-L1 expression in cancer tissue and/or immune cells are
well-known in the art. In certain embodiments, the expression of
PD-L1 in tumor tissue is determined by any assay known in the art,
for example, by an ELISA assay or by an immunohistochemistry (IHC)
assay, as described in PCT publications WO2016124558 or
WO2016191751 or US Patent Application Publication US20160305947. In
certain embodiments, the expression of PD-L1 is determined by
quantitating RNA expression, for example, by in situ hybridization
or by RT-PCR. In certain embodiments, the expression of PD-L1 is
determined by imaging with a labeled anti-PD-L1 antibody, for
example, by immuno-positron emission tomography or iPET [See, e.g.,
The Oncologist, 12: 1379 (2007); Journal of Nuclear Medicine,
52(8): 1171 (2011); US Provisional Patent Application No.
62/428,672, filed Dec. 1, 2016].
[0044] In certain embodiments, the methods of the present invention
are used in a subject with a solid tumor. The terms "tumor",
"cancer" and "malignancy" are interchangeably used herein.
[0045] As used herein, the term "solid tumor" refers to an abnormal
mass of tissue that usually does not contain cysts or liquid areas.
Solid tumors may be benign (not cancer) or malignant (cancer). For
the purposes of the present invention, the term "solid tumor" means
malignant solid tumors. The term includes different types of solid
tumors named for the cell types that form them, viz. sarcomas,
carcinomas and lymphomas. However, the term does not include
leukemias. In various embodiments, the term `solid tumor" includes
cancers arising from connective or supporting tissue (e.g., bone or
muscle) (referred to as sarcomas), cancers arising from the body's
glandular cells and epithelial cells which line body tissues
(referred to as carcinomas), and cancers of the lymphoid organs
such as lymph nodes, spleen and thymus (referred to as lymphomas).
Lymphoid cells occur in almost all tissues of the body and
therefore, lymphomas may develop in a wide variety of organs. In
certain embodiments, the term "solid tumor" includes cancers
including, but not limited to, colorectal cancer, ovarian cancer,
prostate cancer, breast cancer, brain cancer, cervical cancer,
bladder cancer, anal cancer, uterine cancer, colon cancer, liver
cancer, pancreatic cancer, lung cancer, endometrial cancer, bone
cancer, testicular cancer, skin cancer, kidney cancer, stomach
cancer, esophageal cancer, head and neck cancer, salivary gland
cancer, and myeloma. In certain embodiments, the term "solid tumor"
includes cancers including, but not limited to, hepatocellular
carcinoma, non-small cell lung cancer, head and neck squamous cell
cancer, basal cell carcinoma, breast carcinoma, cutaneous squamous
cell carcinoma, chondrosarcoma, angiosarcoma, cholangiocarcinoma,
soft tissue sarcoma, colorectal cancer, melanoma, Merkel cell
carcinoma, and glioblastoma multiforme. In certain embodiments, the
term "solid tumor" comprises more than one solid tumor lesions
located separate from one another, e.g., 2, more than 2, more than
5, more than 10, more than 15, more than 20, or more than 25
lesions in a subject in need of treatment. In certain embodiments,
the more than one lesions are located distally from one another in
the same organ. In certain other embodiments, the tumor lesions may
be located in different organs.
[0046] In certain embodiments, the present invention includes
methods to treat or inhibit growth of a cancer including, but not
limited to, colorectal cancer, ovarian cancer, prostate cancer,
breast cancer, brain cancer, cervical cancer, bladder cancer, anal
cancer, uterine cancer, colon cancer, liver cancer, pancreatic
cancer, lung cancer, endometrial cancer, bone cancer, testicular
cancer, skin cancer, kidney cancer, stomach cancer, esophageal
cancer, head and neck cancer, salivary gland cancer, and myeloma.
In certain embodiments, the present invention includes methods to
treat or inhibit the growth of a cancer including, but not limited
to, hepatocellular carcinoma, non-small cell lung cancer, head and
neck squamous cell cancer, basal cell carcinoma, cutaneous squamous
cell carcinoma, chondrosarcoma, angiosarcoma, cholangiocarcinoma,
soft tissue sarcoma, colorectal cancer, melanoma, Merkel cell
carcinoma, and glioblastoma multiforme. In certain embodiments, the
present invention includes methods to treat advanced solid tumors
including but not limited to, metastatic cutaneous squamous cell
carcinoma (CSCC), unresectable locally advanced CSCC, metastatic
colorectal cancer, advanced or metastatic hepatocellular cancer,
advanced non-small cell lung cancer, basal cell carcinoma,
recurrent glioblastoma multiforme, castrate recurrent prostate
cancer and any advanced solid tumor refractory to first-line
therapy. The methods, according to this aspect, comprise
administering a therapeutically effective amount of an anti-PD-1
antibody. In certain embodiments, the methods comprise
administering a therapeutically effective amount of an anti-PD-1
antibody in combination with an anti-tumor therapy. Anti-tumor
therapies include, but are not limited to, conventional anti-tumor
therapies such as chemotherapy, radiation, surgery. Other
anti-tumor therapies are described elsewhere herein. In one
embodiment, the anti-tumor therapy comprises radiation therapy. In
certain embodiments, one or more doses of an anti-PD-1 antibody are
administered to a subject in need thereof, wherein each dose is
administered 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 weeks after the
immediately preceding dose. In certain embodiments, each dose
comprises 0.1-10 mg/kg (e.g., 0.3 mg/kg, 1 mg/kg, 3 mg/kg, or 10
mg/kg) of the subject's body weight. In certain other embodiments,
each dose comprises 20-600 mg of the anti-PD-1 antibody, e.g., 50
mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg, 400 mg, or 500 mg of
the anti-PD-1 antibody.
[0047] In certain embodiments, the present invention includes
methods to treat a cancer or inhibit the growth of a cancer with
microsatellite instability (MSI). As used herein, the term
"microsatellite instability," also known as "MSI" refers to the
changes in microsatellite repeats in tumor cells or genetic
hypermutability caused due to deficient DNA mismatch repair.
Microsatellites, also known as simple sequence repeats, are
repeated sequences of DNA comprising repeating units 1-6 base pairs
in length. Although the length of microsatellites is highly
variable from person to person and contributes to the DNA
fingerprint, each individual has microsatellites of a set length.
MSI results from the inability of the mismatch repair (MMR)
proteins to fix a DNA replication error. MSI comprises DNA
polymorphisms, wherein the replication errors vary in length
instead of sequence. MSI comprises frame-shift mutations, either
through insertions or deletions, or hypermethylation, leading to
gene silencing. It is known in the art that microsatellite
instability may result in colon cancer, gastric cancer, endometrium
cancer, ovarian cancer, hepatobiliary tract cancer, urinary tract
cancer, brain cancer, and skin cancers. The present invention
includes methods to treat cancers with MSI, the methods comprising
administering to a patient in need thereof a therapeutically
effective amount of an anti-PD-1 antibody, optionally, in
combination with radiation therapy.
[0048] One embodiment of the invention pertains to an anti-PD-1
antibody (e.g., REGN2810) for use in the treatment of advanced
solid tumors with MSI including, but not limited to metastatic
colorectal cancer with MSI, metastatic endometrial cancer with MSI,
and castrate recurrent prostate cancer with MSI. In certain
embodiments, one or more doses of the anti-PD-1 antibody are
administered to a subject with an advanced solid tumor with MSI,
wherein each dose comprises 0.1 to 20 mg/kg of the subject's body
weight, and wherein each dose is administered 0.5 to 4 weeks after
the immediately preceding dose. In certain embodiments, one or more
doses of the anti-PD-1 antibody are administered to a subject with
an advanced solid tumor with MSI, wherein each dose comprises
20-600 mg of the anti-PD-1 antibody, and wherein each dose is
administered 0.5 to 4 weeks after the immediately preceding
dose.
[0049] As used herein, the term "radiation therapy", also referred
to as "XRT" means using ionizing radiation to kill cancer cells,
generally as part of anti-cancer therapy. X-rays, gamma rays or
charged particles (e.g., protons or electrons) are used to generate
ionizing radiation. Radiation therapy may be delivered by a machine
placed outside the patient's body (external-beam radiation
therapy), or by a source placed inside a patient's body (internal
radiation therapy or brachytherapy), or through systemic
radioisotopes delivered intravenously or orally (systemic
radioisotope therapy). Radiation therapy may be planned and
administered in conjunction with imaging-based techniques such a
computed tomography (CT), magnetic resonance imaging (MRI) to
accurately determine the dose and location of radiation to be
administered. In various embodiments, radiation therapy is selected
from the group consisting of total all-body radiation therapy,
conventional external beam radiation therapy, stereotactic
radiosurgery, stereotactic body radiation therapy, 3-D conformal
radiation therapy, intensity-modulated radiation therapy,
image-guided radiation therapy, tomotherapy, brachytherapy, and
systemic radiation therapy. Depending upon the intent, in certain
embodiments, radiation therapy is curative, adjuvinating or
palliative. In specific embodiments, the term "radiation therapy"
refers to hypofractionated radiation therapy. Hypofractionated
radiation therapy refers to radiation therapy in which a radiation
dose is comprised in 2 or more fractions. In various embodiments,
each fraction comprises 2-20 Gy. For example, a radiation dose of
50 Gy may be split up into 10 fractions, each comprising 5 Gy. In
certain embodiments, the 2 or more fractions are administered on
consecutive or sequential days. In certain other embodiments, the 2
or more fractions are administered once in 2 days, once in 3 days,
once in 4 days, once in 5 days, once in 6 days, once in 7 days, or
in a combination thereof.
[0050] According to certain embodiments, the present invention
includes methods for treating, or delaying or inhibiting the growth
of a tumor. In certain embodiments, the present invention includes
methods to promote tumor regression. In certain embodiments, the
present invention includes methods to reduce tumor cell load or to
reduce tumor burden. In certain embodiments, the present invention
includes methods to prevent tumor recurrence. The methods,
according to this aspect of the invention, comprise sequentially
administering a therapeutically effective amount of an anti-PD-1
antibody in combination with radiation therapy to a subject in need
thereof, wherein the antibody is administered to the subject in
multiple doses, e.g., as part of a specific therapeutic dosing
regimen. For example, the therapeutic dosing regimen may comprise
administering one or more doses of an anti-PD-1 antibody to the
subject at a frequency of about once a day, once every two days,
once every three days, once every four days, once every five days,
once every six days, once a week, once every two weeks, once every
three weeks, once every four weeks, once a month, once every two
months, once every three months, once every four months, or less
frequently. In certain embodiments, the one or more doses of
anti-PD-1 antibody are administered in combination with one or more
doses of radiation therapy, wherein the one or more doses of
radiation are administered to the subject at a frequency of about
once a day, once every two days, once every three days, once every
four days, once every five days, once every six days, once a week,
once every two weeks, once every three weeks, once every four
weeks, once a month, once every two months, once every three
months, once every four months, or less frequently.
[0051] In certain embodiments, the one or more doses are comprised
in a treatment cycle. The methods, according to this aspect,
comprise administering to a subject in need thereof at least one
treatment cycle, wherein the at least one treatment cycle comprises
1-10 doses of an anti-PD-1 antibody and optionally one or more
doses of radiation therapy. In certain embodiments, 2-12 treatment
cycles are administered to a subject in need thereof.
[0052] In specific embodiments, the present invention provides
methods for increased anti-tumor efficacy or increased tumor
inhibition. The methods, according to this aspect of the invention,
comprise administering to a subject with a solid tumor a
therapeutically effective amount of an anti-PD-1 antibody prior to
administering a radiation dose, wherein the anti-PD-1 antibody may
be administered about 1 day, more than 1 day, more than 2 days,
more than 3 days, more than 4 days, more than 5 days, more than 6
days, more than 7 days, or more than 8 days prior to the radiation
therapy. In certain embodiments, the methods provide for increased
tumor inhibition, e.g., by about 20%, more than 20%, more than 30%,
more than 40% more than 50%, more than 60%, more than 70% or more
than 80% as compared to a subject administered with a radiation
dose prior to the anti-PD-1 antibody. In certain embodiments, the
radiation therapy comprises hypofractionated radiation therapy.
[0053] In certain embodiments, the present invention provides
methods for treating cancer, the methods comprising selecting a
subject with a first tumor lesion and at least a second tumor
lesion and administering one or more doses of an anti-PD-1 antibody
in combination with radiation therapy such that both the lesions
are treated. In specific embodiments, the methods comprise
administering radiation therapy to the first tumor lesion but not
the second tumor lesion wherein the administration leads to tumor
regression in both the tumor lesions (abscopal effect). In certain
embodiments, the methods comprising selecting a subject with a
first tumor lesion and at least a second tumor lesion and
administering one or more doses of an anti-PD-1 antibody in
combination with hypofractionated radiation therapy wherein the
hypofractionated radiation therapy is administered to the first
lesion but not the second lesion and wherein both the lesions are
treated upon such administration. In certain embodiments, the
anti-PD-1 antibody is administered before radiation therapy.
[0054] In certain embodiments, the present invention includes
methods for treating cancer, the methods comprising administering
to a subject in need thereof one or more sub-therapeutic doses of
an anti-PD-1 antibody in combination with one or more anti-tumor
therapies, e.g., radiation therapy. As defined elsewhere herein,
the term "sub-therapeutic dose" refers to a dose less than a
therapeutic dose and may be used to reduce toxicity of the
administered therapy. In certain embodiments, administering a
sub-therapeutic dose of an anti-PD-1 antibody in combination with
radiation therapy results in therapeutic anti-tumor efficacy as
compared to administration of the sub-therapeutic dose of the
anti-PD-1 antibody alone. In certain other embodiments, the methods
of the present invention comprise administering a therapeutically
effective amount of an anti-PD-1 antibody in combination with a
sub-therapeutic dose of an anti-tumor therapy such as chemotherapy
or radiation. For example, a therapeutically effective amount of an
anti-PD-1 antibody may be administered in combination with a
sub-therapeutic dose of cyclophosphamide, for increased efficacy as
compared to either monotherapy.
[0055] In certain embodiments, the present invention includes
methods to inhibit, retard or stop tumor metastasis or tumor
infiltration into peripheral organs. The methods, according to this
aspect, comprise administering a therapeutically effective amount
of an anti-PD-1 antibody to a subject in need thereof. In certain
embodiments, the anti-PD-1 antibody is administered in combination
with radiation. In one embodiment, the radiation is
hypofractionated radiation. In one embodiment, the radiation is
administered after administering one or more doses of the anti-PD-1
antibody.
[0056] In certain embodiments, the methods of the present invention
comprise administering a therapeutically effective amount of
anti-PD-1 antibody to a subject with advanced solid tumors. In
specific embodiments, the advanced solid tumor is metastatic lung
cancer, head and neck cancer, hepatocellular cancer, or breast
cancer. In certain other embodiments, the advanced solid tumor is
cutaneous squamous cell cancer. In certain embodiments, the
advanced solid tumor is indolent or aggressive. In certain
embodiments, the subject is not responsive to prior therapy or has
relapsed after prior therapy (e.g., with carboplatin). In certain
embodiments, the subject has an advanced solid tumor that is
refractory to first line chemotherapy. In certain further
embodiments, the methods of the present invention further comprise
administering radiation and/or cyclophosphamide to a subject with
an advanced solid tumor.
[0057] In certain embodiments, the present invention includes
methods to treat or inhibit growth of a cancer including, but not
limited to, colorectal cancer, ovarian cancer, prostate cancer,
breast cancer, brain cancer, cervical cancer, bladder cancer, anal
cancer, uterine cancer, colon cancer, liver cancer, pancreatic
cancer, lung cancer, endometrial cancer, bone cancer, testicular
cancer, skin cancer, kidney cancer, stomach cancer, esophageal
cancer, head and neck cancer, salivary gland cancer, and myeloma.
In certain embodiments, the present invention includes methods to
treat or inhibit the growth of a cancer including, but not limited
to, hepatocellular carcinoma, non-small cell lung cancer, head and
neck squamous cell cancer, basal cell carcinoma, cutaneous squamous
cell carcinoma, chondrosarcoma, angiosarcoma, cholangiocarcinoma,
soft tissue sarcoma, colorectal cancer, melanoma, Merkel cell
carcinoma, and glioblastoma multiforme. In certain embodiments, the
present invention includes methods to treat advanced solid tumors
including but not limited to, metastatic cutaneous squamous cell
carcinoma (CSCC), unresectable locally advanced CSCC, metastatic
colorectal cancer, advanced or metastatic hepatocellular cancer,
advanced non-small cell lung cancer, recurrent glioblastoma
multiforme, newly diagnosed glioblastoma multiforme, castrate
recurrent prostate cancer and any advanced solid tumor refractory
to first-line therapy.
[0058] According to one aspect, the present invention includes
methods to treat or inhibit the growth of a tumor, the methods
comprising: (a) selecting a patient with cutaneous squamous cell
carcinoma (CSCC) wherein the patient is selected based on an
attribute selected from the group consisting of: (i) the patient
has locally advanced CSCC; (ii) the patient has metastatic CSCC;
(iii) the tumor is unresectable; (iv) the patient has been earlier
treated with at least one anti-tumor therapy; (v) the patient has
disease that is considered inoperable; (vi) surgery and/or
radiation is contraindicated; (vii) the patient has been earlier
treated with radiation and the tumor is resistant or unresponsive
to radiation; (viii) the patient has locally advanced CSCC and is
not amenable to curative surgery; (ix) the tumor comprises
uv-induced DNA damage; and (x) the patient shows .gtoreq.1%,
.gtoreq.5%, or .gtoreq.10% PD-L1 expression in tumor cells; and (b)
administering a therapeutically effective amount of an anti-PD-1
antibody to the patient need thereof. In certain embodiments, one
or more doses of the anti-PD-1 antibody are administered 1-12 weeks
after the immediately preceding dose, for example, 1, 2, 3, 4, 5,
6, 7, 8, 9, 10, 11 or 12 weeks after the immediately preceding
dose. In certain embodiments, each dose of the anti-PD-1 antibody
comprises 0.1, 1, 0.3, 3, 4, 5, 6, 7, 8, 9 or 10 mg/kg of the
patient's body weight. In certain embodiments, each dose comprises
50-500 mg of the anti-PD-1 antibody, for example 200 mg, 250 mg or
350 mg of the anti-PD-1 antibody, wherein each dose is administered
0.5, 1, 2, 3 or 4 weeks after the immediately preceding dose. In
one embodiment, the anti-PD-1 antibody is REGN2810.
[0059] According to one aspect, the present invention includes
methods to treat or inhibit the growth of a tumor, the methods
comprising: (a) selecting a patient with basal cell carcinoma (BCC)
wherein the patient is selected based on an attribute selected from
the group consisting of: (i) the patient has locally advanced BCC;
(ii) the patient has metastatic BCC; (iii) the tumor is
unresectable; (iv) the patient has been earlier treated with at
least one anti-tumor therapy; (v) the patient has been treated
earlier and progressed upon treatment with a Hedgehog pathway
inhibitor (e.g., vismodegib, sonedegib); (vi) the patient is
intolerant to a Hedgehog pathway inhibitor; (vii) the patient has
disease that is considered inoperable or is not amenable to
curative surgery; (viii) surgery and/or radiation is
contraindicated; (ix) the patient has been earlier treated with
radiation and the tumor is resistant or unresponsive to radiation;
(viii) the patient shows .gtoreq.1%, .gtoreq.5%, or .gtoreq.10%
PD-L1 expression in tumor cells; and (ix) the tumor comprises
uv-induced DNA damage; and (b) administering a therapeutically
effective amount of an anti-PD-1 antibody to the patient need
thereof. In certain embodiments, one or more doses of the anti-PD-1
antibody are administered 1-12 weeks after the immediately
preceding dose, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 or
12 weeks after the immediately preceding dose. In certain
embodiments, each dose of the anti-PD-1 antibody comprises 0.1, 1,
0.3, 3, 4, 5, 6, 7, 8, 9 or 10 mg/kg of the patient's body weight.
In certain embodiments, each dose comprises 50-500 mg of the
anti-PD-1 antibody, for example 200 mg, 250 mg or 350 mg of the
anti-PD-1 antibody, wherein each dose is administered 0.5, 1, 2, 3
or 4 weeks after the immediately preceding dose. In one embodiment,
the anti-PD-1 antibody is REGN2810.
[0060] In certain embodiments, each dose of the anti-PD-1 antibody
is administered 1 week, 2 weeks, 3 weeks, or 4 weeks after the
immediately preceding dose, wherein each dose comprises 50-600 mg
of the anti-PD-1 antibody. In one embodiment, each dose comprises
200, 250, 300 or 350 mg of the anti-PD-1 antibody.
[0061] One embodiment of the invention pertains to an anti-PD-1
antibody (e.g., REGN2810) for use in the treatment of
cholangiocarcinoma. In certain embodiments, one or more doses of
the anti-PD-1 antibody are administered to a subject with
cholangiocarcinoma, wherein each dose comprises 0.1 to 20 mg/kg of
the subject's body weight, and wherein each dose is administered
0.5 to 4 weeks after the immediately preceding dose. In certain
embodiments, each dose comprises 50-500 mg of the anti-PD-1
antibody, for example 200 mg, 250 mg or 350 mg of the anti-PD-1
antibody, wherein each dose is administered 0.5, 1, 2, 3 or 4 weeks
after the immediately preceding dose.
[0062] One embodiment of the invention pertains to an anti-PD-1
antibody (e.g., REGN2810) for use in the treatment of advanced
hepatocellular cancer (HCC). In certain embodiments, one or more
doses of the anti-PD-1 antibody are administered to a subject with
HCC, wherein each dose comprises 0.1 to 20 mg/kg of the subject's
body weight, and wherein each dose is administered 0.5 to 4 weeks
after the immediately preceding dose. In certain embodiments, each
dose comprises 50-500 mg of the anti-PD-1 antibody, for example 200
mg, 250 mg or 350 mg of the anti-PD-1 antibody, wherein each dose
is administered 0.5, 1, 2, 3 or 4 weeks after the immediately
preceding dose.
[0063] One embodiment of the invention pertains to an anti-PD-1
antibody (e.g., REGN2810) for use in the treatment of soft tissue
sarcoma. In certain embodiments, one or more doses of the anti-PD-1
antibody are administered to a subject with soft tissue sarcoma,
wherein each dose comprises 0.1 to 20 mg/kg of the subject's body
weight, and wherein each dose is administered 0.5 to 4 weeks after
the immediately preceding dose. In certain embodiments, each dose
comprises 50-500 mg of the anti-PD-1 antibody, for example 200 mg,
250 mg or 350 mg of the anti-PD-1 antibody, wherein each dose is
administered 0.5, 1, 2, 3 or 4 weeks after the immediately
preceding dose.
[0064] One embodiment of the invention pertains to an anti-PD-1
antibody (e.g., REGN2810) for use in the treatment of non-small
cell lung cancer (NSCLC). In certain embodiments, one or more doses
of the anti-PD-1 antibody are administered to a subject with NSCLC,
wherein each dose comprises 0.1 to 20 mg/kg of the subject's body
weight, and wherein each dose is administered 0.5 to 4 weeks after
the immediately preceding dose. In certain embodiments, one or more
doses of the anti-PD-1 antibody are administered to a subject with
NSCLC, wherein each dose comprises 50-600 mg of the anti-PD-1
antibody, and wherein each dose is administered 0.5 to 4 weeks
after the immediately preceding dose.
[0065] According to one aspect, the present invention includes
methods to treat or inhibit the growth of a tumor, the methods
comprising selecting a subject with a brain cancer and
administering a therapeutically effective amount of an anti-PD-1
antibody or antigen-binding fragment thereof to the subject in need
thereof. In certain embodiments, the brain cancer is glioblastoma
multiforme. In one embodiment, the subject has newly diagnosed
glioblastoma multiforme. In one embodiment, the subject is 65 years
of age. In one embodiment, the anti-PD-1 antibody is administered
as one or more doses, wherein each dose is administered 0.5 to 4
weeks after the immediately preceding dose. In one embodiment, each
dose of the anti-PD-1 antibody comprises 1, 3 or 10 mg/kg of the
subject's body weight. In certain embodiments, the anti-PD-1
antibody is administered in combination with radiation therapy. In
one embodiment, the radiation therapy is hypofractionated radiation
therapy. In one embodiment, the subject is administered 20-60 Gy in
2-20 fractions. In certain embodiments, the one or more doses of
anti-PD-1 antibody are comprised in one or more cycles of
treatment, wherein each cycle of treatment comprises 1-6 doses of
the anti-PD-1 antibody. In one embodiment, at least one cycle of
treatment further comprises radiation therapy. In a further
embodiment, the radiation therapy is hypofractionated radiation
therapy. In certain embodiments, the subject is administered
hypofractionated radiation therapy in the first cycle of treatment,
wherein the hypofractionated radiation therapy comprises 20-60 Gy
in 2-20 fractions. In one embodiment, the subject is administered
hypofractionated radiation therapy one week after the
administration of the anti-PD-1 antibody in the first cycle of
treatment. In certain embodiments, the methods of the present
invention further comprise administering an anti-angiogenic agent
to the subject if the subject develops intracranial edema following
administration of the anti-PD-1 antibody. In one embodiment, the
anti-angiogenic agent is a vascular endothelial growth factor
(VEGF) inhibitor. In one embodiment, the anti-angiogenic agent is
an angiopoietin-2 (Ang-2) inhibitor (e.g., an anti-Ang-2 antibody
such as nesvacumab). In certain embodiments, the VEGF inhibitor is
selected from the group consisting of a VEGF-inhibiting fusion
protein (e.g., a "VEGF-Trap" such as aflibercept or other
VEGF-inhibiting fusion protein as set forth in U.S. Pat. No.
7,087,411), an anti-VEGF antibody (e.g., bevacizumab), and a small
molecule kinase inhibitor of VEGF receptor (e.g., sunitinib,
sorafenib, or pazopanib).
[0066] In certain embodiments, the methods of the present invention
comprise administering an anti-PD-1 antibody in combination with
radiation therapy to a subject in need thereof as a "first line"
treatment (e.g., initial treatment). In other embodiments, an
anti-PD-1 antibody in combination with radiation therapy is
administered as a "second line" treatment (e.g., after prior
therapy). For example, an anti-PD-1 antibody in combination with
radiation therapy is administered as a "second line" treatment to a
subject that has relapsed after prior therapy with, e.g.,
chemotherapy.
[0067] The methods of the present invention, according to certain
embodiments, comprise administering to a subject a therapeutically
effective amount of an anti-PD-1 antibody and radiation in
combination with an additional therapeutic agent or therapeutic
regimen or procedure. The additional therapeutic agent or
therapeutic regimen or procedure may be administered for increasing
anti-tumor efficacy, for reducing toxic effects of one or more
therapies and/or reducing the dosage of one or more therapies. In
various embodiments, the additional therapeutic agent or
therapeutic regimen or procedure is selected from the group
consisting of, e.g., chemotherapy, cyclophosphamide, surgery, a
cancer vaccine, a programmed death ligand 1 (PD-L1) inhibitor
(e.g., an anti-PD-L1 antibody), a lymphocyte activation gene 3
(LAG3) inhibitor (e.g., an anti-LAG3 antibody), a cytotoxic
T-lymphocyte-associated protein 4 (CTLA-4) inhibitor (e.g.,
ipilimumab), a glucocorticoid-induced tumor necrosis factor
receptor (GITR) inhibitor (e.g., an anti-GITR antibody), a T-cell
immunoglobulin and mucin containing -3 (TIM3) inhibitor, a B- and
T-lymphocyte attenuator (BTLA) inhibitor, a T cell immunoreceptor
with Ig and ITIM domains (TIGIT) inhibitor, a CD47 inhibitor, an
indoleamine-2,3-dioxygenase (IDO) inhibitor, a vascular endothelial
growth factor (VEGF) antagonist, an angiopoietin-2 (Ang2)
inhibitor, a transforming growth factor beta (TGF8) inhibitor, an
epidermal growth factor receptor (EGFR) inhibitor, an antibody to a
tumor-specific antigen [e.g., CA9, CA125, melanoma-associated
antigen 3 (MAGE3), carcinoembryonic antigen (CEA), vimentin,
tumor-M2-PK, prostate-specific antigen (PSA), mucin-1, MART-1, and
CA19-9], an anti-CD3/anti-CD20 bispecific antibody, a vaccine
(e.g., Bacillus Calmette-Guerin), granulocyte-macrophage
colony-stimulating factor, a cytotoxin, a chemotherapeutic agent,
an IL-6R inhibitor, an IL-4R inhibitor, an IL-10 inhibitor, a
cytokine such as IL-2, IL-7, IL-21, and IL-15, an anti-inflammatory
drug such as corticosteroids, and non-steroidal anti-inflammatory
drugs, and a dietary supplement such as anti-oxidants. In certain
embodiments, the anti-PD-1 antibody may be administered in
combination with therapy including a chemotherapeutic agent, and
surgery. As used herein, the phrase `in combination with" means
that the anti-PD-1 antibody is administered to the subject at the
same time as, just before, or just after administration of
radiation therapy and the additional therapeutic agent. In certain
embodiments, the additional therapeutic agent is administered as a
co-formulation with the anti-PD-1 antibody.
[0068] One embodiment of the invention pertains to a combination of
an anti-PD-1 antibody (e.g., REGN2810), radiation therapy,
cyclophosphamide and GM-CSF for use in the treatment of head and
neck squamous cell carcinoma (HNSCC). In certain embodiments, one
or more doses of the anti-PD-1 antibody are administered to a
subject with HNSCC, wherein each dose comprises 0.1 to 20 mg/kg of
the subject's body weight, and wherein each dose is administered
0.5 to 4 weeks after the immediately preceding dose. In certain
embodiments, each dose comprises 50-500 mg of the anti-PD-1
antibody, for example 200 mg, 250 mg or 350 mg of the anti-PD-1
antibody, wherein each dose is administered 0.5, 1, 2, 3 or 4 weeks
after the immediately preceding dose.
[0069] One embodiment of the invention pertains to a combination of
an anti-PD-1 antibody (e.g., REGN2810), radiation therapy, and
cyclophosphamide for use in the treatment of breast cancer. In
certain embodiments, one or more doses of the anti-PD-1 antibody
are administered to a subject with breast cancer, wherein each dose
comprises 0.1 to 20 mg/kg of the subject's body weight, and wherein
each dose is administered 0.5 to 4 weeks after the immediately
preceding dose.
[0070] One embodiment of the invention pertains to a combination of
an anti-PD-1 antibody (e.g., REGN2810), radiation therapy,
cyclophosphamide and GM-CSF for use in the treatment of advanced
solid tumors in patients that have been previously treated with an
anti-PD-1 antibody or an anti-PD-L1 antibody. In certain
embodiments, one or more doses of the anti-PD-1 antibody are
administered to a patient in need thereof, wherein each dose
comprises 0.1 to 20 mg/kg of the subject's body weight, and wherein
each dose is administered 0.5 to 4 weeks after the immediately
preceding dose.
[0071] One embodiment of the invention pertains to a combination of
an anti-PD-1 antibody (e.g., REGN2810), docetaxel, and optionally,
carboplatin for use in the treatment of advanced solid tumors that
are refractory to first-line chemotherapy. In certain embodiments,
the docetaxel is administered at a low dose. In certain
embodiments, one or more doses of the anti-PD-1 antibody are
administered to a subject in need thereof, wherein each dose
comprises 0.1 to 20 mg/kg of the subject's body weight, and wherein
each dose is administered 0.5 to 4 weeks after the immediately
preceding dose.
[0072] One embodiment of the invention pertains to a combination of
an anti-PD-1 antibody (e.g., REGN2810), and radiation therapy for
use in the treatment of newly diagnosed, or recurrent glioblastoma
multiforme (GBM). In certain embodiments, one or more doses of the
anti-PD-1 antibody are administered to a subject in need thereof,
wherein each dose comprises 0.1 to 20 mg/kg of the subject's body
weight, and wherein each dose is administered 0.5 to 4 weeks after
the immediately preceding dose. In certain embodiments, the
radiation is hypofractionated radiation therapy as described
herein.
[0073] Certain embodiments of the invention pertain to a
combination of an anti-PD-1 antibody (e.g., REGN2810), and
radiation therapy for use in the treatment of cervix squamous cell
carcinoma, anal squamous cell carcinoma, Merkel cell carcinoma,
small intestine adenocarcinoma or ovarian serous carcinoma. In
certain embodiments, one or more doses of the anti-PD-1 antibody
are administered to a subject in need thereof, wherein each dose
comprises 0.1 to 20 mg/kg of the subject's body weight, and wherein
each dose is administered 0.5 to 4 weeks after the immediately
preceding dose. In certain embodiments, the radiation is
hypofractionated radiation therapy as described herein.
[0074] In certain embodiments, the present invention includes
methods for treating large tumors or advanced malignancies, the
methods comprising administering to a subject in need thereof an
anti-PD-1 antibody in combination with radiation therapy and an
additional therapeutic agent, wherein the additional therapeutic
agent is administered to overcome regulatory T cell (Treg)-mediated
immunosuppression. In certain embodiments, the additional
therapeutic agent is selected from the group consisting of an
anti-GITR antibody, an anti-LAG3 antibody, cyclophosphamide, and
GM-CSF.
[0075] As used herein, the term "large tumor" refers to the size of
the tumor. It typically correlates with higher tumor burden or
tumor load. In certain embodiments, it correlates with stage of the
disease, e.g., advanced malignancy. In certain embodiments, it
correlates with increased probability of metastasis.
[0076] In certain embodiments, the present invention includes
methods comprising administering one or more doses of an anti-PD-1
antibody in combination with radiation therapy and a
sub-therapeutic dose of cyclophosphamide. As used herein, a
sub-therapeutic dose of cyclophosphamide (also referred to herein
as "low-dose cyclophosphamide") means an amount of cyclophosphamide
that by itself does not impart a therapeutic effect and preferably
does not cause toxicity. Exemplary doses of cyclophosphamide that
are considered "sub-therapeutic" in the context of the present
invention include 100 mg/m2, 90 mg/m2, 80 mg/m2, or less.
[0077] In one aspect, the present invention includes methods
comprising administering a therapeutically effective amount of an
anti-PD-1 antibody in combination with radiation to a subject who
is on a background anti-cancer therapeutic regimen. The background
anti-cancer therapeutic regimen may comprise a course of
administration of, e.g., a chemotherapeutic agent. The anti-PD-1
antibody in combination with radiation therapy may be added on top
of the background anti-cancer therapeutic regimen. In some
embodiments, the anti-PD-1 antibody is added as part of a
"background step-down" scheme, wherein the background anti-cancer
therapy is gradually withdrawn from the subject over time (e.g., in
a stepwise fashion) while the anti-PD-1 antibody is administered to
the subject at a constant dose, or at an increasing dose, or at a
decreasing dose, over time. For example, the background anti-cancer
therapy may comprise a chemotherapeutic agent which may be
administered at a low dose or at a subtherapeutic dose. In certain
embodiments, the present invention includes methods for treating
cancer, the methods comprising administering one or more doses of
an anti-PD-1 antibody in combination with radiation therapy and one
or more doses of a chemotherapeutic agent, wherein the
chemotherapeutic agent is administered at a subtherapeutic
dose.
[0078] In certain embodiments, the radiation therapy is
administered to a first tumor lesion, but not to a second tumor
lesion, wherein the administration in combination with the
anti-PD-1 antibody leads to tumor regression in both the first and
second tumor lesions (abscopal effect). In certain embodiments, the
methods of the present invention comprise administering an
anti-PD-1 antibody in combination with radiation therapy to
generate prolonged abscopal effect.
[0079] In certain embodiments, the methods of the present invention
comprise administering to a subject in need thereof a
therapeutically effective amount of an anti-PD-1 antibody,
optionally, in combination with radiation therapy, wherein
administration of the combination leads to increased inhibition of
tumor growth. In certain embodiments, tumor growth is inhibited by
at least about 10%, about 20%, about 30%, about 40%, about 50%,
about 60%, about 70% or about 80% as compared to an untreated
subject or a subject administered with either antibody or radiation
as monotherapy. In certain embodiments, the administration of an
anti-PD-1 antibody and/or radiation therapy leads to increased
tumor regression, tumor shrinkage and/or disappearance. In certain
embodiments, the administration of an anti-PD-1 antibody and/or
radiation therapy leads to delay in tumor growth and development,
e.g., tumor growth may be delayed by about 3 days, more than 3
days, about 7 days, more than 7 days, more than 15 days, more than
1 month, more than 3 months, more than 6 months, more than 1 year,
more than 2 years, or more than 3 years as compared to an untreated
subject or a subject treated with either antibody or radiation as
monotherapy. In certain embodiments, administration of an anti-PD-1
antibody in combination with radiation therapy prevents tumor
recurrence and/or increases duration of survival of the subject,
e.g., increases duration of survival by more than 15 days, more
than 1 month, more than 3 months, more than 6 months, more than 12
months, more than 18 months, more than 24 months, more than 36
months, or more than 48 months than an untreated subject or a
subject which is administered either antibody or radiation as
monotherapy. In certain embodiments, administration of the
anti-PD-1 antibody in combination with radiation therapy increases
progression-free survival or overall survival. In certain
embodiments, administration of an anti-PD-1 antibody in combination
with radiation therapy increases response and duration of response
in a subject, e.g., by more than 2%, more than 3%, more than 4%,
more than 5%, more than 6%, more than 7%, more than 8%, more than
9%, more than 10%, more than 20%, more than 30%, more than 40% or
more than 50% over an untreated subject or a subject which has
received either antibody or radiation as monotherapy. In certain
embodiments, administration of an anti-PD-1 antibody and/or
radiation therapy to a subject with a cancer leads to complete
disappearance of all evidence of tumor cells ("complete response").
In certain embodiments, administration of an anti-PD-1 antibody
and/or radiation therapy to a subject with a cancer leads to at
least 30% or more decrease in tumor cells or tumor size ("partial
response"). In certain embodiments, administration of an anti-PD-1
antibody and/or radiation therapy to a subject with a cancer leads
to complete or partial disappearance of tumor cells/lesions
including new measurable lesions. Tumor reduction can be measured
by any of the methods known in the art, e.g., X-rays, positron
emission tomography (PET), computed tomography (CT), magnetic
resonance imaging (MRI), cytology, histology, or molecular genetic
analyses.
[0080] In certain embodiments, the methods of the present invention
comprise administering to a subject in need thereof a
therapeutically effective amount of an anti-PD-1 antibody, wherein
administration of the anti-PD-1 antibody leads to increased overall
survival (OS) or progression-free survival (PFS) of the patient as
compared to a patient administered with a `standard-of-care` (SOC)
therapy (e.g., chemotherapy, surgery or radiation). In certain
embodiments, the PFS is increased by at least one month, at least 2
months, at least 3 months, at least 4 months, at least 5 months, at
least 6 months, at least 7 months, at least 8 months, at least 9
months, at least 10 months, at least 11 months, at least 1 year, at
least 2 years, or at least 3 years as compared to a patient
administered with any one or more SOC therapies. In certain
embodiments, the OS is increased by at least one month, at least 2
months, at least 3 months, at least 4 months, at least 5 months, at
least 6 months, at least 7 months, at least 8 months, at least 9
months, at least 10 months, at least 11 months, at least 1 year, at
least 2 years, or at least 3 years as compared to a patient
administered with any one or more SOC therapies.
[0081] The present invention also provides kits comprising an
anti-PD-1 antibody for therapeutic uses. Kits typically include a
label indicating the intended use of the contents of the kit and
instructions for use. The term label includes any writing, or
recorded material supplied on or with the kit, or which otherwise
accompanies the kit. Accordingly, this disclosure provides a kit
for treating a subject afflicted with a cancer, the kit comprising:
(a) a dosage of an antibody or an antigen-binding portion thereof
that specifically binds to PD-1 and inhibits PD-1 activity; and (b)
instructions for using the anti-PD-1 antibody in any of the therapy
methods disclosed herein. In certain embodiments for treating human
patients, the kit comprises an anti-human PD-1 antibody disclosed
herein, e.g., REGN2810. In other embodiments, the anti-PD-1
antibody may be any one of nivolumab, pembrolizumab, or any of the
anti-PD-1 antibodies disclosed herein. In certain embodiments, the
dosage of the anti-PD-1 antibody ranges from 0.1 to 10 mg/kg body
weight. In certain embodiments, the dosage of the anti-PD-1
antibody comprises from 50 to 600 mg.
Methods for Suppressing T regulatory Cells
[0082] According to certain aspects, the present invention provides
methods for suppressing or inhibiting the activation and/or
proliferation of T regulatory (Treg) cells. In certain embodiments,
the present invention provides methods for suppressing the activity
of Treg cells. The methods, according to these aspects, comprise
selecting a subject with a solid tumor and administering to the
subject an anti-PD-1 antibody or antigen-binding fragment thereof
in combination with at least one of (i) radiation therapy, and (ii)
a glucocorticoid-induced tumor necrosis factor receptor (GITR)
antagonist. In certain embodiments, the methods comprise
administering to a subject in need thereof an anti-PD-1 antibody or
antigen-binding fragment thereof in combination with radiation
therapy and a GITR antagonist.
[0083] In certain embodiments, the GITR antagonist is an anti-GITR
antibody or antigen-binding fragment thereof. According to certain
exemplary embodiments of the present invention, the anti-GITR
antibody, or antigen-binding fragment thereof comprises a heavy
chain variable region (HCVR), light chain variable region (LCVR),
and/or complementarity determining regions (CDRs) comprising the
amino acid sequences of any of the anti-GITR antibodies as set
forth in U.S. Ser. No. 62/256,922 (filed Nov. 18, 2015), the
contents of which are incorporated herein in their entirety. Other
anti-GITR antibodies that can be used in the context of the methods
of the present invention include any of the anti-GITR antibodies as
set forth in e.g., U.S. Pat. Nos. 9,228,016, 8,709,424, 8,591,886,
7,812,135, or US Patent Publication No. 20150368349.
[0084] In certain embodiments, the present invention provides
methods for suppressing or eliminating Treg activity, the methods
comprising administering to a subject in need thereof an anti-PD-1
antibody or antigen-binding fragment thereof in combination with
one or more doses of radiation and a cytotoxic T-lymphocyte
antigen-4 (CTLA) antagonist. In certain embodiments, the CTLA
antagonist is an anti-CTLA antibody (e.g., ipilimumab).
[0085] In certain embodiments, the present invention provides
methods for suppressing or eliminating Treg activity, the methods
comprising administering to a subject in need thereof an anti-PD-1
antibody or antigen-binding fragment thereof in combination with
one or more doses of radiation and a lymphocyte activation gene 3
(LAG-3) antagonist. In certain embodiments, the LAG-3 antagonist is
an anti-LAG-3 antibody. Anti-LAG-3 antibodies that can be used in
the context of the methods of the present invention are disclosed
in U.S. Ser. No. 15/289,032 (filed Oct. 7, 2016), the contents of
which are incorporated herein in their entirety
[0086] In certain embodiments, the present invention provides
methods for suppressing or eliminating Treg activity, the methods
comprising administering to a subject in need thereof an anti-PD-1
antibody or antigen-binding fragment thereof in combination with
one or more doses of radiation and cyclophosphamide.
[0087] In one aspect, the methods of the present invention comprise
administration of an anti-PD-1 antibody in combination with
radiation therapy and an additional therapeutic agent selected from
the group consisting of a GITR antagonist, an anti-LAG-3 antibody,
and cyclophosphamide to a subject with a solid tumor, wherein the
administration results in an effect selected from the group
consisting of inhibition of tumor growth, reduction in the size of
a tumor, delay in tumor growth, inhibition of tumor metastasis,
reduction in metastatic lesions over time, reduced use of
chemotherapeutic or cytotoxic agents, increased survival, complete
response, partial response, and stable disease. In certain
embodiments, the administration results in reduction of tumor
burden in the subject. In certain embodiments, the subject has a
large tumor. As defined elsewhere herein, the term "large tumor"
refers to the size of the tumor and is correlated with increased
tumor burden and increased probability of occurrence of metastasis.
In certain embodiments, the term refers to an advanced
malignancy.
Anti-PD-1 Antibodies and Antigen-Binding Fragments Thereof
[0088] According to certain exemplary embodiments of the present
invention, the methods comprise administering a therapeutically
effective amount of an anti-PD-1 antibody or antigen-binding
fragment thereof. The term "antibody," as used herein, includes
immunoglobulin molecules comprising four polypeptide chains, two
heavy (H) chains and two light (L) chains inter-connected by
disulfide bonds, as well as multimers thereof (e.g., IgM). In a
typical antibody, each heavy chain comprises a heavy chain variable
region (abbreviated herein as HCVR or V.sub.H) and a heavy chain
constant region. The heavy chain constant region comprises three
domains, C.sub.H1, C.sub.H2 and C.sub.H3. Each light chain
comprises a light chain variable region (abbreviated herein as LCVR
or V.sub.L) and a light chain constant region. The light chain
constant region comprises one domain (C.sub.L1). The V.sub.H and
V.sub.L regions can be further subdivided into regions of
hypervariability, termed complementarity determining regions
(CDRs), interspersed with regions that are more conserved, termed
framework regions (FR). Each V.sub.H and V.sub.L is composed of
three CDRs and four FRs, arranged from amino-terminus to
carboxy-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3,
CDR3, FR4. In different embodiments of the invention, the FRs of
the anti-IL-4R antibody (or antigen-binding portion thereof) may be
identical to the human germline sequences, or may be naturally or
artificially modified. An amino acid consensus sequence may be
defined based on a side-by-side analysis of two or more CDRs.
[0089] The term "antibody," as used herein, also includes
antigen-binding fragments of full antibody molecules. The terms
"antigen-binding portion" of an antibody, "antigen-binding
fragment" of an antibody, and the like, as used herein, include any
naturally occurring, enzymatically obtainable, synthetic, or
genetically engineered polypeptide or glycoprotein that
specifically binds an antigen to form a complex. Antigen-binding
fragments of an antibody may be derived, e.g., from full antibody
molecules using any suitable standard techniques such as
proteolytic digestion or recombinant genetic engineering techniques
involving the manipulation and expression of DNA encoding antibody
variable and optionally constant domains. Such DNA is known and/or
is readily available from, e.g., commercial sources, DNA libraries
(including, e.g., phage-antibody libraries), or can be synthesized.
The DNA may be sequenced and manipulated chemically or by using
molecular biology techniques, for example, to arrange one or more
variable and/or constant domains into a suitable configuration, or
to introduce codons, create cysteine residues, modify, add or
delete amino acids, etc.
[0090] Non-limiting examples of antigen-binding fragments include:
(i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv)
Fv fragments; (v) single-chain Fv (scFv) molecules; (vi) dAb
fragments; and (vii) minimal recognition units consisting of the
amino acid residues that mimic the hypervariable region of an
antibody (e.g., an isolated complementarity determining region
(CDR) such as a CDR3 peptide), or a constrained FR3-CDR3-FR4
peptide. Other engineered molecules, such as domain-specific
antibodies, single domain antibodies, domain-deleted antibodies,
chimeric antibodies, CDR-grafted antibodies, diabodies, triabodies,
tetrabodies, minibodies, nanobodies (e.g. monovalent nanobodies,
bivalent nanobodies, etc.), small modular immunopharmaceuticals
(SMIPs), and shark variable IgNAR domains, are also encompassed
within the expression "antigen-binding fragment," as used
herein.
[0091] An antigen-binding fragment of an antibody will typically
comprise at least one variable domain. The variable domain may be
of any size or amino acid composition and will generally comprise
at least one CDR which is adjacent to or in frame with one or more
framework sequences. In antigen-binding fragments having a V.sub.H
domain associated with a V.sub.L domain, the V.sub.H and V.sub.L
domains may be situated relative to one another in any suitable
arrangement. For example, the variable region may be dimeric and
contain V.sub.H-V.sub.H, V.sub.H-V.sub.L or V.sub.L-V.sub.L dimers.
Alternatively, the antigen-binding fragment of an antibody may
contain a monomeric V.sub.H or V.sub.L domain.
[0092] In certain embodiments, an antigen-binding fragment of an
antibody may contain at least one variable domain covalently linked
to at least one constant domain. Non-limiting, exemplary
configurations of variable and constant domains that may be found
within an antigen-binding fragment of an antibody of the present
invention include: (i) V.sub.H-C.sub.H1; (ii) V.sub.H-C.sub.H2;
(iii) V.sub.H-C.sub.H3; (iv) V.sub.H-C.sub.H1-C.sub.H2; (V)
V.sub.H-C.sub.H1-C.sub.H2-C.sub.H3; V.sub.H-C.sub.H2-C.sub.H3;
(vii) V.sub.H-C.sub.L; (Viii) V.sub.L-C.sub.H1; (ix)
V.sub.L-C.sub.H2; (x) V.sub.L-C.sub.H3; (xi)
V.sub.L-C.sub.H1-C.sub.H2; (xii)
V.sub.L-C.sub.H2-C.sub.H2-C.sub.H3; (xiii)
V.sub.L-C.sub.H2-C.sub.H3; and (xiv) V.sub.L-C.sub.L. In any
configuration of variable and constant domains, including any of
the exemplary configurations listed above, the variable and
constant domains may be either directly linked to one another or
may be linked by a full or partial hinge or linker region. A hinge
region may consist of at least 2 (e.g., 5, 10, 15, 20, 40, 60 or
more) amino acids which result in a flexible or semi-flexible
linkage between adjacent variable and/or constant domains in a
single polypeptide molecule. Moreover, an antigen-binding fragment
of an antibody of the present invention may comprise a homo-dimer
or hetero-dimer (or other multimer) of any of the variable and
constant domain configurations listed above in non-covalent
association with one another and/or with one or more monomeric
V.sub.H or V.sub.L domain (e.g., by disulfide bond(s)).
[0093] The term "antibody," as used herein, also includes
multispecific (e.g., bispecific) antibodies. A multispecific
antibody or antigen-binding fragment of an antibody will typically
comprise at least two different variable domains, wherein each
variable domain is capable of specifically binding to a separate
antigen or to a different epitope on the same antigen. Any
multispecific antibody format may be adapted for use in the context
of an antibody or antigen-binding fragment of an antibody of the
present invention using routine techniques available in the art.
For example, the present invention includes methods comprising the
use of bispecific antibodies wherein one arm of an immunoglobulin
is specific for PD-1 or a fragment thereof, and the other arm of
the immunoglobulin is specific for a second therapeutic target or
is conjugated to a therapeutic moiety. Exemplary bispecific formats
that can be used in the context of the present invention include,
without limitation, e.g., scFv-based or diabody bispecific formats,
IgG-scFv fusions, dual variable domain (DVD)-Ig, Quadroma,
knobs-into-holes, common light chain (e.g., common light chain with
knobs-into-holes, etc.), CrossMab, CrossFab, (SEED) body, leucine
zipper, Duobody, IgG1/IgG2, dual acting Fab (DAF)-IgG, and
Mab.sup.2 bispecific formats (see, e.g., Klein et al. 2012, mAbs
4:6, 1-11, and references cited therein, for a review of the
foregoing formats). Bispecific antibodies can also be constructed
using peptide/nucleic acid conjugation, e.g., wherein unnatural
amino acids with orthogonal chemical reactivity are used to
generate site-specific antibody-oligonucleotide conjugates which
then self-assemble into multimeric complexes with defined
composition, valency and geometry. (See, e.g., Kazane et al., J.
Am. Chem. Soc. [Epub: Dec. 4, 2012]).
[0094] The antibodies used in the methods of the present invention
may be human antibodies. The term "human antibody," as used herein,
is intended to include antibodies having variable and constant
regions derived from human germline immunoglobulin sequences. The
human antibodies of the invention may nonetheless include amino
acid residues not encoded by human germline immunoglobulin
sequences (e.g., mutations introduced by random or site-specific
mutagenesis in vitro or by somatic mutation in vivo), for example
in the CDRs and in particular CDR3. However, the term "human
antibody," as used herein, is not intended to include antibodies in
which CDR sequences derived from the germline of another mammalian
species, such as a mouse, have been grafted onto human framework
sequences.
[0095] The antibodies used in the methods of the present invention
may be recombinant human antibodies. The term "recombinant human
antibody," as used herein, is intended to include all human
antibodies that are prepared, expressed, created or isolated by
recombinant means, such as antibodies expressed using a recombinant
expression vector transfected into a host cell (described further
below), antibodies isolated from a recombinant, combinatorial human
antibody library (described further below), antibodies isolated
from an animal (e.g., a mouse) that is transgenic for human
immunoglobulin genes [see e.g., Taylor et al. (1992) Nucl. Acids
Res. 20:6287-6295] or antibodies prepared, expressed, created or
isolated by any other means that involves splicing of human
immunoglobulin gene sequences to other DNA sequences. Such
recombinant human antibodies have variable and constant regions
derived from human germline immunoglobulin sequences. In certain
embodiments, however, such recombinant human antibodies are
subjected to in vitro mutagenesis (or, when an animal transgenic
for human Ig sequences is used, in vivo somatic mutagenesis) and
thus the amino acid sequences of the V.sub.H and V.sub.L regions of
the recombinant antibodies are sequences that, while derived from
and related to human germline V.sub.H and V.sub.L sequences, may
not naturally exist within the human antibody germline repertoire
in vivo.
[0096] According to certain embodiments, the antibodies used in the
methods of the present invention specifically bind PD-1. The term
"specifically binds," or the like, means that an antibody or
antigen-binding fragment thereof forms a complex with an antigen
that is relatively stable under physiologic conditions. Methods for
determining whether an antibody specifically binds to an antigen
are well known in the art and include, for example, equilibrium
dialysis, surface plasmon resonance, and the like. For example, an
antibody that "specifically binds" PD-1, as used in the context of
the present invention, includes antibodies that bind PD-1 or
portion thereof with a K.sub.D of less than about 500 nM, less than
about 300 nM, less than about 200 nM, less than about 100 nM, less
than about 90 nM, less than about 80 nM, less than about 70 nM,
less than about 60 nM, less than about 50 nM, less than about 40
nM, less than about 30 nM, less than about 20 nM, less than about
10 nM, less than about 5 nM, less than about 4 nM, less than about
3 nM, less than about 2 nM, less than about 1 nM or less than about
0.5 nM, as measured in a surface plasmon resonance assay. An
isolated antibody that specifically binds human PD-1 may, however,
have cross-reactivity to other antigens, such as PD-1 molecules
from other (non-human) species.
[0097] According to certain exemplary embodiments of the present
invention, the anti-PD-1 antibody, or antigen-binding fragment
thereof comprises a heavy chain variable region (HCVR), light chain
variable region (LCVR), and/or complementarity determining regions
(CDRs) comprising the amino acid sequences of any of the anti-PD-1
antibodies as set forth in US Patent Publication No. 20150203579,
hereby incorporated in its entirety. In certain exemplary
embodiments, the anti-PD-1 antibody or antigen-binding fragment
thereof that can be used in the context of the methods of the
present invention comprises the heavy chain complementarity
determining regions (HCDRs) of a heavy chain variable region (HCVR)
comprising the amino acid sequence of SEQ ID NO: 1 and the light
chain complementarity determining regions (LCDRs) of a light chain
variable region (LCVR) comprising the amino acid sequence of SEQ ID
NO: 2. According to certain embodiments, the anti-PD-1 antibody or
antigen-binding fragment thereof comprises three HCDRs (HCDR1,
HCDR2 and HCDR3) and three LCDRs (LCDR1, LCDR2 and LCDR3), wherein
the HCDR1 comprises the amino acid sequence of SEQ ID NO: 3; the
HCDR2 comprises the amino acid sequence of SEQ ID NO: 4; the HCDR3
comprises the amino acid sequence of SEQ ID NO: 5; the LCDR1
comprises the amino acid sequence of SEQ ID NO: 6; the LCDR2
comprises the amino acid sequence of SEQ ID NO: 7; and the LCDR3
comprises the amino acid sequence of SEQ ID NO: 8. In yet other
embodiments, the anti-PD-1 antibody or antigen-binding fragment
thereof comprises an HCVR comprising SEQ ID NO: 1 and an LCVR
comprising SEQ ID NO: 2. In certain embodiments, the methods of the
present invention comprise the use of an anti-PD-1 antibody,
wherein the antibody comprises a heavy chain comprising the amino
acid sequence of SEQ ID NO: 9. In some embodiments, the anti-PD-1
antibody comprises a light chain comprising the amino acid sequence
of SEQ ID NO: 10. An exemplary antibody comprising a heavy chain
comprising the amino acid sequence of SEQ ID NO: 9 and a light
chain comprising the amino acid sequence of SEQ ID NO: 10 is the
fully human anti-PD-1 antibody known as REGN2810 and also known as
emplumab. According to certain exemplary embodiments, the methods
of the present invention comprise the use of REGN2810, or a
bioequivalent thereof. The term "bioequivalent", as used herein,
refers to anti-PD-1 antibodies or PD-1-binding proteins or
fragments thereof that are pharmaceutical equivalents or
pharmaceutical alternatives whose rate and/or extent of absorption
do not show a significant difference with that of REGN2810 when
administered at the same molar dose under similar experimental
conditions, either single dose or multiple dose. In the context of
the invention, the term refers to antigen-binding proteins that
bind to PD-1 which do not have clinically meaningful differences
with REGN2810 in their safety, purity and/or potency.
[0098] According to certain embodiments of the present invention,
the anti-human PD-1, or antigen-binding fragment thereof, comprises
a HCVR having 90%, 95%, 98% or 99% sequence identity to SEQ ID NO:
1.
[0099] According to certain embodiments of the present invention,
the anti-human PD-1, or antigen-binding fragment thereof, comprises
a LCVR having 90%, 95%, 98% or 99% sequence identity to SEQ ID NO:
2.
[0100] According to certain embodiments of the present invention,
the anti-human PD-1, or antigen-binding fragment thereof, comprises
a HCVR comprising an amino acid sequence of SEQ ID NO: 1 having no
more than 5 amino acid substitutions. According to certain
embodiments of the present invention, the anti-human PD-1, or
antigen-binding fragment thereof, comprises a LCVR comprising an
amino acid sequence of SEQ ID NO: 2 having no more than 2 amino
acid substitutions.
[0101] Sequence identity may be measured by any method known in the
art (e.g., GAP, BESTFIT, and BLAST).
[0102] The present invention also includes use of anti-PD-1
antibodies in methods to treat cancer, wherein the anti-PD-1
antibodies comprise variants of any of the HCVR, LCVR and/or CDR
amino acid sequences disclosed herein having one or more
conservative amino acid substitutions. For example, the present
invention includes use of anti-PD-1 antibodies having HCVR, LCVR
and/or CDR amino acid sequences with, e.g., 10 or fewer, 8 or
fewer, 6 or fewer, 4 or fewer, etc. conservative amino acid
substitutions relative to any of the HCVR, LCVR and/or CDR amino
acid sequences disclosed herein.
[0103] Other anti-PD-1 antibodies that can be used in the context
of the methods of the present invention include, e.g., the
antibodies referred to and known in the art as nivolumab (U.S. Pat.
No. 8,008,449), pembrolizumab (U.S. Pat. No. 8,354,509), MED10608
(U.S. Pat. No. 8,609,089), pidilizumab (U.S. Pat. No. 8,686,119),
or any of the anti-PD-1 antibodies as set forth in U.S. Pat. Nos.
6,808,710, 7,488,802, 8,168,757, 8,354,509, 8,779,105, or
8,900,587.
[0104] The anti-PD-1 antibodies used in the context of the methods
of the present invention may have pH-dependent binding
characteristics. For example, an anti-PD-1 antibody for use in the
methods of the present invention may exhibit reduced binding to
PD-1 at acidic pH as compared to neutral pH. Alternatively, an
anti-PD-1 antibody of the invention may exhibit enhanced binding to
its antigen at acidic pH as compared to neutral pH. The expression
"acidic pH" includes pH values less than about 6.2, e.g., about
6.0, 5.95, 5.9, 5.85, 5.8, 5.75, 5.7, 5.65, 5.6, 5.55, 5.5, 5.45,
5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1, 5.05, 5.0, or less. As used
herein, the expression "neutral pH" means a pH of about 7.0 to
about 7.4. The expression "neutral pH" includes pH values of about
7.0, 7.05, 7.1, 7.15, 7.2, 7.25, 7.3, 7.35, and 7.4.
[0105] In certain instances, "reduced binding to PD-1 at acidic pH
as compared to neutral pH" is expressed in terms of a ratio of the
K.sub.D value of the antibody binding to PD-1 at acidic pH to the
K.sub.D value of the antibody binding to PD-1 at neutral pH (or
vice versa). For example, an antibody or antigen-binding fragment
thereof may be regarded as exhibiting "reduced binding to PD-1 at
acidic pH as compared to neutral pH" for purposes of the present
invention if the antibody or antigen-binding fragment thereof
exhibits an acidic/neutral K.sub.D ratio of about 3.0 or greater.
In certain exemplary embodiments, the acidic/neutral K.sub.D ratio
for an antibody or antigen-binding fragment of the present
invention can be about 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0,
7.5, 8.0, 8.5, 9.0, 9.5, 10.0, 10.5, 11.0, 11.5, 12.0, 12.5, 13.0,
13.5, 14.0, 14.5, 15.0, 20.0, 25.0, 30.0, 40.0, 50.0, 60.0, 70.0,
100.0, or greater.
[0106] Antibodies with pH-dependent binding characteristics may be
obtained, e.g., by screening a population of antibodies for reduced
(or enhanced) binding to a particular antigen at acidic pH as
compared to neutral pH. Additionally, modifications of the
antigen-binding domain at the amino acid level may yield antibodies
with pH-dependent characteristics. For example, by substituting one
or more amino acids of an antigen-binding domain (e.g., within a
CDR) with a histidine residue, an antibody with reduced
antigen-binding at acidic pH relative to neutral pH may be
obtained. As used herein, the expression "acidic pH" means a pH of
6.0 or less.
Combination Therapies
[0107] The methods of the present invention, according to certain
embodiments, comprise administering to the subject a
therapeutically effective amount of an anti-PD-1 antibody. In
certain embodiments, the methods of the present invention comprise
administering radiation therapy in combination with an anti-PD-1
antibody for additive or synergistic activity to treat cancer. As
used herein, the expression "in combination with" means that the
radiation therapy is administered before, after, or concurrent with
the anti-PD-1 antibody. The term "in combination with" also
includes sequential or concomitant administration of anti-PD-1
antibody and radiation therapy. For example, when administered
"before" the radiation therapy, the anti-PD-1 antibody may be
administered more than 150 hours, about 150 hours, about 100 hours,
about 72 hours, about 60 hours, about 48 hours, about 36 hours,
about 24 hours, about 12 hours, about 10 hours, about 8 hours,
about 6 hours, about 4 hours, about 2 hours, about 1 hour, or about
30 minutes, about 15 minutes or about 10 minutes prior to the
administration of the radiation therapy. When administered "after"
the radiation therapy, the anti-PD-1 antibody may be administered
about 10 minutes, about 15 minutes, about 30 minutes, about 1 hour,
about 2 hours, about 4 hours, about 6 hours, about 8 hours, about
10 hours, about 12 hours, about 24 hours, about 36 hours, about 48
hours, about 60 hours, about 72 hours, or more than 72 hours after
the administration of the radiation therapy. Administration
"concurrent" with the radiation therapy means that the anti-PD-1
antibody is administered to the subject within less than 10 minutes
(before, after, or at the same time) of administration of the
radiation therapy.
[0108] In certain embodiments, the methods of the present invention
comprise administration of an additional therapeutic agent wherein
the additional therapeutic agent is an anti-cancer drug. As used
herein, "anti-cancer drug" means any agent useful to treat cancer
including, but not limited to, cytotoxins and agents such as
antimetabolites, alkylating agents, anthracyclines, antibiotics,
antimitotic agents, procarbazine, hydroxyurea, asparaginase,
corticosteroids, mytotane (O, P'-(DDD)), biologics (e.g.,
antibodies and interferons) and radioactive agents. As used herein,
"a cytotoxin or cytotoxic agent", also refers to a chemotherapeutic
agent and means any agent that is detrimental to cells. Examples
include, but are not limited to, Taxol.RTM. (paclitaxel),
temozolamide, cytochalasin B, gramicidin D, ethidium bromide,
emetine, cisplatin, mitomycin, etoposide, tenoposide, vincristine,
vinbiastine, coichicin, doxorubicin, daunorubicin, dihydroxy
anthracin dione, mitoxantrone, mithramycin, actinomycin D,
1-dehydrotestosterone, glucocorticoids, procaine, tetracaine,
lidocaine, propranolol, and puromycin and analogs or homologs
thereof.
[0109] In certain embodiments, the methods of the present invention
comprise administration of an additional therapeutic agent or
therapeutic regimen or procedure selected from the group consisting
of surgery, radiation, a programmed death ligand 1 (PD-L1)
inhibitor (e.g., an anti-PD-L1 antibody as disclosed in US Patent
Publication 2015/0203580 or atezolizumab), a lymphocyte activation
gene 3 (LAG-3) inhibitor (e.g., an anti-LAG-3 antibody), a
cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor
(e.g., ipilimumab), a glucocorticoid-induced tumor necrosis factor
receptor (GITR) inhibitor (e.g., an anti-GITR antibody), a T-cell
immunoglobulin and mucin containing -3 (TIM3) inhibitor, a B- and
T-lymphocyte attenuator (BTLA) inhibitor, a T cell immunoreceptor
with Ig and ITIM domains (TIGIT) inhibitor, a CD47 inhibitor, an
antagonist of another T-cell co-inhibitor or ligand (e.g., an
antibody to CD-28, 2B4, LY108, LAIR1, ICOS, CD160 or VISTA), a CD20
inhibitor (e.g., an anti-CD20 antibody, or a bispecific CD3/CD20
antibody) an indoleamine-2,3-dioxygenase (IDO) inhibitor, a
vascular endothelial growth factor (VEGF) antagonist [e.g., a
"VEGF-Trap" such as aflibercept or other VEGF-inhibiting fusion
protein as set forth in U.S. Pat. No. 7,087,411, or an anti-VEGF
antibody or antigen binding fragment thereof (e.g., bevacizumab, or
ranibizumab) or a small molecule kinase inhibitor of VEGF receptor
(e.g., sunitinib, sorafenib, or pazopanib)], an angiopoietin 2
(Ang2) inhibitor (e.g., nesvacumab), a transforming growth factor
beta (TGF.beta.) inhibitor, a CD38 inhibitor, an epidermal growth
factor receptor (EGFR) inhibitor (e.g., erlotinib, cetuximab), an
agonist to a co-stimulatory receptor (e.g., an agonist to
glucocorticoid-induced TNFR-related protein), an antibody to a
tumor-specific antigen [e.g., CA9, CA125, melanoma-associated
antigen 3 (MAGE3), carcinoembryonic antigen (CEA), vimentin,
tumor-M2-PK, prostate-specific antigen (PSA), mucin-1, MART-1, and
CA19-9], a vaccine (e.g., Bacillus Calmette-Guerin, a cancer
vaccine), cyclophosphamide, an adjuvant to increase antigen
presentation (e.g., granulocyte macrophage colony-stimulating
factor), a cytotoxin, a chemotherapeutic agent (e.g., dacarbazine,
temozolomide, docetaxel, doxorubicin, daunorubicin, cisplatin,
carboplatin, gemcitabine, methotrexate, mitoxantrone, oxaliplatin,
paclitaxel, and vincristine), an interleukin-6 receptor (IL-6R)
inhibitor (e.g., sarilumab), an IL-4R inhibitor (e.g., dupilumab),
an IL-10 inhibitor, a cytokine such as IL-2, IL-7, IL-21, and
IL-15, an antibody-drug conjugate (ADC) (e.g., anti-CD19-DM4 ADC,
and anti-DS6-DM4 ADC), chimeric antigen receptor T cells (e.g.,
CD19-targeted T cells), an anti-inflammatory drug (e.g.,
corticosteroids, and non-steroidal anti-inflammatory drugs), and a
dietary supplement such as anti-oxidants.
[0110] In certain embodiments, the methods of the invention
comprise administering an anti-PD-1 antibody in combination with
radiation therapy and optionally, an anti-GITR antibody to generate
long-term durable anti-tumor responses and/or enhance survival of
patients with cancer. In some embodiments, the methods of the
invention comprise administering radiation therapy prior to,
concomitantly or after administering an anti-PD-1 antibody and an
anti-GITR antibody to a cancer patient. For example, radiation
therapy may be administered in one or more doses to tumor lesions
after administration of one or more doses of the antibodies. In
some embodiments, radiation therapy may be administered locally to
a tumor lesion to enhance the local immunogenicity of a patient's
tumor (adjuvinating radiation) and/or to kill tumor cells (ablative
radiation) after systemic administration of an anti-PD-1 antibody
and/or an anti-GITR antibody. In certain embodiments, the radiation
therapy is administered to a first tumor lesion, but not to a
second tumor lesion, wherein the administration in combination with
the anti-PD-1 antibody leads to tumor regression in both the first
and second tumor lesions (abscopal effect). In certain embodiments,
the methods of the present invention comprise administering an
anti-PD-1 antibody in combination with radiation therapy and
optionally, an anti-GITR antibody to generate prolonged abscopal
effect.
[0111] In certain embodiments, an anti-PD-1 antibody may be
administered in combination with radiation therapy and a
chemotherapeutic agent (e.g., temozolomide or cyclophosphamide), a
VEGF antagonist (e.g., aflibercept), or granulocyte macrophage
colony-stimulating factor.
Pharmaceutical Compositions and Administration
[0112] The present invention includes methods which comprise
administering an anti-PD-1 antibody in combination with radiation
to a subject wherein the anti-PD-1 antibody is contained within a
pharmaceutical composition. The pharmaceutical compositions of the
invention may be formulated with suitable carriers, excipients, and
other agents that provide suitable transfer, delivery, tolerance,
and the like. A multitude of appropriate formulations can be found
in the formulary known to all pharmaceutical chemists: Remington's
Pharmaceutical Sciences, Mack Publishing Company, Easton, Pa. These
formulations include, for example, powders, pastes, ointments,
jellies, waxes, oils, lipids, lipid (cationic or anionic)
containing vesicles (such as LIPOFECTIN.TM.), DNA conjugates,
anhydrous absorption pastes, oil-in-water and water-in-oil
emulsions, emulsions carbowax (polyethylene glycols of various
molecular weights), semi-solid gels, and semi-solid mixtures
containing carbowax. See also Powell et al. "Compendium of
excipients for parenteral formulations" PDA (1998) J Pharm Sci
Technol 52:238-311.
[0113] Various delivery systems are known and can be used to
administer the pharmaceutical composition of the invention, e.g.,
encapsulation in liposomes, microparticles, microcapsules,
recombinant cells capable of expressing the mutant viruses,
receptor mediated endocytosis (see, e.g., Wu et al., 1987, J. Biol.
Chem. 262: 4429-4432). Methods of administration include, but are
not limited to, intradermal, intramuscular, intraperitoneal,
intravenous, subcutaneous, intranasal, epidural, and oral routes.
The composition may be administered by any convenient route, for
example by infusion or bolus injection, by absorption through
epithelial or mucocutaneous linings (e.g., oral mucosa, rectal and
intestinal mucosa, etc.) and may be administered together with
other biologically active agents.
[0114] A pharmaceutical composition of the present invention can be
delivered subcutaneously or intravenously with a standard needle
and syringe. In addition, with respect to subcutaneous delivery, a
pen delivery device readily has applications in delivering a
pharmaceutical composition of the present invention. Such a pen
delivery device can be reusable or disposable. A reusable pen
delivery device generally utilizes a replaceable cartridge that
contains a pharmaceutical composition. Once all of the
pharmaceutical composition within the cartridge has been
administered and the cartridge is empty, the empty cartridge can
readily be discarded and replaced with a new cartridge that
contains the pharmaceutical composition. The pen delivery device
can then be reused. In a disposable pen delivery device, there is
no replaceable cartridge. Rather, the disposable pen delivery
device comes prefilled with the pharmaceutical composition held in
a reservoir within the device. Once the reservoir is emptied of the
pharmaceutical composition, the entire device is discarded.
[0115] In certain situations, the pharmaceutical composition can be
delivered in a controlled release system. In one embodiment, a pump
may be used. In another embodiment, polymeric materials can be
used; see, Medical Applications of Controlled Release, Langer and
Wise (eds.), 1974, CRC Pres., Boca Raton, Fla. In yet another
embodiment, a controlled release system can be placed in proximity
of the composition's target, thus requiring only a fraction of the
systemic dose (see, e.g., Goodson, 1984, in Medical Applications of
Controlled Release, supra, vol. 2, pp. 115-138). Other controlled
release systems are discussed in the review by Langer, 1990,
Science 249:1527-1533.
[0116] The injectable preparations may include dosage forms for
intravenous, subcutaneous, intracutaneous and intramuscular
injections, drip infusions, etc. These injectable preparations may
be prepared by known methods. For example, the injectable
preparations may be prepared, e.g., by dissolving, suspending or
emulsifying the antibody or its salt described above in a sterile
aqueous medium or an oily medium conventionally used for
injections. As the aqueous medium for injections, there are, for
example, physiological saline, an isotonic solution containing
glucose and other auxiliary agents, etc., which may be used in
combination with an appropriate solubilizing agent such as an
alcohol (e.g., ethanol), a polyalcohol (e.g., propylene glycol,
polyethylene glycol), a nonionic surfactant [e.g., polysorbate 80,
HCO-50 (polyoxyethylene (50 mol) adduct of hydrogenated castor
oil)], etc. As the oily medium, there are employed, e.g., sesame
oil, soybean oil, etc., which may be used in combination with a
solubilizing agent such as benzyl benzoate, benzyl alcohol, etc.
The injection thus prepared is preferably filled in an appropriate
ampoule.
[0117] Advantageously, the pharmaceutical compositions for oral or
parenteral use described above are prepared into dosage forms in a
unit dose suited to fit a dose of the active ingredients. Such
dosage forms in a unit dose include, for example, tablets, pills,
capsules, injections (ampoules), suppositories, etc.
[0118] In certain embodiments, the present invention provides a
pharmaceutical formulation comprising a therapeutic amount of an
anti-PD-1 antibody and a pharmaceutical carrier. In certain
embodiments, the present invention provides for an anti-PD-1
antibody formulated in a pharmaceutical composition for use in
intravenous administration.
Administration Regimens
[0119] The present invention includes methods comprising
administering to a subject an anti-PD-1 antibody at a dosing
frequency of about four times a week, twice a week, once a week,
once every two weeks, once every three weeks, once every four
weeks, once every five weeks, once every six weeks, once every
eight weeks, once every twelve weeks, or less frequently so long as
a therapeutic response is achieved. In certain embodiments, the
present invention includes methods comprising administering to a
subject radiation therapy at a dosing frequency of about seven
times a week, about four times a week, twice a week, once a week,
once every two weeks, once every three weeks, once every four
weeks, once every five weeks, once every six weeks, once every
eight weeks, once every twelve weeks, or less frequently so long as
a therapeutic response is achieved. In certain embodiments, the
methods involve the administration of an anti-PD-1 antibody in
combination with radiation therapy at a dosing frequency of about
seven times a week, about four times a week, twice a week, once a
week, once every two weeks, once every three weeks, once every four
weeks, once every five weeks, once every six weeks, once every
eight weeks, once every nine weeks, once every twelve weeks, or
less frequently so long as a therapeutic response is achieved.
[0120] In certain embodiments, the methods of the present invention
comprise administering radiation therapy wherein the radiation
therapy is hypofractionated radiation therapy. In certain
embodiments, the hypofractionated radiation therapy comprises 2-12
fractions. In certain embodiments, the 2-12 fractions are
administered on consecutive days. In certain embodiments, the
radiation therapy is administered after administering one or more
doses of an anti-PD-1 antibody. In certain embodiments, the
anti-PD-1 antibody is administered 0.5-2 weeks before
administration of one or more fractions of radiation therapy.
[0121] According to certain embodiments of the present invention,
multiple doses of an anti-PD-1 antibody in combination with
radiation therapy may be administered to a subject over a defined
time course. The methods according to this aspect of the invention
comprise sequentially administering to a subject one or more doses
of an anti-PD-1 antibody in combination with one or more doses of
radiation. As used herein, "sequentially administering" means that
each dose of the antibody is administered to the subject at a
different point in time, e.g., on different days separated by a
predetermined interval (e.g., hours, days, weeks or months). In
certain embodiments, the methods of the present invention comprise
sequentially administering one or more doses of an anti-PD-1
antibody wherein each dose is administered 0.5-12 weeks after the
immediately preceding dose. In certain further embodiments, the
methods further comprise administering radiation therapy. The
radiation therapy may be hypofractionated radiation therapy. In
certain embodiments, the radiation therapy comprises 2-12
fractions. In some embodiments, the radiation fractions are
administered on consecutive days or alternate days. In certain
embodiments, the radiation fractions are administered once in 3
days, once in 4 days, once in 5 days, once in 6 days, once in 7
days, or a combination thereof.
[0122] In certain embodiments, the present invention includes
methods which comprise sequentially administering to the patient a
single initial dose of an anti-PD-1 antibody, followed by one or
more secondary doses of the anti-PD-1 antibody, and optionally
followed by one or more tertiary doses of the anti-PD-1 antibody.
In certain embodiments, the methods further comprise sequentially
administering to the patient a single initial dose of radiation
therapy, followed by one or more secondary doses of radiation
therapy, and optionally followed by one or more tertiary doses of
the radiation therapy. In alternate embodiments, the methods
further comprise sequentially administering one or more fractions
of hypofractionated radiation therapy.
[0123] According to certain embodiments of the present invention,
multiple doses of an anti-PD-1 antibody and radiation therapy may
be administered to a subject over a defined time course. The
methods according to this aspect of the invention comprise
sequentially administering to a subject multiple doses of an
anti-PD-1 antibody and radiation. As used herein, "sequentially
administering" means that each dose of the anti-PD-1 antibody in
combination with the radiation therapy is administered to the
subject at a different point in time, e.g., on different days
separated by a predetermined interval (e.g., hours, days, weeks or
months).
[0124] The terms "initial dose," "secondary doses," and "tertiary
doses," refer to the temporal sequence of administration. Thus, the
"initial dose" is the dose which is administered at the beginning
of the treatment regimen (also referred to as the "baseline dose");
the "secondary doses" are the doses which are administered after
the initial dose; and the "tertiary doses" are the doses which are
administered after the secondary doses. The initial, secondary, and
tertiary doses may all contain the same amount of the antibody
(anti-PD-1 antibody). In certain embodiments, however, the amount
contained in the initial, secondary and/or tertiary doses varies
from one another (e.g., adjusted up or down as appropriate) during
the course of treatment. In certain embodiments, one or more (e.g.,
1, 2, 3, 4, or 5) doses are administered at the beginning of the
treatment regimen as "loading doses" followed by subsequent doses
that are administered on a less frequent basis (e.g., "maintenance
doses"). For example, an anti-PD-1 antibody may be administered to
a patient with a cancer at a loading dose of about 1-3 mg/kg
followed by one or more maintenance doses of about 0.1 to about 20
mg/kg of the patient's body weight.
[0125] In one exemplary embodiment of the present invention, each
secondary and/or tertiary dose is administered 1/2 to 14 (e.g.,
1/2, 1, 11/2, 2, 21/2, 3, 31/2, 4, 41/2, 5, 51/2, 6, 61/2, 7, 71/2,
8, 81/2, 9, 91/2, 10, 101/2, 11, 111/2, 12, 121/2, 13, 131/2, 14,
141/2, or more) weeks after the immediately preceding dose. The
phrase "the immediately preceding dose," as used herein, means, in
a sequence of multiple administrations, the dose of anti-PD-1
antibody (and/or radiation) which is administered to a patient
prior to the administration of the very next dose in the sequence
with no intervening doses.
[0126] The methods according to this aspect of the invention may
comprise administering to a patient any number of secondary and/or
tertiary doses of an anti-PD-1 antibody (and/or radiation therapy).
For example, in certain embodiments, only a single secondary dose
is administered to the patient. In other embodiments, two or more
(e.g., 2, 3, 4, 5, 6, 7, 8, or more) secondary doses are
administered to the patient. Likewise, in certain embodiments, only
a single tertiary dose is administered to the patient. In other
embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8, or more)
tertiary doses are administered to the patient.
[0127] In embodiments involving multiple secondary doses, each
secondary dose may be administered at the same frequency as the
other secondary doses. For example, each secondary dose may be
administered to the patient 1 to 2 weeks after the immediately
preceding dose. Similarly, in embodiments involving multiple
tertiary doses, each tertiary dose may be administered at the same
frequency as the other tertiary doses. For example, each tertiary
dose may be administered to the patient 2 to 4 weeks after the
immediately preceding dose. Alternatively, the frequency at which
the secondary and/or tertiary doses are administered to a patient
can vary over the course of the treatment regimen. The frequency of
administration may also be adjusted during the course of treatment
by a physician depending on the needs of the individual patient
following clinical examination.
[0128] In certain embodiments, one or more doses of an anti-PD-1
antibody and/or radiation are administered at the beginning of a
treatment regimen as "induction doses" on a more frequent basis
(twice a week, once a week or once in 2 weeks) followed by
subsequent doses ("consolidation doses" or "maintenance doses")
that are administered on a less frequent basis (e.g., once in 2-12
weeks). In certain embodiments, one or more doses of an anti-PD-1
antibody and/or radiation are administered at the beginning of a
treatment regimen as "induction doses" on a more frequent basis
(twice a week, once a week or once in 2 weeks) followed by
subsequent doses of the anti-PD-1 antibody.
[0129] The present invention includes methods which comprise
sequentially administering one or more doses of an anti-PD-1
antibody in combination with one or more doses of radiation therapy
wherein the one or more doses are comprised in one or more
treatment cycles.
[0130] According to certain embodiments of the present invention,
the methods comprise administering at least one treatment cycle
wherein the at least one treatment cycle comprises administration
of one or more doses of an anti-PD-1 antibody, and optionally one
or more doses of radiation therapy. In certain embodiments, a
treatment cycle comprises 1-10 doses of the anti-PD-1 antibody
wherein each dose of the anti-PD-1 antibody is administered 0.5-8
weeks after the immediately preceding dose. In certain embodiments,
the methods of the present invention comprise administration of up
to 6 or 8 treatment cycles. In certain other embodiments, the
methods of the present invention comprise administration of up to
12 treatment cycles, or more as required for therapeutic effect. In
certain embodiments, at least one treatment cycle further comprises
radiation therapy. In some embodiments, the radiation therapy is
hypofractionated radiation therapy, wherein the hypofractionated
radiation therapy comprises 2-12 fractions. In certain embodiments,
the 2-12 fractions are administered on consecutive days.
[0131] The present invention includes methods comprising sequential
administration of an anti-PD-1 antibody in combination with
radiation therapy, to a patient to treat a cancer (e.g., a solid
tumor). In some embodiments, the present methods comprise
administering one or more doses of an anti-PD-1 antibody followed
by radiation therapy. In certain further embodiments, the radiation
therapy is administered in fractions (hypofractionated radiation).
In certain embodiments, the present methods comprise administering
a single dose of an anti-PD-1 antibody followed by 2-10 fractions
of radiation therapy followed by one or more doses of the anti-PD-1
antibody. In some embodiments, one or more doses of about 0.1 mg/kg
to about 20 mg/kg of an anti-PD-1 antibody may be administered
followed by radiation therapy to inhibit tumor growth and/or to
prevent tumor recurrence in a subject with a cancer (e.g., a solid
tumor). In some embodiments, the anti-PD-1 antibody is administered
at one or more doses followed by radiation therapy resulting in
increased anti-tumor efficacy (e.g., greater inhibition of tumor
growth, increased prevention of tumor recurrence as compared to an
untreated subject or a subject administered with either antibody or
radiation as monotherapy). Alternative embodiments of the invention
pertain to concomitant administration of anti-PD-1 antibody and
radiation which is administered at a similar or different frequency
relative to the anti-PD-1 antibody. In some embodiments, the
radiation therapy is administered before, after or concurrently
with the anti-PD-1 antibody.
Dosage
[0132] The amount of anti-PD-1 antibody administered to a subject
according to the methods of the present invention is, generally, a
therapeutically effective amount. As used herein, the phrase
"therapeutically effective amount" means an amount of antibody
(anti-PD-1 antibody that results in one or more of: (a) a reduction
in the severity or duration of a symptom or an indication of a
cancer, e.g., a solid tumor; (b) inhibition of tumor growth, or an
increase in tumor necrosis, tumor shrinkage and/or tumor
disappearance; (c) delay in tumor growth and development; (d)
inhibition of tumor metastasis; (e) prevention of recurrence of
tumor growth; (f) increase in survival of a subject with a cancer;
and/or (g) a reduction in the use or need for conventional
anti-cancer therapy (e.g., reduced or eliminated use of
chemotherapeutic or cytotoxic agents) as compared to an untreated
subject or a subject administered with the antibody as
monotherapy.
[0133] In the case of an anti-PD-1 antibody, a therapeutically
effective amount can be from about 0.05 mg to about 600 mg, from
about 1 mg to about 500 mg, from about 10 mg to about 450 mg, from
about 50 mg to about 400 mg, from about 75 mg to about 350 mg, or
from about 100 mg to about 300 mg of the antibody. For example, in
various embodiments, the amount of the anti-PD-1 antibody is about
0.05 mg, about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2.0 mg,
about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 50 mg,
about 60 mg, about 70 mg, about 80 mg, about 90 mg, about 100 mg,
about 110 mg, about 120 mg, about 130 mg, about 140 mg, about 150
mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about
200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg,
about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290
mg, about 300 mg, about 310 mg, about 320 mg, about 330 mg, about
340 mg, about 350 mg, about 360 mg, about 370 mg, about 380 mg,
about 390 mg, about 400 mg, about 410 mg, about 420 mg, about 430
mg, about 440 mg, about 450 mg, about 460 mg, about 470 mg, about
480 mg, about 490 mg, about 500 mg, about 510 mg, about 520 mg,
about 530 mg, about 540 mg, about 550 mg, about 560 mg, about 570
mg, about 580 mg, about 590 mg, or about 600 mg, of the anti-PD-1
antibody. In one embodiment, 250 mg of an anti-PD-1 antibody is
administered according to the methods of the present invention. In
one embodiment, 200 mg of an anti-PD-1 antibody is administered
according to the methods of the present invention. In one
embodiment, 350 mg of an anti-PD-1 antibody is administered
according to the methods of the present invention.
[0134] The amount of either anti-PD-1 antibody contained within the
individual doses may be expressed in terms of milligrams of
antibody per kilogram of subject body weight (i.e., mg/kg). In
certain embodiments, the anti-PD-1 antibody used in the methods of
the present invention may be administered to a subject at a dose of
about 0.0001 to about 100 mg/kg of subject body weight. In certain
embodiments, an anti-PD-1 antibody may be administered at dose of
about 0.1 mg/kg to about 20 mg/kg of a patient's body weight. In
certain embodiments, the methods of the present invention comprise
administration of an anti-PD-1 antibody at a dose of about 1 mg/kg,
3 mg/kg, 5 mg/kg or 10 mg/kg of a patient's body weight.
[0135] In certain embodiments, the amount of anti-PD-1 antibody
administered to a patient may be less than a therapeutically
effective amount, i.e., a subtherapeutic dose. For example, if the
therapeutically effective amount of an anti-PD-1 antibody comprises
3 mg/kg, a subtherapeutic dose comprises an amount less than 3
mg/kg, e.g., 2 mg/kg, 1.5 mg/kg, 1 mg/kg, 0.5 mg/kg or 0.3 mg/kg.
As defined herein, a "subtherapeutic dose" refers to an amount of
the anti-PD-1 antibody that does not lead to a therapeutic effect
by itself. However, in certain embodiments, a subtherapeutic dose
of an anti-PD-1 antibody is administered with a second and
optionally a third therapeutic agent to promote a therapeutic
effect.
[0136] In certain embodiments, the radiation therapy administered
to a subject in need thereof comprises 2-100 Gray (Gy). In certain
embodiments, the radiation therapy comprises 5, 7, 8, 9, 10, 11,
12, 15, 20, 23, 25, 27, 30, 35, 40, or 45 Gy. In certain other
embodiments, the radiation therapy comprises 50-100, 60-90, or
70-80 Gy. In certain embodiments, the radiation therapy is
administered in 2-12 fractions (hypofractionated radiation
therapy), wherein each fraction comprises 2-10 Gy. For example, 30
Gy of radiation is administered comprised in 5 fractions, each
fraction comprising 6 Gy.
Selected Embodiments
[0137] Selected embodiments of the present invention include the
following:
[0138] In some embodiments, the present disclosure provides a
method of treating or inhibiting the growth of a tumor in a subject
comprising: [0139] (a) selecting a subject with a cancer; and
[0140] (b) administering to the subject in need thereof one or more
doses of radiation therapy in combination with one or more doses of
a therapeutically effective amount of an antibody or
antigen-binding fragment thereof that specifically binds programmed
death 1 (PD-1) wherein the administration of the combination
results in enhanced therapeutic efficacy as compared to
administration of the antibody or radiation alone.
[0141] In one embodiment, each dose of the anti-PD-1 antibody
comprises between 0.1-20 mg/kg of the subject's body weight.
[0142] In another embodiment, each dose of the anti-PD-1 antibody
comprises 0.3, 1, 3, 5 or 10 mg/kg of the subject's body
weight.
[0143] In other embodiments, each dose of the anti-PD-1 antibody
comprises 20-400 mg.
[0144] In some embodiments, each dose of the anti-PD-1 antibody
comprises 200 mg.
[0145] In one embodiment, each dose of radiation comprises 2-80
Gray (Gy).
[0146] In another embodiment, each dose of the anti-PD-1 antibody
comprises 1, 3, or 10 mg/kg of the subject's body weight and each
dose of radiation therapy comprises 20-50 Gy.
[0147] In other embodiments, the radiation therapy is fractionated
radiation therapy.
[0148] In some embodiments, the fractionated radiation therapy
comprises 2-10 fractions.
[0149] In one embodiment, the fractionated radiation therapy
comprises 30 Gy in 5 fractions.
[0150] In another embodiment, the fractionated radiation therapy
comprises 27 Gy in 3 fractions.
[0151] In other embodiments, 4-50 doses of the anti-PD-1 antibody
are administered, and wherein each dose is administered 0.5-4 weeks
after the immediately preceding dose.
[0152] In some embodiments, each dose of the anti-PD-1 antibody is
administered 2 weeks after the immediately preceding dose.
[0153] In one embodiment, the anti-PD-1 antibody is administered
prior to, concurrent with or after the radiation therapy.
[0154] In another embodiment, the anti-PD-1 antibody is
administered prior to the radiation therapy.
[0155] In other embodiments, the anti-PD-1 antibody is administered
1 week prior to radiation therapy.
[0156] In some embodiments, enhanced therapeutic efficacy comprises
an effect selected from the group consisting of tumor regression,
abscopal effect, inhibition of tumor metastasis, reduction in
metastatic lesions over time, reduced use of chemotherapeutic or
cytotoxic agents, reduction in tumor burden, increase in
progression-free survival, increase in overall survival, complete
response, partial response, and stable disease.
[0157] In one embodiment, enhanced therapeutic efficacy comprises
tumor regression in a tumor distal to an irradiated tumor.
[0158] In another embodiment, the tumor growth is inhibited by at
least 50% as compared to a subject administered with either
antibody or radiation alone.
[0159] In other embodiments, the tumor growth is inhibited by at
least 50% as compared to a subject administered a dose of radiation
prior to an anti-PD-1 antibody.
[0160] In some embodiments, the present disclosure provides a
method of treating a tumor comprising: (a) selecting a subject with
a cancer; and (b) administering to the subject at least one
treatment cycle wherein the at least one treatment cycle comprises
1-6 doses of an anti-PD-1 antibody and wherein each dose is
administered 2 weeks after the immediately preceding dose.
[0161] In one embodiment, each dose of the anti-PD-1 antibody
comprises 1, 3, 5 or 10 mg/kg of the subject's body weight.
[0162] In another embodiment, the at least one treatment cycle
further comprises radiation therapy.
[0163] In other embodiments, the radiation therapy comprises about
20-50 Gy.
[0164] In some embodiments, the radiation therapy comprises about
27 Gy.
[0165] In one embodiment, the radiation therapy comprises about 30
Gy.
[0166] In another embodiment, the radiation therapy is fractionated
radiation therapy.
[0167] In other embodiments, the fractionated radiation therapy
comprises 2-6 fractions.
[0168] In some embodiments, the fractionated radiation therapy
comprises 3 fractions.
[0169] In one embodiment, the fractionated radiation therapy
comprises 5 fractions.
[0170] In another embodiment, the radiation therapy comprises about
27 Gy in 3 fractions.
[0171] In other embodiments, the radiation therapy comprises about
30 Gy in 5 fractions.
[0172] In some embodiments, the fractions are administered on
sequential days.
[0173] In one embodiment, the anti-PD-1 antibody is administered 1
week before radiation therapy.
[0174] In another embodiment, up to 10 treatment cycles are
administered to the subject in need thereof.
[0175] In other embodiments, 6 treatment cycles are administered to
the subject in need thereof.
[0176] In some embodiments, radiation therapy is administered in
the 1.sup.st treatment cycle.
[0177] In one embodiment, the radiation therapy comprises about
20-50 Gy.
[0178] In another embodiment, the radiation therapy comprises
hypofractionated radiation therapy.
[0179] In other embodiments, the fractionated radiation therapy
comprises 2-6 fractions.
[0180] In some embodiments, the radiation therapy comprises about
27 Gy in 3 fractions.
[0181] In one embodiment, the radiation therapy comprises about 30
Gy in 5 fractions.
[0182] In another embodiment, the fractions are administered on
sequential days.
[0183] In other embodiments, the anti-PD-1 antibody is administered
1 week before radiation therapy.
[0184] In some embodiments, each treatment cycle comprises 4 doses
of the anti-PD-1 antibody.
[0185] In one embodiment, the treatment produces a therapeutic
effect selected from the group consisting of inhibition of tumor
growth, tumor regression, reduction in the size of a tumor,
reduction in tumor cell number, delay in tumor growth, abscopal
effect, inhibition of tumor metastasis, reduction in metastatic
lesions over time, reduced use of chemotherapeutic or cytotoxic
agents, reduction in tumor burden, increase in progression-free
survival, increase in overall survival, complete response, partial
response, and stable disease.
[0186] In another embodiment, the treatment effect comprises tumor
regression in a tumor distal to an irradiated tumor in the
subject.
[0187] In other embodiments, tumor growth is delayed by at least 10
days as compared to an untreated subject.
[0188] In some embodiments, the tumor growth is inhibited by at
least 50% as compared to an untreated subject.
[0189] In one embodiment, the tumor growth is inhibited by at least
50% as compared to a subject administered with either antibody or
radiation alone.
[0190] In some embodiments, the present disclosure provides a
method of treating a tumor comprising: (a) selecting a subject with
a first solid tumor lesion and a second solid tumor lesion, wherein
the second solid tumor lesion is located distally from the first
solid tumor lesion; and (b) administering an anti-PD-1 antibody or
antigen-binding fragment thereof in combination with radiation
therapy.
[0191] In other embodiments, the radiation therapy is administered
to the first tumor lesion but not the second tumor lesion and
wherein the administration leads to tumor regression in both the
first and second tumor lesions.
[0192] In one embodiment, the anti-PD-1 antibody is administered
before radiation therapy.
[0193] In another embodiment, the subject is resistant or
inadequately responsive to, or relapsed after prior therapy.
[0194] In other embodiments, the cancer is recurrent or metastatic
cancer.
[0195] In some embodiments, the method further comprising
administering to the subject an additional therapeutic agent or
therapy, wherein the additional therapeutic agent or therapy is
selected from the group consisting of surgery, a chemotherapeutic
agent, a cancer vaccine, a programmed death ligand 1 (PD-L1)
inhibitor, a lymphocyte activation gene 3 (LAG3) inhibitor, a
cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor, a
glucocorticoid-induced tumor necrosis factor receptor (GITR)
inhibitor, a T-cell immunoglobulin and mucin-domain containing-3
(TIM3) inhibitor, a B- and T-lymphocyte attenuator (BTLA)
inhibitor, a T cell immunoreceptor with Ig and ITIM domains (TIGIT)
inhibitor, a CD47 inhibitor, an indoleamine-2,3-dioxygenase (IDO)
inhibitor, a bispecific anti-CD3/anti-CD20 antibody, a vascular
endothelial growth factor (VEGF) antagonist, an angiopoietin-2
(Ang2) inhibitor, a transforming growth factor beta (TGF.beta.)
inhibitor, an epidermal growth factor receptor (EGFR) inhibitor,
granulocyte-macrophage colony-stimulating factor (GM-CSF),
cyclophosphamide, an antibody to a tumor-specific antigen, Bacillus
Calmette-Guerin vaccine, a cytotoxin, an interleukin 6 receptor
(IL-6R) inhibitor, an interleukin 4 receptor (IL-4R) inhibitor, an
IL-10 inhibitor, IL-2, IL-7, IL-21, IL-15, an antibody-drug
conjugate, an anti-inflammatory drug, and a dietary supplement.
[0196] In one embodiment, the additional therapeutic agent is an
anti-GITR antibody.
[0197] In another embodiment, the additional therapeutic agent is
cyclophosphamide.
[0198] In other embodiments, the additional therapeutic agent is
GM-CSF.
[0199] In some embodiments, the additional therapeutic agent is
selected from the group consisting of docetaxel, carboplatin,
paclitaxel, cisplatin, gemcitabine, and pemetrexed.
[0200] In one embodiment, the anti-PD-1 antibody is administered
intravenously, subcutaneously, or intraperitoneally.
[0201] In another embodiment, the cancer comprises a solid
tumor.
[0202] In other embodiments, the solid tumor is selected from the
group consisting of colorectal cancer, ovarian cancer, prostate
cancer, breast cancer, brain cancer, cervical cancer, bladder
cancer, anal cancer, uterine cancer, colon cancer, liver cancer,
pancreatic cancer, lung cancer, endometrial cancer, bone cancer,
testicular cancer, skin cancer, kidney cancer, stomach cancer,
esophageal cancer, head and neck cancer, salivary gland cancer, and
myeloma.
[0203] In some embodiments, the solid tumor is selected from the
group consisting of hepatocellular carcinoma, non-small cell lung
cancer, head and neck squamous cell cancer, basal cell carcinoma,
breast carcinoma, cutaneous squamous cell carcinoma,
chondrosarcoma, angiosarcoma, cholangiocarcinoma, soft tissue
sarcoma, colorectal cancer, melanoma, Merkel cell carcinoma, and
glioblastoma multiforme.
[0204] In one embodiment, the anti-PD-1 antibody or antigen-binding
fragment thereof comprises the heavy chain complementarity
determining regions (HCDR1, HCDR2 and HCDR3) of a heavy chain
variable region (HCVR) comprising the amino acid sequence of SEQ ID
NO: 1 and three light chain complementarity determining regions
(LCDR1, LCDR2 and LCDR3) of a light chain variable region (LCVR)
comprising the amino acid sequence of SEQ ID NO: 2.
[0205] In another embodiment, the anti-PD-1 antibody or
antigen-binding fragment thereof comprises three HCDRs (HCDR1,
HCDR2 and HCDR3) and three LCDRs (LCDR1, LCDR2 and LCDR3), wherein
HCDR1 comprises the amino acid sequence of SEQ ID NO: 3; HCDR2
comprises the amino acid sequence of SEQ ID NO: 4; HCDR3 comprises
the amino acid sequence of SEQ ID NO: 5; LCDR1 comprises the amino
acid sequence of SEQ ID NO: 6; LCDR2 comprises the amino acid
sequence of SEQ ID NO: 7; and LCDR3 comprises the amino acid
sequence of SEQ ID NO: 8.
[0206] In other embodiments, the HCVR comprises the amino acid
sequence of SEQ ID NO: 1 and the LCVR comprises the amino acid
sequence of SEQ ID NO: 2.
[0207] In another embodiment, the anti-PD-1 antibody comprises a
heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and
a light chain comprising the amino acid sequence of SEQ ID NO:
10.
[0208] In some embodiments, the present disclosure provides a
method for inhibiting the activation and/or proliferation of T
regulatory (Treg) cells comprising: (a) selecting a subject with a
solid tumor; and (b) administering to the subject (i) an anti-PD-1
antibody or antigen-binding fragment thereof, (ii) radiation
therapy and (iii) at least one of an antibody or antigen-binding
fragment thereof that binds specifically to glucocorticoid-induced
tumor necrosis factor receptor (GITR), cyclophosphamide, GM-CSF, an
anti-LAG3 antibody, docetaxel, or carboplatin.
[0209] In one embodiment, the subject has a large tumor.
[0210] In another embodiment, the radiation dose is 2-50 Gy.
[0211] In other embodiments, the administration leads to at least
one effect selected from the group consisting of inhibition of
tumor growth, tumor regression, reduction in the size of a tumor,
reduction in tumor cell number, delay in tumor growth, abscopal
effect, inhibition of tumor metastasis, reduction in metastatic
lesions over time, reduced use of chemotherapeutic or cytotoxic
agents, reduction in tumor burden, increase in progression-free
survival, increase in overall survival, complete response, partial
response, and stable disease.
[0212] In some embodiments, the solid tumor is selected from the
group consisting of colorectal cancer, ovarian cancer, prostate
cancer, breast cancer, brain cancer, cervical cancer, bladder
cancer, anal cancer, uterine cancer, colon cancer, liver cancer,
pancreatic cancer, lung cancer, endometrial cancer, bone cancer,
testicular cancer, skin cancer, kidney cancer, stomach cancer,
esophageal cancer, head and neck cancer, salivary gland cancer, and
myeloma.
[0213] In one embodiment, the anti-PD-1 antibody or antigen-binding
fragment thereof comprises the heavy chain complementarity
determining regions (HCDR1, HCDR2 and HCDR3) of a heavy chain
variable region (HCVR) comprising the amino acid sequence of SEQ ID
NO: 1 and three light chain complementarity determining regions
(LCDR1, LCDR2 and LCDR3) of a light chain variable region (LCVR)
comprising the amino acid sequence of SEQ ID NO: 2.
[0214] In another embodiment, the anti-PD-1 antibody or
antigen-binding fragment thereof comprises three HCDRs (HCDR1,
HCDR2 and HCDR3) and three LCDRs (LCDR1, LCDR2 and LCDR3), wherein
HCDR1 comprises the amino acid sequence of SEQ ID NO: 3; HCDR2
comprises the amino acid sequence of SEQ ID NO: 4; HCDR3 comprises
the amino acid sequence of SEQ ID NO: 5; LCDR1 comprises the amino
acid sequence of SEQ ID NO: 6; LCDR2 comprises the amino acid
sequence of SEQ ID NO: 7; and LCDR3 comprises the amino acid
sequence of SEQ ID NO: 8.
[0215] In other embodiments, the HCVR comprises the amino acid
sequence of SEQ ID NO: 1 and the LCVR comprises the amino acid
sequence of SEQ ID NO: 2.
[0216] In one embodiment, the anti-PD-1 antibody comprises a heavy
chain comprising the amino acid sequence of SEQ ID NO: 9 and a
light chain comprising the amino acid sequence of SEQ ID NO:
10.
[0217] In some embodiments, the present disclosure provides a
method of treating or inhibiting the growth of a tumor comprising:
[0218] (a) selecting a subject with a skin cancer; and [0219] (b)
administering to the subject in need thereof a therapeutically
effective amount of an antibody or antigen-binding fragment thereof
that specifically binds PD-1.
[0220] In one embodiment, said antibody or antigen-binding fragment
thereof that specifically binds PD-1 is administered as a
monotherapy.
[0221] In another embodiment, said skin cancer is an UV-associated
skin cancer.
[0222] In other embodiments, said skin cancer is selected from the
group consisting of cutaneous squamous cell carcinoma (CSCC), basal
cell carcinoma (BCC), Merkel cell carcinoma and melanoma.
[0223] In some embodiments, with the proviso that said skin cancer
is not a squamous cell carcinoma of head and neck.
[0224] In one embodiment, said skin cancer is a metastatic,
unresectable and/or locally advanced cancer.
[0225] In another embodiment, said skin cancer is BCC, and wherein
said patient is intolerant to or progresses after treatment with a
hedgehog pathway inhibitor.
[0226] In other embodiments, said antibody or antigen-binding
fragment thereof is administered as one or more doses, wherein each
dose is administered 0.5 to 4 weeks after the immediately preceding
dose.
[0227] In some embodiments, each dose is administered 2 weeks after
the immediately preceding dose.
[0228] In one embodiment, each dose comprises 1, 3 or 10 mg/kg of
subject's body weight.
[0229] In another embodiment, said antibody or antigen-binding
fragment thereof that specifically binds PD-1 is an antibody as
defined in any one of the preceding embodiments.
[0230] In some embodiments, the present disclosure provides a
method of treating or inhibiting the growth of a tumor in a
subject, the method comprising: selecting a subject with a brain
cancer; and administering to the subject in need thereof a
therapeutically effective amount of an antibody or antigen-binding
fragment thereof that specifically binds PD-1.
[0231] In one embodiment, the subject has glioblastoma multiforme
(GBM).
[0232] In another embodiment, the subject has newly diagnosed
GBM.
[0233] In other embodiments, the subject is .gtoreq.65 years of
age.
[0234] In some embodiments, the anti-PD-1 antibody or
antigen-binding fragment thereof is administered as one or more
doses, wherein each dose is administered 0.5 to 4 weeks after the
immediately preceding dose.
[0235] In one embodiment, each dose is administered 2 weeks after
the immediately preceding dose.
[0236] In another embodiment, each dose comprises 1, 3 or 10 mg/kg
of subject's body weight.
[0237] In other embodiments, the method further comprising
administering radiation therapy to the subject in need thereof.
[0238] In some embodiments, the radiation therapy is
hypofractionated radiation therapy.
[0239] In one embodiment, the subject is administered 20-50 Gy of
radiation in 2-20 fractions.
[0240] In another embodiment, the subject is administered radiation
therapy 1 week after the first dose of the anti-PD-1 antibody.
[0241] In other embodiments, the one or more doses of anti-PD-1
antibody are comprised in one or more cycles of treatment, wherein
each cycle comprises 1-6 doses of the anti-PD-1 antibody.
[0242] In some embodiments, each cycle of treatment comprises 4
doses of the anti-PD-1 antibody, wherein each dose is administered
2 weeks after the immediately preceding dose.
[0243] In one embodiment, each dose comprises 1, 3 or 10 mg/kg of
subject's body weight.
[0244] In another embodiment, the first cycle of treatment further
comprises radiation therapy.
[0245] In other embodiments, the radiation therapy is
hypofractionated radiation therapy.
[0246] In some embodiments, the subject is administered 20-50 Gy of
radiation in 2-20 fractions.
[0247] In one embodiment, the subject is administered 30 Gy in 5
daily fractions.
[0248] In another embodiment, the radiation therapy is administered
one week after the administration of the anti-PD-1 antibody.
[0249] In other embodiments, the method further comprises
administering an anti-angiogenic agent to the subject if the
subject develops intracranial edema following administration of the
anti-PD-1 antibody.
[0250] In some embodiments, the anti-angiogenic agent is selected
from the group consisting of a vascular endothelial growth factor
(VEGF) inhibitor and an angiopoietin-2 (Ang-2) inhibitor.
[0251] In one embodiment, the anti-angiogenic agent is bevacizumab
or aflibercept.
[0252] In other embodiments, said antibody or antigen-binding
fragment thereof that specifically binds PD-1 is an antibody as
defined in any one of the preceding embodiments.
EXAMPLES
[0253] The following examples are put forth so as to provide those
of ordinary skill in the art with a complete disclosure and
description of how to make and use the methods and compositions of
the invention, and are not intended to limit the scope of what the
inventors regard as their invention. Efforts have been made to
ensure accuracy with respect to numbers used (e.g., amounts,
temperature, etc.) but some experimental errors and deviations
should be accounted for. Unless indicated otherwise, parts are
parts by weight, molecular weight is average molecular weight,
temperature is in degrees Centigrade, and pressure is at or near
atmospheric.
Example 1
In Vivo Efficacy of Anti-PD-1 Antibody in Combination with
Radiation Therapy Against MC38 Tumors
[0254] In this Example, the effect of PD-1 blockade in combination
with radiation therapy was examined against established MC38 tumors
in mice.
[0255] 5.times.10.sup.5 MC38 colon carcinoma cells were implanted
subcutaneously into the right flanks of female C57BL/6 mice
(Jackson Laboratory). Treatment was initiated on day 9 post
implantation when average tumor volumes reached approximately 100
mm.sup.3. The mice were randomly assigned to receive either isotype
control (2A3, BioXcell) or PD-1 blocking antibody (RMP1-14,
BioXCell) at 5 mg/kg, 2.times. a week, for a total of 5
intraperitoneal injections. One day post the start of antibody
treatment, mice assigned to the radiotherapy groups received 12 Gy
of irradiation to their right flank tumors. Radiotherapy was
delivered using the RS 2000 Biological Research Irradiator (Rad
Source) to anesthesized mice (ketamine/xylazine) shielded with
partial body irradiation fixtures (Precision X-ray) and lead
sheeting (Images Scientific Instruments). Tumor growth was
evaluated 3.times. a week until days 70-80 when all mice were
euthanized. FIG. 1 shows study design of the experiment which
includes dosing of the anti-PD-1 antibody and radiation.
[0256] FIG. 2 and Table 1 show the average tumor volumes in mice
administered with the anti-PD-1 antibody alone or in combination
with radiation.
TABLE-US-00001 TABLE 1 Average tumor volumes in mice administered
with anti-PD-1 antibody alone or in combination with radiation
Average tumor volume (mm.sup.3 .+-. SEM) Days post- Anti-PD-1
Isotype control + Anti-PD-1 antibody + implantation Isotype control
antibody radiation radiation 4 15.39 .+-. 3.70 8.62 .+-. 3.02 13.28
.+-. 3.44 10.78 .+-. 3.01 7 41.11 .+-. 8.81 38.90 .+-. 7.09 49.86
.+-. 11.38 39.36 .+-. 6.32 8 68.64 .+-. 10.01 72.03 .+-. 12.13
74.03 .+-. 14.83 73.70 .+-. 14.86 10 85.82 .+-. 4.10 94.98 .+-.
22.68 100.88 .+-. 11.46 122.05 .+-. 15.05 14 725.87 .+-. 68.45
834.37 .+-. 206.70 320.10 .+-. 58.80 300.67 .+-. 60.74 16 1023.61
.+-. 191.41 1123.51 .+-. 310.04 276.17 .+-. 82.81 219.29 .+-. 45.94
18 1573.64 .+-. 263.65 1710.30 .+-. 424.30 353.45 .+-. 121.47
250.17 .+-. 74.70 21 2688.69 .+-. 502.39 2569.65 .+-. 633.35 494.53
.+-. 211.90 188.98 .+-. 105.80 23 597.70 .+-. 267.02 141.37 .+-.
73.76 25 671.93 .+-. 347.76 134.87 .+-. 75.67 28 879.64 .+-. 403.70
147.82 .+-. 70.88 30 1081.39 .+-. 426.80 133.13 .+-. 88.88 32
177.73 .+-. 112.81 36 233.44 .+-. 152.91 39 258.23 .+-. 158.67 42
316.58 .+-. 160.91 44 332.73 .+-. 152.43 46 456.13 .+-. 209.45 49
564.05 .+-. 262.32 51 925.92 .+-. 434.29 53 747.14 .+-. 350.90 56
1290.10 .+-. 584.62
[0257] PD-1 (RMP1-14) blockade synergized with local irradiation
(XRT) and significantly induced tumor regression (4/6 mice) in
MC38-tumor bearing mice, in comparison to XRT+isotype control
treated mice (2/6 mice). Tumor growth was inhibited or delayed in
mice treated with anti-PD-1 antibody in combination with radiation.
Mice treated with anti-PD-1 antibody and radiation took more than
40 days to reach 500 mm.sup.3 tumor volume as compared to mice on
monotherapy which took less than 20 days to reach 500 mm.sup.3
tumor volume. Tumor regression was sustained for up to 4 weeks for
the combo (XRT+anti-PD-1 antibody) treated group (1 out of the 4
rejected tumors relapsed at this time point) versus 1.5 weeks for
the XRT+isotype treated group (1 out of the 2 rejected tumors
relapsed). In this tumor model, PD-1 blockade as a monotherapy did
not have an effect on primary tumor growth.
TABLE-US-00002 TABLE 2 Percent survival of mice administered with
anti-PD-1 antibody alone or in combination with radiation days post
Radiation + Radiation + implantation isotype Anti-PD-1 isotype
anti-PD-1 4 100 100 100 100 7 100 100 100 100 8 100 100 100 100 10
100 100 100 100 14 100 100 100 100 16 100 100 100 100 18 100 100
100 100 21 100 100 100 100 23 100 83 100 100 25 67 50 100 100 28 33
50 100 100 30 17 17 100 100 32 0 17 67 100 36 0 0 67 100 44 0 0 50
100 46 0 0 50 100 49 0 0 50 100 51 0 0 33 100 53 0 0 17 100 56 0 0
17 100 58 0 0 17 83 60 0 0 17 50 63 0 0 17 50 65 0 0 17 50 81 0 0
17 50 85 0 0 17 50
[0258] The therapeutic efficacy of the combinatorial treatment
(XRT+anti-PD-1 antibody) was demonstrated by the statistically
increased overall survival of this group (50% alive at 70 days post
tumor implantation) in comparison to all other treatment groups:
isotype control (0% alive at d70), anti-PD-1 antibody treatment (0%
alive at d70), and XRT+isotype treated mice (17% alive at d70)
(FIG. 3; Table 2).
Example 2
In Vivo Efficacy of Anti-PD-1 Antibody and Radiation Therapy
Against B16 Tumors
[0259] In this Example, the anti-tumor effect of anti-mouse PD-1
antibody in combination with radiation therapy was examined against
established B16 tumors in mice.
[0260] 2.times.10.sup.5 B16F10.9 melanoma cells were implanted
subcutaneously into the right flanks of female C57BL/J6 mice
(Jackson Laboratory). Treatment was initiated when average tumor
volumes reached approximately 150 mm.sup.3. The mice were randomly
assigned to receive either isotype control (2A3, BioXcell) or PD-1
blocking antibody (RMP1-14, BioXCell) at 5 mg/kg, 2.times. a week,
for a total of 5 intraperitoneal injections. One day post the start
of antibody treatment, mice assigned to the radiotherapy groups
received 8 Gy of irradiation to their right flank tumors.
Radiotherapy was delivered using the RS 2000 Biological Research
Irradiator (Rad Source) to anesthesized mice (ketamine/xylazine)
shielded with partial body irradiation fixtures (Precision X-ray)
and lead sheeting (Images Scientific Instruments). Tumor growth was
evaluated 3.times. a week until days 70-80 when all mice were
euthanized. FIG. 4 shows study design of the experiment which
includes dosing of the anti-PD-1 antibody and radiation.
[0261] PD-1 (RMP1-14) blocking antibody treatment in combination
with local irradiation (XRT) delayed B16 primary tumor growth in
comparison to XRT or anti-PD-1 antibody monotherapy (FIG. 5; Table
3).
TABLE-US-00003 TABLE 3 Average tumor volumes in mice administered
with anti-PD-1 antibody alone or in combination with radiation
Average tumor volume mm.sup.3 .+-. SEM Days post- Anti-PD-1 Isotype
control + Anti-PD-1 antibody + implantation Isotype control
antibody radiation radiation 6 5.75 .+-. 5.75 8.32 .+-. 8.32 13.79
.+-. 13.79 1.14 .+-. 0.85 8 55.98 .+-. 27.15 62.66 .+-. 15.80 57.18
.+-. 37.79 50.57 .+-. 38.33 12 157.34 .+-. 37.88 144.36 .+-. 37.81
237.84 .+-. 71.27 177.91 .+-. 59.17 15 334.71 .+-. 61.71 193.32
.+-. 35.53 510.95 .+-. 171.15 372.53 .+-. 147.50 18 621.43 .+-.
136.09 363.80 .+-. 45.72 739.62 .+-. 244.10 440.33 .+-. 194.90 20
939.69 .+-. 158.50 561.64 .+-. 49.44 677.48 .+-. 175.75 486.35 .+-.
207.65 22 1329.77 .+-. 202.01 772.16 .+-. 118.26 759.15 .+-. 235.94
512.67 .+-. 220.30 25 2602.08 .+-. 434.08 1343.42 .+-. 120.65
1182.27 .+-. 336.32 789.80 .+-. 299.24 27 1533.03 .+-. 179.88
1321.13 .+-. 400.18 877.82 .+-. 296.51 29 2104.46 .+-. 350.48
944.67 .+-. 333.16 33 1024.71 .+-. 321.20 36 1237.68 .+-.
340.52
TABLE-US-00004 TABLE 4 Percent survival of mice administered with
anti-PD-1 antibody alone or in combination with radiation days post
Radiation + Radiation + implantation isotype Anti-PD-1 isotype
anti-PD-1 0 100 100 100 100 6 100 100 100 100 8 100 100 100 100 12
100 100 100 100 15 100 100 100 100 18 100 100 100 100 20 100 100
100 100 22 100 100 100 100 25 100 100 100 100 27 40 100 100 100 29
0 100 80 100 33 0 80 80 100 36 0 20 60 100 39 0 0 60 83 41 0 0 60
83 43 0 0 20 67 46 0 0 20 67 48 0 0 20 50 50 0 0 0 50 53 0 0 0 33
55 0 0 0 33 57 0 0 0 33 60 0 0 0 17 62 0 0 0 17 64 0 0 0 17 66 0 0
0 0
[0262] Combination of XRT plus anti-PD-1 antibody treatment
increased overall survival (50% alive at d50 post implantation) in
comparison to XRT alone (0% alive by d50), anti-PD-1 antibody alone
(0% alive by d40), and isotype alone (0% alive by d30) (FIG. 6;
Table 4).
Example 3
In Vivo Efficacy of Anti-PD-1 Antibody in Combination with
Radiation Therapy Against Metastatic Lung Tumors
[0263] In this Example, the effect of PD-1 blockade in combination
with radiation therapy was examined against established and
metastatic tumors in mice.
[0264] 1.5.times.10.sup.5 4T1 mammary carcinoma cells were
implanted subcutaneously into the right flanks of female Balb/c
mice (Jackson Laboratory). Treatment was initiated on day 12 post
implantation when average tumor volumes reached approximately 100
mm.sup.3. The mice were randomly assigned to receive either isotype
control (2A3, BioXcell) or PD-1 blocking antibody (RMP1-14,
BioXCell) at 5 mg/kg, 2.times. a week, for a total of 5
intraperitoneal injections. One day post the start of antibody
treatment, mice assigned to the radiotherapy groups received 8 Gy
of irradiation to their right flank tumors. Radiotherapy was
delivered using the RS 2000 Biological Research Irradiator (Rad
Source) to anesthesized mice (ketamine/xylazine) shielded with
partial body irradiation fixtures (Precision X-ray) and lead
sheeting (Images Scientific Instruments). Tumor growth was
evaluated 3.times. a week until day 28 when all mice were
euthanized in order to evaluate lung metastatic burden using a
clonogenic assay. Briefly, lung tissue was dissociated with
DNAse/Liberase TL (Roche) and cultured in media supplemented with
60 uM 6-thioguanine. After two weeks in culture, the plates were
counterstained with methylene blue and the number of colonies
enumerated (one colony represents one metastatic 4T1 cell).
[0265] It is expected that treatment with anti-PD-1 antibody in
combination with radiation promotes tumor regression as well as
mediates suppression of metastatic growth.
Example 4
In Vivo Efficacy of Anti-Human PD-1 Antibody in Combination with
Radiation Therapy Promotes Abscopal Effect Against Distal
Tumors
[0266] In this Example, the effect of PD-1 blockade in combination
with radiation therapy was examined against primary and distal MC38
tumors in mice humanized for PD-1 using anti-human PD-1
antibodies.
[0267] The exemplary anti-PD-1 antibody used in this Example is
REGN2810 (also known as H4H7798N as disclosed in US20150203579), a
fully human monoclonal anti-PD-1 antibody comprising a heavy chain
comprising the amino acid sequence of SEQ ID NO: 9 and a light
chain comprising the amino acid sequence of SEQ ID NO: 10; an
HCVR/LCVR amino acid sequence pair comprising SEQ ID NOs: 1/2; and
heavy and light chain CDR sequences comprising SEQ ID NOs: 3-8.
[0268] Mice humanized for PD-1 were engineered using
VelociGene.RTM. technology (Valenzuela et al 2003, Nat. Biotechnol.
21: 652-659; US Patent Application Publication 2015/0366174).
[0269] 5.times.10.sup.5 MC38 colon carcinoma cells were implanted
subcutaneously into female humanized PD-1/C57BL/6 mice on day 0
(primary tumor on right flank) and day 3 (tumor on left flank;
distal tumor). Treatment was initiated when the average primary
tumor volumes reached approximately 150 mm.sup.3. The mice were
randomly assigned to receive either isotype control or PD-1
blocking antibody (REGN2810) at 5 mg/kg, 2.times. a week, for a
total of 8 intra-peritoneal injections. One day post the start of
antibody treatment, mice assigned to the radiotherapy groups
received 8 Gy of irradiation to their right flank tumors.
Radiotherapy was delivered using the RS 2000 Biological Research
Irradiator (Rad Source) to anesthetized mice (ketamine/xylazine)
shielded with partial body irradiation fixtures (Precision X-ray)
and lead sheeting (Images Scientific Instruments). Primary and
secondary tumor growth was evaluated 3.times. a week until days
70-80 when all mice were euthanized. FIG. 7 shows the study design
of the experiment which includes dosing of the anti-PD-1 antibody
and radiation.
Results
[0270] Primary Tumor: PD-1 blockade (REGN2810) treatment synergized
with local irradiation (XRT) in rejecting primary MC38 tumors (4
out of 6 tumor free mice) in comparison to XRT+isotype control
treated mice (1/6 tumor free mice). Tumor regression was sustained
in the combo treated group for 8 weeks until end of experiment
versus three weeks for the XRT+isotype treated group (the rejected
tumor relapsed at this time point) (FIG. 8; Table 5).
TABLE-US-00005 TABLE 5 Average primary tumor volumes in mice
administered with REGN2810 alone or in combination with radiation
Average tumor volume (mm.sup.3 .+-. SEM) Days post- Isotype control
+ REGN2810 + implantation Isotype control REGN2810 radiation
radiation 4 8.47 .+-. 5.22 13.86 .+-. 7.13 9.02 .+-. 3.07 3.75 .+-.
3.75 5 14.32 .+-. 4.76 22.08 .+-. 2.69 27.54 .+-. 4.90 10.00 .+-.
3.17 7 39.43 .+-. 5.36 35.47 .+-. 6.73 42.72 .+-. 8.00 32.80 .+-.
10.60 9 62.68 .+-. 12.03 84.73 .+-. 20.91 68.27 .+-. 11.65 47.26
.+-. 11.65 10 111.78 .+-. 24.45 108.15 .+-. 27.17 96.18 .+-. 18.07
75.13 .+-. 11.56 11 147.89 .+-. 36.11 176.67 .+-. 43.99 111.87 .+-.
10.12 110.27 .+-. 25.02 12 171.76 .+-. 41.23 154.97 .+-. 44.16
153.69 .+-. 16.06 121.88 .+-. 29.86 14 304.95 .+-. 94.96 221.70
.+-. 65.96 147.22 .+-. 19.77 144.71 .+-. 34.28 17 609.24 .+-.
227.64 296.69 .+-. 95.14 116.65 .+-. 27.03 135.26 .+-. 57.41 19
369.17 .+-. 128.37 114.85 .+-. 38.73 124.59 .+-. 55.50 21 442.13
.+-. 158.80 127.77 .+-. 36.92 130.00 .+-. 78.30 24 641.92 .+-.
275.23 198.40 .+-. 67.81 113.25 .+-. 74.51 26 896.32 .+-. 389.54
252.51 .+-. 98.39 116.90 .+-. 101.35 28 1200.99 .+-. 498.27 331.78
.+-. 125.55 120.05 .+-. 89.32 31 477.34 .+-. 181.97 168.62 .+-.
151.18 33 189.07 .+-. 154.91 35 164.70 .+-. 127.33 38 216.32 .+-.
159.47 40 219.35 .+-. 156.39 42 292.37 .+-. 204.83
[0271] PD-1 blockade as a monotherapy mediated rejection in 2 out
of 5 mice; however, 1 of the mice which rejected its primary tumor,
succumbed to secondary tumor growth, resulting in only 1 mouse
surviving to the end of the experiment. The potent therapeutic
efficacy of combinatorial treatment (XRT+REGN2810) was demonstrated
by statistically increased overall survival (.about.67% alive at 70
days post tumor implantation) in comparison to all other groups:
isotype control or XRT alone (0% alive at d70), and REGN2810 as a
monotherapy (20% alive at d70) (FIG. 9; Table 6).
TABLE-US-00006 TABLE 6 Percent survival of mice administered with
REGN2810 alone or in combination with radiation days post Radiation
+ Radiation + implantation isotype REGN2810 isotype REGN2810 0 100
100 100 100 4 100 100 100 100 5 100 100 100 100 7 100 100 100 100 9
100 100 100 100 10 100 100 100 100 11 100 100 100 100 12 100 100
100 100 14 100 100 100 100 17 100 100 100 100 19 83 100 100 100 21
83 100 100 100 24 83 100 100 100 26 50 100 100 100 28 33 100 100
100 31 33 67 100 100 33 33 33 83 100 35 33 33 67 100 38 33 33 50
100 40 17 17 50 100 42 17 17 50 100 44 17 17 50 100 49 0 17 17 83
54 17 0 83 56 17 0 83 59 17 0 83 61 17 0 67 63 17 0 67
[0272] Distal tumor: REGN2810 in combination with XRT significantly
promoted an abscopal effect (rejection of a tumor implanted at a
distal site) with 5 out of 6 tumor free mice in comparison to XRT
alone (2/6 distal tumor free), REGN2810 alone (1/6 distal tumor
free), and isotype control treated mice (1/6 distal tumor free)
(FIG. 10; Table 7).
TABLE-US-00007 TABLE 7 Average distal tumor volumes in mice
administered with REGN2810 alone or in combination with radiation
Average tumor volume (mm.sup.3 .+-. SEM) Days post- Isotype Isotype
control + REGN2810 + implantation control REGN2810 radiation
radiation 1 0 0 0 0 2 0 0 0 0 4 0 0 0 0 6 0 0 0 0 7 11.13 .+-.
11.13 0 0 0 8 20.01 .+-. 20.01 0 3.26 .+-. 3.26 0 9 25.43 .+-.
25.43 7.00 .+-. 7.00 9.75 .+-. 9.75 0 11 31.93 .+-. 29.32 42.24
.+-. 26.88 28.81 .+-. 17.01 12.13 .+-. 12.13 14 56.20 .+-. 34.46
59.40 .+-. 29.41 57.64 .+-. 29.91 20.93 .+-. 14.07 16 58.64 .+-.
29.57 95.78 .+-. 52.87 14.03 .+-. 9.79 18 151.71 .+-. 76.86 115.16
.+-. 59.43 22.87 .+-. 16.20 21 207.13 .+-. 128.83 227.22 .+-.
105.46 17.01 .+-. 17.01 23 333.43 .+-. 220.57 335.13 .+-. 148.86
9.51 .+-. 9.51 25 506.55 .+-. 355.36 503.71 .+-. 211.49 11.45 .+-.
11.45 28 968.92 .+-. 418.57 31.59 .+-. 31.59 30 57.40 .+-. 57.40 32
83.94 .+-. 83.94 35 133.89 .+-. 133.89 37 224.65 .+-. 224.65
Example 5
In Vivo Efficacy of Anti-PD-1 Antibody in Combination with
Radiation Therapy and a GITR Antagonist Against MC38 Tumors
[0273] In this Example, the effect of PD-1 blockade in combination
with radiation therapy and a glucocorticoid-induced tumor necrosis
factor receptor (GITR) antagonist (an anti-GITR antibody) was
examined against large established MC38 tumors in mice.
[0274] 5.times.10.sup.5 MC38 colon carcinoma cells were implanted
subcutaneously into the right flanks of female C57BL/6 mice
(Jackson Laboratory). Treatment was initiated when average tumor
volumes reached approximately 150-200 mm.sup.3 (categorized as
"large tumors"). The mice were randomly assigned to receive either
isotype control antibody (2A3 or LTF-2; BioXcell), an anti-PD-1
antibody (RMP1-14; BioXcell), an anti-GITR antibody (DTA-1;
BioXcell), or the combination of both anti-PD-1 antibody and
anti-GITR antibody at 5 mg/kg, 2.times. a week, for a total of 5
intraperitoneal injections. One day post the start of antibody
treatment, mice assigned to the radiotherapy groups received 8 Gy
of irradiation to their right flank tumors. Radiotherapy was
delivered using the RS 2000 Biological Research Irradiator (Rad
Source) to anesthesized mice (ketamine/xylazine) shielded with
partial body irradiation fixtures (Precision X-ray) and lead
sheeting (Images Scientific Instruments). Tumor growth was
evaluated 3.times. a week until days 70-80 when all mice were
euthanized. FIG. 11 shows study design of the experiment which
includes dosing of the anti-PD-1 antibody, anti-GITR antibody, and
radiation.
[0275] The anti-PD-1 antibody (RMP1-14) treatment synergized with
local irradiation (XRT) and the anti-GITR antibody in rejecting
large MC38 tumors (4 out of 6 tumor free mice) in comparison to
XRT+anti-GITR antibody (2/6 tumor free), XRT+anti-PD-1 antibody
(2/6 rejected), or XRT alone (0/6 tumor free) treated mice.
Monotherapy (with anti-PD-1 antibody or anti-GITR antibody) or
combinatorial treatment (anti-PD-1 antibody+anti-GITR antibody) had
minimal effect on tumor growth with anti-PD-1 antibody or anti-GITR
antibody treatment mediating rejection in 1/5 mice and the
combination of the two antibodies mediating rejection in 2/5 mice.
Tumor regression was sustained for up to 6.5 weeks after the start
of treatment for the triple combo treated mice versus 2 weeks for
the XRT+anti-GITR antibody treated mice (FIG. 12).
TABLE-US-00008 TABLE 8 Percent survival of mice administered
anti-PD-1 antibody in combination with radiation and anti-GITR
antibody Radiation + Days post Anti-PD-1 + Radiation + Radiation +
Radiation + anti-PD-1 + implantation Isotype Anti-PD-1 Anti-GITR
anti-GITR isotype anti-PD-1 anti-GITR anti-GITR 0 100 100 100 100
100 100 100 100 28 100 100 80 100 100 100 100 100 32 80 80 80 80
100 100 100 100 35 60 60 40 60 100 80 83 100 38 20 20 20 60 40 80
50 100 41 0 20 20 60 20 60 50 100 48 0 20 20 60 0 60 50 83 56 0 20
20 40 0 40 33 67 66 0 20 20 40 0 40 17 67 77 0 20 20 40 0 40 17
67
[0276] Table 8 and FIG. 13 show the survival of mice administered
with anti-PD-1 antibody in combination with radiation therapy and
anti-GITR antibody. Further, administration of anti-PD-1
antibody+XRT led to tumor regression of very large tumors
(.about.300 mm.sup.3).
Example 6
In Vivo Efficacy of Anti-PD-1 Antibody in Combination with
Radiation Therapy and a GITR Antagonist Against B16 Tumors
[0277] In this Example, the effect of PD-1 blockade in combination
with radiation therapy and a GITR antagonist (anti-GITR antibody)
was examined against established B16 tumors in mice.
[0278] 2.5.times.10.sup.5 B16F10.9 melanoma cells were implanted
subcutaneously into the right flanks of female C57BL/6 mice
(Jackson Laboratory). Treatment was initiated when average tumor
volumes reached approximately 100 mm.sup.3. The mice were randomly
assigned to receive either isotype controls (2A3, LTF-2; BioXcell),
anti-PD-1 antibody (RMP1-14, BioXcell), anti-GITR antibody (DTA-1;
BioXcell), or the combination of both the anti-PD-1 antibody and
anti-GITR antibody at 5 mg/kg, 2.times. a week, for a total of 5
intraperitoneal injections. One day post the start of antibody
treatment, mice assigned to the radiotherapy groups received 8 Gy
of irradiation to their right flank tumors. Radiotherapy was
delivered using the RS 2000 Biological Research Irradiator (Rad
Source) to anesthesized mice (ketamine/xylazine) shielded with
partial body irradiation fixtures (Precision X-ray) and lead
sheeting (Images Scientific Instruments). Tumor growth was
evaluated 3.times. a week until days 70-80 when all mice were
euthanized.
[0279] It is expected that anti-PD-1 antibody in combination with
the anti-GITR antibody and radiation therapy promotes more tumor
regression and delay in tumor growth than monotherapy or ant-PD-1
antibody in combination with radiation therapy.
Example 7
Clinical Trial of Anti-PD-1 Antibody and Radiation Therapy in
Patients with Advanced Solid Tumors
[0280] This study is an open-label, multicenter, dose escalation
study with multiple dose escalation and expansion arms to
investigate the efficacy, safety, and tolerability of anti-PD-1
antibody alone and in combination with other anti-cancer therapies
(including radiation therapy), in adult patients with advanced
solid tumors.
[0281] The exemplary anti-PD-1 antibody used in this study is
REGN2810 (also known as H4H7798N as disclosed in US20150203579), a
fully human monoclonal anti-PD-1 antibody comprising a heavy chain
comprising the amino acid sequence of SEQ ID NO: 9 and a light
chain comprising the amino acid sequence of SEQ ID NO: 10; an
HCVR/LCVR amino acid sequence pair comprising SEQ ID NOs: 1/2; and
heavy and light chain CDR sequences comprising SEQ ID NOs: 3-8.
Study Objectives
[0282] The primary objective of the study is to characterize the
safety, tolerability, dose limiting toxicities (DLTs) of REGN2810
administered intravenously (IV) as monotherapy, or in combination
with targeted radiation (with the intent to have this serve as an
immuno-stimulatory, rather than primarily tumor-ablative therapy),
low-dose cyclophosphamide (a therapy shown to inhibit regulatory
T-cell responses), granulocyte macrophage colony-stimulating
factor, carboplatin, docetaxel, or a combination thereof in
patients with advanced malignancies.
[0283] The secondary objectives of the study are: (1) to determine
a recommended phase 2 dose (RP2D) of REGN2810 as monotherapy and in
combination with other anti-cancer therapies (targeted radiation,
low-dose cyclophosphamide, or both); (2) to describe preliminary
antitumor activity of REGN2810, alone and with each combination
partner (s); (3) to characterize the PK of REGN2810 as monotherapy
and in combination with other anti-cancer therapies (targeted
radiation, low-dose cyclophosphamide, or both); and (4) to assess
immunogenicity of REGN2810.
Rationale for Study Design
[0284] The 3+3 model for the dose-escalation phase of this study is
designed to permit evaluation of the safety of REGN2810, both as
monotherapy at different dose levels, and in combination with
immune-enhancing treatments: cyclophosphamide; limited, targeted
radiation delivered in 1 of 2 dosing regimens; or combined
radiation and cyclophosphamide.
[0285] Once the tolerability of REGN2810 has been established alone
and in combination with radiation and/or cyclophosphamide, multiple
expansion cohorts using various combinations or monotherapy in
select indications [NSCLC, BC, HNSCC, CSCC, tumors with MSI
(colorectal, endometrial, prostate, or other tumor types), HCC, and
other advanced solid tumors] are added in order to further confirm
the safety and evaluate the augmentation of antitumor activity.
Granulocyte-macrophage colony-stimulating factor (GM-CSF),
carboplatin, and/or docetaxel are added to some of these
combinations.
[0286] Table 9 lists some of the cohorts using REGN2810 monotherapy
and in combination with other treatment modalities.
TABLE-US-00009 TABLE 9 A list of some of the expansion cohorts for
REGN2810 monotherapy and combination therapies Cohort Indication
Treatment 1 Non-small-cell lung cancer (NSCLC) Flat dose - 200 mg
REGN2810 2 NSCLC 3 mg/kg REGN2810 + radiotherapy (9 Gy .times. 3) 3
Head and neck squamous cell carcinoma 3 mg/kg REGN2810 +
radiotherapy (9 Gy .times. 3) + (HNSCC) cyclophosphamide + GM-CSF 4
Breast cancer (BC) 3 mg/kg REGN2810 + radiotherapy (9 Gy .times. 3)
+ cyclophosphamide 5 Advanced solid tumors - Previous treatment
with 3 mg/kg REGN2810 + radiotherapy (9 Gy .times. 3) + an anti
PD-1/PD-L1 antibody cyclophosphamide + GM-CSF 6 Advanced solid
tumors (excluding NSCLC, 3 mg/kg REGN2810 + radiotherapy (9 Gy
.times. 3) + HNSCC, and BC) cyclophosphamide + GM-CSF 7 Metastatic
(M1) cutaneous squamous cell 3 mg/kg REGN2810 carcinoma (CSCC) 8
Locally and/or regionally advanced CSCC (M0) 3 mg/kg REGN2810 that
is unresectable 9 Metastatic colorectal cancer with microsatellite
3 mg/kg REGN2810 instability (MSI) 10 Metastatic endometrial cancer
with MSI 3 mg/kg REGN2810 11 Castrate recurrent prostate cancer
with MSI 3 mg/kg REGN2810 12 Any other advanced solid tumor with
MSI 3 mg/kg REGN2810 13 Advanced or metastatic hepatocellular
cancer 3 mg/kg REGN2810 (HCC) 14 Advanced solid tumor refractory to
first line 3 mg/kg REGN2810 + carboplatin + docetaxel chemotherapy
(low dose) 15 Advanced solid tumor refractory to first line 3 mg/kg
REGN2810 + docetaxel (low dose) chemotherapy 16 Metastatic
colorectal cancer with MSI, 3 mg/kg REGN2810 previously untreated
17 Advanced NSCLC previously untreated 3 mg/kg REGN2810 +
carboplatin + docetaxel (low dose) 18 Newly diagnosed glioblastoma
multiforme REGN2810 (1 or 3 mg/kg) + radiotherapy (6 Gy .times.
(GBM) 5 days) 19 Recurrent GBM REGN2810 (1 or 3 mg/kg) +
radiotherapy (6 Gy .times. 5 days) 20 HIV and solid tumors 3 mg/kg
REGN2810 21 Advanced NSCLC, previously untreated 3 mg/kg REGN2810 +
Carboplatin + Paclitaxel (Full Dose) 22 Advanced Non-Squamous
NSCLC, previously 3 mg/kg REGN2810 + Cisplatin + Pemetrexed
untreated 23 Advanced Squamous NSCLC, previously 3 mg/kg REGN2810 +
Cisplatin + Gemcitabine untreated 24 Cervical Cancer, recurrent or
metastatic 3 mg/kg REGN2810 25 Basal cell carcinoma, refractory to
hedgehog 3 mg/kg REGN2810 pathway inhibition 26 Advanced Solid
Tumor 3 mg/kg REGN2810
[0287] The initial planned treatment with REGN2810 is every 14 days
for up to 48 weeks, with 24 weeks of follow-up observation.
Radiation is administered a week after the first dose of REGN2810.
Low-dose cyclophosphamide is administered to patients assigned to
cyclophosphamide 1 day before each of the first 4 doses of
REGN2810.
Study Duration
[0288] Patients receive up to 48 weeks of treatment, after which
there is a 24 week follow-up period. A patient receives treatment
until the 48 week treatment period is complete, or until disease
progression, unacceptable toxicity, withdrawal of consent, or
meeting of another study withdrawal criterion. After a minimum of
24 weeks of treatment, patients with confirmed complete responses
(CR) may elect to discontinue treatment and continue with all
relevant study assessments (eg, efficacy assessments). After a
minimum of 24 weeks of treatment, patients with tumor burden
assessments of stable disease (SD) or partial response (PR) that
have been unchanged for 3 successive tumor evaluations may also
elect to discontinue treatment and continue with all relevant study
assessments (e.g., efficacy assessments).
Study Population
[0289] The target population for this study comprises patients with
advanced malignancies who are not candidates for standard therapy,
unwilling to undergo standard therapy, or for whom no available
therapy is expected to convey clinical benefit; and patients with
malignancies that are incurable and have failed to respond to or
showed tumor progression despite standard therapy.
[0290] Inclusion criteria: A patient must meet with the following
criteria to be eligible for inclusion in the study: (1)
demonstrated progression of a solid tumor with no alternative
standard-of-care therapeutic option available; (2) at least 1
lesion for response assessment. Patients assigned to radiotherapy
require at least one additional lesion that can be safely
irradiated while sparing the index lesions and for which radiation
at the limited, palliative doses contemplated would be considered
medically appropriate; (3) patients must have relapsed after, or be
refractory to first-line therapy (and up to 2 prior lines of
therapy) in the recurrent or metastatic disease setting and must
have disease for which palliative radiation therapy is indicated;
(4) patients with metastatic cancer with microsatellite instability
(MSI) refractory to up to 2 prior lines of therapy; (5) Eastern
Cooperative Oncology Group (ECOG) performance status 1; (6) more
than 18 years old; (7) hepatic function: a. total
bilirubin.ltoreq.1.5.times. upper limit of normal (ULN; if liver
metastases.ltoreq.3.times. ULN), b. transaminases.ltoreq.3.times.
ULN (or .ltoreq.5.0.times. ULN, if liver metastases), c. alkaline
phosphatase (ALP) .ltoreq.2.5.times. ULN (or 5.0.times. ULN, if
liver metastases); (8) renal function: serum creatinine 1.5.times.
ULN; (9) neutrophil count (ANC).gtoreq.1.5.times.10.sup.9/L, c.
platelet count.gtoreq.75.times.10.sup.9/L; (10) ability to provide
signed informed consent; and (11) ability and willingness to comply
with scheduled visits, treatment plans, laboratory tests, and other
study-related procedures.
Study Treatments
[0291] REGN2810 is supplied as a liquid in sterile, single-use
vials. Each vial contains a volume sufficient to withdraw 10 mL of
REGN2810 at a concentration of 25 mg/mL. REGN2810 is administered
in an outpatient setting as a 30 minute IV infusion. Each patient's
dose depends on individual body weight. The dose of REGN2810 is
adjusted each cycle for changes in body weight of .gtoreq.10%).
REGN2810 is administered alone, or in combination with radiation
and/or cyclophosphamide. Cyclophosphamide is administered at 200
mg/m2 or as a low dose (100 mg/m2).
Monotherapy
[0292] REGN2810 is administered in an outpatient setting by IV
infusion over 30 minutes every 14 days for 48 weeks (ie, Days 1,
15.+-.3, 29.+-.3, and 43.+-.3 of a 56 day cycle). Planned
monotherapy regimens to be assigned may include: (i) 1 mg/kg IV
infusion over 30 minutes every 14 days for 48 weeks; (ii) 3 mg/kg
infusion over 30 minutes every 14 days for 48 weeks; (iii) 10 mg/kg
infusion over 30 minutes every 14 days for 48 weeks; (iv) 0.3 mg/kg
infusion over 30 minutes every 14 days for 48 weeks (if MTD is
determined to be below 1 mg/kg); and (v) 200 mg flat dose IV
infusion over 30 minutes every 14 days for 48 weeks.
Combination Therapy
[0293] Concomitant radiation therapy, cyclophosphamide, GM-CSF,
carboplatin, and docetaxel is supplied through a prescription and
their usage, dose, dose modifications, reductions, or delays, as
well as any potential AEs resulting from their use, is tracked
along with that of REGN2810.
[0294] Co-administration of REGN2810 and radiation: REGN2810 is
administered by IV infusion over 30 minutes every 14 days for 48
weeks in combination with radiation treatment from day 8 to day 12.
Planned combination REGN2810 and radiation therapy regimens may
include: [0295] 1 mg/kg REGN2810 infusion over 30 minutes every 14
days for 48 weeks plus 30 Gy radiotherapy (6 Gy.times.5 times/week;
given 1 week after the first dose of REGN2810, preferably on
consecutive days) [0296] 1 mg/kg REGN2810 infusion over 30 minutes
every 14 days for 48 weeks plus 27 Gy radiotherapy (9 Gy.times.3
times/week; given 1 week after the first dose of REGN2810,
preferably not on consecutive days) [0297] 3 mg/kg REGN2810
infusion over 30 minutes every 14 days for 48 weeks plus 30 Gy
radiotherapy (6 Gy.times.5 times/week; given 1 week after the first
dose of REGN2810, preferably on consecutive days) [0298] 3 mg/kg
REGN2810 infusion over 30 minutes every 14 days for 48 weeks plus
27 Gy radiotherapy (9 Gy.times.3 times/week; given 1 week after the
first dose of REGN2810, preferably not on consecutive days)
[0299] Patients will receive either 30 Gy given as 5 fractions of 6
Gy administered daily starting 1 week after the first dose of
REGN2810, or 27 Gy given as 3 fractions of 9 Gy administered every
other day starting 1 week after the first dose of REGN2810. The
lesion selected for radiation should be a lesion that can be safely
irradiated with focal irradiation while sparing the index
lesion(s), and for which radiation at the limited, palliative doses
contemplated would be considered medically appropriate.
[0300] Co-administration of REGN2810 and cyclophosphamide: REGN2810
is administered by IV infusion over 30 minutes every 14 days (2
weeks) for 48 weeks in combination with low dose cyclophosphamide
100 mg/m2 IV infusion every 14 days for 4 doses. Each of the 4
cyclophosphamide doses are administered 1 day before each of the
first 4 REGN2810 doses (days -1, 14, 28, and 42 of the first 56 day
cycle).
[0301] The planned combination REGN2810 and cyclophosphamide
regimen is: [0302] Cyclophosphamide 100 mg/m2 or 200 mg/m2 IV every
14 days (days -1, 14, 28, and 42 of the first 56 day cycle) for a
total of 4 doses; plus [0303] 3 mg/kg REGN2810 infusion over 30
minutes every 14 days for 48 weeks (provided monotherapy dose of 3
mg/kg<MTD; if 3 mg/kg>MTD, dose will be 1 mg/kg.
[0304] Co-administration of REGN2810, radiation and
cyclophosphamide: The planned combination REGN2810, radiation, and
cyclophosphamide regimen includes: [0305] Cyclophosphamide 100
mg/m2 (low dose) IV every 14 days (days -1, 14, 28, and 42 of the
first 56 day cycle) for a total of 4 doses; plus [0306] 27 Gy
radiotherapy (9 Gy.times.3 times/week; given 7 or 8 days after the
first dose of REGN2810, preferably not on consecutive days) OR 30
Gy radiotherapy (6 Gy.times.5 times/week; given 7 or 8 days after
the first dose of REGN2810, preferably on consecutive days); plus
[0307] 3 mg/kg REGN2810 infusion over 30 minutes every 14 days for
48 weeks (provided monotherapy dose of 3 mg/kg<MTD; if 3
mg/kg>MTD, dose will be 1 mg/kg)
[0308] Co-administration of REGN2810, radiation and GM-CSF: The
planned combination REGN2810, radiation, and GM-CSF regimen
includes: [0309] GM-CSF 250 mcg SC daily for 7 days, for four 7-day
intervals (days 1 through 7, 15 through 21, 29 through 35, and 43
through 49 of the first 56-day cycle); plus [0310] 27 Gy
radiotherapy (9 Gy.times.3 times/week; given 1-week after the first
dose of REGN2810, preferably not on consecutive days); plus [0311]
3 mg/kg REGN2810 infusion over 30 minutes every 14 days for 48
weeks (provided monotherapy dose of 3 mg/kg<MTD; if 3
mg/kg>MTD, dose will be 1 mg/kg)
[0312] Co-administration of REGN2810, radiation, GM-CSF and
cyclophosphamide: The planned combination REGN2810, radiation,
GM-CSF, and cyclophosphamide regimen includes: [0313] GM-CSF 250
mcg SC daily for 7 days, for four 7-day intervals (days 1 through
7, 15 through 21, 29 through 35, and 43 through 49 of the first
56-day cycle); plus [0314] 27 Gy radiotherapy (9 Gy.times.3
times/week; given 1 week after the first dose of REGN2810,
preferably not on consecutive days); plus [0315] Cyclophosphamide
100 mg/m2 or 200 mg/m2 IV every 14 days (days -1, 14, 28, and 42 of
the first 56 day cycle) for a total of 4 doses; plus [0316] 3 mg/kg
REGN2810 infusion over 30 minutes every 14 days for 48 weeks
(provided monotherapy dose of 3 mg/kg<MTD; if 3 mg/kg>MTD,
dose will be 1 mg/kg)
[0317] Co-administration of REGN2810 and docetaxel with or without
carboplatin: The suggested sequence of drug administration is
docetaxel followed by carboplatin (if enrolled in a
carboplatin-containing cohort), followed by REGN2810: [0318]
Docetaxel 30 mg/m2 IV over approximately 1 hour on days 1, 8, 29,
and 36 of the first 56-day cycle. Dexamethasone 8 mg IV will be
administered prior to the first dose of docetaxel. For subsequent
docetaxel treatments, the dose of dexamethasone premedication may
be 8 mg or 4 mg, per investigator discretion [0319] Carboplatin AUC
2 IV over approximately 30 minutes on days 1, 8, 29, and 36 of the
first 56-day cycle. Carboplatin dosing should use the Calvert
formula on the carboplatin label. Creatinine clearance should be
calculated using the Cockcroft-Gault equation. [0320] 3 mg/kg
REGN2810 infusion over approximately 30 minutes every 14 days for
48 weeks
Procedures and Assessments
[0321] Screening procedures to be performed include serum beta-HCG,
brain MRI, and chest X-rays.
[0322] Safety procedures include medical history, physical
examination, vital signs, electrocardiogram (ECG), coagulation,
immune safety assays (for patients treated with REGN2810),
assessment of B symptoms and evaluation of performance status,
clinical laboratory tests, AEs, and concomitant medications.
[0323] Efficacy procedures to be performed for tumor assessments
include CT or MRI scans, 18F-fluorodeoxyglucose-positron emission
tomography (FDG-PET) scans, and/or tumor biopsies. A CT or MRI for
tumor assessment is performed at the screening visit (within 28
days prior to infusion) and during every cycle (approximately every
8 weeks) on day 56.+-.3, and when disease progression is suspected.
Additionally, for patients who have not progressed on study, tumor
assessments are performed for follow-up visits 3, 5, and 7. Once
the choice has been made to use CT scan or MRI, subsequent
assessments are made using the same modality. Tumor response
assessments are performed according to Response Evaluation Criteria
in Solid Tumors RECIST version 1.1 (Eisenhauer et al 2009, Eur. J.
Cancer 45: 228-247). Measurable lesions selected as target lesions
for RECIST measurements are also included as index lesions for
immune-related response criteria (irRC; Nishino et al 2013, Clin.
Cancer Res. 19: 3936-3943). RECIST response is prioritized as
statistical assessment of response rate. For an individual patient,
irRC can inform the decision regarding whether to continue
treatment at the discretion of the investigator due to the
possibility of unconventional responses.
[0324] Blood samples for PK and anti-drug antibody (ADA) assessment
are collected.
Study Variables
[0325] The primary variables in the study are DLT incidence and the
incidence and severity of TEAEs and abnormal laboratory findings
through 48 weeks of treatment.
[0326] The secondary variables are: [0327] Antitumor activities
assessed using the appropriate criteria for the indication
(described elsewhere herein): [0328] Response Evaluation Criteria
in Solid Tumors (RECIST; Eisenhauer et al 2009, Eur. J. Cancer 45:
228-247) criteria measured by CT or MRI [0329] Other assessment
criteria also are used for specific tumors in which RECIST
measurements are not the standard. [0330] Immune-Related Response
Criteria (irRC; Nishino et al 2013, Clin. Cancer Res. 19:
3936-3943) applied to RECIST measurements. In all cases, RECIST (or
other tumor-specific criteria) is the governing tool to determine
PD, SD, CR, or PR. The irRC is collected for clinical decisions and
information purposes. [0331] Incidence of development of
anti-REGN2810 antibodies [0332] Antitumor activity measured by PFS
and overall survival
[0333] For the purposes of this study, patients are re-evaluated
for response every 8 weeks. Confirmatory scans are also obtained 4
weeks following initial documentation of objective response or
progressive disease. Response and progression is evaluated in this
study using the international criteria proposed by the revised
Response Evaluation Criteria in Solid Tumors (RECIST) guideline
(version 1.1; Eisenhauer et al 2009, Eur. J. Cancer 45: 228-247).
Changes in the largest diameter (unidimensional measurement) of the
tumor lesions and the shortest diameter in the case of malignant
lymph nodes are used in the RECIST criteria.
Selection of Lesions
[0334] Measurable disease: Measurable lesions are defined as those
that can be accurately measured in at least one dimension (longest
diameter to be recorded) as 20 mm (2 cm) by chest x-ray or as
.gtoreq.10 mm (.gtoreq.1 cm) with CT scan, MRI, or calipers by
clinical exam. All tumor measurements must be recorded in
millimeters (or decimal fractions of centimeters). Note: See below
for evaluation of radiated target lesions.
[0335] Malignant lymph nodes: To be considered pathologically
enlarged and measurable, a lymph node must be .gtoreq.15 mm
(.gtoreq.1.5 cm) in short axis when assessed by CT scan (CT scan
slice thickness recommended to be no greater than 5 mm [0.5 cm]).
At baseline and in follow-up, only the short axis will be measured
and followed.
[0336] Non-measurable disease: All other lesions (or sites of
disease), including small lesions (longest diameter<10 mm [<1
cm] or pathological lymph nodes with to .gtoreq.10 to <15 mm
[.gtoreq.1 to <1.5 cm] short axis), are considered
non-measurable disease. Bone lesions, leptomeningeal disease,
ascites, pleural/pericardial effusions, lymphangitis
cutis/pulmonitis, inflammatory breast disease, and abdominal masses
(not followed by CT or MRI), are considered as non-measurable.
Note: Cystic lesions that meet the criteria for radiographically
defined simple cysts should not be considered as malignant lesions
(neither measurable nor non-measurable) since they are, by
definition, simple cysts. `Cystic lesions` thought to represent
cystic metastases can be considered as measurable lesions, if they
meet the definition of measurability described above. However, if
non-cystic lesions are present in the same patient, these are
preferred for selection as target lesions.
[0337] Target lesions: All measurable lesions up to a maximum of 2
lesions per organ and 5 lesions in total, representative of all
involved organs, should be identified as target lesions and
recorded and measured at baseline. Target lesions are selected on
the basis of their size (lesions with the longest diameter), are
representative of all involved organs, but in addition include
those that lend themselves to reproducible repeated measurements.
It may be the case that, on occasion, the largest lesion does not
lend itself to reproducible measurement in which circumstance the
next largest lesion which can be measured reproducibly is selected.
A sum of the diameters (longest for non-nodal lesions, short axis
for nodal lesions) for all target lesions is calculated and
reported as the baseline sum diameters. If lymph nodes are to be
included in the sum, then only the short axis is added into the
sum. The baseline sum diameters are used as reference to further
characterize any objective tumor regression in the measurable
dimension of the disease.
[0338] Non-target lesions: All other lesions (or sites of disease)
including any measurable lesions over and above the 5 target
lesions are identified as non-target lesions and are recorded at
baseline. Measurements of these lesions are not required, but the
presence, absence, or in rare cases unequivocal progression of each
is noted throughout follow-up.
Methods for Evaluation of Measurable Disease
[0339] All measurements are taken and recorded in metric notation
using a ruler or calipers. All baseline evaluations are performed
as closely as possible to the beginning of treatment and never more
than 4 weeks before the beginning of the treatment. The same method
of assessment and the same technique should be used to characterize
each identified and reported lesion at baseline and during
follow-up. Imaging-based evaluation is preferred to evaluation by
clinical examination unless the lesion(s) being followed cannot be
imaged but are assessable by clinical exam.
[0340] Clinical lesions: Clinical lesions are only considered
measurable when they are superficial (eg, skin nodules and palpable
lymph nodes) and mm (1 cm) diameter as assessed using calipers
(e.g., skin nodules). In the case of skin lesions, documentation by
color photography, including a ruler to estimate the size of the
lesion, is recommended.
[0341] Chest x-ray: Lesions on chest x-ray are acceptable as
measurable lesions when they are clearly defined and surrounded by
aerated lung. However, CT is preferable.
[0342] Conventional CT and MRI: This guideline has defined
measurability of lesions on CT scan based on the assumption that CT
slice thickness is 5 mm (0.5 cm) or less. If CT scans have slice
thickness greater than 5 mm (0.5 cm), the minimum size for a
measurable lesion should be twice the slice thickness. MRI is also
acceptable in certain situations.
[0343] PET-CT: If the CT performed as part of a PET-CT is of
identical diagnostic quality to a diagnostic CT (with IV and oral
contrast), then the CT portion of the PET-CT can be used for RECIST
measurements and can be used interchangeably with conventional CT
in accurately measuring cancer lesions over time.
[0344] Ultrasound: Ultrasound is not useful in assessment of lesion
size and should not be used as a method of measurement. If new
lesions are identified by ultrasound in the course of the study,
confirmation by CT or MRI is advised. If there is concern about
radiation exposure at CT, MRI may be used instead of CT in selected
instances.
[0345] Endoscopy, Laparoscopy: The utilization of these techniques
for objective tumor evaluation is not advised. However, such
techniques may be useful to confirm complete pathological response
when biopsies are obtained or to determine relapse in trials where
recurrence following complete response (CR) or surgical resection
is an endpoint.
[0346] Tumor markers: Tumor markers alone cannot be used to assess
response. If markers are initially above the upper normal limit,
they must normalize for a patient to be considered in complete
clinical response.
[0347] Cytology, Histology: These techniques can be used to
differentiate between partial responses (PR) and complete responses
(CR) in rare cases (eg, residual lesions in tumor types, such as
germ cell tumors, where known residual benign tumors can remain).
The cytological confirmation of the neoplastic origin of any
effusion that appears or worsens during treatment when the
measurable tumor has met criteria for response or stable disease is
mandatory to differentiate between response or stable disease (an
effusion may be a side effect of the treatment) and progressive
disease.
[0348] FDG-PET: While FDG-PET response assessments need additional
study, it is sometimes reasonable to incorporate the use of FDG-PET
scanning to complement CT scanning in assessment of progression
(particularly possible `new` disease). New lesions on the basis of
FDG-PET imaging can be identified according to the following
algorithm: a. Negative FDG-PET at baseline, with a positive FDG-PET
at follow-up is a sign of PD based on a new lesion. b. No FDG-PET
at baseline and a positive FDG-PET at follow-up: If the positive
FDG-PET at follow-up corresponds to a new site of disease confirmed
by CT, this is PD. If the positive FDG-PET at follow-up is not
confirmed as a new site of disease on CT, additional follow-up CT
scans are needed to determine if there is truly progression
occurring at that site (if so, the date of PD will be the date of
the initial abnormal FDG-PET scan). If the positive FDG-PET at
follow-up corresponds to a pre-existing site of disease on CT that
is not progressing on the basis of the anatomic images, this is not
PD. c. FDG-PET may be used to upgrade a response to a CR in a
manner similar to a biopsy in cases where a residual radiographic
abnormality is thought to represent fibrosis or scarring. The use
of FDG-PET in this circumstance should be prospectively described
in the protocol and supported by disease-specific medical
literature for the indication. However, it must be acknowledged
that both approaches may lead to false positive CR due to
limitations of FDG-PET and biopsy resolution/sensitivity. Note: A
`positive` FDG-PET scan lesion means one which is FDG avid with an
uptake greater than twice that of the surrounding tissue on the
attenuation corrected image.
Response Criteria for Evaluation of Target Lesions
[0349] Complete Response (CR): Disappearance of all target lesions.
Any pathological lymph nodes (whether target or non-target) must
have reduction in short axis to <10 mm (<1 cm). [0350]
Partial Response (PR): At least a 30% decrease in the sum of the
diameters of target lesions, taking as reference the baseline sum
diameters. [0351] Progressive Disease (PD): At least a 20% increase
in the sum of the diameters of target lesions, taking as reference
the smallest sum on study (this includes the baseline sum if that
is the smallest on study). In addition to the relative increase of
20%, the sum must also demonstrate an absolute increase of at least
5 mm (0.5 cm). (Note: the appearance of one or more new lesions is
also considered progressions). [0352] Stable Disease (SD): Neither
sufficient shrinkage to qualify for PR nor sufficient increase to
qualify for PD, taking as reference the smallest sum diameters
while on study.
Response Criteria for Evaluation of Non-Target Lesions
[0352] [0353] Complete Response (CR): Disappearance of all
non-target lesions and normalization of tumor marker level. All
lymph nodes must be non-pathological in size (<10 mm [<1 cm]
short axis). Note: If tumor markers are initially above the upper
normal limit, they must normalize for a patient to be considered in
complete clinical response. [0354] Non-CR/Non-PD: Persistence of
one or more non-target lesion(s) and/or maintenance of tumor marker
level above the normal limits. [0355] Progressive Disease (PD):
Appearance of one or more new lesions and/or unequivocal
progression of existing non-target lesions. Unequivocal progression
should not normally trump target lesion status. It must be
representative of overall disease status change, not a single
lesion increase.
Immune-Related Response Criteria
[0356] Immune-related response criteria differ from RECIST (Version
1.1) in that the sum of the longest diameters of all target lesions
and new lesions if any are used to determine response. The presence
of new lesions per se does not determine progression; the total
tumor burden is considered.
Evaluation of Target Lesions
[0357] Complete Response (CR): Disappearance of all target lesions.
Any pathological lymph nodes (whether target or non-target) must
have reduction in short axis to <10 mm (<1 cm). [0358]
Partial Response (PR): At least a 30% decrease in the sum of the
diameters of target lesions, including new lesions, taking as
reference the baseline sum diameters. [0359] Progressive Disease
(PD): At least a 20% increase in the sum of the diameters of target
lesions, including new lesions, taking as reference the smallest
sum on study (this includes the baseline sum if that is the
smallest on study). In addition to the relative increase of 20%,
the sum must also demonstrate an absolute increase of at least 5 mm
(0.5 cm). [0360] Stable Disease (SD): Neither sufficient shrinkage
to qualify for PR nor sufficient increase to qualify for PD, taking
as reference the smallest sum diameters while on study and
including the measurements of new lesions.
Evaluation of Non-Target Lesions
[0360] [0361] Complete Response (CR): Disappearance of all
non-target lesions and normalization of tumor marker level. All
lymph nodes must be non-pathological in size (<10 mm [<1 cm]
short axis). Note: If tumor markers are initially above the upper
normal limit, they must normalize for a patient to be considered in
complete clinical response. [0362] Non-CR/Non-PD: Persistence of
one or more non-target lesion(s) and/or maintenance of tumor marker
level above the normal limits. [0363] Progressive Disease (PD):
Unequivocal progression of existing non-target lesions. Unequivocal
progression should not normally trump target lesion status. It must
be representative of overall disease status change, not a single
lesion increase. Although a clear progression of "non-target"
lesions only is exceptional, the opinion of the treating physician
should prevail in such circumstances, and the progression status
should be confirmed at a later time.
Evaluation of Overall Response Criteria
[0364] The best overall response is the best response recorded from
the start of the treatment until disease progression/recurrence
(taking as reference for progressive disease the smallest
measurements recorded since the treatment started). The patient's
best response assignment will depend on the achievement of both
measurement and confirmation criteria. Revised Response Evaluation
Criteria in Solid Tumors (RECIST) Version 1.1 (Eisenhauer et al
2009, Eur. J. Cancer 45: 228-247) and immune-related response
criteria (irRC; Nishino et al 2013, Clin. Cancer Res. 19:
3936-3943) are summarized in Tables 10 and 11 below.
TABLE-US-00010 TABLE 10 Response according to Revised RECIST
(Version 1.1) Target New Overall Best Overall Response when Lesions
Non-target Lesions Lesions Response Confirmation is Required CR CR
No CR .gtoreq.4 weeks confirmation CR Non-CR/Non-PD No PR .gtoreq.4
weeks confirmation CR Not evaluated No PR .gtoreq.4 weeks
confirmation PR Non-CR/Non-PD/not evaluated No PR .gtoreq.4 weeks
confirmation SD Non-CR/Non-PD/not evaluated No SD Documented at
least once .gtoreq.4 weeks from baseline PD Any Yes or No PD No
prior SD, PR or CR Any PD Yes or No PD No prior SD, PR or CR Any
Any Yes PD No prior SD, PR or CR CR: complete response; PD:
progressive disease; PR: partial response; SD: stable disease
TABLE-US-00011 TABLE 11 Immune-related Response Criteria Evaluation
Target New Overall Best Overall Response when Lesions Non-target
Lesions Lesions Response Confirmation is Required CR CR No CR
.gtoreq.4 weeks confirmation CR Non-CR/Non-PD No PR .gtoreq.4 weeks
confirmation CR Not evaluated No PR .gtoreq.4 weeks confirmation PR
Non-CR/Non-PD/not evaluated Yes or No PR .gtoreq.4 weeks
confirmation SD Non-CR/Non-PD/not evaluated Yes or No SD Documented
at least once .gtoreq.4 weeks from baseline PD Any Yes or No PD No
prior SD, PR or CR Any PD Yes or No PD No prior SD, PR or CR CR:
complete response; PD: progressive disease; PR: partial response;
SD: stable disease
Evaluation of Radiated Target Lesions
[0365] Radiated target lesions are evaluated with a modified
version of the international criteria proposed by the Response
Evaluation Criteria in Solid Tumors (RECIST) Committee, version
1.1. Additional definitions beyond the RECIST 1.1 guidelines
specific to this protocol are incorporated to define local
control.
[0366] The response criteria for radiated lesions are as
follows:
[0367] Local enlargement (LE): At least a 20% increase in the LD of
target lesion, taking as reference the smallest LD recorded since
the treatment started. Ideally, this determination will be made
based on CT image evaluation.
[0368] Local failure (LF): Refers to the primary treated tumor
after protocol therapy and corresponds to meeting both of the
following two criteria: (1) Increase in tumor dimension of 20% as
defined above for local enlargement (LE); (2) The measurable tumor
with criteria meeting LE should be avid on Positron Emission
Tomography (PET) imaging with uptake of a similar intensity as the
pretreatment staging PET, OR the measurable tumor should be
biopsied confirming viable carcinoma.
[0369] Local control (LC): The absence of local failure.
[0370] The longest diameter (LD) for the radiated target lesion
calculated from the treatment-planning CT scan, using appropriate
tissue-specific windowing, is reported as the baseline LD. The
baseline LD is used as the reference by which to characterize the
objective tumor. For follow-up assessment, diagnostic CT scans
performed using a 5 mm contiguous reconstruction algorithm using
pulmonary windowing taken as part of scheduled protocol follow-up
are preferred as the method of evaluation for response. When CT
scans are not available, MRI or x-ray determination is allowed, as
long as the target lesion is clearly visible.
Results
[0371] REGN2810 alone and in combination is safe and well-tolerated
by patients. Administration of REGN2810 alone or in combination
with other treatment modalities inhibits tumor growth and/or
promotes tumor regression in patients with advanced solid tumors.
Overall response rate is better for combination therapy with
radiation as compared to monotherapy.
[0372] 60 patients with advanced solid malignancies (47% with four
or more prior therapies) have been treated to-date. The advanced
solid malignancies include colorectal cancer, head and neck cancer,
breast cancer, soft tissue sarcoma, adrenal cancer, anal cancer,
cancer of the appendix, bladder cancer, cervical cancer,
endometrial cancer, esophageal cancer, liver cancer, non-small cell
lung adenocarcinoma, ovarian cancer, pancreatic cancer, prostate
cancer, renal sarcomatoid, salivary gland cancer, non-melanoma skin
cancer, Merkel cell carcinoma, squamous cell carcinoma, basal cell
carcinoma, small intestine cancer, thyroid cancer and uterine
cancer.
[0373] Forty-two patients (70%) experienced one or more
treatment-related adverse events (AEs). The most common
treatment-related AEs were fatigue (28.3%), arthralgia (11.7%) and
nausea (11.7%). Of the 60 patients evaluated for tumor responses,
there were 11 (18.3%) objective responses (PR/CR), while 31
patients (51.7%) showed disease control (CR/PR/SD). In the 36
patients who received combination therapy including radiation
therapy, objective response was seen in 6 patients (16.7%) and
disease control in 19 patients (52.8%). In the 24 patients who did
not receive radiation therapy, objective response was seen in five
patients (20.8%) and disease control was seen in 12 patients (50%).
Table 12 shows a summary of responders.
TABLE-US-00012 TABLE 12 Summary of responders No. Prior Lines
Subject of Best Best % ID Dose Cohort Cancer Type Therapy Response
Reduction 41 R2810: 1 mg/kg Cholangiocarcinoma 5 PR -41.2 50 R2810:
1 mg/kg Cutaneous squamous cell carcinoma 2 CR -100.0 43 R2810: 10
mg/kg Soft tissue sarcoma 5 PR -49.1 37 R2810: 10 mg/kg Basal cell
carcinoma 1 PR -36.7 36 R2810: 3 mg/kg + CPA: 200 mg/m2 Soft tissue
sarcoma 5 PR -33.3 47 R2810: 1 mg/kg + XRT: 6 Gy .times. 5 Cervix
squamous cell carcinoma 4 PR -66.7 46 R2810: 1 mg/kg + XRT: 9 Gy
.times. 3 Anal squamous cell carcinoma 3 PR -57.1 49 R2810: 1 mg/kg
+ XRT: 9 Gy .times. 3 Cervix squamous cell carcinoma 3 CR -100.0 48
R2810: 3 mg/kg + XRT: 6 Gy .times. 5 Merkel Cell Carcinoma 1 PR
-72.5 42 R2810: 3 mg/kg + XRT: 6 Gy .times. 5 Small intestine
adenocarcinoma 2 PR -46.7 44 R2810: 3 mg/kg + XRT: 9 Gy .times. 3
Ovarian serous carcinoma 6 PR -52.4
[0374] Among the responders, the median time to response for
monotherapy was 113 days (range 52-226) and for patients with
radiation therapy was 59 days (range 56-113).
Example 8
Case Reports of PD-1 Blockade with Monoclonal Antibody REGN2810
Achieving Durable Objective Responses in Metastatic, Non-Melanoma
Skin Cancers: Basal Cell Carcinoma and Cutaneous Squamous Cell
Carcinoma
Introduction
[0375] Basal cell carcinoma (BCC) and cutaneous squamous cell
carcinoma (CSCC) share exposure to UV light as the dominant risk
factor, and these tumors are therefore hypermutated (Chalmers et al
2016, AACR Ann. Meeting, Abs 3576). In other malignancies, high
mutation burden has been associated with clinical benefit from
therapy with antibodies directed against the PD-1 immune checkpoint
[Le et al 2015, New Engl. J. Med. May 30 (Epub ahead of print)].
Highly mutated tumors are more likely to express immunogenic tumor
neoantigens that attract effector T cells that can be unleashed by
blockade of the PD-1 immune checkpoint (Mandal and Chan 2016,
Cancer Discov. 6: 1-12). This Example describes a patient with
metastatic BCC and a patient with metastatic CSCC who were treated
with REGN2810, a fully human anti-PD-1 monoclonal antibody in an
ongoing phase 1 trial (NCT02383212; described in Example 7
herein).
Case Report 1
[0376] The patient was a 66 year-old woman who was diagnosed with a
stage 1 BCC arising on the left aspect of the chin, which was
resected with Mohs surgery. A localized recurrence in the same
location was identified 2 years later, and a wide local excision
revealed invasion into the left mandible and involvement of one out
of 18 lymph nodes. The patient received adjuvant radiation and
remained in remission for 4 years, when enlarging lung nodules
observed on surveillance chest imaging were biopsied and confirmed
the presence of metastatic BCC. The patient subsequently received
the Hedgehog pathway inhibitor (H HI) vismodegib for 5 months. She
initially responded but discontinued because of progressive
disease.
[0377] Six months after the vismodegib therapy and upon continued
slow progression, the patient enrolled on the phase 1 study of
REGN2810 to a cohort receiving 10 mg/kg IV every 2 weeks, and
received her first dose. Two lung metastases were followed as
target lesions. Response assessments at the end of 8 weeks (3%
increase) and 16 weeks (10% decrease) demonstrated stable disease
by RECIST criteria. The response assessment at the end of 24 weeks
demonstrated a reduction in tumor measurements of 37% (FIG. 14A),
and this was confirmed at 32 weeks. The patient has tolerated
treatment well, and continues REGN2810, on treatment for
10+months.
Case Report 2
[0378] The patient was a 52 year-old man who was diagnosed with
cutaneous squamous cell carcinoma of the left cheek. He underwent
Mohs surgery with clear margins. He experienced multiple
recurrences, and underwent at least 9 additional Mohs surgeries. He
underwent wide local excision over left mandible 4 years later, and
left parotidectomy subsequently in 20 months. Also, adjuvant
radiotherapy was administered to left cheek, left mandible, left
neck (with concurrent cetuximab), and bilateral neck (with
concurrent carboplatin). Other systemic therapies were
capecitabine, and cisplatin+docetaxel. Ten years after the initial
diagnosis, he underwent excision with clear margins for a 2.2 cm
in-scar recurrence of the left neck. Subsequently, invasive CSCC at
C4-C5 vertebral bodies necessitated emergent decompression of
cervical spinal cord with C4-C5 anterior corpectomy and C4-C6
posterior laminectomy. He also developed lower extremity muscle
weakness thought to be due to perineural involvement and required
the use of a walker for ambulation.
[0379] He was enrolled on the phase 1 study in the first cohort,
receiving 1 mg/kg REGN2810 every two weeks. Within weeks of
beginning treatment, his lower extremity strength gradually
returned and he no longer requires the use of the walker. Response
at Week 16 is shown in FIG. 14B. Complete radiologic response of
the left neck lesion was achieved at Week 40. The patient completed
the planned 48 weeks of protocol treatment with REGN2810. He
continues in close active follow up with his medical oncologist
without clinical or radiographic evidence of disease
recurrence.
Discussion
[0380] This Example discloses the first confirmed partial response
in a patient with metastatic BCC treated with a PD-1 inhibitor
(REGN2810), as well as an ongoing durable complete response in a
patient with metastatic CSCC. The deep and sustained responses of
these heavily pretreated patients to anti-PD-1 monotherapy in this
phase 1 study are consistent with the hypothesis that high mutation
burden in BCC and CSCC would elicit antitumor cellular immunity
that could be unleashed by blockade of the PD-1/PD-L1 checkpoint
pathway.
[0381] This Example supports a general principle that UV-associated
skin cancers beyond melanoma are sensitive to PD-1 blockade. A
reductionist model would predict that UV-associated tumors with
higher load of non-synonymous mutations will be more responsive to
PD-1 blockade than those with lower mutation load.
Example 9
Safety and Efficacy of Anti-PD-1 Antibody in Patients with
Unresectable Locally Advanced or Metastatic Cutaneous Squamous Cell
Carcinoma (CSCC)
Background
[0382] There is no established standard of care for unresectable
locally advanced or metastatic CSCC. Due to UV-induced DNA damage,
most CSCCs are hyper-mutated. Therefore, these tumors may be
responsive to PD-1 checkpoint blockade. This Example describes
patients with locally advanced or metastatic CSCC who were treated
with REGN2810, a fully human anti-PD-1 monoclonal antibody in an
ongoing phase 1 trial (NCT02383212; described in Example 7
herein).
Methods
[0383] Expansion cohorts (ECs) in the phase 1 study of REGN2810
enrolled patients with distantly metastatic CSCC (EC 7) and locally
advanced CSCC (EC8) (Table 9). All patients received 3 mg/kg
REGN2810 by vein every 2 weeks for up to 48 weeks. Research
biopsies were performed at baseline and Day 29 (and at progression,
if possible). To determine overall response rate, tumor
measurements were performed every 8 weeks according to RECIST
1.1.
Results
[0384] 25 patients were enrolled (10 in EC 7 and 15 in EC 8):
median age, 72.5 y (range, 56-88y); median PS 1 (range, 0-1); 20
M:5F; median number of prior systemic therapy regimens, 1 (range,
0-3). Median exposure to REGN2810 was 6 doses (range, 1-22). The
most common treatment-related adverse events of any grade were
fatigue (16.7%), nausea, arthralgia, and rash (8.3% each). Each of
the following Grade 3 related adverse events (AEs) occurred once:
AST elevation, ALT elevation, arthralgia, and rash.
[0385] Overall response rate (uPR+PR+CR) and disease control rate
(ORR+SD) were 48% (11/23; 3uPR, 5 PR, 2 CR, 1 uCR) and 70% (16/23,
including 5 SD), respectively. Two patients are not yet evaluable.
Median PFS and Median OS are calculated, and only one patient has
experienced PD during REGN2810 treatment after initial response.
Correlative science studies are in process, including whole exome
tumor DNA sequencing.
Conclusion
[0386] REGN2810 demonstrates robust antitumor activity in patients
with advanced CSCC.
Example 10
Clinical Trial of Anti-PD-1 Antibody Combined with Hypofractionated
Radiation Therapy Versus Standard of Care in Patients 65 Years of
Age with Newly Diagnosed Glioblastoma
Introduction
[0387] Glioblastoma is a deadly disease with a median survival of
approximately 16 months in newly diagnosed patients (nGBM), and
approximately 9 months in the recurrent setting (rGBM) (Friedman et
al, 2009, J. Clin. Oncol. 27: 4733-4740). The current standard of
care for patients with newly diagnosed glioblastoma is radiation
(60 Gy over 6 weeks) with concurrent temozolomide (TMZ) followed by
adjuvant temozolomide (Stupp et al, 2005, N. Engl. J. Med. 352:
987-996), although subgroup analyses suggests that the addition of
temozolomide may not improve efficacy in older individuals
(Laperriere et al, 2013, Cancer Treat. Rev. 39: 350-357).
[0388] This Example describes a phase 3 study to evaluate efficacy
of an anti-PD-1 antibody in combination with hypofractionated
radiation therapy (hfRT) versus standard of care (SoC) in terms of
overall survival in patients 65 years old with nGBM.
[0389] The exemplary anti-PD-1 antibody used in this study is
REGN2810 (also known as H4H7798N as disclosed in US20150203579), a
fully human monoclonal anti-PD-1 antibody comprising a heavy chain
comprising the amino acid sequence of SEQ ID NO: 9 and a light
chain comprising the amino acid sequence of SEQ ID NO: 10; an
HCVR/LCVR amino acid sequence pair comprising SEQ ID NOs: 1/2; and
heavy and light chain CDR sequences comprising SEQ ID NOs: 3-8.
Study Objectives
[0390] The primary objective of the study is to evaluate efficacy
in terms of overall survival (OS) of REGN2810 given in combination
with hfRT versus standard of care for patients 65 years old with
nGBM.
[0391] The secondary objective of the study is to determine an
improvement in progression-free survival (PFS).
[0392] The other objectives of the study are: (i) improvement in
Objective response rate (ORR), duration of response, and duration
of disease control; (ii) clinical assessment using Neurologic
Assessment in Neuro-Oncology (NANO) scale; (iii) safety; (iv)
improvement in Quality of life (QoL) and mental status; (v) changes
in edema and steroid use; (vi) REGN2810 concentration in serum and
anti-REGN2810 antibodies; and (vii) to explore potential
pharmacodynamic, predictive or prognostic biomarkers.
Study Design
[0393] This is a 2:1 randomized phase 3 study of REGN2810, a fully
human antibody to PD-1, combined with hypofractionated radiation
therapy versus standard of care in patients 65 years of age with
newly diagnosed glioblastoma. Patients are randomized to REGN2810
in combination with hypofractionated radiation therapy versus
standard of care in a 2:1 ratio with methylation status (methylated
vs. unmethylated vs. undetermined) and extent of resection (partial
vs. gross total resection) as stratification factors. Efficacy is
assessed by overall survival.
[0394] nGBM patients who are candidates for radiation therapy are
randomized in a 2:1 ratio to receive one of the following
treatments: [0395] Investigational therapy: 3 mg/kg REGN2810 IV
(every 2 weeks) plus hypofractionated RT (6 Gy.times.5, second week
only). Radiation therapy is provided in Week 2 of Cycle 1, but not
subsequent cycles. [0396] Comparator therapy: standard of care TMZ
(oral, 75 mg/m.sup.2, daily) in combination with standard RT (5
daily radiation fractions/week of 2 Gy) for 6 weeks, followed by
adjuvant TMZ (oral, 150 mg/m2 to 200 mg/m.sup.2 5 days/28 days) for
6 cycles. Radiation therapy is provided in the first 6 week cycle
only.
Study Duration
[0397] The study consists of a 28-day screening period, after which
eligible patients may have up to twelve 56-day (8-week) treatment
cycles for a total of up to 96 weeks of treatment. During the
screening period (day -28 to day -1), all eligible patients are
required to have a pre-treatment tumor resection available (partial
or full resection) or biospy for central pathology confirmation and
MGMT methylation determination and confirmation.
[0398] After day 1/baseline, patients return to the clinic during
cycle 1 on days 8.+-.3, 15.+-.3, 29.+-.3, 43.+-.3, and 56.+-.3. For
each subsequent 8-week cycle (cycles 2-12), patients return to the
clinic on days 1, 15.+-.3, 29.+-.3, 43.+-.3, and 56.+-.3. Tumor
assessments (brain MRI, iRANO and NANO assessments, MMSE, and EORTC
QLQ-C30/BN20 questionnaires) are made at day 1/baseline and at the
end of each treatment cycle. Extensive safety evaluations occur on
day 1 of each cycle; routine safety evaluations will be conducted
at each visit. Samples for assessment of biomarkers (cellular and
molecular, described herein) related to REGN2810 treatment
exposure, clinical activity, or underlying disease are also
collected.
[0399] During the 24-week follow-up period, patients return to the
clinic 21 to 42 days after the last study treatment for the first
follow-up visit. Subsequent follow-up visits (follow-up visit 2
through follow-up visit 7) occur every 28 days.+-.7 days. Tumor
assessments (brain MRI, iRANO and NANO assessments, MMSE, and EORTC
QLQ-C30/BN20 questionnaires) are made at follow-up visit 3,
follow-up visit 5, and follow-up visit 7. Extensive safety
evaluations occur during the first follow-up visit; routine safety
evaluations will be conducted at subsequent follow-up visits.
Samples for assessment of biomarkers (cellular and molecular,
described herein) related to REGN2810 treatment exposure, clinical
activity, or underlying disease are collected.
Target Population
[0400] The target population comprises patients 65 years old with
nGBM.
[0401] Inclusion Criteria: A patient must meet the following
criteria to be eligible for inclusion in the study: (1) newly
diagnosed primary glioblastoma with histological confirmation, cm
in maximum diameter, who has had partial or complete surgical
resection; (2) Eastern Cooperative Oncology Group (ECOG)
performance status 0-2; (3) 65 years old; (4) Hepatic function: (a)
Total bilirubin.ltoreq.1.5.times.upper limit of normal; (b) ALT and
AST.ltoreq.3.times.ULN; (c) Alkaline phosphatase
(ALP).ltoreq.2.5.times.ULN; (5) Renal function: Serum
creatinine.ltoreq.1.5.times.ULN; (6) Bone marrow function:
Hemoglobin.gtoreq.9.0 g/dL; Absolute neutrophil count
(ANC).gtoreq.1.5.times.10.sup.9/L; Platelet
count.gtoreq.75.times.10.sup.9/L; (7) Able to read, understand, and
willing to sign the ICF; and (8) Ability and willingness to comply
with scheduled visits, treatment plans, laboratory tests, and other
study-related procedures.
[0402] Exclusion Criteria: A patient who meets any of the following
criteria will be excluded from the study: (1) Any prior treatment
for GBM (other than surgery); (2) Have known contraindication to
Gd-MRI; (3) Ongoing or recent (within 5 years) evidence of
significant autoimmune disease that required treatment with
systemic immunosuppressive treatments, which may suggest risk for
immune-related adverse events (irAEs). The following are not
exclusionary: vitiligo, childhood asthma that has resolved,
residual hypothyroidism that requires only hormone replacement, or
psoriasis that does not require systemic treatment. (4) Ongoing
systemic corticosteroid treatment, with the exception of
corticosteroid use for other (non-tumor and non-immunosuppressive)
indications up to a maximum of 10 mg/day of prednisone or
equivalent. (5) Primary tumors located in the brainstem, spinal
cord, or any secondary brain tumor active infection requiring
therapy, including known infection with human immunodeficiency
virus, or active infection with hepatitis B or hepatitis C virus.
(6) History of pneumonitis within the last 5 years. (7) Any
investigational or antitumor treatment within 30 days prior to the
initial administration of REGN2810. (8) History of documented
allergic reactions or acute hypersensitivity reaction attributed to
treatment with antibody therapies in general, or to agents
specifically used in the study. (9) Inadequately controlled
hypertension (defined as systolic blood pressure>150 mm Hg
and/or diastolic blood pressure>100 mm Hg) (10) Known allergy to
doxycycline or tetracycline. (Precaution due to presence of trace
components in REGN2810.) (11) Prior history of hypetensive crisis
or hypertensive encephalophathy (12) History within the last 5
years of an invasive malignancy other than the one treated in this
study, with the exception of resected/ablated basal or
squamous-cell carcinoma of the skin or carcinoma in situ of the
cervix, or other local tumors considered cured by local treatment.
(13) Acute or chronic psychiatric problems that, under the
evaluation of the investigator, make the patient ineligible for
participation (14) Use of Novocure Tumor Treating Fields (Optune
NovoTTF-100A device) at screening. Planned or anticipated use of
Novocure Tumor Treating Fields during study participation (15)
Prior treatment with carmustine wafers (16) Continued sexual
activity in men who are unwilling to practice adequate
contraception during the study.
Study Treatments
[0403] Patients receive one of the following treatment
regimens:
[0404] Investigational therapy: 3 mg/kg REGN2810 (administered IV
infusion over 30 minutes every 2 weeks for up to 96 weeks) plus
hfRT in Week 2 of Cycle 1
[0405] Comparator: standard of care TMZ (oral, 75 mg/m2, daily) in
combination with standard RT (5 daily radiation fractions/week of 2
Gy) for 6 weeks, followed by adjuvant TMZ (oral, 150 mg/m2 to 200
mg/m.sup.2 5 days/28 days) for 6 cycles. Radiation therapy is
provided in the first cycle only.
[0406] REGN2810 is supplied as a liquid in sterile, single-use
vials. Each vial contains a volume sufficient to withdraw 10 mL of
REGN2810 at a concentration of 25 mg/mL. REGN2810 is administered
as a 30 minute IV infusion. Each patient's dose will depend on
individual body weight. The dose of REGN2810 must be adjusted each
cycle for changes in body weight of .gtoreq.10%.
[0407] Radiation Therapy: Patients in the control arm receive
standard radiotherapy (60 Gy over 6 weeks). Patients in the
experimental treatment group receive hfRT (6 Gy.times.5 daily
fractions) administered 1 week after the first dose of
REGN2810.
[0408] REGN2810 plus Radiation (Investigational Treatment):
REGN2810 is administered by IV infusion over 30 minutes every 14
days for 96 weeks in combination with hfRT from day 8 to day
12.
[0409] Planned combination REGN2810 and hfRT regimen: 3 mg/kg
REGN2810 infusion over 30 minutes every 14 days for 96 weeks plus
radiation therapy (hfRT at 6 Gy.times.5 daily fractions; given 1
week after the first dose of REGN2810, preferably on consecutive
days).
[0410] Specifications for Radiation Therapy: Patients receive 30 Gy
given as 5 fractions of 6 Gy administered daily starting 1 week
after the first dose of REGN2810.
[0411] Comparator Arm: Standard of Care: TMZ (oral, 75 mg/m.sup.2,
daily) in combination with standard RT (5 daily radiation
fractions/week of 2 Gy) for 6 weeks, followed by adjuvant oral TMZ.
The dose of TMZ is 150 mg/m.sup.2 for the first 5 days of the first
adjuvant cycle, and is increased 200 mg/m.sup.2 for 5 days/28 days
starting with the second cycle if there is no unacceptable
hematologic toxicities with the first adjuvant cycle.
[0412] If, during the first adjuvant cycle, all non-hematologic
toxicities observed are grade 2 (except alopecia, nausea and
vomiting) and platelets are .gtoreq.100.times.109/L and
ANC>=1.5.times.109/L, then the TMZ dose should be escalated to
dose level 1 (200 mg/m.sup.2) and this dose should be used as the
starting dose for subsequent cycles. If after cycle 1 TMZ has to be
delayed because of ongoing non-hematologic toxicities of
grade.gtoreq.2, then no escalation is possible. If the dose was not
escalated at the second cycle, then the dose should not be
escalated in subsequent cycles.
[0413] Treatments for CNS Edema: Any patient who develops
symptomatic intracranial edema during the study has REGN2810 dosing
and radiation therapy held until the edema subsides.
[0414] For patients who develop intracranial edema, bevacizumab is
administered IV, as needed (PRN), at a reduced dose from the
standard (suggested dose of 5 mg/kg Q2W for up to 3 doses, not more
than 10 mg/kg Q2W per dose), unless contraindicated (e.g., unless
the patient had surgery within the past 28 days).
[0415] If bevacizumab does not resolve the intracranial edema,
systemic corticosteroids, in addition to or as replacement for
bevacizumab, at the lowest dose deeded to be appropriate for
symptom management may be administered. For patients who are
bevacizumab intolerant corticosteroids are used at a dose deeded to
be appropriate for symptom management.
Study Variables
[0416] The primary efficacy endpoint is overall survival (OS),
which is defined as the time interval from the date of
randomization to the date of death due to any cause.
[0417] The key secondary endpoint is progression free survival
(PFS), which is defined as the time interval from the date of
randomization to the date of first observation of disease
progression or the date of death (due to any cause). Disease
progression is determined by iRANO criteria.
[0418] The other secondary efficacy endpoints are:
[0419] Objective response rate (ORR): defined as the proportion of
patients with confirmed complete response (CR) or confirmed partial
response (PR), defined by Immunotherapy Response Assessment in
Neuro-Oncology (iRANO) criteria relative to the total number of
patients in the analysis population.
[0420] Duration of response: determined for patients with best
overall response of CR or PR. Duration of response is measured from
the time measurement criteria are first met for CR/PR (whichever is
first recorded) until the first date of recurrent or progressive
disease (radiographic), or death due to any cause.
[0421] Duration of disease control: determined for patients with
best overall response of SD, CR, or PR. Duration of disease control
is measured from the start of treatment until the first date of
recurrent or progressive disease (radiographic), or death due to
any cause.
[0422] Quality of Life and Symptom Control Variables: The quality
of life and symptom control variables are: [0423] Five functional
scales, three symptom scales, one global measure of health status
and six single-item scales assessing symptoms using the EORTC
QLQ-C30 questionnaires during the study [0424] Four scales and
seven single items using the EORTC QLQ-BN20 questionnaires during
the study [0425] Clinical assessment using NANO; [0426] The total
score of the MMSE during the study [0427] Use of corticosteroid at
baseline, cumulative corticosteroid use during the study, and the
duration of steroid-free or low dose steroid use during the
progression-free period of study [0428] Use of bevacizumab PRN at
baseline, cumulative bevacizumab PRN during the study, and the
duration of bevacizumab-free during the progression-free period of
study
[0429] Exploratory Biomarker Variables: Other endpoint includes
pharmacodynamic, prognostic, and predictive biomarkers related to
clinical response, mechanism of action, and possible AEs associated
with REGN2810 after treatment. The biomarker variables include:
[0430] Expression levels of immune checkpoint receptors PD-L1,
GITR, and LAG3, as well as other potential biomarkers (e.g.,
EGFRvIII, Ki67, etc) in tumor samples; [0431] Number and
distribution of TILs in tumor samples; [0432] IDH1 mutational
status, microsatelite instabilty (MSI), and mutational burden in
tumor samples; [0433] Circulating biomarkers including cytokines
and angiogenic factors; [0434] Cell subsets and expression levels
of biomarkers of interest in PBMCs; [0435] MGMT promoter
methylation status (also used for stratification)
[0436] Other variables include REGN2810 concentration in serum
(pharmacokinetic variables) and development of anti-REGN2810
antibodies.
Procedures and Assessments
[0437] After a screening period of up to 28 days, patients receive
up to twelve 56-day treatment cycles for a total of up to 96 weeks
of treatment, followed by a 24 week follow-up period. Efficacy,
safety, PK, ADA, and exploratory biomarker analysis are
performed.
Efficacy Procedures
[0438] MRI: An MRI for tumor assessment is performed 72 hrs
post-surgery, at the screening visit (within 28 days prior to
infusion), on day 56.+-.3 of every cycle (approximately every 8
weeks), and when PD is suspected. Patients for whom disease has not
progressed have additional tumor assessments performed at follow-up
visits 3, 5, and 7. Note: if PD has been confirmed, additional
scans will not be required during follow-up visits. If pre and
post-surgery MRIs were performed prior to enrollment onto the
study, those scans must also be submitted to the study to aid in
determination of tumor volume and tumor progression.
[0439] Tumor response evaluation is performed according to iRANO;
and clinical neurologic assessment will be performed by NANO.
Assessments according to RANO are also performed as a supportive
exploration; however, the primary determination of disease
progression for an individual patient is made according to
iRANO.
[0440] The European Organization for Research and Treatment of
Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the EORTC
Brain Cancer Module (EORTC QLQ-BN20) Questionnaire: The EORTC
QLQ-C30 is a 30-item questionnaire that assesses health-related
quality of life (HRQoL) in cancer patients with 15 scales (single-
or multi-item), each with possible scores ranging from 0 to 100. Of
the 30 items, 24 aggregate into 9 multi-item scales representing
various HRQoL dimensions: 5 functioning scales (physical, role,
emotional, cognitive, and social), 3 symptom scales (fatigue, pain,
and nausea), and 1 global measure of health status. The remaining 6
single-item scales assess symptoms: dyspnea, appetite loss, sleep
disturbance, constipation and diarrhea, and the perceived financial
impact of the disease treatment. High scores indicate better HRQoL
for the global measure of health status and functioning scales, and
worse HRQoL for the symptom scales.
[0441] The EORTC QLQ-BN20 is a 20-item QoL assessment specific to
brain neoplasms and is intended to supplement the EORTC QLQ-C30
when assessing health-related quality of life. The EORTC QLQ-BN20
questionnaire assesses disease symptoms, side-effects of treatment,
and some specific psychosocial issues of importance to patients
with brain cancer using 4 scales (assessing future uncertainty,
visual disorder, motor dysfunction, and communication deficit) and
7 single items (assessing other disease symtpoms [eg, headaches and
seizures] and treatment toxic effects [e.g., hair loss]). The
possible scores range from 0 to 100; high scores indicate worse
HRQoL.
[0442] Mini-Mental Status Assessment: The Mini-Mental State
Examination (MMSE.COPYRGT.) is a brief, quantitative measure of
cognitive status in adults. It can be used to screen for cognitive
impairment, to estimate the severity of cognitive impairment at a
given point in time, and to follow the course of cognitive changes
in an individual over time. In this study, the MMSE score is part
of the neurological examination performed in the context of the
disease assessments.
[0443] MMSE is performed at day 1/baseline, at the end of every
treatment cycle, and every 8 weeks during the follow-up period. The
MMSE assessments coincide with the schedule of disease assessments,
but they must be completed prior to announcing the radiological
assessment result to the patient. The MMSE may be completed at the
beginning of the next scheduled treatment administration. During
survival follow-up period, the MMSE should continue to be completed
at every second survival visit (every 8 weeks) if the patient has
not yet progressed.
[0444] The total score of the MMSE has a possible range from 0
(worst) to 30 (best).
Safety Procedures
[0445] At cycle 1 day 1 and on all subsequent treatment days, vital
signs, including temperature, resting blood pressure, pulse, and
respiration, along with weight will be collected prior to infusion,
and approximately 15 minutes after the completion of the infusion.
A complete physical examination and a 12-lead ECG is carried out at
the beginning of every cycle.
Exploratory Tumor Biomarker Procedures
[0446] The biomarkers of interest that are analyzed by
immunohistochemistry (IHC) include but are not limited to EGFRvIII
and biomarkers of cell proliferation (for example, Ki67).
Expression levels (mRNA and/or protein) of PD-L1, GITR, and LAG-3,
as well as lineage markers of tumor infiltrating lymphocytes (CD4,
CD8, CD25, FoxP3) are analyzed in tumor biopsy samples to explore
potential effect of REGN2810.
[0447] Tumor tissue samples may be used for extraction of tumor DNA
and RNA and subsequent analyses of putative genetic biomarkers
relevant to study treatment and glioblastoma. A blood sample is
collected for isolation of germ-line DNA on day 1/baseline
(predose), or at any study visit, if collection at day 1/baseline
is not possible. Analyses of the tumor DNA include (but are not
limited to) methylation status of MGMT promoter, IDH1 mutational
status, microsatelite instabilty (MSI), and tumor mutation burden
(which both may be predictive of response to REGN2810 and other
immunotherapeutic agents). Analysis of genetic variants in tumor
(somatic) DNA and germ-line DNA that may affect disease
progression, drug response and possible toxicities are performed.
Germ-line DNA is also used for comparison to tumor DNA to explore
potential novel genetic variants underlying malignant
processes.
Results
[0448] REGN2810 in combination with hfRT is safe and well-tolerated
by patients with nGBM. Administration of REGN2810 in combination
with hfRT inhibits tumor growth and/or promotes tumor regression in
patients with nGBM as compared to standard of care therapy.
Patients with nGBM treated with REGN2810 and hfRT show a longer OS
as compared to standard of care therapy.
Example 11
Clinical Trial of REGN2810 in Patients with Advanced Cutaneous
Squamous Cell Carcinoma
[0449] This Example describes a phase 2 trial that was conducted to
confirm the positive results seen in patients with advanced CSCC in
a phase 1 trial (see Examples 7, 8 and 9 herein)
Study Objectives
[0450] The primary objective of this study is to estimate the
clinical benefit of REGN2810 monotherapy for patients with
metastatic (nodal or distant) cutaneous squamous cell carcinoma
(CSCC) (Group 1) or with unresectable locally advanced CSCC (Group
2), as measured by overall response rate (ORR).
[0451] The secondary objectives of the study are: (i) to estimate
ORR; (ii) to estimate the duration of response, progression-free
survival (PFS), and overall survival (OS); (iii) to estimate the
complete response (CR) rate; (iv) to assess the safety and
tolerability of REGN2810; (v) to assess the pharmacokinetics (PK)
of REGN2810; (vi) to assess the immunogenicity of REGN2810; and
(vii) to assess the impact of REGN2810 on quality of life using
EORTC QLQ-030.
Study Design
[0452] This is a phase 2, non-randomized, 2-group, multicenter
study of REGN2810 at a dose of 3 mg/kg administered intravenously
(IV) every 2 weeks for patients with advanced CSCC. The study has 2
groups. Group 1 is for patients with metastatic CSCC. Group 2 is
for patients with unresectable locally advanced CSCC. All patients
undergo screening procedures to determine eligibility within 28
days prior to the initial administration of REGN2810.
[0453] After a screening period of up to 28 days, patients receive
up to twelve 56-day (8-week) treatment cycles for up to 96 weeks of
treatment. Each patient receives 3 mg/kg REGN2810 IV on days 1,
15.+-.3, 29.+-.3, and 43.+-.3 during each treatment cycle. Tumor
assessments are made at the end of each treatment cycle. Extensive
safety evaluations occur on day 1 of each cycle, with routine
safety evaluations to be conducted at each REGN2810 dosing
visit.
[0454] A patient receives treatment until the 96-week treatment
period is complete, or until disease progression, unacceptable
toxicity, withdrawal of consent, or confirmed CR. Patients with
confirmed CR after a minimum of 48 weeks of treatment may elect to
discontinue treatment and continue with all relevant study
assessments (e.g., efficacy assessments).
Study Duration
[0455] Screening (up to 4 weeks), up to 96 weeks of treatment, and
up to 6 months of follow-up.
Study Population
[0456] Patients with metastatic CSCC or with unresectable locally
advanced CSCC
Study Treatment
[0457] REGN2810 3 mg/kg administered IV over 30 minutes every 14
days for 96 weeks
Study Variables
[0458] The primary efficacy endpoint for this study is ORR during
the 12 treatment cycles. Overall response rate is assessed
separately for patients with metastatic CSCC or unresectable
locally advanced CSCC: For patients in Group 1, Response Evaluation
Criteria in Solid Tumors (RECIST) version 1.1 is used to determine
ORR. .cndot.For patients in Group 2, composite response criteria
are used to determine ORR. In patients achieving a CR, tumor
biopsies are used in the final determination of complete versus
partial response (PR).
[0459] The secondary efficacy outcome measures are: duration of
response; duration of disease control; PFS; OS; CR rate; change in
scores of patient-reported outcomes on EORTC QLQ-C30; adverse
events (AEs); concentrations of REGN2810 in serum; and
anti-REGN2810 antibodies.
Procedures and Assessments
[0460] Tumor imaging (computed tomography [CT] or magnetic
resonance imaging [MRI]) and digital medical photography (for
externally visible lesions) is performed to measure tumor burden
and to characterize the efficacy profile of study treatments using
response criteria.
[0461] Physical examination, laboratory tests, vital signs,
electrocardiogram (ECG), pregnancy test for women of childbearing
potential, and recording of AEs and concomitant medications are
performed to ensure patient safety and to characterize the safety
profiles of study treatments.
[0462] Other assessments include: Peripheral blood samples for PK;
Peripheral blood samples to assess anti-REGN2810 antibodies; Tumor
biopsies; and Quality of life assessments.
Results
[0463] The trial is fully enrolled and results to-date are in line
with phase I results (described herein in Examples 7, 8 and 9) with
patients showing inhibition of tumor growth upon administration of
REGN2810. Patients with metastatic CSCC who have been treated with
prior therapies and are not amenable to surgery show complete
response, partial response or stable disease on treatment with
anti-PD-1 antibody REGN2810.
Example 12
Clinical Trial of REGN2810 in Patients with Advanced Basal Cell
Carcinoma
[0464] A phase 2 trial was conducted to confirm the positive
results seen in patients with advanced BCC in a phase 1 trial (see
Examples 7 and 8 herein).
Study Objectives
[0465] The primary objective of the study is to estimate the
overall response rate (ORR) for metastatic basal cell carcinoma
(BCC) (Group I) or unresectable locally advanced BCC (Group II),
when treated with REGN2810 monotherapy in patients who have
progressed on Hedgehog pathway inhibitor (HHI) or were intolerant
of prior HHI therapy.
[0466] The secondary objectives for both Group I and Group II are
to: (i) estimate ORR according to investigator review; (ii)
estimate the duration of response, progression-free survival (PFS)
and overall survival (OS); (iii) estimate the complete response
(CR) rate; (iv) assess the safety and tolerability of REGN2810; (v)
assess the pharmacokinetics (PK) of REGN2810; (vi) assess the
immunogenicity of REGN2810; and (vii) assess the impact of REGN2810
on quality of life using European Organisation for Research and
Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC
QLQ-C30) and Skindex-16.
Study Design
[0467] This is a phase 2, non-randomized, 2-group, multi-center
study of REGN2810 at a 350 mg dose administered intravenously (IV)
every 3 weeks (Q3W) in patients with advanced BCC who experienced
progression of disease on HHI therapy, or were intolerant of prior
HHI therapy. The study has 2 groups. Group 1 is for patients with
metastatic BCC. Group 2 is for patients with unresectable locally
advanced BCC. All patients undergo screening procedures to
determine eligibility within 28 days prior to the initial
administration of REGN2810. There is no randomization or placebo
control.
[0468] After a screening period of up to 28 days, patients receive
up to 93 weeks of treatment. Each patient receives a 350 mg Q3W
dose of REGN2810 IV. The infusion time for REGN2810 is
approximately 30 minutes (.+-.10 minutes). Tumor assessments are
made at the end of each treatment cycle, 5 treatment cycles of 9
weeks followed by 4 treatment cycles of 12 weeks). Extensive safety
evaluations occur on day 1 of each cycle, with routine safety
evaluations to be conducted at each REGN2810 dosing visit.
[0469] A patient receives treatment until the 93-week treatment
period is complete, or until disease progression (PD), unacceptable
toxicity, withdrawal of consent, or confirmed CR. Patients with
confirmed CR after a minimum of 48 weeks of treatment may elect to
discontinue treatment and continue with all relevant study
assessments (e.g., efficacy assessments). Patients who discontinue
study treatment due to PD return to the clinic 30 days (range: 28
days to 42 days) after the last study treatment to complete the
end-of-study (EOS) assessments. After the EOS visit, patients are
followed for survival status until death, loss to follow up, or
study termination.
Study Duration
[0470] After a screening period of up to 28 days, patients receive
up to 93 weeks of treatment. After the end of study visit, there is
a follow-up period consisting of periods of 28 days. Patients are
followed for survival status until death, loss to follow up, or
study termination.
Study Population
[0471] Patients with metastatic (Group 1) or unresectable locally
advanced (Group 2) BCC who experienced progression of disease on
HHI therapy, or were intolerant of prior HHI therapy.
Study Treatment
[0472] Study treatment comprised 350 mg REGN2810 administered IV
over 30 minutes (.+-.10 minutes) once every 3 weeks (q3w) for up to
93 weeks.
Endpoints
[0473] The primary efficacy endpoint for this study is the ORR. The
ORR is assessed separately for patients with metastatic BCC (Group
1) or unresectable locally advanced BCC (Group 2): [0474] For
patients in Group 1 (metastatic BCC), Response Evaluation Criteria
in Solid Tumors (RECIST) version 1.1 is used to determine ORR.
Clinical response criteria may be used for patients with externally
visible target lesions, if all metastatic lesions are not
measurable by RECIST (as may occur in patients with bone-only
metastases). [0475] For patients in Group 2 (unresectable locally
advanced BCC), clinical criteria are used to determine ORR.
Composite response criteria are used for patients with lesions that
are measureable by both clinical response criteria and RECIST
1.1.
[0476] The secondary endpoints are: (i) Duration of response; (ii)
PFS; (iii) OS; (iv) CR rate; (v) Change in scores of
patient-reported outcomes in the EORTC QLQ-C30 and the Skindex-16;
(vi) Adverse events (AEs); (vii) Concentrations of REGN2810 in
serum; and (viii) Anti-REGN2810 antibodies.
Procedures and Assessments
[0477] Tumor imaging (computed tomography [CT] or magnetic
resonance imaging [MRI]) and digital medical photography (for
externally visible lesions) are performed to measure tumor burden
and to characterize the efficacy profile of study treatments using
response criteria. Physical examination, laboratory tests, vital
signs, electrocardiogram (ECG), pregnancy test for women of
childbearing potential, and recording of AEs and concomitant
medications are performed to ensure patient safety and to
characterize the safety profiles of study treatments. Other
assessments include blood samples for PK, blood samples to assess
anti-REGN2810 antibodies, tumor biopsies, biomarkers, and quality
of life assessments.
Results
[0478] It is expected that consistent with phase 1 results (see
Examples 7 and 8 herein) administration of REGN2810 will lead to
tumor regression in patients with advanced basal cell carcinoma who
showed progression of disease upon treatment with a Hedgehog
pathway inhibitor (HHI) or were intolerant of prior HHI therapy.
Patients show complete response, partial response or stable disease
upon treatment with REGN2810.
[0479] The present invention is not to be limited in scope by the
specific embodiments described herein. Indeed, various
modifications of the invention in addition to those described
herein will become apparent to those skilled in the art from the
foregoing description and the accompanying figures. Such
modifications are intended to fall within the scope of the appended
claims.
Sequence CWU 1
1
101117PRTArtificial SequenceR2810 HCVR 1Glu Val Gln Leu Leu Glu Ser
Gly Gly Val Leu Val Gln Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser
Cys Ala Ala Ser Gly Phe Thr Phe Ser Asn Phe 20 25 30 Gly Met Thr
Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ser
Gly Ile Ser Gly Gly Gly Arg Asp Thr Tyr Phe Ala Asp Ser Val 50 55
60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu
Tyr65 70 75 80 Leu Gln Met Asn Ser Leu Lys Gly Glu Asp Thr Ala Val
Tyr Tyr Cys 85 90 95 Val Lys Trp Gly Asn Ile Tyr Phe Asp Tyr Trp
Gly Gln Gly Thr Leu 100 105 110 Val Thr Val Ser Ser 115
2107PRTArtificial SequenceR2810 LCVR 2Asp Ile Gln Met Thr Gln Ser
Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Ser Ile Thr Ile
Thr Cys Arg Ala Ser Leu Ser Ile Asn Thr Phe 20 25 30 Leu Asn Trp
Tyr Gln Gln Lys Pro Gly Lys Ala Pro Asn Leu Leu Ile 35 40 45 Tyr
Ala Ala Ser Ser Leu His Gly Gly Val Pro Ser Arg Phe Ser Gly 50 55
60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Arg Thr Leu Gln
Pro65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Ser Ser Asn
Thr Pro Phe 85 90 95 Thr Phe Gly Pro Gly Thr Val Val Asp Phe Arg
100 105 38PRTArtificial SequenceR2810 HCDR1 3Gly Phe Thr Phe Ser
Asn Phe Gly1 5 48PRTArtificial SequenceR2810 HCDR2 4Ile Ser Gly Gly
Gly Arg Asp Thr1 5 510PRTArtificial SequenceR2810 HCDR3 5Val Lys
Trp Gly Asn Ile Tyr Phe Asp Tyr1 5 10 66PRTArtificial SequenceR2810
LCDR1 6Leu Ser Ile Asn Thr Phe1 5 73PRTArtificial SequenceR2810
LCDR2 7Ala Ala Ser1 89PRTArtificial SequenceR2810 LCDR3 8Gln Gln
Ser Ser Asn Thr Pro Phe Thr1 5 9444PRTArtificial SequenceR2810 HC
9Glu Val Gln Leu Leu Glu Ser Gly Gly Val Leu Val Gln Pro Gly Gly 1
5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Asn
Phe 20 25 30 Gly Met Thr Trp Val Arg Gln Ala Pro Gly Lys Gly Leu
Glu Trp Val 35 40 45 Ser Gly Ile Ser Gly Gly Gly Arg Asp Thr Tyr
Phe Ala Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp
Asn Ser Lys Asn Thr Leu Tyr65 70 75 80 Leu Gln Met Asn Ser Leu Lys
Gly Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Val Lys Trp Gly Asn
Ile Tyr Phe Asp Tyr Trp Gly Gln Gly Thr Leu 100 105 110 Val Thr Val
Ser Ser Ala Ser Thr Lys Gly Pro Ser Val Phe Pro Leu 115 120 125 Ala
Pro Cys Ser Arg Ser Thr Ser Glu Ser Thr Ala Ala Leu Gly Cys 130 135
140 Leu Val Lys Asp Tyr Phe Pro Glu Pro Val Thr Val Ser Trp Asn
Ser145 150 155 160 Gly Ala Leu Thr Ser Gly Val His Thr Phe Pro Ala
Val Leu Gln Ser 165 170 175 Ser Gly Leu Tyr Ser Leu Ser Ser Val Val
Thr Val Pro Ser Ser Ser 180 185 190 Leu Gly Thr Lys Thr Tyr Thr Cys
Asn Val Asp His Lys Pro Ser Asn 195 200 205 Thr Lys Val Asp Lys Arg
Val Glu Ser Lys Tyr Gly Pro Pro Cys Pro 210 215 220 Pro Cys Pro Ala
Pro Glu Phe Leu Gly Gly Pro Ser Val Phe Leu Phe225 230 235 240 Pro
Pro Lys Pro Lys Asp Thr Leu Met Ile Ser Arg Thr Pro Glu Val 245 250
255 Thr Cys Val Val Val Asp Val Ser Gln Glu Asp Pro Glu Val Gln Phe
260 265 270 Asn Trp Tyr Val Asp Gly Val Glu Val His Asn Ala Lys Thr
Lys Pro 275 280 285 Arg Glu Glu Gln Phe Asn Ser Thr Tyr Arg Val Val
Ser Val Leu Thr 290 295 300 Val Leu His Gln Asp Trp Leu Asn Gly Lys
Glu Tyr Lys Cys Lys Val305 310 315 320 Ser Asn Lys Gly Leu Pro Ser
Ser Ile Glu Lys Thr Ile Ser Lys Ala 325 330 335 Lys Gly Gln Pro Arg
Glu Pro Gln Val Tyr Thr Leu Pro Pro Ser Gln 340 345 350 Glu Glu Met
Thr Lys Asn Gln Val Ser Leu Thr Cys Leu Val Lys Gly 355 360 365 Phe
Tyr Pro Ser Asp Ile Ala Val Glu Trp Glu Ser Asn Gly Gln Pro 370 375
380 Glu Asn Asn Tyr Lys Thr Thr Pro Pro Val Leu Asp Ser Asp Gly
Ser385 390 395 400 Phe Phe Leu Tyr Ser Arg Leu Thr Val Asp Lys Ser
Arg Trp Gln Glu 405 410 415 Gly Asn Val Phe Ser Cys Ser Val Met His
Glu Ala Leu His Asn His 420 425 430 Tyr Thr Gln Lys Ser Leu Ser Leu
Ser Leu Gly Lys 435 440 10214PRTArtificial SequenceR2810 LC 10Asp
Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10
15 Asp Ser Ile Thr Ile Thr Cys Arg Ala Ser Leu Ser Ile Asn Thr Phe
20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Asn Leu
Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu His Gly Gly Val Pro Ser
Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr
Ile Arg Thr Leu Gln Pro65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys
Gln Gln Ser Ser Asn Thr Pro Phe 85 90 95 Thr Phe Gly Pro Gly Thr
Val Val Asp Phe Arg Arg Thr Val Ala Ala 100 105 110 Pro Ser Val Phe
Ile Phe Pro Pro Ser Asp Glu Gln Leu Lys Ser Gly 115 120 125 Thr Ala
Ser Val Val Cys Leu Leu Asn Asn Phe Tyr Pro Arg Glu Ala 130 135 140
Lys Val Gln Trp Lys Val Asp Asn Ala Leu Gln Ser Gly Asn Ser Gln145
150 155 160 Glu Ser Val Thr Glu Gln Asp Ser Lys Asp Ser Thr Tyr Ser
Leu Ser 165 170 175 Ser Thr Leu Thr Leu Ser Lys Ala Asp Tyr Glu Lys
His Lys Val Tyr 180 185 190 Ala Cys Glu Val Thr His Gln Gly Leu Ser
Ser Pro Val Thr Lys Ser 195 200 205 Phe Asn Arg Gly Glu Cys 210
* * * * *