Anti-GDF15 antibodies for combination therapy for specific patient group and

Abstract

The present invention relates to the treatment of specific groups of patients using an anti-GDF15 antibody in combination with a checkpoint inhibitor. In addition, the present invention also provides dosage regimens for the treatment of cancer in a human patient using an anti-GDF15 antibody.

Description

Technical Field

[0001] The present invention relates to the use of anti-GDF15 antibodies in combination with checkpoint inhibitors to treat specific patient groups. In addition, the present invention also provides dosage regimens for the use of anti-GDF15 antibodies to treat cancer in human subjects. Background Art

[0002] GDF-15 is a divergent member of the TGF-β superfamily, whose functions in appetite regulation, metabolism, inflammation, cell and tissue survival, and immune tolerance have been described. GDF-15 is a homodimer that is produced as a proprotein that is cleaved into a 25 kDa (2×112 aa) dimeric mature GDF-15 and a 2×18 kDa (2×167 aa) propeptide that is present in tissues (Tsai 2018) and released into the blood.

[0003] To date, two major categories of GDF-15 activity have been described. The first category involves metabolic effects, i.e., GDF-15 mediates cachexia by altering food intake behavior (inducing anorexia) (Johnen 2007). This effect is mediated by a brainstem-specific receptor called GFRAL, which was described in late 2017 (Emmerson 2017). In contrast, the second category involves immunomodulatory effects, i.e., GDF-15 has been shown to be a mediator of immune tolerance in pregnancy (Tong et al. 2004), tissue damage (Chung et al. 2017), and inflammation (Abulizi 2016), autoimmune diseases, and tumor escape. GDF-15 inhibits the activation of leukocyte integrins and thereby prevents their infiltration (Kempf 2011).

[0004] In recent years, increasing evidence has shown that GDF-15 plays a key immunomodulatory role in physiological and pathophysiological situations and in cancer in particular. For cancer cells, it is naturally very attractive to exploit and "hijack" such immune cell exclusion mechanisms, that is, to block the entry of immune cells into the tumor microenvironment and thus prevent the immune system from clearing cancer cells. In line with this, a large number of publications have appeared in recent years, which show that high GDF-15 serum levels in various cancer types are associated with shorter overall survival, and GDF-15 is an independent factor for patient survival in multiple tumor types (Wischhusen et al, 2020).

[0005] Elevated levels of GDF-15 are frequently reported in cancer patients. In a microarray-based study comparing 150 cancers from 10 anatomical origins with 46 normal tissues, GDF-15 showed the highest level of tumor-associated (over)expression (Welsh 2003), and several studies have associated GDF-15 serum levels with lower response / poorer prognosis in cancer.

[0006] Additionally, two proprietary analyses from two different academic melanoma research groups showed that pre-treatment GDF-15 levels also correlated with response to PD-1 antagonists.

[0007] As indicated, cancer tissues, normal organ tissues in distress, and placenta are known to overexpress GDF-15, presumably to prevent excessive immune cell infiltration into the corresponding tissues. Therefore, the inventors believe that GDF-15 produced by the above tissues does significantly reduce vascular T cell adhesion and endothelial transmembrane migration, preventing T cells from entering the corresponding tissues or their adjacent tissues.

[0008] Although anti-GDF-15 antibodies generally exhibit a benign and well-accepted safety profile in animal models, this mode of action naturally carries with it a variety of potential risks when aiming to provide an appropriate dosing regimen for treatment of humans.

[0009] A logical combination partner for an anti-GDF-15 antibody would be a T cell activating compound (e.g., an anti-PD-1 / PD-L1 checkpoint inhibitor), or a cellular T cell therapy (e.g., CAR-T or TCR-T therapy). The efficacy of such compounds and therapies could be significantly enhanced by increasing the intratumor presence of anti-tumor T cells. However, their toxicity may also be enhanced when combined with an anti-GDF-15 neutralizing antibody at a specific dosage regimen.

[0010] WO 2022 / 101263 describes anti-GDF-15 antibodies and dosage regimens for treating cancer.

[0011] A second potential area of ​​concern is the physiological role of GDF-15 in organ protection of organs in distress. If anti-GDF-15 antibodies are used to inhibit GDF-15, and organ distress (e.g., myocardial infarction, infection, other significant organ injury) occurs, excessive organ infiltration of immune cells and unwelcome tissue damage / destruction may occur.

[0012] A third potential area of ​​concern is rare findings in individual mouse knockout models for GDF-15 (Wischhusen 2020).

[0013] Another challenge in the field of cancer therapy is to identify cancer subtypes that are particularly responsive to the corresponding cancer therapy. Although the average therapeutic effect of a particular cancer therapy on a cancer may be only moderate, a particular subtype of the corresponding cancer and a subgroup of corresponding cancer patients may be particularly responsive to the therapy and may therefore face a more favorable clinical situation than other patients. In fact, increasing evidence shows that for many types of cancer, there are different cancer subtypes (especially molecular and / or histological subtypes) with different prognostic and therapeutic implications.

[0014] These considerations are particularly applicable to targeted cancer therapies, ie, therapies that rely on inhibition of a specific target protein. Because treatment with anti-GDF-15 antibodies is a targeted therapy, there is a need to identify types and subtypes of cancer that are particularly responsive to treatment with anti-GDF-15 antibodies.

[0015] Similarly, there is still a challenge in the field of cancer treatment to direct treatment to a patient group that is particularly responsive to treatment. In general, the characterization of a patient group can be based on a variety of factors, such as the patient's treatment history or the presence of biomarkers in cancer tissue. In this regard, immune checkpoint molecules or PD-L1 were previously considered to be potential markers for cancer treatment using anti-PD1 or anti-PD-L1 antibodies. However, there is a special need for the identification of suitable biomarkers for combined treatment with anti-GDF-15 antibodies and immune checkpoint inhibitors (such as anti-PD1 or anti-PD-L1 antibodies). For example, such a combination therapy can even be successfully used for patients who are refractory to monotherapy with anti-PD1 or anti-PD-L1 antibodies or to combined treatment with anti-PD1 or anti-PD-L1 antibodies and other anti-cancer agents. Therefore, such a combination therapy is clinically different from monotherapy with anti-PD1 or anti-PD-L1 antibodies, or different from combined treatment with anti-PD1 or anti-PD-L1 antibodies and other anti-cancer agents, and they are considered to be associated with different biomarkers. Therefore, there remains a need in the art to allow identification / enrichment of specific patient groups that are particularly responsive to cancer treatments, and to allow treatment of these patient groups. Summary of the invention

[0016] To meet the above needs, the present invention provides treatments for specific patient subgroups that are particularly responsive to treatment with a checkpoint inhibitor in combination with an anti-GDF-15 antibody.

[0017] In another aspect, the present invention also provides safe and effective dosing regimens of anti-GDF-15 antibodies in the therapeutic treatment of such patient subgroups.

[0018] According to the present invention, these patient subgroups will particularly benefit from treatment with anti-GDF-15 antibodies.

[0019] Initially, PD-L1 was described as a marker enriched for patients who responded to aPD-1 / -L1 monotherapy. The inventors have now found, among other things, that patients who have relapsed from or are refractory to prior anti-PD-1 / L-1 therapy and who have tumors expressing PD-L1 at baseline (i.e., at the time of initiation of treatment with an anti-GDF-15 antibody) and / or have evidence of an inflamed tumor at baseline (as reflected, for example, by a high Tumor Inflammation Score (TIS) and a certain minimum CD3 or CD8 cell infiltration count) are more likely to have a particularly favorable clinical outcome (e.g., treatment response) when treated with a combination therapy of an anti-GDF-15 antibody with an anti-PD1 / anti-PD-L1 antibody (e.g., nivolumab) than patients with tumors that do not have these characteristics.

[0020] It was previously reported that baseline samples obtained from anti-PD1 / anti-PD-L1 (monotherapy) responder patients showed higher numbers of cells expressing CD8-, PD-1-, and PD-L1 in tumors (Tumeh et al., Nature. 2014 Nov 27;515(7528):568-71). In addition, TIS was also reported to be associated with the expression of PD-L1 (also known as CD274) (Danaher et al., 2018).

[0021] However, the patients studied by the inventors were patients with progressive disease when treated with anti-PD1 or anti-PD-L1 antibodies. In these cases where treatment with anti-PD1 or anti-PD-L1 antibodies in a monotherapy setting has proven to fail, it is very unexpected that patients with cancers with high TIS, specific minimum CD3 or CD8 cell infiltration counts, and PD-L1 expression will particularly benefit from anti-GDF-15 antibody combined with checkpoint blockers (e.g., anti-PD1 / anti-PD-L1 antibodies, such as nivolumab). More specifically, it is expected that the clinical outcome of immunotherapy with anti-GDF-15 antibodies in combination with checkpoint inhibitors will be controlled by completely different biomarkers.

[0022] Furthermore, although inhibition of GDF-15 by anti-GDF-15 antibodies helps increase the percentage of CD3+ T cells and CD8+ T cells in cancer, as has been previously described, for example, in WO 2017 / 055613, the inventors unexpectedly discovered that the pre-existence of CD3+ cells and CD8+ cells and PD-L1 in cancer and a high TIS score still benefit the clinical outcome of treatment. In some aspects of the invention, for example, baseline infiltration indicates a residual anti-tumor immune response, which can then be enhanced by anti-GDF-15 and maintained effective by combination therapy of anti-GDF-15 with a checkpoint inhibitor (e.g., anti-PD-1 / -L1) to ultimately lead to tumor shrinkage.

[0023] Selecting a group of patients with a more favorable clinical outcome according to the present invention is expected to be a helpful and effective selection criterion in clinical practice, because only a subgroup of patients have cancers with such characteristics. For example, although PD-L1 can be expressed in many different cancer types, only a subgroup of cancer patients of each cancer type will express PD-L1 (see Yarchoan et al., JCI Insight. 2019 Mar 21; 4(6): e126908 and Chen et al., Exp Hematol Oncol. 2020 Aug 3; 9: 17. doi: 10.1186 / s40164-020-00173-3. eCollection 2020.).

[0024] Thus, the present invention allows, among other things, the selection and selective treatment of patients who would be in a particularly favorable clinical condition when treated with a combination therapy of an anti-GDF-15 antibody with a checkpoint blocker (e.g., an anti-PD1 / anti-PD-L1 antibody, such as nivolumab).

[0025] According to the present invention, analysis of clinical data revealed that PD-L1 TPS was a positive enrichment factor for clinical response. In addition, clinical data also revealed that patient selection by PD-L1 TPS alone or in combination with either CD8 cell density, CD3 cell density or TIS enriched clinical responders.

[0026] Therefore, the present invention provides the following preferred embodiments: Item 1. A pharmaceutical composition comprising an anti-GDF-15 antibody in combination with at least one checkpoint inhibitor for use in a method of treating cancer in a human patient, wherein the human patient has a PD-L1 positive cancer and / or has a cancer comprising an inflamed tumor. Item 2. A pharmaceutical composition for use according to Item 1, wherein the cancer is a PD-L1 positive cancer as determined by immunohistochemistry (IHC). Item 3. A pharmaceutical composition for use according to Item 2, wherein the IHC assay uses an anti-PD-L1 antibody as a primary antibody and determines the percentage of PD-L1 positive cancer cells. Item 4. A pharmaceutical composition for use according to any one of Items 2 to 3, wherein the PD-L1 positive cancer shows a percentage of cancer cells stained for the presence of PD-L1 on the cell surface of at least 1 in an immunohistochemistry (IHC) assay. Item 5. A pharmaceutical composition for use according to Item 2, wherein the IHC assay uses an anti-PD-L1 antibody as a primary antibody and determines the total percentage of PD-L1-positive cancer cells and PD-L1-positive cancer-infiltrating cells. Item 6. A pharmaceutical composition for use according to any one of Items 1 to 5, wherein the inflammatory tumor is a T-cell inflammatory tumor. Item 7. A pharmaceutical composition for use according to any one of Items 1 to 6, wherein the inflammatory tumor is a tumor comprising CD3+ cells. Item 8. A pharmaceutical composition for use according to Item 7, wherein the inflamed tumor comprises CD3+ cells as determined by immunohistochemistry (IHC) assay, and wherein the IHC assay uses an anti-CD3 antibody as the primary antibody. Item 9. A pharmaceutical composition for use according to Item 8, wherein the inflammatory tumor has an average CD3+ cell density of >300 cells / mm in an immunohistochemical tissue section with a thickness of 4 μm. 2 of tumors, as assessed by immunohistochemistry (IHC) assay. Item 10. A pharmaceutical composition for use according to any one of Items 1 to 9, wherein the inflammatory tumor is a tumor comprising CD8+ cells. Item 11. A pharmaceutical composition for use according to Item 10, wherein the inflamed tumor comprises CD8+ cells as determined by immunohistochemistry (IHC) assay, and wherein the IHC assay uses an anti-CD8 antibody as the primary antibody. Item 12. A pharmaceutical composition for use according to Item 11, wherein the inflammatory tumor has an average CD8+ cell density of >300 cells / mm in an immunohistochemical tissue section with a thickness of 4 μm. 2 of tumors, as assessed by immunohistochemistry (IHC) assay. Item 13. A pharmaceutical composition for use according to any one of Items 6 to 12, wherein the T cell inflamed tumor is inflamed as indicated by its tumor inflammation signature (TIS). Item 14. A pharmaceutical composition for use according to Item 13, wherein the TIS is based on the expression of at least one marker gene selected from PSMB10, HLA-DQA1, HLA-DRB1, CMKLR1, HLA-E, NKG7, CD8A, CCL5, CXCL9, CD27, CXCR6, IDO1, STAT1, TIGIT, LAG3, CD274, PDCD1LG2 and CD276, preferably the expression of all marker genes. Item 15. A pharmaceutical composition for use according to Item 14, wherein the TIS is a linear combination of all the marker genes, calculated as where x i is the log2-transformed normalized expression level of the ith gene, and w i is a predefined weight greater than zero. Item 16. A pharmaceutical composition for use according to Item 15, wherein the TIS is greater than 7.5. Item 17. A pharmaceutical composition for use according to any one of Items 1 to 16, wherein the human patient is an anti-PD-1 patient and / or an anti-PD-L1 relapsed and / or refractory patient. Item 18. A pharmaceutical composition for use according to any one of Items 1 to 17, wherein the checkpoint inhibitor is selected from one or more of the following: an anti-PD-1 antibody or a PD-1 binding fragment thereof, an anti-PD-L1 antibody or a PD-L1 binding fragment thereof, an anti-CD40 antibody or a CD40 binding fragment thereof, an anti-LAG-3 antibody or a LAG-3 binding fragment thereof, an anti-TIM-3 antibody or a TIM-3 binding fragment thereof, an anti-TIGIT antibody or a TIGIT binding fragment thereof, and an anti-CTLA4 antibody or a CTLA4 binding fragment thereof. Item 19. A pharmaceutical composition for use according to Item 18, wherein the checkpoint inhibitor is selected from an anti-PD-1 antibody or a PD-1 binding fragment thereof and an anti-PD-L1 antibody or a PD-L1 binding fragment thereof. Item 20. A pharmaceutical composition for use according to any one of Items 1 to 19, wherein the cancer is a solid cancer. Item 21. A pharmaceutical composition for use according to any one of Items 1 to 20, wherein the cancer is selected from the following: colorectal cancer, gastric cancer, bladder cancer, melanoma, non-small cell lung cancer, head and neck squamous cell carcinoma, hepatocellular carcinoma, prostate adenocarcinoma, pancreatic cancer, uterine cancer, cervical cancer, thyroid cancer, cutaneous squamous cell carcinoma, mesothelioma, cancer of unknown primary (CUP) and breast cancer. Item 22. A pharmaceutical composition for use according to any one of Items 1 to 21, wherein the anti-GDF-15 antibody comprises a heavy chain variable domain and a light chain variable domain, the heavy chain variable domain comprising a CDR1 region represented by the amino acid sequence shown in SEQ ID NO: 1, a CDR2 region represented by the amino acid sequence shown in SEQ ID NO: 2, and a CDR3 region represented by the amino acid sequence shown in SEQ ID NO: 3, and the light chain variable domain comprising a CDR1 region represented by the amino acid sequence shown in SEQ ID NO: 4, a CDR2 region represented by the amino acid sequence ser-ala-ser, and a CDR3 region represented by the amino acid sequence shown in SEQ ID NO: 5. Item 23. A pharmaceutical composition for use according to any one of Items 1 to 22, wherein the anti-GDF-15 antibody has a heavy chain variable domain and a light chain variable domain, the heavy chain variable domain comprises an amino acid sequence represented by SEQ ID NO: 6 or an amino acid sequence that is at least 90% identical, preferably at least 95% identical, and more preferably at least 98% identical to the amino acid sequence shown in SEQ ID NO: 6, and the light chain variable domain comprises an amino acid sequence represented by SEQ ID NO: 7 or an amino acid sequence that is at least 90% identical, preferably at least 95% identical, and more preferably at least 98% identical to the amino acid sequence shown in SEQ ID NO: 7. Item 24. A pharmaceutical composition for use according to any one of Items 1 to 23, wherein the anti-GDF-15 antibody has a heavy chain and a light chain, the heavy chain comprising the amino acid sequence represented by SEQ ID NO: 8 or an amino acid sequence that is at least 90% identical, preferably at least 95% identical, and more preferably at least 98% identical to the amino acid sequence shown in SEQ ID NO: 8, and the light chain comprising the amino acid sequence shown in SEQ ID NO: 9 or an amino acid sequence that is at least 90% identical, preferably at least 95% identical, and more preferably at least 98% identical to the amino acid sequence shown in SEQ ID NO: 9. Item 25. A pharmaceutical composition for use according to any one of Items 1 to 24, wherein the anti-GDF-15 antibody has a heavy chain comprising the amino acid sequence represented by SEQ ID NO: 8 and a light chain comprising the amino acid sequence represented by SEQ ID NO: 9. Item 26. A pharmaceutical composition for use according to any one of Items 1 to 25, wherein the anti-GDF-15 antibody is to be administered to the human patient, preferably i) a dose of 3 to 20 mg / kg, preferably a dose of 10 mg / kg, and a dosage regimen of at least one administration cycle, wherein the cycle is a two-week period, and wherein the dose is to be administered at least once in each cycle of the at least one cycle, ii) a dose of 3 to 20 mg / kg, preferably a dose of 10 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a three week period, and wherein the dose is to be administered at least once in each of the at least one cycle, or iii) a dose of 3 to 20 mg / kg, preferably a dose of 20 mg / kg, and a dosage regimen of at least one administration cycle, wherein the cycle is a period of four weeks, and wherein the dose is to be administered at least once in each cycle of the at least one cycle, And wherein the cancer is selected from colorectal cancer, gastric cancer, bladder cancer, melanoma, non-small cell lung cancer, head and neck squamous cell carcinoma, hepatocellular carcinoma, prostate adenocarcinoma, pancreatic cancer, uterine cancer, cervical cancer, thyroid cancer, skin squamous cell carcinoma, mesothelioma, cancer of unknown primary (CUP) and breast cancer. Item 27. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is colorectal cancer. Item 28. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is bladder cancer. Item 29. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is cancer of unknown primary (CUP). Item 30. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is mesothelioma. Item 31. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is squamous cell carcinoma of the skin. Item 32. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is non-small cell lung cancer. Item 33. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is hepatocellular carcinoma. Item 34. A pharmaceutical composition for use according to any one of Items 1 to 26, wherein the cancer is melanoma. Item 35. A pharmaceutical composition for use according to any of the preceding items, wherein the use is also for treating cancer cachexia. Item 36. A pharmaceutical composition for use according to any one of Items 1 to 35, wherein the anti-GDF-15 antibody is administered at a dose of 3 to 20 mg / kg, preferably 20 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a four-week period, and wherein the dose is administered at least once in each cycle of at least one cycle. Item 37. A pharmaceutical composition for use according to any one of Items 1 to 36, wherein the anti-GDF-15 antibody is administered at a dose of 3 to 20 mg / kg, preferably 10 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a three-week period, and wherein the dose is administered at least once in each cycle of at least one cycle. Item 38. A pharmaceutical composition for use according to any one of Items 1 to 37, wherein the anti-GDF-15 antibody is administered at a dose of 3 to 20 mg / kg, preferably 10 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a two-week period, and wherein the dose is administered at least once in each cycle of at least one cycle. Item 39. A pharmaceutical composition for use according to any one of Items 1 to 38, wherein the anti-GDF-15 antibody can be obtained by expression in CHO cells. Item 40. A pharmaceutical composition for use according to any one of Items 1 to 39, wherein the checkpoint inhibitor is administered at the same dosage regimen as the anti-GDF-15 antibody. Item 41. A pharmaceutical composition for use according to any one of Items 1 to 40, wherein the checkpoint inhibitor is administered before the administration of the anti-GDF-15 antibody, preferably within 120 minutes before the administration of the anti-GDF-15 antibody, and more preferably within 30 minutes before the administration of the anti-GDF-15 antibody. Item 42. A pharmaceutical composition for use according to any one of Items 1 to 41, wherein the dose of anti-GDF-15 antibody is to be administered intravenously. Item 43. A method for predicting the clinical outcome of a human cancer patient treated with a combination of an anti-GDF-15 antibody and at least one checkpoint inhibitor, wherein the method comprises the following steps: (i) analyzing whether the cancer is a PD-L1 positive cancer and / or a cancer comprising an inflammatory tumor, and (ii) predicting the patient's clinical outcome in response to the treatment based on the analysis. Item 44. A method of treating a human patient diagnosed with cancer, comprising the steps of: (a) analyzing whether the cancer is a PD-L1 positive cancer and / or a cancer comprising an inflammatory tumor, (b) predicting the patient's clinical outcome for the treatment based on the analysis, and (c) treating said human patient comprising a combination of an anti-GDF-15 antibody and at least one checkpoint inhibitor. Item 45. A method according to Item 43 or 44, wherein the clinical outcome includes response, complete response, partial response, stable disease, disease progression and / or survival of the human cancer patient. Item 46. A method according to any one of Items 43 to 45, wherein if the cancer is a PD-L1 positive cancer, the patient is predicted to show an improved clinical outcome. Item 47. A method according to Item 46, wherein the PD-L1 positive cancer is as defined in Items 2 to 5. Item 48. A method according to any one of Items 43 to 47, wherein if the cancer comprises an inflammatory tumor, the patient is predicted to exhibit an improved clinical outcome. Item 49. The method according to Item 48, wherein the inflamed tumor is as defined in Items 6 to 16. Item 50. A method according to any one of Items 43 to 49, wherein the checkpoint inhibitor is as defined in Item 18 or 19. Item 51. A method according to any one of Items 43 to 50, wherein the cancer is selected from the cancer defined in Item 20 or 21. Item 52. A method according to any one of Items 43 to 51, wherein the human patient is an anti-PD-1 patient and / or an anti-PD-L1 relapsed and / or refractory patient. Item 53. An anti-GDF-15 antibody for use in a method of treating cancer in a human patient, wherein the anti-GDF-15 antibody is to be administered in combination with at least one checkpoint inhibitor, and wherein the human patient has a PD-L1 positive cancer and / or has a cancer comprising an inflamed tumor. Item 54. An anti-GDF-15 antibody for use according to Item 53, wherein the patient suffers from a cancer as defined in any one of Items 2 to 16, 19 to 21 and 26 to 34. Item 55. An anti-GDF-15 antibody for use according to Item 53 or 54, wherein the patient is as defined in Item 17. Item 56. An anti-GDF-15 antibody for use according to any one of Items 53 to 55, wherein the checkpoint inhibitor is as defined in any one of Items 18 to 19. Item 57. An anti-GDF-15 antibody for use according to any one of Items 53 to 56, wherein the anti-GDF-15 antibody is as defined in any one of Items 22 to 25 and 39. Item 58. An anti-GDF-15 antibody for use according to any one of Items 53 to 57, wherein the anti-GDF-15 antibody is administered as defined in any one of Items 26, 36 to 38 and 42. Item 59. An anti-GDF-15 antibody for use according to any one of Items 53 to 58, wherein the checkpoint inhibitor is administered as defined in any one of Items 40 to 41. Item 60. An anti-GDF-15 antibody for use according to any one of Items 53 to 59, wherein the use is also for treating cancer cachexia. Item 61. A pharmaceutical composition for use according to any one of Items 1 to 42 or an anti-GDF-15 antibody for use according to any one of Items 53 to 60, wherein the PD-L1-positive cancer shows a percentage of cancer cells stained for the presence of PD-L1 on the cell surface in an immunohistochemistry (IHC) assay of at least 1, preferably at least 2, and more preferably at least 5. Item 62. A pharmaceutical composition or anti-GDF-15 antibody for use according to Item 61, wherein the cancer is bladder cancer.

[0027] It should be understood that, according to the present invention, reference to "at least one check point inhibitor" means that the specified check point inhibitor is required, and additional check point inhibitors may be included or not included, i.e., they are optionally included. For example, it should be understood that in the case where the present invention relates to at least one check point inhibitor, wherein the check point inhibitor is selected from anti-PD-1 antibodies or PD-1 binding fragments thereof and anti-PD-L1 antibodies or PD-L1 binding fragments thereof, this means that a check point inhibitor selected from anti-PD-1 antibodies or PD-1 binding fragments thereof and anti-PD-L1 antibodies or PD-L1 binding fragments thereof is required, and additional check point inhibitors (e.g., anti-CD40 antibodies or CD40 binding fragments thereof, anti-LAG-3 antibodies or LAG-3 binding fragments thereof, anti-TIM-3 antibodies or TIM-3 binding fragments thereof, anti-TIGIT antibodies or TIGIT binding fragments thereof, and anti-CTLA4 antibodies or CTLA4 binding fragments thereof) may be included or not included, i.e., they are optionally included. BRIEF DESCRIPTION OF THE DRAWINGS Figure 1 : Treatment of GDF-15-producing tumors with anti-mGDF-15 antibodies significantly enhanced the response to anti-PD1 antibodies.

[0028] Anti-mGDF-15 antibody alone had a moderate effect, whereas combination with anti-PD-1 was able to significantly enhance the therapeutic effect of anti-PD-1 therapy.

[0029] (A): Female albino C57B1 / 6 mice were treated with 1×10 6 Panc02-Luc cells were injected into the pancreatic tail. On day 5, animals were randomized by bioluminescent imaging and treated twice a week with vehicle / anti-mGDF-15 / anti-PD-1 / anti-mGDF-15+anti-PD1. (B) and (C): Tumor burden was assessed at least weekly by in vivo bioluminescent imaging. Tumor growth was assessed by correlating measurements on day 35 with signals during randomization. Tumor growth was compared by Mann-Whitney test and corrected for multiple comparisons according to Bonferroni-Holm. Figure 2 : Animals treated with CTL-002 showed higher immune cell infiltration enriched in CD3+ cells.

[0030] Syngeneic mouse models MBT-2 (left) and Pan02 (right) showed higher immune cell infiltration in aGDF-15-treated animals. Figure 3 :Sequences of CTL-002 binding regions in different species

[0031] The sequences of the CTL-002 binding regions of human, cynomolgus monkey, mouse and rat are shown (first four rows from top to bottom). Figure 4 : GDF-15 serum levels in female monkeys after the first dose of CTL-002 Figure 5 : Predicted GDF-15 inhibition in tumor microvasculature considering different dosing intervals

[0032] Predicted GDF-15 inhibition in tumor microvasculature.

[0033] Hypothesis: Three baseline levels of systemic GDF-15 (0.5, 2, and 10 ng / mL), three different CTL-002 concentrations (3, 10, and 20 mg / kg), and three different CTL-002 dosing intervals (2, 3, and 4 weeks). Figure 6 : Visualization of the correlation between clinical response and PD-L1 TPS and TIS

[0034] Baseline biopsies from clinical responders 1-02-006, 1-03-004, 1-03-002, and long-term SD2-01-003 showed PD-L1 TPS>1 and tumor inflammation score (TIS)>7.5, indicating the predictive value of PD-L1 TPS and TIS for CTL-002 / nivolumab response in anti-PD-1 / PD-L1 refractory patients. In addition, 6 of 19 patients showed PD-L1 TPS>1, and 50% (3 of 6) of them showed PR. Figure 7 : Correlation of PD-L1 TPS relative to CD8 cell count

[0035] (A) Baseline biopsies from clinical responders 1-02-006, 1-03-004, 1-03-002, and long-term SD2-01-003 demonstrated PD-L1 TPS>1 and CD8+ T cell density>300 cells / mm 2 , indicating the predictive value of CTL-002 / nivolumab response of PD-L1 TPS and CD8+ T cell density in patients refractory to anti-PD-1 / PD-L1. In addition, 6 of 19 patients showed PD-L1 TPS>1, and 50% (3 of 6) of them showed PR. In addition, 5 of 19 patients showed PD-L1 TPS>1 and CD8 cell density>300 cells / mm2, and 60% (3 of 5) of them showed PR.

[0036] (B) Updated version of (A) including additional patients, notably including clinical responders 1-02-036 and 1-06-005, who also demonstrated PD-L1 TPS>1 and CD8+ T cell density>300 cells / mm 2 . In addition, 27 of 60 patients showed PD-L1 TPS>1, and 18.5% (5 of 27) of them showed PR. In addition, 15 of 60 patients showed PD-L1TPS>1 and CD8 cell density>300 cells / mm2, and 33.3% (5 of 15) of them showed PR. Figure 8 : Correlation of PD-L1 TPS relative to CD3 cell count

[0037] Baseline biopsies from clinical responders 1-02-006, 1-03-004, 1-03-002 and long-term SD 2-01-003 showed PD-L1 TPS>1 and CD3+ T cell density>300 cells / mm 2, indicating the predictive value of CTL-002 / nivolumab response by PD-L1 TPS and CD3+ T cell density in patients refractory to anti-PD-1 / PD-L1. In addition, 6 of 18 patients showed PD-L1 TPS>1, and 50% of them (3 of 6) showed PR. Fig. 9 : Fold changes in CD8+ and CD3+ki67+ cells in treated human patients at days 14 and 28 compared to baseline (Bsl)

[0038] Immune cell analysis in biopsies from patients at baseline (bs1), day 14, and day 28 showed an increase in CD8+ T cells (upper panel) and proliferating CD3+ki67+ T cells (lower panel) under treatment. DETAILED DESCRIPTION

[0039] Unless specifically defined herein, 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 relates.

[0040] All methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, where suitable methods and materials are described herein.

[0041] All references mentioned herein are incorporated by reference in their entirety for all purposes. Patent applications are referenced herein by using their application numbers and / or publication numbers. Non-patent literature mentioned herein may be cited as a full reference or in abbreviated form (e.g., Danaher et al., 2018), followed by citing the full reference in the "References" section.

[0042] As used herein, each occurrence of terms such as "comprises / includes" and variations thereof may optionally be replaced with "consisting of" or variations thereof.

[0043] The present invention provides anti-GDF15 antibodies that are useful for treating cancer in human patients.

[0044] GDF-15 can be measured by ELISA. ELISAs that can be used to measure GDF-15 include, but are not limited to, R&D systems Quantikine ELISA, radioimmunoassay, luminex TM Sandwich assays and electrochemiluminescent sandwich assays, such as e.g. GDF15 assay (Roche Diagnostics), which is summarized by Wollert et al. (Wollert KC, Kempf T, Giannitsis E, et al. An Automated Assay for Growth Differentiation Factor 15. J Appl Lab Med An AACC Publ. 2018; 1(5): 510-521. doi: 10.1373 / jalm.2016.022376). All mentioned assays are based on the immunosandwich principle, using monoclonal or polyclonal antibodies to capture and quantify GDF-15. Depending on the reagents used and their combination, free GDF-15 or total GDF-15 (free GDF-15 and GDF-15 bound to CTL-002) is measured.

[0045] The term "PD-L1 positive cancer" as used herein relates to a cancer that has been detected as PD-L1 positive. It should be understood that the term "PD-L1 positive cancer" means that at the time point of the first administration of the anti-GDF-15 antibody, the cancer is a PD-L1 positive cancer. In other words, as can be assessed by analyzing a baseline biopsy from a human patient, the cancer is a PD-L1 positive cancer. This is to be distinguished from, but does not exclude the possibility that changes in PD-L1 expression may occur during the course of administration of the anti-GDF-15 antibody, such as upregulation of PD-L1 expression. However, the "PD-L1 positive cancer" referred to herein should be distinguished from and exclude such cancers, which were not PD-L1 positive at the time point of the first administration of the anti-GDF-15 antibody, but only subsequently became PD-L1 positive due to upregulation of PD-L1 expression during the course of administration of the anti-GDF-15 antibody. The detection method used to determine whether a cancer is PD-L1 positive is not particularly limited. Any method that allows direct / indirect detection of the presence of PD-L1 on the cell surface of cancer cells can be used in the context of the present invention. A direct method for detecting PD-L1 can be based on an assay for detecting PD-L1 at the protein level. An exemplary method for directly detecting PD-L1 uses immunohistochemistry to stain cells with PD-L1 on the cell surface. An indirect method for detecting PD-L1 can be based on an assay intended to detect PD-L1 expression at the nucleotide level using, for example, gene expression data. In a preferred embodiment of a direct method for detecting PD-L1, an immunohistochemistry (IHC) assay is used to determine whether a human patient's cancer is a PD-L1-positive cancer. Those skilled in the art know that IHC assays allow the fraction of PD-L1-positive cells in a cancer sample to be determined based on common knowledge. In this regard, those skilled in the art also know that in order to meet the requirements of drug agencies (such as the FDA) for treatment with checkpoint inhibitors, for some therapeutic agents, it is mandatory to perform immunohistochemical assays on cancer tissues to detect the presence / fraction of PD-L1-positive cells. Therefore, it is easy for a technician using common knowledge to know assays that allow determination of whether a cancer is PD-L1-positive. In general, IHC assays can be based on anti-PD-L1 antibodies as primary antibodies, allowing binding to the PD-L1 protein located on the surface of cancer cells. Further analysis allows the determination of a tumor proportion score (TPS) for the cancer, which is the percentage of cancer cells that show staining for the presence of PD-L1 on the cell surface. This percentage of cancer cells can be determined by counting the number of all cancer cells in a cancer sample that show staining for the presence of PD-L1 on the cell surface, dividing the number by the total number of cancer cells in the sample, and multiplying the quotient by 100.Alternatively, a combined positive score (CPS) of PD-L1 can be determined, which is the sum of the percentages of cancer cells and cancer infiltrating cells (e.g., cancer infiltrating immune cells) that show staining for PD-L1 present on the cell surface. The sum of the percentages of cancer cells and cancer infiltrating cells can be determined by counting the sum of the number of all cancer cells and cancer infiltrating cells that show staining for PD-L1 present on the cell surface in the cancer sample, dividing the number by the total number of cancer cells and cancer infiltrating cells in the sample, and multiplying the quotient by 100. Preferably, the percentage of cancer cells (also referred to as TPS) that show staining for PD-L1 present on the cell surface of "PD-L1 positive cancer" is at least 1.

[0046] An exemplary method for determining PD-L1 TPS is as follows:

[0047] For test interpretation and scoring, refer to the manufacturer's interpretation guide: "VENTANA PD-L1 (SP263) Assay Staining of Non-Small Cell Lung Cancer Interpretation Guide", version 1015317EN. Briefly, the percentage of PD-L1 positive tumor cells (TPS) can be determined in an immunohistochemistry (IHC) assay procedure based on formalin fixed and paraffin embedded (FFPE) sections using an anti-PD-L1 monoclonal antibody assay such as the SP263 monoclonal antibody assay (Ventana, catalog number 790-4905). In the anti-PD-L1 monoclonal antibody assay, tissue sections can be dewaxed and heat treated prior to antibody incubation to expose all target antigens. Next, the anti-PD-L1 antibody bound to PD-L1 positive cancer cells is visualized using a secondary antibody HRP enzyme-conjugated antibody (e.g., Ventana optiView Universal DAB Detection Kit, catalog number 760-700). The specific antibody-enzyme complex is visualized based on the precipitated enzyme reaction product. In order to determine the PD-L1 TPS, a predictive assay (741-4905) cleared by CE-IVD can be used. Preferably, a defined cutoff value of ≥1% membrane-stained tumor cells is used to distinguish between negative and positive cancer tissue (e.g., NSCLC tissue) samples. Positive cases can be further subdivided by applying additional ≥5% and ≥10% cutoff values. As described in more detail in the official scoring guide "VENTANA PD-L1 (SP263) Assay für Non-Small Cell Lung Cancer Interpretationsanleitung 2016" version 1015317EN, exemplary slide interpretation and cutoff value determination can be performed.

[0048] For scoring, the percentage of PD-L1-positive tumor cells was determined for each staining intensity (0, 1, 2, 3), and the total percentage of stained tumor cells was calculated by summing the percentages at intensities 1, 2, and 3.

[0049] The term "inflamed tumor" as used herein refers to an inflamed tumor phenotype. The skilled artisan is aware of assays to determine whether a tumor displays an inflamed tumor phenotype using common general knowledge.

[0050] As an exemplary method, the question of whether a tumor is an inflammatory tumor can be evaluated based on gene expression analysis using a subset of genes associated with antigen presentation, chemokine expression, cytotoxic activity, and adaptive immune resistance, which is converted into a tumor inflammation index (TIS) of the tumor. The gene subset used to determine the TIS is not particularly limited and may involve at least one gene selected from the following: PSMB10, HLA-DQA1, HLA-DRB1, CMKLR1, HLA-E, NKG7, CD8A, CCL5, CXCL9, CD27, CXCR6, IDO1, STAT1, TIGIT, LAG3, CD274, PDCD1LG2, and CD276. In a preferred embodiment, the gene subset used to determine the TIS consists of all the genes mentioned above. The TIS score can be determined as a linear combination of the 18 genes specified above, calculated as: where x i is the log2-transformed normalized expression (e.g., mRNA expression) level of the ith gene, and wi is a predefined weight greater than zero, e.g., as described in Ayers M, Lunceford J, Nebozhyn M, Murphy E, Loboda A, Kaufman DR, Albright A, Cheng JD, Kang SP, Shankaran V, Piha-Paul SA, Yearley J, Seiwert TY, Ribas A, McClanahan TK IFN-γ-associated mRNA profiles predict clinical response to PD-1 blockade. J Clin Invest. 2017 Aug 1;127(8):2930-2940. doi:10.1172 / JCI91190. Epub 2017 Jun 26. PMID: 28650338; PMCID: PMC5531419.

[0051] Alternatively or additionally, the question of whether a tumor is an inflammatory tumor can be assessed by assessing whether the tumor is a tumor comprising CD8+ or CD3+ cells. Preferably, an inflammatory tumor comprises CD8+ or CD3+ cells as can be determined by an immunohistochemical (IHC) assay, wherein the IHC assay is preferably based on anti-CD8 or anti-CD3 antibodies as primary antibodies. More preferably, it can be assessed whether an inflammatory tumor is one with an average CD8+ or CD3+ cell density of >300 cells / mm in an immunohistochemical tissue section with a thickness of, for example, 4 μm. 2 of tumors, as assessed by immunohistochemistry (IHC) assay.

[0052] An exemplary immunohistochemistry (IHC) assay for CD8+ cells is as follows: A primary (monoclonal) anti-CD8 antibody (e.g., monoclonal mouse anti-human CD8, clone C8 / 144B) can be applied to formalin-fixed paraffin-embedded (FFPE) cancer tissue sections (thickness: e.g., 4 μm) in a multiplex IHC assay procedure. In order to expose all target antigens, the tissue sections are dewaxed and heat-pretreated prior to antibody incubation. The binding of the specific antibody (e.g., anti-CD8 antibody) can be visualized using a secondary antibody horseradish peroxidase (HRP)- or alkaline phosphatase (AP)-enzyme-conjugated antibody, for example, after applying one or more linker antibodies conjugated to hydroxyquinoxaline (HQ)- or nitropyrazole (NP), thereby allowing amplification of the resulting signal. The enzyme coupled to the secondary antibody catalyzes a chromogenic precipitate formation reaction at the binding site of the primary antibody. Incubation is performed for each step. After each incubation step, an automatic slide stainer (e.g., VENTANA DISCOVERY ULTRA automatic slide stainer) can be used to wash the sections to stop the corresponding reaction and remove unbound substances. Before applying the next primary antibody, if applicable, the previous reagents are removed by hot incubation ("stripping"), leaving only insoluble precipitates on the slide. For quantitative evaluation of stained tissue sections, suitable digital image analysis software (e.g., Visiopharm digital image analysis software VIS2019.02 (TID001673)) can be used. Prior to image analysis, the stained slides can be scanned at a magnification of 20×, for example using Aperio ScanScope XT (Leica). The final workflow not only allows detection of positive staining for a single biomarker (e.g., CD8), but also enables differentiation of tissue compartments of tumors, normal tissues, and peritumoral and intratumoral stroma. To achieve this, additional guided staining with the tumor-specific markers panCK (solid tumors) or SOX10 (malignant melanoma) can be performed, allowing the generation of virtual overlapping images through alignment of serial sections and transfer of information from one slide to another. The final readout can include area measurements (mm) for each tissue compartment. 2 ), cell counts of each cell type in each compartment (e.g., CD8 cell counts), density calculations (per mm 2 cell counts) and distance measurements for biologically relevant combinations of cell types.

[0053] CD3+ T cell density can be determined, for example, by immunohistochemistry (IHC) using anti-CD3 antibodies in 4 μm thick FFPE tissue sections, e.g., using Multiplex immunofluorescence assays (UltiMapper 1 / 0T-actPanel CD3, granzyme B, Ki67 and panCK / SOX10) were used to determine the Staining was performed on a Leica Bond RX using the I / O T-act kit (p / n ULT20110), sections were digitized as whole-mount images using a ZEISS Axioscan Z 1 and subsequently digitally analyzed in Visiopharm.

[0054] The term "clinical outcome" as used herein has the usual meaning understood by those skilled in the art. The term "clinical outcome" refers to an event or endpoint achieved after medical treatment. In clinical terms, classical metrics for evaluating treatment efficiency can be used to describe clinical outcomes. Exemplary metrics reflecting clinical outcomes are overall survival (OS) and progression-free survival (PFS). In addition, clinical outcomes may also include initial efficacy endpoints, such as response rate, complete response, partial response, disease stabilization, survival, or disease progression.

[0055] In a preferred embodiment according to all other embodiments of the present invention, the cancer is a "solid cancer". A "solid cancer" is a cancer that forms one or more solid tumors. Such solid cancers that form solid tumors are well known in the art. The term "solid cancer" encompasses both primary tumors and possible secondary tumors formed by the cancer, the latter also referred to as metastases. "Solid cancer" encompasses all non-hematological cancers, and includes but is not limited to colorectal cancer, gastric cancer, bladder cancer, melanoma, non-small cell lung cancer, head and neck squamous cell carcinoma, hepatocellular carcinoma, prostate adenocarcinoma, pancreatic cancer, uterine cancer, cervical cancer, thyroid cancer, skin squamous cell carcinoma, mesothelioma, cancer of unknown primary focus (CUP) and breast cancer.

[0056] As referred to herein, the terms "CTL-002", "CTL-001IgG4*", "CTL-001IgG4" and "H1L5 IgG4*" and visugromab are used synonymously. They refer to an antibody having a heavy chain amino acid sequence of SEQ ID NO: 8 and a light chain amino acid sequence of SEQ ID NO: 9. It should be understood that any reference to the amino acid sequence of the antibodies of the present invention is intended to cover post-translational modifications of these sequences that occur in mammalian cells (e.g., CHO cells), including but not limited to N-glycosylation, O-glycosylation, deamidation, Asp isomerization / fragmentation, pyroglutamic acid formation, removal of C-terminal lysine, and Met / Trp oxidation.

[0057] In a preferred embodiment according to all other embodiments of the invention, GDF-15 is human GDF-15 (also referred to herein as "hGDF-15"), and the anti-GDF-15 antibody is an anti-human GDF-15 antibody (also referred to herein as "anti-hGDF-15 antibody").

[0058] It should be understood that the antibodies according to the present invention can be administered in the form of a pharmaceutical composition. Such a pharmaceutical composition is prepared in a manner that allows for proper storage and administration, for example by using pharmaceutically acceptable components such as carriers, excipients or stabilizers.

[0059] Such pharmaceutically acceptable components are non-toxic in the amounts used when the pharmaceutical composition is administered to a human patient.The pharmaceutically acceptable components added to the pharmaceutical composition may depend on the route of administration.

[0060] In general, pharmaceutically acceptable components for use in conjunction with the present invention are used according to the knowledge available in the art, for example, from Remington's Pharmaceutical Sciences, Ed. AR Gennaro, 20th edition, 2000, Williams & Wilkins, PA, USA.

[0061] The present invention is illustrated by the following non-limiting Examples and Reference Examples. (1) Reference example Drug Substance (DS)

[0062] CTL-002 is a humanized, hinge-stabilized IgG4 monoclonal antibody targeting Growth Differentiation Factor-15 (GDF-15) and is related to the antibodies of the present invention.

[0063] In one exemplary liquid formulation of the CTL-002 drug substance, the CTL-002 antibody is present at a concentration of about 25 mg / mL, the liquid formulation further comprising 20 mM histidine / histidine HCl, 150 mM sucrose, 50 mM arginine-HCl, and 0.02% w / v polysorbate 20, at a pH of 5.5. Preparation and Control

[0064] CTL-002 drug substance can be expressed in CHO cells (e.g. CHOK1SV GS KO TM The downstream process includes 2 chromatography steps; a protein A-based affinity chromatography (e.g. MabSelect SuRe) followed by anion exchange membrane chromatography (e.g. Sartobind Q).

[0065] Virus inactivation is achieved, for example, by treatment with Triton-X100.

[0066] Analytical testing is performed regularly during production and upon final release. stability

[0067] The following drug product stability studies are currently being conducted: A pilot non-cGMP (Batch DPS026) representative stability study was conducted at +2 to 8°C for (up to) 3 years under expected long-term storage conditions, and at +25°C for 12 months and at +40°C for 6 months to provide representative stability data for setting the interim shelf life of the drug product GMP batches. - GMP (Batch No. F19235) stability studies were performed at +2 to 8°C for (up to) 3 years under expected long-term storage conditions, and at +25°C for 12 months and at +40°C for 6 months to confirm the stability of the proposed IMP. store

[0068] CTL-002 drug product vials must be stored in their original secondary packaging at +2 to 8°C in a secure environment, protected from light and separated from other drug or investigational products. The product should not be frozen. Preparation and administration

[0069] To prepare CTL-002 for intravenous administration, the CTL-002 solution was added to an infusion bag containing 0.9% NaCl. The CTL-002 infusion solution can be administered using IV bags made of polyethylene (PVC, DEHP and latex-free) or polyvinyl chloride (latex-free) and infusion lines made of PE (PVC, DEHP and latex-free) or PVC (DEHP and latex-free) materials. It is mandatory to use a 0.2 μm in-line filter (positively charged / uncharged PES membrane).

[0070] Once prepared, the CTL-002 infusion solution in the infusion bag is ready for use and should be administered at ambient temperature. The infusion bag can be stored at room temperature for up to 6 hours and at +2 to 8°C for up to 24 hours, but should be used within no more than 24 hours after preparation. Nonclinical Pharmacology

[0071] The inventors have identified a mechanism by which GDF-15 blocks the adhesion of primary CD8+ T lymphocytes and blocks their invasion into tissues. With CTL-002 blocking GDF-15, a new therapeutic approach has been established, which promotes the entry of effector T cells into tumor tissues. This can significantly enhance the efficacy of any T cell activator (e.g., checkpoint inhibitors).

[0072] Specifically, in a flow adhesion assay, different immune cell subsets pretreated + / - GDF-15 were perfused on an activated layer of endothelial cells or recombinant adhesion molecules. The adhesion and migration processes were monitored by real-time imaging microscopy. T cell adhesion to the endothelial cell layer was significantly impaired by the addition of GDF-15. Among the T cell subsets, CD8+ T cells were most affected, while the adhesion of other immune cells was not reduced. The inhibitory effect of GDF-15 on CD8+ T cell adhesion was comparable to the effective blocking of LFA-1 by TS1 / 18 antibodies and could be rescued by the anti-GDF-15 antibody CTL-002 with an EC50 of approximately 700 ng / ml.

[0073] This preliminary finding has been further confirmed by data from relevant animal models, in which the anti-GDF-15 antibody CTL-002 or mouse surrogate induced a significant increase in the number of tumor-infiltrating lymphocytes and improved response to T cell activation therapy. Neutralization of GDF-15 by CTL-002 in humanized mice bearing HV18-MK melanoma resulted in a significant increase in the number of tumor-infiltrating leukocytes. Subset analysis revealed an over-proportional enrichment of T cells, especially CD8+ T cells (see WO 2022 / 101263). Figure 6 Consistent with this, neutralization of GDF-15 in the syngeneic mouse models MBT-2 and Pan02 resulted in a significant increase in T cell infiltration ( Figure 2 ).

[0074] GDF-15 can enhance the response to checkpoint blockade in situ Pan02 was validated. Here, the combination of aGDF-15 and aPD-1 doubled the number of tumor-free animals compared to aPD-1 monotherapy ( Figure 1 ). In addition, a syngeneic mouse tumor model with genetically modified mouse colon tumor MC38 cells expressing human GDF-15 (MC38-GDF15) showed an increased response to anti-PD-1 or anti-CD40 / poly(IC:LC) combination therapy, but a decreased response to the others. No adverse effects were observed in any animal (WO 2022 / 101263 Figure 9 to 1 1).

[0075] Therefore, CTL-002 was developed to neutralize the pathological effects mediated by GDF-15. The bioactivity of GDF-15 adhesion and migration processes was monitored by live cell imaging microscopy in an in vitro flow adhesion system with primary immune cells, and the key parameters of GDF-15 inhibition by CTL-002 were determined in this system.

[0076] In addition, secondary pharmacology studies examined the ability of CTL-002 to elicit CDC and ADCC, on-target / non-tissue binding, and off-target binding. Safety pharmacology assessments were included in standard repeated-dose toxicity studies.

[0077] Collectively, these studies provide a comprehensive characterization of the mechanism of action of CTL-002 and a rationale that fully supports its clinical examination in patients with cancer and with elevated GDF-15 in the tumor microenvironment. Binding of the drug CTL-002 to the target GDF-15

[0078] As shown in Table 1, GDF-15 and CTL-002 form a major complex of two CTL-002 antibodies with two dimeric GDF-15 molecules in solution. Other complexes appear less favorable, and only one additional complex of three CTL-002 and three GDF-15 was reliably detected. This complex was greatest during equimolar incubations of CTL-002 and GDF-15, but was still less than 8% and decreased when the ratio was changed in either direction. At more than three molar excesses of antibody, all of the GDF-15 was complexed with the CTL-002 molecules, and no tendency to form high molecular weight aggregates was observed. Table 1: Summary of the complexes formed between CTL-002 and GDF-15

[0079] The affinity of CTL-002 for recombinant human GDF-15 was determined by measuring surface plasmon resonance on a Biacore T3000. In addition, the affinity for cynomolgus monkey, rat and mouse GDF-15 was measured (see Table 2).

[0080] All experiments were performed in 10 mM HEPES buffer, 150 mM NaCl, 3.4 mM EDTA and 0.05% Tween at pH 7.4. Anti-human IgG Fc specific antibody (Jackson, Order No. 109-005-008, Lot # 111148) was covalently immobilized on a Biacore CM5 chip (GE Healthcare, Order No. 61144275, Lot # 10236645) by EDC / NHS chemistry. For the kinetic characterization of antigen-antibody interactions, pulses of increasing GDF-15 concentrations (e.g., 156.3 pM, 312 pM, 625 pM, 1,250 pM) were injected at a flow rate of 30 μl / min. After each measurement cycle (association for 8 minutes, followed by dissociation for 30 minutes), the antibody-antigen complex was disassembled by surface regeneration with 10 mM glycine-HCl at pH 2.0. For the calculation of the dissociation constant of CTL-002, the association and dissociation phases were recorded and evaluated by global fitting using BIAevaluation 4.1 software. Only for the global fitting analysis were those antigen concentrations considered, which made the analysis follow the Langmuir 1:1 binding model or 1:1 binding with drifting baseline.

[0081] K of human GDF-15 D The values ​​are shown in Table 2. Table 2: Summary of species affinity of CTL-002 CTL-002 <![CDATA[K D (People)]]> 38.3pM <![CDATA[K D (Cynomolgus Monkey)]]> 107.7pM <![CDATA[K D (Rat)]]> 449pM <![CDATA[K D (Mouse)]]> 9.76nM

[0082] An overview and comparison of three antibodies used in a panel of nonclinical studies is given in Table 3 . Table 3: Overview of the details of antibodies used in in vitro and in vivo experiments

[0083] In summary, CTL-002 is a humanized IgG4 antibody derived from mouse antibody B1-23 and is highly specific for human GDF-15. CTL-002 binds to human, cynomolgus monkey, and rat GDF-15 with picomolar affinity (38.3, 108, and 449 pM, respectively), and binds to mouse GDF-15 with low nanomolar affinity (9.76 nM). CTL-002 binds to a discontinuous conformational epitope at the carboxyl terminus of mature GDF-15 and specifically recognizes the physiological dimer conformation. In vitro biological activity of CTL-002 in inhibiting GDF-15-mediated T cell adhesion

[0084] A flow adhesion assay system was used to simulate the dynamics at the vessel wall that separates immune cells from tumor tissue and analyze the neutralization of GDF-15 by CTL-002. To evaluate the potency of GDF-15 adhesion inhibition and the sensitivity of the system, the IC50 of GDF-15 in the assay system was determined to be 13.8±2.3ng / ml. This is in accordance with the results of WO 2022 / 101263. Figure 4 Shown in.

[0085] In order to evaluate the efficacy of CTL-002 in preventing GDF-15-mediated inhibition of T cell adhesion, the EC50 of CTL-002 was determined in a flow adhesion assay of T cells. As a result, CTL-002 at an average concentration of 707 ± 17 ng / ml effectively increased T cell adhesion by 50%, as shown in different donors. This is in WO 2022 / 101263 Figure 5 Shown in. In vivo pharmacology

[0086] Among all TGFβ superfamily members, the orthologous GDF-15 molecule shows the lowest sequence conservation. Although mature rat, mouse, and human TGF-β1 and BMP-2 proteins have 99% to 100% sequence identity between humans and mice, GDF-15 has less than 70% homology ( 1999). Therefore, biological differences between the different species cannot be excluded. Murine GDF-15 shows a rather low sequence identity of 67.9% with its human counterpart, which is also reflected in the fact that anti-GDF-15 antibodies show lower affinity for the mouse homologue. Two different in vivo approaches were used to investigate the pharmacodynamic effects.

[0087] First, a humanized mouse model was used in which immunodeficient mice were transplanted with human umbilical cord blood-derived CD34+ hematopoietic stem cells.

[0088] Three months after reconstitution, these mice developed a functional human-like immune system, containing all major human immune cell subsets (Wang 2018). These mice were then inoculated with a patient-derived human melanoma cell line, HV-18MK, which has been shown to secrete high levels of GDF-15. Three days later, mice were treated with isotype controls or CTL-002 twice a week, and tumors were harvested four weeks later and analyzed for immune cell infiltration by flow cytometry.

[0089] Although tumor size was not affected, the CTL-002 treated group showed a 9-fold increase in human tumor infiltrating CD45+ cells. Figure 6In the infiltrating cell population, T cells were enriched 4-fold. In a follow-up study, a more detailed analysis of the infiltrating immune cell population determined the increase in CD45+ infiltration and the enrichment of CD3+, although the 3-fold increase in CD45+ and the 4-fold enrichment of CD3+ T cells were less significant. Similarly, the syngeneic mouse model MBT-2 ( Figure 2 , left) and Pan02( Figure 2 , right panel) shows higher immune cell infiltration in animals treated with aGDF-15.

[0090] As a second experimental model, a genetically modified mouse cell line overexpressing human GDF-15 was generated for testing the therapeutic efficacy of anti-GDF-15 antibodies.

[0091] In this regard, MC38 colon adenocarcinoma cells are the preferred mouse tumor cell for analyzing the activity of immune checkpoint blockade (Selby 2016) and were used to generate in vivo data to support the development of approved anti-PD-1 antibodies. Overexpression was achieved by stable transfection and did not affect in vitro proliferation compared to control-treated MC38.

[0092] Age-matched immunocompetent C57BL / 6 mice and immunodeficient NCI nu / nu mice were cultured with 5 × 10 5 MC38 null colon tumor cells or transgenic derivatives expressing recombinant human GDF-15 MC38 GDF-15 GDF-15 expression has previously been shown to mediate a growth advantage in immunocompetent C57BL / 6 mice compared to in vitro and in vivo proliferation in immunodeficient NCI nu / nu mice, supporting the notion that GDF-15 interferes with the immune system of the tumor host (see WO 2022 / 101263 Figure 7 ).

[0093] In addition, expression of human GDF-15 renders anti-PD-1 responsive MC38 colon cancer tumors anti-PD-1 resistant. This can be partially reversed by anti-GDF-15(B1-23) / anti-PD-1 combination therapy, but not by anti-GDF-15 monotherapy and not by anti-PD-1 alone.

[0094] Similarly, monotherapy with anti-GDF-15 antibodies showed only minimal improvement, whereas GDF-15-secreting tumors (solid line, WO 2022 / 101263) showed significant improvement when treated with a combination of anti-GDF-15B1-23 and anti-PD-1. Fig. 9 B) showed better survival (WO 2022 / 101263 Fig. 9). This combination therapy is not significantly superior to anti-PD-1 monotherapy (WO 2022 / 101263 Figure 8 ).

[0095] Since CTL-002 and its derivatives have only nanomolar affinity for mouse GDF-15, an alternative antibody anti-mGDF-15 (having the light chain variable region domain amino acid sequence of SEQ ID NO: 19 and the heavy chain variable region domain amino acid sequence of SEQ ID NO: 20) with picomolar affinity for mouse GDF-15 was used in another isogenic mouse model. GDF-15-secreting murine pancreatic cancer Panc02 cells expressing the luciferase gene for monitoring tumor growth were implanted into the mouse pancreas. Implantation of cell lines into the corresponding tissues allows for determination of tumorigenesis in a relevant environment that more closely mimics the human disease process. After 5 days, mice were randomized into four groups and treated twice a week with: isotype antibodies, anti-PD-1, anti-GDF-15 or anti-PD-1 or a combination of anti-GDF-15 and anti-PD-1. Tumor size was measured regularly by luciferase imaging. The relative results at day 35 were in Figure 1 The results are summarized in , where a waterfall plot ranks tumor development in each animal within the group from baseline and a bar graph shows the relative mean tumor size change from baseline ( Figure 1 Compared to the vehicle group, in which one of the twelve animals showed spontaneous tumor shrinkage for unknown reasons, tumor shrinkage was observed in five of the twelve animals in the combination treatment group, and to a lesser extent in three of the twelve animals in the anti-PD-1 monotherapy group ( Figure 1 ).

[0096] Since anti-GDF-15 treatment was shown to enhance T cell infiltration, other cancer immunotherapies that rely on the presence of T cells in tumors should benefit from neutralization of GDF-15.

[0097] Another immunotherapy, anti-CD40 and poly(IC:LC) tumor therapy, previously shown to rely on T cell immune responses (van den Boom 2013), was previously tested in a mouse model with MC38 cells expressing human GDF-15. Combination treatment with GDF-15 neutralization and anti-CD40 / poly(IC:LC) resulted in complete tumor rejection in 8 out of 10 animals, whereas treatment with anti-CD40 / poly(IC:LC) alone cleared only 3 out of 10 tumors (Figure 10 of WO 2022 / 101263).

[0098] Although mouse GDF-15 was not detected in wild-type MC38 cells, which may be due to inadequate analytical assays, similar experiments were performed with MC38 cells that were not manipulated to secrete human GDF-15, comparing isotype control antibodies and anti-GDF-15 treatment in combination with anti-CD40 / poly(IC:LC). Similar to experiments with genetically modified MC38, anti-GDF-15 enhanced the efficacy of anti-CD40 / poly(IC:LC) treatment, but to a lesser extent (FIG. 11 of WO 2022 / 101263).

[0099] In the NHP 4wk GLP toxicity study, CTL-002 was shown to be safe and well tolerated at doses that provided adequate exposure margin for clinical testing.

[0100] The proposed FIH starting dose of 0.3 mg / kg / Q2wk is expected to give a maximum plasma concentration (Cmax) of 6 μg / mL at the end of a 1-hour infusion, which is 1 / 683 of the Cmax of CTL-002 in NHPs at exposure to the No-Observed-Effect-Level (NOEL). This dose can only achieve transient inhibition of GDF-15 in the tumor microenvironment and is considered to be the minimum acceptable biological effect level (MABEL).

[0101] Serum total GDF-15 has been shown to be a useful biomarker of GDF-15 target engagement in NHPs, and CTL-002 doses ≥ 10 mg / kg are associated with maintenance of GDF-15 capture (and inferred GDF-15 inhibition). Therefore, total human GDF-15 may be a potential clinical biomarker of GDF-15 target engagement, and the FIH clinical study aims to explore both the maximum inhibition of GDF-15 within a limited time period and the sustained inhibition of GDF-15 throughout each dosing cycle. toxicology

[0102] CTL-002 is being tested as a treatment for patients with advanced cancer.

[0103] To identify relevant species for nonclinical testing, the sequence homology of GDF-15 was compared across species. The sequence homology between humans, cynomolgus monkeys, mice, and rats was 94.6%, 67.9%, and 66.1%, respectively.

[0104] CTL-002 binds to a nonlinear conformational epitope within GDF-15, such as Figure 3The two boxes in FIG. show the sequences of the CTL-002 binding regions of cynomolgus monkey, human, mouse and rat (the first four rows from top to bottom).

[0105] The cynomolgus monkey shows 100% sequence homology to the human CTL-002 binding epitope within GDF-15. Therefore, it is considered a relevant species for toxicity testing. The binding affinity of CTL-002 to human and cynomolgus monkey GDF-15 is 38.3 pM and 108 pM, respectively.

[0106] Dose response finding (DRF) studies of CTL-002 were conducted in rats because the product was expected to have sufficient pharmacological activity at reasonable intravenous dose levels to achieve sustained complete target inhibition (binding affinity for rat GDF-15: 449pM). However, the PK / PD data obtained in the study showed that CTL-002 could not saturate GDF-15 binding even at the highest dose level of 100mg / kg. Therefore, in a study of 4 weeks and weekly intravenous administration of CTL-002, key toxicology was evaluated only in cynomolgus monkeys. No toxicity was observed at the highest tested dose of 100mg / kg.

[0107] Tissue cross-reactivity studies in accordance with Good Laboratory Practice (GLP) were performed using human and cynomolgus monkey tissues. Staining of CTL-002 in the examined tissue groups was limited to the cytoplasm of the trophoblast in human and monkey placenta, which is consistent with the reported expression of its target protein GDF-15 in the placenta. No unexpected cross-reactivity was observed. Toxicology: Non-pivotal studies

[0108] A non-GLP single-dose dose-finding study was conducted in cynomolgus monkeys. The primary objective of this study was to support dose selection for a subsequent GLP-compliant 28-day repeat-dose toxicity study. In addition, the pharmacokinetics of CTL-002 at different dose levels were characterized.

[0109] One male and one female animal were administered per dose level (0.1, 1, 10 or 100 mg / kg) by a single 30-minute intravenous infusion, and the pharmacokinetic profile was recorded over 14 weeks. In addition to the pharmacokinetic analysis, the development of anti-drug antibodies was assessed before dosing and 6 and 12 weeks after dosing. GDF-15 and CTL-002 serum levels were quantified, and pharmacokinetic data were calculated as total CTL-002 (PK total) and free CTL-002 (PK free), respectively.

[0110] As indicators of toxicity, mortality and clinical signs were examined daily. Body weight and food and water consumption were analyzed weekly, and body temperature, ECG, blood pressure, hematology (including coagulation), and clinical chemistry (including cytokines) were assessed on several occasions during the study.

[0111] No animals died prematurely, and there were no signs of CTL-002-related toxicity at any dose level tested.

[0112] A single infusion of 0.1, 1, 10 or 100 mg / kg of CTL-002 on test day 1 resulted in a dose-related increase in total GDF-15 serum levels in all males and females. Target saturation of CTL-002 at the 10 and 100 mg / kg dose levels is indicated by the overlapping GDF-15 curves at these two dose levels.

[0113] Measurement of total and free CTL-002 in serum samples obtained up to test day 43 (Groups 1 and 2; treated with 0.1 or 1 mg / kg CTL-002) or test day 99 (Groups 3 and 4; treated with 10 or 100 mg / kg CTL-002) revealed dose-related exposure of the animals to CTL-002.

[0114] Key pharmacokinetic data for one male and one female animal per group are given in Table 4. Table 4: Key pharmacokinetic data obtained in the monkey DRF study CTL-002-TOX-01

[0115] Based on the results of this study, dose levels of 10, 30, and 100 mg / kg were recommended for the pivotal 4-week repeat-dose toxicity study. Toxicology: Pivotal Studies

[0116] The additional pivotal study was a 4-week repeat-dose toxicity study of CTL-002 in cynomolgus monkeys (age: 3 to 4 years) with a 4-week recovery period.

[0117] In this study, CTL-002 was administered by 30-minute intravenous infusion once a week, on test days 1, 8, 15, 22, and 29. The recovery period ended on day 58. Dose levels of 0, 10, 30, or 100 mg / kg were administered to 3 male and 3 female monkeys per group plus 2 male and 2 female recovery animals in the control and high-dose groups.

[0118] No animals died or had to be sacrificed prematurely, and no local signs of intolerance related to the test items were noted.

[0119] No test item-related effects were noted in any animal at any dose level: behavior and appearance, body weight and weight gain, food and drinking water consumption, electrocardiographic parameters and heart rate, circulatory function, hematological parameters including coagulation parameters, D-dimer levels, clinical chemistry parameters, cytokine levels, urinary parameters, ophthalmological and auditory function, organ weights, and myeloid:erythroid ratio. No macroscopic organ changes were noted in any of the animals examined at any dose level tested.

[0120] Histopathology did not reveal any local or systemic lesions related to the test item. No changes related to the test item were found during or at the end of the 4-week treatment-free recovery period.

[0121] Based on the above results, the no observed effect level (NOEL) was 100 mg CTL-002 / kg by repeated intravenous 30-min infusion once a week for 4 weeks, ie, 5 administrations / animal.

[0122] The Cmax levels and AUC areas of total CTL-002 revealed approximately linear dose-related systemic exposure in the animals. No gender-specific differences were noted. The accumulation of total CTL-002 over time was noted, with accumulation ranging from approximately 2-fold to 6-fold. The calculated mean terminal serum elimination half-life (t 1 / 2 ) ranges from 119 to 651 hours.

[0123] Key pharmacokinetic data for male and female animals following the first (Days 1 to 8) and fourth (Days 22 to 29) administration of CTL-002 are presented in Table 5. Table 5: Key pharmacokinetic data of total CTL-002 obtained in monkey GLP toxicity study CTL-002-TOX-03 after the first and fourth administrations

[0124] Following infusion of CTL-002, serum levels of GDF-15 increased by as much as 100-fold to 1000-fold in all animals at all dose levels and remained elevated throughout the dosing interval. Figure 4 As shown in , GDF-15 levels in female monkeys throughout the first week after dosing were shown, with comparable increases between dose groups.

[0125] Therefore, it can be concluded that complete target inhibition was achieved at all dose levels and across the dosing interval in the pivotal monkey study. Overall study design

[0126] A phase 1, multicenter, first-in-human (FIH), open-label study consisting of Part A (dose escalation) followed by Part B (expansion) will be conducted using the CTL-002 antibody. The primary intent of the study is to (a) demonstrate the safety of CTL-002 and the combination of CTL-002 + anti-PD1 / PD-L1, and (b) demonstrate that patients who relapsed after / are refractory to anti-PD1 / PD-L1 therapy due to elevated GDF-15 will respond again and show tumor shrinkage when the combination of CTL-002 + anti-PD1 / PD-L1 is administered. Part A (dose escalation)

[0127] At least 21 subjects with advanced solid tumors who have relapsed after / are refractory to prior anti-PD1 / PD-L1 therapy and have exhausted all available approved standard therapies or are no longer eligible for standard therapy will receive escalating doses of CTL-002 as monotherapy and in combination with anti-PD-1 checkpoint inhibitors IV in the "3+3" cohort. The "backfill cohort" will enroll additional patients to reach the highest dose level. Part B (Extended)

[0128] In defined tumor entities that have relapsed after or are refractory to previous anti-PD1 / PD-L1 therapy, up to 8 expansion cohorts, each consisting of up to 25 subjects, will be used to further evaluate the safety and efficacy of CTL-002 as a monotherapy (one monotherapy cohort to be explored) or in combination with anti-PD-1 checkpoint inhibitors (up to 8 combination cohorts to be explored), and confirm the RP2D. The designated monotherapy cohort will be used to determine the safety profile of CTL-002 in long-term monotherapy at a dose that is considered therapeutic (without adding anti-PD-1 / PD-L1). Recruitment of all 8 cohorts can occur in parallel. Treatment period Part A (dose escalation)

[0129] This study will use a standard "3+3" dose escalation design, in which each cohort will enroll 3 to 6 subjects at each designated dose level, depending on the occurrence of DLT.

[0130] The doses of CTL-002 planned to be tested are as follows: Group 1: 0.3 mg / kg Group 2: 1.0 mg / kg Group 3: 3.0 mg / kg Group 4: 10 mg / kg Group 5: 20 mg / kg

[0131] The starting dose of 0.3 mg / kg is fixed for Cohort 1. The doses explored in Cohorts 2 to 5 (as described above) may be modified by the Safety Review Committee (SRC) based on emerging data (ie, available safety, PK / pharmacodynamics, other biomarker data).

[0132] The DLT observation period will be the first two treatment cycles (i.e., the first 4 weeks) of each dosing group. All treatment cycles were initially limited to last for 2 weeks. CTL-002 will be administered with IV infusion once every two weeks. The subject will first receive a dose of CTL002 as a monotherapy for one cycle, followed by a combination of the CTL-002 administered and the defined checkpoint inhibitor for one cycle, wherein the defined checkpoint inhibitor will be administered with a dosage of 240 mg IV, once every two weeks.

[0133] For the combination, CTL-002 and the defined checkpoint inhibitor will be given simultaneously on the same day, with CTL-002 being administered first, and for the first combination infusion, there will be a 30-minute observation period to assess safety, followed by the defined checkpoint inhibitor infusion. The observation period may be modified (i.e., shortened or extended) based on emerging safety data.

[0134] The first two treatment cycles (ie, first 4 weeks) represented the DLT observation period.

[0135] Thereafter, subjects will continue on the combination treatment until progression or withdrawal from the study for any other reason (eg, toxicity or subject withdrawal of consent).

[0136] Additionally, based on emerging data and upon request by the Safety Review Committee (SRC), an intermediate dose cohort may be explored.The maximum dose of CTL-002 tested in this study will not exceed 20 mg / kg.

[0137] For the purpose of safety observations and to enable appropriate collection of sampling time points (e.g., PK), all subjects will be hospitalized overnight after receiving the first dose of CTL-002 and after receiving the first combination dose of CTL-002 with a defined checkpoint inhibitor. Intra-patient dose escalation during extended treatment

[0138] If any Cohort 1 subject is still on 0.3 mg / kg treatment when Cohort 2 is completed and passes SRC review, that subject's dose may be escalated to the Cohort 2 dose of 1.0 mg / kg.

[0139] If any Cohort 1 or Cohort 2 subject is still receiving 1.0 mg / kg treatment when Cohort 3 is completed and passes SRC review, the dose of that subject may be escalated to the Cohort 3 dose of 3.0 mg / kg.

[0140] NOTE: Any subject still receiving 0.3 mg / kg treatment must first be treated at 1.0 mg / kg and then increased to 3.0 mg / kg with the consent of the Sponsor Medical Monitor.

[0141] The maximum dose to which subjects may be increased through intradose escalation will be 3.0 mg / kg.

[0142] Available safety, PK / pharmacodynamic data, and preliminary efficacy data will inform decisions regarding the MTD / dose to be further explored in Part B of this study.

[0143] The MTD was defined as the highest dose level of CTL-002 at which no more than 1 of 6 subjects experienced a DLT during the first 2 treatment cycles (i.e., the initial 4 weeks in which CTL-002 was given as monotherapy [weeks 1 and 2] and in combination with a defined checkpoint inhibitor [weeks 3 and 4]).

[0144] In addition, for cohorts 3 to 5, in the absence of any DLT, an additional 3 subjects (up to a total of 6 subjects / cohort) can be recruited in each of these cohorts to improve the understanding of PK and pharmacodynamic data. This occurs as dose escalation continues. These additional "backfill" subjects will receive a combination treatment of CTL-002 with a defined checkpoint inhibitor, starting on day 1 of cycle 1, every two weeks, with CTL-002 always being administered first, followed by a defined checkpoint inhibitor given as described above.

[0145] For Part A subjects (except backfill subjects), three serial tumor biopsies will be performed; one biopsy at baseline, a second biopsy before the start of combination treatment (after 2 weeks), and a third biopsy after the first cycle of combination treatment (at the end of treatment, or at the end of Cycle 2 / start of Cycle 3 if combination treatment is continued).

[0146] For backfill patients, only two biopsies must be performed: one at baseline and a second after 4 weeks of combination treatment (at the end of treatment, or at the end of Cycle 2 / start of Cycle 3 if combination treatment is continued).

[0147] These biopsies are mandatory in order to assess immune cell infiltration in the tumor. If a biopsy cannot be performed for safety reasons, this must be discussed with the Medical Monitor.

[0148] Treatment with CTL-002 as monotherapy (one cycle) and in combination with a checkpoint inhibitor (nivolumab) was safely tolerated up to dose level 5 (20 mg / kg) of CTL-002. No DLTs occurred and no grade 4 adverse events occurred in any of the treated patients. Combination therapy can be started simultaneously, as indicated by the so-called backfill cohort with an immediate combination of CTL-002 and anti-PD1 / PD-L1 therapy.

[0149] Consistent with preclinical data of increased immune infiltration by aGDF-15 biomarker analysis, there was consistently tumor-selective influx of CD8+ cells from DL1 to 5. Preliminary analysis indicated that T cell proliferation in tumors was increased in several patients as indicated by CD3 / ki-67+ staining. Several tumors that were "cold tumors" characterized by fairly low CD8 and CD4 counts at baseline were converted to hot tumors by increasing CD8 and CD4 counts.

[0150] Tumor shrinkage was observed at different dose levels. Data were available for 24 evaluable subjects (Part A: 24 / Part B: 0). All subjects were treated in the late-line, heavily pretreated setting (mean 4.4 prior lines of therapy) and relapsed after / refractory to prior anti-PD-1 / PD-L1 therapy.

[0151] For 6 subjects in this heavily pretreated end-line tumor population, significant and lasting clinical benefits were observed. Three subjects currently experienced a confirmed partial response (PR) lasting up to and exceeding 10 months (1×unknown primary cancer at dose level [dose level, DL] 3, and 1×mesothelioma at DL 5), and the third subject experienced a confirmed PR with durable, prolonged tumor regression (hepatocellular carcinoma at DL4). Another 3 subjects experienced extended disease stabilization, 2 of which exceeded 6 months (1×NSCLC and 2×melanoma). The third subject had a 5.5-month disease stabilization period, and then local progression occurred in a liver lesion, causing vascular compression. According to the decision of the investigator, the study treatment was continued, and the added site was locally irradiated (out of the study). Shortly thereafter, the subject continued to have a deep, confirmed partial response, in which a distant effect was observed in the non-irradiated lesions (with the permission of the sponsor, while continuing to study treatment with CTL-002 and nivolumab). Two other subjects had minor tumor regression in isolated lesions.

[0152] Overall, in dose escalation (Part A), 6 subjects received treatment for up to 10 months in the optional extended treatment phase, and 2 subjects even received treatment for more than a year and demonstrated durable tumor control, including durable, confirmed partial responses. Part B (Extended)

[0153] In Part B of the study, up to 8 cohorts (up to 25 subjects / cohort) may be recruited, with each cohort recruiting subjects with a specific tumor type.

[0154] In the extended part of this study, a dedicated CTL-002 monotherapy cohort may be established to explore the safety profile of CTL-002 given as a monotherapy (e.g., in subjects with advanced melanoma). In addition, mandatory serial tumor biopsies are required for this monotherapy cohort to expand the understanding of the pharmacodynamic effects of CTL-002 in tumor tissue.

[0155] In the monotherapy cohort, two consecutive tumor biopsies must be performed: one biopsy at baseline and a second biopsy 2 weeks later (at the end of Cycle 1 / beginning of Cycle 2). All subjects will receive treatment until progression.

[0156] Up to 8 additional expansion cohorts of defined tumor populations may then be treated with CTL-002 in combination with defined checkpoint inhibitors. Tumor indications will consist of tumor types approved for PD-1 / PD-L1 therapy and subjects who have relapsed / progressed on or after anti-PD-1 / PD-L1 therapy. Recruitment into expansion cohorts may occur in parallel. All subjects will receive treatment until progression.

[0157] For the purpose of safety observations and to enable appropriate collection of sampling time points (i.e., PK sampling), all subjects will be hospitalized overnight after receiving the first dose of CTL002 (monotherapy cohort) or after receiving the first combination dose of CTL-002 with a defined checkpoint inhibitor (combination therapy cohort), respectively. Research Assessment Tumor biopsy

[0158] The timing of the biopsy is as follows: Part A (all subjects except backfill subjects): Three consecutive tumor biopsies must be performed; one biopsy at baseline, a second biopsy before the start of combination therapy (after 2 weeks), and a third biopsy after the first cycle of combination therapy (at the end of treatment visit, or at the end of cycle 2 / start of cycle 3 if combination therapy is continued). These biopsies are mandatory to assess immune cell infiltration in the tumor. Part A (Backfill Subjects): Two serial tumor biopsies must be performed; one at baseline and a second 4 weeks later (at the end of treatment visit or at the end of Cycle 2 / start of Cycle 3 if continuing combination therapy). • Part B (subjects enrolled in the monotherapy cohort): Two consecutive tumor biopsies must be performed; one biopsy at baseline and a second biopsy after the first monotherapy cycle (ie, 2 weeks).

[0159] There must be a lesion suitable for serial biopsy, or a closely adjacent lesion, if possible, but this lesion should not be the only target lesion for radiologic evaluation during the course of the study.

[0160] Biomarkers can be analyzed from biopsy tumor tissue samples. Additional immune cell markers and / or tumor markers specific for any tumor type can be included.

[0161] The biopsied tumor tissue will be fixed with formalin and embedded in paraffin (FFPE) to determine the changes in the number, frequency and spatial location of treatment-induced infiltrating immune cells by histology before and after treatment with CTL-002 or in combination with a defined checkpoint inhibitor, including but not limited to leukocytes, different lymphocytes (e.g., CD4+ and CD8+ T cells, B cells, NK cells). In addition, the expression of CTL-002 drug targets, GDF-15 protein and mRNA will be determined. Tumor lesions

[0162] For subjects in Part A of the study, the target skin lesions selected for RECIST evaluation will be measured by caliper and photographed. In addition, the number of skin lesions will be recorded. For clinical measurements of skin lesions in Part A, color photography (including size measurements) and caliper measurements will be performed on the lesions at baseline within 7 days before infusion of CTL-002, every 4 weeks during extended treatment, at the end of treatment visits, and during follow-up. Safety Assessment

[0163] The safety and tolerability of IV-infused CTL-002 monotherapy and CTL-002 in combination with defined checkpoint inhibitors will be evaluated by AEs (all AEs will be evaluated according to NCI CTCAE v5.0), SAEs, DLTs, and use of concomitant medications. Safety assessments will include: ECG, physical examination (including neurological examination to exclude motor neuropathy), ECOG performance status, vital signs, and clinical laboratory samples (hematology, clinical chemistry, coagulation, thyroid function (thyroid stimulating hormone [TSH] and free T3), cytokines, hemoglobin A1c [HbAlc] assessment, N-terminal b-type natriuretic peptide [NT-proBNP], and urinalysis).

[0164] Subjects will be assessed for safety at screening and during treatment until the safety follow-up visit. Thereafter, study-related safety will be further documented during the 12-month (Part A) / 24-month (Part B) follow-up period after treatment. Vital signs

[0165] Vital signs should be assessed, including systolic and diastolic BP (sitting), pulse rate, temperature, respiratory rate, and oxygen saturation. Additional vital sign measurements may be obtained if clinically necessary. Physical and neurological examination

[0166] A physical examination will be performed at Screening and will include examination of the head, eyes, ears, nose, throat, neck, cardiovascular, chest / lungs, abdomen (including liver and spleen size), extremities, skin, and lymph nodes, as well as a brief neurological examination to evaluate for motor neuropathy. Performance Status

[0167] Performance status will be assessed at Screening according to the following ECOG criteria: 0 = Fully active, able to perform all pre-disease activities without restriction 1 = Limited ability to engage in vigorous physical activity, but ambulatory and able to perform light or sedentary work (e.g., light housework, office work) 2 = Ambulatory and able to care for oneself, but unable to perform any work activities. Up to 50% and approximately more than 50% of waking time 3 = Limited self-care, confined to bed or chair for more than 50% of waking time 4 = Totally disabled, unable to care for oneself, completely confined to bed or chair 5 = Death Heart function monitoring

[0168] Subjects will be thoroughly monitored for cardiac / vascular AEs, and protective measures will be taken to exclude at-risk subjects from trial participation.

[0169] At baseline, subjects will undergo an ECG, an echocardiogram (or MUGA if ECHO is not possible) and a test for N-terminal pro-b-type natriuretic peptide levels (NT-proBNP, heart failure screening). Testing for NT-proBNP will be repeated every 2 weeks for 3 months and monthly thereafter, or if there is suspicion regarding any type of cardiac / vascular injury (then again combined with an ECG and echocardiogram).

[0170] A single 12-lead ECG will be performed.

[0171] All ECG monitoring will be performed locally at the investigator's site.

[0172] The subject should be relaxed and in a recumbent or semi-recumbent position for at least 5 minutes before ECG recording.

[0173] Additional ECG testing may be performed at the investigator's discretion if clinically deemed necessary. Clinical laboratory evaluation

[0174] Samples will be collected for the laboratory tests listed below. All testing is performed locally.

[0175] Prior to CTL002 / PD1 / PD-L1 administration, hematology / coagulation, and clinical chemistry results must be provided and reviewed and deemed acceptable by the investigator or authorized designee.

[0176] Clinically significant abnormal tests must be repeated to determine the nature and extent of the abnormality. Appropriate ancillary investigations should be initiated, if necessary. If the abnormality fails to resolve or cannot be explained by events or conditions unrelated to the study drug or its administration, the Medical Monitor must be consulted.

[0177] The clinical significance of abnormal test values ​​in the context of the disease being studied must be determined by the investigator and includes significant deviations from baseline within the normal range that the investigator considers to be clinically important. Table 6 Safety laboratory tests αPTT = activated partial prothrombin time; AMC = absolute monocyte count; ALT = alanine aminotransferase; ANC = absolute neutrophil count; AST = aspartate aminotransferase; AT III = antithrombin III; CRP = C-reactive protein; GGT = gamma glutamyltransferase; HBV = hepatitis B virus; HCV = hepatitis C virus; HIV1 = human immunodeficiency virus 1; HIV2 = human immunodeficiency virus 2; INR = international normalized ratio; LDH = lactate dehydrogenase; PT = prothrombin time; RBC = red blood cell count; TB = tuberculosis; ULN = upper limit of normal; WBC = white blood cell count Pharmacokinetics

[0178] The PK of CTL-002 administered as a monotherapy and / or in combination with defined checkpoint inhibitors will be measured from blood samples collected at the start of treatment and at various subsequent time points (Part A). Additional PK data may be evaluated in expansion cohorts (Part B).

[0179] Blood samples will be collected at the start of treatment and at various time points thereafter to determine whether antibodies to CTL-002 may have developed. Systemic cytokine / chemokine monitoring (pharmacodynamics)

[0180] Serum samples will be collected for measurement of cytokines, chemokines, and other circulating biomarkers to assess pharmacodynamic effects as well as safety. Cytokines and chemokines to be analyzed may include, but are not limited to, tumor necrosis factor alpha (TNF-α), interferon (IFN)-γ, interleukin (IL) 1β, IL-2, IL-4, IL-6, IL-8, IL10, IL-12p70, IL-13, CXCL9 (monokine induced by γ [MIG]), and CXCL10 (IP-10). Exploratory evaluation

[0181] Serum biomarker testing may be performed on samples (retained aliquots) collected specifically for future biomedical research during this clinical trial to identify serum factors (e.g., but not limited to metabolites, soluble growth factors, cytokines, chemokines) that are important for anti-GDF-15 (CTL-002) treatment. Retrospective biomarker studies will be conducted using appropriate biostatistical design and analysis and compared to PK / pharmacodynamic results, previously assessed biomarkers, or clinical outcomes. Efficacy Assessment: Imaging Assessment (Local Testing)

[0182] Tumor response will be evaluated using RECIST V1.1 as well as imRECIST criteria according to institutional criteria. For the purposes of this study, subjects will be evaluated at baseline scan screening and should be re-evaluated every 8 weeks starting at the 3rd cycle and / or from the end of treatment visit, after which response assessments may be performed as per local institutional guidelines until the end of efficacy and survival follow-up.

[0183] All lesions identified at Screening / Baseline will be tracked continuously using the unique lesion number assigned at Screening / Baseline and will need to be recorded in the subject's file and eCRF.

[0184] The same assessment method (imaging modality, e.g., MRI, CT) must be used to characterize each identified and reported lesion in an individual subject at baseline and during all follow-up examinations. If there is a change in pattern, the trial site may be asked to explain the reason for the change in eCRF. A change in pattern may be considered a protocol deviation.

[0185] Each efficacy time point / visit can be completed within a window of up to ±7 days.

[0186] During the trial, in addition to the on-site interpretation by researchers (local reading), the interpretation center will conduct centralized interpretation of the images afterwards. Definition of progressive disease according to RECIST V1.1 and iRECIST:

[0187] RECIST assessment will be used to identify subjects with possible disease progression (Eisenhaur et al, 2009). As defined by the modified RECIST V1.1 standard or iRECIST standard (Seymour et al, 2017) of immune-based therapeutics, the initial potential progression date scanned by RECIST will be defined as the immune unconfirmed progressive disease (iUPD) date. Stable subjects with iUPD dates will continue to participate in the study as planned and reassess progress 4 to 8 weeks after the first assessment. If the confirmatory assessment supports PD, the disease progression date will be the iUPD date. If the confirmatory assessment does not support PD, the subject has no disease progression and the iUPD date is ignored; Such subjects will remain in the study as planned and continue with the next imaging evaluation as planned according to the protocol.

[0188] Antitumor activity will be evaluated according to investigator assessment using RECIST V1.1 and immune response criteria according to iRECIST, as described below. Contrast-enhanced CT scan, MRI, or positron emission tomography-computed tomography (PET-CT) of the chest, abdomen, and pelvis. RECIST and iRECIST criteria will be used to evaluate disease response and disease progression in this study. Subjects with symptomatic or untreated or current treatment-requiring brain and / or leptomeningeal metastases are not eligible for this study. Brain imaging must not exceed 12 weeks. Results of a brain MRI with abnormal / unexpected findings should be discussed with the Medical Monitor as part of the screening process. The same assessment method and the same technique should be used to characterize each lesion identified and reported at baseline and during follow-up. If there is a change in pattern, the site may be asked to explain the reason for the change in eCRF. A change in pattern may be considered a protocol deviation. result

[0189] The study was initiated in December 2020 and the first patient was enrolled on December 9, 2020. Cohorts 1 to 5 have been completed without dose-limiting toxicity (DLT), and Phase 1 (Part A) of the study has been completed. Note: Interim data. Patients and CTL-002 Treatment:

[0190] This interim report includes demographic and preliminary safety data for all 25 patients treated in Phase 1 (Part A) of the CTL-002-001 trial. Table 7: Patient Demographics for Each Dose Cohort ECOG baseline *1 patient was replaced due to delayed start of combination therapy Preliminary safety and tolerability of CTL-002:

[0191] So far, monotherapy and combination with nivolumab have shown excellent tolerability. So far, no dose-limiting toxicity (DLT) has occurred and no grade 4 or 5 TEAEs have occurred, and no safety events of concern have been observed. In Part A (Phase 1) of the clinical trial CTL-002-001, 25 subjects have received at least 1 dose of vesugromab (CTL-002). Adverse events were coded according to the Medical Dictionary for Regulatory activities (MedDRA).

[0192] No DLTs and no Grade ≥ 4 AEs were reported in any subject treated in Part A of this study.

[0193] During this reporting period, no significant safety findings were found in this clinical trial. So far, the treatment has not been associated with adverse events of any major clinical concern and has been well tolerated in all subjects treated in the context of advanced cancer. So far, as of the interim reporting time point (cutoff date February 10, 2022), 12 SAEs have been reported in 8 subjects (32.0%) in study CTL-002-001. A total of 4 of these SAEs were assessed by the investigator and / or sponsor as possibly related to CTL-002.

[0194] During this reporting period, no Grade 4 (life-threatening) and Grade 5 (fatal) AEs related to CTL-002 were reported.

[0195] Grade 3 AEs reported in more than one patient were increased GGT and anemia (2 subjects each; no transfusions were allowed during the DLT period).No subject prematurely discontinued the study due to an AE. Biomarker strategy and analysis

[0196] This clinical trial explored serum and tissue-based biomarkers. In addition to classic markers of immune system activation such as serum cytokines, specific analyses were performed to evaluate the immunomodulatory effects of GDF-15 in the tumor microenvironment. Among other parameters, baseline GDF-15 levels, intratumoral GDF-15 levels, and the number and spectrum of tumor-infiltrating leukocytes were analyzed before and after neutralization of GDF-15 by CTL-002. For most tumors analyzed, a large amount of tumor-selective GDF-15 expression was determined. In the majority of patients, a predominantly CD8 + and CD4 +Tumor and tumor-stroma selective influx of T cells, with the effects observed starting at dose level 1. Preliminary analysis showed that in several patients, T cell proliferation in the tumors was increased as shown by CD3 / ki-67+ staining. Several tumors that were "cold tumors" characterized by fairly low CD8 and CD4 counts at baseline were converted to hot tumors by increasing CD8 and CD4 counts.

[0197] In addition, some tumors exhibit reactive PD-L1 upregulation, an indirect marker of IFN-γ release and active immune response against tumor cells. Table 8: List of analytes in blood, tumor, and urine used for PD / PK modeling, immune assessment, and biomarker identification. Initial response assessment

[0198] For 6 subjects in this heavily pre-treated end-line tumor population, significant and durable clinical benefits were observed. Three subjects experienced confirmed partial responses (PRs), two of which currently experienced a durable duration of more than 10 months (1×unknown primary cancer at dose level [DL] 3, and 1×mesothelioma at DL5), and the third subject had hepatocellular carcinoma with durable, prolonged tumor regression). Another 3 subjects experienced extended disease stabilization, 2 of which exceeded 6 months (1×NSCLC and 2×melanoma). The third subject had 5.5 months of disease stabilization, and then local progression occurred in one liver lesion, causing vascular compression. At the discretion of the investigator, the study treatment was continued, and local irradiation was performed on the added site (out of study). Shortly thereafter, the subject continued to have a deep, confirmed partial response, with abscopal effects observed in non-irradiated lesions (with the permission of the sponsor, while continuing to study treatment with CTL-002 and nivolumab). Two other subjects had slight tumor regressions in isolated lesions.

[0199] Overall, in dose escalation (Part A), 6 subjects received treatment for up to 11 months in the optional extended treatment phase and demonstrated durable tumor control, including durable, confirmed partial responses. in conclusion

[0200] Recent preclinical data from the present inventors and others indicate that GDF-15 potently (1) blocks T cell infiltration into the tumor microenvironment (TME), and (2) also suppresses potent immune responses within the (TME) through other mechanisms. Thus, GDF-15 plays a key role in suppressing effective anti-tumor immune responses.

[0201] The GDFATHER (GDF-15 Antibody-Mediated Effector Cell Repositioning) Phase 1 / 2 trial explored the safety, PK and PD, and preliminary antitumor activity of the GDF-15 neutralizing antibody CTL-002 as a monotherapy and in combination with a checkpoint-inhibitor (CPI) in a CPI-relapsed / refractory patient population. Anti-cachexia effects were also studied.

[0202] Dose levels 1 to 5 have been completed safely and were well tolerated with no DLTs, and the Phase 2 portion has begun.

[0203] Pharmacodynamic analysis from serial tumor biopsies (dose levels 1 to 5) demonstrated that CTL-002 mediated selective T cell transfer into the tumor microenvironment in the majority of samples studied.

[0204] Preferred doses and dosage regimens for antibodies of the invention, including CTL-002, are 3, 10 or 20 mg / kg / Q2wk; more preferred doses and dosage regimens are 10 mg / kg / Q2wk. As reflected by the favorable clinical effects observed in patients to date, these dose levels are expected to be highly effective. In addition, the dose and dosage regimen selection is based on extensive studies conducted by the inventors, including pharmacological modeling and PK / pharmacodynamic data obtained from Part A, indicating that GDF-15 is completely neutralized at this dose in patients with all ranges of baseline GDF-15 serum levels. A review of all treatment doses and their adverse events, the PK / pharmacodynamics observed to date, and the comprehensive drug model testing performed indicate that at 10 mg / kg of CTL-002, complete GDF-15 inhibition within the tumor vasculature is achieved even at elevated baseline serum concentrations of GDF-15 in the serum as high as 10 ng / ml GDF-15 (equivalent to approximately 160 ng / ml GDF-15 in close proximity to the tumor). So far, no worrying safety events have been observed at this dose, no DLT has occurred at this dose, and there is still a safety margin value of >10 times compared with the NOAEL in non-human primates (NHP). Therefore, it is expected that the above preferred dose is particularly effective and safe.

[0205] The above observations on efficacy, safety and PK / pharmacodynamics data also suggest that it would be possible to advantageously administer the anti-GDF-15 antibody at a preferred dose of 10 to 20 mg / kg, more preferably 20 mg / kg, and at a dose regimen of at least one administration cycle, wherein the cycle is a three-week period at a dose of 10 mg / kg and a four-week period at a dose of 20 mg / kg, and wherein the dose is administered at least once (i.e., preferably once) in each of at least one cycle. This dose regimen has a longer administration cycle of three or four weeks, but preferably a dose of 10 to 20 mg / kg, more preferably 20 mg / kg, which would allow for a favorable safety and efficacy profile similar to the preferred 10 mg / kg / Q2wk regimen. This dosing regimen is consistent with the observed PK / pharmacodynamic profiles, and a population PK / PD modeling approach for modeling total CTL-002 and total GDF-15 in serum was combined with a previously developed GDF-15 tumor model to predict systemic and tumor levels of free GDF-15 in serum for 3, 10, 20 mg / kg dosing q2w, q3w, and q4w. Dosing to maintain free GDF-15 in tumors at or below the nominal healthy value of 0.5 ng / mL is predicted to depend on baseline GDF-15, with higher baseline levels requiring higher doses. These data support a dosing regimen of at least 10 mg / kg every two or three weeks or at least 20 mg / kg every 4 weeks to maintain free GDF-15 in the tumor vasculature below the nominal healthy value of 0.5 ng / ml ( Figure 5 ).

[0206] The above findings suggest that treatment with anti-GDF-15 antibodies according to the present invention may provide substantial clinical benefit to cancer patients with a very low associated risk profile. Importantly, this benefit was observed in patients who were previously refractory to some of the most advanced treatment options, such as treatment with antagonists of the PD-1 / PD-L1 axis (e.g., nivolumab). (2) Embodiment 1

[0207] In view of the favorable findings in the above reference examples, the inventors attempted to identify and further analyze cancers that are particularly responsive to treatment with anti-GDF-15 antibodies and aPD-1 / -L1 antibodies. Based on these further analyses by the inventors, the following cancer subgroups are expected to be particularly responsive to this treatment:

[0208] For colorectal cancer (CRC), 13 selected immune-related analyses were performed in silico using mRNA expression data from a large number of colorectal cancer patients. All calculations and correlation analyses were performed using the statistical software environment R. In these analyses, GDF-15 mRNA expression was associated with 13 immune features, including mRNA expression of genes related to CD8+ cell infiltration, T cell dysfunction, T cell-inflamed tumors, interferon gamma, inflammation, immune prediction score, cytolytic activity, cytotoxic T lymphocytes, T cell rejection, and mRNA expression of genes encoding PD-1, PD-L1, and marker genes for CD8 cells and cytotoxic T lymphocytes, respectively.

[0209] Notably, in all these 13 immune-related analyses, a significant inverse correlation with GDF-15 mRNA expression was observed in CRC patients. In addition, a clear decrease in estimated infiltrating CD8+ T cells was observed from lower to higher GDF15 expression.

[0210] Similarly, for BLCA, BRCA, PAAD, LUAD, KIRC, CESC, and TGCT, inverse correlations with GDF-15 mRNA expression could be observed in at least 10 of the 13 selected immune-related analyses.

[0211] These findings are consistent with the strong T cell rejection induced by GDF-15 in patients with CRC, BLCA, BRCA, PAAD, LUAD, KIRC, CESC, and TGCT.

[0212] Therefore, treatment with anti-GDF-15 antibodies according to the invention is expected to be particularly effective at least in CRC, BLCA, BRCA, PAAD, LUAD, KIRC, CESC and TGCT patients due to restoration of T cell infiltration of tumors. (3) Embodiment 2

[0213] The inventors sought to identify and further analyze cancer patients who were particularly responsive to combination therapy comprising an anti-GDF-15 antibody and a checkpoint inhibitor in a variety of different types of cancer. Based on these additional experiments, the inventors unexpectedly discovered that the following patients were expected to be particularly responsive to combination therapy:

[0214] In this regard, the patients' baseline biopsies were analyzed for PD-L1 TPS and tumor inflammation score (TIS) and T-cell infiltration counts. PD-L1 TPS method

[0215] For test interpretation and scoring, refer to the manufacturer's interpretation guide: "VENTANA PD-L1 (SP263) Assay Staining of Non-Small Cell Lung Cancer Interpretation Guide", version 1015317EN.

[0216] Briefly, the percentage of PD-L1-positive tumor cells (TPS) was determined in an immunohistochemistry (IHC) assay procedure based on formalin-fixed and paraffin-embedded (FFPE) sections using an anti-PD-L1 (SP263) monoclonal antibody (Ventana, catalog number 790-4905). Prior to antibody incubation, tissue sections were dewaxed and heat-pretreated to expose all target antigens. Next, a secondary antibody HRP enzyme-conjugated antibody (Ventana optiView Universal DAB Detection Kit, catalog number 760-700) was used to visualize the binding of anti-PD-L1 antibodies to PD-L1-positive cancer cells. The specific antibody-enzyme complex was visualized based on the precipitated enzyme reaction product. To determine the PD-L1 TPS, a CE-IVD clearance prediction assay (741-4905) was used, which uses a defined cutoff of ≥1% membrane-stained tumor cells to distinguish between negative and positive cancer tissue (e.g., NSCLC tissue) samples. Positive cases were further subdivided by applying additional cutoffs of ≥5% and ≥10% because improved overall survival after treatment with nivolumab (OPDIVO) was observed in patients with higher PD-L1 expression levels. Slide interpretation and cutoff determination are described in more detail in the official scoring guideline "VENTANA PD-L1 (SP263) Assay for Non-Small Cell Lung Cancer Interpretationsanleitung 2016", version 1015317EN.

[0217] For scoring, for each staining intensity (0, 1, 2, 3), the percentage of PD-L1-positive tumor cells was determined, and the total percentage of stained tumor cells was calculated by summing the percentages at intensities 1, 2, and 3.

[0218] Clinical data analysis showed that PD-L1 TPS was a positive enrichment factor for clinical response (see Figure 6 , 7 A / B, 8). Tumor Inflammation Score (TIS) Method:

[0219] TIS includes: 18 functional genes (PSMB10, HLA-DQA1, HLA-DRB1, CMKLR1, HLA-E, NKG7, CD8A, CCL5, CXCL9, CD27, CXCR6, IDO1, STAT1, TIGIT, LAG3, CD274, PDCD1LG2 and CD276) known to be associated with response to PD-1 / PD-L1 inhibitor pathway blockade; and IFN-γ response genes, which are associated with antigen presentation, chemokine expression, cytotoxic activity and adaptive immune resistance genes (see Danaher, Patrick, et al, Ayers M et al.). The TIS method can be performed as briefly described below. First, use RNA extracted from formalin-fixed paraffin-embedded tumor blocks was compared with PanCancer IO360 TM CodeSet hybridization. Next, the raw data for each sample and gene were normalized to the internal ERCC control to eliminate the technical variability of the assay, and then the counts were normalized to the geometric mean of the endogenous housekeeping genes, followed by log2 transformation. Finally, gene expression signatures, including TIS, were calculated as weighted linear averages of the constituent genes.

[0220] Based on analysis of patient baseline biopsies, it is expected that PD-L1 and TIS show predictive value for clinical response to combination therapy comprising anti-GDF-15 Ab (e.g., CTL-002) and nivolumab, particularly in patients who are refractory to anti-PD-1 / PD-L1 therapy (see Figure 6 Clinical responders with PD-L1 TPS>1 and tumor inflammation score (TIS)>7.5 in 1-02-006, 1-03-004, 1-03-002 and long-term SD 2-01-003).

[0221] These findings of the inventors are unexpected, because the combination therapy of the present invention can be successfully used even for patients who are refractory to monotherapy with anti-PD1 or anti-PD-L1 antibodies or to combination therapy with anti-PD1 or anti-PD-L1 antibodies and other anti-cancer agents. Therefore, such combination therapy is clinically different from monotherapy with anti-PD1 or anti-PD-L1 antibodies, or from combination therapy with anti-PD1 or anti-PD-L1 antibodies and other anti-cancer agents, and therefore the combination therapy of the present invention is expected to be associated with different biomarkers. Based solely on the experimental results provided by the inventors, it was unexpectedly found that the combination therapy of the present invention achieved particularly beneficial treatment outcomes in patients with PD-L1-positive cancer or inflammatory tumors, as indicated based on TIS, and this was the last line of treatment after confirmed failure of previous anti-PD1 / PD-L1 therapy.

[0222] CD8+ T cell density (cells / mm) was determined by immunohistochemistry (IHC). 2 ): CD8 protein is a glycoprotein expressed primarily on the surface of CTLs and therefore serves as a general marker for this specific cell population. The function of CD8+CTLs is to eliminate cancer cells or cells infected or damaged by viruses by recognizing antigen fragments presented on MHC class I on these cells. Activated CTLs release cytokines and cytotoxic enzymes, such as granzyme B and perforin, leading to the killing of cancer cells or infected cells. The primary (monoclonal) antibodies (monoclonal mouse anti-human CD8, clone C8 / 144B) used in the multiplex IHC assay procedure described herein bind to their respective antigens in FFPE tissue sections (thickness: 4 μm). In order to expose all target antigens, tissue sections are dewaxed and heat pretreated, followed by antibody incubation. In most cases, after applying one or more linker antibodies conjugated to hydroxyquinoxaline (HQ)- or nitropyrazole (NP)-, a secondary horseradish peroxidase (HRP)- or alkaline phosphatase (AP)-conjugated antibody can be used to visualize the binding of specific antibodies, thereby allowing amplification of the resulting signal. The enzyme coupled to the secondary antibody catalyzes the reaction of chromogenic precipitate formation at the binding site of the actual primary antibody. Incubation is performed for each step. After each incubation step, the sections are washed with the VENTANA DISCOVERY ULTRA automatic slide stainer to stop the corresponding reaction and remove unbound substances that would hinder the desired reaction in the subsequent steps. Before applying the next primary antibody, the previous reagents are removed by heat incubation ("stripping"), leaving only the insoluble precipitate on the slide. For quantitative evaluation of the stained slides, the Visiopharm digital image analysis software VIS 2019.02 (TID 001673) was used. Prior to image analysis, the stained slides were scanned at a magnification of 20× using an Aperio ScanScope XT (Leica). The final workflow not only allows the detection of positive staining for individual biomarkers, but also enables the differentiation of tissue compartments of tumor, normal tissue, and peritumoral and intratumoral stroma. To achieve this, additional guided staining with the tumor-specific markers panCK (solid tumors) or SOX10 (malignant melanoma) was introduced, allowing the generation of a virtual overlay image by aligning serial sections and transferring information from one slide to another. The final readout included area measurements (mm) for each tissue compartment. 2 ), cell counts of each cell type in each compartment, density calculations (cell counts / mm 2 ) and distance measures for biologically relevant combinations of cell types.

[0223] CD3+ T cell density (cells / mm2) was determined by IHC: Multiplex immunofluorescence assays (UltiMapper 1 / 0T-act Panel CD3, granzyme B, Ki67, and panCK / SOX10) using ULTIVUE CD3+ T cell density was determined using the I / O T-act kit (p / n ULT20110) stained on a Leica Bond RX, digitized as whole-mount images using a ZEISS Axioscan Z1, and subsequently digitally analyzed in Visiopharm.

[0224] Baseline biopsies from clinical responders 1-02-006, 1-03-004, 1-03-002, 1-02-036, and 1-06-005 and long-term SD2-01-003 showed PD-L1 TPS>1 and CD8+ T cell density>300 cells / mm 2 ( Figure 7 A, B). Therefore, it is expected that not only TPS, but also CD8+ T cell density has predictive value for treating human patients with anti-GDF-15 antibodies (e.g., CTL-002), for example, when administered in combination with anti-PD-1 or anti-PD-L1 antibodies (e.g., nivolumab) to patients refractory to anti-PD-1 and / or anti-PD-L1. The same applies to CD3+ T cell density ( Figure 8 ).

[0225] In patients treated with anti-GDF15, an approximately 2- to 4-fold change in CD8+ cell influx was observed on average at days 14 and 28 compared with baseline (Bs1), indicating that the anti-GDF15 antibody increased the percentage of CD8+ cells in tumors relative to baseline ( Fig. 9 , top). Similarly, analysis of immune cells in patient biopsies at baseline (bsl), day 14, and day 28 revealed an increase in CD3+Ki67+ T cells proliferating under treatment ( Fig. 9 , figure below).

[0226] In summary, analysis of clinical data revealed PD-L1 TPS in particular as a positive enrichment factor for clinical response (see Figure 6 , 7A / B, 8).

[0227] In addition, clinical data also revealed that patient selection by PD-L1 TPS alone or in combination with either CD8 cell density, CD3 cell density, or TIS enriched clinical responders.

[0228] For example, among 14 bladder cancer patients, 2 patients showed PD-L1 TPS>5, and both patients showed PR. Similarly, among 14 bladder cancer patients, 7 patients showed PD-L1 TPS>1, and 28.6% (2 of 7) of them showed PR.

[0229] In addition, among 14 bladder cancer patients, 2 patients showed PD-L1 TPS>5 and CD8 cell density>300 cells / mm 2 , and both patients showed PR. Similarly, among 14 bladder cancer patients, 3 patients showed PD-L1TPS>1 and CD8 cell density>300 cells / mm2, and 66.7% (2 of 3 names) of them showed PR. sequence

[0230] SEQ ID No: 1 (heavy chain CDR1 region peptide sequence of monoclonal anti-human GDF-15 antibody): GFSLSTSGMG

[0231] SEQ ID No: 2 (heavy chain CDR2 region peptide sequence of monoclonal anti-human GDF-15 antibody): IYWDDDK

[0232] SEQ ID No: 3 (heavy chain CDR3 region peptide sequence of monoclonal anti-human GDF-15 antibody): ARSSYGAMDY

[0233] SEQ ID No: 4 (light chain CDR1 region peptide sequence of monoclonal anti-human GDF-15 antibody): QNVGTN

[0234] Light chain CDR2 region peptide sequence of monoclonal anti-human GDF-15 antibody: SAS

[0235] SEQ ID No: 5 (light chain CDR3 region peptide sequence of monoclonal anti-human GDF-15 antibody): QQYNNFPYT

[0236] SEQ ID No: 6 (heavy chain variable domain of monoclonal anti-human GDF-15 antibody):

[0237] SEQ ID No: 7 (light chain variable domain of monoclonal anti-human GDF-15 antibody):

[0238] SEQ ID No: 8 (heavy chain of monoclonal anti-human GDF-15 antibody CTL-002 without leader peptide sequence):

[0239] SEQ ID No: 9 (light chain of monoclonal anti-human GDF-15 antibody CTL-002 without leader peptide sequence):

[0240] SEQ ID NO: 10 (heavy chain variable domain of anti-human GDF-15 antibody H1L5):

[0241] SEQ ID NO: 11 (light chain variable domain of anti-human GDF-15 antibody H1L5):

[0242] Discontinuous epitope (EVQVTMCIGACPSQFR (SEQ ID NO: 12)-38 amino acids-TDTGVSLQTYDDLLAKDCHCI (SEQ ID NO: 13))

[0243] exist Figure 3 The sequence shown in: GDF-15 people: SEQ ID NO: 14 GDF-15macfa: SEQ ID NO: 15 GDF-15 mouse: SEQ ID NO: 16 GDF-15 rat: SEQ ID NO: 17 Partially shared CTL-002 epitope (b): SEQ ID NO: 18

[0244] SEQ ID NO: 19 (light chain variable region domain of anti-mGDF-15 antibody)

[0245] SEQ ID NO: 20 (heavy chain variable region domain of anti-mGDF-15 antibody) References Abulizi P,Loganathan N,Zhao D,et al.Growth Differentiation Factor-15Deficiency Augments Inflammatory Response and Exacerbates Septic Heart andRenal Injury Induced by Lipopolysaccharide Sci Rep.2017;7(1):1-10. Martina,Martin Laaff,Birgit Schechinger,Gudrun Rappold,KlausUnsicker,and Clemens Suter-Crazzolara.1999.“Characterization of the Rat,Mouse,and Human Genes of Growth / Differentiation Factor-15 / MacrophageInhibiting Cytokine-1(GDF-15 / MIC-1).”Gene237(1):105-11. Chung HK,Kim JT,Kim HW,et al.GDF15 deficiency exacerbates chronicalcohol-and carbon tetrachloride-induced liver injury.Sci Rep.2017;7(1):1-13.doi:10.1038 / s41598-017-17574-w Eisenhauer EA,Therasse P,Bogaerts J,etal.New Response Evaluation Criteria in Solid Tumours:Revised RECIST Guideline(Version 1.1).Eur J Cancer.2009Jan;45(2):228-47. 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Wang M,Yao LC,Cheng M,Cai D,Martinek J,Pan CX,et al.Humanized mice instudying efficacy and mechanisms of PD-1-targeted cancer immunotherapy.FASEBJ.2018;32(3):1537-49. Welsh,John B.,Lisa M.Sapinoso,Suzanne G.Kern,David A.Brown,Tao Liu,Asne R.Bauskin,Robyn L.Ward,et al.2003.“Large-Scale Delineation of SecretedProtein Biomarkers Overexpressed in Cancer Tissue and Serum.” Proceedings ofthe National Academy of Sciences 100(6):3410-15.https: / / doi.org / 10.1073 / PNAS.0530278100. Wischhusen J,Melero l,and Fridman W.GDF-15:From Biomarker to NovelTargettable Immune Checkpoint.Front.Immunol.Accepted23Apr2020.doi:10.3389 / fimmu. Wollert KC,Kempf T,Giannitsis E,et al.An Automated Assay for GrowthDifferentiation Factor15.J Appl Lab With An AACC Publ.2018:1(5):510-521.doi:10.1373 / jalm.2016.022376Jerby-Arnon et al.(2018),Cell.175(4):984-997) Trujillo et al.(2018),Cancer Immunol Res.6(9):990-1000 Proc Natl Acad Sci US A.113(48):E7759-E7768) Spranger et al. Roelands et al.,Int J Mol Sci.2017Oct:18(10):2229 Guinney et al.(Night Med.2015Nov:21(11):1350-6.doi:10.1038 / nm.3967.Epub20150ct 12) McConkey et al.,Curr Oncol Rep.2018Aug 20;20(10):77 Allison et al.(J Clin Oncol.2020Apr 20;38(12):1346-1366.doi:10.1200 / JCO.19.02309.Epub2020Jan 13) Pu et al.(Breast Cancer Res Treat.2020Jan;179(1):197-206) Inamura(Oncotarget.2018Feb 16;9(18):14723-14737.doi:10.18632 / oncotarget.24515.eCollection 2018Mar 6) Augustin et al.(Front Oncol.2020sep 15;10:1751.doi:10.3389 / fonc.2020.01751.eCollection2020) Danaher,Patrick,et al."Pan-cancer adaptive immune resistance asdefined by the Tumor Inflammation Signature(TIs):results from The CancerGenome Atlas(TCGA).″Journal for immunotherapy of cancer 6.1(2018):1-17. Ayers M, Lunceford J, Nebozhyn M, Murphy E, Loboda A, Kaufman DR, Albright A, Cheng JD, Kang SP, Shankaran V, Piha-Paul SA, Yearley J, Seiwert TY, Ribas A, McClanahan TK. IFN-γ-related mRNA profile predicts clinical response to PD-1 blockade.J Clin Invest.2017Aug1;127(8):2930-2940.doi:10.1172 / JCl91190.Epub2017Jun26.PMID:28650338;PMCID:PMC5531419. Tumeh et al., Nature.2014Nov 27;515(7528):568-71. Yarchoan et al., JCI Insight.2019Mar 21;4(6):e126908. Chen et al., Exp Hematol Oncol. 2020Aug 3;9:17.doi:10.1186 / s40164-020-00173-3. eCollection 2020. WO 2022 / 101263 Us 2020 / 0055930 Industrial Applicability

[0246] The anti-GDF-15 antibodies used in the methods for treating cancer in human patients can be industrially prepared and sold as products for the methods and uses listed according to known standards for the preparation of pharmaceutical products. Therefore, the present invention is industrially applicable.

Claims

1. A pharmaceutical composition comprising an anti-GDF-15 antibody in combination with at least one checkpoint inhibitor for use in a method of treating cancer in a human patient, wherein the human patient has a PD-L1 positive cancer and / or has a cancer comprising an inflamed tumor.

2. The pharmaceutical composition for use according to claim 1, wherein the cancer is a PD-L1 positive cancer as determined by immunohistochemistry (IHC) assay.

3. The pharmaceutical composition for use according to claim 2, wherein the IHC assay uses an anti-PD-L1 antibody as a primary antibody and determines the percentage of PD-L1 positive cancer cells.

4. The pharmaceutical composition for use according to any one of claims 2 to 3, wherein the PD-L1 positive cancer shows a percentage of cancer cells stained for the presence of PD-L1 on the cell surface of at least 1 in an immunohistochemistry (IHC) assay.

5. The pharmaceutical composition for use according to claim 2, wherein the IHC assay uses an anti-PD-L1 antibody as a primary antibody and determines the sum percentage of PD-L1-positive cancer cells and PD-L1-positive cancer-infiltrating cells.

6. The pharmaceutical composition for use according to any one of claims 1 to 5, wherein the inflammatory tumor is a T cell inflammatory tumor.

7. The pharmaceutical composition for use according to any one of claims 1 to 6, wherein the inflammatory tumor is a tumor comprising CD3+ cells.

8. The pharmaceutical composition for use according to claim 7, wherein the inflamed tumor comprises CD3+ cells as determined by immunohistochemistry (IHC) assay, and wherein the IHC assay uses an anti-CD3 antibody as a primary antibody.

9. The pharmaceutical composition for use according to claim 8, wherein the inflammatory tumor has an average CD3+ cell density of >300 cells / mm in an immunohistochemical tissue section with a thickness of 4 μm. 2 of tumors, as assessed by immunohistochemistry (IHC) assay.

10. The pharmaceutical composition for use according to any one of claims 1 to 9, wherein the inflammatory tumor is a tumor comprising CD8+ cells.

11. The pharmaceutical composition for use according to claim 10, wherein the inflamed tumor comprises CD8+ cells as determined by immunohistochemistry (IHC) assay, and wherein the IHC assay uses an anti-CD8 antibody as a primary antibody.

12. The pharmaceutical composition for use according to claim 11, wherein the inflammatory tumor has an average CD8+ cell density of >300 cells / mm in an immunohistochemical tissue section with a thickness of 4 μm. 2 of tumors, as assessed by immunohistochemistry (IHC) assay.

13. The pharmaceutical composition for use according to any one of claims 6 to 12, wherein the T cell inflamed tumor is inflamed as indicated by its tumor inflammation index (TIS).

14. The pharmaceutical composition for use according to claim 13, wherein the TIS is based on the expression of at least one marker gene selected from PSMB10, HLA-DQA1, HLA-DRB1, CMKLR1, HLA-E, NKG7, CD8A, CCL5, CXCL9, CD27, CXCR6, IDO1, STAT1, TIGIT, LAG3, CD274, PDCD1LG2 and CD276, preferably the expression of all marker genes.

15. The pharmaceutical composition for use according to claim 14, wherein the TIS is a linear combination of all the marker genes, calculated as where x i is the log2-transformed normalized expression level of the ith gene, and w i is a predefined weight greater than zero.

16. The pharmaceutical composition for use according to claim 15, wherein the TIS is greater than 7.

5.

17. The pharmaceutical composition for use according to any one of claims 1 to 16, wherein the human patient is an anti-PD-1 patient and / or an anti-PD-L1 relapsed and / or refractory patient.

18. A pharmaceutical composition for use according to any one of claims 1 to 17, wherein the checkpoint inhibitor is selected from one or more of the following: an anti-PD-1 antibody or a PD-1 binding fragment thereof, an anti-PD-L1 antibody or a PD-L1 binding fragment thereof, an anti-CD40 antibody or a CD40 binding fragment thereof, an anti-LAG-3 antibody or a LAG-3 binding fragment thereof, an anti-TIM-3 antibody or a TIM-3 binding fragment thereof, an anti-TIGIT antibody or a TIGIT binding fragment thereof, and an anti-CTLA4 antibody or a CTLA4 binding fragment thereof.

19. The pharmaceutical composition for use according to claim 18, wherein the checkpoint inhibitor is selected from anti-PD-1 antibodies or PD-1 binding fragments thereof and anti-PD-L1 antibodies or PD-L1 binding fragments thereof.

20. The pharmaceutical composition for use according to any one of claims 1 to 19, wherein the cancer is a solid cancer.

21. A pharmaceutical composition for use according to any one of claims 1 to 20, wherein the cancer is selected from the group consisting of colorectal cancer, gastric cancer, bladder cancer, melanoma, non-small cell lung cancer, head and neck squamous cell carcinoma, hepatocellular carcinoma, prostate adenocarcinoma, pancreatic cancer, uterine cancer, cervical cancer, thyroid cancer, cutaneous squamous cell carcinoma, mesothelioma, cancer of unknown primary (CUP) and breast cancer.

22. The pharmaceutical composition for use according to any one of claims 1 to 21, wherein the anti-GDF-15 antibody comprises a heavy chain variable domain and a light chain variable domain, the heavy chain variable domain comprising a CDR1 region represented by the amino acid sequence shown in SEQ ID NO: 1, a CDR2 region represented by the amino acid sequence shown in SEQ ID NO: 2, and a CDR3 region represented by the amino acid sequence shown in SEQ ID NO: 3, and the light chain variable domain comprises a CDR1 region represented by the amino acid sequence shown in SEQ ID NO: 4, a CDR2 region represented by the amino acid sequence ser-ala-ser, and a CDR3 region represented by the amino acid sequence shown in SEQ ID NO:

5.

23. The pharmaceutical composition for use according to any one of claims 1 to 22, wherein the anti-GDF-15 antibody has a heavy chain variable domain and a light chain variable domain, the heavy chain variable domain comprising an amino acid sequence represented by SEQ ID NO: 6 or an amino acid sequence having at least 90% identity, preferably at least 95% identity, and more preferably at least 98% identity to the amino acid sequence shown in SEQ ID NO: 6, and the light chain variable domain comprising an amino acid sequence represented by SEQ ID NO: 7 or an amino acid sequence having at least 90% identity, preferably at least 95% identity, and more preferably at least 98% identity to the amino acid sequence shown in SEQ ID NO:

7.

24. The pharmaceutical composition for use according to any one of claims 1 to 23, wherein the anti-GDF-15 antibody has a heavy chain and a light chain, the heavy chain comprising the amino acid sequence represented by SEQ ID NO: 8 or an amino acid sequence having at least 90% identity, preferably at least 95% identity, and more preferably at least 98% identity to the amino acid sequence shown in SEQ ID NO: 8, and the light chain comprising the amino acid sequence shown in SEQ ID NO: 9 or an amino acid sequence having at least 90% identity, preferably at least 95% identity, and more preferably at least 98% identity to the amino acid sequence shown in SEQ ID NO:

9.

25. The pharmaceutical composition for use according to any one of claims 1 to 24, wherein the anti-GDF-15 antibody has a heavy chain comprising the amino acid sequence represented by SEQ ID NO: 8 and a light chain comprising the amino acid sequence represented by SEQ ID NO:

9.

26. The pharmaceutical composition for use according to any one of claims 1 to 25, wherein the anti-GDF-15 antibody is to be administered to the human patient, preferably i) a dose of 3 to 20 mg / kg, preferably a dose of 10 mg / kg, and a dosage regimen of at least one administration cycle, wherein the cycle is a two-week period, and wherein the dose is to be administered at least once in each cycle of the at least one cycle, ii) a dose of 3 to 20 mg / kg, preferably a dose of 10 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a three week period, and wherein the dose is to be administered at least once in each of the at least one cycle, or iii) a dose of 3 to 20 mg / kg, preferably a dose of 20 mg / kg, and a dosage regimen of at least one administration cycle, wherein the cycle is a period of four weeks, and wherein the dose is to be administered at least once in each cycle of the at least one cycle, And wherein the cancer is selected from colorectal cancer, gastric cancer, bladder cancer, melanoma, non-small cell lung cancer, head and neck squamous cell carcinoma, hepatocellular carcinoma, prostate adenocarcinoma, pancreatic cancer, uterine cancer, cervical cancer, thyroid cancer, skin squamous cell carcinoma, mesothelioma, cancer of unknown primary (CUP) and breast cancer.

27. The pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is colorectal cancer.

28. The pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is bladder cancer.

29. The pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is cancer of unknown primary (CUP).

30. A pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is mesothelioma.

31. A pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is squamous cell carcinoma of the skin.

32. The pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is non-small cell lung cancer.

33. A pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is hepatocellular carcinoma.

34. A pharmaceutical composition for use according to any one of claims 1 to 26, wherein the cancer is melanoma.

35. Pharmaceutical composition for use according to any one of the preceding claims, wherein the use is also for use in the treatment of cancer cachexia.

36. A pharmaceutical composition for use according to any one of claims 1 to 35, wherein the anti-GDF-15 antibody is to be administered at a dose of 3 to 20 mg / kg, preferably 20 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a period of four weeks, and wherein the dose is to be administered at least once in each cycle of at least one cycle.

37. A pharmaceutical composition for use according to any one of claims 1 to 36, wherein the anti-GDF-15 antibody is to be administered at a dose of 3 to 20 mg / kg, preferably 10 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a three-week period, and wherein the dose is to be administered at least once in each cycle of at least one cycle.

38. A pharmaceutical composition for use according to any one of claims 1 to 37, wherein the anti-GDF-15 antibody is to be administered at a dose of 3 to 20 mg / kg, preferably 10 mg / kg, and the dosage regimen is at least one administration cycle, wherein the cycle is a two-week period, and wherein the dose is to be administered at least once in each cycle of at least one cycle.

39. The pharmaceutical composition for use according to any one of claims 1 to 38, wherein the anti-GDF-15 antibody is obtainable by expression in CHO cells.

40. The pharmaceutical composition for use according to any one of claims 1 to 39, wherein the checkpoint inhibitor is to be administered in the same dosage regimen as the anti-GDF-15 antibody.

41. A pharmaceutical composition for use according to any one of claims 1 to 40, wherein the checkpoint inhibitor is administered before the administration of the anti-GDF-15 antibody, preferably within 120 minutes before the administration of the anti-GDF-15 antibody, and more preferably within 30 minutes before the administration of the anti-GDF-15 antibody.

42. The pharmaceutical composition for use according to any one of claims 1 to 41, wherein the dose of anti-GDF-15 antibody is to be administered intravenously.

43. A method for predicting clinical outcome in a human cancer patient for treatment with a combination of an anti-GDF-15 antibody and at least one checkpoint inhibitor, wherein the method comprises the following steps: (i) analyzing whether the cancer is a PD-L1 positive cancer and / or a cancer comprising an inflammatory tumor, and (ii) predicting the patient's clinical outcome in response to the treatment based on the analysis.

44. A method of treating a human patient diagnosed with cancer comprising the steps of: (a) analyzing whether the cancer is a PD-L1 positive cancer and / or a cancer comprising an inflammatory tumor, (b) predicting the patient's clinical outcome for the treatment based on the analysis, and (c) treating said human patient comprising a combination of an anti-GDF-15 antibody and at least one checkpoint inhibitor.

45. The method of claim 43 or 44, wherein the clinical outcome comprises response, complete response, partial response, stable disease, progressive disease and / or survival of the human cancer patient.

46. ​​The method of any one of claims 43 to 45, wherein if the cancer is a PD-L1 positive cancer, the patient is predicted to exhibit an improved clinical outcome.

47. The method of claim 46, wherein the PD-L1 positive cancer is as defined in claims 2 to 5.

48. The method of any one of claims 43 to 47, wherein if the cancer comprises an inflammatory tumor, the patient is predicted to exhibit an improved clinical outcome.

49. The method according to claim 48, wherein the inflamed tumor is as defined in claims 6 to 16.

50. The method of any one of claims 43 to 49, wherein the checkpoint inhibitor is as defined in claim 18 or 19.

51. The method according to any one of claims 43 to 50, wherein the cancer is selected from the cancer defined in claim 20 or 21.

52. The method according to any one of claims 43 to 51, wherein the human patient is an anti-PD-1 patient and / or an anti-PD-L1 relapsed and / or refractory patient.

53. An anti-GDF-15 antibody for use in a method of treating cancer in a human patient, wherein the anti-GDF-15 antibody is to be administered in combination with at least one checkpoint inhibitor, and wherein the human patient has a PD-L1 positive cancer and / or has a cancer comprising an inflamed tumor.

54. An anti-GDF-15 antibody for use according to claim 53, wherein the patient suffers from a cancer as defined in any one of claims 2 to 16, 19 to 21 and 26 to 34.

55. An anti-GDF-15 antibody for use according to claim 53 or 54, wherein the patient is as defined in claim 17.

56. An anti-GDF-15 antibody for use according to any one of claims 53 to 55, wherein the checkpoint inhibitor is as defined in any one of claims 18 to 19.

57. An anti-GDF-15 antibody for use according to any one of claims 53 to 56, wherein the anti-GDF-15 antibody is as defined according to any one of claims 22 to 25 and 39.

58. An anti-GDF-15 antibody for use according to any one of claims 53 to 57, wherein the anti-GDF-15 antibody is to be administered as defined in any one of claims 26, 36 to 38 and 42.

59. An anti-GDF-15 antibody for use according to any one of claims 53 to 58, wherein the checkpoint inhibitor is administered as defined in any one of claims 40 to 41.

60. An anti-GDF-15 antibody for use according to any one of claims 53 to 59, wherein the use is also for the treatment of cancer cachexia.

61. The pharmaceutical composition for use according to any one of claims 1 to 42 or the anti-GDF-15 antibody for use according to any one of claims 53 to 60, wherein the PD-L1 positive cancer shows in an immunohistochemistry (IHC) assay a percentage of cancer cells stained for the presence of PD-L1 on the cell surface of at least 1, preferably at least 2, more preferably at least 5.

62. The pharmaceutical composition or anti-GDF-15 antibody for use according to claim 61, wherein the cancer is bladder cancer.

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