Pharmaceutical composition and use thereof

Abstract

The present invention provides a pharmaceutical combination comprising a WRN inhibitor in combination with at least one additional therapeutically active agent. The invention also provides a method of treating cancer involving administering to a subject in need thereof a combination of the WRN inhibitor and the at least one additional therapeutically active agent. For example, the WRN inhibitor compounds or pharmaceutically acceptable salts thereof have Formula (I): wherein R1, R2, R3, R4, R5, R26, R27, y, R, M, W, L, V, T, Y, J, K, and A are as described herein. # imgabs0 #

Description

Technical Field

[0001] The present invention relates to a pharmaceutical combination comprising a combination of a WRN inhibitor and at least one additional therapeutic active agent. The present invention also relates to methods of treating cancer, which methods involve administering to a subject in need thereof a combination of the WRN inhibitor and the at least one additional therapeutic active agent. Background Art

[0002] The emergence of targeted therapies for cancer has extended the lives of patients with various malignancies and has helped to understand the complexity of tumors by studying mechanisms of drug resistance. The fact that the clinical response to targeted agents is often incomplete and / or transient is caused by a variety of factors, which can be broadly divided into two categories: toxicities that prevent optimal dosing of the drug and thus limit target engagement (Brana and Siu 2012; Chapman, Solit et al. 2014), and the ability of cancer to adapt to perturbations and maintain its proliferative potential (Druker 2008; Chandarlapaty 2012; Doebele, Pilling et al. 2012; Duncan, Whittle et al. 2012; Katayama, Shaw et al. 2012; Lito, Rosen et al. 2013; Sullivan and Flaherty 2013; Solit and Rosen 2014). Combinations of drugs can address these factors by improving overall efficacy and simultaneously targeting tumor robustness and complexity to counter drug resistance (Robert, Karaszewska et al. 2015; Turner, Ro et al. 2015). It is not clear how many drugs are needed and which processes need to be jointly targeted to overcome a particular type of cancer. But it is almost certain that different pathways or drivers need to be inhibited, and it is likely that two or more drugs are required (Bozic, Reiter et al. 2013).

[0003] Despite the availability of multiple treatment options for patients with a particular type of cancer, there is still a need for effective and safe combination therapies that can be administered to treat cancer. Summary of the Invention

[0004] It is an object of the present invention to provide a medicament for improving the treatment of cancer, in particular by inhibiting cell growth (proliferation) and / or inducing apoptosis (cell death). Another object of the present invention is to find new combination therapies, for example, those combination therapies that selectively synergistically enhance the inhibition of proliferation and / or the induction of apoptosis.

[0005] Accordingly, in a first aspect of the present invention, there is hereby provided a method for treating cancer (particularly cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of at least one therapeutic active agent selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0006] Accordingly, in a second aspect of the present invention, there is hereby provided a WRN inhibitor for use in the treatment of cancer (particularly cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), wherein the treatment further comprises administering at least one therapeutic active agent selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0007] Accordingly, in a third aspect of the present invention, there is hereby provided a therapeutic active agent for use in the treatment of cancer (particularly cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), wherein the treatment further comprises administering a WRN inhibitor, and wherein the therapeutic active agent is selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0008] Accordingly, in a fourth aspect of the present invention, there is hereby provided a combination comprising i) a WRN inhibitor, and ii) at least one therapeutic active agent selected from the group consisting of: a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, ionizing radiation selected from i) external beam radiation, ii) brachytherapy and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0009] Accordingly, in a fifth aspect of the present invention, there is hereby provided a method of treating colorectal cancer (particularly colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a G4-quadruplex stabilizer.

[0010] Accordingly, in a sixth aspect of the present invention, there is hereby provided a method of treating colorectal cancer (particularly colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a MEK inhibitor.

[0011] Accordingly, in a seventh aspect of the present invention, there is hereby provided a method of treating colorectal cancer (particularly colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a topoisomerase inhibitor.

[0012] Accordingly, in an eighth aspect of the present invention, there is hereby provided a method of treating colorectal cancer or gastric cancer (particularly colorectal cancer or gastric cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ATR inhibitor.

[0013] Accordingly, in a ninth aspect of the present invention, there is hereby provided a method of treating gastric cancer or colorectal cancer (in particular gastric cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR), or colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals.

[0014] Accordingly, in a tenth aspect of the present invention, there is hereby provided a method of treating colorectal cancer (in particular colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a chemotherapeutic agent.

[0015] Accordingly, in an eleventh aspect of the present invention, there is hereby provided a method of treating colorectal cancer (in particular colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an MDM2 inhibitor.

[0016] Accordingly, in a twelfth aspect of the present invention, there is hereby provided a method of treating colorectal cancer (in particular colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ATM inhibitor.

[0017] Accordingly, in a thirteenth aspect of the present invention, there is hereby provided a method of treating colorectal cancer (in particular colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a DNA-PK inhibitor.

[0018] Accordingly, in a fourteenth aspect of the present invention, there is hereby provided a method of treating colorectal cancer (in particular colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a WEE1 inhibitor.

[0019] Accordingly, in a fifteenth aspect of the present invention, there is hereby provided a method of treating colorectal cancer, particularly colorectal cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a CHK1 inhibitor or a CHK2 inhibitor (including a CHK1 and CHK2 dual inhibitor).

[0020] Accordingly, in a sixteenth aspect of the present invention, there is hereby provided a combination comprising i) a WRN inhibitor and ii) temozolomide, and optionally, iii) irinotecan.

[0021] Accordingly, in a seventeenth aspect of the present invention, there is hereby provided temozolomide for use in the treatment of cancer (such as high microsatellite instability (MSI-H), defective mismatch repair (dMMR) or microsatellite stable (MSS) cancer, particularly MSS cancer), wherein the treatment further comprises administering:

[0022] · a WRN inhibitor, or

[0023] · a combination of a WRN inhibitor and irinotecan.

[0024] Accordingly, in an eighteenth aspect of the present invention, there is hereby provided a WRN inhibitor for use in the treatment of cancer (such as high microsatellite instability (MSI-H), defective mismatch repair (dMMR) or microsatellite stable (MSS) cancer, particularly MSS cancer), wherein the treatment further comprises administering:

[0025] · temozolomide, or

[0026] · temozolomide and irinotecan.

[0027] Accordingly, in a nineteenth aspect of the present invention, there is hereby provided irinotecan for use in the treatment of cancer (such as high microsatellite instability (MSI-H), defective mismatch repair (dMMR) or microsatellite stable (MSS) cancer, particularly MSS cancer), wherein the treatment further comprises administering:

[0028] · a WRN inhibitor, or particularly

[0029] · a WRN inhibitor and temozolomide.

[0030] Accordingly, in a twentieth aspect of the present invention, there is hereby provided temozolomide, a WRN inhibitor or irinotecan for use as described in any one of the sixteenth to nineteenth aspects of the present invention, wherein temozolomide is administered as follows:

[0031] · Prior to administration of the WRN inhibitor, or prior to administration of irinotecan, or prior to administration of both the WRN inhibitor and irinotecan, as a pre-treatment, no subsequent combination therapy including temozolomide is carried out, or

[0032] · Administered in combination, no temozolomide pre-treatment is carried out, or

[0033] · Prior to administration of the WRN inhibitor, or prior to administration of irinotecan, or prior to administration of both the WRN inhibitor and irinotecan, as a pre-treatment, followed by combination therapy including temozolomide,

[0034] wherein the combination or combination therapy is described in Aspects Sixteen to Nineteen, and the use is for treating cancer, which is MSI-H, dMMR or MSS cancer, particularly dMMR or MSS cancer, more particularly MSS cancer.

[0035] Accordingly, in a twenty-first aspect of the present invention, there is hereby provided a WRN inhibitor for use in the treatment of dMMR or MSS cancer (particularly MSS cancer).

[0036] Accordingly, in a twenty-second aspect of the present invention, there is hereby provided a method of treating cancer (such as high microsatellite instability (MSI-H), mismatch repair deficiency (dMMR) or microsatellite stability (MSS) cancer, particularly MSS cancer) in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of temozolomide, wherein the treatment further comprises administering:

[0037] · A therapeutically effective amount of a WRN inhibitor, or

[0038] · A combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of irinotecan.

[0039] Accordingly, in a twenty-third aspect of the present invention, there is hereby provided a method of treating cancer (such as high microsatellite instability (MSI-H), mismatch repair deficiency (dMMR) or microsatellite stability (MSS) cancer, particularly MSS cancer) in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a WRN inhibitor, wherein the treatment further comprises administering:

[0040] · A therapeutically effective amount of temozolomide, or

[0041] · A therapeutically effective amount of temozolomide and a therapeutically effective amount of irinotecan.

[0042] Accordingly, in a twenty-fourth aspect of the present invention, there is hereby provided a method of treating cancer (such as high microsatellite instability (MSI-H), defective mismatch repair (dMMR), or microsatellite stable (MSS) cancer, particularly MSS cancer) in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of irinotecan, wherein the treatment further comprises administering:

[0043] · a therapeutically effective amount of a WRN inhibitor, or particularly

[0044] · a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of temozolomide.

[0045] Accordingly, in a twenty-fifth aspect of the present invention, there is hereby provided a WRN inhibitor for use in the treatment of cancer, wherein the treatment further comprises administering an alkylating agent (particularly temozolomide), and the cancer is:

[0046] · MSS cancer,

[0047] · pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-silent cancer, or MGMT-methylated pMMR / MSS cancer, e.g., colorectal cancer,

[0048] · MGMT-methylated glioblastoma,

[0049] · MGMT-hypermethylated CRC, or

[0050] · MGMT-hypermethylated, RAS-mutated or RAS-wild-type CRC,

[0051] And optionally, wherein the treatment further comprises administering chemotherapy, such as irinotecan.

[0052] Accordingly, in a twenty-sixth aspect of the present invention, there is hereby provided an alkylating agent for use in the treatment of cancer, wherein the treatment further comprises administering a WRN inhibitor, and the cancer is:

[0053] · MSS cancer,

[0054] · pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-silent cancer, or MGMT-methylated pMMR / MSS cancer, e.g., colorectal cancer,

[0055] · MGMT-methylated glioblastoma,

[0056] · MGMT-hypermethylated CRC, or

[0057] · MGMT hypermethylated, RAS mutant or RAS wild-type CRC,

[0058] and optionally, wherein the treatment further comprises administering chemotherapy, such as irinotecan.

[0059] Thus, according to the twenty-seventh aspect of the present invention, there is provided a method for treating cancer (especially cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a DNA polymerase α inhibitor (e.g., aphidicolin), for example for treating colorectal cancer.

[0060] Thus, according to the twenty-eighth aspect of the present invention, there is provided a method for treating cancer (especially cancer characterized by MSS or defective mismatch repair (dMMR) (especially MSS)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutic agent that can (or is capable of):

[0061] · Sensitize cancer cells, e.g., for improving the response to the WRN inhibitor,

[0062] · Prime cancer cells, e.g., such priming may include triggering a hypermutable state in the cancer cells,

[0063] · Generate or increase MMR defects in cancer cells,

[0064] · Generate or increase the MSI-H state in cancer cells,

[0065] · Increase the MMR heterogeneity of cancer cells, and / or

[0066] · Generate resistance to temozolomide in cancer cells or increase the resistance of cancer cells to temozolomide,

[0067] Especially

[0068] · Generate or increase MMR defects in cancer cells, or

[0069] · Generate or increase the MSI-H state in cancer cells,

[0070] and optionally, wherein the treatment further comprises administering chemotherapy, such as irinotecan.

[0071] Thus, according to the twenty-ninth aspect of the present invention, there is provided a WRN inhibitor for use in the treatment of cancer, particularly cancer characterized by MSS or defective mismatch repair (dMMR) (particularly MSS), wherein the treatment further comprises administering a therapeutic agent that can (or is capable of):

[0072] · Sensitize cancer cells, e.g., for improving the response to the WRN inhibitor,

[0073] · Prime cancer cells, e.g., such priming can include triggering a hypermutable state in the cancer cells,

[0074] · Generate or increase MMR defects in cancer cells,

[0075] · Generate or increase the MSI-H state in cancer cells,

[0076] · Increase the MMR heterogeneity of cancer cells, and / or

[0077] · Generate resistance to temozolomide in cancer cells or increase the resistance of cancer cells to temozolomide,

[0078] In particular

[0079] · Generate or increase MMR defects in cancer cells, or

[0080] · Generate or increase the MSI-H state in cancer cells,

[0081] And optionally, wherein the treatment further comprises administering chemotherapy, such as irinotecan.

[0082] Thus, according to the thirtieth aspect of the present invention, there is provided a method for treating cancer in a subject in need thereof, wherein the subject has a microsatellite stable (MSS) cancer, and wherein the following is administered to the patient:

[0083] a) An agent that:

[0084] o Sensitize cancer cells, e.g., for improving the response to WRN inhibitor treatment,

[0085] o Prime cancer cells, e.g., such priming can include triggering a hypermutable state in the cancer cells,

[0086] o Generate or increase MMR defects in cancer cells,

[0087] o Generate or increase the MSI-H state in cancer cells, or

[0088] o Increase the MMR heterogeneity of cancer cells,

[0089] And

[0090] b) or a pharmaceutically acceptable salt thereof,

[0091] and optionally,

[0092] c) Irinotecan. Description of the Drawings

[0093] Figure 1 : The SW48 CRC high MSI cell line was treated with compound A, single therapy of irinotecan, or a combination of compound A and irinotecan at the specified concentrations. The compound treatment was renewed on day 7 and removed around day 15. For the remaining experimental days, the cells were not treated further, and the medium was renewed around day 21. Proliferation was monitored using an S3 live cell analyzer (Sartorius).

[0094] Figure 2 : The SW48 CRC high MSI cell line was treated with compound A, single therapy of ATRi (BAY1895344), or a combination of compound A and ATRi at the specified concentrations. The compound treatment was renewed on day 7 and removed around day 15. For the remaining experimental days, the cells were not treated further, and the medium was renewed around day 21. Proliferation was monitored using an S3 live cell analyzer (Sartorius).

[0095] Figure 3 : The SW48 CRC high MSI cell line was treated with compound A, single therapy of DNA-PKi (AZD7648), or a combination of compound A and DNA-PKi at the specified concentrations. The compound treatment was renewed on day 7 and removed around day 15. For the remaining experimental days, the cells were not treated further, and the medium was renewed around day 21. Proliferation was monitored using an S3 live cell analyzer (Sartorius).

[0096] Figure 4 : The HCT116 CRC high MSI cell line was treated with compound A, single therapy of Adavosertib (AZD1775), or a combination of compound A and Adavosertib at the specified concentrations. The compound treatment was renewed on day 7 and removed around day 15. For the remaining experimental days, the cells were not treated further, and the medium was renewed around day 21. Proliferation was monitored using an S3 live cell analyzer (Sartorius).

[0097] Figure 5: Treat the SW48 CRC high-MSI cell line with single-agent compounds A, HDM201, or a combination of compound A and HDM201 at the specified concentrations. Update the compound treatment on day 7 and remove the treatment around day 15. For the remaining experimental days, do not treat the cells further and update the medium around day 21. Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0098] Figure 6 and 7 : Treat the SW48 CRC high-MSI cell line with single-agent compound A or ionizing radiation (IR), or a combination of compound A and IR at the specified concentrations. Irradiate the cells and update the compound on day 7 and remove the treatment around day 15. For the remaining experimental days, do not treat the cells further and update the medium around day 21. Figure 6 : Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0099] Figure 7 : For each condition, plot the % confluence at day 40 (end of treatment), comparing compound A treatment (without IR) to the effect of compound A on irradiated cells (at a rate of (+3 Gy) / min).

[0100] Figure 8 : Treat the SW48 CRC high-MSI cell line with single-agent compounds A, 5FU, or a combination of compound A and 5FU at the specified concentrations. Update the compound treatment on day 7 and remove the treatment around day 15. For the remaining experimental days, do not treat the cells further and update the medium around day 21. Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0101] Figure 9 : Treat the SW48 CRC high-MSI cell line with single-agent compounds A, epirubicin, or a combination of compound A and epirubicin at the specified concentrations. Update the compound treatment on day 7 and remove the treatment around day 15. For the remaining experimental days, do not treat the cells further and update the medium around day 21. Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0102] Figure 10: Treat the HCT116 CRC high-MSI cell line with compound A, single therapy of epirubicin, or a combination of compound A and epirubicin at the specified concentrations. Update the compound treatment on day 7 and remove the treatment around day 15. For the remaining experimental days, the cells are not treated further, and the medium is updated around day 21. Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0103] Figure 11 : Treat the SW48 and HCT116 CRC high-MSI cell lines with compound A, single therapy of trametinib, or a combination of compound A and trametinib at the specified concentrations. Update the compound treatment on day 7 and remove the treatment around day 15. For the remaining experimental days, the cells are not treated further, and the medium is updated around day 21. Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0104] Figure 12 : The figure shows the proliferation of SW48 colorectal carcinoma cells in nude mice (Charles River, Germany) after administration of i) vehicle 5 ml / kg (p.o., qd), ii) trametinib 0.3 mg / kg (p.o, qd), iii) compound A 40 mg / kg (p.o., qd), and iv) a combination of trametinib 0.3 mg / kg (p.o, qd) and compound A 40 mg / kg (p.o., qd).

[0105] Figure 13 : Treat the SW48 CRC high-MSI cell line with compound A, single therapy of docetaxel, or a combination of compound A and docetaxel at the specified concentrations. Update the compound treatment on day 7 and remove the treatment around day 15. For the remaining experimental days, the cells are not treated further, and the medium is updated around day 21. Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0106] Figure 14 : Treat the SW48 CRC high-MSI cell line with compound A, single therapy of carboplatin, or a combination of compound A and carboplatin at the specified concentrations. Update the compound treatment on day 7 and remove the treatment around day 15. For the remaining experimental days, the cells are not treated further, and the medium is updated around day 21. Use the S3 live cell analyzer (Sartorius) to monitor proliferation.

[0107] Figure 15 : The figure shows the proliferation of SW48 colorectal cancer cells in nude mice (Charles River, Germany) after administration of i) vehicle 5 ml / kg (p.o., qd), ii) BAY-1895344 50 mg / kg (p.o., twice daily on the administration days, 3 administration days followed by a 4-day rest), iii) compound A 20 mg / kg (p.o., qd), and iv) a combination of BAY-1895344 50 mg / kg (p.o., twice daily on the administration days, 3 administration days followed by a 4-day rest) and compound A 20 mg / kg (p.o., qd).

[0108] Figure 16 : The figure shows the proliferation of HX-2861MSI 高 colorectal cancer tumors in nude mice (Charles River, Germany) after administration of i) vehicle 5 ml / kg (p.o., qd), ii) BAY-1895344 25 mg / kg (p.o., twice daily on the administration days, 3 administration days followed by a 4-day rest), iii) compound A 40 mg / kg (p.o., qd), and iv) a combination of BAY-1895344 25 mg / kg (p.o., twice daily on the administration days, 3 administration days followed by a 4-day rest) and compound A 40 mg / kg (p.o., qd).

[0109] Figure 17 : The figure shows the proliferation of IM95 gastric carcinoma cells in SCID-BEIGE mice (Charles River, Germany) after administration of i) vehicle 5 ml / kg (p.o., qd), ii) 5 Gy irradiation using an XRad320 from Precision X-Ray TM and an adjustable X-ray collimator (#XD1601-0000, Precision X-Ray), iii) compound A 30 mg / kg (p.o., qd), and iv) a combination of 5 Gy irradiation using an XRad320 from Precision X-Ray TM and an adjustable X-ray collimator (#XD1601-0000, Precision X-Ray) and compound A 30 mg / kg.

[0110] Figure 18: The figure shows the proliferation of SW48 colorectal carcinoma cells in nude mice (Charles River Laboratories, Germany) after administration of i) vehicle 5 ml / kg (p.o., qd), ii) irinotecan 60 mg / kg (i.v. qw), iii) compound A 20 mg / kg (p.o., qd), and iv) a combination of irinotecan 60 mg / kg (i.v. qw) and compound A 20 mg / kg.

[0111] Figure 19 and 20 : In a colony formation assay, the potential effect of the combination of a WRN inhibitor and the G4 stabilizer pyridostatin was tested in SW48 and HCT116 colorectal high-MSI cancer cells. Figure 19 and 20 Images of stained plates are depicted, which contain colonies of the WRN inhibitor compound B from 1.95 nM to 2000 nM (2-fold increments) (with or without pyridostatin). The graphs are signal quantifications relative to DMSO of WRN i alone (top graph of each figure) or relative to DMSO within the plate (i.e., in the presence of pyridostatin).

[0112] Figure 21 : The SW48 CRC high-MSI cell line was treated with compound A, single therapy with CHK1 / 2i (AZD7762), or a combination of compound A and CHK1 / 2i at the specified concentrations. The compound treatment was renewed on day 7, and the treatment was removed around day 15. On the remaining experimental days, the cells were not treated, and the medium was renewed around day 21. Proliferation was monitored using an S3 live cell analyzer (Sartorius).

[0113] Figure 22 : After treatment with a combination of the WRN inhibitor compound B and doxorubicin for 4 days, the in vitro viability of the colorectal cancer cell line HCT116 was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0114] Figure 23 : After treatment with a combination of the WRN inhibitor compound B and 5-fluorouracil (5-FU) for 4 days, the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0115] Figure 24: After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with aphidicolin for 4 days, the in vitro viability was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0116] Figure 25 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with QAP1 for 4 days, the in vitro viability was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0117] Figure 26 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with bleomycin for 4 days, the in vitro viability was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0118] Figure 27 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with cisplatin for 4 days, the in vitro viability was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0119] Figure 28 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with doxorubicin for 4 days, the in vitro viability was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0120] Figure 29 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with gemcitabine for 4 days, the in vitro viability was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0121] Figure 30 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with HDM201 for 4 days, the in vitro viability was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0122] Figure 31 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with camptothecin for 4 days, the in vitro viability of the cells was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0123] Figure 32 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with KU-60019 for 4 days, the in vitro viability of the cells was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0124] Figure 33 : After treating the colorectal cancer cell line SW48 with WRN inhibitor compound B in combination with NU7441 (KU-57788) for 4 days, the in vitro viability of the cells was evaluated using CellTiterGlo. Growth inhibition %: 0 - 99 = proliferation delay, 100 = growth arrest / stasis, 101 - 200 = decrease in cell number / cell death.

[0125] Figure 34 : The HCT116 CRC MSI 高 cell line was treated with compound A, mitomycin C alone, or a combination of compound A and mitomycin C at the specified concentrations. The compound treatment was renewed on day 7 and removed around day 15. For the remaining experimental days, the cells were not treated, and the medium was renewed around day 21. Proliferation was monitored using an S3 live cell analyzer (Sartorius).

[0126] Figure 35 : The figure shows the mean tumor volume in nude mice bearing SW620 (CCL-227, ATCC) [MSS colorectal cancer (CRC)] xenografts after treatment with irinotecan alone, or irinotecan and compound A.

[0127] Figure 36 : The figure shows the mean tumor volume in nude mice bearing SW620 (CCL-227, ATCC) [MSS colorectal cancer (CRC)] xenografts after pretreatment with temozolomide, followed by treatment with temozolomide, irinotecan, and compound A.

[0128] Figure 37: The figure shows the average tumor volume in nude mice bearing SW620 (CCL-227, ATCC) [MSS colorectal cancer (CRC)] xenografts after pretreatment with temozolomide followed by treatment with irinotecan alone or irinotecan and compound A.

[0129] Figure 38 : The figure shows the therapeutic efficacy of the combination of irinotecan, compound A, and temozolomide against parental SW620 tumors.

[0130] Figure 39 : The figure shows the therapeutic efficacy of the combination of irinotecan, compound A, and temozolomide against parental SW620 tumors.

[0131] Figure 40 : The figure shows the change in body weight after treatment of SW620 tumors with the combination of irinotecan, compound A, and temozolomide.

[0132] Figure 41 : The figure shows the therapeutic efficacy of the combination of compound A, irinotecan, and temozolomide (TMZ) against parental T84 tumors.

[0133] Figure 42 : The figure shows the therapeutic efficacy of the combination of compound A, irinotecan, and temozolomide (TMZ) against parental T84 tumors.

[0134] Figure 43 : The figure shows the change in body weight after treatment with the combination of compound A, irinotecan, and temozolomide (TMZ).

[0135] Figure 44 : The figure shows the therapeutic efficacy of irinotecan and temozolomide (TMZ) against parental SHP77 tumors.

[0136] Figure 45 : The figure shows the therapeutic efficacy of the combination of irinotecan, TMZ, and compound A against parental SHP77 tumors.

[0137] Figure 46 : The figure shows the change in body weight after treatment with temozolomide and irinotecan.

[0138] Figure 47 : The figure shows the change in body weight after treatment with temozolomide, irinotecan, and compound A. Detailed Description

[0139] As mentioned above, the object of the present invention is to find new combination therapies for the treatment of cancer (especially cancers characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)). In another object, the combination therapy synergistically enhances the inhibition of proliferation and / or the induction of apoptosis.

[0140] Another object of the present invention is to find new therapies for treating cancers characterized by microsatellite stability (MSS).

[0141] Accordingly, in a first aspect of the present invention, there is provided a method of treating cancer (particularly cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of at least one therapeutic active agent selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-tetraplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0142] Accordingly, in a second aspect of the present invention, there is provided a WRN inhibitor for use in the treatment of cancer (particularly cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), wherein the treatment further comprises administering at least one therapeutic active agent selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-tetraplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0143] Accordingly, in a third aspect of the present invention, there is provided a therapeutic active agent for use in the treatment of cancer (particularly cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)), wherein the treatment further comprises administering a WRN inhibitor, and wherein the therapeutic active agent is selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-tetraplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0144] Accordingly, in a fourth aspect of the invention, there is hereby provided a combination comprising i) a WRN inhibitor, and ii) at least one therapeutic active agent selected from the group consisting of: a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, ionizing radiation selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0145] In an embodiment of any one of the first to fourth aspects of the invention, the WRN inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof:

[0146]

[0147] Wherein

[0148] R, M, W, L, V and T are independently selected from C, CH and N,

[0149] to form sub-formulas 1a, 1b, 1c, 1d, 1e and 1f:

[0150]

[0151] A is a linker selected from -C(O)-, -S(O)-, -S(O)2- and ;

[0152] Y is N, C or CH;

[0153] y is 0, 1, 2, 3 or 4;

[0154] means that when Y is CH, Y is connected to the adjacent carbon atom via a single bond, or when Y is C, Y is connected to the adjacent atom via a double bond, and when is a single bond, Y is an unsubstituted or OH- or F-substituted carbon;

[0155] When Y is N, is a single bond;

[0156] means that K is connected to the adjacent atom via a single or double bond;

[0157] Wherein:

[0158] When is a double bond, is a single bond, K is CH, J is C, and A is a linker selected from -C(O)-, -S(O)-, -S(O)2- and ;

[0159] or

[0160] When is a single bond, K is selected from -CH2-, -CH2CH2-, -NH-, and a bond (to form a 5-membered ring: ), J is N, and A is a linker selected from -C(O)-, -S(O)-, -S(O)2-, and ;

[0161] or

[0162] When is a single bond, K is -CH2-, J is CH, and A is a linker selected from -S(O)-, -S(O)2-, and ;

[0163] R5 is independently selected from:

[0164] · -(C 1- C4) alkyl,

[0165] · -(C 3- C5) cycloalkyl,

[0166] · And two R5 substituents on the same ring carbon atom together with the carbon atom to which they are attached can be linked to form a (C 3- C4) cycloalkyl spiro ring or a 3- or 4-membered heterocyclic spiro ring, wherein the heterocyclic spiro ring contains a ring carbon atom and one ring heteroatom selected from O, N, and S,

[0167] · When is a carbon-nitrogen single bond, the R5 substituents on K and the adjacent carbon atom can be linked to form ring C:

[0168]

[0169] wherein ring C is a fused (C3-C6) cycloalkyl ring, a fused (C3-C6) heterocyclic ring, or a fused phenyl ring, wherein the fused (C3-C6) heterocyclic ring contains a ring carbon atom and one ring heteroatom selected from O, N, and S,

[0170] · When is a carbon-carbon single bond, Y is N and is a single bond, and A is a linker selected from -S(O)-, -S(O)2-, and ; the R5 substituents on K and the adjacent carbon atom can be linked to form ring C:

[0171]

[0172] · and wherein when K is -CH2- and J is N, two R5 substituents may be joined to form a (C1-C3) alkylene bridge or a heteroalkylene bridge, wherein the heteroalkylene bridge is a heteroatom selected from N and O or is -CH2-O-CH2-;

[0173] and wherein the ring:

[0174]

[0175] one or more H atoms thereon may be replaced by deuterium;

[0176] R1 is:

[0177] cycloalkenyl, wherein the cycloalkenyl is a partially unsaturated monocyclic ring containing 5 or 6 ring carbon atoms, and the cycloalkenyl is unsubstituted or substituted with 1, 2, 3 or 4, preferably 1 or 2 R 33 substituents, wherein R 33 is halo, and wherein the cycloalkenyl or halo-substituted cycloalkenyl is substituted with 0, 1 or 2 R 15 substituents,

[0178] or R1 is a heterocyclic group, wherein the heterocyclic group is a 5- or 6-membered fully saturated or partially unsaturated group containing ring carbon atoms and 1 or 2 ring heteroatoms independently selected from N, O and S, and wherein the heterocyclic group is unbridged or bridged, and the bridge is 1 or 2 carbon atoms, wherein the heterocyclic group is unsubstituted or substituted with 1, 2, 3 or 4, preferably 1 or 2 R 33 substituents, wherein R 33 is halo, and wherein the heterocyclic group or halo-substituted heterocyclic group is independently substituted with 0, 1 or 2 substituents selected from R 15 、R 16 、R 17 、R 18 、R 19 、R 20 、R 22 and R 23 ;

[0179] or the heterocyclic group or halo-substituted heterocyclic group is fused to a cyclopropyl ring, wherein the cyclopropyl ring is unsubstituted or substituted with 1, 2 or 3 F;

[0180] or the heterocyclic group or halo-substituted heterocyclic group has 2 substituents at the same ring carbon atom that join to form a cyclopropyl spiro ring;

[0181] or the heterocyclic group or halo-substituted heterocyclic group is fused to a (C3-C5) heteroalkyl ring, wherein the (C3-C5) heteroalkyl ring contains ring carbon atoms and 1 ring O atom;

[0182] Or R1 is a heteroaryl, wherein the heteroaryl is a 5- or 6-membered fully unsaturated monocyclic group containing ring carbon atoms and 1, 2, 3 or 4 ring heteroatoms independently selected from N, O and S, preferably 1 or 2 ring heteroatoms, wherein the total number of ring S atoms does not exceed 1, and the total number of ring O atoms does not exceed 1, and wherein the heteroaryl is unsubstituted or substituted with 1, 2 or 3 substituents independently selected from R 21 and R 30 wherein R 21 and R 30 are independently selected from halo and (C1-C4)alkyl, wherein the (C1-C4)alkyl is unsubstituted or substituted with 1, 2 or 3 halo

[0183] Or R1 is a phenyl, wherein the phenyl is unsubstituted or substituted with 1, 2, 3 or 4, preferably 1 or 2 R 33 substituents, wherein R 33 is halo, and wherein the phenyl or halo-substituted phenyl is substituted with 0, 1 or 2 R 15 substituents

[0184] Or R1 is a (C2-C4)alkynyl or (C2-C4)alkenyl, wherein the (C2-C4)alkynyl and (C2-C4)alkenyl are unsubstituted or substituted with (C1-C4)alkyl-O-C(O)- or morpholinyl;

[0185] R 15 、R 16 、R 17 、R 18 、R 19 、R 20 、R 22 and R 23 are each independently selected from:

[0186] · halo

[0187] · (C 1- C4)alkyl-O- which is unsubstituted or substituted with 1, 2 or 3 halo;

[0188] · (C1-C4)alkyl which is unsubstituted or substituted with OH, -O-(C1-C2)alkyl or 1, 2 or 3 halo,

[0189] · HOC(O)-(CH2) n -,

[0190] · H3C-C(O)(CH2) n -,

[0191] · (C1-C4)alkyl-O-C(O)(CH2) n ​

[0192] ·=O

[0193] ·azetidinyl or pyrrolidinyl, wherein the azetidinyl and pyrrolidinyl are each connected to the remainder of the molecule via an N atom and are each unsubstituted or substituted with 1 or 2 F atoms,

[0194] ·R 25 (R 24 )N-, wherein R 24 is H or (C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halogen atoms, and R 25 is H or (C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halogen atoms,

[0195] ·OH

[0196] wherein n is 0, 1 or 2,

[0197] R 26 is CH3, H or deuterium;

[0198] R 27 is CH3, H or deuterium;

[0199] or R 26 and R 27 together with the carbon atom to which they are attached form a cyclopropyl ring;

[0200] R2 is the following moiety:

[0201]

[0202] R6 is selected from:

[0203] ·H,

[0204] ·halogenated,

[0205] ·(C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halogen atoms,

[0206] ·(C3-C5)cycloalkyl which is unsubstituted or substituted with 1, 2 or 3 halogen atoms,

[0207] ·-O-(C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halogen atoms,

[0208] ·OH, and

[0209] ·CN;

[0210] R8 is selected from H, halogenated, and (C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halogen atoms,

[0211] R9 is selected from H, O-CH3, OH, CN, CH3, and halo;

[0212] R 28 is selected from:

[0213] · SF5,

[0214] · H,

[0215] · -C(O)H,

[0216] · halo,

[0217] · (C1-C4)alkyl, unsubstituted or substituted with 1, 2, or 3 halo;

[0218] · (C1-C4)alkynyl,

[0219] · (C1-C4)alkenyl,

[0220] · (C3-C5)cycloalkyl, unsubstituted or substituted with 1, 2, or 3 halo, and

[0221] · OCF3;

[0222] X is selected from C-R7 and N, where R7 is H or halo, or R7 together with R 28 or R6 and the atoms to which they are attached may form a fused (C4-C6)cycloalkyl ring, where the fused (C4-C6)cycloalkyl ring is unsubstituted or substituted with 1, 2, or 3 halo,

[0223] or

[0224] R2 is selected from:

[0225]

[0226] where

[0227] R 31 is selected from H, halo, and CH3,

[0228] R 32 is selected from H, halo, and CH3,

[0229] R3 is:

[0230] · cyclopropyl,

[0231] · O-CH3,

[0232] · N(CH3)2,

[0233] · S-CH3,

[0234] · (C1-C4)alkyl, unsubstituted or substituted with 1, 2, or 3 substituents independently selected from halo and OH;

[0235] R4 is selected from:

[0236]

[0237] wherein

[0238] R 10 、R 11 、R 12 、R 13 and R 14 are independently selected from:

[0239] · H,

[0240] · halo

[0241] · (C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halo substituents

[0242] · (C1-C2)alkyl substituted with -O-(C1-C2)alkyl or OH

[0243] · -S-(C1-C3)alkyl

[0244] · -O-(C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halo substituents

[0245] · OH

[0246] · (C3-C5)cycloalkyl, wherein the (C3-C5)cycloalkyl is unsubstituted or substituted with 1 or 2 halo substituents

[0247] · -O-(C3-C5)cycloalkyl

[0248] · -NR 34 R 35 where R 34 and R 35 are independently selected from:

[0249] o H

[0250] o (C1-C4)alkyl, wherein the (C1-C4)alkyl is unsubstituted or substituted with OH or -O(C1-C2)alkyl

[0251] o and wherein R 34 and R 35 may together with the atoms to which they are attached form an azetidine, pyrrolidine or piperidine ring, wherein the azetidine, pyrrolidine and piperidine are unsubstituted or substituted with CH3;

[0252] · CN

[0253] · -(C2-C4)alkenyl

[0254] ·-(C2-C4) alkynyl,

[0255] ·-C(O)H, and

[0256] ·-C(O)(C1-C4) alkyl;

[0257] And

[0258] * represents the attachment point,

[0259] or the WRN inhibitor is a compound of formula (1g) or a pharmaceutically acceptable salt thereof:

[0260]

[0261] Wherein

[0262] R1 is selected from:

[0263]

[0264] R 15 is H or F;

[0265] R 16 is H or R 25 (R 24 )N-;

[0266] R 17 is H or F;

[0267] R 18 is H or F;

[0268] R 19 is H or F;

[0269] R 20 is H or F;

[0270] R 21 is H or CH3;

[0271] R 22 is H, CF3, CHF2CH2, HOC(O)-CH2-, H3C-C(O)-, (H3C)3C-O-C(O)-;

[0272] R 23 is H, CF3, CHF2CH2-, (H3C)3C-O-C(O)-;

[0273] R 24 is CH3;

[0274] R 25 is CHF2CH2-;

[0275] R 26 is CH3, H or deuterium;

[0276] R 27 is H or deuterium;

[0277] R2 is one of the following:

[0278]

[0279] wherein R6 is selected from H, Cl, CH3, F and Br;

[0280] R8 is selected from H, Cl, F and CF3;

[0281] R9 is selected from H, CH3 and Cl;

[0282] R 28 is selected from CF3, CF2H, -CH2CH3, Cl, SF5, Br and -C(O)H;

[0283] X is selected from C-R7 and N;

[0284] R7 is selected from H and F;

[0285] R3 is selected from CH3, CH2CH3, cyclopropyl and hydroxyethyl;

[0286] R4 is selected from:

[0287]

[0288] wherein

[0289] R 10 is selected from H, F, Cl, CH3 and OCF3;

[0290] R 11 is selected from H, Cl, F and CH3;

[0291] R 12 is selected from H, Cl and CH3;

[0292] R 13 is selected from H and CH3;

[0293] R 14 is selected from H, CH3, -CH2CH3, cyclopropyl, -OCHF2, OCF3 and Cl;

[0294] y is 0, 1 or 2;

[0295] R5 is CH3; or alternatively, two R5 groups on adjacent carbon atoms together with the carbon atoms to which they are attached form a fused cyclobutyl ring:

[0296]

[0297] and

[0298] * indicates an attachment point.

[0299] In an embodiment of any one of the first to fourth aspects of the present invention, the WRN inhibitor is a compound selected from the following:

[0300]

[0301]

[0302]

[0303]

[0304]

[0305]

[0306]

[0307]

[0308]

[0309]

[0310]

[0311]

[0312]

[0313]

[0314]

[0315] In an embodiment of any one of the first to fourth aspects of the present invention, the WRN inhibitor is selected from:

[0316]

[0317]

[0318]

[0319] In an embodiment of any one of the first to fourth aspects of the present invention, the WRN inhibitor is selected from:

[0320]

[0321]

[0322]

[0323]

[0324] In an embodiment of any one of the first to fourth aspects of the present invention, the WRN inhibitor is

[0325] or its zwitterionic form or salt.

[0326] In an embodiment of any one of the first to fourth aspects of the present invention, the WRN inhibitor is

[0327] or its zwitterionic form or salt.

[0328] In an embodiment of any one of the first to fourth aspects of the present invention, the WRN inhibitor is

[0329] or its zwitterionic form or salt.

[0330] In an embodiment of any one of the first to third aspects of the present invention, the cancer is characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR).

[0331] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is a PD-1 inhibitor. In an embodiment, the PD-1 inhibitor is an anti-PD-1 antibody. In an embodiment, the PD-1 inhibitor is selected from PDR001 (Novartis), nivolumab (Bristol-Myers Squibb), pembrolizumab (Merck & Co), pidilizumab (CureTech), MEDI0680 (Medimmune), cemiplimab (REGN2810, Regeneron), dostarlimab (TSR-042, Tesaro), PF-06801591 (Pfizer), tislelizumab (BGB-A317, Beigene), BGB-108 (Beigene), INCSHR1210 (Incyte), balstilimab (AGEN2035, Agenus), sintilimab (InnoVent), toripalimab (Shanghai Junshi Bioscience), camrelizumab (Jiangsu Hengrui Medicine Co.), and AMP-224 (Amplimmune), particularly PDR001 or tislelizumab. In an embodiment, the PD-1 inhibitor is tislelizumab.

[0332] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is a chemotherapeutic agent. In an embodiment, the chemotherapeutic agent is selected from anastrozole vinblastine, vindesine, vinorelbine, vincristine, bicalutamide bleomycin (e.g., bleomycin sulfate) busulfan busulfan injection calactin, capecitabine N4-pentyloxycarbonyl-5-deoxy-5-fluorocytidine, carboplatin carmustine lomustine chlorambucil bendamustine cisplatin cladribine cyclophosphamide ( or )、 Cytarabine, Cytosine Arabinoside Liposomal Cytarabine Injection Dacarbazine Dactinomycin (Actinomycin D, Cosmegan), Daunorubicin Hydrochloride Daunorubicin Citrate Liposomal Injection Dexamethasone, Docetaxel Doxorubicin (e.g., Doxorubicin Hydrochloride) Etoposide Fludarabine Phosphate 5 - Fluorouracil Flutamide Tizoxanide, Gemcitabine (Difluorodeoxycytidine), Hydroxycarbamide Idarubicin Ifosfamide Irinotecan L - Asparaginase Calcium Folinate, Melphalan 6 - Mercaptopurine Methotrexate Mitomycin (e.g., Mitomycin A, Mitomycin B or Mitomycin C, especially Mitomycin C), Mitoxantrone Gemtuzumab, Paclitaxel phoenix (Yttrium - 90 / MX - DTPA), Pentostatin, Polybis(2 - chloroethyl)methyl Ether Copolymer with Carmustine Implant Tamoxifen Citrate Camptothecin, Teniposide 6 - Thioguanine, Thiotepa, Tirapazamine Topotecan Hydrochloride for Injection Vinblastine Vincristine Oxaliplatin Epirubicin Temozolomide Tegafur, and Vinorelbine Especially Irinotecan. In the examples, the chemotherapeutic agent is selected from Gemcitabine, Camptothecin, Irinotecan Docetaxel Doxorubicin (e.g., Doxorubicin Hydrochloride) 5 - Fluorouracil Capecitabine Etoposide Epirubicin Oxaliplatin Mitomycin (e.g., Mitomycin A, Mitomycin B or Mitomycin C, especially Mitomycin C), Cisplatin Carboplatin and paclitaxel

[0333] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic agent is a WEE1 inhibitor. In an embodiment, the WEE1 inhibitor is selected from adavosertib (also known as AZD1775 and MK-1775) and PDO166285. In an embodiment, the WEE1 inhibitor is adavosertib (also known as AZD1775 and MK-1775).

[0334] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic agent is an ATR inhibitor. In an embodiment, the ATR inhibitor is selected from RP-3500, ceralasertib (also known as AZD6738), bezosertib, ART-0380, gartisertib (also known as M4344), and elimusertib (also known as BAY-1895344). In an embodiment, the ATR inhibitor is elimusertib (BAY-1895344).

[0335] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic agent is a DNA-PK inhibitor. In an embodiment, the DNA-PK inhibitor is selected from AZD-7648, NU7441 (also known as KU-57788), Omipalisib, BAY8400, and M3814. In an embodiment, the DNA-PK inhibitor is AZD-7648 or NU7441 (KU-57788), particularly AZD-7648.

[0336] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic agent is an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals. In an embodiment, the ionizing radiation is external beam radiation. In an embodiment, the ionizing radiation is a radiopharmaceutical. In an embodiment, the radiopharmaceutical is a radioligand agent. In an embodiment, the radioligand agent is selected from 177 Lu-PSMA-617, 177 Lu-PSMA-R2, 177 Lu-NeoB, 177 Lu-FAP-2286.

[0337] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is a MEK inhibitor. In an embodiment, the MEK inhibitor is selected from the group consisting of refametinib, pimasertib, selumetinib, trametinib, binimetinib, and cobimetinib or a pharmaceutically acceptable salt thereof. In an embodiment, the MEK inhibitor is trametinib.

[0338] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is an MDM2 inhibitor. In an embodiment, the MDM2 inhibitor is selected from the group consisting of nutlin-3a, idasanutlin (also known as RG7388), RG7112, KRT-232 (also known as AMG-232), APG-115, RAIN-32 (also known as DS-3032 and milademetan), BI-907828, and HDM201 (also known as siremadlin) or a pharmaceutically acceptable salt thereof. In an embodiment, the MDM2 inhibitor is HDM201.

[0339] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is a G4-quadruplex stabilizer. In an embodiment, the G4-quadruplex stabilizer is pyridostatin.

[0340] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is an ATM inhibitor. In an embodiment, the ATM inhibitor is selected from KU-55933, KU-60019, KU-59403, M3541, CP-466722, AZ31, AZ32, AZD0156, and AZD1390. In an embodiment, the ATM inhibitor is KU-60019.

[0341] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is a PARP inhibitor. In an embodiment, the PARP inhibitor is selected from olaparib, NMS293, niraparib, prexasertib, veliparib, rucaparib, talazoparib, AZD-5305, and KU0058948. In an embodiment, the PARP inhibitor is olaparib.

[0342] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is a chemotherapeutic agent, and the chemotherapeutic agent is a topoisomerase inhibitor. In an embodiment, the topoisomerase inhibitor is selected from QAP1, irinotecan, topotecan, camptothecin, and etoposide. In an embodiment, the topoisomerase inhibitor is selected from QAP1, etoposide, and irinotecan.

[0343] In an embodiment of any one of the first to fourth aspects of the present invention, the (at least one) therapeutic active agent is a CHK1 inhibitor or a CHK2 inhibitor. In an embodiment, the CHK1 inhibitor or CHK2 inhibitor is selected from GDC-0575, prexasertib (also known as LY2606368), SCH900776 (also known as MK-8776), SRA737, PF477736, LY2606368, and AZD7762.

[0344] In an embodiment of any one of the first to fourth aspects of the present invention, the cancer is selected from colorectal cancer (CRC), gastric cancer, prostate cancer, endometrial cancer, adrenocortical cancer, uterine cancer, and cervical cancer, for example, cancers selected from the following: endometrial cancer of the uterine body, colon adenocarcinoma, stomach adenocarcinoma, rectal adenocarcinoma, adrenocortical carcinoma, uterine carcinosarcoma, cervical squamous cell carcinoma, cervical adenocarcinoma, esophageal cancer, breast cancer, renal clear cell carcinoma, prostate cancer, and ovarian serous cystadenocarcinoma. In an embodiment, the cancer is colorectal cancer (CRC) or gastric cancer, particularly colorectal cancer (CRC).

[0345] Thus, according to the fifth aspect of the present invention, there is hereby provided a method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a G4-quadruplex stabilizer. In an embodiment, the G4-quadruplex stabilizer is pyridostatin.

[0346] Thus, according to the sixth aspect of the present invention, there is hereby provided a method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a MEK inhibitor. In an embodiment, the MEK inhibitor is trametinib.

[0347] Thus, according to the seventh aspect of the present invention, there is hereby provided a method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a topoisomerase inhibitor. In an embodiment, the topoisomerase inhibitor is QAP1, etoposide, irinotecan, or camptothecin.

[0348] Thus, according to an eighth aspect of the present invention, there is hereby provided a method of treating colorectal cancer or gastric cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ATR inhibitor. In an embodiment, the ATR inhibitor is alisertib (BAY-1895344).

[0349] Thus, according to a ninth aspect of the present invention, there is hereby provided a method of treating gastric cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals. In an embodiment, the ionizing radiation is external beam radiation. In an embodiment, the ionizing radiation is a radiopharmaceutical. In an embodiment, the radiopharmaceutical is a radioligand agent. In an embodiment, the radioligand agent is selected from 177 Lu-PSMA-617, 177 Lu-PSMA-R2, 177 Lu-NeoB, 177 Lu-FAP-2286.

[0350] Thus, according to a tenth aspect of the present invention, there is hereby provided a method of treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a chemotherapeutic agent. In an embodiment, the chemotherapeutic agent is selected from 5-fluorouracil, cisplatin, bleomycin, docetaxel, epirubicin, etoposide, camptothecin, mitomycin, oxaliplatin, mitomycin (e.g., mitomycin C), and gemcitabine.

[0351] Thus, according to an eleventh aspect of the present invention, there is hereby provided a method of treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an MDM2 inhibitor. In an embodiment, the MDM2 inhibitor is HDM201.

[0352] Thus, according to a twelfth aspect of the present invention, there is hereby provided a method of treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ATM inhibitor. In an embodiment, the ATM inhibitor is KU-60019.

[0353] Thus, according to a thirteenth aspect of the present invention, there is hereby provided a method of treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a DNA-PK inhibitor. In an embodiment, the DNA-PK inhibitor is AZD-7648 or NU7441 (KU-57788).

[0354] Accordingly, in a fourteenth aspect of the present invention, there is hereby provided a method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a WEE1 inhibitor. In an embodiment, the WEE1 inhibitor is adavosertib.

[0355] Accordingly, in a fifteenth aspect of the present invention, there is hereby provided a method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a CHK1 inhibitor or a CHK2 inhibitor. In an embodiment, the CHK1 inhibitor or the CHK2 inhibitor is AZD7762 or SCH900776 (also known as MK-8776).

[0356] In an embodiment of any one of the fifth to fifteenth aspects of the present invention, the colorectal cancer or gastric cancer is characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR). In an embodiment, the colorectal cancer or gastric cancer is characterized by high microsatellite instability (MSI-H).

[0357] In an embodiment of the eighth or ninth aspect of the present invention, the gastric cancer is gastric adenocarcinoma.

[0358] In an embodiment of any aspect of the present invention, the WRN inhibitor is selected from or its zwitterionic form or a pharmaceutically acceptable salt.

[0359] In an embodiment, the WRN inhibitor is or its zwitterionic form or a pharmaceutically acceptable salt.

[0360] Accordingly, in a sixteenth aspect of the present invention, there is hereby provided a combination comprising i) a WRN inhibitor and ii) temozolomide, and optionally, iii) irinotecan.

[0361] Accordingly, in a seventeenth aspect of the present invention, there is hereby provided temozolomide for use in the treatment of cancer, wherein the treatment further comprises administering:

[0362] · a WRN inhibitor, or

[0363] · a combination of a WRN inhibitor and irinotecan.

[0364] Accordingly, in an eighteenth aspect of the present invention, there is hereby provided a WRN inhibitor for use in the treatment of cancer, wherein the treatment further comprises administering:

[0365] · temozolomide, or

[0366] · temozolomide and irinotecan.

[0367] Accordingly, in a nineteenth aspect of the present invention, there is hereby provided irinotecan for use in cancer treatment, wherein the treatment further comprises administering:

[0368] · a WRN inhibitor, or in particular

[0369] · a WRN inhibitor and temozolomide.

[0370] Accordingly, in embodiments of the sixteenth to nineteenth aspects of the present invention, there is hereby provided temozolomide, a WRN inhibitor or irinotecan for use, wherein the cancer is MSI-H, dMMR or MSS cancer, particularly dMMR or MSS cancer, more particularly MSS cancer.

[0371] Accordingly, in a twentieth aspect of the present invention, there is hereby provided temozolomide, a WRN inhibitor or irinotecan for use as described in any one of the sixteenth to nineteenth aspects of the present invention (in combination), wherein temozolomide is administered as follows:

[0372] · as a pre-treatment before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, without subsequent combination treatment comprising temozolomide, or

[0373] · in combination, without temozolomide pre-treatment, or

[0374] · as a pre-treatment before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, followed by combination treatment comprising temozolomide,

[0375] wherein the combination or combination treatment is described in the sixteenth to nineteenth aspects, and the use is for treating cancer, which is MSI-H, dMMR or MSS cancer, particularly dMMR or MSS cancer, more particularly MSS cancer.

[0376] In embodiments of the twentieth aspect, the cancer is selected from colorectal cancer (CRC), gastric cancer, prostate cancer, endometrial cancer, adrenocortical cancer, uterine cancer, small cell lung cancer and cervical cancer, such as cancers selected from the following: endometrial carcinoma of the uterine body, adenocarcinoma of the colon, adenocarcinoma of the stomach, adenocarcinoma of the rectum, adrenocortical carcinoma, carcinosarcoma of the uterus, squamous cell carcinoma of the cervix, adenocarcinoma of the cervix, esophageal cancer, breast cancer, clear cell renal carcinoma, prostate cancer and serous cystadenocarcinoma of the ovary, particularly colorectal cancer (CRC), gastric cancer, prostate cancer, or endometrial cancer, more particularly colorectal cancer or small cell lung cancer.

[0377] In another embodiment of the twentieth aspect, the cancer is selected from dMMR or MSS cancers. In particular, the cancer is MSS colorectal cancer (CRC) or MSS small cell lung cancer.

[0378] In another embodiment of the sixteenth to twentieth aspects, the WRN inhibitor is Compound A.

[0379] Thus, according to the twenty - first aspect of the present invention, there is hereby provided a WRN inhibitor for use in the treatment of dMMR or MSS cancers (especially MSS cancers).

[0380] In one embodiment of the twenty - first aspect, the cancer is MSS colorectal cancer or MSS small cell lung cancer.

[0381] In an embodiment of the twenty - first aspect, the WRN inhibitor is a compound as defined in any one of Examples 5 to 11, 83 or 84 herein. More particularly, the compound is Compound A herein.

[0382] Thus, according to the twenty - second aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of temozolomide, wherein the treatment further comprises administering:

[0383] · a therapeutically effective amount of a WRN inhibitor, or

[0384] · a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of irinotecan.

[0385] Thus, according to the twenty - third aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a WRN inhibitor, wherein the treatment further comprises administering:

[0386] · a therapeutically effective amount of temozolomide, or

[0387] · a therapeutically effective amount of temozolomide and a therapeutically effective amount of irinotecan.

[0388] Thus, according to the twenty - fourth aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of irinotecan, wherein the treatment further comprises administering:

[0389] · a therapeutically effective amount of a WRN inhibitor, or in particular

[0390] · a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of temozolomide.

[0391] In embodiments of the twenty - first to twenty - fourth aspects, the WRN inhibitor is a compound as defined in any one of Examples 5 to 11, 83 or 84 herein. More particularly, the compound is Compound A herein.

[0392] In another embodiment of the twenty - second to twenty - fourth aspects, the cancer is MSI - H, dMMR or MSS cancer, particularly dMMR or MSS cancer, more particularly MSS cancer. Specifically, the cancer is MSS colorectal cancer (CRC) or MSS small cell lung cancer.

[0393] In another embodiment of the twenty - second to twenty - fourth aspects, temozolomide is administered as follows:

[0394] · As a pre - treatment before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, without subsequent combination therapy including temozolomide, or

[0395] · In combination, without temozolomide pre - treatment, or

[0396] · As a pre - treatment before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, followed by combination therapy including temozolomide.

[0397] Thus, according to the twenty - fifth aspect of the present invention, there is hereby provided a WRN inhibitor for use in the treatment of cancer, wherein the treatment further comprises administering an alkylating agent (particularly temozolomide), and the cancer is:

[0398] · MSS cancer,

[0399] · pMMR / MSS MGMT - defective cancer, or pMMR / MSS MGMT - deficient cancer, or pMMR / MSS MGMT - silenced cancer, or MGMT - methylated pMMR / MSS cancer, e.g., colorectal cancer,

[0400] · MGMT - methylated glioblastoma,

[0401] · MGMT - hypermethylated CRC, or

[0402] · MGMT - hypermethylated, RAS - mutant or RAS - wild - type CRC.

[0403] Thus, according to the twenty - sixth aspect of the present invention, there is hereby provided an alkylating agent for use in the treatment of cancer, wherein the treatment further comprises administering a WRN inhibitor, and the cancer is:

[0404] · MSS cancer,

[0405] · pMMR / MSS cancers with defective MGMT, or pMMR / MSS cancers lacking MGMT, or pMMR / MSS cancers with silenced MGMT, or pMMR / MSS cancers with methylated MGMT, such as colorectal cancer or small cell lung cancer,

[0406] · Glioblastoma with methylated MGMT,

[0407] · CRC with hypermethylated MGMT, or

[0408] · CRC with hypermethylated MGMT, RAS-mutated or RAS-wild type.

[0409] Accordingly, in a twenty-seventh aspect of the present invention, there is provided a method for treating cancer (especially cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a DNA polymerase α inhibitor (e.g., aphidicolin), for example for treating colorectal cancer.

[0410] Accordingly, in a twenty-eighth aspect of the present invention, there is provided a method for treating cancer (especially cancer characterized by MSS or defective mismatch repair (dMMR) (especially MSS)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutic agent that can (or is capable of):

[0411] · Sensitize cancer cells, for example for improving the response to WRN inhibitor treatment,

[0412] · Prime cancer cells, for example, such priming may include triggering a hypermutable state in the cancer cells,

[0413] · Generate or increase MMR defects in cancer cells,

[0414] · Generate or increase the MSI-H state in cancer cells,

[0415] · Increase the MMR heterogeneity of cancer cells, and / or

[0416] · Generate resistance to temozolomide in cancer cells or increase the resistance of cancer cells to temozolomide,

[0417] Especially

[0418] · Generate or increase MMR defects in cancer cells, or

[0419] · Generate or increase the MSI-H state in cancer cells.

[0420] In particular, the therapeutic agent is temozolomide.

[0421] Optionally, wherein the treatment further comprises administering chemotherapy, such as irinotecan.

[0422] Thus, according to the twenty-ninth aspect of the present invention, there is provided a WRN inhibitor for use in the treatment of cancer (in particular cancer characterized by MSS or mismatch repair deficiency (dMMR) (in particular MSS)), wherein the treatment further comprises administering a therapeutic agent which can or is capable of:

[0423] · Sensitize cancer cells, for example to improve the response to WRN inhibitor treatment,

[0424] · Prime cancer cells, for example, such priming may include triggering a hypermutable state in the cancer cells,

[0425] · Generate or increase MMR deficiency in cancer cells,

[0426] · Generate or increase the MSI-H state in cancer cells,

[0427] · Increase the MMR heterogeneity of cancer cells, and / or

[0428] · Generate resistance to temozolomide in cancer cells or increase the resistance of cancer cells to temozolomide,

[0429] In particular

[0430] · Generate or increase MMR deficiency in cancer cells, or

[0431] · Generate or increase the MSI-H state in cancer cells.

[0432] In particular, the therapeutic agent is temozolomide.

[0433] Optionally, wherein the treatment further comprises administering chemotherapy, such as irinotecan.

[0434] Thus, the present invention provides the following numbered embodiments:

[0435] Example 1. A method of treating cancer in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of at least one therapeutic active agent selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, a CTLA-4 inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0436] Example 2. A WRN inhibitor for use in cancer treatment, wherein the treatment further comprises administering at least one therapeutic active agent selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, a CTLA-4 inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0437] Example 3. A therapeutic active agent for use in cancer treatment, wherein the treatment further comprises administering a WRN inhibitor, and wherein the therapeutic active agent is selected from the group consisting of: a PD-1 inhibitor, a chemotherapeutic agent, a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, a CTLA-4 inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0438] Example 4. A combination comprising i) a WRN inhibitor, and ii) at least one therapeutic active agent selected from the group consisting of: a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, a CTLA-4 inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, and a PARP inhibitor.

[0439] Example 5. The method as described in Example 1, for use with a WRN inhibitor as described in Example 2, for use with a therapeutic active agent as described in Example 3, or a combination as described in Example 4, wherein the WRN inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof:

[0440]

[0441] wherein

[0442] R, M, W, L, V, and T are independently selected from C, CH, and N,

[0443] to form sub-formulas 1a, 1b, 1c, 1d, 1e, and 1f:

[0444]

[0445]

[0446] A is a linker selected from -C(O)-, -S(O)-, -S(O)2-, and ;

[0447] Y is N, C, or CH;

[0448] y is 0, 1, 2, 3, or 4;

[0449] means that when Y is CH, Y is connected to the adjacent carbon atom via a single bond, or when Y is C, Y is connected to the adjacent atom via a double bond, and when is a single bond, Y is an unsubstituted carbon or a carbon substituted with OH or F;

[0450] When Y is N, is a single bond;

[0451] means that K is connected to the adjacent atom via a single bond or a double bond;

[0452] wherein:

[0453] When is a double bond, is a single bond, K is CH, J is C, and A is a linker selected from -C(O)-, -S(O)-, -S(O)2-, and ;

[0454] Or

[0455] When is a single bond, K is selected from -CH2-, -CH2CH2-, -NH-, and a bond (to form a 5-membered ring: ), J is N, and A is selected from -C(O)-, -S(O)-, -S(O)2- and a linker;

[0456] or

[0457] when is a single bond, K is -CH2-, J is CH, and A is selected from -S(O)-, -S(O)2- and a linker;

[0458] R5 is independently selected from:

[0459] · -(C 1- C4)alkyl,

[0460] · -(C 3- C5)cycloalkyl,

[0461] · and where two R5 substituents on the same ring carbon atom together with the carbon atom to which they are attached can be joined to form a (C 3- C4)cycloalkyl spiro ring or a 3- or 4-membered heterocyclic spiro ring, where the heterocyclic spiro ring contains a ring carbon atom and one ring heteroatom selected from O, N, and S,

[0462] · when is a carbon-nitrogen single bond, the R5 substituents on K and on the adjacent carbon atom can be joined to form ring C:

[0463]

[0464] where ring C is a fused (C3-C6)cycloalkyl ring, a fused (C3-C6)heterocyclic ring, or a fused phenyl ring, where the fused (C3-C6)heterocyclic ring contains a ring carbon atom and one ring heteroatom selected from O, N, and S,

[0465] · when is a carbon-carbon single bond, Y is N and is a single bond, and A is selected from -S(O)-, -S(O)2- and a linker, the R5 substituents on K and on the adjacent carbon atom can be joined to form ring C:

[0466]

[0467] · and where when K is -CH2- and J is N, two R5 substituents can be joined to form a (C1-C3)alkylene bridge or a heteroalkylene bridge, where the heteroalkylene bridge is one heteroatom selected from N and O or is -CH2-O-CH2-;

[0468] and where ring:

[0469]

[0470] One or more H atoms thereon may be replaced by deuterium;

[0471] R1 is:

[0472] Cycloalkenyl, wherein the cycloalkenyl is a partially unsaturated monocyclic ring containing 5 or 6 ring carbon atoms, and the cycloalkenyl is unsubstituted or substituted by 1, 2, 3 or 4, preferably 1 or 2 R 33 substituents, where R 33 is halo, and wherein the cycloalkenyl or halo-substituted cycloalkenyl is substituted by 0, 1 or 2 R 15 substituents,

[0473] Or R1 is a heterocyclic group, wherein the heterocyclic group is a 5-membered or 6-membered fully saturated or partially unsaturated group containing ring carbon atoms and 1 or 2 ring heteroatoms independently selected from N, O and S, and wherein the heterocyclic group is unbridged or bridged, and the bridge is 1 or 2 carbon atoms, wherein the heterocyclic group is unsubstituted or substituted by 1, 2, 3 or 4, preferably 1 or 2 R 33 substituents, where R 33 is halo, and wherein the heterocyclic group or halo-substituted heterocyclic group is independently substituted by 0, 1 or 2 substituents selected from R 15 、R 16 、R 17 、R 18 、R 19 、R 20 、R 22 and R 23 substituents,

[0474] Or the heterocyclic group or halo-substituted heterocyclic group is fused to a cyclopropyl ring, wherein the cyclopropyl ring is unsubstituted or substituted by 1, 2 or 3 Fs,

[0475] Or the heterocyclic group or halo-substituted heterocyclic group has 2 substituents at the same ring carbon atom that forms a cyclopropyl spiro ring,

[0476] Or the heterocyclic group or halo-substituted heterocyclic group is fused to a (C3-C5) heterocycloalkyl ring, wherein the (C3-C5) heterocycloalkyl ring contains ring carbon atoms and 1 ring O atom;

[0477] Or R1 is a heteroaryl, wherein the heteroaryl is a 5-membered or 6-membered fully unsaturated monocyclic group containing ring carbon atoms and 1, 2, 3 or 4 ring heteroatoms independently selected from N, O and S, preferably 1 or 2 ring heteroatoms, wherein the total number of ring S atoms does not exceed 1, and the total number of ring O atoms does not exceed 1, wherein the heteroaryl is unsubstituted or independently substituted by R 21 and R 30substituted by 1, 2 or 3 substituents, where R 21 and R 30 are independently selected from halo and (C1-C4)alkyl, where the (C1-C4)alkyl is unsubstituted or substituted by 1, 2 or 3 halo,

[0478] or R1 is phenyl, where the phenyl is unsubstituted or substituted by 1, 2, 3 or 4, preferably 1 or 2, R 33 substituents, where R 33 is halo, and where the phenyl or halo-substituted phenyl is substituted by 0, 1 or 2 R 15 substituents,

[0479] or R1 is (C2-C4)alkynyl or (C2-C4)alkenyl, where the (C2-C4)alkynyl and (C2-C4)alkenyl are unsubstituted or substituted by (C1-C4)alkyl-O-C(O)- or morpholinyl;

[0480] R 15 、R 16 、R 17 、R 18 、R 19 、R 20 、R 22 and R 23 are each independently selected from:

[0481] · halo

[0482] · (C 1- C4)alkyl-O- which is unsubstituted or substituted by 1, 2 or 3 halo;

[0483] · (C1-C4)alkyl which is unsubstituted or substituted by OH, -O-(C1-C2)alkyl or 1, 2 or 3 halo,

[0484] · HOC(O)-(CH2) n -,

[0485] · H3C-C(O)(CH2) n -,

[0486] · (C1-C4)alkyl-O-C(O)(CH2) n ,

[0487] · =O

[0488] · azetidinyl or pyrrolidinyl, where the azetidinyl and pyrrolidinyl are attached to the remainder of the molecule via an N atom and are each unsubstituted or substituted by 1 or 2 F,

[0489] · R 25 (R 24)N-, where R 24 is H or (C1-C4) alkyl which is unsubstituted or substituted by 1, 2 or 3 halogens, R 25 is H or (C1-C4) alkyl which is unsubstituted or substituted by 1, 2 or 3 halogens,

[0490] ·OH

[0491] where n is 0, 1 or 2,

[0492] R 26 is CH3, H or deuterium;

[0493] R 27 is CH3, H or deuterium;

[0494] or R 26 and R 27 together with the carbon atom to which they are attached form a cyclopropyl ring;

[0495] R2 is the following moiety:

[0496]

[0497] R6 is selected from:

[0498] ·H,

[0499] ·halogen,

[0500] ·(C1-C4) alkyl which is unsubstituted or substituted by 1, 2 or 3 halogens,

[0501] ·(C3-C5) cycloalkyl which is unsubstituted or substituted by 1, 2 or 3 halogens,

[0502] ·-O-(C1-C4) alkyl which is unsubstituted or substituted by 1, 2 or 3 halogens,

[0503] ·OH, and

[0504] ·CN;

[0505] R8 is selected from H, halogen, and (C1-C4) alkyl which is unsubstituted or substituted by 1, 2 or 3 halogens,

[0506] R9 is selected from H, O-CH3, OH, CN, CH3 and halogen;

[0507] R 28 is selected from:

[0508] ·SF5,

[0509] ·H,

[0510] ·-C(O)H,

[0511] · Halo

[0512] · (C1-C4) alkyl, unsubstituted or substituted with 1, 2 or 3 halos

[0513] · (C1-C4) alkynyl

[0514] · (C1-C4) alkenyl

[0515] · (C3-C5) cycloalkyl, unsubstituted or substituted with 1, 2 or 3 halos, and

[0516] · OCF3;

[0517] X is selected from C-R7 and N, where R7 is H or halo, or R7 together with R 28 or R6 and the atoms to which they are attached may be joined to form a fused (C4-C6) cycloalkyl ring, where the fused (C4-C6) cycloalkyl ring is unsubstituted or substituted with 1, 2 or 3 halos

[0518] or

[0519] R2 is selected from:

[0520]

[0521] where

[0522] R 31 is selected from H, halo and CH3

[0523] R 32 is selected from H, halo and CH3

[0524] R3 is:

[0525] · Cyclopropyl

[0526] · O-CH3

[0527] · N(CH3)2

[0528] · S-CH3

[0529] · (C1-C4) alkyl, unsubstituted or substituted with 1, 2 or 3 substituents independently selected from halo and OH;

[0530] R4 is selected from:

[0531]

[0532] where

[0533] R 10 、R 11 、R 12 、R13 and R 14 are independently selected from:

[0534] · H,

[0535] · halo,

[0536] · (C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halo substituents,

[0537] · (C1-C2)alkyl substituted with -O-(C1-C2)alkyl or OH,

[0538] · -S-(C1-C3)alkyl,

[0539] · -O-(C1-C4)alkyl which is unsubstituted or substituted with 1, 2 or 3 halo substituents,

[0540] · OH,

[0541] · (C3-C5)cycloalkyl, wherein the (C3-C5)cycloalkyl is unsubstituted or substituted with 1 or 2 halo substituents,

[0542] · -O-(C3-C5)cycloalkyl,

[0543] · -NR 34 R 35 , where R 34 and R 35 are independently selected from:

[0544] o H,

[0545] o (C1-C4)alkyl, wherein the (C1-C4)alkyl is unsubstituted or substituted with OH or -O(C1-C2)alkyl,

[0546] o and wherein R 34 and R 35 may together with the atoms to which they are attached form an azetidine, pyrrolidine or piperidine ring, wherein the azetidine, pyrrolidine and piperidine are unsubstituted or substituted with CH3;

[0547] · CN,

[0548] · -(C2-C4)alkenyl,

[0549] · -(C2-C4)alkynyl,

[0550] · -C(O)H, and

[0551] · -C(O)(C1-C4)alkyl;

[0552] and

[0553] * indicates an attachment point,

[0554] or

[0555] or the WRN inhibitor is a compound of formula (1g) or a pharmaceutically acceptable salt thereof:

[0556]

[0557] wherein

[0558] R1 is selected from:

[0559]

[0560] R 15 is H or F;

[0561] R 16 is H or R 25 (R 24 )N-;

[0562] R 17 is H or F;

[0563] R 18 is H or F;

[0564] R 19 is H or F;

[0565] R 20 is H or F;

[0566] R 21 is H or CH3;

[0567] R 22 is H, CF3, CHF2CH2, HOC(O)-CH2-, H3C-C(O)-, (H3C)3C-O-C(O)-;

[0568] R 23 is H, CF3, CHF2CH2-, (H3C)3C-O-C(O)-;

[0569] R 24 is CH3;

[0570] R 25 is CHF2CH2-;

[0571] R 26 is CH3, H or deuterium;

[0572] R 27 is H or deuterium;

[0573] R2 is the following moiety:

[0574]

[0575] wherein R6 is selected from H, Cl, CH3, F, and Br;

[0576] R8 is selected from H, Cl, F, and CF3;

[0577] R9 is selected from H, CH3, and Cl;

[0578] R 28 is selected from CF3, CF2H, -CH2CH3, Cl, SF5, Br, and -C(O)H;

[0579] X is selected from C-R7 and N;

[0580] R7 is selected from H and F;

[0581] R3 is selected from CH3, CH2CH3, cyclopropyl, and hydroxyethyl;

[0582] R4 is selected from:

[0583]

[0584] wherein

[0585] R 10 is selected from H, F, Cl, CH3, and OCF3;

[0586] R 11 is selected from H, Cl, F, and CH3;

[0587] R 12 is selected from H, Cl, and CH3;

[0588] R 13 is selected from H and CH3;

[0589] R 14 is selected from H, CH3, -CH2CH3, cyclopropyl, -OCHF2, OCF3, and Cl;

[0590] y is 0, 1, or 2;

[0591] R5 is CH3; or alternatively, two R5 groups on adjacent carbon atoms, together with the carbon atoms to which they are attached, are joined to form a fused cyclobutyl ring:

[0592]

[0593] and

[0594] * represents the point of attachment.

[0595] 6. The method as described in Example 5, the WRN inhibitor for use as described in Example 5, the therapeutic active agent for use as described in Example 5, or the combination as described in Example 5, wherein the WRN inhibitor is a compound selected from the following:

[0596]

[0597]

[0598]

[0599]

[0600]

[0601]

[0602]

[0603]

[0604]

[0605]

[0606]

[0607]

[0608]

[0609]

[0610]

[0611]

[0612] Example 7. The method as described in Example 5, the WRN inhibitor for use as described in Example 5, the therapeutic active agent for use as described in Example 5, or the combination as described in Example 5, wherein the WRN inhibitor is selected from:

[0613]

[0614]

[0615]

[0616]

[0617] Example 8. The method as described in Example 5, the WRN inhibitor for use as described in Example 5, the therapeutic active agent for use as described in Example 5, or the combination as described in Example 5, wherein the WRN inhibitor is selected from:

[0618]

[0619]

[0620]

[0621] Example 9. The method as described in Example 5, the WRN inhibitor for use as described in Example 5, the therapeutic active agent for use as described in Example 5, or the combination as described in Example 5, wherein the WRN inhibitor is

[0622] or its zwitterionic form or salt.

[0623] Example 10. The method as described in Example 5, the WRN inhibitor for use as described in Example 5, the therapeutic active agent for use as described in Example 5, or the combination as described in Example 5, wherein the WRN inhibitor is

[0624] or its zwitterionic form or salt.

[0625] Example 11. The method as described in Example 5, the WRN inhibitor for use as described in Example 5, the therapeutic active agent for use as described in Example 5, or the combination as described in Example 5, wherein the WRN inhibitor is

[0626] or its zwitterionic form or salt.

[0627] Example 12. The method as described in any one of Examples 1 and 5 to 11, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 11, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 11, wherein the cancer is characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR).

[0628] Example 13. The method as described in any one of Examples 1 and 5 to 12, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or the combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a PD-1 inhibitor.

[0629] Example 14. The method as described in Example 13, the WRN inhibitor for use as described in Example 13, the therapeutic active agent for use as described in Example 13, or the combination as described in Example 13, wherein the PD-1 inhibitor is an anti-PD-1 antibody.

[0630] Example 15. The method as described in Example 13, the WRN inhibitor for use as described in Example 13, the therapeutic active agent for use as described in Example 13, or the combination as described in Example 13, wherein the PD-1 inhibitor is selected from PDR001 (Novartis AG), nivolumab (Bristol-Myers Squibb Company), pembrolizumab (Merck & Co., Inc.), pidilizumab (Therapeutic Technology, Inc.), MEDI0680 (MedImmune Limited), cemiplimab (REGN2810, Regeneron Pharmaceuticals, Inc.), dostarlimab (TSR-042, Tesaro, Inc.), PF-06801591 (Pfizer Inc.), tislelizumab (BGB-A317, BeiGene, Ltd.), BGB-108 (BeiGene, Ltd.), INCSHR1210 (Incyte Corporation), balstilimab (AGEN2035, Agenus Inc.), sintilimab (Innovent Biologics, Inc.), toripalimab (Shanghai Junshi Biosciences Co., Ltd.), camrelizumab (Jiangsu Hengrui Medicine Co., Ltd.), and AMP-224 (Amplimmune, Inc.), particularly PDR001 or tislelizumab.

[0631] Example 16. The method as described in Example 15, the WRN inhibitor for use as described in Example 15, the therapeutic active agent for use as described in Example 15, or the combination as described in Example 15, wherein the PD-1 inhibitor is tislelizumab.

[0632] Example 17. The method as described in any one of Examples 1 and 5 to 12, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or the combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a chemotherapeutic agent.

[0633] Example 18. The method as described in Example 17, the WRN inhibitor for use as described in Example 17, the therapeutic active agent for use as described in Example 17 or the combination as described in Example 17, wherein the chemotherapeutic agent is selected from anastrozole vinblastine, vindesine, vinorelbine, vincristine, bicalutamide bleomycin (e.g., bleomycin sulfate) busulfan busulfan injection calactin, capecitabine N4-Pentyloxycarbonyl-5-deoxy-5-fluorocytidine, Carboplatin Carmustine Lomustine Chlorambucil Bendamustine Cisplatin Cladribine Cyclophosphamide( or ), Cytarabine, Cytosine Arabinoside Liposomal Injection of Cytarabine Dacarbazine Dactinomycin (Actinomycin D, Cosmegan), Daunorubicin Hydrochloride Liposomal Injection of Daunorubicin Citrate Dexamethasone, Docetaxel Doxorubicin (e.g., Doxorubicin Hydrochloride) Etoposide Fludarabine Phosphate 5-Fluorouracil Flutamide Tizoxanide, Gemcitabine (Difluorodeoxycytidine), Hydroxyurea Idarubicin Ifosfamide Irinotecan L-Asparaginase Calcium Folinate, Melphalan 6-Mercaptopurine Methotrexate Mitomycin (e.g., Mitomycin A, Mitomycin B or Mitomycin C, especially Mitomycin C), Mitoxantrone Gemtuzumab, Paclitaxel phoenix (Yttrium 90 / MX-DTPA), Pentostatin, Polybis(2,2,2-trifluoroethyl carbonate)-Camustine Implant Tamoxifen Citrate Camptothecin, Teniposide 6-Thioguanine, Thiotepa, Tirapazamine Topotecan Hydrochloride for Injection Vinblastine Vincristine Oxaliplatin Epirubicin Temozolomide Tegafur, and Vinorelbine Especially Irinotecan.

[0634] Example 19. The method according to Example 17 or Example 18, a WRN inhibitor for use as described in Example 17 or Example 18, a therapeutic active agent for use as described in Example 17 or Example 18, or a combination as described in Example 17 or Example 18, wherein the chemotherapeutic agent is selected from gemcitabine, camptothecin, irinotecan Docetaxel Doxorubicin (e.g., doxorubicin hydrochloride) 5-Fluorouracil Capecitabine Etoposide Epirubicin Oxaliplatin Mitomycin (e.g., mitomycin A, mitomycin B, or mitomycin C, especially mitomycin C), cisplatin Carboplatin and Paclitaxel

[0635] Example 20. The method according to any one of Examples 1 and 5 to 12, a WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, a therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or a combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a WEE1 inhibitor.

[0636] Example 21. The method according to Example 20, a WRN inhibitor for use as described in Example 20, a therapeutic active agent for use as described in Example 20, or a combination as described in Example 20, wherein the WEE1 inhibitor is selected from adavosertib (also known as AZD1775 and MK-1775) and PDO166285.

[0637] Example 22. The method according to Example 21, a WRN inhibitor for use as described in Example 21, a therapeutic active agent for use as described in Example 21, or a combination as described in Example 21, wherein the WEE1 inhibitor is adavosertib (also known as AZD1775 and MK-1775).

[0638] Example 23. The method according to any one of Examples 1 and 5 to 12, a WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, a therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or a combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is an ATR inhibitor.

[0639] Example 24. The method according to Example 23, the WRN inhibitor for use as described in Example 23, the therapeutic active agent for use as described in Example 23, or the combination as described in Example 23, wherein the ATR inhibitor is selected from RP-3500, ceralasertib (also known as AZD6738), bezosertib, ART-0380, gatolisib (also known as M4344), and elalisib (also known as BAY-1895344).

[0640] Example 25. The method according to Example 24, the WRN inhibitor for use as described in Example 24, the therapeutic active agent for use as described in Example 24, or the combination as described in Example 24, wherein the ATR inhibitor is elalisib (BAY-1895344).

[0641] Example 26. The method according to any one of Examples 1 and 5 to 12, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or the combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a DNA-PK inhibitor.

[0642] Example 27. The method according to Example 26, the WRN inhibitor for use as described in Example 26, the therapeutic active agent for use as described in Example 26, or the combination as described in Example 26, wherein the DNA-PK inhibitor is selected from AZD-7648, NU7441 (also known as KU-57788), omidubicel, BAY8400, and M3814.

[0643] Example 28. The method according to Example 27, the WRN inhibitor for use as described in Example 27, the therapeutic active agent for use as described in Example 27, or the combination as described in Example 27, wherein the DNA-PK inhibitor is AZD-7648 or NU7441 (KU-57788), particularly AZD-7648.

[0644] Example 29. The method according to any one of Examples 1 and 6 to 12, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or the combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals.

[0645] Example 30. The method according to Example 29, for a WRN inhibitor used as described in Example 29, a therapeutic active agent used as described in Example 29, or a combination as described in Example 29, wherein the ionizing radiation is external beam radiation.

[0646] Example 31. The method according to Example 29, for a WRN inhibitor used as described in Example 29, for a therapeutic active agent used as described in Example 29, or a combination as described in Example 29, wherein the ionizing radiation is a radiopharmaceutical.

[0647] Example 32. The method according to Example 31, for a WRN inhibitor used as described in Example 31, for a therapeutic active agent used as described in Example 31, or a combination as described in Example 31, wherein the radiopharmaceutical is a radioligand agent.

[0648] Example 33. The method according to Example 32, for a WRN inhibitor used as described in Example 32, for a therapeutic active agent used as described in Example 32, or a combination as described in Example 32, wherein the radioligand agent is selected from 177 Lu-PSMA-617, 177 Lu-PSMA-R2, 177 Lu-NeoB, 177 Lu-FAP-2286.

[0649] Example 34. The method according to any one of Examples 1 and 5 to 12, for a WRN inhibitor used as described in any one of Examples 2 and 5 to 12, for a therapeutic active agent used as described in any one of Examples 3 and 5 to 12, or a combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a MEK inhibitor.

[0650] Example 35. The method according to Example 34, for a WRN inhibitor used as described in Example 34, for a therapeutic active agent used as described in Example 34, or a combination as described in Example 34, wherein the MEK inhibitor is selected from the group consisting of refametinib, pimasertib, selumetinib, trametinib, binimetinib, and cobimetinib or a pharmaceutically acceptable salt thereof.

[0651] Example 36. The method according to Example 35, for a WRN inhibitor used as described in Example 35, for a therapeutic active agent used as described in Example 35, or a combination as described in Example 35, wherein the MEK inhibitor is trametinib.

[0652] Example 37. The method according to any one of Examples 1 and 5 to 12, a WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, a therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or a combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is an MDM2 inhibitor.

[0653] Example 38. The method according to Example 37, a WRN inhibitor for use as described in Example 37, a therapeutic active agent for use as described in Example 37, or a combination as described in Example 37, wherein the MDM2 inhibitor is selected from the group consisting of: nutlin-3a, idasanutlin (also known as RG7388), RG7112, KRT-232 (also known as AMG-232), APG-115, RAIN-32 (also known as DS-3032 and milademetan), BI-907828, and HDM201 (also known as siramesine) or a pharmaceutically acceptable salt thereof.

[0654] Example 39. The method according to Example 38, a WRN inhibitor for use as described in Example 38, a therapeutic active agent for use as described in Example 38, or a combination as described in Example 38, wherein the MDM2 inhibitor is HDM201.

[0655] Example 40. The method according to any one of Examples 1 and 5 to 12, a WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, a therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or a combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a G4-quadruplex stabilizer.

[0656] Example 41. The method according to Example 40, a WRN inhibitor for use as described in Example 40, a therapeutic active agent for use as described in Example 40, or a combination as described in Example 40, wherein the G4-quadruplex stabilizer is pyridostatin.

[0657] Example 42. The method according to any one of Examples 1 and 5 to 12, a WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, a therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or a combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is an ATM inhibitor.

[0658] Example 43. The method as described in Example 42, the WRN inhibitor for use as described in Example 42, the therapeutic active agent for use as described in Example 42, or the combination as described in Example 42, wherein the ATM inhibitor is selected from KU-55933, KU-60019, KU-59403, M3541, CP-466722, AZ31, AZ32, AZD0156, and AZD1390.

[0659] Example 44. The method as described in Example 43, the WRN inhibitor for use as described in Example 43, the therapeutic active agent for use as described in Example 43, or the combination as described in Example 43, wherein the ATM inhibitor is KU-60019.

[0660] Example 45. The method as described in any one of Examples 1 and 5 to 12, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or the combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a PARP inhibitor.

[0661] Example 46. The method as described in Example 45, the WRN inhibitor for use as described in Example 45, the therapeutic active agent for use as described in Example 45, or the combination as described in Example 45, wherein the PARP inhibitor is selected from olaparib, NMS293, niraparib, prazacrine, veliparib, rucaparib, talazoparib, AZD-5305, and KU0058948.

[0662] Example 47. The method as described in Example 46, the WRN inhibitor for use as described in Example 46, the therapeutic active agent for use as described in Example 46, or the combination as described in Example 46, wherein the PARP inhibitor is olaparib.

[0663] Example 48. The method as described in any one of Examples 1 and 5 to 12, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or the combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a chemotherapeutic agent, and the chemotherapeutic agent is a topoisomerase inhibitor.

[0664] Example 49. The method as described in Example 48, the WRN inhibitor for use as described in Example 48, the therapeutic active agent for use as described in Example 48, or the combination as described in Example 48, wherein the topoisomerase inhibitor is selected from QAP1, irinotecan, topotecan, camptothecin, and etoposide.

[0665] Example 50. The method as described in Example 49, the WRN inhibitor for use as described in Example 49, the therapeutic active agent for use as described in Example 49 or the combination as described in Example 49, wherein the topoisomerase inhibitor is selected from QAP1, etoposide and irinotecan.

[0666] Example 51. The method as described in any one of Examples 1 and 5 to 12, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 12, the therapeutic active agent for use as described in any one of Examples 3 and 5 to 12, or the combination as described in any one of Examples 4 to 11, wherein the (at least one) therapeutic active agent is a CHK1 inhibitor or a CHK2 inhibitor.

[0667] Example 52. The method as described in Example 51, the WRN inhibitor for use as described in Example 51, the therapeutic active agent for use as described in Example 51, or the combination as described in Example 51, wherein the CHK1 inhibitor or CHK2 inhibitor is selected from GDC-0575, prexasertib (also known as LY2606368), SCH900776 (also known as MK-8776), SRA737, PF477736, LY2606368 and AZD7762, especially AZD7762.

[0668] Example 53. The method as described in any one of Examples 1 and 5 to 52, the WRN inhibitor for use as described in any one of Examples 2 and 5 to 52 or the therapeutic active agent for use as described in any one of Examples 3 and 5 to 52, wherein the cancer is selected from colorectal cancer (CRC), gastric cancer, prostate cancer, endometrial cancer, adrenocortical cancer, uterine cancer and cervical cancer, for example cancers selected from: endometrial carcinoma of the uterine corpus, colonic adenocarcinoma, gastric adenocarcinoma, rectal adenocarcinoma, adrenocortical carcinoma, carcinosarcoma of the uterus, cervical squamous cell carcinoma, cervical adenocarcinoma, esophageal cancer, breast cancer, renal clear cell carcinoma, prostate cancer and ovarian serous cystadenocarcinoma.

[0669] Example 54. The method as described in Example 53, the WRN inhibitor for use as described in Example 53 or the therapeutic active agent for use as described in Example 53, wherein the cancer is colorectal cancer (CRC) or gastric cancer, especially colorectal cancer (CRC).

[0670] Example 55. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a G4-quadruplex stabilizer.

[0671] Example 56. The method as described in Example 55, wherein the G4-quadruplex stabilizer is pyridostatin.

[0672] Example 57. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a MEK inhibitor.

[0673] Example 58. The method according to Example 57, wherein the MEK inhibitor is trametinib.

[0674] Example 59. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a topoisomerase inhibitor.

[0675] Example 60. The method according to Example 59, wherein the topoisomerase inhibitor is QAP1, etoposide, irinotecan or camptothecin.

[0676] Example 61. A method for treating colorectal cancer or gastric cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ATR inhibitor.

[0677] Example 62. The method according to Example 61, wherein the ATR inhibitor is alisertib (BAY-1895344).

[0678] Example 63. A method for treating gastric cancer or colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy and iii) radiopharmaceuticals.

[0679] Example 64. The method according to Example 63, wherein the ionizing radiation is external beam radiation.

[0680] Example 65. The method according to Example 63, wherein the ionizing radiation is a radiopharmaceutical.

[0681] Example 66. The method according to Example 65, wherein the radiopharmaceutical is a radioligand agent.

[0682] Example 67. The method according to Example 66, wherein the radioligand agent is selected from 177 Lu-PSMA-617, 177 Lu-PSMA-R2, 177 Lu-NeoB, 177 Lu-FAP-2286.

[0683] Example 68. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a chemotherapeutic agent.

[0684] Example 69. The method according to Example 68, wherein the chemotherapeutic agent is selected from 5-fluorouracil, cisplatin, bleomycin, docetaxel, doxorubicin, epirubicin, etoposide, camptothecin, mitomycin, oxaliplatin, mitomycin (e.g., mitomycin C), and gemcitabine.

[0685] Example 70. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an MDM2 inhibitor.

[0686] Example 71. The method according to Example 70, wherein the MDM2 inhibitor is HDM201.

[0687] Example 72. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of an ATM inhibitor.

[0688] Example 73. The method according to Example 72, wherein the ATM inhibitor is KU-60019.

[0689] Example 74. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a DNA-PK inhibitor.

[0690] Example 75. The method according to Example 74, wherein the DNA-PK inhibitor is AZD-7648 or NU7441 (KU-57788).

[0691] Example 76. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a WEE1 inhibitor.

[0692] Example 77. The method according to Example 76, wherein the WEE1 inhibitor is adavosertib.

[0693] Example 78. A method for treating colorectal cancer, the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a CHK1 inhibitor or a CHK2 inhibitor.

[0694] Example 79. The method according to Example 78, wherein the CHK1 inhibitor or CHK2 inhibitor is AZD7762 or SCH900776 (also known as MK-8776).

[0695] Example 80. The method according to any one of Examples 55 to 79, wherein the colorectal cancer or gastric cancer is characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR).

[0696] Example 81. The method according to Example 80, wherein the colorectal cancer or gastric cancer is characterized by high microsatellite instability (MSI-H).

[0697] Example 82. The method according to any one of Examples 54, 61 to 67, 80 and 81, wherein the gastric cancer is gastric adenocarcinoma.

[0698] Example 83. The method according to any one of Examples 55 to 82, wherein the WRN inhibitor is selected from or its zwitterionic form or a pharmaceutically acceptable salt.

[0699] Example 84. The method according to Example 83, wherein the WRN inhibitor is or its zwitterionic form or a pharmaceutically acceptable salt.

[0700] Example 85: A combination comprising i) a WRN inhibitor and ii) temozolomide, and optionally, iii) irinotecan.

[0701] Example 86: The combination according to Example 85, as a non-fixed dose combination.

[0702] Example 87: Temozolomide for use in cancer treatment, wherein the treatment further comprises administering:

[0703] · a WRN inhibitor, or

[0704] · a combination of a WRN inhibitor and irinotecan.

[0705] Example 88. A WRN inhibitor for use in cancer treatment, wherein the treatment further comprises administering:

[0706] · temozolomide, or

[0707] · temozolomide and irinotecan.

[0708] Example 89. Irinotecan for use in cancer treatment, wherein the treatment further comprises administering:

[0709] · a WRN inhibitor, or in particular

[0710] · a WRN inhibitor and temozolomide.

[0711] Example 90. Temozolomide for use as described in Example 87, or a WRN inhibitor for use as described in Example 88, or irinotecan for use as described in Example 89, wherein the cancer is an MSI-H, dMMR or MSS cancer, particularly an MSS cancer. For example, the cancer is a pMMR / MSS MGMT-deficient cancer, or a pMMR / MSS MGMT-deficient cancer, or a pMMR / MSS MGMT-silent cancer, or a pMMR / MSS cancer with MGMT methylation. For example, the cancer is selected from the cancers described herein. In another example, the cancer is a pMMR / MSS MGMT-deficient CRC (colorectal cancer), or a pMMR / MSS MGMT-deficient CRC or a pMMR / MSS MGMT-silent CRC, or a pMMR / MSS MGMT-methylated colorectal cancer. Alternatively, the cancer is an MSI-H MGMT-deficient cancer, or an MSI-H MGMT-deficient cancer, or an MSI-H MGMT-silent cancer, or an MSI-H cancer with MGMT methylation, particularly colorectal cancer. In another example, the pMMR / MSS or MSH-H cancer is RAS-mutated or RAS wild-type CRC.

[0712] Example 91. Temozolomide for use as described in Example 90, or a WRN inhibitor for use as described in Example 90, or irinotecan for use as described in Example 90, wherein the cancer is a dMMR or MSS cancer, particularly an MSS cancer. In one example, the cancer is a pMMR / MSS MGMT-deficient cancer, or a pMMR / MSS MGMT-deficient cancer, or a pMMR / MSS MGMT-silent cancer, or a pMMR / MSS cancer with MGMT methylation. For example, the cancer is selected from the cancers described herein. In another example, the tumor is a pMMR / MSS MGMT-deficient CRC, or a pMMR / MSS MGMT-deficient CRC, or a pMMR / MSS MGMT-silent CRC, or a pMMR / MSS MGMT-methylated pMMR / MSS CRC (colorectal cancer).

[0713] Example 92. Temozolomide for use as described in Example 87, 90 or 91, or a WRN inhibitor for use as described in Example 88, 90 or 91, or irinotecan as described in Example 89, 90 or 91, wherein temozolomide is administered as follows:

[0714] · As a pre-treatment before administration of the WRN inhibitor, or before administration of irinotecan, or before administration of both the WRN inhibitor and irinotecan, without subsequent combination treatment including temozolomide, or

[0715] · Administered in combination, without temozolomide pre-treatment, or

[0716] · Administered as a pre-treatment before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, followed by combination therapy including temozolomide,

[0717] wherein said combination or combination therapy is described in Examples 87, 88, 89, 90 or 91.

[0718] Example 93. Temozolomide for use as described in any one of Examples 87, 90 or 91, or a WRN inhibitor for use as described in any one of Examples 88, 90 or 91, or irinotecan for use as described in any one of Examples 89, 90 or 91, wherein said cancer, particularly said MSI-H, dMMR or MSS cancer, is selected from colorectal cancer (CRC), gastric cancer, prostate cancer, endometrial cancer, adrenocortical cancer, uterine cancer and cervical cancer, for example cancers selected from: endometrial cancer of the uterine body, colonic adenocarcinoma, gastric adenocarcinoma, rectal adenocarcinoma, adrenocortical carcinoma, uterine carcinosarcoma, cervical squamous cell carcinoma, cervical adenocarcinoma, esophageal cancer, breast cancer, renal clear cell carcinoma, prostate cancer and ovarian serous cystadenocarcinoma, or glioma, glioblastoma, neuroendocrine tumor, melanoma, colorectal cancer, small cell lung cancer, triple-negative breast cancer, and sarcoma.

[0719] Example 94. Temozolomide for use as described in Example 93, or a WRN inhibitor for use, or irinotecan for use, wherein said cancer, particularly said MSI-H, dMMR or MSS cancer, is colorectal cancer (CRC), gastric cancer, prostate cancer, small cell lung cancer or endometrial cancer, particularly colorectal cancer.

[0720] Example 95. Temozolomide for use as described in Example 94, or a WRN inhibitor for use, or irinotecan for use, wherein the cancer is colorectal cancer (CRC), particularly MSS colorectal cancer or dMMR colorectal cancer, or MSS small cell lung cancer or dMMR small cell lung cancer.

[0721] Example 96: A WRN inhibitor for use in the treatment of dMMR or MSS cancer, particularly MSS cancer. In particular, the WRN inhibitor is a compound as defined in any one of Examples 5 to 11, 83 or 84 herein. More particularly, the compound is Compound A herein.

[0722] Example 97: The combination as described in Example 85, wherein the WRN inhibitor is a compound as defined in any one of Examples 5 to 11, 83 or 84 herein. In particular, the WRN inhibitor is Compound A herein.

[0723] Example 98: A method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of temozolomide, wherein the treatment further comprises administering:

[0724] · A therapeutically effective amount of a WRN inhibitor, or

[0725] · A combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of irinotecan.

[0726] Example 99: A method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a WRN inhibitor, wherein the treatment further comprises administering:

[0727] · A therapeutically effective amount of temozolomide, or

[0728] · A therapeutically effective amount of temozolomide and a therapeutically effective amount of irinotecan.

[0729] Example 100: A method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of irinotecan, wherein the treatment further comprises administering:

[0730] · A therapeutically effective amount of a WRN inhibitor, or in particular

[0731] · A therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of temozolomide.

[0732] Example 101: The method according to any one of Examples 98 to 100, wherein the cancer is MSI-H, dMMR or MSS cancer, particularly dMMR or MSS cancer, such as MSS cancer. In one instance, the cancer is pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-lacking cancer, or pMMR / MSS MGMT-silent cancer, or MGMT-methylated pMMR / MSS cancer. In another instance, the tumor is pMMR / MSS MGMT-deficient colorectal cancer, or pMMR / MSS MGMT-lacking colorectal cancer, or pMMR / MSS MGMT-silent colorectal cancer, or pMMR / MSS MGMT-methylated colorectal cancer. In another instance, the cancer is MSI-H MGMT-deficient cancer, or MSI-H MGMT-lacking cancer, or MSI-H MGMT-silent cancer, or MSI-H MGMT-methylated cancer, particularly colorectal cancer (CRC), more particularly RAS-mutated or RAS wild-type CRC.

[0733] Example 102: The method according to any one of Examples 98 to 101, wherein temozolomide is administered as follows:

[0734] · As a pretreatment before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, subsequent combination therapy including temozolomide is not performed, or

[0735] · Administered in combination, without temozolomide pretreatment, or

[0736] · As a pretreatment before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, followed by combination therapy including temozolomide,

[0737] wherein the combination or combination therapy is described in Examples 98 to 101.

[0738] Example 103: Temozolomide for use as described in any one of Examples 87 to 95 or 98 to 102, or the WRN inhibitor used, or irinotecan used, or the method, wherein temozolomide is used as:

[0739] · A combination agent with at least one combination partner (including the WRN inhibitor), or

[0740] · As a pretreatment agent before combination therapy, wherein the combination therapy includes at least one combination partner that is a WRN inhibitor, or

[0741] · Both as a pretreatment agent and as a combination agent with the WRN inhibitor,

[0742] The purpose is:

[0743] · To sensitize cancer cells, for example, to improve the response to WRN inhibitor therapy,

[0744] · To trigger cancer cells, for example, such triggering may include triggering a highly mutagenic state in cancer cells,

[0745] · To produce or increase MMR deficiency in cancer cells,

[0746] · To produce or increase the MSI-H state in cancer cells,

[0747] · To increase the MMR heterogeneity of cancer cells, and / or

[0748] · To produce resistance to temozolomide in cancer cells or increase the resistance of cancer cells to temozolomide.

[0749] Example 104: A WRN inhibitor for use in cancer treatment, wherein the treatment further includes administering an alkylating agent (especially temozolomide), and the cancer is:

[0750] · MSS cancer,

[0751] · pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-silent cancer, or MGMT-methylated pMMR / MSS cancer, such as colorectal cancer,

[0752] · MGMT-methylated glioblastoma,

[0753] · CRC with MGMT hypermethylation, or

[0754] · CRC with MGMT hypermethylation, RAS-mutated or RAS-wild type.

[0755] Optionally, the use further comprises administering irinotecan.

[0756] Example 105: A WRN inhibitor for use in cancer treatment as described in Example 104, wherein the treatment further comprises administering an alkylating agent, and the cancer is MSS cancer. For example, the cancer is pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-silent cancer, or MGMT-methylated pMMR / MSS cancer. For example, the alkylating agent is temozolomide.

[0757] Example 106: A WRN inhibitor for use in cancer treatment, wherein the treatment further comprises administering an alkylating agent, such as temozolomide, and the cancer is MGMT-deficient, or MGMT-deficient, or MGMT-silent, or MGMT-methylated pMMR / MSS CRC.

[0758] Example 107: Temozolomide for use as described in any one of Examples 87 to 95 or 98 to 105, or a WRN inhibitor for use, or irinotecan for use, or a method, wherein the WRN inhibitor is described in any one of Examples 5 to 8, 83 or 84. In particular, the WRN inhibitor is Compound A herein.

[0759] Example 108: An alkylating agent for use in cancer treatment, wherein the treatment further comprises administering a WRN inhibitor, and the cancer is:

[0760] · MSS cancer,

[0761] · pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-deficient cancer, or pMMR / MSS MGMT-silent cancer, or MGMT-methylated pMMR / MSS cancer, such as colorectal cancer,

[0762] · Glioblastoma with MGMT methylation,

[0763] · CRC with MGMT hypermethylation, or

[0764] · RAS-mutated or RAS wild-type CRC with MGMT hypermethylation.

[0765] For example, the cancer is a pMMR / MSS MGMT-deficient cancer, or a pMMR / MSS MGMT-lacking cancer, or a pMMR / MSS MGMT-silent cancer, or a pMMR / MSS cancer with MGMT methylation. For example, the WRN inhibitor has a structure according to formula (especially compound A) described herein. For example, the alkylating agent is temozolomide. Optionally, the use further comprises administering irinotecan.

[0766] Example 109. A method for treating cancer (especially cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a DNA polymerase α inhibitor (e.g., aphidicolin), for example for treating colorectal cancer.

[0767] Example 110. A method for treating cancer (especially cancer characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a DNA polymerase α inhibitor (e.g., aphidicolin), for example for treating colorectal cancer.

[0768] Example 111: A method for treating cancer (especially cancer characterized by MSS or defective mismatch repair (dMMR) (especially MSS)) in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and the following therapeutic agent, which can:

[0769] · Generate or increase MMR defects in cancer cells, or

[0770] · Generate or increase the MSI-H state in cancer cells.

[0771] In particular, the therapeutic agent is temozolomide.

[0772] Example 112: A WRN inhibitor for use in the treatment of cancer (especially cancer characterized by MSS or defective mismatch repair (dMMR) (especially MSS)), wherein the treatment further comprises administering the following therapeutic agent, which can:

[0773] · Generate or increase MMR deficiency in cancer cells, or

[0774] · Generate or increase the MSI-H state in cancer cells.

[0775] In particular, the therapeutic agent is temozolomide.

[0776] Example 113: Temozolomide for use as described in any of the examples herein, or a WRN inhibitor for use, or irinotecan for use, wherein temozolomide is administered in repeated doses, such as in 2, 3 or more repeated doses.

[0777] The following aspects and examples of the invention are also provided.

[0778] In another aspect, a WRN inhibitor for use in cancer treatment is provided, wherein the treatment further comprises administering:

[0779] i. An agent that can

[0780] o Sensitize cancer cells, for example, to improve the response to WRN inhibitor treatment,

[0781] o Prime cancer cells, for example, such priming may include triggering a hypermutable state in cancer cells,

[0782] o Generate or increase MMR deficiency in cancer cells,

[0783] o Generate or increase the MSI-H state in cancer cells, or

[0784] o Increase MMR heterogeneity in cancer cells,

[0785] And optionally, wherein the treatment further comprises administering:

[0786] ii. Chemotherapy, such as irinotecan.

[0787] In one embodiment, a WRN inhibitor for use in the treatment of MSS (microsatellite stability) cancer is provided. In another embodiment, the agent i. is selected from temozolomide, cisplatin and 6-thioguanine, or the agent i. is an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy and ii) radiopharmaceuticals. In particular, the agent i. is temozolomide. In another embodiment, the treatment further comprises administering both i. temozolomide and ii. irinotecan.

[0788] In another embodiment, a WRN inhibitor is as described herein. In particular, the WRN inhibitor is a compound having formula (I) or formula (1g) as described herein. More particularly, the WRN inhibitor is compound A:

[0789] or a pharmaceutically acceptable salt thereof.

[0790] In particular, the WRN inhibitor is for use in cancer treatment, wherein the cancer is selected from colorectal cancer (CRC), such as colon adenocarcinoma or rectal adenocarcinoma; gastric cancer, such as gastric adenocarcinoma; prostate cancer; endometrial cancer; adrenocortical cancer, such as adrenocortical carcinoma; cervical cancer, such as cervical squamous cell carcinoma or cervical adenocarcinoma; uterine cancer, such as uterine corpus endometrial carcinoma and uterine carcinosarcoma; esophageal cancer, such as esophageal carcinoma; breast cancer, such as breast cancer or triple-negative breast cancer; renal cancer, such as renal clear cell carcinoma; ovarian cancer, such as ovarian serous cystadenocarcinoma; glioma; glioblastoma; neuroendocrine tumor; melanoma; small cell lung cancer and sarcoma; particularly colorectal cancer or small cell lung cancer.

[0791] More particularly, the cancer is selected from MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-silent cancer, or MSS (microsatellite stability) cancer with MGMT methylation.

[0792] In one embodiment, the agent is administered i. as follows:

[0793] · As a pretreatment agent before treatment with the WRN inhibitor,

[0794] · As a combination agent with the WRN inhibitor without pretreatment,

[0795] · Both as a pretreatment agent and as a combination agent with the WRN inhibitor.

[0796] More particularly, the agent i. is temozolomide, and temozolomide is administered as follows:

[0797] · As a pretreatment before administration of the WRN inhibitor, or

[0798] · Administered in combination with the WRN inhibitor without temozolomide pretreatment, or

[0799] · As a pretreatment before administration of the WRN inhibitor, followed by combination therapy including temozolomide and the said WRN inhibitor,

[0800] And the treatment preferably further includes administration of irinotecan.

[0801] In yet another aspect, a combination is provided that comprises i) a WRN inhibitor and ii) temozolomide, and optionally, iii) irinotecan. More particularly, the cancer is MSI-H, dMMR or MSS cancer, especially MSS cancer. In one embodiment, the cancer is selected from colorectal cancer (CRC), such as colon adenocarcinoma or rectal adenocarcinoma; gastric cancer, such as gastric adenocarcinoma; prostate cancer; endometrial cancer; adrenocortical cancer, such as adrenocortical carcinoma; cervical cancer, such as cervical squamous cell carcinoma or cervical adenocarcinoma; uterine cancer, such as uterine corpus endometrial carcinoma and uterine carcinosarcoma; esophageal cancer, such as esophageal carcinoma; breast cancer, such as breast cancer or triple-negative breast cancer; renal cancer, such as renal clear cell carcinoma; ovarian cancer, such as ovarian serous cystadenocarcinoma; glioma; glioblastoma; neuroendocrine tumor; melanoma; small cell lung cancer and sarcoma; especially colorectal cancer or small cell lung cancer, particularly MSS colorectal cancer or MSS small cell lung cancer. In another embodiment, the cancer is selected from MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-silent cancer, or MGMT-methylated MSS (microsatellite stability) cancer.

[0802] In another embodiment, the WRN inhibitor is as described herein. In particular, the WRN inhibitor is a compound having formula (I), or formula (1g) as described herein. More particularly, the WRN inhibitor is compound A:

[0803] or a pharmaceutically acceptable salt thereof.

[0804] In one embodiment, temozolomide is administered as follows:

[0805] · As a pre-treatment before administration of the WRN inhibitor, or before administration of irinotecan, or before administration of both the WRN inhibitor and irinotecan, without subsequent combination treatment including temozolomide, or

[0806] · Administered in combination, without temozolomide pre-treatment, or

[0807] · As a pre-treatment before administration of the WRN inhibitor, or before administration of irinotecan, or before administration of both the WRN inhibitor and irinotecan, followed by combination treatment including temozolomide.

[0808] In yet another aspect, a combination of a WRN inhibitor and the following is provided:

[0809] i. An agent that can

[0810] o Sensitize cancer cells, e.g., for improving the response to WRN inhibitor treatment,

[0811] o Prime cancer cells, e.g., such priming can include triggering a highly mutagenic state in the cancer cells,

[0812] o Generate or increase MMR deficiency in cancer cells,

[0813] o Generate or increase the MSI-H state in cancer cells, or

[0814] o Increase the MMR heterogeneity of cancer cells,

[0815] and optionally:

[0816] ii. Chemotherapy, such as irinotecan.

[0817] In yet another aspect, there is provided a method of treating cancer, particularly microsatellite stable (MSS) cancer, in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of the following components, which are:

[0818] i. An agent that can

[0819] o Sensitize cancer cells, e.g., for improving the response to WRN inhibitor treatment,

[0820] o Prime cancer cells, e.g., such priming can include triggering a highly mutagenic state in the cancer cells,

[0821] o Generate or increase MMR deficiency in cancer cells,

[0822] o Generate or increase the MSI-H state in cancer cells, or

[0823] o Increase the MMR heterogeneity of cancer cells,

[0824] and optionally:

[0825] ii. Chemotherapy, such as irinotecan.

[0826] In another embodiment, there is provided temozolomide for use as described in any of the embodiments herein, or a WRN inhibitor for use, or irinotecan for use, wherein temozolomide is administered in repeated doses, e.g., in 2, 3 or more repeated doses.

[0827] In yet another aspect, there is provided a pharmaceutical composition comprising a combination of: a WRN inhibitor (e.g., a compound having formula (I), (1g), compound A or compound B or a pharmaceutically acceptable salt thereof) and agent i. as defined herein and optionally ii. chemotherapy (e.g., irinotecan) according to the combinations described herein, and one or more pharmaceutically acceptable carriers.

[0828] In particular, there is provided a pharmaceutical composition comprising a combination of: a WRN inhibitor (e.g., a compound having formula (I), (1g), compound A or compound B or a pharmaceutically acceptable salt thereof) and agent i. (temozolomide), and optionally ii. chemotherapy (especially irinotecan).

[0829] In one aspect, there is provided a method of treating cancer in a subject in need thereof, wherein the subject has a microsatellite stable (MSS) cancer, the method comprising administering to the subject a therapeutically effective amount of

[0830] a) temozolomide; and

[0831] b) or a pharmaceutically acceptable salt thereof,

[0832] and optionally,

[0833] c) irinotecan.

[0834] In an embodiment, temozolomide is administered in an amount sufficient to change the status of the subject's MSS cancer to, for example, dMMR or MSI-H cancer (especially MSI-H cancer). In a further embodiment, the status of the subject's MSS and MSI-H cancer is determined by an FDA-approved test.

[0835] In another embodiment, temozolomide is administered in an amount sufficient to:

[0836] o sensitize cancer cells, e.g., for improving the response to WRN inhibitor treatment,

[0837] o prime cancer cells, e.g., such priming can include triggering a hypermutable state in the cancer cells,

[0838] o produce or increase MMR deficiency in the cancer cells,

[0839] o produce or increase the MSI-H status in the cancer cells, or

[0840] o increase MMR heterogeneity in the cancer cells.

[0841] In another aspect, there is provided a method of treating cancer in a subject in need thereof, wherein the subject has a microsatellite stable (MSS) cancer, and wherein there is administered to the patient:

[0842] a) an agent that:

[0843] o sensitizes cancer cells, e.g., for improving the response to WRN inhibitor treatment,

[0844] o primes cancer cells, e.g., such priming can include triggering a hypermutable state in the cancer cells,

[0845] o creates or increases MMR deficiency in the cancer cells,

[0846] o creates or increases an MSI-H state in the cancer cells, or

[0847] o increases MMR heterogeneity in the cancer cells,

[0848] (e.g., as determined according to tests taught in the art, or commercially available tests, or FDA-approved tests, e.g., the agent can be selected from temozolomide, cisplatin, and 6-thioguanine, or the agent is an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals)

[0849] and

[0850] b) or a pharmaceutically acceptable salt thereof,

[0851] and optionally,

[0852] c) irinotecan.

[0853] In an embodiment, the status of the subject's MSS and MSI-H cancer is determined by an FDA-approved test.

[0854] In another embodiment, the agent in a) is administered in an amount sufficient to cause the effects described in a).

[0855] In another embodiment, a WRN inhibitor is administered to a patient who has been treated with agent a), and the effects described in a) are confirmed according to the tests described above.

[0856] Definition

[0857] “MGMT” means 6 -methylguanine DNA methyltransferase.

[0858] "MGMT" refers to the gene encoding MGMT. The MGMT gene encodes a repair protein (MGMT; previously also known as alkylguanine alkyltransferase), which removes DNA alkylation modifications from DNA. Alkylating chemotherapeutic agents (such as TMZ (temozolomide)) induce cytotoxic cell death of tumor cells by alkylating DNA at multiple sites. Repair of the most toxic event (alkylation of the guanine O 6 group) depends on MGMT.

[0859] Unless otherwise indicated herein or clearly contradicted by the context, in the context of describing the present invention (especially in the context of the claims below), the terms "a and an" and "the" and similar indicators shall be construed to include both the singular and the plural. When the plural form is used for compounds, patients, cancers, etc., this also means a single compound, patient, etc.

[0860] References to "the present invention" in this specification are intended to reflect embodiments of several inventions disclosed in this specification and should not be regarded as an undue limitation on the claimed subject matter.

[0861] As used herein, the term "Compound A" refers to the compounds of Example 42 and Example 123 as described in WO 2022 / 249060:

[0862]

[0863] As used herein, the term "Compound B" refers to the compound of Example 58 as described in WO 2022 / 249060:

[0864]

[0865] The WRN inhibitors for use in accordance with the present invention as described herein may alternatively be selected from the compounds disclosed in WO 2023 / 062575 or WO 2019 / 241802.

[0866] "Combination" refers to a fixed combination in the form of a single dosage unit, or combination administration, e.g., wherein a WRN inhibitor (e.g., a compound having formula (I) or (Ig) or a pharmaceutically acceptable salt thereof) and a combination partner (e.g., another drug as explained herein, also referred to as a "therapeutic agent" or "co-agent") can be administered independently at the same time or separately at time intervals, especially where these time intervals allow the combination partner to exhibit a cooperative (e.g., synergistic) effect. The combination partner of a WRN inhibitor (e.g., a compound having formula (I) or (Ig)) can also be, for example, an agent that can sensitize cancer cells to treatment or trigger cancer cells for treatment, e.g., for improving the response to WRN inhibitor treatment. Thus, the combination partner can be used, for example, for

[0867] · sensitizing cancer cells, e.g., for improving the response to WRN inhibitor treatment,

[0868] · triggering cancer cells, e.g., such triggering can include triggering a highly mutagenic state in the cancer cells,

[0869] · generating or increasing MMR deficiency in cancer cells,

[0870] · generating or increasing the MSI-H state in cancer cells,

[0871] · increasing MMR heterogeneity in cancer cells, and / or

[0872] · generating resistance to temozolomide in cancer cells or increasing the resistance of cancer cells to temozolomide.

[0873] The individual components can be packaged in a kit or separately. One or both components (e.g., powder or liquid) can be reconstituted or diluted to the desired dose before administration. As used herein, the terms "co-administer" or "combination administration" etc. are meant to encompass the administration of the selected combination partner to a single subject in need (e.g., a patient), and are intended to include treatment regimens wherein the agents are not necessarily administered by the same route of administration or simultaneously. As used herein, the term "drug combination" means a product resulting from the mixing or combination of more than one therapeutic agent, and includes both fixed and non-fixed combinations of therapeutic agents. The term "fixed combination" means that the therapeutic agents (e.g., the combination partner of the present invention) are administered to a patient simultaneously in the form of a single entity or dose. The term "non-fixed combination" means that the therapeutic agents (e.g., the combination partner of the present invention) are administered to a patient simultaneously, in parallel, or sequentially as separate entities (without a specific time limit), wherein such administration provides a therapeutically effective level of the two compounds in the patient, or one agent provides a sensitizing or triggering effect before or during the treatment with the combination partner. This also applies to cocktail therapies, e.g., the administration of three or more therapeutic agents.

[0874] In the combination therapies of the present invention, the therapeutic agents can be manufactured and / or formulated by the same or different manufacturers. Additionally, the therapeutic agents can be combined to form a combination therapy: (i) before the release of the combination product to a physician (e.g., in the case of a kit containing the therapeutic agents); (ii) shortly before administration, by the physician himself (or under the physician's guidance); (iii) in the patient himself, e.g., during the sequential administration of the therapeutic agents.

[0875] ‘Pre-treatment’ means separate administration before the administration of certain other active compounds, particularly WRN inhibitors. For example, pre-treatment can sensitize or prime cancer cells so that the cancer cells respond better or are more sensitive to one or more active compounds administered subsequently. Pre-treatment can be used, for example, to increase MMR deficiency, or can be used to increase the resistance of cancer cells to the pre-treatment agent. Pre-treatment can be used to generate or increase the MSI-H state in cancer cells, generate or increase MMR deficiency in cancer cells, or increase the MMR heterogeneity of cancer cells. Temozolomide can be used herein as a pre-treatment agent to sensitize cancer cells to subsequent treatment or prime cancer cells for subsequent treatment, particularly subsequent WRN inhibitor treatment. It should be recognized that such effects may also occur when an agent (e.g., temozolomide) is used directly in combination with a WRN inhibitor without prior pre-treatment administration. The effects of such pre-treatment can be determined according to tests taught in the art, or commercially available tests, or FDA-approved tests. The pre-treatment can be, for example, the use of an agent selected from temozolomide, cisplatin, and 6-thioguanine, or the agent can be an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals.

[0876] As used herein, the term "synergistic effect" refers to the action of two or three therapeutic agents that produces an effect, such as slowing the progression of a proliferative disease (particularly cancer or its symptoms), that is greater than the simple sum of the effects of each of the drugs administered alone. The synergistic effect can be calculated, for example, using suitable methods such as the Sigmoid-Emax equation (Holford, N.H.G. and Scheiner, L.B., Clin. Pharmacokinet. [Clinical Pharmacokinetics] 6:429-453 (1981)), the Loewe additivity equation (Loewe, S. and Muischnek, H., Arch. Exp. Pathol Pharmacol. [Archives of Experimental Pathology and Pharmacology] 114:313-326 (1926)), and the median-effect equation (Chou, T.C. and Talalay, P., Adv. Enzyme Regul. [Advances in Enzyme Regulation] 22:27-55 (1984)). Each of the equations mentioned above can be applied to experimental data to generate corresponding graphs to assist in evaluating the effect of the drug combination. The corresponding graphs related to the equations mentioned above are the concentration-effect curve, the isobologram curve, and the combination index curve, respectively.

[0877] The term "pharmaceutically acceptable salt" refers to salts that retain the biological effectiveness and properties of the compound and are typically not undesirable in a biological or other respect. Due to the presence of an amino group, the compound may be capable of forming acid addition salts.

[0878] Unless otherwise stated or clearly indicated in the text, reference to a therapeutic agent useful in the pharmaceutical combinations of the present invention includes the free base of the compound and all pharmaceutically acceptable salts of the compound.

[0879] The term "combination" or "pharmaceutical combination" is defined herein to mean a fixed combination in the form of a single dosage unit, a non-fixed combination for combined administration, or a kit of parts, wherein the therapeutic agents can be administered together simultaneously, independently, or separately at intervals of time, which preferably allows the combination partners to exhibit cooperation, such as a synergistic effect. Thus, the individual compounds of the pharmaceutical combinations of the present invention can be administered simultaneously or sequentially. In addition, the pharmaceutical combinations of the present invention can be in the form of a fixed combination or a non-fixed combination.

[0880] The term "fixed combination" means that the therapeutic agents (such as the individual compounds in the combination) are in the form of a single entity or dosage form.

[0881] The term "non-fixed combination" means that therapeutic agents (e.g., individual compounds in a combination) are administered to a patient simultaneously or sequentially as separate entities or dosage forms, without a specific time limit, where preferably, such administration provides a therapeutically effective level of two therapeutic agents in the body of a subject such as a mammalian or human in need thereof.

[0882] The pharmaceutical combination may further comprise at least one pharmaceutically acceptable carrier. Accordingly, the present invention relates to a pharmaceutical composition comprising the pharmaceutical combination of the present invention and at least one pharmaceutically acceptable carrier.

[0883] As used herein, the term "carrier" or "pharmaceutically acceptable carrier" includes any and all solvents, dispersion media, coatings, surfactants, antioxidants, preservatives (e.g., antibacterial, antifungal agents), isotonic agents, absorption delaying agents, salts, preservatives, drug stabilizers, binders, excipients, disintegrants, lubricants, sweetening agents, flavoring agents, dyes, and the like, and combinations thereof, as would be known to one of ordinary skill in the art (see, e.g., Remington's Pharmaceutical Sciences, 18th Edition, Mack Printing Company, 1990, pp. 1289-1329). Except in cases where any conventional carrier is incompatible with the active ingredient, its use in a therapeutic or pharmaceutical composition is contemplated.

[0884] The phrase "pharmaceutically acceptable" as used herein refers to those compounds, materials, compositions, and / or dosage forms that, within the scope of sound medical judgment, are suitable for use in contact with the tissues of humans and animals without excessive toxicity, irritation, allergic response, or other problems or complications, commensurate with a reasonable benefit / risk ratio.

[0885] Generally, the term "pharmaceutical composition" is defined herein to mean a mixture or solution containing at least one therapeutic agent to be administered to a subject (e.g., a mammal or a human). The pharmaceutical combinations of the present invention can be formulated into pharmaceutical compositions suitable for enteral or parenteral administration, such as those in unit dosage forms, such as dragees, tablets, capsules or suppositories or ampoules. If not otherwise indicated, these are prepared in a manner known per se, for example by means of various conventional mixing, comminuting, direct compression, granulating, sugar coating, dissolving, freeze-drying methods or manufacturing techniques obvious to a person skilled in the art. It should be understood that the unit content of the combination partners contained in the individual doses of each dosage form need not itself constitute an effective amount, since the required effective amount can be achieved by administering multiple dosage units. The pharmaceutical composition can contain from about 0.1% to about 99.9%, preferably from about 1% to about 60% of one or more therapeutic agents. A person skilled in the art can select one or more of the aforementioned carriers by routine experiments without any undue burden with respect to the particular required properties of the dosage form. The amount of each carrier used can vary within the conventional range in the art. The following references disclose techniques and excipients for formulating oral dosage forms. See The Handbook of Pharmaceutical Excipients, 4th Edition, edited by Rowe et al., American Pharmaceuticals Association (2003); and Remington: the Science and Practice of Pharmacy, 20th Edition, edited by Gennaro, Lippincott Williams & Wilkins (2003). These optional additional conventional carriers can be incorporated into the oral dosage form by incorporating one or more conventional carriers into the initial mixture before or during granulation, or by combining one or more conventional carriers with granules of the medicament or the individual medicaments comprising the medicament combination in the oral dosage form. In the latter embodiment, the combined mixture can be further blended, for example, by a V-type blender and then compressed or molded into tablets (e.g., monolithic tablets), encapsulated in capsules, or filled into sachets. Obviously, the pharmaceutical combinations of the present invention can be used for manufacturing medicaments.

[0886] The present invention relates to such pharmaceutical combinations or pharmaceutical compositions, particularly for use as medicaments.

[0887] Specifically, the combinations or compositions of the present invention can be applied to the treatment of cancer.

[0888] The present invention also relates to the use of the pharmaceutical combination or pharmaceutical composition of the present invention for the preparation of a medicament for treating cancer, and to a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of the pharmaceutical combination according to the present invention or the pharmaceutical composition according to the present invention.

[0889] As used herein, the term "treatment" includes treatment that alleviates, reduces or mitigates at least one symptom in a subject, increases progression-free survival, overall survival, prolongs the duration of response or delays disease progression. For example, treatment can be weakening one or several symptoms of a disorder or completely eradicating a disorder (such as cancer). Within the meaning of the present invention, the term "treatment" also means preventing, delaying the onset of a disease (i.e., the period of time before the clinical manifestation of the disease) and / or reducing the risk of disease development or deterioration in a patient (such as a mammal, particularly a human patient). As used herein, the term "treatment" includes the inhibition of tumor growth, which includes the direct inhibition of primary tumor growth and / or the systemic inhibition of metastatic cancer cells.

[0890] "Subject", "individual" or "patient" are used interchangeably herein and refer to vertebrates, preferably mammals, more preferably humans. Mammals include but are not limited to mice, apes, humans, farm animals, game animals and pets.

[0891] The "therapeutically effective amount" of a compound (such as a chemical entity or biopharmaceutical) of the present invention means an amount of the compound of the present invention that will elicit a biological or medical response in a subject (such as a decrease or inhibition of enzyme or protein activity), or improve symptoms, relieve the condition, slow or delay disease progression, or prevent a disease, etc. In one embodiment, the therapeutically effective amount in vivo can range between about 0.1 - 500 mg / kg, or between about 1 - 100 mg / kg, depending on the route of administration.

[0892] As used herein, the term "inhibit (inhibit, inhibition or inhibiting)" means reducing or inhibiting a given condition, symptom or disorder, or disease, or a significant decrease in the baseline activity of a biological activity or process.

[0893] As used herein, the term "therapeutically effective agent" is intended to be construed broadly and includes both pharmaceutical molecules and ionizing radiation-based therapies. Ionizing radiation-based therapies can be provided in any suitable form known in the art, such as in the form of external beam radiation therapy, brachytherapy, or via radiopharmaceuticals (e.g., radioligand agents). External beam radiation therapy refers to radiation targeting a tumor from an external radiation source. The term "brachytherapy" refers to a form of radiotherapy in which a radiation source is positioned at the tumor site, enabling the administration of a high dose of local radiation to that tumor site. Radiopharmaceuticals are discussed in more detail below.

[0894] The optimal dose of each combination partner for treating cancer can be determined empirically for each individual using known methods and will depend on a variety of factors, including but not limited to: the extent of the disease; the age, weight, general health, sex, and diet of the individual; the time and route of administration; and other drugs the individual is taking. Conventional tests and procedures well known in the art can be used to determine the optimal dose. The amount of each combination partner that can be combined with a carrier material to produce a single dosage form will vary depending on the individual being treated and the particular mode of administration. In some embodiments, a unit dosage form containing a combination of agents as described herein will contain an amount of each agent in the combination that is typically administered when the agent is administered alone.

[0895] The frequency of dosing can vary depending on the compound used and the particular condition being treated or prevented. Generally, it is preferred to use the minimum dose sufficient to provide an effective therapy. Typically, assays suitable for the condition being treated or prevented can be used to monitor the therapeutic effectiveness of the patient, and these assays will be familiar to those of ordinary skill in the art.

[0896] The combinations of the present invention can, for example, be in unit dosage forms having about 1 - 1000 mg of each active ingredient for a subject of about 50 - 70 kg.

[0897] ‘zwitterion’ or ‘zwitterionic form’ means a compound containing both positively and negatively charged functional groups.

[0898] For example, a compound having formula (I) as described herein can include the following forms, where R4 is in zwitterionic form (c) or non-zwitterionic form (d),

[0899] or a mixture thereof.

[0900] A compound having formula (I) as described herein can also include the following forms, where R4 is in zwitterionic form (a) or (b) or non-zwitterionic form (e),

[0901] or

[0902] or a mixture of the two, or a mixture of all three of them.

[0903] ‘Compound having formula (I)’ includes zwitterionic and non-zwitterionic forms and mixtures thereof.

[0904] Halo means fluoro, chloro or bromo, particularly fluoro or chloro.

[0905] Alkyl and alkoxy groups containing the required number of carbon atoms can be straight-chain or branched-chain. Examples of alkyl include, but are not limited to, methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl and tert-butyl. Examples of alkoxy include methoxy, ethoxy, n-propoxy, isopropoxy, n-butoxy, isobutoxy, sec-butoxy and tert-butoxy.

[0906] ‘=O’ means an oxo substituent.

[0907] When R1 is a substituted or unsubstituted cycloalkenyl, said cycloalkenyl includes, but is not limited to, cyclohexenyl, particularly groups such as cyclohex-1-en-1-yl, etc.

[0908] When R1 is a substituted or unsubstituted heterocyclic group, said heterocyclic group includes, but is not limited to, morpholinyl, piperidinyl, pyrrolidinyl, 6-oxa-3-azabicyclo[3.1.1]heptan-3-yl, 5,6-dihydro-1,4-dioxin-2-yl, dihydropyranyl (particularly 3,4-dihydro-2H-pyran-6-yl, 5,6-dihydro-2H-pyran-3-yl and 3,6-dihydro-2H-pyran-4-yl), piperazinyl, tetrahydropyridyl (such as 1,4,5,6-tetrahydropyridin-3-yl and 1,2,3,6-tetrahydropyridin-4-yl) and dihydropyridyl (such as 3,6-dihydropyridyl) and other groups.

[0909] When R1 is a substituted or unsubstituted heteroaryl, said heteroaryl includes, but is not limited to, pyridyl, particularly groups such as pyridin-3-yl, etc.

[0910] The term “cancer” refers to a disease characterized by the rapid and uncontrolled growth of abnormal cells. Cancer cells can spread locally or through the bloodstream and lymphatic system to other parts of the body. Examples of various cancers are described herein and include, but are not limited to, colorectal cancer, gastric cancer, endometrial cancer, prostate cancer, adrenocortical cancer, uterine cancer, cervical cancer, esophageal cancer, breast cancer, kidney cancer, ovarian cancer, etc.

[0911] The terms “tumor” and “cancer” are used interchangeably herein. For example, both terms include solids and liquids, such as disseminated or circulating tumors. As used herein, the term “cancer” or “tumor” includes pre-malignant as well as malignant cancers and tumors.

[0912] As used herein, "WRN inhibitor" or "WRN helicase inhibitor" means a compound or therapeutic agent that inhibits Werner syndrome RecQ DNA helicase (WRN). As used herein, the term "WRN" refers to the protein of Werner syndrome RecQ DNA helicase. The term "WRN" includes mutants, fragments, variants, isoforms, and homologs of full-length wild-type WRN. In one embodiment, the protein is encoded by the WRN gene (Entrez Gene ID 7486; Ensembl ID ENSG00000165392). Exemplary WRN sequences can be obtained in the Uniprot database under accession number Q14191.

[0913] "WRN-mediated disease or disorder" includes diseases or disorders that are treated by WRN inhibition, such as cancer. In particular, this can include cancers characterized by high microsatellite instability (MSI-H) or defective mismatch repair (dMMR).

[0914] "Microsatellite instability cancer", "high microsatellite instability cancer", "high microsatellite cancer", "high MSI cancer", "MSI hi ", and "MSI-H" are used interchangeably herein and describe cancers with a high number of alterations in the length of simple repetitive genomic sequences within microsatellites.

[0915] The MSI-H or dMMR tumor status of a patient can be determined using, for example, a polymerase chain reaction (PCR) assay for MSI-H status or an immunohistochemistry (IHC) assay for dMMR. Methods for differentiating MSI-H or dMMR tumor status are described, for example, in Ryan et al. Crit Rev Oncol Hematol. [Critical Reviews in Oncology / Hematology] 2017;116:38-57; Dietmaier and Hofstadter. Lab Invest [Laboratory Investigation] 2001, 81:1453-1456; and Kawakami et al. Curr Treat Options Oncol. [Current Treatment Options in Oncology] 2015;16(7):30.

[0916] "MSS" means microsatellite stability. After a negative result of an MSI-H status test, the cancer is considered to have an MSS status. Accordingly, in embodiments, the methods or uses disclosed herein can further include administering an MSI-H status test to a patient. In some embodiments, the MSI-H status test is an FDA-approved test, such as, for example, FoundationOne CDx.

[0917] "pMMR" means proficient mismatch repair.

[0918] “pMMR / MSS” means “MSS cancer” or “pMMR cancer”. Cancer cells of MSS are intact for MMR (pMMR), so the terms “MSS cancer” or “pMMR cancer” can be used separately and interchangeably.

[0919] Microsatellite instability exists in a variety of cancers, including but not limited to, particularly in colorectal cancer, gastric cancer, and endometrial cancer, and is also seen in adrenocortical carcinoma, uterine cancer, cervical cancer, esophageal cancer, breast cancer, kidney cancer, prostate cancer, and ovarian cancer. Examples of highly microsatellite cancers include endometrial carcinoma of the uterine corpus, colonic adenocarcinoma, gastric adenocarcinoma, rectal adenocarcinoma, adrenocortical carcinoma, uterine carcinosarcoma, cervical squamous cell carcinoma, cervical adenocarcinoma, esophageal cancer, breast cancer, renal clear cell carcinoma, and ovarian serous cystadenocarcinoma.

[0920] Cancers with “deficient mismatch repair” (dMMR) or “dMMR signature” include cancer types associated with documented MLH1, PMS2, MSH2, MSH3, MSH6, MLH3, and PMS1 mutations or epigenetic silencing, microsatellite fragile sites, or other gene inactivation mechanisms, including but not limited to lung cancer, breast cancer, kidney cancer, colorectal cancer, ovarian cancer, prostate cancer, upper respiratory and digestive tract cancer, gastric cancer, endometrial cancer, liver cancer, pancreatic cancer, hematopoietic and lymphoid tissue cancer, skin cancer, thyroid cancer, pleural cancer, autonomic ganglion cancer, central nervous system cancer, soft tissue cancer, pediatric rhabdoid sarcoma, melanoma, and other cancers. Cells or cancers with “deficient” mismatch repair have a significantly reduced (e.g., at least about 25%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% reduction) amount of mismatch repair. In some cases, cells or cancers with deficient mismatch repair will not perform mismatch repair.

[0921] As described herein, WRN inhibitors can be used in combination with at least one therapeutic agent, and the therapeutic agent can be used in one or more of the following ways to:

[0922] · Sensitize cancer cells, e.g., for improving the response to WRN inhibitor treatment,

[0923] · Prime cancer cells, e.g., such priming can include triggering a highly mutagenic state in cancer cells,

[0924] · Generate or increase MMR deficiency in cancer cells,

[0925] · Generate or increase the MSI-H state in cancer cells,

[0926] · Increase the MMR heterogeneity of cancer cells, and / or

[0927] ·Generate resistance to temozolomide in cancer cells or enhance the resistance of cancer cells to temozolomide.

[0928] These effects can be determined according to tests taught in the art, or commercially available tests, or FDA-approved tests. Such agents are known in the art. The therapeutic agent can be an alkylating agent, such as temozolomide. The therapeutic agent can also be cisplatin or 6-thioguanine. The therapeutic agent can also be a therapy based on ionizing radiation, which is selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, as described herein.

[0929] References:

[0930] Cell 177, 821 - 836, May 2, 2019,

[0931] Journal of Clinical Oncology 40, No. 14 (May 10, 2022) 1562 - 1573 DOI: 10.1200 / JCO.21.02583,

[0932] Biochemical Pharmacology, Volume 54, Pages 419 - 424, 1997,

[0933] Nat Genet. July 2021; 53(7): 1088 - 1096. doi: 10.1038 / s41588 - 021 - 00874 - 3.

[0934] Germano, G., Lamba, S., Rospo, G. et al. Inactivation of DNA repair triggers neoantigen generation and impairs tumour growth. Nature 552, 116 - 120 (2017), https: / / doi.org / 10.1038 / nature24673

[0935] Cancer Discov 2022; 12: 1656 - 75 doi: 10.1158 / 2159 - 8290.CD - 21 - 1434

[0936] Initiation with temozolomide can be carried out in patients with MSS cancer, or in patients with MGMT-deficient tumors, or MGMT-deficient tumors, or MGMT-silent tumors. Such initiation can be carried out in patients with pMMR / MSS MGMT-deficient tumors, or pMMR / MSS MGMT-deficient tumors, or pMMR / MSS MGMT-silent tumors. In one example, the tumor is MGMT-deficient, or MGMT-deficient, or MGMT-silent CRC. In particular, the tumor is pMMR / MSS and MGMT-silent mCRC. On the other hand, the tumor is MGMT-methylated glioblastoma.

[0937] Assessment of the MGMT tumor status can be carried out, for example, by protein expression promoter methylation, as described in the following references (which are hereby incorporated by reference in their entirety), or also by MGMT gene mutations. The following references summarize the methods for assessing the MGMT status: Mansouri A, Hachem LD, Mansouri S et al. MGMT promoter methylation status testing to guide therapy for glioblastoma: refining the approach based on emerging evidence and current challenges [MGMT promoter methylation status testing to guide therapy for glioblastoma: refining the approach based on emerging evidence and current challenges]. Neuro Oncol. [Neuro-Oncology] 2019;21(2):167-178. doi:10.1093 / neuonc / noy132.

[0938] References:

[0939] Cancer Discov [Cancer Discovery] 2022;12:1656-75, doi:10.1158 / 2159-8290.CD-21-1434,

[0940] Amodio et al., 2023, Cancer Cell [Cancer Cell] 41, 196-209, https: / / doi.org / 10.1016 / j.ccell.2022.12.003,

[0941] J Clin Oncol [Journal of Clinical Oncology] 40:1562-1573, http: / / ascopubs.org / doi / full / 10.1200 / JCO.21.02583,

[0942] Nature 552, 7 December 2017, http: / / www.nature.com / doifinder / 10.1038 / nature24673.

[0943] In alternative aspects, other alkylating agents can be used in place of temozolomide, for example as a pre-treatment agent or initiator, or for the purpose of:

[0944] · generating or increasing MMR deficiency in cancer cells,

[0945] · generating or increasing the MSI-H state in cancer cells.

[0946] Accordingly, an alkylating agent for use in the embodiments described herein in place of temozolomide is also provided. The treatment is optionally combined with irinotecan.

[0947] In another aspect, a WRN inhibitor is used in combination with cisplatin (in place of temozolomide), which is used, for example, as a pre-treatment agent or initiator, or for the purpose of:

[0948] · generating or increasing MMR deficiency in cancer cells,

[0949] · generating or increasing the MSI-H state in cancer cells.

[0950] The treatment is optionally further combined with irinotecan.

[0951] In another aspect, a WRN inhibitor is used in combination with a therapy based on ionizing radiation, which is used, for example, as a pre-treatment agent or initiator, or for the purpose of:

[0952] · generating or increasing MMR deficiency in cancer cells,

[0953] · generating or increasing the MSI-H state in cancer cells.

[0954] The treatment is optionally further combined with irinotecan.

[0955] In another aspect, in the context described herein, a WRN inhibitor is used in combination with 6-thioguanine (in place of temozolomide), which is used, for example, as a pre-treatment agent or initiator, or for the purpose of:

[0956] · generating or increasing MMR deficiency in cancer cells,

[0957] · generating or increasing the MSI-H state in cancer cells.

[0958] The treatment is optionally further combined with irinotecan.

[0959] ‘Capable of being connected’ means being connected or not being connected.

[0960] ‘Capable of being deuterium-substituted’ means being deuterium-substituted or not being deuterium-substituted.

[0961] As used herein, in certain embodiments, the term “chemotherapeutic agent” or, interchangeably, “chemotherapy agent” refers to cytotoxic drugs. Examples include alkylating agents, anthracyclines, antimetabolites, intercalating agents (such as doxorubicin or epirubicin), and topoisomerase inhibitors. In an embodiment, the chemotherapeutic agent is selected from vinblastine, vindesine, vinorelbine, vincristine, anastrozole bicalutamide bleomycin (e.g., bleomycin sulfate) busulfan busulfan injection calactin, capecitabine N4-pentyloxycarbonyl-5-deoxy-5-fluorocytidine, carboplatin carmustine lomustine chlorambucil bendamustine cisplatin cladribine cyclophosphamide ( or )、cytarabine, cytosine arabinoside liposomal cytarabine injection dacarbazine actinomycin D (Cosmegan), daunorubicin hydrochloride liposomal daunorubicin citrate injection dexamethasone, docetaxel doxorubicin (e.g., doxorubicin hydrochloride) etoposide fludarabine phosphate 5-fluorouracil flutamide tiazofurin, gemcitabine (difluorodeoxycytidine), hydroxyurea idarubicin ifosfamide irinotecan L-asparaginase calcium folinate, melphalan 6-mercaptopurine methotrexate mitomycin (e.g., mitomycin A, mitomycin B, or mitomycin C, especially mitomycin C), mitoxantrone gemtuzumab, paclitaxel Yttrium 90 / MX-DTPA, pentostatin, polylactic-polyglycolic acid copolymer with carmustine implant Tamoxifen citrate Camptothecin, teniposide 6-Thioguanine, thiotepa, tirapazamine Topotecan hydrochloride for injection Vinblastine Vincristine Oxaliplatin Epirubicin Temozolomide Tegafur, gimeracil and vinorelbine Especially irinotecan.

[0962] In the examples, the chemotherapeutic agent is selected from gemcitabine, camptothecin, irinotecan Docetaxel Doxorubicin (e.g., doxorubicin hydrochloride) 5-Fluorouracil Capecitabine Etoposide Epirubicin Oxaliplatin Mitomycin (e.g., mitomycin A, mitomycin B or mitomycin C, especially mitomycin C), cisplatin Carboplatin And paclitaxel

[0963] In the examples, the chemotherapeutic agent is an alkylating agent, such as an alkylating agent selected from cyclophosphamide, ifosfamide, melphalan, chlorambucil and bendamustine.

[0964] In the examples, the chemotherapeutic agent is a topoisomerase inhibitor, such as QAP1, irinotecan, topotecan, camptothecin and etoposide.

[0965] In the examples, the chemotherapeutic agent is a DNA alkylating agent, such as cisplatin, carboplatin or oxaliplatin.

[0966] In the examples, the chemotherapeutic agent is an antimetabolite, such as 5-fluorouracil or tegafur (a prodrug of 5-fluorouracil).

[0967] In the examples, the chemotherapeutic agent is a microtubule polymer stabilizer, such as docetaxel or paclitaxel.

[0968] In the examples, the chemotherapeutic agent is an anti-tumor agent, such as mitomycin (e.g., mitomycin C).

[0969] In an embodiment, the chemotherapeutic agent is an intercalator (e.g., doxorubicin or epirubicin).

[0970] In an embodiment, the chemotherapeutic agent is a vinca alkaloid, such as vinblastine, vindesine, vinorelbine or vincristine.

[0971] In an embodiment, where the chemotherapeutic agent is tegafur, the tegafur is administered in the form of TS-1 (also known as teysuno and S-1), which is a combination of tegafur, gimeracil and oteracil.

[0972] In an embodiment, the PD-1 inhibitor is an anti-PD-1 antibody. In an embodiment, the PD-1 inhibitor is selected from the group consisting of PDR001 (Novartis AG), nivolumab (Bristol-Myers Squibb Company), pembrolizumab (Merck & Co., Inc.), pidilizumab (Therapeutic Technology, Inc.), MEDI0680 (MedImmune Limited), cemiplimab (REGN2810, Regeneron Pharmaceuticals, Inc.), dostarlimab (TSR-042, Tesaro, Inc.), PF-06801591 (Pfizer Inc.), tislelizumab (BGB-A317, BeiGene, Ltd.), BGB-108 (BeiGene, Ltd.), INCSHR1210 (Incyte Corporation), balstilimab (AGEN2035, Agenus Inc.), sintilimab (Innovent Biologics, Inc.), toripalimab (Shanghai Junshi Biosciences Co., Ltd.), camrelizumab (Jiangsu Hengrui Medicine Co., Ltd.), and AMP-224 (Amplimmune, Inc.), particularly PDR001 or tislelizumab.

[0973] In an embodiment of any aspect of the various aspects of the present invention, when an MDM2 inhibitor is present, the MDM2 inhibitor is selected from the group consisting of nutlin-3a, idasanutlin (also known as RG7388), RG7112, AMG-232 (also known as KRT-232), APG-115, BI-907828, milademetan and HDM201 (also known as siramesine), or a pharmaceutically acceptable salt thereof.

[0974] In an embodiment of any aspect of the various aspects of the present invention, when a MEK inhibitor is present, the MEK inhibitor is selected from the group consisting of refametinib, pimasertib, selumetinib, trametinib, binimetinib and cobimetinib or a pharmaceutically acceptable salt thereof.

[0975] In an embodiment of any aspect of the various aspects of the present invention, when a MEK inhibitor is present, the MEK inhibitor can be trametinib or a pharmaceutically acceptable salt thereof.

[0976] In embodiments of any one of the various aspects of the present invention, when a WEE1 inhibitor is present, the WEE1 inhibitor may be selected from adavosertib (also known as AZD1775 and MK-1775) and PDO166285. In an embodiment, the WEE1 inhibitor is adavosertib.

[0977] In embodiments of any one of the various aspects of the present invention, when an ATR inhibitor is present, the ATR inhibitor may be selected from RP-3500, ceralasertib (also known as AZD6738), bezosertib, ART-0380, gatisertib (also known as M4344), and elisertib (BAY-1895344). In an embodiment, the ATR inhibitor is elisertib (BAY-1895344).

[0978] In embodiments of any one of the various aspects of the present invention, when a DNA-PK inhibitor is present, the DNA-PK inhibitor may be selected from AZD-7648, NU7441 (also known as KU-57788), omidubicel, BAY8400, and M3814. In an embodiment, the DNA-PK inhibitor is AZD-7648 or NU7441 (KU-57788), particularly AZD-7648.

[0979] In embodiments of any one of the various aspects of the present invention, when a G4-quadruplex stabilizer is present, the G4-quadruplex stabilizer may be selected from 5ME, Ant1,5, BRAC019, C8, C14, c-exNDI, CORON, CX-3543 (also known as Quarfloxin), EMICORON, IZCZ-0, IZCZ-3, IZTC-1, N,N'-bis(3,4-dihydroxybenzylidene)-1,2-diaminobenzene, PhenDC3, phenyl 1,2,3-triazole-thymidine ligand, pyridostatin, RHPS4, TMPyP4, and trans-resveratrol (tRES). In an embodiment, the G4-quadruplex stabilizer is preferably pyridostatin.

[0980] In embodiments of any one of the various aspects of the present invention, when an ATM inhibitor is present, the ATM inhibitor may be selected from KU-55933, KU-60019, KU-59403, M3541, CP-466722, AZ31, AZ32, AZD0156, and AZD1390. In an embodiment, the ATM inhibitor is KU-60019.

[0981] In embodiments of any aspect of the various aspects of the present invention, when a PARP inhibitor is present, the PARP inhibitor may be selected from olaparib, NMS293, niraparib, veliparib, rucaparib, prexasertib, talazoparib, AZD-5305, and KU0058948. In an embodiment, the PARP inhibitor is olaparib.

[0982] In embodiments of any aspect of the various aspects of the present invention, when a topoisomerase inhibitor is present, the topoisomerase inhibitor may be selected from QAP1, irinotecan, topotecan, camptothecin, and etoposide. In an embodiment, the topoisomerase inhibitor is selected from QAP1, etoposide, and irinotecan. In an embodiment, the topoisomerase inhibitor is a topoisomerase I inhibitor. In another embodiment, the topoisomerase inhibitor is a topoisomerase II inhibitor.

[0983] In embodiments of any aspect of the various aspects of the present invention, when a CHK1 inhibitor or a CHK2 inhibitor is present, the CHK1 inhibitor or the CHK2 inhibitor is selected from GDC-0575, prexasertib (LY2606368), SCH900776 (also known as MK-8776), SRA737, PF477736, LY2606368, and AZD7762. The CHK1 inhibitor or the CHK2 inhibitor may be a CHK1 / 2 dual inhibitor (such as AZD7762). As used herein, "CHK1 inhibitor or CHK2 inhibitor" means an agent that is a selective inhibitor of CHK1 relative to CHK2, or a selective inhibitor of CHK2 relative to CHK1, or an agent that is an inhibitor of both CHK2 and CHK1 ('CHK1 / 2 dual inhibitor').

[0984] In embodiments of any aspect of the various aspects of the present invention, the therapeutic active agent is a PI3K inhibitor, such as a PI3K-α inhibitor. In an embodiment, the PI3K inhibitor is selected from AMG511, buparlisib, idelalisib, copanlisib, duvelisib, alpelisib, and umbralisib. In an embodiment, the PI3K inhibitor is alpelisib. In an embodiment, the therapeutic active agent is a PI3K inhibitor, such as a PI3K-α inhibitor, such as alpelisib, and the cancer is MSI-H. In an embodiment, the PI3K inhibitor is a PI3K-α inhibitor, which is selected from RLY-2608, BPI-21668, PF-06843195, LX-086, HS-10352, HH-CYH33, JS-105, MEN-1611, LOX-22783, TOS-358, STX-478, alpelisib, serabelisib, and inavolisib. In an embodiment, the PI3K-α inhibitor is selected from alpelisib, serabelisib, and inavolisib.

[0985] According to another aspect of the present invention, there is hereby provided a method of treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a polymerase θ inhibitor. In an embodiment, the polymerase θ inhibitor is ART812. In an alternative embodiment, the polymerase θ inhibitor is RP-2119 or a Polθ helicase inhibitor (Ideaya / GSK). In an embodiment, the therapeutic agent is a polymerase θ inhibitor (such as ART812) and the cancer is MSI-H cancer.

[0986] According to another aspect of the present invention, there is hereby provided a method of treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and an IAP inhibitor / SMAC mimetic. In an embodiment, the IAP inhibitor is selected from LCL161, Bininapant, and Xevinapant.

[0987] According to another aspect of the present invention, there is hereby provided a method of treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a CTLA-4 inhibitor. In an embodiment, the CTLA-4 inhibitor is ipilimumab or tremelimumab, such as ipilimumab.

[0988] According to another aspect of the present invention, there is hereby provided a method of treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a KRAS G12C inhibitor.

[0989] KRAS G12C inhibitors useful in the combinations and methods of the present invention include compounds selected from: sotorasib, adagrasib, GDC6036, D-1553, and especially JDQ443. JDQ443 is described in Example 1 of PCT application WO 2021 / 124222 (published on June 24, 2021). WO 2021 / 124222 is hereby incorporated by reference in its entirety.

[0990] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and an SHP2 inhibitor. Examples of SHP2 inhibitors that can be used in the combinations and methods of the present invention include TNO155, JAB3312 or JAB-3068 (Jacobiotech), RLY1971 (Roche), SAR442720 / RMC-4630 (Sanofi / Revolution Medicines), RMC4450 (Revolution Medicines), BBP398 (Navire), BR790 (Shanghai Blueray), SH3809 (Nanjing Sanhome), PF0724982 (Pfizer), ERAS601 (Erasca), RX-SHP2 (Redx Pharma), ICP189 (InnoCare), HBI2376 (HUYA Bioscience), ETS001 (Shanghai ETERN Biopharma), HS-10381 (Hansoh Pharma / JiangsuHansoh), BPI-442096 (Betta Pharmaceuticals), I-0436650 (IRBM), PCC-0208023 (Binzhou Medical University), IACS-15414 (Navire), and X-37-SHP2 (X-37). A particularly preferred SHP2 inhibitor for use according to the present invention is (3S,4S)-8-(6-amino-5-((2-amino-3-chloropyridin-4-yl)thio)pyrazin-2-yl)-3-methyl-2-oxa-8-azaspiro[4.5]decan-4-amine (TNO155) or a pharmaceutically acceptable salt thereof. TNO155 is synthesized according to Example 69 of WO 2015 / 107495, which patent document is hereby incorporated by reference in its entirety. A preferred salt of TNO155 is the succinate salt.

[0991] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a KRAS G12D inhibitor. Examples of KRAS G12D inhibitors that can be used in the combinations and methods of the present invention include siG12D LODER, HRS-4642, and ASP-3082.

[0992] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a YAP / TEAD inhibitor. Examples of YAP / TEAD inhibitors that can be used in the combinations and methods of the present invention include IAG933 (Novartis AG), NSC-682769 (University of California), MSC-4106 (Merck & Co., Inc.), GNE-7883 (Genentech), TED-347 (Indiana University), K-975 (Kyowa Kirin), and compounds in the following patent documents: WO 2021 / 186324, WO 2022 / 087008; WO2021 / 102204; WO 2020 / 214734; WO 2020 / 097389; WO 2019 / 222431; WO 2019 / 113236; WO2019 / 040380; WO 2018 / 204532; WO 2017 / 058716; WO 2022 / 159986; WO 2022 / 120354; WO2022 / 120355; WO 2022 / 120353; WO 2020 / 243423 or WO 2020 / 243415.

[0993] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a BCL2 inhibitor or a BCL2 / BCLxl dual inhibitor. Examples of such inhibitors that can be used in the combinations and methods of the present invention include venetoclax, APG-2575 (lisaftoclax), obatoclax mesylate, BGB-11417 (BeiGene, Ltd.), pelcitoclax, Zn-d5 (Zentalis Pharmaceuticals), AZD-0466 (Astra Zeneca), ABBV-453, ABBV-167 (AbbVie), LP-118, LP-108 (Guangzhou Lupeng), FCN-338 (Fochon Pharmaceuticals), and navitoclax.

[0994] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and an MCL1 inhibitor. Examples of MCL1 inhibitors that can be used in the combinations and methods of the present invention include AMG176 (tapotoclax), GS-9716, ABBV-467, Murizatoclax, AZD-5991, JNJ-1245, JNJ-4355, and PRT-1419 (Prelude Therapeutics).

[0995] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a CDK2 inhibitor. Examples of CDK2 inhibitors that can be used in the combinations and methods of the present invention include BLU222 (Blueprint Medicines), PF-07104091 (Pfizer), and INCB-0123667 (Incyte). Examples of CDK2 / CDK9 or CDK2 / CDK9 / CDK7 inhibitors that can be used in the combinations and methods of the present invention include fadraciclib and seliciclib.

[0996] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and a CDK4 or CDK4 / 6 inhibitor. Examples of CDK4 / 6 inhibitors that can be used in the combinations and methods of the present invention include ribociclib, palbociclib, trilaciclib, birociclib, and lero ciclib.

[0997] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and an HIF2α inhibitor. Examples of HIF2α inhibitors that can be used in the combinations and methods of the present invention include belzutifan, MK-6482, PT2385, and DFF332.

[0998] According to another aspect of the present invention, there is hereby provided a method for treating cancer in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a combination of a WRN inhibitor and the following agents:

[0999] · A PLK1 inhibitor, such as volasertib,

[1000] · A PRMT5 inhibitor, such as SCR-6277, AMG-193, SKL-27969, MRTX-1719, onametostat / JNJ-64619178, TNG-90, and PF-0693999,

[1001] · A STING agonist, such as CDK-002, TAK-500, ONO-7914, VB-85247, KL-340399, TAK-676, SNX-281, SB-11285, and IMSA-101,

[1002] · A TRAIL receptor agonist, such as drozitumab, PRO-95780, CS-1008, IGM-8444, and lexatumumab,

[1003] · A TAK1 inhibitor, such as takinib,

[1004] · An MK2 inhibitor, such as CC-99677,

[1005] ·HDAC inhibitors, such as panobinostat, vorinostat, romidepsin, or belinostat,

[1006] ·Androgen biosynthesis inhibitors, such as abiraterone, or

[1007] ·Androgen receptor modulators, such as enzalutamide.

[1008] Radiopharmaceutical

[1009] As used herein, the term "radiopharmaceutical" refers to a drug that contains one or more radioisotopes that are configured such that the radioisotope is preferentially delivered to a tumor site. In some cases, a radiopharmaceutical can be simply a radioisotope or a pharmaceutically acceptable salt thereof. For example, 223 Ra-radium dichloride (BAY 88-8223, formerly 223 Ra-Alpharadin) (available from Bayer Pharma) is an approved drug for treating cancer types that typically metastasize to bone. Since the chemical properties of radium are similar to those of calcium, radium is preferentially delivered to bone. Other examples are iodine salts based on 131 I (usually in the form of sodium iodide) and 32 P-sodium phosphate, 153 Sm-lanthanum lexidronam ([[]] 153 Sm-ethylenediaminetetramethylenephosphonic acid samarium, 153 Sm-samarium EDTMP, ) 153 Sm-DOTMP (CycloSAM TM ) for relieving bone pain in patients with multiple osteoblastic bone metastases, 153 Sm-Oxabiphor ([[]] 153 Sm-samarium oxa-bis(ethylenedithio)tetramethylphosphonic acid, 153 Sm-OXB, 153 Sm-Oxabifor, 153 Sm-ETMP) for possible treatment of chronic synovitis, 166 Ho-phytic acid, 177 Lu-ST2210 (IART- 177 Lu-DOTA-biotin) (available from Sigma-Tau) for relieving pain associated with metastatic bone cancer186 Rhenium-HEDP ( 186 Re-HEDP, hydroxyethylidene diphosphonate), for isotopic radiation synovectomy of medium-sized joints 186 Rhenium sulfide, suitable for relieving bone pain in cancer metastasis (prostate, breast cancer) 188 Rhenium-HEDP (HEDP).

[1010] In other embodiments, the radioactive isotope is combined with a targeting vector designed to deliver the radionuclide to the target. Such a combination of a radioactive isotope and a targeting vector is referred to herein as a "radioligand agent". The radionuclide is selected based on the application of the drug (diagnostic or therapeutic agent), the type of radiation, and its energy. The targeting vector is designed to preferentially deliver the radionuclide to the target tissue, target organ, or target cell and can be a chemical molecule, peptide, polypeptide, protein (such as an antibody, antigen-binding fragment, bispecific antibody, affibody, or fibronectin type III domain), peptidomimetic, fusion protein / polypeptide, aptamer, antisense oligonucleotide, siRNA, microparticle, or nanoparticle. To attach the radionuclide to the vector, the chemist may have to develop a special chemical structure called a linker. The linker can be an inert moiety used to increase the distance between the binding moiety and the chelator to prevent steric effects during functionalization and loss of cell receptor activity. The length and composition of the linker may affect the binding affinity of the radiopharmaceutical to the receptor, the accumulation of the radionuclide in tumor cells, and the pharmacokinetics.

[1011] Direct binding via a so-called 'covalent' bond is possible, for example, with a radionuclide such as a radioactive halogen 131 I or 211 At binding. Radioactive metals may require a so-called 'chelator' or 'chelating agent', which is a cage-like molecular moiety that can capture the radioactive metal. Examples of chelating agents include, but are not limited to, DOTA, DTPA, AAZTA, TCMC, DAT, DFO, DOTAGA, DOTAM, EDTA, HBED / HBED-CC, HYNIC, NODAGA, NODA, NODASA, NOPO, NOTA, and PCTA, and their derivatives.

[1012] In one embodiment, the radionuclide can be administered in the form of a gel, micelle, sphere, particle, microparticle, or nanoparticle and includes a therapeutic agent, such as: 166 Ho-chitosan (available from Dong Wha.) for the treatment of hepatocellular carcinoma, resin-based microspheres for the treatment of hepatocellular carcinoma 90Y-SIR-Spheres (available from Sirtex), an insoluble glass microsphere suspension for transarterial radioembolization of liver tumors (including hepatocellular carcinoma) 90 Y-TheraSpheres (available from BTG / Boston Scientific), a hydrogel liquid made of a water-based biodegradable polymer that can directly deliver 90Y microspheres to tumor tissues 90 Y-RadioGel (Vivos Inc.), a nanovesicle composed of the conjugation of sapocatin C (SapC) and dioleoyl phosphatidylserine (DOPS) 131 I-SapC-DOPS( 131 I-Saposin; 131 I-BXD-350) (Molecular Targeting Technologies Inc.), a mixture of ethyl iodinated esters of poppy seed oil fatty acids for the treatment of hepatocellular carcinoma (HCC) 131 I-Lipiodol( 131 I-Ethiodized oil, 131 I-IOM-40), particles based on poly(L-lactic acid) (PLLA) 166 Ho-QuiremSpheres (available from Quirem Medical BV / Terumo Corp.), holmium-based microparticles 166 Ho-TheraneaM (Novartis), a dual-modal (therapeutic / fluorescent) product developed based on ultrasmall fluorescent (Cy5) silica nanoparticles (C dots) and conjugated with α-melanocyte-stimulating hormone (αMSH) peptides targeting MC1-R on the surface coated with polyethylene glycol (PEG) 177 Lu-DOTA-αMSH-PEG-C dots (Elucida Oncology Inc.), a delivery system made of dendrimer (G5) diffusion probes for targeting hypoxic tumor cells combined with the β-emitter rhenium-188 188 Re-ImDendrim (Nano Gun Technology), calcium carbonate microspheres for the treatment of ovarian cancer 224 Ra-RadSpherin (Oncoinvent), gold nanoparticles in the form of an injectable radiopharmaceutical for local radiation therapy of cancer as brachytherapy 225 Ac-Au@TADOTAGA(225 AC-Au-2,2′,2”-(10-(4-((2-(5-(1,2-dithiolan-3-yl)pentanamido)ethyl)amino)-1-carboxy-4-oxobutyl)-1,4,7,10-tetraazacyclododecane-1,4,7-triyl)triacetic acid (National Center for Scientific Research "Demokritos" (NCSR Demokritos))。

[1013] In one embodiment, the radionuclide can be conjugated to a small molecule (with a molecular weight from one hundred to several thousand daltons). These molecules are typically but not limited to being designed based on natural ligands that have specific affinities for some receptors expressed on the surface of tumors. Natural molecules that have been used as drugs are usually the starting point for developing such tracers and drugs. Thus, small molecules are most likely to cover all types of indications and include therapeutic agents such as: 47 Sc-cm10( 47 Sc-DOTA-folate, 47 Sc-folate) Folate analogue cm-10 is a combination of the following three entities: folate, DOTA-chelator, and albumin-binding entity. Mechanism of action: folate (Paul Scherrer Institute, Switzerland), 90 Y / 177 Lu-FAPI-04 and 90 Y / 177 Lu-FAPI-46 (a DOTA-conjugated quinolone analogue based on fibroblast activation protein (FAP) specific enzyme inhibitor (FAPI)). Mechanism of action: fibroblasts (Novartis AG), 90 Y / 177 Lu-NM600 (DOTA-18-(p-aminophenyl)octadecylphosphocholine) (alkylphosphocholine targeting tumors). Mechanism of action: alkylcholine phosphate (University of Wisconsin-Madison), 117m Sn-RAGE (a receptor for advanced glycation end products (RAGE) targeting agent for the treatment of Alzheimer's disease). Mechanism of action: receptor for advanced glycation end products (NeuroSn, Inc.), 131 I-CLR-131( 131 I-CLR-1404, 131 I-NM404, 131I-18-p-iodophenyl-octadecylphosphocholine) (an alkylphosphocholine (APC) from the phospholipid ether (PLE) analogue family). Mechanism of action: (PI3K) / Akt (Cellectar Biosciences), 149 Tb-DOTA-folate (a folic acid derivative). Mechanism of action: folate receptor (Paul Scherrer Institute, Switzerland), 131 I-IITM( 131 I-iodo-N-[4-(6-(isopropylamino)pyridin-4-yl)-1,3-thiazol-2-yl]-N-methylbenzamide) (a benzamide targeting the ectopic metabotropic glutamate receptor 1 (mGluR1) used in melanoma). Mechanism of action: mGluR1 (NIQRST), 131 I-BA52( 131 I-benzo(1,3)dioxol-5-carboxylic acid (4-(2-diethylamino-ethylcarbamoyl)-2-iodo-5-methoxy-phenyl)-amide) (a melanin-binding benzamide for the treatment of malignant melanoma). Mechanism of action: melamine (Bayer Pharmaceuticals), 131 I-iodobenzylguanidine( 131 I-metaiodobenzylguanidine, 131 I-MIBG, 123 I-Azedra) (a norepinephrine-like small molecule for the detection and treatment of primary or metastatic pheochromocytoma and paraganglioma (Progenics-Lantheus), 177 Lu-DOTAZOL( 177 Lu-DOTAZOL, 177 Lu-zoledronic acid, 177 Lu-DOTA-ZOL, 177 Lu-DOTA-zoledronate, 177 Lu-zoledronate, 177 Lu-DOTA-BPDOTAZOL, 177 Lu-ZLD, 177 Lu-DOTAMZOL, 177 Lu-DP-4411) (a zoledronic acid derivative for the treatment of metastatic prostate cancer ( 177Lu-(2,2',2”-(10-(2-(2-(1-(2-hydroxy-2,2-diphosphonoethyl)-1H-imidazol-4-yl)ethylamino)-2-oxoethyl)-1,4,7,10-tetraazacyclododecane-1,4,7-triyl)triacetic acid)). Mechanism of action: Bisphosphonate (Mainz University / ITM), 177 Lu-FF-10158 (Antagonist targeting integrin αvβ3 and αvβ5 receptors). Mechanism of action: Integrin (AAA Company / Novartis AG / FUJIFILM), 90 Y-DOTA-EB-MCG (MCG (((I-1-carboxy-2-mercaptoethyl)carbamoyl)-L-glutamic acid) conjugated with Evans blue (EB) derivative binding albumin and having DOTA group). Mechanism of action: GRPR (Johns Hopkins Medical Institutions / NIH), 177 Lu-DO3A-VS-Cys40-exendin-4 (177Lu-exendin-4; 177Lu-DO3A-exendin-4) (Molecule targeting glucagon-like peptide-1). Mechanism of action: GLP-1 (Sanofi), 177 Lu-DOTA-LLP2A( 177 Lu-LLP2A; 177 Lu-DOTA-PEG4-LLP2A) (Molecule with high affinity for VLA-4). Mechanism of action: VLA-4 (University of Pittsburgh), 177 Lu-EBRGD( 177 Lu-EB-RGD; 177 Lu-DOTA-EBRGD) (Molecule targeting integrin αvβ3 receptor conjugated with Evans blue (EB) structure to bind albumin). Mechanism of action: Integrin (Molecular Targeting Technologies Co., Ltd.), 177 Lu-NM600( 177 Lu-DOTA-18-(4-aminophenyl)octadecylphosphocholine) (Alkylphosphocholine targeting tumors). Mechanism of action: Alkylphosphocholine (APC) (University of Wisconsin-Madison), 177 Lu-CTT1403 (Phosphoramide-based molecule developed for the treatment of prostate cancer). Mechanism of action: PSMA (Cancer Targeted Technology), 211 At-AITM( 211At-astatine-N-[4-(6-(isopropylamino)pyridin-4-yl)-1,3-thiazol-2-yl]-N-methylbenzamide (a benzamide targeting ectopic metabotropic glutamate receptor 1 (mGluR1) for use in melanoma). Mechanism of action: mGluR1 (NIQRST), 177 Lu-CTT1403 (an aminophosphonate-based molecule, Cancer Targeting Technologies, Inc.), 225 Ac-DOTA-MC1RL (a melanocortin 1 receptor ligand). Mechanism of action: MCR1 (Moffit Cancer Center and Research Institute), 225 Ac-DOTAZOL( 225 Ac-DOTAZOL, 225 Ac-DOTA-ZOL, 225 Ac-DOTA-zoledronate) (a zoledronic acid derivative). Mechanism of action: bisphosphonate (University of Mainz).

[1014] In one embodiment, the radionuclide can be conjugated to a protein (such as an antibody, antigen-binding fragment, bispecific antibody, affibody, or fibronectin type III domain), including therapeutic agents such as: anti-CEA monoclonal antibody 67 Cu-CTPA-mAB35, an mAb targeting HER2 67 Ga-THP-trastuzumab (St. Thomas’ Hospital, London), a chimeric monoclonal anti-P-cadherin (CDH3) mAb 90 Y-DOTA-FF-21101( 90 Y-FF-21101, FF-21101) (FUJIFILM Pharmaceuticals), an anti-FZD10 (frizzled receptor homolog 10) antibody 90 Y-OTSA101-DTPA( 90 Y-OTSA101, 90 Y-Tabituximab barzuxetan, TT641 pAb, FZD10 mAb) (OncoTherapy Science Inc.), a fully human IgG1 monoclonal antibody against insulin-like growth factor 90 Y-Clivatuzumab tetraxetan (hPAM4-Cide TM)(Immunomedics Inc.), a fully humanized monoclonal antibody targeting glypican-3 225 Ac-Codrituzumab (NIH / Memorial Sloan-Kettering Cancer Center (MSKCC)), a humanized murine monoclonal antibody that binds to CD25 (Interleukin-2) 90 Y-Daclizumab, a humanized IgG1 antibody targeting CD22 for the treatment of non-Hodgkin lymphoma (NHL) and diffuse large B-cell lymphoma (DLBCL) 90 Y-Clivatuzumab tetraxetan (IMMU-102, 90Y-Lymphocide, 90Y-DOTA-hLL2) (Immunomedics Inc.), an IgG1κ-monoclonal murine antibody against the CD20 antigen 90 Y-Ibritumomab tiuxetan (Available from Biogen Idec, Acrotech Biopharma), a rabbit polyclonal antibody targeting ferritin 90 Y-Ferritarg (Alissa Pharma), a monoclonal antibody targeting TAG-72 90 Y-IDEC-159 (Biogen-IDEC), a monoclonal antibody reactive with tumor-associated glycoprotein (TAG-72) 90 Y-IDEC-159 (Biogen), a natural protein that can be used for imaging and treatment of vulnerable plaques, cancer or rheumatoid arthritis 117m Sn-DOTA-Annexin-V (Serene LLC), a monoclonal antibody targeting tenascin-C 131 I-Tenatumomab (ST2146) (Sigma-tau), a DNA / histone targeting monoclonal antibody for the treatment of brain cancer by direct in situ infusion into the tumor 131 I-chTNT( 131 I-chTNT-1 / B; 131 I-TNT, 131I - Derlotuximab (Biotin) (Avid Bioservices, Shanghai Medipharm Biotech), an antibody fragment targeting the hepatocellular carcinoma (HCC)-associated antigen HAb18G / CD147 131 I - Metuximab (Chengdu Taihe Health Technology), an anti-CD20 antibody 131 I - Tositumomab (GlaxoSmithKline), a chimeric antibody 131 I - Weimeisheng (CIRC Company - Shanghai MeienBiotechnology), a single-domain antibody fragment (sdAb) targeting HER2 131 I - CAM-H2( 131 I - SGMIB anti-HER2-VHH1; 131 I - SGMIB (Camel-IDS), an antibody specifically targeting the SARS-CoV-2 RBD (host cell receptor-binding domain) 131 I - CR3022 (MSKCC), a murine IgG2 anti-tenascin monoclonal antibody 131 I - 81C6( 131 I - Monoclonal antibody 81C6, 131I-MoAB 81C6, Neuradiab TM )(Bradmer Pharmaceuticals), a murine IgG3 monoclonal antibody that binds to cell surface GD2 (disialoganglioside antigen) 131 I - Naxitamab( 131 I - 3F8, 131 I - MoAb-3F8 (Y-Mabs Therapeutics), a murine monoclonal antibody IgG1 that recognizes the cell surface antigen 4Ig-B7H3 131 I - Omburtamab( 131 I - Burtomab, 131 I - 8H9; 131 I - 8H9(B7-H3), 131 I - MoAb-8H9 (Y-Mabs Therapeutics), a DNA / histone-targeting monoclonal antibody 131I-chTNT (Tumor Necrosis Therapy-1), 131 I-chTNT-1 / B; 131 I-TNT, 131 I-Dilotumumab Biotin (Avid Bioservices / Shanghai Medomics Biotechnology Co., Ltd.), murine IgG2 anti-tenascin monoclonal antibody 131 I-81C6 mAb( 131 I-Monoclonal Antibody 81C6, 131I-MoAB 81C6, Neuradiab TM )(Bristol-Myers Squibb Company), murine monoclonal antibody targeting CD45 131 I-BC8 (Iomab-B TM , 131 I-Apamistamab (Actinium Pharmaceuticals), human recombinant antibody fragment consisting of the variable region of L19mAb against the external domain B (ED-B) of fibronectin overexpressed in the tumor vasculature 131 I-Rituximab( 131 I-L19-SIP, 131 I-L19SIP)(Philogen), anti-CD37 antibody 177 Lu-Lilotomab (Nordic Nanovector), anti-CD37 antibody 177 Lu-Lilotomab Satetraxetan (Betalutin TM )(Nordic Nanovector), antibody that binds to the carbohydrate antigen sialyl Lewis a (sLea) (CA19-9) 177 Lu-MVT-1075 (177Lu-DFO-HuMab-5B1)(BioNTech SE), murine monoclonal antibody DAB4 177 Lu / 227 Th APOMAB (AusHealth Corp Pty Ltd), anti-CEA Dock-and-Lock bispecific antibody 177 Lu-IMP-288 (Nantes University - Radboud University), anti-PSMA (prostate-specific membrane antigen) antibody highly specific for prostate tumor cells 177Lu-TLX591( 177 Lu-Rosapatumab, 177 Lu-MLN591, 177 Lu-huJ591, 177 Lu-J591, 177 Lu-ATL-101, 177 Lu-TLX591t) (Telix Pharmaceuticals Ltd), anti-CD105 antibody 177 Lu-DTPA-TRC105 (Tracon Pharmaceuticals), PSMA-targeted antibody 177 Lu-225Ac-hu11B6( 177 Lu-DTPA-hu11B6; 177 Lu-h11B6) (Lund University), anti-CD37 antibody 177 Lu-Humalutin( 177 Lu-NNV003) (Nordic Nanovector), anti-PSMA (prostate-specific membrane antigen) antibody highly specific for prostate tumor cells 177 Lu / 225 Ac-Rosapatumab (J591, TLX591) (Telix Pharmaceuticals), chimeric murine-human monoclonal antibody targeting carbonic anhydrase IX (CA-IX) molecule / G250 antigen 177 Lu-TLX250( 177 Lu-cG250, TLX250, 177 Lu-TLX250t, 177 Lu-DOTA-Girentuximab, 177 Lu-Girentuximab) (Telix Pharmaceuticals), murine antibody against IgG isotype melanoma 188 Re / 213 Bi-8C3 (Radimmune Inc.), anti-tenascin chimeric monoclonal antibody 211 At-81C6 (Duke University), 211 At-MX35-F(ab’)2( 211 At-labeled MX35), antibody fragment of murine IgG1-class monoclonal antibody against 95 kDa cell surface glycoprotein on OVCAR-3 cells 211At-MX35 (anti-human SLC34A2) (MSKCC), tetraaminocarbamoylmethyl cyclen (TCMC) conjugated to a monoclonal antibody that interferes with the HER2 / neu receptor (epidermal growth factor receptor EGFR) 212 Pb-TCMC-trastuzumab (Orano Med), human immunoglobulin G1κ (IgG1k) monoclonal antibody against the cell surface glycoprotein CD38, which is expressed on a variety of hematopoietic cells and overexpressed on multiple myeloma (MM) cells 212 Pb-daratumumab ( 212 Pb-anti-CD38, 212 Pb-Dara, 212 Pb-TCMC-daratumumab) (Orano Med), monoclonal antibody that recognizes the B7-H3 (CD276) epitope expressed on ovarian cancer cells, pancreatic tumor cells, and cancer-initiating cells (CIC) 212 Pb-376.96 ( 212 Pb-TCMC-376.96) (University of Alabama), humanized anti-CD37 antibody 212 Pb-NNV003 (Orano Med / Nordic Nanovector), radiolabeled fully human monoclonal antibody (PAN-622) against human asparaginyl (asparaginyl)-hydroxylase (HAAH) 213 Bi-DTPA-PAN-622 ( 213 Bi-PAN-622) (Sensei Biotherapeutics Inc.), humanized anti-CD33 antibody huM195 213 Bi-lintuzumab ( 213 Bi-Bismab-A TM , 213 Bi-DTPA-lintuzumab, 213 Bi-CHX-A”-DTPA-huM195) (Actinium Pharmaceuticals), fully human IgG1 monoclonal antibody against human insulin-like growth factor-1 receptor (IGF-1R) 225 Ac-cetuximab ( 225 Ac-IMC-A12, 225 Ac-DOTA-cetuximab) (University of Saskatchewan), chimeric murine-human monoclonal antibody targeting the carbonic anhydrase IX (CA-IX) molecule / G250 antigen expressed on more than 90% of clear cell renal cell carcinomas 225Ac-Girentuximab (TLX251) (Telix Pharmaceuticals), an anti-PSMA (prostate-specific membrane antigen) antibody highly specific for prostate tumor cells 225 Ac-J591( 225 Ac-ATL-101, 225 Ac-TLX591) (Telix Pharmaceuticals), a chimeric murine-human monoclonal antibody targeting the carbonic anhydrase IX (CA-IX) molecule / G250 antigen expressed on more than 90% of clear cell renal cell carcinomas 225 Ac-TLX251( 225 Ac-cG250, 225 Ac-DOTA-Girentuximab, 225 Ac-Girentuximab) (Telix Pharmaceuticals), an anti-PSMA (prostate-specific membrane antigen) antibody highly specific for prostate tumor cells 225 Ac-TLX591(225Ac-J591) (Telix Pharmaceuticals / Weill Medical College of Cornell University), a re-engineered antibody hu591 targeting PSMA 225 Ac-TLX592( 225 Ac-J591, modified 225 Ac-TLX591) (Telix Pharmaceuticals), a humanized monoclonal antibody targeting the insulin-like growth factor-1 receptor (IGF-1R) 225 Ac-FPI-1434 (Fusion Pharmaceuticals), a humanized anti-CD33 antibody huM195 225 Ac-Lintuzumab( 225 Ac-Actimab-A TM , 225 Ac-DOTA-huM195, 225 Ac-DOTA-Lintuzumab, 225 Ac-CHX-A”-DOTA-huM195, Lin-Ac225, 225 Ac-huM195) (Actinium Pharmaceuticals), a human immunoglobulin G1κ (IgG1k) monoclonal antibody against the cell surface glycoprotein CD38 expressed on multiple hematopoietic cells and overexpressed on multiple myeloma (MM) cells 225 Ac-Daratumumab 225 Ac-anti-CD38, 225 Ac-Dara, 225Ac-DOTA-Daratumumab (Ac Pharmaceutical Co., Ltd.), a human immunoglobulin G1 (IgG1) monoclonal antibody targeting mesothelin 227 Th-Anetumab ravtansine 227 Th-BAY2287411; BAY2287411; BAY2287411) (Bayer Pharma AG), a humanized IgG1 antibody targeting CD22 227 Th-Epratuzumab (Bayer AG), a humanized HER2 monoclonal antibody 227 Th-Trastuzumab (Bayer Pharma AG), a monoclonal antibody that binds to sialoadhesin receptor CD33 (Siglec-3, a 67-kDa protein expressed on leukemic blasts in AML patients) 227 Th-CD33-TTC 227 Th-Lintuzumab 227 Th-Anti-CD33-conjugate) (Bayer Pharma AG), a CD70-targeting antibody (IgG1) 227 Th-CD70-TTC 227 Th-CD70-Thorium-targeted conjugate) (Bayer Pharma AG).

[1015] In one embodiment, the radionuclide can be conjugated to a peptide or polypeptide, including therapeutic agents such as:

[1016] Somatostatin analogs targeting the somatostatin (SST) receptor, such as those using 90 Y-DOTATATE 90 Y-DOTA0-Phe1-Tyr3-octreotate, 90 Y-octreotate, and 90 Y-DOTA-octreotate), lutetium 177 Lu) oxodotreotide [INN]( 177 Lu-DOTATATE, 177 Lu-DOTA0-Tyr3-octreotate, 177 Lu-octreotate, 177 Lu-Lutate, 177 Lu-Edotreotate, official USAN: Lutetium Lu-177 dotatate and INN: lutetium 177 Lu) oxodotreotide) (AAA Company / Novartis AG), 213 Bi-DOTATATE 213 Bi-[DOTA0,Tyr3]-octreotate),225 Ac-Dotatate( 225 Ac-[DOTA0,Tyr3]octreotate)(Bad Berka), an octreotate-based molecule using Evans blue to bind albumin 67 Cu-SARTATE( 67 Cu-MeCOSAR-octreotate; 67 Cu-SAR-[Tyr3]-octreotate)(Clarity Pharmaceuticals), 177 Lu-DOTA-EB-TATE( 177 Lu-DOTA-EBTATE; EBTATE; lutetium-177-1,4,7,10-tetra-azacyclododecane-1,4,7,10-tetraacetic acid-Evans blue-Tyr3-octreotate)(Molecular Targeting Technologies Inc.), 177 Lu-HA-Dotatate( 177 Lu-high affinity-Dotatate, 177 Lu-DOTA-3-iodo-Tyr3-octreotate)(Scintomics), 90 Y-DOTATOC( 90 Y-DOTATOC, 90 Y-SMT487, 90 Y-DOTA0-Phe1-Tyr3-octreotide), somatostatin analogue 177 Lutetium edotreotide( 177 Lu-DOTA0-Phe1-Tyr3-octreotide, 177 Lutetium octreotide, 177 Lu-SMT-487, 177 Lu-DOTATOC, 177 Lu-Edo, 177 Lutetium edotreotide for PRRT)(ITM Solucin GmbH), 149 Tb-DOTANOC(Swiss Paul Scherrer Institute), 152 Tb-DOTATOC(Swiss Paul Scherrer Institute), 213 Bi-DOTATOC, 225 Ac-DOTATOC(US Los Alamos National Laboratory (LANL)), 177 Lu-DOTANOC( 177Lu-DOTA-1-Nal3-Octreotide), a somatostatin analogue that binds to the sst2 receptor 177 Lu-IPN-01072( 177 Lu-OPS201, 177 Lu-DOTA-JR11637, 177 Lu-OPSC001, 177 Lu-Satoreotide tetraxetan (Octreopharm / Ipsen Pharma), 212 Pb-DOTAMTATE( 212 Pb-AR-RMX; 212 Pb-AlphaMedix TM , ORM2110) (Orano Pharma), 90 Y-OPS201( 90 Y-DOTA-JR11, ), 90 Y-DOTALAN( 90 Y-DOTA-Lanreotide, 90 Y-Lanreotide, or 90 Y-Somatulin), 177 Lu-DOTA-LM3( 177 Lu-1,4,7,10-tetraazacyclododecane, 1,4,7-triacetic acid, 10-acetamide N-p-Cl-Phe-cyclo(d-Cys-Tyr-d-4-aminophenyl(aminocarbonyl)-Lys-Thr-Cys)-d-Tyr-NH2) (Zentralklinik Bad Berka),

[1017] Peptides targeting prostate-specific membrane antigen (PSMA), which use, for example

[1018] 44 Sc-PSMA-617, 90 Y-PSMA-617 (Paul Scherrer Institute, Switzerland), 152 Tb-PSMA-617 (Paul Scherrer Institute - Bad Berka Hospital, Switzerland), 177 Lu-PSMA-617( 177 Lu-DKFZ-PSMA-617, 177 Lu-PSMA617, lutetium( 177Lu) Vipivotide tetraxetan [INN] (Novartis AG), 225 Ac-PSMA-617 (Novartis AG), 161 Tb-PSMA-617 (Paul Scherrer Institute / ETH / ILL, Switzerland), 213 Bi-PSMA-617( 213 Bi-Vipivotide tetraxetan) (University Hospital of Heidelberg), a PSMA-617 analogue conjugated with truncated Evans blue 177 Lu-EB-PSMA-617 (Peking Union Medical College), 177 Lu-FC705 (FutureChem), 203 Pb-CA012 (University Hospital of Heidelberg), 177 Lu-PSMA-I&T( 177 Lu-PSMAI&T, 177 Lu-PSMA-TUM1, 177 Lu-DOTAGA-(l-y)fk(Sub-KuE)) (University of Munich - Signetomics), 177 Lu-PSMA-R2 ((Nε-[177Lu-(4,7,10-tricarboxymethyl-1,4,7,10-tetrazacyclododec-1-yl)acetyl]-6-aminohexanoic acid)-(Nε'-4-bromobenzyl)lysine-CO-glutamic acid) (Novartis AG) 177 Lu-PSMA-CC-34( 177 Lu-NODAGA-PSMA-CC-34; 177 Lu-PSMA-CC34), 177 Lu-L1( 177 Lu-DOTAMA-L1) (Johns Hopkins University), a PSMA ligand conjugated with an albumin binder based on a p-(tolyl)-moiety 177 Lu-PSMA-ALB-56( 177 Lu-DOTA-PSMA-ALB-56) (ETH Zurich / PSI), a molecule with a high-affinity PSMA binding domain linked to an albumin binding group (ABG) 177Lu-RPS-063 (Weill Cornell Medicine), 177 Lu-iPSMA( 177 Lu-DOTA-HYNIC-Lys(NaI)-urea-Glu)(ININ), 212 Pb-NG001( 212 Pb-p-SCN-Bn-TCMC-PSMA; 212 Pb-TCMC-PSMA)(Nucligen AS), a molecule with a high-affinity PSMA binding domain linked to an albumin binding group (ABG) 131 I-RPS-027 (Weill Cornell Medicine), 225 Ac-RPS-074 (Weill Cornell Medical), a somatostatin peptide of 11 amino acids 188 Re-P2045 (BAY 86-5284, )(Andarix Pharmaceuticals), a glutamate-urea-lysine analogue for prostate cancer treatment applications 131 I-RPS-001( 131 I-MIP-1095; 131 I-(S)-2-(3-((S)-1-carboxy-5-(3-(4-iodophenyl)ureido)pentyl)ureido)pentanedioic acid)(Progenics / Lanxius), 177 Lu-DOTA-peptide-2( 177 Lu-DOTA-p-Cl-Phe-cyclo(d-Cys-l-BzThi-d-Aph-Lys-Thr-Cys)-d-Tyr-NH2; 177 Lu-[(1,4,7,10-tetrakis(carboxymethyl)-1,4,7,10-tetraazacyclododec-1-yl)acetyl]-(L)p-chlorophenylalanyl-(D)-cysteine-(L)-3-benzothienylpropyl (L-BzThi)-(D)-4-aminocarbamoylphenylalanyl (D-Aph)-(L)-lysyl-(L)-threonyl-(L)-cysteine-(D)-tyrosine-NH2-cyclodisulfide)(Tehran Faculty of Pharmacy).

[1019] In another embodiment, the radioligand agent is selected from any of the agents disclosed in the following documents: 1) Theranostics 2016; 7(7): 1928-1939, 2) The Journal of Nuclear Medicine, Volume 60, Issue 7, 910-916, 3) Mol Imaging Biol April 2020; 22(2): 274-284, and their associated electronic supplementary materials, all of which are hereby incorporated by reference. In a particular embodiment, the radioligand agent is selected from 177 Lu-CTT1401, 177 Lu-CTT1403, CTT1057 (incorporating 18 F) and 177 Lu-CTT1751.

[1020] Bombesin analogs that target the gastrin-releasing peptide receptor (GRPR), such as those using

[1021] 177 Lu-NeoB( 177 Lu-NeoBomb1, 177Lu-DOTA-(p-aminobenzylamine-diglycolic acid)-[D-Phe6-His-NHCH-[(CH2CH(CH3)2]212-des-Leu13-des-Met14]BBN) (Novartis AG), 177 Lu-ProBOMB1( 68 Ga-DOTA-pABzA-DIG-d-Phe-Gln-Trp-Ala-Val-Gly-His-Leu-ψ(CH2N)-Pro-NH2) (University of British Columbia), 212 Pb-RM2( 212 Pb-DOTA-4-amino-1-carboxymethyl-piperidine-D-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH2) (US Department of Veterans Affairs), 177 Lu-RM2( 177 Lu-DOTA-4-amino-1-carboxymethyl-piperidine-D-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH2, 177 Lu-BAY-1017858) (Rostock University),

[1022] Fibroblast activation protein (FAP) inhibitors targeting FAP, for example used

[1023] 177 Lu-FAP-2286( 177 Lu-3BP-3554, 177 Lu-3B-201) (Clovis Oncology / 3B Pharma),

[1024] Peptides targeting L-type amino acid transporter-1 (LAT-1), for example used

[1025] 131 I-TLX101(4- 131 I]-4-L-iodophenylalanine, 131 I-IPA, 131 I-TLX101t, TLX101, previously developed under the name 131I-ACD-101) (Telix Pharmaceuticals Limited), IPA (iodophenylalanine) analog 211 At-TLX102(4- 211 At]-astatophenylalanine) (Telix Pharmaceuticals Limited),

[1026] Minigastrin analogs targeting cholecystokinin-2 (CCK-2) receptor, for example used

[1027] 177 Lu-DOTA-MGS5( 177 Lu-MGS5; 177 Lu-DOTA-D-Glu-Ala-Tyr-Gly-Trp-(N-Me)Nle-Asp-1-Nal-NH2) (Innsbruck University), 177 Lu-Debio 1124( 177 Lu-DOTA-(DGlu)6-Ala-Tyr-Gly-Trp-Nle-Asp-Phe-NH2, Debio 1124, 177 Lu-PSIG-2, 177 Lu-PP-F11N) (Debiopharm International SA / PSI / University Hospital of Basel),

[1028] Modified substance P targeting the GPCR neurokinin-1 receptor (NK-1R), such as those using

[1029] 213 Bi-DOTA-SP( 213 Bi-substance P, 213 Bi-DOTA-substance P, 213 Bi-[Thi8,Met(O2)11]-substance P) (Novacurie), 225 Ac-DOTA-SP( 225 Ac-substance P, 225 Ac-DOTA-substance P) (Novacurie),

[1030] Peptides targeting the CXCR4 receptor, such as those using

[1031] 177 Lu-Pentixather (3-iodo-D-Tyr1-pentixafor; cyclo(D-3-iodo-Tyr1-[NMe]-D-Orn2(AMBS-DOTA)-Arg3-2-Nal4-Gly5)) (Scintomics GmbH), 177 Lu-BL01( 177 Lu-cyclo[Phe-Tyr-Lys(iPr)-d-Arg-2-Nal-Gly-d-Glu]-Lys(iPr)-NH2) (University of British Columbia),

[1032] Peptides that bind to the melanocortin receptor subtype I (MCR1) with high affinity and specificity 212 Pb-DOTA-VMT-MCR1 (Viewpoint Molecular Targeting LLC / RadioMedix), a neurotensin antagonist peptide targeting NTR-1 (or NTSR1 - neurotensin receptor-1) 177 Lu-IPN-01087( 177 Lu-3BP-227) (3B Pharmaceuticals / Ipsen Pharma), a peptide targeting the glucagon-like peptide-1 receptor (GLP-1) 177 Lu-DOTA-Exendin-4( 177 Lu-Exendin-4; 177Lu-DOTA-Ahx-Lys40-Kin-4 (Bhabha Atomic Research Center)

[1033] Integrin radioligands

[1034] 68 Ga-FF58( 68 Ga-2,2’,2”-(10-(2-(((R)-1-((2-(4-(4-(N-((S)-1-carboxy-2-(5-(5,6,7,8-tetrahydro-1,8-naphthyridin-2-yl)pentanamido)ethyl)sulfamoyl)-3,5-dimethylphenoxy)butanamido)ethyl)amino)-1-oxo-3-sulfopropyl-2-yl)amino)-2-oxoethyl)-1,4,7,10-tetraazacyclododecane-1,4,7-triyl)triacetic acid) and 177 Lu-FF58( 177 Lu-2,2’,2”-(10-(2-(((R)-1-((2-(4-(4-(N-((S)-1-carboxy-2-(5-(5,6,7,8-tetrahydro-1,8-naphthyridin-2-yl)pentanamido)ethyl)sulfamoyl)-3,5-dimethylphenoxy)butanamido)ethyl)amino)-1-oxo-3-sulfopropyl-2-yl)amino)-2-oxoethyl)-1,4,7,10-tetraazacyclododecane-1,4,7-triyl)triacetic acid).

[1035] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by the context. The use of any and all examples or exemplary language (e.g., "such as") provided herein is intended only to better illustrate the invention and does not limit the scope of the invention claimed otherwise.

[1036] Isomeric form

[1037] Any asymmetric atom (e.g., carbon or the like) of one or more compounds useful in the present invention may exist in racemic or enantiomerically enriched forms, e.g., in (R)-, (S)-, or (R,S)-configurations. In certain embodiments, each asymmetric atom has at least 50% enantiomeric excess, at least 60% enantiomeric excess, at least 70% enantiomeric excess, at least 80% enantiomeric excess, at least 90% enantiomeric excess, at least 95% enantiomeric excess, or at least 99% enantiomeric excess in the (R)- or (S)-configuration. Substituents at atoms having unsaturated double bonds may exist in the cis-(Z)- or trans-(E)-form, if possible.

[1038] Accordingly, as used herein, a compound useful in the present invention may be in the form of one of the possible stereoisomers, rotamers, atropisomers, tautomers, or mixtures thereof, e.g., as a substantially pure geometric (cis or trans) stereoisomer, diastereomer, optical isomer (enantiomer), racemate, or mixtures thereof.

[1039] Any resulting mixture of stereoisomers may be separated into pure or substantially pure geometric or optical isomers, diastereomers, racemates based on the physicochemical differences of the components, e.g., by chromatography and / or fractional crystallization.

[1040] The racemates of any resulting compound or intermediate useful in the present invention may be resolved into the optical enantiomers by known methods, e.g., by separating the diastereomeric salts obtained with an optically active acid or base and liberating the optically active acidic or basic compound. In particular, thus the basic moiety may be used to resolve a compound useful in the present invention into its optical enantiomers, e.g., by fractional crystallization of salts formed with an optically active acid such as tartaric acid, dibenzoyl tartaric acid, diacetyl tartaric acid, di-O,O’-p-toluoyl tartaric acid, mandelic acid, malic acid, or camphor-10-sulfonic acid. Racemic compounds or racemic intermediates useful in the present disclosure may also be resolved by chiral chromatography (e.g., high performance liquid chromatography (HPLC) using a chiral adsorbent).

[1041] A compound useful in the present invention, i.e., a compound of formula (I) containing groups capable of acting as hydrogen bond donors and / or acceptors, is capable of forming co-crystals with a suitable co-crystal former. These co-crystals may be prepared from the compound of formula (I) by known co-crystal forming procedures. Such procedures include grinding, heating, co-sublimation, co-melting, or contacting the compound of formula (I) with a co-crystal former in solution under crystallization conditions and separating the co-crystals thus formed. Suitable co-crystal formers include those described in WO 2004 / 078163.

[1042] In addition, the compounds (including their salts) useful in the present invention may also be obtained in their hydrate forms, or include other solvents used for their crystallization. The compounds of the present invention may inherently or by design form solvates with pharmaceutically acceptable solvents (including water). The term "solvate" refers to a molecular complex of a compound (including its pharmaceutically acceptable salts) with one or more solvent molecules. Such solvent molecules are those commonly used in the pharmaceutical field and are known to be harmless to recipients, such as water, ethanol, etc. The term "hydrate" refers to a complex in which the solvent molecule is water.

[1043] Bifunctional degrader compound

[1044] As described herein, the compounds having formula (I) can also be used to form bifunctional degrader compounds using the methods and known synthetic routes described herein.

[1045] In an embodiment, the WRN bifunctional degrader compound is a compound having formula Ia:

[1046]

[1047] or a pharmaceutically acceptable salt thereof, wherein:

[1048] The targeting ligand is a group capable of binding to Werner syndrome RecQ DNA helicase (WRN), such as a compound having formula (I) or 1g herein, or compound A, or compound B;

[1049] The linker is a group that covalently links the targeting ligand to the targeting ligase binder; and

[1050] The targeting ligase binder is a group capable of binding to a ligase (e.g., VHL, IAP, or Cereblon E3 ubiquitin ligase, such as a binder moiety using context compounds X, Y, and Z). Bifunctional degrader compounds X, Y, and Z were prepared and tested for WRN activity.

[1051] Compound X:

[1052]

[1053] (2S,4R)-1-((S)-2-(4-(4-(5-Ethyl-6-(4-(3-hydroxypyridine-1-carbonyl)piperazin-1-yl)-4-(2-((2-methyl-4-(trifluoromethyl)phenyl)amino)-2-oxoethyl)-7-oxo-4,7-dihydro-[1,2,4]triazolo[1,5-a]pyrimidin-2-yl)-3,6-dihydropyridin-1(2H)-yl)-4-oxobutanamido)-3,3-dimethylbutanoyl)-4-hydroxy-N-((S)-1-(4-(4-methylthiazol-5-yl)phenyl)ethyl)pyrrolidine-2-carboxamide

[1054] Compound Y:

[1055]

[1056] (2S,3R)-3-Amino-N-((S)-1-(4-(5-Ethyl-6-(4-(3-hydroxypyridine-1-carbonyl)piperazin-1-yl)-4-(2-((2-methyl-4-(trifluoromethyl)phenyl)amino)-2-oxoethyl)-7-oxo-4,7-dihydro-[1,2,4]triazolo[1,5-a]pyrimidin-2-yl)-3,6-dihydropyridin-1(2H)-yl)-4-methyl-1-oxopentan-2-yl)-2-hydroxy-4-phenylbutanamide

[1057] Compound Z:

[1058]

[1059] 2-(2-(1-(6-((2-(2,6-Dioxopiperidin-3-yl)-3-oxoisoindolin-5-yl)oxy)hexanoyl)-1,2,3,6-tetrahydropyridin-4-yl)-5-ethyl-6-(4-(3-hydroxypyridine-1-carbonyl)piperazin-1-yl)-7-oxo-[1,2,4]triazolo[1,5-a]pyrimidin-4(7H)-yl)-N-(2-methyl-4-(trifluoromethyl)phenyl)acetamide

[1060] According to the assays disclosed in Application PCT / IB2022 / 054850 (published as WO 2022 / 249060 and hereby incorporated by reference), these compounds are active as shown in Table X.

[1061] Table X

[1062]

[1063]

[1064] Table Y, LCMS

[1065] Compound Rt, min MS m / z X 1.14 M+Na 1214.5 Y 1.07 <![CDATA[[M+H] + 956.4]]> Z 1.11 <![CDATA[[M-H] - 1020.4]]>

[1066] LCMS method for compounds X, Y, and Z:

[1067] Instrument: Thermo Exactive Plus HRMS, Thermo Vanquish LC instrument Column: Agilent Zorbax SB-AQ 1.8 μM

[1068] Column size: 2.1 * 30 mm

[1069] Column temperature: 40 °C

[1070] Eluent: A: water and 0.04% formic acid

[1071] B: acetonitrile and 0.04% formic acid

[1072] Flow rate: 0.5 mL / min

[1073] Gradient: from 5% to 95% B in 0.5 min, 95% B for 1 min, from 95% to 5% B in 0.1 min, 5% B for 0.4 min

[1074] MS settings: positive ion mode, resolution 35,000, scan range 150 to 1800 m / z, AGC target 3e6, maximum IT 200 ms

[1075] In another aspect of the present invention, there is provided an antibody-drug conjugate comprising a WRN inhibitor compound as described herein. The antibody and linker components can be selected according to those known in the art.

[1076] Synthesis and determination of WRN inhibitor

[1077] According to a specific embodiment of the present invention, the synthesis, biological assays, and data of the WRN inhibitor are described in PCT / IB2022 / 054850 (WO 2022 / 249060), which patent document is hereby incorporated by reference in its entirety.

[1078] Example

[1079] Examples 1 to 11, 13, 14, 21, and 34 (corresponding respectively Figures 1 to 11 to 13, 14, 21, and 34):

[1080] 1. Method

[1081] 1.1. Cell culture

[1082] The following cell lines were obtained from ATCC. The media and culture conditions used were as recommended by ATCC. All cells were maintained in a humidified 5% CO2 incubator at 37°C. SW48 (CCL-231, ATCC) was cultured in RPMI 1640 (#1-41F01-I, AMIMED) supplemented with 10% FCS (#2-0-1F30-I, Bio concept), 2 mM L-glutamate (#5-10K50-H, Bio concept), 1 mM sodium pyruvate (#5-60F00-H, Bio concept), and 10 mM HEPES (#5-31F00-H, Bio concept). HCT116 (CCL-247, ATCC) was cultured in McCoy’s 5A (#16600082, Gibco) supplemented with 10% FCS (#2-0-1F30-I, Bio concept) and 2 mM L-glutamate (#5-10K50-H, Bio concept).

[1083] Cells were passaged by first washing with Dulbecco’s PBS (without Ca 2+ / Mg 2+ )(#3-05F29-I, AMIMED), trypsinizing the cells with EDTA and 0.05% trypsin (in PBS) (#5-51F00-H, AMIMED), centrifuging in their respective media, and splitting the cells 1:8 into fresh media twice a week.

[1084] 1.2. In vitro experiment

[1085] 1.2.1. Long-term proliferation assay

[1086] On day 1, the cells were trypsinized, resuspended in their respective media, and counted using a TC20 cell counter from Bio-Rad. The cells were seeded at 3,000 to 4,000 cells / well in 200 μl of growth media in a clear-bottom 96-well white plate (Corning catalog number 3903).

[1087] On the second day, the cells were incubated overnight at 37 °C in a humidified 5% CO2 atmosphere and then treated in triplicate at the specified concentrations using an HP 300D non-contact digital dispenser (TECAN). In all wells, the final concentration of DMSO was normalized to 0.1%. On day 7 of the experiment, the medium was carefully removed by aspiration and the compound treatment was renewed by adding fresh medium, and then compound administration was performed as on the second day. Around day 15, the compound treatment was removed by carefully aspirating the medium, washing once with fresh medium, and adding 200 μl of fresh medium. Around day 21, the medium was renewed by carefully aspirating the medium and adding 200 μl of fresh medium. The experiment was monitored and images were acquired using an S3 live cell analysis instrument (Sartorius). Images were captured every 6 h starting from the second day until day 40. The data were analyzed and presented using Prism-GraphPad.

[1088] 1.2.2. Irradiation (Examples 6 and 7)

[1089] On the first day, the cells were trypsinized, resuspended in their respective media and counted using a TC20 cell counter from Bio-Rad. The cells were seeded at 3,000 to 4,000 cells / well in 200 μl of growth medium in a clear-bottom 96-well white plate (Corning catalog number 3903) and incubated overnight at 37 °C in a humidified 5% CO2 atmosphere.

[1090] On the second day, the cells were exposed to ionizing radiation (IR) at a dose of 3 Gy / min using an external beam radiation device (RS1800Q X-ray cell irradiator). The irradiated cells were treated in triplicate with compound A at the specified concentration using an HP 300D non-contact digital dispenser (TECAN).

[1091] 2. List of abbreviations

[1092]

[1093]

[1094] Results

[1095] Examples 1, 8 - 10, and 13 - 14: The in vitro proliferation effect of the combination of compound A and chemotherapeutic drugs in an MSI 高 colorectal cancer (CRC) cell model

[1096] Example 1

[1097] In a long-term proliferation assay lasting up to 40 days ( Figure 1) In, the in vitro combination of compound A and irinotecan enhanced WRN inhibition and prevented / delayed the recurrence observed after compound A monotherapy (100 nM) in the SW48 MSI 高 CRC cell model.

[1098] Example 8

[1099] In the SW48 cell model, we also observed a more persistent response in the combination of compound A and 5FU ( Figure 8 ).

[1100] Examples 9 and 10

[1101] Further data showed that in the SW48 model, even at a suboptimal concentration of 30 nM of compound A, the combination of epirubicin and compound A achieved a strong synergistic anti-proliferative effect. In a long-term proliferation assay lasting up to 35 days ( Figure 9 and 10 ), when compound A (100 nM) was combined with epirubicin, a stronger response was obtained in the CRC MSI 高 models (both HCT116 and SW48).

[1102] Example 13

[1103] In a long-term proliferation assay lasting up to 30 days, in SW48, the combination of docetaxel and compound A showed a modest effect in preventing / delaying the recurrence observed after compound A monotherapy (100 nM). ( Figure 13 )

[1104] Example 14

[1105] In the SW48 model, the combination of compound A and carboplatin showed a modest beneficial combination effect ( Figure 14 ).

[1106] Examples 2-5, 11, 21, and 34: In vitro proliferation effects of compound A in combination with DNA damage response (DDR) inhibitors and other targeted therapies in MSI 高 colorectal cancer (CRC) cell models

[1107] Example 2

[1108] In a long-term proliferation assay lasting up to 30 days, even at a sub-effective concentration (30 nM), the in vitro combination of compound A and ATRi (BAY1895344) showed robust inhibition of cell proliferation and a stronger response compared to compound A monotherapy in the SW48 model ( Figure 2)。

[1109] Example 3

[1110] Further data indicate that in a long-term proliferation assay lasting up to 40 days, in the SW48 model, the combination of DNA-PKi and Compound A can prevent / delay the recurrence observed after single-agent Compound A therapy (30 - 100 nM). Figure 3 )。

[1111] Example 4

[1112] The combination of Compound A (30 - 100 nM) and the WEE1 inhibitor Adavosertib (AZD1775) showed a more durable response in HCT116 Figure 4 ) and SW48 (data not shown).

[1113] Example 5

[1114] The combination of the selective inhibitor of the p53-MDM2 interaction, HDM201, and Compound A showed strong inhibition of cell proliferation in SW48, even at a sub-effective concentration of Compound A (30 nM). Figure 5 )。

[1115] Example 11

[1116] In the HCT116 and SW48 models, the combination of Compound A and trametinib induced stronger inhibition of cell proliferation compared to single-agent Compound A therapy (30 nM). In a long-term proliferation assay lasting up to 35 days, a more durable response was observed compared to single-agent Compound A therapy (100 nM). Figure 11 )。

[1117] Example 21

[1118] In a long-term proliferation assay lasting up to 40 days, even at a sub-effective concentration of Compound A (30 nM), the combination of Compound A and the dual CHK1 / 2 inhibitor (AZD7762) produced enhanced anti-proliferative effects in the SW48 model, and a more durable response was achieved with 100 nM Compound A. Figure 21 )。

[1119] Example 34

[1120] In the HCT116 model, the combination of Compound A and mitomycin C induced stronger inhibition of cell proliferation compared to single-agent Compound A therapy (30 nM). In a long-term proliferation assay lasting up to 28 days, a more durable response was observed compared to single-agent Compound A therapy (100 nM).Figure 34 )。

[1121] Examples 6 and 7: The in vitro proliferative effect of compound A in combination with ionizing radiation in an MSI 高 colorectal cancer (CRC) cell model

[1122] External beam irradiation is widely used in cancer treatment. The in vitro combination of compound A with ionizing radiation (IR) was tested in the SW48 model and a dose-dependent increase in cytotoxicity was observed compared to single therapy treatment ( Figure 6 and 7 ). This is particularly interesting as an increase in cytotoxicity was achieved even when both therapies were used at sub-effective doses.

[1123] Examples 12 and 15 - 18:

[1124] All animal studies were conducted in accordance with the procedures covered by license number 2275 issued by the Veterinary Office of the Canton of Basel-Stadt and in strict compliance with the Federal Animal Protection Act and the Federal Animal Welfare Ordinance. All animals were allowed to acclimatize for 7 days and were housed in a pathogen-controlled environment (5 mice / Type III cage), with free access to food and water, and were identified with transponders.

[1125] Example 12( Figure 12 )

[1126]

[1127] Compound A was freshly prepared weekly and stored at 4 °C in the dark. The compound was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107 - 100G, SIGMA) in water (#10977023, Invitrogen) and administered p.o. Trametinib was freshly prepared every 3 weeks and stored at room temperature in the dark. Trametinib was dissolved in 0.5% hydroxypropyl methylcellulose (HPMC, #09963 - 500, SIGMA) and 0.2% Tween-80 (#P4780 - 500ML, SIGMA) in distilled water.

[1127] 5.0 × 10 6 SW48 colorectal cancer cells were subcutaneously implanted into nude mice (Charles River, Germany). When the tumors reached a volume of 150 - 200 mm 3 treatment was initiated. Efficacy studies were conducted as described above and tumor responses were measured.

[1128] In all tumor-bearing mice, 40 mg / kg of Compound A as a single agent continuously induced 40% tumor regression over 30 days, followed by tumor recurrence. As expected, 0.3 mg / kg of trametinib treatment had no effect on BRAF WT SW48 tumor growth. Interestingly, the combination of Compound A with a clinically relevant dose of trametinib showed 95% tumor regression, lasting until day 40. Thereafter, only 30% of the mice had recurrence during the treatment. Unexpectedly, the combination of Compound A and trametinib showed robust benefits and translated into a uniform regression of the BRAF WT MSI 高 SW48 model.

[1129] Example 15( Figure 15 )

[1130] Compound A was freshly prepared weekly and stored at 4 °C in the dark. The compound was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107-100G, Sigma) in water (#10977023, Invitrogen) and administered p.o. BAY-1895344 was freshly prepared weekly and stored at RT in the dark. BAY-1895344 was dissolved in PBS (#10010072, Thermo Fisher Scientific), and then the pH was adjusted to 2 - 2.5 using 1N HCl (#717631L, Fluka).

[1131] 5.0 × 10 6 SW48 colorectal cancer cells were subcutaneously implanted into nude mice (Charles River, Germany). When the tumors reached a volume of 150 - 200 mm 3 , treatment was initiated. The efficacy study was conducted as described above and tumor response was measured.

[1132] Treatment with 50 mg / kg of the ATR inhibitor AZD6738 (BAY-1895344) had no effect on SW48 tumor growth. In all tumor-bearing mice, 20 mg / kg of Compound A as a single agent continuously induced 15% tumor regression over 30 days, followed by tumor recurrence. Interestingly, the combination of a suboptimal dose of Compound A with a non-effective high dose of BAY-1895344 showed 94% tumor regression, with no recurrence until day 105. As mechanistically expected, the combination of Compound A and BAY-1895344 showed strong benefits and translated into a uniform and sustained regression of the MSI 高 SW48 model.

[1133] Example 16( Figure 16 )

[1134] Compound A was freshly prepared weekly and stored in the dark at 4°C. The compound was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107-100G, Sigma-Aldrich) in water (#10977023, Invitrogen) and administered p.o. BAY-1895344 was freshly prepared weekly and stored in the dark at RT. BAY-1895344 was dissolved in PBS (#10010072, Thermo Fisher Scientific), and the pH was then adjusted to 2 - 2.5 using 1N HCl (#717631L, Fluka).

[1135] Surgically resected tumor tissues from untreated cancer patients were implanted into the right flank of nude mice (Charles River, Germany). All samples were anonymized and obtained with informed consent and approval from the institutional review board of the tissue provider and Novartis AG. After serial passaging in mice, the PDX models were histologically characterized and genetically analyzed using various technology platforms. External diagnoses were independently confirmed by in-house pathologists. As previously described, MSI was induced and amplified in CRC HX-2861 tumors by transplantation (Gao, 2015). Approximately 20 - 30 mg of frozen tissue fragments embedded in Matrigel (#354234, Corning) were subcutaneously implanted into the right flank area of nude mice using a trocar. The successfully transplanted tumor models were then passaged to generate sufficient tumor-bearing mice for inclusion in the efficacy experiments. Treatment was initiated when the tumors reached 150 - 200 mm 高 When the tumors reached 150 - 200 mm 3 in size.

[1136] Treatment with 25 mg / kg of the ATR inhibitor AZD6738 (BAY-1895344) had no effect on HX-2861 tumor growth. 40 mg / kg of Compound A as a single agent induced a uniform and sustained stable disease. Interestingly, the combination of Compound A with a sub-effective dose of BAY-1895344 showed 50% tumor regression with no recurrence until day 74. As mechanistically anticipated, the combination of Compound A and BAY-1895344 showed a strong benefit and translated into uniform and sustained regression in the MSI 高 HX-2861 model.

[1137] Example 17( Figure 17 )

[1138] Compound A was freshly prepared weekly and stored in the dark at 4°C. The compound was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107-100G, Sigma-Aldrich) in water (#10977023, Invitrogen) and administered p.o. XRad320 from Precision X-Ray was used TMIrradiation was performed using an adjustable X-ray collimator (#XD1601-0000, Precision X-ray Inc.). Only the subcutaneously implanted tumors were irradiated by using a specific protective shield (#XD1907-2012, Precision X-ray Inc.).

[1139] 1.0×10 7 IM95 gastric cancer cells were subcutaneously implanted into SCID-BEIGE mice (Charles River Laboratories, Germany). Treatment was initiated when the tumors reached a volume of 200 mm 3 . Efficacy studies were conducted as described above and tumor responses were measured.

[1140] Irradiation of the IM95 tumors at 5 Gy induced a persistent and uniform stable disease. In all tumor-bearing mice, 30 mg / kg of Compound A as a single agent also induced a stable disease continuously over 21 days, but the tumors then recurred. Interestingly, the combination showed a 35% tumor regression and no recurrence was observed until day 28. As mechanically expected, the combination of Compound A and irradiation showed interesting benefits and translated into a uniform and continuous regression in the MSI 高 IM95 model.

[1141] Example 18( Figure 18 )

[1142] Compound A was freshly prepared weekly and stored in the dark at 4 °C. The compound was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107-100G, Sigma-Aldrich) in water (#10977023, Invitrogen) and administered p.o. Irinotecan was freshly prepared weekly. Irinotecan was dissolved in 0.9% NaCl (#395158, B. Braun).

[1143] 5.0×106 SW48 colorectal cancer cells were subcutaneously implanted into nude mice (Charles River Laboratories, Germany). Treatment was initiated when the tumors reached a volume of 150 - 200 mm3. Efficacy studies were conducted as described above and tumor responses were measured.

[1144] Treatment with irinotecan at 60 mg / kg weekly had no effect on the growth of SW48 tumors. In all tumor-bearing mice, 20 mg / kg of Compound A as a single agent continuously induced a stable disease over 21 days, but the tumors then recurred. Interestingly, the combination of a suboptimal dose of Compound A and a non-effective high dose of irinotecan showed a 99% tumor regression and no recurrence was observed until day 42. As mechanically expected, the combination of Compound A and irinotecan showed strong benefits and translated into a uniform and continuous regression in the MSI 高 SW48 model.

[1145] Examples 19 and 20 (corresponding respectively to Figure 19 and 20 ): Cell lines were obtained from ATCC and used with the media and culture conditions recommended by ATCC. All cells were maintained in a humidified 5% CO2 incubator at 37 °C. Cells were seeded at 400 HCT116 cells or 300 SW48 cells per well in 1 ml of media in a 12-well plate. The WRN inhibitor example compound B was added at an initial concentration of 2 μM, with or without picolinostat (when used, concentration: for SW48 cells, 0.5 μM ( Figure 19 ); for HCT116 cells, 2.5 μM ( Figure 20 )). After incubation overnight at 37 °C in a humidified 5% CO2 atmosphere, eleven 2-fold serial dilutions of the given compound stock solution (obtained at a concentration of 10 mM in DMSO and stored at 4 °C) were directly dispensed into each assay plate using an HP300D non-contact digital dispenser (Tecan). In all wells, the final concentration of DMSO was normalized to 0.1%. The cells were placed in the incubator for 10 - 20 days and the media was changed every 3 - 4 days. Thereafter, 100 μl of 37% formaldehyde was added directly to each test well and incubated at room temperature for 15 minutes. After rinsing twice with 5 ml of water, 1 ml of crystal violet (Sigma #HT90132) was added at room temperature for 15 minutes. The wells were rinsed three times with water and the plates were photographed. After scanning, 1 mL of 10% acetic acid was added to the plates and shaken until the color was completely dissolved. 200 μl of this solution was transferred to a 96-well plate and the absorbance was measured at 600 nM using a microplate reader (Synergy HT). Figure 19 and 20 depict images of the stained plates with colonies using the WRN inhibitor compound B from 1.95 nM to 2000 nM (2-fold increments) with or without picolinostat. The graphs are signal quantifications relative to DMSO for the individual WRNi (top graph of each figure) or relative to DMSO within the plate (i.e., in the presence of picolinostat).

[1146] Example 22:

[1147] After treatment with the combination of the WRN inhibitor compound B and doxorubicin for 4 days, the in vitro viability of colorectal cancer cell lines was evaluated using CellTiterGlo. The proliferation of HCT116 cells was inhibited by compound B alone and doxorubicin alone. Additionally, the combination showed a synergistic growth inhibitory effect (Loewe score of 3.110) compared to either treatment alone ( Figure 22 )

[1148] Example 23:

[1149] After 4 days of treatment with WRN inhibitor compound B in combination with 5-fluorouracil, the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and 5-fluorouracil alone. Additionally, compared with either treatment alone, the combination showed a synergistic growth inhibitory effect (Loewe score of 2.370)( Figure 23 ).

[1150] Example 24:

[1151] After 4 days of treatment with WRN inhibitor compound B in combination with aphidicolin, the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and aphidicolin alone. Additionally, compared with either treatment alone, the combination slightly showed a synergistic growth inhibitory effect (Loewe score of 1.330)( Figure 24 ).

[1152] Example 25:

[1153] After 4 days of treatment with WRN inhibitor compound B in combination with QAP1, the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and QAP1 alone. Additionally, compared with either treatment alone, the combination slightly showed a synergistic growth inhibitory effect (Loewe score of 1.188).

[1154] ( Figure 25 )

[1155] Example 26:

[1156] After 4 days of treatment with WRN inhibitor compound B in combination with bleomycin, the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and bleomycin alone. Additionally, compared with either treatment alone, the combination slightly showed a synergistic growth inhibitory effect (Loewe score of 1.560)( Figure 26 ).

[1157] Example 27:

[1158] After 4 days of treatment with WRN inhibitor compound B in combination with cisplatin, the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and cisplatin alone. Additionally, compared with either treatment alone, the combination slightly showed a synergistic growth inhibitory effect (Loewe score of 1.450)( Figure 27)。

[1159] Example 28:

[1160] After treating with WRN inhibitor compound B in combination with doxorubicin for 4 days, the in vitro viability of colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and doxorubicin alone. In addition, compared with either treatment alone, the combination showed a synergistic growth inhibitory effect (Loewe score of 5.420)( Figure 28 )。

[1161] Example 29:

[1162] After treating with WRN inhibitor compound B in combination with gemcitabine for 4 days, the in vitro viability of colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and gemcitabine alone. In addition, compared with either treatment alone, the combination showed a synergistic growth inhibitory effect (Loewe score of 4.700)( Figure 29 )。

[1163] Example 30:

[1164] After treating with WRN inhibitor compound B in combination with HDM201 for 4 days, the in vitro viability of colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and, to some extent, HDM201 alone. In addition, compared with either treatment alone, the combination showed a synergistic growth inhibitory effect (Loewe score of 7.940)( Figure 30 )。

[1165] Example 31:

[1166] After treating with WRN inhibitor compound B in combination with camptothecin for 4 days, the in vitro viability of colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and camptothecin alone. In addition, compared with either treatment alone, the combination showed a synergistic growth inhibitory effect (Loewe score of 2.580)( Figure 31 )。

[1167] Example 32:

[1168] After 4 days of treatment with the WRN inhibitor compound B in combination with KU-60019, the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and by KU-60019 alone. In addition, the combination showed a slightly synergistic growth inhibitory effect (Loewe score of 1.420) compared to either treatment alone ( Figure 32 ).

[1169] Example 33:

[1170] After 4 days of treatment with the WRN inhibitor compound B in combination with NU7441 (KU-57788), the in vitro viability of the colorectal cancer cell line SW48 was evaluated using CellTiterGlo. The proliferation of SW48 cells was inhibited by compound B alone and by NU7441 (KU-57788) alone. In addition, the combination showed a synergistic growth inhibitory effect (Loewe score of 9.140) compared to either treatment alone ( Figure 33 ).

[1171] Example 35: In vivo efficacy of WRN inhibitor compound A after administration in nude mice bearing SW620 colorectal cancer MSS (microsatellite stability) xenografts. Combination with temozolomide and / or irinotecan. Materials and methods

[1172] Results

[1173] SW620 (CCL-227, ATCC) [MSS colorectal carcinoma (CRC)] was cultured in DMEM (#1-26F01-I, AMIMED) supplemented with 10% FCS (#2-0-1F30-I, Bioconcept), 4 mM L-glutamate (#5-10K50-H, Bioconcept), and 1 mM sodium pyruvate (#5-60F00-H, Bioconcept). Cells were passaged by first washing with Dulbecco's PBS (without Ca 2+ / Mg 2+ )(#3-05F29-I, AMIMED), trypsinizing the cells with EDTA and 0.05% trypsin (in PBS) (#5-51F00-H, AMIMED), centrifuging in their respective media, and splitting the cells 1:8 into fresh media twice a week.

[1174] Upon arrival at the animal facility, athymic nude mice (Charles River, Germany) were allowed to acclimatize for 7 days and were housed in a pathogen-controlled environment (5 mice / cage type III) with free access to food and water. The animals were identified with transponders. The studies described in this report were conducted according to procedures covered by the license number issued by the Veterinary Office of the Canton of Basel-Stadt.

[1175] By injecting 5.0 x 10 6 SW620 tumor cells (in 50% Matrigel (#354234, Corning) in HBSS (#H6648, Sigma)) into the right flank of nude mice to initiate subcutaneous tumors. Efficacy experiments were started 11 days after cell injection (n = 6).

[1176] Compound A and temozolomide were freshly prepared weekly and stored at 4 °C in the dark. Compound A was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107-100G, Sigma) in UltraPure TM water (#10977-035, Invitrogen) and administered p.o. at 10 mL / kg. Temozolomide was dissolved in 30% PEG-400 (#202398-500G, Sigma) and 70% Dulbecco's PBS without Ca 2+ / Mg 2+ )(#3-05F29-I, AMIMED) and administered p.o. at 10 mL / kg for 5 consecutive days in a 21-day cycle. Irinotecan was freshly prepared weekly for each treatment by diluting with 0.9% NaCl (#3-06S00-I, Bioconcept). The solution was administered i.v. at 5 mL / kg.

[1177] Tumor volume (TVol) was measured twice a week, and tumor volume was determined from caliper measurements (using the formula l*w2*π / 6). Tumor response was quantified as T / C (the ratio of tumor volume in the treatment group to that in the untreated control group) by the change in tumor volume (end point minus starting value, in mm3). In the case of tumor regression or for assessing the percentage change in TVol, tumor response was quantified by the percentage regression of the starting TVol. Animal body weight (BW) was measured three times a week to calculate the percentage change in BW (Δ%BW) relative to the treatment start day (day 0) at any given time point.

[1178] Figure 35

[1179] Figure 36 Shows the mean tumor volume in nude mice bearing SW620 (CCL-227, ATCC) [MSS colorectal cancer (CRC)] xenografts after treatment with irinotecan alone or in combination with compound A. Starting 11 days after cell injection, irinotecan was administered intravenously to the first group at 15 mg / kg once a week for 4 weeks, and to the second group at 15 mg / kg once a week for 5 weeks, combined with oral administration of compound A at 120 mg / kg once a day for 31 days.

[1180] Figure 37 Shows the mean tumor volume in nude mice bearing SW620 (CCL-227, ATCC) [MSS colorectal cancer (CRC)] xenografts after pretreatment with temozolomide and then subsequent treatment with temozolomide, irinotecan, and Compound A. Starting on day 11 after cell injection, temozolomide was orally administered at 100 mg / kg for 5 consecutive days (days 11 to 15 and days 32 to 36) and continued for 5 consecutive days in a 21-day cycle as indicated by the temozolomide (TMZ) dose shown. On day 43 after cell injection, irinotecan was intravenously administered at 15 mg / kg once a week for 7 weeks and in combination with Compound A orally administered at 120 mg / kg once a day starting on day 43 for 52 days.

[1181] Conclusion: Shows the mean tumor volume in nude mice bearing SW620 (CCL-227, ATCC) [MSS colorectal cancer (CRC)] xenografts after pretreatment with temozolomide and then subsequent treatment with either irinotecan alone or a combination of just irinotecan and Compound A. Starting on day 11 after cell injection, temozolomide was orally administered at 100 mg / kg for 5 consecutive days (days 11 to 15 and days 32 to 36) in a 21-day cycle for 5 consecutive days. On day 43 after cell injection, irinotecan was intravenously administered at 15 mg / kg once a week for 6 weeks to the first group and at 15 mg / kg once a week for 6 weeks to the second group and in combination with Compound A orally administered at 120 mg / kg once a day starting on day 43 for 46 days.

[1182] Figure 38

[1183] Treatment of parental SW620 tumors with irinotecan or a combination of irinotecan and compound A induced tumor growth delay. In all treatment groups, treatment with 1 cycle of temozolomide (TMZ) induced 30%-50% tumor regression, and after 3 weeks, recurrence occurred in all treatment groups. After the second cycle of TMZ treatment, all tumors no longer responded. One group was sacrificed, and the other 2 groups were treated with irinotecan or a combination of irinotecan and compound A. Overall, the combination induced stronger tumor regression, reaching maximum regression 15-19 days after the start of treatment. In both cases, when treated with irinotecan and compound A, tumors recurred with subsequent delay. Another group treated with irinotecan and compound A while still receiving TMZ therapy was also included. Interestingly, this triple combination maintained tumor size between stable disease and 50% regression for over 40 days. Tumors only recurred when irinotecan and compound A were discontinued on day 95, which shows that the triple combination has significant benefits.

[1184] Additional efficacy results ( Figure 38 and 39 )

[1185] ( Figure 39 ) Treatment of parental SW620 tumors with irinotecan, compound A, or a combination of the two induced a delay in tumor growth. Treatment with temozolomide (TMZ) alone or in combination with compound A for 1 cycle induced 40% tumor regression and recurrence after 3 weeks. After the second cycle of TMZ treatment, all tumors in both treatment groups no longer responded.

[1186] ( Tolerance ) TMZ in combination with irinotecan or a combination of irinotecan and compound A induced 60%-70% tumor regression in both treatment groups and there was no recurrence after 3 cycles of TMZ. A dose reduction of 25 mg / kg of TMZ and 5 mg / kg of irinotecan for 2 cycles did not affect tumor regression in both treatment groups. However, after discontinuation of temozolomide and irinotecan on day 129, significant differentiation was induced in both groups. In fact, the group that discontinued all treatment (hollow triangles) showed recurrence within 5 weeks, while the group that was still treated only with compound A maintained less than 50% tumor regression. These data show that repeated treatment with TMZ and irinotecan sensitizes SW620 tumors to compound A.

[1187] Figure 40

[1188] ( Example 36: In vivo efficacy of WRN inhibitor compound A after administration in nude mice bearing T84 colorectal cancer MSS (microsatellite stability) xenografts ) Overall, all treatments were well tolerated. Temozolomide (TMZ) as a single agent or as a triple combination caused dose-dependent weight loss, but mice always recovered by the end of the 21-day cycle.

[1189] Combination with temozolomide and / or irinotecanEfficacy results

[1190] T84 (CCL-248, ATCC) is a MSS colorectal carcinoma (CRC). It was cultured in DMEM (#1-26F01-I, AMIMED) supplemented with 10% FCS (#2-0-1F30-I, Bioconcept), 4 mM L-glutamate (#5-10K50-H, Bioconcept), and 1 mM sodium pyruvate (#5-60F00-H, Bioconcept). Cells were passaged by first washing with Dulbecco's PBS (without Ca 2+ / Mg 2+ )(#3-05F29-I, AMIMED), trypsinizing the cells with EDTA and 0.05% trypsin (in PBS) (#5-51F00-H, AMIMED), centrifuging in their respective media, and splitting the cells 1:8 into fresh media twice a week.

[1191] Upon arrival at the animal facility, athymic nude mice (Charles River, Germany) were allowed to acclimatize for 7 days and were housed in a pathogen-controlled environment (5 mice / Type III cage) with free access to food and water. Animals were identified with transponders. The studies described in this report were conducted according to procedures covered by license number 1975 issued by the Veterinary Office of the Canton of Basel-Stadt and in strict compliance with the Federal Animal Protection Act and the Federal Animal Welfare Ordinance.

[1192] Subcutaneous tumors were induced by injecting 5.0 x 10 6 T84 tumor cells (in 50% Matrigel (#354234, Corning) in HBSS (#H6648, Sigma)) into the right flank of nude mice. Approximately 7 days after cell injection, the efficacy experiments were initiated (n = 6).

[1193] Compound A and temozolomide were freshly prepared weekly and stored in the dark at 4 °C. Compound A was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107-100G, Sigma) in UltraPure TM water (#10977-035, Invitrogen) and administered p.o. at 120 mg / kg and 10 mL / kg. Temozolomide was dissolved in 30% PEG-400 (#202398-500G, Sigma) and 70% Dulbecco's PBS (without Ca 2+ / Mg 2+)(#3-05F29-I, AMIMED) and administered p.o. at 25 mg / kg and 10 mL / kg for 5 consecutive days within a 28-day cycle. Irinotecan was freshly formulated for each treatment once a week by dilution with NaCl 0.9% (#3-06S00-I, Bioconcept). The solution was administered i.v. at 5 mg / kg and 5 mL / kg.

[1194] Tumor volume (TVol) was measured twice a week, and tumor volume was determined from caliper measurements (using the formula l*w2*π / 6). Tumor response was quantified as T / C by the change in tumor volume (end point minus starting value, in mm3). In the case of tumor regression or for assessing the percentage change in TVol, tumor response was quantified by the percentage regression of the starting TVol. Animal body weight (BW) was measured three times a week to calculate the percentage change in BW (Δ%BW) relative to the treatment start day (day 0) at any given time point.

[1195] Figure 41

[1196] ( Figure 42 ) Treatment of parental T84 tumors with compound A had no effect on tumor growth. Treatment with irinotecan or in combination with compound A induced tumor growth delay. Treatment with temozolomide (TMZ) alone or in combination with compound A for 1 cycle induced 30%-40% tumor regression, followed by rapid recurrence. After the second cycle of TMZ treatment, all tumors in both treatment groups no longer responded.

[1197] ( Tolerance results ) TMZ in combination with irinotecan or the combination of irinotecan and compound A induced 60%-70% tumor regression in both treatment groups and there was no recurrence after 4 cycles of TMZ. After this time point, the dual combination began to slowly recur and returned to baseline levels at day 179. However, no recurrence was observed in the triple combination treatment group, and 80% tumor regression was achieved at day 179. These data show that repeated treatment with TMZ and irinotecan sensitizes T84 tumors to compound A and differentiation can be achieved after long-term treatment.

[1198] Figure 43

[1199] ( Example 37: In vivo efficacy of WRN inhibitor compound A after administration in combination with temozolomide and irinotecan in nude mice bearing SHP-77 small cell lung cancer (SCLC) MSS (microsatellite stability) xenografts ) Overall, all treatments were well tolerated. Temozolomide (TMZ) as a single agent or as part of the triple combination caused slight weight loss but the mice always recovered by the end of the 28-day cycle.

[1200] Efficacy results Figure 44

[1201] SHP-77 (CRL-2195, ATCC) is a MSS small cell lung cancer (SCLC). It was cultured in RPMI 1640 medium GlutaMAX supplemented with 10% FCS (#2-0-1F30-I, BioConcept) TM (#61870036, Gibco). Cells were passaged by first washing with Dulbecco's PBS (without Ca 2+ / Mg 2+ )(#3-05F29-I, AMIMED), trypsinizing the cells with EDTA and 0.05% trypsin (in PBS) (#5-51F00-H, AMIMED), centrifuging in their respective media, and splitting the cells 1:8 into fresh media twice a week.

[1202] After arrival at the animal facility, athymic nude mice (Charles River, Germany) were allowed to acclimatize for 7 days and were housed in a pathogen-controlled environment (5 mice / cage type III) with free access to food and water. Animals were identified with transponders. The studies described in this report were conducted according to procedures covered by license number 1975 issued by the Veterinary Office of the Canton of Basel-Stadt and in strict compliance with the Federal Animal Protection Law and the Federal Animal Welfare Ordinance.

[1203] Subcutaneous tumors were induced by injecting 2.0 x 10 6 SHP-77 tumor cells (in 50% Matrigel (#354234, Corning) in HBSS (#H6648, Sigma)) into the right flank of nude mice. Approximately 27 days after cell injection, the efficacy experiments were initiated (n = 6 - 12).

[1204] Compounds A and temozolomide were freshly prepared weekly and stored in the dark at 4°C. Compound A was dissolved in 20% hydroxypropyl-β-cyclodextrin (HP-β-CD, #H107-100G, Sigma) in UltraPure TM water (#10977-035, Invitrogen) and administered p.o. at 120 mg / kg and 10 mL / kg. Temozolomide was dissolved in 30% PEG-400 (#202398-500G, Sigma) and 70% Dulbecco's PBS (without Ca 2+ / Mg 2+)(#3-05F29-I, AMIMED) and administered p.o. at 25 mg / kg and 10 mL / kg for 5 consecutive days within a 28-day cycle. Irinotecan was freshly formulated for each treatment once a week by dilution with NaCl 0.9% (#3-06S00-I, BioConcept). The solution was administered i.v. at 5 or 15 mg / kg and 5 mL / kg.

[1205] Tumor volume (TVol) was measured twice a week, and tumor volume was determined from caliper measurements (using the formula l*w2*π / 6). Tumor response was quantified as T / C by the change in tumor volume (end point minus starting value, in mm3). In the case of tumor regression or for assessing the percentage change in TVol, tumor response was quantified by the percentage regression of the starting TVol. Animal body weight (BW) was measured three times a week to calculate the percentage change in BW (Δ%BW) relative to the treatment start day (day 0) at any given time point.

[1206] Figure 45

[1207] ( Tolerance results ) Treatment of parental SHP77 tumors with irinotecan had no effect on tumor growth. Treatment with temozolomide (TMZ) induced 90% tumor regression after 2 cycles, followed by slow recurrence. After the 3rd cycle of TMZ treatment, tumors that were no longer responsive to TMZ were included in 2 treatment groups: TMZ + irinotecan and TMZ + irinotecan + compound A.

[1208] ( Figure 46 ) Adding irinotecan to TMZ stabilized tumor growth for 46 days (days 111 to 157), but then significantly relapsed. However, adding compound A on top of the dual combination showed a stable disease for 87 days (days 111 to 198) and significantly prevented relapse of the dual combination. These data show that repeated treatment with TMZ, followed by TMZ + irinotecan, sensitizes SHP-77 tumors to compound A and differentiation can be achieved after long-term treatment.

[1209] ​

[1210] ( ​ and 47 ) Temozolomide (TMZ) was well tolerated as a single agent, while irinotecan (15 mg / kg) caused a slight weight loss. Over time, the dual combination showed a stable average body weight, while the triple combination caused a slight weight loss with a recovery period.

Claims

1. A WRN inhibitor for use in cancer treatment, wherein the treatment further comprises administering: i. An agent that can ο Sensitize cancer cells, e.g., for improving the response to WRN inhibitor treatment, ο Prime cancer cells, e.g., such priming can include triggering a highly mutagenic state in cancer cells, ο Produce or increase MMR deficiency in cancer cells, ο Produce or increase the MSI-H state in cancer cells, or ο Increase the MMR heterogeneity of cancer cells, And optionally, wherein the treatment further comprises administering: ii. Chemotherapy, such as irinotecan.

2. A WRN inhibitor for use as described in claim 1, wherein the cancer is an MSS (microsatellite stability) cancer.

3. A WRN inhibitor for use as described in claim 1 or claim 2, wherein the agent i. is selected from temozolomide, cisplatin, and 6-thioguanine, or the agent i. is an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals.

4. A WRN inhibitor for use as described in any one of claims 1 to 3, wherein the agent i. is temozolomide.

5. A WRN inhibitor for use as described in any one of claims 1 to 4, wherein the treatment further comprises administering i. temozolomide and ii. irinotecan.

6. A WRN inhibitor for use as described in any one of claims 1 to 5, wherein the WRN inhibitor is a compound of formula (1g) or a pharmaceutically acceptable salt thereof: Wherein R1 is selected from: R 15 is H or F; R 16 is H or R 25 (R 24 )N-; R 17 is H or F; R 18 is H or F; R 19 is H or F; R 20 is H or F; R 21 is H or CH3; R 22 is H, CF3, CHF2CH2, HOC(O)-CH2-, H3C-C(O)-, (H3C)3C-O-C(O)-; R 23 is H, CF3, CHF2CH2-, (H3C)3C-O-C(O)-; R 24 is CH3; R 25 is CHF2CH2-; R 26 is CH3, H or deuterium; R 27 is H or deuterium; R2 is the following moiety: Where R6 is selected from H, Cl, CH3, F, and Br; R8 is selected from H, Cl, F, and CF3; R9 is selected from H, CH3, and Cl; R 28 selected from CF3, CF2H, -CH2CH3, Cl, SF5, Br, and -C(O)H; X is selected from C-R7 and N; R7 is selected from H and F; R3 is selected from CH3, CH2CH3, cyclopropyl, and hydroxyethyl; R4 is selected from: Where R 10 selected from H, F, Cl, CH3, and OCF3; R 11 selected from H, Cl, F, and CH3; R 12 selected from H, Cl and CH3; R 13 selected from H and CH3; R 14 selected from H, CH3, -CH2CH3, cyclopropyl, -OCHF2, OCF3, and Cl; y is 0, 1, or 2; R5 is CH3; or alternatively, two R5 groups on adjacent carbon atoms together with the carbon atoms to which they are attached form a fused cyclobutyl ring: And * represents the point of attachment.

7. A WRN inhibitor for use as described in any one of claims 1 to 6, wherein the WRN inhibitor is compound A: or a pharmaceutically acceptable salt thereof.

8. A WRN inhibitor for use as described in any one of claims 1 to 7, wherein the cancer is selected from colorectal cancer (CRC), e.g., colon adenocarcinoma or rectal adenocarcinoma; gastric cancer, e.g., gastric adenocarcinoma; prostate cancer; endometrial cancer; adrenocortical cancer, e.g., adrenocortical carcinoma; cervical cancer, e.g., cervical squamous cell carcinoma or cervical adenocarcinoma; uterine cancer, e.g., uterine corpus endometrial cancer and uterine carcinosarcoma; esophageal cancer, e.g., esophageal carcinoma; Breast cancer, e.g., breast carcinoma or triple-negative breast carcinoma; renal cancer, e.g., renal clear cell carcinoma; ovarian cancer, e.g., ovarian serous cystadenocarcinoma; glioma; glioblastoma; neuroendocrine tumor; melanoma; small cell lung cancer and sarcoma; particularly colorectal cancer or small cell lung cancer.

9. A WRN inhibitor for use as described in any one of claims 1 to 8, wherein the cancer is selected from MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-silenced cancer, or MSS (microsatellite stability) cancer with MGMT methylation.

10. A WRN inhibitor for use as described in any one of claims 1 to 9, wherein the agent is administered i. as follows: · Before treatment with the WRN inhibitor, as a pretreatment agent, · As a combination agent with the WRN inhibitor, without pretreatment, · Both as a pretreatment agent and as a combination agent with the WRN inhibitor.

11. A WRN inhibitor for use as described in any one of claims 1 to 10, wherein the agent is temozolomide, and temozolomide is administered as follows: · Before administering the WRN inhibitor, as a pretreatment, or · Administered in combination with the WRN inhibitor, without temozolomide pretreatment, or · Before administering the WRN inhibitor, as a pretreatment, followed by combination therapy comprising temozolomide and the WRN inhibitor, and the treatment preferably further comprises administering irinotecan.

12. A combination comprising i) a WRN inhibitor and ii) temozolomide, and optionally, iii) irinotecan.

13. The combination according to claim 12, for use in the treatment of cancer, wherein the cancer is MSI-H, dMMR or MSS cancer, particularly MSS cancer.

14. The combination according to claim 12, for use as described in claim 13, wherein the cancer is selected from colorectal cancer (CRC), such as colon adenocarcinoma or rectal adenocarcinoma; gastric cancer, such as gastric adenocarcinoma; prostate cancer; endometrial cancer; adrenocortical cancer, such as adrenocortical carcinoma; cervical cancer, such as cervical squamous cell carcinoma or cervical adenocarcinoma; uterine cancer, such as uterine corpus endometrial cancer and uterine carcinosarcoma; esophageal cancer, such as esophageal carcinoma; breast cancer, such as breast cancer or triple-negative breast cancer; renal cancer, such as renal clear cell carcinoma; ovarian cancer, such as ovarian serous cystadenocarcinoma; glioma; glioblastoma; neuroendocrine tumor; melanoma; small cell lung cancer and sarcoma; particularly colorectal cancer or small cell lung cancer, especially MSS colorectal cancer or MSS small cell lung cancer.

15. The combination according to claim 12, for use as described in claim 13 or 14, wherein the cancer is selected from MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-deficient cancer, or MSS (microsatellite stability) MGMT-silenced cancer, or MSS (microsatellite stability) cancer with MGMT methylation.

16. The combination according to claim 12, for use as described in any one of claims 13 to 15, wherein the WRN inhibitor is a compound of formula (1g) or a pharmaceutically acceptable salt thereof: wherein R1 is selected from: R 15 is H or F; R 16 is H or R 25 (R 24 )N-; R 17 is H or F; R 18 is H or F; R 19 is H or F; R 20 is H or F; R 21 is H or CH3; R 22 is H, CF3, CHF2CH2, HOC(O)-CH2-, H3C-C(O)-, (H3C)3C-O-C(O)-; R 23 is H, CF3, CHF2CH2-, (H3C)3C-O-C(O)-; R 24 is CH3; R 25 is CHF2CH2-; R 26 is CH3, H or deuterium; R 27 is H or deuterium; R2 is the following moiety: wherein R6 is selected from H, Cl, CH3, F, and Br; R8 is selected from H, Cl, F, and CF3; R9 is selected from H, CH3, and Cl; R 28 selected from CF3, CF2H, -CH2CH3, Cl, SF5, Br, and -C(O)H; X is selected from C-R7 and N; R7 is selected from H and F; R3 is selected from CH3, CH2CH3, cyclopropyl, and hydroxyethyl; R4 is selected from: wherein R 10 selected from H, F, Cl, CH3, and OCF3; R 11 selected from H, Cl, F, and CH3; R 12 selected from H, Cl, and CH3; R 13 selected from H and CH3; R 14 selected from H, CH3, -CH2CH3, cyclopropyl, -OCHF2, OCF3 and Cl; y is 0, 1, or 2; R5 is CH3; or alternatively, two R5 groups on adjacent carbon atoms together with the carbon atoms to which they are attached are joined to form a fused cyclobutyl ring: and * represents the point of attachment.

17. The combination according to claim 12 or 16 for use in accordance with any one of claims 13 to 15, wherein the WRN inhibitor is compound A: or a pharmaceutically acceptable salt thereof.

18. The combination according to claim 12, 16, or 17 for use in accordance with any one of claims 13 to 15, wherein temozolomide is administered as follows: · As a pre-treatment, before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, without subsequent combination therapy comprising temozolomide, or · In combination, without temozolomide pre-treatment, or · As a pre-treatment, before administering the WRN inhibitor, or before administering irinotecan, or before administering both the WRN inhibitor and irinotecan, followed by combination therapy comprising temozolomide.

19. A method of treating cancer, particularly cancer with high microsatellite instability (MSI-H) or defective mismatch repair (dMMR), in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of at least one therapeutic active agent selected from the group consisting of: a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, including CHK1 and CHK2 dual inhibitors, and a DNA polymerase α inhibitor.

20. A WRN inhibitor for use in the treatment of cancer, particularly cancer with high microsatellite instability (MSI-H) or defective mismatch repair (dMMR), wherein the treatment further comprises administering at least one therapeutic active agent selected from the group consisting of: a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, including CHK1 and CHK2 dual inhibitors, and a DNA polymerase α inhibitor.

21. A combination comprising i) a WRN inhibitor, and ii) at least one therapeutic agent selected from the group consisting of: a Wee1 inhibitor, an ATR inhibitor, a DNA-PK inhibitor, ionizing radiation selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals, a MEK inhibitor, an MDM2 inhibitor, a G4-quadruplex stabilizer, an ATM inhibitor, a CHK1 inhibitor or a CHK2 inhibitor, including CHK1 and CHK2 dual inhibitors, and a DNA polymerase α inhibitor.

22. A method for treating cancer, particularly cancer with high microsatellite instability (MSI-H) or defective mismatch repair (dMMR), in a subject in need thereof, the method comprising administering to the subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of at least one chemotherapeutic agent selected from: gemcitabine, camptothecin, irinotecan Docetaxel Doxorubicin (e.g., doxorubicin hydrochloride) 5-Fluorouracil Capecitabine Etoposide Epirubicin Oxaliplatin Mitomycin (e.g., mitomycin A, mitomycin B or mitomycin C, particularly mitomycin C), cisplatin Carboplatin Bleomycin and paclitaxel In particular, the chemotherapeutic agent is selected from irinotecan 5-Fluorouracil Epirubicin Doxorubicin (e.g., doxorubicin hydrochloride) Gemcitabine, camptothecin and mitomycin C.

23. The method according to claim 19 or 22, or the WRN inhibitor for use as claimed in claim 20, wherein the cancer is a cancer with high microsatellite instability (MSI-H) or defective mismatch repair (dMMR).

24. The method according to any one of claims 19, 22 or 23, or the WRN inhibitor for use as claimed in claim 20 or 23, or the combination as claimed in claim 21, wherein the (at least one) therapeutic agent is a WEE1 inhibitor, and the WEE1 inhibitor is adavosertib (also known as AZD1775 and MK-1775).

25. The method according to any one of claims 19, 22 or 23, or the WRN inhibitor for use as claimed in claim 20 or 23, or the combination as claimed in claim 21, wherein the (at least one) therapeutic agent is the ATR inhibitor alisertib (also known as BAY-1895344).

26. The method according to any one of claims 19, 22 or 23, or the WRN inhibitor for use as claimed in claim 20 or 23, or the combination as claimed in claim 21, wherein the (at least one) therapeutic agent is the DNA-PK inhibitor AZD7648 or NU7441.

27. The method according to any one of claims 19, 22 or 23, or the WRN inhibitor for use as claimed in claim 20 or 23, or the combination as claimed in claim 21, wherein the (at least one) therapeutic agent is an ionizing radiation-based therapy selected from i) external beam radiation, ii) brachytherapy, and iii) radiopharmaceuticals.

28. The method according to any one of claims 19, 22 or 23, or the WRN inhibitor for use as claimed in claim 20 or 23, or the combination as claimed in claim 21, wherein the ionizing radiation is external beam radiation.

29. The method according to any one of claims 19, 22 or 23, or the WRN inhibitor for use as claimed in claim 20 or 23, or the combination as claimed in claim 21, wherein the (at least one) therapeutic agent is the MEK inhibitor trametinib.

30. The method according to any one of claims 19, 22 or 23, or a WRN inhibitor for use as claimed in claim 20 or 23, or a combination as claimed in claim 21, wherein the (at least one) therapeutic active agent is the MDM2 inhibitor HDM201 (also known as siramesine), or a pharmaceutically acceptable salt thereof.

31. The method according to any one of claims 19, 22 or 23, or a WRN inhibitor for use as claimed in claim 20 or 23, or a combination as claimed in claim 21, wherein the (at least one) therapeutic active agent is the G4 - quadruplex stabilizer pyridostatin.

32. The method according to any one of claims 19, 22 or 23, or a WRN inhibitor for use as claimed in claim 20 or 23, or a combination as claimed in claim 21, wherein the (at least one) therapeutic active agent is the ATM inhibitor KU - 60019.

33. The method according to any one of claims 19, 22 or 23, or a WRN inhibitor for use as claimed in claim 20 or 23, or a combination as claimed in claim 21, wherein the (at least one) therapeutic active agent is the CHK1 and CHK2 dual inhibitor AZD7762.

34. The method according to any one of claims 19 or 22 to 33, or a WRN inhibitor for use as claimed in claim 20 or 23 to 33, wherein the cancer is selected from colorectal cancer (CRC), such as colon adenocarcinoma or rectal adenocarcinoma; gastric cancer, such as gastric adenocarcinoma; prostate cancer; endometrial cancer; adrenocortical cancer, such as adrenocortical carcinoma; cervical cancer, such as cervical squamous cell carcinoma or cervical adenocarcinoma; uterine cancer, such as uterine corpus endometrial cancer and uterine carcinosarcoma; esophageal cancer, such as esophageal carcinoma; breast cancer, such as breast cancer or triple - negative breast cancer; renal cancer, such as renal clear cell carcinoma; ovarian cancer, such as ovarian serous cystadenocarcinoma; glioma; glioblastoma; neuroendocrine tumor; melanoma; small cell lung cancer and sarcoma.

35. The method according to claim 34, or a WRN inhibitor for use as claimed in claim 34, wherein the cancer is colorectal cancer (CRC) or gastric cancer, particularly colorectal cancer (CRC).

36. A method of treating colorectal cancer, particularly colorectal cancer with high microsatellite instability (MSI - H) or defective mismatch repair (dMMR), the method comprising administering to a subject a combination of a therapeutically effective amount of a WRN inhibitor and a therapeutically effective amount of a topoisomerase inhibitor.

37. The method according to claim 36, wherein the topoisomerase inhibitor is QAP1, etoposide, irinotecan or camptothecin.

38. The method according to any one of claims 19 or 22 to 35, or the method according to claim 36 or 37, or a WRN inhibitor for use as claimed in claim 20 or 23 to 35, wherein the WRN inhibitor is a compound of formula (1g) or a pharmaceutically acceptable salt thereof: wherein R1 is selected from: R 15 is H or F; R 16 is H or R 25 (R 24 )N-; R 17 is H or F; R 18 is H or F; R 19 is H or F; R 20 is H or F; R 21 is H or CH3; R 22 is H, CF3, CHF2CH2, HOC(O)-CH2-, H3C-C(O)-, (H3C)3C-O-C(O)-; R 23 is H, CF3, CHF2CH2-, (H3C)3C-O-C(O)-; R 24 is CH3; R 25 is CHF2CH2-; R 26 is CH3, H or deuterium; R 27 is H or deuterium; R2 is the following moiety: wherein R6 is selected from H, Cl, CH3, F, and Br; R8 is selected from H, Cl, F, and CF3; R9 is selected from H, CH3, and Cl; R 28 selected from CF3, CF2H, -CH2CH3, Cl, SF5, Br, and -C(O)H; X is selected from C-R7 and N; R7 is selected from H and F; R3 is selected from CH3, CH2CH3, cyclopropyl, and hydroxyethyl; R4 is selected from: wherein R 10 selected from H, F, Cl, CH3, and OCF3; R 11 selected from H, Cl, F and CH3; R 12 selected from H, Cl, and CH3; R 13 selected from H and CH3; R 14 selected from H, CH3, -CH2CH3, cyclopropyl, -OCHF2, OCF3 and Cl; y is 0, 1, or 2; R5 is CH3; or alternatively, two R5 groups on adjacent carbon atoms together with the carbon atoms to which they are attached are joined to form a fused cyclobutyl ring: and * represents the point of attachment.

39. The method according to claim 38, the WRN inhibitor for use as claimed in claim 38, or the combination as claimed in claim 21, wherein the WRN inhibitor is: or a pharmaceutically acceptable salt thereof.

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