Treatment of advanced metastatic cancer

Abstract

To provide a method for treatment of advanced metastatic cancer, in particular, advanced hepatoma.SOLUTION: A pharmaceutical composition comprises an A3AR ligand and a pharmaceutically acceptable carrier or a diluent. The pharmaceutical composition is for treating an advanced solid tumor in a mammal subject.SELECTED DRAWING: None

Description

[Technical field]

[0001] The present invention relates to the treatment of advanced metastatic cancer, in particular advanced hepatocellular carcinoma, comprising the administration of an A3AR ligand. [Background technology]

[0002] Primary liver cancer, particularly hepatocellular carcinoma (HCC), is a major global health problem due to its incidence, associated mortality, and lack of effective treatment, especially for patients with moderate or advanced liver dysfunction.

[0003] Patients with advanced HCC and Child-Pugh B (CPB) cirrhosis have borderline liver function, so the benefit of any treatment may be offset by the decline in liver function. The only curative options for these patients include successful downstaging and liver transplantation. However, this approach is only appropriate for a minority of patients and is further limited by the limited number of livers available for transplantation [Granito A.,and Bolondi L.Lancet Oncol.2017;18:e101-e112]. The most common treatment for HCC and CPB is sorafenib, a multikinase inhibitor, which is approved by the US Food and Drug Administration (FDA) for advanced HCC regardless of liver function.

[0004] CPB patients are generally excluded from clinical trials due to their poor prognosis and low expected response rates [Llovet JM, et al. J. Natl. Cancer Inst. 2008;100:698-711]. Clearly, there remains a need for treatments for HCC and CPB cirrhosis.

[0005] The Gi protein-coupled A3 adenosine receptor (A3AR) is overexpressed in various types of solid tumors, including melanoma, breast cancer, colon cancer, prostate cancer, and HCC, but low receptor expression is observed in adjacent normal tissues [Bar-Yehuda S.,et al.Int.J.Oncol.2008;33:287-295].

[0006] Namodenoson, commonly known as Cl-IB-MECA, is a highly selective, orally bioavailable A3AR agonist that induces apoptotic effects on HCC in syngeneic orthotopic and xenograft experimental animal models [Cohen S., et al., J. Cell Physiol. 2011;226:2438-2447].

[0007] An open-label phase I / II study evaluated the safety and efficacy of namodenoson in patients with advanced unresectable hepatocellular carcinoma (HCC), 67% of whom had failed prior sorafenib therapy. Median overall survival (OS) was 7.8 months in the entire study population and 8.1 months in patients on CPB (28%). Namodenoson was safe and well tolerated, and a direct correlation was observed between baseline A3AR expression levels and tumor response to namodenoson [Stemmer SM,et al.Oncologist.2013;18:25-26]. Summary of the Invention

[0008] In its first embodiment, the present invention provides a pharmaceutical composition comprising an A3AR ligand and a pharma- ceutical acceptable carrier or diluent, said pharmaceutical composition for treating advanced solid tumors in a mammalian subject.

[0009] In one embodiment, the advanced solid tumor is advanced hepatocellular carcinoma.

[0010] In one embodiment, the advanced solid tumor is metastatic hepatocellular carcinoma.

[0011] In one embodiment, the subject has advanced hepatocellular carcinoma with a Child-Pugh B (CPB) cirrhosis score of 7 (CPB7), a Child-Pugh B (CPB) cirrhosis score of 8 (CPB8), or a Child-Pugh B (CPB) cirrhosis score of 9 (CPB9).

[0012] In one embodiment, the A3AR ligand is an A3AR agonist or an A3AR allosteric modulator.

[0013] In some embodiments, the A3AR agonist is 6 -2-(4-aminophenyl)ethyladenosine (APNEA), N 6 -(4-amino-3-iodobenzyl)adenosine-5'-(N-methyluronamide) (AB-MECA), N 6 -(3-iodobenzyl)-adenosine-5'-N-methyluronamide (IB-MECA) and 2-chloro-N 6 -(3-iodobenzyl)-adenosine-5'-N-methyluronamide (Cl-IB-MECA, namodenoson).

[0014] In some embodiments, the A3AR allosteric modulator is N-(3,4-dichlorophenyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine; N-(3,4-dichlorophenyl)-2-cycloheptyl-1H-imidazo[4,5-c]quinolin-4-amine; N-(3,4-dichlorophenyl)-2-cyclobutyl-1H-imidazo[4,5-c]quinolin-4-amine; and N-(3,4-dichlorophenyl)-2-cyclohexyl-1H-imidazo[4,5-c]quinolin-4-amine.

[0015] In one embodiment, the treatment further comprises administration of an additional therapeutic agent.

[0016] In some embodiments, the additional therapeutic agent is an anti-cancer drug, such as a monoclonal antibody and / or a multikinase inhibitor.

[0017] In some embodiments, the A3AR ligand is administered once daily, twice daily, or three times daily.

[0018] In one embodiment, the A3AR ligand is administered every 12 hours during the treatment period.

[0019] In one embodiment, the A3AR ligand is administered continuously.

[0020] In one embodiment, the treatment period is divided into cycles (eg, 4 week cycles).

[0021] In one embodiment, the mammalian subject is a human subject.

[0022] In some embodiments, the A3AR ligand is administered in an amount of 50 μg / kg to 10 mg / kg body weight, preferably 100 μg / kg to 5 mg / kg body weight, or 200 μg / Kg to 1 mg / Kg body weight.

[0023] In a particular embodiment, the A3AR ligand is Cl-IB-MECA and is orally administered twice daily at a dose of 1-50 mg, preferably 5-30 mg.

[0024] In certain embodiments, the subject has been administered an A3AR ligand as a second line treatment.

[0025] In certain embodiments, the administration is for a treatment period of at least 9 months, at least 10 months, at least 1 year, at least 2 years, at least 3 years, at least 4 years, or at least 5 years.

[0026] In another aspect, the present invention provides a pharmaceutical composition comprising an A3AR ligand (e.g., Cl-IB-MECA) and a pharma- ceutical acceptable carrier or diluent, wherein the pharmaceutical composition is for extending overall survival of a subject with advanced HCC and CPB7 score.

[0027] In certain embodiments, the increase in overall survival is measured after a treatment period of 9 months, 10 months, 12 months or more, and the treatment comprises an A3AR ligand (e.g., Cl-IB-MECA) administered orally twice daily at a dose of 1-50 mg, preferably 5-30 mg.

[0028] In another aspect, the present invention provides a method for producing a pharmaceutical composition comprising: (a) a pharmaceutical composition comprising an A3AR ligand as described above; and (b) instructions for administration of the pharmaceutical composition for the treatment of a subject having an advanced solid tumor. [Brief description of the drawings]

[0029] In order to understand the invention and how it may be carried out in practice, preferred embodiments will now be described, by way of non-limiting example only, with reference to the accompanying drawings, in which:

[0030] [Figure 1] 1 is a comparative graph of 12-month overall survival (OS) in patients with a Child-Pugh score of 7 (namodenoson 25 mg BID vs. placebo). DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0031] The present invention is based on the surprising discovery that a patient with advanced HCC with CPB treated with namodenoson (Cl-IB-MECA) showed unprecedented results and complete remission of cancer after 5 years of treatment. The patient was included in a randomized, placebo-controlled Phase II study evaluating the efficacy / safety of namodenoson vs. placebo in advanced HCC CPB patients. Furthermore, the Phase II study showed the surprising efficacy of namodenoson in increasing the 12-month overall survival rate of treated patients.

[0032] The present invention is described in the following detailed description with respect to therapeutic methods for the treatment of advanced solid tumors, particularly HCC associated with CPB, comprising administration of an A3AR ligand to a subject in need thereof.

[0033] As used in the specification and claims, the forms "a," "an," and "the" include singular and plural references unless the context clearly dictates otherwise. For example, the term "A3AR ligand" includes one or more ligands.

[0034] Furthermore, as used herein, the term "comprising" is intended to mean that the method or composition includes the recited elements but does not exclude others. Similarly, "consisting essentially of" is used to define methods and compositions that include the recited elements but exclude other elements that may have essentially significant therapeutic activity against joint inflammation. For example, a composition consisting essentially of an A3AR ligand would not include or would not include only minor amounts (amounts that have a minor effect on joint inflammation) of other active ingredients that have such activity. Also, a composition consisting essentially of an A3AR ligand as defined herein would not exclude trace contaminants from isolation and purification methods, pharma- ceutically acceptable carriers such as phosphate buffered saline, excipients, preservatives, etc. "Consisting of" is intended to mean excluding trace or more of other elements. The embodiments defined by each of these transitional phrases are within the scope of the present invention.

[0035] Furthermore, all numerical values, e.g., concentrations or doses or ranges thereof, are approximations that vary (+) or (-) by up to 20%, and sometimes up to 10% of the stated value. It is to be understood, even if not always explicitly stated, that all numerical designations are preceded by the term "about". It is also to be understood, even if not always explicitly stated, that the reagents described herein are merely exemplary and that equivalents of such are known in the art.

[0036] According to the present invention, there is provided a method for treating advanced solid tumors, said method comprising administering to a mammalian subject in need thereof an A3 adenosine receptor (A3AR) ligand or a pharmaceutical composition comprising said A3AR ligand.

[0037] In certain embodiments, the advanced solid tumor is advanced hepatocellular carcinoma (HCC).

[0038] In the context of the present invention, the term "treatment" includes treating advanced solid tumors, such as advanced HCC, by administering a therapeutically effective amount of A3AR ligand to achieve desired therapeutic effect.The desired therapeutic effect may include, but is not limited to, complete or partial reversal of disease symptoms, removal of cancerous lesions, improvement of survival rate, achievement of disappearance of ascites, normal liver function, and disappearance of peritoneal carcinomatosis.

[0039] As used herein, the term "advanced solid tumor" refers to a malignant solid neoplasm that has spread widely to other anatomical sites or is no longer responsive to treatment. Non-limiting examples of malignant solid neoplasms include carcinomas (e.g., adenocarcinoma, breast cancer, ovarian cancer, non-small cell lung cancer, bladder cancer, prostate cancer, colon cancer, hepatocellular carcinoma, squamous cell carcinoma, or glioma) and sarcomas (e.g., bone, tendon, cartilage, muscle, or liposarcoma).

[0040] As used herein, the term "advanced hepatocellular carcinoma" refers to advanced (metastatic) liver cancer that has spread to either the lymph nodes or other organs. At this stage, the cancer is widespread and generally cannot be removed by surgery.

[0041] In one embodiment, the present invention relates to patients with hepatocellular carcinoma with cirrhosis. The cirrhotic status of the liver can be evaluated using the Child-Pugh scoring system (also known as the Child-Pugh-Turcotte score), which is designed to predict the mortality of patients with cirrhosis. This scoring system classifies patients into three categories: A-good liver function, B-moderate liver dysfunction, and C-advanced liver dysfunction. The scoring system uses five clinical and laboratory criteria to classify patients: serum bilirubin, serum albumin, ascites, neuropathy (encephalopathy), and prothrombin time. Each of these criteria is defined using a numerical value that together defines the severity of cirrhosis. Child-Pugh A: 5-6 points Child-Pugh B: 7-9 points Child-Pugh C: 10-15 points

[0042] In accordance with the present invention, the subject may have advanced hepatocellular carcinoma with a Child-Pugh B cirrhosis score of 7 to 9, i.e., Child-Pugh B (CPB) cirrhosis score 7 (CPB7), Child-Pugh B (CPB) cirrhosis score 8 (CPB8), or Child-Pugh B (CPB) cirrhosis score 9 (CPB9).

[0043] According to one embodiment of the present invention, the subject is treated with an A3AR ligand as a second-line treatment, i.e., the subject has previously been treated with another anticancer drug, and the treatment has failed. In other words, in some embodiments, the subject according to the present invention is a patient with advanced HCC with a CPS score of 7 to 9 who has failed other treatment regimens.

[0044] In one embodiment, the present invention provides a method of extending overall survival of advanced HCC patients with a CPB7 score.

[0045] In a particular embodiment, the increase is an increase in overall survival of 12 months or more.

[0046] As used herein, the term "A3 adenosine receptor (A3AR) ligand" encompasses A3AR agonists as well as A3AR allosteric modulators.

[0047] A3AR agonists are known in the art and are readily available.Generally, A3AR agonists are any compounds that can specifically bind to adenosine A3 receptors ("A3R"), thereby fully or partially activating said receptors and producing therapeutic effects (e.g., anti-arthritic effects).Therefore, A3AR agonists are molecules that exert their main effects through the binding and activation of A3AR.This means that at the doses administered, they essentially only bind to and activate A3R.

[0048] In one embodiment, the A3AR agonist has a binding affinity (K) for the human A3AR of less than 1000 nM, desirably less than 500 nM, advantageously less than 200 nM and less than 100 nM, typically less than 50 nM, preferably less than 20 nM, more preferably less than 10 nM and ideally less than 5 nM. i ) K i The lower the dose of A3AR agonist that can be used, the lower the effective dose of A3AR agonist that activates the A3R to achieve a therapeutic effect.

[0049] It should be noted that some A3AR agonists can also interact with and activate other receptors with lower affinity (i.e., higher Ki). A molecule will be considered an A3AR agonist in the context of the present invention (i.e., a molecule that exerts its primary effect via binding and activating A3R) if its affinity for A3R is at least 3 times (i.e., Ki for A3R is at least 3 times lower) than its affinity for any other adenosine receptor, preferably 10 times, desirably 20 times, and most preferably at least 50 times greater.

[0050] The affinity of A3AR agonist to human A3R and relative affinity to other human adenosine receptors can be determined by various assays, such as binding assays. Examples of binding assays include providing membranes or cells with receptors and measuring the ability of A3AR agonist to displace bound radioactive agonist; utilizing cells that display the respective human adenosine receptors and in a functional assay, the ability of A3AR agonist to activate or inactivate downstream signaling events, such as the effect on adenylate cyclase, measured through the increase or decrease of cAMP levels; and the like. Obviously, when the dosage of A3AR agonist is increased so that the blood concentration of A3AR agonist reaches a level close to the Ki of other adenosine receptors, the activation of these receptors may occur after its administration in addition to the activation of A3R. Therefore, A3AR agonist is preferably administered at a dose such that the blood concentration reached essentially causes only the activation of A3R.

[0051] The characteristics of some adenosine A3AR agonists and methods for their preparation are described in detail, inter alia, in U.S. Pat. No. 5,688,774; U.S. Pat. No. 5,773,423; U.S. Pat. No. 5,573,772; U.S. Pat. No. 5,443,836; U.S. Pat. No. 6,048,865; WO 95 / 02604; WO 99 / 20284; WO 99 / 06053; WO 97 / 27173, and WO 01 / 19360, all of which are incorporated herein by reference.

[0052] The following examples are set forth in U.S. Pat. No. 5,688,774 at column 4, line 67 to column 6, line 16, column 5, lines 40-45, column 6, lines 21-42, column 7, lines 1-11, column 7, lines 34-36, and column 7, lines 60-61: N 6 -(3-iodobenzyl)-9-methyladenine; N 6 -(3-iodobenzyl)-9-hydroxyethyladenine; RN 6 -(3-iodobenzyl)-9-(2,3-dihydroxypropyl)adenine; SN 6 -(3-iodobenzyl)-9-(2,3-dihydroxypropyl)adenine; N 6 -(3-iodobenzyladenin-9-yl)acetic acid; N 6 -(3-iodobenzyl)-9-(3-cyanopropyl)adenine; 2-Chloro-N 6 -(3-iodobenzyl)-9-methyladenine; 2-Amino-N 6 -(3-iodobenzyl)-9-methyladenine; 2-Hydrazide-N 6 -(3-iodobenzyl)-9-methyladenine; N 6 -(3-iodobenzyl)-2-methylamino-9-methyladenine; 2-Dimethylamino-N 6 -(3-iodobenzyl)-9-methyladenine; N 6 -(3-iodobenzyl)-9-methyl-2-propylaminoadenine; 2-Hexylamino-N 6 -(3-iodobenzyl)-9-methyladenine; N 6 -(3-iodobenzyl)-2-methoxy-9-methyladenine; N 6 -(3-iodobenzyl)-9-methyl-2-methylthioadenine; N 6 -(3-iodobenzyl)-9-methyl-2-(4-pyridylthio)adenine; (1S,2R,3S,4R)-4-(6-amino-2-phenylethylamino-9H-purin-9-yl)cyclopentane-1,2,3-triol; (1S,2R,3S,4R)-4-(6-amino-2-chloro-9H-purin-9-yl)cyclopentane-1,2,3-triol; (±)-9-[2α,3α-dihydroxy-4β-(N-methylcarbamoyl)cyclopenten-1β-yl]-N 6 -(3-iodobenzyl)-adenine; 2-Chloro-9-(2'-amino-2',3'-dideoxy-β-D-5'-methyl-arabino-furanamide)-N 6 -(3-iodobenzyl)adenine; 2-Chloro-9-(2',3'-dideoxy-2'-fluoro-β-D-5'-methyl-arabinofuranamide)-N 6 -(3-iodobenzyl)adenine; 9-(2-Acetyl-3-deoxy-β-D-5-methyl-ribofuranamide)-2-chloro-N 6 (3-iodobenzyl)adenine; 2-Chloro-9-(3-deoxy-2-methanesulfonyl-β-D-5-methyl-ribofuranamide)-N 6 -(3-iodobenzyl)adenine; 2-Chloro-9-(3-deoxy-β-D-5-methyl-ribofuranamide)-N 6 -(3-iodobenzyl)adenine; 2-Chloro-9-(3,5-1,1,3,3-tetraisopropyldisiloxyl-β-D-5-ribofuranosyl)-N 6 -(3-iodobenzyl)adenine; 2-Chloro-9-(2',3'-O-thiocarbonyl-β-D-5-methyl-ribofuranamide)-N 6 -(3-iodobenzyl)adenine; 9-(2-phenoxythiocarbonyl-3-deoxy-β-D-5-methyl-ribofuranamido)-2-chloro-N 6 -(3-iodobenzyl)adenine; 1-(6-benzylamino-9H-purin-9-yl)-1-deoxy-N,4-dimethyl-β-D-ribofuranosiduronamide; 2-Chloro-9-(2,3-dideoxy-β-D-5-methyl-ribofuranamide)-N 6 benzyladenine; 2-Chloro-9-(2'-azido-2',3'-dideoxy-β-D-5'-methyl-arabino-furanamide)-N 6 -benzyladenine; 2-Chloro-9-(β-D-erythrofuranoside)-N 6 -(3-iodobenzyl)adenine; N 6 -(benzodioxanemethyl)adenosine; 1-(6-Furfurylamino-9H-purin-9-yl)-1-deoxy-N-methyl-β-D-ribofuranosiduronamide; N 6 -[3-(L-prolylamino)benzyl]adenosine-5'-N-methyluronamide; N 6 -[3-(β-alanylamino)benzyl]adenosine-5'-N-methyluronamide; N 6 -[3-(NT-Boc-β-alanylamino)benzyl]adenosine-5'-N-methyluronamide 6-(N'-phenylhydrazinyl)purine-9-β-ribofuranoside-5'-N-methyluronamide; 6-(O-phenylhydroxylamino)purine-9-β-ribofuranoside-5'-N-methyluronamide; 9-(β-D-2',3'-dideoxyerythrofuranosyl)-N 6 -[(3-β-alanylamino)benzyl]adenosine; 9-(β-D-erythrofuranoside)-2-methylamino-N 6 -(3-iodobenzyl)adenine; 2-Chloro-N-(3-iodobenzyl)-9-(2-tetrahydrofuryl)-9H-purin-6-amine; 2-chloro-(2'-deoxy-6'-thio-L-arabinosyl)adenine; and 2-Chloro-(6'-thio-L-arabinosyl)adenine.

[0053] A compound specifically disclosed in column 6, line 39 to column 7, line 14 of US Pat. No. 5,773,423 is a compound comprising the following formula:

[0054] TIFF2024028923000001.tif74169

[0055] Where: X1 is R a R b NC(=O), where R a and R b may be the same or different, and are hydrogen, C1-C 10 Alkyl, Amino, C1-C 10 Haloalkyl, C1-C 10 Aminoalkyl and C3-C 10 cycloalkyl; R2 is hydrogen, halo, C1-C 10 Alkoxy, Amino, C2-C 10 Alkenyl, and C2-C 10 alkynyl; and R5 is R- and S-1-phenylethyl, unsubstituted benzyl, and C1-C 10 Alkyl, amino, halo, C1-C 10 Haloalkyl, nitro, hydroxy, acetamido, C1-C 10 benzyl groups substituted at one or more positions with a substituent selected from the group consisting of alkoxy, and sulfo.

[0056] More specific examples of compounds include those in which R2 is hydrogen or halo, especially hydrogen. a and R bmay be the same or different, hydrogen and C1-C 10 Included are those of the above formula selected from the group consisting of alkyl.

[0057] Further specific compounds and examples include, particularly when R5 is unsubstituted benzyl, a is hydrogen and R2 is hydrogen.

[0058] More specifically, Rb is C1-C 10 Alkyl or C3-C 10 Cycloalkyl, especially C1-C 10 Such compounds are alkyl, more specifically methyl.

[0059] Specifically, R a is hydrogen and R b C1-C 10 Alkyl or C3-C 10 cycloalkyl, R is R- or S-phenylethyl, or halo, amino, acetamido, C-C 10 and benzyl substituted at one or more positions with a substituent selected from the group consisting of haloalkyl, and sulfo, where the sulfo derivative is a salt such as a triethylammonium salt.

[0060] An example of a particularly preferred compound disclosed in U.S. Pat. No. 5,773,423 is IB-MECA. In addition, R2 may be of the formula Rd-C=C- (wherein R d is C1-C8 alkyl) 10 Compounds which are alkenylene are specifically described in the specification. More specific examples of compounds are those in which R2 is other than hydrogen, particularly those in which R2 is halo, C1-C 10 Alkylamino or C1-C 10 alkylthio, and more preferably, when Ra is hydrogen, R b C1-C 10 Included are compounds in which R5 is alkyl and / or R5 is substituted benzyl.

[0061] Examples of such specifically disclosed compounds include 2-chloro-N 6 -(3-iodobenzyl)-9-[5-(methylamido)-β-D-ribofuranosyl]-adenine, N 6 -(3-iodobenzyl)-2-methylamino-9-[5-(methylamido)-β-D-ribofuranosyl]-adenine, and N 6 -(3-iodobenzyl)-2-methylthio-9-[5-(methylamido)-β-D-ribofuranosyl]-adenine.

[0062] Additionally, U.S. Pat. No. 5,773,423 discloses at column 7, line 60 and column 8, line 6, A3AR agonists as modified xanthine-7-ribosides having the following formula:

[0063] TIFF2024028923000002.tif69169

[0064] Where: X is O; R6 is R a R b NC(=O), where R a and R b may be the same or different, hydrogen, C1-C 10 Alkyl, Amino, C1-C 10 Haloalkyl, C1-C 10 Aminoalkyl, and C3-C 10 cycloalkyl; R7 and R8 may be the same or different, and C1-C 10 Alkyl, R- and S-phenylethyl, unsubstituted benzyl groups, and C1-C 10 Alkyl, amino, halo, C1-C 10 Haloalkyl, nitro, hydroxy, acetamido, C1-C 10 benzyl groups substituted at one or more positions with a substituent selected from the group consisting of alkoxy, and sulfo; and R9 is halo, benzyl, phenyl and C3-C 10cycloalkyl.

[0065] WO 99 / 06053 discloses in examples 19-33 a compound selected from: N 6 -(4-Biphenyl-carbonylamino)-adenosine-5'-N-ethyluronamide; N 6 -(2,4-Dichlorobenzyl-carbonylamino)-adenosine-5'-N-ethyluronamide; N 6 -(4-Methoxyphenyl-carbonylamino)-adenosine-5'-N-ethyluronamide; N 6 -(4-Chlorophenyl-carbonylamino)-adenosine-5'-N-ethyluronamide; N 6 -(Phenyl-carbonylamino)-adenosine-5'-N-ethyluronamide; N 6 -(benzylcarbamoylamino)-adenosine-5'-N-ethyluronamide; N 6 -(4-Sulfonamido-phenylcarbamoyl)-adenosine-5'-N-ethyluronamide; N 6 -(4-Acetyl-phenylcarbamoyl)-adenosine-5'-N-ethyluronamide; N 6 -((R)-α-phenylethylcarbamoyl)-adenosine-5'-N-ethyluronamide; N 6 -((S)-α-phenylethylcarbamoyl)-adenosine-5'-N-ethyluronamide; N 6 -(5-Methyl-isoxazol-3-yl-carbamoyl)-adenosine-5'-N-ethyluronamide; N 6 -(1,3,4-Thiadiazol-2-yl-carbamoyl)-adenosine-5'-N-ethyluronamide; N 6-(4-n-propoxy-phenylcarbamoyl)-adenosine-5'-N-ethyluronamide; N 6 -bis-(4-nitrophenylcarbamoyl)-adenosine-5'-N-ethyluronamide; and N 6 -Bis-(5-chloro-pyridin-2-yl-carbamoyl)-adenosine-5'-N-ethyluronamide.

[0066] According to one embodiment of the present invention, the A3AR agonist is a compound that exerts its primary effect through the binding and activation of the adenosine A3AR and is a purine derivative falling within the scope of the general formula (I):

[0067] TIFF2024028923000003.tif41169

[0068] Where: -R 11 represents an alkyl, hydroxyalkyl, carboxyalkyl, cyanoalkyl, or a group of the following general formula (II):

[0069] TIFF2024028923000004.tif30169

[0070] where: -Y represents oxygen, sulfur or CH2: -X 11 is H, alkyl, R e R f NC(=O)- or HOR g -, where: -R e and R f may be the same or different and are selected from the group consisting of hydrogen, alkyl, amino, haloalkyl, aminoalkyl, BOC-aminoalkyl, and cycloalkyl, or are joined together to form a heterocycle containing 2 to 5 carbon atoms; -Rg is selected from the group consisting of alkyl, amino, haloalkyl, aminoalkyl, BOC-aminoalkyl, and cycloalkyl; -X12 is H, hydroxyl, alkylamino, alkylamido, or hydroxyalkyl; -X 13 and X 14 independently represent hydrogen, hydroxyl, amino, amido, azido, halo, alkyl, alkoxy, carboxy, nitrile, nitro, trifluoro, aryl, alkaryl, thio, thioester, thioether, -OCOPh, -OC(=S)OPh, or X 13 and X 14 Both are oxygens connected to C=S to form a 5-membered ring, or X 12 and X 13 forms a ring of formula (III):

[0071] TIFF2024028923000005.tif34169

[0072] wherein R′ and R″ independently represent an alkyl group; -R 12 is selected from the group consisting of hydrogen, halo, alkylether, amino, hydrazide, alkylamino, alkoxy, thioalkoxy, pyridylthio, alkenyl; alkynyl, thio, and alkylthio; -R 13 is the formula -NR 15 R 16 where -R 15 is a hydrogen atom or a group selected from alkyl, substituted alkyl, or aryl -NH-C(Z)-, where Z is O, S, or NR a and R e has the above meaning, where R 15 If is hydrogen, R 16is selected from the group consisting of R- and S-1-phenylethyl, benzyl, phenylethyl or anilido groups, unsubstituted or substituted at one or more positions with a substituent selected from the group consisting of alkyl, amino, halo, haloalkyl, nitro, hydroxyl, acetamido, alkoxy and sulfonic acid or a salt thereof; benzodioxanmethyl, furyl, L-propylalanyl-aminobenzyl, β-alanylamino-benzyl, T-BOC-β-alanylaminobenzyl, phenylamino, carbamoyl, phenoxy or cycloalkyl; or R 16 is a radical of the formula:

[0073] TIFF2024028923000006.tif28169

[0074] or R 15 is alkyl or aryl-NH-C(Z)-, R 16 is selected from the group consisting of heteroaryl-NRa-C(Z)-, heteroaryl-C(Z)-, alkaryl-NRa-C(Z)-, alkaryl-C(Z)-, aryl-NR-C(Z)-, and aryl-C(Z)-; Z represents oxygen, sulfur, or an amine; or a physiologically acceptable salt of the above compounds.

[0075] According to one preferred embodiment, the A3AR agonist is a nucleoside derivative of general formula (IV):

[0076] TIFF2024028923000007.tif78169

[0077] X1, R2' and R5 are as defined above and are physiologically acceptable salts of said compounds.

[0078] Acyclic carbohydrate groups (e.g., alkyl, alkenyl, alkynyl, alkoxy, aralkyl, alkaryl, alkylamine, etc.) which form part of the substituents of the compounds of the invention are either branched or unbranched and preferably contain from 1 or 2 to 12 carbon atoms.

[0079] A particular group of A3AR agonists is the N 6 -benzyladenosine-5'-uronamide derivatives. Some preferred N 6 -benzyladenosine-5'-uronamide derivatives are N 6 -2-(4-aminophenyl)ethyl adenosine (APNEA), N6-(4-amino-3-iodobenzyl)adenosine-5'-(N-methyluronamide) (AB-MECA) and 1-deoxy-1-{6-[({3-iodophenyl}methyl)amino]-9H-purin-9-yl}-N-methyl-β-D-ribofuranuronamide (IB-MECA) and 2-chloro-N6-(3-iodobenzyl)adenosine-5'-N-methyluronamide (Cl-IB-MECA).

[0080] According to another embodiment, the A3AR agonist is N 6 -Benzyl adenosine-5'-N-alkyluronamide-N1-oxide or N 6 -benzyladenosine-5'-N-dialkyluronamide-N1-oxide, where the 2-purine position may be substituted with alkoxy, amino, alkenyl, alkynyl or halogen.

[0081] Reference to an "A3AR allosteric modulator" or "A3ARM" is understood to refer to the positive modulation, activation or increase of receptor activity by binding of an allosteric modulator at an allosteric site on the receptor, which may be distinct from the binding site of the endogenous ligand or agonist.

[0082] In one example, "modulation" refers to the effect of an A3AR ligand on the receptor as demonstrated by at least a 15% increase in the potency of the A3 adenosine receptor upon binding of the compound to the allosteric site of the receptor, and / or a decrease in the dissociation rate of adenosine or an A3AR agonist from the orthosteric binding site.

[0083] In one example, the modulation is by an A3AR allosteric modulator (A3ARAM), which is an imidazoquinoline derivative.

[0084] In one example, A3ARAM, an imidazoquinoline derivative, has the following general formula (V):

[0085] TIFF2024028923000008.tif51169

[0086] where: -R1 is C1-C in the aromatic ring 10 Alkyl, halo, C1-C 10 Alkanol, Hydroxyl, C1-C 10 Acyl, C1-C 10 Alkoxyl;C1-C 10 -Alkoxycarbonyl, C1-C 10 Alkoxyalkyl;C1-C 10 Thioalkoxy;C1-C 10 Alkyl ether, amino, hydrazide, C1-C 10 Alkylamino, pyridylthio, C2-C 10 Alkenyl;C2-C 10 Alkynyl, Thio, C1-C 10 represents an aryl or alkaryl optionally substituted with one or more substituents selected from the group consisting of alkylthio, acetamido, sulfonic acid, or said substituents together may form a cycloalkyl or cycloalkenyl fused to said aryl, said cycloalkyl or cycloalkenyl optionally containing one or more heteroatoms; provided that said aryl is not an unsubstituted phenyl group; -R2 is hydrogen or C1-C 10 Alkyl, C2-C 10 Alkenyl;C2-C 10 Alkynyl, C4-C 10 Cycloalkyl, C4-C 10 Cycloalkenyl, 5-7 membered heterocyclic aromatic ring, C5-C 15 Fused cycloalkyl, bicyclic aromatic or heterocyclic rings; C1-C 10Alkyl ether, amino, hydrazide, C1-C 10 Alkylamino, C1-C 10 Alkoxy, C1-C 10 Alkoxycarbonyl, C1-C 10 Alkanols, C1-C 10 Acyl, C1-C 10 Thioalkoxy, pyridylthio, thio, and C1-C 10 represents a substituent selected from the group consisting of alkylthio, acetamido, and sulfonic acid; and pharma-ceutically acceptable salts thereof.

[0087] According to some embodiments, the R1 substituent in A3ARAM has the following general formula (VI):

[0088] TIFF2024028923000009.tif36169

[0089] wherein n is 0 or an integer selected from 1 to 5; preferably, n is 0, 1 or 2; and X1 and X2, which may be the same or different, are selected from hydrogen, halogen, alkyl, alkanol or alkoxy, indanyl, pyrroline, with the proviso that when n is 0, X1 and X2 are not hydrogen.

[0090] In further examples, R1 of A3ARAM is a substituent having the above formula (VI), where X1 or X2, which may be the same or different, are selected from hydrogen, chloro, methoxy, methanol, or a substituent having the formula (VIa) or (VIb):

[0091] TIFF2024028923000010.tif42169

[0092] wherein Y is selected from N or CH.

[0093] In some further examples, R2 in A3ARAM is H, C 1-10 Alkyl, C 4-10cycloalkyl, where the alkyl chain may be straight or branched, or may form a 4- to 7-membered cycloalkyl ring.

[0094] In one example, R2 of A3ARAM is selected from 5-7 membered heterocyclic aromatic rings.

[0095] In some examples, the R2 substituent of A3ARAM is selected from H, n-pentyl, or a 5-membered heterocyclic aromatic ring having the following formula (VII):

[0096] TIFF2024028923000011.tif30169

[0097] wherein Z is selected from O, S or NH, preferably O.

[0098] According to one example, R2 of A3ARAM contains one or more fused rings, particularly to form a bicyclic substituent.

[0099] Non-limiting examples of bicyclic compounds that can be used to form substituents in the context of A3ARAM include bicyclo[2.2.1]heptane, bicyclo[4.1.0]heptane, bicyclo[4.1.0]heptane-3-carboxylic acid, bicyclo[3.1.0]hexane-3-carboxylic acid, bicyclo[4.1.0]heptane-2-carboxylic acid, bicyclo[3.1.0]hexane-2-carboxylic acid, and bicyclo[2.2.1]heptane-2-carboxylic acid.

[0100] According to still other examples, R2 of A3ARAM is selected from two cyclohexenes and 3-cyclohexene.

[0101] Specific imidazoquinoline derivatives that can be used as allosteric modulators of the A3AR are listed below: N-(4-methyl-phenyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(4-Methoxy-phenyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(3,4-dichloro-phenyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(4-chloro-phenyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(3-methanol-phenyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-([3,4-c]indan)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(1H-indazol-6-yl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(4-Methoxy-benzyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(1H-indol-6-yl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(benzyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(phenylethyl)-2-cyclopentyl-1H-imidazo[4,5-c]quinolin-4-amine N-(3,4-dichloro-phenyl)-2-cycloheptyl-1H-imidazo[4,5-c]quinolin-4-amine N-(3,4-dichloro-phenyl)-2-furyl-1H-imidazo[4,5-c]quinolin-4-amine N-(3,4-dichloro-phenyl)-2-cyclobutyl-1H-imidazo[4,5-c]quinolin-4-amine N-(3,4-dichloro-phenyl)-2-cyclohexyl-1H-imidazo[4,5-c]quinolin-4-amine N-(3,4-dichloro-phenyl)-2--1H-imidazo[4,5-c]quinolin-4-amine N-(3,4-dichloro-phenyl)-2-pentyl-1H-imidazo[4,5-c]quinolin-4-amine.

[0102] The imidazoquinoline derivatives are represented by the formula: A1 and A 2A , A 2B It has been shown to have reduced affinity, if any, for the orthosteric binding site of the adenosine receptor, reduced affinity for the orthosteric binding site of the A3 adenosine receptor, while having high affinity for the allosteric site of the A3 adenosine receptor [International Patent Application No. WO 07 / 089507, incorporated herein by reference], and is therefore believed to be an allosteric modulator.

[0103] A particularly preferred imidazoquinoline derivative according to the present disclosure is N-(3,4-dichloro-phenyl)-2-cyclohexyl-1H-imidazo[4,5-c]quinolin-4-amine (also referred to by the abbreviation LUF6000 or CF602), which is an A3AR allosteric modulator.

[0104] In the context of the general formulae disclosed herein, the following meanings for various terms should be considered.

[0105] As used herein, the term "alkyl" is used to refer to a straight or branched hydrocarbon chain having 1 to 10 carbon atoms, more preferably 1 to 6 carbon atoms, including, but not limited to, methyl, ethyl, n-propyl, isopropyl, n-butyl, t-butyl, n-heptyl, octyl, and the like.

[0106] Similarly, the terms "alkenyl" and "alkynyl" refer to a linear or branched hydrocarbon chain having 2 to 10 or 3 to 10 carbon atoms, more preferably 2 to 6 or 3 to 6 carbon atoms, respectively, where the alkenyl or alkynyl has at least one unsaturated bond.

[0107] Alkyl, alkenyl or alkynyl substituents may be substituted with heteroatom-containing groups. Thus, although not expressly stated, any of the alkyl modifications defined above and below, such as alkylthio, alkoxy, akanol, alkylamine, etc., are understood to also include the corresponding alkenyl or alkynyl modifications, such as akenylthio, akenyloxy, alkenol, alkenylamine, or akenylthio, alkynyloxy, alkynol, alkynylamine, respectively.

[0108] The term "aryl" refers to an unsaturated aromatic carbocyclic group of from 5 to 14 carbon atoms having a single ring (e.g., phenyl) or multiple condensed rings (e.g., naphthyl or anthryl). Preferred examples of aryl include phenyl, indanyl, and benzimidazole.

[0109] The term "alkaryl" refers to -alkylene-aryl groups preferably having from 1 to 10 carbon atoms inclusively in the alkylene moiety and from 6 to 14 carbon atoms inclusively in the aryl moiety. Such alkaryl groups are exemplified by benzyl, phenethyl, and the like.

[0110] The term "substituted aryl" refers to an aromatic moiety substituted with 1 to 3 substituents as defined above. As will be appreciated by those skilled in the art, a variety of substituents are possible. Nevertheless, some preferred examples of substituents include, but are not limited to, halogen, (substituted) amino, nitro, cyano, alkyl, alkoxy, acyloxy or alkanol, sulfonyl, sulfinyl.

[0111] The term "halo" or "halogen" refers to fluoro, chloro, bromo and iodo, preferably chloro.

[0112] The term "acyl" refers to the group HC(O)- as well as alkyl-C(O)-.

[0113] The term "alkanol" refers to the groups -COH and alk-OH, where "alk" means an alkylene, alkenylene, or alkynylene chain.

[0114] The term "alkoxy" as used herein means -O-alkyl, including, but not limited to, methoxy, ethoxy, propoxy, isopropoxy, n-butoxy, and the like.

[0115] The term "alkylthio" as used herein means --S-alkyl and includes, but is not limited to, methylthio, ethylthio, n-propylthio, isopropylthio, n-butylthio, and the like.

[0116] The term "alkoxyalkyl" as used herein means -alkyl-O-alkyl, including, but not limited to, methoxymethyl, ethoxymethyl, n-propoxymethyl, isopropoxymethyl, n-butoxymethyl, isobutoxymethyl, t-butoxymethyl, and the like.

[0117] The term "cycloalkyl" as used herein means a cyclic hydrocarbon radical, including, but not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, and the like.

[0118] The term "alkoxycarbonyl" as used herein means -C(O)O-alkyl, including, but not limited to, methoxycarbonyl, ethoxycarbonyl, propoxycarbonyl, and the like.

[0119] The term "fused cycloalkyl" is used herein to mean any compound or substituent that contains at least two aliphatic rings connected by a single atom (to form a spirocyclic moiety), by two bonded atoms, or by a series of atoms (bridgeheads). Fused rings can include bicyclic, tricyclic, and polycyclic moieties. In accordance with some embodiments of the present disclosure, bicyclic substituents are preferred.

[0120] The present disclosure also utilizes physiologically acceptable salts of A3AR selective ligands such as the above compounds. "Physiologically acceptable salts" refers to any non-toxic alkali metal, alkaline earth metal and ammonium salts commonly used in the pharmaceutical industry, including sodium salts, potassium salts, lithium salts, calcium salts, magnesium salts, barium ammonium salts and protamine zinc salts, which can be prepared by methods known in the art. The term also includes non-toxic acid addition salts, which are generally prepared by reacting the ligand with a suitable organic or inorganic acid. Acid addition salts are those that retain the biological effectiveness and qualitative properties of the free base and are not toxic or otherwise undesirable. Examples include acids derived from mineral acids, hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, metaphosphoric acid, etc., among others. Organic acids include, inter alia, tartaric acid, acetic acid, propionic acid, citric acid, malic acid, malonic acid, lactic acid, fumaric acid, benzoic acid, cinnamic acid, mandelic acid, glycolic acid, gluconic acid, pyruvic acid, succinic acid, salicylic acid and arylsulfonic acids, such as p-toluenesulfonic acid.

[0121] The A3AR ligand may be administered as a single dose (one-time administration) or continuously. In one example, the A3AR ligand is used for long-term treatment.

[0122] In the context of this disclosure, long-term treatment should be understood to include a treatment period that lasts at least days, weeks, months, or years, for example, until discontinuation due to intolerance, withdrawal of consent, or death.The treatment period is continuous, but may be divided into cycles (e.g., 4-week cycles) for data recording.In one embodiment, A3AR ligand is administered every 12 hours until discontinuation.

[0123] Furthermore, in the context of some examples of the present disclosure, long-term treatment includes chronic treatment, for example, long-term daily administration (once, twice, or three times a day) even when there is no anticipated end point of treatment. In some examples, long-term treatment includes daily administration of A3AR ligand for at least one week, sometimes daily treatment for one month, sometimes daily administration of ligand for at least 2, 3, 4, 5, 6, or 12 months, sometimes daily administration of ligand for at least 1, 2, 3, 4, 5, 6, or more years.

[0124] In one embodiment, the treatment period is chronic treatment lasting at least one year.

[0125] A3AR ligand is administered in an amount sufficient to achieve therapeutic anti-cancer effect.As can be understood, the amount of A3AR ligand will depend on the severity of disease, intended treatment regimen, and desired therapeutic dose.For example, if the dose is 50mg per day and the desired administration regimen is twice daily administration, the amount of active agent in pharmaceutical composition is 25mg.

[0126] The amount effective to achieve the desired effect is determined by considerations known in the art. For purposes herein, an "effective amount" must be effective to achieve a therapeutic effect, which is defined above.

[0127] It is understood that the effective amount depends on various factors, such as the affinity of the selected A3AR agonist to A3AR, biodistribution profile, various pharmacological parameters such as half-life in the body, undesirable side effects, if any, and factors such as age and sex of the subject to be treated. The effective amount is usually verified in clinical trials aimed at finding the effective dose range, maximum tolerated dose, and optimal amount. Methods for conducting such clinical trials are well known to those familiar with the art of clinical development.

[0128] According to one embodiment of the present invention, the A3AR agonist is administered once to several times a day, preferably once to twice a day, daily, and the dose in each administration is in the range of about 1 to about 1000 μg / kg body weight, preferably 50 μg / kg to 10 mg / kg body weight, preferably 100 μg / kg to 5 mg / kg body weight, or 200 μg / kg to 1 mg / kg body weight.

[0129] In some embodiments, the A3AR ligand is Cl-IB-MECA administered orally twice daily at a dose of 1-50 mg, preferably 5-30 mg.

[0130] In a specific embodiment, the advanced solid tumor is advanced HCC, the A3AR agonist is Cl-IB-MECA (twice daily) at a dose of 25 mg orally every 12 hours.

[0131] The A3AR agonist is formulated into a pharmaceutical composition. In the context of the present invention, a "composition" is intended to mean a combination of an active agent with a pharma- ceutically acceptable carrier and other additives, either together or separately. The carrier may have the effect of improving the delivery or penetration of the active ingredient into the target tissue, improving the stability of the drug, slowing down the clearance rate, imparting sustained release properties, reducing undesirable side effects, and the like. The carrier may also be a substance (e.g., a preservative) that stabilizes the formulation. For examples of carriers, stabilizers, and adjuvants, see EW Martin, REMINGTON'S PHARMACEUTICAL SCIENCES, MacK Pub Co (June 1990).

[0132] The term "pharmaceutically acceptable carrier" in the context of the present invention refers to any one of the inert, non-toxic materials that do not react with the A3AR agonist and that can be added to the formulation as a diluent, carrier, or that can give form or consistency to the formulation.

[0133] The compositions of the present invention are administered and dosed in accordance with good medical practice, taking into consideration the clinical condition of the individual patient, the site and method of administration, the schedule of administration, the age, sex, weight of the patient, and other factors known to medical practitioners. The choice of carrier will be determined in part by the particular active ingredient, and also by the particular method used to administer the composition. Accordingly, suitable pharmaceutical compositions of the present invention are widely varied.

[0134] As mentioned above, the therapeutic use of A3AR agonists is sometimes combined with other anti-cancer drugs such as monoclonal antibodies (e.g., the antibody atezolizumab alone or in combination with bevacizumab, or the VEGFR2 inhibitor ramucirumab, the anti-PD1 receptor monoclonal antibodies pembrolizumab and nivolumab alone or in combination with the anti-CTLA-4 antibody ipilimumab), and multikinase inhibitors (e.g., sorafenib, regorafenib, cabozantinib, lenvatinib). In such combination treatments, the other drug and the A3AR agonist may be administered to the patient at the same time or at different times, depending on the administration schedule of each drug.

[0135] The present invention has been described in an illustrative manner, and it is to be understood that the terminology that has been used is intended to be descriptive and not limiting. Obviously, many modifications and variations of the present invention are possible in light of the above teachings. It will therefore be understood that, within the scope of the appended claims, the invention may be practiced otherwise than as specifically described below. EXAMPLES

[0136] Study Participants The study population consisted of patients aged 18 years or older with advanced / refractory HCC and CPB cirrhosis who did not tolerate sorafenib or had disease progression on previous sorafenib treatment. Cytology and / or histology were required for HCC diagnosis in subjects without underlying cirrhosis at diagnosis. For subjects with underlying cirrhosis at diagnosis, HCC diagnosis was confirmed according to the American Association of Liver Diseases practice guideline algorithm [Marrero JA, et al., Hepatology. 2018;68:723-750]. For subjects who tolerated sorafenib, ≥3 weeks of prior treatment was required, which was completed ≥2 weeks prior to study initiation. Inclusion criteria were: ECOG PS ≤ 2; presence of CPB cirrhosis (i.e., CP score 7-9); aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels ≤ 5 times the upper limit of normal (ULN); total bilirubin ≤ 3.0 mg / dL; serum albumin ≥ 2.8 g / dL; prothrombin time (PT) ≥ 6 seconds longer than control; serum creatinine ≤ 2.0 mg / dL; absolute neutrophil count ≥ 1500 × 109 / L; platelet count ≥ 75,000 × 109 / L. Exclusion criteria were: presence or absence of hepatic encephalopathy; gastrointestinal bleeding requiring transfusion within 4 weeks.

[0137] Study Design and Treatment This study was a multicenter, randomized, double-blind, placebo-controlled clinical trial (ClinicalTrials.gov ID: NCT02128958). The study was conducted at 15 centers in Israel, Europe, and the United States.

[0138] Subjects were enrolled by participating sites and randomly assigned in a 2:1 ratio using a central randomization schedule created by an independent biostatistician, without pre-randomization stratification. Patients were randomly assigned to receive namodenoson (Cl-IB-MECA) 25 mg or matching placebo, administered orally every 12 hours, until discontinuation due to intolerance, withdrawal of consent, or death. Treatment was continuous, but treatment periods were divided into 4-week cycles for data recording purposes. Initially, crossover was not permitted, but a protocol amendment provided namodenoson (25 mg twice daily) to patients continuing on blinded treatment, with treatment assignment removed. Site staff were blinded to patient treatment throughout the study.

[0139] The study was approved by the relevant national regulatory authorities and local ethical committees / institutional review boards. The study was conducted in accordance with the Declaration of Helsinki and written informed consent was obtained from all patients.

[0140] Evaluation items The primary endpoint of the study was overall survival (OS). Secondary endpoints included progression-free survival (PFS), overall response rate (ORR), disease control rate (DCR), and safety. As with advanced HCC, PFS has been found to be moderately correlated with OS, making PFS a reasonable secondary endpoint in this disease [Llovet JM, et al., J. Hepatol. 2019, 70: 1262-1277]. Disease response assessment was assessed locally by two independent blinded radiologists using RECIST (Response Evaluation Criteria in Solid Tumors) version 1.1 [Eisenhauer EA, et al. Eur. J. Cancer. 2009; 45: 228-247]. Tumor status was assessed by computed tomography or magnetic resonance imaging at baseline and every 8 weeks thereafter. Safety was monitored through assessment of AEs using the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Changes from baseline in vital signs, laboratory parameters, electrocardiogram, physical examination, and ECOG PS were also evaluated. AFP levels were assessed at baseline and every 4 weeks thereafter, as were laboratory parameters related to liver dysfunction and cirrhosis, including serum ALT, AST, bilirubin, albumin levels, PT, and international sensitivity ratio. The ALBI score was calculated from albumin and bilirubin levels as previously described [Johnson PJ, et al. J. Clin. Oncol. 2015;33:550-558].

[0141] Biomarker Testing Another secondary objective was to evaluate the relationship between white blood cell (WBC) A3AR expression (which has been suggested to mirror expression in HCC tumor cells [Bar-Yehuda S., et al. Int. J. Oncol. 2008;33:287-295]) assessed at baseline and each subsequent cycle, and clinical response in selected study centers (n=53 patients). A3AR mRNA expression in WBC was measured from blood collected in PAX gene RNA tubes (Qiagen, Venlo, The Netherlands) using the QuantiGene Plex 2.0® assay (Thermo Fisher, Waltham, MA, USA). β-actin was used as a control and oligonucleotide probe sets were designed by Thermo Fisher. Emissions from each specific probe set were captured with GloMax Multi (Promega, Madison, WI, USA). A3AR is expressed in units, with one unit defined as the mean A3AR expression in healthy subjects (n=50). Healthy subjects were aged between 20 and 70 years and had no known diseases or medical history.

[0142] statistical analysis Power calculations determined that the log-rank test would have 80% power to detect 75 deaths assuming a hazard ratio of 0.5 at a significance level of 0.05. Primary efficacy analyses were performed on the intention-to-treat population. Descriptive statistics were used to summarize patient / tumor characteristics and safety. Kaplan-Meier curves were used to estimate OS / PFS, and the log-rank test was used for comparison. Cox proportional hazards regression models were used to evaluate the influence of covariates. ORR / DCR were determined by treatment using normal approximation of the binomial distribution. The statistical analysis plan was modified before unblinding to include subgroup analyses by CP score. All statistical tests were two-sided, and p<0.05 was considered statistically significant. Statistical analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).

[0143] Example 1 In this phase II, blinded, randomized, placebo-controlled trial, the dose of namodenoson evaluated was 25 mg orally BID (twice daily) in 78 patients with advanced hepatocellular carcinoma (HCC) and CPB cirrhosis receiving namodenoson as second-line treatment. Patients were randomized 2:1 to receive namodenoson 25 mg BID (n=50) or placebo (n=28).

[0144] No treatment-related deaths were reported. Additionally, no patients dropped out of the study, and no dose reductions were observed due to namodenoson. Importantly, no hepatotoxicity was reported, and liver function tests showed no adverse events related to namodenoson. Mean serum albumin levels and albumin-bilirubin (ALBI) scores also did not change significantly in both arms over the course of the study. Only one grade 3 treatment-related AE was reported (hyponatremia).

[0145] Analysis of initial results Regarding antitumor activity, the primary endpoint of OS was not met for superiority over placebo. Median OS was 4.1 months for namodenoson and 4.3 months for placebo (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.49-1.38; p=0.46). Similarly, no superiority was observed for progression-free survival (PFS). Among the CBP patients included in the study, the largest proportion of patients had a Child-Pugh score of 7 (the least severe form of liver dysfunction in the CPB classification) (34 patients in the namodenoson group and 22 in the placebo group). A preplanned analysis evaluating patients by Child-Pugh score showed no significant differences in OS and PFS for patients with a Child-Pugh score of 7. In this subcategory, median OS was 6.9 months in the namodenoson group versus 4.3 months in the placebo group (HR, 0.81; 95% CI, 0.45-1.43; p=0.46), and median PFS was 3.5 months versus 1.9 months (HR, 0.89; 95% CI, 0.51-1.55; p=0.67). In patients with a Child-Pugh score of 8 (n=13, 7 in the namodenoson group and 6 in the placebo group), OS and PFS were similar in the namodenoson and placebo groups and were overall shorter than reported in the subgroup of patients with a Child-Pugh score of 7 (OS: 3.3 vs. 3.4 months; HR, 0.88, 95% CI, 0.28-2.77, p=0.83 for the namodenoson and placebo groups, respectively; PFS: 2.1 vs. 1.9 months; HR, 0.71, 95% CI, 0.23-2.17, p=0.53). The median OS and PFS in the 9 patients with a Child-Pugh score of 9 (all in the namodenoson group) were 3.5 and 2.2 months, respectively, similar to those in the patients with a Child-Pugh score of 8. Exploratory analyses comparing OS by treatment group and stratification by sex, alpha-fetoprotein level, Eastern Cooperative Oncology Group (ECOG) performance status (PS), HPB, HPC status, local therapy, extrahepatic spread status, and portal vein thrombosis status did not show statistically significant differences between study arms in any subgroup, which may be due to the relatively small sample size in some arms.

[0146] Analysis of long-term treatment However, in contrast to the initial results, the difference in 12-month OS rates was statistically significant (44% vs. 18% in the namodenoson and placebo groups, respectively, p = 0.028) ( Figure 1 ).

[0147] Analysis of responses in all patients (55, 34 treated with namodenoson and 21 treated with placebo) who had at least one postbaseline evaluation showed that one patient achieved a CR in the namodenoson group, and three (9%) patients achieved a PR in the namodenoson group and none in the placebo group (see Table 1). The durations of response in the three patients who achieved a PR were 2, 6, and 26 months.

[0148] TIFF2024028923000012.tif86169

[0149] As shown above in Table 1, one patient experienced a complete response. This patient was treated for 5 years in the open-label extension program of a Phase II study of namodenoson in hepatocellular carcinoma (HCC) and experienced a complete response (CR) to namodenoson, meaning that all cancer lesions disappeared.

[0150] A patient with advanced metastatic HCC and underlying Child Pugh B7 (CPB7) cirrhosis has been treated with namodenoson (25 mg orally twice daily) and is currently alive for 5 years. Chest, abdominal, and pelvic scans of the patient have shown clinical efficacy, including disappearance of ascites, normal liver function, disappearance of peritoneal carcinomatosis, and complete disappearance of cancer lesions.

Claims

1. A pharmaceutical composition for treating advanced hepatocellular carcinoma (HCC) in mammals, The aforementioned treatment is characterized by achieving long-term remission of advanced HCC with Child-Pugh B (CPB) cirrhosis score 7 (CPB7) in mammalian subjects, and by increasing the overall survival rate of mammalian subjects with advanced HCC with CPB7. The pharmaceutical composition comprises 2-chloro-N6-(3-iodobenzyl)-adenosine-5'-N-methyluronamide (Cl-IB-MECA, namodenoson) and a pharmaceutically acceptable carrier or diluent, and the pharmaceutical composition is administered for treatment for at least two years, at least three years, at least four years, or at least five years. A pharmaceutical composition characterized by the following features.

2. The pharmaceutical composition according to claim 1, wherein the advanced hepatocellular carcinoma is metastatic hepatocellular carcinoma.

3. The pharmaceutical composition according to any one of claims 1 to 2, wherein the pharmaceutical composition is administered once a day, twice a day, or three times a day.

4. The pharmaceutical composition according to any one of claims 1 to 3, wherein the pharmaceutical composition is administered every 12 hours throughout the treatment period.

5. The pharmaceutical composition according to any one of claims 1 to 4, wherein the Cl-IB-MECA is administered in an amount of 50 μg / kg to 10 mg / kg body weight, preferably 100 μg / kg to 5 mg / kg body weight, or 200 μg / kg to 1 mg / kg body weight.

6. The pharmaceutical composition according to any one of claims 1 to 5, wherein the Cl-IB-MECA is administered orally twice a day in a dose of 1 to 50 mg, preferably 5 to 30 mg.

7. The pharmaceutical composition according to any one of claims 1 to 6, wherein the subject receives the Cl-IB-MECA after having been previously treated with another anticancer drug and the treatment has failed.

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