Combination Therapies for Cancer Treatment

Abstract

Provided herein is a method of treating cancer, the method comprising administering to a patient suffering from cancer an EGFR degrading agent and subjecting the patient to radiation. The cancer can express mutated, overexpressed, or overactivated EGFR, mutant KRAS, or mutant BRAF.

Description

[Background technology]

[0001] Statement of Government Interest This invention was made with Government support under 1R01CA248310-01 awarded by the National Institutes of Health. The Government has certain rights in this invention.

[0002] Three common oncogenes in solid tumors, EGFR, KRAS, and BRAF, are found to be mutated or overexpressed in more than half of all solid tumors, but these mutations / overexpression are usually mutually exclusive, with most tumors exhibiting defects in only one of the three. There are several EGFR inhibitors on the market, but for small molecules, their efficacy is entirely limited to a subset of non-small cell lung cancer (NSCLC) expressing mutant EGFR, and for antibodies, to a similar proportion of colorectal cancer (CRC), and head and neck squamous cell carcinoma (HNSCC) in combination with radiation. Clinical trials have repeatedly shown that patients with either KRAS or BRAF mutations do not respond to EGFR inhibition, regardless of EGFR status. Both of these oncogenes are downstream of EGFR in critical proliferation and survival signaling pathways, so the lack of efficacy to EGFR inhibition can be explained quite easily by their signaling being redundant due to downstream mutations.

[0003] EGFR is a receptor tyrosine kinase (RTK) that provides growth, survival, metabolic, and motility signals within cells primarily by binding cognate receptors such as EGF, HB-EGF, AMPR, EPG, and TGFα. Ligand binding results in activation of the tyrosine kinase, which results in specific phosphorylation of tyrosine hydroxyls on numerous substrate proteins, including EGFR itself. This activity recruits and activates a series of numerous signaling cascades (mainly via serine / threonine phosphorylation) at the cell surface that signal into the nucleus, resulting in gene expression changes that promote growth, and other activities as previously mentioned. In cells and in animal tumor models, EGFR tyrosine kinase inhibitors (TKIs) provide highly potent and general antitumor activity in tumors that overexpress EGFR or have mutant EGFR. However, in models driven by mt-KRAS and mt-BRAF, as expected, these effects are much smaller. Similarly, antibodies that block EGFR TK activation show very good activity in preclinical models in which EGFR is the driving oncogene.

[0004] However, entering the clinic, EGFR inhibitors / antibodies have proven to have much less broad-spectrum activity against EGFR-driven tumors than expected from preclinical models. TKIs work only against mt-EGFR, which is only common in NSCLC (approximately 15% incidence), and antibodies work only against the subset of wt-EGFR expressing CRC and some HNSCC. Overall, the vast majority of apparently EGFR-driven tumors do not respond to any therapy in the clinic, and as expected, no clinical activity has been seen in mt-KRAS and mt-BRAF-driven solid tumors. Currently, there are no approved KRAS-directed therapies, although drugs targeting minor KRAS mutant oncogenes are in clinical trials. Just as there are clinically approved kinase inhibitors against EGFR, there are also clinically approved kinase inhibitors against mt-BRAF. However, in all of these cases, there is dose-limiting toxicity, and even the most dramatic responses to the drugs are transient, with virtually no patients, most significantly fewer, achieving progression-free survival beyond 2 years. Thus, there remains a significant unmet medical need in all of these tumor types. Summary of the Invention

[0005] Provided herein is a method of treating cancer in a patient suffering from cancer, comprising administering to the patient an EGFR degrading agent and subjecting the patient to radiation to treat the cancer.

[0006] In various cases, the EGFR degrading agent degrades wild-type EGFR. In various cases, the EGFR degrading agent degrades mutant EGFR. In some cases, the EGFR degrading agent is a compound (or a pharma- ceutically acceptable salt thereof), an antibody, a protein, a peptide, a PROTAC (Proteolysis Targeting Chimera), a virus, an antibody-drug conjugate, an aptamer, a peptidomimetic, or an oligonucleotide. In some cases, the compound has the formula (I):

[0007] [ka]

[0008] or in some cases, compound A has the structure:

[0009] [ka]

[0010] It has the structure:

[0011] In various cases, the cancer is an EGFR, KRAS, or BRAF mutant cancer. In some cases, the cancer is a solid tumor. In some cases, the cancer is pancreatic cancer, colorectal cancer, head and neck cancer, or lung cancer. [Brief description of the drawings]

[0012] [Figure 1] 1 shows tumor volumes over time in mice bearing (A) PC9 (mutant EGFR tumors), (B) RKO (mutant BRAF tumors), and (C) UMSCC74B (mutant KRAS tumors) following treatment with Compound A (denoted DPI-503), radiation therapy (designated RT), and a combination of Compound A and radiation therapy (denoted DPI-503+RT) relative to controls. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0013] Provided herein is a method of treating cancer in a patient by administering a chemotherapeutic agent and administering radiation to the patient. Surprisingly, it has been found that the combination of radiation and a chemotherapeutic agent with a specific mode of action that degrades the overactivated EGFR found in many solid tumors, regardless of mutation status, has an unexpectedly improved effect in treating cancer compared to the chemotherapeutic agent or radiation alone, when the cancer is driven by mutations in the EGFR, KRAS, or BRAF oncogenes.

[0014] The overactivation driven decomposition agents of EGF receptor (ODDER) compounds are not tyrosine kinase inhibitors (TKIs) because they interact with EGFR in a way that does not appear to affect its kinase activity. However, the binding of ODDER to EGFR prevents activated EGFR from forming the stable molecular complexes necessary to protect them and prevent them from being rapidly internalized and degraded by normal cellular proteolytic mechanisms, which is exactly what these molecules are designed to do. After EGFR is activated, upon binding of its cognate ligand in normal tissues, the kinase domain changes its conformation from an inactive conformation that cannot bind ATP or substrate to an active conformation that allows both ATP and substrate to bind to the enzyme, and then catalyzes the transfer of the γ-phosphate of ATP to the phenolic hydroxy group of the tyrosine side chain. The kinase catalytic domain then unbinds both the product, tyrosyl phosphate monoester, and the by-product ADP, and can then bind further ATP and substrate as the catalytic cycle continues. Tyrosine phosphorylation on substrate molecules appears to have two main uses. First, conformational changes in substrate proteins are often caused by the conversion of neutral and somewhat hydrophobic tyrosine side chains into highly hydrophilic phosphorylated tyrosines that carry two negative charges at physiological pH. Second, many proteins have binding sites for phosphorylated tyrosine residues, allowing substrate proteins to induce new protein-protein interactions and / or assemble into new multiprotein complexes, both of which can display very different activities after phosphorylation. Importantly, some of the most important substrate tyrosines for EGFR are on its own C-terminal domain (CTD), which is located in the cytoplasm of the cell. This recruits intermediate proteins that lead to the activation of the aforementioned signaling cascades. However, some of these phosphorylations also lead to the rapid internalization of the receptor into the cell via several different pathways, resulting in the recruitment of proteins that end up in intracellular vesicles called endosomes.Endosomal trafficking throughout the cell sometimes changes their properties, eventually sorting trafficked proteins like EGFR into endosomes and transporting the receptor back to the cell surface where it can continue to signal, or back to lysosomes where it becomes degraded and non-functional. This is a complex process, but when ODDER is present, it appears to have only a minor effect on non-activated or weakly activated EGFR, but very quickly and efficiently diverts the highly activated EGFR typically found in tumors into a degradation pathway, leading to a total loss of EGFR protein in treated cells over a period of 6-24 hours depending on the cell type. Interestingly, this degradation can be blocked by the use of classical EGFR inhibitor co-treatment, indicating the importance of kinase activation to this mechanism of action. One effect of this protein degradation is to act functionally as an EGFR kinase TKI, since the protein that is no longer present cannot function as a TK, and as expected, these compounds have potent activity in certain EGFR-driven tumor xenograft models.

[0015] EGFR plays such a crucial role in early development that EGFR- / - mice only survive a few days after birth, whereas waved-2 mice, which are severely hypoplastic (94% loss of enzyme activity), have a significantly milder phenotype, including hair and skin problems and early eye opening, but these animals are very vulnerable to gastrointestinal injury and have difficulty healing. Wound-healing studies performed on immunodeficient mice grafted with skin containing wt-EGFR or EGFR- / - skin also show that the latter heal wounds very poorly, suggesting that this is the primary role of EGFR from the neonatal period onwards. Wound-healing properties include proliferation of cells to fill the wound, angiogenesis to obtain new blood vessels to support new tissue, resistance to apoptosis as wounds often allow foreign toxins (including infection) to enter the site of injury, and a greatly increased influx of nutrients into cells to support the rapid anabolic metabolism required to generate new tissue as quickly as possible. EGFR expression and activation cause all these sequelae, which, of course, are all ideal properties for an oncogene.

[0016] Several membrane transporters are induced when EGFR kinase is activated through downstream kinase cascades and can be depleted by kinase inhibition. However, in the dysregulated environment of tumor cells, most of these pathways tend to be reactivated very rapidly by alternative pathways, so kinase-dependent effects on nutrient transporters are often transient. EGFR has been shown to have kinase-independent functions (KIFs) due to its ability to function as a scaffolding protein for both kinase cascade signaling complexes as well as several membrane-bound proteins that have no direct function in kinase signaling cascades. Some of these EGFR scaffolding-dependent proteins are also membrane nutrient transporters, e.g., transporters of glucose and cysteine, which help support increased metabolic growth in cells, allowing cells to assimilate more efficiently, thereby enhancing proliferation. It has been reported that siRNA-mediated loss of EGFR in cells results in the loss of some such transporters from the cell surface, and treatment of cells with ODDER has been shown to result in the loss of some of these transporters from the cell surface, presumably because the complex with EGFR protein is required for stable presence in the cell membrane.

[0017] In addition, surprising data from the NCI60 tumor cell panel for Compound A (ODDER compound) shows significant anti-proliferative activity in several tumors driven by mt-KRAS or mt-BRAF, many of which have been established as completely unaffected by EGFR TKIs or antibodies. ODDER compound has also been shown to have anti-cancer activity in vivo in mt-KRAS and mt-BRAF tumors.

[0018] [ka]

[0019] Examination of the affected cell lines shows that they all co-express wild-type (wt)-EGFR with KRAS or BRAF oncogenes, and ODDER compound treatment results in depletion of EGFR from tumor cells. Successful ablation of EGFR from cells is due to the fact that, although not the driving oncogenes in these tumors, both mt-KRAS and downstream effects of mt-BRAF result in strong activation of EGFR, and often non-gene-driven overexpression, rendering the highly phosphorylated protein susceptible to ODDER-induced degradation.

[0020] It was speculated that the activity seen in these sensitive tumor lines was mainly due to EGFR KIF. Tumor cells are constantly under metabolic stress, and in real tumors, poor circulation exacerbates the stress within the tumor, causing tumors to grow to 100 mm 3When tumor cells grow beyond 100 nm, they usually become hypoxic. Experiments have shown that the specific ODDER, Compound A, results in the loss of EGFR from the cell surface, and two important transporters known to require EGFR chaperoning, SGLT1, the sodium-dependent glucose transporter that imports glucose, and xCT, the cysteine-glutamate cotransporter that imports cysteine, were ablated along with EGFR. Tumor cells have a much greater glucose requirement than normal cells as they attempt to perform oxidative glycolysis, and any impairment of glucose import would be expected to stress the cells and drive them towards oxidative phosphorylation to produce ATP from aerobic glycolysis, which would almost certainly increase the production of reactive oxygen intermediates (ROI) in these already abnormally metabolizing cells. The most common way to process ROI is via conjugation with glutathione or reaction with various reductases, most of which rely on cysteine ​​thiols for their RedOx capabilities. Both of these mechanisms require stressed cells to be able to import large amounts of cysteine, much of which is generated by the liver and circulated, as the high demand completely overwhelms endogenous cysteine ​​biosynthesis (which requires methionine as a sulfur source). Thus, it was reasoned that loss of EGFR protein should increase oxidative stress in any tumor cell, both from forced changes in metabolism and from lack of intracellular cysteine, which may lead to mt-KRAS and mt-BRAF-driven tumors being much more sensitive to EGFR ablation than simple EGFR inhibition. Indeed, simple EGFR inhibition in these cell types may reduce oxidative stress, since EGFR inhibition normally increases cell surface EGFR by blocking the kinase activity required to trigger endocytosis and degradation, as well as perhaps slowing down some of the overall metabolism.

[0021] The signs of oxidative stress in cells were investigated after the addition of increasing amounts of compound A, which was chosen as a marker of oxidative stress in which hydrogen peroxide levels were increased. Six hours after treatment, H 2 O 2 A dose-dependent increase in levels was observed, with the highest dose tested resulting in a 2-4 fold increase in cellular levels, indicating that EGFR ablation indeed increases cellular oxidative stress in cells driven by mt-KRAS, mt-BRAF, and mt-EGFR. Methods to exploit oxidative stress in these tumor types were explored. Oxidative stress contributes to causing DNA damage, making it more difficult to repair DNA damage. Thus, the combination of a DNA damaging agent such as radiation with an ODDER (e.g., Compound A) may result in a useful treatment regimen. Compound A and radiation were examined in in vivo xenograft experiments in mt-EGFR, mt-KRAS, and mt-BRAF driven tumors. What was discovered was that in all three experiments, the radiation antitumor effect was strongly increased in the presence of Compound A. Thus, it is believed that an ODDER compound such as Compound A could be used in combination with radiation to treat localized tumors expressing either mutant KRAS or mutant BRAF. Compound A is also notable for its unique mechanism of action, which results in much lower target toxicity than EGFR inhibitors, and is expected to be used in clinical trials at low toxic doses in combination with standard radiotherapy regimens. Other ODDER compounds are also expected to have similarly low target toxicity.

[0022] EGFR degraders The EGFR degrading agent used in the methods disclosed herein can be any entity that degrades mutant EGFR, such as a compound (or a pharma- ceutically acceptable salt thereof), an antibody, a protein, a peptide, a PROTAC (proteolysis targeting chimera), a virus, an antibody-drug conjugate, an aptamer, a peptidomimetic, or an oligonucleotide.

[0023] Unless otherwise specified within this specification, the term "antibody(s)" broadly encompasses naturally occurring forms of antibodies (e.g., IgG, IgA, IgM, IgE) and recombinant antibodies, such as single chain antibodies, chimeric and humanized antibodies, and multispecific antibodies, as well as fragments and derivatives of all of the foregoing, which fragments and derivatives contain at least an antigen-binding site. Antibody derivatives may include proteins or chemical moieties conjugated to the antibody.

[0024] The term "antibody" as used herein also includes an "antigen-binding portion" of an antibody (or simply an "antibody portion"). The term "antigen-binding portion" as used herein refers to one or more fragments of an antibody that retain the ability to specifically bind to an antigen (e.g., a biomarker polypeptide or a fragment thereof). It has been shown that the antigen-binding function of an antibody can be performed by fragments of a full-length antibody. Examples of binding fragments encompassed by the term "antigen-binding portion" of an antibody include (i) a Fab fragment, a monovalent fragment consisting of the VL, VH, CL, and CH1 domains; (ii) an F(ab') fragment, a monovalent fragment consisting of the VL, VH, CL, and CH1 domains; (iii) an F(ab') fragment, a monovalent fragment consisting of the VL, VH, CL, and CH1 domains; (iv) an F(ab') fragment, a monovalent fragment consisting of the VL, VH, CL, and CH1 domains; (v) an F(ab') fragment, a monovalent fragment consisting of the VL, VH, CL, and CH1 domains; (vi) an F(ab') fragment, a monovalent fragment consisting of the VL, VH, CL, and CH1 domains; (vii) an F(ab') fragment, a monovalent fragment consisting of the VL, VH, CL, and CH1 domains; (viii ... 2(iii) a bivalent fragment comprising two Fab fragments linked by a disulfide bridge at the hinge region; (iii) an Fd fragment consisting of the VH and CH1 domains; (iv) an Fv fragment consisting of the VL and VH domains of a single arm of an antibody; (v) a dAb fragment comprising the VH domain (Ward et al., (1989) Nature 341:544-546); and (vi) an isolated complementarity determining region (CDR). Furthermore, although the two domains of the Fv fragment, VL and VH, are encoded by separate genes, recombinant methods can be used to link them together using a synthetic linker that allows them to be made into a single protein chain in which the VL and VH regions pair to form a monovalent polypeptide (known as single-chain Fv (scFv), see, for example, Bird et al. (1988) Science 242:423-426, and Huston et al. (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883, and Osbourn et al. 1998, Nature Biotechnology 16:778). Such single-chain antibodies are also intended to be encompassed within the term "antigen-binding portion" of an antibody. Any VH and VL sequence of a specific scFv can be linked to human immunoglobulin constant region cDNA or genomic sequences to generate expression vectors encoding complete IgG polypeptides or other isotypes. VH and VL can also be used to generate Fab, Fv, or other fragments of immunoglobulins, using either protein chemistry or recombinant DNA technology. Other forms of single-chain antibodies, such as diabodies, are also included. Diabodies are bivalent, bispecific antibodies in which the VH and VL domains are expressed on a single polypeptide chain, but use a linker that is too short to allow pairing between the two domains on the same chain, thereby forcing the domains to pair with complementary domains on another chain, creating two antigen-binding sites (see, for example, Holliger et al. (1993) Proc. Natl. Acad. Sci. USA, 90; 6444-6448; Poljak et al. (1994) Structure 2: 1121-1123).

[0025] Additionally, an antibody or antigen-binding portion thereof may be part of a larger immunoadhesin polypeptide formed by covalent or non-covalent association of the antibody or antibody portion with one or more other proteins or peptides. Examples of such immunoadhesin polypeptides include the use of a streptavidin core region to generate tetrameric scFv polypeptides (Kipriyanov et al. (1995) Human Antibodies and Hybridomas 6:93-101), and the use of cysteine ​​residues, a biomarker peptide, and a C-terminal polyhistidine tag to generate bivalent and biotinylated scFv polypeptides (Kipriyanov et al. (1994) Mol. Immunol. 31:1047-1058). Fab and F(ab') 2 Antibody portions, such as fragments, can be prepared from whole antibodies using conventional techniques, such as papain or pepsin digestion, respectively, of whole antibodies. Additionally, antibodies, antibody portions, and immunoadhesion polypeptides can be obtained using standard recombinant DNA techniques as described herein.

[0026] Antibodies may be polyclonal or monoclonal, may be xenogeneic, allogeneic, or homogeneous, or may be modified forms thereof (e.g., humanized, chimeric, etc.). Antibodies may also be fully human. The terms "monoclonal antibody" and "monoclonal antibody composition" as used herein refer to a population of antibody polypeptides that contain only one species of antigen-binding site capable of immunoreacting with a particular epitope of an antigen, while the terms "polyclonal antibody" and "polyclonal antibody composition" refer to a population of antibody polypeptides that contain multiple species of antigen-binding sites capable of interacting with a particular antigen. A monoclonal antibody composition typically exhibits a single binding affinity for the particular antigen with which it immunoreacts.

[0027] Antibodies can also be "humanized", which is intended to include antibodies made by non-human cells with variable and constant regions that have been modified to more closely resemble antibodies that can be made by human cells, for example by modifying the non-human antibody amino acid sequence to incorporate amino acids found in human germline immunoglobulin sequences. The humanized antibodies of the invention can include, for example, amino acid residues in the CDRs that are not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo). The term "humanized antibody", as used herein, also includes antibodies in which CDR sequences derived from the germline of another mammalian species have been grafted onto human framework sequences.

[0028] The term "antibody drug conjugate" as used herein refers to the linkage of an antibody or an antigen-binding fragment thereof with another agent, such as a small molecule, a peptide, an imaging probe, etc. The linkage can be a covalent bond or a non-covalent interaction, such as via electrostatic forces. Various linkers known in the art can be used to form an antibody drug conjugate. In addition, the antibody drug conjugate can be provided in the form of a fusion protein that can be expressed from a polynucleotide encoding the antibody drug conjugate.

[0029] As used herein, the terms "polypeptide" and "protein" are used interchangeably to refer to a polymer of amino acid residues and are not limited to a minimum length. These terms include post-expression modifications of the polypeptide, such as glycosylation, acetylation, phosphorylation, and the like. Furthermore, a "polypeptide" can refer to a protein that contains modifications to the native sequence, such as deletions, additions, and substitutions (which are generally conservative in nature), so long as the protein maintains a desired activity. These modifications may be intentional or accidental. A peptide refers to a fragment of a protein that maintains biological activity.

[0030] A protein degradation targeting chimera (PROTAC) refers to a ubiquitin pathway protein binding moiety (e.g., an E3 ubiquitin ligase, alone or in complex with an E2 ubiquitin conjugating enzyme involved in the transfer of ubiquitin to a target protein) and a protein targeting moiety linked or coupled together, where the ubiquitin pathway protein binding moiety recognizes a ubiquitin pathway protein and the targeting moiety recognizes a target protein (e.g., EGFR). Such compounds may be referred to herein as PROTAC compounds or PROTACs. Non-limiting examples of PROTACs include, for example, ACS Med Chem Lett 10,1549 (2019), ACS Med Chem Lett 13,278 (2022), Bioorg Mol Chem Lett 30,127167 (2020), Cancers 11,1094 (2019), Chem Comm 57,12852 (2021), Drug Dev Res 82,422 (2020), Eur J Med Chem 189,112061 (2020), Eur J Med Chem 192,112199 (2020), Eur J Med Chem 218 113328 (2021), Eur J Org Chem 208,112781 (2020), J Med Chem 65,4709 (2022), JMC 65,5057 (2022), Nature Chem Biol 16,577 (2020), Sig Trans Target Ther 5,214 (2020), WO2019 / 121562, and WO2021 / 127561, each of which is incorporated herein by reference. For example, PROTACs include:

[0031] [ka] [ka] [ka] [ka]

[0032] It could be.

[0033] As used herein, the terms "nucleic acid molecule," "nucleotide," "oligonucleotide," "polynucleotide," and "nucleic acid" are used interchangeably herein to refer to polymeric forms of nucleotides of any length. They can include both double-stranded and single-stranded sequences, including, but not limited to, cDNA, mRNA from viral, prokaryotic, and eukaryotic sources, genomic DNA sequences from viral (e.g., DNA viruses and retroviruses) or prokaryotic sources, RNAi, cRNA, antisense molecules, ribozymes, and synthetic DNA sequences. The term also captures sequences that include any of the known base analogs of DNA and RNA.

[0034] As used herein, an aptamer refers to an oligonucleotide or peptide sequence that has the ability to recognize a target molecule with high affinity and specificity. Aptamers can occur naturally, but are typically prepared by screening large random sequence pools for affinity and specificity to a desired target.

[0035] The term "peptidomimetic" generally refers to a peptide, partial peptidomimetic, or non-peptide molecule that mimics the tertiary binding structure or activity of a selected native peptide or protein functional domain (e.g., a binding motif or active site). These peptidomimetics include recombinant or chemically modified peptides, as well as non-peptide agents such as small molecule drug mimetics.

[0036] In various embodiments, the EGFR degrading agent has the structure of Formula I:

[0037] [ka]

[0038] In the formula, X is C 1-6Alkylene, C 2-6 Alkenylene, C 2-6 Alkynylene, C 3-10 Cycloalkylene, 4-6 membered heterocycle, OC 0-6 Alkylene, OC 2-6 Alkenylene, OC 2-6 Alkynylene, OC 3-10 Cycloalkylene, O-(4-6 membered heterocyclene), SC 0-6 Alkylene, SC 2-6 Alkenylene, SC 2-6 Alkynylene, SC 3-10 Cycloalkylene, S-(4-6 membered heterocyclene), NR 3 -C 0-6 Alkylene, NR 3 -C 2-6 Alkenylene, NR 3 -C 2-6 Alkynylene, NR 3 -C 3-10 Cycloalkylene, or NR 3 -(4- to 6-membered heterocyclene), and X is optionally R 3 and Y is substituted with 1 to 5 groups independently selected from 0-6 Alkylene, C 3-6 Alkenylene or C 3-6 alkynylene, and Y is optionally halo, N(R 3 ) 2 , and R 3 and A is substituted with 1 to 3 groups independently selected from C 6-10 aryl or 5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S; A is optionally selected from 1-3 R 4 and B is replaced by C 6-10 aryl, a 5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S, a 3-8 membered cycloalkyl ring, or a 4-10 membered heterocycle having 1-3 heteroatoms selected from N, O, and S; B is optionally selected from 1-3 R 5 is replaced by R 1 and R 2 However, each independently, C 1-6 Alkyl, C3-6 Alkenyl, C 3-6 Alkynyl or C 3-6 cycloalkyl or R 1 and R 2 together with the carbon atom to which they are attached form a 4-8 membered cycloalkyl or heterocyclic ring having 1 or 2 ring heteroatoms selected from O, S, and N, and the cycloalkyl or heterocyclic ring optionally contains 1 to 2 R 4 Each R 3 However, independently, OH, C 1-6 Alkyl, C 2-6 Alkenyl, C 2-6 Alkynyl, C 1-6 Alkoxy, phenyl, O-phenyl, benzyl, O-benzyl, C 3-6 cycloalkyl, a 4-10 membered heterocycle having 1-4 heteroatoms selected from N, O, and S, or (O) having 1-3 heteroatoms selected from N, O, and S 0-1 - 5 to 10 membered heteroaryl or two R 3 together with the atoms to which they are bonded, C 3-6 Cycloalkyl (e.g., C 4-6 cycloalkenyl), or a 4- to 6-membered heterocycle having one heteroatom selected from N, O, and S, 4 and R 5 But independently, halo, NO 2 , oxo, cyano, C 1-4 Alkyl, C 1-4 Haloalkyl (e.g., CF 3 , CHF 2 ), C 1-4 Alkoxy, C 1-4 Haloalkoxy (e.g., OCF 3 , O.C.H.F. 2 ), C 1-4 Thioalkoxy, C 2-4 Alkenyl, C 2-4 Alkynyl, CHO, C(=O)R 6 , C(=O)N(R 6 ) 2 , S(O) 0-2 R 6 , S.O.2 N(R 6 ) 2 , N.H. 2 , N.H.R. 6 , N(R 6 ) 2 , N.R. 7 COR 6 , N.R. 7 SO 2 R 6 , P(=O)(R 6 ) 2 , C 3-6 4-10 membered heterocyclic rings having 1-4 heteroatoms selected from cycloalkyl, N, O, and S (e.g., oxetanyl, oxetanyloxy, oxetanylamino, oxolanyl, oxolanyloxy, oxolanylamino, oxanyl, oxanyloxy, oxanylamino, oxepanyl, oxepanyloxy, oxepanylamino, azetidinyl, azetidinyloxy, azetidylamino, pyrrolidinyl, pyrrolidinyloxy, pyrrolidinylamino, piperidinyl, piperidinyloxy, piperidinylamino, azepanyl, azepanyloxy, azepanylamino, dioxolanyl, dioxanyl, morpholino, thiomorpholino, thiomorpholino-S,S-dioxide, piperazinyl, dioxepanyl, dioxepanyloxy, dioxepanylamino, oxazepanyl, oxazepanyloxy, oxazepanylamino, diazepanyl, diazepanyloxy, or diazepanylamino, and each R 6 However, independently, H, C 1-6 Alkyl, C 1-6 Haloalkyl, C 3-6 Alkenyl, C 3-6 Alkynyl, COOR 7 , CON(R 7 ) 2 , C 0-3 Alkylene-C 3-8 Cycloalkyl, C 0-3 Alkylene-C 6-10 Aryl, C 0-3 alkylene-(4-10 membered heterocycle having 1-4 heteroatoms selected from N, O, and S), or C 0-3alkylene-(5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S), where the aryl, heterocycle, or heteroaryl is optionally selected from 1-3 R 7 is replaced by Each R 7 However, independently, H, C 1-6 Alkyl, C 1-6 Haloalkyl, C 3-6 Alkenyl, C 3-6 Alkynyl, C 1-4 Alkoxy or C 1-4 It may be a haloalkoxy, or a compound or a salt thereof.

[0039] In various embodiments, R 1 and R 2 are each independently 1-6 In some embodiments, R 1 and R 2 Each is methyl.

[0040] In various embodiments, R 1 and R 2 together with the carbon atom to which they are attached form a 4-8 membered cycloalkyl or heterocyclic ring. 1 and R 2 taken together with the carbon atom to which they are attached form a 5- or 6-membered cycloalkyl or heterocyclic ring. In some embodiments, R 1 and R 2 together with the carbon atoms to which they are attached form a cyclohexyl ring.

[0041] In various embodiments, R 1 and R 2 together with the carbon atoms to which they are attached form the structure: [ka]

[0042] where * indicates the point of attachment to the remainder of the compound of formula I. In some embodiments, R 4 is C 1-6 Alkyl, C 1-6 Haloalkyl, (C=O)R 3 , (C=O)OR 3 , CON(R 3 ) 2 , C 0-3 Alkylene-C 3-8 Cycloalkyl, C 0-3 Alkylene-C 6-10 Aryl or C 0-3 alkylene-(5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S), where the aryl or heteroaryl is optionally selected from 1-3 R 5 In some embodiments, R 4 is C 1-6 Alkyl, (C=O)R 3 , (C=O)OR 3 , or CON(R 3 ) 2 In some embodiments, R 4 is C 1-6 In some embodiments, R 4 is methyl, ethyl, propyl, isopropyl, isobutyl, or isopentyl. 4 is methyl. In some embodiments, R 4 is deuterated. In some embodiments, R 4 is C 1-6 In some embodiments, R 4 is 3,3,3-trifluoropropyl. In some embodiments, R 4 is C 0-3 Alkylene-C 3-8 In some embodiments, R 4 is cyclobutyl, cyclopentyl, or cyclohexyl. In some embodiments, R 4 is cyclobutyl or cyclopentyl. In some embodiments, R 4 is C0-3 Alkylene-C 6-10 In some embodiments, R 4 is benzyl. In some embodiments, R 4 is C 0-3 alkylene-(5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S), where the heteroaryl is optionally selected from 1-3 R 5 In some embodiments, R 4 is C 1 alkylene-(5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S), where the heteroaryl is optionally selected from 1-3 R 5 In some embodiments, R 4 is C 0-3 alkylene-(5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S), where the heteroaryl is selected from 1-3 R 5 In some embodiments, R 4 is C 0-3 alkylene-(5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S), where the heteroaryl is unsubstituted. In some embodiments, R 4 teeth,

[0043] [ka]

[0044] It is.

[0045] In various embodiments, A is C 6-10 In some embodiments, A is aryl.

[0046] In various embodiments, B is C 6-10In some embodiments, B is aryl. In some embodiments, B is phenyl. In various embodiments, B is 5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S. In some embodiments, B is pyridinyl. In some embodiments, B is quinolinyl. In various embodiments, B is 3-8 membered cycloalkyl. In some embodiments, B is 5- or 6-membered cycloalkyl.

[0047] In some embodiments, A is one R 4 In some embodiments, A is substituted with the structure:

[0048] [ka]

[0049] In some embodiments, A has two R 4 In some embodiments, at least one R 4 is C 1-6 In some embodiments, at least one R 4 is methyl. In some embodiments, at least one R 4 is halo. In some embodiments, R 4 is bromo. In some embodiments, at least one R 4 is C 1-6 In some embodiments, at least one R 4 is methoxy.

[0050] In some embodiments, B is one R 5 In some embodiments, B is substituted with two R 5 In some embodiments, B is substituted with the structure

[0051] [ka]

[0052] In some embodiments, at least one R 5 is halo. In some embodiments, at least one R 5 is fluoro or chloro. In some embodiments, one R 5 is fluoro, and the other R 5 is chloro. In some embodiments, at least one R 5 is C 1-6 In some embodiments, at least one R 5 is methoxy. In some embodiments, one R 5 is a halo, and the other R 5 is C 1-6 In some embodiments, one R 5 is chloro, and the other R 5 is methoxy.

[0053] In some embodiments, R 4 and R 5 are each independently 1-6 Alkyl, halo, or C 1-6 In some embodiments, R 6 is C 1-6 Alkyl, (C=O)R 3 , (C=O)OR 3 , or CON(R 3 ) 2 It is.

[0054] In various embodiments, X is O-C 0-6 Alkylene or SC 0-6 In some embodiments, X is an alkylene. 0-6 In some embodiments, X is O, S, O-CH 2 - or S-CH 2 In various embodiments, Y is C 0-2 In some embodiments, Y is n-null or CH 2 In some embodiments, X is NR 3-CH 2 , O-CH 2 - or S-CH 2 - and Y is null. In some embodiments, X is NR 3 -CH 2 , O-CH 2 - or S-CH 2 and Y is CH 2 In some embodiments, R 3 is H.

[0055] In various embodiments, X is C 1-6 In some embodiments, X is C 2-6 Alkenylene or C 2-6 In various embodiments, Y is C 0-2 In some embodiments, Y is null (a bond) or CH 2 In various embodiments, Y is C 3-6 Alkenylene or C 3-6 It is alkynylene.

[0056] As used herein, reference to an element, whether by description or by chemical structure, includes all isotopes of that element unless otherwise indicated. As an example, the term "hydrogen" or "H" in a chemical structure used herein includes all isotopes of that element unless otherwise indicated by the use of a particular isotope, e.g., 1 Not only H, but also deuterium ( 2 H), tritium ( 3 H), and mixtures thereof. Other specific, non-limiting examples of elements whose isotopes are included include carbon, phosphorus, iodine, and fluorine.

[0057] In any compound disclosed herein having one or more chiral centers, when the absolute stereochemistry is not explicitly indicated, it is understood that each center may be independently in the R or S configuration, or a mixture thereof. Thus, the compounds provided herein may be enantiomerically pure or may be stereoisomeric mixtures. Furthermore, the compounds provided herein may be scalemic mixtures. Furthermore, in any compound disclosed herein having two or more chiral centers, all diastereomers of the compound are included. Additionally, in any compound having one or more double bonds that generate geometric isomers that can be defined as E or Z, it is understood that each double bond may be independently in the E or Z configuration, or a mixture thereof. Similarly, all tautomeric forms are also intended to be included.

[0058] In some instances, the EGFR degrading agent of the disclosed methods comprises Compound A or a pharma- ceutical acceptable salt thereof:

[0059] [ka]

[0060] Chemical Definition As used herein, the term "alkyl" refers to linear and branched saturated hydrocarbon groups having 1 to 30 carbon atoms, for example, 1 to 20 carbon atoms, or 1 to 10 carbon atoms. n The term means that the alkyl group has "n" carbon atoms. For example, C 4 Alkyl refers to an alkyl group having four carbon atoms. 1 -C 7Alkyl refers to alkyl groups having numbers of carbon atoms inclusive of all ranges (e.g., 1-7 carbon atoms) and all subgroups (e.g., 1-6, 2-7, 1-5, 3-6, 1, 2, 3, 4, 5, 6, and 7 carbon atoms). Non-limiting examples of alkyl groups include methyl, ethyl, n-propyl, isopropyl, n-butyl, sec-butyl (2-methylpropyl), t-butyl (1,1-dimethylethyl), 3,3-dimethylpentyl, and 2-ethylhexyl. Unless otherwise indicated, alkyl groups can be unsubstituted or substituted alkyl groups.

[0061] As used herein, the term "alkylene" refers to an alkyl group that has a substituent. For example, an alkylene group can be -CH 2 CH 2 -or-CH 2 - It can be. C n The term means that the alkylene group has "n" carbon atoms. For example, C 1-6 Alkylene refers to an alkylene group having a number of carbon atoms, including all ranges and all subgroups, as described above for "alkyl" groups. Unless otherwise indicated, an alkylene group can be an unsubstituted or substituted alkylene group. "Alkenylene" and "alkynylene" are similarly defined, but for an alkene or alkyne group.

[0062] As used herein, the term "cycloalkyl" refers to a cyclic hydrocarbon group having 3 to 8 carbon atoms (e.g., 3, 4, 5, 6, 7, or 8 carbon atoms). n The term cycloalkyl group means that the group has "n" carbon atoms. For example, C 5 Cycloalkyl refers to a cycloalkyl group having 5 carbon atoms in the ring. 6 -C 8Cycloalkyl refers to cycloalkyl groups having a number of carbon atoms inclusive of the entire range (e.g., 6-8 carbon atoms) and all subgroups (e.g., 6-7, 7-8, 6, 7, and 8 carbon atoms). Non-limiting examples of cycloalkyl groups include cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, and cyclooctyl. Unless otherwise indicated, cycloalkyl groups can be unsubstituted cycloalkyl groups or substituted cycloalkyl groups. The cycloalkyl groups described herein can be isolated or fused with another cycloalkyl group, heterocycloalkyl group, aryl group, and / or heteroaryl group. Unless otherwise indicated, when a heterocycloalkyl group is fused with another heterocycloalkyl group, each heterocycloalkyl group can have 3-8 carbon atoms. Unless otherwise indicated, cycloalkyl groups can be unsubstituted or substituted.

[0063] As used herein, the term "heterocycle" is defined similarly to cycloalkyl, except that the ring contains 1-3 heteroatoms independently selected from oxygen, nitrogen, and sulfur. Specifically, the term "heterocycle" refers to a monocyclic or fused bicyclic ring having a total of 3-12 (e.g., 3-8, 5-8, 3-6, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12) atoms, of which 1, 2, or 3 ring atoms are heteroatoms independently selected from the group consisting of oxygen, nitrogen, and sulfur, and the remaining atoms in the ring are carbon atoms. Non-limiting examples of heterocyclic groups include piperidine, pyrazolidine, tetrahydrofuran, tetrahydropyran, dihydrofuran, morpholine, and the like. The heterocyclic groups described herein can be isolated or fused with another heterocycloalkyl group, cycloalkyl group, aryl group, and / or heteroaryl group. Unless otherwise indicated, heterocyclic groups can be unsubstituted or substituted.

[0064] The cycloalkyl and heterocyclic groups are non-aromatic, but may be partially unsaturated rings, optionally containing, for example, independently selected alkyl, alkyleneOH, C(O)NH 2, N.H. 2 Heterocyclic groups can be optionally substituted with 1-5 or 1-3 groups that are alkyl, oxo (=O), aryl, alkylenehalo, halo, and OH. Heterocyclic groups can be optionally further N-substituted with alkyl (e.g., methyl or ethyl), alkylene-OH, alkylenearyl, and alkyleneheteroaryl. Other substitutions of specific heterocyclic and cycloalkyl groups are described herein.

[0065] As used herein, the term "aryl" refers to a monocyclic or bicyclic aromatic group having 6 to 10 ring atoms. Unless otherwise indicated, an aryl group can be unsubstituted or substituted with, for example, halo, alkyl, alkenyl, OCF 3 , NO 2 , CN, NC, OH, alkoxy, amino, CO 2 H, CO 2 It may be substituted with one or more, in particular 1 to 5 or 1 to 4 or 1 to 3 groups independently selected from alkyl, aryl, and heteroaryl. The aryl group may be isolated (e.g., phenyl) or fused with a cycloalkyl group (e.g., tetrahydronaphthyl), a heterocyclic group, and / or a heteroaryl group.

[0066] As used herein, the term "heteroaryl" refers to a monocyclic or bicyclic aromatic ring having a total of 5 to 10 ring atoms and having 1 to 4 heteroatoms selected from nitrogen, oxygen, and sulfur atoms in the aromatic ring. Unless otherwise indicated, a heteroaryl group can be unsubstituted or can be substituted with, for example, halo, alkyl, alkenyl, OCF 3 , NO 2 , CN, NC, OH, alkoxy, amino, CO 2 H, CO 2It may be substituted with one or more, particularly 1 to 4, substituents selected from alkyl, aryl, and heteroaryl. In some cases, the heteroaryl group is substituted with one or more of an alkyl group and an alkoxy group. Examples of heteroaryl groups include, but are not limited to, thienyl, furyl, pyridyl, pyrrolyl, oxazolyl, triazinyl, triazolyl, isothiazolyl, isoxazolyl, imidazolyl, pyrazinyl, pyrimidinyl, thiazolyl, and thiadiazolyl.

[0067] As used herein, the term "alkoxy" or "alkoxyl" refers to an "-O-alkyl" group. An alkoxy or alkoxyl group can be unsubstituted or substituted.

[0068] As used herein, "halo" refers to F, Cl, I, or Br.

[0069] As used herein, the term "therapeutically effective amount" means an amount of a compound or combination of therapeutically active compounds that ameliorates, attenuates or eliminates one or more symptoms of a particular disease or condition (e.g., cancer), or prevents or delays the onset of one or more symptoms of a particular disease or condition.

[0070] As used herein, the terms "patient" and "subject" may be used interchangeably and refer to animals such as dogs, cats, cows, horses, and sheep (e.g., non-human animals), as well as humans. A particular patient or subject is a mammal (e.g., a human).

[0071] As used herein, the term "pharmaceutical acceptable" means that a reference substance, such as a compound of the present disclosure, or a formulation containing a compound or a particular excipient, is safe and suitable for administration to a patient or subject. The term "pharmaceutical acceptable excipient" refers to a medium that does not interfere with the effectiveness of the biological activity of the active ingredient and is not toxic to the host to which it is administered.

[0072] The compounds disclosed herein may be pharmaceutically acceptable salts. As used herein, the term "pharmaceutically acceptable salts" refers to salts that are suitable for use in contact with the tissues of humans and lower animals without undue toxicity, irritation, allergic reactions, etc., within the scope of sound medical judgment, and are commensurate with a reasonable benefit / risk ratio. Pharmaceutically acceptable salts are well known in the art. For example, S. M. Berge et al. describe pharmaceutically acceptable salts in detail in J. Pharmaceutical Sciences, 1977, 66, 1-19, which is incorporated herein by reference. Pharmaceutically acceptable salts of the compounds of the present invention include those derived from suitable inorganic and organic acids and bases. Examples of pharmaceutically acceptable non-toxic acid addition salts are salts of amino groups formed with inorganic acids such as hydrochloric acid, hydrobromic acid, phosphoric acid, sulfuric acid, and perchloric acid, or organic acids such as acetic acid, trifluoroacetic acid, oxalic acid, maleic acid, tartaric acid, citric acid, succinic acid, or malonic acid, or by using other methods used in the art, such as ion exchange. Other pharma- ceutically acceptable salts include adipate, alginate, ascorbate, aspartate, benzenesulfonate, benzoate, bisulfate, borate, butyrate, camphorate, camphorsulfonate, citrate, cyclopentanepropionate, digluconate, dodecyl sulfate, ethanesulfonate, formate, fumarate, glucoheptonate, glycerophosphate, gluconate, glutamate, hemisulfate, heptanoate, hexanoate, hydroiodide, 2-hydroxypropyl phosphate, and the like. Examples of the salts include oxy-ethanesulfonate, lactobionate, lactate, laurate, lauryl sulfate, malate, maleate, malonate, methanesulfonate, 2-naphthalenesulfonate, nicotinate, nitrate, oleate, oxalate, palmitate, pamoate, pectinate, persulfate, 3-phenylpropionate, phosphate, picrate, pivalate, propionate, stearate, succinate, sulfate, tartrate, thiocyanate, p-toluenesulfonate, undecanoate, and valerate.Salts of compounds containing a carboxylic acid or other acidic functional group can be prepared by reacting with a suitable base. Such salts include alkali metal, alkaline earth metal, aluminum, ammonium, N, or Zn salts. + (C 1-4 Alkyl) 4 Salts and salts of organic bases, for example, but not limited to, trimethylamine, triethylamine, morpholine, pyridine, piperidine, picoline, dicyclohexylamine, N,N'-dibenzylethylenediamine, 2-hydroxyethylamine, bis-(2-hydroxyethyl)amine, tri-(2-hydroxyethyl)amine, procaine, dibenzylpiperidine, dehydroabietylamine, N,N'-bisdehydroabietylamine, glucamine, N-methylglucamine, collidine, quinine, quinoline, and basic amino acids such as lysine and arginine. The present invention also contemplates the quaternization of any basic nitrogen-containing group of the compounds disclosed herein. Water- or oil-soluble or dispersible products may be obtained by such quaternization. Representative alkali or alkaline earth metal salts include sodium, lithium, potassium, calcium, magnesium, and the like. Further pharma- ceutically acceptable salts include, where appropriate, non-toxic ammonium, quaternary ammonium, and amine cations formed using counterions such as, for example, halides, hydroxides, carboxylates, sulfates, phosphates, nitrates, lower alkylsulfonates, and arylsulfonates.

[0073] As used herein, terms such as "treating," "treat," or "treatment" include preventative (eg, prophylactic) and palliative treatment.

[0074] As used herein, the term "excipient" means a pharma- ceutically acceptable additive, carrier, diluent, adjuvant, or other ingredient other than the active pharmaceutical ingredient (API).

[0075] Pharmaceutical Compositions The EGFR degrading agent disclosed herein can be formulated into a pharmaceutical composition for administration to a patient.The pharmaceutical composition includes an appropriate amount of the EGFR degrading agent in combination with a suitable carrier and optionally other useful components.For example, other useful components include, but are not limited to, encapsulating materials or additives such as absorption enhancers, antioxidants, binders, buffers, coating agents, coloring agents, diluents, disintegrants, emulsifiers, extenders, fillers, flavoring agents, moisturizing agents, lubricants, flavoring agents, preservatives, propellants, release agents, bactericides, sweeteners, solubilizers, wetting agents, and mixtures thereof.

[0076] The pharmaceutical composition is administered to a patient in need thereof by any route that makes the compound bioavailable. In one embodiment, the composition is a solid formulation adapted for oral administration. In another embodiment, the composition is a tablet, powder, or capsule, or the composition is a tablet. In an embodiment, the composition is a liquid formulation adapted for oral administration. In an embodiment, the composition is a liquid formulation adapted for parenteral administration. In an embodiment, the composition is a solution, suspension, or emulsion, or the composition is a solution. In an embodiment, the solid form composition can be converted to a liquid form composition for either oral or parenteral administration immediately prior to use. These particular solid form compositions are provided in unit dose form and are therefore used to provide a single liquid dose unit. These and other pharmaceutical compositions, as well as processes for their preparation, are well known in the art. (See, for example, Remington: The Science and Practice of Pharmacy (DB Troy, Editor, 21st Edition, Lippincott, Williams & Wilkins, 2006).

[0077] Dosage may vary depending on the requirements of the subject, the severity of the condition being treated, and the specific drug being used. Determination of the appropriate dosage for a particular situation can be determined by those skilled in the medical field. The total daily dosage may be divided and administered in portions throughout the day or by any means that provides continuous delivery.

[0078] The EGFR degrading agents and compositions described herein may be initially administered at a suitable dosage, which may be adjusted as necessary depending on the desired clinical response. In certain embodiments, the EGFR degrading agent is administered to a subject at a daily dosage of 0.01 to about 50 mg / kg of body weight. In other embodiments, the dosage is 1 to 1000 mg / day. In certain embodiments, the daily dosage is 1 to 750 mg / day, or 10 to 500 mg / day.

[0079] In an embodiment, the pharmaceutical composition is in a unit dosage form. The composition can be subdivided into unit doses containing an appropriate amount of the EGFR degrading agent. The unit dosage form can be a tablet, capsule, or powder in a vial or ampoule, or any suitable number of these in a packaged form. The unit dosage form can be in packaged form, the package containing discrete amounts of the composition, for example, packaged tablets, capsules, or powder in a vial or ampoule. The amount of the EGFR degrading agent in a unit dose of the composition can vary or be adjusted from about 1 mg to about 100 mg, or from about 1 mg to about 50 mg, or from about 1 mg to about 25 mg, depending on the particular application.

[0080] Cancer for Treatment The methods disclosed herein are useful for treating cancers driven by EGFR mutation, overexpression, or ligand overexpression, mutant KRAS, or mutant BRAF. In some cases, the cancer is characterized by the presence of at least one deleterious KRAS mutation. The deleterious KRAS mutation may include, but is not limited to, one of the following mutations: G12D, G12C, G12V, and G13D. In various cases, the cancer may be characterized by the presence of one or more of the following EGFR mutations: L858R, T790M, C797S, S768I, exon 19 deletion, or a combination thereof. In various cases, the cancer may be characterized by a deleterious BRAF mutation (e.g., V600E). In various cases, the cancer is a solid tumor.

[0081] The cancer, in some embodiments, is acute lymphocytic cancer, acute myeloid leukemia, alveolar rhabdomyosarcoma, bone cancer, brain cancer, breast cancer, anal cancer, anal canal cancer, or anorectal cancer, eye cancer, intrahepatic bile duct cancer, joint cancer, cervical, gallbladder, or pleural cancer, nasal, nasal cavity, or middle ear cancer, oral cancer, vulvar cancer, leukemia (e.g., chronic lymphocytic leukemia), chronic myeloid cancer, colon cancer, esophageal cancer, cervical cancer, gastrointestinal carcinoid tumors. The cancer is selected from the group consisting of cancers of the head and neck, ovarian, cervical, bladder and esophageal, pancreatic, gastric, breast, endometrial and colorectal, hepatocellular carcinoma, glioblastoma, bladder, lung, non-small cell lung cancer (NSCLC), bronchioalveolar carcinoma, ... In some cases, the cancer is pancreatic cancer, head and neck cancer, melanoma, colon cancer, kidney cancer, leukemia, or breast cancer. In some cases, the cancer is melanoma, colon cancer, kidney cancer, leukemia, or breast cancer. In some cases, the cancer treated with the methods disclosed herein can be pancreatic cancer, colorectal cancer, head and neck cancer, lung cancer, such as non-small cell lung cancer (NSCLC), ovarian cancer, cervical cancer, gastric cancer, breast cancer, hepatocellular carcinoma, glioblastoma, liver cancer, malignant mesothelioma, melanoma, multiple myeloma, prostate cancer, and kidney cancer. In some embodiments, the cancer is pancreatic cancer, colorectal cancer, head and neck cancer, or lung cancer. In some embodiments, the cancer is cetuximab-resistant cancer or osimertinib-resistant cancer.

[0082] Route of radiation therapy administration Radiation therapy involves the use of high-energy radiation (e.g., X-rays, gamma rays, or charged particles) to damage and / or kill cancer cells and shrink tumors. In the methods of the present invention, radiation can be delivered to the patient by a machine placed outside the body (external beam radiation therapy), by a radioactive material placed inside the body near the cancer (internal radiation therapy, also called brachytherapy), or by a systemically administered radioactive substance (e.g., radioactive iodine) that travels to the cancer via the bloodstream. Alternatively, these delivery methods can be used in combination.

[0083] Radiation therapies suitable for use in the combination treatments described herein include a) external beam radiation, and b) the use of radiopharmaceuticals that contain radioactive radioisotopes.

[0084] External beam radiation: External beam radiation therapy for the treatment of cancer uses a radiation source that is external to the patient, typically either a radioisotope such as Co, Cs, or a high-energy X-ray source such as a linear accelerator. The external source produces a collimated beam that is directed at the patient, at the tumor site. External source radiation therapy avoids some of the problems of internal source radiation therapy, but irradiates a significant volume of non-tumorous or healthy tissue in the path of the radiation beam along with the tumor tissue. By irradiating the patient with an external radiation beam at various angles and converging the beam at the cancer (e.g., tumor) site, the adverse effects of irradiating healthy tissue can be reduced while maintaining a given dose of radiation in the tumor tissue. The specific volumetric factor of healthy tissue along the path of the radiation beam varies, reducing the total dose to healthy tissue throughout the treatment. Irradiation of healthy tissue can also be reduced by tightly collimating the radiation beam to the entire cross section of the cancer (e.g., tumor) taken perpendicular to the axis of the radiation beam.

[0085] Radiopharmaceutical: A "radiopharmaceutical" refers to a pharmaceutical containing at least one radiation-emitting radioisotope. Radiopharmaceuticals are routinely used in nuclear medicine for the diagnosis and / or treatment of various diseases. For example, a radiolabeled pharmaceutical, such as a radiolabeled antibody, contains a radioisotope (RI) that serves as a radiation source. As contemplated herein, the term "radioisotope" includes metallic and non-metallic radioisotopes. The radioisotope is selected based on the medical use of the radiolabeled pharmaceutical. When the radioisotope is a metallic radioisotope, a chelator is typically used to bind the metallic radioisotope to the molecular remainder. When the radioisotope is a non-metallic radioisotope, the non-metallic radioisotope is typically directly bound to the molecular remainder or bound by a linker. A "metallic radioisotope" is any suitable metallic radioisotope useful in in vivo or in vitro therapeutic or diagnostic procedures. Identifying the most appropriate isotope for radiotherapy requires consideration of various factors. These include tumor uptake and retention, blood clearance, radiation delivery rate, half-life and specific activity of the radioisotope, and the feasibility of large-scale production of the radioisotope in an economical manner. The key to a therapeutic radiopharmaceutical is to deliver the required amount of radiation dose to tumor cells to achieve a cytotoxic or tumoricidal effect without causing unmanageable side effects. The physical half-life of the therapeutic radioisotope is preferably similar to the biological half-life of the radiopharmaceutical at the tumor site. For example, if the half-life of the radioisotope is too short, most of the decay will occur before the radiopharmaceutical reaches its maximum target / background ratio. On the other hand, a half-life that is too long may cause unnecessary radiation doses to normal tissues. Ideally, the radioisotope should have a long enough half-life to achieve the minimum dose rate and irradiate all cells at the most radiosensitive stage of the cell cycle. In addition, the half-life of the radioisotope must be long enough to allow sufficient time for production, release, and transportation.

[0086] The radiation type suitable for use in the method of the present invention may vary. For example, radiation may be electromagnetic or particulate in nature. Electromagnetic radiation useful in the practice of the present invention includes, but is not limited to, X-rays and gamma rays. Particulate radiation useful in the practice of the present invention includes, but is not limited to, electron beam (beta particles), proton beam, neutron beam, alpha particles, and negative pi mesons. Radiation may be delivered using conventional radiological treatment devices and methods, as well as intraoperatively and by stereotactic methods. Additional considerations regarding radiation therapy suitable for use in the practice of the present invention are described throughout Steven A. Leibel et al., Textbook of Radiation Oncology (1998) (publ. WB Saunders Company), for example in Chapters 13 and 14. Radiation may also be delivered by other methods, such as targeted delivery by, for example, radioactive "seeds" or by systemic delivery of targeted radioconjugates. J. Padawer et al., Int. J. Radiat. Oncol. Biol. Phys. 7:347-357 (1981).

[0087] For tumor therapy, both alpha and beta particle emitters are being investigated. Alpha particles are particularly good cytotoxic agents because they dissipate a large amount of energy within one or two cell diameters. Beta particle emitters have a relatively long penetration range (2-12 mm in tissue) depending on the energy level. The long penetration range is particularly important for solid tumors with heterogeneous blood flow and / or receptor expression. Beta particle emitters result in a more homogeneous dose distribution, even when they are distributed heterogeneously within the target tissue.

[0088] Administration of external beam radiation: For administration of external beam radiation, the amount can be at least about 1 Gray (Gy) fraction at least once every other day to the treatment volume. In some embodiments, radiation is administered at least about 2 Gray (Gy) fractions at least once a day to the treatment volume. In another particular embodiment, radiation is administered at least about 2 Gray (Gy) fractions at least once a day to the treatment volume, 5 consecutive days per week. In some embodiments, radiation is administered in 10 Gy fractions, 3 times a week, every other day to the treatment volume. In some embodiments, a total of at least about 20 Gy is administered to the patient in need thereof. In some embodiments, at least about 30 Gy is administered to the patient in need thereof. In some embodiments, at least about 40 Gy is administered to the patient in need thereof. Typically, the patient receives external beam therapy 4 or 5 times a week. The entire course of treatment usually lasts for 1 to 7 weeks, depending on the type of cancer and the goal of treatment. For example, a dose of 2 Gy / day may be administered to a patient for 30 days.

[0089] Radiopharmaceutical Administration: There are several ways to administer radiopharmaceuticals. For example, radiopharmaceuticals can be administered by targeted delivery or by systemic delivery of targeted radioconjugates, such as radiolabeled antibodies, radiolabeled peptides, and liposomal delivery systems. In some embodiments, the radiolabeled agent can be a radiolabeled antibody. See, for example, Ballangrud AM, et al. Cancer Res., 2001; 61: 2008-2014 and Goldenberg, DM J. Nucl. Med., 2002; 43(5): 693-713, the contents of which are incorporated herein by reference. In some embodiments, the radiopharmaceutical can be administered in the form of a liposomal delivery system, such as small unilamellar vesicles, large unilamellar vesicles, and multilamellar vesicles. Liposomes can be formed from various phospholipids, such as cholesterol, stearylamine, or phosphatidylcholine. See, e.g., Emfietzoglou D, Kostarelos K, Sgouro S G. An analytical dosimetry Study for the use of radionuclide-liposome conjugates in internal radiotherapy. J Nucl Med 2001; 42: 499-504, the contents of which are incorporated herein by reference. In some embodiments, the radiopharmaceutical may be a radiolabeled peptide. See, e.g., Weiner RE, Thakur M L. Radiolabeled peptides in the diagnosis and therapy of oncological diseases. Appl Radiat Isot 2002 November; 57 (5): 749 63, the contents of which are incorporated herein by reference.

[0090] In addition to targeted delivery, brachytherapy can be used to deliver radiopharmaceuticals to the target site. Brachytherapy is a technique that places a radiation source as close as possible to the tumor site. In many cases, the source is inserted directly into the tumor. The radiation source can be in the form of a wire, seed, or rod. Cesium, iridium, or iodine are commonly used. There are two types of brachytherapy: intracavitary and interstitial. In intracavitary, a container that holds the radiation source is placed in or near the tumor. The source is placed in a body cavity. In interstitial, only the radiation source is placed in the tumor. These radiation sources can remain in the patient permanently. In most cases, the radiation source is removed from the patient after a few days. The amount of radiation required can be determined by one of skill in the art based on known doses for a particular type of cancer. See, e.g., Cancer Medicine 5th ed., Edited by RC Bast et al., July 2000, BC Decker, the entire contents of which are incorporated herein by reference.

[0091] In view of the many possible embodiments to which the principles of the present disclosure may be applied, it should be recognized that the illustrated embodiments are merely examples and should not be construed as limiting the scope of the invention. EXAMPLES

[0092] Mice bearing locally advanced xenografts (PC9, RKO, or UMSCC74B) were treated with vehicle (control), Compound A (also called DPI-503) administered by daily oral gavage, radiation + vehicle, or a combination of Compound A and radiation administered by daily oral gavage. Tumor volumes were measured using calipers at least three times a week.

[0093] Figure 1A shows mice bearing osimertinib-resistant PC9 non-small cell lung cancer xenografts treated with vehicle, Compound A (75 mg / kg, 5 times per week for 3 weeks), radiation (2 Gy / day, 5 times per week for 3 weeks), or a combination of radiation and Compound A. At day 155, when the experiment was terminated, no active tumors could be detected by histopathology or histochemistry.

[0094] FIG. 1B shows mice bearing RKO BRAF V600E colon cancer tumors treated with vehicle (control), Compound A (100 mg / kg, daily for 8 days), radiation (2 GY / day, 5 days per week for 3 weeks) + vehicle, or a combination of Compound A and radiation, with combination treatment mice continuing to receive Compound A for more than 4 weeks.

[0095] Figure 1C shows that mice bearing UMSCC74B KRAS G12D head and neck squamous cell carcinoma tumors were treated with vehicle (control), Compound A (30 mg / kg biw for 2 weeks), radiation (2 GY / day, 5 days a week for 3 weeks) + vehicle, or radiation and Compound A. The experiment was terminated when the control animals had to be euthanized due to tumor size.

[0096] The data presented in FIG. 1 demonstrates that Compound A and radiation unexpectedly demonstrated efficacy in treating mutant EGFR, mutant BRAF, and mutant KRAS-driven cancers compared to either Compound A alone or radiation alone.

Claims

1. A composition comprising a compound of formula (I) or a pharma- ceutically acceptable salt thereof for use in combination with radiation to treat cancer, comprising: The compound of formula (I) 【Chemistry 1】 [In the formula, X is C １－６ Alkylene, C ２－６ Alkenylene, C ２－６ Alkynylene, C ３－１０ Cycloalkylene, 4- to 6-membered heterocycle, O—C ０－６ Alkylene, O-C ２－６ Alkenylene, O-C ２－６ Alkynylene, O-C ３－１０ Cycloalkylene, O-(4- to 6-membered heterocyclene), S-C ０－６ Alkylene, S-C ２－６ Alkenylene, S-C ２－６ Alkynylene, S-C ３－１０ Cycloalkylene, S-(4- to 6-membered heterocyclene), NR ３ -C ０－６ Alkylene, NR ３ -C ２－６ Alkenylene, NR ３ -C ２－６ Alkynylene, NR ３ -C ３－１０ Cycloalkylene, or NR ３ -(4- to 6-membered heterocyclene), and X is optionally R ３ and is substituted with 1 to 5 groups independently selected from Y is C ０－６ Alkylene, C ３－６ Alkenylene, or C ３－６ alkynylene, and Y is optionally halo, N(R ３ ) ２ , and R ３ and A is C ６－１０ aryl or 5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S; A is optionally selected from 1-3 R ４ is replaced by B is C ６－１０ aryl, a 5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S, a 3-8 membered cycloalkyl ring, or a 3-12 membered heterocycle having 1-3 ring heteroatoms selected from O, S, and N; B is optionally selected from 1-3 R ５ is replaced by R １ and R ２ Each independently, C １－６ Alkyl, C ３－６ Alkenyl, C ３－６ Alkynyl, or C ３－６ cycloalkyl or R １ and R ２ together with the carbon atom to which they are attached form a 4-8 membered cycloalkyl or heterocycle having 1 or 2 ring heteroatoms selected from O, S, and N, and the cycloalkyl or heterocycle optionally contains 1 to 2 R ４ and each R ３ However, independently, OH, C １－６ Alkyl, C １－６ (O) having 1 to 3 heteroatoms selected from alkoxy, phenyl, O-phenyl, benzyl, O-benzyl, or N, O, and S; ０－１ -5 to 10 membered heteroaryl or two R ３ together with the atoms to which they are attached, C ３－６ Cycloalkyl (e.g., C ４－６ cycloalkenyl), or a 4- to 6-membered heterocycle having one heteroatom selected from N, O, and S; R ４ and R ５ each independently represents halo, NO ２ , oxo, cyano, C １－４ Alkyl, C １－４ Haloalkyl, C １－４ Alkoxy, C １－４ Haloalkoxy, C １－４ Thioalkoxy, CHO, C(=O)R ６ , C(=O)N(R ６ ) ２ , S(O) ０－２ R ６ , S.O. ２ N (R ６ ) ２ , N.H. ２ , N.H.R. ６ , N(R ６ ) ２ , N.R. ７ C.O.R. ６ , N.R. ７ SO ２ R ６ , P(=O)(R ６ ) ２ , oxetanyl, oxetanyloxy, oxetanylamino, oxolanyl, oxolanyloxy, oxolanylamino, oxanyl oxanyloxy, oxanylamino, oxepanyl, oxepanyloxy, oxepanylamino, azetidinyl, azetidinyloxy, azetidylamino, pyrrolidinyl, pyrrolidinyloxy, pyrrolidinylamino, piperidinyl, piperidinyloxy, piperidinylamino, azepanyl, azepanyloxy, azepanylamino, dioxolanyl, dioxanyl, morpholino, thiomorpholino, thiomorpholino-S,S-dioxide, piperazinyl, dioxepanyl, dioxepanyloxy, dioxepanylamino, oxazepanyl, oxazepanyloxy, oxazepanylamino, diazepanyl, diazepanyloxy, or diazepanylamino; Each R ６ However, independently, H, C １－６ Alkyl, C １－６ Haloalkyl, C ３－６ Alkenyl, C ３－６ Alkynyl, COOR ７ , CON(R ７ ) ２ , C ０－３ Alkylene-C ３－８ Cycloalkyl, C ０－３ Alkylene-C ６－１０ Aryl, or C ０－３ alkylene-(5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S), wherein the aryl or heteroaryl is optionally selected from 1-3 R ７ is replaced by Each R ７ However, independently, H, C １－６ Alkyl, C １－６ Haloalkyl, C ３－６ Alkenyl, C ３－６ Alkynyl, C １－４ Alkoxy or C １－４ haloalkoxy].

2. R １ and R ２ together with the carbon atom to which they are attached form a 4- to 8-membered cycloalkyl or heterocycle, and optionally R 1 and R 2 together with the carbon atom to which they are attached form a 5- or 6-membered cycloalkyl or heterocycle.

3. R １ and R ２ together with the carbon atoms to which they are attached form the structure: 【Chemistry 2】 3. The pharmaceutical composition of claim 2, wherein the compound of formula (I) forms a heterocycle having the formula:

4. A is C ６－１０ The pharmaceutical composition of claim 1 , wherein the compound is aryl.

5. The pharmaceutical composition of claim 4, wherein A is phenyl.

6. The pharmaceutical composition of claim 1, wherein B is a 5-10 membered heteroaryl having 1-4 heteroatoms selected from N, O, and S.

7. 7. The pharmaceutical composition of claim 6, wherein B is pyridinyl or quinolinyl.

8. A is one R ４ The pharmaceutical composition of claim 1 , wherein the compound is substituted with

9. A has the structure: 【Chemistry 3】 The pharmaceutical composition of claim 8, having the formula:

10. At least one R ４ The pharmaceutical composition of claim 1 , wherein is halo.

11. R ４ The pharmaceutical composition of claim 10, wherein is bromo.

12. X is O-C ０－６ Alkylene or S-C ０－６ The pharmaceutical composition of claim 1 , wherein the alkylene is aryl.

13. X is O, S, O-CH ２ - or S-CH ２ The pharmaceutical composition according to claim 12, wherein

14. The pharmaceutical composition of claim 1, wherein Y is a bond or C 1-6 alkylene.

15. R ３ The pharmaceutical composition of claim 1 , wherein is H.

16. The pharmaceutical composition according to claim 1 , wherein the compound is compound A or a salt thereof. 【Chemistry 5】

17. The pharmaceutical composition of claim 1 , wherein the cancer is an EGFR, KRAS, or BRAF mutant cancer.

18. 18. The pharmaceutical composition of claim 17, wherein the KRAS mutation is G12D, G12V, G12C, or G13D, or a combination thereof, and / or the EGFR mutation is L858R, T790M, C797S, S768I, or del exon 19, or a combination thereof.

19. 2. The pharmaceutical composition of claim 1, wherein the cancer is pancreatic cancer, colorectal cancer, head and neck cancer, or lung cancer.

20. The pharmaceutical composition of any one of claims 1 to 19, wherein the radiation is administered in an amount of at least 2 Gy.

Images