Anticancer drug therapy

Abstract

The present invention relates to a Son of Sevenless 1 (SOS1) inhibitor and / or a mitogen-activated protein kinase kinase (MEK) inhibitor for use in the treatment and / or prevention of cancer, wherein the SOS1 inhibitor or MEK inhibitor is administered alone or the SOS1 inhibitor is administered in combination with a MEK inhibitor, and the cancer is resistant to treatment with an inhibitor of KRAS G12C.

Description

[Technical field]

[0001] The present invention relates to a Son of Sevenless 1 (SOS1) inhibitor or a mitogen-activated protein kinase kinase (MEK) inhibitor, or a combination of a SOS1 inhibitor and a MEK inhibitor, for use in the treatment of cancers which are resistant to treatment with inhibitors of KRAS G12C, in particular in the treatment of cancers in which the cancer cells express a primary KRAS G12C mutation and further express a secondary Y96X mutation, preferably a secondary Y96D or Y96S mutation. [Background technology]

[0002] V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (KRAS) is a human RAS gene that encodes a RAS GTPase. KRAS proteins are small GTPases that function as molecular switches in growth factor signaling pathways that affect diverse cellular processes such as proliferation, metabolism, and growth. KRAS switches between a GDP-bound, inactive conformation and a GTP-bound, active conformation. Binding of guanine nucleotide exchange factors (GEFs) such as SOS1 promotes GDP release from RAS family proteins, allowing GTP binding and activating downstream pathways in the active form. SOS1 (Son of Sevenless 1) is the human homolog of the first identified Drosophila protein Son of Sevenless 1. SOS1 is critically involved in the activation of signaling of RAS family proteins in cancer. Selective pharmacological inhibition of the binding of the catalytic site of SOS1 to RAS family proteins prevents SOS1-mediated activation of RAS family proteins to their GTP-bound form, and SOS1 inhibitors inhibit signaling in cells downstream of RAS family proteins. In cancer cells associated with a dependency on RAS family proteins, SOS1 inhibitors provide anti-cancer efficacy. A combination of SOS1 inhibitors with inhibitors of MEK (mitogen-activated protein kinase kinase) for use in the treatment of cancer is known from WO 2020 / 254451. KRAS is a gene that is frequently mutated in cancer. KRAS mutations, such as amino acids G12, G13, Q61, and A146, are found in various human cancers, such as lung cancer, colorectal cancer, and pancreatic cancer. The majority of KRAS mutations in non-small cell lung cancer (NSCLC) occur at codon 12, and roughly half are glycine to cysteine ​​substitutions (G12C). Despite their high frequency, the development of targeted therapies for KRAS mutant cancers has long been unsatisfactory. In recent years, several drugs have been developed that can inhibit the function of KRAS protein with G12C mutation. Several KRAS G12C inhibitors, such as adagrasib and sotorasib, have reached clinical trials and demonstrated promising results in metastatic non-small cell lung cancer with KRAS G12C mutation.

[0003] In general, in almost all solid tumors that respond to targeted therapy, acquired on-target drug resistance inevitably occurs, leading to clinical relapse. Therefore, acquisition of secondary mutations in target genes (on-target mechanisms) that inevitably lead to acquired resistance will occur in targeted therapy using adagrasib and sotorasib. Possible targets for combination therapy and mechanisms of resistance to KRAS G12C inhibitors are currently being discussed (Dunnett-Kane et al., Cancers, 2021, 13(1), 151), and both adagrasib and sotorasib have already been tested in combination with SHP2 (Src homology region 2 domain-containing phosphatase 2) inhibitors in early clinical trials (Hata et al., Nat. Med., 2020, 26, 169-170). However, no data have been reported to date describing secondary mutations in KRAS that cause acquired resistance to KRAS G12C inhibitors. Secondary mutations in KRAS that confer acquired resistance to sotrasib and adagrasib are still expected, and possible strategies to overcome this resistance are needed. It is therefore an object of the present invention to provide inhibitors that allow a second line treatment option for cancers that have acquired resistance to KRAS G12C inhibitors. Summary of the Invention

[0004] In cell line models of acquired on-target resistance to sotorasib and adagrasib, clones with secondary mutations of Y96D or Y96S (Y96D / S) were found to be resistant to the KRAS G12C inhibitors sotorasib and adagrasib. SOS1 inhibitors such as BI-3406 and combinations of SOS1 inhibitors with MEK inhibitors such as trametinib showed potent activity against cells with secondary mutations of Y96D or Y96S in addition to the primary mutation of G12C. This provides a second-line therapy option to overcome acquired resistance caused by secondary mutations of KRAS that are expected to emerge during the course of treatment with sotorasib and adagrasib. According to a first aspect, there is provided a Son of Sevenless 1 (SOS1) inhibitor and / or a mitogen-activated protein kinase kinase (MEK) inhibitor for use in the treatment and / or prevention of cancer, wherein the SOS1 inhibitor or MEK inhibitor is administered alone, or the SOS1 inhibitor is administered in combination with a MEK inhibitor, and the cancer is resistant to treatment with a KRAS G12C inhibitor. In one embodiment, the cancer has become resistant to treatment with a KRAS G12C inhibitor after previous treatment with an inhibitor of KRAS G12C. In one embodiment, the cancer is resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849). In a preferred embodiment, the cancer has become resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849) after previous treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849). In one embodiment, cancer cells of the cancer exhibit a primary KRAS G12C mutation and further exhibit a secondary Y96X mutation, preferably a Y96X secondary mutation selected from the group consisting of Y96D and Y96S. In one aspect, cancer cells of the cancer have been determined to exhibit a primary KRAS G12C mutation and further exhibit a secondary Y96X mutation, preferably a Y96X secondary mutation selected from the group consisting of Y96D and Y96S.

[0005] In one or more embodiments, the SOS1 inhibitor is the following compound: [ka]

[0006] [ka]

[0007] [ka]

[0008] [ka]

[0009] [ka] or a pharma- ceutically acceptable salt thereof.

[0010] In one or more embodiments, the MEK inhibitors include trametinib, cobimetinib, binimetinib, selumetinib, refametinib, as well as the following compounds: [ka]

[0011] [ka]

[0012] [ka]

[0013] [ka]

[0014] [ka]

[0015] [ka]

[0016] [ka]

[0017] [ka]

[0018] [ka]

[0019] [ka] or a pharma- ceutically acceptable salt thereof.

[0020] In one or more embodiments, the cancer is selected from the group consisting of pancreatic cancer, lung cancer, colorectal cancer, cholangiocarcinoma, multiple myeloma, melanoma, uterine cancer, endometrial cancer, thyroid cancer, acute myeloid leukemia, bladder cancer, urothelial cancer, gastric cancer, cervical cancer, squamous cell carcinoma of the head and neck, diffuse large B-cell lymphoma, esophageal cancer, chronic lymphocytic leukemia, hepatocellular carcinoma, breast cancer, ovarian cancer, prostate cancer, glioblastoma, renal carcinoma, and sarcoma. Another aspect relates to a pharmaceutical composition comprising an SOS1 inhibitor as an active ingredient.Another aspect relates to a pharmaceutical composition comprising an MEK inhibitor as an active ingredient.Another aspect relates to a pharmaceutical combination comprising an SOS1 inhibitor and a MEK inhibitor as active ingredients for use in the treatment and / or prevention of cancer, wherein the cancer is resistant to treatment with a KRAS G12C inhibitor. Another aspect is to provide one or more containers with (i) a (first) pharmaceutical composition or dosage form comprising an SOS1 inhibitor and optionally a pharma- ceutically acceptable carrier, excipient and / or vehicle; and / or (ii) a (second) pharmaceutical composition or dosage form comprising a MEK inhibitor and optionally a pharma- ceutically acceptable carrier, excipient and / or vehicle; Including, (iii) Package insert, including instructions may include, The present invention relates to a kit for use in the treatment and / or prevention of cancer, wherein the cancer is resistant to treatment with a KRAS G12C inhibitor.

[0021] Another aspect relates to a method of treating and / or preventing cancer comprising administering to a patient a therapeutically effective amount of an SOS1 inhibitor or a therapeutically effective amount of a MEK inhibitor, or administering to a patient a therapeutically effective amount of an SOS1 inhibitor in combination with a therapeutically effective amount of a MEK inhibitor, wherein the cancer is resistant to treatment with a KRAS G12C inhibitor. Another aspect relates to the use of an SOS1 inhibitor and / or a MEK inhibitor for the manufacture of a medicament for the treatment and / or prevention of cancer, wherein the SOS1 inhibitor or MEK inhibitor is used alone or the SOS1 inhibitor is used in combination with a MEK inhibitor, and the cancer is resistant to treatment with a KRAS G12C inhibitor. In one embodiment of all aspects disclosed herein, particularly the pharmaceutical composition or medical combination, kit, method, or use, the cancer has become resistant to treatment with a KRAS G12C inhibitor after previous treatment with a KRAS G12C inhibitor. In one embodiment of all aspects disclosed herein, particularly the pharmaceutical compositions or medical combinations, kits, methods or uses, the SOS1 inhibitor is a compound as defined herein or a pharma- ceutically acceptable salt thereof. In one embodiment of all aspects disclosed herein, particularly the pharmaceutical compositions or medical combinations, kits, methods, or uses, the MEK inhibitor is a compound as defined herein or a pharma- ceutical acceptable salt thereof. In one embodiment of all aspects disclosed herein, particularly the pharmaceutical composition or medical combination, kit, method, or use, the cancer is resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849).

[0022] In a preferred embodiment of all aspects disclosed herein, particularly the pharmaceutical composition or medical combination, kit, method, or use, the cancer has become resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849) after previous treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849). In one embodiment of all aspects disclosed herein, particularly the pharmaceutical composition or medical combination, kit, method, or use, the cancer cells of the cancer exhibit a primary KRAS G12C mutation and further exhibit a secondary Y96X mutation, preferably a secondary Y96X mutation selected from the group consisting of Y96D and Y96S. In a preferred embodiment of all aspects disclosed herein, particularly the pharmaceutical composition or medical combination, kit, method, or use, cancer cells of the cancer are determined to exhibit a primary KRAS G12C mutation and further exhibit a secondary Y96X mutation, preferably a secondary Y96X mutation selected from the group consisting of Y96D and Y96S. In all aspects disclosed herein, particularly in one or more embodiments of the pharmaceutical compositions or medical combinations, kits, methods, or uses, the cancer is selected from the group consisting of pancreatic cancer, lung cancer, colorectal cancer, cholangiocarcinoma, multiple myeloma, melanoma, uterine cancer, endometrial cancer, thyroid cancer, acute myeloid leukemia, bladder cancer, urothelial cancer, gastric cancer, cervical cancer, squamous cell carcinoma of the head and neck, diffuse large B-cell lymphoma, esophageal cancer, chronic lymphocytic leukemia, hepatocellular carcinoma, breast cancer, ovarian cancer, prostate cancer, glioblastoma, renal cancer, and sarcoma.

[0023] Another aspect is an in vitro method for detecting or diagnosing an individual having acquired resistance to treatment with a KRAS G12C inhibitor and / or an individual having sensitivity to treatment with a SOS1 inhibitor, or a MEK inhibitor, or a combination of a SOS1 inhibitor and a MEK inhibitor, comprising: - determining the presence of a KRAS mutation selected from the group consisting of Y96X, preferably Y96D and Y96S, in a biological sample taken from the individual, The method relates to said method, wherein, based on detection of a KRAS mutation Y96X, preferably a mutation selected from the group consisting of Y96D and Y96S, the individual is classified as resistant to treatment with a KRAS G12C inhibitor and as sensitive to treatment with an SOS1 inhibitor, or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor. Another aspect relates to the use of the KRAS mutation Y96X, preferably a mutation selected from the group consisting of Y96D and Y96S, as a biomarker for cancers or cancer cells that are resistant to treatment with an inhibitor of KRAS G12C and / or cancers or cancer cells that are sensitive to treatment with an SOS1 inhibitor, or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor. [Brief description of the drawings]

[0024] [Figure 1] Growth inhibition curves of modified Ba / F3 cells with KRAS G12C, G12D, or G12V. FIG. 1A shows cells treated with the indicated concentrations of sotorasib for 72 hours. Results are shown as the average of three separate experiments. Error bars indicate standard deviation (SD). FIG. 1B shows growth inhibition curves of modified Ba / F3 cells with KRAS G12C, G12D, or G12V treated with the indicated concentrations of adagrasib for 72 hours. [Diagram 2] Growth inhibition curves of Ba / F3 cells carrying KRAS G12C as well as secondary mutations resulting from ENU mutagenesis. Figure 2A shows cells treated with sotorasib at the indicated concentrations for 72 hours. Results are shown as the average of three separate experiments. Error bars indicate standard deviation (SD). Figure 2B shows growth inhibition curves of Ba / F3 cells carrying KRAS G12C as well as secondary mutations resulting from ENU mutagenesis treated with adagrasib at the indicated concentrations for 72 hours. [Diagram 3]Growth inhibition assay of Ba / F3 cells with both KRAS G12C and a secondary mutation introduced into Ba / F3 cells. Figure 3A shows cells treated with sotorasib at the indicated concentrations for 72 hours. Results are shown as the average of three separate experiments. Error bars indicate standard deviation (SD). Figure 3B shows growth inhibition assay of Ba / F3 cells with KRAS G12C as well as a secondary mutation treated with adagrasib at the indicated concentrations for 72 hours. [Figure 4] Growth inhibition assay of H358 cells with KRAS G12C and a secondary mutation introduced into H358 cells. Figure 4A shows cells treated with sotorasib at the indicated concentrations for 72 hours. Results are shown as the average of three separate experiments. Error bars indicate standard deviation (SD). Figure 4B shows growth inhibition assay of H358 cells with KRAS G12C and a secondary mutation treated with adagrasib at the indicated concentrations for 72 hours. [Diagram 5] In Figure 5A, growth inhibition assay of Ba / F3 cells harboring KRAS G12C as well as secondary A59S, Y96D, or Y96S mutations (all introduced into Ba / F3 cells) treated with the indicated concentrations of BI 3406 for 72 hours. Results are shown as the mean of three separate experiments. Error bars indicate standard deviation (SD). Figure 5B shows a three-dimensional (3D) growth inhibition assay of H358 cells harboring KRAS G12C as well as secondary A59S, Y96D, or Y96S mutations (all introduced into H358 cells) treated with the indicated concentrations of BI 3406 for 72 hours. FIG. 5C shows a three-dimensional (3D) growth inhibition assay of H358 cells harboring KRAS G12C as well as secondary Y96D or Y96S mutations (introduced into H358 cells) treated with the indicated concentrations of trametinib and 1 μM BI 3406 for 72 hours. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0025] SOS1 inhibitors As used herein, the term "SOS1" refers to the human homolog of Drosophila protein Son of Sevenless 1. As used herein, the term "SOS1 inhibitor" refers to a compound that inhibits the binding of SOS1 to KRAS and prevents SOS1-mediated activation of KRAS to GTP-bound form. In one embodiment, the SOS1 inhibitor binds to SOS1. SOS1 inhibitors that belong to different compound classes are known. Preferably, for all aspects and embodiments of the methods of treatment, uses, combinations and compositions, the SOS1 inhibitor is - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2018 / 115380, All of the SOS1 inhibitors I-1 to I-383 disclosed in WO 2018 / 115380, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2019 / 122129, All of the SOS1 inhibitors I-1 to I-179 disclosed in WO 2019 / 122129, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2020 / 180768, All of the SOS1 inhibitor examples 1 to 103 disclosed in WO 2020 / 180768, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2020 / 180770, All of the SOS1 inhibitors disclosed in WO 2020 / 180770, examples 1 to 540; - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2018 / 172250, All of the SOS1 inhibitors disclosed in WO 2018 / 172250, Examples 1 to 458, SOS1 inhibitors as generally described and / or specifically disclosed in WO 2019 / 201848, and All of the SOS1 inhibitors disclosed in International Publication WO 2019 / 201848, examples 1 to 100 The entire contents of said disclosure, together with their respective syntheses and properties, are hereby incorporated by reference.

[0026] In addition, with respect to all aspects and embodiments of the methods of treatment, uses, combinations and compositions, the SOS1 inhibitors are - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 074227; All of the SOS1 inhibitor examples 1 to 342 disclosed in WO 2021 / 074227; - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 092115; All of the SOS1 inhibitor examples 1 to 71 and P disclosed in WO 2021 / 092115 (Table A, Tables 1 to 21), - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 130731, All of the SOS1 inhibitor examples / compounds 1 to 152 disclosed in WO 2021 / 130731, SOS1 inhibitors as generally described and / or specifically disclosed in Chinese Publication No. 113200981; All of the SOS1 inhibitor examples / compounds 1 to 22 disclosed in China Publication No. 113200981; - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 249519; All of the SOS1 inhibitor examples / compounds 1 to 29 disclosed in WO 2021 / 249519, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 249475, All of the SOS1 inhibitor examples 1 to 112 disclosed in WO 2021 / 249475, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 173524, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 127429; - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2022 / 026465, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 203768, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2021 / 228028; - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2022 / 017339; - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2022 / 017519, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2022 / 026465, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2022 / 028506, - SOS1 inhibitors as generally described and / or specifically disclosed in WO 2022 / 058344, SOS1 inhibitors generally described and / or specifically disclosed in China Publication No. 113801114 The entire contents of said disclosure, together with their respective syntheses and properties, are hereby incorporated by reference.

[0027] The term "SOS1 inhibitor" as used herein also includes the tautomers, pharmaceutically acceptable salts, hydrates or solvates of the SOS1 inhibitors shown above (including the hydrates or solvates of pharmaceutically acceptable salts).The term also includes any solid form, preferably crystalline form, of the SOS1 inhibitor, and any crystalline form of its pharmaceutically acceptable salts, hydrates and solvates (including the hydrates or solvates of pharmaceutically acceptable salts). As used herein, "pharmaceutically acceptable salts" includes both acid and base addition salts. Pharmaceutically acceptable acid addition salts refer to salts formed with inorganic or organic acids that retain the biological effectiveness and properties of the free bases and are not biologically or otherwise undesirable salts. Pharmaceutically acceptable base addition salts include salts derived from inorganic or non-toxic organic bases. As used herein, the term "solvate" refers to an aggregate or complex of one or more solvent molecules and a compound of the present invention. Examples of solvents include water, isopropanol, ethanol, methanol, DMSO, ethyl acetate, acetic acid, and ethanolamine. The term "hydrate" refers to a complex where the solvent molecule is water.

[0028] In one embodiment, the SOS1 inhibitor is compound I-1 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-2 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-3 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-4 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-13 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-20 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-21 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-22 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-23 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-25 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-26 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-37 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-38 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-45 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-49 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-50 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-52 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-53 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-54 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-55 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-57 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-58 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-59 or a pharma- ceutically acceptable salt thereof.In another embodiment, the SOS1 inhibitor is compound I-61 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-69 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-71 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-73 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-77 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-78 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-82 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-87 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-96 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-97 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-98 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-99 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-100 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-101 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-102 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-103 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-121 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-123 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-126 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-128 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-130 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-156 or a pharma- ceutically acceptable salt thereof. In another embodiment, the SOS1 inhibitor is compound I-157 or a pharma- ceutically acceptable salt thereof.In another embodiment, the SOS1 inhibitor is the compound BI-3406 or a pharma- ceutically acceptable salt thereof.All of these embodiments are preferred embodiments with respect to the properties of the SOS1 inhibitor.

[0029] MEK inhibitors As used herein, the term "MEK" refers to mitogen-activated protein kinase kinase. As used herein, the term "MEK inhibitor" refers to a compound that inhibits and / or reduces the biological activity of MEK. MEK inhibitors belonging to different compound classes are known. Preferably, for all aspects and embodiments of the methods of treatment, uses, combinations and compositions, the MEK inhibitor is MEK inhibitors as generally described and / or specifically disclosed in WO 2013 / 136249, All of the MEK inhibitors Examples 1 to 79 disclosed in WO 2013 / 136249, MEK inhibitors as generally described and / or specifically disclosed in WO 2013 / 136254, All of the MEK inhibitors Examples 1 to 21 disclosed in WO 2013 / 136254, MEK inhibitors as generally described and / or specifically disclosed in WO 2005 / 121142, and Compound [I], which is an example of a MEK inhibitor disclosed in International Publication WO 2005 / 121142 The entire contents of said disclosure, together with their respective syntheses and properties, are hereby incorporated by reference.

[0030] As used herein, "MEK inhibitors" also includes tautomers, pharma- ceutically acceptable salts, hydrates, or solvates of the MEK inhibitors set forth above (including hydrates or solvates of pharma- ceutical acceptable salts). The term also includes any solid form, preferably crystalline form, of the MEK inhibitors, as well as any crystalline form of the pharma- ceutical acceptable salts, hydrates, and solvates thereof (including hydrates or solvates of pharma- ceutical acceptable salts). The MEK inhibitor may also be selected from the group consisting of trametinib, cobimetinib, binimetinib, selumetinib, refametinib, and pharma- ceutically acceptable salts thereof. The compound with the INN name trametinib has the formula (T): [ka] (T) or a pharma- ceutically acceptable salt thereof, or a hydrate or solvate thereof (e.g., a DMSO solvate thereof). WO 2005 / 121142 describes trametinib as Example 4-1. The compound is commercially available.

[0031] In addition, compounds in which INN is represented by cobimetinib (ATC code: L01XE38), binimetinib (ATC code: L01XE41), selumetinib (ATC code: L01EE04), and refametinib (BAY 869766) are known in the art and / or commercially available. More preferably, the MEK inhibitor is one of the following specific MEK inhibitors: 1-1, 1-2, 1-3, 1-4, 1-5, 1-6, 1-7, 1-8, 1-9, 1-10, 1-11, 1-12, 1-13, 1-14, 1-15, 1-16, 1-17, 1-18, 1-19, 1-20, 1-21, 1-22, 1-23, 1-24, 1-25, 1-26, 1-27, 1-28, 1-29, 1-30, 1-31, 1-32, 1-33, 1-34, 1-35, 1-36, 1-37, 1-38, 1-39, 1-40, 1-41, 1-42, 1-43, 1-44, 1 -45, 1-46, 1-47, 1-48, 1-49, 1-50, 1-51, 1-52, 1-53, 1-54, 1-55, 1-56, 1-57, 1-58, 1-59, 1-60, 1-61, 1-62, 1-63, 1-64, 1-65, 1-66, 1-67, 1-68, 1-69, 1-70, 1-71, 1-72, 1-73, 1-74, 1-75, 1-76, 1-77, 1-78, 1-79, 2-1, 2-2, 2-3, 2-4, 2-5, 2-6, 2-7, 2-8, 2-9, 2-10, 2-11, 2-12, 2-13, 2-14, 2-15, and a MEK inhibitor or a salt thereof selected from the group consisting of 2-16, 2-17, 2-18, 2-19, 2-20, and 2-21. All of the MEK inhibitors listed are disclosed in WO 2013 / 136249 and WO 2013 / 136254, along with their respective syntheses and properties.

[0032] In one embodiment, the MEK inhibitor is trametinib or a pharmaceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is cobimetinib or a pharmaceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is binimetinib or a pharmaceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is selumetinib or a pharmaceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is refametinib or a pharmaceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-1 or a pharmaceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-2 or a pharmaceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-3 or a pharmaceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-4 or a pharmaceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-5 or a pharmaceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-6 or a pharmaceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-7 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-8 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-9 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-10 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-11 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-12 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-13 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-14 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-15 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK1 inhibitor is compound 1-16 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-17 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-18 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-19 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-20 or a pharma- ceutically acceptable salt thereof.In one embodiment, the MEK inhibitor is compound 1-21 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-22 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-23 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-24 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-25 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-26 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-27 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-28 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-29 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-30 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-31 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-32 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-33 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-34 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-35 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-36 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-37 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-38 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-39 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-40 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-41 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-42 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-43 or a pharma- ceutically acceptable salt thereof.In one embodiment, the MEK inhibitor is compound 1-44 or a pharma- ceutically acceptable salt thereof.In one embodiment, the MEK inhibitor is compound 1-45 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-46 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-47 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-48 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-49 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-50 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-51 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-52 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-53 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-54 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-55 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-56 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-57 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-58 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-59 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-60 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-61 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-62 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-63 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-64 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-65 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-66 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-67 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-68 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-69 or a pharma- ceutically acceptable salt thereof.In one embodiment, the MEK inhibitor is compound 1-70 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-71 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-72 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-73 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-74 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-75 or a pharma- ceutically acceptable salt thereof. In one embodiment, the MEK inhibitor is compound 1-76 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-77 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-78 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 1-79 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-1 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-2 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-3 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-4 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-5 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-6 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-7 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-8 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-9 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-10 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-11 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-12 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-13 or a pharma- ceutically acceptable salt thereof.In another embodiment, the MEK inhibitor is compound 2-14 or a pharma- ceutically acceptable salt thereof.In another embodiment, the MEK inhibitor is compound 2-15 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-16 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-17 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-18 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-19 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-20 or a pharma- ceutically acceptable salt thereof. In another embodiment, the MEK inhibitor is compound 2-21 or a pharma- ceutically acceptable salt thereof. All of these embodiments are preferred embodiments in terms of the properties of the MEK inhibitor.

[0033] combination The combination of all aspects of the properties of the SOS1 inhibitors described herein with all aspects of the properties of the MEK inhibitors described herein results in a particular combination or group of combinations, all of which are considered to be specifically disclosed and are considered to be all aspects of the invention, and of its combinations, compositions, kits, methods, uses and compounds for use.Preferred embodiments relate to the properties of the SOS1 inhibitors: I-1, I-2, I-3, I-4, I-13, I-20, I-21, I-22, I-23, I-25, I-26, I-37, I-38, I-45, I-49, I-50, I-52, I-53, I-54, I-55, I-57, I-58, I-59, I-61, I-69, I-71, I-73, I-77, I-78, I-82, I-87, I-96, I-97, I-98, I-99, I-100, I-101, I-102 , I-103, I-121, I-123, I-126, I-128, I-130, I-156, I-157 and BI-3406, or a pharma- ceutical acceptable salt thereof, and trametinib, cobimetinib, binimetinib, selumetinib, refametinib, which are aspects relating to the properties of MEK inhibitors, aspects 1-1, 1-2, 1-3, 1-4, 1-5, 1-6, 1-7, 1-8, 1-9, 1-10, 1-11, 1-12, 1-13, 1-14, 1-15, 1-16, 1-17, 1-18, 1- 19, 1-20, 1-21, 1-22, 1-23, 1-24, 1-25, 1-26, 1-27, 1-28, 1-29, 1-30, 1-31, 1-32, 1-33, 1-34, 1-35, 1-36, 1-37, 1-38, 1-39, 1-40, 1-41, 1-42, 1-43, 1-44, 1-45, 1-46, 1-47, 1-48, 1-49, 1-50, 1-51, 1-52, 1-53, 1-54, 1-55, 1-56, 1-57, 1-58, 1-59, 1-60, 1-61 , 1-62, 1-63, 1-64, 1-65, 1-66, 1-67, 1-68, 1-69, 1-70, 1-71, 1-72, 1-73, 1-74, 1-75, 1-76, 1-77, 1-78, 1-79, 2-1, 2-2, 2-3, 2-4, 2-5, 2-6, 2-7, 2-8, 2-9, 2-10, 2-11, 2-12, 2-13, 2-14, 2-15, 2-16, 2-17, 2-18, 2-19, 2-20, and 2-21, or a pharma- ceutically acceptable salt thereof.

[0034] For use in therapy, the SOS1 inhibitor and the MEK inhibitor can be separately or together included in a suitable pharmaceutical composition for easy administration.Thus, the compounds can be formulated separately or together into a suitable unit dosage formulation containing conventional non-toxic pharma-ceutically acceptable carriers, excipients and / or vehicles suitable for each administration route.Examples of typical pharmaceutical compositions for administering the SOS1 inhibitor and the MEK inhibitor separately or together include, for example, tablets, capsules, suppositories, liquids (e.g., injections and infusions), elixirs, emulsions or dispersible powders.The dosage forms and formulations of active ingredients are known in the art. The SOS1 inhibitor can be administered by oral administration route, and can be formulated alone or together in a suitable unit-dosage formulation containing conventional non-toxic pharmacologic acceptable carriers, excipients and vehicles suitable for each administration route. Similarly, the MEK inhibitor can be administered by oral administration route, and can be formulated alone or together in a suitable unit-dosage formulation containing conventional non-toxic pharmacologic acceptable carriers, excipients and vehicles suitable for each administration route. From the viewpoint of drug compliance, oral administration may be preferred, but the administration route of the SOS1 inhibitor and / or MEK inhibitor described herein is not limited to oral administration, and the compound can be administered parenterally (e.g., intramuscularly, intraperitoneally, intravenously, transdermally or subcutaneously, or by implantation), intestine, nasally, intravaginally, rectally, or topically.

[0035] Monotherapy and combination therapy An object of the present invention is to provide a second-line treatment option for cancers that have acquired resistance to KRAS G12C inhibitors. In cell line models, clones carrying secondary Y96D or Y96S mutations were found to be resistant to both KRAS G12C inhibitors sotrasib and adagrasib in vitro. Surprisingly, SOS1 inhibitors such as BI-3406 and combinations of SOS1 inhibitors with MEK inhibitors such as trametinib showed potent activity against cells expressing, in addition to the primary G12C mutation, secondary Y96D and / or Y96S (Y96D / S) mutations. Specifically, treatment with the SOS1 inhibitor BI-3406 and combination treatment with the SOS1 inhibitor BI-3406 and the MEK inhibitor trametinib reduced cell proliferation. Although cancer treatment with KRAS G12C inhibitors such as sotorasib and adagrasib is known in the prior art, there is still a lack of therapeutic concepts for second-line treatment options for cancers that have acquired resistance to KRAS G12C inhibitors.

[0036] Thus, the present invention relates to an SOS1 inhibitor, a MEK inhibitor, or a combination of an SOS1 inhibitor and an MEK inhibitor as described herein for use in anticancer therapy when the cancer is resistant to treatment with an inhibitor of KRAS G12C. For monotherapy, the SOS1 inhibitor or the MEK inhibitor can be administered in a pharmaceutical composition or dosage form. For combination therapy, the SOS1 inhibitor and the MEK inhibitor can be administered in a dependent formulation (e.g., formulated together in one composition) or independently (e.g., formulated in separate compositions). In other words, in combination therapy, the SOS1 inhibitor and the MEK inhibitor can be administered as part of the same pharmaceutical composition or dosage form, or preferably in separate pharmaceutical compositions or dosage forms. Another aspect relates to a pharmaceutical composition comprising as an active ingredient an SOS1 inhibitor as described herein.A further aspect relates to a pharmaceutical composition comprising as an active ingredient an MEK inhibitor as described herein.Another aspect relates to a pharmaceutical combination comprising as active ingredients both an SOS1 inhibitor as described herein and a MEK inhibitor, optionally including pharma- ceutical acceptable carriers, excipients and / or vehicles, for use in the treatment and / or prevention of cancer, wherein the cancer is resistant to treatment with an inhibitor of KRAS G12C.

[0037] The term "pharmaceutical acceptable carrier, excipient and / or vehicle" refers to a non-toxic carrier, excipient or vehicle that does not destroy the pharmacological activity of the compound that is formulated. Pharmaceutically acceptable carriers, excipients or vehicles that can be used in the compositions of the present invention include, but are not limited to, ion exchangers, alumina, aluminum stearate, lecithin, serum proteins such as human serum albumin, buffer substances such as phosphates, glycine, sorbic acid, potassium sorbate, partial glyceride mixtures of vegetable saturated fatty acids, water, salts or electrolytes (e.g., protamine sulfate, disodium hydrogen phosphate, potassium hydrogen phosphate, sodium chloride, zinc salts), polyvinylpyrrolidone, cellulose-based substances, sodium carboxymethylcellulose, or polyethylene glycol. As used herein, the term "active ingredient" refers to an ingredient that is intended to provide pharmacological activity or other direct effect. The SOS1 inhibitor, or the MEK inhibitor, or the combination of the SOS1 inhibitor and the MEK inhibitor, can be administered or included in a pharmaceutical composition, dosage form, or pharmaceutical combination in a therapeutically effective amount. A "therapeutically effective amount" refers to an amount effective, at dosages and for periods of time necessary, to achieve the desired therapeutic result, which is the minimum amount necessary to prevent, ameliorate, or treat a disease or disorder, or the minimum amount in which the toxic or adverse effects of the compound are outweighed by the therapeutically beneficial effects.

[0038] As used herein, the term "pharmaceutical combination" can refer to a fixed combination in one pharmaceutical composition or dosage form unit, or preferably to a kit of parts for combined administration, in which the SOS1 inhibitor can be administered independently and simultaneously with the MEK inhibitor, or can be administered separately within a time interval. The compounds of the pharmaceutical combination can be combined or separated. This means that the pharmaceutical combination of the SOS1 inhibitor and the MEK inhibitor refers to the use, application or formulation of the separate partners, or refers to a combination product, with or without instructions for combined use. Thus, the combination partners can be completely administered separately or in completely separate pharmaceutical dosage forms. The combination partners can be pharmaceutical compositions that are sold independently of each other, and only appropriate instructions for their combined use are provided for simultaneous or sequential use to be active together, in the package insert (e.g., leaflet, etc.), or in other information provided to physicians and medical professionals, for example, by oral communication, written communication, etc. As used herein, the terms "administered together" or "administered in combination" or "co-administration" and the like are intended to encompass the administration of the selected combination partners to a single subject (e.g., patient) in need thereof, and are intended to include treatment regimens in which the active ingredients are not necessarily administered by the same route of administration and / or at the same time.

[0039] Another aspect is to provide one or more containers with (i) a (first) pharmaceutical composition or dosage form comprising an SOS1 inhibitor as described herein or a pharma- ceutically acceptable salt thereof, and optionally comprising a pharma- ceutically acceptable carrier, excipient and / or vehicle; and / or (ii) a second pharmaceutical composition or dosage form comprising a MEK inhibitor as described herein and optionally comprising a pharma- ceutically acceptable carrier, excipient and / or vehicle; Including, (iii) Package insert, including instructions may include, The present invention relates to a kit for use in the treatment and / or prevention of cancer, wherein the cancer is resistant to treatment with a KRAS G12C inhibitor. As used herein, the terms "first" and "second" with respect to pharmaceutical compositions are intended only to indicate that the compositions are two different compositions, and thus, these terms should not be understood as referring to an order or sequence of administration. Preferably, the package insert contains printed instructions for simultaneous, concomitant, sequential, consecutive, alternating or separate use in the treatment of a hyperproliferative disease as described herein, particularly cancer, in a patient in need of such treatment.

[0040] All formulations of SOS1 inhibitors and MEK inhibitors disclosed herein, as well as the SOS1 inhibitor and MEK inhibitor combinations, pharmaceutical compositions and pharmaceutical combinations disclosed herein, can be administered simultaneously, simultaneously, sequentially, consecutively, alternatingly or separately. The term "simultaneous" refers to administration of both compounds / compositions at substantially the same time. The term "concurrent" refers to administration of the active ingredients in the same general time period, e.g., on the same day, but not necessarily at the same time. The term "sequential" administration includes administration of one active ingredient using one or more dosages during a first time period (e.g., over the course of hours, days, or a week), followed by administration of another active ingredient using one or more dosages during a second time period (e.g., over the course of hours, days, or a week). Overlapping schedules may also be used, which do not necessarily follow a regular order, and include administration of the active ingredients on different days over the treatment period. Alternatively, the term "sequential" administration refers to administration in which administration of the first compound is terminated immediately followed by a second administration step. Alternating administration involves administration of one active ingredient for one period of time (e.g., over the course of hours, days, or a week), followed by administration of another active ingredient for a next period of time (e.g., over the course of hours, days, or a week), and then repeating the pattern for one or more cycles, the total number of repetitions depending on the dosing regimen selected. Variations of these general dosage forms may also be used.

[0041] KRAS G12C inhibitors As used herein, the term "KRAS G12C inhibitor" refers to a compound that inhibits and / or reduces the biological activity of KRAS that exhibits a G12C mutation. KRAS G12C inhibitors belonging to different compound classes are known. Examples include sotorasib (AMG 510) and adagrasib (MRTX 849). Sotorasib and adagrasib are selective inhibitors of KRAS G12C for which clinical data have been reported. The compound known as INN adagrasib is also known as lab code MRTX 849. For example, WO 2017 / 201161 and WO 2019 / 099524 describe general reaction schemes for preparation, synthetic routes, and properties. The compound known as INN sotorasib is also known as lab code AMG 510. For example, WO 2018 / 217651 and WO 2020 / 102730 describe general reaction schemes for preparation, synthetic routes, and properties. As used herein, the term "KRAS G12C inhibitor" also encompasses tautomers of the compound, and pharma- ceutically acceptable salts, and all other solid forms. Further examples include the compounds known as JNJ-74699157 and LY3499446. JNJ-74699157 (ARS-3248) is another small molecule KRAS G12C inhibitor that has recently reached human clinical trials. A KRAS G12C inhibitor known as LY3499446 is also known to be entering phase 1 trials (Nagasaka et al., Cancer Treat Rev., 2020, 84, 101974).

[0042] cancer The combinations, compositions, kits, uses, methods and compounds for use of the present invention may be used to treat cancers that are resistant to treatment with inhibitors of KRAS G12C. According to one aspect, there is provided an SOS1 inhibitor and / or a MEK inhibitor for use in the treatment and / or prevention of cancer, wherein the SOS1 inhibitor or MEK inhibitor is administered alone, or the SOS1 inhibitor is administered in combination with a MEK inhibitor, and the cancer is resistant to treatment with an inhibitor of KRAS G12C. Another aspect refers to a pharmaceutical composition, or combination, or kit as described above for use in a method for the treatment and / or prevention of cancer, wherein the cancer is resistant to treatment with an inhibitor of KRAS G12C as described herein. Another aspect relates to a method of treating and / or preventing cancer comprising administering to a patient a therapeutically effective amount of an SOS1 inhibitor or a therapeutically effective amount of a MEK inhibitor, or administering to a patient a therapeutically effective amount of an SOS1 inhibitor in combination with a therapeutically effective amount of a MEK inhibitor, wherein the cancer is resistant to treatment with a KRAS G12C inhibitor. Another aspect relates to the use of an SOS1 inhibitor and / or a MEK inhibitor for the manufacture of a medicament for the treatment and / or prevention of cancer, wherein the SOS1 inhibitor or MEK inhibitor is used alone or the SOS1 inhibitor is used in combination with a MEK inhibitor, and the cancer is resistant to treatment with a KRAS G12C inhibitor.

[0043] Patients who have relapsed and / or have resistance to one or more KRAS G12C inhibitors are particularly suitable for combination treatment according to the invention, e.g., as a second or third line treatment cycle (which may further be combined with one or more other anti-cancer agents) or as an add-on combination or replacement therapy. Thus, the potential therapeutic applications of SOS1 inhibitors, or MEK inhibitors, or the combination of SOS1 inhibitors and MEK inhibitors may include second, third or further lines of patient treatment.Cancer may be recurrent, relapsed, resistant or refractory to one or more anti-cancer drug treatments using KRAS G12C inhibitors.Thus, a patient may have received previous anti-cancer drug treatments with one or more KRAS G12C inhibitors, but the disease may not yet be cured. Therapy using an SOS1 inhibitor or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor, is effective in treating subjects whose cancer has relapsed, whose cancer has acquired drug resistance to a KRAS G12C inhibitor, or whose cancer has failed one, two or more lines of monotherapy or combination therapy with one or more KRAS G12C inhibitors.Cancer that initially responded to a KRAS G12C inhibitor may relapse and acquire resistance to the KRAS G12C inhibitor, for example, when the KRAS G12C inhibitor is no longer effective in treating the subject with cancer, despite increasing the dose of the KRAS G12C inhibitor.

[0044] Thus, in one embodiment of the combinations, compositions, kits, uses, methods and compounds for use of the present invention, the cancer has become resistant to treatment with a KRAS G12C inhibitor after previous treatment with an inhibitor of KRAS G12C. In another embodiment, the cancer has become resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849). In a preferred embodiment, the cancer has become resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849) after previous treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849). As used herein, the term "cancer" refers to a malignant disease state in which cell proliferation is increased above normal levels. Cancer can be classified in several ways: by the type of tissue in which it arises (histological type), by primary site, i.e., the location in the body where the cancer first begins, and / or by molecular characterization. In a preferred embodiment of the combinations, compositions, kits, uses, methods and compounds for use of the present invention, the cancer is defined as one in which the cancer cells of the cancer display a molecular signature that represents a primary mutation of KRAS G12C and further represents a secondary mutation of Y96X, preferably a secondary mutation of Y96X selected from the group consisting of Y96D and Y96S. In a preferred embodiment, the cancer cells of the cancer have been determined to represent a primary mutation of KRAS G12C and further represent a secondary mutation of Y96X, preferably a secondary mutation of Y96X selected from the group consisting of Y96D and Y96S.

[0045] The combinations, compositions, kits, uses, methods and compounds for use of the present invention (including all aspects) can be used to treat various cancers, for example cancers selected from the group consisting of pancreatic cancer, lung cancer, colorectal cancer, cholangiocarcinoma, multiple myeloma, melanoma, uterine cancer, endometrial cancer, thyroid cancer, acute myeloid leukemia, bladder cancer, urothelial cancer, gastric cancer, cervical cancer, head and neck squamous cell carcinoma, diffuse large B-cell lymphoma, esophageal cancer, chronic lymphocytic leukemia, hepatocellular carcinoma, breast cancer, ovarian cancer, prostate cancer, glioblastoma, renal cancer and sarcoma. Lung cancer includes non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). In one embodiment, the cancer is non-small cell lung cancer (NSCLC). In a further embodiment, the cancer is colon cancer. In a further embodiment, the cancer is pancreatic cancer.

[0046] KRAS G12C, Y96X, and Y96D, and / or Y96S mutations As used herein, the term "Y96X" refers to any substitution of tyrosine with another amino acid, preferably a substitution of tyrosine with serine (Y96S) or aspartic acid (Y96D). Determining whether a tumor or cancer contains a KRAS G12C, Y96X, preferably Y96S and / or Y96D mutation can be performed by evaluating the nucleotide sequence encoding the KRAS protein, by evaluating the amino acid sequence of the KRAS protein, or by evaluating the characteristics of a putative KRAS mutant protein. The sequence of wild-type human KRAS is known in the art. Methods for detecting mutations in KRAS nucleotide sequences are known to those skilled in the art. Such methods include, but are not limited to, polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay, polymerase chain reaction-single-strand conformation polymorphism analysis (PCR-SSCP) assay, real-time PCR assay, PCR sequencing, mutant allele-specific PCR amplification (MASA) assay, direct sequencing, primer extension reaction, electrophoresis, oligonucleotide ligation assay, hybridization assay, TaqMan assay, SNP genotyping assay, high resolution melting curve assay, and microarray analysis. In some embodiments, samples are evaluated for KRAS mutations by real-time PCR. In real-time PCR, a fluorescent probe specific for KRAS mutation is used. If a mutation is present, the probe binds and fluorescence is detected. In some embodiments, a direct sequencing method of a specific region (e.g., exon 2 and / or exon 3) in the KRAS gene is used to identify KRAS mutation. This technique identifies all possible mutations in the sequenced region. Methods for detecting mutations in KRAS are known to those skilled in the art. Such methods include, but are not limited to, detection of KRAS mutants using binding agents (e.g., antibodies) specific to mutant proteins, protein electrophoresis, Western blotting, and direct sequencing of peptides.

[0047] The method for determining whether a tumor or cancer contains a KRAS mutation can use a variety of samples. In some embodiments, the sample is taken from a subject with a tumor or cancer. In some embodiments, the sample is a fresh tumor / cancer sample. In some embodiments, the sample is a frozen tumor / cancer sample. In some embodiments, the sample is a formalin-fixed paraffin-embedded sample. In some embodiments, the sample is processed into a cell lysate. In some embodiments, the sample is processed into DNA or RNA. In some embodiments, the sample is a liquid biopsy and the test is performed on a sample of blood to look for cancer cells from the tumor circulating in the blood, or DNA fragments from tumor cells present in the blood. Another aspect is based on revealing a correlation between the KRAS mutation status of a patient and their potential sensitivity to a treatment according to the invention. The treatment may be a monotherapy with either an SOS1 inhibitor or a MEK inhibitor, or a combination therapy with an SOS1 inhibitor and a MEK inhibitor. Such a treatment can be advantageously used to treat patients who have a KRAS mutation and who may be resistant to other therapies. This therefore provides an opportunity, a method and a means for selecting patients, in particular cancer patients, to be treated according to the invention. The selection is based on whether the tumor cells to be treated are or have become resistant to a treatment with a KRAS G12C inhibitor (e.g. sotorasib (AMG 510) and / or adagrasib (MRTX 849)), in particular when the tumor cells express G12C as the primary mutation of KRAS and a secondary Y96X mutation, preferably a secondary Y96X mutation selected from the group consisting of Y96D and Y96S. Thus, the genetic status of KRAS (G12C Y96X, preferably G12C Y96D and / or G12C Y96S) can be used as a biomarker indicating that selecting the treatments described herein may be advantageous.

[0048] One aspect is an in vitro method for detecting or diagnosing an individual having acquired resistance to treatment with a KRAS G12C inhibitor and / or an individual having sensitivity to treatment with a SOS1 inhibitor, or a MEK inhibitor, or a combination of a SOS1 inhibitor and a MEK inhibitor, comprising: - determining the presence of a KRAS mutation selected from the group consisting of Y96X, preferably Y96D and Y96S, in a biological sample taken from the individual, The method relates to said method, wherein, based on detection of a KRAS mutation Y96X, preferably a mutation selected from the group consisting of Y96D and Y96S, the individual is classified as resistant to treatment with a KRAS G12C inhibitor and as sensitive to treatment with an SOS1 inhibitor, or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor. As used herein, the term "individual" refers to a subject or patient.

[0049] According to another aspect, there is provided a method for selecting a patient to receive treatment with an SOS1 inhibitor, or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor, comprising the steps of: - Providing a tumor cell-containing sample from a patient; - determining whether the gene expresses a mutated KRAS having a primary mutation of G12C and a secondary mutation of Y96X, preferably a secondary mutation of Y96X selected from the group consisting of Y96D and Y96S (i.e., G12C Y96D or G12C Y96S, respectively); -Selecting patients to be treated based on the above decisions The method includes: The method may or may not include the step of isolating an actual patient sample. If the DNA of the tumor cells has a G12C Y96X mutated KRAS gene, the patient may be selected to receive the treatment. In one aspect, a patient may be selected to receive the treatment if the DNA of the tumor cells has a G12C Y96D mutated KRAS gene. In another aspect, a patient may be selected to receive the treatment if the DNA of the tumor cells has a G12C Y96S mutated KRAS gene.

[0050] A further related aspect refers to the use of the KRAS mutation Y96X, preferably a mutation selected from the group consisting of Y96D and Y96S, as a biomarker for cancers or cancer cells that are resistant to treatment with an inhibitor of KRAS G12C and / or that are sensitive to treatment with an SOS1 inhibitor, or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor. As used herein, the term "biomarker" refers to a biochemical parameter associated with the presence of a particular physiological condition, such as resistance to a KRAS G12C inhibitor. As described above, determination methods that evaluate the nucleotide sequence encoding the KRAS protein and / or methods for detecting mutations in the KRAS nucleotide sequence can be used. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. The following examples are provided to illustrate the present invention in more detail, but are not intended to limit the present invention. EXAMPLES

[0051] Cell lines and reagents NSCLC cell lines expressing KRAS G12 mutation (NCI-H358(G12C) cells, NCI-H23(G12C) cells, NCI-H2122(G12C) cells, NCI-H2009(G12A) cells, and NCI-H441(G12V) cells) were kindly provided by the late Dr. Adi F. Gazdar. A549(G12S) cells and SK-LU1(G12D) cells were kindly provided by the late Dr. Hirotaka Nagata. The immortalized mouse pro-B cell line Ba / F3 was obtained from the RIKEN BioResource Research Center (Tsukuba, Japan). Cells other than SK-LU1 cells were cultured in RPMI 1640 medium (Wako, Osaka, Japan) supplemented with 10% fetal bovine serum (FBS, Sigma-Aldrich, St. Louis, MO, USA) supplemented with 1% penicillin / streptomycin (P / S, Wako) at 37 °C with 5% CO2. SK-LU1 cells were cultured in DMEM (Sigma-Aldrich) with 10% FBS (Sigma-Aldrich) and 1% P / S (Wako). Parental Ba / F3 cells were maintained under sterile conditions in the presence of mouse IL-3. Mycoplasma contamination was confirmed using the TaKaRa PCR Mycoplasma Detection Set (Takara, Kusatsu, Japan). KRAS G12C inhibitors sotorasib and adagrasib were purchased from MedChem Express (Monmouth Junction, NJ, USA). SOS1 inhibitor BI-3406 was provided by Boehringer Ingelheim (Ingelheim, Germany). TNO155 was purchased from Selleck Biotech (Houston, TX, USA). Drugs were dissolved in 10 mM dimethyl sulfoxide (Sigma-Aldrich) and stored at -80°C.

[0052] method Introduction of KRAS mutations into Ba / F3 and H358 cells: As previously reported by Koga T. et al. (Lung Cancer 2018;126:72-79.26), the G12C, G12D, and G12V mutations were introduced into Ba / F3 or H358 cells using a retroviral system. These three mutations account for ~80% of KRAS mutations in NSCLC. Briefly, each KRAS mutation was introduced into the pBABE-puro-KRas construct (Addgene, Cambridge, MA, USA) with the designed primers using the PrimeSTAR Mutagenesis Basal Kit (Takara). Retroviral particles were generated by co-transfecting each pBABE-puro-KRAS construct and the pVSV-G vector (Clontech, Fremont, CA, USA) into gp-IRES 293 cells with FuGENE6 transfection reagent (Roche Diagnostics, Basel, Switzerland). Viral particles were concentrated using a retrovirus concentration kit (Clontech). Each retrovirus was transfected with Ba / F3 cells (3 × 10 3 ) or H358 cells (1 × 10 4 ) and the cells were cultured at 37°C for several days. The transfected Ba / F3 cells or H358 cells were selected with 0.8-1.0 μg / mL or 2.0 μg / mL puromycin, respectively. After puromycin selection, the presence of each KRAS mutation was confirmed as follows. Total RNA was extracted from the cells using the mirVana miRNA Isolation Kit (Qiagen, Hilden, Germany), and cDNA was generated by reverse transcription using ReverTra Ace (Toyobo, Osaka, Japan). The KRAS coding sequence was amplified by PCR. The KRAS nucleotide sequence was confirmed by Sanger sequencing using a 3130 or 3500XL Genetic Analyzer (Applied Biosystems, Waltham, MA).

[0053] Cell proliferation and growth inhibition assays: Ba / F3 cells expressing one of the KRAS mutations (3 × 10 4) were placed in 6-well plates and cultured in the absence of IL-3. As a control, non-cotransfected Ba / F3 cells were cultured in the presence or absence of IL-3. Cell numbers were counted three times every 24 h using a One Cell Counter (Biomedical Science, Tokyo, Japan) for up to 96 h. In a two-dimensional (2D) growth inhibition assay, 5 × 10 3 Cells were cultured in 96-well plates for 24 h and treated with 10 different concentrations of reagents for 72 h. Cell viability assays were performed using Cell Counting Kit-8 (Dojindo Laboratories, Kumamoto, Japan). The amount of formazan dye, which reflects cell viability, was measured by reading the absorbance at 450 nm using a multiplate reader (Tecan, Männedorf, Switzerland). In the 3D growth inhibition assay, 5 × 10 3 Cells were embedded in growth factor-reduced Matrigel (Corning, New York, USA) and cultured in RPMI 1640 medium (Wako) containing 10% FBS (Sigma-Aldrich) and P / S (Wako) in 96-well plates. After 72 h of incubation, cells were treated with the indicated concentrations for 72 h and cell viability assays were performed as described above. IC50 values ​​were determined by nonlinear regression curve fitting utilizing a variable slope model with normalized responses in GraphPad Prism version 8 (GraphPad Software, San Diego, CA).

[0054] Establishment of clones resistant to KRAS G12C inhibitors: Mutagenesis with ENU (Sigma-Aldrich) was performed to generate clones resistant to sotrasib and adagrasib as described in Kobayashi Y. et al., Mol Cancer Ther 2017;16:357-364. Ba / F3 cells carrying KRAS G12C (1 × 10 in total) were used. 6) were exposed to 100 μg / ml ENU for 24 h. After washing with PBS, cells were cultured for 48 h and then plated in 96-well plates with the indicated concentrations of KRAS G12C inhibitors. Cells were treated for 14–21 days, with medium and drugs replaced every 3–5 days. During the course of treatment, clones resistant to KRAS G12C inhibitors were generated. Immunoblotting: Preparation of cell lysates and immunoblotting were performed using standard methods. After treatment with the indicated concentrations of KRAS G12C inhibitor or DMSO, cell pellets were dissolved in lysis buffer. Protein concentrations were measured using the DC protein assay (Bio-Rad, Hercules, CA) with BSA as a standard curve. A total of 20–30 μg of protein was loaded into each well of 5–20% acrylamide gel and electrophoresis was performed at 120 V for 2 h. Separated proteins were transferred to PVDF membranes (Trans-Blot® Turbo™ Mini 0.2 μm PVDF Transfer Pack, Bio-Rad) using the Trans-Blot® Turbo™ Transfer System (Bio-Rad). After blocking with blocking buffer (Takara), the membrane was probed overnight at 4°C with antibodies against the following proteins: phosphorylated (p)-p44 / 42MAPK (Thr202 / Tyr204, CST#9101s), p44 / 42MAPK (CST#9102s), pMEK1 (S298, CST#9128s), MEK1 (CST#9146s), pS6 (S235 / 236, CST#4858s), S6 (CST#2217), KRAS (CST#53270s), and β-actin (CST#4970s). As a secondary antibody, HRP-conjugated anti-rabbit IgG (CST#7040) was incubated with the complex of the target protein and the primary antibody for 2 hours. For chemiluminescence assay, ECL solution (GE Healthcare, Chicago, IL) was added to the membrane and scanned with an Amersham Imager 680 (GE Healthcare) to detect the expression of target proteins.

[0055] Example 1 Determination of secondary mutations occurring after treatment with sotrasib or adagrasib 1.1 Confirmation of the proliferation inhibitory effect of sotrasib and adagrasib in cells harboring KRAS G12C mutation First, we evaluated the growth inhibitory activity of the clinical-stage KRAS G12C inhibitors sotorasib and adagrasib in six NSCLC cell lines harboring KRAS G12 mutations in both 2D and 3D cultures as described above. Growth inhibition curves of KRAS G12 mutated NSCLC cell lines H358(G12C), H23(G12C), A549(G12S), H2009(G12A), H441(G12V), and SK-LU1(G12D) treated with sotrasib and adagrasib confirmed that both KRAS G12C inhibitors showed growth inhibitory activity in H358 and H2122 cells harboring KRAS G12C mutations, whereas NSCLC cell lines harboring KRAS mutations other than G12C were resistant to sotrasib and adagrasib (except for H23 cells, which express KRAS G12C but are less sensitive to sotrasib).

[0056] We also tested the growth inhibition effects of sotorasib and adagrasib in Ba / F3 cell lines driven by KRAS G12 mutant variants, KRAS G12C, G12V, or G12D. Figure 1A shows the growth inhibition curves of modified Ba / F3 cells with KRAS G12C, G12D, or G12V treated with sotorasib at the indicated concentrations for 72 hours. Results are shown as the average of three separate experiments. Error bars indicate standard deviation (SD). Figure 1B shows the growth inhibition curves of modified Ba / F3 cells with KRAS G12C, G12D, or G12V treated with adagrasib at the indicated concentrations for 72 hours. As can be seen from Figures 1A and 1B, Ba / F3 cells expressing KRAS G12C were sensitive to sotrasib and adagrasib, whereas Ba / F3 cells with either KRAS G12D or G12V mutations were resistant to sotrasib and adagrasib. The IC values ​​of Ba / F3 cells with KRAS G12C against sotrasib and adagrasib were 50 The values ​​were 12.4 nM and 1.3 nM, respectively. These results indicate that sotorasib or adagrasib is effective in H358 cells and Ba / F3 cells that exhibit the KRAS G12C mutation.

[0057] 1.2 Search for secondary KRAS mutations causing resistance to sotrasib or adagrasib To identify secondary mutations that confer acquired resistance to sotorasib or adagrasib, ENU mutagenesis screening was performed as described above. The lowest concentration of sotorasib (100 nM) and adagrasib (20 nM) was determined as the lowest concentration that inhibited the growth of parental G12C Ba / F3 cells. The highest concentration of sotorasib (2000 nM) and adagrasib (1000 nM) was determined as the lowest concentration that inhibited the growth of parental G12C Ba / F3 cells. G12C Inhibitor IC 50 The resistant clones were determined to be more than 100-fold higher than those of the control clones. In total, 142 resistant clones were generated in this study. Among these clones, secondary KRAS mutations were identified in 124 of the 142 clones, corresponding to 87.3%. In the clones treated with sotorasib, 68 clones with secondary KRAS mutations and resistance were identified. After treatment with high concentrations (≥1000 nM) of sotorasib, A59T (n=6), R68M (n=3) and Y96D (n=1) mutations were identified, whereas G13D (n=13), A59S (n=11), R68M (n=8) and Q61L (n=5) mutations were most commonly detected in cells grown with lower concentrations of sotorasib. After treatment with adagrasib, 74 resistant clones were obtained. The Y96D mutation was identified in cells (n=13) established with high concentrations (≥500 nM) of adagrasib, while Q99L (n=38), R68S (n=10), V8E (n=5), M72I (n=5) and A59S (n=3) were detected in cells grown with lower concentrations of adagrasib. Common secondary mutations between cells resistant to sotrasib and cells resistant to adagrasib were determined to be the A59S and Y96D mutations.

[0058] 1.3 Determination of secondary cross-resistance mutations to sotrasib or adagrasib To evaluate cross-resistance, growth inhibition assays with sotorasib and adagrasib were performed on resistant clones generated by ENU mutagenesis. Figure 2A shows the growth inhibition curves of Ba / F3 cells carrying KRAS G12C as well as secondary mutations generated by ENU mutagenesis treated with the indicated concentrations of sotorasib for 72 hours. Results are shown as the average of three separate experiments. Error bars indicate standard deviation (SD). Figure 2B shows the growth inhibition curves of Ba / F3 cells carrying KRAS G12C as well as secondary mutations generated by ENU mutagenesis treated with the indicated concentrations of adagrasib for 72 hours. IC of sotorasib and adagrasib against KRAS G12C parental Ba / F3 cells 50 Because the IC values ​​were different (12.4 nM and 1.3 nM, respectively), the resistance index (RI) was used to clearly compare the degree of resistance of each secondary mutation. RI is the respective IC of each drug for parental Ba / F3 cells harboring KRAS KRAS G12C. 50 IC of each drug for each resistant clone against 50 It was defined as the ratio of

[0059] Table 1 summarizes the resistance index (RI) values ​​of clones resistant to sotrasib and adagrasib generated by ENU mutagenesis. The RI values ​​were calculated using the formula: IC 50 / IC of parental Ba / F3 cells carrying KRAS G12C 50 In Table 1, low resistance corresponds to an RI value less than 10, moderate resistance corresponds to an RI value greater than 10 but less than 100, and high resistance corresponds to an RI value greater than 100. Table 1: Resistance Index (RI) values [Table 1] As can be seen from Table 1, G13D, A59S / T, R68M and Y96D / S had high resistance (RI>100) to sotorasib, while Y96D / S and Q99L had high resistance to adagrasib.

[0060] The spectrum of secondary mutations between clones resistant to sotorasib and those resistant to adagrasib was quite different: for example, G13D, A59S / T, and R68M conferred resistance to sotorasib but maintained sensitivity to adagrasib, whereas the secondary mutation Q99L conferred resistance to adagrasib but maintained sensitivity to sotorasib. The model of Ba / F3 cells subjected to ENU mutagenesis provides secondary mutations in KRAS that confer resistance to the KRAS G12C inhibitors sotorasib or adagrasib. Although this method is artificial and known to favor G:C to A:T transitions and A:T to T:A transversions, as well as A:T to G:C base changes, as seen here, this method is efficient in generating clones that carry secondary mutations and are resistant. Nevertheless, the secondary mutations identified by this assay are consistent with acquired resistance mutations seen in the clinical setting after failure of EGFR, ALK, and MET-TKI treatment. However, results using this model indicate that the Y96D / S secondary mutation is common to both KRAS G12C inhibitors sotorasib and adagrasib as a resistance mutation, and that the Y96D / S secondary mutation causes cross-resistance to both sotorasib and adagrasib. Without wishing to be bound by any theory, Y96 is thought to be located at the entrance to the hydrophobic pocket through which sotorasib and adagrasib bind to the KRAS G12C protein.

[0061] Example 2 Verification of secondary mutations of KRAS Y96D and Y96S 2.1 Verification of secondary KRAS mutations detected in Ba / F3 cells resistant to sotrasib or adagrasib To confirm that the observed resistance was due to the emergence of secondary KRAS mutations and not due to an unidentified mechanism, in addition to KRAS G12C, any of the seven secondary mutations with RIs of >100 as determined in Example 1, G13D, A59S / T, R68M, Y96D / S, or Q99L, was introduced into Ba / F3 cells, and then a growth inhibition assay was performed using these Ba / F3 cells. FIG. 3A shows a growth inhibition assay of Ba / F3 cells harboring a secondary mutation in addition to KRAS G12C, treated with the indicated concentrations of sotorasib for 72 hours. Results are shown as the average of three separate experiments. Error bars indicate standard deviation (SD). FIG. 3B shows a growth inhibition assay of Ba / F3 cells harboring a secondary mutation in addition to KRAS G12C, treated with the indicated concentrations of adagrasib for 72 hours.

[0062] Table 2 summarizes the resistance index (RI) values ​​of Ba / F3 cells that have a secondary mutation in addition to KRAS G12C. The RI values ​​were calculated using the following formula: IC 50 / IC of parental Ba / F3 cells carrying KRAS G12C 50 In Table 2, low resistance corresponds to an RI value of less than 10, moderate resistance corresponds to an RI value of more than 10 but less than 100, and high resistance corresponds to an RI value of more than 100. [Table 2] As can be seen from Table 2, some of the resistance mutations, such as G13S, A59S / T, R68M, and Q99L, could be overcome by switching the KRAS G12C inhibitor from sotorasib to adagrasib or vice versa, whereas the Y96D / S mutation, which appeared after treatment with high concentrations of sotorasib or adagrasib, was highly resistant to both inhibitors.

[0063] 2.2 Verification of secondary KRAS mutations detected in H358 cells resistant to sotrasib or adagrasib In further tests, KRAS G12C plus Y96D, G12C plus Y96S, and G12C plus A59S were retrovirally introduced into NCI-H358 cells originally carrying the KRAS G12C mutation. Figure 4A shows the growth inhibition assay of H358 cells carrying KRAS G12C plus secondary mutations treated with the indicated concentrations of sotorasib for 72 hours. Results are shown as the average of three separate tests. Error bars indicate standard deviation (SD). Figure 4B shows the growth inhibition assay of H358 cells carrying KRAS G12C plus secondary mutations treated with the indicated concentrations of adagrasib for 72 hours. As can be seen from Figures 4A and 4B, in the growth inhibition assay, H358 cells carrying G12C plus Y96D or H358 cells carrying G12C plus Y96S had approximately 30-fold higher IC20 values ​​compared to the parental H358 cells. 50 The values ​​were shown. This indicates that H358 cells harboring G12C plus A59S were less resistant to both KRAS G12C inhibitors compared with H358 cells harboring G12C plus Y96D or H358 cells harboring G12C plus Y96S (consistent with the results in Ba / F3 cells).

[0064] Example 3 To determine the efficacy of the SOS1 inhibitor BI-3406, and in combination with the MEK inhibitor trametinib, to overcome resistance to KRAS G12C inhibitors due to secondary mutations Y96D and Y96S 3.1 Measurement of the effect of BI-3406, an SOS1 inhibitor, in Ba / F3 cells Ba / F3 cells harboring either A59S, Y96D or Y96S in addition to G12C were incubated with the SOS1 inhibitor BI-3406 or the SHP2 inhibitor TNO155 as described previously. Figure 5A shows the growth inhibition assay of Ba / F3 cells harboring KRAS G12C plus secondary mutations A59S, Y96D or Y96S treated with the indicated concentrations of BI-3406 for 72 h. Results are shown as the mean of three separate experiments. Error bars indicate standard deviation (SD). Table 3 below shows the IC of Ba / F3 cells harboring KRAS G12C as well as secondary A59S, Y96D, or Y96S mutations treated with the indicated concentrations of BI-3406 or TNO155 for 72 hours. 50 It is a collection of values.

[0065] [Table 3] When Ba / F3 cells carrying either Y96D or Y96S in addition to G12C were treated with BI-3406, the IC 50 The IC values ​​of TNO155 for Ba / F3 cells carrying a secondary mutation in addition to G12C were 38.0 nM and 25.7 nM, respectively. 50 In Ba / F3 cells mutated at A59S in addition to G12C, BI-3406 and TNO155 had IC values ​​of 4850 nM and 3050 nM, respectively. 50 However, none of them were able to reduce the proliferation of tumor cells. These results demonstrate that the SOS1 inhibitor BI-3406 exhibited activity against in vitro models harboring concurrent G12C and Y96D or Y96S secondary mutations.

[0066] 3.2 Measurement of the effect of the SOS1 inhibitor BI-3406 alone and in combination with the MEK inhibitor trametinib in H358 cells carrying the KRAS G12C mutation and the Y96D or Y96S mutation In 2D and 3D growth inhibition assays, H358 cells expressing G12C plus Y96D or G12C plus Y96S were incubated with the SOS1 inhibitor BI-3406 alone or in combination with the MEK inhibitor trametinib as described above. Figure 5B shows a three-dimensional (3D) growth inhibition assay of H358 cells harboring KRAS G12C plus secondary mutations A59S, Y96D, or Y96S, treated with the indicated concentrations of BI-3406 for 72 hours. Table 4 below shows the IC40 of H358 isogenic cells harboring KRAS G12C plus secondary mutations A59S, Y96D, and Y96S, treated with different concentrations of BI-3406 alone for 72 hours in the 2D assay and the 3D assay shown in Figure 5B. 50 Value and IC 50 * The IC 50 * Values ​​indicate concentrations that gave responses intermediate between maximum and minimum inhibition.

[0067] [Table 4] As can be seen from Table 4 and FIG. 5B, in both 2D and 3D assays, BI-3406 monotherapy modestly inhibited the proliferation of not only parental H358 cells but also H358 cells harboring the secondary Y96D / S mutation.

[0068] Figure 5C shows a three-dimensional (3D) growth inhibition assay of H358 cells harboring a KRAS G12C secondary mutation Y96D or Y96S treated for 72 hours with 1 μM BI-3406 in combination with the indicated concentrations of trametinib. Table 5 shows the IC of H358 cells harboring a KRAS G12C secondary mutation Y96D and a KRAS G12C secondary mutation Y96S treated for 72 hours with the SOS1 inhibitor BI-3406 in combination with the MEK inhibitor trametinib in the 3D assay shown in Figure 5C. 50 It is a collection of values. [Table 5] As can be seen from Table 5 and FIG. 5C, H358 cells carrying the secondary mutations Y96D / S in addition to G12C were sensitive to treatment with the SOS1 inhibitor BI-3406 in combination with the MEK inhibitor trametinib, and their sensitivity was comparable to that of the parental H358 cells. These results indicate that the SOS1 inhibitor BI-3406 alone or in combination with the MEK inhibitor trametinib showed potent inhibitory activity in Ba / F3 and H358 cells harboring KRAS G12C and secondary Y96D / S mutations, providing an option to switch to second-line therapy and overcome acquired resistance caused by secondary KRAS mutations that would be expected to emerge upon resistance acquisition during the course of treatment with sotrasib and adagrasib.

Claims

1. A Son of Sevenless 1 (SOS1) inhibitor and / or a Mitogen-activated protein kinase kinase (MEK) inhibitor for use in the treatment and / or prevention of cancer, wherein the SOS1 inhibitor or MEK inhibitor is administered alone or the SOS1 inhibitor is administered in combination with a MEK inhibitor, and the cancer is resistant to treatment with an inhibitor of KRAS G12C.

2. 2. The SOS1 inhibitor and / or MEK inhibitor for use according to claim 1, wherein the cancer is resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849).

3. 3. The SOS1 inhibitor and / or MEK inhibitor for use according to claim 1 or 2, wherein the cancer cells of the cancer present a primary KRAS G12C mutation and further present a secondary Y96X mutation, preferably a secondary Y96X mutation selected from the group consisting of Y96D and Y96S.

4. The SOS1 inhibitor is selected from the group consisting of the following compounds: 【Chemistry 1】 【change】 【change】 【change】 【change】 【change】 2. The SOS1 inhibitor and / or MEK inhibitor for use according to claim 1, which is selected from the group consisting of:

5. MEK inhibitors include trametinib, cobimetinib, binimetinib, selumetinib, refametinib, and the following compounds: 【Chemistry 2】 【change】 【change】 【change】 【change】 【change】 【change】 【change】 【change】 【change】 【change】 2. The SOS1 inhibitor and / or MEK inhibitor for use according to claim 1, which is selected from the group consisting of:

6. 2. The SOS1 inhibitor and / or MEK inhibitor for use according to claim 1, wherein the cancer is selected from the group consisting of pancreatic cancer, lung cancer, colorectal cancer, cholangiocarcinoma, multiple myeloma, melanoma, uterine cancer, endometrial cancer, thyroid cancer, acute myeloid leukemia, bladder cancer, urothelial cancer, gastric cancer, cervical cancer, head and neck squamous cell carcinoma, diffuse large B-cell lymphoma, esophageal cancer, chronic lymphocytic leukemia, hepatocellular carcinoma, breast cancer, ovarian cancer, prostate cancer, glioblastoma, renal cancer and sarcoma.

7. A pharmaceutical composition comprising an SOS1 inhibitor or a MEK inhibitor as an active ingredient, or a combination of medicines comprising an SOS1 inhibitor and a MEK inhibitor as active ingredients, for use in the treatment and / or prevention of cancer, wherein the cancer has resistance to treatment with a KRAS G12C inhibitor.

8. In one or more containers, (i) a first pharmaceutical composition or dosage form comprising an SOS1 inhibitor and optionally comprising a pharma- ceutically acceptable carrier, excipient and / or vehicle; and / or (ii) a second pharmaceutical composition or dosage form comprising a MEK inhibitor and optionally a pharma- ceutically acceptable carrier, excipient and / or vehicle; Including, (iii) Package insert, including instructions may include, 1. A kit for use in the treatment and / or prevention of cancer, wherein the cancer is resistant to treatment with an inhibitor of KRAS G12C.

9. 1. Use of an SOS1 inhibitor and / or a MEK inhibitor for the manufacture of a medicament for the treatment and / or prevention of cancer, wherein the SOS1 inhibitor or the MEK inhibitor is used alone or the SOS1 inhibitor is used in combination with a MEK inhibitor, and the cancer is resistant to treatment with an inhibitor of KRAS G12C.

10. 10. The pharmaceutical composition or pharmaceutical combination of claim 7, the kit of claim 8, or the use of claim 9, wherein the SOS1 inhibitor is a compound of claim 4 or a pharma- ceutically acceptable salt thereof, and / or the MEK inhibitor is a compound of claim 5 or a pharma- ceutically acceptable salt thereof.

11. 10. The pharmaceutical composition or pharmaceutical combination of claim 7, the kit of claim 8 or the use of claim 9, wherein the cancer is resistant to treatment with sotorasib (AMG 510) and / or adagrasib (MRTX 849).

12. 10. The pharmaceutical composition or pharmaceutical combination of claim 7, the kit of claim 8 or the use of claim 9, wherein cancer cells of the cancer express a primary KRAS G12C mutation and further express a secondary Y96X mutation, preferably a secondary Y96X mutation selected from the group consisting of Y96D and Y96S.

13. 10. The pharmaceutical composition or pharmaceutical combination of claim 7, the kit of claim 8, or the use of claim 9, wherein the cancer is selected from the group consisting of pancreatic cancer, lung cancer, colorectal cancer, cholangiocarcinoma, multiple myeloma, melanoma, uterine cancer, endometrial cancer, thyroid cancer, acute myeloid leukemia, bladder cancer, urothelial cancer, gastric cancer, cervical cancer, head and neck squamous cell carcinoma, diffuse large B-cell lymphoma, esophageal cancer, chronic lymphocytic leukemia, hepatocellular carcinoma, breast cancer, ovarian cancer, prostate cancer, glioblastoma, renal cancer, and sarcoma.

14. 1. An in vitro method for detecting or diagnosing an individual having acquired resistance to treatment with an inhibitor of KRAS G12C and / or an individual having sensitivity to treatment with an SOS1 inhibitor, or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor, comprising: - determining the presence of KRAS mutations Y96X, preferably selected from the group consisting of Y96D and Y96S, in a biological sample taken from the individual, The method, wherein based on detection of a KRAS mutation Y96X, preferably a mutation selected from the group consisting of Y96D and Y96S, the individual is classified as resistant to treatment with a KRAS G12C inhibitor and as sensitive to treatment with a SOS1 inhibitor, or a MEK inhibitor, or a combination of a SOS1 inhibitor and a MEK inhibitor.

15. 1. Use of a KRAS mutation Y96X, preferably a mutation selected from the group consisting of Y96D and Y96S, as a biomarker for cancer or cancer cells that are resistant to treatment with an inhibitor of KRAS G12C and / or that are sensitive to treatment with an SOS1 inhibitor, or a MEK inhibitor, or a combination of an SOS1 inhibitor and a MEK inhibitor.

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