CYP11A1 INHIBITORS FOR USE IN THE TREATMENT OF PROSTATE CANCER - Patent application

Abstract

The present invention relates to the use of an activating AR gene alteration as a biomarker for identifying prostate cancer patients who are more likely to respond to treatment with a CYP11A1 inhibitor.The present invention also relates to a method for treating prostate cancer, comprising: a) obtaining or having obtained a sample from a patient; b) assaying or having assayed the sample to determine whether the patient has an activating AR gene alteration; and c) treating the patient with a therapeutically effective amount of a CYP11A1 inhibitor if the patient has an activating AR gene alteration.

Description

[Technical field]

[0001] The present disclosure relates to a method for treating prostate cancer using a CYP11A1 inhibitor as an active ingredient. The present disclosure provides the use of an activated androgen receptor (AR) genetic alteration as a biomarker to identify patients who are more likely to respond to treatment with a CYP11A1 inhibitor. [Background technology]

[0002] Prostate cancer is the second most common cancer in men. The majority of deaths from prostate cancer are due to the development of metastatic disease that does not respond to conventional androgen deprivation therapy (ADT). Androgen deprivation, using either surgical or medical approaches, has been the standard of care for advanced and metastatic prostate cancer for decades. It has become apparent that prostate cancer that emerges after androgen deprivation therapy remains dependent on androgen receptor signaling. Prostate cancer cells that do not survive or respond to ADT often demonstrate the ability to acquire or import low levels of circulating androgens (expressed from the adrenal glands), becoming much more sensitive to these low levels of testosterone and actually synthesizing testosterone within the prostate cancer cells themselves. This stage of prostate cancer is called "castration-resistant prostate cancer" or CRPC.

[0003] The androgen receptor (AR) is a ligand-inducible steroid hormone receptor that is widely distributed throughout the body and is involved in diverse activities, but its primary and predominant function is in male sexual development and differentiation. It is a member of the nuclear receptor superfamily that shares structural and functional similarities. It contains three major domains, (i) a hypervariable N-terminal domain that regulates transcriptional activity, (ii) a central highly conserved DNA-binding domain, and (iii) a large C-terminal ligand-binding domain (AR-LBD), as well as a short linker between the DNA-binding domain and the AR-LBD. AR is the master regulatory intracellular transcription factor of genes involved in the proliferation and differentiation of the prostate.

[0004] AR signaling axis is important in all stages of prostate cancer. In CRPC stage, disease is characterized by high AR expression, AR amplification, and persistent activation of AR signaling axis by residual tissue / tumor androgens and other steroid hormone and steroid biosynthesis intermediates. Therefore, current treatment of CRPC includes androgen receptor signaling inhibitors (ARSi), such as AR antagonists (e.g., flutamide, nilutamide, bicalutamide, enzalutamide, apalutamide, and darolutamide) and androgen synthesis inhibitors (e.g., CYP17A1 inhibitors, including abiraterone acetate).

[0005] Although therapy may initially lead to disease regression, the majority of patients eventually develop disease that is refractory to currently available therapies. It has been hypothesized that the increase in progesterone levels in patients treated with abiraterone acetate is one of the resistance mechanisms. Several preclinical and clinical studies have shown upregulation of enzymes that catalyze steroid biosynthesis in the later stages of CRPC. Furthermore, it has been addressed that prostate cancer resistance to CYP17A1 inhibition may remain steroid-dependent and responsive to therapy that can further suppress de novo intratumoral steroid synthesis upstream of CYP17A1, such as by CYP11A1 inhibitor therapy (Cai, C. et al, Cancer Res., 71(20), 6503-6513, 2011).

[0006] Cytochrome P450 monooxygenase 11A1 (CYP11A1), also known as cholesterol side-chain cleavage enzyme, is a mitochondrial monooxygenase that catalyzes the conversion of cholesterol to pregnenolone, the precursor of all steroid hormones. By inhibiting CYP11A1, the key enzyme in steroid biosynthesis upstream of CYP17A1, a total block of all steroid biosynthesis can be achieved. Thus, CYP11A1 inhibitors may have great potential for treating steroid hormone-dependent cancers, such as prostate cancer, even at advanced stages of the disease, especially in patients who appear to be hormone refractory. Recently, two selective CYP11A1 inhibitors, 2-(isoindolin-2-ylmethyl)-5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-4H-pyran-4-one (1A) and 5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-2-((5-(trifluoromethyl)isoindolin-2-yl)methyl)-4H-pyran-4-one (1B), have entered clinical trials for the treatment of patients with prostate cancer.

[0007] Activating AR genetic alterations such as AR gene amplification and mutations in the ligand-binding domain (LBD) of AR are other mechanisms of resistance to antiandrogen therapy. AR gene amplification can lead to overexpression of AR, which allows tumor cells to continue AR-dependent growth despite low concentrations of serum androgens. Mutations in the AR-LBD can result in functional changes in the LBD that cause AR gain-of-function. Various point mutations in the AR-LBD have been shown to result in AR activation by mutation-driven conversion of weak adrenal androgens, steroidal and nonsteroidal ligands, and AR inhibitors to agonists. For example, the F877L point mutation in the AR-LBD has been reported to be associated with enzalutamide resistance in both preclinical models and clinical studies. The F877L mutation is also detected in a clinically relevant number of enzalutamide-resistant patients.

[0008] Thus, there is a need for improved therapies for prostate cancer and methods for identifying patients most likely to respond to therapy. Summary of the Invention

[0009] CYP11A1 inhibitors such as 2-(isoindolin-2-ylmethyl)-5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-4H-pyran-4-one (1A) and 5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-2-((5-(trifluoromethyl)isoindolin-2-yl)methyl)-4H-pyran-4-one (1B) have been found to be particularly effective in treating prostate cancer patients with activating AR gene alterations, such as AR gene amplification or activating AR-LBD mutations. It has been found that patients with such activating AR gene alterations are more likely to respond to treatment with CYP11A1 inhibitors such as compound (1A) or (1B) than patients without activating AR gene alterations. Thus, such activating AR gene alterations are also useful as biomarkers for selecting prostate cancer patients who are more likely to benefit from treatment with CYP11A1 inhibitors.

[0010] According to one aspect, the disclosure provides a method for the treatment of prostate cancer in a patient having an activating AR gene alteration, the method comprising administering to the patient a therapeutically effective amount of a CYP11A1 inhibitor.

[0011] According to another aspect, the disclosure provides a CYP11A1 inhibitor for use in a method for the treatment of prostate cancer in a patient having an activating AR gene alteration.

[0012] According to another aspect, the present disclosure provides a method for treating prostate cancer, comprising: a) obtaining or having obtained a sample from a patient; b) assaying or having assayed the sample to determine whether the patient has an activating AR gene alteration; c) if the patient has an activating AR gene alteration, treating the patient with a therapeutically effective amount of a CYP11A1 inhibitor.

[0013] According to one embodiment, the activating AR genetic modification is an activating AR-LBD mutation. According to another embodiment, the activating AR genetic modification is an AR gene amplification.

[0014] According to yet another aspect, the present disclosure provides a method for selecting a patient suffering from prostate cancer for treatment with a CYP11A1 inhibitor, comprising: a) obtaining or having obtained a sample from a patient; b) assaying or having assayed the sample to determine whether the patient has an activating AR gene alteration; c) if the patient has an activating AR gene alteration, selecting the patient for treatment with a CYP11A1 inhibitor.

[0015] According to one embodiment, the activating AR gene modification is activating AR-LBD mutation. According to another embodiment, the activating AR gene modification is AR gene amplification. In at least one embodiment, the patient selected for treatment with CYP11A1 inhibitor is administered a therapeutically effective amount of CYP11A1 inhibitor.

[0016] According to another aspect, the present disclosure provides a method for identifying patients suffering from prostate cancer who are more likely to respond to treatment comprising a CYP11A1 inhibitor, comprising: assaying or assaying a sample obtained from the patient to determine whether the patient has an activating AR gene modification, and such modification identifies the patient as more likely to respond to treatment.In at least one embodiment, the patient selected for treatment with a CYP11A1 inhibitor is administered a therapeutically effective amount of a CYP11A1 inhibitor. [Brief description of the drawings]

[0017] [Figure 1] Figure 1 shows the prostate-specific antigen (PSA) change (%) from baseline in 37 prostate cancer patients with and without identified activating AR gene alteration(s) who received prior ARSi treatment. [Diagram 2] FIG. 1 shows % PSA change from baseline in 16 patients with activating AR-LBD mutations, with the identity of the mutation(s) in each patient indicated. [Diagram 3] Figure 1 shows % PSA change from baseline in 25 prostate cancer patients with prior ARSi treatment, with and without identified activating AR gene alteration(s). [Figure 4] FIG. 1 shows % PSA change from baseline in 15 patients with activating AR-LBD mutations, with the identity of the mutation(s) in each patient indicated. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0018] The present disclosure provides a method for treating prostate cancer in a patient with an activating AR gene alteration, comprising administering a therapeutically effective amount of a CYP11A1 inhibitor to the patient. According to one embodiment, the CYP11A1 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof: [ka] wherein R1 is hydrogen or -CF3.

[0019] According to another embodiment, the CYP11A1 inhibitor is 2-(isoindolin-2-ylmethyl)-5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-4H-pyran-4-one (1A) or a pharma- ceutically acceptable salt thereof. According to yet another embodiment, the CYP11A1 inhibitor is 5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-2-((5-(trifluoromethyl)isoindolin-2-yl)methyl)-4H-pyran-4-one (1B). These compounds have recently entered clinical trials for the treatment of prostate cancer patients.

[0020] Clinical studies have shown that patients with activating AR gene modifications are more likely to respond to treatment with CYP11A1 inhibitors than patients without activating AR gene modifications.

[0021] The term "selective CYP11A1 inhibitor" as used herein refers to a compound that selectively binds to and inhibits the activity of the CYP11A1 enzyme. According to one embodiment, a selective CYP11A1 inhibitor inhibits CYP11A1 at least 100-fold, e.g., at least 500-fold, more potently than other drug-metabolizing CYP inhibitors, including CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A4.

[0022] The term "activating AR genetic modification" as used herein refers to a modification of the androgen receptor (AR) that broadens the ligand specificity of the androgen receptor (AR), causes activation of the AR by alternative ligands, and / or sensitizes the AR to low levels of endogenous androgens, such as dihydrotestosterone. Examples of activating AR genetic modifications include, but are not limited to, AR gene amplification and activating AR-LBD mutations.

[0023] The term "AR gene amplification" or "AR amplification" as used herein refers to the formation of additional or multiple copies of the AR gene. Examples of AR gene amplification include at least 2 copies, at least 3 copies, at least 5 copies, at least 8 copies, at least 10 copies, at least 15 copies, and at least 20 copies of the AR gene.

[0024] The term "activating AR-LBD mutation" as used herein refers to a gain-of-function mutation in the ligand-binding domain (LBD) of the androgen receptor (AR), which broadens the ligand specificity of the androgen receptor (AR), causes the activation of the AR by alternative ligands, and / or sensitizes the AR to low levels of endogenous androgens, such as dihydrotestosterone. Activating AR-LBD mutations can include, for example, activating AR-LBD point mutations, activating AR-LBD insertion mutations, or activating AR-LBD deletion mutations. In one aspect of the present disclosure, activating AR-LBD mutations are activating AR-LBD point mutations.

[0025] The term "activating AR-LBD point mutation," as used herein, refers to an activating AR-LBD mutation that is a single amino acid mutation, such as changing a wild-type amino acid in the AR-LBD amino acid sequence to another amino acid.

[0026] Human androgen receptor amino acid numbering, as used herein, refers to UniProt ID: P10275.1 (updated March 16, 2016). The ligand-binding domain (LBD) of the androgen receptor (AR) covers amino acid residues 663 to 919 (Wang et al., Acta Cryst., F62, 1067-1071, 2006).

[0027] As used herein, the nomenclature of point mutations in the AR-LBD follows the standard of delineating the amino acid position in the mutated variation and the wild-type amino acid following the amino acid substitution. For example, the point mutation "L702H" means that the amino acid leucine (L) has been replaced with the amino acid histidine (H) at AR-LBD position 702.

[0028] Various activating AR-LBD mutations are described, for example, in Shi, XB. et al., “Functional Analysis of 44 Mutant Androgen Receptors from Human Prostate Cancer”, Cancer Research, 62, 1496-1502, 2002 (AR-LBD point mutations Q671R, I673T, L702H, V716M, K718E, R727L, V731M, A749T, A749V, G751S, V758A, S783N, Q799E, R847G, H875Y, T878A, D891N, A897T, K911R, Q920R), Lallous, N. et al., “Functional analysis of androgen receptor mutations that confer anti-androgen resistance identified in circulating cell-free DNA from prostate cancer patients”, Genome Biology,17:10,1-15,2016(AR-LBD point mutation L702H, V716M, V731M, W742C, W742L, H875Y, H875Q , F877L, T878A, T878S, D880E, L882I, S889G, D891H, E894K, M896T, M896V, E898G, T919S), Chen, G. et al., “Androgen Receptor Mutants Detected in Recurrent Prostate Cancer Exhibit Diverse Functional Characteristics”, The Prostate, 63, 395-406, 2005 (AR-LBD point mutation E873Q), and Buchanan, G. et al., "Mutations at the Boundary of the Hinge and Ligand Binding Domain of the Androgen Receptor Confer Increased Transactivation Function", Molecular Endocrinology, 15(1), 46-56, 2001 (AR-LBD point mutations Q671R and I673T).

[0029] In one aspect of the disclosed methods, the patient is selected from the group consisting of Q671R, I673T, L702H, V716M, V716L, K718E, R727L, V731M, W742L, W742C, A749T, A749V, M750I, G751S, V758A, S783N, Q799E, R847G, E873Q, H875Y ... 75Q, F877L, T878A, T878S, D880E, L882I, S889G, D891N, D891H, D891Y, E894K, M896T, M896V, A897T, E898G, K911R, T919S, and Q920R.

[0030] In another aspect of the methods of the present disclosure, the patient has one or more AR-LBD point mutations selected from the group consisting of L702H, V716M, V716L, W742L, W742C, H875Y, F877L, T878A, T878S, D891Y, M896T, and M896V.

[0031] In another aspect of the methods of the present disclosure, the patient has one or more AR-LBD point mutations selected from the group consisting of L702H, V716M, V716L, W742C, H875Y, F877L, T878A, D891Y, and M896T.

[0032] In another embodiment of the method of the present disclosure, the patient to be treated has previously been treated with androgen receptor signaling inhibitors (ARSi), such as androgen receptor antagonists and CYP17A1 inhibitors, and / or chemotherapeutic agents.Exemplary androgen receptor antagonists include, but are not limited to, enzalutamide, apalutamide, darolutamide, bicalutamide, flutamide, nilutamide, and their pharmaceutically acceptable salts.Exemplary CYP17A1 inhibitors include, but are not limited to, abiraterone acetate and ceviteronel.Exemplary chemotherapeutic agents include, but are not limited to, docetaxel, paclitaxel, and cabazitaxel.

[0033] In another embodiment of the disclosed method, the patient being treated has previously been treated with enzalutamide, apalutamide, darolutamide, and / or abiraterone acetate, or a pharmaceutically acceptable salt thereof. In another embodiment, the patient being treated has previously been treated with enzalutamide and / or abiraterone acetate, or a pharmaceutically acceptable salt thereof.

[0034] In another embodiment of the method of the present disclosure, the patient being treated is resistant to androgen receptor antagonist therapy or CYP17A1 inhibitor therapy.In another embodiment, the patient being treated is resistant to treatment with enzalutamide, apalutamide, darolutamide, and / or abiraterone acetate, or a pharmaceutically acceptable salt thereof.In another embodiment, the patient being treated is resistant to treatment with enzalutamide and / or abiraterone acetate, or a pharmaceutically acceptable salt thereof.

[0035] The present disclosure provides a method for treating prostate cancer, comprising: a) obtaining or having obtained a sample from a patient; b) assaying or having assayed the sample to determine whether the patient has an activating AR gene alteration; and c) if the patient has an activating AR gene alteration, treating the patient with a therapeutically effective amount of a CYP11A1 inhibitor.

[0036] According to one embodiment, the activating AR genetic modification is an activating AR-LBD mutation. According to another embodiment, the activating AR genetic modification is an AR gene amplification.

[0037] The sample may be, for example, a blood sample or a tissue sample. The sample suitably comprises the patient's AR polypeptide or a polynucleotide encoding the AR polypeptide. In one embodiment, the sample comprises the patient's AR-LBD polypeptide or a polynucleotide encoding the AR-LBD polypeptide. In one aspect, the method may comprise determining the sequence of the AR (e.g., AR-LBD) polynucleotide or a portion thereof, and then comparing the sequence of the patient's AR (e.g., AR-LBD) polynucleotide or polypeptide or a portion thereof with the wild-type sequence of the AR (e.g., AR-LBD) polynucleotide or polypeptide or a portion thereof to determine whether the patient has an activating AR genetic modification (e.g., an activating AR-LBD mutation or an AR amplification). Alternatively, the sample may be subjected to a suitable gene panel assay that targets the AR region designed to hybridize capture known AR mutation modifications. It has been found that patients with activating AR genetic modifications (e.g., an activating AR-LBD mutation or an AR amplification) are more likely to respond to treatment with a CYP11A1 inhibitor than patients without activating AR genetic modifications (e.g., an activating AR-LBD mutation or an AR amplification).

[0038] According to one aspect of the present disclosure, the CYP11A1 inhibitor is a selective CYP11A1 inhibitor. According to another aspect of the present disclosure, the CYP11A1 inhibitor is a compound of formula (I) or a pharma- ceutically acceptable salt thereof: [ka] (wherein R1 is hydrogen or -CF3).

[0039] In particular, the compounds of formula (I) are 2-(isoindolin-2-ylmethyl)-5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-4H-pyran-4-one (1A) and 5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-2-((5-(trifluoromethyl)isoindolin-2-yl)methyl)-4H-pyran-4-one (1B), or a pharma- ceutically acceptable salt thereof.

[0040] The present disclosure provides a method for selecting a patient suffering from prostate cancer for treatment with a CYP11A1 inhibitor, comprising: a) assaying or having assayed a sample obtained from the patient to determine whether the patient has an activating AR gene alteration; b) if the patient has an activating AR gene alteration, selecting the patient for treatment with a CYP11A1 inhibitor.

[0041] According to one embodiment, the activating AR genetic modification is activating AR-LBD mutation. According to another embodiment, the activating AR genetic modification is AR amplification. In at least one embodiment, the patient selected for treatment with CYP11A1 inhibitor is administered a therapeutically effective amount of CYP11A1 inhibitor.

[0042] The disclosure further provides a method for identifying a patient suffering from prostate cancer who is more likely to respond to a treatment comprising a CYP11A1 inhibitor, comprising determining whether the patient has an activating AR gene alteration, such alteration identifying the patient as more likely to respond to the treatment.

[0043] According to one embodiment, the activating AR genetic modification is an activating AR-LBD mutation. According to another embodiment, the activating AR genetic modification is an AR amplification.

[0044] The present disclosure further provides a pharmaceutical composition for use in treating prostate cancer in patients with an activating AR genetic alteration, comprising a CYP11A1 inhibitor as an active ingredient and a pharma- ceutically acceptable carrier. Patients with an activating AR genetic alteration are more likely to respond to treatment with the pharmaceutical composition than patients without an activating AR genetic alteration. According to one embodiment, the activating AR genetic alteration is an activating AR-LBD mutation. According to another embodiment, the activating AR genetic alteration is an AR amplification. In one embodiment, the pharmaceutical composition comprises a compound of formula (I) or a pharma- ceutically acceptable salt thereof: [ka] (wherein R1 is hydrogen or -CF3). In one embodiment, R1 is hydrogen. In another embodiment, R1 is -CF3.

[0045] In one embodiment, the prostate cancer to be treated is castration-resistant prostate cancer (CRPC). In another embodiment, the prostate cancer to be treated is metastatic castration-resistant prostate cancer (mCRPC). In another embodiment, the prostate cancer to be treated is non-metastatic castration-resistant prostate cancer (nmCRPC). In yet another embodiment, the prostate cancer to be treated is castration-sensitive prostate cancer (CSPC).

[0046] In one embodiment, administration of a CYP11A1 inhibitor, e.g., a compound of formula (I), to a prostate cancer patient with an activating AR genetic alteration (e.g., an activating AR-LBD mutation or AR amplification), e.g., a patient suffering from mCRPC, results in an increase in radiological progression-free survival (rPFS), overall survival, and / or a decrease in PSA levels. In another embodiment, administration of a CYP11A1 inhibitor, e.g., a compound of formula (I), to a prostate cancer patient with an activating AR genetic alteration (e.g., an activating AR-LBD mutation or AR amplification), e.g., a patient suffering from mCRPC, results in a higher increase in radiological progression-free survival (rPFS), a higher increase in overall survival, and / or a higher decrease in PSA levels, compared to patients without an activating AR genetic alteration (e.g., an activating AR-LBD mutation or AR amplification).

[0047] Sample preparation and genomic profiling There are various methods available for determining whether a sample from a patient contains AR with specific genetic alteration.Methods include, but are not limited to, nucleic acid sequencing (e.g., DNA sequencing, RNA sequencing, protein sequencing, whole transcriptome sequencing, or other methods known in the art), or use antibodies or nucleic acids specific to the mutation.For various references related to sequencing, see, for example, Morin et al., Nature 476:298-303(2011); Kridel et al., Blood 119:1963-1971(2012); Ren et al., Cell Res.22:806-821(2012).

[0048] The detection of somatically activated AR gene alterations can be preferably carried out by collecting circulating cell-free DNA (cfDNA) from the patient's plasma. First, a whole blood sample is collected from the patient. The sample is processed to obtain plasma according to a suitable protocol for genomic profiling of cfDNA. cfDNA is extracted from the plasma, and somatically activated AR gene alterations from prostate tumor cells are detected, for example, by suitable hybrid capture method, preferably using a commercially available gene panel that targets AR region. Examples of suitable methods include, for example, the Guardant360 CDx digital next generation sequencing (NGS) assay available from Guardant Health, Inc. (Odegaard, J. et al., Clin Cancer Res, 2018, 24(15), 3539-3549) (AR-LBD mutations and AR amplification), the OncoBEAM® digital PCR assay available from Sysmex Inostics, Inc. (AR-LBD mutations), and FoundationOne Liquid CDx available from Foundation Medicine and Caris Assure™ available from Caris Life Sciences.

[0049] Alternatively, obtaining samples for genomic profiling of the patient's prostate tumor cells can be done by traditional tumor tissue biopsy, although less invasive methods such as the biofluid-based cfDNA method described above are preferred.

[0050] In vitro functional testing of AR-LBD mutations Whether an observed genetic alteration in the AR is an "activating AR genetic alteration" as defined herein can be tested, for example, as follows.

[0051] Wild-type human androgen receptor (WT-AR) is encoded in a suitable expression plasmid, for example, pcDNA3.1.AR modification (for example, AR-LBD point mutation) can be generated in AR cDNA using a site-directed mutagenesis system known in the art.Then, mutagenic oligonucleotide primers are individually designed with desired AR mutations to obtain the AR cDNA of the mutations to be tested.Then, mutated AR expression plasmid can be prepared using a method known in the art.

[0052] Suitable cells lacking AR expression, such as PC-3 or CV-1 cells, are grown in medium with charcoal-stripped serum (CSS). The cells are co-transfected with wt-AR or modified AR expression plasmid and AR-driven reporter plasmid, such as luciferase, using a transfection reagent. The transiently transfected cells are stimulated with increasing concentrations of the ligand to be tested. The ligands to be tested include endogenous hormonal steroids, as well as antiandrogens and corticosteroids used to treat prostate cancer patients. The endogenous hormonal steroids to be tested include, but are not limited to, testosterone, dihydrotestosterone, progesterone, androstenedione, dehydroepiandrosterone (DHEA), estradiol, cortisol, and cortisone. The antiandrogens to be tested include, but are not limited to, bicalutamide, flutamide, hydroxyflutamide, enzalutamide, apalutamide, and darolutamide. Corticosteroids that may be tested include, but are not limited to, hydrocortisone, prednisone, and dexamethasone.

[0053] Typically, 24 hours after ligand treatment, the medium is aspirated, cells are lysed, and luciferase activity is measured to determine AR activation by the ligand.See, for example, Campana, C. et al, Semin Reprod Med. 2015 May; 33(3): 225-234.

[0054] Ligand-induced AR activation of wild-type AR and modified AR is compared. Higher AR activation of modified AR by ligand indicates that the tested AR genetic modification is an "activated AR genetic modification" as defined herein.

[0055] Treatment method According to one embodiment of the present disclosure, a CYP11A1 inhibitor, for example, a compound of formula (I), is administered to a patient with an activating AR genetic alteration (e.g., an activating AR-LBD mutation or AR amplification) and suffering from prostate cancer, such as castration-resistant prostate cancer (CRPC), for example, metastatic castration-resistant prostate cancer (mCRPC). A patient with an activating AR genetic alteration (e.g., an activating AR-LBD mutation or AR amplification) is more likely to respond to treatment with a CYP11A1 inhibitor than a patient without an activating AR genetic alteration (e.g., an activating AR-LBD mutation or AR amplification). According to one embodiment, the patient has previously received an androgen receptor signaling inhibitor (ARSi), such as an androgen receptor antagonist or a CYP17A1 inhibitor, and / or chemotherapy. According to another embodiment, the patient is resistant to an androgen receptor signaling inhibitor (ARSi) therapy, for example, an androgen receptor antagonist therapy and / or a CYP17A1 inhibitor therapy.

[0056] The CYP11A1 inhibitor may be administered to the patient in a therapeutically effective amount that may range from about 0.1 mg to about 500 mg, or from about 1 mg to about 500 mg, and more typically from about 2 mg to about 300 mg, or from about 3 mg to about 150 mg daily, depending on the age, weight, condition of the patient, condition being treated, route of administration, and active ingredient used. When the compound of formula (I) is used to treat prostate cancer, it may be administered to the patient in a daily dose that may range from about 0.1 mg to about 300 mg, or from about 1 mg to about 300 mg, more typically from about 2 mg to about 150 mg, or from about 3 mg to about 100 mg, for example, from about 5 mg to about 100 mg, from about 5 mg to about 50 mg, or from about 7 mg to about 20 mg.

[0057] The CYP11A1 inhibitor is preferably administered together with a glucocorticoid and / or a mineralocorticoid, and optionally with one or more anticancer drugs. Examples of suitable glucocorticoids include, but are not limited to, hydrocortisone, prednisone, prednisolone, methylprednisolone, and dexamethasone. Examples of suitable mineralocorticoids include, but are not limited to, fludrocortisone, deoxycorticosterone, 11-deoxycortisone, and deoxycorticosterone acetate. The glucocorticoid may be administered at a dose recommended for the treatment of chronic adrenal insufficiency, for example, about 0.2 mg to about 50 mg / day, depending on the glucocorticoid used. The mineralocorticoid may be administered at a dose recommended for the treatment of chronic adrenal insufficiency, for example, about 0.01 mg to about 0.5 mg or about 0.05 mg to about 0.5 mg / day, depending on the mineralocorticoid used.

[0058] The CYP11A1 inhibitor can be formulated into a dosage form. The compound can be administered to a patient as is or in combination with a suitable pharmaceutical excipient in the form of tablets, granules, capsules, suppositories, emulsions, suspensions or solutions. Suitable carriers, solvents, gel-forming components, dispersion-forming components, antioxidants, colorants, sweeteners, wetting compounds, and other components used to formulate dosage forms may also be used. The composition containing the active compound can be administered enterally or parenterally, with the oral route being the preferred method. The content of the active compound in the composition is about 0.5 to 100%, for example, about 0.5 to about 20%, by weight of the total composition.

[0059] CYP11A1 inhibitors, e.g., compounds of formula (I), may be administered in combination with other anti-cancer therapies useful in the treatment of prostate cancer, including, but not limited to, androgen deprivation therapy (ADT), AR antagonists, PARP (poly-ADP ribose polymerase) inhibitors, chemotherapeutic agents (e.g., docetaxel, paclitaxel, and cabazitaxel), and radiation therapy.

[0060] The present invention is further illustrated by the following non-limiting examples. EXAMPLES

[0061] Example 1. Clinical Trial of Treating Prostate Cancer Patients with the CYP11A1 Inhibitor 2-(isoindolin-2-ylmethyl)-5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-4H-pyran-4-one (1A) method Patients with advanced mCRPC were enrolled in a clinical trial to study the effects of the CYP11A1 inhibitor 2-(isoindolin-2-ylmethyl)-5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-4H-pyran-4-one (1A). Patients were receiving ADT therapy and had previously received androgen receptor signaling inhibitor (ARSi) therapy and chemotherapy, or were chemotherapy ineligible. Five different daily dose levels of the compound (1A), including dexamethasone and fludrocortisone, were orally administered to 27 patients in the dose escalation / deescalation portion. The corticosteroid dose was allowed to be adjusted during the study based on the subject's clinical status. Daily doses were 10 mg (5 mg bid), 30 mg (15 mg bid), 50 mg (25 mg bid), 100 mg (50 mg bid), and 150 mg (75 mg bid). In a separate dosing evaluation portion, 25 mg of compound (1A) once daily and two different glucocorticoid replacement therapies, hydrocortisone and prednisone, were evaluated in 14 patients. Subjects were allowed to continue therapy until disease progression or intolerable toxicity. Antitumor activity was determined by measuring changes in PSA (prostate specific antigen) levels in a PSA-evaluable patient population (n=37, at least 4 weeks of values ​​available). A decrease in PSA levels indicates antitumor activity. PSA response in patients was defined as at least a 50% decrease from baseline PSA levels.

[0062] The OncoBEAM® Prostate Cancer Digital PCR Assay Panel (Sysmex Inostics, Inc.) and the Guardant360 CDx (Guardant Health, Inc.) assay panel were used to analyze the presence of activating AR-LBD somatic point mutations and AR gene amplification in plasma cfDNA samples obtained from patients. The assay panel was used to test for the presence of activating AR-LBD point mutations, including L702H, V716M, V716L, W742C, W742L, H875Y, F877L, T878A, T878S, D891Y, M896T, and M896V.

[0063] result Multiple activating AR-LBD point mutations (2–4) were detected in 9 subjects and a single activating AR-LBD point mutation was detected in 7 subjects. AR amplification (>5 copies) was detected in 2 subjects. AR-LBD mutation L702H occurred in 11 subjects, T878A mutation in 9 subjects, H875Y in 6 subjects, F877L in 1 subject, and T878S in 1 subject. Antitumor activity was observed to be substantially higher in subjects with activating AR gene alterations (n=17) compared with subjects without activating AR gene alterations (n=20). 70.6% of subjects with activating AR gene alterations (12 of 17 subjects) had a PSA decline of ≥50% compared with 5.0% of subjects without activating AR gene alterations (1 of 20 subjects). In total, 92.3% of subjects with a PSA response (≥50% reduction) were positive for activating AR gene alterations (12 of 13 subjects). PSA responses were also seen in patients who received androgen receptor signaling inhibitors (ARSi), such as enzalutamide or abiraterone acetate or both. The results are summarized in Figures 1 and 2. Figure 1 shows PSA changes in 37 evaluable patients. Patients with activating AR-LBD mutations (16 patients) are represented by a solid line in the center of the bar. Patients with ≥5 copies of AR amplification (2 patients) are represented by a dot below the bar. Previously administered medications are also shown. Figure 2 shows PSA changes in patients with activating AR-LBD mutations, with the identity of the mutation(s) in each patient shown.

[0064] Example 2. Clinical Trial of Treating Prostate Cancer Patients with the CYP11A1 Inhibitor 5-((1-(Methylsulfonyl)piperidin-4-yl)methoxy)-2-((5-(trifluoromethyl)isoindolin-2-yl)methyl)-4H-pyran-4-one (1B) method Patients with advanced mCRPC were enrolled in a clinical trial to study the effects of the CYP11A1 inhibitor 2-5-((1-(methylsulfonyl)piperidin-4-yl)methoxy)-2-((5-(trifluoromethyl)isoindolin-2-yl)methyl)-4H-pyran-4-one (1B). Patients were receiving ADT therapy and had previously received androgen receptor signaling inhibitor (ARSi) therapy and chemotherapy, or were chemotherapy ineligible. Three different daily dose levels of the compound (1B), including hydrocortisone and fludrocortisone, were orally administered to 13 subjects in the dose escalation portion. The corticosteroid dose was allowed to be adjusted during the study based on the subjects' clinical status. Daily doses were 10 mg (10 mg qd), 15 mg (15 mg qd), and 20 mg (20 mg qd). In another dosing evaluation part, 5mg and 10mg twice daily dosing of compound (1B) was evaluated in 16 patients, as well as different glucocorticoid replacement therapy, dexamethasone, and different hydrocortisone dosing regimens. Subjects were allowed to continue therapy until disease progression or intolerable toxicity. Antitumor activity was determined by measuring changes in PSA (prostate specific antigen) levels. A decrease in PSA levels indicates antitumor activity. PSA response in patients was defined as at least a 50% decrease from baseline PSA levels.

[0065] The OncoBEAM® Prostate Cancer Digital PCR Assay Panel (Sysmex Inostics, Inc.) and the Guardant360 CDx (Guardant Health, Inc.) assay panel were used to analyze the presence of activating AR-LBD somatic point mutations and AR gene amplification in plasma cfDNA samples obtained from patients. The assay panel was used to test for the presence of activating AR-LBD mutations, including L702H, V716M, V716L, W742C, W742L, H875Y, F877L, T878A, T878S, D891Y, M896T, and M896V.

[0066] result Multiple activating AR-LBD point mutations (2-4) were detected in 5 subjects and a single activating AR-LBD point mutation was detected in 10 subjects. AR amplification (>5 copies) was detected in 3 subjects. AR-LBD mutation L702H occurred in 6 subjects, T878A mutation occurred in 7 subjects, H875Y occurred in 5 subjects, and F877L, V716M, M896T, D891Y, and V716L occurred in 1 subject each. Antitumor activity was observed to be substantially higher in subjects with activating AR gene alterations (n=17) compared to subjects without activating AR gene alterations (n=8). 35.3% of subjects with activating AR gene alterations (6 of 17 subjects) experienced a PSA decline of ≥50% compared to 0% of subjects without activating AR gene alterations (0 of 8 subjects). In total, 100% of subjects with a PSA response (≥50% drop) were positive for activating AR gene alterations (6 out of 6 subjects). PSA responses were also seen in patients who received androgen receptor signaling inhibitors (ARSi), such as enzalutamide or abiraterone acetate or both. The results are summarized in Figures 3 and 4. Figure 3 shows PSA changes in 25 evaluable patients. Patients with activating AR-LBD mutations (15 patients) are represented by a solid line in the middle of the bar. Patients with more than 5 copies of AR amplification (3 patients) are represented by a dot below the bar. Previously administered medications are also shown. Figure 4 shows PSA changes in patients with activating AR-LBD mutations, with the identity of the mutation(s) in each patient shown.

Claims

1. A pharmaceutical composition for the treatment of prostate cancer in patients with an activating androgen receptor (AR) genetic alteration, comprising a therapeutically effective amount of a CYP11A1 inhibitor.

2. The CYP11A1 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof 【Chemical 1】 (In the formula, R １ is hydrogen or —CF ３ The pharmaceutical composition of claim 1 .

3. R １ The pharmaceutical composition of claim 2, wherein is hydrogen.

4. The pharmaceutical composition of any one of claims 1 to 3, wherein the patient with an activating AR gene alteration is more likely to respond to the treatment than the patient without an activating AR gene alteration.

5. The pharmaceutical composition according to any one of claims 1 to 3, wherein the activating AR gene modification is AR gene amplification.

6. The pharmaceutical composition according to any one of claims 1 to 3, wherein the activating AR gene modification is an activating AR-LBD mutation.

7. The pharmaceutical composition of claim 6, wherein the activating AR-LBD mutation is an activating AR-LBD point mutation.

8. the patient having Q671R, I673T, L702H, V716M, V716L, K718E, R727L, V731M, W742L, W742C, A749T, A749V, M750I, G751S, V758A, S783N, Q799E, R847G, E873Q, H875Y, H875Q, F877L, T878A, 8. The pharmaceutical composition of claim 7, having one or more of the activating AR-LBD point mutations selected from the group consisting of T878S, D880E, L882I, S889G, D891N, D891H, D891Y, E894K, M896T, M896V, A897T, E898G, K911R, T919S, and Q920R.

9. 9. The pharmaceutical composition of claim 8, wherein the patient has one or more of the activating AR-LBD point mutations selected from the group consisting of L702H, V716M, V716L, W742L, W742C, H875Y, F877L, T878A, T878S, D891Y, M896T, and M896V.

10. 10. The pharmaceutical composition of claim 9, wherein the patient has one or more of the activating AR-LBD point mutations selected from the group consisting of L702H, V716M, V716L, W742C, H875Y, F877L, T878A, D891Y, and M896T.

11. The pharmaceutical composition of any one of claims 1 to 3, wherein the patient has previously received therapy with an androgen receptor antagonist or a CYP17A1 inhibitor.

12. 12. The pharmaceutical composition of claim 11, wherein the patient has previously received therapy with enzalutamide or abiraterone acetate or a pharmaceutically acceptable salt thereof.

13. The pharmaceutical composition according to any one of claims 1 to 3, wherein the patient is resistant to androgen receptor antagonist therapy or CYP17A1 inhibitor therapy.

14. 14. The pharmaceutical composition of claim 13, wherein the patient is resistant to treatment with enzalutamide or abiraterone acetate or a pharmaceutically acceptable salt thereof.

15. The pharmaceutical composition of any one of claims 1 to 3, wherein the prostate cancer to be treated is castration-resistant prostate cancer (CRPC).

16. 16. The pharmaceutical composition of claim 15, wherein the prostate cancer to be treated is metastatic castration-resistant prostate cancer (mCRPC).

17. 1. A pharmaceutical composition for use in a method for treating prostate cancer in a patient, said pharmaceutical composition comprising a CYP11A1 inhibitor; The method comprises: a) obtaining or having obtained a sample from said patient; b) assaying or having assayed said sample to determine whether said patient has an activating AR gene alteration; and c) treating said patient with a therapeutically effective amount of said CYP11A1 inhibitor if said patient has an activating AR gene alteration.

18. The CYP11A1 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof 【Chemistry 2】 (In the formula, R １ is hydrogen or —CF ３ The pharmaceutical composition of claim 17, wherein

19. R １ 19. The pharmaceutical composition of claim 18, wherein is hydrogen.

20. The pharmaceutical composition of any one of claims 17 to 19, wherein the patient with an activating AR gene alteration is more likely to respond to the treatment than a patient without an activating AR gene alteration.

21. The pharmaceutical composition according to any one of claims 17 to 19, wherein the activating AR gene modification is AR gene amplification.

22. The pharmaceutical composition according to any one of claims 17 to 19, wherein the activating AR gene modification is an activating AR-LBD mutation.

23. The pharmaceutical composition according to any one of claims 17 to 19, wherein the sample comprises AR or a part thereof derived from the patient.

24. The pharmaceutical composition according to any one of claims 17 to 19, wherein the sample comprises a polynucleotide encoding AR or a part thereof derived from the patient.

25. 25. The pharmaceutical composition of claim 24, comprising determining the sequence of an AR-LBD polynucleotide or a portion thereof from said patient.

26. 25. The pharmaceutical composition of claim 24, comprising subjecting the sample to a gene panel assay targeting the AR-LBD region designed to hybrid-capture known AR-LBD alterations.

27. The pharmaceutical composition of any one of claims 17 to 19, wherein the prostate cancer to be treated is castration-resistant prostate cancer (CRPC).

28. 28. The pharmaceutical composition of claim 27, wherein the prostate cancer being treated is metastatic castration-resistant prostate cancer (mCRPC).

29. The pharmaceutical composition of any one of claims 17 to 19, wherein the prostate cancer to be treated is castration-sensitive prostate cancer (CSPC).

30. 30. The method of claim 29, wherein the prostate cancer being treated is metastatic castration-sensitive prostate cancer (mCSPC).

31. 1. A method for selecting a patient suffering from prostate cancer for treatment with a CYP11A1 inhibitor, comprising: a) assaying or having assayed a sample to determine whether said patient has an activating AR gene alteration; b) if said patient has an activating AR-LBD gene alteration, selecting said patient for said treatment with a CYP11A1 inhibitor.

32. The CYP11A1 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof 【Chemistry 3】 (In the formula, R １ is hydrogen or —CF ３ 32. The method of claim 31 , wherein

33. R １ 33. The method of claim 32, wherein is hydrogen.

34. 34. The method of any one of claims 31 to 33, wherein the patient with an activating AR gene alteration is more likely to respond to the treatment than a patient without an activating AR gene alteration.

35. The method of any one of claims 31 to 33, wherein the patient is suffering from castration-resistant prostate cancer (CRPC).

36. 36. The method of claim 35, wherein the patient is afflicted with metastatic castration-resistant prostate cancer (mCRPC).

37. The method of any one of claims 31 to 33, wherein the patient is suffering from castration-sensitive prostate cancer (CSPC).

38. 38. The method of claim 37, wherein the patient is afflicted with metastatic castration-sensitive prostate cancer (mCSPC).

39. 1. A method for identifying a patient suffering from prostate cancer who is more likely to respond to a treatment comprising a CYP11A1 inhibitor, the method comprising assaying or having assayed a sample obtained from the patient to determine whether the patient has an activating AR gene alteration, wherein such alteration identifies the patient as more likely to respond to the treatment.

40. The CYP11A1 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof 【Chemistry 4】 (In the formula, R １ is hydrogen or —CF ３ 40. The method of claim 39, wherein

41. R １ 41. The method of claim 40, wherein is hydrogen.

42. A pharmaceutical composition for use in treating prostate cancer in patients with an activating AR gene alteration, comprising a CYP11A1 inhibitor as an active ingredient and a pharmaceutically acceptable carrier.

43. The CYP11A1 inhibitor is a compound of formula (I) or a pharmaceutically acceptable salt thereof 【Chemistry 5】 (In the formula, R １ is hydrogen or —CF ３ 43. The composition of claim 42, wherein

44. R １ 44. The composition of claim 43, wherein is hydrogen.

45. 45. The composition of any one of claims 42 to 44, wherein the patient with an activating AR gene alteration is more likely to respond to the treatment with a CYP11A1 inhibitor than a patient without an activating AR gene alteration.

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