Use of glucocorticoid receptor modulators to potentiate checkpoint inhibitors

Abstract

To provide glucocorticoid receptor modulators for potentiating checkpoint inhibitors.SOLUTION: The invention provides a method for treating cancer, for example cancer sensitive to checkpoint inhibitors, by a combined use of a checkpoint inhibitor and a glucocorticoid receptor modulator. The glucocorticoid receptor modulator is administered to a patient suffering from tumor load in an amount effective to potentiate the activity of the checkpoint inhibitor. The combination therapy of checkpoint inhibitor and SGRM provides superior tumor load reduction compared to treatment with a checkpoint inhibitor alone.SELECTED DRAWING: Figure 2

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of and priority to U.S. Provisional Patent Application No. 62 / 302,106, filed March 1, 2016, and to U.S. Provisional Patent Application No. 62 / 320,276, filed April 8, 2016, both of which are hereby incorporated by reference in their entireties. [Background technology]

[0002] background Cancer is a group of various diseases characterized by the uncontrolled growth and spread of abnormal cells. In cancer cells, the pathways that control cell division and / or cell communication are altered so that the effect of these regulatory mechanisms in controlling and limiting cell growth is not functioning or is circumvented. Through a successive series of mutations and natural selection, a group of abnormal cells, generally derived from a single mutant cell, accumulates additional mutations that provide a selective growth advantage over other cells, evolving into a dominant cell type in the cell mass. As cancer cells further evolve, some become locally invasive and then metastasize to colonize tissues other than the original cancer cell tissue. This characteristic and the heterogeneity of the tumor cell population make cancer a particularly difficult disease to treat and eradicate.

[0003] Traditional cancer treatments exploit the high proliferative capacity of cancer cells and their high sensitivity to DNA damage: ionizing radiation (including gamma rays, X-rays) and cytotoxic agents such as bleomycin, cisplatin, vinblastine, cyclophosphamide, 5'-fluorouracil and methotrexate rely on general damage to DNA and destabilization of chromosomal structure, which ultimately leads to the destruction of cancer cells. These treatments are particularly effective in cancer types with cell cycle checkpoint defects, limiting the ability of these cells to repair damaged DNA before undergoing cell division. However, the nonselective nature of these treatments often results in severe and debilitating side effects. Systemic use of these drugs can usually result in damage to healthy organs and tissues, compromising the long-term health of the patient.

[0004] Recently, immunotherapy targeting immune checkpoint signaling pathways has been shown to be effective in the treatment of cancer. These pathways suppress immune responses and are important for maintaining self-tolerance, modulating the duration and amplitude of physiological immune responses in peripheral tissues, and minimizing collateral tissue damage. It is believed that tumor cells can activate immune checkpoint signaling pathways to reduce the effectiveness of immune responses against tumor tissues. Many of these immune checkpoint signaling pathways are initiated by the interaction between checkpoint proteins and their ligands present on the surface of cells involved in the immune response (e.g., T cells), so that they can be easily blocked by drugs or modulated by recombinant checkpoint proteins or ligands or receptors. Drugs that block immune suppressive pathways induced by checkpoint proteins are generally referred to as checkpoint inhibitors, and several are commercially available. Cytotoxic T-lymphocyte-associated antigen 4 (CTLA4) antibodies, which block immune suppressive pathways by the checkpoint protein CTLA4, were the first immunotherapeutic drug of this class to gain approval from the U.S. Food and Drug Administration (FDA). Clinical findings with blockade of additional immune checkpoint proteins, such as programmed cell death protein 1 (PD-1), indicate broad and diverse opportunities to enhance antitumor immunity with the potential to generate durable clinical responses.

[0005] Glucocorticoid receptor (GR)-mediated signaling pathways have dynamic biological effects involving different components of the immune system, and their in vivo effects are unpredictable. For example, glucocorticoids have been reported to have both immunosuppressive effects (e.g., suppression of proinflammatory cytokines, promotion of antiinflammatory cytokines, inhibition of dendritic cells, suppression of natural killer cells, promotion of T regulatory cells and induction of T cell apoptosis) and immune enhancing effects. See Hinrichs J.Immunother.2005:28(6):517-524. Similarly, the effect of GR-mediated signaling pathways on cancer cells is also difficult to understand. On the one hand, activation of GR signaling pathways is thought to induce apoptosis in certain types of cancer cells, such as malignant lymphoid cancers. See Schlossmacher, J.Endocrino.(2011). On the other hand, it has also been reported that drugs that block GR signaling pathways can enhance chemotherapy in killing cancer cells. See U.S. Pat. No. 9,149,485. The present invention uses a novel combination therapy that targets both the checkpoint and GR signaling pathways to treat patients suffering from tumor burden. [Prior art documents] [Patent documents]

[0006] [Patent Document 1] U.S. Patent No. 9,149,485 [Non-patent literature]

[0007] [Non-Patent Document 1] Hinrichs J.Immunother.2005:28(6):517-524 [Non-Patent Document 2] Schlossmacher, J. Endocrino. (2011) Summary of the Invention [Means for solving the problem]

[0008] overview The methods of cancer treatment disclosed herein include administering to a patient suffering from tumor burden a therapeutic amount of a checkpoint inhibitor and a selective glucocorticoid receptor modulator (SGRM) in an amount effective to enhance the activity of the checkpoint inhibitor. The combination therapy of the checkpoint inhibitor and the SGRM provides superior tumor burden reduction compared to treatment with the checkpoint inhibitor alone.

[0009] In some cases, the checkpoint inhibitor is an antibody against at least one checkpoint protein, such as PD-1, CTLA-4, PD-L1, or PD-L2. In some cases, the checkpoint inhibitor is an antibody effective against two or more of the checkpoint proteins selected from the group of PD-1, CTLA-4, PD-L1, and PD-L2.

[0010] In some cases, the checkpoint inhibitor is a small molecule non-proteinaceous compound that inhibits at least one checkpoint protein. In one embodiment, the checkpoint inhibitor is a small molecule non-proteinaceous compound that inhibits a checkpoint protein selected from the group consisting of PD-1, CTLA-4, PD-L1 and PD-L2.

[0011] In one embodiment, the SGRM is mifepristone. In some cases, the SGRM is a compound having a non-steroidal backbone. In some cases, the SGRM is a fused azadecalin.

[0012] In some cases, the SGRM has the following structure: [ka] and CORT125134, (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, having the formula:

[0013] In some cases, the SGRM is mifepristone.

[0014] In some cases, the SGRM has the following structure: [ka] and CORT125281, having the formula ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone.

[0015] In one embodiment, the cancer is a glucocorticoid receptor (GR + ) is expressed.

[0016] In some cases, cancer is a GR + The cancer is selected from the group consisting of breast cancer, prostate cancer, melanoma, sarcoma, renal cell carcinoma, head and neck cancer, hepatocellular carcinoma, glioblastoma, cervical cancer, neuroendocrine cancer, bladder cancer, prostate cancer, esophageal cancer, mesothelioma, lung cancer, ovarian cancer, pancreatic cancer, gallbladder cancer, gastric cancer, endometrial cancer and colon cancer.

[0017] In one embodiment, the checkpoint inhibitor and the SGRM are co-administered. In a preferred embodiment, the SGRM is CORT125134 and the checkpoint inhibitor is an antibody against PD-1.

[0018] In some embodiments, provided herein is a selective glucocorticoid receptor modulator (SGRM) for use in combination with a checkpoint inhibitor in a method of treating a patient with a tumor burden, comprising administering to a patient suffering from a tumor burden a therapeutic amount of the checkpoint inhibitor and the SGRM in an amount effective to enhance the activity of the checkpoint inhibitor. In addition, all of the above related embodiments are also included in these embodiments of the present disclosure. In certain embodiments, for example, the following items are provided: (Item 1) A method for treating a patient having a tumor burden, comprising administering to the patient therapeutic amounts of a checkpoint inhibitor and a selective glucocorticoid receptor modulator (SGRM), wherein the SGRM is administered in an amount effective to enhance activity of the checkpoint inhibitor to reduce the tumor burden in the patient. (Item 2) 2. The method of claim 1, wherein the tumor burden is due to the presence of a checkpoint inhibitor-sensitive tumor. (Item 3) 2. The method of claim 1, wherein the checkpoint inhibitor is an antibody effective against PD-1. (Item 4) 2. The method of claim 1, wherein the checkpoint inhibitor is an antibody effective against CTLA-4. (Item 5) 2. The method of claim 1, wherein the checkpoint inhibitor is an antibody effective against PD-L1 or PD-L2. (Item 6) 2. The method of claim 1, wherein the checkpoint inhibitor is a small molecule non-protein compound. (Item 7) 2. The method of claim 1, wherein the SGRM is mifepristone. (Item 8) 2. The method of claim 1, wherein the SGRM is a compound having a non-steroidal backbone. (Item 9) 2. The method of claim 1, wherein the SGRM is a condensed azadecalin. (Item 10) The SGRM is CORT125134 [ka] The method according to item 1, (Item 11) The SGRM is CORT125281 [ka] The method according to item 1, (Item 12) The cancer is a glucocorticoid receptor (GR + (Item 13) The method according to item 1, wherein the nucleic acid sequence of The cancer is GR + 2. The method according to item 1, wherein the cancer is selected from the group consisting of breast cancer, prostate cancer, melanoma, sarcoma, renal cell carcinoma, head and neck cancer, hepatocellular carcinoma, glioblastoma, cervical cancer, neuroendocrine cancer, bladder cancer, prostate cancer, esophageal cancer, mesothelioma, lung cancer, ovarian cancer, pancreatic cancer, gallbladder cancer, gastric cancer, endometrial cancer and colon cancer. (Item 14) 2. The method of claim 1, wherein the SGRM is CORT125281 and the checkpoint inhibitor is an antibody effective against PD-1. (Item 15) 2. The method of claim 1, wherein the SGRM is CORT125134 and the checkpoint inhibitor is an antibody effective against PD-1. (Item 16) 2. The method of claim 1, wherein the SGRM is mifepristone and the checkpoint inhibitor is an antibody effective against PD-1. [Brief description of the drawings]

[0019] [Figure 1]FIG. 1 shows tumor growth data from three (3) groups of mice that were respectively: 1) treated intraperitoneally (ip) twice weekly with anti-PD-1 vehicle (PBS, 10 ml / kg) and orally (po) daily with CORT125134 vehicle (10% DMSO, 0.1% Tween 80 and 89.9% HPMC (0.5%), 10 ml / kg); 2) treated intraperitoneally (ip) twice weekly with murine anti-PD-1 antibody (clone RPM1-14, 10 mg / kg); and 3) treated intraperitoneally (ip) twice weekly with murine anti-PD-1 antibody (clone RPM1-14, 10 mg / kg) and orally treated daily with CORT125134 (SGRM) (30 mg / kg). The results show that the combination of anti-PD-1 and CORT125134 is superior to both the anti-PD-1 and vehicle groups in reducing tumor growth. [Diagram 2] Figure 2 shows the average tumor volume of 10 mice in each group plotted against the number of days of tumor growth since the start of treatment. Anti-PD-1 vehicle and CORT125281 vehicle were administered to mice in group I; mouse anti-PD-1 antibody was administered to mice in group II; mouse anti-PD-1 antibody and CORT125281 were administered to mice in group III. The combination of anti-PD-1 and CORT125281 is superior to both the anti-PD-1 group and the vehicle group in reducing tumor growth. [Diagram 3] Figure 3 shows the average tumor volume of 10 mice in each group plotted against the number of days of tumor growth since the start of treatment. Anti-CTLA4 vehicle and CORT125134 vehicle were administered to mice in group I; mouse anti-CTLA4 antibody was administered to mice in group II; mouse anti-CTLA4 antibody and CORT125134 were administered to mice in group III; mouse anti-CTLA4 antibody and CORT125281 were administered to mice in group IV. The combination of anti-CTLA4 with CORT125134 and the combination of anti-CTLA4 with CORT125281 were each superior to both the anti-CTLA4 group and the vehicle group in reducing tumor growth. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0020] Detailed Description A. Introduction The method disclosed herein can be used to treat patients with tumor burden by administering at least one SGRM and at least one checkpoint inhibitor.The checkpoint inhibitor is administered in an amount effective to treat cancer when administered alone or in combination with the SGRM.The SGRM is administered in an amount effective to enhance the activity of the checkpoint inhibitor that blocks checkpoint signaling pathway.In some cases, the tumor burden is caused by checkpoint inhibitor-sensitive cancer. B. Definition

[0021] As used herein, the term "subject" or "patient" refers to a human or non-human organism. Thus, the methods and compositions described herein are applicable to both human and veterinary diseases. In certain embodiments, the subject is a "patient" (i.e., a living human undergoing medical treatment for a disease or condition). This includes those who do not have a defined illness and are being investigated for signs of a pathology. Subjects with an existing diagnosis of the particular cancer targeted by the compositions and methods of the present invention are preferred. In some cases, the subject may simultaneously suffer from one or more types of cancer, at least one of which is targeted by the compositions and methods of the present invention. Preferred cancers for treatment with the compositions described herein include, but are not limited to, prostate cancer, renal carcinoma, melanoma, pancreatic cancer, cervical cancer, ovarian cancer, colon cancer, head and neck cancer, lung cancer, sarcoma, breast cancer, hepatocellular tumor, glioblastoma, neuroendocrine tumor, bladder cancer, gallbladder cancer, gastric cancer, endometrial cancer, and mesothelioma.

[0022] As used herein, the term "tumor burden" or "tumor mass" generally refers to the number of cancer cells, the size of a tumor, or the amount of cancer in a subject's body at any given time. Tumor burden can be detected, for example, by measuring the expression of tumor-specific gene markers and measuring tumor size by several well-known biochemical or imaging methods disclosed herein below.

[0023] The term "immune response" refers to the action of, for example, lymphocytes, antigen-presenting cells, phagocytes, granulocytes, and soluble macromolecules produced by such cells or the liver, including antibodies, cytokines, and complement, that result in the selective damage to, destruction of, or elimination from the body of invading pathogens, pathogen-infected cells or tissues, cancerous cells, or, in the case of autoimmunity or pathological inflammation, normal human cells or tissues.

[0024] As used herein, the term "checkpoint inhibitor-sensitive cancer" refers to a cancer that is responsive to a checkpoint inhibitor. Administration of one or more checkpoint inhibitors to a patient with such a tumor will result in a reduction in tumor burden or other desired beneficial clinical outcomes associated with cancer amelioration.

[0025] As used herein, the term "effective amount" or "therapeutic amount" refers to an amount of a pharmacological agent effective to treat, eliminate or alleviate at least one symptom of the disease being treated. In some cases, "therapeutically effective amount" or "effective amount" may refer to an amount of a functional agent or pharmaceutical composition useful for exhibiting a detectable therapeutic or inhibitory effect. This effect may be detected by any assay method known in the art. An effective amount may be an amount effective to induce an anti-tumor response. An effective amount may be an amount effective to induce a humoral and / or cellular immune response in a recipient subject, resulting in growth inhibition or death of target cells. For the purposes of this disclosure, a therapeutic amount of a checkpoint inhibitor is an amount that will reduce tumor burden or result in other desired beneficial clinical outcomes related to cancer improvement.

[0026] As used herein, the term "amount effective to enhance" refers to an amount of a pharmacological agent effective to enhance the activity of another therapeutic agent in treating, eliminating or alleviating at least one symptom of the disease being treated. An agent used to enhance the activity of another may be effective or ineffective in treating, eliminating or alleviating the symptoms of the disease itself. In some cases, the enhancer is ineffective and the effect of enhancement may be indicated by an increase in the degree of alleviation of symptoms resulting from treatment with a combination of the two agents compared to treatment with the therapeutic agent alone. In some cases, the enhancer itself is effective in treating the symptoms and the enhancement effect may be indicated by a synergistic effect between the enhancer and the therapeutic agent. For the purposes of this disclosure, an SGRM acts as an enhancer to enhance the activity of a checkpoint inhibitor in treating cancer, regardless of whether the SGRM is effective in treating cancer when administered alone. In some embodiments, an enhancement effect of 10% to 1000% may be achieved. In some embodiments, the SGRM is administered in an amount that sensitizes the tumor to the checkpoint inhibitor (i.e., exhibits a reduction in tumor burden or otherwise exhibits other relevant clinical benefit that would not be apparent if the tumor were treated with the checkpoint inhibitor in the absence of the SGRM).

[0027] As used herein, the term "combination therapy" refers to administering at least two pharmaceutical agents to a subject to treat a disease. The two agents can be administered simultaneously or sequentially in any order during the entire or part of the treatment period. The two agents can be administered according to the same or different dosing regimens. In some cases, one agent is administered according to a scheduled regimen, and the other agent is administered intermittently. In some cases, both agents are administered intermittently. In some embodiments, one agent, such as an SGRM, is administered daily, and the other agent, such as a checkpoint inhibitor, is administered weekly or every other week.

[0028] As used herein, the terms "administer," "administering," "administered," or "administration" refer to providing a compound or composition (e.g., those described herein) to a subject or patient.

[0029] As used herein, the term "co-administration" refers to the administration of two compositions simultaneously or within a short period of each other, for example, within about 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, or 24 hours of each other.

[0030] As used herein, the term "compound" is used to describe a molecular moiety of a unique and identifiable chemical structure. The molecular moiety ("compound") may exist in the form of a free species that is not associated with other molecules. A compound may also exist as part of a larger aggregate in which it is associated with other molecules, but nevertheless retains its chemical identity. A solvate, in which a molecular moiety of a defined chemical structure ("compound") is associated with a molecule of a solvent, is an example of such an associated form. A hydrate is a solvate in which the associated solvent is water. The description of a "compound" refers to the molecular moiety itself (of the described structure), regardless of whether it exists in free or associated form.

[0031] As used herein, the term "small molecule non-protein compound" refers to a low molecular weight organic compound, typically having a molecular weight of less than 900 Daltons.

[0032] As used herein, the term "pharmaceutically acceptable carrier" is intended to include any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, etc., that are compatible with pharmaceutical administration. The use of such media and agents for pharmaceutically active substances is well known in the art. Except in the case where any conventional media or agent is incompatible with the active compound, its use in the composition is contemplated. Auxiliary active compounds can also be incorporated into the composition.

[0033] As used herein, the term "checkpoint protein" refers to a protein present on the surface of certain types of cells, such as T cells and certain tumor cells, which can induce checkpoint signaling pathways and lead to suppression of immune response. Commonly known checkpoint proteins include CTLA4, PD-1, PD-L1, LAG3, B7-H3, B7-H4, TIM3, CD160, CD244, VISTA, TIGIT and BTLA. (Pardoll, 2012, Nature Reviews Cancer 12:252-264; Baksh, 2015, Semin Oncol. 2015 Jun; 42(3):363-77). Among these, CTLA4, PD-1 and PD-L1 are the most well-studied, and therapies targeting these proteins have made more clinical progress than therapies targeting other checkpoint proteins.

[0034] As used herein, the term "PD-1" refers to programmed cell death protein 1 (also known as CD279), a cell surface membrane protein of the immunoglobulin superfamily. PD-1 is expressed by B cells, T cells, and NK cells. The main role of PD-1 is to limit the activity of T cells in peripheral tissues during inflammation in response to infection and to limit autoimmunity. On activated T cells, PD-1 expression is induced, and binding of PD-1 to one of its endogenous ligands acts to inhibit T cell activation by inhibiting stimulatory kinases. PD-1 also acts to inhibit TCR "stop signals." PD-1 is highly expressed on Treg cells (regulatory T cells) and can increase their proliferation in the presence of ligand (Pardoll, 2012, Nature Reviews Cancer 12:252-264).

[0035] As used herein, the term "PD-L1" refers to the ligand of PD-1, programmed cell death 1 ligand 1 (also known as CD274 and B7-H1). PD-L1 is found on activated T cells, B cells, myeloid cells, macrophages and tumor cells. There are two endogenous ligands for PD-1, PD-L1 and PD-L2, but anti-tumor therapy focuses on anti-PD-L1. The complex of PD-1 and PD-L1 inhibits the proliferation of CD8+ T cells and reduces immune responses (Topalian et al., 2012, N. Engl J. Med. 366:2443-54; Brahmer et al., 2012, N. Engl J. Med. 366:2455-65).

[0036] As used herein, the term "CTLA4" refers to cytotoxic T-lymphocyte antigen 4 (also known as CD152), a member of the immunoglobulin superfamily that is exclusively expressed on T cells.CTLA4 acts to inhibit T cell activation, and is reported to inhibit helper T cell activity and enhance regulatory T cell immunosuppressive activity.Although the exact mechanism of action of CTL4-A is still under investigation, it has been suggested that it inhibits T cell activation by outcompeting CD28 in binding to CD80 and CD86 on antigen-presenting cells and actively delivering inhibitor signals to T cells (Pardoll, 2012, Nature Reviews Cancer 12:252-264).

[0037] As used herein, the term "checkpoint inhibitor" refers to any molecule (including antibodies and small molecules) that blocks the immunosuppressive pathways induced by one or more checkpoint proteins.

[0038] As used herein, the term "antibody" also includes full-length antibodies and "antigen-binding portions" of antibodies. As used herein, the term "antigen-binding portion" refers to one or more fragments of an antibody that retain the ability to specifically bind to an antigen (e.g., PD-1). Examples of binding fragments encompassed by the term "antigen-binding portion" of an antibody include (i) a Fab fragment, which is a monovalent fragment consisting of the VL, VH, CL and CH1 domains; (ii) a F(ab')2 fragment, which is a bivalent fragment containing two Fab fragments linked by a disulfide bridge at the hinge region; (iii) an Fd fragment consisting of the VH and CH1 domains; (iv) an Fv fragment consisting of the VL and VH domains of a single arm of an antibody; (v) a dAb fragment consisting of the VH domain (Ward et al., (1989) Nature 341:544-546); and (vi) an isolated complementarity determining region (CDR). Furthermore, although the two domains of the Fv fragment, VL and VH, are encoded by separate genes, they can be connected by a synthetic linker that allows them to be made using recombinant methods as a single protein chain (also known as single-chain Fv (scFv); see, e.g., Bird et al., (1988) Science 242:423-426; and Huston et al., (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883; and Osbourn et al., 1998, Nature Biotechnology 16:778) in which the VL and VH regions pair to form a monovalent molecule. Such single-chain antibodies are also intended to be encompassed by the term "antigen-binding portion" of an antibody. Any VH and VL sequence of a particular scFv can be linked to human immunoglobulin constant region cDNA or genomic sequences to generate expression vectors encoding complete IgG molecules or other isotypes. The VH and VI may also be used in the generation of Fab, Fv or other fragments of immunoglobulins, using either protein chemistry or recombinant DNA techniques. Other forms of single chain antibodies, such as diabodies, are also encompassed.Diabodies are bivalent, bispecific antibodies in which the VH and VL domains are expressed on a single polypeptide chain, but use a linker that is too short to allow pairing between the two domains on the same chain, thereby forcing them to pair with the complementary domains on another chain and creating two antigen-binding sites (see, e.g., Holliger, P. et al., (1993) Proc. Natl. Acad. Sci. USA 90:6444-6448; Poljak, R. J. et al., (1994) Structure 2:1121-1123).

[0039] The antibody may be polyclonal or monoclonal; xenogeneic, allogeneic or syngeneic; or modified forms thereof, such as humanized, chimeric, etc. The antibody of the present invention specifically or substantially specifically binds to one or more checkpoint proteins. The term "monoclonal antibody" refers to a population of antibody molecules that contain only one species of antigen binding site that can immunoreact with a particular epitope of an antigen, whereas the terms "polyclonal antibody" and "polyclonal antibody composition" refer to a population of antibody molecules that contain multiple species of antigen binding site that can interact with a particular antigen. A monoclonal antibody composition typically exhibits a single binding affinity for the particular antigen with which it immunoreacts.

[0040] As used herein, the term "antibody effective against a checkpoint protein" refers to an antibody that can bind to a checkpoint protein and antagonize the function of the checkpoint protein in suppressing immune response. For example, an antibody against PD-1 refers to an antibody that can bind to PD-1 and block the inhibitory function of PD-1 on immune response, for example, through blocking the interaction between PD-1 and PD-L1. In some cases, the antibody can be against two checkpoint proteins (i.e., has the ability to bind to two checkpoint proteins and inhibit their function).

[0041] As used herein, the term "glucocorticoid receptor" ("GR") refers to a family of intracellular receptors that specifically bind cortisol and / or cortisol analogs. Glucocorticoid receptors are also referred to as cortisol receptors. This term includes isoforms of GR, recombinant GR and mutant GR. "Glucocorticoid receptor" ("GR") refers to type II GR that specifically binds cortisol and / or cortisol analogs, such as dexamethasone (see, e.g., Turner & Muller, J Mol Endocrinol October 1, 2005 35 283-292).

[0042] "Glucocorticoid receptor modulators" ("GRM"), also known as glucocorticoid receptor antagonists and described in the scientific and patent literature, refer to any compound that inhibits any biological response associated with the binding of GR to an agonist. For example, GR agonists such as dexamethasone increase the activity of tyrosine aminotransferase (TAT) in HepG2 cells (human liver hepatocellular carcinoma cell line; ECACC, UK). Thus, GR modulators of the present invention can be identified by measuring the ability of a compound to inhibit the effect of dexamethasone. TAT activity can be measured as outlined in the literature A. Ali et al., J. Med. Chem., 2004, 47, 2441-2452. Modulators have an IC of less than 10 micromolar. 50 (half maximal inhibitory concentration). See Example 1 below.

[0043] As used herein, the term "selective glucocorticoid receptor modulator" refers to any composition or compound that inhibits any biological response associated with the binding of GR to an agonist. "Selective" refers to a drug that preferentially binds to GR rather than other nuclear receptors, such as the progesterone receptor (PR), mineralocorticoid receptor (MR), or androgen receptor (AR). A selective glucocorticoid receptor antagonist has an affinity (K) that is 10-fold higher than the affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d In a more preferred embodiment, the selective glucocorticoid receptor antagonist binds to the GR with an affinity (K 100-fold greater) than its affinity for the MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d In another embodiment, the selective glucocorticoid receptor antagonist binds to GR with an affinity (K ) that is 1000-fold greater than its affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d It binds to GR at a concentration of 1 / 1000 of the original value.

[0044] As used herein, the term "composition" is intended to include products that contain specified amounts of specified components, such as the compounds, their tautomeric forms, their derivatives, their analogs, their stereoisomers, their polymorphs, their pharmaceutically acceptable salts, esters, ethers, metabolites, mixtures of isomers, their pharmaceutically acceptable solvates and pharmaceutically acceptable compositions, as well as any products that result directly or indirectly from the combination of specified amounts of specified components. Such terms regarding pharmaceutical compositions are intended to include products that contain active components and inactive components that constitute the carrier, as well as any products that result directly or indirectly from the combination, complexation or aggregation of any two or more of the components, or from the dissociation of one or more of the components, or from other types of reactions or interactions of one or more of the components. Thus, the pharmaceutical compositions of the present invention are meant to include any compositions made by mixing the compounds of the present invention with their pharmaceutically acceptable carriers.

[0045] As used herein, the phrase "not otherwise indicated for treatment with glucocorticoid receptor modulators" refers to patients who do not suffer from any condition that is recognized by the medical community as being effectively treatable with glucocorticoid receptor antagonists, except for hepatic steatosis.Conditions known in the art that are recognized by the medical community as being effectively treatable with glucocorticoid receptor antagonists include psychosis associated with interferon-α therapy, psychotic major depression, dementia, stress disorder, autoimmune disease, neurological injury and Cushing's syndrome.

[0046] In some embodiments, the term "consisting essentially of" refers to a composition whose only active ingredient is the indicated active ingredient, but which may contain other compounds that are for stabilization, storage, etc., but are not directly involved in the therapeutic effect of the indicated active ingredient. In some embodiments, the term "consisting essentially of" may refer to a composition that includes an active ingredient and an ingredient that facilitates the release of the active ingredient. For example, the composition may include one or more ingredients that provide a sustained release of the active ingredient to the subject over time. In some embodiments, the term "consisting essentially of" refers to a composition that includes an active ingredient and a pharma- ceutically acceptable carrier or excipient.

[0047] The term "steroid backbone" in the context of glucocorticoid receptor antagonists that contain a steroid backbone refers to glucocorticoid receptor antagonists that contain modifications of the basic structure of cortisol, an endogenous steroid glucocorticoid receptor ligand. The basic structure of the steroid backbone is represented by Formula I: [ka] The two most well-known classes of structural modifications of the cortisol steroid backbone to generate glucocorticoid antagonists include modifications of the 11-β hydroxy group and modifications of the 17-β side chain (see, e.g., Lefebvre (1989) J. Steroid Biochem. 33:557-563).

[0048] As used herein, the phrase "non-steroidal backbone" in the context of SGRMs refers to SGRMs that do not share structural homology with or are not modifications of cortisol, which has a steroidal backbone containing 17 carbon atoms bonded to four fused rings. Such compounds include synthetic mimetics and analogs of proteins, including partially peptidic, pseudopeptidic and nonpeptidic molecular entities.

[0049] Non-steroidal SGRM compounds include SGRMs with condensed azadecalin backbone, heteroaryl ketone condensed azadecalin backbone or octahydro condensed azadecalin backbone.Exemplary glucocorticoid receptor modulators with condensed azadecalin backbone include those described in U.S. Patent No. 7,928,237 and U.S. Patent No. 8,461,172.Exemplary glucocorticoid receptor modulators with heteroaryl ketone condensed azadecalin backbone include those described in U.S. Patent Application Publication No. 2014 / 0038926. Exemplary glucocorticoid receptor modulators having an octohydro fused azadecalin backbone include those described in U.S. Provisional Patent Application No. 61 / 908,333, filed November 25, 2013, entitled Octahydro Fused Azadecalin Glucocorticoid Receptor Modulators, Attorney Docket No. 85178-887884 (007800US).

[0050] Where substituents are specified by their conventional chemical formula written from left to right, they equally encompass chemically identical substituents which may be derived by writing the structure from right to left, e.g., -CH2O- is equivalent to -OCH2-.

[0051] "Alkyl" refers to a straight or branched chain saturated aliphatic radical having the indicated number of carbon atoms. Alkyl can be any number of carbons (e.g., C 1-2 , C 1-3 , C 1-4 , C 1-5 , C 1-6 , C 1-7 , C 1-8 , C 1-9 , C 1-10 , C 2-3 , C 2-4 , C 2-5 , C 2-6 , C 3-4 , C 3-5 , C3-6 , C 4-5 , C 4-6 and C 5-6 ) For example, C 1-6 Alkyl includes, but is not limited to, methyl, ethyl, propyl, isopropyl, butyl, isobutyl, sec-butyl, tert-butyl, pentyl, isopentyl, and hexyl.

[0052] "Alkoxy" refers to an alkyl group having an oxygen atom connecting the alkyl group to the point of attachment: alkyl-O-. Like alkyl groups, alkoxy groups can be C 1-6 Alkoxy groups can have any suitable number of carbon atoms, such as, for example, methoxy, ethoxy, propoxy, iso-propoxy, butoxy, 2-butoxy, iso-butoxy, sec-butoxy, tert-butoxy, pentoxy, hexoxy, and the like.

[0053] "Halogen" refers to fluorine, chlorine, bromine and iodine.

[0054] "Haloalkyl" refers to an alkyl, as defined above, in which some or all of the hydrogen atoms have been replaced with halogen atoms. Similar to alkyl groups, haloalkyl groups include C 1-6 and haloalkyl groups can have any suitable number of carbon atoms, such as aryl, aryloxy ...

[0055] The term "perfluoro" can be used to define a compound or radical in which all hydrogens have been replaced with fluorines, for example, perfluoromethane includes 1,1,1-trifluoromethyl.

[0056] "Haloalkoxy" refers to an alkoxy group in which some or all of the hydrogen atoms are replaced with halogen atoms. Similar to alkyl groups, haloalkoxy groups can be C 1-6Alkoxy groups may have any suitable number of carbon atoms, such as 1, 2, 3 or more halogens. When all hydrogens are replaced with halogens, such as fluorine, the compound is per-substituted, such as perfluorinated. Haloalkoxy includes, but is not limited to, trifluoromethoxy, 2,2,2,-trifluoroethoxy and perfluoroethoxy.

[0057] "Cycloalkyl" means a saturated or partially unsaturated monocyclic, fused bicyclic or bridged polycyclic ring assembly containing three to twelve ring atoms, or the number of atoms indicated. Cycloalkyl refers to an alkyl group consisting of any number of carbons (e.g., C 3-6 , C 4-6 , C 5-6 , C 3-8 , C 4-8 , C 5-8 , C 6-8 , C 3-9 , C 3-10 , C 3-11 and C 3-12 ). Saturated monocyclic cycloalkyl rings include, for example, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and cyclooctyl. Saturated bicyclic and polycyclic cycloalkyl rings include, for example, norbornane, [2.2.2]bicyclooctane, decahydronaphthalene, and adamantane. The cycloalkyl group can also be partially unsaturated, having one or more double or triple bonds within the ring. Representative cycloalkyl groups that are partially unsaturated include, but are not limited to, cyclobutene, cyclopentene, cyclohexene, cyclohexadiene (1,3- and 1,4-isomers), cycloheptene, cycloheptadiene, cyclooctene, cyclooctadiene (1,3-, 1,4-, and 1,5-isomers), norbornene, and norbornadiene. When the cycloalkyl is a saturated monocyclic C 3-8When cycloalkyl, exemplary groups include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, and cyclooctyl. 3-6 When it is cycloalkyl, exemplary groups include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, and cyclohexyl.

[0058] "Heterocycloalkyl" refers to a saturated ring system having 3-12 ring members and 1-4 heteroatoms of N, O, and S. Additional heteroatoms may also be useful, including but not limited to B, Al, Si, and P. The heteroatoms may also be oxidized, such as but not limited to -S(O)- and -S(O)2-. Heterocycloalkyl groups may contain any number of ring atoms (e.g., 3-6, 4-6, 5-6, 3-8, 4-8, 5-8, 6-8, 3-9, 3-10, 3-11, or 3-12 ring members). Any suitable number of heteroatoms (e.g., 1, 2, 3, or 4, or 1-2, 1-3, 1-4, 2-3, 2-4, or 3-4) may be included in the heterocycloalkyl group. The heterocycloalkyl groups may include groups such as aziridine, azetidine, pyrrolidine, piperidine, azepane, azocane, quinuclidine, pyrazolidine, imidazolidine, piperazine (1,2-, 1,3- and 1,4-isomers), oxirane, oxetane, tetrahydrofuran, oxane (tetrahydropyran), oxepane, thiirane, thietane, thiolane (tetrahydrothiophene), thiane (tetrahydrothiopyran), oxazolidine, isoxalidine, thiazolidine, isothiazolidine, dioxolane, dithiolane, morpholine, thiomorpholine, dioxane, or dithiane. Heterocycloalkyl groups may also be fused with aromatic or non-aromatic ring systems to form members including, but not limited to, indoline.

[0059] When a heterocycloalkyl contains 3 to 8 ring members and 1 to 3 heteroatoms, representative members include, but are not limited to, pyrrolidine, piperidine, tetrahydrofuran, oxane, tetrahydrothiophene, thiane, pyrazolidine, imidazolidine, piperazine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, morpholine, thiomorpholine, dioxane, and dithiane. Heterocycloalkyls can also form rings with 5 to 6 ring members and 1 to 2 heteroatoms, representative members include, but are not limited to, pyrrolidine, piperidine, tetrahydrofuran, tetrahydrothiophene, pyrazolidine, imidazolidine, piperazine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, and morpholine.

[0060] "Aryl" refers to an aromatic ring system having any suitable number of ring atoms and any suitable number of rings. An aryl group can contain any suitable number of ring atoms (e.g., 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, or 16 ring atoms) and 6 to 10, 6 to 12, or 6 to 14 ring members. Aryl groups can be monocyclic, fused to form bicyclic or tricyclic groups, or linked by bonds to form biaryl groups. Representative aryl groups include phenyl, naphthyl, and biphenyl. Other aryl groups include benzyl, which has a methylene linking group. Some aryl groups have 6 to 12 ring members (e.g., phenyl, naphthyl, or biphenyl). Other aryl groups have 6 to 10 ring members (e.g., phenyl or naphthyl). Some other aryl groups have 6 ring members (e.g., phenyl). Aryl groups can be substituted or unsubstituted.

[0061] "Heteroaryl" refers to a monocyclic or fused bicyclic or tricyclic aromatic ring assembly containing 5-16 ring atoms, where 1-5 of the ring atoms are heteroatoms such as N, O, or S. Additional heteroatoms may also be useful, including but not limited to B, Al, Si, and P. The heteroatoms may also be oxidized, such as but not limited to N-oxide, -S(O)-, and -S(O)2-. Heteroaryl groups may contain any number of ring atoms, such as 3-6, 4-6, 5-6, 3-8, 4-8, 5-8, 6-8, 3-9, 3-10, 3-11, or 3-12 ring members. Any suitable number of heteroatoms, such as 1, 2, 3, 4, or 5; or 1-2, 1-3, 1-4, 1-5, 2-3, 2-4, 2-5, 3-4, or 3-5, may be included in the heteroaryl group. Heteroaryl groups can have 5 to 8 ring members and 1 to 4 heteroatoms, or 5 to 8 ring members and 1 to 3 heteroatoms, or 5 to 6 ring members and 1 to 4 heteroatoms, or 5 to 6 ring members and 1 to 3 heteroatoms. Heteroaryl groups can include groups such as pyrrole, pyridine, imidazole, pyrazole, triazole, tetrazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiophene, furan, thiazole, isothiazole, oxazole and isoxazole. Heteroaryl groups may also be fused to an aromatic ring system, such as a phenyl ring, to form members including, but not limited to, benzopyrroles (e.g., indole and isoindole), benzopyridines (e.g., quinoline and isoquinoline), benzopyrazines (quinoxalines), benzopyrimidines (quinazolines), benzopyridazines (e.g., phthalazine and cinnoline), benzothiophenes, and benzofurans. Other heteroaryl groups include heteroaryl rings linked by bonds, such as bipyridines. Heteroaryl groups may be substituted or unsubstituted.

[0062] The heteroaryl group may be linked through any position on the ring. For example, pyrrole includes 1-, 2-, and 3-pyrrole; pyridine includes 2-, 3-, and 4-pyridine; imidazole includes 1-, 2-, 4-, and 5-imidazole; pyrazole includes 1-, 3-, 4-, and 5-pyrazole; triazole includes 1-, 4-, and 5-triazole; tetrazole includes 1- and 5-tetrazole; pyrimidine includes 2-, 4-, 5-, and 6-pyrimidine; pyridazine includes 3- and 4-pyridazine; 1,2,3-triazine includes 4- and 5-triazine; 1,2,4-triazine includes 3-, 5-, and 6-triazine; 1,3,5-triazine includes 2-triazine; thiophene includes 2- and 3-thiophene; furan includes 2- and and 3-furan; thiazoles include 2-, 4-, and 5-thiazoles; isothiazoles include 3-, 4-, and 5-isothiazoles; oxazoles include 2-, 4-, and 5-oxazoles; isoxazoles include 3-, 4-, and 5-isoxazoles; indoles include 1-, 2-, and 3-indole; isoindoles include 1- and 2-isoindole; quinolines include 2-, 3-, and 4-quinolines; isoquinolines include 1-, 3-, and 4-isoquinolines; quinazolines include 2- and 4-quinoazolines; cinnolines include 3- and 4-cinnolines; benzothiophenes include 2- and 3-benzothiophenes; benzofurans include 2- and 3-benzofurans.

[0063] Some heteroaryl groups include heteroaryl groups having 5 to 10 ring members and 1 to 3 ring atoms containing N, O, or S (e.g., pyrrole, pyridine, imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiophene, furan, thiazole, isothiazole, oxazole, isoxazole, indole, isoindole, quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine, cinnoline, benzothiophene, and benzofuran). Other heteroaryl groups include heteroaryl groups having 5 to 8 ring members and 1 to 3 heteroatoms (e.g., pyrrole, pyridine, imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiophene, furan, thiazole, isothiazole, oxazole and isoxazole).Some other heteroaryl groups include heteroaryl groups having 9 to 12 ring members and 1 to 3 heteroatoms (e.g., indole, isoindole, quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine, cinnoline, benzothiophene, benzofuran and bipyridine). Still other heteroaryl groups include heteroaryl groups having 5 to 6 ring members and 1 to 2 ring heteroatoms including N, O or S (e.g., pyrrole, pyridine, imidazole, pyrazole, pyrazine, pyrimidine, pyridazine, thiophene, furan, thiazole, isothiazole, oxazole and isoxazole).

[0064] Some heteroaryl groups contain 5-10 ring members and only nitrogen heteroatoms (e.g., pyrrole, pyridine, imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), indole, isoindole, quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine and cinnoline). Other heteroaryl groups contain 5-10 ring members and only oxygen heteroatoms (e.g., furan and benzofuran). Some other heteroaryl groups contain 5-10 ring members and only sulfur heteroatoms (e.g., thiophene and benzothiophene). Still other heteroaryl groups contain 5 to 10 ring members and at least two heteroatoms (e.g., imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiazole, isothiazole, oxazole, isoxazole, quinoxaline, quinazoline, phthalazine, and cinnoline).

[0065] "Heteroatom" refers to O, S or N.

[0066] "Salt" refers to the acid salt or base salt of the compound used in the method of the present invention. Illustrative examples of pharmaceutically acceptable salts are salts of mineral acids (such as hydrochloric acid, hydrobromic acid, phosphoric acid, etc.), salts of organic acids (such as acetic acid, propionic acid, glutamic acid, citric acid, etc.), and salts of quaternary ammonium (such as methyl iodide, ethyl iodide, etc.). It is understood that pharmaceutically acceptable salts are non-toxic. Further information regarding suitable pharmaceutically acceptable salts can be found in Remington's Pharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton, Pa., 1985 (incorporated herein by reference).

[0067] "Isomers" refers to compounds that have the same chemical formula but are structurally distinguishable.

[0068] "Tautomer" refers to one of two or more structural isomers that exist in equilibrium and are readily converted from one form to another.

[0069] The description of the compound of the present invention is limited by the principle of chemical bonding known to those skilled in the art.Therefore, when a group can be substituted by one or more of several substituents, such substitutions are selected to be compatible with the principle of chemical bonding and to generate compounds that are not inherently unstable and / or compounds that may be known to those skilled in the art to be unstable under ambient conditions (e.g., aqueous, neutral or physiological conditions).

[0070] "Pharmaceutically acceptable excipient" and "pharmaceutically acceptable carrier" refer to substances that aid in the administration of and absorption of active agents by subjects, and can be included in the compositions of the present invention without causing significant adverse toxicological effects to the patient. Non-limiting examples of pharmaceutically acceptable excipients include water, NaCl, normal saline solution, lactated Ringer's solution, normal sucrose, normal glucose, binders, fillers, disintegrants, lubricants, coating agents, sweeteners, flavors and colors, etc. Those skilled in the art will recognize that other pharmaceutical excipients are useful in the present invention.

[0071] As used herein, the term "GR + "Cancer" refers to a cancer that expresses GR. GR expression can be determined by molecular biochemical methods routine in the art, such as immunohistochemical staining. In one embodiment, GR + The cancer is one having at least 10% of the tumor cells exhibiting nuclear staining of GR at any intensity. + Cancers are those that have an H-score equal to or exceeding a predefined threshold (eg, 150) using the methods disclosed in the section entitled "Identifying GR Expression." C. Selection of Patient Population i. Cancer diagnosis

[0072] Cancer is characterized by the unregulated growth and / or spread of abnormal cells. Typically, a biopsy is taken and the cells or tissue from the biopsy are examined under a microscope to confirm suspicious symptoms. In some cases, further tests must be performed on the cells' proteins, DNA and RNA to verify the diagnosis. ii. Identification of checkpoint inhibitor-sensitive cancers

[0073] In some embodiments of the present invention, the method is used to treat patients with at least one checkpoint inhibitor-sensitive cancer.Checkpoint inhibitor-sensitive cancer is one that is responsive to checkpoint inhibitor (i.e., administration of one or more checkpoint inhibitors can reduce tumor burden or achieve beneficial or desired clinical results related to cancer improvement).For example, administration of checkpoint inhibitor can result in one or more of the following: reduction in the number of cancer cells; reduction in tumor size; inhibition (i.e., slowing down and / or stopping to some extent) of cancer cell invasion into peripheral organs; inhibition (i.e., slowing down and / or stopping to some extent) of tumor metastasis; inhibition (i.e., slowing down and / or stopping to some extent) of tumor growth; and / or alleviation to some extent of one or more of symptoms related to disorder; reduction in tumor size; reduction in symptoms caused by disease; increase in the quality of life of those who suffer from the disease, reduction in the dose of other medicines required for the treatment of the disease; delay in the progression of the disease; and / or prolongation of patient survival.

[0074] Checkpoint inhibitor-sensitive tumors often have high expression of ligands (e.g., PD-L1 or B7) that bind to checkpoint proteins PD-1 or CTLA-4, respectively. These interactions suppress the immune response to tumor cells. Non-limiting examples of checkpoint inhibitor-sensitive tumors include lung cancer, liver cancer, ovarian cancer, cervical cancer, skin cancer, bladder cancer, colon cancer, breast cancer, glioma, renal carcinoma, stomach cancer, esophageal cancer, oral squamous cell carcinoma, head and neck cancer, melanoma, sarcoma, renal cell tumor, hepatocellular tumor, glioblastoma, neuroendocrine tumor, bladder cancer, pancreatic cancer, gallbladder cancer, gastric cancer, prostate cancer, endometrial cancer, thyroid cancer and mesothelioma. iii. Identification of GR expression

[0075] In some embodiments, the checkpoint inhibitor-sensitive cancer also has GR + Cancer. GR expression in cancer cells can be examined using one or more of routine biochemical analysis. In some embodiments, GR expression is determined by detecting GR transcript expression using methods such as microarray and RT-PCR. In other embodiments, GR expression is determined by detecting protein expression using methods such as Western blot analysis and immunohistochemical staining. In still other embodiments, GR expression is determined by using a combination of these methods.

[0076] In a preferred embodiment, immunohistochemical staining is performed and the H-score method is used to quantify the expression of GR in cancer tissue. In one exemplary assay, formalin-fixed paraffin-embedded tumor tissue sections are deparaffinized and treated with an antigen retrieval solution to make the glucocorticoid receptor easily accessible to the anti-GR antibody. The anti-GR antibody is then incubated with the tissue section, and the antibody bound to GR on the tissue section is detected by the addition of a horse peroxidase (HRP)-conjugated secondary antibody that recognizes the anti-GR antibody. The HRP on the secondary antibody conjugate catalyzes a colorimetric reaction, which, upon contact with a suitable substrate, produces staining where GR is present. In one approach, the intensity levels of GR staining are represented by 0 for negative staining, 1+ for weak staining, 2+ for moderate staining, and 3+ for strong staining. See www.ihcworld.com / ihc_scoring.htm. GR at each intensity level is expressed as 0, 1+ for weak staining, 2+ for moderate staining, and 3+ for strong staining. + The percentage of cells is multiplied by the intensity level and the results of all intensity levels are summed to generate an H-score between 0 and 300. In one embodiment, cancer types with an H-score equal to or exceeding a pre-defined threshold are classified as GR. + In a preferred embodiment, the threshold is 150. + Cancers are those with at least 10% of tumor cells that exhibit GR staining at any intensity. Using an H-score threshold of 150, many cancer types exhibit GR staining. + See Table 1 below. As shown by published clinical trial results, most of these cancer types are also checkpoint inhibitor sensitive cancers. See www.clinicaltrial.gov. D. Checkpoint inhibitors

[0077] The methods disclosed herein use at least one SGRM in combination with at least one checkpoint inhibitor to treat cancer. In some embodiments, the checkpoint inhibitor is an antibody ("CIA") against at least one checkpoint protein. In some embodiments, the checkpoint inhibitor is a small molecule non-protein compound ("CIC") that blocks the immunosuppressive pathway induced by one or more checkpoint proteins. i. Checkpoint Inhibitor Antibodies ("CIAs")

[0078] In one embodiment, the method for treating cancer comprises administering SGRM in combination with checkpoint inhibitor antibody. Such antibody can block the immunosuppressive activity of checkpoint protein. Many such antibodies have already been shown to be effective in treating cancer (e.g., antibodies against PD-1, CTLA4 and PD-L1).

[0079] Anti-PD1 antibodies have been used to treat melanoma, non-small cell lung cancer, bladder cancer, prostate cancer, colorectal cancer, head and neck cancer, triple-negative breast cancer, leukemia, lymphoma and renal cell carcinoma. Exemplary anti-PD-1 antibodies include lambrolizumab (MK-3475, MERCK), nivolumab (BMS-936558, BRISTOL-MYERS SQUIBB), AMP-224 (MERCK) and pidilizumab (CT-011, CURETECH LTD.).

[0080] Anti-PD-L1 antibodies have been used to treat non-small cell lung cancer, melanoma, colorectal cancer, renal cell carcinoma, pancreatic cancer, gastric cancer, ovarian cancer, breast cancer and hematological malignancies. Exemplary anti-PD-L1 antibodies include MDX-1105 (MEDAREX), MEDI4736 (MEDIMMUNE), MPDL3280A (GENENTECH) and BMS-936559 (BRISTOL-MYERS SQUIBB).

[0081] Anti-CTLA4 antibodies are being used in clinical trials for the treatment of melanoma, prostate cancer, small cell lung cancer, and non-small cell lung cancer.An important feature of anti-CTLA4A is the kinetics of antitumor effect, with a lag phase of up to 6 months after initial treatment, which is necessary for physiological response.In some cases, tumors may actually increase in size after treatment begins before shrinkage is observed (Pardoll, 2012, Nature Reviews Cancer 12:252-264).Exemplary anti-CTLA4 CIAs include ipilimumab (Bristol-Myers Squibb) and tremelimumab (PFIZER).

[0082] CIA against other checkpoint proteins, such as LAG3, B7-H3, B7-H4 and TIM3, can also be used in combination with the SGRMs disclosed herein to treat cancer.

[0083] In particular, when the target checkpoint proteins, such as PD-1 and CTLA4, suppress immune responses through different signaling pathways, the CIA used in the present disclosure can be a combination of different CIAs. Thus, a combination of CIAs against any of the checkpoint proteins, or a single CIA against both checkpoint proteins, can provide an enhanced immune response. Creation of the CIA

[0084] CIA can be developed using methods well known in the art. For example, see Kohler and Milstein, Nature 256:495 (1975) and Coligan et al., (eds.), CURRENT PROTOCOLS IN IMMUNOLOGY, VOL.1, pages 2.5.1-2.6.7 (John Wiley & Sons 1991). Monoclonal antibodies can be obtained by injecting a mouse with a composition containing an antigen, such as a checkpoint protein or an epitope thereof, removing the spleen to obtain B lymphocytes, fusing the B lymphocytes with myeloma cells to produce hybridomas, cloning the hybridomas, selecting positive clones that produce antibodies against the antigen, culturing the clones that produce antibodies against the antigen, and isolating the antibodies from the hybridoma culture.

[0085] The monoclonal antibodies produced can be isolated and purified from the hybridoma culture by a variety of well-established techniques. Such isolation techniques include affinity chromatography using protein A sepharose, size-exclusion chromatography, and ion-exchange chromatography. See, for example, Coligan at pages 2.7.1-2.7.12 and pages 2.9.1-2.9.3. See also Baines et al., "Purification of Immunoglobulin G (IgG)," in METHODS IN MOLECULAR BIOLOGY, VOL. 10, pages 79-104 (The Humana Press, Inc. 1992). After initial generation of antibodies against checkpoint proteins, the antibodies can be sequenced and subsequently prepared by recombinant techniques. Humanization and chimerization of mouse antibodies and antibody fragments are well known to those skilled in the art. See, e.g., Leung et al., Hybridoma 13:469 (1994); U.S. Patent Application Publication No. 20140099254A1.

[0086] Human antibodies can be produced using transgenic mice that are genetically engineered to produce specific human antibodies in response to antigen challenge using checkpoint proteins. See Green et al., Nature Genet. 7:13 (1994); Lonberg et al., Nature 368:856 (1994). Human antibodies against checkpoint proteins can also be constructed by gene or chromosome transfection methods, phage display techniques, or in vitro activated B cells. See, e.g., McCafferty et al., 1990, Nature 348:552-553; U.S. Patent Nos. 5,567,610 and 5,229,275. CIA modifications

[0087] CIA can also be produced by introducing conservative modifications compared to existing CIA. For example, modified CIA can contain heavy and light chain variable regions and / or Fc regions that are homologous to the counterpart of the produced antibody. Modified CIA that can be used in the method disclosed herein must retain the desired functional properties that can block checkpoint signaling pathway.

[0088] CIAs can also be produced by altering protein modification sites. For example, the glycosylation site of an antibody can be altered to produce an antibody lacking glycosylation, and such modified CIAs typically have increased affinity of the antibody for the antigen. Antibodies can also be pegylated by reacting with polyethylene glycol (PEG) under conditions in which one or more PEG groups are attached to the antibody. Pegylation can increase the biological half-life of the antibody. Antibodies with such modifications can also be used in combination with the selective GR modulators disclosed herein, so long as they retain the desired functional property of blocking checkpoint pathways. ii. Small Molecule Non-Protein Checkpoint Inhibitor Compounds ("CICs")

[0089] In another embodiment, the method for treating cancer, such as checkpoint inhibitor-sensitive cancer, uses SGRM in combination with CIC.CIC is a small molecule non-protein compound that antagonizes the immunosuppressive function of checkpoint protein.Many CICs are known in the art, such as those disclosed in PCT publications, WO2015034820, WO20130144704 and WO2011082400.

[0090] CICs can also be identified using any of the many approaches in combinatorial library methods known in the art, for example, disclosed in EP 2360254. Combinatorial libraries include biological libraries; spatially addressable parallel solid-phase or solution-phase libraries; synthetic library methods that require deconvolution; "one bead one compound" library methods; and synthetic library methods that use affinity chromatography selection. While the biological library approach is limited to peptide libraries, the other four approaches are applicable to peptide, non-peptide oligomer or small molecule libraries of compounds (Lam, KS (1997) Anticancer Drug Des. 12: 145). iii. Evaluation of the functional properties of candidate checkpoint inhibitors

[0091] Many well-known assays can be used to assess whether a candidate (i.e., an antigen comprising a checkpoint protein, an antibody generated by immunizing an animal with an epitope of a checkpoint protein, or a test compound from a combinatorial library, as disclosed above) is a checkpoint inhibitor. Non-limiting exemplary assays include binding assays, such as enzyme-linked immunosorbent assays (ELISAs), radioimmunoassays (RIAs), fluorescence-activated cell sorting (FACS) analysis, cell-based assays, and in vivo assays. Binding assays

[0092] In one embodiment, the assay is a direct binding assay. The checkpoint protein can be coupled with a radioisotope or enzyme label so that binding of the checkpoint protein to the candidate can be determined by detecting the labeled checkpoint protein in the complex. For example, the checkpoint protein can be coupled with a radioisotope or enzyme label such that binding of the checkpoint protein to the candidate can be determined by detecting the labeled checkpoint protein in the complex. 125 I, 35 S, 14 C or 3 Candidates can be directly or indirectly labeled with H, and the radioisotope detected by direct counting of radioactive emission or by scintillation counting. Determining the ability of candidates to bind to their cognate checkpoint protein can be accomplished, for example, by measuring direct binding. Alternatively, checkpoint protein molecules can be enzymatically labeled, for example, with horseradish peroxidase, alkaline phosphatase, or luciferase, and binding of the candidate to the target checkpoint protein is determined by conversion of an appropriate substrate to product.

[0093] Enzyme-linked immunosorbent assays (ELISAs) are commonly used to assess the binding specificity of CIA candidates to target checkpoint proteins. In a typical assay, microtiter plates are coated with checkpoint proteins by coating overnight at 37°C with 5 μg / ml checkpoint protein. Serum samples containing candidate CIAs are diluted in PBS, 5% serum, 0.5% Tween-20 and incubated in the wells at room temperature for 1 h, followed by the addition of anti-human IgG Fc and IgG F(ab')-horseradish peroxidase in the same diluent. After 1 h at room temperature, enzyme activity is assessed by the addition of ABTS substrate (Sigma, St. Louis Mo.) and read at 415-490 nm after 30 min.

[0094] The binding kinetics (e.g., binding affinity) of the candidates can also be evaluated by standard assays known in the art, such as Biacore analysis (Biacore AB, Uppsala, Sweden). In one exemplary assay, purified recombinant human checkpoint proteins are covalently coupled to a CM5 chip (carboxymethyl dextran coated chip) via primary amines using standard amine coupling chemistry and a kit provided by Biacore. Binding is measured by flowing the candidates in HBS EP buffer (provided by Biacore AB) at a concentration of 267 nM at a flow rate of 50 μL / min. Checkpoint protein-candidate binding kinetics are followed for 3 minutes and dissociation kinetics are followed for 7 minutes. Binding and dissociation curves are fitted to a 1:1 Langmuir binding model using BIA evaluation software (Biacore AB). To minimize the effect of avidity in estimating the binding constant, only the initial segments of data corresponding to the association and dissociation phases are used for fitting. The K of the interaction is calculated by the following equation: D , K on and K. off A preferred checkpoint inhibitor is one that is 1×10 -7 They can bind to their target checkpoint proteins with a Kd of M or less.

[0095] For checkpoint proteins that block immune responses through binding to ligands, additional binding assays can be used to test the ability of candidates to block ligand binding to checkpoint proteins. In one exemplary assay, flow cytometry is used to test blocking of ligand (e.g., PD-L1) binding to checkpoint proteins (e.g., PD-1) expressed on transfected CHO cells. Various concentrations of candidates are added to suspensions of cells expressing the checkpoint protein and incubated at 4°C for 30 minutes. Unbound inhibitors are washed away, and FITC-labeled ligand protein is added to the tubes and incubated at 4°C for 30 minutes. FACS analysis is performed using a FACScan flow cytometer (Becton Dickinson, San Jose, Calif.). The mean fluorescence intensity (MFI) of the staining of cells indicates the amount of ligand bound to the checkpoint protein. A decrease in MFI in samples spiked with the candidate indicates that the candidate is effective in blocking ligand binding to the target checkpoint protein.

[0096] Homogeneous time-resolved fluorescence (HTRF) binding assays, e.g., as described in PCT publication WO 2015034820, may also be used to assay the ability of candidates to block checkpoint protein-ligand interactions. In one embodiment, the CIC used in the method has an IC of 10 pM or less, e.g., 0.01-10 pM, preferably 1 pM or less, e.g., 0.01-1 pM, as measured by a PD-1 / PD-L1 homogeneous time-resolved fluorescence (HTRF) binding assay. 50 levels, which may inhibit PD-1 / PD-L1 interaction. Cell-based assays

[0097] In another embodiment, the assay for assessing whether a candidate is a checkpoint inhibitor is a cell-based assay. The mixed lymphocyte reaction (MLR) assay, described in U.S. Pat. No. 8,008,449, is routinely used to measure T cell proliferation, IL-2 and / or IFN-γ production. In one exemplary assay, human CD4 + Human T cells are purified from PBMCs using T cell enrichment columns (R&D systems). Candidates are added to a number of T cell cultures at different concentrations. Cells are cultured at 37°C for 5 days and 100 μl of medium is taken from each culture for cytokine measurement. OptEIA ELISA kits (BD Biosciences) are used to measure the levels of IFN-γ and other cytokines. 3 The cells are labeled with H-thymidine, cultured for an additional 18 hours, and analyzed for cell proliferation. Results showing that cultures containing the candidate exhibit increased T cell proliferation, increased production of IL-2 and / or IFN-γ compared to controls indicate that the candidate is effective in blocking inhibition of checkpoint proteins of the T cell immune response. In vivo assay

[0098] In another embodiment, the assay used to evaluate whether a candidate is a checkpoint inhibitor is an in vivo assay. In one exemplary assay, 6-8 week old female AJ mice (Harlan Laboratories) are randomized into 6 groups by weight. On day 0, 2×10 mAbs dissolved in 200 μl of DMEM medium are added to the 100-well plate. 6 SA1 / N fibrosarcoma cells are implanted subcutaneously into the right flank of mice. Mice are treated with PBS vehicle or a given dose of candidate. Animals are dosed by intraperitoneal injection of approximately 200 μl of PBS containing candidate or vehicle on days 1, 4, 8, and 11. Mice are monitored twice weekly for tumor growth for approximately 6 weeks. Tumors are measured three-dimensionally (height x width x length) using electronic calipers and tumor volumes are calculated. Tumors are measured at tumor endpoint (1500 mm 3Mice are euthanized when the tumor volume reaches 1500 mm or when the mice show more than 15% weight loss. Tumor growth delay in the candidate treatment group compared to the control group, or tumor endpoint volume (1500 mm) is evaluated. 3 Results showing an increase in the mean time to reach IL-1 ) indicate that the candidate has inhibitory activity against cancer growth. E. Glucocorticoid receptor modulators (GRMs)

[0099] The combination therapy for treating cancer disclosed herein also involves at least one selective glucocorticoid receptor modulator in combination with at least one checkpoint inhibitor for treating cancer, such as checkpoint inhibitor-sensitive cancer. Exemplary GRM classes and specific members of such classes are provided herein. However, those skilled in the art will readily recognize other related or unrelated SGRMs that can be used in the treatment methods described herein. 1. GRM with a steroid skeleton

[0100] In some embodiments, an effective amount of SGRM with steroid skeleton is administered to a subject for cancer treatment.Steroidal GRM can be obtained by modifying the basic structure of glucocorticoid agonist, i.e., changing the shape of steroid skeleton.The structure of cortisol can be modified in various ways.The two most well-known classes of structural modification of cortisol steroid skeleton to create GRA include modification of 11-β hydroxyl group and modification of 17-β side chain (see, for example, Lefebvre, J.Steroid Biochem.33:557-563,1989).

[0101] Examples of steroidal GR antagonists include androgenic steroid compounds such as those described in U.S. Pat. No. 5,929,058, as well as those described in U.S. Pat. Nos. 4,296,206; 4,386,085; 4,447,424; 4,477,445; 4,519,946; 4,540,686; and 4,54 No. 7,493; No. 4,634,695; No. 4,634,696; No. 4,753,932; No. 4,774,236; No. 4,808,710; No. 4,81 No. 4,327; No. 4,829,060; No. 4,861,763; No. 4,912,097; No. 4,921,638; No. 4,943,566; No. 4,95 No. 4,490; No. 4,978,657; No. 5,006,518; No. 5,043,332; No. 5,064,822; No. 5,073,548; No. 5,08 No. 9,488; No. 5,089,635; No. 5,093,507; No. 5,095,010; No. 5,095,129; No. 5,132,299; No. 5,16 Nos. 6,146; 5,166,199; 5,173,405; 5,276,023; 5,380,839; 5,348,729; 5,426,102; 5,439,913; 5,616,458, 5,696,127 and 6,303,591. Such steroidal GR antagonists include cortexolone, dexamethasone-oxetanone, 19-nordeoxycorticosterone, 19-norprogesterone, cortisol-21-mesylate; dexamethasone-21-mesylate, 11β-(4-dimethylaminoethoxyphenyl)-17α-propynyl-17β-hydroxy-4,9-estradien-3-one (RU009) and (17α)-17-hydroxy-19-(4-methylphenyl)androsta-4,9(11)-dien-3-one (RU044).

[0102] Other examples of steroidal antiglucocorticoids are disclosed in Van Kampen et al. (2002) Eur. J. Pharmacol. 457(2-3):207, WO 03 / 043640, EP 0683172B1 and EP 0763541B1, each of which is incorporated herein by reference. EP 0763541B1 and Hoyberg et al., Int'l J. of Neuro-psychopharmacology, 5:Supp.1, S148 (2002) disclose the compound (11β,17β)-11-(1,3-benzodioxol-5-yl)-17-hydroxy-17-(1-propynyl)estra-4,9-dien-3-one (ORG34517), which in one embodiment is administered in an amount effective to treat an ACTH-secreting tumor in a subject. 2. Removal or replacement of 11-β hydroxy groups

[0103] In one embodiment of the present invention, glucocorticoid antagonists with modified steroid skeletons, including removal or replacement of 11-β hydroxyl groups, are administered. This class includes natural GRMs, including cortexolone, progesterone and testosterone derivatives, as well as synthetic compositions, such as mifepristone (Lefebvre et al., supra). A preferred embodiment of the present invention includes all 11-β aryl steroid skeleton derivatives, because in some cases, these compounds may lack progesterone receptor (PR) binding activity (Agarwal, FEBS 217:221-226, 1987). In another embodiment, 11-β phenyl-aminodimethyl steroid skeleton derivatives, which are effective antiglucocorticoid and antiprogesterone agents, are administered. These compositions can act as reversibly binding steroid receptor antagonists. For example, when a steroid receptor is bound to an 11-β phenyl-aminodimethyl steroid, the steroid receptor may be maintained in a conformation in which it cannot bind its natural ligand (e.g., cortisol in the case of GR) (Cadepond, 1997, supra).

[0104] Synthetic 11-beta phenyl-amino dimethyl steroids include mifepristone, also known as RU486, i.e. 17-β-hydroxy-11-β-(4-dimethyl-aminophenyl) 17-α-(1-propynyl)estra-4,9-dien-3-one). Mifepristone has been shown to be a potent antagonist of both the progesterone receptor and the glucocorticoid (GR) receptor. Thus, in some embodiments, the GRM administered to treat ACTH-secreting tumors is mifepristone or a salt, tautomer or derivative thereof. However, in other embodiments, administration of mifepristone is specifically excluded as a GRM for the treatment of ACTH-secreting tumors.

[0105] Another 11-β phenyl-aminodimethyl steroid shown to have GR antagonist activity is the dimethylaminoethoxyphenyl derivative RU009 (RU39.009), 11-β-(4-dimethyl-aminoethoxyphenyl)-17-α-(propynyl-17-β-hydroxy-4,9-estradien-3-one) (see Bocquel, J. Steroid Biochem. Molec. Biol. 45:205-215, 1993). Another GR antagonist related to RU486 is RU044 (RU43.044) 17-β-hydroxy-17-α-19-(4-methyl-phenyl)-androsta-4,9(11)-dien-3-one) (Bocquel, 1993, supra). Teutsch, Steroids 38:651-665, 1981; see also U.S. Pat. Nos. 4,386,085 and 4,912,097.

[0106] One embodiment includes compositions that are irreversible antiglucocorticoids. Such compounds include alpha-keto-methanesulfonate derivatives of cortisol, including cortisol-21-mesylate (4-pregnene-11-β,17-α,21-triol-3,20-dione-21-methanesulfonate and dexamethasone-21-mesylate (16-methyl-9-α-fluoro-1,4-pregnadiene-11β,17-α,21-triol-3,20-dione-21-methanesulfonate). See Simons, J. Steroid Biochem. 24:25-32, 1986; Mercier, J. Steroid Biochem. 25:11-20, 1986; U.S. Patent No. 4,296,206. 3.17-beta Side Group Modification

[0107] Steroidal antiglucocorticoids, which can be obtained by various structural modifications of the 17-β side chain, are also used in the methods of the invention. This class includes synthetic antiglucocorticoids, such as dexamethasone-oxetanone, the various 17,21-acetonide and 17-beta-carboxamide derivatives of dexamethasone (Lefebvre, 1989, supra; Rousseau, Nature 279:158-160, 1979). 4. Other steroid backbone modifications

[0108] GRMs used in various embodiments of the present invention include any steroid backbone modification that inhibits a biological response resulting from GR-agonist interaction. The steroid backbone antagonist can be any natural or synthetic variation of cortisol, such as adrenal steroids lacking the C-19 methyl group, such as 19-nordeoxycorticosterone and 19-norprogesterone (Wynne, Endocrinology 107:1278-1280, 1980).

[0109] In general, the 11-β side chain substituent, and especially the size of that substituent, can play an important role in determining the degree of antiglucocorticoid activity of a steroid. Substitutions in the A ring of the steroid backbone can also be important. For example, a 17-hydroxypropenyl side chain can in some cases reduce antiglucocorticoid activity compared to 17-propynyl side chain-containing compounds.

[0110] Additional glucocorticoid receptor antagonists known in the art and suitable for the practice of the present invention include 21-hydroxy-6,19-oxidoprogesterone (see Vicent, Mol. Pharm. 52:749-753, 1997), Org31710 (see Mizutani, J Steroid Biochem Mol Biol. 42(7):695-704, 1992), RU43044, RU40555 (see Kim, J Steroid Biochem Mol. Biol. 67(3):213-22, 1998), and RU28362. 5. Nonsteroidal anti-glucocorticoid receptor modulators

[0111] Exemplary classes of nonsteroidal glucocorticoid receptor modulators (GRMs) and specific members of such classes that can be used in the methods disclosed herein are provided herein. However, those skilled in the art will readily recognize other related or unrelated glucocorticoid receptor modulators that can be used in the treatment methods described herein. These include synthetic mimetics and analogs of proteins, including partially peptidic, pseudopeptidic and nonpeptidic molecular entities. For example, oligomeric peptidomimetics useful in the present invention include (α-β-unsaturated) peptide sulfonamides, N-substituted glycine derivatives, oligocarbamates, oligourea peptidomimetics, hydrazinopeptides, oligosulfones, etc. (see, for example, Amour, Int. J. Pept. Protein Res. 43: 297-304, 1994; de Bont, Bioorganic & Medicinal Chem. 4: 667-672, 1996).

[0112] Examples of nonsteroidal GR modulators include the GR antagonist compounds disclosed in U.S. Pat. Nos. 5,696,127; 6,570,020; and 6,051,573; the GR antagonist compounds disclosed in U.S. Patent Application 20020077356; the glucocorticoid receptor antagonists disclosed in Bradley et al., J. Med. Chem. 45, 2417-2424 (2002), such as 4α(S)-benzyl-2(R)-chloroethyl ester. and 4α(S)-benzyl-2(R)-prop-1-ynyl-1,2,3,4,4α,9,10,10α(R)-octahydro-phenanthrene-2,7-diol ("CP394531") and 4α(S)-benzyl-2(R)-prop-1-ynyl-1,2,3,4,4α,9,10,10α(R)-octahydro-phenanthrene-2,7-diol ("CP409069"); as well as compounds disclosed in PCT International Application No. WO 96 / 19458, which describes non-steroidal compounds that are high affinity and highly selective antagonists for steroid receptors (e.g., 6-substituted-1,2-dihydro-N-protected-quinolines).

[0113] For additional compounds which may be utilized in the methods of the present invention, as well as methods of identifying and making such compounds, see U.S. Pat. Nos. 4,296,206 (see above); 4,386,085 (see above); 4,447,424; 4,477,445; 4,519,946; 4,540,686; 4,547,493; 34,695; 4,634,696; 4,753,932; 4,774,236; 4,808,710; 4,814,327; 4,829,060; No. 4,861,763; No. 4,912,097; No. 4,921,638; No. 4,943,566; No. 4,954,490; No. 4,978,657; No. 5,006,51 No. 8; No. 5,043,332; No. 5,064,822; No. 5,073,548; No. 5,089,488; No. 5,089,635; No. 5,093,507; No. 5,09 5,010; 5,095,129; 5,132,299; 5,166,146; 5,166,199; 5,173,405; 5,276,023; See, for example, Nos. 5,380,839; 5,348,729; 5,426,102; 5,439,913; and 5,616,458; as well as WO 96 / 19458 (which describes nonsteroidal compounds, such as 6-substituted-1,2-dihydro N-1 protected quinolines, that are high affinity, highly selective modulators (antagonists) of steroid receptors).

[0114] In some embodiments, the combination therapy for treating cancer involves a non-steroidal GRM having a fused azadecalin backbone, a heteroaryl ketone fused azadecalin backbone, or an octahydro fused azadecalin backbone.

[0115] Exemplary GRMs having a fused azadecalin backbone include those described in U.S. Patent Nos. 7,928,237 and 8,461,172, which are incorporated herein by reference in their entirety. In some cases, the GRM having a fused azadecalin backbone has the following structure: [ka] (In the formula, L 1 and L 2 is a member independently selected from a bond and unsubstituted alkylene; R 1 is an unsubstituted alkyl, an unsubstituted heteroalkyl, an unsubstituted heterocycloalkyl, -OR 1A , -NR 1C R 1D , -C(O)NR 1C R 1D and -C(O)OR 1A is a member selected from R 1A is a member selected from hydrogen, unsubstituted alkyl, and unsubstituted heteroalkyl; R 1C and R 1D is a member independently selected from unsubstituted alkyl and unsubstituted heteroalkyl; Here, R 1C and R 1D are optionally linked to form an unsubstituted ring together with the nitrogen to which they are attached, said ring optionally containing an additional ring nitrogen; R 2 is the expression: [ka] (In the formula, R 2G is a member selected from hydrogen, halogen, unsubstituted alkyl, unsubstituted heteroalkyl, unsubstituted cycloalkyl, unsubstituted heterocycloalkyl, -CN, and -CF3; J is phenyl; t is an integer from 0 to 5; X is -S(O2)- having; R 5 is 1 to 5 R 5A phenyl optionally substituted with a group, where R 5A is hydrogen, halogen, -OR 5A1 , -S(O2)NR 5A2 R 5A3 , -CN and unsubstituted alkyl, R 5A1 is a member selected from hydrogen and unsubstituted alkyl; R 5A2 and R 5A3 are members independently selected from hydrogen and unsubstituted alkyl. or its salts and isomers.

[0116] Compounds containing a fused azadecalin scaffold can be prepared as described in U.S. Pat. No. 7,928,237. For example, a fused azadecalin scaffold can be prepared as described in Scheme 1, where R 5 , R 1A , R 1C , R 1D , L 2 and R 2 is as defined above in the compounds of the present invention. In Scheme 1, L is 2 -R 2 can be substituted with a suitable protecting group such as BOC or benzyl. The keto-ester 1 is directly converted to the enone 3 by a Robinson annelation reaction which involves treatment of 1 with a base (e.g., potassium or sodium alkoxide) in an alcoholic solvent (e.g., methanol, ethanol, or tert-butanol) followed by the addition of methyl vinyl ketone (MVK). Typically, the reaction is carried out at 0-250°C. [ka]

[0117] Exemplary GRMs having a heteroaryl ketone-fused azadecalin backbone include those described in U.S. Patent Application Publication No. 2014 / 0038926, which is incorporated herein by reference in its entirety. In some cases, the GRM having a heteroaryl ketone-fused azadecalin backbone has the following structure: [ka] (In the formula, R 1 is R 1a is a heteroaryl ring having 5-6 ring members and 1-4 heteroatoms each independently selected from the group consisting of N, O and S, optionally substituted with 1-4 groups each independently selected from Each R 1a are independently hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, -CN, N-oxide, C 3-8 Cycloalkyl and C 3-8 heterocycloalkyl; Ring J is selected from the group consisting of a cycloalkyl ring, a heterocycloalkyl ring, an aryl ring, and a heteroaryl ring, wherein the heterocycloalkyl ring and the heteroaryl ring have 5-6 ring members and 1-4 heteroatoms each independently selected from the group consisting of N, O, and S; Each R 2 are independently hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, C 1-6 Alkyl-C 1-6 Alkoxy, -CN, -OH, -NR 2a R 2b , -C(O)R 2a , -C(O)OR 2a , -C(O)NR2a R 2b , -SR 2a , -S(O)R 2a , -S(O)2R 2a , C 3-8 Cycloalkyl and C 3-8 heterocycloalkyl, wherein the heterocycloalkyl group is selected from the group consisting of 1 to 4 R 2c is optionally substituted with a group; Alternatively, two R's attached to the same carbon 2 the groups taken together form an oxo group (=O); Or, two R's 2 The groups taken together form a heterocycloalkyl ring having 5-6 ring members and 1-3 heteroatoms each independently selected from the group consisting of N, O and S, where the heterocycloalkyl ring is comprised of 1-3 R 2d optionally substituted with a group; R 2a and R 2b are each independently hydrogen and C 1-6 selected from the group consisting of alkyl; Each R 2c are independently hydrogen, halogen, hydroxy, C 1-6 Alkoxy, C 1-6 Haloalkoxy, -CN and -NR 2a R 2b selected from the group consisting of; Each R 2d are independently hydrogen and C 1-6 alkyl, or two R attached to the same ring atom 2d the groups taken together form (=O); R 3 is 1 to 4 R 3a selected from the group consisting of phenyl and pyridyl, each optionally substituted with a group; Each R 3a are independently hydrogen, halogen and C 1-6 haloalkyl; The subscript n is an integer from 0 to 3. or its salts and isomers.

[0118] Compounds containing a fused azadecalin scaffold can be prepared as described in Scheme 2. Scheme 2 [ka]

[0119] Exemplary GRMs having an octahydro-fused azadecalin backbone include those described in U.S. Provisional Patent Application No. 61 / 908,333, entitled Octahydro Fused Azadecalin Glucocorticoid Receptor Modulators, filed November 25, 2013, Attorney Docket No. 85178-887884 (007800US), which is incorporated herein by reference in its entirety. In some cases, the GRM having an octahydro-fused azadecalin backbone has the following structure: [ka] (In the formula, R 1 is R 1a is a heteroaryl ring having 5-6 ring members and 1-4 heteroatoms each independently selected from the group consisting of N, O and S, optionally substituted with 1-4 groups each independently selected from Each R 1a are independently hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, N-oxide and C 3-8 cycloalkyl; Ring J is selected from the group consisting of aryl and heteroaryl rings having 5-6 ring members and 1-4 heteroatoms each independently selected from the group consisting of N, O, and S; Each R2 are independently hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, C 1-6 Alkyl-C 1-6 Alkoxy, -CN, -OH, -NR 2a R 2b , -C(O)R 2a , -C(O)OR 2a , -C(O)NR 2a R 2b , -SR 2a , -S(O)R 2a , -S(O)2R 2a , C 3-8 Cycloalkyl and C having 1 to 3 heteroatoms each independently selected from the group consisting of N, O and S 3-8 selected from the group consisting of heterocycloalkyl; Alternatively, two R on adjacent ring atoms 2 The groups taken together form a heterocycloalkyl ring having 5-6 ring members and 1-3 heteroatoms each independently selected from the group consisting of N, O and S, where the heterocycloalkyl ring is comprised of 1-3 R 2c optionally substituted with a group; R 2a , R 2b and R 2c are each independently hydrogen and C 1-6 selected from the group consisting of alkyl; Each R 3a are independently halogen; The subscript n is an integer from 0 to 3. or its salts and isomers.

[0120] Compounds containing an octahydro-fused azadecalin scaffold can be prepared as described in Scheme 3. Scheme 3 [ka] F. Identification of Selective Glucocorticoid Receptor Modulators (SGRMs)

[0121] To determine whether a test compound is an SGRM, the compound is first subjected to an assay to measure its ability to bind to GR and inhibit GR-mediated activity, thereby determining whether the compound is a glucocorticoid receptor modulator.If the compound is confirmed to be a glucocorticoid receptor modulator, the compound is subjected to a specificity test to determine whether the compound can specifically bind to GR compared to non-GR proteins, such as estrogen receptor, progesterone receptor, androgen receptor or mineralocorticoid receptor.In one embodiment, the SGRM binds to GR with substantially higher affinity than non-GR proteins, for example at least 10-fold higher affinity.The SGRM can show 100-fold, 1000-fold or more selectivity for binding to GR compared to binding to non-GR proteins. i. Binding assay

[0122] The ability of a test compound to bind to the glucocorticoid receptor can be measured using various assays, for example, by screening for the ability of the test compound to compete with a glucocorticoid receptor ligand, such as dexamethasone, for binding to the glucocorticoid receptor. Those skilled in the art will recognize that there are many ways to perform such competitive binding assays. In some embodiments, the glucocorticoid receptor is pre-incubated with a labeled glucocorticoid receptor ligand and then contacted with the test compound. This type of competitive binding assay can also be referred to herein as a binding displacement assay. A decrease in the amount of labeled ligand bound to the glucocorticoid receptor indicates that the test compound binds to the glucocorticoid receptor. In some cases, the labeled ligand is a fluorescently labeled compound (e.g., a fluorescently labeled steroid or steroid analog). Alternatively, the binding of the test compound to the glucocorticoid receptor can be measured directly using a labeled test compound. This latter type of assay is referred to as a direct binding assay.

[0123] Both direct and competitive binding assays can be used in a variety of different formats. The formats can be similar to those used in immunoassays and receptor binding assays. For descriptions of various formats for binding assays, including competitive and direct binding assays, see Basic and Clinical Immunology 7th Edition (D. Stites and A. Terr ed.) 1991; Enzyme Immunoassay, E.T. Maggio, ed., CRC Press, Boca Raton, Florida (1980); and "Practice and Theory of Enzyme Immunoassays," P. Tijssen, Laboratory See Techniques in Biochemistry and Molecular Biology, Elsevier Science Publishers BV Amsterdam (1985), each of which is incorporated herein by reference.

[0124] In a solid-phase competitive binding assay, for example, a sample compound can compete with a labeled analyte for a specific binding site on a binding agent bound to a solid surface. In this type of format, the labeled analyte can be a glucocorticoid receptor ligand and the binding agent can be a glucocorticoid receptor bound to a solid phase. Alternatively, the labeled analyte can be a labeled glucocorticoid receptor and the binding agent can be a solid phase glucocorticoid receptor ligand. In a binding assay, the concentration of labeled analyte bound to the capture agent is inversely proportional to the competitive ability of the test compound.

[0125] Alternatively, competitive binding assays can be performed in liquid phase, and any of a variety of techniques known in the art can be used to separate bound labeled protein from unbound labeled protein.For example, several procedures have been developed to distinguish between bound and excess bound ligand, or between bound and excess unbound test compound.These include sedimentation in sucrose gradients, gel electrophoresis or gel isoelectric focusing to identify bound complexes; precipitation of receptor-ligand complexes with protamine sulfate or adsorption onto hydroxylapatite; and removal of unbound compounds or ligands by adsorption onto dextran-coated charcoal (DCC) or binding to immobilized antibodies.After separation, the amount of bound ligand or test compound is determined.

[0126] Alternatively, homogeneous binding assays can be performed that do not require a separation step. For example, the label on the glucocorticoid receptor can be altered by the binding of the glucocorticoid receptor to its ligand or test compound. This change in the labeled glucocorticoid receptor results in a decrease or increase in the signal emitted by the label, such that measurement of the label at the end of the binding assay allows detection or quantification of the bound glucocorticoid receptor. A wide variety of labels can be used. The components can be labeled by any one of several methods. Useful radioactive labels include: 3 H, 125 I, 35 S, 14 C or 32 P is incorporated. Useful non-radioactive labels include those that incorporate fluorophores, chemiluminescent agents, phosphorescent agents, electrochemiluminescent agents, and the like. Fluorescent agents are particularly useful in analytical techniques used to detect shifts in protein structure, such as fluorescence anisotropy and / or fluorescence polarization. The choice of label depends on the required sensitivity, ease of conjugation with the compound, stability requirements, and available instrumentation. For a review of various labeling or signal generating systems that may be used, see U.S. Pat. No. 4,391,904, which is incorporated herein by reference in its entirety for all purposes. The label may be directly or indirectly coupled to the desired components of the assay according to methods well known in the art. In some cases, the test compound is contacted with GR in the presence of a fluorescently labeled ligand (e.g., a steroid or steroid analog) with known affinity for GR, and the amount of bound and free labeled ligand is estimated by measuring the fluorescence polarization of the labeled ligand. ii. HepG2 tyrosine aminotransferase (TAT) assay

[0127] Compounds that exhibit the desired binding affinity to GR are tested for their activity in inhibiting GR-mediated activity. In one approach, compounds are subjected to a tyrosine aminotransferase assay (TAT) to evaluate the ability of the test compound to inhibit the induction of tyrosine aminotransferase activity by dexamethasone. See Example 1. GR modulators suitable for the methods disclosed herein have an IC of less than 10 micromolar. 50 (half maximal inhibitory concentration). iii. Cell-based assays

[0128] Cell-based assays involving whole cells or cell fractions containing glucocorticoid receptors can also be used to assay for binding of test compounds or modulation of glucocorticoid receptor activity.Exemplary cell types that can be used according to the methods of the present invention include, for example, any mammalian cell, such as white blood cells, such as neutrophils, monocytes, macrophages, eosinophils, basophils, mast cells and lymphocytes, such as T cells and B cells, leukemia cells, Burkitt's lymphoma cells, tumor cells (including mouse mammary tumor virus cells), endothelial cells, fibroblasts, cardiac cells, muscle cells, breast tumor cells, ovarian carcinomas, cervical carcinomas, glioblastomas, liver cells, kidney cells, neuronal cells and fungal cells (including yeast).The cells can be primary cells or tumor cells or other types of immortal cell lines.Of course, glucocorticoid receptors can be expressed in cells that do not express an endogenous form of glucocorticoid receptor.

[0129] In some cases, fragments and protein fusions of glucocorticoid receptor can be used for screening. When a molecule that competes for binding with glucocorticoid receptor ligand is desired, the GR fragment used is a fragment that can bind to the ligand (e.g., dexamethasone). Alternatively, any fragment of GR can be used as a target to identify molecules that bind to glucocorticoid receptor. Glucocorticoid receptor fragments can include, for example, any fragment of at least 20, 30, 40, 50 amino acids of glucocorticoid receptor, up to a protein that contains all but one amino acid.

[0130] In some embodiments, the reduction of signal transduction triggered by glucocorticoid receptor activation is used to identify glucocorticoid receptor modulators. The signal transduction activity of glucocorticoid receptor can be determined in many ways. For example, downstream molecular events can be monitored to determine signal transduction activity. Downstream events include the activity or expression that occurs as a result of stimulation of glucocorticoid receptor. Exemplary downstream events useful in functional evaluation of transcription activation and antagonism in non-altered cells include the upregulation of several glucocorticoid response element (GRE)-dependent genes (PEPCK, tyrosine aminotransferase, aromatase). In addition, certain cell types that are sensitive to GR activation can be used, such as osteocalcin expression in osteoblasts, which is downregulated by glucocorticoids; primary hepatocytes that show glucocorticoid-mediated upregulation of PEPCK and glucose-6-phosphate (G-6-Pase). GRE-mediated gene expression has also been demonstrated in transfected cell lines using well-known GRE-regulated sequences (e.g., mouse mammary tumor virus promoter (MMTV) transfected upstream of a reporter gene construct). Examples of useful reporter gene constructs include luciferase (luc), alkaline phosphatase (ALP) and chloramphenicol acetyltransferase (CAT). Functional evaluation of transcriptional repression can be performed in cell lines such as monocytes or human dermal fibroblasts. Useful functional assays include IL-1beta-stimulated IL-6 expression; downregulation of collagenase, cyclooxygenase-2 and various chemokines (MCP-1, RANTES); LPS-stimulated cytokine release, e.g., TNFα; or measuring the expression of genes controlled by NFkB or AP-1 transcription factors in transfected cell lines.

[0131] Compounds tested in whole cell assays can also be tested in cytotoxicity assays. Cytotoxicity assays are used to determine the extent to which the sensed effect is due to non-glucocorticoid receptor-binding cellular effects. In an exemplary embodiment, the cytotoxicity assay involves contacting constitutively active cells with the test compound. Any reduction in cellular activity indicates a cytotoxic effect. iv. Further Assays

[0132] Further illustrative of the many assays that can be used to identify compositions for use in the methods of the invention are assays based on glucocorticoid activity in vivo. For example, an assay can be used that evaluates the ability of a putative GR modulator to inhibit the incorporation of 3H-thymidine into DNA in cells stimulated by glucocorticoids. Alternatively, a putative GR modulator can complete the binding of 3H-dexamethasone to hepatoma tissue culture GR (see, e.g., Choi et al., Steroids 2002). 57:313-318, 1992). As another example, the ability of a putative GR modulator to block nuclear binding of the 3H-dexamethasone-GR complex can be used (Alexandrova et al., J. Steroid Biochem. Mol. Biol. 41:723-725, 1992). Kinetic assays that can distinguish glucocorticoid agonists and modulators by receptor binding kinetics can also be used to further identify putative GR modulators (as described in Jones, Biochem J. 204:721-729, 1982).

[0133] In another example, to identify anti-glucocorticoid activity, the assay described in Daune, Molec. Pharm. 13:948-955, 1977; and U.S. Patent No. 4,386,085 can be used. Briefly, thymocytes from adrenalectomized rats are incubated with various concentrations of the test compound (putative GR modulator) in nutrient medium containing dexamethasone. 3H-uridine is added to the cell culture, which is further incubated, and the extent of incorporation of the radiolabel into the polynucleotide is measured. 3 H-uridine reduces the amount of H-uridine, so a GR modulator would antagonize this effect. v. Selectivity

[0134] The GR modulators selected above are then subjected to a selectivity assay to determine whether they are SGRMs. Typically, the selectivity assay involves testing the compounds that bind to glucocorticoid receptors in vitro for the degree of binding to non-glucocorticoid receptor proteins. The selectivity assay can be performed in vitro or in a cell-based system, as described above. Binding can be tested against any suitable non-glucocorticoid receptor protein, including antibodies, receptors, enzymes, and the like. In an exemplary embodiment, the non-glucocorticoid receptor binding protein is a cell surface receptor or a nuclear receptor. In another exemplary embodiment, the non-glucocorticoid receptor protein is a steroid receptor, such as an estrogen receptor, a progesterone receptor, an androgen receptor, or a mineralocorticoid receptor.

[0135] The selectivity of an antagonist for GR compared to MR can be measured using various assays known to those skilled in the art. For example, a particular antagonist can be identified by measuring the ability of the antagonist to bind to GR compared to MR (see, for example, U.S. Patent Nos. 5,606,021; 5,696,127; 5,215,916; and 5,071,773). Such analysis can be performed using direct binding assays or by evaluating competitive binding to purified GR or MR in the presence of a known ligand. In an exemplary assay, cells stably expressing high levels of glucocorticoid receptor or mineralocorticoid receptor (see, for example, U.S. Patent No. 5,606,021) are used as a source of purified receptor. The affinity of the ligand to the receptor is then measured directly. GR modulators that show at least 10-fold, 100-fold, and often 1000-fold higher affinity to GR compared to MR are then selected for use in the methods of the present invention.

[0136] Selectivity assays may also include assaying for the ability to inhibit GR-mediated activity but not MR-mediated activity. One way to identify such selective GR modulators is to use transfection assays to evaluate the ability of antagonists to prevent the activation of reporter constructs (see, for example, Bocquel et al., J.Steroid Biochem Molec.Biol.45:205-215,1993; U.S. Patent Nos. 5,606,021 and 5,929,058). In an exemplary transfection assay, an expression plasmid encoding a receptor and a reporter plasmid containing a reporter gene linked to a receptor-specific control element are co-transfected into suitable receptor-negative host cells. The transfected host cells are then cultured in the presence and absence of hormones (e.g., cortisol or its analogs) that can activate hormone-responsive promoter / enhancer elements of the reporter plasmid. The transfected cultured host cells are then monitored for induction (i.e., presence) of the product of the reporter gene sequence. Finally, the expression and / or steroid binding capacity of the hormone receptor protein (encoded by the receptor DNA sequence on the expression plasmid and produced in the transfected cultured host cells) is measured by determining the activity of the reporter gene in the presence and absence of antagonist. The antagonist activity of the compound can be determined by comparing it with known antagonists of GR and MR receptors (see, for example, U.S. Patent No. 5,696,127). Efficacy is then reported as the maximum response rate observed for each compound compared with a reference antagonist compound. GR modulators that show at least 100-fold, and often 1000-fold or more activity against GR compared with MR, PR or AR are then selected for use in the methods disclosed herein.

[0137] An exemplary SGRM that can be used in the methods disclosed herein has the following structure: [ka] and CORT125134, (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, having the formula:

[0138] Another exemplary SGRM that can be used in the methods disclosed herein has the following structure: [ka] and CORT125281, having the formula ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone. g. Pharmaceutical Compositions and Administration i. Preparation

[0139] In some embodiments, the present invention provides a pharmaceutical composition comprising a pharma- ceutically acceptable excipient, an SGRM, a pharma- ceutically acceptable excipient, and a CIC or a CIA.

[0140] Any of the SGRMs, CICs or CIAs disclosed herein can be formulated and administered with a pharma- ceutically acceptable carrier. Such compositions can contain one or a combination of (e.g., two or more different) antibodies or immunoconjugates or bispecific molecules of the present invention. For example, pharmaceutical compositions of the present invention can contain a combination of antibodies (or immunoconjugates or bispecifics) that bind to different epitopes on the target antigen or have complementary activities.

[0141] The pharmaceutical composition of the present invention can be prepared in a wide variety of oral, parenteral and topical dosage forms.Preferably, oral preparations for SGRMs and CICs include tablets, pills, powders, dragees, capsules, liquids, lozenges, gels, syrups, slurries, suspensions, etc., suitable for oral ingestion by patients.The pharmaceutical composition can also be administered by injection, i.e., intravenously, intramuscularly, intradermally, subcutaneously, intraduodenally, or intraperitoneally.The pharmaceutical composition can also be administered by inhalation, for example, intranasally.In addition, non-steroidal SGRMs can be administered transdermally.Therefore, the present invention also provides pharmaceutical compositions comprising a pharma-ceutically acceptable carrier or excipient and an SGRM or checkpoint inhibitor.Depending on the route of administration, the active compound can be coated in a material to protect the compound from the action of enzymes, acids, and other natural conditions that may inactivate the compound.

[0142] The pharmaceutical compositions of the present invention may be provided as salts, which may be formed with many acids, including but not limited to hydrochloric acid, sulfuric acid, acetic acid, lactic acid, tartaric acid, malic acid, succinic acid, and the like. Salts tend to be more soluble in aqueous or other polar solvents than the corresponding free base forms. In other cases, the preparation may be a lyophilized powder in 1 mM-50 mM histidine, 0.1%-2% sucrose, 2%-7% mannitol, pH range 4.5-5.5, and mixed with a buffer prior to use.

[0143] When preparing pharmaceutical compositions from SGRM or CIC or CIA, pharma- ceutically acceptable carriers can be solid or liquid. Solid form preparations include powders, tablets, pills, capsules, cachets, suppositories and dispersible granules. A solid carrier can be one or more substances that can also act as diluents, flavoring agents, binders, preservatives, tablet disintegrating agents or encapsulating materials. Details regarding techniques for formulation and administration are fully described in the scientific and patent literature, for example in Remington's Pharmaceutical Sciences, Maack Publishing, Inc., 19 ... Co., Easton PA ("Remington's"), latest edition.

[0144] In powders, the carrier is a finely divided solid, which is in a mixture with the finely divided active ingredient. In tablets, the active ingredient is mixed with a carrier having the necessary binding properties in suitable proportions and compacted in the shape and size desired.

[0145] The powders and tablets preferably contain 5% or 10% to 70% of the active compound. Suitable carriers are magnesium carbonate, magnesium stearate, talc, sugar, lactose, pectin, dextrin, starch, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose, low melting wax, cocoa butter, and the like. The term "preparation" is intended to include formulations of the active compound with encapsulating materials as carriers to provide a capsule in which the active ingredient is surrounded by and bound to the carrier, with or without other carriers. Similarly, cachets and lozenges are included. Tablets, powders, capsules, pills, cachets, and lozenges can be used as solid dosage forms suitable for oral administration.

[0146] Suitable solid excipients are carbohydrate or protein fillers, including, but not limited to, sugars (including lactose, sucrose, mannitol or sorbitol); starches from corn, wheat, rice, potato or other plants; celluloses (such as methylcellulose, hydroxypropylmethyl-cellulose or sodium carboxymethylcellulose); and gums (including arabic and tragacanth); and proteins (such as gelatin and collagen).If desired, disintegrants or solubilizers (such as cross-linked polyvinylpyrrolidone, agar, alginic acid or its salt (such as sodium alginate)) can be added.

[0147] Dragee cores are provided with suitable coatings (e.g., concentrated sugar solutions), which may also include gum arabic, talc, polyvinylpyrrolidone, carbopol gel, polyethylene glycol and / or titanium dioxide, lacquer solutions, and suitable organic solvents or solvent mixtures. Dyes or pigments may be added to the tablets or dragee coatings for product identification or to characterize the amount of active compound (i.e., dosage). The pharmaceutical preparations of the present invention may also be used orally, for example, using push-fit capsules made of gelatin, as well as sealed soft capsules made of gelatin and a coating agent (e.g., glycerol or sorbitol). Push-fit capsules may contain the GR modulator mixed with a filler or binder (e.g., lactose or starch), a lubricant (e.g., talc or magnesium stearate), and optionally a stabilizer. In soft capsules, the GR modulator compound may be dissolved or suspended in a suitable liquid (e.g., fatty oils, liquid paraffin, or liquid polyethylene glycol) with or without stabilizers.

[0148] Liquid form preparations include solutions, suspensions and emulsions, for example, water or water / propylene glycol solutions. For parenteral injection, liquid preparations can be formulated in a solution of aqueous polyethylene glycol. Pharmaceutical compositions suitable for injection use include sterile aqueous solutions (where water soluble) or dispersions, and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions. In all cases, the composition must be sterile and must be fluid to the extent that it may be easily delivered by syringe. It must be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms, such as bacteria and fungi. The carrier can be a solvent or dispersion medium, including, for example, water, ethanol, polyol (for example, glycerol, propylene glycol, and liquid polyethylene glycol, and the like), and suitable mixtures thereof. Suitable fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants. Protection against the action of microorganisms can be achieved by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, ascorbic acid, thimerosal, and the like. In many cases, it is preferable to include isotonic agents, such as sugars, polyalcohols, such as mannitol, sorbitol, sodium chloride in the composition. Prolonged absorption of the injectable compositions can be brought about by including in the composition an agent that delays absorption, such as aluminum monostearate and gelatin.

[0149] Sterile injection solution can be prepared by incorporating the checkpoint inhibitor, for example, CIA, in the appropriate solvent containing one or a combination of the above-listed components in the required amount, followed by filtration sterilization.Generally, dispersion is prepared by incorporating active compound in a sterile vehicle containing a basic dispersion medium and other components required from the above-listed ones.For the preparation of sterile powder for the preparation of sterile injection solution, the preferred preparation method is vacuum drying and freeze-drying, which produces a powder of active ingredient + any additional desired ingredients from the solution that has been previously sterilized and filtered.

[0150] Aqueous solutions suitable for oral use can be prepared by dissolving the active ingredient in water and adding suitable colorants, flavors, stabilizers and thickening agents as desired. Aqueous suspensions suitable for oral use can be prepared by dissolving the active ingredient in finely divided water, optionally with the addition of suitable colorants, flavors, stabilizers and thickening agents. Aqueous suspensions suitable for oral use can be prepared by dissolving the active ingredient in finely divided water, optionally with the addition of suitable colorants, flavors, stabilizers and thickening agents as desired ... The aqueous suspension may be prepared by dispersing in water with a condensation product of ethylene oxide with an ester (e.g., polyoxyethylene sorbitol mono-oleate) or a condensation product of ethylene oxide with a partial ester derived from a fatty acid and a hexitol anhydride (e.g., polyoxyethylene sorbitan mono-oleate). The aqueous suspension may also contain one or more preservatives (e.g., ethyl p-hydroxybenzoate or n-propyl p-hydroxybenzoate), one or more coloring agents, one or more flavoring agents, and one or more sweetening agents (e.g., sucrose, aspartame, or saccharin). The formulation may be adjusted for osmolality.

[0151] Also includes the preparation in solid form that is intended to be converted into the preparation in liquid form for oral administration immediately before use.Such liquid forms include solution, suspension and emulsion.These preparations can contain, in addition to active ingredient, coloring agent, flavoring agent, stabilizer, buffer, artificial and natural sweetener, dispersing agent, thickener, solubilizer, etc.

[0152] Oily suspensions can be formulated by suspending the SGRM or checkpoint inhibitor in a vegetable oil (e.g., peanut oil, olive oil, sesame oil or coconut oil) or mineral oil (e.g., liquid paraffin); or mixtures thereof. The oily suspensions can contain a thickening agent (e.g., beeswax, hard paraffin or cetyl alcohol). Sweeteners (e.g., glycerol, sorbitol or sucrose) can be added to provide a palatable oral preparation. These preparations can be preserved by adding an antioxidant such as ascorbic acid. For an example of an injectable oily vehicle, see Minto, J. Pharmacol. Exp. Ther. 281:93-102, 1997. The pharmaceutical preparations of the present invention can also be in the form of oil-in-water emulsions. The oily phase can be a vegetable oil or mineral oil as described above or mixtures thereof. Suitable emulsifying agents include naturally occurring gums (e.g., gum arabic and gum tragacanth), naturally occurring phosphatides (e.g., soybean lecithin), esters or partial esters derived from fatty acids and hexitol anhydrides (e.g., sorbitan mono-oleate) and the condensation products of these partial esters with ethylene oxide (e.g., polyoxyethylene sorbitan mono-oleate). Emulsions may also contain sweetening and flavoring agents, as in the formulation of syrups and elixirs. Such formulations may also contain a demulcent, preservative or coloring agent.

[0153] The pharmaceutical compositions of the present invention may be delivered transdermally by topical routes formulated as applicator sticks, solutions, suspensions, emulsions, gels, creams, ointments, pastes, jellies, paints, powders and aerosols.

[0154] Lipid-based drug delivery systems include lipid solutions, lipid emulsions, lipid dispersions, self-emulsifying drug delivery systems (SEDDS) and self-microemulsifying drug delivery systems (SMEDDS). In particular, SEDDS and SMEDDS are isotropic mixtures of lipids, surfactants and co-surfactants that can spontaneously disperse in aqueous media and form fine emulsions (SEDDS) or microemulsions (SMEDDS). The lipids useful in the formulation of the present invention include any natural or synthetic lipids, including but not limited to sesame seed oil, olive oil, castor oil, peanut oil, fatty acid esters, glycerol esters, Labrafil®, Labrasol®, Cremophor®, Solutol®, Tween®, Capryol®, Capmul®, Captex® and Peceol®.

[0155] The pharmaceutical composition of the present invention can also be delivered as microspheres for slow release in the body. For example, microspheres can be administered via intradermal injection of drug-containing microspheres that slowly release subcutaneously (see Rao, J.Biomater Sci.Polym.Ed.7:623-645,1995); as biodegradable injectable gel formulations (see, e.g., Gao, Pharm.Res.12:857-863,1995); or as microspheres for oral administration (see, e.g., Eyles, J.Pharm.Pharmacol.49:669-674,1997). Both transdermal and intradermal routes provide constant delivery over a period of weeks or months.

[0156] The pharmaceutical compositions of the present invention may be provided as salts, which may be formed with many acids, including but not limited to hydrochloric acid, sulfuric acid, acetic acid, lactic acid, tartaric acid, malic acid, succinic acid, and the like. Salts tend to be more soluble in aqueous or other protic solvents than the corresponding free base forms. In other cases, the preparation may be a lyophilized powder in 1 mM-50 mM histidine, 0.1%-2% sucrose, 2%-7% mannitol, pH range 4.5-5.5, and mixed with a buffer prior to use.

[0157] In another embodiment, the pharmaceutical composition of the present invention can be delivered by using liposomes, which fuse with cell membrane or are endocytosed, i.e., endocytosis is brought about by using ligands attached to the liposomes or ligands attached directly to oligonucleotides that bind to cell surface membrane protein receptors.In particular, liposomes can be used to focus the delivery of GR modulators to target cells in vivo, when the liposome surface has ligands specific to target cells or is otherwise preferentially directed to specific organs (see, for example, Al-Muhammed, J.Microencapsul.13:293-306,1996; Chonn, Curr.Opin.Biotechnol.6:698-708,1995; Ostro, Am.J.Hosp.Pharm.46:1576-1587,1989).

[0158] The pharmaceutical composition of the present disclosure may also contain one or more adjuvants suitable for the indicated route of administration.When administered orally, the compound used in the method disclosed herein, such as CIC or SGRM, can be mixed with lactose, sucrose, starch powder, cellulose ester of alkanoic acid, cellulose alkyl ester, talc, stearic acid, magnesium stearate, magnesium oxide, sodium and calcium salts of phosphoric acid and sulfate, gelatin, gum acacia, sodium alginate, polyvinylpyrrolidone and / or polyvinyl alcohol, and then tableted or encapsulated for convenient administration.Such capsules or tablets can be provided with a dispersion of active compound in hydroxypropylmethylcellulose, and therefore can contain a controlled release formulation. ii. Dosage

[0159] Pharmaceutical compositions suitable for administration include compositions containing active ingredients (e.g., checkpoint inhibitors and SGRMs) in an amount effective to achieve the intended purpose. Dosage regimens are adjusted to provide the optimum desired response (e.g., therapeutic response). For example, a single bolus can be administered, multiple divided doses can be administered over time, or the dose can be proportionally reduced or increased as indicated by the exigencies of the therapeutic situation. For ease of administration and uniformity of dosage, it is particularly advantageous to formulate parenteral compositions in unit dosage form. Unit dosage form as used herein refers to a physically discrete unit suitable as a unitary dosage for the subject to be treated; each unit contains a predetermined amount of active compound calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier. The specifications of the unit dosage forms of the present invention are determined by and depend on (a) the unique characteristics of the active compound and the particular therapeutic effect to be achieved, and (b) the limitations inherent in the technique of compounding such compounds for the treatment of susceptibility in an individual.

[0160] The actual dosage level of the active ingredient in the pharmaceutical composition of the present invention may be varied to obtain an amount of the active ingredient that is effective for achieving the desired therapeutic response for a particular patient, composition and mode of administration and is not toxic to the patient. The dosage level selected will depend directly on a variety of factors, including the activity of the particular composition of the present invention or its ester, salt or amide used, the pharmacokinetics of the composition, the route of administration, the time of administration, the excretion rate of the particular compound used, the duration of treatment, other drugs, compounds and / or materials used in combination with the particular composition used, the age, sex, weight, symptoms, general health and past medical history of the patient being treated, and similar factors well known in the medical field.

[0161] The pharmaceutical composition of the present invention is preferably in unit dosage form.In such form, preparation is divided into unit doses containing suitable amount of active ingredient SGRM or checkpoint inhibitor.Unit dosage form can be a packaged preparation containing a discrete amount of preparation, for example, tablet, capsule and powder packaged in vial or ampoule.Also, unit dosage form can be capsule, tablet, cachet or lozenge itself, or it can be any suitable number of these in packaged form.

[0162] The dosing regimen for the checkpoint inhibitor or SGRM will also take into account pharmacokinetic parameters well known in the art, i.e., rate of absorption, bioavailability, metabolism, clearance, etc. (see, e.g., Hidalgo-Aragones (1996) J. Steroid Biochem. Mol. Biol. 58:611-617; Groning (1996) Pharmazie 51:337-341; Fotherby (1996) Contraception 54:59-69; Johnson (1995) J. Pharm. Sci. 84:1144-1146; Rohatagi (1995) Pharmazie 50:610-613; Brophy (1983) Eur. J. Clin. Pharmacol. 24:103-108; Remington's, latest edition, supra). Current technology allows the clinician to determine the dosing regimen for each individual patient, SGRM and checkpoint inhibitor, based on the disease or condition being treated.

[0163] The amount of active ingredient in a unit dose preparation may vary or be adjusted from 0.1 mg to 6000 mg, more typically from 1.0 mg to 3000 mg, and most typically from 10 mg to 300 mg. Suitable dosages include about 1 mg, 5, 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 200, 300, 400, 500, 600, 700, 800, 900, 1000, 1100, 1200, 1300, 1400, 1500, 1600, 1700, 1800, 1900, or 2000 mg, depending on the particular application and the potency of the active ingredient. The composition may also contain other compatible therapeutic agents, if desired. Single or multiple administrations of the composition may be administered, depending on the dosage and frequency required and tolerated by the patient.

[0164] A composition comprising a checkpoint inhibitor, when administered alone or in combination with an SGRM, should provide a sufficient amount of the active ingredient (i.e., checkpoint inhibitor) to effectively treat cancer, e.g., an amount capable of reducing tumor burden or achieving other beneficial or desired clinical outcomes associated with cancer improvement. See section h, "Evaluation of Improvement in Reduction of Tumor Burden." Thus, dosing regimens can vary widely, but can be routinely determined using standard methods. In some cases, the pharmaceutical composition comprises a CIC, and administration of a daily dose of about 1 to 2000 mg, preferably about 10 to about 1000 mg, and most preferably about 250 to 500 mg of the active ingredient can be suitable. The daily dose can be administered in one to four doses per day. Other dosing schedules include cycles of administration once a week and once every two days.

[0165] In some cases, the pharmaceutical composition includes a CIA, and the dosage (of the active ingredient) is in the range of about 0.0001-100 mg / kg body weight of the host, more usually 0.01-20 mg / kg body weight of the host. For example, the dosage can be in the range of 0.3 mg / kg body weight, 1 mg / kg body weight, 3 mg / kg body weight, 5 mg / kg body weight, 10 mg / kg body weight, or 0.1-20 mg / kg. Exemplary treatment regimes involve administration once a day, once a week, twice a week, once every two weeks, once every three weeks, once every four weeks, once a month, once every three months, or once every three to six months. In some cases, the treatment involves administering the CIA according to one of the above dosage regimens for a first period of time and another of the above dosage regimens for a second period of time. In some cases, the treatment is discontinued for a period of time before the same or a different dosage regimen is resumed. For example, a patient may be on a CIA dosing regimen for two weeks, rest for one week, and then on for another two weeks, etc. Preferred dosing regimens for CIA of the present invention include 0.1 mg / kg body weight, 0.3 mg / kg body weight, 2 mg / kg body weight, 3 mg / kg body weight or 10 mg / kg by intravenous administration, with the antibody being administered using one of the following dosing schedules: (i) six doses every four weeks, then every three months; (ii) every three weeks; (iii) one dose of 3 mg / kg body weight, followed by 1 mg / kg body weight every three weeks.

[0166] In some methods, two or more CIAs with different binding specificities are co-administered, in which case the dosage of each antibody administered is within the ranges indicated. The CIAs are usually administered multiple times. The intervals between single doses can be, for example, weekly, monthly, every three months, or yearly. The intervals can also be irregular, as indicated by measuring blood levels of antibodies against the target antigen in the patient. In some methods, the dosage is adjusted to achieve a plasma antibody concentration of about 1-1000 μg / ml, and in some methods about 25-300 μg / ml.

[0167] The composition comprising the SGRM used in the combination therapy should provide a sufficient amount of active agent to effectively enhance the activity of the checkpoint inhibitor in the treatment of cancer, for example, in an amount that, when combined with a therapeutic amount of a checkpoint inhibitor, can reduce tumor burden or otherwise significantly alleviate associated cancer symptoms or achieve a better beneficial or desired clinical outcome compared to administration of the same therapeutic amount of the checkpoint inhibitor without the SGRM. In some cases, the composition provides the SGRM in an amount that sensitizes the tumor to the checkpoint inhibitor (i.e., shows a reduction in tumor burden or shows other relevant clinical benefits that would not otherwise appear if the tumor were treated with only the checkpoint inhibitor). Methods for evaluating the reduction in tumor burden and other beneficial outcomes are disclosed in section h "Evaluating Improvement in Tumor Load Reduction" below. Thus, the administration regimen can vary widely depending on the route of administration and the type of cancer to be treated, but can be routinely determined using standard methods. In some embodiments, the SGRM is administered once a month, twice a month, three times a month, every other week, once a week, twice a week, three times a week, four times a week, five times a week, six times a week, every other day, once a day, twice a day, three times a day, or more frequently. In some cases, a daily oral dosage of a pharmaceutical composition comprising a SGRM may be used in the methods disclosed herein and ranges from about 1 to about 2000 mg / day (mg / day). In some embodiments, the daily dosage is about 10 to 1000 mg / day, 50 to 500 mg / day, 100 to 300 mg / day. Lower dosages may be used, particularly when administering a drug to a remote anatomical site, such as the cerebrospinal fluid (CSF) space, as opposed to oral administration, administration to the bloodstream, a body cavity, or the lumen of an organ. Substantially higher dosages may be used for local administration. Actual methods for preparing compositions for parenteral administration will be well known or apparent to those skilled in the art and are described in more detail in publications such as Remington's, supra.See also Nieman, In "Receptor Mediated Antisteroid Action," Agarwal et al., eds., De Gruyter, New York (1987). In some embodiments, the SGRM is CORT125281. In some embodiments, the SGRM is CORT125134.

[0168] After the pharmaceutical composition containing the SGRM or checkpoint inhibitor of the invention has been formulated in an acceptable carrier, it can be placed in a suitable container and labeled for treatment of an indicated condition. For administration of the SGRM or checkpoint inhibitor, such labeling would include, for example, instructions regarding the amount, frequency and method of administration. iii. Combination therapy

[0169] The methods disclosed herein involve combination therapy in which both an SGRM and a checkpoint inhibitor are administered to a subject suffering from a tumor burden, which in some cases is due to the presence of a checkpoint inhibitor-sensitive cancer. In some embodiments, the combination therapy involves sequential administration of the checkpoint inhibitor and the SGRM in any order for all or part of the treatment period.

[0170] In some cases, the SGRM and the checkpoint inhibitor are administered according to the same or different dosing regimen. In some cases, the SGRM is administered according to a scheduled regimen, and the checkpoint inhibitor is administered intermittently. In some cases, the checkpoint inhibitor is administered according to a scheduled regimen, and the SGRM is administered intermittently. In some cases, both the SGRM and the checkpoint inhibitor are administered intermittently. In some embodiments, the SGRM is administered daily, and the checkpoint inhibitor, for example, the checkpoint inhibitor, is administered weekly or every other week.

[0171] In some cases, the SGRM and checkpoint inhibitor are administered sequentially or concomitantly continuously for a period ranging from about 1 day to about 1 week, from about 2 weeks to about 4 weeks, from about 1 month to about 2 months, from about 2 months to about 4 months, from about 4 months to about 6 months, from about 6 months to about 8 months, from about 8 months to about 1 year, from about 1 year to about 2 years, or from about 2 years to about 4 years or more, such as once or twice per month, three times per month, every other week, once per week, twice per week, three times per week, four times per week, five times per week, six times per week, every other day, once per day, twice per day, three times per day, or more frequently.

[0172] In some embodiments, the combination therapy includes co-administration of an SGRM and a checkpoint inhibitor. In some embodiments, co-administration of a checkpoint inhibitor and an SGRM involves administering the two agents simultaneously or near simultaneously (e.g., within about 1, 5, 10, 15, 20, or 30 minutes of each other). iv. Duration

[0173] The duration of treatment with SGRM and checkpoint inhibitor to reduce tumor burden may vary depending on the severity of symptoms in the subject and the subject's response to the combined therapy. In some embodiments, SGRM and / or checkpoint inhibitor may be administered for about 1 week to 104 weeks (2 years), more typically about 6 weeks to 80 weeks, and most typically about 9 to 60 weeks. Suitable administration periods also include 5 to 9 weeks, 5 to 16 weeks, 9 to 16 weeks, 16 to 24 weeks, 16 to 32 weeks, 24 to 32 weeks, 24 to 48 weeks, 32 to 48 weeks, 32 to 52 weeks, 48 ​​to 52 weeks, 48 ​​to 64 weeks, 52 to 64 weeks, 52 to 72 weeks, 64 to 72 weeks, 64 to 80 weeks, 72 to 80 weeks, 72 to 88 weeks, 80 to 88 weeks, 80 to 96 weeks, 88 to 96 weeks, and 96 to 104 weeks. Suitable administration periods also include 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 24, 25, 30, 32, 35, 40, 45, 48, 50, 52, 55, 60, 64, 65, 68, 70, 72, 75, 80, 85, 88, 90, 95, 96, 100 and 104 weeks. In general, administration of SGRM and / or checkpoint inhibitor should be continued until desired clinically significant reduction or improvement is observed. Treatment with SGRM and checkpoint inhibitor according to the present invention can continue for 2 years or more. In some embodiments, the duration of SGRM administration is the same as the duration of checkpoint inhibitor. In some embodiments, the duration of SGRM administration is shorter or longer than that of checkpoint inhibitor.

[0174] In some embodiments, administration of the SGRM or checkpoint inhibitor is not continuous, but may be interrupted for one or more periods followed by resumption of administration for one or more periods. Suitable periods for interruption of administration include 5-9 weeks, 5-16 weeks, 9-16 weeks, 16-24 weeks, 16-32 weeks, 24-32 weeks, 24-48 weeks, 32-48 weeks, 32-52 weeks, 48-52 weeks, 48-64 weeks, 52-64 weeks, 52-72 weeks, 64-72 weeks, 64-80 weeks, 72-80 weeks, 72-88 weeks, 80-88 weeks, 80-96 weeks, 88-96 weeks, and 96-100 weeks. Suitable periods of time for which administration is suspended also include 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 24, 25, 30, 32, 35, 40, 45, 48, 50, 52, 55, 60, 64, 65, 68, 70, 72, 75, 80, 85, 88, 90, 95, 96, and 100 weeks. h. Assessment of improvement in reducing tumor burden

[0175] The combination therapies disclosed herein may reduce tumor burden. Methods for measuring these responses are described, for example, in the Response Evaluation Criteria in As set forth in the Clinical Trials for Solid Tumors ("RECIST") guidelines, these are well known to those of skill in the art of cancer treatment.

[0176] In one approach, tumor burden is measured by assaying the expression of tumor-specific gene markers.This approach is particularly useful for metastatic tumors or tumors that are not easily measurable, such as bone marrow cancer.Tumor-specific gene markers are proteins or other molecules that are unique to cancer cells or that are significantly more abundant in cancer cells compared to non-cancerous cells.See, for example, WO2006104474. Non-limiting examples of tumor-specific gene markers include alpha-fetoprotein (AFP) for liver cancer, beta-2-microglobulin (B2M) for multiple myeloma, beta-human chorionic gonadotropin (beta-hCG) for choriocarcinoma and germ cell tumors, CA19-9 for pancreatic, gallbladder, bile duct and gastric cancer, CA-125 and HE4 for ovarian cancer, carcinoembryonic antigen (CEA) for colorectal cancer, chromogranin A (CgA) for neuroendocrine tumors, fibrin / fibrinogen for bladder cancer, prostate-specific antigen (PSA) for prostate cancer, and thyroglobulin for thyroid cancer. See http: / / www.cancer.gov / about-cancer / diagnosis-staging / diagnosis / tumor-markers-fact-sheet.

[0177] Methods for measuring the expression level of tumor-specific gene markers are well known. In some embodiments, the mRNA of gene markers is isolated from blood samples or tumor tissues, and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) is carried out to quantify the expression of gene markers. In some embodiments, Western blot or immunohistochemistry analysis is carried out to evaluate the protein expression of tumor-specific gene markers. Typically, the level of tumor-specific gene markers is measured in multiple samples taken over time of the combination therapy of the present invention, and a decrease in the level correlates with a decrease in tumor burden.

[0178] In another approach, the reduction of tumor burden by the combination therapy disclosed herein is shown by the reduction of tumor size or the reduction of the amount of cancer in the body.The measurement of tumor size is typically achieved by imaging-based techniques.For example, computed tomography (CT) scan can provide accurate and reliable anatomical information about the progression of disease, not just the shrinkage or growth of tumor, by identifying either the growth of existing lesions or the occurrence of new lesions or tumor metastasis.

[0179] In another approach, the reduction in tumor burden can be assessed by functional and metabolic imaging techniques. These techniques can provide an early assessment of therapeutic response by observing changes in perfusion, oxygenation and metabolism. For example, 18 F-FDG PET uses radiolabeled glucose analog molecules to assess tissue metabolism. Tumors typically have elevated glucose uptake, and changes in values ​​corresponding to decreased tumor tissue metabolism indicate decreased tumor burden. A similar imaging technique is disclosed in Kang et al., Korean J.Radiol.(2012)13(4)371-390.

[0180] Patients receiving the combination therapy disclosed herein may show various degrees of tumor burden reduction. In some cases, patients may show complete response (CR), also referred to as "disease-free survival (NED)". CR means that all detectable tumors have disappeared as shown by examination, physical examination and scan. In some cases, patients receiving the combination therapy disclosed herein may experience partial response (PR), which roughly corresponds to at least a 50% reduction in total tumor volume, but there is evidence that some residual disease still remains. In some cases, the residual disease in deep partial response may actually be dead tumor or scar, so that a small number of patients classified as having PR may actually have CR. Also, many patients who show shrinkage during treatment may show further shrinkage and achieve CR with continued treatment. In some cases, patients receiving the combination therapy may experience minor response (MR), which generally means a small amount of shrinkage of total tumor volume of more than 25% and less than 50% (50% will be PR). In some cases, patients receiving combination therapy may show stable disease (SD), which means that the tumor remains about the same size, but may include a small amount of growth (typically less than 20 or 25%) or a small amount of shrinkage (anything less than PR, unless a minor remission occurs, in which case SD is typically defined as less than 25%).

[0181] The desired beneficial results or desired clinical results from combination therapy may include, for example, the reduction (i.e., slowing down and / or stopping) of cancer cell infiltration into peripheral organs; the inhibition (i.e., slowing down and / or stopping) of tumor metastasis; the increase in remission rate (RR); the increase in duration of response; the reduction to some extent of one or more symptoms associated with cancer; the reduction in the dose of other medicines required for the treatment of disease; the delay in the progression of disease; and / or the prolongation of patient survival and / or improvement of quality of life.The methods for evaluating these effects are well known and / or are disclosed, for example, in http: / / cancerguide.org / endpoints.html and the RECIST guidelines cited above.

[0182] All patents, patent applications and publications discussed herein are hereby incorporated by reference in their entirety. EXAMPLES

[0183] Example 1. HepG2 Tyrosine Aminotransferase (TAT) Assay In the following protocol, an assay is described to measure the induction of TAT by dexamethasone in HepG2 cells (human liver hepatocellular carcinoma cell line; ECACC, UK). HepG2 cells are cultured at 37 °C, 5% / 95% (v / v) CO2 / air using MEME medium supplemented with 10% (v / v) fetal bovine serum; 2 mM L-glutamine and 1% (v / v) NEAA. HepG2 cells are then counted and cultured at 0.125 x 10 cells in RPMI 1640 without phenol red, 10% (v / v) charcoal-stripped FBS, 2 mM L-glutamine. 6 The cells are adjusted to give a density of 10,000 cells / ml and 200 μl at 25,000 cells / well are plated into 96-well sterile tissue culture microtiter plates and incubated at 37° C., 5% CO 2 for 24 hours.

[0184] Growth medium is then removed and replaced with assay medium {RPMI 1640 without phenol red, 2 mM L-glutamine + 10 μM forskolin}. Test compounds are then screened against a 100 nM dexamethasone challenge. Compounds are then serially half-log diluted in 100% (v / v) dimethylsulfoxide from a 10 mM stock. An 8-point half-log dilution curve is then generated, followed by a 1:100 dilution in assay medium to determine 10x final assay compound concentrations, resulting in final assay compound concentrations ranging from 10 to 0.003 μM in 0.1% (v / v) dimethylsulfoxide.

[0185] Test compounds were pre-incubated with cells in microtiter plates for 30 min at 37° C., 5 / 95 (v / v) CO2 / air, followed by addition of 100 nM dexamethasone, followed by a 20-h period to allow optimal TAT induction.

[0186] HepG2 cells are then lysed with 30 μl of cell lysis buffer containing a protease inhibitor cocktail for 15 minutes at 4° C. Then 155 μl of substrate mixture containing 5.4 mM tyrosine sodium salt, 10.8 mM α-ketoglutarate and 0.06 mM pyridoxal 5′ phosphate in 0.1 M potassium phosphate buffer (pH 7.4) can be added. After 2 hours of incubation at 37° C., the reaction can be stopped by adding 15 μl of 10 M aqueous potassium hydroxide solution, and the plate can be incubated for an additional 30 minutes at 37° C. TAT activity products can be measured by absorbance at λ340 nm.

[0187] The IC was calculated by plotting % inhibition (normalized to 100 nM dexamethasone TAT stimulation) against compound concentration and fitting the data to a four-parameter logistic equation. 50 Assuming that the antagonist is a competitive inhibitor with respect to dexamethasone, the IC value can be calculated using the Cheng and Prusoff equation. 50 The values ​​may be converted to Ki (equilibrium dissociation constant). Example 2. Quantification of GR expression in cancer types

[0188] Formalin-fixed, paraffin-embedded (FFPE) tumor tissue sections, 4–5 μm thick, were cut onto positively charged slides (Fisher ProbeOn Plus™, Thermo Fisher Scientific), baked at 65°C (dry heat) for 1 h within 1 week prior to use, deparaffinized in four changes of 100% xylene, and rehydrated through a graded ethanol series (100%, 70%, 30%) to distilled water.

[0189] Citra Plus Target Retrieval System was used with a commercially available steamer (Black and Decker HS1000 model steamer; Black and Decker, Baltimore, MD, USA) as a heat source. Prepared slides are incubated at 98°C for 20 min in IHC staining solution (BioGenex [Cat #: HK080-9K], Fremont, CA, USA). After cooling for 5 min, automated staining is performed using the TechMate™ 500 or 1000 automated IHC staining platform (Roche Diagnostics, Oro Valley, AZ, USA) and WorkMate™ software, version 3.96. For all reagent exchanges, including antibody incubations, detection steps up to counterstaining and washes along the way, this automated platform uses a capillary gap process 29. All procedures are performed at room temperature (25°C). After a 15 min incubation with protein serum block (QualTek Proprietary), slides are incubated for 1 h with anti-GR antibody clone D8H2 (Cell Signaling Technology [#3660S]) at a concentration of 1:1,750 in primary antibody diluent (QualTek Proprietary).

[0190] A rabbit Polink2+HRP (horseradish peroxidase) reagent kit (Golden Bridge International [GBI], Cat #: D39-110, Los Angeles, CA, USA), which is biotin-independent and reduces the possibility of background or nonspecific staining from endogenous biotin, is used for primary antibody detection. The steps included a 25-minute incubation with rabbit Polink2+ secondary, a 7.5-minute peroxidase blocking step (adding 3% USP H2O2 with approximately 0.02% v / v Tween-20), a 25-minute incubation with rabbit Polink2+HRP conjugated polymer, and a 15-minute incubation with GBI (Cat #: C09-100) 3,3'-diaminobenzidine (DAB) chromogen. Between all incubation steps, slides are washed thoroughly with Tris-buffered saline containing 0.02% v / v Tween®-20 surfactant (TBST) (Thermo Fisher Scientific). Slides are counterstained with hematoxylin for 1 min, rinsed in distilled water, dehydrated off the platform in an ethanol series (95%, 100%) and four changes of 100% xylene, and permanently sealed with coverslips (Cytoseal™ XYL mounting media, Thermo Fisher Scientific).

[0191] A percentage score is used to semiquantitatively assess tumor GR expression in samples with at least 100 viable invasive carcinoma cells. Nuclear staining intensity is reported based on the H-score method, with 0 for negative staining, 1+ for weak staining, 2+ for moderate staining, and 3+ for strong staining. H-scores are calculated by multiplying the staining intensity by the percentage of cells with that intensity. For example, a sample with 20% of cells with weak staining and 2% of cells with moderate staining would have an H-score of 24 [(20×1)+(2×2)=24]. In this assay, GR positivity is defined as 10% nuclear staining of tumor cells at any intensity. A certified pathologist scores nuclear tumor staining in the total area of ​​available viable tissue sections; areas of cytoplasmic or interstitial staining, in situ carcinoma, necrosis, or areas of obviously poorly fixed tissue are not evaluated. Example 3. Reduction of Tumor Growth Using Combination Therapy of CORT125134 and Anti-PD-1

[0192] A suspension of mouse MC38 cancer cells was injected subcutaneously into the left flank of 5-6 week-old immunocompetent female mice (C57BL / 6) at 1 million cells / mouse. 3 Tumors were allowed to grow until they reached a volume of 100 mg / kg. Mice were then divided into three groups with 10 mice per group. Group I received anti-PD-1 vehicle (PBS, 10 ml / kg) intraperitoneally (ip) twice weekly and CORT125134 vehicle (10% DMSO, 0.1% Tween 80 and 89.9% HPMC (0.5%), 10 ml / kg) orally (po) daily. Group II received mouse anti-PD-1 antibody (clone RPM1-14, 10 mg / kg) intraperitoneally (ip) twice weekly. Group III received mouse anti-PD-1 antibody (clone RPM1-14, 10 mg / kg) intraperitoneally (ip) twice weekly and CORT125134 (a SGRM) (30 mg / kg) orally (orally) daily.

[0193] The longest (L) and shortest (S) diameters of the tumor were measured three times a week using electronic calipers and calculated according to the ellipsoidal spheroid formula: S 2Tumor volumes were calculated using x L x (0.5). Tumor growth data is shown in Figure 1, where the mean tumor volume compared to the mean pre-dose tumor volume for each group of mice is plotted against the number of days of tumor growth since the start of treatment. The results show that the combination of anti-PD-1 and CORT125134 is superior to both the anti-PD-1 and vehicle groups in reducing tumor growth. Example 4. Reduction of Tumor Growth Using Combination Therapy of CORT125281 and Anti-PD-1

[0194] A suspension of mouse A20 cancer cells was injected subcutaneously into the left flank of 5-6 week-old immunocompetent female mice (C57BL / 6) at 500,000 cells / mouse. 3 Tumors were allowed to grow until they reached a volume of 1000 mg / kg. Mice were then divided into three groups with 10 mice per group. Group I received anti-PD-1 vehicle (PBS, 10 ml / kg) intraperitoneally (ip) twice weekly and CORT125281 vehicle (10% DMSO, 0.1% Tween 80 and 89.9% HPMC (0.5%), 10 ml / kg) orally (po) daily. Group II received mouse anti-PD-1 antibody (clone RPM1-14, 10 mg / kg) intraperitoneally (ip) twice weekly. Group III received mouse anti-PD-1 antibody (clone RPM1-14, 10 mg / kg) intraperitoneally (ip) twice weekly and CORT125281 (a SGRM) (30 mg / kg) orally (orally) daily.

[0195] The longest (L) and shortest (S) diameters of the tumor were measured three times a week using electronic calipers and calculated according to the ellipsoidal spheroid formula: S 2 Tumor volumes were calculated using x L x (0.5). Tumor growth data is shown in Figure 2, where the mean tumor volume for each group of mice is plotted against the number of days of tumor growth since the start of treatment. The results show that the combination of anti-PD-1 and CORT125281 is superior to both the anti-PD-1 and vehicle groups in reducing tumor growth. Example 5. Reduction of Tumor Growth Using Combination Therapy of CORT125134 or CORT125281 with Anti-CTLA4

[0196] A suspension of mouse CT26 cancer cells was injected subcutaneously into the left flank of 6- to 7-week-old immunocompetent female mice (C57BL / 6) at 500,000 cells / mouse. 3 Tumors were allowed to grow until they reached a volume of 100 mg / kg. Mice were then divided into three groups with 10 mice per group. Group I received anti-CTLA4 vehicle (PBS, 10 ml / kg) intraperitoneally (ip) twice weekly and CORT125134 vehicle (10% DMSO, 0.1% Tween 80 and 89.9% HPMC (0.5%), 10 ml / kg) orally (po) daily. Group II received mouse anti-CTLA4 antibody (clone 9D9, 10 mg / kg) intraperitoneally (ip) twice weekly. Group III received mouse anti-CTLA4 antibody (clone 9D9, 10 mg / kg) intraperitoneally (ip) twice weekly and CORT125134 (a SGRM) (30 mg / kg) orally (orally) daily. Group IV received mouse anti-CTLA4 antibody (clone 9D9, 10 mg / kg) intraperitoneally (ip) twice weekly and CORT125281 (a SGRM) (30 mg / kg) orally daily.

[0197] The longest (L) and shortest (S) diameters of the tumor were measured three times a week using electronic calipers and calculated according to the ellipsoidal spheroid formula: S 2 Tumor volumes were calculated using x L x (0.5). Tumor growth data is shown in Figure 3, where the mean tumor volume for each group is plotted against the number of days of tumor growth since the start of treatment. The results show that the combination of anti-CTLA4 with CORT125134 and the combination of anti-CTLA4 with CORT125281 are superior to both the anti-CTLA4 and vehicle groups in reducing tumor growth. Example 6. Treatment of Breast Cancer Patients with Combination Therapy

[0198] A patient suffering from breast cancer is treated with pembrolizumab at a dose of 3 mg / kg every 2 weeks and CORT125134 at a dose of 200 mg once a day for 8 weeks. Her tumor burden is monitored using enhanced magnetic resonance imaging before, during and after treatment. Imaging results show a gradual reduction in tumor size, with a reduction of more than 20% at the end of the treatment period.

Claims

[Claim 1] The method described in the specification.

Images