BT1718 for use in treating cancer

Abstract

To provide a method of treating cancer in a subject.SOLUTION: The present invention provides a method of treating certain cancers in a subject, comprising administering to the subject an effective amount of a drug conjugate comprising a high affinity binder of MT1-MMP, such as BT1718, or a pharmaceutically acceptable salt or composition thereof. The present invention also provides a composition comprising BT1718 or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, adjuvant, or vehicle.SELECTED DRAWING: None

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to U.S. Provisional Patent Application No. 62 / 753,005, filed October 30, 2018, U.S. Provisional Patent Application No. 62 / 788,391, filed January 4, 2019, and U.S. Provisional Patent Application No. 62 / 907,106, filed September 27, 2019, each of which is incorporated by reference in its entirety. [Background technology]

[0002] Membrane type I matrix metalloproteinase (MT1-MMP) protein is a member of the matrix metalloproteinase (MMP) family involved in tissue remodeling mediated by proteolysis of collagen and other extracellular matrix components [1]. Overexpression of MT1-MMP in many solid tumors (including the surrounding stroma) is associated with cell invasion and migration [2]. This in turn is associated with poor prognosis and shorter survival in NSCLC [3, 4], breast cancer [5, 6] and other solid malignancies [7, 8, 9].

[0003] Matrix metalloproteinase inhibitors have been investigated but have failed for various reasons, including poor pharmacology, metabolic stability, suboptimal bioavailability and / or DLT.

[10] Using an alternative approach, BT1718 was developed to exploit overexpression of MT1-MMP as a cell surface target for selective binding and enhanced delivery of the cytotoxic DM1 payload to tumors, rather than inhibiting its activity.

[0004] For this study, the target population is adult patients with advanced solid malignancies refractory to all reasonable standard of care (SOC) treatment options. Dose escalation is planned to be open to patients with all solid tumor types, with the potential for benefit not restricted solely to a limited subset of tumor types or limited MT1-MMP expression levels. However, phase IIa expansion at optimal dose / schedule will explore clinical signals in enriched populations with tumor types where MT1-MMP is known to be commonly overexpressed and where MT1-MMP overexpression was confirmed during prospective selection at enrollment. These tumor types will be identified based on further preclinical data, but are currently proposed to include tumors such as NSCLC, TNBC, ovarian, sarcoma, and tumor types expressing MT1. Non-small cell lung cancer

[0005] Lung cancer is the second most common cancer in the United Kingdom (UK) and the United States (USA) and is the leading cause of cancer death in both countries. Outcome is poor, with a 5-year survival of only 10%. Non-small cell lung cancer accounts for 87% of all lung cancers in the UK. A small proportion of patients have early stage disease amenable to curative surgery and many more may be suitable for definitive (chemo)radiotherapy, but cure rates are low.

[11]

[0006] In those with progressive or relapsed disease, treatment is palliative and prognosis is poor. A minority of patients (<10%) have tumors that may respond to treatment targeting mutations with epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) inhibitors. Chemotherapy has been the mainstay of treatment for the majority of patients, but has now been joined by immunotherapy. For patients suitable for first-line platinum doublet chemotherapy, the median overall survival (OS) is still only 11 months [12, 13]. Second-line chemotherapy such as docetaxel has moderate activity for patients who are fit enough to receive it, with objective response rates (ORR) ranging from 8 to 12% (docetaxel, pemetrexed) [14-18]. Antibodies and inhibitors targeting programmed cell death protein 1 (PD-1) checkpoint blockade have now replaced chemotherapy as second-line (now first-line) with ORRs of approximately 20% for second-line treatments (nivolumab, pembrolizumab, atezolizumab) and at least 30% when programmed death-ligand 1 (PD-L1) is selected [ 14 – 16 , 18 ]. There is no SOC beyond these agents.

[0007] In this context, promising new agents for NSCLC can therefore be expected to demonstrate a greater ORR than that seen with the comparator of second-line chemotherapy, aiming for 30% in selected populations.Membrane type I matrix metalloproteinases are highly expressed in NSCLC, and BT1718 has shown excellent activity in multiple in vivo NSCLC models.

[0008] Triple-negative breast cancer

[0009] Triple-negative breast cancer is characterized by tumors that do not overexpress estrogen receptors, progesterone receptors, or human epidermal growth factor receptor 2 (HER2). Triple-negative breast cancer may not respond to current targeted agents and also tends to behave more aggressively than other breast cancers, therefore, it represents a significant area of ​​unaddressed need. Approximately 10-15% of breast cancers diagnosed in the UK are classified as TNBC, which equates to >8000 cases per year

[19] .

[0010] In cases with progressive or relapsed disease, treatment consists of palliative chemotherapy, with the most commonly used first-line agents being taxanes or platinums. These have an ORR of 30–35%, but progression-free survival (PFS) is only approximately 4 months and OS is approximately 12 months [20–22]. There is no clear SOC for subsequent treatment, but approved third-line agents (e.g., capecitabine or eribulin) have an ORR of only 9–12%

[23] . Fourth-line response rates can be as low as 2%

[24] . New, more active agents are clearly needed. Programmed cell death protein 1 checkpoint inhibitors have shown sufficient promise to progress to phase III trials, but reported ORRs are <20%. CDX-011, an antibody-drug conjugate (ADC) against the glycoprotein NMB, has also shown some promise, with an ORR of 30% for NMB-selected tumors in a small phase I expansion

[25] . Another ADC, sacituzumab govitecan (IMMU 132), has shown similar activity targeting Trop-2.

[26] Interestingly, the ADC ado-trastuzumab emtansine (T-DM1) was first approved in third-line setting for HER2-positive breast cancer, but the ORR in this HER2-positive population was 31%.

[27]

[0011] Thus, similar to NSCLC, promising new agents for TNBC can be expected to demonstrate ORRs greater than those seen with chemotherapy comparators, aiming for 30% in select populations. Similar to NSCLC, MT1-MMP is highly expressed in TNBC, and BT1718 has shown excellent activity in multiple in vivo TNBC models.

[0012] sarcoma

[0013] Sarcomas arise in supportive or connective tissues and represent a wide range of distinct biological subtypes, with an overall incidence of approximately 6 per 100,000 cases per year. Although not a common cancer (1% of all cancers), sarcomas represent an area of ​​unmet need due to lack of drug efficacy / refractory nature in advanced disease [28, 29].

[0014] In those with progressive or relapsed disease, treatment consists of palliative chemotherapy (except for gastrointestinal stromal tumors (GIST), where KIT / platelet-derived growth factor (PDGF) receptor inhibitors are effective agents), with the most commonly used first-line agents being doxorubicin or ifosfamide. These have an ORR of only 10%-25%. Taxanes, trabectedin, and pazopanib are other agents available for certain subtypes of sarcoma, but all similarly have limited benefit. There is no clear SOC beyond first-line therapy. The European Organization for Research and Treatment Cancer (EORTC) Soft Tissue and Bone Sarcoma Group has established criteria for determining promising new sarcoma therapeutics in early phase trials

[30] . Stable disease (SD) is included in this criterion by defining a target PFS rate at 3 months, which is expected to be >20%, with 40% being the target. Available data show that MT1-MMP is more highly expressed in sarcomas than in any other cancer type, and have shown superior activity of BT1718 in an in vivo fibrosarcoma model. [Prior art documents] [Non-patent literature]

[0015] [Non-Patent Document 1] Pahwa, S., MJ Stawikowski, and GB Fields, Monitoring and Inhibiting MT1-MMP during Cancer Initiation and Progression. Cancers (Basel), 2014. 6(1): p. 416-35. [Non-Patent Document 2] Kessenbrock, K., V. Plaks, and Z. Werb, Matrix Metalloproteinases: Regulators of the Tumor Microenvironment. Cell, 2010. 141(1): p. 52-67. [Non-Patent Document 3] Wang, YZ, et al., MMP-14 overexpression correlates with poor prognosis in non-small cell lung cancer. Tumor Biol, 2014. 35(10): p. 9815-21. [Non-Patent Document 4] Zhou, H., et al., Significance of semaphorin-3A and MMP-14 protein expression in non-small cell lung cancer. Oncology Letters, 2014. 7(5): p. 1395-1400. [Non-Patent Document 5] Laudanski, P., et al., Increased serum level of membrane type 1-matrix metalloproteinase (MT1-MMP / MMP-14) in patients with breast cancer. Folia Histochem Cytobiol, 2010. 48(1): p. 101-3. [Non-Patent Document 6] Tetu, B., et al., The influence of MMP-14, TIMP-2 and MMP-2 expression on breast cancer prognosis. Breast Cancer Research, 2006. 8(3): p. R28-R28. [Brief description of the drawings]

[0016] [Figure 1] FIG. 1A shows the efficacy of BT1718 at 3 mg / kg twice weekly and at 10 mg / kg twice weekly in the LU-010-0046 (MT1-MMP high expression) non-small cell lung cancer (NSCLC) patient-derived xenograft (PDX) animal model.

[0017] FIG. 1B shows the efficacy of BT1718 at 3 mg / kg twice weekly and at 10 mg / kg twice weekly in the LU-010-0251 (MT1-MMP high expression) non-small cell lung cancer (NSCLC) patient-derived xenograft (PDX) animal model.

[0018] FIG. 1C shows the efficacy of BT1718 at 3 mg / kg twice weekly and at 10 mg / kg twice weekly in the LU-010-0486 (MT1-MMP low expression) non-small cell lung cancer (NSCLC) patient-derived xenograft (PDX) animal model.

[0019] [Diagram 2] Figure 2 is a graph showing the plasma drug concentration-time curves for BT1718 at doses of 0.015, 0.031, 0.061, 0.123, and 0.245 mg / kg / hour, which can also be expressed as 0.6, 1.2, 2.4, 4.8, and 9.6 mg / m2.

[0020] [Diagram 3] FIG. 3 is a schematic diagram of the study design.

[0021] [Figure 4] FIG. 4 shows an overview of the BT1718 clinical trial.

[0022] [Diagram 5] FIG. 5 shows an overview of Phase 1 and Phase 2a.

[0023] [Figure 6] FIG. 6 is a graph showing the patient's status during treatment with BT1718.

[0024] [Figure 7] FIG. 7A is a graph showing increased tumor cell death following BT1718 dosing as demonstrated by M30 and M65 assays for patient no. 36 / 011.

[0025] FIG. 7B is a graph showing increased tumor cell death following BT1718 dosing as demonstrated by M30 and M65 assays for patient no. 31 / 012.

[0026] FIG. 7C is a graph showing increased tumor cell death following BT1718 dosing as demonstrated by M30 and M65 assays for patient no. 16 / 013.

[0027] FIG. 7D is a graph showing increased tumor cell death following BT1718 dosing as demonstrated by M30 and M65 assays for patient no. 36 / 010.

[0028] FIG. 7E is a graph showing increased tumor cell death following BT1718 dosing as demonstrated by M30 and M65 assays for patient no. 31 / 014.

[0029] FIG. 7F is a graph showing increased tumor cell death following BT1718 dosing as demonstrated by M30 and M65 assays for patient no. 16 / 015.

[0030] [Figure 8]FIG. 8 shows the dose escalation scheme including dose levels and patient numbers.

[0031] [Figure 9A] FIG. 9A is a graph showing spaghetti plots of BT1718 plasma concentrations versus time since first dose in cycles 1 & 2 dosing at 0.6 mg / m2, 1.2 mg / m2, and 2.4 mg / m2.

[0032] [Figure 9B] FIG. 9B shows a spaghetti plot of BT1718 plasma concentrations versus time since first dose in cycles 1 & 2 with dosing at 4.8 mg / m2, 7.2 mg / m2, and 9.6 mg / m2.

[0033] [Figure 9C] FIG. 9C shows a spaghetti plot of BT1718 plasma concentrations versus time since first dose in cycles 1 & 2 with dosing at 15 mg / m2, 20 mg / m2, and 25 mg / m2.

[0034] [Figure 10A] FIG. 10A is a scatter plot of AUC versus dose of BT1718.

[0035] [Figure 10B] FIG. 10B is a scatter plot of Cmax versus dose of BT1718. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0036] 1.Compound Utilizing proprietary phage display and cyclic peptide technology (Bicycle® Technology), we identified high affinity binding peptides for membrane type 1-matrix metalloproteinase (MT1-MMP / MMP14). MT1-MMP (MT1) is a cell surface membrane protease that is found to be overexpressed in many solid tumors and is commonly involved in tissue remodeling. Overexpression of MT1 has been associated with cancer aggressiveness and poor prognosis. Attempts to target the proteolytic activity of MT1 and other MMPs in cancer have failed in clinical trials, largely due to toxicity caused by insufficient selectivity, but MT1-MMP remains an attractive cancer target for targeted cytotoxic delivery approaches.

[0037] 10 Posttranslationally Cyclized on a Thiol-Reactive Scaffold 11 ~10 13 Using a diverse selection phage library containing species-specific unique peptide sequences, we identified small (1.5-2 kDa) constrained bicyclic peptidic binders (Bicycles) to the hemopexin domain of MT1. Initial binders were subjected to affinity maturation by directed screening and stabilization by chemical optimization.

[0038] We identified a bicyclic constrained peptide binder (Bicycle) that binds to the hemopexin domain of MT1 with an apparent Kd of approximately 2 nM. The Bicycle peptide (N241) binds with similar affinity to the entire ectodomain of the protease, but does not show binding to the catalytic domain. N241 also shows no binding to any of the closely related MMP family members tested (MMP15, MMP16, MMP24, MMP1, Pro-MMP1, MMP2). Characterization of the pharmacological effects of N241 on MT1 in vitro indicates that the peptide does not directly affect the catalytic activity of the protease, related MMP catalytic activity (MMP1, MMP2, and MMP9), or cell migration or invasion. However, binding of fluorescently tagged N241 to MT1 on HT1080 fibrosarcoma cells results in rapid internalization of the compound and subsequent localization in lysosomes. Furthermore, 177 When Lu-loaded N241 was IV injected into mice bearing MT1-positive tumor xenografts, rapid tumor localization was demonstrated, with levels as high as 15-20% of the injected dose per gram of tumor in less than 60 min. In contrast, the non-binding Bicycle peptide showed no tumor localization. These properties suggest that N241 may be a good delivery vehicle for cytotoxic payloads targeting MT1-positive tumor cells. Bicycle drug conjugates (BDCs) with various linkers and cytotoxic payloads that retain binding to MT1 were prepared. Antitumor activity of selected BDCs was demonstrated in MT1-positive human tumor cell xenografts in mice.

[0039] BT1718 is a constrained bicyclic peptide and its hindered dicyclic peptide that binds to membrane type 1 matrix metalloproteinase (MT1-MMP; MMP14) with high affinity and specificity. Bicycle is a drug conjugate (BDC) composed of the potent antitubulin agent DM1 covalently linked through a sulfide linker. MT1-MMP is naturally involved in tissue remodeling, but overexpression of the cell surface protease has been linked to tumor aggressiveness and invasiveness, as well as poor patient outcomes for many cancer indications. We identified a Bicycle binder (N241) for BT1718 using a proprietary phage display peptide technology consisting of a highly diverse phage library of linear amino acid sequences constrained in two loops by a central chemical scaffold. The Bicycle peptide binds with similar affinity and specificity to that observed with monoclonal antibodies, but its small size (1.5-2 kDa) aids in its rapid extravasation and tumor penetration, making the Bicycle peptide an ideal format for targeted delivery of cytotoxic payloads.

[0040] A series of maytansinoid-BDC conjugates were prepared using various linker formats to tune cleavability and evaluated for their antitumor activity in MT1-positive tumor xenograft models. The BDC (BT1718) selected for further evaluation was evaluated for efficacy in an array of tumor xenograft models.

[0041] The mono-hindered linker-DM1 construct (BT1718) was one of the most active constructs against MT1-positive EBC-1 lung tumor xenografts. Efficacy in this model was reduced for conjugates containing the smallest cleavable linker. Dosing of BT1718 on a twice-weekly schedule for 2 weeks resulted in a significant reduction in tumor growth at 3 mg / kg, with 10 mg / kg causing complete regression in this model. Effective treatment was also observed when the same total dose was given on a schedule ranging from daily to weekly doses. Treatment with BT1718 in selected MT1-positive tumor xenograft models (e.g., HT1080 fibrosarcoma; HCC1806 triple-negative breast cancer; SNU-16 gastric cancer) demonstrated activity at minimally effective doses ranging from 3 to 10 mg / kg once or twice weekly, with 10 mg / kg twice weekly causing complete regression in the majority of models. Preliminary metabolism studies indicate that BT1718 is primarily excreted in the urine via the kidney.

[0042] Bicycle drug conjugate (BDC) BT1718 shows strong antitumor activity in human tumor xenograft models of fibrosarcoma, lung cancer and breast cancer.Without being bound by any particular theory, it is believed that the small size of BDC may provide a significant advantage over other targeted cytotoxicity approaches, such as antibody-drug conjugates, due to the rapid extravasation and improved tumor penetration.

[0043] BT1718 is a potent and highly selective Bicycle Drug Conjugate (BDC) consisting of a novel bicyclic peptide (Bicycle) that selectively binds to membrane type 1-matrix metalloproteinase (MT1-MMP) and DM1, a potent cytotoxic tubulin inhibitor, connected to it through a molecular spacer and a cleavable disulfide linker. Upon binding to tumor cells expressing MT1-MMP, the DM1 payload is activated by being released from the conjugate, where it disrupts microtubule dynamics, resulting in tumor cell death.

[0044] BT1718 is a potent, highly selective BDC developed by BicycleRD using their novel platform technology of constrained bicyclic peptidic binders, referred to herein as Bicycle. The BDC has a low molecular weight (3.5 kDA) compared to other conjugated toxin approaches, allowing for rapid penetration of tumor tissue. It is most potent due to its short half-life and excretion via the kidney. Small systemic toxicity is predicted, potentially reducing gastrointestinal (GI) and hepatotoxicity, frequent target toxicities seen with small molecule cytotoxic drugs and ADCs. BT1718 specifically binds to cell surface MT1-MMP, which is overexpressed on tumor cells, facilitating delivery of its cytotoxic payload, DM1, to the tumor. Once localized in the tumor and released by linker cleavage, active unconjugated DM1 is then able to block normal microtubule function during cell division, ultimately leading to apoptosis, cell death and reduction in tumor size.

[0045] In certain aspects, the present invention provides a method of treating certain cancers in a subject, comprising administering to the subject an effective amount of a drug conjugate comprising a high affinity binding agent for MT1-MMP, such as BT1718, or a pharma- ceutically acceptable salt or composition thereof.

[0046] The preparation of BT1718 is described in detail in WO2016 / 067035, filed October 29, 2015, which is hereby incorporated by reference in its entirety. BT1718 has the structure shown below: [ka] 2.Definition

[0047] As used herein, the term "about" or "approximately" when used in conjunction with a numerical value refers to a range that the boundary above and below that numerical value spans. For example, the term "about" or "approximately" can span a value defined by a variance of 30%, 25%, 20%, 15%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, or 0.5% above and / or below (higher or lower). In some embodiments, the term "about" or "approximately" spans a value defined by a variance of 25% above and / or below (higher or lower). In some embodiments, the term "about" or "approximately" spans a value defined by a variance of 10% above and / or below (higher or lower). In some embodiments, the term "about" or "approximately" spans a value defined by a variance of 5% above and / or below (higher or lower). Safety Considerations

[0048] Nonclinical Pharmacology

[0049] BT1718 is a BDC that binds to MT1-MMP and releases the cytotoxic tubulin inhibitor DM1 upon cleavage of its disulfide linker (also called DM1-SH). BT1718 has high affinity and selectivity for the hemopexin domain of MT1-MMP (inhibitory constant Ki, 1.75±0.92 nM), and the Bicycle component has no significant binding to the catalytic domain of MT1-MMP (at least 50-fold selectivity) or to the hemopexin domains of other related MMPs (more than 200-fold selectivity). Furthermore, BT1718 does not interfere with the proteolytic activity of MT1-MMP.

[0050] Bicycle, a membrane type I matrix metalloproteinase-binding enzyme, has been shown to bind to cell surface MT1 MMP and localize there after internalization. BT1718 demonstrated potent cell killing activity against tumor cells expressing MT1-MMP that was at least two orders of magnitude greater than that of cells not expressing MT1-MMP (nM IC 50S In contrast, all cells showed similar sensitivity to unconjugated DM1 alone, regardless of their MT1-MMP expression levels. Furthermore, excess Bicycle components of BT1718 antagonized BT1718 cytotoxicity. Together, these data demonstrate that BT1718 binds to cells expressing MT1-MMP and mediates target-dependent cell killing.

[0051] In vivo, intravenous administration of BT1718 demonstrated dose-dependent antitumor activity in multiple xenograft models representing a variety of tumor types, including lung, breast, gastric, fibrosarcoma, nasal, and colorectal, accompanied by disease stabilization and / or regression. The minimal effective dose in the EBC-1 model was 1 mg / kg (3 mg / m 2 ) given three times a week (which slowed tumor growth), and 2 mg / kg (6 mg / m) given twice a week in the HT-1080 model. 2 ) (Table 1). 2 ) twice weekly resulted in SD or better in some models, with the highest dose tested being 10 mg / kg (30 mg / m 2) twice weekly induced complete regression of the majority of MT1-MMP-expressing xenograft tumors tested (Table 1), and in many cases, mice remained tumor-free until the end of the study. In some cases where tumor regrowth occurred after dosing was suspended, administration of BT1718 was nevertheless able to induce significant regression or reduced tumor growth upon rechallenge. The antitumor activity of BT1718 in xenograft models tended to correlate with the cytotoxic potency observed in in vitro assays. Moreover, as also demonstrated in vitro, excess unconjugated MT1-MMP-binding Bicycle attenuated the antitumor effect, suggesting that MT1 MMP binding is important for the efficacy of BT1718 in vivo. Consistent with this finding, immunohistochemistry (IHC) of xenograft tumors confirmed that models in which BT1718 produced the greatest antitumor effect exhibited strong membrane staining for MT1-MMP, whereas models that did not respond as well to BT1718 (SD at the highest dose) had limited or no membrane MT1-MMP expression.

[0052] The relationship between antitumor activity and dosing schedule for BT1718 was investigated. Antitumor activity was compared when equal total weekly doses were administered either once, twice, or three times a week or once daily. 2 All schedules induced complete tumor regression, and the 60 mg / m 2 It was well tolerated, except that once weekly, it caused notable weight loss (>10%). 2 ) weekly and twice weekly schedules were most effective, with more frequent schedules (three times weekly or daily) showing some loss of antitumor efficacy. In summary, the nonclinical data support clinical evaluation of different schedules, such as weekly. Additionally, less frequent dosing schedules could be evaluated.

[0053] Data generated in NSCLC patient-derived xenograft (PDX) models that did not express high levels of MT1-MMP demonstrated a lack of antitumor activity in response to BT1718. However, PDX models expressing MT1-MMP were sensitive to BT1718, demonstrating a 3 mg / kg (9 mg / m 2 ) twice a week resulted in SD, whereas All control animals demonstrated progressive disease (PD), with tumor growth reaching 2,000 mm by day 27. 3 (Figure 1A, 1B, and 1C). Furthermore, BT1718 produced antitumor effects in MT1 MMP-expressing NSCLC PDX models, regardless of the sensitivity of the models to the SOC chemotherapy drug docetaxel. 2 2x per week) induced complete tumor regression in both models, whereas clinically relevant doses of docetaxel (60 mg / m 2 , once weekly) induced regression only in docetaxel-sensitive models. 2 Treatment with BT1718 at 100x the usual dose (twice weekly) resulted in SD in both models. PDX models confirm that MT1-MMP expression is required for the antitumor activity of BT1718.

[0054] Summary of in vitro and in vivo antitumor activity Table 1. Summary of in vitro antitumor activity [Table 1] Table 2. Summary of in vivo antitumor activity [Table 2]

[0055] Notes for Tables 1 and 2: In general, regression and stabilization correlated with in vitro cytotoxicity and MT1-MMP expression. Female BALB / c mice, n=3 / group of animals, EBC-1 was dosed 3 times per week, the rest were dosed twice per week. Tumor growth inhibition (TGI) (%)=[1-(Ti-T0) / (Vi-V0)]×100; Ti is the mean tumor volume of the treatment group on a given day, T0 is the mean tumor volume of the treatment group on the day treatment started, Vi is the mean tumor volume of the vehicle control group on the same day as Ti, and V0 is the mean tumor volume of the vehicle group on the day treatment started. One-way ANOVA was performed to compare tumor volumes between groups, and when a significant F-statistic (ratio of treatment variance to error variance) was obtained, a Games-Howell test was used to compare between groups. All data were analyzed using GraphPad Prism. *p<0.05, **p<0.01, ***p<0.001. In vitro cytotoxicity was measured by CellTiter-Glo®, MT1-MMP membrane H score was from immunohistochemical staining, NM indicates not measured. Tumor size is on day 1 of dosing.

[0056] Antitumor activity dependent on MT1-MMP expression in a patient-derived xenograft model of non-small cell lung cancer

[0057] Patient-derived xenograft (PDX) lung models were selected for their MT1-MMP expression. Mice were dosed twice weekly with vehicle or with BT1718 at 3 mg / kg or 10 mg / kg twice weekly. Mean ± SEM, n=6 / group. 21–2 depending on model. Tumor growth inhibition (TGI) was calculated on day 7, and one-way ANOVA was performed to compare tumor volumes between groups, and if a significant F-statistic (ratio of treatment variance to error variance) was obtained, a Games-Howell test was used to compare between groups. In 01 0046, LU-01-0251 and LU-01-0486 animals, the TGI was 91%, 71% and 11%, respectively, and in the 10 mg / kg group, the TGI was 105%, 106% and 17%, respectively. MT1-MMP expression-dependent antitumor activity in non-small cell lung cancer patient-derived xenograft models is shown in Figure 1A, Figure 1B and Figure 1C.

[0058] A core battery of safety pharmacology studies was conducted as part of a Good Laboratory Practice (GLP)-compliant toxicity study. BT1718 was administered to rats at doses of 0.2, 0.5, or 1 mg / kg (1.2, 3, and 6 mg / m, respectively). 2 No effects were seen in central nervous system (CNS) behavioral models (Irwin test) after single dosing at dose levels of 0.2, 0.5, 1 and 1.5 mg / kg (2.4, 6, 12 and 18 mg / m, respectively). 2 ) twice weekly on days 4, 22 (after the 2nd and 7th doses) and during the recovery period (0, 6 and 12 mg / m 2 Electrocardiogram (ECG) and respiratory plethysmography measurements were obtained (for animals dosed twice weekly at 100 mg / kg / day). Blood pressure (BP) measurements were also assessed on days 1 and 25 and during the recovery period in the same monkeys. Safety studies were performed against the GLP and showed no findings related to BT1718 for any parameter measured on any day. It was therefore concluded that BT1718 does not pose any cardiac, respiratory or behavioral adverse effects at the doses and schedules tested in the GLP toxicity studies.

[0059] In conclusion, BT1718 confers antitumor efficacy in MT1 MMP-expressing xenograft and PDX models, with long-lasting regressions. Based on the available preclinical data, twice-weekly dosing appeared to be the most tolerable and effective dosing schedule. In a GLP-compliant safety pharmacology study, the highest dose tested (18 mg / m 2No BT1718-related effects on cardiovascular, respiratory or behavioral function were observed until 2013. BT1718 is a novel delivery platform capable of delivering DM1 to MT1-MMP expressing cells commonly found in cancers such as NSCLC, TNBC and sarcoma.

[0060] Pharmacokinetics

[0061] The stability of BT1718 in plasma and whole blood from humans, monkeys, dogs, mice, and rats was evaluated. In vitro, at 37°C, the half-life of BT1718 in plasma was >6 hours for humans, rats, and dogs, and >5 hours for mice and monkeys. In vitro, at 37°C, the half-life of BT1718 in whole blood was >24 hours for mice, rats, and dogs, and 2-4 hours for humans and monkeys. The mechanism by which the stability of the BT1718 peptide in whole blood differs between different species is unknown. BT1718 showed limited distribution to blood cells (consistent with the expectation of low uptake into cells lacking MT1-MMP expression), which was comparable across humans and all preclinical species tested.

[0062] BT1718 binding to plasma proteins was also evaluated. Mean binding of the BT1718 peptide to plasma proteins ranged from 87% to 98%, with free fractions of BT1718 being 13% in human plasma, 2.6% in rat plasma, 7.5% in mouse plasma, 3.8% in monkey plasma, and 1.5% in dog plasma. These results did not correlate with the plasma and whole blood stability data. BT1718 showed limited distribution to blood cells (MT1- This was comparable across humans and all preclinical species tested (consistent with the expectation of lower uptake in cells lacking MMP expression). Plasma protein binding of unconjugated DM1 has been previously reported with unbound fractions of 7% in humans and monkeys and 3% in rats [31, 32]. Preliminary biodistribution and recovery in PK studies suggest that BT1718 is primarily cleared by the kidney and therefore differences in plasma protein binding are unlikely to be clinically significant from a safety perspective.

[0063] The PK profile of BT1718 in rodents was characterized by a moderate volume of distribution, a rapid rate of plasma clearance, and a short half-life (Table 3). The area under the curve (AUC) in CD1 mice was dose proportional.

[0064] PK samples were also analyzed in the lung cancer xenograft (EBC-1) study, and the 10 mg / kg (30 mg / m 2 ) was associated with a maximal exposure at the first measurement time point (5 min), which was 7.6 ± 0.6 μM. In studies in CD1 mice, a dose of 10 mg / kg (30 mg / m 2 ), an estimated C0 of 9.3 μM was obtained with an AUC of 5.3 μM h, which is a more reliable measure of exposure. 2 ) resulted in SD in several xenograft models within the EBC-1 model, including a maximum observed plasma concentration (C max In BALB / c mice, the 5 mg / kg (15 mg / m 2 ) at a dose of C max A dose of 20 mg / kg (60 mg / m) and an AUC of approximately 2.5 μM h were measured. 2 ) dose was associated with significant weight loss, which was accompanied by C max Dose-dependent efficacy is supported by dose-dependent exposure to BT1718.

[0065] Repeated-dose studies with BT1718 did not reveal any significant sex-related differences in TK parameters for rats or monkeys. Exposure increased approximately linearly with dose in both rats and monkeys and was sustained over 28 days with repeated dosing. Plasma t 1 / 2 The plasma clearance and volume of distribution were similar across doses of BT1718, consistent with PK studies. Table 3. Summary of pharmacokinetic and toxicokinetic parameters [Table 3]

[0066] Table 3 Notes: Mean ± SD; All studies were intravenous; C max , maximum concentration; C0, estimated C at 0 h max ;AUC, area under the curve;CL, clearance;t 1 / 2 , terminal half-life; Vd ss , steady state volume of distribution, NC, not calculated. EBC-1 xenograft study, female mice, C max * is for the 5 min time point. BALB / c PK study, female mice only, CD1 male mouse dose-response study and Sprague Dawley male rat study, Wister Han rat non-GLP toxicity study, only male day 1 numbers shown. max is for the 1 hour time point. Wistar Han rat GLP study, values ​​are for males on day 1. No significant differences between sexes or with repeated dosing, due to the composite nature of the study design. Mean C max , AUC and Tmax were calculated only. Monkey GLP study, values ​​are for males on Day 1. No significant differences between sexes or with repeated dosing. C max The mean and median AUC / dose was 1.5 and the AUC / dose was 0.5 across all pharmacokinetic studies in both mice and rats.

[0067] To detect DM1 in BT1718, any peptidyl-DM1 metabolites of BT1718, other DM1-containing mixed disulfides, and free DM1, the concentrations of total DM1 in plasma and urine were also measured after the reduction step. The levels of total DM1 in plasma and urine increased with increasing dose, and approximately 85% of total DM1 was recovered in urine within 48 hours of BT1718 administration. Little intact BT1718 was recovered in urine, suggesting that the Bicycle component of BT1718 may undergo proteolytic cleavage. Free DM1 is cleared through the liver and excreted in the bile and feces, where it has been demonstrated to undergo extensive metabolism by phase 1 and phase 2 enzymes. The high recovery of total DM1 in urine suggests that the majority of excreted DM1 is still conjugated to Bicycle fragments (peptidyl-DM1).33 Due to the instability of free thiols in biological matrices, assays for free DM1 have not been successfully developed.

[0068] Photoacoustic studies demonstrated rapid tumor penetration compared to MT1-MMP-specific antibodies. Furthermore, biodistribution and organ distribution studies of radiolabeled Bicycle in tumor-bearing mice showed rapid accumulation of radioactivity in the tumor, reaching a peak of 12.02 ± 2.37% initial dose per gram (%ID / g) 1 hour after dosing, followed by a decrease to 1.54 ± 0.06%ID / g at 24 hours, accompanied by rapid clearance from the vasculature (within 20 minutes). The majority of the radioactivity was found to accumulate in the kidney and bladder, independent of the dose of the labeled peptide; this indicates excretion through the kidney after either nonsaturable excretion or proteolysis. Furthermore, the intrinsic clearance of BT1718 and its Bicycle component N241 was small as measured in cryopreserved hepatocytes. The negligible metabolism by hepatocytes of Bicycle components seen in the in vivo imaging / radiolabeling studies, combined with the total DM1 in urine in the preliminary PK studies, suggests an entirely different excretion and metabolic pathway for unconjugated DM1. 3 It was reported that [H]-DM1 (91 μCi / kg, 200 μg / kg, IV) was rapidly and extensively distributed to the lungs, liver, kidneys, spleen, heart, gastrointestinal tract, and adrenal glands of rats. The major route of excretion of DM1 is via bile / feces, with minimal excretion in urine.

[33] This is completely different from the distribution of BT1718 and its metabolites, whose accumulation in other organs such as the heart, liver, GI, and lungs was minor and short-lived, meaning that these organs may be spared systemic toxicity.

[0069] BT1718 has a high rate of plasma clearance and, as a result, a short half-life. In preclinical studies, BT1718 is excreted by the kidney either as the intact parent or as proteolytic fragments / metabolites. As such, BT1718 has a completely different excretion and metabolic pathway than free DM1. Furthermore, Bicycle has been shown to penetrate tumors within 20 minutes of administration, unlike high molecular weight ADCs.

[0070] toxicology

[0071] A program of in vivo preclinical safety evaluation studies was conducted with BT1718 to support the clinical use of intravenous administration. These included in vitro tissue microarrays and in vitro and in vivo evaluations of immunogenicity in human, rat and monkey tissues. In vivo evaluations included single dose toxicity in mice and rats, multiple dose range-finding studies (non-GLP) in mice, rats, dogs and monkeys, and GLP-compliant multiple dose studies in rats and monkeys consisting of a 28-day testing phase and a 28-day recovery period. N241, the Bicycle component of BT1718, elicited positive responses in only 2% of the donor cohort (n=50) in an in vitro immunogenicity study, indicating a low risk of clinical immunogenicity, as supported by all serum samples being negative for anti-drug antibodies (ADA) in both rats and monkeys in a 28-day GLP-compliant study. Important target organs following administration of BT1718 were identified as the hematopoietic and lymphoid systems, kidneys, and bladder, liver, neuronal nervous system, skin (changes were generally in the vicinity of the injection site), and to a lesser extent other highly replicating tissues such as reproductive tract, GI, and secretory cells of adrenal tissue, pancreatic tissue, and salivary tissue. All toxicities were dose-dependent, reversible, or showed signs of recovery during the recovery phase, with the exception of axonal degeneration and minimal changes in reproductive organs.

[0072] In a GLP-compliant study in cynomolgus monkeys, the highest non-severely toxic dose (HNSTD) of BT1718 was 18 mg / m 2 The highest dose of 6 mg / m2 administered twice weekly was established, which corresponds to a human dose of 0.48 mg / kg. GLP-compliant studies in rats have demonstrated 2The MTD was not reached at twice weekly doses. At this dose level, nephrotoxicity was observed (without effect on clinical status) and testicular toxicity was also observed. After 28 days off dosing, there was evidence of partial reversal of renal findings, but no reversal of testicular effects was observed at this dose level. In a non-GLP rat study, 2 The twice weekly dose was not well tolerated, therefore the MTD for twice weekly dosing in rats was considered to be between 1 and 1.5 mg / kg.

[0073] Target tissues for BT1718 toxicity across GLP and non-GLP studies were:

[0074] Hematological changes

[0075] Hematological changes were observed in rats, dogs, and monkeys administered BT1718.

[0076] 1 mg / kg or 1.5 mg / kg (12 mg / m 2 or 18 mg / m 2 ) twice weekly, reversible thymic atrophy and a decrease in germinal centers in lymph nodes were observed in monkeys. 2 ) twice weekly, a reversible decrease in white blood cell (WBC) and reticulocyte counts was observed, and a dose of 1 mg / kg (12 mg / m 2 ) twice weekly, a reversible decrease in reticulocytes was observed (maximum 0.11× and 0.2×, respectively), which was accompanied by a dose-dependent but minimal decrease (0.63–0.93×) in red blood cells and parameters. 2 Monkeys receiving 1.4- to 2.5-fold more thrombocytopenic acid twice weekly or at higher doses showed a dose-dependent increase in platelet counts.

[0077] In rat GLP studies, BT1718 was administered at 1 mg / kg (6 mg / m 2) twice weekly caused a decrease in reticulocytes (0.06x in males and 0.37x in females), a decrease in red blood cell parameters (maximum drop of 0.64x), and an increase in platelets (maximum increase of 2.3x). Loss of cellularity and lymphoid depletion in lymph nodes was noted, but unlike monkeys, no decrease in leukocytes was observed. All hematological toxicities were reversible.

[0078] In non-GLP studies, peripheral hematological changes were observed in all preclinical species administered BT1718 at doses above the MTD; rats (1.5 mg / kg; 9 mg / m 2 twice weekly), dogs (1 mg / kg; 20 mg / m 2 twice weekly), and monkeys (2 mg / kg; 24 mg / m 2 In a randomized controlled trial (1x weekly), a significant reduction in WBC (lymphocytes and neutrophils were the most affected populations) as well as in erythroid lineages was observed, which correlated with an overall decrease in lymphoid, thymic and bone marrow cellularity. Hematological toxicities such as neutropenia, leucopenia and erythrombocytopenia and thrombocytosis are not uncommon with agents affecting the cell cycle and are clinically manageable.

[0079] Kidney and bladder changes

[0080] BT1718 and potentially its peptidyl metabolites are predicted to be cleared via the kidneys and bladder.

[0081] In rat GLP studies, 2 ) with twice-weekly initiation, renal tubular epithelial degeneration was observed, with incidence and severity increasing with dose (minimal to moderate). 2 twice weekly), dogs (1 mg / kg; 20 mg / m 2 twice weekly) and mice (3.3.5 mg / kg; 10 mg / m 2In a non-GLP study of 1.5 mg / kg (18 mg / m 3 times per week), moderate renal tubular degeneration and epithelial mitosis were observed at doses above the MTD. In a GLP monkey study, the highest dose tested, 1.5 mg / kg (18 mg / m 3 times per week), was observed in both sexes. 2 ) no renal changes were observed.

[0082] Moderate degeneration correlated with elevated creatinine and urea levels. Tubular basophilia was also seen, consistent with repair and regeneration.

[34] The rat GLP study showed signs of improvement in renal epithelial degeneration during the recovery phase, and urea and creatinine levels returned to baseline; recovery was not assessed in the non-GLP study.

[0083] In non-GLP studies, bladder epithelial degeneration was observed in both rats and dogs at doses above the MTD (40 mg / m 2 and 14 mg / m 2 (A single dose twice weekly at 100 mg / kg / day). No bladder changes were observed in either species in GLP-compliant studies. In addition, moderate or strong MT1-MMP staining (2 out of 3 human sections) was observed in the urothelium of human bladder tissue microarray (TMA) studies. However, no membranous staining was seen in rat or monkey bladders.

[0084] Neuronal changes

[0085] Peripheral neuropathy is a common clinical side effect of antibodies conjugated to microtubule inhibitors

[35] and DM1. In GLP monkey studies, BT1718 caused peripheral neuropathy at approximately 2.4 mg / m 2 DM1, equivalent to 1 mg / kg (12 mg / m 2 ) induced minimal axonal degeneration with initiation of twice-weekly doses (0.5 mg / kg [6 mg / m 2One male receiving three doses of 2x weekly had minimal axonal degeneration. This degeneration was not observed in the rat study and was not evaluated in the dog study. BT1718 has a completely different distribution profile than ADCs. It is significantly shorter-lived than the ADCs conjugated to DM1 (t 1 / 2 40 hours) for cantuzumab mertansine, 58-228 mg / m 2 (0.85 and 3.3 mg / m 2 Animals receiving IMGN901 at a weekly dose (DM1) showed mild axonal degeneration

[36] , which translated clinically to some neurosensory AEs that were not severe even at the MTD (DLT for elevated transaminases)

[37] . 1 / 2 The mean time to response was approximately 40 hours, and neurosensory AEs (all grades) were reported in 17% of patients.

[38] Ado-trastuzumab emtansine (T-DM1) 1 / 2 is about 4 days and therefore has a completely different distribution compared to BT1718, 120 and 360 mg / m 2 (DM1 content 2 and 6 mg / m 2 When T-DM1 was administered at 0.5 mg / kg / day, moderate to severe axonal degeneration was observed. Hyperplasia and hypertrophy of Schwann cells, and in some cases, infiltrating neutrophils, were also associated with this T-DM1-mediated axonal degeneration [31, 32, 39], findings that were not observed with BT1718. These preclinical findings following T-DM1 administration were translated clinically into peripheral neuropathy in 20% of patients [31, 32, 39].

[0086] Liver changes

[0087] In a 28-day repeated dose study of GLP in rats, 2 ) twice weekly, minimal to slight reversible hepatocellular atrophy was observed. These findings were consistent with the increase in alkaline phosphatase (ALP) and aspartate aminotransferase (AST) levels. This correlated with a reversible increase in cholesterol (neither of which exceeded 1.5× above control values) and a rise in liver enzymes in non-GLP rat studies (3.35 mg / kg; 20.1 mg / m 2 twice weekly) and non-GLP studies in dogs (1 mg / kg; 20 mg / m 2 2 times weekly) with histopathological correlation. In GLP-compliant monkey studies, 2 No liver toxicity was observed up to 100 mg / kg / day (up to 100 mg / kg / day, twice weekly). Hepatotoxicity has previously been observed with maytansine toxin (DM1) alone and with antibodies conjugated with DM1, both preclinically and clinically, but due to the hypothesis that the route of clearance is altered for BT1718 (by the kidney) compared to these maytansinoid compounds (by the liver), patients may be able to clear through the kidney and bladder and the liver may be spared the clinically relevant DLT of hypertransaminasemia seen with these other agents.

[0088] Local toxicity (at or around the injection site)

[0089] In GLP-compliant monkey studies, 2 Skin darkening in areas near the injection sites (and occasionally distal to these sites, e.g., ankles or forelimbs) in animals dosed at 1.5 mg / kg twice weekly and above was ascribed to melanocyte activation, and the appearance, distribution, and incidence of this finding increased with increasing dose. This finding was often accompanied by skin shedding / dermatitis near the injection sites, which improved with veterinary inventions, if necessary. At the microscopic level, these clinical findings correlated with minimal to slight hyperkeratosis and epidermal hyperplasia observed along with minimal to slight epidermal pigmentation. Dermal inflammatory cell infiltrates were occasionally seen, but these were observed in only a small proportion of animals and were not observed at the highest doses tested (1.5 mg / kg; 18 mg / m 2This was presumed to be a transient inflammatory response, as no microscopic skin findings were observed in animals that recovered, although dermal and dermal pigmentation was still evident. The pathogenesis of epidermal hyperpigmentation may represent the post-inflammatory hyperpigmentation reported with some chemotherapeutic agents.

[40] This local toxicity at the injection site was not observed in any other preclinical toxicology studies.

[0090] Gastrointestinal changes

[0091] No GI-related findings were observed in GLP-compliant studies in rats and monkeys.

[0092] In non-GLP studies in mice, rats, dogs, and monkeys, overt GI tract toxicity was seen only at doses above the MTD. 2 ) twice weekly, slight to moderate small intestinal degeneration was observed. In rats, 2 ) twice weekly resulted in single cell necrosis in the ileum. In monkeys, 2 ) at 3 mg / kg (36 mg / m 2 A single dose of 13.4 mg / kg (40.2 mg / m) induced mild single-cell necrosis of glandular epithelial cells in the cecum, accompanied by a mild increase in epithelial cell mitosis in the cecal and colonic mucosa. 2 ) induced intestinal mucosal mitosis after a single dose of

[0093] Changes in reproductive organs

[0094] Reproductive system changes are a common side effect of drugs that affect the cell cycle. 2 Testicular degeneration / atrophy of the seminiferous tubules and absence of sperm were observed in all males receiving twice weekly doses of 100 mg / kg / day ...

[0095] Adrenal changes

[0096] In rat GLP studies, 2 Final adrenal weights were significantly smaller in males dosed twice weekly at 0.2 mg / kg (1.2 mg / m 2 ) twice weekly, 2 of 10 males received 0.5 mg / kg (3 mg / m 2 ) twice weekly and 3 of 10 males received 1 mg / kg (6 mg / m 2 ) twice weekly, and 4 of 10 males received 1 mg / kg (6 mg / m 2 Minimal hypertrophy of the zona glomerulosa was also seen in 5 of 10 females receiving 2 doses of 100 mg / kg twice weekly. The changes were minimal and considered stress related, and therefore may not have had clinical correlation. However, rat sections (3 of 3) had weak MT1-MMP staining in the zona glomerulosa in the TMA study, indicating that it may be related to the target. Weak to moderate membrane staining was seen in all human sections (3 of 3) in the TMA study. No toxicological changes or TMA staining were seen in monkeys.

[0097] Salivary gland changes

[0098] Dry mouth and associated toxicity are common side effects associated with chemotherapy,

[41] and these symptoms tend to resolve within 3–4 weeks of stopping treatment. Human TMA studies showed weak membrane staining for MT1-MMP in two out of three human parotid gland sections, thus making the salivary gland a potential target of toxicity.

[0099] Changes in pancreatic acini

[0100] Pancreatic secretory cells had occasional weak to moderate MT1-MMP specific staining in human pancreatic sections (3 out of 3), and therefore there is a risk that these cells could be targets for toxicity associated with treatment with BT1718. No expression was observed in rat or dog TMAs, and not surprisingly, no in vivo toxicity findings were observed.

[0101] Summary of non-clinical data

[0102] Target organs for BT1718 toxicity in preclinical models were identified as hematopoietic and lymphatic tissues, kidney and bladder, liver, neurons, and skin (changes generally near the injection site), and to a lesser extent, other highly replicating tissues, such as reproductive tract, GI and secretory cells of adrenal tissue, pancreatic tissue, and salivary tissue. Most of the toxicity was minimal and reversible. Rats appear to be more sensitive to BT1718 than other preclinical species tested (mouse, dog, and monkey).

[0103] In GLP-compliant studies in cynomolgus monkeys, the HNSTD of BT1718 was 18 mg / m 2 The recommended dose for administration of 0.48 mg / kg twice weekly was established, which corresponds to a human dose of 0.48 mg / kg. In GLP-compliant studies in rats, the highest dose of 6 mg / m 2 The MTD was not reached at twice weekly doses. At this dose level, nephrotoxicity was observed (without effect on clinical status) and testicular toxicity was also observed. After 28 days off dosing, there was evidence of partial reversal of renal findings, but no reversal of testicular effects was observed at this dose level. In a non-GLP rat study, 2 The twice-weekly dose was not well tolerated.

[0104] Therefore, the MTD for twice weekly dosing in rats is between 1 and 1.5 mg / kg (6–9 mg / m 2 Based on pharmacodynamic studies, the lowest dose resulting in significant growth inhibition was considered to be 3 mg / m 2twice weekly (equivalent human dose [HED] 0.08 mg / kg twice weekly) and 9 mg / m in several cell-based and PDX tumor models. 2 In the EBC-1 lung xenograft model, BT1718 at 18 mg / m twice weekly (HED, 0.24 mg / kg twice weekly) was shown to be effective in treating SD or better. 2 Similar efficacy was seen when administered at 30 mg / m only once a week. Furthermore, BT1718 induced SD and regression in a docetaxel-resistant lung PDX model. Furthermore, BT1718 at 30 mg / m 2 (HED, 0.8 mg / kg) administered twice weekly resulted in long-term complete regression. The degree of response to BT1718 in these models correlated with moderate to high expression of MT1 MMP.

[0105] Suggested Starting Dose

[0106] The HNSTD established in a 28-day repeated-dose GLP monkey study was 1.5 mg / kg (18 mg / m 2 ) twice weekly. Using allometric scaling and applying the standard safety factor of 6 as described in the ICH guidance (ICH S9), the human starting dose was 3 mg / m 2 In a one-month repeated-dose GLP rat study, the MTD was also at the severe toxic dose (STD) in 10% of animals. 10 ) was not established and therefore the highest dose tested, 1 mg / kg (6 mg / m 2 Based on twice weekly dosing at 10 mg / m 2 with allometric scaling and a standard safety factor of 10 10 (ICH S9), the human starting dose was 0.6 mg / m 2 2 twice weekly (which is approximately 0.12 mg / m 2 (equivalent to a twice weekly DM1 dose). The starting dose was based on the highest dose tested in rats, as rats are the most sensitive species to BT1718.

[0107] Therefore, the proposed starting dose for FIH Phase I trials is 0.6 mg / m 2 That is twice a week.

[0108] Clinical experience (Phase I / other compounds in the same class)

[0109] No clinical trials have been conducted previously with BT1718. However, maytansine, the parent analog of DM1, has been evaluated in clinical trials, and DM1 has also been evaluated clinically as a component of an ADC, exemplified by T-DM1, approved under the trade name Kadcyla® by Roche Holding AG. Adverse events that have occurred with conjugated DM1 are summarized in Table 4 below. Table 4. Summary of adverse events occurring with conjugated DM1 [Table 4-1] [Table 4-2] [Table 4-3]

[0110] Anticipated safety profile of BT1718

[0111] Hematopoietic changes

[0112] Changes in hematological parameters have been observed in rats, dogs, and monkeys administered BT1718. Hematological toxicities such as neutropenia, lymphopenia, erythropenia, and thrombocytosis are not uncommon with agents that affect the cell cycle, and these changes are clinically manageable. Minimal lymphopenia, erythropenia, and thrombocytosis were seen with BT1718 in GLP studies, and histopathological correlations were observed at doses above the MTD in non-GLP studies. It is likely that BT1718 will result in hematological changes in patients, and therefore standard hematological evaluations will be attempted as part of the clinical plan.

[0113] Kidney and bladder changes

[0114] BT1718 and potential peptidyl metabolites are predicted to be cleared via the kidney and bladder. In preclinical species, renal tubular epithelial degeneration was observed in rats, the severity and incidence of which was dose-dependent. In general, use at or above the MTD is recommended. Increased creatinine and urea levels were also observed in animals at doses of 40 mg / m2. Renal tubular basophilia was also found, which is consistent with repair and regeneration.

[34] In non-GLP studies, bladder epithelial degeneration was seen in both rats and dogs above the later determined MTD (40 mg / m2, respectively). 2 and 14 mg / m 2 ) Furthermore, the bladder urothelium showed moderate to strong MT1-MMP staining in TMA studies performed (2 out of 3 human sections).

[0115] Liver changes

[0116] In rats, minimal to slight reversible hepatocellular atrophy was observed, correlating with small elevations in ALP, AST, and cholesterol levels. Similar findings were seen at higher doses in dogs, but not in monkeys. Hepatotoxicity was a common finding with maytansine and antibody-maytansinoid conjugates, which are primarily cleared by the liver, but may be minimal with BT1718, given the differential renal clearance pathway for this maytansinoid conjugate. However, as a precaution, standard liver function tests will be performed as part of the clinical plan. Further investigations or imaging will be initiated if clinically indicated.

[0117] Neuronal changes

[0118] Peripheral neuropathy is a common side effect of microtubule inhibitors

[35] and has been a prominent AE with antibody-DM1 conjugates. BT1718 caused minimal axonal degeneration in monkeys without any overt neurological clinical findings. Altered biodistribution and limited systemic exposure may reduce the incidence of clinical neuropathy. Patients will be evaluated for any AEs involving the nervous system at study visits. Symptom-directed clinical examination and further investigations or imaging will be initiated if clinically indicated. Further investigations or imaging will be initiated if clinically indicated.

[0119] skin

[0120] Dose-related findings involving the skin, including shedding, dermatitis, and increased pigmentation, were observed in monkeys. Patients will be evaluated for any skin-related AEs at study visits. Additionally, DM1 and other chemotherapy agents may cause extravasation and / or are vesicants, irritants, inflammatory agents, or skin peeling agents [56, 57], and as a precaution, BT1718 will be treated as a vesicant. Patients will be evaluated for evidence of extravasation during treatment and at each study visit. Standard local policy for management of vesicant extravasation will generally begin with cessation of infusion, aspirating topical hydrocortisone if possible, and continuing with review. The role of specific treatments such as hot or cold compresses, dimethyl sulfoxide (DMSO), or hyaluronidase is unknown.

[0121] Gastrointestinal changes

[0122] No gastrointestinal effects were seen in animals when BT1718 was used at doses below their MTD in GLP studies, and degenerative and apoptotic histopathology was seen at higher doses in non-GLP studies. Thus, gastrointestinal toxicity is considered unlikely below the MTD in humans. Patients will be evaluated for any AEs involving the GI tract at the study visit (see pancreatic acinar section below). Further investigations or imaging may be initiated if clinically indicated.

[0123] Changes in reproductive organs

[0124] Reproductive system changes are a common side effect of drugs that affect the cell cycle. 2 ) twice weekly, all males had testicular degeneration / atrophy of the seminiferous tubules and absence of sperm. No changes in reproductive organs were seen in the monkey study.

[0125] Reproductive changes are a possible side effect of administration of BT1718. Patients will be informed of the potential effects of BT1718 on fertility and patients will be asked to comply with standard clinical trial contraceptive practices. Phase I trials will be for refractory / relapsed patients whose prognosis and fertility are likely to be very limited, and therefore, in this situation, it is considered an acceptable risk. The possibility of sperm banking should be considered when appropriate for male patients who may be in a position to consider having or increasing their family. Patients wishing to undertake sperm banking should also consider the implications of their own prognosis, as well as the possible effects of previous treatments on sperm production, function and genetic health.

[0126] Adrenal changes

[0127] In the rat GLP study, minimal hypertrophy of the zona glomerulosa was seen in some of the animals at each dose. Additionally, the rat TMA study performed found that 3 out of 3 sections had weak MT1-MMP staining in the zona glomerulosa, and human TMA sections also showed weak to moderate staining in 3 out of 3 sections. Administration of BT1718 may lead to alterations in adrenal function, including in the zona glomerulosa (aldosterone secretion). As such, BP and standard clinical chemistry parameters are evaluated as part of the clinical plan. Persistent unexplained hypotension / hypertension or altered potassium levels are further investigated as necessary along with serum renin:aldosterone, cortisol or ACTH assays, and treatment such as fluid replacement and steroid replacement, or conversely antihypertensive drugs, are initiated if clinically indicated.

[0128] Salivary gland changes

[0129] Dry mouth and associated toxicity are common side effects with chemotherapy,

[41] and these symptoms tend to resolve within 3–4 weeks of stopping treatment. Human TMA studies showed weak membrane staining for MT1-MMP in two out of three human parotid gland sections, thus making the salivary gland a potential target of toxicity.

[0130] Patients will be assessed for any AEs at study visits, including dry mouth. Symptoms will be targeted with laboratory tests and / or further investigations as clinically indicated.

[0131] Changes in pancreatic acini

[0132] Pancreatic secretory cells had weak to moderate MT1-MMP specific staining in the three TMAs performed, therefore there is a risk that these cells may be targets for toxicity associated with treatment with BT1718. No expression was observed in rat or dog TMAs, nor were there any signs of MT1-MMP toxicity in vivo. Toxicity can be expected to manifest as impaired exocrine function of the pancreas. Patients are evaluated for any AEs involving the GI tract at the study visit (see also Gastrointestinal section above). Flatulence, steatorrhea and / or diarrhea can be further investigated with fecal elastase evaluation, and treatments such as CREON can be initiated if clinically indicated.

[0133] Rationale for the proposed test

[0134] BT1718 is predicted to induce selective tumor cell death by targeting tumor cells expressing MT1-MMP. This is predicted to translate into objective radiological responses with an acceptable therapeutic window, ultimately improving PFS and OS in patients with tumors expressing MT1-MMP. Preclinical data demonstrates activity in relevant models, and toxicology shows monitorable and reversible toxicity predicted to be manageable in the clinic.

[0135] BT1718 has a low molecular weight (3.5 kDA) compared to other conjugated toxin approaches, allowing for rapid penetration of tumor tissue. Furthermore, preclinical PK and toxicokinetic studies have estimated a half-life of 15-30 minutes, which contrasts with ADCs. Thus, hypothesized advantages over ADCs include reduced systemic exposure of normal tissues to circulating BT1718, the ability to manage toxicity during the recovery phase, and improved tumor penetration. Other potential advantages include a fixed peptide:conjugate ratio of 1:1 (compared to ADCs, which result in a mixed population as a result of various conjugations), and more scalable manufacturing as a small molecule (compared to biologics such as ADCs).

[0136] Overexpression of MT1-MMP has been reported in NSCLC [3, 4], breast cancer [5, 6, 58] and other solid tumors [7, 8, 9]. Studies are being conducted to identify which of these tumor types have the highest incidence of MT1-MMP overexpression. Antitumor activity of BT1718 is generally higher in xenograft models with high levels of MT1-MMP expression, but antitumor activity has been observed in some models with low MT1-MMP expression. Because the majority of cancers may express some MT1-MMP and the relationship between efficacy and MT1-MMP expression has not been fully elucidated, the dose escalation phase of the study will not be restricted to supplementation based on the level of MT1-MMP expression and will be open to patients with all solid malignant tumor types. Phase IIa, an expansion phase with optimal dose / schedule, will generally enroll patients with tumor types predicted to overexpress MT1-MMP and if elevated MT1-MMP overexpression is identified during prospective screening selection at enrollment. Confirmation of this expression tests the hypothesis that MT1-MMP overexpression is predicted to translate into favorable clinical outcomes for patients treated with BT1718. These tumor types are currently proposed to include NSCLC, TNBC, ovarian, sarcoma, and MT1-expressing tumor types for Phase IIa.

[0137] The route of administration will be intravenous. To support this delivery method, all preclinical efficacy and toxicity studies have been intravenous. First, twice-weekly dosing will be evaluated, which is supported by preclinical efficacy and toxicity studies. Due to the PK of BT1718, more frequent dose intervals may allow for higher dose density, allowing safety and clinical PK to be directly correlated with preclinical species. During the titration phase, a once-weekly regimen will also be explored, which is expected to be more convenient for patients and preliminary preclinical data suggests that it may have similar activity. Further embodiments Inclusion criteria

[0138] As described herein, patients must meet the eligibility criteria listed in Table 8. In some embodiments, patients meet the eligibility criteria listed in Table 8. Exclusion criteria

[0139] As described herein, a patient is excluded if the patient meets any of the criteria listed in Table 9. In some embodiments, an excluded patient meets the criteria in Table 9. dose

[0140] As described herein, BT1718 is administered at a concentration of about 0.3 mg / m 2 ~about 45mg / m 2 In some embodiments, BT1718 is administered at a dose of about 0.3 mg / m 2 ~about 45mg / m 2 In some embodiments, BT1718 is administered at a dose of about 0.3 mg / m 2 ~about 45mg / m 2 In some embodiments, BT1718 is administered at a dose of about 0.5 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 1 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 2 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 3 mg / m 2In some embodiments, BT1718 is administered at a dose of about 4 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 5 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 6 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 7 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 8 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 9 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 10 mg / m 2 is administered at a dose of

[0141] In some embodiments, BT1718 is at about 11 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 12 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 13 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 14 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 15 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 16 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 17 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 18 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 19 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 20 mg / m 2 is administered at a dose of

[0142] In some embodiments, BT1718 is about 21 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 22 mg / m 2In some embodiments, BT1718 is administered at a dose of about 23 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 24 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 25 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 26 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 27 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 28 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 29 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 30 mg / m 2 is administered at a dose of

[0143] In some embodiments, BT1718 is about 31 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 32 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 33 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 34 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 35 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 36 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 37 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 38 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 39 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 40 mg / m 2 is administered at a dose of

[0144] In some embodiments, BT1718 is about 41 mg / m 2In some embodiments, BT1718 is administered at a dose of about 42 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 43 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 44 mg / m 2 In some embodiments, BT1718 is administered at a dose of about 45 mg / m 2 is administered at a dose of Route of administration

[0145] As described herein, BT1718 is administered intravenously. Dosage schedule

[0146] As described herein, BT1718 is administered intravenously once a week for three out of four weeks.As described herein, BT1718 is administered intravenously twice a week for three out of four weeks.

[0147] In some embodiments, BT1718 is administered at about 0.6-9.6 mg / m twice weekly. 2 In some embodiments, BT1718 is administered intravenously at a dose of about 0.6 mg / m twice weekly. 2 In some embodiments, BT1718 is administered intravenously at a dose of about 1.2 mg / m twice weekly. 2 In some embodiments, BT1718 is administered intravenously at a dose of about 2.4 mg / m twice weekly. 2 In some embodiments, BT1718 is administered intravenously at a dose of about 4.8 mg / m twice weekly. 2 In some embodiments, BT1718 is administered intravenously at a dose of about 7.2 mg / m twice weekly. 2 In some embodiments, BT1718 is administered intravenously at a dose of about 9.6 mg / m twice weekly. 2 It is administered intravenously at a dose of

[0148] In some embodiments, BT1718 is administered by infusion for about 1 hour at each administration. In some embodiments, BT1718 is administered intravenously at an infusion rate of about 0.015-0.245 mg / kg / hour twice weekly. In some embodiments, BT1718 is administered intravenously at an infusion rate of about 0.015 mg / kg / hour twice weekly. In some embodiments, BT1718 is administered intravenously at an infusion rate of about 0.031 mg / kg / hour twice weekly. In some embodiments, BT1718 is administered intravenously at an infusion rate of about 0.061 mg / kg / hour twice weekly. In some embodiments, BT1718 is administered intravenously at an infusion rate of about 0.123 mg / kg / hour twice weekly. In some embodiments, BT1718 is administered intravenously at an infusion rate of about 0.184 mg / kg / hour twice weekly. In some embodiments, BT1718 is administered intravenously at an infusion rate of about 0.245 mg / kg / hour twice weekly.

[0149] In some embodiments, BT1718 is administered at the doses and schedules set forth in FIGS. Pharmacokinetic data

[0150] In some embodiments, CLp is about 10 mL / min / kg to 12 mL / min / kg. In some embodiments, CLp is about 10 mL / min / kg. In some embodiments, CLp is about 12 mL / min / kg. In some embodiments, CLp is about 11 mL / min / kg.

[0151] In some embodiments, t1 / 2 is about 10-20 minutes. In some embodiments, t1 / 2 is about 10 minutes. In some embodiments, t1 / 2 is about 11 minutes. In some embodiments, t1 / 2 is about 12 minutes. In some embodiments, t1 / 2 is about 13 minutes. In some embodiments, t1 / 2 is about 14 minutes. In some embodiments, t1 / 2 is about 15 minutes. In some embodiments, t1 / 2 is about 16 minutes. In some embodiments, t1 / 2 is about 17 minutes. In some embodiments, t1 / 2 is about 18 minutes. In some embodiments, the t is about 19 minutes. In some embodiments, the t is about 20 minutes. Pharmaceutically acceptable compositions

[0152] According to another embodiment, the present invention provides a composition comprising BT1718, or a pharma- ceutically acceptable salt thereof, and a pharma- ceutically acceptable carrier, adjuvant, or vehicle.

[0153] As used herein, the term "pharmaceutically acceptable salt" refers to a salt that is within the scope of good medical judgment, suitable for use in contact with the tissues of humans and lower animals without undue toxicity, irritation, allergic reaction, etc., and commensurate with a reasonable benefit / risk ratio. Pharmaceutically acceptable salts are well known in the art. For example, SM Berge et al. describe pharmaceutically acceptable salts in detail in J. Pharmaceutical Sciences, 1977, 66, 1-19, which is incorporated herein by reference. Pharmaceutically acceptable salts of the compounds of the present invention include salts derived from suitable inorganic and organic acids and bases. Examples of pharmaceutically acceptable non-toxic acid addition salts are salts of amino groups formed with inorganic acids such as hydrochloric acid, hydrobromic acid, phosphoric acid, sulfuric acid, and perchloric acid, or with organic acids such as acetic acid, oxalic acid, maleic acid, tartaric acid, citric acid, succinic acid, or malonic acid, or by using other methods used in the art, such as ion exchange. Other pharma- ceutically acceptable salts include adipate, alginate, ascorbate, aspartate, benzenesulfonate, benzoate, bisulfate, borate, butyrate, camphorate, camphorsulfonate, citrate, cyclopentanepropionate, digluconate, dodecyl sulfate, ethanesulfonate, formate, fumarate, glucoheptanoate, glycerophosphate, gluconate, hemisulfate, heptanoate, hexanoate, hydroiodide, 2-hydroxy-ethanesulfate, and 1,2-dimethyl-2,3-trimethylsilyl 1,2-dihydro ... Examples of the salts include sulfonate, lactobionate, lactate, laurate, lauryl sulfate, malate, maleate, malonate, methanesulfonate, 2-naphthalenesulfonate, nicotinate, nitrate, oleate, oxalate, palmitate, pamoate, pectinate, persulfate, 3-phenylpropionate, phosphate, pivalate, propionate, stearate, succinate, sulfate, tartrate, thiocyanate, p-toluenesulfonate, undecanoate, and valerate.

[0154] Salts derived from appropriate bases include alkali metal salts, alkaline earth metal salts, ammonium salts and N+ (C 1~4 Representative alkali or alkaline earth metal salts include sodium, lithium, potassium, calcium, magnesium, and the like. Where appropriate, alternative pharma- ceutically acceptable salts include non-toxic ammonium, quaternary ammonium, and amine cations formed using counterions such as halides, hydroxides, carboxylates, sulfates, phosphates, nitrates, lower alkylsulfonates, and arylsulfonates.

[0155] The term "subject" as used herein is used interchangeably with the term "patient" and refers to an animal, preferably a mammal. In some embodiments, the subject or patient is a human. In other embodiments, the subject (or patient) is an animal subject (or patient). In some embodiments, the animal subject (or patient) is a canine, feline, or equine subject.

[0156] The term "pharmaceutically acceptable carrier, adjuvant, or vehicle" refers to a non-toxic carrier, adjuvant, or vehicle that does not destroy the pharmacological activity of the compound with which it is formulated. Pharmaceutically acceptable carriers, adjuvants, or vehicles that can be used in the compositions of the present invention include, but are not limited to, ion exchangers, alumina, sucrose, ethyl acetate ... Examples of suitable additives include aluminum tearate, lecithin, serum proteins such as human serum albumin, buffer substances such as phosphates, glycine, sorbic acid, potassium sorbate, partial glyceride mixtures of saturated vegetable fatty acids, water, salts or electrolytes such as protamine sulfate, disodium hydrogen phosphate, potassium hydrogen phosphate, sodium chloride, zinc salts, colloidal silica, magnesium trisilicate, polyvinylpyrrolidone, cellulose-based substances, polyethylene glycol, sodium carboxymethylcellulose, polyacrylates, waxes, polyethylene-polyoxypropylene-block polymers, polyethylene glycol and wool fat.

[0157] The compositions of the present invention can be administered orally, parenterally, by inhalation spray, topically, rectally, nasally, bucally, vaginally or via an implanted reservoir. The term "parenterally" as used herein includes subcutaneous, intravenous, intramuscular, intra-articular, intrasynovial, intrasternal, intrathecal, intrahepatic, intralesional and intracranial injection or infusion techniques. The compositions are preferably administered orally, intraperitoneally or intravenously. Sterile injectable forms of the compositions of the present invention can be aqueous or oily suspensions. These suspensions can be formulated according to techniques known in the art using suitable dispersing or wetting agents and suspending agents. The sterile injectable preparations can also be sterile injectable solutions or suspensions in non-toxic parenterally acceptable diluents or solvents, such as, for example, a solution in 1,3-butanediol. Acceptable vehicles and solvents that can be used include water, Ringer's solution and isotonic saline. In addition, sterile, non-volatile oils are conventionally used as solvents or suspending media.

[0158] For this purpose, any non-irritating fixed oil can be used, including synthetic mono- or diglycerides.Fatty acids such as oleic acid and its glyceride derivatives are useful in the preparation of injections, as well as natural pharmaceutically acceptable oils such as olive oil or castor oil, especially their polyoxyethylated versions.These oil solutions or suspensions can also contain long-chain alcohol diluents or dispersants, such as carboxymethylcellulose or similar dispersants that are commonly used to formulate pharmaceutically acceptable dosage forms, including emulsions and suspensions.Other commonly used surfactants, such as Tweens, Spans, and other emulsifying agents or bioavailability enhancers that are commonly used to produce pharmaceutically acceptable solid, liquid, or other dosage forms, can also be used for formulation.

[0159] The pharmaceutically acceptable composition of the present invention can be orally administered in any orally acceptable dosage form, including but not limited to capsule, tablet, aqueous suspension or solution.In the case of tablet for oral use, commonly used carriers include lactose and corn starch.Also generally added lubricant such as magnesium stearate.For oral administration in the form of capsule, useful diluents include lactose and dried corn starch.When aqueous suspension is required for oral use, active ingredient is combined with emulsifying agent and suspending agent.If desired, certain sweetener, flavoring agent or coloring agent can also be added.

[0160] Alternatively, the pharma- ceutically acceptable composition of the present invention can be administered in the form of suppositories for rectal administration.These can be prepared by mixing the drug with a suitable non-irritating excipient that is solid at room temperature but liquid at rectal temperature, and therefore melts in the rectum to release the drug.Such materials include cocoa butter, beeswax and polyethylene glycol.

[0161] The pharma- ceutically acceptable compositions of this invention are useful in treating various conditions, particularly when the target of treatment includes areas or organs readily accessible by topical application, including diseases of the eye, the skin, or the lower intestinal tract. Suitable topical formulations are readily prepared for each of these areas or organs.

[0162] Topical application for the lower intestinal tract can be effected in a rectal suppository formulation (see above) or in a suitable enema formulation. A topical transdermal patch may also be used.

[0163] For topical application, the provided pharma- ceutically acceptable composition can be formulated into a suitable ointment, containing the active ingredient suspended or dissolved in one or more carriers.Carriers for topical administration of the compounds of the present invention include, but are not limited to, mineral oil, liquid petrolatum, white petrolatum, propylene glycol, polyoxyethylene, polyoxypropylene compounds, emulsifying wax and water.Alternatively, the provided pharma-ceutically acceptable composition can be formulated into a suitable lotion or cream, containing the active ingredient suspended or dissolved in one or more pharma-ceutically acceptable carriers.Suitable carriers include, but are not limited to, mineral oil, sorbitan monostearate, polysorbate 60, cetyl ester wax, cetearyl alcohol, 2-octyldodecanol, benzyl alcohol and water.

[0164] For ophthalmic use, the provided pharma- ceutically acceptable compositions can be formulated as a micronized suspension in isotonic, pH-adjusted, sterile saline, with or without a preservative, such as benzylalkonium chloride, or, preferably, as a solution in isotonic, pH-adjusted, sterile saline. Alternatively, for ophthalmic use, the pharma-ceutically acceptable compositions can be formulated in an ointment, such as petrolatum.

[0165] The pharma- ceutically acceptable compositions of the invention may also be administered by nasal aerosol or inhalation.Such compositions are prepared by techniques well known in the art of pharmaceutical formulation and may be prepared as a solution in saline using benzyl alcohol or other suitable preservatives, absorption enhancers to enhance bioavailability, fluorocarbons, and / or other conventional solubilizing or dispersing agents.

[0166] In certain embodiments, the pharma- ceutically acceptable composition of the present invention is formulated for oral administration. Such formulations can be administered with or without food. In some embodiments, the pharma- ceutically acceptable composition of the present invention is administered without food. In other embodiments, the pharma- ceutically acceptable composition of the present invention is administered with food.

[0167] The pharma- ceutically acceptable compositions of the invention can be administered to humans and other animals orally, rectally, parenterally, intracisternally, intravaginally, intraperitoneally, topically (such as by powders, ointments, or drops), bucally, as an oral or nasal spray, etc., depending on the severity of the infection being treated. In certain embodiments, the compounds of the invention can be administered orally or parenterally at dosage levels of about 0.01 mg to about 50 mg per kg of subject body weight per day, and preferably from about 1 mg / kg to about 25 mg / kg, one or more times per day to obtain the desired therapeutic effect.

[0168] Liquid dosage forms for oral administration include, but are not limited to, pharma- ceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs.In addition to the active compound, liquid dosage forms contain an inert diluent commonly used in the art, such as water or other solvents, solubilizers and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, dimethylformamide, oils (especially cottonseed oil, peanut oil, corn oil, germ oil, etc.), and / or other suitable solvents. Oils such as olive oil, castor oil, and sesame oil, glycerol, tetrahydrofurfuryl alcohol, polyethylene glycol, and fatty acid esters of sorbitan, and the like, and mixtures thereof. In addition to inert diluents, the oral compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening agents, flavoring agents, and perfuming agents.

[0169] Injectable preparations, for example, sterile injectable aqueous or oleaginous suspensions, can be formulated according to known techniques using suitable dispersants or wetting agents and suspending agents. Sterile injectable preparations can be sterile injectable solutions, suspensions or emulsions in non-toxic parenterally acceptable diluents or solvents, such as solutions in 1,3-butanediol. Acceptable vehicles and solvents that can be used include water, Ringer's solution, USP and isotonic saline. In addition, sterile non-volatile oils are conventionally used as solvents or suspending media. For this purpose, any non-irritating non-volatile oils, including synthetic mono- or diglycerides, can be used. In addition, fatty acids such as oleic acid are used in the preparation of injectables.

[0170] The injectable preparations can be sterilized, for example, by filtration through a bacterial-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved or dispersed in sterile water or other sterile injectable medium prior to use.

[0171] To prolong the effect of BT1718, it may be desirable to slow the absorption of the compound from subcutaneous or intramuscular injection. This can be accomplished by using a liquid suspension of crystalline or amorphous material with poor water solubility. The rate of absorption of the compound then depends on its rate of dissolution, which in turn may depend on crystal size and crystalline form. Alternatively, delayed absorption of a parenterally administered compound form is accomplished by dissolving or suspending the compound in an oil vehicle. Injectable depot forms are prepared by forming microencapsule matrices of the compound in biodegradable polymers such as polylactide-polyglycolide. Depending on the ratio of compound to polymer and the nature of the particular polymer used, the release rate of the compound can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly(anhydrides). Depot injectable formulations are also prepared by entrapping the compound in liposomes or microemulsions that are compatible with body tissues.

[0172] Compositions for rectal or vaginal administration are preferably suppositories which can be prepared by mixing the compounds of the present invention with a suitable non-irritating excipient or carrier such as cocoa butter, polyethylene glycol or a suppository wax which is solid at ambient temperature but liquid at body temperature and therefore will melt in the rectum or vaginal cavity and release the active compound.

[0173] Solid dosage forms for oral administration include capsules, tablets, pills, powders, and granules. In such solid dosage forms, the active compound is mixed with at least one inert pharma- ceutically acceptable excipient or carrier, such as, for example, sodium citrate or dicalcium phosphate, and / or a) fillers or extenders, such as, for example, starches, lactose, sucrose, glucose, mannitol, and silicic acid; b) binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidinone, sucrose, and acacia; c) humectants, such as, for example, glycerol; d) disintegrating agents, such as, for example, agar-agar, calcium carbonate, potato or tapioca starch, alginates, certain silicates, and sodium carbonate; e) solution retarding agents, such as, for example, paraffin; f) absorption accelerators, such as, for example, quaternary ammonium compounds; g) wetting agents, such as, for example, cetyl alcohol and glycerol monostearate; h) absorbents, such as, for example, kaolin and bentonite clay; and i) lubricants, such as, for example, talc, stearic acid. Calcium, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, and the like, and mixtures thereof. In the case of capsules, tablets and pills, the dosage forms may also comprise buffering agents.

[0174] The same kind of solid composition can also be used as a filler in soft-filled gelatin capsules and hard-filled gelatin capsules, using excipients such as lactose or milk sugar and high molecular weight polyethylene glycol. The solid dosage forms of tablets, dragees, capsules, pills, and granules can be prepared with coatings and shells, such as enteric coatings and other coatings well known in the pharmaceutical formulation art. These solid dosage forms can optionally contain opacifying agents, and can also be of a composition that releases the active ingredient only, or preferentially, in a certain part of the intestinal tract, optionally in a delayed manner. Examples of embedding compositions that can be used include polymeric substances and waxes. The same kind of solid composition can also be used as a filler in soft-filled gelatin capsules and hard-filled gelatin capsules, using excipients such as lactose or milk sugar and high molecular weight polyethylene glycol.

[0175] BT1718 or its pharma-ceutically acceptable salts can also be in the form of microencapsulation with one or more of the above-mentioned excipients. Tablets, dragees, capsules, pills, and granules solid dosage forms can be prepared with coatings and shells, such as enteric coatings, release-controlling coatings, and other coatings well known in the art of pharmaceutical formulation. In such solid dosage forms, the active compound can be mixed with at least one inert diluent, such as sucrose, lactose, or starch. Such dosage forms can also contain additional substances other than inert diluents, as is customary, such as tableting lubricants and other tableting aids, such as magnesium stearate and microcrystalline cellulose. In the case of capsules, tablets, and pills, the dosage forms can also contain buffering agents. These dosage forms can optionally contain opacifying agents, and can also be of a composition that releases the active ingredient only or preferentially, optionally in a delayed manner, in a certain part of the intestinal tract. Examples of embedding compositions that can be used include polymeric substances and waxes.

[0176] The topical or transdermal dosage forms of the compounds of the present invention include ointments, pastes, creams, lotions, gels, powders, solutions, sprays, inhalants or patches. The active ingredient is mixed under sterile conditions with a pharma- ceutically acceptable carrier and any necessary preservatives or buffers as required. Eye drop formulations, ear drops, and eye drops are also contemplated to be within the scope of the present invention. In addition, the present invention contemplates the use of transdermal absorption patches, which have the added advantage of providing controlled delivery of the compound to the body. Such dosage forms can be made by dissolving or dispensing the compound in a suitable medium. Absorption enhancers can also be used to increase the flux of the compound across the skin. The rate can be controlled by either providing a rate-limiting membrane or dispersing the compound in a polymer matrix or gel. EXAMPLES

[0177] The following examples illustrate the above-mentioned invention, but do not limit the scope of the invention in any way. The beneficial effects of the pharmaceutical compounds, combinations and compositions of the present invention can also be determined by other test models known per se to those skilled in the art. Example 1 A Phase I / IIA Study of Intravenous BT1718 in Patients with Advanced Solid Tumors Study design Clinical Trial Objectives and Endpoints Primary Objectives and Endpoints

[0178] The primary objectives and endpoints are presented in Table 5 below. Table 5. Primary Objectives and Endpoints [Table 5]

[0179] Secondary objectives and endpoints are presented in Table 6 below. Table 6. Secondary objectives and endpoints. [Table 6]

[0180] The tertiary objectives and endpoints are presented in Table 7 below. Table 7. Tertiary objectives and endpoints. [Table 7-1] [Table 7-2]

[0181] Clinical trial design

[0182] This is a multicenter, FIH, Phase I / IIa, open-label, dose-escalation study with expansion phase in patients with advanced solid tumors.

[0183] This clinical trial consists of two phases, Phase I and Phase IIa (Figure 4).

[0184] Phase I, dose escalation phase:

[0185] Phase I consists of Stage 1 and Stage 2. Stage 2 can begin before Stage 1 is completed:

[0186] Stage 1 - BT1718 is administered intravenously twice weekly for 3 out of 4 weeks until RP2D and / or MTD are established.

[0187] Single-patient cohorts 1, 2, 3, and 4 on the twice-weekly schedule were completed without significant toxicity, reached target thresholds, and triggered a 3+3 escalation. Cohort 5 (9.6 mg / m 2 ) was completed with 2 × DLT (GGT, fatigue) and 7.2 mg / m 2 A cohort of 100 mg / kg / day was opened, with weekly titration also being opened (9.6 mg / m 2 ).

[0188] Stage 2 - BT1718 is administered intravenously once weekly for 3 out of 4 weeks until the RP2D and / or MTD is established.

[0189] Stage 2 will be opened at doses where potential biological activity is expected based on available toxicity, PK and / or PD data from Stage 1. This stage will follow a 3+3 dose escalation design and include a minimum of 3 evaluable patients at each dose level. Dose escalation will be up to 100% and will be driven by reported safety and available PK data.

[0190] Phase IIa, expansion phase

[0191] Phase IIa, an expansion at optimal dose / schedule, will further characterize tolerability and explore clinical signals in enriched populations with tumor types known to be commonly overexpressed in MT1-MMP and where MT1-MMP overexpression was identified during prospective selection at enrollment. These tumor types are currently proposed to include NSCLC, TNBC or sarcoma.

[0192] Part A - BT1718 will be administered intravenously twice weekly at the MTD and / or RP2D established in Phase I, Stage 1. 14 patients will be included, consisting of equal numbers of patients from the two indications with MT1-MMP positive tumors currently proposed to be NSCLC and TNBC. At least 6 patients will have paired tumor biopsies pre- and on-treatment. Phase IIa, Part A (twice weekly, expansion) can be run in parallel with Phase I, Stage 2 (once weekly, dose escalation).

[0193] Part B - BT1718 will be administered intravenously once weekly at the MTD and / or RP2D established in Phase I, Stage 2. Fourteen patients will be included, consisting of an equal number of patients with MT1-MMP positive tumors currently proposed to be NSCLC and TNBC. At least six patients will have paired pre- and on-treatment tumor biopsies. Phase IIa, Part B (weekly, expansion) can be run in parallel with Phase I, Stage 1 (twice weekly, dose escalation).

[0194] Part C & Part D - After completion of Parts A and B, the results will be reviewed by the Joint Development Committee, consisting of team members from the sponsor BicycleRD and CIs. After review of the data generated to date in Phase I (Stages 1 and 2) and Phase IIa (Parts A and B), a decision will be made regarding which dosing scheme will be used (once or twice weekly), the starting dose and which tumors are indicated. Following this decision, up to two additional cohorts of approximately 15-16 patients each will be enrolled in Parts C and D, respectively, with the patient population being selected based on preclinical and clinical emerging data. These tumor types are currently proposed to include NSCLC, TNBC or sarcoma.

[0195] The study is expected to enroll 50-60 patients with advanced solid tumors whose tumors have progressed despite any appropriate standard of care in Phase I, Stages 1 and 2. The final patient population will depend on the number of dose escalations required to identify the MTD and / or RP2D for one or more dosing schedules.

[0196] The sponsor may consider alternative dosing schedules based on new data during the study, for example, continuous twice-weekly dosing may be evaluated if the toxicology profile is benign with a twice-weekly dosing regimen. New data obtained during Phase I may be used to advance the study to the Phase IIa stage. Additionally, increased dosing frequency may be considered depending on the selected patient population. Any changes to the dosing schedule will be submitted to the MHRA, REC and HRA for approval. In Phase IIa, Parts A, B, C and D, up to an additional 60-70 patients are expected to be identified based on preclinical and clinical data and evaluated for up to three tumor types currently proposed to be NSCLC, TNBC and sarcoma.

[0197] In Phase I, Stage 1, BT1718 is administered intravenously twice weekly for 3 out of 4 weeks (dosing on days 1, 4, 8, 11, 15, and 18). The starting dose is 0.6 mg / m 2 Each cycle lasts 28 days. Patients can continue treatment until disease progression (subject to availability of BT1718).

[0198] In Phase I, Stage 2, BT1718 will be administered intravenously once weekly for 3 out of 4 weeks (dosing on days 1, 8, and 15). The starting dose of the once weekly regime will be up to 100% of the overall weekly dose of the last completed cohort deemed safe from the twice weekly schedule (Phase I, Stage 1). Patients may continue treatment until disease progression (subject to BT1718 availability).

[0199] Definition of dose-limiting toxicity

[0200] Some of the definitions of DLT and MTD are derived from NCI CTCAE Version 4.02. Note that not all events listed as DLTs are fully supported by the NCI CTCAE, but are formed by a mixture of different events to aid in the evaluation of AEs.

[0201] DLTs are defined as likely or very likely drug-related AEs occurring during Cycle 1 (i.e., the first 28 days) that meet one or more of the following criteria despite adequate supportive clinical management (however, all clinically significant toxicities will be considered in dose screening decisions and Phase II dose determinations): Grade 4 neutropenia (absolute neutrophil count [ANC] < 0.5 × 10) for ≥ 7 days 9 / L), *see notes; Febrile neutropenia with grade 3 or 4 neutropenia (ANC < 1.0 × 10 9 / L and a single body temperature of 38.3°C or higher or a temperature of 38°C or higher sustained for more than 1 hour); Grade 3 or 4 neutropenia (ANC < 1.0 × 10 9 / L) clinically significant infection (clinically or microbiologically demonstrated); Grade 4 thrombocytopenia: a) for more than 5 days, *see notes, or b) with active bleeding, or c) Requires platelet transfusion. Grade 3 or 4 toxicity to organs other than bone marrow, excluding the following: grade 3 nausea; Grade 3 or 4 vomiting in patients not receiving optimal antiemetic treatment; or Grade 3 or 4 diarrhea in patients not receiving optimal treatment with antidiarrheal medications. Transient, asymptomatic, grade 3 biochemical abnormalities, with the consent of the study sponsor and the study team, including the Chief Investigator (CI). Fatal events; any other relevant toxicity leading to discontinuation of treatment in cycle 1 or a delay in dosing of more than 7 days (excluding cases where the delay was due to scheduling rather than a clinical decision and exceeded 7 days); CI and any other relevant toxicities greater than baseline that are deemed to be DLTs by the sponsor, including the Principal Investigator (PI).

[0202] *Note: If Grade 4 neutropenia or Grade 4 thrombocytopenia occurs, a complete blood count must be performed at least 7 days (neutropenia) and 5 days (thrombocytopenia) after the event to determine if a DLT has occurred. Investigators should continue to monitor patients closely until resolution to Grade 3 or less.

[0203] Dose-limiting toxicities, as defined above, will be taken into account for purposes of determining dose escalation, but also in determining either the next dose level or the RP2D if cumulative toxicity becomes evident.

[0204] Definition of maximum tolerated dose

[0205] If one case of DLT as defined (in the dose limit section above) is observed in a cohort of three patients, a maximum of six total patients will be treated at that dose level. If one of six patients experiences a DLT, continue dose escalation. If two or more of up to six patients experience a DLT, stop dose escalation and define the dose as intolerable. To define the MTD, a maximum of six evaluable patients will be treated at a dose below the intolerable level.

[0206] The MAD is defined as the highest dose that can be tolerated. This usually represents an intolerable dose above the MTD, but may instead represent the maximum dose that can be administered when the dose is limited by the feasible infusion volume before toxicity limits the dose.

[0207] The RP2D for the expansion phase (Parts A and B) will be determined after all clinically relevant toxicity, efficacy data, and PK outcome data for both once-weekly and twice-weekly dosing have been reviewed by the CI, PI, and Sponsor's Medical Advisor. All available data from all cycles and cohorts of treatment will be included and any significant toxicities will be taken into account in determining the RP2D.

[0208] Patient evaluability

[0209] response

[0210] All patients who meet the eligibility criteria, receive ≥75% of the planned exposure dose of BT1718, and have a baseline assessment of disease and at least one repeat disease assessment are evaluable for response.

[0211] A repeat assessment at least 4 weeks later is required to determine whether a patient has a complete or partial response (CR or PR). To be assigned to SD status, follow-up measurements must meet SD criteria at least once and at least 6 weeks after administration of the first dose of BT1718.

[0212] safety

[0213] All patients who meet the eligibility criteria and receive at least one dose of BT1718 will be evaluable for safety.

[0214] Dose escalation

[0215] In the Phase I, Stage I, single-patient dose escalation phase of this study, each patient must have received all of their planned BT1718 doses during cycle 1 (28-day DLT period) in order for a decision to be made to escalate to the next single-patient cohort. If a patient has not received all of their planned BT1718 doses during that cycle for reasons other than toxicity, it may be necessary to recruit additional evaluable patients before a decision can be made.

[0216] Once the dose escalation cohorts have been expanded according to the 3+3 design, patients must have received ≥75% of their planned BT1718 exposure dose during the first cycle (28-day DLT period) in order to undergo dose escalation. If any patient in the 3-6 patient cohort receives <75% of their planned dosing during the first cycle (28-day DLT period) for reasons other than BT1718-related toxicity, it may be necessary to recruit additional evaluable patients before a decision can be made.

[0217] Patient Selection

[0218] Eligibility Criteria

[0219] Patients must meet the eligibility criteria listed in Table 8 below: Table 8. Inclusion criteria. [Table 8-1] [Table 8-2] [Table 8-3]

[0220] Exclusion criteria

[0221] The exclusion criteria are presented in Table 9 below. Table 9. Exclusion criteria [Table 9-1] [Table 9-2]

[0222] Patient Enrollment

[0223] Prior to enrolling a patient in the study, the study investigator or designated representative will conduct a study screening Patient eligibility should be determined during the review period.

[0224] Eligible patients should be enrolled in the Electronic Data Capture (EDC) system by site staff and then formally enrolled at the Centre for Drug Development (CDD) before treatment with BT1718 begins. Eligible patients will be assigned a study number by the EDC system during the enrollment process. After enrolling the patient, the CDD will send confirmation of the patient's formal enrollment, including the assigned dose level, to the investigator. Study treatment may only be administered once confirmation has been received.

[0225] treatment

[0226] Phase I Starting Dose and Schedule Selection

[0227] The HNSTD established in a 28-day repeated-dose GLP monkey study was 18 mg / m 2 Using allometric scaling and applying the standard safety factor of 6 (ICH S9), the human starting dose was 3 mg / m 2 In a GLP-compliant study in rats, the highest dose of 6 mg / m 2 Using allometric scaling and the standard safety factor of 10 (ICH S9), the human starting dose was 0.6 mg / m 2 twice weekly (which is approximately 0.12 mg / m 2(equivalent to a DM1 dose twice weekly). Since rats are a species more sensitive to BT1718, the starting dose will be based on the MTD in rats.

[0228] Therefore, the proposed starting dose for the FIH Phase I trial was 0.6 mg / m 2 That is twice a week.

[0229] Medication Schedule / Treatment Schedule

[0230] Phase I, Dose Escalation Phase, Stage 1, Dosing Schedule / Treatment Schedule

[0231] BT1718 is administered intravenously twice weekly for 3 out of 4 weeks (dosing on days 1, 4, 8, 11, 15 and 18 + / - 1). Each cycle of treatment consists of 28 days and patients may continue until disease progression, depending on the availability of BT1718. The starting dose is 0.6 mg / m 2 Let us assume that.

[0232] Phase I, Dose Escalation Phase, Stage 2, Dosing Schedule / Treatment Schedule

[0233] In addition to evaluating the twice-weekly dosing schedule in Stage 1 above, a once-weekly dosing schedule will also be evaluated in Stage 2. Stage 2 will be opened at doses that are expected to have potential biological activity based on available PK, toxicity and / or PD data from Stage 1.

[0234] BT1718 will be administered intravenously once weekly for 3 out of 4 weeks (dosing on days 1, 8 and 15 + / - 1). Each cycle of treatment will consist of 28 days and patients may continue until disease progression, depending on the availability of BT1718. The starting dose of the once weekly regime will be up to 100% of the overall weekly dose of the last completed cohort deemed safe from the twice weekly schedule (Phase I, Stage 1). Stage 2 will include a minimum of 3 evaluable patients according to a 3+3 design and can be evaluated in parallel with recruitment to the Phase IIa, Part A twice weekly dose expansion phase (see Figure 3).

[0235] Sponsors may consider alternative dosing schedules based on emerging data during the study. For example, if the toxicology profile is benign with a twice-weekly dosing regimen, continuous twice-weekly dosing can be evaluated. New data obtained during Phase I can be used to decide to proceed to the Phase IIa stage. Furthermore, depending on the selected patient population, an increase in dosing frequency can also be considered. If any changes are made to the dosing schedule, a substantive revision is submitted to the MHRA, REC and HRA for approval.

[0236] Phase IIa, Expansion Phase (Part A)

[0237] BT1718 will be administered intravenously twice weekly with the RP2D and schedule defined by Phase I, Stage 1. Phase IIa, Part A can begin when the RP2D for twice weekly dosing is available, so this expansion can be evaluated in parallel with the ongoing supplementation to once weekly dose escalation in Phase I, Stage 2 (see above and Figure 4).

[0238] Phase IIa, Expansion Phase (Part B)

[0239] BT1718 will be administered intravenously once weekly with the RP2D and schedule defined by Phase I, Stage 2. Phase IIa, Expansion Part B can begin when the RP2D for once weekly dosing is available, thus this expansion can be evaluated in parallel with the ongoing twice weekly, Phase I, Stage 1 dose escalation (if refills for this stage are ongoing) or Phase IIa, Expansion (Part A).

[0240] Phase IIa, Expansion Phase (Parts C&D)

[0241] After completion of parts A and B, the results will be reviewed. After review of the data generated to date in phase I, stages 1 and 2, and phase IIa, parts A and B, a decision will be made regarding which dosing scheme will be used (once or twice weekly), the starting dose, and which tumors are indicated. Following this decision, up to two additional cohorts of approximately 15-16 patients each will be enrolled in parts C and D, with patient populations selected based on preclinical and clinical emerging data. These tumor types are currently proposed to include NSCLC, TNBC, or sarcoma. Selection biomarkers or thresholds may also be reviewed prior to parts C and D.

[0242] Dose Escalation Scheme

[0243] Phase I, dose escalation phase, stage 1- (twice weekly dosing)

[0244] In Phase I, dose escalation phase, Stage 1, dose escalation will be initially up to 100% in a single patient cohort, driven by reported safety data and any available PK data, until the first CTCAE grade 2 toxicity deemed by the investigator to be at least likely related to BT1718 is observed or until the dose is increased to 6 mg / m 2 twice weekly (i.e., 12 mg / m2 over the week) 2) until the dose exceeds 100%. Subsequent cohorts will revert to the standard 3+3 format with dose escalation steps to 100% driven by reported safety and available PK data. If a single DLT is seen among the first 3 patients, the cohort will be expanded to a maximum of 6 evaluable patients total. If <2 of 6 evaluable patients experience a DLT, the dose will be considered tolerable.

[0245] In single-patient cohorts, the next patient will be enrolled once the previous patient has completed the DLT period (first 28 days). Once the sponsor and study team deem it safe to proceed to the next cohort, they will receive their first dose of BT1718. In the 3+3 patient cohort, the first patient will be observed for toxicity from Day 1 through Day 7 before subsequent patients receive their first dose of BT1718.

[0246] Patients who receive less than 75% of their planned dosing during the first cycle (28-day DLT period) for reasons other than toxicity are not evaluable for evaluation of DLT for dose screening decisions and may be returned to that cohort. However, reported safety information for these patients may be considered as a guide for the percentage change in dose level. A required number of evaluable patients must have completed one cycle (approximately 28 days) before a decision to escalate the dose of BT1718 can be made.

[0247] Phase I, Dose Escalation, Stage 2- (Weekly dosing)

[0248] In Phase I, dose escalation phase (Stage 2), dose escalation may be up to 100% of the previous dose level and is driven by reported safety and available PK data. If a single DLT is seen among the first 3 patients, the cohort will be expanded to a maximum of 6 total evaluable patients. If DLT occurs in less than 2 of 6 evaluable patients, the dose will be considered tolerable.

[0249] In the 3+3 patient cohort, the first patient will be observed for toxicity from Day 1 to 7 days before subsequent patients receive their first dose of BT1718.

[0250] Patients who receive less than 75% of their planned dosing during the first cycle (28-day DLT period) for reasons other than toxicity are not evaluable for evaluation of DLT for dose screening decisions and may be returned to that cohort. However, reported safety information for these patients may be considered as a guide for the percentage change in dose level. A required number of evaluable patients must have completed one cycle (approximately 28 days) before a decision to escalate the dose of BT1718 can be made.

[0251] Intra-patient dose escalation

[0252] Intrapatient dose escalation is not permitted.

[0253] Dose level expansion

[0254] If one case of DLT as defined above is observed in a cohort of 3 patients, up to 6 patients will be treated at that dose level. If 1 of 6 patients experience a DLT, dose escalation will continue. If 2 or more of up to 6 patients experience a DLT, dose escalation will be stopped and the dose will be defined as intolerable. Up to 6 evaluable patients will be treated at a dose below the intolerable level to define the MTD.

[0255] The MAD is defined as the highest dose that can be tolerated. This usually represents an intolerable dose above the MTD, but may instead represent the maximum dose that can be administered when the dose is limited by the feasible infusion volume before toxicity limits the dose.

[0256] If new or multiple DLTs occur during the dose expansion phase at RP2D, dose levels for new patients in the expansion cohort may be reduced based on ongoing safety reports, which will be monitored continuously as well as formally evaluated after the first six patients have received two cycles of treatment.

[0257] Dose Modification

[0258] Dose delays and reductions

[0259] Patients who experience a DLT (only those defined in Cycle 1) that resolves to less than Grade 1 or returns to baseline within 15 days of initiation of the DLT may resume treatment with PI, sponsor, and patient consent. The dose should be reduced to the previous dose level. If the AE does not resolve or return to baseline within 15 days, the patient will be taken off study. If the patient experiences a DLT at this reduced dose, either of the same or a different toxicity, no further dose reductions will be made and the patient will be withdrawn from the study.

[0260] hematological toxicity

[0261] For patients who experience Grade 3 or greater hematologic toxicity, subsequent doses are omitted during that cycle until toxicity resolves to less than Grade 3. Once resolved to less than Grade 3, treatment may be resumed at the same dose level for that cycle.

[0262] If BT1718-related (likely or very likely) Grade 2 toxicity is still present when the patient is scheduled to start the next cycle, the cycle should be delayed for up to 14 days until toxicity has resolved to Grade 1 or less.

[0263] The first time a dose is omitted or delayed, the same dose may be given the next time, but if a subsequent omission or delay is necessary, the dose should be reduced to the previous dose level (unless in exceptional circumstances where the PI, sponsor, and patient agree that further dose omissions / delays are reasonable and will result in effective control of toxicity).

[0264] If toxicity does not return to less than grade 2 within 15 days, patients will be taken off the study.

[0265] Dose reductions will be permitted only once per patient, except in exceptional circumstances where the PI, sponsor, and patient agree that further treatment is warranted and that the dose reduction is expected to result in effective control of toxicity.

[0266] Non-hematological toxicity:

[0267] Grade 2

[0268] Patients who experience clinically significant Grade 2 non-hematologic toxicity related to BT1718 (likely or very likely) that is unresponsive to supportive clinical management (<7 days) will have subsequent doses omitted during that cycle until toxicity resolves to Grade 1 or less.

[0269] If clinically significant Grade 2 BT1718-related toxicity is still present when a patient is scheduled to start the next cycle, the cycle should be delayed for up to 14 days until toxicity has resolved to Grade 1 or less.

[0270] The first time a dose is omitted or delayed, it may be given at the same dose when restarted. However, if a subsequent omission or delay is necessary, the dose should be reduced to the previous dose level (assuming the PI, sponsor, and patient have discretion over further dose omissions / delays). (unless in exceptional circumstances where it is agreed that a delay is reasonable and will result in effective control of toxicity).

[0271] If toxicity does not return to grade 1 or less within 15 days, patients will be removed from the study.

[0272] Dose reductions will be permitted only once per patient, except in exceptional circumstances where the PI, sponsor, and patient agree that further treatment is warranted and that the dose reduction is expected to result in effective control of toxicity.

[0273] Grade 3

[0274] Patients who develop grade 3 non-hematologic toxicity that does not rapidly respond (<3 days) to supportive clinical management will have subsequent doses omitted during that cycle until toxicity resolves to grade 1 or less.

[0275] If clinically significant Grade 2 BT1718-related toxicity is still present when a patient is scheduled to start the next cycle, the cycle should be delayed for up to 14 days until toxicity has resolved to Grade 1 or less.

[0276] If a patient resumes treatment after grade 3 non-hematologic toxicity, the dose should be reduced to the previous dose level. If toxicity does not return to grade 1 or less within 15 days, the patient will be taken off study.

[0277] Dose reductions will be permitted only once per patient, except in exceptional circumstances where the PI, sponsor, and patient agree that further treatment is warranted and that the dose reduction is expected to result in effective control of toxicity.

[0278] Grade 4

[0279] Patients who developed grade 4 non-hematologic toxicity consistent with Hy's Law (bilirubin >2 × ULN and ALT / AST >3 × ULN, with no non-drug explanation) or changes in liver enzymes were discontinued for further treatment and removed from the study once test accuracy was confirmed.

[0280] Duration of the procedure

[0281] Treatment should be continued unless: (a) the patient requests to be withdrawn; (b) there is evidence of disease progression; (c) the patient is experiencing unacceptable toxicity; or (d) the investigator feels that the patient should be withdrawn for any other reason.

[0282] If the sponsor and CI agree that the patient is benefiting from treatment with BT1718 (i.e., has stable or responsive disease as measured by RECIST 1.1) and is not experiencing any clinically significant grade 2 or higher BT1718-related AEs, the patient may continue treatment until disease progression (subject to availability of BT1718), after which the patient will be withdrawn from the study. Follow-up information should be collected as described in the protocol (see below).

[0283] The Sponsor will review the complete toxicity and efficacy profile, including radiological data, to determine the objective response reported for the patient when considering whether the patient should continue on treatment. If the Sponsor decides not to continue the patient on treatment based on information provided or other information received, or for any other reason, the Sponsor will discontinue the study. The client's decision shall be final.

[0284] Patient replacement

[0285] Phase I, Dose Escalation Phase (Stage 1 and Stage 2)

[0286] If a patient receives less than 75% of the planned BT1718 exposure dose during the first cycle (28-day DLT period) for reasons other than BT1718-related (likely or very likely) toxicity, the patient will be replaced with another patient treated at the same dose level during the dose escalation phase. For single patient cohorts, patients may be replaced if they have not received all of their planned dosing.

[0287] Phase II, expansion phase

[0288] If a patient receives less than 75% of the planned exposure dose of BT1718 during the first cycle (28-day DLT period) for reasons other than drug-related (likely or very likely) toxicity, the patient will be replaced in the expansion cohorts (Parts A, B, C, and D) unless there is evidence of PD.

[0289] Patient replacement will be determined by the Sponsor. There may be circumstances where patient replacement does not occur based on new data from the study or BT1718 availability. This will be documented by the Sponsor.

[0290] Concomitant medications and treatments

[0291] Concomitant medications may be administered if medically necessary. This includes symptomatic clinical management of AEs related or unrelated to BT1718. Details (including names of concomitant medications and start and stop dates of concomitant medication) must be recorded in the patient's medical record and details entered into the electronic Case Report Form (eCRF).

[0292] Palliative radiation therapy may be given concomitantly to control bone pain or other symptoms. These irradiated lesions are not evaluable for response.

[0293] Patients must not receive any other anti-cancer treatments or investigational drugs during the study.

[0294] As noted above, dosing of BT1718 can also be delayed for up to 15 days if necessary to manage toxicity without requiring patients to withdraw from the study.

[0295] Sun exposure precautions

[0296] BT1718 absorbs in the UV spectrum (290-700 nm), especially in the 290-300 nm range, with a molar extinction coefficient of >1000 L mol -1 cm -1 As such, although there is no evidence of phototoxicity in patients with DM-1-containing drugs, it should be considered possible and precautions against UV exposure are necessary during treatment and for one week thereafter. Patients should avoid excessive sun exposure, and when outdoors during the day, patients should wear protective clothing, including hats and sunglasses where appropriate, and should apply a broad-spectrum sunscreen with a high sun protection factor (SPF 30 or higher) to any potentially exposed skin. Sunbeds should not be used.

[0297] Drug Information

[0298] Pharmaceutical Data

[0299] Formulation of BT1718

[0300] For clinical use, BT1718 drug product is supplied as a white to off-white lyophilized powder for reconstitution in 20 mL Type I clear glass vials with chlorobutyl stopper and aluminum seal. The actual drug content of the vial will be 21.2 mg of BT1718.

[0301] Storage conditions

[0302] All supplies must be stored in a secure, restricted access storage area within the hospital pharmacy. BT1718 must be stored in its original packaging at -20°C ± 5°C protected from light.

[0303] Method for preparation of IMP

[0304] Good sterile practice should be used in preparing solutions of BT1718 for injection.

[0305] BT1718 is reconstituted with 5.0 mL of sterile water for injection (to bring the solution back to a target volume of 5.3 mL) to provide a target concentration of 4.0 mg / mL BT1718 for further dilution with 5% dextrose prior to IV administration (by infusion). The vial contents ensure the availability of 20 mg of BT1718 per vial, based on a removable volume of 5.0 mL after reconstitution.

[0306] Stability of diluted BT1718

[0307] The solution prepared for infusion can be stored at 2-8 ° C for 20 hours, then at room temperature (21 ° C ± 4 ° C) for 4 hours before administration. Infusion must be completed within 2 hours. From a microbiological point of view, administration should be performed as soon as possible after preparation of the diluted drug.

[0308] BT1718 administration

[0309] The correct dose should always be double checked by a second qualified person prior to administration.

[0310] Monitoring during injection

[0311] Vital signs (temperature, pulse rate, BP) should be monitored before and after infusion and repeated if there is any concern during treatment or observation. Patients with diabetes should have glucose finger prick testing before and after each BT1718 infusion for at least the first two cycles and thereafter as clinically indicated.

[0312] To fully assess any adverse effects of BT1718, patients should not receive any premedication prior to their first infusion of BT1718 as primary prophylaxis. Should a patient experience any adverse effects of BT1718, they may be premedicated as a secondary prophylaxis prior to any subsequent infusions (e.g., dexamethasone, chlorphenamine or antiemetics). However, if emerging safety data suggest that premedication is necessary for all patients as primary prophylaxis, premedication will occur prior to Day 1 of Cycle 1 and for all infusions thereafter. The sponsor will ensure that this requirement is communicated to each investigator.

[0313] Granulocyte-macrophage colony-stimulating factor (GM-CSF) or granulocyte colony-stimulating factor (GCSF) should not be used in primary or secondary prophylaxis during the study, even to accelerate bone marrow recovery and increase dose density. However, therapeutic use of GM-CSF or GCSF is permitted when there is an acute clinical requirement for bone marrow support (e.g., therapeutically in cases of febrile neutropenia). Establishing the duration of any leukopenia, neutropenia, erythropenia or thrombocytopenia forms part of the DLT evaluation, so the use of GM-CSF or GCSF should be avoided within the patient's first cycle of BT1718 if possible, although patient safety and well-being remain the primary concerns in clinical decisions regarding bone marrow support.

[0314] Venous extravasation / accidental extravasation

[0315] DM1 and other chemotherapy drugs may cause extravasation and / or are vesicants, irritants, inflammatory agents or skin abrasors [56, 57], so as a precaution, BT1718 is treated as a vesicant. Careful attention should be paid to cannula placement, patency and any signs of extravasation during or after infusion. Standard local policies for management of vesicant extravasation should be followed, generally starting with the end of infusion, with topical hydrocortisone aspiration if possible, and continued review. The role of specific treatments such as hot or cold compresses, DMSO or hyaluronidase is unknown. Gloves and disposable aprons should be worn at all times during preparation, investigation, administration, disposal or management of extravasation of BT1718.

[0316] Survey Schedule

[0317] If patients undergo investigations at different hospitals, e.g. weekly blood samples, scans as required, and other investigations, it is their responsibility to ensure that the investigator receives and reviews the reported results. These results must be available for source data validation (SDV). Laboratory reference ranges, including effective dates and evidence of laboratory certification, must be obtained from all laboratories used. For scan results, the original images and reports must be available for comparison with any scans performed at the investigator's site and in a format suitable for comparison. For all other investigations, any supporting data for SDV or review, apart from the results, must be made available.

[0318] The Investigator or designee must inform the Sponsor of any changes in laboratory normal ranges or any laboratory certifications and provide any new documentation.

[0319] Pre-treatment evaluation

[0320] Details of all assessments / investigations for enrolled patients, including baseline dates, as required by the protocol must be recorded in the medical record.

[0321] Obtaining written informed consent

[0322] Written informed consent must be obtained from the patient prior to any protocol-specific procedures. You must obtain a copy of the

[0323] Consent for analysis of the initial archived or fresh screening tumor sample for MT1-MMP must be obtained before the sample is analyzed for the study and should be obtained prior to screening (prescreening consent) or at the time of consent to the full study (primary consent).

[0324] Patients should be given sufficient time to consider their obligations to the study. If more than 28 days have elapsed since informed consent was obtained before initiation of BT1718 dosing, the investigator should consider whether repeated consent should be obtained from the patient. If a newer approved version of the Informed Consent Document (ICD) is available, repeated consent should be obtained before any protocol-specific investigations are performed.

[0325] Only the PI and Sub-Investigators with delegated responsibilities by the PI and who have signed the Delegation Log are permitted to obtain informed consent from patients and sign consent forms. All signatures must be obtained before any intervention required by the protocol is performed. The patient should sign and date the consent form in the presence of the PI / Sub-Investigator, who will then sign it. The signature dates of both the patient and the PI / Sub-Investigator obtaining the informed consent should be the same.

[0326] The PI or subinvestigator must inform the patient about the background and current knowledge of the patient's disease and the usual management of BT1718 and must ensure that the patient is aware of the following:

[0327] BT1718 is new and the exact extent of its activity is currently unknown, but further knowledge will be gained as these patients undergo treatment;

[0328] the known toxicities and potential side effects of BT1718;

[0329] the potential risk of becoming pregnant (or of the patient's partner becoming pregnant) and that the patient has been informed of reasonable medically approved contraception;

[0330] that the patient may refuse treatment either before or at any time during the study, and that refusal to participate will not entail any penalty or loss of benefits to which he or she would otherwise be entitled;

[0331] Who should be contacted to answer relevant questions about the research and patient rights, and who should be contacted in the unlikely event of a research-related injury.

[0332] Prescreening (Phase IIa and expansion phase only)

[0333] In Phase IIa, the expansion phase, all patients should provide separate written consent before sending archival tissue for MT1-MMP IHC profiling or before obtaining and sending fresh screening tumor biopsies.

[0334] The following should be done / obtained within 6 months before patients receive their first dose:

[0335] Retrieval of archival samples - Recovery of archival tumor samples for MT1-MMP IHC profiling Revenue

[0336] Fresh tumor biopsy samples - If archived tumor samples for MT1-MMP IHC profiling are not available, obtain fresh tumor biopsies.

[0337] For patients for whom an archived tumor biopsy is unavailable or MT1-MMP IHC profiling is inconclusive, eligibility will be determined by a fresh screening tumor biopsy, which must be performed / obtained within 8 weeks before the patient is expected to be enrolled.

[0338] Evaluation within 28 days prior to the first dose of BT1718 (day -28 to day 1 of cycle 1)

[0339] The following must be performed / obtained within 28 days before the patient receives the first dose of BT1718. Pre-existing results, such as radiological measurements, may be used even if they were performed before the patient's informed consent for the study, provided they were performed within the required time window.

[0340] Demographic details

[0341] Medical history including diagnosis (histological or cytological), pre-treatment, concurrent conditions / diseases, baseline signs and symptoms, and concurrent treatments

[0342] Radiological Disease Assessment: Radiological measurements (computerized tomography [CT] or magnetic resonance imaging [MRI] scans of the chest, abdomen, pelvis, and any other relevant areas)-must be performed within 4 weeks before the patient receives the first dose of BT1718 and reported against RECIST Version 1.1.

[0343] Collection of archival tumor samples for retrospective evaluation of MT1-MMP expression by IHC as well as other molecular pathology techniques during the dose escalation phase.

[0344] Pre-treatment tumor biopsies are optional for patients in the dose escalation phase (Phase I, stages 1 and 2) and mandatory for a minimum of six patients in the expansion phase (Phase IIa, parts A and B).

[0345] Note: A baseline pre-treatment tumor biopsy (performed within 28 days prior to the first dose) is not required for patients who provide a fresh screening tumor sample (to confirm eligibility by MT1-MMP IHC profiling) within 8 weeks prior to the first dose.

[0346] Fresh non-tumor biopsy samples on demand: Patients with pre-implantation tumor biopsies will also have fresh non-tumor biopsies on demand. The non-tumor biopsies can be obtained at approximately the same time as the tumor biopsies. This applies to patients in the dose escalation phase (Phase I, stages 1 and 2) as well as those in the expansion phase (Phase IIa, parts A and B).

[0347] Clinical disease evaluation (if applicable)

[0348] Please note that from the time the patient consents through any protocol-specific procedures, all AEs, including SAEs, must be monitored and recorded in the eCRF.

[0349] Evaluation within 8 days of study enrollment

[0350] The following must be done within 8 days prior to study enrollment:

[0351] Complete physical examination

[0352] Height, weight, BSA, WHO performance status, temperature, pulse rate and BP (BP should be obtained after 5 minutes of rest in a sitting or lying position)

[0353] 12-lead ECG;

[0354] Female patients of child-bearing potential must have a negative result on a human chorionic gonadotropin (HCG) pregnancy test (serum or urine tests are acceptable) prior to the first dose of BT1718 and only 30 days after the final dose (note that frequent testing is unlikely to be warranted except for those sensitive to specific concerns given the patient's advanced disease, the patient's limited prognosis, the lack of fecundity, and cautionary tales regarding how the cancer will affect the patient's future / fertility / family life).

[0355] Laboratory tests (blood / urine samples):

[0356] Hematology - Hb, WBC with 2-point differential (neutrophils, lymphocytes) and platelets

[0357] Biochemistry - sodium, potassium, adjusted calcium, magnesium, phosphate, urea, creatinine, albumin, bilirubin, ALP, ALT and / or AST, fasting blood glucose

[0358] Urine tests – including pH, glucose, protein and blood

[0359] Renal function - serum creatinine, calculated creatinine clearance (Wright or Cockcroft & Gault) or measured isotope clearance (GFR scan). Isotope clearance results are used when calculated C&G / Wright results indicate GFR=50mL / min.

[0360] Coagulation tests - include INR / PT and APTT. Should be repeated prior to any biopsy procedure.

[0361] Once eligibility is confirmed, the patient is enrolled in the study.

[0362] Research blood samples: for pharmacodynamic and genetic analysis.

[0363] Evaluation during the test

[0364] Day 1 of each cycle

[0365] On Day 1 of each cycle, the following must be performed prior to BT1718 administration:

[0366] Body Weight and BSA - Must be repeated on Day 1 of each cycle to calculate the required dose of BT1718. The BT1718 dose only needs to be recalculated if there is a 10% or greater change in body weight from baseline, a 10% or greater change in body weight since the last weight adjustment, or if the dose is reduced due to toxicity.

[0367] 12-lead ECG - should be performed prior to and within 1.5 hours (+15 minutes) after BT1718 administration on Day 1 of Cycle 1. On Day 1 of Cycle 2, an ECG should be performed either prior to or within 1.5 hours (+15 minutes) after BT1718 administration. From Cycle 2 onwards, an ECG should be repeated on Day 1 of every 2 cycles (e.g., Day 1 of Cycle 4, Day 1 of Cycle 6) prior to or within 1.5 hours (+15 minutes) after BT1718 administration.

[0368] Haematological tests: Detailed in paragraph

[0342] .

[0369] Biochemistry tests: as detailed in paragraph

[0343] . Fasting blood glucose results are not required except for baseline, therefore patients do not need to fast before the visit;

[0370] Urine testing - detailed in paragraph

[0344] . This evaluation should only be repeated on Day 22 (+ / - 1 day) of Cycle 1 (i.e., when not receiving BT1718).

[0371] Research urine sampling; for PK analysis.

[0372] Research blood samples: for PK, pharmacodynamic and genetic analysis.

[0373] Prior to each planned dose of BT1718

[0374] Symptomatic Physical Examination: If clinically indicated, a symptom-directed physical examination should be performed prior to administration of BT1718.

[0375] WHO Performance Status

[0376] Vital Signs: Temperature, pulse rate, and BP (BP should be obtained after 5 minutes of rest while sitting or lying down) will be performed prior to BT1718 administration and 1 hour (+ / - 15 minutes) after infusion. Also during the infusion if clinically indicated. These assessments should only be repeated on Day 22 (+ / - 1 day) of Cycle 1 (i.e., when BT1718 administration is not occurring).

[0377] For patients with diabetes, a glucose finger prick test (non-fasting) should be performed within 1 hour before and 1 hour (+15 minutes) after each BT1718 infusion for at least the first 2 cycles, and thereafter as clinically indicated.

[0378] Adverse Events and Concomitant Medications: At each visit, prior to each BT1718 administration, an assessment of any AEs arising from the previous visit must be performed by the investigator, study nurse, or a qualified member of the investigator's team. The start and end dates of the AE must be recorded in the medical record along with the relationship of the event to BT1718 administration. All AEs will be evaluated by NCI Grading should be done according to CTCAE Version 4.02. Any concurrent treatment should be documented in the medical record.

[0379] Laboratory Testing:

[0380] Hematology and biochemistry:

[0381] Haematological tests: Detailed in paragraph

[0342] .

[0382] Core biochemistry: sodium, potassium, urea, creatinine, albumin, bilirubin, ALP, ALT and / or AST.

[0383] Phase I, Dose Escalation, Stage 1, and Phase IIa, Part A (twice weekly dosing)

[0384] During Cycle 1, laboratory tests (as defined above) must be performed and confirmed prior to BT1718 administration on Days 1, 4, 8, 11, 15, and 18. Additional laboratory tests must also be performed on Day 22 (i.e., when no BT1718 dose is administered). Laboratory tests may be performed up to 24 hours prior to BT1718 administration, but results must be available and reviewed by the Investigator prior to administration of BT1718.

[0385] During Cycles 2 and beyond, laboratory tests must be performed and verified prior to BT1718 administration on Days 1, 8, and 15, and thereafter as clinically indicated. After 6 cycles, the frequency of hematological and biochemistry assessments may be reduced at the discretion of the PI and sponsor, but must be performed at a minimum on Day 1 of each cycle. Laboratory tests may be performed up to 24 hours prior to BT1718 administration, but results must be available and reviewed by the investigator prior to administration of BT1718.

[0386] Phase I, Dose Escalation, Stage 2, and Phase IIa, Part B (Weekly Dosing)

[0387] Laboratory testing must be performed and confirmed prior to administration of BT1718 on Days 1, 8, and 15. Additional laboratory testing must also be performed on Day 22 (i.e., when no BT1718 doses are administered). Laboratory testing may be performed up to 24 hours prior to administration of BT1718, but results must be available and reviewed by the study investigator prior to administration of BT1718.

[0388] After 6 cycles, the frequency of hematological and biochemical assessments may be reduced at the discretion of the PI and sponsor, but must be performed at a minimum on each cycle on Day 1. Laboratory testing may be performed up to 24 hours prior to BT1718 administration, but results must be available and reviewed by the investigator prior to administration of BT1718.

[0389] Radiological disease assessment: This must be repeated at the end of every 2 cycles (+ / - 7 days). Assessments may continue for up to 2 years until disease progression or may be performed more frequently than every 2 cycles if there is clinical concern or suspicion of disease progression. Radiological measurements (CT or MRI scans of chest, abdomen, pelvis and any other relevant sites) will be reported against Response Evaluation Criteria in Solid Tumors (RECIST) Version 1.1.

[0390] Clinical Disease Assessment (if applicable): This should be repeated at the end of every 2 cycles (+ / - 7 days) for up to 2 years until disease progression, or if there is clinical concern or suspicion of disease progression.

[0391] Other evaluations during treatment with BT1718:

[0392] Post-treatment tumor biopsies are optional for patients in the dose escalation phase (Phase I, stages 1 and 2) and mandatory for at least 6 patients in the expansion phase (Phase IIa, parts A and B). Tumor biopsies for pharmacodynamic evaluation will be performed by day 8 of cycle 1. Biopsy will be obtained on days 8 or 15 (4+ / - 2 hours) of Cycle 2. If the biopsy procedure cannot be performed during Cycle 1, it may be performed on days 8 or 15 (4+ / - 2 hours) of Cycle 2.

[0393] Post-treatment non-tumor biopsies are optional for patients in the dose escalation phase (Phase I, stages 1 and 2) and expansion phase (Phase IIa, parts A and B). Non-tumor biopsies for pharmacodynamic evaluation are obtained from the same patients with post-treatment tumor biopsies. Non-tumor biopsies may be obtained at approximately the same time as the tumor biopsies on days 8 or 15 (4+ / -2 hours after treatment) of cycle 1. If the biopsy procedure cannot be performed during cycle 1, it may be performed on days 8 or 15 (4+ / -2 hours after treatment) of cycle 2.

[0394] Research blood samples: for pharmacodynamic and genetic analysis.

[0395] NB: Evaluation for Phase IIa, Expansion Phase Parts C and D will be defined after completion of Expansion Phase Parts A and B.

[0396] Evaluation at study stop visit

[0397] Study stop is defined as the date on which the decision is made to withdraw the patient from the study. The "Study Stop" visit evaluation should be performed 28 days (+ / - 7 days) after the last dose of BT1718. Whenever possible, the following investigations should be performed:

[0398] Symptom-directed physical examination: If clinically indicated;

[0399] WHO performance status, temperature, pulse rate and BP (BP should be obtained after 5 min of rest in a sitting or lying position);

[0400] Haematological tests: as detailed in paragraph

[0342] ;

[0401] Biochemistry tests: as detailed in paragraph

[0343] ; fasting blood glucose results are not required and patients are not required to fast before the visit;

[0402] Urine testing; as detailed in paragraph

[0344] ;

[0403] Female patients capable of having children must have a negative result on an HCG pregnancy test (serum or urine tests are acceptable);

[0404] 12-lead ECG;

[0405] radiological evaluation of oncological disease, unless the patient has been shown to have PD on a previous study scan or the evaluation was performed within the previous 28 days;

[0406] Clinical evaluation of disease, if applicable;

[0407] Assessment of AEs (see also above);

[0408] Concomitant medication review; and

[0409] Research blood samples: for pharmacodynamic and genetic analysis.

[0410] Follow-up survey

[0411] Safety follow-up

[0412] For eligible patients, collection and monitoring of SAEs and AEs will continue until 28 days after the last dose of BT1718 or until the patient starts another anti-cancer treatment. Any drug-related AEs that are still ongoing after this period will be followed monthly until resolution or stabilization to baseline, unless the patient starts another anti-cancer treatment.

[0413] If the investigator becomes aware of any BT1718-related AEs or SAEs after this period, these must also be reported to the sponsor within the priority timelines.

[0414] Efficacy and survival follow-up

[0415] All patients should be followed for first progression and for survival until the end of the study. For patients no longer on treatment, the patient's status should be checked at least every 3 months by the on-site study team (through NHS / HSC electronic data records or by telephone only where appropriate) to determine when the patient will start another systemic anti-cancer treatment or when PD will occur (if not already occurring) and whether the patient remains alive. Patients no longer on treatment will not be required to make further study visits, but the on-site team should check their status.

[0416] If a patient is lost to follow-up, has not progressed, or has died at the time of final database lock for the Clinical Study Report (CSR), their information will be censored as unknown if they have progressed / died at that time.

[0417] Timeline of events Table 10. Phase I, Stage 1 and Phase IIa, Part A (twice weekly dosing). [Table 10-1] [Table 10-2] [Table 10-3] [Table 10-4] [Table 10-5] Table 11. Phase I, Stage 2 and Phase IIa, Part B (Weekly Dosing) [Table 11-1] [Table 11-2] [Table 11-3] [Table 11-4] [Table 11-5]

[0418] Pharmacokinetic and pharmacodynamic evaluation

[0419] Summary of PK and Pharmacodynamic Evaluation Table 12. Summary of PK and Pharmacodynamic Evaluations [Table 12-1] [Table 12-2]

[0420] Secondary evaluation

[0421] Pharmacokinetics of BT1718 (plasma)

[0422] Plasma intact BT1718 and total DM1 (DM1 in BT1718, any peptidyl-DM1 metabolites of BT1718, and other DM1 containing mixed disulfide and free DM1) will be measured according to agreed standard operating procedures (SOPs) and validated methods in Phase I, dose escalation phases (Stages 1 and 2) and potentially in Phase IIa, expansion phases (Parts A and B) depending on new data.

[0423] Tertiary / Research Evaluation

[0424] MT1-MMP expression in tumor tissues

[0425] A validated MT1-MMP prototype IHC assay will be deployed to determine MT1-MMP expression according to agreed SOPs and validated methods. For Phase I, dose escalation phase (Stages 1 and 2), MT1 MMP expression will be measured retrospectively using archived samples and pre- and post-treatment biopsies as appropriate. A prospective analysis of MT1-MMP will be performed for Phase IIa, expansion phase (Parts A and B) to select patients prior to study entry. Additionally, a minimum of six paired fresh biopsies will be mandated in each expansion arm (A and B) to investigate pre- versus post-treatment MT1-MMP expression levels.

[0426] Depending on new knowledge regarding target expression, biology and availability of tumor material, markers of tumor-infiltrating immune cells can also be investigated using molecular histology techniques.

[0427] Pharmacokinetics of BT1718 (urine)

[0428] Total DM1 in urine after cycle 1 day 1 will be measured according to agreed SOPs and validated methods. Depending on emerging data, intact BT1718 will also potentially be measured in these urine samples.

[0429] immunogenicity

[0430] In Phase I, dose escalation phases (Stages 1 and 2) and potentially in Phase IIa, expansion phases (Parts A and B) depending on emerging data, serum samples will be analyzed for potential immunogenicity to BT1718 according to agreed SOPs and validated methods.

[0431] Markers of cytotoxicity in tumor and non-tumor samples

[0432] Fresh tumor and non-tumor biopsies (if available) from patients in Phase I, dose escalation phase (stages 1 and 2) will be used to measure markers of cytotoxicity according to agreed SOPs and validated methods.

[0433] Fresh paired biopsies from at least six patients in each Phase IIa expansion phase (Parts A and B) will be used to measure markers of cytotoxicity according to agreed SOPs and validated methods.

[0434] Resistance markers in tumor samples

[0435] In Phase IIa and expansion phases (Parts A and B), tumor biopsies were used to identify resistant tumors. The markers are measured according to agreed SOPs and validated methods.

[0436] Circulating biomarkers

[0437] At specific time points pre- and post-treatment during Phase IIa, expansion phase (Parts A and B), blood will be collected according to agreed SOPs and validated methods.

[0438] Circulating tumor cells

[0439] In Phase IIa, expansion phase (Parts A and B), circulating tumor cells in the blood will be measured according to agreed SOPs and validated methods. Circulating tumor cells will be stored and can be analyzed at the end of the study.

[0440] extracellular free DNA

[0441] In the Phase I, dose escalation phase (Stages 1 and 2) and the Phase IIa, expansion phase (Parts A and B), extracellular free DNA will be measured in plasma from patients according to agreed SOPs and validated methods.

[0442] circulating immune cells

[0443] In Phase IIa, expansion phase (Parts A and B), MT1-MMP expression and other expression markers in various circulating immune cells known to express MT1-MMP can be assessed according to agreed SOPs.

[0444] Circulating cell death markers-M30 and M65

[0445] Samples for cell death markers will be obtained from patients in the study. In Phase I, dose escalation phase (Stages 1 and 2) and Phase IIa, expansion phase (Parts A and B), markers of cell death will be measured in serum using M30 and M65 ELISA assays according to agreed SOPs and validated methods.

[0446] Safety assessment

[0447] Investigator Responsibilities

[0448] As described in the following sections, the investigators are responsible for monitoring the safety of patients enrolled in the study and for accurately documenting and reporting information.

[0449] Definition of adverse events

[0450] Adverse events

[0451] An AE is any untoward, unwanted, or unexpected medical occurrence in a patient receiving an investigational medicinal product (IMP), comparator product, or approved drug.

[0452] An AE may be a sign, symptom, disease, and / or laboratory or physiological observation that may or may not be related to the IMP or comparator.

[0453] AEs include, but are not limited to, those in the following list:

[0454] A clinically significant worsening of a pre-existing condition, including conditions that may resolve completely and then subsequently become abnormal again.

[0455] AEs resulting from accidental or intentional overdosing of IMP.

[0456] AEs resulting from lack of effectiveness of the IMP, e.g., if the investigator suspects that a drug batch is ineffective or if the investigator suspects that the IMP contributed to disease progression.

[0457] Serious Adverse Events

[0458] A serious adverse event is any of the following AEs, regardless of dose, causality, or foreseeability:

[0459] causing death;

[0460] Life-threatening*;

[0461] Requires hospitalization or prolongs a current hospitalization (some hospitalizations are exempt from SAE reporting - e.g., hospitalizations planned before the patient entered the study; overnight stays for planned procedures such as blood transfusions);

[0462] resulting in persistent or significant incapacity or impairment;

[0463] have a birth abnormality or birth defect;

[0464] Any other medically significant event**.

[0465] *A life-threatening event is defined as one in which the patient was at substantial risk of death at the time of the adverse event or where the use or continued use of a device or other medical product may have contributed to the patient's death.

[0466] **A medically significant event is defined as any event that may put the patient at risk or require intervention to prevent one of the outcomes listed above. Examples include allergic bronchospasm (severe breathing problems) requiring emergency room treatment, severe hematological dyscrasia (blood disorder) or seizures / convulsions that do not result in hospitalization. The development of drug dependence or abuse is also an example of a medically significant event.

[0467] For fatal SAEs, similar to SAEs with a fatal outcome, report the cause of death whenever possible rather than reporting the death as an SAE term. Autopsy reports, when available, will be provided to the sponsor.

[0468] Any dose DLT must be reported to the sponsor's CSM and CRA within 24 hours of site staff becoming aware of the DLT. The sponsor's Pharmacovigilance Department must be copied on any initial or follow-up email notifications.

[0469] Other reportable events that must be treated as SAEs are listed below.

[0470] Overmedication with or without AEs.

[0471] For example, inadvertent or accidental exposure to IMP with or without AE, including spillage of IMP contaminating staff.

[0472] Any AE potentially related to protocol procedures and potentially altering the conduct of the study.

[0473] Pregnancy events should be reported and treated similarly to SAEs:

[0474] Pregnancy. Any pregnancies that occur in the patient or the patient's partner during treatment with an IMP or within 6 months of the last IMP dose must be reported to the Pharmacovigilance Department on the Pregnancy Report Form in the same timeline as SAEs. These should be reported even if the patient withdraws from the study.

[0475] If other medically significant events are identified during the course of the study and specific events outside of the standard criteria require reporting, this will be communicated to the site and the protocol will be updated to reflect this.

[0476] Suspected unexpected serious adverse reactions

[0477] A SUSAR is a suspected unexpected serious adverse reaction. All AEs and SAEs are assessed by the sponsor for severity, causality and predictability. The Pharmacovigilance Department dispatches all SUSARs to the relevant regulatory authority / authority and relevant REC within the timelines specified in the legislation (SI 2004 / 1031, as amended).

[0478] Determining causality of adverse events

[0479] The relationship between AE and BT1718 is determined as follows:

[0480] Very likely

[0481] Beginning within the time period related to IMP administration,

[0482] There is no obvious alternative medical explanation.

[0483] Likely

[0484] Beginning within the time period related to IMP administration,

[0485] It cannot be reasonably explained by known features of the patient's clinical condition.

[0486] Possible

[0487] Beginning within the time period related to IMP administration,

[0488] There is at least a reasonable possibility of a causal relationship between the IMP and the AE.

[0489] Unlikely

[0490] The temporal relationship or the patient's clinical condition makes it unlikely that the study drug was associated with the observed effect.

[0491] Not relevant

[0492] The AE is not clearly related to the IMP administered.

[0493] Note: Drug-related means that the event was rated as possible, likely, or very likely.

[0494] The investigator must endeavor to obtain sufficient information to determine the causal relationship of the AEs (i.e., IMPs, other diseases, progressive malignancies, etc.) and must provide their opinion on the causal relationship of each AE to the IMP. For significant AEs, this may require initiating additional investigations based on clinical judgment regarding factors likely to be responsible for them and / or may include seeking further opinion from an expert in the field of that AE.

[0495] The following guidance should be taken into account when assessing the causality of an AE:

[0496] Previous experience with IMP and whether AEs were known to have occurred with IMP.

[0497] Alternative explanations for the AE, such as concomitant medications, concurrent illnesses, nonpharmacologic treatments, diagnostic tests, procedures, or other confounding influences.

[0498] Timing of events between administration of IMP and AE.

[0499] Blood levels of IMP and evidence of overdosing, if any.

[0500] Dechallenge, i.e., what happens to adverse reactions if IMP is discontinued or the dose is reduced?

[0501] What happens in case of re-attack, i.e. resumption of IMP after dissipation of AE?

[0502] Assessment of causality of an AE should be based on the information available at the time of reporting.

[0503] Predictability

[0504] An assessment of predictability for BT1718 will be performed by the Pharmacovigilance Department against the current version of the IB.

[0505] Collection of safety information

[0506] Screening failure

[0507] For patients who fail screening, SAEs from the date of consent through the date the patient is identified as ineligible must be reported to the sponsor's pharmacovigilance department.

[0508] Eligible patients

[0509] For eligible patients, collection and monitoring of SAEs and AEs will begin from the time the patient provides written consent to participate in the study and will continue until 28 days after the last dose of BT1718 or until the patient initiates another anti-cancer treatment.

[0510] If the investigator becomes aware of any drug-related SAEs after this 28-day period, these must also be reported to the sponsor within the expedited timeline.

[0511] Follow-up of AEs and SAEs

[0512] Follow-up of AEs with possible, probable, or very likely causality will continue until the event resolves, stabilizes, or the patient begins another anti-cancer treatment.

[0513] Pharmacovigilance will periodically request further information from the study site regarding the SAE. Requested follow-up information should be reported to Pharmacovigilance within 24 hours after the follow-up information is first recognized. For fatal or life-threatening cases, follow-up information must be requested and reported to Pharmacovigilance as soon as it is recognized.

[0514] Safety information for other purposes

[0515] Information about the following conditions will also be collected, whether or not they are related to an AE:

[0516] Abuse or Misuse

[0517] Any of these occurrences should be reported in the same manner as an SAE.

[0518] Reporting of SAEs to the sponsor's pharmacovigilance department

[0519] All SAEs, regardless of causality, must be reported to the Pharmacovigilance Department on the expedited form.

[0520] SAEs should be documented on the AE reporting form using the completion guidelines provided.

[0521] Each episode of SAE must be recorded on a separate SAE reporting form. NCI The severity of each SAE should be graded using CTCAE Version 4.02, with the worst grade recorded. If new or revised information becomes available regarding a previously reported SAE, the investigator should report this to the Pharmacovigilance department on a new SAE reporting form.

[0522] If an SAE is not reported within the specified time frame, the reason for the delay must be added to the SAE reporting form when it is sent to the Pharmacovigilance Department.

[0523] If the investigator becomes aware of any drug-related SAEs after the patient is "off study," these must also be reported to the Pharmacovigilance department within the specified timelines specified above.

[0524] Events that are exempt from being reported to the pharmacovigilance department as SAEs

[0525] Events specified in this section do not need to be reported as SAEs in this study, except in the case of prolonged hospitalization for any reason, after which an SAE form must be completed. The event must still be recorded in the appropriate section of the eCRF.

[0526] Elective Hospitalization - Elective hospitalization for procedures planned prior to study entry is not an SAE. Hospitalization for administration of IMP per the study protocol is also exempt from reporting as an SAE.

[0527] Death due to disease progression – Death due to disease progression does not require SAE reporting unless the death is considered related to IMP.

[0528] Recording of adverse events and serious adverse events in eCRF

[0529] For eligible patients, all AEs, including SAEs, must be recorded in the eCRF. All concomitant medications, including herbs and supplements, must be recorded. Any treatments used to treat the event must be recorded. The eCRF will be reconciled with the safety database during and at the end of the study. Therefore, sites should ensure that data entered into the paper SAE reporting form (used only by pharmacovigilance) matches data entered into the eCRF. The sponsor's consulting physician and investigator will regularly review both the safety data from the safety database and the safety data from the clinical database.

[0530] Emergency Safety Measures

[0531] A sponsor or investigator may take reasonable emergency safety measures (USM) to protect clinical trial patients from any imminent danger to their health or safety, including steps taken to protect patients from a pandemic or infection that poses a serious risk to human health.

[0532] USM can be taken without prior authorization from the supervisory authority.

[0533] The MHRA and RECs must notify you within three days of taking any such action.

[0534] If a site initiates USM, the investigator must notify the sponsor immediately.

[0535] The notification must include:

[0536] USM date;

[0537] Decision makers; and

[0538] Reasons for Implementation

[0539] The sponsor must then notify the MHRA and the REC within three days of initiating the USM.

[0540] Efficacy evaluation

[0541] Measurement of disease

[0542] Disease should be measured according to RECIST v1.1 criteria as presented in Appendix 2.

[0543] Timing and type of tumor evaluation

[0544] Detailed clinical and radiological evaluation of malignancies, as deemed appropriate by the investigator and in accordance with the protocol, must be performed before patients receive their first dose of BT1718. The same methods that detected evaluable lesions at baseline must be used to follow these lesions throughout the study. To ensure suitability, radiological evaluations used to determine response must be performed using the same techniques. When both imaging-based and laboratory-based methods are used to evaluate the antitumor effect of treatment, imaging-based evaluations are preferred over laboratory-based evaluations.

[0545] All radiological evaluations must be performed within 4 weeks (28 days) prior to initiating treatment with BT1718. The interval between the last anticancer treatment and these measurements must be at least 4 weeks. All clinical measurements to determine response must be performed within 1 week of the first dose of BT1718.

[0546] Complete responses (CR) and partial responses (PR) must be confirmed by subsequent evaluations at least 4 weeks later. To be defined as SD, stable disease criteria must be met at least once after study entry with a maximum interval of 6 weeks. Repeat evaluations are not required to assign patients to CR or PR.

[0547] Copies of scans must be available for external, independent review upon request by the sponsor.

[0548] Baseline assessment

[0549] These must include radiological measurements by CT or MRI scan of lesions in the chest, abdomen, and pelvis and / or other radiological measurements as clinically indicated, or clinical measurements as appropriate, e.g., assessment of palpable lesions or measurement of tumor markers. All areas where disease is present must be documented (even if a particular lesion is not followed for response) and measurements of all measurable lesions must be clearly recorded on the scan report. The presence of any non-measurable lesions must be indicated. With regard to clinical measurements, documentation by color photographs, including rulers to estimate lesion size, is strongly recommended as this will assist external independent review of response (see Appendix 2).

[0550] Evaluation during the test and at "test stop"

[0551] Tumor assessments must be repeated every 2 cycles (+ / - 7 days) or more frequently if clinically indicated. All lesions measured at baseline must be measured at each subsequent disease assessment and clearly recorded on the scan report. All non-measurable lesions noted at baseline must be noted as present or absent on the scan report.

[0552] All patients who are removed from the study for reasons other than PD must be reevaluated at the time of treatment discontinuation unless a tumor evaluation has been performed within the previous 4 weeks.

[0553] It is the investigator's responsibility to ensure that the radiologist is aware of the follow-up requirements and that findings for all target and non-target lesions listed at baseline are measured according to RECIST 1.1 criteria.

[0554] Tumor response

[0555] All patients who meet the eligibility criteria, receive at least one cycle of study medication, and have a baseline assessment of disease and at least one post-baseline assessment are evaluable for response. Patients who develop clear evidence of PD but without formal disease assessment are considered non-responders. At least 4 weeks after the first signs of CR or PR, a confirmatory repeat assessment is required to assign patients to confirmed CR or PR status. To be assigned to SD status, follow-up measurements must meet SD criteria at least once and at least 6 weeks after administration of the first dose of BT1718.

[0556] If rapid tumor progression occurs before the completion of 4 weeks, the patient is classified as having early progression.

[0557] Tumor responses should be classified as "not evaluable" only when classification into another response category is not possible, e.g., when baseline and / or follow-up assessments are not performed or cannot be reasonably performed.

[0558] Expert reviewers appointed by the sponsor may undertake an independent review of the investigator-assessed objective responses (CR and PR). The expert reviewers will include at least one expert who is not the investigator of the study. Any independent reviewer assessments will be documented in the final CSR along with the assessment made by the investigator. The eCRF will reflect the investigator's opinion.

[0559] Recording responses to eCRFs

[0560] The applicable overall response category for each visit that includes a disease assessment must be recorded on the eCRF.

[0561] Other definitions of outcome

[0562] Toxic Death: Any death considered to be primarily due to drug toxicity.

[0563] Early mortality: death during the first 28 days of treatment.

[0564] Withdrawal of patients prior to completion of treatment schedule

[0565] The investigator must make all reasonable efforts to keep each patient on the study for the entire duration of the study (i.e., until 28 ± 7 days after the last BT1718 dose). However, if the investigator removes a patient from the study or the patient declines further participation, a final "off-study" evaluation should be performed, ideally before any further therapeutic intervention. The results of all assessments and observations must be recorded in the medical record and eCRF, along with an explanation of the reason for withdrawal from the study.

[0566] Patients withdrawn from the study due to adverse events (clinical or laboratory) will be treated and followed according to accepted medical practice. All relevant information regarding the outcome of such treatment must be recorded in the eCRF and, if necessary, in the Serious Adverse Event (SAE) Reporting Form.

[0567] The following are valid reasons for an investigator to withdraw a patient from the study:

[0568] Adverse events (AEs) / SAEs;

[0569] Withdrawal of consent;

[0570] significant deviations from the study protocol (including persistent patient non-attendance and persistent non-compliance);

[0571] Sponsor's decision to close the study;

[0572] Investigator initiated withdrawal for clinical reasons unrelated to BT1718;

[0573] evidence of disease progression;

[0574] Pregnancy (for female patients on the study)

[0575] Definition of Exam Completion

[0576] "End of study" is defined as the date the last patient completes the "Stop Study" visit or the final follow-up visit (whichever occurs later). The "Stop Study" visit is scheduled to occur 28 + / - 7 days after the last dose of BT1718 is administered.

[0577] The IMP will be available for 2 years from the latest date that any remaining patient begins treatment, after which any remaining patient will be taken off study and the study will be terminated as described above.

[0578] The end of the study cannot be declared while any patients still have study visits or while study data, eg, progression-free or OS data, are still being collected.

[0579] If arrangements become available to allow patients to continue sustained or extended use of IMP beyond the end of the trial, such arrangements are separate from the trial and do not prevent the trial being declared ended.

[0580] It is the CDD's responsibility to notify the MHRA and RECs within 90 days of the 'study close' date when the trial is closed.

[0581] In the event of early termination of a trial (e.g. due to toxicity) or temporary suspension by the CDD, the CDD will notify the MHRA and the REC within 15 days of its decision and provide a detailed explanatory document regarding the termination / suspension.

[0582] Stop supplementing if:

[0583] If the toxicity of the drug is deemed too great to continue treatment before the required number of patients has been recruited.

[0584] When the specified number of patients to be replenished has been reached.

[0585] The stated objectives of the test are achieved.

[0586] All data available for the patient at the time of discontinuation of follow-up must be recorded in the eCRF, regardless of the reason for termination. All reasons for discontinuation of treatment must be documented.

[0587] Upon closure of a trial, sponsors and investigators must ensure that the protection of patients' interests is duly taken into consideration.

[0588] Data analysis and statistical considerations

[0589] A final analysis will be performed after one of the following conditions is met:

[0590] Trials end early

[0591] End of test reached

[0592] Sample size

[0593] Phase I, dose escalation phase

[0594] The number of patients required for Phase I will depend on the number of dose levels that need to be explored to determine the MTD. Approximately 50-60 patients are expected to be enrolled during stages 1 and 2, with the final number depending on the number of dose escalations required and the number of evaluable patients.

[0595] Phase IIa, expansion phase

[0596] Part A and Part B - 14 patients will be recruited to both Part A and B to further characterize the toxicity profile and tolerability of RP2D. A total of 14 patients will allow for detection of a 30% response rate and exclusion of a 10% response rate with 80% power and a significance level of 0.2.

[0597] For the Part C&D-TNBC or NSCLC cohorts, using a Simon two-stage design with power = 80% and α = 0.2, a maximum of 15 patients are needed to detect a desirable response rate of 30% and to exclude responses as low as 10%. An interim analysis is performed after 6 patients, and recruitment continues up to a total of 15 patients if at least one response is seen at 4 months. If no response is seen, the cohort is terminated for futility. If responses are observed in 3 or more of the 15 patients, it is concluded that the response rate is more likely to be ≥ 30% rather than < 10%.

[0598] For the cohort of sarcoma patients, using a Simon two-stage design with power = 80% and α = 0.2, a maximum of 16 patients is needed to detect the desired clinical benefit rate of 40% and to exclude a clinical benefit rate as low as 20%. An interim analysis is performed after 11 patients, and recruitment continues up to a total of 16 patients if at least 3 respond / disease stabilization occurs at 3 months. If fewer than 3 respond / disease stabilization occurs, the cohort is terminated for futility. If 5 or more of the 16 patients respond or have disease stabilization, we conclude that the clinical benefit rate is more likely to be ≥ 40% rather than < 20%.

[0599] Therefore, it is anticipated that approximately 15–16 patients per cohort will be required in Parts C / D. However, the final tumor types recruited into Parts C and D may be informed by results from Parts A / B or external evidence available at the start of this phase of the study.

[0600] Presenting the data

[0601] Data will be presented in a descriptive format. Variables will be analyzed to determine if the criteria for study execution were met. This will include descriptions of patients who did not meet all of the eligibility criteria, evaluation of protocol deviations, IMP accountability, and other data that impacts general study conduct.

[0602] Baseline characteristics will be summarized for all enrolled patients. Patients who die or withdraw before starting treatment or do not complete the required safety observations will be described and evaluated separately.

[0603] Administration of treatment will be described for all cycles. Administration of medication, modifications or delays in medication and duration of therapy will be described.

[0604] safety

[0605] Safety data will be collected from the date of written consent. Safety variables will be summarized by descriptive statistics. Laboratory variables will be described using NCI CTCAE Version 4.02.

[0606] Adverse events will be reported for each dose level and presented as tables of the frequency of AEs by organ system class and by the worse severity grade observed. Tables should indicate related and unrelated events.

[0607] Pharmacokinetics

[0608] Plasma concentration / time data are analyzed using non-compartmental methods. PK parameters determined for intact BT1718 are C max , T max , AUC,t 1 / 2 , total body clearance (CL T ) and Vd SS The PK parameters determined for total DM1 include C max , T max , AUC and t 1 / 2 Includes.

[0609] Total DM1-SH will be measured in urine collected over a 24 hour period following the first dose to determine the percentage of DM1 excreted in the urine. Additionally, intact BT1718 can also be assessed.

[0610] An immunogenicity assessment for BT1718 will also be performed and reported as positive or negative.

[0611] Pharmacodynamics

[0612] The pharmacodynamic analysis and report will undergo quality control steps before being finalized and signed off by the person responsible for performing the assay and, where appropriate, the laboratory QA manager.

[0613] The expected data analysis paradigm is subject to change throughout the course of the study. As a result, data are compiled in a consistent format agreed upon between the laboratory and sponsor for each assay. The results are then analyzed prior to the development and validation of each assay against agreed SOPs.

[0614] Data will be reported in a format and timeframe agreed upon between the laboratory and the sponsor.

[0615] All pharmacodynamic samples collected will be analyzed as described above.

[0616] Antitumor activity

[0617] Documentation of antitumor activity is a secondary objective of this study. Patients must receive at least one cycle of study medication evaluable for response. Objective responses, best tumor response achieved by each patient during the study, and time to progression will be presented in data tables by cohort.

[0618] Response rates (proportion of evaluable patients with an objective response) are reported by cohort. Progression-free survival is calculated from study entry to documented disease progression or death (whichever occurs first). Patients who are alive and progression-free or lost to follow-up at the time of analysis are censored at the last time the patient was known to be alive and progression-free. Overall survival is calculated from study entry to death from any cause. Patients who are alive or lost to follow-up at the time of analysis are censored at the last time the patient was known to be alive. Duration of response is measured from the date of the first scan showing a response to the date of first radiographic progression or death. Median PFS, OS and duration of response are presented. PFS and OS rates at 6 months are also presented. 95% confidence intervals are reported.

[0619] Administration

[0620] This study will be conducted under a clinical trial authorisation and approval from the MHRA and the relevant REC will be obtained prior to commencing the study. This study is sponsored by and will be monitored by Cancer Research UK, CDD. The applicable regulatory requirements are set out in this section.

[0621] Protocol Deviations and Amendments

[0622] The protocol should be strictly adhered to throughout the conduct of the study, and if a situation arises that may lead to a non-compliance with the study protocol, the site should contact CDD to discuss this.

[0623] Amendments to a protocol may only be made by the sponsor. Protocol amendments may be subject to review by an appointed Ethics Committee, the HRA and the MHRA. Amendments must receive written documentation of an 'accepting opinion' (i.e. approval) from the Ethics Committee and the HRA (and where appropriate the MHRA) before being implemented and, if necessary, incorporated into the protocol.

[0624] Material violations of GCP

[0625] A serious violation is one that may significantly affect the safety or physical or mental integrity of a study subject, or the scientific value of the study.

[0626] The sponsor must report any significant breach of GCP to the MHRA within seven calendar days of becoming aware of it. To enable the study sponsor to fulfil its obligations in respect of the accuracy, site staff must inform the sponsor of any unanticipated deviations from the study protocol (or GCP principles) as soon as possible after the deviation occurs to enable rapid evaluation by the sponsor.

[0627] Completion of electronic case report form (eCRF)

[0628] Data will be collected using sponsor-approved electronic CRFs. Investigators are responsible for ensuring the accuracy, completeness, clarity, and timeline of data reported in the eCRF.

[0629] Only personnel authorized by the Investigator, who has signed the Delegation Log provided by the Investigator and Sponsor, should enter or modify data in the eCRF. Authorized users will be included in the User List to provide access to the eCRF. All investigations required by the protocol must be reported in the eCRF. The Investigator must retain all original reports, traces, and images from these investigations for future reference.

[0630] The collection and processing of personal data from patients enrolled in this clinical trial will be limited to data necessary to investigate the efficacy, safety, quality and usefulness of BT1718 used in this trial. Data collection and processing must be carried out with sufficient precautions to ensure patient confidentiality and compliance with applicable data privacy protections in accordance with applicable regulations. The collected data will comply with Directive 95 / 46 / EC of the European Parliament and of the Council of 24 October 1995 on the protection of individuals with regard to the processing of personal data.

[0631] Data is entered directly into the eCRF by authorised on-site personnel. Modifications to eCRF data are made directly to the system, with the system audit trail retaining details of the original value, who made the change, the date and time, and the reason for the change.

[0632] Once the eCRF form is completed by the field personnel, manual and automated validation is used to clean the data. A query is issued electronically to the field. Authorized personnel must respond to the query by making relevant corrections to the data or by providing a response. Once answered, the query is closed or reissued as necessary.

[0633] Once the patient is "off-study" and the eCRF is completely completed, the investigator must provide an electronic signature to authenticate the complete subject casebook.

[0634] At the end of the study, the sponsor will retain and store all eCRFs and provide PDF copies to the investigator who will be responsible for on-site storage.

[0635] Testing, monitoring, auditing and inspection

[0636] Before the start of an examination, the prerequisites for carrying out the examination must be clearly defined and organisational arrangements made at the examination centre. Any changes in personnel involved in the conduct of the examination must be immediately notified to the sponsor.

[0637] During the study, the sponsor's CRA is responsible for monitoring data quality according to the SOPs. Where appropriate, a strategic monitoring approach should be implemented, including targeted source data verification. To carry out.

[0638] Prior to study initiation, the investigator will be informed of the expected frequency of monitoring visits. The investigator will receive reasonable notification prior to each monitoring visit.

[0639] The CRA is responsible for:

[0640] reviewing test records and comparing them with source documents;

[0641] Verifying pharmacokinetic and pharmacodynamic samples and storage;

[0642] Conducting the study and discussing emerging issues with the study investigators;

[0643] Ensuring that the storage, dispensing and retrieval of medications is reliable and reasonable; and

[0644] Verify that available facilities remain acceptable.

[0645] At the end of the trial, all BT1718s supplied but not used must be destroyed on site (only after authorization for destruction has been granted by the CRA or CSM).

[0646] It is the sponsor's responsibility to notify the REC of 'study completion'.

[0647] During the course of a study, on-site audit visits may be conducted by CDD's Quality Assurance Department or by external auditors contracted by CDD.

[0648] The investigators conducting this trial accept the potential for review by the MHRA.

[0649] Validating source documents

[0650] Unless otherwise agreed in writing, all data collected in the eCRF must be verifiable by the source data. It is therefore the investigator's responsibility to ensure that both he and his research team record all relevant data in the medical record. The investigator must allow the CRA direct access to relevant source documents to verify the data entered in the eCRF, taking into account data protection regulations. Compare the eCRF entries with the patient's medical record and record the verification in the eCRF.

[0651] Some source data may only exist electronically and can be entered or loaded directly into the eCRF.

[0652] Patient medical records and other relevant data may also be reviewed by suitably qualified personnel independent of the sponsor appointed to audit the trial, NHS Trust staff and regulators. Details will remain confidential and patient names will not be recorded outside the hospital.

[0653] Clinical trial report

[0654] Interim data tables will be prepared at reasonable intervals for the investigators to review and collect data. This enables the MHRA and REC to verify the completeness of the information collected. All clinical data is presented in a final data listing at the end of the trial. The sponsor prepares a clinical study report based on the final data listing. This report is submitted to the investigator for review and confirmation that it accurately represents the data collected during the course of the trial. Summary results of the trial are provided by the sponsor to the MHRA and REC.

[0655] Record keeping

[0656] During and after study closure, the investigator must maintain sufficient and accurate records to allow both the conduct of the clinical trial and the assessment and verification of the quality of the data generated. These required documents (detailed in Chapter V of Volume 10 (Clinical Trials) of The Rules Governing Medicinal Products in the European Union based upon Section 8 of the ICH GCP Guidelines), including source documents such as scans, copies of study-related documents and eCRFs, accompanying audit trails and SAE reporting forms, E6(R2) should demonstrate whether the investigator followed GCP principles and guidelines.

[0657] All essential documentation required to be retained by the investigator must be kept in a manner that ensures that it is readily available upon request by regulatory authorities or the sponsor for the minimum period required by national legislation or for a longer period if required by the sponsor. Records must not be destroyed without the sponsor's prior written approval.

[0658] The medical files of study subjects should be kept in accordance with national legislation and for the maximum period permitted by hospital, institutional or individual practice.

[0659] Ethical considerations

[0660] Before a trial can commence, the protocol and ICD must go through the CDD external review process, be approved by the Protocol and Safety Review Board, and receive an acceptable opinion from an appointed REC.

[0661] It is the responsibility of the Principal Investigator to update the patient (or the patient's authorised representative, if applicable) whenever new information becomes available (either its nature or severity) that may affect the patient's willingness to continue on the study. The Principal Investigator / Investigator must ensure that this is documented in the patient's medical notes and that re-consent from the patient is obtained.

[0662] The sponsor and the principal investigator / investigator acknowledge that the study complies with the principles of GCP and the requirements of the UK Clinical Trials Regulations (SI2004 / 1031 and SI2006 / 1928, as amended), the ICH GCP guidelines and the WMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects adopted by the 18th WMA General Assembly, Helsinki, The EPA must ensure that all amendments made to the International Convention on International Trade in Endangered Specified Commercial Code, adopted in June 1964 by the European Commission and all subsequent amendments, including those of ... October 2013 by the European Commission, are in accordance with the International Convention on International Trade

[0663] The status of patients during treatment with BT1718 is shown in Table A below and in FIG. Table A: Patient status during treatment with BT1718 [Table A-1] [Table A-2]

[0664] Disease was defined according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 based on documentation of target and non-target lesions as specified in the BT1718 study protocol. All clinical measurements to determine response must be performed within 1 week of the first dose of BT1718.

[0665] Complete responses (CR) and partial responses (PR) must be confirmed by subsequent evaluation at least 4 weeks later. Stable disease criteria must be met at least once after study entry for a maximum interval of 6 weeks to be defined as SD. Patients are classified as having early progression if rapid tumor progression occurs before the completion of 4 weeks. [Table 20]

[0666] An open-label, first-in-human Phase I / IIa study of once-weekly (QW) and twice-weekly (BIW) dosing schedules in patients with advanced solid tumors was initiated.

[0667] 4-week cycle: 1-hour intravenous (IV) infusion for 3 weeks, followed by 1 week off. Purpose of the test:

[0668] major To propose a recommended Phase II dose (RP2D) by establishing the maximum tolerated dose (MTD) and maximum administered dose (MAD) for one or both dosing schedules (Phase I) Safety and tolerability profile of BT1718 (Phase I / IIa)

[0669] secondary To investigate the pharmacokinetics (PK) of BT1718 in humans (Phase I) To evaluate preliminary signals of BT1718 efficacy in tumors expressing MT1-MMP (Phase IIa)

[0670] Tertiary · To explore potential predictive pharmacodynamic biomarkers, including DM1 tumor levels.

[0671] A summary of patient characteristics in the open-label, first-in-human Phase I / IIa study is shown in Table B below. Table B. Patient characteristics [Table B]

[0672] The dose escalation scheme, including dose levels and patient numbers, is presented in Figure 8. Safety and Efficacy Results

[0673] 9.6 mg / m 2 Two DLTs were reported in BIW: increased GGT (grade 4) and fatigue (grade 3), both of which resolved after cessation or interruption of treatment with BT1718.

[0674] The most common associated adverse event class reported to date was grade 1-3 gastrointestinal disorders (18 / 28 patients), including nausea, diarrhea, and vomiting.

[0675] Grade 1-2 associated peripheral neuropathy occurred more commonly with increasing dose.

[0676] With once-weekly dosing, BT1718 appears to be tolerable at the dose levels tested, with manageable toxicity.

[0677] No objective responses (RECIST 1.1) have been observed to date in this unselected population. 6 / 20 patients had stable disease at 8 weeks; one patient had a reduction of target lesions by approximately 14% in cycle 6, and one of the lesions had a reduction of approximately 45%. The median number of cycles received was 3 months (n=28).

[0678] Summary of Adverse Events: Table C lists drug-related events reported in ≥15% of patients. Table C. Drug-related events reported in ≥15% of patients [Table C] Pharmacokinetic results

[0679] The AUC of BT1718 is 0.6 to 25 mg / m 2 The response rate was approximately dose-proportional over the range of 0.01 to 0.1, with cycle 2 values ​​consistent with cycle 1.

[0680] Spaghetti plots: BT1718 plasma concentrations versus time after first dose in cycles 1 & 2 are shown in Figures 9A, 9B, and 9C.

[0681] The mean (±SD) plasma clearance (CLp) was 32.3 (±24.9) L / h, and the mean (±SD) volume of distribution (Vss) was 22.9 (37.4) L, resulting in a terminal half-life (t1 / 2) of 0.2-1 h.

[0682] Scatter plots: AUC versus dose of BT1718 is shown in FIG. 10A, and Cmax versus dose of BT1718 is shown in FIG. 10B.

[0683] Data for all patients: CLp = 10 mL / min / kg; t1 / 2 = 18 min.

[0684] Data for cycle 1 only: CLp=12 mL / min / kg; t1 / 2=18 min.

[0685] The AUC of BT1718 increased with dose after 1-hour IV infusion and was consistent between cycles 1 and 2.

[0686] The determined RP2D for twice weekly dosing was 7.2 mg / m 2 The larger total dose of BT1718 per cycle was administered weekly (dose escalation to 32 mg / m 2This was achieved using a once-weekly schedule (currently ongoing); therefore, the RP2D used in the expansion phase is for a once-weekly schedule only.

[0687] Weekly RP2D was administered to patients selected for MT1-MMP expression in their tumors. Evaluate the gender. Example 2 PK results of administered BT1718 in humans PK results for cohorts 1-5

[0688] The results of BT1718 administered in cohorts 1 to 5 are shown in Figure 2.

[0689] Preliminary clinical pharmacokinetic data for BT1718 following a 1 hour intravenous infusion in patients is shown in Table 13 below. Table 13. Preliminary clinical pharmacokinetic data for BT1718 following a 1-hour intravenous infusion in patients [Table 13]

[0690] The BT1718 plasma assay is fully validated with sufficient dynamic range. Systemic exposure is measured at the starting dose. Plasma concentrations are found to increase with dose and are consistent with preclinical data (rat and primates). Example 3 Increased tumor cell death after BT1718 treatment

[0691] BT1718 increases tumor epithelial cell apoptotic death / necrosis as shown by M30 and M65 assays (Figure 7A-F). In cycle 1, measurements were performed in serum at C1D1 (pre-dose) & 24 hours (post-dose), then before each dose. Changes in cell death markers were observed in all patients (5 / 5) at the highest dose evaluated. All five patients had SD at first disease evaluation (two representative curves are presented). The data may represent early pharmacodynamic markers of antitumor activity of BT1718. Example 4 Analysis of DM1 delivery to tumors in patients

[0692] A quantitative high-performance liquid chromatography-tandem mass spectrometry (LC-MS / MS) method was developed to quantify DM1 in tissue samples.

[0693] DM1 was administered as BT1781 complexed with a bicyclic peptide. To determine the concentration of free DM1, the conjugated molecule was reduced and then derivatized with vinylpyridine.

[0694] The same sample preparation procedure used for PK determination in GLP preclinical studies is applied for the determination of DM1 in tissue samples. Briefly, after tissue homogenization, samples are reduced with TCEP and then derivatized with vinylpyridine. Derivatization is necessary to stabilize the highly reactive thiol groups in DM1.

[0695] Unless otherwise specified, the designation DM1 in this example is used to refer to vinylpyridine-derivatized DM1.

[0696] A general overview of the main steps of the method can be outlined as follows: 1) Tissue homogenization 2) Reduction / Alkylation 3) Protein precipitation 4) Analysis of sample extracts by LC-MS / MS

[0697] The homogenization method was optimized as follows: 1) Thaw the tissue sample at room temperature. 2) Using the Analytical Balance, measure the desired amount of tissue into a Precellys 2mL reinforced tube. 3) Calculate the volume of the solution using the weight of the tissue. The tissue / solution ratio should be 1:30 W(mg) / V(μL). Homogenization solution: (NaCl(0.9%):SDS(0.2mg / mL)(50:50v / v%)) 4) Add the calculated amount of solution to the tissue. 5) Vortex for approximately 5 seconds. 6) Pre-cool the sample in a wet ice bath for approximately 8 minutes. 7) Homogenize in a Precellys-24 Dual at 5000 rpm for 5 sessions of 40 seconds each. 8) The homogenate samples are centrifuged at 3000 rpm for 3 minutes at 4° C. using a 5810-R centrifuge.

[0698] SDS was added to a final concentration of 0.1 mg / mL to increase the recovery rate. The homogenate yield in the presence of SDS was higher compared to the homogenate yield in the presence of ammonium acetate buffer. As a control, Milli Q, SDS and ammonium acetate buffer were used.

[0699] Analysis of tumor samples from three patients demonstrated delivery of DM1 to the tumor in two patients, consistent with preclinical models.

[0700] Preliminary analysis of total DM1 levels in tumors indicates that DM1 is localized to tumors.

[0701] References [ka] [ka] [ka] [ka] [ka] [ka] appendix

[0702] Appendix 1: WHO performance measures (Table 14) Table 14. WHO performance measures [Table 14] Appendix 2: Determination of disease response

[0703] Assessment of disease response in this study should be performed according to the RECIST criteria specified below.

[0704] New response evaluation criteria in solid tumors (RECIST criteria):

[0705] Revised RECIST guidelines (version 1.1)

[0706] EA Eisenhauer et al. (2009) European Journal of Cancer 45: 228-247

[0707] Please note that this is a summarized version of the RECIST criteria, for a detailed appendix and when in doubt please refer to the above paper.

[0708] Tumor measurability at baseline

[0709] definition

[0710] At baseline, tumor lesions / lymph nodes will be categorized as measurable or non-measurable as follows:

[0711] measurable

[0712] Tumor Lesions: Must be accurately measured in at least one dimension (record the largest diameter in the cross-section) and have the following minimum sizes:

[0713] 10 mm on CT scan (CT scan slice thickness ≤5 mm; see Appendix II for diagnostic imaging guidelines).

[0714] 10 mm as measured by caliper on clinical examination (lesions that cannot be accurately measured by caliper should be recorded as non-measurable).

[0715] Chest X-ray: 20 mm

[0716] Malignant lymph nodes: To be considered pathologically enlarged and measurable, lymph nodes must measure 15 mm in short axis as assessed by CT scan (a CT scan slice thickness of 5 mm or less is recommended). Only the short axis is measured and tracked during baseline and follow-up.

[0717] unmeasurable

[0718] All other lesions, including small lesions (pathologic lymph nodes <10 mm in greatest dimension or 10-15 mm in shortest diameter) as well as true nonmeasurable lesions. Lesions considered true nonmeasurable lesions include leptomeningeal disease, ascites, pleural or pericardial effusions, inflammatory breast disease, cutaneous or pulmonary lymphangitis, and abdominal masses / organomegaly identified by physical exam and not measurable by reproducible imaging techniques.

[0719] Special considerations regarding lesion measurability

[0720] Bone lesions, cystic lesions, and lesions previously treated with local therapy require specific comments:

[0721] Bone lesions:

[0722] Bone scans, PET scans or plain films are not considered suitable imaging techniques for measuring bone lesions, however, these techniques can be used to confirm the presence or absence of bone lesions.

[0723] Lytic bone lesions or mixed lytic and osteoblastic lesions that contain an identifiable soft tissue component and can be assessed by cross-sectional imaging techniques such as CT or MRI can be considered measurable lesions if the soft tissue component meets the definition of measurability above.

[0724] Blastoblastic bone lesions are not measurable.

[0725] Cystic lesions:

[0726] Lesions that meet the criteria for a radiologically defined simple cyst should not be considered malignant (whether measurable or nonmeasurable) because, by definition, they are simple cysts.

[0727] If a "cystic lesion" believed to represent a cystic metastasis meets the definition of measurable above, it can be considered a measurable lesion. However, if noncystic lesions are present in the same patient, it is preferable to select these noncystic lesions as target lesions.

[0728] Previously treated lesions:

[0729] Tumor lesions located within areas previously irradiated or subjected to other locoregional treatments are not generally considered to be measurable unless progression of the lesion has been documented. The conditions under which such lesions are considered measurable should be detailed in the study protocol. be.

[0730] Details for each measurement method

[0731] Measurement of lesions

[0732] All measurements should be recorded in metric units using calipers when clinically assessed. All baseline evaluations should be performed as close to the start of treatment as possible, but no earlier than 4 weeks prior to initiation of treatment.

[0733] Evaluation method

[0734] The same assessment method and the same techniques should be used to characterize each lesion identified and reported at baseline and during follow-up. Evaluation should always be based on imaging rather than clinical examination, unless the lesion being followed up cannot be imaged but can be assessed by clinical examination.

[0735] Clinical manifestations:

[0736] Clinical lesions are considered measurable only if they are superficial and ≥10 mm in diameter as assessed using calipers (e.g., skin nodules). For skin lesions, documentation by color photography including a ruler to estimate the size of the lesion is recommended. As mentioned above, imaging assessment is more objective and can also be reviewed at the end of the study, so if lesions can be assessed both clinically and by imaging, imaging assessment should be used.

[0737] Chest X-ray:

[0738] Chest CT is preferred over chest x-ray, especially when progression is the key endpoint, because CT is more sensitive than x-ray in identifying new lesions. However, lesions on chest x-ray can be considered measurable if they are well-defined and surrounded by air-containing lung.

[0739] CT, MRI:

[0740] CT is currently the best available and reproducible method to measure lesions selected for response assessment. In this guideline, we defined the measurability of lesions on CT scans based on the assumption that the CT slice thickness is 5 mm or less. If the CT scan slice thickness is greater than 5 mm, the minimum size of a measurable lesion should be twice the slice thickness. MRI is also acceptable in certain circumstances (e.g., body scans). More details on the use of both CT and MRI to determine objective tumor response assessments are presented in the publication by Eisenhauer et al.

[0741] Ultrasound:

[0742] Ultrasound is not useful for assessing lesion size and should not be used as a method of measurement. Ultrasound examinations are not fully reproducible at a later independent review and are operator dependent and cannot guarantee identical techniques and measurements with each evaluation (as described in more detail in Appendix II). If new lesions are identified by ultrasound during the course of the study, confirmation by CT or MRI is recommended. If there are concerns about radiation exposure, MRI can be used instead of CT in selected circumstances.

[0743] Endoscopy, laparoscopy:

[0744] The use of these techniques for objective tumor assessment is not recommended, but may be useful to confirm complete pathologic response when biopsies are obtained or to determine relapse in trials where recurrence after complete response or surgical resection is the endpoint.

[0745] Tumor markers:

[0746] Tumor markers cannot be used alone to determine objective tumor response, but if the marker is initially above the upper limit of normal, it must return to normal for the patient to be considered in complete response.

[0747] Cytology, histology:

[0748] These techniques can be used to distinguish PR from CR in rare cases when required by protocol (e.g., residual disease in tumor types such as germ cell tumors, where there may be residual known benign tumor). When effusion is known to be a potential adverse effect of treatment (e.g., certain taxanes or angiogenesis inhibitors), cytological confirmation of neoplastic origin of any effusion that appears or worsens during treatment can be considered to distinguish response (or stable disease) from PD, provided that measurable tumor meets the criteria for response or stable disease.

[0749] Tumor response assessment

[0750] Assessment of overall tumor burden and measurable disease

[0751] To assess objective response or future progression, it is necessary to estimate the overall tumor burden at baseline and use it as a comparator for subsequent measurements. Measurable disease is defined by the presence of at least one measurable lesion (as detailed above).

[0752] Baseline documentation of "target" and "non-target" lesions

[0753] If there is more than one measurable lesion at baseline, all lesions up to a total of five lesions (and a maximum of two lesions per organ) representative of all affected organs should be identified as target lesions, recorded and measured at baseline (this means that if a patient has only one or two affected organ sites, a maximum of two and four lesions are recorded, respectively). For evidence supporting the selection of only five target lesions, see the analysis of a large prospective database by Bogaerts et al. Target lesions are selected based on their size (lesion with the largest diameter) and should be representative of all involved organs, but additionally lend themselves to reproducible repeated measurements. It may sometimes be the case that the largest lesion is not suitable for reproducible measurements, in which case the next largest lesion that can be reproducibly measured should be selected. Example from Figure 3 in the publication by Eisenhauer et al.

[0754] Lymph nodes deserve special mention because they are normal anatomical structures that can be visualized by imaging modalities even when not affected by tumor. To be defined as measurable and identifiable as a target lesion, pathological lymph nodes must meet the criterion of a short axis of 15 mm or greater on a CT scan. Only the short axis of these lymph nodes contributes to the baseline diameter sum. The short axis of a lymph node is the diameter that radiologists typically use to determine whether a lymph node is affected by a solid tumor. Lymph node size is usually reported in two dimensions of the plane in which the image is obtained (for CT scans, this is almost always the transverse plane; for MRI, the imaged plane can be the transverse, sagittal, or coronal plane). The smaller of these measurements is the short axis. For example, an abdominal lymph node that is reported to be 20 mm × 30 mm has a short axis of 20 mm and is a measurable lymph node of malignancy. In this example, 20 mm should be recorded as the lymph node measurement. All other pathological lymph nodes (those with a short axis of 10 mm or greater but less than 15 mm) should be considered nontarget lesions. Lymph nodes measuring less than 10 mm in short diameter are considered nonpathological and should not be recorded or followed.

[0755] The sum of the diameters of all target lesions (longest diameter for non-nodal lesions, shortest diameter for nodal lesions) is calculated and reported as the baseline sum diameter. When lymph nodes are added to the sum, only the shortest diameter is added to the sum as described above. The baseline sum diameter is used as a reference to further characterize any objective tumor regression in the measurable dimension of disease.

[0756] All other lesions (or sites of disease), including pathological lymph nodes, should be identified as non-target lesions and should also be recorded at baseline. Measurements are not necessary, and these lesions should be tracked as "present," "absent," or, in rare cases, "definite progression" (more details below). In addition, multiple non-target lesions affecting the same organ can be recorded as a single item on the case record form (e.g., "multiple enlarged pelvic lymph nodes" or "multiple liver metastases").

[0757] Response Criteria

[0758] Target Lesion Evaluation

[0759] Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes (target or non-target) must shrink to less than 10 mm in short axis.

[0760] Partial response (PR): At least a 30% reduction in the sum of the diameters of target lesions compared to the sum at baseline.

[0761] Progression (PD): At least a 20% increase in the sum of the diameters of the target lesions taken as reference for the smallest sum of diameters during the study (including the baseline sum of diameters, if this was the smallest during the study). In addition to the 20% relative increase, there must also be an absolute increase in the sum of diameters of at least 5 mm (Note: the appearance of one or more new lesions is also considered as progression).

[0762] Stable disease (SD): Based on the smallest sum of diameters during the study, there is neither a sufficient reduction in diameter to be considered PR nor a sufficient increase to be considered PD.

[0763] Special considerations regarding evaluation of target lesions

[0764] Lymph nodes

[0765] Lymph nodes identified as target lesions were those that regressed to less than 10 mm during the study. For all studies, the actual measurement of the short axis (measured in the same anatomical plane as at the baseline examination) should always be recorded. This means that if lymph nodes are included in the target lesions, the "sum diameter" of the lesions may not be zero even if the criteria for complete response are met, since normal lymph nodes are defined as having a short axis of less than 10 mm. Therefore, case report forms or other data collection methods can be designed so that target lymph node lesions are recorded in a separate column, where each lymph node must achieve a short axis of less than 10 mm to be considered a CR. For PR, SD, and PD, the actual measurement of the short axis of the lymph nodes is included in the sum of the diameters of the target lesions.

[0766] Target lesions that were "too small to measure."

[0767] During the study, all lesions (lymph nodes and non-lymph nodes) recorded at baseline should have their actual measurements recorded at each subsequent evaluation, even if they have become very small (e.g., 2 mm). However, sometimes a lesion or lymph node recorded as a target lesion at baseline may become so faint on the CT scan that the radiologist hesitates to assign an accurate measurement and reports it as "too small to measure." In such cases, it is important to record some value in the case report. If it is the radiologist's opinion that the lesion has likely disappeared, the measurement should be recorded as 0 mm. If a lesion is thought to be present and faintly visible but too small to measure, a default value of 5 mm should be assigned. (Note: This rule is unlikely to be used for lymph nodes, since lymph nodes usually have a definable size even when normal, and are often surrounded by fat, such as in the retroperitoneum; however, if a lymph node is thought to be present and faintly visible but too small to measure, a default value of 5 mm should be assigned in this situation as well.) This default value is derived from a CT slice thickness of 5 mm (but should not change as CT slice thickness varies). Measurements of these lesions are potentially not reproducible, so this default value prevents false responses or progressions based on measurement error. However, again, if the radiologist is able to provide an actual measurement, it should be recorded even if it is less than 5 mm.

[0768] Lesions that split or merged during the procedure:

[0769] When non-lymph node lesions are "fragmented," the maximum diameters of the fragmented portions should be added together to calculate the sum of the diameters of the target lesions. Similarly, lesions can fuse and maintain an interface between them, which helps to obtain the maximum diameter measurement for each individual lesion. If lesions are truly fused and therefore can no longer be separated, then the vector of the maximum diameter should be taken as the maximum longest diameter of the "fused lesion."

[0770] Evaluation of non-target lesions

[0771] Although some non-target lesions may in fact be measurable, there is no need to measure them; instead, they should only be qualitatively assessed at protocol-defined time points.

[0772] Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor marker levels. All lymph nodes must be non-pathological in size (minor axis <10 mm).

[0773] Non-CR / Non-PD: persistence of one or more non-target lesions and / or maintenance of tumor marker levels above the normal range.

[0774] Progressive disease (PD): Obvious progression of existing non-target lesions (see comments below). (Note: 1 The appearance of one or more new lesions is also considered a progression.

[0775] Special considerations regarding evaluation of progression of non-target disease

[0776] The concept of non-target disease progression requires the following additional clarification:

[0777] If the patient also has measurable disease.

[0778] In this situation, for "clear progression" to be achieved based on non-target disease, the overall level of substantial worsening in the non-target disease must have increased enough in overall tumor burden to merit discontinuing treatment, even in the presence of SD or PR in the target disease. A modest "increase" in size of one or more non-target lesions is usually not sufficient to qualify as a state of clear progression. Thus, it is extremely rare to designate overall progression based solely on changes in non-target disease when the target disease is SD or PR.

[0779] If the patient has only nonmeasurable disease.

[0780] This situation arises in some Phase III trials when having measurable disease is not a criterion for study entry. The same general concept as above applies, but in this case the measurable disease assessment does not factor into the interpretation of the increase in non-measurable disease burden. Since the worsening of non-target disease cannot be easily quantified (by definition: when all lesions are truly non-measurable), a useful test that can be applied when assessing patients for overt progression is to consider whether the degree of increase in overall disease burden based on the change in non-measurable disease is comparable to the increase required to declare PD of measurable disease: i.e., whether the increase in tumor burden represents an additional 73% increase in "volume" (which is equivalent to a 20% increase in diameter for measurable lesions). Such examples include an increase in pleural effusion from "trace" to "massive," widespread expansion of lymphangiopathy that was localized, or the protocol could state "sufficient to require a change in treatment." If "overt progression" is observed, the patient should be considered to have had overall PD at that point. While it would be ideal to have an objective criterion to apply to non-measurable disease, the nature of the disease makes this impossible, and therefore the increase must be substantial.

[0781] New Lesions

[0782] The appearance of new malignant lesions indicates disease progression, and therefore, it is important to mention the detection of new lesions. Although there are no specific criteria for the identification of lesions on new radiographic studies, the finding of new lesions should be obvious; that is, it should not be due to differences in scanning techniques, changes in imaging modalities, or findings that may indicate something other than a tumor (e.g., some "new" bone lesions may simply be healing or enlargement of existing lesions). This is particularly important when a patient's baseline lesions show a partial or complete response. For example, necrotic liver lesions may be reported on the CT scan report as "new" cystic lesions when in fact they are not new.

[0783] Lesions identified in an anatomical location on a follow-up study that were not scanned at baseline are considered new and represent disease progression. An example of this would be a patient with visceral disease at baseline who had a brain CT or MRI requested during the study that revealed metastases. A patient's brain metastases would be considered evidence of PD even if they did not have brain imaging at baseline.

[0784] If the new lesion is not evident, for example because of small size, continued treatment and follow-up evaluation will reveal whether it is truly new disease. If a repeat scan clearly establishes a new lesion, the date of the first scan should be used to declare progression.

[0785] Determination of response by fluorodeoxyglucose (FDG)-positron emission tomography (PET) requires additional testing, but it is sometimes reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in the evaluation of progression, especially when "new" disease is possible. New lesions based on FDG-PET imaging can be identified according to the following algorithm:

[0786] a. A negative FDG-PET scan at baseline followed by a positive FDG-PET scan at follow-up is a sign of PD based on new lesions.

[0787] b. FDG-PET not performed at baseline and positive FDG-PET at follow-up:

[0788] PD was defined as a disease progression if the FDG-PET positivity at follow-up corresponded to new disease sites confirmed by CT.

[0789] If a follow-up FDG-PET positivity is not identified as a new site of disease on CT, an additional follow-up CT scan is necessary to determine whether the site has developed true progression (if so, the date of PD is the date of the first abnormal FDG-PET scan). An FDG-PET scan "positive" lesion is one that has FDG uptake greater than twice that of the surrounding tissue on attenuation-corrected images.

[0790] If the FDG-PET positivity at follow-up corresponds to an area of ​​pre-existing disease on CT and that area of ​​pre-existing disease has not progressed based on the anatomical images, it is not PD.

[0791] Determination of best overall response

[0792] Best overall response is the best response recorded between the start of study treatment and the end of treatment, taking into account all requirements for confirmation. If a response is not documented until after the end of treatment on this study, post-treatment evaluations may be considered in determining the best overall response, unless alternative anticancer treatments have been administered. The assignment of a patient's best overall response depends on findings regarding both target and non-target disease, and also takes into account the appearance of new lesions.

[0793] Responses at each time point

[0794] It is envisioned that response assessments will occur at each protocol-specified time point. Table 15 provides a summary of the overall response status calculated at each time point for patients with measurable disease at baseline.

[0795] If the patient has only non-measurable (and therefore non-target) disease, Table 16 should be used.

[0796] Provisions for lack of assessment and non-assessment

[0797] If no imaging / measurements were performed at a particular time point, the patient is not evaluable (NE) at that time point. If only some lesions are measured at the time of evaluation, the patient is generally not evaluable at that time point. is considered NE, unless a compelling argument can be made that the contribution of individual missing lesions does not change the assigned response at each time point. This would most likely occur in the case of PD. For example, if a patient had three lesions measured at baseline with a sum of 50 mm, and at follow-up only two lesions are assessed with a sum of 80 mm, the patient has an achieved PD status, regardless of the contribution of the missing lesions.

[0798] Best overall response: any time point

[0799] Once all data for a patient is known, a best overall response is determined.

[0800] The best response in this study is defined as the best response across all time points (e.g., a patient with SD at first evaluation, PR at second evaluation, confirmed after 4 weeks, and PD at last evaluation has a confirmed PR as their best overall response). All CRs or PRs must be confirmed at least 4 weeks after the time of the "undetermined" CR or PR. And the date of PR or CR is the first date a response was first observed, not the date of the confirmatory scan. If SD is considered to be the best response, the minimum duration from baseline specified in the protocol must also be met. In other circumstances, if SD is the best response at each time point and the minimum duration is not met, the patient's best response will depend on the subsequent evaluation. For example, a patient with SD at first evaluation and PD at second evaluation who does not meet the minimum duration of SD will have a best response of PD. If a similar patient is lost to follow-up after the first SD evaluation, they will be considered unevaluable. FDG-PET scan "positive" lesions are those with FDG uptake greater than twice that of the surrounding tissue in attenuation-corrected images. Table 15. Response at each time point: Patients with target (+ / - non-target) disease [Table 15] Table 16. Responses at each time point: Patients with non-target disease only. [Table 16] Table 17. Best Overall Response When Confirmation of CR and PR is Required [Table 17]

[0801] Special considerations regarding response decisions

[0802] Lymph node disease was included in the target lesion diameter sum and lymph nodes were considered to be of “normal” size (<10 mm). If the lymph node size has shrunk to 0.5 mm (0.01 in), the patient may still have a measurement reported on the scan. This measurement should be recorded even if the nodes are normal, to avoid overestimating progression if it is based on an increase in lymph node size. As previously noted, this means that patients with CR may not have a total of "zero" on their Case Report Form (CRF).

[0803] Patients with a global deterioration in health status that necessitates discontinuation of treatment without evidence of objective disease progression at that time should report "symptomatic worsening." Every effort should be made to demonstrate objective progression, even after treatment has been discontinued. Symptomatic worsening is not a descriptor of objective response, but a reason for discontinuing study treatment. The objective response status of such patients is determined by the evaluation of target and non-target disease as shown in Tables 1-3.

[0804] The conditions defined as "early progression, early death, and non-evaluable" are study specific and should be clearly described in each protocol (depending on duration of treatment, periodicity of treatment).

[0805] In some cases, it may be difficult to distinguish residual disease from normal tissue. If assessment of complete response depends on this decision, a survey of residual disease (fine needle aspiration / biopsy) is recommended before assigning complete response status. FDG-PET can be used in a similar fashion to the biopsy to upgrade the response to CR if residual radiographic abnormalities are thought to represent fibrosis or scarring.

[0806] If evidence of progression is unclear (e.g., very small, poorly defined new lesions; cystic changes or necrosis of existing lesions), treatment may continue until the next scheduled evaluation. If progression is confirmed at the next scheduled evaluation, the date of progression should be the date of the previous suspected progression.

[0807] Duration of response

[0808] Duration of response will be measured from the first fulfillment of the CR / PR (whichever is first documented) metric to the first date of objectively documented recurrence or progression (the reference for progression will be the lowest measurement documented during the study).

[0809] Duration of overall complete response will be measured from the time the CR criteria were first met to the first date of objective documentation of recurrent disease.

[0810] Duration of stability

[0811] Stable disease is measured from the start of treatment (in randomized trials, from the date of randomization) until progression criteria are met and refers to the smallest diameter sum during the study (if the baseline diameter sum is the smallest, this is the reference for calculating PD). Appendix 3: New York Heart Association (NYHA) Scale. Table 18. New York Heart Association (NYHA) Scale [Table 18]

[0812] Appendix 4: Table of abbreviations and definitions Table 19. Definitions of abbreviations and terms [Table 19-1] [Table 19-2] [Table 19-3] [Table 19-4]

Claims

1. A method of administering BT1718 to a patient in need of BT1718, comprising administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, ｍａｘ A method by which this is achieved.

2. The above-mentioned C to be realized ｍａｘ The method of claim 1, wherein the concentration of the antibody is from about 10 ng / mL to about 10,000 ng / mL.

3. The above-mentioned C to be realized ｍａｘ The method of claim 1 or 2, wherein the concentration of the antibody is about 100 ng / mL to about 1,000 ng / mL.

4. The BT1718 is about 0.3 mg / m ２ ~Approx. 45mg / m ２ The method according to any one of claims 1 to 3, wherein the dose is

5. The BT1718 is about 0.6 mg / m ２ , about 1.2mg / m ２ , about 2.4mg / m ２ , about 4.8mg / m ２ , about 9.6 mg / m ２ , about 19.2mg / m ２ , about 38.4mg / m ２ and about 45 mg / m ２ 5. The method of claim 1, wherein the dose is selected from the group consisting of:

6. 11. A method of administering BT1718 to a patient in need thereof, comprising administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein a therapeutically effective AUC is achieved.

7. 7. The method of claim 6, wherein the AUC achieved is from about 5 ng h / mL to about 5,000 ng h / mL.

8. 8. The method of claim 6 or 7, wherein the AUC achieved is from about 5 ng h / mL to about 100 ng h / mL.

9. 1. A method of administering BT1718 to a patient in need of BT1718, comprising administering to said patient BT1718 or a pharma- ceutical acceptable salt and / or composition thereof, wherein the patient has a CL of about 1 mL / min / kg to about 200 mL / min / kg. ｐ A method by which this is achieved.

10. The CL to be realized ｐ is from about 1 mL / min / kg to about 100 mL / min / kg.

11. The CL to be realized ｐ is about 4.4 mL / min / kg to about 20 mL / min / kg.

12. A method of administering BT1718 to a patient in need of BT1718, comprising administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, ｓｓ A method by which this is achieved.

13. The V realized ｓｓ is from about 0.05 L / kg to about 20 L / kg.

14. The V realized ｓｓ The method of claim 12 or 13, wherein the flow rate is about 0.2 L / kg.

15. A method of administering BT1718 to a patient in need of BT1718, comprising administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, １／２ A method by which this is achieved.

16. The t realized １／２ The method of claim 15, wherein the time is from about 5 minutes to about 1,440 minutes.

17. The t realized １／２ The method according to claim 15 or 16, wherein the time is from about 10 minutes to about 120 minutes.

18. The t realized １／２ The method according to any one of claims 15 to 17, wherein the heating time is from about 10 minutes to about 60 minutes.

19. 1. A method of administering BT1718 to a patient in need thereof, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein urinary concentrations of DM1-SH consistent with renal excretion are observed.

20. 1. A method of administering BT1718 to a patient in need of BT1718, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein achievement of a therapeutically effective dose is indicated by the presence of a biomarker of cell death or inhibition of cell proliferation.

21. 21. The method of claim 20, wherein the biomarker is a biomarker for cell death.

22. 22. The method of claim 21, wherein the biomarker of cell death is selected from the group consisting of p-histone H3 and cleaved caspase 3.

23. 21. The method of claim 20, wherein the biomarker is a biomarker for inhibition of cell proliferation.

24. 24. The method of claim 23, wherein the biomarker of inhibition of cell proliferation is Ki67.

25. A method of administering BT1718 to a patient in need thereof, comprising administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein immune cell infiltration into the tumor is monitored by markers of an immune-stimulatory response via immunohistochemistry (IHC) or another suitable method for detecting immune cell infiltration.

26. 1. A method of administering BT1718 to a patient in need of BT1718, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein achievement of a therapeutically effective dose is indicated by the presence of a circulating biomarker.

27. 27. The method of claim 26, wherein the circulating biomarker is selected from the group consisting of MMP14, MMP2, TIMP-1, and vascular endothelial growth factor.

28. 1. A method of administering BT1718 to a patient in need thereof, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein achievement of a therapeutically effective dose is predicted by the presence of a circulating tumor cell (CTC) biomarker.

29. 1. A method of administering BT1718 to a patient in need thereof, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein the achievement of a therapeutically effective response is predicted by the presence of a prognostic biomarker.

30. 30. The method of claim 29, wherein the prognostic biomarker is plasma total extracellular free DNA (cfDNA).

31. 1. A method of administering BT1718 to a patient in need of BT1718, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein achievement of a therapeutically effective dose is indicated by the presence of a circulating biomarker of cell death.

32. 32. The method of claim 31 , wherein the circulating biomarkers of cell death are selected from the group consisting of M30 and M65.

33. A method of administering BT1718 to a patient in need of BT1718, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein achievement of a therapeutically effective dose is indicated by the presence of an alteration in expression of MT1 MMP in immune cells.

34. 34. The method of claim 33, wherein the immune cells are selected from the group consisting of myeloid cells and lymphoid cells.

35. 35. The method of claim 34, wherein the bone marrow cells are selected from the group consisting of neutrophils, monocytes, eosinophils, and basophils.

36. 35. The method of claim 34, wherein the lymphoid cell is selected from the group consisting of a T cell, a B cell, and a NK cell.

37. 1. A method of administering BT1718 to a patient in need of BT1718, comprising the step of administering to said patient BT1718 or a pharma- ceutically acceptable salt and / or composition thereof, wherein said BT1718 is provided in a 20 mL type I clear glass vial with a chlorobutyl stopper and an aluminum seal.

38. 38. The method of claim 37, wherein the BT1718 is a white to off-white lyophilized powder for reconstitution.

39. 39. The method of claim 38, wherein the vial contains about 21.2 mg of BT1718.

40. 40. The method of any one of claims 1 to 39, wherein the patient is a cancer patient.

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