Use of oncolytic viruses in neoadjuvant therapy of cancer

Abstract

To provide a method of using an oncolytic virus in a neoadjuvant treatment regimen for the treatment of cancer.SOLUTION: A method for the treatment of cancer comprises: administering a combination of an oncolytic virus and a first checkpoint inhibitor; surgically removing any remaining tumor; and administering a second checkpoint inhibitor, where the first and second checkpoint inhibitors may be the same or different.SELECTED DRAWING: Figure 1

Description

Technical Field

[0001] Cross - Reference to Related Applications This application claims the benefit and priority of U.S. Provisional Patent Application No. 62 / 825,929, filed Mar. 29, 2019; U.S. Provisional Patent Application No. 62 / 882,013, filed Aug. 2, 2019; and U.S. Provisional Patent Application No. 62 / 898,889, filed Sep. 11, 2019, each of which is hereby incorporated by reference in its entirety.

[0002] Reference to a Sequence Listing This application includes a sequence listing in computer - readable form. The sequence listing is provided as a text file named A - 2364 - WO - PCT_SeqListing_ST25.txt, created on Feb. 18, 2020, and having a size of 15,346 bytes. The information in the sequence listing in electronic format is hereby incorporated by reference in its entirety.

Background Art

[0003] Despite the ease of early detection, the prognosis remains poor for patients with high-risk primary melanoma or patients with macroscopic lymph node metastasis. The best option for patients with higher-risk melanoma (e.g., resectable melanoma) is to receive effective adjuvant therapy to reduce their likelihood of recurrence. Multiple systemic therapies have been tested as adjuvant therapy for melanoma with demonstrated benefit. In recent years, high-dose ipilimumab at 10 mg / kg has shown significant improvement in recurrence-free and overall survival in stage 3 melanoma patients, but at a significant cost in terms of immune-related toxicities. The results of recent clinical trials with immunotherapy (PD-1 inhibitors) and molecularly targeted therapy (BRAF inhibitor + MEK inhibitor) have led to improved management of adjuvant therapy for melanoma. As the results from these trials mature, new questions will arise regarding treatment decisions, such as patient selection by predictive and prognostic biomarkers, and optimization of the management of adverse events, particularly those related to immune-related toxicities. Cancer Treat Rev. 2018 Sep;69:101-111. doi: 10.1016 / j.ctrv.2018.06.003. Epub 2018 Jun 9.

[0004] Achieving pCR after neoadjuvant chemotherapy has been observed to be associated with a significant improvement in disease recurrence and survival in the context of triple-negative and HER2+ breast cancer. Spring et al., Cancer Res February 15 2019(79)(4 Supplement)GS2-03; DOI:10.1158 / 1538-7445.SABCS18-GS2-03. More recently, data presented by the International Neoadjuvant Melanoma Consortium (INMC) has concluded that the ability to achieve a pathologic complete response correlates with improved RFS (Menzies a et al, 2019 ASCO Annual Meeting). However, further investigation is still needed to evaluate the clinical utility of the up-titration / down-titration approach in the adjuvant setting based on the patient's neoadjuvant response.

[0005] Therefore, within the scope of their treatment plans, there is still a need for novel neoadjuvant treatment plans (such as those utilizing oncolytic viruses) that optimize neoadjuvant, primary, and adjuvant treatments.

Prior Art Documents

Non-Patent Documents

[0006]

Non-Patent Document 1

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Non-Patent Document 3

Summary of the Invention

Means for Solving the Problems

[0007] The present invention includes administering a combination of an oncolytic virus and a first checkpoint inhibitor, surgically removing any residual tumor, and administering a second checkpoint inhibitor, wherein the first and second checkpoint inhibitors may be the same or different, and relates to a method for treating cancer.

[0008] The oncolytic virus used in the present invention may be an adenovirus, a reovirus, a measles virus, a herpes simplex virus, a Newcastle disease virus, a Seneca virus, or a vaccinia virus. In certain embodiments, the oncolytic virus is an adenovirus, a reovirus, a herpes simplex virus, a Newcastle disease virus, or a vaccinia virus. In some embodiments, the oncolytic virus is a herpes simplex virus such as herpes simplex virus type 1 virus (HSV-1). HSV-1 may lack a functional ICP34.5 gene, lack a functional ICP47 gene, and be modified to include a gene encoding a heterologous gene. In some embodiments, the heterologous gene is a cytokine such as GM-CSF (e.g., human GM-CSF). In certain embodiments, the oncolytic virus is talimogene laherparepvec, RP1, RP2, or RP3. In another specific embodiment, the oncolytic virus is talimogene laherparepvec.

[0009] The first and second checkpoint inhibitors used in the present invention may be independently selected from the list including CTLA-4 blockers, PD-1 blockers, and PD-L1 blockers. In some embodiments, the CTLA-4 blocker is an anti-CTLA-4 antibody, the PD-1 blocker is an anti-PD-1 antibody, and the PD-L1 blocker is an anti-PD-L1 antibody. The CTLA-4 blocker may be ipilimumab. The PD-1 blocker may be nivolumab, pembrolizumab, CT-011, AMP-224, semipramab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10. The PD-L1 blocker may be atezolizumab, avelumab, durvalumab, or BMS-936559.

[0010] Cancers that can be treated using the methods of the present invention include melanoma, breast cancer (e.g., triple negative breast cancer), renal cancer, bladder cancer, colorectal cancer, lung cancer, nasopharyngeal cancer, pancreatic cancer, liver cancer, non-melanoma skin cancer, neuroendocrine tumors, T cell lymphoma (e.g., peripheral), or cancer of unknown primary origin, pediatric solid tumors with unresectable epidermal lesions. In some embodiments, the cancer is a melanoma of stage 2, 3a, 3b, 3c, 3d or 41a.

[0011] The present invention also relates to a package insert or label indicating the treatment of cancer by administering in combination [1] a herpes simplex virus lacking a functional ICP34.5 gene, lacking a functional ICP47 gene, and comprising a gene encoding human GM-CSF, [2] an oncolytic virus and a first checkpoint inhibitor, surgically removing any residual tumor, and administering a second checkpoint inhibitor, wherein the first and second checkpoint inhibitors may be the same or different package insert or label, and to a kit comprising the same. In some embodiments, the present invention relates to a method of manufacturing such a kit.

Brief Description of the Drawings

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Mode for Carrying Out the Invention

[0013] As used herein, the term "immune checkpoint inhibitor" refers to a molecule that completely or partially reduces, inhibits, interferes with, or modulates one or more checkpoint proteins. Checkpoint proteins control T cell activation or its function. A number of checkpoint proteins are known, such as CTLA-4 and its ligands CD80 and CD86, and PD-1 together with its ligands PD-L1 and P-DL2 (Pardoll, Nature Reviews Cancer 12:252-264, 2012). These proteins are involved in co-stimulatory or inhibitory interactions of T cell responses. Immune checkpoint proteins control and maintain self-tolerance and the duration and amplitude of physiological immune responses. Immune checkpoint inhibitors include, for example, antibodies or are derived from antibodies.

[0014] As used herein, the term "antibody" refers to a protein having a conventional immunoglobulin structure that includes heavy and light chains and includes variable and constant regions. For example, an antibody can be an IgG that has a "Y-shaped" structure with two pairs of identical polypeptide chains, each pair having one "light" chain (usually having a molecular weight of about 25 kDa) and one "heavy" chain (usually having a molecular weight of about 50-70 kDa). Antibodies have variable and constant regions. In the IgG structure, the variable region generally consists of about 100-110 or more amino acids, includes three complementarity-determining regions (CDRs), is mainly involved in antigen recognition, and is substantially different among other antibodies that bind different antigens. The constant region enables the antibody to recruit cells and molecules of the immune system. The variable region is made up of the N-terminal regions of each light and heavy chain, while the constant region is made up of the respective C-terminal portions of the heavy and light chains (Janeway et al., "Structure of the Antibody Molecule and the Immunoglobulin Genes", Immunobiology: The Immune System in Health and Disease, 4 thed. Elsevier Science Ltd. / Garland Publishing, (1999)).

[0015] As used herein, the terms "patient" or "subject" are used interchangeably and mean a mammalian subject, including but not limited to a human or non-human mammal such as a cow, horse, dog, sheep or cat. Preferably, the patient is human.

[0016] All clinical efficacy evaluations described herein (e.g., ORR, DoR, etc.) are measured according to Response Evaluation Criteria in Solid Tumors (RECIST). See Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: Revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45:228-247 (which is incorporated herein by reference in its entirety).

[0017] As used herein, "response rate" refers to the incidence of either confirmed complete response or partial response.

[0018] As used herein, "time to response" refers to the time from treatment to the date of the first confirmed objective response according to modified RECIST.

[0019] As used herein, "duration of response" refers to the time from the first confirmed objective response according to modified RECIST to the date of confirmed disease progression or death, whichever occurs first.

[0020] As used herein, "progression-free survival" refers to the time from treatment to the date of the first confirmed disease progression according to modified RECIST criteria.

[0021] As used herein, "recurrence-free survival period" or "disease-free survival period" refers to the time from treatment (surgery) to the date of the first recurrence or death.

[0022] As used herein, "event-free survival period" refers to the time from randomization until the occurrence of any one of the following: progression of a disease that interferes with surgery, local or distant recurrence, or death from any cause.

[0023] As used herein, "distant metastasis-free survival period" or "distant disease-free survival period" refers to the time from surgery until the first occurrence of distant metastasis.

[0024] As used herein, "survive" refers to patients who are alive and includes overall survival period and progression-free survival period. The 1-year survival rate and 2-year survival rate refer to the Kaplan-Meier estimators of the proportion of subjects who survive for 12 months or 24 months.

[0025] As used herein, "prolong the survival period" refers to increasing the overall survival period and / or progression-free survival period in patients receiving treatment as compared to a control treatment protocol such as treatment with ipilimumab alone. Survival is monitored for at least about 1 month, 2 months, 4 months, 6 months, 9 months, or at least about 1 year, or at least about 2 years, or at least about 3 years, or at least about 4 years, or at least about 5 years, or at least about 10 years, etc. after the start of treatment or after the initial diagnosis.

[0026] As used herein, "reduce or suppress" refers to the ability to cause an overall reduction of 20%, 30%, 40%, 50%, 60%, 70%, 75%, 80%, 85%, 90%, 95% or more. Reduce or suppress can refer to the symptoms of a disease being treated, the presence or size of metastases, or the size of the primary tumor.

[0027] Cancer can be classified into "stages" based on the progression / development of the disease. Generally, the stages are subdivided into stages 1, 2, 3, and 4, where stage 1 indicates an early-stage disease and stage 4 indicates a late-stage / more advanced disease. For example, in the context of melanoma, patients with stage 1 and 2 melanoma have a localized disease, while patients with stage III and IV melanoma have locally metastatic and distant metastatic diseases, respectively. Despite being partially defined by the absence of local disease, stage 2 melanoma patients with high-risk features (such as a large tumor thickness and the presence of ulceration) may have a worse prognosis than primary melanoma patients with better features and patients with limited potential for local metastasis (stage 3A). For example, stage 2C melanoma patients have a worse expected 5-year and 10-year survival rate compared to stage 3A disease patients (82% and 75% respectively, compared to 93% and 88%).

[0028] In addition, stage 3 melanoma is divided into four subgroups based on the tumor thickness, ulceration status, and the number of lymph nodes with tumor (and whether these were clinically occult or clinically detected), as well as the presence or absence of non-lymph node local metastasis. There are significant differences in the prognosis among the four subgroups of stage 3, and the 5-year melanoma-specific survival (MSS) ranges from 93% for stage 3A disease to 32% for stage 3D disease. Compared to the 5-year MSS of stage 3A, 3B, and 3C diseases in the 7th edition, these rates are extremely favorable (78%, 59%, and 40% respectively), which has a significant impact on clinical decision-making, patient counseling, and clinical trial design.

[0029] The melanoma of stage 4 is described as a melanoma that has spread through the bloodstream to other parts of the body, such as remote sites on the epidermis or soft tissue, remote lymph nodes, or other organs such as the lung, liver, brain, bone, or gastrointestinal tract. Stage 4 is further evaluated based on the site of distant metastasis. Stage 4a: The cancer has spread only to remote epidermal and / or soft tissue sites. Stage 4M1b: The cancer has spread to the lung. Stage 4M1c: The cancer has spread to other sites excluding the central nervous system. Stage 4M1d: The cancer has spread to the central nervous system, including the brain, spinal cord and / or cerebrospinal fluid, or the meninges of the brain and / or spinal cord.

[0030] The terms "CD8 density", "CD8+ density", or "CD8+ T cell density" refer to the number of CD8+ T cells present in a sample, such as a tumor sample. In an exemplary embodiment, the CD8+ T cell density is the number of cells present in a sample of a tumor from a subject, such as a sample of 1 mm 2 (e.g., punch biopsy) or a sample of 1 mL (i.e., 1 cm 3 ). In a certain exemplary embodiment, a low CD8+ T cell density (associated with a "cold" tumor) is less than about 3000 cells per 1 mm 2 or 1 mL sample, less than about 2900 cells per 1 mm 2 or 1 mL sample, less than about 2800 cells per 1 mm 2 or 1 mL sample, less than about 2700 cells per 1 mm 2 or 1 mL sample, less than about 2600 cells per 1 mm 2 or 1 mL sample, less than about 2500 cells per 1 mm 2 or 1 mL sample, less than about 2400 cells per 1 mm 2 or 1 mL sample, less than about 2300 cells per 1 mm 2 or 1 mL sample, less than about 2200 cells per 1 mm 2 or 1 mL sample, less than about 2100 cells per 1 mm 2 or 1 mL sample, less than about 2100 cells per 1 mm2 less than about 2000 cells per sample of 1 mm 2 less than about 1900 cells per sample of 1 mm 2 or less than about 1800 cells per 1 mL sample, 1 mm 2 or less than about 1700 cells per 1 mL sample, 1 mm 2 or less than about 1600 cells per 1 mL sample, 1 mm 2 or less than about 1500 cells per 1 mL sample, 1 mm 2 or less than about 1400 cells per 1 mL sample, 1 mm 2 or less than about 1300 cells per 1 mL sample, 1 mm 2 or less than about 1200 cells per 1 mL sample, 1 mm 2 or less than about 1100 cells per 1 mL sample, 1 mm 2 or less than about 1000 cells per 1 mL sample, 1 mm 2 or less than about 900 cells per 1 mL sample, 1 mm 2 or less than about 800 cells per 1 mL sample, 1 mm 2 or less than about 700 cells per 1 mL sample, 1 mm 2 or less than about 600 cells per 1 mL sample, 1 mm 2 or less than about 500 cells per 1 mL sample, 1 mm 2 or less than about 400 cells per 1 mL sample, 1 mm 2 or less than about 300 cells per 1 mL sample, 1 mm 2 or less than about 200 cells per 1 mL sample, or 1 mm 2 or less than about 100 cells per 1 mL sample. In certain exemplary embodiments, a low CD8+ T cell density is 1 mm 2 or about 3000 - 500 cells per 1 mL sample, 1 mm 2 or about 2900 - 500 cells per 1 mL sample, 1 mm 2or about 2,800 to 500 cells per mL of sample, 1 mm 2 or about 2,700 to 500 cells per mL of sample, 1 mm 2 or about 2,600 to 500 cells per mL of sample, 1 mm 2 or about 2,500 to 500 cells per mL of sample, 1 mm 2 or about 2,400 to 500 cells per mL of sample, 1 mm 2 or about 2,300 to 500 cells per mL of sample, 1 mm 2 or about 2,200 to 500 cells per mL of sample, 1 mm 2 or about 2,100 to 500 cells per mL of sample, 1 mm 2 or about 2,000 to 500 cells per mL of sample, 1 mm 2 or about 1,900 to 500 cells per mL of sample, 1 mm 2 or about 1,800 to 500 cells per mL of sample, 1 mm 2 or about 1,700 to 500 cells per mL of sample, 1 mm 2 or about 1,600 to 500 cells per mL of sample, 1 mm 2 or about 1,500 to 500 cells per mL of sample, 1 mm 2 or about 1,400 to 600 cells per mL of sample, 1 mm 2 or about 1,300 to 700 cells per mL of sample, 1 mm 2 or about 1,200 to 800 cells per mL of sample, 1 mm 2 or about 1,100 to 900 cells per mL of sample, or 1 mm 2 or about 1,050 to 950 cells per mL of sample. In certain exemplary embodiments, a low CD8+ T cell density is 1 mm 2 or about 10 to 1,000 cells per mL of sample, 1 mm 2 or about 20 to 900 cells per mL of sample, 1 mm 2or about 30 to 800 cells per mL of sample, 1 mm 2 or about 40 to 700 cells per mL of sample, 1 mm 2 or about 50 to 600 cells per mL of sample, 1 mm 2 or about 60 to 500 cells per mL of sample, 1 mm 2 or about 70 to 400 cells per mL of sample, 1 mm 2 or about 80 to 300 cells per mL of sample, or 1 mm 2 or about 90 to 100 cells per mL of sample. In certain exemplary embodiments, the sample does not contain detectable CD8+ T cells.

[0031] Use of Oncolytic Viruses in Neoadjuvant Therapy of Cancer The present invention provides a method for using oncolytic viruses for the treatment of cancer. For example, oncolytic viruses can be used in a neoadjuvant treatment regimen for the treatment of cancer. Generally, neoadjuvant treatment is given as a first step to shrink the tumor prior to primary treatment. Examples of primary treatment include surgery, checkpoint inhibitor therapy (e.g., anti-PD-1, anti-PD-L1, and anti-CTLA-4), BRAF inhibitor therapy, MEK inhibitor therapy, chemotherapy, and combinations thereof. Examples of neoadjuvant treatment include chemotherapy, radiation therapy, hormone therapy, checkpoint inhibitor therapy, BRAF inhibitor therapy, MEK inhibitor therapy, and oncolytic virus therapy. In certain embodiments, the primary treatment is surgery and the neoadjuvant treatment is an oncolytic virus.

[0032] In one embodiment, the present invention relates to the treatment of cancer by administering a neo - adjuvant oncolytic virus followed by primary treatment. In another embodiment, the present invention relates to the treatment of cancer by administering a neo - adjuvant oncolytic virus, followed by primary treatment and then adjuvant therapy. In another embodiment, the present invention relates to the treatment of cancer by administering a neo - adjuvant oncolytic virus in combination with a checkpoint inhibitor therapy, followed by primary treatment and then adjuvant therapy. In one embodiment, the neo - adjuvant therapy is an oncolytic virus such as HSV - 1 (e.g., talimogene laherparepvec, RP1, RP2, or RP3). In one embodiment, the neo - adjuvant therapy is a combination of an oncolytic virus such as HSV - 1 (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and a checkpoint inhibitor (e.g., an anti - PD - 1 such as pembrolizumab, nivolumab, or an anti - PD - 1 antibody comprising any one or more of SEQ ID NOs: 1 - 10). In another embodiment, the neo - adjuvant therapy is a combination of an oncolytic virus such as HSV - 1 (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and a checkpoint inhibitor (e.g., an anti - CTLA - 4 such as ipilimumab). In another embodiment, the primary treatment is surgery. In yet another embodiment, the adjuvant therapy is a checkpoint inhibitor (e.g., an anti - PD - 1 such as pembrolizumab, nivolumab, or an anti - PD - 1 antibody comprising any one or more of SEQ ID NOs: 1 - 10). In other embodiments, the oncolytic virus is talimogene laherparepvec.

[0033] Without being bound by logic, the present invention utilizes combination therapies to increase the rate of pCR (pathological complete response), RFS, and / or OS without excessive toxicity. Additionally, the neo - adjuvant treatment plan of the present invention can reduce or eliminate the dosage and / or duration of primary treatment or adjuvant therapy, thereby reducing the treatment cost and the burden on the patient during treatment while maintaining clinical utility.

[0034] Patients untreated with anti-PD-1 therapy The present invention can be used to treat untreated patients before checkpoint inhibitor therapy (e.g., anti-PD-1 such as pembrolizumab or nivolumab). That is, the patient has not previously received checkpoint inhibitor therapy.

[0035] In certain embodiments, the present invention administers a neoadjuvant oncolytic virus (e.g., talimogene laherparepvec) in combination with a checkpoint inhibitor therapy (e.g., pembrolizumab or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10), followed by primary treatment (e.g., surgery), and then a checkpoint inhibitor (e.g., pembrolizumab or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10) adjuvant therapy for the treatment of cancer. In some embodiments, the cancer is melanoma, breast cancer (e.g., triple negative breast cancer), renal cancer, bladder cancer, colorectal cancer, lung cancer, nasopharyngeal cancer, pancreatic cancer, liver cancer, non-melanoma skin cancer, neuroendocrine tumor, T cell lymphoma (e.g., peripheral), or cancer of unknown primary, pediatric solid tumor with unresectable cutaneous lesions. In some embodiments, the cancer is a stage 3a, 3b, 3c, 3d, or 41a cancer. In certain embodiments, the cancer is melanoma (e.g., stage 2 melanoma). In certain embodiments, the cancer is melanoma (e.g., stage 3a, 3b, 3c, 3d, or 41a melanoma).

[0036] An appropriate dosage can be determined, for example, by a physician. In some embodiments, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations. In certain embodiments, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3). In another embodiment, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of a checkpoint inhibitor (e.g., pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10). In yet another embodiment, the neoadjuvant treatment comprises a combination of 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of a checkpoint inhibitor (e.g., pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10). In other embodiments, the neoadjuvant treatment comprises a combination of 1, 2, 3, 4, or 5 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and 1, 2, or 3 administrations of a checkpoint inhibitor (e.g., pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10). In still other embodiments, the neoadjuvant treatment comprises a combination of 1, 2, or 3 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and 1, 2, or 3 administrations of a checkpoint inhibitor (e.g., pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10). In certain embodiments, the neoadjuvant treatment comprises a combination of talimogene laherparepvec and pembrolizumab. In a particular embodiment, the neoadjuvant treatment comprises a combination of 3 administrations of talimogene laherparepvec and 1 administration of pembrolizumab or nivolumab.

[0037] In some embodiments, primary treatment includes surgery.

[0038] In some embodiments, adjuvant treatment includes checkpoint inhibitor therapy (e.g., anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10) at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 months. In other embodiments, adjuvant treatment includes checkpoint inhibitor therapy (e.g., anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10) at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months. In some embodiments, adjuvant treatment includes checkpoint inhibitor therapy (e.g., anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10) at 3, 6, 9, or 12 months. In certain embodiments, adjuvant treatment includes treatment with pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10 at 6 months or 12 months.

[0039] Patients in whom the aforementioned anti-PD-1 treatment was ineffective In still other embodiments of the present invention, the patient was ineffective (i.e., the disease progressed thereafter) prior to checkpoint inhibitor (e.g., anti-PD-1 such as pembrolizumab or nivolumab) therapy. That is, the patient's disease progressed after receiving checkpoint inhibitor therapy.

[0040] In certain embodiments, the present invention relates to the treatment of cancer by administering a neo - adjuvant oncolytic virus (e.g., talimogene laherparepvec) in combination with a checkpoint inhibitor therapy (e.g., anti - CTLA - 4 such as ipilimumab), followed by administering a checkpoint inhibitor (e.g., anti - CTLA - 4 such as ipilimumab) adjuvant therapy after primary treatment (e.g., surgery). In some embodiments, the cancer is melanoma, breast cancer (e.g., triple - negative breast cancer), renal cancer, bladder cancer, colorectal cancer, lung cancer, nasopharyngeal cancer, pancreatic cancer, liver cancer, non - melanoma skin cancer, neuroendocrine tumor, T - cell lymphoma (e.g., peripheral), or cancer of unknown primary, pediatric solid tumor with unresectable epidermal lesions. In some embodiments, the cancer is a stage 3a, 3b, 3c, 3d, or 41a cancer. In certain embodiments, the cancer is melanoma (e.g., stage 3a, 3b, 3c, 3d, or 41a melanoma).

[0041] An appropriate dosage can be determined, for example, by a physician. In some embodiments, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations. In certain embodiments, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3). In another embodiment, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of a checkpoint inhibitor (e.g., anti-CTLA-4 such as ipilimumab). In yet another embodiment, the neoadjuvant treatment comprises a combination of 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of a checkpoint inhibitor (e.g., anti-CTLA-4 such as ipilimumab). In other embodiments, the neoadjuvant treatment comprises a combination of 1, 2, 3, 4, or 5 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and 1, 2, 3, 4, or 5 administrations of a checkpoint inhibitor (e.g., anti-CTLA-4 such as ipilimumab). In still other embodiments, the neoadjuvant treatment comprises a combination of 1, 2, or 3 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3) and 2, 3, or 4 administrations of a checkpoint inhibitor (e.g., anti-CTLA-4 such as ipilimumab). In certain embodiments, the neoadjuvant treatment comprises a combination of talimogene laherparepvec and ipilimumab. In a particular embodiment, the neoadjuvant treatment comprises a combination of 3 administrations of talimogene laherparepvec and 4 administrations of an anti-CTLA-4 such as ipilimumab.

[0042] In some embodiments, the primary treatment comprises surgery.

[0043] In some embodiments, adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-CTLA-4 such as ipilimumab) for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, or 30 months. In other embodiments, adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-CTLA-4 such as ipilimumab) for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 months. In some embodiments, adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-CTLA-4 such as ipilimumab) for 3, 6, 9, 12, 15, 18, 21, or 24 months. In certain embodiments, adjuvant therapy includes treatment with ipilimumab for 12 months or 24 months.

[0044] Patients with early-stage melanoma In still other embodiments of the present invention, neoadjuvant therapy can be used to treat cancer patients at stage 1 or stage 2. In certain embodiments, the patient has stage 1 or stage 2 melanoma. In another embodiment, the patient has stage 1 melanoma. In another embodiment, the patient has stage 2 melanoma.

[0045] In certain embodiments, the present invention relates to the treatment of stage 1 or stage 2 cancer (e.g., melanoma), wherein a neoadjuvant oncolytic virus (e.g., talimogene laherparepvec) is administered, followed by primary treatment (e.g., surgery), and optionally followed by adjuvant therapy with a checkpoint inhibitor (e.g., anti-CTLA-4 such as ipilimumab, or anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10). In some embodiments, the cancer is stage 1 or stage 2 melanoma, breast cancer (e.g., triple negative breast cancer), renal cancer, bladder cancer, colorectal cancer, lung cancer, nasopharyngeal cancer, pancreatic cancer, liver cancer, non-melanoma skin cancer, neuroendocrine tumor, T cell lymphoma (e.g., peripheral), or cancer of unknown primary, pediatric solid tumor with unresectable epidermal lesions. In certain embodiments, the cancer is stage 2 melanoma.

[0046] An appropriate dosage can be determined, for example, by a physician. In some embodiments, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations. In certain embodiments, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3). In other embodiments, the neoadjuvant treatment comprises 1, 2, 3, 4, 5, or 6 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3). In still other embodiments, the neoadjuvant treatment comprises 2, 3, 4, or 5 administrations of an oncolytic virus (e.g., talimogene laherparepvec, RP1, RP2, or RP3). In certain embodiments, the neoadjuvant treatment comprises talimogene laherparepvec. In certain specific embodiments, the neoadjuvant treatment comprises 4 administrations of talimogene laherparepvec.

[0047] In some embodiments, the primary treatment comprises surgery.

[0048] In some embodiments, optional adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-CTLA-4 such as ipilimumab) for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, or 30 months. In other embodiments, optional adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-CTLA-4 such as ipilimumab) for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 months. In some embodiments, optional adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-CTLA-4 such as ipilimumab) for 3, 6, 9, 12, 15, 18, 21, or 24 months. In certain embodiments, optional adjuvant therapy includes treatment with ipilimumab for 12 months or 24 months.

[0049] In some embodiments, optional adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10) for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 months. In other embodiments, optional adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10) for 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months. In some embodiments, optional adjuvant therapy includes checkpoint inhibitor therapy (e.g., anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10) for 3, 6, 9, or 12 months. In certain embodiments, optional adjuvant therapy includes treatment with pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10 for 6 months or 12 months.

[0050] Patients with low CD8+ cell density at the baseline time point Using the present invention, patients with low CD8+ cell density at the baseline time point can be treated. It has been observed that treatment with talimogene laherparepvec resulted in an increase in CD8+ cell density within the tumor (see Figure 8). Importantly, this increase in CD8+ cell density within the tumor after treatment with talimogene laherparepvec correlates with a longer RFS (sensitivity analysis) and a longer OS (see Figure 9). Thus, in some embodiments, the treatment regimen of the present invention is used to treat patients with "cold" tumors, i.e., tumors with a low level of CD8+ cell density within the tumor at the baseline time point. In particular, by administering a neoadjuvant oncolytic virus (e.g., talimogene laherparepvec) to a "cold" tumor, the outcomes of subsequent primary treatment (e.g., surgery), such as RFS and OS, are improved.

[0051] In one embodiment, patients with "cold" tumors are selected for treatment with the treatment regimen of the present invention. In one embodiment, the patient has a cold tumor with a CD8+ T cell density of 1 mm 2 or less than about 3000 cells per mL (i.e., 1 cm 3 ) of sample, such as about 3000, about 2900, about 2800, about 2700, about 2600, about 2500, about 2400, about 2300, about 2200, about 2100, about 2000, about 1900, about 1800, about 1700, about 1600, about 1500, about 1400, about 1300, about 1200, about 1100, about 1000, about 900, about 800, about 700, about 600, or less than about 500 cells. In some embodiments, the patient has a cold tumor with a CD8+ T cell density of about 1500, about 1400, about 1300, about 1200, about 1100, about 1000, about 900, about 800, about 700, about 600, or less than about 500 cells / mm 2 or less.

[0052] Oncolytic virus In one embodiment, the oncolytic virus used in the present invention is an adenovirus, a reovirus, a measles virus, a herpes simplex virus, a Newcastle disease virus, a Seneca virus, or a vaccinia virus. In certain embodiments, the oncolytic virus is a herpes simplex virus (HSV). In an exemplary aspect, the oncolytic virus is a herpes simplex virus type 1 (HSV-1) or herpes simplex virus type 2 (HSV-2) strain or a derivative thereof, preferably derived from HSV-1. Derivative strains include heterologous recombinant strains containing DNA from HSV-1 and HSV-2 strains. Such heterologous recombinant strains are described in the art, for example, in Thompson et al., (1998) Virus Genes 1(3);275286 and Meignier et al., (1998) J. Infect. Dis. 159;602614.

[0053] Herpes simplex virus strains may be derived from clinical isolates. Such strains are isolated from infected individuals suffering from recurrent herpes simplex. As described in U.S. Patent Nos. 7,063,835 and 7,223,593, clinical isolates can be screened for desired capabilities or characteristics, such as enhanced replication in tumors and / or other cells in vitro and / or in vivo, compared to standard laboratory strains, and each of the above documents is incorporated herein by reference in its entirety. In one embodiment, the herpes simplex virus is a clinical isolate from recurrent herpes simplex. Further herpes simplex virus type 1 virus strains include, but are not limited to, the JS1 strain, the 17+ strain, the F strain, the KOS strain, and the Patton strain.

[0054] Examples of HSV genes that can be modified include pathogenic genes encoding proteins such as ICP34.5 (γ34.5). ICP34.5 acts as a pathogenic factor during HSV infection, restricts replication in non-dividing cells, and renders the virus non-pathogenic. Another HSV gene that can be modified is the gene encoding ICP47. ICP47 downregulates the expression of major histocompatibility complex (MHC) class I on the surface of infected host cells and the binding to the antigen presentation-related transporter (TAP) of MHC class I. Such an action blocks antigen peptide transport in the endoplasmic reticulum and the loading of MHC class I molecules. Another HSV gene that can be modified is ICP6, which is the large subunit of ribonucleotide reductase that is involved in nucleotide metabolism and viral DNA synthesis in non-dividing cells but not in dividing cells. Thymidine kinase (involved in phosphorylating acyclovir to acyclovir monophosphate), virion trans-activating protein vmw65, glycoprotein H, vhs, ICP43, and the early genes encoding ICP4, ICP27, ICP22, and / or ICP0 can also be modified (in addition to, or instead of, the genes listed above).

[0055] Herpes virus strains and methods for making such strains are described in U.S. Patent Nos. 5,824,318; 6,764,675; 6,770,274; 7,063,835; 7,223,593; 7,749,745; 7,744,899; 8,273,568; 8,420,071; and 8,470,577; International Publication Nos. WO 96 / 00007; WO 96 / 39841; WO 99 / 07394; WO 00 / 54795; WO 06 / 002394; and WO 13 / 06795; CN Patent Nos. 128303, 10230334, and 10230335; Varghese and Rabkin, (2002) Cancer Gene Therapy 9:967-97 and Cassady and Ness Parker, (2010) The Open Virology Journal 4:103-108, which are incorporated herein by reference in their entirety.

[0056] In one embodiment, the oncolytic virus is talimogene laherparepvec (IMLYGIC®), which is derived from the clinical strain (HSV-1 strain JS1) deposited with the European collection of cell cultures (ECACC) under accession number 01010209. In talimogene laherparepvec, the HSV-1 viral genes encoding ICP34.5 and ICP47 are functionally deleted. The functional deletion of ICP47 results in the early expression of US11, a gene that promotes viral growth in tumor cells without reducing tumor selectivity. The coding sequence of human GM-CSF has been inserted into the viral genome at the former site of ICP34.5 (see Liu et al., Gene Ther 10:292-303, 2003).

[0057] In some embodiments, the oncolytic virus lacks the gene encoding functional ICP34.5, lacks the gene encoding functional ICP47, contains a nucleic acid encoding Fms related tyrosine kinase 3 ligand (FLT3L), and is HSV-1 containing a nucleic acid encoding interleukin-12 (IL-12). In some embodiments, the oncolytic virus is derived from a clinical strain (HSV-1 strain JS1) deposited with the European collection of cell cultures (ECAAC) under accession number 01010209.

[0058] Other examples of oncolytic viruses include RP1 (HSV-1 / ICP34.5 - / ICP47 - / GM-CSF / GALV-GP R(-); RP2 (HSV-1 / ICP34.5 - / ICP47 - / GM-CSF / GALV-GP R(-) / anti-CTLA-4 binder; and RP3 (HSV-1 / ICP34.5 - / ICP47 - / GM-CSF / GALV-GP R(-) / anti-CTLA-4 binder / costimulatory ligand (e.g., CD40L, 4-1BBL, GITRL, OX40L, ICOS-L)). In such oncolytic viruses, GALV (gibbon ape leukemia virus) has been modified by specific deletion of the R-peptide, thereby obtaining GALV-GP R(-). Such oncolytic viruses are discussed in International Publication Nos. WO 2017 / 118864, WO 2017 / 118865, WO 2017 / 118866, WO 2017 / 118867 and WO 2018 / 127713A1, each of which is incorporated by reference in its entirety.

[0059] Additional examples of oncolytic viruses include NSC-733972, HF-10, BV-2711, JX-594, Myb34.5, AE-618, Brainwel™ and Heapwel™, Cavatak® (coxsackievirus, CVA21), HF-10, Seprehvir®, Reolysin®, enadenotucirev, ONCR-177, and those described in U.S. Patent No. 10,105,404, International Publication No. 2018006005 Pamphlet, No. 2018026872A1 Pamphlet, and No. 2017181420 Pamphlet, each of which is incorporated herein by reference in its entirety.

[0060] Additional examples of oncolytic viruses include the following.

[0061] [A] G207, an oncolytic HSV-1 derived from the F strain of wild-type HSV-1, has deletions in both copies of the HSV neurotoxicity major determinant, the ICP34.5 gene, and an inactivating insertion of the E. coli lacZ gene into UL39, which encodes infected cell protein 6 (see Mineta et al. (1995) Nat Med. 1:938-943).

[0062] [B] OrienX010, a herpes simplex virus with deletions in both copies of the γ34.5 and ICP47 genes, an interruption of the ICP6 gene, and an insertion of the human GM-CSF gene (see Liu et al., (2013) World Journal of Gastroenterology 19(31):5138-5143).

[0063] [C]Herpes simplex virus lacking the junction region of the long (L) and short (S) regions, containing one copy of NV1020, i.e., ICP34.5, UL24, and UL56.34, 35. The deleted region was replaced with HSV-2 US DNA (US2, US3(PK), gJ, and gG) fragments (see Todo, et al. (2001) Proc Natl Acad Sci USA. 98:6396-6401).

[0064] [D]M032, i.e., herpes simplex virus having deletions of both copies of the ICP34.5 gene and insertion of interleukin 12 (see Cassady and Ness Parker, (2010) The Open Virology Journal 4:103-108).

[0065] [E]ImmunoVEX HSV2, i.e., herpes simplex virus (HSV-2) having functional deletions of the genes encoding vhs, ICP47, ICP34.5, UL43, and US5.

[0066] [F]OncoVEX GALV / CD Also derived from the JS1 strain of HSV-1, with the genes encoding ICP34.5 and ICP47 functionally deleted, and instead of this ICP34.5 gene, a gene encoding cytosine deaminase and feline leukemia fusion glycoprotein is inserted into the viral genome.

[0067] The herpes simplex virus of the present invention may also contain one or more heterologous genes. A heterologous gene is a gene introduced into the genome of a virus that is not normally found in the genome of that virus or is a homolog of a gene expressed by a virus from a different species, has a different nucleic acid sequence, and acts via a different biochemical mechanism. Heterologous genes may encode one or more proteins, such as cytotoxins, immunomodulatory proteins (i.e., proteins that enhance or suppress the host immune response to an antigen), tumor antigens, prodrug activating factors, tumor suppressors, prodrug converting enzymes, proteins capable of causing cell-to-cell fusion, TAP inhibitors, antisense RNA molecules, or ribozymes. Examples of immunomodulatory proteins include, for example, cytokines. Cytokines include interleukins, such as IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL-10, IL-11, IL-12, IL-13, IL-14, IL-15, IL-16, IL-17, IL-18, IL-20; interferon α, interferon β or interferon γ, tumor necrosis factor alpha (TNFα), CD40L, granulocyte macrophage colony-stimulating factor (GM-CSF), macrophage colony-stimulating factor (M-CSF) and granulocyte colony-stimulating factor (G-CSF), chemokines (neutrophil activating protein (NAP), macrophage chemotactic activating factor (MCAF), RANTES and macrophage inflammatory peptide MIP-1a and MIP-1b, etc.), complement components and their receptors, immune system accessory molecules (e.g., B7.1 and B7.2), adhesion molecules (e.g., ICAM-1, 2 and 3) and adhesion receptor molecules. Examples of tumor antigens include the E6 and E7 antigens of human papillomavirus, EBV-derived proteins, mucins such as MUC1, melanoma tyrosinase, and MZ2-E. Examples of prodrug activating factors include nitroreductase and cytochrome p450, an example of a tumor suppressor is p53, and an example of a prodrug converting enzyme is cytosine deaminase. An example of a protein capable of causing cell-to-cell fusion is the baboon leukemia fusion glycoprotein.Examples of TAP inhibitors include the bovine herpesvirus (BHV) UL49.5 polypeptide. Antisense RNA molecules can be used to block the expression of cellular or pathogen mRNA. The RNA molecule can be a ribozyme (e.g., a hammerhead or hairpin ribozyme) designed to repair defective cellular RNA or to destroy unwanted cellular RNA or RNA encoded by a pathogen.

[0068] Also included is the insertion of multiple viral genes into the herpes simplex genome, such as the insertion of one or more copies of the gene encoding the viral protein Us11.

[0069] Talimogene laherparepvec, HSV-1 [JS1 strain] ICP34.5- / ICP47- / hGM-CSF (OncoVex GM-CSFTalimogene laherparepvec (also known as OncoVEXGM-CSF), is an intratumoral delivered oncolytic immunotherapy that contains an immune-enhancing HSV-1 that selectively replicates within solid tumors (Lui et al., Gene Therapy, 10:292-303, 2003; U.S. Patent No. 7,223,593 and U.S. Patent No. 7,537,924). HSV-1 was derived from the JS1 strain deposited with the European collection of cell cultures (ECACC) under accession number 01010209. In talimogene laherparepvec, the HSV-1 viral gene encoding ICP34.5 is functionally deleted. The functional deletion of ICP34.5, which acts as a pathogenicity factor during HSV infection, restricts replication in non-dividing cells and renders the virus non-pathogenic. The safety of HSV with a functionally deleted ICP34.5 has been demonstrated in multiple clinical trials (MacKie et al, Lancet 357:525-526, 2001; Markert et al, Gene Ther 7:867-874, 2000; Rampling et al, Gene Ther 7:859-866, 2000; Sundaresan et al, J.Virol 74:3822-3841, 2000; Hunter et al, J Virol Aug;73(8):6319-6326, 1999). Additionally, ICP47 (which blocks viral antigen presentation to major histocompatibility complex class I and II molecules) is functionally deleted from talimogene laherparepvec. The functional deletion of ICP47 also results in the early expression of US11, a gene that promotes viral growth in tumor cells without reducing tumor selectivity. The viral genome of talimogene laherparepvec has the coding sequence of human GM-CSF, a cytokine involved in the stimulation of the immune response, inserted into it. By replacing almost all of the ICP34.5 gene with the insertion of the gene encoding human GM-CSF, it becomes possible to ensure that any potential recombination events between talimogene laherparepvec and wild-type virus result only in inactivated non-pathogenic virus, and to prevent the generation of wild-type virus carrying the gene for human GM-CSF.The HSV thymidine kinase (TK) gene remains intact in talimogene laherparepvec, thereby rendering the virus sensitive to antiviral agents such as acyclovir. Therefore, acyclovir may be used as needed to inhibit the replication of talimogene laherparepvec.

[0070] Talimogene laherparepvec produces a direct oncolytic effect due to viral replication in tumors and induces an antitumor immune response enhanced by the local expression of GM-CSF. Since melanoma is a disseminated disease, this dual activity is beneficial as a therapeutic treatment. The intended clinical effects include destruction of the injected tumors, destruction of local and distant uninjected tumors, reduction in the formation of new metastases, reduction in the overall rate of progression and recurrence rate after treatment of the initially existing disease, and extension of overall survival.

[0071] Talimogene laherparepvec has been tested for efficacy in various in vitro (cell line) and in vivo murine tumor models and has been shown to eradicate tumors or substantially inhibit tumor growth at doses equivalent to those used in clinical trials. Also, nonclinical evaluation has confirmed that GM-CSF enhances the resulting immune response and enhances the response of both injected and uninjected tumors, and that the increased surface level of MHC class I molecules results from the deletion of ICP47. Talimogene laherparepvec has been injected into normal and tumor-bearing mice and its safety has been evaluated. This virus is generally well tolerated and showed no signs of safety concerns at doses up to 1 × 10 8 PFU per dose (see, for example, Liu et al., Gene Ther 10:292-303, 2003).

[0072] Clinical trials of several advanced tumor types (advanced solid tumors, melanoma, head and neck squamous cell carcinoma, and pancreatic cancer) involving over 400 subjects treated with talimogene laherparepvec have been completed or are ongoing (see, for example, Hu et al., Clin Can Res 12:6737-6747, 2006; Harrington et al., J Clin Oncol. 27(15a):abstract 6018, 2009; Kaufman et al., Ann Surgic Oncol. 17:718-730, 2010; Kaufman and Bines, Future Oncol. 6(6):941-949, 2010). Clinical data indicate that talimogene laherparepvec may provide overall clinical utility in patients with advanced melanoma. In particular, in stage 3c to stage 4 melanoma, a high rate of complete responses was achieved (Scenzer et al., J.Clin.Oncol. 271(12):907-913, 2009). In addition, responses were observed in both injected and non-injected sites, including visceral sites.

[0073] Talimogene laherparepvec is administered by intratumoral injection at a maximum dose of 4.0 mL at 10 6 plaque-forming units / mL (PFU / mL) on day 1 of week 1, followed by a maximum dose of 4.0 mL at 10 8 PFU / mL on day 1 of week 4, and then every two weeks (±3 days). The recommended amount of talimogene laherparepvec to be injected into the tumor should be determined according to the size of the tumor and in accordance with the injection volume guidelines in Table 1.

[0074]

Table 1

[0075] All lesions that can be reasonably injected (skin, subcutaneous, and lymph node diseases that can be injected with or without an ultrasound guide) must be injected at the maximum dose effective for each individual administration case. On each treatment day, it is recommended to prioritize injections as follows: new injectable tumors that have appeared since the last injection; starting with the largest tumor for each tumor size; any tumors that could not be injected previously but are now injectable.

[0076] Continue the course of therapy as long as there are medical indications or until the desired therapeutic effect (e.g., as described herein) is achieved. For example, according to the Response Evaluation Criteria in Solid Tumors (RECIST), patients can be treated with talimogene laherparepvec until complete response, until all injectable tumors disappear, until disease progression. Due to the mechanism of action, patients may experience growth of existing tumors or the appearance of new tumors before the clinical utility of talimogene laherparepvec is maximized. Therefore, it is expected that administration should be continued for at least 6 months from the first dose, provided that there is no evidence of a clinically significant worsening of health conditions that would require interruption of treatment and the patient can tolerate the treatment. However, the treatment course for any individual patient can be changed in clinical practice.

[0077] Primary treatment Any primary treatment of the treatment plan of the present invention described herein may be surgery, checkpoint inhibitor therapy (e.g., anti-PD-1, anti-PD-L1, and anti-CTLA-4), BRAF inhibitor therapy, MEK inhibitor therapy, and combinations thereof. In certain embodiments, the primary treatment is surgery.

[0078] Adjuvant therapy Any adjuvant therapy among the treatment plans of the present invention described in this specification may be a checkpoint inhibitor therapy (e.g., anti-PD-1, anti-PD-L1, and anti-CTLA-4), BRAF inhibitor therapy, MEK inhibitor therapy, and combinations thereof. In certain embodiments, the adjuvant therapy is a checkpoint inhibitor (e.g., anti-CTLA-4 such as ipilimumab; or anti-PD-1 such as pembrolizumab, nivolumab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10).

[0079] The immune system has multiple inhibitory pathways essential for maintaining self-tolerance and regulating the immune response. In T cells, the amplitude and nature of their responses are induced through antigen recognition by the T cell receptor and are regulated by immune checkpoint proteins that balance co-stimulatory and inhibitory signals.

[0080] Cytotoxic T lymphocyte-associated protein 4 (CTLA-4) is an immune checkpoint molecule that downregulates the pathway of T cell activation (Fong et al., Cancer Res. 69(2):609-615, 2009; Weber Cancer Immunol. Immunother, 58:823-830, 2009). Blockade of CTLA-4 has been shown to enhance T cell activation and its proliferation. Examples of CTLA-4 inhibitors include anti-CTLA-4 antibodies. Anti-CTLA-4 antibodies bind to CTLA-4 and block the interaction of CTLA-4 with its ligand CD80 / CD86 expressed on antigen-presenting cells. This blocks the negative downregulation of the immune response induced by the interaction of these molecules. Examples of anti-CTLA-4 antibodies are described in U.S. Patent Nos. 5,811,097; 5,811,097; 5,855,887; 6,051,227; 6,207,157; 6,682,736; 6,984,720; and 7,605,238. An example of an anti-CDLA-4 antibody is tremelimumab (ticilimumab, CP-675,206). In one embodiment, the anti-CTLA-4 antibody is ipilimumab (also known as 10D1, MDX-D010), a fully human monoclonal IgG antibody that binds to CTLA-4. Ipilimumab is commercially available under the name Yervoy® and is approved for the treatment of unresectable or metastatic melanoma.

[0081] Another immune checkpoint protein is programmed cell death 1 (PD-1). PD-1 restricts the activity of T cells in peripheral tissues during the inflammatory response to infection and enhances T cell proliferation and cytokine production in response to challenge by specific antigen targets or allogeneic cells during the mixed lymphocyte reaction by restricting autoimmune PD-1 blockade in vitro. A strong correlation between PD-1 expression and response has been shown by blocking PD-1 (Pardoll, Nature Reviews Cancer, 12:252-264, 2012). Blockade of PD-1 can be achieved by various mechanisms including antibodies that bind to PD-1 or its ligand PD-L1. Examples of PD-1 and PD-L1 blocking agents are described in U.S. Patent Nos. 7,488,802; 7,943,743; 8,008,449; 8,168,757; 8,217,149, and PCT International Publication Nos. WO 03 / 042402; WO 2008 / 156712; WO 2010 / 089411; WO 2010 / 036959; WO 2011 / 066342; WO 2011 / 159877; WO 2011 / 082400; and WO 2011 / 161699. In certain embodiments, the PD-1 blocking agent comprises an anti-PD-L1 antibody. In certain other embodiments, PD-1 blocking agents include anti-PD-1 antibodies and similar binding proteins such as nivolumab (MDX 1106, BMS 936558, ONO 4538), a fully human IgG4 antibody that binds to PD-1 and blocks activation of PD-1 by its ligands PD-L1 and PD-L2; pembrolizumab (MK-3475 or SCH 900475), a humanized monoclonal IgG4 antibody against PD-1; a humanized antibody that binds to PD-1, CT-011; AMP-224, a fusion protein of B7-DC; the Fc portion of an antibody; BMS-936559 (MDX-1105-01) that blocks PD-L1 (B7-H1); and semiprimab-rwlc (an anti-PD-1 antibody).

[0082] In certain embodiments, the anti-PD-1 antibody (or antigen-binding antibody fragment thereof) comprises one, two, three, four, five, or all six CDR amino acid sequences of SEQ ID NOs: 1-6, which represent HC CDR1, HC CDR2, HC CDR3, LC CDR1, LC CDR2, and LC CDR3, respectively. In certain embodiments, the anti-PD-1 antibody (or antigen-binding antibody fragment thereof) comprises all six of the CDR amino acid sequences of SEQ ID NOs: 1-6. In other embodiments, the anti-PD-1 antibody (or antigen-binding antibody fragment thereof) comprises (a) the heavy chain variable region amino acid sequence of SEQ ID NO: 7 or a variant sequence thereof (where only one or two amino acids are different or having at least or about 70% sequence homology), or (b) the light chain variable region amino acid sequence of SEQ ID NO: 8 or a variant sequence thereof (where only one or two amino acids are different or having at least or about 70% sequence homology). In an exemplary embodiment, the anti-PD-1 antibody (or antigen-binding antibody fragment thereof) comprises the heavy chain variable region amino acid sequence of SEQ ID NO: 7 and the light chain variable region amino acid sequence of SEQ ID NO: 8. In other embodiments, the anti-PD-1 antibody (or antigen-binding antibody fragment thereof) comprises (a) the heavy chain amino acid sequence of SEQ ID NO: 9 or a variant sequence thereof (where only one or two amino acids are different or having at least or about 70% sequence homology); or (b) the light chain amino acid sequence of SEQ ID NO: 10 or a variant sequence thereof (where only one or two amino acids are different or having at least or about 70% sequence homology). In an exemplary embodiment, the anti-PD-1 antibody (or antigen-binding antibody fragment thereof) comprises the heavy chain amino acid sequence of SEQ ID NO: 9 and the light chain amino acid sequence of SEQ ID NO: 10.

[0083] In certain embodiments, the anti-PD-1 antibody is encoded by one or more nucleic acid sequences (or antigen-binding portions thereof). In an exemplary embodiment, the antibody comprises one, two, three, four, five, or all six of the CDRs encoded by the nucleic acids of SEQ ID NOs: 11-16 (representing HC CDR1, HC CDR2, HC CDR3, LC CDR1, LC CDR2, and LC CDR3, respectively). In another exemplary embodiment, the antibody comprises all six of the CDRs encoded by the nucleic acids of SEQ ID NOs: 11-16. In some embodiments, the anti-PD-1 antibody (or antigen-binding portion thereof) comprises (a) a heavy chain variable region encoded by SEQ ID NO: 17 or a variant sequence thereof (where only one, two, three, four, five, or six nucleic acids differ or have at least or about 70%, 85%, 90%, or 95% sequence identity), or (b) a light chain variable region encoded by SEQ ID NO: 18 or a variant sequence thereof (where only one, two, three, four, five, or six nucleic acids differ or have at least or about 70%, 85%, 90%, or 95% sequence identity). In an exemplary embodiment, the anti-PD-1 antibody (or antigen-binding portion thereof) comprises a heavy chain variable region encoded by SEQ ID NO: 17 and a light chain variable region encoded by SEQ ID NO: 18. In other embodiments, the anti-PD-1 antibody (or antigen-binding portion thereof) comprises (a) a heavy chain encoded by SEQ ID NO: 19 or a variant sequence thereof (where only one, two, three, four, five, or six nucleic acids differ or have at least or about 70%, 85%, 90%, or 95% sequence identity), or (b) a light chain encoded by SEQ ID NO: 20 or a variant sequence thereof (where only one, two, three, four, five, or six nucleic acids differ or have at least or about 70%, 85%, 90%, or 95% sequence identity). In an exemplary embodiment, the anti-PD-1 antibody (or antigen-binding portion thereof) comprises a heavy chain encoded by SEQ ID NO: 19 and a light chain encoded by SEQ ID NO: 20.

[0084] Other immune checkpoint inhibitors include lymphocyte activation gene-3 (LAG-3) inhibitors, such as IMP321, a soluble Ig fusion protein (Brignone et al., 2007, J. Immunol. 179:4202-4211). Other immune checkpoint inhibitors include B7 inhibitors such as B7-H3 and B7-H4 inhibitors. In particular, anti-B7-H3 antibodies, MGA271 (Loo et al., 2012, Clin. Cancer Res. July 15(18)3834) are included. Also included are TIM3 (T cell immunoglobulin domain and mucin domain 3) inhibitors (Fourcade et al., 2010, J. Exp. Med. 207:2175-86 and Sakuishi et al., 2010, J. Exp. Med. 207:2187-94).

[0085] Kit A kit for use by a physician includes the oncolytic virus of the present invention (e.g., herpes simplex virus type 1 lacking a functional ICP34.5 gene, lacking a functional ICP47 gene, and containing a gene encoding human GM-CSF, such as talimogene laherparepvec), and an attached document and label with instructions for treating melanoma, breast cancer (e.g., triple negative breast cancer), renal cancer, bladder cancer, colorectal cancer, lung cancer, nasopharyngeal cancer, pancreatic cancer, liver cancer, non-melanoma skin cancer, neuroendocrine tumor, T cell lymphoma (e.g., peripheral), or cancer of unknown primary origin, pediatric solid tumors with unresectable epidermal lesions using the oncolytic virus as neoadjuvant therapy. In some embodiments, the cancer is a stage 3a, 3b, 3c, 3d, or 41a cancer. In certain embodiments, the cancer is melanoma (e.g., stage 2 melanoma). In certain embodiments, the cancer is melanoma (e.g., stage 3a, 3b, 3c, 3d, or 41a melanoma). In certain embodiments, the oncolytic virus is talimogene laherparepvec, RP1, RP2, or RP3. In another embodiment, the oncolytic virus is talimogene laherparepvec.

[0086] In other embodiments, the present invention relates to a kit comprising: [1] a herpes simplex virus lacking a functional ICP34.5 gene, lacking a functional ICP47 gene, and containing a gene encoding human GM-CSF; and [2] an instructional package insert or label for treating cancer by administering a oncolytic virus in combination with a first checkpoint inhibitor, surgically removing any residual tumor, and administering a second checkpoint inhibitor, wherein the first and second checkpoint inhibitors may be the same or different instructional package inserts or labels. In some embodiments, the oncolytic virus is talimogene laherparepvec, RP1, RP2, or RP3. In another embodiment, the oncolytic virus is talimogene laherparepvec. In some embodiments, the first and second checkpoint inhibitors may be independently selected from the list comprising CTLA-4 blockers, PD-1 blockers, and PD-L1 blockers. In some embodiments, the CTLA-4 blocker is an anti-CTLA-4 antibody, the PD-1 blocker is an anti-PD-1 antibody, and the PD-L1 blocker is an anti-PD-L1 antibody. The CTLA-4 blocker may be ipilimumab. The PD-1 blocker may be nivolumab, pembrolizumab, CT-011, AMP-224, semipilimab, or an anti-PD-1 antibody comprising any one or more of SEQ ID NOs: 1-10. The PD-L1 blocker may be atezolizumab, avelumab, durvalumab, or BMS-936559.

[0087] In other embodiments, the present invention relates to a method of manufacturing such a kit.

[0088] Unless otherwise defined, scientific and technical terms used in connection with the present invention shall have the meanings commonly understood by those of ordinary skill in the art. Further, unless the context requires a different interpretation, singular terms shall include the plural, and plural terms shall include the singular. Generally, the nomenclature and techniques used in connection with cell and tissue culture, molecular biology, immunology, microbiology, genetics, and the chemistry and hybridization of the proteins and nucleic acids described herein are well known and commonly used in the art. Unless otherwise indicated, the methods and techniques of the present invention are generally carried out according to conventional methods well known in the art, and such methods and techniques are described in various general and specific references cited and discussed throughout this specification. All patents and other publications identified are expressly incorporated herein by reference in their entirety.

Example

[0089] The following examples are provided to illustrate certain embodiments or features of the present invention and are not intended to limit its scope.

[0090] Example 1: A Phase 2 multi-center randomized open-label trial evaluating the efficacy and safety of talimogene laherparepvec in combination with surgery compared to surgery alone in patients with resectable stage 3B to 4M1a melanoma Patients with resectable stage 3B / C / 4M1a MEL ≥ 1, injectable skin lesions, subcutaneous lesions, or lymph node lesions ≥ 10 mm, and who had not received systemic treatment in the previous 3 months were randomized at a 1:1 ratio, and talimogene laherparepvec was administered 6 times every 12 weeks. Surgery was then performed between weeks 13 and 18 (arm 1), while surgery was performed upfront between weeks 1 to 6 of the trial (arm 2). See the chart in Figure 1. Talimogene laherparepvec was administered at the standard dose until there were no injectable tumors or intolerance until surgery. Analysis was performed on the ITT set, and it was evaluated that there was a difference in RFS between the groups for 1 year. RFS events were defined as the first recurrence among local recurrence, regional recurrence, distant recurrence of melanoma, or death due to any cause after surgery. Patients who were not confirmed to be disease-free after surgery (i.e., the surgical result was not R0), or patients who dropped out before surgery were considered events at the time of RFS randomization. In the sensitivity analysis, without considering the surgical result to be R0, RFS was calculated up to the date of the removed event from randomization.

[0091] 150 patients were randomized (76 in arm 1 and 74 in arm 2). As planned, 75% of arm 1 and 93% of arm 2 had surgery. The rate of R0 was 42.1% (arm 1) versus 37.8% (arm 2). The rate of R1 (arm 2 versus arm 1 respectively) was 31.6% versus 51.4%. The rate of R2 was 1.3% versus 4.1%. At the 1-year time point, 33.5% of the patients in arm 1 and 21.9% of the patients in arm 2 remained recurrence-free. (HR 0.73, P = 0.048). The rate of OS at the 1-year time point was 95.9% for the patients in arm 1 and 85.8% for the patients in arm 2 (HR 0.47, P = 0.078). According to the sensitivity analysis, 55.8% of the patients in arm 1 and 39.3% of arm 2 remained recurrence-free at the 1-year landmark time point (HR 00.63, P = 0.0024).

[0092] Neoadjuvant talimogene laherparepvec demonstrated improved recurrence-free survival at 1 year compared to surgery alone, with 55.8% vs 39.3% respectively, HR 0.63, P = 0.0024. 95.9% of patients in Arm 1 and 85.8% of patients in Arm 2 were alive after 1 year (HR 0.47, P = 0.078). The overall survival at 2 years was 88.9% in Arm 1 and 77.4% in Arm 2 (HR: 0.49, P = 0.050).

[0093] These results show that [1] in resectable stage IIIB-IVM1a melanoma, neoadjuvant talimogene laherparepvec improves 2-year RFS and OS, and [2] it is possible to reduce the dose and / or duration of adjuvant therapy using neoadjuvant oncolytic virus therapy (e.g., talimogene laherparepvec).

[0094] In addition, in Arm 1, treatment with talimogene laherparepvec resulted in a three-fold increase in CD8+ cells within the tumor (P < 0.001) and an increase in PD-L1 (P ≤ 0.05). Both the mean CD8 + density and the mean H score of PD-L1 after treatment in Arm 1 were significantly higher than the mean in Arm 2 (P < 0.001 in both comparisons; see Figure 8). The improved intratumoral CD8+ density after treatment was correlated with longer RFS and OS (see Figure 9). These results indicate that the influx of T cells and upregulation of PD-L1 after treatment with talimogene laherparepvec assist the role of the adaptive immune system. Objective Primary objective: · To estimate the recurrence-free survival (RFS) by comparing the treatment effect of neoadjuvant talimogene laherparepvec combined with surgery with the treatment effect of surgery alone. Secondary objectives: · Estimate the 1-year, 2-year, 3-year, and 5-year RFS by comparing the effect of neoadjuvant talimogene laherparepvec combined with surgery with the effect of surgery alone. · Estimate the rate of surgical resection with negative margins (R0) of histopathologically tumor-free by comparing the effect of neoadjuvant talimogene laherparepvec combined with surgery with the effect of surgery alone. · Estimate the effect of neoadjuvant talimogene laherparepvec in terms of the rate of pathologic complete response (pCR). · Estimate the local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), and distant metastasis-free survival (DMFS) by comparing the effect of neoadjuvant talimogene laherparepvec combined with surgery with the effect of surgery alone. · Estimate the 1-year, 2-year, 3-year, 5-year, and overall survival (OS) by comparing the effect of neoadjuvant talimogene laherparepvec combined with surgery with the effect of surgery alone. · Estimate the response of neoadjuvant talimogene laherparepvec overall and individually in the injected and non-injected lesions during treatment (arm 1 only). · Evaluate the safety of neoadjuvant talimogene laherparepvec combined with surgery by comparing it with the safety of surgery alone. Results:

[0095] [Table 2]

[0096] [Table 3]

[0097] [Table 4]

[0098] Example 2: A phase 3 placebo-controlled, randomized, multi-center clinical trial designed to evaluate the efficacy and safety of adjuvant anti-PD-1 therapy after administration of talimogene laherparepvec in combination with a PD-1 inhibitor in a neoadjuvant setting, in patients with resectable melanoma (stages IIIB-IVM1a). Approximately 700 eligible subjects were randomized in a 1:1 ratio to the following treatment arms. Arm A: Subjects who received talimogene laherparepvec + PD-1 inhibitor in a neoadjuvant setting prior to resection Arm B: Subjects who received placebo + PD-1 inhibitor in a neoadjuvant setting prior to resection

[0099] Subjects in Arm A received three administrations of talimogene laherparepvec (week 1: up to 4 mL at 10 6 PFU / mL, weeks 4 and 7: up to 4 mL at 10 8 PFU / mL) and anti-PD-1 therapy using a treatment plan known in the art. Subjects in Arm B received placebo and anti-PD-1 therapy at weeks 1, 4, and 7 in a neoadjuvant setting.

[0100] All subjects underwent resection at week 10 and subsequently received anti-PD-1 therapy in an adjuvant setting for 1 year. Subjects were evaluated by radiography prior to resection and for tumor response every 3 months after resection, which was evaluated by independent readers. The primary endpoint was event-free survival (EFS), and the major secondary endpoints were overall survival (OS), disease-free survival (DFS), pathologic complete response (pCR), and tumor response (RECIST 1.1) endpoints (objective response rate (ORR), complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD)). Subjects in this clinical trial were followed for 5 years.

[0101] In this study, the disease stage may be extended to include stage 2 resectable melanoma. Additionally, adjuvant therapy may be induced in one arm of the trial using postoperative pCR.

[0102] The period of adjuvant anti-PD-1 therapy may be adjusted to less than 1 year.

[0103] In addition, the co-primary endpoints of OS and EFS / DFS may be evaluated.

Claims

**Claim 1** A method for treating cancer, comprising: administering a combination of an oncolytic virus and a first checkpoint inhibitor; surgically removing any residual tumor; administering a second checkpoint inhibitor; wherein the first and second checkpoint inhibitors may be the same or different; a method. **Claim 2** The method according to claim 1, wherein the oncolytic virus is an adenovirus, a reovirus, a measles virus, a herpes simplex virus, a Newcastle disease virus, a Seneca virus, or a vaccinia virus. **Claim 3** The method according to claim 2, wherein the oncolytic virus is an adenovirus, a reovirus, a herpes simplex virus, a Newcastle disease virus, or a vaccinia virus. **Claim 4** The method according to claim 2, wherein the oncolytic virus is a herpes simplex virus. **Claim 5** The method according to claim 4, wherein the herpes simplex virus is herpes simplex virus type 1 (HSV-1). **Claim 6** The HSV1 is lacking a functional ICP34.5 gene, lacking a functional ICP47 gene, and modified to contain a gene encoding a heterologous gene, according to the method of claim 5. **Claim 7** The method according to claim 6, wherein the heterologous gene is a cytokine. **Claim 8** The method according to claim 7, wherein the cytokine is GM-CSF. **Claim 9** The method according to any one of claims 1 to 8, wherein the oncolytic virus is talimogene laherparepvec, RP1, RP2, or RP3. **Claim 10** The method according to any one of claims 1 to 9, wherein the first and second checkpoint inhibitors are independently selected from the list comprising CTLA-4 blockers, PD-1 blockers, and PD-L1 blockers. **Claim 11** The method according to claim 10, wherein the CTLA-4 blocker is an anti-CTLA-4 antibody, the PD-1 blocker is an anti-PD-1 antibody, and the PD-L1 blocker is an anti-PD-L1 antibody. **Claim 12** The method according to claim 10 or 11, wherein the CTLA-4 blocker is ipilimumab. **Claim 13** The method according to claim 10 or 11, wherein the PD-1 blocker is selected from the list comprising nivolumab, pembrolizumab, CT-011, AMP-224, and semiprimab. **Claim 14** The method according to claim 10 or 11, wherein the PD-L1 blocking agent is selected from the list comprising atezolizumab, avelumab, durvalumab, and BMS-936559.

15. The method according to any one of claims 1 to 14, wherein the cancer is melanoma, breast cancer (e.g., triple-negative breast cancer), renal cancer, bladder cancer, colorectal cancer, lung cancer, nasopharyngeal cancer, pancreatic cancer, liver cancer, non-melanoma skin cancer, neuroendocrine tumor, T cell lymphoma (e.g., peripheral), or cancer of unknown primary origin, pediatric solid tumor with unresectable epidermal lesions.

16. The method according to claim 15, wherein the cancer is melanoma of stage 2, 3a, 3b, 3c, 3d or 41a.

17. A herpes simplex virus lacking a functional ICP34.5 gene, lacking a functional ICP47 gene, and containing a gene encoding human GM-CSF, A package insert or label, administered in combination with an oncolytic virus and a first checkpoint inhibitor, surgically removing any residual tumor, A package insert or label instructed for treating cancer by administering a second checkpoint inhibitor, A kit comprising, wherein the first and the second checkpoint inhibitors may be the same or different, Kit.

18. A method for manufacturing the kit according to claim 17.

19. A method for treating cancer, comprising: administering an oncolytic virus; surgically removing any residual tumor; administering a checkpoint inhibitor. Method.

20. The method according to claim 19, wherein the oncolytic virus is adenovirus, reovirus, measles virus, herpes simplex virus, Newcastle disease virus, Seneca virus, or vaccinia virus.

21. The method according to claim 20, wherein the oncolytic virus is adenovirus, reovirus, herpes simplex virus, Newcastle disease virus, or vaccinia virus.

22. The method according to claim 20, wherein the oncolytic virus is herpes simplex virus.

23. The method according to claim 22, wherein the herpes simplex virus is herpes simplex type 1 virus (HSV-1).

24. The HSV1 lacks a functional ICP34.5 gene, lacks a functional ICP47 gene, The method according to claim 23, which is modified to contain a gene encoding a heterologous gene.

25. The method according to claim 24, wherein the heterologous gene is a cytokine.

26. The method according to claim 25, wherein the cytokine is GM-CSF.

27. The method according to any one of claims 19 to 26, wherein the oncolytic virus is talimogene laherparepvec, RP1, RP2, or RP3.

28. The method according to any one of claims 19 to 27, wherein the checkpoint inhibitor is selected from the list comprising a CTLA-4 blocker, a PD-1 blocker, and a PD-L1 blocker.

29. The method according to claim 28, wherein the CTLA-4 blocker is an anti-CTLA-4 antibody, the PD-1 blocker is an anti-PD-1 antibody, and the PD-L1 blocker is an anti-PD-L1 antibody.

30. The method according to claim 28 or 29, wherein the CTLA-4 blocker is ipilimumab.

31. The method according to claim 28 or 29, wherein the PD-1 blocker is selected from the list comprising nivolumab, pembrolizumab, CT-011, AMP-224, and semiprimab.

32. The method according to claim 28 or 29, wherein the PD-L1 blocker is selected from the list comprising atezolizumab, avelumab, durvalumab, and BMS-936559.

33. The method according to any one of claims 19 to 32, wherein the cancer is melanoma, breast cancer (e.g., triple-negative breast cancer), renal cancer, bladder cancer, colorectal cancer, lung cancer, nasopharyngeal cancer, pancreatic cancer, liver cancer, non-melanoma skin cancer, neuroendocrine tumor, T cell lymphoma (e.g., peripheral), or cancer of unknown primary origin, pediatric solid tumor with unresectable epidermal lesions.

34. The method according to claim 33, wherein the cancer is melanoma of stage 2, 3a, 3b, 3c, 3d, or 41a.

35. A herpes simplex virus lacking a functional ICP34.5 gene, lacking a functional ICP47 gene, and containing a gene encoding human GM-CSF, An accompanying document or label, Administering an oncolytic virus, Surgically removing any residual tumor, An accompanying document or label with instructions for treating cancer by administering a checkpoint inhibitor, A kit comprising.

36. A method for manufacturing the kit according to claim 35.

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