Biomarkers for cancer therapy using MDM2 antagonists

Abstract

To provide biomarkers to predict effective treatment of cancer using an MDM2 antagonist.SOLUTION: Biomarkers are (i) BAP1; and / or (ii) CDKN2A; and / or (iii) one, two, three, four, five, six, seven, eight, nine, ten or more of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, and the like.SELECTED DRAWING: None

Description

[Technical Field]

[0001] The present invention relates to biomarkers for cancer treatment.In particular, the present invention provides biological markers that identify cancer cells as potentially sensitive to MDM2 antagonists.These biomarkers can be incorporated into methods, systems and kits for predicting response to treatment, and into personalized cancer treatment. [Background technology]

[0002] Precision medicine, or personalized medicine, is a new approach to treating and preventing disease that takes into account each patient's individual differences in genes, environment, and lifestyle. It is often described as the practice of administering the right dose of the right drug at the right time.

[0003] A particular focus of precision medicine is the need to predict whether a given patient will respond to a particular drug. Tests that can predict whether a particular drug will effectively treat an individual patient are often called companion diagnostics. Effective companion diagnostics are highly desirable because they can improve patient outcomes while saving the significant economic costs of providing ineffective treatments. An effective companion diagnostic for a new therapeutic agent can also improve the chances that the therapy will be trialed in the appropriate population and ultimately approved.

[0004] Precision medicine and companion diagnostics often rely on biomarkers that can reliably predict whether a patient is likely to respond to a particular treatment. Identifying reliable biomarkers for any therapy and disease is a significant challenge.

[0005] WO-A-2016 / 056673 describes a complex gene signature that is said to provide a predictive molecular tool for clinical application. The disclosure also relates to methods for predicting the sensitivity of a cancer or tumor to anticancer drugs, particularly inhibitors of MDM2 activity and antagonists of the interaction between MDM2 and p53 proteins, which may have an impact on the treatment of the cancer or tumor.

[0006] US-A-2015 / 0211073 also generally describes a gene panel comprising at least four genes as biomarkers for predicting the response of cancer to MDM2 antagonists.

[0007] Iorio et al. (Cell. 2016 Jul 28;166(3):740-75) report in "A Landscape of Pharmacogenomic Interactions in Cancer" how cancer-related alterations (incorporating somatic mutations, copy number alterations, DNA methylation, and gene expression) identified in 11,289 tumors from 29 tissues could be mapped to 1,001 molecularly annotated human cancer cell lines and correlated with sensitivity to 265 drugs. While such studies provide a resource for linking genotype to cellular phenotype and identifying treatment options for select cancer subpopulations, developing clinically relevant molecularly targeted cancer therapies remains a formidable challenge.

[0008] There remains a need to identify reliable biomarkers for use in precision medicine. Summary of the Invention

[0009] The present invention is based on the identification of biomarkers that can be used to predict effective treatment of cancer with MDM2 antagonists. Identification of one or more of these biomarkers in a cancer patient allows for a determination of whether the patient's cancer is likely to be treated, or likely to be successfully treated, with an MDM2 antagonist. Thus, in certain aspects, the present invention generally relates to companion diagnostics for MDM2 antagonist therapy.

[0010] The biomarkers identified in the present invention are: (i) BAP1; and / or (ii) CDKN2A; and / or (iii) CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, and BRCA1. These proteins and their encoding genes are well known in the art, and Entrez Gene IDs are provided below. As used herein, these biomarkers are referred to as "biomarkers of the invention."

[0011] In particular, in one aspect, the present invention provides an MDM2 antagonist for use in a method of treating cancer, the cancer comprising: are BAP1 depleted; and / or are CDKN2A depleted; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, H ERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF 7, exhibiting increased expression of one, two, three, four, five or more of LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1.

[0012] Sensitivity to MDM2 antagonism is associated with: (i) decreased BAP1 expression; and / or (ii) decreased CDKN2A expression; and / or (iii) decreased expression of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, D The disease can be identified by increased expression of one, two, three, four, five, six, seven, eight, nine, ten or more of HX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1.

[0013] In one embodiment, MDM2 antagonists are provided for use in methods of treating cancers that are BAP1-depleted. In this embodiment, the BAP1-depleted cancer may also be CDKN2A-depleted; and / or exhibit increased expression of one, two, three, four, five or more interferon signature genes.

[0014] For CDKN2A, protein is generally evaluated.This can be achieved, for example, by immunohistochemistry (IHC).In some embodiments, mutation analysis (e.g., DNA sequencing) can be used to detect CDKN2A status.

[0015] For BAP1, protein is generally evaluated. This can be achieved, for example, by immunohistochemistry (IHC). In some embodiments, cellular location can also be evaluated. In some embodiments, mutation analysis (e.g., DNA sequencing) can be used to detect BAP1 status.

[0016] CDKN2A and BAP1 may be referred to herein as protein biomarkers. CDKN2A gene encodes p16 (INK4A) and p14 (ARF) proteins, and when referring to gene CDKN2A, it includes the protein encoded by CDKN2A. CDKN2A deficiency can be assessed by low protein expression product level, i.e., expression level lower than the control expression level of p16 (INK4A) and / or p14 (ARF), that is, the result of CDKN2A gene deficiency is deficiency of p16 and / or p14.

[0017] There are various biomarker assessments, including the presence or absence of a gene, gene mutations, gene expression levels, and protein expression levels. The term depletion can refer to the absence or complete absence of a gene, for example, mutation and loss of function of a gene such as BAP1 or CDKN2A, or the term can refer to low gene expression and low protein expression and function resulting from gene deletion or mutation or otherwise. All of these depletions are encompassed by the term "depletion."

[0018] The remaining biomarkers identified herein (i.e., those identified above as having increased expression) may be referred to as interferon signature, or IFN signature, biomarkers. They are also referred to as type 1 interferon pathway genes. Generally, these biomarkers are detected as mRNA. Thus, techniques for assessing one or more IFN signature biomarkers may include quantitative techniques, such as rtPCR or nanostring analysis, as known in the art. DNA can also be assessed. In some embodiments, copy number variation (CNV) analysis and / or mutation analysis (e.g., DNA sequencing) can be used to detect the status of biomarker genes.

[0019] The biomarkers of the present invention can be evaluated directly or indirectly. Indirect evaluation generally involves detecting molecules functionally upstream or downstream of the biomarker, the levels of which correlate with the levels of the biomarker. For example, the substrate on which the biomarker acts can be used as an indirect evaluation of the biomarker. In one embodiment, the BAP1 level can be evaluated by detecting the level of histone H2A ubiquitination, and an increase in H2A ubiquitination generally reflects a decrease in BAP1. In another embodiment, the depletion of BAP1 can be evaluated by determining an increase in the expression or activity of EZH2.

[0020] The data in the Examples below show that depletion, e.g., deficiency (also known as total or complete deficiency), of CDKN2A and / or BAP1, and / or elevated levels of one or more of the IFN signature biomarkers, predicts the sensitivity of cancer cells to MDM2 antagonists. Thus, low levels of CDKN2A and / or BAP1; and / or elevated levels of one or more of the IFN signature biomarkers, can be used to identify cancers that are amenable to treatment with an MDM2 antagonist.

[0021] In some embodiments, the decrease or increase in expression of the biomarkers or biomarkers of the present invention is determined in comparison with non-cancerous cells. This cancer:non-cancerous comparison can be particularly useful for evaluating BAP1 deficiency and / or CDKN2A deficiency. The non-cancerous cells are generally cells of the same type as the cancer cells. The non-cancerous cells may be from the same patient or a different patient, or may be a known value for non-cancerous cells of this type. In this way, expression can be compared to a control level determined in a healthy individual or a control level determined in normal, non-proliferating tissue.

[0022] In some other embodiments, the decreased or increased expression of the biomarkers or biomarkers of the present invention is determined in comparison with multiple cancer cell samples from multiple MDM2 inhibitor non-responders, or in one cancer cell sample from one MDM2 inhibitor non-responder. In some embodiments, one or more IFN signature biomarkers are increased or elevated compared to RNA determined in multiple cancer cell samples from multiple MDM2 inhibitor non-responders, or in one cancer cell sample from one MDM2 inhibitor non-responder. The non-responder cancer cells are generally cells of the same cancer type as the tested cancer cells. The non-responder cancer cells are generally from one or more patients different from the tested sample, or may be known values ​​for non-responder cancer cells of that cancer type.

[0023] In some embodiments, the patient has expression levels of BAP1 and / or CDKN2A below the upper limit of normal (ULN) and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58 , TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1, if the expression level is higher than the upper limit of normal (ULN).

[0024] Optionally, the method may comprise administering to the patient a therapeutically effective amount of an MDM2 antagonist.

[0025] In all aspects and embodiments described herein, the cancer is generally a p53 wild-type cancer.

[0026] In one embodiment, the invention provides an MDM2 antagonist for use in the treatment of cancer, particularly p53 wild-type cancer, wherein the cancer is characterized by one or more of the biomarkers of the invention in a biological sample obtained from a patient.

[0027] According to another embodiment of the invention, there is provided a method of treating cancer in a patient, comprising the steps of selecting a patient based on an expression profile of one or more of the biomarkers of the invention; and Optionally, the method further comprises the step of administering to said patient a therapeutically effective amount of an MDM2 antagonist. decreased BAP1 expression in a biological sample obtained from said patient; and / or decreased CDKN2A expression in a biological sample obtained from said patient; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, Increased expression of one, two, three, four, five or more of the following: OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; and Optionally, then administering to said patient a therapeutically effective amount of an MDM2 antagonist; are selected based on

[0028] According to a further embodiment of the present invention there is provided an MDM2 antagonist for use in treating cancer in a patient, said patient comprising: Decreased or low BAP1 expression in a biological sample obtained from said patient; and / or Decreased or low CDKN2A expression in a biological sample obtained from said patient; and / or In biological samples obtained from the patients, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM1 4, increased or high expression of one, two, three, four, five or more of the following: OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 and wherein the ion exchange layer is selected as having

[0029] In certain embodiments, patient tissue samples are tested before treatment to determine cancer biomarker expression profiles.The sample can generally comprise one or more cancer cells, cancer DNA, or circulating tumor DNA.The sample can be a blood sample.The sample can be a tumor sample, for example, a tumor biopsy.This test can comprise an assay for detecting protein, mRNA, DNA, and / or ctDNA.

[0030] In another aspect, the invention provides the use of the expression level of one or more biomarkers of the invention in a cancer cell sample from a human patient as a biomarker for assessing whether the cancer will be susceptible to treatment with an MDM2 antagonist.

[0031] In a further aspect, the invention provides a method for predicting or assessing the responsiveness of a human cancer patient to treatment with an MDM2 antagonist, comprising assessing the expression level of one or more biomarkers of the invention in a sample from the cancer patient, and determining whether the expression level examined indicates that the cancer should be treated with an MDM2 antagonist.

[0032] In some embodiments, one or more biomarkers of the present invention indicate that a cancer is likely to effectively undergo apoptosis, and thus, in some embodiments, the present invention can identify patients for whom treatment would be particularly effective.

[0033] In some embodiments, the evaluating step comprises an in vitro assay to determine the biomarker or expression level of the biomarker.

[0034] In some embodiments, the evaluating step comprises comparing the expression level to an expression level known to be associated with responsiveness or non-responsiveness to treatment with an MDM2 antagonist, hi some embodiments, the evaluating step comprises comparing the observed expression level to a threshold value that also reflects an expression level associated with susceptibility to treatment with an MDM2 antagonist, to assess whether the examined expression level indicates that the cancer is treatable with an MDM2 antagonist.

[0035] In some embodiments, patients are classified into groups based on their biomarker profiles, which may include classifying patients as likely or unlikely to respond well (or strongly) to treatment with an MDM2 antagonist.

[0036] In a further aspect, the invention provides a method for determining whether a human cancer patient is suitable for treatment with an MDM2 antagonist, comprising: detecting the expression of one or more biomarkers of the invention in a cancer cell sample from the patient; and assessing whether the patient's cancer is likely to be treated with an MDM2 antagonist in the sample based on the expression level of the biomarker. Optionally, the method of this aspect comprises the further step of treating cancer in a patient with an MDM2 antagonist.

[0037] In a further embodiment, the invention provides an MDM2 antagonist for use in treating cancer in a patient in combination with an anti-cancer compound, wherein said cancer in said patient is characterized as a p53 wild-type cancer selected as having one or more biomarkers of the invention.

[0038] In a further embodiment, the invention provides a method of treating cancer in a patient, wherein said cancer in said patient is optionally a p53 wild-type cancer, and wherein the patient is selected as having one or more biomarkers of the invention at levels indicating that MDM2 antagonist treatment would be efficacious, comprising administering to the selected patient a therapeutically effective amount of an MDM2 antagonist and optionally another anti-cancer drug.

[0039] In a further embodiment, the invention provides a method for identifying a cancer patient suitable for treatment with an MDM2 antagonist, said method comprising detecting and optionally quantifying the expression of one or more biomarkers of the invention.

[0040] In a further embodiment, the invention provides a method of selecting a patient (e.g., suffering from cancer), said method comprising the step of selecting the patient by detecting and optionally quantifying expression of one or more biomarkers of the invention.

[0041] In a further embodiment, the invention provides a method for determining the likelihood that a cancer patient will respond to therapy with an MDM2 antagonist, said method comprising: obtaining a measure of decreased BAP1 expression in a cancer cell sample from the patient compared to corresponding non-cancerous cells; and / or obtaining a measure of reduced CDKN2A expression in a sample of cancer cells from the patient compared to corresponding non-cancerous cells; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC 6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGAL obtaining measurements indicative of increased expression of one, two, three, four, five or more of S3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; and determining that the patient is likely to respond to therapy with an MDM2 antagonist based on the measurements. The compound comprises:

[0042] In a further embodiment, the present invention provides a method for producing a pharmaceutical composition comprising: determining one or more biomarkers of the invention; administering a therapeutically effective amount of an MDM2 antagonist to a patient having one or more of the biomarkers of the invention. a drug administration procedure comprising:

[0043] In yet a further aspect, the invention provides methods for detecting expression of one or more biomarkers of the invention in a human patient suffering from cancer. The methods generally comprise: (a) obtaining a cancer cell sample from a human patient; and (b) detecting whether the biomarker is expressed in the sampled cancer cells by contacting the sample with one or more reagents for detecting expression of the biomarker. The compound comprises:

[0044] In yet a further aspect, the invention provides a kit or device for detecting the expression level of at least one biomarker for susceptibility to MDM2 antagonism in a sample from a human patient, said kit or device comprising one or more detection reagents or detection reagents for detecting one or more biomarkers of the invention.

[0045] In a further aspect, the invention resides in a system for assessing whether a human cancer patient will be susceptible to treatment with an MDM2 antagonist, said system comprising: a detection means capable of and adapted to detect one or more biomarkers of the invention in a sample from a human patient; and a processor adapted to determine from the determined biomarker or biomarkers an indication of the likelihood that the patient will be treated with an MDM2 antagonist. The compound comprises:

[0046] The system optionally includes a data connection to an interface, particularly a graphical user interface, capable of presenting information and preferably inputting information such as the subject's age, and optionally other patient information such as gender and / or medical history information, said interface being either part of the system or a remote interface. Optionally, one or more of the foregoing items, particularly the processor, can function "in the cloud," i.e., by means of an internet-based application rather than on a fixed device.

[0047] The present invention also provides methods, combinations, and kits for identifying and screening patients.

[0048] In a further embodiment, the invention provides a method of screening or identifying a patient for treatment with an MDM2 antagonist, wherein the patient has: Decreased expression of BAP1 in a biological sample obtained from said patient; and / or Decreased expression of CDKN2A in a biological sample obtained from said patient; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TR in biological samples obtained from said patients Increased expression of one, two, three, four, five or more of the following: IM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 and determining whether the antibody has:

[0049] In a further embodiment, the present invention provides a method for producing a pharmaceutical composition comprising: has decreased BAP1 expression in a biological sample obtained from said patient; and / or CDKN2A expression is decreased in a biological sample obtained from said patient; and / or In a biological sample obtained from the patient, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM Increased expression of one, two, three, four, five, or more of the following genes: 14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 The present invention provides a method for identifying patient responders, comprising testing the patient for:

[0050] In a further embodiment, the present invention provides a method for producing a pharmaceutical composition comprising: (a) to identify patients in need of treatment for cancer, possibly p53 wild-type cancers such as mesothelioma; (b) the patient Decreased expression of BAP1 in a biological sample obtained from said patient; and / or Decreased expression of CDKN2A in a biological sample obtained from said patient; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OAS determining that the patient has an expansion of one, two, three, four, five or more of L, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; and (c) treating said patient with a therapeutically effective amount of an MDM2 antagonist. The present invention provides a method of treatment comprising:

[0051] In a further embodiment, the present invention provides a method for producing a pharmaceutical composition comprising: (a) Identifying patients who require treatment for cancer, and possibly mesothelioma; (b) determining one or more biomarkers of the invention in the patient; (c) selecting an MDM2 antagonist as treatment for a patient based on the recognition that the MDM2 antagonist is effective in said patient having one or more biomarkers of the invention; (d) treating said patient with a therapeutically effective amount of an MDM2 antagonist. The present invention provides a method of treatment comprising:

[0052] In a further embodiment, the present invention provides a method of selecting a treatment for a cancer patient, comprising: (a) assaying one or more biological samples, thereby determining in the patient one or more biomarkers of the present invention; (b) selecting the patient for treatment with a therapeutically effective amount of an MDM2 antagonist based on that determination. The method comprises:

[0053] In a further embodiment, the invention provides a procedure for selecting a patient (e.g., suffering from cancer) for treatment with an MDM2 antagonist, said patient comprising: Decreased or low BAP1 expression in a biological sample obtained from said patient; and / or reduced or low CDKN2A expression in a biological sample obtained from said patient; and / or In biological samples obtained from the patients, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM1 4, increased or high expression of one, two, three, four, five or more of the following: OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 and wherein the ion exchange layer is selected as having

[0054] In a further embodiment, the invention provides an MDM2 antagonist for use in treating cancer in a patient, said patient suffering from: Decreased expression of BAP1 in a biological sample obtained from said patient; and / or Decreased expression of CDKN2A in a biological sample obtained from said patient; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TR in biological samples obtained from said patients Increased expression of one, two, three, four, five or more of the following: IM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 It is characterized in that it is known to have

[0055] In a further embodiment, the present invention provides a kit for treating cancer in a patient, said kit comprising a biosensor for the detection and / or quantification of one or more biomarkers of the invention and / or reagents for the detection of one or more biomarkers of the invention, optionally together with instructions for use of the kit according to the methods as defined herein.

[0056] In a further embodiment, the present invention provides a method for treating a cancer-affected individual, comprising: Decreased expression of BAP1 in a biological sample obtained from said patient; and / or Decreased expression of CDKN2A in a biological sample obtained from said patient; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TR in biological samples obtained from said patients Increased expression of one, two, three, four, five or more of the following: IM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 The present invention provides a method for determining responsiveness to treatment with an MDM2 antagonist comprising:

[0057] In a further embodiment, the present invention provides a method for determining the responsiveness of an individual having cancer to treatment with an MDM2 antagonist, comprising: reduced BAP1 expression in a biological sample obtained from said patient; and / or reduced CDKN2A expression in a biological sample obtained from said patient; and / or In biological samples obtained from the patients, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM Increased expression of one, two, three, four, five, or more of the following genes: OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 Identifying the patient; and then administering to said patient a therapeutically effective amount of an MDM2 antagonist. Administering The method comprises:

[0058] In a further embodiment, the present invention provides a method of treating cancer in a patient, said method comprising: BAP1 expression is decreased in a biological sample obtained from said patient; and / or CDKN2A expression is decreased in a biological sample obtained from said patient. a step of selecting patients; The patient selected in the steps herein is administered a therapeutically effective amount of an MDM2 antagonist, and the patient is administered one of the following: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, L in combination with interferon (e.g., interferon alpha) to increase the expression levels of one, two, three, four, five or more of GALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1.

[0059] In a further embodiment, the present invention provides a method for producing a pharmaceutical composition comprising: (i) directing the determination of BAP1 expression; and / or (ii) directing the determination of CDKN2A expression; and / or (iii) CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, L directing the determination of the expression levels of one, two, three, four, five or more of GALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; and (iv) have reduced levels of BAP1 and / or CDKN2A and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL administering a therapeutically effective amount of an MDM2 antagonist to a patient having increased levels of one, two, three, four, five or more of: IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1. a drug administration procedure comprising:

[0060] In a further embodiment, the present invention provides a method for producing a pharmaceutical composition comprising: (i) MDM2 antagonists; (ii) a patient package insert detailing instructions for the use of an MDM2 antagonist in treating patients identified using the biomarker profile described herein; The present invention provides a packaged pharmaceutical product comprising:

[0061] In a further embodiment, the present invention provides a method of treating cancer in a patient, said method comprising: (i) contacting a sample from a patient with primers, antibodies, substrates or probes to detect BAP1 and / or CDKN2A and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, determining the expression levels of one, two, three, four, five or more of CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; (ii) the patient has decreased levels of BAP1 and / or CDKN2A in a biological sample obtained from said patient, and / or has a mutation in any of the following: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, Selecting patients with increased levels of one, two, three, four, five or more of the following: C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; (iii) then administering to said patient selected in step (ii) a therapeutically effective amount of an MDM2 antagonist. The compound comprises:

[0062] In a further embodiment, the invention provides a method for identifying a patient for treatment with an MDM2 antagonist, said method comprising: (a) contacting a sample from a patient with a plurality of oligonucleotide primers, said plurality of primers comprising: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C 1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1; (b) performing PCR on the sample to amplify gene expression products / transcription products in the sample; (c) determining the level of the expression product of at least one of said genes; and (d) identifying said patient as a candidate for treatment with an MDM2 antagonist if the expression level of said at least one gene is higher than the upper limit of normal (ULN). The compound comprises:

[0063] The patient optionally has expression levels of BAP1 and / or CDKN2A lower than (e.g., below) the upper limit of normal (ULN), and / or has expression levels of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, T A patient may be identified as a candidate for treatment with an MDM2 antagonist if the expression level of at least one of RIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 is higher than (e.g., above) the upper limit of normal (ULN).

[0064] In a further embodiment, the invention provides a method for identifying a patient for treatment with an MDM2 antagonist, said method comprising: (a) contacting a sample from a patient with an antibody to one or more biomarkers of the invention; (b) performing an assay on said sample; (c) determining the level of one or more biomarkers of the invention; and (d) identifying said patient as a candidate for treatment with an MDM2 antagonist if the level of one or more biomarkers of the invention is elevated or decreased below the upper limit of normal (ULN). The compound comprises:

[0065] The assay in step (b) can be or comprise an immunohistochemical assay. In some embodiments, the assay can be or comprise an ELISA. When a sample from a patient is contacted with an antibody against BAP1 and / or CDKN2A, an immunohistochemical assay is generally performed on the sample, and the patient is identified as a candidate for treatment with an MDM2 antagonist if the level of BAP1 or CDKN2A is below the upper limit of normal (ULN) (or absent).

[0066] Once a patient is identified for treatment, the methods described herein can further comprise treating the patient's cancer with an MDM2 antagonist.

[0067] In a further embodiment, the present invention provides a method for selecting a cancer patient for receiving MDM2 antagonist therapy for cancer, comprising: (a) BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C determining the level of one or more of 1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1; and (b) in a biological sample from the patient, the level of BAP1 and / or CDKN2A is lower than a predetermined value, and / or in a biological sample from the patient, the level of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI Patients with levels of one or more of the following genes above a predetermined value were selected: 1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1. The method comprises:

[0068] In a further embodiment, the present invention provides a method for predicting the efficacy of an MDM2 antagonist for cancer in a patient, or for predicting a cancer patient's response to an MDM2 antagonist for cancer, comprising detecting in a biological sample from the patient, the expression of any of BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFI Levels of one or more of the following: T3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and / or BRCA1 and determining whether the biological sample levels of BAP1 and / or CDKN2A are equal to or generally less than a predetermined value, and / or whether the biological sample levels of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST A level of one or more of: 2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 equal to or, typically, greater than a predetermined value predicts efficacy in the patient.

[0069] In a further embodiment, the invention provides a method for selecting a patient having cancer in need of treatment with an MDM2 antagonist, comprising: (a) screening a tumor sample obtained from the patient for the following: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, T and / or (a) testing a tumor sample obtained from the patient for elevated levels of RIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1, and / or (b) testing a tumor sample obtained from the patient for low levels of BAP1 and / or CDKN2A.

[0070] In a further embodiment, the present invention provides a method of treating cancer, comprising: (i) testing a tumor sample obtained from a patient having or suspected of having cancer for elevated IFN signature biomarkers and / or defects in BAP1 and / or CDKN2A; and (ii) administering an MDM2 antagonist to the patient from whom the sample was obtained.

[0071] In a further embodiment, the invention provides a method for identifying patients having cancer who are most likely to benefit from treatment with an MDM2 antagonist, comprising measuring the levels of one or more biomarkers of the invention in a tumor sample obtained from the patient, and identifying whether the patient is likely to benefit from treatment with an MDM2 antagonist according to the levels present.

[0072] Some embodiments of the invention comprise detecting the presence of mutations in BAP1 and / or CDKN2A indicative of BAP1 and / or CDKN2A deficiency, which can be compared to control levels or the absence of mutations determined in normal non-proliferative tissue.

[0073] The present invention provides various methods for determining whether a cancer patient will respond to treatment with an MDM2 antagonist; a method for predicting the sensitivity of tumor cell growth to inhibition by an MDM2 antagonist; a method for predicting the responsiveness of a subject's cancer to a cancer therapy including an MDM2 antagonist; a method for developing a treatment plan for a subject with cancer; and an in vitro method for identifying patients who will respond or be sensitive to a treatment regimen with an MDM2 antagonist. These methods generally comprise comparing the levels of one or more biomarkers of the present invention in a sample, generally a tumor sample, with a reference level, and predicting the responsiveness of the cancer to treatment with a cancer therapy including an MDM2 antagonist. In one embodiment, these methods comprise analyzing one or more biomarkers described herein, for example, two or more, or three or more, or four or more, or five or more, or six or more, or seven or more, or eight or more, or nine or more, or ten or more, or eleven or more. In one embodiment, the one or more biomarkers include BAP1. In certain embodiments, the two or more biomarkers include BAP1 and CDKN2A, and in one embodiment, the two or more biomarkers include BAP1 and one or more biomarkers selected from CDKN2A, CXCL10, CXCL11, IRF7, IFITM1, IRF9, MX1 or IFI35.

[0074] In a further embodiment, the present invention provides an in vitro method for predicting the likelihood that a patient having a tumor who is a candidate for treatment with an MDM2 antagonist will respond to treatment with the compound, comprising: (a) detecting in one or more tissue samples obtained from the patient: BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS The present invention provides methods comprising determining the levels of one or more of: 3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1; and (i) determining the levels of one or more of: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, I FIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP , DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, F and / or (ii) elevated levels of LI1 and BRCA1 (e.g., compared to reference values ​​in at least one healthy reference individual), and / or BAP1 deficiency and / or CDKN2A deficiency (e.g., compared to reference values ​​in at least one normal non-proliferating tissue) indicate that the patient is likely to respond to the treatment; and / or (iii) lower levels of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44,HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1, and / or normal or high levels of BAP1 and / or CDKN2A indicate that the patient is unlikely to respond to the treatment.

[0075] In a further embodiment, the present invention provides a method for the detection of a mutated or mutated antibody against one or more of the following: (a) BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, CSF2, CSF3, CSF4, CSF5, CSF6, CSF7, CSF8, CSF9, CSF9, CSF10, CSF11, CSF12, CSF13, CSF14, CSF15, CSF16, CSF17, CSF18, CSF19, CSF19, CSF19, CSF19, CSF19, CSF20, CSF21, CSF22, CSF23, CSF24, CSF25, CSF26, CSF27, CSF28, CSF29, CSF30, CSF31, CSF32, CSF40, CSF41, CSF42, CSF43, CSF44, CSF51, CSF52, CSF53, CSF54, CSF55, CSF56, CSF57, CSF58, CSF59, CSF60, CSF61, CSF62, CSF63, CSF64, CSF65, CSF66, CSF67, CSF68, CSF69, CSF69, CSF70, CSF71, CSF72, CSF73, CSF74, CSF75, CSF76, CSF77, CSF78, CSF79, measuring or quantifying the levels of one or more of 1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1;(b)CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, H LA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PAR compared to the levels of P9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 (e.g., compared to control levels determined in healthy individuals), and / or the levels of BAP1 and / or CDKN2A (e.g., compared to control levels determined in normal non-proliferative tissue), and the levels of CXCL10, CXCL11, RSAD2, MX1 , BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI 1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1 identifying the patient as suitable for treatment with an MDM2 antagonist if they have elevated levels of IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 (e.g., compared to control levels determined in healthy individuals), and / or a deficiency of BAP1 and / or CDKN2A (e.g., compared to control levels determined in normal non-proliferative tissue);

[0076] In a further embodiment, the present invention provides a method for producing a pharmaceutical composition comprising: (i) Biological samples obtained from patients are screened using antibodies (e.g., BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, contacting the cells with an antibody specific for one or more of C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1; (ii) washing the sample to remove unbound antibody; (iii) measuring the intensity of the signal from the bound antibody; (iv) comparing the measured signal intensity with a reference value, and if the measured intensity is increased compared to the reference value; (v) a biological sample obtained from the patient; a. Primers (e.g., for the following genes: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM1 4, at least one oligonucleotide primer pair of any one or more of OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1); b. Antibodies (e.g., BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX 58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1), and / or c. Primers for genes or mutations indicating BAP1 deficiency or CDKN2A deficiency to come into contact with; (vi) performing PCR, RT-PCR or next generation sequencing on the sample to amplify gene expression products / transcription products in the sample; (vii) determining the level of at least one expression product of said gene; and (viii) identifying subjects as having a high probability of being suitable for treatment with an MDM2 antagonist; An assay comprising:

[0077] In a further embodiment, the present invention relates to the detection of the following genes in tumor samples as determined by sequencing or immunoassay: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OAS Methods for treating cancer are provided, comprising administering an MDM2 antagonist to a subject having elevated expression of one or more of L, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA, and / or defects in BAP1 and / or CDKN2A.

[0078] In a further embodiment, the present invention provides a method of administering an MDM2 antagonist to a patient in need thereof, comprising: (1)BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFI H1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX Determining patient levels of 58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and / or BRCA1; (2) assigning a phenotype to the patient based on the levels of the genes listed above and the genotype of the tumor as determined in (1), the phenotype being selected from low sensitivity (P), intermediate (I), and sensitivity (S), and the phenotype is assigned based on the levels of the genes in the tumor; and (3) administering MDM2 antagonists to patients with phenotype S; The method comprises:

[0079] In a further embodiment, the invention provides the use of an MDM2 antagonist in the manufacture of a medicament for use in treating cancer in a patient, wherein the cancer tumor has a BAP1 deficiency and / or a CDKN2A deficiency, and / or the patient has expression of any of the following genes: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HL Expression of one or more of A-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 is elevated.

[0080] In a further embodiment, the invention provides for the use of an MDM2 antagonist in the manufacture of a medicament for use in treating cancer in a patient identified according to the methods described herein as likely to respond to treatment with an MDM2 antagonist.

[0081] In a further embodiment, the invention provides an article of manufacture comprising an MDM2 antagonist drug in a pharmaceutically acceptable carrier packaged together and a package insert indicating that the cancer (e.g., mesothelioma, nephroma, or glioblastoma) drug is for treating a cancer patient based on the level of one or more biomarkers identified herein as determined by the assay method used to measure the level.

[0082] In a further embodiment, the present invention provides a method for delivering to a target audience the following genes: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, L Methods for promoting an MDM2 antagonist drug are provided, comprising promoting the use of an MDM2 antagonist drug to treat cancer patients with elevated levels of one or more of AP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 and / or BAP1 deficiency and / or CDKN2A deficiency.

[0083] In a further embodiment, the present invention provides a device configured to identify tumors (e.g., mesothelioma) in cancer patients as likely or unlikely to benefit from treatment with a therapeutic agent or combination of therapeutic agents that target MDM2. The device uses the following genes from tumor or blood-based samples to identify patients as likely or unlikely to benefit from treatment with a therapeutic agent or combination of therapeutic agents that target MDM2: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, The device may comprise a memory device that stores sequencing or immunoassay data relating to levels of one or more of DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1, and / or BAP1 deficiency and / or CDKN2A deficiency.

[0084] In one embodiment of the methods described herein, BAP1 and / or CDKN2A levels are low or absent (e.g., BAP1 deficiency or CDKN2A deficiency) and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, B The patient is administered an MDM2 antagonist if the level of one or more of ST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 is abnormal (e.g., increased or high).

[0085] In another embodiment of the methods described herein, elevated (or present) levels of BAP1 and / or CDKN2A and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, If the level of one or more of C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 is normal or low, the patient will not be administered an MDM2 antagonist.

[0086] In certain embodiments, an MDM2 antagonist may be administered to a patient in combination with an additional cancer treatment that is not an MDM2 antagonist. In one embodiment, at least one biomarker of the invention can be used to select patients for treatment with an MDM2 antagonist in combination with an agent described in (i)-(xlix) below. [Brief explanation of the drawings]

[0087] [Figure 1] Figure 1: Cancer cell lines with CDKN2A deficiency showed increased sensitivity to Compound 1 compared to those with wild-type CDKN2A in all tumor types tested (A) and in specific indications such as non-small cell lung cancer (NSCLC) (B). [Figure 2] Figure 2: Percentage of activated caspase-3 positive cells after 72 h treatment with DMSO and 1 μM compound 1 in human patient-derived mesothelioma cell lines. [Figure 3] Figure 3: Heatmap of significantly differentially expressed genes in a comparison of apoptotic and non-apoptotic mesothelioma cell lines. Columns are cell lines, rows are genes. The key in the upper left indicates the log fold change of genes. [Figure 4] Figure 4: GSEA enrichment plot for the interferon-α signaling pathway. The x-axis represents genes (black vertical lines) and the y-axis represents the enrichment score (ES), which corresponds to the enrichment of the interferon-α signaling pathway at the top of the ranked gene list. Genes with a clear peak at the beginning of the plot have a high positive correlation with the apoptotic phenotype. [Figure 5] Figure 5: Interferon signaling pathway generated by Ingenuity Pathway Analysis (IPA). Both up- and down-regulated genes were used in the analysis. Genes significantly up-regulated in apoptotic cell lines are highlighted with a gray background. [Figure 6]Figure 6: Interferon signature genes also upregulated in kidney tumors. For each gene, the bars represent, from left to right, GTEx (normal tissue), TCGA-GBM (glioblastoma), TCGA-KIRC (renal clear cell carcinoma), and TCGA-MESO (mesothelioma). [Figure 7] Figure 7: Western blot showing protein levels of BAP1 and β-actin in total lysates of mesothelioma cell lines derived from 12 patients. Cell lines are classified as apoptotic and non-apoptotic (*non-specific binding) as shown in Figure 2 (A). Tukey boxplot shows quantification of BAP1 protein expression normalized to β-actin obtained from Figure 7A. **P<0.005, Mann-Whitney test (B). [Figure 8] Figure 8: BAP1 knockdown in renal cancer cell lines increases apoptosis. Correlation with the degree of KD achieved with three different shRNAs. [Figure 9] Figure 9: BAP1 knockdown in renal cancer cell lines increases apoptosis. Correlation with the degree of KD achieved with three different shRNAs. [Figure 10] Figure 10: BAP1 knockdown in patient-derived mesothelioma cell lines also increases apoptosis after Compound 1 addition. [Figure 11] Figure 11: BAP1 protein expression status correlates with apoptosis in renal cancer cell lines. [Figure 12] Figure 12: X-ray powder diffractogram of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid. [Figure 13] Figure 13: Measurement of apoptosis induction in the OCI-AML3 cell line after 72 hours of treatment by measuring cleaved caspase-3 by cytometry. Specific Description of the Invention

[0088] definition The terms "MDM2 inhibitor" and "MDM2 antagonist" are used synonymously and define an MDM2 compound as described herein or an analog thereof, including salts, solvates, isomers, tautomers, N-oxides, esters, prodrugs, isotopes, and protected forms thereof (preferably, salts or tautomers or isomers or N-oxides or solvates thereof, more preferably, salts or tautomers or N-oxides or solvates thereof), as described above.

[0089] "MDM2 antagonist" refers to an antagonist of one or more MDM2 family members, particularly MDM2 and MDM4 (also called MDMx). The term "antagonist" refers to a type of receptor ligand or drug that blocks or reduces biological responses mediated by agonists. Antagonists have affinity for their cognate receptors but lack agonist potency, and binding prevents interaction and inhibits the function of any ligand (e.g., endogenous ligand or substrate, agonist or inverse agonist) at the receptor. Antagonism can occur directly or indirectly and can be mediated by any mechanism and at any physiological level. As a result, ligand antagonism can manifest functionally differently under different circumstances. Antagonists may mediate their effects by binding to the receptor's active or allosteric site, or they may interact at a unique binding site not normally involved in the biological regulation of receptor activity. Antagonist activity can be reversible or irreversible depending on the lifetime of the antagonist-receptor complex, which in turn depends on the nature of the antagonist-receptor binding.

[0090] "Potency" is a measure of drug activity expressed in terms of the amount required to produce an effect of a given strength. Highly potent drugs produce a greater response at lower concentrations. Potency is proportional to affinity and efficacy. Affinity is the ability of a drug to bind to a receptor. Efficacy is the relationship between receptor occupancy and the ability to initiate a response at the molecular, cellular, tissue, or system level.

[0091] As used herein, the term "mediated," when used in conjunction with, for example, MDM2 / p53 as described herein (and applied, for example, to various physiological processes, diseases, pathologies, conditions, therapies, treatments, or interventions), is intended to mean that the various processes, diseases, states, conditions, treatments, and interventions to which the term is applied function exclusively in such a way that the protein plays a biological role. When the term is applied to a disease, condition, or condition, the biological role played by the protein may be direct or indirect and may be necessary and / or sufficient for the manifestation of symptoms of (or the etiology or progression of) the disease, condition, or condition. Thus, protein function (and particularly abnormal levels of function, e.g., overexpression or underexpression) need not necessarily be the proximal cause of the disease, condition, or condition; rather, it is intended that mediated diseases, conditions, or conditions include those with multifactorial etiologies and complex progressions in which the subject protein is only partially responsible. When the term is applied to treatment, prevention, or intervention, the role played by the protein may be direct or indirect and may be necessary and / or sufficient for the outcome of the treatment, prevention, or intervention. Thus, a protein-mediated disease state or condition includes the development of resistance to any particular cancer drug or treatment.

[0092] The term "treatment," as used herein with reference to treating a condition, i.e., a condition, disorder, or disease, generally relates to treatment and therapy for either humans or animals (e.g., veterinary applications), where some desired therapeutic effect is achieved, such as inhibiting the progression of the condition, including slowing the rate of progression, stopping the rate of progression, ameliorating the condition, reducing or alleviating at least one symptom associated with or caused by the condition being treated, and curing the condition. For example, treatment can be the alleviation of one or more symptoms of the disorder, or the complete eradication of the disorder.

[0093] The term "prophylaxis" (i.e., use of a compound as a preventative measure), when used herein with reference to treating a pathology, i.e., a condition, disorder, or disease, generally relates to prophylaxis or prevention, either for humans or animals (e.g., veterinary uses), where some desired prophylactic effect is achieved, for example, in preventing the onset of or protecting against a disease. Prophylaxis includes completely and totally blocking all symptoms of a disorder indefinitely, simply delaying the onset of one or more symptoms of a disease, or reducing the likelihood of a disease occurring.

[0094] References to the prevention or treatment of a disease state or condition such as cancer include within their scope, for example, alleviating or reducing the incidence of cancer.

[0095] The combinations of the present invention may produce therapeutically beneficial effects compared to the therapeutic effects of the individual compounds / agents when administered separately.

[0096] The term "effective" includes beneficial effects such as additivity, synergy, reduced side effects, reduced toxicity, prolonged time to disease progression, prolonged survival time, sensitization or resensitization of one agent to another, or improved response rate. Advantageously, an effective effect may allow a patient to administer a lower dose of each or any of the components, thereby reducing the toxicity of chemotherapy while producing and / or maintaining the same therapeutic effect. In this context, a "synergistic" effect refers to a therapeutic effect produced by the combination that is greater than the sum of the therapeutic effects of the combined agents when presented individually. In this context, an "additive" effect refers to a therapeutic effect produced by the combination that is greater than the therapeutic effect of any of the combined agents when presented individually. The term "response rate," as used herein, refers to the degree of tumor size reduction at a given time point, for example, 12 weeks, in the case of solid tumors. Thus, for example, a 50% response rate means a 50% reduction in tumor size. In this specification, the term "clinical response" refers to a response rate of 50% or more. A "partial response" is defined herein as a response rate of less than 50%.

[0097] As used herein, the term "combination," when used to refer to two or more compounds and / or agents, is intended to define a material in which the two or more agents are associated. The terms "combination" and "combining" in this context should be interpreted accordingly.

[0098] The association of two or more compounds / agents in a combination can be physical or non-physical. Examples of physically associated combination compounds / agents include: Compositions (e.g., single formulations) comprising two or more compounds / agents in a mixture (e.g., in the same unit dose); Compositions comprising materials in which two or more compounds / drugs are chemically / physicochemically linked (e.g., by cross-linking, molecular aggregation or binding to a common vehicle moiety); Compositions comprising materials in which two or more compounds / drugs are chemically / physicochemically co-packaged (e.g., disposed on or within lipid vesicles, particles (e.g., microparticles or nanoparticles) or emulsion droplets); · Pharmaceutical kits, pharmaceutical packs or patient packs in which two or more compounds / agents are packaged or provided together (e.g., as part of a series of unit doses).

[0099] Examples of non-physically associated combination compounds / drugs include: - extemporaneous compounding of at least one of two or more compounds / drugs to form a physical association of the two or more compounds / drugs. a material comprising the compound (e.g., a non-unitary formulation) together with instructions regarding the compound; · material comprising at least one of two or more compounds / drugs together with instructions for combination therapy with those two or more compounds / drugs (e.g., non-unitary formulations); a material comprising at least one of two or more compounds / drugs together with instructions for administration to a patient population to which the other of the two or more compounds / drugs has been (or will be) administered; A material comprising at least one of two or more compounds / agents in an amount or form adapted by one skilled in the art for use in combination with the other(s) of those two or more compounds / agents.

[0100] As used herein, the term "combination therapy" is intended to define a therapy comprising the use of a combination of two or more compounds / agents (as defined above). Thus, in this application, "combination therapy," "combination," and the use of "combined" compounds / agents can refer to compounds / agents administered as part of the same overall treatment regimen. Thus, the dosage regimen of each of the two or more compounds / agents may differ, and each may be administered simultaneously or at different times. It is understood that the compounds / agents of a combination may be administered sequentially (e.g., before or after) or simultaneously, either in the same pharmaceutical formulation (i.e., together) or in different pharmaceutical formulations (i.e., separately). Simultaneous administration in the same formulation is the same as a single formulation, while simultaneous administration in different formulations is a non-single formulation. The dosage regimen of each of the two or more compounds / agents in a combination therapy may also differ with respect to the route of administration.

[0101] As used herein, the term "pharmaceutical kit" defines a series of one or more unit doses of a pharmaceutical composition, together with a dosing means (e.g., a metering device) and / or a delivery means (e.g., an inhaler or syringe), optionally all contained within a common outer packaging. In a pharmaceutical kit comprising a combination of two or more compounds / agents, the individual compounds / agents may be in a single formulation or a non-single formulation. The unit doses may be contained in a blister pack. The pharmaceutical kit may optionally further comprise instructions for use.

[0102] As used herein, the term "pharmaceutical pack" defines a series of one or more unit doses of a pharmaceutical composition, optionally contained within a common outer packaging. In a pharmaceutical pack comprising a combination of two or more compounds / drugs, each compound / drug may be a single formulation or a non-single formulation. The unit doses may be contained in a blister pack. The pharmaceutical pack may optionally further comprise instructions for use.

[0103] The term "optionally substituted," as used herein, refers to a group that is unsubstituted or that may be substituted with substituents as defined herein.

[0104] Detailed Description of the Invention The present invention is based on the identification of biomarkers that allow for the determination of a cancer patient's likely response to MDM2 antagonist therapy, which provides for precision cancer treatment using MDM2 antagonists.

[0105] In certain embodiments, the present invention provides a companion diagnostic for the treatment of cancer with an MDM2 antagonist. As used herein, the term companion diagnostic refers to both a test required to determine whether a patient will respond to a drug (i.e., a necessary companion diagnostic) and a test intended to identify whether a patient will respond favorably or optimally (which may also be referred to as a complementary diagnostic). In certain embodiments, the biomarker identifies responding patients, thus distinguishing responders from non-responders. In another embodiment, the biomarker identifies optimally responding patients, thereby allowing a physician to subsequently select the optimal treatment for that patient.

[0106] In some embodiments, the invention provides assays for determining the expression levels of one, two, three, four, five, six, seven, eight, nine, ten, twenty, twenty-five, or more of the biomarkers identified herein. The assays may or may not include a step of predicting a prognostic outcome. The assays are generally in vitro assays performed on a sample from a patient, such as a cancer biopsy or a blood sample (whether or not the cancer is a blood cancer).

[0107] Biomarkers for effective cancer treatment The present disclosure provides biomarkers that indicate increased sensitivity of cancer cells to treatment with MDM2 antagonists, and thus, identification of one or more of the identified biomarkers allows for the selection of cancer patients for MDM2 antagonist treatment.

[0108] One of these biomarkers is the expression level of CDKN2A. In Example 2, CDKN2A depletion (e.g., deletion, loss, silencing, lack of heterozygosity, and / or inactivation) is shown to be a statistically significant (adjusted p-value <0.020) biomarker predicting enhanced sensitivity to Compound 1 (FIG. 1).

[0109] In some embodiments, CDKN2A depletion can result from one or more nucleic acid substitutions and / or deletions in the CDKN2A gene. In some embodiments, the one or more nucleic acid substitutions and / or deletions in the CDKN2A gene are inactivating, as described in Yarbrough et al., Journal of the National Cancer Institute, 91(18): 1569-1574, 1999; Liggett and Sidransky, Biology of Neoplasia, Journals of Oncology, 16(3): 1197-1206, 1998; and / or Cairns et al., Nature Genetics, 11:210-212, 1995. Examples of these inactivating mutations include a C to T change at codon 232 of the human CDKN2A gene, converting it from an arginine codon to a stop codon; a 19 base pair germline deletion at nucleotide 223, resulting in a reading frame shift and a large terminal truncation of p16; a 6 base pair deletion at nucleotides 363-368 of the CDKN2A gene; and a G to T change at nucleotide 34 of the human CDKN2A gene.

[0110] The CDKN2A gene encodes two proteins, p16(ink4) and p14(arf), through the use of alternatively spliced ​​first exons. Expression levels of either or both of these proteins can be used to measure CDKN2A expression. Human p16 has UniProtKB accession number P42771. Human p14ARF has UniProtKB accession number Q8N726.

[0111] Another biomarker identified herein is the expression level of BAP1. Example 6 (e.g., Figure 7) shows that BAP1 depletion is a predictive marker for sensitivity to apoptosis induced by Compound 1.

[0112] In some embodiments, BAP1 depletion can result from one or more alterations to the BAP1 gene located on human chromosome 3p21.1. The mutations can include one or more nucleotide substitutions, additions, deletions, inversions, or other DNA rearrangements, or any combination thereof. The one or more genetic alterations resulting in BAP1 depletion can occur in introns, exons, or both, including alterations at or near exon-intron splice sites. The one or more alterations can be mutations in the nucleic acid sequence of germline or somatic cells.

[0113] Non-limiting examples of alterations resulting in BAP1 depletion are described in WO-A-2012 / 112846. BAP1 depletion can result from an adenosine insertion between positions 1318 and 1319 of the BAP1 cDNA, as described in Harbour et al. (2010) Science 330:1410-3. Another alteration commonly involves a C to T substitution in exon 16 at position 52436624 of human chromosome 3. An A to G substitution at position 52441334, two nucleotides upstream of the 3' end of intron 6, can result in BAP1 depletion. This A to G substitution can result in an aberrant splice site product lacking exon 7. A five-nucleotide deletion and one-nucleotide substitution at the 3' end of exon 3 can result in BAP1 depletion. The five nucleotide deletion can occur between positions 52443570 and 52443575 on human chromosome 3.

[0114] The alteration to BAP1 may comprise a deletion of a cytosine in exon 13, for example, at position 52437444 of human chromosome 3. The alteration may comprise a deletion of four nucleotides from exon 14. These four nucleotides may comprise TCAC and may be located at positions 52437159 to 52437162 of human chromosome 3. A 25-nucleotide deletion in exon 4 can result in BAP1 depletion. The deleted nucleotides can be located at positions 52442507 to 52442531 on human chromosome 3.

[0115] In one embodiment, the BAP1 protein can be a full-length protein with one or more mutations. The mutant BAP1 can be a partial or complete deletion of the wild-type BAP1 protein. The partial deletion or mutation of BAP1 can be in the nuclear localization signal, the active site of wild-type BAP1, the ASXL binding site, or anywhere in the gene that is thought to result in functional loss of BAP1. In another embodiment, BAP1 depletion can result from a non-functional BAP1 protein. The term "non-functional BAP1 protein" can refer to, but is not limited to, a BAP1 protein that does not exhibit deubiquitinase activity. WO-A-2018 / 051110 provides non-limiting examples of mutant BAP1 protein sequences that result in the depletion of functional BAP1.

[0116] In another embodiment, biomarker depletion can be the result of epigenetic silencing. Epigenetic silencing includes, but is not limited to, histone methylation, as described in WO-A-2017 / 139404. Epigenetic changes from wild type can inhibit, reduce, or eliminate the activity of biomarkers. In one embodiment, epigenetic changes from wild type inhibit, reduce, or eliminate the activity of BAP1 protein. In one embodiment, BAP1 depletion can be the result of upregulation of histone H3K27me3, as described in WO-A-2015 / 196064. Methods for measuring histone methylation and other epigenetic changes are known in the art.

[0117] Thus, low levels of CDKN2A and / or BAP1 predict enhanced sensitivity to MDM2 antagonist treatment.

[0118] These examples also demonstrate the use of the following proteins in cancer cells: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14 ... It is shown that the increased or upregulated expression of at least one of ASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 is associated with increased sensitivity to MDM2 inhibition.These biomarkers are collectively referred to herein as "interferon signature".As mentioned above, the expression of these proteins is generally determined by measuring mRNA transcripts. In certain embodiments, cancer cells are identified as sensitive to MDM2 antagonists if two, three, four, five, six, seven, eight, nine, ten, eleven, twelve, thirteen, fourteen, fifteen, or more, e.g., twenty or more, twenty-five or more, or all, of these proteins are expressed in the cells. In typical embodiments, the expression levels of these biomarkers are increased. Thus, high levels of one, two, three, four, five, ten, fifteen, twenty, twenty-five, or more, of these proteins predict enhanced sensitivity to MDM2 antagonist treatment.

[0119] In certain embodiments, expression of one, two, three, four, or all of CXCL10, CXCL11, RSAD2, MX1, and BATF2 predicts sensitivity to an MDM2 antagonist.

[0120] In certain embodiments, expression of one, two, three, four, or all of IFI44L, IFITM1, ISG15, CMPK2, and IFI27 predicts sensitivity to an MDM2 antagonist.

[0121] In certain embodiments, expression of one, two, three, four, five or more of IRF7, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, IRF9, FLI1 and BRCA1.

[0122] In certain embodiments, the expression levels of (a) one, two, three, four, or all of CXCL10, CXCL11, RSAD2, MX1, and BATF2; and (b) one, two, three, four, or all of IFI44L, IFITM1, ISG15, CMPK2, and IFI27; and (c) one, two, three, four, five, or all of IRF7, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, IRF9, FLI1, and BRCA1 predict sensitivity to an MDM2 antagonist.

[0123] For ease of reference, the biomarkers of the present disclosure can be characterized into four groups according to the manner in which they were identified: a. Loss of the CDKN2A biomarker was identified as predictive of enhanced sensitivity to MDM2 antagonists based on assays of a range of cancer cell lines. b. The following biomarkers were identified in the Examples as being differentially expressed between cells undergoing robust apoptosis upon treatment with an MDM2 antagonist and cells that are only weakly induced by the MDM2 antagonist (using induction in 40% of cells as an exemplary threshold): CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS. c. The following biomarkers were identified as being involved in the genetic pathways listed in "b": IRF7, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, IRF9, FLI1, and BRCA1. d. Loss of BAP1 as a biomarker was identified in cancer cells sensitive to MDM2-induced apoptosis.

[0124] In some embodiments, one biomarker is determined, which may be from any of groups a), b), c), or d).

[0125] In some embodiments, multiple biomarkers are determined, e.g., 2, 3, 4, 5, 6, 7, 8, 9, 10 or more biomarkers. These may comprise or consist of multiple biomarkers from a single group (i.e., group b) or group c), or may be multiple biomarkers from multiple groups, e.g., CDKN2A (group a); and 0, 1, 2 or more from group b); and 0, 1, 2 or more from group c); and with or without BAP1 (group d); or 0, 1, 2 or more from group b); and 0, 1, 2 or more from group c), with or without BAP1 (group d); or two or more from group b); two or more from group c); with or without BAP1 (group d) The biomarkers may comprise or consist of one or more biomarkers from different genes, such as:

[0126] When multiple biomarkers are determined, the combination of biomarkers may be referred to as a biomarker panel. A biomarker panel may comprise or consist of the identified biomarkers.

[0127] In addition to the biomarkers of the invention, other biomarkers and / or data such as demographic data (e.g., age, sex) can be included in the dataset applied to determine the suitability of MDM2 inhibition. Optionally, when other biomarkers are included, the total number of biomarkers (i.e., the biomarker panel of the invention plus other biomarkers) can be 3, 4, 5, 6, or more. In some embodiments, a predictive biomarker panel with fewer components can simplify the testing required.

[0128] The terms "deficiency" and "reduction," as used herein, should be given their ordinary meaning. The terms "increase" and "enhancement," as used herein, should be given their ordinary meaning.

[0129] Biomarkers can be determined by any suitable technique that will be apparent to those skilled in the art. Biomarkers can be determined by direct or indirect techniques. Gene expression can be detected by detecting mRNA transcripts. Protein biomarkers can be detected by immunohistochemistry.

[0130] In some embodiments, depletion of one or more of the biomarkers of the present invention can be determined by assessing the function of one or more biomarkers. The level of biomarker expression can be directly proportional to the level of function. The function of one or more biomarkers can be determined directly or indirectly. For example, as described in WO-A-2015 / 196064, modulation of SUZ12 expression can be determined to assess BAP1 function. Since BAP1 depletion has been shown to result in EZH2 expression and activity, in one embodiment, BAP1 depletion is assessed by determining increased EZH2 expression. In a further exemplary embodiment, binding to ASXL protein can be used to determine BAP1 expression, as described in WO-A-2018 / 051110. Decreased binding of BAP1 to ASXL protein can be used to identify BAP1 depletion.

[0131] In some embodiments, the expression level can be compared to a threshold that also reflects an expression level known to be associated with susceptibility to treatment to assess whether the test value is indicative of susceptibility to MDM2 inhibitor treatment in the patient.

[0132] Patients evaluated in accordance with the present disclosure may be known or suspected of having cancer. The sample tested may be known or suspected of containing cancer cells. In a typical embodiment, the sample tested is a biopsy of cancerous tissue. The biopsy can be a liquid biopsy or a solid tissue (eg, solid tumor) biopsy.

[0133] Biomarker levels The present invention provides for increased or decreased levels of one or more biomarkers. Generally, the comparison is made to normal, healthy individuals, or more generally, to non-cancerous cells of the same type as the cancer cells.

[0134] In some embodiments, an increase or decrease in biomarker levels is determined relative to non-cancerous cells from the same individual, generally non-cancerous cells of the same type from the same individual.

[0135] In a further embodiment, an increase or decrease in biomarker level is determined relative to a value based on a test standard and known normal population values. Generally, the known levels are obtained from non-cancerous cells.

[0136] In other embodiments, increases or decreases in biomarker levels are compared to known values ​​from normal (non-cancerous) individuals. For example, GTEx, as described elsewhere herein, is a source of gene expression data from normal, healthy individuals from 44 different tissues. BloodSpot (www.bloodspot.eu) is a source of gene expression data from normal and malignant blood cells, including AML gene expression data.

[0137] In some other embodiments, the increase or decrease in biomarker levels is assessed relative to levels determined in multiple cancer samples from multiple MDM2 inhibitor non-responder subjects, or in one cancer sample from one MDM2 inhibitor non-responder subject. This may be particularly useful for one or more IFN signature biomarkers.

[0138] In one embodiment, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS The RNA level of one or more of 3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1 is assessed relative to the amount of said RNA in a control sample obtained from a normal subject not afflicted with cancer.

[0139] In another embodiment, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3B The RNA levels of P, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1 are assessed relative to the amount of said RNA in an earlier sample obtained from the same patient when the patient did not have cancer.

[0140] In one embodiment, it is elevated or increased compared to normal levels (eg, the "upper limit of normal" or ULN).

[0141] In one embodiment, the level of at least one of the biomarkers is such that the area under the curve (AUC) of the cancer sample relative to the control sample is greater than 0.5 (for an increased biomarker) or less than 0.5 (for a depleted biomarker) relative to (a) the level of at least one of the biomarkers in a sample from a tissue or person not having cancer, or (b) the level of one or more control proteins in a sample from the subject. Optionally, the AUC is greater than or less than 0.6, 0.7, 0.8, 0.9, 0.95, 0.975, or 0.99.

[0142] In some embodiments, the level of at least one of these biomarkers is at least one standard deviation from the control relative to (a) the level of one or more biomarkers in a sample from a tissue or person with cancer, or (b) the level of one or more control proteins in a sample from a subject with cancer.

[0143] In some embodiments, the control for comparison is a sample obtained from a healthy patient or a non-cancerous tissue sample obtained from a patient diagnosed with cancer, e.g., a non-cancerous tissue sample from the same organ in which the tumor is located (e.g., non-cancerous colon tissue can serve as a control for colon cancer). In some embodiments, the control is a histological control or standard value (i.e., a group of previously tested subject samples or samples representing a baseline or normal value).

[0144] The control or standard to compare with the sample for determining differential expression includes a sample that is considered normal (in that it is not altered with respect to the desired characteristics, for example, a sample from a subject who does not have colon cancer) and a test value, even if it is set arbitrarily.Test standards and values ​​can be set based on known or determined population values, and can be provided in the form of a graph or table that allows the comparison of measured and experimentally determined values.

[0145] In such embodiments, the reference score for one or more biomarkers is based on normal, healthy individuals.

[0146] cancer Cancers that exhibit one or more of the specific biomarkers are likely to respond to treatment with an MDM2 antagonist. The cancer to be treated is not particularly limited, as long as it exhibits one or more of the biomarkers.

[0147] Cancer is generally p53 wild type.As recognized in the art, p53 wild type cancer cells express the tumor suppressor p53 at wild type level and with wild type function.Wild type p53 cells do not contain the mutation of p53 gene, which leads to the reduction of p53 tumor suppressor function.

[0148] The data presented in the examples was generated from a range of cancer tissues, including colon, blood, breast, lung, skin, ovary, and pancreas. In one embodiment, the cancer is colon cancer. In another embodiment, the cancer is blood cancer. In a further embodiment, the cancer is breast cancer. In another embodiment, the cancer is lung cancer. In yet another embodiment, the cancer is skin cancer, e.g., melanoma or carcinoma. In another embodiment, the cancer is ovarian cancer. In a different embodiment, the cancer is pancreatic cancer.

[0149] Particular cancers that can be evaluated for treatment according to the present invention include, but are not limited to, mesothelioma, non-small cell lung cancer (NSCLC), glioblastoma (e.g., GBM), and renal cancer (e.g., KIRC).

[0150] In certain embodiments, cancer cell proliferation is inhibited by an IC in the nanomolar range. 50 In certain embodiments, the MDM2 antagonist has an IC 50 In some embodiments, the IC value is less than 500 nM, less than 400 nM, less than 300 nM, or less than 200 nM. 50 The IC value is less than 100 nM. 50Values ​​can be calculated, for example, using GraphPad Prism software as exemplified herein or methods known in the art.

[0151] In certain embodiments, MDM2 antagonists induce apoptosis in cancer cells. Apoptosis can generally be mediated by activated caspase-3. Induction of apoptosis can be determined by detecting cells positive for activated caspase-3 after 72 hours of treatment with 1 μM of MDM2 antagonist. As will be apparent to those skilled in the art, other assay concentrations and / or treatment periods, such as 48 hours at 1 μM or 48 hours at 5 μM of MDM2 antagonist, can also be used. In certain embodiments, positive staining of at least 10%, at least 20%, or at least 30% of cells for activated caspase-3 indicates apoptosis induction. In certain embodiments, 40% is the confidence level for identifying strong apoptosis induction, and apoptosis can be considered when >40% of cells in a population stain positive for activated caspase-3. As will be apparent to those skilled in the art, other levels, such as 10%, 20%, 30%, 50%, 60%, 70%, 75% or more, can be used depending on the needs of the cells and the assay. Active caspase-3 staining kits are commercially available, for example, the "Cleaved Caspase-3 Staining Kit (Red)" available from Abcam (Cambridge, UK) under catalog number ab65617. Invitrogen Cell Event dye (C10423) can also be used.

[0152] Annexin V dye can also be used to detect apoptosis, which is used in Figure 9 and is well known in the art as a useful dye for detecting apoptosis.

[0153] MDM2 antagonists The transformation-related protein 53 (TP53) gene encodes the 53-kDa protein p53. The tumor suppressor protein p53 responds to cellular stresses, such as hypoxia, DNA damage, and oncogenic activation, through several post-translational modifications, including phosphorylation, acetylation, and methylation, and serves as a signaling node in the activated diverse pathways. p53 has additional roles in other physiological processes, including autophagy, cell adhesion, cell metabolism, fertility, and stem cell aging and development. Phosphorylation of p53, resulting from activation of kinases including ATM, CHK1 and 2, and DNA-PK, generates stable and transcriptionally active forms of the protein, thus generating a range of gene products. Responses to p53 activation include apoptosis, survival, cell cycle arrest, DNA repair, angiogenesis, invasion, and autoregulation. The specific combination of these, consistent with the cell's genetic background, results in the observed cellular effects, i.e., apoptosis, cell cycle arrest, or senescence. In tumor cells, defects in tumor suppressor proteins and associated cell cycle checkpoint controls, coupled with oncogenic stress, can favor the apoptotic pathway.

[0154] Under stress conditions such as hypoxia and DNA damage, cellular levels of the protein p53 are known to increase. p53 is known to initiate the transcription of many genes that govern cell cycle progression, initiation of DNA repair, and programmed cell death. This provides a mechanism for the tumor suppressor role of p53, which has been demonstrated through genetic studies.

[0155] p53 activity is negatively and tightly regulated by its binding interaction with the MDM2 protein, and its transcription is itself directly regulated by p53. p53 is inactivated upon binding of the MDM2 protein to its transactivation domain. Upon inactivation, p53 function is suppressed and the p53-MDM2 complex becomes a target for ubiquitination.

[0156] In normal cells, the balance between active p53 and inactive MDM2-bound p53 is maintained by an autoregulatory negative feedback loop: p53 can activate the expression of MDM2, which in turn leads to the repression of p53.

[0157] Mutational inactivation of p53 has been found to be common in approximately half of all common adult sporadic cancers. Furthermore, in approximately 10% of tumors, gene amplification and overexpression of MDM2 results in a nonfunctional form of p53, thereby enabling malignant transformation and uncontrolled tumor growth.

[0158] Inactivation of p53 by a range of mechanisms is a frequent causative event in cancer development and progression. These include mutational inactivation, targeting by oncogenic viruses, and, in a significant proportion of cases, amplification and / or increased transcription rate of the MDM2 gene, leading to overexpression or increased activation of the MDM2 protein. Gene amplification of MDM2, resulting in overexpression of the MDM2 protein, has been observed in tumor samples from common sporadic cancers. Overall, approximately 10% of tumors show MDM2 amplification, with the highest incidence observed in hepatocellular carcinoma (44%), lung (15%), sarcoma and osteosarcoma (28%), and Hodgkin's disease (67%) (Danovi et al., Mol. Cell. Biol. 2004, 24, 5835-5843; Toledo et al., Nat Rev Cancer 2006, 6, 909-923; Gembarska et al., Nat Med 2012, 18, 1239-1247). Normally, transcriptional activation of MDM2 by activated p53 leads to increased MDM2 protein levels, forming a negative feedback loop. The essential nature of p53 regulation by MDM2 and MDMX has been demonstrated in gene knockout mouse models. MDM2- / - knockout mice are fetally lethal around the time of implantation. Lethality is rescued by double knockout of MDM2 and TP53. MDM2 directly inhibits p53 activity by binding to and occluding the p53 transactivation domain and promoting proteasomal destruction of the complex via its E3-ubiquitin ligase activity. Furthermore, because MDM2 is a transcriptional target of p53, the two proteins are linked in an autoregulatory feedback loop, ensuring that p53 activation is transient.

[0159] Induction of the p14ARF protein, the product of the alternative reading frame (ARF) of the p16INK4a locus (CDKN2A), is also a mechanism for negatively regulating the p53-MDM2 interaction. p14ARF directly interacts with MDM2, leading to upregulation of the p53 transcriptional response. Deficiency of p14ARF due to homozygous mutations in the CDKN2A (INK4A) gene leads to elevated levels of MDM2 and, therefore, impaired p53 function and cell cycle control. Tagawa et al. (Molecular Therapy, Volume 24, Supplement 1, May 2016: Abstract 211) reported that forced transduction of p53 combined with agents blocking the MDM2-p53 interaction resulted in synergistic cytotoxicity in mesothelioma cells defective in the INK4A / ARF region. Similarly, Tagawa et al (Human Gene Therapy, Volume 26 (10) October 2015: Abstract P014) described that inhibiting the interaction between p53 and Mdm2 enhanced p53-mediated cytotoxic activity against INK4A / ARF-deficient mesothelioma.

[0160] Although MDMX shares strong amino acid sequence and structural homology with MDM2, neither protein can substitute for the other; MDMX-null mice are lethal in utero, and MDM2 knockouts are lethal during early embryonic development. However, both are rescued by p53 knockout, demonstrating lethal p53 dependence. MDMX also binds to p53 and inhibits p53-dependent transcription, but unlike MDM2, it is not transcriptionally activated by p53 and therefore does not form the same autoregulatory loop. Furthermore, MDMX lacks E3 ubiquitin ligase activity or a nuclear localization signal, but it is thought to form heterodimers with MDM2, contributing to the stabilization of MDM2 and thereby contributing to p53 degradation.

[0161] The therapeutic rationale for MDM2-p53 inhibition is that potent antagonists of this protein-protein interaction would liberate p53 from MDM2's inhibitory control and activate p53-mediated cell death in tumors. In tumors, selectivity is postulated to result from p53 sensing pre-existing DNA damage or oncogenic activation signals that were previously blocked by the action of normal or overexpressed MDM2. In normal cells, p53 activation is predicted to activate non-apoptotic pathways, resulting in a rather protective growth-inhibitory response. Furthermore, the non-genotoxic mechanism of action of MDM2-p53 antagonists makes them suitable for the treatment of cancer, particularly in pediatric populations. MDM4 is also an important negative regulator of p53.

[0162] Approximately 50% of cancers harbor cells in which TP53, the gene that encodes p53, has been mutated, resulting in versions of the p53 protein that are deficient in the protein's tumor-suppressing function and, in some cases, even acquire new oncogenic functions.

[0163] Cancers in which high levels of MDM2 amplification are present include liposarcoma (88%), soft tissue sarcoma (20%), osteosarcoma (16%), esophageal cancer (13%), and certain pediatric malignancies, including B-cell malignancies.

[0164] Examples of MDM2 antagonists Roche's small molecule antagonist of MDM2, idasanutlin (RG-7388), is reportedly in Phase I-III clinical trials for solid and hematological tumors, AML, diffuse large B-cell lymphoma, essential thrombocythemia, polycythemia vera, and follicular lymphoma. Idasanutlin (RG-7388) has the following structure: [ka]

[0165] Idasanutlin (RG-7388) is commercially available or can be prepared, for example, as described in PCT patent application WO2014 / 128094 or by procedures analogous thereto.

[0166] HDM-201 (NVP-HDM201) is being developed by Novartis in Phase I / II clinical trials for wild-type TP53 characterized advanced / metastatic solid tumors, hematologic malignancies including ALL, AML, and MS, metastatic uveal melanoma, dedifferentiated liposarcoma, and well-differentiated liposarcoma. The antagonist HDM-201 (NVP-HDM201) has the following chemical structure: [ka]

[0167] HDM-201 (NVP-HDM201) is commercially available or can be prepared, for example, as described in PCT patent application WO2013 / 111105 or by procedures analogous thereto.

[0168] KRT-232 (AMG-232), a small molecule antagonist of MDM2, is being developed by NCI / Amgen / GSK in Phase I-I / II clinical trials for solid tumors, soft tissue sarcomas such as liposarcoma, recurrent or newly diagnosed glioblastoma, metastatic breast cancer, refractory MM, metastatic cutaneous melanoma, and recurrent / refractory AML. KRT-232 (AMG-232) has the following chemical structure: [ka]

[0169] KRT-232 (AMG-232) is commercially available or can be prepared, for example, as described in PCT patent application WO 011 / 153509 or by procedures analogous thereto.

[0170] ALRN-6924 (SP-315), a peptide dual antagonist of MDM2 and MDM4, is being developed in Phase II clinical trials by Aileron Therapeutics and Roche for the intravenous treatment of solid tumors, small cell lung cancer, and pediatric tumors, including lymphoma, acute myeloid leukemia, acute lymphocytic leukemia, retinoblastoma, hepatoblastoma, brain tumors, liposarcoma, and metastatic breast cancer. ALRN-6924 (SP-315) is a synthetic peptide developed based on stapled peptide technology, which locks peptides into a specific folded (biologically active) conformation that is resistant to proteases. ALRN-6924 (SP-315) has the following structure: [ka]

[0171] ALRN-6924 (SP-315) is commercially available or can be prepared, for example, as described in PCT patent application WO2017205786, or by procedures analogous thereto.

[0172] CGM-097 (NVP-CGM-097), a small molecule antagonist of MDM2, is being developed by Novartis in Phase I clinical trials for advanced solid tumors and acute lymphoblastic leukemia (B-ALL). CGM-097 (NVP-CGM-097) has the following chemical structure: [ka]

[0173] CGM-097 (NVP-CGM-097) is commercially available or can be prepared, for example, as described in PCT patent application WO2011076786, or by procedures analogous thereto.

[0174] Milademethanthosylate (DS-3032), a small molecule antagonist of MDM2, is being developed by Daiichi Sankyo in Phase I clinical trials for advanced solid tumors, lymphoma, melanoma, refractory or relapsed AML, ALL, multiple myeloma, blast phase CML, or high-risk MDS and diffuse large B-cell lymphoma. Milademethanthosylate (DS-3032) has the following chemical structure: [ka]

[0175] Milademethanthosylate (DS-3032) is commercially available or can be prepared, for example, as described in PCT patent application WO2015 / 033974, or by procedures analogous thereto.

[0176] APG-115 (AAA-115; NCT-02935907), a small molecule antagonist of MDM2, is being developed by Ascentage Pharma in Phase I clinical trials for the treatment of tumors and lymphomas, AML, and adenoid cystic carcinoma (ACC). APG-115 (AAA-115; NCT-02935907) has the following chemical structure: [ka]

[0177] APG-115 (AAA-115; NCT-02935907) is commercially available or can be prepared, for example, as described in PCT patent application WO2015 / 161032, or by procedures analogous thereto.

[0178] BI-907828, an MDM2 antagonist, is being developed by BI in Phase I clinical trials for the treatment of GBM, metastatic brain tumors, NSCLC, soft tissue sarcoma, and transitional cell carcinoma (urothelial cell carcinoma).

[0179] BI-907828 is commercially available or can be prepared, for example, as described in PCT Patent Application No. 2015 / 161032, or by procedures analogous thereto.

[0180] The University of Michigan is developing LE-004, a conjugate of the MI-1061 PROTAC and thalidomide, which has been shown to effectively inhibit the growth of a mouse model of human leukemia by inducing MDM2 degradation. Its structure is as follows and can be prepared, for example, as described in PCT patent applications WO2017 / 176957 or WO2017 / 176958, or by procedures analogous thereto. LE-004 has the following chemical structure: [ka]

[0181] MI-773 (SAR405838) is a highly potent and selective MDM2 inhibitor that binds to MDM2 with higher specificity than other proteins and potently inhibits cell proliferation in cancer cell lines. SAR405838 effectively induces apoptosis, potently inhibits cell proliferation, and induces dose-dependent apoptosis. It is currently being investigated in clinical trials. Its structure is as follows: [ka] SAR405838 can be prepared, for example, as described in WO-A-2011 / 060049.

[0182] DS-5272 is an MDM2 antagonist being developed by Daiichi Sankyo for oral administration. The structure is: [ka]

[0183] DS-5272 may be prepared for example as described in PCT patent application WO2015 / 033974, or by procedures analogous thereto.

[0184] SJ-0211 is an MDM2 antagonist being developed for retinal therapy treatment by the University of Tennessee, the University of Kentucky and St. Jude's Children's Research Hospital.

[0185] BI-0252 is an MDM2 antagonist being developed by BI for oral administration. BI-0252 inhibits the interaction between MDM2 and p53. Its structure is as follows: [ka]

[0186] AM-7209 is an MDM2 antagonist being developed by Amgen as a backup for AMG-232. The structure is: [ka]

[0187] AM-7209 can be prepared for example as described in PCT patent application WO2014 / 200937, or by procedures analogous thereto.

[0188] SP-141 (JapA) is a direct MDM2 antagonist under development at Texas Tech University. Its structure is as follows: [ka]

[0189] SCH-1450206 is an antagonist of MDM2 and is being developed for oral administration by Schering-Plough & Merck. An example structure is: [ka]

[0190] Cytarabine, also known as MK-8242 and SCH-900242, is an antimetabolite analog of cytidine with a modified sugar moiety (arabinose instead of ribose). Upon oral administration, the HDM2 inhibitor MK-8242, an orally bioavailable inhibitor of human homolog of double minute 2 (HDM2), with potential antitumor activity, inhibits HDM2 protein binding to the transcriptional activation domain of the tumor suppressor protein p53. Preventing this HDM2-p53 interaction inhibits p53 degradation and potentially restores p53 signaling, which induces p53-mediated tumor cell apoptosis.

[0191] Nutlin-3a is an antagonist or inhibitor of MDM2 (mouse double minute 2 human homologue) and prevents its interaction with p53, leading to the stabilization and activation of p53. Its structure is as follows: [ka]

[0192] NXN-6 (NXN-7; NXN-552; NXN-561; NXN-11) are MDM2 antagonists being developed for oral administration by Nexus, Priaxon, and BI. Exemplary structures are as follows: [ka]

[0193] ADO-21 is an MDM2 antagonist being developed by the Adamed Group.

[0194] CTX-50-CTX-1 is a small molecule MDM2 antagonist being developed by MiRx Pharmaceuticals, CRC.

[0195] ISA-27 is a small molecule MDM2 antagonist being developed by the Universities of Naples and Salerno. Its structure is: [ka]

[0196] RG-7112 (RO5045337) is a potent, selective, early clinical, orally active, and blood-brain barrier penetrating MDM2-p53 inhibitor. The structure is: [ka]

[0197] RO-8994 is a small molecule MDM2 antagonist being developed by Roche. RO-8994 has been shown to inhibit tumor growth and induce the mitochondrial effects of p53. Its structure is: [ka]

[0198] RO-8994 is commercially available or can be prepared, for example, as described in PCT patent application WO2011 / 067185, or by procedures analogous thereto.

[0199] RO-6839921 (RG-7775) is a small molecule MDM2 antagonist being developed by Roche for IV administration. The structure is: [ka]

[0200] RO-6839921 (RG-7775) can be prepared for example as described in PCT patent application WO2014 / 206866, or by procedures analogous thereto.

[0201] JNJ 26854165 (celdemethane) is an oral HDM2 inhibitor (or antagonist) that has shown potent activity against multiple myeloma (MM) cells in vitro and ex vivo, and is a potential agent for restoring p53 function and potentially affecting other HDM2-dependent pathways. [ka]

[0202] ATSP-7041 (SP-154), a stapled synthetic peptide dual antagonist of MDM2 and MDM4, is being developed by Aileron Therapeutics and Roche and is in preclinical development. ATSP-7041 (SP-154) has the following structure: [ka]

[0203] SAH-p53-8, a stapled synthetic peptide antagonist of MDM4, Hdm2, and caspase 3, is being developed by Harvard University and Dana-Faber and is in preclinical development. SAH-p53-8 has the following structure: [ka]

[0204] PM-2 (sMTide-02), a stapled synthetic peptide antagonist of MDM4, Hdm2, and caspase-3, is being developed by Harvard College and Dana-Faber and is in preclinical development. PM-2 (sMTide-02) has the following structure: [ka]

[0205] K-178 is a small molecule MDM4 antagonist currently in preclinical development at Kansai Medical University. K-178 has the following chemical structure: [ka]

[0206] MMRi-64 is a discovery-stage small molecule antagonist of MDM2 and MDM4 being developed by Roswell Park Cancer Institute. MMRi-64 has the following chemical structure: [ka]

[0207] Small molecule antagonists of MDM2 and MDM4 are also under development by Jagiellonian University and Second Medical University. One example has the following chemical structure: [ka]

[0208] Small molecule antagonists of MDM2 and MDM4 are being developed by Emory and Georgia State University and are in preclinical development for the treatment of acute lymphoblastic leukemia.

[0209] Small molecule antagonists of MDM2 and MDM4 are in development by Adamed and are at the discovery stage.

[0210] In one embodiment of the invention, the MDM2 antagonist is selected from the group consisting of idasanutlin, HDM-201, KRT-232, ALRN-6924, CGM-097, milademethanthosylate, APG-115, BI-907828, LE-004, DS-5272, SJ-0211, BI-0252, AM-7209, SP-141, SCH-1450206, NXN-6, ADO-21, CTX-50-CTX-1, ISA-27, RO-8994, RO-6839921, ATSP-7041, SAH-p53-8, PM-2, K-178, MMRi-64, and [ka] or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

[0211] In one embodiment of the invention, the MDM2 antagonist is selected from the group consisting of idasanutlin, HDM-201, KRT-232 (AMG-232), ALRN-6924, CGM-097, milademethanthosylate (DS-3032b), APG-115, BI-907828, LE-004, DS-5272, SJ-0211, APG-155, RG-7112, RG7388, SAR405939 , cytarabine (also known as MK-8242 and SCH-900242), BI-0252, AM-7209, SP-141, SCH-1450206, NXN-6, ADO-21, CTX-50-CTX-1, ISA-27, RO-8994, RO-6839921, RO-6839921, ATSP-7041, SAH-p53-8, PM-2, K-178, MMRi-64, and [ka] or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

[0212] In one embodiment of the invention, the MDM2 antagonist is selected from the group consisting of idasanutlin, HDM-201, KRT-232 (AMG-232), ALRN-6924, CGM-097, milademethanthosylate (DS-3032b), APG-115, BI-907828, LE-004, DS-5272, SJ-0211, BI-0252, AM-7209, SP-141, SCH-1450206, NXN-6, ADO-21, CTX-50-CTX-1, ISA-27, RO-8994, RO-6839921, RO-6839921, ATSP-7041, SAH-p53-8, PM-2, K-178, MMRi-64, and [ka] or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

[0213] In one embodiment of the invention, the MDM2 antagonist is selected from the group consisting of idasanutlin (RG-7388), HDM-201, KRT-232 (AMG-232), ALRN-6924, MI-773 (SAR405838), milademetan (DS-3032b), APG-115, BI-907828, or a tautomer or solvate or pharmaceutically acceptable salt thereof.

[0214] In one embodiment of the invention, the MDM2 antagonist is idasanutlin (RG-7388), HDM-201, KRT-232 (AMG-232), ALRN-6924, MI-773 (SAR405838), milademetan (DS-3032b), APG-115, BI-907828, or a compound of formula I o or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

[0215] Formula I o Compounds of Particular MDM2 antagonists are the isoindoline compounds disclosed in the inventors' earlier international patent applications PCT / GB2016 / 053042 and PCT / GB2016 / 053041, filed September 29, 2016, which claim priority to UK Patent Applications Nos. 1517216.6 and 1517217.4, filed September 29, 2015, the contents of all of which are incorporated herein by reference in their entireties. In particular, the compound (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid ("Compound 1") is disclosed in our earlier international patent application PCT / GB2016 / 053042.

[0216] In one embodiment, the MDM2 antagonist has the formula I o Compounds of: [ka] or a tautomer, solvate, or pharmaceutically acceptable salt thereof; wherein cyc is phenyl or a heterocyclic group Het, which is pyridinyl, pyrimidinyl, pyrazinyl or pyridazinyl, or an N-oxide thereof; R 1 is hydroxy, halogen, nitro, nitrile, C 1-4 Alkyl, HaloC 1-4 Alkyl, hydroxy C 1-4 Alkyl, C 2-6 Alkenyl, C 1-4 Alkoxy, HaloC 1-4 Alkoxy, C 2-4 Alkynyl, -O 0,1 -(CR x R y ) v -CO2H, -(CR x R y ) v -CO2C 1-4 Alkyl, -(CRx R y ) v -CON(C 1-4 alkyl)2, -P(=O)(R x )2, -S(O) d -R x , -S(O) having 3 to 6 ring members d -heterocyclic group and -S(O) d -N(R 8 )2 independently selected from, where cyc is Het, then R 1 is bonded to a carbon atom; R 2 is hydrogen, C 1-4 Alkyl, C 2-6 Alkenyl, Hydroxy C 1-4 Alkyl, -(CR x R y ) u -CO2H, -(CR x R y ) u -CO2C 1-4 Alkyl, and -(CR x R y ) u -CONR x R y Selected from; s is selected from 0 and 1; R 3 is hydrogen or -(A) t -(CR x R y ) q -X; t is selected from 0 and 1; q is selected from 0, 1 and 2; where R 3 Ga-(A) t -(CR x R y ) q -X, then (i) at least one of s, t, and q is non-zero, and (ii) if t is 0, then s is 1 and q is non-zero; A is C 3-6a cycloalkyl group or a heterocyclic group having 3 to 6 ring members, wherein the heterocyclic group comprises one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof; X is hydrogen, halogen, -CN, -OR 9 , -(CH2) v -CO2H, -(CH2) v -CO2C 1-4 Alkyl, -S(O) d -R x , -C(=O)-C 1-4 Alkyl, -S(O) d -N(H) e (C 1-4 alkyl) 2-e , -NR x R y , -NHSO2R x , -NR x COR y , and -C(=O)NR x R y Selected from; R 4 and R 5 is halogen, nitrile, C 1-4 Alkyl, HaloC 1-4 Alkyl, C 1-4 Alkoxy and HaloC 1-4 independently selected from alkoxy; R 6 and R 7 is hydrogen, C 1-6 Alkyl, HaloC 1-6 Alkyl, C 2-6 Alkenyl, C 2-6 Alkynyl, Hydroxy, HydroxyC 1-6 Alkyl, -COOC 1-6 Alkyl, -(CH2) j -OC 1-6 Alkyl, -(CH2) j -O-(hydroxy C 1-6 alkyl), -C 1-6 Alkyl-NR x R y , -(CR x R y ) p -CONR x Ry , -(CR x R y ) p -NR x COR y , -(CR x R y ) p -O-CH2-CONR x R y , a heterocyclic group having 3 to 7 ring members, a -CH2-heterocyclic group having 3 to 7 ring members, a -CH2-O-heterocyclic group having 3 to 7 ring members, a -CH2-NH-heterocyclic group having 3 to 7 ring members, a -CH2-N(C 1-6 alkyl)-heterocyclic group, -C(=O)NH-heterocyclic group having 3 to 7 ring members, C 3-8 Cycloalkyl, -CH2-C 3-8 Cycloalkyl, -CH2-OC 3-8 Cycloalkyl, and C 3-8 cycloalkenyl, wherein said cycloalkyl, cycloalkenyl or heterocyclic group is independently selected from one or more R z groups, and in each instance the heterocyclic group comprises one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof; or R 6 and R 7 The groups, together with the carbon atoms to which they are attached, form a C 3-6 forming a cycloalkyl or heterocyclyl group having 3 to 6 ring members, wherein the heterocyclic group comprises one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof, and wherein the C 3-6 Cycloalkyl and heterocyclyl groups may be formed by one or more R z optionally substituted with a group; R 8 and R 9 is hydrogen, C 1-6 Alkyl, HaloC 1-6 Alkyl, Hydroxy C 1-6 Alkyl, -(CH2) k -OC 1-6 Alkyl, -(CH2) k-O-(hydroxy C 1-6 alkyl), hydroxy C 1-6 Alkoxy, -(CH2) k -CO2C 1-6 Alkyl, -(CH2) k -CO2H, -C 1-6 Alkyl-N(H) e (C 1-4 alkyl) 2-e , -(CH2) j -C 3-8 Cycloalkyl and -(CH2) j -C 3-8 cycloalkenyl; R x and R y is hydrogen, halogen, nitro, nitrile, C 1-6 Alkyl, HaloC 1-6 Alkyl, C 2-6 Alkenyl, C 2-6 Alkynyl, Hydroxy, HydroxyC 1-6 Alkyl, C 1-6 Alkoxy, -(CH2) k -OC 1-6 Alkyl, Hydroxy C 1-6 Alkoxy, -COOC 1-6 Alkyl, -N(H) e (C 1-4 alkyl) 2-e , -C 1-6 Alkyl-N(H) e (C 1-4 alkyl) 2-e , -(CH2) k -C(=O)N(H) e (C 1-4 alkyl) 2-e , C 3-8 Cycloalkyl and C 3-8 cycloalkenyl; or R x and R y The groups, together with the carbon or nitrogen atom to which they are attached, form a C 3-6 It can form a cycloalkyl or saturated heterocyclyl group having 3 to 6 ring members, which may optionally be fused with an aromatic heterocyclyl group having 3 to 5 ring members; or on a carbon atom, R x and R y The groups can be linked together to form a =CH2 group; R z is halogen, nitro, nitrile, C 1-6 Alkyl, HaloC 1-6 Alkyl, C 2-6 Alkenyl, C 2-6 Alkynyl, =O, Hydroxy, HydroxyC 1-6 Alkyl, C 1-6 Alkoxy, -(CH2) k -OC 1-6 Alkyl, Hydroxy C 1-6 Alkoxy, -C(=O)C 1-6 Alkyl, -C(=O)C 1-6 Alkyl-OH, -C(=O)C 1-6 Alkyl-N(H) e (C 1-4 alkyl) 2-e , -C(=O)N(H) e (C 1-4 alkyl) 2-e , -(CH2) r -CO2C 1-6 Alkyl, -(CH2) r -COH, -N(H) e (C 1-4 alkyl) 2-e , -C 1-6 Alkyl-N(H) e (C 1-4 alkyl) 2-e , heterocyclyl groups having 3 to 6 ring members, -C(=O)C 1-4 Heterocyclyl groups having 3 to 6 ring members substituted by alkyl, -C(=O)OC 1-4 Heterocyclyl groups having 3 to 6 ring members substituted with alkyl, -C(=O)N(H) e (C 1-4 alkyl) 2-e heterocyclyl having 3 to 6 ring members, a —C(═O)heterocyclyl group having 3 to 6 ring members, C 3-8 Cycloalkyl and C 3-8 cycloalkenyl, where R 7is pyridine, R z is other than -NH2; a, j, d, e, n, r and p are independently selected from 0, 1 and 2; k and m are independently selected from 1 and 2; u is selected from 0, 1, 2 and 3; and v is selected from 0 and 1.

[0217] Formula (I o ) compounds are referred to as * It has a chiral center marked with "." [ka]

[0218] Formula (I o The compound of formula (I) contains a stereocenter at the indicated position (referred to herein as (3)) and is chiral and non-racemic. o ) has the stereochemistry shown by the dashed bond and solid wedge, and this stereoisomer predominates.

[0219] Generally, the compound of formula (I o In one general embodiment, at least 55% (e.g., at least 60%, 65%, 70%, 75%, 80%, 85%, 90% or 95%) of the compounds of formula (I) are present as the depicted stereoisomer. o ) may be present as a single stereoisomer, with 97% (eg, 99%) or more (eg, substantially all) of the total amount of the compounds.

[0220] These compounds may also contain one or more additional chiral centers (e.g., -CR 6 R 7 OH groups and / or R 3 group and / or -CHR 2 Based on.

[0221] Generally, the compound of formula (I oIn one general embodiment, the enantiomeric excess of the compound of formula (I) is at least 10% (e.g., at least 20%, 40%, 60%, 80%, 85%, 90%, or 95%). o ) has an enantiomeric excess of 97% (e.g., 99%) or greater.

[0222] For the purposes of this section, the isoindolin-1-one ring is numbered as follows: [ka]

[0223] Compounds are named according to protocols utilized by chemical naming software packages.

[0224] Formula (I) wherein cyc is phenyl o ) compounds Formula (I) wherein cyc is phenyl o ) are disclosed in our earlier international patent application PCT / GB2016 / 053042, published as WO2017 / 055860 on April 6, 2017. The compounds, subformulas, and substituents disclosed in WO2017 / 055860 (e.g., Formulas (I), I(e), I(f), I(g), I(g'), I(h), I(i), I(j), I(k), I(L), I(m), I(m'), I(n), I(o), I(o'), I(o''), I(p), I(p'), I(q), I(q'), I(q''), I(q'''), I(q''''), I(r), I(s), I(t), I(t), I(t) A cross-reference is made to I(u), I(v), I(v'), I(w), I(x), I(x'), I(y), (II), (IIa), (IIb), (IIIa), (IIIb), (IVa), (IVb), (V), (VI), (Via), (VII), (VIIa), (VIIb), (VIIc), (VIId), (VIId'), (VIIe), (VIIe'), (a), (b), (ba), (bb), (bc) or (c)). By virtue of this cross-reference, the compounds, subformulas and substituents of WO2017 / 055860 are therefore directly and unambiguously disclosed in this application.

[0225] Formula (I) wherein cyc is phenyl o Specific subformulas, embodiments and compounds of include:

[0226] In one embodiment, R 1 is chloro or nitrile, especially chloro.

[0227] R 2 is other than hydrogen, the formula (I o ) can exist as at least two diastereoisomers. [ka]

[0228] For the avoidance of doubt, the general formula (I o ) and all subexpressions are -CHR 2 In one embodiment, the compounds of formula (I) include both individual diastereoisomers and mixtures of diastereoisomers related as epimers of the - group. o In one embodiment, the compound of formula (I) is diastereoisomer 1A or a tautomer or solvate or a pharmaceutically acceptable salt thereof. o ) is diastereoisomer 1B or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

[0229] In one embodiment, R 2 is hydrogen and -(CR x R y ) u -CO2H (e.g., selected from -COOH, -CH2COOH, -CH2CH2-CO2H, -(CH(CH3))-CO2H and -(C(CH3)2)-CO2H).

[0230] In one embodiment, a is 1 and the substituent R 4 is at the 4-position of isoindolin-1-one, and has the formula (I o) is a compound of formula (Ir) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0231] R 4 is halogen, nitrile, C 1-4 Alkyl, HaloC 1-4 Alkyl, C 1-4 Alkoxy and HaloC 1-4 alkoxy.

[0232] In one embodiment, R 4 is halogen. In one embodiment, R 4 is fluoro or chloro. In another embodiment, R 4 is fluoro.

[0233] In one embodiment, a is 1 and the substituent R 4 is at the 4-position of isoindolin-1-one, and R 4 is F, and the formula (I o ) is a compound of formula (Is) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0234] R 6 and R 7 is different, and the formula (I o ) can exist as at least two diastereoisomers. [ka]

[0235] For the avoidance of doubt, the general formula (I o ) and all subexpressions are -CR 6 R 7It includes both individual diastereoisomers and mixtures of diastereoisomers which are related as epimers at the OH group.

[0236] In one embodiment, R 6 is C 1-6 alkyl (e.g., methyl or ethyl, e.g., methyl), and R 7 is oxanyl, and o ) is a compound of formula (Iw). [ka]

[0237] In one embodiment of Formula (Iw), R z is hydrogen or fluorine.

[0238] subexpression In one embodiment, R 6 is methyl or ethyl, and o ) is a compound of formula (IIIb) or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] In the formula, R 1 , R 2 , R 3 , R 4 , R 5 , R 7 , a, m and s are as defined herein.

[0239] In one embodiment, s is 0 and the compound of formula (I o ) is a compound of formula (IVb) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka] In the formula, R 1 , R 2 , R 3 , R 4 , R5 , R 7 , a, m and s are as defined herein.

[0240] In one embodiment, m is 1 and the substituent R 4 is at the 4-position of the phenyl group a, and is represented by the formula (I o ) is a compound of formula (VI) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0241] In one embodiment, R 5 is chloro and the compound of formula (VI) is a compound of formula (VIa) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0242] In one embodiment, R 3 is methyl and the compound of formula (VI) is a compound of formula (VIIf) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0243] In one embodiment of formula (VIIf), R 6 is ethyl.

[0244] In one embodiment of the compound of Formula (VIIf), R 7 is selected from methyl, oxanyl, pyrazolyl, imidazolyl, piperidinyl, and cyclohexyl, and said cycloalkyl and heterocyclic groups are each selected from one or more R z It may be optionally substituted with groups such as methyl, fluorine, or hydroxy.

[0245] In one embodiment of the compound of Formula (VIIf), R 7 is selected from oxanyl and methyl.

[0246] In one embodiment of the compound of Formula (VIIf), R 7 is an R greater than or equal to 1. z piperidinyl optionally substituted with a group such as methyl, fluorine, or hydroxy.

[0247] In another embodiment of the subformula described above, R 2 is selected from —(CH(CH3))—CO2H and —(C(CH3)2—CO2H).

[0248] In one embodiment, the MDM2 antagonist has the formula (I o or a tautomer or solvate or a pharmaceutically acceptable salt thereof, wherein R 1 is a halogen (e.g., Cl), nitrile, O 0,1 (CR x R y ) v COOH (e.g., -COOH, -CHCOOH, -OCHCOOH, or -C(CH)COOH); n is 1 or 2; R 2 is hydrogen and -(CR x R y ) u -CO2H (e.g., selected from -COOH, -CH2COOH, -CH2CH2-CO2H, -(CH(CH3))-CO2H and -(C(CH3)2)-CO2H).

[0249] R 3 is hydrogen and s is 1; R 4 is a halogen (e.g., F); R 5 is a halogen (e.g., Cl); m is 1; R 6is hydrogen or C 1-6 alkyl (e.g., -CH3 or -CH2CH3); R 7 is C 1-4 Alkyl (e.g., methyl), hydroxyl C 1-4 Alkyl (e.g., hydroxymethyl), methoxy C 1-4 alkyl (e.g., methoxymethyl), heterocyclic groups having 5 or 6 ring members (e.g., piperidinyl, oxanyl, imidazolyl, or pyrazolyl); The heterocyclic group having 5 or 6 ring members is C 1-4 one or two R independently selected from alkyl (e.g., methyl) z The group may be optionally substituted with a group.

[0250] In one embodiment, the MDM2 antagonist is one of Examples 1-137, or a compound of formula (I) selected from Examples 1-137 described in the first set of examples defined herein or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, i.e., a compound wherein cyc is phenyl, as also described in WO2017 / 055860. o ) is a compound of

[0251] In one embodiment, the MDM2 antagonist is one of Examples 1-97 (examples where cyc is phenyl) or a compound of formula (I) selected from Examples 1-97 (examples where cyc is phenyl) set forth in the first set of examples defined herein or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, i.e., a compound where cyc is phenyl, as also described in WO2017 / 055860. o ) is a compound of

[0252] In one embodiment, the MDM2 antagonist is the following compound, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof: 4-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-1-{[1-(hydroxymethyl)cyclopropyl]methoxy}-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}benzonitrile, for example [ka] ; and (3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(oxan-4-yl)ethyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]propanoic acid for example, [ka] Formula (I) o ) is a compound of

[0253] In one embodiment, the MDM2 antagonist is the following compound, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof: 4-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-1-{[1-(hydroxymethyl)cyclopropyl]methoxy}-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}benzonitrile; and (3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(oxan-4-yl)ethyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]propanoic acid Formula (I) o ) is a compound of

[0254] In one embodiment, the MDM2 antagonist is diastereoisomer 2B of formula (Io ), which is the following compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof: 4-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-1-{[1-(hydroxymethyl)cyclopropyl]methoxy}-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}benzonitrile; and (3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(oxan-4-yl)ethyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]propanoic acid is selected from.

[0255] In one embodiment, the compound of formula (I o ) is 2-(5-chloro-2-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}phenyl)-2-methylpropanoic acid, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, such as [ka] is.

[0256] In one embodiment, the MDM2 antagonist is (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid (“Compound 1”) or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof, such as, for example, [ka] Formula (I o ) is a compound of

[0257] For the avoidance of doubt, it is to be understood that each general and specific embodiment and example of a substituent may be combined with one or more, in particular with all, other examples of substituents as defined herein, and all such embodiments are encompassed by this application.

[0258] Formula (I) wherein cyc is a heterocyclic group o ) compounds Formula (I) wherein cyc is a heterocyclic group o ) is disclosed in our earlier international patent application PCT / GB2016 / 053041, published as WO2017 / 055859 on April 6, 2017. The compounds, subformulas, and substituents disclosed in WO2017 / 055859 (e.g., formulae e(I), I(a), I(a'), I(b), I(c), I(d), I(e), I(f), I(g), I(g'), I(h), I(i), I(j), I(k), I(L), I(m), I(m'), I(n), I(o), I(o'), I(o''), I(p), I(p'), I(q), I(q'), I(q''), I(q'''), I(q''''), I(r), I(s), I(t), Cross-reference is made to I(u), I(v), I(v'), I(w), I(x), I(x'), I(y), (II), (IIa), (IIb), (IIIa), (IIIb), (IVa), (IVb), (V), (VI), (VIa), (VII), (VIIa), (VIIb), (VIIc), (VIId), (VIId'), (VIIe), (VIIe'), (a), (b), (ba), (bb), (bc), or (c)) and examples thereof as defined herein. By virtue of this cross-reference, the compounds, subformulas, and substituents of WO2017 / 055859 are thus directly and unambiguously disclosed in this application.

[0259] Formula (I) wherein cyc is a heterocyclic group o Specific subformulas, embodiments and compounds of include:

[0260] In another embodiment, R 2 is hydrogen, and o ) is a compound of formula (Ie) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0261] R 2 is other than hydrogen, the formula (I o ) can exist as at least two diastereoisomers. [ka]

[0262] For the avoidance of doubt, the general formula (I o ) and all subexpressions are -CHR 2 In one embodiment, the compounds of formula (I) include both individual diastereoisomers and mixtures of diastereoisomers related as epimers of the - group. o In one embodiment, the compound of formula (I) is diastereoisomer 1A or a tautomer or solvate or a pharmaceutically acceptable salt thereof. o ) is diastereoisomer 1B or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

[0263] In one embodiment, A is C 3-6 is a cycloalkyl group (i.e., g is 1, 2, or 3), and t is 1 and s is 0 or 1; o The compound of formula (If) is a compound of formula (If) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0264] In one embodiment, A is C 3-6is a cycloalkyl group (i.e., g is 1, 2, or 3), and t is 1, s is 1, and is a group represented by the formula (I o ) is a compound of formula (Ig) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0265] In one embodiment, A is C 3-6 is a cycloalkyl group (i.e., g is 1, 2, or 3), and t is 1 and s is 1, and the cycloalkyl group is geminally disubstituted (i.e., the group -(CR x R y ) q -X and -CH2-O-isoindolinone groups are both attached to the same atom of the cycloalkyl group), o ) is a compound of formula (Ih) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0266] In one embodiment, A is a cyclopropyl group (i.e., g is 1), t is 1, and s is 1. Thus, the cycloalkyl group is a cyclopropyl group and is represented by the formula (I o ) is a compound of formula (Ii) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0267] In one embodiment, A is C 3-6 is a cycloalkyl group (i.e., g is 1, 2, or 3), t is 1, s is 1, and X is —CN; o) is a compound of formula (Ik') or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0268] In another embodiment, A is C 3-6 is a cycloalkyl group (i.e., g is 1, 2, or 3), t is 1, s is 1, and R x and R y is hydrogen ( 1 H and 2 H), and o ) is a compound of formula (IL) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0269] In one embodiment, A is a C3-cycloalkyl group (i.e., g is 1), t is 1, s is 1, and X is -CN, and the compound of formula (I o ) is a compound of formula (In') or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] wherein q is 0 or 1. In one embodiment of compound (In), q is 0.

[0270] In one embodiment, R 3 Ha-(CR x R y ) q -X, and s is 1, t is 0, and q is 1 or 2, o ) is a compound of formula (Ip). [ka]

[0271] In one embodiment, A is C 3-6 a cycloalkyl group or a saturated heterocyclic group having 3 to 6 ring members, wherein t is 1, s is 1, Y is independently selected from —CH—, O, or SO, i is 0 or 1, g is 1, 2, 3, or 4, and i+g is 1, 2, 3, or 4, and is represented by the formula (I o ) is a compound of formula (Iq) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0272] In one embodiment, i is 1 and Y is O or SO, particularly O. In one embodiment, the compound of formula (Iq) is a compound of formula (Iq''") or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0273] In one embodiment, s is 0, t is 1, A is tetrahydrofuranyl, q is 0, and X is hydrogen. 3 is tetrahydrofuranyl and s is 0.

[0274] In one embodiment, a is 1 and the substituent R 4 is at the 4-position of isoindolin-1-one, and has the formula (I o ) is a compound of formula (Ir) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka] R 4 is halogen, nitrile, C 1-4 Alkyl, HaloC 1-4 Alkyl, C 1-4 Alkoxy and HaloC 1-4alkoxy.

[0275] In one embodiment, R 4 is halogen. In one embodiment, R 4 is fluoro or chloro. In another embodiment, R 4 is fluoro.

[0276] In one embodiment, a is 1 and the substituent R 4 is at the 4-position of isoindolin-1-one, and R 4 is F, and the formula (I o ) is a compound of formula (Is) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0277] R 6 and R 7 are different, the formula (I o ) can exist as at least two diastereoisomers. [ka]

[0278] For the avoidance of doubt, the general formula (I o ) and all subexpressions are -CR 6 R 7 It includes both individual diastereoisomers and mixtures of diastereoisomers which are related as epimers at the OH group.

[0279] In one embodiment, R 7 is 4-fluoro-1-methylpiperidin-4-yl, and is represented by the formula (I o ) is a compound of formula (Ix″) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka]

[0280] subexpression In one embodiment, the compound of formula (I o ) is a compound of formula (II) or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] In the formula, L is CR 1 , CH or N, and R 1 , R 2 , R 3 , R 4 , R 5 , R 6 , R 7 , a, m, and s are as defined herein. In one embodiment, L is CH. In one embodiment, L is N. In one embodiment, L is CR 1 , e.g., C-OH or C-hydroxyC 1-4 It is alkyl (e.g., C-OH or C-CH2OH).

[0281] In another embodiment, R 1 is chloro or nitrile, and the compound of formula (II) is a compound of formula (IIa) or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] In the formula, R 1 , R 2 , R 3 , R 4 , R 5 , R 7 , m and s are as defined herein.

[0282] In one embodiment, R 6 is ethyl, and the compound of formula (II) is a compound of formula (IIIb) or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] In the formula, R 1 , R 2 , R 3 , R 4 , R 5 , R 7 , a, m and s are as defined herein.

[0283] In one embodiment, s is 0 and the compound of Formula (II) is a compound of Formula (IVb) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka] In the formula, R 1 , R 2 , R 3 , R 4 , R 5 , R 7 , m and s are as defined herein.

[0284] In one embodiment, R 4 is F, and the formula (I o ) is a compound of formula (V) or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] In the formula, R 1 , R 2 , R 3 , R 5 , R 7 , m and s are as defined herein.

[0285] In one embodiment, m is 1 and the substituent R 4 is at the 4-position of the phenyl group, and the compound of formula (II) is a compound of formula (VI) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0286] In one embodiment, R 5 is chloro and the compound of formula (VI) is a compound of formula (VIa) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0287] In one embodiment, A is C 3-6 is a cycloalkyl group (g is 1, 2 or 3) and t is 1, and the compound of formula (VI) is a compound of formula (VII) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0288] In one embodiment, A is C 3-6 cycloalkyl groups (g is 1, 2, or 3), t is 1, and the cycloalkyl groups are geminally disubstituted (i.e., the group -(CR x R y )—X and the CH group (when s is 1) or the oxygen atom (when s is 0) are both attached to the same atom of the cycloalkyl group, and the compound of formula (VII) is a compound of formula (VIIa) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0289] In one embodiment, g is 1, and therefore the cycloalkyl group is a cyclopropyl group, and the compound of formula (VIIa) is a compound of formula (VIIb) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0290] In one embodiment, s is 1 and the compound of formula (VIIb) is a compound of formula (VIIc) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0291] In one embodiment, X is —CN and the compound of formula (VlId) is a compound of formula (VIle″) or a tautomer or solvate or a pharmaceutically acceptable salt thereof: [ka] wherein q is 0 or 1, and in particular q is 0.

[0292] In one embodiment, R 3 is methyl and the compound of formula (VI) is a compound of formula (VIIf) or a tautomer or solvate or a pharmaceutically acceptable salt thereof. [ka]

[0293] In one embodiment of the compound of formula (a), R 7 is C 1-6 Piperidinyl or piperazinyl optionally substituted with alkyl (eg methyl) and / or halo (eg fluoro).

[0294] In one embodiment of the compound of formula (a'), R 7 is C 1-6 and piperidinyl optionally substituted with alkyl (eg, methyl) and / or halo (eg, fluoro).

[0295] In one embodiment, A is a heterocyclyl group having 3 to 6 ring members, wherein the heterocyclic group comprises one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and their oxidized forms (t is 1; g is 1, 2, 3, or 4; Z represents N, O, S, and their oxidized forms; i is 1, 2, or 3; and i+g=2, 3, 4, or 5), and the compound of Formula (VI) is a compound of Formula (b) or a tautomer, solvate, or pharmaceutically acceptable salt thereof. [ka]

[0296] In one embodiment, s is 0, g is 2, q is 0, and X is hydrogen, and the compound of formula (b) is a compound of formula (bb) or a tautomer or solvate or pharmaceutically acceptable salt thereof. [ka]

[0297] In another embodiment, a compound of formula (I o ) is a compound of formula (c) or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] In the formula, R 1 is chloro or nitrile, s is 1 and X is hydroxyl, or s is 0 and X is -C(=O)NH2.

[0298] In another embodiment, a compound of formula (I o ) is a compound of formula (c') or a tautomer or solvate or a pharmaceutically acceptable salt thereof, [ka] In the formula, R 1is chloro or nitrile, s is 1 and X is hydroxyl, or s is 0 and X is —CN.

[0299] In one embodiment, the MDM2 antagonist has the formula (I o or a tautomer or solvate or a pharmaceutically acceptable salt thereof, wherein Het is pyridinyl or pyrimidinyl, R 1 is bonded to a carbon atom and is hydroxy, halogen, nitro, nitrile and C 1-4 independently selected from alkyl; R 2 is hydrogen, C 1-4 Alkyl, C 2-6 Alkenyl, Hydroxy C 1-4 selected from alkyl and -CH2CO2H; R 3 is hydrogen or -(A) t -(CR x R y ) q -X; s and t are independently selected from 0 and 1; q is selected from 0, 1 and 2; where R 3 Ga-(A) t -(CR x R y ) q -X, then (i) at least one of s, t, and q is non-zero, and (ii) when t is 0, then s is 1 and q is non-zero; A is a heterocyclic group having 3 to 6 ring members, said heterocyclic group comprising one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof; X is hydrogen, halogen, —CN, and —OR. 9 Selected from; R 4 and R 5 is halogen, nitrile and C 1-4 alkyl; R 6 is hydrogen and C1-6 alkyl; R 7 represents a heterocyclic group having 3 to 7 ring members, a —CH2-heterocyclic group having 3 to 7 ring members, C 3-8 Cycloalkyl, and -CH2-C 3-8 cycloalkyl, wherein said cycloalkyl or heterocyclic group is selected from one or more R z groups, in each instance said heterocyclic group comprising one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof; R 9 is hydrogen and C 1-6 alkyl; R x and R y is hydrogen and C 1-6 independently selected from alkyl; R z is halogen, nitro, nitrile, C 1-6 Alkyl, HaloC 1-6 Alkyl, C 2-6 Alkenyl, Hydroxy, HydroxyC 1-6 Alkyl, C 1-6 Alkoxy, -C(=O)C 1-6 Alkyl, and -N(H) e (C 1-4 alkyl) 2-e are independently selected from; n and e are independently selected from 0, 1 and 2; m is selected from 1 and 2; and a is selected from 0 and 1.

[0300] In one embodiment, the MDM2 antagonist has the formula (I o or a tautomer or solvate or a pharmaceutically acceptable salt thereof, wherein Het is pyridinyl or pyrimidinyl, R 1 is attached to a carbon atom and is independently selected from halogen, hydroxy, and nitrile; R 2 is hydrogen, C1-4 selected from alkyl and -CH2CO2H; R 3 is hydrogen or -(A) t -(CR x R y ) q -X; A is a heterocyclic group having 3 to 6 ring members, said heterocyclic group comprising one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof; and t is independently selected from 0 and 1; q is selected from 0, 1 and 2; where R 3 Ga-(A) t -(CR x R y ) q -X, then (i) at least one of s, t, and q is non-zero, and (ii) when t is 0, then s is 1 and q is non-zero; X is hydrogen, halogen or -OR 9 Selected from; R 4 and R 5 are independently selected from halogens; R 6 is hydrogen and C 1-6 alkyl; R 7 represents a heterocyclic group having 3 to 7 ring members, a —CH2-heterocyclic group having 3 to 7 ring members, C 3-8 Cycloalkyl, and -CH2-C 3-8 cycloalkyl, wherein said cycloalkyl, cycloalkenyl or heterocyclic group is selected from one or more R z groups, in each case said heterocyclic group comprising one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof; R 9 is hydrogen and C 1-6 alkyl; R x and R y is hydrogen and C 1-6 independently selected from alkyl; R z is halogen, nitro, nitrile, and C 1-6 alkyl; n is 1 and m is 1; and a is selected from 0 and 1.

[0301] In one embodiment, the MDM2 antagonist has the formula (I o or a tautomer or solvate or a pharmaceutically acceptable salt thereof, wherein Het is pyridinyl or pyrimidinyl, R 1 is attached to the carbon atom and is independently selected from halogen, hydroxy, and nitrile; R 2 is hydrogen, C 1-4 selected from alkyl and -CH2CO2H; R 3 is -(A) t -(CR x R y ) q -X; A is a heterocyclic group having 3 to 6 ring members, said heterocyclic group comprising one or more (e.g., 1, 2, or 3) heteroatoms selected from N, O, S, and oxidized forms thereof; s and t are independently selected from 0 and 1; q is selected from 0, 1 and 2; where (i) at least one of s, t, and q is non-zero, and (ii) if t is 0, then s is 1 and q is non-zero; X is hydrogen, halogen and -OR 9 Selected from; R 4 and R 5 are independently selected from halogens; R 6 is hydrogen and C 1-6 alkyl; R 7 is an R greater than or equal to 1. z a heterocyclic group having 3 to 7 ring members, optionally substituted with a group; R9 is hydrogen and C 1-6 alkyl; R x and R y is hydrogen and C 1-6 independently selected from alkyl; R z is halogen and C 1-6 independently selected from alkyl; n is 1 and m is 1 and a is 1.

[0302] In one embodiment, the MDM2 antagonist is one of Examples 1-580 (examples where cyc is a heterocyclic group), or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof (as defined in Formula I, as set forth in the second set of examples defined herein). o compounds of formula (I) selected from the group consisting of cyc and Het, as also described in WO2017 / 055859; o ) is a compound of

[0303] In one embodiment, the MDM2 antagonist is one of Examples 1-460, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof (as defined in Formula I as set forth in the second set herein). o compounds of formula (I) selected from the group consisting of compounds of formula (I) o ) is a compound of

[0304] In one embodiment, the MDM2 antagonist is one of Examples 1-459, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof (as defined in Formula I as set forth in the second set herein). o compounds of formula (I) selected from the group consisting of compounds of formula (I) o ) is a compound of

[0305] In one embodiment, the MDM2 antagonist is the following compound, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof: (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-{1-hydroxy-1-[trans-4-hydroxycyclohexyl]ethyl}-3-{[1-(hydroxymethyl)cyclopropyl]methoxy}-2,3-dihydro-1H-isoindol-1-one; for example, [ka] 2-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-1-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-2-yl]methyl}pyrimidine-5-carbonitrile; for example, [ka] (3R)-2-[(5-chloro-3-hydroxypyridin-2-yl)methyl]-3-(4-chlorophenyl)-4-fluoro-6-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-(2-hydroxyethoxy)-2,3-dihydro-1H-isoindol-1-one; for example, [ka] 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-(4-fluorooxan-4-yl)-1-hydroxypropyl]-3-oxo-1-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; for example, [ka] 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-1-[(3-fluorooxetan-3-yl)methoxy]-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; for example, [ka] 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-1-({1-[hydroxy( 2 H2) methyl]cyclopropyl}( 2 H2) methoxy)-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; for example, [ka] and (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-hydroxy-1-(1-methylpiperidin-4-yl)propyl]-3-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-1-one for example, [ka] Formula (I) o ) is a compound of

[0306] In one embodiment, the MDM2 antagonist is diastereoisomer 2A of formula (I o ), which is the following compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof: (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-{1-hydroxy-1-[trans-4-hydroxycyclohexyl]ethyl}-3-{[1-(hydroxymethyl)cyclopropyl]methoxy}-2,3-dihydro-1H-isoindol-1-one; 2-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-1-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-2-yl]methyl}pyrimidine-5-carbonitrile; (3R)-2-[(5-chloro-3-hydroxypyridin-2-yl)methyl]-3-(4-chlorophenyl)-4-fluoro-6-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-(2-hydroxyethoxy)-2,3-dihydro-1H-isoindol-1-one; 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-(4-fluorooxan-4-yl)-1-hydroxypropyl]-3-oxo-1-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-1-[(3-fluorooxetan-3-yl)methoxy]-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-1-({1-[hydroxy( 2 H2) methyl]cyclopropyl}( 2 H2) methoxy)-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; and (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-hydroxy-1-(1-methylpiperidin-4-yl)propyl]-3-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-1-one is selected from.

[0307] In one embodiment, the MDM2 antagonist is diastereoisomer 2B of formula (I o ), which is the following compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof: (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-{1-hydroxy-1-[trans-4-hydroxycyclohexyl]ethyl}-3-{[1-(hydroxymethyl)cyclopropyl]methoxy}-2,3-dihydro-1H-isoindol-1-one; 2-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-1-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-2-yl]methyl}pyrimidine-5-carbonitrile; (3R)-2-[(5-chloro-3-hydroxypyridin-2-yl)methyl]-3-(4-chlorophenyl)-4-fluoro-6-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-(2-hydroxyethoxy)-2,3-dihydro-1H-isoindol-1-one; 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[1-(4-fluorooxan-4-yl)-1-hydroxypropyl]-3-oxo-1-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-1-[(3-fluorooxetan-3-yl)methoxy]-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; 6-{[(1R)-1-(4-chlorophenyl)-7-fluoro-1-({1-[hydroxy( 2 H2) methyl]cyclopropyl}( 2 H2) methoxy)-5-[1-hydroxy-1-(1-methyl-1H-imidazol-4-yl)propyl]-3-oxo-2,3-dihydro-1H-isoindol-2-yl]methyl}pyridine-3-carbonitrile; and (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-hydroxy-1-(1-methylpiperidin-4-yl)propyl]-3-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-1-one is selected from.

[0308] In one embodiment, the MDM2 antagonist is the following compound, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof: (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[2-hydroxy-1-(4-methylpiperazin-1-yl)butan-2-yl]-3-[(3S)-oxolan-3-yloxy]-2,3-dihydro-1H-isoindol-1-one; for example, [ka] (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-methoxy-2,3-dihydro-1H-isoindol-1-one; for example, [ka] 1-({[(1R)-1-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-7-fluoro-5-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-oxo-2,3-dihydro-1H-isoindol-1-yl]oxy}methyl)cyclopropane-1-carbonitrile; for example, [ka] (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-[cis-3-hydroxycyclobutoxy]-2,3-dihydro-1H-isoindol-1-one; for example, [ka] and (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-[(2R)-2-hydroxypropoxy]-2,3-dihydro-1H-isoindol-1-one for example, [ka] Formula (I) o ) is a compound of

[0309] In one embodiment, the MDM2 antagonist is a compound of formula (I), which is 1-({[(1R)-1-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-7-fluoro-5-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-oxo-2,3-dihydro-1H-isoindol-1-yl]oxy}methyl)cyclopropane-1-carbonitrile. o ) or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

[0310] In one embodiment, the MDM2 antagonist is a compound of formula (I), which is (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-methoxy-2,3-dihydro-1H-isoindol-1-one. o ) or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

[0311] In one embodiment, the MDM2 antagonist is diastereoisomer 2A of formula (I o ), which is 1-({[(1R)-1-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-7-fluoro-5-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-oxo-2,3-dihydro-1H-isoindol-1-yl]oxy}methyl)cyclopropane-1-carbonitrile, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0312] In one embodiment, the MDM2 antagonist is diastereoisomer 2A of formula (I o), which is (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-methoxy-2,3-dihydro-1H-isoindol-1-one, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0313] In one embodiment, the MDM2 antagonist is diastereoisomer 2B of formula (I o ), which is 1-({[(1R)-1-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-7-fluoro-5-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-oxo-2,3-dihydro-1H-isoindol-1-yl]oxy}methyl)cyclopropane-1-carbonitrile, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0314] In one embodiment, the MDM2 antagonist is diastereoisomer 2B of formula (I o ), which is (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-methoxy-2,3-dihydro-1H-isoindol-1-one, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0315] In one embodiment, the MDM2 antagonist is (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[(1S)-1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-methoxy-2,3-dihydro-1H-isoindol-1-one, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0316] In one embodiment, the MDM2 antagonist is (3R)-3-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-4-fluoro-6-[(1R)-1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-methoxy-2,3-dihydro-1H-isoindol-1-one, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0317] In one embodiment, the MDM2 antagonist is 1-({[(1R)-1-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-7-fluoro-5-[(1S)-1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-oxo-2,3-dihydro-1H-isoindol-1-yl]oxy}methyl)cyclopropane-1-carbonitrile, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0318] In one embodiment, the MDM2 antagonist is 1-({[(1R)-1-(4-chlorophenyl)-2-[(5-chloropyrimidin-2-yl)methyl]-7-fluoro-5-[(1R)-1-(4-fluoro-1-methylpiperidin-4-yl)-1-hydroxypropyl]-3-oxo-2,3-dihydro-1H-isoindol-1-yl]oxy}methyl)cyclopropane-1-carbonitrile, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

[0319] For the avoidance of doubt, it is to be understood that each general and specific embodiment and example of a substituent may be combined with one or more, in particular with all, other examples of substituents as defined herein, and all such embodiments are encompassed by this application.

[0320] Specific compounds The uses and methods of the present invention comprise a compound of formula I as described herein. oi.e., MDM2 antagonists are compounds of formula I o or any specific compound described herein, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

[0321] In one embodiment, the MDM2 antagonist is a compound of Formula I selected from Examples 1-134 as set forth in the first set of examples defined herein. o (i.e., a compound in which cyc is phenyl, as also described in WO2017 / 055860).

[0322] In one embodiment, the MDM2 antagonist is a compound of Formula I selected from Examples 1-580 as set forth in the second set of examples defined herein. o (i.e., compounds in which cyc is Het, as also described in WO2017 / 055859).

[0323] In certain embodiments of the present invention, the MDM2 antagonist is a compound of formula (I) as defined herein. o ) or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof, i.e., (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid.

[0324] (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid is referred to herein as "Compound 1." For example, [ka]

[0325] (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid is disclosed as Example 124 in International Patent Application No. PCT / GB2016 / 053042, published as WO2017 / 055860 on April 6, 2017.

[0326] Methods for the preparation of Compound 1 can be found in International Patent Application No. PCT / GB2018 / 050845, published as WO2018 / 178691 on October 4, 2018.

[0327] In one embodiment, the MDM2 antagonist is the free acid form of Compound 1. In another embodiment, the MDM2 antagonist is a pharmaceutically acceptable salt of Compound 1.

[0328] overview Other MDM2 antagonists can be prepared in a conventional manner, for example, by procedures similar to those described.

[0329] The pharmacokinetics of MDM2 antagonist is known to those skilled in the art.It will be recognized that the preferred administration method and dosage and administration regimen of each MDM2 antagonist will vary according to the specific tumor that is treated and the specific host that is treated.The optimal method, administration schedule, dosage and administration regimen can be easily determined by those skilled in the art by using conventional methods and considering the information provided herein.

[0330] Salts, solvates, tautomers, isomers, N-oxides, esters, prodrugs and isotopes Reference herein to any compound includes its ionic forms, salts, solvates, isomers (including geometric and stereochemical isomers unless specified), tautomers, N-oxides, esters, prodrugs, isotopes, and protected forms, for example as described below, particularly salts or tautomers or isomers or N-oxides or solvates thereof; more particularly salts or tautomers or N-oxides or solvates thereof. In one embodiment, a reference to a compound also includes its salts or tautomers or solvates.

[0331] salt The compounds may exist in the form of salts, for example, acid addition salts or, in certain cases, salts of organic and inorganic bases such as carboxylates, sulfonates and phosphates. All such salts are within the scope of the present invention and are not intended to be limiting unless otherwise specified. o ) includes salt forms of the compound.

[0332] N-oxide Compounds containing an amine function may also form N-oxides, and references herein to compounds containing an amine function also include N-oxides.

[0333] Geometric Isomers and Tautomers These compounds may exist in several different geometric isomeric and tautomeric forms and are represented by the formula (I o ) includes all such forms. For the avoidance of doubt, it is possible that a compound may exist in one of several geometric isomeric or tautomeric forms, and where only one is specifically described or shown, all others are also included in the invention.

[0334] For example, certain heteroaryl rings can exist in two tautomeric forms, such as A and B shown below: For simplicity, the formula may show one form, but the formula should be understood to cover both tautomeric forms.

[0335] stereoisomer Unless otherwise stated or indicated, the chemical designation of a compound represents a mixture of all possible stereochemically isomeric forms.

[0336] Formula (I o ) compounds Stereocenters are indicated in the usual manner using "dashed" or "solid" wedges, for example: [ka]

[0337] When a compound is described as a mixture of two diastereoisomers / epimers, the configuration of stereocenters is not explicitly stated but is shown as a straight line.

[0338] Where a compound contains one or more chiral centers and can exist in two or more optically isomeric forms, a reference to the compound, unless the context requires otherwise, includes all optically isomeric forms thereof (e.g., enantiomers, epimers and diastereoisomers), either as individual optical isomers or mixtures (e.g., racemic or scalemic mixtures) or two or more optical isomers.

[0339] Of particular interest are stereochemically pure compounds. For example, if a compound is designated as R, this means that the compound is substantially free of the S isomer. For example, if a compound is designated as E, this means that the compound is substantially free of the Z isomer. The terms cis, trans, R, S, E, and Z are well known to those skilled in the art.

[0340] Isotope variants The present invention includes all pharmaceutically acceptable isotopically labeled compounds, i.e., compounds in which one or more atoms are replaced by an atom having the same atomic number but an atomic mass or mass number different from the atomic mass or mass number usually found in nature.

[0341] Solvates and Crystal Forms Also included in the compounds are any polymorphs and solvates, such as hydrates, alcoholates, and the like, of the compounds.

[0342] In one embodiment, the MDM2 antagonist is a crystalline form of the free acid of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid.

[0343] In one embodiment, the MDM2 antagonist is (a) an X-ray powder diffraction pattern characterized by peaks at diffraction angles 15.1, 15.5, 15.8, and 22.3° 2θ (±0.2° 2θ); or (b) Planar spacings 3.99, 5.62, 5.71, and 5.87 Å The crystalline form of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid has the formula:

[0344] In particular, the crystalline form of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid is (a) an X-ray powder diffraction pattern characterized by peaks at diffraction angles 11.3, 15.1, 15.5, 15.8, 17.2, 20.8, 22.3, and 28.6° 2θ (±0.2° 2θ); or (b) Planar spacings 3.12, 3.99, 4.27, 5.17, 5.62, 5.71, 5.87, and 7.85 Å It has.

[0345] In particular, the crystalline form of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid has an X-ray powder diffraction pattern characterized by the presence, interplanar spacings (d) and intensities of major peaks at diffraction angles (2θ) set forth in Table 6 herein.

[0346] In particular, the crystalline form of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid has an X-ray powder diffraction pattern that exhibits peaks at the same diffraction angles as the X-ray powder diffraction pattern shown in Figure 12, preferably in which the peaks have the same relative intensities as the peaks in Figure 12.

[0347] In particular, the crystalline form of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid has an X-ray powder diffraction pattern substantially as shown in FIG. 12.

[0348] In one embodiment, the crystalline form of (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid exhibits an exothermic peak at 266 to 267°C (e.g., 266.61°C) when subjected to DSC.

[0349] The crystalline form may be substantially crystalline, meaning that one single crystalline form may predominate and other crystalline forms may be present in minor, preferably negligible, amounts.

[0350] For example, a crystalline form may contain up to 5% by weight of any other crystalline form.

[0351] Complex These compounds also include within their scope complexes of the compounds (e.g., inclusion complexes or clathrates with compounds such as cyclodextrins, or complexes with metals). Inclusion complexes, clathrates, and metal complexes can be formed by methods well known to those skilled in the art.

[0352] Prodrug Any prodrug of a compound is also included within the scope of the compound. "Prodrug" means, for example, any compound that is converted in vivo into a biologically active compound.

[0353] Processes for the preparation of compounds used in the present invention Formula (I o ) compounds In this section, as in all other sections of this application, unless the context indicates otherwise, the term "compounds" refers to compounds of formula I. o When "a" is used, it also includes all other sub-formulas and examples thereof as defined herein.

[0354] Formula (I o Compounds of formula (I) can be prepared according to synthetic methods well known to those skilled in the art.

[0355] The requisite intermediates are commercially available, known in the literature, prepared by methods analogous to those in the literature, or prepared by methods analogous to those described in the exemplary experimental procedures below. Other compounds can be prepared by functional interconversion of groups using methods well known in the art.

[0356] General procedures for making, isolating, and purifying compounds where cyc is phenyl can be found in International Patent Application No. PCT / GB2016 / 053042, published as WO2017 / 055860 on April 6, 2017.

[0357] General procedures for making, isolating, and purifying compounds where cyc is Het can be found in International Patent Application No. PCT / GB2016 / 053041, published as WO2017 / 055859 on April 6, 2017.

[0358] Biomarker detection In some embodiments, a sample of patient tissue is tested. The tissue may comprise one or more cancer cells, or may comprise nucleic acid, generally DNA, from cancer cells, such as circulating tumor DNA (ctDNA), which can be obtained from blood.

[0359] In some embodiments, the sample is loaded into an in vitro diagnostic device that measures the relative expression of one or more biomarkers of interest.

[0360] The patient generally may be known to have or suspected of having cancer when the present invention is practiced to determine whether treatment may be effective. Thus, in certain embodiments, the method is for assessing whether a human patient known to have or suspected of having cancer is treatable with an MDM2 antagonist.

[0361] The methods of the present invention generally comprise detecting one or more of the identified biomarkers, and optionally additional biomarkers, by using one or more detection reagents and / or detection techniques. Detection is generally performed ex vivo, e.g., in vitro, on a sample from a patient. In one embodiment, the biomarker is measured directly. In another embodiment, a biomarker substrate may be measured to indirectly measure biomarker levels.

[0362] "Detecting" means measuring, quantifying, scoring, or assaying the expression level of a biomarker. Methods for evaluating biological compounds, including biomarker proteins, genes, or mRNA transcripts, are known in the art. It is recognized that methods for detecting a biomarker include direct and indirect measurement. One skilled in the art can select an appropriate method for assaying a particular biomarker.

[0363] A "detection reagent" is an agent or compound that binds to, specifically (or selectively) interacts with, or detects a biomarker of interest. Such detection reagents may include, but are not limited to, antibodies, polyclonal antibodies, or monoclonal antibodies that preferentially bind to protein biomarkers, or oligonucleotides that are complementary to mRNA or DNA biomarkers and generally selectively bind under stringent hybridization conditions.

[0364] The phrases "specifically (or selectively) bind" or "specifically (or selectively) immunoreact" when used in reference to a detection reagent refer to a binding reaction that indicates the presence of a biomarker in a heterogeneous population of biomolecules. For example, under specified immunoassay conditions, a designated detection reagent (e.g., an antibody) binds to a specific protein at least twice the background level and does not bind in substantially significant amounts to other proteins present in the sample. Specific binding under such conditions may require an antibody selected for its specificity for a particular protein. Various immunoassay formats can be used to select antibodies specifically immunoreactive with a particular protein. For example, solid-phase ELISA immunoassays (enzyme-linked immunosorbent assays) are commonly used to select antibodies specifically immunoreactive with a protein (see, e.g., Harlow & Lane, Antibodies, A Laboratory Manual (1988) for a description of immunoassay formats and conditions that can be used to determine specific immunoreactivity). Generally, a specific or selective reaction will be at least twice the background signal or noise, more commonly greater than 10-100 times the background signal or noise.

[0365] Techniques such as in situ hybridization (ISH), quantitative real-time polymerase chain reaction (qRT-PCR), and immunohistochemistry (IHC) have traditionally been used to diagnose or detect disease biomarkers. However, the emergence of high-throughput, highly sensitive approaches such as next-generation sequencing, single-molecule real-time sequencing, digital pathology, and quantitative histopathology has led to a shift in the technology platforms enabling companion diagnostics or CDx. Both quantitative histopathology and digital pathology are medical image-based diagnostic approaches that provide localization and measurement of protein biomarkers in tissue samples. Tissue markers are identified and quantified using automated, fluorescence-based imaging platforms.

[0366] When the biomarker to be detected is a protein, the detection method includes antibody-based assay, protein array assay, mass spectrometry (MS)-based assay, and (near) infrared spectroscopy-based assay. For example, immunoassays include, but are not limited to, competitive and non-competitive assay systems using techniques such as Western blot, radioimmunoassay, ELISA, "sandwich" immunoassay, immunoprecipitation assay, precipitin reaction, gel diffusion precipitin reaction, immunodiffusion assay, and fluorescent immunoassay. Such assays are conventional and well known in the art.

[0367] "Analyzing" includes determining a set of values ​​associated with a sample by measuring a marker in the sample (e.g., the presence or absence of a marker or component expression level, etc.) and comparing the measurements to a sample or set of samples from the same subject or other control subjects. The markers of the present teachings can be analyzed by any of a variety of conventional methods known in the art. "Analyzing" can include, for example, performing a statistical analysis to determine whether a subject is a responder or non-responder to a therapy (e.g., an MDM2 antagonist treatment as described herein).

[0368] In the context of the present teachings, a "sample" refers to any biological sample isolated from a subject, such as a blood sample or biopsy. A sample may include, but is not limited to, a single cell or multiple cells, cell fragments, an aliquot of bodily fluid, whole blood, platelets, serum, plasma, red blood cells, white blood cells, endothelial cells, tissue biopsies, synovial fluid, lymphatic fluid, ascites, and interstitial or extracellular fluid. The term "sample" also encompasses intercellular fluids, including gingival crevicular fluid, bone marrow, cerebrospinal fluid (CSF), saliva, mucous membranes, sputum, semen, sweat, urine, or other bodily fluids. A "blood sample" may refer to whole blood or any fraction thereof, including blood cells, red blood cells, white blood cells, platelets, serum, and plasma. A sample may be obtained from a subject by means including, but not limited to, venipuncture, voiding, ejaculation, massage, biopsy, needle aspiration, lavage, scraping, surgical incision, or other interventional or other means known in the art.

[0369] analysis technology Prior to administration of the MDM2 antagonist, the patient may be screened to determine whether the disease or condition the patient is suffering from or may be suffering from is susceptible to treatment with a compound that inhibits MDM22 / p53. The term "patient" includes human and veterinary subjects, such as primates, particularly human patients.

[0370] For example, a biological sample taken from a patient can be analyzed to determine whether a condition or disease, such as cancer, that the patient may be suffering from or may be experiencing is characterized by a genetic abnormality or aberrant protein expression that results in upregulation of MDM2 levels or upregulation of biochemical pathways downstream of MDM2 / p53. Additionally, a biological sample taken from a patient can be analyzed to determine whether a condition or disease, such as cancer, that the patient may be suffering from or may be experiencing is characterized by a biomarker of the present invention.

[0371] Examples of such abnormalities include activation or sensitization of MDM2, defects or inhibition of regulatory pathways affecting MDM2 expression, upregulation of receptors or their ligands, cytogenetic abnormalities, or the presence of mutant receptors or ligands. Tumors that exhibit upregulation of MDM2 / p53, particularly overexpression of MDM2, or wild-type p53, may be particularly sensitive to MDM2 / p53 inhibitors. For example, amplification of MDM2 and / or deletion of its negative regulators, such as p14ARF, have been identified in a range of cancers, as discussed herein. Additionally, defects in BAP1 and / or CDKN2A and / or increased expression of the genes outlined herein may be observed.

[0372] The terms "elevated" and "amplified" include upregulated expression or overexpression, including gene amplification (i.e., multiple gene copies), cytogenetic abnormalities, and increased expression due to transcriptional or post-translational effects. Thus, patients can be subjected to diagnostic tests to detect appropriate proteins or markers characteristic of upregulation of the biomarkers of the invention. The term diagnostic includes screening.

[0373] The term "marker" or "biomarker" includes genetic markers, including, for example, measurement of DNA composition to identify the presence of mutations in p53 or amplified MDM2 or deletions (deletions) of p14ARF, or generally the biomarkers of the present invention as broadly discussed herein. The term marker also includes markers characteristic of upregulation of MDM2 / p53 or upregulation or downregulation of the biomarkers outlined herein, including protein levels, protein status, and mRNA levels of the aforementioned proteins. Gene amplification includes gains of more than seven copies, as well as gains of two to seven copies.

[0374] The terms "reduced," "depleted," or "reduced" include decreased expression or decreased expression, including decreased expression due to downregulation (i.e., fewer gene copies), cytogenetic abnormalities, and transcriptional effects. Thus, patients can be subjected to diagnostic tests to detect lower levels of the biomarkers of the invention.

[0375] Diagnostic testing and screening is generally performed on a biological sample (i.e., body tissue or fluid) selected from a tumor biopsy sample, a blood sample (isolation and enrichment of sloughed tumor cells, or isolation of circulating tumor DNA), cerebrospinal fluid, plasma, serum, saliva, stool biopsy, saliva, chromosomal analysis, pleural fluid, ascites, buccal spears, skin biopsy, or urine.

[0376] Additionally, liquid biopsies, such as blood-based (systematic) circulating tumor DNA (ctDNA) tests or NGS-based liquid biopsy tests, can also be used, particularly for cancer detection or mutation identification. Liquid-based biopsies, including next-generation sequencing (NGS), complement traditional detection methods of PCR and tumor biopsy, for example, with whole-genome sequencing of circulating tumor cells (CTCs) or massively parallel sequencing of circulating tumor DNA (ctDNA).

[0377] In one embodiment, the sample obtained is a blood sample, such as a plasma or serum sample, particularly a serum sample. In one embodiment, the sample obtained is a tumor biopsy sample.

[0378] In one embodiment, blood, typically collected in serum separator tubes, is analyzed in a medical laboratory or clinical setting. In a second embodiment, tumors are analyzed by biopsy and analyzed in a medical laboratory.

[0379] Screening methods include, but are not limited to, standard methods such as reverse transcriptase polymerase chain reaction (RT-PCR), protein analysis, or in-situ hybridization such as fluorescent in situ hybridization (FISH).

[0380] Methods for identifying and analyzing cytogenetic abnormalities, gene amplification, deletion, protein downregulation, mutation, and upregulation are known to those skilled in the art. Screening methods can include, but are not limited to, standard methods such as DNA sequence analysis by conventional Sanger or next-generation sequencing, reverse transcriptase polymerase chain reaction (RT-PCR), RNA sequencing (RNase q), nanostring hybridization proximity RNA nCounter assay, or in-situ hybridization, such as fluorescent in situ hybridization (FISH), or allele-specific polymerase chain reaction (PCR). In addition, methods for evaluating protein levels include immunohistochemistry or other immunoassays. Thus, in one embodiment, protein expression is analyzed in patient samples. In another embodiment, gene expression, for example, gene abnormalities, is analyzed in patient samples using techniques such as FISH. Methods for assessing gene copy changes include techniques routinely used in cytogenetic laboratories, such as MLPA (Multiplex Ligation-dependent Probe Amplification), a multiplex PCR method that detects abnormal copy numbers, and other PCR techniques that can detect gene amplifications, gains, and deletions.

[0381] In RT-PCR screening, tumor mRNA levels are assessed by creating a cDNA copy of the mRNA followed by amplification of the cDNA by PCR. PCR amplification methods, primer selection, and amplification conditions are known to those skilled in the art.Nucleic acid manipulation and PCR are carried out by standard methods, for example, as described in Ausubel, FM et al. (eds.), (2004) Current Protocols in Molecular Biology, John Wiley & Sons Inc., or Innis, MA et al. (eds.), (1990) PCR Protocols: a guide to methods and applications, Academic Press, San Diego.Reactions and manipulations, including diffusion techniques, are also described in Sambrook et al., (2001), 3rd Edition, Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press. Alternatively, commercially available kits for RT-PCR (e.g., Roche Molecular Biochemicals) can be used, or methods such as those described in U.S. Patent Nos. 4,666,828; 4,683,202; 4,801,531; 5,192,659; 5,272,057; 5,882,864; and 6,218,529 can be used, which are incorporated herein by reference.Mutations, such as the genes outlined herein, can be determined by PCR.In one embodiment, specific primer pairs are commercially available or are described in the literature.

[0382] An example of an in-situ hybridization technique for assessing mRNA expression is fluorescent in-situ hybridization (FISH) (see Angerer (1987) Meth. Enzymol., 152: 649).

[0383] Next generation sequencing (NGS), DNA sequencing or nanostringing can be performed.

[0384] Generally, in situ hybridization involves the following major steps: (1) fixation of the tissue to be analyzed; (2) prehybridization treatment of the sample to increase the accessibility of the target nucleic acid and reduce nonspecific binding; (3) hybridization of the nucleic acid mixture to the nucleic acid in the biological structure or tissue; (4) posthybridization washes to remove unbound nucleic acid fragments; and (5) detection of the hybridized nucleic acid fragments. Probes used in such applications are generally labeled, for example, with radioisotopes or fluorescent reporters. Particular probes are of sufficient length, for example, from about 50, 100, or 200 nucleotides to about 1,000 or more nucleotides, to allow specific hybridization with the target nucleic acid under stringent conditions. Standard methods for performing FISH are described in Ausubel, FM et al., eds. (2004) Current Protocols in Molecular Biology, John Wiley & Sons Inc and Fluorescence In Situ Hybridization: Technical Overview by John MS Bartlett in Molecular Diagnosis of Cancer, Methods and Protocols, 2nd Edition; ISBN: 1-59259-760-2; March 2004, pp. 077-088; Series: Methods in Molecular Medicine.

[0385] The method for gene expression profiling has been described by DePrimo et al. (2003), BMC Cancer, 3:3. Briefly, the protocol is as follows: double-stranded cDNA is synthesized from total RNA using a (dT)24 oligomer to prime first-strand cDNA synthesis, followed by second-strand cDNA synthesis using a random hexamer primer. The double-stranded cDNA is used as a template for in vitro transcription of cRNA using biotinylated ribonucleotides. The cRNA was chemically fragmented according to the protocol described by Affymetrix (Santa Clara, CA, USA) and then hybridized overnight on a human genome array. Alternatively, a single nucleotide polymorphism (SNP) array, a type of DNA microarray, can be used to detect polymorphisms within a population.

[0386] Additionally, the test kit may use nanostring technology or ddPCR.

[0387] Alternatively, protein products expressed from mRNA can be assayed by immunohistochemistry (or other immunoassays) of tumor samples, solid-phase immunoassays using microtiter plates, Western blotting, two-dimensional SDS-polyacrylamide gel electrophoresis, ELISA, flow cytometry, and other methods known in the art for detecting specific proteins, for example, by capillary electrophoresis. Detection methods may include the use of site-specific antibodies. Those skilled in the art will recognize that all such well-known techniques for detecting upregulation of MDM2 and p53, MDM2 or p53 mutants or variants, or defects in negative regulators of MDM2 (e.g., p14ARF) or the genes described herein are applicable to the present example. In particular, the levels of the genes described herein can be measured using immunohistochemistry. Cytoplasmic expression can be assessed by staining of tumor cells. In some embodiments, one or both of the protein biomarkers of the present invention are assayed using these techniques. In some embodiments, one or more biomarker substrates are assayed using these techniques.

[0388] Protein level, particularly increased, decreased or abnormal level of protein, can be evaluated using standard protein assay.In addition, increased or decreased expression level, or under-expression or overexpression can also be detected by measuring protein level in tissue sample, for example, tumor tissue, using assay such as that obtained from Chemicon International.The target protein is immunoprecipitated from sample lysate, and its level is measured.

[0389] In embodiments in which the gene is CDKN2A or BAP1, it will be appreciated that a variety of analytical methods are available for determination, including ELISA, immunoturbidimetry, rapid immunodiffusion, and visual agglutination.

[0390] For example, in embodiments examining gene expression for IFN signature biomarkers, it will be appreciated that there are a variety of analytical methods available for determination.

[0391] In one embodiment comprising detection of BAP1 or CDKN2A deficiency, such detection can generally be performed on biopsies using validated assays at the DNA level (i.e., DNA sequencing), RNA (i.e., qPCR, gene array, exome sequencing, etc.), or protein (i.e., immunohistochemistry) level. In another embodiment, detection of BAP1 or CDKN2A deficiency comprises one or more of reverse-phase protein array, Western blotting, semi-quantitative or quantitative IHC.

[0392] Immunohistochemistry (IHC) is an important technique for biomarker detection. First, it allows direct visualization of biomarker expression in histologically relevant regions of the examined cancer tissue. Second, IHC is performed on FFPE tissue sections processed using standard methods, allowing biomarker assays to be performed on clinically available specimens. Third, validated IHC assays can be easily implemented into clinical practice. For example, there are multiple validated IHC assays in clinical use, such as assays for detecting PD-L1, HER2, and ALK (https: / / www.fda.gov / medical-devices / vitro-diagnostics / list-cleared-or-approved-companion-diagnostic-devices-vitro-and-imaging-tools). Traditionally, pathologists visually score IHC data. For example, the calculation of HSCORE involves generating a sum of the percentage of area stained at each intensity level multiplied by a weighted intensity of staining (e.g., 1, 2, or 3; 0 = no staining, 1 = weak staining, 2 = moderate staining, and 3 = strong staining) [McCarty et al: Cancer Res 1986, 46:4244s-4248s]. For assay validation purposes, these analyses are often performed on specimens arrayed on stained TMA sections, allowing for a sufficiently large number of specimens to be presented for statistically rigorous testing. Histological specimens are adequately presented with very few tissue cores on a slide, minimizing IHC costs and tissue use and facilitating intraobserver, interobserver, and interlaboratory studies. Computer-assisted methods for classifying image regions of interest (e.g., cancerous regions of a tissue specimen) and quantifying IHC staining intensity within those regions are also available for data generation.

[0393] It will be appreciated that such techniques are equally applicable to the detection of other genes described herein. In some embodiments, the detection of increased levels of a gene described herein comprises a polymerase chain reaction (PCR) assay, or direct nucleic acid sequencing or hybridization with a nucleic acid probe specific for the gene.

[0394] Thus, all of these techniques can also be used to identify tumors that are particularly suitable for treatment with the MDM2 antagonists of the present invention.

[0395] Ex vivo functional assays, such as measurement of circulating leukemic cells in cancer patients, can also be used, where appropriate, to assess response to stimulation with MDM2 / p53 inhibitors.

[0396] Thus, a further aspect of the invention includes the use of an MDM2 antagonist for the manufacture of a medicament for the treatment or prevention of a disease state or condition in a patient who has been screened and determined to be suffering from, or at risk of suffering from, a disease or condition that may be susceptible to treatment with an MDM2 / p53 inhibitor.

[0397] In another aspect of the present invention, the following genes, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, and L Included is an MDM2 antagonist for use in preventing or treating cancer in patients selected from the subpopulation having elevated levels of one or more of AMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1, and / or having a BAP1 deficiency and / or a CDKN2A deficiency.

[0398] Another aspect of the invention includes p53 wild-type and the following: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, Included is an MDM2 antagonist for use in the prevention or treatment of cancer in patients selected from the subpopulation having elevated levels of one or more of LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1, and / or a BAP1 deficiency and / or a CDKN2A deficiency.

[0399] Another aspect of the invention is the detection of deficiencies of negative MDM2 regulators such as p14ARF, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, L Included are MDM2 antagonists for the prevention or treatment of cancer in patients with elevated levels of one or more of GALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1, and / or BAP1 deficiency and / or CDKN2A deficiency.

[0400] MRI determination of vascular normalization (e.g., using MRI gradient echo, spin echo, and contrast enhancement to measure blood volume, relative vessel size, and vascular permeability) in combination with circulating biomarkers can also be used to identify patients suitable for treatment with the compounds used in the present invention.

[0401] Accordingly, a further aspect of the present invention is a method for the diagnosis and treatment of a disease state or condition mediated by MDM2 / p53, comprising (i) screening a patient to determine whether the disease or condition from which the patient is suffering or likely to suffer is one that would be susceptible to treatment with an MDM2 / p53 inhibitor, and (ii) if the patient's disease or condition is shown to be so susceptible, then administering to the patient an MDM2 antagonist, and subgroups or examples thereof, as defined herein.

[0402] In one embodiment, the method of the invention further comprises the step of screening patients for overexpression of one or more MDM family members (eg, MDM2 and / or MDMx).

[0403] In one embodiment, the method of the invention further comprises the step of screening patients with cytogenetic abnormalities that result in overexpression of MDM2, e.g., patients selected as having a deficiency in the negative regulator p14ARF.

[0404] In one embodiment, a sample obtained from a patient is contacted with primers, antibodies, substrates or probes to determine the levels of the genes described herein.

[0405] In one embodiment, the method comprises (i) contacting a patient sample with a primer, antibody, substrate, or probe, and (ii) determining the level of a gene described herein.

[0406] Basal levels can be analyzed by intracellular staining of intact cells with antibodies, e.g., antibodies conjugated to fluorescent probes. Antibodies against the biomarkers described herein are commercially available from a range of suppliers. In particular, the antibodies used may be part of an FDA-approved in vitro diagnostic kit (IVD).

[0407] In one embodiment, the method comprises (i) contacting a patient sample with an antibody, and (ii) determining the level of one or more biomarkers described herein.

[0408] In one embodiment, the method comprises (i) contacting a patient sample with an antibody, and (ii) determining the level of nuclear localization to assess the level of one or more biomarkers described herein.

[0409] Where appropriate, the level of nuclear localization can be determined using antibodies and immunohistochemistry or immunofluorescence.

[0410] Mutations that result in the loss of BAP1 or CDKN2A can be detected using reverse-phase protein array, Western blotting, semi-quantitative or quantitative IHC, or DNA sequencing.In one embodiment, this method comprises: (i) contacting a patient sample with an anti-mutant antibody, and (ii) determining that the patient tumor is BAP1-deficient and / or CDKN2A-deficient.In one embodiment, this method comprises: (i) contacting a patient sample with an anti-mutant antibody, and (ii) determining the level of BAP1 or CDKN2A (or its loss).

[0411] Detection of BAP1 or CDKN2A deletions and mutations can be performed by extracting DNA from patient samples, such as tumor biopsies, amplifying it with appropriate primers, and sequencing the DNA. PCR primers can be designed or are commercially available. Mutation array kits are also available.

[0412] In one embodiment, the method comprises (i) contacting a patient sample with one or more BAP1 and / or CDKN2A PCR primers, and (ii) determining the presence or absence of a BAP1 and / or CDKN2A mutation or deletion. In another embodiment, step (i) of the method comprises contacting the patient sample with one or more PCR primers for one or more biomarker substrates.

[0413] In one embodiment, the method comprises (i) contacting the patient sample with a BAP1 antibody and / or a CDKN2A antibody, and (ii) determining the presence or absence of a BAP1 and / or CDKN2A mutation or deletion. In another embodiment, step (i) of the method comprises contacting the patient sample with a biomarker substrate antibody.

[0414] Protein levels can be determined using ELISA kits. ELISA kits for use with patient samples can be used to evaluate blood chemistry in clinical settings. These utilize protein-specific antibodies, such as anti-biomarker antibodies such as anti-BAP1 or anti-CDKN2A, or conjugated antibodies. In particular, the antibodies used are part of FDA-approved in vitro diagnostic kits. In one embodiment, levels are determined according to tests that comply with the standards defined by the Association for Clinical Biochemistry (ACB).

[0415] In one embodiment, the method comprises (i) contacting a patient sample with an antibody, and (ii) determining the level of a protein from a gene described herein.

[0416] In particular, the sample is contacted under conditions for quantifying the level.

[0417] For example, in the contacting step described above, the sample is generally contacted with a primer, probe, substrate, or antibody in the presence of a buffer. The substrate can be, for example, a fluorescent probe.

[0418] Patient selection Patients selected for treatment with an MDM2 antagonist according to the present invention may be selected from the group consisting of BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, B It will be appreciated that ST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1 may be tested or assessed.

[0419] For example, such selected patients may Decreased or reduced BAP1 expression; and / or Decreased or reduced CDKN2A expression; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HE RC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, Increased or high expression of one, two, three, four, five or more of the following: LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 Shows.

[0420] In one embodiment, the selected patient shows or exhibits at least one symptom of cancer, particularly a TP53 wild-type tumor.

[0421] In one embodiment, the cancer patient selected has not received prior MDM2 antagonist treatment. In one embodiment, the patient selected has not previously responded to therapy with an MDM2 antagonist.

[0422] In some embodiments, nucleic acid expression profiles (e.g., IFN gene signatures) are determined by PCR, HTG EdgeSeq, or quantitative gene expression assays such as NanoString nCounter. In some embodiments, protein expression profiles (e.g., BAP1 and / or CDKN2A) are determined by immunoassays.

[0423] Gene signature (IFN) In one embodiment, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS The RNA level of one or more of 3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1 is elevated compared to the amount of said RNA in a control sample obtained from a normal, cancer-free subject.

[0424] In another embodiment, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LG The RNA levels of ALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and / or BRCA1 are elevated in tumors compared to the amount of said RNA in non-tumor samples obtained from the same patient.

[0425] In one embodiment, the cancer exhibits increased expression of CXCL10 or CXCL11.

[0426] In another embodiment, the cancer exhibits increased expression of IRF7, IFITM1, IRF9, MX1, or IFI35.

[0427] In another embodiment, the cancer exhibits increased expression of one or more, eg, two or more, of IRF7, IFITM1, IRF9, MX1, IFI35, CXCL10, or CXCL11.

[0428] In some embodiments, the elevated level is compared to the amount of RNA determined in a sample from an MDM2 inhibitor non-responder subject.

[0429] In one embodiment, there is an increase or elevation compared to normal levels.

[0430] The upper limit of normal (ULN) refers to the 95% level of the total range. It is the set of values ​​within which 95 percent of the normal population falls (i.e., the 95% prediction interval).

[0431] In one embodiment, the elevated level is >1-fold difference from a control sample, the upper limit of normal (ULN), or the sample taken from said patient, e.g., 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5, 9.0, 9.5, 10, 10.5, 11, 11.5, 12, 12.5, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100-fold difference, or any range therebetween. In one embodiment, the elevated level is 1-50-fold difference from a control sample or the ULN. In one embodiment, the elevated level is very high, e.g., >10-fold difference from a control sample, the ULN, or a sample taken from the patient, e.g., 10, 10.5, 11, 11.5, 12, 12.5, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 1000, or any range therebetween. In one embodiment, the elevated level is 10-1000-fold difference from a control sample or the ULN. In one embodiment, the elevated level is 2-10-fold (e.g., 5-fold) difference from a control sample.

[0432] The fold difference can be determined between diseased individuals and normal individuals (reference value or control sample). This reference value can be calculated from normal individuals or based on a pool of samples excluding the sample type being tested (e.g., TP53 wild-type and CDKN2A or BAP1 deficient). In one embodiment, the difference in interferon gene expression between normal tissues (source GTEx; Nat Biotechnol. 2017 Apr 11;35(4):314-316) and patient mesothelioma samples (source: TCGA) is greater than 5-fold and 0.05-fold (log2 scale), and in particular, the gene set has an average increase of 1.5-fold (log2 scale).

[0433] In one embodiment, the concentration of RNA is determined by rtPCR and / or microarray and / or nanostring. Each assay typically has an "upper limit of normal" (ULN) value associated with the specific assay method. Such ULN is then typically determined from a sufficient sample size of normal healthy subjects using a specific assay method for measuring RNA concentration. The ULN is typically determined as the highest RNA concentration that is still considered to be within the normal range (e.g., within two standard deviations of the mean). Such ULN values ​​vary depending on the specific assay method used to measure the concentration, and therefore each specific assay has a unique ULN value associated with that assay method.

[0434] As shown herein, concentrations can be used to predict whether a cancer patient is likely to benefit from MDM2 antagonist treatment.

[0435] BAP1 and CDKN2A assays In one embodiment, the protein level of one or more of BAP1 and / CDKN2A is decreased compared to the amount of said protein in a control sample obtained from a normal subject not afflicted with cancer.

[0436] In another embodiment, the protein levels of BAP1 and / CDKN2A are decreased compared to the amount of said proteins in an earlier sample obtained from the same patient.

[0437] In one embodiment, it is decreased or reduced compared to normal levels.

[0438] The upper limit of normal (ULN) refers to the 95% level of the total range. It is the set of values ​​within which 95 percent of the normal population falls (i.e., the 95% prediction interval).

[0439] In one embodiment, the decrease in level is >1-fold difference from the control sample, the upper limit of normal (ULN), or the sample taken from the patient, e.g., 0.75, 0.5, 0.4, 0.3, 0.2, 0.15, 0.1, 0.09, 0.08, 0.07, 0.06, 0.05, 0.04, 0.03, 0.02, or 0.01, or any range therebetween. In one embodiment, the decrease in level is 1-0.01-fold difference from the control sample or the ULN. In one embodiment, the decrease in level is very low, e.g., >0.01-fold difference from the control sample, the ULN, or the sample taken from the patient, e.g., 0.001-fold difference, or any range therebetween. In one embodiment, the decrease in level is 0, i.e., not present at all.

[0440] In another embodiment, BAP1 or CDKN2A levels are determined by immunohistochemistry.

[0441] Proteins, protein complexes, or proteomic markers can be specifically identified and / or quantified by a variety of methods known in the art, which can be used alone or in combination. Immunological or antibody-based techniques include enzyme-linked immunosorbent assay (ELISA), radioimmunoassay (RIA), Western blotting, immunofluorescence, microarrays, some chromatographic techniques (i.e., immunoaffinity chromatography), flow cytometry, immunoprecipitation, etc. Such methods are based on the specificity of one or more antibodies for a particular epitope or combination of epitopes associated with the protein or protein complex of interest. Non-immunological methods include those based on the physical characteristics of the protein or protein complex itself. Examples of such methods include electrophoresis, several chromatographic techniques (e.g., high-performance liquid chromatography (HPLC), fast protein liquid chromatography (FPLC), affinity chromatography, ion exchange chromatography, size exclusion chromatography, etc.), mass spectrometry, sequencing, protease digestion, etc. Such methods are based on mass, charge, hydrophobicity, or hydrophilicity, which are derived from the amino acid complement of the protein or protein complex and the specific sequence of amino acids.

[0442] In one embodiment, there is no expression of BAP1 or CDKN2A. Samples with low levels of BAP1 or CDKN2A can be identified as BAP1-negative or CDKN2A-negative, eg, BAP1-deficient or CDKN2A-deficient.

[0443] In one embodiment, the BAP1 or CDKN2A defect is assessed by mutation analysis, eg, DNA sequencing.

[0444] The levels of cytoplasmic and nuclear expression of BAP1 or CDKN2A can also be determined. Nuclear localization of BAP1 or CDKN2A proteins is a marker for intracellular expression. The level of nuclear expression can be scored using histology and a score (range 0-100) representing the percentage of positive cells obtained after treatment with an antibody (e.g., a monoclonal anti-human antibody against the biomarker). An immunostaining expression score can be created.

[0445] Cytoplasmic BAP1 and / or CDKN2A levels can also be measured using immunohistochemistry or immunofluorescence.

[0446] In one embodiment, the level of one or more of BAP1 and / or CDKN2A is decreased relative to the amount of said protein in a control sample obtained from a normal subject not afflicted with cancer.

[0447] In one embodiment, the level of one or more of BAP1 and / or CDKN2A is decreased in the tumor relative to the amount of said protein in a non-tumor sample obtained from the same patient.

[0448] In one embodiment, the expression level of one or more of BAP1 and / or CDKN2A is reduced by 50%, 60%, 70%, 80%, 90%, 95%, 96, 97%, 98%, 99%, 99.5%, 99.9%, or 100%. A 100% reduction in expression is a complete reduction, i.e., a total absence. In some embodiments, a reduction of at least 50% is provided. In some embodiments, a reduction of at least 75% is provided.

[0449] In some embodiments, a reduction of at least 80% is provided.

[0450] In some embodiments, a reduction of at least 95%, for example at least 99%, is provided.

[0451] Quantification method The present invention relates to identifying patients for treatment with MDM2 antagonists. In some embodiments, the method comprises at least (a) contacting a sample from a patient with antibodies to BAP1 and / or CDKN2A (or one or more BAP1 and / or CDKN2A substrates); (b) performing an ELISA or immunohistochemistry assay on the sample; (c) determining the levels of BAP1 and / or CDKN2A; and (d) identifying the patient as a candidate for treatment with an MDM2 antagonist if (i) levels of BAP1 and / or CDKN2A are decreased relative to the upper limit of normal (ULN); or (ii) BAP1 and / or CDKN2A are absent; or (iii) levels of BAP1 and / or CDKN2A are low relative to the upper limit of normal (ULN). The compound comprises:

[0452] In other embodiments, the method for identifying a patient for treatment with an MDM2 antagonist comprises: (a) contacting a sample from the patient with an antibody to BAP1 (and / or one or more BAP1 substrates) to determine the level of protein expression; and / or (b) contacting a sample from the patient with an antibody to CDKN2A (and / or one or more BAP1 substrates) to determine the level of protein expression; (c) treating said patient with an MDM2 antagonist if the levels of BAP1 and / or CDKN2A are decreased relative to the upper limit of normal (ULN). The compound comprises:

[0453] In other methods, a method for treating cancer in a patient includes: (a) contacting a sample from a patient with a plurality of oligonucleotide primers, said plurality of primers identifying the following genes: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, CSF2, and CSF3. at least one pair of oligonucleotide primers for any one or more of: 1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1; and (b) treating the patient with an MDM2 antagonist if the expression level of the at least one gene is higher than the upper limit of normal (ULN). The compound comprises:

[0454] Also provided is a method for identifying or selecting a patient for treatment with an MDM2 antagonist, the method comprising: (a) contacting a sample from the patient with an antibody to BAP1 and / or an antibody to CDKN2A to determine the level of protein expression; and / or (b) contacting a sample from the patient with an antibody to BAP1 and / or CDKN2A to determine the level of protein expression; and / or (c) contacting a sample from the patient with a plurality of oligonucleotide primers, the plurality of primers identifying the following genes: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1 , C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1; (d) Decreased levels of BAP1 and / or CDKN2A compared to the upper limit of normal (ULN) and / or the following genes: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S; If the level of one or more of DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 is elevated compared to the upper limit of normal (ULN), then the patient is treated with an MDM2 antagonist. The compound comprises:

[0455] The selected patient is typically a cancer patient. The patient typically has a level of BAP1 and / or CDKN2A lower than a predetermined value (or absent) in a biological sample from the patient, and / or has a level of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF1, IRF2, IRF3, IRF4, IRF5, IRF6, IRF7, IRF8, IRF9, IRF10, IRF11, IRF12, IRF13, IRF14, IRF15, IRF16, IRF17, IRF18, IRF19, IRF20, IRF21, IRF22, IRF23, IRF24, IRF25, IRF26, IRF27, IRF28, IRF29, IRF30, IRF31, IRF32, IRF33, IRF34, IRF45, IRF46, IRF47, IRF48, IRF50, IRF51, IRF52, IRF53, IRF54, IRF55, IRF56, IRF57, IRF58, IRF59, IRF60, IRF61, IRF62, IRF63, IRF64, IRF65, IRF66, IRF67, IRF68, IRF69, IRF70, IRF71, IRF72, IRF73, IRF74, IRF75, IRF76, IRF77, IRF78, IRF79, IRF70, IRF71, IRF72, IRF74, IRF75, IRF76, I 9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 are selected when the level of one or more of these is equal to or greater than a predetermined value.

[0456] The method for predicting the efficacy of an MDM2 antagonist against cancer in a patient includes detecting in a biological sample from the patient, BAP1, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, US determining the levels of P18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; 1 and / or CDKN2A biological sample levels below predetermined values, and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1 A level of one or more of S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 above a predetermined value is predictive of efficacy in the patient.

[0457] Systems for implementing these methods The methods described herein may utilize a system for assisting in patient assessment or prognosis. The system may be a single device that integrates various device components (units). The system may also include its various components, or some of these components, as separate devices. The components may include a measuring device, a graphical user interface, and a computer processing unit.

[0458] The system typically includes a data connection to the interface, which may itself be part of the system or may be a remote interface. The latter refers to the possibility of using a different device, preferably a handheld device such as a smartphone or tablet computer, to provide the actual interface. The data connection in such cases preferably involves wireless data transfer, such as via Wi-Fi or Bluetooth, or other technologies or standards.

[0459] In certain embodiments, the measurement device is configured to receive a tissue sample, for example, by placing one or more cancer cells or a drop of blood in a cartridge that can be inserted into the device. The device can be an existing device that can determine the level of one or more biomarkers or multiple biomarkers from the same sample. The processing unit can receive the protein concentration values ​​from the measurement device. The processing unit is typically provided with software (typically built-in software) that can calculate a score based on the input data.

[0460] In another embodiment, a system for assessing whether a human cancer patient is suitable for treatment with an MDM2 antagonist comprises: (a) A detection means capable of and adapted to detect one or more biomarkers of the invention in a sample from a human patient. Such means are known and readily available to those skilled in the art. Generally, a container is provided for receiving a sample of interest, and the container is equipped with a detection means. (b) a processor capable of and adapted to determine from the determined concentration of said protein an indication of the likelihood that the patient will be treated with an MDM2 antagonist.

[0461] Optionally, the system comprises a user interface (or a data connection to a remote interface) through which information can be presented, particularly a graphical user interface (GUI); a GUI is a type of user interface that allows a user to interact with an electronic device through graphic icons and visual indicators—e.g., secondary notation—in lieu of text-based user interfaces, typed command labels, or text navigation (though nothing in this invention excludes such interface types); GUIs are commonly known and typically used in handheld mobile devices such as MP3 players, portable media players, gaming devices, smartphones, and smaller home, office, and industrial controls; as noted above, the interface may optionally also be selected to allow for input of information, such as information about the patient.

[0462] In one embodiment, a system for determining the suitability of a human cancer patient for treatment with an MDM2 antagonist comprises a memory device for storing data relating to a sample from the patient, the data comprising data relating to a panel of biomarkers indicative of biomarker expression levels in the sample from the subject; a panel of biomarkers comprising one or more biomarkers of the invention; and a processor communicatively connected to the memory device for classifying the patient.

[0463] kit The present invention also provides kits, either separately or as part of the aforementioned systems, for detecting one or more of the biomarkers of the invention to assess a patient's likelihood of responding to MDM2 inhibition for the treatment of cancer. The kits generally comprise one or more detection reagents for detecting one or more of the biomarkers of the invention. These reagents can be for direct or indirect detection of the biomarker, e.g., detection of a correlation substrate.

[0464] Generally, the kit comprises two or more, or three or more detection reagents, each directed to a different biomarker of the invention.

[0465] As described above with reference to the methods of the invention, the kit may comprise more detection reagents, such as those for other proteins. In preferred embodiments, the detection reagents available in the kit consist of detection reagents for the detection of two, three, or four proteins that make up the biomarker panel of the invention, as described above.

[0466] The kit may comprise a chip, microtiter plate or solid support such as beads or resin comprising said detection reagent. In some embodiments, the kit comprises a mass spectrometry probe.

[0467] The kit may also provide a wash solution and / or a non-bound detection reagent or detection reagents specific for any of the biomarkers (sandwich type assays).

[0468] Such kits suitably comprise a biosensor for the detection and / or quantification of one or more of the biomarkers of the invention, optionally together with instructions for using the kit according to the methods as described herein.

[0469] There are well-established genetic and biochemical means to characterize the status of one or more of the biomarkers of the invention, as well as well-established biochemical means to characterize the amount of a protein in a blood, e.g., serum, sample.

[0470] In one embodiment, the present invention includes a packaged cancer therapeutic. The packaged therapeutic comprises a composition packaged with instructions for using an effective amount of the composition for its intended use in a patient selected using the present invention. In another embodiment, the present invention provides the use of any of the compositions of the present invention for the manufacture of a medicament for treating cancer in a subject.

[0471] In one embodiment, the invention provides a kit or panel or array for determining the level of one or more of the biomarkers of the invention from a single patient sample.

[0472] Biological effects The compounds described herein, their subgroups and examples have been shown to inhibit the interaction between p53 and MDM2.This inhibition leads to the stop of cell proliferation and cell death (generally apoptosis), which can be useful for preventing or treating the disease states or pathological conditions described herein, such as the diseases and pathological conditions discussed below, and the above-mentioned diseases and pathological conditions in which p53 and MDM2 play a role.Therefore, for example, it is believed that the compounds used in the present invention can be useful for alleviating or reducing the occurrence of cancer.

[0473] The compounds described herein may be useful for the treatment of the adult population. The compounds of the invention may be useful for the treatment of the pediatric population.

[0474] The compounds described herein have been shown to be good antagonists of the formation of the MDM2-p53 complex. The compounds described herein can bind to MDM2 and exhibit potency against MDM2. The potency of the compounds of the present invention has been determined against MDM2 / p53 using the assay protocols described herein and other methods known in the art. More specifically, the compounds of formula (I) o ) and its subgroups have affinity for MDM2 / p53.

[0475] Particular compounds for use in the present invention are IC 50 values ​​below 0.1 μM, in particular below 0.01 or 0.001 μM.

[0476] MDM2 / p53 function has been implicated in many diseases due to its role in various processes, such as vascular remodeling, antiangiogenic processes, and metabolic pathway regulation, as well as oncogenesis. As a result of their affinity for MDM2, compounds have been shown to be effective in treating autoimmune pathologies; diabetes mellitus; chronic inflammatory diseases, such as lupus nephritis, systemic lupus erythematosus (SLE), autoimmune glomerulonephritis, rheumatoid arthritis, psoriasis, inflammatory bowel disease, autoimmune diabetes, eczema hypersensitivity reactions, asthma, COPD, rhinitis, and upper respiratory tract diseases; hyperkeratotic diseases, such as autosomal recessive congenital ichthyosis (ARCI); glomerular disorders, chronic kidney disease (CKD), renal inflammation, podocyte loss, glomerulosclerosis, and proteinuria. and renal diseases, including progressive renal disease; cardiovascular diseases, e.g., cardiac hypertrophy, restenosis, arrhythmias, atherosclerosis; ischemic injury-related myocardial infarction, vascular injury, stroke, and reperfusion injury; vascular proliferative diseases; ocular diseases such as age-related macular degeneration, particularly the wet form of age-related macular degeneration; ischemic proliferative retinopathies, such as retinopathy of prematurity (ROP) and diabetic retinopathy, and hemangiomas.

[0477] It is expected that as a result of their affinity for MDM2, the compounds may prove useful in the treatment or prevention of proliferative disorders such as cancer.

[0478] Examples of cancers (and their benign counterparts) that may be treated (or inhibited) include, but are not limited to, tumors of epithelial origin (various types of adenomas and carcinomas, including adenocarcinoma, squamous cell carcinoma, transitional cell carcinoma, and other cancers) such as those of the bladder and urinary tract, breast, gastrointestinal tract (including the esophagus, stomach, small intestine, colon, intestines, colorectum, rectum, and anus), liver (hepatocellular carcinoma), gallbladder and biliary system, exocrine pancreas, kidney (e.g., renal cell carcinoma), lung (e.g., adenocarcinoma, small cell lung carcinoma, non-small cell lung carcinoma, bronchoalveolar carcinoma, and mesothelioma), head and neck (e.g., tongue, buccal cavity, larynx, pharynx, nasopharynx, tonsils, saliva, and the like), and tumors of the urinary tract, such as the bladder and urinary tract, breast, gastrointestinal tract (including the esophagus, stomach, small intestine, colon, intestines, colorectum, rectum, and anus), liver (hepatocellular carcinoma), gallbladder and biliary system, exocrine pancreas, kidney (e.g., renal cell carcinoma), lung (e.g., adenocarcinoma, small cell lung carcinoma, non-small cell lung carcinoma, bronchoalveolar carcinoma, and mesothelioma), head and neck (e.g., tongue, buccal cavity, larynx, pharynx, nasopharynx, tonsils, saliva, and the like). Cancers of the ovarian glands, nasal cavity and paranasal sinuses), ovaries, fallopian tubes, peritoneum, vagina, vulva, penis, testes, cervix, uterine muscle, endometrium, thyroid (e.g., follicular thyroid carcinoma), brain, adrenal glands, prostate, skin and adnexa (e.g., melanoma, basal cell carcinoma, squamous cell carcinoma, keratoacanthoma, dysplastic nevi); hematologic malignancies and related conditions of the lymphatic lineage (e.g., acute lymphocytic leukemia [ALL], chronic lymphocytic leukemia [CLL], B-cell lymphomas, e.g., diffuse large B-cell lymphoma [DLBCL], follicular lymphoma, Burkitt's lymphoma, mantle cell lymphoma, T-cell lymphoma) and leukemia, natural killer [NK] cell lymphoma, Hodgkin's lymphoma, hairy cell leukemia, monoclonal gammopathy of undetermined significance, plasmacytoma, multiple myeloma, and post-transplant lymphoproliferative disorder) and hematologic malignancies and related conditions of the myeloid lineage (e.g., acute myeloid leukemia [AML], chronic myeloid leukemia [CML], chronic myelomonocytic leukemia [CMML], hypereosinophilic syndromes, myeloproliferative disorders such as polycythemia vera, essential thrombocythemia and primary myelofibrosis, myeloproliferative syndromes, myelodysplastic syndromes, and promyelocytic leukemia). Hematological malignancies (i.e., leukemia, lymphoma), premalignant hematological disorders, and borderline malignant disorders; tumors of mesenchymal origin, such as sarcomas of soft tissue, bone, or cartilage, e.g., osteosarcoma, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma, leiomyosarcoma, liposarcoma, angiosarcoma, Kaposi's sarcoma, Ewing's sarcoma, synovial sarcoma, epithelioid sarcoma, gastrointestinal stromal tumors, benign and malignant histiocytomas, and dermatofibrosarcoma protuberans; tumors of the central or peripheral nervous system (e.g., astrocytomas (e.g., gliomas), neuromas and glioblastomas, meningiomas, ependymomas, pineal tumors, and schwannomas);Endocrine tumors (e.g., pituitary tumors, adrenal tumors, pancreatic islet cell tumors, parathyroid tumors, carcinoid tumors, and medullary carcinoma of the thyroid); ocular and adnexal tumors (e.g., retinoblastoma); germ cell and trophoblastic tumors (e.g., teratomas, seminomas, dysgerminomas, hydatidiform moles, and choriocarcinomas); and pediatric and embryonal tumors (e.g., medulloblastomas, neuroblastomas, Wilms' tumors, and primitive neuroectodermal tumors); or congenital or other syndromes that predispose patients to malignancies (e.g., xeroderma pigmentosum).

[0479] Cell growth is a tightly regulated function. Cancer, a pathological condition of abnormal cell proliferation, occurs when cells replicate (increase in number) in an uncontrolled manner, proliferate (grow larger) uncontrollably, and / or undergo reduced cell death by apoptosis (programmed cell death), necrosis, or anoikis. In one embodiment, the abnormal cell proliferation is selected from uncontrolled cell proliferation, excessive cell proliferation, or reduced programmed cell death. In particular, the pathological condition or disease of abnormal cell proliferation is cancer.

[0480] Thus, in the pharmaceutical compositions, uses or methods of the present invention for treating a disease or condition comprising abnormal cell proliferation (i.e., uncontrolled and / or rapid cell growth), in one embodiment the disease or condition comprising abnormal cell proliferation is cancer.

[0481] Many diseases are characterized by persistent and uncontrolled angiogenesis.Chronic proliferative diseases are often accompanied by significant angiogenesis, which may contribute to or maintain inflammatory and / or proliferative conditions, or lead to tissue destruction due to invasive growth of blood vessels.It has been found that tumor growth and metastasis depend on angiogenesis.Therefore, the compound used in the present invention can be useful for preventing and destroying the initiation of tumor angiogenesis.

[0482] Angiogenesis is generally used to refer to the development of new or replacement blood vessels, or neovascularization, which is a necessary and physiological normal process by which the vascular system is established in the embryo. Generally, most normal adult tissues do not undergo angiogenesis, except at sites of ovulation, menstruation, and wound healing, but many diseases are characterized by persistent and unregulated angiogenesis. For example, in arthritis, new capillaries invade the joints and destroy cartilage. In diabetes (and many different eye diseases), new blood vessels invade the macula or retina or other structures of the eye, which can cause blindness. The process of atherosclerosis is associated with angiogenesis. Tumor growth and metastasis are known to be dependent on angiogenesis. These compounds may be beneficial in the treatment of diseases such as cancer and metastasis, eye diseases, arthritis, and hemangiomas.

[0483] Therefore, the compounds for use in the present invention may be useful in treating metastasis and metastatic cancer. Metastasis or metastatic disease is the spread of disease from one organ or part to another non-adjacent organ or part. Cancers that can be treated with the compounds for use in the present invention include primary tumors (i.e., cancer cells at the site of origin), local invasion (cancer cells that penetrate and invade normal tissues surrounding the local area), and metastatic (or secondary) tumors, i.e., tumors formed from malignant cells that have circulated to other parts or tissues in the body via the bloodstream (hematogenous spread), lymphatic vessels, or across body cavities (transcoelomic spread). In particular, the compounds for use in the present invention may be useful in treating metastasis and metastatic cancer.

[0484] In one embodiment, the hematological malignancy is leukemia. In another embodiment, the hematological malignancy is lymphoma. In one embodiment, the cancer is AML. In another embodiment, the cancer is CLL.

[0485] In one embodiment, the compounds used in the present invention are for use in the prevention or treatment of acute or chronic leukemia, particularly leukemia such as acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), or chronic myelogenous leukemia (CML). In one embodiment, the compounds used in the present invention are for use in the prevention or treatment of acute or chronic lymphoma, particularly lymphoma such as Burkitt's lymphoma, Hodgkin's lymphoma, non-Hodgkin's lymphoma, or diffuse large B-cell lymphoma.

[0486] In one embodiment, the compounds used in the present invention are for use in the prevention or treatment of acute myeloid leukemia (AML) or acute lymphocytic leukemia (ALL).

[0487] In one embodiment, the compounds used in the present invention are useful in the treatment of hematological malignancies of the lymphoid lineage and related conditions (e.g., acute lymphocytic leukemia [ALL], chronic lymphocytic leukemia [CLL], B-cell lymphomas such as diffuse large B-cell lymphoma [DLBCL], follicular lymphoma, Burkitt's lymphoma, mantle cell lymphoma, T-cell lymphomas and leukemias, natural killer [NK] cell lymphoma, Hodgkin's lymphoma, hairy cell leukemia, monoclonal gammopathy of undetermined significance, plasmacytoma, multiple myeloma, and and post-transplant lymphoproliferative disorders) and hematological malignancies (i.e., leukemias, lymphomas) and pre-malignant hematological disorders and borderline malignant disorders, including hematological malignancies and related conditions of the myeloid lineage (e.g., acute myeloid leukemia [AML], chronic myeloid leukemia [CML], chronic myelomonocytic leukemia [CMML], hypereosinophilic syndromes, myeloproliferative disorders such as polycythemia vera, essential thrombocythemia and primary myelofibrosis, myeloproliferative syndromes, myelodysplastic syndromes, and promyelocytic leukemia).

[0488] One embodiment includes a compound used in the present invention for use in the prevention or treatment of cancer in patients selected from the subpopulation with cancer that is p53 wild-type or has MDM2 amplification.

[0489] The cancers may be cancers that are sensitive to treatment with an MDM2 antagonist. The cancers may be cancers that overexpress MDM2. The cancers may be cancers that are p53 wild-type.

[0490] Particular cancers include those with MDM2 amplification and / or MDM2 overexpression, such as hepatocellular carcinoma, lung, sarcoma, osteosarcoma, and Hodgkin's disease.

[0491] Particular cancers include those that have wild-type p53. Particular cancers include cancer cells that have wild-type p53, particularly, but not necessarily, where expression of MDM2 is high.

[0492] In one embodiment, the cancer is a p53-functional tumor. In one embodiment, the disease to be treated is a p53-functional solid or hematological malignant tumor. In another embodiment, the patient to be treated has a p53-mutated tumor, for example, an AML patient with a p53-mutated tumor.

[0493] In one embodiment, the cancer is a brain tumor, for example, a glioma or a neuroblastoma.

[0494] In one embodiment, the cancer is a cancer of the skin, for example, melanoma.

[0495] In one embodiment, the cancer is a lung cancer, such as NSCLC or mesothelioma. In one embodiment, the cancer is a lung cancer, such as mesothelioma. In one embodiment, the mesothelioma is malignant peritoneal mesothelioma or malignant pleural mesothelioma.

[0496] In one embodiment, the cancer is of the digestive tract, eg, GIST, gastric, colorectal or intestinal cancer.

[0497] In one embodiment, the cancer is osteosarcoma.

[0498] In one embodiment, the cancer is liposarcoma.

[0499] In one embodiment, the cancer is Ewing's sarcoma.

[0500] In one embodiment, the cancer is a particular pediatric malignancy, including liposarcoma, soft tissue sarcoma, osteosarcoma, esophageal cancer, and B-cell malignancies.

[0501] In one embodiment, the cancer is colorectal cancer, breast cancer, lung cancer and brain cancer.

[0502] In one embodiment, the cancer is a childhood cancer.

[0503] In one embodiment, the cancer is p53 wild-type.

[0504] In one embodiment, the cancer is a lung cancer, such as NSCLC or mesothelioma, a kidney cancer, such as KIRC, or a brain cancer, such as glioblastoma.

[0505] In one embodiment, the cancer is a cancer that is often known to exhibit BAP1 deficiency. In one embodiment, the cancer is brain cancer, kidney cancer, such as clear cell renal cell carcinoma (ccRCC) or KIRC, esophageal cancer, or melanoma. In one embodiment, the cancer is a cancer that is often known to exhibit BAP1 deficiency, and is a solid tumor or carcinoma.

[0506] In one embodiment, the cancer is a tumor of epithelial origin; a tumor of mesenchymal origin; a tumor of the central or peripheral nervous system; an endocrine tumor; a tumor of the eye and adnexa; a germ cell and trophoblastic tumor; a pediatric and embryonal tumor; or a syndrome, congenital or otherwise, that predisposes a patient to malignancies. In one embodiment, the cancer is a tumor of epithelial origin; a tumor of mesenchymal origin; a tumor of the central or peripheral nervous system; an endocrine tumor; a tumor of the eye and adnexa; a germ cell and trophoblastic tumor.

[0507] Whether a particular cancer is sensitive to an MDM2 antagonist can be determined by methods such as those set forth in the section headed "Methods of Diagnosis."

[0508] A further aspect provides the use of a compound for the manufacture of a medicament for the treatment of a disease or condition described herein, in particular cancer.

[0509] Certain cancers are resistant to treatment with certain drugs. This may be due to the type of tumor (most common epithelial malignancies are inherently chemoresistant, while the prostate is relatively resistant to currently available chemotherapy or radiotherapy regimens), or natural resistance may occur as a result of disease progression or treatment. In this regard, reference to the prostate includes prostate resistant to antiandrogen therapy, particularly abiraterone or enzalutamide, or castration-resistant prostate. Similarly, reference to multiple myeloma includes bortezomib-insensitive or refractory multiple myeloma, and reference to chronic myeloid leukemia includes imitanib-insensitive and refractory chronic myeloid leukemia. In this regard, reference to mesothelioma includes mesothelioma resistant to topoisomerase poisons, alkylating agents, antitubulin agents, folate antagonists, platinum compounds, and radiotherapy, particularly cisplatin-resistant mesothelioma.

[0510] The compounds may also be useful in the treatment of tumor growth, pathogenesis, resistance to chemotherapy and radiotherapy, and as anti-metastatic agents by sensitizing cells to chemotherapy.

[0511] All types of therapeutic anti-cancer interventions inevitably increase stress on target tumor cells. MDM2 / p53 antagonists represent a class of chemotherapy that may (i) sensitize malignant cells to anti-cancer drugs and / or treatments; (ii) attenuate or reduce the incidence of resistance to anti-cancer drugs and / or treatments; (iii) reverse resistance to anti-cancer drugs and / or treatments; (iv) enhance the activity of anti-cancer drugs and / or treatments; and (v) delay or prevent the development of resistance to anti-cancer drugs and / or treatments.

[0512] In one embodiment, the present invention provides a compound for use in treating a disease or condition mediated by MDM2. In a further embodiment, the MDM2-mediated disease or condition is a cancer characterized by overexpression and / or increased activity of MDM2 or high copy numbers of MDM2 and / or wild-type p53.

[0513] A further aspect provides the use of a compound for the manufacture of a medicament for the treatment of a disease or condition described herein, in particular cancer.

[0514] In one embodiment, compounds are provided for use in the prevention or treatment of diseases or conditions mediated by MDM2 / p53. In one embodiment, compounds are provided for inhibiting the interaction between MDM2 protein and p53.

[0515] In one embodiment, a pharmaceutical composition is provided comprising an effective amount of at least one compound as defined.

[0516] In one embodiment, a method is provided for the prevention or treatment of cancer comprising administering to a mammal a medicament comprising at least one compound as defined.

[0517] Pharmaceutical preparations While it is possible for the active compound to be administered alone, it will generally be presented as a pharmaceutical composition (eg, a formulation).

[0518] The present invention therefore further relates to a pharmaceutical composition as defined above, as well as to a compound of formula (I o ), together with (e.g., in admixture with) one or more pharmaceutically acceptable excipients, and optionally, other therapeutic or prophylactic agents as described herein.

[0519] The pharmaceutically acceptable excipient may be selected from, for example, a carrier (e.g., a solid, liquid, or semi-solid carrier), an adjuvant, a diluent, a filler or extender, a granulating agent, a coating agent, a release-controlling agent, a binder, a disintegrant, a lubricant, a preservative, an antioxidant, a buffer, a suspending agent, a thickener, a flavoring agent, a sweetener, a taste-masking agent, a stabilizer, or any other excipient conventionally used in pharmaceutical compositions. Examples of excipients for various types of pharmaceutical compositions are provided in more detail below.

[0520] The term "pharmaceutically acceptable," as used herein, refers to compounds, materials, compositions, and / or dosage forms that are, within the scope of sound medical judgment, suitable for use in contact with the tissues of a subject (e.g., a human subject) without undue toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit / risk ratio. Each excipient must also be "acceptable" in the sense of being compatible with the other ingredients of the formulation.

[0521] Formula (I oPharmaceutical compositions containing MDM2 antagonists, including compounds of formula (I), can be formulated according to known techniques. See, for example, Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA, USA.

[0522] The pharmaceutical compositions may be in any form suitable for oral, parenteral, topical, intranasal, intrabronchial, sublingual, intraocular, intraaural, rectal, intravaginal, or transdermal administration. When the compositions are intended for parenteral administration, they can be formulated for intravenous, intramuscular, intraperitoneal, subcutaneous administration, or for direct delivery to a target organ or tissue by injection, infusion, or other delivery means. Delivery may be by bolus injection, short-term infusion, or long-term infusion, and may be achieved via passive delivery or by using a suitable infusion pump or syringe driver.

[0523] Pharmaceutical formulations suitable for parenteral administration include aqueous and non-aqueous sterile injection solutions that may contain antioxidants, buffers, bacteriostats, cosolvents, surfactants, organic solvent mixtures, cyclodextrin complexing agents, emulsifiers (for forming and stabilizing emulsion formulations), liposome components for forming liposomes, gellable polymers for forming polymer gels, lyoprotectants, and especially combinations of agents for stabilizing the active ingredient in a soluble form and making the formulation isotonic with the blood of the intended recipient. Pharmaceutical formulations for parenteral administration can also be in the form of aqueous and non-aqueous sterile suspensions that may contain suspending agents and thickening agents (RG Strickly, Solubilizing Excipients in Oral and Injectable Formulations, Pharmaceutical Research, Vol. 21(2) 2004, p. 201-230).

[0524] The formulation may be provided in a unit-dose or multi-dose container, such as sealed ampoules, vials and pre-filled syringes, and may be stored in a freeze-dried (lyophilized) state, and just before use, sterile liquid carriers such as water for injections are added.In one embodiment, the formulation is provided as an active pharmaceutical ingredient in a bottle, which is then reconstituted with a suitable diluent.

[0525] The pharmaceutical formulation comprises a compound of formula (I o MDM2 antagonists, including compounds of the formula (I), or subgroups thereof, can be prepared by lyophilization. Lyophilization refers to the procedure of freeze-drying a composition. Thus, freeze-drying and lyophilization are used synonymously herein.

[0526] Extemporaneous injection solutions and suspensions may be prepared from sterile powders, granules and tablets.

[0527] The pharmaceutical compositions of the present invention for parenteral injection can also comprise pharmaceutically acceptable sterile aqueous or non-aqueous solutions, dispersions, suspensions, or emulsions, as well as sterile powders for reconstitution into sterile injectable solutions or dispersions immediately before use. Examples of suitable aqueous and non-aqueous carriers, diluents, solvents, or excipients include water, ethanol, polyols (e.g., glycerol, propylene glycol, polyethylene glycol, etc.), carboxymethylcellulose and suitable mixtures thereof, vegetable oils (e.g., sunflower oil, safflower oil, corn oil, or olive oil), and injectable organic esters such as ethyl oleate. Proper fluidity can be maintained, for example, by using thickeners such as lecithin, maintaining the required particle size in the case of dispersions, and using surfactants.

[0528] The composition of the present invention may also contain adjuvants such as preservatives, wetting agents, emulsifiers, and dispersants.Prevention of microbial action can be ensured by including various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, sorbic acid, etc.It may also be desirable to include agents for adjusting tonicity, such as sugars and sodium chloride.The inclusion of agents that delay absorption, such as aluminum monostearate and gelatin, can result in prolonged absorption of injectable pharmaceutical forms.

[0529] In one exemplary embodiment of the present invention, the pharmaceutical composition is in a form suitable for iv administration, e.g., administration by injection or infusion. For intravenous administration, the solution can be administered as is or can be injected into an infusion bag (containing a pharmaceutically acceptable excipient such as 0.9% saline or 5% dextrose) before administration.

[0530] In another exemplary embodiment, the pharmaceutical composition is in a form suitable for subcutaneous (sc) administration.

[0531] Pharmaceutical dosage forms suitable for oral administration include tablets (coated or uncoated), capsules (hard or soft shell), caplets, pills, lozenges, syrups, solutions, powders, granules, elixirs and suspensions, sublingual tablets, wafers or patches such as buccal patches.

[0532] Thus, the tablet composition may contain a unit dose of the active compound together with an inert diluent or carrier such as a sugar or sugar alcohol, for example, lactose, sucrose, sorbitol, or mannitol; and / or a non-sugar-derived diluent such as sodium carbonate, calcium phosphate, calcium carbonate, or cellulose or its derivatives, for example, microcrystalline cellulose (MCC), methylcellulose, ethylcellulose, hydroxypropylmethylcellulose, and starch, for example, corn starch. Tablets may also contain standard ingredients such as binding and granulating agents such as polyvinylpyrrolidone, disintegrants (e.g., swellable cross-linked polymers such as cross-linked carboxymethylcellulose), lubricants (e.g., stearates), preservatives (e.g., parabens), antioxidants (e.g., BHT), buffers (e.g., phosphate or citrate buffers), and effervescent agents such as citric acid / bicarbonate mixtures. Such excipients are well known and need not be described in detail here.

[0533] Tablets can be designed to release the drug on contact with gastric juices (immediate-release tablets) or to release over an extended period of time or in a controlled manner in specific areas of the gastrointestinal tract (controlled-release tablets).

[0534] Capsule formulations may be of the hard or soft gelatin variety and may contain the active ingredient in solid, semi-solid, or liquid form. Gelatin capsules may be formed from animal gelatin or its synthetic or vegetable-derived equivalents.

[0535] Solid dosage forms (e.g., tablets, capsules, etc.) may be coated or uncoated. Coatings may function as protective films (e.g., polymers, waxes, or varnishes), as mechanisms for controlling drug release, or for aesthetic or identification purposes. Coatings (e.g., Eudragit™-type polymers) can be designed to release the active ingredient at a desired location in the gastrointestinal tract. Thus, coatings can be selected to degrade under specific pH conditions in the gastrointestinal tract, thereby selectively releasing the compound in the stomach or the ileum, duodenum, jejunum, or colon.

[0536] Instead of or in addition to a coating, the drug may be present in a solid matrix comprising a release-controlling agent, e.g., a release-retardant agent, which may be adapted to release the compound in a controlled manner in the gastrointestinal tract. Alternatively, the drug may be present in a polymer coating, e.g., a polymethacrylate polymer coating, which may be adapted to selectively release the compound under conditions of changing acidity or alkalinity in the gastrointestinal tract. Alternatively, the matrix material or release-retardant coating may take the form of an erodible polymer (e.g., maleic anhydride polymer) that erodes substantially continuously as the dosage form passes through the gastrointestinal tract. Alternatively, the coating may be designed to disintegrate under microbial action in the intestine. As a further option, the active compound may be formulated in a delivery system that provides osmotic control of the release of the compound. Osmotic release and other delayed- or sustained-release formulations (e.g., formulations based on ion exchange resins) may be prepared according to methods well known to those skilled in the art.

[0537] Formula (I oMDM2 antagonists, including compounds of the formula (I), can be formulated with carriers and administered in the form of nanoparticles, where the increased surface area of ​​nanoparticles aids their absorption. Furthermore, nanoparticles offer the possibility of direct penetration into cells. Nanoparticle drug delivery systems are described in "Nanoparticle Technology for Drug Delivery," edited by Ram B. Gupta and Uday B. Kompella, Informa Healthcare, ISBN 9781574448573, published March 13, 2006. Nanoparticles for drug delivery are also described in J. Control. Release, 2003, 91 (1-2), 167-172, and Sinha et al., Mol. Cancer Ther. August 1, (2006) 5, 1909.

[0538] A pharmaceutical composition generally comprises approximately 1% (w / w) to approximately 95% of an active ingredient and 99% (w / w) to 5% (w / w) of a pharmaceutically acceptable excipient or a combination of excipients. Generally, a composition comprises approximately 20% (w / w) to approximately 90% (w / w) of an active ingredient and 80% (w / w) to 10% of a pharmaceutically acceptable excipient or a combination of excipients. A pharmaceutical composition comprises approximately 1% to approximately 95%, generally approximately 20% to approximately 90%, of an active ingredient. A pharmaceutical composition according to the present invention may be, for example, in unit dose form, such as an ampule, vial, suppository, pre-filled syringe, dragee, tablet, or capsule.

[0539] Pharmaceutically acceptable excipients can be selected according to the desired physical form of the formulation and can be selected from, for example, diluents (e.g., solid diluents such as fillers or bulking agents; and liquid diluents such as solvents and cosolvents), disintegrants, buffers, lubricants, flow aids, release-controlling (e.g., release-retarding or delaying polymers or waxes) agents, binders, granulating agents, dyes, plasticizers, antioxidants, preservatives, flavors, taste-masking agents, tonicity adjusters, and coating agents.

[0540] Those skilled in the art have the expertise to select appropriate amounts of ingredients for use in a formulation. For example, tablets and capsules typically contain 0-20% disintegrant, 0-5% lubricant, 0-5% flow aid, and / or 0-99% (w / w) filler or extender (depending on drug dose). They also contain 0-10% (w / w) polymer binder, 0-5% (w / w) antioxidant, and 0-5% (w / w) pigment. Extended-release tablets additionally contain 0-99% (w / w) polymer (depending on dose). The film coat of a tablet or capsule typically contains 0-10% (w / w) release-controlling (e.g., retarding) polymer, 0-3% (w / w) pigment, and / or 0-2% (w / w) plasticizer.

[0541] Parenteral formulations generally contain 0-20% (w / w) buffer, 0-50% (w / w) cosolvent, and / or 0-99% (w / w) water for injection (WFI) (depending on the dose, if freeze-dried). Formulations for intramuscular depots may also contain 0-99% (w / w) oil.

[0542] Pharmaceutical compositions for oral administration can be obtained by combining the active ingredient with a solid carrier, optionally granulating the resulting mixture, and, after adding suitable excipients if desired or necessary, processing the mixture into tablets, dragee cores or capsules. They can also be incorporated into polymer or wax matrices that allow the active ingredient to diffuse or release in measured amounts.

[0543] The compounds used in the present invention can also be formulated as solid dispersions. A solid dispersion is a homogeneous, very finely dispersed phase of two or more solids. Solid solutions (molecular dispersion systems), a type of solid dispersion, are well known for use in pharmaceutical technology (see Chiou and Riegelman, J. Pharm. Sci., 60, 1281-1300 (1971)), and are useful for increasing the dissolution rate and bioavailability of poorly water-soluble drugs.

[0544] The present invention also provides solid dosage forms comprising the solid solutions described herein. Solid dosage forms include tablets, capsules, chewable tablets, and dispersible or effervescent tablets. Known excipients can be mixed with the solid solution to obtain the desired dosage form. For example, capsules can contain the solid solution mixed with (a) a disintegrant and a lubricant, or (b) a disintegrant, a lubricant, and a surfactant. Additionally, capsules can contain a filler such as lactose or microcrystalline cellulose. Tablets can contain the solid solution mixed with at least one disintegrant, a lubricant, a surfactant, a filler, and a glidant. Chewable tablets can contain the solid solution mixed with a filler, a lubricant, and optionally, an additional sweetener (e.g., an artificial sweetener), and a suitable flavor. Solid solutions can also be formed by spraying a solution of the drug and a suitable polymer onto the surface of an inert carrier, such as sugar beads ("nonpareils"). These beads can then be filled into capsules or compressed into tablets.

[0545] Pharmaceutical preparations can be presented to patients in "patient packs" that contain the entire course of treatment in a single package, usually a blister pack. Patient packs have an advantage over traditional prescriptions, in which a pharmacist portions out a patient's supply of medication from a bulk supply, in that the patient has ready access to the package insert contained in the patient pack, which is typically not present on the patient's prescription. The inclusion of a package insert has been shown to improve patient compliance with physician instructions.

[0546] Compositions for topical use and nasal delivery include ointments, creams, sprays, patches, gels, drops, and inserts (e.g., intraocular inserts). Such compositions can be formulated according to known methods.

[0547] Examples of formulations for rectal or vaginal administration include pessaries and suppositories, which may be formed, for example, from a moldable or waxy material containing the active compound. Solutions of the active compound may also be used for rectal administration.

[0548] The composition for inhalation administration can take the form of an inhalable powder composition or a liquid or powder spray, and can be administered in standard form using a powder inhaler or aerosol dispensing device. Such devices are well known. For inhalation administration, powder formulations generally comprise the active compound together with an inert solid powder diluent such as lactose.

[0549] Formula (I o MDM2 antagonists, including compounds of the formula (I), are generally provided in unit dosage form and, thus, generally contain sufficient compound to provide a desired level of biological activity. For example, a formulation may contain 1 nanogram to 2 grams of active ingredient, e.g., 1 nanogram to 2 milligrams of active ingredient. Within these ranges, specific subranges of compound may contain 0.1 milligram to 2 grams of active ingredient (more usually 10 milligrams to 1 gram, e.g., 50 milligrams to 500 milligrams), or 1 microgram to 20 milligrams (e.g., 1 microgram to 10 milligrams, e.g., 0.1 milligram to 2 milligrams of active ingredient).

[0550] For oral compositions, a unit dosage form may contain from 1 microgram to 2 grams, more usually 10 milligrams to 1 gram, for example, 50 milligrams to 1 gram, for example, 100 milligrams to 1 gram of active compound.

[0551] The active compound is administered to a patient (eg, a human or animal patient) in need thereof in an amount sufficient to achieve the desired therapeutic effect.

[0552] Combination with other anticancer drugs MDM2 antagonists as defined herein may be useful in the prevention or treatment of a range of diseases or conditions mediated by MDM2 / p53, examples of such diseases and conditions are set out above.

[0553] These compounds are generally administered to a subject in need of such administration, for example a human or animal patient, generally a human.

[0554] Such compounds are generally administered in amounts that are therapeutically or prophylactically useful and generally non-toxic. However, in certain circumstances (e.g., in the case of life-threatening diseases), compounds of formula (I) may be administered. o It is possible that the benefits of administering a compound used in a therapeutic agent may outweigh the drawbacks of toxic or side effects, in which case it may be desirable to administer the compound with some degree of toxicity.

[0555] The compounds may be administered over an extended period of time to maintain beneficial therapeutic effects, or for a shorter period of time, or they may be administered continuously or in a manner to provide intermittent dosing (e.g., in a pulsatile manner).

[0556] A typical daily dose of an MDM2 antagonist can range from 100 picograms to 100 milligrams per kilogram of body weight, more typically from 5 nanograms to 25 milligrams per kilogram of body weight, and more usually from 10 nanograms to 15 milligrams per kilogram (e.g., 10 nanograms to 10 milligrams, more typically from 1 microgram / kilogram to 20 milligrams per kilogram, e.g., 1 microgram to 10 milligrams per kilogram) per kilogram of body weight, although higher or lower doses can be administered if necessary. o The compound of formula (I) can be administered daily or repeatedly, for example, every 2, or 3, or 4, or 5, or 6, or 7, or 10, or 14, or 21, or 28 days.

[0557] Dose is also defined as the amount of drug administered relative to the patient's body surface area (mg / m 2 A typical daily dose of an MDM2 antagonist is 3700 pg / m 2 ~3700mg / m 2 , more commonly 185 ng / m 2 ~925mg / m 2 , more usually 370 ng / m 2 ~555mg / m 2 (e.g., 370 ng / m2 ~370mg / m 2 , more commonly 37 mg / m 2 ~740mg / m 2 , e.g., 37 mg / m 2 ~370mg / m 2 ), although higher or lower doses can be administered if necessary. o The compound of formula (I) can be administered daily or repeatedly, for example, every 2, or 3, or 4, or 5, or 6, or 7, or 10, or 14, or 21, or 28 days.

[0558] The compounds used in the present invention can be administered orally in a range of doses, e.g., 0.1 to 5000 mg, or 1 to 1500 mg, 2 to 800 mg, or 5 to 500 mg, e.g., 2 to 200 mg or 10 to 1000 mg, specific dose examples including 10, 20, 50, and 80 mg. The compounds can be administered one or more times daily. The compound can be administered continuously (i.e., taken daily without a break for the duration of the treatment regimen). Alternatively, the compound can be administered intermittently (i.e., taken continuously for a predetermined period, such as one week, for the duration of the treatment regimen, followed by a break for a period, such as one week, followed by another period, such as one week). Examples of treatment regimens involving intermittent administration include regimens in which the compound is administered for one week on and one week off; or two weeks on and one week off; or three weeks on and one week off; or two weeks on and two weeks off; or four weeks on and two weeks off; or one week on and three weeks off, for one or more cycles, e.g., 2, 3, 4, 5, 6, 7, 8, 9, or 10 cycles. This intermittent treatment can also be based on days rather than weeks. For example, treatment can include daily dosing for one to six days, followed by one to six days off, with this pattern repeated throughout the treatment protocol. The number of days (or weeks) during which the compound used in the present invention is not administered does not necessarily have to be equal to the number of days (or weeks) during which the compound used in the present invention is administered.

[0559] In one embodiment, the compounds used in the present invention are administered at a dose of 3 mg / m daily. 2 ~125mg / m 2 The amount of 5-HT-1000 administered may be in the range of 0.01 to 0.01. Treatment may be by continuous daily administration or, more usually, may consist of multiple therapeutic cycles separated by treatment breaks. An example of a single treatment cycle is five consecutive daily doses followed by three weeks without treatment.

[0560] One particular dosing regimen is once daily (e.g., orally) for one week (e.g., five days of treatment) followed by one, two, or three weeks off treatment. Another dosing regimen is once weekly (e.g., orally) for one, two, three, or four weeks.

[0561] In one particular dosing schedule, the patient receives a dose of Formula (I o Infusion of the compound is given for one hour daily for up to 10 days, particularly up to 5 days per week, with the treatment repeated at desired intervals, for example every 2-4 weeks, particularly every 3 weeks.

[0562] More particularly, the patient is treated with a compound of formula (I o ) compound is infused for 1 hour daily for 5 days, with this treatment repeated every 3 weeks.

[0563] In another particular dosing schedule, the patient is given an infusion over 30 minutes to 1 hour, followed by a maintenance infusion of variable duration, for example, 1 to 5 hours, eg, 3 hours.

[0564] The compound used in the present invention can also be administered by bolus or continuous infusion.The compound used in the present invention can be administered every day to once a week, or once every two weeks, or once every three weeks, or once every four weeks during a treatment cycle.When administered every day during a treatment cycle, this daily administration can be discontinuous over the number of weeks of the treatment cycle, for example, administering for one week (or several days) and not administering for one week (or several days), and this pattern is repeated during the treatment cycle.

[0565] In a more particular dosing schedule, the patient is given a continuous infusion for 12 hours to 5 days, particularly a continuous infusion for 24 hours to 72 hours.

[0566] Ultimately, however, the amount of compound administered and the type of composition used will be commensurate with the nature of the disease or physiological condition being treated and will be at the discretion of the physician.

[0567] It may be beneficial to use the compounds used in the present invention as a single agent or to combine the compounds used in the present invention with another agent that acts through a different mechanism to regulate cell proliferation to treat two of the characteristic features of cancer development. Combination experiments can be performed, for example, as described in Chou TC, Talalay P. Quantitative analysis of dose-effect relationships: the combined effects of multiple drugs or enzyme inhibitors. Adv Enzyme Regulat 1984;22:27-55.

[0568] The compounds as defined herein can be administered as a single therapeutic agent, or can be administered in combination with one or more other compounds (or therapies) for the treatment of certain conditions, such as tumor diseases, such as cancers as defined above. For the treatment of the above conditions, the compounds used in the present invention can be advantageously used in cancer treatment in combination with one or more other drugs, more particularly other anti-cancer drugs or adjuvants (auxiliary agents in treatment). Examples of other therapeutic agents or treatments that can be administered together with the MDM2 antagonist (simultaneously or at different time intervals) include, but are not limited to: Topoisomerase I inhibitors ·Antimetabolites Tubulin-targeting drugs DNA binders and topoisomerase II inhibitors Alkylating agents Monoclonal antibodies Antihormonal agents Signal transduction inhibitors Proteasome inhibitors DNA methyltransferase inhibitors Cytokines and retinoids Chromatin-targeted therapy Radiation therapy, and Other therapeutic or preventative medications

[0569] Specific examples of anti-cancer agents or adjuvants (or salts thereof) include, but are not limited to, any of the agents selected from the following groups (i) to (xlviii), and optionally group (xlix): (i) platinum compounds, such as cisplatin (optionally in combination with amifostine), carboplatin or oxaliplatin; (ii) a taxane compound, such as paclitaxel, paclitaxel protein-bound particles (Abraxane™), docetaxel, cabazitaxel, or larotaxel; (iii) a topoisomerase I inhibitor, e.g., a camptothecin compound, e.g., camptothecin, irinotecan (CPT11), SN-38, or topotecan; (iv) topoisomerase II inhibitors, such as antitumor epipodophyllotoxins or podophyllotoxin derivatives, such as etoposide or teniposide; (v) Vinca alkaloids, such as vinblastine, vincristine, liposomal vincristine (Onco-TCS), vinorelbine, vindesine, vinflunine, or vinbecil; (vi) nucleoside derivatives, such as 5-fluorouracil (5-FU, optionally in combination with leucovorin), gemcitabine, capecitabine, tegafur, UFT, S1, cladribine, cytarabine (Ara-C, cytosine arabinoside), fludarabine, clofarabine, or nelarabine; (vii) antimetabolites, e.g., clofarabine, aminopterin, or methotrexate, azacitidine, cytarabine, floxuridine, pentostatin, thioguanine, thiopurine, 6-mercaptopurine, or hydroxyurea (hydroxycarbamide); (viii) alkylating agents, e.g., nitrogen mustards or nitrosoureas, e.g., cyclophosphamide, chlorambucil, carmustine (BCNU), bendamustine, thiotepa, melphalan, treosulfan, lomustine (CCNU), altretamine, busulfan, dacarbazine, estramustine, fotemustine, ifosfamide (optionally in combination with mesna), pipobroman, procarbazine, streptozocin, temozolomide, uracil, mechlorethamine, methylcyclohexylchloroethylnitrourea, or nimustine (ACNU); (ix) anthracyclines, anthracenediones and related drugs, such as daunorubicin, doxorubicin (optionally in combination with dexrazoxane), liposomal doxorubicin formulations (e.g., Kaelix™, Myocet™, Doxil™), idarubicin, mitoxantrone, epirubicin, amsacrine, or valrubicin; (x) Epothilones, such as ixabepilone, patupilone, BMS-310705, KOS-862 and ZK-EPO, epothilone A, epothilone B, desoxyepothilone B (also known as epothilone D or KOS-862), azaepothilone B (also known as BMS-247550), laulimalide, isolaulimalide, or lueterobin; (xi) a DNA methyltransferase inhibitor, e.g., temozolomide, azacitidine, or decitabine; (xii) a folate antagonist, e.g., methotrexate, pemetrexed disodium, or raltitrexed; (xiii) cytotoxic antibiotics, such as antinomycin D, bleomycin, mitomycin C, dactinomycin, carminomycin, daunomycin, levamisole, plicamycin, or mithramycin; (xiv) tubulin-binding agents, such as combrestatin, colchicine, or nocodazole; (xv) signal transduction inhibitors, for example, kinase inhibitors, for example, receptor tyrosine kinase inhibitors (e.g., EGFR (epidermal growth factor receptor) inhibitors, VEGFR (vascular endothelial growth factor receptor) inhibitors, PDGFR (platelet-derived growth factor receptor) inhibitors, Axl inhibitors, MTKI (multiple targeted kinase inhibitors), Raf inhibitors, ROCK inhibitors, mTOR inhibitors, MEK inhibitors or PI3K inhibitors), for example, imatinib mesylate, erlotinib, gefitinib, dasatinib, lapatinib, dovotinib, axitinib, nilotinib, vandetanib, vatalinib, pazopanib, sorafenib, sunitinib, temsirolimus, everolimus (RAD 001), vemurafenib (PLX4032 or RG7204), dabrafenib, encorafenib, selumetinib (AZD6244), trametinib (GSK121120212), dactolisib (BEZ235), buparlisib (BKM-120; NVP-BKM-120), BYL719, copanlisib (BAY-80-6946), ZSTK-474, CUDC-907, apitolisib (GDC-0980; RG-7422), pictilisib (pictilisib, GDC-0941, RG-7321), GDC-0032, GDC-0068, GSK-2636771, idelalisib (formerly CAL-101, GS 1101, GS-1101), MLN1117 (INK1117), MLN0128 (INK128), IPI-145 (INK1197), LY-3023414, ipatasertib, afuresertib, MK-2206, MK-8156, LY-3023414, LY294002, SF1126 or PI-103, sonolisib (PX-866), or AT13148, (xvi) Aurora kinase inhibitors, such as AT9283, barasertib (AZD1152), TAK-901, MK0457 (VX680), cenisertib (R-763), danusertib (PHA-739358), alisertib (MLN-8237), or MP-470; (xvii) CDK inhibitors, for example, AT7519, roscovitine, seliciclib, alvocidib (flavopiridol), dinaciclib (SCH-727965), 7-hydroxy-staurosporine (UCN-01), JNJ-7706621, BMS-387032 (also known as SNS-032), PHA533533, ZK-304709, or AZD-5438, and also CDK4 inhibitors such as palbociclib (PD332991) and ribociclib (LEE-011); (xviii) PKA / B inhibitors and PKB(akt) pathway inhibitors, such as AT13148, AZ-5363, Semaphore, SF1126, and MTOR inhibitors, such as rapamycin analogs, AP23841 and AP23573, calmodulin inhibitors (forkhead translocation inhibitors), API-2 / TCN (triciribine), RX-0201, enzastaurin HCl (LY317615), NL-71-101, SR-13668, PX-316, or KRX-0401 (Perifosine / NSC 639966); (xix) Hsp90 inhibitors, such as onarespib (AT13387), herbimycin, geldanamycin (GA), 17-allylamino-17-desmethoxygeldanamycin (17-AAG), such as NSC-330507, Kos-953, and CNF-1010, 17-dimethylaminoethylamino-17-demethoxygeldanamycin hydrochloride (17-DMAG), such as NSC-707545 and Kos-1022, NVP-AUY922 (VER-52296), NVP-BEP800, CNF-2024 (BIIB-021 as an oral purine), ganetespib (STA-9090), SNX-5422 (SC-102112), or IPI-504; (xx) Monoclonal antibodies (unconjugated or conjugated to radioisotopes, toxins or other drugs), antibody derivatives and related drugs, for example, anti-CD antibodies, anti-VEGFR antibodies, anti-HER2 antibodies or anti-EGFR antibodies, for example, rituximab (CD20), ofatumumab (CD20), ibritumomab tiuxetan (CD20), GA101 (CD20), tositumomab (CD20), epratuzumab (CD22), lintuzumab (CD33), Gemtuzumab-ozogamicin (CD33), alemtuzumab (CD52), galiximab (CD80), trastuzumab (HER2 antibody), pertuzumab (HER2), trastuzumab-DM1 (HER2), ertumaxomab (HER2 and CD3), cetuximab (EGFR), panitumumab (EGFR), necitumumab (EGFR), nimotuzumab (EGFR), bevacizumab (VEGF), catumaxomab (EpCAM and CD 3), abagovomab (CA125), farletuzumab (folate receptor), elotuzumab (CS1), denosumab (RANK ligand), figitumumab (IGF1R), CP751,871 (IGF1R), mapatumumab (TRAIL receptor), metMAB (met), mitumomab (GD3 ganglioside), naptumomab estafenatox (5T4), or siltuximab (IL6) or immunomodulatory agents, such as CTLA-4 blocking antibodies and / or antibodies against PD-1 and PD-L1 and / or PD-L2, such as ipilimumab (CTLA4), MK-3475 (pembrolizumab, formerly lambrolizumab, anti-PD-1), nivolumab (anti-PD-1), BMS-936559 (anti-PD-L1), MPDL320A, AMP-514 or MEDI4736 (anti-PD-L1), or tremelimumab (formerly ticilimumab, CP-675,206, anti-CTLA-4); (xxi) estrogen receptor antagonists or selective estrogen receptor modulators (SERMs) or estrogen synthesis inhibitors, such as tamoxifen, fulvestrant, toremifene, droloxifene, faslodex, or raloxifene; (xxii) aromatase inhibitors and related drugs, such as exemestane, anastrozole, letrazole, testolactone aminoglutethimide, mitotane or vorozole; (xxiii) antiandrogens (i.e., androgen receptor antagonists) and related agents, such as bicalutamide, nilutamide, flutamide, cyproterone, or ketoconazole; (xxiv) hormones and their analogs, such as medroxyprogesterone, diethylstilbestrol (also known as diethylstilboestrol) or octreotide; (xxv) steroids, such as dromostanolone propionate, megestrol acetate, nandrolone (decanoate, phenpropionate), fluoxymestrone or gossypol; (xxvi) steroid cytochrome P450 17α-hydroxylase-17,20-lyase inhibitors (CYP17), such as abiraterone; (xxvii) gonadotropin-releasing hormone agonists or antagonists (GnRAs), such as abarelix, goserelin acetate, histrelin acetate, leuprolide acetate, triptorelin, buserelin, or deslorelin; (xxviii) Glucocorticoids, such as prednisone, prednisolone, dexamethasone; (xxix) differentiation inducers such as retinoids, rexinoids, vitamin D or retinoic acid and retinoic acid metabolism blockers (RAMBAs), for example, Accutane, alitretinoin, bexarotene, or tretinoin; (xxx) farnesyltransferase inhibitors, for example, tipifarnib; (xxxi) chromatin-targeted therapeutic agents, for example, histone deacetylase (HDAC) inhibitors, such as sodium butyrate, suberoylanilide hydroxamic acid (SAHA), depsipeptide (FR 901228), dacinostat (NVP-LAQ824), R306465 / JNJ-16241199, JNJ-26481585, trichostatin A, vorinostat, chlamydocin, A-173, JNJ-MGCD-0103, PXD-101, or apicidin; (xxxii) proteasome inhibitors, such as bortezomib, carfilzomib, CEP-18770, MLN-9708, or ONX-0912; NEDD8 inhibitors; drugs targeting the ubiquitin-proteasome pathway, including HDM2 antagonists and deubiquitinases (DUBs); (xxxiii) photodynamic agents, such as porfimer sodium or temoporfin; (xxxiv) anticancer agents derived from marine organisms, for example, trabectidin; (xxxv) Radiolabeled drugs for radioimmunotherapy, for example, with beta particle-emitting isotopes (e.g., iodine-131, yttrium-90) or alpha particle-emitting isotopes (e.g., bismuth-213 or actinium-225), such as ibritumomab or iodine tositumomab or alpha radium-223; (xxxvi) telomerase inhibitors, for example, telomestatin; (xxxvii) matrix metalloproteinase inhibitors, such as batimastat, marimastat, prinostat, or metastat; (xxxviii) recombinant interferons (e.g., interferon-gamma and interferon-alpha) and interleukins (e.g., interleukin-2), such as aldesleukin, denileukin diftitox, interferon-alpha-2a, interferon-alpha-2b, or pegylated interferon-alpha-2b; (xxxix) selective immune response modifiers, such as thalidomide or lenalidomide; (xl) therapeutic vaccines, e.g., sipuleucel-T (Provenge) or OncoVex; (xli) Cytokine activators include picibanil, romurtide, sizofiran, virulidin, or thymosin; (xlii) arsenic trioxide; (xliii) G protein-coupled receptor (GPCR) inhibitors, for example, atrasentan; (xliv) an enzyme, such as L-asparaginase, pegaspargase, rasburicase, or pegademase; (xlv) DNA repair inhibitors, for example, PARP inhibitors, for example, olaparib, veliparib, iniparib, INO-1001, AG-014699, or ONO-2231; (xlvi) agonists of death receptors (e.g., TNF-related apoptosis-inducing ligand (TRAIL) receptors), for example, mapatumumab (formerly HGS-ETR1), conatumumab (formerly AMG655), PRO95780, lexatumumab, dulanermin, CS-1008, multitargeted or recombinant TRAIL ligands, for example, recombinant human TRAIL / Apo2 ligand; (xlvii) Immunotherapeutic drugs, such as immune checkpoint inhibitors; cancer vaccines and CAR-T cell therapies; (xlviii) regulators of cell death (apoptosis)-inducing Bcl-2 (B-cell lymphoma 2) antagonists, such as venetoclax (ABT-199 or GDC-0199), ABT-737, ABT-263, TW-37, sabutoclax, obatoclax, as well as LCL-161 (Novartis), Debio-1143 (Debiopharma / Ascenta), MIM1 and IAP antagonists, including AZD5582, birinapant / TL-32711 (TetraLogic), CUDC-427 / GDC-0917 / RG-7459 (Genentech), JP1201 (Joyant), T-3256336 (Takeda), GDC-0152 (Genentech), or HGS-1029 / AEG-40826 (HGS / Aegera); (xlix) Prophylactic (adjuvant) agents; i.e., agents that reduce or alleviate some of the side effects associated with chemotherapy drugs, e.g., antiemetics, Agents that prevent or shorten the duration of chemotherapy-related neutropenia and prevent complications resulting from decreased levels of platelets, red blood cells, or white blood cells, such as interleukin-11 (e.g., oprelvekin), erythropoietin (EPO) and its analogs (e.g., darbepoetin alfa), colony-stimulating factor analogs such as granulocyte-macrophage-colony-stimulating factor (GM-CSF) (e.g., sargramostim), and granulocyte-colony-stimulating factor (G-CSF) and its analogs (e.g., filgrastim, pegfilgrastim), Agents that inhibit bone resorption, such as denosumab or bisphosphonates, such as zoledronate, zoledronic acid, pamidronate and ibandronate; Agents that suppress the inflammatory response, such as dexamethasone, prednisone, and prednisolone; Medications used to reduce blood levels of growth hormone and IGF-I (and other hormones) in patients with acromegaly or other rare hormone-producing tumors, such as synthetic forms of the hormone somatostatin, e.g., octreotide acetate; antidotes to drugs that reduce folic acid levels, such as leucovorin or folinic acid; medicines for pain, such as opiates, e.g., morphine, diamorphine and fentanyl; Nonsteroidal anti-inflammatory drugs (NSAIDs), such as COX-2 inhibitors, for example, celecoxib, etoricoxib, and lumiracoxib; Medications for mucositis, such as Palifermin, Agents for the treatment of side effects including anorexia, cachexia, edema or thromboembolic stroke, such as megestrol acetate.

[0570] In one embodiment, the biomarkers of the invention, particularly BAP1 and / or CDKN2A and / or the genes listed herein, can be used to select patients for treatment with an MDM2 antagonist in combination with one or more of the agents listed in (i)-(xlix) above. In one embodiment, the biomarkers of the invention, particularly BAP1 and / or CDKN2A and / or the interferon genes listed herein, can be used to select patients for treatment with an MDM2 antagonist in combination with recombinant interferon, a DNA repair inhibitor such as a PARP inhibitor; an IAP antagonist; a platinum compound; an alkylating agent, and / or radiation therapy.

[0571] In one embodiment, a patient's tumor is determined to be unsuitable for treatment with an MDM2 inhibitor as a single agent due to the presence of normal or high levels of BAP1 and / or CDKN2A, and / or low levels of interferon signature genes, and therefore the patient can be treated with an MDM2 inhibitor in combination with an additional agent that can be used to sensitize the tumor to the MDM2 antagonist. In one embodiment, the patient's tumor is determined to have normal or high BAP1 and / or normal or high CDKN2A, and / or low interferon signature genes, and is treated with an MDM2 antagonist in combination with an additional anti-cancer agent. In one embodiment, the patient's tumor is determined to exhibit the presence of BAP1 and / or CDKN2A and / or normal or elevated levels of BAP1 and / or CDKN2A gene expression, and / or low expression levels of interferon signature genes, and is treated with an MDM2 antagonist in combination with one or more of the agents listed in (i)-(xlix) above.

[0572] In one embodiment, the biomarkers of the invention, particularly BAP1 and / or CDKN2A and / or the genes listed herein, e.g., the interferon signature genes, can be used to treat a patient with an MDM2 antagonist in combination with one or more of the agents listed in (i) through (xlix) above.

[0573] In one embodiment, the biomarkers of the invention, particularly BAP1 and / or CDKN2A, can be used to select patients for treatment with an MDM2 antagonist in combination with recombinant interferons (e.g., interferon-gamma and interferon alpha) and interleukins (e.g., interleukin-2), such as aldesleukin, denileukin diftitox, interferon alpha-2a, interferon alpha-2b, or pegylated interferon alpha-2b. In one embodiment, a patient's tumor is determined to have normal or high BAP1 and / or CDKN2A and / or a low interferon signature and is treated with an MDM2 antagonist in combination with one or more recombinant interferons.

[0574] In one embodiment, the biomarkers of the present invention, particularly BAP1 and / or CDKN2A and / or the genes listed herein, can be used to select patients for treatment with an MDM2 antagonist in combination with a DNA repair inhibitor, such as a PARP inhibitor, for example, olaparib, veliparib, iniparib, INO-1001, AG-014699, or ONO-2231. In one embodiment, the patient's tumor is determined to have normal or high BAP1 and / or CDKN2A and / or low interferon signature genes, and is treated with an MDM2 antagonist in combination with a PARP inhibitor. In one embodiment, the PARP inhibitor is selected from, for example, olaparib, rucaparib, veliparib, iniparib, INO-1001, AG-014699, ONO-2231; and talazoparib.

[0575] In one embodiment, the biomarkers of the invention, in particular BAP1 and / or CDKN2A and / or the genes listed herein, can be used to select patients for treatment with an MDM2 antagonist in combination with an IAP antagonist, including LCL-161 (Novartis), Debio-1143 (Debiopharma / Ascenta), AZD5582, Birinapant / TL-32711 (TetraLogic), CUDC-427 / GDC-0917 / RG-7459 (Genentech), JP1201 (Joyant), T-3256336 (Takeda), GDC-0152 (Genentech), or HGS-1029 / AEG-40826 (HGS / Aegera). In one embodiment, the patient's tumor is determined to have normal or high BAP1 and / or CDKN2A, and / or low interferon signature genes, and is treated with an MDM2 antagonist in combination with an IAP antagonist. In one embodiment, the IAP antagonist is selected from, for example, LCL-161 (Novartis), Debio-1143 (Debiopharma / Ascenta), AZD5582, Birinapant / TL-32711 (TetraLogic), CUDC-427 / GDC-0917 / RG-7459 (Genentech), JP1201 (Joyant), T-3256336 (Takeda), GDC-0152 (Genentech), ASTX660, and HGS-1029 / AEG-40826 (HGS / Aegera).

[0576] In one embodiment, the biomarkers of the invention, in particular BAP1 and / or CDKN2A and / or the interferon genes mentioned herein, are administered in combination with platinum compounds such as cisplatin (optionally in combination with amifostine), carboplatin or oxaliplatin; alkylating agents such as nitrogen mustards or nitrosoureas, for example, cyclophosphamide, chlorambucil, carmustine (BCNU), bendamustine, thiotepa, melphalan, threonine ... It can be used to select patients for treatment with an MDM2 antagonist in combination with sulfane, lomustine (CCNU), altretamine, busulfan, dacarbazine, estramustine, fotemustine, ifosfamide (optionally in combination with mesna), pipobroman, procarbazine, streptozocin, temozolomide, uracil, mechlorethamine, methylcyclohexylchloroethylnitrosourea, or nimustine (ACNU), and / or radiation therapy. In one embodiment, the patient's tumor is determined to have normal or high BAP1 and / or CDKN2A and / or low interferon signature genes, and is treated with platinum compounds, e.g., cisplatin (optionally in combination with amifostine), carboplatin, or oxaliplatin; alkylating agents, e.g., nitrogen mustards or nitrosoureas, e.g., cyclophosphamide, chlorambucil, carmustine (BCNU), bendamustine, thiourea, or thiazolinone; Patients are treated with an MDM2 antagonist in combination with paclitaxel, melphalan, treosulfan, lomustine (CCNU), altretamine, busulfan, dacarbazine, estramustine, fotemustine, ifosfamide (optionally in combination with mesna), pipobroman, procarbazine, streptozocin, temozolomide, uracil, mechlorethamine, methylcyclohexylchloroethylnitrosourea, or nimustine (ACNU), and / or radiation therapy. In one embodiment, the platinum compound is selected from, for example, cisplatin (optionally in combination with amifostine), carboplatin, oxaliplatin, dicycloplatin, heptaplatin, lobaplatin, nedaplatin, satraplatin or triplatin tetranitrate, in particular cisplatin, carboplatin, and oxaliplatin. In one embodiment, the alkylating agent, such as a nitrogen mustard or nitrosourea, is selected from the group consisting of, for example, cyclophosphamide, chlorambucil, carmustine (BCNU), ambamustine, bendamustine, thiotepa, melphalan, treosulfan, lomustine (CCNU), busulfan, dacarbazine, estramustine, fotemustine, ifosfamide (optionally in combination with mesna), pipobroman, procarbazine, streptozocin, temozolomide, uracil, mechlorethamine, mechlorethamine oxide hydrochloride, methylcyclohexylchloroethylnitrourea, nimustine (ACNU), prednimustine, mechlorethamine, etoglucide; streptozotocin, irofulven, mitolactol, glufosfamide, evofosfamide, In one embodiment, the biomarkers of the invention, particularly BAP1 and / or CDKN2A and / or the genes listed herein, can be used to select patients for treatment with an MDM2 antagonist in combination with radiation therapy. In one embodiment, the patient's tumor is determined to have normal or high BAP1 and / or CDKN2A and / or low interferon signature genes and is treated with an MDM2 antagonist in combination with radiation therapy.

[0577] In another embodiment, a method of treating cancer in a patient is provided, the method comprising: (a) selecting patients having normal or high levels of BAP1 and / or CDKN2A (or low levels of an interferon signature) in a biological sample obtained from said patients; and (b) administering to the patient selected in step (a) a therapeutically effective amount of an MDM2 antagonist and an agent that induces sensitivity to the MDM2 antagonist, e.g., by decreasing the level of BAP1 and / or CDKN2A (or increasing the level of an interferon signature). The compound comprises:

[0578] In one embodiment, the agent or treatment for reducing the level of BAP1 and / or CDKN2A (or increasing the level of interferon signature) is an anti-cancer agent or anti-cancer treatment.In one embodiment, the agent or treatment for reducing the level of BAP1 and / or CDKN2A (or increasing the level of interferon signature) is recombinant interferon (for example, interferon-gamma and interferon alpha) and interleukin (for example, interleukin 2), such as aldesleukin, denileukin diftitox, interferon alpha 2a, interferon alpha 2b, or pegylated interferon alpha 2b, or DNA repair inhibitors, such as PARP inhibitors, or IAP antagonists, or platinum compounds, such as cisplatin (optionally in combination with amifostine), carboplatin or oxaliplatin; alkylating agents, such as nitrogen mustards or nitrosoureas, for example, cyclophosphamide, chlorambucil, carmustine (BCNU), bendamustine, thiotepa, melphalan, treosulfan, lomustine (CCNU), altretamine, busulfan, dacarbazine, estramustine, fotemustine, ifosfamide (optionally in combination with mesna), pipobroman, procarbazine, streptozocin, temozolomide, uracil, mechlorethamine, methylcyclohexylchloroethylnitrosourea, or nimustine (ACNU), and / or radiation therapy.

[0579] In one embodiment, the agent or treatment for inducing sensitivity, e.g., reducing the level of BAP1 and / or CDKN2A (or increasing the level of an interferon signature), is a recombinant interferon and interleukin, a DNA repair inhibitor, an IAP antagonist, or a platinum compound. In one embodiment, the agent or treatment for inducing sensitivity, e.g., reducing the level of BAP1 and / or CDKN2A (or increasing the level of an interferon signature), is an IAP antagonist.

[0580] In one embodiment, the agent or treatment for inducing apoptosis is an IAP antagonist. In one embodiment, the IAP antagonist is LCL-161 (Novartis), Debio-1143 (Debiopharma / Ascenta), AZD5582, Birinapant / TL-32711 (TetraLogic), CUDC-427 / GDC-0917 / RG-7459 (Genentech), JP1201 (Joyant), T-3256336 (Takeda), GDC-0152 (Genentech), or HGS-1029 / AEG-40826 (HGS / Aegera).

[0581] In one embodiment, the IAP antagonist is ASTX660, LCL-161 (Novartis), Debio-1143 (Debiopharma / Ascenta), AZD5582, Birinapant / TL-32711 (TetraLogic), CUDC-427 / GDC-0917 / RG-7459 (Genentech), JP1201 (Joyant), T-3256336 (Takeda), GDC-0152 (Genentech), or HGS-1029 / AEG-40826 (HGS / Aegera). In one embodiment, the IAP antagonist is ASTX660. In one embodiment, the invention relates to a combination of an MDM2 antiagonist, such as (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid and ASTX660.

[0582] In one aspect, the present invention provides a method for producing a medicament for a medicament comprising: (i) (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid ("isoindolin-1-one compound"), or a tautomer or solvate or pharmaceutically acceptable salt thereof; and (ii) 1-{6-[(4-fluorophenyl)methyl]-5-(hydroxymethyl)-3,3-dimethyl-1H,2H,3H-pyrrolo[3,2-b]pyridin-1-yl}-2-[(2R,5R)-5-methyl-2-{[(3R)-3-methylmorpholin-4-yl]methyl}piperazin-1-yl]ethan-1-one ("ASTX660"), or a tautomer, solvate, or pharmaceutically acceptable salt thereof. The combination of

[0583] In particular, this aspect of the invention provides: A combination as disclosed herein (e.g., a combination of an isoindolin-1-one compound or a tautomer or solvate or pharmaceutically acceptable salt thereof with ASTX660 or a tautomer or solvate or pharmaceutically acceptable salt thereof) and optionally one or more (e.g., one or two) other therapeutic agents (e.g., anticancer agents).

[0584] A combination as disclosed herein comprising an isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, e.g., ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, wherein the isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and the additional therapeutic agent, e.g., ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, are physically associated.

[0585] A combination comprising an isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and an additional therapeutic agent as disclosed herein, e.g., ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, wherein the isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and the additional therapeutic agent, e.g., ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, are (a) a mixture; (b) chemically / physicochemically linked; (c) chemically / physicochemically co-packaged; or (d) not mixed but co-packaged or coexisting.

[0586] A combination comprising an isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and an additional therapeutic agent as disclosed herein, e.g., ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, wherein the isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and the therapeutic agent, e.g., ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, are non-physically associated.

[0587] A combination comprising an isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and an additional therapeutic agent as disclosed herein, e.g., ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, which combination comprises: (a) at least one of two or more compounds with instructions for extemporaneous preparation association of at least one compound to form a physical association of the two or more compounds; or (b) at least one of two or more compounds with instructions for combination therapy using the two or more compounds; or (c) at least one of two or more compounds with instructions for administration to a patient population to which the other of the two or more compounds has been (or will be) administered; or (d) at least one of two or more compounds in an amount or form particularly suitable for use in combination with the other of the two or more compounds.

[0588] A combination comprising an isoindolin-1-one compound or a tautomer or solvate or pharmaceutically acceptable salt thereof and an additional therapeutic agent as disclosed herein, e.g., ASTX660 or a tautomer or solvate or pharmaceutically acceptable salt thereof, in the form of a pharmaceutical kit or patient pack.

[0589] A pharmaceutical composition comprising a combination comprising an isoindolin-1-one compound or a tautomer or solvate or pharmaceutically acceptable salt thereof and an additional therapeutic agent as disclosed herein, e.g., ASTX660 or a tautomer or solvate or pharmaceutically acceptable salt thereof.

[0590] A combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising such a combination as disclosed herein for use in therapy.

[0591] A combination comprising an isoindolin-1-one compound or a tautomer or solvate or pharmaceutically acceptable salt thereof and an additional therapeutic agent, such as ASTX660 or a tautomer or solvate or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising such a combination as disclosed herein for use in the prevention or treatment of a disease state or condition as described herein.

[0592] Use of a combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising a combination as disclosed herein, for the manufacture of a medicament for use in the prevention or treatment of a disease state or condition as described herein.

[0593] A method for the prevention or treatment of a disease or condition as described herein, comprising administering a combination comprising an isoindolin-1-one compound, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer, solvate, or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising a combination as disclosed herein.

[0594] A method for the prevention or treatment of a disease or condition as described herein, comprising administering to a patient in need thereof (i) an additional therapeutic agent, such as ASTX660, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, and (ii) an isoindolin-1-one compound as defined herein, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

[0595] In particular, a combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, for use in a method for the prevention or treatment as disclosed herein, wherein the disease state or condition is mediated by MDM2-p53, or a pharmaceutical composition comprising a combination as disclosed herein.

[0596] A combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising a combination as disclosed herein, or a method for prevention or treatment using a combination as disclosed herein (wherein the patient is selected according to the biomarkers described herein, in particular BAP1 depletion and / or CDKN2A depletion and / or increased expression of one or more interferon signature genes).

[0597] A combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising a combination as disclosed herein, or a method for prevention or treatment using a combination as disclosed herein (wherein the patient is selected as having a tumor with normal or high BAP1 and / or CDKN2A, and / or low interferon signature genes).

[0598] A combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising a combination as disclosed herein, or a method for the prevention or treatment using a combination as disclosed herein, wherein the disease state or condition is cancer.

[0599] A combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent, such as ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising a combination as disclosed herein, or a method for the prevention or treatment using a combination as disclosed herein, wherein the disease state or condition is cancer or acute myeloid leukemia.

[0600] A combination comprising an isoindolin-1-one compound, or a tautomer or solvate or pharmaceutically acceptable salt thereof, and an additional therapeutic agent as disclosed herein, e.g., ASTX660, or a tautomer or solvate or pharmaceutically acceptable salt thereof, for use as disclosed herein for the prevention or treatment of acute myeloid leukemia.

[0601] An isoindolin-1-one compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for use in the prevention or treatment of a disease state or condition as described herein (wherein the isoindolin-1-one compound is used in combination with an additional therapeutic agent, such as ASTX660, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof).

[0602] An isoindolin-1-one compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for use in the prevention or treatment of cancer as described herein (wherein the isoindolin-1-one compound is used in combination with an additional therapeutic agent, such as ASTX660, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof).

[0603] ASTX660, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for use in the prevention or treatment of a disease state or condition as described herein (wherein the therapeutic agent is used in combination with an isoindolin-1-one compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof).

[0604] An isoindolin-1-one compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for use in the prevention, treatment or management of cancer in a patient in need thereof, in combination therapy with an additional therapeutic agent, such as ASTX660, or a tautomer, solvate or pharmaceutically acceptable salt thereof, and optionally one or more other therapeutic agents.

[0605] Use of an isoindolin-1-one compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for the manufacture of a medicament for the treatment of cancer when the patient is being treated with another therapeutic agent, e.g., ASTX660, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

[0606] Use of a therapeutic agent, e.g., ASTX660, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for the manufacture of a medicament for the treatment of cancer, wherein a patient is treated with an isoindolin-1-one compound as disclosed herein, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

[0607] Use of an isoindolin-1-one compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for the manufacture of a medicament for use in improving or enhancing the response rate in a patient suffering from cancer when the patient is treated with another therapeutic agent, such as ASTX660, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

[0608] An isoindolin-1-one compound, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof...

Claims

1. An MDM2 antagonist for use in a method of treating a cancer that is BAP1 depleted.

2. The cancer is is CDKN2A depleted; and / or exhibiting increased expression of one, two, three, four, five or more interferon signature genes; 2. An MDM2 antagonist for use according to claim 1.

3. The interferon signature genes are CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, T 3. The MDM2 antagonist for use according to claim 2, which is RIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1.

4. The MDM2 antagonist for use according to any one of claims 1 to 3, wherein a sample of patient tissue is examined to determine a pre-treatment cancer expression profile.

5. 5. The MDM2 antagonist for use according to claim 4, wherein the sample comprises cancer DNA, ctDNA, or cancer cells.

6. 6. The MDM2 antagonist for use according to claim 4 or 5, wherein the test comprises an assay for detecting protein, mRNA and / or ctDNA.

7. 7. The MDM2 antagonist for use according to claim 6, wherein (i) the protein is detected using an immunoassay, a protein-binding assay, an antibody-based assay, an antigen-binding protein-based assay, a protein-based array, an enzyme-linked immunosorbent assay (ELISA), flow cytometry, a protein array, a blot, a Western blot, nephelometry, turbidimetry, chromatography, mass spectrometry, enzyme activity, radioimmunoassay, immunofluorescence, immunochemiluminescence, immunoelectrochemiluminescence, immunoelectrophoresis, competitive immunoassay, or immunoprecipitation; and / or (ii) the mRNA is detected using RT-PCR or a quantitative gene expression assay.

8. The MDM2 antagonist for use according to any one of claims 4 to 7, wherein the patient undergoes a selection of treatment based on the determined expression profile.

9. The cancer (i) non-small cell lung cancer, mesothelioma, glioblastoma, or clear cell renal carcinoma; or (ii) brain, clear cell renal cell carcinoma (ccRCC), esophageal cancer or melanoma 9. The MDM2 antagonist for use according to any one of claims 1 to 8, which is

10. The MDM2 antagonist for use according to any one of claims 1 to 9, wherein the cancer is P53 wild type.

11. The MDM2 antagonist for use according to any one of claims 1 to 10, wherein the cancer cells undergo apoptosis after the treatment step.

12. The MDM2 antagonist for use according to any one of claims 1 to 11, wherein the MDM2 antagonist induces activated caspase-3 in at least a proportion of cancer cells.

13. 13. The MDM2 antagonist for use according to claim 12, wherein the MDM2 antagonist induces activated caspase-3 in at least 40% of cancer cells or at least 60% of cancer cells.

14. the cancer has a higher expression level of CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, 14. The MDM2 antagonist for use according to any one of claims 1 to 13, which exhibits increased expression of one, two, three, four, five or more of C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1 and WARS.

15. 15. The MDM2 antagonist for use according to claim 14, wherein the cancer exhibits increased expression of CXCL10 or CXCL11.

16. 16. The MDM2 antagonist for use according to any one of claims 1 to 15, wherein the cancer exhibits increased expression of one, two, three, four, five or more of IRF7, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, IRF9, FLI1 and BRCA1.

17. The MDM2 antagonist is of formula (I) as defined herein. ｏ or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof, such as (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

18. The MDM2 antagonist is selected from the group consisting of idasanutlin (RG-7388), HDM-201, KRT-232 (AMG-232), ALRN-6924, MI-773 (SAR405838), CGM-097, milademethanthosylate, APG-115, BI-907828, LE-004, and DS-5272. , SJ-0211, BI-0252, AM-7209, SP-141, SCH-1450206, NXN-6, ADO-21, CTX-50-CTX- 1, ISA-27, RO-8994, RO-6839921, ATSP-7041, SAH-p53-8, PM-2, K-178, MMRi-64 and 【Chemical 1】 18. The MDM2 antagonist for use according to any one of claims 1 to 17, selected from the group consisting of: or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

19. the expression level of BAP1 in a cancer cell sample from a human patient as one or more biomarkers for assessing whether the cancer is sensitive to treatment with an MDM2 antagonist, and optionally CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1 , CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S , DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1; The use of expression levels of one or more of For example, the MDM2 antagonist may be a compound of formula I as defined herein. ｏ or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof, for example, (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid, or a tautomer, N-oxide, pharmaceutically acceptable salt or solvate thereof.

20. 1. A method for predicting or assessing the responsiveness of a human cancer patient to treatment with an MDM2 antagonist, comprising detecting in a sample from the cancer patient BAP1, and optionally: CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM assessing the expression levels of one or more of 14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1; and determining whether the cancer indicates that it should be treated with an MDM2 antagonist. The method comprising:

21. 21. The method of claim 20, wherein the evaluating step comprises comparing the expression level with (i) an expression level associated with responsiveness or non-responsiveness to treatment with an MDM2 antagonist, or (ii) an expression level from a healthy, non-cancerous cell of the same type.

22. The patients are classified into groups based on their biomarker profiles, and optionally the groups are further divided into: (iii) responders and non-responders; or (iv) Strong Responders 22. The method of claim 20 or 21, comprising or consisting of:

23. The following markers: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PA 23. The method of any one of claims 20 to 22, wherein a patient is identified as particularly suitable for treatment if one, two, three, four, five, six, seven, eight, nine, ten or more of RP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 are expressed at a higher level than in patients identified as unsuitable for treatment.

24. 24. The method of any one of claims 20 to 23, wherein the patient is identified as a patient for treatment with an MDM2 antagonist if (i) an expression level associated with non-responsiveness to treatment with an MDM2 antagonist, or (ii) decreased BAP1 expression and / or decreased CDKN2A expression relative to expression levels from healthy, non-cancerous cells of the same type is detected.

25. The method of any one of claims 20 to 24, comprising detecting the expression level of said biomarker in a cancer cell sample from said human patient.

26. 26. The method of claim 25, wherein the detection is performed using an in vitro detection assay.

27. 1. A method for determining the susceptibility of a human cancer patient to treatment with an MDM2 antagonist, comprising measuring in a cancer cell sample from said patient BAP1 and, optionally, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1 , CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S , DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 detecting expression of one or more of: and assessing whether the patient's cancer is likely to respond to treatment with an MDM2 antagonist based on the expression level of the biomarker in the sample. The method comprising:

28. In a human patient suffering from cancer, BAP1 and optionally CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1 , CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S , DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 A method for detecting the expression of one or more of:

29. (a) obtaining a cancer cell sample from a human patient; and (b) detecting whether said biomarkers are expressed in the sampled cancer cells by contacting said sample with one or more reagents for detecting expression of said biomarkers.

29. The method of claim 28, comprising:

30. The MDM2 antagonist is of formula (I) as defined herein. ｏ or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof, such as (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

31. The MDM2 antagonist is selected from the group consisting of idasanutlin, HDM-201, KRT-232 (AMG-232), ALRN-6924, MI-773 (SAR405838), CGM-097, milademethanthosylate, APG-115, BI-907828, LE-004, DS-5272, SJ- 0211, BI-0252, AM-7209, SP-141, SCH-1450206, NXN-6, ADO-21, CTX-50-CTX-1, ISA-27, RO-8994, RO-6839921, ATSP-7041, SAH-p53-8, PM-2, K-178, MMRi-64 and 【Chemistry 2】 30. The method of any one of claims 20 to 29, wherein the compound is selected from the group consisting of: or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

32. 32. The method of any one of claims 20 to 31, further comprising treating the patient's cancer by administering an MDM2 antagonist.

33. The MDM2 antagonist is of formula (I) as defined herein. ｏ or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof, such as (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

34. The MDM2 antagonist is selected from the group consisting of idasanutlin, HDM-201, KRT-232 (AMG-232), ALRN-6924, MI-773 (SAR405838), CGM-097, milademethanthosylate, APG-115, BI-907828, LE-004, DS-5272, SJ- 0211, BI-0252, AM-7209, SP-141, SCH-1450206, NXN-6, ADO-21, CTX-50-CTX-1, ISA-27, RO-8994, RO-6839921, ATSP-7041, SAH-p53-8, PM-2, K-178, MMRi-64 and 【Chemistry 3】 or a tautomer or solvate or a pharmaceutically acceptable salt thereof.

35. The method of any one of claims 32 to 34, wherein said treatment is provided to said patient based on the results of said method.

36. 1. A kit or device for detecting the expression level of at least one biomarker for sensitivity to MDM2 inhibition in a sample from a human patient, comprising: a detection reagent for detecting BAP1, and optionally, CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCR L2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TR Detection reagents for detecting one or more of IM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 A kit or device comprising:

37. 1. A system for determining suitability of a human cancer patient for treatment with an MDM2 antagonist, comprising: a biomarker panel indicative of biomarker expression levels in a sample from the subject, the biomarker panel including BAP1, and optionally CDKN2A, CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1 , CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S , DHX58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 a memory device for storing data relating to the sample from the patient, comprising data relating to the sample; a processor communicatively connected to the storage device for classifying patients. A system comprising:

38. Cancer, is BAP1 depleted; and / or is CDKN2A depleted; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL 2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DH X58, TRIM14, OASL, IRF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1, and BRCA1 exhibiting increased expression of one, two, three, four, five or more of: An MDM2 antagonist for use in a method of treating cancer.

39. The cancer is: being BAP1 depleted; and / or being CDKN2A depleted; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HE RC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7 , LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1.

10. An MDM2 antagonist for use in a method for treating cancer, characterized by one or more, or two or more of:

40. The MDM2 antagonist for use, use, method, kit or system according to any one of claims 1 to 39, wherein said cancer exhibits a BAP1 deficiency.

41. The MDM2 antagonist for use, use, method, kit or system according to any one of claims 1 to 40, wherein said cancer exhibits CDKN2A deficiency.

42. 42. The MDM2 antagonist for use, use or method of any one of claims 1 to 35 or 38 to 41, wherein said MDM2 antagonist is part of a combination therapy with a second therapeutic agent.

43. 1. An MDM2 antagonist for use in a method of treating cancer in combination with an agent to induce sensitivity to the MDM2 antagonist, for example to decrease the level of BAP1 and / or CDKN2A, or to increase the level of an interferon signature gene, comprising: Cancer, having normal or elevated levels of BAP1; and / or have CDKN2A present at normal or elevated levels; and / or Interferon signature genes: CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HERC6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, I 10. An MDM2 antagonist that exhibits a reduction in expression of one, two, three, four, five or more of RF7, LGALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1.

44. 1. A method of treating cancer in a patient, comprising: (a) selecting patients having normal or high levels of BAP1 and / or CDKN2A, and / or low levels of interferon signature genes in a biological sample obtained from said patient; and (b) administering to said patient selected in step (a) a therapeutically effective amount of an MDM2 antagonist and an agent for inducing sensitivity to the MDM2 antagonist, e.g., by decreasing the level of BAP1 and / or CDKN2a and / or increasing the level of an interferon signature gene. The method comprising:

45. 45. The method of claim 43 or 44, wherein the agent for inducing sensitivity to an MDM2 antagonist is ASTX660.

46. A pharmaceutical composition comprising an MDM2 inhibitor for use in the treatment of cancer as defined in any one of claims 1 to 3 in a patient, wherein the MDM2 inhibitor is a compound of formula (I) ｏ or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof, for example, (2S,3S)-3-(4-chlorophenyl)-3-[(1R)-1-(4-chlorophenyl)-7-fluoro-5-[(1S)-1-hydroxy-1-(oxan-4-yl)propyl]-1-methoxy-3-oxo-2,3-dihydro-1H-isoindol-2-yl]-2-methylpropanoic acid, or a tautomer, N-oxide, pharmaceutically acceptable salt, or solvate thereof.

47. (i) the sample from the patient is being BAP1 depleted; and / or CDKN2A depletion; and / or CXCL10, CXCL11, RSAD2, MX1, BATF2, IFI44L, IFITM1, ISG15, CMPK2, IFI27, CD74, IFIH1, CCRL2, IFI44, HER C6, ISG20, IFIT3, HLA-C, OAS1, IFI35, IRF9, EPSTI1, USP18, BST2, CSF1, C1S, DHX58, TRIM14, OASL, IRF7, L exhibiting increased expression of one, two, three, four, five or more of GALS3BP, DDX60, LAP3, LAMP3, PARP12, PARP9, SP110, PLSCR1, WARS, IRF7, STAT1, IRF3, IRF5, MSC, JUN, SPI1, IRF1, COMMD3-BMI1, STAT2, RUNX3, SREBF1, FLI1 and BRCA1 determining the (ii) administering to said patient an effective amount of an MDM2 antagonist.

10. An MDM2 antagonist for use in a method of treating a cancer patient, comprising:

Images