Administration of hypoxia activated prodrugs in combination with immune modulatory agents for treating cancer

Abstract

To treat cancer.SOLUTION: TH-302 is administered in combination with an immunomodulator.SELECTED DRAWING: None

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of priority to U.S. Provisional Patent Application No. 62 / 369,691, filed August 1, 2016, which is incorporated herein by reference in its entirety. FIELD OF THE INVENTION

[0002] The present invention provides methods for treating cancer, as well as pharmaceutical formulations and unit dosage forms useful in those methods. As such, the present invention relates to the fields of medicine and pharmacology. [Background technology]

[0003] Background of the Invention Certain agents have been created to treat cancer by targeting hypoxic cancer cells (e.g., U.S. Patent Nos. 7,550,496; 8,299,088; 8,003,625; 8,507,464; 8,664,204; 9,226,932; 8,552,048; and 8,946,275, which disclose hypoxia-activated prodrugs (HAPs), and U.S. Patent Application Nos. 13 / 806,088; 13 / 809,135; 14 / 009,068; 14 / 110,819; 14 / 110,819). See PCT International Patent Applications Nos. PCT / US2014 / 062532; PCT / US2015 / 029297; PCT / US2015 / 040642; PCT / US15 / 41100; and PCT / US2015 / 61248 (each of which is incorporated herein by reference). One example of such a HAP is TH-302 or evofosfamide.

[0004] Many cancers defend themselves against the immune system by inhibiting T cell signaling. CTLA-4 (cytotoxic T lymphocyte antigen 4, commonly known as CD152), PD-1 (programmed cell death 1), and KIR (killer cell immunoglobulin-like receptor) receptors are immune checkpoints that similarly downregulate the immune system. See Noman et al. J. Exp. Med. 211(5): 781-790 (2014); Corzo et al. J. Exp. Med. 207(11): 2439-2453 (2010); Marotta et al. Cancer Res., 71(3): 779-789 (2011) (incorporated herein by reference). In recent years, CTLA-4 and PD-1 inhibitors have increasingly been considered new targets for cancer immunotherapy, due to the efficacy of two checkpoint inhibitors first demonstrated in advanced melanoma. Ipilimumab (trade name Yervoy) is a monoclonal antibody that activates the immune system by targeting CTLA-4. Pembrolizumab (trade name Keytruda) is a human antibody used in cancer immunotherapy that targets the PD-1 receptor. PD-1 has two ligands, PD-L1 and PD-L2. Nivolumab (trade name Opdivo) is a human IgG4 anti-PD-1 monoclonal antibody developed to activate the immune system by targeting PD-L1. Another strategy is to target immune checkpoint agonists that upregulate the immune system, such as the 4-1BB receptor (CD137). Agonistic 4-1BB monoclonal antibodies activate the immune system by targeting 4-1BB. 4-1BB agonists are not approved for cancer or immunotherapy, either alone or in combination with other anticancer drugs.

[0005] Despite the success of T cell immune checkpoint blockade in the treatment of melanoma, other carcinomas, such as adenocarcinomas of the prostate and pancreas, are largely resistant to CTLA-4 and PD-1 antibody therapy in animal models and humans. Hypoxic areas of these tumors are resistant to infiltration by T cells even in the context of healthy infiltration of T cells in normoxic regions of the same tumors (e.g., in the context of T cell checkpoint blockade). Thus, there remains a need for more effective and safer cancer therapies. The present invention provides such treatments. Summary of the Invention

[0006] Summary of the Invention In a first aspect, the present invention provides a method of treating cancer, said method comprising administering to a patient in need of such treatment a therapeutically effective amount of HAP in combination with a therapeutically effective amount of an immunomodulatory agent or substance, such as an anti-CTLA-4, anti-PD-1, anti-PD-L1, anti-PD-L2 antibody or an agonistic 4-1BB antibody, including but not limited to ipilimumab, pembrolizumab and nivolumab.

[0007] In various embodiments, the HAP is the compound known as TH-302, shown below; and a pharmaceutically acceptable carrier, excipient, or diluent. TH-302 is converted in vivo to the alkylating agent / nitrogen mustard compound Br-IPM, as shown below: [ka]

[0008] In various embodiments, TH-302 can be prepared using the methods described in U.S. Patent Nos. 7,550,496; 8,299,088; 8,003,625; 8,507,464; 8,664,204; 9,226,932; 8,552,048; and 8,946,275, and U.S. Patent Application Nos. 13 / 806,088; 13 / 809,135; 14 / 009,068; 14 / 110,819; 14 / 033491; 14 / 367,188; 14 / 367,152; 14 / 375,417; 14 / 380,054; 14 / 783776; and 14 / 907,190, and PCT International Patent Application Nos. PCT / US2014 / 062532; PCT / US2015 / 029297; PCT / US2015 / 040642; PCT / US15 / 41100; and PCT / US2015 / 61248, which are incorporated herein by reference.

[0009] In one embodiment, the present invention provides a method for increasing the anti-tumor effect of HAP in a patient, comprising co-administering an immunomodulator to tumor cells (or to a patient with a tumor) in combination with HAP. As used herein, "increasing the anti-tumor effect" of HAP by co-administering an immunomodulator refers to one or more of: (i) increasing the number of tumor cells killed by HAP compared to the number killed in the absence of co-administration of an immunomodulator; or (ii) overcoming tumor cell resistance to alkylating agents. As used herein, co-administration contemplates that the two co-administered drugs exert their pharmacological effects on tumor cells simultaneously, and such co-administration can be achieved by simultaneous, contemporaneous, or sequential administration of the two drugs. In one embodiment, the immunomodulator is ipilimumab, pembrolizumab, or nivolumab. In another embodiment, the HAP is TH-302. In one embodiment, TH-302 is administered once a week for five weeks. In other embodiments, TH-302 is administered no more than once a week. Within these embodiments, in some embodiments, TH-302 therapy is continued for several weeks, or in some embodiments, TH-302 is not administered for some weeks of a multi-week cycle.

[0010] In a second aspect, the present invention provides pharmaceutical formulations and unit dosage forms suitable for use in the methods of the present invention. In one embodiment, the hypoxia-activated prodrug and the immunomodulator are separately formulated in separate unit dosage forms. In another embodiment, the hypoxia-activated prodrug and the immunomodulator are formulated together in a mixture or other combined pharmaceutical formulation and combined unit dosage form. In various embodiments, the hypoxia-activated prodrug in the formulation and unit dosage form is TH-302. DETAILED DESCRIPTION OF THE INVENTION

[0011] Detailed Description of the Invention The practice of the present invention involves the use of conventional techniques of organic chemistry, molecular biology (including recombinant techniques), microbiology, cell biology, biochemistry and immunology, within the skill of the art.

[0012] definition In the following specification and claims, reference will be made to a number of terms that have the following meanings: All numerical designations, such as pH, temperature, time, concentration, and weight (including their respective ranges), are approximations that may be varied (+) or (-) by increments of 0.1, 1.0, or 10.0, where appropriate. All numerical designations may be understood as preceded by the term "about." Reagents described herein are typical of and equivalent to those that may be known in the art.

[0013] The singular forms "a," "an," and "the" include plural references unless the context clearly dictates otherwise.

[0014] The term "comprising" means that any recited elements are necessarily included, and that other elements may optionally be included. "Consisting essentially of" means that any recited elements are necessarily included, and that elements that significantly affect the basic and novel characteristics of the recited elements are excluded, and that other elements may optionally be included. "Consisting of" means that all elements other than those recited are excluded. Embodiments defined by each of these terms are within the scope of the present invention.

[0015] Certain compounds used in the present invention possess asymmetric carbon atoms (optical centers) or double bonds; the racemates, diastereomers, geometric isomers, positional isomers, and individual isomers (e.g., separate enantiomers) are all intended to be encompassed within the scope of the present invention. Compounds of the present invention may also contain unnatural proportions of atomic isotopes at one or more of the atoms that constitute such compounds. For example, compounds may contain, but are not limited to, tritium ( 3 H), iodine-125( 125 I) or carbon-14 ( 14C). All isotopic variations of the compounds of the present invention, whether radioactive or not, are intended to be encompassed within the scope of the present invention.

[0016] Other terms relevant to the present invention are defined below.

[0017] "Administering" or "administration" of a drug to a patient (and grammatical equivalents of this phrase) refers to direct administration, which may be administration to the patient by a medical professional or self-administration, and / or indirect administration, which may be the effect of prescribing the drug. For example, a physician who instructs a patient to self-administer a drug and / or provides a patient with a prescription for a drug is administering the drug to the patient.

[0018] "Cancer" refers to malignant solid tumors that can grow indefinitely and can spread locally by invasion and throughout the body by metastasis, as well as various blood cancers that may originate from cancer stem cells in the bone marrow. Examples of cancer include, but are not limited to, cancer of the adrenal gland, bone, brain, breast, bronchus, colon and / or rectum, gallbladder, gastrointestinal tract, head and neck, kidney, pharynx, liver, lung, nervous tissue, pancreas, prostate, parathyroid gland, skin, stomach, and thyroid gland. Other examples of cancer include adenocarcinoma, adenoma, basal cell carcinoma, cervical dysplasia and carcinoma in situ, Ewing's sarcoma, epidermoid carcinoma, giant cell tumor, glioblastoma multiforme, hairy cell tumor, intestinal ganglioneuroma, hyperplastic corneal nerve tumor, islet cell carcinoma, Kaposi's sarcoma, leiomyoma, leukemia, lymphoma, malignant carcinoid, malignant melanoma, malignant hypercalcemia, marfanoid habitus tumor, medullary carcinoma, metastatic skin cancer, mucosal neuroma, myelodysplastic syndrome, myeloma, mycosis fungoides, neuroblastoma, osteosarcoma, osteogenic and other sarcomas, ovarian tumor, pheochromocytoma, polycythemia vera, primary brain tumor, small cell lung tumor, both ulcerative and papillary squamous cell carcinoma, seminoma, soft tissue sarcoma, retinoblastoma, rhabdomyosarcoma, renal cell tumor or carcinoma, reticulum cell sarcoma, and Wilms' tumor. Examples of cancer also include astrocytoma, gastrointestinal stromal tumor (GIST), glioma or glioblastoma, renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and pancreatic neuroendocrine carcinoma.

[0019] "Combination therapy" or "combination treatment" refers to the use of two or more drugs in treatment, i.e., the use of one or more immunomodulators with the hypoxia-activated prodrugs described herein, to treat cancer. "Combined" administration refers to the administration of two or more drugs (e.g., a hypoxia-activated prodrug and an immunomodulator for treating cancer, and optionally one or more anticancer drugs) in any manner that allows both pharmacological effects to be simultaneously expressed in patients. Thus, combined administration does not require that a single pharmaceutical composition, the same dosage form, or the same administration route be used to administer both drugs, or that the two drugs be administered exactly at the same time. For example, but not limited to, it is contemplated that an immunomodulator can be administered as a combination therapy with the hypoxia-activated prodrug of the present invention.

[0020] "Hyperproliferative disease" refers to a disease characterized by cellular hyperproliferation (e.g., an abnormal increase in the rate or amount of cell proliferation). Cancer is a hyperproliferative disease. Examples of non-cancer hyperproliferative diseases include, but are not limited to, allergic vasculitis and granulomatosis (Churg-Strauss disease), asbestosis, asthma, atrophic gastritis, benign prostatic hyperplasia, bullous pemphigoid, celiac disease, chronic bronchitis and chronic obstructive airway disease, chronic sinusitis, Crohn's disease, demyelinating neuropathy, dermatomyositis, eczema such as atopic dermatitis, Eustachian tube disease, giant cell arteritis, transplant rejection, hypersensitivity pneumonitis, hypersensitivity vasculitis (Henoch-Scholein purpura), irritant dermatitis, inflammatory hemolytic anemia, inflammatory neutropenia, inflammatory bowel disease, Kawasaki disease, multiple myeloma, and rheumatoid arthritis. These include: vascular sclerosis, myocarditis, myositis, nasal polyps, nasolacrimal duct disease, neoplastic vasculitis, pancreatitis, pemphigus vulgaris, primary glomerulonephritis, psoriasis, periodontal disease, polycystic kidney disease, polyarteritis nodosa, polyangiitis overlap syndrome, primary sclerosing cholangitis, rheumatoid arthritis, serum sickness, surgical adhesions, stenosis or restenosis, scleritis, scleroderma, strictures of the bile ducts, strictures (of the duodenum, small intestine, and colon), silicosis and other forms of pneumoconiosis, type 1 diabetes, ulcerative colitis, ulcerative proctitis, vasculitis associated with connective tissue disorders, vasculitis associated with congenital complement system deficiencies, vasculitis of the central nervous system, and Wegener's granulomatosis.

[0021] "Hypoxia-activated prodrug" refers to a drug that is less active or inactive under normoxia than under hypoxia or anoxia. Hypoxia-activated prodrugs include drugs that are activated by a variety of reducing agents, including, but not limited to, one-electron transferases (such as cytochrome P450 reductase) and two-electron transfer (or hydride ion transfer) enzymes (see U.S. Patent Nos. 7,550,496; 8,299,088; 8,003,625; 8,507,464; 8,664,204; 9,226,932; 8,552,048; and 8,946,275, and U.S. Patent Application Nos. 13 / 806,088; 13 / 809,135; 14 / 009, See PCT International Patent Applications Nos. PCT / US2014 / 068; 14 / 110,819; 14 / 033491; 14 / 367,188; 14 / 367,152; 14 / 375,417; 14 / 380,054; 14 / 783776, and 14 / 907,190, and PCT International Patent Applications Nos. PCT / US2014 / 062532; PCT / US2015 / 029297; PCT / US2015 / 040642; PCT / US15 / 41100 and PCT / US2015 / 61248 (each of which is incorporated herein by reference). Examples of specific HAPs useful in the methods of the present invention include, but are not limited to, TH-302. Methods for the synthesis, formulation, and use of TH-302 and other HAPs are described in various patent publications and patent applications cited above in the "Background of the Invention" and incorporated herein by reference.

[0022] "Immunomodulator" refers to an activator of costimulatory molecules, an inhibitor of immune inhibitory molecules, or a vaccine. Programmed cell death 1 protein (PD-1) is an inhibitory member of the extended CD28 / CTLA4 family of T cell regulators (Okazaki et al. (2002) Curr Opin Immunol 14:391779-82; Bennett et al. (2003) J. Immunol.170:711-8). PD-1 is expressed on activated B cells, T cells, and monocytes. PD-1 is an immune inhibitory protein that negatively regulates TCR signaling (Ishida, Y. et al. (1992) EMBO J. 11:3887-3895; Blank, C. et al. (Epub 2006 Dec. 29) Immunol. Immunother. 56(5):739-745) and is upregulated in chronic infections. The interaction between PD-1 and PD-L1 can act as an immune checkpoint, which can result in, for example, a reduction in infiltrating lymphocytes, a reduction in T cell receptor-mediated proliferation, and / or immune evasion by cancer cells or infected cells (Dong et al. (2003) J. Mol. Med. 81: 281-7; Blank et al. (2005) Cancer Immunol. Immunother. 54:307-314; Konishi et al., (2004) Clin. Cancer Res.10:5094-100). Immune suppression can be reversed by inhibiting the local interaction of PD-1 with PD-L1 or PD-L2; the effect is additive when the interaction of PD-1 with PD-L2 is similarly blocked (Iwai et al., (2002) Proc. Nat'l. Acad. Sci. USA 99:12293-7; Brown et al. (2003) J. Immunol. 170:1257-66). Immune modulation can be achieved either by binding to immune inhibitory proteins (e.g., PD-1) or by binding to proteins that modulate inhibitory proteins (e.g., PD-L1, PD-L2).In one embodiment, the combination therapy of the present invention includes an immunomodulatory agent that is an inhibitor or antagonist of an inhibitory molecule of an immune checkpoint molecule. In another embodiment, the immunomodulatory agent binds to a protein that naturally inhibits an immune inhibitory checkpoint molecule. When used in combination with an anti-cancer compound, these immunomodulatory agents can enhance the anti-cancer response and therefore enhance efficacy compared to treatment with the anti-cancer compound alone.

[0023] The term "immune checkpoint" refers to a group of molecules on the cell surface of CD4 and CD8 T cells. These molecules can effectively serve as "brakes" that downregulate or inhibit adaptive immune responses. Immune checkpoint molecules include, but are not limited to, programmed cell death 1 (PD-1) and cytotoxic T-lymphocyte antigen 4 (CTLA-4), which directly inhibit immune cells.

[0024] Immunotherapeutic agents that can act as immune checkpoint inhibitors useful in the methods of the present invention include, but are not limited to, inhibitors of PD-1, PD-L1, PD-L2, and CTLA4. Inhibition of inhibitory molecules can be achieved by inhibition at the DNA, RNA, or protein level. In some embodiments, inhibitory nucleic acids (e.g., dsRNA, siRNA, or shRNA) can be used to inhibit the expression of inhibitory molecules. In other embodiments, the inhibitor of inhibitory signals is a polypeptide that binds to the inhibitory molecule, such as a soluble ligand, or an antibody or antigen-binding fragment thereof.

[0025] "Patient" or "subject" refers to mammals, particularly humans, and therefore includes animals for veterinary and research purposes, such as simians, cattle, horses, dogs, cats and rodents, with cancer or another hyperproliferative disease.

[0026] "Pharmaceutically acceptable salts" refers to pharmaceutically acceptable salts derived from various organic and inorganic counterions well known in the art, including, by way of example only, sodium, potassium, calcium, magnesium, ammonia, and tetraalkylammonium salts, and, when the molecule contains a basic functional group, includes salts of organic or inorganic acids such as hydrochloride, hydrobromide, tartrate, mesylate, acetate, maleate, and oxalate. Suitable salts include those described in Stahl and Wermuth (Eds.), Handbook of Pharmaceutical Salts Properties, Selection, and Use; 2002.

[0027] QnD or qnd refers to drug administration once every n days. For example, QD (or qd) refers to dosing once per day or once daily, Q2D (or q2d) refers to dosing once every two days, Q7D refers to dosing every seven days or once per week, and Q5D refers to dosing once every five days.

[0028] "Reduction" of a symptom(s) (and grammatical equivalents of this phrase) refers to a decrease in the severity or frequency of the symptom(s), or elimination of the symptom(s).

[0029] "Relapsed or refractory" refers to a type of cancer that is resistant to treatment with an agent, such as an immunomodulator or a hypoxia-activated prodrug, or that responds to treatment with an agent but recurs with or without resistance to such agent.

[0030] A "therapeutically effective amount" of a drug or agent refers to the amount of drug or agent that, when administered to a patient with cancer or another hyperproliferative disease, has the intended therapeutic effect, such as reducing, improving, alleviating, or eliminating one or more manifestations of cancer or another hyperproliferative disease in the patient. A therapeutic effect does not necessarily occur by administering a single dose, but may occur only after administering a series of doses. Thus, a therapeutically effective amount can be administered in one or more administrations.

[0031] "Treating" or "treatment" of a condition or patient refers to taking steps to obtain a beneficial or desired result, including a clinical result. For purposes of this invention, a beneficial or desired clinical result includes, but is not limited to, reduction or amelioration of one or more symptoms of cancer or another hyperproliferative disease, such as conditional survival and reduction in tumor burden or volume, reduction in the extent of disease, delay in or slowing of disease progression, improvement, palliation, or stabilization of the disease state, or other beneficial result.

[0032] The present invention arises, in part, from the discovery that pharmacological activation of immune checkpoints can enhance the efficacy of TH-302 and other HAPs when administered according to the methods of the present invention. As illustrated in the Examples below, immunomodulators in combination with TH-302 exhibit enhanced anti-cancer efficacy. Taken together, these results support that effective cancer treatment can be achieved by administering one or more immunomodulators in combination with a tumor hypoxia-targeting HAP, such as TH-302.

[0033] In certain embodiments, the HAPs described herein are administered in combination with one or more immunomodulatory agents that are inhibitors of PD-1, PD-L1, and / or PD-L2, or agonists of 4-1BB. Each such inhibitor may be an antibody, an antigen-binding fragment thereof, an immunoadhesin, a fusion protein, or an oligopeptide. Examples of such immunomodulatory agents are known in the art and are further described in more detail herein.

[0034] Hypoxia-activated drug administration In one aspect, the present invention provides a method for treating cancer, comprising administering a therapeutically effective amount of HAP and a therapeutically effective amount of an immunomodulator to a patient in need of cancer treatment, thereby treating the cancer. In one embodiment, the combination therapy is administered to a patient who has previously been treated with an immunomodulator or HAP, but whose cancer has progressed despite treatment or whose treatment has been discontinued due to cancer progression. In another embodiment, the patient has not previously been treated with any anti-cancer drug. In another embodiment, the patient has previously been treated with an anti-cancer drug other than an immunomodulator or HAP.

[0035] In one embodiment, the HAP is TH-302. Therapeutic doses of TH-302 will likely be in the range of 1 mg to 3000 mg per day. The specific dose level selected for any particular patient will depend on a variety of factors, including the particular compound used, age, body weight, general health, sex, diet, time of administration, route of administration, and rate of excretion, formulation combination, and the severity of the condition being treated.

[0036] In another embodiment, the present invention provides a method for administering about 320 mg / m 2 In another embodiment, the present invention provides a method of treating cancer by administering a therapeutically effective amount of TH-302 in the range of about 320 mg / m 2 In another embodiment, the present invention provides a method of treating cancer by administering about 400 mg / m TH-302. 2 In one embodiment, the present invention provides a method of treating cancer by administering about 420 mg / m TH-302. 2 The present invention provides a method for treating cancer by administering TH-302 to a patient in need thereof. Animal studies demonstrating therapeutically effective administration of TH-302 with antitumor effects are described in the Examples below.

[0037] In one embodiment, a therapeutically effective amount of TH-302 is administered at least once a week, at least once every two weeks, or up to once a month. In one embodiment, TH-302 is administered for a period of 1 to 40 weeks, at least 1 week, at least 2 weeks, or up to at least 12 weeks. In other embodiments, longer administration periods are employed.

[0038] Various frequencies and durations of TH-302 administration for effective cancer treatment according to this method are described in the Examples below.

[0039] Each of the above schedules can be considered a "cycle" of treatment. Generally, patients receive more than one cycle of treatment, but there may be a break of at least one day, more usually one week or more, between each cycle of treatment. Other HAPs are generally administered according to the above schedule, with the dosage adjusted to take into account how active the compound is compared to TH-302.

[0040] When an immunomodulator is combined with a hypoxia activated prodrug of the present invention, it is contemplated that the immunomodulator will be administered in the amounts and at the dosage frequencies disclosed herein below, or as would be apparent to one of ordinary skill in the art in view of this disclosure, or as approved by the FDA or other regulatory agency for use in the treatment of cancer.

[0041] In various embodiments, the patient's cancer being treated is metastatic cancer or a refractory and / or recurrent cancer that is refractory to first-, second-, or third-line therapy. In another embodiment, the therapy is a first-, second-, or third-line therapy. As used herein, the phrases "first-line" or "second-line" or "third-line" refer to the order of treatments a patient receives. A first-line treatment plan is the treatment given first, while a second- or third-line treatment is given after the first-line therapy or second-line therapy, respectively. Thus, a first-line treatment is the first treatment for a disease or condition. In a patient with cancer, the first treatment can be surgery, chemotherapy, radiation therapy, or a combination of these treatments. A first-line treatment is also referred to by those skilled in the art as a first therapy or primary treatment. Typically, a patient receives a subsequent chemotherapy plan because they did not show a positive clinical response to the first-line therapy, or showed only a subclinical response, or because the first-line treatment was discontinued. In this context, "chemotherapy" is used in its broadest sense, including not only classical cytotoxic chemotherapy but also molecularly targeted therapy and immunotherapy.

[0042] In another embodiment, the therapeutic methods of the invention are used to treat hyperproliferative diseases other than cancer.

[0043] Methods for preparing and pharmaceutical compositions of hypoxia-activated prodrugs, as well as other methods of treating cancer by administering various HAPs, are described in U.S. Patent Nos. 7,550,496; 8,299,088; 8,003,625; 8,507,464; 8,664,204; 9,226,932; 8,552,048; and 8,946,275, and U.S. patent application Ser. Nos. 13 / 806,088; 13 / 809,135; 14 / 009,068; 14 / 110,819; 14 / 110,819; Nos. 033491; 14 / 367,188; 14 / 367,152; 14 / 375,417; 14 / 380,054; 14 / 783776; and 14 / 907,190, and PCT International Patent Application Nos. PCT / US2014 / 062532; PCT / US2015 / 029297; PCT / US2015 / 040642; PCT / US15 / 41100; and PCT / US2015 / 61248 (each of which is incorporated herein by reference).

[0044] Other methods for treating cancer that can be used in combination with the methods of the present invention are known to those skilled in the art and are described, for example, in the latest editions of the Physician's Desk Reference, Medical Economics Company, Inc., Oradell, NJ, from 2010 onwards; Goodman and Gilman's The pharmacological basis of therapeutics, Eds. Hardman et al., McGraw-Hill, New York. (US) 2011, 12th Ed.; and product descriptions found in publications of the U.S. Food and Drug Administration and NCCN (National Comprehensive Cancer Network) guidelines. Such methods can be appropriately modified by those skilled in the art with reference to this disclosure in order to carry out the therapeutic methods of the present invention.

[0045] Immunomodulators and their administration The following compounds are useful for administration in combination with HAP in accordance with the present invention.

[0046] In some embodiments, the immunomodulatory agent is an immunoadhesin, for example, an immunoadhesin comprising the extracellular or PD-1-binding portion of PD-L1 or PD-L2 fused to a constant region (e.g., the Fc region of an immunoglobulin sequence).

[0047] In some embodiments, the immunomodulatory agent is a PD-1 inhibitor, such as AMP-224.

[0048] In some embodiments, the immunomodulatory agent is a PD-L1 inhibitor, such as an anti-PD-L1 antibody.

[0049] In some embodiments, the immunomodulatory agent is an anti-PD-L1 binding antagonist selected from YW243.55.S70, MPDL3280A, MEDI-4736, MSB-0010718C, or MDX-1105. MDX-1105, also known as BMS-936559, is an anti-PD-L1 antibody described in WO2007 / 005874. Antibody YW243.55.S70 is an anti-PD-L1 antibody described in WO2010 / 077634.

[0050] In some embodiments, the immunomodulatory agent is nivolumab (CAS Registry Number: 946414-94-4). Other names for nivolumab include MDX-1106, MDX-1106-04, ONO-4538, or BMS-936558. Nivolumab is a fully human IgG4 monoclonal antibody that specifically blocks PD-1. Nivolumab (clone 5C4) and other human monoclonal antibodies that specifically bind to PD-1 are disclosed in U.S. Patent No. 8,008,449, EP 2161336, and WO 2006 / 121168.

[0051] In some embodiments, the immunomodulatory agent is the anti-PD-1 antibody pembrolizumab. Pembrolizumab (also known as lambrolizumab, MK-3475, MK03475, SCH-900475, or KEYTRUDA®; Merck) is a humanized IgG4 monoclonal antibody that binds to PD-1. Pembrolizumab and other humanized anti-PD-1 antibodies are disclosed in Hamid, O. et al. (2013) New England Journal of Medicine 369(2): 134-44, U.S. Patent No. 8,354,509, WO2009 / 114335, and WO2013 / 079174.

[0052] In some embodiments, the immunomodulatory agent is pidilizumab (CT-011; Cure Tech), a humanized IgG1k monoclonal antibody that binds to PD1. Pidilizumab and other humanized anti-PD-1 monoclonal antibodies are disclosed in WO2009 / 101611.

[0053] Other anti-PD1 antibodies useful as immunomodulatory agents for use in the methods disclosed herein include AMP514 (Amplimmune) and the anti-PD1 antibodies disclosed in U.S. Patent No. 8,609,089, US2010028330, and / or US20120114649. In some embodiments, the anti-PD-L1 antibody is MSB0010718C. MSB0010718C (also referred to as A09-246-2; Merck Serono) is a monoclonal antibody that binds to PD-L1.

[0054] In some embodiments, the immunomodulatory agent is MDPL3280A (Genentech / Roche), a human Fc-optimized IgG1 monoclonal antibody that binds to PD-L1. MDPL3280A and other human monoclonal antibodies to PD-L1 are disclosed in U.S. Patent No. 7,943,743 and US20120039906. Other anti-PD-L1 binding agents useful as immunomodulatory agents for the methods of the invention include YW243.55.S70 (see WO2010 / 077634), MDX-1105 (also referred to as BMS-936559), and the anti-PD-L1 binding agents disclosed in WO2007 / 005874.

[0055] In some embodiments, the immunomodulatory agent is AMP-224 (B7-DCIg; Amplimmune; disclosed, e.g., in WO2010 / 027827 and WO2011 / 066342), a PD-L2 Fc fusion soluble receptor that blocks the interaction between PD1 and B7-H1.

[0056] In a specific embodiment, the immunomodulator is a 4-1BB agonist antibody.

[0057] In one embodiment, the immunomodulatory agent used is a soluble ligand (e.g., CTLA-4-Ig) that binds to PD-L1, PD-L2, or CTLA4, or an antibody or antibody fragment. For example, an anti-PD-1 antibody molecule can be administered in combination with an anti-CTLA-4 antibody, such as ipilimumab. Exemplary anti-CTLA4 antibodies include tremelimumab (an IgG2 monoclonal antibody available from Pfizer, formerly known as ticilimumab, CP-675,206); and ipilimumab (a CTLA-4 antibody, also known as MDX-010, CAS No. 477202-00-9).

[0058] In one embodiment, the anti-PD-1 antibody molecule is administered after treatment with a compound of the invention described herein.

[0059] In another embodiment, the anti-PD-1 or PD-L1 antibody molecule is administered in combination with an antigen-binding fragment thereof. In another embodiment, the anti-PD-1 or PD-L1 antibody molecule is administered in combination with an antigen-binding fragment thereof. In yet other embodiments, the anti-PD-1 or PD-L1 antibody molecule is administered in combination with an antigen-binding fragment thereof. The antibody combinations listed herein can be administered separately, e.g., as separate antibodies, or linked, e.g., as bispecific or trispecific antibody molecules. In one embodiment, a bispecific antibody comprising an anti-PD-1 or PD-L1 antibody molecule, or an antigen-binding fragment thereof, is administered. In certain embodiments, the antibody combinations listed herein are used to treat those cancers (e.g., solid tumors) listed herein. The efficacy of the aforementioned combinations can be tested in animal models known in the art. For example, animal models for testing the synergistic effects of anti-PD-1 antibodies are described, for example, in Woo et al. (2012) Cancer Res. 72(4):917-27.

[0060] Exemplary doses of such immunomodulatory agents that can be used in combination with the compounds of the invention include a dose of about 1 to 10 mg / kg, e.g., 3 mg / kg, of the anti-PD-1 antibody molecule, and a dose of about 3 mg / kg of the anti-CTLA-4 antibody, e.g., ipilimumab.

[0061] Exemplary embodiments of methods for using the HAPs of the present invention in combination with immunomodulatory agents include the following methods. i. A method of treating cancer in a subject, comprising administering to the subject a HAP and an immunomodulatory agent described herein. ii. The method of any one of the preceding embodiments i-iii, wherein the inhibitor of an immune checkpoint molecule is selected from PD-1, PD-L1, PD-L2, and CTLA4. iii. The method of any one of embodiments i-ii, wherein the inhibitor of an immune checkpoint molecule is selected from an inhibitor of PD-1, PD-L1, or CTLA4, or any combination thereof. iv. The method of any one of embodiments i-iii, wherein the inhibitor of the immune checkpoint molecule is a soluble ligand or an antibody or antigen-binding fragment thereof that binds to the immune checkpoint molecule. v. The method of any one of embodiments i-iv, wherein the antibody molecule is a bispecific or multispecific antibody molecule having a first binding specificity for PD-1 or PD-L1, and a second binding specificity for PD-L2. vi. The method of any one of embodiments i-v, wherein the immunomodulatory agent is an anti-PD-1 antibody selected from nivolumab, pembrolizumab, or pidilizumab. vii. The method of any one of embodiments i-x, wherein the immunomodulatory agent is an anti-PD-L1 antibody selected from YW243.55.S70, MPDL3280A, MEDI-4736, MSB-0010718C, or MDX-1105. viii. The method of any one of embodiments i-vii, wherein the immunomodulatory agent is an anti-PD-1 antibody molecule administered by injection (e.g., subcutaneously or intravenously) at a dose of about 1 to 30 mg / kg, e.g., about 5 to 25 mg / kg, about 10 to 20 mg / kg, about 1 to 5 mg / kg, or about 3 mg / kg, e.g., once a week to once every 2, 3, or 4 weeks. ix. The method of embodiment viii, wherein the anti-PD-1 antibody molecule is administered at a dose of about 10 to 20 mg / kg every other week. x. The method of embodiment ix, wherein the anti-PD-1 antibody molecule, e.g., nivolumab, is administered intravenously every two weeks at a dose of about 1 mg / kg to 3 mg / kg, e.g., about 1 mg / kg, 2 mg / kg, or 3 mg / kg. xi. The method of embodiment x, wherein the anti-PD-1 antibody molecule, e.g., nivolumab, is administered intravenously at a dose of about 2 mg / kg at intervals of 3 weeks.

[0062] Thus, according to the present invention, TH-302 or another HAP is co-administered with an immunomodulator, optionally in combination with other treatments. A systemic effect can be achieved by using more than one compound in the pharmaceutical composition of the present invention, i.e., the HAP is combined with at least another active ingredient, either another HAP, or an immunomodulator, or both, or another anti-cancer agent. The active ingredients useful in the methods of the present invention can be used simultaneously (as a mixed preparation) or sequentially. Thus, the present invention also relates to a compound or pharmaceutical composition for inhibiting abnormal cell growth or cancer in a mammal, comprising an amount of HAP or a pharmaceutically acceptable salt, solvate, or prodrug thereof, combined with an amount of another immunomodulator, wherein the amounts of the compound, salt, solvate, or prodrug and the immunomodulator together are effective in inhibiting abnormal cell growth or cancer in a patient. Thus, the combination therapy described herein is suitable for use in combination with known anti-cancer agents.

[0063] The present invention also relates to a set of items that can be packaged into a kit, consisting of separate packs of effective amounts of HAP and an immunomodulator (or pharmaceutically acceptable salts, derivatives, solvates, and stereoisomers thereof, e.g., mixtures thereof in all proportions, and, optionally, an effective amount of an additional pharmaceutically active ingredient). The set or kit includes suitable containers such as boxes, individual bottles, bags, or ampoules. For example, the set can include separate ampoules, each containing an effective amount of HAP and an immunomodulator (or pharmaceutically acceptable salts, derivatives, solvates, and stereoisomers thereof, e.g., mixtures thereof in all proportions, and, optionally, an effective amount of an additional pharmaceutically active ingredient), each in dissolved or lyophilized form. The set or kit of the present invention can also include an article that includes written instructions, or directs the user to written instructions, describing how to administer the compounds according to the present invention to treat a disease, such as cancer.

[0064] The present invention also relates to the use of HAP and immunomodulatory substances and / or physiologically acceptable salts thereof for the prophylactic or therapeutic treatment of and / or monitoring of diseases, such as cancer, that are caused, mediated, and / or propagated by abnormal cell proliferative activity.

[0065] Furthermore, the present invention relates to the use of HAP and immunomodulatory substances and / or physiologically acceptable salts thereof for the manufacture of medicaments for the prophylactic or therapeutic treatment of, and / or the monitoring of, diseases such as cancer caused, mediated, and / or propagated by abnormal cell proliferative activity.

[0066] HAP and immunomodulators and / or their physiologically acceptable salts can also be used as intermediates for the preparation of additional pharmaceutical active ingredients.Preferably, the pharmaceuticals are prepared in a non-chemical manner, for example, by combining the active ingredient with at least one solid, liquid and / or semi-liquid carrier or excipient, and optionally with one or more other active substances in a suitable dosage form.

[0067] Another object of the present invention is the HAP and immunomodulatory substance according to the present invention and / or physiologically acceptable salts thereof for use in the preventive or therapeutic treatment of and / or monitoring of diseases, such as cancer, that are caused, mediated, and / or propagated by abnormal cell proliferative activity. Another preferred aspect of the present invention relates to the HAP and immunomodulatory substance according to the present invention and / or physiologically acceptable salts thereof for use in the preventive or therapeutic treatment of and / or monitoring of hyperproliferative disorders, such as cancer.

[0068] The previous teachings herein regarding HAP and immunomodulators, including any preferred embodiments thereof, are valid and applicable to, but not limited to, HAP and immunomodulators and their salts for use in the prophylactic or therapeutic treatment of and / or monitoring of hyperproliferative disorders.

[0069] The following examples illustrate various aspects and embodiments of the present invention. [Example]

[0070] Example 1. Enhancement of the antitumor activity of TH-302 by immunomodulators in mouse xenografts 5×10 5 ~1×10 6 TRAMP-C2, C57BL / 6J, B6, FVB F1 cells, and / or luciferase-expressing Panc02 pancreatic ductal adenocarcinoma cells were orthotopically implanted subcutaneously into the right flank of albino or ODD-Luc reporter mice. Mice were treated with TH-302 alone (50 mg / kg ip, daily for 5 days) at either 1, 3, or 16 weeks after TRAMP cell implantation, with a 1-week rest period in between. Some mice were also treated with the CTLA-4 blocking antibody 9H10, the PD-1 blocking antibody RMP1-14, and / or the agonistic 4-1BB antibody, given ip on days 1, 4, and 7 and days 13, 16, and 19 over 1 to 3 cycles. Mice were monitored for survival (log-rank, Mantel-Cox test) and tumor growth by IVIS once a week for up to 140 days after tumor implantation. Mice were then sacrificed, their organs were weighed, and tumors were isolated, fixed with paraformaldehyde or acetone, embedded / mounted in OCT, frozen, sectioned, and stained for hypoxia with anti-piminidazole FITC, GR-1 V450, CD11b Alexa546, and / or F4 / 80 Alexa647. The data demonstrated that TH-302 alone or with immunomodulators alone caused growth delay, and that the combination of TH-302 and immunomodulators significantly prolonged the time required for tumor volume doubling compared to either drug alone.

[0071] These examples demonstrated that TH-302 activity is significantly enhanced by co-administration with an immunomodulator; and that co-administration of an immunomodulator significantly enhanced TH-302-mediated anti-tumor activity in xenografts.

[0072] The data presented in these examples support a novel approach for the treatment of cancer in which immunomodulators are administered in combination with HAPs such as TH-302 to provide more effective therapy.

[0073] While the present invention has been specifically disclosed by certain aspects, embodiments and best features, it is to be understood that alterations, improvements and variations of such aspects, embodiments and best features may be made by those skilled in the art, and that such alterations, improvements and variations are deemed to be within the scope of the present disclosure.

[0074] The invention has been described broadly and generically herein. Each of the narrower species and subgeneric groupings falling within the generic disclosure also form part of the invention. Also, when features or aspects of the invention are described in terms of a Markush group, those skilled in the art will understand that the invention is also described in terms of any individual member or subgroup of members of the Markush group.

Claims

1. A hypoxia-activated prodrug (HAP) for use in a method for treating cancer, wherein the HAP is administered to a patient in need of such treatment in combination with an anti-PD-1 antibody and an anti-CTLA-4 antibody, and the HAP is TH-302, and the patient is refractory to immunotherapy alone.

2. The HAP of claim 1, wherein the cancer is prostate cancer.

3. The HAP of claim 1, wherein the cancer is pancreatic cancer.

4. The HAP of claim 1, wherein the cancer is head and neck cancer.

5. The HAP of claim 4, wherein the head and neck cancer is human papillomavirus (HPV)-negative head and neck cancer.

6. The HAP according to any one of claims 1 to 5, wherein the cancer is a metastatic cancer.

7. The HAP according to any one of claims 1 to 6, wherein the anti-CTLA-4 antibody is ipilimumab.

8. The HAP according to any one of claims 1 to 7, wherein the anti-PD-1 antibody is pembrolizumab.

9. The HAP according to any one of claims 1 to 7, wherein the anti-PD-1 antibody is nivolumab.

10. The HAP of any one of claims 1 to 9, wherein the cancer is refractory to first-line, second-line or third-line treatments received by the patient.

11. The HAP of any one of claims 1 to 10, wherein the HAP is administered in combination with an immunomodulator to a patient who has previously been treated with an immunomodulator or a HAP, and whose cancer has progressed despite the treatment or whose treatment has been discontinued due to cancer progression.

12. The HAP is about 320 mg / m ２ The HAP according to any one of claims 1 to 11, which is administered to a patient in a dose of less than 100mg / kg.

13. The HAP is about 320 mg / m ２ ~About 480mg / m ２ The HAP according to any one of claims 1 to 11, which is administered to a patient by injection at a dose of