Methods of Treating Neuroepithelial Tumors Using Selective Glucocorticoid Receptor Modulators - Patent application

Abstract

Applicant provides a method for treating glucocorticoid receptor-positive (GR) tumors in a subject, comprising administering a selective glucocorticoid receptor modulator (SGRM) in an amount effective to reduce tumor burden in the subject. + ) A method for treating neuroepithelial tumors is disclosed. + The neuroepithelial tumor may be a neurofibromatosis type 2 (NF2) tumor; + The neuroepithelial tumor may be a schwannoma, a meningioma, or an ependymoma. + The neuroepithelial tumor is not an adrenocorticotropic hormone (ACTH)-secreting tumor. In an embodiment, the SGRM comprises a steroid skeleton. In an embodiment, the SGRM is mifepristone. In an embodiment, the SGRM comprises a non-steroid skeleton, such as a cyclohexylpyrimidine, fused azadecalin, heteroaryl ketone-fused azadecalin, or octahydro-fused azadecalin skeleton. The SGRM can be administered orally. The SGRM can be administered alone.

Description

[Background technology]

[0001] background Meningiomas, schwannomas, and ependymomas are neuroepithelial tumors frequently seen in patients with neurofibromatosis type 2 ("NF2"). Meningiomas account for approximately 36.1% of all primary brain tumors. Meningiomas arise from the meninges, a thin three-layered tissue that covers the brain and spinal cord, and are commonly found near the top and outer curve of the brain and at the base of the skull. Schwannomas account for approximately 8% of all primary brain tumors. Schwannomas are nerve sheath tumors made of Schwann cells. The tumor cells always remain on the outside of the nerve, but the tumor itself may push the nerve aside and / or up against bony structures. The incidence of both meningiomas and schwannomas increases with age, occurring approximately twice as often in women as in men. Ependymomas account for approximately 5% of intracranial gliomas in adults and up to 10% of childhood tumors of the central nervous system (CNS). Ependymomas arise from cells that line both the cavities of the brain and the tubes that contain the spinal cord, but they usually arise in the floor of the fourth ventricle, located at the bottom back of the brain.

[0002] Conventional treatment options for neuroepithelial tumors, such as meningiomas, schwannomas, and ependymomas, include surgery, radiation therapy, and chemotherapy. Surgery is currently the main treatment option for patients with meningiomas, schwannomas, or ependymomas. However, surgery often fails to completely remove the tumor, and may not be possible if the tumor has spread or cannot be removed without damaging the brain. Radiation therapy and chemotherapy take advantage of the fact that cancer cells generally have high proliferation capacity and are more sensitive to DNA damage, causing general damage to DNA and destabilizing chromosomal structure, thereby killing tumor cells and ultimately causing the destruction of the cancer cells. Non-limiting examples of radiation therapy include gamma rays and X-rays, and non-limiting examples of chemotherapeutic agents include bleomycin, cisplatin, vinblastine, cyclophosphamide, 5'-fluorouracil, and methotrexate. These treatments are particularly effective for types of cancer that have defective cell cycle checkpoints that limit the ability of these cells to repair damaged DNA before undergoing cell division. However, the non-selective nature of these treatments often results in severe and debilitating side effects.The systemic use of these drugs can usually result in damage to healthy organs and tissues, and can impair the long-term health of patients.Therefore, there is a need for new therapeutic options for treating neuroepithelial tumors, such as meningiomas, schwannomas and ependymomas, and the methods of the present invention disclosed below meet these and other needs. Summary of the Invention [Means for solving the problem]

[0003] overview As used herein, the GR of a subject + Neuroepithelial tumors (herein, "GR +Disclosed is a method for treating a tumor that expresses a glucocorticoid receptor (GR) ("meaning that the tumor expresses the glucocorticoid receptor (GR)) by administering to the subject a glucocorticoid receptor modulator (GRM), e.g., a selective glucocorticoid receptor modulator (SGRM), and administering to the subject a GR + in an amount effective to reduce tumor burden of a neuroepithelial tumor, provided that the subject Other Provided that the patient does not suffer from a disorder treatable with an SGRM. Non-limiting examples of disorders for which treatment involving administration of an SGRM has been shown to be beneficial include Cushing syndrome, psychiatric disorders such as psychotic major depression, cocaine addition, stress disorder, postpartum psychosis, and cancers treatable with a combination of a taxane and an SGRM (e.g., breast cancer and prostate cancer). In an embodiment of the method disclosed herein, GR + The neuroepithelial tumor is not an adrenocorticotropic hormone (ACTH)-secreting tumor. + The neuroepithelial tumor is neurofibromatosis type 2 (NF2). In some embodiments, the GR + The neuroepithelial tumor is a tumor selected from a schwannoma, a meningioma, and an ependymoma.

[0004] In some cases, the SGRM is administered orally. In some cases, the SGRM is administered by transdermal application, by nebulized suspension, or by aerosol spray. In some cases, the SGRM is a nonsteroidal glucocorticoid receptor modulator. In some cases, the nonsteroidal glucocorticoid receptor modulator is administered orally. In some cases, the nonsteroidal glucocorticoid receptor modulator is administered by transdermal application, by nebulized suspension, or by aerosol spray. In some cases, the SGRM is administered to the subject for at least 2 weeks. In some cases, the SGRM is administered to the subject for at least 3 weeks, or 4 weeks, or 2 months, or 3 months, or longer.

[0005] In some cases, the effective amount of the SGRM is a daily dose of 1-100 mg / kg / day, where the SGRM is administered alone or in combination with at least one non-SGRM therapy, such as chemotherapy, radiation therapy, or other therapeutic agent. In some embodiments, the daily dose is 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 30, 40, 50, 60, 70, 80, 90, or 100 mg / kg / day. In some cases, the nonsteroidal glucocorticoid receptor modulator is administered for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80 weeks.

[0006] In some embodiments, the glucocorticoid receptor modulator, e.g., SGRM, comprises a steroid skeleton with at least one phenyl-containing moiety at the 11-β position of the steroid skeleton. In some cases, the phenyl-containing moiety at the 11-β position of the steroid skeleton is a dimethylaminophenyl moiety. In some cases, the glucocorticoid receptor modulator is mifepristone. In some embodiments, the glucocorticoid receptor modulator is selected from the group consisting of 11β-(4-dimethylaminoethoxyphenyl)-17α-propynyl-17β-hydroxy-4,9 estradien-3-one and (17α)-17-hydroxy-19-(4-methylphenyl)androsta-4,9(11)-dien-3-one. In some embodiments, the glucocorticoid receptor modulator is (11β,17β)-11-(1,3-benzodioxol-5-yl)-17-hydroxy-17-(1-propynyl)estra-4,9-dien-3-one.

[0007] In some embodiments, the glucocorticoid receptor modulator, e.g., SGRM, has a non-steroidal backbone. In some cases, the glucocorticoid receptor modulator backbone is a cyclohexylpyrimidine. In some cases, the cyclohexylpyrimidine has the following formula: [ka] (wherein the dashed line is absent or a bond; X is selected from the group consisting of O and S; R 1 1 to 3 R 1a Based on Depending on the situation is selected from the group consisting of substituted cycloalkyl, heterocycloalkyl, aryl, and heteroaryl; 1a , H, C 1-6 Alkyl, C 2-6 Alkenyl, C 2-6 Alkynyl, C 1-6 Alkoxy, C 1-6 Alkyl OR 1b , halogen, C1-6 Haloalkyl, C 1-6 Haloaloxy, OR 1b , N.R. 1b R 1c , C(O)R 1b , C(O)OR 1b , O.C.(O)R 1b , C(O)NR 1b R 1c , N.R. 1b C(O)R 1c , SO2R 1b , SO2NR 1b R 1c R is independently selected from the group consisting of cycloalkyl, heterocycloalkyl, aryl, and heteroaryl; 1b and R 1c H and C 1-6 alkyl; R 2 , H, C 1-6 Alkyl, C 1-6 Alkyl-OR 1b , C 1-6 Alkyl NR 1b R 1c and C 1-6 alkyleneheterocycloalkyl; R 3 H and C 1-6 alkyl; Ar is selected from the group consisting of 1 to 4 R 4 Based on Depending on the situation is a substituted aryl; 4 , H, C 1-6 Alkyl, C 1-6 Alkoxy, halogen, C 1-6 Haloalkyl and C 1-6 haloalkoxy; L 1 is a bond or C 1-6 and the subscript n is an integer from 0 to 3, or salts and isomers thereof.

[0008] In some cases, the glucocorticoid receptor modulator scaffold is a fused azadecalin. In some cases, the fused azadecalin has the following formula: [ka] (In the formula, L 1 and L 2 is a member independently selected from a bond and unsubstituted alkylene; R 1 is an unsubstituted alkyl, an unsubstituted heteroalkyl, an unsubstituted heterocycloalkyl, -OR 1A , N.R. 1C R 1D , -C(O)NR 1C R 1D and -C(O)OR 1A where R is a member selected from 1A is a member selected from hydrogen, unsubstituted alkyl, and unsubstituted heteroalkyl; R 1C and R 1D is a member independently selected from unsubstituted alkyl and unsubstituted heteroalkyl, where R 1C and R 1D are optionally joined to form an unsubstituted ring together with the nitrogen to which they are attached, said ring optionally containing an additional ring nitrogen; R 2 is the expression: [ka] (In the formula, R 2G is a member selected from hydrogen, halogen, unsubstituted alkyl, unsubstituted heteroalkyl, unsubstituted cycloalkyl, unsubstituted heterocycloalkyl, -CN, and -CF; J is phenyl; t is an integer from 0 to 5; X is -S(O)-; and R 5 is 1 to 5 R 5A phenyl optionally substituted with a group, where R 5A is hydrogen, halogen, -OR 5A1 , S(O2)NR 5A2 R 5A3 , —CN, and unsubstituted alkyl, where R 5A1 is a member selected from hydrogen and unsubstituted alkyl, and R 5A2 and R 5A3are members independently selected from hydrogen and unsubstituted alkyl, or salts and isomers thereof.

[0009] In some cases, the glucocorticoid receptor modulator scaffold is a heteroaryl ketone fused azadecalin or an octahydro fused azadecalin. In some cases, the heteroaryl ketone fused azadecalin has the formula: [ka] (In the formula, R 1 is a heteroaryl ring having 5-6 ring members and 1-4 heteroatoms independently selected from the group consisting of N, O, and S; R 1a and each R is a heteroaryl ring optionally substituted with 1 to 4 groups independently selected from 1a is hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, CN, N-oxide, C 3-8 Cycloalkyl and C 3-8 ring J is selected from the group consisting of a cycloalkyl ring, a heterocycloalkyl ring, an aryl ring, and a heteroaryl ring, wherein said heterocycloalkyl and heteroaryl rings have 5 to 6 ring members and 1 to 4 heteroatoms each independently selected from the group consisting of N, O, and S; each R 2 is hydrogen, C 1-6 Alkyl, halogen, C 1 6 Haloalkyl, C 1 6 Alkoxy, C 1-6 Haloalkoxy, C 1-6 Alkyl-C 1-6 Alkoxy, CN, OH, NR 2a R 2b , C(O)R 2a , C(O)OR 2a , C(O)NR 2a R 2b , S.R. 2a, S(O)R 2a , S(O)2R 2a , C 3-8 Cycloalkyl and C 3-8 heterocycloalkyl, wherein the heterocycloalkyl group is selected from the group consisting of 1 to 4 R 2c or two R 2 groups taken together form an oxo group (=O); or two R 2 The groups taken together form a heterocycloalkyl ring having 5-6 ring members and 1-3 heteroatoms each independently selected from the group consisting of N, O, and S, wherein the heterocycloalkyl ring is selected from 1-3 R 2d optionally substituted with R 2a and R 2b is hydrogen and C 1-6 alkyl; 2c is hydrogen, halogen, hydroxy, C 1-6 Alkoxy, C 1-6 Haloalkoxy, CN and NR 2a R 2b each R 2d is hydrogen and C 1-6 alkyl, or two R attached to the same ring atom 2d The groups together form (=O); R 3 is 1 to 4 R 3a each R is selected from the group consisting of phenyl and pyridyl, each optionally substituted with a group; 3a is hydrogen, halogen and C 1-6 haloalkyl; and the subscript n is an integer from 0 to 3, or a salt or isomer thereof.

[0010] In some cases, the octahydro-fused azadecalin has the formula: [ka] (In the formula, R1 is a heteroaryl ring having 5-6 ring members and 1-4 heteroatoms independently selected from the group consisting of N, O, and S; R 1a and each R is a heteroaryl ring optionally substituted with 1 to 4 groups independently selected from 1a is hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, N-oxide and C 3-8 ring J is selected from the group consisting of aryl and heteroaryl rings having 5-6 ring members and 1-4 heteroatoms each independently selected from the group consisting of N, O, and S; 2 is hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, C 1-6 Alkyl-C 1-6 Alkoxy, CN, OH, NR 2a R 2b , C(O)R 2a , C(O)OR 2a , C(O)NR 2a R 2b , S.R. 2a , S(O)R 2a , S(O)2R 2a , C 3-8 Cycloalkyl and C having 1 to 3 heteroatoms independently selected from the group consisting of N, O and S 3-8 or two R on adjacent ring atoms are independently selected from the group consisting of heterocycloalkyl; 2 The groups taken together form a heterocycloalkyl ring having 5-6 ring members and 1-3 heteroatoms each independently selected from the group consisting of N, O, and S, wherein the heterocycloalkyl ring is selected from 1-3 R 2c optionally substituted with R 2a , R 2b and R 2care hydrogen and C, respectively. 1-6 alkyl; each R 3a is independently a halogen; and the subscript n is an integer from 0 to 3, or salts and isomers thereof.

[0011] In some cases, the SGRM has the following structure: [ka] and CORT125134, (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone, having the formula:

[0012] In some cases, the SGRM has the following structure: [ka] and CORT125281, having the formula ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone. In certain embodiments, for example, the following are provided: (Item 1) Subject's GR + A method of treating a neuroepithelial tumor, comprising administering a selective glucocorticoid receptor modulator (SGRM) to a subject in an amount effective to reduce the tumor burden of the neuroepithelial tumor in the patient, provided that the subject is not otherwise afflicted with a disorder treatable with an SGRM and the tumor does not secrete adrenocorticotropic hormone (ACTH). (Item 2) The GR + 2. The method of item 1, wherein the neuroepithelial tumor is neurofibromatosis type 2. (Item 3) The GR + 2. The method of claim 1, wherein the neuroepithelial tumor is selected from the group consisting of schwannoma, meningioma, and ependymoma. (Item 4) 2. The method of claim 1, comprising administering the SGRM for at least two weeks. (Item 5) 2. The method of claim 1, wherein the effective amount is a daily dose of 1 to 100 mg / kg / day, and the SGRM is administered alone or in combination with at least one non-SGRM therapy, and the at least one non-SGRM therapy is chemotherapy, radiation therapy, or other therapeutic agent. (Item 6) 2. The method of claim 1, wherein the daily dose is 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 30, 40, 50, 60, 70, 80, 90 or 100 mg / kg / day. (Item 7) 2. The method of claim 1, wherein the nonsteroidal glucocorticoid receptor modulator is administered for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80 weeks. (Item 8) 8. The method according to any of items 1 to 7, wherein the glucocorticoid receptor modulator comprises a steroidal backbone having at least one phenyl-containing moiety at the 11-β position of the steroidal backbone. (Item 9) 9. The method of claim 8, wherein the phenyl-containing moiety at the 11-β position of the steroid skeleton is a dimethylaminophenyl moiety. (Item 10) 9. The method of claim 8, wherein the glucocorticoid receptor modulator is mifepristone. (Item 11) 8. The method according to any one of items 1 to 7, wherein the glucocorticoid receptor modulator is selected from the group consisting of 11β-(4-dimethylaminoethoxyphenyl)-17α-propynyl-17β-hydroxy-4,9estradien-3-one and (17α)-17-hydroxy-19-(4-methylphenyl)androsta-4,9(11)-dien-3-one. (Item 12) The method according to any one of items 1 to 7, wherein the glucocorticoid receptor modulator is (11β,17β)-11-(1,3-benzodioxol-5-yl)-17-hydroxy-17-(1-propynyl)estra-4,9-dien-3-one. (Item 13) 8. The method according to any one of items 1 to 7, wherein the glucocorticoid receptor modulator has a non-steroidal skeleton. (Item 14) 14. The method of claim 13, wherein the glucocorticoid receptor modulator scaffold is a cyclohexylpyrimidine. (Item 15) The cyclohexylpyrimidine has the formula:

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[0013] Detailed Description A. Introduction The methods disclosed herein can be used to treat patients having neuroepithelial tumors, such as, for example, meningiomas, schwannomas, or ependymomas, by administering an effective amount of an SGRM, alone or in combination with other therapies.

[0014] B. Definition As used herein, the term "subject" or "patient" refers to a human or non-human organism. Thus, the methods and compositions described herein are applicable to both human and veterinary diseases. In certain embodiments, the subject is a "patient" (i.e., a living human undergoing medical treatment for a disease or condition). This includes those who do not have a defined illness and are being investigated for signs of pathology. Subjects who have been diagnosed with the presence of a particular cancer targeted by the compositions and methods disclosed herein are preferred. In some cases, subjects may simultaneously suffer from one or more types of cancer, at least one of which is targeted by the compositions and methods disclosed herein. Preferred cancers for treatment with the compositions described herein include, but are not limited to, neuroepithelial tumors, such as meningiomas, schwannomas, and ependymomas.

[0015] As used herein, the term "tumor burden" or "tumor mass" generally refers to the number of cancer cells, the size of a tumor, or the amount of cancer in a subject's body at any given time. Tumor burden can be detected, for example, by measuring the expression of tumor-specific gene markers and measuring tumor size by several well-known biochemical or imaging methods disclosed herein below.

[0016] As used herein, the term "effective amount" or "therapeutic amount" refers to an amount of a pharmacological agent effective to treat, eliminate or alleviate at least one symptom of the disease being treated. In some cases, "therapeutically effective amount" or "effective amount" may refer to an amount of a functional agent or pharmaceutical composition useful for exhibiting a detectable therapeutic or inhibitory effect. This effect may be detected by any assay method known in the art. An effective amount may be an amount effective to induce an anti-tumor response. An effective amount may be an amount effective to induce a humoral and / or cellular immune response in a recipient subject that results in growth inhibition or death of target cells. For purposes of this disclosure, a therapeutic amount of a SGRM is an amount that, when used alone or with other therapies, is likely to reduce tumor burden or result in other desired beneficial clinical outcomes related to cancer improvement.

[0017] As used herein, the terms "administer," "administering," "administered," or "administration" refer to providing a compound or composition (e.g., those described herein) to a subject or patient.

[0018] As used herein, the term "compound" is used to describe a molecular moiety of a unique and identifiable chemical structure. The molecular moiety ("compound") may exist in the form of a free species that is not associated with other molecules. A compound may also exist as part of a larger aggregate in which it is associated with other molecules, but nevertheless retains its chemical identity. A solvate, in which a molecular moiety of a defined chemical structure ("compound") is associated with a molecule of a solvent, is an example of such an associated form. A hydrate is a solvate in which the associated solvent is water. The description of a "compound" refers to the molecular moiety itself (of the described structure), regardless of whether it exists in free or associated form.

[0019] As used herein, the term "pharmaceutically acceptable carrier" is intended to include any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, etc., that are compatible with pharmaceutical administration. The use of such media and agents for pharmaceutically active substances is well known in the art. Except in the case where any conventional media or agent is incompatible with the active compound, its use in the composition is contemplated. Auxiliary active compounds can also be incorporated into the composition.

[0020] As used herein, the term "mineralocorticoid receptor" (MR) refers to the type I glucocorticoid receptor that binds mineralocorticoids. Because the MR binds aldosterone, it is also called the "aldosterone receptor."

[0021] As used herein, the term "glucocorticoid receptor" ("GR") refers to the type II glucocorticoid receptor ("type II" of a family of intracellular receptors that specifically bind cortisol and / or cortisol analogs such as dexamethasone (see, e.g., Turner & Muller, J. Mol. Endocrinol. October 1, 2005 35 283-292). GR is also called the cortisol receptor. The term GR includes isoforms of GR, recombinant GR, and mutant GR. Cells, tissues, organs, tumors, or other animal parts or materials that express GR are said to be GR "positive" (GR + ) is called.

[0022] The term "glucocorticoid receptor modulator" and its acronym "GRM" are also known and described in the scientific and patent literature, e.g., as either glucocorticoid receptor agonists or glucocorticoid receptor antagonists, and refer to any compound that modifies, e.g., inhibits, any biological response associated with the binding of GR to an agonist. For example, GR agonists, such as dexamethasone, increase the activity of tyrosine aminotransferase (TAT) in HepG2 cells (a human liver hepatoma cell line; ECACC, UK). Thus, the GRMs discussed herein can be identified by measuring the ability of a compound to inhibit the effects of dexamethasone. TAT activity can be measured as outlined in the literature A. Ali et al., J. Med. Chem., 2004, 47, 2441-2452. Modulators have an IC of less than 10 micromolar. 50 (half maximal inhibition concentration). See Example 1 below.

[0023] As used herein, the term "selective glucocorticoid receptor modulator" and its acronym "SGRM" refer to any composition or compound that alters (e.g., inhibits) any biological response associated with the binding of GR to an agonist. "Selective" refers to a drug that preferentially binds to GR rather than other nuclear receptors (e.g., progesterone receptor (PR), mineralocorticoid receptor (MR) or androgen receptor (AR)). A selective glucocorticoid receptor modulator has a 10-fold higher affinity (1 / 10 K) than its affinity for MR, AR or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR and PR. d In a more preferred embodiment, a selective glucocorticoid receptor modulator (SGRM) binds to GR with an affinity that is 100-fold higher (1 / 100th of a K value) than its affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR.d In another embodiment, a selective glucocorticoid receptor modulator binds to GR with an affinity that is 1000-fold greater (1 / 1000th of a K value) than its affinity for MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or MR, AR, and PR. d value) to GR.

[0024] As used herein, the terms "anti-glucocorticoid" and "anti-glucocorticoid activity" refer to compounds, and the actions of such compounds, that modulate GR to oppose, reduce or prevent one or more of the binding of a glucocorticoid receptor ligand to GR, activation of GR, expression of GR, levels of glucocorticoid ligand, or otherwise reduce or eliminate the action or activity of GR.

[0025] As used herein, the term "composition" is intended to include products that contain specified amounts of specified components, such as the compounds, their tautomeric forms, their derivatives, their analogs, their stereoisomers, their polymorphs, their pharmaceutically acceptable salts, esters, ethers, metabolites, mixtures of isomers, their pharmaceutically acceptable solvates and pharmaceutically acceptable compositions, as well as any products that result directly or indirectly from the combination of specified amounts of specified components. Such terms regarding pharmaceutical compositions are intended to include products that contain active components and inactive components that constitute the carrier, as well as any products that result directly or indirectly from the combination, complexation or aggregation of any two or more of the components, or from the dissociation of one or more of the components, or from other types of reactions or interactions of one or more of the components. Thus, the pharmaceutical compositions disclosed herein are meant to include any compositions made by mixing the compounds discussed herein with their pharmaceutically acceptable carriers.

[0026] In some embodiments, the term "consisting essentially of" refers to a composition whose only active ingredient is the indicated active ingredient, but which may contain other compounds that are for stabilization, storage, etc., but are not directly involved in the therapeutic effect of the indicated active ingredient. In some embodiments, the term "consisting essentially of" may refer to a composition that includes an active ingredient and an ingredient that facilitates the release of the active ingredient. For example, the composition may include one or more ingredients that provide a sustained release of the active ingredient to the subject over time. In some embodiments, the term "consisting essentially of" refers to a composition that includes an active ingredient and a pharma- ceutically acceptable carrier or excipient.

[0027] The term "steroid backbone," in the context of glucocorticoid receptor antagonists that include such, refers to glucocorticoid receptor antagonists that include modifications of the basic structure of the endogenous steroid glucocorticoid receptor ligand, cortisol. The basic structure of the steroid backbone is provided as Formula I. [ka] The two most commonly known classes of structural modifications of the cortisol steroid backbone to generate glucocorticoid antagonists include modifications of the 11-β hydroxy group and modifications of the 17-β side chain (see, e.g., Lefebvre (1989) J. Steroid Biochem. 33:557-563).

[0028] As used herein, the phrase "non-steroidal backbone" in the context of SGRMs refers to SGRMs that do not share structural homology with or are not modifications of cortisol, which has a steroidal backbone containing 17 carbon atoms bonded to four fused rings. Such compounds include synthetic mimetics and analogs of proteins, including partially peptidic, pseudopeptidic and nonpeptidic molecular entities.

[0029] Non-steroidal GRMs, such as SGRM compounds, include GRMs with fused azadecalin backbone, heteroaryl ketone fused azadecalin backbone, and octahydro fused azadecalin backbone.Exemplary GRMs with fused azadecalin backbone include those described in U.S. Patent Application Publication No. 7,928,237; and U.S. Patent Application No. 8,461,172.Exemplary SGRMs with heteroaryl ketone fused azadecalin backbone include those described in U.S. Patent Application Publication No. 2014 / 0038926, now U.S. Patent Application No. 8,859,774.Exemplary GRMs with octohydro fused azadecalin backbone include those described in U.S. Patent Application Publication No. 2015 / 0148341, entitled Octahydro Fused Azadecalin Glucocorticoid Receptor Modulators.

[0030] Where substituents are specified by their conventional chemical formula written from left to right, they equally encompass chemically identical substituents which may be derived by writing the structure from right to left, e.g., -CH2O- is equivalent to -OCH2-.

[0031] "Alkyl" refers to a straight or branched chain saturated aliphatic radical having the indicated number of carbon atoms. Alkyl can be any number of carbons (e.g., C 1-2 , C 1-3 , C 1-4 , C 1-5 , C 1-6 , C 1-7 , C 1-8 , C 1-9 , C 1-10 , C 2-3 , C 2-4 , C 2-5 , C 2-6 , C 3-4 , C 3-5 , C 3-6 , C 4-5 , C 4-6 and C 5-6 ) For example, C 1-6Alkyl includes, but is not limited to, methyl, ethyl, propyl, isopropyl, butyl, isobutyl, sec-butyl, tert-butyl, pentyl, isopentyl, and hexyl.

[0032] "Alkoxy" refers to an alkyl group having an oxygen atom connecting the alkyl group to the point of attachment: alkyl-O-. Like alkyl groups, alkoxy groups can be C 1-6 Alkoxy groups can have any suitable number of carbon atoms, such as, for example, methoxy, ethoxy, propoxy, iso-propoxy, butoxy, 2-butoxy, iso-butoxy, sec-butoxy, tert-butoxy, pentoxy, hexoxy, and the like.

[0033] "Halogen" refers to fluorine, chlorine, bromine and iodine.

[0034] "Haloalkyl" refers to an alkyl, as defined above, in which some or all of the hydrogen atoms have been replaced with halogen atoms. Similar to alkyl groups, haloalkyl groups include C 1-6 and haloalkyl groups can have any suitable number of carbon atoms, such as aryl, aryloxy ...

[0035] The term "perfluoro" can be used to define a compound or radical in which all hydrogens have been replaced with fluorines, for example, perfluoromethane includes 1,1,1-trifluoromethyl.

[0036] "Haloalkoxy" refers to an alkoxy group in which some or all of the hydrogen atoms are replaced with halogen atoms. Similar to alkyl groups, haloalkoxy groups can be C 1-6Alkoxy groups may have any suitable number of carbon atoms, such as 1, 2, 3 or more halogens. When all hydrogens are replaced with halogens, such as fluorine, the compound is per-substituted, such as perfluorinated. Haloalkoxy includes, but is not limited to, trifluoromethoxy, 2,2,2,-trifluoroethoxy and perfluoroethoxy.

[0037] "Cycloalkyl" refers to a saturated or partially unsaturated, monocyclic, fused bicyclic or bridged polycyclic ring assembly containing 3 to 12 ring atoms, or the number of atoms indicated. Cycloalkyl can be any number of carbons (e.g., C 3-6 , C 4-6 , C 5-6 , C 3-8 , C 4-8 , C 5-8 , C 6-8 , C 3-9 , C 3-10 , C 3-11 and C 3-12 ). Saturated monocyclic cycloalkyl rings include, for example, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and cyclooctyl. Saturated bicyclic and polycyclic cycloalkyl rings include, for example, norbornane, [2.2.2]bicyclooctane, decahydronaphthalene, and adamantane. The cycloalkyl group can also be partially unsaturated, having one or more double or triple bonds within the ring. Representative cycloalkyl groups that are partially unsaturated include, but are not limited to, cyclobutene, cyclopentene, cyclohexene, cyclohexadiene (1,3- and 1,4-isomers), cycloheptene, cycloheptadiene, cyclooctene, cyclooctadiene (1,3-, 1,4-, and 1,5-isomers), norbornene, and norbornadiene. When the cycloalkyl is a saturated monocyclic C 3-8When cycloalkyl, exemplary groups include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, and cyclooctyl. 3-6 When it is cycloalkyl, exemplary groups include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, and cyclohexyl.

[0038] "Heterocycloalkyl" refers to a saturated ring system having 3-12 ring members and 1-4 heteroatoms of N, O, and S. Additional heteroatoms may also be useful, including but not limited to B, Al, Si, and P. The heteroatoms may also be oxidized, such as but not limited to -S(O)- and -S(O)2-. Heterocycloalkyl groups may contain any number of ring atoms (e.g., 3-6, 4-6, 5-6, 3-8, 4-8, 5-8, 6-8, 3-9, 3-10, 3-11, or 3-12 ring members). Any suitable number of heteroatoms (e.g., 1, 2, 3, or 4, or 1-2, 1-3, 1-4, 2-3, 2-4, or 3-4) may be included in the heterocycloalkyl group. The heterocycloalkyl groups may include groups such as aziridine, azetidine, pyrrolidine, piperidine, azepane, azocane, quinuclidine, pyrazolidine, imidazolidine, piperazine (1,2-, 1,3- and 1,4-isomers), oxirane, oxetane, tetrahydrofuran, oxane (tetrahydropyran), oxepane, thiirane, thietane, thiolane (tetrahydrothiophene), thiane (tetrahydrothiopyran), oxazolidine, isoxalidine, thiazolidine, isothiazolidine, dioxolane, dithiolane, morpholine, thiomorpholine, dioxane, or dithiane. Heterocycloalkyl groups may also be fused with aromatic or non-aromatic ring systems to form members including, but not limited to, indoline.

[0039] When a heterocycloalkyl contains 3 to 8 ring members and 1 to 3 heteroatoms, representative members include, but are not limited to, pyrrolidine, piperidine, tetrahydrofuran, oxane, tetrahydrothiophene, thiane, pyrazolidine, imidazolidine, piperazine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, morpholine, thiomorpholine, dioxane, and dithiane. Heterocycloalkyls can also form rings with 5 to 6 ring members and 1 to 2 heteroatoms, representative members include, but are not limited to, pyrrolidine, piperidine, tetrahydrofuran, tetrahydrothiophene, pyrazolidine, imidazolidine, piperazine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, and morpholine.

[0040] "Aryl" refers to an aromatic ring system having any suitable number of ring atoms and any suitable number of rings. An aryl group can contain any suitable number of ring atoms (e.g., 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, or 16 ring atoms) and 6 to 10, 6 to 12, or 6 to 14 ring members. Aryl groups can be monocyclic, fused to form bicyclic or tricyclic groups, or linked by bonds to form biaryl groups. Representative aryl groups include phenyl, naphthyl, and biphenyl. Other aryl groups include benzyl, which has a methylene linking group. Some aryl groups have 6 to 12 ring members (e.g., phenyl, naphthyl, or biphenyl). Other aryl groups have 6 to 10 ring members (e.g., phenyl or naphthyl). Some other aryl groups have 6 ring members (e.g., phenyl). Aryl groups can be substituted or unsubstituted.

[0041] "Heteroaryl" refers to a monocyclic or fused bicyclic or tricyclic aromatic ring assembly containing 5-16 ring atoms, where 1-5 of the ring atoms are heteroatoms such as N, O, or S. Additional heteroatoms may also be useful, including but not limited to B, Al, Si, and P. The heteroatoms may also be oxidized, such as but not limited to N-oxide, -S(O)-, and -S(O)2-. Heteroaryl groups may contain any number of ring atoms, such as 3-6, 4-6, 5-6, 3-8, 4-8, 5-8, 6-8, 3-9, 3-10, 3-11, or 3-12 ring members. Any suitable number of heteroatoms, such as 1, 2, 3, 4, or 5; or 1-2, 1-3, 1-4, 1-5, 2-3, 2-4, 2-5, 3-4, or 3-5, may be included in the heteroaryl group. Heteroaryl groups can have 5 to 8 ring members and 1 to 4 heteroatoms, or 5 to 8 ring members and 1 to 3 heteroatoms, or 5 to 6 ring members and 1 to 4 heteroatoms, or 5 to 6 ring members and 1 to 3 heteroatoms. Heteroaryl groups can include groups such as pyrrole, pyridine, imidazole, pyrazole, triazole, tetrazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiophene, furan, thiazole, isothiazole, oxazole and isoxazole. Heteroaryl groups may also be fused to an aromatic ring system, such as a phenyl ring, to form members including, but not limited to, benzopyrroles (e.g., indole and isoindole), benzopyridines (e.g., quinoline and isoquinoline), benzopyrazines (quinoxalines), benzopyrimidines (quinazolines), benzopyridazines (e.g., phthalazine and cinnoline), benzothiophenes, and benzofurans. Other heteroaryl groups include heteroaryl rings linked by bonds, such as bipyridines. Heteroaryl groups may be substituted or unsubstituted.

[0042] The heteroaryl group may be linked through any position on the ring. For example, pyrrole includes 1-, 2-, and 3-pyrrole; pyridine includes 2-, 3-, and 4-pyridine; imidazole includes 1-, 2-, 4-, and 5-imidazole; pyrazole includes 1-, 3-, 4-, and 5-pyrazole; triazole includes 1-, 4-, and 5-triazole; tetrazole includes 1- and 5-tetrazole; pyrimidine includes 2-, 4-, 5-, and 6-pyrimidine; pyridazine includes 3- and 4-pyridazine; 1,2,3-triazine includes 4- and 5-triazine; 1,2,4-triazine includes 3-, 5-, and 6-triazine; 1,3,5-triazine includes 2-triazine; thiophene includes 2- and 3-thiophene; furan includes 2- and and 3-furan; thiazoles include 2-, 4-, and 5-thiazoles; isothiazoles include 3-, 4-, and 5-isothiazoles; oxazoles include 2-, 4-, and 5-oxazoles; isoxazoles include 3-, 4-, and 5-isoxazoles; indoles include 1-, 2-, and 3-indole; isoindoles include 1- and 2-isoindole; quinolines include 2-, 3-, and 4-quinolines; isoquinolines include 1-, 3-, and 4-isoquinolines; quinazolines include 2- and 4-quinoazolines; cinnolines include 3- and 4-cinnolines; benzothiophenes include 2- and 3-benzothiophenes; benzofurans include 2- and 3-benzofurans.

[0043] Some heteroaryl groups include heteroaryl groups having 5 to 10 ring members and 1 to 3 ring atoms containing N, O, or S (e.g., pyrrole, pyridine, imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiophene, furan, thiazole, isothiazole, oxazole, isoxazole, indole, isoindole, quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine, cinnoline, benzothiophene, and benzofuran). Other heteroaryl groups include heteroaryl groups having 5 to 8 ring members and 1 to 3 heteroatoms (e.g., pyrrole, pyridine, imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiophene, furan, thiazole, isothiazole, oxazole and isoxazole).Some other heteroaryl groups include heteroaryl groups having 9 to 12 ring members and 1 to 3 heteroatoms (e.g., indole, isoindole, quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine, cinnoline, benzothiophene, benzofuran and bipyridine). Still other heteroaryl groups include heteroaryl groups having 5 to 6 ring members and 1 to 2 ring heteroatoms including N, O or S (e.g., pyrrole, pyridine, imidazole, pyrazole, pyrazine, pyrimidine, pyridazine, thiophene, furan, thiazole, isothiazole, oxazole and isoxazole).

[0044] Some heteroaryl groups contain 5-10 ring members and only nitrogen heteroatoms (e.g., pyrrole, pyridine, imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), indole, isoindole, quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine and cinnoline). Other heteroaryl groups contain 5-10 ring members and only oxygen heteroatoms (e.g., furan and benzofuran). Some other heteroaryl groups contain 5-10 ring members and only sulfur heteroatoms (e.g., thiophene and benzothiophene). Still other heteroaryl groups contain 5 to 10 ring members and at least two heteroatoms (e.g., imidazole, pyrazole, triazole, pyrazine, pyrimidine, pyridazine, triazine (1,2,3-, 1,2,4- and 1,3,5-isomers), thiazole, isothiazole, oxazole, isoxazole, quinoxaline, quinazoline, phthalazine, and cinnoline).

[0045] "Heteroatom" refers to O, S or N.

[0046] "Salt" refers to the acid salt or base salt of the compound used in the method disclosed herein. Illustrative examples of pharmaceutically acceptable salts are salts of mineral acids (such as hydrochloric acid, hydrobromic acid, phosphoric acid, etc.), salts of organic acids (such as acetic acid, propionic acid, glutamic acid, citric acid, etc.), and salts of quaternary ammonium (such as methyl iodide, ethyl iodide, etc.). It is understood that pharmaceutically acceptable salts are non-toxic. Further information regarding suitable pharmaceutically acceptable salts can be found in Remington's Pharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton, Pa., 1985 (incorporated herein by reference).

[0047] "Isomers" refers to compounds that have the same chemical formula but are structurally distinguishable.

[0048] "Tautomer" refers to one of two or more structural isomers that exist in equilibrium and are readily converted from one form to another.

[0049] The description of the compounds disclosed herein is limited by the principles of chemical bonding known to those skilled in the art.Therefore, when a group can be substituted by one or more of several substituents, such substitutions are selected to be compatible with the principles of chemical bonding and to produce compounds that are not inherently unstable and / or compounds that may be known to those skilled in the art to be unstable under ambient conditions (e.g., aqueous, neutral or physiological conditions).

[0050] "Pharmaceutically acceptable excipients" and "pharmaceutically acceptable carriers" refer to substances that aid in the administration of and absorption of active agents by a subject, and may be included in the compositions discussed herein without causing significant adverse toxicological effects to the patient. Non-limiting examples of pharmaceutically acceptable excipients include water, NaCl, normal saline solution, lactated Ringer's solution, normal sucrose, normal glucose, binders, fillers, disintegrants, lubricants, coating agents, sweeteners, flavors and colors, etc. Those skilled in the art will recognize that other pharmaceutical excipients are useful in compositions for use in the methods disclosed herein.

[0051] C.GR positive (GR + ) Neuroepithelial tumor The methods disclosed herein include inhibiting GR by administering an effective amount of an SGRM. +It is useful for the treatment of neuroepithelial tumors. Neuroepithelial tumors arise from cells that arise developmentally from primitive neuroepithelium and represent the largest group of intracranial neoplasms. See, for example, the "Oncology Encyclopedia" article at the oncolex.org website under the link "CNS-tumors / Diagnoses / Intracranial-tumors / Background / Histology" entitled "Histology of Intracranial Tumors". Based on the premise that each type of tumor results from the abnormal growth of a specific cell type, neuroepithelial tumors can be classified according to the World Health Organization (WHO) into the following classes: astrocytic tumors, oligodendroglial tumors, ependymal cell tumors, mixed gliomas, neuroepithelial tumors of unknown origin, tumors of the choroid plexus, neuronal and mixed neuronal-glial tumors, pineal parenchymal tumors, and tumors with neuroblastic or glioblastic elements (embryonal tumors).

[0052] The GR expression status of these various neuroepithelial tumors is examined by using one or more routine biochemical analyses. In some embodiments, GR expression is determined by detecting the expression of GR transcripts using methods such as microarray and RT-PCR. In other embodiments, GR expression is determined by detecting protein expression using methods such as Western blot analysis and immunohistochemical staining. In still other embodiments, GR expression is determined using a combination of these methods.

[0053] In a preferred embodiment, immunohistochemical staining is performed and the H-score method is used to quantify the expression of GR in tumor tissue. In one exemplary assay, formalin-fixed, paraffin-embedded tumor tissue sections are deparaffinized and treated with antigen retrieval solution to make the glucocorticoid receptor easily accessible to anti-GR antibody. Anti-GR antibody is then incubated with the tissue section, and the antibody bound to GR on the tissue section is detected by the addition of horseradish peroxidase (HRP)-conjugated secondary antibody that recognizes the anti-GR antibody. The HRP on the secondary antibody conjugate catalyzes a colorimetric reaction and, upon contact with an appropriate substrate, produces staining where GR is present. In one approach, the intensity levels of GR staining are represented as 0 for negative staining, 1+ for weak staining, 2+ for moderate staining, and 3+ for strong staining. (See the article titled "ihc scoring" available at www.ihcworld.com). Each intensity level of GR + The percentage of cells is multiplied by the intensity level and the results of all intensity levels are summed to generate an H-score between 0 and 300. In one embodiment, tumor types with an H-score equal to or higher than a predefined threshold are classified as GR. + In a preferred embodiment, the threshold is 150. In another embodiment, the GR + Tumors are those in which at least 10% of the tumor cells exhibit GR staining of any intensity.

[0054] D. Diagnosis of Meningiomas, Schwannomas, and Ependymomas Schwannomas, meningiomas, and ependymomas are neuroepithelial tumors that are generally classified as GR +These tumors are frequently observed in patients with neurofibromatosis type 2 (NF2, also known as the MISME syndrome for Multiple Hereditary Schwannomas, Meningiomas, and Ependymomas). NF2 is caused by mutations in the NF2 gene, which puts individuals at higher risk for developing cancerous and benign tumors and other symptoms of NF2. The NF2 gene codes for a protein called merlin (also known as schwannomin). This protein is produced in the nervous system, particularly in Schwann cells, which surround and insulate nerve cells (neurons) in the brain and spinal cord. The merlin protein acts as a tumor suppressor, and mutations in the NF2 gene result in the production of a non-functional version of the merlin protein that cannot regulate cell growth and division.

[0055] Signs of NF2 usually appear in the late teens or early twenties. NF2 patients are at high risk for developing cataracts in the eyes and benign skin tumors, and may have light brown pigmentation of the skin. Symptoms of NF2 often include hearing loss, tinnitus, dysequilibrum, headaches, and facial numbness and weakness. NF2 patients may also show abnormal corneal reflexes, nystagmus, and facial hypoesthesia on clinical examination, enlarged cochlear foramina on CT scans, tumor enhancement in the region of the cerebellopontine angle on gadolinium-enhanced MRI scans, hearing loss on hearing tests, and possibly pathological findings on electronystagmus testing. Genetic testing for mutations in the NF2 gene is available for patients diagnosed with NF2 to confirm the diagnosis.

[0056] Patients with meningiomas may present with symptoms including one or more of the following: vision changes such as double vision or blurred vision; hearing loss; memory loss; loss of smell; facial pain; headaches that worsen over time; personality changes; arm or leg weakness; and seizures. One or more imaging-based methods, such as magnetic resonance imaging (MRI), computed tomography (CT), X-ray, cerebral angiography, and positron emission tomography (PET) scan, or ultrasound (US), are often performed on subjects suspected of having meningiomas, for example, based on the presentation of relevant clinical symptoms. The results of these imaging tests are often combined with the patient's medical history, physical examination, and neurological examination to provide an accurate diagnosis and information regarding the origin of the meningioma and whether or where it has spread.

[0057] Common symptoms of Schwannoma include, but are not limited to, one or more of the following: unilateral hearing loss and buzzing or ringing in the ear, dizziness, facial paralysis, difficulty swallowing, impaired eye movement, impaired taste, and unsteadiness, changes in facial and corneal sensation, nystagmus, and ataxia. Imaging-based methods, such as those disclosed above, can also be performed to confirm the presence of Schwannoma.

[0058] Common symptoms of ependymoma include, but are not limited to, one or more of the following: severe headache, vision loss, vomiting, bilateral Babinski sign, lethargy (several hours after the above symptoms), gait changes (turning of the feet while walking), and constipation. Imaging-based methods, such as those described above, can also be used to confirm the presence of ependymoma.

[0059] In some cases, a biopsy, often obtained at the time the tumor is surgically removed, is analyzed to further confirm the presence of NF2, eg, meningioma, schwannoma, or ependymoma.

[0060] E. Glucocorticoid receptor modulators (GRMs) In general, GR + Treatment of neuroepithelial tumors, such as schwannoma, meningioma, or ependymoma, can be provided by administering an effective amount of SGRM of any chemical structure or mechanism of action.Exemplary GRM classes and specific members of such classes are provided herein.However, those skilled in the art will easily recognize other related or unrelated SGRMs that can be used in the treatment methods described herein.

[0061] 1. GRM with a steroid skeleton In some embodiments, an effective amount of SGRM with steroid skeleton is administered to a subject for the treatment of cancer.Steroid GRM can be obtained by modifying the basic structure of glucocorticoid agonist, i.e., various forms of steroid skeleton.The structure of cortisol can be modified in various ways.The two most commonly known classes of structural modification of cortisol steroid skeleton to generate GRM include modification of 11-β hydroxyl group and modification of 17-β side chain (see, for example, Lefebvre, J.Steroid Biochem.33:557-563,1989).

[0062] Examples of steroid GRMs, including steroid SGRMs, include the androgenic steroid compounds described in U.S. Pat. No. 5,929,058, and the compounds described in U.S. Pat. Nos. 4,296,206; 4,386,085; 4,447,424; 4,477,445; 4,519,946; 4,540,686; and 4,54 No. 7,493; No. 4,634,695; No. 4,634,696; No. 4,753,932; No. 4,774,236; No. 4,808,710; No. 4,81 No. 4,327; No. 4,829,060; No. 4,861,763; No. 4,912,097; No. 4,921,638; No. 4,943,566; No. 4,95 No. 4,490; No. 4,978,657; No. 5,006,518; No. 5,043,332; No. 5,064,822; No. 5,073,548; No. 5,0 No. 89,488; No. 5,089,635; No. 5,093,507; No. 5,095,010; No. 5,095,129; No. 5,132,299; No. 5,1 Nos. 6,66,146; 5,166,199; 5,173,405; 5,276,023; 5,380,839; 5,348,729; 5,426,102; 5,439,913; 5,616,458, 5,696,127, and 6,303,591. Such steroid GR antagonists include cortexolone, dexamethasone-oxetanone, 19-nordeoxycorticosterone, 19-norprogesterone, cortisol-21-mesylate; dexamethasone-21-mesylate, 11β-(4-dimethylaminoethoxyphenyl)-17α-propynyl-17β-hydroxy-4,9-estradien-3-one (RU009), and (17α)-17-hydroxy-19-(4-methylphenyl)androsta-4,9(11)-dien-3-one (RU044).

[0063] Other examples of steroidal antiglucocorticoids are disclosed in Van Kampen et al. (2002) Eur. J. Pharmacol. 457(2-3):207, WO 03 / 043640, EP 0683172 B1, and EP 0763541 B1, each of which is incorporated herein by reference. EP 0763541 B1 and Hoyberg et al., Int'l J. of Neuro-psychopharmacology, 5:Supp.1, S148 (2002) disclose the compound (11β,17β)-11-(1,3-benzodioxol-5-yl)-17-hydroxy-17-(1-propynyl)estra-4,9-dien-3-one (ORG34517), which in one embodiment is administered in an amount effective to treat an ACTH-secreting tumor in a subject.

[0064] 2. Removal or replacement of the 11-β hydroxy group GRMs, including SGRMs with modified steroid backbones, including removal or replacement of 11-β hydroxyl groups, are administered in one embodiment of the method disclosed herein. This class includes natural GRMs, including cortexolone, progesterone and testosterone derivatives, and synthetic compositions, such as mifepristone (Lefebvre et al., supra). Preferred embodiments of the method disclosed herein include all 11-β aryl steroid backbone derivatives, because in some cases, these compounds may lack progesterone receptor (PR) binding activity (Agarwal, FEBS 217:221-226, 1987). In another embodiment, 11-β phenyl-aminodimethyl steroid backbone derivatives, which are effective anti-glucocorticoid and anti-progesterone agents, are administered. These compositions can act as reversibly binding steroid receptor antagonists. For example, when bound to 11-β phenyl-aminodimethyl steroids, the steroid receptor may be maintained in a conformation that is unable to bind its natural ligand, such as cortisol in the case of GR (Cadepond, 1997, supra).

[0065] Synthetic 11-β phenyl-amino dimethyl steroids include mifepristone (also known as RU486), or 17-β-hydroxy-11-β-(4-dimethyl-aminophenyl) 17-α-(1-propynyl)estra-4,9-dien-3-one). Mifepristone has been shown to be a potent antagonist of both the progesterone receptor and the glucocorticoid (GR) receptor. Thus, in some embodiments, the GR receptor is activated by a steroid hormone receptor. + The GRM administered to treat neuroepithelial or ACTH-secreting tumors is mifepristone, or a salt, tautomer, or derivative thereof. However, in other embodiments, administration of mifepristone is + Specifically excluded as a GRM for the treatment of neuroepithelial tumors. However, in other embodiments, administration of mifepristone is specifically excluded as a GRM for the treatment of ACTH-secreting tumors.

[0066] Another 11-β phenyl-aminodimethyl steroid that has been shown to have GR antagonist effects is the dimethylaminoethoxyphenyl derivative RU009 (RU39.009), 11-β-(4-dimethyl-aminoethoxyphenyl)-17-α-(propynyl-17-β-hydroxy-4,9-estradien-3-one) (see Bocquel, J. Steroid Biochem. Mol. Biol. 45:205-215, 1993). Another GR antagonist related to RU486 is RU044 (RU43.044) 17-β-hydroxy(hydrox)-17-α-19-(4-methyl-phenyl)-androsta-4,9(11)-dien-3-one) (Bocquel, 1993, supra). Teutsch, Steroids 38:651-665, 1981; see also U.S. Pat. Nos. 4,386,085 and 4,912,097.

[0067] One embodiment includes compositions that are irreversible antiglucocorticoids. Such compounds include alpha-keto-methanesulfonate derivatives of cortisol, including cortisol-21-mesylate (4-pregnene-11-beta, 17-alpha, 21-triol-3, 20-dione-21-methanesulfonate and dexamethasone-21-mesylate (16-methyl-9-alpha-fluoro-1,4-pregnadiene-11 beta, 17-alpha, 21-triol-3, 20-dione-21-methanesulfonate). See Simons, J. Steroid Biochem. 24:25-32, 1986; Mercier, J. Steroid Biochem. 25:11-20, 1986; U.S. Pat. No. 4,296,206.

[0068] 3. Modification of 17-β side chain group Steroid antiglucocorticoids that can be obtained by various structural modifications of the 17-β side chain are also used in the methods disclosed herein.This class includes synthetic antiglucocorticoids, such as dexamethasone-oxetanone, various 17,21-acetonide derivatives and 17-β-carboxamide derivatives of dexamethasone (Lefebvre, 1989, supra; Rousseau, Nature 279:158-160, 1979).

[0069] 4. Other modifications of the steroid skeleton GRMs, including SGRMs, used in various embodiments of the methods disclosed herein include any steroid backbone modification that affects the biological response resulting from GR-agonist interaction.Steroid backbone antagonists can be any natural or synthetic variation of cortisol, such as adrenal steroids that lack the C-19 methyl group, such as 19-nordeoxycorticosterone and 19-norprogesterone (Wynne, Endocrinology 107:1278-1280, 1980).

[0070] In general, the 11-β side chain substituent, and especially the size of that substituent, can play a significant role in determining the degree of antiglucocorticoid activity of a steroid. Substitutions on the A ring of the steroid backbone can also be important. For example, a 17-hydroxypropenyl side chain can in some cases reduce antiglucocorticoid activity compared to 17-propynyl side chain-containing compounds.

[0071] Additional glucocorticoid receptor antagonists known in the art and suitable for the practice of the methods disclosed herein include 21-hydroxy-6,19-oxidoprogesterone (see Vicent, Mol. Pharm. 52:749-753, 1997), ORg31710 (see Mizutani, J Steroid Biochem Mol Biol 42(7):695-704, 1992), RU43044, RU40555 (see Kim, J Steroid Biochem Mol Biol. 67(3):213-22, 1998), and RU28362.

[0072] 5. Nonsteroidal anti-glucocorticoid receptor modulators Exemplary classes of nonsteroidal glucocorticoid receptor modulators (GRMs) and specific members of such classes that can be used in the methods disclosed herein are provided herein.Such nonsteroidal GRMs can be nonsteroidal SGRMs.However, those skilled in the art will easily recognize other related or unrelated glucocorticoid receptor modulators that can be used in the treatment methods described herein.These include synthetic mimetics and analogs of proteins, including partially peptidic, pseudopeptidic and nonpeptidic molecular entities. For example, oligomeric peptidomimetics useful in the methods disclosed herein include (α-β-unsaturated) peptide sulfonamides, N-substituted glycine derivatives, oligocarbamates, oligourea peptidomimetics, hydrazinopeptides, oligosulfones, and the like (see, e.g., Amour, Int. J. Pept. Protein Res. 43:297-304, 1994; de Bont, Bioorganic & Medicinal Chem. 4:667-672, 1996).

[0073] Examples of nonsteroidal GR modulators include the GR antagonist compounds disclosed in U.S. Pat. Nos. 5,696,127; 6,570,020; and 6,051,573; the GR antagonist compounds disclosed in U.S. Patent Application 20020077356; the glucocorticoid receptor antagonists disclosed in Bradley et al., J. Med. Chem. 45, 2417-2424 (2002), such as 4α(S)-benzyl-2(R)-chloroethyl ester. and 4α(S)-benzyl-2(R)-prop-1-ynyl-1,2,3,4,4α,9,10,10α(R)-octahydro-phenanthrene-2,7-diol ("CP394531") and 4α(S)-benzyl-2(R)-prop-1-ynyl-1,2,3,4,4α,9,10,10α(R)-octahydro-phenanthrene-2,7-diol ("CP409069"); as well as compounds disclosed in PCT International Application No. WO 96 / 19458, which describes non-steroidal compounds that are high affinity and highly selective antagonists for steroid receptors (e.g., 6-substituted-1,2-dihydro-N-protected-quinolines).

[0074] For additional compounds that may be utilized in the methods disclosed herein, as well as in methods of identifying and making compounds useful in practicing these methods, see U.S. Pat. Nos. 4,296,206 (see above); 4,386,085 (see above); 4,447,424; 4,477,445; 4,519,946; 4,540 , 686; 4,547,493; 4,634,695; 4,634,696; 4,753,932; 4,774,236; 4,808,710; 4,814 ,327; 4,829,060; 4,861,763; 4,912,097; 4,921,638; 4,943,566; 4,954,490; 4,978 ,657; 5,006,518; 5,043,332; 5,064,822; 5,073,548; 5,089,488; 5,089,635; 5,093 ,507; 5,095,010; 5,095,129; 5,132,299; 5,166,146; 5,166,199; 5,173,405; 5,276 ,023; 5,380,839; 5,348,729; 5,426,102; 5,439,913; and 5,616,458; as well as WO 96 / 19458 (which describes nonsteroidal compounds, e.g., 6-substituted-1,2-dihydro N-1 protected quinolines, that are high affinity, highly selective modulators (antagonists) of steroid receptors).

[0075] In some embodiments, the combination therapy for treating cancer involves a non-steroidal GRM having a fused azadecalin backbone, a heteroaryl ketone fused azadecalin backbone, or an octahydro fused azadecalin backbone.

[0076] Exemplary GRMs having a fused azadecalin backbone include those described in U.S. Patent No. 7,928,237; U.S. Patent No. 8,461,172; and U.S. Patent No. 8,557,839, all three of which are incorporated herein by reference in their entireties. In some cases, the GRM having a fused azadecalin backbone has the following structure: [ka] (In the formula, L 1 and L 2 is a member independently selected from a bond and unsubstituted alkylene; R 1 is an unsubstituted alkyl, an unsubstituted heteroalkyl, an unsubstituted heterocycloalkyl, -OR 1A , -NR 1C R 1D , -C(O)NR 1C R 1D and -C(O)OR 1A is a member selected from R 1A is a member selected from hydrogen, unsubstituted alkyl, and unsubstituted heteroalkyl; R 1C and R 1D is a member independently selected from unsubstituted alkyl and unsubstituted heteroalkyl; Here, R 1C and R 1D are optionally joined to form an unsubstituted ring together with the nitrogen to which they are attached, said ring optionally containing an additional ring nitrogen; R 2 is the expression: [ka] (In the formula, R 2G is a member selected from hydrogen, halogen, unsubstituted alkyl, unsubstituted heteroalkyl, unsubstituted cycloalkyl, unsubstituted heterocycloalkyl, -CN, and -CF3; J is phenyl; t is an integer from 0 to 5; X is -S(O2)-; and R 5 is 1 to 5 R 5A phenyl optionally substituted with a group, R 5A is hydrogen, halogen, -OR 5A1 , -S(O2)NR 5A2 R 5A3 , -CN and unsubstituted alkyl, R 5A1 is a member selected from hydrogen and unsubstituted alkyl, and R 5A2 and R 5A3 are members independently selected from hydrogen and unsubstituted alkyl) or salts and isomers thereof.

[0077] Compounds containing a fused azadecalin backbone can be prepared as described in U.S. Pat. No. 7,928,237. For example, a fused azadecalin backbone can be prepared as described in Scheme 1, where R 5 , R 1A , R 1C , R 1D , L 2 and R 2 is as defined above in the compounds useful in the practice of the methods disclosed herein. In Scheme 1, L 2 -R 2 can be replaced by a suitable protecting group, such as BOC or benzyl, to facilitate the synthesis. The keto-ester 1 is directly converted to the enone 3 by Robinson annealing reaction involving treatment of 1 with a base (e.g., potassium or sodium alkoxide) in an alcoholic solvent (e.g., methanol, ethanol, or tert-butanol) followed by the addition of methyl vinyl ketone (MVK). The reaction is generally carried out at 0-250 °C. Scheme 1 [ka]

[0078] Exemplary GRMs having a heteroaryl ketone-fused azadecalin backbone include those described in U.S. Patent Application Publication No. 2014 / 0038926, now U.S. Patent No. 8,859,774, which is incorporated by reference in its entirety. In some cases, the GRM having a heteroaryl ketone-fused azadecalin backbone has the following structure: [ka] (In the formula, R 1 is a heteroaryl ring having 5-6 ring members and 1-4 heteroatoms independently selected from the group consisting of N, O, and S; R 1a is a heteroaryl ring optionally substituted with 1 to 4 groups each independently selected from: Each R 1a is hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, -CN, N-oxide, C 3-8 Cycloalkyl and C 3-8 heterocycloalkyl; Ring J is selected from the group consisting of a cycloalkyl ring, a heterocycloalkyl ring, an aryl ring, and a heteroaryl ring, wherein said heterocycloalkyl and heteroaryl rings have 5 to 6 ring members and 1 to 4 heteroatoms each independently selected from the group consisting of N, O, and S; Each R 2 is hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, C 1-6 Alkyl-C 1-6 Alkoxy, -CN, -OH, -NR 2a R 2b , -C(O)R 2a, -C(O)OR 2a , -C(O)NR 2a R 2b , -SR 2a , -S(O)R 2a , -S(O)2R 2a , C 3-8 Cycloalkyl and C 3-8 heterocycloalkyl, wherein the heterocycloalkyl group is selected from the group consisting of 1 to 4 R 2c optionally substituted with a group; Alternatively, two R's linked to the same carbon 2 The groups taken together form an oxo group (=O); Or, two R 2 The groups taken together form a heterocycloalkyl ring having 5-6 ring members and 1-3 heteroatoms each independently selected from the group consisting of N, O, and S, wherein the heterocycloalkyl ring is selected from 1-3 R 2d optionally substituted with a group; R 2a and R 2b is hydrogen and C 1-6 each independently selected from the group consisting of alkyl; Each R 2c is hydrogen, halogen, hydroxy, C 1-6 Alkoxy, C 1-6 Haloalkoxy, -CN and -NR 2a R 2b independently selected from the group consisting of: Each R 2d is hydrogen and C 1-6 alkyl, or two R attached to the same ring atom 2d The groups join together to form (=O); R 3 is 1 to 4 R 3a selected from the group consisting of phenyl and pyridyl, each of which is optionally substituted with a group; Each R 3a is hydrogen, halogen and C 1-6 haloalkyl; and The subscript n is an integer from 0 to 3) or salts and isomers thereof.

[0079] Compounds containing a fused azadecalin scaffold can be prepared as described in Scheme 2. Scheme 2 [ka]

[0080] Exemplary GRMs having an octahydro-fused azadecalin backbone include those described in U.S. Patent Application No. 14 / 549,885, entitled Octahydro Fused Azadecalin Glucocorticoid Receptor Modulators, and published as U.S. Patent Application Publication No. 2015-0148341, the entire contents of which are incorporated herein by reference in their entirety. In some cases, the GRM having an octahydro-fused azadecalin backbone has the following structure: [ka] (In the formula, R 1 is a heteroaryl ring having 5-6 ring members and 1-4 heteroatoms independently selected from the group consisting of N, O, and S; R 1a is a heteroaryl ring optionally substituted with 1 to 4 groups each independently selected from: Each R 1a is hydrogen, C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, N-oxide and C 3-8 independently selected from the group consisting of cycloalkyl; Ring J is selected from the group consisting of aryl and heteroaryl rings having 5-6 ring members and 1-4 heteroatoms each independently selected from the group consisting of N, O, and S; Each R 2 is hydrogen, C1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxy, C 1-6 Alkyl-C 1-6 Alkoxy, -CN, -OH, -NR 2a R 2b , -C(O)R 2a , -C(O)OR 2a , -C(O)NR 2a R 2b , -SR 2a , -S(O)R 2a , -S(O)2R 2a , C 3-8 Cycloalkyl and C having 1 to 3 heteroatoms independently selected from the group consisting of N, O and S 3-8 heterocycloalkyl; Alternatively, two R on adjacent ring atoms 2 The groups taken together form a heterocycloalkyl ring having 5-6 ring members and 1-3 heteroatoms each independently selected from the group consisting of N, O, and S, wherein the heterocycloalkyl ring is selected from 1-3 R 2c optionally substituted with a group; R 2a , R 2b and R 2c are hydrogen and C, respectively. 1-6 independently selected from the group consisting of alkyl; Each R 3a are independently halogen; and The subscript n is an integer from 0 to 3) or salts and isomers thereof.

[0081] Compounds containing an octahydro-fused azadecalin scaffold can be prepared as described in Scheme 3. Scheme 3 [ka]

[0082] F. Identification of Selective Glucocorticoid Receptor Modulators (SGRMs) To determine whether a test compound is an SGRM, the compound is first subjected to an assay to measure its ability to bind to GR and inhibit GR-mediated activity, thereby determining whether the compound is a glucocorticoid receptor modulator. If the compound is confirmed to be a glucocorticoid receptor modulator, the compound is subjected to a selectivity test to determine whether the compound can specifically bind to GR compared to non-GR proteins, such as estrogen receptor, progesterone receptor, androgen receptor or mineralocorticoid receptor. In one embodiment, the SGRM binds to GR with substantially higher affinity than non-GR proteins, such as at least 10-fold higher affinity. The SGRM can show 100-fold, 1000-fold or more selectivity for binding to GR compared to binding to non-GR proteins.

[0083] i. Join The ability of a test compound to bind to the glucocorticoid receptor can be measured using various assays, for example, by screening for the ability of the test compound to compete with a glucocorticoid receptor ligand, such as dexamethasone, for binding to the glucocorticoid receptor. Those skilled in the art will recognize that there are many ways to perform such competitive binding assays. In some embodiments, the glucocorticoid receptor is pre-incubated with a labeled glucocorticoid receptor ligand and then contacted with the test compound. This type of competitive binding assay can also be referred to herein as a binding displacement assay. A decrease in the amount of labeled ligand bound to the glucocorticoid receptor indicates that the test compound binds to the glucocorticoid receptor. In some cases, the labeled ligand is a fluorescently labeled compound (e.g., a fluorescently labeled steroid or steroid analog). Alternatively, the binding of the test compound to the glucocorticoid receptor can be measured directly using a labeled test compound. This latter type of assay is referred to as a direct binding assay.

[0084] Both direct and competitive binding assays can be used in a variety of different formats. The formats can be similar to those used in immunoassays and receptor binding assays. For descriptions of various formats for binding assays, including competitive and direct binding assays, see Basic and Clinical Immunology 7th Edition (D. Stites and A. Terr ed.) 1991; Enzyme Immunoassay, ET Maggio, ed., CRC Press, Boca Raton, Florida (1980); and "Practice and Theory of Enzyme Immunoassays," P. Tijssen, Laboratory Techniques in Biochemistry and Molecular Biology, Elsevier Science Publishers BV Amsterdam (1985), each of which is incorporated herein by reference.

[0085] In a solid-phase competitive binding assay, for example, a sample compound can compete with a labeled analyte for a specific binding site on a binding agent bound to a solid surface. In this type of format, the labeled analyte can be a glucocorticoid receptor ligand and the binding agent can be a glucocorticoid receptor bound to a solid phase. Alternatively, the labeled analyte can be a labeled glucocorticoid receptor and the binding agent can be a solid phase glucocorticoid receptor ligand. In a binding assay, the concentration of labeled analyte bound to the capture agent is inversely proportional to the competitive ability of the test compound.

[0086] Alternatively, competitive binding assays can be performed in liquid phase, and any of a variety of techniques known in the art can be used to separate bound labeled protein from unbound labeled protein.For example, several procedures have been developed to distinguish between bound and excess bound ligand, or between bound and excess unbound test compound.These include sedimentation in sucrose gradients, gel electrophoresis or gel isoelectric focusing to identify bound complexes; precipitation of receptor-ligand complexes with protamine sulfate or adsorption onto hydroxylapatite; and removal of unbound compounds or ligands by adsorption onto dextran-coated charcoal (DCC) or binding to immobilized antibodies.After separation, the amount of bound ligand or test compound is determined.

[0087] Alternatively, homogeneous binding assays can be performed that do not require a separation step. For example, the label on the glucocorticoid receptor can be altered by the binding of the glucocorticoid receptor to its ligand or test compound. This change in the labeled glucocorticoid receptor results in a decrease or increase in the signal emitted by the label, such that measurement of the label at the end of the binding assay allows detection or quantification of the bound glucocorticoid receptor. A wide variety of labels can be used. The components can be labeled by any one of several methods. Useful radioactive labels include: 3 H, 125 I, 35 S, 14 C or 32P is incorporated. Useful non-radioactive labels include those that incorporate fluorophores, chemiluminescent agents, phosphorescent agents, electrochemiluminescent agents, and the like. Fluorescent agents are particularly useful in analytical techniques used to detect shifts in protein structure, such as fluorescence anisotropy and / or fluorescence polarization. The choice of label depends on the required sensitivity, ease of conjugation with the compound, stability requirements, and available instrumentation. For a review of various labeling or signal generating systems that may be used, see U.S. Pat. No. 4,391,904, which is incorporated herein by reference in its entirety for all purposes. The label may be directly or indirectly coupled to the desired components of the assay according to methods well known in the art. In some cases, the test compound is contacted with GR in the presence of a fluorescently labeled ligand (e.g., a steroid or steroid analog) with known affinity for GR, and the amount of bound and free labeled ligand is estimated by measuring the fluorescence polarization of the labeled ligand.

[0088] ii.Activity 1) HepG2 tyrosine aminotransferase (TAT) assay Compounds that exhibit the desired binding affinity to GR are tested for their activity in inhibiting GR-mediated activity. Typically, the compounds are subjected to a tyrosine aminotransferase assay (TAT) to evaluate the ability of the test compound to inhibit the induction of tyrosine aminotransferase activity by dexamethasone. See Example 1. GR modulators suitable for the methods disclosed herein have an IC of less than 10 micromolar. 50 (half maximal inhibitory concentration). Other assays, including but not limited to those described below, can also be used to confirm the GR modulation activity of a compound.

[0089] 2) Cell-based assays Cell-based assays involving whole cells or cell fractions containing glucocorticoid receptors can also be used to assay for binding of test compounds or modulation of glucocorticoid receptor activity. Exemplary cell types that can be used according to the methods disclosed herein include, for example, any mammalian cell, such as white blood cells, such as neutrophils, monocytes, macrophages, eosinophils, basophils, mast cells and lymphocytes, such as T cells and B cells, leukemia cells, Burkitt's lymphoma cells, tumor cells (including mouse mammary tumor virus cells), endothelial cells, fibroblasts, cardiac cells, muscle cells, breast tumor cells, ovarian carcinomas, cervical carcinomas, glioblastomas, liver cells, kidney cells, neuronal cells and fungal cells (including yeast). The cells can be primary cells or tumor cells or other types of immortal cell lines. Of course, glucocorticoid receptors can be expressed in cells that do not express an endogenous form of glucocorticoid receptor.

[0090] In some cases, fragments and protein fusions of glucocorticoid receptor can be used for screening. When a molecule that competes for binding with glucocorticoid receptor ligand is desired, the GR fragment used is a fragment that can bind to the ligand (e.g., dexamethasone). Alternatively, any fragment of GR can be used as a target to identify molecules that bind to glucocorticoid receptor. Glucocorticoid receptor fragments can include, for example, any fragment of at least 20, 30, 40, 50 amino acids of glucocorticoid receptor, up to a protein that contains all but one amino acid.

[0091] In some embodiments, the reduction of signal transduction triggered by glucocorticoid receptor activation is used to identify glucocorticoid receptor modulators. The signal transduction activity of glucocorticoid receptor can be determined in many ways. For example, downstream molecular events can be monitored to determine signal transduction activity. Downstream events include the activity or expression that occurs as a result of stimulation of glucocorticoid receptor. Exemplary downstream events useful in functional evaluation of transcription activation and antagonism in non-altered cells include the upregulation of several glucocorticoid response element (GRE)-dependent genes (PEPCK, tyrosine aminotransferase, aromatase). In addition, certain cell types that are sensitive to GR activation can be used, such as osteocalcin expression in osteoblasts, which is downregulated by glucocorticoids; primary hepatocytes that show glucocorticoid-mediated upregulation of PEPCK and glucose-6-phosphate (G-6-Pase). GRE-mediated gene expression has also been demonstrated in transfected cell lines using well-known GRE-regulated sequences (e.g., mouse mammary tumor virus promoter (MMTV) transfected upstream of a reporter gene construct). Examples of useful reporter gene constructs include luciferase (luc), alkaline phosphatase (ALP) and chloramphenicol acetyltransferase (CAT). Functional evaluation of transcriptional repression can be performed in cell lines such as monocytes or human dermal fibroblasts. Useful functional assays include IL-1beta-stimulated IL-6 expression; downregulation of collagenase, cyclooxygenase-2 and various chemokines (MCP-1, RANTES); LPS-stimulated cytokine release, e.g., TNFα; or measuring the expression of genes controlled by NFkB or AP-1 transcription factors in transfected cell lines.

[0092] Compounds tested in whole cell assays can also be tested in cytotoxicity assays. Cytotoxicity assays are used to determine the extent to which the sensed effect is due to non-glucocorticoid receptor-binding cellular effects. In an exemplary embodiment, the cytotoxicity assay involves contacting constitutively active cells with the test compound. Any reduction in cellular activity indicates a cytotoxic effect.

[0093] 3) Further Assays Further illustrative of the many assays that can be used to identify the compositions that are utilized in the methods disclosed herein are assays based on glucocorticoid activity in vivo.For example, an assay that evaluates the ability of a putative GR modulator to inhibit the incorporation of 3H-thymidine into DNA in cells stimulated by glucocorticoids can be used.Alternatively, a putative GR modulator can complete the binding of 3H-dexamethasone to hepatoma tissue culture GR (see, for example, Choi et al., Steroids 57:313-318, 1992).As another example, the ability of a putative GR modulator to block the nuclear binding of 3H-dexamethasone-GR complex can be used (Alexandrova et al., J.Steroid Biochem.Mol.Biol.41:723-725, 1992). Kinetic assays capable of distinguishing between glucocorticoid agonists and modulators by receptor binding kinetics (as described in Jones, Biochem J. 204:721-729, 1982) can also be used to further identify putative GR modulators.

[0094] In another example, to identify anti-glucocorticoid activity, the assay described in Daune, Molec. Pharm. 13:948-955, 1977; and U.S. Patent No. 4,386,085 can be used. Briefly, thymocytes from adrenalectomized rats are incubated with various concentrations of the test compound (putative GR modulator) in nutrient medium containing dexamethasone. 3H-uridine is added to the cell cultures, which are further incubated, and the extent of incorporation of the radiolabel into the polynucleotides is measured. 3 H-uridine reduces the amount of H-uridine, so a GR modulator would antagonize this effect.

[0095] iii.Selectivity The GR modulators selected above are then subjected to a selectivity assay to determine whether they are SGRMs. Typically, the selectivity assay involves testing the compounds that bind to glucocorticoid receptors in vitro for the degree of binding to non-glucocorticoid receptor proteins. The selectivity assay can be performed in vitro or in a cell-based system, as described above. Binding can be tested against any suitable non-glucocorticoid receptor protein, including antibodies, receptors, enzymes, and the like. In an exemplary embodiment, the non-glucocorticoid receptor binding protein is a cell surface receptor or a nuclear receptor. In another exemplary embodiment, the non-glucocorticoid receptor protein is a steroid receptor, such as an estrogen receptor, a progesterone receptor, an androgen receptor, or a mineralocorticoid receptor.

[0096] The selectivity of an antagonist for GR compared to MR can be measured using various assays known to those skilled in the art. For example, a particular antagonist can be identified by measuring the ability of the antagonist to bind to GR compared to MR (see, for example, U.S. Patent Nos. 5,606,021; 5,696,127; 5,215,916; and 5,071,773). Such analysis can be carried out using direct binding assays or by evaluating competitive binding to purified GR or MR in the presence of a known ligand. In an exemplary assay, cells that stably express high levels of glucocorticoid receptor or mineralocorticoid receptor (see, for example, U.S. Patent No. 5,606,021) are used as a source of purified receptor. The affinity of the ligand to the receptor is then measured directly. GR modulators that exhibit at least a 10-fold, 100-fold, and often a 1000-fold greater affinity for the GR compared to the MR are then selected for use in the methods disclosed herein.

[0097] Selectivity assays may also include assaying the ability to inhibit GR-mediated activity but not MR-mediated activity. One way to identify such GR-specific modulators is to use transfection assays to evaluate the ability of antagonists to prevent the activation of reporter constructs (see, for example, Bocquel et al., J.Steroid Biochem Molec.Biol.45:205-215,1993; U.S. Patent Nos. 5,606,021 and 5,929,058). In an exemplary transfection assay, an expression plasmid encoding a receptor and a reporter plasmid containing a reporter gene linked to a receptor-specific control element are co-transfected into suitable receptor-negative host cells. The transfected host cells are then cultured in the presence and absence of hormones (e.g., cortisol or its analogs) that can activate hormone-responsive promoter / enhancer elements of the reporter plasmid. The transfected and cultured host cells are then monitored for induction (i.e., presence) of the product of the reporter gene sequence. Finally, the expression and / or steroid binding capacity of the hormone receptor protein (encoded by the receptor DNA sequence on the expression plasmid and produced in the transfected and cultured host cells) is measured by determining the activity of the reporter gene in the presence and absence of antagonist. The antagonist activity of the compound can be determined by comparing it with known antagonists of GR and MR receptors (see, for example, U.S. Patent No. 5,696,127). Efficacy is then reported as the maximum response rate observed for each compound compared to a reference antagonist compound. GR modulators that show at least 100-fold, and often 1000-fold or more activity against GR compared to MR, PR or AR are then selected for use in the methods disclosed herein.

[0098] An exemplary SGRM that can be used in the methods disclosed herein is CORT125134, which has the following structure: [ka] The compound is (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazol-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone having the formula:

[0099] Another exemplary SGRM that can be used in the methods disclosed herein is CORT125281, which has the following structure: [ka] The compound is ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazol-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinolin-4a-yl)(4-(trifluoromethyl)pyridin-2-yl)methanone having the formula:

[0100] G. Pharmaceutical Compositions and Administration In some embodiments, pharmaceutical compositions comprising a pharma- ceutically acceptable excipient and a non-steroidal GRM are useful in the practice of the methods disclosed herein.

[0101] The nonsteroidal GRM may be prepared and administered in a wide variety of oral, parenteral and topical dosage forms. Oral preparations include tablets, pills, powders, dragees, capsules, liquids, lozenges, gels, syrups, slurries, suspensions, and the like suitable for ingestion by the patient. The nonsteroidal GRM may also be administered by injection, i.e., intravenously, intramuscularly, intradermally, subcutaneously, intraduodenally, or intraperitoneally. The nonsteroidal GRM may also be administered by inhalation, e.g., intranasally. Additionally, the nonsteroidal GRM may be administered transdermally. Thus, pharmaceutical compositions comprising a pharma- ceutically acceptable carrier or excipient and the nonsteroidal GRM are useful in the practice of the methods disclosed herein.

[0102] When preparing pharmaceutical compositions from non-steroidal GRM, pharma- ceutically acceptable carriers can be solid or liquid.Solid form preparations include powders, tablets, pills, capsules, cachets, suppositories and dispersible granules.Solid carriers can be one or more substances that can also act as diluents, flavorings, binders, preservatives, tablet disintegrating agents or encapsulating materials.Details about the techniques for formulation and administration are fully described in the scientific and patent literature, see, for example, the latest edition of Remington's Pharmaceutical Sciences, Maack Publishing Co, Easton PA ("Remington's").

[0103] In powders, the carrier is a finely divided solid that is in admixture with the finely divided active ingredient, the nonsteroidal GRM. In tablets, the active ingredient is mixed with a carrier having the necessary binding properties in suitable proportions and compacted into the desired shape and size.

[0104] Powders and tablets preferably contain 5% or 10% to 70% of the active compound. Suitable carriers are magnesium carbonate, magnesium stearate, talc, sugar, lactose, pectin, dextrin, starch, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose, low melting wax, cocoa butter, and the like. The term "preparation" is intended to include formulations of the active compound with encapsulating materials as carriers to provide a capsule in which the active ingredient is surrounded by and bound to the carrier, with or without other carriers. Similarly, cachets and lozenges are included. Tablets, powders, capsules, pills, cachets, and lozenges can be used as solid dosage forms suitable for oral administration.

[0105] Suitable solid excipients are carbohydrate or protein fillers, including, but not limited to, sugars (including lactose, sucrose, mannitol or sorbitol); starches from corn, wheat, rice, potato or other plants; celluloses (such as methylcellulose, hydroxypropylmethyl-cellulose or sodium carboxymethylcellulose); and gums (including arabic and tragacanth); and proteins (such as gelatin and collagen).If desired, disintegrants or solubilizers (such as cross-linked polyvinylpyrrolidone, agar, alginic acid or its salt (such as sodium alginate)) can be added.

[0106] Dragee cores are provided with suitable coatings (e.g., concentrated sugar solutions) which may also include gum arabic, talc, polyvinylpyrrolidone, carbopol gel, polyethylene glycol and / or titanium dioxide, lacquer solutions and suitable organic solvents or solvent mixtures. Dyes or pigments may be added to the tablets or dragee coatings for product identification or to characterize the amount of active compound (i.e., dosage). Pharmaceutical preparations useful for practicing the method of pharmaceutical compositions comprising a pharma-ceutically acceptable carrier or excipient and a nonsteroidal GRM may also be used orally using push-fit capsules made of gelatin, as well as soft sealed capsules made of gelatin and a coating such as glycerol or sorbitol. Push-fit capsules may contain fillers or binders (e.g., lactose or starch), lubricants (e.g., talc or magnesium stearate) and a coating such as glycerol or sorbitol. Depending on the situation It may contain a GR modulator mixed with a stabilizer. In soft capsules, the GR modulator compound may be dissolved or suspended in a suitable liquid, such as fatty oils, liquid paraffin, or liquid polyethylene glycol, with or without stabilizers.

[0107] Liquid form preparations include solutions, suspensions and emulsions, for example, water or water / propylene glycol solutions.For parenteral injection, liquid preparations can be formulated in solution in aqueous polyethylene glycol solution.

[0108] Aqueous solutions suitable for oral use can be prepared by dissolving the active ingredient in water and adding suitable colorants, flavorings, stabilizers and thickeners as desired. Aqueous suspensions suitable for oral use can be prepared by dissolving the finely divided active ingredient in water and adding suitable colorants, flavorings, stabilizers and thickeners as desired. Aqueous suspensions suitable for oral use can be prepared by dissolving the finely divided active ingredient in water and adding suitable colorants, flavorings, stabilizers and thickeners as desired. Aqueous suspensions suitable for oral use can be prepared by dissolving the finely divided active ingredient in water and adding suitable colorants, flavorings, stabilizers and thickeners as desired. Aqueous suspensions suitable for oral use can be prepared by dissolving the finely divided active ingredient in water and adding suitable colorants, flavorings, stabilizers and thickeners as desired. Aqueous suspensions suitable for oral use can be prepared by dissolving the finely divided active ingredient in water and adding suitable colorants, flavorings, stabilizers and thickeners as desired. In the case of the aqueous suspension, the aqueous suspension may be prepared by dispersing in water with a condensation product of ethylene oxide with a ter (e.g., polyoxyethylene sorbitol mono-oleate) or a condensation product of ethylene oxide with a partial ester derived from a fatty acid and a hexitol anhydride (e.g., polyoxyethylene sorbitan mono-oleate). The aqueous suspension may also contain one or more preservatives (e.g., ethyl p-hydroxybenzoate or n-propyl p-hydroxybenzoate), one or more coloring agents, one or more flavoring agents, and one or more sweetening agents (e.g., sucrose, aspartame, or saccharin). The formulation may be adjusted for osmolality.

[0109] Also included are the solid form preparations that are intended to be converted into the liquid form preparations for oral administration immediately before use.Such liquid forms include solutions, suspensions and emulsions.These preparations may contain, in addition to active ingredients, colorants, flavors, stabilizers, buffers, artificial and natural sweeteners, dispersants, thickeners, solubilizers, etc.

[0110] Oil suspensions can be formulated by suspending the nonsteroidal GRM in a vegetable oil (e.g., peanut oil, olive oil, sesame oil or coconut oil) or a mineral oil (e.g., liquid paraffin); or a mixture thereof. The oil suspension can contain a thickening agent (e.g., beeswax, hard paraffin or cetyl alcohol). Sweeteners (e.g., glycerol, sorbitol or sucrose) can be added to provide a palatable oral preparation. These preparations can be preserved by adding an antioxidant such as ascorbic acid. For an example of an injectable oil vehicle, see Minto, J. Pharmacol. Exp. Ther. 281:93-102, 1997. Pharmaceutical preparations useful in the practice of the methods disclosed herein can also be in the form of oil-in-water emulsions. The oil phase can be a vegetable oil or a mineral oil as described above or a mixture thereof. Suitable emulsifying agents include naturally occurring gums (e.g., gum arabic and gum tragacanth), naturally occurring phosphatides (e.g., soybean lecithin), esters or partial esters derived from fatty acids and hexitol anhydrides (e.g., sorbitan mono-oleate) and the condensation products of these partial esters with ethylene oxide (e.g., polyoxyethylene sorbitan mono-oleate). Emulsions may also contain sweetening and flavoring agents, as in the formulation of syrups and elixirs. Such formulations may also contain a demulcent, preservative or coloring agent.

[0111] Nonsteroidal GRMs can be formulated as applicator sticks, solutions, suspensions, emulsions, gels, creams, ointments, pastes, jellies, paints, powders and aerosols, and can be delivered topically, transdermally.

[0112] Nonsteroidal GRAs can also be delivered as microspheres for slow release in the body. For example, microspheres can be administered via intradermal injection of drug-containing microspheres that slowly release subcutaneously (see Rao, J. Biomater Sci. Polym. Ed. 7:623-645, 1995); as biodegradable injectable gel formulations (see, e.g., Gao, Pharm. Res. 12:857-863, 1995); or as microspheres for oral administration (see, e.g., Eyles, J. Pharm. Pharmacol. 49:669-674, 1997). Both the transdermal and intradermal routes provide constant delivery over weeks or months.

[0113] Pharmaceutical formulations useful in the practice of the methods disclosed herein may be provided as salts, which may be formed with many acids, including but not limited to hydrochloric acid, sulfuric acid, acetic acid, lactic acid, tartaric acid, malic acid, succinic acid, and the like. Salts tend to be more soluble in aqueous or other protic solvents than the corresponding free base forms. In other cases, the preparations may be lyophilized powders in 1 mM-50 mM histidine, 0.1%-2% sucrose, 2%-7% mannitol, pH range 4.5-5.5, and are combined with a buffer prior to use.

[0114] In another embodiment, the pharmaceutical preparations useful in carrying out the method disclosed herein can be delivered by using liposomes, which fuse with cell membrane or are endocytosed, i.e., endocytosis is brought about by using ligands attached to the liposomes or ligands attached directly to oligonucleotides that bind to cell surface membrane protein receptors.In particular, liposomes can be used to focus the delivery of GR modulators to target cells in vivo, when the liposome surface has ligands specific to target cells or is otherwise preferentially directed to specific organs (see, for example, Al-Muhammed, J.Microencapsul.13:293-306,1996; Chonn, Curr.Opin.Biotechnol.6:698-708,1995; Ostro, Am.J.Hosp.Pharm.46:1576-1587,1989).

[0115] Pharmaceutical preparation is preferably in unit dosage form.In such form, preparation is divided into unit doses containing suitable amount of active ingredient, nonsteroidal GRA.Unit dosage form can be a packaged preparation containing a discrete amount of preparation, for example, tablet, capsule and powder in a packet in vial or ampoule.Also, unit dosage form can be capsule, tablet, cachet or lozenge itself, or it can be any suitable number of these in packaged form.

[0116] The amount of active ingredient in a unit dose preparation may vary or be adjusted from 0.1 mg to 10,000 mg, more typically from 1.0 mg to 6,000 mg, and most typically from 600 mg to 1,200 mg. Suitable dosages include about 1 mg, 5, 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 200, 300, 400, 500, 600, 700, 800, 900, 1000, 1100, 1200, 1300, 1400, 1500, 1600, 1700, 1800, 1900, or 2000 mg, depending on the particular application and the potency of the active ingredient. The composition may also contain other compatible therapeutic agents, if desired.

[0117] Depending on the dosage and frequency required and tolerated by the patient, single or multiple doses of the formulation may be administered. The formulation should provide a sufficient amount of active agent to effectively treat the disease state. Thus, in one embodiment, the pharmaceutical formulation for oral administration of nonsteroidal GRM is a daily dose of about 0.01 to about 150 mg per kilogram of body weight per day (mg / kg / day). In some embodiments, the daily dose is about 1.0 to 100 mg / kg / day, 5 to 50 mg / kg / day, 10 to 30 mg / kg / day, and 10 to 20 mg / kg / day. Lower doses may be used, particularly when administering the drug to a distant anatomical site, such as the cerebrospinal fluid (CSF) space, as opposed to oral administration, administration to the bloodstream, body cavities, or lumen of an organ. Substantially higher doses may be used for local administration. Actual methods for preparing parenterally administrable formulations are known or apparent to those skilled in the art and are described in more detail in publications such as Remington's, supra. See also Nieman, In "Receptor Mediated Antisteroid Action", Agarwal et al., eds., De Gruyter, New York (1987).

[0118] The duration of treatment with a nonsteroidal GRM to reduce the tumor burden of NF2 (e.g., meningioma or schwannoma) or otherwise ameliorate the symptoms of these tumors can vary depending on the severity of the condition in the subject and the subject's response to the nonsteroidal GRM. In some embodiments, the nonsteroidal GRM can be administered for about 1 week to 104 weeks (2 years), more typically about 6 weeks to 80 weeks, and most typically about 9 to 60 weeks. Suitable administration periods also include 5 to 9 weeks, 5 to 16 weeks, 9 to 16 weeks, 16 to 24 weeks, 16 to 32 weeks, 24 to 32 weeks, 24 to 48 weeks, 32 to 48 weeks, 32 to 52 weeks, 48 ​​to 52 weeks, 48 ​​to 64 weeks, 52 to 64 weeks, 52 to 72 weeks, 64 to 72 weeks, 64 to 80 weeks, 72 to 80 weeks, 72 to 88 weeks, 80 to 88 weeks, 80 to 96 weeks, 88 to 96 weeks, and 96 to 104 weeks. Suitable administration periods also include 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 24, 25, 30, 32, 35, 40, 45, 48, 50, 52, 55, 60, 64, 65, 68, 70, 72, 75, 80, 85, 88, 90, 95, 96, 100 and 104 weeks. In general, administration of nonsteroidal GRM should be continued until clinically significant reduction or improvement is observed. Treatment with nonsteroidal GRM according to the method disclosed herein can continue for 2 years or more.

[0119] In some embodiments, administration of the nonsteroidal GRM is not continuous, but may be interrupted for one or more periods, followed by resumption of administration for one or more periods. Suitable periods for interruption of administration include 5-9 weeks, 5-16 weeks, 9-16 weeks, 16-24 weeks, 16-32 weeks, 24-32 weeks, 24-48 weeks, 32-48 weeks, 32-52 weeks, 48-52 weeks, 48-64 weeks, 52-64 weeks, 52-72 weeks, 64-72 weeks, 64-80 weeks, 72-80 weeks, 72-88 weeks, 80-88 weeks, 80-96 weeks, 88-96 weeks, and 96-100 weeks. Suitable periods of time for which administration is suspended also include 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 24, 25, 30, 32, 35, 40, 45, 48, 50, 52, 55, 60, 64, 65, 68, 70, 72, 75, 80, 85, 88, 90, 95, 96, and 100 weeks.

[0120] The dosing regimen will also take into account pharmacokinetic parameters, i.e., rate of absorption, bioavailability, metabolism, clearance, etc., as are well known in the art (see, e.g., Hidalgo-Aragones (1996) J. Steroid Biochem. Mol. Biol. 58:611-617; Groning (1996) Pharmazie 51:337-341; Fotherby (1996) Contraception 54:59-69; Johnson (1995) J. Pharm. Sci. 84:1144-1146; Rohatagi (1995) Pharmazie 50:610-613; Brophy (1983) Eur. J. Clin. Pharmacol. 24:103-108; the latest Remington's, supra). Current technology allows the clinician to determine the dosing regimen for each individual patient, GR modulator and disease or condition being treated.

[0121] Nonsteroidal GRMs may be used in combination with other active agents known to be useful in modulating the glucocorticoid receptor, or with adjunct agents that may not be effective alone but may contribute to the effectiveness of the active agent.

[0122] In some embodiments, co-administration includes administering one active agent, a nonsteroidal GRM, within 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, or 24 hours of a second active agent. Co-administration includes administering two active agents simultaneously, at about the same time (e.g., within about 1, 5, 10, 15, 20, or 30 minutes of each other), or sequentially in any order. In some embodiments, co-administration can be achieved by co-formulation (i.e., preparing a single pharmaceutical composition that includes both active agents). In other embodiments, the active agents can be formulated separately. In another embodiment, the active agents and / or adjuncts can be linked or conjugated to each other.

[0123] After the pharmaceutical composition containing the GRM of the present invention has been formulated in an acceptable carrier, it can be placed in a suitable container and labeled for treatment of an indicated condition. For administration of a nonsteroidal GRM, such labeling would include, for example, instructions regarding the amount, frequency and method of administration.

[0124] Pharmaceutical compositions useful in the practice of the methods disclosed herein may be provided as salts, which may be formed with many acids, including, but not limited to, hydrochloric acid, sulfuric acid, acetic acid, lactic acid, tartaric acid, malic acid, succinic acid, and the like. Salts tend to be more soluble in aqueous solvents or other protic solvents than the corresponding free base form. In other cases, the preparation may be a lyophilized powder of 1 mM-50 mM histidine, 0.1%-2% sucrose, 2%-7% mannitol, at a pH range of 4.5-5.5, and combined with a buffer prior to use.

[0125] In another embodiment, the compositions useful in carrying out the methods disclosed herein are useful for parenteral administration, for example, intravenous (IV) administration or administration into a body cavity or lumen of an organ. The formulations for administration generally comprise a solution of the compositions useful in carrying out the methods disclosed herein dissolved in a pharma- ceutically acceptable carrier. Among the acceptable vehicles and solvents that may be used are water and Ringer's solution, isotonic sodium chloride. In addition, sterile fixed oils may be conventionally used as a solvent or suspending medium. For this purpose, any bland fixed oil may be used, including synthetic mono- or diglycerides. In addition, fatty acids such as oleic acid may be used in the preparation of injectables as well. These solutions are sterile and generally free of undesirable matter. These formulations may be sterilized by conventional, well-known sterilization techniques. The formulations may contain pharma- ceutical acceptable auxiliary substances as required to approximate physiological conditions (e.g., pH adjusting and buffering agents, toxicity adjusting agents, e.g., sodium acetate, sodium chloride, potassium chloride, calcium chloride, sodium lactate, etc.). The concentration of the compositions useful in the practice of the methods disclosed herein in these formulations can vary widely and can be selected mainly based on fluid volume, viscosity, body weight, etc., according to the specific mode of administration selected and the needs of the patient. For intravenous (IV) administration, the formulation can be a sterile injectable preparation (e.g., a sterile injectable aqueous or oily suspension). This suspension can be formulated according to known techniques using suitable dispersing or wetting agents and suspending agents. The sterile injectable preparation can also be a sterile injectable solution or suspension in a non-toxic parenterally acceptable diluent or solvent (e.g., a solution of 1,3-butanediol).

[0126] H. Combination Therapy Also included in the methods disclosed herein are combination therapies for treating NF2, e.g., meningioma or schwannoma, including SGRM and another conventional cancer therapy, e.g., chemo- or radiation-based treatments, other therapeutic agents, and surgery, as disclosed in U.S. Patent Publication No. 2011269728. The relevant disclosures are incorporated herein by reference in their entirety. Non-limiting examples of chemotherapy include temozolamide, cisplatin (CDDP), carboplatin, procarbazine, mechlorethamine, cyclophosphamide, camptothecin, ifosfamide, melphalan, chlorambucil, busulfan, nitrosurea, dactinomycin, daunorubicin, doxorubicin, bleomycin, plicomycin, mitomycin, etoposide (VP16), tamoxifen, raloxifene, estrogen receptor binding agents, taxol, gemcitabine, navelbine, farnesyl protein, transferase inhibitors, transplatinum, 5-fluorouracil, vincristine, vinblastine, and methotrexate, or any analog or derivative variant of the above. In some embodiments, the chemotherapeutic agent is a composition comprising nanoparticles comprising a thiocolchicine derivative and a carrier protein (e.g., albumin). In further embodiments, a combination of chemotherapeutic agents is administered to tumor cells.The chemotherapeutic agents can be administered sequentially (within minutes, hours, or days of each other) or in parallel; they can be administered to patients in a single premixed composition.Non-limiting examples of radiation therapy include gamma rays and X-rays.

[0127] Suitable therapeutic agents include, for example, vinca alkaloids, agents that disrupt microtubule formation (e.g., colchicine and its derivatives), antiangiogenic agents, such as anti-VEGF antibodies (e.g., bevacizumab), therapeutic antibodies, EGFR targeting agents, tyrosine kinase targeting agents (e.g., tyrosine kinase inhibitors), serine kinase targeting agents, transition metal complexes, proteasome inhibitors, antimetabolites (e.g., nucleoside analogs), alkylating agents, platinum-based agents, anthracycline antibiotics, topoisomerase inhibitors, macrolides, therapeutic antibodies, retinoids (e.g., all-trans retinoic acid or derivatives thereof); geldanamycin or a derivative thereof (e.g., 17-AAG), and other standard chemotherapeutic agents well recognized in the art. In one embodiment, the methods disclosed herein explicitly provide for the combination of an SGRM from the methods disclosed herein with somatostatin or a derivative thereof.

[0128] Various combinations of SGRMs and anti-cancer drugs or compounds (or combinations of such drugs and compounds) may be used to reduce the tumor burden in patients. The SGRM and anti-cancer drug or compound may be administered according to the same or different dosing regimens. In some embodiments, the SGRM and anti-cancer drug or compound are administered sequentially in any order during all or part of the treatment period. In some embodiments, the SGRM and anti-cancer drug are administered simultaneously or nearly simultaneously (e.g., within about 1, 5, 10, 15, 20, or 30 minutes of each other). Non-limiting examples of combination therapy are as follows, where, for example, with respect to administration of an SGRM and an anti-cancer drug, the SGRM is "A" and the anti-cancer drug or compound given as part of the anti-cancer therapy regimen is "B":

[0129] A / B / AB / A / BB / B / AA / A / BA / B / BB / A / AA / B / B / BB / A / B / B

[0130] B / B / B / AB / B / A / BA / A / B / BA / B / A / BA / B / B / AB / B / A / A

[0131] B / A / B / AB / A / A / BA / A / A / BB / A / A / AA / B / A / AA / A / B / A

[0132] Administration of the therapeutic compound or agent to the patient will follow standard protocols for administering such compounds, taking into account the toxicity, if any, of the treatment. Surgical intervention may also be applied in combination with the described treatment.

[0133] I. Assessing Improvement in Reduction of Tumor Burden The SGRM therapy disclosed herein can reduce tumor burden and provide beneficial clinical outcomes to patients with NF2, such as meningioma or schwannoma.The methods for measuring these responses are well known to those skilled in the art of cancer therapy, for example, as described in the Response Evaluation Criteria in Solid Tumors ("RECIST") guidelines, as described in the PDF named "protocolDevelopment / docs / recist_guideline.pdf" available at ctep.cancer.gov, and in the html article "Endpoints: How the Results of Clinical Trials are Measured" available at www.cancerguide.org.

[0134] In one approach, tumor burden is measured by assaying the expression of tumor-specific gene markers. This approach is particularly useful for metastatic tumors. Tumor-specific gene markers are proteins or other molecules that are unique to cancer cells or are much more abundant than non-cancerous cells. Tumor biomarkers useful for schwannoma are known, for example, VEGF and the biomarkers described in Toren et al., Human Genomics 2014(8):10. Tumor biomarkers useful for meningitis are also known, for example, the biomarkers described in Stuart et al., J.Neurol.70(1):10(2011).

[0135] Methods for measuring the expression level of tumor-specific gene markers are well known. In some embodiments, the mRNA of gene markers is isolated from blood samples or tumor tissues, and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) is performed to quantify the expression of gene markers. In some embodiments, Western blot or immunohistochemistry analysis is performed to evaluate the protein expression of tumor-specific gene markers. Typically, the levels of tumor-specific gene markers are measured in multiple samples taken over the course of the combination therapy disclosed herein, and a decrease in the level correlates with a decrease in tumor burden.

[0136] In another approach, the reduction of tumor burden by the combination therapy disclosed herein is shown by the reduction of tumor size or the reduction of the amount of cancer in the body.The measurement of tumor size is typically achieved by imaging-based techniques.For example, computed tomography (CT) scan can provide accurate and reliable anatomical information about the progression of disease, not just the shrinkage or growth of tumor, by identifying either the growth of existing lesions or the occurrence of new lesions or tumor metastasis.

[0137] In yet another approach, the reduction in tumor burden can be assessed by functional and metabolic imaging techniques. These techniques can provide an early assessment of therapeutic response by observing changes in perfusion, oxygenation and metabolism. For example, 18 F-FDG PET uses radiolabeled glucose analog molecules to assess tissue metabolism. Tumors typically have elevated glucose uptake, and changes in values ​​corresponding to decreased tumor tissue metabolism indicate decreased tumor burden. A similar imaging technique is disclosed in Kang et al., Korean J.Radiol.(2012)13(4)371-390.

[0138] Patients undergoing the treatments disclosed herein may show various degrees of tumor burden reduction. In some cases, patients may show a Complete Response (CR), also referred to as "No Evidence of Disease (NED)". CR means that all detectable tumors have disappeared as shown by examination, physical examination and scans. In some cases, patients undergoing the combination therapy disclosed herein may experience a Partial Response (PR), which roughly corresponds to at least a 50% reduction in total tumor volume, but there is evidence that some residual disease still remains. In some cases, the residual disease in a deep partial response may actually be dead tumor or scar, so that a small number of patients classified as having a PR may actually have a CR. Also, many patients who show shrinkage during treatment may show further shrinkage and achieve a CR with continued treatment. In some cases, patients undergoing the combination therapy may experience a Minor Response (MR), which roughly means a small shrinkage of more than 25% and less than 50% (50% will be PR) of total tumor volume. In some cases, patients receiving combination therapy may show stable disease (SD), which means that the tumor remains about the same size, but may include a small amount of growth (typically less than 20 or 25%) or a small amount of shrinkage (anything less than PR, unless a minor response occurs, in which case SD is typically defined as less than 25%).

[0139] The desired beneficial results or desired clinical results from combination therapy can also include, for example, the reduction (i.e., slowing down and / or stopping to some extent) of cancer cell infiltration into peripheral organs; the inhibition (i.e., slowing down and / or stopping to some extent) of tumor metastasis; the increase in response rate (RR); the increase in duration of response; the alleviation to some extent of one or more of the symptoms associated with cancer; the reduction in the dose of other medicines required for the treatment of disease; the delay in the progression of disease; and / or the prolongation of patient survival and / or improvement of quality of life.The methods for evaluating these effects are well known and / or are disclosed, for example, in cancerguide.org / endpoints.html and the RECIST guidelines cited above. EXAMPLES

[0140] Example 1. HepG2 Tyrosine Aminotransferase (TAT) Assay In the following protocol, an assay is described to measure the induction of TAT by dexamethasone in HepG2 cells (human liver hepatocellular carcinoma cell line; ECACC, UK). HepG2 cells are cultured at 37 °C, 5% / 95% (v / v) CO2 / air using MEME medium supplemented with 10% (v / v) fetal bovine serum; 2 mM L-glutamine and 1% (v / v) NEAA. HepG2 cells are then counted and cultured at 0.125 x 10 cells in RPMI 1640 without phenol red, 10% (v / v) charcoal-stripped FBS, 2 mM L-glutamine. 6 The cells are adjusted to give a density of 10,000 cells / ml and 200 μl at 25,000 cells / well are plated into 96-well sterile tissue culture microtiter plates and incubated at 37° C., 5% CO 2 for 24 hours.

[0141] Growth medium is then removed and replaced with assay medium {RPMI 1640 without phenol red, 2 mM L-glutamine + 10 μM forskolin}. Test compounds are then screened against a 100 nM dexamethasone challenge. Compounds are then serially half-log diluted from a 10 mM stock in 100% (v / v) dimethyl sulfoxide. An 8-point half-log dilution curve is then generated, followed by a 1:100 dilution in assay medium to determine 10x final assay compound concentrations, resulting in final assay compound concentrations ranging from 10 to 0.003 μM in 0.1% (v / v) dimethyl sulfoxide.

[0142] Test compounds were pre-incubated with cells in microtiter plates for 30 min at 37°C, 5 / 95 (v / v) CO2 / air, followed by addition of 100 nM dexamethasone, followed by a 20-h period to allow optimal TAT induction.

[0143] HepG2 cells are then lysed with 30 μl of cell lysis buffer containing a protease inhibitor cocktail for 15 minutes at 4° C. Then 155 μl of substrate mixture containing 5.4 mM tyrosine sodium salt, 10.8 mM α-ketoglutarate and 0.06 mM pyridoxal 5′ phosphate in 0.1 M potassium phosphate buffer (pH 7.4) can be added. After 2 hours of incubation at 37° C., the reaction can be stopped by adding 15 μl of 10 M aqueous potassium hydroxide solution, and the plate can be incubated for an additional 30 minutes at 37° C. TAT activity products can be measured by absorbance at λ340 nm.

[0144] Half-maximal inhibition concentrations (IC) were calculated by plotting % inhibition (normalized to 100 nM dexamethasone TAT stimulation) against compound concentration and fitting the data to a four-parameter logistic equation. 50 Assuming that the antagonist is a competitive inhibitor with respect to dexamethasone, the IC value can be calculated using the Cheng and Prusoff equation. 50The values ​​may be converted to Ki (equilibrium dissociation constant).

[0145] Example 2. Inhibition of glioblastoma cell growth by SGRMs The effect of GRMs on growth in cultures of human and mouse glioblastoma cells was investigated. The GRMs mifepristone and CORT125134 inhibited growth in cultures of each of five different glioblastoma cell lines. The maximum drug concentration tested was 50 μM. The cell lines used were serum-standard human glioblastoma (GBM) cell lines: U251, GL261, U87, and patient-derived neurosphere cell lines GBM8 and GBM4. Cells were seeded in a 96-well format at a cell number of 2000 cells / well; experiments were performed in triplicate. Cell growth inhibition by the applied drugs was assayed. Cell growth inhibition was quantified by the Alamar Blue method using a commercially available assay kit. Cell growth inhibition was determined ("read") 72 hours after treatment. The half-maximal inhibitory concentration (IC) determined for mifepristone was: 50 ) values ​​ranged from about 16 micromolar (μM) to about 24 μM. The IC determined for CORT125134 50 Values ​​ranged from about 5 μM to about 29 μM.

[0146] Cell culture: Human glioblastoma cell lines tested (obtained from the American Type Cell Collection (ATCC), Manassas, VA, USA) were U251 and U87 (human), and GL261 (mouse), which were grown as adherent monolayers in DMEM supplemented with 10% fetal bovine serum (FBS) (Seradigm, Radnor, PA, USA, a subsidiary of VWR) and 1% glutamine penicillin-streptomycin (pen-strep) (Omega Scientific, Tarzana, CA, USA). GBM8 (passage 12) and GBM4 are patient-derived glioma stem cell lines obtained and cultured as neurospheres (spheroids) as described in Galli et al., "Isolation and characterization of tumorigenic, stem-like neural precursors from human glioblastoma," Cancer Res 2004,64(19),7011-21 and Lee et al., "Tumor stem cells derived from glioblastomas cultured in bFGF and EGF more closely mirror the phenotype and genotype of primary tumors than do serum-cultured cell lines," Cancer Cell 2006,9(5),391-403. The primary GBM surgical specimen was dissociated in stem cell isolation medium containing human recombinant EGF (20ng / μl), human bFGF (10ng / μl) and heparin (2μg / ml), washed, filtered through a 30μm mesh and plated at 5×10 cells in ultra-low attachment flasks. 5 ~1.5×10 6 Sphere cultures were passaged by dissociation, washing and resuspension in neural stem cell culture medium according to the manufacturer's instructions (NeuroCult™ NS-A Proliferation Kit #05751, Stemcell Technologies, Vancouver, BC, Canada).

[0147] Cell viability assay: Cells were seeded in 96-well plates at a density of 2000 cells per well. Compounds were added 24 h after cell seeding. All compounds were diluted in 1% FBS / DMEM. Controls were treated with medium only. After 3 days of incubation (37°C / 5% CO2), Alamar Blue (#BUF012B, AbDSerotec, Kidlington, UK) was added directly to the medium according to the manufacturer's protocol and returned to the tissue culture incubator (37°C 5% CO2). After 3–18 h, the fluorescent signal was read on a 544ex / 590em (SpectraMax i3x plate reader, Molecular Devices, San Jose, CA, USA) to determine the number of viable cells. IC 50 Values ​​were calculated using commercially available software (Prism 5 software, GraphPad, La Jolla, CA, USA).

[0148] After 24 hours of incubation, the cells were treated with various concentrations of drugs for 72 hours. Cell viability was measured by Alamar Blue after 72 hours and the results are reported for triplicate experiments. The table below shows the IC values ​​determined in these experiments. 50 Represents a value. [Table 1]

[0149] Example 3. Treatment of Meningioma Patients with SGRM A 52-year-old female patient presents with tinnitus and right-sided hearing loss for 6 months. Enhanced axial T1-weighted MRI of the posterior fossa shows a heterogeneous fixed lesion measuring 16 x 11 x 18 mm, which extends into the patient's internal auditory canal. The patient is treated with CORT125134 at a dose of 200 mg once daily for 8 weeks. The patient's tumor burden is monitored before, during and after treatment using enhanced MRI. Imaging results show that the tumor size is reduced compared to the tumor size at the pretreatment baseline, with the reduction exceeding 50% at the end of the treatment period.

[0150] Example 4. Treatment of Meningioma Patients with SGRM A 52-year-old female patient presents with tinnitus and right-sided hearing loss for 6 months. Enhanced axial T1-weighted MRI of the posterior fossa shows a heterogeneous fixed lesion measuring 16 x 11 x 18 mm, which extends into the patient's internal auditory canal. The patient is treated with CORT125281 at a dose of 200 mg once daily for 8 weeks. The patient's tumor burden is monitored before, during and after treatment using enhanced MRI. Imaging results show that the tumor size is reduced compared to baseline, with the reduction exceeding 50% at the end of the treatment period.

[0151] All patents, patent publications, and all other publications cited herein are hereby incorporated by reference in their entirety for all purposes.

Claims

1. Subject GR ＋ 1. A composition for treating a neuroepithelial tumor comprising a selective glucocorticoid receptor antagonist (SGRA), wherein the glucocorticoid receptor antagonist is selected from CORT125134 and CORT125281, and wherein the SGRA is administered to a subject in an amount effective to reduce the tumor burden of the neuroepithelial tumor in the subject, provided that the subject is not otherwise afflicted with a disorder treatable with an SGRA and the tumor does not secrete adrenocorticotropic hormone (ACTH).

2. The GR ＋ The composition of claim 1, wherein the neuroepithelial tumor is neurofibromatosis type 2.

3. The GR ＋ The composition of claim 1 , wherein the neuroepithelial tumor is selected from the group consisting of schwannoma, meningioma, and ependymoma.

4. 10. The composition of claim 1, wherein the composition is administered for at least two weeks.

5. 2. The composition of claim 1, wherein the effective amount is a daily dose of 1-100 mg / kg / day, and wherein the composition is administered alone or in combination with at least one non-SGRA therapy, wherein the at least one non-SGRA therapy is chemotherapy, radiation therapy or other therapeutic agent.

6. 2. The composition of claim 1, wherein the daily dose is 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 30, 40, 50, 60, 70, 80, 90 or 100 mg / kg / day.

7. 2. The composition of claim 1, wherein the nonsteroidal glucocorticoid receptor antagonist is administered for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80 weeks.

8. The SGRA is CORT125134 【Chemistry 24】 2. The composition of claim 1 ,

9. The SGRA is CORT125281 【Chemistry 26】 2. The composition of claim 1 ,

10. The composition of claim 8 , wherein the tumor is a schwannoma.

11. 1. A composition for treating a schwannoma or meningioma in a patient, comprising a selective glucocorticoid receptor antagonist (SGRA), wherein the glucocorticoid receptor antagonist is selected from CORT125134 and CORT125281, and wherein the SGRA is administered to the patient in an amount effective to reduce the tumor burden of the schwannoma or meningioma in the patient.

12. 12. The composition of claim 11, wherein the composition is administered for at least two weeks.

13. The composition of claim 11, wherein the effective amount is a daily dose of 1 to 100 mg / kg / day.

14. 12. The composition of claim 11, wherein the daily dose is 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 30, 40, 50, 60, 70, 80, 90 or 100 mg / kg / day.

15. 12. The composition of claim 11, wherein the nonsteroidal glucocorticoid receptor antagonist is administered for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80 weeks.

16. The SGRA is CORT125134 【Chemical 33】 The composition of claim 11 ,

17. The SGRA is CORT125281 【Chemistry 35】 The composition of claim 11 ,

18. The composition of claim 16, wherein the tumor is a schwannoma.

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