Treatment of adrenocortical carcinoma with selective glucocorticoid receptor modulators (SGRMs) and antibody checkpoint inhibitors

Abstract

Methods and compositions for treating a subject with adrenocortical carcinoma and hypercortisolism are disclosed. The methods result in a reduction in ACC tumor burden, restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, increased infiltration of T cells and NK cells into ACC tumors, and decreased infiltration of neutrophils into ACC tumors, among other therapeutic effects. The methods include administering a glucocorticoid receptor modulator (GRM) (which may be a selective glucocorticoid receptor modulator (SGRM)) and an antibody checkpoint inhibitor. In some embodiments, the GRM (e.g., the SGRM) is administered orally. The GRM may be a non-steroidal compound containing a fused azadecalin structure; a heteroaryl ketone-fused azadecalin structure; or an octahydro-fused azadecalin structure.

Description

[Technical Field]

[0001] The adrenal glands are the natural source of the glucocorticoid (GC) cortisol. Cortisol is produced and secreted by the adrenal glands in response to adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Cortisol levels fluctuate throughout the day and can be measured in the blood (e.g., serum, plasma, or whole blood), and also in the morning (typically when cortisol levels are highest). Cortisol levels can also be measured in urine (e.g., 24-hour urinary cortisol measurement, which allows for cortisol measurement less affected by the time of sampling), saliva (e.g., nocturnal salivary cortisol, typically when cortisol levels are lowest), and other bodily fluids (e.g., tears and sweat). Cortisol may also be measured after a dexamethasone suppression test, in which case cortisol serves as an indicator of the hypothalamic-pituitary-adrenal system's response to glucocorticoids such as dexamethasone administered externally. [Background technology]

[0002] Elevated glucocorticoid (GC) activity, such as "cortisol excess" or "excess cortisol," has been associated with the pathophysiology of multiple cancer types, although accurate quantification is difficult. Approximately half of patients with adrenocortical carcinoma (ACC) present with systemic GC excess (GC+), a unique case for correlational evaluation of GC activity, demonstrating clear clinical and biochemical evidence. This broad immunosuppressive effect of GC can limit the tumor immune response and the efficacy of immune checkpoint inhibitors (ICIs).

[0003] In adrenocortical carcinoma (ACC), the efficacy of antibody checkpoint inhibitors is limited. Approximately half of ACC patients present with systemic cortisol excess (GC+). Cortisol excess causes disorders such as Cushing's syndrome. In addition, cortisol has immunosuppressive effects. Immunosuppression is associated with an insufficient response to checkpoint inhibitors. The specific immunosuppressive effects of cortisol in ACC are unknown. In other words, the immunosuppressive effects of SGRM in GC+ ACC are unknown.

[0004] There is a need in the art to provide more effective treatments for ACC, including enhancing the effects of antibody checkpoint inhibitor treatment for ACC patients. [Overview of the project]

[0005] Multi-omics analysis of adrenocortical carcinoma (ACC) identified the molecular consequences of glucocorticoid (GC) activity, and evaluated the rationale for combining relacorilant, a glucocorticoid receptor (GR) antagonist, with an immune checkpoint inhibitor (ICI) in adrenocortical carcinoma with glucocorticoid excess (GC+ACC). The applicant analyzed published data on gene transcription and GC excess (e.g., cortisol excess) in ACC tumors.

[0006] Treatment methods include administering selective glucocorticoid receptor modulators (SGRMs) and antibody checkpoint inhibitors to patients with cortisol excess in adrenocortical carcinoma (ACC). Patients have cortisol excess, which means their cortisol levels are above the normal range, for example, above the upper limit of normal cortisol. In some embodiments, cortisol excess is identified when a patient's cortisol level is approximately 1.5 times or more the normal cortisol level, or approximately 2 times or more the normal cortisol level. In some embodiments, cortisol excess is identified when an irregular increase is observed in the patient's circadian rhythm of cortisol.

[0007] The effects of excess cortisol include, for example, increased immune responses in tumors and increased cortisol activity against immune responses to tumors (e.g., immunosuppression in tumors, lymph nodes, etc.). In some embodiments, administering SGRM in combination with an antibody checkpoint inhibitor may be effective in reducing or reversing the effects of excess cortisol in ACC patients with excess cortisol, and may be effective in reducing ACC tumor load in such patients. In some embodiments, administering SGRM in combination with an antibody checkpoint inhibitor may be effective in reducing or reversing the effects of excess cortisol in ACC patients with excess cortisol, and may be effective in restoring T cell signaling pathways and natural killer (NK) cell signaling pathways in such patients. In some embodiments, administering SGRM in combination with an antibody checkpoint inhibitor may be effective in reducing or reversing the effects of excess cortisol in ACC patients with excess cortisol, and may be effective in increasing T cell and natural killer (NK) cell infiltration into ACC tumors in such patients. In one embodiment, administering SGRM in combination with an antibody checkpoint inhibitor may be effective in reducing or reversing the effects of cortisol excess in ACC patients with cortisol excess, and may be effective in reducing neutrophil infiltration into ACC tumors in such patients.

[0008] In some cases, the GRM (e.g., SGRM) is a nonsteroidal compound comprising a condensed azadecalin structure, the condensed azadecalin structure as described and disclosed in U.S. Patents 7,928,237 and 8,461,172, which are incorporated herein by reference in their entirety.

[0009] In some cases, the GRM (e.g., SGRM) is a nonsteroidal compound comprising a heteroarylketone condensed azadecalin structure, the heteroarylketone condensed azadecalin structure as described and disclosed in U.S. Patent No. 8,859,774, which is incorporated herein by reference in whole.

[0010] In some cases, the GRM (e.g., SGRM) is a nonsteroidal compound comprising an octahydrocondensed azadecalin structure, the octahydrocondensed azadecalin structure as described and disclosed in whole in U.S. Patent No. 10,047,082, which is incorporated herein by reference.

[0011] In some cases, the GRM (e.g., SGRM, e.g., nonsteroidal SGRM) is administered orally.

[0012] This method provides an improved treatment method for adrenocortical carcinoma (ACC). The method disclosed herein is expected to have therapeutic effects on ACC patients, such as, for example, a reduction in ACC tumor volume, restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, increased infiltration of T cells and NK cells into ACC tumors, decreased infiltration of neutrophils into ACC tumors, and other therapeutic effects. [Brief explanation of the drawing]

[0013] [Figure 1] Figure 1 shows the differences in transcriptional pathways in GC+ACC cases ("GC+" indicates ACC patients with GC excess). Decreased expression refers to pathways that are reduced in GC+ACC cases, while increased expression refers to pathways that are increased in GC+ACC.

[0014] [Figure 2]Figure 2 shows the abundance of specific immune cell types in ACC tumors. In GC+ cases, the abundance of lymphocytes was low (left), while the abundance of mesenchymal stem cells and neutrophils was high (right).

[0015] [Figure 3A] Classification of ACC tumors based on hormonal status. In four comparisons performed, the presence or absence of GC excess (GC+ / -) was associated with the maximum number of significantly different genes in ACC (where "GC-" represents ACC patients without GC excess).

[0016] [Figure 3B] Effects of GC overexposure on transcription. The expression of 858 genes was found to be significantly affected by GC overexposure. Genes with increased expression levels in GC+ cases (P ≤ 0.05 and more than a twofold change in expression compared to GC-) are shown on the right. Genes with decreased expression levels in GC+ cases are shown on the left.

[0017] [Figure 4] The effect of GC on promoter methylation. In GC-positive tumors, genes in a hypomethylated state (P ≤ 0.05, Δβ < -0.2) were significantly more numerous than genes in a hypermethylated state (P ≤ 0.05, Δβ > 0.2). The β value represents the percentage of methylation in a given gene.

[0018] [Figure 5]Unsupervised clustering of normalized gene expression for two KEGG pathways. The pathways shown include the T cell receptor signaling pathway and the natural killer cell-mediated cytotoxicity pathway. The top two columns show the GC and general hormone status for each tumor (black: GC+ / H+, white: GC- / H-), and the blue / red shading (shown in grayscale) indicates the normalized gene expression for each tumor, with darker blue indicating lower expression. When gene expression is clustered, GC+ cases appear on the right side of the figure, showing low expression for many genes. ("H+" indicates the presence of a hormone, and "H-" indicates the absence of a hormone.)

[0019] [Figure 6] Supervised clustering of normalized gene expression for the two KEGG pathways shown in Figure 5. In GC+ cases (clustered on the right), low gene expression is dominant in these pathways (dark blue).

[0020] [Figure 7] Elevated tumor gene mutation load in GC+ACC. More missense and nonsense mutations were observed in GC+ cases compared to GC- cases.

[0021] [Figure 8] GR activity scores for various tumor types and ACC subsets. ACC showed higher GR-driven gene activity compared to other tumors, and hormone status was independent (see inset).

[0022] [Figure 9] Derivation of gene signatures to distinguish between GC+ACC and GC-ACC cases using random forests. NLRP1 and ZNF683 (highlighted) were identified as important signature components. Only signature genes with a threshold above 0.0028 are shown (where "au" represents an artificial unit of importance for each gene).

[0023] [Figure 10A] Application of the ACC gene signature to TCGA tumors. Note that data obtained from ACC tumors are both shown in the leftmost box (indicated by a bar above the label "ACC"). Data points from ACC patients without GC excess (GC-) and data points from patients with GC excess (GC+) are shown separately by labeled arrows at the top of the corresponding boxes. Uveal melanoma (UVM) and cutaneous melanoma (SKCM) are predicted to have the highest frequency of tumors similar to GC+ACC.

[0024] [Figure 10B] Prediction of the frequency of tumor cases similar to GC+ACC. Uveal melanoma (UVM) and cutaneous melanoma (SKCM) are predicted to have the highest frequency of tumors similar to GC+ACC.

[0025] [Figure 11A] Effects of stimulating isolated human NK cells with IL-2, cortisol, and / or relacolinant in vitro. The addition of relacolinant significantly enhanced IL-2-responsive natural killer (NK) cell activation.

[0026] [Figure 11B] Effects of stimulating isolated human NK cells with IL-2, cortisol, and / or relacolinant in vitro. The addition of relacolinant significantly enhanced IL-2-responsive NK cell proliferation.

[0027] [Figure 12]Figure 12A. Effects of stimulation with IL-2, cortisol, and / or relacorant on cytokine secretion and gene expression of isolated human NK cells. Addition of relacorant improved interferon-γ (IFNγ) secretion compared to NK cells treated with cortisol alone. Figure 12B. Effects of stimulation with IL-2, cortisol, and / or relacorant on cytokine secretion and gene expression of isolated human NK cells. Addition of relacorant improved tumor necrosis factor (TNFα) secretion compared to NK cells treated with cortisol alone. Figure 12C. Effects of stimulation with IL-2, cortisol, and / or relacorant on cytokine secretion and gene expression of isolated human NK cells. Addition of relacorant improved granzyme A secretion compared to NK cells treated with cortisol alone.

[0028] [Figure 12D] Figure 12D. Effects of stimulation with IL-2, cortisol, and / or relacorant on gene expression in isolated human NK cells. In addition to other important NK activity regulators, including LAG3 and IL2RA (encoding the interleukin-2 (IL2) receptor), transcription of IFNG (encoding IFNγ) is also enhanced by relacorant.

[0029] [Figure 13A] Figure 13A. In vitro, glucocorticoids suppress tumor cell death by human NK cells. K562 cell death at various effector cell:tumor cell ratios under the treatment conditions described in the caption. This is counteracted by relacoriants.

[0030] [Figure 13B] Figure 13B. In vitro, glucocorticoids suppress tumor cell death by human NK cells. At an effector cell:tumor cell ratio of 5:1, the significant reduction in tumor cell death in the presence of cortisol is offset by relacoriants. [Modes for carrying out the invention]

[0031] A. Introduction The applicant analyzed the transcription of adrenal cortical carcinoma (ACC) tumor genes. The data were screened to identify gene transcriptions in ACC patients with glucocorticoid (GC) excess (e.g., excess cortisol) and those without. The applicant found that cortisol excess alters the expression of 858 genes in adrenal cortical carcinoma (ACC), specifically natural killer cell (NK)-mediated cytotoxicity, T H 17 cell differentiation, T cell receptor signaling, T H Genes involved in 1 / 2 differentiation and antigen processing and presentation were downregulated in ACC patients with cortisol excess (GC+; Figure 1). Further differences are shown in Figure 1 and elsewhere in this specification.

[0032] The applicant also found that the presence of certain immune cells differed between ACC tumors with and without cortisol excess. Naive and memory CD4+ cells, CD8+ cells, CD8+ central memory cells, and natural killer T cells (NKTs) were less frequent in GC+ cases (see Figure 2). In contrast, tumor-associated neutrophils (TANs) were more frequent in GC+ ACC patients.

[0033] Patient clinical responses to antibody checkpoint inhibitors depend on the immune system. Specifically, T cell function and antigen presentation are important for the clinical efficacy of antibody checkpoint inhibitors. Furthermore, the infiltration of immune cells into tumors is associated with the clinical efficacy of antibody checkpoint inhibitors. Tumors with low T cell counts or high neutrophil infiltration tend to respond poorly to antibody checkpoint inhibitors.

[0034] The applicant discloses that administering an antibody checkpoint inhibitor in conjunction with SGRM administration (SGRM administration is effective in reducing or reversing the effects of cortisol excess in cortisol-excessive ACC patients) improves the response of ACC patients to antibody checkpoint inhibitor administration and thereby improves the treatment of cortisol-excessive ACC patients. In embodiments, administration of SGRM in combination with an antibody checkpoint inhibitor is effective in reducing or reversing the effects of cortisol excess in cortisol-excessive ACC patients and may be effective in reducing the ACC tumor burden in patients.

[0035] The applicant further discloses herein the administration of an antibody checkpoint inhibitor in conjunction with the administration of an SGRM, wherein the administration of the SGRM is effective in restoring T cell and NK cell signaling pathways in the patient (including the patient's ACC tumor). Such restoration of T cell and NK cell signaling pathways can improve the patient's response to the administration of an antibody checkpoint inhibitor and thus improve the treatment of ACC patients with cortisol excess. In embodiments, the administration of an SGRM effective in restoring T cell and NK cell signaling pathways in the patient (including the patient's ACC tumor) may be effective in reducing the patient's ACC tumor burden.

[0036] The applicant further discloses herein the administration of an antibody checkpoint inhibitor in conjunction with the administration of SGRM, wherein the administration of SGRM is effective in increasing T cell and NK cell infiltration into the patient's ACC tumor. Such increased T cell and NK cell infiltration can improve the patient's response to the administration of an antibody checkpoint inhibitor and improve the treatment of ACC patients with cortisol excess. In embodiments, the administration of SGRM, which is effective in increasing T cell and NK cell infiltration into the patient's ACC tumor, may be effective in reducing the patient's ACC tumor volume.

[0037] The applicant further discloses herein the administration of an antibody checkpoint inhibitor in conjunction with the administration of SGRM, wherein the administration of SGRM is effective in reducing neutrophil infiltration into the patient's ACC tumor. Such reduction in neutrophil infiltration improves the patient's response to the administration of the antibody checkpoint inhibitor and thus can improve the treatment of ACC patients with cortisol excess. In embodiments, the administration of SGRM, which is effective in reducing neutrophil infiltration into the patient's ACC tumor, may be effective in reducing the patient's ACC tumor volume.

[0038] B. Definition When the term "approximately" is used in relation to a given value, it indicates a range that includes ±10% of that given value.

[0039] Information on cancer can be found in resources such as the Cancer Genome Atlas (TGCA). The TGCA can be accessed via the National Cancer Institute website (www.cancer.gov) at the page "about-nci / organization / ccg / research / structural-genomics / tcga". The following abbreviations are used herein to refer to various types of cancer:

[0040] [Table 1]

[0041] As used herein, the terms “tumor” and “cancer” are interchangeable and both refer to abnormal tissue growth resulting from excessive cell division. A tumor that can invade and / or metastasize to surrounding tissues is called “malignant.” A tumor that does not metastasize is called “benign.”

[0042] As used herein, the term "adrenocortical carcinoma" and the acronym "ACC" are used synonymously to refer to adrenocarcinoma.

[0043] As used herein, the term “natural killer cell” and abbreviations such as “NK cell” and “NKT cell,” including their plural forms, refer to cytotoxic lymphocytes of the immune system, as is well known in the art.

[0044] As used herein, the term "T cell" refers to thymic lymphocytes that play a vital role in the immune response, as is well known in the art.

[0045] As used herein, the term "neutrophil" refers to the most abundant type of leukocyte in mammals, as is well known in the art, and neutrophils are the most abundant type of granulocyte. Neutrophils are sometimes also called "neutrocytes."

[0046] As used herein, the term "invasion" refers to the intrusion and occupation of one tissue by cells (such as T cells, NK cells, and neutrophils) originating from another tissue.

[0047] As used herein, the term “patient” means a person who is receiving, scheduled to receive, or has received medical treatment for a disease or condition.

[0048] As used herein, the terms “administer,” “to administer,” “to be administered,” or “administer” mean to give a compound or composition (e.g., those described herein) to a subject or patient. For example, a compound or composition may be administered orally to a patient.

[0049] As used herein, the terms “administer,” “to administer,” “to be administered,” or “administer” mean to give a compound or composition (for example, those described herein) to a subject or patient. Administration may be by oral administration (i.e., the subject receives the compound or composition orally in the form of a pill, capsule, liquid, or other form suitable for oral administration). Oral administration may be buccal (the compound or composition is held in the oral cavity, for example, under the tongue, and absorbed there). Administration may be by injection, i.e., by delivering the compound or composition via a needle, microneedle, pressure syringe, or by means of puncturing the skin or forcing the compound or composition through the subject's skin. Injection may be intravenous (i.e., into a vein); intraarterial (i.e., into an artery); intraperitoneal (i.e., into the peritoneum); intramuscular (i.e., into the muscle); or other injection routes. Routes of administration may also include rectal, vaginal, percutaneous, pulmonary (e.g., by inhalation), subcutaneous (e.g., by absorption into the skin from an implant containing the compound or composition), or other routes.

[0050] As used herein, the term “adrenocorticotropic hormone” (ACTH) refers to a peptide hormone produced and secreted by the anterior pituitary gland, which stimulates the adrenal cortex to secrete glucocorticoid hormones that help cells synthesize glucose, catabolize proteins, mobilize free fatty acids, and inhibit inflammation in allergic reactions. One such glucocorticoid hormone is cortisol, which regulates carbohydrate, fat, and protein metabolism. In healthy mammals, ACTH secretion is tightly regulated. ACTH secretion is positively regulated by corticotropin-releasing hormone (CRH), which is released by the hypothalamus. ACTH secretion is negatively regulated by cortisol and other glucocorticoids.

[0051] In the context of ACTH, cortisol, or other analytes, the term “measure levels” means, for example, determining, detecting, or quantifying the amount, level, or concentration of cortisol, ACTH, or other analytes in a sample obtained from a subject. The sample may be, for example, a blood sample, saliva sample, urine sample, or other sample obtained from a patient. Levels may be measured from a fraction of the sample. For example, levels (e.g., ACTH or cortisol) may be measured in the plasma fraction of a blood sample; in the serum fraction of a blood sample; in embodiments, in whole blood; in saliva; in urine; or in other body fluids.

[0052] The term "cortisol" refers to a naturally occurring glucocorticoid hormone (also known as hydrocortisone) produced by the zona fasciculata of the adrenal gland. Cortisol has the following structure:

[0053] [ka]

[0054] The term "total cortisol" refers to cortisol bound to cortisol-binding globulin (CBG or transcortin), and free cortisol (cortisol not bound to CBG). The term "free cortisol" refers to cortisol not bound to cortisol-binding globulin (CBG or transcortin). As used herein, the term "cortisol" refers to total cortisol, free cortisol, and / or cortisol bound to CBG.

[0055] Cortisol levels can be measured in blood (e.g., serum or plasma), urine, saliva, and other body fluids. Urinary free cortisol (UFC, a measure of urinary cortisol excreted over a 24-hour period) is a common method of measuring cortisol levels and requires a full day's worth of sample to cover daily cortisol fluctuations. Plasma cortisol (a measure of cortisol levels at the time of blood sample collection) is often used in dexamethasone suppression tests (to examine a patient's response to a surge in glucocorticoid levels). Cortisol levels can also be measured in serum samples according to methods known in the art. Salivary cortisol may also be measured. Cortisol levels vary depending on the measurement method; that is, blood cortisol levels (e.g., serum or plasma levels) sample cortisol at the time the blood sample is taken, which is numerically different from salivary cortisol levels (sample cortisol at the time the saliva sample is taken), and urinary free cortisol levels (representing cortisol levels over a 24-hour period).

[0056] Cortisol levels can be measured in a sample (e.g., serum, plasma, saliva, urine, or any other biological fluid) using various methods, including, but not limited to, immunoassays such as competitive immunoassays, radioimmunoassays (MA), immunofluorescence quantitative enzyme assays, and ELISA; competitive protein binding assays; liquid chromatography (e.g., HPLC); and mass spectrometry such as high-performance liquid chromatography / triple quadrupole mass spectrometry (LC-MS / MS). In preferred embodiments, cortisol levels are measured using LC-MS / MS, for example, by Quest Diagnostics (Sicaucus, New Jersey, 07094).

[0057] The term "normal value" refers to the average value of an analyte obtained from measurements of samples taken from multiple healthy subjects. For comparison, it is necessary to use the same type of measurement (e.g., plasma or serum; saliva; or urine) as the comparison target.

[0058] The term "normal cortisol level" refers to the average cortisol level obtained by measuring samples (e.g., serum samples) from multiple healthy subjects. For example, according to a report by Putignano et al. (European Journal of Endocrinology, Vol. 145: pp. 165-171 (2001)), normal plasma cortisol levels in healthy women were approximately 420 nanomoles / liter (nmol / l) at 8:00 AM (morning), approximately 250 nmol / l at 5:00 PM (evening), and approximately 90 nmol / l at 12:00 PM (midnight). Salivary cortisol levels obtained from these women were approximately 14 nmol / l at 8:00 AM (morning), approximately 7 nmol / l at 5:00 PM (evening), and approximately 5 nmol / l at 12:00 PM (midnight). The urinary free cortisol level measured in these healthy women was approximately 130 nmol per 24 hours (nmol / 24 hours). Cortisol levels are suppressed by the dexamethasone suppression test (DST), as evidenced by the plasma cortisol level being approximately 24 nmol / l after the DST and the salivary cortisol level being approximately 4 nmol / l after the DST.

[0059] The applicant found that by measuring cortisol levels in patients with ACC tumors, it is possible to identify patients for whom combined treatment with SGRM and antibody checkpoint inhibitors would be effective by determining whether the patients have cortisol excess.

[0060] As used herein, the term "cortisol excess" refers to a cortisol level that is approximately 1.5 times or approximately 2 times the cortisol level measured in a healthy subject (where the cortisol level of a healthy subject is measured by the same method used to measure the patient's cortisol), regardless of the measurement method. For example, using Putignano et al.'s morning plasma cortisol levels, a patient with a morning plasma cortisol level of approximately 630 nmol / l or higher, or approximately 840 nmol / l or higher, would be considered cortisol excess. Using Putignano et al.'s morning salivary cortisol levels, a patient with a morning salivary cortisol level of approximately 21 nmol / l or higher, or approximately 28 nmol / l or higher, would be considered cortisol excess. Using Putignano et al.'s 24-hour urinary free cortisol levels, a patient with a 24-hour urinary cortisol level of approximately 195 nmol / 24 hours or higher, or approximately 260 nmol / 24 hours or higher, would be judged to have cortisol excess.

[0061] In one embodiment, a combination of criteria may be used to identify patients with cortisol excess. For example, two or more, all, or the following criteria may be used to determine whether a patient has cortisol excess: 1. Urinary free cortisol (UFC) levels exceed the upper limit of normal (ULN). 2. Salivary cortisol (LNSC) levels exceeded ULN for two consecutive nights. 3. Cortisol levels exceed 1.8 μg / dL in the dexamethasone suppression test (DST). 4. Adrenocorticotropic hormone (ACTH) level is less than 10 picograms / milliliter (pg / mL).

[0062] As used herein, “standard control” means a sample containing a predetermined amount of an analyte (such as ACTH or cortisol) suitable for the application of the present invention, to serve as a comparative standard that provides an index of the relative amount of the analyte (e.g., ACTH or cortisol) present in the test sample. A sample acting as a standard control provides the average content of an analyte, such as ACTH or cortisol, representative of a specified sample type (e.g., plasma, serum, saliva, or urine), collected at a specified time (e.g., 8:00 a.m.) from an average individual who does not subsequently develop hypokalemia or any related disorders or complications, or is not at high risk thereof, and who has received the same GRM treatment. As used herein, “blood sample” may be a whole blood sample, serum sample, plasma sample, or blood cell sample, as appropriate, for measuring the analyte level by methods known in the art, depending on the conventional application. Similarly, “blood level” of a particular analyte may be the level of the analyte in whole blood, serum, plasma, or within blood cells. For example, blood levels of potassium, ACTH, or cortisol may be the levels of the respective analytes in serum or plasma samples taken from the subject under test.

[0063] The term "mean" refers to a specific characteristic that, when used in the context of describing individuals (especially human subjects) who, prior to GRM treatment, do not have hypokalemia or any related disease or disorder, and are not at high risk of developing them, and which is present in a randomly selected group of individuals who are not diagnosed with hypokalemia or any related disease or condition, and who are not at high risk of developing them, and which can therefore function as a "mean normal value" or "standard control value" for a particular analyte before GRM treatment. This selection group should include a sufficient number of individuals (e.g., at least 200 or 500) so that the mean value (i.e., level or content) of the analyte of interest (e.g., ACTH or cortisol) evaluated among individuals fairly accurately reflects the corresponding level or content of the analyte in a population of non-hypokalemia individuals who are not at risk of disorder or related disease at the time of GRM treatment. In some cases, the extracted populations are typically of the same sex, similar age (e.g., within 5 or 10 years of each other), and have similar ethnic and medical backgrounds. Depending on the analyte, it may be necessary to confirm the mean or standard control value from samples taken from these individuals at approximately the same time (e.g., 6 a.m., 8 a.m., 12 p.m., 4 p.m., or 6 p.m.). The mean or standard control value for a particular analyte may also vary depending on the specific assay or assay format (including specific reagents) used to quantitatively measure the analyte, and may therefore be made available through information from the experimental method or assay manufacturer.

[0064] The term "glucocorticosteroid" ("GC") or "glucocorticoid" refers to steroid hormones that bind to glucocorticoid receptors. Glucocorticosteroids typically have 21 carbon atoms, an α,β-unsaturated ketone on the A ring, and an α-ketol group attached to the D ring. Glucocorticosteroids differ in the degree of oxygenation or hydroxylation at C-11, C-17, and C-19. See Rawn, "Biosynthesis and Transport of Membrane Lipids and Formation of Cholesterol Derivatives," Biochemistry, Daisy et al. (eds.), 1989, p. 567. Cortisol is a glucocorticosteroid.

[0065] Mineralocorticoid receptors (MR), also known as type I glucocorticoid receptors (GR I), are activated by aldosterone in humans.

[0066] As used herein, the term “glucocorticoid receptor” (”GR”) refers to type II GR, a family of intracellular receptors that specifically bind to cortisol and / or cortisol analogs, such as dexamethasone (see, for example, Turner & Muller, J. Mol. Endocrinol. October 1, 2005, 35 283-292). The glucocorticoid receptor is also referred to as the cortisol receptor. The term also includes isoforms of GR, recombinant GR, and mutant GR.

[0067] The term “glucocorticoid receptor modulator” (GRM) refers to any compound that modulates glucocorticoid binding to GR, or any biological response related to the binding of GR to an agonist. For example, GRMs that act as agonists, such as dexamethasone, increase tyrosine aminotransferase (TAT) activity in HepG2 cells (a human hepatocellular carcinoma cell line; ECACC, UK). GRMs that act as antagonists, such as mifepristone, decrease tyrosine aminotransferase (TAT) activity in HepG2 cells. TAT activity can be measured as outlined in the literature by A. Ali et al., J. Med. Chem., 2004, 47, 2441-2452.

[0068] As used herein, the term “selective glucocorticoid receptor modulator” (SGRM) means any composition or compound that modulates GC binding to GR, or any biological response related to the binding of GR to an agonist. “Selective” means that the drug preferentially binds to GR rather than to other nuclear receptors such as the progesterone receptor (PR), mineralocorticoid receptor (MR), or androgen receptor (AR). Such a selective glucocorticoid receptor modulator may bind to MR, AR, or PR, both MR and PR, both MR and AR, both AR and PR, or has an affinity 10 times greater than its affinity for MR, AR, and PR (K d It is preferable that the selective glucocorticoid receptor modulator binds to GR with an affinity of 1 / 10 of the value. In a more preferred embodiment, the selective glucocorticoid receptor modulator is MR, AR, or PR; both MR and PR; both MR and AR; both AR and PR; or 100 times greater (K) than its affinity to MR, AR, and PR. d It binds to GR with an affinity of 1 / 100 of the value. In another embodiment, the selective glucocorticoid receptor modulator is MR, AR, or PR; both MR and PR; both MR and AR; both AR and PR; or 1000 times greater (K) than its affinity to MR, AR, and PR. dIt binds to GR with an affinity of 1 / 1000 of the value. The relacolinant is SGRM.

[0069] A "glucocorticoid receptor antagonist" (GRA) is any compound that inhibits GC binding to GR, or inhibits any biological response associated with GR binding to an agonist. Therefore, GR antagonists can be identified by measuring the compound's ability to inhibit the effects of dexamethasone. TAT activity can be measured as outlined in the literature by A. Ali et al., J. Med. Chem., 2004, 47, 2441-2452. Antagonists have an IC50 activity of less than 10 micromoles. 50 The compound has an inhibitory concentration of up to half the maximum amount. See Example 1 of U.S. Patent No. 8,859,774, which is incorporated herein by reference in its entirety.

[0070] As used herein, the term “selective glucocorticoid receptor antagonist” (SGRA) means any composition or compound that inhibits GC binding to GR or modulates any biological response related to the binding of GR to an agonist (inhibition is determined with respect to the response in the absence of the compound). By “selective,” the drug preferentially binds to GR rather than to other nuclear receptors such as progesterone receptors (PR), mineralocorticoid receptors (MR), or androgen receptors (AR). The selective glucocorticoid receptor antagonist may have an affinity for MR, AR, or PR; both MR and PR; both MR and AR; both AR and PR; or an affinity 10 times greater than its affinity for MR, AR, and PR (K d It is preferable that the selective glucocorticoid receptor antagonist binds to GR with an affinity of 1 / 10 of the value. In a more preferred embodiment, the selective glucocorticoid receptor antagonist binds to MR, AR, or PR; both MR and PR; both MR and AR; both AR and PR; or with an affinity 100 times greater (K) than its affinity to MR, AR, and PR. dIt binds to GR with an affinity (1 / 100 of the value). In another embodiment, the selective glucocorticoid receptor antagonist has an affinity for MR, AR, or PR; both MR and PR; both MR and AR; both AR and PR; or GR that is 1000-fold greater than its affinity for MR, AR, and PR (K d It binds to GR with an affinity (1 / 1000 of the value). Cortirrolilant (CORT125134) is an SGRA.

[0071] As used herein, the expression "no indication for treatment with a glucocorticoid receptor modulator" refers to a patient who does not have any condition recognized in the medical community as being effectively treatable with a glucocorticoid receptor antagonist, except for fatty liver. Conditions known in the art and recognized in the medical community as being effectively treatable with a glucocorticoid receptor antagonist include psychosis associated with interferon-α therapy, psychotic major depression, dementia, stress disorder, autoimmune diseases, nerve damage, and Cushing's syndrome.

[0072] The term "immune response" refers to the actions of lymphocytes, antigen-presenting cells, phagocytes, granulocytes, and soluble macromolecules (including antibodies, cytokines, and complement) produced by the above cells or the liver, which result in selective damage, selective destruction, or elimination from the human body of invading pathogens, cells or tissues infected with pathogens, cancerous cells, or, in the case of autoimmunity or pathological inflammation, normal human cells or human tissues.

[0073] As used herein, the term "checkpoint inhibitor-sensitive cancer" refers to a cancer responsive to a checkpoint inhibitor. Administration of one or more checkpoint inhibitors to a patient having such a tumor can cause a decrease in the amount of ACC tumor, restoration of the T cell signaling pathway and the natural killer (NK) cell signaling pathway, an increase in the infiltration of T cells and NK cells into the ACC tumor, and a decrease in the infiltration of neutrophils into the ACC tumor, or other desired beneficial clinical outcomes associated with cancer improvement.

[0074] As used herein, the terms “effective dose” or “therapeutic dose” refer to the amount of drug effective in treating, eliminating, or alleviating at least one symptom of a disease being treated. In some cases, “therapeutic effective dose” or “effective dose” may refer to the amount of a functional drug or pharmaceutical composition useful in exhibiting a detectable therapeutic or inhibitory effect. This effect can be detected by any assay known in the art. The effective dose may be the amount effective in eliciting an antitumor response. The effective dose may be the amount effective in eliciting a therapeutically beneficial response (e.g., an antitumor immune response, a humoral immune response, and / or a cellular immune response) in the recipient, for example, inhibiting the growth or killing target cells. For the purposes of this disclosure, an effective dose of SGRM or antibody checkpoint inhibitor (and optionally chemotherapeutic agent) is the amount that would cause in a patient a reduction in ACC tumor volume, restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, increased infiltration of T cells and NK cells into ACC tumors, and decreased infiltration of neutrophils into ACC tumors, or other desired beneficial clinical outcomes associated with cancer improvement.

[0075] As used herein, the expression “effective amount for enhancement” means an amount of drug that is effective in enhancing the activity of another therapeutic agent in treating, eliminating, or alleviating at least one symptom of the disease being treated. For example, an effective amount of SGRM administered in combination with an antibody checkpoint inhibitor is the amount of SGRM that improves the therapeutic response to the antibody checkpoint inhibitor. The agent used to enhance the activity of another agent may or may not be effective in treating, eliminating, or alleviating the disease symptoms itself. In some cases, the enhancer may have no effect, and its synergistic effect may be demonstrated by the increased degree of symptom relief obtained from the combination of the two agents compared to treatment with the therapeutic agent alone. In some cases, the enhancer may be effective in treating the symptoms itself, and its enhancing effect may be demonstrated by the synergistic effect between the enhancer and the therapeutic agent. For the purposes of this disclosure, SGRM acts as an enhancer to enhance the activity of a checkpoint inhibitor when treating cancer, regardless of whether it is effective in treating the cancer when administered alone. In some embodiments, enhancement effects of 10% to 1000% can be achieved. In some embodiments, the SGRM is administered in a quantity that makes the tumor sensitive to the checkpoint inhibitor, i.e., a quantity that results in a reduction in ACC tumor volume, restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, increased infiltration of T cells and NK cells into the ACC tumor, and decreased infiltration of neutrophils into the ACC tumor, or other relevant clinical benefits that would not occur if the tumor were treated with an antibody checkpoint inhibitor in the absence of the SGRM.

[0076] As used herein, the term “combination therapy” means administering at least two different drugs to a subject to treat a disease. These two drugs may be administered simultaneously or sequentially in any order during the entire or partial treatment period. These two drugs may be administered according to the same dosing schedule or according to different dosing schedules. In some cases, one drug may be administered according to a planned schedule and the other drug may be administered intermittently. In some cases, both drugs may be administered intermittently. In some embodiments, one drug, e.g., SGRM, may be administered daily, and the other drug, e.g., an antibody checkpoint inhibitor, may be administered every two days, every three days, every four days, or weekly or bi-weekly.

[0077] As used herein, the term “simultaneous administration” means administering two compositions simultaneously or within a short time interval between them, for example, within approximately 0.5 hours, 1 hour, 2 hours, 4 hours, 6 hours, 8 hours, 10 hours, 12 hours, 16 hours, 20 hours, or 24 hours from each other.

[0078] As used herein, the term “checkpoint protein” refers to a protein present on the surface of certain types of cells, such as T cells and certain tumor cells, that can induce checkpoint signaling pathways and result in the suppression of the immune response. Commonly known checkpoint proteins include CTLA4, PD-1, PD-L1, LAG3, B7-H3, B7-H4, TIM3, CD160, CD244, VISTA, TIGIT, and BTLA (Pardoll, 2012, Nature Reviews Cancer, Vol. 12: pp. 252-264; Baksh, 2015, Semin Oncol., June 2015; Vol. 42 (No. 3): pp. 363-77). Of these, CTLA4, PD-1, and PD-L1 are the most well-studied, and treatments targeting these proteins are more advanced in clinical practice than treatments targeting other checkpoint proteins.

[0079] As used herein, the term "PD-1" refers to programmed cell death protein 1 (also known as CD279), a cell surface membrane protein of the immunoglobulin superfamily. PD-1 is expressed by B cells, T cells, and NK cells. The main roles of PD-1 are to limit T cell activity in peripheral tissues during inflammation in response to infection and to limit autoimmunity. PD-1 expression is induced on activated T cells, and the binding of PD-1 to one of its endogenous ligands inhibits T cell activation by inhibiting stimulant kinases. PD-1 also inhibits the TCR "stop signal." PD-1 is highly expressed on Treg cells (regulatory T cells) and may increase Treg cell proliferation in the presence of ligands (Pardoll, 2012, Nature Reviews Cancer, Vol. 12: pp. 252-264).

[0080] As used herein, the term "PD-L1" refers to programmed cell death ligand 1 (also known as CD274 and B7-H1), a ligand for PD-1. PD-L1 is present on active T cells, B cells, myeloid cells, macrophages, and tumor cells. PD-1 has two endogenous ligands, PD-L1 and PD-L2, but antitumor therapy has focused on anti-PD-L1. The PD-1-PD-L1 complex inhibits the proliferation of CD8+ T cells and reduces the immune response (Topalian et al., 2012, N. Engl J. Med., Vol. 366: pp. 2443-54; Brahmer et al., 2012, N. Engl J. Med., Vol. 366: pp. 2455-65).

[0081] As used herein, the term "CTLA4" refers to cytotoxic T lymphocyte antigen 4 (also known as CD152), a member of the immunoglobulin superfamily expressed only on T cells. CTLA4 has been reported to inhibit T cell activation, suppress helper T cell activity, and enhance the immunosuppressive activity of regulatory T cells. While the precise mechanism of action of CTL4-A is still under investigation, it has been suggested that CTL4-A inhibits T cell activation by competing with and outperforming CD28 in binding to CD80 and CD86 on antigen-presenting cells, and furthermore, actively delivers inhibitory signals to T cells (Pardoll, 2012, Nature Reviews Cancer, Vol. 12: pp. 252-264).

[0082] As used herein, the term “checkpoint inhibitor” refers to any molecule, including antibodies and small molecules, that blocks an immunosuppressive pathway induced by one or more checkpoint proteins. Therapies that utilize checkpoint inhibitors to treat disorders such as cancer may be referred to as immune system checkpoint inhibitor therapies, and the acronym “ICI” refers to immune system checkpoint inhibitors. In some embodiments, ICI therapy utilizes an antibody checkpoint inhibitor and involves administering an antibody checkpoint inhibitor to a patient requiring such therapy, and the therapy may be a combination therapy that includes combining GRM, SGRM, GRA, or SGRA with an antibody checkpoint inhibitor. In some embodiments, ICI therapy utilizes a small molecule checkpoint inhibitor and involves administering a small molecule checkpoint inhibitor to a patient requiring such therapy, and the therapy may be a combination therapy that includes combining GRM, SGRM, GRA, or SGRA with a small molecule checkpoint inhibitor.

[0083] As used herein, the term “antibody checkpoint inhibitor” refers to an antibody that blocks an immunosuppressive pathway induced by one or more checkpoint proteins. Therapies that utilize checkpoint inhibitors to treat disorders such as cancer may be referred to, for example, as antibody checkpoint inhibitor therapy. In some embodiments, antibody checkpoint inhibitor therapy comprises administering an antibody checkpoint inhibitor to a patient in need of such therapy, and such therapy may be a combination therapy including a combination of GRM, SGRM, GRA, or SGRA with an antibody checkpoint inhibitor.

[0084] As used herein, the term "antibody effective against a checkpoint protein" refers to an antibody that binds to a checkpoint protein and can antagonistize its function in suppressing the immune response. For example, an antibody against PD-1 refers to an antibody that binds to PD-1 and can block its inhibitory function against the immune response, such as by blocking the interaction between PD-1 and PD-L1. In some cases, it may be an antibody against two different checkpoint proteins, i.e., an antibody that has the ability to bind to two different checkpoint proteins and inhibit their functions. An "antibody effective against a checkpoint protein" is also known as an "antibody checkpoint inhibitor."

[0085] As used herein, the term “antibody” includes not only the full-length antibody but also the “antigen-binding portion” of an antibody. As used herein, the term “antigen-binding portion” refers to one or more antibody fragments that retain the ability to specifically bind to an antigen (e.g., PD-1). Examples of binding fragments included in the term “antigen-binding portion” of an antibody include: (i) a Fab fragment, which is a monovalent fragment consisting of a VL domain, a VH domain, a CL domain, and a CH1 domain; (ii) a F(ab')2 fragment, which is a bivalent fragment consisting of two Fab fragments crosslinked by disulfide crosslinking at a hinge region; (iii) an Fd fragment consisting of a VH domain and a CH1 domain; (iv) an Fv fragment consisting of a VL domain and a VH domain of a single arm of an antibody; (v) a dAb fragment consisting of a VH domain (Ward et al., (1989), Nature, vol. 341: pp. 544-546); and (vi) an isolated complementarity-determining region (CDR). Furthermore, although the two domains of the Fv fragment, VL and VH, are encoded by separate genes, they can be linked using a synthetic linker that allows the VL and VH regions to pair up and form a single protein chain that is monovalent (known as single-chain Fv (scFv); see, for example, Bird et al. (1988), Science, Vol. 242: pp. 423-426; and Huston et al. (1988), Proc. Natl. Acad. Sci. USA, Vol. 85: pp. 5879-5883; and Osbourn et al., 1998, Nature Biotechnology, Vol. 16: p. 778). Such single-chain antibodies are also intended to be included in the term "antigen-binding portion" of an antibody. To construct an expression vector encoding a complete IgG molecule or other isotype, any VH and VL sequences of a particular scFv can be linked to the cDNA sequence or genomic sequence of the constant region of human immunoglobulin. VH and VI can also be used to produce immunoglobulin fragments such as Fab or Fv using either protein chemistry or recombinant DNA technology. Other forms of single-chain antibodies, such as diabodies, are also being considered.A diabody is a bivalent, bispecific antibody in which the VH and VL domains are expressed on a single-chain polypeptide. However, because the linker used is too short, pairing between the two domains on the same chain is not possible. As a result, each domain pairs with its complementary domain on another chain, forming two antigen-binding sites. (See, for example, Holliger, P. et al. (1993) Proc. Natl. Acad. Sci. USA, Vol. 90: pp. 6444-6448; Poljak, RJ et al. (1994) Structure, Vol. 2: pp. 1121-1123).

[0086] Antibodies may be polyclonal antibodies or monoclonal antibodies; heterologous antibodies, homologous antibodies, or analogous antibodies; or modified versions thereof, such as humanized antibodies or chimeric antibodies. The antibodies of the present invention bind specifically or very specifically to one or more checkpoint proteins. The term "monoclonal antibody" refers to a group of antibody molecules containing only one antigen-binding site capable of immune reaction with a specific epitope of an antigen, while the terms "polyclonal antibody" and "polyclonal antibody composition" refer to a group of antibody molecules containing multiple antigen-binding sites capable of interacting with a specific antigen. Monoclonal antibody compositions typically exhibit a single binding affinity to the specific antigen with which they immune reaction.

[0087] As used herein, the term “composition” is intended to encompass products comprising specific components such as the above-mentioned compounds in specific amounts, their tautomers, their derivatives, their analogues, their stereoisomers, their polymorphs, their deuterated species, their pharmaceutically acceptable salts, esters, ethers, metabolites, mixtures of isomers, their pharmaceutically acceptable solvates, and pharmaceutically acceptable compositions, as well as any products obtained directly or indirectly from combinations of such specific components in specific amounts. In relation to pharmaceutical compositions, such term is intended to encompass products comprising active components and inactive components constituting a support, as well as any products resulting directly or indirectly from combinations, complexes, or aggregations of any two or more of the above components, or from the dissociation of one or more of the above components, or from one or more other types of reactions or interactions of the above components. Accordingly, the pharmaceutical compositions of the present invention are intended to encompass any compositions prepared by mixing the compounds of the present invention and their pharmaceutically acceptable support.

[0088] In some embodiments, the term "essentially consisting of" means that in a formulation, the composition contains only the active ingredient shown, but other compounds may be included for purposes such as stabilization and preservation of the formulation, but do not directly contribute to the therapeutic effect of the shown active ingredient. In some embodiments, the term "essentially consisting of" means that the composition contains the active ingredient and components that facilitate the release of the active ingredient. For example, the composition may contain one or more components that impart sustained release of the active ingredient to a subject over time. In some embodiments, the term "consisting of" means that the composition contains the active ingredient and a pharmaceutically acceptable carrier or excipient.

[0089] As used herein, the term “compound” is used to describe a molecular component of a specific, identifiable chemical structure. A molecular component (“compound”) may exist as a free species, unbound to other molecules. A compound may also exist as part of a larger aggregate, bound to other molecules while retaining its chemical identity. A solvate is an example of the above-mentioned binding forms, in which a molecular component (“compound”) with a defined chemical structure is bound to a solvent molecule. A hydrate is a solvate to which the bound solvent is water. When we say “compound,” we mean the molecular component itself (whether it exists in a free or bound form).

[0090] Substituents, when identified by these conventional chemical formulas written from left to right, equally encompass chemically identical substituents that could result from writing the structure from right to left; for example, -CH2O- is equivalent to -OCH2-.

[0091] Substituents, when identified by these conventional chemical formulas written from left to right, equally encompass chemically identical substituents that could result from writing the structure from right to left; for example, -CH2O- is equivalent to -OCH2-.

[0092] "Alkyl" refers to a linear or branched saturated aliphatic radical having the number of carbon atoms indicated. 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 It can contain any number of carbon atoms, such as C. 1-6Examples of alkyl groups, though not limited to them, include methyl, ethyl, propyl, isopropyl, butyl, isobutyl, sec-butyl, tert-butyl, pentyl, isopentyl, and hexyl.

[0093] "Alkoxy" refers to an alkyl group having an oxygen atom attached to the alkyl group at the attachment point: alkyl-O-. With respect to the alkyl group, the alkoxy group is C 1-6 It may have any suitable number of carbon atoms, such as methoxy, ethoxy, propoxy, iso-propoxy, butoxy, 2-butoxy, iso-butoxy, sec-butoxy, tert-butoxy, pentoxy, and hexoxy.

[0094] "Halogens" refer to fluorine, chlorine, bromine, and iodine.

[0095] "Haloalkyl" refers to an alkyl group as defined above, in which some or all of the hydrogen atoms are replaced by halogen atoms. Regarding the alkyl group, haloalkyl groups include trifluoromethyl, fluoromethyl, etc. 1-6 It may have any suitable number of carbon atoms, such as the following.

[0096] The term "perfluoro" can be used to define a compound or radical in which all hydrogen atoms are replaced by fluorine. For example, perfluoromethane contains 1,1,1-trifluoromethyl.

[0097] A "haloalkoxy" refers to an alkoxy group in which some or all of the hydrogen atoms are replaced by halogen atoms. With respect to the alkyl group, the haloalkoxy group is C 1-6The alkoxy group may have any suitable number of carbon atoms. The alkoxy group may be substituted with 1, 2, 3, or more halogens. When all hydrogens are replaced by halogens, for example with fluorine, the compound is oversubstituted, for example, perfluorinated. Examples of haloalkoxys, but not limited to, include trifluoromethoxy, 2,2,2,-trifluoroethoxy, and perfluoroethoxy.

[0098] "Cycloalkyl" refers to a saturated or partially unsaturated monocyclic, fused bicyclic, or bridging polycyclic ring assembly containing 3 to 12 ring atoms, or the number of atoms indicated. Cycloalkyl is 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 It may have any number of carbon atoms, such as cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and cyclooctyl. Examples of saturated monocyclic cycloalkyl rings include norbornane, [2.2.2]bicyclooctane, decahydronaphthalene, and adamantane. The cycloalkyl group may be partially unsaturated, having one or more double or triple bonds in its ring. Representative partially unsaturated cycloalkyl groups 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. 3-8 When the group is cycloalkyl, exemplary groups include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, and cyclooctyl. 3-6When the group is cycloalkyl, exemplary groups include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, and cyclohexyl.

[0099] A "heterocycloalkyl" refers to a saturated ring system having 3 to 12 ring members and 1 to 4 heteroatoms of N, O, and S. Further heteroatoms, including but not limited to B, Al, Si, and P, may also be useful. The heteroatoms may also be oxidized, for example, -S(O)- and -S(O)2-. A heterocycloalkyl group may contain any number of ring atoms, such as 3 to 6, 4 to 6, 5 to 6, 3 to 8, 4 to 8, 5 to 8, 6 to 8, 3 to 9, 3 to 10, 3 to 11, or 3 to 12 ring members. The heterocycloalkyl group may contain any preferred number of heteroatoms, such as 1, 2, 3, or 4, or 1 to 2, 1 to 3, 1 to 4, 2 to 3, 2 to 4, or 3 to 4. The heterocycloalkyl group may include groups such as aziridine, azetidine, pyrrolidine, piperazine, azepane, azocane, quinuclidine, pyrazoline, imidazolidine, piperazine (1,2-, 1,3- and 1,4-isomers), oxirane, oxetane, tetrahydrofuran, oxane (tetrahydropyran), oxepane, thiran, thiethane, thiolane (tetrahydrothiophene), thian (tetrahydrothiopyran), oxazolidine, isooxalidine, thiazolidine, isothiazolidine, dioxolane, dithiolane, morpholine, thiomorpholine, dioxane, or dithiane. The heterocycloalkyl group may also condense with aromatic or non-aromatic ring systems to form members including, but not limited to, indoline.

[0100] When a heterocycloalkyl group contains 3 to 8 ring members and 1 to 3 heteroatoms, typical members include, but are not limited to, pyrrolidine, piperazine, tetrahydrofuran, oxane, tetrahydrothiophene, thiane, pyrazoline, imidazolidine, piperazine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, morpholine, thiomorpholine, dioxane, and dithiane. The heterocycloalkyl group may also form a ring with 5 to 6 ring members and 1 to 2 heteroatoms, and typical members include, but are not limited to, pyrrolidine, piperazine, tetrahydrofuran, tetrahydrothiophene, pyrazoline, imidazolidine, piperazine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, and morpholine.

[0101] "Aryl" refers to an aromatic ring system having any preferred number of ring atoms and any preferred number of rings. An aryl group may contain any preferred number of ring atoms, such as 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, or 16 ring atoms, and 6-10, 6-12, or 6-14 ring members. An aryl group may be monocyclic, condensed to form a bicyclic or tricyclic group, or linked by bonds to form a biaryl group. Representative aryl groups include phenyl, naphthyl, and biphenyl. Another example of an aryl group is benzyl having a methylene linkage. Some aryl groups have 6-12 ring members, such as phenyl, naphthyl, or biphenyl. Other aryl groups have 6-10 ring members, such as phenyl or naphthyl. Some other aryl groups have 6 ring members, such as phenyl. An aryl group may be substituted or unsubstituted.

[0102] A "heteroaryl" refers to a monocyclic, fused bicyclic, or tricyclic aromatic ring assembly containing 5 to 16 ring atoms, wherein 1 to 5 of the ring atoms are heteroatoms such as N, O, or S. Further heteroatoms, including but not limited to B, Al, Si, and P, may also be useful. The heteroatoms may also be oxidized, for example, N-oxide, -S(O)-, and -S(O)2-. A heteroaryl group may contain any number of ring atoms, such as 3 to 6, 4 to 6, 5 to 6, 3 to 8, 4 to 8, 5 to 8, 6 to 8, 3 to 9, 3 to 10, 3 to 11, or 3 to 12 ring members. The heteroaryl group may contain any preferred number of heteroatoms, such as 1, 2, 3, 4, or 5; or 1 to 2, 1 to 3, 1 to 4, 1 to 5, 2 to 3, 2 to 4, 2 to 5, 3 to 4, or 3 to 5. The heteroaryl group may 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. The heteroaryl group may 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. The heteroaryl group may also condense with aromatic ring systems such as phenyl rings to form benzopyrrole such as indole and isoindole, benzopyridine such as quinoline and isoquinoline, benzopyrazine (quinoxaline), benzopyrimidine (quinazoline), benzopyridazine such as phthalazine and cinnoline, benzothiophene, and benzofuran. Other heteroaryl groups include heteroaryl rings linked by bonds, such as bipyridine. Heteroaryl groups may be substituted or unsubstituted.

[0103] The heteroaryl group can be linked at any position on the ring. For example, pyrroles include 1-, 2-, and 3-pyrrole; pyridines include 2-, 3-, and 4-pyridine; imidazoles include 1-, 2-, 4-, and 5-imidazoles; pyrazoles include 1-, 3-, 4-, and 5-pyrazoles; triazoles include 1-, 4-, and 5-triazoles; tetrazoles include 1-, and 5-tetrazoles; pyrimidines include 2-, 4-, 5-, and 6-pyrimidines; pyridazines include 3-, and 4-pyridazines; 1,2,3-triazines include 4-, and 5-triazines; 1,2,4-triazines include 3-, 5-, and 6-triazines; 1,3,5-triazines include 2-triazines; thiophenes include 2-, and 3-thiophenes; and furans include 2- Examples include 3- and 3-furan; as thiazoles, examples include 2-, 4- and 5-thiazoles; as isothiazoles, examples include 3-, 4- and 5-isothiazoles; as oxazoles, examples include 2-, 4- and 5-oxazoles; as isoxazoles, examples include 3-, 4- and 5-isoxazoles; as indoles, examples include 1-, 2- and 3-indoles; as isoindoles, examples include 1- and 2-isoindoles; as quinolines, examples include 2-, 3- and 4-quinolines; as isoquinolines, examples include 1-, 3- and 4-isoquinolines; as quinazolines, examples include 2- and 4-quinoazolines; as sinnolines, examples include 3- and 4-sinnolines; as benzothiophenes, examples include 2- and 3-benzothiophenes; as benzofurans, examples include 2- and 3-benzofurans.

[0104] Examples of heteroaryl groups include those with 5 to 10 ring members and 1 to 3 ring atoms containing N, O, or S, such as 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 those with 5 to 8 ring members and 1 to 3 heteroatoms, such as 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 those with 9 to 12 ring members and 1 to 3 heteroatoms, such as indole, isoindole, quinoline, isoquinoline, quinoxaline, quinazoline, phthalazine, cinnoline, benzothiophene, benzofuran, and bipyridine. Other heteroaryl groups include those with 5-6 ring members and 1-2 ring heteroatoms containing N, O, or S, such as pyrrole, pyridine, imidazole, pyrazole, pyrazine, pyrimidine, pyridazine, thiophene, furan, thiazole, isothiazole, oxazole, and isoxazole.

[0105] Some heteroaryl groups have 5 to 10 ring members and consist only of a nitrogen heteroatom, such as 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 have 5 to 10 ring members and consist only of an oxygen heteroatom, such as furan and benzofuran. Some other heteroaryl groups have 5 to 10 ring members and consist only of a sulfur heteroatom, such as thiophene and benzothiophene. Other heteroaryl groups include 5 to 10 ring members and at least 2 heteroatoms, such as 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 sinnoline.

[0106] A "heteroatom" refers to an O, S, or N atom.

[0107] "Salt" means a salt of an acid or base of a compound used in the method of the present invention. Exemplary examples of pharmaceutically acceptable salts are mineral acid salts (e.g., hydrochloric acid, hydrobromic acid, phosphoric acid), organic acid salts (e.g., acetic acid, propionic acid, glutamic acid, citrate), and quaternary ammonium salts (e.g., methyl iodide, ethyl iodide). It is understood that the pharmaceutically acceptable salts are nontoxic. Further information on preferred pharmaceutically acceptable salts can be found in Remington's Pharmaceutical Sciences, 17th ed., Mack Publishing Company, Easton, Pa., 1985, which is incorporated herein by reference.

[0108] "Isomers" refer to compounds that have the same chemical formula but are structurally distinguishable.

[0109] A "tautomer" is one of two or more structural isomers that exist in equilibrium and can be easily converted from one form to the other.

[0110] The description of the compounds of the present invention is limited by the principles of chemical bonding known to those skilled in the art. Therefore, when a group may be substituted by one or more of a number of substituents, such substitutions are selected to conform to the principles of chemical bonding and to produce compounds that are not inherently unstable and / or are known to those skilled in the art to be prone to instability under ambient conditions—e.g., aqueous, neutral, or physiological conditions.

[0111] Examples of nonsteroidal compounds include SGRMs having a condensed azadecalin skeleton, SGRMs having a heteroarylketone condensed azadecalin skeleton, and SGRMs having an octahydro condensed azadecalin skeleton. Examples of glucocorticoid receptor modulators having a condensed azadecalin skeleton include those described in U.S. Patent Nos. 7,928,237 and 8,461,172. Examples of glucocorticoid receptor modulators having a heteroarylketone condensed azadecalin skeleton include those described in U.S. Patent No. 8,859,774. Examples of glucocorticoid receptor modulators having an octahydro condensed azadecalin skeleton include those described in U.S. Patent No. 10,047,082.

[0112] "Medically acceptable excipients" and "medically acceptable carriers" refer to substances that assist in the administration and absorption of activators to a subject and may be included in the compositions of the present invention without causing significant adverse toxic effects to the patient. As used herein, these terms are intended to include all solvents, dispersion media, coatings, antimicrobial and antifungal agents, antioxidants, isotonic and absorption retardants, etc., that are compatible with drug administration. Non-limiting examples of medically acceptable excipients include water, NaCl, physiological saline, lactated Ringer's solution, ordinary sucrose, ordinary glucose, binders, fillers, disintegrants, encapsulating agents, plasticizers, lubricants, coatings, sweeteners, flavorings, and pigments. Those skilled in the art will recognize that other medious excipients may be useful in the present invention. The use of such media and agents for mediously active substances is well known in the art. Unless any conventional media or agent is not compatible with such active compound, their use in the compositions described above is intended. Additional active compounds may be incorporated into the composition. Those skilled in the art will recognize that other pharmaceutical additives may be useful in the present invention.

[0113] A method for treating ACC tumors in patients with cortisol excess by combined treatment of SGRM and antibody checkpoint inhibitors is disclosed herein. In one embodiment, the tumor is a checkpoint inhibitor-sensitive tumor. In one embodiment, the checkpoint inhibitor-sensitive tumor is GR + It's also cancer.

[0114] Cancer diagnosis This method is intended for the treatment of patients with adrenocortical carcinoma (ACC). The cancer is characterized by the uncontrolled growth and / or spread of abnormal cells. Typically, a biopsy is performed, and cells or tissue from the biopsy are examined under a microscope to confirm the suspected condition. In some cases, further testing of cellular proteins, DNA, and RNA may be necessary to verify the diagnosis.

[0115] Identification of checkpoint inhibitor-sensitive cancers In some embodiments of the present invention, the method is used to treat a patient having at least one checkpoint inhibitor-sensitive cancer. Checkpoint inhibitor-sensitive cancer is one that is responsive to checkpoint inhibitors, i.e., administration of one or more checkpoint inhibitors may reduce ACC tumor burden or achieve beneficial or desired clinical outcomes related to cancer improvement. For example, the administration of the checkpoint inhibitors may result in one or more of the following: reduction of cancer cell number; reduction of tumor size; inhibition of cancer cell invasion into surrounding organs (i.e., slowing to some extent and / or stopping); inhibition of tumor metastasis (i.e., slowing to some extent and / or stopping); inhibition of tumor growth to some extent; and / or alleviation to some extent of one or more symptoms associated with the disorder; reduction of tumor size; reduction of symptoms arising from the disease; improvement of the quality of life of the person affected by the disease; reduction of the dose of other medicines required to treat the disease; delay of disease progression; and / or extension of the patient's survival.

[0116] Tumors sensitive to checkpoint inhibitors often highly express ligands such as PD-L1 and B7, which bind to checkpoint proteins PD-1 and CTLA-4, respectively. The interaction of these ligands suppresses the immune response against tumor cells. In addition to ACC, non-limiting examples of checkpoint inhibitor-sensitive tumors include lung cancer, liver cancer, ovarian cancer, cervical cancer, skin cancer, bladder cancer, colon cancer, breast cancer, glioma, renal carcinoma, gastric cancer, esophageal cancer, oral squamous cell carcinoma, head and neck cancer, melanoma, sarcoma, renal cell tumor, hepatocellular tumor, gliablastoma, neuroendocrine tumor, bladder cancer, pancreatic cancer, gallbladder cancer, gastric cancer, prostate cancer, endometrial cancer, thyroid cancer, and mesothelioma.

[0117] (Checkpoint inhibitors) The methods disclosed herein involve treating cancer using at least one SGRM in combination with at least one checkpoint inhibitor. In some embodiments, the checkpoint inhibitor is an antibody against at least one checkpoint protein ("CIA"). In some embodiments, the checkpoint inhibitor is a small molecule nonprotein compound ("CIC") that blocks an immunosuppressive pathway induced by one or more checkpoint proteins.

[0118] Checkpoint inhibitor antibodies (also known as "CIAs" or "antibody checkpoint inhibitors") In one embodiment, the method for treating the cancer includes administering SGRM in combination with a checkpoint inhibitor antibody. Such an antibody can block the immunosuppressive activity of the checkpoint protein. Numerous such antibodies, such as antibodies against PD-1, CTLA4, and PD-L1, have already been shown to be effective in treating cancer.

[0119] Anti-PD-1 antibodies are used to treat melanoma, non-small cell lung cancer, bladder cancer, prostate cancer, colorectal cancer, head and neck cancer, triple-negative breast cancer, leukemia, lymphoma, and renal cell carcinoma. Exemplary anti-PD-1 antibodies include lambrolizumab (MK-3475, MERCK), nivolumab (BMS-936558, BRISTOL-MYERS SQUIBB), AMP-224 (MERCK), and pizilizumab (CT-011, CURETECH LTD.).

[0120] Anti-CTLA4 antibodies are used in clinical trials for the treatment of melanoma, prostate cancer, small cell lung cancer, and non-small cell lung cancer. A notable characteristic of anti-CTL4A is the kinetics of its antitumor effect, which requires a delay of up to 6 months after initial treatment for a physiological response. In some cases, tumors may actually increase in size after the start of treatment before shrinkage is observed (Pardoll, 2012, Nature Reviews Cancer 12:252-264). Exemplary anti-CTLA4CIAs include ipilimumab (Bristol-Myers Squibb) and tremelimumab (PFIZER).

[0121] For example, CIAs targeting other checkpoint proteins such as LAG-3 (lymphocyte activation gene 3), B7-H3 (B7 homolog 3 protein), B7-H4 (B7 homolog 4 protein), TIM-3 (T cell immunoglobulin and mucin domain 3), CD160, CD244, VISTA (V domain Ig inhibitor of T cell activation), TIGIT (T cell immunoglobulin and ITIM domain), and BTLA (B cell and T cell lymphocyte attenuation factor) may also be used in combination with SGRMs disclosed herein to treat cancer. For example, antibodies that inhibit LAG-3 include IMP321 / Eftilagimod alpha (Immutep), Relatlimab (BMS-986016, Bristol Myers Squibb (BMS)), LAG525 (Novartis), and MK-4280 (Merck). Antibodies that inhibit B7-H3 include Enoblituzumab / MGA271 (MacroGenics) and MGD009. e (Macrogenics Corporation) 131 I-8H9 / omburtamab (Y-mAbs), and 124I-8H9 / ombrutamab (Y-mAbs) is one example. Antibodies that inhibit TIM-3 include LY3321367 (also known as LY332; Eli Lilly and Company), TSR-022 (Tesaro), MBG453 (Novartis), Sym023 (Symphogen), INCAGN2390 (Incyte), BMS-986258 (BMS), RO7121661 (Roche), and SHR-1702 (Jiangsu HengRui). For example, LY3321367 showed promise in early clinical trials, including when used in combination with PD-L1 checkpoint inhibitors. Antibodies that inhibit VISTA include JNJ-61610588 (Johnson & Johnson) and CA-170. d Examples of antibodies that inhibit TIGIT include MK-7684 (Merck), Tiragolumab / MTIG7192A / RG-6058 (Genentech), Etigilimab / OMP-313M32 (OncoMed), BMS-986207 (BMS), AB-154 (Arcus Biosciences), and ASP-8374 (Potenza).

[0122] The CIAs used in this disclosure may be combinations of different CIAs, particularly when target checkpoint proteins, such as PD-1 and CTLA4, suppress the immune response via different signaling pathways. A combination of multiple CIAs targeting any one of the checkpoint proteins, or a single CIA targeting both checkpoint proteins, may provide an enhanced immune response.

[0123] (Created by the CIA) CIA can be expressed using methods well known in the field. See, for example, Kohler and Milstein, Nature 256:495 (1975), and Coligan et al. (eds.), CURRENT PROTOCOLS IN IMMUNOLOGY, VOL.1, pages 2.5.1-2.6.7 (John Wiley & Sons 1991). Monoclonal antibodies can be obtained by injecting mice with a composition containing an antigen, such as a checkpoint protein or its epitope, removing the spleen to obtain B lymphocytes, fusing the B lymphocytes with myeloma cells to produce hybridomas, cloning the hybridomas, selecting positive clones that produce antibodies against the antigen, culturing the clones that produce antibodies against the antigen, and isolating the antibodies from the hybridoma culture.

[0124] The produced monoclonal antibodies can be isolated and purified from hybridoma cultures using various established techniques. Such isolation techniques include affinity chromatography with protein-A Sepharose, size exclusion chromatography, and ion-exchange chromatography. See, for example, Coligan at pages 2.7.1-2.7.12 and pages 2.9.1-2.9.3. See also Baines et al., "Purification of Immunoglobulin G (IgG)" in METHODS IN MOLECULAR BIOLOGY, VOL.10, pages 79-104 (The Humana Press, Inc. 1992). After initial growth of antibodies against checkpoint proteins, the antibodies can be sequenced and subsequently prepared by recombinant techniques. Humanization and chimerization of mouse antibodies and antibody fragments are well known to those skilled in the art. For example, see Leung et al. Hybridoma 13:469 (1994); U.S. Patent Application Publication No. 20140099254A1.

[0125] Human antibodies can be produced using transgenic mice genetically engineered to produce specific human antibodies in response to antigen administration using checkpoint proteins. See Green et al., Nature Genet. 7:13 (1994) and Lonberg et al., Nature 368:856 (1994). Human antibodies against checkpoint proteins can also be constructed by gene or chromosome transfection, phage display technology, or in vitro activated B cells. See, for example, McCafferty et al., 1990, Nature 348:552-553; U.S. Patents 5,567,610 and 5,229,275.

[0126] (CIA modification) CIA can also be produced by introducing conservative modifications to existing CIA. For example, a modified CIA may include heavy chain variable regions and light chain variable regions, and / or Fc regions homologous to the counterparts of the antibody produced above. The modified CIA that can be used in the methods disclosed herein must retain the desired functional properties that enable the blocking of checkpoint signaling pathways.

[0127] CIAs can also be produced by modifying protein modification sites. For example, the glycosylation site of an antibody can be modified to produce an antibody lacking glycosylation, and such modified CIAs typically increase the antibody's affinity for the antigen. Antibodies may also be PEGylated by reacting with polyethylene glycol (PEG) under conditions that one or more PEG groups adhere to the antibody. PEGylation can increase the biological half-life of the antibody. Antibodies having such modifications may also be used in combination with the selective GR modulators disclosed herein, insofar as they retain the desired functional properties of blocking the checkpoint pathway.

[0128] iii. Evaluation of the functional properties of candidate checkpoint inhibitors Numerous well-known assays can be used to assess whether a candidate antibody, i.e., an antibody produced by immunizing an animal with an antigen containing a checkpoint protein, an epitope of a checkpoint protein, or a test compound from a combinatorial library as disclosed above, is an antibody checkpoint inhibitor. Non-limiting examples of assays include binding assays (e.g., enzyme-linked immunosorbent assays (ELISA), radioimmunoassays (RIA)), fluorescence-activated cell classification (FACS) analysis, cell-based assays, and in vivo assays.

[0129] (Binding assay) In one embodiment, the assay is a direct binding assay. The checkpoint protein may be coupled with a radioisotope or enzyme label so that the binding of the checkpoint protein and the candidate can be measured by detecting the labeled checkpoint protein in the complex. For example, the checkpoint protein is 125 I, 35 S, 14 C, or 3 The candidate can be labeled directly or indirectly with 1H, and such radioactive isotopes are detected by direct counting of radioactive emissions or by scintillation counting. Determining the candidate's ability to bind to these homogeneous checkpoint proteins can be achieved, for example, by measuring direct binding. Alternatively, the checkpoint protein molecule can be enzymatically labeled with, for example, horseradish peroxidase, alkaline phosphatase, or luciferase, and the binding of the candidate to the target checkpoint protein is determined by converting a suitable substrate into a product.

[0130] Enzyme-linked immunosorbent assay (ELISA) is commonly used to evaluate the binding specificity of CIA candidates to their target checkpoint proteins. In a typical assay, microtiter plates are coated with checkpoint proteins by coating them overnight at 37°C with 5 μg / ml of checkpoint protein. Serum samples containing candidate CIAs are diluted in PBS, 5% serum, and 0.5% Tween-20, incubated in wells at room temperature for 1 hour, and then anti-human IgG Fc and IgG F(ab')-horseradish peroxidase are added in the same diluents. After 1 hour at room temperature, enzyme activity is assessed by adding ABTS substrate (Sigma, St. Louis Mo.) and read at 415–490 nm after 30 minutes.

[0131] The binding kinetics (e.g., binding affinity) of the candidate proteins can also be assessed by standard assays known in the field, such as Biacore analysis (Biacore AB, Uppsala, Sweden). In one exemplary assay, purified recombinant human checkpoint proteins are covalently bound to a CM5 chip (carboxymethyl dextran coated chip) via a primary amine using standard amine coupling chemistry and a kit provided by Biacore. Binding is measured by flowing the candidate protein in HBS EP buffer (provided by Biacore AB) at a concentration of 267 nM at a flow rate of 50 μl / min. Checkpoint protein-candidate association kinetics are tracked for 3 minutes, and dissociation kinetics for 7 minutes. The association and dissociation curves are fitted to a 1:1 Langmuir binding model using BIA evaluation software (Biacore AB). To minimize the influence of binding force on the estimation of the binding constant, only the initial segments of data corresponding to the association and dissociation phases are used for fitting. D , K on and K off The value can be measured. A preferred checkpoint inhibitor is 1 × 10⁻⁶. -7These target checkpoint proteins can bind to Kd values ​​of M or less.

[0132] For checkpoint proteins that block the immune response through ligand binding, the ability of the candidate to block the binding of the ligand to the checkpoint protein can be tested using further binding assays. In one exemplary assay, flow cytometry is used to test the blockage of ligand binding (e.g., PD-L1) to checkpoint protein (e.g., PD-1) expressed in transfected CHO cells. Various concentrations of the candidate are added to a suspension of cells expressing the checkpoint protein and incubated at 4°C for 30 minutes. The non-binding inhibitor is washed away, and the FITC-labeled ligand protein is added to the tube and incubated at 4°C for 30 minutes. FACS analysis is performed using a FACScan flow cytometer (Becton Dickinson, San Jose, Calif.). The mean fluorescence intensity (MFI) of the stained cells indicates the amount of ligand that binds to the checkpoint protein. A reduced MFI in the sample with the candidate indicates that the candidate is effective in blocking the binding of the ligand to the target checkpoint protein.

[0133] For example, the homogeneous time-resolved fluorescence (HTRF) binding assay described in PCT Publication WO2015034820 can also be used to assay the ability of the candidate to block checkpoint protein-ligand interactions. In one embodiment, the CIC used in the above method is the IC measured by the PD-1 / PD-L1 homogeneous time-resolved fluorescence (HTRF) binding assay. 50 A value of 10 pM or less, for example 0.01 to 10 pM, preferably 1 pM or less, for example 0.01 to 1 pM, can inhibit the PD-1 / PD-L1 interaction.

[0134] (Cell-based assay) In another embodiment, the assay for evaluating whether a candidate is a checkpoint inhibitor is a cell-based assay. The mixed lymphocyte reaction (MLR) assay described in U.S. Patent No. 8,008,449 is commonly used to measure T cell proliferation, IL-2 and / or IFN-γ production. In one exemplary assay, human T cells are human CD4 + Candidate cells are purified from PBMCs using a T cell enrichment column (R&D systems). Candidate cells are added to numerous T cell cultures at different concentrations. The cells are cultured at 37°C for 5 days, and 100 μl of medium is taken from each culture for cytokine measurement. The levels of IFN-gamma and other cytokines are measured using the OptEIA ELISA kit (BD Biosciences). 3 The cells were labeled with H-thymidine and cultured for a further 18 hours, and cell proliferation was analyzed. The results showing that cultures containing the candidate cells exhibit increased T cell proliferation and increased production of IL-2 and / or IFN-gamma compared to the control indicate that the candidate cells are effective in inhibiting checkpoint proteins in the T cell immune response.

[0135] (In vivo assay) In another embodiment, the assay used to evaluate whether a candidate is a checkpoint inhibitor is an in vivo assay. In one exemplary assay, 6-8 week old female AJ mice (Harlan Laboratories) are randomized into 6 groups based on body weight. On day 0, 2 × 10¹⁶ ions dissolved in 200 μl of DMEM medium are placed in the right flank of these mice. 6 SA1 / N fibrosarcoma cells are subcutaneously transplanted into the mice. These mice are treated with a PBS vehicle or the candidate at a predetermined dosage. On days 1, 4, 8, and 11, these animals are administered approximately 200 μl of PBS containing the candidate or vehicle by intraperitoneal injection. These mice are monitored twice a week for approximately 6 weeks for tumor growth. The tumor is measured three-dimensionally (height × width × length) using an electronic caliper, and the tumor volume is calculated. The tumor endpoint (1500 mm) is calculated. 3The mice are euthanized when they reach ) or when they show a weight loss of more than 15%. Compared to the control, the candidate treatment group shows slower tumor growth, or the tumor endpoint volume (1500 mm) is reached. 3 Results showing a longer average time to reach ) indicate that the candidate is active in inhibiting cancer growth.

[0136] (Glucocorticoid receptor modulator (GRM)) Generally, treatment of adrenocortical carcinoma (ACC) in patients with glucocorticoid excess can be achieved by administering an effective dose of a selective glucocorticoid receptor modulator (SGRM) having a condensed azadecalin structure, a heteroaryl-ketone condensed azadecalin structure, or an octahydro condensed azadecalin structure, along with an antibody checkpoint inhibitor. In some embodiments, the antibody checkpoint inhibitor is effective against cells and tumors expressing one or more of the PD-1 antigen, CTLA-4 antigen, PD-L1 antigen, or PD-L2 antigen. In some embodiments, cancer chemotherapeutic agents may be administered. Cancer chemotherapeutic agents can be selected from, for example, taxanes, alkylating agents, topoisomerase inhibitors, endoplasmic reticulum stress inducers, antimetabolites, mitotic inhibitors, and combinations thereof.

[0137] Selective glucocorticoid receptor modulator (SGRM) compounds include those containing a heteroaryl-ketone condensed azadecalin structure (sometimes referred to as a heteroaryl-ketone condensed azadecalin skeleton). Exemplary SGRM compounds containing a heteroaryl-ketone condensed azadecalin structure are described in U.S. Patents 8,859,774; 9,273,047; 9,707,223; and 9,956,216. All patents, patent publications, and patent applications disclosed herein are incorporated herein by reference in their entirety.

[0138] In some cases, the GRM skeleton is condensed azadecalin. In some cases, the GRM having a condensed azadecalin skeleton is SGRM, which may be GRA or SGRA. In some cases, condensed azadecalin is a compound having the following formula, or a salt or isomer thereof.

[0139] [ka]

[0140] During the ceremony, L 1 and L 2 These are elements independently selected from bonded and unsubstituted alkylenes; R 1 These are unsubstituted alkyl, unsubstituted heteroalkyl, unsubstituted heterocycloalkyl, and -OR 1A , NR 1C R 1D -C(O)NR 1C R 1D , and -C(O)OR 1A The element is selected from, where R 1A is an element selected from hydrogen, unsubstituted alkyl, and unsubstituted heteroalkyl; R 1C and R 1D These are elements independently selected from unsubstituted alkyl and unsubstituted heteroalkyl groups, which optionally bond to each other to form an unsubstituted ring with the nitrogen to which they are bonded, where the ring optionally contains additional ring nitrogen; R 2 It has the following formula:

[0141] [ka]

[0142] During the ceremony, R 2G is an element selected from hydrogen, halogen, unsubstituted alkyl, unsubstituted heteroalkyl, unsubstituted cycloalkyl, unsubstituted heterocycloalkyl, -CN, and -CF3; J is phenyl; t is an integer between 0 and 5; X is -S(O2)-; R 5 1 to 5 R 5A A phenyl compound optionally substituted with a base, R 5A is hydrogen, halogen, -OR 5A1 , S(O2)NR 5A2 R 5A3 The element is selected from -CN and unsubstituted alkyl groups. R 5A1 This element is selected from hydrogen and unsubstituted alkyl groups. R 5A2 and R 5A3 This element is independently selected from hydrogen and unsubstituted alkyl groups. Examples of such compounds include those disclosed in U.S. Patent No. 7,928,237 and U.S. Patent No. 8,461,172, both of which are incorporated herein by reference in their entirety.

[0143] In one embodiment, the condensed azadecalin SGRM is CORT108297, namely (R)-(4a-ethoxymethyl-1-(4-fluorophenyl)-6-(4-trifluoromethylbenzenesulfonyl)-4,4a,5,6,7,8-hexahydro-1H,1,2,6-triazacyclopenta[b]naphthalene, which has the following structure.

[0144] [ka]

[0145] In some cases, the GRM skeleton is heteroarylketone condensed azadecalin or octahydro condensed azadecalin. In some cases, a GRM having a heteroarylketone condensed azadecalin skeleton or an octahydro condensed azadecalin skeleton is an SGRM, which may be either GRA or SGRA.

[0146] Exemplary GRMs containing a heteroaryl ketone-fused azadecalin structure include those disclosed in U.S. Patent No. 8,859,774, which can be prepared as disclosed, and the entire disclosure of the above U.S. Patent is incorporated herein by reference. Such exemplary GRMs may be SGRMs. In some cases, a GRM containing a heteroaryl ketone-fused azadecalin structure is one having the following structure, or a salt or isomer thereof.

[0147] [Chemical Formula]

[0148] In the formula, R 1 is a heteroaryl ring having 5 to 6 ring members and 1 to 4 heteroatoms each independently selected from the group consisting of N, O, and S, and optionally substituted with 1 to 4 groups each independently selected from R 1a ; R 1a are each independently 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, and the heterocycloalkyl ring and the heteroaryl ring have 5 to 6 ring members and 1 to 4 heteroatoms each independently selected from the group consisting of N, O, and S; R 2 are each independently 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 R2b , -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 Selected from the group consisting of heterocycloalkyl groups, the above heterocycloalkyl group has 1 to 4 R 2c It is replaced as desired in the base; Alternatively, two R atoms bonded to the same carbon atom 2 The groups combine to form an oxo group (=O); Alternatively, two R 2 The groups are combined to form a heterocycloalkyl ring having 5 to 6 ring members and 1 to 3 heteroatoms independently selected from the group consisting of N, O, and S, where the heterocycloalkyl ring optionally has 1 to 3 R 2d It is substituted with the base; R 2a and R 2b Each is independently hydrogen and C 1-6 Selected from the group consisting of alkyl groups; R 2c These are independently hydrogen, halogen, hydroxyl, and C. 1-6 Alkoxy, C 1-6 Haloalkoxy, -CN, and -NR 2a R 2b Selected from the group consisting of; R 2d Each is independently hydrogen and C 1-6 Selected from the group consisting of alkyl groups, or two R atoms bonded to the same ring atom. 2d The bases combine to form (=O); R 3 Each has 1 to 4 R 3a Selected from the group consisting of phenyl and pyridyl, which are optionally substituted with a base; R 3a These are hydrogen, halogen, and C, respectively, independently. 1-6Selected from the group consisting of haloalkyl groups; The subscript n is an integer between 0 and 3.

[0149] In some cases, heteroaryl-ketone condensed azadecalin GRM is relacolinant (CORT125134), namely (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazole-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinoline-4a-yl)(4-(trifluoromethyl)pyridine-2-yl)methanone, which has the following structure.

[0150] [ka]

[0151] In one embodiment, heteroaryl-ketone condensed azadecalin SGRM is compound (R)-(1-(4-fluorophenyl)-6-((4-(trifluoromethyl)phenyl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1-H-pyrazolo-P,4-g]isoquinoline-4a-yl)(pyridine-2-yl)methanone (referred to as "CORT113176"), which has the following structure.

[0152] [ka]

[0153] Examples of GRMs containing an octahydrocondensed azadecalin structure include the compounds disclosed in U.S. Patent No. 10,047,082, which is incorporated herein by reference in its entirety. In some embodiments, the octahydrocondensed azadecalin GRM has the following formula, or a salt or isomer thereof.

[0154] [ka]

[0155] During the ceremony, R 1 It has 5 to 6 ring members and 1 to 4 heteroatoms independently selected from the group consisting of N, O, and S, and optionally each independently R 1a A heteroaryl ring substituted with 1 to 4 groups selected from; R 1a Each is independently hydrogen and C 1-6 Alkyl, halogen, C 1-6 Haloalkyl, C 1-6 Alkoxy, C 1-6 Haloalkoxys, N-oxides, and C 3-8 Selected from the group consisting of cycloalkyl groups; Ring J is selected from the group consisting of aryl rings and heteroaryl rings, each having 5 to 6 ring members and 1 to 4 heteroatoms independently selected from the group consisting of N, O, and S; R 2 Each of them is independently of hydrogen and 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 groups, and C groups having 1 to 3 heteroatoms independently selected from the group consisting of N, O, and S. 3-8 Selected from the group consisting of heterocycloalkyl groups; Alternatively, two R atoms on adjacent ring atoms 2 The groups are combined to form a ring with 5-6 ring members and 1-3 heteroatoms independently selected from the group consisting of N, O, and S, and optionally 1-3 R 2cIt forms a heterocycloalkyl ring substituted with a group; R 2a , R 2b , and R 2c Each is independently hydrogen and C 1-6 Selected from the group consisting of alkyl groups; R 3a Each of them is an independent halogen; The subscript n is an integer between 0 and 3.

[0156] In some cases, octahydrocondensed azadecalin GRM is CORT125281, i.e., ((4aR,8aS)-1-(4-fluorophenyl)-6-((2-methyl-2H-1,2,3-triazole-4-yl)sulfonyl)-4,4a,5,6,7,8,8a,9-octahydro-1H-pyrazolo[3,4-g]isoquinoline-4a-yl)(4-(trifluoromethyl)pyridine-2-yl)methanone, which has the following structure.

[0157] [ka]

[0158] (Confirmation of selective glucocorticoid receptor modulators (SGRMs)) To determine whether a test compound is an SGRM, the compound is first assayed to measure its ability to bind to GR and inhibit activity through GR to determine whether the compound is a glucocorticoid receptor modulator. If it is confirmed that the compound is a glucocorticoid receptor modulator, the compound is then subjected to a selectivity test to determine whether the compound can specifically bind to GR when compared to proteins other than GR, such as estrogen receptor, progesterone receptor, androgen receptor, or mineralocorticoid receptor. In certain embodiments, the SGRM binds to GR with a significantly higher affinity, e.g., at least 10-fold higher affinity, than to proteins other than GR. The binding affinity of the SGRM for GR may exhibit selectivity 100-fold, 1000-fold, or more compared to the binding affinity for proteins other than GR.

[0159] Binding property The binding property of a test compound to the glucocorticoid receptor can be measured using various assays, e.g., by screening for the competitiveness of the test compound with a glucocorticoid receptor ligand, such as dexamethasone, for binding to the glucocorticoid receptor. It is recognized by those skilled in the art that there are several methods for performing 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 is sometimes referred to as a binding displacement assay. A decrease in the amount of labeled ligand bound to the glucocorticoid receptor indicates that the test compound is binding 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 property of the test compound to the glucocorticoid receptor can be directly measured using a labeled test compound. This latter type of assay is called a direct binding assay.

[0160] Both direct binding assays and competitive binding assays can be used in a variety of formats. These formats can be similar to those used in immunoassays and receptor binding assays. For descriptions of the various formats of binding assays, including competitive binding assays and direct binding assays, reference is made to Basic and Clinical Immunology, 7th Edition (D. Stites and A. Terr (eds.)), 1991; Enzyme Immunoassay, E.T. 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 B.V., Amsterdam (1985), each of which is incorporated herein by reference.

[0161] For example, in a solid-phase competitive binding assay, a sample compound can be made to compete with a labeled analyte at a specific binding site on a binder bound to a solid surface. In this type of format, the labeled analyte can be a glucocorticoid receptor ligand and the binder can be a glucocorticoid receptor bound to a solid phase. Alternatively, the labeled analyte can be a labeled glucocorticoid receptor and the binder can be a solid-phase glucocorticoid receptor ligand. The concentration of the labeled analyte bound to the capture agent is inversely proportional to the competitive ability of the test compound in the binding assay.

[0162] Alternatively, the competitive binding assay may be performed in liquid phase, and any of the various techniques known in the art may be used to separate the bound labeled protein from the unbound labeled protein. For example, several methods have been developed to distinguish between bound ligands and excess bound ligands, or between bound test compounds and excess unbound test compounds. These methods involve identification of the bound complex by sucrose gradient centrifugation, gel electrophoresis, or gel isoelectric focusing; precipitation of the receptor-ligand complex with protamine sulfate or adsorption on hydroxyl apatite; and removal of the unbound compound or ligand by adsorption on dextran-coated carbon (DCC) or binding to an immobilized antibody. After separation, the amount of bound ligand or test compound can be determined.

[0163] Alternatively, a homogeneous binding assay that does not require a separation step may be performed. For example, a label on a glucocorticoid receptor may change upon binding of the glucocorticoid receptor to its ligand or test compound. This change in the labeled glucocorticoid receptor will result in a decrease or increase in the signal emitted by the label, allowing for the detection or quantification of the bound glucocorticoid receptor by measuring the label at the end of the binding assay. A variety of labels can be used. The components may be labeled by any of several methods. Useful radiolabels include: 3 H, 125 I, 35 S, 14 C, or 32Examples include those incorporating P. Useful non-radioactive labels include those incorporating fluorophores, chemiluminescent substances, phosphorescent substances, and electrochemiluminescent substances. Fluorescent substances are particularly useful in analytical methods used to detect shifts in protein structures, such as fluorescence anisotropy and / or fluorescence polarization. The selection of a label is based on the required sensitivity, ease of binding to the compound, stability requirements, and available measurement methods. For an overview of the various labeling or signal-generating systems that can be used, see U.S. Patent No. 4,391,904, which is incorporated herein by reference in its entirety for all purposes. Labels can be directly or indirectly bound to the desired component of the assay according to methods well known in the art. In some cases, the amount of bound and free labeled ligand is estimated by contacting the test compound with a fluorescently labeled ligand (e.g., a steroid or steroid analog) having a known affinity for GR, and measuring the fluorescence polarization of the labeled ligand.

[0164] HepG2 tyrosine aminotransferase (TAT) assay Compounds that exhibit a desired binding affinity to GR are tested for their activity in inhibiting GR-mediated activity. Typically, these compounds are subjected to a tyrosine aminotransferase assay (TAT assay) to evaluate the ability of a test compound to inhibit the induction of tyrosine aminotransferase activity by dexamethasone. See Example 1. Suitable GR modulators for the methods disclosed herein are IC 50 The (50% inhibitory concentration) is less than 10 micromoles. The GR-modulating activity of the compound can also be confirmed using other assays, including but not limited to those listed below.

[0165] Cell-based assays Cell-based assays using whole cells or cell fractions containing glucocorticoid receptors can also be used to measure the binding affinity of test compounds and their ability to modulate glucocorticoid receptor activity. Exemplary cell types that can be used in the method of the present invention include, for example, any mammalian cells including leukocytes (neutrophils, monocytes, macrophages, eosinophils, basophils, mast cells, and lymphocytes such as T cells and B cells), leukemia cells, Burkitt lymphoma cells, tumor cells (including mouse mammary gland tumor virus cells), endothelial cells, fibroblasts, cardiac cells, myocytes, mammary gland tumor cells, ovarian cancer carcinomas, cervical cancer cells, gliablastoma cells, hepatocytes, renal cells, and nerve cells, as well as fungal cells including yeast. The cells can be primary cells, tumor cells, or other types of immortal cell lines. Naturally, glucocorticoid receptors can be expressed in cells that do not express endogenous glucocorticoid receptors.

[0166] In some cases, in addition to protein fusions, glucocorticoid receptor fragments can also be used for screening. If a molecule that competes with the glucocorticoid receptor ligand for binding is desired, the GR fragment used is a fragment capable of binding to the ligand (e.g., dexamethasone). Alternatively, any GR fragment can be used as a target to identify molecules that bind to the glucocorticoid receptor. Examples of glucocorticoid receptor fragments include any fragment of the glucocorticoid receptor consisting of, for example, at least 20, at least 30, at least 40, or at least 50 amino acids, to proteins containing all but one amino acid.

[0167] In some embodiments, a decrease in signaling triggered by glucocorticoid receptor activation is used to identify glucocorticoid receptor modulators. Glucocorticoid receptor signaling activity can be measured in many ways. For example, signaling activity can be measured by monitoring downstream molecular phenomena. Downstream phenomena include activity or expression resulting from glucocorticoid receptor stimulation. Exemplary downstream phenomena useful in functional evaluation of transcriptional activation and antagonism in unchanged cells include increased expression of several glucocorticoid response element (GRE)-dependent genes (PEPCK, tyrosine aminotransferase, aromatase). Additionally, specific cell types prone to GR activation, such as osteocalcin expression in osteoblasts downregulated by glucocorticoids, or primary hepatocytes showing increased expression of PEPCK and glucose-6-phosphate (G-6-Pase) via glucocorticoids, may be used. Furthermore, GRE-mediated gene expression has been demonstrated in transfected cell lines using well-known GRE regulatory 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 measuring IL-6 expression induced by IL-1β stimulation in transfected cell lines; measuring decreased expression of collagenase, cyclooxygenase-2, and various chemokines (MCP-1, Lantes); measuring cytokine release induced by LPS stimulation (e.g., TNFα); or measuring the expression of genes regulated by NFκB transcription factors or AP-1 transcription factors.

[0168] Compounds tested using whole-cell assays may also be tested using cytotoxicity assays. Cytotoxicity assays are used to determine the extent to which the detected effect is due to cellular actions other than glucocorticoid receptor binding. In exemplary embodiments, the cytotoxicity assay involves contacting constitutively active cells with the test compound. Any decrease in cellular activity indicates a cytotoxic effect.

[0169] 3) Additional assays Further examples of the many assays that can be used to confirm the compositions used in the method of the present invention include in vivo assays based on glucocorticoid activity. For example, an assay can be used to evaluate the ability of a putative GR modulator to inhibit the uptake of 3H-thymidine into DNA in glucocorticoid-stimulated cells. Alternatively, the putative GR modulator can be made to compete with 3H-dexamethasone for binding to hepatocellular carcinoma tissue culture GR (see, e., Choi et al., Steroids, Vol. 57: pp. 313-318, 1992). Another example is the ability of the putative GR modulator to block the nuclear binding of the 3H-dexamethasone-GR complex (Alexandrova et al., J. Steroid Biochem. Mol. Biol, Vol. 41: pp. 723-725, 1992). For further confirmation of the putative GR modulator, a kinetic assay can be used to distinguish between glucocorticoid agonists and modulators by receptor-binding kinetics (Jones, Biochem J., Vol. 204: pp. 721-729, 1982).

[0170] In another exemplary example, to confirm anti-glucocorticoid activity, the assay described in Daune, Molec. Pharm., Vol. 13: pp. 948-955, 1977; and U.S. Patent No. 4,386,085 can be used. Briefly, thymocytes from adrenalectomized rats are incubated in a nutrient medium containing dexamethasone and the test compound (a putative GR modulator) at various concentrations. 3 H-uridine was added to the cell culture and incubated, and the uptake of the radiolabeled polynucleotide was measured. The glucocorticoid agonist was taken up. 3 It reduces the amount of H-uridine. In other words, the GR modulator counteracts this effect.

[0171] iii. Selectivity Next, the GR modulators selected above are subjected to a selective assay to determine whether they are SGRMs. Typically, a selective assay involves testing a compound that binds to a glucocorticoid receptor in vitro for the degree of binding to a protein other than the glucocorticoid receptor. The selective assay may be performed in vitro or in a cell-based system as described above. Binding tests can be performed against any suitable protein other than the glucocorticoid receptor, including antibodies, receptors, enzymes, etc. In exemplary embodiments, 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, progesterone receptor, androgen receptor, or mineralocorticoid receptor.

[0172] The selectivity of an antagonist to GR can be measured compared to MR using various assays known to those skilled in the art. For example, a specific antagonist can be identified by measuring the binding ability of an antagonist to GR compared to MR (see, e.g., U.S. Patents 5,606,021; 5,696,127; 5,215,916; and 5,071,773). Such analysis can be performed using direct binding assays or by evaluating competitive binding to purified GR or purified MR in the presence of a known ligand. In an exemplary assay, cells stably expressing glucocorticoid receptors or mineralocorticoid receptors at high levels (see, e.g., U.S. Patent 5,606,021) are used as a source of purified receptors. The affinity of the ligand to the receptor is then measured directly. GR modulators exhibiting at least 10-fold, 100-fold, and often 1000-fold higher affinity to GR compared to MR are then selected for use in the method of the present invention.

[0173] Selective assays may include the quantification of the ability to inhibit GR-mediated activity without inhibiting MR-mediated activity. One way to identify such GR-specific modulators is to evaluate the ability of an antagonist to prevent activation of the reporter construct using a transfection assay (see, e.g., Bocquel et al., J. Steroid Biochem Molec. Biol., vol. 45: pp. 205-215, 1993; U.S. Patent Nos. 5,606,021 and 5,929,058). In an exemplary transfection assay, an expression plasmid encoding the receptor and a reporter plasmid containing a reporter gene linked to a receptor-specific regulatory element are cotransfected into suitable receptor-negative host cells. The transfected host cells are then cultured in and out of the presence of a hormone, such as cortisol or an analog, that can activate the hormone-responsive promoter / enhancer element of the reporter plasmid. Next, the transfected and cultured host cells are monitored for induction (i.e., presence) of reporter gene sequence production. 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 the antagonist. The antagonist activity of the compound may be determined in comparison to known antagonists of receptors GR and MR (see, for example, U.S. Patent No. 5,696,127). The potency is then reported as the percentage maximum response observed for each compound against the reference antagonist compound. GR modulators exhibiting at least 100-fold, often 1000-fold or more, activity against GR compared to MR, PR, or AR are selected for use in the manner disclosed herein.

[0174] (Pharmaceutical composition and administration) i. Formulations In some embodiments, the present invention provides pharmaceutical compositions comprising a pharmaceutically acceptable pharmaceutical additive and SGRM, and pharmaceutical compositions comprising a pharmaceutically acceptable pharmaceutical additive and CIC or CIA.

[0175] Any of the SGRM, CIC, or CIA disclosed herein can be formulated with a pharmaceutically acceptable carrier. Such compositions may contain one or a combination (e.g., two or more different) of the antibodies, immune complexes, or bispecific molecules of the present invention. For example, the pharmaceutical compositions of the present invention may contain a combination of antibodies (or immune complexes or bispecific molecules) that bind to different epitopes on a target antigen or have complementary activity.

[0176] In one embodiment, the present invention provides a pharmaceutical composition for treating ACC patients with cortisol excess, comprising a pharmaceutically acceptable pharmaceutical additive and a GRM. In some embodiments, the pharmaceutical composition comprises a pharmaceutically acceptable pharmaceutical additive and a SGRM. In a preferred embodiment, the pharmaceutical composition comprises a pharmaceutically acceptable pharmaceutical additive and a non-steroidal SGRM.

[0177] GRM and SGRM (as used herein, GRM and SGRM include nonsteroidal GRM and nonsteroidal SGRM) can be prepared and administered in a wide variety of oral, parenteral, and topical dosage forms. Oral preparations are preferred. Examples of oral preparations include tablets, pills, powders, sugar-coated tablets, capsules, liquids, lozenges, gels, syrups, slurries, and suspensions suitable for patient ingestion. GRM and SGRM can also be administered by injection, i.e., intravenously, intramuscularly, intradermally, subcutaneously, intraduodenally, or intraperitoneally. GRM and SGRM can also be administered by inhalation, for example, intranasally. Furthermore, GRM and SGRM can be administered transdermally. Accordingly, the present invention also provides pharmaceutical compositions containing pharmaceutically acceptable carriers or additives and GRM or SGRM.

[0178] For preparing pharmaceutical compositions from GRM and SGRM, the pharmaceutically acceptable carrier may be either solid or liquid. Solid forms of preparations include powders, tablets, pills, capsules, cachets, suppositories, and dispersible granules. The solid carrier can be one or more substances that can also act as diluents, flavoring agents, binders, preservatives, tablet disintegrants, or encapsulating materials. Details regarding techniques for formulation and administration are well described in the scientific and patent literature. See, for example, the latest edition of Remington’s Pharmaceutical Sciences, Mack Publishing Co, Easton PA (“Remington’s”).

[0179] In powders, the carrier is a micronized solid that is in a mixture with the micronized active component, GRM or SGRM. In tablets, the active component is mixed with the carrier having the required binding properties in a suitable proportion and compressed into the desired shape and size.

[0180] The powders and tablets preferably contain 5% or 10% - 70% of the active compound. Suitable carriers include magnesium carbonate, magnesium stearate, talc, sugar, lactose, pectin, dextrin, starch, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose, low melting point wax, cocoa butter, etc. The term “preparation” is intended to include such preparations that are formulations of the active compound together with an encapsulating material as the carrier for capsules, where the active component, with or without other carriers, is surrounded by the carrier and thus combined. Similarly, cachets and lozenges are included. Tablets, powders, capsules, pills, cachets, and lozenges can be used as solid dosage forms suitable for oral administration.

[0181] Suitable solid additives include, but are not limited to, carbohydrate or protein fillers, sugars containing lactose, sucrose, mannitol, or sorbitol; starches derived from corn, wheat, rice, potato, or other plants; celluloses such as methylcellulose, hydroxypropylmethylcellulose, or sodium carboxymethylcellulose; gums containing arabic and tragacanth; and proteins such as gelatin and collagen. Optionally, disintegrants or solubilizers such as cross-linked polyvinylpyrrolidone, agar, alginic acid, or salts thereof such as sodium alginate may be added.

[0182] The sugar-coated tablet core comprises a suitable coating such as a concentrated sugar solution which may contain gum arabic, talc, polyvinylpyrrolidone, carbopole gel, polyethylene glycol, and / or titanium dioxide, a lacquer solution, and a suitable organic solvent or solvent mixture. Dyes or pigments may be added to the tablet or sugar-coated tablet coating for product identification or to characterize the amount of the active compound (i.e., dosage). The pharmaceutical preparations of the present invention may also be used orally using, for example, push-fit capsules made of gelatin, and soft-seal capsules made of gelatin and a coating, for example, glycerol or sorbitol. The push-fit capsules may contain a filler or binder such as lactose or starch, a lubricant such as talc or magnesium stearate, and optionally a GR modulator mixed with a stabilizer. In the soft capsule, such GR modulator compound may be dissolved or suspended in a suitable liquid such as fatty acid oil, liquid paraffin, or liquid polyethylene glycol, with or without a stabilizer.

[0183] Liquid preparations include solutions, suspensions, and emulsions, such as water or water / propylene glycol solutions. For parenteral injection, the liquid preparation may be formulated in solution in an aqueous polyethylene glycol solution.

[0184] An aqueous solution suitable for oral use can be prepared by dissolving the above-mentioned active components in water and optionally adding suitable colorants, flavorings, stabilizers, and thickeners. Aqueous suspensions suitable for oral use can be prepared by dispersing the micronized active components in water with a dispersion or wetting agent such as natural or synthetic gums, resins, methylcellulose, sodium carboxymethylcellulose, hydroxypropyl methylcellulose, sodium alginate, polyvinylpyrrolidone, tragacanth gum, and acacia gum, as well as naturally occurring phospholipids (e.g., lecithin), condensation products of alkylene oxides and fatty acids (e.g., polyoxyethylene stearate), condensation products of ethylene oxides and long-chain aliphatic alcohols (e.g., heptadecaethyleneoxycetanol), condensation products of ethylene oxides and partial esters derived from fatty acids and hexitol (e.g., polyoxyethylene sorbitol monooleate), or condensation products of ethylene oxides and partial esters derived from fatty acids and hexitol anhydride (e.g., polyoxyethylene sorbitan monooleate). The aqueous suspension may also contain one or more preservatives such as ethyl p-hydroxybenzoate or n-propyl, one or more colorants, one or more flavoring agents, and one or more sweeteners such as sucrose, aspartame, or saccharin. The osmotic pressure of the formulation may be adjusted.

[0185] This also includes solid preparations intended to be converted into liquid preparations for oral administration shortly before use. Such liquid preparations include solutions, suspensions, and emulsions. These preparations may contain, in addition to the active components described above, colorants, flavorings, stabilizers, buffers, artificial and natural sweeteners, dispersants, thickeners, solubilizers, and the like.

[0186] The oil suspension may be formulated by suspending SGRM in a vegetable oil such as peanut oil, olive oil, sesame oil, or coconut oil, or in a mineral oil such as liquid paraffin; or in a mixture thereof. The oil suspension may contain thickeners such as beeswax, hard paraffin, or cetyl alcohol. Sweeteners such as glycerol, sorbitol, or sucrose may be added to provide an oral preparation with a pleasant mouthfeel. These formulations may be preserved by the addition of antioxidants such as ascorbic acid. For an example of an injectable oil vehicle, see Minto, J. Pharmacol. Exp. Ther. 281:93-102, 1997. The pharmaceutical formulation of the present invention may also be in the form of an oil-in-water emulsion. The oil phase may be a vegetable oil, a mineral oil, or a mixture thereof. Suitable emulsifiers include naturally occurring gums such as acacia gum and tragacanth gum, naturally occurring phospholipids such as soy lecithin, esters or partial esters derived from fatty acids such as sorbitan monooleate and hexitol anhydride, and condensation products of these partial esters with ethylene oxide, such as polyoxyethylene sorbitan monooleate. The emulsion may also contain sweeteners and flavorings, as in syrup and elixir formulations. Such formulations may also contain analgesics, preservatives, or colorants.

[0187] GRM and SGRM can be formulated as applicator sticks, solutions, suspensions, emulsions, gels, creams, ointments, pastes, jellies, paints, powders, and aerosols, and delivered transdermally or via topical routes.

[0188] GRM and SGRM may also be delivered as sustained-release microspheres into the body. For example, microspheres may be administered via intradermal injection of drug-containing microspheres that sustainably release the drug under the skin (see Rao, J. Biomator Sci. Polym. Ed. 7:623-645, 1995); as biodegradable and injectable gel formulations (see, for example, Gao Pharm. Res. 12:857-863, 1995); or as orally administered microspheres (see, for example, Eyles, J. Pharm. Pharmacol. 49:669-674, 1997). Both transdermal and intradermal routes allow for constant delivery over several weeks or months.

[0189] The pharmaceutical formulations of the present invention may, but are not limited to, be provided as salts, and may be formed with many acids, including hydrochloric acid, sulfuric acid, acetic acid, lactic acid, tartaric acid, malic acid, succinic acid, and the like. The salts tend to be soluble in aqueous or other protic solvents, which are the corresponding free salt forms. In other cases, the preparation may be a lyophilized powder in 1 mM to 50 mM histidine, 0.1% to 2% sucrose, and 2% to 7% mannitol in a pH range of 4.5 to 5.5, and may be combined with a buffer before use.

[0190] In another embodiment, the formulation of the present invention may be delivered by the use of liposomes that fuse with or are taken up by the cell membrane, i.e., by using ligands attached to the liposomes or directly attached to oligonucleotides that bind to cell surface membrane protein receptors resulting in endocytosis. By using liposomes, the focus can be on in vivo delivery of the GR modulator to the target cells, particularly when the liposome surface carries a ligand specific to the target cell or otherwise preferentially targets a particular organ. (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).

[0191] The pharmaceutical preparation is preferably in unit dosage form. In this form, the preparation is subdivided into unit doses containing an appropriate amount of the active component, GRM, or SGRM. The unit dosage form may be a packaged preparation containing separate amounts of the preparation, such as packaged tablets, capsules, and powder in vials or ampoules. Alternatively, the unit dosage form may be a capsule, tablet, cachet, or lozenge itself, or an appropriate number of any of these in packaged form.

[0192] The amount of the active component in a unit dose preparation can 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 50 mg to 500 mg. Suitable dosages include approximately 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 specific application and the efficacy of the active component. The composition may also optionally contain other suitable therapeutic agents.

[0193] The pharmaceutical preparation is preferably in the form of a unit dosage form. In this form, the preparation is subdivided into unit doses containing appropriate amounts of the compounds and compositions of the present invention. The unit dosage form may be a packaged preparation containing separate amounts of the preparation, such as packaged tablets, capsules, and powders in vials or ampoules. Alternatively, the unit dosage form may be a capsule, tablet, cachet, or lozenge itself, or an appropriate number of any of these in packaged form.

[0194] GRMs, including SGRMs, can be administered orally. For example, the GRMs may be administered as pills, capsules, or liquid formulations as described herein. Alternatively, GRMs may be provided via parenteral administration. For example, the GRMs may be administered intravenously (e.g., by injection or infusion). Further methods of administering the compounds and their pharmaceutical compositions or formulations described herein are described herein.

[0195] In some embodiments, the GRM is administered in a single dose. In other embodiments, the GRM is administered in more than one dose, for example, two, three, four, five, six, seven, or more doses. In some cases, the doses are equivalent amounts. In other cases, the doses are different amounts. The doses may increase or decrease over the duration of administration. The amounts may vary, for example, according to the properties of the GRM and the characteristics of the patient.

[0196] Any suitable dose of GRM can be used in the manner disclosed herein. The dose of GRM administered can be at least, for example, about 100 milligrams (mg) per day, about 150 mg / day, about 200 mg / day, about 250 mg / day, about 300 mg / day, about 350 mg / day, about 400 mg / day, about 450 mg / day, about 500 mg / day, about 550 mg / day, about 600 mg / day, about 650 mg / day, about 700 mg / day, about 750 mg / day, about 800 mg / day, about 850 mg / day, about 900 mg / day, about 950 mg / day, about 1000 mg / day, or more.

[0197] In some cases, the effective dose of GRM (e.g., SGRMs such as nonsteroidal SGRMs) is 1 to 30 mg / kg / day when administered with at least one chemotherapeutic agent. In some embodiments, the daily dose of GRM is 1, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 25, or 30 mg / kg / day. In some cases, GRM may be administered for at least 1 week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 8 weeks, at least 9 weeks, at least 10 weeks, at least 11 weeks, at least 12 weeks, at least 13 weeks, at least 14 weeks, at least 15 weeks, at least 16 weeks, at least 17 weeks, at least 18 weeks, at least 19 weeks, at least 20 weeks, at least 25 weeks, at least 30 weeks, at least 35 weeks, at least 40 weeks, at least 45 weeks, at least 50 weeks, at least 55 weeks, at least 60 weeks, at least 65 weeks, at least 70 weeks, at least 75 weeks, or at least 80 weeks.

[0198] In some embodiments, GRM is administered orally. In some embodiments, GRM is administered in at least one dose. In other words, GRM may be administered in one, two, three, four, five, six, seven, eight, nine, ten, or more doses. In some embodiments, GRM is administered orally in one, two, three, four, five, six, seven, eight, nine, ten, or more doses.

[0199] GRM may be administered to the patient in at least one dose, in one or more doses, over a period of, for example, 2 to 48 hours. In some embodiments, the GRM is administered in a single dose. In other embodiments, the GRM is administered in more than one dose, for example, two, three, four, five, or more doses, over a period of 2 to 48 hours, for example, a period of 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 hours, 12 hours, 14 hours, 16 hours, 18 hours, 20 hours, 22 hours, 24 hours, 26 hours, 28 hours, 30 hours, 32 hours, 34 hours, 36 hours, 38 hours, 40 hours, 42 hours, 44 hours, 46 hours, or 48 hours. In some embodiments, the GRM is administered over a period of 2-48 hours, 2-36 hours, 2-24 hours, 2-12 hours, 2-8 hours, 8-12 hours, 8-24 hours, 8-36 hours, 8-48 hours, 9-36 hours, 9-24 hours, 9-20 hours, 9-12 hours, 12-48 hours, 12-36 hours, 12-24 hours, 18-48 hours, 18-36 hours, 18-24 hours, 24-36 hours, 24-48 hours, 36-48 hours, or 42-48 hours.

[0200] Single-dose or multi-dose formulations can be administered according to the required and acceptable dosage and frequency for the patient. The formulations may provide a sufficient amount of the active agent to effectively treat the disease condition. Therefore, in some embodiments, the daily dose of the pharmaceutical formulation for oral administration of GRM is approximately 0.01 to approximately 150 mg per kilogram of body weight per day (mg / kg / day). In some embodiments, the daily dose is approximately 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. In particular, lower doses may be used when such drugs are administered, in contrast to oral administration, to anatomically isolated sites such as the cerebrospinal fluid (CSF) space, into the bloodstream, into body cavities, or into organ lumenes. Substantially higher doses may be used for local administration. Practical methods for preparing parenterally administered formulations are known or obvious to those skilled in the art and are described in more detail in publications such as Remington's (above). See also Agarwal, et al., eds., De Gruyter, New York (1987), in Nieman, "Receptor-Mediated Antisteroid Action."

[0201] The duration of treatment with GRM or SGRM to treat ACC in patients with excess cortisol may vary depending on the severity of the condition in the subject and the subject's response to GRM or SGRM. In some embodiments, GRM and SGRM may be administered for periods of about 1 to 104 weeks (2 years), more typically about 6 to 80 weeks, and most typically about 9 to 60 weeks. Preferred 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 durations of administration 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 GRM or SGRM should be continued until the desired clinically significant reduction or improvement is observed. Treatment with GRM or SGRM according to the present invention may be continued for two years or more.

[0202] In some embodiments, administration of GRM or SGRM may be interrupted for one or more periods, rather than being continuous, and then resumed for one or more periods. Preferred 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. Preferred periods for discontinuing administration 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.

[0203] The drug regimen should also take into account pharmacokinetic parameters well known in the field, namely absorption rate, bioavailability, metabolism, and clearance (see, for example, 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; and the recent Remington study, as mentioned above). Clinicians can use state-of-the-art technology to determine individual patient-specific medication regimens, GR modulators, and the diseases or conditions being treated.

[0204] SGRM may be used in combination with other activators known to be useful in modulating glucocorticoid receptors, or with adjuvants that may not be effective on their own but may contribute to the efficacy of the above activators. Novel methods disclosed herein include administering SGRM in combination with antibody checkpoint inhibitors.

[0205] In some embodiments, co-administration involves administering one activator, GRM, or SGRM, within 0.5, 1, 2, 4, 6, 8, 10, 12, 16, 20, or 24 hours of a second activator. Co-administration also involves administering two activators simultaneously, approximately simultaneously (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., by preparing a single pharmaceutical composition containing both activators. In other embodiments, the activators may be formulated separately. In another embodiment, the activators and / or adjuvants may be linked or conjugated to each other.

[0206] After a pharmaceutical composition containing SGRM is formulated on an acceptable carrier, it can be placed in a suitable container and labeled for treatment of a specified condition. For the administration of GRM or SGRM, such label may include, for example, instructions regarding the amount, frequency, and method of administration.

[0207] The pharmaceutical compositions of the present invention may, but are not limited to, be provided as salts, and may be formed with many acids, including hydrochloric acid, sulfuric acid, acetic acid, lactic acid, tartaric acid, malic acid, succinic acid, and the like. The salts tend to be soluble in aqueous or other protic solvents, which are the corresponding free salt forms. In other cases, the preparation may be a lyophilized powder in 1 mM to 50 mM histidine, 0.1% to 2% sucrose, and 2% to 7% mannitol in a pH range of 4.5 to 5.5, and may be combined with a buffer before use.

[0208] In another embodiment, the compositions of the present invention are useful for parenteral administration, such as intravenous (IV) administration or administration into a lumen or organ lumen. Formulations for administration may generally consist of a solution of the composition of the present invention dissolved in a pharmaceutically acceptable carrier. Acceptable vehicles and solvents that can be used include water and Ringer's solution and isotonic sodium chloride. In addition, sterile fixatives may conventionally be used as solvents or suspension media. For this purpose, any sterile fixative containing synthetic monoglycerides or synthetic diglycerides may be used. In addition, fatty acids such as oleic acid may similarly be used in injectable preparations. These solutions are sterile and generally free of undesirable substances. These formulations may be sterilized by conventional, well-known sterilization techniques. The formulations may contain pharmaceutically acceptable auxiliary substances and toxicity modifiers required for approximate physiological conditions, such as pH adjusters and buffers, and sodium acetate, sodium chloride, potassium chloride, calcium chloride, sodium lactate, etc. The concentration of the composition of the present invention in these formulations can vary widely and is selected according to the specific dosage form selected and the patient's requirements, mainly based on body fluid volume, viscosity, body weight, etc. For IV administration, the formulation may be a sterile injectable preparation, such as a sterile injectable aqueous or oily suspension. This suspension may be formulated according to known techniques using these suitable dispersants or wetting agents and suspending agents. The sterile injectable preparation may also be a sterile injectable solution or suspension in a non-toxic, parenterally acceptable diluent or solvent, such as a solution of 1,3-butanediol.

[0209] ii. Medication Suitable pharmaceutical compositions for administration include compositions containing active ingredients, such as checkpoint inhibitors and SGRMs, in amounts effective to achieve the intended use. The administration plan is adjusted to obtain the optimal desired response (e.g., treatment response). For example, a single bolus dose may be administered, several divided doses may be administered over a long period, or the dose may be reduced or increased in proportion to the urgency of the treatment situation. To facilitate administration and ensure uniformity of the dose, it is particularly advantageous to formulate parenteral compositions into unit dose forms. As used herein, a unit dose form refers to a physically distinct unit suitable as a unit dose to the target of treatment; each unit contains a predetermined amount of the active compound, calculated to produce the desired treatment effect, together with the necessary pharmaceutical carrier. The specifications of the unit dose forms of the present invention are defined by and directly depend on (a) the inherent characteristics of the active compound and the specific treatment effect to be achieved, and (b) the inherent limitations in the art of formulating such active compounds for treating individual sensitivity.

[0210] The actual dose level of the active ingredient in the pharmaceutical composition of the present invention may be modified in a particular patient, composition, and mode of administration to obtain an amount of the active ingredient effective in achieving the desired treatment response without being toxic to the patient. The selection of the dose level will depend on various factors, such as the activity of the particular composition of the present invention used, or its ester, salt, or amide; the pharmacokinetics of the composition; the route of administration; the timing of administration; the excretion rate of the particular compound used; the duration of treatment; other drugs, compounds, and / or materials used in combination with the particular composition used; the age, sex, weight, condition, overall health, and medical history of the patient being treated; and similar factors well known in the medical field.

[0211] The pharmaceutical composition of the present invention is preferably in unit dose form. In such form, the formulation is divided into unit doses containing an appropriate amount of the active ingredient, GRM (e.g., SGRM), or antibody checkpoint inhibitor. This unit dose form can be a packaged formulation, the package containing individual amounts of the formulation, for example, tablets, capsules, and powders packaged in vials or ampoules. Alternatively, the unit dose form can be the capsules, tablets, cachets, or confectionery tablets themselves, or it can be a form in which an appropriate number of any of these are packaged.

[0212] In the administration planning of checkpoint inhibitors or GRMs (e.g., SGRMs), pharmacokinetic parameters well known in the art, namely absorption rate, bioavailability, metabolism, and clearance, should also be considered (e.g., Hidalgo-Aragones (1996), J. Steroid). Biochem.Mol.Biol., vol. 58: pp. 611-617; Groning (1996), Pharmazie, vol. 51: pp. 337-341; Fotherby (1996), Contraception, vol. 54: pp. 59-69; Johnson (1995), J.Pharm.Sci., vol. 84: pp. 1144-1146; Rohatagi (1995), Pharmazie, vol. 50: pp. 610-613; Brophy (1983), Eur.J.Clin.Pharmacol., vol. 24: pp. 103-108; see the latest edition of Remington's mentioned above). With the current level of technology, clinicians can determine the dosage regimen for each individual patient, SGRM, and checkpoint inhibitor based on the disease or condition being treated.

[0213] The amount of active ingredient in a unit dose formulation can be changed or adjusted within the range of 0.1 mg to 6000 mg, more typically within the range of 1.0 mg to 3000 mg, and most typically within the range of 10 mg to 300 mg. Furthermore, suitable dosages, depending on the specific use and the potency of the active ingredient, include approximately 1 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg, 80 mg, 90 mg, 100 mg, 200 mg, 300 mg, 400 mg, 500 mg, 600 mg, 700 mg, 800 mg, 900 mg, 1000 mg, 1100 mg, 1200 mg, 1300 mg, 1400 mg, 1500 mg, 1600 mg, 1700 mg, 1800 mg, 1900 mg, or 2000 mg. The composition may also contain other suitable treatment agents if necessary. The composition can be administered as a single dose or multiple doses based on the dosage and frequency required and tolerated by the patient.

[0214] A composition containing an antibody checkpoint inhibitor should provide a sufficient amount of the active ingredient, i.e., the antibody checkpoint inhibitor, to effectively treat cancer when administered alone or in combination with a GRM (e.g., SGRM), such as an amount that reduces ACC tumor volume or achieves other beneficial or desired clinical outcomes related to cancer improvement. In other words, the administration schedule can vary but can be routinely determined using standard methods. In some cases, the pharmaceutical composition may contain a CIC, and it may be appropriate to administer the active ingredient at a daily dose of about 1 to 2,000 mg, preferably about 10 to about 1,000 mg, most preferably about 250 to 500 mg. This daily dose can be administered in one to four doses per day. Other administration schedules include once a week and once every two days.

[0215] In some cases, the pharmaceutical composition contains CIA, and the dosage (dosage of the active ingredient) ranges from approximately 0.0001 to 100 mg / kg of host body weight, with a more typical range of 0.01 to 20 mg / kg. For example, the dosage may be 0.3 mg / kg body weight, 1 mg / kg body weight, 3 mg / kg body weight, 5 mg / kg body weight, 10 mg / kg body weight, or within the range of 0.1 to 20 mg / kg. An exemplary regimen may require administration once daily, once weekly, twice weekly, once every two weeks, once every three weeks, once every four weeks, once monthly, once every three months, or once every three to six months. In some cases, treatment may involve administering CIA according to one of the above regimens for the first period and another of the above regimens for the second period. In some cases, the same or a different regimen may be resumed after a period of interruption of treatment. For example, a patient may follow a CIA administration plan that involves two weeks of administration, a one-week break, and then another two weeks of administration. Preferred CIA administration plans of the present invention include intravenous administration of 0.1 mg / kg body weight, 0.3 mg / kg body weight, 2 mg / kg body weight, 3 mg / kg body weight, or 10 mg / kg, and the antibody is administered using one of the following administration schedules: (i) six administrations every four weeks, followed by administration every three months; (ii) every three weeks; (iii) one dose of 3 mg / kg body weight, followed by 1 mg / kg body weight every three weeks.

[0216] In some methods, two or more CIAs with different binding specificities are administered simultaneously, in which case the dose of each antibody falls within the range described above. CIAs are usually administered multiple times. The interval between each single dose may be, for example, weekly, monthly, every three months, or yearly. The interval can also be made irregular, as described above, by measuring the blood levels of antibodies against the target antigen in the patient. In some methods, the dose is adjusted to achieve plasma antibody concentrations of approximately 1–1000 μg / ml, and in others, approximately 25–300 μg / ml.

[0217] A composition containing a GRM (e.g., SGRM) used in combination therapy should provide a sufficient amount of the active agent to effectively enhance the activity of the checkpoint inhibitor when treating cancer. For example, when combined with a therapeutic dose of an antibody checkpoint inhibitor, this amount should be such that, compared to the same therapeutic dose of the checkpoint inhibitor without a GRM (e.g., SGRM), it can reduce ACC tumor burden, restore T cell and natural killer (NK) cell signaling pathways, increase T cell and NK cell infiltration into ACC tumors, decrease neutrophil infiltration into ACC tumors, or more significantly alleviate associated cancer symptoms, or achieve a more beneficial or desirable clinical outcome in the patient. In some cases, the composition provides a GRM (e.g., SGRM) in an amount that makes the ACC tumor sensitive to the checkpoint inhibitor, i.e., an amount that shows a reduction in tumor burden or other relevant clinical benefit that would not occur if the tumor were treated with the checkpoint inhibitor alone. Thus, while the administration plan may vary depending on the route of administration and the type of cancer being treated, it can be routinely determined using standard methods. In some embodiments, GRM (e.g., SGRM) is administered at a frequency of once a month, twice a month, three times a month, every other week, once a week, twice a week, three times a week, four times a week, five times a week, six times a week, every other day, once a day, twice a day, three times a day, or more.

[0218] In some cases, the daily oral dose of a pharmaceutical composition containing GRM (e.g., SGRM) can be used in the methods disclosed herein, ranging from approximately 1 to approximately 2000 mg (mg / day). In some embodiments, the above daily dose is approximately 10 to 1000 mg / day, 50 to 500 mg / day, or 100 to 300 mg / day. Lower doses may be used, especially when the drug is administered into the bloodstream, into a body cavity, or into the lumen of an organ, in an anatomically isolated location such as the cerebrospinal fluid (CSF) cavity, unlike oral administration. Doses used for topical administration can be considerably higher. Practical methods for preparing parenteral administration compositions are known or obvious to those skilled in the art and are described in detail in publications such as Remington's. See also Nieman, "Receptor Mediated Antisteroid Action," in Agarwal et al. (eds.), De Gruyter, New York (1987). In some embodiments, SGRM is CORT125281. In some embodiments, SGRM is CORT125134.

[0219] The pharmaceutical composition comprising a GRM (e.g., SGRM) or antibody checkpoint inhibitor of the present invention can be formulated on an acceptable carrier, placed in a suitable container, and labeled for treatment of a specified condition. In the case of administration of a GRM (e.g., SGRM) or checkpoint inhibitor, such a label would include, for example, instructions regarding the amount, frequency, and method of administration.

[0220] Combination therapy The methods disclosed herein include combination therapy involving the administration of both a GRM (e.g., SGRM) and an antibody checkpoint inhibitor to a subject exhibiting a certain ACC tumor burden, which may in some cases be due to the presence of antibody checkpoint inhibitor-sensitive cancer. In some embodiments, the combination therapy includes the administration of the antibody checkpoint inhibitor and SGRM sequentially in any order during all or part of the treatment period. Combination therapy involving the administration of both a GRM (e.g., SGRM) and an antibody checkpoint inhibitor to a subject exhibiting a certain ACC tumor burden is considered effective in reducing the ACC tumor burden, restoring T cell signaling pathways and natural killer (NK) cell signaling pathways, increasing T cell and NK cell infiltration into ACC tumors, decreasing neutrophil infiltration into ACC tumors, and producing other therapeutic effects in the patient.

[0221] In some cases, GRMs (e.g., SGRMs) and checkpoint inhibitors are administered according to the same or different dosing schedules. In some cases, GRMs (e.g., SGRMs) are administered according to a planned dosing schedule, and checkpoint inhibitors are administered intermittently. In some cases, checkpoint inhibitors are administered according to a planned dosing schedule, and GRMs (e.g., SGRMs) are administered intermittently. In some cases, both GRMs (e.g., SGRMs) and checkpoint inhibitors are administered intermittently. In some embodiments, GRMs (e.g., SGRMs) are administered daily, and checkpoint inhibitors, such as antibody checkpoint inhibitors, are administered weekly or bi-weekly.

[0222] In some cases, GRMs (e.g., SGRMs) and checkpoint inhibitors are administered sequentially or simultaneously at frequencies of once or twice a month, three times a month, every other week, once a week, twice a week, three times a week, four times a week, five times a week, six times a week, every other day, once a day, twice a day, three times a day, or more, for a period ranging from about one day to about one week, about two weeks to about four weeks, about one month to about two months, about two months to about four months, about four months to about six months, about six months to about eight months, about eight months to about one year, about one year to about two years, or about two years to about four years, or longer.

[0223] In some embodiments, the combination therapy includes the simultaneous administration of a GRM (e.g., SGRM) and an antibody checkpoint inhibitor. In some embodiments, the simultaneous administration of an antibody checkpoint inhibitor and a GRM (e.g., SGRM) includes administering the two drugs simultaneously or approximately simultaneously (e.g., within about 1 minute, 5 minutes, 10 minutes, 15 minutes, 20 minutes, or 30 minutes from each other).

[0224] Various combinations of GRM or SGRM and antibody checkpoint inhibitors can be used to treat ACC patients with cortisol excess. Such treatments may be effective in reducing ACC tumor volume, restoring T cell signaling pathways and natural killer (NK) cell signaling pathways, increasing T cell and NK cell infiltration into ACC tumors, decreasing neutrophil infiltration into ACC tumors, and producing other therapeutic effects in the patient. The terms "combination therapy" or "in combination" are not intended to mean that the therapeutic agents must be administered simultaneously and / or formulated to be delivered together, but these delivery methods are also included within the scope described herein. GRM or SGRM and antibody checkpoint inhibitors may be administered according to the same dosing regimen or according to different dosing regimens. In some embodiments, GRM or SGRM and antibody checkpoint inhibitors may be administered sequentially in any order during the entire or partial treatment period. In some embodiments, GRM or SGRM and the antibody checkpoint inhibitor are administered simultaneously or approximately simultaneously (for example, within about 1 minute, 5 minutes, 10 minutes, 15 minutes, 20 minutes, or 30 minutes from each other). For example, a non-limiting example of combination therapy with the administration of GRM or SGRM and an antibody checkpoint inhibitor is as follows: Here, GRM or SGRM is "A", and the antibody checkpoint inhibitor given as part of a chemotherapy regime is "B".

[0225] A / B / AB / A / BB / B / AA / A / BA / B / BB / A / AA / B / B / BB / A / B / B

[0226] B / B / B / AB / B / A / BA / A / B / BA / B / A / BA / B / B / AB / B / A / A

[0227] B / A / B / AB / A / A / BA / A / A / BB / A / A / AA / B / A / AA / A / B / A

[0228] The administration of therapeutic compounds or agents to patients should follow the general protocol for the administration of such compounds, taking into consideration any therapeutic toxicity. Surgical interventions may be applied in combination with the treatments described.

[0229] This method can be combined with other treatment methods such as surgery, radiation, targeted therapy, immunotherapy, the use of growth factor inhibitors, or anti-angiogenic factors.

[0230] period The duration of treatment with GRMs (e.g., SGRMs) and antibody checkpoint inhibitors to reduce tumor burden, restore T cell and natural killer (NK) cell signaling pathways, increase T cell and NK cell infiltration into ACC tumors, decrease neutrophil infiltration into ACC tumors, and produce other therapeutic effects in patients may vary depending on the severity of the condition in the subject and their response to combination therapy. In some embodiments, GRMs (e.g., SGRMs) and / or checkpoint inhibitors may be administered for a period of approximately 1 week to 104 weeks (2 years), more typically approximately 6 weeks to 80 weeks, and most typically approximately 9 weeks to 60 weeks. Suitable administration periods 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 96-104 weeks. Suitable durations of administration 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. Typically, administration of SGRMs and / or antibody checkpoint inhibitors should be continued until the desired clinical benefit is confirmed, and may be continued even after such benefit is confirmed to maintain or further enhance it. Treatment with GRM (e.g., SGRM) and antibody checkpoint inhibitors in this invention may continue for two years or even longer. In some embodiments, the duration of GRM (e.g., SGRM) administration is the same as the duration of checkpoint inhibitor administration.In some embodiments, the duration of SGRM administration is shorter or longer than the duration of checkpoint inhibitor administration.

[0231] In some embodiments, administration of GRM (e.g., SGRM) or antibody checkpoint inhibitors may not be continuous, but may be accompanied by one or more drug-free periods followed by one or more drug-resumption periods. Preferred drug-free periods 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 drug-free periods include 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 17 weeks, 18 weeks, 19 weeks, 20 weeks, 24 weeks, 25 weeks, 30 weeks, 32 weeks, 35 weeks, 40 weeks, 45 weeks, 48 ​​weeks, 50 weeks, 52 weeks, 55 weeks, 60 weeks, 64 weeks, 65 weeks, 68 weeks, 70 weeks, 72 weeks, 75 weeks, 80 weeks, 85 weeks, 88 weeks, 90 weeks, 95 weeks, 96 weeks, and 100 weeks.

[0232] (Evaluation of improvements in ACC treatment for patients with cortisol excess, including reduction in tumor volume) The combination therapies disclosed herein are considered effective in treating patients with cortisol excess and ACC tumors; in some embodiments, such therapies may be effective in reducing tumor burden, restoring T cell signaling pathways and natural killer (NK) cell signaling pathways, increasing T cell and NK cell infiltration into ACC tumors, decreasing neutrophil infiltration into ACC tumors, and producing other therapeutic effects in patients. Methods for measuring these responses are well known to those skilled in the field of cancer treatment. For example, methods for measuring tumor burden are described in the Response Evaluation Criteria in Solid Tumors ("RECIST") criteria, available at http: / / ctep.cancer.gov / protocolDevelopment / docs / recist_guideline.pdf.

[0233] One approach involves measuring tumor burden by quantifying the expression of tumor-specific gene markers. This approach is particularly useful for metastatic tumors and tumors that are difficult to measure (e.g., myeloma). Tumor-specific gene markers are molecules, such as proteins, that are unique to cancer cells or are more abundant in cancer cells than in non-cancerous cells. See, for example, International Publication No. 2006104474. Non-limiting examples of tumor-specific gene markers include alpha-fetoprotein (AFP) in liver cancer, beta-2-microglobulin (B2M) in multiple myeloma, beta-human chorionic gonadotropin (β-hCG) in choriocarcinoma and germ cell tumors, CA19-9 in pancreatic, gallbladder, bile duct, and gastric cancers, CA-125 and HE4 in ovarian cancer, carcinoembryonic antigen (CEA) in colorectal cancer, chromogranin A (CgA) in neuroendocrine tumors, fibrin / fibrinogen in bladder cancer, prostate-specific antigen (PSA) in prostate cancer, and thyroglobulin in thyroid cancer. See http: / / www.cancer.gov / about-cancer / diagnosis-staging / diagnosis / tumor-markers-fact-sheet for more information.

[0234] Methods for measuring the expression levels of tumor-specific gene markers are well known. In some embodiments, the mRNA of the gene marker is isolated from a blood sample or tumor tissue, and the expression of the gene marker is quantified by real-time reverse transcriptase polymerase chain reaction (RT-PCR). In some embodiments, the protein expression of the tumor-specific gene marker is evaluated by Western blotting or immunohistochemical analysis. Typically, the levels of the tumor-specific gene marker are measured in multiple samples collected over a long period of time in the combination therapy of the present invention, and a decrease in levels correlates with a decrease in tumor volume.

[0235] Alternatively, tumor burden reduction by the combination therapies disclosed herein is indicated by a reduction in tumor size or a reduction in the amount of cancer throughout the body. Tumor size is typically measured by imaging-based methods. For example, computed tomography (CT) can provide accurate and reliable anatomical information not only about tumor reduction or growth but also about disease progression by identifying the growth of existing lesions or the development of new lesions or tumor metastases. Restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, increased T cell and NK cell infiltration into ACC tumors, and decreased neutrophil infiltration in ACC tumors in patients can be measured by imaging-based methods or other appropriate means.

[0236] Alternatively, in patients, reductions in tumor volume, restoration of T cell and natural killer (NK) cell signaling pathways, increased T cell and NK cell infiltration into ACC tumors, and decreased neutrophil infiltration in ACC tumors can be evaluated using functional and metabolic imaging techniques. These techniques allow for earlier assessment of therapeutic responses by observing changes in perfusion, oxygenation, and metabolism. For example, 18F-FDG PET uses radiolabeled glucose analog molecules to evaluate tissue metabolism. Tumors typically show elevated glucose uptake, and changes in values ​​corresponding to decreased tumor tissue metabolism indicate a decrease in tumor volume. A similar imaging technique is disclosed in Kang et al., Korean J. Radio., (2012), Vol. 13 (No. 4), pp. 371-390.

[0237] Patients receiving the combination therapies disclosed herein may exhibit variability in the degree of tumor burden reduction, as well as variability in the recovery of T cell and natural killer (NK) cell signaling pathways, increased T cell and NK cell infiltration into ACC tumors, and decreased neutrophil infiltration in ACC tumors. In some cases, patients may achieve a complete response (CR), also referred to as "negative disease (NED)." A CR means that all detectable tumor has disappeared, as indicated by examinations, physical examinations, and scans. In some cases, patients receiving the combination therapies disclosed herein may achieve a partial response (PR), which is approximately equivalent to a reduction of at least 50% of the total tumor volume, but with some residual lesion findings remaining. In some cases, residual lesions in deep partial responses may actually be dead tumor or scar tissue, so a small number of patients classified as PR patients may actually be CR patients. Also, many patients who show reduction during treatment may show further reduction and achieve a CR with continued treatment. In some cases, patients receiving combination therapy may exhibit a minor response (MR), which means a small reduction of approximately 25% of the total tumor volume but less than the 50% reduction that results in a partial response (PR). In some cases, patients receiving combination therapy may exhibit stable disease (SD), which means the tumor remains nearly the same size but exhibits either small growth (typically less than 20% or less than 25%) or small reduction (any reduction less than a PR, in which case SD is typically defined as less than 25%).

[0238] In addition to a reduction in ACC tumor volume, restoration of T cell and natural killer (NK) cell signaling pathways, increased T cell and NK cell infiltration into ACC tumors, and decreased neutrophil infiltration into ACC tumors, desired beneficial or clinical outcomes from combination therapy may include, for example, reducing (i.e., delaying to some extent and / or stopping) the infiltration of cancer cells into peripheral organs; inhibiting (i.e., delaying to some extent and / or stopping) tumor metastasis; increasing the response rate (RR); extending the duration of effect; alleviating to some extent one or more of the symptoms associated with the cancer; reducing the dosage of other therapeutic agents necessary to treat the disease; slowing the progression of the disease; and / or extending patient survival and / or improving quality of life. Methods for evaluating these effects are well known and / or disclosed in http: / / cancerguide.org / endpoints.html and the RECIST guidelines, among others. [Examples]

[0239] The following examples are provided for illustrative purposes only and are not limiting. Those skilled in the art will readily understand that various non-essential parameters may be changed or modified to produce essentially similar results.

[0240] (Example 1. HepG2 tyrosine aminotransferase (TAT) assay) The following protocol describes an assay for measuring dexamethasone-induced TAT induction in HepG2 cells (human hepatocellular carcinoma cell line from the liver; ECACC, UK). HepG2 cells are cultured at 37°C in MEME medium supplemented with 10% (v / v) fetal bovine serum, 2 mM L-glutamine, and 1% (v / v) NEAA at 5% / 95% (v / v) CO2 / air. The HepG2 cells are then counted and measured in RPMI1640 without phenol red, 10% (v / v) charcoal strip FBS, and 2 mM L-glutamine at 0.125 × 10⁶ 6Adjust the density to produce cells / ml, and seed 25,000 cells / well in 200 μl into a 96-well sterile tissue culture microtiter plate, then incubate at 37°C and 5% CO2 for 24 hours.

[0241] Next, the growth medium is removed and replaced with assay medium {RPMI1640 without phenol red, 2 mM L-glutamine + 10 μM forskolin}. The test compound is then screened against a 100 nM dexamethasone challenge. The compound is then sequentially semi-logarithmically diluted with 100% (v / v) dimethyl sulfoxide from 10 mM stock. An 8-point semi-logarithmic dilution curve is then constructed and subsequently diluted 1:100 in assay medium to give a 10× final assay compound concentration, thereby resulting in a final assay compound concentration in the range of 10 to 0.003 μM in 0.1% (v / v) dimethyl sulfoxide.

[0242] The test compound was pre-incubated in a microtiter plate at 37°C in 5 / 95 (v / v) CO2 / air for 30 minutes, followed by the addition of 100 nM dexamethasone, and then allowed to be incubated for 20 hours thereafter to enable optimal TAT induction.

[0243] Next, HepG2 cells are lysed in 30 μl of cell lysis buffer containing a protease inhibitor cocktail at 4°C for 15 minutes. Then, 155 μl of a substrate mixture containing 5.4 mM tyrosine sodium salt, 10.8 mM alpha-ketoglutarate, and 0.06 mM pyridoxal 5' phosphate in 0.1 M potassium phosphate buffer (pH 7.4) can be added. After incubation at 37°C for 2 hours, the reaction can be terminated by adding 15 μl of 10 M potassium hydroxide aqueous solution, and the plate can be incubated for a further 30 minutes at 37°C. The TAT activity product can be measured by absorbance at λ340 nm.

[0244] I C 50The value can be calculated by plotting the % inhibition (normalized to 100 nM dexamethasone TAT stimulation) against the compound concentration and fitting this data to a four-parameter logistic equation. 50 The value can be converted to Ki (equilibrium dissociation constant) using the Cheng-Prusoff equation, assuming that the antagonist is a competitive inhibitor of dexamethasone.

[0245] (Example 2: Gene expression in ACC tumor patients with cortisol excess) Methods: GC status, mRNA expression, DNA mutation, and DNA methylation data obtained from separate adrenalectomy procedures (n=71) were accessed from the Cancer Genome Atlas (TCGA) (accessible via "cancer.gov" at URL about-nci / organization / ccg / research / structural-genomics / tcga). xCell was applied to the above mRNA data to analyze the abundance of immune cell types. Gene signatures were extracted using a random forest (Aran, Dvir, Zicheng Hu, and Atul J. Butte, "xCell: digitally portraying the tissue cellular heterogeneity landscape," Genome Biology, Vol. 18, No. 1 (2017): p220). Genetic analysis may also be performed using cBioPortal (accessible from cbioportal.org).

[0246] Results: The expression of 858 genes differed significantly between GC-ACC and GC+ACC cases. KEGG pathway analysis showed elevated gene expression in 7 pathways involved in steroid synthesis and secretion in GC+ cases. Nineteen pathways showed decreased expression, the majority of which were related to natural killer cells, T cells, and immune activity. Hypomethylation was mainly observed in the steroid synthesis pathway. In GC+ cases, tumor-infiltrating CD4 +Memory T cells (P=.003), CD8 + Memory T cells (P<.001) and NKT cells (P=.014) were depleted, while tumor-associated neutrophils were enriched (P<.001). In GC+ cases, elevated tumor mutational burden (TMB) was observed (P=.029).

[0247] GC+ACC tumors showed specific differences in immune processes compared to ACC tumors without systemic cortisol excess. Specifically, they differed in genes involved in natural killer (NK)-mediated cytotoxicity, such as T H 17 genes involved in cell differentiation, genes involved in T cell receptor signaling, T H Genes involved in 1 / 2 differentiation, as well as genes involved in antigen processing and antigen presentation, were downexpressed in GC+ACC tumors (Figure 1).

[0248] Furthermore, the presence or absence of specific immune cells differed between ACC tumors with cortisol excess and those without. CD4+ naive T cells, CD4+ memory T cells, CD8+ T cells, CD8+ central memory T cells, and natural killer T cells (NKTs) were less frequent in GC+ cases (Figure 2). In contrast, tumor-associated neutrophils (TANs) were more frequent in GC+ ACC.

[0249] The abundance of immune cells and immune-related transcripts was lower in GC+ACC. The higher TMB levels in GC+ tumors may be related to increased neoantigen resistance. These findings suggest that GR antagonism may promote the tumor immune response in ACC or other malignancies with elevated GC activity by reversing the immunosuppressive effect of endogenous GC.

[0250] Conclusion: Clinical responses to antibody checkpoint inhibitors are dependent on the immune system. Specifically, T cell function and antigen presentation are important for the clinical efficacy of antibody checkpoint inhibitors. Furthermore, immune cell infiltration is associated with the clinical efficacy of antibody checkpoint inhibitors. Tumors with low T cell infiltration or high neutrophil infiltration tend to have a poor response to antibody checkpoint inhibitors. In other words, reversing the action of GC+ using a GRM (e.g., SGRM) may improve the response to antibody checkpoint inhibitors. Therefore, it is thought that co-administration of a GRM such as SGRM with an antibody checkpoint inhibitor is effective in reducing tumor volume, restoring T cell signaling pathways and natural killer (NK) cell signaling pathways, increasing T cell and NK cell infiltration into ACC tumors, and decreasing neutrophil infiltration into ACC tumors in ACC patients with cortisol excess.

[0251] (Example 3: Gene expression in ACC tumor patients with cortisol excess) Methods: Data on GC status (based on clinical signs and symptoms or biochemical findings), mRNA expression, DNA mutations, and DNA methylation obtained from separate adrenalectomy (n=71) were accessed from TCGA (www.cancer.gov / tcga). Two sarcomatoid cases were excluded from the analysis. 394,036 methylation probes were analyzed, and the data were normalized using BMIQ (beta-mixture quantile normalization). xCell was applied to the above mRNA data to analyze the abundance of immune cell types (Aran et al., Genome Biol. Vol. 18 (No. 1): p220 (2017)). Each tumor case was scored using a previously published GR activity signature (West et al., Vol. 24 (No. 14): pp3433~3446 (2018)). Gene signatures predicting GC+ tumors were extracted using a random forest. Signature genes were identified by bootstrapping a random forest on a random subset containing 80% of the data and comparing the mean bootstrap gene importance to a threshold. The threshold was calculated by applying the same procedure to a random forest that predicted randomized labels instead of true GC+ / - labels to simulate signal deficiencies. The 99.9th quantile of gene importance was selected as the threshold.

[0252] Results: Adrenocortical carcinomas were classified using the glucocorticoid status of the tumors (Figure 3A). Using TCGA mRNA data, gene groups with significant differences in common hormones and GC status (more than a twofold change and adjusted P ≤ 0.05) were identified. It was identified that the presence or absence of GC excess (GC+ / -) affected the maximum number of genes (858 genes, illustrated in Comparison 1 in Figure 3A and Figure 3B). In determining the presence or absence of any hormone (H+ / -), significant differences were found in 439 genes (Comparison 2). (H+ indicates the presence of a hormone, and H- indicates the absence of a hormone (e.g., no GC, no androgen, no estrogen, no progesterone, etc. were detected).) There was no significant difference between H- tumors and tumors expressing only hormones other than GC (NGC+, Comparison 3). When comparing NGC+ and GC+, significant differences were found in 185 genes (Comparison 4). Pathway analysis using the Kyoto Gene Genome Database (KEGG) confirmed that in GC+ cases, gene expression in several steroid synthesis pathways was elevated, while the expression of numerous immune-related pathways was low (Figure 1).

[0253] As described in Example 2 above, Figure 2 shows the abundance of specific immune cell types in ACC tumors. In GC+ cases, the abundance of lymphocytes was low (left), while the abundance of mesenchymal stem cells and neutrophils was high (right). In GC+ ACC tumors, the abundance of lymphocytes was low, the abundance of myeloid stem cells and mesenchymal stem cells was high, and the amount of tumor gene mutations was high. xCell analysis showed that compared to GC- (Figure 2, left), GC+ cases had lower abundances of T cells (P<.005) and natural killer T cells (NKT cells, P=.014). On the other hand, mesenchymal stem cells and neutrophils were more abundant in GC+ cases (P<.001, Figure 2, right). The amount of tumor gene mutations was also confirmed to be higher in GC+ cases (P=.029, Figure 7).

[0254] As shown in Figure 3B, the expression of 858 genes was found to be significantly affected by GC overexposure. Genes with high expression levels in GC+ cases (P ≤ 0.05 and more than a twofold change in expression level compared to GC-) are shown in the upper right. Genes with low expression levels in GC+ cases are shown in the upper left.

[0255] GC excess is associated with hypomethylation of steroid synthesis genes (Figure 4). In GC+ACC cases, many genes were significantly hypomethylated (Figure 4, upper left), while only a few genes were hypermethylated (Figure 4, upper right). In GC+ tumors, there were more significantly hypomethylated genes (P≦0.05, Δβ<-0.2) than hypermethylated genes (P≦0.05, Δβ>0.2) (Figure 4). The β value represents the percentage of methylation in a given gene. Differences in methylation may explain increased expression in steroid production pathways, but not decreased expression in immune pathways. The hypomethylated genes were mainly associated with aldosterone, GC, and bile synthesis / secretion pathways, which are upexpressed in GC+ACC (Figure 1). In contrast, immune pathways whose gene expression was downregulated by mRNA analysis were not enriched in either the hypomethylated or hypermethylated sets.

[0256] As shown in Figures 5 and 6, immunogene suppression is associated with GC production. Unsupervised clustering of normalized gene expression for the T cell receptor signaling KEGG pathway and the natural killer cell-mediated cytotoxic KEGG pathway showed lower gene expression in GC+ cases (Figure 5). Conversely, when GC+ and GC- were clustered separately, GC+ cases tended to show lower expression in these two immune-related pathways (Figure 6).

[0257] Figure 5 shows unsupervised clustering of normalized gene expression for two KEGG pathways. The pathways shown include the T cell receptor signaling pathway and the natural killer cell-mediated cytotoxicity pathway. The top two columns show the GC and general hormone status of each tumor (black: GC+ / H+, white: GC- / H-), and the blue / red shading (shown on a grayscale) indicates the normalized gene expression of each tumor, with darker blue corresponding to lower expression. When clustered by gene expression, GC+ cases appear on the right side of the figure, showing low expression of many genes.

[0258] Figure 6. Supervised clustering of normalized gene expression for the two KEGG pathways shown in Figure 5. In GC+ cases (clustered on the right), low gene expression is dominant in these pathways (dark blue).

[0259] Figure 7. Increased tumor gene mutation load in GC+ACC. More missense and nonsense mutations were identified in GC+ cases compared to GC- cases. (A case refers to the tumor of an individual patient. "Mutations per case" refers to the total number of mutations identified in a single tumor.)

[0260] Figure 8. GR activity scores for various tumor types and ACC subsets. ACC showed higher GR-driven gene activity compared to other tumors, and hormone status was independent (see inset). GR activity was high in ACC and independent of hormone status. Tumor scoring was performed using previously published GR-driven gene signatures determined from 74 GR activation-related genes (West et al., Vol. 24 (No. 14): pp. 3433-3446 (2018)), and it was confirmed that GR activity was higher in ACC compared to other tumor types in the Cancer Genome Atlas (TCGA; Figure 8). There was no difference between ACC cases with different hormone status or GC status (inset in Figure 8).

[0261] Figure 9. Gene signatures can predict GC+-like tumor cases. Figure 9 shows the results of deriving gene signatures that distinguish between GC+ACC and GC-ACC cases using random forest analysis. NLRP1 and ZNF683 (highlighted) were identified as important signature components. Only signature genes with a threshold of 0.0028 are shown. A model that distinguishes between GC+ACC and GC-ACC cases with an ROC AUC of 0.87±0.09 was derived using the random forest method (Figure 9). The inflammasome sensor component (NLRP1) and the IL-15-mediated NK activation mediator (ZNF683) were identified as important parts of this signature (inset in Figure 9).

[0262] Next, as shown in Figures 10A and 10B, the above gene signature was applied to other tumor types in TCGA, and tumor types with GC+-like transcriptional profiles were identified. Figure 10A shows the application of the ACC gene signature to TCGA tumors. Based on the known distribution of GC+ and GC- cases in ACC, a cutoff score of 0.75 was derived to distinguish between GC+ and GC- tumors (horizontal line in Figure 10A). According to this score, uveal melanoma (UVM) and cutaneous melanoma (SKCM) are likely to have the highest frequency of cases similar to GC+ACC (Figure 10B). Figure 10B shows the frequency prediction of tumor cases similar to GC+ACC. Uveal melanoma (UVM) and cutaneous melanoma (SKCM) are predicted to have the highest frequency of tumors similar to GC+ACC.

[0263] In ACC, glucocorticoid excess (GC+) affects far more genes than other hormones. In GC+ ACC, steroid synthesis gene expression was elevated, while immune-related genes were suppressed. Normal adrenal cells express steroid synthesis genes but not immunosuppressive genes. Steroid synthesis genes were hypomethylated in GC+ cases, but no difference in immune gene methylation was observed between GC+ and GC- cases. Furthermore, GC+ cases showed fewer infiltrating immune cells (T cells and NKT cells) compared to GC- cases, suggesting that the immune response is due to changes in immune cell infiltration rather than transcriptional changes. Tumor gene mutational load was higher in GC+ ACC cases, which may be related to immunosuppression or immune cell elimination, possibly associated with the higher non-self antigen tolerance observed in GC+ cases. Previously published GR activity scores showed no difference between GC+ and GC- cases, which may be due to locally higher GC concentrations in the adrenal gland, regardless of systemic GC levels. On the other hand, immune infiltration into ACC tumors may be negatively affected by lymph node exposure to elevated GC activity. Newly derived gene signatures suggest that GC+-like tumors are most frequent in uveal melanoma and cutaneous melanoma. The observation of reduced levels of immune cells and immune-related transcripts in GC+ACC provides a clue to the mechanism by which GC may limit the response to immune system checkpoint inhibitor (ICI) therapy. Because GR antagonism increases immune-related transcript and immune cell infiltration, the tumor immune response may be enhanced in malignancies such as GC+ACC with elevated GC activity.

[0264] Example 4. Effects of cortisol and relacorirant on natural killer cell function in vitro. Considering the significant differences in natural killer (NK) cells between GC+ACC and GC-ACC, the effects of cortisol on human NK cells were evaluated in vitro. Cortisol suppressed NK cell activation, proliferation, and direct tumor cell death (relacorilant restored these). The reduced abundance of immune cells, including NK cells, in GC+ACC provides a clue to the mechanism by which GC may limit the response to ICI therapy. Because GR antagonism increases the abundance and function of immune cells, including NK cells, in tumors, the tumor immune response may be enhanced in malignancies such as GC+ACC where GC activity is elevated. This hypothesis will be tested in a phase 1 clinical trial of relacorilant + ICI.

[0265] Effects of cortisol and relacorirant on NK cell function in vitro Considering the significant suppression of NK-related genes in GC+ cases, the direct effects of GR regulation on human NK cells were evaluated. NK cells were isolated from healthy donors and stimulated with IL-2. Activation (abundance of CD25+CD69+ cells) increased with stimulation, was suppressed by cortisol, and restored by relacorilant (Mann-Whitney p=0.0039) (Figure 11A). NK cell proliferation also increased with stimulation, was suppressed by cortisol, and restored by relacorilant (Mann-Whitney p=0.0099) (Figure 11B). Cytokine secretion (both transcripts and secreted proteins) also increased with stimulation, was suppressed by cortisol, and restored by relacorilant (Figures 12A-12D). Genes significantly induced by stimulation, suppressed by cortisol, and restored by relacorilant included important NK activating genes, including the IL2 receptor and activator LAG3 (Figure 12D). These data experimentally confirm the effect of GC on the NK cell population in observed ACC tumors.

[0266] Activation, proliferation, and cytokine secretion all indicate functional changes in NK cells mediated by cortisol and relacorilant. To confirm whether these functional changes also affect target cell death, NK cells were incubated with K562 tumor cells. At various NK cell:tumor cell ratios, cortisol suppressed tumor cell death, while relacorilant restored it (Figure 13A). When relacorilant was added to NK cells in a 5:1 ratio, tumor death by NK cells was significantly improved (Mann-Whitney p=0.004) (Figure 13B). Therefore, in vitro, glucocorticoids suppress tumor cell death by human NK cells.

[0267] Cortisol is a potent transcription factor and mediator of immune cell function. Diurnal and trans-diurnal variations in cortisol limit the interpretability of single cortisol assessments, making it difficult to evaluate the effects of systemic cortisol activity. Multi-omics data from ACC offer a unique scenario where rich multi-omics data are paired with the clinical assessment of cortisol excess. To deepen our understanding of ACC and gather insights into the potential symptoms of cortisol activity in other tumor types, we investigated this exaggerated cortisol physiology.

[0268] Significant differences were found in 858 genes between ACC cases showing GC excess and ACC cases not showing GC excess. In other comparisons, such as comparisons between cases with and without any steroid hormone, there were few genes that showed significant differences. Genes involved in steroid synthesis were, unsurprisingly, highly expressed in cases showing GC excess. Hypomethylation of promoters was observed in steroid synthesis genes. On the other hand, the decreased expression of immune genes in GC+ cases is likely a result of insufficient infiltration of immune cells into GC+ tumors. Evaluation of GR activity (evaluation via previously published gene signatures; see West et al., Clin Cancer Res, 2018, Vol. 24 (No. 14): pp. 3433-3446) suggested that intratumoral GR activity was similar in both ACC cases showing GC excess and those not showing GC excess. This may be caused by high cortisol levels in the adrenal gland, regardless of systemic cortisol levels. In other words, the differences in immune infiltration may be due to systemic GC effects, including those on primary and secondary lymphoid organs throughout the body. Since high levels of GC can increase tolerance to neoantigens, the effects of GC on lymphoid organs may also be related to the increase in TMB observed in GC+ACC cases.

[0269] By comparing GC+ and GC- cases, we identified a genetic signature that distinguishes these two types of cases. This genetic signature may be useful in future efforts to diagnose GC excess from tumor biopsies and tumor resections. When we scored tumors other than ACC against this signature, uveal melanoma and cutaneous melanoma showed the most cases (though still rare) that resembled the transcriptional signature of GC+ACC. This supports previous reports of local cortisol production in the skin (see Vekulic et al., and Tissue Injury., J Biological Chemistry, 2011, vol. 286 (12), pp. 10265-10275). Such tumors would be a reasonable choice for evaluating the immunological effects of GR antagonism outside of ACC.

[0270] In multi-omics data from GC+ACC, the suppression of NK cells was prominent. NK-activating genes were significantly underexpressed in GC+ cases, and the NK-activating gene ZNF683 was particularly important in distinguishing GC+ cases from GC- cases. Functional studies using human NK cells, cortisol, and the GR modulator relacolinant confirmed that GR is a key regulator of NK function. Cortisol suppressed NK proliferation, increased expression of cell surface markers of activation, tumor cell death, IFNγ secretion, and IFNγ transcription. Cortisol also suppressed the secretion of other effector cytokines and the expression of the IL-2 receptor (il2ra). These findings confirm the reduction in NK-activating genes observed in GC+ACC. Cortisol suppressed the expression of LAG3 (CD223, lag3) and 4-1BB (CD137, tnfrsf9), both targets of experimental agonists aimed at improving the antitumor immune response, while relacolinant promoted their expression. In stimulated NK cells, the expression of chemokine ligand 3-like 1 (ccl3l1), a lymphocyte-attracting chemokine, was also suppressed by cortisol, which may also explain the decrease in T cell infiltration into GC+ACC. A decrease in the abundance of immune-related transcripts was observed in GC+ACC, which may provide clues to a mechanism that may limit the response to ICI therapy.

[0271] Adrenal cancer is a serious disease in which patients face challenges in both tumor management and hormone management. Patients with ACC (Adrenal Cortisol Overload) who have excess cortisol may develop Cushing's syndrome, a condition characterized by systemic excess cortisol of adrenal, pituitary, or ectopic origin. Cushing's syndrome itself can lead to death in these patients through vascular events, cardiovascular events, or infections (see Yaneva M. et al., European J Endocrinology, 2013, Vol. 169, pp. 621-627). The GR modulator Korylm® (mifepristone) is approved for the treatment of symptoms of excess cortisol. These data go a step further, suggesting that selective GR modulation by relacorirant may mitigate immunosuppression caused by systemic cortisol. Specifically, selective GR antagonism may enhance the antitumor activity of other immunomodulators, such as immune checkpoint inhibitors and more experimental NK-targeted drugs, while reducing the risky sequelae of excess cortisol. This hypothesis is currently being directly investigated in the ongoing Phase I trial or with leracorilant + pembrolizumab in ACC patients exhibiting GC excess.

[0272] The effects of GC-excess on NK cells were particularly striking. Direct in vitro evaluation of cortisol activity on NK cells revealed potent and broad-spectrum inhibitory activity. Furthermore, relacolinant was able to reverse the effects of cortisol, restoring NK cell activation, proliferation, and target cell death. These findings suggest that the combined administration of GR modulators such as relacolinant with immune checkpoint inhibitors (ICIs) in patients with cortisol-excess adrenocortical carcinoma (GC+ACC) provides a more effective and improved treatment compared to ICI monotherapy.

[0273] All patents, patent publications, publications, and patent applications listed in this specification are incorporated herein by reference in whole, as if each individual publication or patent application were specifically and individually indicated to be incorporated by reference. In addition, although the above inventions are described in some detail by examples and illustrations for the purpose of clarity of understanding, it will be readily apparent to those skilled in the art in light of the teachings of the present invention that certain modifications and modifications can be made without departing from the spirit or scope of the appended claims. Exemplary embodiments of the present invention are described below. <1> A method for treating a subject having an adrenocortical carcinoma tumor and cortisol excess, wherein the method is: a) Identify patients who have an adrenocortical tumor and b) have glucocorticoid excess; 1) administering a selective glucocorticoid receptor modulator (SGRM) and 2) administering an antibody checkpoint inhibitor to the identified patient; This will result in better treatment outcomes from the identified patients than those that would have been achieved with treatment using antibody checkpoint inhibitors alone. Includes, The treatment outcome is selected from a) a reduction in ACC tumor volume, b) restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, c) increased infiltration of T cells and NK cells into the ACC tumor, and d) decreased infiltration of neutrophils into the ACC tumor. <2> The antibody checkpoint inhibitor is selected from antibodies effective against PD-1, antibodies effective against CTLA-4, antibodies effective against PD-L1, and antibodies effective against PD-L2. <1> Methods used. <3> The aforementioned checkpoint inhibitor is an antibody effective against PD-1. <2> Methods used. <4> The aforementioned checkpoint inhibitor is an antibody effective against CTLA-4. <2> Methods used. <5> The aforementioned checkpoint inhibitor is an antibody effective against PD-L1. <2> Methods used. <6> The aforementioned checkpoint inhibitor is an antibody effective against PD-L2. <2> Methods used. <7> The further method includes administering a chemotherapeutic agent selected from the group consisting of taxanes, alkylating agents, topoisomerase inhibitors, endoplasmic reticulum stress inducers, antimetabolites, mitotic inhibitors, and combinations thereof. <1> ~ <6> One of the following methods. <8> The aforementioned chemotherapeutic agent is a taxane. <7> Methods used. <9> The aforementioned chemotherapeutic agent is selected from the group consisting of nab-paclitaxel, 5-fluorouracil (5-FU), gemcitabine, cisplatin, and capecitabine. <8> Methods used. <10> The aforementioned SGRM is a heteroaryl-ketone condensed azadecalin compound having the following formula, a salt thereof, or an isomer thereof. <1> ~ <9> The method described in any one of the following ways: [ka] During the ceremony, R 1 This is a heteroaryl ring having 5 to 6 ring members and each having 1 to 4 heteroatoms independently selected from the group consisting of N, O, and S, and each of the heteroaryl rings independently has R 1a It may also be replaced by 1 to 4 elements selected from; R 1a Each is independently hydrogen and 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 C3-8 Selected from the group consisting of heterocycloalkyl groups; Ring J is selected from the group consisting of cycloalkyl rings, heterocycloalkyl rings, aryl rings, and heteroaryl rings, where the heterocycloalkyl ring and heteroaryl ring each have 5 to 6 ring members and 1 to 4 heteroatoms independently selected from the group consisting of N, O, and S; R 2 Each is independently hydrogen and 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) 2 R 2a 、C 3-8 Cycloalkyl, and C 3-8 Selected from the group consisting of heterocycloalkyl groups, where the heterocycloalkyl group consists of 1 to 4 R 2c It may also be substituted with the base; Alternatively, two R atoms bonded to the same carbon atom 2 The groups combine to form an oxo group (=O); Alternatively, two R 2 The groups are combined to form a heterocycloalkyl ring having 5 to 6 ring members and 1 to 3 heteroatoms independently selected from the group consisting of N, O, and S, where the heterocycloalkyl ring has 1 to 3 R 2d It may also be substituted with the base; R 2a and R 2b Each is independently hydrogen and C 1-6 Selected from the group consisting of alkyl groups; R 2c These are independently hydrogen, halogen, hydroxyl, and C. 1-6 Alkoxy, C 1-6 Haloalkoxys, CN, and NR 2a R 2b Selected from the group consisting of; R2d Each is independently hydrogen and C 1-6 Selected from the group consisting of alkyl groups, or two R atoms bonded to the same ring atom. 2d The bases combine to form (=O); R 3 Each has 1 to 4 R 3a Selected from the group consisting of phenyl and pyridyl, which may be substituted with a group; R 3a These are hydrogen, halogen, and C, respectively, independently. 1-6 Selected from the group consisting of haloalkyl groups; The subscript n is an integer between 0 and 3. <11> The compound comprising heteroaryl-ketone condensed azadecalin is a relacolinant having the following formula: <10> Methods used.

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Claims

1. A combination drug of a selective glucocorticoid receptor modulator (SGRM) and an antibody checkpoint inhibitor for treating adrenocortical carcinoma (ACC) in subjects with cortisol excess. Here, the above procedure is, a) Identify patients who have adrenocortical carcinoma and b) have cortisol excess, wherein the patient is cortisol excess if the patient's cortisol level is more than approximately 1.5 times the cortisol level measured in healthy subjects; Administering the selective glucocorticoid receptor modulator (SGRM) and the antibody checkpoint inhibitor to the identified patient; This will result in better treatment outcomes from the identified patients than those that would have been achieved with treatment using antibody checkpoint inhibitors alone. Includes, The treatment outcomes are selected from the following in the patient: a) restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, b) increased infiltration of T cells and NK cells into ACC tumors, and c) decreased infiltration of neutrophils into ACC tumors. The antibody checkpoint inhibitor is selected from antibodies effective against CTLA-4, antibodies effective against PD-L1, and antibodies effective against PD-L2. The aforementioned SGRM is a combination drug having the following formula: (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazole-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinoline-4a-yl)(4-(trifluoromethyl)pyridine-2-yl)methanone (also known as relacolinant). 【Chemistry 1】

2. A pharmaceutical product comprising a selective glucocorticoid receptor modulator (SGRM) for treating adrenocortical carcinoma (ACC) in subjects with cortisol excess, Here, the above procedure is, a) Identify patients who have adrenocortical carcinoma and b) have cortisol excess, wherein the patient is cortisol excess if the patient's cortisol level is more than approximately 1.5 times the cortisol level measured in healthy subjects; Administering the aforementioned selective glucocorticoid receptor modulator (SGRM) and antibody checkpoint inhibitor to the identified patient; This will result in better treatment outcomes from the identified patients than those that would have been achieved with treatment using antibody checkpoint inhibitors alone. Includes, The treatment outcomes are selected from the following in the patient: a) restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, b) increased infiltration of T cells and NK cells into ACC tumors, and c) decreased infiltration of neutrophils into ACC tumors. The antibody checkpoint inhibitor is selected from antibodies effective against CTLA-4, antibodies effective against PD-L1, and antibodies effective against PD-L2. The aforementioned SGRM is a pharmaceutical product having the following formula: (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazole-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinoline-4a-yl)(4-(trifluoromethyl)pyridine-2-yl)methanone (also known as relacolinant). 【Chemistry 2】

3. A pharmaceutical product containing an antibody checkpoint inhibitor for treating adrenocortical carcinoma (ACC) in subjects with adrenocortical carcinoma and cortisol excess. Here, the above procedure is, a) Identify patients who have adrenocortical carcinoma and b) have cortisol excess, wherein the patient is cortisol excess if the patient's cortisol level is more than approximately 1.5 times the cortisol level measured in healthy subjects; Administering the antibody checkpoint inhibitor and a selective glucocorticoid receptor modulator (SGRM) to the identified patient; This will result in better treatment outcomes from the identified patients than those that would have been achieved with treatment using antibody checkpoint inhibitors alone. Includes, The treatment outcomes are selected from the following in the patient: a) restoration of T cell signaling pathways and natural killer (NK) cell signaling pathways, b) increased infiltration of T cells and NK cells into ACC tumors, and c) decreased infiltration of neutrophils into ACC tumors. The antibody checkpoint inhibitor is selected from antibodies effective against CTLA-4, antibodies effective against PD-L1, and antibodies effective against PD-L2. The aforementioned SGRM is a pharmaceutical product having the following formula: (R)-(1-(4-fluorophenyl)-6-((1-methyl-1H-pyrazole-4-yl)sulfonyl)-4,4a,5,6,7,8-hexahydro-1H-pyrazolo[3,4-g]isoquinoline-4a-yl)(4-(trifluoromethyl)pyridine-2-yl)methanone (also known as relacolinant). 【Transformation 3】

4. The pharmaceutical product or combination pharmaceutical product according to any one of claims 1 to 3, wherein the antibody checkpoint inhibitor is an antibody effective against CTLA-4.

5. The pharmaceutical product or combination pharmaceutical product according to any one of claims 1 to 3, wherein the antibody checkpoint inhibitor is an antibody effective against PD-L1.

6. The pharmaceutical product or combination pharmaceutical product according to any one of claims 1 to 3, wherein the antibody checkpoint inhibitor is an antibody effective against PD-L2.

7. A pharmaceutical product or combination pharmaceutical product according to any one of claims 1 to 6, further comprising administering a chemotherapeutic agent selected from the group consisting of taxanes, alkylating agents, topoisomerase inhibitors, endoplasmic reticulum stress inducers, antimetabolites, mitotic inhibitors, and combinations thereof.

8. The pharmaceutical or combination pharmaceutical according to claim 7, wherein the chemotherapeutic agent is a taxane.

9. The pharmaceutical or combination pharmaceutical according to claim 7, wherein the chemotherapeutic agent is selected from the group consisting of nab-paclitaxel, 5-fluorouracil (5-FU), gemcitabine, cisplatin, and capecitabine.

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