Combination of a protein kinase inhibitor with immunomodulatory agents

Abstract

The present invention relates to a method for treating a cancer in a subject, comprising administering to the subject compound of formula (I) or a pharmaceutically acceptable salt thereof and at least an immunomodulator. The present invention also provides a combination and a kit for the treatment of cancer in a subject.

Description

[0001] COMBINATION OF A PROTEIN KINASE INHIBITOR WITH

[0002] IMMUNOMODULATORY AGENTS

[0003] This application claims the benefit of Indian provisional application number 202341027926, filed on April 17, 2023, the specifications of which are hereby incorporated by reference in their entirety.

[0004] FIELD OF THE INVENTION

[0005] The present invention relates to a method for treating cancer in a subject, comprising administering compound of formula (I) or a pharmaceutically acceptable salt thereof and at least an immunomodulator. The present invention also provides a combination and a kit for the treatment of cancer.

[0006] BACKGROUND OF THE INVENTION

[0007] The compound N-(2',4'-difluoro-5-(5-(l-methyl-lH-pyrazol-4-yl)-lH- benzo[d]imidazol-l-yl)-[l,l'-biphenyl]-3-yl)cyclopropanesulfonamide also referred to as “compound of formula (I)” or “Compound 1” and derivatives thereof have been disclosed in WO 2013 / 053983.

[0008] Compound 1 is an orally bioavailable clinical stage spectrum kinase inhibitor that inhibits the activity of oncogenic pathway-related kinases including DDR1, SIK2, and related RTKs (FGFR, VEGFR, PDGFR, and RET). DDR1 instigates immune exclusion by promoting collagen fibre alignment thereby altering extracellular matrix (ECM) components in tumor immune microenvironment (TIME). DDR1 expression inversely correlated with reduced immune cell infiltration in TIME leading to exhaustion of tumor-fighting immune cells, tumor escape, EMT and metastasis. DDR1 expression levels in tumor immune microenvironment was known to have a direct role in the regulation of cytokine / chemokine milieu, cancer associated fibroblasts (CAF), tumor associated macrophages (TAM), regulatory T cells (T cells) and T cell exhaustion markers like CCR8, PD-1, CTLA-4, and TIM-3 (Wang et al, Front. Immunol. 13:933165, 2022). FGFRs induce the expression the PD-L1 and VEGFRs promote the proliferation of Tregs, inhibit T-cell development and maturation of dendritic cells. These findings suggest that the spectrum-selective inhibition of these RTKs has the potential to strongly modulate the antitumor immune response.

[0009] Clinically successful immune checkpoint inhibitors (ICI) (anti-PDl, anti-PD-Ll, and anti-CTLA4 antibodies) block the pathways that inhibit immune cell activation thus stimulating immune responses against the tumor cells. Although ICIs show improved survival in patients with many types of cancers, they suffer from the lack of response in majority of patients along with the development of resistance to therapy (Siwen Hu et al., Future Oncol. 2021 Apr; 17(11): 1401-1439). DDR1 and SIK2 kinases are known to modulate Wnt / p-catenin signalling through phosphorylation of BCR and LRP6, respectively. WNT / p-catenin signalling affects cancer immunosurveillance across many cancers. It regulates tumor-immune cell interactions including the immunogenicity of cancer cells and the ability of immune cells (NK cells, Treg cells, MDSCs and CTLs) to elicit effective tumor-targeting immune responses.

[0010] In general, tumor progression is the result of dysregulation of multiple signalling pathways and thus single agent therapy is not effective for durable anti-tumor response. In view of the inhibition of key regulatory pathways impacting immune suppression, angiogenesis and tumor proliferation, attempts have been made to increase the response rate of currently available therapeutic agents including immune checkpoint inhibitors by combining with Compound 1.

[0011] SUMMARY OF THE INVENTION

[0012] It has now been found that Compound 1 either as a single agent or in combination with immunomodulators demonstrated dose dependent tumor growth inhibition and enhanced antitumor efficacy in immune competent tumor models.

[0013] In one aspect, the present invention provides a method for treating a cancer in a subject, comprising administering to the subject an effective amount of a first anti -cancer agent and an effective amount of at least a second anti-cancer agent, wherein the first anti-cancer agent is represented by formula (I) or a pharmaceutically acceptable salt thereof and wherein the second anti-cancer agent is an immunomodulator, as described herein.

[0014]

[0015] In another aspect, the present invention provides a kit comprising compound of formula I, an immunomodulator, and a package insert comprising instructions for using the compound of formula I, to treat or delay the progression of cancer in a subject.

[0016] In yet another aspect, the present invention provides a combination comprising a first anticancer agent and at least a second anticancer agent, wherein the first anticancer agent is represented by a compound of formula (I) or a pharmaceutically acceptable salt thereof and wherein the second anti-cancer agent is an immunomodulator.

[0017] BRIEF DESCRIPTION OF THE DRAWINGS

[0018] FIG. 1A illustrates change in the body weight in C57BL mice (MC38 model) that received the Compound 1 (20 mg / kg or 40 mg / kg), anti -mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (20 mg / kg or 40 mg / kg) and anti-mouse PD-1 antibody (200 pg / animal) at various treatment days;

[0019] FIG. IB illustrates change in tumour volume in C57BL mice (MC38 model) that received the Compound 1 (20 mg / kg or 40 mg / kg), anti -mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (20 mg / kg or 40 mg / kg) and anti-mouse PD-1 antibody (200 pg / animal) at various treatment days;

[0020] FIG. 2A illustrates change in body weight change in Balb / c mice (CT26 model) that received the Compound 1 (20 mg / kg or 40 mg / kg), anti-mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (20 mg / kg or 40 mg / kg) and anti-mouse PD-1 antibody (200 pg / animal) at various treatment days;

[0021] FIG. 2B illustrates the change in tumour volume in Balb / c mice (CT26 model) that received the Compound 1 (20 mg / kg or 40 mg / kg), anti-mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (20 mg / kg or 40 mg / kg) and anti-mouse PD-1 antibody (200 pg / animal) at various treatment days; FIG. 3A illustrate the change in average body weight in Balb / c mice (CT26 model) that received the Compound 1 (20 mg / kg or 40 mg / kg), anti-mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (40 mg / kg) and anti-mouse PD-1 antibody (200 pg / animal) at various treatment days;

[0022] FIG. 3B illustrate the change in tumour volume in Balb / c mice (CT26 model) that received the Compound 1 (20 mg / kg or 40 mg / kg), anti -mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (40 mg / kg) and anti-mouse PD-1 antibody (200 pg / animal) at various treatment days;

[0023] FIG. 4 illustrates in change in tumour volume in naive control and animals that received combination of Compound 1 (40 mg / kg) and anti -PD-1 (200 pg / animal) antibody after rechallenging with tumour cells;

[0024] FIG. 5A illustrates the effect on total T cells in spleen in naive control and animals treated with combination of Compound 1 (40 mg / kg) and anti -PD-1 antibody (200 pg / animal) after rechallenging with tumour cells;

[0025] FIG. 5B illustrates the effect on total T cells in lymph nodes in naive control and animals treated with combination of Compound 1 (40 mg / kg) and anti-PD-1 antibody (200 pg / animal) after re-challenging with tumour cells;

[0026] FIG. 5C illustrates the effect on total activated T cells in spleen in naive control and animals treated with combination of Compound 1 (40 mg / kg) and anti-PD-1 antibody (200 pg / animal) after re-challenging with tumour cells;

[0027] FIG. 5D illustrates the effect on total effector CD4+ memory T cells in spleen in naive control and animals treated with combination of Compound 1 (40 mg / kg) and anti-PD-1 antibody (200 pg / animal) after re-challenging with tumour cells;

[0028] FIG. 5E illustrates the effect on total effector CD4+ memory T cells in lymph node in naive control and animals treated with combination of Compound 1 (40 mg / kg) and anti-PD-1 antibody (200 pg / animal) after re-challenging with tumour cells;

[0029] FIG. 5F illustrates the effect on total effector CD 8+ memory T cells in lymph node in naive control and animals treated with combination of Compound 1 (40 mg / kg) and anti-PD-1 antibody (200 pg / animal) after re-challenging with tumour cells;

[0030] FIG. 6A illustrates the change in average body weight change in C57BL / 6 mice (MC38 model expressing human PD-L1) that received the Compound 1 (40 mg / kg), anti -mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (40 mg / kg) and anti-mouse PD-1 antibody (200 pg / animal) at various treatment days; and

[0031] FIG. 6B illustrates the change in tumour volume in C57BL / 6 mice (MC38 model expressing human PD-L1) that received the Compound 1 (40 mg / kg), anti-mouse PD-1 antibody (200 pg / animal), combination of Compound 1 (40 mg / kg) and anti -mouse PD-1 antibody (200 pg / animal) at various treatment days.

[0032] DETAILED DESCRIPTION OF THE INVENTION

[0033] In one embodiment, the present invention provides a method for treating cancer in a subj ect, comprising administering to a subject an effective amount of a first anti-cancer agent and an effective amount of at least a second anti-cancer agent, wherein the first anti-cancer agent is represented by formula (I): or a pharmaceutically acceptable salt thereof; and wherein the second anti-cancer agent is an immunomodulator.

[0034] In one embodiment, the compound of formula (I) is an oral, selective kinase inhibitor targeting DDR1, SIK2, FGFRs and VEGFRs. The selectivity profile of compound of formula (I) makes it suitable for the treatment or delay in progression of wide variety of cancers.

[0035] In one embodiment, the immunomodulator is an immune checkpoint inhibitor.

[0036] In one embodiment, the immune checkpoint inhibitor is an antibody or a small molecule targeting an immune checkpoint molecule.

[0037] In one embodiment, the immune checkpoint molecule is one or more selected from

[0038] CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha and KIR. In one embodiment, the immune checkpoint inhibitor is one or more selected from PD- 1 inhibitor and PD-L1 inhibitor.

[0039] In one embodiment, the immune checkpoint inhibitor is PD-1 inhibitor.

[0040] In one embodiment, the immune checkpoint inhibitor is PD-L1 inhibitor.

[0041] In one embodiment, the antibody is selected from a polyclonal antibody, a monoclonal antibody, an antibody fragment, a single chain Fv (scFv), a chimeric antibody, a humanized antibody, or a fusion protein, wherein the antibody binds to CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha or KIR.

[0042] In one embodiment, the PD-1 (programmed death-1) is a checkpoint protein on T cells that acts as a type of “off switch” to keep the immune system in check. The PD-1 inhibitors can block this binding and boost the immune response against cancer cells.

[0043] In one embodiment, the programmed death-ligand 1 (PD-L1) is a checkpoint protein on T cells that acts as a type of “off switch” to help keep the immune system in check. The PD- L1 inhibitors can block this binding and boost the immune response against cancer cells.

[0044] In one embodiment, the programmed death-ligand 2 (PD-L2) is a checkpoint protein on T cells that acts as a type of “off switch” to help keep the immune system in check. The PD- L2 inhibitors can block this binding and boost the immune response against cancer cells.

[0045] In one embodiment, the Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) is a checkpoint protein on T cells that acts as a type of “off switch” to help keep the immune system in check. The CTLA-4 inhibitors attach to CTLA-4 and stop it from working, thus allowing the body’s immune response against cancer cells.

[0046] In one embodiment, the Lymphocyte-activation gene 3 (LAG-3) is a checkpoint protein on T cells that acts as a type of “off switch” to help keep the immune system in check. The LAG-3 inhibitors attach to CTLA-4 and stop it from working, thus allowing the body’s immune response against cancer cells.

[0047] In one embodiment, the B and T lymphocyte attenuator (BTLA inhibitors) is a co- inhibitory checkpoint molecule that is structurally related to PD-1. BTLA is highly expressed on tumour-specific T cells in cancer patients and is upregulated in several cancers.

[0048] In one embodiment, the B7 homolog 3 protein (B7H3, also known as CD276), B7H3 inhibits cytotoxic immune cells in the tumour microenvironment and contributes to tumour growth. The use of B7H3 inhibitors is useful in the treatment of cancers. In one embodiment, the B7H4 is expressed in high levels in numerous tumour tissues, particularly the B7H4 is expressed on tumour cells and tumor-associated macrophages. The B7H4 inhibitors favourably alter the tumour microenvironment allowing for antigen-specific clearance of tumour cells.

[0049] In one embodiment, the T-cell immunoglobulin and mucin domain 3 (TIM3 inhibitors) is a negative immune checkpoint. The TIM3 inhibitor inhibits treg function and myeloid- derived suppressor cell function, contributing to an improved immune response.

[0050] In one embodiment, the V-domain immunoglobulin (Ig) suppressor of T cell activation (VISTA) is a negative checkpoint regulator that mediates T cell proliferation and cytokine production. The blocking of VISTA signaling pathway plays a key role in the cancer immunotherapy.

[0051] In one embodiment, the T-cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibition motif domain (TIGIT) is an immune checkpoint inhibiting lymphocyte T cells by several mechanisms. Inhibition of TIGIT restores antitumor response.

[0052] In one embodiment, the killer immunoglobulin-like receptors (KIR) are an inhibitory receptor expressed by natural killer cells that suppress the immune response against tumour cells.

[0053] In one embodiment, the immune checkpoint inhibitor is a small molecule.

[0054] In one embodiment, the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, nivolumab, toripalimab, camrelizumab, tislelizumab, and sintilimab, atezolizumab, avelumab, durvalumab, adebrelimab, envafolimab, BMS-936559, ipilimumab, dostarlimab, serplulimab, penpulimab, zimberelimab, cadonilimab, sabatolimab, cobolimab, surzebiclimab, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab, evorpacept, KN-046, PSB-205, BCD-217, BA-3071, ADG-126, BMS-986213, KB035, CK-301, AUNP12, CA-170, BMS-986189, AZD-7789, RG-7769, GS-0189 or any derivatives thereof.

[0055] In one embodiment, the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, nivolumab, toripalimab, camrelizumab, tislelizumab, and sintilimab. In one embodiment, the immune checkpoint inhibitor is one or more selected from atezolizumab, avelumab durvalumab, adebrelimab, envafolimab, and BMS-936559.

[0056] In one embodiment, the immune checkpoint inhibitor is one or more selected from dostarlimab, serplulimab, tislelizumab, penpulimab, toripalimab, zimberelimab, camrelizumab, sintilimab, cadonilimab, sabatolimab, cobolimab, surzebiclimab, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab, and evorpacept.

[0057] In one embodiment, the immune checkpoint inhibitor is one or more selected from KN- 046, PSB-205, BCD-217, BA-3071, ADG- 126, BMS-986213, KB035, CK-301, AUNP12, CA- 170, BMS-986189, AZD-7789, RG-7769, GS-0189 or any derivatives thereof

[0058] In one embodiment, the immune checkpoint inhibitor is CA-170.

[0059] In one embodiment, the CA-170 is an oral, small molecule dual inhibitor of PDL1 and VISTA. The CA-170 provides the benefit of ease of dosing and the ability to manage immune- related adverse events (irAEs).

[0060] In one embodiment, the immune checkpoint inhibitor is administered at least once in one week to three weeks.

[0061] In one embodiment, the immune checkpoint inhibitor is administered 1 to 6 times weekly.

[0062] In one embodiment, the immune checkpoint inhibitor is administered 2 to 3 times weekly.

[0063] In one embodiment, the immune checkpoint inhibitor is administered 2 to 6 times weekly.

[0064] In one embodiment, the immune checkpoint inhibitor is administered once in every two weeks.

[0065] In one embodiment, the immune checkpoint inhibitor is administered once in every three weeks.

[0066] In one embodiment, the first anticancer agent is a hydrochloride salt of compound of formula (I).

[0067] In one embodiment, the compound of formula I or a pharmaceutically acceptable salt thereof is administered to a subject at a daily dose of 50 mg to 400 mg. In one embodiment, the compound of formula I or a pharmaceutically acceptable salt thereof is administered to a subject at a daily dose of 80 mg to 350 mg.

[0068] In one embodiment, the compound of formula I or a pharmaceutically acceptable salt thereof is administered to a subject at a daily dose of 90 mg to 300 mg.

[0069] In one embodiment, the subject is mammal.

[0070] In one embodiment, the subject is human.

[0071] In one embodiment, the compound of formula I or a pharmaceutically acceptable salt thereof is administered to mice at a daily dose of 10 mg / kg to 60 mg / kg.

[0072] In one embodiment, the immunomodulator is atezolizumab.

[0073] In one embodiment, the atezolizumab is administered at a dose of 840 mg every two weeks.

[0074] In one embodiment, the atezolizumab is administered at a dose of 1200 mg every three weeks.

[0075] In one embodiment, the immunomodulator is avelumab.

[0076] In one embodiment, the avelumab is administered at a dose of 800 mg every two weeks.

[0077] In one embodiment, the immunomodulator is durvalumab.

[0078] In one embodiment, the durvalumab is administered to an adult subject at a dose of 1500 mg.

[0079] In one embodiment, the durvalumab is administered once in two weeks or four weeks.

[0080] In one embodiment, the immunomodulator is pembrolizumab.

[0081] In one embodiment, the pembrolizumab is administered at a dose of 200 mg to 400 mg.

[0082] In one embodiment, the pembrolizumab is administered once in two weeks or four weeks.

[0083] In one embodiment, the immunomodulator is nivolumab.

[0084] In one embodiment, the nivolumab is administered at a dose of 240 mg to 480 mg.

[0085] In one embodiment, the nivolumab is administered once in two weeks or four weeks.

[0086] In one embodiment, the immunomodulator is cemiplimab. In one embodiment, the cemiplimab is administered at a dose of 350 mg for every three weeks.

[0087] In one embodiment, the cancer is bladder cancer, breast cancer, cervical cancer, colorectal cancer, cancer of the small intestine, colon cancer, rectal cancer, cancer of the anus, endometrial cancer, gastric cancer, head and neck cancer, laryngeal cancer, hypopharyngeal cancer, nasopharyngeal cancer, oropharyngeal cancer, lip cancer, mouth cancer, kidney cancer, liver cancer, hepatocellular carcinoma, cholangiocellular carcinoma, lung cancer, adenocarcinoma, small cell lung cancer, non-small cell lung cancer, parvicellular carcinoma, non-parvicellular carcinoma, bronchial carcinoma, bronchial adenoma, pleuropulmonary blastoma, ovarian cancer, prostate cancer, testicular cancer, uterine cancer, esophageal cancer, gall bladder cancer, pancreatic cancer, exocrine pancreatic carcinoma, stomach cancer, thyroid cancer, parathyroid cancer, skin cancer, squamous cell carcinoma, Kaposi sarcoma, Merkel cell skin cancer, brain cancer, astrocytoma, medulloblastoma, ependymoma, neuro- ectodermal tumors, pineal tumors, or any combination thereof.

[0088] In one embodiment, the cancer is hematopoietic malignancies selected from leukemia, lymphoma, multiple myeloma, chronic lymphocytic lymphoma, adult T cell leukemia, B-cell lymphoma, cutaneous T-cell lymphoma, acute myelogenous leukemia, Hodgkin's lymphoma, non-Hodgkin's lymphoma, myeloproliferative neoplasms, polycythemia vera, essential thrombocythemia, primary myelofibrosis, Waldenstrom's Macroglubulinemia, hairy cell lymphoma, chronic myelogenic lymphoma, acute lymphoblastic lymphoma, AIDS-related lymphomas, and Burkitt's lymphoma.

[0089] In one embodiment, the cancer is lung cancer, non-small cell lung cancer (NSCLC), gastric cancer, kidney cancer, liver cancer, bladder cancer, head cancer and neck cancer.

[0090] In one embodiment, the cancer is lung cancer.

[0091] In one embodiment, the cancer is non-small cell lung cancer (NSCLC).

[0092] In one embodiment, the cancer is gastric cancer.

[0093] In one embodiment, the cancer is kidney cancer.

[0094] In one embodiment, the cancer is liver cancer.

[0095] In one embodiment, the cancer is bladder cancer.

[0096] In one embodiment, the cancer is head and neck cancer. In another aspect, the present invention provides a kit comprising compound of formula I, an immunomodulator, and a package insert.

[0097] In one embodiment, the kit comprises compound of formula I, an immunomodulator, and a package insert instructions for using the compound of formula I and immunomodulator to treat or delay the progression of cancer in a subject.

[0098] In one embodiment, the kit comprises at least one dose of compound of formula I and at least one dose of immunomodulator.

[0099] In one embodiment, the kit comprises compound of formula I and immunomodulator for a week dose.

[0100] In one embodiment, the kit comprises 3 to 7 doses of compound of formula I and 1 to 3 doses of immunomodulator.

[0101] In one embodiment, the kit comprises 7 doses of compound of formula I and 1 dose of immunomodulator.

[0102] In one embodiment, the kit comprises 7 doses of compound of formula I and 2 doses of immunomodulator.

[0103] In one embodiment, the package insert comprises instructions for treating or delaying the progression of cancer in a subject by using the compound of formula I and an immunomodulator.

[0104] In one embodiment, the immunomodulator is an immune checkpoint inhibitor.

[0105] In one embodiment, the immune checkpoint inhibitor is an antibody or a small molecule targeting an immune checkpoint molecule.

[0106] In one embodiment, the immune checkpoint molecule is one or more selected from CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha and KIR.

[0107] In one embodiment, the immune checkpoint inhibitor is one or more selected from PD- 1 inhibitor and PD-L1 inhibitor.

[0108] In one embodiment, the immune checkpoint inhibitor is PD-1 inhibitor.

[0109] In one embodiment, the immune checkpoint inhibitor is PD-L1 inhibitor. In one embodiment, the antibody is selected from a polyclonal antibody, a monoclonal antibody, an antibody fragment, a single chain Fv (scFv), a chimeric antibody, a humanized antibody, or a fusion protein, wherein the antibody binds to CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha or KIR.

[0110] In one embodiment, the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, ipilimumab, nivolumab, toripalimab, camrelizumab, tislelizumab, sintilimab, atezolizumab, avelumab, durvalumab, adebrelimab, envafolimab, and BMS-936559.

[0111] In one embodiment, the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, nivolumab, toripalimab, camrelizumab, tislelizumab, and sintilimab.

[0112] In one embodiment, the immune checkpoint inhibitor is one or more selected from atezolizumab, avelumab, durvalumab, adebrelimab, envafolimab, and BMS-936559.

[0113] In one embodiment, the immune checkpoint inhibitor is one or more selected from dostarlimab, serplulimab, tislelizumab, penpulimab, toripalimab, zimberelimab, camrelizumab, sintilimab, cadonilimab, sabatolimab, cobolimab, surzebiclimab, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab, and evorpacept.

[0114] In one embodiment, the immune checkpoint inhibitor is one or more selected from KN- 046, PSB-205, BCD-217, BA-3071, ADG- 126, BMS-986213, KB035, CK-301, AUNP12, CA- 170, BMS-986189, AZD-7789, RG-7769, and GS-0189.

[0115] In another aspect, the present invention provides a combination comprising a first anticancer agent and at least a second anticancer agent for the treatment of cancer.

[0116] In one embodiment, the first anticancer agent is represented by a compound of formula or a pharmaceutically acceptable salt thereof.

[0117] In one embodiment, the second anti-cancer agent is an immunomodulator.

[0118] In one embodiment, the immunomodulator is an immune checkpoint inhibitor.

[0119] In one embodiment, the immune checkpoint inhibitor is an antibody or a small molecule targeting an immune checkpoint molecule.

[0120] In one embodiment, the immune checkpoint molecule is selected from an inhibitor targeting CTLA-4, PD1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha, or KIR or any combination thereof.

[0121] In one of preceding embodiments, the antibody comprises a polyclonal antibody, a monoclonal antibody, an antibody fragment, a single chain Fv (scFv), a chimeric antibody, a humanized antibody, or a fusion protein, each of which specifically binds to CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha, or KIR.

[0122] In any one of preceding embodiments, the immune checkpoint inhibitor is a small molecule.

[0123] In any one of preceding embodiments, the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, nivolumab, toripalimab, camrelizumab, tislelizumab, and sintilimab, atezolizumab, avelumab, durvalumab, adebrelimab, envafolimab, BMS-936559, ipilimumab, dostarlimab, serplulimab, penpulimab, zimberelimab, cadonilimab, sabatolimab, cobolimab, surzebiclimab, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab, evorpacept, KN-046, PSB-205, BCD-217, BA-3071, ADG-126, BMS-986213, KB035, CK-301, AUNP12, CA-170, BMS-986189, AZD-7789, RG-7769, GS- 0189.

[0124] In any one of preceding embodiments, the immune checkpoint inhibitor is selected from KN-046, PSB-205, BCD-217, BA-3071, ADG-126, dostarlimab, BMS-986213, serplulimab, tislelizumab, penpulimab, toripalimab, zimberelimab, camrelizumab, pembrolizumab, sintilimab, cemiplimab cadonilimab, ipilimumab, atezolizumab, avelumab, durvalumab, nivolumab, KB035, CK-301, AUNP12, CA-170, BMS-986189, sabatolimab, cobolimab, surzebiclimab, AZD-7789, RG-7769, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab , evorpacept, GS-0189 or any derivatives thereof. In one of preceding embodiments, the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, nivolumab, toripalimab, camrelizumab, tislelizumab, and sintilimab.

[0125] In any one of preceding embodiments, the immune checkpoint inhibitor is one or more selected from atezolizumab, avelumab durvalumab, adebrelimab, envafolimab, and BMS- 936559.

[0126] In any one of preceding embodiments, the first anticancer agent is a hydrochloride salt of compound of formula (I).

[0127] As used herein the terms “subject” and “patient” may be used interchangeably, and mean a mammal in need of treatment, e.g., companion animals (e.g., dogs, cats, and the like), farm animals (e.g., cows, pigs, horses, sheep, goats and the like) and laboratory animals (e.g., rats, mice, guinea pigs and the like). Typically, the subject is a human in need of treatment.

[0128] An “effective amount” of the compound of formula (I), or a pharmaceutically acceptable salt, is an amount sufficient to provide a therapeutic benefit in the treatment of a cancer or to delay or minimize one or more symptoms associated with the condition when combined with a second anti-cancer agent, such as an immunomodulators. An “effective amount” of the second anti -cancer agent, as described herein, is an amount sufficient to provide a therapeutic benefit in the treatment of a condition or to delay or minimize one or more symptoms associated with the condition when combined with the compound of formula (I), or a pharmaceutically acceptable salt thereof. The terms “therapeutically effective amount” and “effective amount” are used interchangeably. The term “effective amount” can encompass an amount that improves overall therapy, reduces, or avoids symptoms, signs, or causes of the condition, and / or enhances the therapeutic efficacy of another therapeutic agent. In certain embodiments, an effective amount is an amount sufficient for eliciting therapeutic effects in the treatment of a cancer (including solid tumors and hematological cancers as further described herein).

[0129] The precise amount of the compound of formula (I) (or pharmaceutically acceptable salt thereof), or immune checkpoint inhibitors administered to a subject will depend on various factors, such as the given drug, the pharmaceutical formulation, the route of administration, the type of disease or disorder, the identity of the subject being treated, and the like, but can nevertheless be routinely determined by one skilled in the art. For example, determination of an effective amount will also depend on the degree, severity, and type of cell proliferation. The skilled artisan will be able to determine appropriate dosages depending on these and other factors. When co-administered with other therapeutic agents, e.g., when co-administered with an anti-cancer agent, an “effective amount” of any additional therapeutic agent(s) will depend on the type of drug used. Suitable dosages are known for approved therapeutic agents and can be adjusted by the skilled artisan according to the condition of the subject, the type of condition(s) being treated and the amount of the compound of formula (I) or pharmaceutically acceptable salt thereof. In cases where no amount is expressly noted, an effective amount should be assumed. Non-limiting examples of an effective amount of the compound of formula (I) or pharmaceutically acceptable salt thereof are provided herein below.

[0130] An effective amount of the compound of formula (I), a pharmaceutically acceptable salt thereof, or a second anti -cancer agent is generally in the range from 0.1 pg to 100 mg / kg of body weight of the recipient (mammal) per day and particularly typically in the range from 1 to 10 mg / kg of body weight per day. Thus, the actual amount per day for an adult mammal weighing 70 kg is usually between 70 and 700 mg, where this amount can be administered as an individual dose per day or usually in a series of part-doses (such as, for example, two, three, four, five or six) per day, so that the total daily dose is the same. The effective dose of the compound of formula (I) or pharmaceutically acceptable salt thereof to a subject can be 10 pg -500 mg. Effective amounts of immunomodulators are known to those skilled in the art.

[0131] The term “co administering” as used herein with respect to the at least one second anti-cancer agent means that the at least one second anti-cancer agent may be administered together with Compound 1, or a pharmaceutically acceptable salt thereof, as part of a single dosage form (such as a composition comprising Compound 1, or a pharmaceutically acceptable salt thereof, and the at least one second anti -cancer agent) or as separate, multiple dosage forms. Alternatively, the at least one second anti-cancer agent may be administered prior to, consecutively with, or following the administration of Compound 1, or a pharmaceutically acceptable salt thereof. In such combination therapy treatment, both Compound 1, or a pharmaceutically acceptable salt thereof, and the at least one second anti-cancer agent are administered by conventional methods. The administration of a composition comprising both Compound 1, or a pharmaceutically acceptable salt thereof, and the at least one second anti- cancer agent, to a subject does not preclude the separate administration of that same therapeutic agent, any other second therapeutic agent or any compound provided herein to said subject at another time during a course of treatment. The term “co administering” as used herein with respect to an additional cancer treatment means that the additional cancer treatment may occur prior to, consecutively with, concurrently with or following the administration of a compound provided herein. The term “treat” means decrease, suppress, attenuate, diminish, arrest, or stabilize the development or progression of a disease / disorder (e.g., cancer) or lessen the severity of the disease / disorder or improve the symptoms associated with the disease / disorder. Treatment may also be continued after symptoms have resolved, for example to reduce the likelihood of or delay their recurrence.

[0132] Positive therapeutic effects in cancer can be measured in a number of ways. The administration of a therapeutically effective amount of the combinations herein described are advantageous over the individual component compounds. As used herein "advantageous combinations" are those combinations that provide at least one of the following improved properties when compared to the individual administration of a therapeutically effective amount of a component compound: i) a greater anticancer effect than the most active single agent, alone; ii) synergistic anticancer effect; or iii) additive activity.

[0133] The synthetic procedures for the preparation of Compound 1, described in the present invention, were disclosed in international publication No. WO 2013 / 053983 dated 18thApril 2013. The contents of this publication are hereby incorporated by reference in their entirety.

[0134] Experiments

[0135] Experiment 1: Antitumor efficacy on MC38 and CT26 syngeneic models

[0136] The antitumor efficacy of Compound 1, when administered individually and in combination with anti -mouse PD1 antibody was evaluated in two syngeneic colorectal carcinoma models, MC38 and CT26.

[0137] MC38 model: 6-8 week old female C57BL / 6 mice were injected with 0.5 million MC38 cells subcutaneously in the right flank. Once the tumors became palpable, the animals with an average tumour volume of ~40 mm3were randomized into 6 treatment groups of 10 animals each, as outlined below.

[0138] Gl: Vehicle control,

[0139] G2: Compound 1, 20 mg / kg,

[0140] G3: Compound 1, 40 mg / kg,

[0141] G4: Anti-mouse PD-1 antibody, 200 pg / animal, twice weekly

[0142] G5: Compound 1, 20 mg / kg + anti-mouse PD-1 antibody, 200 pg / animal, twice weekly, and G6: Compound 1, 40 mg / kg + anti-mouse PD-1 antibody, 200 pg / animal, twice weekly

[0143] The Compound 1 was formulated using 5 parts of (Dimethylacetamide) DMA + 50 parts of PEG200 + 10 parts of Tween 80 + 35 parts of 5% Dextrose water and dosed per orally on a once daily dosing. The anti-mouse PD1 antibody (RMP1-14) (BioXcell) was dosed at the indicated dose for the respective group via intraperitoneal route on a twice weekly schedule. Compound 1 was administered at a dose volume of 10 mL / kg based on the most recent body weight measurement recorded prior to dose administration on a daily basis. The study animals were monitored for clinical signs and / or mortality once every day throughout the study period (14 days). The tumour volumes in the animals were recorded thrice a week using calibrated digital vernier calipers in two perpendicular planes and the tumour volume was calculated using the formula:

[0144] Tumour volume (TV) = (D X d2) / 2 wherein,

[0145] D represents “largest tumour diameter (mm)”; d represents “smallest tumour diameter (mm)”.

[0146] As a measure of efficacy, the % T / C and % TGI (% Tumour growth inhibition) values were calculated.

[0147] Changes in tumour volume (A volumes) for each treated (T) and control (C) group were calculated by subtracting the mean tumour volume on the first day of treatment (starting day) from the mean tumour volume on the specified observation day. These values were used to calculate a percentage growth (% T / C) using the below formula:

[0148] % T / C = (AT / AC) X 100 where AT > 0 or

[0149] % T / C = (AT / Ti) X 100 where AT < 0, Ti is the mean tumour volume at the start of the experiment.

[0150] Percentage tumour growth inhibition (% TGI) was then be calculated using the below formula:

[0151] % TGI = 100 - % T / C

[0152] Where applicable, results are presented as mean ± SEM.

[0153] After 14 days, the tumour volume data was evaluated for all the groups using One-way ANOVA with Dunnett’s and / or Tukey’s multiple comparison test. The statistical analysis was performed using GraphPad Prism®, Version 8 or above. All analyses and comparisons were evaluated at the 5% (p<0.05) level. The results are provided below in Table-1.

[0154] Table - 1: Tumour Growth Inhibition (TGI) studies in MC38 model

[0155] It is observed that all treatment regimens (compound 1 alone, anti-mouse PD1 antibody alone and combination therapies) were well tolerated without any significant treatment related clinical signs and / or body weight loss. In terms of antitumor efficacy, treatment with Compound 1 resulted in dose dependent efficacy in MC38 model. Further, Compound 1 in combination with anti -mouse PD1 antibody, exhibited enhanced antitumor efficacy over the monotherapies. The Compound 1 at a dose of 40 mg / kg when combined with anti -mouse PD1 antibody resulted in tumour growth inhibition value of more than 90%, illustrated in FIG. 1A and FIG. IB

[0156] CT26 model: 6-8 week old female Balb / c mice were injected with 1 million CT26 cells subcutaneously in the right flank. Once the tumors became palpable, the animals with an average tumour volume of ~40 mm3were randomized into 6 treatment groups of 10 animals each as outlined below.

[0157] Gl: Vehicle control,

[0158] G2: Compound 1, 20 mg / kg,

[0159] G3: Compound 1, 40 mg / kg,

[0160] G4: Anti-mouse PD-1 antibody, 200 pg / animal, thrice weekly

[0161] G5: Compound 1 20 mg / kg + anti-mouse PD-1 antibody, 200 pg / animal, thrice weekly, and G6: Compound 1, 40 mg / kg + anti-mouse PD-1 antibody, 200 pg / animal, thrice weekly

[0162] Compound 1 was formulated using 5 parts of DMA + 50 parts of PEG200 + 10 parts of Tween 80 + 35 parts of 5% Dextrose water and dosed per orally on a once daily dosing. The anti -mouse PD1 antibody (RMP1-14) (BioXcell) was dosed at the indicated dose via intraperitoneal route on a thrice weekly schedule. Compound 1 was administered at a dose volume of 10 mL / kg based on the most recent body weight measurement recorded prior to dose administration on a daily basis. The study animals were monitored for clinical signs and / or mortality once every day throughout the study period (14 days). The tumour volumes in the animals were recorded thrice a week using calibrated digital vernier calipers in two perpendicular planes and the tumour volume was calculated as described earlier. The results are provided below in Table-2.

[0163] Table - 2: Tumour Growth Inhibition (TGI) studies in CT26 model

[0164] All treatments (compound 1 alone, anti -mouse PD1 antibody alone and combination therapies) were well tolerated without any significant treatment related clinical signs and / or body weight loss. In terms of anti-tumor efficacy, treatment with Compound 1 resulted in dose dependent efficacy in MC38 model. Further, Compound 1 in combination with anti -mouse PD1 antibody exhibited enhanced antitumor efficacy over the monotherapies was observed. Compound 1 (40 mg / kg) when administered in combination with anti -mouse PD-1 antibody resulted in tumour growth inhibition of 96%, which resulted in significant tumor growth inhibition in comparison to monotherapies, illustrated in FIG. 2A and FIG. 2B.

[0165] Experiment 2: Antitumor efficacy on CT26 colon carcinoma model

[0166] 6 week old female Balb / c mice were injected with 1 million CT26 cells subcutaneously in the right flank region.

[0167] The mice were randomized into 5 treatment groups of 10 animals each, based on the tumor volume and dosing was initiated when the mean tumor volumes were ~47 mm3. The treatment groups are outlined below.

[0168] Gl: Vehicle control,

[0169] G2: Compound 1, 20 mg / kg,

[0170] G3: Compound 1, 40 mg / kg,

[0171] G4: Anti-mouse PD-1 antibody, 200 pg / animal, thrice weekly, and

[0172] G5: Compound 1, 40 mg / kg + anti-mouse PD-1 antibody, 200 pg / animal, thrice weekly The Compound 1 was formulated using 5 parts of (Dimethylacetamide) DMA + 50 parts of PEG200 + 10 parts of Tween 80 + 35 parts of 5% Dextrose water and dosed per orally on a once daily dosing. The anti -mouse PD1 antibody was dosed at the indicated dose for the respective group via intraperitoneal route on a thrice weekly schedule.

[0173] The animals were monitored daily for body weight loss and clinical signs of toxicity while the tumor volumes were measured twice weekly. Compound 1 was well tolerated at 20 mg / kg and 40 mg / kg once-daily dosing when administered alone and in combination with antimouse PD-1 antibody (FIG. 3A). Further, the treatment with Compound 1 demonstrated dose dependent anti-tumor efficacy with %TGI values of 33% and 69% when administered at a dose of 20 mg / kg and 40 mg / kg, respectively. Compound 1 (40 mg / kg) in combination with antimouse PD-1 antibody (200 pg / mice, thrice weekly) resulted in significant improvement in antitumor efficacy with a %TGI of 97% (FIG. 3B). Furthermore, in the combination treatment group 3 out of 10 animals were completely free of measurable tumors. The results are provided below in Table-3.

[0174] Table - 3: % Tumour growth inhibition by Compound 1 in CT-26 tumour model

[0175] The tumour-free animals were monitored without treatment for a period of 30 days to assess the tumour regrowth. At the end of 30 days, these tumour-free animals were rechallenged with CT26 tumour cells along with inoculation of tumour cells into age-matched naive female Balb / c mice. These animals were monitored for tumour growth. The tumour volumes in naive animals grew rapidly to reach a mean tumour volume of 1087 mm3in 21 days post challenge (FIG. 4). However, CT26 tumour growth was not observed in animals treated with combination of Compound 1 and PD-1 antibody indicating a significant immunological memory response. These animals were further observed for the amount of T cells, activated T cells, and effector memory of both CD4+ and CD8+ T cell populations. It was observed that the total T cell population to be significantly higher in spleen (FIG. 5A) and lymph nodes (FIG. 5B) of the animals treated with combination of Compound 1 and anti-PD-1 antibody as compared to the naive animals. Furthermore, increased activation of the T cell population (CD3+IFNY+) (FIG. 5C) was observed in the spleen of the combination treatment group, indicating a rapid immune response in these animals. The effector memory (CD44+CD62L+) of both CD4+ and CD8+ T cell populations, that rapidly acquire effector function on the cancer cells, was observed to be significantly higher in both spleen and lymph nodes of the combination group (FIG. 5D-5F) than the naive ones. The elevated immunological effector and memory response in the treatment group would be the indication for the hindrance of the tumour growth in these animals. Thus, the combination establishes that it not only inhibits the tumor growth progression, but the immune system also effectively inhibits future attacks.

[0176] Experiment 3: Antitumor efficacy in MC38 model (murine colon carcinoma cells)

[0177] 7 week old female C57BL / 6 mice were injected with 1 million MC38 cells on the right flank region expressing human PD-L1 (Biocytogen). The mice were randomized into 4 treatment groups of 10 animals each, based on the tumor volume and dosing was initiated when the mean tumor volumes were ~57 mm3. The treatment groups are outlined below.

[0178] Gl: Vehicle control,

[0179] G2: Compound 1, 40 mg / kg,

[0180] G3: Anti-mouse PD-1 antibody, 200 pg / animal, twice weekly, and

[0181] G4: Compound 1, 40 mg / kg + anti-mouse PD-1 antibody, 200 pg / animal, twice weekly.

[0182] The Compound 1 was formulated using 5 parts of (Dimethylacetamide) DMA + 50 parts of PEG200 + 10 parts of Tween 80 + 35 parts of 5% Dextrose water and dosed per orally on a once daily dosing. The anti -mouse PD1 antibody was dosed at the indicated dose for the respective group via intraperitoneal route on a thrice weekly schedule.

[0183] The animals were monitored daily for body weight loss and clinical signs of toxicity while the tumor volumes were measured twice weekly. All treatments were well tolerated with no evidence of treatment related adverse events or body weight loss (FIG. 6A). Compound 1 as a monotherapy exhibited significant antitumor efficacy with a TGI of 87%. The results are provided below in Table-4. Table 4: % Tumor growth inhibition by Compound 1 in MC-38 model expressing hPD- L1

[0184] Brown-Forsythe & Welch ANOVA tests: - **** _p < 0.0001 compared to vehicle controls.

[0185] It is evident from the above results that Compound 1, in combination with anti PD-1 antibody, exhibits a synergistic antitumor efficacy resulting in complete tumor regression and all the animals free of measurable tumors (FIG. 6B).

[0186] Incorporation by Reference

[0187] All publications and patents mentioned herein are hereby incorporated by reference in their entirety as if each individual publication or patent were specifically and individually indicated to be incorporated by reference. In case of conflict, the present application, including any definitions herein, will control.

[0188] Equivalents

[0189] While specific embodiments of the subject invention have been discussed, the above specification is illustrative and not restrictive. Many variations of the invention will become apparent to those skilled in the art upon review of this specification and the claims below. The full scope of the invention should be determined by reference to the claims, along with their full scope of equivalents and the specification, along with such variations.

Claims

Claims:

1. A method for treating cancer in a subj ect, comprising administering to a subj ect an effective amount of a first anti-cancer agent and an effective amount of at least a second anti -cancer agent, wherein the first anti-cancer agent is represented by formula (I):or a pharmaceutically acceptable salt thereof; and wherein the second anti-cancer agent is an immunomodulator.

2. The method of claim 1, wherein the immunomodulator is an immune checkpoint inhibitor.

3. The method of claim 1, wherein the immune checkpoint inhibitor is an antibody or a small molecule targeting an immune checkpoint molecule.

4. The method of claim 3, wherein the immune checkpoint molecule is one or more selected from CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha and KIR.

5. The method of claim 3, wherein the immune checkpoint inhibitor is one or more selected from PD-1 inhibitor and PD-L1 inhibitor.

6. The method of claim 3, wherein the immune checkpoint inhibitor is PD-1 inhibitor.

7. The method of claim 3, wherein the immune checkpoint inhibitor is PD-L1 inhibitor.

8. The method of claim 3, wherein the antibody is selected from a polyclonal antibody, a monoclonal antibody, an antibody fragment, a single chain Fv (scFv), a chimeric antibody, a humanized antibody, or a fusion protein, wherein the antibody binds to CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha or KIR.

9. The method of claim 3, wherein the immune checkpoint inhibitor is a small molecule.

10. The method of any one of claims 2 to 9, wherein the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, nivolumab, toripalimab, camrelizumab, tislelizumab, and sintilimab.

11. The method of any one of claims 2 to 9, wherein the immune checkpoint inhibitor is one or more selected from atezolizumab, avelumab, durvalumab, adebrelimab, envafolimab, and BMS-936559.

12. The method of any one of claims 2 to 9, wherein the immune checkpoint inhibitor is one or more selected from ipilimumab, dostarlimab, serplulimab, penpulimab, zimberelimab, cadonilimab, sabatolimab, cobolimab, surzebiclimab, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab, and evorpacept.

13. The method of any one of claims 2 to 9, wherein the immune checkpoint inhibitor is one or more selected from KN-046, PSB-205, BCD-217, BA-3071, ADG-126, BMS-986213, KB035, CK-301, AUNP12, CA-170, BMS-986189, AZD-7789, RG-7769, GS-0189 or any derivatives thereof.

14. The method of any one of claims 2 to 9, wherein the immune checkpoint inhibitor is CA- 170.

15. The method of claim 1, wherein the first anticancer agent is a hydrochloride salt of compound of formula (I).

16. The method of claim 1, wherein the cancer is bladder cancer, breast cancer, cervical cancer, colorectal cancer, cancer of the small intestine, colon cancer, rectal cancer, cancer of the anus, endometrial cancer, gastric cancer, head and neck cancer, cancers of the laryngeal cancer, hypopharyngeal cancer, nasopharyngeal cancer, oropharyngeal cancer, lip cancer, mouth cancer, kidney cancer, liver cancer, hepatocellular carcinoma, cholangiocellular carcinoma, lung cancer, adenocarcinoma, small cell lung cancer, non-small cell lung cancer, parvicellular carcinoma, non-parvicellular carcinoma, bronchial carcinoma, bronchial adenoma, pleuropulmonary blastoma, ovarian cancer, prostate cancer, testicular cancer, uterine cancer, esophageal cancer, gall bladder cancer, pancreatic cancer, exocrine pancreatic carcinoma, stomach cancer, thyroid cancer, parathyroid cancer, skin cancer, squamous cell carcinoma, Kaposi sarcoma, Merkel cell skin cancer, brain cancer, astrocytoma, medulloblastoma, ependymoma, neuro- ectodermal tumors, pineal tumors, or any combination thereof.

17. The method of claim 1, wherein the cancer is hematopoietic malignancies selected from leukemia, lymphoma, multiple myeloma, chronic lymphocytic lymphoma, adult T cell leukemia, B-cell lymphoma, cutaneous T-cell lymphoma, acute myelogenous leukemia, Hodgkin's lymphoma, non- Hodgkin's, myeloproliferative neoplasms, polycythemia vera, essential thrombocythemia, primary myelofibrosis, Waldenstrom’s macroglubulinemia, hairy cell lymphoma, chronic myelogenic lymphoma, acute lymphoblastic lymphoma, AIDS-related lymphomas, and Burkitt's lymphoma.

18. A kit comprising compound of formula I, an immunomodulator, and a package insert comprising instructions for using the compound of formula I and immunomodulator to treat or delay the progression of cancer in a subject.

19. A kit of claim 18, wherein the kit comprises at least one dose of compound of formula I and at least one dose of immunomodulator.

20. A kit of claim 18, wherein the package insert comprises instructions for treating or delaying the progression of cancer in a subject by using the compound of formula I and an immunomodulator.

21. A kit of claim 18, wherein the immunomodulator is an immune checkpoint inhibitor.

22. A kit of claim 18, wherein the immune checkpoint inhibitor is an antibody or a small molecule targeting an immune checkpoint molecule.

23. The kit of claim 21, wherein the immune checkpoint molecule is one or more selected from CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha and KIR.

24. The kit of claim 21, wherein the immune checkpoint inhibitor is one or more selected from PD-1 inhibitor and PD-L1 inhibitor.

25. The kit of claim 22, wherein the antibody is selected from a polyclonal antibody, a monoclonal antibody, an antibody fragment, a single chain Fv (scFv), a chimeric antibody, a humanized antibody, or a fusion protein, wherein the antibody binds to CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha or KIR.

26. The kit of claim 21, wherein the immune checkpoint inhibitor is one or more selected from pembrolizumab, cemiplimab, nivolumab, atezolizumab, avelumab durvalumab,toripalimab, camrelizumab, tislelizumab, sintilimab, adebrelimab, envafolimab, and BMS- 936559.

27. The kit of any one of claim 18, wherein the immune checkpoint inhibitor is one or more selected from ipilimumab, dostarlimab, serplulimab, penpulimab, toripalimab, zimberelimab, camrelizumab, sintilimab, cadonilimab, sabatolimab, cobolimab, surzebiclimab, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab, evorpacept, KN-046, PSB-205, BCD-217, BA-3071, ADG-126, BMS-986213, KB035, CK-301, AUNP12, CA-170, BMS-986189, AZD-7789, RG-7769, and GS-0189 or any derivatives thereof.

28. A combination comprising a first anticancer agent and at least a second anticancer agent: wherein the first anticancer agent is represented by a compound of formula (I):or a pharmaceutically acceptable salt thereof; and wherein the second anti-cancer agent is an immunomodulator.

29. The combination of claim 28, wherein the immunomodulator is an immune checkpoint inhibitor.

30. The combination of claim 29, wherein the immune checkpoint inhibitor is an antibody or a small molecule targeting an immune checkpoint molecule.

31. The combination of claim 30, wherein the immune checkpoint molecule is one or more selected from CTLA-4, PD1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, KIR, VISTA, TIGIT, CD47 and SIRP-alpha.

32. The combination of claim 30, wherein the antibody is selected from a polyclonal antibody, a monoclonal antibody, an antibody fragment, a single chain Fv (ScFv), a chimeric antibody, a humanized antibody, or a fusion protein, wherein the antibody binds to CTLA-4, PD-1, PD-L1, PD-L2, LAG-3, BTLA, B7H3, B7H4, TIM3, VISTA, TIGIT, CD47, SIRP-alpha, or KIR.

33. The combination of claim 28, wherein the immune checkpoint inhibitor is a small molecule.

34. The combination of any one of claims 29 to 33, wherein the immune checkpoint inhibitor is one or more selected from KN-046, PSB-205, BCD-217, BA-3071, ADG-126, dostarlimab, BMS-986213, serplulimab, tislelizumab, penpulimab, toripalimab, zimberelimab, camrelizumab, pembrolizumab, sintilimab, cemiplimab cadonilimab, ipilimumab, atezolizumab, avelumab, durvalumab, nivolumab, KB035, CK-301, AUNP12, CA-170, BMS-986189, sabatolimab, cobolimab, surzebiclimab, AZD-7789, RG-7769, ociperlimab, tiragolumab, vibostolimab, domvanalimab, magrolimab, evorpacept, GS- 0189 or any derivatives thereof.

35. The combination of claim 28, wherein the first anti cancer agent is a hydrochloride salt of compound of formula (I).

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