Use of ecubectedin in the treatment of cancers including combination therapy with atezolizumab

Abstract

The present invention relates to therapeutic treatment of cancer, particularly mesothelioma, using ecubectedin (PM14) as single agent or in combination therapy using ecubectedin and atezolizumab.

Description

[0001] TITLE Use of ecubectedin in the treatment of cancers including combination therapy with atezolizumab FIELD OF THE INVENTION The present invention relates to therapeutic treatment of cancer, particularly mesothelioma, using ecubectedin (PM14) as single agent or in combination therapy using ecubectedin and atezolizumab. BACKGROUND TO THE INVENTION Malignant pleural mesothelioma (MPM), an aggressive tumor of the pleural surface, mainly associates with asbestos exposure. Most case detections occur at advanced stages due to its long latency period -frequently longer than 30 years- and challenging diagnosis. MPM is classified in three histotypes: epithelioid carcinoma (50 to 60% of cases), associated with a favourable prognosis; sarcomatoid carcinoma (10% of cases), drug-resistant and associated with a worse prognosis, and biphasic carcinoma (30 to 40% of cases) in which, variable proportion of the tumor presents one of the other two histotypes. Regardless of these histotypes, current available treatments are limited and have mild clinical benefit, which offer overall survival (OS) rates between 12 to 36 months. First-line (1L) standard treatment is platinum-based combined with pemetrexed chemotherapy, with or without bevacizumab. MPM microenvironment is highly infiltrated by immunosuppressive cells which justifies the exploratory evaluation of treatments based on the immune checkpoint inhibitors (ICI). In the past, it was demonstrated improved OS in patients treated with the combination of anti-PD-1 with anti- CTLA-4 compared to standard 1L chemotherapy. However, and despite efforts made with different therapeutic approaches, a second-line (2L) therapy has not yet been approved. The wide genomic heterogeneity present in MPM may help explain the lack of an effective targeted therapy. Most frequent mutations in MPM, i.e., BAP1, CDKN2A, NF2, TP53 and SETD2, are tumor suppressor inactivating genes. Mutations in BAP1 tend to accelerate asbestos-induced MPM in mice and have been associated with multi-cancer-related syndromes. Thus, deubiquitinase-related tumor suppression may be potentially relevant as a promising DNA- interacting agent-based therapy for MPM. Ecteinascidins are exceedingly potent antitumor agents isolated from the marine tunicate Ecteinascidia turbinata. WO2018 / 197663 describes synthetic ecteinascidin compounds including ecubectedin (PM14) which is described as compound 4-S with the following formula: Ecubectedin (PM14) was shown in WO2018 / 197663 and WO2022 / 2434482 and demonstrated in vitro activity against lung cancer, colorectal adenocarcinoma, gastric cancer, breast adenocarcinoma, pancreas adenocarcinoma, prostate adenocarcinoma, prostate carcinoma cell lines, melanoma, renal cancer and in vivo activity in fibrosarcoma, breast adenocarcinoma, NSCLC, ovarian carcinoma, gastric carcinoma, small cell lung cancer (SCLC), prostatic adenocarcinoma, and prostatic carcinoma xenograft models. Despite the positive results obtained in clinical applications in chemotherapy, there is a need for further effective cancer therapies. SUMMARY OF THE INVENTION In a first aspect, the invention provides ecubectedin, which is a compound of formula I, for use in the treatment of malignant mesothelioma. In an embodiment, ecubectedin, is not administered in combination with a topoisomerase I inhibitor. In an embodiment, ecubectedin, is administered as a monotherapy. In an embodiment, the malignant mesothelioma is malignant pleural mesothelioma. In another embodiment, the malignant mesothelioma is malignant peritoneal mesothelioma. In a preferred embodiment, the malignant mesothelioma is epithelioid mesothelioma. In another preferred embodiment, the malignant mesothelioma is sarcomatoid mesothelioma. In a further preferred embodiment, the malignant mesothelioma is biphasic mesothelioma. In another embodiment, the malignant mesothelioma is progressive. In another embodiment, the malignant mesothelioma has progressed from first-line therapy, preferably standard first-line therapy. In a preferred embodiment, the first-line therapy also includes radiotherapy. In another embodiment, ecubectedin is administered once every one to four weeks, preferably once every three weeks. In another embodiment, ecubectedin is administered at a dose of 2 to 7 mg / m2body surface area, 2.5 to 5 mg / m2body surface area, about 3.6 mg / m2body surface area. In a preferred embodiment, ecubectedin is administered to a patient in need thereof at a dose of 4.5 mg / m2. In an embodiment, ecubectedin is administered as an infusion, preferably with an infusion time of up to 24 hours, 1 to 12 hours, 1 to 6 hours and most preferably 3 hours. In a further embodiment, the patient is additionally treated with radiotherapy. In a preferred embodiment, the radiotherapy is administered prior to or subsequent to administration of ecubectedin, preferably at least an hour, three hours, five hours, 12 hours, a day, a week, a month, more preferably several months (e.g. up to three months) prior or subsequent to administration of ecubectedin. In a further aspect, the invention provides a pharmaceutical package comprising ecubectedin, together with instructions for treating malignant mesothelioma as defined herein. In a further aspect, the invention provides ecubectedin which is a compound of formula I, for use in the treatment of malignant mesothelioma, wherein in said treatment ecubectedin is administered in combination with atezolizumab to a patient in need thereof. In an embodiment, the malignant mesothelioma is malignant pleural mesothelioma. In another embodiment, the malignant mesothelioma is malignant peritoneal mesothelioma. In a preferred embodiment, the malignant mesothelioma is epithelioid mesothelioma. In another preferred embodiment, the malignant mesothelioma is sarcomatoid mesothelioma. In a further preferred embodiment, the malignant mesothelioma is biphasic mesothelioma. In another embodiment, the malignant mesothelioma is progressive. In another embodiment, ecubectedin and atezolizumab are administered sequentially in said treatment. In another embodiment, atezolizumab is administered initially, followed by ecubectedin. In another embodiment, the administration cycle in combination with atezolizumab is once every three to four weeks, preferably once every 21 days. In a preferred embodiment, ecubectedin is administered in combination withatezolizumab on day 1 of a cycle in said treatment. In another preferred embodiment, ecubectedin is administered in combination with atezolizumab on day 1 and administered alone on day 8 of a cycle. In a further embodiment, ecubectedin is administered at least 2 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. In a further embodiment, ecubectedin is administered over 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. In a preferred embodiment, ecubectedin is administered as 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. In a further embodiment, atezolizumab is administered at least 1 hour intravenous infusion during each administration cycle allowing -5 minutes to +30 minutes. In another embodiment, said treatment further comprises administration of a prophylactic compound before the administration of ecubectedin in combination with atezolizumab. In a preferred embodiment, said prophylactic compound is selected from corticosteroid and 5-HT3 receptor antagonist. In another embodiment, said treatment further comprises administration of granulocyte-colony stimulating factor (G-CSF). In another embodiment, atezolizumab is administered as at least 1 hour intravenous infusion followed by ecubectedin which is administered as 3 hours intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. In a further embodiment, ecubectedin is administered at a dose from 2.5 to 5 mg / m2and atezolizumab is administered at a dose of 1200 mg in said treatment. In another embodiment, ecubectedin is administered at a dose from 3 to 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg in said treatment. In a preferred embodiment, ecubectedin is administered at a dose of 3.6 mg / m2and atezolizumab is administered at a dose of 1200 mg in said treatment. In a more preferred embodiment, ecubectedin is administered at a dose of 4.5 mg / m2and is atezolizumab is administered at a dose of 1200 mg. In another embodiment, atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as 3 hours intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. A further aspect of the invention provides a pharmaceutical package comprising ecubectedin, together with instructions for treating malignant mesothelioma in combination with atezolizumab, as defined herein. A further aspect of the invention provides ecubectedin, which is a compound of formula I , for use in the treatment of cancer, wherein in said treatment ecubectedin is administered in combination with atezolizumab to a patient in need thereof, as defined herein. In an embodiment, the cancer is a solid tumor. In a preferred embodiment, the solid tumor is selected from neuroendocrine tumor, gastrointestinal cancer, lung cancer, sarcoma, gynaecological cancer, breast cancer, malignant pleural mesothelioma, extrapulmonary small cell carcinoma, adrenocortical carcinoma, adenoid cystic carcinoma, skin cancer, genitourinary tract tumors, microsatellite instability (MSI) solid tumors, head and neck squamous cell carcinoma. In another preferred embodiment, the solid tumor is selected from melanoma, Merkel cell carcinoma, urothelial bladder carcinoma, clear cell renal carcinoma, prostate adenocarcinoma, esophageal carcinoma, gastric adenocarcinoma, hepatocarcinoma, non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), epithelial ovarian carcinoma (including primary peritoneal disease and / or fallopian tube carcinomas and / or endometrial adenocarcinomas), endometrial carcinoma, carcinoma of cervix, triple negative breast cancer, liposarcoma, leiomyosarcoma, synovial sarcoma and Ewing sarcoma. In a further preferred embodiment, the solid tumor is non-small cell lung cancer. In a further preferred embodiment, the solid tumor is squamous non-small cell lung cancer. In a further preferred embodiment, the solid tumor is small cell lung cancer. In a further preferred embodiment, the solid tumor is gastric cancer. In a further preferred embodiment, the solid tumor is melanoma. In a more preferred embodiment, the solid tumor is malignant mesothelioma. In another preferred embodiment, the malignant mesothelioma is malignant pleural mesothelioma. In another preferred embodiment, the malignant mesothelioma is malignant peritoneal mesothelioma. In another preferred embodiment, malignant mesothelioma is epithelioid mesothelioma. In another preferred embodiment, wherein the malignant mesothelioma is sarcomatoid mesothelioma. In another preferred embodiment, the malignant mesothelioma is biphasic mesothelioma. In another embodiment, the malignant mesothelioma is progressive. In a further embodiment, ecubectedin and atezolizumab are administered sequentially. In a preferred embodiment, atezolizumab is administered initially, followed by ecubectedin. In another embodiment, the administration cycle in combination with atezolizumab is once every three to four weeks, preferably once every 21 days. In a preferred embodiment, ecubectedin is administered in combination with atezolizumab on day 1 of a cycle in said treatment. In another preferred embodiment, ecubectedin is administered in combination with atezolizumab on day 1 and administered alone on day 8 of a cycle. In a further embodiment, ecubectedin is administered at least 2 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. In a further embodiment, ecubectedin is administered over 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. In a preferred embodiment, ecubectedin is administered as 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. In another embodiment, atezolizumab is administered at least 1 hour intravenous infusion during each administration cycle allowing -5 minutes to +30 minutes. In another embodiment, said treatment further comprises administration of a prophylactic compound before the administration of ecubectedin in combination with atezolizumab. In a preferred embodiment, said prophylactic compound is selected from corticosteroid and 5-HT3 receptor antagonist. In a further embodiment, said treatment further comprises administration of granulocyte-colony stimulating factor (G-CSF). In a preferred embodiment, atezolizumab is administered as at least 1 hour intravenous infusion followed by ecubectedin which is administered as 3 hours intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1 in said treatment. In an embodiment, ecubectedin is administered at a dose from 2.5 to 5 mg / m2and atezolizumab is administered at a dose of 1200 mg in said treatment. In another embodiment, ecubectedin is administered at a dose from 3 to 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg in said treatment. In a preferred embodiment, ecubectedin is administered at a dose of 3.6 mg / m2and atezolizumab is administered at a dose of 1200 mg. In a more preferred embodiment, ecubectedin is administered at a dose of 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg. In an embodiment, the cancer is malignant mesothelioma and atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as a 3 hour intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. In an embodiment, the cancer is non-small cell lung cancer and atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as a 3 hour intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. In an embodiment, the cancer is squamous non-small cell lung cancer and atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as a 3 hour intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. In an embodiment, the cancer is small cell lung cancer and atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as a 3 hour intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. In an embodiment, the cancer is melanoma and atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as 3 hours intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. In an embodiment, the cancer is gastric cancer and atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as 3 hours intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. In a further aspect, the invention provides a pharmaceutical package comprising ecubectedin, together with instructions for its use in combination with atezolizumab for treating cancer. In embodiments, ecubectedin is in the form of a pharmaceutically acceptable salt or ester. BRIEF DESCRIPTION OF THE FIGURES Figure 1A. In vitro IC50 median values (2L) of cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) determined in 12 patient-derived histotypes of MPM (epithelioid: square; sarcomatoid: circle; biphasic: diamond) with BAP1 positive (solid symbol) and BAP1 negative (open symbol). Results are mean of 4 independent experiments. Figure 1B. In vitro IC10 median values (2L) of cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) determined in 12 patient-derived histotypes of MPM (epithelioid: square; sarcomatoid: circle; biphasic: diamond) with BAP1 positive (solid symbol) and BAP1 negative (open symbol). Results are mean of 4 independent experiments. Figure 2. Histograms showing the percentage of total DNA in the tail of COMET assay in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) at IC50for 24 h. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3A. Representative immunoblot images of the indicated proteins belonging to the cGAS / STING pathway, in MPM#1 (epithelioid, BAP1 positive: Epi, BAP+) and MPM#7 (sarcomatoid, BAP1 negative: Sar, BAP-), treated or not (-) with cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) at their IC50 for 24 h, actin was used as a loading control. The figure is representative of 1 out of 3 experiments. Figure 3B. Activation of NF-kB after the treatment indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). **p<0.01, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3C. Pro-inflammatory IFN-β levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3D. Pro-inflammatory CXCL5 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3E. Pro-inflammatory CXCL10 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3F. Pro-inflammatory TNF-α levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3G. Pro-inflammatory IL-6 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3H. Pro-inflammatory IL-12 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4A. Percentage of cells positive for surface calreticulin (CRT) measured by flow-cytometry. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4B. ATP release measured by a chemiluminescent- based assay. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4C. HMGB1 release measured by ELISA. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4D. Phagocytized MPM cells counted by flow cytometry. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4E. Percentage of CD8+CD107a+INFγ+cells, as index of cytotoxic T-lymphocyte activation. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4F. Percentage of annexin V-FITC+ / PI+MPM cells, as index of tumor cells immunokilling by CD8+T-lymphocytes, measured by flow cytometry. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. DETAILED DESCRIPTION OF THE INVENTION In the present application, a number of general terms and phrases are used, which should be interpreted as follows. The term “treating”, as used herein, unless otherwise indicated, means reversing, attenuating, alleviating or inhibiting the progress of the disease or condition to which such term applies, or one or more symptoms of such disorder or condition. The term “treatment”, as used herein, unless otherwise indicated, refers to the act of treating as “treating” is defined immediately above. "Patient" includes a living organism that is treated with a compound of the present invention, including a mammal, such as a human, other primates, sports animals, animals of commercial interest such as cattle, farm animals such as horses, or pets such as dogs and cats. Preferably, the subject is a human. In the present application, by “cancer” it is meant to include tumors, neoplasias and any other malignant disease having as cause malignant tissue or cells. “G-CSF” or granulocyte-colony stimulating factor is a growth factor, which encourages production of neutrophils. “Malignant mesothelioma” is a disease in which malignant (cancer) cells are found in the pleura (the thin layer of tissue that lines the chest cavity and covers the lungs) or the peritoneum (the thin layer of tissue that lines the abdomen and covers most of the organs in the abdomen). Malignant mesothelioma may also form in the heart or testicles, but this is rare. The four types of mesothelioma are therefore pleural (lung lining), peritoneal (abdominal lining), pericardial (heart sac) and testicular. Mesothelioma can also be identified by three cancer cell types: epithelioid, sarcomatoid and biphasic, and can therefore be defined as epithelioid mesothelioma (epithelioid cells), sarcomatoid mesothelioma (sarcomatoid cells) or biphasic mesothelioma (epithelioid and sarcomatoid cells). Pleural is the most common mesothelioma. Approximately 70% to 75% of cases occur in the pleura. Peritoneal disease accounts for 10% to 20% of mesothelioma cases. There is less research available on peritoneal compared to pleural; however, the prognosis for this tumor type is better. Pericardial Mesothelioma is extremely rare. Around 200 cases are reported in medical literature. Testicular mesothelioma develops in the lining of the testes. This form of mesothelioma is the most rare. Less than 100 cases are reported in the medical literature. The three mesothelioma cell varieties are epithelial, sarcomatoid and biphasic. Biphasic is a mix of the first two cell types. Different mesothelioma tumors respond differently to treatment. Epithelial or epithelioid cells typically respond the best to treatment, and sarcomatoid cells are typically more resistant to treatment. Epithelioid mesothelioma makes up approximately 70% to 75% of all cases of asbestos-related mesothelioma cancers. Epithelioid cell typically has the best prognosis. It tends to be less aggressive and doesn’t spread as quickly as sarcomatoid and biphasic cell disease. About 50% of pleural disease is epithelioid. Around 75% of peritoneal tumors are made up of epithelioid cells. Sarcomatoid is the least common mesothelioma cell category. It is typically the most aggressive and difficult to treat. It accounts for around 10% to 20% of all mesothelioma diagnoses. About 20% of pleural tumors are sarcomatoid, while only 1% of peritoneal mesothelioma are sarcomatous. Biphasic mesothelioma refers to tumors that contain epithelial and sarcomatoid cells. Life expectancy after diagnosis with biphasic mesothelioma depends upon which cell predominates in the tumor. More epithelioid cells generally mean a better prognosis. If the tumor is mostly sarcomatous, it is harder to treat and life expectancy is shorter. Around 30% of pleural and 25% of peritoneal tumors are biphasic cell. Table 1. Prevalence of Mesothelioma Tumors by Cell Type Cell type Pleural Peritoneal epithelioid 50% to 60% 75% to 90% biphasic 30% to 40% 25% sarcomatoid 10% 1% The present invention is preferably the use of ecubectedin as single agent or in combination with another drug for the treatment of malignant pleural mesothelioma (MPM). The malignant mesothelioma to be treated may be epithelioid. The malignant mesothelioma to be treated may be sarcomatoid. The malignant mesothelioma to be treated may be biphasic. “Progressive malignant mesothelioma” is where the disease has progressed after first-line therapy. In an embodiment, the present invention is directed to treatment of patients who experience progression after standard treatment. “First-line therapy” means the initial treatment given to the patient. Standard first line therapy of malignant mesothelioma is typically platinum-pemetrexed chemotherapy with or without surgery, and potentially additional radiotherapy. Thus, standard first-line therapy may comprise platinum- pemetrexed chemotherapy, platinum-pemetrexed chemotherapy and surgery, platinum- pemetrexed chemotherapy and radiotherapy or platinum-pemetrexed chemotherapy and surgery plus radiotherapy. Progressive therapy according to the present invention may therefore be after platinum- pemetrexed chemotherapy with or without surgery, and potentially additional radiotherapy. “Monotherapy” means the patient is treated with ecubectedin as the sole chemotherapeutic agent and not in combination. For example, the patient is treated with ecubectedin alone and not ecubectedin in combination with a platinum agent, for example cisplatin. Ecubectedin monotherapy does not, however, preclude the patient from other medicaments such as, for example, an anti-emetic. In embodiments, ecubectedin monotherapy may include radiotherapy. Sarcomas are rare cancers that develop in the muscle, bone, nerves, cartilage, tendons, blood vessels and the fatty and fibrous tissues. They can affect almost any part of the body, on the inside or the outside. Sarcomas commonly affect the arms, legs and trunk. They also appear in the stomach and intestines as well as behind the abdomen (retroperitoneal sarcomas) and the female reproductive system (gynecological sarcomas). Bone sarcomas affect less than 500 people in the UK each year, making it a very rare form of cancer. Not all bone cancers will be sarcomas. “Soft-tissue sarcoma” can affect any part of the body. They develop in supporting or connective tissue such as the muscle, nerves, fatty tissue, and blood vessels. Unless detected at an early stage when the tumor can be removed by surgery there is currently no cure for soft tissue sarcoma. Approximately 16% of patients with soft tissue sarcoma have advanced stage (metastatic) disease. For these patients, the relative 5 year survival rate is 16% (American Cancer Society). There are more than 50 different types of soft tissue sarcomas, including: Leiomyosarcoma is a type of cancer that starts in smooth muscle tissue. These tumors often start in the abdomen, but they can also start in other parts of the body, such as the arms or legs, or in the uterus. Liposarcomas are malignant tumors of fat tissue. They can start anywhere in the body, but they most often start in the thigh, behind the knee, and inside the back of the abdomen. They occur mostly in adults between 50 and 65 years old. Synovial sarcoma is a malignant tumor of the tissue around joints. The most common locations are the hip, knee, ankle, and shoulder. This tumor is more common in children and young adults, but it can occur in older people. The “Ewing family of tumors” is a group of cancers that start in the bones or nearby soft tissues that share some common features. These tumors can develop at any age, but they are most common in the early teen years. The main types of Ewing tumors are: Ewing sarcoma of bone: most Ewing tumors occur in the bones. The most common sites are: the pelvis (hip bones), the chest wall (such as the ribs or shoulder blades), or the legs, mainly in the middle of the long bones. Extraosseous Ewing tumors can occur almost anywhere. Extraosseous Ewing tumor (EOE): Extraosseous Ewing tumors start in soft tissues around bones, but they look and act very much like Ewing sarcomas in bones. They are also known as extraskeletal Ewing sarcomas. “Carcinosarcoma” is a malignant tumor that is a mixture of carcinoma (cancer of epithelial tissue, which is skin and tissue that lines or covers the internal organs) and sarcoma (cancer of connective tissue, such as bone, cartilage, and fat). Clear cell sarcoma is a rare cancer that often starts in tendons of the arms or legs. Under the microscope, it has some features of malignant melanoma, a type of cancer that starts in pigment- producing skin cells. How cancers with these features start in parts of the body other than the skin is not known. Desmoplastic small round cell tumor is a rare sarcoma of teens and young adults. It's found most often in the abdomen. Epithelioid sarcoma most often starts in tissues under the skin of the hands, forearms, feet, or lower legs. Teens and young adults are often affected. Fibromyxoid sarcoma, low-grade is a slow-growing cancer that most often starts as a painless growth in the trunk or arms and legs (particularly the thigh). It is more common in young to middle aged adults. It is sometimes called an Evans’ tumor. Gastrointestinal stromal tumor (GIST) is a type of sarcoma that starts in the digestive tract. Kaposi sarcoma is a type of sarcoma that starts in the cells lining lymph or blood vessels. Malignant peripheral nerve sheath tumors include neurofibrosarcomas, malignant schwannomas, and neurogenic sarcomas. These are sarcomas that start in the cells that surround a nerve. Myxofibrosarcomas, low-grade are most often found in the arms and legs of elderly patients. They are most common in or just under the skin and there might be more than one tumor. Rhabdomyosarcoma is the most common type of soft tissue sarcoma seen in children. Undifferentiated pleomorphic sarcoma (UPS) was once called malignant fibrous histiocytoma (MFH). It's most often found in the arms or legs. Less often, it can start inside at the back of the abdomen (the retroperitoneum). This sarcoma is most common in older adults. It mostly tends to grow into other tissues around the place it started, but it can spread to distant parts of the body. Intermediate soft tissue tumors may grow and invade nearby tissues and organs, but they tend to not spread to other parts of the body. Infantile fibrosarcoma is the most common soft tissue sarcoma in children under one year of age. It tends to be slow-growing and is less likely to spread to other organs than adult fibrosarcomas. Adult fibrosarcoma usually affects fibrous tissue in the legs, arms, or trunk. “Endometrial carcinoma” is a cancer that forms in the tissue lining the uterus. Most endometrial cancers are adenocarcinomas (cancers that begin in cells that make and release mucus and other fluids). There are various types of endometrial carcinomas including adenocarcinoma (particularly endometrioid cancer), uterine carcinosarcoma, squamous cell carcinoma, small cell carcinoma, transitional carcinoma or serous carcinoma. Clear-cell carcinoma, mucinous adenocarcinoma, undifferentiated carcinoma, dedifferentiated carcinoma, and serous adenocarcinoma are less common types of endometrial adenocarcinomas. They tend to grow and spread faster than most types of endometrial cancer. Most endometrial cancers are adenocarcinomas, and endometrioid cancer is the most common type of adenocarcinoma. Endometrioid cancers start in gland cells. Some of these cancers have squamous cells (squamous cells are flat, thin cells), as well as glandular cells. There are many sub-types of endometrioid cancers including: adenocarcinoma, (with squamous differentiation), adenoacanthoma, adenosquamous (or mixed cell), secretory carcinoma, ciliated carcinoma, and villoglandular adenocarcinoma. Cervical cancer starts in the cells lining the cervix. The main types of cervical cancers are squamous cell carcinoma and adenocarcinoma. “Ovarian cancer” includes epithelial ovarian carcinoma, primary peritoneal disease, fallopian tube carcinomas, or ovarian germ cell tumors. “Epithelial ovarian tumors” start in the outer surface of the ovaries. These tumors can be benign, borderline, or malignant. Epithelial ovarian tumors that are benign don’t spread and usually don’t lead to serious illness. There are several types of benign epithelial tumors including serous cystadenomas, mucinous cystadenomas, and Brenner tumors. When looked at in the lab, some ovarian epithelial tumors don’t clearly appear to be cancerous and are known as borderline epithelial ovarian cancer. The two most common types are atypical proliferative serous carcinoma and atypical proliferative mucinous carcinoma. Primary peritoneal carcinoma (PPC) is a rare cancer closely related to epithelial ovarian cancer. At surgery, it looks the same as an epithelial ovarian cancer that has spread through the abdomen. Other names for this cancer include extra-ovarian (meaning outside the ovary) primary peritoneal carcinoma (EOPPC) and serous surface papillary carcinoma. PPC appears to start in the cells lining the inside of the fallopian tubes. Fallopian tube cancer is another rare cancer that is similar to epithelial ovarian cancer but begins in the fallopian tube. Like PPC, fallopian tube cancer and ovarian cancer have similar symptoms. Most ovarian germ cell tumors are benign, but <2% of ovarian cancers are germ cell tumors. There are several subtypes of germ cell tumors. The most common germ cell tumors are teratomas, dysgerminomas, endodermal sinus tumors, and choriocarcinomas. Germ cell tumors can also be a mix of more than a single subtype. Teratomas are germ cell tumors which have a benign form called mature teratoma and a cancerous form called immature teratoma. Immature teratomas occur in girls and young women, usually younger than 18. These are rare cancers that contain cells that look like those from embryonic or fetal tissues such as connective tissue, respiratory passages, and brain. Dysgerminoma is rare, but it is the most common ovarian germ cell cancer. It usually affects women in their teens and twenties. Endodermal sinus tumor (yolk sac tumor) and choriocarcinoma are very rare tumors which typically affect girls and young women. They tend to grow and spread rapidly but are usually very sensitive to chemotherapy. The ovarian cancers according to embodiments of the present invention may be selected regardless of platinum sensitivity. Breast cancer is a kind of cancer that begins as a growth of cells in the breast tissue. The most common type of breast cancer is ductal carcinoma, which begins in the lining of the milk ducts. Another type of breast cancer is lobular carcinoma, which begins in the lobules of the breast. Invasive breast cancer is breast cancer that has spread from where it began in the breast ducts or lobules to surrounding normal tissue. Triple negative breast cancer is a type of breast cancer. Around 15 out of 100 (around 15%) breast cancers are of this type. Triple negative breast cancers are cancers whose cells don’t have receptors for the hormones oestrogen and progesterone and / or a protein called Human Epidermal Growth Factor Receptor 2 (HER2). Urothelial carcinoma (also called transitional cell carcinoma) is cancer that begins in the urothelial cells, which line the urethra, bladder, ureters, renal pelvis, and some other organs. Almost all bladder cancers are urothelial carcinomas. Clear cell renal cell carcinoma, or ccRCC, is a type of kidney cancer. In adults, ccRCC is the most common type of kidney cancer, and makes up about 80% of all renal cell carcinoma cases. Hepatocellular carcinoma is also called hepatoma or HCC. This type of liver cancer develops from the main liver cells called hepatocytes. It's the most common type of primary liver cancer. Squamous cell carcinoma of the head and neck is a cancer that begins in squamous cells (thin, flat cells that form the surface of the skin, eyes, various internal organs, and the lining of hollow organs and ducts of some glands). Squamous cell carcinoma of the head and neck includes cancers of the nasal cavity, sinuses, lips, mouth, salivary glands, throat, and larynx (voice box). Most head and neck cancers are squamous cell carcinomas. Lung cancer is a disease in which malignant (cancer) cells form in the tissues of the lung. The two major types of lung cancer are small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). SCLC comprises only about 13-15% of all lung cancers at diagnosis; however, SCLC is the more aggressive form of lung cancer. With SCLC, the cancer cells tend to grow quickly and travel to other parts of the body, or metastasize, more easily. The median survival of patients with untreated SCLC is two to four months. The most common regimens include cisplatin or carboplatin and etoposide. Unfortunately, despite the 40-90% response rate to first-line chemotherapy, long-term survival is unusual because patients develop resistance to chemotherapy and relapse. The overall expected mean survival after disease relapse without treatment was typically two to four months. “Pancreatic adenocarcinoma” is a disease in which malignant (cancer) cells are found in the tissues of the pancreas. Pancreatic cancer can develop from two kinds of cells in the pancreas: exocrine cells and neuroendocrine cells, such as islet cells. The exocrine type is more common and is usually found at an advanced stage. Pancreatic neuroendocrine tumors (islet cell tumors) are less common but have a better prognosis (discussed separately below). The most common type of pancreatic cancer, adenocarcinoma of the pancreas, starts when exocrine cells in the pancreas start to grow out of control. Exocrine cancers are by far the most common type of pancreas cancer. About 95% of cancers of the exocrine pancreas are adenocarcinomas. These cancers usually start in the ducts of the pancreas. Less often, they develop from the cells that make the pancreatic enzymes, in which case they are called acinar cell carcinomas. Other, less common exocrine cancers include adenosquamous carcinomas, squamous cell carcinomas, signet ring cell carcinomas, undifferentiated carcinomas, and undifferentiated carcinomas with giant cells. Ampullary cancer (carcinoma of the ampulla of Vater) is a cancer which starts in the ampulla of Vater. Ampullary cancers often block the bile duct while they are still small and have not spread far. This blockage causes bile to build up in the body, which leads to yellowing of the skin and eyes (jaundice). “GEP-NET” is a rare type of tumor that can form in the pancreas or in other parts of the gastrointestinal tract, including the stomach, small intestine, colon, rectum, and appendix. GEP- NETs usually form in cells that secrete hormones. Some of these tumors make extra amounts of hormones and other substances that may cause signs and symptoms of disease, including a condition called carcinoid syndrome. GEP-NETs may be benign or malignant. They are sometimes called carcinoid tumors or islet cell tumors. Also called gastroenteropancreatic neuroendocrine tumor. Pancreatic NETs are classified based on whether they are functioning (making hormones that cause symptoms) or non-functioning (not making hormones). Functioning NETs: About half of pancreatic NETs make hormones that are released into the blood and cause symptoms. These are called functioning NETs. Each one is named for the type of hormone the tumor cells make. Insulinomas come from cells that make insulin; glucagonomas come from cells that make glucagon; gastrinomas come from cells that make gastrin; somatostatinomas come from cells that make somatostatin; VIPomas come from cells that make vasoactive intestinal peptide (VIP); ACTH-secreting tumors come from cells that make adrenocorticotropic hormone (ACTH). Most (up to 70%) functioning NETs are insulinomas. The other types are much less common. Non-functioning NETs: These tumors don’t make enough excess hormones to cause symptoms. Because they don’t make excess hormones that cause symptoms, they can often grow quite large before they're found. Symptoms that may occur when they grow to a large size include abdominal (belly) pain, lack of appetite, and weight loss. Carcinoid tumors: These NETs are much more common in other parts of the digestive system, although rarely they can start in the pancreas. These tumors often make serotonin. “Gastric carcinoma” is a cancer that forms in tissues lining the stomach. Risk factors include smoking, infection with H. pylori bacteria, and certain inherited conditions. “Colorectal carcinoma (CRC)” is a cancer that develops in the colon (the longest part of the large intestine) and / or the rectum (the last several inches of the large intestine before the anus). Colorectal cancer often begins as a growth called a polyp inside the colon or rectum. Most colorectal cancers are adenocarcinomas. These cancers start in cells that make mucus to lubricate the inside of the colon and rectum. Some sub-types of adenocarcinoma, such as signet ring and mucinous, may have a worse prognosis than other subtypes of adenocarcinoma. Prostate cancer is a type of cancer arising from the prostate gland. The most common type is adenocarcinoma of the prostate. Melanoma is a form of cancer that begins in melanocytes. It may begin in a mole (skin melanoma), but can also begin in other pigmented tissues, such as in the eye or in the intestines. Merkel cell carcinoma is a rare type of skin cancer that usually appears as a flesh-colored or bluish-red nodule, often on the face, head or neck. Ecubectedin, which is also known as PM14, is a synthetic compound under clinical investigation. PM14 was first disclosed in WO2018 / 197663 (as compound 4-S), the contents of which are herein incorporated by reference. PM14 can be prepared following the synthesis set out in WO2018 / 197663. The structure for PM14 is: . In embodiments, ecubectedin is in the form of a pharmaceutically acceptable salt or ester. The terms “pharmaceutically acceptable salt” and “ester” refers to any pharmaceutically acceptable salt or ester which, upon administration to the patient is capable of providing (directly or indirectly) a compound as described herein. However, it will be appreciated that non- pharmaceutically acceptable salts also fall within the scope of the invention since those may be useful in the preparation of pharmaceutically acceptable salts. The preparation of salts can be carried out by methods known in the art. For instance, pharmaceutically acceptable salts of the compounds provided herein are synthesized from the parent compounds, which contain a basic or acidic moiety, by conventional chemical methods. Generally, such salts are, for example, prepared by reacting the free acid or base of these compounds with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent or in a mixture of both. Generally, nonaqueous media like ether, ethyl acetate, ethanol, 2-propanol or acetonitrile are preferred. Examples of the acid addition salts include mineral acid addition salts such as, for example, hydrochloride, hydrobromide, hydroiodide, sulfate, nitrate, phosphate, and organic acid addition salts such as, for example, acetate, trifluoroacetate, maleate, fumarate, citrate, oxalate, succinate, tartrate, malate, mandelate, methanesulfonate and p-toluenesulfonate. Examples of the alkali addition salts include inorganic salts such as, for example, sodium, potassium, calcium and ammonium salts, and organic alkali salts such as, for example, ethylenediamine, ethanolamine, N,N- dialkylenethanolamine, triethanolamine and basic amino acids salts. The compounds of the invention may be in crystalline or amorphous form either as free compounds or as solvates (e.g. hydrates) and it is intended that all forms are within the scope of the present invention. Methods of solvation are generally known within the art. In addition, compounds referred to herein may exist in isotopically-labelled forms. All pharmaceutically acceptable salts, esters and isotopically labelled forms of the compounds referred to herein, and mixtures thereof, are considered within the scope of the present invention. Atezolizumab (MPDL3280A) is a humanized lgG1 monoclonal antibody consisting of two heavy chains (448 amino acid residues each) and two light claims (214 amino acid residues each) and is produced in Chinese hamster ovary cells. Atezolizumab targets human PD-L1 and inhibits its interaction with its receptors, programmed cell death protein 1 (PD-1) and B7.1 (CD80, B7-1). Both of these interactions are reported to provide inhibitory signals to T cells. Atezolizumab is approved in USA and Europe for the treatment of patients with metastatic NSCLC whose disease progressed during or following platinum-containing chemotherapy. “Radiotherapy” means that in a further embodiment of the present invention, the patient in need of said treatment is given radiation therapy with (including prior to, during or after) treatment with ecubectedin. In embodiments of the present invention, the patient is treated with ecubectedin and radiotherapy. In an embodiment, the radiation therapy is administered prior or subsequent to administration of ecubectedin, preferably at least an hour, three hours, five hours, 12 hours, a day, a week, a month, more preferably several months (e.g. up to three months) prior or subsequent to administration of ecubectedin. The patient may also receive prophylactic medication whilst getting treatment as described in the present invention. Prophylactic medication includes corticosteroids and 5-HT3 receptor antagonists. Particular corticosteroids include dexamethasone. Particular 5-HT3 receptor antagonists include ondansetron. Particular dosages include dexamethasone 8 mg i.v. (or an equivalent dose of another i.v. corticosteroid) and ondansetron 8 mg i.v. (or an equivalent dose of another i.v.5-HT3 receptor antagonist). Prophylactic medication may be administered on Day 1 and Day 8 of each cycle. In addition, further prophylactic medication may be administered as needed. An example includes metoclopramide or equivalent, which in embodiments may be administered every eight hours. After Day 1 of each cycle extended oral corticosteroids (for example dexamethasone not exceeding 20 mg / days) and / or 5-HT3 receptor antagonists (for example oral (or i.v.) ondansetron 4-8 mg (or equivalent)) may be administered. The patient may also be administered granulocyte-colony stimulating factor G-CSF. In embodiments, In Cycle 1, patients may receive primary prophylaxis with G-CSF starting 24-72 hours after Day 1 of Cycle 1, and during five days. Primary G-CSF prophylaxis for further cycles may be administered at the same regimen, but could also be administered according to physician discretion. The preferred route of administration is parenteral administration including, but not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, intracerebral, intraventricular, intrathecal, intravaginal or transdermal. The preferred mode of administration is left to the discretion of the practitioner, and will depend in part upon the site of the medical condition. In a more preferred embodiment, the compound(s) according to the present invention are administered intravenously. Infusion times of up to 24 hours are preferred to be used, more preferably 1 to 12 hours, with 1 to 6 hours being most preferred, for example 3 hours. Short infusion times which allow treatment to be carried out without an overnight stay in a hospital are especially desirable. However, infusion may be 12 to 24 hours or even longer if required. Infusion may be carried out at suitable intervals of, for example, 1 to 4 weeks, and preferably once every three weeks. In a further embodiment, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 administration cycles are administered, and preferably 10, 11, 12, 13, 14, 15, 16, 17, 18 administration cycles are administered. The invention will now be described further with reference to the following examples. EXAMPLES Example 1: in vitro antiproliferative activity of ecubectedin and in malignant pleural mesothelioma (MPM) cancer cells Twelve primary MPM cell lines (Table 2) derived from patients with different histology, BAP1 status and clinical administered treatments were evaluated for in vitro activity of cisplatin+pemetrexed (Pt+ PMX), lurbinectedin (L), and ecubectedin (Ec).

[0002] Table 2. Malignant pleural mesothelioma primary samples, clinical features and treatments. APN=Anonymized Patient Number; OS means Overall Survival; M=male; F=female; C=carboplatin; P=pemetrexed; G=gemcitabine; T=trabectedin. Age Treatments APN Histotype BAP1 Gender (years Asbestos OS exposur Surgery ) e st n(months) 1 -line 2d-line #1Epithelioid + M 78 Possible No Palliative No 6 #2Epithelioid - F 74 Yes No C+P No 13 #3Epithelioid + M 70 Yes Yes No No 3 #4Epithelioid + M 79 Possible No C+P G 16 #5Epithelioid + M 68 Yes No C+P P 9 #6Sarcomatoid + M 69 Yes No C+P T 10 #7Sarcomatoid - M 77 Yes No No No 3 #8Sarcomatoid - M 61 Yes Yes No No 7 #9Biphasic - M 65 No No C+P No 11#10Biphasic - M 55 Possible No C+P T 10#11Biphasic + F 69 Yes Yes C+P G 14#12Biphasic - F 80 Yes No C+P T 5 Compound-induced antitumor activity was assessed by the crystal violet proliferation assay as described by Riganti et al., J. Natl. Cancer Inst.2015. Inhibition concentrations (IC50 and IC10) were calculated with GraphPad Prism software, v.9.4.1 (GraphPad Software Inc., La Jolla, CA, USA). 2×103cells / well were seeded into 96-well plates and incubated for 72 hours with increasing concentrations of Pt+PMX (0.1 nM to 100 nM), lurbinectedin, and ecubectedin (both, 0.01 nM to 100 nM). Lurbinectedin, ecubectedin, as well as the combination Pt+PMX (1st-line clinical treatment) induced a concentration-dependent decrease in cell viability in a panel of twelve 2D-cultures of patient-derived MPM, independent of histotype or BAP1 status. In these experiments, while the median IC50 for Pt+PMX was 6.0 nM, those obtained with lurbinectedin, and ecubectedin were 0.1 nM, and 0.15 nM, respectively, thus showing 60-, and 40-fold higher in vitro potency than Pt+PMX. A very similar activity relationship was found with the IC10 values, whose mean values were calculated as 2.5, 0.045, and 0.06 nM for Pt+PMX, lurbinectedin, and ecubectedin, respectively, the latter two compounds being thus 56-, and 42-fold more active in vitro than Pt+PMX (Table 3 and 4; Fig.1A and 1B). Table 3. In vitro activity (IC10, nM) of cisplatin plus pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) in a panel of 12 patient-derived MPM cells. APN Histotype BAP1 IC10 Pt+PMX IC10 L IC10 Ec #1 Epithelioid + 0.3±0.2 0.05±0.01 0.08±0.042 #2 Epithelioid - 1.5±0.3 0.01±0.005 0.008±0.002 #3 Epithelioid + 0.9±0.4 0.03±0.02 0.002±0.003 #4 Epithelioid + 2.5±0.7 0.04±0.002 0.03±0.002 #5 Epithelioid + 3.3±0.6 0.07±0.02 0.04±0.003 #6 Sarcomatoid + 1.9±0.4 0.13±0.04 0.14±0.03 #7 Sarcomatoid - 4.5±1.1 0.05±0.02 0.06±0.03 #8 Sarcomatoid - 5.1±0.7 0.04±0.01 0.06±0.03 #9 Biphasic - 2.5±0.4 0.03±0.01 0.07±0.004 #10 Biphasic - 5.6±0.9 0.54±0.74 0.41±1.3 #11 Biphasic + 2.3±0.5 0.07±0.02 0.09±0.03 #12 Biphasic - 3.1±0.5 0.04±0.01 0.05±0.02 Table 4. In vitro activity (IC50, nM) of cisplatin plus pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) in a panel of 12 patient-derived MPM cells. Values represent mean±SD of 3 independent experiments. APN=Anonymized patient number. APN Histotype BAP1 IC50 Pt+PMX IC50 L IC50 Ec #1 Epithelioid + 1.7±0.5 0.6±0.2 0.14±0.1 #2 Epithelioid - 2.9±0.7 0.07±0.03 0.03±0.02 #3 Epithelioid + 1.2±0.5 0.06±0.02 0.02±0.01 #4 Epithelioid + 5.6±0.4 0.05±0.001 0.03±0.02 #5 Epithelioid + 4.7±0.8 0.06±0.002 0.2±0.1 #6 Sarcomatoid + 4.4±0.6 0.5±0.08 0.63±0.06 #7 Sarcomatoid - 9.8±1.4 0.11±0.008 0.15±0.03 #8 Sarcomatoid - 6.4±1.1 0.09±0.04 0.15±0.03 #9 Biphasic - 6.7±1.4 0.12±0.05 0.11±0.04 #10 Biphasic - 9.4±1.1 0.85±0.12 1.1±0.7 #11 Biphasic + 10.3±1.7 0.11±0.4 0.18±0.07 #12 Biphasic - 8.7±1.5 0.3±0.07 0.4±0.1 Major different results were obtained in long-term experiments with Pt+PMX as compared with either lurbinectedin and ecubectedin. In long-term assays, cells (4×103 / well) were incubated with Pt+PMX, lurbinectedin, and ecubectedin at their corresponding IC10 and the exposure to the compounds were maintained for 10 weeks according to the following schedule: 4-week treatment-on; 2-week treatment-off; 4- week treatment-on. Pt+PMX induced heterogeneous effect after the first treatment period, with cell viability percentages ranging from 32 ± 14% (APN#3; histotype epithelioid, BAP1 positive) to 78 ± 14% (APN#12; histotype biphasic, BAP1 negative). After treatment interruption for 2 weeks followed by the second treatment period, most cultures experienced a rebound in cell viability, suggesting a strong possibility of induction of resistance to Pt+PMX treatment (median cell viability, 63 ± 12%) on week 10. However, lurbinectedin, and mainly, ecubectedin induced a continuous and strong decrease in MPM cell viability, unaffected by the 2-week period without treatment. At the end of the experimental period (week 10), the cell viability median values for lurbinectedin, and ecubectedin were 12 ± 4%, and 3 ± 4%, respectively, resulting in a very low potential for the induction to treatment resistance, regardless of the histotype and BAP1 status of tested MPM cell. Example 2: in vitro cell invasion impairment with ecubectedin in malignant pleural mesothelioma (MPM) cancer cells In the wound healing assay, MPM cells were scratched (at a density of 90–100% of confluence in 6-well plates) using a 200-µl sterile tip, washed twice with phosphate buffered saline (PBS), and incubated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) at their corresponding IC50. Cell migration was monitored by contrast phase microscopy at 0, 24 and 48 hours. The percentage of migrated cells (number of cells counted within the scratch / number of seeded cells) was calculated using ImageJ software and results are shown in Table 5. Table 5. Percentage of migrated cells in wound healing assay at 24h and 48h in MPM cells incubated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec). untreated Pt+PMX L Ec %migrated cells 24h 45±8 21±4 11±5 6±4 %migrated cells 48h 73±9 48±9 16±8 9±4 Pt+PMX induced a modest effect at 24 hours (comparing treated vs untreated migrated cells; p<0.05) and 48 hours (p<0.05) of incubation. However, a strong and very highly statistically significant reduction in the percentage of migrated cells was observed (p<0.001 vs untreated cultures) with lurbinectedin and ecubectedin with the percentages obtained with ecubectedin being statistically much lower than with lurbinectedin. A similar result pattern in invasion was observed (Table 6). In the Transwell invasion assay, re- suspended MPM cells in 0.45% type VII low melting and 10% FBS-supplemented agarose were coated on a 0.9% agarose layer in the upper chamber of 6-well transwell plates (1x105cells / plate). Then, they were diluted in complete medium, and incubated for three weeks with Pt+PMX, lurbinectedin, and ecubectedin at their corresponding IC10. Afterwards, cells in the bottom chamber were stained by crystal violet, images acquired by contrast phase microscopy, absorbance measured (Cytation 3 Imaging Reader, Bio-tek Instruments), quantification performed and the percentage of migrated cells / field (number of cells in the bottom chamber versus number of cells seeded in the upper chamber) calculated. Table 6. Percentage of migrated cells / field in invasion assay in MPM cells incubated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec). untreated Pt+PMX L Ec %migrated cells / field 786±205 452 ± 103 108±25 27±6 A very highly statistically significant reduction (p<0.001) in the number of cells migrated after incubation with lurbinectedin, and ecubectedin compared to untreated or Pt+PMX was observed. Notably, ecubectedin induced a lower cell migration than lurbinectedin (p<0.001). Example 3: cell cycle analysis and apoptosis quantitation on mesothelioma cancer cells treated with ecubectedin For both assays, cells were plated in 6-well plates (1.2×105cells / well) and treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) at their IC50 for 24 hours. Once the incubation period finalized, cells were washed with PBS, treated with RNAse (167 μg / mL) and stained propidium iodide (33 μg / mL for 15 min at room temperature -RT-). Samples were analyzed by FACSCalibur flow cytometer (Becton Dickinson, Franklin Lanes, NJ, USA) and calculated using CellQuest (Becton Dickinson). For the quantitation of apoptosis, floating and adherent cells were washed with PBS and stained with the Annexin V-FITC Apoptosis Detection Kit (Sigma). Percentage of necro-apoptotic (Annexin V FITC+ / PI+) cells was measured by FACSCalibur flow cytometer and calculated using CellQuest program. The following Table 7 summarizes the results on the possible cell cycle perturbations after 24 h exposure to to cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) at their corresponding IC50 in a panel of 12 patient-derived MPM cells. Values represent the percentage (%) of cells in each phase of the cell cycle. It is shown the mean±SD of 3 independent experiments. a=p<0.05, c=p<0.001: vs untreated cells; APN=Anonymized patient number. Table 7. Cell cycle phase Untreated Pt+PMX L Ec Sub-G1 4±2 6±322±4 c23±3 c G0 / G1 65±11 69±1253±1254±11 S-phase 4±2 6±3 14±4 c 18±4 c G2 / M 21±5 16±49±4 a8±4 a Lurbinectedin or ecubectedin induced a clear increase in the S-phase population in MPM cells that was statistically higher (p<0.001) to that recorded in untreated or Pt+PMX-treated cells. In agreement, a decrease in the G2 / M population was also observed, as well as an increase in the subG1 population. Taken together, these results are likely due to DNA damage and mitotic arrest leading to an increase in the percentage of necro-apoptotic cells (Table 8) that was recorded in lurbinectedin, and ecubectedin, all highly statistically (p<0.001) greater than that induced by Pt+PMX or found in untreated cultures. Table 8. Percentage of necro-apoptotic cells (% Annex V+PI+cells) produced under treatment with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec) versus untreated cells. Untreated Pt+PMX L Ec % necro-apoptotic cells 5±2 6±3 46±6 41±4 Example 4: Effects on DNA, STING pathway, NF-κB, and pro-inflammatory cytokines with ecubectedin The transcriptome profile (Table 9) in MPM cells exposed to the different tested compounds was analyzed. The heat map showed that lurbinectedin and ecubectedin induced down-regulation of DNA damage sensors (e.g., ABL1, BRACA1 and TP53) and up-regulation of repair machinery protein expressions (e.g., ATR, ATM, CHEK1, CHEK2, PRKDC and RAD51), all resulting unaltered after Pt+PMX treatment. Table 9. The expression pattern of DNA damage genes up-regulated (with values of level of expression from about 5 to about 25) and down-regulated (with values of level of expression from about 2.5 to about 0.25) in MPM cell lines after a 24 h treatment with cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), ecubectedin (Ec) at their IC50 for 24 h, was shown as mRNA abundance versus a pool of housekeeping gens (n=3 independent experiments, in triplicates).

[0003] Ecubectedin induced a statistically significant (p<0.001) increase in DNA in the tailed COMET assay (Table 10) compared to untreated and Pt+PMX-treated cells (Fig.2), regardless of BAP1 status. Taken together, these results strongly suggest that ecubectedin induces DNA damage and genome instability. Table 10. Comet assay results for cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec) versus untreated cells. Untreated Pt+PMX L Ec %DNA damage in COMET tail 2±1 21±11 59±11 69±15 In contrast to Pt+PMX, incubation of MPM cells with lurbinectedin, and ecubectedin induced activation of the cGAS / STING pathway resulting in an increase of STING as well as activated and phosphorylated TBK1 / IRF3 and IKKβ proteins (Fig. 3A), resulting in statistically significant (p<0.001) increases in NF-κB transcription (Fig. 3B, Table 11) as well as the levels of proinflammatory cytokines, namely INF-β, TNF-α, CXCL5, CXCL10, IL-6 and Il-12 (Fig.3C to 3H). Table 11. Activation of cGAS / STING pathway by incubation of MPM cells with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec) versus untreated cells. Untreated Pt+PMX L Ec NF-κB (U / mg prot) 0.3±0.1 1.2±0.4 5.2±0.8 6.2±1.1 INF-β (pg / ml) 89±23 154±36 489±54 594±43 TNF-α (pg / ml) 502±65 985±265 1721±239 1456±367 CXCL5 (pg / ml) 38±12 78±14 182±24 221±26 CXCL10 (pg / ml) 87±14 234±45 453±44 478±98 IL-6 (pg / ml) 45±14 178±29 278±39 332±45 Il-12 (pg / ml) 56±13 178±28 231±29 247±34 Example 5: Ecubectedin induces immunogenic cell death and immune killing by CD8+T- lymphocytes, and reshape the immune-environment of MPM cells To investigate whether ecubectedin was able to increase MPM recognition by immune cells, three classical parameters (Table 12, Fig.4A to 4C) of immunogenic cell death (ICD) were measured namely, pre-apoptotic translocation of calreticulin (CRT) on cell surface, extracellular release of adenosine triphosphate (ATP) and, high mobility group 1 box protein (HMGB1) in MPM-PBMC co-cultures. Table 12. Values of calreticulin, extracellular release of adenosine triphosphate and, high mobility group 1 box protein in MPM-PBMC co-cultures treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec) versus untreated cells. Untreated Pt+PMX L Ec Calreticulin (%positive cells) 3±2 7±4 29±6 36±6 ATP (pmol / ml) 0.7±0.09 1.2±0.4 3.4±0.7 3.2±0.8 HMGB1 (pg / ml) 102±19 298±78 1871±182 2293±203 Pt + PMX combination only elicited a small increase in HMGB1, while lurbinectedin (L) and ecubectedin (Ec) increased all three parameters. Consistent with these results, lurbinectedin- treated cells were more phagocytized by DCs (Table 13; Fig.4D). Table 13. Values of phagocytosis in in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec) versus untreated cells. Untreated Pt+PMX L Ec Phagocytosis 1±0.7 2±1 5±1.3 6±2.2 Moreover, the CD8+T-lymphocytes co-incubated with DCs that have phagocytized MPM cells (previously treated with either lurbinectedin, or ecubectedin) were more endorsed with cytotoxic properties, as indicated by the highest percentage of CD8+CD107a+INFγ+T-cells (Table 14; Fig.4E). Table 14. Values of CD8 activation in in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec) versus untreated cells. Untreated Pt+PMX L Ec CD8 activation (%CD8-Cd107a+IFNƔ+ 3.4±1.1 7.3±2.2 21.4±3.6 28.9±4.3 cells) In these settings, MPM cells were more significantly killed with activated CD8+T-lymphocytes by lurbinectedin and ecubectedin than with Pt+PMX (Table 15, Fig.4F). Table 15. Values of tumor immune killig in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and ecubectedin (Ec) versus untreated cells. Untreated Pt+PMX L Ec Tumor immune killing (%Annexin 3.2±1.2 7.4±2.1 21.4±3.9 33.2±4.9 V+PI+ MPM cells) In parallel, it was investigated whether MPM cells treatment with lurbinectedin, and ecubectedin changes the immune-suppressive phenotype that is typically induced by these cells. For this aim, PBMC from healthy volunteers were co-incubated 5 days with MPM cells, previously grown 24 h in drug-free medium (untreated), cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) at their IC50. Then, PBMC were collected and immunophentyped by flow cytometry. The immune-phenotype analysis of PBMC suggested that Pt + PMX did not generate any change, while lurbinectedin and ecubectedin increased NK cells and decreased Treg cells an d myeloid-derived suppressor cells (Mo MDSC)(Table 16). Table 16. Immunophenotype of PBMC after 5 day-incubation with MPM cells. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). a p<0.05: vs untreated cells; d p<0.05: vs Pt+PMX. Untreated Pt+PMX L Ec T-helper lymphocytes (CD3+CD4+) 42.3±8.1 40.2±6.7 34.6±5.4 32.4±6.7 T-cytotoxic lymphocytes (CD3+CD8+) 10.3±2.3 11.3±3.4 15.6±4.1 16.7±4.5 NK (CD56+CD335+) 2.6±0.8 2.1±1.1 3.5±1.3 4.2±1.2 Treg (CD4+CD25+CD127low) 5.4±1.2 4.5±1.5 5.2±1.4 3.8±1.1 Monocytes (CD14+) 27.5±2.9 25.3±5.8 18.7±5.6 16.3±4.1 Macrophages (CD14+CD68+) 32.3±6.7 30.5±4.5 27.4±5.7 26.7±5.9 Gr-MDSC (CD11b+CD14+CD15+HLA-DR-cells) 4.2±1.4 2.3±1.5 2.1±0.8 2.6±1.4 Mo-MDSC (CD11b+CD14+CD15lowHLA-DR- cells) 13.4±4.5 10.4±4.5 7.5±2.5 7.2±4.2 Notably, MPM cells treated with lurbinectedin (L), and ecubectedin (Ec) displayed a reduced expression of ICP ligands PD-L1 and LAG-3. Additionally, ICPs expression on CD8+and CD4+T- lymphocytes plays a key role in MPM-induced immune suppression. Hence, CD4+T-helper cells, CD8+T-cytotoxic cells and NK cells were collected after a 5 day- co-culture with MPM cells previously treated with Pt + PMX, lurbinectedin or ecubectedin measuring then the levels of ICPs (PD-1, TIM-3, LAG-3, CTLA-4, HVEM, TIGIT) and immuno- senescence markers (CD160, CD57). Particularly, MPM cells were grown 24 h in drug-free medium (untreated), cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec) at their IC50. Then, an aliquot was used to quantify the expression of ICP ligands by flow cytometry. A second aliquot was washed and incubated 5 days with the PBMC of healthy donors. After this, ICP and immune-senescence markers were evaluated by flow cytometry on isolated CD4+T-helper lymphocytes, CD8+T- cytotoxic lymphocytes and NK cells. In CD4+T-lymphocytes, ecubectedin produced a small reduction of LAG-3 and CD57 (p<0.05). Furthermore, in CD8+T-cells, lurbinectedin, and ecubectedin reduced PD-1, LAG-3 and CD57, while in NK cells they decreased PD-1 and CD57 (for all parameters: p<0.05). Conversely, standard treatment of Pt + PMX did not produce any significant change (Table 17). Table 17. ICP / ICP ligands and immune-senescence expression on T-lymphocytes and MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and ecubectedin (Ec). Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). a p<0.05: vs untreated cells; d p<0.05: vs Pt+PMX. Untreated Pt+PMX L Ec PD-L1 14.5±3.5 10.9±3.4 7.8±3.1 a 7.3±2.5 a PD-L2 8.9±3.2 7.5±1.7 8.4±1.5 7.6±1.9 TIM-3 7.8±2.1 6.9±1.4 7.3±0.8 5.2±1.5 LAG-310.3±2.4 9.1±1.8 6.3±1.4 a 5.3±1.9 a PD-1 2.4±1.5 3.4±0.9 2.7±1.7 1.7±1.1TIM-3 5.4±2.0 4.9±3.4 3.4±1.1 3.1±1.2 LAG-3 9.8±3.1 7.9±3.2 5.6±2.3 4.1±1.9 a CTLA-4 6.7±3.5 6.1±3.1 7.2±4.3 6.4±3.2 HVEM 3.4±2.5 2.9±1.2 2.8±1.2 3.4±3.2 TIGIT 3.9±1.2 2.5±1.1 4.1±0.8 3.9±2.1 CD160 4.8±2.4 4.5±2.1 2.4±1.6 2.8±1.2 CD57 12.7±3.6 10.8±3.1 7.2±2.1 5.9±1.7 a,d PD-1 43.7±10.9 34.5±9.1 27.8±8.3 a 23.4±9.1 aTIM-3 5.4±1.6 4.6±1.3 5.1±1.5 4.9±1.4 LAG-3 9.8±1.8 7.8±1.9 5.6±1.4 a 5.1±1.4 a CTLA-4 4.3±1.3 4.3±2.1 5.4±1.4 4.7±1.4 HVEM 2.1±1.8 2.8±1.4 2.4±1.2 2.6±1.1 TIGIT 6.7±1.9 6.6±1.1 5.8±1.6 5.3±1.2 CD160 7.6±2.1 6.5±2.1 4.9±1.8 5.5±1.2 CD57 39.9±7.8 32.9±5.9 21.4±3.8 a,d 19.8±4.9 a,d PD-1 26.3±4.9 29.8±5.6 13.8±2.5 a,d 12.4±2.5 a,d TIM-3 6.7±2.1 6.5±1.4 5.9±1.8 6.3±1.4 LAG-3 4.9±1.1 4.7±1.1 5.9±1.4 4.8±1.7 CTLA-4 4.5±1.2 5.6±1.2 5.8±1.5 5.3±1.4 HVEM 4.3±0.9 4.5±2.3 4.9±1.8 4.7±1.1 TIGIT 5.6±1.2 4.3±1.1 5.6±1.4 5.6±1.7 CD160 9.8±1.3 8.5±1.8 7.6±2.1 8.5±1.4 CD57 25.7±2.4 19.8±4.5 17.8±3.4 a 14.3±2.8 a Data suggest that the treatment with lurbinectedin or ecubectedin qualitatively and quantitatively changed the immune cells to a more anti-tumor than tumor tolerant / immunosuppressive phenotype. Example 6: Ecubectedin increased the efficacy of atezolizumab in immune-PDX models of malignant pleural mesothelioma (MPM) The decrease of PD-L1 on MPM cells and PD-1 in co-cultured T-lymphocytes constituted the rationale for testing the combination of lurbinectedin, and ecubectedin with an ICI targeting the PD-1 / PD-L1 axis. A platform of Hu-NSG mice, bearing an active human immune system, and two MPMs representative of the best case of an epitheliod histotype, BAP1 positive, and a worst case of a sarcomatoid histotype, BAP1 negative was set up. MPM PDX#1 (epithelioid, BAP1 positive) and MPM PDX#7 (sarcomatoid, BAP1 negative) were subcutaneously (s.c.) injected (1x107cells) in the right flank of 6-week-old female NOD SCID-γ (NSG) mice engrafted with human hematopoietic CD34+cells (herein referred as humanized Hu- CD34+NSG mice; The Jackson Laboratories, Bar Harbor, MA, USA) or in NSG mice. Animals were housed (5 / cage) under 12 hours light / dark cycle, with food and water ad libitum. Calliper measurements of the tumor diameters were made daily, and tumor volumes calculated according to (LxW2) / 2, where L and W were the length and width tumor, respectively. Animal weights were monitored throughout the study. When tumors reached a volume of ca. 50 mm3, animals (n=4 / group) were randomly allocated in the experimental groups: vehicle (0.1 mL saline solution); cisplatin (5 mg / kg)+pemetrexed (100 mg / kg) (Pt+PMX); lurbinectedin (L, 0.18 mg / kg); atezolizumab (A, 10 mg / kg); ecubectedin (Ec, 1.2 mg / kg); lurbinectedin (0.18 mg / kg)+atezolizumab (10 mg / kg) (L+A); ecubectedin (1.2 mg / kg)+atezolizumab (10 mg / kg) (Ec+A). All compounds were intravenously (i.v.) administered, except for vehicle and atezolizumab (intraperitoneal). Regardless of compound administration (single agent or combination), the schedule was one dose per week for three consecutive weeks except for atezolizumab, which was administered twice a week for three consecutive weeks. Animals were euthanized with zolazepam: xylazine (0.2 mL / kg: 16 mg / kg) on day 49 after randomization. Tumors were removed, digested with 1 mg / mL collagenase (Sigma) and 0.2 mg / mL hyaluronidase (Sigma) for 1 hour at 37 °C and filtered (70-μm cell strainer) to obtain a single cell suspension. Infiltrating immune cells were collected by centrifugation on Ficoll-Hypaque density gradient and immunostained as detailed above. Cells were quantified with Guava®easyCyte flow cytometer and InCyte software. Table 18. Median tumor volume evaluation in MPM xenografts (PDX#1) in NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), ecubectedin (Ec) and combination of ecubectedin and atezolizumab (Ec+A). Median tumor volume (mm3) DAYS Vehicle Pt+PMX L A L+A Ec Ec+A 0 49.0 54.0 49.5 51.0 46.5 50.0 49.0 4 169.0 172.5 156.0 194.0 136.5 109.5 100.5 7 320.5 316.5 207.0 281.0 235.0 174.5 163.5 10 572.0 471.5 425.5 513.5 397.0 238.5 256.0 14 636.5 636.5 475.0 647.5 473.5 320.0 311.5 17 769.5 722.0 507.5 819.5 513.5 465.5 422.0 21 918.5 806.0 542.5 1024.0 568.5 513.5 510.0 Table 19. Median tumor volume evaluation in MPM xenografts (PDX#7) in NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), ecubectedin (Ec) and combination of ecubectedin and atezolizumab (Ec+A). Median tumor volume (mm3) DAYS Vehicle Pt+PMX L A L+A Ec Ec+A 0 55.5 50.0 48.5 51.5 49.5 50.0 49.5 4 168.0 180.5 178.0 207.0 123.5 105.0 107.5 7 336.5 273.0 240.5 342.0 239.0 149.5 139.5 10 530.5 427.0 440.0 488.0 441.0 218.5 252.5 14 697.5 597.5 509.0 657.0 493.0 384.5 346.0 17 959.5 695.0 583.0 919.5 562.0 466.0 429.5 21 1034.0 810.0 633.0 1110.5 659.5 527.5 535.5 The combination of Pt + PMX was poorly effective in reducing tumor growth (Tables 18 and 19). On Day 21 (one week after the last administration), the treatment of patient derived xenografts PDX#1 or PDX#7 bearing NSG mice with either lurbinectedin, or ecubectedin resulted in a statistically significant reduction. As expected, atezoluzimab treatment resulted in no antitumoral activity in this mouse strain. In humanized Hu-CD34+NSG mice xenografted with either PDX#1 or PDX#7 (Tables 20 and 21), lurbinectedin, and ecubectedin as single agents also induced a strong antitumor effect, which was very similar to that observed in NSG xenografted mice (described above). In these humanized mice, atezoluzimab treatment induced a strong and statistically significant reduction in tumor volume in comparison to vehicle-treated mice. Table 20. Median tumor volume evaluation in MPM xenografts (PDX#1) in Hu-CD34+NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), ecubectedin (Ec) and combination of ecubectedin and atezolizumab (Ec+A). Median tumor volume (mm3) DAYS Vehicle Pt+PMX L A L+A Ec Ec+A 0 50.0 46.5 49.5 49.5 49.0 54.5 45.5 4 139.5 164.5 133.0 139.5 88.0 110.0 73.0 7 218.0 198.0 161.5 190.0 107.0 155.0 84.5 10 491.0 495.5 267.0 293.5 196.5 218.0 107.5 14 588.0 651.5 371.5 377.0 245.5 305.0 191.5 17 755.0 817.0 407.0 464.0 269.0 371.5 238.0 21 959.0 949.5 493.5 511.5 299.5 410.0 303.5 Table 21. Median tumor volume evaluation in MPM xenografts (PDX#7) in Hu-CD34+NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), ecubectedin (Ec) and combination of ecubectedin and atezolizumab (Ec+A). Median tumor volume (mm3) DAYS Vehicle Pt+PMX L A L+A Ec Ec+A 0 47.0 49.5 50.0 51.0 53.0 52.0 50.0 4 149.5 153.0 147.5 138.0 103.0 118.0 110.0 7 228.0 186.0 182.0 216.0 105.5 172.5 139.5 10 503.5 502.0 267.0 234.0 145.0 211.0 161.0 14 671.5 626.5 255.0 339.0 205.5 250.5 187.0 17 803.5 777.0 367.0 405.5 277.0 295.0 221.5 21 959.0 957.5 502.0 452.5 285.5 379.0 234.0 Additionally, atezoluzimab combined with either lurbinectedin, or ecubectedin, significantly improved the antitumor effect obtained with atezoluzimab as a single agent. These results were even stronger in PDX#7, the most clinically aggressive tumor. A significant increase in the anti-tumor CD8+T-lymphocytes and NK cells, as well as a reduction in the immune-suppressive populations Mo-MDSC and TAM2 was detected when the quantitative immune-infiltrating of both PDXs were exposed to atezolizumab plus lurbinectedin, or atezolizumab and ecubectedin, CD8+T-lymphocytes and NK cells were analyzed. However, none of the treatments induced changes in CD4+T-lymphocytes, Treg cells, TAM1 or Gr-MDSC (Table 22). Table 22. Quantification of the immune-infiltrating cells in excised MPM#1 implanted in Hu-NSG mice. Data are expressed as means±SD (n=4 mice / group). a=p<0.05, b=p<0.01, c=p<0.001: vs untreated cells; d=p<0.05, e=p<0.01,f=p<0.001: vs Pt+PMX. Untreated Pt+PMX L A L+A Ec Ec+A T-helper lymphocytes 43.0±12.3 51.0±18.3 62.0±13.1 48.2±5.8 41.2±7.0 52.3±6.2 44.5±8.7 (CD3+CD4+) T-cytotoxic lymphocytes 19.0±7.9 20.5±6.9 33.0±4 b 22.0±2.9 36.8±6.2 28.8±4. 36.0±4.2 (CD3+CD8+) b,d 0 b,d NK (CD56+CD335+ 2.8±1.7 3.5±1.3 4.5±1.3 2.7±0.9 5.0±0.8 a 5.0±0.6 a 6.5±1.3 a ) Treg (CD4+CD25+C 4.0 ±8.0 4.5±1.3 5.0±1.8 4.7±0.9 4.8±1.5 5.0±1.8 3.8±1.0 D127low) TAM1 (CD68+CD86+i 31.8±10.0 45.5±2.6 40.3±6.8 29.7±6.8 26.3±4.3 31.8±8.5 34.0±2.2 NOS+) TAM2 (CD68+CD206+ 40.5±5.4 30.5±4.5 34.3±7.7 42.2±7.1 30.3±6.4 21.5±3.3 23.8±7.2 Arg1+) c,e b Gr-MDSC (CD11b+CD14+ CD15+HLA-DR- 9.8±2.2 12.3±3.1 9.5±2.6 10.2±3.5 8.3±2.5 10.5±2.1 8.5±2.1 cells) Mo-MDSC (CD11b+CD14+ 15.0±5.1 15.8±2.2 9.0±1.8 15.0 4.8±1.5 4.3±2.1 CD15lowHLA- ±2.1 c,f 9.3±1.9 c,f DR-cells) In PDX#7, the most clinically a gg ressive tumor, the combination of atezolizumab+lurbinectedin or atezolizumab+ecubectedin produced even stronger effects: it increased lymphoid (CD8+T- lymphocytes and NK cells) and myeloid (TAM1) anti-tumor cells; decreased the immune-tolerant populations (TAM2, Gr-MDSC, Mo-MDSC) (Table 23), recapitulating the immune-phenotype observed in MPM-PBMC co-cultures. Table 23. Quantification of the immune-infiltrating cells in excised MPM#7 implanted in Hu-NSG mice. Data are expressed as means±SD (n=4 mice / group). a=p<0.05, b=p<0.01, c=p<0.001: vs untreated cells; d=p<0.05, e=p<0.01,f=p<0.001: vs Pt+PMX. Untreated Pt+PMX L A L+A Ec Ec+A T-helper lymphocytes 47.3±12.9 47.5±4.7 56.8±7.1 53±11.5 50.5±8.4 44.8±3.1 42.8±6.8 (CD3+CD4+) T-cytotoxic lymphocytes 18.05±4.8 24.0±2.4 37.0±3.9 2 38.5±5.3 29.3±4.6 39.8±7.9 (CD3+CD8+) c,f 6.2±5.3 c,f b c,e NK D56+CD335+2.5±1.3 2.8±1.05.0a±1.43.0±1.86.55.8±1.0 7.5±1.3 b±,d1.3b,d c,e ) Treg D4+CD25+C 4.5±1.3 3.3±1.0 4.5±1.3 3.7±1.7 4.3±1.0 3.8±1.7 3.8±1.7 D127low) Untreated Pt+PMX L A L+A Ec Ec+A TAM1 (CD68+CD86+i21.5±5.1 25.0±7.336.833.2±5.7 39.5±4.0 36.8±2.1 34.5±3.0 a±4.0a b,d c,f c,f NOS+) TAM2 (CD68+CD206+40.3±6.2 37.0±4.729.b3,±d3.931.5±9.418.826.8±3.1 19.3±5.3 c,±f5.0a,d c,f Arg1+) Gr-MDSC (CD11b+CD14+ CD15+HLA-DR-9.0±3.2 8.3±3.3 6.5±1.9 9.7±3.74.8a±,d1.76.0±1.84.0a±,d1.4cells) Mo-MDSC (CD11b+CD14+ CD15lowHLA-18.5±5.2 20.0±7.1 14.8±2.6 20.7+4.8 12.5±3.9 13.3±1.77.8b±,e1.7DR-cells) Although ecubectedin produced similar effects when used as a single agent, the widest changes in immune-infiltrating cells were produced by its combination with atezolizumab. In summary, the preclinical data shows that ecubectedin is useful in the treatment of malignant pleural mesothelioma (MPM). The data also shows that the combination of ecubectedin and atezolizumab is effective. The data shows that ecubectedin alone and ecubectedin in combination with atezolizumab effectively treats cancer, with data demonstrating effectiveness in malignant pleural mesothelioma (MPM). Example 7: phase Ib study with ecubectedin in combination with atezolizumab In order to evaluate the efficacy of ecubectedin in combination with atezolizumab in advanced solid tumors, a prospective, open-label, dose-ranging, uncontrolled and multicenter phase Ib study was performed. 7.1. Study objectives Primary: To determine the maximum tolerated dose (MTD) and the recommended dose (RD) of ecubectedin in combination with atezolizumab in patients with selected advanced solid tumors. Secondary: ^ To characterize the safety profile and feasibility of this combination in patients with selected advanced solid tumors. ^ To obtain preliminary information on the clinical antitumor activity of this combination. ^ To characterize the pharmacokinetics (PK) of ecubectedin and to detect major drug-drug PK interactions. ^ To evaluate pharmacogenetics (PGt) in germline DNA by the presence or absence of PGt polymorphisms in genes relevant for ecubectedin disposition (distribution, metabolism and excretion) that may explain individual variability in main ecubectedin PK parameters. ^ To conduct an exploratory pharmacogenomics (PGx) analysis substudy in tumor and blood samples from patients consenting to the substudy and exposed to ecubectedin and atezolizumab, to identify potential biomarkers of response and / or resistance to the combination of ecubectedin and atezolizumab. Expansion stage: Primary Objective: To confirm the safety profile and tolerability of the combination at the RD determined during the dose escalation stage, and to evaluate the antitumor activity of ecubectedin and atezolizumab in terms of overall response rate (ORR), according to the Response Evaluation Criteria in Solid Tumors (RECIST) v.1.1 in patients with selected advanced solid tumors. Secondary Objectives: ^ To further characterize the antitumor activity of the combination in terms of duration of response (DoR), clinical benefit (ORR or stable disease [SD] lasting ≥4 months), progression free survival (PFS), overall survival (OS), and mid- and long-term survival (OS at 12, 18 and 24 months). ^ To characterize the PK of ecubectedin and to detect major drug-drug PK interactions. ^ To evaluate PGt in germline DNA by the presence or absence of PGt polymorphisms in genes relevant for ecubectedin disposition (distribution, metabolism and excretion) that may explain individual variability in main ecubectedin PK parameters. ^ To conduct an exploratory PGx analysis substudy in tumor and blood samples from patients consenting to the substudy and exposed to ecubectedin and atezolizumab, to identify potential biomarkers of response and / or resistance to the combination of ecubectedin and atezolizumab. 7.2. Study design Patients will receive atezolizumab at a fixed dose of 1200 mg intravenously (i.v.) as a 60 minutes infusion (the second and subsequent infusions may be administered over 30 minutes) on Day 1, followed by ecubectedin at a starting dose level (DL1) of 3.0 mg / m2i.v. as a three hours infusion on Day 1 and 8 every three weeks (q3wk). A treatment cycle is defined as an interval of three weeks (every three weeks = one treatment cycle). Other schedule evaluated will be atezolizumab at a fixed dose of 1200 mg i.v. as a 60 minutes infusion (the second and subsequent infusions may be administered over 30 minutes) on Day 1, followed by ecubectedin at a starting dose level (DL1) of 3.6 mg / m2i.v. as a three hours infusion on Day 1 q3wk. A treatment cycle is defined as an interval of three weeks (every three weeks = one treatment cycle). The study will be divided into two stages: a dose-ranging stage with escalating doses of ecubectedin in combination with a fixed dose of atezolizumab, followed by an expansion stage of the combination at the RD determined during the escalation stage. Dose escalation stage: Ecubectedin doses will be escalated in successive cohorts of patients following a classical 3+3 design, and according to observed tolerance and safety. Three to six patients will be included at each dose level to receive fixed dose of atezolizumab on Day 1 and ecubectedin at successively increasing dose levels, starting at 3.0 mg / m2, on Day 1 and Day 8, or starting at 3.6 mg / m2, on Day 1. If dose-limiting toxicity (DLT) occurs in less than one third of evaluable patients in each cohort, escalation can proceed to the next dose level within each group. The MTD will be the lowest dose level explored during dose escalation in which one third or more of evaluable patients develops a DLT in Cycle 1. At any dose level, if one among the first three evaluable patients has a DLT, the dose level should be expanded up to six patients. Dose escalation will be terminated once the MTD or the last dose level is reached, whichever occurs first, except if DLTs occurring at a given dose level are related to neutropenia (i.e., febrile neutropenia, grade 4 neutropenia lasting > 3 days, grade 3 neutropenia lasting > 7 days or neutropenic sepsis) in which case dose escalation may be resumed, starting at the same dose level and following the same original schedule but with mandatory primary granulocyte colony- stimulating factor (G-CSF) prophylaxis. Once the MTD has been reached, six additional evaluable patients will be recruited at the immediately lower dose level (or at the last dose level if the MTD is not defined yet): this level will be confirmed as the RD if less than one third of the total evaluable patients develop DLT during Cycle 1. Expansion stage: Once the RD has been determined, expansion cohort will be included to have approximately 20 fully evaluable patients treated at the RD, and thus have an adequate number of patients to assess safety. Patients of this expansion stage may be enrolled simultaneously. Specific tumor type indications could be included in this expansion stage. These tumor types may be determined based on the efficacy results observed in the escalation stage and in ongoing clinical trials with ecubectedin and preclinical data. Patients treated at the expansion stage will have measurable disease and will be evaluable by the Response Evaluation Criteria in Solid Tumors (RECIST) v.1.1. 7.3. Study population Inclusion criteria 1) Voluntarily signed and dated written informed consent prior to any specific study procedure. 2) Age ≥18 years. 3) Eastern Cooperative Oncology Group (ECOG) performance status (PS) score ≤1. 4) Histologically or cytologically confirmed selected advanced solid tumors (see below) for whom the standard of care therapies have failed, no effective alternative therapeutics are available, or are intolerant to standard of care therapies that are known to provide clinical benefit. a) Genitourinary tract tumors: urothelial bladder carcinoma, clear cell renal carcinoma and prostate adenocarcinoma. b) Skin: melanoma and Merkel cell carcinoma. c) Head and neck squamous cell carcinoma d) Gastrointestinal: esophageal carcinoma, gastric adenocarcinoma and hepatocarcinoma. e) Lung: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). f) Gynecological tumors: epithelial ovarian carcinoma (including primary peritoneal disease and / or fallopian tube carcinomas and / or endometrial adenocarcinomas), endometrial carcinoma and carcinoma of cervix. g) Breast: triple negative breast cancer. h) Microsatellite instability (MSI) solid tumors i) Sarcoma: liposarcoma, leiomyosarcoma, synovial sarcoma and Ewing sarcoma. j) Other: malignant pleural mesothelioma, extrapulmonary small cell carcinoma, adrenocortical carcinoma and adenoid cystic carcinoma. 5) Patients included in the Expansion stage must have: a) Measurable disease according to the RECIST v.1.1. (Note: irradiated lesions may qualify as target if progression has been documented). b) Documented disease progression per RECIST v.1.1 during or immediately after last therapy at study entry. 6) Wash-out periods: a) At least three weeks since the last chemotherapy. b) At least four weeks since the last monoclonal antibody (MAb)-containing therapy or radiotherapy (RT) >30 Gytotal dose. c) At least two weeks since the last biological / investigational single-agent therapy (excluding MAbs) and / or palliative RT (≤10 fractions or ≤30 Gy total dose). d) Castrate-resistant prostate cancer (CRPC) patients may continue receiving hormone therapy prior to and during study treatment. Note: washout periods will be referred to the day of first cycle administration (Day 1), not to the day of registration. 7) Adequate bone marrow, renal, hepatic, and metabolic function (assessed ≤ 7 days before registration): a) Platelet count ≥100 x 109 / L, hemoglobin ≥9.0 g / dL and absolute neutrophil count (ANC) ≥1.5 x 109 / L. b) Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤3.0 x the upper limit of normal (ULN), independently of the presence of liver metastases. c) Total bilirubin ≤1.5 x ULN or direct bilirubin ≤ULN. d) Calculated creatinine clearance (CrCL) ≥30 mL / minute (using Cockcroft and Gault´s formula). e) Creatine phosphokinase (CPK) ≤2.5 x ULN. f) Serum albumin ≥3.0 g / dL (Note: Albumin infusion to fulfill the inclusion criterion is forbidden). 8) Recovery to grade ≤ 1 from any adverse event (AE) related to previous anticancer treatment (excluding peripheral neuropathy, anemia, asthenia and alopecia, all grade ≤ 2) according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) v.5. Exclusion criteria 1) Active or untreated central nervous system (CNS) involvement. Exception: patients with previously treated CNS metastases are eligible provided they have to show radiographic stability (defined as no CNS progression for at least four weeks from post- radiotherapy brain scan to brain scan performed during study screening), and patients should not have neurologic sign / symptoms secondary to the brain metastases or RT. Any steroid treatment must be completed ≥ 14 days before first dose of study treatment. Note: for all SCLC patients regardless of prior history of brain metastases or patients with other solid tumors and previously treated CNS metastases, adequate CNS imaging (contrast enhanced-computed tomography [CT] or magnetic resonance imaging [MRI], if applicable) will be performed at baseline to document any disease involvement. 2) History of previous bone marrow and / or stem cell transplantation. 3) Impending need for RT (e.g., painful bone metastasis and / or risk of spinal cord compression). 4) History of allergy or hypersensitivity to any of the study drugs or their excipients. 5) Prior therapy with ecubectedin. 6) Prior treatment with trabectedin (Yondelis®) or lurbinectedin (Zepzelca®). 7) Use of (strong or moderate) inhibitors or strong inducers of CYP3A4 activity within two weeks prior to the first infusion of ecubectedin and atezolizumab. 8) Live vaccines within 30 days prior to start of study treatment and while on treatment. 9) Concomitant diseases / conditions: a) Increased cardiac risk: ^ History or presence of unstable angina, myocardial infarction, congestive heart failure defined as abnormal left ventricular ejection fraction (LVEF) < 50% assessed by multiple- gated acquisition scan (MUGA) or equivalent by ultrasound (US), or clinically significant valvular heart disease within 12 months prior first study dose. ^ Symptomatic arrhythmia (excluding anemia-related sinusal tachycardia grade ≤2) or any arrhythmia requiring ongoing treatment; corrected QT-QTc grade ≥ 450msec; or presence of unstable atrial fibrillation. Patients with stable atrial fibrillation on treatment are allowed provided they do not meet any other cardiac or prohibited drug exclusion criterion. b) Ongoing chronic alcohol consumption, or cirrhosis with Child-Pugh score B or C. c) Active uncontrolled infection. Serious non-healing wound, ulcer or bone fracture. d) Diagnose of immunodeficiency or receiving systemic steroids therapy (more than a daily dose of 10 mg of prednisone or equivalent per day) or any other form of immunosuppressive therapy within seven days prior to the first study dose. e) Active autoimmune disease that required systemic treatment in the past two years (i.e., with disease-modifying agents, corticosteroids and immunosuppressive drugs). Patients with vitiligo or resolved childhood asthma / atopy are eligible, as well as patients who require intermittent use of bronchodilators or local steroid injections, patients with hypothyroidism stable on hormone replacement, patients syndrome. f) History of idiopathic pulmonary fibrosis, organizing pneumonia, drug-induced pneumonitis, idiopathic pneumonitis or evidence of active pneumonitis on screening chest CT scans. g) Known history of active tuberculosis (Mycobacterium tuberculosis) h) Ongoing treatment-requiring, non-neoplastic chronic liver disease of any origin. For hepatitis B, this includes positive tests for both Hepatitis B surface antigen (HBsAg) and quantitative Hepatitis B polymerase chain reaction (PCR). For hepatitis C, this includes positive tests for both Hepatitis C antibody and quantitative Hepatitis C PCR. Patients taking hepatitis-related antiviral therapy within six months prior to the first study dose will also be excluded. i) Known human immunodeficiency virus (HIV) infection. j) Myopathy or any clinical situation that causes significant and persistent elevation of CPK (>2.5 x ULN in two different determinations performed one week apart). 10) Women who are pregnant or breast feeding and fertile patients (men and women) who are not using an effective method of contraception. * 11) Limitation of the patient’s ability to comply with the treatment or follow-up procedures. 12) Any other major illness that, in the Investigator’s judgment, will substantially increase the risk associated with the patient’s participation in this study (e.g., COVID-19 disease). * Women of childbearing potential (WOCBP) must agree to use an effective contraception method to avoid pregnancy during the course of the trial (and for at least six months after the last infusion). Fertile male patients must agree to refrain from fathering a child or donating sperm during the trial and for four months after the last infusion. 7. Study drug Formulation Ecubectedin: ^ Pharmaceutical form: ecubectedin drug product (DP) is provided as a sterile lyophilized powder for concentrate for solution for infusion. ^ Route of administration: ecubectedin (DP) was developed for administration by the i.v. route. Before use, the vials are reconstituted with sodium chloride 9 mg / mL (0.9%) solution for infusion to give a solution containing 0.5 mg / mL of ecubectedin. Prior to administration, the reconstituted DP solution should be further diluted with sodium chloride 9 mg / mL (0.9%) solution for infusion. ^ Vial composition: The composition of the ecubectedin vial is ecubectedin, sucrose, potassium dihydrogen phosphate, phosphoric acid, potassium hydroxide, sodium chloride for the reconstitution and water for injection. Atezolizumab: Commercially available presentations for injection vials containing atezolizumab (1200 mg / 20 mL per vial) will be provided as appropriate. Patients will consecutively receive atezolizumab and ecubectedin on Day 1, followed by ecubectedin alone on Day 8, q3wk (every three weeks = one treatment cycle). Other schedule evaluated will consist of both atezolizumab and ecubectedin administered on Day 1, q3wk (every three weeks = one treatment cycle). The administration route is the following: ^ Atezolizumab: i.v. infusion over 60 minutes (or over 30 minutes for the second and subsequent infusions) of 1200 mg, via a central or peripheral venous catheter through a pump device (with a window of -5-min / +10-min), followed by: ^ Ecubectedin: as an i.v. infusion (central or peripheral line) in a total volume of 250 mL of 0.9% sodium chloride. The infusion will be administered over three hours (-15-min / +30- min). From Cycle 3, a window of ± 2 days is allowed for administration of the combination of ecubectedin with atezolizumab on Day 1, and a window of + 3 days is allowed for administration of ecubectedin on Day 8. 7.5. Dose escalation schedule Dose escalation will be conducted in accordance with the following guidelines: The dose escalation will follow pre-defined dose levels, starting at DL1 and including a minimum of three evaluable patients per dose level, as summarized in the following table: Table 24. Dose escalation levels. A= atezolizumab; Ec=Ecubectedin, DL=dose level; a=DL-1 will be initiated if DL1 is defined as maximum tolerated dose, D1=Day 1; D8=Day 8. Dose level N. patients A dose Ec dose (mg / m2), D1, D8, Ec dose (mg / m2), D1 (mg), D1 q3wk schedule q3wk schedule DL-1 a 0-6 1200 2.5 3.0 DL1 (starting 3-6 1200 3 3.6 dose) DL2 3-6 1200 3.6 4.0 DLX 3-6 1200 Further dose levels, or Further dose levels, or intermediate- dose levels intermediate- dose levels (in case of PM4 related (in case of PM4 related AEs) may be evaluated AEs) may be evaluated Intermediate doses of ecubectedin (between MTD and the immediate DL below explored) could be explored once the MTD is found. Additional DL could be explored with G-CSF prophylaxis in case neutropenia is the only dose- limiting toxicity (DLT) avoiding dose escalation. 7.6. Prophylactic medication All patients must receive the following prophylactic medication before infusion of study treatment: ^ Dexamethasone 8 mg i.v. (or an equivalent dose of another i.v. corticosteroid). ^ Ondansetron 8 mg i.v. (or an equivalent dose of another i.v.5-HT3 receptor antagonist). ^ If necessary and in addition to the above, 10 mg of oral or i.v. metoclopramide or equivalent can be administered every eight hours (according to tolerance and Investigator criteria). After Day 1 of each cycle, extended oral ondansetron (or equivalent) or metoclopramide will be optional and according to Investigator criteria. For the purpose of safety evaluations, an optimal antiemetic prophylaxis is defined as all the medications at their respectively maximum dose of either option described above. Additional antiemetics might be used, if needed. Use of moderate inhibitors of CYP3A4 based on aprepitant or any other NK-1 antagonist or related Substance P-antagonists (except for rolapitant) is forbidden. An acceptable alternative is the use of rolapitant. Antidiarrheal prophylaxis with 0.25-1 mg of i.v. or subcutaneous atropine (unless clinically contraindicated) should be considered in patients experiencing cholinergic syndrome. 7.7. Allowed medications / therapies ^ Therapies for preexisting and treatment-emergent medical conditions, including pain management. ^ Blood products and transfusions, as clinically indicated. ^ Bisphosphonates. ^ In case of nausea or vomiting, secondary prophylaxis and / or symptomatic treatment for emesis according to American Society of Clinical Oncology (ASCO) guidelines. ^ Corticosteroids at a dose ≤ 10 mg / day of prednisone or equivalent. Higher doses are permitted for treatment of immune-related adverse event or as a pre-medication prior to a CT scan. Temporary treatment with steroids other than the exceptions above may be allowed if clinically indicated, after agreement with the Sponsor. ^ Erythropoietin use according to ASCO guidelines. ^ Secondary prophylaxis or therapeutic use of G-CSF. Note: a patient who develops severe non-febrile neutropenia during Cycle 1 of the Dose Escalation study stage should not receive therapeutic G-CSF unless the DLT criterion for neutropenia was met or it was clinically indicated. ^ Palliative limited field bone RT (e.g. for pain control) if needed once Cycle 1 has been completed. ^ Megestrol acetate for appetite stimulation. ^ Rolapitant for antiemetic prophylaxis or treatment. Inactivated vaccines (e.g., COVID-19). 7.8. Prohibited medications / therapies ^ Concomitant administration of any other antineoplastic therapy, other than androgen suppression for prostate cancer. ^ Other investigational agents. ^ Medroxyprogesterone (if given for the treatment of endometrial cancer). ^ Immunosuppressive therapies other than corticosteroids. ^ Primary G-CSF prophylaxis (unless dose escalation with primary G-CSF is implemented during the trial). ^ Strong and moderate CYP3A4 inhibitors and strong CYP3A4 inducers. This includes aprepitant or any other NK-1 antagonist or related Substance P-antagonists (except for rolapitant), as they are moderate inhibitors of CYP3A4. ^ Substrates of CYP3A4, OATP1B1 and OATP1B3 should be avoided. A washout period of at least two weeks prior to the first infusion of ecubectedin is recommended. If this is not possible, patients receiving these comedications should be carefully monitored. 7.10. Criteria for treatment continuation Patients will be treated with additional cycles of ecubectedin combined with atezolizumab as long as no unacceptable toxicity and / or progression of the disease as per RECIST v.1.1 and / or withdrawal of consent occurs. Clinically stable patients with suspected pseudoprogression and Investigator’s perceived clinical benefit might continue treatment despite RECIST-defined progression. Administration should be delayed if the criteria in Table 25 are not met for treatment administration. If a patient does not meet the requirements for treatment continuation on Day 1, re-assessments should be performed at least every 48-72 hours (dose escalation stage) or at least every seven days (expansion stage) until recovery. Treatment will be withheld, until appropriate recovery, for a maximum of 15 days after the treatment due date. If there is no recovery after 15 days of treatment delay, treatment must be discontinued, except if objective clinical benefit is adequately documented by the Investigator, and upon agreement with the Sponsor. Then, treatment may continue after appropriate dose reduction (up to two dose reductions are allowed), appropriate secondary prophylaxis with G-CSF (when due to neutropenia exclusively), or atezolizumab discontinuation. In case the treatment delay >15 days is related to immune-toxicity, atezolizumab will be interrupted according to the prescribing information and treatment may continue with ecubectedin alone at the same dose as 3-hour i.v. infusion on Day 1 and 8, q3wk schedule or on Day 1, q3wk schedule. If clinical benefit with the combination was perceived during treatment, after resolution or improvement of the atezolizumab toxicity, the combination might be re-restarted but after prior discussion and agreement with the Sponsor. For patients treated with the Day 1 and Day 8, q3wk schedule, if treatment continuation criteria are not met on Day 8 (+72 hours) of any cycle, the scheduled infusion will be skipped. Table 25. Criteria for treatment continuation. a=applicable only to patients treated with the Day 1 and Day 8, q3wk schedule. Only infusions scheduled on Day 1 can be delayed. If treatment continuation criteria are not met on Day 8 (+72 hours) of any cycle, the scheduled infusion will be skipped. The window of +72 hours is for allowing recovery from possible toxicities. b=albumin infusion is forbidden. c=only applicable to atezolizumab. d=non-symptomatic metabolic abnormalities (e.g., increase / decrease of sodium, potassium, total calcium). AEs=adverse event(s); ALT=alanine aminotransferase; ANC=absolute neutrophil count; AST=aspartate aminotransferase; CrCL=creatinine clearance; ECOG PS=Eastern Cooperative Oncology Group performance status; GGT=gammaglutamyltransferase; q3wk=every three weeks; ULN=upper limit of normal. If a patient does not meet the requirements for treatment continuation on Day 1 of Cycle 2 or further cycles, both drug (ecubectedin and atezolizumab) infusions will be withheld until recovery for a maximum of 15 days after the theoretical treatment date. If recovery has not occurred after a delay of >15 days, the patient should be withdrawn from the trial, except in case of Investigator’s perceived clinical benefit and upon agreement with the Sponsor. In case the treatment delay > 15 days is related to immune-toxicity, atezolizumab will be interrupted according to the prescribing information and treatment may continue with ecubectedin alone at the same dose as 3-hour i.v. infusion on Day 1, 8, q3wk schedule or on Day 1, q3wk schedule. If clinical benefit with the combination was perceived during treatment, after resolution or improvement of the atezolizumab toxicity, the combination might be re-restarted but after prior discussion and agreement with the Sponsor. 7.11. Dose reduction Ecubectedin dose reduction should be implemented when any of the following occurs: ^ An event fulfilling the criteria for defining a DLT (regardless of cycle number and stage of the trial). ^ Any other toxicity that is considered unacceptable by the Investigator. Under these circumstances, and following recovery to pre-specified re-treatment criteria, the patient will be re-treated at the immediately lower dose level within the dose escalation scheme (except if, according to the seriousness of the event, a different dose reduction scheme is required for a specific patient). If additional dose levels need to be explored, up to two ecubectedin dose reductions at a dose level 20% lower than the one administered during the previous infusion will be allowed. Up to two ecubectedin dose reductions will be allowed per patient during treatment; any patients requiring more than two dose reductions will be withdrawn from the study (unless clinical benefit is observed and therefore the patient could continue treatment). Once the dose has been reduced for an individual patient, it will not be re-escalated again under any circumstances. Patients requiring dose reduction exclusively due to grade 4 neutropenia, grade 3 neutropenia lasting >7 days or any grade febrile neutropenia that occurred during the preceding cycle are allowed to receive secondary prophylaxis with G-CSF instead of a dose reduction per Investigator decision. If toxicity re-occurs despite G-CSF use, up to two dose reductions should then be implemented. In those cases of atezolizumab discontinuation, treatment may continue with ecubectedin alone at the same dose as 3-hour i.v. infusion on Day 1 and 8, q3wk schedule or on Day 1, q3wk schedule. On the contrary, patients cannot discontinue ecubectedin alone and continue treatment with single-agent atezolizumab as part of this trial. 7.12. Results Dose escalation During the dose escalation, in a first step, two Dose levels (DL) were explored: ^ DL1: Three patients treated with Atezolizumab 1200mg D1 + ecubectedin 3.0 mg / m2D1 & D8. ^ DL2: Three patients treated with Atezolizumab 1200mg D1 + ecubectedin 3.6 mg / m2D1 & D8. The efficacy, and baseline characteristics of the patients treated during escalation stage on day 1 & day8 schedule are shown in the following table. Table 26: DL Patient Diagnosis DLT Cycles Efficacy Adenoid cystic Male, 53 years old No 7 SD carcinoma Female 36 years old Triple negative Breast cancer No 4 SD Adenoid cystic Male 58 years ol d No 3 SD carcinoma DL Patient Diagnosis DLT Cycles Efficacy Adenoid cystic Female 41 years old No 10 SD carcinoma SD Male, 74 years old SCLC No 40* Ongoing Yes Ovarian G5 Suspicion N / A Fe male 45 years old 0.5 carcinoma of viral Death encephalitis * This patient was moved to day 1 schedule after cycle 11 Table 27: Summary of laboratory abnormalities regardless of relationship and AE related / UNL on day 1 and day 8 schedule (escalation stage) DL1 DL2 PM143.0 mg / m2D1 + PM143.6 mg / m2D1 + Atezolizumab 1200 mg Atezolizumab 1200mg D1 D1 (n=3) (n=3) Gr 1-2 Gr 3 Gr 4 Gr 1-2 Gr 3 Gr 4 n (%) n (%) n (%) n (%) n (%) n (%) Anemia 3 (100) . . 3 (100) . . Neutropenia 3 (100) . . 2 (66.7) 1 (33.3) . Thrombocytopenia . . . 2 (66.7) . . ALT increased 3 (100) . . 2 (66.7) 1 (33.3) . AST increased 1 (33.3) . . 1 (33.3) . . Creatinine increased 1 (33.3) . . 2 (66.7) . . CPK increased 1 (33.3) 1 (33.3) . 1 (33.3) . . Fatigue / asthenia 2 (66.7) . . 2 (66.7) . . Nausea 1 (33.3) . . 2 (66.7) . . Vomiting . . . 2 (66.7) . . Constipation 1 (33.3) . .1 (33.3). . Decreased appetite 1 (33.3) . .1 (33.3). . Dyspepsia . . .1 (33.3). . Diarrhea . . .1 (33.3). . Phlebitis 1 (33.3) . . . . . A Recommended dose (RD) was not achieved in the D1 & D8 schedule due to: ^ Dose intensity could not be maintained due to treatment modifications required. ^ The presence of a probably related death during Cycle 1. It was decided to move to Day 1 scheme starting with ecubectedin 3.6 mg / m2and to test 3 Dose level: ^ DL1: Four patients treated with Atezolizumab 1200 mg D1 + ecubectedin 3.6 mg / m2D1 ^ DL2: Four patients treated with Atezolizumab 1200 mg D1 + ecubectedin 4.0 mg / m2D1 ^ DL3: Three patients treated with Atezolizumab 1200 mg D1 + ecubectedin 4.5 mg / m2D1 The efficacy, and baseline characteristics of the patients treated during escalation stage on day 1 schedule are shown in the following Table 28. Table28 DL Patient Diagnosis DLT Cycles Efficacy Female 54 years old Adenoid cystic carcinoma No 23 SD Female 62 years oldOvarian cancerNo 2 PDMale 82 years old Mesothelioma No* 1 DNe / aAth Female 58 years old NCSLC No 19 SD Male, 73 years old Gastric adenocarcinoma No 4 SD Male, 51 years old Gastric adenocarcinoma No 10 PR Female 59 years old Leiomyosarcoma No 2 PD CR Female 64 years old SCLC No 29 Ongoing Triple negative Breast Female 53 years old cancerNo4 SDPD Male, 63 years old Clear cell renal carcinoma No 2 (NR death) Female 57 years old Cervix Carcinoma No 5 SD In order to confirm the DL3 as the recommended dose, according to protocol, 6 more patients were included. As no DLTs occurred in these new 6 patients, DL3 was determined as recommended dose with Atezolizumab 1200 mg D1 + ecubectedin 4.5 mg / m2D1 q3wk. The efficacy, and baseline characteristics of the 6 more patients treated at DL3 during escalation stage on day 1 schedule are shown in the following Table 29. Table 29 DL Patient Diagnosis DLT Cycles Efficacy Female 81 Mesothelioma No 4 SD years old Male 80 years oldMerkel cell carcinomaNo 16 SD OngoingFemale 51 Triple negative breast No 2 PD years old cancer Female 70 NCSLC No 5 years old SD Female, 56 Triple negative breast PD No 1 years old cancer (NR death) Female, 67 Epithelial ovarian No 5 SD years old carcinoma Table 30: Summary of laboratory abnormalities regardless of relationship and AE related / UNK on day 1 schedule (escalation stage) DL1 DL PM143.6 mg / m2 2 D1 + PM144.0 mg / m2D1 + DL3 PM14 2 Atezolizumab Atezolizumab 4.5 mg / m D1 + 1200mg D1 1200mg D1 Atezolizumab 1200mg D1 (n=4) (n=4) (n=9) Gr 1-2 Gr 3 Gr 4 Gr 1- 2 Gr 3 Gr 4 Gr 1-2 Gr 3 Gr 4 n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Anemia 4 (100) . . 2 1 (50) (25) . 8 (88.9) 1 (11.1) . Neutropenia 1 (25) . . 2 (50) . 1 (25) 3 (33.3) 1 (11.1) 1 (11.1) Thrombocytopenia . . . . . 1 (25) 3 (33.3) . . ALT increased 1 (25) 1 (25) . 3 (75) . . 4 (44.4) 4 (44.4) . AST increased 3 (75) . . 2 (50) . . 5 (55.6) 2 (22.2) . Bilirubin increased . . . 1 . . (25) . 1 (11.1) . Creatinine increased 1 (25) 1 . (25) . . . . 3 (33.3) . CPK increased . . . 3 . . 2 (22 . (75) .2) . Fatigue / asthenia 2 (50) . . 3 (75) . . 7 (77.8) 1 (11.1) . Nausea 2 (50) . . 1 . . 7 (77.8) . (25) . Vomiting 2 (50) . . 1 . (25) . . 6 (66.7) . Decreased appetite . . . 1 3 (33.3) . (25) . . . Dyspepsia . . . 1 . . (25) . . . Diarrhea 1(25) . . 1 . . (25) . . . Phlebitis . . . . . . 1 (11.1) . Infusion site reaction . . . . . . 1 (11.1) . Summary of escalation stage: For the day 1 schedule, a recommended dose of atezolizumab 1200 mg D1 + ecubectedin 4.5 mg / m2on day 1 q3wk has been established. This day 1 schedule achieved a partial response (PR) in a patient with gastric adenocarcinoma and a complete response (CR) in a patient with SCLC. Again, patients using the day 1 schedule received over 29 cycles demonstrating a prolonged response or stabilizations. Expansion stage Based on the efficacy observed during escalation stage, as well as the efficacy observed in other clinical trials with ecubectedin and compiling data from preclinical studies these four cohorts were included in the expansion stage. A total of 27 patients were included. - NSCLC (n = 8) - Gastric carcinoma (n = 9) - Melanoma (n = 5) - Mesothelioma (n = 5). Table 31 summarizes the efficacy results obtained in the Expansion stage. Table 31 Efficacy results Tumor Type CR PR SD PD NE NSCLC . 2 3 3 Gastric carcinoma . 1* 3 4 1 Melanoma . . 4 1 Mesothelioma . . 3 2 *Non confirmed PR NE: Non evaluable Summary of expansion stage: One non confirmed partial response was observed in in gastric carcinoma and two partial responses in NSCLC. These both partial responses were in the squamous subtype NSCLC, so it was decided to increase the expansion in this subtype up to 15 more patients. Recruitment of this last expansion is ongoing, 10 patients have been treated. No objective responses have been observed so far in the 6 evaluated patients, two ongoing SD have been observed. Table 32: Summary of laboratory abnormalities regardless of relationship and AE related / UNK on day 1 schedule (expansion stage) 2DL3PM144.5 mg / m D1 + Atezolizumab 1200mg D1 (n=37) Gr 1-2 Gr 3 Gr 4 n (%) n (%) n (%) Anemia 26 (74.3) 6 (17.1) 3 (8.6) Neutropenia 6 (17.1) 2 (5.4) 2 (5.4) Thrombocytopenia 11 (31.4) 2 (5.4) 2 (5.4) Febrile neutropenia . . 1 (2.9) ALT increased 13 (37.1) 15 (42.9) 3 (8.6) AP increased 12 (34.3) . . AST increased 23 (67.6) 3 (8.6) 3 (8.6) Bilirubin increased 8 (22.9) . . Creatinine increased 8 (22.9) . . GGT increased 25 (71.4) 1 (2.9) . LDH increased 26 (74.3) . . Asthenia / Fatigue 24 (64.9) 4 (10.8) . Nausea 24 (64.9) 2 (5.4) . Vomiting 13 (35.1) 1 (2.9) . 2 DL3 PM144.5 mg / m D1 + Atezolizumab 1200mg D1 (n=37) Gr 1-2 Gr 3 Gr 4 n (%) n (%) n (%) Diarrhoea 3 (8.6) . . Constipation 8 (22.9) . Decrease appetite 22 (59.5) . . Mucosal inflamation 6 (17.1) . . Rash 6 (17.1) . . Data from 27 patients from the NSCL, gastric, melanoma and mesothelioma expansion plus 10 patients from the squamous NSCLC expansion. In conclusion, reviewing the totality of the pre-clinical and clinical data, the present invention has demonstrated the effectiveness of ecubectedin in the treatment of mesothelioma, particularly MPM. In addition, the present invention has demonstrated the effectiveness of the combination of ecubectedin and atezolizumab. The present invention has also identified the recommended dose for ecubectedin and atezolizumab, with patients demonstrating a clinical response, namely a partial response in multiple cancer types.

[0004] References - Janes et al., Perspectives on the Treatment of Malignant Pleural Mesothelioma, N. Engl. J. Med.2021, 385, 1207-1218 - Cinausero et al., Chemotherapy treatment in malignant pleural mesothelioma: a difficult history, J. Thor. Dis, 2018, 304-310 - Zalcman et al., Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial, Lancet, 2016, 387, 1405-1414 - Hiltbrunner et al., Tumor Immune Microenvironment and Genetic Alterations in Mesothelioma, , Front Oncol., 2021,11:660039 - Ceresoli et al, Immune checkpoint inhibitors in mesothelioma: a turning point, 2021, 397, 348-349 - Leal et al., what's Current and What's New in Mesothelioma?, Clin. Onc., 2022;34(11):771-780. - Cantini et al., Emerging treatments for malignant pleural mesothelioma: where are we heading? Oncol., 2020, 10 - Hiltbrunner et al., Genomic landscape of pleural and peritoneal mesothelioma tumours, 2022, 127, 1997-2005 - Santamaria Nunez G, et al., Lurbinectedin Specifically Triggers the Degradation of Phosphorylated RNA Polymerase II and the Formation of DNA Breaks in Cancer Cells. Mol Cancer Ther, 2016, 15(10):2399–412. - WO2021043949 - WO2018 / 197663 - WO2022 / 2434482 - Galluzzi et al., Consensus guidelines for the definition, detection and interpretation of immunogenic cell death, J Immunother Cancer.2020;8(1):e000337. doi: 10.1136 / jitc- 2019-000337. - Riganti et al, Bromodomain inhibition exerts its therapeutic potential in malignant pleural mesothelioma by promoting immunogenic cell death and changing the tumor immune- environment. Oncoimmunology.2017;7(3):e1398874. doi: 10.1080 / 2162402X.2017. - Salaroglio et al, Potential Diagnostic and Prognostic Role of Microenvironment in Malignant Pleural Mesothelioma, J Thorac Oncol., 2019 ;14(8):1458-1471. - Terenziani et al., Immunotherapeutic approaches in malignant pleural mesothelioma, Cancers, 2021, 13. - NCT05841563 - AEMPS 2023-508644-22-00 - Press release PharmaMar 28 / 02 / 2024 - Press release PharmaMar 26 / 10 / 2023 - Press release PharmaMar 26 / 04 / 2023 - Financial report PharmaMar 28 / 02 / 2022 - Financial report PharmaMar 28 / 10 / 2021 - Napoli F. et al., Pathological Characterization of Tumor Immune Microenvironment (TIME) in Malignant Pleural Mesothelioma. Cancers (Basel).2021,13(11):2564. - Wu L. et al., Defining and targeting tumor-associated macrophages in malignant mesothelioma. Proc Natl Acad Sci U S A.2023;120(9):e2210836120. - Ferrara, Circulating T-cell Immunosenescence in Patients with Advanced Non-small Cell Lung Cancer Treated with Single-agent PD-1 / PD-L1 Inhibitors or Platinum-based Chemotherapy., Clin Cancer Res 2021, 27(2):492-503. - Gu et al, Enhancing anti-tumor immunity through liposomal oxaliplatin and localized immunotherapy via STING activation. J Control Release.2023;357:531-544 - Taieb et al, Deficient mismatch repair / microsatellite unstable colorectal cancer: Diagnosis, prognosis and treatment. Eur J Cancer.2022, 175:136-157 - Liu et al, On-demand integrated nano-engager converting cold tumors to hot via increased DNA damage and dual immune checkpoint inhibition. Acta Pharm Sin B.2023, 13(4):1740-1754 - Gemelli M, Immune Checkpoint Inhibitors in Malignant Pleural Mesothelioma: A Systematic Review and Meta-Analysis. Cancers (Basel).2022;14(24):6063. - Kepp O, Lurbinectedin: an FDA-approved inducer of immunogenic cell death for the treatment of small-cell lung cancer. Oncoimmunology.2020;9(1):1795995. - Chee SJ, Evaluating the effect of immune cells on the outcome of patients with mesothelioma. Br J Cancer.2017;117(9):1341-1348. - Miselis NR, Kinetics of host cell recruitment during dissemination of diffuse malignant peritoneal mesothelioma. Cancer Microenviron.2010;4(1):39-50. - Guo X, Immunotherapy vs. Chemotherapy in Subsequent Treatment of Malignant Pleural Mesothelioma: Which Is Better? J Clin Med.2023;12(7):2531. - Tagliamento M, Meta-Analysis on the Combination of Chemotherapy With Programmed Death-Ligand 1 and Programmed Cell Death Protein 1 Blockade as First-Line Treatment for Unresectable Pleural Mesothelioma. J Thorac Oncol.2024;19(1):166-172. - Knelson Eh. Et al., Activation of Tumor-Cell STING Primes NK-Cell Therapy. Cancer Immunol Res.2022;10(8):947-961. - Aoki M. et al., IRF3 Knockout Results in Partial or Complete Rejection of Murine Mesothelioma. J Clin Med.2021;10(21):5196. - Cantini L, Emerging Treatments for Malignant Pleural Mesothelioma: Where Are We Heading? Front Oncol.2020;10:343. - Hiltbrunner S, Genomic landscape of pleural and peritoneal mesothelioma tumours. Br J Cancer.2022;127(11):1997-2005. - Leal JF, PM01183, a new DNA minor groove covalent binder with potent in vitro and in vivo anti-tumour activity. Br J Pharmacol.2010;161(5):1099-110. - Harlow ML, Lurbinectedin Inactivates the Ewing Sarcoma Oncoprotein EWS-FLI1 by Redistributing It within the Nucleus. Cancer Res.2016;76(22):6657-6668. - Belgiovine C, Lurbinectedin reduces tumour-associated macrophages and the inflammatory tumour microenvironment in preclinical models. Br J Cancer. 2017;117(5):628-638. - Farago A, ATLANTIS: a Phase III study of lurbinectedin / doxorubicin versus topotecan or cyclophosphamide / doxorubicin / vincristine in patients with small-cell lung cancer who have failed one prior platinum-containing line. Future Oncol.2019;15(3):231-239. - Cote GM, A phase II multi-strata study of lurbinectedin as a single agent or in combination with conventional chemotherapy in metastatic and / or unresectable sarcomas. Eur J Cancer.2020;126:21-32. - Gaillard S, Lurbinectedin versus pegylated liposomal doxorubicin or topotecan in patients with platinum-resistant ovarian cancer: A multicenter, randomized, controlled, open-label phase 3 study (CORAIL). Gynecol Oncol.2021;163(2):237-245. - Kristeleit R, Doxorubicin plus lurbinectedin in patients with advanced endometrial cancer: results from an expanded phase I study. Int J Gynecol Cancer.2021;31(11):1428-1436. - Poveda A, A phase I dose-finding, pharmacokinetics and genotyping study of olaparib and lurbinectedin in patients with advanced solid tumors. Sci Rep.2021;11(1):4433. - Mark M, Long-term benefit of lurbinectedin as palliative chemotherapy in progressive malignant pleural mesothelioma (MPM): final efficacy and translational data of the SAKK 17 / 16 study. ESMO Open.2022;7(3):100446. - Mark M, Long-term benefit of lurbinectedin as palliative chemotherapy in progressive malignant pleural mesothelioma (MPM): final efficacy and translational data of the SAKK 17 / 16 study. ESMO Open.2022;7(3):100446. - Trigo J, Lurbinectedin as second-line treatment for patients with small-cell lung cancer: a single-arm, open-label, phase 2 basket trial. Lancet Oncol. 2020;21(5):645-654. Epub 2020 Mar 27. Erratum in: Lancet Oncol.2020;21(12):e553. - Milosevic V, Wnt / IL-1β / IL-8 autocrine circuitries control chemoresistance in mesothelioma initiating cells by inducing ABCB5. Int J Cancer.2020;146(1):192-207. - Riganti C, The role of C / EBP-β LIP in multidrug resistance. J Natl Cancer Inst. 2015;107(5):djv046. - Freyria FS, Hematite nanoparticles larger than 90 nm show no sign of toxicity in terms of lactate dehydrogenase release, nitric oxide generation, apoptosis, and comet assay in murine alveolar macrophages and human lung epithelial cells. Chem Res Toxicol. 2012;25(4):850-61. - Kopecka J, Loss of C / EBP-β LIP drives cisplatin resistance in malignant pleural mesothelioma. Lung Cancer.2018;120:34-45. - Obeid M, Calreticulin exposure dictates the immunogenicity of cancer cell death. Nat Med.2007;13(1):54-61. - Salaroglio IC, Mitochondrial ROS drive resistance to chemotherapy and immune-killing in hypoxic non-small cell lung cancer. J Exp Clin Cancer Res.2022;41(1):243. - Vogelzang NJ, Phase III Study of Pemetrexed in Combination With Cisplatin Versus Cisplatin Alone in Patients With Malignant Pleural Mesothelioma. J Clin Oncol. 2023;41(12):2125-2133. - Nowak AK, Durvalumab with first-line chemotherapy in previously untreated malignant pleural mesothelioma (DREAM): a multicentre, single-arm, phase 2 trial with a safety run- in. Lancet Oncol.2020;21(9):1213-1223. - Anobile DP, Evaluation of the Preclinical Efficacy of Lurbinectedin in Malignant Pleural Mesothelioma. Cancers (Basel).2021;13(10):2332. - Kwon J, BAP1 as a guardian of genome stability: implications in human cancer. Exp Mol Med.2023;55(4):745-754. - Bellini A, Relapse Patterns and Tailored Treatment Strategies for Malignant Pleural Mesothelioma Recurrence after Multimodality Therapy. J Clin Med.2021;10(5):1134. - Shi Y, Starvation-induced activation of ATM / Chk2 / p53 signaling sensitizes cancer cells to cisplatin. BMC Cancer.2012 Dec 4;12:571 - - Salaroglio, I C, Ecteinascidin synthetic analogues: a new class of selective inhibitors of transcription, exerting immunogenic cell death in refractory malignant pleural mesothelioma. J. Exp. Clin. Cancer Res.2024, 43(1):327. - Eudrat 2021000415-13.

[0005] CLAUSES 1. Ecubectedin, which is a compound of formula I: I, for use in the treatment of malignant mesothelioma. 2. Ecubectedin for use according to clause 1, wherein ecubectedin is not administered in combination with a topoisomerase I inhibitor. 3. Ecubectedin for use according to clause 1 or 2, wherein ecubectedin is administered as a monotherapy. 4. Ecubectedin for use according to any one of clauses 1 to 3, wherein the malignant mesothelioma is malignant pleural mesothelioma. 5. Ecubectedin for use according to any one of clauses 1 to 3, wherein the malignant mesothelioma is malignant peritoneal mesothelioma. 6. Ecubectedin for use according to any one of clauses 1 to 5, wherein the malignant mesothelioma is epithelioid mesothelioma. 7. Ecubectedin for use according to any one of clauses 1 to 5, wherein the malignant mesothelioma is sarcomatoid mesothelioma. Ecubectedin for use according to any one of clauses 1 to 5, wherein the malignant mesothelioma is biphasic mesothelioma. 9. Ecubectedin for use according to any one of clauses 1 to 8, wherein the malignant mesothelioma is progressive. 10. Ecubectedin for use according to any preceding clause, wherein ecubectedin is administered once every one to four weeks, preferably once every three weeks. 11. Ecubectedin for use according to any preceding clause, wherein ecubectedin is administered at a dose of 2 to 7 mg / m2body surface area, 2.5 to 5 mg / m2body surface area, about 3.6 mg / m2body surface area. 12. Ecubectedin for use according to clause 11, wherein ecubectedin is administered to a patient in need thereof at a dose of 4.5 mg / m2. 13. Ecubectedin for use according to any preceding clause, wherein ecubectedin is administered as an infusion, preferably with an infusion time of up to 24 hours, 1 to 12 hours, 1 to 6 hours and most preferably 3 hours. 14. Ecubectedin for use according to any one of clauses 1 to 13, wherein ecubectedin is in the form of a pharmaceutically acceptable salt or ester. 15. Ecubectedin, which is a compound of formula I: for use in the treatment of malignant mesothelioma, wherein in said treatment ecubectedin is administered in combination with atezolizumab to a patient in need thereof. 16. Ecubectedin for use according to clause 15, wherein the malignant mesothelioma is malignant pleural mesothelioma. 17. Ecubectedin for use according to clause 15, wherein the malignant mesothelioma is malignant peritoneal mesothelioma. 18. Ecubectedin for use according to clauses 15 to 17, wherein the malignant mesothelioma is epithelioid mesothelioma. 19. Ecubectedin for use according to clauses 15 to 17, wherein the malignant mesothelioma is sarcomatoid mesothelioma. 20. Ecubectedin for use according to clauses 15 to 17, wherein the malignant mesothelioma is biphasic mesothelioma. 21. Ecubectedin for use according to any one of clauses 15 to 20, wherein the malignant mesothelioma is progressive. 22. Ecubectedin for use according to clauses 15 to 21, wherein in said treatment ecubectedin and atezolizumab are administered sequentially. 23. Ecubectedin for use according to clause 22, wherein atezolizumab is administered initially, followed by ecubectedin. 24. Ecubectedin for use according to clauses 15 to 23, wherein the administration cycle in combination with atezolizumab is once every three to four weeks, preferably once every 21 days. 25. Ecubectedin for use according to clauses 15 to 24, wherein in said treatment ecubectedin is administered in combination with atezolizumab on day 1 of a cycle. 26. Ecubectedin for use according to clauses 15 to 24, wherein in said treatment ecubectedin is administered in combination with atezolizumab on day 1 and administered alone on day 8 of a cycle. 27. Ecubectedin for use according to clauses 15 to 26, wherein ecubectedin is administered at least 2 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. 28. Ecubectedin for use according to clauses 15 to 26, wherein ecubectedin is administered as 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. 29. Ecubectedin for use according to clauses 15 to 26, wherein ecubectedin is administered over 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. 30. Ecubectedin for use according to clauses 15 to 26, wherein atezolizumab is administered at least 1 hour intravenous infusion during each administration cycle allowing -5 minutes to +30 minutes. 31. Ecubectedin for use according to clauses 15 to 30, wherein ecubectedin is administered at a dose from 2.5 to 5 mg / m2and atezolizumab is administered at a dose of 1200 mg. 32. Ecubectedin for use according to clauses 15 to 30, wherein ecubectedin is administered at a dose from 3 to 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg. 33. Ecubectedin for use according to clauses 15 to 32, wherein ecubectedin is administered at a dose of 3.6 mg / m2and atezolizumab is administered at a dose of 1200 mg. 34. Ecubectedin for use according to clauses 15 to 32, wherein ecubectedin is administered at a dose of 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg. 35. Ecubectedin for use according to claim 34, wherein atezolizumab is administered at a dose of 1200 mg as 1 hour intravenous infusion followed by ecubectedin which is administered at a dose of 4.5 mg / m2as 3 hours intravenous infusion with an interval between both administrations of 10 minutes on Day 1 during the cycle 1. 36. Ecubectedin for use according to any one of clauses 15 to 35, wherein ecubectedin is in the form of a pharmaceutically acceptable salt or ester. 37. Ecubectedin, which is a compound of formula I: I, for use in the treatment of cancer, wherein in said treatment ecubectedin is administered in combination with atezolizumab to a patient in need thereof. 38. Ecubectedin for use according to clause 37, wherein the cancer is a solid tumor. 39. Ecubectedin for use according to clause 38, wherein the solid tumor is selected from neuroendocrine tumor, gastrointestinal cancer, lung cancer, sarcoma, gynaecological cancer, breast cancer, malignant mesothelioma, extrapulmonary small cell carcinoma, adrenocortical carcinoma, adenoid cystic carcinoma, skin cancer, genitourinary tract tumors, microsatellite instability (MSI) solid tumors, head and neck squamous cell carcinoma. 40. Ecubectedin for use according to clause 39, wherein the solid tumor is malignant mesothelioma. 41. Ecubectedin for use according to clause 40, wherein the malignant mesothelioma is malignant pleural mesothelioma. 42. Ecubectedin for use according to clause 40, wherein the malignant mesothelioma is malignant peritoneal mesothelioma. 43. Ecubectedin for use according to clause 40 to 42, wherein the malignant mesothelioma is epithelioid mesothelioma. 44. Ecubectedin for use according to clause 40 to 42, wherein the malignant mesothelioma is sarcomatoid mesothelioma. 45. Ecubectedin for use according to clause 40 to 42, wherein the malignant mesothelioma is biphasic mesothelioma. 46. Ecubectedin for use according to any one of clause 40 to 45, wherein the malignant mesothelioma is progressive. 47. Ecubectedin for use according to clause 38, wherein the solid tumor is non-small cell lung cancer. 48. Ecubectedin for use according to clause 47, wherein the solid tumor is squamous non- small cell lung cancer. 49. Ecubectedin for use according to clause 38, wherein the solid tumor is small cell lung cancer. 50. Ecubectedin for use according to clause 38, wherein the solid tumor is gastric cancer. 51. Ecubectedin for use according to clause 38, wherein the gastric cancer is gastric adenocarcinoma. 52. Ecubectedin for use according to clause 38, wherein the solid tumor is melanoma. 53. Ecubectedin for use according to any of clauses 37 to 52, wherein in said treatment ecubectedin and atezolizumab are administered sequentially. 54. Ecubectedin for use according to clause 53, wherein atezolizumab is administered initially, followed by ecubectedin. 55. Ecubectedin for use according to any previous clauses 37 to 54, wherein the administration cycle in combination with atezolizumab is once every three to four weeks, preferably once every 21 days. 56. Ecubectedin for use according to any of any previous clauses 35 to 55, wherein in said treatment ecubectedin is administered in combination with atezolizumab on day 1 of a cycle. 57. Ecubectedin for use according to any of clauses 37 to 55, wherein in said treatment ecubectedin is administered in combination with atezolizumab on day 1 and administered alone on day 8 of a cycle. 58. Ecubectedin for use according to any of previous clauses 37 to 57, wherein ecubectedin is administered at least 2 hours intravenous infusion during each administration cycle allowing - 15 minutes to +30 minutes. 59. Ecubectedin for use according to clauses 37 to 57, wherein ecubectedin is administered as 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. 60. Ecubectedin for use according to clauses 37 to 57, wherein ecubectedin is administered over 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes. 61. Ecubectedin for use according to clauses 37 to 57, wherein atezolizumab is administered at least 1 hour intravenous infusion during each administration cycle allowing -5 minutes to +30 minutes. 62. Ecubectedin for use according to clauses 37 to 61, wherein ecubectedin is administered at a dose from 2.5 to 5 mg / m2and atezolizumab is administered at a dose of 1200 mg. 63. Ecubectedin for use according to clauses 37 to 61, wherein ecubectedin is administered at a dose from 3 to 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg. 64. Ecubectedin for use according to clauses 37 to 63, wherein ecubectedin is administered at a dose of 3.6 mg / m2and atezolizumab is administered at a dose of 1200 mg. 65. Ecubectedin for use according to clauses 37 to 63, wherein ecubectedin is administered at a dose of 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg. 66. Ecubectedin for use according to any one of clauses 37 to 65, wherein ecubectedin is in the form of a pharmaceutically acceptable salt or ester.

Claims

CLAIMS 1. Ecubectedin, which is a compound of formula I:I, for use in the treatment of cancer, wherein in said treatment ecubectedin is administered in combination with atezolizumab to a patient in need thereof.

2. Ecubectedin for use according to claim 1, wherein the cancer is a solid tumor.

3. Ecubectedin for use according to claim 2, wherein the solid tumor is selected from neuroendocrine tumor, gastrointestinal cancer, lung cancer, sarcoma, gynaecological cancer, breast cancer, malignant mesothelioma, extrapulmonary small cell carcinoma, adrenocortical carcinoma, adenoid cystic carcinoma, skin cancer, genitourinary tract tumors, microsatellite instability (MSI) solid tumors, head and neck squamous cell carcinoma.

4. Ecubectedin for use according to claim 2, wherein the solid tumor is non-small cell lung cancer.

5. Ecubectedin for use according to claim 4, wherein the solid tumor is squamous non- small cell lung cancer.

6. Ecubectedin for use according to claim 2, wherein the solid tumor is small cell lung cancer.

7. Ecubectedin for use according to claim 2, wherein the solid tumor is gastric cancer.

8. Ecubectedin for use according to claim 7, wherein the gastric cancer is gastric adenocarcinoma.

9. Ecubectedin for use according to claim 2, wherein the solid tumor is malignant mesothelioma.

10. Ecubectedin for use according to claim 9, wherein the malignant mesothelioma is malignant pleural mesothelioma.

11. Ecubectedin for use according to claim 9, wherein the malignant mesothelioma is malignant peritoneal mesothelioma.

12. Ecubectedin for use according to any of claims 9 to 11, wherein the malignant mesothelioma is epithelioid mesothelioma, sarcomatoid mesothelioma or biphasic mesothelioma.

13. Ecubectedin for use according to any one of claims 9 to 12, wherein the malignant mesothelioma is progressive.

14. Ecubectedin for use according to any of claims 1 to 13, wherein in said treatment ecubectedin and atezolizumab are administered sequentially.

15. Ecubectedin for use according to claim 14, wherein atezolizumab is administered initially, followed by ecubectedin.

16. Ecubectedin for use according to any previous claim 1 to 15, wherein the administration cycle in combination with atezolizumab is once every three to four weeks, preferably once every 21 days.

17. Ecubectedin for use according to any of any previous claims 1 to 16, wherein in said treatment ecubectedin is administered in combination with atezolizumab on day 1 of a cycle.

18. Ecubectedin for use according to any of previous claims 1 to 17, wherein ecubectedin is administered at least 2 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes.

19. Ecubectedin for use according to claims 1 to 18, wherein ecubectedin is administered as 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes.

20. Ecubectedin for use according to claims 1 to 19, wherein ecubectedin is administered over 3 hours intravenous infusion during each administration cycle allowing -15 minutes to +30 minutes.

21. Ecubectedin for use according to claims 1 to 19, wherein atezolizumab is administered at least 1 hour intravenous infusion during each administration cycle allowing -5 minutes to +30 minutes.

22. Ecubectedin for use according to claims 1 to 21, wherein ecubectedin is administered at a dose from 2.5 to 5 mg / m2and atezolizumab is administered at a dose of 1200 mg.

23. Ecubectedin for use according to claims 1 to 22, wherein ecubectedin is administered at a dose from 3 to 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg.

24. Ecubectedin for use according to claims 1 to 23, wherein ecubectedin is administered at a dose of 3.6 mg / m2and atezolizumab is administered at a dose of 1200 mg.

25. Ecubectedin for use according to claims 1 to 24, wherein ecubectedin is administered at a dose of 4.5 mg / m2and atezolizumab is administered at a dose of 1200 mg.

26. Ecubectedin for use according to claims 1 to 25, wherein ecubectedin is in the form of a pharmaceutically acceptable salt or ester.

Images