Use of a RXR agonist in treating cancer

Abstract

The present specification provides combinations of RXR agonists and CAR-modified immune cells for the treatment of cancer or autoimmune diseases.

Description

USE OF AN RXR AGONIST IN TREATING CANCERRELATED APPLICATION(S)

[0001] This application claims priority from U.S. Provisional Patent Application Serial Number 63 / 678,456, filed on August 1 , 2024, the entirety of which is incorporated herein by reference.BACKGROUND

[0002] Compounds which have retinoid-like biological activity are well known in the art and are described in numerous United States patents including, but not limited to, U.S. Pat. Nos. 5,466,861 ; 5,675,033 and 5,917,082, all of which are herein incorporated by reference. Preclinical studies with rexinoids (compounds which bind to the retinoid X receptor family of nuclear receptors) suggest that selective activation of retinoid X receptors (RXR), which modulate functions associated with differentiation, inhibition of cell growth, apoptosis and metastasis, can be useful in treating a variety of diseases associated with the biochemical functions modulated by RXR.

[0003] For example, TARGRETIN® (bexarotene), which is an RXR agonist with retinoic acid receptor (RAR) agonist activity as well, was approved by the U.S. Food and Drug Administration for the treatment, both oral and topical, of cutaneous manifestations of cutaneous T cell lymphoma in patients who are refractory to at least one prior systemic therapy. Encouraging results were obtained with TARGRETIN® in several Phase II studies in NSCLC. However, the pivotal Phase III clinical study did not show increased survival. One possible explanation for the limited success of bexarotene is that its activation of RAR decreases its efficacy as an anticancer agent. Thus, more selective RXR agonists can hold greater promise.

[0004] Treatments for cancer are ever evolving, gaining in specificity and sophistication. Early non-surgical cancer treatments generally targeted rapidly dividing cells which were more sensitive to radiological and chemical assault. Over time, more specific and less generally toxic treatments have been developed. Some treatments appear to have broad applicability, for example immune checkpoint inhibitors or rexinoids. Others are targeted to cancers that express a particular antigen or other biomarker involved in the regulation of proliferation or differentiation; including many monoclonal antibodies and kinase inhibitors. Yet as the variety of cancer treatments has grown, it has become ever harder to determine which treatments might be productively combined and for what indications.SUMMARY

[0005] Described herein generally are methods of promoting killing of cancer cells by CAR- modified immune cells in combination with a RXR agonist. In one embodiment, a method of promoting killing of cancer cells by CAR-modified immune cells in a subject with cancer, comprises administrating a RXR agonist compound in combination with CAR-modified immune cells to the subject.

[0006] The RXR agonist is a compound of Formula I:wherein R is H, or lower alkyl of 1 to 6 carbons; or a pharmaceutically acceptable salt thereof.In some embodiments, the RXR agonist is a compound of Formula II:(Formula II).

[0007] In other embodiments, the RXR agonist is an ester of the compound of Formula I.

[0008] The CAR-modified immune cells are CAR-T cells. The use of the RXR agonist to promote killing of pathologic cells by CAR-modified immune cells in the subject, results in improvement of the subject’s disease.

[0009] In some embodiments, the cancer is a non-hematologic cancer. The non- hematologic cancer, can be, but is not limited to, of breast, lung, colorectal, gastric, esophageal, small bowel, prostate, bladder, kidney, adrenal, pancreas, gall bladder, bile duct, uterine, cervical, ovarian, endometrial, genital, cutaneous, melanoma, nervous systems, endocrine systems, head and neck, salivary gland, larynx, trachea, skeletal muscle, smooth muscle, cardiac muscle, bone, or cartilage origin.

[0010] In one embodiment, the non-hematologic cancer is a Her2+ cancer. The Her2+ cancer is a Her2+ breast cancer.

[0011] In other embodiments, the cancer is a hematologic cancer. The hematologic cancer can be, but is not limited to, a leukemia, a lymphoma, a plasma cell cancer, or a myeloma.

[0012] In one embodiment, the hematologic cancer is not a myeloma.

[0013] In some embodiments, the RXR agonist is administered directly to the patient. The RXR agonist is delivered to the patient orally, parenterally, or topically.

[0014] In other embodiments, the RXR agonist is administered to the CAR-modified immune cells in vitro during the process of preparing the CAR-modified immune cells for administration to the patient / subject. The administration of the RXR agonist to the CAR-modified immune cells either by direct administration to the patient, or in vitro during the process of preparation of the CAR-modified immune cells, increases the numbers or the cancer cell killing activity or both, of the CAR-modified immune cells.

[0015] The CAR-modified immune cells are of autologous or allogeneic origin.

[0016] Also described herein are methods of promoting killing of autoimmune diseasemediating lymphocytes by CAR-modified immune cells in a subject with an autoimmune disease. In some embodiments, promoting killing of autoimmune disease-mediating lymphocytes by CAR-modified immune cells in a subject with an autoimmune disease, comprises administrating a RXR agonist in combination with CAR-modified immune cells to the subject.

[0017] The RXR agonist is a compound of Formula I(Formula I) wherein R is H, or lower alkyl of 1 to 6 carbons; or a pharmaceutically acceptable salt thereof.In some embodiments, the RXR agonist is a compound of Formula II(Formula II).

[0018] In other embodiments, the RXR agonist is an ester of the compound of Formula I.

[0019] The CAR-modified immune cells are CAR-T cells.

[0020] In some embodiments, the pathologic cells being killed by the CAR-modified immune cells are autoimmune disease-mediating lymphocytes. The autoimmune disease-mediating lymphocytes are B lymphocytes. The autoimmune disease-mediating B lymphocytes produce autoantibodies which damage at least one type of tissue.

[0021] In other embodiments, the autoimmune disease-mediating lymphocytes are T- lymphocytes. The autoimmune disease-mediating T lymphocytes damage at least one type of tissue.

[0022] The autoimmune disease is a vasculitis, a musculoskeletal disease, a neurologic disease, an endocrine system disease, a skin disease, a lung disease, a cardiovascular disease, a kidney disease, or a gastrointestinal disease.

[0023] In one embodiment, the RXR agonist is administered directly to the patient. The RXR agonist is delivered to the patient orally, parenterally, or topically.

[0024] In another embodiment, the RXR agonist is administered to the CAR-modified immune cells in vitro during the process of preparing the CAR-modified immune cells for administration to the patient.

[0025] The administration of the RXR agonist compound to the CAR-modified immune cells either by direct administration to the patient, or in vitro during the process of preparation of the CAR-modified immune cells, increases the numbers or the autoimmune-mediating cell killing activity or both, of the CAR-modified immune cells. The CAR-modified immune cells are of either autologous or allogeneic origin.BRIEF DESCRIPTION OF THE FIGURES

[0026] FIG. 1 illustrates the anti-tumor activity of IRX4204 in combination with CAR-T cells evaluating cytotoxicity.

[0027] FIG. 2 illustrates the anti-tumor activity of IRX4204 in combination with CAR-T cells evaluating T-cell infiltration.DETAILED DESCRIPTION

[0028] The herein disclosed embodiments include methods of treating cancers with a combination a retinoid X (rexinoid) receptor (RXR) agonist and chimeric antigen receptor (CAR)-modified immune cells (sometimes abbreviated as CAR-MIC) to potentiate the anticancer activity of the CAR-modified immune cells. Some embodiments further comprise administration of thyroid hormone in conjunction with the RXR agonist and CAR-MIC. In some embodiments, the cancer is a human epidermal growth factor receptor 2 (Her2) positive (Her2+) cancer.

[0029] By potentiation it is meant that the CAR-modified immune cells have greater and / or more rapid effect when a RXR agonist is used with the CAR-modified immune cells than when a RXR selective agonist is not used with the CAR-modified immune cells or, similarly, that a given degree of effect can be obtained with a smaller dosage of CAR-modified immune cells when the RXR agonist is also used than would be required if the RXR selective agonist were not used.

[0030] As used herein, the term “potentiate" refers to an improved efficacy of CAR-modified immune cells, or an improved response by the patient, when used in combination with a RXR agonist compared to the use of CAR-modified immune cells in the absence of a RXR agonist. As used herein, the term “augment” also refers to an improved effect when using a RXR agonist in comparison to not using a RXR agonist.

[0031] The methods of treatment include the administration of a combination of two, three, or more therapeutic agents. Moreover, the administration of one of these agents can be described as being done in coordination or conjunction with another of these agents. By such combination, or administration of in coordination or in conjunction with, it is meant that the manner of administration of each of these agents is such that the physiologic effects of the agents overlap in time. This does not require that the agents be contained in the same composition or formulation, or that they be administered as separate compositions at the same time, by the same route of administration, or on the same schedule, though in some embodiments any of the foregoing can be the case. Indeed, while it is possible to administer RXR agonists, thyroid hormone, and Her2 kinase inhibitors on a daily schedule, antibodies are more typically administered at intervals measured in weeks.RXR agonists

[0032] Preclinical studies with rexinoids suggest that selective activation of Retinoid X Receptors (RXR), which modulate functions associated with differentiation, inhibition of cell growth, apoptosis and metastasis, can be useful in treating a variety of diseases associated with the biochemical functions modulated by RXR.

[0033] The Retinoic Acid Receptors (RARs) and RXRs and their cognate ligands function by distinct mechanisms. The term “RAR” as used herein refers to one or more of RARa, RARp, or RARy. The term “RXR” as used herein refers to one or more of RXRa, RXRp, or RXRy. A RAR biomarker is a distinctive biological, biochemical or biologically derived indicator that signifies patient RAR activity. RAR biomarkers include, but are not limited to, CYP26 levels, CRBPI levels, and the like, and combinations thereof.

[0034] In some embodiments, the RAR activation threshold means one or more of a CYP26 level which is 25% increased over baseline and a CRBPI level 25% increased over baseline. The RARs form heterodimers with RXRs and these RAR / RXR heterodimers bind to specific response elements in the promoter regions of target genes. The binding of RAR agonists to the RAR receptor of the heterodimer results in activation of transcription of target genes leading to retinoid effects. On the other hand, the disclosed RXR agonists do not activate RAR / RXR heterodimers. RXR heterodimer complexes like RAR / RXR can be referred to as non-permissive RXR heterodimers as activation of transcription due to ligand-binding occurs only at the non-RXR protein (e.g., RAR); activation of transcription does not occur due to ligand binding at the RXR.

[0035] RXRs also interact with nuclear receptors other than RARs and RXR agonists can elicit some of its biological effects by binding to such RXR / receptor complexes. These RXR / receptor complexes can be referred to as permissive RXR heterodimers as activation of transcription due to ligand-binding can occur at the RXR, the other receptor, or both receptors. Examples of permissive RXR heterodimers include, without limitation, peroxisome proliferator activated receptor / RXR (PPAR / RXR), farnesyl X receptor / RXR (FXR / RXR), nuclear receptor related-1 protein (Nurr1 / RXR) and liver X receptor / RXR (LXR / RXR). Alternately, RXRs can form RXR / RXR homodimers which can be activated by RXR agonists leading to rexinoid effects. Also, RXRs interact with proteins other than nuclear receptors and ligand binding to an RXR within such protein complexes can also lead to rexinoid effects. Due to these differences in mechanisms of action, RXR agonists and RAR agonists elicit distinct biological outcomes and even in the instances where they mediate similar biological effects, they do so by different mechanisms. Moreover, the unwanted side effects of retinoids, such as pro- inflammatory responses or mucocutaneous toxicity, are mediated by activation of one or more of the RAR receptor subtypes. Stated another way, biological effects mediated via RXR pathways would not induce pro-inflammatory responses, and thus, do not not result in unwanted side effects.

[0036] Thus, aspects of the present disclosure provide, in part, a RXR agonist. As used herein, the term “RXR agonist”, is synonymous with “selective RXR agonist” and refers to a compound that selectively binds to one or more RXR receptors like a RXRa, a RXRp, or aRXRy in a manner that elicits gene transcription via an RXR response element. As used herein, the term “selectively binds,” when made in reference to a RXR agonist, refers to the discriminatory binding of a RXR agonist to the indicated target receptor like a RXRa, a RXRp, or a RXRy such that the RXR agonist does not substantially bind with non-target receptors like a RARa, a RARp or a RARy. In some embodiments, the term “RXR agonist” includes esters of a RXR agonist.

[0037] For each of the herein disclosed embodiments the RXR agonists can be compounds having the structure of Formula Iwherein R is H, or lower alkyl of 1 to 6 carbons; or the agonist is a pharmaceutically acceptable salt of the compounds.

[0038] Also disclosed herein are esters of RXR agonists. An ester can be derived from a carboxylic acid of C1 , or an ester can be derived from a carboxylic acid functional group on another part of the molecule, such as on a phenyl ring. While not intending to be limiting, an ester can be an alkyl ester, an aryl ester, or a heteroaryl ester. The term alkyl has the meaning generally understood by those skilled in the art and refers to linear, branched, or cyclic alkyl moieties. Ci-6alkyl esters are particularly useful, where alkyl part of the ester has from 1 to 6 carbon atoms and includes, but is not limited to, methyl, ethyl, propyl, isopropyl, n-butyl, secbutyl, / so-butyl, f-butyl, pentyl isomers, hexyl isomers, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and combinations thereof having from 1-6 carbon atoms, etc. In some embodiments the RXR agonist is the ethyl ester of Formula I.

[0039] In some embodiments the RXR agonist is 3,7-dimethyl-6(S),7(S)-methano,7- [1 ,1 ,4,4-tetramethyl-1 ,2,3,4-tetrahydron-aphth-7-yl]2(E), 4(E) heptadienoic acid, also known as IRX4204, and has the following chemical structure:(Formula II)

[0040] Pharmaceutically acceptable salts of RXR agonists can also be used in the disclosed embodiments. Compounds disclosed herein possess a sufficiently acidic, a sufficiently basic, or both functional groups, and accordingly can react with any of a number of organic or inorganic bases, and inorganic or organic acids, to form a salt.

[0041] Acids commonly employed to form acid addition salts from RXR agonists with basic groups are inorganic acids such as hydrochloric acid, hydrobromic acid, hydroiodic acid, sulfuric acid, phosphoric acid, and the like, and organic acids such as p-toluenesulfonic acid, methanesulfonic acid, oxalic acid, p-bromophenyl-sulfonic acid, carbonic acid, succinic acid, citric acid, benzoic acid, acetic acid, and the like. Examples of such salts include the sulfate, pyrosulfate, bisulfate, sulfite, bisulfite, phosphate, monohydrogenphosphate, dihydrogenphosphate, metaphosphate, pyrophosphate, chloride, bromide, iodide, acetate, propionate, decanoate, caprylate, acrylate, formate, isobutyrate, caproate, heptanoate, propiolate, oxalate, malonate, succinate, suberate, sebacate, fumarate, maleate, butyne-1 ,4- dioate, hexyne-1 ,6-dioate, benzoate, chlorobenzoate, methylbenzoate, dinitrobenzoate, hydroxy benzoate, methoxybenzoate, phthalate, sulfonate, xylenesulfonate, phenylacetate, phenylpropionate, phenylbutyrate, citrate, lactate, gamma-hydroxybutyrate, glycolate, tartrate, methanesulfonate, propanesulfonate, naphthalene-1-sulfonate, naphthalene-2-sulfonate, mandelate, and the like.

[0042] Bases commonly employed to form base addition salts from RXR agonists with acidic groups include, but are not limited to, hydroxides of alkali metals such as sodium, potassium, and lithium; hydroxides of alkaline earth metal such as calcium and magnesium; hydroxides of other metals, such as aluminum and zinc; ammonia, and organic amines, such as unsubstituted or hydroxy-substituted mono-, di-, or trialkylamines; dicyclohexylamine; tributyl amine; pyridine; N-methyl,N-ethylamine; diethylamine; triethylamine; mono-, bis-, or tris-(2- hydroxy-lower alkyl amines), such as mono-, bis-, or tris-(2-hydroxyethyl)amine, 2-hydroxy- tert-butylamine, or tris-(hydroxymethyl)methylamine, N,N-di-lower alkyl-N-(hydroxy lower alkyl)-amines, such as N,N-dimethyl-N-(2-hydroxyethyl)amine, or tri-(2-hydroxyethyl)amine; N-methyl-D-glucamine; and amino acids such as arginine, lysine, and the like.

[0043] IRX4204, like some other RXR ligands, does not activate non-permissive heterodimers such as RAR / RXR. However, IRX4204, is unique in that it specifically activates the Nurr1 / RXR heterodimer and does not activate other permissive RXR heterodimers such as PPAR / RXR, FXR / RXR, and LXR / RXR. Other RXR ligands generally activate these permissive RXR heterodimers. Thus, all RXR ligands cannot be classified as belonging to one class. IRX4204 belongs to a unique class of RXR ligands which specifically activate RXR homodimers and only one of the permissive RXR heterodimers, namely the Nurr1 / RXR heterodimer.

[0044] In one embodiment, the selective RXR agonist does not activate to any appreciable degree the permissive heterodimers PPAR / RXR, FXR / RXR, and LXR / RXR. In another embodiment, the selective RXR agonist, activates the permissive heterodimer Nurr1 / RXR. One example of such a selective RXR agonist is 3,7-dimethyl-6(S),7(S)-methano,7-[1 ,1 ,4,4- tetramethyl-1 ,2,3,4-tetrahydronaphth-7-yl]2(E),4(E) heptadienoic acid (IRX4204) disclosed herein, the structure of which is shown in Formula II. In other aspects of this embodiment, the RXR agonist activates the permissive heterodimers PPAR / RXR, FXR / RXR, or LXR / RXR by 1% or less, 2% or less, 3% or less, 4% or less, 5% or less, 6% or less, 7% or less, 8% or less, 9% or less, or 10% or less relative to the ability of activating agonists to the non-RXR receptor to activate the same permissive heterodimer. Examples of RXR agonists, which activate one or more of PPAR / RXR, FXR / RXR, or LXR / RXR include LGD1069 (bexarotene) and LGD268.

[0045] Binding specificity is the ability of a RXR agonist to discriminate between a RXR receptor and a receptor that does not contain its binding site, such as a RAR receptor.

[0046] Particular embodiments provide methods of treating cancer comprising administering to a patient in need of such treatment a RXR agonist at a level below an RAR activating threshold and at or above an RXR activating threshold.

[0047] For IRX4204, the RAR ECw (the concentration effective to cause a 10% of maximal activation of the RAR) is 300 nM for the a isoform and 200 nM for the p and y isoforms. Thus, in some embodiments, concentrations not exceeding 200 nM are considered to be below an RAR activating concentration. For IRX4204, the RXR EC90(the concentration effective to cause a 90% of maximal activation of the RXR) is 0.1 nM for the a and y isoforms and 1 nM for the p isoform. Thus, in some embodiments concentrations of at least 0.1 nM are considered to be above an RXR activating threshold. Based on studies in humans, oral dosages of IRX4204 of 20 mg / m2 / day produce systemic concentrations that remain below 200 nM. Similarly, it is determined that an oral dosage in the range of 0.01 to 0.02 mg / m2 / day produces systemic concentrations of 0.1 nM or greater. Thus, in various individual embodiments adosage of IRX4204 is at least 0.01 , 0.02, 0.03, 0.05, 0.1 , 0.3, 0.5, 1 , 3 or 5 mg / m2 / day and does not exceed 150, 200, or 300 mg / m2 / day, or any range bound by a pair of these values.

[0048] In other embodiments, the dosage for a human adult of the RXR agonist, for example IRX4204, is from 0.2 to 300 mg / day, such as in individual embodiments, from 0.5, 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 mg / day, but not to exceed 10, 15, 20, 50, or 100 mg / day, or any range bound by a pair of these values.

[0049] The RXR agonist can be administered to a mammal using standard administration techniques, including parenteral, oral, intravenous, intraperitoneal, subcutaneous, pulmonary, transdermal, intramuscular, intranasal, buccal, sublingual, or suppository administration. The term "parenteral," as used herein, includes intravenous, intramuscular, subcutaneous, rectal, vaginal, and intraperitoneal administration. The RXR agonist is suitable for oral administration, for example as a pill, tablet or capsule. Administration can be continuous or intermittent. In certain embodiments, the total daily dosage of RXR agonist can be administered as a single dose or as two doses administered within a 24 hour period spaced 8 to 16, or 10 to 14, hours apart.Chimeric Antigen Receptor-modified Cells

[0050] Tumor cells often down-regulate major histocompatibility complex (MHC) expression and furthermore, when they do express MHC alleles, the immunodominant epitopes are not often known. Thus, MHC-dependent cancer immunotherapies are often not effective. Chimeric antigen receptor (CAR)-modified immune cells react with target antigens on cancer cells in an MHC-independent matter. The CAR allows binding via the antigen-binding domain to target cells wherein the CAR-modified cells kill the target cells in a MHC non-restricted manner by binding to the target cells and induction of activation and cytotoxicity of the modified cells against the tumor target. Binding to target cells can also induce proliferation of the CAR- modified cells.

[0051] As used herein, the term “target cells” refers to cells expressing a surface antigen that can be bound by the CAR. The antigen can also be referred to as the “target antigen.” Target antigens are antigens that are differentially expressed on cancer cells such that the CAR targets the cancer cells preferentially over non-cancer cells.

[0052] Once the modified immune cells bind to target antigen, the internal stimulatory domains of the CAR provide the necessary signals for the immune cell to become fully active. In this fully active state, the immune cells can more effectively proliferate and attack cancer cells.

[0053] CAR-modified cells can recognize a variety of types of antigen, not only protein but also carbohydrate and glycolipid structures typically expressed on the tumor cell surface. Unlike T cell receptor (TCR) recognition, the antigen does not need to be processed and presented by MHC and therefore the same CAR-molecule can be used in all patients who express the same tumor antigen regardless of HLA type.

[0054] The CAR comprises a recombinant polypeptide construct comprising at least an antigen-binding domain, a transmembrane domain, and one or more intracellular stimulatory domains (also referred to as a cytoplasmic signaling domain or an intracellular signaling domain). The antigen-binding domain allows the modified immune cells to specifically bind to the target antigen, the transmembrane domain anchors the CAR in the plasma membrane of the immune cells, and the intracellular stimulatory domain induces persistence, trafficking, and effector functions in the transduced cells.

[0055] The antigen-binding domain of a CAR is often derived from a monoclonal antibody, but other ligands (e.g., heregulin, cytokines) and receptors (e.g., NKp30) can also be used. The antigen-binding domain can include an antibody, or a fragment of an antibody that retains antigen-binding function. For example, the CAR antigen-binding domain is often contributed by a single-chain variable fragment (scFv), which is formed from the variable regions of heavy and light chains of an antibody.

[0056] In one aspect, the transmembrane domain comprises a sequence of the zeta ( chain associated with the T cell receptor complex, such as the intracellular domain of human CD3 chain.

[0057] The one or more intracellular stimulatory domains of the CAR can include an intracellular stimulatory domain of one or more of CD28, 4-1 BB (CD137), CD134 (OX-40), ICOS, and CD40L.

[0058] The antigen-binding domain, transmembrane domain, and the intracellular stimulatory domain(s) are linked either directly or via a spacer sequence.

[0059] The CAR sequences are incorporated in an expression vector. Various expression vectors are known in the art and any such vector can be utilized. In some embodiments, the vector is a retroviral or lentiviral vector. In other embodiments the vector is derived from an adeno-associated virus.

[0060] Immune cells are transformed with the CAR and the CAR is then expressed on the cell surface. Typically, the immune cell stably expresses the CAR, although in some embodiments, the immune cell can transiently express the CAR. The immune cell is thus transfected with a nucleic acid, e.g., mRNA, cDNA, DNA, encoding a CAR. Immune cells ofthe disclosure include mammalian cells (e.g., human cells), and can be autologous cells, syngeneic cells, allogenic cells, and even in some cases, xenogeneic cells. The cells are engineered to express a CAR and, therefore like the CAR itself, are not found in nature. Exemplary immune cells include T lymphocytes (T cells), natural killer (NK) cells, NKT cells, and macrophages (including monocytes and dendritic cells). In some embodiments, the CAR- modified immune cell is a CAR-T cell.

[0061] The CAR-modified immune cells are then cultured to expand the population and obtain a suitable number of cells for a single dose or for multiple doses.

[0062] In certain embodiments, an RXR agonist is added to the expansion cultures during the culture period and have an effect on the CAR-modified cells directly. For example, in culturing CAR-MIC, the RXR agonist added to the expansion cultures is chosen for its ability to, for example, suppress the development of Treg cells and / or its ability to promote the development of Th17 cells. In some embodiments, the RXR agonist is included in the expansion culture of CAR-modified immune cells and administered directly to a subject.

[0063] In certain embodiments, an RXR agonist is added to the expansion cultures during the culture period and have an effect on the CAR-modified cells directly. In some embodiments, the RXR agonist is included in the expansion culture of CAR-modified immune cells and administered directly to a subject. In some embodiments, the RXR agonist is administered to the subject before, concurrently with, or after, administration of the CAR- modified immune cells.Thyroid hormone

[0064] Both biologically sourced and synthetic thyroid hormones have been used in medicine. The major forms of thyroid hormone referred to are T3 (triiodothyronine) and T4(thyroxine). Thyroxine is less active but has a longer half-life and is sometimes considered a prohormone of triiodothyronine. As used herein, the term “thyroid hormone” refers to thyroxine and triiodothyronine. Thyroxine (thyroid hormone T4, levothyroxine sodium) is a tyrosinebased hormone produced by the thyroid gland and is primarily responsible for regulation of metabolism. Both have wide commercial availability and are suitable for use in the herein disclosed embodiments. However, the synthetic form of T4, levothyroxine, is much more commonly utilized (except in patients unable to convert T4into T3) as its longer half-life in the body facilitates once-daily administration. In some embodiments, the administered thyroid hormone is specifically thyroxine. In some embodiments, the administered thyroid hormone is triiodothyronine.

[0065] Administration of RXR agonists, or esters thereof, can lead to the suppression of serum thyroid hormones and possibly to clinical hypothyroidism and related conditions.However, in some embodiments thyroid hormone is not co-administered (or is not primarily co-administered) to remediate a suppression of serum thyroid hormone levels. Coadministration of thyroid hormone with a RXR agonist improves the RXR agonist's anti-cancer efficacy, as compared to the effect of the RXR agonist alone, likely through multiple mechanisms of action. The co-administered thyroid hormone can also mitigate the hypothyroid-inducing effects of the RXR agonist, thereby improving the clinical safety and tolerability of the treatment. Thus, in some embodiments, thyroid hormone is co-administered with a RXR agonist to improve the efficacy of the treatment, whether or not administration of the RXR agonist has caused, or is expected to cause, clinical hypothyroidism. By administration of thyroid hormone in coordination or in conjunction with the RXR agonist it is meant that the manner of administration of each of these two agents is such that the physiologic effects of the two agents overlap in time. This does not require that the RXR agonist and thyroid hormone be contained in the same composition or formulation, or that they be administered as separate compositions at the same time, by the same route of administration, or on the same schedule, though in some embodiments any of the foregoing can be the case.

[0066] Suitable thyroxine doses are generally from about 5 pg / day to about 250 pg / day orally initially with an increase in dose every 2-4 weeks as needed. In other embodiments, the suitable thyroxine dose is from about 5 pg / day to about 225 pg / day, from about 7.5 pg / day to about 200 pg / day, from about 10 pg / day to about 175 pg / day, from about 12.5 pg / day to about 150 pg / day, from about 15 pg / day to about 125 pg / day, from about 17.5 pg / day to about 100 pg / day, from about 20 pg / day to about 100 pg / day, from about 22.5 pg / day to about 100 pg / day, from about 25 pg / day to about 100 pg / day, from about 5 pg / day to about 200 pg / day, from about 5 pg / day to about 100 pg / day, from about 7.5 pg / day to about 90 pg / day, from about 10 pg / day to about 80 pg / day, from about 12.5 pg / day to about 60 pg / day, or from about 15 pg / day to about 50 pg / day. Increases in dose are generally made in increments of about 5 pg / day, about 7.5 pg / day, about 10 pg / day, about 12.5 pg / day, about 15 pg / day, about 20 pg / day, or about 25 pg / day. In certain embodiments, the suitable thyroid hormone dose is a dose able to produce serum levels of T4in the top 50%, the top 60%, the top 70%, the top 80%, or the top 90% of the normal range for the testing laboratory. As the normal range of T4levels can vary by testing laboratory, the target T4levels are based on normal ranges determined for each particular testing laboratory.

[0067] For each embodiment involving a combination of an RXR agonist and CAR-modified immune cells, there is a parallel embodiment in which the combination further comprises a thyroid hormone.Pharmaceutical compositions and formulations

[0068] The various component active agents used in the herein described treatments exist as pharmaceutical compositions or formulations. Such compositions or formulations can be a liquid formulation, semi-solid formulation, or a solid formulation. A formulation disclosed herein can be produced in a manner to form one phase, such as, e.g., an oil or a solid. Alternatively, a formulation disclosed herein can be produced in a manner to form two phases, such as, e.g., an emulsion. A pharmaceutical composition disclosed herein intended for such administration can be prepared according to any method known to the art for the manufacture of pharmaceutical compositions.

[0069] Liquid formulations suitable for parenteral injection or for nasal sprays can comprise physiologically acceptable sterile aqueous or nonaqueous solutions, dispersions, suspensions or emulsions and sterile powders for reconstitution into sterile injectable solutions or dispersions. Formulations suitable for nasal administration can comprise physiologically acceptable sterile aqueous or nonaqueous solutions, dispersions, suspensions or emulsions. Examples of suitable aqueous and nonaqueous carriers, diluents, solvents or vehicles include water, ethanol, polyols (propylene glycol, polyethyleneglycol (PEG), glycerol, and the like), suitable mixtures thereof, vegetable oils (such as olive oil) and injectable organic esters such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersions and by the use of surfactants.

[0070] A pharmaceutical composition disclosed herein can optionally include a pharmaceutically acceptable carrier that facilitates processing of an active compound into pharmaceutically acceptable compositions. As used herein, the term "pharmaceutically acceptable" refers to those compounds, materials, compositions, and / or dosage forms which are, within the scope of sound medical judgment, suitable for contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem complications commensurate with a reasonable benefit / risk ratio. (This definition is also application to the phrase “pharmaceutically-acceptable salts”). As used herein, the term “pharmacologically acceptable carrier” is synonymous with “pharmacological carrier” and refers to any carrier that has substantially no long term or permanent detrimental effect when administered and encompasses terms such as “pharmacologically acceptable vehicle, stabilizer, diluent, additive, auxiliary, or excipient.” Such a carrier generally is mixed with an active compound or permitted to dilute or enclose the active compound and can be a solid, semi-solid, or liquid agent. It is understood that the active compounds can be soluble or can be delivered as a suspension in the desired carrier or diluent. Any of a variety of pharmaceutically acceptable carriers can be used including, without limitation, aqueous mediasuch as, e.g., water, saline, glycine, hyaluronic acid and the like; solid carriers such as, e.g., starch, magnesium stearate, mannitol, sodium saccharin, talcum, cellulose, glucose, sucrose, lactose, trehalose, magnesium carbonate, and the like; solvents; dispersion media; coatings; antibacterial and antifungal agents; isotonic and absorption delaying agents; or any other inactive ingredient. Selection of a pharmacologically acceptable carrier can depend on the mode of administration. Except insofar as any pharmacologically acceptable carrier is incompatible with the active compound, its use in pharmaceutically acceptable compositions is contemplated. Non-limiting examples of specific uses of such pharmaceutical carriers can be found in Pharmaceutical Dosage Forms and Drug Delivery Systems (Howard C. Ansel et al., eds., Lippincott Williams & Wilkins Publishers, 7thed. 1999); Remington: The Science and Practice of Pharmacy (Alfonso R. Gennaro ed., Lippincott, Williams & Wilkins, 20thed. 2000); Goodman & Gilman's The Pharmacological Basis of Therapeutics (Joel G. Hardman et al., eds., McGraw-Hill Professional, 10thed. 2001); and Handbook of Pharmaceutical Excipients (Raymond C. Rowe et al., APhA Publications, 4thedition 2003). These protocols are routine and any modifications are well within the scope of one skilled in the art and from the teaching herein.

[0071] A pharmaceutical composition disclosed herein can optionally include, without limitation, other pharmaceutically acceptable components (or pharmaceutical components), including, without limitation, buffers, preservatives, tonicity adjusters, salts, antioxidants, osmolality adjusting agents, physiological substances, pharmacological substances, bulking agents, emulsifying agents, wetting agents, sweetening or flavoring agents, and the like. Various buffers and means for adjusting pH can be used to prepare a pharmaceutical composition disclosed herein, provided that the resulting preparation is pharmaceutically acceptable. Such buffers include, without limitation, acetate buffers, borate buffers, citrate buffers, phosphate buffers, neutral buffered saline, and phosphate buffered saline. It is understood that acids or bases can be used to adjust the pH of a composition as needed. Pharmaceutically acceptable antioxidants include, without limitation, sodium metabisulfite, sodium thiosulfate, acetylcysteine, butylated hydroxyanisole, and butylated hydroxytoluene. Useful preservatives include, without limitation, benzalkonium chloride, chlorobutanol, thimerosal, phenylmercuric acetate, phenylmercuric nitrate, a stabilized oxy chloro composition, such as, e.g., sodium chlorite and chelants, such as, e.g., DTPA or DTPA- bisamide, calcium DTPA, and CaNaDTPA-bisamide. Tonicity adjustors useful in a pharmaceutical composition include, without limitation, salts such as, e.g., sodium chloride, potassium chloride, mannitol or glycerin and other pharmaceutically acceptable tonicity adjustor. The pharmaceutical composition can be provided as a salt and can be formed with many acids, including but not limited to, hydrochloric, sulfuric, acetic, lactic, tartaric, malic,succinic, etc. Salts tend to be more soluble in aqueous or other protonic solvents than are the corresponding free base forms. It is understood that these and other substances known in the art of pharmacology can be included in a pharmaceutical composition useful in the invention.

[0072] Pharmaceutical formulations suitable for administration by inhalation include fine particle dusts or mists, which can be generated by means of various types of metered, dose pressurized aerosols, nebulizers, or insufflators.

[0073] Semi-solid formulations suitable for topical administration include, without limitation, ointments, creams, salves, and gels. In such solid formulations, the active compound can be admixed with at least one inert customary excipient (or carrier) such as, a lipid and / or polyethylene glycol.

[0074] Solid formulations suitable for oral administration include capsules, tablets, pills, powders and granules. In such solid formulations, the active compound can be admixed with at least one inert customary excipient (or carrier) such as sodium citrate or dicalcium phosphate or (a) fillers or extenders, as for example, starches, lactose, sucrose, glucose, mannitol and silicic acid, (b) binders, as for example, carboxymethylcellulose, alignates, gelatin, polyvinylpyrrolidone, sucrose and acacia, (c) humectants, as for example, glycerol, (d) disintegrating agents, as for example, agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain complex silicates and sodium carbonate, (e) solution retarders, as for example, paraffin, (f) absorption accelerators, as for example, quaternary ammonium compounds, (g) wetting agents, as for example, cetyl alcohol and glycerol monostearate, (h) adsorbents, as for example, kaolin and bentonite, and (i) lubricants, as for example, talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate or mixtures thereof. In the case of capsules, tablets and pills, the dosage forms can also comprise buffering agents.

[0075] The small molecule components of the various embodiments, that is, the RXR agonist, thyroid hormone, and Her2 kinase inhibitors are capable of being formulated in solid, oral dosage forms. The antibody components are generally formulated as liquids typically for intravenous infusion. In alternative embodiments the antibody components can be supplied in lyophilized form for reconstitution as a liquid locally at the site of treatment, where they are also typically infused intravenously into the patient. While intravenous infusion is typical, in alternative embodiments the antibody can be administered by another route of administration, such as subcutaneous injection or infusion.Cancer Treatment

[0076] As used herein, the terms "treatment," "treating," and the like refer to obtaining a desired pharmacologic and / or physiologic effect. This can be observed directly as a slowing of tumor growth, stabilization of disease, or a partial or complete response (that is, tumor regression or elimination of tumors), or extended overall or disease-free survival. Treatment can also be observed as an amelioration or reduction of symptoms related to the underlying cancer. However, as cancer treatment, the disclosed embodiments’ aim and mechanism is directed to inhibiting, stabilizing, or reducing tumor growth (including metastases), or partially or completely eliminating tumors, or extending overall or disease-free survival; effects on other cancer symptoms are secondary. Direct treatment of such other symptoms (for example, pain, nausea, loss of appetite, etc.) is not within the scope of treating cancer as used herein. That is, treating a symptom, for example, cachexia in a cancer patient is not treating cancer. However, an agent that treats cancer (e.g., has an impact on the growth and / or spread of cancer) can also ameliorate a symptom, such as cachexia, either indirectly, through its effect on the cancer, or directly, through a pleiotropic effect. A "therapeutically effective amount" refers to an amount effective, at dosages and for periods of time necessary, to achieve a desired therapeutic result. The therapeutically effective amount can vary according to factors such as the disease state, age, sex, and weight of the individual, and the ability of the CAR- modified immune cells, RXR agonist, and if used, thyroid hormone, to elicit a desired response in the individual.

[0077] However, the dose administered to a mammal, particularly a human, in the context of the present methods, should be sufficient to effect a therapeutic response in the mammal over a reasonable timeframe. One skilled in the art will recognize that the selection of the exact dose and composition and the most appropriate delivery regimen is also influenced by inter alia the pharmacological properties of the formulation, the nature and severity of the condition being treated, and the physical condition and mental acuity of the recipient, as well as the potency of the specific compound, the age, condition, body weight, sex and response of the patient to be treated, and the stage / severity of the disease.

[0078] Treatment activity includes the administration of the medicaments, dosage forms, and pharmaceutical compositions described herein to a patient, especially according to the various methods of treatment disclosed herein, whether by a healthcare professional, the patient his / herself, or any other person. Treatment activities include the orders, instructions, and advice of healthcare professionals such as physicians, physician’s assistants, nurse practitioners, and the like that are then acted upon by any other person including other healthcare professionals or the patient his / herself. In some embodiments, treatment activity can also include encouraging, inducing, or mandating that a particular medicament, orcombination thereof, be chosen for treatment of a condition - and the medicament is actually used - by approving insurance coverage for the medicament, denying coverage for an alternative medicament, including the medicament on, or excluding an alternative medicament, from a drug formulary, or offering a financial incentive to use the medicament, as might be done by an insurance company or a pharmacy benefits management company, and the like. In some embodiments, treatment activity can also include encouraging, inducing, or mandating that a particular medicament be chosen for treatment of a condition - and the medicament is actually used - by a policy or practice standard as might be established by a hospital, clinic, health maintenance organization, medical practice or physicians group, and the like.

[0079] To benefit from the combined effect of a RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) and CAR-modified immune cells, embodiments described herein include methods of treatment comprising or consisting of administering RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) and CAR-modified immune cells to a patient having cancer. Some embodiments described herein further comprise administration of a thyroid hormone in coordination with administration of the RXR agonist. Incorporated by reference herein are US2008 / 0300312, US2020 / 0390736, US2023 / 0172890, and US2023 / 0172872 for all they disclose regarding treatment of cancer with RXR agonists.

[0080] As used herein, the term "cancer" refers to a cellular disorder characterized by uncontrolled or dysregulated cell proliferation, decreased cellular differentiation, inappropriate ability to invade surrounding tissue, and / or ability to establish new growth at ectopic sites. The term "cancer" includes, but is not limited to, solid tumors and hematologic tumors. The term "cancer" encompasses diseases of skin, tissues, organs, bone, cartilage, blood, and vessels. The term "cancer" further encompasses primary and metastatic cancers. Included within the term “cancer cells” are cancer stem cells.

[0081] The disclosed methods can be used to treat any type of cancer known in the art. In some embodiments, the cancer is a solid tumor. Non-limiting examples of solid tumors that can be treated by the disclosed methods include pancreatic cancer, bladder cancer, colorectal cancer, breast cancer, prostate cancer (e.g., androgen-dependent and androgen-independent prostate cancer), renal cancer, hepatocellular cancer, lung cancer (e.g., non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), bronchoalveolar carcinoma (BAC), and adenocarcinoma of the lung), ovarian cancer (e.g., progressive epithelial or primary peritoneal cancer), cervical cancer, gastric cancer, esophageal cancer, head and neck cancer (e.g., squamous cell carcinoma of the head and neck), melanoma, neuroendocrine cancer, brain tumors (e.g., glioma, anaplastic oligodendroglioma, adult glioblastoma multiforme, and adult anaplastic astrocytoma), bone cancer, and soft tissue sarcoma.

[0082] In some embodiments, the cancer is a Her2+cancer. In some embodiments the Her2+cancer is a Her2+breast cancer, gastroesophageal cancer, ovarian cancer, stomach cancer, adenocarcinoma of the lung, uterine cancer (such as serous endometrial carcinoma), or salivary duct carcinoma. Some embodiments specifically include one or more of these cancers. Other embodiments specifically exclude one or more of these cancers.

[0083] In certain embodiments, the cancer is a hematologic malignancy. Non-limiting examples of hematologic malignancy include acute myeloid leukemia, chronic myelogenous leukemia (CML), including accelerated CML and CML blast phase, acute lymphoblastic leukemia, chronic lymphocytic leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, including follicular lymphoma and mantle cell lymphoma, B-cell lymphoma, T-cell lymphoma, multiple myeloma, Waldenstrom's macroglobulinemia, myelodysplastic syndromes, including refractory anemia, refractory anemia with ringed sideroblasts, refractory anemia with excess blasts (RAEB), and RAEB in transformation, and myeloproliferative syndromes.

[0084] In select embodiments a particular type of cancer is treated. In other select embodiments a particular type of cancer is excluded from treatment.

[0085] In some embodiments, the cancer is not multiple myeloma.

[0086] In various embodiments the herein disclosed treatments can be applied as a primary therapy, as a debulking therapy prior to surgical removal of tumor, or as an adjuvant therapy subsequent to any mode of primary therapy (especially surgery) to address residual disease and / or lower the risk of recurrent cancer.

[0087] In some embodiments the patient having cancer has not been previously treated with either RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) or CAR-modified immune cells. In some embodiments the patient has been previously treated with RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) and has achieved stable disease or a partial response (in some embodiments, as defined by RECIST or iRECIST criteria) - that is, the cancer is sensitive to RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) - and CAR-modified immune cells are added to the treatment regimen. In some embodiments the patient has been previously treated with CAR-modified immune cells and has achieved stable disease or a partial response (in some embodiments, as defined by RECIST or iRECIST criteria) - that is, the cancer is sensitive to CAR-modified immune cells - and RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) is added to the treatment regimen.

[0088] Thus some embodiments entail administration of an RXR agonist to a patient with a tumor who has received, is receiving, or is scheduled to receive, CAR-modified immune cells. Some embodiments entail administration of an RXR agonist to a patient in whom CAR-modified immune cells have had some therapeutic effect (less than a complete response), that is administration of the RXR agonist is added to the therapeutic regimen for the CAR-modified immune cells. Some embodiments entail administration of CAR-modified immune cells to a patient in whom an RXR agonist (or RXR agonist in conjunction with thyroid hormone) has had some therapeutic effect (less than a complete response), that is administration of the CAR-modified immune cells are added to the therapeutic regimen for the RXR agonist.

[0089] Therapeutic efficacy can be monitored by periodic assessment of treated patients. For repeated administrations over several days or longer, the treatment can be repeated until a desired suppression of disease or disease symptoms occurs. However, other dosage regimens can be useful and are within the scope of the present disclosure. Antibodies typically have a much longer half-life in the body than the other active agents used in these methods and therefore there are substantially longer intervals (measured in weeks) between administrations.

[0090] The effectiveness of cancer therapy is typically measured in terms of "response." The techniques to monitor responses can be similar to the tests used to diagnose cancer such as, but not limited to:• A lump or tumor involving some lymph nodes can be felt and measured externally by physical examination.• Some internal cancer tumors show up on an X-ray or CT scan and can be measured with a ruler.• Blood tests, including those that measure organ function can be performed.• A tumor marker test can be done for certain cancers.

[0091] Regardless of the test used, whether blood test, cell count, or tumor marker test, it is repeated at specific intervals so that the results can be compared to earlier tests of the same type.

[0092] Response to cancer treatment is defined several ways:• Complete response - all of the cancer or tumor disappears; there is no evidence of disease. Expression level of tumor marker (if applicable) can fall within the normal range.• Partial response - the cancer has shrunk by a percentage but disease remains. Levels of a tumor marker (if applicable) can have fallen (or increased, based on the tumor marker, as an indication of decreased tumor burden) but evidence of disease remains.• Stable disease - the cancer has neither grown nor shrunk; the amount ofdisease has not changed. A tumor marker (if applicable) has not changed significantly.• Disease progression - the cancer has grown; there is more disease now than before treatment. A tumor marker test (if applicable) shows that a tumor marker has risen.

[0093] Other measures of the efficacy of cancer treatment include intervals of overall survival (that is time to death from any cause, measured from diagnosis or from initiation of the treatment being evaluated), cancer-free survival (that is, the length of time after a complete response cancer remains undetectable), and progression-free survival (that is, the length of time after disease stabilization or partial response that resumed tumor growth is not detectable).

[0094] There are two standard methods for the evaluation of solid cancer treatment response with regard to tumor size (tumor burden), the WHO and RECIST standards. These methods measure a solid tumor to compare a current tumor with past measurements or to compare changes with future measurements and to make changes in a treatment regimen. In the WHO method, the solid tumor’s long and short axes are measured with the product of these two measurements is then calculated; if there are multiple solid tumors, the sum of all the products is calculated. In the RECIST method, only the long axis is measured. If there are multiple solid tumors, the sum of all the long axes measurements is calculated. However, with lymph nodes, the short axis is measured instead of the long axis. There is also a variation of the RECIST method for immunotherapies (iRECIST) which takes into account distinctive behaviors linked to these types of therapeutics, such as delayed responses after pseudoprogression. Both the RECIST 1.1 guidelines and the iRecist guidelines are incorporated by reference herein in their entirety.

[0095] In some embodiments of the herein disclosed methods, the tumor burden of a treated patient is reduced by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55% about 60%, about 65%, about 70%, about 75%, about 80%, about 90%, about 95%, about 100%, or any range bound by these values.

[0096] In other embodiments, the 1-year survival rate of treated subjects is increased by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55% about 60%, about 65%, about 70%, about 75%, about 80%, about 90%, about 95%, about 100%, or any range bound by these values.

[0097] In other embodiments, the 5-year survival rate of treated subjects is increased by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%,about 45%, about 50%, about 55% about 60%, about 65%, about 70%, about 75%, about 80%, about 90%, about 95%, about 100%, or any range bound by these values.

[0098] In other embodiments, the 10-year survival rate of treated subjects is increased by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55% about 60%, about 65%, about 70%, about 75%, about 80%, about 90%, about 95%, about 100%, or any range bound by these values.

[0099] In yet other embodiments, the subject has a sustained remission of at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 1 1 months, at least 12 months, at least 14 months, at least 16 months, at least 18 months, at least 20 months, at least 22 months, at least 24 months, at least 27 months, at least 30 months, at least 33 months, at least 36 months, at least 42 months, at least 48 months, at least 54 months, or at least 60 months or more.

[0100] In other embodiments, the methods can additionally help to treat or alleviate conditions, symptoms, or disorders related to cancer. In some embodiments, these conditions or symptoms can include, but are not limited to, anemia, asthenia, cachexia, Cushing’s Syndrome, fatigue, gout, gum disease, hematuria, hypercalcemia, hypothyroidism, internal bleeding, hair loss, mesothelioma, nausea, night sweats, neutropenia, paraneoplastic syndromes, pleuritis, polymyalgia rheumatica, rhabdomyolysis, stress, swollen lymph nodes, thrombocytopenia, Vitamin D deficiency, or weight loss. While a cancer treatment can reduce or treat associated symptoms, treating symptoms associated with cancer, is not treating cancer if there is no expectation that the tumor is reduced or eliminated or their growth or spread is inhibited.

[0101] Toxicities and adverse events are sometimes graded according to a 5 point scale. A grade 1 or mild toxicity is asymptomatic or induces only mild symptoms; can be characterized by clinical or diagnostic observations only; and intervention is not indicated. A grade 2 or moderate toxicity can impair activities of daily living (such as preparing meals, shopping, managing money, using the telephone, etc.) but only minimal, local, or non-invasive interventions are indicated. Grade 3 toxicities are medically significant but not immediately lifethreatening; hospitalization or prolongation of hospitalization is indicated; activities of daily living related to self-care (such as bathing, dressing and undressing, feeding oneself, using the toilet, taking medications, and not being bedridden) can be impaired. Grade 4 toxicities are life-threatening and urgent intervention is indicated. Grade 5 toxicity produces an adverse event-related death. Thus, in various embodiments, use of a RXR agonist, or RXR agonist and CAR-modified immune cells, reduces the grade of a toxicity that is otherwise associated with use of the CAR-modified immune cell, by allowing a lower dose to be used withoutsubstantial sacrifice of efficacy. In some embodiments, use of a RXR agonist, or RXR agonist and thyroid hormone, in combination with CAR-modified immune cells limits a toxicity to grade 1 or less, or produces no observation of the toxicity, without substantial reduction of efficacy as is expected from the CAR-modified immune cells alone. In some embodiments, the combined use of the CAR-modified immune cells and the RXR agonist, or RXR agonist and thyroid hormone, allows continued use of the CAR-modified immune cells at a lower dosage with therapeutic effect in instances where treatment with the CAR-modified immune cells are discontinued due to unacceptable toxicity.

[0102] For each method of treatment there are further parallel embodiments related to the foregoing methods directed to use of the RXR agonist in conjunction with CAR-modified immune cells, or CAR-modified immune cells and thyroid hormone, to treat cancer; directed to use of the RXR agonist in the manufacture of a medicament for use in combination with CAR-modified immune cells, or CAR-modified immune cells and thyroid hormone, to treat cancer.

[0103] Further embodiments include a combination comprising a RXR agonist as herein described and CAR-modified immune cells. Some embodiments further comprise a thyroid hormone.Autoimmune Disease Treatment

[0104] To benefit from the combined effect of a RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) and CAR-modified immune cells, embodiments include methods of treatment comprising or consisting of administering RXR agonist of Formula I (or pharmaceutically acceptable salt thereof) and CAR-modified immune cells to a patient having an autoimmune disease. Some embodiments further comprise administration of thyroid hormone in coordination with administration of the RXR agonist. Incorporated by reference herein are US2013 / 0190395 and US2019 / 0381022 for all they disclose regarding treatment of autoimmune diseases with RXR agonists.

[0105] The autoimmune disorder can be a systemic autoimmune disorder or an organspecific autoimmune disorder. Non-limiting examples of an autoimmune disorder that can be treated using a compound, composition, or combination disclosed herein include acute disseminated encephalomyelitis (ADEM), Addison's disease, an allergy, allergic rhinitis, antiphospholipid antibody syndrome (APS), an arthritis such as, e.g., monoarthritis, oligoarthritis, or a polyarthritis like osteoarthritis, rheumatoid arthritis, juvenile idiopathic arthritis, septic arthritis, spondyloarthropathy, gout, pseudogout, or Still's disease, asthma, acquired immunodeficiency syndrome, acquired immunodeficiency syndrome (AIDS), autoimmune hemolytic anemia, autoimmune hepatitis, autoimmune inner ear disease, bullous pemphigoid,celiac disease, Chagas disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 1 (IDDM), endometriosis, a gastrointestinal disorder such as, e.g., an irritable bowel disease or an inflammatory bowel disease like Crohn's disease or ulcerative colitis, a glomerulonephritis, Goodpasture's syndrome, Graves' disease, Guillain-Barre syndrome (GBS), Hashimoto's thyroiditis, hidradenitis suppurativa, idiopathic thrombocytopenic purpura, interstitial nephritis, interstitial cystitis, a lupus, such as, e.g., discoid lupus erythematosus, drug-induced lupus erythematosus, lupus nephritis, neonatal lupus, subacute cutaneous lupus erythematosus, or systemic lupus erythematosus, morphea, multiple sclerosis (MS), myasthenia gravis, a myopathy such as, e.g., dermatomyositis, inclusion body myositis, or polymyositis, myositis, narcolepsy, neuromyotonia, pemphigus vulgaris, pernicious anemia, primary biliary cirrhosis, psoriasis, psoriatic arthritis, a pulmonary fibrosis, recurrent disseminated encephalomyelitis, rheumatic fever, schizophrenia, scleroderma, Sjogren's syndrome, a skin disorder such as, e.g., dermatitis, eczema, statis dermatitis, hidradenitis suppurativa, psoriasis, rosacea or scleroderma, tenosynovitis, uveitis, a vasculitis such as, e.g., Buerger's disease, cerebral vasculitis, Churg-Strauss arteritis, cryoglobulinemia, essential cryoglobulinemic vasculitis, giant cell arteritis, Golfer's vasculitis, Henoch-Schonlein purpura, hypersensitivity vasculitis, Kawasaki disease, microscopic polyarteritis / polyangiitis, polyarteritis nodosa, polymyalgia rheumatica (PMR), rheumatoid vasculitis, Takayasu arteritis, Wegener's granulomatosis, or vitiligo.

[0106] In some embodiments, the disease is not multiple sclerosis.

[0107] In certain embodiments, the autoimmune disease is psoriasis, glomerulonephritis, pulmonary fibrosis, rheumatoid arthritis, or an inflammatory bowel disease.

[0108] Aspects of the present disclosure include, in part, reducing at least one symptom associated with an autoimmune disorder. The actual symptoms associated with an autoimmune disorder disclosed herein are well known and can be determined by a person of ordinary skill in the art by taking into account factors, including, without limitation, the location of the autoimmune disorder, the cause of the autoimmune disorder, the severity of the autoimmune disorder, the tissue or organ affected by the autoimmune, and the inflammation associated with the autoimmune disorder. Non-limiting examples of a symptom reduced by a method of treating an autoimmune disorder disclosed herein include inflammation, fatigue, pain, cognitive deficits, neurologic deficits, dizziness, malaise, elevated fever and high body temperature, extreme sensitivity to cold in the hands and feet, weakness, soreness, and / or stiffness in muscles and joints, weight changes, digestive or gastrointestinal problems, breathing problems, low or high blood pressure, irritability, anxiety, or depression, infertility or reduced sex drive (low libido), blood sugar changes, and depending on the type of autoimmune disease, an increase in the size of an organ or tissue, or the destruction of anorgan or tissue. Non-limiting examples of an inflammation symptom reduced by a method of treating an autoimmune disorder disclosed herein include pain, loss of neurologic function, loss of cognitive function, edema, hyperemia, erythema, bruising, tenderness, stiffness, swollenness, fever, a chill, congestion of the respiratory tract including nose, and bronchi, congestion of a sinus, a breathing problem, fluid retention, a blood clot, a loss of appetite, an increased heart rate, a formation of granulomas, fibrinous, pus, or non-viscous serous fluid, a formation of an ulcer, or pain.

[0109] In certain embodiments, treatment with a combination of a RXR agonist and a thyroid hormone reduces at least one symptom, at least two symptoms, at least three symptoms, at least four symptoms, or at least five symptoms of an autoimmune disorder. In some embodiments, treatment with a combination of a RXR agonist and a thyroid hormone reduces more than one symptom, more than two symptoms, more than three symptoms, more than four symptoms, or more than five symptoms.

[0110] In other embodiments, the methods described herein can help to treat or alleviate conditions, symptoms, or disorders related to autoimmune diseases. In some embodiments, these conditions or symptoms can include, but are not limited to, anemia, asthenia, cachexia, Cushing’s Syndrome, fatigue, gout, gum disease, hematuria, hypercalcemia, hypothyroidism, internal bleeding, hair loss, mesothelioma, nausea, night sweats, neutropenia, paraneoplastic syndromes, pleuritis, polymyalgia rheumatica, rhabdomyolysis, stress, swollen lymph nodes, thrombocytopenia, Vitamin D deficiency, or weight loss. In other embodiments, the administration of the combination of the RXR agonist with the thyroid hormone prolongs the survival of the individual being treated.

[0111] In some embodiments of the methods described herein, the mammal can experience improvements from the autoimmune disease as a result of treatment with the combination of RXR agonist and a thyroid hormone.

[0112] In some embodiments, the methods described herein can treat rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory disorder which causes pain and swelling in a patient’s joints, generally effecting joints in the hands, wrist, feet, elbows, knees, hips, shoulders, and ankles. Rheumatoid arthritis is an autoimmune disease believed to be caused by the patient’s immune system attacking the patient’s joints causing inflammation and joint damage. Inflammation can cause damage to the cartilage and bone of the joint. Such damage can cause narrowing of joint spacing and leading the joints to become loose, unstable, painful, and immobile.

[0113] Clinical diagnosis of rheumatoid arthritis can be measured through the disease activity score (DAS). The DAS is a clinical index to measure rheumatoid arthritis diseaseactivity by combining information measured from swollen joints, tender joints, the acute phase response, and general health. The DAS has a continuous scale ranging from 0-10. The level of disease activity can be interpreted as low (DAS < 2.4), moderate (2.4 < DAS < 3.7), or high (DAS > 3.7). A DAS < 1.6 corresponds to a state of remission according to the American Rheumatism Association (ARA) criteria. The DAS28 is a variation of DAS. DAS28 consists of a 28 tender joint count, a 28 swollen joint count (range 0-28), erythrocyte sedimentation rate (ESR), and an optional general health assessment on a visual analogue scale (range 0- 100). The level of disease activity can be interpreted as low (DAS28 < 3.2), moderate (3.2< DAS28 < 5.1), or high (DAS28 > 5.1). The DAS28 has a scale ranging from 0 to 9.4. DAS and DAS28 values cannot be directly compared.

[0114] In some embodiments, the treatment of rheumatoid arthritis by the methods described herein can result in the amelioration or improvement of at least one of the symptoms related to rheumatoid arthritis. These symptoms can include, but are not limited to, joint pain, stiffness, tenderness, deformity, and swelling, loss of joint range, rheumatoid nodules, fatigue, and fever. In other embodiments, the methods described herein can help to reduce inflammation and damage caused to the affected joint’s cartilage and bone. In some embodiments, the methods described herein can help to prevent or reduce the disease progression of rheumatoid arthritis.

[0115] In some embodiments, the methods described herein can result in the mammal having a reduced DAS score as compared to prior to treatment. In other embodiments, the mammal can experience a DAS score reduced by 1 , 2, 3, 4, 5, 6, 7, 8, 9, or 10 units. In some embodiments, the methods described herein can result in the mammal having a reduced DAS28 score as compared to prior to treatment. In other embodiments, the mammal can experience a DAS28 score reduced by 1 , 2, 3, 4, 5, 6, 7, 8, or 9 units.

[0116] In some embodiments, the methods described herein can be used to treat psoriasis and / or psoriatic arthritis. Psoriasis is a chronic, autoimmune disease caused by the immune system attacking skin cells which then causes abnormally accelerated growth of skin cells. As a result, an unusually high number of old skin cells and white blood cells are pushed to the skin’s surface causing itchy patches of red skin and silvery scales and systemic inflammation. Psoriasis often affects the elbows, knees, scalp, lower back, face, palms, feet, fingernails, toenails, and mouth. Psoriasis episodes can be triggered by a number of factors, including infections, medications, injuries, and stress. Types of psoriasis include plaque, guttate, inverse, pustular, and erythrodermic. Psoriasis is typically diagnosed by a dermatologist or other medical professional who considers the patient’s medical history and examines the affected skin, scalp, and / or nails. Affected skin can also be examined under a microscope; skin affected by psoriasis generally looks thicker and inflamed as compared to non-affectedskin. Psoriasis is also associated with psoriatic arthritis which is an inflammatory-type of arthritis. Psoriatic arthritis can generally affect any joint and can cause soreness, stiffness, swelling, and can lead to joint damage.

[0117] The current standard for assessment of extensive psoriasis has been the Psoriasis Area and Severity Index (PASI). The PASI is a measure of the average redness, thickness, and scaliness of the lesions (each graded on a 0-4 scale), weighted by the area of involvement.

[0118] In some embodiments, the treatment of psoriasis and / or other conditions associated with psoriasis by the method can result in the amelioration or improvement of at least one of the symptoms related to psoriasis and / or other conditions associated with psoriasis, such as psoriatic arthritis. These symptoms can include, but are not limited to, itchiness, patches of skin, dry cracked skin, pain, pustules, rash, inflammation, hypothermia, dehydration, malnutrition, burning, soreness; thickened, pitted, or ridged nails; leukonychia, subungual hyperkeratosis, loosened nails, nail crumbling, splinter hemorrhage, spotted lunula, onychomycosis, paronychia, hair loss, swollen and / or stiff joints, nail discoloration, joint pain, redness, swelling, reduced range of joint motion, iritis, uveitis, spondylitis, and skin bleeding. In some embodiments, the method can reduce the number and / or duration of psoriatic episodes experienced by the patient.

[0119] In some embodiments, the methods described herein can be used to treat glomerulonephritis (nephritis). Glomerulonephritis is a condition where the glomeruli of the kidney become inflamed. The glomeruli remove excess fluid, electrolytes, and waste from the bloodstream to be excreted in urine. Glomerulonephritis can be acute, such as from infection or injury, or of gradual / chronic onset. Primary glomerulonephritis occurs without cause from another condition while secondary glomerulonephritis is caused by another disease, such as lupus, diabetes, Goodpasture's syndrome, Wegener's disease, or polyarteritis nodosa. Severe or prolonged inflammation associated with glomerulonephritis can damage the kidneys and lead to kidney failure. Non-proliferative forms of glomerulonephritis include, but are not limited to, Minimal Change Disease (MCD, or Nil Lesions, Nil Disease, or lipoid nephrosis), focal segmental glomerulosclerosis, membranous gomerulonephritis, and thin basement disease. Proliferative forms of glomerulonephritis can include, but are not limited to, IgA nephropathy (Berger’s disease), post-infectious glomerulonephritis, membranoproliferative glomerulonephritis, and rapidly progressive glomerulonephritis.

[0120] In some embodiments, thetreatment of glomerulonephritis by the methods described herein can result in the amelioration or improvement of at least one symptom associated with the glomerulonephritis or subsequent kidney dysfunction. These symptoms can include, butare not limited to, edema, swelling, hematuria, proteinuria, decreased urination, increased nighttime urination, darkened urine, abdominal pain, nosebleeds, high blood pressure, foamy urine, decrease / lack of appetite, nausea, vomiting, tiredness, difficulty sleeping / insomnia, dry and itchy skin, nighttime muscle cramps, reduced kidney function, electrolyte imbalances, blood in vomit or stools, cough and shortness of breath, diarrhea, fever, joint or muscle aches, and urinary tract infections (UTIs). In other embodiments, treatment of glomerulonephritis can help to treat or prevent complications due to glomerulonephritis such as, but not limited to, acute kidney failure, chronic kidney failure, congestive heart failure, malignant hypertension, and susceptibility to other infections.

[0121] In some embodiments of the methods herein, the patient can show improved kidney function. Improved kidney function can be shown through laboratory tests, such as through urinalysis testing. In other embodiments, the patient can return to what is considered medically normal urinalysis after treatment with the method. In some embodiments, the patient can have creatinine clearance levels of about 75 mL / min to about 150 mL / min for men and about 80 mL / min to about 130 mL / min for women, urine specific gravity of about 1 .000 to about 1.050, urine RBC levels of about four RBCs or less per sample, urine osmolality levels of about 50 mOsm / kg and about 1250 mOsm / kg, blood iron levels of about 50 pg / dL to about 170 pg / dL in men and about 35 pg / dL to about 165 pg / dL in women, an albumin level of about 3.0 g / dL to about 5.0 g / dL, an average urea nitrogen level of about 4 mg / dL to about 6 mg / dL or about 5 mg / dL for low protein diets (e.g., about 0.5 g / kg body weight daily protein intake), about 10 mg / dL to about 15 mg / dL or about 12 mg / dL for average protein diets (e.g., about 1 g / kg body weight daily protein intake), or about 20 mg / dL to about 25 mg / dL or about 22 mg / dL for high protein diets (e.g., about 2 g / kg body weight daily protein intake), or a blood creatinine level of about 0.5 to about 1.5 mg / dL.

[0122] In some embodiments, the methods herein can be used to treat pulmonary fibrosis. Fibrosis is a condition which generally leads to excessive accumulation and deposition of extracellular matrix (ECM), immune components, connective, and / or scar tissue within the body. Fibrosis can lead to scarring, inflammation, or damage and possibly the ultimate failure of the tissue or organ where the fibrosis occurs. In the case of pulmonary fibrosis, the scar tissue accumulates in the lung’s air sac walls, thickening the air sac walls, and making it difficult for oxygen to enter the blood. Pulmonary fibrosis is not known to have one specific cause (i.e., idiopathic), however, it can be a secondary condition caused by other exposure. Some risk factors which have been associated with pulmonary fibrosis include cigarette smoking, viral infections, environmental pollutants (e.g., silica, hard metal dusts, bacterial / animal proteins, gas / fumes, asbestos fibers, grain dust, bird and animal droppings, etc.), certain medications, genetics, and gastroesophageal reflux disease (GERD). Certainautoimmune diseases have been associated with the development of pulmonary fibrosis, including, but not limited to, Churg-Strauss syndrome, lupus, polymyositis / dermatomyositis, polyangiitis, rheumatoid arthritis, and scleroderma.

[0123] Pulmonary fibrosis is generally diagnosed through evaluation of patient history and physical examination, computerized tomography (CT) scan, removal of lung tissue (biopsy), and pulmonary function tests. Pulmonary functions tests can include spirometry, pulse oximetry, arterial blood gas test, and exercise testing; abnormal pulmonary function can be the result of restriction vital capacity (VC) often with an increased forced expiratory volume in 1 sec (FEVi)Zforced vital capacity (FVC) ratio and / or impaired gas exchange (increased alveolar-arterial oxygen gradient (AaPo2) with rest or exercise or decreased diffusing capacity of the lung for carbon monoxide (DLCO).

[0124] In some embodiments, the treatment of pulmonary fibrosis by the methods herein can result in the amelioration or improvement of at least one symptom associated with pulmonary fibrosis. These symptoms can include, but are not limited to, exertional dyspnea, non-productive / dry cough, shortness of breath, weight loss, low-grade fivers, fatigue, arthralgias, myalgias, fine bibasilar inspiratory crackles (Velcro crackles), digital clubbing, apnea, or pulmonary hypertension. In some embodiments, the treatment of pulmonary fibrosis by the methods herein can result in the amelioration or prevention of at least one complication associated with pulmonary. These complications can include, but are not limited to, heart attack, stroke, pulmonary embolism, respiratory failure, heart failure, or lung infections.

[0125] In some embodiments, the patient can show a decrease in existing fibrotic tissue or a decrease in the formation of new fibrotic tissue after treatment with the method. In other embodiments, the patient can have improved lung function after treatment with the methods herein. In some embodiments, the patient can have a FVC and FEVi, which is repeatable to within 0.15 L upon repeat efforts, or if the largest value for either FVC or FEVi less than 1 L, then the patient can have a repeatability to within 0.1 L of the largest value. In other embodiments, the patient after treatment with the methods herein can have a peripheral capillary oxygen saturation (SpO2) of greater than about 90%, an arterial blood gas test with a partial pressure of oxygen (PaO2) of about 70 mmHg to about 100 mmHg or about 10 kPa to about 13 kPa, a partial pressure of carbon dioxide (PaCO2) of about 30 mmHg to about 50 mmHg, or about 4 kPa to about 6 kPa; a pH of about 7.3 to about 7.5, a bicarbonate (HCO3) level of about 20 mEq / L or mmol / L to about 30 mEq / L or mmol / L, or an oxygen content (O2CT) level of about 20 m L / 100 mL of blood to about 25 m L / 1 OOmL of blood or about 6 mmol / L.

[0126] In some embodiments, the methods can be used to treat an inflammatory bowel disease (IBD). IBD comprises a group of conditions associated with chronic inflammation inthe digestive tract. Inflammation is caused by a cell-mediated immune response in the gastrointestinal mucosa which can be caused by genetic predisposition, viral illness, or environmental factor. IBD can include such diseases as ulcerative colitis, Crohn’s disease, collagenous colitis, diversion colitis, Behcet’s disease, indeterminate colitis, and lymphocytic colitis.

[0127] In some embodiments, the treatment of IBD by the methods herein can result in the amelioration or improvement of at least one symptom associated with IBD. These symptoms can include, but are not limited to, diarrhea, rectal bleeding, abdominal pain, urgent need to move bowels, sensation of incomplete evacuation, constipation, cramping, constipation, loss of appetite, fever, weight loss, nausea, vomiting, malaise, fatigue, night sweats, loss of normal menstrual cycle, anemia, ulcers, hematochezia, arthralgias, growth delays or failed sexual maturity in children, arthritis, uveitis, liver disease, bloody stools, perianal disease, abscesses, joint pain, skin rashes, eye pain, or mouth sores. In some embodiments, the treatment of inflammatory bowel disease by the methods can result in the amelioration or prevention of at least one complication associated with IBD. These complications can include, but are not limited to, malnutrition, colon cancer, fistulas, strictures, fissures, intestinal rupture, or bowel obstruction. IBD is generally diagnosed through patient history and elimination of other diseases through blood tests (e.g., complete blood cell tests, electrolyte panel, liver function tests, etc.), and endoscopic and imaging procedure.

[0128] A compound, composition, or combination disclosed herein can also be administered to a mammal in combination with other therapeutic compounds to increase the overall therapeutic effect of the treatment. The use of multiple compounds to treat an indication can increase the beneficial effects while reducing the presence of side effects.EXAMPLES

[0129] The following non-limiting examples are provided for illustrative purposes only in order to facilitate a more complete understanding of representative embodiments now contemplated. These examples should not be construed to limit any of the embodiments described in the present specification,Example 1Anti-Tumor Activity of IRX4204 in combination with Her2 CAR-T cells

[0130] IRX4204 and controls were administered via cell culture media on study day 1 . Test agents were diluted with cell culture media. Cells were cultured in the presence of test agent overnight for 12-16 hours. The study endpoint was 12-16 hours after treating the cells with the test agents or controls. Cells were then analyzed via cell cytometry.Table 1

[0131] A 3D ex vivo assay in which SBKR3 spheroids are tested were performed in a 96- well plate. After formation, spheroids were treated overnight with 20 conditions (5 concentrations of CAR-T x 4 concentrations of IRX-4204) as depicted in Table 1 . All conditions were done in triplicate for 60 wells in total. The endpoint was a readout of CAR-T labeling vs. tumor cell labeling vs viability to evaluate T-cell infiltration and cytotoxicity.

[0132] SKBR3 cells were stained with cell tracker deep red and seeded in densities of 40,000 / well, 80,000 / well, 160,000 / well, 320,000 / well in 6 well plate. The wells were observed daily until the spheroids reached 60pm.

[0133] SKBR3 cells were thawed and stained with CellTracker™ Deep Red Dye for 20 minutes in PBS and resuspended in organoid culture media. Following staining, an equal number of cells were plated into 6-well plate in 2000pl organoid culture media as shown in Table 2.

[0134] Once the SKBR3 spheroids have reached the desired size, CAR-T cells were thawed and stained with 5pM CellTrace™ Violet dye in PBS for 20 minutes and resuspended in IMDM Medium. Organoid culture media was removed before fluorescently stained CAR-T cells and IRX4204 were administered and cultured overnight.

[0135] On study day 10, 5pl SYTOX™ Green Ready reagent was added to each well for HCA fluorescent cytotoxicity analysis. Imaging and analysis was performed by Celllnsight CX7 High content screening (HCS) platform and HCS studio software.

[0136] High content imager was programmed to identify SKBR3 spheroids, CAR-T cells, and dead cells by recognizing the emission spectra of the red, violet and green fluorescent dyes respectively. Colocalization of green and red emission spectra was analyzed to calculate cytotoxicity and T-cell infiltration.Table 2

[0137] The results are presented in FIG. 1 and FIG. 2. FIG. 1 illustrates the anti-tumor activity of IRX4204 in combination with CAR-T cells evaluating cytotoxicity. FIG. 2 illustrates the anti-tumor activity of IRX4204 in combination with CAR-T cells evaluating T-cell infiltration.

[0138] In closing, it is to be understood that although aspects of the present specification are highlighted by referring to specific embodiments, one skilled in the art will readily appreciate that these disclosed embodiments are only illustrative of the principles of the subject matter disclosed herein. Therefore, it should be understood that the disclosed subject matter is in no way limited to a particular methodology, protocol, and / or reagent, etc., described herein. As such, various modifications or changes to or alternative configurations of the disclosed subject matter can be made in accordance with the teachings herein without departing from the spirit of the present specification. Lastly, the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to limit the scope of the present invention, which is defined solely by the claims. Accordingly, the present invention is not limited to that precisely as shown and described.

[0139] Certain embodiments of the present invention are described herein, including the best mode known to the inventors for carrying out the invention. Of course, variations on these described embodiments will become apparent to those of ordinary skill in the art upon reading the foregoing description. The inventor expects skilled artisans to employ such variations as appropriate, and the inventors intend for the present invention to be practiced otherwise than specifically described herein. Accordingly, this invention includes all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law. Moreover, any combination of the above-described embodiments in all possible variations thereof is encompassed by the invention unless otherwise indicated herein or otherwise clearly contradicted by context.

[0140] Groupings of alternative embodiments, elements, or steps of the present invention are not to be construed as limitations. Each group member may be referred to and claimed individually or in any combination with other group members disclosed herein. It is anticipated that one or more members of a group may be included in, or deleted from, a group for reasonsof convenience and / or patentability. When any such inclusion or deletion occurs, the specification is deemed to contain the group as modified thus fulfilling the written description of all Markush groups used in the appended claims.

[0141] Unless otherwise indicated, all numbers expressing a characteristic, item, quantity, parameter, property, term, and so forth used in the present specification and claims are to be understood as being modified in all instances by the term “about.” As used herein, the term “about” means that the characteristic, item, quantity, parameter, property, or term so qualified encompasses a range of plus or minus ten percent above and below the value of the stated characteristic, item, quantity, parameter, property, or term. Accordingly, unless indicated to the contrary, the numerical parameters set forth in the specification and attached claims are approximations that may vary. At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the scope of the claims, each numerical indication should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. Notwithstanding that the numerical ranges and values setting forth the broad scope of the invention are approximations, the numerical ranges and values set forth in the specific examples are reported as precisely as possible. Any numerical range or value, however, inherently contains certain errors necessarily resulting from the standard deviation found in their respective testing measurements. Recitation of numerical ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate numerical value falling within the range. Unless otherwise indicated herein, each individual value of a numerical range is incorporated into the present specification as if it were individually recited herein.

[0142] The terms “a,” “an,” “the” and similar referents used in the context of describing the present invention (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., “such as”) provided herein is intended merely to better illuminate the present invention and does not pose a limitation on the scope of the invention otherwise claimed. No language in the present specification should be construed as indicating any non-claimed element essential to the practice of the invention.

[0143] Specific embodiments disclosed herein may be further limited in the claims using consisting of or consisting essentially of language. When used in the claims, whether as filed or added per amendment, the transition term “consisting of’ excludes any element, step, or ingredient not specified in the claims. The transition term “consisting essentially of” limits the scope of a claim to the specified materials or steps and those that do not materially affect thebasic and novel characteristic(s). Embodiments of the present invention so claimed are inherently or expressly described and enabled herein.

[0144] All patents, patent publications, and other publications referenced and identified in the present specification are individually and expressly incorporated herein by reference in their entirety for the purpose of describing and disclosing, for example, the compositions and methodologies described in such publications that might be used in connection with the present invention. These publications are provided solely fortheir disclosure prior to the filing date of the present application. Nothing in this regard should be construed as an admission that the inventors are not entitled to antedate such disclosure by virtue of prior invention or for any other reason. All statements as to the date or representation as to the contents of these documents is based on the information available to the applicants and does not constitute any admission as to the correctness of the dates or contents of these documents.

Claims

We Claim:1 . A method of promoting killing of cancer cells by CAR-modified immune cells in a subject with cancer, comprising administrating a RXR agonist compound in combination with CAR-modified immune cells to the subject.

2. The method of Claim 1 , wherein the RXR agonist is a compound of Formula Iwherein R is H, or lower alkyl of 1 to 6 carbons; or a pharmaceutically acceptable salt thereof.

3. The method of Claim 2, wherein the RXR agonist is a compound of Formula II(Formula II).

4. The method of Claim 2, wherein the RXR agonist is an ester of the compound of Formula I.

5. The method of any one of Claims 1-4, wherein the CAR-modified immune cells are CAR-T cells.

6. The method of any one of Claims 1-5, wherein the use of the RXR agonist to promote killing of pathologic cells by CAR-modified immune cells in the subject, results in improvement of the subject’s disease.

7. The method of any one of Claims 1-6, wherein the cancer is a non- hematologic cancer.

8. The method of Claim 7, wherein the non-hematologic cancer is of breast, lung, colorectal, gastric, esophageal, small bowel, prostate, bladder, kidney, adrenal, pancreas, gall bladder, bile duct, uterine, cervical, ovarian, endometrial, genital, cutaneous, melanoma, nervous systems, endocrine systems, head and neck, salivary gland, larynx, trachea, skeletal muscle, smooth muscle, cardiac muscle, bone, or cartilage origin.

9. The method of Claim 7, wherein the non-hematologic cancer is a Her2+ cancer.

10. The method of Claim 9, wherein the Her2+ cancer is a Her2+ breast cancer.11 . The method of any one of Claims 1-6, wherein the cancer is a hematologic cancer.

12. The method of Claim 11 , wherein the hematologic cancer is a leukemia, a lymphoma, a plasma cell cancer, or a myeloma.

13. The method of Claim 11 , wherein the hematologic cancer is not a myeloma.

14. The method of any one of Claims 1-4, wherein the RXR agonist is administered directly to the patient.

15. The method of Claim 14, wherein the RXR agonist is delivered to the patient orally, parenterally, or topically.

16. The method of any one of Claims 1-5, wherein the RXR agonist is administered to the CAR-modified immune cells in vitro during the process of preparing the CAR-modified immune cells for administration to the patient.

17. The method of any one of Claims 14-16, wherein the administration of the RXR agonist to the CAR-modified immune cells either by direct administration to the patient, or in vitro during the process of preparation of the CAR-modified immune cells, increases the numbers or the cancer cell killing activity or both, of the CAR-modified immune cells.

18. The method of any one of Claims 1-17, wherein the CAR-modified immune cells are of autologous or allogeneic origin.

19. A method of promoting killing of autoimmune disease-mediating lymphocytes by CAR-modified immune cells in a subject with an autoimmune disease, comprising administrating a RXR agonist in combination with CAR-modified immune cells to the subject.

20. The method of Claim 19, wherein the RXR agonist is a compound of Formula(Formula I) wherein R is H, or lower alkyl of 1 to 6 carbons; or a pharmaceutically acceptable salt thereof.21 . The method of Claim 20, wherein the RXR agonist is a compound of FormulaII(Formula II).

22. The method of Claim 20, wherein the RXR agonist is an ester of the compound of Formula I.

23. The method of Claim 19, wherein the CAR-modified immune cells are CAR-T cells.

24. The method of any one of Claims 19-23, wherein the pathologic cells being killed by the CAR-modified immune cells are autoimmune disease-mediating lymphocytes.

25. The method of Claim 24, wherein the autoimmune disease-mediating lymphocytes are B lymphocytes.

26. The method of Claim 25, wherein the autoimmune disease-mediating B lymphocytes produce autoantibodies which damage at least one type of tissue.

27. The method of Claim 24, wherein the autoimmune disease-mediating lymphocytes are T-lymphocytes.

28. The method of Claim 25, wherein the autoimmune disease-mediating T lymphocytes damage at least one type of tissue.

29. The method of any one of Claims 19-28, wherein the autoimmune disease is a vasculitis, a musculoskeletal disease, a neurologic disease, an endocrine system disease, a skin disease, a lung disease, a cardiovascular disease, a kidney disease, or a gastrointestinal disease.

30. The method of any one of Claims 19-23, wherein the RXR agonist is administered directly to the patient.31 . The method of Claim 30, wherein the RXR agonist is delivered to the patient orally, parenterally, or topically.

32. The method of any one of Claims 19-23, wherein the RXR agonist is administered to the CAR-modified immune cells in vitro during the process of preparing the CAR-modified immune cells for administration to the patient.

33. The method of any one of Claims 19-23, wherein the administration of the RXR agonist compound to the CAR-modified immune cells either by direct administration to the patient, or in vitro during the process of preparation of the CAR-modified immune cells, increases the numbers or the autoimmune-mediating cell killing activity or both, of the CAR- modified immune cells.

34. The method of any one of Claims 19-33, wherein the CAR-modified immune cells are of either autologous or allogeneic origin.

Images