Combination therapies for the treatment of advanced malignancies including solid tumors

Abstract

Methods are provided for treating cancers in subjects in need of such treatment. Such methods include methods of treating cancers, including VHL-expressing cancers and chemotherapy-resistant solid tumor cancers, such as malignancies reliant on BCL-xL, with combinations of chemotherapeutic agents and DT2216. These methods include treatment of malignancies which utilize any mechanism which drives resistance by BCL-xL.

Description

Attorney Docket No.123698.0030 COMBINATION THERAPIES FOR THE TREATMENT OF ADVANCED MALIGNANCIES INCLUDING SOLID TUMORS CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This is an International Patent Application claiming priority to and the benefit of U.S. Patent Application No.63 / 687,577, filed 27 August 2024, which is incorporated by reference herein in its entirety. TECHNICAL FIELD

[0002] The invention relates generally to methods of treating cancer in patients by the administration of BCL-xL targeting / degrading substances in conjunction with the administration of chemotherapy and / or other anti-cancer agents. In some aspects, the invention teaches the use of bifunctional degraders to drive selective degradation of BCL-xL proteins in patients. This improvement in target selectivity over occupancy-based small molecule treatments results in less thrombocytopenia observed in the patients. In other aspects, the invention teaches the use of such bifunctional degraders in combination with chemotherapeutic agents. In these methods, synergies are observed which render treatment more effective than a treatment with either the chemotherapeutic agent or the BCL-xL degrader alone. In some embodiments, the methods are used for the treatment of advanced malignancies in human patients. BACKGROUND OF CERTAIN ASPECTS OF THE DISCLOSURE

[0003] Apoptosis is a term used to describe an intrinsic cellular pathway that causes dissolution of a cell in response to specific stimuli or signals. This pathway is required during organ development and in an adult organism may be activated in certain situations, some of which may include tissue injury. Some important signals for apoptosis include metabolic stress and / or the presence of unrepaired DNA damage in dividing cells. It is understood that signals that have the potential to trigger apoptosis can occur in cancer cells as well for similar reasons, along with others. Indeed, the genetic instability that is a hallmark of malignancy can create “replication stress”. This is often seen when a cell continues to divide despite inaccuracies in DNA replication. Situations and stressors such as this may act as potential initiating signals of apoptosis.

[0004] The apoptosis pathway consists of a series of interacting signaling proteins, regulatory proteins, and enzymes which, if activated, digest essential cellular structures,Attorney Docket No.123698.0030 triggering cell death. This pathway is also regulated by proteins that oppose pathway activation. It has been found that in many malignancies these anti-apoptotic regulatory proteins are present in levels higher than those found in normal cells. Other malignancies demonstrate a higher dependence on a single anti-apoptotic signaling protein (e.g. BCL-XL). In some cases, this results in the malignant cells having a reduced sensitivity to the apoptotic triggers that could normally result from the replication stress discussed above, or from the metabolic stress that often accompanies tumor growth.

[0005] Examples of such regulatory proteins that inhibit the apoptosis pathway include BCL2, BCL-xL, and MCL1. (Letai. Apoptosis and Cancer. Ann Rev Cancer Biology 2017; 1:15.1 – 15.20; see also Figure 1.)

[0006] One indicator of the importance of these anti-apoptotic proteins is the fact that although cancer cell genomes show numerous mutations, some of which are seen to be “driver” mutations, and others regarded as merely “bystander” mutations, gene deletion and / or loss of function mutations are almost never found in the genes for BCL2, BCL-xL (BCL2L1), and MCL1. See Figure 2.

[0007] Further, the increased expression of BCL-xL following chemotherapy in a patient has been observed in several important studies. Without being limited to any one conclusion, this may imply that this higher barrier to apoptosis initiation is a mechanism of resistance of cancer cells to chemotherapy. See Figure 3.

[0008] The importance of BCL-xL is also suggested by the correlation of higher expression of the BCL2L gene, which encodes BCL-xL, with shorter patient survival periods in patients suffering from pancreatic cancer. See Figure 4.

[0009] Such observations have driven attempts at the development of drugs to target BCL- xL for the treatment of cancer. One such example is navitoclax, which is a synthetic, orally- active small molecule that inhibits both BCL2 and BCL-xL. Although it has been assessed in numerous laboratory studies, its clinical development was halted following the determination of its close association with dose-dependent thrombocytopenia. Normal platelets are produced from the cytoplasm of megakaryocytes in the bone marrow of a patient. It is thought that such platelets require BCL-xL to prevent apoptosis because they are destroyed rapidly by navitoclax and BCL-XL levels decline during the normal aging process (Lebois M. Platelets 2016; 27:497). Megakaryocytes also produce the antiapoptotic protein MCL1 and may thus be less sensitive to navitoclax. (Kile BT. Br J Haematology 2014; 165:217). While the thrombocytopenia observed was reversable with the discontinuation of navitoclax treatmentAttorney Docket No.123698.0030 and release of new platelets by megakaryocytes, this effect was sufficiently challenging to be a significant obstacle to the development of this or other similar drugs operating via occupancy-based inhibition.

[0010] It would be an improvement in the art to provide BCL-xL targeting molecules and methods of using such BCL-xl targeting molecules in conjunction with chemotherapeutic agents to interfere with this resistance mechanism of malignant cells, rendering them more susceptible to apoptosis via normal apoptotic pathways and / or the administration of chemotherapeutic agents, while reducing the toxicity to platelets. BRIEF SUMMARY OF SOME ASPECTS OF THE DISCLOSURE

[0011] In some aspects of the invention, methods are provided for treating cancer in patients by administering BCL-xL targeting / degrading substances. The use of such bifunctional degraders to drive selective degradation of BCL-xL proteins in patients can be beneficial in making some cancer cells more vulnerable to apoptotic signals while avoiding the thrombocytopenia observed in other treatments. In other methods of the present invention, methods are provided for treating cancer in patients by administering BCL-xL targeting / degrading substances in conjunction with the administration of chemotherapy and / or other anti-cancer agents to the patients. In these methods chemotherapeutic agents may be made more effective than treatments using either the chemotherapeutic agent or the BCL-xL degrader alone, improving patient outcomes. In some such embodiments, the methods are used for the treatment of advanced malignancies in human patients. In still other such embodiments, the methods are used in the treatment of solid tumor cancers by co-administration of DT2216 and chemotherapeutic agents.

[0012] DT2216 is a drug developed to target BCL-xL while sparing normal platelets. DT2216 has been termed a “PROTAC”, or targeted protein degrader. Within the scope of the invention, methods of treatment are provided in which DT2216 is administered in conjunction with a standard chemotherapeutic agent to block / prevent / counter BCL-xL- mediated resistance mechanisms.

[0013] The structure of DT2216 is as follows:Attorney Docket No.123698.0030

[0014] Without being limited to any one theory, it is thought that as is characteristic of this new class of drugs, there are two binding sites on DT2216. One portion of the molecule was designed to bind to BCL-xL, while the second binding site binds the Von Hippel Lindau (VHL) E3 ligase. The molecular structure of DT2216 is also illustrated in Figure 5, and the posited binding / BCL-xL degradation pathway is illustrated in Figure 6.

[0015] More specifically, and without limitation, it is understood that when the VHL E3 ligase is in proximity to BCL-xL in the correct orientation, it transfers a molecule of ubiquitin to BCL-xL. The ubiquinated BCL-xL is then a substrate for the proteosome and is degraded. Since it is believed that the DT2216 molecule is not consumed in this process, one molecule of DT2216 can bring about the destruction of a number of molecules of BCL-xL.

[0016] Because the amount of the VHL E3 ligase in platelets is very low, it is believed that platelets will be less sensitive to DT2216 than to currently-used substances such as navitoclax and other similar agents.

[0017] As taught herein, effective DT2216 treatment methodologies require the agent to be administered only 1-2 times weekly to a patient, improving their quality of life during their treatment regimen. While the plasma half-life of DT2216 in humans is approximately 7-10 hours, there is sustained retention and protein degradation in tumor cells, based on preclinical studies. Those studies showed that BCL-xL levels in white blood cells were very low at intervals of 48-96 hours after treatment. As a result, in a sense, the methods and dosing regimens taught herein provide intermittent dosing with the BCL-xL targeting / degrading compound interspersed with extended periods of “drug holiday” to circulating platelets newly released by megakaryocytes, in contrast to existing methodologies which result in sustained exposure of platelets to substances such as navitoclax required for BCL-xL inhibition in tumors. These effects are seen in the study of the effect of DT2216 onAttorney Docket No.123698.0030 MOLT leukemia cells and on human platelets and its greater selectivity compared to the occupancy-based inhibitor ABT263 (navitoclax), shown in Figures 7A-C.

[0018] According to methods of the present invention, the activity of DT2216 in degradation of BCL-xL and the safety of DT2216 in human subjects was demonstrated in a first-in-human clinical trial conducted by the applicants. The clinical trial (NCT04886622) enrolled patients with advanced solid tumor malignancies. Treatment in the study was DT2216 as a monotherapy administered as a 30-minute i.v. infusion twice weekly (BIW). A 3 + 3 dose escalation plan was used. Eligible subjects had solid tumors of any histology that had progressed on standard of care treatment and had measurable tumor as determined by RECIST 1.1.

[0019] Tumor assessment was repeated at 8-week intervals during the term of the study. A total of 20 subjects were treated over six dose levels (cohorts) ranging from 0.04 – 0.4 mg / kg BIW. The median age of the enrollees was 60.5, demographically 60% were female, 45% were Hispanic and 15% were African American. 55% of the patients had colorectal or pancreatic cancers. Blood samples were taken before and a at various time points after DT2216 administration for analyses of complete blood count, PK and biomarker pharmacodynamics (PD, tumor regression and measurement of BCL-xL levels in peripheral blood white cells by Western blot).

[0020] No dose limiting toxicities were observed. Patients remained on study for a median of 57 days of treatment. The reasons for discontinuation of treatment were tumor progression for 85%, patient choice 5%, physician decision 5%, and a non-treatment related adverse event for 5%. There were no patients with complete or partial tumor regression by RECIST 1.1. Stable disease was observed in 20% of patients. One patient with NSCLC remained on treatment for 9 months before deciding to discontinue therapy.

[0021] Thrombocytopenia occurred in the first treatment cycle with most events in dose escalation cohorts 4 – 6. The lowest platelet count for each patient in their first cycle ranged from 24,000 to 297,000 with a median of 84,000. In all cases the platelet count recovered to > 50,000 within 4 days and > 75,000 in 1 week. There were no episodes of bleeding associated with thrombocytopenia. All patients were able to continue treatment with DT2216. Patients in cohort 6 received 0.4 mg / kg / dose of DT2216. Assays on peripheral blood white cells (PBMCs) during the first cycle of treatment showed rapid and sustained degradation of BCL-xL. The recommended phase 2 dose was 0.4 mg / kg i.v. BIW.Attorney Docket No.123698.0030

[0022] This Phase 1 study for DT2216 has defined the MTD and demonstration of transient, reversible thrombocytopenia as the dose-limiting effect, in contrast to navitoclax, which caused sustained Grade 3 / 4 thrombocytopenia and neutropenia in clinical trials. Platelet changes are readily monitorable, and no dose-limiting toxicities were observed for DT2216.

[0023] Beyond the demonstration of safety and activity (BCL-xL degradation in PBMCs) is the question of best use of DT2216 as a treatment for cancer. While there have been some preclinical studies with DT2216 and chemotherapy drugs as well as targeted anti-cancer agents in a variety of cancer cell lines that showed greater anti-cancer effect in the combination than as single agents, no work has been showing efficacy of such treatments against solid tumors, including, without limitation, chemotherapy-resistant solid tumors.

[0024] Applicants see their pioneering work in confirming the safety and efficacy of DT2216 as fundamental to the disclosed methods of treating solid tumor cancers with DT2216 alone and / or in combination with standard anti-cancer drugs to achieve more effective therapy for malignancies including, without limitation, advanced cancers.

[0025] For decades, possible cancer treatments have been evaluated by modeling treatment with the proposed drug or modality against cancer, most often either grown as cells in culture or as tumor tissue implanted in animals. Countless observations have indicated that treatments that are beneficial in clinical treatment have demonstrated activity in at least some of these model systems but that many agents have been discovered that do not fulfil in the clinic the promise of the results observed in the lab. The analysis of predictive validity is complex and has not been conclusively solved. A person of skill in cancer treatment development would be aware of this problem.

[0026] There are other novel aspects and features of this disclosure. They will become apparent as this specification proceeds. Accordingly, this brief summary is provided to introduce a selection of concepts in a simplified form that are further described below in the detailed description. The summary and the background are not intended to identify key concepts or essential aspects of the disclosed subject matter, nor should they be used to constrict or limit the scope of the claims. For example, the scope of the claims should not be limited based on whether the recited subject matter includes any or all aspects noted in the summary and / or addresses any of the issues noted in the background.Attorney Docket No.123698.0030 BRIEF DESCRIPTION OF THE DRAWINGS

[0027] A further understanding of the nature and advantages of the embodiments of the methods taught herein may be realized by reference to the following drawings. In the appended figures, similar components or features may have the same reference label.

[0028] Figure 1 is an illustration of an exemplary cellular apoptosis pathway;

[0029] Figure 2 illustrates the results of an analysis of the DNA of 26 cancer cell types, illustrating the rarity of gene deletion or loss of function mutations in the genes for BCL2, BCL-xL, and MCL1;

[0030] Figures 3A and 3B illustrate the results of experiments showing increases in the expression of BCL-xL in ovarian cell lines following exposure to chemotherapeutic agents;

[0031] Figure 4 illustrates the results of an experiment correlating higher levels of BCL2L expression with shorter patient survival periods in pancreatic cancer patient populations;

[0032] Figure 5 illustrates the structure of DT2216, a BCL-xL-targeting drug disclosed for use in the methods of treatment discussed herein;

[0033] Figure 6 illustrates a posited mechanism of BCL-xL degradation mediated by DT2216;

[0034] Figures 7A, 7B and 7C show the results of work done to compare the effect of DT2216 on MOLT leukemia cells and on human platelets;

[0035] Figures 8A, 8B and 8C report the effects of DT2216 and either azacytidine or ruxolitinib on leukemic cell lines derived from patients;

[0036] Figures 9Aand 9B illustrate the results of the administration of DT2216 and chemotherapy to T-ALL cells engrafted in immune-deficient mice;

[0037] Figure 10 reports the results of the addition of DT2216 to chemotherapy in an in vitro context on human breast cancer, prostate cancer, hepatocellular carcinoma and colon cancer-derived cell lines;

[0038] Figures 11A, 11B, and 11C show the effect of the addition of DT2216 to gemcitabine therapy, an agent frequently used in the treatment of pancreatic cancers;

[0039] Figure 12 reports the comparative benefits of co-adminstration of DT2216 with irinotecan versus irinotecan alone in tumor cell lines;Attorney Docket No.123698.0030

[0040] Figure 13 illustrates enhanced efficacy of everolimus and DT2216 in some SCLC cell lines;

[0041] Figure 14 shows potential synergistic effects of DT2216 and the KRAS G12C inhibitor sotorasib on lung cancer cell lines;

[0042] Figures 15A, 15B and 15C show similar synergies in xenograft experiments in immune-deficient mice;

[0043] Figures 16A, 16B and 16C show the results of a combination treatment of xenografted colon cancer cell lines;

[0044] Figure 17 shows the results of navitoclax co-administered with trametinib on patients with KRAS-mutated tumors;;

[0045] Figures 18A and 18B show the results of the use of a small-molecule BCL-xL inhibitor, A-385358, on non-small cell cancer cell lines;

[0046] Figure 19 illustrates the results of A-385359 on a variety of cancer cell lines;

[0047] Figures 20A and 20B illustrate the results of xenograft experiments using lung cancer cell lines treated with paclitaxel, A-385358, or a combination of both agents;

[0048] Figure 21 shows the results of a study conducted using navitoclax and 52 other lung cancer cell lines;

[0049] Figure 22 illustrates the results of work done on breast cancer patient-derived tumors treated with a HER2-targeting antibody-drug conjugate TDM-1 and a BCL-xL inhibitor ABT-263 or ABT-737;

[0050] Figure 23 shows the results of several different regimens, with combination therapies tuned to minimize associated weight loss and thrombocytopenia; and

[0051] Figure 24 shows that treatment of pancreatic cancer cells alone with gemcitabine and nab-paclitaxel is less effective than combination therapies with A-1331852.

[0052] While the embodiments described herein are susceptible to various modifications and alternative forms, specific embodiments have been shown by way of example in the drawings and will be described in detail herein. However, the exemplary embodiments described herein are not intended to be limited to the particular forms disclosed. Rather, the instant disclosure covers all modifications, equivalents, and alternatives falling within the scope of the appended claims.Attorney Docket No.123698.0030 DETAILED DESCRIPTION

[0053] The methods disclosed herein relate to, among other things, methods of treating cancers in patients. In some instances, the methods are for treating cancer in patients by administering BCL-xL targeting / degrading substances. The use of such bifunctional degraders to drive selective degradation of BCL-xL proteins in patients can be beneficial in making some cancer cells more vulnerable to apoptotic signals while avoiding the thrombocytopenia observed in other treatments. In other methods of the present invention, methods are provided for treating cancer in patients by administering BCL-xL targeting / degrading substances in conjunction with the administration of chemotherapy and / or other anti-cancer agents to the patients. In these methods chemotherapeutic agents may be made more effective than treatments using either the chemotherapeutic agent or the BCL-xL degrader alone, improving patient outcomes. In some such embodiments, the methods are used for the treatment of advanced malignancies in human patients. In still other such embodiments, the methods are used in the treatment of solid tumor cancers by co-administration of DT2216 and chemotherapeutic agents.

[0054] In accordance with the present invention, methods are provided for the treatment of cancers in which BCL-xL is present. In others, methods are provided for the treatment of cancers in which BCL-xL is significant to the resistance of the cancer to chemotherapy. In some such methods, BCL-xL may be upregulated. In still others, cancers may show dependence on BCL-xL to resist apoptosis. In some methods of the invention, mono- or co- administration of the BCL-xL targeting / degrading substance with a chemotherapeutic agent may be used in patients with solid tumor cancers, including malignancies in which BCL-xL is present, or in which BCL-xL drives chemotherapy-resistance.

[0055] The instant application relates to methods of treating cancer / cancer therapy. In some embodiments, the methods of the invention relate to the treatment of an individual having cancer by administering to the individual a BCL-xL targeting / degrading substance. In others, the methods of the invention relate to the treatment of an individual having cancer by administering a BCL-xL targeting / degrading substance and a chemotherapeutic agent. In some embodiments, that BCL-XL targeting / degrading substance is DT2216, as discussed above. In some methods, as described herein, the cancer is a VHL-expressing cancer.

[0056] In describing and claiming features of this disclosure, the following terminology will be used in accordance with the definitions described below unless indicated otherwise.Attorney Docket No.123698.0030

[0057] As used in this specification, the singular forms “a,” “an,” and “the” include plural referents unless the context clearly indicates otherwise.

[0058] Similarly, the term “about”, when used to modify a numerically defined parameter, (such as, without limitation, dosage ranges or the length of treatment time with a combination therapy, as described herein) means that the parameter may vary by as much as 10% below or above the stated numerical value for that parameter. Further, when used at the beginning of a listing of parameters, “about” is meant to modify each parameter. For example, about 0.5 mg, 0.75 mg or 1.0 mg means about 0.5 mg, about 0.75 mg or about 1.0 mg. Similarly, about 5% or more, 10% or more, 15% or more, 20% or more, and 25% or more means about 5% or more, about 10% or more, about 15% or more, about 20% or more, and about 25% or more.

[0059] The term “administering” refers to the delivery of a therapeutic agent to a subject, using any of a variety of methods and delivery systems known to those skilled in the art. Exemplary routes of administration include intravenous, intramuscular, subcutaneous, intraperitoneal, spinal or other parenteral routes of administration, such as by injection or infusion. The phrase “parenteral administration” as used herein means modes of administration other than enteral and topical administration, such as by injection, and includes, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intralymphatic, intralesional, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural and intrasternal injection and infusion, as well as in vivo electroporation. In some instances, a therapeutic agent may be administered via a non- parenteral route, or orally. Other non-parenteral routes may include topical, epidermal or mucosal routes of administration, such as intranasally, vaginally, rectally, sublingually or topically. Administering can also be performed, for example, once, a plurality of times, and / or over one or more extended periods.

[0060] A “chemotherapeutic agent” is a chemical compound useful in the treatment of cancer and is known to those skilled in cancer treatment. Specific examples include, without limitation, a wide variety of substances, some of which are included under the classes of antibody drug conjugates, BCL2 inhibitors, biologic response modifiers, cellular therapies, cytotoxins, enzyme inhibitors, hormonal agents, HIF 2 alpha inhibitors, immunotherapy agents, nuclear export inhibitors, PARP inhibitors, protein synthesis inhibitors, proteosome inhibitors, PROTACs, radiopharmaceuticals, telomerase inhibitors, therapeutic antibodies,Attorney Docket No.123698.0030 therapeutic enzymes. Some exemplary chemotherapeutic agents include, without limitation or exclusion, the following compounds: Antibody drug conjugates

[0061] Adcetris (Brentuximab Vedotin), Ado-Trastuzumab Emtansine, Besponsa (Inotuzumab Ozogamicin), Elahere (Mirvetuximab Soravtansine-gynx), Enfortumab Vedotin-ejfv, Enhertu (Fam-Trastuzumab Deruxtecan-nxki), Gemtuzumab Ozogamicin, Loncastuximab Tesirine-lpyl, Polatuzumab Vedotin-piiq, Sacituzumab Govitecan-hziy, Tisotumab Vedotin-tftv

[0062] BCL2 Inhibitors

[0063] Venclexta (Venetoclax) Biologic response modifier

[0064] Adstiladrin (Nadofaragene Firadenovec-vncg), Anktiva (Nogapendekin Alfa Inbakicept-pmln), Besremi (Ropeginterferon Alfa-2b-njft), Dexamethasone, IL-2 (Aldesleukin), Imlygic (Talimogene Laherparepvec), Nogapendekin Alfa Inbakicept-pmln Cellular therapies

[0065] Abecma (Idecabtagene Vicleucel),Amtagvi (Lifileucel), Axicabtagene Ciloleucel, Brexucabtagene Autoleucel, Breyanzi (Lisocabtagene Maraleucel), Carvykti (Ciltacabtagene Autoleucel), Idecabtagene Vicleucel, Kymriah (Tisagenlecleucel), Provenge (Sipuleucel-T) Cytotoxins

[0066] Abraxane (Paclitaxel Albumin-stabilized Nanoparticle Formulation), Adriamycin (Doxorubicin Hydrochloride), Alimta (Pemetrexed Disodium), Alkeran for Injection (Melphalan Hydrochloride), Alkeran Tablets (Melphalan), Arranon (Nelarabine), Arsenic Trioxide, Azacitidine, Beleodaq (Belinostat), Bendamustine Hydrochloride, BiCNU (Carmustine), Bleomycin Sulfate, Busulfan, Cabazitaxel , Camptosar (Irinotecan Hydrochloride), Capecitabine, Carboplatin, Carmustine, Chlorambucil, Cisplatin, Cladribine, Clofarabine, Cosmegen (Dactinomycin), Cyclophosphamide, Cytarabine, Dacarbazine, Dacogen (Decitabine), Daunorubicin Hydrochloride, Docetaxel, Doxorubicin Hydrochloride, Doxorubicin Hydrochloride Liposome, Ellence (Epirubicin Hydrochloride), Eloxatin (Oxaliplatin), Eribulin Mesylate, Etoposide, 5-FU (Fluorouracil Injection), Fludarabine Phosphate, Folotyn (Pralatrexate, Gemcitabine Hydrochloride, HalavenAttorney Docket No.123698.0030 (Eribulin Mesylate), Hycamtin (Topotecan Hydrochloride), Hydroxyurea, Idarubicin Hydrochloride, Ifosfamide, Inqovi (Decitabine and Cedazuridine), Istodax (Romidepsin), Ixabepilone, Jelmyto (Mitomycin), Lomustine, Lonsurf (Trifluridine and Tipiracil Hydrochloride), Lurbinectedin, Matulane (Procarbazine Hydrochloride), Mechlorethamine Hydrochloride, Mercaptopurine, Methotrexate Sodium, Mitomycin , Mitoxantrone Hydrochloride, Nanoparticle Paclitaxel (Paclitaxel Albumin-stabilized Nanoparticle Formulation), Nelarabine, Onivyde (Irinotecan Sucrosofate), Oxaliplatin, Paclitaxel, Procarbazine Hydrochloride, Purinethol (Mercaptopurine), Thioguanine, Thiotepa, Targretin (Bexarotene), Tazemetostat Hydrobromide, Temodar (Temozolomide), Thioguanine, Thiotepa, Topotecan Hydrochloride, Trabectedin, Vinblastine Sulfate, Vincristine Sulfate, Vinorelbine Tartrate, Vorinostat, Vyxeos (Daunorubicin Hydrochloride and Cytarabine Liposome)

[0067] Enzyme inhibitors

[0068] Abemaciclib, Acalabrutinib Maleate Monohydrate, Adagrasib, Afatinib Dimaleate, Afinitor (Everolimus), Alectinib, Alpelisib, Alunbrig (Brigatinib), Asciminib Hydrochloride, Augtyro (Repotrectinib), Avapritinib, Axitinib, Ayvakit (Avapritinib), Balversa (Erdafitinib), Belzutifan, Binimetinib, Bosutinib, Braftovi (Encorafenib), Brukinsa (Zanubrutinib), Cabozantinib-S-Malate, Calquence (Acalabrutinib Maleate Monohydrate), Capivasertib, Capmatinib Hydrochloride, Ceritinib, Cobimetinib Fumarate, Crizotinib, Dabrafenib Mesylate, Dacomitinib, Dasatinib, Duvelisib, Eflornithine Hydrochloride, Enasidenib Mesylate, Entrectinib, Erlotinib Hydrochloride, Everolimus, Fedratinib Hydrochloride, Fotivda (Tivozanib Hydrochloride), Fruquintinib, Gavreto (Pralsetinib), Gefitinib, Gilteritinib Fumarate, Gleevec (Imatinib Mesylate), Ibrance (Palbociclib), Ibrutinib, Iclusig (Ponatinib Hydrochloride), Idelalisib, Inrebic (Fedratinib Hydrochloride), Ivosidenib, Jakafi (Ruxolitinib Phosphate), Jaypirca (Pirtobrutinib), Kisqali (Ribociclib), Koselugo (Selumetinib Sulfate), Lapatinib Ditosylate, Larotrectinib Sulfate, Lenvatinib Mesylate, Lorlatinib, Lumakras (Sotorasib), Lytgobi (Futibatinib), Mekinist (Trametinib Dimethyl Sulfoxide), Mektovi (Binimetinib), Midostaurin, Momelotinib Dihydrochloride Monohydrate, Nerlynx (Neratinib Maleate), Nexavar (Sorafenib Tosylate), Nilotinib, Ojemda (Tovorafenib), Olutasidenib, Osimertinib Mesylate, Pacritinib Citrate, Pazopanib Hydrochloride, Pemazyre (Pemigatinib), Pexidartinib Hydrochloride, Qinlock, (Ripretinib), Quizartinib Dihydrochloride, Regorafenib, Retevmo (Selpercatinib), Sorafenib Tosylate, Sunitinib Malate,Attorney Docket No.123698.0030 Temsirolimus, Tepmetko (Tepotinib Hydrochloride), Tucatinib, Vandetanib, Vemurafenib, Zaltrap (Ziv-Aflibercept) Hormonal agents

[0069] Abiraterone Acetate,Anastrozole, Apalutamide, Arimidex (Anastrozole), Aromasin (Exemestane), Bicalutamide, Darolutamide, Elacestrant Dihydrochloride, Eligard (Leuprolide Acetate), Enzalutamide, Evista (Raloxifene Hydrochloride), Fareston (Toremifene), Faslodex (Fulvestrant), Femara (Letrozole), Firmagon (Degarelix), Goserelin Acetate, Lanreotide Acetate, Megestrol Acetate, Nilandron (Nilutamide), Orgovyx (Relugolix), Raloxifene Hydrochloride, Tamoxifen Citrate, Toremifene HIF 2 alpha inhibitors

[0070] Welireg (Belzutifan) Immunotherapy agents

[0071] Aldara (Imiquimod), Aldesleukin, Atezolizumab, Avelumab, Bavencio (Avelumab), Cemiplimab-rwlc, Copiktra (Duvelisib), Dostarlimab-gxly, Durvalumab, Imjudo (Tremelimumab-actl), Ipilimumab, Keytruda (Pembrolizumab), Loqtorzi (Toripalimab-tpzi), Nivolumab, Retifanlimab-dlwr, Tevimbra (Tislelizumab-jsgr) Nuclear Export Inhibitors

[0072] Selinexor PARP inhibitors

[0073] Akeega (Niraparib Tosylate Monohydrate and Abiraterone Acetate), Lynparza (Olaparib), Rucaparib Camsylate, Talazoparib Tosylate Protein Synthesis Inhibitors

[0074] Omacetaxine Mepesuccinate Proteosome inhibitors

[0075] Bortezomib, Carfilzomib, Ixazomib Citrate PROTACs

[0076] Lenalidomide, Pomalidomide RadiopharmaceuticalsAttorney Docket No.123698.0030

[0077] Ibritumomab Tiuxetan, Iobenguane I 131, Lutetium (Lu 177-Dotatate), Pluvicto (Lutetium Lu 177 Vipivotide Tetraxetan), Radium 223 Dichloride Telomerase Inhibitors

[0078] Imetelstat Sodium Therapeutic antibodies

[0079] Actemra (Tocilizumab), Alemtuzumab, Alymsys (Bevacizumab), Amivantamab- vmjw, Arzerra (Ofatumumab), Avastin (Bevacizumab), Blinatumomab, Cetuximab, Columvi (Glofitamab-gxbm), Cyramza (Ramucirumab), Danyelza (Naxitamab-gqgk), Daratumumab, Dinutuximab, Elotuzumab, Elranatamab-bcmm, Emapalumab-lzsg, Epcoritamab-bysp, Gamifant (Emapalumab-lzsg), Gazyva (Obinutuzumab), Herceptin (Trastuzumab), Imdelltra (Tarlatamab-dlle), Isatuximab-irfc, Kimmtrak (Tebentafusp-tebn), Margetuximab-cmkb, Monjuvi (Tafasitamab-cxix), Mosunetuzumab-axgb, Necitumumab, Panitumumab, Perjeta (Pertuzumab), Poteligeo (Mogamulizumab-kpkc), Rituximab, Siltuximab, Talquetamab-tgvs, Teclistamab-cqyv, Tocilizumab, Zynlonta (Loncastuximab Tesirine-lpyl) Therapeutic enzymes

[0080] Asparaginase Erwinia Chrysanthemi, Asparaginase Erwinia Chrysanthemi (Recombinant)-rywn, Asparlas (Calaspargase Pegol-mknl), Calaspargase Pegol- mknl, Glucarpidase

[0081] As used herein, “chemotherapy” refers to the use of a chemotherapeutic agent, as defined above, or a combination of multiple such agents, such as, without limitation, two, three, four or chemotherapeutic agents together, for the treatment of cancer in a subject. When a chemotherapy includes more than one chemotherapeutic agent, the chemotherapeutic agents can be administered to the patient on the same day or on different days in the same treatment cycle.

[0082] The term “cancer” is used to refer to a broad group of diseases characterized by uncontrolled growth of abnormal cells in the body of a subject. A “cancer” or “cancer tissue” may include a tumor. In some instances, unregulated cell division and growth results in the formation of malignant tumors that may invade other tissues, such as adjoining tissues, and which may also metastasize to more distant parts of the body of the subject, in some instances through the lymphatic system or bloodstream of the subject. Any distal tumors formed as a result may be said to be “derived from” the pre-metastatic tumor. Examples of cancer include, without limitation, carcinoma, lymphoma, leukemia, blastoma, and sarcoma.Attorney Docket No.123698.0030 More specific examples include squamous cell carcinoma, myeloma, small-cell lung cancer, non-small cell lung cancer, glioma, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, acute myeloid leukemia (AML), multiple myeloma, gastrointestinal (tract) cancer, renal cancer, ovarian cancer, liver cancer, lymphoblastic leukemia, lymphocytic leukemia, colorectal cancer, endometrial cancer, kidney cancer, prostate cancer, thyroid cancer, melanoma, chondrosarcoma, neuroblastoma, pancreatic cancer, glioblastoma multiforme, cervical cancer, brain cancer, stomach cancer, bladder cancer, hepatoma, breast cancer, colon carcinoma, and head and neck cancer. Another particular example of cancer includes renal cell carcinoma.

[0083] Within the bounds of this disclosure, it is understood that wherever aspects are described herein with the language “comprising,” otherwise analogous aspects described in terms of “consisting of” and / or “consisting essentially of” are also included.

[0084] Furthermore, as used in this disclosure, an “effective dosage” or “effective amount” of a drug, compound, or pharmaceutical composition is an amount sufficient to effect any one or more beneficial or desired results. For prophylactic uses, beneficial or desired results would include elimination or reduction of risk, lessening the severity, or delaying the outset of the disease, including biochemical, histological and / or behavioral symptoms of the disease, its complications and intermediate pathological phenotypes presenting during development of the disease. For therapeutic uses, beneficial or desired results may include clinical results such as reducing incidence or amelioration of one or more symptoms of various diseases or conditions (such as for example cancer), decreasing the dose of other medications required to treat the disease, enhancing the effect of another medication, and / or delaying the progression of the disease. An effective dosage can be administered in one or more administrations. In some methods of the present invention, an effective dosage may include a dosage at which a therapeutic effect is observed without dose-limiting toxicity of thrombocytopenia being observed in the patient.

[0085] For the purposes of this disclosure, an effective dosage of drug, compound, or pharmaceutical composition is an amount sufficient to accomplish prophylactic or therapeutic treatment either directly or indirectly. As is understood in the clinical context, an effective dosage of a drug, compound, or pharmaceutical composition may or may not be achieved in conjunction with another drug, compound, or pharmaceutical composition. Thus, an “effective dosage” may be considered in the context of administering one or moreAttorney Docket No.123698.0030 therapeutic agents, and a single agent may be considered to be given in an effective amount if, in conjunction with one or more other agents, a desirable result may be or is achieved.

[0086] The term “patient,” or “subject”, as used herein, refers to a living organism suffering from or prone to a described condition. Such conditions can be prevented or treated by administration of a compound or composition or combination as provided herein, such as a cancer. The terms “patient” or “subject” and include both humans and animals. Subjects include, but are not limited to, mammals (e.g., murines, simians, equines, bovines, porcines, canines, felines, and the like), and are preferably human.

[0087] The terms “pharmaceutically acceptable excipient” or “pharmaceutically acceptable carrier” refer to a component of a formulation or composition that may be included in any combination of the compositions described herein and which causes no significant adverse toxicological effects to a subject.

[0088] The terms “protein”, “polypeptide” and “peptide” are used interchangeably herein and refer to any peptide-linked chain of amino acids, regardless of length co-translational or post-translational modification.

[0089] The terms “treat” or “treating” a cancer, as used herein, mean to administer a combination therapy according to the present invention to a subject having cancer, or diagnosed with cancer, to achieve at least one positive therapeutic effect. Such positive therapeutic effects may include, without limitation, reduced number of cancer cells, reduced tumor size, reduced rate of cancer cell infiltration into peripheral organs, or reduced rate of tumor metastases or tumor growth, reversing, alleviating, inhibiting the progress of, or preventing the disorder or condition to which such term applies, or one or more symptoms of such disorder or condition. The term “treatment”, as used herein, unless otherwise indicated, refers to the act of treating as “treating” as defined herein. “Treating” also includes adjuvant and neo-adjuvant treatment of a subject. For the purposes of this disclosure, beneficial or desired results may include, but are not limited to, one or more of: reducing the proliferation of (or destroying) neoplastic or cancerous cell; inhibiting metastasis or neoplastic cells; shrinking or decreasing the size of a tumor; remission of the cancer; decreasing symptoms resulting from the cancer; increasing the quality of life of a subject or patient suffering from the cancer; decreasing the dose of other medications required to treat the cancer; delaying cancer progression; curing the cancer; overcoming one or more resistance mechanisms of any given cancer; and / or prolonging the survival of a subject diagnosed with the cancer.Attorney Docket No.123698.0030

[0090] Positive therapeutic effects in cancer, as described herein, can be measured in a variety of ways. In some embodiments, an effect realized by administering the combination therapies described herein may include any one or more of a partial response (PR), a complete response (CR), an overall response (OR), an objective response rate (ORR), a progression free survival (PFS), a radiographic PFS, disease free survival (DFS) and overall survival (OS). PFS, also referred to as “Time to Tumor Progression” describes a length of time during and after treatment that the cancer does not grow, and includes an amount of time during which patients experience a CR or PR, as well as the amount of time patients experience stable disease (SD). DFS refers to the length of time during and after treatment that a subject remains disease free. OS refers to the prolongation in life expectancy observed when compared to naïve or untreated subjects. In some embodiments, response to a combination therapy of the invention may include any one or more of PR, CR, PFS, DFS, ORR, OR or OS. A treatment regimen for a combination therapy as described herein which is effective to treat a cancer patient may vary according to factors such as the specific disease state, age, and weight of the subject.

[0091] As used herein, the term “co-administration” should not be taken to mean that the drugs in the combination are administered all at once. Each drug has a characteristic duration of effect related to time course of absorption, distribution, uptake by cells, degradation by metabolism and elimination or excretion as well as the duration of its effects in cancer cells. Depending on the specific type of tumor and the specific drugs in the combination there are situations in which the best result will be when both drugs are present simultaneously in the cancer cell but there are also situations in which treatment with one agent creates a temporary period of heightened vulnerability to other agents. Thus “co-administration” might be achieved with various schedules of concurrent or sequential administration, and are both included within the scope of the present disclosure.

[0092] Preclinical studies conducted with DT2216 combined with chemotherapy or targeted agents against human cancer cell lines in Acute myeloid leukemia (AML) and lymphoma support the methods disclosed herein targeting treatment of solid tumor cancers.

[0093] It is thought that AML which arises from myeloproliferative neoplasms that have a mutation in the JAK2 gene have a particularly poor prognosis. Current standard chemotherapies have little effect. A study by Konopleva et al reported synergistic effects for the combination of DT2216 and either azacytidine or ruxolitinib tested against patient- derived leukemic cell lines. (See Figure 8, in which (A) The JAK2-mut Pa and Ruxo-Re AMLAttorney Docket No.123698.0030 cell lines, including HEL, SET2, and UKE-1, were treated with ruxolitinib and / or DT2216 at the indicated concentrations for a duration of 72 hours. (B) The SET2 and UKE-1 were treated with AZA and / or DT2216 at the indicated concentrations for a duration of 72 hours. (C) The HEL and SET2 were treated with AZA and / or DT2216 at the indicated concentrations for a duration of 72 hours. In these experiments, a combination index (CI) of less than 1 indicates a synergistic effect, with this experiment showing strong synergy for DT2216 and azacytidine. See Wang, Konopleva, et al. American Society of Hematology 2023 Annual meeting abstract #4154).

[0094] In the treatment of T-cell acute lymphoblastic leukemia (T-ALL), chemotherapy with the combination of asparaginase, dexamethasone, and vincristine is much less useful than in B-cell ALL. Experiments using human T-ALL cells engrafted in immune-deficient mice showed significantly greater treatment effect with the addition of DT2216 to chemotherapy, supporting the solid tumor treatment methods taught herein. (See Figures 9a, 9b.)

[0095] Other studies of the addition of DT2216 to chemotherapy in short term in vitro cultures of human cancer cell lines derived from breast cancer, prostate cancer, hepatocellular carcinoma, and colon cancer were also completed. Interestingly, the addition of DT2216 resulted in a synergistic effect in all experiments except for two. It produced synergism but not strong synergism when used with doxorubicin against colon cancer. DT2216 was not synergistic with chemotherapy when used against a renal cancer cell line because renal cancers typically lack VHL and therefore DT2216 is not able to degrade BCL- xL in such cells (Khan, Zhou, et al. Nature Medicine 2019; 25:1938). It did have a CI <1 (0.454) and the definition of synergistic is <1. However, it is much less potent than ABT263, in contrast to similar or greater potency to ABT263 in the other tumor models. See Figure 10.

[0096] In work against pancreatic carcinoma cancer cell lines, in vitro Figures 11A and B), and in two pancreatic cancer patient-derived tumors (PDX) in immune deficient mice (Figure 11C), the addition of DT2216 increased the efficacy of gemcitabine, a standard chemotherapy drug for pancreatic cancer.

[0097] High levels of BCL-xL have been found in fibrolamellar carcinoma, an uncommon malignancy found as an aggressive tumor of the liver driven by DNA gene fusion, DNAJB1- PRKACA. Testing using tumor cell lines in immune-deficient mice demonstrated greater efficacy for the combination of DT2216 and irinotecan compared to chemotherapy or DT2216 alone. See Figure 12.Attorney Docket No.123698.0030

[0098] An investigation of anti-apoptotic proteins in small cell lung cancer cell lines (SCLC) used A1155463, an inhibitor of BCL-xL; venetoclax, an inhibitor of BCL2; S63845, an inhibitor of MCL-1; navitoclax, and inhibitor of BCL2 and BCL-xL; and DT2216, a degrader of BCL-xL. The results showed that many cell SCLC cell lines depend on BCL-xL based on the greater sensitivity to A1155463, navitoclax and DT2216 than to venetoclax or S63845 (Khan, Zhou, et al. Cell Death Discovery 2023; 9:1), Figure 13. It was found that everolimus, an approved mTOR inhibitor caused decreased expression of MCL1 in some SCLC cell lines and that the combination of DT2216 and everolimus had enhanced efficacy. Figure 14.

[0099] The gene KRAS is mutated in most cases of pancreatic cancer and in many cases of non-small cell lung cancer, colorectal cancer, and other tumors of the gastrointestinal system. The protein created by the mutated form of the KRAS gene activates a signaling pathway that stimulates cell replication in the cancer cells. Several drugs have been developed recently that can block this anormal signal in cells with a specific, common mutation identified as KRAS G12C. Unfortunately, cancers with KRAS G12C mutation can develop resistance to treatment with these drugs. Preclinical studies using cancer cell lines from lung cancer (H358), pancreatic cancer (MIA PACA2), and colorectal cancer (SW837) with KRAS G12C mutation showed synergistic effects in vitro for the combination of DT2216 and the KRAS G12C inhibitor sotorasib (Sot). Figures 15A-C, from Khan, Zhou, et al. J Hematology & Oncology 2022; 15:23

[0100] The synergistic effect was also demonstrated in xenograft experiments in immune- deficient mice using the same three cancer cell lines. It was observed that the combination therapy did not cause weight loss in the mice nor were there significant changes in blood counts, including platelet counts, during treatment (Figures 16A-C).

[0101] The studies reviewed above have demonstrated that DT2216 contributes to the anti- tumor efficacy of azacytidine, dexamethasone, docetaxel, doxorubicin, everolimus, gemcitabine, irinotecan, ruxolitinib, sotorasib, and vincristine when used in experiments on cancer cell lines from a variety of cancers, including AML, ALL, breast cancer, colon cancer, fibrolamellar carcinoma, hepatocellular carcinoma, non-small cell lung cancer, pancreatic cancer, prostate cancer, and small cell lung cancer. The inventors listed herein teach methods of using DT2216 in combination against solid tumor cancers of similar types.

[0102] Navitoclax is a small molecule inhibitor of both BCL2 and BCL-xL and has been shown to have synergistic activity with numerous chemotherapy drugs with in vitro cancer cell line experiments (Chen, Elmore, et al. Mol Cancer Ther 2011; 10:2340). However clinicalAttorney Docket No.123698.0030 translation has been unsuccessful. Since navitoclax, working by an occupancy-based competitive inhibition, does not have specificity in the mechanism of action, it causes thrombocytopenia and neutropenia that limits the dose that can be administered safely. Nevertheless, the drug has been used extensively in preclinical studies to explore the importance of BCL-xL in resistance to chemotherapy as illustrated by the following studies.

[0103] A non-randomized clinical trial for 53 patients with relapsed, refractory ALL or lymphoblastic lymphoma were treated with standard chemotherapy using peg-asparaginase, dexamethasone, and vincristine combined with both venetoclax (BCL2 inhibitor) and (navitoclax BCL2 and BCL-xL inhibitor). The most frequent adverse effects with febrile neutropenia and thrombocytopenia. Nevertheless, the investigators concluded “dual inhibition of BCL2 and BCL-xL with the combination of venetoclax and navitoclax with chemotherapy was associated with marked response rates and a well-tolerated safety profile in adult and pediatric patients with relapsed / refractory B-ALL, T-ALL, and LL, many of whom had failed multiple therapies, including stem cell transplant, targeted agents, and immunotherapies” (Pillarkat, Stock, et al. Cancer Discovery 2021; 11:1440).

[0104] The MEK protein is a component of the signaling pathway activated by activating mutations in KRAS. However, inhibition of MEK has not been effective as a therapy for these tumors. A screen was preformed using shRNA to detect the genes that, when inhibited, were associated increased effectiveness of inhibition of MEK in KRAS mutant tumors. BCL-XL appeared to be the most significant target for inhibition. Combined treatment was tested and found more effective than either ABT263 or selumetinib alone in xenograft experiments using 3 KRAS mutant colon cancer cell lines (Figure 17).

[0105] This work was subsequently assessed in a clinical trial (Corcoran, Shapiro, et al. Clin Cancer Research 2024; 30:1739). The study used trametinib, a MEK inhibitor, and navitoclax. Patients had solid tumors with KRAS mutations that had metastasized or progressed and for whom there were no known potentially curative treatment options. There were dose escalation cohorts evaluating alternative drug schedules followed by dose expansion. Among the 49 patients treated with the combination and the recommended phase 2 dose, objective responses were seen only in patients with gynecologic malignancies. See Figures 18A-B.

[0106] A-385358 is a small molecule inhibitor of BCL-xL that lacked suitable properties for development as a therapeutic drug. However preclinical studies showed that it significantly potentiated the effects of several chemotherapy drugs when tested against non-small cellAttorney Docket No.123698.0030 cancer cell lines. Figure 19. Xenograft experiments with (Figure 20A) H549 and (Figure 20B) LX-1, both lung cancer cell lines. Solid triangles are for paclitaxel 15mg / kg / dose. Solid squares are combination therapy. Open diamonds are treatment with A-385358 monotherapy. Open squares are treatment with combination vehicles. (Shoemaker, Elmore, et al. Cancer Res 2006; 66: 8731).

[0107] A subsequent study tested the combination of navitoclax (ABT-263) and paclitaxel against 52 different lung cancer cell lines in vitro. Greater than additive effect for the combination was observed in all cases. See Figure 21. Tan, Belmont, et al. Clin Cancer Res 2011; 17:1394.

[0108] Xenograft studies were carried out with administration of docetaxel, navitoclax, or the combination in mice implanted with SW1573 lung cancer cell line. There was a strong synergistic effect with no significant change in animal body weights. See Figure 22.

[0109] Five breast cancer patient-derived tumors (PDX models) were studied for possible interaction between treatment with the HER2-targeting antibody-drug conjugate TDM-1 and BCL-xL inhibitor ABT-263 or ABT-737. Synergistic effect was not observed in one tumor that was highly sensitive to TDM-1 or in one tumor that was refractory to TDM-1 but was significant in the remaining three PDX tumors. See Figure 23.

[0110] In an analysis of metabolic heterogeneity of malignant cells in pancreatic cancer, it was observed that nutrient scarcity gives rise to malignant cells in a quiescent state that depend on BCL-xL and are resistant to chemotherapy. The effect of treatment with gemcitabine and nab-paclitaxel (nP) or A-1331852 (an inhibitor of BCL-xL) alone was less effective than in combination. See Figure 24.

[0111] Summary of studies with BCL-xL inhibitor other than DT2216 – The results of the published studies, both laboratory and clinical, are fairly consistent in demonstrating that either inhibition or degradation of BCL-xL can potentiate the anti-tumor effect of chemotherapy. This result occurs in many but not in all malignancies. There are some cancers that, for a variety of reasons, may be invulnerable to any specific chemotherapy drug. If the cancer cell is not damaged by the chemotherapy, the status of the apoptotic system will not be important. There are some malignancies in which anti-apoptotic proteins other than BCL-xL, such as BCL2 or MCL1 are important in resistance. However, the studies reviewed include observations with cancer cell lines derived from ALL, breast cancer, colon cancer, fibrolamellar cancer, liver cancer, non-small cell lung cancer, ovarian cancer, pancreatic cancer, and prostate cancer and included approved anti-cancer treatments azacytidine,Attorney Docket No.123698.0030 dexamethasone, docetaxel, doxorubicin, irinotecan, paclitaxel, peg-asparaginase, ruxolitinib, sotorasib, and vincristine.

[0112] The development history of navitoclax (ABT-263) has been informative for both tumor types and PK / PD relationship to efficacy and safety, beginning with tumor cell line testing, tumor-bearing murine models and clinical studies. As an example, ABT-263 was evaluated preclinically for treatment of small cell lung cancer. A panel of 11 SCLC xenograft models was established to evaluate the efficacy of ABT-263 (Shoemaker AR. Clin Cancer Res 2008; 14:3268. Single agent activity was examined on a continuous dosing schedule in each of these models. The H146 model was used to further evaluate dose and schedule, comparison to standard cytotoxic agents, and induction of apoptosis.

[0113] ABT-263 exhibited a range of antitumor activity, leading to complete tumor regression in several models. ABT-263 exhibited a wide range of potency against these cell lines in vitro. Testing was then extended to the in vivo evaluation in a panel of 11 different SCLC xenograft models. Sensitivity to ABT-263 also varied significantly in this tumor population, and there was good correlation between in vitro cellular potency and in vivo tumor efficacy. Cell lines with an EC50 of <200 nmol / L were associated with 100% overall response rate (ORR) in vivo. The two cell lines with an EC50 of ~400 nmol / L showed significant inhibition of tumor growth rate and some evidence of tumor regression in vivo, whereas minimal in vivo efficacy was observed in two models where the cellular EC50 was >1 umol / L

[0114] However, a discordance in two cell lines was informative. ABT-263 was active in two models despite EC50s of >2 umol / L in these two cell lines. It appeared that robust growth of these cells in vivo was associated with an increased resistance to apoptosis, perhaps resulting from a reliance on up-regulation of Bcl-2 family proteins (versus low levels in cell culture), and this may contribute to the enhanced sensitivity to ABT-263 observed in vivo.

[0115] The larger sample set enabled characterization of factors likely to influence clinical response to this compound. Minimal tumor regrowth was noted several weeks after the cessation of treatment, demonstrating its durable effect, equal or superior to that of several clinically approved cytotoxic agents. Regression of large established tumors was observed through several cycles of therapy and efficacy was retained in a Pgp-1 overexpressing line which often leads to tumor resistance. Significant efficacy was observed on several dose and therapeutic schedules and was associated with significant induction of apoptosis. Regarding mechanism-based toxicity, ABT-263 treatment resulted in transient thrombocytopenia andAttorney Docket No.123698.0030 lymphopenia but was otherwise well-tolerated in mice, which the authors concluded was manageable and warranted further clinical testing (Shoemaker AR. Clin Cancer Res 2008; 14:3268.

[0116] A Phase 1 study in patients with SCLC and other solid tumors studied both intermittent and continuous dosing, and concluded “Navitoclax is safe and well tolerated, with dose-dependent thrombocytopenia as the major adverse effect. Preliminary efficacy data are encouraging in SCLC.” The most frequent AEs excluding thrombocytopenia were diarrhea (40%), vomiting (36%), nausea (34%), and fatigue (34%). The majority of these were grade 1 or 2. Consistent with the dose-limiting toxicity an animal safety studies, all patients experienced some degree of thrombocytopenia, but only 15% met criteria for Grade 3 / 4 AEs (Gandhi G, J Clin Oncol 2011; 29:909.

[0117] Subsequently, both single-agent and combination studies with chemotherapy were initiated in SCLC to further define the role of navitoclax in this disease. These studies used the continuous dosing schedule defined here to minimize platelet variability. In contrast to the earlier Phase 1 study, when tested in 39 patients with SCLC given the same daily dose (325 mg, following a 7-day lead-in at 150 mg), grade 3 / 4 thrombocytopenia was observed in 43% of the patients. Partial response was observed in one (2.6%) patient and stable disease in 9 (23%) patients. Median progression-free survival was 1.5 months and median overall survival was 3.2 months. A total of 17 of 39 patients (46.3%) required dose interruption, and 7 (17.9%) required dose reduction on study. The authors concluded “The level of single- agent activity of navitoclax in recurrent SCLC was disappointing, given its remarkable preclinical in vivo activity as a single agent in multiple SCLC cell line xenograft models” (Rudin CM, Clin Cancer Res; 2012; 18:3163).

[0118] More recently, navitoclax as a monotherapy was evaluated in a prospective multicenter single-arm phase II study to assess the efficacy in 46 heavily pretreated (2–12 lines, median = 4) patients with high-grade serous platinum-resistant ovarian tumors (Joly F, Gynecol Oncol, 2022; 165:30–39). The daily dose regimen of 150 mg during a lead-in period (7– 14 days) and then increased to 250 mg daily in the absence of dose-limiting thrombocytopenia (<G3). Navitoclax dosing was found to be continued at the daily dose of 250 mg from Day 1 Cycle 1 in 36 patients (78%). The others experienced thrombocytopenia grade 3 or higher during the lead-in period and thus continued treatment at the dose of 150 mg. A median number of two cycles of Navitoclax [0−11] was administered. The major reason for end of treatment was progressive disease (38 patients; 83%). Five patients (11%)Attorney Docket No.123698.0030 discontinued treatment for toxicities, including 2 patients with grade 3 thrombocytopenia and one patient with grade 4 thrombocytopenia. The authors concluded “Navitoclax monotherapy had poor activity that was not correlated with the expression of Bim, Mcl-1 and P-ERK, without unacceptable toxicity”.

[0119] Thus, the present disclosure teaches the use of the BCL-xL degrader DT2216, including in some methods, its use in combination with approved anti-cancer drugs. Applicants note that although mice in PDX models tolerated occupancy-based inhibitors of BCL-xL, the treatment of solid tumor malignancies using such inhibitors has not been demonstrated in humans. Without limitation, use of the disclosed methods is contemplated against a wide variety of cancers, including those which express VHL. Some such cancers include, without limitation, ovarian cancer, fibrolamellar liver cancer, cutaneous t-cell lymphoma, childhood T-cell ALL, prostate cancer, NK Cell lymphoma, myelofibrosis, leukemia, acute myeloid leukemia, pancreatic cancer, and small cell lung cancer, among others.

[0120] In some embodiments directed to the treatment of small cell lung cancer, the dose schedule for DT2216 would be that used in the phase I trial with continuous, twice weekly i.v. infusions given over 30 minutes without premedication.

[0121] Because of the possibility of thrombocytopenia, a management plan would be developed for the patient. Such a plan would be developed with parameters that would change based on the cancer type being treated and the specific chemotherapeutic agent selected for use. One of ordinary skill in the art would utilize a dosing holiday to assure appropriate platelet regeneration. In some methods of the invention, a management plan would include the following rules: complete blood count and platelet count is measured prior to each DT2216 infusion. Treatment with DT2216 is not given if the platelet count is less than 50,000. When used against small cell lung cancer, treatment with paclitaxel would not be administered if the platelet count is less than 100,000. If there is a period of 2 weeks during which treatment has been held, then when treatment is resumed, the dose of DT2216 would be reduced by about 25%. If a second such period occurs, that treatment with DT2216 is discontinued for that patient. Other plans are contemplated within the scope of the present invention.

[0122] It is anticipated that episodes of transient thrombocytopenia are most likely during the first month of therapy. Episodes of thrombocytopenia could stimulate platelet formation in the bone marrow allowing continued treatment possibly with a platelet count that is lessAttorney Docket No.123698.0030 than baseline prior to treatment but still satisfactory for patient safety. If there are repeated episodes requiring cancelation of treatment with DT2216, then other interventions could be tested to allow the trial to continue. One possibility is lead-in treatment with DT2216 alone for one or two weeks before starting paclitaxel. Another is treatment with romiplastim (or a similar thrombopoietic agent) to stimulate platelet production before starting the combination of DT2216 and paclitaxel.

[0123] Currently available treatments for small cell lung cancer that has progressed with standard initial chemotherapy and checkpoint immunotherapy have very limited efficacy. There are no second line therapies with a reported response rate > 35% or duration of response > 4 months. Therefore, in a phase I, non-randomized trial with dose escalation followed by dose expansion at the RP2D, an objective response rate > 40% with duration of response > 5 months would indicate clinically significant activity for the combination.

[0124] More generally, methods are taught herein of treating a solid tumor cancer in a patient in need thereof. Such methods include the steps of administering a chemotherapeutic agent appropriate to the cancer type to the patient; and administering DT2216 to the patient. In some such methods, the subject is a mammal. In others, the subject is a human. In some methods, the cancer is selected from the group consisting of pancreatic cancer and small cell lung cancer.

[0125] Other disclosed methods include the treatment of a chemotherapy-resistant solid tumor cancer in a patient in need therof, where the methods comprise administering a chemotherapeutic agent appropriate to the cancer type to the patient; and administering DT2216 to the patient; wherein the chemotherapeutic agent and DT2216 are administered to the patient in a therapeutically effective amount. In some such methods, the subject is a mammal. In others, the subject is a human. In some methods, the cancer is selected from the group consisting of pancreatic cancer and small cell lung cancer. In some such methods, the chemotherapeutic agent and DT2216 are administered to the patient twice weekly. Further, DT2216 may be administered in an amount of from about 0.04 to about 0.4 mg / kg to the patient. In other specific methods, DT2216 may be administered in an amount of from about 0.12 to about 0.4 mg / kg to the patient. In still others, DT2216 is administered in an amount of about 0.4 mg / kg to the patient.

[0126] Still other methods of the disclosure include methods of treating a chemotherapy- resistant solid tumor cancer reliant on BCL-xL upregulation in a patient in need therof. These methods include the steps of administering a chemotherapeutic agent appropriate toAttorney Docket No.123698.0030 the cancer type to the patient; and administering DT2216 to the patient; wherein the chemotherapeutic agent and DT2216 are administered to the patient in a therapeutically effective amount.

[0127] The description herein is provided to enable a person skilled in the art to make or use the disclosure. Various modifications to the disclosure will be readily apparent to those skilled in the art, and the generic principles defined herein may be applied to other variations without departing from the scope of the disclosure. Thus, the disclosure is not limited to the examples and designs described herein but is to be accorded the broadest scope consistent with the principles and novel features disclosed herein. Terminology and Interpretative Conventions

[0128] Any methods described in the claims or specification should not be interpreted to require the steps to be performed in a specific order unless stated otherwise. Also, the methods should be interpreted to provide support to perform the recited steps in any order unless stated otherwise.

[0129] Spatial or directional terms, such as “left,” “right,” “front,” “back,” and the like, relate to the subject matter as it is shown in the drawings. However, it is to be understood that the described subject matter may assume various alternative orientations and, accordingly, such terms are not to be considered as limiting.

[0130] Articles such as “the,” “a,” and “an” can connote the singular or plural. Also, the word “or” when used without a preceding “either” (or other similar language indicating that “or” is unequivocally meant to be exclusive – e.g., only one of x or y, etc.) shall be interpreted to be inclusive (e.g., “x or y” means one or both x or y).

[0131] The term “and / or” shall also be interpreted to be inclusive (e.g., “x and / or y” means one or both x or y). In situations where “and / or” or “or” are used as a conjunction for a group of three or more items, the group should be interpreted to include one item alone, all the items together, or any combination or number of the items.

[0132] The terms have, having, include, and including should be interpreted to be synonymous with the terms comprise and comprising. The use of these terms should also be understood as disclosing and providing support for narrower alternative embodiments where these terms are replaced by “consisting” or “consisting essentially of.”

[0133] Unless otherwise indicated, all numbers or expressions, such as those expressing dimensions, physical characteristics, and the like, used in the specification (other than theAttorney Docket No.123698.0030 claims) are understood to be modified in all instances by the term “approximately.” At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the claims, each numerical parameter recited in the specification or claims which is modified by the term “approximately” should be construed in light of the number of recited significant digits and by applying ordinary rounding techniques.

[0134] All disclosed ranges are to be understood to encompass and provide support for claims that recite any and all subranges or any and all individual values subsumed by each range. For example, a stated range of 1 to 10 should be considered to include and provide support for claims that recite any and all subranges or individual values that are between and / or inclusive of the minimum value of 1 and the maximum value of 10; that is, all subranges beginning with a minimum value of 1 or more and ending with a maximum value of 10 or less (e.g., 5.5 to 10, 2.34 to 3.56, and so forth) or any values from 1 to 10 (e.g., 3, 5.8, 9.9994, and so forth).

[0135] All disclosed numerical values are to be understood as being variable from 0-100% in either direction and thus provide support for claims that recite such values or any and all ranges or subranges that can be formed by such values. For example, a stated numerical value of 8 should be understood to vary from 0 to 16 (100% in either direction) and provide support for claims that recite the range itself (e.g., 0 to 16), any subrange within the range (e.g., 2 to 12.5) or any individual value within that range (e.g., 15.2).

[0136] The terms recited in the claims should be given their ordinary and customary meaning as determined by reference to relevant entries in widely used general dictionaries and / or relevant technical dictionaries, commonly understood meanings by those in the art, etc., with the understanding that the broadest meaning imparted by any one or combination of these sources should be given to the claim terms (e.g., two or more relevant dictionary entries should be combined to provide the broadest meaning of the combination of entries, etc.) subject only to the following exceptions: (a) if a term is used in a manner that is more expansive than its ordinary and customary meaning, the term should be given its ordinary and customary meaning plus the additional expansive meaning, or (b) if a term has been explicitly defined to have a different meaning by reciting the term followed by the phrase “as used in this document shall mean” or similar language (e.g., “this term means,” “this term is defined as,” “for the purposes of this disclosure this term shall mean,” etc.). References to specific examples, use of “i.e.,” use of the word “invention,” etc., are not meant to invoke exception (b) or otherwise restrict the scope of the recited claim terms. Other than situationsAttorney Docket No.123698.0030 where exception (b) applies, nothing contained in this document should be considered a disclaimer or disavowal of claim scope.

[0137] The subject matter recited in the claims is not coextensive with and should not be interpreted to be coextensive with any embodiment, feature, or combination of features described or illustrated in this document. This is true even if only a single embodiment of the feature or combination of features is illustrated and described in this document.

Claims

Attorney Docket No.123698.0030 CLAIMS What is claimed:

1. A method of treating cancer in a patient in need thereof, the method comprising: providing a patient with a VHL-expressing cancer; administering a BCL-xL targeting / degrading substance to the patient; and administering a therapeutically effective amount of a chemotherapeutic agent appropriate to the cancer to the patient.

2. The method of claim 1, wherein the subject is a mammal.

3. The method of claim 1, wherein the subject is a human.

4. The method of claim 1, wherein the cancer is selected from the group consisting of ovarian cancer, fibrolamellar liver cancer, cutaneous t-cell lymphoma, childhood T-cell ALL, prostate cancer, NK Cell lymphoma, myelofibrosis, leukemia, acute myeloid leukemia, pancreatic cancer, and small cell lung cancer.

5. The method of claim 1, wherein the chemotherapeutic agent and DT2216 are administered to the patient twice weekly.

6. The method of claim 1, wherein DT2216 is administered in an amount of from about 0.04 to about 0.4 mg / kg to the patient.

7. The method of claim 10, wherein DT2216 is administered in an amount of from about 0.12 to about 0.4 mg / kg to the patient.

8. The method of claim 11, wherein DT2216 is administered in an amount of about 0.4 mg / kg to the patient.

9. A method of treating a solid tumor cancer in a patient in need thereof, the method comprising: providing a patient with a VHL-expressing cancer; administering a BCL-xL targeting / degrading substance to the patient; andAttorney Docket No.123698.0030 administering a therapeutically effective amount of a chemotherapeutic agent appropriate to the cancer to the patient.

10. The method of claim 10, wherein the subject is a mammal.

11. The method of claim 10, wherein the subject is a human.

12. The method of claim 10, wherein the cancer is selected from the group consisting of ovarian cancer, fibrolamellar liver cancer, cutaneous t-cell lymphoma, childhood T-cell ALL, prostate cancer, NK Cell lymphoma, myelofibrosis, leukemia, acute myeloid leukemia, pancreatic cancer, and small cell lung cancer.

13. The method of claim 10, wherein the chemotherapeutic agent and DT2216 are administered to the patient twice weekly.

14. The method of claim 10, wherein DT2216 is administered in an amount of from about 0.04 to about 0.4 mg / kg to the patient.

15. The method of claim 10, wherein DT2216 is administered in an amount of from about 0.12 to about 0.4 mg / kg to the patient.

16. The method of claim 15, wherein DT2216 is administered in an amount of about 0.4 mg / kg to the patient.

17. A method of treating a chemotherapy-resistant solid tumor cancer reliant on BCL-xL upregulation in a patient in need therof, the method comprising: administering a chemotherapeutic agent appropriate to the cancer type to the patient; and administering DT2216 to the patient; wherein the chemotherapeutic agent and DT2216 are administered to the patient in a therapeutically effective amount.

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