RU2771759C2 - Antibodies against pd-1 for treatment of lung cancer - Google Patents

Abstract

FIELD: biotechnology.

SUBSTANCE: invention relates to the field of biotechnology, in particular to methods for the treatment of lung cancer. Methods include the selection of a patient with non-small cell lung cancer, where patient’s tumor tissue expresses PD-L1 in ≥50% of tumor cells, and the patient is not tested as positive relatively to mutations of an epidermal growth factor receptor (EGFR), translocations of anaplastic lymphoma kinase (ALK) and/or fusions of ROS1, as well as the injection to the patient of therapeutically effective amount of an antibody specifically binding to PD-1.

EFFECT: invention is effective for the treatment of non-small cell lung cancer.

28 cl, 14 dwg, 13 tbl, 15 ex

Description

[0001] This application was filed February 20, 2018 as a PCT International Patent Application and claims priority over U.S. Provisional Application No. 62/461,672, filed February 21, 2017, and U.S. Provisional Patent Application No. 62/595,190, filed December 6, 2017 year, the description of each of which is included in the present description by reference in its entirety.

FIELD OF THE INVENTION

[0002] The present invention relates to methods of treating lung cancer comprising administering to an individual in need thereof a therapeutically effective amount of an antibody that specifically binds to programmed cell death 1 (PD-1) receptor.

BACKGROUND OF THE INVENTION

[0003] Lung cancer is one of the most commonly diagnosed malignancies and the leading cause of cancer-related death worldwide (Bray et al 2013, Int. J. Cancer 132:1133-45; Siegel et al 2016, CA Cancer J. Clin. 66: 7-30). Non-small cell lung cancer (NSCLC) accounts for 80-85% of all lung cancers and represents several histological subtypes, the most common being adenocarcinoma (40-60%) and squamous cell carcinoma (30%). Most patients with NSCLC have advanced malignancy at the time of diagnosis (Leighl 2012, Curr. Oncol. 19:S52-8). With chemotherapy, these patients experience a median overall survival (OS) of up to 12-18 months and a 5-year survival rate of approximately 18% (Leighl 2012, Curr. Oncol. 19:S52-8; Siegel et al 2016, CA Cancer J. Clin. 66: 7-30).

[0004] Systemic therapy using dual platinum-based chemotherapy regimens with or without maintenance therapy has until recently been the standard first-line treatment for all patients with advanced NSCLC whose tumors do not contain an epidermal growth factor receptor (EGFR) mutation. , anaplastic lymphoma kinase (ALK) translocation, or oncogenic receptor tyrosine kinase C-ros (ROS1) mutation (Besse et al 2014, Ann. Oncol. 25: 1475-84; Ettinger et al 2016, J. Natl. Compr. Canc. Netw. 14: 255-64; Reck et al 2014, Ann. Oncol. 25 Suppl 3: iii27-39). Despite initial therapy with platinum-based dual chemotherapy regimens, the disease often progresses and options for additional treatment are limited. Thus, newer therapeutic approaches are needed that will improve long-term survival and quality of life (QOL) in patients with advanced NSCLC.

[0005] In recent years, immunotherapy has been researched as a potential therapeutic approach that will improve long-term survival and QOL in patients with advanced NSCLC. Tumors modulate and evade the host's immune response through a number of mechanisms, including the formation of an immunosuppressive environment within the tumor. Programmed cell death protein-1 (PD-1) is a co-receptor expressed on the surface of activated T cells that mediates immunosuppression. Binding of PD-1 to one of its ligands, programmed cell death ligand 1 (PD-L1) or programmed cell death ligand 2 (PD-L2), results in inhibition of the cytotoxic T cell response. Increased expression of PD-L1 in the tumor microenvironment facilitates escape from the immune surveillance mechanism (T-cell-induced antitumor activity). Conversely, blocking this interaction results in an increased T cell response with antitumor activity.

[0006] Blocking the PD-1/PD-L1 T-cell checkpoint pathway has been shown to be an effective and well-tolerated approach to stimulate an immune response and achieve objective responses in NSCLC patients (Topalian et al 2012, N. Engl. J. Med. 366: 2443-54; Borghaei et al 2015, N. Engl. J. Med. 373: 1627-39; Brahmer et al 2015, N. Engl. J. Med. 373: 123-35; Herbst et al 2016, Lancet 387: 1540-50; Fehrenbacher et al 2016, Lancet 387: 1837-46; Rittmeyer et al 2017, Lancet 389: 255-65; Reck et al 2016; N. Engl. J. Med. 375 : 1823-33; Roach et al 2016, App. l Immunohistochem. Mol. Morphol. 24: 392-7; Socinski et al 2016, Ann. Oncol. 27 Suppl 6:LBA7_PR).

SUMMARY OF THE INVENTION

[0007] In some embodiments, the present invention relates to methods for treating or improving at least one symptom or sign of lung cancer, inhibiting the growth of lung cancer, and/or improving survival in an individual. The methods of this aspect include administering to an individual in need thereof one or more doses of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to programmed cell death 1 (PD-1) protein. In some embodiments, the lung cancer is non-small cell lung cancer. In one embodiment, the subject has advanced recurrent or metastatic lung cancer. In one embodiment, the individual has squamous non-small cell lung cancer. In one embodiment, the individual has non-squamous non-small cell lung cancer. In some embodiments, the individual has lung cancer, where the tumors express programmed cell death ligand 1 (PD-L1) in <50% of the tumor cells. In some embodiments, the individual has lung cancer (e.g., non-small cell lung cancer), where tumors express PD-L1 at <50%, ≤45%, ≤40%, ≤30%, ≤20%, ≤10%, .5% , ≤2%, ≤1% or approximately 0% tumor cells. In some other embodiments, the individual has lung cancer, where the tumors express PD-L1 in ≥50% of the tumor cells. In some embodiments, the subject has lung cancer (eg, non-small cell lung cancer), where the tumors express PD-L1 in ≥50%, ≥60%, ≥70%, ≥80%, or ≥90% of the tumor cells. In some embodiments, the individual is being treated for lung cancer (anticancer therapy, eg, chemotherapy). In some embodiments, the methods include administering to an individual in need thereof one or more doses of anti-PD-1 antibody, where each dose contains 20 mg to 1500 mg of anti-PD-1 antibody, and where each dose is administered after 1 week, 2 weeks, 3 weeks or 4 weeks after the previous dose. In some embodiments, the methods comprise administering to an individual in need thereof a therapeutically effective amount of an anti-PD-1 antibody, optionally in combination with chemotherapy or a CTLA-4 inhibitor (eg, an anti-CTLA-4 antibody such as ipilimumab). In one embodiment, the chemotherapy comprises a platinum-based chemotherapeutic agent (eg, pemetrexed, cisplatin, gemcitabine, or a combination thereof). In one embodiment, the anti-PD-1 antibody is REGN2810.

[0008] In some embodiments, the present invention relates to methods of treating cancer, comprising selecting an individual with lung cancer and administering one or more doses of an anti-PD-1 antibody, wherein administration results in tumor growth inhibition, improved overall survival, and/or improved survival. without progression in the individual.

[0009] In some embodiments, the present invention relates to methods for treating or improving at least one symptom or sign or inhibiting the growth of a cancer in an individual. In some embodiments, the present invention relates to methods for slowing tumor growth or preventing tumor recurrence. In some embodiments, the present invention relates to methods for improving overall survival or progression-free survival in a patient with cancer. The methods of the invention in this aspect comprise the sequential administration of one or more doses of a therapeutically effective amount of an antibody, or antigen-binding fragment thereof, that specifically binds to PD-1. In one embodiment, the anti-PD-1 antibody is administered in combination with chemotherapy. In one embodiment, the anti-PD-1 antibody is administered in combination with a CTLA-4 inhibitor (eg, an anti-CTLA-4 antibody such as ipilimumab). In some embodiments, the cancer or tumor is a solid tumor or cancer. In some embodiments, the solid tumor is selected from the group consisting of colorectal cancer, ovarian cancer, prostate cancer, breast cancer, brain malignancy, cervical cancer, bladder cancer, anal cancer, uterine cancer, colon cancer, liver cancer, pancreatic cancer, lung cancer, endometrial cancer, bone cancer, testicular cancer, skin cancer, kidney cancer, stomach cancer, esophageal cancer, head and neck cancer, salivary gland cancer and myeloma.

[0010] In some embodiments, the methods include administering one or more doses of an anti-PD-1 antibody to a patient with advanced cancer or metastatic cancer (e.g., advanced non-small cell lung cancer), where the patient's tumor tissue expresses PD-L1 in ≤1%, ≤2%, ≤5%, ≤10%, ≤20%, ≤30%, ≤40%, ≤45%, or <50% of tumor cells. In some embodiments, the methods include administering one or more doses of an anti-PD-1 antibody to a patient with a cancer (eg, advanced lung cancer or metastatic lung cancer) where the patient's tumor tissue expresses PD-L1 at ≥50%, ≥60%. , ≥70%, ≥80%, or ≥90% of tumor cells.

[0011] In some embodiments, the anti-PD-1 antibody is administered to a patient with cancer as a first-line treatment where the patient has not previously been subjected to systemic cancer treatment. In some embodiments, an anti-PD-1 antibody is administered to a patient with a cancer (e.g., metastatic cancer) as a second-line treatment, where the patient has previously been treated, including, but not limited to, an anti-PD-1 antibody (e.g., nivolumab or pembrolizumab ), a CTLA-4 inhibitor (eg, an anti-CTLA-4 antibody), chemotherapy, surgery, and/or radiation therapy.

[0012] In some embodiments, each dose of anti-PD-1 antibody contains 0.1-20 mg/kg of the individual's body weight. In some embodiments, each dose of anti-PD-1 antibody contains 0.3, 1, 3, 5, or 10 mg/kg of the individual's body weight. In some embodiments, each dose of anti-PD-1 antibody contains 20-1500 mg. In one embodiment, each dose of anti-PD-1 antibody contains approximately 200 mg. In one embodiment, each dose of anti-PD-1 antibody contains approximately 250 mg. In one embodiment, each dose of anti-PD-1 antibody contains approximately 350 mg. In one embodiment, each dose of anti-PD-1 antibody contains about 1000 mg or about 1050 mg.

[0013] In some embodiments, the implementation of the methods of the present invention include the introduction of a therapeutically effective amount of antibodies against PD-1 before, simultaneously with or after chemotherapy. In one embodiment, the methods of the present invention comprise administering an anti-PD-1 antibody prior to a dose of chemotherapy.

[0014] In some embodiments, the implementation of the methods of the present invention include the introduction of one or more therapeutic doses of antibodies against PD-1, where each dose is administered 0.5-12 weeks after the previous dose. In one embodiment, each dose is administered 1 week after the previous dose. In one embodiment, each dose is administered 2 weeks after the previous dose. In one embodiment, each dose is administered 3 weeks after the previous dose.

[0015] In some embodiments, one or more doses of an anti-PD-1 antibody and optionally a second therapeutic agent (eg, a chemotherapeutic agent) are included in a treatment cycle. The methods of the invention in this aspect include subjecting an individual in need thereof to at least one treatment cycle, wherein at least one treatment cycle comprises one or more doses of anti-PD-1 antibody. In some embodiments, at least one treatment cycle further comprises one or more doses of a chemotherapeutic agent (eg, a platinum-based chemotherapeutic agent such as gemcitabine, pemetrexed, cisplatin).

[0016] In some embodiments, the anti-PD-1 antibody is administered in combination with an additional therapeutic agent or therapy (eg, an anti-CTLA-4 antibody or any of the agents or therapy described herein).

[0017] In some embodiments, the treatment results in one or more therapeutic effects selected from the group consisting of tumor regression, abscopal effect, inhibition of tumor metastasis, reduction of metastases over time, reduction in the use of chemotherapeutic or cytotoxic agents, reduction in tumor burden, increase progression-free survival, improved overall survival, complete response, partial response, and stable disease.

[0018] In some embodiments, the anti-PD-1 antibody or antigen binding protein comprises a heavy chain variable region (HCVR) complementarity determining region (HCDR) comprising the amino acid sequence of SEQ ID NO: 1 and a light chain variable region CDR (LCVR) comprising amino acid sequence of SEQ ID NO: 2. One such type of antigen-binding protein that can be used in the methods of the present invention is an anti-PD-1 antibody such as REGN2810 (also known as cemiplimab).

[0019] In some embodiments, the present invention relates to the use of an anti-PD-1 antibody or antigen-binding fragment thereof in the manufacture of a medicament for the treatment or inhibition of the growth of a cancer in individuals, including humans. In some embodiments, the cancer is lung cancer. In some embodiments, the lung cancer is non-small cell lung cancer. In some embodiments, the cancer is colorectal cancer, ovarian cancer, prostate cancer, breast cancer, brain cancer, cervical cancer, bladder cancer, anal cancer, uterine cancer, colon cancer, liver cancer, pancreatic cancer. cancer, lung cancer, endometrial cancer, bone cancer, testicular cancer, skin cancer, kidney cancer, stomach cancer, esophageal cancer, head and neck cancer, salivary gland cancer, or myeloma.

[0020] Other embodiments of the present invention will be apparent from the following detailed description.

BRIEF DESCRIPTION OF THE DRAWINGS

[00921] Figure 1 shows a study design involving dosing of anti-PD-1 antibody and radiation therapy (XRT) in mice implanted with MC38 tumors (study described in Example 1 herein).

), антитело против PD-1 (

), изотипический контроль+лучевую терапию (XRT) (

) или антитело против PD-1+XRT (

), в исследовании, описанном в примере 1 в настоящем описании.[0022] Figure 2 shows mean tumor growth in mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), isotype control+radiotherapy (XRT) (

) or anti-PD-1+XRT antibody (

), in the study described in example 1 in the present description.

), антитело против PD-1 (

), изотипический контроль+лучевую терапию (XRT) (

) или антитело против PD-1+XRT (

), в исследовании, описанном в примере 1 в настоящем описании.[0023] Figure 3 shows the overall survival of mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), isotype control + radiation therapy (XRT) (

) or anti-PD-1+XRT antibody (

), in the study described in example 1 in the present description.

[0024] Figure 4 shows a study design involving dosing of anti-PD-1 antibody and radiation therapy (XRT) in mice implanted with B16F10.9 tumors (study described in Example 2 herein).

), антитело против PD-1 (

), изотипический контроль+лучевую терапию (XRT) (

) или антитело против PD-1+XRT (О) в исследовании, описанном в примере 2 в настоящем описании.[0025] Figure 5 shows mean tumor growth in mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), isotype control + radiation therapy (XRT) (

) or an antibody against PD-1+XRT (O) in the study described in example 2 in the present description.

), антитело против PD-1 (

), изотипический контроль+лучевую терапию (XRT) (

) или антитело против PD-1+XRT (О), в исследовании, описанном в примере 2 в настоящем описании.[0026] Figure 6 shows the overall survival of mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), isotype control+radiotherapy (XRT) (

) or an antibody against PD-1+XRT (O), in the study described in example 2 in the present description.

[0027] Figure 7 shows a study design involving dosing of anti-PD-1 antibody and radiation therapy (XRT) in mice implanted with MC38 tumors (study described in Example 4 herein).

), антитело против PD-1 (

), изотипический контроль+лучевую терапию (XRT) (

) или антитело против PD-1+XRT (

), в исследовании, описанном в примере 4 в настоящем описании.[0028] Figure 8 shows mean primary tumor growth in mice treated with isotype control antibody (

), anti-PD-1 antibody (

), isotype control+radiotherapy (XRT) (

) or anti-PD-1+XRT antibody (

), in the study described in example 4 in the present description.

), антитело против PD-1 (

), изотипический контроль+лучевую терапию (XRT) (

) или антитело против PD-1+XRT (

), в исследовании, описанном в примере 4 в настоящем описании.[0029] Figure 9 shows the overall survival of mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), isotype control+radiotherapy (XRT) (

) or anti-PD-1+XRT antibody (

), in the study described in example 4 in the present description.

), антитело против PD-1 (

), изотипический контроль+лучевую терапию (XRT) (

) или антитело против PD-1+XRT (

), в исследовании, описанном в примере 4 в настоящем описании.[0030] Figure 10 shows secondary tumor growth in mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), isotype control+radiotherapy (XRT) (

) or anti-PD-1+XRT antibody (

), in the study described in example 4 in the present description.

[0031] Figure 11 shows a study design including dosing of anti-PD-1 antibody, anti-GITR antibody, and radiation therapy (XRT) in mice implanted with MC38 tumors (study described in Example 5 herein).

), антитело против PD-1 (

), антитело против GITR (

), комбинацию антитела против PD-1 и антитела против GITR (

), изотипический контроль+лучевую терапию (XRT) (

),антитело против PD-1+XRT (О), антитело против GITR+XRT (

) или комбинацию антитела против PD-1, антитела против GITR+XRT (

), в исследовании, описанном в примере 5 в настоящем описании.[0032] Figure 12 shows mean tumor growth in mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), anti-GITR antibody (

), a combination of an anti-PD-1 antibody and an anti-GITR antibody (

), isotype control+radiotherapy (XRT) (

), anti-PD-1+XRT (O), anti-GITR+XRT (

) or a combination of anti-PD-1 antibody, anti-GITR+XRT antibody (

), in the study described in example 5 in the present description.

), антитело против PD-1 (

), антитело против GITR (

), комбинацию антитела против PD-1 и антитела против GITR (

), изотипический контроль+радиация (XRT) (

),антитело против PD-1+XRT (О), антитело против GITR+XRT (

) или комбинацию антитела против PD-1, антитела против GITR+XRT (

), в исследовании, описанном в примере 5 в настоящем описании.[0033] Figure 13 shows the overall survival of mice treated with an isotype control antibody (

), anti-PD-1 antibody (

), anti-GITR antibody (

), a combination of an anti-PD-1 antibody and an anti-GITR antibody (

), isotype control+radiation (XRT) (

), anti-PD-1+XRT (O), anti-GITR+XRT (

) or a combination of anti-PD-1 antibody, anti-GITR+XRT antibody (

), in the study described in example 5 in the present description.

[0034] Figure 14A shows an X-ray image of lung metastases in a patient with basal cell carcinoma (BCC), indicated by arrows, at baseline (left) and at week 24 (right).

[0035] Figure 14B shows an x-ray image of a neck mass in a patient with skin squamous cell carcinoma (CSCC) at baseline (left) and week 16 (right).

DETAILED DESCRIPTION

[0036] Before describing the present invention, it should be noted that it is not limited to the specific methods described and experimental conditions, since such methods and conditions may vary. It should also be understood that the terminology used in the present description is intended to describe only specific embodiments, and not to limit, because. the scope of the present invention will be limited solely by the claims.

[0037] Unless otherwise indicated, all technical and scientific terms used in the present description have the meaning generally understood by a person skilled in the art to which the invention belongs. For the purposes of the invention, the term "about" when used in relation to a particular recited numerical value means that the value may vary from the recited value by no more than 1%. For example, within the meaning of the invention, the expression "about 100" includes 99 and 101 and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.).

[0038] While any methods and materials similar or equivalent to those described herein may be used in the practice of the present invention, preferred methods and materials are described below. All publications mentioned in the present description are incorporated herein by reference in their entirety.

Methods for treating or inhibiting the growth of a cancer

[0039] The present invention relates to methods for treating, improving, or reducing the severity of at least one symptom or sign, or inhibiting the growth of a cancer in an individual. The methods of the invention in this aspect include administering to an individual in need thereof a therapeutically effective amount of an antibody, or antigen-binding fragment thereof, that specifically binds to PD-1. In some embodiments, the anti-PD-1 antibody is administered in combination with an antitumor therapy (described elsewhere herein). Within the scope of the invention, the terms "treat", "treatment", or the like. means improvement in symptoms, temporary or permanent elimination of the cause of symptoms, slowing down or inhibition of tumor growth, reduction of tumor burden or tumor mass, stimulation of tumor regression, induction of tumor shrinkage, necrosis and/or disappearance, prevention of tumor recurrence, prevention or inhibition of metastasis, inhibition of growth of a metastatic tumors and/or increase the duration of survival of the individual.

[0040] In the context of the invention, the expression "in need thereof" means a human or non-human mammal showing one or more symptoms or signs of malignancy, and/or who has been diagnosed with a malignant neoplasm, including a solid tumor, and in need of its treatment. In many embodiments, the term "individual" can be used interchangeably with the term "patient". For example, a person may be diagnosed with a primary or metastatic tumor and/or one or more symptoms or signs, including, but not limited to, unexplained weight loss, general weakness, persistent fatigue, loss of appetite, fever, night sweats, bone pain, shortness of breath, swelling of the abdomen, pain/pressure in the chest, enlargement of the spleen, and increased levels of malignant biomarkers (eg, CA125). The term includes individuals with primary or advanced tumors. In some embodiments, the expression includes people being treated and/or in need of treatment for a solid tumor, e.g., colon cancer, breast cancer, lung cancer, prostate cancer, skin cancer, liver cancer, bone cancer, ovarian cancer, cervical cancer, pancreatic cancer, head and neck cancer, and brain malignancy. In some preferred embodiments, the expression includes people being treated and/or in need of treatment for lung cancer, including non-small cell lung cancer. In one of the preferred embodiments, the expression includes patients undergoing treatment and/or in need of treatment for recurrent or metastatic advanced non-small cell lung cancer. In another preferred embodiment, the expression includes patients being treated and/or in need of treatment for squamous or non-squamous non-small cell lung cancer. The term includes individuals with primary or metastatic tumors (advanced malignancies). In some embodiments, the term "in need thereof" includes patients with a solid tumor, resistant or refractory, or not sufficiently controlled by previous therapy (eg, treatment with an anticancer agent). For example, the expression includes individuals who have been treated with one or more lines of prior therapy, such as treatment with chemotherapy (eg, carboplatin or docetaxel). In some embodiments, the expression "in need of it" includes patients with a solid tumor who were treated using one or more lines of prior therapy, but who then observed a relapse or metastasis. For example, patients with a solid tumor who may have been treated with one or more anticancer agents resulting in tumor regression, but who then experienced a recurrence of a cancer that is resistant to one or more anticancer agents (e.g., a cancer that is resistant to chemotherapy), treated with the methods of the present invention. The expression also includes individuals with a solid tumor for whom conventional antitumor therapy is not feasible, for example, due to toxic side effects. For example, the expression includes patients who have been subjected to one or more cycles of chemotherapy with toxic side effects.

[0041] In some embodiments, the methods of the present invention can be used to treat patients who experience elevated levels of one or more cancer biomarkers [e.g., programmed cell death ligand 1 (PD-L1), CA125, CA19-9, prostate specific antigen (PSA), lactate dehydrogenase, KIT, carcinoembryonic antigen, epidermal growth factor receptor (EGFR), ALK gene shuffling]. For example, the methods of the present invention include administering a therapeutically effective amount of an anti-PD-1 antibody to a patient with elevated levels of PD-L1 in tumor tissue. In some embodiments, the methods of the present invention comprise administering a therapeutically effective amount of an anti-PD-1 antibody to a patient with lung cancer, wherein the patient's tumor tissue expresses PD-L1 at <50%, ≤45%, ≤40%, ≤30%, ≤20 %, ≤10%, ≤5%, ≤2% or ≤1% tumor cells. In some embodiments, the methods of the present invention comprise administering a therapeutically effective amount of an anti-PD-1 antibody to a patient with lung cancer, wherein the patient's tumor tissue expresses PD-L1 at ≥50%, ≥60%, ≥70%, ≥80%, or ≥90 % tumor cells.

[0042] In some embodiments, the implementation of the methods of the present invention is used for an individual with a solid tumor. The terms "tumor" and "malignant neoplasm" are used interchangeably herein.

[0043] As used herein, the term "solid tumor" refers to an abnormal mass of tissue, typically free of a cyst or area of fluid. Solid tumors can be benign (non-cancerous) or malignant. For the purposes of the present invention, the term "solid tumor" means malignant solid tumors. The term includes various types of solid tumors named after the types of cells that form them, namely sarcomas, carcinomas and lymphomas. However, the term does not include leukemia. In various embodiments, the term "solid tumor" includes malignancies arising from connective or supporting tissue (e.g., bone or muscle) (referred to as sarcomas), malignancies arising from glandular cells, and epithelial cells lining body tissues (referred to as carcinomas ), and malignancies of lymphoid organs such as lymph nodes, spleen, and thymus (referred to as lymphomas). Lymphoid cells are found in almost all tissues of the body, and thus lymphomas can develop in various organs. In some embodiments, the term "solid tumor" includes malignancies, including, but not limited to, colorectal cancer, ovarian cancer, prostate cancer, breast cancer, brain cancer, cervical cancer, bladder cancer, anal cancer , uterine cancer, colon cancer, liver cancer, pancreatic cancer, lung cancer, endometrial cancer, bone cancer, testicular cancer, skin cancer, kidney cancer, stomach cancer, esophageal cancer, head and neck cancer, salivary gland cancer, and myeloma. In some embodiments, the term "solid tumor" includes malignancies, including, but not limited to, hepatocellular carcinoma, non-small cell lung cancer, head and neck squamous cell carcinoma, basal cell carcinoma, breast carcinoma, squamous cell carcinoma of the skin, chondrosarcoma, angiosarcoma, cholangiocarcinoma, soft tissue sarcoma, colorectal cancer, melanoma, Merkel's carcinoma and glioblastoma multiforme. In some embodiments, the term "solid tumor" includes multiple solid tumor lesions located separately from each other, for example, 2, more than 2, more than 5, more than 10, more than 15, more than 20, or more than 25 lesions in an individual in need of treatment. In some embodiments, multiple lesions are located distally from each other in the same organ. In some other embodiments, the implementation of tumor foci may be in different organs.

[0044] In some embodiments, the present invention relates to methods for treating or inhibiting the growth of a cancer, including, but not limited to, colorectal cancer, ovarian cancer, prostate cancer, breast cancer, brain cancer, cervical cancer, cancer bladder cancer, anal cancer, uterine cancer, colon cancer, liver cancer, pancreatic cancer, lung cancer, endometrial cancer, bone cancer, testicular cancer, skin cancer, kidney cancer, stomach cancer, esophageal cancer, head cancer, and neck, salivary gland cancer and myeloma. In some embodiments, the present invention relates to methods for treating or inhibiting the growth of a malignant neoplasm, including, but not limited to, hepatocellular carcinoma, non-small cell lung cancer, head and neck squamous cell carcinoma, basal cell carcinoma, squamous cell carcinoma of the skin, chondrosarcoma, angiosarcoma, cholangiocarcinoma , soft tissue sarcoma, colorectal cancer, melanoma, Merkel cell carcinoma and glioblastoma multiforme. In some embodiments, the present invention relates to methods for treating advanced solid tumors, including, but not limited to, metastatic squamous cell carcinoma of the skin (CSCC), unresectable locally advanced CSCC, metastatic colorectal cancer, advanced hepatic cell carcinoma, or metastatic hepatocellular carcinoma, non-small cell advanced lung cancer, recurrent glioblastoma multiforme, castration-resistant prostate cancer, and any advanced solid tumor refractory to first-line therapy. The methods of this aspect include administering a therapeutically effective amount of an anti-PD-1 antibody, optionally in combination with an anticancer therapy. Anticancer therapies include, but are not limited to, conventional anticancer therapy such as chemotherapy, radiation therapy, a CTLA-4 inhibitor (eg, an anti-CTLA-4 antibody), and surgery. Other anticancer therapy is described elsewhere in the present description. In one embodiment, the antitumor therapy comprises platinum chemotherapy. In some embodiments, an individual in need thereof is administered one or more doses of anti-PD-1 antibody, where each dose is administered 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 weeks after the previous doses. In some embodiments, each dose contains 0.1-10 mg/kg (eg, 0.3 mg/kg, 1 mg/kg, 3 mg/kg, or 10 mg/kg) of the individual's body weight. In some other embodiments, each dose contains 20-1500 mg of anti-PD-1 antibody, e.g. 50 mg, 100 mg, 150 mg, 200 mg, 250 mg, 300 mg, 350 mg, 400 mg, 500 mg, 550 mg 600 mg, 700 mg, 750 mg, 800 mg, 900 mg, 1000 mg, 1050 mg, 1200 mg or 1500 mg anti-PD-1 antibody.

[0045] In some embodiments, the present invention relates to methods for treating cancer or inhibiting the growth of cancer with microsatellite instability (MSI). In the context of the invention, the term "microsatellite instability", also known as "MSI", refers to changes in microsatellite repeats in tumor cells or genetic hypermutability caused by a lack of mismatch repair in DNA. Microsatellites, also known as simple repeat sequences, are DNA repeat sequences containing repeat units 1-6 base pairs in length. Although the length of microsatellites varies widely from individual to individual and contributes to the DNA fingerprint, each individual has microsatellites of a certain length. MSI results from the instability of mismatch repair (MMR) proteins in correcting DNA replication errors. MSI includes DNA polymorphisms where replication errors vary in length rather than sequence. MSI includes frameshift mutations through insertions or deletions or hypermethylation leading to gene silencing. It is known in the art that microsatellite instability can lead to colon cancer, gastric cancer, endometrial cancer, ovarian cancer, hepatobiliary system cancer, urinary tract cancer, brain malignancy, and skin cancer. The present invention relates to methods for treating malignant neoplasms with MSI comprising administering to a patient in need thereof a therapeutically effective amount of an anti-PD-1 antibody, optionally in combination with a second antitumor agent (eg, chemotherapy, radiation therapy).

[0046] As used herein, the term "chemotherapy" refers to the use of a chemotherapeutic agent (a chemical compound used for anticancer therapy). The term includes, but is not limited to, alkylating agents, antimetabolites, kinase inhibitors, plant alkaloids that are spindle poisons, cytotoxic/antineoplastic antibiotics, topoisomerase inhibitors, photosensitizers, antiestrogenic agents and selective estrogen receptor modulators (SERMs), antiprogesterone agents, estrogen receptor suppressors. (ERD), estrogen receptor antagonists, luteinizing hormone releasing factor agonists, antiandrogens, aromatase inhibitors, EGFR inhibitors, and VEGF inhibitors. Examples of chemotherapeutic agents are given elsewhere in the present description. In one embodiment, the term refers to platinum-based chemotherapeutic agents (eg, gemcitabine, cisplatin, carboplatin, pemetrexed, or combinations thereof). Chemotherapeutic agents are administered in accordance with administration schemes known in the art.

[0047] In the context of the invention, the term "radiotherapy", also referred to as "XRT", means the use of ionizing radiation to kill malignant cells, usually as part of anticancer therapy. To produce ionizing radiation, X-rays, gamma rays, or charged particles (eg, protons or electrons) are used. Radiation therapy can be delivered from a device outside the patient's body (external beam radiation therapy), or from a source inside the patient's body (internal beam radiation therapy or brachytherapy), or systemic radioactive isotopes given intravenously or orally (systemic radiotherapy). isotopes). Radiation therapy can be planned and delivered in combination with imaging modalities such as computed tomography (CT), magnetic resonance therapy (MRI) to accurately determine the dose and position of the applied radiation. In various embodiments, the radiotherapy is selected from the group consisting of total body radiotherapy, conventional external beam radiotherapy, stereotaxic radiosurgery, stereotactic body radiotherapy, 3D conformal radiotherapy, intensity modulated radiotherapy, image-guided radiotherapy, tomotherapy. , brachytherapy and systemic radiation therapy. Depending on the goals, in some embodiments, the implementation of radiation therapy is curative, adjuvant or palliative. In some embodiments, the term "radiotherapy" refers to hypofractionated radiotherapy. The term "hypofractionated radiation therapy" refers to radiation therapy in which the dose of radiation is contained in 2 or more fractions. In various embodiments, each fraction contains 2-20 Gy. For example, a radiation dose of 50 Gy can be divided into 10 fractions, each containing 5 Gy. In some embodiments, 2 or more fractions are administered on consecutive days. In some other embodiments, 2 or more fractions are administered every 2 days, every 3 days, every 4 days, every 5 days, every 6 days, every 7 days, or combinations thereof.

[0048] In some embodiments, the present invention relates to methods of treating, or slowing down, or inhibiting tumor growth. In some embodiments, the present invention relates to methods for promoting tumor regression. In some embodiments, the present invention relates to methods for reducing tumor burden or reducing tumor burden. In some embodiments, the present invention relates to methods for preventing tumor recurrence. The methods of the invention in this aspect comprise sequentially administering to a subject in need thereof a therapeutically effective amount of an anti-PD-1 antibody in combination with a second antitumor therapy wherein the antibody is administered to the subject in multiple doses, e.g., as part of a particular therapeutic dosing regimen. For example, a therapeutic dosing regimen may include administering to an individual one or more doses of an anti-PD-1 antibody at a frequency of approximately once a day, once every two days, once every three days, once every four days, once every five days, once every six days, once a week, once every two weeks, once every three weeks, once every four weeks, once a month, once every two months, once every three months, once every four months or less. In some embodiments, one or more doses of the anti-PD-1 antibody are administered in combination with one or more doses of a second anticancer therapy, wherein one or more doses of the second anticancer therapy is administered to an individual at a frequency of about weekly, biweekly, every three weekly, every four weeks, once a month, once every two months, once every three months, once every four months or less.

[0049] In some embodiments, one or more doses are included in a treatment cycle. The methods of this aspect include subjecting an individual in need thereof to at least one treatment cycle, wherein at least one treatment cycle comprises 1-10 doses of an anti-PD-1 antibody and optionally one or more doses of chemotherapy. In some embodiments, an individual in need thereof is subjected to 2-12 or more treatment cycles.

[0050] In some embodiments, the present invention relates to methods for improving antitumor efficacy or enhancing tumor inhibition. The methods of the invention in this aspect comprise administering to a subject with a solid tumor a therapeutically effective amount of an anti-PD-1 antibody prior to administering a dose of a second anti-tumor therapy (e.g., chemotherapy or an anti-CTLA-4 antibody), wherein the anti-PD-1 antibody can be administered about 1 day before , more than 1 day, more than 2 days, more than 3 days, more than 4 days, more than 5 days, more than 6 days, more than 7 days, or more than 8 days before the second anticancer therapy. In some embodiments, the methods provide tumor inhibition increased, for example, by about 20%, more than 20%, more than 30%, more than 40%, more than 50%, more than 60%, more than 70%, or more than 80% compared to an individual, which is dosed with an antitumor therapy (eg, chemotherapy) up to the anti-PD-1 antibody. In some embodiments, the chemotherapy includes platinum chemotherapy. In some embodiments, the second antitumor therapy comprises a CTLA-4 inhibitor (eg, an anti-CTLA-4 antibody).

[0051] In some embodiments, the present invention provides methods for treating cancer, comprising selecting an individual with a first tumor and at least a second tumor and administering one or more doses of an anti-PD-1 antibody in combination with radiation therapy such that treat both lesions. In some embodiments, the methods include exposing a first tumor lesion, but not a second tumor lesion, to radiation therapy, wherein the radiation therapy results in tumor regression in both tumor foci (abscopal effect). In some embodiments, the methods include selecting an individual with a first tumor site and at least a second tumor site and administering one or more doses of an anti-PD-1 antibody in combination with hypofractionated radiotherapy, wherein the first site but not the second site is exposed to hypofractionated radiotherapy, and where both lesions are treated with such radiotherapy. In some embodiments, the anti-PD-1 antibody is administered prior to radiation therapy.

[0052] In some embodiments, the present invention relates to methods for treating cancer, comprising administering to an individual in need thereof one or more subtherapeutic doses of an anti-PD-1 antibody in combination with one or more antitumor therapies, such as radiation therapy. As defined elsewhere in the present description, the term "subtherapeutic dose" refers to a dose less than a therapeutic dose, and which can be used to reduce the toxicity of the therapy. In some embodiments, administration of a subtherapeutic dose of anti-PD-1 antibody in combination with radiation therapy results in therapeutic antitumor efficacy compared to administration of a subtherapeutic dose of anti-PD-1 antibody alone. In some other embodiments, the methods of the present invention comprise administering a therapeutically effective amount of an anti-PD-1 antibody in combination with a subtherapeutic dose of an anticancer therapy such as chemotherapy or radiation therapy. For example, a therapeutically effective amount of an anti-PD-1 antibody can be administered in combination with a sub-therapeutic dose of cyclophosphamide to increase efficacy over any monotherapy.

[0053] In some embodiments, the present invention relates to methods for inhibiting, delaying, or stopping tumor metastasis or tumor cell infiltration of peripheral organs. The methods of this aspect include administering to an individual in need thereof a therapeutically effective amount of an anti-PD-1 antibody. In some embodiments, the anti-PD-1 antibody is administered in combination with chemotherapy. In one embodiment, the chemotherapy is platinum chemotherapy. In one embodiment, chemotherapy is administered before, concurrently, or after one or more doses of anti-PD-1 antibody.

[0054] In some embodiments, the methods of the present invention comprise administering a therapeutically effective amount of an anti-PD-1 antibody to an individual with advanced solid tumors. In some embodiments, the advanced solid tumor is metastatic lung cancer, head and neck cancer, hepatocellular carcinoma, or breast cancer. In some other embodiments, the late stage solid tumor is a squamous cell skin cancer. In some embodiments, the late-stage solid tumor is silent or aggressive. In some embodiments, the individual does not respond to prior therapy or has experienced a relapse following prior therapy (eg, with carboplatin). In some embodiments, the individual has an advanced solid tumor refractory to first line chemotherapy. In some additional embodiments, the methods of the present invention further comprise subjecting the individual with a solid tumor to an advanced stage of additional anticancer therapy (eg, a CTLA-4 inhibitor).

[0055] In some embodiments, the present invention relates to methods for treating or inhibiting the growth of a cancer, including, but not limited to, colorectal cancer, ovarian cancer, prostate cancer, breast cancer, brain cancer, cervical cancer, cancer bladder cancer, anal cancer, uterine cancer, colon cancer, liver cancer, pancreatic cancer, lung cancer, endometrial cancer, bone cancer, testicular cancer, skin cancer, kidney cancer, stomach cancer, esophageal cancer, head cancer, and neck, salivary gland cancer and myeloma. In some embodiments, the present invention relates to methods for treating or inhibiting the growth of a malignant neoplasm, including, but not limited to, hepatocellular carcinoma, non-small cell lung cancer, head and neck squamous cell carcinoma, basal cell carcinoma, squamous cell carcinoma of the skin, chondrosarcoma, angiosarcoma, cholangiocarcinoma , soft tissue sarcoma, colorectal cancer, melanoma, Merkel cell carcinoma and glioblastoma multiforme. In some embodiments, the present invention relates to methods for treating advanced solid tumors, including, but not limited to, metastatic squamous cell carcinoma of the skin (CSCC), unresectable locally advanced CSCC, metastatic colorectal cancer, advanced hepatic cell carcinoma, or metastatic hepatocellular carcinoma, non-small cell advanced lung cancer, recurrent glioblastoma multiforme, newly diagnosed glioblastoma multiforme, castration-resistant prostate cancer, and any advanced solid tumor refractory to first-line therapy.

[0056] In one aspect, the present invention relates to methods for treating or inhibiting tumor growth, comprising: (a) selecting a patient with squamous cell carcinoma of the skin (CSCC), where the patient is selected based on a characteristic selected from the group consisting of the following: (i a) the patient has locally advanced CSCC; (ii) the patient has metastatic CSCC; (iii) the tumor is inoperable; (iv) the patient has previously been treated with at least one anticancer therapy; (v) the patient has a disease considered inoperable; (vi) surgery and/or radiotherapy is contraindicated; (vii) the patient has previously been treated with radiation therapy and the tumor is resistant to, or does not respond to, radiation therapy; and (viii) the tumor contains UV-induced DNA damage; and (b) administering a therapeutically effective amount of the anti-PD-1 antibody to a patient in need thereof. In some embodiments, one or more doses of the anti-PD-1 antibody are administered 1-12 weeks after the previous dose, e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 weeks after the previous dose. In some embodiments, each dose of anti-PD-1 antibody contains 0.1, 1, 0.3, 3, 4, 5, 6, 7, 8, 9, or 10 mg/kg of the patient's body weight. In some embodiments, each dose contains 50-500 mg of anti-PD-1 antibody. In one embodiment, the anti-PD-1 antibody is REGN2810.

[0057] In one aspect, the present invention relates to methods of treating a tumor or improving the survival of a patient with a malignant neoplasm, including: (a) selecting a patient having lung cancer, where the patient is selected based on a characteristic selected from the group consisting of the following: ( i) the patient has non-small cell lung cancer; (ii) the patient's tumor tissue expresses PD-L1 in <50% of the tumor cells; (iii) the patient has stage III or IV squamous cell or non-squamous cell lung cancer; (iv) the patient has not previously received systemic treatment for recurrent lung cancer; and (v) the patient has been previously treated with an anticancer therapy; and (b) administering to the patient one or more doses of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to PD-1. In one embodiment, the patient has advanced non-small cell lung cancer or recurrent non-small cell lung cancer, the patient's tumor tissue expresses PD-L1 in <50% of the tumor cells, and the patient has not previously received systemic lung cancer treatment. In one embodiment, the patient has advanced non-small cell lung cancer or recurrent non-small cell lung cancer, the patient's tumor tissue expresses PD-L1 in <50% of the tumor cells, and the patient has previously undergone systemic lung cancer treatment (eg, chemotherapy). In some embodiments, the patient has advanced non-small cell lung cancer or recurrent non-small cell lung cancer and the patient's tumor tissue expresses PD-L1 at <50%, ≤45%, ≤40%, ≤30%, ≤20%, ≤10% , ≤5%, ≤2% or ≤1% of tumor cells.

[0058] In some embodiments, the present invention relates to methods for treating cancer or improving the survival of a patient with cancer, including: (a) selecting a patient with lung cancer, where the patient's tumor tissue expresses PD-L1 in ≥50% of tumor cells; and (b) administering to the patient one or more doses of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to PD-1. In one embodiment, the patient's tumor tissue expresses PD-L1 in ≥60%, ≥70%, ≥80%, or ≥90% of tumor cells. In one embodiment, the patient has advanced non-small cell lung cancer or metastatic non-small cell lung cancer. In one embodiment, the patient has stage III or stage IV squamous or non-squamous non-small cell lung cancer. In one embodiment, the patient has not previously received systemic treatment for lung cancer.

[0059] In one aspect, the present invention relates to methods for treating cancer or improving the survival of a patient with cancer, comprising: (a) selecting a patient with lung cancer, where the patient has at least one of the following characteristics: (i) the patient has advanced non-small cell lung cancer or metastatic non-small cell lung cancer; (ii) the patient has stage III or stage IV squamous or non-squamous cell lung cancer; (iii) the patient has not previously been subjected to systemic treatment for lung cancer; and (iv) the patient has previously received anticancer therapy (eg, platinum chemotherapy, surgery, and/or radiation therapy); (b) determining the expression of PD-L1 in tumor tissue; and (c) administering to the patient one or more doses of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to PD-1 if the tumor tissue expresses PD-L1 in <50% of the tumor cells. In one embodiment, the tumor tissue expresses PD-L1 at <50%, ≤45%, ≤40%, ≤30%, ≤20%, ≤10%, .5%, ≤2%, ≤1%, or 0%. tumor cells.

[0060] In one aspect, the present invention relates to methods for treating cancer or improving the survival of a patient with cancer, comprising: (a) selecting a patient with lung cancer, where the patient has at least one of the following characteristics: (i) the patient has advanced non-small cell lung cancer or metastatic non-small cell lung cancer; (ii) the patient has stage III or stage IV squamous or non-squamous cell lung cancer; (iii) the patient has not previously been subjected to systemic treatment for lung cancer; and (iv) the patient has previously received anticancer therapy (eg, platinum chemotherapy, surgery, and/or radiation therapy); (b) determining the expression of PD-L1 in tumor tissue; and (c) administering to the patient one or more doses of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to PD-1 if the tumor tissue expresses PD-L1 in ≥50% of the tumor cells. In one embodiment, the tumor tissue expresses PD-L1 in ≥60%, ≥70%, ≥80%, or ≥90% of tumor cells.

[0061] In some embodiments, each dose of anti-PD-1 antibody is administered 1 week, 2 weeks, 3 weeks, or 4 weeks after the previous dose, where each dose contains 20-1500 mg of anti-PD-1 antibody. In one embodiment, each dose contains 200, 250, 300, 350, 500, 600, 700, 800, 900, 1000, or 1050 mg of anti-PD-1 antibody. In one embodiment, the anti-PD-1 antibody is REGN2810 (cemiplimab).

[0062] In some embodiments, the methods include administering one or more doses of a therapeutically effective amount of an anti-PD-1 antibody to a cancer patient, wherein the patient is selected to express PD-L1 in less than 1% of the tumor cells. In some embodiments, the patient's tumor tissue expresses PD-L1 in less than 2%, less than 5%, less than 10%, less than 20%, less than 30%, less than 40%, or less than 50% of the tumor cells. In some embodiments, the methods include selecting a cancer patient, wherein the patient is selected based on PD-L1 expression in ≥50% of the tumor cells, and administering to the patient one or more doses of a therapeutically effective amount of an anti-PD-1 antibody. In some embodiments, expression of PD-L1 in tumor tissue is determined using any assay known in the art, such as an ELISA assay or an immunohistochemical (IHC) assay as described in PCT Publication Nos. In some embodiments, PD-L1 expression is determined by quantitative analysis of RNA expression, e.g., hybridizationin situ or RT-PCR. In some embodiments, PD-L1 expression is determined by imaging using a labeled anti-PD-L1 antibody, such as immune positron emission tomography or iPET [see, For example,The Oncologist, 12:1379 (2007);Journal of Nuclear Medicine, 52(8): 1171 (2011); U.S. interim patent application No. 62/428672, filed December 1, 2016].

[0063] In some embodiments, administration of at least one dose of anti-PD-1 antibody results in improved progression-free survival (PFS) or overall survival (OS) of the patient compared to a patient who was treated with platinum chemotherapy as monotherapy. In some embodiments, the PFS is increased by at least one month, about 2 months, about 3 months, about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 1 year, about 2 years, about 3 years or more compared to a patient undergoing platinum chemotherapy. In some embodiments, OS is increased by at least one month, about 2 months, about 3 months, about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 1 year, about 2 years, about 3 years or more compared to a patient undergoing platinum chemotherapy.

[0064] In one aspect, the present invention provides methods for treating or inhibiting tumor growth, comprising selecting an individual with a brain cancer and administering a therapeutically effective amount of an anti-PD-1 antibody or antigen-binding fragment thereof to an individual in need thereof. In some embodiments, the brain malignancy is glioblastoma multiforme. In one embodiment, the individual has a newly diagnosed glioblastoma multiforme. In one embodiment, the age of the individual is ≥65 years. In one embodiment, the anti-PD-1 antibody is administered in one or more doses, where each dose is administered 0.5-4 weeks after the previous dose. In one embodiment, each dose of anti-PD-1 antibody contains 1, 3, or 10 mg/kg of the individual's body weight. In some embodiments, the anti-PD-1 antibody is administered in combination with radiation therapy. In one embodiment, the radiotherapy is hypofractionated radiotherapy. In one embodiment, the individual is administered 20-60 Gy in 2-20 fractions. In some embodiments, one or more doses of anti-PD-1 antibody are included in one or more treatment cycles, where each treatment cycle includes 1-6 doses of anti-PD-1 antibody. In one embodiment, at least one treatment cycle further comprises radiation therapy. In a further embodiment, the radiation therapy is hypofractionated radiation therapy. In some embodiments, the individual is subjected to hypofractionated radiation therapy in the first cycle of treatment, where the hypofractionated radiation therapy comprises 20-60 Gy in 2-20 fractions. In one embodiment, the subject is subjected to hypofractionated radiation therapy one week after administration of the anti-PD-1 antibody in the first cycle of treatment. In some embodiments, the methods of the present invention further comprise administering an anti-angiogenic agent to the subject if the subject develops cerebral edema following administration of the anti-PD-1 antibody. In one embodiment, the anti-angiogenic agent is an inhibitor of vascular endothelial growth factor (VEGF). In one embodiment, the anti-angiogenic agent is an angiopoietin-2 (Ang-2) inhibitor (eg, an anti-Ang-2 antibody such as nesvacumab). In some embodiments, the VEGF inhibitor is selected from the group consisting of a VEGF inhibitory fusion protein (e.g., a "VEGF decoy" such as aflibercept or other VEGF inhibitory fusion protein as described in US Pat. No. 7,087,411), an anti-VEGF antibody ( e.g. bevacizumab) and a small molecule VEGF receptor kinase inhibitor (e.g. sunitinib, sorafenib or pazopanib).

[0065] In some embodiments, the methods of the present invention comprise administering to a subject a therapeutically effective amount of an anti-PD-1 antibody in combination with an additional therapeutic agent or regimen or method. An additional therapeutic agent or treatment regimen or method can be used to increase antitumor efficacy, reduce the toxic effects of one or more therapies, and/or reduce the dose of one or more therapeutic agents. In various embodiments, the additional therapeutic agent or treatment regimen or method is selected from the group consisting of, for example, chemotherapy, cyclophosphamide, surgery, radiation therapy, cancer vaccine, programmed cell death ligand 1 (PD-L1) inhibitor (e.g., antibodies against PD-L1), a lymphocyte activation gene 3 (LAG3) inhibitor (e.g. anti-LAG3 antibodies), an inhibitor of cytotoxic T-lymphocyte antigen 4 (CTLA-4) antigen (e.g. an anti-CTLA-4 antibody such as ipilimumab), an inhibitor glucocorticoid-inducible tumor necrosis factor receptor (GITR) (eg, anti-GITR antibodies), T-cell immunoglobulin and mucin domain-containing protein-3 inhibitor (TIM3), B- and T-lymphocyte attenuator (BTLA) inhibitor, T- cellular immunoreceptor with Ig and ITIM domains (TIGIT), CD47 inhibitor, indolamine-2,3-dioxygenase (IDO) inhibitor, vascular endothelial growth factor (VEGF) antagonist [selected from the group, cos consisting of a VEGF inhibitory fusion protein (e.g., a "VEGF decoy" such as aflibercept or another VEGF inhibitory fusion protein as described in US Pat. No. 7,087,411), an anti-VEGF antibody (e.g., bevacizumab), and a small molecule inhibitor of VEGF receptor kinase (eg, sunitinib, sorafenib, or pazopanib)], an angiopoietin-2 (Ang2) inhibitor, a transforming growth factor beta (TGFβ) inhibitor, an epidermal growth factor receptor (EGFR) inhibitor, an antibody against a tumor-specific antigen [eg, CA9, CA125, melanoma- associated antigen 3 (MAGE3), carcinoembryonic antigen (CEA), vimentin, tumor M2-PK, prostate-specific antigen (PSA), mucin-1, MART-1, and CA19-9], anti-CD3/anti-CD20 bispecific antibody, vaccine (eg, Bacillus Calmette-Guerin), granulocyte-macrophage colony-stimulating factor, cytotoxin, chemotherapeutic agent, IL-6R inhibitor, IL-4R inhibitor, IL-10 inhibitor, cytokine such as IL-2, IL-7, IL-21 and IL-15, T-cell therapy, an anti-inflammatory drug such as corticosteroids and non-steroidal anti-inflammatory drugs, and a dietary supplement such as antioxidants. In some embodiments, the anti-PD-1 antibody may be administered in combination with therapy including a chemotherapeutic agent and surgery. In the context of the invention, the phrase "in combination with" means that the anti-PD-1 antibody is administered to the individual simultaneously, immediately before or immediately after the administration of radiation therapy and administration of an additional therapeutic agent. In some embodiments, an additional therapeutic agent is administered as a co-formulation with an anti-PD-1 antibody.

[0066] In some embodiments, the present invention relates to methods for treating large tumors or advanced malignancies, comprising administering to an individual in need thereof an anti-PD-1 antibody in combination with radiation therapy and an additional therapeutic agent, wherein the additional therapeutic agent is administered to overcome Regulatory T cell (Treg) mediated immunosuppression. In some embodiments, the additional therapeutic agent is selected from the group consisting of an anti-GITR antibody, an anti-LAG3 antibody, cyclophosphamide, and GM-CSF.

[0067] In the context of the invention, the term "large tumor" refers to the size of the tumor. It generally correlates with higher tumor mass or tumor burden. In some embodiments, it correlates with the stage of the disease, such as advanced cancer. In some embodiments, it correlates with an increased likelihood of metastasis.

[0068] In some embodiments, the present invention provides methods comprising administering one or more doses of an anti-PD-1 antibody in combination with radiation therapy and a subtherapeutic dose of cyclophosphamide. As used herein, the term "sub-therapeutic dose of cyclophosphamide" (also referred to herein as "low dose cyclophosphamide") means an amount of cyclophosphamide that does not in itself have a therapeutic effect and preferably toxicity. Examples of doses of cyclophosphamide considered "sub-therapeutic" in the context of the present invention include 100 mg/m ² , 90 mg/m ² , 80 mg/m ² or less.

[0069] In some embodiments, radiation therapy is used for a first tumor site, but not a second tumor site, where it in combination with an anti-PD-1 antibody results in tumor regression in the first and second tumor sites (abscopal effect). In some embodiments, the implementation of the methods of the present invention include the introduction of antibodies against PD-1 in combination with radiation therapy to achieve a long abscopal effect.

[0070] In some embodiments, the methods of the present invention comprise administering to an individual in need thereof a therapeutically effective amount of an anti-PD-1 antibody, optionally in combination with a second antitumor therapy, wherein administration of the combination results in increased inhibition of tumor growth. In some embodiments, tumor growth is inhibited by at least about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, or about 80% compared to an untreated individual, or an individual who was administered an antibody or subjected to a second anticancer therapy as monotherapy. In some embodiments, administration of an anti-PD-1 antibody and/or administration of a second anticancer therapy results in increased tumor regression, shrinkage, and/or disappearance of the tumor. In some embodiments, administration of an anti-PD-1 antibody and/or a chemotherapeutic agent results in a slowdown in tumor growth and development, e.g., tumor growth can be slowed down by about 3 days, more than 3 days, about 7 days, more than 7 days, more than 15 days, more than 1 month, more than 3 months, more than 6 months, more than 1 year, more than 2 years or more than 3 years compared with an untreated individual or an individual who was treated with antibody or chemotherapy as monotherapy. In some embodiments, administration of the anti-PD-1 antibody in combination with a second anticancer therapy (e.g., chemotherapy) prevents tumor recurrence and/or increases the duration of survival of the individual, e.g., increases the duration of survival by more than 15 days, more than 1 month, more more than 3 months, more than 6 months, more than 12 months, more than 18 months, more than 24 months, more than 36 months, or more than 48 months compared to the untreated or untreated individual , which is administered an antibody or is subjected to a second anticancer therapy as monotherapy. In some embodiments, administration of an anti-PD-1 antibody in combination with additional anticancer therapy improves progression-free survival or overall survival. In some embodiments, administration of an anti-PD-1 antibody in combination with chemotherapy increases response and duration of response in an individual, e.g., greater than 2%, greater than 3%, greater than 4%, greater than 5%, greater than by 6%, more than 7%, more than 8%, more than 9%, more than 10%, more than 20%, more than 30%, more than 40% or more than 50 % compared with an untreated individual or an individual who was administered an antibody or chemotherapeutic agent as monotherapy. In some embodiments, administration of an anti-PD-1 antibody to an individual with cancer and/or administration of a second antitumor therapy results in the complete disappearance of all evidence of tumor cells ("complete response"). In some embodiments, administration of an anti-PD-1 antibody to an individual with cancer and/or administration of a second anticancer therapy results in at least a 30% or greater reduction in tumor cells or tumor size ("partial response"). In some embodiments, administering an anti-PD-1 antibody to a cancer individual and/or administering a second anticancer therapy results in complete or partial disappearance of the tumor cells/lesions, including new measurable lesions. Tumor shrinkage can be measured by any of the methods known in the art, for example, by X-ray, positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), cytological, histological or molecular genetic analyses.

[0071] In some embodiments, the methods of the present invention comprise administering to an individual in need thereof a therapeutically effective amount of an anti-PD-1 antibody, wherein administration of the anti-PD-1 antibody results in improved overall survival (OS) or progression-free survival (PFS) of the patient by compared to a patient being treated according to a "standard of care" (eg, chemotherapy, surgery, or radiation therapy). In some embodiments, the PFS is increased by at least one month, about 2 months, about 3 months, about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 1 year, about 2 years, about 3 years or more compared to a patient undergoing platinum chemotherapy. In some embodiments, OS is increased by at least one month, about 2 months, about 3 months, about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 1 year, about 2 years, about 3 years or more compared to a patient undergoing platinum chemotherapy.

Ways to suppress regulatory T cells

[0072] In some aspects, the present invention relates to methods of suppressing or inhibiting the activation and/or proliferation of regulatory T cells (Treg). In some embodiments, the present invention relates to methods for suppressing the activity of Treg cells. In these aspects, the methods include selecting an individual with a solid tumor and administering to the individual an anti-PD-1 antibody or antigen-binding fragment thereof in combination with at least one of (i) radiation therapy and (ii) a glucocorticoid-inducible tumor necrosis factor receptor (GITR) antagonist . In some embodiments, the methods include administering to an individual in need thereof an anti-PD-1 antibody, or an antigen-binding fragment thereof, in combination with radiation therapy and a GITR antagonist.

[0073] In some embodiments, the GITR antagonist is an anti-GITR antibody or an antigen-binding fragment thereof. In some exemplary embodiments, an anti-GITR antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region (HCVR), a light chain variable region (LCVR), and/or complementarity determining regions (CDRs) comprising the amino acid sequences of any of the anti-GITR antibodies described in US Patent Application No. 62/256922 (filed Nov. 18, 2015), the contents of which are incorporated herein in their entirety. Other anti-GITR antibodies that can be used in the context of the methods of the present invention include any of the anti-GITR antibodies described in, for example, US Pat.

[0074] In some embodiments, the present invention provides methods for suppressing or eliminating Treg activity, comprising administering to an individual in need thereof an anti-PD-1 antibody, or an antigen-binding fragment thereof, in combination with one or more doses of radiation therapy and a cytotoxic T-antigen-4 antagonist. lymphocytes (CTLA). In some embodiments, the CTLA antagonist is an anti-CTLA antibody (eg, ipilimumab).

[0075] In some embodiments, the present invention provides methods for suppressing or eliminating Treg activity, comprising administering to an individual in need thereof an anti-PD-1 antibody or antigen-binding fragment thereof, in combination with one or more doses of radiation therapy and a lymphocyte activation gene 3 (LAG) antagonist. -3). In some embodiments, the LAG-3 antagonist is an anti-LAG-3 antibody. Anti-LAG-3 antibodies useful in the context of the methods of the present invention are described in US Patent Application No. 62/239524 (filed October 9, 2015), the contents of which are incorporated herein in their entirety.

[0076] In some embodiments, the present invention provides methods for suppressing or eliminating Treg activity, comprising administering an anti-PD-1 antibody, or antigen-binding fragment thereof, to an individual in need, in combination with one or more doses of radiation therapy and cyclophosphamide.

[0077] In one aspect, the methods of the present invention comprise administering to an individual with a solid tumor an anti-PD-1 antibody in combination with radiation therapy and an additional therapeutic agent selected from the group consisting of a GITR antagonist, an anti-LAG-3 antibody, and cyclophosphamide, wherein administration results in an effect selected from the group consisting of tumor growth inhibition, tumor size reduction, tumor growth retardation, tumor metastasis inhibition, metastasis reduction over time, reduced use of chemotherapeutic or cytotoxic agents, improved survival, complete response, partial response, and stable diseases. In some embodiments, the implementation of the introduction leads to a decrease in tumor mass in the individual. In some embodiments, the individual has a large tumor. As defined elsewhere in the present description, the term "large tumor" refers to the size of the tumor, and it correlates with increased tumor mass and increased likelihood of metastasis. In some embodiments, the term refers to advanced cancer.

Anti-PD-1 antibodies and their antigen-binding fragments

[0078] In some illustrative embodiments of the present invention, the methods include administering a therapeutically effective amount of an anti-PD-1 antibody or antigen-binding fragment thereof. In the context of the invention, the term "antibody" includes immunoglobulin molecules containing four polypeptide chains, two heavy (H) chains and two light (L) chains connected to each other by disulfide bonds, as well as their multimers (eg, IgM). In a typical antibody, each heavy chain contains a heavy chain variable region (abbreviated herein as HCVR or V _H ) and a heavy chain constant region. The heavy chain constant region contains three domains, C _H 1 , C _H 2 and C _H 3. Each light chain contains a light chain variable region (abbreviated herein as LCVR or V _L ) and a light chain constant region. The light chain constant region contains one domain (C _L 1). The V _H and V _L regions can be further divided into hypervariable regions, referred to as complementarity determining regions (CDRs), interspersed with regions that are more conserved, referred to as framework regions (FRs). Each V _H and V _L consists of three CDRs and four FRs, arranged from amino to carboxy in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In various embodiments, the FR of an anti-IL-4R antibody (or antigen-binding portion thereof) may be identical to human germline sequences, or naturally or artificially modified. The consensus amino acid sequence can be determined by simultaneously analyzing two or more CDRs.

[0079] As used herein, the term "antibody" also includes antigen-binding fragments of complete antibody molecules. Within the scope of the invention, the terms "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, and the like. include any naturally occurring, enzymatically produced, synthetic or genetically engineered polypeptide or glycoprotein that specifically binds to an antigen to form a complex. Antigen-binding fragments of an antibody can be obtained, for example, from complete antibody molecules by any suitable standard methods, such as proteolytic cleavage or recombinant genetic engineering methods, including exposure to DNA encoding the variable and optionally constant domains of the antibody, and its expression. Such DNA is known and/or available from, for example, commercial sources, DNA libraries (including, for example, antibody phage libraries), or can be synthesized. DNA can be sequenced and manipulated chemically or by molecular biology techniques, e.g., to arrange one or more variable and/or constant domains in a suitable configuration, or to insert codons, create cysteine residues, modify, add or delete amino acids, etc.

[0080] Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single chain Fv molecules (scFv); (vi) dAb fragments; and (vii) minimal recognition units consisting of amino acid residues that mimic an antibody hypervariable region (e.g., a distinguished complementarity determining region (CDR) such as a CDR3 peptide), or a FR3-CDR3-FR4 peptide with limited conformational freedom. Other engineered molecules such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, tribodies, tetrabodies, minibodies, nanobodies (e.g., monovalent nanobodies, bivalent nanobodies, etc.) , small modular immunopharmaceuticals (SMIPs), and shark IgNAR variable domains are also included within the scope of the invention.

[0081] An antigen binding fragment of an antibody will typically contain at least one variable domain. The variable domain may be of any size or amino acid composition and will typically contain at least one CDR adjacent to or in-frame with one or more framework sequences. In antigen-binding fragments containing a V _H domain associated with a V _L domain, the V _H and V _L domains can be positioned relative to each other in any suitable configuration. For example, the variable region may be dimeric and contain V _H -V _H , V _H -V _L or V _L -V _L dimers. Alternatively, the antigen-binding fragment of an antibody may comprise a V _H or V _L monomeric domain.

[0082] In some embodiments, an antigen-binding fragment of an antibody may comprise at least one variable domain covalently linked to at least one constant domain. Non-limiting examples of variable and constant domain configurations that can be found in an antigen-binding fragment of an antibody of the present invention include: (i) V _{H -CH} 1; (ii) V _H -C _H 2; (iii) V _H -C _H 3; (iv) V _H -C _H 1 -C _H 2; (v) V _H -C _H 1 -C _H 2 -C _H 3; (vi) V _H -C _H 2 -C _H 3; (vii) V _H -C _L ; (viii) V _L -C _H 1; (ix) V _{L -CH} 2; (x) V _L -C _H 3; (xi) V _L -C _H 1 -C _H 2; (xii) V _L -C _H 1 -C _H 2 -C _H 3; (xiii) V _L -C _H 2 -C _H 3; and (xiv) V _L -C _L . In any configuration of variable and constant domains, including any of the configuration examples above, the variable and constant domains can be connected directly to each other or through a full or partial hinge or linker region. The hinge region may be composed of at least 2 (e.g., 5, 10, 15, 20, 40, 60 or more) amino acids, resulting in a flexible or semi-flexible connection between adjacent variable and/or constant domains in a single polypeptide molecule. In addition, an antigen-binding fragment of an antibody of the present invention may comprise a homodimer or heterodimer (or other multimer) of any of the variable and constant domain configurations above, in non-covalent association with each other and/or with one or more V _H or V monomeric domains. _L (for example, using disulfide bonds).

[0083] As used herein, the term "antibody" also includes multispecific (eg, bispecific) antibodies. A multispecific antibody or antigen-binding fragment of an antibody will typically contain at least two different variable domains, where each variable domain can specifically bind to a different antigen or to a different epitope on the same antigen. Any multispecific antibody format can be adapted for use in the context of an antibody or antigen-binding fragment of an antibody of the present invention using conventional techniques available in the art. For example, the present invention relates to methods involving the use of bispecific antibodies, where one arm of the immunoglobulin is specific for PD-1 or a fragment thereof, and the other arm of the immunoglobulin is specific for a second therapeutic target or conjugated to a therapeutic substance. Non-limiting examples of bispecific formats that can be used in the context of the present invention include, for example, scFv or diabody based bispecific formats, IgG-scFv fusion proteins, Ig dual variable domain (DVD), quadroma, ridge-to-cavity proteins , common light chain (e.g., common light chain with bumps in the valley, etc.), CrossMab, CrossFab, antibody containing a chain replacement engineered domain (SEED), leucine zipper, duobody, IgG1/IgG2, IgG with dual acting Fab (DAF) and Mab ² bispecific formats (see review of the above formats, for example, in Klein et al . 2012, mAbs 4:6, 1-11 and references cited therein). Bispecific antibodies can also be constructed using peptide/nucleic acid conjugation, for example, where unnatural amino acids with independent reactivity are used to generate site-specific antibody-oligonucleotide conjugates, which then self-assemble into multimeric complexes with specific composition, valence, and configuration (see , for example, Kazane et al ., J. Am. Chem. Soc . [ Epub : Dec. 4, 2012 ]).

[0084] The antibodies used in the methods of the present invention may be human antibodies. As used herein, the term "human antibody" is intended to include antibodies containing variable and constant regions derived from human germline immunoglobulin sequences. However, human antibodies of the invention may include amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations inserted by in vitro random or site-specific mutagenesis or by in vivo somatic mutation), for example, in CDRs and, in in particular, CDR3. However, within the scope of the invention, the term "human antibody" is not intended to include antibodies in which CDR sequences derived from the germline of another mammalian species, such as a mouse, are grafted onto human framework sequences.

[0085] The antibodies used in the methods of the present invention may be recombinant human antibodies. For the purposes of the invention, the term "recombinant human antibody" is intended to include all human antibodies produced, expressed, generated or isolated by recombinant methods, such as antibodies expressed using a recombinant expression vector transfected into a host cell (described below), antibodies isolated from a recombinant, combinatorial human antibody library (described below), antibodies isolated from an animal (eg, mouse) that is transgenic for human immunoglobulin genes [see for example, Taylor et al. (1992) Nucl. Acids Res. 20:6287-6295], or antibodies produced, expressed, constructed or isolated by any other means, including splicing human immunoglobulin gene sequences with other DNA sequences. Such recombinant human antibodies contain variable and constant regions derived from human germline immunoglobulin sequences. However, in some embodiments, such human recombinant antibodies are subjected to in vitro mutagenesis (or, if an animal transgenic for human Ig sequences is used, to somatic in vivo mutagenesis), and thus the amino acid sequences of the V _H and V _L regions of the recombinant antibodies are sequences which, although derived from and related to human germline V _H and V _L sequences, may not naturally exist in the in vivo human germline antibody repertoire.

[0086] In some embodiments, the antibodies used in the methods of the present invention specifically bind to PD-1. The term "specifically binds" or the like. means that the antibody or antigen-binding fragment forms a complex with an antigen that is relatively stable under physiological conditions. Methods for determining whether an antibody specifically binds to an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, an antibody "specifically binding" to PD-1, in the context of the present invention, includes antibodies that bind to PD-1, or a portion thereof, with a K _D of less than about 500 nM, less than about 300 nM, less than about 200 nM, less than about 100 nM , less than about 90 nM, less than about 80 nM, less than about 70 nM, less than about 60 nM, less than about 50 nM, less than about 40 nM, less than about 30 nM, less than about 20 nM, less than about 10 nM, less than about 5 nM , less than about 4 nM, less than about 3 nM, less than about 2 nM, less than about 1 nM, or less than about 0.5 nM, as measured by surface plasmon resonance analysis. However, an isolated antibody that specifically binds to human PD-1 may be cross-reactive with other antigens, such as non-human PD-1 molecules.

[0087] In some illustrative embodiments of the present invention, the anti-PD-1 antibody, or antigen-binding fragment thereof, comprises a heavy chain variable region (HCVR), a light chain variable region (LCVR), and/or complementarity determining regions (CDRs) containing the amino acid sequences of any of the anti-PD-1 antibodies described in US Patent Publication No. 20150203579, which is hereby incorporated herein by reference in its entirety. In some exemplary embodiments, an anti-PD-1 antibody or antigen-binding fragment thereof that can be used in the context of the methods of the present invention comprises a heavy chain variable region (HCVR) complementarity determining region (HCDR) comprising the amino acid sequence of SEQ ID NO: 1, and light chain variable region (LCVR) complementarity determining regions (LCDR) comprising the amino acid sequence of SEQ ID NO: 2. LCDR1, LCDR2 and LCDR3), where HCDR1 contains the amino acid sequence of SEQ ID NO: 3; HCDR2 contains the amino acid sequence of SEQ ID NO: 4; HCDR3 contains the amino acid sequence of SEQ ID NO: 5; LCDR1 contains the amino acid sequence of SEQ ID NO: 6; LCDR2 contains the amino acid sequence of SEQ ID NO: 7; and LCDR3 comprises the amino acid sequence of SEQ ID NO: 8. In other embodiments, the anti-PD-1 antibody or antigen-binding fragment thereof comprises an HCVR comprising SEQ ID NO: 1 and an LCVR comprising SEQ ID NO: 2. In some embodiments, the methods of of the present invention include the use of an anti-PD-1 antibody, wherein the antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9. In some embodiments, the anti-PD-1 antibody comprises a light chain comprising the amino acid sequence of SEQ ID NO: 10. An example of an antibody, containing a heavy chain containing the amino acid sequence of SEQ ID NO: 9 and a light chain containing the amino acid sequence of SEQ ID NO: 10 is a fully human anti-PD-1 antibody known as REGN2810 (also known as cemiplimab). In some illustrative embodiments, the implementation of the methods of the present invention include the use of REGN2810 or its bioequivalent. In the context of the invention, the term "bioequivalent" refers to antibodies against PD-1 or PD-1 binding proteins or fragments thereof, which are pharmaceutical equivalents or pharmaceutical alternatives, the rate and/or extent of absorption of which does not differ significantly from the rate and/or extent of absorption of REGN2810 when administered at the same molar dose under similar experimental conditions in a single dose or multiple doses. In the context of the invention, the term refers to antigen-binding proteins that bind to PD-1 and do not have clinically significant differences from REGN2810 in safety, purity and/or activity.

[0088] Other anti-PD-1 antibodies that can be used in the context of the methods of the present invention include, for example, antibodies designated and known in the art as nivolumab (US Pat. No. 8,008,449), pembrolizumab (US Pat. No. 8,354,509), MEDI0608 (U.S. Patent No. 8,609,089), pidilizumab (U.S. Patent No. 8,686,119), or any of the anti-PD-1 antibodies described in US Pat.

[0089] Anti-PD-1 antibodies used in the context of the methods of the present invention may have pH dependent binding characteristics. For example, an anti-PD-1 antibody for use in the methods of the present invention may exhibit reduced binding to PD-1 at acidic pH compared to neutral pH. Alternatively, an anti-PD-1 antibody of the invention may exhibit increased binding to its antigen at acidic pH compared to neutral pH. The expression "acidic pH" includes pH values less than about 6.2, for example, about 6.0, 5.95, 5.9, 5.85, 5.8, 5.75, 5.7, 5.65, 5 .6, 5.55, 5.5, 5.45, 5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1, 5.05, 5.0 or less. In the context of the invention, the expression "neutral pH" means a pH of from about 7.0 to about 7.4. The expression "neutral pH" includes pH values of approximately 7.0, 7.05, 7.1, 7.15, 7.2, 7.25, 7.3, 7.35 and 7.4.

[0090] In some cases, "reduced binding to PD-1 at acidic pH compared to neutral pH" is expressed in terms of the ratio of the K _D value of antibody binding to PD-1 at acidic pH and the K _D value of antibody binding to PD-1 at neutral pH (or vice versa). For example, an antibody or antigen-binding fragment thereof may be considered to exhibit "reduced binding to PD-1 at acidic pH compared to neutral pH" for the purposes of the present invention if the antibody or antigen-binding fragment thereof exhibits an acidic/neutral pH K _D ratio of approximately 3 ,0 or more. In some illustrative embodiments, the acid/neutral pH K _D ratio for an antibody or antigen-binding fragment of the present invention may be about 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6, 0, 6.5, 7.0, 7.5, 8.0, 8.5, 9.0, 9.5, 10.0, 10.5, 11.0, 11.5, 12.0, 12.5, 13.0, 13.5, 14.0, 14.5, 15.0, 20.0, 25.0, 30.0, 40.0, 50.0, 60.0, 70, 0, 100.0 or more.

[0091] Antibodies with pH-dependent binding characteristics can be obtained, for example, by screening a population of antibodies for reduced (or increased) binding to a particular antigen at acidic pH compared to neutral pH. In addition, by modifying the antigen-binding domain at the amino acid level, antibodies with pH-dependent characteristics can be obtained. For example, by replacing one or more amino acids of an antigen-binding domain (eg, in a CDR) with a histidine residue, an antibody with reduced antigen binding at acidic pH relative to neutral pH can be obtained. In the context of the invention, the expression "acidic pH" means a pH of 6.0 or less.

Methods of combined treatment

[0092] In some embodiments, the methods of the present invention include subjecting the individual to additional anticancer therapy in combination with an anti-PD-1 antibody. In some embodiments, the methods of the present invention include administering radiation therapy or chemotherapy in combination with an anti-PD-1 antibody for additive or synergistic activity in the treatment of cancer. Within the meaning of the invention, the expression "in combination with" means that the additional anticancer therapy is carried out before, after or simultaneously with the administration of the anti-PD-1 antibody. The term "in combination with" also includes the sequential or simultaneous administration of an anti-PD-1 antibody and the implementation of additional antitumor therapy. For example, when administered "before" additional antitumor therapy, the anti-PD-1 antibody can be administered more than 150 hours, approximately 150 hours, approximately 100 hours, approximately 72 hours, approximately 60 hours, approximately 48 hours, approximately 36 hours, approximately 24 hours , about 12 hours, about 10 hours, about 8 hours, about 6 hours, about 4 hours, about 2 hours, about 1 hour, or about 30 minutes, about 15 minutes, or about 10 minutes before additional therapy. When administered "after" additional antitumor therapy, the anti-PD-1 antibody can be administered at about 10 minutes, about 15 minutes, about 30 minutes, about 1 hour, about 2 hours, about 4 hours, about 6 hours, about 8 hours, about 10 hours, about 12 hours, about 24 hours, about 36 hours, about 48 hours, about 60 hours, about 72 hours, or more than 72 hours after additional antitumor therapy. The introduction of "simultaneously" with additional antitumor therapy means that the antibody against PD-1 is administered to the individual within less than 10 minutes (before, after or simultaneously) relative to the implementation of additional antitumor therapy.

[0093] In some embodiments, the methods of the present invention comprise administering an additional therapeutic agent, wherein the additional therapeutic agent is an anticancer drug. As used herein, the term "antineoplastic drug" means any agent that can be used to treat cancer, including, but not limited to, cytotoxins and agents such as antimetabolites, alkylating agents, anthracyclines, antibiotics, antimitotics, procarbazine, hydroxyurea, asparaginase , corticosteroids, mitotane (O,P'-(DDD)), biological agents (eg antibodies and interferons), and radioactive agents. Within the scope of the invention, the term "cytotoxin or cytotoxic agent" also refers to a chemotherapeutic agent and means any agent that is harmful to cells. Non-limiting examples include Taxol® (paclitaxel), temozolomide, cytochalasin B, gramicidin D, ethidium bromide, emetine, cisplatin, mitomycin, etoposide, teniposide, vincristine, vinblastine, colchicine, doxorubicin, daunorubicin, dihydroxyanthracindione, mitoxantrone, mithramycin, actinomycin D, 1 -dehydrotestosterone, glucocorticoids, procaine, tetracaine, lidocaine, propranolol and puromycin and their analogs or homologues.

[0094] In some embodiments, the methods of the present invention include the use of an additional therapeutic agent or regimen or method selected from the group consisting of surgery, radiation therapy, a programmed cell death ligand 1 (PD-L1) inhibitor (e.g., anti-PD-L1 antibodies as described in US Patent Publication No. 2015/0203580 or atezolizumab), an inhibitor of the lymphocyte activation gene 3 (LAG-3) (e.g. anti-LAG-3 antibodies), an inhibitor of cytotoxic T-lymphocyte antigen-4 ( CTLA-4) (eg, anti-CTLA-4 antibodies such as ipilimumab), glucocorticoid-inducible tumor necrosis factor receptor (GITR) inhibitor (eg, anti-GITR antibodies), protein-3 inhibitor containing T-cell immunoglobulin and mucin domain (TIM3), inhibitor of B- and T-lymphocyte attenuator (BTLA), inhibitor of T-cell immunoreceptor with Ig domains and ITIM (TIGIT), inhibitor of CD47, antagonist of another T-cell coinhibito ra or ligand (eg, anti-CD28, 2B4, LY108, LAIR1, ICOS, CD160, or VISTA antibodies), CD20 inhibitor (eg, anti-CD20 antibody or CD3/CD20 bispecific antibody), indolamine 2,3-dioxygenase (IDO) inhibitor , a vascular endothelial growth factor (VEGF) antagonist [e.g., "VEGF decoys" such as aflibercept or another VEGF inhibitory fusion protein as described in US Pat. ranibizumab) or a small molecule VEGF receptor kinase inhibitor (eg, sunitinib, sorafenib, or pazopanib)], an angiopoietin 2 (Ang2) inhibitor (eg, nesvacumab), a transforming growth factor beta (TGFβ) inhibitor, an epidermal growth factor receptor (EGFR) inhibitor (eg. , erlotinib, cetuximab), costimulatory receptor agonist (eg, glucocorticoid-inducible TNFR-related protein agonist), antibodies against a tumor-specific antigen [eg, CA9, CA125, melanin oma-associated antigen 3 (MAGE3), carcinoembryonic antigen (CEA), vimentin, tumor M2-PK, prostate-specific antigen (PSA), mucin-1, MART-1, and CA19-9], vaccines (e.g., Bacillus Calmette- Guerin, cancer vaccine), cyclophosphamide, adjuvant to increase antigen presentation (eg, granulocyte-macrophage colony-stimulating factor), cytotoxin, chemotherapeutic agent (eg, dacarbazine, temozolomide, docetaxel, doxorubicin, daunorubicin, cisplatin, carboplatin, gemcitabine, methotrexate, mitoxantrone, oxaliplatin, paclitaxel and vincristine), an interleukin-6 receptor (IL-6R) inhibitor (eg sarilumab), an IL-4R inhibitor (eg dupilumab), an IL-10 inhibitor, a cytokine such as IL-2, IL-7, IL-21 and IL-15, antibody-drug conjugate (ADC) (eg, anti-CD19-DM4 ADC and ADC against DS6-DM4), chimeric antigen receptor T-cells (eg, anti-CD19 T-cells), anti-inflammatory lek an herbal agent (for example, corticosteroids and non-steroidal anti-inflammatory drugs) and a nutritional supplement such as antioxidants.

[0095] In some embodiments, the methods of the invention include administering an anti-PD-1 antibody in combination with radiation therapy and optionally an anti-GITR antibody to achieve long-lasting, sustained antitumor responses and/or improve survival in patients with cancer. In some embodiments, the methods of the invention include administering radiation therapy before, simultaneously with, or after administration of an anti-PD-1 antibody and an anti-GITR antibody to a cancer patient. For example, radiation therapy can be administered at one or more doses to tumor foci after administration of one or more doses of the antibody. In some embodiments, a tumor lesion may be topically exposed to radiation therapy to increase local immunogenicity in a patient's tumor (adjuvant radiation therapy) and/or to kill tumor cells (ablative radiation therapy) following systemic administration of an anti-PD-1 antibody and/or an anti-GITR antibody. In some embodiments, the first tumor site, but not the second tumor site, is subjected to radiation therapy, where administration in combination with an anti-PD-1 antibody results in tumor regression in the first and second tumor sites (abscopal effect). In some embodiments, the methods of the present invention include administering an anti-PD-1 antibody in combination with radiation therapy and optionally an anti-GITR antibody to achieve a long-term abscopal effect.

[0096] In some embodiments, the anti-PD-1 antibody can be administered in combination with radiation therapy and a chemotherapeutic agent (eg, temozolomide or cyclophosphamide), a VEGF antagonist (eg, aflibercept), or granulocyte-macrophage colony-stimulating factor.

Pharmaceutical compositions and administration

[0097] The present invention relates to methods comprising administering an anti-PD-1 antibody to a subject in combination with radiation therapy, wherein the anti-PD-1 antibody is contained in a pharmaceutical composition. Pharmaceutical compositions of the invention may be formulated with suitable carriers, excipients, and other means to provide suitable transfer, delivery, tolerability, and the like. Many relevant formulations can be found in reference books known to all pharmaceutical chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, vesicles containing lipid (cationic or anionic) (such as LIPOFECTIN™), DNA conjugates, anhydrous absorption pastes, oil-in-water emulsions " and "water-in-oil", emulsions of carbovax (polyethylene glycols of various molecular weights), semi-solid gels and semi-solid mixtures containing carbovax. See also Powell et al. "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52:238-311.

[0098] Various delivery systems are known and can be used to administer the pharmaceutical composition of the invention, e.g., liposome encapsulation, microparticles, microcapsules, recombinant cells that can express mutant viruses, receptor-mediated endocytosis (see, e.g., Wu et al., 1987, J Biol Chem 262: 4429-4432). Administration routes include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, and oral routes. The composition can be administered by any convenient route, for example, by infusion or bolus injection, by absorption through epithelial or mucosal linings (eg, oral mucosa, intestinal mucosa, etc.), and it can be administered together with other biologically active agents .

[0099] The pharmaceutical composition of the present invention can be administered subcutaneously or intravenously using a standard needle and syringe. In addition, with regard to subcutaneous administration, a pen can be easily used to administer the pharmaceutical composition of the present invention. Such a syringe pen can be reusable or disposable. A reusable pen typically uses a replaceable cartridge containing a pharmaceutical composition. After all the pharmaceutical composition in the cartridge has been introduced and the cartridge has been emptied, the empty cartridge can be discarded and replaced with a new cartridge containing the pharmaceutical composition. The pen can then be reused. There is no replaceable cartridge in the disposable syringe pen. Instead, the disposable pen is pre-filled with the pharmaceutical composition contained in the reservoir of the device. After emptying the tank, the entire device is discarded.

[00100] In some cases, the pharmaceutical composition can be administered in a controlled release system. In one embodiment, a pump may be used. In another embodiment, polymeric materials can be used; see, Medical Applications of Controlled Release, Langer and Wise (eds.), 1974, CRC Pres., Boca Raton, Florida. In yet another embodiment, the controlled release system can be placed near the target site for the composition, thus requiring only a fraction of the systemic dose (see, for example, Goodson, 1984, in Medical Applications of Controlled Release, supra, vol. 2, pp. 115-138). Other controlled release systems are reviewed by Langer, 1990, Science 249:1527-1533.

[00101] Injectable preparations may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injections, drip infusions, etc. These injectables can be prepared by known methods. For example, injectable preparations can be obtained, for example, by dissolving, suspending or emulsifying the antibody or salt thereof, described above, in a sterile aqueous or oily medium commonly used for injection. As the aqueous injection medium, there may be mentioned, for example, physiological saline, isotonic solution containing glucose and other auxiliaries, etc., which can be used in combination with a suitable solubilizer such as alcohol (eg ethanol), polyalcohol (eg , propylene glycol, polyethylene glycol), non-ionic surfactant [eg, polysorbate 80, HCO-50 (adduct of polyoxyethylene (50 mol) and hydrogenated castor oil)], etc. As the oil medium, for example, sesame oil, soybean oil, etc. are used, which can be used in combination with a solubilizer such as benzyl benzoate, benzyl alcohol, etc. The injectable preparation thus obtained is preferably filled into a suitable ampoule.

[00102] Preferably, the pharmaceutical compositions for oral or parenteral use described above are prepared in single dose dosage forms corresponding to the dosage of the active ingredients. Such single dose dosage forms include, for example, tablets, pills, capsules, injectables (ampoules), suppositories, and the like.

[00103] In some embodiments, the present invention provides a pharmaceutical composition comprising a therapeutic amount of an anti-PD-1 antibody and a pharmaceutical carrier. In some embodiments, the present invention provides an anti-PD-1 antibody formulated in a pharmaceutical composition for intravenous administration.

Introduction schemes

[00104] The present invention relates to methods comprising administering an anti-PD-1 antibody to a subject at a frequency of about four times a week, twice a week, once a week, once every two weeks, once every three weeks, once every four weeks, once every five weeks, once every six weeks, once every eight weeks, once every twelve weeks or less, provided that a therapeutic response is achieved. In some embodiments, the methods include administering an anti-PD-1 antibody in combination with a second anticancer therapy (e.g., chemotherapy) at a frequency of approximately twice a week, once a week, once every two weeks, once every three weeks, once every four weeks, once at five weeks, once every six weeks, once every eight weeks, once every nine weeks, once every twelve weeks or less, provided that a therapeutic response is achieved.

[00105] In some embodiments, the methods of the present invention include the implementation of radiation therapy, where radiation therapy is hypofractionated radiation therapy. In some embodiments, hypofractionated radiation therapy includes 2-12 fractions. In some embodiments, 2-12 fractions are administered on consecutive days. In some embodiments, the implementation of radiation therapy is carried out after the introduction of one or more doses of antibodies against PD-1. In some embodiments, the anti-PD-1 antibody is administered 0.5-2 weeks prior to the use of one or more radiation therapy fractions.

[00106] In some embodiments of the present invention, multiple doses of an anti-PD-1 antibody in combination with a second anticancer therapy (eg, chemotherapy) can be administered to an individual over a period of time. The methods of the invention in this aspect comprise sequentially administering to an individual one or more doses of an anti-PD-1 antibody in combination with one or more doses of said second anticancer therapy. In the context of the invention, the term "sequential administration" means that each dose of the antibody is administered to an individual at different times, eg on different days at predetermined intervals (eg, hours, days, weeks or months). In some embodiments, the methods of the present invention comprise sequential administration of one or more doses of anti-PD-1 antibody, where each dose is administered 0.5-12 weeks after the previous dose. In some additional embodiments, the implementation of the methods further include the implementation of the second antitumor therapy (eg, chemotherapy). In some embodiments, the chemotherapy may be platinum chemotherapy. In some embodiments, the methods further comprise administering one or more doses of a chemotherapeutic agent, where each dose is administered 1-6 weeks after the previous dose.

[00107] In some embodiments, the present invention relates to methods comprising sequentially administering to a patient one initial dose of an anti-PD-1 antibody, followed by one or more secondary doses of an anti-PD-1 antibody, and optionally one or more tertiary doses of an anti-PD-1 antibody. one. In some embodiments, the methods further comprise sequentially administering to the patient one initial dose of a chemotherapeutic agent, followed by one or more secondary doses of a chemotherapeutic agent, and optionally one or more tertiary doses of a chemotherapeutic agent.

[00108] The terms "initial dose", "secondary doses" and "tertiary doses" refer to the time sequence of administration. Thus, "initial dose" is the dose that is administered at the beginning of the treatment regimen (also referred to as "initial dose"), "secondary doses" are doses that are administered after the initial dose, and "tertiary doses" are doses that are administered after secondary doses. Initial, secondary and tertiary doses may contain the same amount of antibody (anti-PD-1 antibodies). However, in some embodiments, the amount contained in the initial, secondary, and/or tertiary doses varies relative to each other (eg, increased or decreased as needed) during treatment. In some embodiments, one or more (eg, 1, 2, 3, 4, or 5) doses are administered at the beginning of the treatment regimen as "loading doses" followed by doses that are administered less frequently (eg, "maintenance doses"). For example, an anti-PD-1 antibody may be administered to a cancer patient at a loading dose of about 1-3 mg/kg followed by one or more maintenance doses of about 0.1 to about 20 mg/kg of the patient's body weight.

[00109] In one example embodiment of the present invention, each secondary and/or tertiary dose is administered ½-14 (e.g., ½, 1, 1½, 2, 2½, 3, 3½, 4, 4½, 5, 5½, 6, 6½ , 7, 7½, 8, 8½, 9, 9½, 10, 10½, 11, 11½, 12, 12½, 13, 13½, 14, 14½ or more) weeks after the previous dose. In the context of the invention, the phrase "prior dose" in a sequence of multiple administrations means the dose of the anti-PD-1 antibody (and optionally the second anticancer therapy) that is administered to the patient prior to the administration of the immediately following dose in the sequence without intermediate doses.

[00110] The methods of the invention in this aspect may include administering any number of secondary and/or tertiary doses of anti-PD-1 antibody (and/or second anticancer therapy) to the patient. For example, in some embodiments, only one secondary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) secondary doses are administered to the patient. Similarly, in some embodiments, only one tertiary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) tertiary doses are administered to the patient.

[00111] In embodiments involving multiple secondary doses, each secondary dose may be administered at the same frequency as the other secondary doses. For example, each secondary dose may be administered to a patient 1-2 weeks after the previous dose. Similarly, in embodiments involving multiple tertiary doses, each tertiary dose may be administered at the same frequency as the other tertiary doses. For example, each tertiary dose may be administered to a patient 2-4 weeks after the previous dose. Alternatively, the frequency with which secondary and/or tertiary doses are administered to a patient may vary throughout the treatment regimen. The attending physician may also adjust the frequency of administration during treatment after clinical examination, depending on the needs of the individual patient.

[00112] In some embodiments, one or more doses of the anti-PD-1 antibody and/or second antitumor therapy are administered at the start of the treatment regimen as "induction doses" more frequently (twice a week, once a week, or every 2 weeks) followed by doses ("consolidating doses" or "maintenance doses") that are administered less frequently (eg, once every 2-12 weeks). In some embodiments, one or more doses of anti-PD-1 antibody and/or radiation therapy are administered at the start of the treatment regimen as "induction doses" more frequently (twice a week, once a week, or every 2 weeks) followed by doses of anti-PD antibody -one.

[00113] The present invention relates to methods comprising the sequential administration of one or more doses of an anti-PD-1 antibody in combination with one or more doses of additional anticancer therapy, where one or more doses are included in one or more treatment cycles.

[00114] In some embodiments, implementation of the present invention, the methods include the implementation of at least one cycle of treatment, where at least one cycle of treatment includes the introduction of one or more doses of antibodies against PD-1 and, optionally, one or more doses of the second anticancer therapy (for example , chemotherapy, radiotherapy). In some embodiments, the treatment cycle comprises 1-10 doses of anti-PD-1 antibody, where each dose of anti-PD-1 antibody is administered 0.5-8 weeks after the previous dose. In some embodiments, the implementation of the methods of the present invention include the implementation of up to 6 or 8 cycles of treatment. In some other embodiments, the implementation of the methods of the present invention include the implementation of up to 100 or more cycles of treatment, as required for therapeutic effect. In some embodiments, at least one treatment cycle further comprises a second anticancer therapy (eg, chemotherapy). In some embodiments, the chemotherapy is platinum chemotherapy. In some embodiments, doses of the chemotherapeutic agent are administered weekly, every 2 weeks, every 3 weeks, every 4 weeks, or more.

[00115] The present invention relates to methods comprising sequentially administering an anti-PD-1 antibody to a patient in combination with chemotherapy for the treatment of a malignant neoplasm (e.g., lung cancer), resulting in increased antitumor efficacy (e.g., greater inhibition of tumor growth, enhanced prevention of recurrence tumor compared with an untreated individual or an individual who is administered an antibody or chemotherapeutic agent as monotherapy). In some embodiments, the chemotherapeutic agent is administered before, after, or simultaneously with the anti-PD-1 antibody.

Dosage

[00116] The amount of anti-PD-1 antibody administered to an individual by the methods of the present invention is generally a therapeutically effective amount. As used herein, the phrase "therapeutically effective amount" means an amount of an antibody (anti-PD-1 antibody) that results in one or more of: (a) reducing the severity or duration of a symptom or sign of a malignant neoplasm, eg, a solid tumor; (b) inhibiting tumor growth or increasing tumor necrosis, tumor shrinkage and/or tumor disappearance; (c) slowing the growth and development of the tumor; (d) inhibition of tumor metastasis; (e) preventing recurrence of tumor growth; (f) improving the survival of an individual with cancer; and/or (g) reducing the use of, or need for, conventional anticancer therapy (e.g., reducing or discontinuing the use of chemotherapeutic or cytotoxic agents) compared to an untreated individual or an individual administered an antibody to as monotherapy.

[00117] In the case of an anti-PD-1 antibody, a therapeutically effective amount can be from about 0.05 mg to about 1500 mg, from about 1 mg to about 1500 mg, from about 10 mg to about 1400 mg, from about 50 mg to about 1400 mg, about 75 mg to about 1400 mg, or about 100 mg to about 1300 mg of antibody. For example, in various embodiments, the amount of anti-PD-1 antibody is about 0.05 mg, about 0.1 mg, about 1.0 mg, about 2.0 mg, about 10 mg, about 20 mg, about 30 mg, about 40 mg, approximately 50 mg, approximately 60 mg, approximately 70 mg, approximately 80 mg, approximately 90 mg, approximately 100 mg, approximately 150 mg, approximately 200 mg, approximately 220 mg, approximately 240 mg, approximately 260 mg, approximately 280 mg , approximately 300 mg, approximately 350 mg, approximately 400 mg, approximately 450 mg, approximately 500 mg, approximately 550 mg, approximately 600 mg, approximately 650 mg, approximately 700 mg, approximately 750 mg, approximately 800 mg, approximately 850 mg, approximately 900 mg, approximately 950 mg, approximately 1000 mg, approximately 1050 mg, approximately 1100 mg, approximately 1150 mg, approximately 1200 mg, approximately 12 50 mg, about 1300 mg, about 1400 mg, or about 1500 mg anti-PD-1 antibody. In one embodiment, 250 mg of anti-PD-1 antibody is administered by the methods of the present invention. In one embodiment, 200 mg of anti-PD-1 antibody is administered by the methods of the present invention. In one embodiment, 350 mg of anti-PD-1 antibody is administered by the methods of the present invention. In one embodiment, 1050 mg of anti-PD-1 antibody is administered by the methods of the present invention.

[00118] The amount of anti-PD-1 antibody contained in individual doses can be expressed as milligrams of antibody per kilogram of an individual's body weight (ie, mg/kg). In some embodiments, the anti-PD-1 antibody used in the methods of the present invention may be administered to an individual at a dose of from about 0.0001 to about 100 mg/kg of the individual's body weight. In some embodiments, the anti-PD-1 antibody may be administered at a dose of about 0.1 mg/kg to about 20 mg/kg of the patient's body weight. In some embodiments, the methods of the present invention comprise administering an anti-PD-1 antibody at a dose of approximately 1 mg/kg, 3 mg/kg, 5 mg/kg, or 10 mg/kg of the patient's body weight.

[00119] In some embodiments, the amount of anti-PD-1 antibody administered to a patient may be less than a therapeutically effective amount, i. may be a sub-therapeutic dose. For example, if the therapeutically effective amount of the anti-PD-1 antibody is 3 mg/kg, the subtherapeutic dose contains an amount of less than 3 mg/kg, e.g., 2 mg/kg, 1.5 mg/kg, 1 mg/kg, 0.5 mg /kg or 0.3 mg/kg. As defined herein, the term "subtherapeutic dose" refers to an amount of anti-PD-1 antibody that does not, by itself, result in a therapeutic effect. However, in some embodiments, a subtherapeutic dose of the anti-PD-1 antibody is administered with a second and optionally a third therapeutic agent to promote a therapeutic effect.

EXAMPLES

[00120] The following examples are provided to provide those skilled in the art with a complete description of how to make and use the methods and compositions of the invention, and are not intended to limit the scope of what the authors consider their invention. Attempts have been made to ensure accuracy with respect to the numbers used (eg amounts, temperatures, etc.), but some experimental errors and deviations must be taken into account. Unless otherwise indicated, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Celsius, and pressure is at or near atmospheric.

Example 1 Efficacy of Anti-PD-1 Antibody in Vivo in Combination with Radiation Therapy on MC38 Tumors

[00121] In this example, the effect of blocking PD-1 in combination with radiation therapy on established MC38 tumors in mice was investigated.

[00122] 5×10 ⁵ MC38 colon carcinoma cells were subcutaneously implanted in the right flank of female C57BL/6 mice (Jackson Laboratory). Treatment was started on day 9 post-implantation when the mean tumor volumes reached approximately 100 mm ³ . Mice were randomized into groups that received an isotype control (2A3, BioXcell) or an anti-PD-1 blocking antibody (RMP1-14, BioXCell) at 5 mg/kg twice a week for a total of 5 intraperitoneal injections. One day after the start of antibody administration, mice were divided into radiation therapy groups, which were exposed to radiation of tumors in the right side at a dose of 12 Gy. Radiation therapy was performed using an RS 2000 Biological Research Irradiator (Rad Source) on mice under anesthesia (ketamine/xylazine) shielded with partial body irradiation devices (Precision X-ray) and lead sheet (Images Scientific Instruments). Tumor growth was assessed 3 times per week until days 70-80 when all mice were sacrificed. Figure 1 shows a study design for an experiment involving doses of anti-PD-1 antibody and radiation therapy.

[00123] Figure 2 and Table 1 show mean tumor volumes in mice treated with anti-PD-1 antibody alone or in combination with radiation therapy.

Table 1: Mean tumor volumes in mice treated with anti-PD-1 antibody alone or in combination with radiotherapy

Days after implantation Mean tumor volume (mm ³ ±SEM) Isotype control Anti-PD-1 antibody Isotype control + radiation therapy Anti-PD-1 antibody+radiotherapy 4 15.39±3.70 8.62±3.02 13.28±3.44 10.78±3.01 7 41.11±8.81 38.90±7.09 49.86±11.38 39.36±6.32 eight 68.64±10.01 72.03±12.13 74.03±14.83 73.70±14.86 ten 85.82±4.10 94.98±22.68 100.88±11.46 122.05±15.05 fourteen 725.87±68.45 834.37±206.70 320.10±58.80 300.67±60.74 sixteen 1023.61±191.41 1123.51±310.04 276.17±82.81 219.29±45.94 eighteen 1573.64±263.65 1710.30±424.30 353.45±121.47 250.17±74.70 21 2688.69±502.39 2569.65±633.35 494.53±211.90 188.98±105.80 23 597.70±267.02 141.37±73.76 25 671.93±347.76 134.87±75.67 28 879.64±403.70 147.82±70.88 thirty 1081.39±426.80 133.13±88.88 32 177.73±112.81 36 233.44±152.91 39 258.23±158.67 42 316.58±160.91 44 332.73±152.43 46 456.13±209.45 49 564.05±262.32 51 925.92±434.29 53 747.14±350.90 56 1290.10±584.62

[00124] Blocking PD-1 (RMP1-14) acted synergistically with local irradiation (XRT) and significantly induced tumor regression (4/6 mice) in MC38 tumor-bearing mice compared to mice treated with XRT and isotype control ( 2/6 mice). Tumor growth was inhibited or retarded in mice treated with anti-PD-1 antibody in combination with radiation therapy. In the case of mice injected with anti-PD-1 antibody and exposed to radiation, it took more ^than 40 days to reach a tumor volume ^of 500 mm . Tumor regression was maintained up to 4 weeks in the case of the group treated with the combination (XRT + anti-PD-1 antibody) (at this time, 1 of 4 rejected tumors recurred), compared to 1.5 weeks in the case of the group treated with XRT and isotype control (1 out of 2 rejected tumors recurred). In this tumor model, blocking PD-1 as monotherapy had no effect on primary tumor growth.

Table 2: Survival Percentage of Mice Administered with Anti-PD-1 Antibody Alone or in Combination with Radiation Therapy

Days after implantation Isotype control Anti-PD-1 antibody Radiation therapy + isotype control Radiation therapy + antibody against PD-1 4 100 100 100 100 7 100 100 100 100 eight 100 100 100 100 ten 100 100 100 100 fourteen 100 100 100 100 sixteen 100 100 100 100 eighteen 100 100 100 100 21 100 100 100 100 23 100 83 100 100 25 67 fifty 100 100 28 33 fifty 100 100 thirty 17 17 100 100 32 0 17 67 100 36 0 0 67 100 44 0 0 fifty 100 46 0 0 fifty 100 49 0 0 fifty 100 51 0 0 33 100 53 0 0 17 100 56 0 0 17 100 58 0 0 17 83 60 0 0 17 fifty 63 0 0 17 fifty 65 0 0 17 fifty 81 0 0 17 fifty 85 0 0 17 fifty

[00125] The therapeutic efficacy of combination treatment (XRT+anti-PD-1 antibody) was evidenced by a statistically significant increase in overall survival in this group (50% remained alive 70 days after tumor implantation) compared to all other treatment groups: isotype control (0 % remained alive by day 70), anti-PD-1 antibody (0% remained alive by day 70) and XRT + isotype control (17% remained alive by day 70) (figure 3; table 2).

Example 2 Efficacy of Anti-PD-1 Antibody and In Vivo Radiation Therapy on B16 Tumors

[00126] In this example, the antitumor effect of an anti-mouse PD-1 antibody in combination with radiation therapy on established B16 tumors in mice was investigated.

[00127] 2×10 ⁵ B16F10.9 melanoma cells were subcutaneously implanted in the right flank of female C57BL/6 mice (Jackson Laboratory). Treatment was started when the average tumor volumes reached approximately 150 mm ³ . Mice were randomized into groups that received an isotype control (2A3, BioXcell) or an anti-PD-1 blocking antibody (RMP1-14, BioXCell) at 5 mg/kg twice a week for a total of 5 intraperitoneal injections. One day after the start of antibody administration, the mice were divided into radiation therapy groups, which were exposed to radiation of tumors in the right side at a dose of 8 Gy. Radiation therapy was performed using an RS 2000 Biological Research Irradiator (Rad Source) on mice under anesthesia (ketamine/xylazine) shielded with partial body irradiation devices (Precision X-ray) and lead sheet (Images Scientific Instruments). Tumor growth was assessed 3 times per week until days 70-80 when all mice were sacrificed. Figure 4 shows a study design for an experiment involving doses of anti-PD-1 antibody and radiation therapy.

[00128] Administration of a blocking anti-PD-1 antibody (RMP1-14) in combination with local irradiation (XRT) slowed the growth of the primary B16 tumor compared to either XRT monotherapy or anti-PD-1 antibody (Figure 5; Table 3).

Table 3: Mean tumor volumes in mice treated with anti-PD-1 antibody alone or in combination with radiotherapy

Days after implantation Mean tumor volume mm ³ ±SEM Isotype control Anti-PD-1 antibody Isotype control + radiation therapy Anti-PD-1 antibody+radiotherapy 6 5.75±5.75 8.32±8.32 13.79±13.79 1.14±0.85 eight 55.98±27.15 62.66±15.80 57.18±37.79 50.57±38.33 12 157.34±37.88 144.36±37.81 237.84±71.27 177.91±59.17 fifteen 334.71±61.71 193.32±35.53 510.95±171.15 372.53±147.50 eighteen 621.43±136.09 363.80±45.72 739.62±244.10 440.33±194.90 20 939.69±158.50 561.64±49.44 677.48±175.75 486.35±207.65 22 1329.77±202.01 772.16±118.26 759.15±235.94 512.67±220.30 25 2602.08±434.08 1343.42±120.65 1182.27±336.32 789.80±299.24 27 1533.03±179.88 1321.13±400.18 877.82±296.51 29 2104.46±350.48 944.67±333.16 33 1024.71±321.20 36 1237.68±340.52

Table 4: Survival Percentage of Mice Administered with Anti-PD-1 Antibody Alone or in Combination with Radiation Therapy

Days after implantation Isotype control Anti-PD-1 antibody Radiation therapy + isotype control Radiation therapy + antibody against PD-1 0 100 100 100 100 6 100 100 100 100 eight 100 100 100 100 12 100 100 100 100 fifteen 100 100 100 100 eighteen 100 100 100 100 20 100 100 100 100 22 100 100 100 100 25 100 100 100 100 27 40 100 100 100 29 0 100 80 100 33 0 80 80 100 36 0 20 60 100 39 0 0 60 83 41 0 0 60 83 43 0 0 20 67 46 0 0 20 67 48 0 0 20 fifty fifty 0 0 0 fifty 53 0 0 0 33 55 0 0 0 33 57 0 0 0 33 60 0 0 0 17 62 0 0 0 17 64 0 0 0 17 66 0 0 0 0

[00129] Treatment with a combination of XRT and anti-PD-1 antibody increased overall survival (50% survived by day 50 post-implantation) compared to XRT alone (0% survived by day 50), anti-PD-1 antibody alone ( 0% remained alive by day 40) and isotype control alone (0% remained alive by day 30) (figure 6; table 4).

Example 3 Efficacy of anti-PD-1 antibody in combination with in vivo radiotherapy against metastatic lung tumors

[00130] In this example, the effect of blocking PD-1 in combination with radiation therapy on established and metastatic tumors in mice was investigated.

[00131] 1.5×10 ⁵ 4T1 breast carcinoma cells were implanted subcutaneously in the right flank of female Balb/c mice (Jackson Laboratory). Treatment was started on day 12 post-implantation when the mean tumor volumes reached approximately 100 mm ³ . Mice were randomized into groups that received an isotype control (2A3, BioXcell) or an anti-PD-1 blocking antibody (RMP1-14, BioXCell) at 5 mg/kg twice a week for a total of 5 intraperitoneal injections. One day after the start of antibody administration, mice were divided into radiation therapy groups, which were exposed to radiation of tumors in the right side at a dose of 8 Gy. Radiation therapy was performed using an RS 2000 Biological Research Irradiator (Rad Source) on mice under anesthesia (ketamine/xylazine) shielded with partial body irradiation devices (Precision X-ray) and lead sheet (Images Scientific Instruments). Tumor growth was assessed 3 times a week until day 28, when all mice were sacrificed to assess the volume of lung metastases using clonogenic analysis. Briefly, lung tissue was dissociated using DNase/Libertase TL (Roche) and cultured in media supplemented with 60 μM 6-thioguanine. After two weeks of cultivation, the plates were counterstained with methylene blue and the number of colonies was counted (one colony corresponds to one metastatic 4T1 cell).

[00132] Anti-PD-1 antibody treatment in combination with radiation therapy is expected to promote tumor regression as well as mediate suppression of metastasis growth.

Example 4 In Vivo Efficacy of Anti-Human Antibody PD-1 in Combination with Radiation Therapy Promotes Abscopal Effect on Distal Tumors

[00133] In this example, the effect of blocking PD-1 in combination with radiation therapy on primary and distal MC38 tumors in mice humanized for PD-1 was investigated using anti-human PD-1 antibodies.

[00134] An example of an anti-PD-1 antibody used in this example is REGN2810 (also known as H4H7798N as described in US20150203579), a fully human anti-PD-1 monoclonal antibody containing a heavy chain containing the amino acid sequence of SEQ ID NO: 9 , and a light chain containing the amino acid sequence of SEQ ID NO: 10, a pair of HCVR/LCVR amino acid sequences containing SEQ ID NO: 1/2, and heavy and light chain CDR sequences containing SEQ ID NO: 3-8.

[00135] PD-1 humanized mice were generated using VelociGene® technology (Valenzuela et al 2003, Nat. Biotechnol. 21: 652-659; US Patent Application Publication No. 2015/0366174).

[00136] 5x10 ⁵ MC38 colon carcinoma cells were implanted subcutaneously in female humanized PD-1/C57BL/6 mice on day 0 (right flank primary tumor) and day 3 (left flank tumor; distal tumor). Treatment was started when the average primary tumor volumes reached approximately 150 mm ³ . Mice were randomly allocated to groups that were injected with an isotype control or blocking antibody against PD-1 (REGN2810) at a dose of 5 mg/kg 2 times a week for a total of 8 intraperitoneal injections. One day after the start of the administration of the antibody, the mice were divided into radiation therapy groups, which were exposed to tumors in the right side at a dose of 8 Gy. Radiation therapy was performed using an RS 2000 Biological Research Irradiator (Rad Source) on mice under anesthesia (ketamine/xylazine) shielded with partial body irradiation devices (Precision X-ray) and lead sheet (Images Scientific Instruments). Growth of primary and secondary tumors was assessed 3 times per week until days 70-80 when all mice were sacrificed. Figure 7 shows a study design for an experiment involving doses of anti-PD-1 antibody and radiation therapy.

results

[00137] Primary Tumor: PD-1 blocking treatment (REGN2810) acted synergistically with local irradiation (XRT) in rejection of primary MC38 tumors (4 of 6 tumor-free mice) compared to mice treated with XRT and isotype control (1/ 6 mice without tumors). Tumor regression was maintained in the combination-treated group for 8 weeks until the end of the experiment compared to three weeks in the XRT and isotype control group (the rejected tumor recurred at this time point) (Figure 8; Table 5).

Table 5: Mean primary tumor volumes in mice treated with REGN2810 alone or in combination with radiotherapy

Days after implantation Mean tumor volume (mm ³ ±SEM) Isotype control REGN2810 Isotype control + radiotherapy REGN2810+radiotherapy 4 8.47±5.22 13.86±7.13 9.02±3.07 3.75±3.75 5 14.32±4.76 22.08±2.69 27.54±4.90 10.00±3.17 7 39.43±5.36 35.47±6.73 42.72±8.00 32.80±10.60 nine 62.68±12.03 84.73±20.91 68.27±11.65 47.26±11.65 ten 111.78±24.45 108.15±27.17 96.18±18.07 75.13±11.56 eleven 147.89±36.11 176.67±43.99 111.87±10.12 110.27±25.02 12 171.76±41.23 154.97±44.16 153.69±16.06 121.88±29.86 fourteen 304.95±94.96 221.70±65.96 147.22±19.77 144.71±34.28 17 609.24±227.64 296.69±95.14 116.65±27.03 135.26±57.41 nineteen 369.17±128.37 114.85±38.73 124.59±55.50 21 442.13±158.80 127.77±36.92 130.00±78.30 24 641.92±275.23 198.40±67.81 113.25±74.51 26 896.32±389.54 252.51±98.39 116.90±101.35 28 1200.99±498.27 331.78±125.55 120.05±89.32 31 477.34±181.97 168.62±151.18 33 189.07±154.91 35 164.70±127.33 38 216.32±159.47 40 219.35±156.39 42 292.37±204.83

[00138] Blocking PD-1 as monotherapy mediated rejection in 2 of 5 mice; however, 1 of the mice that rejected the primary tumor died due to secondary tumor growth, resulting in only 1 mouse surviving by the end of the experiment. The strong therapeutic efficacy of combination treatment (XRT+REGN2810) is evidenced by a statistically significant increase in overall survival (~67% survived 70 days after tumor implantation) compared with all other groups: isotype control or XRT alone (0% remained alive by day 70) and REGN2810 as monotherapy (20% remained alive by day 70) (figure 9; table 6).

Table 6: Survival Percentage of Mice Administered with REGN2810 Alone or in Combination with Radiation Therapy

Days after implantation Isotype control REGN2810 Radiation therapy + isotype control Radiotherapy+REGN2810 0 100 100 100 100 4 100 100 100 100 5 100 100 100 100 7 100 100 100 100 nine 100 100 100 100 ten 100 100 100 100 eleven 100 100 100 100 12 100 100 100 100 fourteen 100 100 100 100 17 100 100 100 100 nineteen 83 100 100 100 21 83 100 100 100 24 83 100 100 100 26 fifty 100 100 100 28 33 100 100 100 31 33 67 100 100 33 33 33 83 100 35 33 33 67 100 38 33 33 fifty 100 40 17 17 fifty 100 42 17 17 fifty 100 44 17 17 fifty 100 49 0 17 17 83 54 17 0 83 56 17 0 83 59 17 0 83 61 17 0 67 63 17 0 67

[00139] Distal tumor: REGN2810 in combination with XRT significantly contributed to the abscopal effect (rejection of a tumor implanted at the distal site) in 5 of 6 tumor-free mice compared to XRT alone (2/6 without distal tumors), REGN2810 in separately (1/6 without distal tumors) and isotype control (1/6 without distal tumors) (figure 10; table 7).

Table 7: Mean volumes of distal tumors in mice treated with REGN2810 alone or in combination with radiotherapy

Days after implantation Mean tumor volume (mm ³ ±SEM) Isotype control REGN2810 Isotype control + radiation therapy REGN2810+radiotherapy one 0 0 0 0 2 0 0 0 0 4 0 0 0 0 6 0 0 0 0 7 11.13±11.13 0 0 0 eight 20.01±20.01 0 3.26±3.26 0 nine 25.43±25.43 7.00±7.00 9.75±9.75 0 eleven 31.93±29.32 42.24±26.88 28.81±17.01 12.13±12.13 fourteen 56.20±34.46 59.40±29.41 57.64±29.91 20.93±14.07 sixteen 58.64±29.57 95.78±52.87 14.03±9.79 eighteen 151.71±76.86 115.16±59.43 22.87±16.20 21 207.13±128.83 227.22±105.46 17.01±17.01 23 333.43±220.57 335.13±148.86 9.51±9.51 25 506.55±355.36 503.71±211.49 11.45±11.45 28 968.92±418.57 31.59±31.59 thirty 57.40±57.40 32 83.94±83.94 35 133.89±133.89 37 224.65±224.65

Example 5 Efficacy of Anti-PD-1 Antibody in Vivo in Combination with Radiation Therapy and a GITR Antagonist on MC38 Tumors

[00140] In this example, the effect of blocking PD-1 in combination with radiation therapy and a glucocorticoid-inducible tumor necrosis factor receptor (GITR) antagonist (anti-GITR antibodies) was studied on large, established MC38 tumors in mice.

[00141] 5×10 ⁵ MC38 colon carcinoma cells were subcutaneously implanted in the right flank of female C57BL/6 mice (Jackson Laboratory). Treatment was initiated when average tumor volumes reached approximately 150-200 mm ³ (classified as "large tumors"). Mice were randomly assigned to receive an isotype control antibody (2A3 or LTF-2; BioXcell), an anti-PD-1 antibody (RMP1-14; BioXcell), an anti-GITR antibody (DTA-1; BioXcell), or a combination of an anti-PD antibody. -1 and antibodies against GITR at a dose of 5 mg/kg 2 times a week for a total of 5 intraperitoneal injections. One day after the start of antibody administration, mice were divided into radiation therapy groups, which were exposed to radiation of tumors in the right side at a dose of 8 Gy. Radiation therapy was performed using an RS 2000 Biological Research Irradiator (Rad Source) on mice under anesthesia (ketamine/xylazine) shielded with partial body irradiation devices (Precision X-ray) and lead sheet (Images Scientific Instruments). Tumor growth was assessed 3 times per week until days 70-80 when all mice were sacrificed. Figure 11 shows a study design for an experiment involving administration of an anti-PD-1 antibody, an anti-GITR antibody, and administration of radiation therapy.

[00142] Treatment with anti-PD-1 antibody (RMP1-14) acted synergistically with local irradiation (XRT) and anti-GITR antibody in rejection of large MC38 tumors (4 of 6 tumor-free mice) compared to mice treated with XRT and anti-GITR antibody. GITR (2/6 tumor free), XRT and anti-PD-1 antibody (2/6 rejection) or XRT alone (0/6 tumor free). Monotherapy (anti-PD-1 antibody or anti-GITR antibody) or combination treatment (anti-PD-1 antibody and anti-GITR antibody) had minimal effect on tumor growth, with treatment with anti-PD-1 antibody or anti-GITR antibody mediating rejection in 1 /5 mice, and the combination of two antibodies mediated rejection in 2/5 mice. Tumor regression was maintained for up to 6.5 weeks after the start of treatment in mice treated with the triple combination compared to 2 weeks in mice treated with XRT and anti-GITR antibody (Figure 12).

Table 8: Survival percentage of mice treated with anti-PD-1 antibody in combination with radiotherapy and anti-GITR antibody

Days after implantation Isotype control Anti-PD-1 antibody Anti-GITR antibody Anti-PD-1+anti-GITR Radiation therapy + isotype control Radiation therapy + antibody against PD-1 Radiation therapy + anti-GITR antibody Radiation therapy + anti-PD-1 antibody + anti-GITR antibody 0 100 100 100 100 100 100 100 100 28 100 100 80 100 100 100 100 100 32 80 80 80 80 100 100 100 100 35 60 60 40 60 100 80 83 100 38 20 20 20 60 40 80 fifty 100 41 0 20 20 60 20 60 fifty 100 48 0 20 20 60 0 60 fifty 83 56 0 20 20 40 0 40 33 67 66 0 20 20 40 0 40 17 67 77 0 20 20 40 0 40 17 67

[00143] Table 8 and Figure 13 show survival of mice treated with anti-PD-1 antibody in combination with radiation therapy and anti-GITR antibody. In addition, the introduction of antibodies against PD-1 and XRT led to the regression of very large tumors (~300 mm ³ ).

Example 6 Efficacy of Anti-PD-1 Antibody in Vivo in Combination with Radiation Therapy and a GITR Antagonist on B16 Tumors

[00144] In this example, the effect of blocking PD-1 in combination with radiation therapy and a GITR antagonist (anti-GITR antibody) on established B16 tumors in mice was investigated.

[00145] 2.5×10 ⁵ B16F10.9 melanoma cells were subcutaneously implanted in the right flank of female C57BL/6 mice (Jackson Laboratory). Treatment was started when the average tumor volumes reached approximately 100 mm ³ . Mice were randomly assigned to receive an isotype control (2A3, LTF-2; BioXcell), an anti-PD-1 antibody (RMP1-14, BioXcell), an anti-GITR antibody (DTA-1; BioXcell), or a combination of anti-PD- 1 and antibodies against GITR at a dose of 5 mg/kg 2 times a week for a total of 5 intraperitoneal injections. One day after the start of the administration of the antibody, the mice were divided into radiation therapy groups, which were exposed to tumors in the right side at a dose of 8 Gy. Radiation therapy was performed using an RS 2000 Biological Research Irradiator (Rad Source) on mice under anesthesia (ketamine/xylazine) shielded with partial body irradiation devices (Precision X-ray) and lead sheet (Images Scientific Instruments). Tumor growth was assessed 3 times per week until days 70-80 when all mice were sacrificed.

[00146] An anti-PD-1 antibody in combination with an anti-GITR antibody and radiation therapy is expected to promote greater tumor regression and slow tumor growth than either monotherapy or an anti-PD-1 antibody in combination with radiation therapy.

Example 7 Clinical Trial of Anti-PD-1 Antibody and Radiation Therapy in Patients with Advanced Solid Tumors

[00147] This study is an open-label, multicenter, dose-escalation study with multiple dose-escalation and extended groups to investigate the efficacy, safety, and tolerability of anti-PD-1 antibody alone and in combination with other cancer therapies (including radiation therapy) in adult patients with advanced solid tumors.

[00148] An example of an anti-PD-1 antibody used in this study is REGN2810 (also known as H4H7798N as described in US20150203579), a fully human anti-PD-1 monoclonal antibody containing a heavy chain containing the amino acid sequence of SEQ ID NO: 9 , and a light chain containing the amino acid sequence of SEQ ID NO: 10, a pair of HCVR/LCVR amino acid sequences containing SEQ ID NO: 1/2, and heavy and light chain CDR sequences containing SEQ ID NO: 3-8.

Research objectives

[00149] The primary goal of the study is to characterize the safety, tolerability, dose-limiting toxicity (DLT) of REGN2810 administered intravenously (IV) as monotherapy or in combination with targeted irradiation (intended for immunostimulatory rather than primarily ablative therapy), cyclophosphamide at low doses (a therapy shown to inhibit regulatory T cell responses), granulocyte-macrophage colony stimulating factor, carboplatin, docetaxel, or a combination thereof, in patients with advanced malignancies.

[00150] The secondary objectives of the study are: (1) to determine the recommended dose of REGN2810 for phase 2 (RP2D) as monotherapy and in combination with other antitumor therapies (targeted radiation, low dose cyclophosphamide, or both); (2) a description of the preliminary antitumor activity of REGN2810 alone and in each combination; (3) characterization of PK REGN2810 as monotherapy and in combination with other anticancer therapies (targeted irradiation, low dose cyclophosphamide, or both); and (4) REGN2810 immunogenicity assay.

Study Design Rationale

[00151] The 3+3 model for the dose escalation phase in this study is designed to evaluate the safety of REGN2810 as monotherapy at various dose levels and in combination with immunostimulatory treatment: cyclophosphamide, limited, targeted irradiation, administered in 1 of 2 treatment regimens, or a combination of radiation therapy and cyclophosphamide.

[00152] After determining the tolerability of REGN2810 alone and in combination with radiotherapy and/or cyclophosphamide, a plurality of expanded cohorts are added that use various combinations or monotherapy for selected features [NSCLC, BC, HNSCC, CSCC, tumors with MSI (colorectal tumors, endometrial tumors, prostate tumors, or other types of tumors), HCC and other advanced solid tumors] to further confirm safety and evaluate antitumor enhancement. Some of these combinations are supplemented with granulocyte-macrophage colony-stimulating factor (GM-CSF), carboplatin and/or docetaxel.

[00153] Table 9 lists some of the cohorts using REGN2810 as monotherapy and in combination with other treatments.

Table 9: List of some of the expanded cohorts for REGN2810 monotherapy and combination treatments

Cohort sign Treatment one Non-small cell lung cancer (NSCLC) Constant dose - 200 mg REGN2810 2 NSCLC 3 mg/kg REGN2810+radiotherapy (9 Gy×3) 3 Head and neck squamous cell carcinoma (HNSCC) 3 mg/kg REGN2810 + radiotherapy (9 Gy×3) + cyclophosphamide + GM-CSF 4 Breast Cancer (BC) 3 mg/kg REGN2810 + radiotherapy (9 Gy×3) + cyclophosphamide 5 Late stage solid tumors - Prior treatment with anti-PD-1/PD-L1 antibody 3 mg/kg REGN2810+ radiotherapy (9 Gy×3) + cyclophosphamide+GM-CSF 6 Advanced solid tumors (excluding NSCLC, HNSCC and BC) 3 mg/kg REGN2810+ radiotherapy (9 Gy×3) + cyclophosphamide+GM-CSF 7 Metastatic (M1) squamous cell carcinoma of the skin (CSCC) 3 mg/kg REGN2810 eight Locally and/or regionally advanced CSCC (M0) that is unresectable 3 mg/kg REGN2810 nine Metastatic colorectal cancer with microsatellite instability (MSI) 3 mg/kg REGN2810 ten Metastatic endometrial cancer with MSI 3 mg/kg REGN2810 eleven Castration-resistant prostate cancer with MSI 3 mg/kg REGN2810 12 Any other advanced solid tumor with MSI 3 mg/kg REGN2810 thirteen Advanced hepatocellular carcinoma or metastatic hepatocellular carcinoma (HCC) 3 mg/kg REGN2810 fourteen Advanced solid tumor refractory to first-line chemotherapy 3mg/kg REGN2810+carboplatin+docetaxel (low dose) fifteen Advanced solid tumor refractory to first-line chemotherapy 3mg/kg REGN2810+docetaxel (low dose) sixteen Previously untreated metastatic colorectal cancer with MSI 3 mg/kg REGN2810 17 Advanced NSCLC, previously untreated 3mg/kg REGN2810+carboplatin+docetaxel (low dose) eighteen Newly diagnosed glioblastoma multiforme (GBM) REGN2810 (1 or 3 mg/kg) + radiotherapy (6 Gy x 5 days) nineteen Recurrent GBM REGN2810 (1 or 3 mg/kg) + radiotherapy (6 Gy x 5 days) 20 HIV and solid tumors 3 mg/kg REGN2810 21 Advanced NSCLC, previously untreated 3mg/kg REGN2810+Carboplatin+Paclitaxel (full dose) 22 Non-squamous NSCLC at an advanced stage, previously untreated 3 mg/kg REGN2810+Cisplatin+Pemetrexed 23 Advanced squamous NSCLC, previously untreated 3 mg/kg REGN2810+Cisplatin+Gemcitabine 24 Cervical cancer, recurrent or metastatic 3 mg/kg REGN2810 25 Basal cell carcinoma refractory to hedgehog pathway inhibition 3 mg/kg REGN2810 26 Solid tumor at an advanced stage 3 mg/kg REGN2810

[00154] The initial scheduled treatment with REGN2810 is carried out every 14 days for up to 48 weeks with 24 weeks of follow-up. Radiation therapy is carried out one week after the first dose of REGN2810. Low dose cyclophosphamide is administered to patients who are prescribed cyclophosphamide 1 day prior to each of the first 4 doses of REGN2810.

Study duration

[00155] Patients were treated for up to 48 weeks, followed by follow-up for 24 weeks. The patient is treated until the completion of the 48-week treatment period or until disease progression, unacceptable toxicity occurs, consent to the study is withdrawn, or another study exclusion criterion is met. After at least 24 weeks of treatment, patients with confirmed complete responses (CR) may decide to withdraw from the study and continue with all relevant study evaluations (eg, efficacy evaluations). After at least 24 weeks of treatment, patients with stable disease (SD) or partial response (PR) tumor mass scores remaining unchanged at 3 consecutive tumor evaluations may also choose to withdraw from the study and continue with all relevant study evaluations. (eg performance evaluations).

Study sample

[00156] The target population for this study includes patients with advanced cancer who are not candidates for standard therapy, who are unwilling to undergo standard therapy, or for whom there is no available therapy expected to provide clinical benefit; and patients with cancers that are incurable, fail to respond to standard therapy, or show tumor progression despite standard therapy.

[00157] Inclusion Criteria: The patient must meet the following study inclusion criteria: (1) progression of a solid tumor without available alternative therapies in accordance with standard of care; (2) at least 1 lesion to assess response. Patients who are prescribed radiotherapy should have at least one additional lesion that can be safely irradiated while sparing the index lesion, and for which radiation therapy at the prescribed limited, palliative doses would be considered medically appropriate; (3) patients must relapse after first-line therapy, or must be refractory to first-line therapy (and up to 2 previous lines of therapy) in the setting of recurrent or metastatic disease, and must have disease for which palliative radiotherapy is indicated; (4) patients with metastatic malignancy with microsatellite instability (MSI) refractory to up to 2 previous lines of therapy; (5) Eastern United Cancer Group (ECOG) status ≤1; (6) over 18 years of age; (7) liver function: a. total bilirubin ≤1.5 times the upper limit of normal (ULN; with liver metastases ≤3 times the ULN), b. transaminase ≤3-fold ULN (or ≤5.0-fold ULN for liver metastases), c. alkaline phosphatase (ALP) ≤2.5 times the ULN (or 5.0 times the ULN for liver metastases); (8) kidney function: serum creatinine ≤1.5 times the ULN; (9) neutrophil count (ANC) ≥1.5×10 ⁹ /l, c. platelet count ≥75×10 ⁹ /l; (10) the possibility of providing signed informed consent; and (11) the ability and willingness to follow scheduled visits, treatment plans, laboratory tests, and other study procedures.

Investigational treatment

[00158] REGN2810 is supplied as a liquid in sterile disposable vials. Each vial contains enough volume to draw 10 ml of REGN2810 at 25 mg/ml. REGN2810 is administered on an outpatient basis as a 30-minute IV infusion. The dose for each patient depends on the body weight of the individual. The dose of REGN2810 is adjusted for each cycle in case of changes in body weight by ≥10%. REGN2810 is administered alone or in combination with radiation therapy and/or cyclophosphamide. Cyclophosphamide is administered at a dose of 200 mg/m ² or low dose (100 mg/m ² ).

Monotherapy

[00159] REGN2810 is administered on an outpatient basis via IV infusion over 30 minutes every 14 days for 48 weeks (eg, days 1, 15±3, 29±3, and 43±3 of a 56-day cycle). Planned monotherapy regimens that may be prescribed may include: (i) IV infusion of 1 mg/kg over 30 minutes every 14 days for 48 weeks; (ii) infusion of 3 mg/kg over 30 minutes every 14 days for 48 weeks; (iii) infusion of 10 mg/kg over 30 minutes every 14 days for 48 weeks; (iv) infusion of 0.3 mg/kg over 30 minutes every 14 days for 48 weeks (if the MTD is determined to be less than 1 mg/kg); and (v) IV infusion of a constant dose of 200 mg over 30 minutes every 14 days for 48 weeks.

Combined treatment

[00160] Concomitant radiotherapy, cyclophosphamide, GM-CSF, carboplatin, and docetaxel are administered by prescription, and their use, dose, dose modifications, reduction or delay in administration, and any potential AEs resulting from their use are monitored along with such the same indicators for REGN2810.

[00161] Combination of REGN2810 and radiotherapy : REGN2810 is administered by IV infusion over 30 minutes every 14 days for 48 weeks in combination with radiotherapy from day 8 to day 12. Planned combination regimens using REGN2810 and radiotherapy may include:

infusion of 1 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks, and

radiation therapy at a dose of 30 Gy (6 Gy x 5 times/week; given 1 week after the first dose of REGN2810, preferably on consecutive days)

infusion of 1 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks, and

radiation therapy at a dose of 27 Gy (9 Gy x 3 times/week; given 1 week after the first dose of REGN2810, preferably not on consecutive days)

infusion of 3 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks, and

radiation therapy at a dose of 30 Gy (6 Gy x 5 times/week; given 1 week after the first dose of REGN2810, preferably on consecutive days)

infusion of 3 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks, and

radiation therapy at a dose of 27 Gy (9 Gy x 3 times/week; given 1 week after the first dose of REGN2810, preferably not on consecutive days)

[00162] Patients will be treated with 30 Gy in 5 fractions of 6 Gy administered daily starting 1 week after the first dose of REGN2810, or 27 Gy in 3 fractions of 9 Gy administered every other day starting 1 week after administration first dose of REGN2810. The site selected for irradiation should be one that can be safely irradiated using focal irradiation while preserving index lesions, and for which radiation therapy at the limited, palliative doses envisaged would be considered medically appropriate.

[00163] Combination of REGN2810 and cyclophosphamide : REGN2810 is administered by IV infusion over 30 minutes every 14 days (2 weeks) for 48 weeks in combination with cyclophosphamide at a low dose of 100 mg/m ² by IV infusion every 14 days for 4 doses . Each of the 4 doses of cyclophosphamide was administered 1 prior to each of the first 4 doses of REGN2810 (days -1, 14, 28 and 42 of the first 56 day cycle).

[00164] The planned combination treatment regimen for REGN2810 and cyclophosphamide is:

Cyclophosphamide at a dose of 100 mg/m ² or 200 mg/m ² IV every 14 days (days -1, 14, 28 and 42 of the first 56-day cycle) for a total of 4 doses; and

infusion of 3 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks (provides a monotherapy dose of 3 mg/kg <MTD; if 3 mg/kg >MTD, the dose will be 1 mg/kg).

[00165] Combination of REGN2810, radiation therapy and cyclophosphamide : The planned combination regimen using REGN2810, radiation therapy and cyclophosphamide includes:

cyclophosphamide 100 mg/m ² (low dose) IV every 14 days (days -1, 14, 28 and 42 of the first 56-day cycle) for a total of 4 doses; and

radiation therapy at a dose of 27 Gy (9 Gy x 3 times/week; given 7 or 8 days after the first dose of REGN2810, preferably not on consecutive days) or radiation therapy at a dose of 30 Gy (6 Gy x 5 times/week; performed 7 or 8 days after the first dose of REGN2810, preferably on consecutive days); and

infusion of 3 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks (provides a monotherapy dose of 3 mg/kg <MTD; if 3 mg/kg > MTD, the dose will be 1 mg/kg)

[00166] Combination of REGN2810, radiotherapy and GM-CSF : The planned combination treatment regimen using REGN2810, radiotherapy and GM-CSF includes:

250 mcg GM-CSF SC daily for 7 days at four 7-day intervals (days 1-7, 15-21, 29-35, and 43-49 of the first 56-day cycle); and

radiation therapy at a dose of 27 Gy (9 Gy×3 times/week; carried out 1 week after the first dose of REGN2810, preferably not on consecutive days); and

infusion of 3 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks (provides a monotherapy dose of 3 mg/kg < MTD; if 3 mg/kg > MTD, the dose will be 1 mg/kg)

[00167] Combination of REGN2810, radiotherapy, GM-CSF and cyclophosphamide : The planned combination treatment regimen using REGN2810, radiotherapy, GM-CSF and cyclophosphamide includes:

250 mcg GM-CSF SC daily for 7 days at four 7-day intervals (days 1-7, 15-21, 29-35, and 43-49 of the first 56-day cycle); and

radiation therapy at a dose of 27 Gy (9 Gy×3 times/week; carried out 1 week after the first dose of REGN2810, preferably not on consecutive days); and

cyclophosphamide at a dose of 100 mg/m ² or 200 mg/m ² IV every 14 days (days -1, 14, 28 and 42 of the first 56-day cycle) for a total of 4 doses; and

infusion of 3 mg/kg REGN2810 over 30 minutes every 14 days for 48 weeks (provides a monotherapy dose of 3 mg/kg < MTD; if 3 mg/kg > MTD, the dose will be 1 mg/kg)

[00168] Combination of REGN2810 and docetaxel with or without carboplatin : The proposed sequence of drug administration is docetaxel, then carboplatin (if included in the carboplatin cohort), then REGN2810:

docetaxel 30 mg/m ² IV over approximately 1 hour on days 1, 8, 29 and 36 of the first 56 day cycle. Dexamethasone 8 mg IV will be administered prior to the first dose of docetaxel. In the case of subsequent treatment with docetaxel, the dose of dexamethasone for premedication may be 8 mg or 4 mg at the discretion of the investigator

Carboplatin AUC 2 IV for approximately 30 minutes on days 1, 8, 29 and 36 of the first 56 day cycle. When dosing carboplatin, use the Calvert formula on the carboplatin label. Creatinine clearance should be calculated using the Cockcroft-Gault formula.

infusion of 3 mg/kg REGN2810 over approximately 30 minutes every 14 days for 48 weeks

Procedures and assessments

[00169] Screening procedures to be performed include serum beta-hCG, brain MRI, and chest X-ray.

[00170] Procedures for safety assessment include history taking, physical examination, vital signs assessment, electrocardiography (ECG), coagulation analysis, immunological safety tests (for patients treated with REGN2810), symptom assessment B and assessment of general condition, clinical laboratory tests, assessment of AE and determination of concomitant medicinal products.

[00171] Efficacy procedures to be performed to evaluate a tumor include CT or MRI, 18F-tordeoxyglucose positron emission tomography (FDG-PET), and/or tumor biopsy. CT or MRI for tumor evaluation is performed at the screening visit (within 28 days prior to infusion) and during each cycle (approximately every 8 weeks) on day 56±3 and when disease progression is suspected. In addition, in the case of patients who do not progress during the study, tumor evaluation is performed at follow-up visits 3, 5 and 7. After selecting CT or MRI, subsequent evaluations are performed in the same way. Tumor response scores are performed according to the RECIST Solid Tumor Response Evaluation Criteria version 1.1 (Eisenhauer et al 2009, Eur. J. Cancer 45: 228-247). Measurable lesions selected as targets for measurement according to RECIST were also included as index lesions for immune-mediated response criteria (irRC; Nishino et al 2013, Clin. Cancer Res. 19: 3936-3943). Response according to RECIST is given priority as a statistical measure of response rate. In the case of an individual patient, irRC may be used in deciding whether to continue treatment at the investigator's discretion due to the potential for unusual responses.

[00172] Blood samples were collected for PK and anti-drug antibodies (ADA) analysis.

Study variables

[00173] The primary variables in the study are the frequency of DLT and the frequency and severity of TEAE and abnormal laboratory results during the 48 weeks of the study.

[00174] Secondary variables are:

Antitumor activity, assessed using the appropriate criteria for a feature (as described elsewhere in the present description):

√ Solid tumor response criteria (RECIST; Eisenhauer et al 2009, Eur. J. Cancer 45: 228-247) as determined by CT or MRI

√ Also use other scoring criteria for specific tumors for which RECIST measurements are not standard.

√ Immune mediated response criteria (irRC; Nishino et al 2013, Clin. Cancer Res. 19: 3936-3943) used in relation to RECIST measurements. In all cases, RECIST (or other tumor-specific criteria) is the primary tool for determining PD, SD, CR, or PR. irRC is defined for clinical decision making and informational purposes.

Frequency of Anti-REGN2810 Antibodies

Antitumor activity as measured by PFS and overall survival

[00175] For the purposes of this study, patients are re-evaluated for response every 8 weeks. Confirmation scans are also performed 4 weeks after baseline documentation of objective response or disease progression. Response and progression in this study is assessed using the international criteria proposed in the revised Solid Tumor Response Evaluation Criteria (RECIST) guidelines (version 1.1; Eisenhauer et al 2009, Eur. J. Cancer 45: 228-247). The RECIST criteria use changes in the largest diameter (one-dimensional measurement) of tumor foci and the smallest diameter in the case of malignant lymph nodes.

Choice of foci

[00176] Measurable disease: Measurable lesions are defined as lesions that can be accurately measured in at least one direction (largest diameter to be recorded) as ≥20 mm (≥2 cm) on chest x-ray or as ≥10 mm (≥1 cm) with CT, MRI or with the help of a caliper during a clinical examination. All measurements of tumors must be recorded in millimeters (or decimal fractions of centimeters). Note: See below for evaluation of irradiated target foci.

[00177] Malignant lymph nodes: To be considered pathologically enlarged and measurable, a lymph node must have a size of ≥15 mm (≥1.5 cm) in the short axis when assessed by CT (recommended slice thickness on CT should be no more than 5 mm [0.5 cm]). At baseline and at follow-up, only the short axis will be measured and tracked.

[00178] Non-measurable disease: All other lesions, including small lesions (maximum diameter <10 mm [<1 cm] or abnormal short-axis lymph nodes ≥10 to <15 mm [≥1 to <1.5 cm]), considered an unmeasured disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial exudate, skin lymphangitis/pneumonitis, inflammatory breast disease, and abdominal masses (not monitored by CT or MRI) are considered immeasurable. Note: Cystic lesions meeting the criteria for radiographically detectable simple cysts should be considered malignant lesions (neither measurable nor non-measurable), as they are, by definition, simple cysts. "Cystic lesions", considered to be cystic metastases, may be considered measurable lesions if they meet the definition of measurability described above. However, if the same patient has non-cystic lesions, they are preferred for selection as target lesions.

[00179] Target lesions: All measurable lesions up to a maximum of 2 lesions per organ and a total of 5 lesions representing all affected organs must be identified as target lesions and recorded and measured at baseline. Target lesions are selected based on their size (lesions with the largest diameter), they represent all affected organs, but also include lesions that are amenable to reproducible repeated measurements. It may happen that sometimes the largest lesion cannot be measured reproducibly, in which case the next largest lesion that can be measured is chosen. Calculate the sum of the diameters (largest for non-nodal lesions, short axis for nodal lesions) for all target lesions and record as the original total diameters. If lymph nodes are included in the total, then only the short axis is added to it. Initial total diameters are used as a reference for further characterization of any objective tumor regression in a measurable direction of the disease focus.

[00180] Non-target lesions: All other lesions, including any measurable lesions outside the 5 target lesions, are identified as non-target lesions and recorded at baseline. Measurements of these lesions are not required, but the presence, absence or, in rare cases, unequivocal progression of each of them is recorded throughout the follow-up.

Ways to assess measurable disease

[00181] All measurements are made and recorded in metric units using a ruler or caliper. All baseline assessments are made as close to the start of treatment as possible and never more than 4 weeks before the start of treatment. At baseline and during follow-up, the same scoring method should be used to characterize each identified and reported lesion. Evaluation by imaging is preferred to evaluation by clinical examination, but if traceable lesions cannot be visualized, they are evaluated by clinical examination.

[00182] Clinical lesions: Clinical lesions are considered measurable only if they are superficial (eg, skin nodules and palpable lymph nodes) and ≥10 mm (≥1 cm) in diameter when measured using a caliper (eg, skin nodules). In the case of skin lesions, it is recommended to document them with a color photograph using a ruler to assess the size of the lesions.

[00183] Chest x-ray: Lesions on chest x-ray are considered measurable lesions if they are clearly defined and surrounded by a ventilated lung. However, CT is preferred.

[00184] Conventional CT and MRI: This guideline defines the measurability of lesions on CT assuming CT slice thicknesses of 5 mm (0.5 cm) or less. If slices greater than 5 mm (0.5 cm) are used in CT, the minimum size of a measurable lesion should be twice the slice thickness. In some cases, an MRI is also acceptable.

[00185] PET-CT: If the CT performed as part of PET-CT has diagnostic quality identical to diagnostic CT (with IV and oral contrast), then the CT part of PET-CT can be used for RECIST measurements, and it can also be used interchangeably with conventional CT in accurately measuring malignant lesions over time.

[00186] Ultrasound: Ultrasound is not suitable for evaluating the size of a lesion and cannot be used as a measurement method. If new lesions are identified by ultrasound during the study, it is recommended to confirm them with CT or MRI. If there are concerns about radiation exposure from CT, MRI may be used instead of CT in some cases.

[00187] Endoscopy, laparoscopy: These methods are not recommended for objective tumor evaluation. However, such methods can be used to confirm pathological complete response in biopsy or to determine recurrence in trials where recurrence after complete response (CR) or surgical resection is the endpoint.

[00188] Tumor markers: Tumor markers alone cannot be used to evaluate response. If markers initially exceed the upper limit of normal, they must be normalized for the patient to consider that he has a complete clinical response.

[00189] Cytology and Histology: These methods can be used to differentiate between partial responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types such as germ cell tumors where known residual benign tumors may remain). tumors). Cytological confirmation of the neoplastic origin of any exudate that develops or worsens during treatment, if the measurable tumor meets the criteria for response or stable disease, is essential to distinguish between response or stable disease (exudate may be a side effect of treatment) and progressive disease.

[00190] FDG-PET: Although additional testing is needed when evaluating response with FDG-PET, it is sometimes appropriate to include the use of an FDG-PET scan to complement the CT scan when assessing progression (in particular, a possible "new" disease). New lesions based on FDG-PET imaging can be identified using the following algorithm: a. Negative FDG-PET results at baseline with positive FDG-PET results at follow-up are indicative of PD given a new lesion. b. No FDG-PET at baseline and positive FDG-PET results at follow-up: If a positive FDG-PET result at follow-up is consistent with a new lesion confirmed by CT, this is PD. If positive FDG-PET results at follow-up are not confirmed as a new lesion on CT, an additional CT scan at follow-up is needed to determine if there is in fact progression at that lesion (if so, the PD date will be the date of the original scan FDG-PET with deviations). If a positive follow-up FDG-PET is consistent with a pre-existing lesion on CT that is not progressing on anatomical imaging, it is not PD. c. FDG-PET can be used to increase response to CR in a manner similar to a biopsy in cases where residual radiographic abnormalities are thought to represent fibrosis or scarring. The use of FDG-PET in these cases should be routinely described in the protocol and justified using the medical literature relevant to the disease for this indication. However, it should be noted that both approaches can lead to a false positive CR due to the limitations of FDG-PET and resolution/sensitivity of the biopsy. Note: The term "positive" on an FDG-PET scan of a lesion means that, on an attenuation-corrected image, FDG uptake is more than twice that of the surrounding tissue.

Response criteria for assessing target lesions

Complete response (CR): Disappearance of all target lesions. Any pathological lymph nodes (target or non-target) should decrease in the short axis to <10 mm (<1 cm).

Partial Response (PR): At least a 30% reduction in the sum of target lesion diameters using the original total diameters as a reference.

Progressive Disease (PD): At least a 20% increase in the sum of target lesion diameters using the lowest per-study amount (it includes the original total if it is the lowest per-study amount) as reference. In addition to the 20% relative increase, the sum must also have an absolute increase of at least 5 mm (0.5 cm). (Note: the appearance of one or more new lesions is also considered progression).

Stable disease (SD): No tumor reduction sufficient for classification as PR and no sufficient increase for classification as PD using the smallest total diameters per study as reference.

Response criteria for evaluating non-target lesions

Complete response (CR): Disappearance of all non-target lesions and normalization of tumor marker levels. All lymph nodes must be nonpathological in size (<10 mm [<1 cm] on the short axis). Note: If tumor markers initially exceed the upper limit of normal, they should normalize to consider that the patient has a clinical complete response.

Non-CR/Non-PD: Persistence of one or more off-target lesions and/or maintenance of tumor marker levels above normal limits.

Progressive disease (PD): Occurrence of one or more new lesions and/or clear progression of existing non-target lesions. Unequivocal progression should generally not be overridden by the status of the target lesions. It should correspond to a general change in the status of the disease, and not to an increase in one focus.

Immune-mediated response criteria

[00191] Immune-mediated response criteria differ from RECIST (version 1.1) in that the sum of the largest diameters of all target lesions and new lesions, if any, is used to determine the response. The presence of new lesions does not essentially determine progression, instead the total tumor mass is taken into account.

Assessment of target foci

Complete response (CR): Disappearance of all target lesions. Any pathological lymph nodes (target or non-target) should decrease in the short axis to <10 mm (<1 cm).

Partial Response (PR): At least a 30% reduction in the sum of target lesion diameters, including new lesions, using the original total diameters as a reference.

Progressive disease (PD): At least a 20% increase in the sum of target lesion diameters, including new lesions, using the lowest per-study amount (it includes the original total if it is the lowest per-study amount) as reference. In addition to the 20% relative increase, the sum must also have an absolute increase of at least 5 mm (0.5 cm).

Stable disease (SD): No tumor reduction sufficient to be classified as PR and no sufficient increase to be classified as PD when using the smallest total diameters per study as a reference and including measurements of new lesions.

Evaluation of non-target foci

Complete response (CR): Disappearance of all non-target lesions and normalization of tumor marker levels. All lymph nodes must be nonpathological in size (<10 mm [<1 cm] on the short axis). Note: If tumor markers initially exceed the upper limit of normal, they should normalize to consider that the patient has a clinical complete response.

Non-CR/non-PD: Persistence of one or more off-target lesions and/or maintenance of tumor marker levels above normal limits.

Progressive disease (PD): Definite progression of existing non-target lesions. Unequivocal progression should generally not be overridden by the status of the target lesions. It should correspond to a general change in the status of the disease, and not an increase in one focus. Although a clear progression of "off-target" lesions is unusual, in such cases the judgment of the treating physician should take precedence, and progression status should be confirmed later.

Evaluation of general response criteria

[00192] The best overall response is the overall response recorded from the start of treatment to progression/relapse of the disease (using the lowest measurement recorded from the start of treatment as a reference for progressive disease). Determining the best patient response will depend on the achievement of measurement and validation criteria. Revised Solid Tumor Response Evaluation Criteria (RECIST) version 1.1 (Eisenhauer et al 2009, Eur. J. Cancer 45: 228-247) and immune-mediated response criteria (irRC; Nishino et al 2013, Clin. Cancer Res. 19: 39363-943 ) are shown in tables 10 and 11 below.

Table 10: Response according to revised RECIST criteria (version 1.1)

Target foci Non-target outbreaks New outbreaks General response Best overall answer when confirmation is needed CR CR Not CR Confirmation within ≥4 weeks CR Non-CR/non-PD Not PR Confirmation within ≥4 weeks CR Not rated Not PR Confirmation within ≥4 weeks PR Non-CR/non-PD/do not evaluate Not PR Confirmation within ≥4 weeks SD Non-CR/non-PD/do not evaluate Not SD Documented at least once within ≥4 weeks from baseline PD Any Yes or no PD No previous SD, PR or CR Any PD Yes or no PD No previous SD, PR or CR Any Any Yes PD No previous SD, PR or CR

CR: full answer; PD: progressive disease; PR: partial response; SD: stable disease

Table 11: evaluation of immune-mediated response criteria

Target foci Non-target foci New outbreaks General response Best overall answer when confirmation is needed CR CR Not CR Confirmation within ≥4 weeks CR Non-CR/non-PD Not PR Confirmation within ≥4 weeks CR Not rated Not PR Confirmation within ≥4 weeks PR Non-CR/non-PD/ do not evaluate Yes or no PR Confirmation within ≥4 weeks SD Non-CR/non-PD/ do not evaluate Yes or no SD Documented at least once within ≥4 weeks from baseline PD Any Yes or no PD No previous SD, PR or CR Any PD Yes or no PD No previous SD, PR or CR

CR: full answer; PD: progressive disease; PR: partial response; SD: stable disease

Evaluation of irradiated target foci

[00193] Irradiated target lesions are scored using a modified version of the international criteria proposed by the Solid Tumor Response Evaluation Criteria (RECIST) Development Committee version 1.1. For the definition of local control, additional definitions are included that go beyond the RECIST 1.1 guidelines and are specific to this protocol.

[00194] The response criteria for irradiated lesions are as follows:

[00195] Local increase (LE): At least a 20% increase in the LD of the target lesion using the lowest LD recorded since the start of treatment as a reference. Theoretically, this determination will be made taking into account the evaluation of CT images.

[00196] Local failure (LF): The term refers to the primary tumor treated following protocol therapy and represents meeting two criteria: (1) A 20% increase in tumor size as defined above for local enlargement (LE); (2) A measurable tumor with LE criteria must show increased uptake on positron emission tomography (PET) capture at an intensity similar to pre-treatment staging PET, or a measurable tumor must be biopsied, confirming a possible carcinoma.

[00197] Local control (LC): No local inefficiency.

[00198] The largest diameter (LD) of the irradiated target lesion, calculated from the CT scan results in treatment planning using the appropriate tissue-specific window adjustment, is recorded as baseline LD. The original LD is used as a reference by which to characterize the objective tumor. For follow-up assessment, diagnostic CT performed with a reconstruction algorithm using adjacent 5 mm slices using a pulmonary window adjustment performed as part of a scheduled protocol follow-up is the preferred method for evaluating response. If CT is not available, MRI or X-ray is acceptable, provided the target lesion is clearly visible.

results

[00199] REGN2810 alone and in combination is safe and well tolerated by patients. Administration of REGN2810 alone or in combination with other therapies inhibits tumor growth and/or promotes tumor regression in patients with advanced solid tumors. The overall response rate in the case of combined treatment with radiotherapy is superior to the response rate in the case of monotherapy.

[00200] To date, 60 patients with advanced malignant solid tumors have been treated (47% had previously undergone four or more prior therapies). Advanced malignant solid tumors include colorectal cancer, head and neck cancer, breast cancer, soft tissue sarcoma, adrenal cancer, anal cancer, appendix cancer, bladder cancer, cervical cancer, endometrial cancer, esophageal cancer, liver cancer, non-small cell lung adenocarcinoma, ovarian cancer, pancreatic cancer, prostate cancer, sarcomatoid kidney cancer, salivary gland cancer, non-melanoma skin cancer, Merkel carcinoma, squamous cell carcinoma, basal cell carcinoma, small intestine cancer, thyroid cancer, and uterine cancer.

[00201] Forty-two patients (70%) experienced one or more treatment-related adverse events (AEs). The most common treatment-related AEs were fatigue (28.3%), arthralgia (11.7%), and nausea (11.7%). Of the 60 patients evaluated for tumor responses, 11 (18.3%) had objective responses (PR/CR), while 31 patients (51.7%) had disease control (CR/PR/SD). Of the 36 patients who underwent combined treatment, including radiation therapy, an objective response was observed in 6 patients (16.7%), and disease control was observed in 19 patients (52.8%). Of the 24 patients who did not receive radiation therapy, an objective response was observed in five patients (20.8%), and disease control was observed in 12 patients (50%). Table 12 provides a summary of patient responses to treatment.

Table 12: Summary of Patient Responses

Individual ID Dose cohort Type of cancer Number of previous lines of therapy best answer Best % Reduction 41 R2810: 1 mg/kg Cholangiocarcinoma 5 PR -41.2 fifty R2810: 1 mg/kg Squamous cell carcinoma of the skin 2 CR -100.0 43 R2810: 10 mg/kg soft tissue sarcoma 5 PR –49.1 37 R2810: 10 mg/kg Basal cell carcinoma one PR -36.7 36 R2810: 3 mg/kg+CPA: 200 mg/ ^m2 soft tissue sarcoma 5 PR -33.3 47 R2810: 1 mg/kg+XRT: 6 Gy×5 Squamous cell carcinoma of the cervix 4 PR -66.7 46 R2810: 1 mg/kg+XRT: 9 Gy×3 Squamous cell carcinoma of the anal canal 3 PR –57.1 49 R2810: 1 mg/kg+XRT: 9 Gy×3 Squamous cell carcinoma of the cervix 3 CR -100.0 48 R2810: 3 mg/kg+XRT: 6 Gy×5 Merkel's carcinoma one PR -72.5 42 R2810: 3 mg/kg+XRT: 6 Gy×5 Adenocarcinoma of the small intestine 2 PR -46.7 44 R2810: 3 mg/kg+XRT: 9 Gy×3 Serous ovarian carcinoma 6 PR -52.4

[00202] Among patients who responded to treatment, the median time to response in the case of monotherapy was 113 days (range 52-226), and in the case of patients subjected to, including radiation therapy, 59 days (range 56-113) .

Example 8: Case reports of blocking PD-1 using monoclonal antibody REGN2810 with long-term objective responses in metastatic non-melanoma skin cancer - basal cell carcinoma and squamous cell carcinoma of the skin

Introduction

[00203] Basal cell carcinoma (BCC) and squamous cell carcinoma of the skin (CSCC) share a dominant risk factor, UV radiation, and thus these tumors are hypermutant (Chalmers et al 2016, AACR Ann. Meeting, Abs 3576) . In other malignancies, high mutation load is associated with the clinical benefit of antibody therapy against PD-1 immune checkpoints [Le et al 2015, New Engl. J. Med. May 30 (Epub ahead of print)]. It is more likely that highly mutated tumors will express immunogenic tumor neoantigens that recruit effector T cells that can activate blocking of PD-1 immune checkpoints (Mandal and Chan 2016, Cancer Discov. 6: 1-12). This example describes a patient with metastatic BCC and a patient with metastatic CSCC who were treated with REGN2810, a fully human anti-PD-1 monoclonal antibody in an ongoing Phase 1 trial (NCT02383212; described in Example 7 herein).

Case Description 1

[00204] The patient was a 66 year old female diagnosed with stage 1 BCC occurring on the left side of the chin and resected using the Mohs procedure. After 2 years, a localized recurrence was determined in the same place, and with a wide local excision, invasion into the left lower jaw and involvement of one of the 18 lymph nodes was revealed. The patient was subjected to adjuvant radiation therapy and remained in remission for 4 years when enlarged nodules in the lungs, determined by chest imaging at observation, were biopsied and confirmed the presence of metastatic BCC. Subsequently, the patient was administered the Hedgehog pathway inhibitor (HHI) vismodegib for 5 months. At first, she had a response, but the treatment was stopped due to the progression of the disease.

[00205] Six months after vismodegib therapy and after continued slow progression, the patient was enrolled in the phase 1 study REGN2810 in the 10 mg/kg IV every 2 weeks cohort and given her first dose. Two lung metastases were monitored as target lesions. When evaluating the response at the end of 8 weeks (increase by 3%) and 16 weeks (increase by 10%), stable disease was observed according to RECIST criteria. When evaluating the response at the end of 24 weeks, a 37% reduction in tumor size was observed (Figure 14A) and confirmed after 32 weeks. The patient tolerated the treatment well and continued treatment with REGN2810 for more than 10 months.

Case description 2

[00206] The patient was a 52 year old male diagnosed with squamous cell carcinoma of the skin on the left cheek. He was subjected to a Mohs operation with clear boundaries. He has had multiple relapses and at least 9 additional Mohs surgeries. He underwent a wide local excision on the left side of the mandible 4 years later and a left parotidectomy 20 months later. In addition, the left cheek, left mandible, left side of the neck (with concomitant administration of cetuximab) were subjected to adjuvant radiation therapy, and bilateral adjuvant radiation therapy of the neck (with concomitant administration of carboplatin) was also carried out. Other systemic therapies were capecitabine and cisplatin + docetaxel. Ten years after diagnosis, he underwent a well-demarcated excision due to tumor recurrence in 2.2 cm scar tissue on the left side of the neck. Subsequently, invasive CSCC in the C4-C5 vertebral bodies necessitated emergency decompression of the cervical spinal cord using anterior corpectomy at the C4-C5 level and posterior laminectomy at the C4-C6 level. He also developed muscle weakness in the lower extremities, believed to be the result of perineural involvement, in which case he required the use of a walker to move around.

[00207] He was included in the Phase 1 study in the first cohort and administered 1 mg/kg REGN2810 every two weeks. Within weeks of starting treatment, strength in his lower limbs has gradually returned and he no longer needs a walker. The response at week 16 is shown in Figure 14B. A complete radiological response in the lesion on the left side of the neck was achieved at week 40. The patient completed the planned 48-week treatment protocol using REGN2810. He continues to be under close, active follow-up by an oncologist with no clinical or radiographic evidence of disease recurrence.

Discussion

[00208] This example describes the first confirmed partial response in a patient with metastatic BCC who was treated with a PD-1 inhibitor (REGN2810), as well as an ongoing long-term complete response in a patient with metastatic CSCC. The profound and sustained responses in these heavily pre-treated patients to anti-PD-1 antibody monotherapy in this phase 1 study is consistent with the hypothesis that high mutation load in BCC and CSCC will induce anti-tumor cellular immunity that can be activated by blocking the pathway. control points PD-1/PD-L1.

[00209] This example confirms the general principle that UV-associated skin cancers other than melanoma are susceptible to blocking PD-1. Using a reductionist model, it was predicted that UV-associated tumors with a higher load of non-synonymous mutations would have a higher responsiveness to blocking PD-1 than tumors with a lower mutation load.

Example 9 Safety and Efficacy of Anti-PD-1 Antibody in Patients with Unresectable Locally Advanced or Metastatic Skin Squamous Cell Carcinoma (CSCC)

Prerequisites

[00210] There is no established standard for the treatment of unresectable locally advanced or metastatic CSCC. As a result of UV-induced DNA damage, most CSCCs are hypermutant. Thus, these tumors may respond to blocking of PD-1 checkpoints. This example describes patients with locally advanced or metastatic CSCC treated with REGN2810, a fully human anti-PD-1 monoclonal antibody, in an ongoing Phase 1 study (NCT02383212; described in Example 7 herein).

Ways

[00211] The expanded cohorts (EC) in the REGN2810 phase 1 study included patients with CSCC with distant metastases (EC 7) and locally advanced CSCC (EC8) (Table 9). All patients received 3 mg/kg REGN2810 intravenously every 2 weeks for up to 48 weeks. Exploratory biopsy was performed at baseline and on day 29 (and progression if possible). To determine the overall response rate, tumor measurement was performed every 8 weeks according to RECIST 1.1.

results

[00212] The study included 25 patients (10 in EC 7 and 15 in EC 8): median age 72.5 years (range 56-88 years); median PS 1 (range 0-1); 20M:5F; median number of prior systemic therapy regimens 1 (range 0-3). Median exposure to REGN2810 was 6 doses (range 1-22). The most common treatment-related adverse events of any grade were fatigue (16.7%), nausea, arthralgia, and rash (8.3% each). Each of the following grade ≥3 treatment-related adverse events (AEs) occurred once: AST elevation, ALT elevation, arthralgia, and rash.

[00213] The overall response rate (uPR+PR+CR) and disease control rate (ORR+SD) were 48% (11/23; 3uPR, 5PR, 2CR, 1uCR) and 70% (16/23, including 5 SD), respectively. Two patients have not yet been evaluated. Median PFS and median OS are calculated, and only one patient had PD during REGN2810 treatment after baseline response. Comparative research is ongoing, including whole exome sequencing of tumor DNA.

Conclusion

[00214] REGN2810 demonstrates robust antitumor activity in patients with advanced CSCC.

Example 10 Clinical Trial of Anti-PD-1 Antibody in Combination with Hypofractionated Radiation Therapy Compared to Standard of Care in Patients ≥65 Years of Age with Newly Diagnosed Glioblastoma

Introduction

[00215] Glioblastoma is a fatal disease with a median survival of approximately 16 months in patients with a newly diagnosed tumor (nGBM) and approximately 9 months in a relapsed setting (rGBM) (Friedman et al, 2009, J. Clin. Oncol. 27: 4733-4740 ). The current standard of care for patients with newly diagnosed glioblastoma is radiotherapy (60 Gy in 6 weeks) with concomitant administration of temozolomide (TMZ) followed by adjuvant treatment with temozolomide (Stupp et al, 2005, N. Engl. J. Med. 352:987- 996), although subgroup analysis suggests that the addition of temozolomide may not improve efficacy in older individuals (Laperriere et al, 2013, Cancer Treat. Rev. 39: 350-357).

[00216] This example describes a phase 3 study to evaluate the efficacy of anti-PD-1 antibody in combination with hypofractionated radiotherapy (hfRT) versus standard of care (SoC) in terms of overall survival in nGBM patients ≥65 years of age.

[00217] An example of an anti-PD-1 antibody used in this study is REGN2810 (also known as H4H7798N as described in US20150203579), a fully human anti-PD-1 monoclonal antibody containing a heavy chain containing the amino acid sequence of SEQ ID NO: 9 , and a light chain containing the amino acid sequence of SEQ ID NO: 10, a pair of HCVR/LCVR amino acid sequences containing SEQ ID NO: 1/2, and heavy and light chain CDR sequences containing SEQ ID NO: 3-8.

Research objectives

[00218] The primary goal of the study is to evaluate efficacy in terms of overall survival (OS) when REGN2810 is administered in combination with hfRT compared to standard of care for nGBM patients ≥65 years of age.

[00219] A secondary objective of the study is to determine improvement in progression-free survival (PFS).

[00220] Other objectives of the study are: (i) improving the objective response rate (ORR), duration of response, and duration of disease control; (ii) clinical evaluation using the Neurological Assessment in Neurooncology (NANO) scale; (iii) safety assessment; (iv) improved quality of life (QoL) and mental health; (v) changes in edema and steroid use; (vi) determination of serum REGN2810 concentration and anti-REGN2810 antibodies; and (vii) investigation of potential pharmacodynamic or predictive biomarkers.

Study design

[00221] This study was a 2:1 randomized phase 3 study of REGN2810, a fully human anti-PD-1 antibody, in combination with hypofractionated radiotherapy compared to standard of care in patients with newly diagnosed glioblastoma ≥65 years of age. Patients are randomly assigned to treatment groups using REGN2810 in combination with hypofractionated radiotherapy or standard of care, in a 2:1 ratio with determination of methylation status (methylated, or unmethylated, or indeterminate) and resection volume (partial or total total resection). ) as stratification factors. Efficacy is assessed by overall survival.

[00222] Patients with nGBM who are candidates for radiotherapy are randomly assigned in a 2:1 ratio to one of the following groups:

Investigational therapy: 3 mg/kg REGN2810 IV (every 2 weeks) and hypofractionated RT (6 Gy×5, second week only). Radiation therapy is carried out at week 2 of cycle 1, but not subsequent cycles.

Comparative therapy: standard of care - TMZ (oral, 75 mg/m ² daily) in combination with standard RT (5 daily radiation fractions/week of 2 Gy) for 6 weeks, followed by adjuvant therapy (oral, from 150 mg/day). m ² to 200 mg/m ² , 5 days/28 days) for 6 cycles. Radiation therapy is carried out only during the first 6-week cycle.

Study duration

[00223] The study consists of a 28-day screening period, after which eligible patients could be subjected to up to twelve 56-day (8-week) treatment cycles for a total of up to 96 weeks of treatment. During the screening period (day -28 to day -1), all eligible patients should have available pre-treatment tumor resection (partial or total resection) or biopsy results for central pathology confirmation and MGMT methylation determination and confirmation.

[00224] After day 1/baseline, patients return to the clinic for cycle 1 on days 8±3, 15±3, 29±3, 43±3, and 56±3. On each subsequent 8-week cycle (cycles 2-12), patients return to the clinic on days 1, 15±3, 29±3, 43±3, and 56±3. Tumor assessment (brain MRI, iRANO and NANO scores, MMSE and EORTC QLQ-C30/BN20 scores) is performed on day 1/at baseline and at the end of each treatment cycle. An extensive safety assessment is performed on day 1 of each cycle; a routine safety assessment will be carried out during each visit. Samples are also collected to evaluate biomarkers (cellular and molecular markers provided herein) associated with treatment exposure to REGN2810, clinical activity, or underlying disease.

[00225] During the 24-week follow-up period, patients return to the clinic 21-42 days after the last study treatment for the first follow-up visit. Subsequent follow-up visits (follow-up visits 2-7) are performed every 28 days ± 7 days. Tumor evaluation (brain MRI, iRANO and NANO scores, MMSE and EORTC QLQ-C30/BN20 scores) is performed at Follow-up Visit 3, Follow-up Visit 5, and Follow-up Visit 7. An extensive safety assessment is performed during time of the first follow-up visit, a routine safety assessment will be performed at subsequent follow-up visits. Collect samples for analysis of biomarkers (cellular and molecular markers presented in the present description) associated with exposure to REGN2810 in treatment, clinical activity or underlying disease.

Target sample

[00226] The target sample includes nGBM patients ≥65 years of age.

[00227] Inclusion Criteria : A patient must meet the following criteria to be eligible for inclusion in the study: (1) newly diagnosed primary glioblastoma with histological confirmation, having a maximum diameter of ≤5 cm and undergoing partial or complete surgical resection; (2) Eastern United Cancer Group (ECOG) General Condition 0-2; (3) age ≥65 years; (4) liver function: (a) total bilirubin ≤1.5 times upper limit of normal; (b) ALT and AST ≤3 times ULN; (c) alkaline phosphatase (ALP) ≤2.5-fold ULN; (5) kidney function: serum creatinine ≤1.5 times the ULN; (6) bone marrow function: hemoglobin ≥9.0 g/dl; absolute neutrophil count (ANC) ≥1.5×10 ⁹ /l; platelet count ≥75×10 ⁹ /l; (7) the ability to read, understand and desire to sign the ICF; and (8) the ability and willingness to follow scheduled visits, treatment plans, laboratory tests, and other study procedures.

[00228] Exclusion Criteria : A patient meeting any of the following criteria will be excluded from the study: (1) any prior GBM treatment (other than surgery); (2) has a known contraindication to Gd-MRI; (3) persistent or recent (within 5 years) evidence of significant autoimmune disease requiring treatment with systemic immunosuppression, which may pose a risk of immune-mediated adverse events (irAE). The following diseases are not exclusive: vitiligo, resolved childhood asthma, residual hypothyroidism, in which only hormone replacement therapy is required, or psoriasis, in which systemic treatment is not required. (4) Ongoing treatment with corticosteroids, except for the use of corticosteroids for other (non-neoplastic and non-immunosuppressive) indications up to a maximum of 10 mg/day of prednisone or its equivalent. (5) Primary tumors located in the brain stem, spinal cord, or any active infection in a secondary brain tumor requiring therapy, including known human immunodeficiency virus infection, or active hepatitis B or hepatitis C virus infection. (6) Pneumonitis in history for the last 5 years. (7) Implementation of any investigative or anticancer treatment within 30 days prior to initial administration of REGN2810. (8) Documented allergic reactions or history of acute hypersensitivity reaction attributable to treatment with antibodies in general or agents specifically used in this study. (9) Not adequately controlled hypertension (defined as systolic pressure >150 mmHg and/or diastolic pressure >100 mmHg). (10) Known allergy to doxycycline or tetracycline (caution due to trace amounts in REGN2810). (11) History of hypertensive crisis or hypertensive encephalopathy. (12) History of invasive malignancy within the past 5 years, other than malignancy being treated in this study, excluding resected/ablated basal cell or squamous cell carcinoma of the skin, or cervical carcinoma in situ , or other localized tumors considered to be curable by topical treatment. (13) Acute or chronic psychiatric disorders, at the discretion of the investigator, may render the patient ineligible for participation in the study. (14) Use of Novocure Tumor Treating Fields technology (Optune NovoTTF-100A devices) at the time of screening. Planned or expected use of Novocure Tumor Treating Fields technology during the study. (15) Prior treatment with carmustine implant capsules. (16) Continued sexual activity in men unwilling to use appropriate contraception during the study.

Investigational treatment

[00229] Patients use one of the following treatment regimens:

[00230] Investigational Therapy : 3mg/kg REGN2810 (given via IV infusion over 30 minutes every 2 weeks for up to 96 weeks) and hfRT at cycle 2 week 1

[00231] Comparative treatment: TMZ standard of care (oral, 75 mg/m ² , daily) in combination with standard RT (5 daily radiation fractions/week of 2 Gy) for 6 weeks followed by adjuvant TMZ therapy (oral, from 150 mg/ ^m2 to 200 mg/ ^m2 , 5 days/28 days) for 6 cycles. Radiation therapy is carried out only during the first cycle.

[00232] REGN2810 is supplied as a liquid in a sterile disposable vial. Each vial contains enough volume to draw 10 ml of REGN2810 at 25 mg/ml. REGN2810 is administered as a 30-minute IV infusion. The dose for each patient will depend on the body weight of the individual. The dose of REGN2810 must be adjusted during each cycle for changes in body weight of ≥10%.

[00233] Radiotherapy : Patients in the control group are subjected to standard radiotherapy (60 Gy in 6 weeks). Patients in the experimental treatment group are subjected to hfRT (6 Gy×5 daily fractions) administered 1 week after the first dose of REGN2810.

[00234] REGN2810 and radiotherapy (exploratory treatment) : REGN2810 is administered by IV infusion over 30 minutes every 14 days for 96 weeks in combination with hfRT from day 8 to day 12.

[00235] Planned combination treatment regimen for REGN2810 and hfRT : 3 mg/kg REGN2810 infusion over 30 minutes every 14 days for 96 weeks and radiotherapy (hfRT at 6 Gy x 5 daily fractions; given 1 week after first dose REGN2810, preferably on consecutive days).

[00236] Characteristics of radiotherapy: Patients receive 30 Gy in 5 fractions of 6 Gy daily starting 1 week after the first dose of REGN2810.

[00237] Comparison group: standard of care : TMZ (oral, 75 mg/m ² daily) in combination with standard RT (5 daily radiation fractions/week of 2 Gy) for 6 weeks followed by adjuvant therapy with oral TMZ. The TMZ dose is 150 mg/m ² during the first 5 days of the first cycle of adjuvant therapy and is increased to 200 mg/m ² for 5 days/28 days from the second cycle if there is no unacceptable haematological toxicity during the first cycle of adjuvant therapy .

[00238] If during the first cycle of adjuvant therapy, all observed cases of non-hematological toxicity are grade ≤2 (except for alopecia, nausea and vomiting), and the platelet count is ≥100×10 ⁹ /l, and ANC ≥1.5×10 ⁹ /l, then the dose of TMZ should be increased to dose level 1 (200 mg/m ² ) and this dose should be used as the initial dose for subsequent cycles. If TMZ must be discontinued after Cycle 1 due to persistent Grade ≥2 non-haematological toxicity, dose escalation is not possible. If the dose was not increased during the second cycle, the dose should not be increased in subsequent cycles.

[00239] Treatment of CNS Edema: Administration of REGN2810 and radiation therapy is discontinued for any patient who develops symptomatic cerebral edema during the study until the edema subsides.

[00240] Patients who develop cerebral edema are given bevacizumab IV as needed (PRN) at a dose reduced from the standard dose (assumed dose of 5 mg/kg Q2W up to 3 doses, but not more than 10 mg/kg Q2W per dose) if there are no contraindications (for example, if the patient has not undergone surgery in the last 28 days).

[00241] If administration of bevacizumab does not resolve the cerebral edema, systemic corticosteroids may be administered in addition to or instead of bevacizumab at the lowest dose considered appropriate to treat the symptom. In the case of patients intolerant to bevacizumab, corticosteroids are used at a dose considered appropriate for the treatment of the symptom.

Study variables

[00242] The primary efficacy endpoint is overall survival (OS), defined as the time interval between the date of randomization and the date of death from any cause.

[00243] A key secondary endpoint is progression-free survival (PFS), defined as the time interval between the date of randomization and the date of first observation of disease progression or date of death (for any cause). Disease progression is determined using the iRANO criteria.

[00244] Other secondary endpoints in evaluating effectiveness are:

[00245] Objective Response Rate (ORR): defined as the proportion of patients with confirmed complete response (CR) or confirmed partial response (PR) as determined by the Neurooncology Immunotherapy Response Evaluation Criteria (iRANO) relative to the total number of patients in the analyzed sample .

[00246] Duration of response: determined for patients with the best overall CR or PR response. Duration of response is measured from when the measurement criteria first meet CR/PR (whichever is recorded first) to the first date of disease recurrence or progression (as measured by x-ray) or death from any cause.

[00247] Duration of disease control: determined for patients with the best overall SD, CR or PR response. The duration of disease control is measured from the start of treatment to the first date of recurrence or disease progression (as determined by x-ray) or death from any cause.

[00248] Quality of life and symptom control variables: The quality of life and symptom control variables are:

Five functional scales, three symptom scales, one global health assessment scale, and six one-item symptom scales using the EORTC QLQ-C30 questionnaires during the study

Four scales and seven one-item scales using the EORTC QLQ-BN20 questionnaires during the study

Clinical assessment using NANO;

Total MMSE scores during the study

Corticosteroid use at baseline, cumulative corticosteroid use during the study, and duration of no or low-dose steroid use during the progression-free period during the study

Use of bevacizumab PRN at baseline, cumulative use of bevacizumab PRN during the study, and duration of non-use of bevacizumab during the progression-free period during the study

[00249] Biomarker Investigational Variables : Another endpoint includes pharmacodynamic and prognostic biomarkers associated with clinical response, mechanism of action, and possible AEs associated with REGN2810 after treatment. Biomarker variables include:

Expression levels of PD-L1, GITR, and LAG3 immune checkpoint receptors, as well as other potential biomarkers (eg, EGFRvIII, Ki67, etc.) in tumor samples;

Number and distribution of TIL in tumor samples;

IDH1 mutation status, microsatellite instability (MSI) and mutation load in tumor samples;

Circulating biomarkers, including cytokines and angiogenic factors;

Cell subpopulations and expression levels of biomarkers of interest in PBMCs;

MGMT promoter methylation status (also used for stratification)

[00250] Other variables include serum concentration of REGN2810 (pharmacokinetic variables) and the occurrence of anti-REGN2810 antibodies.

Procedures and assessments

[00251] After a screening period of up to 28 days, patients are subjected to up to twelve 56-day treatment cycles for a total of up to 96 weeks of treatment, followed by a 24-week follow-up period. Perform efficacy evaluation, safety evaluation, PK, ADA and research biomarker analyses.

Performance evaluation procedures

[00252] MRI : MRI for tumor assessment is performed 72 hours after surgery, at the screening visit (within 28 days prior to infusion), on day 56±3 of each cycle (approximately every 8 weeks), and when PD is suspected. Patients in whom the disease is not progressing are subject to additional tumor evaluations at follow-up visits 3, 5, and 7. Note: If PD is confirmed, no additional scans at follow-up visits are required. If pre- and post-surgical MRIs were performed prior to enrollment in the study, the results of these scans should also be submitted to the study to facilitate determination of tumor volume and tumor progression.

[00253] Tumor response evaluation is performed according to iRANO; and clinical neurological assessment will be performed by NANO. Estimates according to RANO are also carried out as a subsurvey; however, the primary determination of disease progression in the case of an individual patient is carried out in accordance with iRANO.

[00254] European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and EORTC Brain Malignancy Module Questionnaire (EORTC QLQ-BN20) : The EORTC QLQ-C30 is a 30-item questionnaire that assesses health-related quality of life (HRQoL) in cancer patients using 15 scales (single or multiple items), each including possible scores ranging from 0 to 100. Of the 30 items, 24 are combined into 9 multi-item scales, representing various indicators of HRQoL: 5 scales of functionality (physical, role, emotional, cognitive and social), 3 scales of symptoms (fatigue, pain and nausea) and 1 global scale of health status. The remaining 6 one-point scales evaluate symptoms: shortness of breath, loss of appetite, sleep disturbances, constipation and diarrhea, and the subjective financial consequences of treating the disease. High scores indicate better HRQoL on the Global Health and Functionality Scales and worse HRQoL on the Symptom Scales.

[00255] EORTC QLQ-BN20 is a 20-item QoL score specific to brain neoplasia and is intended to complement the EORTC QLQ-C30 in assessing health-related quality of life. The EORTC QLQ-BN20 measures symptoms of illness, side effects of treatment, and some specific psychosocial issues relevant to patients with brain malignancy using 4 scales (assessment of uncertainty about the future, visual impairment, motor dysfunction, and communication deficits) and 7 separate items (assessment of other disease symptoms [eg headaches and seizures] and toxic effects of treatment [eg hair loss]). The range of possible scores is from 0 to 100, with high scores indicating worse HRQoL.

[00256] Mini Mental Status Scale: The Mini Mental Status Assessment (MMSE ^© ) is a short, quantitative measure of cognitive status in adults. It can be used to screen for cognitive impairment, assess the severity of cognitive impairment at a point in time, and track the dynamics of an individual's cognitive changes over time. In the present study, MMSE scores are part of the neurological examination performed in the context of disease assessment.

[00257] MMSE is performed on day 1/at baseline, at the end of each treatment cycle, and every 8 weeks during the follow-up period. The MMSE scores are the same as the disease score scheme, but must be completed before the patient is informed of the radiographic results. MMSE must be completed at the start of the next administration scheduled in the treatment regimen. During the survival follow-up period, MMSE should continue to be assessed at every second survival visit (every 8 weeks) if the patient is not yet progressing.

[00258] Overall MMSE scores have a possible range of 0 (worst) to 30 (best).

Safety assessment procedures

[00259] On Day 1 of Cycle 1 and all subsequent days of treatment, vital signs including temperature, resting blood pressure, pulse, and respiratory rate will be assessed along with body weight before infusion and approximately 15 minutes after completion of infusion. A complete physical examination and 12-lead ECG are performed at the beginning of each cycle.

Procedures for Evaluation of Investigational Tumor Biomarkers

[00260] Biomarkers of interest analyzed by immunohistochemistry (IHC) include, but are not limited to, EGFRvIII and cell proliferation biomarkers (eg, Ki67). To study the potential effect of REGN2810 in tumor biopsies, expression levels (mRNA and/or protein) of PD-L1, GITR and LAG-3, as well as markers of differentiation lines of tumor-infiltrating lymphocytes (CD4, CD8, CD25, FoxP3) are analyzed.

[00261] Tumor tissue samples can be used for isolation of tumor DNA and RNA and subsequent analyzes of putative genetic biomarkers related to investigational treatments and glioblastoma. Blood samples are collected for germline DNA isolation on day 1/baseline (pre-dose) or at any study visit if day 1/baseline collection is not available. Tumor DNA analyzes include (but are not limited to) MGMT promoter methylation status, IDH1 mutation status, microsatellite instability (MSI), and tumor mutation load (both of which can be predictive of response to REGN2810 and other immunotherapeutic agents). An analysis is made of genetic variants in tumor (somatic) DNA and germline DNA that may influence disease progression, drug response, and possible toxicity. Germline DNA is also used for comparison with tumor DNA to explore potential new genetic variants underlying malignant processes.

results

[00262] REGN2810 in combination with hfRT is safe and well tolerated by nGBM patients. Administration of REGN2810 in combination with hfRT inhibits tumor growth and/or promotes tumor regression in nGBM patients compared to standard of care. Patients with nGBM treated with REGN2810 and hfRT experienced a longer OS compared to standard of care.

Example 11: Tolerability and Antitumor Activity of REGN2810 in Non-Small Cell Lung Cancer Patients: Interim Data from a Phase 1 Study

[00263] A phase 1 dose escalation (DE) study (described in Example 7 herein) evaluated monotherapy with REGN2810 (cemiplimab) at 1 mg/kg administered intravenously (IV) over 30 minutes every 2 weeks (Q2W) , in association with non-small cell lung cancer (NSCLC). The expanded NSCLC cohort (EC 1) included patients relapsed after first-line therapy or refractory to at least first-line therapy in the setting of recurrent or metastatic disease; patients were given 200 mg cemiplimab IV over 30 minutes Q2W for up to 48 weeks. Exploratory biopsy was performed at baseline and on day 29 (and progression if possible). Tumor measurement was performed every 8 weeks according to RECIST (Regulation Criteria for Response in Solid Tumors) 1.1.

[00264] Intermediate results: The study included 21 patients with NSCLC (1 in DE; 20 in EC 1); median age was 65.0 years (range 50-82; 14 males/7 females); 81.0% had an Eastern United Cancer Group median status of 1. The majority (61.9%) had histologic evidence of adenocarcinoma at baseline. Overall, the most common treatment-related adverse events (TRAE) were asthenia, pneumonitis, and rash (each n=3, 14.3%). Each of the following grade ≥3 TRAEs occurred once: pneumonitis, diabetic ketoacidosis, and nephritis. Six of the patients in EC 1 had a partial response (PR) and 4 had stable disease (SD). The overall response rate (ORR=complete response [CR] + PR) based on the results of the centralized independent review (data transmission: August 31, 2017) was 28.6% (n=6/21). The disease control rate (ORR+SD) was 57.1% (n=12/21; of which 1 had non-CR/non-progressive disease [PD]). Overall, 9 patients (all from EC 1) experienced PD during cemiplimab treatment.

[00265] Cemiplimab was generally well tolerated and its antitumor activity was observed in NSCLC patients in this study.

Example 12 Clinical Trial of REGN2810 in First Line Treatment of Patients with Advanced PD-L1+ Non-Small Cell Lung Cancer or Metastatic PD-L1+ Non-Small Cell Lung Cancer

[00266] This study is a randomized, international, open-label Phase 3 trial of REGN2810 monotherapy versus standard of care, dual platinum chemotherapy, in patients with advanced squamous or non-squamous NSCLC or metastatic squamous or non-squamous NSCLC where tumors express PD-L1 in ≥50% of tumor cells, and where patients have not previously been subjected to systemic treatment of their disease at an advanced stage.

Research objectives

[00267] The primary objective of the study is to determine whether REGN2810 improves progression-free survival (PFS) compared to the standard of care, dual platinum chemotherapy, in patients with advanced squamous or non-squamous NSCLC or metastatic squamous or non-squamous NSCLC where tumors express PD-L1 in ≥50% of tumor cells. The key secondary objectives of the study are to compare REGN2810 with platinum-based chemotherapy in relation to:

Overall Survival (OS)

Objective Response Rates (ORR)

[00268] Other secondary research objectives are:

Duration of response (DOR) comparison for REGN2810 versus platinum chemotherapy

Assessment of the quality of life (QOL) of patients treated with REGN2810 compared with patients treated with platinum drugs, performed using the Core 30 Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) and the Quality of Life Questionnaire for lung cancer 13 (EORTC QLQ-LC13).

Evaluation of the safety and tolerability of REGN2810 versus platinum chemotherapy

Measurement of REGN2810 Serum Concentrations and Pharmacokinetic (PK) Characterization of REGN2810

[00269] Search targets include:

Evaluation of immunogenicity as measured by the REGN2810 immunogenicity score

Analysis of the correlation of the level of expression of PD-L1 at baseline and the effectiveness of the study treatment

Estimating time to new anticancer therapy

Study design

[00270] This study is a randomized, multicentre, open-label, phase 3 pivotal study of REGN2810 monotherapy versus dual platinum chemotherapy in patients with stage IIIB or stage IV squamous or non-squamous NSCLC where tumors express PD-L1 in ≥50% of tumor cells , and where patients have not previously received systemic treatment for their advanced disease.

[00271] The study consists of the following 3 periods: screening, treatment and follow-up. Patients are screened to determine their eligibility within 28 days prior to randomization. Eligible patients are randomly assigned to one of the following 2 treatment groups: REGN2810 350 mg monotherapy or standard of care chemotherapy. Randomization is stratified by histology (non-squamous versus squamous) and geographic area (EU or ROW). For patients with NSCLC who are randomly assigned to chemotherapy, one of the following regimens may be used:

Paclitaxel + cisplatin or carboplatin

gemcitabine + cisplatin or carboplatin

Pemetrexed + cisplatin or carboplatin followed by optional maintenance treatment with pemetrexed (for patients with squamous NSCLC, it is recommended not to use regimens that include pemetrexed)

[00272] Patients assigned to the REGN2810 treatment group are given 350 mg of REGN2810 as an intravenous (IV) infusion on Day 1 of each treatment cycle (every 3 weeks [Q3W]) for up to 108 weeks or until defined by Criteria for Response to Solid tumors (RECIST) 1.1 disease progression, unacceptable toxicity, death, or withdrawal of consent to participate in the study. Patients in the REGN2810 arm who experience RECIST 1.1-determined disease progression during therapy may continue treatment with REGN2810 if the patient is determined to be clinically benefiting and if the patient has not completed the 108-week treatment period. If further disease progression is confirmed (defined as an additional 10% increase in tumor mass since initial disease progression), REGN2810 administration should be discontinued and, if necessary, other anticancer therapy should be considered.

[00273] For patients assigned to chemotherapy, select one of the protocol's dual platinum chemotherapy options for up to 4-6 cycles or until RECIST 1.1-defined disease progression, unacceptable toxicity, death, or withdrawal of consent to study participation . Patients who experience disease progression during chemotherapy are offered the option of switching treatment with 350 mg REGN2810 Q3W for up to 108 weeks, provided they meet specific criteria. Patients make follow-up visits every 6 weeks for 6 months and then at 9 months and 12 months after the last dose. The duration of the study for each patient is approximately 40 months.

Study sample

[00274] Patients included in this study are male and female ≥18 years of age with diagnosed non-squamous or squamous NSCLC stage IIIB or stage IV, whose tumors express PD-L1 in ≥50% of tumor cells (as determined using diagnostic analysis ) and who have not previously received systemic treatment for their advanced disease.

[00275] Inclusion Criteria: A patient must meet the following criteria to be eligible for inclusion in the study:

1. Men and women aged ≥18 years

2. Patients with histologically or cytologically documented stage IIIB or stage IV squamous or non-squamous NSCLC who have not previously received systemic treatment for recurrent or metastatic NSCLC. Eligible patients are those who have received adjuvant or neoadjuvant dual platinum chemotherapy (following surgery and/or radiation therapy) and who develop recurrent or metastatic disease more than 6 months after completion of therapy.

3. Archival or recently obtained formalin-fixed tumor tissue from a metastatic/recurrent site that has not been previously irradiated

4. Tumor cells expressing PD-L1 in ≥50% of tumor cells as determined by IHC

5. At least 1 radiographically measurable lesion on computed tomography (CT) or magnetic resonance imaging (MRI) according to RECIST 1.1 criteria. Target lesions may be localized in a previously irradiated field if disease progression is documented (radiographically) in this focus.

6. ECOG status ≤1

7. Life expectancy of at least 3 months

8. Adequate organ and bone marrow function as defined below: a. Hemoglobin ≥9.0 g/dl b. Absolute neutrophil count ≥1.5×109/L c. Platelet count ≥100,000/mm ³ d. Glomerular filtration rate (GFR) >30 ml/min/1.73 m ² e. Total bilirubin ≤1.5 times the upper limit of normal (ULN) (with liver metastases ≤3 times the ULN), except in patients diagnosed with clinically confirmed Gilbert's syndrome f. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤3-fold ULN or ≤5-fold ULN in liver metastases g. Alkaline phosphatase ≤2.5-fold ULN (or ≤5.0-fold ULN for liver or bone metastases) h. Failure to meet High's Law criteria (ALT >3x ULN and bilirubin >2x ULN)

9. Willingness and ability to comply with clinic visits and study procedures

10. Providing signed informed consent

11. Ability to understand and complete survey-related questionnaires.

[00276] Exclusion Criteria: A patient meeting any of the following criteria will be excluded from the study: 1. Patients who never smoked were defined as having smoked ≤100 cigarettes in their lifetime. 2. Active or untreated brain metastases or spinal cord compression. Patients are eligible if central nervous system (CNS) metastases are adequately treated and patients have returned to baseline neurological status (excluding residual CNS treatment-related signs or symptoms) for at least 2 weeks prior to study entry. Patients should stop therapy with corticosteroids (immunosuppressive doses). 3. Patients with tumors positive for EGFR gene mutation, ALK gene translocation, or ROS1 fusion as tested. 4. Encephalitis, meningitis or uncontrolled seizures within a year before signing the informed consent. 5. History of interstitial lung disease (eg, idiopathic pulmonary fibrosis, organizing pneumonia) or active non-infectious pneumonitis in which immunosuppressive doses of glucocorticoids are needed to facilitate treatment. Let's say radiation pneumonitis in an irradiated field. 6. Patients with active, known or suspected autoimmune disease requiring systemic treatment in the last 2 years. Patients with vitiligo, type I diabetes mellitus, and hypothyroidism (including hypothyroidism due to autoimmune thyroiditis) who require hormone replacement therapy alone may be included. 7. Patients with a condition requiring corticosteroid therapy (>10 mg prednisone/day or equivalent) within 14 days prior to randomization. Physiological replacement doses are acceptable, even if they are >10 mg prednisone/day or equivalent, provided they are not administered for immunosuppressive purposes. Inhaled or topical steroids are acceptable, provided they are not intended to treat an autoimmune disorder. 8. Other malignancy progressing or requiring treatment, excluding non-melanoma skin cancer undergoing potentially curative therapy or carcinoma in situ of the cervix or any other tumor undergoing treatment and the patient is considered to be in complete remission for at least 2 years before enrollment in the study, and during the study does not require additional therapy. 9. Known active hepatitis B (positive) or hepatitis C (known positive) and known quantitative HCV RNA test result above the lower limit of detection for analysis. 10. History of human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome with evidence of uncontrolled active infection. Patients on highly active antiretroviral therapy with undetectable RNA levels and CD4 counts above 350 may be included. 11. Active infection requiring systemic therapy within 14 days prior to randomization. 12. Prior therapy with anti-PD-1 or anti-PD-L1 antibodies. Prior exposure to other immunomodulatory therapy or vaccine therapy, such as anti-cytotoxic T-lymphocyte antigen 4 (CTLA-4) antibodies, is acceptable, but the last dose of such antibody must be given at least 3 months prior to the first dose of study drug. 13. Treatment-related immune-mediated adverse events (AE) in response to immunomodulatory agents (including, but not limited to, anti-PD1/PD-L1 Mabs, anti-CTLA4 monoclonal antibodies, and PI3K-δ inhibitors) that did not resolve to baseline by at least 3 months prior to initiation of study therapy. Patients are excluded from treatment with REGN2810 if they develop immune-mediated AE associated with prior treatment with a PD-1/PD-L1 pathway blocker that was grade 3 or 4 in severity and/or required drug discontinuation, regardless of time of occurrence. 14. Prescription of the investigational drug or device within 30 days prior to screening or within 5 times the half-life of the investigational drug or therapy (whichever is longer). 15. Prescribing a live vaccine within 30 days of the scheduled start of study drug administration. 16 Major surgery or significant trauma within 4 weeks prior to first dose 17 Documented allergic or acute hypersensitivity reaction attributable to antibody treatment. 18. Known allergy to doxycycline or other tetracycline antibiotics. 19. Known psychiatric disorder or drug or alcohol dependence that would interfere with participation in study compliance, including current use of any illicit drug. 20. Pregnant or breastfeeding women. 21. Women of childbearing age who do not wish to use highly effective contraception before the initial dose, during the study, and for at least 6 months after the last dose. 22. Patients deprived of their liberty by judicial or administrative order will be excluded from the study.

Investigational treatment

[00277] Study drug: REGN2810 is administered at a dose of 350 mg as an IV infusion of Q3W for up to 108 weeks.

[00278] Reference drug: Standard of care chemotherapy (one of the two protocol platinum chemotherapy options, Table 13) is administered for up to 4-6 cycles or until RECIST 1.1-defined disease progression, unacceptable toxicity, death, or withdrawal of consent to participation in the study.

Table 13: Guidelines for platinum dual chemotherapy regimens

Option Chemotherapy regimen Administration frequency Supportive care one Pemetrexed 500 mg/m ² and cisplatin 75 mg/m ² IV Day 1 every 21 days for 4-6 cycles Optional, pemetrexed 500 mg/m ² IV on day 1 every 21 days 2 Pemetrexed 500 mg/m ² IV and carboplatin AUC as 5–6 mg/mL/minute IV Day 1 every 21 days for 4-6 cycles Optional, pemetrexed 500 mg/m ² IV on day 1 every 21 days 3 Paclitaxel 200 mg/m ² IV and cisplatin 75 mg/m ² IV Day 1 every 21 days for 4-6 cycles Undefined 4 Paclitaxel 200 mg/m ² IV and carboplatin AUC 5–6 mg/mL/minute IV Day 1 every 21 days for 4-6 cycles Undefined 5 Gemcitabine 1250 mg/m ² IV and cisplatin 100 mg/m ² IV Day 1 and Day 8 (gemcitabine only) every 21 days for 4-6 cycles Undefined 6 Gemcitabine 1250 mg/m ² IV and carboplatin AUC 5–6 mg/mL/minute IV Day 1 and Day 8 (gemcitabine only) every 21 days for 4-6 cycles Undefined

Study Endpoints

[00279] The primary endpoint is PFS assessed using RECIST 1.1. The key secondary endpoints in the study are OS and ORR. Other secondary endpoints include DOR and QOL, and the REGN2810 safety and tolerability score.

Procedures and evaluation

[00280] Screening procedures include obtaining informed consent; registration of medical and oncological anamnesis and concomitant medicines; registration of demographic data; obtaining tumor tissue for PD-L1 analysis; testing of tumor tissue for epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutations and fusion of the human homologue of the v-ros transforming gene of avian sarcoma virus UR2 (ROS1); radiographic assessment of the tumor; assessment of tumor mass; chest x-ray; serum pregnancy test; electrocardiography in 12 leads (ECG); a complete physical examination, including the determination of vital signs, height and body weight; Eastern United Cancer Group (ECOG) status assessment and laboratory tests. It is also possible to obtain samples for an optional genomic subassay. During treatment and follow-up, the following procedures are carried out to assess safety: physical examination; assessment of status on the ECOG scale; determination of vital signs; laboratory tests, including testing women of childbearing age for pregnancy; ECG and chest x-ray (at the discretion of the investigator) and recording of adverse events (AE) and concomitant medications. Computed tomography (CT) or magnetic resonance imaging (MRI) to evaluate the tumor is performed at various time points throughout the study. Quality of life is measured using validated patient self-administered questionnaires (EORTC QLQ-C30 and EORTC QLQ-LC13). Other evaluations include obtaining biomarker samples, REGN2810 concentration samples, and REGN2810 immunogenicity samples.

results

[00281] Treatment with REGN2810 is expected to result in improved progression-free survival and overall survival compared to treatment with chemotherapy in patients with advanced non-small cell lung cancer whose tumors express PD-L1 in ≥50% of tumor tissue.

Example 13 Standard and high dose combination of REGN2810 (cemiplimab) and ipilimumab (anti-CTLA-4 antibody) in second-line treatment of patients with metastatic non-small cell lung cancer with tumors expressing PD-L1 in <50%

[00282] This example describes a clinical study of standard and high dose combinations of REGN2810 (cemiplimab, anti-PD-1 antibody) and ipilimumab (anti-CTLA-4 antibody) in second-line treatment in patients with metastatic non-small cell lung cancer with tumors expressing PD- L1 in <50%.

[00283] The main objective of the study is to compare the objective response rate (ORR) for combination treatment of REGN2810 at high dose ("HDREGN2810") and REGN2810 at standard dose ("SDREGN2810/ipi") and ipilimumab and for REGN2810 at standard dose ("SDREGN2810" ) in second-line treatment in patients with advanced squamous or non-squamous non-small cell lung cancer (NSCLC) or metastatic squamous or non-squamous non-small cell lung cancer (NSCLC) in patients whose tumors express programmed cell death ligand 1 (PD-L1) in <50 % tumor cells.

[00284] The secondary objectives of the study are: (1) Comparison of overall survival (OS) for combined treatment of SDREGN2810, HDREGN2810 and SDREGN2810/ipi in second-line treatment in patients with advanced squamous or non-squamous NSCLC whose tumors express PD-L1 in <50% tumor cells. (2) Comparison of progression-free survival (PFS) of HDREGN2810 and SDREGN2810/ipi with SDREGN2810 in second-line treatment in patients with advanced squamous or non-squamous NSCLC whose tumors express PD-L1 in <50% of tumor cells. (3) Evaluation of the safety and tolerability of HDREGN2810 and SDREGN2810/ipi compared to SDREGN2810 therapy. (4) Evaluation of OS after 12 and 18 months of HDREGN2810 and SDREGN2810/ipi therapy compared with SDREGN2810 therapy in second-line treatment in patients with advanced squamous or non-squamous NSCLC whose tumors express PD-L1 in <50% of tumor cells. (5) Assessment of quality of life (QOL) in patients with advanced squamous or non-squamous NSCLC treated with HDREGN2810 and SDREGN2810/ipi compared with SDREGN2810 therapy (6) Assessment of immunogenicity as measured by anti-drug antibodies (ADA) against REGN2810 . (7) Characterization of the pharmacokinetics (PK) of REGN2810 when administered in combination with ipilimumab or as HDREGN2810.

Study design

[00285] This study is a clinical study of HDREGN2810 and SDREGN2810/ipi versus SDREGN2810 therapy in second-line treatment of patients with advanced squamous or non-squamous NSCLC or metastatic squamous or non-squamous NSCLC with tumors expressing PD-L1 <50%. The study will consist of the following 3 periods: screening, treatment and follow-up. Patients will be screened to determine their eligibility for the study within 28 days prior to randomization. Eligible patients will be randomly assigned in a 1:1:1 ratio to use one of the following treatment regimens:

Treatment Group A: 350 mg REGN2810 every 3 weeks (Q3W) for 108 weeks (hereinafter referred to as "SDREGN2810")

Treatment Group B: 350 mg REGN2810 Q3W for 108 weeks and 50 mg ipilimumab every 6 weeks (Q6W) for a total of up to 4 doses (hereinafter referred to as "SDREGN2810/ipi")

Treatment Group C: 1050 mg REGN2810 Q3W for 108 weeks (hereinafter referred to as "HDREGN2810")

[00286] Upon randomization, patients will be stratified by histology (squamous and non-squamous) and PD-L1 expression level (<1% and 1%-<50%). Patients will be subjected to their prescribed treatment during the treatment period (as above). Treatment may be discontinued prematurely due to disease progression, unacceptable toxicity, withdrawal of consent to study participation, death, initiation of other anticancer therapy, or in specific cases, confirmed complete response (CR), partial response (PR) or stable disease (SD). Patients experiencing RECIST 1.1-defined progressive disease may continue investigational treatment during therapy if the investigator determines that the patient will benefit clinically and if the patient has not completed the 108-week treatment period. If further disease progression is confirmed (defined as an additional 10% increase in tumor mass since initial disease progression), REGN2810 (and ipilimumab, if necessary) should be discontinued and other anticancer therapy considered, if necessary. Patients will be followed up after study treatment is discontinued. Each patient will have a first follow-up visit within 14 to 30 days (±7 days) after the last dose of study drug if treatment is stopped early due to disease progression, toxicity, or other reason. Otherwise, each patient will have a first follow-up visit within 14 to 30 days (±7 days) after the last cycle visit. Follow-up visits 2-7 will be performed within 28 days (±7 days) of the previous visit. Survival data will then be collected via phone call or in the doctor's office during a visit every 3 months until death, failure to attend follow-up, or withdrawal of consent to participate in the study.

Study sample

[00287] Patients in this study will include males and females ≥18 years of age who are diagnosed with advanced non-squamous or squamous NSCLC or metastatic non-squamous or squamous NSCLC who have received only 1 previous line of treatment for late-stage NSCLC or metastatic NSCLC, and whose tumors express PD-L1 in <50%.

[00288] Inclusion Criteria : 1. Men and women ≥18 years of age; 2. Patients with histologically or cytologically documented stage IIIb squamous or non-squamous NSCLC who are not candidates for treatment with definitive combination chemoradiotherapy, or patients with stage IV disease if previously treated with systemic advanced NSCLC or metastatic NSCLC, and who subjected to 1 previous line of NSCLC treatment at a late stage; 3. Availability of archival or formalin-fixed, paraffin-embedded biopsy of tumor tissue obtained during the study. Biopsy recommendations: a. Archival or recent biopsies are acceptable; b. If an archival biopsy is used, it must be less than 5 months old; c. The biopsy must be obtained from a site of metastasis or recurrence that has not previously been irradiated. Exception: The primary tumor is still in place and other sites of metastasis are not available (brain) or cannot be used (bone) or the biopsy would be risky for the patient. 4. Expression of PD-L1 in <50% of tumor cells, determined by the analysis of IHC PD-L1 22C3 pharmDx, carried out in the central laboratory; 5. At least 1 radiographically measurable lesion on computed tomography (CT) according to RECIST 1.1 criteria. Target foci may be in a previously irradiated field if there is a documented (radiographic) progression of the disease in that foci; 6. ECOG status ≤1; 7. Life expectancy of at least 3 months.

[00289] Exclusion Criteria : 1. Patients who have never smoked are defined as having smoked ≤100 cigarettes in their lifetime; 2. Active or untreated brain metastases or spinal cord compression. Patients are eligible if central nervous system (CNS) metastases are adequately treated and patients have returned to baseline neurological status (excluding residual CNS treatment-related signs or symptoms) for at least 2 weeks prior to study entry. Patients should stop therapy with corticosteroids (immunosuppressive doses) (see details of the temporary steroid discontinuation regimen in exclusion criteria 7). 3. Patients with tumors positive for EGFR gene mutation, ALK gene translocation, or ROS1 fusion as tested. All patients will be subjected to tumor analysis for EGFR mutation, ALK rearrangement, and ROS1 fusion. 4. Encephalitis, meningitis or uncontrolled seizures within a year before signing the informed consent. 5. History of interstitial lung disease (eg, idiopathic pulmonary fibrosis, organizing pneumonia) or active non-infectious pneumonitis requiring immunosuppressive doses of glucocorticoids to facilitate treatment, or pneumonitis in the last 5 years. A history of radiation pneumonitis in an irradiated field is acceptable provided that the pneumonitis resolved ≥6 months prior to study entry. 6. Current or recent evidence of significant autoimmune disease requiring systemic immunosuppressive treatment, in which a risk of immune-mediated treatment-related adverse events (irTEAE) may be suspected. The following diseases are not exclusive: vitiligo, resolved childhood asthma, residual hypothyroidism, in which only hormone replacement therapy is required, or psoriasis, in which systemic treatment is not required. 7. Patients with a condition requiring corticosteroid therapy (>10 mg prednisone/day or equivalent) within 14 days prior to randomization. Physiological replacement doses are acceptable, even if they are >10 mg prednisone/day or equivalent, provided they are not administered for immunosuppressive purposes. Inhaled or topical steroids are acceptable, provided they are not intended to treat an autoimmune disorder.

Investigational treatment

REGN2810 350 mg intravenous (IV) infusion of Q3W for 108 weeks ("SDREGN2810")

REGN2810 350 mg IV infusion of Q3W for 108 weeks, in combination with ipilimumab IV 50 mg Q6W for up to 4 doses ("SDREGN2810/ipi")

REGN2810 given at 1050 mg as an IV infusion of Q3W for 108 weeks ("HDREGN2810")

Study Endpoints

[00290] The primary endpoint is ORR, defined as the proportion of patients who achieved CR or PR based on RECIST 1.1 as assessed by a masked independent review committee (IRC).

[00291] The secondary endpoints in the study are: (1) Overall survival (OS), defined as time from randomization to date of death. An undeceased patient will be evaluated by the last known date that the patient was alive. (2) Progression-free survival (PFS) is defined as the time from randomization to the date of first documented tumor progression as determined by RECIST 1.1 masked IRC score, or to the date of death from any cause. (3) Overall survival at 12 months and 18 months and at the end of treatment. (4) Safety and tolerability of SDREGN2810, HDREGN2810 and SDREGN2810/ipi combination treatment as measured by the incidence of adverse events occurring during treatment, dose-limiting toxicity, serious adverse events, death, and laboratory abnormalities. (5) Quality of life as measured by the European Organization for Research and Treatment of Cancer Core 30 Quality of Life Questionnaire (EORTC QLQ-C30) and Lung Cancer Quality of Life Questionnaire 13 (EORTC QLQ-LC13). (6) Characterization of PK REGN2810 when administered in combination with ipilimumab or HDREGN2810. (7) Immunogenicity assay as measured by ADA titers against REGN2810. (8) Investigator's assessment of hair pigmentation. (9) Tumor mutation load as assessed using the Foundation Medicine "FoundationOne®" panel. (10) Estimation of tumor volume. (11) Proportion of ICOS+ CD4 T cells and other markers of T cell activation.

Procedures and evaluation

[00292] The procedures to be followed in screening will include obtaining informed consent; assessment of inclusion/exclusion criteria; registration of medical and oncological anamnesis and concomitant medicines; registration of demographic data; obtaining and testing tumor tissue samples for analysis of PD-L1 and epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutations and receptor tyrosine kinase C-ros (ROS1) oncogene fusion; radiographic assessment of the tumor; assessment of tumor mass; chest x-ray; serum pregnancy test; electrocardiography in 12 leads; registration of adverse events (AE); physical examination, including the determination of vital signs, height and body weight; Eastern United Cancer Group (ECOG) status assessment and laboratory tests. It is also possible to obtain samples for an optional genomic subassay. During the treatment period, the following procedures will be performed to assess efficacy and safety: QOL determination using validated questionnaires filled out by the patient; physical examination; assessment of status on the ECOG scale; determination of vital signs; laboratory tests, including testing women of childbearing age for pregnancy; registration of adverse events (AE) and concomitant medicinal products. Computed tomography for radiographic assessment of tumor mass and assessment of tumor mass using RECIST 1.1 criteria will be performed at certain time points throughout the study. Other evaluations will include the investigator's assessment of hair repigmentation, REGN2810 concentration measurement, ADA vs. REGN2810 analysis, and biomarker analysis. Biomarker analysis will include the use of tumor tissue samples to validate additional PD-L1 assays. Survival data will then be collected via phone call or in the doctor's office during a visit every 3 months until death, failure to attend follow-up, or withdrawal of consent to participate in the study.

results

[00293] SDREGN2810/ipi or HDREGN2810 is expected to result in a higher response rate than SDREGN2810 in patients whose tumors express PD-L1 in <50% of tumor cells. Considering an overall response rate of 10% in patients with 1-<50% PD-L1 expression treated with SDREGN2810, it is expected that with HDREGN2810 or SDREGN2810/ipi an ORR of 30%, an absolute increase of 20% compared to SDREGN2810, can be achieved.

Example 14: Clinical study of combinations of REGN2810 (anti-PD-1 antibodies), ipilimumab (anti-CTLA4 antibodies) and dual platinum chemotherapy in first-line treatment in patients with advanced non-small cell lung cancer or metastatic non-small cell lung cancer whose tumors express PD- L1 in <50%

[00294] This example describes a clinical trial of combinations of REGN2810 (anti-PD-1 antibodies), ipilimumab (anti-CTLA-4 antibodies), and dual platinum chemotherapy in first-line treatment in patients with advanced non-small cell lung cancer or metastatic non-small cell lung cancer. with tumors expressing PD-L1 in <50%, which have not previously been subjected to systemic treatment for their disease at an advanced stage.

[00295] The primary objective of the study is to compare progression-free survival (PFS) for combination treatment with REGN2810 and 4-6 cycles of standard of care, dual platinum chemotherapy (REGN2810/chemo-f) and combination treatment of REGN2810 and only 2 cycles of standard of care, dual chemotherapy. chemotherapy with platinum drugs, and ipilimumab (REGN2810/chemo-l/ipi) with standard of care, dual platinum chemotherapy, in first-line treatment in patients with advanced squamous or non-squamous non-small cell lung cancer (NSCLC) in a subgroup of patients whose tumors express programmed cell death ligand 1 (PD-L1) in 1-<50% of tumor cells, and in the total sample of patients studied whose tumors express PD-L1 in <50% of tumor cells.

[00296] Secondary objectives include: (1) Comparison of overall survival (OS) for REGN2810/chemo-f and REGN2810/chemo-l/ipi with standard of care, dual platinum chemotherapy, in first-line treatment in patients with squamous or non-squamous NSCLC at a late stage in a subgroup of patients whose tumors express PD-L1 in 1-<50% of tumor cells, and in the general population of studied patients whose tumors express PD-L1 in <50% of tumor cells. (2) Comparison of objective response rates (ORR) for REGN2810/chemo-f and REGN2810/chemo-l/ipi versus standard of care, dual platinum chemotherapy, in first-line treatment in patients with advanced squamous or non-squamous NSCLC at an advanced stage in subgroup of patients whose tumors express PD-L1 in 1-<50% of tumor cells, and in the total sample of patients studied, whose tumors express PD-L1 in <50% of tumor cells. (3) Evaluation of the safety and tolerability of REGN2810 and 4-6 cycles of dual chemotherapy with platinum and REGN2810 and ipilimumab. (4) Characterization of the pharmacokinetics of REGN2810 and 4-6 cycles of dual chemotherapy with platinum and REGN2810 and ipilimumab. (5) Comparison of OS at 12 and 18 months for REGN2810/chemo-f or REGN2810/chemo-l/ipi versus the standard of care, dual platinum chemotherapy, in first-line treatment in patients with advanced squamous or non-squamous NSCLC at an advanced stage in subgroup of patients whose tumors express PD-L1 in 1-<50% of tumor cells, and in the total sample of patients studied, whose tumors express PD-L1 in <50% of tumor cells. (6) Immunogenicity analysis by measuring anti-drug antibodies against REGN2810.

Study sample

[00297] The target population includes men and women ≥18 years of age with <50% PD-L1+ tumor cells, stage IIIB or stage IV squamous or non-squamous NSCLC, previously untreated for their advanced disease.

[00298] Inclusion Criteria :

1) Men and women aged ≥18 years

2) Patients with histologically or cytologically documented stage IIIB or stage IV squamous or non-squamous NSCLC who have not previously received systemic treatment for recurrent or metastatic NSCLC

3) Eligible patients who have been treated with adjuvant or neoadjuvant dual platinum chemotherapy (following surgery and/or radiotherapy) and who develop recurrent or metastatic disease more than 6 months after completion of therapy

4) Eligible patients are those who have been subjected to adjuvant or neoadjuvant PD-1 or PD-L1 blocking and who develop recurrent or metastatic disease more than 12 months after completion of therapy

5) Archival or recent formalin-fixed tumor tissue from a metastatic/recurrent site that has not been previously irradiated

6) Tumor cells expressing PD-L1 in <50% of tumor cells as determined by central laboratory IHC

7) At least 1 radiographically measurable lesion on computed tomography (CT) or magnetic resonance imaging (MRI) according to RECIST 1.1 criteria. Target lesions may be localized in a previously irradiated field if disease progression is documented (radiographically) in this focus.

8) ECOG status ≤1

9) Life expectancy of at least 3 months

10) Adequate organ and bone marrow function as defined below:

11) Hemoglobin ≥10.0 g/dl

12) Absolute neutrophil count ≥1.5×10 ⁹ /l

13) Platelet count ^≥100000 /mm3

14) Glomerular filtration rate (GFR) >30 ml/min/ ^1.73m2

15) Total bilirubin ≤1.5 times the upper limit of normal (ULN) (with liver metastases ≤3 times the ULN), except in patients diagnosed with clinically confirmed Gilbert's syndrome

16) Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤3x ULN or ≤5x ULN in liver metastases

17) Alkaline phosphatase ≤2.5-fold ULN (or ≤5.0-fold ULN for liver or bone metastases)

18) Failure to meet High's Law criteria (ALT >3x ULN and bilirubin >2x ULN)

19) Willingness and ability to comply with clinic visits and study procedures

20) Providing signed informed consent

21) Ability to understand and complete survey-related questionnaires

[00299] Exclusion Criteria : 1. Patients who never smoked were defined as having smoked ≤100 cigarettes in their lifetime; 2. Active or untreated brain metastases or spinal cord compression. Patients are eligible if central nervous system (CNS) metastases are adequately treated and patients have returned to baseline neurological status (excluding residual CNS treatment-related signs or symptoms) for at least 2 weeks prior to study entry. Patients should stop therapy with corticosteroids (immunosuppressive doses) (see details of the temporary steroid discontinuation regimen in exclusion criteria 7). 3. Patients with tumors positive for EGFR gene mutation, ALK gene translocation, or ROS1 fusion as tested. All patients will be subjected to tumor analysis for EGFR mutation, ALK rearrangement, and ROS1 fusion. 4. Encephalitis, meningitis or uncontrolled seizures within a year before signing the informed consent. 5. History of interstitial lung disease (eg, idiopathic pulmonary fibrosis, organizing pneumonia) or active non-infectious pneumonitis requiring immunosuppressive doses of glucocorticoids to facilitate treatment, or pneumonitis in the last 5 years. A history of radiation pneumonitis in an irradiated field is acceptable provided that the pneumonitis resolved ≥6 months prior to study entry. 6. Current or recent evidence of significant autoimmune disease requiring systemic immunosuppressive treatment, in which a risk of immune-mediated treatment-related adverse events (irTEAE) may be suspected. The following diseases are not exclusive: vitiligo, resolved childhood asthma, residual hypothyroidism, in which only hormone replacement therapy is required, or psoriasis, in which systemic treatment is not required. 7. Patients with a condition requiring corticosteroid therapy (>10 mg prednisone/day or equivalent) within 14 days prior to randomization. Physiological replacement doses are acceptable, even if they are >10 mg prednisone/day or equivalent, provided they are not administered for immunosuppressive purposes. Inhaled or topical steroids are acceptable, provided they are not intended to treat an autoimmune disorder.

Study design

[00300] This clinical trial is a study of REGN2810/chemo-f versus REGN2810/chemo-l/ipi and the standard of care, dual platinum chemotherapy, in first-line treatment in patients with stage IIIB or stage IV squamous or non-squamous NSCLC, tumor who express PD-L1 in <50% of tumor cells, and who have not previously been subjected to systemic treatment for their disease at an advanced stage. For PD-L1 analysis using a validated PD-L1 assay, tumor tissue (block of tumor tissue or at least 12 unstained sections) will be obtained.

[00301] Patients with advanced NSCLC previously untreated are randomly assigned in a 1:1:1 ratio to one of the following treatment groups:

[00302] Treatment Group A: Standard of care, dual platinum chemotherapy every 3 weeks (Q3W) for 4-6 cycles (followed by optional maintenance treatment with pemetrexed in patients initially prescribed a regimen including pemetrexed)

[00303] Treatment Group B: 350 mg REGN2810 Q3W for 108 weeks with the standard of care, dual platinum chemotherapy, for 4-6 cycles (hereinafter referred to as "REGN2810/chemo-f")

[00304] Treatment Group C: 350 mg REGN2810 Q3W for 108 weeks with standard of care, dual platinum chemotherapy for 2 cycles and 50 mg ipilimumab every 6 weeks (Q6W) for up to 4 doses (hereinafter referred to as "REGN2810/chemo-l/ipi")

[00305] Randomization is stratified by histology (non-squamous and squamous) and PD-L1 expression levels (<1% versus 1-24% and 25-<50%).

[00306] Patients will be subjected to prescribed treatment during the treatment period (as above). Treatment may be discontinued prematurely due to disease progression, unacceptable toxicity, withdrawal of consent to study participation, death, initiation of other anticancer treatment, as determined by the Solid Tumor Response Evaluation Criteria version 1.1 (RECIST 1.1) , in some cases a confirmed complete response (CR) or partial response (PR).

Investigational treatment

[00307] Treatment group (A) : Standard of care, dual platinum chemotherapy given IV Q3W for 4-6 cycles (followed by optional maintenance treatment with pemetrexed in patients initially prescribed a regimen including pemetrexed)

[00308] Treatment group (B) : REGN2810 administered at a dose of 350 mg as an intravenous (IV) infusion of Q3W for 108 weeks, in combination with the standard of care, dual platinum chemotherapy administered by Q3W IV for 4-6 cycles

[00309] Treatment group (C) : REGN2810 administered at a dose of 350 mg as an IV infusion of Q3W for 108 weeks, in combination with standard of care, dual platinum chemotherapy administered by Q3W IV for 2 cycles, and ipilimumab administered IV for approximately 90 minutes at a dose of 50 mg Q6W up to 4 doses

[00310] 4-6 cycles of the standard of care, dual platinum chemotherapy, is administered according to one of the following treatment regimens:

[00311] (i) Paclitaxel+Cisplatin: Participants will receive paclitaxel 200 mg/m ² IV followed by cisplatin 75 mg/m ² IV on day 1 every 21 days for 4-6 cycles or until documented disease progression . (ii) Paclitaxel+Carboplatin: Participants will receive paclitaxel 200 mg/ ^m2 IV, then carboplatin AUC at 5 or 6 mg/mL/min IV on Day 1 every 21 days for 4-6 cycles or up to documented disease progression. (iii) Gemcitabine+Cisplatin: Participants will receive 1250 mg/m ² gemcitabine given IV on days 1 and 8 of each 21 day cycle and 75 mg/m ² cisplatin given IV on day 1 every 21 days for 4- 6 cycles or until disease progression. (iv) Gemcitabine+Carboplatin: Participants will receive 1250 mg/m ² gemcitabine given IV on days 1 and 8 of each 21-day cycle and carboplatin AUC at 5 or 6 mg/mL/min given IV on day 1 each 21 days for 4-6 cycles or until disease progression. (v) Pemetrexed + Cisplatin ( only for non-squamous cell carcinoma based on histological analysis ): Participants will be treated with 500 mg/m ² pemetrexed IV followed by 75 mg/m ² cisplatin IV on day 1 every 21 days for 4-6 cycles, followed by an optional maintenance dose of pemetrexed 500 mg/m ² for the remainder of the study or until documented disease progression. (vi) Pemetrexed+Carboplatin ( only for non-squamous cell carcinoma as determined by histology ): Participants will be treated with 500 mg/m ² pemetrexed administered IV followed by carboplatin AUC at 5 or 6 mg/mL/min IV on day 1 every 21 days for 4-6 cycles, then an optional maintenance dose of pemetrexed 500 mg/m ² for the remainder of the study or until documented disease progression.

Procedures and assessments

[00312] The procedures to be followed in screening will include obtaining informed consent; assessment of inclusion/exclusion criteria; registration of medical and oncological anamnesis and concomitant medicines; registration of demographic data; obtaining and testing tumor tissue samples for analysis of PD-L1 and epidermal growth factor receptor and anaplastic lymphoma kinase mutations and C-ros receptor tyrosine kinase oncogene fusion; radiographic assessment of the tumor; assessment of tumor mass; chest x-ray; serum pregnancy test; electrocardiography in 12 leads; registration of adverse events (AE); physical examination, including the determination of vital signs, height and body weight; Eastern United Cancer Group (ECOG) status assessment and laboratory tests. It is also possible to obtain samples for an optional genomic subassay.

[00313] During the treatment period, the following procedures are carried out to evaluate efficacy and safety: QOL determination using validated questionnaires filled out by the patient, physical examination, assessment of status on the ECOG scale; determination of vital signs; laboratory tests, including testing women of childbearing age for pregnancy; registration of adverse events (AE) and concomitant medicinal products. Computed tomography or magnetic resonance imaging (or positron emission tomography) for radiographic assessment of tumor mass and assessment of tumor mass using RECIST 1.1 criteria are performed at certain time points throughout the study.

[00314] Survival data will be collected by phone call or in the doctor's office during a visit every 3 months until death, failure to appear for follow-up, or withdrawal of consent to participate in the study.

results

[00315] The R2810 combination regimen is expected to increase median PFS by 4 months (increase from 6 months for the standard of care, dual platinum chemotherapy to 10 months for any of the R2810 combination regimens) in patients with tumors expressing PD-L1 in 1-<50%, and in the total study sample. REGN2810 with 4-6 cycles of platinum dual chemotherapy or REGN2810 or REGN2810 with ipilimumab will prolong OS and improve ORR compared to platinum dual chemotherapy.

Example 15: Clinical study of combinations of REGN2810 (anti-PD-1 antibodies), dual platinum chemotherapy and ipilimumab (anti-CTLA-4 antibodies) versus pembrolizumab monotherapy in first-line treatment in patients with advanced non-small cell lung cancer or metastatic non-small cell cancer lungs whose tumors express PD-L1 in ≥50%

[00316] The example describes a clinical study of combinations of REGN2810 monotherapy, platinum dual chemotherapy, and ipilimumab (given in up to 4 doses) versus pembrolizumab monotherapy in patients with advanced squamous or non-squamous NSCLC or metastatic squamous or non-squamous NSCLC whose tumors are express PD-L1 in ≥50% of tumor cells, and who have not previously been subjected to systemic treatment for their disease at an advanced stage.

[00317] The primary objective of the study is to compare progression-free survival (PFS) with combination treatment of REGN2810 (cemiplimab) and ipilimumab (hereinafter referred to as REGN2810/ipi) and combination treatment of REGN2810 with only 2 cycles of dual chemotherapy with platinum drugs and ipilimumab (hereinafter herein referred to as "REGN2810/chemo/ipi") with the standard of care, pembrolizumab monotherapy, in first-line treatment in patients with advanced squamous or non-squamous non-small cell lung cancer (NSCLC) whose tumors express programmed cell death ligand 1 (PD -L1) in ≥50% of tumor cells. Additional objectives include further characterization of overall survival, tumor responses, patient-reported outcomes, safety, and pharmacokinetics (PK).

Study sample

[00318] The target population includes men and women ≥18 years of age with ≥50% PD-L1+ tumor cells, stage IIIB or stage IV squamous or non-squamous NSCLC who have not previously been treated for their advanced disease.

[00319] Inclusion Criteria :

1) Men and women aged ≥18 years

2) Patients with histologically or cytologically documented stage IIIB or stage IV squamous or non-squamous NSCLC who have not previously received systemic treatment for recurrent or metastatic NSCLC

3) Eligible patients who have been treated with adjuvant or neoadjuvant dual platinum chemotherapy (following surgery and/or radiotherapy) and who develop recurrent or metastatic disease more than 6 months after completion of therapy

4) Eligible patients are those who have been subjected to adjuvant or neoadjuvant PD-1 or PD-L1 blocking and who develop recurrent or metastatic disease more than 12 months after completion of therapy

5) Archival or recent formalin-fixed tumor tissue from a metastatic/recurrent site that has not been previously irradiated

6) Tumor cells expressing PD-L1 in <50% of tumor cells as determined by central laboratory IHC

7) At least 1 radiographically measurable lesion on computed tomography (CT) or magnetic resonance imaging (MRI) according to RECIST 1.1 criteria. Target lesions may be localized in a previously irradiated field if disease progression is documented (radiographically) in this focus.

8) ECOG status ≤1

9) Life expectancy of at least 3 months

10) Adequate organ and bone marrow function as defined below:

11) Hemoglobin ≥8.0 g/dl

12) Absolute neutrophil count ≥1.0×10 ⁹ /l

13) Platelet count ^≥75000 /mm3

14) Glomerular filtration rate (GFR) >30 ml/min/ ^1.73m2

15) Total bilirubin ≤1.5 times the upper limit of normal (ULN) (with liver metastases ≤3 times the ULN), except in patients diagnosed with clinically confirmed Gilbert's syndrome

16) Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤3x ULN or ≤5x ULN in liver metastases

17) Alkaline phosphatase ≤2.5-fold ULN (or ≤5.0-fold ULN for liver or bone metastases)

18) Failure to meet High's Law criteria (ALT >3x ULN and bilirubin >2x ULN)

19) Willingness and ability to comply with clinic visits and study procedures

20) Providing signed informed consent

21) Ability to understand and complete survey-related questionnaires

[00320] Exclusion Criteria : 1. Patients who never smoked were defined as having smoked ≤100 cigarettes in their lifetime; 2. Active or untreated brain metastases or spinal cord compression. Patients are eligible if central nervous system (CNS) metastases are adequately treated and patients have returned to baseline neurological status (excluding residual CNS treatment-related signs or symptoms) for at least 2 weeks prior to study entry. Patients should stop therapy with corticosteroids (immunosuppressive doses) (see details of the temporary steroid discontinuation regimen in exclusion criteria 7). 3. Patients with tumors positive for EGFR gene mutation, ALK gene translocation, or ROS1 fusion as tested. All patients will be subjected to tumor analysis for EGFR mutation, ALK rearrangement, and ROS1 fusion. 4. Encephalitis, meningitis or uncontrolled seizures within a year before signing the informed consent. 5. History of interstitial lung disease (eg, idiopathic pulmonary fibrosis, organizing pneumonia) or active non-infectious pneumonitis requiring immunosuppressive doses of glucocorticoids to facilitate treatment, or pneumonitis in the last 5 years. A history of radiation pneumonitis in an irradiated field is acceptable provided that the pneumonitis resolved ≥6 months prior to study entry. 6. Current or recent evidence of significant autoimmune disease requiring systemic immunosuppressive treatment, in which a risk of immune-mediated treatment-related adverse events (irTEAE) may be suspected. The following diseases are not exclusive: vitiligo, resolved childhood asthma, residual hypothyroidism, in which only hormone replacement therapy is required, or psoriasis, in which systemic treatment is not required. 7. Patients with a condition requiring corticosteroid therapy (>10 mg prednisone/day or equivalent) within 14 days prior to randomization. Physiological replacement doses are acceptable, even if they are >10 mg prednisone/day or equivalent, provided they are not administered for immunosuppressive purposes. Inhaled or topical steroids are acceptable, provided they are not intended to treat an autoimmune disorder.

Study Design

[00321] This clinical trial is a study of the efficacy and safety of REGN2810/ipi versus REGN2810/chemo/ipi and pembrolizumab monotherapy in patients with stage IIIB or stage IV squamous or non-squamous NSCLC whose tumors express PD-L1 in ≥50% of tumor cells and who have not previously received systemic treatment for their advanced disease.

[00322] The study consists of the following 3 periods: screening, treatment and follow-up. Patients are screened to determine their eligibility within 28 days prior to randomization. Eligible patients are randomly assigned in a 1:1:1 ratio to one of the following treatment groups:

Treatment group A : pembrolizumab monotherapy 200 mg every 3 weeks (Q3W) for 108 weeks

Treatment group B : 350 mg REGN2810 Q3W for 108 weeks and 50 mg ipilimumab every 6 weeks (Q6W) for up to 4 doses

Treatment Group C : 350 mg REGN2810 Q3W for 108 weeks, Q3W platinum dual chemotherapy for 2 cycles, and 50 mg ipilimumab every 6 weeks (Q6W) for up to 4 doses

[00323] Patients are subjected to their prescribed treatment for a 108-week treatment period. Treatment may be discontinued prematurely due to disease progression, unacceptable toxicity, withdrawal of consent, death, initiation of other anticancer treatment, as determined by the Solid Tumor Response Evaluation Criteria version 1.1 (RECIST 1.1) , in some cases a confirmed complete response (CR) or partial response (PR). Patients who experience RECIST 1.1-determined disease progression during therapy may continue treatment if the Investigator believes that the patient will benefit clinically and if the patient has not completed the 108-week treatment period. If further disease progression is confirmed (defined as an additional 10% increase in tumor mass since initial disease progression), treatment should be discontinued and, if necessary, other anticancer therapy should be considered. A similar treatment approach after the first signs of disease progression can be offered to patients in treatment group A treated with pembrolizumab.

Investigational treatment

[00324] Treatment Group A : Pembrolizumab 200 mg IV infusion Q3W for 108 weeks

[00325] Treatment Group B : REGN2810 given at 350 mg as an intravenous (IV) infusion of Q3W for 108 weeks, in combination with ipilimumab given IV over approximately 90 minutes at 50 mg of Q6W for up to 4 doses.

[00326] Treatment Group C : REGN2810 given at 350 mg as an IV infusion of Q3W for 108 weeks, in combination with dual platinum chemotherapy given IV with Q3W for 2 cycles and ipilimumab given IV over approximately 90 minutes at a dose of 50 mg Q6W in up to 4 doses

Procedures and evaluation

[00327] The procedures to be followed in screening will include obtaining informed consent; assessment of inclusion/exclusion criteria; registration of medical and oncological anamnesis and concomitant medicines; registration of demographic data; obtaining and testing tumor tissue samples for analysis of PD-L1 and epidermal growth factor receptor and anaplastic lymphoma kinase mutations and C-ros receptor tyrosine kinase oncogene fusion; baseline radiographic assessment of the tumor and assessment of tumor mass; chest x-ray; serum pregnancy test; electrocardiography in 12 leads; a complete physical examination, including the determination of vital signs, height and body weight; assessment of the status on the scale of the Eastern United Oncology Group (ECOG); registration of adverse events (AE) and laboratory tests. It is also possible to obtain samples for an optional genomic subassay.

[00328] During the treatment period, the following procedures are performed to assess efficacy and safety: QOL determination using validated questionnaires filled out by the patient, physical examination, assessment of status on the ECOG scale; determination of vital signs; laboratory tests, including testing women of childbearing age for pregnancy; registration of AE and concomitant medicinal products. Computed tomography or magnetic resonance imaging (or positron emission tomography) for radiographic assessment of tumor mass and assessment of tumor mass using RECIST 1.1 criteria are performed at certain time points throughout the study.

[00329] Survival data is collected by phone call or in the doctor's office during a visit every 3 months until death, failure to appear for follow-up, or withdrawal of consent to participate in the study.

results

[00330] Any combination of REGN2810 is expected to prolong PFS by 1-5 months compared to pembrolizumab alone. REGN2810 in combination with chemotherapy and/or anti-CTLA-4 antibody will prolong OS and improve ORR compared to pembrolizumab alone.

[00331] The scope of the present invention is not limited to the specific embodiments presented in the present description. In fact, various modifications of the invention in addition to those presented herein will be apparent to those skilled in the art from the foregoing description and accompanying drawings. Such modifications are intended to be included within the scope of the claims.

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<---

Claims (35)

1. A method for the treatment of lung cancer, including: (a) selecting a patient with non-small cell lung cancer where the patient's tumor tissue expresses PD-L1 in ≥50% of the tumor cells and the patient is not tested positive for epidermal growth factor receptor (EGFR) mutations, anaplastic lymphoma kinase (ALK) translocations and/or ROS1 mergers; and (b) administering to a patient one or more doses of a therapeutically effective amount of an antibody, or antigen-binding fragment thereof, that specifically binds to programmed cell death 1 (PD-1) protein, and thereby treating lung cancer in the patient, where the antibody or antigen-binding fragment contains three heavy chain variable region (HCVR) complementarity determining regions (HCDR1, HCDR2 and HCDR3) and three light chain variable region (LCVR) complementarity determining light chain regions (LCDR1, LCDR2 and LCDR3), where HCDR1 contains the amino acid sequence of SEQ ID NO: 3; HCDR2 contains the amino acid sequence of SEQ ID NO: 4; HCDR3 contains the amino acid sequence of SEQ ID NO: 5; LCDR1 contains the amino acid sequence of SEQ ID NO: 6; LCDR2 contains the amino acid sequence of SEQ ID NO: 7; and LCDR3 contains the amino acid sequence of SEQ ID NO: 8. 2. The method of claim 1 wherein the patient has not previously received systemic treatment for lung cancer. 3. The method of claim 1, wherein the patient has previously been subjected to chemotherapy. 4. The method of any one of claims 1 to 3, wherein the non-small cell lung cancer is locally advanced and the patient is not a candidate for treatment with radical chemoradiotherapy, or the non-small cell lung cancer is metastatic non-small cell lung cancer. 5. The method of claim 3 or 4, wherein the antitumor therapy comprises platinum-based chemotherapy. 6. The method of any one of claims 1 to 5, wherein the patient has stage III or stage IV squamous or non-squamous non-small cell lung cancer. 7. The method of any one of claims 1 to 5, wherein the patient has recurrent non-small cell lung cancer or advanced non-small cell lung cancer. 8. The method of any one of claims 1 to 7, wherein each dose of antibody is administered once a week, once every 2 weeks, once every 3 weeks, or once every 4 weeks. 9. The method according to any one of claims 1-8, wherein each dose contains 20-1500 mg of antibody. 10. The method according to any one of claims 1 to 7, wherein each dose contains 200, 250, 300, 350, 450, 600, 750, 800, 1000, or 1050 mg of antibody. 11. The method of any one of claims 1 to 7, wherein each dose contains 350 mg of antibody and is administered every 3 weeks. 12. The method according to any one of claims 1-7, wherein each dose of the antibody contains 0.1-10 mg/kg of the patient's body weight. 13. The method of claim 12, wherein each dose of the antibody contains 1, 3, 4, 5, 6, or 10 mg/kg of the patient's body weight. 14. The method of claim 13 wherein each dose is administered every other week, once every 2 weeks, once every 3 weeks, or once every 4 weeks. 15. The method of any one of claims 1-14, wherein the antibody is administered to the patient as an intravenous infusion. 16. The method of any one of claims 1-15, wherein the antibody is administered in combination with a second therapeutic agent or regimen selected from the group consisting of chemotherapy, cytotoxic T-lymphocyte antigen 4 (CTLA-4) inhibitor, radiation therapy, surgery surgery, lymphocyte activation gene 3 (LAG-3) inhibitor, epidermal growth factor receptor (EGFR) inhibitor, PD-L1 inhibitor, cyclophosphamide, vaccine, glucocorticoid-inducible tumor necrosis factor receptor (GITR) antibody, growth factor inhibitory fusion protein vascular endothelial (VEGF), antibodies to VEGF, sunitinib, sorafenib, pazopanib, antibodies to tumor-specific antigen, granulocyte-macrophage colony-stimulating factor, cytotoxin, cytokine, T-cell therapy, anti-inflammatory drug, dietary supplement. 17. The method of claim 16 wherein the anti-PD-1 antibody is administered in combination with platinum chemotherapy. 18. The method of claim 16 or 17 wherein the anti-PD-1 antibody is administered in combination with an anti-CTLA-4 antibody. 19. The method according to any one of claims 1 to 15, wherein administration of at least one dose of anti-PD-1 antibody results in improved progression-free survival (PFS) or overall survival (OS) of the patient compared to a patient who was subjected to chemotherapy with platinum drugs as monotherapy. 20. The method according to claim 19, wherein the PFS is increased by at least one month compared to a patient who has been subjected to platinum chemotherapy. 21. The method according to claim 19 or 20, wherein the OS is increased by at least one month compared to a patient who was subjected to platinum chemotherapy. 22. The method according to any one of claims 1-21, wherein the HCVR contains the amino acid sequence of SEQ ID NO: 1 and the LCVR contains the amino acid sequence of SEQ ID NO: 2. 23. The method according to any one of claims 1-22, wherein the anti-PD-1 antibody contains a heavy chain containing the amino acid sequence of SEQ ID NO: 9 and a light chain containing the amino acid sequence of SEQ ID NO: 10. 24. The method of any one of claims 1-22, wherein the anti-PD-1 antibody is REGN2810 (cemiplimab). 25. A method for the treatment of lung cancer, including: (a) selecting a patient having non-small cell lung cancer, where: (i) the patient's tumor tissue expresses programmed cell death ligand 1 (PD-L1) in ≥50% of tumor cells; (ii) the patient is not tested positive for epidermal growth factor receptor (EGFR) mutations, anaplastic lymphoma kinase (ALK) translocations, and/or ROS1 fusions; (iii) the patient is not a candidate for definitive chemoradiotherapy or the non-small cell lung cancer is metastatic non-small cell lung cancer; (iv) the patient has not previously been subjected to systemic treatment for lung cancer; and (b) administering to the patient a therapeutically effective amount of an antibody specifically binding to programmed cell death 1 (PD-1) protein, and thereby treating lung cancer in the patient, where the antibody or antigen-binding fragment contains three heavy chain variable region (HCVR) complementarity determining regions (HCDR1, HCDR2 and HCDR3) and three light chain variable region (LCVR) complementarity determining light chain regions (LCDR1, LCDR2 and LCDR3), where HCDR1 contains the amino acid sequence of SEQ ID NO: 3; HCDR2 contains the amino acid sequence of SEQ ID NO: 4; HCDR3 contains the amino acid sequence of SEQ ID NO: 5; LCDR1 contains the amino acid sequence of SEQ ID NO: 6; LCDR2 contains the amino acid sequence of SEQ ID NO: 7; and LCDR3 contains the amino acid sequence of SEQ ID NO: 8; and the specified antibody is administered intravenously every three weeks at a dose of 350 mg. 26. The method of claim 25, wherein the HCVR contains the amino acid sequence of SEQ ID NO: 1 and the LCVR contains the amino acid sequence of SEQ ID NO: 2. 27. The method according to claim 25 or 26, wherein the antibody comprises a heavy chain containing the amino acid sequence of SEQ ID NO: 9 and a light chain containing the amino acid sequence of SEQ ID NO: 10. 28. The method according to any one of paragraphs. 25-27 wherein the anti-PD-1 antibody is cemiplimab.

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