CN112426424A - Application of EGFR/HER2 receptor tyrosine kinase inhibitor in preparation of medicine for treating HER2 mutant cancer - Google Patents

Abstract

The invention relates to application of an EGFR/HER2 receptor tyrosine kinase inhibitor in preparing a medicament for treating HER2 mutant cancer. In particular to application of a compound shown in a formula A or a pharmaceutically acceptable salt thereof in preparing a medicament for treating HER2 mutant cancer.

Description

Application of EGFR/HER2 receptor tyrosine kinase inhibitor in preparation of medicine for treating HER2 mutant cancer

The application is a divisional application of Chinese patent application with the application number of 201780000888.0, the application date of 2017, 01-23 and the invention name of 'application of an EGFR/HER2 receptor tyrosine kinase inhibitor in preparing a medicament for treating HER2 mutant cancer'.

Technical Field

Use of an EGFR/HER2 receptor tyrosine kinase inhibitor for the manufacture of a medicament for the treatment of HER2 mutant cancer.

Background

Worldwide, lung cancer has become a leading cause of cancer death, both in men and women. Statistics according to the annual report of Chinese tumor registration in 2015 show that the incidence and mortality of lung cancer in China are the first. The incidence and mortality of lung cancer increase with age, and the incidence of lung cancer generally increases after the age of 40, reaches a peak around the age of 75, and then decreases (Shiyuankai, Sunpi. clinical oncology Manual. Beijing: people health Press 2015: 315-341). Among lung cancers, non-small cell lung Cancer (NSCLC) accounts for approximately 85% of all lung Cancer patients (Siegel R, Ma J, Zou Z, et al. Cancer statistics. CA Cancer J Clin,2014,64(1): 9-29). Adenocarcinoma is the most common type of pathology in non-small cell lung cancer in developed countries, accounting for approximately 40%. Most NSCLC are diagnosed with locally advanced or distant metastases and are not amenable to surgical resection.

First-line treatment of metastatic NSCLC depends on the type of pathology and genetic alterations. EGFR-TKI treatment is recommended for patients positive for EGFR gene mutation, and crizotinib treatment is recommended for ALK positive patients (Kiryuki, Sunyan. clinical oncology department Manual. Beijing: human health Press, 2015: 315-341). The non-squamous cancer patients with negative gene expression recommend pemetrexed or other platinum-containing two-drug combination schemes for chemotherapy, and can be combined with vascular endothelial chalone (YH-16) or Cetuximab (Cetuximab) on the basis of the chemotherapy. Maintenance therapy may be selected for patients with first line treatment to achieve disease control (complete remission, partial remission, and stabilization). The current drugs supported by evidence of evidence include pemetrexed (non-squamous cell carcinoma) and gemcitabine, and epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) maintenance therapy may be selected for patients with EGFR gene mutations. The second line therapy may be selected from docetaxel, pemetrexed and EGFR-TKI. However, there is no clear recommended treatment for the third-line therapy, and a large number of clinical trials are exploring other effective treatment methods (Shiyuan Kai, Sunpi. clinical oncology Manual [ M ]. Beijing: human health Press, 2015: 315-. In addition to the above-mentioned targets, lung cancer studies have also found a number of alterations in genetic abnormalities, including amplification of MET and FGFR1, PIK3CA, AKT, KRAS, NRAS, BRAF, MEK1, AKT1, FGFR2, DDR2 and HER2 mutations, and RET and ROS1 rearrangements, among others (Mazi res J, Peters S, Lepage B, et al.

Wherein the human epidermal factor receptor 2(HER2) gene belongs to a member of HER tyrosine receptor family, and the HER2 mutation mainly occurs in 20 exons and accounts for about 2-4% of NSCLC patients (Clin Cancer Res.2012,18: 4910-4918; Cancer Res.2005,65: 1642-1646; Lung Cancer 2011,74: 139-144.). However, Barlesi et al in 2013 found that the HER2 mutation rate was 0.9% in 10,000 patients with advanced NSCLC (J Clin Oncol,2013,31(suppl): abstr 8000). Maziefres et al reported detection of 65 (1.7%) HER2 mutations in 3800 patients with lung adenocarcinoma (J Clin Oncol,2013,31 (16): 1997-. The HER2 mutation is mutually exclusive of other driver gene abnormalities (EGFR, KRAS, BRAF mutations, ALK rearrangements, etc.) (Lung Cancer,2015,87(1): 14-22). Suzuki et al (Lung Cancer,2015,87(1):14-22) also reported that the HER2 mutation was an independent contributor to poor prognosis in patients with invasive non-small cell Lung adenocarcinoma (p ═ 0.005). In clinical trials, Tomizawa et al observed that 1 HER2 mutant female Lung adenocarcinoma patient who was refractory to platinum-based chemotherapy and gefitinib treatment was efficacious against trastuzumab in combination with vinorelbine as the third line treatment (Lung Cancer,2011,7: 139-144). Analysis of clinical characteristics and efficacy of another study, maziefres et al, in NSCLC patients with HER2 mutation shows: a total of 16 patients with HER2 mutated non-small cell lung adenocarcinoma received HER2 targeted drug therapy, some of which received 2 (3) or 4(1) different HER2 targeted drugs (J Clin Oncol,2013,31 (16): 1997-2003). A total of 16 HER2 mutant non-small cell lung adenocarcinoma patients received 22 HER2 targeted drug treatments with evaluable efficacy outcomes of 4 disease Progression (PD), 7 stable (SD, 32%), 11 partial remission (PR, 50%), and 82% Disease Control Rate (DCR). Among them, 15 patients treated with trastuzumab (trastuzumab) had a DCR of 96%, 4 patients treated with afatinib (afatinib) had a DCR of 100%, and 2 patients treated with lapatinib (lapatinib) and 1 patient treated with masatinib were evaluated for efficacy as PD. The median PFS of 15 patients who used HER 2-targeted drug at one line was 5.1 months (Mazieres J et al, J Clin Oncol,2013,31 (16): 1997-2003). Another clinical study of neratinib alone or in combination with temsirolimus (temsirolimus) for the treatment of HER2 mutant non-small cell lung cancer (NCT01827267) with 9-month release 2014 showed: in 13 patients taking the single-dose neratinib, PR 0 patients have 54% of SD and 31% of SD which is more than or equal to 12 weeks; i.e., ORR of 0 and DCR of 54%. PR 3 (21%), SD 11 (79%), SD ≥ 12 weeks 9 (64%) in 14 patients taking lenatinib in combination with temsirolimus; i.e., 21% ORR and 100% DCR. The PFS of the single drug or the drug combination of temsirolimus of the Neratinib is respectively 2.9 months and 4 months (http:// www.bioportfolio.com/resources/trial/131948/Neratinib-With-and-Without-Tems irolimus-for-Patients-With-HER 2-Activating-Mutations-in.html). The results of the above experiments show that some HER2 and/or EGFR targeting drugs may have anti-tumor efficacy in HER2 mutated non-small cell lung cancer patients, while some HER2 and/or EGFR targeting drugs are not effective, and it is difficult to predict whether a particular HER2 and/or EGFR targeting drug is effective for HER2 mutated cancer.

CN102471312B discloses a compound represented by the following formula A (chemical name (E) -N- [4- [ [ 3-chloro-4- (2-pyridylmethoxy) phenyl ] amino ] -3-cyano-7-ethoxy-6-quinolyl ] -3- [ (2R) -1-methylpyrrolidin-2-yl ] prop-2-enamide), and discloses that it has a strong inhibitory effect on EGFR and HER2, and is expected to be useful for the treatment of EGFR and HER2 overexpressed cancer,

CN102933574B discloses a series of pharmaceutically acceptable salts of compounds of formula a. CN103974949B discloses a crystalline form of the dimaleate salt of the compound of formula a.

None of the above documents, however, discloses the effect of the compounds of formula a on the treatment of HER2 mutated cancer.

Disclosure of Invention

The present invention has surprisingly found that compound a, or a pharmaceutically acceptable salt thereof, has a surprising effect on the treatment of HER2 mutant cancer, thereby completing the present invention.

In a preferred embodiment of the invention, the cancer is lung cancer, breast cancer or gastrointestinal cancer. Preferably, the lung cancer is non-small cell lung cancer, more preferably HER2 mutant non-small cell lung adenocarcinoma, especially an advanced non-small cell lung adenocarcinoma patient with HER2 mutation. Preferably, the cancer of the gastrointestinal tract is gastric cancer.

In the present invention, the HER2 mutant cancer refers to cancer driver mutation (driver mutation) of HER2 gene which can be detected in these cancer patients, the type of mutation is mainly non-frameshift insertion mutation of exon 20, and is followed by some missense mutations and small insertion and deletion mutations in tyrosine kinase domain and other segments, such as 772-775YVMA duplification (the amino acid at position 772-775 in the original protein is a YVMA, and duplication of YVMA is caused by insertion of 12 bases in the gene to form another pair of YVMA), G776delinsVC (three amino acids of GSP are inserted between amino acids 781 caused by insertion of 3 bases at the corresponding position, and amino acid C is inserted, which can also be expressed as insG776V C or G776> VC), P780-Y781 insGSP (three amino acids of GSP are inserted between amino acids 781 caused by insertion of 9 bases at the corresponding position), V777 sense mutation (three amino acids of V777 are caused by insertion of one base 777), L755S, S310F, S310Y, G309A, G309E, D769Y, D769H, V842I, L866M, R896C, L755_ E757delins (substitution of amino acid No. 3 to amino acid No. 755 and 757 by one amino acid S due to deletion of 6 bases at the corresponding site), L869R, L841V, G776V, L755-T759Del (deletion of amino acid No. 755 and 759 to amino acid No. 755 due to deletion of 15 bases at the corresponding site), G776L, V777L, L36755 85, and S779_ P780insVGS (insertion of three amino acids VGS between amino acids No. 779 and 780 due to insertion of 9 bases at the corresponding site) (the amino acid sequence numbers refer to P04 2_ HUMAN).

In a preferred embodiment of the invention, the cancer is a cancer that is EGFR mutation negative or ALK fusion gene negative, or both.

In a preferred embodiment of the invention, the cancer is a cancer that has progressed following chemotherapy, radiotherapy or targeted therapy. I.e., patients with the cancer do not have control of the disease after chemotherapy, radiation therapy, or targeted therapy, and continue to progress. The chemotherapy may be treatment with a variety of conventional chemotherapeutic agents, such as alkylating agents (e.g., cyclophosphamide, ifosfamide, melphalan, busulfan, nimustine, ramustine, dacarbazine, temozolomide, mechlorethamine hydrochloride, dibromomannitol, etc.), platinum complexing agents (e.g., cisplatin, carboplatin, oxaliplatin, etc.), metabolic antagonists (e.g., methotrexate, 5-fluorouracil, tegafur, gemcitabine, capecitabine, fulvestrant, pemetrexed, etc.), plant alkaloids (e.g., vincristine, vinblastine, vindesine, etoposide, docetaxel, paclitaxel, irinotecan, vinorelbine, mitoxantrone, vinflunine, topotecan, etc.), hormonal anticancer agents (e.g., leuprolide, goserelin, dutasteride, dexamethasone, tamoxifene, etc.), proteasome inhibitors (e.g., bortezomib, melphalan, dexamethasone, tamoxifen, etc.), proteasome inhibitors (e.g., cyclophosphamide, norgest, Lenalidomide, etc.), aromatase inhibitors (e.g., exemestane, letrozole, anastrozole, etc.), preferably via chemotherapy with one or more agents selected from carboplatin, cisplatin, oxaliplatin, pemetrexed, gemcitabine, or docetaxel. The targeted therapy may be treatment with one or more selected from EGFR inhibitors and VEGFR inhibitors. Such targeted drugs are well known in the art, for example, the EGFR inhibitor may be selected from one or more of gefitinib, erlotinib and afatinib; the VEGFR inhibitor is selected from one or more of sunitinib, apatinib and famitinib.

In the present invention, when compound a is actually used, it is preferably in the form of a pharmaceutically acceptable salt thereof, particularly a maleate salt or a dimaleate salt.

In the present invention, the daily dosage of compound A or its pharmaceutically acceptable salt may be in the range of 1mg/kg to 20mg/kg, preferably 2mg/kg to 10mg/kg, and more preferably 4 mg/kg to 8 mg/kg. . For adult humans, preferably 100mg to 1000mg, preferably 240 to 560mg, more preferably 320 to 480mg, based on compound A. In the case of Asians, the daily dosage may also be in the range of 240 to 400mg, in particular 400 mg.

Compound A or a pharmaceutically acceptable salt thereof can also be formulated with pharmaceutically acceptable carriers into compositions well known in the art, such as tablets, capsules, granules, injections, etc. The invention also relates to the use of a pharmaceutical composition comprising compound a for HER2 mutant cancer.

Drawings

Figure 1 shows the inhibitory effect of compound a and lapatinib on proliferation of cultured tumor cells in vitro (dose-effect curve).

Detailed Description

The present invention will be further described with reference to the following examples, which are not intended to limit the scope of the present invention.

Example 1: effect of compound a and lapatinib on proliferation of ATCC H1781 cells cultured in vitro.

1. Test drug

The name of the medicine is: dimaleate salt of compound a (batch No. S0915100514), lapatinib di-p-toluenesulfonate salt (batch No. 20090105). The preparation method comprises the following steps: all formulated in DMSO.

2. Cell line

ATCC H1781 cells from the Shanghai Lung Hospital were mutated at HER2 (InsG776V, C), and the patient was a 66-year-old women with caucasian lung adenocarcinoma, cultured in PRIM 1640 medium containing 10% Fetal Bovine Serum (FBS).

3. Reagent and instrument

PRIM 1640 was purchased from Gibco BRL; fetal bovine serum was purchased from Gibco; multifunctional microplate readers were purchased from BioTek corporation; sulforhodamine B (SRB) was purchased from Sigma.

4. Test method

The SRB protein staining method is used for detecting the inhibition effect of the medicine on the proliferation and growth of tumor cells. The method mainly comprises the following steps:

cells in logarithmic growth phase are inoculated to 96-well culture plates, drugs (1-10000nM) with corresponding concentration are added, each concentration is provided with multiple wells, and simultaneously, a solvent control with corresponding concentration is provided. Tumor cells were incubated at 37 ℃ with 5% CO₂Culturing for 72h under the condition. The cells were stained with SRB at room temperature, and finally dissolved in Tris solution, OD was measured at 510nm using a microplate reader (BioTek), and the cell growth inhibition rate was calculated according to the following formula:

inhibition rate (OD value)_{Control well}OD value_{Medicine feeding hole}) OD value_{Control well}×100％

Calculating half inhibitory concentration IC according to non-linear regression method based on each concentration inhibition rate₅₀。

5. Test results

The test results show that the compound A has a good inhibition effect on HER2 mutant lung adenocarcinoma cells, while lapatinib has a poor effect, and the specific results are shown in Table 1 and figure 1:

TABLE 1 proliferation of tumor cells ATCC H1781 by Compounds A, Lapatinib in vitro₅₀Summary of the invention

Medicine	IC50(nM)	95% confidence interval	R2
				Compound A	59	38.92to 89.19	0.9805
Lapatinib	2430	1354to 4362	0.9593

And R is a correlation coefficient.

Example 2: effect of Compound A and Lapatinib on the Activity of HER2 recombinant protease in vitro

1. Test drug

Compound A (batch number SHR120201-002-06), and lapatinib (batch number SHR115758-010-17), both provided by Jiangsu Henry medicine, staurosporine was purchased from MedChem (Monmouth Junction, NJ) in USA (batch number MC-2104).

2. Recombinant proteins

Recombinant human protein HER2 WT (Lot # W353-1) and 5 HER2 muteins (A775_ G776insYVMA: Lot # Z1251-6; D769H: Lot # K1683-5; D769Y: Lot # P8-9; V771687 _ G778insCG: Lot # Z1287-3; V777L: Lot # K1850-3) were all purchased from SignalChem (Richmond, BC V6V 2J2, CANADA). these recombinant proteins are polypeptides from amino acid 676 to amino acid 1255 of HER2 protein, both expressed by baculovirus in Sf9 insect cells, and the N-terminus was labeled with GST. The EGFR gene index is NM-004448. The protein purity of WT HER2 and four HER2 muteins (A775_ G776insYVMA, D769H, D769Y, V777_ G778insCG) is more than 85%, and the protein purity of another HER2 mutein V777L is more than 90%.

3. Test method

To a reaction system (20mM Hepes (pH7.5), 10mM MgCl2, 1mM EGTA, 0.02% Brij35, 0.02mg/ml BSA, 0.1mM Na3VO4,2mM DTT, 1% DMSO) was added 10. mu.M to 0.5nM of the test compound (Compound A or the positive control staurosporine) with Bovine Serum Albumin (BSA) as a substrate, and then 33P-ATP 0.01. mu. Ci/. mu.l (Perkin Elmer) was added to initiate phosphorylation reaction to measure the enzymatic activity of EGFR. The experimental result shows that the compound A has stronger inhibiting effect on the enzyme activities of the recombinant human wild EGFR and the exon 20 insertional mutation, and the whole enzyme activity of the EGFR is gradually reduced along with the continuous increase of the concentration of the compound A, thus showing a concentration dependence relationship. IC50 values were calculated using Prism4 software (GraphPad) using the logarithm of the concentration as the abscissa and the probability unit of the inhibition rate for the corresponding concentration as the ordinate.

4 results of the test

The test result shows that the compound A has a better inhibiting effect on HER2 mutant lung adenocarcinoma cells, wherein lapatinib, neratinib and staurosporine are used as control compounds. The specific results are shown in table 2:

TABLE 2 Compound A Activity IC on HER2 recombinant protease in vitro₅₀Summary of the invention

Example 3: effect of compound a and lapatinib on proliferation of HER2 mutant MCF10A cell line in vitro culture.

1. Test drug

The name of the medicine is: compound A (batch No. S0915151219), Lapatinib (batch No. SHR 115758-010-17). The preparation method comprises the following steps: all formulated in DMSO.

2. Cell line

MCF10A cells were purchased from ATCC, the cells were used as mother cells, lentivirus was overexpressed by packaging with vector GV341, and then infection with lentivirus was used to establish 19 mixed clone stable cell lines, including empty vector control (NC), HER2 WT, HER2 YVMAdup, P780_ Y781insGSP, G776> VC, V777L, L755S, D769H, G776R, G776C, L755P, V842I, L866M, R896C, S310F, S310Y, G309A, G309E, and D769Y. All cells were cultured in DMEM/F12 medium plus 5% horse serum, 20ng/ml EGF, 10. mu.g/ml insulin, 0.5. mu.g/ml hydrocortisone, 1% penicillin/streptomycin (P/S) and 100ng/ml Cholera Toxin.

3. Reagent and instrument

DMEM/F12(Gibco, 10-092-CVR), horse serum (original phyllobacteria, MP20006), insulin (original phyllobacteria, 11070-73-8), epidermal growth factor (Peprotech, AF-100-15-100), cholera toxin (sigma,9012-63-9),

Hydrocortisone (source leaf organism, 50-23-7), trypsin (Gibco,25200-072), Puromycin (assist in san-Chi, 60210ES25), RIPA lysate (Dingguo, WB-0071), MTT (Genview, JT 343).

4. Test method

The inhibition effect of the medicine on the proliferation and growth of tumor cells is detected by applying an MTT (methyl thiazolyl tetrazolium) drug sensitivity test method. 10 concentration points, 1 detection time point, 2 replicate wells per drug. The 96-well culture plate is inoculated with 2000 cells (100. mu.l of culture medium/well) per well, and the drug (0.00128-500 nM for compound A; 0.00128-500. mu.M for lapatinib) is added at the corresponding concentration, and each concentration is repeated with a corresponding concentration of vehicle control. The tumor cells were cultured at 37 ℃ for 72h with 5% CO 2. Then MTT detection is carried out. The absorbance of each well was measured using an enzyme linked immunosorbent assay OD490nm, and the cell growth inhibition rate was calculated according to the following formula:

inhibition ═ OD value (OD value vs control well-OD value dosing well)/OD value control well x 100%

From each concentration inhibition ratio, the median inhibitory concentration IC50 was calculated according to a nonlinear regression method.

5. Test results

The test result shows that the compound A has better inhibition effect on HER2 mutant lung adenocarcinoma cells, while the control compound lapatinib has poor inhibition effect. Specific results are shown in table 3:

TABLE 3 inhibition of HER2 mutant cell proliferation by Compound A in vitro IC₅₀Summary of the invention

Example 4: test for Compound A treatment of advanced non-Small cell Lung adenocarcinoma with HER2 mutation

The test method comprises the following steps: the test subjects were pathologically diagnosed patients with advanced non-small cell lung adenocarcinoma, and were confirmed to have HER2 gene mutation by detection (tumor pathological sections of the patients were detected by "fluorescent PCR method using human HER2 gene detection kit (examples 1 to 7 and 10) and NGS-generation sequencing method (examples 8, 9 and 11)" of xiamen edend biomedical science and technology ltd). Subjects who meet the requirements of inclusion are administered compound a320 mg/d and/or 400mg/d orally once a day, continuously until the patient develops disease progression/intolerance. By 8 months of 2016, 11 patients with advanced non-small cell lung adenocarcinoma with HER2 mutation have been enrolled. The mean age of the subjects was 58.4 years. All subjects continued to progress after treatment with different modalities, such as docetaxel or pemetrexed chemotherapy, or gefitinib, afatinib, and other targeted drugs. Adverse events were all grade 1-2, including 1/2 grade diarrhea (4 cases), 2 grade debilitation (2 cases), 1 grade rash (2 cases) and 1 grade dyspnea (1 case), and were clinically controllable. No Serious Adverse Events (SAE) occurred and cases of discontinuation of dosing, down-regulation of dose and early group withdrawal due to adverse events. PR was obtained in 6 (54.5%) patients, disease was stable in 3 (27.3%) patients, PD in 2 (18.2%) patients, ORR was 54.5%, and DCR was 81.8%. Median PFS was 6.2 months (95% CI 1.23-11.57). There are still 5 patients in the group treatment.

The test results show that in HER2 mutant non-small cell lung adenocarcinoma patients, 320mg/d and 400mg/d of the compound A have good safety and tolerance, clinical controllability and obvious anti-tumor curative effect.

Details of patients for whom efficacy was assessed are given in table 4 below. Wherein each English abbreviation has the following meaning.

PD: disease progression, at least a 20% increase in the diameter sum over the minimum of the sum of the diameters of the target lesions and at least a 5mm increase in the absolute value of the diameter sum (the appearance of one or more new lesions is also considered disease progression); SD: the disease is stable, and the sum of the maximum diameters of the target foci reduces the underreach PR or increases the underreach PD PR: partial remission, with the sum of target lesion diameters reduced from baseline by at least 30%, for at least 4 weeks. UK: is unknown.

Claims (14)

1. Use of a compound of formula A or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the treatment of HER2 mutated cancer, wherein the type of HER2 mutation is selected from the group consisting of a non-frameshift insertion mutation of exon 20, a 772-775YVMA duplication mutation, a G776 mutation, a P780_ Y781insGSP mutation, a V777L mutation, an L755S mutation, an S310F mutation, an S310Y mutation, a G309A mutation, a G309E mutation, a D769Y mutation, a D769H mutation, a V842I mutation, an L866M mutation, a R896C mutation, an L755E 757delinsS mutation, an L869R mutation, an L841 mutation, an L755-T759Del mutation, an L755P mutation and an S779_ P780insVGS mutation, preferably a non-frameshift insertion mutation of exon 20, a P780_ Y, a G587 mutation, a G7729 mutation and a 7762 mutation,

2. the use according to claim 1, wherein the cancer is selected from lung cancer, breast cancer and gastrointestinal cancer.

3. The use according to claim 2, wherein the lung cancer is non-small cell lung cancer.

4. The use of claim 2, wherein the lung cancer is lung adenocarcinoma.

5. The use according to claim 2, wherein the lung cancer is advanced lung cancer.

6. The use of claim 1, wherein the cancer is a cancer that has progressed following chemotherapy, radiation therapy, or targeted therapy.

7. The use according to claim 6, wherein the chemotherapy is carried out using one or more agents selected from the group consisting of alkylating agents, platinum complexing agents, metabolic antagonists, plant alkaloids, hormonal anticancer agents, proteasome inhibitors, aromatase inhibitors; preferably, chemotherapy is performed using one or more selected from carboplatin, cisplatin, oxaliplatin, 5-fluorouracil, vinorelbine, gemcitabine, pemetrexed or docetaxel.

8. The use of claim 6, wherein the targeted therapy is treatment with one or more selected from the group consisting of EGFR inhibitors and VEGFR inhibitors.

9. The use according to claim 8, wherein the EGFR inhibitor is selected from one or more of gefitinib, erlotinib and afatinib.

10. The use of claim 8, wherein the VEGFR inhibitor is selected from the group consisting of sunitinib, apatinib, and famitinib.

11. Use according to claim 1, wherein the pharmaceutically acceptable salt of compound a is a maleate salt, preferably a dimaleate salt.

12. The use according to claim 1, wherein the amount of compound a or the pharmaceutically acceptable salt thereof is 1mg/kg to 20mg/kg, preferably 2mg/kg to 10mg/kg, more preferably 4 mg to 8mg/kg, based on compound a per day.

13. The use according to claim 1, wherein the amount of compound a or a pharmaceutically acceptable salt thereof is 100mg to 1000mg, preferably 240 mg to 560mg, more preferably 320mg to 480mg, daily, based on compound a.

14. The use according to any one of claims 1 to 13, wherein the compound a or a pharmaceutically acceptable salt thereof is prepared as a composition further comprising a pharmaceutically acceptable carrier.

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