DE112022001882T5 - CANCER THERAPY USING TOLL-LIKE RECEPTOR AGONISTS - Google Patents

Abstract

Embodiments of the present invention provide methods of treating cancer and methods of administering Toll-like receptor (TLR) agonists to solid tumors in the liver using locoregional therapy through the vasculature. In one aspect, the present invention relates to a method for treating primary liver cancers such as hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC), comprising administering TLR9 agonists to the liver.

Description

CROSS REFERENCE TO RELATED APPLICATION(S)

This application claims the benefit of U.S. Provisional Patent Application No. 63/169,674 , filed April 1, 2021, and U.S. Provisional Patent Application No. 63/298,589 , filed on January 11, 2022, both of which are incorporated by reference in their entirety.

SEQUENCE PROTOCOL

This application contains a sequence listing that was submitted electronically in ASCII format and is hereby incorporated by reference in its entirety. The ASCII copy in question, created on September 16, 2020, is named A372-502_SL.txt and has a size of 484 bytes.

FIELD OF THE INVENTION

The present disclosure relates generally to methods of treating cancer and methods of administering Toll-like receptor (TLR) agonists to solid tumors in the liver using locoregional therapy via the vasculature.

BACKGROUND OF THE INVENTION

Cancer is a devastating disease that involves the uncontrolled growth of cells, which can lead to the growth of solid tumors in a range of organs such as the skin, liver and pancreas. Tumors can initially appear in any number of organs or can be the result of metastasis or spread from other locations.

Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) are the most common primary liver tumors and are solid organ malignancies in which progression within the liver leads to rapidly progressive and often fatal disease.

HCC accounts for more than 90% of primary liver tumor cases. HCC and ICC patients share many of the same characteristics and treatment challenges. For both diseases, the 5-year survival rate is <20%.

Surgery is the only potentially curative treatment for primary liver cancers such as HCC and ICC. However, approximately 70% of patients are diagnosed at advanced stages due to a lack of specific symptoms, and even after potentially curative resection, the tumor often recurs. Because of their effectiveness in other malignancies, checkpoint inhibitors (CPIs) have also been tested in patients with HCC and ICC. However, their success so far has been limited due to problems in administering the drug and suppressing the immune response in the liver.

Accordingly, there is still a need for a safe and effective therapy to treat primary liver cancers such as HCC and ICC.

SUMMARY OF THE INVENTION

The present invention relates to methods of treating primary liver cancers using a therapeutically effective amount of a Toll-like receptor (TLR) agonist.

In one aspect, the present invention relates to a method for treating primary liver cancers comprising administering a TLR agonist via a hepatic arterial infusion (HAI) device. According to another embodiment, treatment of primary liver cancers includes administration of a TLR agonist via a portal vein infusion (PVI) device.

In some embodiments, the TLR agonist is administered by pressure-enabled drug delivery (PEDD), which involves the administration of a therapeutic agent via a device such as a device. B. includes a catheter device. In some embodiments, the catheter device includes a one-way valve that dynamically responds to local pressure changes. In some In embodiments, the catheter device creates, causes, and/or contributes to a net increase in fluid pressure within the vessel and/or the target tissue or tumor. In some embodiments, the catheter device creates, causes, and/or contributes to a net decrease in fluid pressure within the vessel and/or the target tissue or tumor. In some embodiments, the catheter device creates, causes, and/or contributes to an initial decrease and then an increase in fluid pressure within the vessel and/or the target tissue or tumor.

In some embodiments, the TLR agonist is administered via a pressure-activated device, such as a device that modulates vascular pressure.

In some embodiments, the amount of TLR agonist administered is in the range of about 0.01-20 mg or is at least one of 0.5 mg, 2 mg, 4 mg, or 8 mg.

In some embodiments, the TLR agonist is administered in a solution in the range of 1-100 ml or at least one of 10 ml, 25 ml or 50 ml.

In some embodiments, the TLR agonist is in the range of 0.0001-20 mg/ml or at least one of 0.01 mg/ml, 0.04 mg/ml, 0.08 mg/ml or 0.16 mg/ml. ml administered.

In some embodiments, the TLR agonist is administered over a period of about 10-200 minutes. In another embodiment, the TLR agonist is administered over a period of about 10-60 minutes. In another embodiment, the TLR agonist is administered over a period of about 25 minutes.

In some embodiments, the TLR agonist is administered in combination with one or more CPls. In some embodiments, the CPls are administered systemically, either concurrently with, before, or after administration of the TLR agonist. In some embodiments, the CPIs include at least one of nivolumab, pembrolizumab, and ipilimumab.

In some embodiments, administration of the TLR agonist includes a dosage regimen that includes cycles. In some embodiments, one or more of the cycles include administration of the TLR agonist via a catheter device via HAI, followed by systemic administration of one or more CPIs.

In some embodiments, one cycle of the dosage regimen includes administration of the TLR agonist once per week for three consecutive weeks. In some embodiments, the dosage regimen includes two cycles.

In some embodiments, administration of a TLR agonist into the liver by an intravascular device results in a reduction in myeloid-derived suppressor cells (MDSC) or a functional change in MDSCs to limit immunosuppression. In some embodiments, administration of a TLR agonist into the liver by an intravascular device results in antitumor effects.

In some embodiments, the TLR agonist is a TLR9 agonist. In some embodiments, the TLR9 agonist is SD-101.

These and other objects, features, and advantages of the exemplary embodiments of the present disclosure will become apparent upon reading the following detailed description of the exemplary embodiments of the present disclosure when considered in conjunction with the entire specification.

BRIEF DESCRIPTION OF THE DRAWINGS

• 1 zeigt die Struktur von SD-101.
• 2 zeigt eine In-vitro-Analyse von humanen PMBC, die gesunden Spendern entnommen und mit IL6 und GM-CSF behandelt wurden, um MDSC zu induzieren.
• 3 zeigt eine In-vitro-Analyse von Mäuseknochenmarkszellen, bei der GM-CSF zur Induktion von MDSC verwendet wurde, von Mäusen mit oder ohne Tumor.
• 4 zeigt Querschnittsbilder der Leberlappen von Schweinen nach der Infusion von SD-101.
• 5 zeigt das allgemeine Studiendesign einer Immunonkologie-Studie der Phase 1b/2 zu regionaler druckaktivierter HAI von SD-101 mit systemischer Checkpoint-Blockade bei HCC und ICC.

Additional objects, features, and advantages of the present disclosure will become apparent from the following detailed description in conjunction with the accompanying figures showing illustrative embodiments of the present disclosure.

• 1 shows the structure of SD-101.
• 2 shows an in vitro analysis of human PMBC collected from healthy donors and treated with IL6 and GM-CSF to induce MDSC.
• 3 shows an in vitro analysis of mouse bone marrow cells using GM-CSF to induce MDSC from mice with or without tumor.
• 4 shows cross-sectional images of the liver lobes of pigs after infusion of SD-101.
• 5 shows the general study design of a phase 1b/2 immuno-oncology study of regional pressure-activated HAI of SD-101 with systemic checkpoint blockade in HCC and ICC.

Unless otherwise indicated, the same reference numbers and characters are used throughout the drawings to identify like features, elements, components, or parts of the illustrated embodiments. While the present disclosure will now be described in detail with reference to the figures, this is done in conjunction with the illustrative embodiments and is not limited to the specific embodiments illustrated in the figures and the accompanying paragraphs.

DETAILED DESCRIPTION

The following description of embodiments includes non-limiting representative examples, which are referred to by reference numerals to particularly describe features and teachings of various aspects of the invention. The described embodiments should be understood to be implemented separately or in combination with other embodiments from the description of the embodiments. One of ordinary skill in the art reading the description of the embodiments should be able to understand the various aspects of the invention described. The description of the embodiments is intended to enable the invention to be understood to the extent that other embodiments not expressly described but known to those skilled in the art who have read the description of the embodiments are considered compatible with the practice of the invention.

Toll-like receptor agonists

Toll-like receptors are pattern recognition receptors that can recognize microbial pathogen-associated molecular patterns (PAMPs). The stimulation of TLRs, such as B. stimulation of TLR9, can not only cause a broad stimulation of the innate immune response, but also specifically target the dominant drivers of immunosuppression in the liver. TLR1-10 are expressed in humans and recognize a variety of microbial PAMPs. In this context, TLR9 can respond to unmethylated CpG DNA, including microbial DNA. CpG refers to the motif of a cytosine-guanine dinucleotide 1. TLR9 is constitutively expressed in B cells, plasmacytoid dendritic cells (pDCs), activated neutrophils, monocytes/macrophages, T cells and MDSCs. TLR9 is also expressed in non-immune cells, including keratinocytes and epithelial cells of the intestine, cervix and respiratory tract. TLR9 can bind to its agonists in endosomes. Signaling can occur via MYD88/IkB/NfκB to induce gene expression of proinflammatory cytokines. A parallel signaling pathway via IRF7 induces type 1 and 2 interferons (e.g., IFN-α, IFN-γ, etc.), which stimulate adaptive immune responses. In addition, TLR9 agonists can induce the production of cytokines and IFN as well as the functional maturation of antigen-presenting dendritic cells.

According to one embodiment, a TLR9 agonist can reduce and reprogram MDSCs. MDSCs are important drivers of immunosuppression in the liver. MDSCs also drive the expansion of other suppressor cell types such as T regulatory cells (Tregs), tumor-associated macrophages (TAMs), and cancer-associated fibroblasts (CAFs). MDSCs can downregulate immune cells and impair the effectiveness of immunotherapy drugs. Furthermore, high MDSC levels generally predict poor treatment outcomes in cancer patients. In this context, reducing, altering or eliminating MDSCs is thought to improve the ability of the host immune system to attack the cancer and the ability of immunotherapy to induce more favorable therapeutic responses. In one embodiment, TLR9 agonists can convert MDSCs into immunostimulatory M1 macrophages, convert immature dendritic cells into mature dendritic cells, and expand effector T cells to create a responsive tumor microenvironment to promote anti-tumor activity.

According to one embodiment, synthetic CpG oligonucleotides (CPG-ONs) that mimic the immunostimulatory nature of microbial CpG DNA can be developed for therapeutic use. According to one embodiment, the oligonucleotide is an oligodeoxynucleotide (ODN). There are a number of different CpG ODN class types, such as: B. Class A, Class B, Class C, Class P and Class S, which share certain structural and functional characteristics. In this regard, class A CPG-ODNs (or CPG-A ODNs) are associated with the maturation of pDCs with little effect on B cells as well as with the highest level of IFNα induction; Class B CPG-ODNs (or CPG-B ODNs) potently induce B cell proliferation, activate pDC and monocyte maturation, NK cell activation, and inflammatory cytokine production; and class C CPG-ODNs (or CPG-C ODNs) can induce B cell proliferation and IFN-α production.

According to one embodiment, CPG-C ODNs may also be associated with the following properties: (i) unmethylated CpG dinucleotide motifs, (ii) adjacent CpG motifs with flanking nucleotides (e.g. AACGTTCGAA), (iii) a complete phosphorothioate (PS) backbone connecting the nucleotides (as opposed to the natural phosphodiester (PO) backbones found in bacterial DNA), and (iv) a self-complementary palindromic sequence (e.g. AACGTT) . In this context, due to their palindromic nature, CPG-C ODNs can self-bind, forming double-stranded duplex or hairpin structures.

Further, according to one embodiment, the CPG-C ODNs may include one or more 5' TCG trinucleotides, with the 5' T positioned 0.1, 2 or 3 bases from the 5' end of the oligonucleotide, and at least one palindromic sequence with a length of at least 8 bases comprising one or more unmethylated CG dinucleotides. The one or more 5'-TCG trinucleotide sequences may be separated from the 5' end of the palindromic sequence by 0, 1, or 2 bases, or the palindromic sequence may contain all or part of the one or more 5'-TCG trinucleotide sequences. In one embodiment, the CpG-C ODNs are 12 to 100 bases long, preferably 12 to 50 bases long, preferably 12 to 40 bases long, or preferably 12 to 30 bases long. In one embodiment, the CpG-C ODN is 30 bases long. In one embodiment, the ODN is at least (lower limit) 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 34, 36, 38, 40, 50, 60, 70, 80 or 90 bases long. In one embodiment, the ODN is at most (upper limit) 100, 90, 80, 70, 60, 50, 49, 48, 47, 46, 45, 44, 43, 42, 41, 40, 39, 38, 37, 36, 35, 34, 33, 32, 31 or 30 bases long.

In one embodiment, the at least one palindromic sequence is 8 to 97 bases long, preferably 8 to 50 bases long, or preferably 8 to 32 bases long. In one embodiment, the at least one palindromic sequence is at least (lower limit) 8, 10, 12, 14, 16, 18, 20, 22, 24, 26, 28 or 30 bases long. In one embodiment, the at least one palindromic sequence is at most (upper limit) 50, 48, 46, 44, 42, 40, 38, 36, 34, 32, 30, 28, 26, 24, 22, 20, 18, 16, 14 , 12 or 10 bases long.

In one embodiment, the CpG-C ODN may comprise the sequence of SEQ ID NO: 1.

According to one embodiment, the CpG-C ODN may include the SD-101. SD-101 is a 30-mer phosphorothioate oligodeoxynucleotide having the following sequence: 5'-TCG AAC GTT CGA ACG TTC GAA CGT TCG AAT-3' (SEQ ID NO: 1)

The drug substance SD-101 is isolated as a sodium salt. The structure of SD-101 is in 1 shown.

The molecular formula of free acid SD-101 is C ₂₉₃ H ₃₆₉ N ₁₁₂ O ₁₄₉ P ₂₉ S ₂₉ and the molecular mass of free acid SD-101 is 9672 Daltons. The molecular formula of SD-101 sodium salt is C ₂₉₃ H ₃₄₀ N ₁₁₂ O ₁₄₉ P ₂₉ S ₂₉ Na ₂₉ and the molecular mass of SD-101 sodium salt is 10,309 daltons.

Further, according to one embodiment, the CPG-C ODN sequence may correspond to SEQ ID NO: 172 as described in US Pat US Patent No. 9,422,564 is described, which is incorporated herein in its entirety by reference.

In one embodiment, the CpG-C ODN may comprise a sequence that has at least 75% homology to one of the aforementioned sequences, such as: B. SEQ ID NO.: 1.

According to another embodiment, the CPG-C ODN sequence may correspond to one of the other sequences described in the US Patent No. 9,422,564 are described. Furthermore, the CPG-C ODN Sequence also correspond to one of the sequences contained in the US Patent No. 8,372,413 are described, which is also incorporated herein in its entirety by reference.

According to one embodiment, each of the CPG-C ODNs discussed herein may be in their pharmaceutically acceptable salt forms. Examples of basic salts include ammonium salts, alkali metal salts such as sodium, lithium and potassium salts, alkaline earth metal salts such as calcium and magnesium salts, zinc salts, salts with organic bases (e.g. organic amines) such as N-Me-D-glucamine, N- [1-(2,3-Dioleoyloxy)propyl]-N,N,N-trimethylammonium chloride, choline, tromethamine, dicyclohexylamine, t-butylamine and salts with amino acids such as arginine, lysine and the like. In one embodiment, the CpG-C ODNs are in the salt forms of ammonium, sodium, lithium or potassium. In a preferred embodiment, the CpG-C ODNs are in the salt form of sodium. The CpG-C ODN can be provided in a pharmaceutical solution comprising a pharmaceutically acceptable excipient. Alternatively, the CpG-C ODN may also be provided as a lyophilized solid which is subsequently reconstituted in sterile water, saline, or a pharmaceutically acceptable buffer prior to administration.

The pharmaceutically acceptable excipients of the present disclosure include, for example, solvents, fillers, buffering agents, tonicity regulators and preservatives. In one embodiment, the pharmaceutical compositions may contain an excipient that functions as one or more solvents, bulking agents, buffering agents, and tonicity regulators (e.g., sodium chloride in saline may serve as both an aqueous vehicle and a tonicity regulator). The pharmaceutical compositions of the present disclosure are suitable for parenteral and/or percutaneous administration.

In one embodiment, the pharmaceutical compositions comprise an aqueous vehicle as a solvent. Suitable vehicles include, for example, sterile water, saline, phosphate-buffered saline and Ringer's solution. In one embodiment, the composition is isotonic.

The pharmaceutical compositions may comprise a filler. Fillers are particularly useful when the pharmaceutical composition is to be lyophilized prior to administration. In one embodiment, the filler is a protective agent that helps stabilize and prevent degradation of the active ingredients during freeze or spray drying and/or during storage. Suitable fillers are sugars (mono-, di- and polysaccharides) such as sucrose, lactose, trehalose, mannitol, sorbital, glucose and raffinose.

The pharmaceutical compositions may comprise a buffering agent. Buffering agents control pH to prevent degradation of the active ingredient during processing, storage and, if necessary, reconstitution. Suitable buffers include, for example, salts comprising acetate, citrate, phosphate or sulfate. Other suitable buffers include amino acids such as arginine, glycine, histidine and lysine. The buffering agent may also include hydrochloric acid or sodium hydroxide. In some embodiments, the buffering agent maintains the pH of the composition in a range of 4 to 9. In one embodiment, the pH is higher than (lower limit) 4, 5, 6, 7 or 8. In some embodiments, the pH Value lower than (upper limit) 9, 8, 7, 6 or 5. That is, the pH value is in the range of approximately 4 to 9, with the lower limit being less than the upper limit.

The pharmaceutical compositions may comprise a tonicity regulator. Suitable tonicity regulators include, for example, dextrose, glycerol, sodium chloride, glycerin and mannitol.

The pharmaceutical compositions may comprise a preservative. Suitable preservatives include, for example, antioxidants and antimicrobials. However, in one embodiment, the pharmaceutical composition is prepared under sterile conditions and is in a single-use container such that the addition of a preservative is not required.

Table 1 describes the batch formula for the drug SD-101 - 16 g/l: Table 1 ingredient Degree concentration Quantity per batch Clinical lot DVXA05 Batch size 2.224 l Active ingredient SD-101* GMP 1.6% 16.00g 35.584g ¹ Sodium phosphate, dibasic anhydric USP/NF, EP 1.02% 1.02g 2.268g Sodium phosphate, monobasic anhydrous USP 0.34% 0.34g 0.747g Sodium chloride USP/NF, EP 7.31% 7.31g 16.257g Sterile water for injection USP/NF, EP QS QS 2.224 I (kg) (QS) ¹ Quantity based on measured content in solution (not taking into account moisture in freeze-dried powder) * Drug substance SD-101 in Table 1 reflects the totality of all oligonucleotide contents, including SD-101.

In some embodiments, the single dose strength may include a value from about 0.1 mg/ml to about 20 mg/ml. In one embodiment, the single dose strength of SD-101 is 13.4 mg/ml.

In some embodiments, the amount of SD-101 administered is in the range of about 0.01-20 mg or is at least one of 0.5 mg, 2 mg, 4 mg, or 8 mg.

In some embodiments, SD-101 is administered in a solution in the range of 1-100 ml or at least one of 10 ml, 25 ml or 50 ml.

In some embodiments, the administered dose of SD-101 is in the range of 0.0001-20 mg/ml. In some embodiments, the dose of SD-101 administered is one of 0.01 mg/ml, 0.04 mg/ml, 0.08 mg/ml, or 0.16 mg/ml.

CpG-C ODNs may contain modifications. Suitable modifications may include, but are not limited to, 3'OH or 5'OH group modifications, nucleotide base modifications, sugar moiety modifications, and phosphate group modifications. Modified bases can be included in the palindromic sequence as long as the modified base(s) maintain the same specificity for their natural complement through Watson-Crick base pairing (e.g. the palindromic part of the CpG-C ODN remains self-complementary) . Examples of 5'OH group modifications may include biotin, cyanine 5.5, the cyanine dye family, Alexa Fluor 660, the Alexa Fluor dye family, IRDye 700, IRDye 800, IRDye 800CW and the IRDye dye family.

CpG-C ODNs can be linear, can be circular, or contain circular parts and/or a hairpin loop. CpG-C ODNs can be single-stranded or double-stranded. CpG-C ODNs can be DNA, RNA or a DNA/RNA hybrid.

CpG-C ODNs can contain naturally occurring or modified non-naturally occurring bases as well as modified sugars, phosphates and/or termini. In addition to the phosphodiester bonds, the phosphate modifications include, for example, methyl phosphonate, phosphorothioate, phosphoramidate (bridging or non-bridging), phosphotriester and phosphorodithioate and can be used in any combination. In one embodiment, CpG-C ODNs have only phosphorothioate bonds, only phosphodiester bonds, or a combination of phosphodiester and phosphorothioate bonds.

Sugar modifications known in the art, such as 2'-alkoxy-RNA analogs, 2'-amino-RNA analogs, 2'-fluoro-DNA and 2'-alkoxy or amino-RNA/DNA chimeras and others herein Sugar modifications described can also be prepared and combined with any phosphate modification. Examples of base modifications include, but are not limited to, the addition of an electron-withdrawing moiety to C-5 and/or C-6 of a cytosine of the CpG-C ODN (e.g. 5-bromocytosine, 5-chlorocytosine, 5-fluorocytosine, 5-iodocytosine ) and C-5 and/or C-6 of a uracil of the CpG-C ODN (e.g. 5-bromouracil, 5-chlorouracil, 5-fluorouracil, 5-ioduracil). As already mentioned, the use of a base modification in a palindromic sequence of a CpG-C ODN should not affect the self-complementarity of the bases involved in Watson-Crick base pairing. However, outside of a palindromic sequence, modified bases can be used without this restriction. For example, 2'-O-methyl-uridine and 2'-O-methyl-cytidine can be used outside the palindromic sequence, whereas 5-bromo-2'-deoxycytidine can be used both inside and outside the palindromic sequence. Other modified nucleotides that can be used both inside and outside the palindromic sequence include 7-deaza-8-aza-dG, 2-amino-dA and 2-thio-dT.

Duplex (i.e., double-stranded) and hairpin forms of most ODNs are often in dynamic equilibrium, with the hairpin form generally predominant at low oligonucleotide concentration and higher temperatures. Covalent interstrand or intrastrand crosslinks increase the duplex or hairpin stability against thermal, ionic, pH, and concentration-induced conformational changes. Chemical cross-links can be used to fix the polynucleotide in either the duplex or hairpin form for physicochemical and biological characterization.
Cross-linked ODNs that are conformationally homogeneous and “fixed” in their most active form (either duplex or hairpin) could potentially be more active than their uncross-linked counterparts. Accordingly, some CpG-C ODNs of the present disclosure may contain covalent interstrand and/or intrastrand crosslinks.

The techniques for producing polynucleotides and modified polynucleotides are known in the art. Naturally occurring DNA or RNA containing phosphodiester bonds can generally be synthesized by sequentially coupling the corresponding nucleoside phosphoramidite to the 5'-hydroxy group of the growing ODN, which is attached to a solid support at the 3' end, followed by oxidation the intermediate phosphite triester to a phosphate triester. Once the desired polynucleotide sequence has been synthesized, the polynucleotide is removed from the support using this process, the phosphate triester groups are deprotected to phosphate diesters, and the nucleoside bases are deprotected using aqueous ammonia or other bases.

The CpG-C ODN may contain phosphate-modified oligonucleotides, some of which are known to stabilize the ODN. Accordingly, some embodiments include stabilized CpG-C ODNs. The phosphorus derivative (or modified phosphate group) that can be attached to the sugar or sugar analog moiety in the ODN can be a monophosphate, diphosphate, triphosphate, alkyl phosphonate, phosphorothioate, phosphorodithioate, phosphoramidate or the like.

CpG-C ODNs may include one or more ribonucleotides (containing ribose as the sole or major sugar component), deoxyribonucleotides (containing deoxyribose as the major sugar component), modified sugars, or sugar analogs. In addition to ribose and deoxyribose, the sugar component can also be pentose, deoxypentose, hexose, deoxyhexose, glucose, arabinose, xylose, lyxose and a sugar-analogous cyclopentyl group. The sugar can have a pyranosyl or furanosyl form. In the CpG-C oligonucleotide, the sugar moiety is preferably the furanoside of ribose, deoxyribose, arabinose or 2'-0-alkylribose, and the sugar may be bound to the respective heterocyclic bases in any anomeric configuration. The production of these sugars or sugar analogues and the corresponding nucleosides, whereby these sugars or analogues are bound to a heterocyclic base (nucleic acid base), is known per se and therefore does not need to be described here. Sugar modifications can also be made and combined with any phosphate modification in producing a CpG-C ODN.

The heterocyclic bases or nucleic acid bases incorporated into the CpG-C ODN may include the major naturally occurring purine and pyrimidine bases (namely, uracil, thymine, cytosine, adenine and guanine, as mentioned above), as well as naturally occurring ones and synthetic modifications of these main bases. Thus, a CpG-C ODN may include one or more of inosine, 2'-deoxyuridine and 2-amino-2'-deoxyadenosine.

According to another embodiment, the CPG-ODN is one of Class A CPG-ODNs (CPG-A ODNs), Class B CPG-ODNs (CPG-B ODNs), Class P CPG-ODNs (CPG-P ODN), and Class S CPG ODNs (CPG-S ODN). The CPG-A ODN in this context can be CMP-001.

In another embodiment, the CPG-ODN may be tilsotolimod (IMO-2125).

According to one embodiment, in vitro studies in human peripheral blood mononuclear cells (PMBC) further demonstrate that SD-101 is a class B TLR9 agonist and a TLR7 agonist in reducing MDSC , reducing M2 macrophages and promoting M1 macrophages is superior. 2 for example, shows an in vitro analysis of human PMBC obtained from healthy donors and treated with IL6 and GM-CSF to induce MDSC. In this regard, SD-101 (i) showed better elimination of the dominant MDSC subset in the liver, e.g. the M-MDSC, and (ii) a more favorable effect on the M1/M2 macrophage ratio (ie, induction of M1 and reduction of M2).

Further, in vitro studies on mouse bone marrow cells according to one embodiment demonstrate that SD-101 is similarly superior to a class B TLR9 agonist and a TLR7 agonist in programming murine myeloid cells. 3 for example, shows an in vitro analysis of murine bone marrow cells in which GM-CSF was used to induce MDSC, from mice with or without tumor. In this regard, SD-101 was superior to TLR9 class A agonists, TLR9 class B agonists, and TLR7 agonists in reducing MDSC and M2 macrophages in addition to inducing M1 macrophages.

Checkpoint inhibitors

According to one embodiment, the TLR agonists of the present invention can be used in combination with one or more CPls. The CPI may include a programmed death-1 receptor (PD-1) antagonist. A PD-1 antagonist can be any chemical compound or biological molecule that interferes with the binding of programmed cell death-1 ligand-1 (PD-L1) expressed on a cancer cell to that expressed on an immune cell (T cell, B cell or NKT cell) blocks PD-1 and preferably also blocks the binding of the PD-L2 programmed cell death 1 ligand 2 (PD-L2) expressed on a cancer cell to the PD expressed by the immune cell. 1 blocked. Alternative names or synonyms for PD-1 and its ligands include: PDCD1, PD1, CD279 and SLEB2 for PD-1; PDCD1L1, PDL1, B7H1, B7-4, CD274 and B7-H for PD-L1; and PDCD1L2, PDL2, B7-DC, Btdc and CD273 for PD-L2. In all treatment methods, drugs and applications of the present invention in which a human is being treated, the PD-1 antagonist blocks the binding of human PD-L1 to human PD-1 and preferably the binding of both human PD-L1 and PD-L2 to human PD-1.

According to one embodiment, the PD-1 antagonist may include a monoclonal antibody (mAb) or an antigen-binding fragment thereof that specifically binds to PD-1 or PD-L1, and preferably specifically to human PD-1 or human PD-L1 binds. The mAb may be a human antibody, a humanized antibody or a chimeric antibody and may contain a human constant region. In some embodiments, the human constant region is selected from the group consisting of IgG1, IgG2, IgG3, and IgG4 constant regions, and in preferred embodiments, the human constant region is an IgG1 or IgG4 constant region. In some embodiments, the antigen-binding fragment is selected from the group consisting of Fab, Fab'-SH, F(ab') ₂ , scFv and Fv fragments.

According to one embodiment, the PD-1 antagonist may include an immunoadhesin that specifically binds to PD-1 or PD-L1 and preferably specifically binds to human PD-1 or human PD-L1, e.g. B. a fusion protein containing the extracellular or PD-1 binding portion of PD-L1 or PD-L2 fused to a constant region such as an Fc region of an immunoglobulin molecule.

According to one embodiment, the PD-1 antagonist can block PD-L1 expressed by tumor cells and MDSC as well as other suppressive immune cells.

According to one embodiment, the PD-1 antagonist can inhibit the binding of PD-L1 to PD-1, and preferably also inhibits the binding of PD-L2 to PD-1. In some embodiments of the foregoing treatment method, drugs and uses, the PD-1 antagonist is a monoclonal antibody or an antigen-binding fragment thereof that specifically targets PD-1 or binds to PD-L1 and blocks the binding of PD-L1 to PD-1. In one embodiment, the PD-1 antagonist is an anti-PD-1 antibody comprising a heavy chain and a light chain.

According to one embodiment, the PD-1 antagonist may be one of nivolumab, pembrolizumab, cemiplimab and dostarlimab.

According to one embodiment, nivolumab is administered intravenously (IV) via a peripheral vein at a dose of 480 mg every four weeks (“Q4W”) or 240 mg every two weeks (“Q2W”). According to another embodiment, nivolumab is administered intravenously (IV) via a peripheral vein at a dose of 360 mg nivolumab every three weeks (“Q3W”). In another embodiment, the dosage of nivolumab is weight-dependent, based on 3 mg/kg Q2W or 10 mg/kg Q2W nivolumab.
In another embodiment, the dosage of nivolumab is weight-dependent, based on 1 mg/kg Q3W nivolumab. In another embodiment, nivolumab is administered concurrently, at the same time, at approximately the same time, or on the same day as SD-101. In another embodiment, nivolumab is administered weekly, every two weeks, every three weeks, every four weeks, or monthly after administration of one or more cycles of SD-101.

According to another embodiment, pembrolizumab is administered intravenously (IV) via a peripheral vein at a dose of 200 mg Q3W or 400 mg every 6 weeks (“Q6W”). In another embodiment, pembrolizumab is administered concurrently, at the same time, at approximately the same time, or on the same day as SD-101.

According to another embodiment, the CPI may include a PD-L1 antagonist. In this context, the PD-L1 antagonist can be any of atezolizumab, avelumab and durvalumab.

According to another embodiment, the CPI may include a CTLA-4 antagonist. The CTLA-4 antagonist in this context can be ipilimumab.

According to one embodiment, ipilimumab is administered intravenously (IV) via a peripheral vein at a dose of 3 mg/kg every three weeks. In another embodiment, ipilimumab is administered concurrently, at the same time, at approximately the same time, or on the same day as SD-101 and/or nivolumab. In another embodiment, ipilimumab is administered weekly, every two weeks, every three weeks, every four weeks, or monthly after administration of one or more cycles of SD-101 and/or nivolumab.

Devices for achieving locoregional administration

According to one embodiment, each of the devices described above may include any device useful for achieving locoregional delivery to a tumor, including a catheter itself, or may include a catheter together with other components (e.g., filter valve, balloon, pressure sensor system, pump system, syringe, external delivery catheter, etc.) that can be used in combination with the catheter. In certain embodiments, the catheter is a microcatheter.

In some embodiments, the device may have one or more features including, but not limited to: self-centering capability that can provide homogeneous distribution of therapy in a downstream branching network of vessels; anti-reflux ability, which can block or inhibit the retrograde flow of the TLR agonist (for example, using a valve and filter and/or a balloon); a system for measuring the pressure inside the vessel; and a means for modulating the pressure inside the vessel, e.g. B. by causing a decrease in pressure during placement and during infusion of the TLR agonist, and an increase in pressure during the saline bolus or during bolus infusion of the TLR agonist. In some embodiments, the system is designed to monitor pressure or flow in real time throughout the procedure.

In some embodiments, the apparatus that may be used to carry out the methods of the present invention is an apparatus as described in U.S. Patent No. 8,500,775 , US Patent No. 8,696,698 , US Patent No. 8,696,699 , US Patent No. 9,539,081 , US Patent No. 9,808,332 , US Patent No. 9,770,319 , US Patent No. 9,968,740 , US Patent No. 10,813,739 , US Patent No. 10,588,636 , US Patent No. 11,090,460 , US Patent Publication No. 2018/0193591 , US Patent Publication No. 2018/0250469 , US Patent Publication No. 2019/0298983 , US Patent Publication No. 2020/0038586 and US Patent Publication No. 2020-0383688 is disclosed, all of which are incorporated herein in their entirety by reference.

In some embodiments, the device is a device such as that described in U.S. Patent No. 9,770,319 is revealed. In certain embodiments, the device may be a device known as a Surefire Infusion System.

In some embodiments, the device supports measurement of intravascular pressure during use. In some embodiments, the device is a device as disclosed in U.S. Patent Publication No. 2020-0383688. In certain embodiments, the device may be a device known as a TriSalus Infusion System. In certain embodiments, the device may be a device known as a ^TriNav® Infusion System. The TriNav ^® is a single-lumen catheter equipped with a one-way valve that responds dynamically to local pressure and flow changes, such as those found in: B. caused by the cardiac cycle or by infusions. The valve structure modulates distal vascular pressures and blood flow. This, in turn, may alter therapeutic distribution and first-pass absorption due to the prolonged contact time in the vasculature.

In some embodiments, the TLR agonist may be administered via a device using PEDD. In some embodiments, the TLR agonist may be administered while monitoring the pressure in the vessel, which may be used to adjust and correct the positioning of the device at the infusion site and/or adjust the infusion rate. The pressure can e.g. B. be monitored by a pressure sensor system that includes one or more pressure sensors.

The infusion rate can be adjusted to alter vascular pressure or flow, which may promote penetration and/or binding of the TLR agonist into or on the surface of the target tissue or tumor. In some embodiments, the infusion rate may be adjusted and/or controlled using a syringe pump as part of the delivery system or by another method (e.g., a device for regulating the infusion flow rate). In some embodiments, the infusion rate may be adjusted and/or controlled using a pump system. In some embodiments, the infusion rate using a pump system may be about 0.1 cc/min to about 40 cc/min, or about 0.1 cc/min to about 30 cc/min, or about 0.5 cc/min to about 25 cc/min, or about 0.5 cc/min to about 20 cc/min, or about 1 cc/min to about 15 cc/min, or about 1 cc/min to about 10 cc/min, or about 1 cc/min min to about 8 cc/min, or about 1 cc/min to about 5 cc/min. Additionally, when using a bolus infusion, the infusion rate may be about 30 cc/min to about 360 cc/min or about 120 cc/min to about 240 cc/min. In one embodiment, the SD-101 infusion procedure takes approximately 10-200 minutes. In another embodiment, the SD-101 infusion procedure takes approximately 10-60 minutes. In another embodiment, the SD-101 infusion procedure takes approximately 25 minutes.

Methods involving administration to the liver

In one embodiment, the methods of the present invention include methods of treating a solid tumor in the liver, such as: B. a tumor that is the result of at least one primary liver cancer such as HCC and ICC, or a tumor that has features of both HCC and ICC, the method comprising administering a Toll-like receptor agonist to a patient, which requires it, wherein the Toll-like receptor agonist is administered via a device via HAI to the solid tumor in the liver. HAI refers to the infusion of treatment into the hepatic artery or branches of the hepatic artery. According to one embodiment, the Toll-like receptor agonist(s) are delivered into the branches of a hepatic artery or portal vein by percutaneous introduction of a device, such as. B. a catheter and/or a device that enables pressure-activated administration. According to one embodiment, the Toll-like receptor agonist is a TLR9 agonist, and in some embodiments the TLR9 agonist is SD-101. In one embodiment, the patient is a human patient. According to another embodiment, the methods include administration to a subject who is male or female and eighteen years of age or older.

According to another embodiment, the methods of the present invention include methods of treating a solid tumor in the liver, such as: B. a tumor that is the result of at least one primary liver cancer such as HCC and ICC, or a tumor that has features of both HCC and ICC, the method comprising administration of a Toll-like receptor agonist to a Patient in need thereof, wherein the Toll-like receptor agonist is administered via a device via PVI to the solid tumor in the liver. PVI refers to the infusion of treatment into the hepatic portal system. According to one embodiment, the Toll-like receptor agonist(s) are delivered into the branches of a hepatic portal system by percutaneous introduction of a device such as: B. a catheter and/or a device that enables pressure-activated administration. According to one embodiment, the Toll-like receptor agonist is a TLR9 agonist, and in some embodiments the TLR9 agonist is SD-101. In one embodiment, the patient is a human patient.

According to another embodiment, the methods of the present invention include methods for treating at least one primary liver cancer such as HCC and ICC or a tumor having features of both HCC and ICC, wherein the subject has no prior cytotoxic chemotherapy, targeted therapy or external beam radiation therapy within from 14 days before admission. According to another embodiment, the methods of the present invention are administered to subjects who have never received therapy with SD-101. According to one embodiment of the invention, the methods also include administration to subjects who have never received HAI embolic therapy with permanent embolic material.

According to another embodiment, the methods of the present invention include a method of treating at least one primary liver cancer such as HCC and ICC or a tumor having features of both HCC and ICC, wherein the subject has no history of malignancy or other concurrent malignancy , unless the malignancy is clinically insignificant. In another embodiment, subjects treated according to the methods of the present invention may not receive ongoing treatment. In another embodiment, the subject is clinically stable.

In another embodiment, the methods of the present invention may include administration to a subject having measurable disease in the liver according to the criteria of RECIST V.1.1. In another embodiment, the methods of the present invention may include administration to a subject who has an Eastern Cooperative Oncology Group (ECOG) Performance Score (PS) of 0-1 at screening. In another embodiment, subjects receiving therapy according to the methods of the present invention have an investigator-estimated life expectancy of greater than 3 months at the time of examination. In another embodiment, subjects have a QTc interval ≤ 480 msec.

In another embodiment, any associated clinically significant drug-related toxicities of prior cancer therapy have resolved prior to treatment. In this embodiment, the resolution corresponds to grade ≤ 1 or the patient's pretreatment value. In another embodiment, the subject may have grade 2 alopecia and endocrinopathies that are controlled by replacement therapy.

In another embodiment, the methods of the present invention may include administration to a subject who has adequate organ function upon screening. In one embodiment, a subject with adequate organ function may have one or more of the following: (i) platelet count > 100,000/µL, (2) hemoglobin ≥ 8.0 g/dL, (3) white blood cell (WBC) count > 2,000/ µl, (4) serum creatinine ≤ 2.0 mg/dl, unless the measured creatinine clearance is ≥ 30 ml/min, calculated using the Cockcroft-Gault formula, (5) total and direct bilirubin ≤ 2, 0 x the upper limit of normal (ULN) and alkaline phosphatase ≤ 5 x ULN, (6) in patients with documented Gilbert's disease, total bilirubin up to 3.0 mg/dL, (7) ALT and AST ≤ 5 x ULN and (8) Prothrombin time/International Normalized Ratio (INR) or activated partial thromboplastin time (aPTT) test results at screening ≤1.5 x ULN (this only applies to patients not receiving therapeutic anticoagulation; patients receiving therapeutic anticoagulation should be treated prior to the first dose of the study intervention on a stable dose for at least 4 weeks).

According to one or more embodiments, the methods of the present invention include methods of treating a primary liver cancer, such as: B. HCC or ICC, where the subject has histologically or cytologically confirmed HCC or ICC with disease that affects only the liver or is liver dominant. In liver-dominant disease, intrahepatic disease may account for the majority of the disease or, with progression of HCC or ICC, pose a significant threat to the patient's life.

In one or more embodiments, the methods of the present invention may include administering to a subject scoring on the Child-Pugh Liver Function Scale (a scale with three categories [A, B, or C], where C indicates the most severe impairment of liver function). Class A rating. In one or more further embodiments, the methods of the present invention may include administration to a subject with adequate hematologic and organic function.

In one or more embodiments, methods of the present invention may include administration to a subject who has previously received at least one standard line of systemic therapy for liver cancer and has persistent or progressive measurable disease as defined by RECIST Version 1.1, refractory to curative therapies addresses.

According to another embodiment, the tumor is unresectable.

According to another embodiment, the methods of the present invention may be administered with other cancer therapeutics such as immunomodulators, tumoricidal agents, and/or other targeted therapeutics.

According to one embodiment, TLR9 therapy may be administered in combination with cell therapy (enabling cell therapy by modulating the immune system), chemoembolic treatment, or radioembolic treatment.

In one embodiment, the above methods of liver administration are intended to result in penetration of the Toll-like receptor agonist throughout the entire solid tumor, throughout the entire organ, or substantially throughout the entire tumor. In one embodiment, such methods improve the perfusion of the Toll-like receptor agonist to a patient in need thereof, including by overcoming interstitial fluid pressure and tumor solid stress. In another embodiment, perfusion through an entire organ or a portion thereof may provide benefits for the treatment of the disease by fully exposing the tumor to the therapeutic agent. In one embodiment, such methods are better able to facilitate delivery of the Toll-like receptor to areas of the tumor that have poor access to systemic circulation. In another embodiment, such methods administer higher concentrations of the Toll-like receptor agonist into such a tumor, with a lower amount of Toll-like receptor agonist being administered to non-target tissue, compared to conventional systemic administration via a peripheral route Vein. Non-target tissues are tissues that are perfused directly through the arterial network in direct connection with the infusion device. In one embodiment, such procedures result in reduction in size, reduction in growth rate, shrinkage, or elimination of the solid tumor.

The methods of the present invention may also include mapping the vessels leading to the right and left lobes of the liver before performing HAI, or selective infusion into specific sectors or segments and, if necessary, occlusion of vessels not leading to the liver or that are otherwise not a target. In some embodiments, patients may undergo a mapping angiogram prior to infusion, e.g. B. via access to the common femoral artery.

Methods for mapping vessels in the body and administering therapeutics are well known to those of ordinary skill in the art. For example, occlusion can be achieved through the use of microcoil embolization, which allows the doctor to block arteries or vessels outside the target area, thereby optimizing the delivery of the modified cells to the liver. Microcoil embolization may be performed as needed, for example before administration of the first dose of TLR9 agonists, to allow optimal infusion of a pharmaceutical composition comprising the TLR9 agonists. In another embodiment, a sterile sponge (e.g. GELFOAM) may be used. In this context, the sterile sponge can be cut and pushed into the catheter. In another embodiment, the sterile sponge can be provided as granules.

In some embodiments, doses of a TLR9 agonist, such as: B. SD-101, about 0.01 mg, about 0.03 mg, about 0.05 mg, about 0.1 mg, about 0.3 mg, about 0.5 mg, about 1 mg, about 1.5 mg, about 2 mg, about 2.5 mg, about 3 mg, about 3.5 mg, about 4 mg, about 4.5 mg, about 5 mg, about 5.5 mg, about 6 mg, about 6.5 mg, about 7 mg, about 7.5 mg or about 8 mg. In some embodiments, SD-101 is administered in doses of 12 mg, 16 mg, and 20 mg. Administration of a milligram amount of SD-101 (e.g., about 2 mg) describes administration of about 2 mg of the in 1 composition shown. For example, such an amount of SD-101 (e.g., about 2 mg) may also be included in a composition that, in addition to such an amount of SD-101, also contains other material, such as: B. other related and unrelated compounds. Equivalent molar amounts of other pharmaceutically acceptable salts are also considered.

In some embodiments, doses of a TLR9 agonist, such as: B. SD-101, between about 0.01 mg and about 20 mg, about 0.01 mg and about 10 mg, between about 0.01 mg and about 8 mg and between about 0.01 mg and about 4 mg. In some embodiments, doses of a TLR9 agonist, such as: B. SD-101, between about 2 mg and about 10 mg, between about 2 mg and about 8 mg and between about 2 mg and about 4 mg. In some embodiments, doses of a TLR9 agonist, such as: B. SD-101, less than about 10 mg, less than about 8 mg, less than about 4 mg or less than about 2 mg. Such doses may be administered daily, weekly, or biweekly. In one embodiment, the dose of SD-101 is increased gradually, e.g. B. by administering about 2 mg, followed by about 4 mg and then followed by about 8 mg.

In some embodiments, the methods of the present invention may include administering a dosage regimen comprising cycles in which one or more of the cycles include administration of SD-101 via HAI and PEDD. As used herein, a “cycle” is a repetition of a dosing sequence. In one embodiment, a cycle includes three weekly doses per cycle (i.e., administration of SD-101 once per week for three consecutive weeks). In one embodiment, a treatment cycle according to the present invention may include periods of administration of SD-101 followed by periods of “non-administration” or rest periods. In another embodiment, in addition to the three weekly doses per cycle, the cycle includes one week, two weeks, three weeks, or four weeks as a rest period following weekly administration of SD-101. In another embodiment, in addition to the three weekly doses per cycle, the cycle includes approximately thirty-eight days as a rest period following weekly administration of SD-101. In another embodiment, the entire cycle includes approximately fifty-two days. In another embodiment, the dosage regimen comprises at least one, at least two, or at least three cycles or longer.

In some embodiments, the present invention relates to the use of a TLR9 agonist in the manufacture of a medicament for treating a solid tumor in the liver, such as: B. a tumor that is the result of a primary liver cancer such as HCC and ICC, the method comprising administering the TLR9 agonist to a patient in need thereof, the TLR9 agonist being delivered to the solid tumor via a device via HAI is administered to the liver.

In some embodiments, SD-101 is administered for the treatment of primary liver cancers such as HCC and ICC at a dose of 0.5 mg via HAI, and in some embodiments, the SD-101 is further administered via a device that modulates pressure (i.e., PEDD). In some embodiments, SD-101 is administered at a dose of 0.5 mg via HAI via a vascular pressure modulating device in combination with a CPI, the CPI being nivolumab. In other embodiments, SD-101 is administered at a dose of 0.5 mg via HAI and via a pressure modulating device in combination with ipilimumab. In some embodiments, SD-101 is administered at a dose of 0.5 mg by HAI and via a pressure modulating device in combination with ipilimumab and nivolumab. In other embodiments, SD-101 is administered at a dose of 0.5 mg via HAI and via a pressure modulating device in combination with pembrolizumab.

In some embodiments, SD-101 is administered for the treatment of primary liver cancers such as HCC and ICC at a dose of 2 mg via HAI, and in some embodiments, the SD-101 is further administered via a pressure modulating device (ie, PEDD). . In some embodiments, SD-101 is administered at a dose of 2 mg by HAI via a vascular pressure modulating device in combination with a CPI, the CPI being nivolumab. In other embodiments, SD-101 is administered at a dose of 2 mg via HAI and via a pressure modulating device in combination with ipilimumab. In some embodiments, SD-101 is administered at a dose of 2 mg using HAI and via a pressure modulating device in combination with Ipili mumab and nivolumab administered. In other embodiments, SD-101 is administered at a dose of 2 mg via HAI and via a pressure modulating device in combination with pembrolizumab.

In some embodiments, SD-101 is administered for the treatment of primary liver cancers such as HCC and ICC at a dose of 4 mg via HAI, and in some embodiments, the SD-101 is further administered via a pressure modulating device (i.e., PEDD). . In some embodiments, SD-101 is administered at a dose of 4 mg via HAI via a vascular pressure modulating device in combination with a CPI, the CPI being nivolumab. In other embodiments, SD-101 is administered at a dose of 4 mg via HAI and via a pressure modulating device in combination with ipilimumab. In some embodiments, SD-101 is administered at a dose of 4 mg by HAI and via a pressure modulating device in combination with ipilimumab and nivolumab. In other embodiments, SD-101 is administered at a dose of 4 mg via HAI and via a pressure modulating device in combination with pembrolizumab.

In some embodiments, SD-101 is administered for the treatment of primary liver cancers such as HCC and ICC at a dose of 8 mg via HAI, and in some embodiments, the SD-101 is further administered via a pressure modulating device (i.e., PEDD). . In some embodiments, SD-101 is administered at a dose of 8 mg via HAI via a vascular pressure modulating device in combination with a CPI, the CPI being nivolumab. In other embodiments, SD-101 is administered at a dose of 8 mg via HAI and via a pressure modulating device in combination with ipilimumab. In some embodiments, SD-101 is administered at a dose of 8 mg by HAI and via a pressure modulating device in combination with ipilimumab and nivolumab. In other embodiments, SD-101 is administered at a dose of 8 mg via HAI and via a pressure modulating device in combination with pembrolizumab.

In one or more embodiments, methods of the present invention may include administering up to 6 doses (maximum 2 cycles of SD-101, 3 weekly doses per cycle) to a subject. In one or more embodiments, fewer doses or cycles of SD-101 may be administered based on the subject's toxicity or tolerability.

In one or more embodiments, a solution of SD-101 may be administered to a subject via HAI using a PEDD device such as the ^TriNav® . In some such embodiments, vascular access may be achieved via the femoral artery or the radial artery. Hemangiomas, shunt vessels or other vascular lesions in the liver that could compromise the therapeutic effect may be embolized at the discretion of the treating interventional radiologist. In one or more embodiments, SD-101 may be prepared and provided in a 50 mL syringe (therapeutic dose) and a 100 mL vial containing the volume required for therapeutic irrigation (10 mL), each in the therapeutic concentration. The PEDD device can then be advanced into the target vessels.

In one or more embodiments, the 50 ml solution of SD-101 may be administered per segment or sector of the liver. In one or more embodiments, the therapeutic dose of 50 ml of SD-101 may be allocated as follows: 3 x 10 ml infusions into the target blood vessels of the right hepatic lobe and 2 x 10 ml infusions into the target blood vessels of the left hepatic lobe. Additionally, the distribution of the 10 mL aliquots can be adjusted based on the location of measurable disease and the target vessel diameter. In one or more embodiments, the infusion of SD-101 is expected to take approximately 10 to 60 minutes. For example, in some embodiments, the infusion time may be approximately 25 minutes. Furthermore, in another embodiment, the entire interventional procedure may take between 30 and 80 minutes. This includes all handling time between infusions at different locations. In some embodiments, the 50 mL solution of SD-101 may include one of 0.5 mg, 2 mg, 4 mg, or 8 mg of SD-101. In this context, the infused dose of SD-101 may be one of 0.01 mg/ml, 0.04 mg/ml, 0.08 mg/ml or 0.16 mg/ml.

According to another embodiment, SD-101 may be prepared and provided in a 25 ml solution. In some embodiments, the 25 mL solution of SD-101 may include one of 0.5 mg, 2 mg, 4 mg, or 8 mg of SD-101. In this context, the infused dose of SD-101 may be one of 0.02 mg/ml, 0.08 mg/ml, 0.16 mg/ml or 0.32 mg/ml.

According to another embodiment, SD-101 may be prepared and provided in a 10 ml solution. In some embodiments, the 10 mL solution of SD-101 may be one of 0.5 mg, 2 mg, 4 mg or 8 mg SD-101. In this context, the infused dose of SD-101 may be one of 0.05 mg/ml, 0.2 mg/ml, 0.4 mg/ml or 0.8 mg/ml.

In some embodiments, the methods of the present invention result in the treatment of target lesions. In this embodiment, the methods of the present invention can result in a complete response that includes the disappearance of all target lesions. In some embodiments, the methods of the present invention may result in a partial response that includes a decrease in the sum of the longest diameters of the target lesions by at least 30%, using the baseline sum of the longest diameters as a reference. In some embodiments, the methods of the present invention may result in stable disease of the target lesions that includes neither sufficient shrinkage to be considered a partial response nor sufficient enlargement to be considered progressive disease, the smallest sum of the longest diameter serves as a reference since the start of treatment. In such an embodiment, a progressive disease is characterized by an increase of at least 20% in the sum of the longest diameters of the target lesions, taking as reference the smallest sum of the longest diameters recorded since the start of treatment or the appearance of one or more new lesions serves. The total must show an absolute increase of 5 mm.

In another embodiment, the methods of the present invention result in the treatment of non-target lesions. Non-target lesions are lesions that are not directly perfused through the arterial network in direct communication with the infusion system. In this embodiment, the methods of the present invention can result in a complete response that includes the disappearance of all non-target lesions. In some embodiments, the methods of the present invention result in the persistence of one or more non-target lesions while not resulting in complete response or progressive disease. In such an embodiment, progressive disease is characterized by clear progression of existing non-target lesions and/or the appearance of one or more new lesions.

In some embodiments, the methods of the present invention result in a beneficial overall response rate, such as: B. an overall response rate according to RECIST V.1.1. In these embodiments, the methods of the present invention result in an overall response, which is a complete response, wherein the subject has a complete response of the target lesions, a complete response of the non-target lesions, and no new lesions. In other embodiments, the methods of the present invention result in an overall response that is a partial response, wherein the subject has a complete response of the target lesions, an incomplete response and non-progressive disease of the non-target lesions, and no new lesions. In other embodiments, the methods of the present invention result in an overall response that is a partial response, wherein the subject has a partial response of the target lesions, non-progressive disease of the non-target lesions, and no new lesions. In another embodiment, the methods of the present invention result in an overall response that is stable disease, wherein the subject has stable disease of target lesions, non-progressive disease of non-target lesions, and no new lesions.

In some embodiments, the methods of the present invention result in an extended duration of overall response. In some embodiments, the duration of overall response is measured from the time the measurement criteria for a complete response or a partial response (whichever is determined first) are met to the first date on which a recurrence or progression occurs the disease is objectively documented (with the lowest measurements since the start of treatment serving as a reference for progression). The duration of complete overall response can be measured from the time when the measurement criteria for a complete response are first met to the first date on which disease progression is objectively documented. In some embodiments, the duration of stable disease is measured from the start of treatment until the criteria for progression are met, using the lowest measurements recorded since the start of treatment, including baseline measurements, as a reference.

In another embodiment, the methods of the present invention result in improved overall survival rates. For example, overall survival can be calculated from the date of enrollment to the date of death. Patients enrolled before the data cutoff date for the final effective Those who are still alive after the end of the study or who drop out before the end of the study are censored on the day on which they were last proven to be alive.

In other embodiments, the methods of the preventative invention result in progression-free survival. For example, progression-free survival can be calculated from the date of enrollment to the time of the CT scan documenting recurrence (or other clear indicator of disease development) or to the date of death, whichever occurs first. Patients who do not have a documented recurrence and are still alive before the data cutoff for the final efficacy analysis or who drop out before the end of the study will be censored at the date of the last radiological evidence documenting the absence of a recurrence.

In some embodiments, the methods of the present invention result in a beneficial overall response rate, such as: B. an overall response rate according to mRECIST. In these embodiments, the methods of the present invention result in an overall response, which is a complete response, wherein the subject has a complete response of the target lesions, a complete response of the non-target lesions, and no new lesions. In other embodiments, the methods of the present invention result in an overall response that is a partial response, wherein the subject has a complete response of the target lesions, an incomplete response and incomplete response of the non-target lesions, and no new lesions. In other embodiments, the methods of the present invention result in an overall response that is a partial response, wherein the subject has a partial response of the target lesions, non-progressive disease of the non-target lesions, and no new lesions. In another embodiment, the methods of the present invention result in an overall response that is stable disease, wherein the subject has stable disease of target lesions, non-progressive disease of non-target lesions, and no new lesions.

In some embodiments, the methods of the present invention result in a beneficial overall response rate, such as: B. an overall response rate according to iRECIST.

According to another embodiment, the methods of the present invention include a method for treating a primary liver cancer such as HCC and ICC, wherein administration of SD-101 results in a reduction in tumor burden. In some embodiments, the tumor burden is reduced by about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90% or reduced by about 100%.

According to another embodiment, the methods of the present invention include a method for treating a primary liver cancer such as HCC and ICC, wherein administration of SD-101 results in a reduction in tumor progression or a stabilization of tumor growth. In some embodiments, tumor progression is reduced by about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90% or reduced by about 100%.

According to another embodiment, the methods of the present invention include a method for treating a primary liver cancer such as HCC and ICC, wherein administration of SD-101 reprograms the MDSC compartment of the liver to enable immune control of the liver cancer and/or response to systemic anti-PD-1 therapy by eliminating MDSC. In some embodiments, the methods of the present invention are superior in controlling MDSC. In some embodiments, the methods of the present invention include a method for treating primary liver cancers such as HCC and ICC, wherein administration of SD-101 increases the frequency of MDSC cells (CD11b+Gr1+), monocytic MDSC cells (M-MDSC; CD11b +Ly6C+), granulocytic MDSC cells (G-MDSC; CD11b+LY6G+) or human MDSC (CD33+CDllb+HLADR- (CD14+ for m-MDSC and CD15+ for G-MDSC)). According to another embodiment, the methods of the present invention enhance M1 macrophages (CD 14+CD86+). According to another embodiment, the methods of the present invention deplete M2 macrophages (CD14+CD163+CD206+).

In another embodiment, the methods of the present invention increase NFκB activation. In another embodiment, the methods of the present invention increase IL-6. In another embodiment, the methods of the present invention increase IL-10. In another embodiment, the methods of the present invention increase IL-29. In another embodiment, increase hen the methods of the present invention IFNα. In another embodiment, the methods of the present invention reduce STAT3 phosphorylation.

The present invention is further illustrated and/or demonstrated in the following examples, which are for illustration and demonstration purposes only and are not intended to limit the invention in any way.

example 1

This study aimed to investigate the distribution of an infused TLR9 agonist, SD-101, in and around a primary liver tumor. In particular, the study was carried out on a novel pig model that forms liver tumors in situ. To recapitulate the development of a primary liver tumor, liver tissue biopsies were taken from the pigs and the cells were then exposed to a vector to induce cancer growth. These cells were then transplanted into the liver tissue through a local needle injection and allowed to develop tumors approximately 2 cm in diameter.

The TLR9 agonist SD-101 sequence oligo was synthesized and conjugated with the fluorophore IRD800CW (ex. 767 nm, em.791 nm). Then, the IRD800CW-SD-101 (1 mL containing 2.5 nmol) was mixed with SD-101 (0.3 mL, containing 4 mg of SD-101 drug) in 9 mL of sterile saline to make a total volume of 10.3 ml for infusion. The solution was infused via HAI using a PEDD device, ie the ^TriNav® .

The Seldinger technique was used to gain access through the femoral artery of the pig under study. A 5F introducer sheath was fixed in place. Angiography was performed using a 5F angiography catheter to identify the anatomy of the hepatic arteries. A vessel with a diameter of 1.5 to 3.5 mm was then selected to supply the entire left lateral, left medial, right medial, or right lateral lobe containing the tumor. The TriNav ^® was then tracked to the location of the target vessel.

The syringe containing the solution was then placed in a syringe pump and administered at a rate of 2 ml/min via the ^TriNav® . After the first 4 mL of solution was infused, a 1 mL high-pressure bolus was administered at a rate of 2 cc/sec for 0.5 seconds. The remainder of the solution was then administered at 2 ml/min.

Normal physiological conditions were maintained for 60 minutes, after which the pigs were euthanized and their livers removed. Each liver lobe was separated and NIR imaging was performed using a Pearl Trilogy Imaging System to identify patterns of drug uptake. Each flap was then cut into 1 cm thick sections and imaged separately on both tissue sides using the Pearl system (85 μm resolution, 700 nm, 800 nm, and white light channels). Total liver volume was analyzed to visualize the distribution of fluorescently labeled SD-101 as in 4 shown. In this context, A shows the regions of tumor tissue and necrosis, B shows the regions of the growing primary tumor and surrounding normal tissue with high uptake of fluorescently labeled SD-101, and C shows the normal tissue (which has little to no fluorescent signal for labeled SD-101 shows).

The study showed that pressure-activated administration of labeled SD-101 using a TriNav ^® resulted in preferential accumulation of the fluorescent compound in the region around the periphery of the actively growing primary liver tumor and the normal tissue surrounding it. This region is expected to contain the majority of immune cells that express TLR9, which is the target of SD-101. In addition, the infusions were passed through vessels that supplied an entire lobe containing a primary tumor, while the majority of the tissue in the blood-supplied area was normal liver. Although SD-101 was not infused through specific vessels supplying the tumor, the use of PEDD resulted in preferential distribution of SD-101 in and around the tumor, with normal liver tissue having relatively low drug exposure.

Example 2

In this example, infusions of a TLR9 agonist, SD-101, were administered with the aim of increasing response rates to CPI therapy in patients with primary liver cancers such as HCC and ICC hen. SD-101 is a TLR9 agonist that can stimulate a variety of immune cells and can also beneficially eliminate or reprogram suppressive immune cells that drive tumor progression in the liver. This study will use pressure-activated delivery (PEDD) via hepatic artery infusion (PEDD/HAI) to enable effective delivery of SD-101 to HCC tumors while limiting systemic exposure.

The study has two phases, namely Phases 1b and 2. In this context, the primary objective of Phase 1b is to determine the safety and maximum tolerated dose (MTD) or optimal dose of SD-101 administered via PEDD/HAI alone , the MTD or optimal dose of SD-101 in combination with pembrolizumab or in combination with both nivolumab and ipilimumab in patients with HCC or ICC or a mixture of HCC and ICC. In addition, the secondary objective is to evaluate the preliminary efficacy in terms of the ORR according to REClST for immune-based therapeutics (iRECIST), the ORR according to modified RECIST (mRECIST), the liver-specific response rate (HRR) according to RECIST 1.1, the overall progression-free survival (PFS) and clinical benefit (complete response [CR] + partial response [PR] + stable disease [SD]). The primary objective of Phase 2 is to evaluate the overall response rate (ORR) to PEDD/HAI of SD-101 in combination with intravenous (IV) immune checkpoint blockade according to the Response Evaluation Criteria in Solid Tumors (RECIST) V1.1. The checkpoint scheme used in combination with SD-101 will be selected based on the safety and response data from Phase 1b. Separate cohorts for HCC and ICC will be enrolled. Furthermore, the secondary objective is to evaluate the duration of response (DOR), 12-month overall survival (OS) and safety/toxicity of the selected MTD or optimal dose of SD-101 in combination with CPI. In addition, there are also exploratory objectives: (i) to evaluate liver-specific progression-free survival (HPFS) according to RECIST V1.1; (ii) the evaluation of pathological response after PEDD/HAI of SD-101 with or without systemic i.v. CPI infusion and the correlation with imaging-based response scoring; (iii) to assess the intratumoral immunological effects of treatment on MDSC, lymphocyte and cytokine profiles using paired biopsies of liver tumors and normal liver tissue at baseline and during treatment; (iv) assessing the peripheral immunologic pharmacodynamic effects of treatment using serial blood samples for circulating tumor cells (CTCs), circulating cytokines, and other immunologic correlates; (v) assessing changes in ECOG PS compared to baseline over time; (vi) the assessment of changes in quality of life compared to baseline using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire for Cancer (EORTC-QLQ-C30).

The overall design of the study is in 5 to find. It is an open, multicenter and non-randomized study.

As further described below, in Phase 1b, escalating doses of SD-101 may be administered alone (Cohort A), with pembrolizumab (Cohort B), or with a combination of ipilimumab and nivolumab (Cohort C). Cohorts B and C will begin at a dose level below the MTD or optimal dose of Cohort A to optimize safety when adding CPI to SD-101. Cohort B will not begin until the DLT window for the last patient in Cohort A is complete (Cohort B will continue concurrently with Cohort A expansion). Cohort C will not begin until the DLT window for the last patient in Cohort B is completed. A standard 3+3 dose escalation design is used to determine the MTD.

After the first infusion of SD-101, each patient in Phase 1b will require overnight observation or admission. If the first dose of SD-101 is well tolerated, it is at the discretion of the treating physician to order additional observation or overnight admission for subsequent infusions of SD-101. If subsequent infusions are performed on an outpatient basis, the patient will be observed for at least 6 hours after the infusion before being discharged in clinically stable condition. If events > Grade 2 occur associated with SD-101 administered via PEDD/HAI that require hospitalization after the first infusion, the patient will be observed or admitted overnight after each subsequent infusion of SD-101.

After determining the recommended MTD or optimal dose of SD-101 for PEDD/HAI and the tolerable CPI regimen(s), the study will proceed to Phase 2 to assess efficacy. In Phase 2, patients will receive the SD-101 dose selected in Phase 1b along with single- or dual-drug systemic checkpoint blockade. When deciding, Whether single- or dual-drug CPI therapy is used together with SD-101 in Phase 2, safety data will be taken into account in addition to the response rates from Cohorts B and C in Phase 1b. SD-101 will be administered over 2 cycles, with 3 weekly doses per cycle.

Admission criteria

1. 1. 18 Jahre oder älter mit lokal fortgeschrittenem, metastasiertem oder inoperablem hepatozellulärem Karzinom oder intrahepatischem Cholangiokarzinom, wobei die Diagnose durch histologische oder zytologische Analyse oder klinische Merkmale gemäß der American Association for the Study of Liver Diseases bestätigt wurde.
2. 2. Hat zuvor mindestens eine Standardlinie einer systemischen Therapie für Leberkrebs erhalten und weist eine persistierende oder progressive messbare Erkrankung gemäß der Definition von RECIST Version 1.1 auf, die nicht auf kurative Therapien anspricht.
3. 3. Hat einen Performance Score von 0 oder 1 auf der ECOG-Skala (die Scores reichen von 0 bis 5, wobei höhere Werte eine größere Behinderung widerspiegeln).
4. 4. Einstufung in Klasse A auf der Child-Pugh-Leberfunktionsskala (eine dreiteilige Skala [A, B oder C], wobei C die schwerste Beeinträchtigung der Leberfunktion anzeigt).
5. 5. Angemessene Leber- und Organfunktion.
6. 6. Ein histologisch oder zytologisch bestätigtes HCC oder ICC mit einer Erkrankung, die nur die Leber betrifft oder leberdominant ist. Als leberdominant gilt eine intrahepatische Erkrankung, die den größten Anteil der Erkrankung ausmacht.
7. 7. Fähigkeit, die Studie zu verstehen und vor der Durchführung der Studie eine schriftliche Einwilligungserklärung abzugeben.
8. 8. Hat innerhalb von 14 Tagen vor dem Screening keine vorherige zytotoxische Chemotherapie, gezielte Therapie oder externe Strahlentherapie erhalten.
9. 9. Hat noch nie eine embolische HAI-Therapie mit permanentem Emboliematerial erhalten. Hinweis: Eine vorangegangene embolische HAI-Therapie mit permanentem Emboliematerial ist kein Ausschlusskriterium, wenn basierend auf dem Screening des Patienten nach dieser Therapie die Zielgefäße nicht verschlossen und die Tumore perfundiert sind.
10. 10. Hat keine Vorgeschichte von oder gleichzeitige bösartige Erkrankung, mit Ausnahme klinisch unbedeutender Malignitäten, keine laufende erforderliche Behandlung und der Patient ist klinisch stabil.
11. 11. Hat eine messbare Erkrankung in der Leber gemäß den Kriterien von RECIST V.1.1.
12. 12. Hat zum Zeitpunkt der Untersuchung eine vom Prüfarzt geschätzte Lebenserwartung von > 3 Monaten.
13. 13. Hat ein QTc-Intervall ≤ 480 msec.
14. 14. Alle damit verbundenen klinisch bedeutsamen (nach Ermessen des Prüfarztes) medikamentenbedingten Toxizitäten aus früheren Krebstherapien müssen vor der Verabreichung der Studienbehandlung abgeklungen sein (auf Grad ≤1 oder das Niveau des Patienten vor der Behandlung) (Alopezie Grad 2 und Endokrinopathien, die durch eine Ersatztherapie kontrolliert werden, sind erlaubt).
15. 15. Verfügt beim Screening über eine ausreichende Organfunktion, was nachgewiesen wird durch:
    • • Thrombozytenzahl > 100.000/µl.
    • • Hämoglobin ≥ 8,0 g/dl.
    • • Anzahl der weißen Blutkörperchen (WBC) > 2.000/µl.
    • • Serumkreatinin ≤ 2,0 mg/dl, es sei denn, die gemessene Kreatinin-Clearance ist ≥ 30 ml/min, berechnet nach der Cockcroft-Gault-Formel.
    • • Gesamtbilirubin und direktes Bilirubin ≤2,0 x die normale Obergrenze (ULN) und alkalische Phosphatase ≤ 5 x ULN. Bei Patienten mit nachgewiesener Gilbert-Krankheit ist ein Gesamtbilirubinwert von bis zu 3,0 mg/dl erlaubt.
    • • ALT und AST ≤ 5 x ULN.
    • • Testergebnisse für die Prothrombinzeit/International Normalized Ratio (INR) oder die aktivierte partielle Thromboplastinzeit (aPTT) beim Screening ≤1,5 x ULN (dies gilt nur für Patienten, die keine therapeutische Antikoagulation erhalten; Patienten, die eine therapeutische Antikoagulation erhalten, sollten vor der ersten Dosis der Studienintervention mindestens 4 Wochen lang eine stabile Dosis erhalten). Hinweis: Labortests, deren Ergebnisse nach Ansicht des Prüfarztes nicht mit dem klinischen Status des Patienten vereinbar sind, können einmal wiederholt werden, um die Eignung für eine Teilnahme zu prüfen.
16. 16. Gebärfähige Frauen dürfen nicht schwanger und laktierend oder postmenopausal sein und müssen beim Screening einen negativen Schwangerschaftstest auf humanes Choriongonadotropin (hCG) und vor der ersten Dosis der Studienintervention einen negativen Urin- oder Serumschwangerschaftstest aufweisen.
    • • Gebärfähige Frauen müssen sich bereit erklären, auf sexuelle Aktivitäten mit nicht sterilisierten männlichen Partnern zu verzichten, oder wenn sie mit einem nicht sterilisierten männlichen Partner sexuell aktiv sind, müssen sie sich bereit erklären, ab dem Screening und während der gesamten Studie hochwirksame Verfahren zur Empfängnisverhütung anzuwenden und diese Vorsichtsmaßnahmen bis 100 Tage nach der letzten Dosis der Studienintervention beizubehalten.
    • • Nicht sterilisierte Männer, die mit einer gebärfähigen Frau sexuell aktiv sind, müssen sich verpflichten, wirksame Verfahren zur Empfängnisverhütung anzuwenden und eine Samenspende ab Tag 1 während der gesamten Studie und für 30 Tage nach der letzten Dosis der Studienintervention vermeiden.

According to one embodiment, to be included in the study, the patient must meet all of the following inclusion criteria:

1. 1. 18 years of age or older with locally advanced, metastatic or unresectable hepatocellular carcinoma or intrahepatic cholangiocarcinoma, with the diagnosis confirmed by histologic or cytologic analysis or clinical features according to the American Association for the Study of Liver Diseases.
2. 2. Has previously received at least one standard line of systemic therapy for liver cancer and has persistent or progressive measurable disease as defined by RECIST version 1.1 that is unresponsive to curative therapies.
3. 3. Has a performance score of 0 or 1 on the ECOG scale (scores range from 0 to 5, with higher scores reflecting greater disability).
4. 4. Class A on the Child-Pugh Liver Function Scale (a three-point scale [A, B, or C], with C indicating the most severe impairment of liver function).
5. 5. Adequate liver and organ function.
6. 6. A histologically or cytologically confirmed HCC or ICC with disease that affects the liver only or is liver dominant. Intrahepatic disease, which accounts for the majority of the disease, is considered liver dominant.
7. 7. Ability to understand the study and provide written informed consent before conducting the study.
8. 8. Has not received prior cytotoxic chemotherapy, targeted therapy, or external beam radiation therapy within 14 days prior to screening.
9. 9. Has never received HAI embolic therapy with permanent embolic material. Note: Previous embolic HAI therapy with permanent embolic material is not an exclusion criterion if, based on patient screening after this therapy, the target vessels are not occluded and the tumors are perfused.
10. 10. Has no history of or concurrent malignancy, except for clinically insignificant malignancies, no ongoing required treatment and the patient is clinically stable.
11. 11. Has measurable disease in the liver according to RECIST V.1.1 criteria.
12. 12. Has an investigator-estimated life expectancy of >3 months at the time of evaluation.
13. 13. Has a QTc interval ≤ 480 msec.
14. 14. All associated clinically significant (at the investigator's discretion) drug-related toxicities from prior anticancer therapies must have resolved (to Grade ≤1 or the patient's pre-treatment level) prior to administration of study treatment (Grade 2 alopecia and endocrinopathies caused by a replacement therapy are permitted).
15. 15. Has adequate organ function at screening as demonstrated by:
    • • Platelet count > 100,000/µl.
    • • Hemoglobin ≥ 8.0 g/dL.
    • • White blood cell (WBC) count > 2,000/µl.
    • • Serum creatinine ≤ 2.0 mg/dL unless measured creatinine clearance is ≥ 30 mL/min, calculated using the Cockcroft-Gault formula.
    • • Total bilirubin and direct bilirubin ≤2.0 x the upper limit of normal (ULN) and alkaline phosphatase ≤5 x ULN. In patients with proven Gilbert's disease, a total bilirubin level of up to 3.0 mg/dL is permitted.
    • • ALT and AST ≤ 5 x ULN.
    • • Prothrombin time/International Normalized Ratio (INR) or activated partial thromboplastin time (aPTT) test results at screening ≤1.5 x ULN (this only applies to patients not receiving therapeutic anticoagulation; patients receiving therapeutic anticoagulation should received a stable dose for at least 4 weeks before the first dose of study intervention). Note: Laboratory tests whose results, in the opinion of the investigator, are inconsistent with the patient's clinical status may be repeated once to assess eligibility for participation.
16. 16. Females of childbearing potential must be non-pregnant and lactating or postmenopausal and must have a negative human chorionic gonadotropin (hCG) pregnancy test at screening and a negative urine or serum pregnancy test prior to the first dose of study intervention.
    • • Women of childbearing potential must agree to abstain from sexual activity with non-sterilized male partners, or if sexually active with a non-sterilized male partner, they must agree to use highly effective methods of contraception beginning at screening and throughout the study to apply and maintain these precautions until 100 days after the last dose of study intervention.
    • • Nonsterilized men who are sexually active with a woman of childbearing potential must commit to using effective contraceptive methods and avoiding sperm donation beginning on Day 1 throughout the study and for 30 days after the last dose of study intervention.

PHASE 1b

The individual Phase 1b patient cohorts are as follows:

• • Dosisstufe 1: 4 mg (n = 3-6).
• • Dosisstufe 2: 8 mg (n = 3-6).

Cohort A - Dose escalation cohort with SD-101 administered via PEDD/HAI as monotherapy (2 cycles, 1 dose per week x 3 weeks, per cycle) using a standard 3+3 design, followed by an optional expansion group to achieve the MTD or To determine optimal dose of SD-101 alone and estimate the response rate of monotherapy in HCC and ICC patients:

• • Dose level 1: 4 mg (n = 3-6).
• • Dose level 2: 8 mg (n = 3-6).

The first 2 patients in each dose level will be enrolled at least 48 hours apart. Additional incremental dose increments (4 mg increments) may be added based on safety and response data. An optional expansion group of 10 patients with the MTD or optimal dose of SD-101 as monotherapy may be conducted concurrently with Cohort B.

• • Dosisstufe 1: Pembrolizumab zusammen mit PEDD/HAI von SD-101 in 1 Dosisstufe unterhalb der MTD oder optimalen Dosis aus Kohorte A (d. h. MTD-1 oder optimale Dosis-1) (n = 3-6).
• • Dosisstufe 2: Pembrolizumab zusammen mit PEDD/HAI von SD-101 in der MTD oder optimalen Dosis aus Kohorte A (n = 3-6), oder wenn MTD-1 oder optimale Dosis-1 nicht vertragen wird, wird auf MTD-2 oder optimale Dosis-2 deeskaliert.

Cohort B - Dose re-escalation cohort with SD-101 administered via PEDD/HAI (2 cycles, 1 dose per week x 3 weeks, per cycle) using a standard 3+3 design together with IV pembrolizumab 200 mg every 3 weeks (Q3W), To determine the MTD or optimal dose of SD-101 with single-agent pembrolizumab:

• • Dose level 1: Pembrolizumab coadministered with PEDD/HAI from SD-101 at 1 dose level below the MTD or optimal dose from Cohort A (ie, MTD-1 or optimal dose-1) (n = 3-6).
• • Dose level 2: Pembrolizumab coadministered with PEDD/HAI from SD-101 at the MTD or optimal dose from Cohort A (n=3-6), or if MTD-1 or optimal dose-1 is not tolerated, upgrade to MTD-2 or optimal dose-2 de-escalated.

The first 2 patients in each dose level will be enrolled at least 48 hours apart. An optional expansion group of up to 10 patients receiving SD-101 along with pembrolizumab may be conducted concurrently with Cohort C.

• • Dosisstufe 1: Nivolumab und Ipilimumab zusammen mit PEDD/HAI von SD-101 in 1 Dosisstufe unterhalb der MTD oder optimalen Dosis aus Kohorte B (n = 3-6).
• • Dosisstufe 2: Nivolumab und Ipilimumab zusammen mit PEDD/HAI von SD-101 in der MTD oder optimalen Dosis von SD-101 aus Kohorte B (n = 3-6), oder wenn MTD-1 oder optimale Dosis-1 nicht vertragen wird, Deeskalation auf MTD-2 oder optimale Dosis-2.

Cohort C - Dose re-escalation study of SD-101 delivered via PEDD/HAI (2 cycles, 1 dose per week x 3 weeks, per cycle) using a standard 3+3 design along with 1 mg/kg nivolumab in combination with 3 mg/ kg ipilimumab every 3 weeks for four doses followed by 240 mg of single-agent nivolumab every 2 weeks to determine the MTD or optimal dose of SD-101 with dual-agent CPI:

• • Dose level 1: Nivolumab and ipilimumab together with PEDD/HAI from SD-101 at 1 dose level below the MTD or optimal dose from Cohort B (n = 3-6).
• • Dose level 2: Nivolumab and ipilimumab together with PEDD/HAI of SD-101 in the MTD or optimal dose of SD-101 from Cohort B (n = 3-6), or if MTD-1 or optimal dose-1 is not tolerated , de-escalation to MTD-2 or optimal dose-2.

The first 2 patients in each dose level will be enrolled at least 48 hours apart. An optional expansion group of 10 patients may be enrolled if additional data is needed to decide between single- or dual-agent CPI with SD-101 delivered via PEDD/HAI for Phase 2.

PHASE 2

Two separate cohorts for HCC and ICC will be enrolled. Phase 2 will use a two-stage design to determine whether the proportion of response to the MTD of SD-101 or the optimal dose + CPI with one or two agents is sufficiently high to warrant further testing. For each tumor type, a two-stage design with the smallest overall sample is used.

Duration of administration

Duration of SD-101 administration (for participants in Phase 1b and Phase 2):

Phase 1b Cohorts A, B, C and Phase 2 - Up to 6 doses (maximum 2 cycles of SD-101, 3 weekly doses per cycle). Based on toxicity or tolerability, fewer doses or cycles of SD-101 may be administered. All patients who have measurable disease at baseline, have received post-baseline tumor evaluation, have received at least 1 dose of treatment, and do not violate any key inclusion or exclusion criteria will be considered evaluable. However, it is considered a serious protocol violation if patients were enrolled despite violating key inclusion or exclusion criteria, and such patients are considered not evaluable.

• Phase 1b, Kohorte A:
  • • Nicht anwendbar.
• Phase 1b, Kohorte B und optionale Expansionskohorte:
  • • Bis zu 6 Monate Pembrolizumab 200 mg Q3W.
• Phase 1b, Kohorte C und optionale Expansionskohorte:
  • • 1 mg/kg Nivolumab i.v. Q3W für 4 Dosen, dann 240 mg alle 2 Wochen (Q2W) für bis zu 12 Monate.
  • • 3 mg/kg Ipilimumab i.v. Q3W für 4 Dosen.
• Phase 2:
  • • CPI-Schema wie durch Phase 1b bestimmt für bis zu 6 Monate.
• Phase 1, Kohorte B und optionale Expansionskohorte:
  • • Bis zu zwölf Monate Nivolumab 480 mg Q4W.
• Phase 1, optionale Kohorte B1:
  • • 3 mg/kg Ipilimumab systemisch i.v. Q3W für 4 Dosen.
• Phase 1, Kohorte C und optionale Expansionskohorte:
  • • 1 mg/kg Nivolumab systemisch i.v. Q3W für 4 Dosen, dann 480 mg/kg Q4W für bis zu zwölf Monate und (ii) 3 mg/kg Ipilimumab systemisch i.v. Q3W für 4 Dosen.
• Phase 1b:
  • • CPI-Schema wie durch Phase 1 bestimmt für bis zu zwölf Monate.

Duration of CPI administration

• Phase 1b, Cohort A:
  • • Not applicable.
• Phase 1b, Cohort B and Optional Expansion Cohort:
  • • Up to 6 months pembrolizumab 200 mg Q3W.
• Phase 1b, Cohort C and Optional Expansion Cohort:
  • • 1 mg/kg nivolumab IV Q3W for 4 doses, then 240 mg every 2 weeks (Q2W) for up to 12 months.
  • • 3 mg/kg ipilimumab IV Q3W for 4 doses.
• Phase 2:
  • • CPI regimen as determined by Phase 1b for up to 6 months.
• Phase 1, Cohort B and Optional Expansion Cohort:
  • • Up to twelve months Nivolumab 480 mg Q4W.
• Phase 1, optional cohort B1:
  • • 3 mg/kg ipilimumab systemic IV Q3W for 4 doses.
• Phase 1, Cohort C and Optional Expansion Cohort:
  • • 1 mg/kg nivolumab systemic IV Q3W for 4 doses, then 480 mg/kg Q4W for up to twelve months and (ii) 3 mg/kg ipilimumab systemic IV Q3W for 4 doses.
• Phase 1b:
  • • CPI scheme as determined by Phase 1 for up to twelve months.

Interventions administered

The interventions and planned dose levels are summarized in Table 2 below. Table 2 Intervention Name SD-101 Keytruda ^® (pembrolizumab) Opdivo® ⁽ nivolumab) Yervoy ^® (ipilimumab) Type drug (ODN) Biologic (antibody) Biologic (antibody) Biologic (antibody) Formulation of the dose Solution Solution for injection Solution for injection Solution for injection Single dose strength(s) 13.4 mg/ml 100mg/4ml 40mg/4ml 5mg/ml 100mg/10ml 240mg/24ml Dose level(s) 4 or 8 mg 200 mg 1 mg/kg iv 3 mg/kg iv 240 mg IV Method of administration ^a Intravascular injection using PEDD/HAI over 10-60 minutes iv iv iv Application Experimental Background intervention Background intervention Background intervention IMP and CPI IMP HCC FDA approved ICC IMP HCC FDA approved ICC IMP HCC FDA approved ICC IMP Sourcing TriSalus Commercial - delivery to the testing center Commercial - delivery to the testing center Commercial delivery to the testing center Packaging and labeling Single-use vial ^b Single-dose vial Single-dose vial Single-dose vial Abbreviations: HAI = hepatic artery infusion; IMP = investigational drug; iv = intravenous; ODN = oligodeoxynucleotide; PEDD = Pressure Activated Drug Delivery Device. ^a Each segmental, sectoral, or lobar infusion must be completed within 60 minutes to ensure that the SD-101 is not left in the TriNav device for longer than this time. This does not limit the overall duration of the procedure. ^c The vial is discarded after preparing the dose for an individual patient. In no case will more than one dose be taken from a vial.

PEDD/HAI from SD-101

The SD-101 solution can be used with a PEDD device, e.g. B. the TriNav ^® , can be infused via the hepatic arterial system. Vascular access can be achieved via the femoral or radial approach. Hemangiomas, shunt vessels or other vascular lesions in the liver that could compromise the therapeutic effect may be embolized at the discretion of the treating interventional radiologist. For SD-101 infusion procedures, the drug is prepared at the local pharmacy and is supplied in a 50 ml syringe (therapeutic dose) and a 100 ml vial containing the volume required for therapeutic irrigation (10 ml). , delivered to the interventional radiology department, each in the therapeutic concentration. The pharmacy may be notified 1 day before the scheduled infusion time and again when the patient is on the table. The PEDD device, the TriNav ^® , is advanced into the target vessels.

In one embodiment, the volume of 50 ml to be administered is allocated per segment or sector of the liver. In one embodiment, the therapeutic dose of 50 ml can be allocated as follows: 3 x 10 ml infusions into the target vessels of the right liver lobe and 2 x 10 ml infusions into the target vessels of the left liver lobe. Additionally, the distribution of the 10 mL aliquots can be adjusted based on the location of measurable disease and the target vessel diameter. In one embodiment, the infusion of SD-101 is expected to take approximately 10-60 minutes. The infusion time can be, for example, about 25 minutes. Furthermore, in one embodiment, the entire interventional procedure may take between 30 and 80 minutes. This includes all handling time between infusions at different locations.

Tumor response assessments

All patients undergo magnetic resonance imaging (MRI) or CT imaging to assess disease in the liver and other sites, as well as liver biopsies and studies of CTC, circulating cytokines, and other immunologic correlates. Tumor response will be measured radiographically according to standard RECIST V1.1 criteria. Official response scoring (according to RECIST V1.1) will be provisionally assessed on Day 84. Additional response assessments will be performed on Day 168 to confirm previous scoring in the event of pseudo-progression. Imaging procedures will be performed every 90 days thereafter. Whenever possible, an MRI scan of the liver with Eovist ^® contrast media should be performed. Local imaging results will be used for response assessment in Phase 1b and Phase 2. An independent central review to assess response may be performed during Phase 2.

• • An Tag 1 wird vor der ersten Infusion von SD-101 eine Baseline-Biopsie durchgeführt, sowie eine Biopsie nach der Infusion an Tag 1. Vor der Infusion zu Beginn des zweiten Zyklus von SD-101 (vor Infusion Nr. 4 von SD-101) wird eine Biopsie durchgeführt, und die letzte Biopsie erfolgt an Tag 100.
• • Das pathologische Ansprechen wird basierend auf der Überprüfung durch den Pathologen am Prüfzentrum bewertet, wobei ein Score für Nekrose und Fibrose in Proben des Tumors und normalen Gewebes ermittelt wird.

Up to 4 liver biopsies will be performed:

• • A baseline biopsy will be performed on Day 1 prior to the first infusion of SD-101, and a post-infusion biopsy will be performed on Day 1. Prior to infusion at the start of the second cycle of SD-101 (prior to infusion #4 of SD-101 101) a biopsy is performed and the last biopsy is done on day 100.
• • Pathological response is assessed based on review by the pathologist at the site, obtaining a score for necrosis and fibrosis in samples of tumor and normal tissue.

life quality

To assess general patient status and quality of life, the ECOG PS scale and the EORTC-QLQ-C30 questionnaire can be used.

Pharmacokinetics

• • Phase 1b: Für jede Dosisstufe in den Kohorten A, B und C werden serielle venöse Blutproben zur Messung der Plasmakonzentrationen von SD-101 vor der Dosierung und nach dem Ende der jeweiligen Dosis entnommen. Die Probenahmezeiten können basierend auf den Ergebnissen, die nach den ersten Dosen für Kohorte A in Phase 1b der Studie beobachtet wurden, angepasst werden.
• • Phase 2: Wenn die Konzentrationen in Phase 1b meist unter der unteren Bestimmungsgrenze des Assays liegen, können diese Messungen in Phase 2 ausgelassen werden.

Blood samples will be collected to characterize systemic exposure of SD-101 following PEDD/HAI. No sampling or testing will be performed for pembrolizumab, nivolumab, or ipilimumab concentrations.

• • Phase 1b: For each dose level in Cohorts A, B and C, serial venous blood samples will be collected to measure plasma concentrations of SD-101 before dosing and after the end of each dose. Sampling times may be adjusted based on the results observed after the first doses for Cohort A in Phase 1b of the study.
• • Phase 2: If the concentrations in Phase 1b are mostly below the lower limit of quantification of the assay, these measurements in Phase 2 can be omitted.

SD-101 tumor levels will be measured in pre- and post-infusion biopsy samples collected on the following days: Day 1 and Day 57 (pre-infusion only) for Cohorts A, B, and C.

Each plasma sample can be divided into 2 aliquots of approximately 2-3 ml each (1 for the measurement of SD-101 and 1 as a reserve). Samples collected for analyzes of SD-101 may also be used to evaluate safety or efficacy aspects related to concerns that arise during or after the study.

Pharmacodynamics

Blood samples can be collected for measurement of CTC, circulating cytokines, and other immunological correlates that include IFN-α and IFN-γ related gene signatures, which may be more informative than pharmacokinetic assessments for this class of therapeutics.

Security

Safety assessments include adverse events (AEs), clinical laboratory tests, vital signs, physical examinations, and electrocardiograms (ECGs).

• • ≥ Zytokinfreisetzungssyndrom (CRS) Grad 3 gemäß der National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0.
• • Autoimmune UE ≥ Grad 3 gemäß NCI CTCAE.
• • UE aufgrund allergischer Reaktion ≥ Grad 3 gemäß NCI CTCAE.
• • Hämatologische UE Grad 4 gemäß NCI CTCAE, die nicht innerhalb von 7 Tagen auf ≤ Grad 2 abklingt.
• • UE Grad 4 gemäß NCI CTCAE in einem beliebigen Organsystem.

The following will be considered DLTs if observed during Phase 1b within 2 weeks of the last dose of SD-101 in Cycle 1 and will be considered the study intervention (SD-101 or CPI therapy) and/or assignable to the TriNav device. However, it should be noted that the same adjustment or cancellation rules apply to any DLTs (defined below) that may occur during the Cycle 2 infusion period:

• • ≥ Cytokine release syndrome (CRS) grade 3 according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), version 5.0.
• • Autoimmune AEs ≥ grade 3 according to NCI CTCAE.
• • AE due to allergic reaction ≥ grade 3 according to NCI CTCAE.
• • NCI CTCAE Grade 4 hematologic AE that does not resolve to ≤ Grade 2 within 7 days.
• • NCI CTCAE grade 4 AE in any organ system.

For patients who experience DLT, the study intervention will be permanently discontinued. The patient can be treated according to clinical practice and monitored for resolution of toxicity.

• • Der Patient hat klinische Gelbsucht.
• • Der Patient weist Anzeichen einer Koagulopathie auf.
• • Der Patient weist klinische Anzeichen einer portalen Hypertension auf, einschließlich unter anderem mit Aszites oder Varizenblutung.

If severe or life-threatening infusion-related reactions occur, therapy with SD-101 and/or CPI is permanently discontinued. Dose interruption, delay, or discontinuation of SD-101 and/or CPI therapy is necessary if a patient experiences a Grade 3 or higher immune-mediated reaction. Discontinuation of SD-101 and/or CPI therapy due to abnormal liver tests is necessary if a patient meets any of the conditions listed below or if there are abnormal liver tests that do not meet the discontinuation rules established in the protocol, if the investigator believes it that this is in the best interest of the patient.

• • The patient has clinical jaundice.
• • The patient has signs of coagulopathy.
• • The patient has clinical signs of portal hypertension including, but not limited to, ascites or variceal bleeding.

All patients in this study can be followed for safety for at least 6 months after treatment initiation and for disease status for 1 year.

Patients who discontinue study treatment for reasons other than disease progression (e.g., toxicity, withdrawal of consent) may continue to undergo scheduled tumor examinations every 90 days until the patient dies, disease progression (intra- or extrahepatic) occurs, or he further systemic cancer therapy begins, whichever comes first.

Emergency medications and therapy

• Medikamente
  • • 4-8 mg/kg IL-6-Rezeptor-Antikörper Tocilizumab systemisch i.v. über 60 Minuten bei CRS, kann je nach klinischer Indikation wiederholt werden.
  • • 2 mg/kg Methylprednisolon systemischer i.v. Bolus, gefolgt von 0,5 mg/kg i.v. alle 6-12 Stunden bei CRS Grad > 2 oder neurologischer Dysfunktion. Die erste Dosis kann ohne Rücksprache mit dem Prüfarzt oder Beauftragten verabreicht werden. Die nachfolgenden Dosen müssen jedoch nach Rücksprache mit dem Prüfarzt oder Verantwortlichen verabreicht werden.
  • • Es sollten 1 bis 2 Dosen von Anti-TNFα-Mitteln (Infliximab oder Etanercept) in Betracht gezogen werden. Der Nutzen ist nicht bekannt, aber da TNFa akut ansteigen kann, sollte es in einem frühen Stadium des Erkrankungsprozesses in Betracht gezogen werden.
  • • 25 mg Etanercept s.c. zweimal wöchentlich für 2 Dosen, die im Abstand von 3 bis 4 Tagen verabreicht werden (0,4 mg/kg zweimal wöchentlich, maximal 25 mg pro Dosis.
  • • 10 mg/kg Infliximab-Dosis systemisch i.v. wöchentlich x 2 Dosen. Interventionen
  • • Endoskopische Cholangiographie und Platzierung eines Stents.
  • • Perkutane Cholangiographie und Platzierung eines Stents.

The trial site will provide emergency immunomodulatory medications that will be sourced locally. The following emergency medications may be used:

• Medication
  • • 4-8 mg/kg IL-6 receptor antibody tocilizumab systemically IV over 60 minutes for CRS, may be repeated as clinically indicated.
  • • 2 mg/kg methylprednisolone systemic IV bolus followed by 0.5 mg/kg IV every 6-12 hours for CRS grade > 2 or neurological dysfunction. The first dose may be administered without consulting the investigator or designee. However, subsequent doses must be administered after consultation with the investigator or responsible person.
  • • 1 to 2 doses of anti-TNFα agents (infliximab or etanercept) should be considered. The benefit is unknown, but since TNFa can increase acutely, it should be considered early in the disease process.
  • • 25 mg etanercept sc twice weekly for 2 doses administered 3 to 4 days apart (0.4 mg/kg twice weekly, maximum 25 mg per dose.
  • • 10 mg/kg infliximab dose systemically IV weekly x 2 doses. Interventions
  • • Endoscopic cholangiography and stent placement.
  • • Percutaneous cholangiography and stent placement.

Although the use of rescue medication is permitted at any time during the study, if possible and clinically appropriate, the use of rescue medication should be delayed until at least 6 hours after administration of the study intervention. The date and time of rescue medication administration as well as the name and dosage regimen of the rescue medication must be recorded.

Adverse events that are clearly attributable to disease progression, unrelated to the study drug, or expected in the appropriate study patient population are not considered DLTs.

Examination for cytokine release syndrome

The investigator or designee will examine each patient for the presence of CRS. The classification of CRS is determined based on NCI CTCAE V5.0 and treated as shown in Table 3. Table 3: Classification criteria for cytokine release syndrome CRS severity manifestation management Grade 1 Fever (≥ 38°C) ^a with or without constitutional symptoms, and/or ALT/AST > ULN-3xULN, and/or alkaline phosphatase > ULN-2.5xULN, and/or bilirubin > ULN-1.5xULN For fever, antipyretic agent and hypothermia blanket as needed. Examination for infection. IV fluids as needed. Symptomatic treatment of constitutional symptoms and organ toxicities as needed Grade 2 Hypotension (SBP < 90 mmHg or < 20% baseline) responsive to fluid, and/or hypoxia responsive to < 40% oxygen, and/or ALT/AST > 3-5xULN, and/or alkaline phosphatase > 2, 5-5xULN, and/or bilirubin > 1.5-3xULN Fever: Manage according to Grade 1 guidelines Hypotension: IV fluid bolus of 500-1000 mL NS, repeat as necessary to maintain SBP > 90 mmHg If SBP is refractory to NS bolus, use of corticosteroids should be considered . If hypotension persists after IV fluid bolus and corticosteroids, the following should be considered: transfer to intensive care unit, vasopressin, 2D echocardiogram Hypoxia: Supplemental oxygen as needed to maintain oxygen saturation ≥ 92% Grade 3 Hypotension treated with a pressor, and/or hypoxia requiring ≥ 40% oxygen, and/or AST/ALT/alkaline phosphatase > 5-20xULN, and/or bilirubin > 3-10xULN The patient should be in the ICU: Fever: Treatment as for CRS Grade 1 Hypotension: IV fluid bolus as needed as for CRS Grade 2 Vasopressors as needed There should be 8 mg/kg of tocilizumab (maximum 800 mg per dose) IV with up to 3 doses Consider obtaining an echocardiogram in a 24-hour period (maximum 4 doses in total) if not already performed. Hypoxia: Supplemental oxygen (≥ 6 L/min), including high-flow oxygen and non-invasive positive pressure ventilation, use of corticosteroids as needed , IL-6 receptor antagonists as described above, and supportive care Grade 4 Life-threatening consequences; urgent intervention indicated, and/or ALT/AST/alkaline phosphatase > 20xULN, and/or bilirubin > 10xULN Fever: Treatment as for CRS Grade 1 Hypotension: IV fluids, IL-6 receptor antagonist, vasopressors and hemodynamic monitoring as for Grade 3 High-dose corticosteroids Hypoxia: Positive pressure ventilation/mechanical ventilation Use of high-dose corticosteroids, IL-6 receptor antagonists, and supportive treatment Abbreviations: 2D = 2-dimensional; ALT = alanine aminotransferase; AST = aspartate aminotransferase; ASTCT = American Society for Transplantation and Cellular Therapy; CRS = cytokine release syndrome; CTCAE = Common Terminology Criteria for Adverse Events; ICU = intensive care unit; IL = interleukin; iv = intravenous; NCI = National Cancer Institute; NS = normal saline; SBP = systolic blood pressure; ULN = normal upper limit ^a Fever is defined as a temperature ≥ 38 °C that is not due to another cause.

Source: Adapted from the NCI CTCAE and ASTCT (Lee DW, Santomasso BD, Locke FL, Ghobadi A, Turtle CJ, Brudno JN, et al. ASTCT consensus grading for cytokine release syndrome and neurologic toxicity associated with immune effector cells. Biol Blood Marrow Transplant. 2019;25;625-38).

Imaging

The extent of disease will be measured radiographically at the Cohort A, Cohort B, and Cohort C time points. Screening examinations must include an MRI of the abdomen and pelvis (with oral/IV Eovist contrast unless contraindicated) and a brain scan (CT with IV contrast or MRI). In addition to MRI of the abdomen and pelvis, a spiral CT scan of the chest should be performed. If MRI is medically contraindicated or at the physician's discretion, a CT scan of the chest, abdomen, and pelvis may be performed with a three-phase i.v. Contrast medium is carried out. If a site is unable to perform triphasic CT of the chest, abdomen and pelvis, CT of the chest, abdomen and pelvis with i.v. Contrast agent is performed and imaging of the arterial phase and portal vein phase is performed. If a PET/CT scan is performed (not required), the CT portion of the study must meet the standards for a full contrast CT scan. The response of liver metastases is assessed using abdominal CT or MRI, while extrahepatic lesions are assessed using whole-body PET/CT scans or CT/MRI scans covering the chest, abdomen and pelvis. Whenever possible, MRI with Eovist contrast agent should be performed to evaluate liver tumors. The same imaging method as screening must be used throughout the study.

Any evaluable or measurable disease must be documented at screening and reassessed at each subsequent tumor examination. In patients with measurable disease, response will be assessed according to REClST V1.1. Local imaging results will be used for response assessment in Phase 1b. An Independent Central Review (ICR) to assess response may be considered in Phase 2.

At the investigator's discretion, imaging may be performed at any time if PD is suspected. In addition, mRECIST and iREC!ST assessments will be performed to collect secondary endpoint data, but will not be included in official response scoring.

ECOG performance status

• • Voll aktiv, kann alles ohne Einschränkung tun, was auch vor der Erkrankung möglich war
• • Einschränkungen bei anstrengender physischer Aktivität, aber ambulant und in der Lage, leichte oder sitzende Tätigkeiten auszuführen, z. B. leichte Hausarbeit, Büroarbeit
• • Ambulant und in der Lage, sich vollständig selbst zu versorgen, aber nicht in der Lage, Arbeitstätigkeiten auszuführen; mehr als 50 % der Wachzeit auf den Beinen
• • Nur begrenzte Selbstversorgung möglich; 50 % oder mehr der Wachzeit an Bett oder Stuhl gebunden
• • Vollständig behindert; kann sich nicht selbst versorgen; ist vollständig an Bett oder Stuhl gebunden
• • Tot

The ECOG PS scale is used to assess how the disease affects the patient's activities of daily living and ability to care for themselves. At each designated time point, qualified clinical site personnel will assess the patient using the following scale:

• • Fully active, can do everything without restrictions that was possible before the illness
• • Limitations on strenuous physical activity but ambulatory and able to perform light or sedentary tasks e.g. B. light housework, office work
• • Ambulatory and able to fully care for themselves but unable to perform work activities; on your feet more than 50% of your waking hours
• • Only limited self-sufficiency possible; Confined to bed or chair for 50% or more of waking hours
• • Totally disabled; cannot take care of himself; is completely tied to bed or chair
• • Dead

changes, i.e. H. Deteriorations are not documented as AEs unless they are reported as part of the untargeted AE survey.

Definitions according to RECIST V1.1

Measurable disease - The presence of at least 1 measurable lesion. If measurable disease is limited to a single lesion, its neoplastic nature should be confirmed using cytology/histology.

Measurable lesions - Lesion that can be accurately measured in at least one dimension and whose longest diameter is ≥ 10 mm (CT scan slice thickness ≤ 5 mm).

Non-measurable lesions - All other lesions, including small lesions (longest diameter < 10 mm) as well as truly non-measurable lesions (such as leptomeningeal disease, ascites, pleural/pericardial effusion, inflammatory breast disease, lymphangitic involvement of skin or lungs, abdominal masses associated with cannot be measured using reproducible imaging techniques).

Documentation at baseline

All measurable lesions, up to a maximum of 2 lesions per organ and 5 lesions total, representative of all organs involved, should be identified as target lesions and recorded and measured at baseline.

Target lesions should be selected based on their size (lesions with the longest diameter) and their suitability for accurate repeated measurements by consistent imaging techniques.

The sum of the longest diameter (LD) for all target lesions (non-nodal) is calculated and reported as the sum of the baseline LD. The sum of the baseline LD is used as a reference to characterize the objective tumor response in the measurable dimension of the disease.

All other lesions (or diseased sites) should be identified as non-target lesions and also recorded at baseline. Measurements of these lesions are not required, but are present The presence or absence of each of these lesions should be noted throughout follow-up.

Assessment of target lesions

Complete response (CR): disappearance of all target lesions

Partial response (PR): A decrease in the sum of the LD of the target lesions by at least 30%, using the sum of the baseline LD as a reference.

Progressive disease (PD): Increase in the sum of the LD of the target lesions by at least 20%, taking as reference the smallest sum of the LD recorded since the start of treatment or the appearance of 1 or more new lesions. The total must show an absolute increase of 5 mm.

Stable disease (SD): Neither sufficient shrinkage to be classified as PR nor sufficient increase to be classified as PD, using the smallest sum of LD since the start of treatment as a reference.

Assessment of non-target lesions

Complete response (CR): disappearance of all non-target lesions

Non-CR/Non-PD: Persistence of one or more non-target lesion(s)

Progressive disease (PD): Clear progression of existing non-target lesions and/or the appearance of one or more new lesions.

Response ratings

Response will be assessed at the time points for Cohort A, Cohort B and Cohort C according to Table 4: Table 4: Response assessment according to RECIST V1.1 Time point response Target lesions Non-target lesions New lesions Overall response CR CR No CR CR Non-CR/Non-PD No PR PR Non-PD No PR SD Non-PD No SD P.D Every Yes or no P.D Every P.D Yes or no P.D Every Every Yes P.D Abbreviations: CR = complete response; PD = progressive disease; PR = partial response; SD = stable disease.

Duration of overall response

Duration of overall response is measured from the time the measurement criteria for a CR or a PR (whichever is determined first) are met to the first date a recurrence or PD is objectively documented (where the lowest measurements since the start of treatment serve as a reference for PD). The duration of CR is measured from the time the measurement criteria for a CR are first met to the first date a PD is objectively documented. Duration of SD: The duration of stable disease is measured from the start of treatment until the criteria for progression are met, with the sum of the lowest measurements values recorded since the start of treatment, including baseline measurements, serve as a reference.

Overall survival

For all patients, OS will be calculated from the date of enrollment to the time of death. Patients who are alive before the data cutoff date for the final efficacy analysis or who drop out before the end of the study will be censored on the day they were last confirmed to be alive.

Progression-free survival

Progression-free survival is calculated for all patients from the date of enrollment to the date of CT scan documenting recurrence (or other clear indicator of disease progression) or the date of death, whichever occurs first . Patients who do not have a documented recurrence and are still alive before the data cutoff for the final efficacy analysis or who drop out before the end of the study will be censored at the date of the last radiological evidence documenting the absence of a recurrence.

Modified RECIST (mRECIST)

The mRECIST definitions for hepatocellular carcinoma are as follows:

Complete response (CR) = disappearance of any intratumoral arterial enhancement in all target lesions

Partial response (PR) = At least 30% decrease in the sum of the diameters of the viable (enhancement in the arterial phase) target lesions, using the baseline value of the sum of the diameters of the target lesions as a reference.

Stable disease (SD) = All cases that cannot be classified as either PR or progressive disease

Progressive Disease (PD) = An increase in the sum of viable (enhancing) target lesion diameters of at least 20%, using the smallest sum of viable (enhancing) target lesion diameters recorded since the start of treatment as a reference.

Response will also be assessed using mRECIST, as shown in Table 5. Table 5: Assessment of response according to mRECIST Target lesions Non-target lesions New lesions Overall response CR CR No CR CR IR/SD No PR PR Non-PD No PR SD Non-PD No SD P.D Every Yes or no P.D Every P.D Yes or no P.D Every Every Yes P.D Abbreviations: CR = complete response; PR = partial response; IR = incomplete response; SD = stable disease; PD = progressive disease.

Source: Lencioni R, Llovet JM. Modified RECIST (mRECIST) assessment for hepatocellular carcinoma. Sem Liver Dis. 2010; 30:52-60.

RECIST 1.1 for immune-based therapeutics (iRECIST)

• „Die Prinzipien zur Bestimmung des objektiven Tumoransprechens sind gegenüber RECIST 1.1 weitgehend unverändert. Die wichtigste Änderung bei iRECIST ist jedoch das Konzept, die Messlatte neu zu setzen, wenn auf eine Progression nach RECIST 1.1 bei der nächsten Beurteilung eine Tumorschrumpfung folgt. iRECIST definiert iUPD auf der Grundlage der Prinzipien von REClST 1.1.; iUPD erfordert jedoch eine Bestätigung durch die Beobachtung entweder einer weiteren Zunahme der Größe (oder der Anzahl neuer Läsionen) in der Läsionskategorie, in der zuerst eine Progression festgestellt wurde (d. h. Ziel- oder Nicht-Ziel-Erkrankung), oder die Beobachtung einer Progression (definiert nach RECIST 1.1) in Läsionskategorien, die zuvor die Kriterien für eine Progression nach RECIST 1.1 nicht erfüllten. Wenn jedoch keine Progression, sondern eine Tumorschrumpfung (im Vergleich zum Ausgangswert), die die Kriterien von iCR, iPR oder iSD erfüllt, bestätigt wird, dann wird die Messlatte zurückgesetzt, so dass iUPD erneut auftreten muss (im Vergleich zu den Nadir-Werten) und dann bei der nächsten Bewertung (basierend auf weiterem Wachstum) bestätigt werden muss, damit eine Einstufung als iCPD vorgenommen werden kann. Kommt es zu keiner Veränderung der Tumorgröße oder -ausdehnung gegenüber iUPD, dann wäre die Time-Point Response wieder iUPD. Dieser Ansatz ermöglicht es, atypisches Ansprechen, wie z. B. verzögertes Ansprechen nach Pseudoprogression, zu identifizieren, besser zu verstehen und besser zu charakterisieren.“

Tabelle 6: Bewertung des Ansprechens nach iRECIST Zielläsionen* Nicht-Zielläsionen* Neue Läsionen* Time-Point Response Keine vorherige iUPD** Vorherige iUPD** *** iCR iCR Nein iCR iCR iCR NichtiCR/NichtiUPD Nein iPR iPR iPR NichtiCR/NichtiUPD Nein iPR iPR iSD NichtiCR/NichtiUPD Nein iSD iSD iUPD ohne Änderung ODER Rückgang seit letztem TP iUPD ohne Änderung ODER Rückgang seit letztem TP Ja NA NLs bestätigen iCPD, wenn NLs zuvor identifiziert wurden und an Größe (≥ 5 mm der SOM für NLT oder jegliche Zunahme für NLNT) oder Anzahl zunehmen. Wenn sich die NLs (Größe oder Anzahl) seit dem letzten TP nicht verändert haben, dann weiterhin iUPD iSD, iPR, iCR iUPD Nein iUPD Weiterhin iUPD, außer iCPD wird aufgrund einer weiteren Größenzunahme der NT-Erkrankung bestätigt (muss nicht die Kriterien nach RECIST 1.1 für eine eindeutige PD erfüllen) iUPD NichtiCR/NichtiUPD Nein iUPD Weiterhin iUPD, außer iCPD wird bestätigt aufgrund von: weiterer Zunahme der SOM um mindestens 5 mm, sonst weiterhin iUPD iUPD iUPD Nein iUPD Weiterhin iUPD, außer iCPD wird bestätigt aufgrund von weiterer Zunahme von: zuvor identifizierter Zielläsion iUPD SOM ≥ 5 mm oder NT-Läsion iUPD (vorherige Beurteilung - muss keine eindeutige PD sein) iUPD iUPD Ja iUPD Weiterhin iUPD, außer iCPD wird bestätigt aufgrund von weiterer Zunahme von: zuvor identifizierter Zielläsion iUPD ≥ 5 mm oder zuvor identifizierter NT-Läsion iUPD (muss nicht eindeutig sein) oder Größe oder Anzahl der zuvor identifizierten neuen Läsionen NichtiUPD/PD NichtiUPD/PD Ja iUPD Weiterhin iUPD, außer iCPD wird bestätigt aufgrund von: Zunahme der Größe oder Anzahl neuer, zuvor identifizierter Läsionen Abkürzungen: CR = komplettes Ansprechen; iCPD = Confirmed Immune PD; iCR = Immune Complete Response; iPR = Immune Partial Response; iRECIST = Response Evaluation Criteria in Solid Tumors for immune based therapeutics; iSD = Immune Stable Disease; iUPD = Immune Unconfirmed PD; NA = nicht anwendbar; NL = neue Läsionen; NLT = New Lesion Target; NLNT = New Lesion Nontarget; NT = Nontarget; PD = progressive Erkrankung; PR = partielles Ansprechen; RECIST = Response Evaluation Criteria in Solid Tumors; SD = stabile Erkrankung; SOM = Summe der Messungen; TP = Zeitpunkt * Unter Verwendung der RECIST 1.1-Prinzipien. Wenn keine Pseudoprogression auftritt, wären die Kategorien für CR, PR und SD nach RECIST 1.1 und iRECIST gleich. ** in jeder beliebigen Läsionskategorie. *** bereits in der Bewertung unmittelbar vor diesem TP identifiziert. Response will also be assessed according to iRECIST as shown in Table 6. The main differences between RECIST and iREC!ST are discussed in Seymour et al. 2017 briefly explained as follows:

• “The principles for determining objective tumor response are largely unchanged from RECIST 1.1. However, the most important change in iRECIST is the concept of resetting the bar when progression according to RECIST 1.1 is followed by tumor shrinkage at the next assessment. iRECIST defines iUPD based on the principles of REClST 1.1.; However, iUPD requires confirmation by observing either a further increase in size (or number of new lesions) in the lesion category in which progression was first noted (i.e., target or non-target disease), or observation of progression ( defined according to RECIST 1.1) in lesion categories that did not previously meet the criteria for progression according to RECIST 1.1. However, if not progression but tumor shrinkage (compared to baseline) meeting the criteria of iCR, iPR or iSD is confirmed, then the bar is reset so that iUPD must reoccur (compared to nadir values) and then needs to be confirmed at the next assessment (based on further growth) in order to be classified as iCPD. If there is no change in tumor size or extent compared to iUPD, then the time-point response would again be iUPD. This approach makes it possible to detect atypical responses, such as: B. delayed response after pseudoprogression, to be identified, better understood and better characterized.”

Table 6: Response assessment according to iRECIST Target lesions* Non-target lesions* New lesions* Time point response No previous iUPD** Previous iUPD** *** iCR iCR No iCR iCR iCR Non-iCR/non-iUPD No iPR iPR iPR Non-iCR/non-iUPD No iPR iPR iSD Non-iCR/non-iUPD No iSD iSD iUPD without change OR decrease since last TP iUPD without change OR decrease since last TP Yes N/A NLs confirm iCPD when NLs have been previously identified and are increasing in size (≥5 mm of SOM for NLT or any increase for NLNT) or number. If the NLs (size or number) have not changed since the last TP, then continue iUPD iSD, iPR, iCR iUPD No iUPD Continued iUPD unless iCPD is confirmed due to further increase in size of NT disease (does not need to meet RECIST 1.1 criteria for definite PD) iUPD Non-iCR/non-iUPD No iUPD Continued iUPD, unless iCPD is confirmed due to: further increase in SOM of at least 5 mm, otherwise continued iUPD iUPD iUPD No iUPD Continued iUPD unless iCPD is confirmed due to further increase in: previously identified target lesion iUPD SOM ≥ 5 mm or NT lesion iUPD (previous assessment - does not have to be definite PD) iUPD iUPD Yes iUPD Continued iUPD, unless iCPD is confirmed due to further increase of: previously identified target lesion iUPD ≥ 5 mm or previously identified NT lesion iUPD (does not have to be definite) or size or number of previously identified new lesions Non-iUPD/PD Non-iUPD/PD Yes iUPD Continued iUPD, unless iCPD is confirmed due to: Increase in size or number of new, previously identified lesions Abbreviations: CR = complete response; iCPD = Confirmed Immune PD; iCR = Immune Complete Response; iPR = Immune Partial Response; iRECIST = Response Evaluation Criteria in Solid Tumors for immune based therapeutics; iSD = Immune Stable Disease; iUPD = Immune Unconfirmed PD; NA = not applicable; NL = new lesions; NLT = New Lesion Target; NLNT = New Lesion Nontarget; NT = nontarget; PD = progressive disease; PR = partial response; RECIST = Response Evaluation Criteria in Solid Tumors; SD = stable disease; SOM = sum of measurements; TP = time * Using RECIST 1.1 principles. If pseudoprogression does not occur, the categories for CR, PR and SD would be the same according to RECIST 1.1 and iRECIST. ** in any lesion category. *** already identified in the review immediately before this TP.

The foregoing merely illustrates the principles of revelation. Various modifications and variations of the described embodiments will be apparent to those skilled in the art in light of the teachings contained herein. Those skilled in the art will therefore be able to develop numerous systems, arrangements and procedures which, although not explicitly shown or described herein, embody the principles of the disclosure and thus correspond to the spirit of the disclosure and may fall within the scope thereof. Various exemplary embodiments may be used both together and interchangeably, as should be apparent to those of ordinary skill in the art. Additionally, certain terms used in the present disclosure, including the specification, may be used interchangeably in certain cases, such as the terms data and information. It should be noted that while these words and/or other words that may be synonymous with each other may be used interchangeably herein, there may also be cases where these words are not intended to be used interchangeably. To the extent that the prior art has not been expressly incorporated by reference above, it is expressly incorporated herein in its entirety. All referenced publications are incorporated herein by reference in their entirety.

QUOTES INCLUDED IN THE DESCRIPTION

This list of documents listed by the applicant was generated automatically and is included solely for the better information of the reader. The list is not part of the German patent or utility model application. The DPMA assumes no liability for any errors or omissions.

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Claims (18)

A method of treating a primary liver cancer comprising administering to a subject in need thereof a therapeutically effective amount of a Toll-like receptor 9 (TLR9) agonist, the TLR9 agonist having the following structure: 5'-TCG AAC GTT CGA ACG TTC GAA CGT TCG AAT-3' (SEQ ID NO: 1). Procedure according to Claim 1 , where the primary liver cancer is hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC). Procedure according to Claim 1 , wherein the TLR9 agonist is administered via a hepatic arterial infusion (HAI) device. Procedure according to Claim 1 , where the TLR9 agonist is administered via a portal vein infusion (PVI) device. Procedure according to Claim 1 , wherein the therapeutically effective amount of TLR9 agonist administered is selected from the group consisting of 0.01 mg/ml, 0.04 mg/ml, 0.08 mg/ml or 0.16 mg/ml. Procedure according to Claim 1 , wherein the therapeutically effective amount of TLR9 agonist administered is selected from the group consisting of 0.5 mg, 2 mg, 4 mg or 8 mg. Procedure according to Claim 1 , wherein the TLR9 agonist can be administered via a catheter device. Procedure according to Claim 7 , wherein the catheter device includes a one-way valve that responds dynamically to local pressure and/or flow changes. Procedure according to Claim 7 , wherein the TLR9 agonist is administered via the catheter device using pressure-activated drug delivery. Procedure according to Claim 7 , where the TLR9 agonist is administered over a period of approximately 10-200 minutes. Procedure according to Claim 10 , where the TLR9 agonist is administered over a period of approximately 10-60 minutes. Procedure according to Claim 11 , where the TLR9 agonist is administered over a period of approximately 25 minutes. Procedure according to Claim 1 , wherein the TLR9 agonist is administered in combination with one or more checkpoint inhibitors (CPls), the CPls being administered systemically, either concurrently with, before or after administration of the TLR9 agonist. Procedure according to Claim 13 , wherein the one or more CPIs include at least one of nivolumab, pembrolizumab and ipilimumab. Procedure according to Claim 1 , wherein the administration of the TLR9 agonist comprises a dosage regimen comprising cycles, wherein one or more of the cycles comprises administration of the TLR9 agonist via a catheter device via hepatic arterial infusion, followed by systemic administration of the one or more checkpoint inhibitors ( CPls). Procedure according to Claim 15 , wherein a cycle comprises administration of the therapeutically effective amount of the TLR9 agonist once per week for three consecutive weeks. Procedure according to Claim 16 , with the dosage regimen comprising two cycles. Procedure according to Claim 15 , wherein the one or more CPIs include at least one of nivolumab, pembrolizumab and ipilimumab.

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