Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K33/00—Medicinal preparations containing inorganic active ingredients
  • A61K33/24—Heavy metals; Compounds thereof
  • A61K33/243—Platinum; Compounds thereof
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/4353—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom ortho- or peri-condensed with heterocyclic ring systems
  • A61K31/436—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom ortho- or peri-condensed with heterocyclic ring systems the heterocyclic ring system containing a six-membered ring having oxygen as a ring hetero atom, e.g. rapamycin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/555—Heterocyclic compounds containing heavy metals, e.g. hemin, hematin, melarsoprol
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/66—Phosphorus compounds
  • A61K31/675—Phosphorus compounds having nitrogen as a ring hetero atom, e.g. pyridoxal phosphate
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P13/00—Drugs for disorders of the urinary system
  • A61P13/08—Drugs for disorders of the urinary system of the prostate
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
  • A61P35/02—Antineoplastic agents specific for leukemia
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00

Definitions

• This invention relates to the use of combinations of an mTOR inhibitor (e.g rapamycin 42-ester with 3-hydroxy-2-(hydroxymethyl)-2-methyIpropionic acid (CCI-779)) and an antineoplastic alkylating agent in the treatment of neoplasms, to the use of an mTOR inhibitor and an antineoplastic alkylating agent in the preparation of a medicament for the treatment of a neoplasm, to a product comprising an mTOR inhibitor and an antineoplastic alkylating agent as a combined preparation for simultaneous, separate or sequential use in the treatment of a neoplasm, and to pharmaceutical compositions comprising an mTOR inhibitor, an antineoplastic alkylating agent and a pharmaceutically acceptable carrier.
• an mTOR inhibitor e.g rapamycin 42-ester with 3-hydroxy-2-(hydroxymethyl)-2-methyIpropionic acid (CCI-779)
• an antineoplastic alkylating agent in the treatment of ne
• Rapamycin is a macrocyclic triene antibiotic produced by Streptomyces hygroscopicus, which was found to have antifungal activity, particularly against Candida albicans. both in vitro and in vivo [C. Vezina et al., J. Antibiot. 28, 721 (1975); S.N. Sehgal et al., J. Antibiot. 28, 727 (1975); H. A. Baker et al., J. Antibiot. 31 , 539 (1978); U.S. Patent 3,929,992; and U.S. Patent 3,993,749]. Additionally, rapamycin alone (U.S. Patent 4,885,171) or in combination with picibanil (U.S. Patent 4,401 ,653) has been shown to have antitumor activity.
• Rapamycin is effective in the experimental allergic encephalomyelitis model, a model for multiple sclerosis; in the adjuvant arthritis model, a model for rheumatoid arthritis; and effectively inhibited the formation of IgE-like antibodies. Rapamycin is also useful in preventing or treating systemic lupus erythematosus [U.S. Patent 5,078,999], pulmonary inflammation [U.S. Patent 5,080,899], insulin dependent diabetes mellitus [U.S. Patent 5,321 ,009], skin disorders, such as psoriasis [U.S. Patent 5,286,730], bowel disorders [U.S.
• Patent 5,286,731 smooth muscle cell proliferation and intimal thickening following vascular injury [U.S. Patents 5,288,711 and 5,516,781], adult T-cell leukemia/lymphoma [European Patent Application 525,960 A1], ocular inflammation [U.S. Patent 5,387,589], malignant carcinomas [U.S. Patent 5,206,018], cardiac inflammatory disease [U.S. Patent 5,496,832], and anemia [U.S. Patent 5,561 ,138]. Rapamycin 42-ester with 3-hydroxy-2-(hydroxymethyl)-2-methylpropionic acid
• CCI-779 is ester of rapamycin which has demonstrated significant inhibitory effects on tumor growth in both in vitro and in vivo models.
• the preparation and use of hydroxyesters of rapamycin, including CCI-779, are disclosed in U.S. Patent 5,362,718.
• CCI-779 exhibits cytostatic, as opposed to cytotoxic properties, and may delay the time to progression of tumors or time to tumor recurrence.
• CCI-779 is considered to have a mechanism of action that is similar to that of sirolimus.
• CCI-779 binds to and forms a complex with the cytoplasmic protein FKBP, which inhibits an enzyme, mTOR (mammalian target of rapamycin, also known as FKBP12-rapamycin associated protein [FRAP]). Inhibition of mTOR's kinase activity inhibits a variety of signal transduction pathways, including cytokine-stimulated cell proliferation, translation of mRNAs for several key proteins that regulate the G1 phase of the cell cycle, and IL-2-induced transcription, leading to inhibition of progression of the cell cycle from GI to S.
• the mechanism of action of CCI-779 that results in the Gl S phase block is novel for an anticancer drug.
• CCI-779 has been shown to inhibit the growth of a number of histologically diverse tumor cells.
• Central nervous system (CNS) cancer, leukemia (T-cell), breast cancer, prostate cancer, and melanoma lines were among the most sensitive to CCI-779.
• the compound arrested cells in the G1 phase of the cell cycle.
• CCI-779 has activity against human tumor xenografts of diverse histological types. Gliomas were particularly sensitive to CCI-779 and the compound was active in an orthotopic glioma model in nude mice.
• Growth factor (platelet-derived)-induced stimulation of a human glioblastoma cell line in vitro was markedly suppressed by CCI-779.
• the growth of several human pancreatic tumors in nude mice as well as one of two breast cancer lines studied in vivo also was inhibited by CCI-779.
• This invention provides the use of combinations of an mTOR inhibitor and an antineoplastic alkylating agent as antineoplastic combination chemotherapy.
• these combinations are useful in the treatment of renal cancer, soft tissue cancer, breast cancer, neuroendocrine tumor of the lung, cervical cancer, uterine cancer, head and neck cancer, glioma, non-small lung cell cancer, prostate cancer, pancreatic cancer, lymphoma, melanoma, small cell lung cancer, ovarian cancer, colon cancer, esophageal cancer, gastric cancer, leukemia, colorectal cancer, and unknown primary cancer.
• This invention also provides combinations of an mTOR inhibitor and an antineoplastic alkylating agent for use as antineoplastic combination chemotherapy, in which the dosage of either the mTOR inhibitor or the antineoplastic alkylating agent or both are used in subtherapeutically effective dosages.
• the invention provides the use of combinations of an mTOR inhibitor and an antineoplastic alkylating agent in the preparation of a medicament for the treatment of a neoplasm.
• the invention provides a product comprising an mTOR inhibitor and an antineoplastic alkylating agent as a combined preparation for simultaneous, separate or sequential use in the treatment of a neoplasm in a mammal.
• the invention provides a pharmaceutical composition comprising an mTOR inhibitor, an antineoplastic alkylating agent and a pharmaceutically acceptable carrier.
• treatment means treating a mammal having a neoplastic disease by providing said mammal an effective amount of a combination of an mTOR inhibitor and an antineoplastic alkylating agent with the purpose of inhibiting growth of the neoplasm in such mammal, eradication of the neoplasm, or palliation of the mammal.
• the term "providing,” with respect to providing the combination means either directly administering the combination, or administering a prodrug, derivative, or analog of one or both of the components of the combination which will form an effective amount of the combination within the body.
• mTOR is the mammalian target of rapamycin, also known as FKBP12- rapamycin associated protein [FRAP]. Inhibition of mTOR's kinase activity inhibits a variety of signal transduction pathways, including cytokine-stimulated cell proliferation, translation of mRNAs for several key proteins that regulate the G1 phase of the cell cycle, and IL-2-induced transcription, leading to inhibition of progression of the cell cycle from G1 to S. mTOR regulates the activity of at least two proteins involved in the translation of specific cell cycle regulatory proteins (Burnett, P.E., PNAS 95: 1432 (1998) and Isotani, S., J. Biol. Chem. 274: 33493 (1999)).
• One of these proteins p70s6 kinase is phosphorylated by mTOR on serine 389 as well as threonine 412. This phosphorylation can be observed in growth factor treated cells by Western blotting of whole cell extracts of these cells with antibody specific for the phosphoserine 389 residue.
• an "mTOR inhibitor” means a compound or ligand which inhibits cell replication by blocking progression of the cell cycle from G1 to S by inhibiting the phosphorylation of serine 389 of p70s6 kinase by mTOR.
• a compound is an mTOR inhibitor, as defined herein.
• Treatment of growth factor stimulated cells with an mTOR inhibitor like rapamycin completely blocks phosphorylation of serine 389 as evidenced by Western blot and as such constitutes a good assay for mTOR inhibition.
• whole cell lysates from cells stimulated by a growth factor (eg. IGF1) in culture in the presence of an mTOR inhibitor should fail to show a band on an acrylamide gel capable of being labeled with an antibody specific for serine 389 of p70s6K.
• Cell lines were grown in optimal basal medium supplemented with 10% fetal bovine serum and penicillin/treptomycin. For phosphorylation studies, cells were subcultured in 6-well plates. After the cells have completely attached, they were either serum-starved. Treatment with mTOR inhibitors ranged from 2 to 16 hours. After drug treatment, the cells were rinsed once with PBS (phosphate buffered saline without Mg++ and Ca++) and then lysed in 150-200 ⁇ l NuPAGE LDS sample buffer per well. The lysates were briefly sonicated and then centrifuged for 15 minutes at 14000 rpm. Lysates were stored at minus -80 C until use.
• PBS phosphate buffered saline without Mg++ and Ca++
• test procedure can also be run by incubating the cells in growth medium overnight after they have completely attached.
• results under both sets of conditions should be the same for an mTOR inhibitor.
• a rapamycin defines a class of immunosuppressive compounds which contain the basic rapamycin nucleus (shown below).
• the rapamycins of this invention include compounds which may be chemically or biologically modified as derivatives of the rapamycin nucleus, while still retaining immunosuppressive properties.
• a rapamycin includes esters, ethers, oximes, hydrazones, and hydroxylamines of rapamycin, as well as rapamycins in which functional groups on the rapamycin nucleus have been modified, for example through reduction or oxidation.
• a rapamycin also includes pharmaceutically acceptable salts of rapamycins, which are capable of forming such salts, either by virtue of containing an acidic or basic moiety.
• esters and ethers of rapamycin are of the hydroxyl groups at the 42- and/or 31 -positions of the rapamycin nucleus, esters and ethers of a hydroxyl group at the 27-position (following chemical reduction of the 27-ketone), and that the oximes, hydrazones, and hydroxylamines are of a ketone at the 42-position (following oxidation of the 42-hydroxyl group) and of 27-ketone of the rapamycin nucleus.
• Preferred 42- and/or 31 -esters and ethers of rapamycin are disclosed in the following patents, which are all hereby incorporated by reference: alkyl esters (U.S. Patent 4,316,885); aminoalkyl esters (U.S. Patent 4,650,803); fluorinated esters (U.S. Patent 5,100,883); amide esters (U.S. Patent 5,118,677); carbamate esters (U.S. Patent 5,118,678); silyl ethers (U.S. Patent 5,120,842); aminoesters (U.S. Patent 5,130,307); acetals (U.S. Patent 5,51 ,413); aminodiesters (U.S.
• Patent 5,162,333 sulfonate and sulfate esters
• U.S. Patent 5,177,203 esters
• esters U.S. Patent 5,221 ,670
• alkoxyesters U.S. Patent 5,233,036
• O-aryl, -alkyl, -alkenyl, and -alkynyl ethers U.S. Patent 5,258,389
• carbonate esters U.S. Patent 5,260,300
• arylcarbonyl and alkoxycarbonyl carbamates U.S. Patent 5,262,423
• carbamates U.S. Patent 5,302,584
• hydroxyesters U.S. Patent 5,362,718)
• hindered esters U.S.
• Patent 5,385,908 ; heterocyclic esters (U.S. Patent 5,385,909); gem-disubstituted esters (U.S. Patent 5,385,910); amino alkanoic esters (U.S. Patent 5,389,639); phosphorylcarbamate esters (U.S. Patent 5,391 ,730); carbamate esters (U.S. Patent 5,411 ,967); carbamate esters (U.S. Patent 5,434,260); amidino carbamate esters (U.S. Patent 5,463,048); carbamate esters (U.S. Patent 5,480,988); carbamate esters (U.S. Patent 5,480,989); carbamate esters (U.S.
• Patent 5,489,680 hindered N-oxide esters (U.S. Patent 5,491 ,231); biotin esters (U.S. Patent 5,504,091); O-alkyl ethers (U.S. Patent 5,665,772); and PEG esters of rapamycin (U.S. Patent 5,780,462).
• the preparation of these esters and ethers are disclosed in the patents listed above.
• Preferred oximes, hydrazones, and hydroxylamines of rapamycin are disclosed in U.S. Patents 5,373,014, 5,378,836, 5,023,264, and 5,563,145, which are hereby incorporated by reference.
• the preparation of these oximes, hydrazones, and hydroxylamines are disclosed in the above listed patents.
• the preparation of 42- oxorapamycin is disclosed in 5,023,263, which is hereby incorporated by reference.
• rapamycins include rapamycin [U.S. Patent 3,929,992],
• pharmaceutically acceptable salts of the rapamycin can be formed from organic and inorganic acids, for example, acetic, propionic, lactic, citric, tartaric, succinic, fumaric, maleic, malonic, mandelic, malic, phthalic, hydrochloric, hydrobromic, phosphoric, nitric, sulfuric, methanesulfonic, napthalenesulfonic, benzenesulfonic, toluenesulfonic, camphorsulfonic, and similarly known acceptable aids when the rapamycin contains a suitable basic moiety.
• organic and inorganic acids for example, acetic, propionic, lactic, citric, tartaric, succinic, fumaric, maleic, malonic, mandelic, malic, phthalic, hydrochloric, hydrobromic, phosphoric, nitric, sulfuric, methanesulfonic, napthalenesulfonic, benzenesulfonic, to
• Salts may also be formed from organic and inorganic bases, such as alkali metal salts (for example, sodium, lithium, or potassium) alkaline earth metal salts, ammonium salts, alkylammonium salts containing 1-6 carbon atoms or dialkylammonium salts containing 1-6 carbon atoms in each alkyl group, and trialkylammonium salts containing 1-6 carbon atoms in each alkyl group, when the rapamycin contains a suitable acidic moiety.
• alkali metal salts for example, sodium, lithium, or potassium alkaline earth metal salts
• ammonium salts for example, sodium, lithium, or potassium alkaline earth metal salts
• alkylammonium salts containing 1-6 carbon atoms or dialkylammonium salts containing 1-6 carbon atoms in each alkyl group such as sodium, lithium, or potassium alkaline earth metal salts, ammonium salts, alkylammonium salts containing 1-6 carbon atoms or dial
• the mTOR inhibitor used in the antineoplastic combinations of this invention is a rapamycin, and more preferred that the mTOR inhibitor is rapamycin, CCI-779, or 42-0-(2-hydroxy)ethyl rapamycin.
• CCI-779 was evaluated as a representative mTOR inhibitor in the mTOR inhibitor plus antimetabolite combinations of this invention.
• CCI-779 is described in U.S. Patent 5,362,718, which is hereby incorporated by reference.
• initial i.v. infusion dosages will be between about 0.1 and 100 mg/m 2 when administered on a daily dosage regimen (daily for 5 days, every 2-3 weeks), and between about 0.1 and 1000 mg/m 2 when administered on a once weekly dosage regimen.
• Oral or intravenous infusion are the preferred routes of administration, with intravenous being more preferred.
• the term "antineoplastic alkylating agent” means a substance which reacts with (or “alkylates”) many electron-rich atoms in cells to form covalent bonds.
• the most important reactions with regard to their antitumor activities are reactions with DNA bases.
• Some alkylating agents are monofunctional and react with only one strand of DNA. Others are bifunctional and react with an atom on each of the two strands of DNA to produce a "cross-link” that covalently links the two strands of the DNA double helix. Unless repaired, this lesion will prevent the cell from replicating effectively.
• the lethality of the monofunctional alkylating agents results from the recognition of the DNA lesion by the cell and the response of the cell to that lesion.
• Antineoplastic alkylating agents are roughly classified, according to their structure or reactive moiety, into several categories which include nitrogen mustards, such as mustargen, cyclophosphamide, ifosfamide, melphalan, and chlorambucil; azidines and epoxides, such as thiotepa, mitomycin C, dianhydrogalactitol, and dibromodulcitol; alkyl sulfonates, such as busulfan; nitrosoureas, such as bischloroethylnitrosourea (BCNU), cyclohexyl-chloroethylnitrosourea (CCNU), and methylcyclohexylchloroethylnitrosourea (MeCCNU); hydrazine and triazine derivatives, such as procarbazine, dacarbazine, and temozolomide; and platinum compounds.
• nitrogen mustards such as mustargen,
• Platinum compounds are platinum containing agents that react preferentially at the N7 position of guanine and adenine residues to form a variety of monofunctional and bifunctional adducts.
• These compounds include cisplatin, carboplatin, platinum IV compounds, and multinuclear platinum complexes.
• Meclorethamine is commercially available as an injectable (MUSTARGEN).
• Cyclophosphamide is commercially available as an injectable
• cyclophosphamide lyophilized CYTOXAN, or NEOSAR
• oral tablets cyclophosphamide or CYTOXAN
• Ifosfamide is commercially available as an injectable (IFEX).
• Chlorambucil is commercially available in oral tablets (LEUKERAN).
• Thiotepa is commercially available as an injectable (thiotepa or THIOPLEX).
• Mitomycin is commercially available as an injectable (mitomycin or MUTAMYCIN).
• Busulfan is commercially available as an injectable (BUSULFEX) and in oral tablets (MYLERAN).
• Lomustine (CCNU) is commercially available in oral capsules (CEENU).
• BCNU Carmustine
• LMIADEL intracranial implant
• BICNU injectable injectable
• Procarbazine is commercially available in oral capsules (MATULANE).
• Temozolomide is commercially available in oral capsules (TEMODAR).
• Cisplatin is commercially available as an injectable (cisplatin, PLATINOL, or PLATINOL-AQ).
• Carboplatin is commercially available as an injectable (PARAPLATIN).
• Preferred mTOR inhibitor plus antineoplastic alkylating agent combinations of this invention include CCI-779 plus cisplatin; CCI-779 plus cyclophosphamide; CCI- 779 plus carboplatin; and CCI-779 plus BCNU.
• Human rhabdomyosarcoma lines Rh30 and Rh1 and the human glioblastoma line SJ-GBM2 were used for in vitro combination studies with CCI-779 and alkylating agents.
• In vivo studies used a human neuroblastoma (NB1643) and human colon line
• Dose response curves were determined for each of the drugs of interest.
• the cell lines Rh30, Rh1 and SJ-G2 were plated in six-well cluster plates at 6x10 3 , 5x10 3 and 2.5x10 4 cells/well respectively. After a 24 hour incubation period, drugs were added in either 10%FBS+RPMI 1640 for Rh30 and Rh1 or 15%FBS+DME for SJ-G2.
• the nuclei were released by treating the cells with a hypotonic solution followed by a detergent. The nuclei were then counted with a Coulter Counter. The results of the experiments were graphed and the IC 50 (drug concentration producing 50% inhibition of growth) for each drug was determined by extrapolation. Because the IC50s varied slightly from experiment to experiment, two values that bracketed the IC50 of each drug were used in the interaction studies. The point of maximum interaction between two drugs occurs when they are present in a 1 :1 ratio if the isobole is of standard shape.
• each of the three approximate IC 50 concentrations of CCI-779 was mixed in a 1 :1 ratio with each of three approximated IC 50 s of cisplatin, BCNU, and melphanan. This resulted in nine 1 :1 combinations of drugs in each experiment plus three IC 5 Q concentrations for CCI-779 and the other drug. This protocol usually resulted in at least one combination for each drug containing an IC 50 value.
• mice Female CBA/CaJ mice (Jackson Laboratories, Bar Harbor, ME), 4 weeks of age, were immune-deprived by thymectomy, followed 3 weeks later by whole-body irradiation (1200 cGy) using a 137 Cs source. Mice received 3 x 10 6 nucleated bone marrow cells within 6-8 h of irradiation. Tumor pieces of approximately 3 mm 3 were implanted in the space of the dorsal lateral flanks of the mice to initiate tumor growth. Tumor-bearing mice were randomized into groups of seven prior to initiating therapy. Mice bearing tumors each received drug when tumors were approximately 0.20-1 cm in diameter.
• Tumor size was determined at 7-day intervals using digital Vernier calipers interfaced with a computer. Tumor volumes were calculated assuming tumors to be spherical using the formula [( ⁇ /6) x d 3 ], where of is the mean diameter.
• CCI- 779 was given on a schedule of 5 consecutive days for 2 weeks with this cycle repeated every 21 days for 3 cycles. This resulted in CCI-779 being given on days 1- 5, 8-12 (cycle 1); 21-25, 28-32 (cycle 2); and 42-46, 49-53 (cycle 3).
• the schedule of the other chemotherapy drug for each study was as follows:
• CCI-779 and cyclophosphamide were evaluated using a human rhabdosarcoma (Rh18) using the mouse xenograft test procedure described above. In this test procedure, the effect of CCI-779 with cyclophosphamide (44 mg/kg) was additive. When combined as suboptimum dosages, CCI-779 plus cyclophosphamide was equivalent to cyclophosphamide given at an optimum dosage.
• combinations of an mTOR inhibitor plus an antineoplastic alkylating agent are useful as antineoplastic therapy. More particularly, these combinations are useful in the treatment of renal carcinoma, soft tissue sarcoma, breast cancer, neuroendocrine tumor of the lung, cervical cancer, uterine cancer, head and neck cancer, glioma, non- small cell lung cancer, prostate cancer, pancreatic cancer, lymphoma, melanoma, small cell lung cancer, ovarian cancer, colon cancer, esophageal cancer, gastric cancer, leukemia, colorectal cancer, and unknown primary cancer.
• these combinations contain at least two active antineoplastic agents
• the use of such combinations also provides for the use of combinations of each of the agents in which one or both of the agents is used at subtherapeutically effective dosages, thereby lessening toxicity associated with the individual chemotherapeutic agent.
• a chemotherapy cocktail that may contain one or more additional antineoplastic agents depending on the nature of the neoplasia to be treated.
• this invention also covers the use of the mTOR inhibitor/alkylating agent combination used in conjunction with other chemotherapeutic agents, such as antimetabolites (i.e., 5-fluorouracil, floxuradine, thioguanine, cytarabine, fludarabine, 6-mercaptopurine, methotrexate, gemcitabine, capecitabine, pentostatin, trimetrexate, or cladribine); hormonal agents (i.e., estramustine, tamoxifen, toremifene, anastrozole, or letrozole); antibiotics (i.e., plicamycin, bleomycin, mitoxantrone, idarubicin, dactinomycin, mitomycin, or daunorubicin); immunomodulators (i.e., interferons, IL-2, or BCG); antimitotic agents (i.e., vinblastine, vincristine, teniposide, or vinor
• the combination regimen can be given simultaneously or can be given in a staggered regimen, with the mTOR inhibitor being given at a different time during the course of chemotherapy than the alkylating agent.
• This time differential may range from several minutes, hours, days, weeks, or longer between administration of the two agents. Therefore, the term combination does not necessarily mean administered at the same time or as a unitary dose, but that each of the components are administered during a desired treatment period.
• the agents may also be administered by different routes. For example, in the combination of an mTOR inhibitor plus an alkylating agent, it is anticipated that the mTOR inhibitor will be administered orally or parenterally, with parenterally being preferred, while the alkylating agent may be administered parenterally, orally, or by other acceptable means. These combination can be administered daily, weekly, or even once monthly. As typical for chemotherapeutic regimens, a course of chemotherapy may be repeated several weeks later, and may follow the same timeframe for administration of the two agents, or may be modified based on patient response.
• dosage regimens are closely monitored by the treating physician, based on numerous factors including the severity of the disease, response to the disease, any treatment related toxicities, age, health of the patient, and other concomitant disorders or treatments.
• the initial i.v. infusion dosage of the mTOR inhibitor will be between about 0.1 and 100 mg/m 2 , with between about 2.5 and 70 mg/m 2 being preferred. It is also preferred that the mTOR inhbitor be administered by i.v., typically over a 30 minute period, and administered about once per week.
• the initial dosages of the alkylating agent component will depend on the component used, and will be based initially on physician experience with the agents chosen. After one or more treatment cycles, the dosages can be adjusted upwards or downwards depending on the results obtained and the side effects observed.
• Oral formulations containing the active compounds of this invention may comprise any conventionally used oral forms, including tablets, capsules, buccal forms, troches, lozenges and oral liquids, suspensions or solutions.
• Capsules may contain mixtures of the active compound(s) with inert fillers and/or diluents such as the pharmaceutically acceptable starches (e.g.
• Useful tablet formulations may be made by conventional compression, wet granulation or dry granulation methods and utilize pharmaceutically acceptable diluents, binding agents, lubricants, disintegrants, surface modifying agents (including surfactants), suspending or stabilizing agents, including, but not limited to, magnesium stearate, stearic acid, talc, sodium lauryl sulfate, microcrystalline cellulose, carboxymethylcellulose calcium, polyvinylpyrrolidone, gelatin, alginic acid, acacia gum, xanthan gum, sodium citrate, complex silicates, calcium carbonate, glycine, dextrin, sucrose, sorbitol, dicalcium phosphate, calcium sulfate, lactose, kaolin, mannitol, sodium chloride,
• Preferred surface modifying agents include nonionic and anionic surface modifying agents.
• Representative examples of surface modifying agents include, but are not limited to, poloxamer 188, benzalkonium chloride, calcium stearate, cetostearyl alcohol, cetomacrogol emulsifying wax, sorbitan esters, colloidal silicon dioxide, phosphates, sodium dodecylsulfate, magnesium aluminum silicate, and triethanolamine.
• Oral formulations herein may utilize standard delay or time release formulations to alter the absorption of the active compound(s).
• the oral formulation may also consist of administering the active ingredient in water or a fruit juice, containing appropriate solubilizers or emulsifiers as needed. In some cases it may be desirable to administer the compounds directly to the airways in the form of an aerosol.
• the compounds may also be administered parenterally or intraperitoneally.
• Solutions or suspensions of these active compounds as a free base or pharmacologically acceptable salt can be prepared in water suitably mixed with a surfactant such as hydroxy-propylcellulose.
• Dispersions can also be prepared in glycerol, liquid polyethylene glycols and mixtures thereof in oils. Under ordinary conditions of storage and use, these preparation contain a preservative to prevent the growth of microorganisms.
• the pharmaceutical forms suitable for injectable use include sterile aqueous solutions or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersions. In all cases, the form must be sterile and must be fluid to the extent that easy syringability exists.
• the carrier can be a solvent or dispersion medium containing, for example, water, ethanol, polyol (e.g., glycerol, propylene glycol and liquid polyethylene glycol), suitable mixtures thereof, and vegetable oils.
• transdermal administrations are understood to include all administrations across the surface of the body and the inner linings of bodily passages including epithelial and mucosal tissues. Such administrations may be carried out using the present compounds, or pharmaceutically acceptable salts thereof, in lotions, creams, foams, patches, suspensions, solutions, and suppositories (rectal and vaginal). Transdermal administration may be accomplished through the use of a transdermal patch containing the active compound and a carrier that is inert to the active compound, is non toxic to the skin, and allows delivery of the agent for systemic absorption into the blood stream via the skin.
• the carrier may take any number of forms such as creams and ointments, pastes, gels, and occlusive devices.
• the creams and ointments may be viscous liquid or semisolid emulsions of either the oil- in-water or water-in-oil type.
• Pastes comprised of absorptive powders dispersed in petroleum or hydrophilic petroleum containing the active ingredient may also be suitable.
• a variety of occlusive devices may be used to release the active ingredient into the blood stream such as a semi-permeable membrane covering a reservoir containing the active ingredient with or without a carrier, or a matrix containing the active ingredient. Other occlusive devices are known in the literature.
• Suppository formulations may be made from traditional materials, including cocoa butter, with or without the addition of waxes to alter the suppository's melting point, and glycerin.
• Water soluble suppository bases such as polyethylene glycols of various molecular weights, may also be used.

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