TW202231283A - Improved fluorouracil-based multi-agent chemotherapy for treatment of metastatic colorectal cancer - Google Patents

Abstract

This invention is in the area of improved colorectal cancer treatment protocols that provide reduced toxicity compared to currently used regimens, including reduced chemotherapy-induced myelosuppression (CIM), diarrhea, mucositis, and/or stomatitis, while, in some embodiments, also improving anti-cancer efficacy. The improved protocols incorporate a highly selective, transient cyclin dependent kinase (CDK) 4/6 inhibitor into the colorectal cancer treatment protocol, allowing for the expanded use of effective fluorouracil-based multi-agent chemotherapies, for example FOLFOXIRI or FOLFIRINOX, into patient populations previously excluded from these protocols.

Description

Modified fluorouracil-based multiagent chemotherapy for the treatment of metastatic colorectal cancer

The present invention is in the field of improved colorectal cancer treatment regimens that provide reduced toxicity compared to currently used therapies, including reduced chemotherapy-induced myelosuppression (CIM), Diarrhea, mucositis and/or stomatitis, and in some embodiments, also improve anticancer efficacy. Improved regimen to incorporate highly selective transient cyclin-dependent kinase (CDK) 4/6 inhibitors into colorectal cancer treatment regimens, allowing such potent fluorouracil-based multi-agent chemotherapy, such as but not limited to FOLFOXIRI and FOLFIRINOX were expanded for use in patient populations previously excluded from these regimens.

Each year, 1.85 million people are diagnosed with colorectal cancer (CRC), and approximately 880,000 people will die from the disease (WHO International Agency for Research on Cancer, 2019). Fluorouracil-based multi-agent chemotherapy remains the basis for the treatment of metastatic disease, and almost all patients will receive fluorouracil (5-FU), aldofolic acid (leucovorin), or levoleucovorin )), a combination of oxaliplatin and/or irinotecan, and a monoclonal antibody (mAb) targeting the VEGF pathway, such as bevacizumab, or directed against patients with KRAS Monoclonal antibodies for patients with wild-type and BRAF wild-type disease, or mAbs targeting the EGFR pathway, such as cetuximab or panitumumab.

Until recently, the standard of care has focused on FOLFOX (5-FU, folates (such as tetrahydrofolate or levothyroxine) and oxaliplatin) or FOLFIRI (5-FU, folates, and irinotecan) For use in the first-line setting, mAbs (anti-VEGF or anti-EGFR) will be added to this first-line setting. After progress on this treatment, the patient then received alternative treatment. For example, if a patient starts FOLFOX/mAb, they will switch to FOLFIRI/mAb after FOLFOX/mAb progresses, and vice versa. A combination of all four drugs called FOLFOXIRI (5-FU, aldehyde folate (methyltetrahydrofolate or, alternatively, levothyroxine), oxaliplatin, and irinotecan; and another called FOLFIRINOX A recent study in modified protocol) now shows that four drugs are better than three drugs in terms of antitumor efficacy in metastatic colorectal cancer (mCRC).

For example, in the TRIBE trial, patients treated with FOLFOXIRI/bevacizumab had a median progression-free survival (PFS) of 12.1 months compared to patients treated with FOLFIRI/bevacizumab with a median progression-free survival (PFS) of 9.7 months month median PFS (hazard ratio [HR]: 0.75); and median overall survival (OS) compared to a median overall survival (OS) of 25.8 months in the FOLFIRI/bevacizumab group 29.8 months (HR: 0.8) (Loupakis et al, Initial therapy with FOLFOXIRI and bevacizumab for metastatic colorectal cancer. N Engl J Med. 2014; 371(17):1609-18; Cremolini et al, FOLFOXIRI/bevacizumab versus FOLFIRI /bevacizumab as first-line treatment of patients with metastatic colorectal cancer: updated overall survival and molecular subgroup analyses of the open-label, phase 3 TRIBE study. Lancet Oncol. 2015; 16: 1306-15). Similarly, in VISNU-1, in the subset of mCRC patients with poor treatment outcomes in the first-line setting, FOLFOXIRI/bevacizumab was significantly better than FOLFOX/bevacizumab in prolonging median PFS (12.4 months). versus 9.3 months) (Sastre et al., Randomized phase III study comparing FOLFOX + bevacizumab versus FOLFOXIRI + bevacizumab (BEV) as 1st line treatment in patients with metastatic colorectal cancer (mCRC) with ≥3 baseline circulating tumor cells (bCTCs). J Clin Oncol. 2019; 37: suppl abstract 3507).

Although the FOLFOXIRI regimen has shown significantly better progression-free survival (PFS) and overall survival (OS) compared to FOLFOX or FOLFIRI, such improvements have come at the expense of increased chemotherapy-induced toxicity (see Montagnani et al, A systematic review of FOLFOXIRI chemotherapy for the first-line treatment of metastatic colorectal cancer: improved efficacy at the cost of increased toxicity. Colorectal Dis. 2011; 13: 846-52). Although the toxicities associated with the FOLFOX and FOLFIRI regimens were considerable, the toxicities associated with FOLFOXIRI were significantly more severe. For example, in the TRIBE study, compared to FOLFIRI/bevacizumab, patients receiving FOLFOXIRI/bevacizumab had a higher rate of: Grade 3 or 4 neutropenia (50% vs. 20.5%), febrile neutropenia (8.8% vs. 6.3%), diarrhea (18.8% vs. 10.6%), and stomatitis (8.8% vs. 4.3%) (see Loupakis et al., Initial therapy with FOLFOXIRI and bevacizumab for metastatic colorectal cancer. N Engl J Med. 2014;371(17):1609-18). Similarly, in VISNU-1, rates of grade ≥3 neutropenia, febrile neutropenia, and diarrhea were higher in patients receiving FOLFOXIRI/bevacizumab (35%, 9%, 21% ) than in patients receiving FOLFOX/bevacizumab (26%, 2%, 6%) were all significantly higher. In VISNU-1, mucositis was also numerically higher in the FOLFOXIRI group at 9% versus 4% in the FOLFOX group (Sastre, 2019).

Although the development of chemotherapy-induced myelosuppression (CIM) is potentially problematic in all fluorouracil-based multi-agent chemotherapy, this CIM is particularly problematic during FOLFOXIRI and FOLFIRINOX treatments, as the additional chemotherapeutic agents can Increased myelosuppression toxicity, and patients with myelosuppression are more likely to experience infection, sepsis, bleeding, and fatigue, often resulting in the need for hospitalization, hematopoietic growth factor support, blood transfusions (red blood cells [RBCs] and/or platelets), and even death (See e.g., Gustinetti et al., Bloodstream infections in neutropenic cancer patients: A practical update. Virulence. 2016; 7(3): 280-97; Li et al., Relationship between severity and duration of chemotherapy-induced neutropenia and risk of infection among patients with nonmyeloid malignancies. Support Care Cancer 2016; 24(10): 4377-83; Caggiano et al. Incidence, cost, and mortality of neutropenia hospitalization associated with chemotherapy. Cancer. 2005; 103(9): 1916-24) . In addition, CIM often results in dose reductions and delays, which limit therapeutic dose intensity and can compromise the antitumor efficacy benefits of fluorouracil-based multi-agent chemotherapy. Attempts to develop and implement clinical algorithms to guide chemotherapy dose reduction and treatment delay in patients with neutropenia and/or thrombocytopenia during treatment have been tested (see, e.g., Clinical Trial of a Novel Dose Adjustment Algorithm for Preventing Cytopenia-Related Delays During FOLFOX Chemotherapy, ClinicalTrials.gov Identifier: NCT04526886). Nonetheless, chemotherapy-induced damage to immune system cells can also limit antitumor efficacy because the host immune system cannot effectively respond to cancer. Long-term exposure to myelosuppressive agents can cause cumulative myelotoxicity and myelosuppression, which can limit the ability to follow standard-of-care doses and schedules for subsequent lines of therapy. To date, there is no single regulatory approved treatment available that prevents or mitigates the myelosuppressive effects of fluorouracil-based multi-agent chemotherapy regimens prior to the advent of fluorouracil-based multi-agent chemotherapy regimens. Existing interventions are often passively used to treat acute cytopenias and are spectrum-specific; each has its own associated set of risks (see eg, Blumberg et al., (2010) Platelet transfusions: trigger, dose, benefits, and risks. F1000 Med Rep 2:5. https://doi.org/10.3410/m2-5 ; Bohlius et al. (2019) Management of cancer-associated anemia with erythropoiesis-stimulating agents: ASCO/ASH Clinical Practice Guideline Update. J Clin Oncol 37(15):1336-1351. https://doi.org/10.1200/jco.18.02142 ; Xu et al., (2016) Risk factors for bone pain among patients with cancer receiving myelosuppressive chemotherapy and pegfilgrastim . Support Care Cancer 24(2):723-730. https://doi.org/10.1007/s00520-015-2834-2 ; Corey-Lisle et al, (2014) Transfusions and patient burden in chemotherapy-induced anaemia in France. Ther Adv Med Oncol 6(4):146-153. https://doi.org/10.1177/1758834014534515).

The development of chemotherapy-induced diarrhea (CID) can be debilitating and, in some cases, even life-threatening. Findings in such patients include hypovolemia, renal failure, and electrolyte disturbances such as metabolic acidosis and, depending on water intake, hyponatremia (increased water intake that cannot be excreted due to hypovolemic stimulation of antidiuretic hormone release) (2007) Prevention and management of chemotherapy-induced diarrhea in patients with colorectal cancer: a consensus statement by the Canadian working group on chemotherapy-induced diarrhea . Curr Oncol 14: 13-20). CIDs can interfere with and impair cancer treatment by causing delays or reductions in doses that can have an impact on survival. Patients who experience multiple episodes of severe diarrhea (grade 3 or higher) while receiving fluorouracil-based multi-agent chemotherapy, especially FOLFOXIRI and FOLFIRINOX, may permanently discontinue treatment due to associated risks.

Stomatitis/mucositis is the result of the toxic effects of chemotherapeutic agents on the rapidly dividing epithelial cells lining the gastrointestinal tract (which travels from the mouth to the anus), thereby predisposing the mucosal tissue to bleeding ulcers and infection. Stomatitis/mucositis typically begins 5 to 10 days after initiation of chemotherapy and lasts from one to six weeks or more. In patients with stomatitis/mucositis, the inability to eat due to associated pain causes significant nutritional problems, resulting in hypovolemia, electrolyte abnormalities, malnutrition and even death. Severe stomatitis/mucositis often results in dose reductions or interference with treatment regimens.

Thus, chemotherapy-related toxicities, including chemotherapy-induced myelosuppression (CIM), diarrhea, stomatitis, and mucositis, can affect the risk/benefit ratio of administration of fluorouracil-based multi-agent chemotherapy such as FOLFOXIRI and FOLFIRINOX. Because of the increased toxicity associated with more aggressive regimens such as FOLFOXIRI and FOLFIRINOX, the use of these regimens is often limited to younger patients who have fewer comorbidities and require aggressive cytoreduction surgery. Most clinical trials evaluating FOLFOXIRI specifically excluded patients over the age of 70 with an Eastern Cooperative Oncology Group (ECOG) performance status other than 0 (fully active, able to perform all pre-disease performance without limitation). For example, in the United States (US), the median age for colorectal cancer detection is 68 years for men and 72 years for women, indicating that substantially the majority of diagnosed patients will not be considered for more aggressive fluorouracil-based Multi-agent chemotherapy regimens such as FOLFOXIRI. In addition, chronic exposure to cytotoxic chemotherapeutic agents, including fluorouracil-based multi-agent chemotherapy regimens such as FOLFOXIRI, can cause cumulative myelotoxicity and myelosuppression, which can limit the ability to follow standard-of-care doses and schedules for subsequent lines of therapy.

Therefore, there is a need for improved regimens that increase the safety profile of fluorouracil-based multi-agent chemotherapy regimens and allow for broader and more aggressive administration of effective regimens such as FOLFOXIRI and FOLFIRINOX to a larger population of colorectal cancer patients.

The present invention provides methods for the treatment of colorectal cancer in human subjects by incorporating into a regimen the selective, short-acting and transient CDK4/6 inhibitor trilaciclib, or a pharmaceutically acceptable salt thereof An improved fluorouracil-based multi-agent chemotherapy regimen that provides a reduction in chemotherapy-associated side effects, including chemotherapy-induced myelosuppression (CIM) and gastrointestinal toxicity. Alternatively, the present invention may provide improved anticancer efficacy, progression free survival and/or overall survival. In one embodiment, the tralasiclib is provided in the form of a hydrochloride salt, such as dihydrochloride salt. In one embodiment, Trelacinab is a reconstituted form of dihydrochloride dihydrate, which may be in a lyophilized form.

By incorporating Tralacidib into fluorouracil-based multi-agent chemotherapy regimens and reducing chemotherapy-associated toxicity, regimens can be administered more safely at standard-of-care doses and schedules. Whereas current treatments for CIM such as administration of erythropoiesis stimulating agents (ESA) and/or granulocyte colony stimulating factor (G-CSF) are blood lineage specific and have been Employed after emergence—putting patients at risk for additional toxicities associated with administering these CIM treatments—incorporating tralacidib into fluorouracil-based multi-agent chemotherapy regimens to prevent or limit exposure to hematopoietic stem cells and Damage to precursor cells (HSPCs) and thus associated CIM, resulting in an overall improved safety profile and reduced use of standard blood lineage specific treatments. Furthermore, by reducing chemotherapy-associated toxicity, patient populations who have been excluded from treatment regimens such as FOLFOXIRI in the past - eg, individuals over 70 years of age with an ECOG performance status other than 0 - may safely receive such regimens. This is especially important in regimens such as FOLFOXIRI and FOLFIRINOX because FOLFOXIRI and FOLFIRINOX are more effective than either FOLFOX or FOLFIRI, but may be less tolerated by older, more severely ill patients. By including tralasiclib in regimens such as FOLFOXIRI or FOLFIRINOX, increased benefit can be achieved in a larger patient population than currently treated, resulting in superior quality of life and/or outcomes for the entire colorectal cancer patient population.

In addition to the improved safety profile of including trelacitinib in fluorouracil-based multi-agent chemotherapy, trelacitinib was also able to enhance the anticancer efficacy of these regimens in certain patient subpopulations with colorectal tumors As a result, these patient subgroups may be immunologically susceptible to immunosuppression. It has been shown that metastatic colorectal cancer can have a variable tumor immune microenvironment in patient populations, allowing for the presence or absence of certain immunogenic biomarkers and signals associated with prognosis and recurrence based on immune effector cell populations In contrast, tumors are immunologically classified as immune-hot, immune-variant, and immune-cold (see Camus et al., Coordination of intratumoral immune reaction and human colorectal cancer recurrence, Cancer Research 69, 2685-2693 (2009), cit. is incorporated herein by means). In addition, fluorouracil-based multi-agent chemotherapy regimens employ agents associated with induction of immunogenic cell death (ICD), including 5-FU, irinotecan, and/or oxaliplatin (see Ruan et al., Immunogenic cell death). in colon cancer prevention and therapy. Molecular Carcinogenesis 2020;59:783-793). ICD is a modulated form of cell death apoptosis that induces the release of tumor-associated antigens and is capable of triggering anti-tumor immune responses, and involves the release of damage-associated molecular pathways (DAMPS) that contribute to host immunity System alerts cells to damage (see Locy et al, immunomodulation of the tumor microenvironment: turn foe into friend: Frontiers in Immunology, 2018; 9:2020; Wang et al, Immunogenic effects of chemotherapy induced tumor cell death. Genes & Diseases (2018 ) 5, 194-203).

In addition to reducing CIM and other toxicities, the addition of trelacitinib to fluorouracil-based multi-agent chemotherapy, which includes one or more ICD-induced chemotherapeutic agents, may enhance quality of life and/or anti-tumor efficacy and increase due to Preservation of immune effector cells and differential G1 arrest of cytotoxic T cells (CTLs) and regulatory T cells (Tregs) during chemotherapy with tralacidib in patients with immunothermal or variant tumors and/or progression-free survival or overall survival, which in the tumor microenvironment allows for faster recovery of cytotoxic T cells from G1 arrest compared to regulatory T cells. This differential change in cell cycle kinetics between CTLs and Tregs results in a higher ratio of CTLs to Tregs, enhanced T cell activation, and decreased Treg-mediated immunosuppressive function. Thus, the antitumor effects of trelacidib may result from a transient proliferative arrest of T cells (protecting them from chemotherapy-induced damage) followed by activation of CTLs in the tumor microenvironment with fewer Tregs. In addition, trelacitinib may play an important role in expanding antitumor T cell subsets and inducing immune-mediated responses during therapy.

Importantly, this improved immune-mediated response occurs without the addition of immune checkpoint inhibitors, eg, anti-PD-1, anti-PD-L1, or anti-CTLA4 agents such as antibodies.

Accordingly, the present invention provides a method of treating a human subject suffering from colorectal cancer, including metastatic colorectal cancer, comprising administering to the subject an effective amount of trelacinib and fluorouracil-based multi-agent chemotherapy, wherein the subject is receiving Trelacinib was administered prior to administration of the chemotherapeutic agent during this regimen.

In one aspect, trelacinib is added to a FOLFOX-based therapy. FOLFOX therapy typically involves the administration of 5-FU, aldehyde folate (eg, methyltetrahydrofolate or levothyroxine), and oxaliplatin. In FOLFOX therapy, 5-FU is administered as a continuous infusion or both as a bolus injection and as a continuous infusion, wherein the continuous infusion is administered over, eg, 22 hours per day, for 2 days, or over about 44 hours to 48 hours for more than 2 days. Examples of FOLFOX therapy useful for the treatment of colorectal cancer and suitable for use with FOLFOX therapy including trelacitinib include FOLFOX4, FOLFOX6, modified FOLFOX6 (mFOLFOX6), FOLFOX7, and modified FOLFOX7 (mFOLFOX7). The various FOLFOX regimens offer variations in dosage and/or timing of administration. Anti-VEGF or anti-EGFR monoclonal antibodies or compounds can also be administered in various FOLFOX regimens. In some embodiments, in the FOLFOX regimen and variations thereof, the first dose of trelacinib is about 4 hours or earlier before the initiation of the FOLFOX regimen, and 18 to 26 hours after the first dose A second pitch in between.

In an alternative aspect, Trelacinib is added to the FOLFIRI-based therapy. FOLFIRI therapy typically involves the administration of 5-FU, aldehyde folate (eg, methyltetrahydrofolate or levothyroxine), and irinotecan, with 5-FU as a continuous infusion or as a bolus and a continuous infusion Both are administered, wherein a continuous infusion is administered over, eg, 22 hours per day for 2 days, or over between about 44 hours and 48 hours for over 2 days. A modification of the FOLFIRI regimen has been administered to colorectal patients that provides for changes in dosage and/or timing of administration. Anti-VEGF or anti-EGFR monoclonal antibodies may also be administered in various FOLFIRI regimens. In some embodiments, in the FOLFIRI regimen and variations thereof, the first dose of tralacidamide is about 4 hours or earlier before the initiation of the FOLFIRI regimen, and 18 hours to 26 hours after the first dose A second pitch in between.

In an alternate aspect, Trelacinib is added to the FOLFOXIRI-based therapy. FOLFOXIRI therapy comprises 5-FU, folate (eg, methyltetrahydrofolate or levothyroxine), oxaliplatin, and irinotecan, wherein 5-FU is administered as a continuous infusion over about 44 hours to 48 hours for 2 days. Modifications to the FOLFOXIRI regimen have been administered to colorectal patients involving changes in dose and/or timing of administration. Anti-VEGF or anti-EGFR monoclonal antibodies or compounds may also be administered in various FOLFOXIRI regimens. In some embodiments, the tralasiclib-FOLFOXIRI-based therapy is administered to a patient who is previously ineligible for FOLFOXIRI administration, including, but not limited to, patients over 70 years of age with an ECOG > 1. In some embodiments, in the FOLFOXIRI regimen and variations thereof, the first dose of tralacidlib is about 4 hours or earlier before the initiation of the FOLFOXIRI regimen, and 18 hours to 26 hours after the first dose A second pitch in between.

In an alternative aspect, Trelacinax is added to the FOLFIRINOX-based therapy. FOLFIRINOX therapy consists of 5-FU, aldehyde folate (such as methyltetrahydrofolate or levothyroxine), oxaliplatin, and irinotecan, with 5-FU given both as a bolus injection and as a continuous infusion administered, wherein a continuous infusion is administered over between about 44 hours and 48 hours for more than 2 days. Modifications to the FOLFIRINOX regimen have been administered to colorectal patients involving changes in dosage and/or timing of administration. Anti-VEGF or anti-EGFR monoclonal antibodies or compounds may also be administered in various FOLFIRI regimens. In some embodiments, the Tralacinib-FOLFOXIRI-based therapy is administered to patients who are previously ineligible for FOLFIRINOX administration, including, but not limited to, patients over 70 years of age with an ECOG > 1. In some embodiments, in the FOLFIRINOX regimen and variations thereof, the first dose of tralaciclib is about 4 hours or earlier before the initiation of the FOLFIRINOX regimen, and between 18 hours and 26 hours after the first dose A second pitch in between.

In some embodiments, the colorectal cancer treated is metastatic colorectal cancer (mCRC). In some embodiments, the metastatic colorectal cancer is mismatch repair intact (pMMR) mCRC. In some embodiments, the metastatic colorectal cancer is microsatellite stable (MSS) mCRC. In some embodiments, the metastatic colorectal cancer is mismatch repair intact (pMMR)/microsatellite stable (MSS) mCRC (pMMR/MSS mCRC). In some embodiments, the pMMR/MSS mCRC does not respond to prior treatment with a single-agent checkpoint inhibitor. In some embodiments, the mCRC has a BRAF or KRAS mutation. In some embodiments, the BRAF mutation is a V600E substitution mutation. In some embodiments, the colorectal cancer is CDK4/6 replication dependent. In some embodiments, the colorectal cancer is CDK4/6 replication-independent. In some embodiments, the colorectal cancer is indeterminate of CDK4/6 replication. In some embodiments, treated individuals have tumors that exhibit specific characteristics as described herein, according to Ayer's interferon-gamma signature, Ayer's amplified immune signature, or Thorsson et al.'s six types of immune signatures. In one embodiment, the tumor is dominant for interferon-γ (IFN-γ) according to Thorsson's six-type immune signature, or has high IFN-γ signature or amplification according to Ayer's IFN-γ signature score or amplified immune signature score Immunization label. In some embodiments, the cancer is PD-L1 positive.

In some embodiments, the inclusion of trelacinib in the regimen results in one or more toxicities associated with fluorouracil-based multi-agent chemotherapy, such as, but not limited to, chemotherapy-induced myelosuppression (CIM), chemotherapy-induced Alleviation and/or prevention of induced diarrhea (CID), stomatitis and/or mucositis. In some embodiments, the inclusion of trelacitinib results in improved PFS compared to the predicted progression-free survival (PFS) based on administration of fluorouracil-based multi-agent chemotherapy that does not include trelacitinib.

In some embodiments, the inclusion of trelacitinib results in improved OS as compared to predicted overall survival (OS) based on administration of fluorouracil-based multi-agent chemotherapy alone.

In some embodiments, the individual has not received prior chemotherapy for the treatment of colorectal cancer. In some embodiments, the individual has failed previous chemotherapy regimens for the treatment of colorectal cancer. In some embodiments, the multi-agent therapy based on Trelacinib/fluorouracil is administered every 14 days. In some embodiments, the multi-agent therapy based on Trelacinib/fluorouracil is administered with 3 or more induction cycles, 4 or more induction cycles, 5 or more induction cycles, 6 or more induction cycles, or More induction cycles, 7 or more induction cycles, 8 or more induction cycles, 9 or more induction cycles, 10 or more induction cycles, or 11 or more induction cycles Make a donation. In some embodiments, up to 12 administrations of multi-agent chemotherapy based on Trelacinib/fluorouracil are administered. In some embodiments, after cessation of the multi-agent chemotherapy induction regimen based on Trelasinib/fluorouracil, the individual is further administered with Trelacinib, 5-FU, and an aldehyde folic acid (eg, tetrahydrofolate or levothyroxine tetrahydrofolate) maintenance therapy. In some embodiments, the subject maintains an absolute neutrophil count (ANC) of greater than 1.0 x ¹⁰⁹ /L when measured prior to the initiation of each cycle of Trelacinib/fluorouracil-based multi-agent chemotherapy treatment. In some embodiments, the subject maintains a platelet count of greater than 75 x ¹⁰⁹ /L when measured prior to beginning each cycle of Trelacinib/fluorouracil-based multi-agent chemotherapy treatment.

In one aspect, a method of treating a human subject suffering from colorectal cancer is provided, comprising: i) administering to the subject an effective amount of trelacine; ii) administer an effective amount of 5-FU to the individual; iii) administering to the individual an effective amount of an aldehyde folic acid (such as methyltetrahydrofolate or levothyroxine); iv) administering to the subject an effective amount of oxaliplatin and/or irinotecan; and v) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject, as appropriate; Wherein, the administration of tracinil was performed before the initial administration of 5-FU, aldehyde folic acid, and oxaliplatin and/or irinotecan. In some embodiments, trelacinib is administered about 4 hours or more prior to administration of 5-FU, aldofolic acid, and oxaliplatin and/or irinotecan. In some embodiments, the first administration of trelacinib is performed about 4 hours or more prior to the administration of 5-FU, aldehyde folic acid, and oxaliplatin and/or irinotecan, and the first administration The second administration was performed between 18 hours and 26 hours after administration. In some embodiments, the first administration of trelacinib is performed about 4 hours or earlier before the administration of 5-FU, and the second administration is performed between 18 hours and 26 hours after the first administration and. In some embodiments, the individual is further administered an anti-VEGF or anti-EGFR antibody or compound. In some embodiments, the individual is administered an anti-VEGF antibody selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept (ziv -aflibercept). In some embodiments, an anti-EGFR antibody selected from cetuximab or panitumumab is administered to the individual. In some embodiments, oxaliplatin is administered to the individual. In some embodiments, irinotecan is administered to the individual. In some embodiments, both irinotecan and oxaliplatin are administered to the individual. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, provided herein is a method of treating a human subject with colorectal cancer, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) administer to the subject an effective amount of Trelacinib on Days 1 and 2 of each 14-day cycle; ii) Administer an effective amount of 5-FU to the subject on days 1 and 2 of each 14-day cycle, wherein the 5-FU is in the form of a continuous infusion (CI) over a period between about 20 hours and 24 hours to contribute, or iii) administering to the subject an effective amount of folate (e.g., methyltetrahydrofolate or levothyroxine) on Days 1 and 2 of each 14-day cycle; and iv) administering to the subject an effective amount of oxaliplatin on Day 1 of each 14-day cycle; and v) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject on Day 1 of each 14-day cycle, as appropriate; Wherein Tracinib was administered on day 1 of each 14-day cycle approximately 4 hours or earlier prior to initial administration of 5-FU, aldofolic acid, and oxaliplatin, and on day 1 of each cycle Day 2 was administered approximately 4 hours or earlier prior to the initial administration of 5-FU and aldehyde folic acid. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on Day 1 of each 14-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody is cetuximab or panitumumab . In some embodiments, up to 12 cycles of the above regimen are administered to the individual. In some embodiments, after cessation of the above regimen, the subject is further administered one or more maintenance cycles of Tralacidib, 5-FU, and aldofolic acid on the same schedule above. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, there is provided a method of treating a human subject suffering from colorectal cancer comprising one or more 14-day cycles, the one or more 14-day cycles comprising: i) administer to the subject an effective amount of Trelacinib on Days 1 and 2 of each 14-day cycle; ii) administer an effective amount of 5-FU to the subject on Day 1 of each 14-day cycle, wherein the 5-FU is administered as a bolus intravenous injection; iii) Administer an effective amount of 5-FU to the subject beginning on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) over a period between about 44 hours and 48 hours ; iv) administering to the subject an effective amount of aldehyde folic acid (eg, methyltetrahydrofolate or levothyroxine) on Day 1 of each 14-day cycle; and v) administer an effective amount of oxaliplatin to the subject on Day 1 of each 14-day cycle; and vi) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject on Day 1 of each 14-day cycle, as appropriate; wherein trelasinil is administered on day 1 of each 14-day cycle approximately 4 hours or more prior to the initiation of administration of 5-FU, aldofolic acid, and oxaliplatin, and wherein trelasinil is Administration was performed on Day 2 approximately 18 hours to 26 hours after it was administered on Day 1. In some embodiments, the first administration of trelacinib is performed about 4 hours or earlier before the administration of 5-FU, and the second administration is performed between 18 hours and 26 hours after the first administration and. In some embodiments, trelacinib is administered on day 2 between about 20 hours and 24 hours after it is administered on day 1. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on Day 1 of each 14-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody is cetuximab or panitumumab . In some embodiments, up to 12 cycles of the above regimen are administered to the individual. In some embodiments, after cessation of the above regimen, the subject is further administered one or more maintenance cycles of Tralacidib, 5-FU, and aldofolic acid on the same schedule above. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, a method of treating a human subject with colorectal cancer is provided, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) administer to the subject an effective amount of Trelacinib on Days 1 and 2 of each 14-day cycle; ii) The subject is administered an effective amount of 5-FU starting on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) over a period between about 44 hours and 48 hours and; iii) administering to the subject an effective amount of aldehyde folic acid (eg, methyltetrahydrofolate or levothyroxine) on Day 1 of each 14-day cycle; and iv) administering to the subject an effective amount of oxaliplatin on Day 1 of each 14-day cycle; and v) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject on Day 1 of each 14-day cycle, as appropriate; wherein trelasinil is administered on day 1 of each 14-day cycle approximately 4 hours or more prior to the initiation of administration of 5-FU, aldofolic acid, and oxaliplatin, and wherein trelasinil is Administration was performed on Day 2 approximately 18 hours to 26 hours after it was administered on Day 1. In some embodiments, the first administration of trelacinib is performed about 4 hours or earlier before the administration of 5-FU, and the second administration is performed between 18 hours and 26 hours after the first administration and. In some embodiments, trelacinib is administered on day 2 between about 20 hours and 24 hours after it is administered on day 1. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on Day 1 of each 14-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody is cetuximab or panitumumab . In some embodiments, up to 12 cycles of the above regimen are administered to the individual. In some embodiments, after cessation of the above regimen, the individual is further administered one or more maintenance cycles of Trelacinib, 5-FU, and an aldehyde folic acid (eg, methotrexate) on the same schedule as the above regimen Hydrofolate or L-formyltetrahydrofolate). In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, a method of treating a human subject with colorectal cancer is provided, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) administer to the subject an effective amount of Trelacinib on Days 1 and 2 of each 14-day cycle; ii) administer an effective amount of 5-FU to the subject on Day 1 of each 14-day cycle, wherein the 5-FU is administered as a bolus intravenous injection; iii) Administer an effective amount of 5-FU to the subject beginning on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) over a period between about 44 hours and 48 hours ; iv) administering to the subject an effective amount of aldehyde folic acid (eg, methyltetrahydrofolate or levothyroxine) on Day 1 of each 14-day cycle; and v) administer an effective amount of irinotecan to the subject on Day 1 of each 14-day cycle; and vi) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject on Day 1 of each 14-day cycle, as appropriate; wherein trelacidide is administered on day 1 of each 14-day cycle approximately 4 hours or more prior to the initiation of administration of 5-FU, tetrahydrofolate and irinotecan, and wherein trelacidide is administered Nixon is administered on Day 2 of each cycle between about 18 hours and 26 hours after its dosing on Day 1 of each cycle. In some embodiments, the first administration of trelacinib is performed about 4 hours or earlier before the administration of 5-FU, and the second administration is performed between 18 hours and 26 hours after the first administration and. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 24 hours after it is administered on Day 1 of each cycle. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of Tralacidib will be administered to ensure that there is no synchronization and release of HSPC G1 arrest (approximately 24 hours to 32 hours after a single dose of Tralacidib), and that the concentration of 5-FU is sufficient to allow 5FU-related myelosuppression was exacerbated rather than alleviated. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on Day 1 of each 14-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody is cetuximab or panitumumab . In some embodiments, up to 12 cycles of the above regimen are administered to the individual. In some embodiments, after cessation of the above regimen, the subject is further administered one or more maintenance cycles of Trelacinib, 5-FU, and aldofolic acid on the same schedule as the above regimen. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, a method of treating a human subject with colorectal cancer is provided, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) administer to the subject an effective amount of Trelacinib on Days 1 and 2 of each 14-day cycle; ii) Administration of an effective amount of 5-FU to the subject beginning on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) over a period between about 44 hours and 48 hours ; iii) administering to the subject an effective amount of aldehyde folic acid (eg, methyltetrahydrofolate or levothyroxine) on Day 1 of each 14-day cycle; and iv) administer an effective amount of irinotecan to the subject on Day 1 of each 14-day cycle; and v) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject on Day 1 of each 14-day cycle, as appropriate; wherein trelacinib is administered on day 1 of each 14-day cycle approximately 4 hours or more prior to the initiation of administration of 5-FU, aldofolic acid, and irinotecan, and wherein trelacinib is administered on It is administered on Day 2 of each cycle between about 18 hours and 26 hours after dosing on Day 1 of each cycle. In some embodiments, the first administration of trelacinib is performed about 4 hours or earlier before the administration of 5-FU, and the second administration is performed between 18 hours and 26 hours after the first administration and. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 24 hours after it is administered on Day 1 of each cycle. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on Day 1 of each 14-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody is cetuximab or panitumumab . In some embodiments, up to 12 cycles of the above regimen are administered to the individual. In some embodiments, after cessation of the above regimen, the subject is further administered one or more maintenance cycles of Tralacidib, 5-FU, and aldofolic acid on the same schedule above. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, a method of treating a human subject with colorectal cancer is provided, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) administer to the subject an effective amount of Trelacinib on Days 1 and 2 of each 14-day cycle; ii) Administration of an effective amount of 5-FU to the subject beginning on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) over a period between about 44 hours and 48 hours ; iii) administering to the subject an effective amount of aldehyde folic acid (e.g., methyltetrahydrofolate or L-methyltetrahydrofolate) on day 1 of each 14-day cycle; iv) administering to the subject an effective amount of oxaliplatin on Day 1 of each 14-day cycle; and v) administer an effective amount of irinotecan to the subject on Day 1 of each 14-day cycle; and vi) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject on Day 1 of each 14-day cycle, as appropriate; wherein trelacidide is administered on day 1 of each 14-day cycle approximately 4 hours or more prior to administration of 5-FU, aldofolic acid, oxaliplatin, and irinotecan, and wherein trelacidide is administered Nixon is administered on Day 2 of each cycle between about 18 hours and 26 hours after its dosing on Day 1 of each cycle. In some embodiments, the first administration of trelacinib is performed about 4 hours or earlier before the administration of 5-FU, and the second administration is performed between 18 hours and 26 hours after the first administration and. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 24 hours after it is administered on Day 1 of each cycle. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on Day 1 of each 14-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody is cetuximab or panitumumab . In some embodiments, up to 12 cycles of the above regimen are administered to the individual. In some embodiments, after cessation of the above regimen, the subject is further administered one or more maintenance cycles of Tralacidib, 5-FU, and aldofolic acid on the same schedule above. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, a method of treating a human subject with colorectal cancer is provided, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) administer to the subject an effective amount of Trelacinib on Days 1 and 2 of each 14-day cycle; ii) administer an effective amount of 5-FU to the subject on Day 1 of each 14-day cycle, wherein the 5-FU is administered as a bolus injection; iii) The subject is administered an effective amount of 5-FU starting on day 1 of each 14-day cycle, wherein 5-FU is administered as a continuous infusion (CI) starting on day 1 over a period between approximately 44 hours and 48 hours. ) in the form of investment; iv) administering to the subject an effective amount of aldehyde folic acid (e.g., methyltetrahydrofolate, L-methyltetrahydrofolate) on day 1 of each 14-day cycle; v) administer an effective amount of oxaliplatin to the subject on Day 1 of each 14-day cycle; and vi) administer an effective amount of irinotecan to the subject on Day 1 of each 14-day cycle; and vii) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the subject on Day 1 of each 14-day cycle, as appropriate; wherein Trelacinib is administered on day 1 of each 14-day cycle about 4 hours or more prior to the initiation of administration of 5-FU, aldofolic acid, oxaliplatin, and irinotecan, and wherein trelacine is administered Lascinib is administered on Day 2 of each cycle between about 18 hours and 26 hours after its dosing on Day 1 of each cycle. In some embodiments, the first administration of trelacinib is performed about 4 hours or earlier before the administration of 5-FU, and the second administration is performed between 18 hours and 26 hours after the first administration and. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 24 hours after it is administered on Day 1 of each cycle. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of Tralacidib will be administered to ensure that there is no synchronization and release of HSPC G1 arrest (approximately 24 hours to 32 hours after a single dose of Tralacidib), and that the concentration of 5-FU is sufficient to allow 5FU-related myelosuppression was exacerbated rather than alleviated. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on Day 1 of each 14-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody is cetuximab or panitumumab . In some embodiments, up to 12 cycles of the above regimen are administered to the individual. In some embodiments, after cessation of the above regimen, the subject is further administered one or more maintenance cycles of Trelacinib, 5-FU, and aldofolic acid on the same schedule as the above regimen. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In one aspect, a method of treating a human subject with colorectal cancer is provided, wherein the treatment comprises one or more 56-day cycles, the one or more 56-day cycles comprising: i) administering to the subject an effective amount of Trelacinib on Day 1, Day 8, Day 15, Day 22, Day 29 and Day 36 of each 56-day cycle; ii) Administer an effective amount of 5-FU to the subject on Day 1, Day 8, Day 15, Day 22, Day 29 and Day 36 of each 56-day cycle, wherein 5-FU is administered as a bolus injection administered by injection; iii) Administer an effective amount of folate (e.g. tetrahydrofolate or levothyroxine) to the subject on day 1, day 8, day 15, day 22, day 29 and day 36 of each 56-day cycle formyltetrahydrofolate); iv) administering to the subject an effective amount of oxaliplatin on days 1, 15 and 29 of each 56-day cycle; and v) As appropriate, administer anti-VEGF or anti-EGFR monoclonal antibodies to subjects on days 1, 15 and 29 of each 56-day cycle; Wherein Tracinib is administered about 4 hours or earlier prior to the initial administration of 5-FU, aldehyde folic acid or oxaliplatin. In some embodiments, trelacinib is administered about 4 hours or earlier prior to administration of 5-FU. In some embodiments, the subject is further administered an anti-VEGF or anti-EGFR antibody or compound on days 1, 15, and 29 of each 56-day cycle. In some embodiments, the anti-VEGF antibody system is selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept, and the anti-EGFR antibody system is selected from cetuximab or panitum monoclonal antibody. In some embodiments, the individual is administered up to 3 cycles or more of the regimen. In some embodiments, after cessation of the above regimen, the subject is further administered one or more maintenance cycles of Trelacinib, 5-FU, and aldofolic acid on the same schedule as the above regimen. In some embodiments, the aldehyde folate is tetrahydrofolate. In some embodiments, the aldehyde folic acid is L-formyltetrahydrofolate.

In some embodiments, the colorectal cancer treated with one of the five fluorouracil-based multi-agent regimens provided herein is metastatic colorectal cancer. In alternative embodiments, the cancer is selected from pancreatic cancer, gastric cancer, gastroesophageal junction adenocarcinoma, biliary tract cancer, neuroendocrine cancer, peritoneal carcinomatosis, or liver cancer.

In some embodiments, the treatment results in alleviation and/or prevention of one or more toxicities associated with fluorouracil-based multi-agent chemotherapy (eg, chemotherapy-induced myelosuppression (CIM), chemotherapy-induced diarrhea (CID), oral inflammation and/or mucositis). In some embodiments, the treatment results in an improvement in PFS compared to predicted progression free survival (PFS) based on administration of fluorouracil-based multi-agent chemotherapy without trelacitinib. In some embodiments, the treatment results in improved OS as compared to predicted overall survival (OS) based on administration of multi-agent fluorouracil-based chemotherapy without trelacitinib.

In some embodiments, administration of the protocols described herein provides improved bone marrow preservation of hematopoietic stem and precursor cells (HSPCs) and immune effector cells such as lymphocytes including T lymphocytes. In some embodiments, administration of the regimens described herein provides an individual with enhanced anti-tumor efficacy as compared to the anti-tumor efficacy in the individual receiving fluorouracil-based multi-agent chemotherapy without trelacitinib. In some embodiments, administration of the regimens described herein provides an individual's neutrophil repertoire as compared to those receiving fluorouracil-based multi-agent chemotherapy without trelacitinib Bone marrow preservation. In some embodiments, the regimens described herein are administered compared to the duration of their severe (grade 4) neutropenia receiving fluorouracil-based multi-agent chemotherapy without trelacitinib Provides a reduction in the duration of severe (grade 4) neutropenia in individuals. In some embodiments, administration of the regimens described herein provides an individual's CIF compared to chemotherapy-induced fatigue (CIF) receiving fluorouracil-based multi-agent chemotherapy without trelacitinib lighten. In some embodiments, the reduction in CIF is a reduction in time to first confirmed fatigue deterioration (TTCD fatigue), as measured by the Functional Assessment of Cancer Therapy Fatigue Scale (FACIT-F). In some embodiments, the administration of a drug described herein is compared to progression-free survival (PFS) and/or overall survival (OS) in individuals receiving fluorouracil-based multi-agent chemotherapy without The regimen provides improved PFS and/or OS for the individual. In some embodiments, the improvement in PFS is based on Response Evaluation Criteria in Solid Tumors 1.1 (RECIST 1.1). In some embodiments, administration of the regimens described herein provides a reduction in severe neutropenic events, a reduction in granulocyte population stimulating factor (G-CSF) therapy, or febrile neutropenia (FN). ) reduction in adverse events (AEs). In some embodiments, administration of the regimens described herein provides a grade 3 or 4 reduction in laboratory values of erythrocytes, red blood cell (RBC) transfusion, or erythropoiesis stimulating agent (ESA) administration. In some embodiments, administration of a regimen described herein provides a grade 3 or 4 reduction in the laboratory value of platelet count and/or a reduction in the number of platelets transfused. In some embodiments, administration of a regimen described herein provides a reduction in grade 3 or 4 hematology laboratory values. In some embodiments, administration of the regimens described herein provides all-cause dose reduction or cycle delay and reduction in relative dose intensity of fluorouracil-based multi-agent chemotherapy. In some embodiments, administration of a regimen described herein provides i) all-cause, febrile neutropenia/neutropenia, anemia/RBC transfusion, thrombocytopenia/bleeding, or Hospitalization for infection, or ii) reduction in antibiotic use, including but not limited to intravenous (IV), oral, and oral and IV administration of antibiotics. In some embodiments, administration of a regimen described herein provides an improvement in one or more of the following: Functional Assessment of Cancer Therapy-General (FACT-G) category scores (Functional Assessment of Cancer Therapy-General (FACT-G) FACT-G) domain scores) (physical, social/family, emotional, and functional health); Functional Assessment of Cancer Therapy in Anemia (FACT-An): Anemia Subscale; Functional Assessment of Cancer Therapy in Colorectal Cancer (FACT-C) : Colorectal Cancer Subscale; Level 5 EQ-5D (EQ-5D-5L); Patient Global Impression of Change (PGIC) Fatigue Item; or Patient Global Impression of Severity (PGIS) Fatigue Item.

Cross-references to related applications

This application claims US Provisional Patent Application Nos. 63/196,148 filed on June 8, 2021, US Provisional Patent Application Nos. 63/094,193, filed on October 20, 2020, and 19 October 2020 Interest in US Provisional Patent Application No. 63/093,756. The entire contents of each of these applications are hereby incorporated by reference for all purposes.

Provided herein are improved methods and compositions for the treatment of colorectal cancer, including metastatic or advanced colorectal cancer. In particular, provided herein are modified fluorouracil-based multi-agent chemotherapeutics, such as FOLFOX, FOLFIRI, FOLFOXIRI, FOLFIRINOX, and FLOX, that include the CDK4/6 inhibitor Tralasiclib.

Tracinibil is a highly potent and selective, reversible CDK4/6 inhibitor that is typically administered intravenously (IV) prior to fluorouracil-based multi-agent chemotherapy, including but not limited to FOLFOXIRI or FOLFIRINOX and Designed to preserve HSPCs during chemotherapy (bone marrow preservation) and to enhance anti-tumor immunity (anti-tumor efficacy). Both HSPC and lymphocyte populations depend on CDK4/6 proliferative activity (see eg, Kozar et al., Mouse development and cell proliferation in the absence of D-cyclins. Cell. 2004;118(4):477-91; Malumbres et al., Mammalian cells cycle without the D-type cyclin-dependent kinases Cdk4 and Cdk6. Cell. 2004;118(4):493-504.; Ramsey et al., Expression of p16Ink4a Compensates for p16Ink4a Loss in Cyclin-Dependent Kinase 4 /6-Dependent Tumors and Tissues. Cancer Res 2007; 67: 4732-41; Horsley et al., NFATc1 balances quiescence and proliferation of skin stem cells. Cell. 2008; 132(2):299-310). HSPCs and lymphocytes were arrested in the G1 phase of the cell cycle after exposure to trelacitinib. This transient drug-induced cell cycle arrest by tralacidib was successfully altered by preventing HSPC and immune effector cells from proliferating in the presence of cytotoxic chemotherapy and by transient T cell inhibition when combined with ICD chemotherapy The tumor immune microenvironment provides protection from chemotherapy-induced cellular damage during treatment. Upon release of transient G1 arrest, immune effector cells are positioned to respond to the increased antigenicity induced by the ICD chemotherapeutic agents contained in these chemotherapeutic regimens. Furthermore, in addition to myelopreserving protection, Tralacidib also protects other CDK4/6-dependent replicating cells such as the epithelial lining of the gastrointestinal tract from the deleterious and toxic effects associated with these regimens and reduces side effects, Such as mucositis/stomatitis.

Safer, less toxic fluorouracil-based multi-agent chemotherapy regimens, such as FOLFOXIRI or FOLFIRINOX, allow administration to patients who have been excluded from these other effective treatments in the past, such as those over 70 years of age with an ECOG score of 1 or more big patient.

Definitions Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this application belongs. In this specification, the singular forms also include the plural unless the context clearly dictates otherwise. Although methods and materials similar or equivalent to those described herein can be used in the practice and testing of the present application, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated herein by reference. The references cited herein are not admitted to be prior art to the claimed application. In case of conflict, the present specification, including definitions, will control. Additionally, the materials, methods, and examples are illustrative only and are not intended to be limiting.

Compounds are described using standard nomenclature. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs.

Compounds are described using standard nomenclature. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs.

In one embodiment of each compound described herein, unless the context specifically excludes, the compound may be a racemate, enantiomer, mixture of enantiomers, diastereomer, diastereomer mixtures, tautomers, N-oxides or isomer forms, such as rotamers, as if each were specifically described.

The term "a/an" does not denote a limitation of quantity, but rather denotes the presence of at least one of the referenced items. The term "or" means "and/or". Unless otherwise indicated herein, the recitation of numerical ranges is merely intended to serve as a shorthand method of referring individually to each separate value that falls within the range, and each separate value is incorporated into this specification as if it were individually recited herein. The endpoints of all ranges are included within the range and independently combinable. All methods described herein can be performed in a suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of examples or illustrative language (eg, "such as") is only intended to better illustrate the invention and does not limit the scope of the invention unless otherwise claimed.

In one embodiment of each compound described herein, unless the context specifically excludes the compound, the compound may be in the form of a tautomer, N-oxide or isomer, such as a rotamer, as if each specifically described .

As used herein, an "effective amount" means an amount that provides a therapeutic or prophylactic benefit.

The term "treating" a disease, as used herein, means reducing the frequency or severity of at least one sign or symptom of a disease, disorder, or side effect experienced by an individual (ie, palliative treatment) or reducing the individual's exposure to the administration of a therapeutic agent and the cause or effect of the disease, condition (ie, disease-modifying treatment) or side effect experienced.

Throughout this disclosure, various aspects of the present invention may be presented in a range format. It should be understood that the description in range format is for convenience only and should not be considered as a limitation on the scope of the invention. The description of a range should be deemed to have specifically disclosed all possible subranges as well as individual numerical values within that range. For example, the description of a range such as 1 to 6 should be considered to have specifically disclosed subranges such as 1 to 3, 1 to 4, 1 to 5, 2 to 4, 2 to 6, 3 to 6, etc., and Individual values within a range, such as 1, 2, 2.7, 3, 4, 5, 5.3, and 6. This applies regardless of the breadth of the scope.

As used herein, a "pharmaceutical composition" is a composition comprising at least one active agent and at least one other substance such as a carrier. A "pharmaceutical combination" is a combination of at least two active agents, which may be combined in a single dosage form or provided in separate dosage forms together with instructions for the active agents to be used in the treatment of any of the conditions described herein.

As used herein, "pharmaceutically acceptable salts" are derivatives of the disclosed compounds wherein the parent compound is modified by preparing inorganic and organic, nontoxic, acid or base addition salts thereof. Salts of the compounds of the present invention can be synthesized from the parent compound containing a basic or acidic moiety by conventional chemical methods. In general, such salts can be prepared by reacting the free acid forms of these compounds with a stoichiometric amount of an appropriate base such as a hydroxide, carbonate, bicarbonate or the like of Na, Ca, Mg or K , or by reacting the free base forms of these compounds with a stoichiometric amount of the appropriate acid. Such reactions are usually carried out in water or organic solvents, or in a mixture of the two. In general, non-aqueous media such as diethyl ether, ethyl acetate, ethanol, isopropanol or acetonitrile are typical where feasible. Salts of the compounds of the present invention further include solvates of the compounds and salts of the compounds.

Examples of pharmaceutically acceptable salts include, but are not limited to, inorganic or organic acid salts of basic residues such as amines; basic or organic salts of acidic residues such as carboxylic acids; and the like. Pharmaceutically acceptable salts include the conventional nontoxic and quaternary ammonium salts of the parent compound formed from, for example, nontoxic inorganic or organic acids. For example, conventional non-toxic acid salts include those derived from inorganic acids such as hydrochloric, hydrobromic, sulfuric, sulfamic, phosphoric, nitric and similar acids; and those derived from inorganic acids such as acetic, propionic, succinic, ethanol acid, stearic acid, lactic acid, malic acid, tartaric acid, citric acid, ascorbic acid, pamoic acid, maleic acid, hydroxymaleic acid, phenylacetic acid, glutamic acid, benzoic acid, salicylic acid, Methanesulfonic acid, ethanesulfonic acid, benzenesulfonic acid, p-aminobenzenesulfonic acid, 2-acetoxybenzoic acid, fumaric acid, toluenesulfonic acid, methanesulfonic acid, ethanedisulfonic acid, oxalic acid, Isethionic acid, HOOC-(CH2)n-COOH (where n is from 0 to 4) and organic acids like acids, or salts prepared using different acids that give the same relative ion. A list of additional suitable salts can be found, for example, in Remington's Pharmaceutical Sciences, 17th Edition, Mack Publishing Company, Easton, Pa., p. 1418 (1985). Where the methods described herein identify the administration of a particular compound, it is to be understood that, where applicable, the administration of a pharmaceutically acceptable salt of the compound is encompassed as an example.

As used herein, the term "prodrug" means a compound that converts to the parent drug when administered to a host in vivo. As used herein, the term "parent drug" means useful in the treatment of any of the conditions described herein, or in the control or amelioration of a host (usually a human) associated with any of the physiological or pathological conditions described herein Any of the currently described compounds of the underlying cause or symptom. Prodrugs can be used to achieve any desired effect, including enhancing the properties of the parent drug or improving the pharmaceutical or pharmacokinetic properties of the parent drug. Existing prodrug strategies that provide the option to modulate the condition for the in vivo production of the parent drug are all considered to be included herein. Non-limiting examples of prodrug strategies include covalent attachment of removable groups or removable moieties of groups, such as, but not limited to, phosphonylation, phosphorylation, phosphinylation, amidophosphate derivatives, phosphonium Amination, reduction, oxidation, esterification, alkylation, other carboxyl derivatives, sulfoxy or sulfoxide derivatives, carbonylation or anhydrides.

The term "carrier" as used in the pharmaceutical compositions/combinations of the present invention refers to a diluent, excipient or vehicle by which the active compound is provided.

"Pharmaceutically acceptable excipient" means an excipient suitable for use in the preparation of pharmaceutical compositions/combinations that is generally safe and neither biologically inappropriate nor biologically inappropriate for the host (usually a human) to administer to. other inappropriate. In one embodiment, an excipient acceptable for veterinary use is used.

In a non-limiting example, trelacine may be used in a form with at least one desired isotopic substitution of an atom in an amount above the natural abundance, ie, enrichment, of the isotope. Isotopes are atoms with the same atomic number but different mass numbers, that is, the same number of protons but different numbers of neutrons.

Examples of isotopes that may be incorporated into trelacinib for use in the present invention include isotopes of hydrogen, carbon, nitrogen, oxygen, phosphorus, fluorine, chlorine, and iodine, such as 2H, 3H, 11C, 13C, 14C, 15N, 18F 31P, 32P, 35S, 36CI and 125I. In one non-limiting example, isotopically-labeled compounds can be used in metabolic studies (using 14C); reaction kinetic studies (using eg 2H or 3H); detection or imaging techniques such as positron emission tomography (PET). ) or single photon emission computed tomography (SPECT), including drug or substrate distribution analysis, or for radiotherapy of patients. In particular, 18F-labeled compounds may be particularly desirable for PET or SPECT studies. Isotopically-labeled compounds of the invention and prodrugs thereof can generally be obtained by substituting a readily available isotopically-labeled reagent for a non-isotopically-labeled reagent by carrying out the procedures disclosed in the Schemes described below or in the Examples and Preparations to prepare.

By way of general example and without limitation, isotopes of hydrogen, such as deuterium (2H) and tritium (3H), can be used at any position in the described structures to achieve the desired results. Alternatively or additionally, isotopes of carbon such as 13C and 14C can be used.

Isotopic substitution, such as deuterium substitution, may be partial or complete. Partial deuterium substitution means that at least one hydrogen is replaced by deuterium. In certain embodiments, the isotope at any position of interest is 90%, 95%, or 99% enriched or more. In one non-limiting example, at the desired location, deuterium is 90%, 95% or 99% enriched.

Tralacinib used in the present invention can form solvates with solvents, including water. Thus, in one non-limiting embodiment, the present invention includes solvated forms of Tralacidazole. The term "solvate" refers to a molecular complex of tralasiclib (including salts thereof) with one or more solvent molecules. Non-limiting examples of solvents are water, ethanol, dimethylsulfoxide, acetone, and other common organic solvents. The term "hydrate" refers to a molecular complex comprising a compound of the present invention and water. Pharmaceutically acceptable solvates according to the present invention include those in which the solvent may be isotopically substituted, eg, D2O, d6-acetone, d6-DMSO. Solvates can be in liquid or solid form.

The "patient" or "individual" treated is typically a human patient, although it is understood that the methods described herein are effective relative to other animals such as mammals. More specifically, the term patient may include animals used in assays, such as those used in preclinical testing, including but not limited to mice, rats, monkeys, dogs, pigs, and rabbits; and Pigs (pigs and hogs), ruminants, horses, poultry, felines, bovines, rodents, canines and the like.

As generally considered herein, the term "hematopoietic stem and precursor cells" (HSPC) includes, but is not limited to, long-term hematopoietic stem cells (LT-HSC), short-term hematopoietic stem cells (ST-HSC), hematopoietic precursor cells (HPC), pluripotent precursors cells (MPP), oligodendrocyte precursor cells (OPP), monocyte precursor cells, granulocyte precursor cells, common myeloid precursor cells (CMP), common lymphoid precursor cells (CLP), granulocyte monocyte precursor cells (GMP), granulocyte precursor cells, monocyte precursor cells and megakaryocyte erythrocyte precursor cells (MEP), megakaryocyte precursor cells, erythroid precursor cells, HSC/MPP (CD45dim/CD34+/CD38-), OPP (CD45dim /CD34+/CD38+), monocyte precursors (CD45+/CD14-/CD11b+), granulocyte precursors (CD45+/CD14-/CD11b+), erythroid precursors (CD45-/CD71+) and megakaryocyte precursors (CD45+ /CD61+).

The term "immune effector cell" generally refers to an immune cell that performs one or more specific functions. Immune effector cells are known in the art and include, for example, but not limited to, T cells, including naive T cells, memory T cells, activated T cells (Thelper (CD4+)), and cytotoxic T cells (CD8+)), TH1 Activated T cells, TH2 activated T cells, TH17 activated T cells, naive B cells, memory B cells, plasmablasts, dendritic cells, monocytes and natural killer (NK) cells.

As used herein, the term "immune checkpoint inhibitor (ICI)" refers to suppressive therapy that targets immune checkpoints, key regulators of the immune system that, when stimulated, suppress the immune response to immune stimulation. Some cancers protect themselves from attack by stimulating immune checkpoint targets. ICIs block inhibitory checkpoints, thereby restoring immune system function. ICIs include those inhibitors that target immune checkpoint proteins such as programmed cell death-1 protein (PD-1), PD-1 ligand-1 (PD-L1), PD- 1 Ligand-2 (PD-L2), CTLA-4, LAG-3, TIM-3 and V domain Ig inhibitor of T cell activation (VISTA), B7-H3/CD276, indoleamine 2,3- Dioxygenase (IDO), killer immunoglobulin-like receptor (KIR), carcinoembryonic antigen cell adhesion molecule (CEACAM) such as CEACAM-1, CEACAM-3 and CEACAM-5, sialic acid-binding immunoglobulin-like Lectin 15 (Siglec-15), T cell immune receptor with Ig and ITIM domains (TIGIT), and B and T lymphocyte attenuator (BTLA) proteins. Immune checkpoint inhibitors are known in the art.

Colorectal Cancer Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer-related death. The majority of CRC cases are detected in Western countries as their incidence increases year by year. The chance of developing colorectal cancer is approximately 4% to 5%, and the risk of developing CRC is associated with personal characteristics or habits such as age, chronic medical history, and lifestyle. By sex, CRC is the second most common cancer in women (9.2%) and the third most common cancer in men (10%) (Edited by Stewart B., Wild CP. World Cancer Report 2014. International Agency for Research on Cancer (IARC); Lyon, France: 2014. The incidence of CRC has increased by more than 200,000 new cases per year from 1990 to 2012).

Colorectal cancer starts in the colon or rectum. These cancers can also be called colorectal or rectal cancers depending on where they start. Adenocarcinomas of the colon and rectum account for 95% of all colorectal cancer cases. Other types include carcinoids involving hormone-producing cells in the gut, gastrointestinal stromal tumors that are soft tissue sarcomas that start in the blood vessels or connective tissue of the colon, and colorectal lymphoma.

Like a large number of other solid tumors, CRC is a heterogeneous disease with different subtypes distinguishable by their specific clinical and/or molecular features. Mutations in certain genes can lead to the onset of colorectal cancer, as occurs in other types of cancer. Such mutations can occur in oncogenes, tumor suppressor genes, and genes involved in DNA repair mechanisms. Colorectal carcinomas can be classified as sporadic, hereditary, and familial, depending on the source of the mutation.

Point mutations that occur in life are not associated with hereditary syndromes and affect only individual cells and their progeny. Cancers derived from point mutations are called sporadic cancers and account for 70% of all colorectal cancers. The molecular pathogenesis of sporadic cancers is heterogeneous due to the fact that mutations can target different genes (see Marmol et al., Colorectal Carcinoma: A General Overview and Future Perspectives in Colorectal Cancer. Int. J. Mol. Sci. 2017 Jan; 18(1):197). However, approximately 70% of CRC cases follow a series of specific mutations that are then transformed into specific morphological sequences that begin with adenoma formation and end with a cancerous state. The first mutation occurs in a tumor suppressor gene: adenomatous polyposis of the colon (APC) that triggers the formation of non-malignant adenomas, also known as polyps. It is expected that approximately 15% of these adenomas will escalate to cancerous status within a ten-year period. This APC mutation is followed by mutations in KRAS, TP53 and ultimately DCC (deleted in colorectal cancer) (see Marmol 2017).

Genome instability is a potentially important feature of colorectal cancer. The pathogenic mechanism leading to this condition can be included in three different pathways, namely, chromosomal instability (CIN), microsatellite instability (MSI) and CpG island methylation phenotype (CIMP) (see Marmol 2017 ).

The CIN pathway, also considered the classical pathway because it represents the etiology of up to 80% to 85% of all CRC cases, is characterized by an imbalance in the number of chromosomes, thus leading to aneuploidy tumors and loss of heterozygosity (LOH). Potential mechanisms of CIN include chromosomal segregation, telomere dysfunction, and variation in DNA damage response, which affect key genes involved in maintaining proper cellular function, such as APC, KRAS, PI3K, and TP53. APC mutations cause β-catenin to translocate to the nucleus and drive transcription of genes involved in tumorigenicity and invasion, while mutations in KRAS and PI3K lead to persistent activation of MAP kinases, thus increasing cell proliferation. Ultimately, loss-of-function mutations in TP53 encoding the main cell cycle checkpoint p53 lead to uncontrolled entry into the cell cycle (Pino et al., The chromosomal instability pathway in colon cancer. Gastroenterology. 2010 Jun; 138(6): 2059-72).

The microsatellite instability pathway results from a hypervariable phenotype resulting from loss of DNA repair machinery. In tumors with microsatellite instability, the ability to repair short DNA strands or tandem repeats (two to five base pair repeats) is reduced; therefore, mutations tend to accumulate in those regions. These mutations can affect non-coding regions as well as encoding microsatellites, and tumors arise when the reading frames of oncogenes or tumor suppressor genes encoded in microsatellites are altered (see Marmol 2017). Loss of expression of mismatch repair genes (MMRs) can result from spontaneous events (promoter hypermethylation) or germline mutations such as those found in Lynch syndrome. These tumors are predominantly diploid and contain less LOH. Genes mutated in tumors with microsatellite instability include MLH1, MSH2, MSH6, PMS1 and PMS2. In general, MSI tumors have a better prognosis than episodic tumors (Umar et al. Revised Bethesda Guidelines for hereditary nonpolyposis colorectal cancer (Lynch syndrome) and microsatellite instability. J Natl Cancer Inst. 2004 Feb 18;96( 4):261-8). To obtain the MSI status of cancer, a standard panel of five microsatellite markers has been recommended according to the Bethesda specification, including two mononucleotides (BAT26 and BAT25) and three dinucleotides (D2S123 , D5S346 and D17S250) were repeated. Tumors were then classified based on the number of microsatellites exhibiting instability. Specifically, tumors were classified as MSI high (MSI-H) when ≥30% of the markers showed instability; those tumors with <30% of the markers showing instability were defined as MSI low, And those tumors without apparent instability are microsatellite stable (MSS). MSI is now well recognized to be associated with post-replication DNA MMR defects, mainly involving mutL homolog 1 (MLH1) and mutS homolog 2 (MSH2) (see Nguyen et al., The molecular characteristics of colorectal cancer: Implications for diagnosis and therapy). (Review)). Damage to the MMR gene can occur by mutational inactivation or by epigenetic inactivation via CpG island methylation of the gene promoter. Loss or insufficiency of MMR activity results in replication errors with increased mutation rates and a higher likelihood of malignancy.

Epigenetic instability responsible for the CpG island methylation phenotype is another common feature of CRC. A major feature of CIMP tumors is hypermethylation of oncogene promoters, which results in gene silencing and loss of protein expression. Genetics and epigenetics are not mutually exclusive in colorectal cancer, and the two cooperate in the development of colorectal cancer, where more methylation events than point mutations are frequently found (Lao et al., Nat Rev. Gastroenterol Hepatol. 2011 Oct 18;8(12):686-700). An example of the combined role of genetics and epigenetics in the development of colorectal cancer is the presence of BRAF mutations and microsatellite instability in many CIMP tumors (Weisenberger et al., CpG island methylator phenotype underlies sporadic microsatellite instability and is tightly associated with BRAF mutation in colorectal cancer. Nat. Genet. 2006;38:787-793. Digital Object Identifier: 10.1038/ng1834).

Methods for detecting MSI, CIN and CIMP are well known in the art and can be determined from tumor samples, blood and/or stool. 2017 Jan; 18(1):197 provides for the determination of CRC in Marmol et al., Colorectal Carcinoma: A General Overview and Future Perspectives in Colorectal Cancer. Int. J. Mol. Sci. 2017 Jan; 18(1):197 A technical review of mutation status.

Colorectal cancer is often CDK4/6 replication-independent, although heterogeneity does exist. In some embodiments, CDK4/6-replication-independent colorectal cancer refers to CRC that does not significantly require the activity of CDK4/6 for replication. CDK4/6 replication-independent cancers often have retinoblastoma gene (Rb1) aberrations. The gene product of Rb1-Rb-protein is a downstream target of CDK4/6. RB1 is typically dysregulated in cancer cells through deletions, mutations or epigenetic modifications that lead to loss of RB expression and by aberrant CDK kinase activity leading to hyperphosphorylation and inactivation of RB function (Chen et al., Novel RB1 -Loss Transcriptomic Signature Is Associated with Poor Clinical Outcomes across Cancer Types. Clin Cancer Res. 2019;25(14); Sherr, C.J., and McCormick, F. The RB and p53 pathways in cancer. Cancer Cell, 2002;2:103 12.). CCNE1/2 (Cyclin E) is part of a parallel pathway that provides CDK4/6 for functional redundancy and helps transition cells from G1 to S phase. Overexpression will reduce dependence on the CDK4/6 pathway leading to CDK4/6 independence (Turner et al., Cyclin E1 Expression and Palbociclib Efficacy in Previously Treated Hormone Receptor-Positive Metastatic Breast Cancer. J Clin Oncol. 2019;37(14 ): 1169-78.). Therefore, tumors with CCNE1/2 amplification or RB loss will generally be considered "CDK4/6-independent".

Due to their heterogeneity, a smaller fraction of colorectal cancers are CDK4/6 replication dependent. Cancers that are CDK4/6 replication dependent require CDK4/6 activity for replication or proliferation. CDK 4/6 replication-dependent CRCs often have an intact and functional Rb pathway and increased expression of an activator of /CDK4/6 (cyclin D), and/or a d-type cyclin activation signature (DCAF)—including CCND1 translocation, loss of CCND1-3 3'UTR, and amplification of CCND2 or CCND3 (see Gong et al., Genomic aberrations that activate D-type cyclins are associated with enhanced sensitivity to the CDK4 and CDK5 inhibitor abemaciclib. Cancer Cell. 2017; 32(6):761-76). Tumors that are wild-type for RB and CCNE1/2 and have one of the DCAFs described above are generally classified as "CDK4/6-dependent."

Tumors that cannot be classified as CDK4/6-replication-dependent or CDK4/6-replication-independent are generally classified as "CDK4/6 indeterminate," as these tumors cannot be identified as CDK4/6-dependent dependent or independent.

Methods for determining CDK4/6 genetic signature assays are known in the art and involve the use of tumor tissue collected from patient biopsies (colorectal primary or metastatic sites) and are described in Shapiro GI. Genomic biomarkers predicting response to selective CDK4/6 inhibition: Progress in an elusive search. Cancer Cell. 2017;32(6):721-3 and Gong et al., Genomic aberrations that activate D-type cyclins are associated with enhanced sensitivity to the CDK4 and CDK5 inhibitor abemaciclib. Cancer Cell. 2017;32(6):761-76.

The use of anti-VEGF or anti-EGFR targeting agents in colorectal cancer depends on KRAS (Kirsten rat sarcoma virus oncogene homolog) and BRAF (v-Raf mouse sarcoma virus oncogene homolog B) in the tumor ) mutation status. The use of anti-EGFR targeting agents is generally limited to those colorectal cancers with wild-type KRAS and BRAF status. In contrast, the use of anti-VEGF agents does not depend on KRAS and BRAF status. Methods for assessing BRAF and KRAS mutations are generally known in the art. Several methods have been developed and are currently used to detect BRAF and KRAS mutations, including high-resolution melting curve analysis (HRM)/Sanger sequencing, pyrosequencing, mutation-specific polymerase chain reaction (PCR), and mutation-specific Real-time PCR (Cobas), immunohistochemistry (IHC), digital droplet PCR (ddPCR), matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS; Sequenom), and next-generation sequencing (NGS). Such methods are well known in the art and are described in Vanni I et al., The Current State of Molecular Testing in the BRAF-Mutated Melanoma Landscape. Front Mol Biosci. 2020;7:113. Jun 30, 2020 Published, Digital Object Identifier: 10.3389/fmolb.2020.00113.

Accordingly, the methods described herein are directed to treating individuals with colorectal cancer. In some embodiments, the colorectal cancer is colorectal adenocarcinoma. In some embodiments, the colorectal cancer is metastatic colorectal cancer (mCRC). In some embodiments, the colorectal cancer is mismatch repair intact (pMMR) mCRC. In some embodiments, the CRC is not pMMR. In some embodiments, the colorectal cancer is microsatellite stable (MSS) CRC. In some embodiments, the colorectal cancer is MSI-Hi CRC. In some embodiments, the colorectal cancer is MSI-Lo CRC. In some embodiments, the colorectal cancer is pMMR/MSS mCRC. In some embodiments, the colorectal cancer is pMMR/MSS mCRC and has not responded to prior treatment with a single-agent checkpoint inhibitor. In some embodiments, the colorectal cancer has a mutation, chromosomal change, or translocation that affects one or more of the WNT, MAPK/PI3K, TGF-beta, or TP53 pathways. In some embodiments, the colorectal cancer has a mutation in a gene selected from c-MYC, KRAS, NRAS, HRAS, BRAF, PIK3CA, PTEN, SMAD2, or SMAD4. In some embodiments, the mCRC has a BRAF or KRAS mutation. In some embodiments, the BRAF mutation is a V600E substitution mutation. In some embodiments, the KRAS mutation is a V9, G12, G13, V14, L19, Q22, D33, A59, G60, Q61 R68, K117, A146, R164, K176, or K180 substitution. In some embodiments, KRAS is mutated to G12D, G12V, G12C, G12A, or other G12 variants. In some embodiments, the NRAS mutant line is selected from G12, G13, G60, Q61, E123, or P185. In some embodiments, the HRAS mutant is G12, G13, Q61, K117, R164, or P167. In some embodiments, the colorectal cancer is KRAS wild-type. In some embodiments, the colorectal cancer is BRAF wild-type.

In alternative embodiments, the cancer to be treated according to the regimens described herein is pancreatic cancer. In some embodiments, the pancreatic cancer is metastatic or advanced pancreatic cancer.

In an alternative embodiment, the cancer to be treated according to the regimens described herein is gastric cancer. In some embodiments, the gastric cancer is metastatic or advanced gastric cancer.

In an alternative embodiment, the cancer to be treated according to the protocols described herein is gastroesophageal junction adenocarcinoma. In some embodiments, the gastroesophageal junction adenocarcinoma is metastatic or advanced gastroesophageal junction adenocarcinoma.

In an alternate embodiment, the cancer to be treated according to the regimens described herein is biliary tract cancer (cholangiocarcinoma), including intrahepatic cholangiocarcinoma, hilar cholangiocarcinoma, and distal cholangiocarcinoma. In some embodiments, the biliary tract cancer is metastatic or advanced biliary tract cancer.

In an alternative embodiment, the cancer to be treated according to the regimens described herein is neuroendocrine cancer. In some embodiments, the neuroendocrine carcinoma is metastatic or advanced neuroendocrine carcinoma.

In an alternative embodiment, the cancer to be treated according to the regimens described herein is peritoneal carcinomatosis. In some embodiments, the peritoneal carcinomatosis is metastatic or advanced peritoneal carcinomatosis.

In an alternative embodiment, the cancer to be treated according to the regimens described herein is liver cancer, including but not limited to hepatocellular carcinoma (HCC). In some embodiments, liver cancer, including but not limited to hepatocellular carcinoma, is metastatic or advanced.

Immunologically susceptible colorectal cancer In some embodiments, the colorectal cancer to be treated is an immunologically susceptible cancer. In some embodiments, the cancer is highly immunogenic or "febrile", or alternatively "variant immunosuppressive." In some embodiments, the colorectal cancer to be treated has a high immune score. In some embodiments, the treated individual has a colorectal tract that exhibits specific characteristics as described herein, according to Ayer's interferon-gamma signature, Ayer's amplified immune signature, or Thorsson et al.'s six types of immune signatures cancer. In one embodiment, the cancer is dominant for interferon-γ (IFN-γ) according to Thorsson's six-type immune signature, or has a high IFN-γ signature or amplification according to Ayer's IFN-γ signature score or amplified immune signature score Immunization label. In some embodiments, the cancer is PD-L1 positive.

Specifically, when highly immunogenic cancers such as febrile tumors (eg Galon, J. & Bruni, D., Approaches to treat immune hot, altered and cold tumors with combination immunotherapies” Nature Reviews Drug Discovery (18), 2019 As defined in March, 197-218, which is incorporated herein by reference and discussed further below), high IFN-γ expression, or other acceptable indicators of susceptibility to immunogenicity, and at least in the administration of chemotherapy Previously administered or alternatively, administered prior to and concurrently with chemotherapy in combination with a short-acting CDK4/6 inhibitor, when treated with chemotherapy that causes an immune-mediated response, improves progression-free survival and/or Overall survival, the immune-mediated response includes, but is not limited to, immunogenic cell death and/or regulatory T cell (Treg) suppression. When cancer therapy includes these three components in an appropriate dosing regimen, there is an immuno-oncological effect by altering the environment of T cells away from an immunosuppressive environment (ie, Treg cells) and toward enhancing T cells Cell viability and increased orientation of cytotoxic T cells (CD8+ cells) to promote progression-free survival and/or overall survival.

As provided herein, febrile immune tumors are those tumors that have: (i) a high degree of T cell and cytotoxic T cell infiltration, i.e., a high immune score; and (ii) the capacity for checkpoint activation (planned cell death protein 1 (PD-1), cytotoxic T lymphocyte associated antigen 4 (CTLA4), T cell immunoglobulin mucin receptor 3 (TIM3), and lymphocyte activation gene 3 (LAG3)) or other impaired of T cell function (eg, extracellular potassium-driven T cell suppression). In addition to the presence of tumor-infiltrating lymphocytes (TILs) and the expression of anti-planned death-ligand 1 (PD-L1) on tumor-associated immune cells, febrile tumors are characterized by underlying genomic instability and Presence of a pre-existing antitumor immune response. See e.g., in Galon, J. and Bruni, D., Approaches to treat immune hot, altered and cold tumors with combination immunotherapies, Nature Reviews Drug Discovery (18), March 2019, 197-218, cited in its entirety manner is incorporated herein. An exemplary resected tumor with characteristics of a febrile immune tumor is illustrated in Figure 7A.

Variant immunosuppressive tumors are classified by: (i) poor, not absent T cell and cytotoxic T cell infiltration (intermediate immune score); (ii) presence of soluble inhibitory mediators (transforming growth factor-beta ( TGFβ), interleukin 10 (IL-10), and vascular endothelial growth factor (VEGF)); (iii) the presence of immunosuppressive cells (myeloid-derived suppressor cells and regulatory T cells); and (iv) the presence of T cells Checkpoints (PD-1, CTLA4, TIM3 and LAG3). Variant immunosuppressive tumor sites showed a lower degree of immune infiltration (FIG. 7A), indicating the absence of a physical barrier and the presence of an immunosuppressive environment that limits further T cell recruitment and expansion. See e.g., in Galon, J. and Bruni, D., Approaches to treat immune hot, altered and cold tumors with combination immunotherapies, Nature Reviews Drug Discovery (18), March 2019, 197-218, cited in its entirety manner is incorporated herein. An exemplary resected tumor characterized by a variant-immunosuppressive immune tumor is illustrated in Figure 7A.

Determination of immunogenicity classification of tumors can be performed on resected tumors (primary or metastatic) (see eg, Figure 7A). Less invasive diagnostic procedures such as immunopositron emission tomography (PET) imaging to detect intratumoral CD8+ T cells may also be used. For a description of immuno-PET detection of intratumoral CD8+ T cells, see Rooney et al., Molecular and genetic properties of tumors associated with local immune cytolytic activity, Cell 160, 48-61 (2015), which is incorporated herein by reference middle.

In addition to the above, a number of gene expression profiles can be used to determine the immunogenicity classification of tumors (see Ali et al., Patterns of immune infiltration in breast cancer and their clinical implications: a gene-expression-based retrospective study, PLOS Med. 13 , e1002194 (2016); Newman et al., Robust enumeration of cell subsets from tissue expression profiles, Nat. Methods 12, 453-457 (2015); Rooney et al., Molecular and genetic properties of tumors associated with local immune cytolytic activity, Cell 160, 48-61 (2015), Bindea, G. et al., Spatiotemporal dynamics of intratumoral immune cells reveal the immune landscape in human cancer. Immunity 39, 782-795 (2013), each of which is incorporated by reference in this article).

Various additional tools such as CIBERSORT (which infers the relative fraction of immune subsets in the total leukocyte population), xCell (which predicts the abundance of immune cells in the overall TME), TIMER (which is based on the ratio to generate an enrichment score) and an integrated immune-genome approach (using a CIBERSORT-based approach, notably, which identifies six immune subtypes of cancer) can be used for deconvolution by using large amounts of gene expression data. to estimate the abundance of immune infiltration within tumors (see Newman et al., Robust enumeration of cell subsets from tissue expression profiles, Nat. Methods 12, 453-457 (2015); Gentles et al., The prognostic landscape of genes and infiltrating immune cells across human cancers, Nat. Med. 21, 938-945 (2015); Aran et al., xCell: digitally portraying the tissue cellular heterogeneity landscape, Genome Biol. 18, 220 (2017); Li et al., TIMER: a web server for comprehensive analysis of tumor-infiltrating immune cells, Cancer Res. 77, e108-e110 (2017); Thorsson, V. et al., The immune landscape of cancer. Immunity 48, 812-830 (2018), each by reference manner is incorporated herein).

In some embodiments, the cancer to be treated has a high immune score. Immunoscore is a digital pathology IHC-based immunoassay measuring the density of CD3+ and CD8+ T cells at different tumor locations. The Immunoscore score has been defined in a large international SITC-guided retrospective validation study of more than 2500 patients with St I-III colorectal cancer (see Pagès et al., International validation of the consensus Immunoscore for the classification of colon cancer: a prognostic and accuracy study, The Lancet Volume 391, ISSUE 10135, pp. 2128-2139, May 26, 2018, incorporated herein by reference). Commercial immunoscore assays are available via, eg, HalioDx, Inc. (Richmond, Va). Briefly, CD3-immunostained formalin-fixed paraffin-embedded (FFPE) slides and CD8-immunostained formalin-fixed paraffin-embedded slides were scanned and the two corresponding digital images were verified by the operator. Image analysis via dedicated software (Immunoscore Analyzer, HalioDx): automatic detection of histological structure, followed by operator-guided definition of tumor, healthy tissue (submucosa, muscularis propria, serosa) and epithelium (mucosa) ). The operator also excluded all areas of necrosis, abscesses and artifacts (bubble folds, tear areas, background) to avoid false positives. The IM spanning 360 μm into healthy tissue and across 360 μm into tumor was calculated automatically by the software. In the presence of multiple FFPE blocks, the block selected for immune score evaluation was the block containing IM.

In some embodiments, the cancer to be treated has a high IFN-γ signature that amplifies the immune signature, as described in Ayers et al., Ayers M et al. "IFN-γ-Related MRNA Profile Predicts Clinical Response to PD-1 Blockade." Journal of Clinical Investigation, Vol. 127, No. 8, 2017, pp. 2930-2940, Digital Object Identifier: 10.1172/jci91190 (incorporated by reference in its entirety), which outlines a method for constructing predictive responses to immunity Thorough iterative approach to gene expression signature of response to checkpoint inhibitors (eg, pembrolizumab). Beginning with the melanoma data, a one-sided t-test was used to detect genes that were differentially expressed between pembrolizumab responders and non-responders. Noting that many of these differentially expressed genes are associated with IFN-γ signaling, Ayers et al. developed preliminary IFN-γ signatures for ICI responses by averaging the IFN-γ pathways and their expression within associated genes.

The robustness of the preliminary signature of response was assessed in additional melanoma, HNSCC and gastric cancer. Preliminary labels showed significant associations with BOR and PFS, but not OS. To improve prediction of non-melanoma cancers, immune signatures were fine-tuned and amplified by assessing univariate correlations between individual genes and BOR and PFS within amplified cohorts. Genes with statistically insignificant associations were pruned from the tags and genes with significant associations were added to form an intermediate IFN-γ tag.

Citing the success of preliminary and intermediate IFN-γ signatures in distinguishing between responders and non-responders to anti-PD1 therapy as proof-of-concept for extending such predictive signatures to multiple cancer types, using identifiers from KEYNOTE-012 (ClinicalTRials.gov: NCT01848834) and the KENYNOTE-028 trial (ClinicalTRials.gov identifier: NCT02054806) to develop final signatures for multiple cancer types. Penalized logistic regression on BOR was used to further restrict the intermediate signature to the final set of 18 PD-1/PD-L1-response-related genes.

The IFN-γ signature analysis consisted of measuring the expression profile of the following six genes: IDO1, CXCL10, CXCL9, HLA-DRA; STAT1 and IFN-γ. Amplified immune signature analysis consists of measuring the expression profiles of the following 18 genes: CCL5, CD27, CD274, CD276, CD8A, CMKLR1, CXCL9, CXCR6, HLA-DRB1, HLA-DQA1, HLA-E, IDO1, LAG3, NKG7, PDCD1LG2, PSMB10, STAT1 and TIGIT.

Ayers et al. used a 680 gene panel for sequencing quantification on the Nanostring platform. To calculate sample scores for polygenic signatures (IFN-γ signature or amplified immune signature), quantile normalization was performed prior to log10 transformation and then gene sets were averaged. The calculation of the area under the ROC curve was used as a measure of the discriminative power of the label scores. The Youden index, a comprehensive measure of the ROC curve (see Youden WJ. Index for rating diagnostic tests. Cancer. 1950;3(1):32-35, incorporated herein by reference) was used as an option An agnostic approach to the "best" cut-off value, ie, the "high"/"low" label score to account for potential clinical usefulness. For example, a "high" IFN-γ signature or amplified immune signature can be determined based on a comparison of the scores of samples of known immunogenicity. In some embodiments, a "high" IFN-γ signature or amplified immune signature score is a score greater than at least 2.25, 2.5, or 2.75. In some embodiments, a "high" IFN-gamma signature or amplified immune signature score is a score greater than at least 2.5.

In some embodiments, the cancer to be treated is IFN-γ dominant in the six immune signature categories, as described in Thorsson et al. "The Immune Landscape of Cancer." Immunity, Vol. 51, No. 2, 2018 , pp. 812-830 (incorporated herein by reference in its entirety). Thorsson et al. conducted an extensive literature search for performance signatures characterizing different aspects of the immune response. This search yielded 160 tags for inspection. Weighted Gene Correlation Network Analysis (WGCNA) within the entire TCGA (The Cancer Genome Atlas) dataset was used to aggregate these 160 signatures into 9 distinct signature modules, or to measure consistent immune phenomena Label collection. Candidate labels are then limited to the label closest to representing the "average profile" of each of the 9 modules.

Further investigation identified that 4 of these 9 representative labels were not robust classifiers for TCGA data and resulted in highly variable classifications depending on which samples were used for model training. The remaining 5 immunolabels for sample classification are identified in Table 1 below. Table 1 : Thorsson et al. Labels label tag label tag CSF1_Response Indicates the activation of macrophages and monocytes LIexpression_Score Indicates global lymphocyte infiltration TGF-beta Indicates TGF-β response Module3_IFN_Score Indicates IFN-γ response CHANG_CORE_SERUM_RESPONSE_UP Indicates wound healing (ie, angiogenesis, etc.)

Scores for each of these five signatures were calculated in the TCGA dataset using single sample gene set enrichment analysis (ssGSEA). These data were then clustered using an unsupervised consistent clustering method, resulting in six identified immune response subtypes, as described in Table 2. Table 2 : Thorsson et al. Six immunolabels group describe C1 Wound healing: high proliferation rate, high angiogenic gene expression, TH2-type bias C2 IFN-γ dominant: high M1/M2 polarization, strong CD8 and high TCR diversity C3 Inflammatory: Elevated Th17 and Th1 genes, low to moderate proliferation, low aneuploidy and overall somatic replica number variation. C4 Lymphocyte deficiency: prominent macrophage signature with Th1 suppression and high M2 response C5 Immunologically resting: low lymphocyte response, high macrophage response dominated by M2 C6 TGF-β dominant: mixed tumor subgroup with high TGF-β and lymphocyte infiltration

In some embodiments, the cancer to be treated is positive for planned death-1 ligand (PD-L1). PD-L1 is a transmembrane protein that downregulates immune responses by binding to its two inhibitory receptors, planned death-1 (PD-1) and B7.1. PD-1 is an inhibitory receptor expressed on T cells following T cell activation that persists in states of chronic stimulation, such as in chronic infection or cancer (Blank, C and Mackensen, A, Contribution of the PD-1 L1/PD-1 pathway to T-cell exhaustion: an update on implications for chronic infections and tumor evasion. Cancer Immunol Immunother, 2007. 56(5): pp. 739-745). The binding of PD-L1 to PD-1 inhibits T cell proliferation, interleukin production, and cytolytic activity, resulting in functional inactivation or exhaustion of T cells. B7.1 is a molecule expressed on antigen presenting cells and activated T cells. PD-L1 binding to B7.1 on T cells and antigen-presenting cells mediates the downregulation of immune responses, including inhibition of T cell activation and cytokine production (see Butte MJ, Keir ME, Phamduy TB et al Programmed death- 1 ligand 1 interacts specifically with the B7-1 costimulatory molecule to inhibit T cell responses. Immunity. 2007;27(1):111-122). PD-L1 expression has been observed in immune cells and tumor cells. See Dong H, Zhu G, Tamada K, Chen L. B7-H1, a third member of the B7 family, co-stimulates T-cell proliferation and interleukin-10 secretion. Nat Med. 1999;5(12):1365- 1369; Herbst RS, Soria JC, Kowanetz M et al. Predictive correlates of response to the anti-PD-L1 antibody MPDL3280A in cancer patients. Nature. 2014;515(7528):563-567. It has been reported that abnormal expression of PD-L1 on tumor cells hinders anti-tumor immunity, resulting in immune evasion. Thus, disruption of the PD-L1/PD-1 pathway represents an attractive strategy to restore tumor-specific T-cell immunity suppressed by PD-L1 expression in the tumor microenvironment. In cancer, upregulation of PD-L1 allows the cancer to evade the host immune system.

PD-L1 expression can be determined by methods known in the art. For example, PD-L1 expression can be performed using the PD-L1 IHC 22C3 pharmDx (FDA approved in vitro diagnostic immunohistochemistry (IHC) test developed by Dako and Bristol-Meyers Squibb as a companion test for treatment with pembrolizumab) to detect. This line uses the monoclonal mouse anti-PD-L1 clone 22C3 PD-L1 and the EnVision FLEX visualization system on Autostainer Lin 48 to detect PD-L1 in formalin-fixed paraffin-embedded (FFPE) human non-small cell lung cancer tissue qualitative analysis. The amount of expression can be measured using the Tumor Proportion Score (TTPS), which measures the percentage of viable tumor cells showing partial or complete membrane staining. Staining can show PD-L1 expression from 1% to 100%.

PD-L1 expression can also be performed using PD-L1 IHC 28-8 pharmDx (FDA-approved in vitro diagnostic immunohistochemistry (IHC) test developed by Dako and Merck as a companion test for treatment with nivolumab) to detect. This qualitative analysis uses the monoclonal rabbit anti-PD-L1 clone 28-8 and the EnVision FLEX visualization system on Autostainer Lin 48 to detect PD-L1 in formalin-fixed paraffin-embedded (FFPE) human non-small cell lung cancer tissue.

Other commercially available assays for PD-L1 detection include the Ventana SP263 assay (developed by Ventana in collaboration with AstraZeneca) using the monoclonal rabbit anti-PD-L1 clone SP263 and the Ventana SP142 assay using the rabbit monoclonal anti-PD-L1 clone SP142 (Developed by Ventana in partnership with Genentech/Roche). Determination of PD-L1 status is indication-specific and the assessment is based on the proportion (% IC) of tumor area occupied by tumor-infiltrating immune cells expressing PD-L1 at any intensity or the difference between any intensity expressing PD-L1 Percentage of tumor cells (% TC). For example, in urothelial carcinoma tissue, PD-L1 performance of ≥ 5% IC is determined by, for example, the Ventana PD-L1 (SP142) assay, while PD-L1-positive status in TNBC is considered ≥ 1% IC and NSCLC Considered ≥ 50% TC or ≥ 10% IC.

In some embodiments, the colorectal cancer to be treated is a PD-L1 positive colorectal cancer with PD-L1 expression of > 1% IC. In some embodiments, the colorectal cancer to be treated is a PD-L1 positive colorectal cancer with PD-L1 expression > 5% IC.

。 Component of fluorouracil-based multi-agent chemotherapy therapy ',8'-Dihydro-6'H-spiro(cyclohexane-1,9'-pyrido(1',2':1,5)pyrrolo(2,3-d)pyrimidine)-6 '-keto) is a highly selective CDK4/6 inhibitor with the following structure:

.

As provided herein, Trelacinab, or a pharmaceutically acceptable salt thereof, composition, isotopic analog or prodrug thereof, is administered in a suitable carrier. Tralacidib is FDA-approved for the treatment of extensive-stage small cell lung cancer to reduce the incidence of chemotherapy-induced myelosuppression in patients administered prior to platinum/etoposide-containing therapy or topotecan-containing therapy rate and is sold under the tradename Cosela® from G1 Therapeutics, Inc.

Tracinatinib is described in US 2013-0237544, which is incorporated herein by reference in its entirety. Tralacinib can be synthesized as described in US 2019-0135820, which is incorporated herein by reference in its entirety. Trelacinab can be administered in any manner that achieves the desired results, including systemic, parenteral, intravenous, intramuscular, subcutaneous, or intradermal. For injection, in some embodiments, tralasinib may be administered, for example, at 300 mg/vial to provide 300 mg of tralacidlib (equivalent to 349 mg of tralacidyl dihydrochloride dihydrate) Supplied as a sterile lyophilized yellow cake. The product may be provided, for example, in a single-use 20-mL clear glass vial without preservatives. For example, 300 mg/vial of Tralacidide for Injection can be reconstituted with 19.5 ml of 0.9% Sodium Chloride Injection or 5% Dextrose Injection prior to administration. This reconstituted solution has a trelacitinib concentration of 15 mg/mL and will typically be followed by dilution prior to intravenous administration. Trelacinib can be administered intravenously, generally as described herein. In some embodiments, the trelacinil is administered in an amount between about 180 mg/m ² and 300 mg/m ² . In some embodiments, at about 180, 185, 190, 195, 200, 205, 210, 215, 220, 225, 230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 285, or about 300 mg/m ² administered trelasinil. In some embodiments, before administration of the other fluorouracil-based multi-agent chemotherapeutic agent, eg, about 4 hours or earlier, eg, about 4 hours before administration of any of the other fluorouracil-based multi-agent chemotherapeutic agents Administer trelasinil at about 240 mg/m ² or earlier, 3 hours or earlier, 2 hours or earlier, about 1 hour or earlier, or about 30 minutes earlier. In some embodiments, trelacinib is administered intravenously over a period of about 30 minutes.

Tracinatinib is administered on Day 1 of each 14-day cycle during the induction and maintenance periods, as provided herein, or as otherwise provided herein. Tracinatinib is administered prior to the initial administration of the other chemotherapeutic agents, usually about 4 hours or earlier, eg, about 3 hours or earlier, 2 hours or earlier, before the initiation of administration of the other agents in the regimen , 1 hour or earlier or about 30 minutes via intravenous injection/infusion for about 30 minutes. In some embodiments, trelacitinib is administered completely on Day 1 prior to initial administration of any of the other fluorouracil-based multi-agent chemotherapeutic agents.

If 5-FU is administered as a continuous infusion for two days, trelacinil is also administered during the induction period and optionally during the maintenance period on day 2 of each 14-day cycle, or as otherwise provided herein . Tracinib may be administered on Day 2 between about 16 hours and 26 hours after its administration on Day 1. In particular embodiments, the trelasinib is administered on day 2 within about 24 hours after the administration of trelasinib on day 1. In some embodiments, trelacinib is administered on day 2 about 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, or 28 hours after its administration on day 2. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of Tralacidib will be administered to ensure that there is no synchronization and release of HSPC G1 arrest (approximately 24 hours to 32 hours after a single dose of Tralacidib), and that the concentration of 5-FU is sufficient to allow 5-FU-related myelosuppression was exacerbated rather than alleviated.

或 或其醫藥學上可接受之組合物、鹽、同位素類似物或前藥，其描述於以全文引用之方式併入本文中的US 2013-0237544中且可如以全文引用之方式併入本文中的US 2019-0135820中所描述來合成。 In an alternative embodiment, different CDK4/6 inhibitors are administered. For example, in an alternative embodiment, the CDK4/6 inhibitor used in place of Tralaciclib in the regimens described herein are ribociclib (Novartis), palbociclib (Pfizer) ) or abemaciclib (Eli Lily), or a pharmaceutically acceptable salt thereof. In an additional alternative embodiment, the CDK4/6 inhibitor is lerociclib, which has the following structure:

or a pharmaceutically acceptable composition, salt, isotopic analog or prodrug thereof, which is described in US 2013-0237544, which is incorporated herein by reference in its entirety and may be incorporated herein by reference in its entirety was synthesized as described in US 2019-0135820.

， 或其醫藥學上可接受之組合物、鹽、同位素類似物或前藥，其描述於以全文引用之方式併入本文中的US 2013-0237544中且可如以全文引用之方式併入本文中的US 2019-0135820中所描述來合成。 In an additional alternative embodiment, the CDK4/6 inhibitor is leroxinib, which has the following structure:

, or a pharmaceutically acceptable composition, salt, isotopic analog or prodrug thereof, which is described in US 2013-0237544, which is incorporated herein by reference in its entirety and may be incorporated herein by reference in its entirety was synthesized as described in US 2019-0135820.

。 Fluorouracil (5-FU or 5FU) also known as FU, 5FU or 5-FU of fluorouracil is one of the most commonly used drugs for the treatment of colorectal cancer and forms the basis of many multi-agent chemotherapy used in colorectal therapy. Fluorouracil is an antimetabolite fluoropyrimidine analog of a nucleoside pyrimidine with antitumor activity. Fluorouracil and its metabolites have several different mechanisms of action. In vivo, fluorouracil is converted to the active metabolite 5-fluorodeoxyuridine monophosphate (F-UMP); F-UMP replaces uracil and binds to RNA and inhibits RNA processing, thereby inhibiting cell growth. Another active metabolite, 5-5-fluoro-2'-deoxyuridine-5'-O-monophosphate (F-dUMP), inhibits thymidylate synthase, resulting in thymidine triphosphate (TTP) depletion, which Thymidine triphosphate is one of four nucleotide triphosphates used in the synthesis of DNA in vivo. Other fluorouracil metabolites bind to both RNA and DNA; binding in RNA has a major impact on RNA processing and function. Fluorouracil is sold under trade names such as Adrucil. Fluorouracil is a fluorinated pyrimidine and is chemically named 5-fluoro-2,4(1H,3H)-pyrimidinedione. The structure of fluorouracil is:

.

Fluorouracil is contraindicated in patients with low or no dipyrimidine dehydrogenase (DPD) activity and is associated with numerous toxicities, including: ● Cardiotoxicity: Fluorouracil can cause cardiotoxicity, including angina pectoris, myocardial infarction/ischemia, arrhythmia, and heart failure; ● Hyperammonic encephalopathy: altered mental status, confusion, disorientation, coma or ataxia, and elevated serum ammonia levels within 72 hours after initiation of fluorouracil; ● Neurotoxicity: Fluorouracil can cause acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances. ; ● diarrhea (severe); ● Palmoplantar erythematosus disorder (hand-foot syndrome; HFS): Symptoms of HFS include tingling, pain, swelling and tender erythema, and peeling; ● myelosuppression (severe and potentially fatal); and ● Mucositis (severe).

In some embodiments, the use of 5-FU in the described embodiments is substituted with an alternative fluoropyrimidine. In some alternative embodiments, the use of 5-FU in the described embodiments is replaced by capecitabine. In some alternative embodiments, the use of 5-FU in the described embodiments is substituted with furanfluridine. In some alternative embodiments, the use of 5-FU in the described embodiments is substituted with carmofur (HCFU). In some alternative embodiments, the use of 5-FU in the described embodiments is substituted with deoxyfluridine.

Aldofolate The fluorouracil-based multi-agent chemotherapy provided herein generally involves the use of aldofolic acid. As used herein, folate is 5-FU that modulates an agent by inhibiting thymidylate synthase.

。 Also known as aldehyde folate, limonene factor, calcium aldehyde folate, or 5-formyl-5,6,7,8-tetrahydrofolate or calcium carbamoyl tetrahydrofolate. The chemical name of methyl tetrahydrofolate is N- [p[[[(6RS)-2-amino-5-carbamoyl-5,6,7,8-tetrahydro-4-hydroxy-6-pteridyl]methyl]amino]benzyl base]-L-calcium glutamate (1:1). Methyltetrahydrofolate is sold under trade names such as Wellcovorin. The structural formula of calcium tetrahydrofolate is:

.

Formyltetrahydrofolate is a mixture of diastereoisomers of the 5-formyl derivative of tetrahydrofolate (THF). The biologically active compound of the mixture is the (-)-1-isomer or (-)-aldehyde folic acid known as lignan factor. Methyltetrahydrofolate enhances the cytotoxic effects of 5-FU in cells (de Gramont et al., Leucovorin and fluorouracil with or without oxaliplatin as first-line treatment in advanced colorectal cancer. J. Clin. Oncol. 2000 Aug; 18(16):2938-47). In cells, 5-FU is converted to fluorodeoxyuridylic acid, a molecule that functions to inhibit thymidylate synthase. Thymidylate synthase is an important enzyme in DNA repair and replication. The functional derivative of aldofolic acid, 5,10 methylenetetrahydrofolate, stabilizes fluorodeoxyuridylic acid bound to thymidylate synthase. This interaction produces a ternary complex called thymidylate synthase 5-fluorodeoxyuridine monophosphate-methylenetetrahydrofolate complex, which ultimately acts to inhibit thymidylate synthase. Increased cellularity of functional aldolfolate derivatives results in increased stability of the aforementioned inhibitory complexes, which results in depletion of thymidylate synthesis and interference with DNA synthesis and repair (Priest et al., Pharmacokinetics of leucovorin metabolites in human plasma as a function of dose administered orally and intravenously. J. Natl. Cancer Inst. 1991 Dec 18;83(24):1806-120).

L-formyltetrahydrofolate is the levorotatory isomer form of racemic d,l-formyltetrahydrofolate that exists as a calcium salt. L-formyltetrahydrofolic acid is the pharmacologically active isomer of methyltetrahydrofolate [(6-S)-formyltetrahydrofolate]. Levomethyltetrahydrofolate is sold under the trade names Fusilev and Kapzory. L-formyltetrahydrofolate is usually administered at one-half the usual dose of methyltetrahydrofolate when replacing methyltetrahydrofolate.

。 Oxaliplatin is also sold under various trade _names such _{as Eloxatin .} Amine-N,N'][oxalate (2-)-O,O']platinum antitumor agent. Oxaliplatin is an organoplatinum complex in which a platinum atom is complexed with 1,2-diaminocyclohexane (DACH) and an oxalate ligand as a leaving group, and has a chemical structure:

.

Oxaliplatin undergoes non-enzymatic conversion to active derivatives in physiological solution via displacement of labile oxalate ligands. Several transient reactive species are formed, including DACH platinum monohydrate and dihydrate, which are covalently bound to macromolecules. Both interstrand Pt-DNA crosslinks and intrastrand Pt-DNA crosslinks are formed. A crosslink is formed between two adjacent guanines (GG), adjacent adenine-guanines (AG) and the N7 positions of guanines separated by an intermediate nucleotide (GNG). These crosslinks inhibit DNA replication and transcription. Cytotoxicity is cell cycle nonspecific.

Oxaliplatin is associated with a high rate of gastrointestinal toxicity such as nausea/vomiting, diarrhea, abdominal pain and stomatitis. In addition, the following are important risks associated with oxaliplatin use: ● Anaphylactic reactions to oxaliplatin have been reported, can be fatal and can occur within minutes of oxaliplatin administration. ● Oxaliplatin is associated with two types of neuropathy: o Acute, reversible, predominantly peripheral sensory neuropathy with early onset, onset within hours or one to two days of dosing, resolution within 14 days and frequent recurrence with further dosing. ○ Persistent (>14 days), predominantly peripheral sensory neuropathy, usually characterized by paresthesias, hypoesthesia, and hypoesthesia, but can also include proprioceptive deficits that interfere with daily activities (e.g., from proprioceptive impaired writing, buttoning, difficulty swallowing and walking). ● Reversible Posterior Leukoencephalopathy Syndrome (RPLS, also known as PRES, Posterior Reversible Encephalopathy Syndrome) has been observed in clinical trials (< 0.1%) and post-marketing experience. ● Severe neutropenia (grade 3 or 4)

。 Irinotecan Irinotecan, also sold under various trade names such as Campostar, is an antineoplastic agent in the class of topoisomerase I inhibitors. The chemical name is (S)-4,11-diethyl-3,4,12,14-tetrahydro-4-hydroxy-3,14-dioxo1H-pyrano[3',4':6, 7]-Indolizine[1,2-b]quinolin-9-yl-[1,4'bipiperidine]-1'-carboxylate, monohydrochloride, trihydrate, and has the following structure:

.

Irinotecan is a derivative of camptothecin. Camptothecin interacts specifically with topoisomerase I, which relieves DNA torsional tension by inducing reversible single-strand breaks. Irinotecan and its active metabolite SN-38 bind to the topoisomerase I-DNA complex and prevent religation of these single-strand breaks. The current study indicates that the cytotoxicity of irinotecan is due to the double-stranded formation during DNA synthesis when replicase interacts with the ternary complex formed by topoisomerase I, DNA and irinotecan or SN-38 caused by DNA damage. Mammalian cells cannot repair these double-strand breaks efficiently.

The following are important risks associated with the use of irinotecan: ● Early and late forms of diarrhea can occur. Early diarrhea can be accompanied by choline-induced symptoms. Advanced diarrhea can be life-threatening. ● Severe myelosuppression can occur. ● Individuals who are homozygous (UGT1A1 7/7 genotype) as the dual gene of UGT1A1*28 have an increased risk of neutropenia. ● Kidney injury and acute renal failure are usually identified in patients with volume depletion due to severe vomiting and/or diarrhea.

Anti- VEGF Compounds Fluorouracil-based multi-agent chemotherapy in combination with anti-VEGF compounds has become a common standard of care for a variety of cancers including colorectal cancer. Anti-VEGF monoclonal antibodies include bevacizumab (Avastin, Genentech) or bevacizumab-awwb (Mvasi, Amgen). Bevacizumab is a vascular endothelial growth factor introduction antibody. Bevacizumab is a recombinant humanized monoclonal IgGl antibody containing human framework regions and murine complementarity determining regions (CDRs).

Bevacizumab binds to VEGF and prevents the interaction of VEGF with its receptors (Flt-1 and KDR) on the surface of endothelial cells. In an in vitro model of angiogenesis, the interaction of VEGF with its receptors results in endothelial cell proliferation and neovascularization. Administration of bevacizumab resulted in reduced microvascular growth and inhibition of metastatic disease progression.

Bevacizumab-awwb has a similar mechanism of action and is a biosimilar of bevacizumab.

In fluorouracil-based multi-agent chemotherapy regimens, bevacizumab is usually administered intravenously at doses between about 4 mg/kg and 12 mg/kg, with dose adjustment as needed, during induction and maintenance Administered on Day 1 of each 14-day period or once every 2 weeks. In some embodiments, bevacizumab is administered in an amount of about 5 mg/kg. In some embodiments, bevacizumab is administered in an amount of about 10 mg/kg.

Bevacizumab has been associated with GI toxicities including nausea, diarrhea and stomatitis, and myelosuppression. The following are important risks associated with bevacizumab use: ● Serious and sometimes fatal perforation of the gastrointestinal tract. ● Severe and sometimes fatal non-gastrointestinal fistula formation involving the tracheoesophageal, bronchopleural, bile duct, vaginal and bladder sites. ● Serious, sometimes fatal, arterial thromboembolic events, including cerebral infarction, transient ischemic attack, myocardial infarction, and angina.

The anti-VEGF compound aflibercept (Ziltrap; Sanofi/Genzyme) is a vascular endothelial growth factor inhibitor. It is a recombinant fusion protein consisting of a vascular endothelial growth factor (VEGF) binding moiety from the extracellular domains of human VEGF receptors 1 and 2 fused to the Fc portion of human IgGl. Aflibercept was produced by recombinant DNA technology in the Chinese Hamster Ovary (CHO) K-1 Mammalian Expression System. Aflibercept is a dimeric glycoprotein with a protein molecular weight of 97 kilodaltons (kDa) and contains glycosylation, which constitutes an additional 15% of the total molecular weight, resulting in a total molecular weight of 115 kDa. ZALTRAP (aflibercept) injection is a sterile, clear, colorless to pale yellow, non-pyrolytic, preservative-free solution for intravenous use. ZALTRAP is available in single-dose vials of 100 mg/4 mL and 200 mg/8 mL, which are formulated with 25 mg/mL aflibercept in polysorbate 20 (1 mg/mL), sodium chloride (5.84 mg/mL), sodium citrate (1.45 mg/mL), sodium phosphate (0.8 mg/mL), and sucrose (200 mg/mL) to 25 mg/mL aflibercept in Water for Injection USP pH 6.2 .

When used in fluorouracil-based multi-agent chemotherapy, aflibercept is usually administered as an intravenous infusion at a dose of between about 2 mg/kg and 10 mg/kg, with dose adjustment as needed, during induction Administered on Day 1 of each 14-day period or once every two weeks during the period and maintenance period. In some embodiments, aflibercept is administered as an intravenous infusion in an amount of about 4 mg/kg over 1 hour.

Aflibercept acts as a soluble receptor that binds to human VEGF-A (with equilibrium dissociation constants KD of 0.5 pM for VEGF- _{A 165} and 0.36 pM for VEGF-A ₁₂₁ ), human VEGF- _B (KD 1.92 pM) and human PlGF ( _KD of 39 pM for PlGF-2). By binding to these endogenous ligands, aflibercept inhibits the binding and activation of its cognate receptors. This inhibition can result in decreased neovascularization and decreased vascular permeability.

Aflibercept has been associated with GI toxicity including perforation, fistula formation and diarrhea, neutropenia and neutropenic complications.

Ramucirumab (Cyramza; Eli Lily) is a human vascular endothelial growth factor receptor 2 (VEGFR2) antagonist that specifically binds VEGFR2 and blocks VEGFR ligands, VEGF-A, VEGF-C and VEGF- Combination of D. Thus, ramucirumab inhibits ligand-stimulated activation of VEGFR2, thereby inhibiting ligand-induced proliferation and migration of human endothelial cells. Ramucirumab is a recombinant human IgG1 monoclonal antibody. The molecular weight of ramucirumab is approximately 147 kDa. Ramucirumab is produced in genetically engineered mammalian NS0 cells.

Ramucirumab for intravenous injection is a sterile, preservative-free, clear to slightly opalescent and colorless to slightly yellow solution. Ramucirumab is provided in single-dose vials of 100 mg (10 mL) or 500 mg (50 mL) at a concentration of 10 mg/mL. Ramucirumab was formulated in glycine (9.98 mg/mL), histidine (0.65 mg/mL), histidine monohydrochloride (1.22 mg/mL), polysorbate 80 (0.1 mg /mL), sodium chloride (4.383 mg/mL) and water for injection USP pH 6.0.

When used in fluorouracil-based multi-agent chemotherapy, ramucirumab is usually administered as an intravenous infusion at a dose of between about 5 mg/kg and 15 mg/kg, with dose adjustment as needed, at induction Administered on Day 1 of each 14-day period or once every two weeks during the period and maintenance period. In some embodiments, ramucirumab is administered as an intravenous infusion in an amount of about 8 mg/kg over 1 hour.

Anti- EGFR Monoclonal Antibodies Anti-EGFR monoclonal antibodies or compounds are also routinely included in fluorouracil-based multi-agent chemotherapy regimens in patients with colorectal cancer with RAS (including KRAS and NRAS) and BRAF wild-type tumors. Commonly used anti-EGFR monoclonal antibodies include cetuximab (Erbitux; Eli Lilly) and panitumumab (Vectibix; Amgen).

EGFR is overexpressed in certain human cancers including colon and rectal cancer. The interaction of EGFR with its normal ligands (eg, EGF, transforming growth factor-alpha) results in the phosphorylation and activation of a series of intracellular proteins, which in turn regulate the transcription of genes related to cell growth and survival, motility and proliferation. KRAS (Kirsten Rat Sarcoma 2 Virus Oncogene Homolog) and NRAS (Neuroblastoma RAS Virus Oncogene Homolog) are highly related members of the RAS oncogene family. Signaling via EGFR can lead to activation of wild-type KRAS and NRAS proteins; however, in cells with activating RAS somatic mutations, RAS mutant proteins are persistently active and appear to be EGFR-independent regulation. Panitumumab specifically binds to EGFR on normal cells and tumor cells, and competitively inhibits the binding of EGFR ligands. Binding of anti-EGFR antibodies to EGFR prevents ligand-induced receptor autophosphorylation and activation of receptor-related kinases, resulting in inhibition of cell growth, induction of apoptosis, pro-inflammatory interleukins and angiogenic growth factors Production reduction and internalization of EGFR.

Panitumumab is a human IgG2 kappa monoclonal antibody with a molecular weight of approximately 147 kDa produced in genetically engineered mammalian (Chinese Hamster Ovary) cells. In fluorouracil-based multi-agent chemotherapy regimens, panitumumab is usually administered intravenously at doses between about 2 mg/kg and 10 mg/kg, with dose adjustment as needed, during induction and maintenance 1st day of each 14-day period of the period or once every two weeks. In some embodiments, panitumumab is administered in an amount of about 5 mg/kg.

Cetuximab is a recombinant human/mouse chimeric monoclonal antibody that specifically binds to the extracellular domain of the human epidermal growth factor receptor (EGFR). Cetuximab consists of the Fv region of a mouse anti-EGFR antibody and human IgGl heavy and kappa light chain constant regions and has a molecular weight of approximately 152 kDa. Cetuximab is produced in mammalian (mouse myeloma) cell culture. In the fluorouracil-based multi-agent chemotherapy regimens described herein, cetuximab is typically administered at doses between about ²⁰⁰ mg/m and 1000 ^mg /m, with dose adjustments as needed. Intravenous forms are administered on Day 1 of each 14-day cycle during the induction and maintenance phases or every two weeks. In some embodiments, cetuximab is administered at about 500 ^mg /m2.

The use of anti-EGFR monoclonal antibodies has been associated with several risks and toxicities, including diarrhea and stomatitis.

Colorectal Treatment Using Tralacidib + FOLFOX In some aspects, provided herein are modified FOLFOX treatment regimens that include administration of the CDK4/6 inhibitor, Trelacitinib. Tracinibil is an extremely potent and selective, reversible inhibitor of CDK4/6, which is administered intravenously (IV) on day ¹ in amounts between approximately ²⁰⁰ mg/m and 280 mg/m. with, and preferably administered intravenously in an amount of about 240 mg/m no more than about ⁴ hours prior to initiation of FOLFOX administration, and if fluorouracil is continuously infused over two days, on the first Administer intravenously (IV) at the same dose on day 2 about 18 hours to 26 hours or about 22 hours to 24 hours or about 20 hours to 22 hours after administration, or not more than about 10 minutes before initiation of 5-fluorouracil Administer intravenously on day 2 of 4 hours, and if feasible, fluorouracil is administered as an infusion on day 1 (eg, within about 22 hours) and as an infusion on day 2 (eg, within about 22 hours). Aldehydic acid (methyltetrahydrofolate or levothyroxine) is administered in the case of another infusion form. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated. This dosing cycle of trelacinab is designed to preserve HSPCs during chemotherapy (bone marrow preservation), enhance anti-tumor immunity (anti-tumor efficacy), and mitigate other toxicities associated with the dosing regimen, such as stomatitis and mucositis.

FOLFOX is a three-drug therapy consisting of fluorouracil (5-FU), aldehyde folic acid (methyltetrahydrofolate or levothyroxine) and oxaliplatin commonly used in the treatment of mCRC (National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology Colon Cancer. 2nd Edition. 2019. NCCN, Fort Washington, PA). Versions of FOLFOX include FOLFOX4, FOLFOX6, modified FOLFOX6 (mFOLFOX6), FOLFOX7 and modified FOLFOX7 (mFOLFOX7).

FOLFOX is administered for a maximum of 12 induction cycles (every 14 days), followed by maintenance consisting of intravenous-5-FU and aldehyde folic acid administered in 14 day cycles until disease progression, unacceptable toxicity, etc. occurs. FOLFOX is usually administered in further combination with an anti-VEGF antibody or an anti-EGFR monoclonal antibody such as bevacizumab (Avastin, Genentech) or bevacizumab-awwb (Mvasi, Amgen), ramucirumab ( Cyramza, Eli Lilly) or aflibercept (Zaltrap, Sanofi/Regeneron), the anti-EGFR monoclonal antibodies such as panitumumab (Vectibix, Amgen) (for RAS wild-type (both KRAS and NRAS) CRC) or Cetuximab (Erbitux, Lily) (RAS wild-type (both KRAS and NRAS) CRC).

In a FOLFOX-based regimen, oxaliplatin is typically administered as an intravenous infusion at doses of about 85 mg/m and 130 mg/m ^over about, e.g., ² hours at induction with dose adjustment as needed. Invested on day 1 of each 14-day period of the period. In some embodiments, oxaliplatin, eg, FOLFOX4, mFOLFOX6, and mFOLFOX7, is administered as an intravenous infusion at about 85 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin (eg, FOLFOX6 and mFOLFOX6) is administered as an intravenous infusion at about 100 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin (eg, FOLFOX7) is administered as an intravenous infusion at about 130 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin is administered concurrently with aldehyde folate (formyltetrahydrofolate or levothyroxine). In some embodiments, oxaliplatin is administered prior to 5FU administration.

In the FOLFOX regimen, tetrahydrofolate is typically administered as an intravenous infusion at a dose of between about 50 mg/m to about 400 mg/m ^over about, eg, ² hours, with dose adjustment as needed Administered on day 1 of each 14-day cycle of the induction and maintenance periods. In some embodiments, tetrahydrofolate (eg, FOLFOX6, mFOLFOX6, FOLFOX7) is administered as an intravenous infusion at about 400 mg/m over about, eg, ² hours, on Day 1. In some embodiments, tetrahydrofolate (eg, FOLFOX 4) is administered as an intravenous infusion at about 200 mg/m over about, eg, ² hours, on Days 1 and 2. In some embodiments, tetrahydrofolate (eg, mFOLFOX7) is administered as an intravenous infusion at about 200 mg/m over about, eg, ² hours, on Day 1. In some embodiments, tetrahydrofolate is administered concurrently with oxaliplatin. In some embodiments, tetrahydrofolate is administered prior to 5FU. In the case of L-formyltetrahydrofolate, it is usually administered at one-half of racemic d,l-formyltetrahydrofolate, such as in the FOLFOX regimen, with dose adjustment as needed, Doses between about 25 mg/m ² and about 200 mg/m ² are administered as an intravenous infusion over about, eg, 2 hours, on Day 1 of each 14-day cycle of the induction and maintenance periods. In some embodiments, levoformyltetrahydrofolate (eg, FOLFOX6, mFOLFOX6, FOLFOX7) is administered as an intravenous infusion on Day 1 at about 200 mg/m over about, eg, ² hours. In some embodiments, L-formyltetrahydrofolate (eg, FOLFOX 4) is administered as an intravenous infusion at about 100 mg/m over about, eg, ² hours, on Days 1 and 2. In some embodiments, levoformyltetrahydrofolate (eg, mFOLFOX7) is administered as an intravenous infusion at about 100 mg/m on Day 1 over about, eg, ² hours. In some embodiments, levothyroxine is administered concurrently with oxaliplatin. In some embodiments, L-formyltetrahydrofolate is administered prior to 5FU.

In the FOLFOX regimen, fluorouracil is administered initially as a 400 mg/m bolus IV on Day ¹ , followed by a continuous infusion (CI) over approximately 22 hours on Day 1 and on Day 2 Administer as a single continuous infusion (eg, FOLFOX4) over about 22 hours, or about 46 hours to 48 hours starting on day 1 of each 14-day cycle of induction and maintenance periods (eg, FOLFOX6, mFOLFOX6, and FOLFOX7) administered as a single continuous infusion. In some embodiments, fluorouracil is administered initially as a bolus intravenous injection of about 400 mg/m on day ¹ , followed by continuous infusion (CI) over about 22 hours on day 1 and on day 1 2 days administered as a single continuous infusion (e.g. FOLFOX4) over about 22 hours, or about e.g. administered as a single continuous infusion. The bolus dose of fluorouracil may vary within the range of about 240 mg/m ² to about 400 mg/m ² with dose adjustment as needed. The continuous infusion dose of fluorouracil may vary within the range of about 600 mg/m ² to about 2400 mg/m ² with dose adjustment as needed. In some embodiments, fluorouracil is administered as a continuous infusion (CI) of about 2400 mg/m2 ^over 46 hours, with dose adjustment as needed (eg, mFOLFOX7).

In some embodiments, an anti-VEGF or anti-EGFR monoclonal antibody or compound as described herein is administered on Day 1. In one embodiment, the anti-VEGF or anti-EGFR monoclonal antibody or compound is administered in a dosage according to the approved label.

Non-limiting representative examples of regimens for administration of Trelacinib and FOLFOX4 are provided in Table 3 and Figure 1A. Table 3 - Tralacinib + FOLFOX4 Regimen Exemplary FOLFOX4 Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the FOLFOX4 regimen Day ² - 240 mg/m ⁴ hours or earlier before administration of tetrahydrofolate/fluorouracil Oxaliplatin Day 1 - 85 mg/ ^m2 tetrahydrofolate Day 1 - 200 mg/ ^m2 (or alternatively, 100 mg/m2 of L-formyltetrahydrofolate) Day ² - 200 mg/ ^m2 (or alternatively, 100 mg/ ^m2 of L-formyl tetrahydrofolate) Fluorouracil Day 1 - bolus dose of 400 mg/m2 Day ¹ - 600 mg/m2 continuous infusion over 22 hours Day ² - 600 mg/ ^m2 continuous infusion over 22 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - 240 mg 4 hours or earlier before dosing of tetrahydrofolate/fluorouracil /m ² tetrahydrofolate Day 1 - 200 mg/ ^m2 (or alternatively, 100 mg/m2 of L-formyltetrahydrofolate) Day ² - 200 mg/ ^m2 (or alternatively, 100 mg/ ^m2 of L-formyl tetrahydrofolate) Fluorouracil Day 1 - bolus dose of 400 mg/m2 Day ¹ - 600 mg/m2 continuous infusion over 22 hours Day ² - 600 mg/ ^m2 continuous infusion over 22 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Non-limiting representative examples of regimens for administration of Trelacinab and FOLFOX6 are provided in Table 4 and Figure IB. Table 4 - Tralacinib + FOLFOX6 regimen Exemplary FOLFOX6 Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the FOLFOX6 regimen ² Day 2 - 240 mg/m between approximately 18 hours and 24 hours after Trelacinib administration on Day 1 ² Oxaliplatin Day 1 - 100 mg/ ^m2 tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 to 3000 mg/ ^m2 continuous infusion over approximately 46 to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 to 3000 mg/ ^m2 continuous infusion over approximately 46 to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Non-limiting representative examples of regimens for administration of trelacitinib and mFOLFOX6 are provided in Table 5 and Figure 1C. Table 5 - Tralacinib + mFOLFOX6 regimen Exemplary mFOLFOX6 protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before the initiation of the mFOLFOX6 regimen Day ² - 240 mg/m between approximately 18 and 24 hours after the administration of Trelacinib on Day 1 ² Oxaliplatin Day 1 - 85 mg/ ^m2 tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Non-limiting representative examples of regimens for administration of Trelacinib and FOLFOX7 are provided in Table 6 and Figure ID. Table 6 - Tralacinib + FOLFOX7 regimen Exemplary FOLFOX7 Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the FOLFOX7 regimen Day ² - 240 mg/m between approximately 18 hours and 24 hours after Trelacinib administration on Day 1 ² Oxaliplatin Day 1 - 130 mg/ ^m2 tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Non-limiting representative examples of regimens for administration of trelacitinib and mFOLFOX7 are provided in Table 7 and Figure IE. Table 7 - Tralacinib + mFOLFOX7 regimen Exemplary mFOLFOX7 protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the mFOLFOX7 regimen Day ² - 240 mg/m between approximately 18 hours and 24 hours after Trelacinib administration on Day 1 ² Oxaliplatin Day 1 - 85 mg/ ^m2 tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/m ² (or 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Colorectal Treatment with Tralacidib + FOLFIRI In some aspects, provided herein are modified FOLFIRI treatment regimens that include administration of the CDK4/6 inhibitor Tralacidib. As provided herein, Trelacinab is administered intravenously (IV) in an amount between about ²⁰⁰ mg/m and 280 mg/m on Day ¹ , and preferably at the initiation of FOLFIRI administration administered intravenously at about 240 mg/m no more than about ⁴ hours prior, for example, about 1 hour or more prior to initiation of FOLFIRI, and about 18 hours to 26 hours or about 22 hours after its administration on Day 1 Administered intravenously (IV) on Day 2 from 1 hour to 24 hours. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated. Tracinatinib can be administered in doses between about ^{200 mg} /m to about 280 mg/m, but preferably about 240 ^mg /m by intravenous injection or infusion over about 30 minutes Make a donation. Tralacinib can be administered in a dose of about 200 mg/m ² to about 280 mg/m ² , but is preferably administered in an amount of about 240 mg/m ² . The dosing cycle of this trelacinib can be incorporated into any of the various FOLFIRI regimens and is designed to preserve HSPCs during chemotherapy (bone marrow preservation), enhance anti-tumor immunity (anti-tumor efficacy), and relieve and administer regimens Associated other toxicities such as stomatitis and mucositis.

FOLFIRI is a three-drug therapy consisting of fluorouracil (5-FU), aldehyde folic acid (such as methyltetrahydrofolate or levothyroxine), and irinotecan commonly used in the treatment of mCRC (National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology Colon Cancer. 2nd Edition. 2019. NCCN, Fort Washington, PA). FOLFIRI is administered for a maximum of 12 induction cycles (every 14 days), followed by maintenance consisting of 5-FU and folate administered in 14 day cycles until disease progression, unacceptable toxicity, etc. occurs. FOLFIRI is typically administered in further combination with an anti-VEGF antibody or anti-EGFR monoclonal antibody such as bevacizumab (Avastin, Genentech) or bevacizumab-awwb (Mvasi, Amgen), ramucirumab ( Cyramza, Eli Lilly) or aflibercept (Zaltrap, Sanofi/Regeneron), an anti-EGFR monoclonal antibody such as panitumumab (Vectibix, Amgen) (for RAS wild-type (both KRAS and NRAS) CRC) or Cetuximab (Erbitux, Lily) (RAS wild-type (both KRAS and NRAS) CRC).

In the FOLFIRI regimen, irinotecan is usually administered as an intravenous infusion at a dose of between about ¹²⁰ mg/m and 180 mg/m ^over about, eg, 90 minutes, during the induction period, with dose adjustments as needed. Administered on day 1 of each 14-day cycle. In some embodiments, irinotecan is administered as an intravenous infusion at about 180 mg/m ^over about, eg, 90 minutes. In some embodiments, irinotecan is administered as an intravenous infusion at about 150 mg/m ^over about, eg, 90 minutes. In some embodiments, irinotecan is administered as an intravenous infusion at about 120 mg/m ^over about, eg, 90 minutes. In some embodiments, irinotecan is administered concurrently with tetrahydrofolate. In some embodiments, irinotecan is administered before 5FU.

In the FOLFIRI regimen, tetrahydrofolate is typically administered as an intravenous infusion at a dose of between about ²⁰⁰ mg/m and 400 mg/m over about, eg, ² hours, on the first day of each 14-day cycle of the induction period. 1 day to vote. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 200 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 400 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered concurrently with irinotecan. In some embodiments, tetrahydrofolate is administered prior to 5FU. If L-formyltetrahydrofolate is used, it is usually administered at one-half the dose of racemic d,l-formyltetrahydrofolate. For example, in the FOLFIRI regimen, levothyroxine is typically administered as an intravenous infusion at a dose of between about 100 ^mg /m and ²⁰⁰ mg/m at each of the induction period as an intravenous infusion over about, for example, 2 hours. Vote on day 1 of a 14-day cycle. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 100 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 200 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered concurrently with irinotecan. In some embodiments, tetrahydrofolate is administered prior to 5-FU.

In the FOLFIRI regimen, fluorouracil is administered as a bolus intravenous injection of, for example, about 400 mg/m on day ¹ , followed by about 46 hours starting on day 1 of each 14-day cycle of the induction and maintenance phases Administered as a continuous infusion (CI) (eg, FOLFIRI), or only within approximately 46 hours to 48 hours beginning on day 1 of each 14-day cycle of the induction and maintenance phases (eg mFOLFIRI). The bolus dose of fluorouracil may vary within the range of about 240 mg/m ² to about 400 mg/m ² with dose adjustment as needed. In some embodiments, the bolus dose is about 400 mg/m ² . In some embodiments, the bolus dose is about 320 mg/m ² . The continuous infusion dose of fluorouracil may vary from about 1600 mg/m ² to about 2800 mg/m ² over a period of about 46 to 48 hours, subject to dose adjustment as needed. In some embodiments, the continuous infusion dose is about 2800 mg/m ² . In some embodiments, the continuous infusion dose is about 2400 mg/m ² . In some embodiments, the continuous infusion dose is about 2000 mg/m ² . In some embodiments, the continuous infusion dose is about 1600 mg/m ² . In some embodiments, the fluorouracil is administered as a bolus intravenous injection of about 400 mg/m on day ¹ , followed by a continuous infusion (CI) of about 2400 mg/m ^over about 46 to 48 hours vote. In some embodiments, the fluorouracil is administered as a bolus intravenous injection of about 320 mg/m on day ¹ , followed by a continuous infusion (CI) of about 2000 mg/m ^over about 46 to 48 hours vote. In some embodiments, the fluorouracil is administered as a bolus intravenous injection of about 240 mg/m on day ¹ , followed by a continuous infusion (CI) of about 1600 mg/m ^over about 46 hours.

In some embodiments, an anti-VEGF or anti-EGFR monoclonal antibody or compound as described herein is administered on Day 1. In one embodiment, the anti-VEGF or anti-EGFR monoclonal antibody or compound is administered in a dosage according to the approved label.

Non-limiting representative examples of regimens for administration of Trelacinib and FOLFIRI are provided in Table 8 and Figure 2A. Table 8 - Tralacinib + FOLFIRI regimen Exemplary FOLFIRI Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier prior to initial administration of the FOLFIRI regimen Day ² - 240 mg/m between approximately 18 hours and 24 hours after Trelacinib administration on Day 1 ² irinotecan Day 1 - 180 mg/m ² tetrahydrofolate Day 1 - 400 mg/ ^m2 (or alternatively, 200 mg/ ^m2 as L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose of 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/ ^m2 (or alternatively, 200 mg/ ^m2 as L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Non-limiting representative examples of regimens for administration of Trelacinib and mFOLFIRI are provided in Table 9 and Figure 2B. Table 9 - Tralacinib + mFOLFIRI regimen Exemplary mFOLFIRI Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the mFOLFIRI regimen Day ² - 240 mg/m between approximately 18 and 24 hours after Trelacinib administration on Day 1 ² irinotecan Day 1 - 180 mg/m ² tetrahydrofolate Day 1 - 400 mg/ ^m2 (or alternatively, 200 mg/ ^m2 as L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/ ^m2 (or alternatively, 200 mg/ ^m2 as L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Colorectal Treatment with Trasitinib + FOLFOXIRI In particular, provided herein is a modified FOLFOXIRI treatment regimen that includes administration of the CDK4/6 inhibitor Trelasinib. As provided herein, Trelacinab is administered intravenously (IV) no more than about 4 hours prior to initiation of FOLFOXIRI administration, eg, about 1 hour prior to initiation of FOLFOXIRI or earlier on Day 1, and on It is administered intravenously (IV) on day 2 about 18 hours to 26 hours or about 22 hours to 24 hours following day 1 administration. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of Tralacidib will be administered to ensure that there is no synchronization and release of HSPC G1 arrest (approximately 24 hours to 32 hours after a single dose of Tralacidib), and that the concentration of 5-FU is sufficient to allow 5-FU-related myelosuppression was exacerbated rather than alleviated. Tracinatinib can be administered in doses between about ^{200 mg} /m to about 280 mg/m, but preferably about 240 ^mg /m by intravenous injection or infusion over about 30 minutes Make a donation. This dosing cycle of Trelacinab can be incorporated into any variation of the FOLFOXIRI regimen, and is designed to preserve HSPCs during chemotherapy (bone marrow preservation), enhance anti-tumor immunity (anti-tumor efficacy), reduce the dose associated with the dosing regimen Other toxicities, such as stomatitis and mucositis, and importantly, expanded the availability of FOLFOXIRI treatment to previously excluded patients. In some embodiments, a patient greater than 70 years of age with ECOG > 1 is administered the Tralacinib-FOLFOXIRI regimen described herein.

FOLFOXIRI is a four-drug therapy consisting of infusion fluorouracil (5-FU), aldehyde folic acid (such as methyltetrahydrofolate or levothyroxine), oxaliplatin and irinotecan commonly used in the treatment of mCRC (National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology Colon Cancer. 2nd Edition. 2019. NCCN, Fort Washington, PA). FOLFOXIRI is administered for a maximum of 12 induction cycles (every 14 days) followed by a maintenance cycle consisting of an infusion of 5-FU and folate (formyltetrahydrofolate or L-formyltetrahydrofolate) administered in a 14-day cycle , until disease progression, unacceptable toxicity, etc. FOLFOXIRI is typically administered in further combination with an anti-VEGF antibody or anti-EGFR monoclonal antibody such as bevacizumab (Avastin, Genentech) or bevacizumab-awwb (Mvasi, Amgen), ramucirumab ( Cyramza, Eli Lilly) or aflibercept (Zaltrap, Sanofi/Regeneron), an anti-EGFR monoclonal antibody such as panitumumab (Vectibix, Amgen) (for RAS wild-type (both KRAS and NRAS) CRC) or Cetuximab (Erbitux, Lily) (RAS wild-type (both KRAS and NRAS) CRC).

In the FOLFOXIRI regimen, irinotecan is usually administered as an intravenous infusion at a dose of between about 125 mg/m and ²⁰⁰ mg/m over about, e.g., ² hours during the induction period, with dose adjustment as needed Administered on day 1 of each 14-day cycle. In some embodiments, irinotecan is administered as an intravenous infusion at about 165 mg/m over about, eg, ² hours. In some embodiments, irinotecan is administered as an intravenous infusion at about 175 mg/m over about, eg, ² hours. In some embodiments, irinotecan is administered prior to the administration of tetrahydrofolate and oxaliplatin.

In the FOLFOXIRI regimen, tetrahydrofolate is typically administered as an intravenous infusion at a dose of between about 140 mg/m and about 400 mg/m ^over about, eg, ² hours, with dose adjustment as needed Administered on day 1 of each 14-day cycle of the induction and maintenance periods. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 200 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 400 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered concurrently with oxaliplatin. In some embodiments, tetrahydrofolate is administered after irinotecan. In some embodiments, tetrahydrofolate is administered before fluorouracil. If L-formyltetrahydrofolate is used, it is usually administered at one-half the dose of racemic d,l-formyltetrahydrofolate, eg, in FOLFOXIRI, L-formyltetrahydrofolate is usually administered on an as-needed basis Subject to dose adjustment, at a dose between about 70 mg/m2 to about ²⁰⁰ mg/m2 as an intravenous infusion over about, e.g., ² hours, on the first day of each 14-day cycle of the induction and maintenance periods. 1 day to vote. In some embodiments, levothyroxine is administered as an intravenous infusion at about 100 mg/m over about, eg, ² hours. In some embodiments, levothyroxine is administered as an intravenous infusion at about 200 mg/m over about, eg, ² hours. In some embodiments, levothyroxine is administered concurrently with oxaliplatin. In some embodiments, levothyroxine is administered after irinotecan. In some embodiments, levothyroxine is administered before fluorouracil.

In the FOLFOXIRI regimen, oxaliplatin is typically administered as an intravenous infusion at a dose of between about 50 mg/m and 100 mg/m ^over about, e.g., ² hours at induction with dose adjustment as needed. Invested on day 1 of each 14-day period of the period. In some embodiments, oxaliplatin is administered as an intravenous infusion at about 85 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin is administered as an intravenous infusion at about 100 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin is administered concurrently with tetrahydrofolate. In some embodiments, oxaliplatin is administered after irinotecan. In some embodiments, oxaliplatin is administered before fluorouracil.

In the FOLFOXIRI regimen, fluorouracil is administered as a continuous infusion (CI) within 48 hours starting on day 1 of each 14-day cycle of the induction and maintenance phases. The dose of fluorouracil can be varied within the range of about 1200 ^mg / ^m2 to about 4000 mg/m2, subject to dose adjustment as needed. In some embodiments, the fluorouracil is administered as a continuous infusion at a dose of between about 2400 ^mg /m to about 3200 mg/m ^over about, eg, 46 to 48 hours, subject to dose adjustment as needed . In some embodiments, fluorouracil is administered as a continuous infusion at a dose of 3200 mg/m ² over about, eg, 46 to 48 hours. In some embodiments, fluorouracil is administered as a continuous infusion at a dose of 3800 mg/m ² over about, eg, 46 to 48 hours.

In some embodiments, an anti-VEGF or anti-EGFR monoclonal antibody or compound as described herein is administered on Day 1. In one embodiment, the anti-VEGF or anti-EGFR monoclonal antibody or compound is administered in a dosage according to the approved label.

Non-limiting representative examples of regimens for administration of Trelacinib and FOLFOXIRI are provided in Table 10 and Figure 3A. Table 10 - Tralacinib + FOLFOXIRI regimen Exemplary FOLFOXIRI Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the FOLFOXIRI regimen Day ² - 240 mg/m between approximately 18 hours and 24 hours after Trelacinib administration on Day 1 ² irinotecan Day 1 - 165 mg/ ^m2 Oxaliplatin Day 1 - 85 mg/ ^m2 tetrahydrofolate Day 1 - 400 mg/m ² (or alternatively, 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 to 3200 mg/ ^m2 continuous infusion over approximately 46 to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/m ² (or alternatively, 200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 to 3200 mg/ ^m2 continuous infusion over approximately 46 to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

Non-limiting representative examples of administration of Trelacinib and alternative FOLFOXIRI regimens are provided in Table 11 and Figure 3B.

In some embodiments of the above regimens, 5-FU is administered at a dose of about 75% of each of the above, ie, about 1800 to 2400 mg/m ² . In some embodiments of the above regimens, 5-FU is administered at a dose of about 50% of each of the above, ie, about 1200 to 1600 mg/m ² .

In some embodiments of the above regimens, irinotecan is administered at a dose of about 75% of each of the above, ie, about 125 ^mg /m2. In some embodiments of the above regimens, irinotecan is administered at a dose of about 50% of each of the above, ie, about 80 ^mg /m2.

In some embodiments of the above regimens, oxaliplatin is administered at a dose of about 75% of each of the above, ie, about 65 mg/m ² . In some embodiments of the above regimens, oxaliplatin is administered at a dose of about 50% of each of the above, ie, about 40 mg/m ² . Table 11 - Tralacinib + FOLFOXIRI regimen Exemplary FOLFOXIRI Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the FOLFOXIRI regimen Day ² - 240 mg/m between approximately 18 hours and 24 hours after Trelacinib administration on Day 1 ² irinotecan Day 1 - 165 mg/ ^m2 Oxaliplatin Day 1 - 85 mg/ ^m2 tetrahydrofolate Day 1 - ²⁰⁰ mg/m2 (or alternatively, 100 mg/m2 of L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 to 3200 mg/ ^m2 continuous infusion over approximately 46 to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 200 mg/m ² (or alternatively, 100 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - 2400 to 3200 mg/ ^m2 continuous infusion over approximately 46 to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg)

In some embodiments of the above regimens, 5-FU is administered at a dose of about 75% of each of the above, ie, about 1800 to 2400 mg/m ² . In some embodiments of the above regimens, 5-FU is administered at a dose of about 50% of each of the above, ie, about 1200 to 1600 mg/m ² .

In some embodiments of the above regimens, irinotecan is administered at a dose of about 75% of each of the above, ie, about 125 ^mg /m2. In some embodiments of the above regimens, irinotecan is administered at a dose of about 50% of each of the above, ie, about 80 ^mg /m2.

In some embodiments of the above regimens, oxaliplatin is administered at a dose of about 75% of each of the above, ie, about 65 mg/m ² . In some embodiments of the above regimens, oxaliplatin is administered at a dose of about 50% of each of the above, ie, about 40 mg/m ² .

Colorectal Treatment with Trasitinib + FOLFIRINOX Specifically, provided herein is a modified FOLFIRINOX treatment regimen, which includes administration of the CDK4/6 inhibitor Trelacitinib. As provided herein, Trelacinab is administered intravenously (IV) on Day 1 no more than about 4 hours prior to initiation of FOLFIRINOX administration, eg, about 1 hour or earlier, and on Day 1 Intravenous (IV) administration on day 2 about 18 hours to 26 hours or about 22 hours to 24 hours after administration. In some embodiments, Trelacinab is administered on Day 2 of each cycle between about 20 hours and 22 hours after it is administered on Day 1 of each cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated. The dosing cycle of this trelacidib can be incorporated into any variation of the FOLFIRINOX regimen, and is designed to preserve HSPCs during chemotherapy (bone marrow preservation), enhance anti-tumor immunity (anti-tumor efficacy), reduce the dose associated with the dosing regimen Other toxicities, such as stomatitis and mucositis, and importantly, expanded the availability of FOLFIRINOX therapy to previously excluded patients.

FOLFIRINOX is a combination of bolus injections commonly used in the treatment of mCRC + intravenous fluorouracil (5-FU), intravenous folate (such as methyltetrahydrofolate or levothyroxine), intravenous oxaliplatin, and intravenous Rinotecan constitutes a four-drug therapy (National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology Colon Cancer. 2nd Edition. 2019. NCCN, Fort Washington, PA). FOLFIRINOX is administered for up to 12 induction cycles (every 14 days), followed by a maintenance cycle consisting of intravenous-5-FU and formyltetrahydrofolate (folate) administered in 14-day cycles until disease progression occurs , unacceptable toxicity, etc. FOLFIRINOX is typically administered in further combination with anti-VEGF antibodies or anti-EGFR monoclonal antibodies such as bevacizumab (Avastin, Genentech), bevacizumab-awwb (Mvasi, Amgen), ramucirumab ( Cyramza, Eli Lilly) or aflibercept (Zaltrap, Sanofi/Regeneron), the anti-EGFR monoclonal antibodies such as panitumumab (Vectibix, Amgen) (for RAS wild-type (both KRAS and NRAS) CRC) or Cetuximab (Erbitux, Lily) (RAS wild-type (both KRAS and NRAS) CRC).

In the FOLFIRINOX regimen, oxaliplatin is usually administered as an intravenous infusion at a dose of between about 60 mg/m and 85 mg/m ^over about, e.g., ² hours, at induction doses adjusted as needed. Invested on day 1 of each 14-day period of the period. In some embodiments, oxaliplatin is administered as an intravenous infusion at about 85 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin is administered as an intravenous infusion at about 60 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin is administered before irinotecan and tetrahydrofolate.

In the FOLFIRINOX regimen, irinotecan is typically administered as an intravenous infusion at a dose of between about ¹²⁰ mg/m and 180 mg/m ^over about, eg, 90 minutes, during the induction period, with dose adjustments as needed. Administered on day 1 of each 14-day cycle. In some embodiments, irinotecan is administered as an intravenous infusion at about 180 mg/m ^over about, eg, 90 minutes. In some embodiments, irinotecan is administered as an intravenous infusion at about 150 mg/m ^over about, eg, 90 minutes. In some embodiments, irinotecan is administered as an intravenous infusion at about 120 mg/m ^over about, eg, 90 minutes. In some embodiments, irinotecan is administered concurrently with tetrahydrofolate. In some embodiments, irinotecan is administered after oxaliplatin. In some embodiments, irinotecan is administered before 5FU.

In the FOLFIRINOX regimen, tetrahydrofolate is typically administered as an intravenous infusion at a dose of between about ²⁰⁰ mg/m and 400 mg/m over about, eg, ² hours, on the first day of each 14-day cycle of the induction period. 1 day to vote. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 200 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 400 mg/m over about, eg, ² hours. In some embodiments, tetrahydrofolate is administered concurrently with irinotecan. In some embodiments, tetrahydrofolate is administered after oxaliplatin. In some embodiments, tetrahydrofolate is administered prior to 5FU. If L-formyltetrahydrofolate is administered, it is typically administered at one-half the dose of d,l-formyltetrahydrofolate. For example, in the FOLFIRINOX regimen, levothyroxine is typically administered as an intravenous infusion at a dose of between about 100 ^mg /m and ²⁰⁰ mg/m at each of the induction period as an intravenous infusion over about, for example, 2 hours. Vote on day 1 of a 14-day cycle. In some embodiments, levothyroxine is administered as an intravenous infusion at about 100 mg/m over about, eg, ² hours. In some embodiments, levothyroxine is administered as an intravenous infusion at about 100 mg/m over about, eg, ² hours. In some embodiments, levothyroxine is administered concurrently with irinotecan. In some embodiments, oxaliplatin is followed by administration of levothyroxine. In some embodiments, L-formyltetrahydrofolate is administered prior to 5FU.

In the FOLFIRINOX regimen, fluorouracil is administered initially as a bolus intravenous injection of approximately 400 mg/m on day ¹ , followed by approximately 46 hours starting on day 1 of each 14-day cycle of the induction and maintenance cycles Administered as continuous infusion (CI). The bolus dose of fluorouracil can be varied within the range of about 200 mg/m ² to about 400 mg/m ² with dosage adjustment as needed. In some embodiments, the bolus dose is about 400 mg/m ² . In some embodiments, the bolus dose is about 300 mg/m ² . In some embodiments, the bolus dose is about 200 mg/m ² . The continuous infusion dose of fluorouracil may vary from about 1200 mg/m ² to about 2400 mg/m ² over a period of about 46 to 48 hours, subject to dose adjustment as needed. In some embodiments, the continuous infusion dose is about 2400 mg/m ² . In some embodiments, the continuous infusion dose is about 1800 mg/m ² . In some embodiments, the continuous infusion dose is about 1200 mg/m ² . In some embodiments, the fluorouracil is administered as a bolus intravenous injection of about 400 mg/m on day ¹ , followed by a continuous infusion (CI) of about 2400 mg/m ^over about 46 to 48 hours vote. In some embodiments, the fluorouracil is administered as a bolus intravenous injection of about 300 mg/m on day ¹ , followed by a continuous infusion (CI) of about 1800 mg/m ^over about 46 to 48 hours vote. In some embodiments, the fluorouracil is administered as a bolus intravenous injection of about ²⁰⁰ mg/m on day ¹ , followed by a continuous infusion (CI) of about 1200 mg/m over about 46 to 48 hours vote.

In some embodiments, an anti-VEGF or anti-EGFR monoclonal antibody or compound as described herein is administered on Day 1. In one embodiment, the anti-VEGF or anti-EGFR monoclonal antibody or compound is administered in a dosage according to the approved label.

Non-limiting representative examples of regimens for administration of Trelacinib and FOLFIRINOX are provided in Table 12 and FIG. 4 . Table 12 - Tralacidib + FLFIRINOX regimen Exemplary FOLFIRINOX Protocol Induction ( up to 12 cycles ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial administration of the FOLFIRINOX regimen Day ² - 240 mg/m between approximately 18 hours and 24 hours after Trelacinib administration on Day 1 ² irinotecan Day 1 - 165 mg/ ^m2 Oxaliplatin Day 1 - 85 mg/ ^m2 tetrahydrofolate Day 1 - 400 mg/m ² (200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label (eg bevacizumab 5 mg/kg) maintain ( as long as tolerated ) drug Schedule and Dosage Trelacini Day 1 - 240 mg/m 4 hours or earlier before initial dosing of tetrahydrofolate/fluorouracil Day ² - approximately 18 hours to 24 hours after Trelacinib administration on Day 1 between 240 mg/m ² tetrahydrofolate Day 1 - 400 mg/m ² (200 mg/m ² of L-formyltetrahydrofolate) Fluorouracil Day 1 - bolus dose 400 mg/m2 Day ¹ - 2400 mg/ ^m2 continuous infusion over approximately 46 hours to 48 hours As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1 - Dosing according to approved label

Colorectal Treatment with Trasitinib + FLOX In some alternative aspects, provided herein are modified FLOX treatment regimens that include administration of the CDK4/6 inhibitor, Trelacitinib. Tracinatinib is a highly potent and selective, reversible inhibitor of CDK4/6, which is administered in amounts between about 200 mg/m ² and 280 mg/m ² on the first day of each 8-week cycle (56 days). Administered intravenously (IV) on day 1, day 8, day 15, day 22, day 29 and day 36, and preferably no more than about 4 hours prior to initiation of FLOX administration at about 240 mg/ ^m2 was administered intravenously. The dosing cycle of this trelacidib can be incorporated into any of the various FLOX regimens and is designed to preserve HSPCs during chemotherapy (bone marrow preservation), enhance anti-tumor immunity (anti-tumor efficacy), and relieve and administer regimens Associated other toxicities such as stomatitis and mucositis.

FLOX is a three-drug therapy consisting of fluorouracil (5-FU), aldehyde folic acid (methyltetrahydrofolate or levothyroxine) and oxaliplatin commonly used in the treatment of CRC (National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology Colon Cancer. 2nd Edition. 2019. NCCN, Fort Washington, PA).

FLOX was administered for up to 3 induction cycles (every 8 weeks). FLOX can be administered in further combination with anti-VEGF antibodies or anti-EGFR monoclonal antibodies such as bevacizumab (Avastin, Genentech) or bevacizumab-awwb (Mvasi, Amgen), ramucirumab ( Cyramza, Eli Lilly) or aflibercept (Zaltrap, Sanofi/Regeneron), the anti-EGFR monoclonal antibodies such as panitumumab (Vectibix, Amgen) (for RAS wild-type (both KRAS and NRAS) CRC) or Cetuximab (Erbitux, Lily) (RAS wild-type (both KRAS and NRAS) CRC).

In a FLOX-based regimen, oxaliplatin is typically administered as an intravenous infusion at a dose of between about 65 mg/m and 105 mg/m ^over about, eg, ² hours, with dose adjustment as needed Administered on days 1, 15, and 29 of an 8-week cycle of induction. In some embodiments, oxaliplatin is administered as an intravenous infusion at about 85 mg/m over about, eg, ² hours. In some embodiments, oxaliplatin is administered concurrently with tetrahydrofolate. In some embodiments, oxaliplatin is administered prior to the administration of tetrahydrofolate and 5FU.

In the FLOX regimen, tetrahydrofolate is typically administered as an intravenous infusion at a dose of between about ²⁵ mg/m and about 600 mg/m over about, e.g., ² hours, with dose adjustment as needed Administered on Day 1, Day 8, Day 15, Day 22, Day 29, and Day 36 of each 8-week cycle of the induction period. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 500 mg/m on Day ¹ over about, eg, 2 hours. In some embodiments, tetrahydrofolate is administered as an intravenous infusion at about 50 mg/m over about, eg, ² hours, on Day 1. In some embodiments, tetrahydrofolate is administered concurrently with oxaliplatin. In some embodiments, tetrahydrofolate is administered after administration of 5-FU. If L-formyltetrahydrofolate is administered, it is typically administered at one-half the dose of d,l-formyltetrahydrofolate. For example, in a FLOX regimen, L-formyltetrahydrofolate is typically administered at a dose of between about 12.5 ^mg /m and about 300 mg/m within about, e.g., ² hours, with dose adjustments as needed Administered as an intravenous infusion on Day 1, Day 8, Day 15, Day 22, Day 29, and Day 36 of each 8-week cycle of the induction period. In some embodiments, levothyroxine is administered as an intravenous infusion at about 250 mg/m over about, eg, ² hours, on Day 1. In some embodiments, levothyroxine is administered as an intravenous infusion at about 25 mg/m2 over about, eg, ² hours, on Day 1. In some embodiments, levothyroxine is administered concurrently with oxaliplatin. In some embodiments, levothyroxine is administered after administration of 5-FU.

In the FLOX regimen, fluorouracil was administered as a bolus intravenous injection on days 1, 8, 15, 22, 29, and 36 of each 8-week cycle. The bolus dose of fluorouracil can be varied within the range of about 200 mg/m ² to about 1000 mg/m ² with dose adjustment as needed. In some embodiments, the fluorouracil is administered at about 500 ^mg /m.

In some embodiments, an anti-VEGF or anti-EGFR monoclonal antibody or compound as described herein is administered on days 1, 15, and 29 of each 8-week cycle. In one embodiment, an anti-VEGF or anti-EGFR monoclonal antibody or compound as described herein is administered in a dosage according to the approved label.

Non-limiting representative examples of regimens for administration of Trelacinib and FLOX are provided in Table 13 and FIG. 5 . Table 13 - Tralacinib + FLOX regimen Exemplary FLOX Protocol Induction ( up to 3 cycles ) drug Schedule and Dosage Trelacini Day 1, Day 8, Day 15, Day 22, Day 29, and Day 36 - 240 mg/m ⁴ hours or earlier before the start of the FLOX regimen Oxaliplatin Day 1, Day 15, Day 29 - 85 mg/ ^m2 tetrahydrofolate Day 1, Day 8, Day 15, Day 22, Day 29, Day 36 - 500 mg/ ^m2 (or alternatively, 250 mg/ ^m2 of L-formyltetrahydrofolate) Fluorouracil Day 1, Day 8, Day 15, Day 22, Day 29 and Day 36 - bolus dose 500 mg/ ^m2 As appropriate: Anti-EGFR or anti-VEGF antibody or compound Day 1, Day 15, Day 29 - Dosage according to approved label

Anti-Tumor Efficacy Assessment In some embodiments, trelacitinib is included as much as fluorouracil-based as described herein compared to those individuals receiving a multi-agent fluorouracil-based chemotherapeutic regimen without trelacitinib Pharmacological chemotherapy regimens provide increased antitumor efficacy. Methods for obtaining tumor responses are well known in the art and include, for example, RECIST v1.1 (Eisenhauer et al., New response evaluation criteria in solid tumors: revised RECIST guideline (version 1.1). Eur J Cancer. 2009; 45: 228-247). In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the inclusion of trelacitinib in the fluorouracil-based multi-agent chemotherapy regimens described herein provides increased or prolonged progression-free survival as compared to those individuals not receiving trelacitinib (PFS). PFS is generally defined as the time (months) from the date of administration of the regimen until the date of documented radiation disease progression or death from any cause. Methods to obtain increased PFS are well known in the art and include, for example, RECIST v1.1 (Eisenhauer et al., New response evaluation criteria in solid tumors: revised RECIST guideline (version 1.1). Eur J Cancer. 2009; 45: 228-247). In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the inclusion of trelasiclib in the fluorouracil-based multi-agent chemotherapy regimens described herein provides increased or prolonged overall survival as compared to those individuals not receiving trelasiclib ( OS). OS is typically calculated as the time (months) from the date of initiation of regimen administration to the date of death from any cause.

In some embodiments, the inclusion of trelacitinib in the fluorouracil-based multi-agent chemotherapy regimens described herein provides an improved objective response rate (ORR) compared to those individuals not receiving trelacitinib ). ORR is generally defined as the proportion of patients whose tumors have decreased in size by a predetermined amount over a minimal period of time. Objective response (OR) includes complete response (CR) and partial response (PR). The complete response (CR) is the disappearance of all tumor symptoms in response to treatment, and the partial response (PR) is the reduction in tumor size in response to treatment. Small. In some embodiments, the objective response (OR) is a complete response (CR). In some embodiments, the objective response (OR) is a partial response (PR). ORR is an important parameter to demonstrate treatment efficacy, and it serves as the primary or secondary endpoint of clinical trials. Methods for assessing ORR are well known in the art and include, for example, RECIST v1.1 (Eisenhauer et al., New response evaluation criteria in solid tumors: revised RECIST guideline (version 1.1). Eur J Cancer. 2009; 45: 228 -247) and the World Health Organization (WHO) (World Health Organization. WHO Handbook for Reporting Results of Cancer Treatment. World Health Organization Offset Publication No. 48; Geneva (Switzerland), 1979). Statistical methods of measuring objective response rates are well known in the art and include, for example, the Clopper-Pearson method (Clopper, C.; Pearson, E. S. (1934). "The use of confidence" or fiducial limits illustrated in the case of the binomial”. Biometrika. 26(4): 404-413. Digital Object Identifier: 10.1093/biomet/26.4.404). In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the inclusion of trelacitinib in the fluorouracil-based multi-agent chemotherapy regimens described herein provides improved objective duration of response ( DOR). DOR is generally defined as the time between the first objective response of CR or PR and the first date of objectively documenting disease progression or death, whichever comes first. Methods for assessing improved DOR are well known in the art and include, for example, RECIST v1.1 (Eisenhauer et al., New response evaluation criteria in solid tumors: revised RECIST guideline (version 1.1). Eur J Cancer. 2009; 45: 228-247). In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

Mitigation of Toxicity In some embodiments, the use of trelaxil in the fluorouracil-based multi-agent chemotherapy regimens described herein is compared to those individuals receiving the fluorouracil-based multi-agent chemotherapy regimen without trelacitinib Cyni induces improved bone marrow preservation and enhanced antitumor efficacy of hematopoietic stem and precursor cells (HSPCs) and immune effector cells such as lymphocytes including T lymphocytes in individuals. Decrease in severe adverse events (AE) by hematological assessment (complete blood count (CBC), red blood cell count (RBC), platelet count, white blood cell count (WBC) and absolute neutrophil count (ANC)) , reduction in supportive care interventions (including blood transfusion and G-CSF administration), reduction in dose modification, and improved patient-recorded outcomes (PRO) measurements of hematopoietic stem and precursor cells (HSPC) and lymphocytes such as T lymphocytes Improvement in bone marrow preservation of immune effector cells in the sphere. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of trelacitinib in a fluorouracil-based multi-agent chemotherapy regimen described herein in an individual is compared to an individual receiving a fluorouracil-based multi-agent chemotherapy regimen without trelacitinib Resulting in bone marrow preservation of the neutrophil lineage. Endpoints that measure bone marrow preservation of the neutrophilic lineage include, for example, a reduction in the duration of severe neutropenia and a reduction in the incidence of severe neutropenia after the first induction cycle. Neutropenia is generally defined as a condition that occurs when the body does not have enough neutrophils, which are important white blood cells that fight infection. The lower the neutrophil count, the more likely it is to contract the disease. Neutropenia is usually quantified as an absolute neutrophil count (ANC) of less than 1500 per microliter (1500/µL). Severe neutropenia is usually quantified as an absolute neutrophil count (ANC) of less than 500 per microliter (500/µL). Methods of calculating the absolute neutrophil count (ANC) are well known in the art and involve multiplying the WBC count by the percentage of neutrophils in the differential WBC count. The percentage of neutrophils consists of segmented (completely mature neutrophils) + band (almost mature neutrophils). In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of trelacitinib in a fluorouracil-based multi-agent chemotherapy regimen described herein in an individual is compared to an individual receiving a fluorouracil-based multi-agent chemotherapy regimen without trelacitinib Moderate causes a reduction in the duration of severe (grade 4) neutropenia (DSN). Duration of SN (DSN) is generally defined as the number of days from the day when the first ANC value is < 0.5 × 10 ⁹ /L to the day when the first ANC value is ≥ 0.5 × 10 ⁹ /L, where no Additional ANC values of < 0.5 x ¹⁰⁹ /L were observed. Severe neutropenia is usually quantified as an absolute neutrophil count (ANC) of less than 500 per microliter (500/microliter). Methods of calculating the absolute neutrophil count (ANC) are well known in the art and involve multiplying the WBC count by the percentage of neutrophils in the differential WBC count. The percentage of neutrophils consists of segmented (completely mature neutrophils) + band (almost mature neutrophils). In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of trelacitinib in a fluorouracil-based multi-agent chemotherapy regimen described herein in an individual is compared to an individual receiving a fluorouracil-based multi-agent chemotherapy regimen without trelacitinib Induced reduction in chemotherapy-induced fatigue (CIF). In some embodiments, the reduction in CIF is a reduction in time to first confirmed fatigue deterioration (TTCD fatigue), as measured by the Functional Assessment of Cancer Therapy Fatigue Scale (FACIT-F). The FACIT-F is a 13-item scale that measures the severity of fatigue and the effect of fatigue on functioning and is described in Yellen et al., Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. J Pain Symptom Manage. 1997; 13: 63-74. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, use of Tralacidib in a fluorouracil-based multi-agent chemotherapy regimen described herein results in a reduction in severe neutropenic events, a reduction in granulocyte population stimulating factor (G-CSF) treatment, or Reduced febrile neutropenia (FN) adverse events (AEs). G-CSF will be used according to the treatment guidelines outlined in Aapro et al, 2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumors. Eur J Cancer. 2011;47:8-32. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of Tralacidib in a fluorouracil-based multi-agent chemotherapy regimen described herein results in a reduction in grade 3 or 4 reduction in laboratory values of erythrocytes, red blood cell (RBC) transfusion, or stimulation of erythropoiesis Pharmacy (ESA) administration. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, use of Tralacidib in a fluorouracil-based multi-agent chemotherapy regimen described herein results in a reduction in grade 3 or 4 decreased platelet count laboratory values and/or platelet transfusion numbers. Platelets are typically transfused at a threshold value of < 10,000/μL as described in (Kaufman, 2015; Schiffer, 2017). Platelets are also typically transfused in any bleeding patient with a platelet count <50,000/μL (100,000/μL for central nervous system or ocular bleeding). In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of trelacitinib in a fluorouracil-based multi-agent chemotherapy regimen described herein results in a reduction in grade 3 or 4 hematology laboratory values. In some embodiments, use of tralacidamide in a fluorouracil-based multi-agent chemotherapy regimen described herein results in an all-cause dose reduction or cycle delay and reduction in relative dose intensity or fluorouracil-based as much as described herein Decrease in pharmaceutical chemotherapy regimens. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of Tralacidib in the fluorouracil-based multi-agent chemotherapy regimens described herein results in i) a reduction in hospitalizations including, but not limited to, all-cause, febrile neutropenia their hospitalization for leukopenia/neutropenia, anemia/RBC transfusion, thrombocytopenia/bleeding or infection or ii) reduction in antibiotic use including but not limited to intravenous (IV), via Oral, as well as oral and IV administration of antibiotics. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of tralasiclib in the fluorouracil-based multi-agent chemotherapy regimens described herein results in an improvement in one or more of the following: Functional Assessment of Cancer Therapy General Scale (FACT-G) category scores (Physical, Social/Family, Emotional, and Functional Health); Functional Assessment of Cancer Therapy in Anemia (FACT-An): Anemia Subscale; Functional Assessment of Cancer Therapy in Colorectal Cancer (FACT-C): Colorectal Cancer Subscale; Level 5 EQ-5D (EQ-5D-5L); Patient Global Impression of Change (PGIC) Fatigue Item; or Patient Global Impression of Severity (PGIS) Fatigue Item. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, trelaxil is used in the fluorouracil-based multi-agent chemotherapy regimens described herein as compared to their fluorouracil-based multi-agent chemotherapy regimens described herein without trelacitinib Niacin resulted in a reduction in the number of episodes of severe diarrhea (grade 3 or higher) experienced by an individual. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, trelax is used in a fluorouracil-based multi-agent chemotherapy regimen described herein as compared to an individual receiving a fluorouracil-based multi-agent chemotherapy regimen described herein without trelacitinib Sini causes a reduction in the occurrence, severity, or number of episodes of mucositis experienced by the individual. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

In some embodiments, the use of trelacidyl in a fluorouracil-based multi-agent chemotherapy regimen described herein is compared to an individual receiving a fluorouracil-based multi-agent chemotherapy regimen described herein without trelacitinib Lacinib causes a reduction in the occurrence, severity, or number of bouts of stomatitis experienced by an individual. In some embodiments, the fluorouracil-based multi-agent chemotherapy regimen is FOLFOXIRI or FOLFOXIRI + anti-VEGF or anti-EGFR antibody or compound.

Combinations with Immune Checkpoint Inhibitors In some embodiments, the multi-agent fluorouracil-based chemotherapy regimen for administration to individuals with colorectal cancer or other cancers described herein further comprises administering an immune checkpoint Suppressant or immunomodulatory agent. In some embodiments, the immune checkpoint inhibitor or immunomodulatory agent is administered on Day 1 of each 14-day cycle or every two weeks. Examples of immune checkpoint inhibitors and immunomodulatory agents include, but are not limited to, PD-1 inhibitors, PD-L1 inhibitors, PD-L2 inhibitors, CTLA-4 inhibitors, LAG-3 inhibitors, TIM-3 inhibitors , V domain Ig inhibitor of T cell activation (VISTA) inhibitor, TIGIT inhibitor, Siglec-15 inhibitor, B7-H3 (CD272) inhibitor, BTLA inhibitor (CD272), small molecule, peptide, nucleotide or other inhibitors. In certain aspects, the immunomodulatory agent is an antibody, such as a monoclonal antibody.

In one embodiment, the immune checkpoint inhibitor is a PD-1 inhibitor that blocks the interaction of PD-1 with PD-L1 by binding to the PD-1 receptor and thereby inhibits immunosuppression. In one embodiment, the immune checkpoint inhibitor is a PD-1 immune checkpoint inhibitor selected from, but not limited to, nivolumab (Opdivo®), pembrolizumab ( Keytruda®), pidilizumab (Medivation), AMP-224 (Amplimmune); sasanlimab (PF-06801591; Pfizer), spartalizumab (PDR001) Novartis), cemiplimab (Libtayo®; REGN2810; Regeneron), retifanlimab (MGA012; MacroGenics), tislelizumab (BGB-A317; BeiGene) , camrelizumab (SHR-1210; Jiangsu Hengrui Medicine Company and Incyte Corporation) and dostarlimab (TSR-042; Tesaro).

In one embodiment, the immune checkpoint inhibitor is a PD-L1 inhibitor that blocks the interaction of PD-1 with PD-L1 by binding to the PD-L1 receptor and thereby inhibits immunosuppression. PD-L1 inhibitors include, but are not limited to, atezolizumab (Tecentriq®, Genentech), durvalumab (Imfinzi®, AstraZeneca); avelumab (Bavencio) ®; Merck), envafolimab (KN035; Alphamab), BMS-936559 (Bristol-Myers Squibb), lodapolimab (LY3300054; Eli Lilly), cosibelimab ( cosibelimab (CK-301; Checkpoint Therapeutics), sugemalimab (CS-1001; Cstone Pharmaceuticals), adebrelimab (SHR-1316; Jiangsu HengRui Medicine), CBT-502 (CBT Pharma) and BGB-A333 (BeiGene).

In one embodiment, the immune checkpoint inhibitor is a PD-L1/VISTA inhibitor. PD-L1-VISTA inhibitors include, but are not limited to, CA-170 (Curis Inc.). In one embodiment, the immune checkpoint inhibitor is a VISTA immune checkpoint inhibitor. VISTA inhibitors include, but are not limited to, JNJ-61610588 (Johnson & Johnson).

In one aspect of this embodiment, the immune checkpoint inhibitor is a CTLA-4 immune checkpoint inhibitor that binds to CTLA-4 and inhibits immunosuppression. CTLA-4 inhibitors include but are not limited to ipilimumab (Yervoy®, Bristol Myers Squibb); tremelimumab (AstraZeneca/MedImmune), zalifrelimab (AGEN1884); Agenus) and AGEN2041 (Agenus).

In another embodiment, the immune checkpoint inhibitor is a LAG-3 immune checkpoint inhibitor. Examples of LAG-3 immune checkpoint inhibitors include, but are not limited to, relatlimab (BMS-986016; Bristol-Myers Squibb), GSK2831781 (GlaxoSmithKline), eftilagimod alpha (IMP321; Prima) BioMed), leramilimab (LAG525; Novartis), MK-4280 (Merck), REGN3767 (Regeneron), TSR-033 (Tesaro), BI754111 (Bohringer Ingelheim), Sym022 (Symphogen); dual PD- 1 and the LAG-3 inhibitor tebotelimab (MGD013; MacroGenics) and the dual PD-L1 and LAG-3 inhibitor FS118 (F-Star).

In yet another aspect of this embodiment, the immune checkpoint inhibitor is a TIM-3 immune checkpoint inhibitor. TIM-3 inhibitors include, but are not limited to, TSR-022 (Tesaro), MBG453 (Novartis), Sym023 (Symphogen), INCAGN2390 (Incyte), LY3321367 (Eli Lilly and Company), BMS-986258 (BMS), SHR-1702 ( Jiangsu HengRui) and RO7121661 (Roche).

In yet another aspect of this embodiment, the immune checkpoint inhibitor is a TIGIT (T cell immune receptor with Ig domain and ITIM domain) immune checkpoint inhibitor. TIGIT immune checkpoint inhibitors include but are not limited to MK-7684 (Merck), Etigilimab (Etigilimab)/OMP-313M32 (OncoMed), Tiragolumab (Tiragolumab)/MTIG7192A/RG-6058 (Genentech ), BMS-986207 (BMS), AB-154 (Arcus Biosciences) and ASP-8374 (Potenza).

Other immune checkpoint inhibitors described herein for use in the present invention include, but are not limited to, B7-H3/CD276 immune checkpoint inhibitors, such as enoblituzumab (MGA217, Macrogenics), MGD009 (Macrogenics) , 131I-8H9/omburtamab (Y-mabs) and I-8H9/omburtamab (Y-mabs); indoleamine 2,3-dioxygenase (IDO) ) immune checkpoint inhibitors such as Indoximod and INCB024360; killer immunoglobulin-like receptor (KIR) immune checkpoint inhibitors such as Lirilumab (BMS-986015), cancer Embryonic antigen cell adhesion molecule (CEACAM) inhibitors (eg, CEACAM-1, CEACAM-3 and/or CEACAM-5). Exemplary anti-CEACAM-1 antibodies are described in WO 2010/125571, WO 2013/082366 and WO 2014/022332, eg monoclonal antibodies 34B1, 26H7 and 5F4; or recombinant forms thereof, eg, US 2004/0047858, US Pat. No. 7,132,255 and WO 99/052552. In other embodiments, the anti-CEACAM antibody binds to CEACAM-5, as e.g. Zheng et al., PLoS One. 2010 Sep 2; 5(9). Publication Identifier: e12529 (Digital Object Identifier: 10: 1371/journal.pone.0021146), or cross-react with CEACAM-1 and CEACAM-5, as described, for example, in WO 2013/054331 and US 2014/0271618.

Additionally, other checkpoint inhibitors may be molecules associated with B and T lymphocyte attenuator (BTLA) molecules, eg, as in Zhang et al., Monoclonal antibodies to B and T lymphocyte attenuator (BTLA) have no effect on in vitro B cell proliferation and act to inhibit in vitro T cell proliferation when presented in a cis, but not trans, format relative to the activating stimulus, Clin Exp Immunol. 2011 Jan;163(1):77-87, and TAB004/JS004 (Junshi Biosciences).

In another embodiment, the immune checkpoint inhibitor is a sialic acid-binding immunoglobulin-like lectin 15 (Siglec-15) inhibitor, including but not limited to NC318 (anti-Siglec-15 mAb).

In an alternative embodiment, the fluorouracil-based multi-agent chemotherapy regimen is administered to the individual without an immune checkpoint inhibitor or immunomodulatory agent other than trelacitinib.

Pharmaceutical Compositions Selected compounds of the protocols described herein, or pharmaceutically acceptable salts thereof, may be administered as pure chemicals, but are more typically administered as pharmaceutical compositions that are Included in a pharmaceutically acceptable carrier is an amount effective for a patient (usually a human) in need of such treatment. A pharmaceutical composition may contain a compound or salt thereof as the sole active agent, or, in an alternative embodiment, may contain the compound or salt thereof and at least one additional active agent for the disease to be treated.

Pharmaceutical compositions can be administered in therapeutically effective amounts by any desired mode of administration, but are typically administered by intravenous injection or infusion. In alternative embodiments, the compound or pharmaceutically acceptable salt is delivered in an effective amount with a pharmaceutically acceptable carrier for oral delivery. As a more general, non-limiting example, the pharmaceutical composition is suitable for oral (including buccal and sublingual), rectal, nasal, topical, transdermal, pulmonary, vaginal or parenteral (including intramuscular) , intraarterial, intrathecal, subcutaneous and intravenous), injection, inhalation or spray, intra-aortic, intracranial, subcutaneous, intraperitoneal, subcutaneous, or by other administration containing conventional pharmaceutically acceptable carriers The pharmaceutical composition of the means.

Suitable dosage ranges depend on a number of factors, such as the severity of the disease being treated, the age and relative health of the individual, the potency of the compound employed, the route and form of administration, and the preferences and experience of the practitioner involved. Those of ordinary skill in the art of treating such diseases will be able to determine the therapeutically effective amount of the compositions of the present invention for a given disease without undue experimentation and relying on personal knowledge and the disclosure of this application.

In certain embodiments, the pharmaceutical composition is about 0.01 mg to about 1000 mg, about 0.1 mg to about 750 mg, about 1 mg to about 500 mg, or about 5, 10, 15 or 20 mg to about 250 mg A dosage form of the active compound or a pharmaceutically acceptable salt thereof. Examples are such dosage forms that deliver at least 0.01, 0.05, 0.1, 1, 5, 10, 25, 50, 100, 200, 250, 300, 400, 500, 600, 700 or 750 mg of the active compound or salt thereof. When weight is used herein, it can refer to a compound alone or in combination with a pharmaceutically acceptable salt thereof.

An effective amount of a disclosed compound or salt thereof can be administered based on the patient's weight, size, or age. For example, in at least one dosage, the therapeutic amount can range, for example, from about 0.01 mg/kg to about 250 mg/kg of body weight, or from about 0.1 mg/kg to about 10 mg/kg. The patient may be administered as many doses as necessary to reduce and/or alleviate and/or cure the disorder in question. If desired, the formulations may be prepared with enteric coatings suitable for sustained or controlled release administration of the active ingredient.

In certain embodiments, the dose is in the range of about 0.01 to 100 mg/kg of the patient's body weight, eg, about 0.01 mg/kg, about 0.05 mg/kg, about 0.1 mg/kg, about 0.5 mg/kg, about 1 mg/kg kg, about 1.5 mg/kg, about 2 mg/kg, about 2.5 mg/kg, about 3 mg/kg, about 3.5 mg/kg, about 4 mg/kg, about 4.5 mg/kg, about 5 mg/kg, About 10 mg/kg, about 15 mg/kg, about 20 mg/kg, about 25 mg/kg, about 30 mg/kg, about 35 mg/kg, about 40 mg/kg, about 45 mg/kg, about 50 mg/kg, about 55 mg/kg, about 60 mg/kg, about 65 mg/kg, about 70 mg/kg, about 75 mg/kg, about 80 mg/kg, about 85 mg/kg, about 90 mg/kg kg, about 95 mg/kg, or about 100 mg/kg.

The pharmaceutical formulations are preferably in unit dosage form. In such form, the preparation is subdivided into unit doses containing appropriate quantities of the active component. The unit dosage form can be a packaged preparation, the package containing discrete quantities of preparation, such as lozenges, capsules, and powders in packaged vials or ampoules. Also, the unit dosage form can be a capsule, lozenge, cachet, or lozenge itself, or it can be the appropriate number of any of these in packaged form.

In certain embodiments, compounds are administered as pharmaceutically acceptable salts. Non-limiting examples of pharmaceutically acceptable salts include: acetate, adipate, alginate, ascorbate, aspartate, benzenesulfonate, benzoate, bisulfate, boric acid Salt, butyrate, camphorate, camphorsulfonate, citrate, cyclopentane propionate, digluconate, lauryl sulfate, ethanesulfonate, fumarate , Glucoheptonate, Glycerophosphate, Hemisulfate, Heptanoate, Caproate, Hydrobromide, Hydrochloride, Hydroiodide, 2-Hydroxy-ethanesulfonate, Lactobionate, Lactate, Laurate, Lauryl Sulfate, Malate, Maleate, Malonate, Mesylate, 2-Naphthalene Sulfonate, Nicotinate, Nitrate, Oleic Acid Salt, Oxalate, Palmitate, Pamoate, Pectate, Persulfate, 3-Phenylpropionate, Phosphate, Picrate, Pivalate, Propionate, Hard Fatty acid, succinate, sulfate, tartrate, thiocyanate, tosylate, undecanoate and valerate. Representative alkali or alkaline earth metal salts include sodium, lithium, potassium, calcium and magnesium and non-toxic ammonium, quaternary ammonium and amine cations including but not limited to ammonium, tetramethylammonium, tetraethylammonium, methylamine, dimethylamine , trimethylamine, triethylamine and ethylamine.

Depending on the intended mode of administration, pharmaceutical compositions may be in solid, semisolid or liquid dosage forms such as lozenges, suppositories, pills, capsules, powders, liquids, syrups, suspensions, creams, ointments, emulsions, pastes, gels Glues, sprays, aerosols, foams or oils, injection or infusion solutions, transdermal patches, subcutaneous patches, inhalation formulations, suppositories in medical devices, buccal or lingual formulations, parenteral formulations Or ophthalmic solutions or the like, preferably in unit dosage forms suitable for single administration of precise doses.

Some dosage forms, such as tablets and capsules, are subdivided into suitably sized unit doses containing appropriate quantities of the active component, eg, an effective amount to achieve the desired purpose. The composition will include an effective amount of the selected drug in combination with a pharmaceutically acceptable carrier and may additionally include other pharmaceutical agents, adjuvants, diluents, buffers, and the like.

Carriers include excipients and diluents, and should be of sufficiently high purity and sufficiently low toxicity to be suitable for administration to a patient undergoing treatment. The carrier may be inert or may itself have pharmaceutical benefits. The amount of carrier employed in connection with the compound is sufficient to provide an actual amount of material for administration based on a unit dose of the compound.

Classes of carriers include, but are not limited to, adjuvants, binders, buffering agents, coloring agents, diluents, disintegrating agents, excipients, emulsifiers, flavoring agents, gelling agents, glidants, lubricants, preservatives, Stabilizers, surfactants, solubilizers, tableting agents, wetting agents or setting materials.

Some carriers may fall into more than one category, eg vegetable oils may be used as lubricants in some formulations and as diluents in others.

Exemplary pharmaceutically acceptable carriers include sugar, starch, cellulose, powdered tragacanth, malt, gelatin, talc, petroleum jelly, lanolin, polyethylene glycol, ethanol, transdermal enhancers, and vegetable oils. Optionally, active agents that do not substantially interfere with the activity of the compounds of the present invention can be included in the pharmaceutical compositions.

Some excipients include, but are not limited to, liquids such as water, saline, glycerol, polyethylene glycol, hyaluronic acid, ethanol, and the like. The compounds may optionally be provided in the form of solids, liquids, spray-dried substances, microparticles, nanoparticles, controlled release systems, and the like, as desired, depending on the object of treatment. Suitable excipients for non-liquid formulations are also known to those skilled in the art. A thorough discussion of pharmaceutically acceptable excipients and salts can be found in Remington's Pharmaceutical Sciences, 18th Edition (Easton, Pennsylvania: Mack Publishing Company, 1990).

Additionally, auxiliary substances such as wetting or emulsifying agents, biological buffering substances, surfactants, and the like can be present in such vehicles. A biological buffer can be any solution that is pharmacologically acceptable and provides the formulation with the desired pH, ie, a pH in the physiologically acceptable range. Examples of buffered solutions include saline, phosphate buffered saline, Tris buffered saline, Hank's buffered saline, and the like.

For solid compositions, conventional non-toxic solid carriers include, for example, pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharin, talc, cellulose, glucose, sucrose, magnesium carbonate, and the like. Liquid pharmaceutically administrable compositions can be prepared, for example, by dissolving, dispersing, and resembling, for example, the active compounds as described herein and optional pharmaceutical adjuvants such as, for example, water, saline, aqueous dextrose, glycerol, ethanol, and similar excipients, thereby forming solutions or suspensions. If desired, the pharmaceutical compositions to be administered may also contain minor amounts of non-toxic auxiliary substances, such as wetting or emulsifying agents, pH buffering agents, and the like, for example, sodium acetate, sorbitan monolaurate, triethanolamine acetic acid Sodium, triethanolamine oleate and the like. Actual methods of preparing such dosage forms are known or will be apparent to those skilled in the art; see, eg, Remington's Pharmaceutical Sciences, referenced above.

In yet another embodiment provides the use of penetration enhancers comprising polymers such as: polycations (polyglucosamine and its quaternary ammonium derivatives, poly-L-arginine, aminated gelatin); polyanions (N-carboxymethyl polyglucamine, polyacrylic acid); and thiolated polymers (carboxymethyl cellulose cysteine, polycarbophil-cysteine, polyglucamine) sugar thiobutylamidine, polyglucosamine thioglycolic acid, polyglucosamine glutathione conjugate).

In certain embodiments, the excipient is selected from the group consisting of butylated hydroxytoluene (BHT), calcium carbonate, calcium phosphate (dibasic), calcium stearate, croscarmellose, crospovidin ketone, citric acid, crospovidone, cysteine, ethyl cellulose, gelatin, hydroxypropyl cellulose, hydroxypropyl methyl cellulose, lactose, magnesium stearate, maltitol, mannitol , methionine, methylcellulose, methylparaben, microcrystalline cellulose, polyethylene glycol, polyvinylpyrrolidone, povidone, pregelatinized starch, propylparaben , Retinyl palmitate, shellac (shellac), silica, sodium carboxymethyl cellulose, sodium citrate, sodium starch glycolate, sorbitol, starch (corn), stearic acid, sucrose, talc, Titanium dioxide, vitamin A, vitamin E, vitamin C and xylitol.

Pharmaceutical compositions/combinations can be formulated for oral administration. For oral administration, the compositions will take the form of lozenges, capsules, soft gel capsules or may be aqueous or non-aqueous solutions, suspensions or syrups. Tablets and capsules are typical forms of oral administration. Tablets and capsules for oral use may include one or more conventional carriers such as lactose and corn starch. Lubricating agents, such as magnesium stearate, are also often added. Generally, the compositions of the present invention can be combined with oral, non-toxic, pharmaceutically acceptable inert carriers such as lactose, starch, sucrose, glucose, methylcellulose, magnesium stearate, dicalcium phosphate, calcium sulfate, Combinations of mannitol, sorbitol and the like. Furthermore, when desired or necessary, suitable binders, lubricants, disintegrating agents, and coloring agents can also be incorporated into the mixture. Suitable binders include starch, gelatin, natural sugars (such as glucose or beta-lactose), corn sweeteners, natural and synthetic gums (such as acacia, tragacanth or sodium alginate), carboxymethyl cellulose, poly Glycols, waxes and the like. Lubricants used in these dosage forms include sodium oleate, sodium stearate, magnesium stearate, sodium benzoate, sodium acetate, sodium chloride and the like. Disintegrants include, but are not limited to, starch, methyl cellulose, agar, bentonite, sangel and the like.

When liquid suspensions are employed, the active agent can be combined with any oral non-toxic pharmaceutically acceptable inert carrier, such as ethanol, glycerol, water and the like, and with emulsifying and suspending agents. If desired, flavoring agents, coloring agents, and/or sweetening agents may also be added. Other optional ingredients for use in the oral formulations incorporated herein include, but are not limited to, preservatives, suspending agents, thickening agents, and the like.

For ocular delivery, the compound can be administered as desired, eg, via intravitreal, intrastromal, intracameral, subsaccular, subretinal, retro-bulbar, periocular, suprachoroidal, conjunctival, subconjunctival , episcleral, periocular, transscleral, retrobulbar, retroscleral, pericorneal or lacrimal injection, or via mucus, mucin or mucosal barriers, in immediate or controlled release, or via ocular devices vote.

Parenteral formulations can be prepared in the well-known forms, either as liquid solutions or suspensions, in solid forms suitable for solution or suspension in liquid prior to injection, or as emulsions. Generally, sterile injectable suspensions are formulated according to techniques known in the art using suitable carriers, dispersing or wetting agents, and suspending agents. The sterile injectable formulation may also be a sterile injectable solution or suspension in an acceptable nontoxic parenterally acceptable diluent or solvent. Among the acceptable vehicles and solvents that may be employed are water, Ringer's solution and isotonic sodium chloride solution. In addition, sterile, fixed oils, fatty esters, or polyols are conventionally employed as solvents or suspending media. In addition, parenteral administration may involve the use of slow release or sustained release systems such that a constant level of dosage is maintained.

Parenteral administration includes intra-articular, intravenous, intramuscular, intradermal, intraperitoneal and subcutaneous routes and includes aqueous isotonic sterile injectable solutions and non-aqueous isotonic sterile injectable solutions, which may contain antioxidants, buffers, bacteriostatic Agents and solutes that make the formulation isotonic with the blood of the intended recipient, and may include suspending agents, solubilizers, thickening agents, stabilizers and preservatives, both aqueous and non-aqueous sterile suspensions. Administration via certain parenteral routes may involve introducing the formulations of the invention into the body of a patient via a needle or catheter advanced by a sterile syringe or some other mechanical device such as a continuous infusion system. The formulations provided by the present invention can be administered using a syringe, infuser, pump, or any other device recognized in the art for parenteral administration.

EXAMPLES At least the following examples are provided herein:

或其醫藥學上可接受之鹽，其中在FOLFOXIRI化學治療方案中投與CDK4/6抑制劑，且其中CDK4/6抑制劑係i)在FOLFOXIRI化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 1. A method for treating a human suffering from colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, wherein the CDK4/6 inhibitor is administered in the FOLFOXIRI chemotherapy regimen, and wherein the CDK4/6 inhibitor is i) performed 4 hours or earlier before the initiation of FOLFOXIRI chemotherapy administration One administration and ii) a second administration between 18 hours and 26 hours after the first CDK4/6 inhibitor administration.

或其醫藥學上可接受之鹽，且其中CDK4/6抑制劑係i)在FOLFOXIRI化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 2. A method of alleviating chemotherapy-induced myelosuppression in a human undergoing a FOLFOXIRI chemotherapy regimen for the treatment of colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, and wherein the CDK4/6 inhibitor is i) the first administration is performed 4 hours or earlier before the initiation of FOLFOXIRI chemotherapy administration and ii) the first CDK4/6 inhibitory The second dose was administered between 18 hours and 26 hours after the dose was administered.

或其醫藥學上可接受之鹽； vii)     向人類投與有效量之5-FU； viii)   向人類投與有效量之醛葉酸； ix)      向人類投與有效量之奧沙利鉑； x)        向人類投與有效量之伊立替康；且 xi)      視情況，向人類投與抗VEGF或抗EGFR單株抗體或化合物； 且其中CDK4/6抑制劑係i)在第一次待投與5-FU、醛葉酸、奧沙利鉑或伊立替康之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 3. A method of treating colorectal cancer in a human, comprising: vi) administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof; vii) administering an effective amount of 5-FU to a human; viii) administering an effective amount of aldehyde folic acid to a human; ix) administering an effective amount of oxaliplatin to a human; x ) administering an effective amount of irinotecan to the human; and xi) as the case may be, administering an anti-VEGF or anti-EGFR monoclonal antibody or compound to the human; and wherein the CDK4/6 inhibitor is i) at the first to-be-administered 4 hours or earlier before the first dose of 5-FU, aldfolate, oxaliplatin or irinotecan and ii) between 18 hours and 26 hours after the first dose of the CDK4/6 inhibitor Second pitch.

4. The method of any one of embodiments 1-3, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before the administration of 5-FU.

5. The method of any one of embodiments 1 to 4, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 24 hours after the first administration.

6. The method of any one of embodiments 1 to 4, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 22 hours after the first administration.

7. The method of any one of embodiments 1 to 6, wherein the human is further administered an anti-VEGF or anti-EGFR antibody or compound.

8. The method of any one of embodiments 1 to 7, wherein the human is administered an anti-VEGF antibody selected from the group consisting of bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept .

9. The method of embodiment 8, wherein bevacizumab or a biosimilar thereof is administered to the human.

10. The method of any one of embodiments 1-7, wherein an anti-EGFR antibody selected from cetuximab or panitumumab is administered to the human.

11. The method of embodiment 10, wherein cetuximab or a biosimilar thereof is administered to the human.

12. The method of any one of embodiments 1 to 11, wherein the aldehyde folic acid administered to it is tetrahydrofolate.

13. The method of any one of embodiments 1 to 11, wherein the aldehyde folic acid administered is L-formyltetrahydrofolic acid.

或其醫藥學上可接受之鹽， ii)       在每個14天週期之第1天開始向人類投與有效量之氟尿嘧啶(5-FU)，其中5-FU以連續輸注(CI)形式投與約44小時至48小時之間的時間； iii)      在每個14天週期之第1天向人類投與有效量之醛葉酸； iv)      在每個14天週期之第1天向人類投與有效量之奧沙利鉑；及 v)        在每個14天週期之第1天向人類投與有效量之伊立替康；且 vi)      視情況，在每個14天週期之第1天向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在每個14天週期之第1天在第一次待投與5-FU、醛葉酸、奧沙利鉑或伊立替康的投與之前約4小時或更早進行投與，且其中CDK4/6抑制劑係在其於每個週期之第1天投藥之後約18小時至26小時之間的每個週期之第2天進行投與。 14. A method of treating colorectal cancer in a human, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) on Days 1 and 2 of each 14-day cycle Humans are administered an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, ii) administering to the human an effective amount of fluorouracil (5-FU) starting on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) for a time between about 44 hours and 48 hours; iii) administer an effective amount of aldehyde folic acid to humans on Day 1 of each 14-day cycle; iv) administer an effective amount to humans on Day 1 of each 14-day cycle and v) administer an effective amount of irinotecan to humans on Day 1 of each 14-day cycle; and vi) optionally, administer to humans on Day 1 of each 14-day cycle with an anti-VEGF or anti-EGFR monoclonal antibody or compound; wherein the CDK4/6 inhibitor is first administered 5-FU, aldofolic acid, oxaliplatin, or iritinib on day 1 of each 14-day cycle The administration of the CDK4/6 inhibitor is performed about 4 hours or earlier before the administration of the drug, and wherein the CDK4/6 inhibitor is administered on the 2nd of each cycle between about 18 hours and 26 hours after its administration on the 1st day of each cycle day to contribute.

15. The method of any one of embodiments 14, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before the 5-FU is administered.

16. The method of embodiment 14 or 15, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 24 hours after its administration on day 1.

17. The method of embodiment 14 or 15, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 22 hours after its administration on day 1.

18. The method of any one of embodiments 14-17, wherein the human is further administered an anti-VEGF or anti-EGFR antibody or compound.

19. The method of embodiment 18, wherein the human is administered an anti-VEGF antibody or compound selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept.

20. The method of embodiment 19, wherein bevacizumab or a biosimilar thereof is administered to the human.

21. The method of any one of embodiments 14-17, wherein an anti-EGFR antibody selected from cetuximab or panitumumab is administered to the human.

22. The method of embodiment 21, wherein cetuximab or a biosimilar thereof is administered to the human.

23. The method of any one of embodiments 14-17, wherein the CDK4/6 inhibitor is administered in an amount between about 190 mg/m ² and 300 mg/m ² .

24. The method of embodiment 23, wherein the CDK4/ ⁶ inhibitor is administered at about 240 mg/m2.

25. The method of any one of embodiments 14 to 24, wherein the 5-FU is administered as a continuous infusion of between about 2200 ^mg /m and 3800 ^mg /m for a time between about 44 hours and 48 hours .

26. The method of embodiment 25, wherein the 5-FU is administered as a continuous infusion of about 2400 mg/m ² and 3200 mg/m ² for about 46 to 48 hours.

27. The method of embodiment 26, wherein the 5-FU is administered as a continuous infusion of about 2400 ^mg /m2 for about 46 to 48 hours.

28. The method of any one of embodiments 14-27, wherein a bolus dose of between about 200 mg/m ² and 600 mg/m ² of 5-FU is administered to the human on Day 1 .

29. The method of embodiment 28, wherein a bolus dose of between about 400 mg/m ² of 5-FU is administered to the human on Day 1.

30. The method of any one of embodiments 14 to 29, wherein a dose of irinotecan between about 150 mg/m ² and 200 mg/m ² is administered to the human.

31. The method of embodiment 30, wherein a dose of irinotecan of about 165 ^mg /m2 is administered to the human.

32. The method of embodiment 30, wherein a dose of irinotecan of about 180 ^mg /m2 is administered to the human.

33. The method of any one of embodiments 14 to 32, wherein a dose of oxaliplatin between about 50 mg/m ² and 150 mg/m ² is administered to the human.

34. The method of embodiment 33, wherein a dose of about 85 mg/m ² of oxaliplatin is administered to the human.

35. The method of embodiment 33, wherein a dose of about 100 mg/m ² of oxaliplatin is administered to the human.

36. The method of embodiment 33, wherein a dose of about 130 mg/m ² of oxaliplatin is administered to the human.

37. The method of any one of embodiments 14 to 36, wherein a dose of tetrahydrofolate between about 100 mg/m ² and 500 mg/m ² is administered to the human on Day 1 .

38. The method of embodiment 37, wherein the human is administered a dose of about 400 mg/m ² of tetrahydrofolate on day 1.

39. The method of embodiment 37, wherein the human is administered on day 1 a dose of about 200 mg/m ² of tetrahydrofolate.

40. The method of any one of embodiments 14 to 36, wherein a dose of tetrahydrofolate between about 50 mg/m ² and 250 mg/m ² is administered to the human on Day 1 .

41. The method of embodiment 40, wherein the human is administered a dose of about ²⁰⁰ mg/m2 of L-formyltetrahydrofolate on Day 1.

42. The method of embodiment 40, wherein the human is administered a dose of about 100 mg/m ² of tetrahydrofolate on day 1.

43. The method of any one of embodiments 14-42, wherein up to 12 14-day cycles are administered to the human.

44. The method of any one of embodiments 1-43, wherein the human is further administered a maintenance therapy comprising administration of a CDK4/6 inhibitor, 5-FU after discontinuation of the method of embodiments 14-43 and aldehyde folic acid.

或其醫藥學上可接受之鹽，其中在FOLFIRINOX化學治療方案中投與CDK4/6抑制劑，且其中CDK4/6抑制劑係i)在FOLFIRINOX化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 45. A method of treating a human suffering from colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, wherein the CDK4/6 inhibitor is administered in the FOLFIRINOX chemotherapy regimen, and wherein the CDK4/6 inhibitor is i) performed 4 hours or earlier before the initiation of FOLFIRINOX chemotherapy administration One administration and ii) a second administration between 18 hours and 26 hours after the first CDK4/6 inhibitor administration.

或其醫藥學上可接受之鹽，且其中CDK4/6抑制劑係i)在FOLFIRINOX化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 46. A method of alleviating chemotherapy-induced myelosuppression in a human undergoing a FOLFIRINOX chemotherapy regimen for the treatment of colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, and wherein the CDK4/6 inhibitor is i) the first administration is performed 4 hours or earlier before the initiation of FOLFIRINOX chemotherapy administration and ii) the first CDK4/6 inhibitory The second dose was administered between 18 hours and 26 hours after the dose was administered.

或其醫藥學上可接受之鹽； ii)       向人類投與有效量之5-FU，其中5-FU以推注注射形式進行投與； iii)      向人類投與有效量之5-FU，其中5-FU以連續輸注(CI)形式進行投與； iv)      向人類投與有效量之醛葉酸； v)        向人類投與有效量之奧沙利鉑；及 vi)      向人類投與有效量之伊立替康；且 vii)     視情況，向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在第一次待投與5-FU、醛葉酸、奧沙利鉑或伊立替康的投與之前約4小時或更早進行第一次投與，且其中CDK4/6抑制劑係在其第一次投藥之後約18小時至26小時之間進行第二次投與。 47. A method of treating colorectal cancer in a human, comprising: i) administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof; ii) administering to a human an effective amount of 5-FU, wherein the 5-FU is administered as a bolus injection; iii) administering to a human an effective amount of 5-FU, wherein 5-FU is administered as a continuous infusion (CI); iv) an effective amount of aldehyde folic acid is administered to a human; v) an effective amount of oxaliplatin is administered to a human; and vi) an effective amount of oxaliplatin is administered to a human irinotecan; and vii) as the case may be, administering an anti-VEGF or anti-EGFR monoclonal antibody or compound to humans; wherein the CDK4/6 inhibitor is administered in the first dose of 5-FU, aldfolate, oxaliplatin or the first administration of irinotecan is performed about 4 hours or earlier, and wherein the CDK4/6 inhibitor is administered a second time between about 18 hours and 26 hours after its first administration .

48. The method of any one of embodiments 45-47, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before the administration of 5-FU.

49. The method of any one of embodiments 45-48, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 24 hours after the first administration.

50. The method of any one of embodiments 45-48, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 22 hours after the first administration.

51. The method of any one of embodiments 45-50, wherein the human is further administered an anti-VEGF or anti-EGFR antibody or compound.

52. The method of any one of embodiments 45-51, wherein the human is administered an anti-VEGF antibody selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept .

53. The method of embodiment 52, wherein bevacizumab or a biosimilar thereof is administered to the human.

54. The method of any one of embodiments 45-51, wherein an anti-EGFR antibody selected from cetuximab or panitumumab is administered to the human.

55. The method of embodiment 54, wherein cetuximab or a biosimilar thereof is administered to the human.

56. The method of any one of embodiments 45 to 54, wherein the aldehyde folic acid administered is tetrahydrofolate.

57. The method of any one of embodiments 45 to 54, wherein the aldehyde folic acid administered is L-formyltetrahydrofolate.

58. The method of any one of embodiments 45-54, wherein the human is further administered maintenance therapy, the maintenance therapy comprising administering a CDK4/6 inhibitor, 5-FU after discontinuation of the method of embodiments 45-55 and aldehyde folic acid.

或其醫藥學上可接受之鹽； ii)       在每個14天週期之第1天向人類投與有效量之5-FU，其中5-FU以推注注射形式進行投與； iii)      在每個14天週期之第1天開始向人類投與有效量之5-FU，其中5-FU以連續輸注(CI)形式在第1天開始投與約44小時至48小時之間的時間； iv)      在每個14天週期之第1天向人類投與有效量之醛葉酸； v)        在每個14天週期之第1天向人類投與有效量之奧沙利鉑；及 vi)      在每個14天週期之第1天向人類投與有效量之伊立替康；且 vii)     視情況，在每個14天週期之第1天向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在每個14天週期之第1天在第一次待投與5-FU、醛葉酸、奧沙利鉑或伊立替康的投與之前約4小時或更早進行投與，且其中CDK4/6抑制劑係在其於每個週期之第1天投藥之後約18小時至26小時之間的每個週期之第2天進行投與。 59. A method of treating colorectal cancer in a human, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) on Days 1 and 2 of each 14-day cycle. Humans are administered an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof; ii) administering an effective amount of 5-FU to a human on Day 1 of each 14-day cycle, wherein the 5-FU is administered as a bolus injection; iii) on each 14-day cycle Administration of an effective amount of 5-FU to humans beginning on day 1 of each 14-day cycle, wherein 5-FU is administered as a continuous infusion (CI) for a period between about 44 hours and 48 hours beginning on day 1; iv ) administer an effective amount of aldehyde folic acid to humans on Day 1 of each 14-day cycle; v) administer an effective amount of oxaliplatin to humans on Day 1 of each 14-day cycle; and vi) Administer an effective amount of irinotecan to humans on Day 1 of each 14-day cycle; and vii) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to humans on Day 1 of each 14-day cycle, as appropriate; wherein the CDK4/6 inhibitor was administered on day 1 of each 14-day cycle approximately 4 hours or earlier prior to the first to-be-administered administration of 5-FU, aldofolic acid, oxaliplatin, or irinotecan and wherein the CDK4/6 inhibitor is administered on Day 2 of each cycle between about 18 hours and 26 hours after its administration on Day 1 of each cycle.

60. The method of embodiment 59, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before the administration of 5-FU.

61. The method of embodiment 60, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 24 hours after its administration on day 1.

62. The method of embodiment 60, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 22 hours after its administration on day 1.

63. The method of any one of embodiments 60-62, wherein an anti-VEGF or anti-EGFR antibody or compound is further administered to the human.

64. The method of embodiment 63, wherein the human is administered an anti-VEGF antibody or compound selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept.

65. The method of embodiment 63, wherein bevacizumab or a biosimilar thereof is administered to the human.

66. The method of embodiment 63, wherein an anti-EGFR antibody or compound selected from cetuximab or panitumumab is administered to the human.

67. The method of any one of embodiments 60 to 66, wherein the CDK4/6 inhibitor is administered in an amount between about 190 mg/m ² and 300 mg/m ² .

68. The method of embodiment 67, wherein the CDK4/ ⁶ inhibitor is administered at about 240 mg/m2.

69. The use of any one of claims 60 to 68, wherein between about 100 mg/m ² and 500 mg/m ² of 5-FU is administered as a bolus injection.

70. The method of embodiment 69, wherein a 5-FU bolus injection of between about 400 ^mg /m is administered.

71. The method of embodiment 69, wherein a 5-FU bolus injection of between about ²⁰⁰ mg/m is administered.

72. The method of any one of embodiments 60 to 71, wherein a continuous infusion of between about 2200 mg/m ² and 3800 mg/m ² of 5-FU is administered between about 44 hours and 48 hours.

73. The method of embodiment 72, wherein the 5-FU is administered as a continuous infusion, between about 2400 mg/m ² and 3200 mg/m ² administered over a period of about 46 hours to 48 hours.

74. The method of embodiment 72, wherein the 5-FU is administered as a continuous infusion at about 2400 mg/m2 ^over a period of about 46 hours to 48 hours.

75. The method of any one of embodiments 60 to 74, wherein a dose of irinotecan between about 150 mg/m ² and 200 mg/m ² is administered to the human.

76. The method of embodiment 75, wherein a dose of irinotecan of about 165 ^mg /m2 is administered to the human.

77. The method of embodiment 75, wherein a dose of irinotecan of about 180 ^mg /m2 is administered to the human.

78. The method of any one of embodiments 60 to 77, wherein a dose of oxaliplatin between about 50 mg/m ² and 150 mg/m ² is administered to the human.

79. The method of embodiment 78, wherein a dose of about 85 mg/m ² of oxaliplatin is administered to the human.

80. The method of embodiment 78, wherein a dose of about 100 mg/m ² of oxaliplatin is administered to the human.

81. The method of embodiment 78, wherein a dose of about 130 mg/m ² of oxaliplatin is administered to the human.

82. The method of embodiments 60 to 81, wherein a dose of tetrahydrofolate between about 100 mg/m ² and 500 mg/m ² is administered to the human on day 1 .

83. The method of embodiment 82, wherein a dose of tetrahydrofolate of about 400 ^mg /m2 is administered to the human on day 1.

84. The method of embodiment 82, wherein the human is administered a dose of about 200 mg/m ² of tetrahydrofolate on day 1.

85. The method of embodiments 60-81, wherein the human is administered a dose of between about 50 mg/m ² and 250 mg/m ² of L-formyltetrahydrofolate on day 1.

86. The method of embodiment 85, wherein the human is administered a dose of about 200 mg/m ² of tetrahydrofolate on day 1.

87. The method of embodiment 85, wherein the human is administered a dose of about 100 mg/m ² of tetrahydrofolate on day 1.

88. The method of any one of embodiments 60-87, wherein up to 12 14-day cycles are administered to the human.

89. The method of any one of embodiments 60-88, wherein the human is further administered a maintenance therapy comprising administration of a CDK4/6 inhibitor, 5-FU after discontinuation of the method of embodiments 60-88 and aldehyde folic acid.

或其醫藥學上可接受之鹽，其中在基於FOLFOX之化學治療方案中投與CDK4/6抑制劑，且其中CDK4/6抑制劑係i)在基於FOLFOX之化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 90. A method of treating a human suffering from colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, wherein a CDK4/6 inhibitor is administered in a FOLFOX-based chemotherapy regimen, and wherein the CDK4/6 inhibitor is i) 4 hours prior to initiation of FOLFOX-based chemotherapy administration or The first administration was performed earlier and ii) the second administration was performed between 18 hours and 26 hours after the first CDK4/6 inhibitor administration.

或其醫藥學上可接受之鹽，且其中CDK4/6抑制劑係i)在基於FOLFOX之化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 91. A method of alleviating myelosuppression induced by chemotherapy in a human undergoing a FOLFOX-based chemotherapy regimen for the treatment of colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, and wherein the CDK4/6 inhibitor is i) the first administration is performed 4 hours or earlier before the initiation of FOLFOX-based chemotherapy administration and ii) the first CDK4/6 6 A second dose was administered between 18 hours and 26 hours after inhibitor administration.

92. The method of embodiments 90-91, wherein the FOLFOX-based chemotherapy regimen is FOLFOX4.

93. The method of embodiments 90-91, wherein the FOLFOX-based chemotherapy regimen is FOLFOX6.

94. The method of embodiments 90-91, wherein the FOLFOX-based chemotherapy regimen is modified FOLFOX6 (mFOLFOX6).

95. The method of embodiments 90-91, wherein the FOLFOX-based chemotherapy regimen is FOLFOX7.

96. The method of embodiments 90-91, wherein the FOLFOX-based chemotherapy regimen is modified FOLFOX7 (mFOLFOX7).

或其醫藥學上可接受之鹽， ii)       向人類投與有效量之5-FU，其中5-FU以連續輸注(CI)形式進行投與； iii)      向人類投與有效量之5-FU，其中5-FU以推注劑量形式進行投與； iv)      向人類投與有效量之醛葉酸；及 v)        向人類投與有效量之奧沙利鉑；及 vi)      視情況，向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在第一次待投與5-FU、醛葉酸或奧沙利鉑的投與之前約4小時或更早進行第一次投與，且其中CDK4/6抑制劑係在其第一次投藥之後約18小時至26小時之間進行第二次投與。 97. A method of treating colorectal cancer in a human comprising: i) administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, ii) administering an effective amount of 5-FU to a human, wherein the 5-FU is administered as a continuous infusion (CI); iii) administering an effective amount of 5-FU to a human , wherein 5-FU is administered in a bolus dose; iv) an effective amount of aldehyde folic acid is administered to a human; and v) an effective amount of oxaliplatin is administered to a human; and vi) optionally, an effective amount of oxaliplatin is administered to a human with an anti-VEGF or anti-EGFR monoclonal antibody or compound; wherein the CDK4/6 inhibitor is first administered about 4 hours or earlier before the first administration of 5-FU, aldofolic acid or oxaliplatin and wherein the CDK4/6 inhibitor is administered a second time between about 18 hours and 26 hours after its first administration.

或其醫藥學上可接受之鹽， ii)       在每個14天週期之第1天及第2天向人類投與有效量之5-FU，其中5-FU以連續輸注(CI)形式投與約20小時至24小時之間的時間； iii)      在每個14天週期之第1天投與有效量之5-FU，其中5-FU以推注劑量形式進行投與； iv)      在每個14天週期之第1天及第2天向人類投與有效量之醛葉酸；及 v)        在每個14天週期之第1天向人類投與有效量之奧沙利鉑；及 vi)      視情況，在每個14天週期之第1天向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在每個14天週期之第1天在起始投與5-FU、醛葉酸及奧沙利鉑之前4小時或更早進行投與，且 其中CDK4/6抑制劑係在每個週期之第2天且在起始投與5-FU及醛葉酸之前4小時或更早進行投與。 98. A method of treating colorectal cancer in a human, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) on Days 1 and 2 of each 14-day cycle. Humans are administered an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, ii) administering to the human an effective amount of 5-FU on Days 1 and 2 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) between about 20 hours and 24 hours; iii) administer an effective amount of 5-FU on Day 1 of each 14-day cycle, wherein the 5-FU is administered in a bolus dose; iv) on each administering an effective amount of aldehyde folic acid to humans on Days 1 and 2 of a 14-day cycle; and v) administering an effective amount of oxaliplatin to humans on Day 1 of each 14-day cycle; and vi) depending on In some cases, an anti-VEGF or anti-EGFR monoclonal antibody or compound is administered to humans on day 1 of each 14-day cycle; wherein the CDK4/6 inhibitor is administered initially on day 1 of each 14-day cycle 5 - FU, folate and oxaliplatin administered 4 hours or earlier, and wherein the CDK4/6 inhibitor is on day 2 of each cycle and 4 hours prior to initiation of administration of 5-FU and aldofolic acid hours or earlier.

或其醫藥學上可接受之鹽； ii)       在每個14天週期之第1天向人類投與有效量之5-FU，其中5-FU以推注靜脈注射形式進行投與； iii)      在每個14天週期之第1天開始向人類投與有效量之5-FU，其中5-FU以連續輸注(CI)形式投與約44小時至48小時之間的時間； iv)      在每個14天週期之第1天向人類投與有效量之醛葉酸；及 v)        在每個14天週期之第1天向人類投與有效量之奧沙利鉑；及 vi)      視情況，在每個14天週期之第1天向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在每個14天週期之第1天在第一次待投與5-FU、醛葉酸或奧沙利鉑的投與之前約4小時或更早進行投與，且其中CDK4/6抑制劑係在其於每個週期之第1天投藥之後約18小時至26小時之間的每個週期之第2天進行投與。 99. A method of treating colorectal cancer in a human, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) on Days 1 and 2 of each 14-day cycle. Humans are administered an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof; ii) administering an effective amount of 5-FU to the human on Day 1 of each 14-day cycle, wherein the 5-FU is administered as a bolus intravenous injection; iii) on An effective amount of 5-FU is administered to humans beginning on day 1 of each 14-day cycle, wherein 5-FU is administered as a continuous infusion (CI) for a period between about 44 hours and 48 hours; iv) at each administering an effective amount of aldehyde folic acid to humans on Day 1 of a 14-day cycle; and v) administering an effective amount of oxaliplatin to humans on Day 1 of each 14-day cycle; and vi) optionally, on each Anti-VEGF or anti-EGFR monoclonal antibodies or compounds are administered to humans on day 1 of each 14-day cycle; wherein the CDK4/6 inhibitor is administered with 5-FU on day 1 of each 14-day cycle , aldofolic acid or oxaliplatin is administered about 4 hours or earlier, and wherein the CDK4/6 inhibitor is administered between about 18 hours and 26 hours after its administration on Day 1 of each cycle Administer on the 2nd day of each cycle of .

100. The method of any one of embodiments 90 to 99, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier prior to administration of either bolus 5-FU or intravenous 5-FU .

101. The method of embodiments 90-95, 97, and 99-100, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 24 hours after its administration on day 1.

102. The method of embodiments 90-95, 97 and 99-100, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 22 hours after its administration on day 1.

103. The method of any one of embodiments 90-103, wherein the human is further administered an anti-VEGF or anti-EGFR antibody or compound.

104. The method of embodiment 103, wherein the human is administered an anti-VEGF antibody or compound selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept.

105. The method of embodiment 103, wherein an anti-EGFR antibody or compound selected from cetuximab or panitumumab is administered to the human.

106. The method of any one of embodiments 90 to 105, wherein the CDK4/6 inhibitor is administered in an amount between about 190 mg/m ² and 300 mg/m ² .

107. The method of embodiment 106, wherein the CDK4/6 inhibitor is administered at about 240 mg/m ² .

108. The method of any one of embodiments 96, 98, and 100 to 107, wherein the 5-FU is in the form of a continuous infusion between about 400 mg/m and 800 mg/m on days ¹ and ² within approximately 22 hours.

109. The method of embodiment 108, wherein the 5-FU is administered as a continuous infusion of about 600 mg/m2 over about 22 hours on days 1 and ² .

110. The method of any one of embodiments 90 to 95, 97 and 99 to 107, wherein 5-FU is in the form of a continuous infusion between about 2000 mg/m ² and 3200 mg/m ² on days 1 and 10. Administer within approximately 46 hours to 48 hours over 2 days.

111. The method of embodiment 110, wherein the 5-FU is administered as a continuous infusion between about 2400 mg/m and 3000 mg/m on days ¹ and ² within about 46 hours to 48 hours. and.

112. The method of embodiment 110, wherein the 5-FU is administered as a continuous infusion of about 2400 mg/m2 over about 46 hours to 48 hours on days 1 and ² .

113. The method of any one of embodiments 90-112, wherein a bolus dose of between about 200 mg/m ² and 600 mg/m ² of 5-FU is administered to the human on Day 1 .

114. The method of embodiment 113, wherein a bolus dose of 5-FU of about ²⁰⁰ mg/m2 is administered to the human.

115. The method of embodiment 113, wherein a bolus dose of between about 400 mg/m ² of 5-FU is administered to the human on Day 1.

116. The method of any one of embodiments 90 to 114, wherein a dose of between about 50 mg/m ² and 150 mg/m ² of oxaliplatin is administered to the human.

117. The method of embodiment 115, wherein the human is administered a dose of about 85 mg/m ² of oxaliplatin.

118. The method of embodiment 115, wherein a dose of about 100 mg/m ² of oxaliplatin is administered to the human.

119. The method of embodiment 115, wherein the human is administered a dose of about 130 mg/m ² of oxaliplatin.

120. The method of any one of embodiments 90 to 118, wherein the aldehyde folic acid is tetrahydrofolate.

121. The method of embodiments 96, 98, 100 to 109, 113 to 119, wherein on day 1 and day 2 the human is administered between about 100 mg/m ² and 500 mg/m ² of methyl tetramine Dosage of Hydrofolate.

122. The method of embodiment 121, wherein the human is administered a dose of about 200 mg/m ² of tetrahydrofolate on days 1 and 2.

123. The method of embodiments 90 to 95, 97, 99 to 107, 110 to 120, wherein on day ¹ the human is administered between about 100 mg/m and 500 ^mg /m of tetrahydrofolate dose.

124. The method of embodiment 123, wherein the human is administered a dose of about 400 mg/m ² of tetrahydrofolate on day 1.

125. The method of any one of embodiments 90 to 118, wherein the aldehyde folic acid is L-formyltetrahydrofolate.

126. The method of embodiment 96, 98, 100 to 109, 113 to 119, wherein on the 1st day and the 2nd day the human is administered between about 50 mg/m ² and 250 mg/m ² of levoformamide Dosage of tetrahydrofolate.

127. The method of embodiment 126, wherein the human is administered a dose of about 100 mg/m ² of L-formyltetrahydrofolate on Days 1 and 2.

128. The method of embodiments 90 to 95, 97, 99 to 107, 110 to 120, wherein on day 1 the human is administered between about 50 mg/m ² and 250 mg/m ² of L-formyltetrahydro Dosage of folic acid.

129. The method of embodiment 128, wherein the human is administered a dose of about ²⁰⁰ mg/m2 of L-formyltetrahydrofolate on day 1.

130. The method of any one of embodiments 90-129, wherein up to 12 14-day cycles are administered to the human.

131. The method of any one of embodiments 90-130, wherein the human is further administered a maintenance therapy comprising administering a CDK4/6 inhibitor, 5-FU after discontinuation of the method of embodiments 90-130 and aldehyde folic acid.

或其醫藥學上可接受之鹽，其中在基於FOLFIRI之化學治療方案中投與CDK4/6抑制劑，且其中CDK4/6抑制劑係i)在基於FOLFIRI之化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 132. A method of treating a human suffering from colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, wherein the CDK4/6 inhibitor is administered in a FOLFIRI-based chemotherapy regimen, and wherein the CDK4/6 inhibitor is i) 4 hours prior to the initiation of FOLFIRI-based chemotherapy administration or The first administration was performed earlier and ii) the second administration was performed between 18 hours and 26 hours after the first CDK4/6 inhibitor administration.

或其醫藥學上可接受之鹽，且其中CDK4/6抑制劑係i)在基於FOLFIRI之化學治療投藥起始之前4小時或更早進行第一次投與且ii)在第一次CDK4/6抑制劑投藥之後18小時至26小時之間進行第二次投與。 133. A method of alleviating myelosuppression induced by chemotherapy in a human undergoing a FOLFIRI-based chemotherapy regimen for the treatment of colorectal cancer, comprising administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, and wherein the CDK4/6 inhibitor is i) the first administration is performed 4 hours or earlier before the initiation of FOLFIRI-based chemotherapy administration and ii) the first CDK4/6 6 A second dose was administered between 18 hours and 26 hours after inhibitor administration.

134. The method of embodiments 90-91, wherein the FOLFIRI-based chemotherapy regimen is FOLFIRI.

135. The method of embodiments 90-91, wherein the FOLFOX-based chemotherapy regimen is modified FOLFIRI (mFOLFIRI).

或其醫藥學上可接受之鹽， ii)       向人類投與有效量之5-FU，其中5-FU以連續輸注(CI)形式進行投與； iii)      向人類投與有效量之醛葉酸；及 iv)      向人類投與有效量之伊立替康；且 v)        視情況，向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在第一次待投與5-FU、醛葉酸或伊立替康的投與之前約4小時或更早進行第一次投與，且其中CDK4/6抑制劑係在其第一次投藥之後約18小時至26小時之間進行第二次投與。 136. A method of treating colorectal cancer in a human, comprising: i) administering to the human an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof, ii) administering to the human an effective amount of 5-FU, wherein the 5-FU is administered as a continuous infusion (CI); iii) administering to the human an effective amount of aldehyde folic acid; and iv) administering an effective amount of irinotecan to the human; and v) as appropriate, administering an anti-VEGF or anti-EGFR monoclonal antibody or compound to the human; wherein the CDK4/6 inhibitor is administered 5 - the first administration of FU, alfolate or irinotecan is performed about 4 hours or earlier, and wherein the CDK4/6 inhibitor is administered between about 18 hours and 26 hours after its first administration Second throw.

137. The method of embodiment 136, wherein the human is further administered 5-FU in a bolus dose.

或其醫藥學上可接受之鹽； ii)       在每個14天週期之第1天開始向人類投與有效量之5-FU，其中5-FU以連續輸注(CI)形式投與約44小時至48小時之間的時間； iii)      在每個14天週期之第1天向人類投與有效量之醛葉酸；及 iv)      在每個14天週期之第1天向人類投與有效量之伊立替康；且 v)        視情況，在每個14天週期之第1天向人類投與抗VEGF或抗EGFR單株抗體或化合物； 其中CDK4/6抑制劑係在每個14天週期之第1天在起始投與5-FU、醛葉酸及伊立替康之前約4小時或更早進行投與，且其中CDK4/6抑制劑係在其於第1天投藥之後約18至26小時的第2天進行投與。 137. A method of treating colorectal cancer in a human, wherein the treatment comprises one or more 14-day cycles, the one or more 14-day cycles comprising: i) on day 1 and day 2 of each 14-day cycle Humans are administered an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof; ii) administering to the human an effective amount of 5-FU starting on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion (CI) for approximately 44 hours time between to 48 hours; iii) administer an effective amount of folate to humans on day 1 of each 14-day cycle; and iv) administer an effective amount of folate to humans on day 1 of each 14-day cycle irinotecan; and v) as appropriate, administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the human on Day 1 of each 14-day cycle; wherein the CDK4/6 inhibitor is administered on Day 1 of each 14-day cycle Day 1 was administered about 4 hours or earlier before the initial administration of 5-FU, aldofolic acid, and irinotecan, and wherein the CDK4/6 inhibitor was administered approximately 18 to 26 hours after its administration on day 1. Dosing on day 2.

139. The method of embodiment 138, further comprising administering to the human on Day 1 of each 14-day cycle an effective amount of 5-FU, wherein the 5-FU is administered as a bolus injection.

140. The method of any one of embodiments 132 to 139, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier prior to administration of either bolus 5-FU or intravenous 5-FU .

141. The method of embodiments 132-140, wherein the CDK4/6 inhibitor is administered a second time between about 20 hours and 24 hours after its first administration.

142. The method of embodiments 132-140, wherein the CDK4/6 inhibitor is administered a second time between about 20 hours and 24 hours after its first administration.

143. The method of any one of embodiments 132-142, wherein an anti-VEGF or anti-EGFR antibody or compound is further administered to the human.

144. The method of embodiment 143, wherein the human is administered an anti-VEGF antibody or compound selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept.

145. The method of embodiment 143, wherein an anti-EGFR antibody or compound selected from cetuximab or panitumumab is administered to the human.

146. The method of any one of embodiments 132 to 145, wherein the CDK4/6 inhibitor is administered in an amount between about 190 mg/m ² and 300 mg/m ² .

147. The method of embodiment 146, wherein the CDK4/ ⁶ inhibitor is administered at about 240 mg/m2.

148. The method of any one of embodiments 132 to 147, wherein the 5-FU is administered as a continuous infusion of between about 2200 ^mg /m and 3800 ^mg /m for a time between about 44 hours and 48 hours .

149. The method of embodiment 148, wherein the 5-FU is administered as a continuous infusion of about 2400 mg/m ² and 3000 mg/m ² for about 46 to 48 hours.

150. The method of embodiment 148, wherein the 5-FU is administered as a continuous infusion of about 2400 ^mg /m2 for about 46 to 48 hours.

151. The method of any one of embodiments 134, 137, and 139-150, wherein a bolus dose of ⁵ -FU between about ²⁰⁰ mg/m and 600 mg/m is administered to the human on day 1 .

152. The method of embodiment 151, wherein a bolus dose of between about 400 mg/m ² of 5-FU is administered to the human on day 1.

153. The method of any one of embodiments 132 to 152, wherein a dose of irinotecan between about 150 mg/m ² and 200 mg/m ² is administered to the human.

154. The method of embodiment 153, wherein the human is administered a dose of about 165 mg/m ² of irinotecan.

155. The method of embodiment 153, wherein a dose of irinotecan of about 180 ^mg /m2 is administered to the human.

156. The method of any one of embodiments 132 to 155, wherein the aldehyde folic acid is tetrahydrofolate.

157. The method of embodiment 156, wherein a dose of tetrahydrofolate between about 100 mg/m ² and 500 mg/m ² is administered to the human.

158. The method of embodiment 157, wherein a dose of tetrahydrofolate of about 400 mg/m ² is administered to the human.

159. The method of any one of embodiments 132 to 155, wherein the aldehyde folic acid is L-formyltetrahydrofolate.

160. The method of embodiment 159, wherein the human is administered a dose of L-formyltetrahydrofolate between about 50 mg/m ² and 250 mg/m ² .

161. The method of embodiment 160, wherein the human is administered a dose of L-formyltetrahydrofolate of about 200 mg/m ² .

162. The method of any one of embodiments 132-161, wherein up to 12 14-day cycles are administered to the human.

163. The method of any one of embodiments 132-162, wherein the human is further administered maintenance therapy with a CDK4/6 inhibitor, 5-FU, and aldofolic acid after discontinuation of the method as in embodiments 132-162.

或其醫藥學上可接受之鹽； ii)    在每個56天週期之第1天、第8天、第15天、第22天、第29天及第36天向人類投與有效量之5-FU，其中5-FU以推注注射方式進行投與； iii)   在每個56天週期之第1天、第8天、第15天、第22天、第29天及第36天向人類投與有效量之醛葉酸； iv)    在每個56天週期之第1天、第15天及第29天向人類投與有效量之奧沙利鉑；且 v)     視情況，在每個56天週期之第1天、第15天及第29天向人類投與抗VEGF或抗EGFR單株抗體； 其中CDK4/6抑制劑係在起始投與5-FU、醛葉酸或奧沙利鉑之前約4小時或更早進行投與。 164. A method of treating a human suffering from colorectal cancer, wherein the treatment comprises one or more 56-day cycles, the one or more 56-day cycles comprising: i) on days 1, 8 of each 56-day cycle Day, Day 15, Day 22, Day 29, and Day 36 The human is administered an effective amount of a CDK4/6 inhibitor having the following structure:

or a pharmaceutically acceptable salt thereof; ii) administering to humans an effective amount of 5 -FU, wherein 5-FU is administered as a bolus injection; iii) to humans on Day 1, Day 8, Day 15, Day 22, Day 29, and Day 36 of each 56-day cycle administering an effective amount of folate; iv) administering an effective amount of oxaliplatin to the human on Days 1, 15, and 29 of each 56-day cycle; and v) optionally, on each 56 Anti-VEGF or anti-EGFR monoclonal antibodies are administered to humans on days 1, 15, and 29 of the day cycle; wherein the CDK4/6 inhibitor is administered at initial administration of 5-FU, aldofolic acid, or oxaliplatin Administer approximately 4 hours before or earlier.

165. The method of embodiment 166, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before the administration of 5-FU.

166. The method of any one of embodiments 164-165, wherein an anti-VEGF or anti-EGFR antibody or compound is further administered to the human.

167. The method of embodiment 166, wherein the human is administered an anti-VEGF antibody or compound selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept.

168. The method of embodiment 166, wherein an anti-EGFR antibody or compound selected from cetuximab or panitumumab is administered to the human.

169. The method of any one of embodiments 164 to 168, wherein the CDK4/6 inhibitor is administered in an amount between about 190 mg/m ² and 300 mg/m ² .

170. The method of embodiment 169, wherein the CDK4/6 inhibitor is administered at about 240 mg/m ² .

171. The method of any one of embodiments 164 to 170, wherein 5-FU is administered in a bolus dose form of between about 400 mg/m ² and 600 mg/m ² .

172. The method of embodiment 171, wherein 5-FU is administered in a bolus dose of about 500 ^mg /m2.

173. The method of any one of embodiments 164 to 172, wherein a dose of between about 50 mg/m ² and 150 mg/m ² of oxaliplatin is administered to the human.

174. The method of embodiment 173, wherein the human is administered a dose of about 85 mg/m ² of oxaliplatin.

175. The method of embodiment 173, wherein a dose of about 100 mg/m ² of oxaliplatin is administered to the human.

176. The method of embodiment 173, wherein the human is administered a dose of about 130 mg/m ² of oxaliplatin.

177. The method of any one of embodiments 164 to 176, wherein the aldehyde folic acid is tetrahydrofolate.

178. The method of embodiment 177, wherein a dose of tetrahydrofolate between about 100 mg/m ² and 600 mg/m ² is administered to the human.

179. The method of embodiment 178, wherein the human is administered a dose of tetrahydrofolate of about 500 mg/m ² .

180. The method of any one of embodiments 164 to 176, wherein the aldehyde folic acid is L-formyltetrahydrofolate.

181. The method of embodiment 180, wherein a dose of between about 50 mg/m ² and 300 mg/m ² of levothyroxine is administered to the human.

182. The method of embodiment 181, wherein the human is administered a dose of tetrahydrofolate of about 250 mg/m ² .

183. The method of any one of embodiments 164-182, wherein up to three 56-day cycles are administered to the human.

184. The method of any one of embodiments 164-183, wherein maintenance therapy of a CDK4/6 inhibitor, 5-FU, and aldofolic acid is further administered to the human after discontinuation of the method of embodiments 164-183.

185. The method of any one of embodiments 1 to 184, wherein the treatment results in a reduction and/or prevention of one or more toxicities selected from the group consisting of chemotherapy-induced myelosuppression (CIM), chemotherapy-induced Diarrhea (CID), stomatitis and mucositis.

186. The method of any one of embodiments 1 to 185, wherein the treatment results in an improvement in PFS compared to predicted progression-free survival (PFS) based on administration of a chemotherapy regimen without a CDK4/6 inhibitor.

187. The method of any one of embodiments 1 to 186, wherein the treatment results in improved OS compared to predicted overall survival (OS) based on administration of a chemotherapy regimen without a CDK4/6 inhibitor.

188. The method of any one of embodiments 1-187, wherein the treatment results in bone marrow preservation of hematopoietic stem and precursor cells (HSPCs).

189. The method of any one of embodiments 1 to 188, wherein the treatment results in protection against immune effector cells.

190. The method of any one of embodiments 1-189, wherein the treatment results in enhanced anti-tumor efficacy in humans compared to those receiving a chemotherapy regimen without a CDK4/6 inhibitor.

191. The method of any one of embodiments 1 to 190, wherein the treatment results in bone marrow preservation of human neutrophils compared to those of the human neutrophil lineage receiving a chemotherapy regimen without a CDK4/6 inhibitor White blood cell lineage.

192. The method of any one of embodiments 1 to 191, wherein compared to the duration of severe (grade 4) neutropenia in those humans receiving a chemotherapy regimen without a CDK4/6 inhibitor, The treatment resulted in a reduction in the duration of severe (grade 4) neutropenia in humans.

193. The method of any one of embodiments 1 to 192, wherein the treatment results in a reduction in human chemotherapy-induced fatigue (CIF) compared to those humans receiving a chemotherapy regimen without a CDK4/6 inhibitor Fatigue induced by chemotherapy.

194. The method of any one of embodiments 1 to 193, wherein the therapeutic outcome of alleviating CIF is a reduction in time to first confirmed fatigue deterioration (TTCD fatigue).

195. The method of any one of embodiments 1-194, wherein the treatment outcome of improving PFS is based on Response Evaluation Criteria in Solid Tumors 1.1 (RECIST 1.1).

196. The method of any one of embodiments 1 to 195, wherein the treatment results in a reduction in severe neutropenic events, reduction in granulocyte population stimulating factor (G-CSF) treatment, or reduction in febrile neutropenia Symptomatic (FN) adverse events (AE).

197. The method of any one of embodiments 1 to 196, wherein the treatment results in a reduction in a grade 3 or 4 reduced erythrocyte laboratory value, red blood cell (RBC) transfusion, or erythropoiesis stimulating agent (ESA) administration.

198. The method of any one of embodiments 1 to 197, wherein the treatment results in a reduction in a grade 3 or 4 decreased platelet count laboratory value and/or platelet transfusion number.

199. The method of any one of embodiments 1-198, wherein the treatment results in a reduction in a grade 3 or 4 hematology laboratory value.

200. The method of any one of embodiments 1 to 199, wherein the treatment results in a reduction in i) attributable to all causes, febrile neutropenia/neutropenia, anemia/RBC transfusion, thrombocytopenia Symptoms/bleeding, or infection and hospitalization or ii) antibiotic use.

201. The method of any one of embodiments 1 to 200, wherein the treatment results in an improvement in one or more of the following: Functional Assessment of Cancer Therapy General Scale (FACT-G) category scores (physical, social/family, emotional and functional health); Functional Assessment of Cancer Therapy in Anemia (FACT-An): Anemia Subscale; Functional Assessment of Cancer Therapy in Colorectal Cancer (FACT-C): Colorectal Cancer Subscale; Level 5 EQ-5D (EQ- 5D-5L); Patient Global Impression of Change (PGIC) fatigue items; or Patient Global Impression of Severity (PGIS) fatigue items.

202. The method of any one of embodiments 1-201, wherein the colorectal cancer treated is metastatic colorectal cancer (mCRC).

203. The method of any one of embodiments 1-202, wherein the colorectal cancer is mismatch repair intact (pMMR) mCRC.

204. The method of any one of embodiments 1 to 203, wherein the colorectal cancer is microsatellite stable (MSS) mCRC.

205. The method of any one of embodiments 1-204, wherein the colorectal cancer is mismatch repair intact (pMMR)/microsatellite stable (MSS) mCRC (pMMR/MSS mCRC).

206. The method of any one of embodiments 1-205, wherein the colorectal cancer does not respond to prior treatment with a single-agent checkpoint inhibitor.

207. The method of any one of embodiments 1 to 206, wherein the colorectal cancer has a BRAF or KRAS mutation.

208. The method of any one of embodiments 1-207, wherein the colorectal cancer has a BRAF V600E substitution mutation.

209. The method of any one of embodiments 1 to 208, wherein the colorectal cancer is CDK4/6 replication dependent.

210. The method of any one of embodiments 1-208, wherein the colorectal cancer is CDK4/6 replication-independent.

211. The method of any one of embodiments 1 to 208, wherein the colorectal cancer is CDK4/6 replication indeterminate.

212. The method of any one of embodiments 1 to 211, wherein colorectal cancer is interferon-gamma (IFN-gamma) dominant according to Thorsson's six-type immune signature.

213. The method of any one of embodiments 1-212, wherein the colorectal cancer has a high IFN-γ signature or amplified immune signature according to Ayer's IFN-γ signature score or amplified immune signature score.

214. The method of any one of embodiments 1 to 213, wherein the colorectal cancer is PD-L1 positive.

215. The method of any one of embodiments 1 to 214, wherein the colorectal cancer has a KRAS mutation selected from the group consisting of: V9, G12, G13, V14, L19, Q22, D33, A59, G60, Q61 R68, K117, A146, R164, K176 or K180 substitution.

216. The method of any one of embodiments 1-214, wherein the colorectal cancer has a KRAS mutation selected from the group consisting of G12D, G12V, G12C, G12A, or other G12 variants.

217. The method of any one of embodiments 1-214, wherein the colorectal cancer has an NRAS mutation selected from the group consisting of G12, G13, G60, Q61, E123, or P185.

218. The method of any one of embodiments 1-194, wherein the colorectal cancer has an HRAS mutation selected from G12, G13, Q61, K117, R164, or P167.

219. The method of any one of embodiments 1-214, wherein the colorectal cancer is KRAS wild-type.

220. The method of any one of embodiments 1 to 214, wherein the colorectal cancer is BRAF wild-type.

221. The method of any one of embodiments 1-220, wherein the human has not received prior chemotherapy for the treatment of colorectal cancer.

222. The method of any one of embodiments 1 to 221, wherein prior chemotherapy in the human for the treatment of colorectal cancer has failed.

223. The method of any one of embodiments 1 to 222, wherein the human maintains an absolute neutrophil count (ANC) greater than 1.0 x ¹⁰⁹ /L when measured prior to beginning each chemotherapy treatment cycle.

224. The method of any one of embodiments 1 to 223, wherein the human maintains a platelet count of greater than 75 x ¹⁰⁹ /L when measured prior to beginning each chemotherapy treatment cycle.

225. The method of any one of embodiments 1 to 224, wherein the human has mismatch repair intact (pMMR)/microsatellite stable (MSS) metastatic colorectal cancer (pMMR/MSS mCRC) and has not received treatment for metastatic disease. Systemic treatment.

226. The method of any one of embodiments 1-225, wherein the chemotherapy regimen does not include administration of an immune checkpoint inhibitor.

227. In an alternative embodiment of the method as in any one of embodiments 1 to 225, the cancer treated is not colorectal cancer, but advanced or metastatic pancreatic cancer.

228. In an alternative embodiment of the method as in any one of embodiments 1 to 225, the cancer treated is not colorectal cancer, but advanced or metastatic gastric cancer.

229. In an alternative embodiment of the method as in any one of embodiments 1 to 225, the cancer treated is not colorectal cancer, but advanced or metastatic gastroesophageal junction adenocarcinoma.

230. In an alternative embodiment of the method as in any one of embodiments 1 to 225, the cancer treated is not colorectal cancer, but advanced or metastatic biliary tract cancer.

231. The method of embodiment 230, wherein the advanced or metastatic biliary tract cancer is intrahepatic cholangiocarcinoma.

232. The method of embodiment 230, wherein the advanced or metastatic cholangiocarcinoma is hilar cholangiocarcinoma.

233. The method of embodiment 230, wherein the advanced or metastatic biliary tract cancer is distal cholangiocarcinoma.

234. In an alternative embodiment of the method as in any one of embodiments 1 to 225, the cancer treated is not colorectal cancer, but advanced or metastatic neuroendocrine cancer.

235. In an alternative embodiment of the method as in any one of embodiments 1 to 225, the cancer treated is not colorectal cancer, but advanced or metastatic peritoneal carcinomatosis.

236. In an alternative embodiment of the method as in any one of embodiments 1 to 225, the cancer treated is not colorectal cancer, but advanced or metastatic liver cancer.

237. In an alternative embodiment of the method of any one of embodiments 1 to 236, the use of 5-FU in the described embodiment is substituted with an alternative fluoropyrimidine, wherein the alternative fluoropyrimidine is selected from capecitab pyridoxine, fenfluridine, carmofur (HCFU), or deoxyfluridine.

238. The method of any one of embodiments 1-237, wherein the treatment results in alleviation and/or prevention of chemotherapy-induced myelosuppression (CIM).

239. The method of any one of embodiments 1-238, wherein the treatment results in alleviation and/or prevention of chemotherapy-induced diarrhea (CID).

240. The method of any one of embodiments 1-239, wherein the treatment results in alleviation and/or prevention of stomatitis.

241. The method of any one of embodiments 1-239, wherein the treatment results in alleviation and/or prevention of mucositis.

EXAMPLES : Example 1 - Phase 3 Randomized Double-Blind Trial of Tralasiclib Versus Placebo in Patients Receiving FOLFOXIRI/ Bevacizumab for Metastatic Colorectal Cancer Randomized, Double-Blind, Placebo-Controlled, Global, Multiple A central, phase 3 trial is ongoing evaluating the effect of tralacidamide on bone marrow when administered prior to FOLFOXIRI/bevacizumab in patients with pMMR/MSS mCRC who have not received systemic therapy for metastatic disease. effects on preservation and antitumor efficacy. A general schematic depicting the clinical trial is provided in FIG. 8 .

Approximately 296 patients with metastatic colorectal cancer (mCRC) will be randomized (1:1) to receive IV prior to FOLFOXIRI/bevacizumab on Days 1 and 2 of a 14-day cycle (IV) Administer placebo or trelacitinib for up to 12 cycles (induction period). There were three stratification factors for randomization: country of treatment, prior therapy in the adjuvant/neoadjuvant setting, and presence of the BRAF V600E mutation. In each country, patients will be randomized by history of systemic cytotoxic therapy in the adjuvant/neoadjuvant setting (yes/no) and BRAF V600E mutation status (yes/no).

Induction During the induction period, all patients will receive either Tralacinib 240 mg/m2 or placebo IV on Days 1 and ² of each 14-day induction cycle (up to a total of 12 cycles). On Day 1, Trelacinib/placebo will be administered no more than 4 hours prior to the start of chemotherapy administration; a second dose of Trelacinib/placebo should be administered on Day 2. FOLFOXIRI/bevacizumab should not be administered until after completion of Day 1 infusion of Tralacinib or placebo. Patients should meet the requirements to continue prior to initiation of Cycle 2 and each subsequent induction cycle. Since individual drugs can be discontinued due to toxicity, induction refers to any treatment cycle in which 5-FU and oxaliplatin or irinotecan will also be administered, such as 5-FU + oxaliplatin + bevacizumab; 5-FU+irinotecan+bevacizumab; 5-FU+oxaliplatin; or 5-FU+irinotecan. Although there is no requirement for a minimum number of chemotherapy cycles during induction, patients should continue induction therapy (in the absence of disease progression) as long as tolerated.

Study drugs were administered during induction as follows: - Tralacidib (240 mg/m ² ) or placebo: 250 mL of 5% dextrose in water during each 14-day cycle of induction and maintenance ^A dose of 240 mg/m 240 mg/m 240 mg/m of Tralacidazole diluted in solution or 0.9% sodium chloride solution will be administered by IV infusion no more than 4 hours before each Day 1 FOLFOXIRI/bevacizumab administration ±10) minutes. A second dose of Trelacinib should be administered on day 2. - FOLFOXIRI/Bevacizumab - In each 14 day cycle of induction, the following agents will be administered according to standard label instructions: o Irinotecan 165 mg/m ² - IV, Day 1. ○ Oxaliplatin 85 mg/m ² - IV on Day 1. ○ Aldehyde folic acid (formyltetrahydrofolate 400 mg/m ² or L-formyl tetrahydrofolate 200 mg/m ² ) - IV, day 1. ○ 5-FU (fluorouracil) 2400 to 3200 mg/m ² - continuous infusion (CI) over 48 hours starting on Day 1; this dose range is provided to reflect geographic differences in prescribed fluorouracil (5-FU) dose; however, In addition to the need for dose modification for toxicity management, each patient should continue to receive the same dose throughout the study. ○ Bevacizumab 5 mg/kg - IV, Day 1.

Since the infused 5FU component of FOLFOXIRI/bevacizumab was administered over a 48 hour period, Tralacinib was planned to be administered on days 1 and 2 of each 14-day cycle. A day 2 infusion of tralasiclib will be administered to ensure that synchronization and release of HSPC G1 arrest does not occur (approximately 24 hours to 32 hours after a single dose of tralasiclib), and that the concentration of 5FU is sufficient to correlate 5FU The myelosuppression is exacerbated rather than alleviated.

Maintenance patients who have completed induction without radiographic or clinical disease progression and who are still eligible to receive 5-FU/aldofolate (methyltetrahydrofolate or levothyroxine)/bevacizumab will continue Maintenance treatment. These patients included those who were able to complete up to 12 induction cycles and those who were unable to complete 12 cycles due to toxicity (no documented disease progression) when the treating physician believed that the patient would receive additional clinical benefit by switching to maintenance therapy. During each 14-day cycle during the maintenance period, patients will receive Trila at the same dose and schedule prior to the infusion of 5-FU/aldehyde folic acid (Methyltetrahydrofolate or L-Methyltetrahydrofolate)/bevacizumab Cyni or placebo (assigned by the same randomization at the start of the study). An infusion of 5-FU/Folic acid (methyltetrahydrofolate or levothyroxine)/bevacizumab should not be administered on Day 1 until after completion of the administration of Tralacinib or the placebo infusion. Patients should meet the requirements prior to initiating each maintenance cycle. Since individual drugs can be discontinued due to toxicity, maintenance refers to those in which only 5FU/aldehyde folate (formyltetrahydrofolate or L-formyltetrahydrofolate) or 5FU/formalfolate (formyltetrahydrofolate or levothyroxine is administered) tetrahydrofolate) + bevacizumab for any treatment cycle. Treatment cycles will occur continuously without interruption, except for the need to manage toxicity or for management reasons. Following discontinuation of study treatment, patient survival will be followed, i.e., patients or their caregivers will be contacted approximately every 2 months until the end of the trial (or death) to document the patient's status (survival or death). ) and details of any subsequent systemic anticancer therapy initiated.

Criteria for Initiating Cycle 2 and Each Subsequent Cycle of Induction or Maintenance After completion of Cycle 1, patients must meet all of the following criteria to receive the Day 1 dose of study treatment during Cycle 2 and each subsequent cycle of induction or maintenance : • ANC ≥ 1.0 × 10 ⁹ /L, • Platelet count ≥ 75 × 10 ⁹ /L, and • Non-hematological drug-related toxicity must be ≤ Grade 1 or have returned to baseline.

Evaluation Criteria : Efficacy : Bone marrow preservation efficacy will be assessed based on reported hematological assessments, details of serious adverse events (AEs), and supportive care interventions including blood transfusions. Fatigue will be assessed by the Chronic Illness Treatment Functional Assessment-Fatigue Scale (FACIT-F). Tumor response criteria including PFS, OS, Duration of Objective Response (DOR) and Best Overall Response (BOR) will be based on RECIST v1.1.

Safety : Safety will be determined by monitoring AEs, clinical laboratory test results (hematology, clinical chemistry, coagulation [international normalized ratio, activated partial thromboplastin time] and urine analysis), vital sign measurements (blood pressure, heartbeat rate [HR] and oral temperature), 12-lead safety electrocardiogram (ECG) results, dose modifications, and physical examination results.

Methods of Statistical Analysis for Primary Endpoint and Key Secondary Endpoints General Test Strategies Treatment for Primary Myelosuppression Endpoint (DSN in Cycle 1 and appearance of SN during Induction) and Key Secondary PRO Endpoint (TTCD-Fatigue) The effect will be tested at the 2-sided α1=0.04 level, while the treatment effect on PFS and OS will be tested at the 2-sided α2=0.01 level. A fixed sequence procedure will be used to assess treatment effect on the two primary endpoints, and then on the key PRO secondary endpoint, assuming a stratified testing strategy from PFS to OS. If analysis of the occurrence of DSN and SN in cycle 1 has shown statistically significant results at the 2-sided 0.04 level, then a TTCD fatigue analysis will be performed. If statistical significance can be established at the 2-sided 0.04 level of TTCD fatigue, the assigned α_1 = 0.04 will be cycled to test PFS and OS after the fallback procedure (Wiens, 2003). At that moment, testing PFS and OS will be performed at the level of 0.05 on the 2 side (ie, at the level of α_1+α_2).

Analysis for Primary Efficacy Endpoint and Key Secondary Efficacy Endpoints The primary myelosuppression endpoints were DSN in Cycle 1 and the appearance of SN during induction. Severe neutropenia (SN) is defined as an absolute neutrophil count (ANC) laboratory value that satisfies ≥ grade 4 toxicity (ie, ANC < 0.5 x 10 ⁹ /L, at SI Common Terminology Criteria for Adverse Events (CTCAE). For patients with at least one SN event in Cycle 1, the duration of SN (DSN) was defined as the day from the day when the first ANC value was < 0.5 x 10 ⁹ /L to the first ANC value ≥ 0.5 x 10 ⁹ /L The number of days on which no additional ANC values < 0.5 x 10 ⁹ /L were observed for the remainder of that period. All observations from scheduled or unscheduled visits within Cycle 1 will be included in the derivation. For those patients who did not have any SN in cycle 1, the DSN would be set to 0. Treatment group differences in DSN in cycle 1 will be assessed using nonparametric analysis of covariance (ANCOVA) (Quade, 1967). In this analysis, rank-transformed (within each stratum) DSN values were analyzed by the ANCOVA model according to treatment, region (US, Eastern or Western Europe), and history of systemic cytotoxic therapy in the adjuvant/neoadjuvant setting (yes or no). The rank transformed baseline ANC (within each stratum) will be included in the model as a covariate. Additionally, the mean difference (tralacinib-placebo), standard error, and 96% confidence interval resulting from the Satterthwaite t-test will be presented.

Occurrence of SN during induction was defined as having SN in at least one cycle of induction and was thus a binary variable (yes or not). This co-primary endpoint will be analyzed using a modified Poisson regression model with the same parameters used in the nonparametric ANCOVA model for DSN in cycle 1 with baseline ANC values as covariates item. The log-transformed number of cycles will be used as an offset in the model. In addition to the 2-sided p-value, the adjusted relative risk (aRR) (tralasiclib vs placebo) and its 96% confidence interval will be calculated and reported.

Analysis of the key secondary PRO efficacy endpoint of TTCD fatigue as measured by FACIT-F was performed once treatment effects were established for the two primary endpoints at a 2-sided significance level of 0.04. The time (months) to the first fatigue deterioration (confirmed at two consecutive visits) was calculated as the duration from the date of randomization to the date of the first confirmed deterioration. Patients who did not experience confirmed regression will be censored on the date of the last instrument completion (ie, the date of the last non-missing value). Patients without a baseline assessment will be reviewed on the day of the baseline assessment. For the time to first fatigue worsening, the Kaplan Meier method will be used to estimate the median, 25% and 75% percent duration of TTCD fatigue and their corresponding 96% confidence intervals. Treatment group differences in TTCD fatigue will be assessed using a stratified log-rank test with the same terms used in the nonparametric ANCOVA model of DSN in Cycle 1. Hazard ratios (HR) between the 2 treatment groups (tralasiclib versus placebo) and their 96% confidence intervals will be calculated from Cox proportional hazards models using the same terms as included in the stratified log-rank test.

Analysis of PFS and OS will assess the effect of treatment on PFS and OS using a stratified log-rank test that controls for three factors: region, history of systemic cytotoxic therapy in the adjuvant/neo-adjuvant setting, and Presence of BRAF V600E mutation (yes or no). In addition, a Cox proportional hazards model with the same covariate terms as in the stratified log-rank test will be used to estimate the 2 treatment groups (tralasiclib HR relative to placebo).

Analysis of Safety Endpoints AEs were defined as events that occurred or worsened after initiation of treatment in this study. AE data will be coded into system organ classes and priorities using the Medical Dictionary of Regulatory Activities (MedDRA). The total number and percentage of patients who will experience any AE will be tabulated by system organ class and priority for each treatment group. Adverse events considered by the investigator to be treatment-related will also be addressed for each treatment group according to the treatment attributable to it (e.g., tralacidib/placebo, fluorouracil, tetrahydrofolate, irinotecan, oxaliplatin, valizumab) for a summary. The severity of AEs will be tabulated based on the highest severity observed for each patient. In the table of rank and causality, if the same AE occurs on multiple occasions, the highest rank and strongest relationship to study drug will be used in the overview. Adverse events of special interest (AESI), AEs leading to discontinuation of study drug, and use of concomitant drug therapy to treat AEs for trelacitinib will be tabulated separately. Concomitant drug therapy and previous and subsequent anticancer therapies will be coded as Anatomical Therapeutic Classifications (ATCs) using the World Health Organization Drug Dictionary (WHO-DD).

Observations and changes from baseline to each visit (including maximum and minimum values) for vital signs, ECG intervals, and laboratory assessments of hematology, clinical chemistry, urine analysis, and liver function parameters will be tabulated as needed. Where possible, toxicity ratings for clinical laboratory parameters (self, hematology, chemistry) will be characterized according to the National Cancer Institute (NCI) CTCAE v5.0. The shift in toxicity grade from baseline to each visit and from baseline to worst grade during the study period will be summarized. Both scheduled and unscheduled data will be included in the safety assessment. Graphical representations of security data will be presented as deemed appropriate.

The pharmacokinetics of trelacitinib will be determined using a nonlinear mixed effects modeling approach. Population pharmacokinetic parameters, including clearance (CL), volume of distribution (V), and other parameters, will be estimated as data permit.

Definition of Tumor Response and Disease Progression ( according to RECIST v1.1) The adjudication of tumor response and progression will be based on RECIST v1.1 criteria. Neoplastic lesions will be classified as follows:

Measurable Lesions : Tumor lesions with the longest diameter (measured in at least 1 dimension), of which the smallest dimensions are as follows: - 10 mm according to CT or MRI (scan slice thickness not exceeding 5 mm) - Measurable lymph nodes Must be ≥15 mm in short axis according to CT or MRI (scan slice thickness not exceeding 5 mm); only short axis was measured at baseline and follow-up. - Osteolytic lesions or mixed osteolytic-osteogenic lesions with soft tissue components meeting the above definition of measurability may be considered measurable lesions. - Cystic lesions representing cystic metastases meeting the definition of measurability described above may be considered measurable lesions. If present, non-cystic lesions should be selected as target lesions for this study. - A tumor lesion that has been previously irradiated can be considered measurable if it has demonstrated definite growth.

Target Lesions : At baseline, up to 5 measurable tumor lesions/lymph nodes (up to 2 lesions per organ) should be identified as target lesions. The lesion with the longest diameter representing all involved organs and for which reproducible repeat measurements can be obtained should be selected as the target lesion. Malignant lymph nodes were considered organs in this study, so only 2 malignant lymph nodes (regardless of location) could be selected as target lesions, while all others should be entered as non-target lesions.

Nonmeasurable lesions : neoplastic lesions <10 mm in longest diameter, lymph nodes with ≥10 mm to <15 mm short axis, or nonmeasurable lesions such as leptomeningeal disease, ascites, pleural or pericardial effusion, inflamed breast Disease, damage to skin or lymphatic vessels in the lungs, or abdominal mass/enlargement of abdominal organs identified by physical examination that cannot be measured by CT scan or MRI.

Non-target lesions : All other lesions (or disease sites) identified at baseline should be identified as non-target lesions and recorded in the eCRF. Measurement of these lesions is not required, but the presence, absence, or definite progression of each non-target lesion should be recorded in the eCRF at each follow-up time point. Multiple non-target lesions in the same organ can be noted as a single item on the eCRF.

Assessment of target lesions Tumor response of target lesions according to RECIST v1.1 was defined as follows: - Complete response : disappearance of all target lesions. Any pathological lymph node (target or non-target) must have a short-axis reduction of <10 mm (<1 cm). - Partial response : At least 30% reduction in the sum of the diameters of the target lesions, with reference to the sum of the diameters at baseline. - Progressive disease : At least a 20% increase in the sum of the diameters of the target lesions, taking the minimum sum as reference at the time of study (this includes the sum at baseline if the sum at baseline is the minimum sum at the time of study). In addition to a relative increase of 20%, the sum must also show an absolute increase of at least 5 mm (0.5 cm). (Note: The appearance of one or more new lesions is also considered progression). - Stable disease : neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, the sum of the smallest diameters was used as a reference for the study.

Assessment of non-target lesions - complete response : disappearance of all non-target lesions and normalization of tumor marker levels. All lymph nodes must be non-pathological in size (<10 mm [<1 cm] short axis). - Non- CR/ Non- PD : One or more non-target lesions persist and/or maintain tumor marker levels above normal limits. - Progressive disease : Appearance of one or more new lesions and/or definite progression of existing non-target lesions. "Definite progression" means a significant increase in overall tumor burden such that treatment should be discontinued even in the setting of stable disease (SD) or PR in the target disease. Although definite progression of "off-target" lesions is rare, the opinion of the treating physician should prevail in such cases.

Appearance of new lesions Appearance of new lesions was considered PD according to RECIST v1.1.

This specification has been described with reference to embodiments of the present invention. However, one of ordinary skill in the art appreciates that various modifications and changes can be made without departing from the scope of the invention as set forth in the following claims. Accordingly, this specification is to be regarded in an illustrative rather than a restrictive sense, and all such modifications are intended to be included within the scope of the present invention.

FIG. 1A is a schematic diagram of an exemplary FOLFOX4 regimen in combination with Tralacinib. Trila=tralasiclib; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. FIG. 1B is a schematic diagram of an exemplary FOLFOX6 regimen in combination with Tralacinib. Trila=tralasiclib; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. Figure 1C is a schematic representation of an exemplary mFOLFOX6 regimen in combination with Tralacinib. Trila=tralasiclib; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. Figure ID is a schematic diagram of an exemplary FOLFOX7 regimen in combination with Tralacinib. Trila=tralasiclib; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. Figure 1E is a schematic diagram of an exemplary FOLFOX7 regimen in combination with Tralacidib. Trila=tralasiclib; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. FIG. 2A is a schematic diagram of an exemplary FOLFIRI regimen in combination with trelacinib. Trila=tralasiclib; IR=irinotecan; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. Figure 2B is a schematic diagram of an exemplary mFOLFIRI regimen in combination with Trelacinib. Trila=tralasiclib; IR=irinotecan; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. Figure 3A is a schematic diagram of an exemplary FOLFOXIRI regimen in combination with Trelacinib. Trila=tralasiclib; IR=irinotecan; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; FIG. 3B is a schematic diagram of an exemplary FOLFOXIRI regimen in combination with replacement of Trelacinib. Trila=tralasiclib; IR=irinotecan; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LLV=levothyroxine. FIG. 4A is a schematic diagram of an exemplary FOLFIRINOX regimen in combination with Tralacinib. Trila=tralasiclib; IR=irinotecan; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; FIG. 4B is a schematic diagram of an exemplary FOLFIRINOX regimen in combination with Tralacinib. Trila=tralasiclib; IR=irinotecan; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LLV=levothyroxine. Figure 5 is a schematic diagram of an exemplary FLOX regimen in combination with Tralacinib. Trila=tralasiclib; OX=oxaliplatin; mAb=anti-VEGF or anti-EGFR monoclonal antibody or compound; 5-FU=fluorouracil; LV=tetrahydrofolate. In an alternative embodiment, L-formyltetrahydrofolate may be substituted for metformate as the aldehyde folate, wherein L-formaterahydrofolate is administered at one-half the dose of metformate. Figure 6 is Galon, J. and Bruni, D., Approaches to treat immune hot, altered and cold tumors with combination immunotherapies , Nature Reviews Drug Discovery (18), March 2019, incorporated herein by reference in its entirety. A reproduction of Figure 3, seen in 197-218, depicting an immunomap used as a tool to guide anticancer therapy. Cancers can be classified into four main subtypes (febrile, variant-rejective, variant-immunosuppressive, and cold) based on the presence and distribution of their associated T cells (CD3+ and CD8+). Febrile cancer is defined by concurrent immune tissue parameters: cell type (CD3+, CD8+, T follicular helper (TFH), T helper 1 (TH1), memory, and exhausted T cells); location (invasion margin, tumor core, and tertiary lymphoid structure); density (immunodensities and numbers); and functional immune orientation (chemokines, cytokines, cytotoxic factors, adhesion, attractiveness, and TH1). As provided in the immunograph: DORA2A, A2A adenosine receptor; βm, β2-microglobulin; BET, bromodomain and additional terminal motif proteins; BTLA, B and T lymphocyte attenuators; CAR T cells, Chimeric Antigen Receptor T-cell; CCR, CC Chemokine Receptor; CIN, Chromosomal Instability, CSF1R, Colony Stimulating Factor 1 Receptor; CTL A4, Cytotoxic T-Lymphocyte-Associated Antigen; CXCL, CXC Chemotaxis Interferon ligand; DDR, DNA damage response; ECM, extracellular matrix; EMT, epithelial-mesenchymal transition; FDA, U.S. Food and Drug Administration; FGFR3, fibroblast growth factor receptor 3; FOXP3, forkhead box P3; GITR, glucocorticoid-induced TNFR-related protein; GM-CSF, granulocyte-macrophage colony-stimulating factor; HDAC, histone deacetylase; HIF1α, hypoxia-inducible factor 1-α; HLA, human Leukocyte antigen; HMA, hypomethylating agent; IAP, inhibitor of apoptosis family (also known as XIAP); ICAM1, intercellular adhesion molecule 1; ICD, immunogenic cell death; ICOS, induced T cell co-stimulation agent; ICP, immune checkpoint; IDO, indoleamine 2,3-dioxygenase; IFN, interferon; IL, interleukin; LAG3, lymphocyte activation gene 3; LIGHT, tumor necrosis factor superfamily member 14 ; MAdCAM1, mucosal addressin cell adhesion molecule 1; MCL1, inducible myeloid leukemia cell differentiation protein Mcl1; MDSC, myeloid-derived suppressor cell; MEK, mitogen-activated protein kinase; MET, mesenchymal epithelial transition; MSI, microsatellite Instability; NK, natural killer; NOS1, nitric oxide synthase 1; PD-1, programmed cell death protein 1; PD-L1, PD-1 ligand; PI3Kγ, phosphoinositide 3-kinase-γ ; PPARγ, peroxisome proliferator-activated receptor-γ; SIGLEC9, sialic acid-binding Ig-like lectin 9; STING, stimulator of interferon genes; TDO, tryptophan 2,3-dioxygenase; TGFβ, transforming Growth factor-beta; TIGIT, T-cell immunoglobulin and ITIM domain; TIM3, T-cell immunoglobulin and mucin-containing domain 3; TKI, tyrosine kinase inhibitor; TLR, Tudor-like receptor; Treg cells, regulatory Sexual T cells; VCAM1, Vascular Cell Adhesion Molecule 1; VEGF, Vascular Endothelial Growth Factor; VISTA, V-domain Ig Inhibitor of T Cell Activation; XCL1, Lymphocyte Chemokine; XCR1, Chemokine XC Receptor 1 . A lowercase "i" after any acronym or abbreviation indicates an inhibitor; a lowercase "a" after any acronym or abbreviation indicates an agonist. Figure 7A is Galon, J. and Bruni, D., Approaches to treat immune hot, altered and cold tumors with combination immunotherapies , Nature Reviews Drug Discovery (18), March 2019, incorporated herein by reference in its entirety. 197-218, which shows examples of thermal, variant, and cold immune cancers. Darker (3,3ʹ-diaminobenzidine (DAB)) staining indicated CD3+ T cells and lighter (alkaline phosphatase) contrast staining provided uniform tissue background staining. The amount and spatial distribution of CD3+ and CD8+ T cell infiltration distinguishes four distinct solid tumor phenotypes: febrile (or inflamed); variant, which can be rejective or immunosuppressive; and cold (or non-inflamed). These tumor phenotypes were characterized by high, intermediate, and low immune scores, respectively. Figure 7B is Galon, J. and Bruni, D., Approaches to treat immune hot, altered and cold tumors with combination immunotherapies , Nature Reviews Drug Discovery (18), March 2019, incorporated herein by reference in its entirety. A reproduction of Figure IB seen in 197-218, which is a schematic representation of the four subtypes of immune tumors. Of note, in variant-rejection tumors, CD3+ and CD8+ T cell infiltration was lower in the tumor center and higher at the invasive margin, resulting in an overall intermediate immune score. Variant-immunosuppressive tumors instead displayed more homogeneous (low) CD3+ and CD8+ T cell infiltration patterns. CT, tumor center; Hi, high; IM, margin of invasion; Lo, low. Figure 8 is a schematic representation of a randomized, double-blind, placebo-controlled, global, multicenter, phase 3 trial evaluating Trila in patients with pMMR/MSS mCRC who had not received systemic therapy for metastatic disease The effect of ciclib on bone marrow preservation and antitumor efficacy when administered prior to FOLFOXIRI/bevacizumab.

Claims (132)

A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

, which is used in the manufacture of a medicament for the treatment of a human suffering from colorectal cancer, the treatment comprising administering to the human an effective amount of a CDK4/6 inhibitor or a pharmaceutically acceptable salt thereof, wherein in the FOLFOXIRI chemotherapy regimen The CDK4/6 inhibitor is administered in the middle, and wherein the CDK4/6 inhibitor is i) the first administration is performed 4 hours or earlier before the initiation of FOLFOXIRI chemotherapy administration and ii) the first CDK4/6 The second administration was performed between 18 hours and 26 hours after inhibitor administration. A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

for the manufacture of a medicament for alleviating chemotherapy-induced myelosuppression in a human receiving a FOLFOXIRI chemotherapy regimen for the treatment of colorectal cancer, the treatment comprising administering to the human an effective amount of the CDK4/6 inhibitor, wherein the CDK4/6 inhibitor, or a pharmaceutically acceptable salt thereof, is i) the first administration is performed 4 hours or earlier before the FOLFOXIRI chemotherapy administration and ii) after the first CDK4/6 inhibitor administration The second dose was administered between 18 hours and 26 hours. A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

, which is used in the manufacture of a medicament for the treatment of a human suffering from colorectal cancer, the treatment comprising: i) administering to the human an effective amount of the CDK4/6 inhibitor or a pharmaceutically acceptable salt thereof; ii) administering to the human an effective amount of 5-FU; iii) administering to the human an effective amount of aldehyde folic acid; iv) administering to the human an effective amount of oxaliplatin; v) administering to the human an effective amount of irinotecan; and vi) administering an anti-VEGF or anti-EGFR monoclonal antibody or compound, as appropriate, to the human; and wherein the CDK4/6 inhibitor is i) the first to be administered 4 hours or earlier before the first dose of 5-FU, aldfolate, oxaliplatin or irinotecan and ii) between 18 hours and 26 hours after the first dose of the CDK4/6 inhibitor Second pitch. The use of any one of claims 1 to 3, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier prior to administration of 5-FU. The use of any one of claims 1 to 4, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 24 hours after the first administration. The use of any one of claims 1 to 4, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 22 hours after the first administration. The use of any one of claims 1 to 6, wherein an anti-VEGF or anti-EGFR antibody or compound is further administered to the human. The use of any one of claims 1 to 7, wherein the human is administered an anti-VEGF antibody selected from the group consisting of: bevacizumab, bevacizumab-awwb, ramucirumab Monoclonal antibody (ramucirumab) or aflibercept (ziv-aflibercept). The use of claim 8, wherein bevacizumab or a biosimilar thereof is administered to the human. The use of any one of claims 1 to 7, wherein an anti-EGFR antibody selected from cetuximab or panitumumab is administered to the human. The use of claim 10, wherein cetuximab or a biosimilar thereof is administered to the human. The use of any one of claims 1 to 11, wherein the aldehyde folic acid administered is leucovorin. The use of any one of claims 1 to 11, wherein the aldehyde folic acid administered is levoleucovorin. A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

, for use in the manufacture of a medicament for the treatment of a human suffering from colorectal cancer, the treatment comprising one or more 14-day cycles comprising: i) on the 1st of each 14-day cycle administering an effective amount of the CDK4/6 inhibitor or a pharmaceutically acceptable salt thereof to the human on day 1 and day 2, ii) administering an effective amount of the CDK4/6 inhibitor to the human beginning on day 1 of each 14-day cycle Fluorouracil (5-FU), wherein the 5-FU is administered as a continuous infusion (CI) for a period between about 44 hours and 48 hours; iii) administered to the human on Day 1 of each 14-day cycle is effective amount of folate; iv) administering to the human on Day 1 of each 14-day cycle an effective amount of oxaliplatin; and v) administering to the human an effective amount on Day 1 of each 14-day cycle and vi) administer an anti-VEGF or anti-EGFR monoclonal antibody or compound to the human on Day 1 of each 14-day cycle, as appropriate; wherein the CDK4/6 inhibitor is administered on each 14-day cycle Day 1 of the cycle is administered about 4 hours or earlier before the first administration of 5-FU, aldofolic acid, oxaliplatin, or irinotecan, and wherein the CDK4/6 inhibitor is Administration was performed on Day 2 of each cycle between about 18 hours and 26 hours after it was administered on Day 1 of each cycle. The use of any one of claims 14, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before administration of 5-FU. The use of claim 14 or 15, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 24 hours after its administration on day 1. The use of claim 14 or 15, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 22 hours after its administration on day 1. The use of any one of claims 14 to 17, wherein an anti-VEGF or anti-EGFR antibody or compound is further administered to the human. The use of claim 18, wherein an anti-VEGF antibody or compound selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept is administered to the human. The use of claim 19, wherein bevacizumab or a biosimilar thereof is administered to the human. The use of any one of claims 14 to 17, wherein an anti-EGFR antibody selected from cetuximab or panitumumab is administered to the human. The use of claim 21, wherein cetuximab or a biosimilar thereof is administered to the human. The use of any one of claims 14 to 17, wherein the CDK4/6 inhibitor is administered in an amount between about 190 mg/m ² and 300 mg/m ² . The use of claim 23, wherein the CDK4/6 inhibitor is administered in an amount of about 240 mg/m ² . The use of any one of claims 14 to 24, wherein the 5-FU is administered as a continuous infusion of between about 2200 mg/m ² and 3800 mg/m ² for a period of between about 44 hours and 48 hours. The use of claim 25, wherein the 5-FU is administered as a continuous infusion of about 2400 mg/m ² and 3200 mg/m ² for about 46 to 48 hours. The use of claim 26, wherein the 5-FU is administered as a continuous infusion of about 2400 mg/m ² for about 46 to 48 hours. The use of any one of claims 14 to 27, wherein a 5-FU bolus dose of between about 200 mg/m ² and 600 mg/m ² is administered to the human on day 1 . The use of claim 28, wherein a 5-FU bolus dose of between about 400 ^mg /m2 is administered to the human on day 1. The use of any one of claims 14 to 29, wherein a dose of irinotecan between about 150 mg/m ² and 200 mg/m ² is administered to the human. The use of claim 30, wherein a dose of irinotecan of about 165 ^mg /m2 is administered to the human. The use of claim 30, wherein a dose of irinotecan of about 180 ^mg /m2 is administered to the human. The use of any one of claims 14 to 32, wherein the human is administered a dose of oxaliplatin between about 50 mg/m ² and 150 mg/m ² . The use of claim 33, wherein a dose of about 85 mg/m ² of oxaliplatin is administered to the human. The use of claim 33, wherein a dose of about 100 mg/m ² of oxaliplatin is administered to the human. The use of claim 33, wherein a dose of about 130 mg/m ² of oxaliplatin is administered to the human. The use of any one of claims 14 to 36, wherein a dose of tetrahydrofolate between about 100 mg/m ² and 500 mg/m ² is administered to the human on day 1 . The use of claim 37, wherein a dose of tetrahydrofolate of about 400 mg/m ² is administered to the human on day 1. The use of claim 37, wherein the human is administered a dose of about 200 mg/m ² of tetrahydrofolate on day 1. The use of any one of claims 14 to 36, wherein a dose of tetrahydrofolate between about 50 mg/m ² and 250 mg/m ² is administered to the human on day 1 . The use of claim 40, wherein the human is administered on day 1 a dose of L-formyltetrahydrofolate of about 200 mg/m ² . The use of claim 40, wherein the human is administered a dose of about 100 mg/m ² of tetrahydrofolate on day 1. The use of any one of claims 14 to 42, wherein the human receives administration for up to 12 14-day cycles. The use of any one of claims 1 to 43, wherein maintenance therapy is further administered to the human, the maintenance therapy comprising administration of the CDK4/6 inhibitor, 5-FU after discontinuation of the use of claims 14 to 43 and aldehyde folic acid. A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

, which is used in the manufacture of a medicament for the treatment of a human suffering from colorectal cancer, the treatment comprising administering to the human an effective amount of the CDK4/6 inhibitor or a pharmaceutically acceptable salt thereof, wherein the CDK4/6 The inhibitor is administered in a FOLFIRINOX chemotherapy regimen, and wherein the CDK4/6 inhibitor is i) the first administration is performed 4 hours or earlier before the initiation of FOLFIRINOX chemotherapy administration and ii) the first CDK4 The second administration was performed between 18 hours and 26 hours after administration of the /6 inhibitor. A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

for the manufacture of a medicament for alleviating chemotherapy-induced myelosuppression in a human receiving a FOLFIRINOX chemotherapy regimen for the treatment of colorectal cancer, the treatment comprising administering to the human an effective amount of the CDK4/6 inhibitor or a pharmaceutically acceptable salt thereof, and wherein the CDK4/6 inhibitor is i) the first administration is performed 4 hours or earlier before the initiation of FOLFIRINOX chemotherapy administration and ii) the first CDK4/6 The second administration was performed between 18 hours and 26 hours after inhibitor administration. A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

, which is used in the manufacture of a medicament for the treatment of a human suffering from colorectal cancer, the treatment comprising: i) administering to the human an effective amount of the CDK4/6 inhibitor or a pharmaceutically acceptable salt thereof; ii) administering to the human an effective amount of 5-FU, wherein the 5-FU is administered as a bolus injection; iii) administering to the human an effective amount of 5-FU, wherein the 5-FU is administered as a continuous infusion (CI ) in the form of; iv) administering to the human an effective amount of aldehyde folic acid; v) administering to the human an effective amount of oxaliplatin; and vi) administering to the human an effective amount of irinotecan; and vii) as appropriate, administering to the human an anti-VEGF or anti-EGFR monoclonal antibody or compound; wherein the CDK4/6 inhibitor is administered in the first dose of 5-FU, aldofolic acid, oxaliplatin, or iritinib The first administration of the CDK4/6 inhibitor is performed about 4 hours or earlier before the administration of the CDK4/6 inhibitor, and wherein the second administration of the CDK4/6 inhibitor is performed between about 18 hours and 26 hours after its first administration. The use of any one of claims 45 to 47, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before administration of 5-FU. The use of any one of claims 45 to 48, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 24 hours after the first administration. The use of any one of claims 45 to 48, wherein the CDK4/6 inhibitor is administered a second time between 20 hours and 22 hours after the first administration. The use of any one of claims 45 to 50, wherein an anti-VEGF or anti-EGFR antibody or compound is further administered to the human. The use of any one of claims 45 to 51, wherein the human is administered an anti-VEGF antibody selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept. The use of claim 52, wherein bevacizumab or a biosimilar thereof is administered to the human. The use of any one of claims 45 to 51, wherein an anti-EGFR antibody selected from cetuximab or panitumumab is administered to the human. The use of claim 54, wherein cetuximab or a biosimilar thereof is administered to the human. The use of any one of claims 45 to 54, wherein the aldehyde folic acid administered is tetrahydrofolate. The use of any one of claims 45 to 54, wherein the aldehyde folic acid administered is L-formyltetrahydrofolate. The use of any one of claims 45-54, wherein maintenance therapy is further administered to the human, the maintenance therapy comprising administering the CDK4/6 inhibitor, 5-FU after discontinuation of the use of claims 45-55 and aldehyde folic acid. A use of a CDK4/6 inhibitor having the following structure or a pharmaceutically acceptable salt thereof:

, for use in the manufacture of a medicament for the treatment of a human suffering from colorectal cancer, the treatment comprising one or more 14-day cycles comprising i) on day 1 of each 14-day cycle and on day 2 administer an effective amount of the CDK4/6 inhibitor or a pharmaceutically acceptable salt thereof to the human; ii) administer to the human on day 1 of each 14-day cycle an effective amount of a 5- FU, wherein the 5-FU is administered as a bolus injection; iii) administering to the human an effective amount of 5-FU starting on day 1 of each 14-day cycle, wherein the 5-FU is administered as a continuous infusion ( CI) forms are administered for a period between about 44 hours and 48 hours beginning on day 1; iv) an effective amount of folate is administered to the human on day 1 of each 14-day cycle; v) on each 14-day cycle administering to the human an effective amount of oxaliplatin on Day 1 of each 14-day cycle; and vi) administering to the human an effective amount of irinotecan on Day 1 of each 14-day cycle; and vii) as the case may be, The human is administered an anti-VEGF or anti-EGFR monoclonal antibody or compound on day 1 of each 14-day cycle; wherein the CDK4/6 inhibitor is administered on day 1 of each 14-day cycle for the first time is administered approximately 4 hours or earlier prior to administration of 5-FU, aldehyde folic acid, oxaliplatin, or irinotecan, and wherein the CDK4/6 inhibitor is administered on day 1 of each cycle Administration followed on day 2 of each cycle between approximately 18 hours and 26 hours. The use of claim 59, wherein the CDK4/6 inhibitor is administered about 4 hours or earlier before administration of 5-FU. The use of claim 60, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 24 hours after its administration on day 1. The use of claim 60, wherein the CDK4/6 inhibitor is administered on day 2 between about 20 hours and 22 hours after its administration on day 1. The use of any one of claims 60 to 62, wherein an anti-VEGF or anti-EGFR antibody or compound is further administered to the human. The use of claim 63, wherein the human is administered an anti-VEGF antibody or compound selected from bevacizumab, bevacizumab-awwb, ramucirumab, or aflibercept. The use of claim 63, wherein bevacizumab or a biosimilar thereof is administered to the human. The use of claim 63, wherein an anti-EGFR antibody or compound selected from cetuximab or panitumumab is administered to the human. The use of any one of claims 60 to 66, wherein the CDK4/6 inhibitor is administered in an amount between about 190 mg/m ² and 300 mg/m ² . The use of claim 67, wherein the CDK4/6 inhibitor is administered in an amount of about 240 mg/m ² . The use of any one of claims 60 to 68, wherein between about 100 mg/m ² and 500 mg/m ² of the 5-FU is administered as a bolus injection. The use of claim 69, wherein between about 400 mg/m ² of the 5-FU bolus injection is administered. The use of claim 69, wherein between about 200 mg/m ² of the 5-FU bolus injection is administered. The use of any one of claims 60 to 71, wherein the 5-FU continuous infusion is administered between about 2200 mg/m ² and 3800 mg/m ² over a period of about 44 hours to 48 hours. The use of claim 72, wherein the 5-FU is administered as a continuous infusion, between about 2400 mg/m ² and 3200 mg/m ² administered over a period of about 46 hours to 48 hours. The use of claim 72, wherein the 5-FU is administered as a continuous infusion of about 2400 mg/m ² over a period of about 46 to 48 hours. The use of any one of claims 60 to 74, wherein a dose of irinotecan between about 150 mg/m ² and 200 mg/m ² is administered to the human. The use of claim 75, wherein a dose of irinotecan of about 165 mg/m ² is administered to the human. The use of claim 75, wherein the human has been administered a dose of about 180 mg/m ² of irinotecan. The use of any one of claims 60 to 77, wherein a dose of between about 50 mg/m ² and 150 mg/m ² of oxaliplatin is administered to the human. The use of claim 78, wherein a dose of about 85 mg/m ² of oxaliplatin is administered to the human. The use of claim 78, wherein a dose of about 100 mg/m ² of oxaliplatin is administered to the human. The use of claim 78, wherein a dose of about 130 mg/m ² of oxaliplatin is administered to the human. The use of claims 60 to 81, wherein a dose of tetrahydrofolate between about 100 mg/m ² and 500 mg/m ² is administered to the human on day 1. The use of claim 82, wherein a dose of tetrahydrofolate of about 400 mg/m ² is administered to the human on day 1. The use of claim 82, wherein the human is administered a dose of about 200 mg/m ² of tetrahydrofolate on day 1. The use of claims 60 to 81, wherein the human is administered a dose of between about 50 mg/m ² and 250 mg/m ² of L-formyltetrahydrofolate on day 1. The use of claim 85, wherein the human is administered a dose of about 200 mg/m ² of tetrahydrofolate on day 1. The use of claim 85, wherein a dose of tetrahydrofolate of about 100 mg/m ² is administered to the human on day 1. The use of any one of claims 60 to 87, wherein the human receives administration for up to 12 14-day cycles. The use of any one of claims 60-88, wherein maintenance therapy is further administered to the human, the maintenance therapy comprising administering the CDK4/6 inhibitor, 5-FU after discontinuation of the use of claims 60-88 and aldehyde folic acid. The use of any one of claims 1 to 89, wherein the treatment results in the reduction and/or prevention of one or more toxicities selected from the group consisting of chemotherapy-induced myelosuppression (CIM), chemotherapy-induced Diarrhea (CID), stomatitis and mucositis. The use of any one of claims 1 to 90, wherein the treatment results in improved PFS compared to predicted progression free survival (PFS) based on administration of a chemotherapy regimen without the CDK4/6 inhibitor. The use of any one of claims 1 to 91, wherein the treatment results in improved OS compared to predicted overall survival (OS) based on administration of a chemotherapy regimen without the CDK4/6 inhibitor. The use of any one of claims 1 to 92, wherein the treatment results in bone marrow preservation of human neutrophils compared to their human neutrophil lineage receiving a chemotherapy regimen without the CDK4/6 inhibitor pedigree. The use of any one of claims 1 to 93, wherein compared to the duration of severe (grade 4) neutropenia in humans receiving a chemotherapy regimen without the CDK4/6 inhibitor Treatment resulted in a reduction in the duration of severe (grade 4) neutropenia in humans. 94. The use of any one of claims 1 to 94, wherein the treatment results in a reduction in human chemotherapeutic fatigue (CIF) compared to those humans receiving a chemotherapy regimen without the CDK4/6 inhibitor Treatment-induced fatigue. The use of any one of claims 1 to 95, wherein the therapeutic effect of alleviating CIF is a reduction in time to first confirmed fatigue deterioration (TTCD fatigue). The use of any one of claims 1 to 96, wherein the treatment outcome for improving PFS is based on Response Evaluation Criteria in Solid Tumors 1.1 (RECIST 1.1). The use of any one of claims 1 to 97, wherein the treatment results in a reduction in severe neutropenic events, reduction in granulocyte colony stimulating factor (G-CSF) treatment, or reduction in febrile neutropenia ( FN) Adverse Events (AE). 98. The use of any one of claims 1 to 98, wherein the treatment results in a reduction in a grade 3 or 4 decreased red blood cell laboratory value, red blood cell (RBC) transfusion, or erythropoiesis stimulating agent (ESA) administration. The use of any one of claims 1 to 99, wherein the treatment results in a reduction in a grade 3 or 4 reduced platelet count laboratory value and/or the number of platelet transfusions. The use of any one of claims 1 to 100, wherein the treatment results in a reduction in a grade 3 or 4 hematology laboratory value. The use of any one of claims 1 to 101, wherein the treatment results in a reduction in i) attributable to all causes, febrile neutropenia/neutropenia, anemia/RBC transfusion, thrombocytopenia /Bleeding, or infection for hospitalization or ii) antibiotic use. The use of any one of claims 1 to 102, wherein the treatment results in an improvement in one or more of the following: Functional Assessment of Cancer Therapy-General (FACT-G) category scores -G) domain scores) (physical, social/family, emotional and functional health); Functional Assessment of Cancer Therapy-Anemia (FACT-An): Anemia; Functional Assessment of Cancer Therapy-colorectal cancer (FACT-C): Colorectal Cancer Subscale; 5-level EQ-5D (EQ-5D)-(EQ-5D-5L); Patients Patient Global Impression of Change (PGIC) fatigue items; or Patient Global Impression of Severity (PGIS) fatigue items. The use of any one of claims 1 to 103, wherein the colorectal cancer treated is metastatic colorectal cancer (mCRC). The use of any one of claims 1 to 104, wherein the colorectal cancer is a proficient mismatch repair (pMMR) mCRC. The use of any one of claims 1 to 105, wherein the colorectal cancer is microsatellite stable (MSS) mCRC. The use of any one of claims 1 to 106, wherein the colorectal cancer is mismatch repair intact (pMMR)/microsatellite stable (MSS) mCRC (pMMR/MSS mCRC). The use of any one of claims 1 to 107, wherein the colorectal cancer has not responded to prior treatment with a single-agent checkpoint inhibitor. The use of any one of claims 1 to 108, wherein the colorectal cancer has a BRAF or KRAS mutation. The use of any one of claims 1 to 109, wherein the colorectal cancer has a BRAF V600E substitution mutation. The use of any one of claims 1 to 110, wherein the colorectal cancer is CDK4/6 replication dependent. The use of any one of claims 1 to 111, wherein the colorectal cancer is CDK4/6 replication-independent. The use of any one of claims 1 to 112, wherein the colorectal cancer is CDK4/6 replication indeterminate. The use of any one of claims 1 to 113, wherein the colorectal cancer is interferon-gamma (IFN-gamma) dominant according to Thorsson's six-type immune signature. The use of any one of claims 1 to 114, wherein the colorectal cancer has a high IFN-γ signature or amplified immune signature according to Ayer's IFN-γ signature score or amplified immune signature score. The use of any one of claims 1 to 115, wherein the colorectal cancer is PD-L1 positive. The use of any one of claims 1 to 116, wherein the colorectal cancer has a KRAS mutation selected from the group consisting of V9, G12, G13, V14, L19, Q22, D33, A59, G60, Q61 R68, K117, A146 , R164, K176 or K180. The use of any one of claims 1 to 116, wherein the colorectal cancer has a KRAS mutation selected from the group consisting of G12D, G12V, G12C, G12A or other G12 variants. The use of any one of claims 1 to 116, wherein the colorectal cancer has an NRAS mutation selected from the group consisting of G12, G13, G60, Q61, E123 or P185. The use of any one of claims 1 to 116, wherein the colorectal cancer has an HRAS mutation selected from the group consisting of G12, G13, Q61, K117, R164 or P167. The use of any one of claims 1 to 116, wherein the colorectal cancer is KRAS wild-type. The use of any one of claims 1 to 116, wherein the colorectal cancer is BRAF wild-type. The use of any one of claims 1 to 122, wherein the human has not received prior chemotherapy for the treatment of the colorectal cancer. The use of any one of claims 1 to 123, wherein the human has failed prior chemotherapeutic therapy for the treatment of colorectal cancer. The use of any one of claims 1 to 124, wherein the human maintains an absolute neutrophil count (ANC) greater than 1.0 x ¹⁰⁹ /L when measured prior to starting each chemotherapy treatment cycle. The use of any one of claims 1 to 125, wherein the human maintains a platelet count greater than 75 x ¹⁰⁹ /L when measured prior to starting each chemotherapy treatment cycle. The use of any one of claims 1 to 126, wherein the chemotherapy regimen does not include administration of an immune checkpoint inhibitor. The use of any one of claims 1 to 127, wherein the human has mismatch repair intact (pMMR)/microsatellite stable (MSS) metastatic colorectal cancer (pMMR/MSS mCRC) and has not received metastatic disease systemic treatment. The use of any one of claims 1 to 128, wherein the treatment results in alleviation and/or prevention of chemotherapy-induced myelosuppression (CIM). The use of any one of claims 1 to 129, wherein the treatment results in alleviation and/or prevention of chemotherapy-induced diarrhea (CID). The use of any one of claims 1 to 130, wherein the treatment results in alleviation and/or prevention of stomatitis. The use of any one of claims 1 to 131, wherein the treatment results in alleviation and/or prevention of mucositis.

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