UA144014U - KIT FOR TREATMENT OF BREAST CANCER AROMATASE RESISTANT - Google Patents

Abstract

A kit for the treatment of aromatase-resistant breast cancer inhibitor comprising a combination of entinostat and exemestane or a pharmaceutically acceptable salt, solvate or prodrug thereof and instructions for administration of this dosage form.

Description

A useful model belongs to the methods of treating breast cancer, which are based on the introduction of NOAS inhibitors (histone diacetylases) and aromatase inhibitors.

Cancer, tumors, tumor-related disorders, and neoplastic disease states are serious and often life-threatening conditions. These diseases and disorders, which are characterized by cell growth that spreads rapidly, continue to be the subject of research efforts aimed at identifying therapeutic agents that are effective in their treatment. Such agents prolong the life of the patient, inhibit the rapid growth of rapidly spreading cells associated with the neoplasm or affect the regression of the neoplasm.

Usually, surgery and radiation therapy are the initial treatments designed to treat cancer that is thought to be locally confined and has a better prognosis. Treatment of certain types of cancer with chemotherapy usually results in disappointing survival rates, but still offers a survival benefit. For example, aromatase inhibitor chemotherapy regimens such as letrozole, anastrozole, or exemestane are used for breast cancer patients. If patients do not respond to aromatase inhibitor treatment, conventional treatment is of limited benefit.

Despite the approval of several aromatase inhibitors for the treatment of early and late-stage breast cancer, as with most therapeutic agents, side effects occur due to their use. For example, common side effects include flushing, vasodilation, and nausea. Of greater concern is the growing notion that although the use of aromatase inhibitors to treat tumors may initially reduce tumor size, the tumor may eventually increase in size, indicating, among other things, the development of resistance. Letrozole, a widely used aromatase inhibitor, may be representative of the types of therapeutic agents used to treat cancer; in that its use affects the cancer, but due to other factors that are not fully known, the tumor develops resistance and progresses.

SPAIN inhibitors are an emerging class of therapeutic agents that promote differentiation and apoptosis in hematological and solid malignancies through chromatin remodeling and regulation of gene expression. Several NOAS inhibitors have been identified, including benzamides (entinostat), short-chain fatty acids (ie, sodium phenylbutyrate); hydroxamic

Zo acids (ie, hydroxamic acid suberoylanilide and trichostatin A); cyclic tetrapeptides containing a 2-amino-8-oxo-9, 10-epoxy-decanoyl component (i.e., trapoxin A) and cyclic peptides without a 2-amino-8-oxo-9, 10-epoxy-decanoyl component (i.e., EC228). Entinostat (bZupdakh RvPagtaseshiisaI!e company, Ips.) is a benzamide inhibitor of NAAS undergoing clinical research on numerous types of solid tumors and cancerous tumors of the hematopoietic system.

Entinostat is rapidly absorbed and has a half-life of approximately 100 hours; changes in histone acetylation persisted for several weeks after entinostat administration.

Therefore, there is a need for therapeutic compositions or methods of cancer treatment that take advantage of the synergy found in a therapeutic combination that can increase the effectiveness of the agents and reduce and/or eliminate the side effects usually associated with conventional treatments.

One embodiment provides a method of treating breast cancer in a patient, which includes (i) measuring the level of protein lysine acetylation before prescribing therapy with an entinostat-aromatase inhibitor combination, (ii) prescribing therapy with an aromatase inhibitor combination, (ii) measuring the level of protein lysine acetylation after appointment of entinostat - aromatase inhibitor combination therapy, (i) comparison of protein lysine acetylation level after appointment of entinostat - aromatase inhibitor combination therapy with protein lysine acetylation level before appointment of entinostat - aromatase inhibitor combination therapy, and (m) continuation of treatment through entinostat - aromatase inhibitor combination therapy aromatase, if the level of acetylation of protein lysine after the appointment of therapy with the combination of entinostat - aromatase inhibitor is greater than the level of acetylation of protein lysine before the appointment of therapy with the combination of entinostat - aromatase inhibitor.

One embodiment provides a method of treating breast cancer in a patient, comprising (i) prescribing therapy with a combination of entinostat - an aromatase inhibitor and (ii) determining a change in protein lysine acetylation levels during the course of said therapy compared to protein lysine acetylation levels before therapy.

One embodiment offers a method of treating breast cancer in a patient, which includes (i) determining the level of acetylation of protein lysine before prescribing, (ii) prescribing therapy with a combination of entinostat - an aromatase inhibitor, and (ii) determining the level of acetylation of protein lysine during the course of therapy.

Another embodiment offers a method that differs in that the determination of the change in the level of protein lysine acetylation during the course of said therapy occurs after approximately

2 days of therapy, approximately 5 days of therapy, approximately 7 days of therapy, approximately 15 days of therapy or approximately 21 days of therapy.

Another embodiment offers a method that differs in that protein lysine acetylation levels are obtained from a tissue sample selected from B cells, T cells, or monocytes.

Another embodiment offers a method that differs in that the aromatase inhibitor is exemestane. Another embodiment offers a method that differs in that the aromatase inhibitor is anasrozole. Another embodiment offers a method that differs in that the aromatase inhibitor is letrozole. Another embodiment offers a method that differs in that the aromatase inhibitor is administered daily. Another embodiment offers a method that differs in that the aromatase inhibitor is exemestane and is administered daily. Another embodiment offers a method that differs in that entinostat is administered every 7 days of a 28-day cycle. Another embodiment offers a method that differs in that therapy with a combination of entinostat - an aromatase inhibitor includes oral administration of entinostat every 7 days of a 28-day cycle and oral administration of exemestane every other day.

Another embodiment offers a method that differs in that the step of determining the level of protein lysine acetylation during the course of therapy is performed more than once. Another embodiment offers a method that differs in that the step of determining the level of protein lysine acetylation is performed once during the course of therapy.

Another embodiment provides a method that further includes selecting a patient for further treatment if the level of protein lysine acetylation increases during a course of therapy.

Another embodiment provides a method that further includes selecting a patient for further treatment if the level of protein lysine acetylation increases during the first week of therapy. Another embodiment provides a method that further includes selecting a patient for further treatment if the level of protein lysine acetylation increases during the first and second weeks of the course of therapy.

One embodiment provides a method of selecting a patient for subsequent therapy with an entinostat-aromatase inhibitor combination that includes comparing the level of acetylation

Of protein lysine in a tissue sample obtained after the start of therapy, with levels of protein lysine acetylation determined before the start of therapy.

One embodiment provides a method of selecting a patient for further therapy with an entinostat - aromatase inhibitor combination, which includes comparing the level of protein lysine acetylation in a tissue sample obtained after the start of therapy with the levels of protein lysine acetylation determined before the start of therapy, characterized in that the increase in the level acetacetylation of protein lysine after the start of therapy indicates that the patient's condition will improve with further therapy.

Another embodiment offers a method that differs in that the level of protein lysine acetylation in a tissue sample obtained after the start of therapy is determined more than once. Another variant of implementation offers a method that differs in that the increase in the level of acetylation of protein lysine after the start of therapy occurs in a time period of one week. Another embodiment offers a method that differs in that the level of protein lysine acetylation after the start of therapy is determined on days 2, 8 and 15.

Another embodiment provides a method wherein the magnification is from about 10 95 to about 500 95. Another embodiment provides a method wherein the magnification is from about 10 95 to about 400 95. Another embodiment provides a method wherein the increase is from about 10 95 to about 300 95. Another embodiment provides a method wherein the increase is from about 10 95 to about 200 95. Another embodiment provides a method that characterized in that the increase is from about 10 95 to about 100 95. Another embodiment provides a method characterized in that the increase is about 10 95, about 20 95, about 3095, about 40 95, about 5095, or about 6095. Another embodiment provides a method wherein the increase is about 25 95, about 50 95, about 75 95 , about 100 95, about 125 95 or about 150 95.

Another embodiment offers a method that differs in that the tissue sample is selected from B cells, T cells, or monocytes.

Another embodiment offers a method that differs in that the tissue sample obtained after the start of therapy is obtained at least 2 days after the start of therapy. Yet another embodiment offers a method that differs in that the tissue sample obtained after the start of therapy is obtained between day 2 and day 28 after the start of therapy. Another embodiment provides a method in which the tissue sample obtained after initiation of therapy is obtained on day 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 after starting therapy.

One embodiment provides a method of selecting a patient for further therapy with an entinostat-aromatase inhibitor combination, comprising comparing the percent change in protein lysine acetylation levels in a tissue sample obtained after initiation of therapy with protein lysine acetylation levels determined prior to initiation of therapy, wherein a percent reduction in protein lysine acetylation levels after initiation of therapy from approximately 5 95 to approximately 50 95 indicates that the patient will not improve with further therapy.

One embodiment provides a method of treating breast cancer that is resistant to prior aromatase inhibitor therapy, the method comprising administering to a patient a combination comprising entinostat and an aromatase inhibitor, wherein the patient has not demonstrated a complete response, partial response, or stable disease within more than six months during prior aromatase inhibitor treatment.

Another embodiment offers a method that differs in that the patient has relapsed during treatment within b months after completing a previous course of a non-steroidal aromatase inhibitor prescribed as adjuvant therapy.

Another embodiment provides a method wherein the patient has demonstrated progressive disease after at least 3 months of treatment with a prior non-steroidal aromatase inhibitor.

Another embodiment offers a method that differs in that the breast cancer is EC-positive.

Another embodiment offers a method that differs in that the aromatase inhibitor administered in combination with entinostat is letrozole. Another embodiment offers a method that differs in that the aromatase inhibitor administered in combination with entinostat is anastrozole. Another embodiment offers a method that differs in that the aromatase inhibitor administered in combination with entinostat is exemestane.

Another embodiment offers a method that differs in that entinostat and

The aromatase inhibitor is administered sequentially in any order or simultaneously. Another embodiment offers a method that differs in that entinostat and an aromatase inhibitor are administered simultaneously. Another embodiment offers a method that differs in that the aromatase inhibitor is administered first. Another embodiment offers a method that differs in that the aromatase inhibitor is administered daily and the entinostat is administered periodically. Another embodiment offers a method that differs in that the entinostat is administered weekly and the aromatase inhibitor is administered daily. Another embodiment offers a method that differs in that entinostat is introduced into the course of therapy with an aromatase inhibitor.

One embodiment provides a kit for the treatment of aromatase inhibitor-resistant breast cancer, which includes a combination of entinostat and an aromatase inhibitor and instructions for the administration of this dosage form.

Yet another embodiment provides a kit wherein the kit includes one dosage form of entinostat for every seven dosage forms of an aromatase inhibitor. Another embodiment offers a kit that is characterized by the fact that the kit includes one dosage form for every 14 dosage forms of an aromatase inhibitor. Another embodiment offers a kit, which differs in that the kit includes 4 dosage forms of entinostat and 28 dosage forms of an aromatase inhibitor. Another embodiment offers a kit, which differs in that the kit includes 4 dosage forms of entinostat and 56 dosage forms of an aromatase inhibitor.

Another embodiment offers a kit that differs in that the aromatase inhibitor is letrozole. Another embodiment offers a kit that differs in that the aromatase inhibitor is anastrozole. Another embodiment offers a kit that differs in that the aromatase inhibitor is exemestane.

Another embodiment provides a method that further comprises administering to the patient one or more therapies in addition to the combination of entinostat and an aromatase inhibitor selected from the group consisting of: letrozole, anastrozole, or exemestane, or pharmaceutically acceptable salts, solvates thereof, or prodrugs

Another embodiment provides a method wherein the one or more therapies include one or more of radiation therapy, chemotherapy, high-dose chemotherapy with stem cell transplantation, and monoclonal antibody therapy. Another embodiment offers a method that differs in that the radiation therapy includes internal bo or external radiation therapy. Another embodiment provides a method wherein the chemotherapy comprises administering to the patient one or more of doxorubicin, cyclophosphamide, paclitaxel, lapatinib, capecitabine, trastuzumab, bevacizumab, gemcitabine, eribulin, or nab-paclitaxel

All publications, patents, and patent applications referenced in this utility model description are incorporated by reference to the same extent as if each individual publication, patent, or patent application were specifically and individually designated as being incorporated by reference.

The new features of the useful model are detailed in the attached formula of the useful model. A better understanding of the features and advantages of the claimed utility model will be obtained by reference to the following detailed description, which sets forth illustrative embodiments in which the principles of the utility model are used, and the attached drawings, in which:

Fig. 1 provides a summary of the Phase 2 clinical trial;

Fig. 2 provides a summary of the criteria for inclusion in the Phase 2 clinical trial;

Fig. C provides a summary of the patient population included in the Phase 2 clinical trial;

Fig. 4 provides a detailed analysis of the patient population included in the Phase 2 clinical trial;

Fig. 5 provides a summary of progression-free survival during the clinical trial

Phases 2;

Fig. 6 provides an analysis of benefit by subgroup during the Phase 2 clinical trial;

Fig. 7 provides an analysis of the change in tumor volume and response type observed during the Phase 2 clinical trial;

Fig. 8 summarizes the overall survival observed in the Phase 2 clinical trial;

Fig. 9 provides a summary of the adverse effects observed during the Phase 2 clinical trial;

Fig. 10 provides a general summary of the Phase 2 clinical trial;

Fig. 11 gives an introduction to protein lysine acetylation;

Fig. 12 provides a summary of the Phase 2 study that confirms;

Fig. 13, 14 and 15 provide an overview of the interim results of the Phase 2 study, which confirms;

Fig. 16 provides a summary of the pharmacodynamic analysis performed to measure changes in protein lysine acetylation in the Phase 2 study;

From Fig. 17 provides a comparison between the population of patients with biomarkers and the general population of patients in the Phase 2 study;

Fig. 18 gives a comparison of BNP with percent change in acetacetylation levels;

Fig. 19 provides a comparison of PFS with percent change in acetylation levels in each treatment group in the Phase 2 study;

Fig. 20 provides a comparison of PFS with percent change in acetylation levels in each treatment group in the Phase 2 study when the analysis was performed with B cells;

Fig. 21 and 22 provide an overview of the adverse effects against the acetylation state;

Fig. 23 provides a summary of the interim biomarker study;

Fig. 24 provides an analysis of the primary endpoint in the Phase 2 study;

Fig. 25 provides a timeline for dosing and sampling in the pharmacodynamic analysis portion of the Phase 2 study;

Fig. 26 gives a schedule of treatment groups on the change of adeethylation against BBP;

Fig. 27 summarizes the changes in acetylation for two treatment groups in three different tissue types;

Fig. 28 provides a comparison of PFS with percent change in acetylation levels in each treatment group in the Phase 2 study;

Fig. 29 provides a comparison of PFS with percent change in acetylation levels in each treatment group in the Phase 2 study when the analysis was performed with B cells;

Fig. 30 shows that clinical benefit is associated with acetylation levels;

Fig. 31 shows that trends in acetylation differentiate treatment responders;

Fig. 32 shows that maintenance of adethylation levels is the main factor for obtaining a positive clinical result; and

Fig. 33 summarizes a study that demonstrated that protein lysine acetylation is associated with longer disease-free survival.

This document proposes methods of cancer treatment based on the introduction of an inhibitor

NSAIDS and aromatase inhibitor. Methods may further include types of treatment that differ in that the combination is supplemented with one or more therapeutic agents or therapies. Treatment methods may include patient selection based on levels of protein lysine acetylation observed during treatment.

To facilitate understanding of the disclosure set forth in this document, a number of terms are defined below.

As used herein, the term "pathological cell growth" refers to cell growth that is independent of normal regulatory mechanisms (eg, loss of contact inhibition), including pathological growth of normal cells and growth of pathological cells.

"Neoplasia" as defined herein is a pathological, unregulated and disorganized proliferation of cells that differs from normal cells in autonomous growth and somatic mutations. As neoplastic cells grow and divide, they pass on their genetic mutations and proliferative characteristics to progeny cells. A neoplasm or tumor is a cluster of neoplastic cells. In some embodiments, the neoplasm may be benign or malignant.

As used herein, the term "metastasis" refers to the spread of tumor cells through lymphatic or blood vessels. Metastasis also refers to the migration of tumor cells by direct spread through serous cavities or subarachnoid or other spaces. Through the process of metastasis, the migration of tumor cells to other areas of the body creates neoplasms in areas distant from the place of initial manifestation.

The term "angiogenesis" used here is widely known in tumor formation and metastasis.

Angiogenic factors have been found to be associated with several solid tumors, such as rhabdomyosarcoma, retinoblastoma, Ewing's tumor, neuroblastoma, and osteosarcoma. A tumor cannot spread without a blood supply to provide nutrients and remove cellular waste. Tumors in which angiogenesis is important include solid tumors such as kidney cancer, hepatocellular carcinoma, and benign tumors such as leukemias. Angiogenesis is believed to play some role in bone marrow pathologies that lead to leukemia. Prevention of angiogenesis can stop the growth of cancerous tumors and the corresponding infection of the object due to the presence of the tumor.

The term "subject" refers to an animal, including, but not limited to, a primate (eg, a humanoid), a cow, a sheep, a goat, a horse, a dog, a cat, a rabbit, a rat, or a mouse. The terms "subject" and "patient" are used interchangeably herein when referring to, for example, a mammalian subject, such as a human subject.

The terms "treat", "treating" and "treatment" include the reduction of symptoms or the elimination of one or more symptoms associated with the disorder, disease or condition; or reducing or eliminating the cause (or causes) of the disorder, disease or condition.

The term "therapeutically effective amount" refers to an amount of a compound which, after administration, is sufficient to prevent the development or reduce to some extent one or more symptoms of the disorder, disease or condition being treated. The term "therapeutically effective amount" also refers to an amount of a compound that is sufficient to cause a biological or medical response in a cell, tissue, system, animal or human that is expected by the researcher, veterinarian, practitioner or clinician.

The term "pharmaceutically acceptable carrier", "pharmaceutically acceptable excipient", "physiologically acceptable carrier" or "physiologically acceptable excipient" refers to a pharmaceutically acceptable material, composition or medium, such as a liquid or solid excipient, diluent, excipient, diluent or encapsulating material in a capsule

Each component must be "pharmaceutically acceptable" in the sense of compatibility with other ingredients of the pharmaceutical composition. It must also be suitable for use in contact with tissue or organ of humans and animals without excessive toxicity, irritation, allergic reaction, immunogenicity or other problems or complications, in proportion to the reasonable ratio of benefit and risk (see Vetipaiop: TNne bsiepse apa Rgasiise oi Rnaptasu, 2151 Ediiope;

Prripsoy UMiPShatve 5 UMKipo: RpPadeirnia, RA, 2005; NapabrookK oi Rpapptaseshisa! Ekhsiriepiv, 5Ii

Eapiop; NKome sei a!., Ed5., Te Rpaptasetsifsai! Rge55 apa She Ategisap Rpagtaseshisa! Avzosiyaop: 2005; and Napabook oi Rpaptaseshisa! Adaiimev, Za Eyaop; AvP apa Avp Ea5., Someg Rybiizpipa

Sotrapu: 2007; Rpagtaseciisa! Rhegoptiiainop apa Roptiiaiop, sirzop Ed., SAS Rgev5 GI S: Vosa

Wow, NO. 2004).

The term "pharmaceutical composition" refers to a mixture of a compound disclosed herein with other chemical components, such as diluents or carriers. The pharmaceutical composition facilitates the introduction of the compound into the body. In this field, there are many methods of administration of the compound, including, but not limited to, oral administration, injection, aerosol, parenteral administration, and topical administration. Pharmaceutical compositions can also be obtained by reacting compounds with inorganic or organic acids, such as hydrochloric acid,

hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid, etc.

Methods of treatment of breast cancer.

One embodiment provides a method of treating breast cancer in a patient, comprising (i) measuring the level of protein lysine acetylation prior to prescribing therapy with an oentinostat-aromatase inhibitor combination, (ii) prescribing therapy with an entinostat-aromatase inhibitor combination, (ii) measuring the level of protein lysine acetylation after the appointment of therapy with the combination of entinostat - an aromatase inhibitor, (i) comparison of the level of acetylation of protein lysine after the appointment of therapy with the combination of entinostat - an aromatase inhibitor with the level of acetylation of protein lysine before the appointment of therapy with the combination of entinostat - an aromatase inhibitor and (m) continuation of treatment by the combination of therapy with entinostat - an inhibitor aromatase, if the level of acetylation of protein lysine after the appointment of therapy with the combination of entinostat - aromatase inhibitor is greater than the level of acetylation of protein lysine before the appointment of therapy with the combination of entinostat - aromatase inhibitor.

One embodiment provides a method of treating breast cancer in a patient, comprising (i) prescribing therapy with a combination of entinostat - an aromatase inhibitor and (ii) determining a change in protein lysine acetylation levels during the course of said therapy compared to protein lysine acetylation levels before therapy.

One embodiment offers a method of treating breast cancer in a patient, which includes (i) determining the level of acetylation of protein lysine before prescribing, (ii) prescribing therapy with a combination of entinostat - an aromatase inhibitor, and (ii) determining the level of acetylation of protein lysine during the course of therapy.

Another embodiment offers a method that differs in that the determination of the change in the level of protein lysine acetylation during the course of said therapy occurs after about 2 days of therapy, about 5 days of therapy, about 7 days of therapy, about 15- you are on or about the 21st day of therapy.

Another embodiment offers a method that differs in that the levels of protein lysine acacetylation are obtained from a tissue sample selected from B-cells, T-cells or monocytes.

Another embodiment offers a method that differs in that the aromatase inhibitor is exemestane. Another embodiment offers a method that differs in that the aromatase inhibitor is anasrozole. Another embodiment offers a method that differs in that the aromatase inhibitor is letrozole. Another embodiment offers a method that differs in that the aromatase inhibitor is administered daily. Another embodiment offers a method that differs in that the aromatase inhibitor is exemestane and is administered daily. Another embodiment offers a method that differs in that etinostat is administered every 7 days of a 28-day cycle. Another embodiment offers a method that differs in that therapy with a combination of entinostat - an aromatase inhibitor includes oral administration of entinostat every 7 days of a 28-day cycle and oral administration of exemestane every other day.

Another embodiment offers a method that differs in that the step of determining the level of protein lysine acetylation during the course of therapy is performed more than once. Another embodiment offers a method that differs in that the step of determining the level of protein lysine acetylation is performed once during the course of therapy.

Another embodiment provides a method that further includes selecting a patient for further treatment if the level of protein lysine acetylation increases during a course of therapy.

Another embodiment provides the method further includes selecting a patient for further treatment if the level of protein lysine acetylation increases during the first week of therapy. Another embodiment offers a method that, in addition, includes selecting a patient for further treatment if the level of protein lysine acetylation increases during the first and second weeks of the course of therapy.

One embodiment offers a method of selecting a patient for further therapy with a combination of entinostat - an aromatase inhibitor, which includes comparing the level of protein lysine acetylation in a tissue sample obtained after the start of therapy with the levels of protein lysine acetylation determined before the start of therapy.

One embodiment provides a method of selecting a patient for further therapy with an entinostat - aromatase inhibitor combination, which includes comparing the level of protein lysine acetylation in a tissue sample obtained after the start of therapy with the levels of protein lysine acetylation 60 determined before the start of therapy, characterized in that the increase the level of protein lysine acetylation after the start of therapy indicates that the patient's condition will improve with further therapy.

Another embodiment offers a method that differs in that the level of protein lysine acetylation in a tissue sample obtained after the start of therapy is determined more than once. Another variant of implementation offers a method that differs in that the increase in the level of acetylation of protein lysine after the start of therapy occurs in a period of time of one week. Another embodiment offers a method that differs in that the level of protein lysine acetylation after the start of therapy is determined on days 2, 8 and 15.

Another embodiment provides a method characterized in that the increase is from about 10 95 to about 500 95. Another embodiment provides a method characterized in that the increase is from about 10 95 to about 400 95.

Another embodiment provides a method wherein the magnification is from about 10 95 to about 300 95. Another embodiment provides a method wherein the magnification is from about 10 95 to about 200 95. Another embodiment provides a method wherein the magnification is from about 1095 to about 100 95. Another embodiment provides a method wherein the magnification is approximately 10 95, approximately 20 95, approximately 30 95, approximately 40 95, approximately 50 95 or about 60 95. Another embodiment offers a method wherein the increase is about 25 95, about 50 95, about 75 95, about 100 95, about 125 95, or about 150 95.

Another embodiment offers a method that differs in that the tissue sample is selected from B cells, T cells, or monocytes.

Another embodiment offers a method that differs in that the tissue sample obtained after the start of therapy is obtained at least 2 days after the start of therapy. Another embodiment offers a method that differs in that the tissue sample obtained after the start of therapy is obtained between day 2 and day 28 after the start of therapy. Another embodiment provides a method wherein the post-treatment tissue sample is obtained on day 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 after starting therapy.

One embodiment provides a method of selecting a patient for further therapy with an entinostat-aromatase inhibitor combination, comprising comparing the percent change in protein lysine acetylation levels in a tissue sample obtained after initiation of therapy with protein lysine acetylation levels determined prior to initiation of therapy, which differs in that , that a percent reduction in protein lysine acetylation levels after initiation of therapy from approximately 5 95 to approximately 50 95 indicates that the patient will not improve with further therapy.

One embodiment provides a method of treating breast cancer that is resistant to prior therapy with an aromatase inhibitor, the method comprising administering to a patient a combination comprising entinostat and an aromatase inhibitor and characterized in that the patient has not demonstrated a complete response, partial response, or stable disease for more than than six months during prior aromatase inhibitor treatment.

Another embodiment offers a method that differs in that the patient has relapsed during treatment within b months after completing a previous course of a non-steroidal aromatase inhibitor prescribed as adjuvant therapy.

Another embodiment provides a method wherein the patient has demonstrated progressive disease after at least 3 months of treatment with a prior non-steroidal aromatase inhibitor.

Another embodiment offers a method that differs in that the breast cancer is EC-positive.

Another embodiment offers a method that differs in that the aromatase inhibitor administered in combination with entinostat is letrozole. Another embodiment offers a method that differs in that the aromatase inhibitor administered in combination with entinostat is anastrozole. Another embodiment offers a method that differs in that the aromatase inhibitor administered in combination with entinostat is exemestane.

Another embodiment offers a method that differs in that entinostagt and an aromatase inhibitor are administered sequentially in any order or simultaneously. Another embodiment offers a method that differs in that entinostat and an aromatase inhibitor are administered simultaneously. Another embodiment offers a method that differs in that the aromatase inhibitor is administered first. Another embodiment offers a method that differs in that the aromatase inhibitor is administered daily and the entinostat is administered periodically. Another embodiment 60 provides a method that differs in that the entinostat is administered weekly and the aromatase inhibitor is administered daily. Another embodiment offers a method that differs in that entinostat is introduced into the course of ongoing therapy with an aromatase inhibitor.

One embodiment provides a kit for the treatment of aromatase inhibitor-resistant breast cancer, which includes a combination of entinostat and an aromatase inhibitor and instructions for the administration of this dosage form.

Yet another embodiment provides a kit wherein the kit includes one dosage form of entinostat for every seven dosage forms of an aromatase inhibitor. Another embodiment offers a kit that is characterized in that the kit includes one dosage form of entinostat for every 14 dosage forms of an aromatase inhibitor. Another embodiment offers a kit, which differs in that the kit includes 4 dosage forms of entinostat and 28 dosage forms of an aromatase inhibitor. Another embodiment offers a kit, which differs in that the kit includes 4 dosage forms of entinostat and 56 dosage forms of an aromatase inhibitor.

Another embodiment offers a kit that differs in that the aromatase inhibitor is letrozole. Another embodiment offers a kit that differs in that the aromatase inhibitor is anastrozole. Another embodiment offers a kit that differs in that the aromatase inhibitor is exemestane.

Another embodiment provides a method further comprising administering to the patient one or more therapies in addition to the combination of entinostat and an aromatase inhibitor selected from the group consisting of: letrozole, anastrozole, or exemestane, or pharmaceutically acceptable salts, solvates, or prodrugs thereof.

Another embodiment provides a method wherein the one or more therapies include one or more of radiation therapy, chemotherapy, high-dose chemotherapy with stem cell transplantation, and monoclonal antibody therapy. Another embodiment offers a method that differs in that the radiation therapy includes internal iMabo external radiation therapy. Another embodiment provides a method wherein the chemotherapy comprises administering to the patient one or more of doxorubicin, cyclophosphamide, paclitaxel, lapatinib, capecitabine, trastuzumab, bevacizumab, gemcitabine, eribulin, or nab-paclitaxel.

From histone deacetylases

Histone deacetylases (HDEs) are a family of at least 18 enzymes grouped into three classes (Classes I, II, and PP). Class I SPEAs include, but are not limited to, SPEAs 1, 2, 3, and 8. Class I SPEAs can be located in the nucleus and are believed to be involved in repressors of transcriptional control. Class II SPLAs include, but are not limited to, SPLAs 4, 5, 6, 7, and 9, which can be located in the cytoplasm as well as in the nucleus. Class X NSAIDs are believed to be SUPER-dependent proteins and include, but are not limited to, members of the sirtuin family. Non-limiting examples of sirtuins include 5IKT1-7. As used herein, the term "selective NSAID" refers to an NSAID inhibitor that does not interact with all three classes of NSAID.

NAS inhibitors

NAAC inhibitors can be broadly classified as general NAAC inhibitors and selective NAAC inhibitors. Although there is a large structural diversity of known inhibitors

SPOAs, they share common features: a part that interacts with the active site of the enzyme and a side chain that is located in the channel leading to the active site. This can be seen with hybroxamates such as 5ANA, where the hydroxamate group is thought to interact with the active site. In the case of depsipeptides, intracellular reduction of the disulfide bond is believed to create a free thiol group (which interacts with the active site) attached to the 4-carbon alkenyl chain. The difference between SPOA inhibitors is how they interact with the edge of the SPOA channel, which is at the opposite end of the channel to the active site. It is this interaction between the NOAS inhibitor and the channel edge that is believed to be responsible, at least in part, for some of the observed differences in selectivity

NSAIDs between general-acting NSAIDs such as 5ANA and selective NSAIDs such as depsipeptides. Entinostat is a particularly preferred NOAA inhibitor. Entinostat has the chemical name and chemical structure shown below.

Min; what; MN" - M

M

Aromatase

Estrogen is one of the female sex hormones and performs many functions in the body.

Approximately 80 95 breast cancer tumors have been found to overexpress the estrogen receptor and respond positively to the presence of estrogen. Ovarian estrogen production is reduced in postmenopausal women, and plasma estrogen levels are usually lower than in premenopausal women.

The residual source of estrogen in postmenopausal women is the synthesis of estrogens from androgens, catalyzed by aromatase. Inhibition of aromatase activity should lead to a decrease in estrogen levels and, therefore, to a decrease in the growth of breast cancer tumors that respond positively to the presence of estrogen. Aromatase is an enzyme of the cytochrome P450 family and a product of the SUR19 gene. The chemical function of aromatase is to convert testosterone into estradiol and androstenedione into estrone.

Aromatase inhibitors

Aromatase inhibitors reduce estrogen levels in the body by blocking aromatase's conversion of androgen to estrogen. For the treatment of early-stage breast cancer, certain aromatase inhibitors can be used as adjuvant therapy instead of tamoxifen or after 2 or more years of tamoxifen. For the treatment of metastatic breast cancer, aromatase inhibitors are currently being tested in clinical trials to compare them with the hormone therapy tamoxifen.

As used herein, an "aromatase inhibitor" is a molecule that inhibits the activity of the aromatase enzyme. Compounds that are aromatase inhibitors can be readily identified by one skilled in the art using methods such as, for example, standard pharmacological assays that measure inhibition of the conversion of 1,2-3H-androstenedione to estrone.

Briefly, the microsomal fraction is prepared from human placenta in the manner described

Thompson and Siiteri (Tpotrzop apa 5iyegi) (9. Vioi. Spet., Moi. 249, p. 5364 (1974)). The microsomal preparation obtained in this way is lyophilized and stored at -40 C. Microsomes from the human placenta are added to 1,2-ZH-androstenedione and incubated for 20 minutes at 37 "C. The amount of aromatization of the observed substrate is detected by the loss of ZNO into the incubation medium. The substrate is removed by extraction with chloroform and then adsorption onto charcoal in suspension The charcoal is removed by centrifugation and the steroid-free medium

Zo is counted in a scintillation counter. The compositions are tested for aromatase inhibitor activity by adding them to the incubation medium before adding the microsomes. The relative number of scintillations per minute, obtained with and without the composition, is used to calculate the percent inhibition of aromatization of androstenedione into estrone. The ISbo value can be determined graphically as the concentration of the composition being tested, at which the aromatization of androstenedione into estrone is reduced by 50 9o from the control value.

ON On agotaiavze --- o no teviovieegope ezigadio o o agotaiavze - n- n--- o no apagosiepediope eziope

Subcutaneous fat is the main site of aromatase activity and it has been suggested that plasma estrogen levels correlate with body mass index (Longcope et al.

Meiaroiist 1986, 35, 235-7). It has been suggested that at menopause plasma estrogen levels fall from about 110 pg/ml to a much lower level of about 7 pg/ml. However, in postmenopausal women, intratumoral estradiol concentrations have been found to be approximately 10-fold higher than in plasma, possibly due to aromatase activity in the tumor.

Aromatase inhibition as a treatment option for breast cancer has been investigated with some success. Three aromatase inhibitors are currently approved in the US for the treatment of breast cancer at various stages in postmenopausal women. Letrozole (Betagat) is indicated for several treatment options, including extended adjuvant treatment of early-stage breast cancer in postmenopausal women with 5 years of prior tamoxifen treatment, treatment of postmenopausal women with locally advanced or metastatic breast cancer with positive (or unknown) hormone receptors and treatment of advanced breast cancer in postmenopausal women with disease progression after antiestrogen therapy.

Anastrozole (AgitidexF)) is indicated for several treatment options, including adjuvant therapy in postmenopausal women with early-stage hormone-receptor-positive breast cancer, initial treatment in postmenopausal women with locally advanced or metastatic hormone-receptor-positive breast cancer ( or unknown) and progressive breast cancer in postmenopausal women with disease progression after tamoxifen therapy.

Exemestane (AgotavzipF) is indicated for several treatment options, including adjuvant therapy in postmenopausal women with early-stage hormone-receptor-positive (g) breast cancer who have been treated with tamoxifen for 2-3 years and advanced breast cancer in postmenopausal women with disease progression after tamoxifen therapy.

M

- lyach DO Me 9 pk M. m. M

M Me

Mo SM Me sm cme SN"

Ye eygo20oie Apavzigog2oYe Ehetevziape

These drugs are grouped into two classes: (type 1) based on a steroidal chemical structure, and (type 2) letrozole and based on a non-steroidal chemical structure. Clinical trials have shown that letrozole is superior to tamoxifen in the treatment of progressive EC disease (w). In the early stage of the disease, adjuvant therapy with anastrozole appears to be superior to tamoxifen therapy in reducing the risk of relapse. The results of recent clinical trials have led to the replacement of tamoxifen with aromatase inhibitors as the standard of care for breast cancer.

From the gland.

Breast cancer

Today, among women in the United States, breast cancer remains the most frequently diagnosed cancer. One in 8 women in the US is at risk of developing breast cancer. Age, family history, diet, and genetic factors have been identified as risk factors for breast cancer. Breast cancer is the second leading cause of death among women.

NENg/pei-positive breast cancer

Cancer types associated with overexpression of NEK2g/pei include breast, ovarian, endometrial, prostate, gastric, salivary gland, pancreatic, colorectal, oral, and non-small cell lung cancers. Breast cancer is the main target of anti-HNg/PE treatment.

Approximately 25-30 95 breast cancers have amplifications of the NEK2/PEI gene or overexpression of its protein product. Overexpression of this receptor in breast cancer is associated with increased disease recurrence and worse prognosis.

Hormone-positive cancer

Many types of breast cancer need the hormone estrogen to grow. In menopausal women, the main source of estrogen is the conversion of androgens into estrogens. As mentioned above, this process is carried out by the aromatase enzyme.

Triple negative breast cancer

In the treatment of triple negative breast cancer, which is distinguished by the fact that the cancer is estrogen receptor negative, progesterone receptor negative and NEKZ2 negative, the compositions and therapies described herein can be combined with other therapeutic agents.

Such agents include, but are not limited to, the drugs cetuximab, paclitaxel, docetaxel, taxane, for example, ArgahapeF (AVI-007), RasiyaheI-Stetorpog EG, Rasiyahe! roiidishtekh and emulsion for injections of Rasiyaheya! (RIE). These combinations may be advantageous when a cancer association with HEK2 overexpression is present but not detected due to technical limitations of the assays used to quantify HEK2 expression.

Hormonal therapies are the mainstay of treatment for estrogen-receptor-positive (EC) breast cancer (BC). Because of the clinical activity and generally favorable side effect and tolerability profile of hormonal agents, the standard of care usually involves sequential administration of hormonal agents either until resistance develops or until visceral crises necessitate a switch to chemotherapy. In postmenopausal women, aromatase inhibitors (AIs) are the best class of anti-estrogen therapy that works by blocking the synthesis of endogenous estrogens. Exemestane is a steroidal IA that irreversibly binds and inactivates the aromatase enzyme with demonstrated efficacy in metastases after progression on non-steroidal IA (NSIA); i.e. letrozole or anastrozole (Chia S., Gradishar U., Moriak L., et al. (Spia 5, Ogadiepag UM, Mashgias JI, ei a): A double-blind, placebo-controlled, randomized trial of fulvestrant versus exemestane after pretreatment with a nonsteroidal inhibitor aromatase in postmenopausal women with advanced hormone receptor-positive breast cancer: results from EREST. U Siip Opsoi! 26:1664-1670, 2008).

The development of resistance to hormonal therapy in progressive breast cancer is a serious challenge. Putative mechanisms of resistance include estrogen-independent growth, hypersensitivity to low estrogen concentrations, overexpression of cyclins O1, activation of essential nuclear factor kappa B (MEkV), up-regulation of growth factor signaling pathways, and down-regulation of estrogen receptor alpha (ECa) expression. These pathways and mechanisms provide potential targets for therapeutic interventions. Entinostat is a novel, oral histone deacetylase (NSAID) inhibitor with high specificity for class 1 NSAIDS and a unique pharmacologic profile that allows for weekly administration. Inhibition of NAS leads to an increase in effective acetylation of protein lysine in tumor and peripheral blood cells, which serves as a surrogate potential pharmacodynamic

From activity marker. The class 1 specificity of entinostat distinguishes it from the US Food and Drug Administration (FDA)-approved NOAC inhibitors (NOACs) - vorinstat (20yiplaf) and romidepsin (isodachf). Prior to clinical trials, entinostat demonstrated inhibition of ECa-positive tumor growth and restoration of hormone sensitivity as a result of downregulation of estrogen-independent growth factor signaling pathways, normalization of ECa levels, and increased aromatase enzyme levels. (Sabnis G.J., Golubeva 0O,.,

Chumeri S. et al. (Zabpiz 3), sSoIoirema O, SpPitvegi 5, ei a): Functional activation of alpha-receptors of estrogens and aromatase by the NSAIDS inhibitor entinostat increases the sensitivity of EC-negative tumors to letrozole. Sapseg Kez 71:1893-903, 2011; Sabnis G.J., Kazi A., Golubeva

O., Brody AMH (Zarpi5 (y, Ka;i A, cSooiirema OO, Vgodie AMN). The NOAS inhibitor entinostat restores the reactivity of letrozole-resistant MCE-7Ca xenografts to aromatase inhibitors through modulation of Neg-2 (presented at the 33rd of the San Antonio Annual Breast Cancer Symposium, San Antonio, TX, December 8-12, 2010).The specific clinical trial results described herein demonstrate that the combination of entinostat with exemestane in EC-positive types breast cancer inhibits the mechanisms of resistance to hormonal therapy thereby increasing the sensitivity of cells to anti-estrogen therapy with exemestane.

Additional therapy

Additional breast cancer treatments are available that may be advantageously used in conjunction with the therapies disclosed herein, including, but not limited to, radiation therapy, chemotherapy, antibody therapy, and tyrosine kinase inhibitors as adjuvant therapy.

Radiation therapy is a cancer treatment that uses high-energy X-rays or other types of radiation to kill cancer cells or stop their growth. Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells or by stopping them from dividing. When chemotherapy is given by mouth or by injection into a vein or muscle, drugs enter the bloodstream and can reach cancer cells through the body (systemic chemotherapy). When chemotherapy is placed directly into the spine, an organ, or a body cavity such as the abdomen, the medicine mainly affects the cancer cells in those areas (regional chemotherapy). The method of chemotherapy depends on the type and stage of cancer.

Various chemotherapeutic agents for the treatment of breast cancer are known in this area.

Cytotoxic agents used in the treatment of breast cancer include doxorubicin, cyclophosphamide, methotrexate, 5-fluoracil, »mitomycin C, mitoxantrone, paxtaxel, taxane drugs such as, for example, AbgahapefF (AVI-007), RasiyacheI-Stetornog EI,

Russia! roiidishtekh and emulsion for injections-this Rasiyahe! (RIE), gemcitabine, docetaxel, capecitabine and epirubicin.

Another method of chemotherapy for breast cancer includes treatment with one or more of bendamustine, carboplatin (eg, RagariapF), carmustine (eg, VSMIOF), chlorambucil (eg, IkegapF), cisplatin (eg, RiaippoKe), injection of cyclophosphamide (eg, Suiohap (8), an oral cyclophosphamide (eg

SuyuhapF), dacarbazine (e.g. OTISF), ifosfamide (e.g. iechb), lomustine (e.g. CSMOF), mechlorethamine (e.g. nitrogen mustard, Myx5iagdep?t), melphalan (e.g. AiYKegapF), procarbazine (e.g. Maiyshi-iapeF ), bleomycin (for example,

ViepohapefF), doxorubicin (e.g. LagpatusipF, KybrekhFf), epirubicin, idarubicin (e.g. Idatusip F), mitoxantrone (e.g. Momapigope F), gemcitabine (e.g.

Set?lag), oral mercaptopurine (for example, Rigipeipo!F). methotrexate, pentostatin

IM (e.g. MirepiF), oral thioguanine (e.g. Iapmi5F)), oral etoposide (e.g. MP-16, MeReziF, Eororpo5) - IM etoposide (e.g. MP-16, MeReziaf,

Eurorpo5), vinblastine (e.g. MeIrapPf)), vincristine (e.g. OpsomipF)), vinorelbine (e.g. MameIripe (8), dexamethasone (e.g. OyuOesaigopF), methylprednisolone (e.g. MeagoiF)), and prednisone (e.g. OeCazopef) ).

Monoclonal antibody therapy is a cancer treatment that uses antibodies obtained in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that can promote the growth of cancer cells. Antibodies attach to these substances and kill cancer cells, block their growth or prevent them from spreading. Monoclonal antibodies are administered by infusion. They can be used as such or deliver drugs, toxins or radioactive material directly to cancer cells. Monoclonal antibodies are also used in combination with chemotherapy as adjuvant therapy.

Zo Trastuzumab (NegseriiptF) is a monoclonal antibody that blocks the effects of the growth factor protein NEK2, which transmits signals for the growth of breast cancer cells.

Trastuzumab results in clinical responses as a single agent and improves survival when added to chemotherapy for advanced HEK2-positive breast cancer.

However, some patients do not respond to trastuzumab and eventually develop clinical resistance. Mechanisms of intrinsic and acquired resistance to trastuzumab are currently poorly understood. One study was reported that used a cell line-based approach to identify genetic and protein changes associated with resistance (D. Tripathi et al. Mo 165, 3121). These investigators studied two NENK2-positive breast cancer cell lines (81474 and ZKVVAZ) that were sequentially passaged in the presence of trastuzumab until IP myo resistance was documented. Resistant cell lines emerged after 12 months and showed three times faster growth in the absence of trastuzumab. After exposure to trastuzumab, there was a 10/21 stop in sensitivity compared to resistant cells (84 vs 68 95), with fewer cells in phase 5 (Z vs 14 95). Resistant cell lines showed fewer changes in gene expression with trastuzumab, as well as up-regulation of the chemokine receptor SCHSONBA and mitotic checkpoint regulators and down-regulation of RTEM compared to sensitive cells.

Additional illustrative methods of treatment that may be advantageously combined with the compositions and therapies disclosed herein may include, without limitation,

BO administration of agents including, but not limited to, lapatinib alone or in combination with capecitabine, doxetaxel, epirubicin, epothilone A, B or 0, goserelin acetate, paclitaxel, pamidronate, bevacizumab, or trastuzumab.

In some embodiments, the additional therapy includes chemotherapy comprising administering to the subject one or more of doxorubicin, cyclophosphamide, paclitaxel, lapatinib, capecitabine, trastuzumab, bevacizumab, gemcitabine, eribulin, or nab-paclitaxel.

Oral drugs

Oral preparations containing the active pharmaceutical ingredients described herein may include any conventionally used oral form, including tablets, capsules, pills, lozenges, lozenges, granules, medicated chewing gum, bulk powders, whether effervescent or non-effervescent powders, or granules. , solutions, emulsions, suspensions, wafers, sprays, elixirs,

syrups, buccal forms and liquids. Capsules may contain mixtures of active compounds with inert fillers or diluents, such as pharmaceutically acceptable starches (eg, corn, potato, or tapioca), sugars, artificial sweeteners, powdered celluloses, such as crystalline and microcrystalline celluloses, flour, gelatin, gum, and the like. Suitable tablet formulations may be prepared by conventional compression, wet granulation or dry granulation using pharmaceutically acceptable diluents, binders, lubricants, disintegrating agents, surface modifying agents (including surfactants), suspending or stabilizing agents including, but not limited to, magnesium stearate, stearic acid, talc, sodium lauryl sulfate, microcrystalline cellulose, calcium carboxymethyl cellulose, polyvinylpyrrolidone, gelatin, alginic acid, gum arabic, xanthan gum, sodium citrate, complex silicates, calcium carbonate, glycine, dextrin, sucrose, sorbitol , dicalcium phosphate, calcium sulfate, lactose, kaolin, mannitol, sodium chloride, talc, dry starches and powdered sugar. In some embodiments, surface modifying agents are used, which include nonionic and anionic surface modifying agents.

For example, surface-modifying agents include, but are not limited to, poloxamer 188, benzalkonium chloride, calcium stearate, cetostearyl alcohol, cetomacrocephalic emulsion wax, sorbitan ethers, colloidal silicon dioxide, phosphates, sodium dodecyl sulfate, magnesium aluminum silicate, magnesium aluminum silicate, and triethanolamine. . Oral preparations herein may include standard preparations for delaying or delaying the absorption of active compounds. The oral preparation may also consist of the active ingredient in water or fruit juice containing the necessary solubilizers or emulsifiers.

Oral administration

As stated herein, the combination therapy described herein may be given simultaneously or in a staggered manner, with the entinostat being given at a different time during the course of chemotherapy than the aromatase inhibitor. This difference in time between the introduction of two connections can be several minutes, hours, days, weeks or more. Therefore, the term "combination" does not necessarily mean administration at the same time or as a single dose, but means that each of

The components are administered during the desired period of treatment. Agents can also be administered by various routes. As is typical of chemotherapy regimens, the chemotherapy regimen may be repeated several weeks later and may be with the same time frame for administration of the two compounds or may be modified based on patient response.

In other embodiments, the pharmaceutical compositions provided herein may be presented in solid, semi-solid, or liquid dosage forms for oral administration.

As used herein, the term "oral administration" also includes buccal, lingual, and sublingual administration. Suitable oral dosage forms include, but are not limited to, tablets, capsules, pills, cakes, lozenges, granules, medicated chewing gum, bulk powders, effervescent or non-effervescent powders, or granules, solutions, emulsions, suspensions, wafers, sprays, elixirs and syrups . In addition to the active ingredient (or ingredients), the pharmaceutical compositions may contain one or more pharmaceutically acceptable carriers or excipients, including, but not limited to, binders, fillers, diluents, disintegrants, wetting agents, lubricants, flow regulators, colorants, dye migration inhibitors, sweeteners and flavorings.

Binders or granulators give the tablet cohesiveness to ensure the integrity of the tablet after compression. Suitable binders or granulators include, but are not limited to, starches such as corn starch, potato starch, and pregelatinized starch (eg, ZTAKSN 1500); gelatin; sugars such as sucrose, glucose, dextrose, molasses and lactose; natural and synthetic gums such as gum arabic, alginic acid, alginates, carrageenan extract, panwar gum, gatti gum, plantain seed gum, carboxymethyl cellulose, methyl cellulose, polyvinylpyrrolidone (PVP), wigum, larch arabinogalactan, tragacanth powder, and guar gum ; celluloses, such as ethyl cellulose, cellulose acetate, calcium carboxymethyl cellulose, sodium carboxymethyl cellulose, methyl cellulose, hydroxyethyl cellulose (HES), hydroxypropyl cellulose (HPC), hydroxypropyl methyl cellulose (HPLC); microcrystalline cellulose, such as AMISEG-RN-101, AMISEG-RN-103, AMISEI VO-581, AMISEI -RN-105 (company

EMC Sogr., Marcus-Hook, Pennsylvania) and their mixtures. Suitable excipients include, but are not limited to, talc, calcium carbonate, microcrystalline cellulose, powdered cellulose, dextrates, kaolin, mannitol, silicic acid, sorbitol, starch, pregelatinized starch, and mixtures thereof. The binder or excipient may be present in the pharmaceutical compositions provided herein in an amount of from about 50 to about 99% by weight.

Suitable diluents include, but are not limited to, dicalcium phosphate, calcium sulfate, lactose, sorbitol, sucrose, inositol, cellulose, kaolin, mannitol, sodium chloride, dry starch, and powdered sugar. Certain diluents, such as mannitol, lactose, sorbitol, sucrose, and inositol, when present in sufficient amounts, can impart properties to compressed tablets that allow them to disintegrate in the mouth when chewed. Such pressed tablets can be used as chewable tablets.

Suitable disintegrants include, but are not limited to, agar; bentonite; celluloses such as methylcellulose and carboxymethylcellulose; wood products; natural sponge; cation exchange resins; alginic acid; gums such as guar gum and wigum NM; citrus pulp; crosslinked celluloses such as croscarmellose; cross-linked polymers such as crospovidone; cross-linked starches; calcium carbonate; microcrystalline cellulose, such as sodium starch glycolate; Polacrylin potassium; starches such as corn starch, potato starch, tapioca starch and pregelatinized starch; clay; substances "aiydp5"; and mixtures of the above.

The amount of disintegrant in the pharmaceutical compositions proposed here varies depending on the type of drug and is easily understood by those of ordinary skill in the art.

The pharmaceutical compositions provided herein may contain a disintegrant in an amount of about 0.5 to about 15 95 or about 1 to about 5 95 by weight.

Suitable lubricants include, but are not limited to, calcium stearate; magnesium stearate; mineral oil; light mineral oil; glycerin; sorbitol; mannitol; glycols such as glycerol behenate and polyethylene glycol (PES); stearic acid; sodium lauryl sulfate; talc; hydrogenated vegetable oil, including chestnut oil, cottonseed oil, sunflower oil, sesame oil, olive oil, corn oil, and soybean oil; zinc stearate; ethyl oleate; ethyl laurate; agar; starch; lycopodium; silicon dioxide or silica gels such as

AEKOFBI 8,200 (MUK Ogase So. company, Baltimore, Maryland) and SAV-O-51| F (the company Saboi So.,

Boston, Massachusetts); and mixtures of the above. The pharmaceutical compositions provided herein may contain lubricants in an amount of from about 0.1 to about 5 95 by weight.

Suitable flow regulators include colloidal silicon dioxide, SAV-O-51(8

Zo (Saboy Co., Boston, Mass.) and talc, which does not contain asbestos. Dyes include any of the approved, certified, water-soluble BO 8. C water-insoluble dyes

EO "4. With dyes suspended on aluminum hydrate, colorful varnishes and mixtures of the above.

Colorful varnish is obtained by combining a water-soluble dye with an aqueous oxide of a heavy metal, which gives an insoluble form of such a dye. Flavorings include natural flavors extracted from plants, such as fruit, and synthetic mixtures of compounds that impart a pleasant taste sensation, such as peppermint and methyl salicylate. Sweeteners include sucrose, lactose, mannitol, syrups, glycerin, and artificial sweeteners such as saccharin and aspartame. Suitable emulsifiers include gelatin, gum arabic, tragacanth, bentonite and surfactants such as polyoxyethylene sorbitan monooleate (TUUMEEME 20), polyoxyethylene sorbitan monooleate 80 (TMUEEMF 80) and triethanolaminooleate. Suspending and dispersing agents include sodium carboxymethyl cellulose, pectin, tragacanth, wigum, gum arabic, sodium carboxymethyl cellulose, hydroxypropyl cellulose and polyvinylpyrrolidone.

Preservatives include glycerin, methyl and propylparaben, benzoic acid, sodium benzoate and alcohol. Wetting agents include propylene glycol monostearate, sorbitan monooleate, diethylene glycol monolaurate, and polyoxyethylene lauryl ether. Solvents include glycerin, sorbitol, ethyl alcohol and syrup. Examples of such liquids used in emulsions include mineral oil and cottonseed oil. Organic acids include citric and tartaric acids. Sources of carbon dioxide include sodium bicarbonate and sodium carbonate.

It should be understood that many carriers and fillers can perform several functions, even in a single preparation.

In other embodiments, the pharmaceutical compositions provided herein may be presented as compressed tablets, pulverulent tablets, chewable tablets, fast-dissolving tablets, multi-compressed tablets or enteric-coated tablets, sugar- or film-coated tablets. Enteric-coated tablets are coated with substances that resist the action of stomach acid, but dissolve or disintegrate in the intestine, thus protecting the active ingredients from the acidic environment of the stomach.

Enteric coatings include, but are not limited to, fatty acids, fats, phenyl salicylate, waxes, shellac, ammoniated shellac, and cellulose acetate phthalates. The 60 sugar-coated pressed tablets are surrounded by a sugar coating, which may be suitable to mask objectionable tastes or odors and to protect the tablets from oxidation. Film-coated compressed tablets are coated with a thin layer or film of a water-soluble material. Film coatings include, but are not limited to, hydroxyethyl cellulose, sodium carboxymethyl cellulose, polyethylene glycol 4000, and cellulose acetate phthalate. The film coating gives the tablet the same general characteristics as the sugar coating. Multi-compressed tablets are tablets made in more than one compression cycle, including laminated tablets and press-coated or dry-coated tablets.

Tablet dosage forms may be prepared from the active ingredient in powder, crystalline, or granular forms, alone or in combination with one or more of the carriers or excipients specified herein, including binders, disintegrants, controlled release polymers, lubricants, diluents, and/or dyes Flavorings and sweeteners are especially suitable for the production of chewable tablets and lozenges.

The pharmaceutical compositions provided here can be presented as soft or hard capsules, which can be made of gelatin, methylcellulose, starch or calcium alginate. A hard gelatin capsule, also known as a dry-fill capsule, consists of two sections, one of which overlaps the other, thus completely enclosing the active ingredient. A soft elastic capsule is a soft spherical shell, such as a gelatin shell, which is plasticized by adding glycerin, sorbitol or a similar polyol. Soft gelatin shells may contain a preservative to prevent the growth of microorganisms.

Suitable preservatives are those specified herein, including methyl and propylarabene and sorbic acid. The liquid, semi-solid and solid dosage forms indicated here can be placed in the capsule. Suitable liquid and semi-solid dosage forms include solutions and suspensions in propylene carbonate, vegetable oils or triglycerides. Capsules containing such solutions may be prepared as described in US Pat. Nos. 4,328,245, 4,409,239 and 4,410,545. Capsules can also be coated by methods known to those skilled in the art to modify or prolong the dissolution of the active ingredient.

In other embodiments, the pharmaceutical compositions proposed here can be presented in liquid and semi-solid dosage forms, including emulsions, solutions, suspensions,

From elixirs and syrups. An emulsion is a two-phase system in which one liquid is dispersed in the form of small droplets in another liquid and which can be of the oil-in-water or water-in-oil type. Emulsions may include a pharmaceutically acceptable non-aqueous liquid or solvent, an emulsifier, and a preservative. Suspensions may include a pharmaceutically acceptable suspending agent and a preservative. Aqueous alcohol solutions may include a pharmaceutically acceptable acetal, such as di(lower alkyl) acetal (lower alkyl) aldehyde (the term "lower" means alkyl having from 1 to 6 carbon atoms), for example, diethyl acetal of acetaldehyde; and a water-miscible solvent having one or more hydroxyl groups, such as propylene glycol and ethanol. Elixirs are transparent, sweetened and water-alcohol solutions. Syrups are concentrated aqueous solutions of sugar, such as sucrose, which may also contain a preservative. For a liquid dosage form, for example, a solution in polyethylene glycol may be diluted with a sufficient amount of a pharmaceutically acceptable liquid carrier, such as water, so that it can be conveniently measured for administration.

Other suitable liquid and semisolid dosage forms include, but are not limited to, those containing the active ingredient (or ingredients) proposed herein, and dialkylated mono- or polyalkylene glycols, including 1,2-dimethoxymethane, diglyme, triglyme, tetraglyme, polyethylene glycol-350- dimethyl ether, polyethylene glycol-250-dimethyl ether, polyethylene glycol-750-dimethyl ether, where 350, 550 and 750 refer to the approximate average molecular weight of polyethylene glycol. These preparations may also include one or more antioxidants such as butylated hydroxytoluene (BHT), butylated hydroxyanisole (BHA), propyl gallate, vitamin E, hydroquinone, hydroxycoumarins, ethanolamine, lecithin, cephalin, ascorbic acid, malic acid, sorbitol, phosphoric acid, bisulfite, sodium metabisulfite, thiodipropionic acid and its esters and dithiocarbamates.

The pharmaceutical compositions for oral administration provided herein may also be presented in the form of liposomes, micelles, microspheres or nanosystems. Micellar dosage forms can be prepared as described in US Pat. No. 6,350,458.

In other embodiments, the pharmaceutical compositions provided herein may be presented as non-effervescent or effervescent granules and powders to be converted into a liquid dosage form. Pharmaceutically acceptable carriers and excipients used in non-effervescent granules or powders may include diluents, sweeteners, and wetting agents. Pharmaceutically acceptable carriers and excipients used in effervescent granules or powders may include organic acids and a source of carbon dioxide.

Dyes and flavors can be used in all of the above dosage forms.

The pharmaceutical compositions provided herein may be formulated as immediate or modified release dosage forms, including sustained, sustained, pulsed, controlled, targeted and programmed release forms.

In other embodiments, the pharmaceutical compositions provided herein may be formulated with other active ingredients that do not impair the desired therapeutic effect, or with substances that complement the desired effect.

Examples

An example of her

A randomized, double-blind, Phase 2 study of exemestane with and without enthinstat in postmenopausal women with locally recurrent or metastatic estrogen receptor-positive breast cancer progressing on nonsteroidal aromatase inhibitor therapy.

The purpose of this study is to evaluate the safety and efficacy of entinostat in combination with exemestane in the treatment of advanced breast cancer.

The primary endpoint is a comparison of the efficacy of exemestane alone with exemestane plus entinostat, as measured by progression-free survival (PFS) measured from the date of randomisation.

Secondary endpoints are to compare objective response rate (ORR) and clinical benefit index (CBI) and to assess the safety and tolerability of entinostat in combination with exemestane as measured by adverse events (AEs) and laboratory safety parameters.

Scheme of the study. 1 Grula.7////////////7СсС1С 1: Experimental Medicines: entinostat exemestane (aromasin) 25 mg in the morning plus entinostat |5MOX-275 tablet 5 mg PO once 5 mg orally (PO) once per week to week

Interventions: Medication: exemestane

Medicines: entinostat exemestane 25 mg PO 00

Drug: exemestane Other name: aromasin 2: Placebo for comparison. exemestane 25 mg PO 00 once a week,

I Another name: aromasin

Interventions: Medication: exemestane

Criteria for inclusion in the study

Eligible age for study: 18 years and older

Eligible gender for the study: women

Reception of healthy volunteers: none

Coo)

Inclusion criteria: - postmenopausal female patients - histologically or cytologically confirmed EC breast cancer - recurrence or progression on prior aromatase inhibitor treatment - metastatic disease must be measurable - patients receiving palliative radiation to non-targeted lesions must have a 2-week washout period after completion of treatment before inclusion - patient may have had one prior chemotherapy as part of first-line therapy, if it was received before the start of prior aromatase inhibition - ESOS performance status: 0-1 - Laboratory parameters: a) hemoglobin 29.0 g/dL; platelets 2100.0x109/l; AMC21.5x109/l without the use of hematopoietic growth factors; B) creatinine is less than 2.5 times the upper limit of the normal level for the institution; c) A5T and BP less than 2.5 times the upper limit of the normal level for the institution - Ability to understand and give written informed consent and follow research procedures

Exclusion criteria: - Relapse on nonsteroidal aromatase inhibitor treatment after less than 12 months for patients in the adjuvant regimen - Progressive disease less than 3 months after treatment with the most recent aromatase inhibitor for patients with metastatic disease - Rapidly progressive, life-threatening metastases - Any palliative radiotherapy to a measurable lesion - Prior treatment with 5MOX-275 or any other NSAID inhibitor including valproic acid - Allergy to benzamides or inactive ingredients of the study medication - History of allergy to any active or inactive ingredients of exemestane - Any co-existing medical condition that prevents adequate adherence to study treatment - Patient is currently enrolled in (or completed within 30 days prior to study drug administration) another drug trial - Patient is currently receiving treatment with valproic acid, 20mg7a (vorinostat), or any another NOAS inhibitor, or an inhibitor DNA methyltransferases or any systemic anticancer treatment (except Lupron)

Fig. 1 provides a summary of the Phase 2 clinical trial, indicating the dosing schedule for the treatment groups.

Fig. 2 provides a summary of the inclusion criteria for the Phase 2 clinical trial, detailing eligible prior treatment.

Fig. C provides a brief overview of the patient population included in the Phase 2 clinical trial.

Fig. 4 provides a detailed analysis of the patient population included in the Phase 2 clinical trial.

Fig. 5 provides a summary of progression-free survival during the clinical trial

Phase 2. The placebo group (exemestane only) had a median PFS of 2.3 months, the treatment group (exemestane and entinostat) had a median PFS of 4.3 months.

Fig. 6 provides a subgroup analysis of benefit in the Phase 2 clinical trial. Patients with hormone resistance showed a better outcome.

From Fig. 7 provides an analysis of the change in tumor volume and response type observed during the Phase 2 clinical trial.

Fig. 8 summarizes the overall survival observed in the Phase 2 clinical trial.

Fig. 9 provides a summary of the adverse effects observed during the Phase 2 clinical trial. The combination of exemestane and entinostat was well tolerated.

Fig. 10 provides a general summary of the Phase 2 clinical trial.

The clinical trial described in Example 1a was a multicenter, randomized, double-blind, placebo-controlled, Phase 2 study of exemestane with and without entinostat in 130 postmenopausal women with locally recurrent or metastatic estrogen receptor-positive breast cancer that had progressed on nonsteroidal therapy. aromatase inhibitors anastrozole or letrozole. The primary endpoint of the study was progression-free survival. Other endpoints included objective response rate (OSR), clinical benefit index (CBI), overall survival (OS), safety, and tolerability. All patients had previously received hormonal therapy (1 previous line 42 905; »1 previous line 58 Fo), and 33 9o had received previous chemotherapy for advanced breast cancer. The results of this study in well-balanced groups included the following: - in the treatment-assigned population, progression-free survival was significantly longer (defined prospectively as 1-sided p of 0.10) on exemestane plus entinostat than on exemestane plus placebo (4.28 vs 2.27 months, respectively; risk of death (RS)-0.73; p-0.06); - in the treatment-assigned population, with a median follow-up of 18 months, overall survival was significantly longer on exemestane plus entinostat than on exemestane plus placebo (26.94 vs. 20.33 months, respectively; risk of death (RS)-0, 56; p-0.027); - in the subgroup of patients on entinostat with data on protein acetylation (27 patients), average

PFS increased by more than six months in patients showing hyperacetylation of protein lysine; - entinostat in combination with exemestane was well tolerated by patients with adverse events (AEs), which most frequently occurred, consisting of fatigue, 60 gastrointestinal disorders, and hematological abnormalities; and

- the rate of serious AEs was similar for exemestane plus entinostat (13 95) and exemestane plus placebo (12 95).

The study showed that patients who received entinostat with exemestane hormone therapy lived longer without their disease getting worse than patients who received exemestane alone. Entinostat in combination with exemestane prolonged progression-free survival, reduced the risk of disease progression by 27 95, and showed an improvement in overall survival for postmenopausal women with estrogen receptor-positive metastatic breast cancer. In a subset of patients evaluated for entinostat efficacy by a pharmacodynamic measure, this study demonstrated evidence of an association of protein lysine hyperacetylation with positive clinical outcome.

Example 16

At a 23-month follow-up of patients enrolled in the Phase 2 study described in Example Ta, a multicenter, randomized, double-blind, placebo-controlled, Phase 2 study of exemestane with and without entinostat in 130 patients with locally recurrent or metastatic, positive to of estrogen receptors in breast cancer, the median overall survival of patients on exemestane plus entinostat was 26.9 months versus 19.8 months on exemestane plus placebo. This represents a 42 95th reduction (p-0.04) in the risk of death for these patients. Earlier data from this study demonstrated a near doubling of progression-free survival (PFS) (4.3 vs. 2.3 months) with exemestane plus entinostat and identified a subgroup of these patients whose median PFS was 8.5 months.

The conclusion is that after two years of follow-up of patients on entinostat and exemestane, the benefit was an additional seven months of overall survival. This study showed not only an advantage in progression-free survival (4.3 months vs. 2.3 months), but also an advantage in overall survival for this combination, which, together with the excellent safety and tolerability profile, provides evidence of the benefit of this therapy.

Key data at 23-month follow-up include: - overall survival: 26.9 months on exemestane and entinostat versus 19.8 months on exemestane and placebo; RS - 0.58 (95 95 CI: 0.34, 0.97); p-0.04;

Zo - progression-free survival: 4.3 months on exemestane and entinostat versus 2.3 months on exemestane and placebo; RS-0.73 (95595 01: 0.49, 1.09); p-0.06; 1-sided significance is prospectively defined as “0.10; - progression-free survival of 8.5 months on exemestane and entinostat in the subgroup of patients with increased protein acetylation versus 2.8 months without it; RS - 0.32 (95 95 C1: 0.13, 0.79); - trend toward improved progression-free survival in hormone-resistant versus hormone-sensitive patients; and - exemestane in combination with entinostat was well tolerated, and the most frequent adverse effects were fatigue, gastrointestinal disturbances, and hematologic abnormalities.

Example 1c

A confirmatory Phase 2 study

The primary endpoint was progression-free survival (PFS). Peripheral blood mononuclear cells were taken from a subset of patients pre-dose and post-dose in cycle 1 to assess protein lysine acetylation as a biomarker of entinostat activity (Fig. 11).

Patients and methods

Study design: This was a randomized, double-blind, placebo-controlled Phase 2 study of exemestane and entinostat in patients with locally advanced or metastatic breast cancer that had progressed on a nonsteroidal aromatase inhibitor (Figure 12). 130 patients were selected between June 2008 and July 2010 at 38 sites in Northern

America, Central Europe and Russia. All patients gave written informed consent. Patients were randomized 1:11 using a blocked randomization design to exemestane plus entinostat (EE; n-64) or exemestane plus placebo (EP; n-66b). Randomization was stratified by 1) prior treatment with a nonsteroidal aromatase inhibitor (adjuvant/metastatic); 2) metastases only in bones (yes/no); and 3) geographic region (North America/Central Europe and Russia). The randomization schedule was prepared and maintained by an independent statistical service provider. This protocol allowed the inclusion of approximately 20,95 patients with unmeasurable disease. Treatment with exemestane 25 mg orally (PO) once daily plus entinostat 5 mg or placebo PO once weekly was continued until disease progression (PO) or unacceptable toxicity.

Inclusion criteria: postmenopausal women with EC-positive RMU who at that time experienced disease relapse or progression while receiving a non-steroidal aromatase inhibitor (NSI) were eligible for inclusion. Patients either had 1) relapse after at least 12 months of adjuvant NSIA treatment, or 2) progression after at least 3 months of NSIA treatment in a metastatic/progressive state. One previous line of chemotherapy for metastases was allowed if it was performed before the most recent NSIA. Patients must have had at least 1 measurable lesion area (220 mm by conventional methods or 210 mm by spiral computed tomography) within 4 weeks before the start of the study

YCTI), or bone metastases only, positive bone scan confirmed by magnetic resonance imaging (MRI) or positron emission tomography (PET)-CT. Additional requirements included: status 0 or 1 performance of the Eastern United Group of Oncologists (ESObS); adequate hematological parameters; levels of creatinine, aspartate transaminase and alanine transaminase "2.5 times the upper limit of normal. Patients with prior fulvestrant, exemestane, entinstat, or any other NOAA inhibitor were excluded.

Procedures and treatment: The duration of treatment cycles was 28 days. Patients were evaluated on days 1, 8, and 15 during cycle 1 and on day 1 of all subsequent cycles. Peripheral blood samples were obtained from a subset of patients pre- and post-dose on days 1, 8, or 15 of cycle 1. Patient response/disease assessments were performed on day 22 of cycle 2 and every other cycle thereafter. After completion of the study, patients were followed up to assess overall survival and subsequent therapies. Patients were to be followed until death, withdrawal of consent, or termination of the study by the sponsor.

Assessments

Safety Assessment: Safety was assessed by adverse events using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0, electrocardiograms, hematology and serum biochemistry, ESOS performance status, and vital signs.

Efficacy assessment: Disease was assessed using the Response Evaluation Criteria in Solid Tumors (RESCIT), version 1.0. Contrast-enhanced CT scans were obtained at baseline, every second cycle for 12 months, and every third cycle thereafter. PW was also assessed by bone scan and clinical symptoms in appropriate cases.

Endpoints: The primary endpoint was PFS, defined as the number of months from

From randomization to documented PW or death from any cause. Secondary endpoints included overall response (S; complete response IPR| and partial response |CRI) and indicators of clinical benefit (PCV; SR and stable disease |SZ| during 26 months). Overall survival (OS) was the endpoint studied. Predefined subgroups were included

NSIA-sensitive: patients who had a PR, CR, or CVD within 6 months of previous NSIA therapy in a progressive state or who relapsed within at least 1 year after completion of adjuvant NSIA, and NSIA-resistant: all other patients.

Research pharmacodynamics: acetylation of protein lysine was measured by multiparameter flow cytometry in peripheral blood mononuclear cells (PBMCs: CO019-B cells, COZ-T cells and CO14 monocytes) taken before and after treatment on days 1, 8 and 15 of cycle 1 to investigate the association with BBP.

Statistical methods

Chia et al (Spia, et al.) reported a median PFS of 3.7 months on exemestane in the treatment of advanced BC showing PZ or relapse after NSIA. The addition of entinostat to exemestane was hypothesized to increase median PFS by 2.3 months (ie, from 3.7 to 6.0 months), corresponding to a target risk of death (RR) of 0.62. For the primary analysis of PFS, a total of 77 progression events were required to detect such an improvement in ROS with a possibility of 280,956, a one-tailed significance level of 0.10, and the construction of lifetime curves. A total of 92 events were required for a probability of 85,905, and 112 events were required for a probability of 90,96. The original type 1 and 2 error rates selected for this study and the target treatment effect size are consistent with those proposed by Rubenstein et al. (Kybepzieip, ei ai.) ii Kornom et al. (Cop, ei a), for screening studies of Phase 2 (Kibipeieip

YM, Kot EIH, Egeidiip V, EI AI: Design issues for Phase 2 randomized trials and a proposal for Phase 2 screening trials. in Siip Opsoi 23:7199-7206, 2005; Cop EI,

Agrisk 5a, Ritsaa OM, ey a): Clinical trial schemes for cytostatic agents: are new approaches needed? .) Siip Opsoi 19:265-272, 2001).

PFS was summarized descriptively using the Kaplan-Meier method and reported based on 116 progression events from March 2012. MS was assessed using a stratified Soch proportional hazards model, with placebo as the base point in the calculations. The primary logical comparison between groups was performed using the construction of life curves stratified by three factors of randomization. For patients who died before documenting the PW,

the date of death was used as the date of PP. PFS duration was right-censored at last disease assessment for patients who started unspecified anticancer therapy, were lost to follow-up, or had no documented PFS.

Multivariate Soh models were used to determine whether the reduced risk of death in PFS and CV attributable to entinostat treatment was still present in a univariate model after accounting for patient, disease, and prior treatment factors. Efficacy analyzes were performed using the treatment-assigned population, defined as all randomized patients. All reported p-values are one-tailed and evaluated at a significance level of 0.10.

Safety analyzes were performed using the safety population (all patients who received 21 doses of entinostat/placebo). Security was assessed by an independent data security review board. All investigators and participating patients remained blinded to the treatment used in the study, as follow-up for CV after treatment is ongoing.

The association of PFS with the degree of change in protein lysine acetylation from baseline in PCOS was assessed as an exploratory a posteriori analysis in a patient subgroup using the Soh proportional hazard model. Analyzes of all three cell types (B cells, T cells, monocytes) were performed for uniformity of results and to assist in selecting the optimal cell type for analysis in future studies.

The results

Patient characteristics: a total of 130 patients were randomized, 64 to EE and 66 to

EP (Fig. 12). The treatment groups were generally well balanced with the exception of cytomegaly (53 to EE vs. 67 95 EP), the average duration since the initial diagnosis of BC (7.9 years

EE vs. 4.6 years EP) and the average duration since the diagnosis of progressive breast cancer (19.5 vs. 17.2 months, respectively).

Of the 130 randomized patients, 85 (EE-45, EP-40) met the study definition (see Endpoints) of NSIA-sensitive (1 progressed after adjuvant NSIA and 84 progressed after metastatic OSA), and 45 (EE- 19, EP-26) were NSIA-resistant (18 progressed after adjuvant NOS, and 27 progressed after metastatic NSIA).

Effectiveness: in the population with prescribed treatment, the average PFS was 4.3 months on EE versus 2.3 months on EP with RS-O.73; 95 95 SI 0.50, 1.07; p-0.055 (significant according to the previously defined criterion of the research scheme). The advantage in PFS with EE was consistent in all subgroups of prognostic importance, including patients with acquired resistance (NSIA-susceptible;

RS-O,85; n-85) and primary resistance (NSIA-resistant; RSO-0O,47; n-45). ZR and PCV were similar for EE and EP (OR: 6.3 95 and 4.6 95, respectively; PCV: 28.1 95 and 25.8 95, respectively). The average length of stay was 28.1 months (EE) and 19.8 months (EP); ROS 0.59; SI 0.36, 0.97; p-0.018 with mortality 42 95 for EE and 65 95 for EP. Multivariate analyzes showed favorable results in PFS and ZV for EE vs

EP after adjustment for baseline factors, including cytomegaly and duration of diagnosis of progressive PM3.

Safety: A total of 129 patients (EEE-63, EP-6b) were in the safety population. One EE patient withdrew from the study before receiving treatment. Compared to patients on EP, patients on EE had a higher frequency of NP (95 95 vs. 85 95), Type (B) C NP (44 95 vs. 23 9o), B4 NP (6 9o vs. C 95), NP, before modification doses (35,905 vs. 6,9b), and AEs leading to study discontinuation (11,95 vs. 2,95), regardless of study drug ratio.

AEs leading to most EE dose modifications included neutropenia (14,95), thrombocytopenia (14,95), and fatigue (695). AEs leading to discontinuation of the EE study included nausea and vomiting (n-2), neutropenia (n-1), limb weakness increasing (n-1), hypoxia and radiation pneumonitis (n-1), fatigue ( p-1) and inflammation of the mucous membrane (p-1).

One patient on EP discontinued participation due to fatigue, anemia, thrombocytopenia, and leukopenia.

The NP profile on the entinostat was consistent with previous clinical experience. The most frequent (x15 95 patients) adverse events in the EE group were fatigue, nausea, neutropenia, peripheral edema, vomiting, anemia, shortness of breath, thrombocytopenia, weight loss, diarrhea, and pain. Neutropenia was most often attributed to entinostat (13 of 19 cases; 68 95). The frequency of serious adverse events (EE-16b 96, EP-12 95) was similar. Four (6,95) patients on EE experienced AEs of VA, including fatigue, leukopenia, neutropenia, and hypercalcemia. One fatal AE occurred in each treatment group; the event in the group on EE was qualified as belonging to P3.

Biomarker analysis: in cycle 1, pre- and post-treatment samples were taken from subgroups of 49 patients (EE-27, EP-22), as shown in Fig. 16. Baseline characteristics coincided with the general study population (Fig. 17). Hyperacetylation in patients on EE was associated with prolonged median PFS for all cell types tested (Fig. 18): 8.5 versus 2.7 60 months for low levels of adeacetylation (OR 0.32, 95 95 CI 0.13 , 0.79) (B cells); 6.6 vs. 3.6 months for low adethylation levels (RS-0.44, 95 95 CI 0.18, 1.08) (T cells), and 6.2 vs. 3.6 months for low adethylation levels ( RS-0.50, 95 95 SI 0.21, 1.20) (monocytes). Entinostat plasma concentrations at the time points used to assess acetylation were generally at or below the limit of detection (“0.5 ng/mL), preventing correction for entinostat concentration and acetylation status. The percent change in acetylation from baseline was determined from the last sample taken. The degree of transformational changes in acetylation was then divided into "high" (ie, above average or "hyperacetylation") and "low" (ie, below average) subgroups using a non-model-based approach: patients with changes from baselines that were greater than or equal to the 50th percentile (median) of the overall distribution were assigned to the "high" group; patients with a change less than the 50th percentile were assigned to the "low" group. The cut-off point for the analysis (50th percentile) was determined in advance but was not based on data from previous studies.

Progression-free survival was found to be greatest in the entinostat hyperacetylation group (Fig. 19). As shown in Fig. 20 for B-cell analysis, patients with high EE acetylation were associated with a PFS of 8.5 versus 1.9 in patients with high EP acetylation, 2.7 for patients with low EE acetylation, and 1, 8 for patients with a low level of acetylation on EP. Similar results were obtained in the analysis of T-cells and monocytes.

Analysis of adverse events versus acetylation status is shown in Fig. 21 and 22.

In Fig. 25 presents a timeline for entinostat and exemestane dosing and a schedule for sampling for acetylation analysis. In Fig. 26 provides an analysis of transformational changes in acetylation levels against BBP. In Fig. 27 shows the mean percent change in protein lysine acetylation from pretreatment levels for monocytes, B cells, and T cells. In Fig. 28 shows Kaplan-Meier graphs for PFS by treatment group for monocytes, B cells, and T cells.

It was found that the PFS was the greatest in patients with a high level of acetylation on EE. In Fig. 29 presents a Kaplan-Meier plot of PFS by treatment group for B-cell tissue samples, and PFS was greatest in patients with high EE acetylation. In Fig. 30 gives an analysis of BNP versus percentage change for groups on EE and EP. In Fig. 31 presents the analysis of acetylation trends during the course of treatment in relation to the clinical outcome. patients,

Those who maintain or increase acetylation levels after the first dose receive increased clinical benefit. In Fig. 32 showed that maintenance of acetacetylation levels during the course of treatment is a major factor in clinical benefit, and this can be identified after two weeks of therapy.

In Fig. 33 gives a summary of the data that acetylation of protein lysine is associated with longer disease-free survival.

In conclusion, the addition of entinostat to exemestane prolonged PFS and CV in postmenopausal women with EC-positive advanced breast cancer who progressed after treatment

NSIA. The key data of this study was the benefit in survival observed in patients on EE versus EP (28.1 vs. 19.8 months; RS 0.59 195 95 CI 0.36, 0.97 | p-0.018). These results demonstrate for the first time that the addition of epigenetic therapy (ie, entinostat) to antiestrogen therapy is an effective approach to identify pathways of resistance in breast cancer, particularly in hormone-positive disease. Although entinostat added toxicity to hormone therapy, it was felt to have an acceptable safety profile in this patient population. More importantly, and discovered for the first time, the association of NOAA inhibition with entinostat-induced protein lysine acetylation and improved clinical outcomes was demonstrated in a subset of patients.

Example 2

Background: Despite promising preclinical data and extensive clinical trials, histone deacetylase inhibitors (HAIs) as a class have not demonstrated significant activity in solid tumors as single agents or in combination. Even in indications (or conditions) when

NOAAs have been shown to be effective, for example, in cutaneous or peripheral T-cell lymphomas, yet there is an inability to identify patients most likely to benefit from this, as no correlation was found between outcome and acetacetylation.

Pharmacodynamic (PD) analysis of patient samples from EMSOKE-301 in a recently completed randomized, placebo-controlled Phase 2 study of exemestane with and without entinostat as histone deacetylase inhibitors in postmenopausal breast cancer patients (p-130) demonstrates an association of NOASi-induced lysine hyperacetylation with improved clinical outcome.

Methods: protein lysine acetylation is measured in circulating B-cells (B), T-cells (T), and monocytes (M) by multiparameter flow cytometry on samples taken before treatment, on days 1, 8, and 15 of cycle 1 in patients who were treated with exemestane plus entinostat (EE) or exemestane plus placebo (EP). The percent change is calculated and correlated with progression-free survival (PFS). Hyperacetylation, regardless of treatment group, was defined as an increase in percent change to a level above the calculated mean percent change for each cell type.

Results: samples before and after treatment were taken from subgroups of 49 patients (EE-27; EP-22).

An examination of the baseline characteristics in this subgroup shows that they appear to be consistent with those of the entire population. Hyperacetylation in all cell types in EE vs. EP was associated with prolonged median PFS (B-cells: 8.54 months vs. 1.92; RS-0.24 (95 96 CI 0.081, 0.690); T-cells: 6, 57 vs. 1.77; RS-0.24 (95,905 CI 0.087, 0.640); Monocytes: 6.21 vs. 1.87; RS-O0.50 (95595 CI 0.211, 1.203). Previous trends in overall survival are also favorable for the hyperacetylation group on EE Samples taken to measure entinostat plasma concentrations show that entinostat levels at days 8 and 15, the time points used for PP analysis, are generally at or below the limits of detection (`0.5 ng/mL) and do not allow correlation between increased acetylation and entinostat concentration.

That adverse events are characterized by a difference of 10 95 or more between types of treatment in

EMSOVE-301 safety population (p-129) in a subset of 49 patients with biomarkers, shows that the incidence of thrombocytopenia may be related to hyperacetylation in the EE group, whereas the incidence of other AEs, including fatigue, appears to be unrelated to hyperacetylation.

Conclusion: these data for the first time establish a clear relationship between NOACi-induced hyperacetylation of protein lysine and clinical outcome. Several factors may have contributed to the success in demonstrating this relationship, including the randomized controlled trial design, the positive result of EMSOBE-301, and the sensitive pharmacodynamic assay that allows measurement of overall changes in protein lysine acetylation. In combination with the overall positive results of EMSOVE-301 (mean PFS EE vs. EP 4.28 vs. 2.27 months; RS 0.73 (9595 CI 0.49, 1.09)) and CV at a median patient follow-up of 18 months EE vs EP 26.9 vs 20.3 months; RS 0.56 (95 95 CI 0.31, 1.02)) these data provide evidence of a potential breakthrough in the extension of epigenetic therapy to solid tumors.

Claims (5)

USEFUL MODEL FORMULA Co.) 1. A kit for the treatment of aromatase inhibitor-resistant breast cancer comprising a combination of entinostat and exemestane or a pharmaceutically acceptable salt, solvate or prodrug thereof and instructions for administering this dosage form. 2. The kit according to claim 1, which is characterized in that the kit includes one dosage form of entinostat for every seven dosage forms of exemestane or its pharmaceutically acceptable salt, solvate or prodrug. 3. The kit according to claim 1, which is characterized in that the kit includes one dosage form of entinostat for every 14 dosage forms of exemestane or its pharmaceutically acceptable salt, solvate or prodrug. 4. The kit according to claim 1, which is characterized by the fact that the kit includes 4 dosage forms of entinostat and 28 dosage forms of exemestane or its pharmaceutically acceptable salt, solvate or prodrug. 5. 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A - mon eye durok that lin BK poh ke 1 not mya you U BAN peE eho zhi VEU NAANU BAKU Z LV paz al, 1 KM i I s i AJ fate U tki THIS myh pla IHI VNU OVU pEashO dyap, 1 i : MN ii Tebugpyavist pe pok no, determination as SO BK aka Z lshe ME in under the snow book pkmeakiy porodnmi iy dpa ABU Beni nih perremiya, including TM MO Va 35 chd zho BE kuTrMMKEII I As an adjuvant tera VYUNachemi di STIZH To A. and Fig. 14 Updated with an increase in tires Zenkkok ENTINOSTAT: Wednesday 3 months! hey | in And! d acebsok: g vredv is se zhk composition of E st i CHANNYA --SHY2Y 62 6(« eT i I I llyayannnininys2ya I YayaAa--b- - Ж pcs. Zo y - yes Zh. I am guilty of it st pt g she I m Risk of death sing Ka, and - still po ayu BEOBTTO dishes Bokov Sochnii g -- What RO vesrure ke newiv kraeviva DuMaTtYA Hey g their ХЕ - keV! nyny ni i p p p v BIDE ve ene Chek VA Middle pepper kodetvono Em'bvostae azh zh: ok she zh VE zh a ZHK che ee VO: pev Kinpanom z VNOVEMYA AZH KEME Kiya Fig. 15 Acetylation of fatty lysine p. he NNYA! Batavagivranek rey, pretsznivy cit etheric analyi hi umakvaniya! of protein lysine KO Shi nn ny B dnu ie and dnu . Ken about pen o. En o. oh oh oh And GE Fig. 16 snkneni er ayekerokn pre VNS prezeenNiV ven Razugetat pjechnia with biuksarkers dere lne brkaye brkae genna ponelation pazzhnize Wumgaah zo Juan: Kaplamaeleknestia ha month to VE for hibberianii gave tales DEN TYPES DRINK YOU INE E V Ron. Vdvmikhnya Mohyennayuv What From I sten МНН ЖЕНЕ ВОК Ek I х ныны ин ЕНН | N pa E i TZ : m ne : ZK x N I E mchi i Neeldyukh s, Z-BOV) S y TO Nekrnankh sperti He khz, i i Vi N za | Shk Y and tu N with shi UP i in xx Z; NO I Z om m m a mov om same invitations of the canta of the city vm bath Current censoring indicated vertkkavnok zerthka Risk of death and SM I all B tro vo TB de riznueii vkahuue preference nayeru pizmarkarih Zagrava vk xx bu zagoisin B I Z BEH ma sya sh Fig. 17 Increased acetylation of the concentration of T-decreased acetylation is associated with the non-intensifying BI from aging of SOZs of vindian cells to Meonecytes Sova T-kligtzhny y, vuneak MN. . and dste i zli Kaplan-Mener curves for months to ee Kaplan-Meierch curves for months Kaplan Mer curves for months for zeethylationgm in Vequitins, xx de HV with acetylation to BBP and acetylation in U Comparison for Anticostat In manazites, He T-illites, ze pa Pozhtsebo Comparison for Entinostat 0/ Comparison for Entinostat o laPlacebo pan a NAAN oz: zn nn nn But VYN o and Anna asan TU zn o YAN z EH -B cells, ba ZMyZhzh ok VENICE, o YAMMZH. and Toklianya 5 ZNM. zho --Vzhvitnny Zo Midvescho same 000 ee monomets, Zb podvnsche Zh. te cells, Zo PEDVYSHCH. She svia B still. How do you write NN mere i or VE M in 7! sho Oh iv Eh NE shi : in Mu B Shen : o A, ' Zh ze in EV whose SE S ! Moscow Street. we hey drink. о охжщжкнк I уж, : PY dernu oh 0 Оц 5 of royu Mrshe u u b : : yuodo dary nn m nn i i I i ZK Esh i lo i Z V NE PI ZE I i zh ni IN I I M ZysiatsiE eeknerel after exhaustion Months kantradikk vie title Tek tsikentkkmya pissza survival Wheelbarrows of censorship are indicated Folders of censorshipa vkahami Wheelbarrows of censorship are indicated vartekalnak chertek vgrtikavnaon arte vertical belly Nana (ov, 037) nA-bao0 328, 0 Neo. yaBo (vav. ya) WEB: - chik sk B Progratasto veterans y y snenia Zv Zyna x oeredne meaning " yaavikt.hah was launched by EMINE movredne Zmachennie Z laov2Oz BP on 2935420 p day Fig. 18 Stimulates the mechanism of entinostat before inhibition of NODO Y. Yakhkokivn mk Sa VUKokevati. SOS T-nlityn Kaplanachianer curve by months to Kaplan-chener curve and Kaplan-Lkeyer curve by months to tail and VBBN treatment and changed x VBItza treatment and change in VO after treatment and changed in VE cells, Zo Movne cyts, "T- kvizhinyakh, Z» IBEL as of 29.01.2011) TVP stansm on w 31 IVBBG stanov 9 EI Program: uUtakh oi vas kt: uma started and 81 KE Con AGAIN in un nn HOW tt tet t tet tet titan EK U Sh -- PltsebaannYAH I: ! EOR and 0 Pdacebe will increase in: EZK NK. 100 -- Entinostat nizh zhor ve na M m A I she Shev -Entineetatpodvoo She 007 isher her i : Ed EN day ish 3 h iv B i : Y shi SHE or oi yi ish g pechi i G-E ron yi: ("I Kene yi and NYA | V : Я : other books cumin and in them now are guilty y me ak o ki i p a A V p KK A NN NK NK PI M VA NN KE V S A NE Z NE NE NK KN NN : MNE U z i E Za E ZY I SUV EE en DE ee DE A VE V Z ZE DO E: zhe she She a S EE Z KE zle acE Cantrovyu after harvesting Months of control after survival Months of control after expulsion Carts of censoring vkhachni Carts of cenzmruvan are indicated Censoring points are indicated by vertical "black" dertical: alternately vertical Beijing devil DISMUMRE A WITH CHANGES i EVEINE DESTROYMENT 0.5.0 AVENIA EM OBVIOUS SEPED NIGHTING SHMK amines average value 00000 AVOMeAKMT changes average value o I Fig. 19 in the unrecognized patient population of Osynia with Kryvi Kanvlyana and Beivre months before VBL for Lihuyuan nyavya g ZAYANAANI in YacetlialkvaninE Bektitan IVPLE became on ze o 1 NO 1. zennn DEMENCHI Z yam keroznach, Her yo and | зкккннкю БЕХ ТУЮЮ ДНА Fr НОИ млини em et DATVeh MU VO) še SCHE ; ! VERYAECHE KO to ES EE E ! 5 MORE K. Hey! zooos VESLUNECHI SAME ZMINE khirdoznah, 1 BONN MOVNE K vky Fosnennynu, I Tess ssh p Y EN oti EN and WINDOW Y Yama kronakh Uh and, in ee she carried VAV: still E SHY her and pi N E BEBPIV. OK «a 3 U ee: I nn KY Ennnis now: I un, x x 5 z dya still wn ns v nn nn ny ny pis z i I In i i p i p z p z p p s y ME i Z Z I p ZY Z ZM u Z SM Z go z «NI SYA Months of control after vizheEvnyach tochi ERI IDNO MMZ VOK TIHA TOMOMI ЧТ meaning of fragile breaths dokiTty with shenyutyu chans Byadh ZMOV Udagreaka z skelii kupah in vve kli aa aklupema OO I Fig. 20 iv t" and E oPeefennyakyae zr ap zbo yaole szob) zolyu, Huta ztron o oNeeen zu t v. | Bo i t» Fig. 21 shin no puanh i z Z Ya B nia TV prozhmbopvoyeyueniyu in V M a 1 Fig. 22 KEZOME 0 ..|. .| F .) .. Ж Ж.....ЙПМсся« with The greatest effect of treatment is visible in the groove x pprecetylation on cromazyme and antinastan - INTRODUCES VNU b nov ze Mom VeTEN EMO podaleMM kentrollysyutvznnd peceentiv tenaentsi v'ZV zeMeshchttch with VU Bananm i VG "In the analysis of the characteristics, there was no evidence that the difference between the groups on Dromasin and Entostat with a reduction occurred because of the non-infectious lines of the patient's blood lines. The long-standing support for the mechanism of action of the HAS penisitor is increased acetylation of the fatty acid with the help of the NOAE shift. maal gland can be used to catch the patient, how to make MAM lLlN peren nn eko i pos pn no with shk S ! zesevvmnk: MB: MervdNe VEGYA. hatch - and Y sshkne ER; Average VEGILYA month o Z ! Gases emeryuv in Kk y, OK and I ee g ME Teov vs: strativ ank cry y: DOZHITKV 1 EichNYH ! y i: ME b. nai - az De en CHI W KAH i Te her KK, Z dya .. ХЕ Vk ininininininini kinni pikov nininininininii kinni inn nik pinni , lines ninininia, pinni no no ninininini nik ninininini young nik nininin nia kinni inn nik ninininin women rondo ntodny Meeyatsi Pratsebe ZA Z eV YANT t ozh BE a EnNUnostat V V V Be JE KK sh I EE: TEH rakhank v zeknn vn nn o v v pp p p v v V p V V OO ZO posmayudy mch y zas o Engbtary NOAE induce Ppreracetyping of lysines on the pods and related proteins whose mechanism of action is the same. 21101111 115155. Fig. 25 NN about EN re, t also investments In what. ppruputtttettya 0 shi oikhnoyuov POOMOO nn ZOM hg. I OIiVVTSEVAYA 0 DRINK PI VALY WRITE HER WITH PTYM ZHK Oporu s BalNOManametevnya be 05, S nn sh- / NN nyshhnnanannnnyny, dad who calls Kit SHY her pchne NN serevnvoko zamin Fet---5 5 -- 5 Os E | ! floor NN and I X 7 | ! o Mowing of the oefnu posvoth peunannya to 0 B OTbbbyedaetenya som acenununannanni bo ereaneya OV in, o S orilzhsssomek 00000000 SHE s OID re hvitina still p pro: and te z tysia Y pteh i schi Fig. 26 Mi: Sey v nn u NINU EV Is SHY ie 5 SHY t NN NN, x i ? ; x fronnnnnnnnia | I x Ro rentnoi; w З - г BOBSHUIIKHV what WHAT PAN in | m: it's peokoya! in: plvEa ; pedlkgya that Se: Si " ionni nia Pn zni z pop ik syvyna Khotyn adiantrtnnnnnyaya HR EE ER EE ER EE (claim 222 klei ip-eb2 (pe ergy P value for comparison between types of treatment from the Bilkakeivka test, Fig. 27 BEbNy EE U no in NO NO Subconscious zagraponovannia mechanczm i entinostat apamogoyuk inbuvation NOV si a B-cells, ia» menevcints PI yaks Gyuzhyn, Kaplan-mener curves for months 0 Kaplan-Mener curves with lysets Kaplan-Mener curves for vysatsevs to VBP for treatment and changes in WBP according to aging and changes in pre-salvation with new B-fourths (8BP as of 2920) monocytes (WBA as of 292011). t klytnneh (8BP as of 29.0152011, вх NK E EL ! ше ! ЖЖ U NE Be : 5 th і rai Ж o Ko YN HO Mchch : m shi tk gy she amp z za Shi. Tu SHE SHE SHE SHE : l МН і х х TE . ut etldityd zhu mk kn, the same her in SHOYU EE Ku Kryk, ak vmon pe CHI M V NN shk nE ni EM EK Y NE ZUBI VIA NIV RZ VI MZa These camera Raya vin ennia and boiler house of survival dough shines una after traveling to Soch tsenkharuvaniya vKzak:vartkekhpkaok charton Mraeraea became kumiv We kazlothkhvh zapushianya PU OO ! EE 76 virgins »" average ER 5 zinn from "erovny Fig. 28 VEK for tinam forging and change 35 acetpievvannkya z-chnnya skkkkkyu KE HU nm » servne lei: zvi KTK hyusooh BEZ VEMy M okrodme it: I SHY poni NN. 287. 5 and g Z E REF in mk V.V mov and xx In schi Jossyan Hoossseketttssssya and SHE y I | pen KEZE CHANGE g seradne (zhi8i zpoZa pvh Still bot Uh EV vm Z vovna Zno ! still I | NizO ZO (0 cat, О.В! 55, Ш втулок: WEB ka U yo ! EE: ; I i ! va izU di pekeeeeeeeeeesye tu reretekevekyu, with E Kr i o 17 od ne I I ZY YN Z Sp p M p p p sp z p VI M I) and E them Bu KHE 5 and Z Z KU with 13 her her 15 EZU U I 3 Months ZUEHMnn rez an lya t hyuMNN and ZEM NININA ' vch ach Fig. 29 s pl vch a podov y No rea ns s EM san and Ann s oBeeme an and otsevo ko ; piehenn and Z "nikvanchya Zhe I BK lNEIntTayu: OKO; 1 Z hna x u Z that Z i shcha schu z | sht I. a i ra x kosh i. BM sl still still Tk g -- - may; and t - zazha ve y Y. dose su za y KAH x another 5-2 cups. z x a -Z y bennh her "KK y S ko BI. Be" y SVK syavk ko VE SFE SO ЖEO ЖЖ ШЭ ж и и A М В М В ВЯ (Days Output ksh- 037 pi OYA OZ ark yuvchannchc kenh wl AKNE NK EE VE Ken ee VelchY Fig. 30 and Tevdeniya same acepankvanmya same top of patients with VBO More In the city NOT KS Y nn v nn NN VO Bodrov non she 0 A ТНЩНЭНТОЙ ЯКЕ НОО Т still pa y y Shi p INN s s nsh y NN nn NI MDikl y loba Tevdeatsie in auelenkyavanh в вдив рен чехземтв Z VE kivmikha From the contents of KO Kuk : Zhe o pon Zk Se - she V she SHY Z is ivnnniya xx nyny nyn ve shi 7 Esh: scoop dovovovovvko VYUVKV. In nn and I - STILL nin ki IN Fig. 31 Y ss Average ZO of changes in acetylation tendencies I E g y I E o z un Yay y Zh s ; Because of one PF one VSH blames VN SHI sa Ko identical WEB" b months НеТИППюванНЯ PSLЯ TE k still I RE "Z months doz NN Ж: y Sharan v ya shiny chn v -42 t PA s Ah ANA A V Shi ' ZO DK . ож Можавопотенцнне с чан A A A A A A A A A A A A NN pe sho vdlnyu V dKya pe NN g Fig. 32 First positive, counter-intuitive study of epigenetic therapy in breast cancer "White lysine adethylation is associated with longer disease-free survival" Preracetyping is not associated with increased tumorigenicity "Results may be related to differential entinostat pharmacotherapy" - Danny suggests ; further clinical benefit may be determined after the first or second dose of entinestat I Confirmation of results is planned for follow-up phases Fig. 33