US20170049775A1 - Methods for Treating Metastatic Pancreatic Cancer Using Combination Therapies Comprising Liposomal Irinotecan and Oxaliplatin - Google Patents

Methods for Treating Metastatic Pancreatic Cancer Using Combination Therapies Comprising Liposomal Irinotecan and Oxaliplatin Download PDF

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US20170049775A1
US20170049775A1 US15/241,106 US201615241106A US2017049775A1 US 20170049775 A1 US20170049775 A1 US 20170049775A1 US 201615241106 A US201615241106 A US 201615241106A US 2017049775 A1 US2017049775 A1 US 2017049775A1
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oxaliplatin
dose
irinotecan
leucovorin
administered
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Eliel Bayever
Sarah F. Blanchette
Jonathan Basil FITZGERALD
Daniel F. Gaddy
Bart S. Hendriks
Ashish Kalra
Helen Lee
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Ipsen Biopharm Ltd
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Merrimack Pharmaceuticals Inc
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Priority to US15/809,815 priority patent/US11344552B2/en
Priority to US17/711,500 priority patent/US20230062425A1/en
Priority to US18/676,591 priority patent/US20240358706A1/en
Priority to US19/188,672 priority patent/US20250381191A1/en
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
    • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with heterocyclic rings
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    • A61K31/4353—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom ortho- or peri-condensed with heterocyclic ring systems
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    • A61K47/20—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite containing sulfur, e.g. dimethyl sulfoxide [DMSO], docusate, sodium lauryl sulfate or aminosulfonic acids
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Definitions

  • This disclosure relates to novel therapies useful in the treatment of pancreatic cancer, including the use of liposomal irinotecan in combination with 5-fluorouracil and oxaliplatin for the (first line) treatment of patients diagnosed with previously untreated pancreatic cancer.
  • Pancreatic cancer is chemotherapy-resistant, with an extremely poor prognosis. It is the fourth leading cause of cancer death in the United States; the 5-year survival rate is 6%.
  • the incidence of pancreatic cancer has increased during the past several decades and in 2014, an estimated 46,420 patients were diagnosed with pancreatic cancer and 39,590 died.
  • Pancreatic cancer is projected to surpass liver, breast, prostate, and colorectal cancers to become the second-leading cause of cancer-related death by 2030. These statistics reflect the dire nature of the disease and lack of effective therapies.
  • the location of the tumor results in few early symptoms and is often diagnosed at a late stage as a result.
  • the absence of effective screening tools, and a limited understanding of risk factors means that patients have advanced or metastatic disease at the time of diagnosis. Given the poor prognosis and the low median survival rates of less than one year for patients with metastatic disease, new treatment options are still needed.
  • FOLFIRINOX has been recommended by the National Comprehensive Cancer Network (NCCN) as a preferred option for first-line metastatic disease since 2011, there are some concerns about the toxicity associated with FOLFIRINOX.
  • One dose regimen of FOLFIRINOX is 85 mg/m 2 oxaliplatin, 180 mg/m 2 irinotecan, and fluorouracil at a dose of 400 mg/m 2 administered by IV bolus followed by a continuous infusion of 2400 mg/m 2 .
  • modified FOLFIRINOX regimens are often used (e.g. elimination of the 5-FU bolus) with unknown effects on the efficacy and safety of modified schedules.
  • CPT-11 is irinotecan hydrochloride trihydrate, marketed as Camptosar® in the United States.
  • MM-398 is a liposomal irinotecan and is marketed in the U.S. as the FDA-approved product ONIVYDE® in combination with 5-fluorouracil and leucovorin for the treatment of patients with metastatic adenocarcinoma of the pancreas after disease progression following gemcitabine-based therapy.
  • Improved antineoplastic therapies for the treatment of pancreatic cancer provide the administration of liposomal irinotecan in combination with oxaliplatin and 5-fluorouracil to patients with previously untreated pancreatic cancer (e.g., untreated metastatic pancreatic adenocarcinoma, or mPAC).
  • the 5-fluorouracil can be administered in combination with leucovorin.
  • the improved antineoplastic therapies can provide improved therapeutic index (e.g., improved toxicity profiles) relative to prior FOLFIRINOX regimens.
  • a method of treating pancreatic cancer can comprise the administration of an antineoplastic therapy of liposomal irinotecan, oxaliplatin, and 5-fluorouracil once every two weeks to the patient.
  • leucovorin can also be administered prior to each administration of the 5-fluorouracil.
  • Each administration of the liposomal irinotecan can be administered in a total dose of 60 mg/m 2 liposomal irinotecan (dose based on the amount of irinotecan hydrochloride trihydrate, as defined herein).
  • a total of 2,400 mg/m 2 5-fluorouracil can be administered over 46 hours starting on each day when the liposomal irinotecan is administered.
  • a total of 60, 75 or 85 mg/m 2 oxaliplatin can be administered on each day the liposomal irinotecan is administered.
  • a total of 200 mg/m 2 (l) leucovorin can be administered prior to each administration of the 5-flurouracil (e.g., optionally administered as 400 mg/m 2 of (l+d) leucovorin).
  • the antineoplastic therapy can be administered starting on days 1 and 15 of a 28-day treatment cycle, with the liposomal irinotecan, oxaliplatin, and optionally leucovorin administered on days 1 and 15 and initiating the 46-hour administration of the 5-fluorouracil on days 1 and 15.
  • the invention is based in part on several pre-clinical discoveries.
  • liposomal irinotecan improved anti-tumor activity of the topoisomerase 1 inhibitor SN-38 (an active metabolite of irinotecan) relative to exposure-matched doses of non-liposomal irinotecan.
  • liposomal irinotecan combined with 5-fluorouracil and oxaliplatin consistently improved tumor growth inhibition and survival in mouse xenograft models of pancreatic cancer relative to non-liposomal irinotecan, without exacerbating the baseline toxicities of these agents.
  • the invention is based in part on the discovery that the administration of a dose of 80 mg/m 2 liposomal irinotecan was not well tolerated in humans when administered in combination with 60 mg/m 2 oxaliplatin, 2400 mg/m 2 5-fluorouracil and 400 mg/m 2 (l+d) leucovorin. Accordingly, preferred methods of treating (previously untreated) pancreatic cancer provide for the administration of a human-tolerated antineoplastic therapy once every two weeks, where each administration of the antineoplastic therapy is a combination of the antineoplastic agents liposomal irinotecan, oxaliplatin and 5-fluorouracil provided herein.
  • the antineoplastic therapy administered once every two weeks consists of: (a) a total dose of 60 mg/m 2 liposomal irinotecan (dose based on the amount of irinotecan hydrochloride trihydrate, as defined herein), (b) a total dose of 60-85 mg/m 2 oxaliplatin (including, e.g., 60 or 85 mg/m 2 ), and (c) a total of 2,400 mg/m 2 5-fluorouracil optionally administered in combination with leucovorin.
  • a total dose of 60 mg/m 2 liposomal irinotecan dose based on the amount of irinotecan hydrochloride trihydrate, as defined herein
  • a total dose of 60-85 mg/m 2 oxaliplatin including, e.g., 60 or 85 mg/m 2
  • a total of 2,400 mg/m 2 5-fluorouracil optionally administered in combination with leucovorin.
  • the combination can include administration of a total of 200 mg/m 2 (l) leucovorin (optionally administered as 400 mg/m 2 of (l+d) leucovorin), prior to initiating the administration of the 5-fluorouracil.
  • no other antineoplastic agent is administered during the antineoplastic therapy, other than amounts of SN-38 produced within the patient from the liposomal irinotecan, after administration of the liposomal irinotecan.
  • the antineoplastic therapy can be administered without (non-liposomal) CPT-11 irinotecan.
  • the liposomal irinotecan, oxaliplatin, and (optionally) leucovorin are consecutively administered as separate infusions on a single (first) day and the 5-fluorouracil is administered starting on the first day after the administration of the leucovorin (if administered) and continuing into the following day (e.g., over a total of 46 hours).
  • FIG. 1A is a graph showing the simulated levels of the active irinotecan metabolite SN-38 over time based on liposomal irinotecan human clinical biopsy data and human clinical trial data.
  • FIG. 1B is a schematic showing how the tumor exposure of SN-38 over time observed with liposomal irinotecan (MM-398) is prolonged compared to SN-38 tumor exposure from non-liposomal irinotecan (CPT-11).
  • FIG. 1C is a graph showing the percent relative cell growth inhibition of SN-38 based on various times of total SN-38 cell exposure for 5 different cell lines.
  • FIG. 1D is a graph showing the percent relative cell growth inhibition of the cell lines tested in FIG. 1C at different exposure times (4 hours or 48 hours) for different combinations of SN-38 with 5-fluorouracil (5-FU) or oxaliplatin (oxali).
  • FIG. 2A is a graph showing the cell viability as a function of SN-38 exposure for BxPC-3 pancreatic cancer cells.
  • FIG. 2B is a graph showing the cell viability as a function of SN-38 exposure for CFPAC-1 pancreatic cancer cells.
  • FIG. 3A is a graph showing the tumor volume over time measured in a BxPC-3 pancreatic cancer xenograft mouse efficacy model after treatment with individual antineoplastic agents: including 5-fluorouracil (5FU), oxaliplatin (Ox), (non-liposomal) irinotecan (IRI) and MM-398 liposomal irinotecan (nal-IRI).
  • individual antineoplastic agents including 5-fluorouracil (5FU), oxaliplatin (Ox), (non-liposomal) irinotecan (IRI) and MM-398 liposomal irinotecan (nal-IRI).
  • FIG. 3B is a graph showing the tumor volume over time measured in a BxPC-3 pancreatic cancer xenograft mouse efficacy model after treatment with various combinations of antineoplastic agents: (non-liposomal) irinotecan (IRI) and 5FU; (non-liposomal)irinotecan (IRI), oxaliplatin and 5FU; MM-398 liposomal irinotecan (nal-IRI) and 5FU; and 398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU.
  • antineoplastic agents include (non-liposomal) irinotecan (IRI) and 5FU; (non-liposomal)irinotecan (IRI), oxaliplatin and 5FU; MM-398 liposomal irinotecan (nal-IRI) and 5FU; and 398 liposomal irinotecan (n
  • FIG. 4A is a graph showing the tumor volume over time measured in a BxPC-3 pancreatic cancer xenograft mouse efficacy model after treatment with oxaliplatin monotherapy, MM-398 liposomal irinotecan (nal-IRI) monotherapy, and a combination of MM-398 liposomal irinotecan (nal-IRI) and oxaliplatin (Ox).
  • FIG. 4B is a graph showing the tumor volume over time measured in a CFPAC-1 pancreatic cancer xenograft mouse efficacy model after treatment with oxaliplatin monotherapy, MM-398 liposomal irinotecan (nal-IRI) monotherapy, and a combination of MM-398 liposomal irinotecan (nal-IRI) and oxaliplatin (Ox).
  • FIG. 5A is a graph showing the tumor volume over time measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with MM-398 liposomal irinotecan (nal-IRI) monotherapy, (non-liposomal) irinotecan monotherapy (irinotecan), and various combination therapies: MM-398 liposomal irinotecan (nal-IRI) and 5-fluorouracil (5FU); (non-liposomal) irinotecan (irinotecan) and 5FU; MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • MM-398 liposomal irinotecan nal-IRI
  • 5FU 5-fluorouracil
  • FIG. 5B is a graph showing the tumor volume over time measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with the MM-398 containing combination therapies shown in FIG. 5A : MM-398 liposomal irinotecan (nal-IRI) and 5-fluorouracil (5FU), MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • FIG. 5C is a graph showing the tumor volume over time measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with the oxaliplatin containing combination therapies shown in FIG. 5A : MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • FIG. 6A is a graph showing the percent tumor volume change over time measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with a saline control, MM-398 liposomal irinotecan (nal-IRI) monotherapy, or (non-liposomal) irinotecan monotherapy (irinotecan).
  • PDX #19015 pancreatic cancer mouse efficacy model after treatment with a saline control
  • MM-398 liposomal irinotecan (nal-IRI) monotherapy or (non-liposomal) irinotecan monotherapy (irinotecan).
  • FIG. 6B is a graph showing the percent tumor volume change over time measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with saline control or two oxaliplatin containing combination therapies: MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • FIG. 6C is a graph of the progression free survival measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with two oxaliplatin containing combination therapies: MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • FIG. 6D is a graph of the overall survival measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with two oxaliplatin containing combination therapies: MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • FIG. 7 is a graph showing the tumor volume measured in a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with MM-398 liposomal irinotecan (nal-IRI) monotherapy, (non-liposomal) irinotecan monotherapy (irinotecan), and various combination therapies: MM-398 liposomal irinotecan (nal-IRI) and 5-fluorouracil (5FU); (non-liposomal) irinotecan (irinotecan) and 5FU; MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • MM-398 liposomal irinotecan oxaliplatin and 5FU
  • irinotecan oxaliplatin and 5FU.
  • FIG. 8 is a table showing the results obtained from a patient-derived xenograft (PDX #19015) pancreatic cancer mouse efficacy model after treatment with MM-398 liposomal irinotecan alone, non-liposomal irinotecan alone (monotherapy), MM-398 liposomal irinotecan in combination with 5FU (NAPOLI, double therapy), MM-398 liposomal irinotecan in combination with 5FU+oxaliplatin (NAPDX, triple therapy) and non-liposomal irinotecan combined with oxaliplatin and 5-fluorouracil (FOLFIRINOX).
  • PDX #19015 pancreatic cancer mouse efficacy model after treatment with MM-398 liposomal irinotecan alone, non-liposomal irinotecan alone (monotherapy), MM-398 liposomal irinotecan in combination with 5FU (NAPOLI, double therapy),
  • FIG. 9 is a graph showing the tolerability of various therapies in a mouse model, measured by recording the body weight of the mouse after administration of a saline control, liposomal irinotecan (nal-IRI), a combination of nanoliposomal irinotecan, 5-FU and oxaliplatin or a combination of non-liposomal irinotecan (CPT11), 5FU and oxaliplatin on days 0, 7, 14 and 21.
  • a saline control liposomal irinotecan
  • CPT11 non-liposomal irinotecan
  • FIG. 10A is a graph showing the tolerability of various therapies in a mouse model, measured by recording the body weight of the mouse after administration of high doses of MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and a combination of MM-398 liposomal irinotecan and oxaliplatin given together on the same day.
  • FIG. 10B is a graph showing the tolerability of various therapies in a mouse model, measured by recording the body weight of the mouse after administration of high doses of MM-398 liposomal irinotecan (nal-IRI), oxaliplatin and a combination of MM-398 liposomal irinotecan and oxaliplatin given sequentially on separate successive days with the MM-398 administered on day 1 and the oxaliplatin administered on day 2.
  • MM-398 liposomal irinotecan nal-IRI
  • oxaliplatin a combination of MM-398 liposomal irinotecan and oxaliplatin given sequentially on separate successive days with the MM-398 administered on day 1 and the oxaliplatin administered on day 2.
  • FIGS. 11A, 11B and 11C are bar graphs depicting hematological toxicities observed in mice after administration of high doses of MM-398 liposomal irinotecan (nal-IRI) and oxaliplatin administered on the same day or with oxaliplatin administered at least one day after administration of MM-398: A. White blood cells; B. Neutrophils; and C. Lymphocytes.
  • FIGS. 11D, 11E and 11F is bar graphs depicting liver enzyme levels observed in mice after administration of high doses of MM-398 liposomal irinotecan (nal-IRI) and oxaliplatin administered on the same day or with oxaliplatin administered at least one day after administration of MM-398: D. aspartate aminotransferase (AST); E. alanine transaminase (ALT); F. alkaline phosphatase (ALKP).
  • AST aspartate aminotransferase
  • ALT alanine transaminase
  • AKP alkaline phosphatase
  • FIG. 12 is a schematic of methods of treating pancreatic cancer, including methods comprising the administration of liposomal irinotecan, oxalipaltin, 5-fluorouracil and leucovorin.
  • the dose of liposomal irinotecan or irinotecan liposome as recited herein refers to the amount of irinotecan hydrochloride trihydrate providing an amount of irinotecan encapsulated in the liposome of the liposomal irinotecan or irinotecan liposome.
  • a dose of 60 mg/m 2 liposomal irinotecan refers to an amount of the liposomal irinotecan providing the same amount of liposome encapsulated irinotecan that is present in 60 mg/m 2 of irinotecan hydrochloride trihydrate, and is equivalent to a dose of about 50 mg/m 2 of liposomal irinotecan based on the amount of the irinotecan free base encapsulated in the liposomal irinotecan.
  • nucleic-IRI non-liposomal irinotecan hydrochloride trihydrate.
  • 5-FU and “5FU” and used interchangeably and refer to 5-fluorouracil.
  • pancreatic cancer cell lines (Example 1), we demonstrated enhanced cell death when liposomal irinotecan treatment is simulated using prolonged exposure of SN-38 (the active metabolite of irinotecan) in combination with 5-FU and oxaliplatin.
  • FIG. 1 shows that prolonged exposure of SN-38 simulates MM-398 treatment in vitro.
  • MM-398 treatment results in prolonged tumor exposure to the active metabolite, SN-38, compared to non-liposomal irinotecan (CPT-11).
  • FIG. 1B prolonged low-dose exposure of SN-38 mimics MM-398 tumor delivery in vitro.
  • FIG. 1A shows that prolonged exposure of SN-38 simulates MM-398 treatment in vitro.
  • FIG. 2 is two line graphs that depict cell viability following treatment with SN-38 as a single agent or the combination of SN-38 and oxaliplatin.
  • BxPC-3 ( FIG. 2A ) or CFPAC-1 ( FIG. 2B ) cells were treated for 4 h or 72 h, washed and then incubated for an additional 24 h or 144 h with fresh media, following which cell viability was assessed.
  • the data traces are labeled “1” (SN-38 alone for four hours followed by a 24 hour incubation; “2” SN-38+oxaliplatin for four hours followed by a 24 hour incubation; “3” SN-38 alone for 72 hours followed by a 144 hour incubation; and “4” SN-38+oxaliplatin for 72 hours followed by a 144 hour incubation.
  • Treatment of the cells with a combination of SN-38 and oxaliplatin decreased the IC-50 when cells were treated for 4 h only as compared to treatment with single agents in both cell lines tested.
  • Example 2 Testing of cell line-derived and patient-derived xenograft models of pancreatic cancer in Example 2 demonstrated improved anti-tumor activity of liposomal irinotecan relative to exposure-matched doses of non-liposomal irinotecan.
  • a dose of “x” mg/kg liposomal irinotecan provides about the same exposure to the topoisomerase 1 inhibitor (irinotecan and/or SN-38) as a dose of “5x” non-liposomal irinotecan (CPT-11).
  • the liposomal irinotecan consistently improved tumor growth inhibition and survival relative to non-liposomal irinotecan in preclinical models, both as a monotherapy and in combination with 5-FU and oxaliplatin.
  • the addition of MM-398 to 5-FU and/or oxaliplatin did not exacerbate the baseline toxicities of these agents, including weight loss and neutropenia, and tolerability could be further improved by delaying the administration of oxaliplatin to 1 day post-MM-398.
  • Liposomal irinotecan (MM-398) performed better than conventional (non-liposomal) irinotecan (CPT-11) at equivalent exposure doses (5 mg/kg MM-398 vs. 25 mg/kg free IRI) in the BxPC-3 pancreatic xenograft cancer models (Example 2) either alone (e.g., FIG. 3A ), or in combination with oxaliplatin and/or 5-FU (e.g., FIG. 3B ).
  • FIG. 3A depicts a line graph representing tumor growth after treatment with various individual treatment agents.
  • FIG. 3B depicts a line graph representing tumor growth after treatment with various combinations of treatment agents.
  • MM-398 in a 5-FU insensitive pancreatic cancer model (BxPC-3). Cancer cells were implanted subcutaneously in mice; when tumors were well established and had reached mean volumes of ⁇ 300 mm 3 , IV treatment with doublet or triplet regimens containing either IRI or MM-398 in combination with oxaliplatin and/or 5-FU was initiated. Doses are indicated above for each treatment, and were given weekly ⁇ 4 weeks, at time points indicated by dashed lines on graphs. In comparison to FIG.
  • doublet or triplet regimens containing either IRI or MM-398 in combination with oxaliplatin and/or 5-FU demonstrate that the MM-398-containing doublet and triplet regimens inhibit tumor growth significantly better than the IRI-containing regimens.
  • the addition of oxaliplatin to the doublet combinations of FOLFIRI or MM-398+5-FU/LV causes a slight increase in tumor growth inhibition ( FIG. 3B : compare IRI+5FU to IRI+5FU+Ox for FOLFIRI vs. FOLFIRINOX; compare nal-IRI+5FU to nal-IRI+5FU+Ox for MM-398+5-FU/LV vs.
  • FIGS. 4A and 4B are two line graphs depicting tumor growth in mouse xenograft models following intravenous treatment with saline (control, circles), 5 mg/kg oxaliplatin (triangles), 5 mg/kg MM-398 (light squares), or the combination of BxPC-3 ( FIG. 4A ) or CFPAC-1 ( FIG. 4B ) tumor cells were implanted subcutaneously in mice. Treatment was initiated after tumors were well established, and treatments were given four times (BxPC-3 model) or three times (CFPAC-1 model) at the time points indicated by dashed lines on the graphs.
  • FIGS. 5A, 5B, 5C, 6A, 6B, 6C, 6D and 7 are graphs obtained by measuring tumor growth inhibition in mice following various treatments.
  • Tumor cells PDX model 19015
  • MM-398 or non-liposomal irinotecan alone, or in combination with 5-FU or 5-FU+oxaliplatin was initiated.
  • Treatment doses are indicated in the figure beside each treatment, and were given 4 times.
  • FIGS. 5A-5C are three line graphs depicting tumor growth inhibition in mice following various treatments.
  • Tumor cells PDX 19015 model
  • PDX 19015 model were implanted subcutaneously in mice.
  • IV treatment with MM-398 or non-liposomal irinotecan as monotherapy, or in combination with 5-FU and Oxaliplatin was initiated.
  • Treatment doses are indicated in the legend beside each treatment, and were given four times, at time points indicated by dashed lines on the graphs.
  • the addition of 5-FU to MM-398 or non-liposomal irinotecan significantly improved tumor growth inhibition relative to the respective monotherapies.
  • FIG. 5A is a line graph comprising data from all of the combinations (both those with MM-398 and those with irinotecan), and shows that the combination of MM-398, oxaliplatin, and 5-FU resulted in the most inhibition of tumor growth (lowest line trace), although the combination of MM-398 and 5-FU also inhibited tumor growth (next lowest line).
  • FIG. 5A is a line graph comprising data from all of the combinations (both those with MM-398 and those with irinotecan), and shows that the combination of MM-398, oxaliplatin, and 5-FU resulted in the most inhibition of tumor growth (lowest line trace), although the combination of MM-398 and 5-FU also inhibited tumor growth (next lowest line).
  • FIG. 5B is a line graph comprising data from the MM-398 combinations only (no irinotecan combinations or control line) for the purpose of comparison.
  • the triple combination treatment resulted in the most tumor growth inhibition (lowest line), and the double combination of irinotecan and 5-FU (middle line) was better than MM-398 alone (highest line) in inhibiting tumor growth.
  • FIG. 5C is a subset of the same data that allows comparison of the oxaliplatin combinations to the saline control.
  • FIG. 6A is a graph showing the percent tumor volume change over time measured in a PDX 19015 pancreatic cancer xenograft mouse efficacy model after treatment with a saline control, MM-398 liposomal irinotecan (MM-398) monotherapy, or (non-liposomal) irinotecan monotherapy (irinotecan).
  • the data in FIG. 6A shows a significantly greater reduction in the percent tumor volume change for administration of 10 mg/kg liposomal irinotecan (MM-398) compared to non-liposomal irinotecan (CPT-11) at 50 mg/kg, each administered on days 0, 7, 14 and 21 followed by observation for a total of about 60 days.
  • 6B is a graph showing the percent tumor volume change over time measured in a PDX 19015 pancreatic cancer xenograft mouse efficacy model after treatment with saline control or two oxaliplatin containing combination therapies: MM-398 liposomal irinotecan (MM-398), oxaliplatin and 5FU; and (non-liposomal) irinotecan, oxaliplatin and 5FU.
  • mice receiving the combination of liposomal irinotecan (MM-398, also called MM-398) with 5FU and oxaliplatin on days 0, 7, 14 and 21 showed significantly reduced tumor volume percent change through the observation period of about 60 days, compared to mice receiving the combination of non-liposomal irinotecan (CPT-11) with oxaliplatin and 5-FU on days 0, 7, 14 and 21.
  • CPT-11 non-liposomal irinotecan
  • 5-FU oxaliplatin
  • the addition of 5-FU and oxaliplatin to MM-398 significantly improve overall survival relative to the control group. No benefit of added 5-FU or oxaliplatin was observed with non-liposomal irinotecan.
  • the addition of oxaliplatin to MM-398+5-FU significantly delays tumor progression relative to MM-398 monotherapy, as indicated by significantly reduced tumor volume at day 35.
  • FIG. 8 is a table showing results of tumor growth and survival in mice following various treatments.
  • Tumor cells (PDX 19015 model) were implanted subcutaneously in mice. When tumors were well-established, and had reached a mean volume of ⁇ 250 mm 3 , IV treatment with MM-398 or non-liposomal irinotecan alone (monotherapy), or in combination with 5-FU (NAPOLI, double therapy) or 5-FU+oxaliplatin (NAPDX, triple therapy), was initiated. Mice treated with the triple therapy, NAPDX (50%) had the best Overall Response Rate (ORR), as compared to double NAPOLI (38%), or monotherapy MM-398 monotherapy (0%).
  • ORR Overall Response Rate
  • mice also had a better Disease Control Rate (DCR): NAPDX (75%), NAPOLI (63%), MM-398 monotherapy (38%), and Progression Free Survival (PFS): NAPDX was 47 days, relative to 36.5 days for NAPOLI and 12 days for MM-398 monotherapy.
  • DCR Disease Control Rate
  • PFS Progression Free Survival
  • NAPDX was 47 days, relative to 36.5 days for NAPOLI and 12 days for MM-398 monotherapy.
  • NAPDX PFS was significantly better than the monotherapy, whereas NAPOLI is not significantly better than the monotherapy.
  • the combination of liposomal irinotecan with 5FU and oxaliplatin was better tolerated than the combination of an SN-38 exposure-matched dose of non-liposomal irinotecan with 5FU and oxaliplatin in a mouse tolerability study over 100 days.
  • FIG. 9 is a graph showing the body weight of mice after administration of various regimens: a saline control, liposomal irinotecan (MM-398), a combination of nanoliposomal irinotecan, 5-FU and oxaliplatin or a combination of non-liposomal irinotecan (CPT11), 5FU and oxaliplatin.
  • Liposomal irinotecan improved tolerability in a mouse model following repeated dosing in mice relative to non-liposomal irinotecan when combined with 5-FU and oxaliplatin. Significance was determined by ordinary 2-way analysis of variance (ANOVA). The regimens were administered on days 0, 7, 14 and 21 of the study.
  • the administration of 10 mg/kg liposomal irinotecan and the 50 mg/kg dose of non-liposomal free irinotecan (CPT11) provide a comparable dose of SN-38 to tumor cells in the mouse model.
  • FIGS. 10A and 10B depict line graphs demonstrating the toxicities associated with MM-398 and oxaliplatin given as monotherapy or combined therapy given concurrently (A) or staggered, with oxaliplatin given 1 day after MM-398 administration (B).
  • Co-administration of MM-398 and oxaliplatin leads to significant toxicities as measured by loss of body weight, whereas delaying oxaliplatin administration by 24 h after MM-398 does not lead to significant changes in body weight.
  • FIG. 11A-11F are bar graphs depicting hematological and liver toxicities following treatment with MM-398 with or without oxaliplatin given either concurrently or sequentially with MM-398.
  • Hematological toxicities A-C
  • liver enzymes D-F
  • FIG. 12 depicts a graphical representation of the study design employing the combination of MM-398+5-FU/LV+oxaliplatin in (Arm 1) and MM-398+5-FU/LV (Arm 2), and nab-paclitaxel+gemcitabine (Arm 3) as described herein.
  • a combination of liposomal irinotecan, oxaliplatin, and 5-fluorouracil in treating metastatic adenocarcinoma of the pancreas in a human patient who has not previously received chemotherapy to treat the metastatic adenocarcinoma of the pancreas, the use comprising administering an antineoplastic therapy to the patient a total of once every two weeks, the antineoplastic therapy consisting of: (a) 60 mg/m 2 of liposomal irinotecan, 60 mg/m 2 oxaliplatin, 200 mg/m 2 of (l)-form of leucovorin or 400 mg/m 2 of the (l+d) racemic form of leucovorin, and 2,400 mg/m 2 5-fluorouracil to treat the metastatic adenocarcinoma of the pancreas in the human patient; (b) 60 mg/m 2 of liposomal irinotecan, 85 mg/m 2 oxa
  • the liposomal irinotecan comprises irinotecan sucrose octasulfate encapsulated in liposomes.
  • the liposomal irinotecan comprises irinotecan encapsulated in liposome vesicles consisting of 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC), cholesterol, and a N-(carbonylmethoxypolyethlyene glycol-2000)-1,2-distearoly-sn-glycero-3-phosphoethanolamine (MPEG-2000-DSPE).
  • DSPC 1,2-distearoyl-sn-glycero-3-phosphocholine
  • MPEG-2000-DSPE N-(carbonylmethoxypolyethlyene glycol-2000)-1,2-distearoly-sn-glycero-3-phosphoethanolamine
  • irinotecan can be administered in an irinotecan liposome preparation.
  • the liposomal irinotecan is irinotecan sucrose sulfate liposome injection (otherwise termed “irinotecan sucrose octasulfate salt liposome injection” or “irinotecan sucrosofate liposome injection”), the formulation referred to herein as “MM-398” (also known as PEP02, see U.S. Pat. No. 8,147,867) is a form of “nanoliposomal irinotecan” (also called “irinotecan liposome” or “liposomal Irinotecan”).
  • MM-398 is irinotecan as the irinotecan sucrose octasulfate salt encapsulated in a nanoliposome drug delivery system.
  • the liposomal irinotecan can be a pharmaceutical composition prepared for human intravenous administration.
  • the liposomal irinotecan may be provided as a sterile, injectable parenteral liquid for intravenous injection.
  • the required amount of liposomal irinotecan may be diluted, e.g., in 500 mL of 5% dextrose injection USP, to provide a variety of concentrations, for example, 5 mg/mL, and may be infused over a 90 minute period.
  • irinotecan The active ingredient of the MM-398 injection, irinotecan, is a member of the topoisomerase I inhibitor class of drugs and is a semi-synthetic and water soluble analog of the naturally-occurring alkaloid, camptothecin. Topoisomerase I inhibitors work to arrest uncontrolled cell growth by preventing the unwinding of DNA and therefore preventing replication.
  • the pharmacology of irinotecan is complex, with extensive metabolic conversions involved in the activation, inactivation, and elimination of the drug.
  • Innotecan is a pro-drug that is converted by nonspecific carboxylesterases into a 100-1000 fold more active metabolite, SN-38.
  • SN-38 is cleared via glucuronidation, (for which major pharmacogenetic differences have been shown), and biliary excretion. These drug properties contribute to the marked differences in efficacy and toxicity observed in clinical studies with irinotecan.
  • the liposomal irinotecan can be a unilamellar lipid bilayer vesicle of approximately 80-140 nm in diameter that encapsulates an aqueous space that contains irinotecan complexed in a gelated or precipitated state as a salt with sucrose octasulfate.
  • the lipid membrane of the liposome is composed of phosphatidylcholine, cholesterol, and a polyethyleneglycol-derivatized phosphatidyl-ethanolamine in the amount of approximately one polyethyleneglycol (PEG) molecule for every 200 phospholipid molecules.
  • the amount of liposomal irinotecan administered to the human patient can range from about 40 mg/m 2 to about 180 mg/m 2 , preferably 60 mg/m 2 when administered in combination with oxaliplatin and 5-fluorouracil for treatment of pancreatic cancer (dose expressed in terms of the amount of irinotecan hydrochloride trihydrate salt).
  • the plasma pharmacokinetics of total irinotecan and total SN-38 were evaluated in patients with cancer who received MM-398, as a single agent or as part of combination chemotherapy, at doses between 50 and 155 mg/m 2 (amount of irinotecan base, equivalent to 60-180 mg/m 2 dose expressed in terms of the amount of irinotecan hydrochloride trihydrate salt) and 353 patients with cancer using population pharmacokinetic analysis. Over the dose range of 50 to 155 mg/m 2 , the C max and AUC of total irinotecan increases with dose. Additionally, the C max of total SN-38 increases proportionally with dose; however, the AUC of total SN-38 increases less than proportionally with dose.
  • the combination treatment described herein encompasses administration of MM-398 liposomal irinotecan in combination with multiple additional active agents: oxaliplatin, leucovorin and 5-fluorouracil, in doses and schedules to human patients with metastatic pancreatic cancer not previously treated with a prior chemotherapeutic agent in the metastatic setting as described herein.
  • 5-Fluorouracil is a pyrimidine antagonist that interferes with nucleic acid biosynthesis.
  • the deoxyribonucleotide of the drug inhibits thymidylate synthetase, thus inhibiting the formation of thymidylic acid from deoxyuridylic acid, thus interfering in the synthesis of DNA. It also interferes with RNA synthesis.
  • An exemplary effective amount of 5-fluorouracil administered to a human patient can range from about 2,000 mg/m 2 to about 3,000 mg/m 2 . In some embodiments, the amount of 5-fluorouracil administered to the human patient is 2,400 mg/m 2 .
  • Leucovorin is optionally administered prior to the 5-fluorouracil.
  • Leucovorin acts as a biochemical cofactor for 1-carbon transfer reactions in the synthesis of purines and pyrimidines.
  • Leucovorin does not require the enzyme dihydrofolate reductase (DHFR) for conversion to tetrahydrofolic acid.
  • DHFR dihydrofolate reductase
  • the effects of methotrexate and other DHFR-antagonists are inhibited by leucovorin.
  • Leucovorin can potentiate the cytotoxic effects of fluorinated pyrimidines (i.e., fluorouracil and floxuridine).
  • 5-FU is activated within the cell, it is accompanied by a folate cofactor, and inhibits the enzyme thymidylate synthetase, thus inhibiting pyrimidine synthesis.
  • Leucovorin increases the folate pool, thereby increasing the binding of folate cofactor and active 5-FU with thymidylate synthetase.
  • Leucovorin has dextro- and levo-isomers, only the latter one being pharmacologically useful. As such, the bioactive levo-isomer (“levo-leucovorin”) has also been approved by the FDA for treatment of cancer.
  • the dosage of leucovorin is that of the racemic mixture containing both dextro (d) and levo (l) isomers, or optionally the (l) form of leucovorin at half the dosage of the (l+d) racemic form.
  • An exemplary effective amount of leucovorin administered to the human patient can include an amount of (l)-form leucovorin ranging from about 100 mg/m 2 to about 300 mg/m 2 . In some embodiments, the amount of (l)-form leucovorin administered to the human patient is 200 mg/m 2 .
  • the leucovorin administered is the (l+d)-form of leucovorin, in an amount ranging from about 200 mg/m 2 to about 600 mg/m 2 . In some embodiments, the amount of (l+d)-form of leucovorin administered is 400 mg/m 2 .
  • Oxaliplatin is a platinum-based drug that acts as a DNA cross-linking agent to effectively inhibit DNA replication and transcription, resulting in cytotoxicity which is cell-cycle non-specific. Oxaliplatin is typically used in combination with infusional 5-FU/LV, and is approved for use in advanced colorectal cancer (refer to package insert for more details).
  • the effective amount of oxaliplatin administered to the human patient can range from about 30 mg/m 2 to about 150 mg/m 2 , for example, from about 40 mg/m 2 to about 100 mg/m 2 , or an amount of oxaliplatin of 50 mg/m 2 , 55 mg/m 2 , 60 mg/m 2 , 65 mg/m 2 , 70 mg/m 2 , 75 mg/m 2 , 80 mg/m 2 , 85 mg/m 2 , 90 mg/m 2 , or 95 mg/m 2 .
  • Dose modifications may be made to methods of administering the combination treatment described herein as a result of adverse events, include hematological and non-hematological adverse events.
  • methods of administering the combination treatment described herein to patients having one or more characteristics can include reducing or otherwise modifying the dose of MM-398 administered according to the embodiments herein.
  • the dose of MM-398 is modified according to Table 1.
  • the first, second or any subsequent dose of MM-398 can be reduced by 20-30% (including dose reductions of 20%, 25% and/or 30%) in response to patient tolerability considerations such as an adverse reaction to a first or subsequent dose of MM-398 and/or other antineoplastic agent, and/or identifying a patient as being homozygous for the UGT1A1*28 allele.
  • the second or subsequent dose of MM-398 is reduced by about 20%, 25% or 30% (e.g., a dose reduction from 60 mg/m2 to.
  • the dose of MM-398 is reduced by 25%.
  • the dose of MM-398 is reduced by 30%.
  • the reduced dose of MM-398 is in a range starting from 30 mg/m 2 to (and including) 55 mg/m 2 . In some embodiments, the dose of MM-398 is reduced to 60 mg/m 2 . In some embodiments, the dose of MM-398 is reduced to 45 mg/m 2 . In some embodiments, the dose of MM-398 is reduced to 35 mg/m 2 .
  • the first dose reduction in response to a grade III or IV hematotoxicity is preferably a 25% dose reduction for each of the MM-398, 5-FU and Oxaliplatin doses for each administration of the antineoplastic therapy.
  • an additional 25% dose reduction in each of the antineoplastic agents of MM-398, 5-fluorouracil and oxaliplatin is preferred.
  • hematotoxicity For non-hematologic toxicities, the same dose reduction schema can be followed as for hematotoxicity, except for the specific toxicities associated with the drug (ie 5FU hand foot syndrome, and oxaliplatin neuropathy) which can be selected based on the medically appropriate dose for the patient.
  • the specific toxicities associated with the drug ie 5FU hand foot syndrome, and oxaliplatin neuropathy
  • methods of administering the combination treatment described herein to patients having one or more characteristics can include reducing or otherwise modifying the dose of Oxaliplatin administered according to the embodiments herein.
  • the dose of Oxaliplatin is reduced by 20-30%. In some embodiments, the, the dose of Oxaliplatin is reduced by 20%. In some embodiments, the, the dose of Oxaliplatin is reduced by 25%. In some embodiments, the, the dose of Oxaliplatin is reduced by 30%. In some embodiments, the reduced dose of Oxaliplatin is in a range from 30 mg/m 2 to 75 mg/m. In some embodiments, the dose of Oxaliplatin is reduced to 75 mg/m.
  • the dose of Oxaliplatin is reduced to 65 mg/m 2 . In some embodiments, the dose of Oxaliplatin is reduced to 60 mg/m 2 . In some embodiments, the dose of Oxaliplatin is reduced to 45 mg/m 2 . In some embodiments, the dose of Oxaliplatin is reduced to 45 mg/m 2 . In some embodiments, the dose of Oxaliplatin is reduced to 34 mg/m 2 .
  • methods of administering the combination treatment described herein to patients having one or more characteristics can include reducing or otherwise modifying the dose of 5-fluorouracil administered according to the embodiments herein.
  • the dose of 5-fluorouracil is reduced by 20-30%. In some embodiments, the, the dose of 5-fluorouracil is reduced by 20%. In some embodiments, the, the dose of 5-fluorouracil is reduced by 25%. In some embodiments, the, the dose of 5-fluorouracil is reduced by 30%.
  • the reduced dose of 5-fluorouracil is in a range from 1000 mg/m 2 to 1800 mg/m 2 . In some embodiments, the dose of 5-fluorouracil is reduced to 1800 mg/m 2 . In some embodiments, the dose of 5-fluorouracil is reduced to 1350 mg/m 2 . In some embodiments, the dose of 5-fluorouracil is reduced to 1200 mg/m 2 .
  • methods of administering the combination treatment described herein to patients having one or more characteristics can include further reducing or otherwise modifying the dose of MM-398, Oxaliplatin and/or 5-fluorouracil administered according to the embodiments herein.
  • methods of administering the combination treatment described herein to patients having one or more characteristics can include reducing or otherwise modifying the dose of more than one of MM-398, Oxaliplatin and 5-fluorouracil administered according to the embodiments herein.
  • the method of administering the combination treatment comprises 34, 45, or 60 mg/m 2 of liposomal irinotecan, 34, 42, 45, 60 or 85 mg/m 2 oxaliplatin, 200 mg/m 2 of (1)-form of leucovorin or 400 mg/m 2 of the (l+d) racemic form of leucovorin, and 1,200, 1,350, 1,800 or 2,400 mg/m 2 5-fluorouracil to treat the metastatic adenocarcinoma of the pancreas in the human patient.
  • the method of administering the combination treatment to treat the metastatic adenocarcinoma of the pancreas in the human patient comprises:
  • (A) 35 mg/m 2 of liposomal irinotecan, 35 mg/m 2 oxaliplatin, 200 mg/m 2 (l)-form or 400 mg/m 2 racemic leucovorin, and 1,200 mg/m 2 5-FU; (ii) 35 mg/m 2 of liposomal irinotecan, 35 mg/m 2 oxaliplatin, 200 mg/m 2 (l)-form or 400 mg/m 2 racemic leucovorin, and 1,350 mg/m 2 5-FU; (iii) 35 mg/m 2 of liposomal irinotecan, 35 mg/m 2 oxaliplatin, 200 mg/m 2 (l)-form or 400 mg/m 2 racemic leucovorin, and 1,800 mg/m 2 5-FU; (iv) 35 mg/m 2 of liposomal irinotecan, 35 mg/m 2 oxaliplatin, 200 mg/m 2 (l)-form or 400 mg/m 2 racemic leu
  • Liposomal irinotecan is preferably administered intravenously, in combination with oxaliplatin, 5-fluorouracil (5-FU) and leucovorin.
  • liposomal irinotecan is administered prior to oxaliplatin, 5-FU and leucovorin.
  • leucovorin is administered prior to 5-FU.
  • the MM-398 liposomal irinotecan is administered followed by administration of the oxaliplatin, followed by administration of the leucovorin, and followed by the administration of the 5-fluorouracil.
  • the liposomal irinotecan is administered to the patient intravenously over 90 minutes.
  • the oxaliplatin is administered to the patient intravenously over 120 minutes. In another embodiment, 5-FU is administered intravenously over 46 hours. In one embodiment, the oxaliplatin is administered from about 6 to about 72 hours after administration of the liposomal irinotecan. In another embodiment, the oxaliplatin is administered for example, 6 hours, 12 hours, 24 hours, 36 hours, 48 hours, 60 hours, or 72 hours, after administration of the liposomal irinotecan. In another embodiment, leucovorin is administered intravenously over 30 minutes. In various embodiments the liposomal irinotecan is MM-398.
  • the human patient with metastatic pancreatic cancer is pre-medicated with dexamethasone and a 5-HT3 antagonist or other anti-emetic prior to administering the MM-398 liposomal irinotecan, and other active agents.
  • the invention provides methods for treating pancreatic cancer in a human patient, such as in a patient not previously treated with a chemotherapeutic agent in the metastatic setting, the method comprising administering to the patient liposomal irinotecan, also referred to as MM-398 (e.g., irinotecan sucrose octasulfate salt liposome injection) in combination with oxaliplatin, leucovorin and 5-FU.
  • MM-398 e.g., irinotecan sucrose octasulfate salt liposome injection
  • a method for treating pancreatic cancer in a human subject who has not previously received chemotherapy to treat the pancreatic cancer comprising: administering to the subject a therapeutically effective amount of MM-398 liposomal irinotecan in combination with oxaliplatin, leucovorin, and 5-FU to treat the pancreatic cancer in the human subject.
  • a method for treating pancreatic cancer in a human subject who has not previously received chemotherapy to treat the pancreatic cancer comprising: administering to the subject 60 mg/m 2 of MM-398 liposomal irinotecan in combination with oxaliplatin, leucovorin, and 5-FU to treat the pancreatic cancer in the human subject.
  • any one of embodiments 1-3 wherein the amount of oxaliplatin administered is from about 50 mg/m 2 to about 100 mg/m 2 , such as about 60 mg/m 2 to about 85 mg/m 2 , for example 60 mg/m 2 , 75 mg/m 2 , or 85 mg/m 2 .
  • pancreatic cancer is adenocarcinoma of the pancreas, such as unresectable, locally advanced or metastatic adenocarcinoma of the pancreas, for example, wherein the pancreatic cancer is metastatic adenocarcinoma of the pancreas; or wherein the metastatic pancreatic cancer is an exocrine metastatic pancreatic cancer selected from the group consisting of Duct cell carcinoma, Acinar cell carcinoma, Adenosquamous carcinoma, Cyst adenocarcinoma (serous and mucinous types), Giant cell carcinoma, Invasive adenocarcinoma associated with cystic mucinous neoplasm or intraductal papillary mucinous neoplasm, Mixed type (ductal-endocrine or acinar-endocrine), Mucinous carcinoma, Pancreatoblastoma, Papillary-cystic neoplasm (
  • a human patient with metastatic adenocarcinoma of the pancreas who has not previously been treated with any chemotherapeutic agent in the metastatic setting is treated with a combination regimen of the present disclosure, the method comprising, intravenously administering to the patient, beginning on day 1 of a 2-week cycle, 80 mg/m 2 of MM-398 liposomal irinotecan over 90 minutes, followed by 60-85 mg/m 2 oxaliplatin, followed by 200 mg/m 2 of the (l) form of leucovorin, or 400 mg/m 2 of the (14-d) racemic form of leucovorin, followed by 2,400 mg/m 2 5-FU, wherein the human patient is treated with one or multiple cycles.
  • the effective amount of MM-398 liposomal irinotecan administered to the human patient can range from about 40 mg/m 2 to about 100 mg/m 2 , for example, from about 60 mg/m 2 to about 80 mg/m 2 .
  • the amount of MM-398 liposomal irinotecan administered to the human patient is 60 mg/m 2 or 80 mg/m 2 .
  • the effective amount of Oxalyplatin administered to the human patient can range from about 40 mg/m 2 to about 100 mg/m 2 , for example, from about 60 mg/m 2 to about 85 mg/m 2 .
  • the amount Oxalyplatin administered to the human patient is 60 mg/m 2 or 85 mg/m 2 .
  • oxaliplatin is administered over 120 minutes
  • leucovorin is administered over 30 minutes
  • 5-FU is administered over 46 hours.
  • FIG. 1A Simulated tumor exposure of SN-38 in patients administered with free irinotecan or MM-398 were shown in FIG. 1A .
  • MM-398 is shown to result in prolonged SN-38 duration in tumors compared to free irinotecan (CPT-11).
  • CPT-11 free irinotecan
  • FIG. 1B illustrates the in vitro conditions for mimicking this clinically comparable SN-38 exposure of the 2 drugs, where cells exposed to SN-38 at high concentrations for a short period of time approximates for free irinotecan, and at low concentrations for a long period of time for MM-398.
  • the results and experimental conditions are summarized in FIG. 1C .
  • cells incubated with 139 nM of SN-38 for 144 h vs. 417 nM for 24 h have similar SN-38 tumor exposure ratios of MM-398 vs. free irinotecan in patient tumors. Under these clinically relevant conditions, prolonged exposure (i.e.
  • MM-3978 primarily resulted in more pancreatic cancer cell growth inhibition compared to short exposure at high concentrations (i.e. free irinotecan). Similar results were also obtained when SN-38 were combined with 5-FU or oxaliplatin, demonstrating that prolonged exposure also led to increased cell growth inhibition when combined with these other chemotherapeutics agents that are used in the FOLFIRINOX regimen.
  • BxPC-3 cells were cultured in RPMI growth media supplemented with 10% FBS and 1% penicillin/streptomycin.
  • CFPAC-1 cells were also cultured in RPMI growth media supplemented with 10% FBS and 1% penicillin/streptomycin.
  • mice Experiments were performed according to approved guidelines. Female NOD.scid mice were obtained from Charles River Laboratories (Wilmington, Mass.). BxPC-3 or CFPAC-1 cells were inoculated into the right hind flank at 5e6 cells in a total volume of 50 uL per mouse. Eight animals were treated per group, unless otherwise indicated. Animals were randomized and dosing initiated when tumors reached an average volume of 200-250 mm 3 (range 100-400 mm 3 ), unless otherwise indicated.
  • Treatment efficacy MM-398, irinotecan and oxaliplatin were administered intravenously. 5-FU was administered intraperitoneally. Administration of the indicated doses of each agent was initiated when tumors reached an average volume of 200-250 mm 3 and continued for a total of 4 weekly doses. Tumor volumes were measured weekly until tumors reached 1000-2000 mm 3 , as indicated, animals were in poor general health, or 2 weeks post-final dose.
  • PDX19015 Mouse Xenograft Study (Efficacy and Tolerability): Animals: Experiments were performed according to approved guidelines. Female CB.17 SCID mice were obtained from Roswell Park Cancer Institute (Buffalo, N.Y.), initially at 6-8 weeks of age. Per treatment group, 8 animals were treated, unless otherwise indicated. Tumor pieces were derived from donor mice and engrafted subcutaneously. Animals were randomized and dosing initiated when tumors reached an average volume of 200-250 mm 3 (range 100-400 mm 3 ), unless otherwise indicated.
  • Treatment efficacy MM-398, irinotecan and oxaliplatin were administered intravenously. 5-FU was administered intraperitoneally. Administration of the indicated doses of each agent was initiated when tumors reached an average volume of 200-250 mm 3 and continued for a total of 4 weekly doses. Tumor volumes were measured twice weekly during the dosing cycle, then once weekly until tumors reached 1000-2000 mm 3 , as indicated, animals were in poor general health, or 100 days post-first dose. Tolerability: Mouse weights were measured once weekly to monitor treatment tolerability. Mice were euthanized when body weight declined to 20% below baseline, or they exhibited overt signs of poor general health.
  • mice Experiments were performed according to approved guidelines. Female CD-1 mice were obtained from Charles River Laboratories (Wilmington, Mass.). Tolerability studies were performed in nave (non-tumor-bearing) mice. Three animals were treated per group.
  • Treatment tolerability Agents were administered intravenously at their pre-defined maximum tolerated doses (MM-398, 50 mg/kg; oxaliplatin, 17 mg/kg). Each drug was administered individually, or in combination. Combinations were given in one of 3 independent dosing schedules: coinjection (drugs administered simultaneously), MM-398 given on day 1 and oxaliplatin given on day 2 (24 h delay), or MM-398 given on day 1 and oxaliplatin given on day 4 (72 h delay). A single administration of each drug was given. Mouse body weights were measured daily for up to 2 weeks post-treatment. Mice were euthanized when body weight declined to 20% below baseline, they exhibited overt signs of poor general health, or at 2 weeks post-treatment (end of study).
  • Hematologic and liver toxicities At the end of study, terminal bleeds were performed for each mouse via cardiac puncture. Hematologic function (blood cell count) was measured by Hemavet (Drew Scientific, Miami Lakes, Fla.), according to manufacturer's protocol. Liver function (enzyme levels) was measured by CatalystDx (Idexx Laboratories, Westbrook, Me.) according to the manufacturer's protocol.
  • the present study is an open-label, phase 2 comparative study to assess the safety, tolerability, and efficacy of MM-398 in combination with other anticancer therapies, compared to nab-paclitaxel+gemcitabine, in patients with metastatic pancreatic adenocarcinoma who have not received prior chemotherapy.
  • This study assesses the following regimens: (1) MM-398+5-FU/LV+oxaliplatin (Arm 1), (2) MM-398+5-FU/LV (Arm 2) and (3) nab-paclitaxel+gemcitabine (Arm 3).
  • This phase 2 study evaluates the preliminary safety and efficacy of MM-398+5-FU/LV with or without oxaliplatin versus nab-paclitaxel+gemcitabine in patients with previously untreated mPAC.
  • the study may also provide important information on the impact of MM-398 combination treatment on patient HRQL and identify potential biomarkers of response.
  • MM-398 is administered instead of conventional irinotecan to improve the safety, tolerability, and ultimately efficacy of a FOLFIRINOX regimen.
  • the addition of oxaliplatin to the NAPOLI-1 regimen is included to increase DNA damage and potentiate efficacy.
  • using MM-398 instead of conventional irinotecan is designed to further improve upon the efficacy of FOLFIRINOX.
  • a modified triplet combination regimen of liposomal irinotecan, oxaliplatin, 5-fluorouracil (5-FU)/leucovorin is provided herein, whereby no bolus of 5-FU will be administered.
  • the target dose of oxaliplatin 60-85 mg/m 2
  • the target dose of oxaliplatin is evaluated in the Arm 1 combination regimen with the continuous infusion dose of 5-FU (excluding the bolus), and the every 2 week dose of MM-398 previously shown to be tolerable and efficacious in combination with 5-FU. Note that with MM-398 dosing, the C max of SN-38 is expected to be lower than would be expected for standard dosing with free irinotecan.
  • the study is conducted in two parts, as illustrated in the schematic of FIG. 12 : 1) a safety run-in of the MM-398+5-FU/LV+oxaliplatin regimen, and 2) a randomized, efficacy study of the MM-398+5-FU/LV+oxaliplatin regimen, the MM-398+5-FU/LV combination that previously demonstrated efficacy in the Phase 3 NAPOLI-1 trial (i.e. the NAPOLI regimen), and a nab-paclitaxel+gemcitabine control arm.
  • Part 1 consists of an open-label safety run-in of the combination regimen in Arm 1: MM-398+5-FU/LV+oxaliplatin.
  • the Arm 2 and Arm 3 regimens have established doses, and MM-398+5-FU/LV has been demonstrated tolerable, yielding antitumor responses in a Phase 3 study of patients with relapsed metastatic pancreatic cancer, and therefore was not included in this part of the study.
  • the safety run-in enrolls small cohorts of patients following a traditional 3+3 dose escalation design in order to confirm the target dose of oxaliplatin.
  • Dose limiting toxicities (DLTs) are evaluated during the first cycle of treatment (i.e.
  • the target combination dose is based on the established dose of the FOLFIRINOX regimen. If there are no DLTs within the safety evaluation period, then the subsequent cohort is initiated following agreement between the Investigators, Medical Monitor, and the Sponsor. If one DLT occurs, then the cohort is expanded to 6 patients. If 2 or more patients have DLTs within a given dose level, that dose is considered to exceed the safety and tolerability criteria of the combination, and the dose is not be escalated further; however, lower doses can be explored. The Part 2 dose is then defined as the next lower dose level in which 6 patients were treated and 1 patient experienced a toxicity that qualifies as a DLT.
  • UGT1A1*28 allele status is considered when evaluating DLTs.
  • individuals who are homozygous for the UGT1A1*28 allele are at increased risk for neutropenia following initiation of irinotecan treatment.
  • the prescribing information for irinotecan in a study of 66 patients who received single-agent irinotecan (350 mg/m 2 once every-3-weeks), the incidence of grade 4 neutropenia in patients homozygous for the UGT1A1*28 allele was as high as 50%, and in patients heterozygous for this allele (UGT1A1 6/7 genotype) the incidence was 12.5%.
  • Part 2 consists of an open-label, randomized, Phase 2 study where patients will be randomized to treatment (1:1:1) to either MM-398+5-FU/LV+oxaliplatin, MM-398+5-FU/LV, or nab-paclitaxel+gemcitabine. The randomization is stratified based on region (East Asia vs. rest of the world) and performance status (ECOG 0 vs. 1).
  • a dose of oxaliplatin of 85 mg/m 2 is the target dose for Part 2 of this study.
  • the purpose of Part 1 is to confirm whether this dose is compatible when MM-398 is used instead of conventional irinotecan.
  • 3 to 6 patients are initially treated at a lower dose of oxaliplatin (60 mg/m 2 , see Table 1) prior to administration of oxaliplatin at the highest proposed dose of 85 mg/m 2 .
  • the dose of the triplet combination to be administered in Part 2 of the study is defined as the highest dose level at which a DLT is experienced by fewer than 2 patients in a cohort of 3 to 6 patients.
  • the dose to be used in Part 2 is then defined as the next lower dose level in which 6 patients were treated and ⁇ 1 patient experienced a toxicity that qualifies as a DLT.
  • Dosing of patient cohorts begins at dose level ⁇ 1 with planned escalation to dose level ⁇ 2B (target dose), in which the dose for one of the three drugs is increased while the other two drugs will maintain a constant dose. If the ⁇ 1 dose level is evaluated and deemed to be safe, escalation to the ⁇ 2B dose level may be initiated. Any decisions to de-escalate, as well as enrollment at alternative doses following de-escalation, must be made according to the established decision process for dose escalation, as described herein. Planned dose escalation for the Arm 1 combination regimen is outlined in Table 2 below; additional details on dose administration as described herein in the section “Study Treatment”.
  • the order of the infusions to be administered in the clinic is as follows: MM-398 administered first, followed by oxaliplatin, then LV, followed by 5-FU.
  • Part 1 patients receive the oxaliplatin infusion 2 hours after the completion of the MM-398 infusion. If no infusion reactions are seen, Part 2 patients can receive oxaliplatin directly after completion of the MM-398 infusion. If any grade 3 or higher infusion reactions are seen in Part 2 patients, the DSMB may elect to revert back to administration of oxaliplatin two hours after the completion of the MM-398 infusion.
  • All patients must be premedicated prior to MM-398 infusion, 5-FU/LV infusion, and oxaliplatin infusion with standard doses of dexamethasone and a 5-HT3 antagonist, or equivalent other anti-emetics according to standard institutional practices for irinotecan, 5-FU, and oxaliplatin administration, or the Summary of Product Characteristics (SmPC) for sites located in the European Union (EU).
  • Atropine may be prescribed prophylactically for patients who experienced acute cholinergic symptoms in the previous cycles.
  • MM-398 will be administered first, followed by LV, followed by 5-FU.
  • All patients must be premedicated prior to MM-398 infusion and 5-FU/LV infusion with standard doses of dexamethasone and a 5-HT3 antagonist, or equivalent other anti-emetics according to standard institutional practices for irinotecan and 5-FU administration, or the SmPC for sites located in the EU.
  • Atropine may be prescribed prophylactically, according to standard institutional practices, for patients who experienced acute cholinergic symptoms in the previous cycles.
  • MM-398 is administered by intravenous (IV) infusion over 90 minutes ( ⁇ 10 minutes) every two weeks.
  • the first cycle Day 1 is a fixed day; subsequent doses should be administered on the first day of each cycle+/ ⁇ 2 days.
  • MM-398 Prior to administration, the appropriate dose of MM-398 must be diluted in 5% Dextrose Injection solution (D5W) or normal saline to a final volume of 500 mL. Care should be taken not to use in-line filters or any diluents other than D5W or normal saline. MM-398 can be administered at a rate of up to 1 mL/sec (30 mg/sec).
  • MM-398 to be administered will be determined by calculating the patient's body surface area at the beginning of each cycle. A +/ ⁇ 5% variance in the calculated total dose will be allowed for ease of dose administration. Since MM-398 vials are single-use vials, site staff must not store any unused portion of a vial for future use and they must discard unused portions of the product.
  • Leucovorin is administered at a dose of 400 mg/m 2 of the (l+d)-racemic form, or (l) form 200 mg/m 2 , as an IV infusion over 30 minutes ( ⁇ 5 minutes), on Days 1 and 15 of each 28-day cycle
  • 5-FU is administered at a dose of 2400 mg/m 2 as an IV infusion over 46-hours ( ⁇ 60 minutes), on Days 1 and 15 of each 28-day cycle
  • Leucovorin should be reconstituted per the instructions on the package insert, SmPC or standard institutional guidelines for reconstitution of leucovorin.
  • Leucovorin should be administered prior to the 5-FU infusion (on Arm 1, leucovorin will be given concurrently with oxaliplatin).
  • Actual dose of 5-FU and leucovorin to be administered is determined by calculating the patient's body surface area prior to each cycle. A +/ ⁇ 5% variance in the calculated total dose will be allowed for ease of dose administration.
  • oxaliplatin is administered at increasing dose levels as indicated in Table 2 (from 60 mg/m 2 -85 mg/m 2 ), IV over 120 minutes ( ⁇ 10 minutes), on Days 1 and 15 of each 28-day cycle
  • oxaliplatin is administered at a dose of 85 mg/m 2 , IV over 120 minutes ( ⁇ 10 minutes), on Days 1 and 15 of each 28-day cycle (if target dose is confirmed in accordance with methods described herein).
  • Oxaliplatin should be prepared according to the instructions on the package insert, SmPC or per standard institutional guidelines for preparation and administration of oxaliplatin.
  • Oxaliplatin should be administered following MM-398 infusion; in Part 1, the first 3 patients in Dose Level 1 begin the oxaliplatin infusion two hours after the completion of the MM-398 infusion.
  • Actual dose of oxaliplatin to be administered is determined by calculating the patient's body surface area prior to each cycle. A +/ ⁇ 5% variance in the calculated total dose is allowed for ease of dose administration.
  • nab-paclitaxel will be administered first, followed by gemcitabine.
  • nab-paclitaxel and gemcitabine All patients receiving nab-paclitaxel and gemcitabine should be pre-medicated per the respective package inserts. If different institutional guidelines exist for premedication of weekly nab-paclitaxel and/or gemcitabine, the investigator should use their standard practice or the SmPC for sites located in the EU.
  • nab-paclitaxel will be administered at 125 mg/m 2 IV over 35 minutes ( ⁇ 5 minutes), on Days 1, 8 and 15 of each 28-day cycle.
  • the gemcitabine will be administered at 1000 mg/m 2 IV over 30 minutes ( ⁇ 5 minutes), on Days 1, 8 and 15 of each 28-day cycle.
  • DLTs Dose Limiting Toxicities
  • DLTs dose limiting toxicities
  • Any toxicity that is related to disease progression will not be considered a DLT.
  • the safety assessment period for purposes of DLT evaluation and dose escalation decisions is one cycle of treatment (i.e. 28 days; or 14 days after the 2nd dose of study treatment if there is a treatment delay according as described herein).
  • the dose can escalate to the next level only after the safety data have been evaluated at the current dose level (once the last patient enrolled in the cohort completes the first cycle of treatment) and the criteria for safety and tolerability of the optimal dose have not been exceeded (see Section Part 2 dose definition).
  • any drug-related toxicities of Grade 3 or higher that arise after Cycle 1 (if applicable) are assessed for their potential relationship to cumulative MM-398 or combination therapy doses and considered in the decision to escalate the dose.
  • PK data may be available, but is not be required for decisions on dose escalation.
  • Inclusion Criteria In order for inclusion into the study, Patients must meet all the inclusion criteria and none of patients must have/be: the following exclusion criteria: Pathologically confirmed Prior treatment of pancreatic cancer in the adenocarcinoma of the pancreas metastatic setting with surgery, radiotherapy, that has not been previously chemotherapy or investigational therapy (note: treated in the metastatic setting placement of biliary stent is allowed)
  • Part 1 unresectable, Prior treatment of pancreatic cancer with cytotoxic locally advanced or doses of chemotherapy (patients receiving prior metastatic disease is treatment with chemotherapy as a radiation allowed, diagnosed sensitizer are eligible if ⁇ 6 months has elapsed from within 6 weeks prior to completion of therapy) enrollment
  • Known metastasis to the central nervous system Part 2 must have Clinically significant gastrointestinal disorder metastatic disease including hepatic disorders, bleeding, inflammation, diagnosed within 6 occlusion, diarrhea > grade 1, malabsorption weeks prior to syndrome, ulcerative colitis, inflammatory bowel randomization; locally disease, or partial bowel obstruction advanced disease
  • liver metastases are during screening visits or on the first scheduled day present) of dosing (at the discretion of the investigator, Adequate renal function as patients with tumor fever may be enrolled), which in evidenced by serum creatinine ⁇ 1.5 ⁇ the investigator's opinion might compromise the ULN, and calculated patient's participation in the trial or affect the study clearance ⁇ 60 mL/min/1.72 m 2 outcome for patients with serum Use of strong CYP3A4 inhibitors or inducers, or creatinine levels above or below presence of any other contraindications for the institutional normal value.
  • BMI body mass index
  • Dosing may be held for up to 2 weeks from when it was due to allow for recovery from toxicity related to the study treatment. If the time required for recovery from toxicity is more than 2 weeks, the patient should be discontinued from the study, unless the patient is benefiting from the study treatment, in which case the patient's continuation on study should be discussed between Investigator and Sponsor regarding risks and benefits of continuation. If oxaliplatin is not well tolerated in patients enrolled in Arm 1, oxaliplatin may be discontinued and patients may continue to receive MM-398+5-FU/LV at the discretion of the Investigator.
  • a patient's dose is reduced during the study due to toxicity, it should remain reduced for the duration of the study; dose re-escalation to an earlier dose is not permitted. Any patient who has 2 dose reductions and experiences an adverse event that would require a third dose reduction must be discontinued from study treatment.
  • patients Prior to each dosing, patients must have: ANC ⁇ 1500/mm 3 , WBC ⁇ 3500/mm 3 , Platelet count ⁇ 100,000/mm 3 and Diarrhea Grade ⁇ 1.
  • Treatment should be delayed to allow sufficient time for recovery to levels noted above, and upon recovery, treatment should be administered according to the guidelines in the tables below. If the patient had febrile neutropenia, the ANC must have resolved to 1500/mm 3 and the patient must have recovered from infection. For Grade 3 or 4 non-hematological toxicities, treatment should be delayed until they resolve to Grade 1 or baseline. Guidelines for dose adjustments of each individual treatment within the regimen are found in the tables below for Arm 1 (Table 3), and for Arm 2 (Tables 6 through 14). In case a patient experiences an infusion reaction, either institutional guidelines or the guidelines provided for infusion reaction management should be followed.
  • the starting dose of ONIVYDE will be 60 mg/m 2 , 5FU 2400 mg/m 2 , LV 400 mg/m 2 and Oxaliplatin either 85 mg/m 2 or 60 mg/m 2 .
  • Dose reduction will be 25% reduction in all agents for any grade III-IV Hematotoxicity. For persistent toxicities despite the first dose reduction, and additional 25% dose reduction in all agents will occur. Further toxicity will then lead to discontinuation from trial.
  • the dose reduction will be the same dose reduction schema as for hematotoxicity, except for the specific toxicities associated with the drug (ie 5FU hand foot syndrome, and oxaliplatin neuropathy) which will be as shown in Table 3.
  • Grade 1 diarrhea 2-3 stools/day > pretreatment
  • Grade 2 diarrhea 4-6 stools/day > pretreatment
  • Grade 3 diarrhea 7-9 stools/day > pretreatment
  • Grade 4 diarrhea >10 stools/day > pretreatment
  • Dosing may be held for up to 3 weeks from when it was due, to allow for recovery from toxicity related to the study treatments. If the time required for recovery from toxicity is more than 3 weeks, the patient should be discontinued from the study, unless the patient is benefiting from the study treatment, in which case the patient's continuation on study should be discussed between Investigator and Sponsor or its designee regarding risks and benefits of continuation.
  • a patient's dose is reduced during the study due to toxicity, it should remain reduced for the duration of the study; dose re-escalation to an earlier dose is not permitted. Any patient who has 2 dose reductions and experiences an adverse event that would require a third dose reduction must be discontinued from study treatment.
  • Infusion reactions will be monitored. Infusion reactions will be defined according to the National Cancer Institute CTCAE (Version 4.0) definition of an allergic reaction/infusion reaction and anaphylaxis, as defined below:
  • Grade 1 Transient flushing or rash, drug fever ⁇ 38° C. ( ⁇ 100.4° F.); intervention not indicated Grade 2: Intervention or infusion interruption indicated; responds promptly to symptomatic treatment (e.g., antihistamines, NSAIDS, narcotics); prophylactic medications indicated for ⁇ 24 hrs Grade 3: Symptomatic bronchospasm, with or without urticaria; parenteral intervention indicated; allergy-related edema/ angioedema; hypotension Grade 4: Life-threatening consequences; urgent intervention indicated
  • dexamethasone 10 mg IV For patients who experience a second grade 1 or 2 infusion reaction, administer dexamethasone 10 mg IV. All subsequent infusions should be premedicated with diphenhydramine hydrochloride 50 mg IV, dexamethasone 10 mg IV, and acetaminophen 650 mg orally.
  • Treatment should be delayed to allow sufficient time for recovery and upon recovery, treatment should be administered according to the guidelines in the tables below. If the patient had febrile neutropenia, the ANC must have resolved to >1500/mm 3 and the patient must have recovered from infection.
  • Treatment should be delayed until diarrhea resolves to ⁇ Grade 1, and for other Grade 3 or 4 non-hematological toxicities, until they resolve to Grade 1 or baseline. Guidelines for dose adjustment of MM-398 for drug related diarrhea and other Grade 3 or 4 non-hematological toxicities are provided below. Infusion reactions should be handled as described above.
  • the patients Prior to the next dose in a cycle or prior to initiating a new cycle of therapy, the patients must have:
  • Treatment should be delayed to allow sufficient time for recovery and upon recovery, treatment should be administered according to the guidelines provided in the table below.
  • the duration of the cycles is fixed at 6 weeks, and if a patient is unable to receive the D8, D15 or D22 dose due to toxicity, the dose will be considered as skipped.
  • Treatment should be delayed until all Grade 3 or 4 non-hematological toxicities resolve to Grade 1 or baseline. Guidelines for dose adjustment of 5-FU related toxicities are provided below. The duration of the cycles is fixed at 6 weeks, and if a patient is unable to receive the D8, D15 or D22 dose due to toxicity, the dose will be considered as skipped.
  • Adverse Drug Reaction Nab-paclitaxel Gemcitabine Febrile Neutropenia: Withhold until fever resolves and ANC ⁇ 1500; Grade 3 or 4 resume at next lower dose level Peripheral Neuropathy: Withhold until improves No dose reduction Grade 3 or 4 ⁇ Grade 1; resume at next dose level Cutaneous Toxicity: Reduce to next lower dose level; discontinue Grade 2 or 3 treatment if toxicity persists Gastrointestinal Toxicity: Withhold until improves to ⁇ Grade 1; Grade 3 mucositis or resume at next dose level diarrhea
  • Tumor responses are evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, to establish disease progression by CT or MRI.
  • RECIST Solid Tumors
  • other imaging procedures as deemed appropriate by the Investigator, are performed to assess sites of neoplastic involvement. The same method of assessment must be used throughout the study.
  • Investigators should select target and non-target lesions in accordance with RECIST v1.1 guidelines. follow up measurements and overall response should also be in accordance with these guidelines.
  • Tumor assessments should be completed until it has been determined that the patient has progressive disease (in accordance with RECIST v1.1).
  • imaging studies should be continually performed into the follow-up period every 8 weeks until disease progression is documented. Continued imaging follow-up on schedule is recommended to reduce potential bias in the evaluations of the impacts of the experimental treatments on disease.
  • the EORTC-QLQ-C30 Health-related quality of life (HRQL) is assessed by the EORTC-QLQ-C30 and EQ-5D-5L instruments.
  • the EORTC-QLQ-C30 is a reliable and valid measure of the quality of life of cancer patients in multicultural clinical research settings. It incorporates nine multi-item scales: five functional scales (physical, role, cognitive, emotional, and social); three symptom scales (fatigue, pain, and nausea and vomiting); and a global health and quality-of-life scale. Several single-item symptom measures are also included.
  • EQ-5D is a generic, preference-based measurement of HRQL.
  • the EQ-5D-5L descriptive system comprises the following 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems, and unable to do.
  • each MM-398-containing arm is compared to the control arm.
  • Efficacy comparisons use stratified analyses, incorporating randomization strata. Each comparison uses 0.10 level one-sided testing to evaluate whether the MM-398-containing arm improves the efficacy parameter. Confidence intervals are presented at two-sided 95% level for descriptive purposes. Hypothesis tests and confidence intervals are not adjusted for multiple comparisons. The primary efficacy comparisons are based on the ITT population, which includes all randomized patients.
  • progression free survival time is determined as the time from randomization (for patients in Part 1, the reference start time will be date of first study drug) to the first documented radiographical Progression of Disease (PD), per investigator using RECIST 1.1, or death from any cause, whichever comes first. If the progression or death occurs at a time point that is greater than 12 weeks after the non-PD last tumor assessment, then progression-free survival time is censored at the time of the last non-PD tumor assessment.
  • a primary analysis is conducted when the Week 24 progression-free status for all randomized patients can be determined, anticipated at approximately 24 weeks after the last patient is randomized.
  • a subsequent analysis for PFS and other endpoints is performed when PFS events have occurred in at least 120 (i.e. 80% of randomized patients) patients.
  • a patient In the intention-to-treat (ITT) analysis, a patient is considered to have achieved progression-free survival at 24 weeks if the patient has data to indicate the patient has not progressed at 24 weeks. That is, a patient is considered a responder if there is at least one non-PD assessment, prior to progression or new anticancer therapy, at Week 24 or later.
  • ITT intention-to-treat
  • the progression-free survival achievement rate at 24 weeks is estimated by the number of patients meeting the 24 week achievement criteria divided by the number of ITT patients in the arm.
  • the rate estimates are presented with corresponding 95% confidence intervals.
  • Each MM-398 containing arm is assessed for increase in rate relative to the control arm using a one-sided Cochran-Mantel-Haenszel test, incorporating randomization stratification factors, at 0.10 level of significance.
  • PFS Progression-Free Survival
  • Best Overall Response is defined as the best response as recorded from the start of study drug until disease progression. Patients without a post-baseline tumor assessment are considered to be non-evaluable for BOR. To classify BOR as stable disease (SD), there should be a qualifying SD assessment at least 6 weeks from randomization.
  • Objective Response Rate is defined as the proportion of patients with a BOR characterized as either a Complete Response (CR) or Partial Response (PR) relative to the total number of evaluable patients. Only patients with measurable disease at baseline will be included in the analysis of the objective response. Estimates of objective response rate and its corresponding 95% CI are calculated for each treatment arm. For each MM-398-containing arm, ORR is compared to the control arm. Differences in objective response rate between each MM-398-containing arm and control arm are provided with 95% CIs. Cochran-Mantel-Haenszel tests, adjusting by randomization strata, are used to compare objective response rates.
  • the maximum reduction (% change from baseline) in CA19-9 is computed, including analyses by time period (up to Week 8, 16 and 24 visits).
  • CA 19-9 response analyses is carried out using 3 thresholds for maximum reduction: 20%, 50%, 90%.
  • a patient without post-baseline CA19-9 measurement is considered as a non-responder.
  • Only patients with CA 19-9 elevated (>37 U/mL) at baseline are included in the analysis of the CA19-9 response.
  • the proportion of CA19-9 response is estimated, along with corresponding 95% confidence intervals, by treatment arm.
  • OS Overall Survival
  • Scoring is carried out as described in the EORTC QLQ-C30 Scoring Manual (Fayers, Aaronson, Bjordal, Curran, & Groenvald, 2001). Linear transformations are applied to the raw scores so that the reported score will have range 0-100 for all scales. Summary statistics are presented for each subscale. A summary health state index value is computed for each EQ-5D-5L assessment. Summary statistics are presented for summary health state index. For each EQ-5D-5L attribute (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), responses are tabulated.
  • Safety analysis of patients in Part 1 is to include a summary of dose-limiting toxicity events.
  • the period for treatment-emergent adverse events and safety findings is from the time of first study drug administration to 30 days after the date of last study drug administration. If an adverse event begins on the date of first study drug administration with no time recorded, the event is then considered as treatment-emergent.
  • Analyses are performed to assess the associations between potential biomarkers (from plasma and archived tissue) and efficacy parameters (ORR, percent change in target lesion size, and PFS or as appropriate). Graphical displays are performed when appropriate.
  • Plasma concentrations of MM-398 and oxaliplatin can be used to characterize PK parameters. Due to the sparse PK sampling schedule, PK parameters for individual patients can be estimated based on the Empirical Bayesian Estimation method with priors from the previously estimated (MM-398) or published (oxaliplatin) population PK model parameters.
  • the model simulated exposures e.g., C max , AUC (area under the curve), are used to examine any possible interactions between MM-398 and oxaliplatin by comparing the least squares geometric mean ratios (LS-GMR) of drug exposures.
  • LS-GMR least squares geometric mean ratios
  • NONMEM® Version 7.3, is used to estimate individual PK parameters and simulate plasma exposures.
  • nal-IRI and 5-FU/LV in Dose Level 1 and 2 above is the same dose and schedule that was previously used in the NAPOLI-1 Phase 3 study.
  • Table 16 summarizes the results from treating a total of seven (7) patients as part of Part 1 of Arm 1 shown in FIG. 12 . All seven patients met the applicable inclusion criteria specified below, including a diagnosis of pancreatic cancer.
  • a “check mark” ( ⁇ ) in Table 16 indicates the patient received the antineoplastic therapy of dose level 1 in Table 15 above, starting on the indicated days of 3 consecutive 28-day treatment cycles: 80 mg/m 2 liposomal irinotecan (MM-398, dose based on the corresponding amount of irinotecan hydrochloride trihydrate salt), 60 mg/m 2 oxaliplatin, 400 mg/m 2 (l+d) leucovorin and 2,400 mg/m 2 5-fluorouracil, as described in the protocol of Example 3.
  • a “R” in Table 16 indicates the patient received a reduced dose of antineoplastic therapy of dose level ⁇ 1 in Table 2 (Example 3 above) on the corresponding cycle and day: 60 mg/m 2 liposomal irinotecan (MM-398, dose based on the corresponding amount of irinotecan hydrochloride trihydrate salt), 60 mg/m 2 oxaliplatin, 400 mg/m 2 (l+d) leucovorin and 2,400 mg/m 2 5-fluorouracil, as described in the protocol of Example 3.
  • An “X” in Table 16 indicates the patient did not receive an antineoplastic therapy combining liposomal irinotecan, oxaliplatin, 5-fluorouracil and leucovorin or combining liposomal irinotecan, oxaliplatin, and 5-fluorouracil.
  • patient 2 was determined to be homozygous for the UGT1A1*28 allele, and subsequent reduced doses of the antineoplastic therapy were administered on days indicated in Table 16, based on the protocol of Example 3. Patients 1 and 3-7 were not homozygous for UGT1A1*28 allele.
  • the antineoplastic therapy of dose level 1 in Table 15 was only administered to 2 of these 6 patients on day 15 of (28-day) cycle 1, no patients received dose level 1 for more than 2 consecutive doses, and none of the patients received this therapy after cycle 1.
  • antineoplastic therapies combining a dose of 80 mg/m 2 liposomal irinotecan with 60 mg/m 2 oxaliplatin and doses of 2,400 and 400 mg/m 2 of 5-fluorouracil and (l+d) leucovorin were not well tolerated in a human clinical trial (resulting in dose limiting toxicities).
  • Examples of antineoplastic therapies combining a dose of 80 mg/m 2 liposomal irinotecan with 60 mg/m 2 oxaliplatin and doses of 2,400 and 400 mg/m 2 of 5-fluorouracil and (l+d) leucovorin include the therapies in Table 15.
  • antineoplastic therapies combining a dose of 60 mg/m 2 liposomal irinotecan with 60 mg/m 2 oxaliplatin and doses of 2,400 and 400 mg/m2 of 5-fluorouracil and (l+d) leucovorin were tolerated in a human clinical trial.
  • dose level ⁇ 1 in Table 17 (a 60 mg/m 2 (salt) M-398 dose) was administered two or more consecutive times to multiple human patients in the clinical trial described in Example 3.
  • antineoplastic therapies comprising the reduced 60 mg/m 2 (salt) of liposomal irinotecan (MM-398) in combination with oxaliplatin and 5-fluorouracil/leucovorin were better tolerated in humans than dose level 1 in Table 15.
  • patients are administered the therapy of dose level ⁇ 2B in Table 17.
  • Table 18 summarizes the results from treating a total of five (5) patients as part of Part 1 of Arm 1 shown in FIG. 12 . All five patients met the applicable inclusion criteria specified in Example 3, including a diagnosis of pancreatic cancer.
  • a “check mark” ( ⁇ ) in Table 18 indicates the patient received the antineoplastic therapy of dose level ⁇ 1 in Table 17 above, starting on the indicated days of 3 consecutive 28-day treatment cycles: 60 mg/m 2 liposomal irinotecan (MM-398, dose based on the corresponding amount of irinotecan hydrochloride trihydrate salt), 60 mg/m 2 oxaliplatin, 400 mg/m 2 (l+d) leucovorin and 2,400 mg/m 2 5-fluorouracil, as described in the protocol of Example 3.
  • the antineoplastic therapy of dose level ⁇ 1 in Table 2 was administered repeatedly to patients 2 and 6 for at least 3 consecutive administrations (including 4 consecutive administrations for patient 6).
  • the antineoplastic therapy of dose level ⁇ 1 in Table 2 was administered to 5 of 5 patients on days 1 and 15 of (28-day) cycle 1, and days 1 and 15 of (28 day) to 3 of 4 patients in the study, with no dose limiting toxicities.
  • the antineoplastic therapy of dose level ⁇ 1 was administered repeatedly to all 5 patients for at least 2 consecutive administrations.
  • a “check mark” ( ⁇ ) in Table 18 indicates the patient received the antineoplastic therapy of dose level ⁇ 1 in Table 17 above, starting on the indicated days of 3 consecutive 28-day treatment cycles: 80 mg/m 2 liposomal irinotecan (MM-398, dose based on the corresponding amount of irinotecan hydrochloride trihydrate salt), 60 mg/m 2 oxaliplatin, 400 mg/m 2 (l+d) leucovorin and 2,400 mg/m 2 5-fluorouracil, as described in the protocol of Example 3.
  • a “R2” in Table 18 indicates the patient received a reduced dose of antineoplastic therapy of dose on the corresponding cycle and day: 50 mg/m 2 liposomal irinotecan (MM-398, dose based on the corresponding amount of irinotecan hydrochloride trihydrate salt), 60 mg/m 2 oxaliplatin, 400 mg/m 2 (l+d) leucovorin and 1,800 mg/m 2 5-fluorouracil (a 25% reduction compared to dose level ⁇ 1 dose), as described in the protocol of Example 3.
  • One patient in Table 18 received this reduced dose in response to Grade II symptoms (non-hematologic), but without a dose limiting toxicity.
  • antineoplastic therapies combining a dose of 60 mg/m 2 liposomal irinotecan with 60 mg/m 2 oxaliplatin and doses of 2,400 and 400 mg/m 2 of 5-fluorouracil and (l+d) leucovorin were well tolerated in a human clinical trial.
  • Examples of antineoplastic therapies combining a dose of 80 mg/m 2 liposomal irinotecan with 60 mg/m 2 oxaliplatin and doses of 2,400 and 400 mg/m 2 of 5-fluorouracil and (l+d) leucovorin include the therapies in Table 17.
  • ONIVYDE® irinotecan liposome injection
  • ONIVYDE® is a topoisomerase inhibitor, formulated with irinotecan in a liposomal dispersion, for intravenous use.
  • the finished ONIVYDE® product is a white to slightly yellow opaque sterile concentrate for infusion. It consists of an isotonic dispersion of liposomes containing irinotecan hydrochloride trihydrate.
  • the liposomes are small unilamellar lipid bilayer vesicles, approximately 110 nm in diameter, enclosing an aqueous compartment that contains irinotecan in a gelated or precipitated state, as sucrosofate salt.
  • the vesicle is composed of 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC) 6.81 mg/mL, cholesterol 2.22 mg/mL, and methoxy-terminated polyethylene glycol (MW 2000)-distearoylphosphatidyl ethanolamine (MPEG-2000-DSPE) 0.12 mg/mL.
  • DSPC 1,2-distearoyl-sn-glycero-3-phosphocholine
  • MPEG-2000-DSPE methoxy-terminated polyethylene glycol
  • MPEG-2000-DSPE methoxy-terminated polyethylene glycol
  • MPEG-2000-DSPE methoxy-terminated polyethylene glycol
  • MPEG-2000-DSPE methoxy-terminated polyethylene glycol
  • MPEG-2000-DSPE methoxy-terminated polyethylene glycol
  • MPEG-2000-DSPE methoxy-terminated polyethylene glycol
  • MPEG-2000-DSPE methoxy-terminated polyethylene glycol
  • the ONIVYDE® product contains irinotecan sucrosofate encapsulated in a liposome, obtained from an irinotecan hydrochloride trihydrate starting material.
  • the chemical name of irinotecan is (S)-4,11-diethyl-3,4,12,14-tetrahydro-4-hydroxy-3,14-dioxo1H-pyrano[3′,4′:6,7]-indolizino[1,2-b]quinolin-9-yl-[1,4′bipiperidine]-1′-carboxylate.
  • the dosage of ONIVYDE® can be calculated based on the equivalent amount of irinotecan trihydrate hydrochloride starting material used to prepare the irinotecan liposomes, or based on the amount of irinotecan in the liposome. There are about 866 mg of irinotecan per gram of irinotecan trihydrate hydrochloride.
  • an ONIVYDE® dose of 80 mg based on the amount of irinotecan hydrochloride trihydrate starting material actually contains about 0.866 ⁇ (80 mg) of irinotecan in the final product (i.e., a dose of 80 mg/m 2 of ONIVYDE® based on the weight of irinotecan hydrochloride starting material is clinically equivalent to about 70 mg/m 2 of irinotecan in the final product).
  • Each 10 mL single-dose vial contains 43 mg irinotecan free base at a concentration of 4.3 mg/mL.

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