US20200360545A1 - Protocol for minimizing toxicity of combination dosages and imaging agent for verification - Google Patents

Protocol for minimizing toxicity of combination dosages and imaging agent for verification Download PDF

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US20200360545A1
US20200360545A1 US16/961,633 US201916961633A US2020360545A1 US 20200360545 A1 US20200360545 A1 US 20200360545A1 US 201916961633 A US201916961633 A US 201916961633A US 2020360545 A1 US2020360545 A1 US 2020360545A1
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conjugate
tumor
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Brian Hearn
Daniel V. Santi
Shaun FONTAINE
Gary W. Ashley
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Prolynx LLC
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Definitions

  • the invention is in the field of combination treatments of solid tumors and of diagnostic methods that assess pharmacokinetics of administered entities, specifically with respect to the enhanced permeability and retention (EPR) effect exhibited when entities of nanometer dimensions are administered to subjects with solid tumors. More specifically, the invention relates to taking advantage of the EPR effect exhibited when conjugates of nanometer dimensions are administered to subjects with solid tumors.
  • EPR enhanced permeability and retention
  • Chemotherapeutic agents that are used to treat solid tumors are toxic to normal tissue as well. Levels of such agents administered are limited by their maximum tolerated dose. When combinations of such agents are used, the toxicity of both agents is experienced by normal tissue which further limits effective dosage levels. This problem has been addressed by designing protocols that avoid simultaneous administration of more than one agent essentially on a trial-and-error basis which does not lead to optimal results. Another approach has been to utilize synergistic combinations of two or more agents where their synergistic ratio is maintained by controlling the pharmacokinetics using suitable delivery vehicles, as set forth in U.S. Pat. Nos. 7,850,990 and 9,271,931. Since the drugs are acting in synergy, lower dosage levels are effective, thus also ameliorating the inherent toxicity of the drugs.
  • the present invention solves this problem by taking advantage of the enhanced permeability and retention effect (EPR) of large molecules that can be used as carriers in order to control exposure of normal tissue to the toxic drug and, by virtue of the present invention, assuring that the EPR effect is shown by these conjugates.
  • EPR enhanced permeability and retention effect
  • the cutoff pore size of normal vasculature is in the range of 2-6 nm
  • the neovasculature in solid tumors has a pore cutoff range of 100-700 nm (Dreher, M. R., et al., J. Natl. Cancer Inst . (2006) 98:335-344; Singh, Y., et al., Molecular Pharmaceutics (2012) 9:144-155).
  • the present invention relies on taking advantage of the EPR effect even for small molecules by providing conjugates to nanomolecular carriers, especially flexible carriers and by permitting determination of the pharmacokinetics associated with the EPR effect by providing an imaging agent coupled to a carrier of similar dimensions to those of a carrier used to deliver small molecules administered as conjugates to nanomolecular carriers, especially flexible carriers.
  • Jain, et al. have described features of the EPR effect relevant to nanomedicine design (Chauhan, V. P., and Jain, R. K., Nat. Mater . (2013) 12:958-962; Chauhan, V. P., et al., Angew. Chem. Int. Ed. Engl . (2011) 50:11417-11420; Chauhan, V. P., et al., Nat. Nanotechnol . (2012) 7:383-388).
  • Tumor vessel walls and tissue matrix exist as a series of inter-connected pores with variable cross-sections. Cutoff sizes only indicate the largest particle that penetrates, and large particles generally penetrate tumors heterogeneously and suboptimally compared with smaller particles.
  • the vascular pore-size distribution within a single tumor can vary by orders of magnitude, with most of the pores actually being much smaller than the pore cutoff size.
  • the effective vascular permeability of small particles does not necessarily correlate with cutoff size; smaller particles penetrate tumors more rapidly and uniformly than larger particles and smaller particles carrying drugs should be more generally effective against solid tumors than larger particles.
  • Non-spherical nanoparticles can penetrate tumors more rapidly and accumulate at higher levels than size-matched spheres, because of enhanced penetration through the pores is related to the shortest dimension of the particle.
  • the advantage of non-spherical particles holds for smaller vessel-pore-sizes but is lost with respect to large pore sizes.
  • nanoparticles for EPR drug delivery and imaging utilize larger 100 nm liposomes/particles containing appropriate drugs or isotopes. As described above, regardless of cut-off pore size these larger nanoparticles are likely not the optimal size for accumulation in many tumors since most will contain neovasculature with heterogeneous pore sizes; thus the present invention is focused on carriers with hydrodynamic radii of less than 50 nm.
  • the present invention employs linking technologies that are particularly favorable for preparation of conjugates designed to take advantage of the EPR effect.
  • linkages that release a small molecule chemotherapeutic agent (drug) by beta elimination have been disclosed. See, for example, U.S. Pat. Nos. 8,680,315; 9,387,254; 8,754,190; 8,946,405; and 8,703,907, and WO 2015/051307, all incorporated herein by reference.
  • Such linkers permit tuning of the time of release of the coupled drug by adjusting the acidity of a carbon-hydrogen bond positioned beta to a suitable leaving group.
  • PET positron emission tomography
  • Tumor deposition was stratified and uptake levels were retrospectively associated with treatment outcomes: high uptake tumors were susceptible to the effect of the TNPs (75% partial remission/stable disease) whereas low-uptake tumors (43% stable disease) were not. Brain metastases were also imaged, suggesting their vasculature had increased pore sizes that could make such metastasis susceptible to TNPs.
  • protocols are constructed that ameliorate the toxic effect of combination therapy on normal tissue.
  • One goal of the invention is to confine the cytotoxic effect of drugs administered in combination to tumor tissue while sparing normal tissue to the extent possible.
  • this can be done by adjusting the dosage administration protocol so that while a first chemotherapeutic agent is sequestered in a solid tumor and no longer available in the system to exert an effect on normal tissue a second therapeutic agent is administered so that effectively only the toxic effects of the second drug, without supplementation by the first, are exerted in the system while the combined effects are exerted in the tumor.
  • both agents are sequestered as conjugates in the solid tumor so that higher concentrations of both agents are experienced by tumor cells than are experienced by normal tissue and the agents are cleared from normal tissue while remaining in the tumor.
  • the invention is directed to a method to ameliorate the toxicity to normal tissue in a subject resulting from administering to said subject a first and second chemotherapeutic agent in a protocol for combination therapy against a solid tumor employing said first and second agent, which method comprises:
  • the carrier is a nanoparticle or macromolecule each with a hydrodynamic radius of 5-50 nm (i.e., a diameter of 10-100 nm) which conjugate exhibits enhanced permeability and retention (EPR) in solid tumors so as to concentrate said conjugate in the tumor and wherein the rate of release from the tumor of the conjugate and first agent released from the conjugate is substantially slower than the rate of clearance of the conjugate and released agent from the systemic circulation of the subject;
  • EPR enhanced permeability and retention
  • an additional agent that has a non-overlapping toxicity with the second agent may also be administered.
  • the invention is directed to a method to minimize the toxic effects on normal tissue of a subject of a first and second chemotherapeutic agent used in combination to treat a solid tumor in said subject which method comprises administering both said first and second agents as releasable conjugates to carriers, wherein the carriers are nanoparticles or macromolecules each with a hydrodynamic radius of 5-50 nm (10-100 nm diameter) wherein said conjugates exhibit enhanced permeability and retention (EPR) and effect concentration of both said conjugates in said tumor.
  • EPR enhanced permeability and retention
  • the simultaneous administration only the first agent is conjugated and the second agent is in unconjugated form.
  • a third similarly conjugated or unconjugated therapeutic agent may be employed as well.
  • the carriers mimic those of the first agent.
  • labeled non-releasable conjugates comprising carriers with the same characteristics as those used in conjugating the drugs can be used to monitor the uptake of the conjugates by the solid tumor.
  • Administering such conjugate where the carrier is non-releasably linked to the label permits verification (or not) that the corresponding conjugates of drugs will exhibit an EPR effect.
  • the labels used in such monitoring are preferentially those detectable by positron emission tomography (PET).
  • the present invention also offers a method to mimic the pharmacokinetics of a conjugate of a drug with respect to its behavior in the context of an EPR effect in solid tumors.
  • a suitable imaging agent with a carrier similar in size and shape to a carrier conjugated to a drug
  • the pharmacokinetics of the drug can be predicted by monitoring the pharmacokinetics of the imaging agent.
  • diagnostic agents are also useful in the determining the suitability of treating patients with conjugates of therapeutic agents.
  • the invention is directed to an imaging agent of the formula (1)
  • PEG represents a polyethylene glycol comprising a plurality of 2-6 arms of 40-60 kD
  • chelator represents a desferrioxamine or a plur-hydroxypyridinone multidentate
  • I is a radioisotope suitable for positron emission tomography (PET);
  • n is an integer of 1 up to the number of arms of said PEG.
  • the invention also includes hybrid conjugates of formula (2)
  • PEG represents a polyethylene glycol comprising a plurality of 2-6 arms of 40-60 kD
  • chelator represents a desferrioxamine or a plur-hydroxypyridinone multidentate
  • I is a radioisotope suitable for positron emission tomography (PET);
  • ⁇ indicates sequestration of I in the chelator
  • L is a linker
  • D is a therapeutic agent
  • n is an integer of 1 up to the number of arms of said PEG minus x
  • x is an integer of up to the number of arms of said PEG minus n.
  • the imaging agent will optimally have a diameter of approximately 20 nm (a hydrodynamic radius of approximately 10 nm).
  • the diameter can be in the range of 10-100 nm, or 10-50 nm or 10-25 nm, corresponding to hydrodynamic radii of 5-50, 5-25 or 5-12.5 nm.
  • the invention is directed to a method to monitor accumulation of the imaging agent in a tumor which method comprises administering said imaging agent and detecting the location of said imaging agent by PET.
  • the invention is directed to a method to assess the pharmacokinetics of a drug conjugate and its accumulation in tumor which method comprises matching the size of a conjugate of said drug to the size of the imaging agent, administering said imaging agent and monitoring the accumulation of said agent in the tumor by PET as diagnostic of the behavior of the drug conjugate.
  • the invention further includes method to assess suitability of treating a patient with a conjugated drug based on the diagnostic agent.
  • the dimensions of the diagnostic agent are matched to those of a drug conjugate intended for patient treatment. More broadly the diagnostic agent can simply identify patients that can be treated taking advantage of the EPR effect.
  • kits that include the imaging agent of the invention and a conjugate of a drug of similar size and shape as the imaging agent.
  • the invention is directed to a method to identify a subject that will likely benefit from treatment with a drug modified to exhibit the EPR effect, which comprises administering the imaging agent of the invention to a candidate subject and monitoring the distribution of the imaging agent in the subject, whereby a subject that accumulates said imaging agent in an undesirable tissue mass is identified as a subject that will benefit from such treatment.
  • a method to identify a subject that will likely benefit from treatment with a drug modified to exhibit the EPR effect comprises administering the imaging agent of the invention to a candidate subject and monitoring the distribution of the imaging agent in the subject, whereby a subject that accumulates said imaging agent in an undesirable tissue mass is identified as a subject that will benefit from such treatment.
  • the imaging agents of the invention having carriers with the same characteristics as those used in conjugating the drugs are used to monitor the uptake of the conjugates by the solid tumor. This permits verification (or not) that the corresponding conjugates of drugs will exhibit an EPR effect.
  • the invention includes a method to identify a subject having a tumor that will respond to treatment with an inhibitor of DNA repair which method comprises determining the presence or absence of a mutation in a gene that encodes a protein that participates in effecting DNA repair, wherein the presence of said mutation in the subject identifies the subject as having such a tumor.
  • the invention is directed to a hybrid conjugate for treatment and imaging of solid tumors
  • conjugate comprises a flexible carrier wherein the carrier is a nanoparticle or macromolecule each with a hydrodynamic radius of 5-50 nm which conjugate exhibits enhanced permeability and retention (EPR) in solid tumors so as to concentrate said conjugate in the tumor and wherein said carrier is releaseably coupled to a therapeutic agent and also to an imaging agent, and to a method to correlate imaging and treatment of a solid tumor using said hybrid conjugate.
  • EPR enhanced permeability and retention
  • FIG. 1 is a graph showing the concentration of coupled SN-38 in the form of a conjugate to a four-armed 40 kD PEG (PLX038) in the plasma as a function of time. Similar results for the released SN-38 and the detoxified form of the drug, i.e., the glucuronide (SN-38G) are shown in the same figure. The rates are similar showing half-lives of 50 hours in the rat.
  • FIG. 2 shows the effect of various concentrations of PLX038 administered to the HT29 xenograft-bearing rat as compared to irinotecan.
  • FIGS. 3A and 3B show the concentrations of PLX038 in free SN-38 at various dosages in the tumor as compared to plasma.
  • FIG. 4 is a diagram showing a hypothetical dosing schedule in humans of a combination of PLX038 and a second drug (e.g., a poly ADP ribose polymerase (PARP) inhibitor) administered systemically.
  • PLX038 is administered on day 1; the conjugate accumulates in the tumor and releases the free drug (dotted line) in the vicinity of the tumor and both conjugate and free drug are cleared from the system (solid line).
  • systemic PLX038 is reduced to 25% of its original concentration, and the concentration lies below its minimal effective (and toxic) level.
  • the second drug is administered on an effective schedule.
  • FIG. 5 shows C vs. t plots of SN-38 released from PLX038 in the rat and from PLX038A in mouse.
  • the curve for SN-38 released from PLX038 at 3.2 nmol (200 mg)/kg in the rat was modeled using previously determined pharmacokinetic parameters (Santi, D. V., et al., Proc. Natl. Acad. Sci. USA (2012) 109:6211-6216).
  • FIGS. 6A-6E are maximum intensity projections (MIP) at 72h and 120h of PEG40 kDa-DFB- 89 Zr in mice bearing HT-29 xenografts (A) on both flanks overlaid on a CT scan; ex vivo biodistribution study of PEG40 kDa-DFB- 89 Zr in mice bearing HT-29 xenografts (B) and tumor to blood ratios (C) vs time in mice bearing HT-29 tumors; 72h MIP image (D) of PEG-(SN-38)3-DFB- 89 Zr in single flank tumor bearing mice and biodistribution of PEG-(SN-38)3-DFB- 89 Zr (black) vs PEG-DFB- 89 Zr (grey) at 72h (E).
  • MIP maximum intensity projections
  • FIGS. 7A-7C show the biodistribution of PEG 40kDa -(DFB)- 89 Zr 4 in mice bearing tumors.
  • FIG. 8 shows the biodistribution of various 89 Zr conjugates in HT-29 xenografts.
  • FIG. 9 shows the biodistribution of various 89 Zr conjugates in MX-I xenografts.
  • FIG. 10 shows the effectiveness of PEG-SN38 in tumor treatment.
  • FIGS. 11A-11C show synergy of an SN38 conjugate and separately administered talazoparib.
  • FIG. 12 shows a generic hybrid drug/label conjugate theranostic.
  • the first approach is to ensure that a first therapeutic agent or drug is captured in a solid tumor to be treated by coupling the drug to a carrier such that the EPR effect results in substantially retaining the conjugate and released drug in the solid tumor, while the administered conjugate and released drug not captured in the tumor are more rapidly cleared from the systemic circulation, wherein the carrier is a nanoparticle or macromolecule each with a hydrodynamic radius of 5-50 nm preferably about 10 nm (diameter of 10-100 nm preferably about 20 nm).
  • the carrier is a nanoparticle or macromolecule each with a hydrodynamic radius of 5-50 nm preferably about 10 nm (diameter of 10-100 nm preferably about 20 nm).
  • the clearance rate from the systemic circulation is much greater than the clearance rate of the conjugate and released drug from the tumor, an effective amount of drug both in conjugated and free form remain to exert a cytotoxic effect on tumor cells while their concentration in the systemic circulation has diminished to a desired level.
  • the level of the conjugate and free drug in circulation and in contact with normal tissue is reduced to 25% of the initial concentration, and this may be sufficiently low to ameliorate toxicity. Since the conjugate remains in the tumor to release the agent, the agent is able to exert its cytotoxic effect on the tumor although its concentration in the systemic domain is quite low, and exposure of normal tissue to the drug is therefore also quite low.
  • a second drug is administered systemically and thus the normal tissue is exposed only to the toxic effect of the second drug while the first drug remains out of reach in the tumor. This minimizes the toxic effect of the combination on normal tissue while retaining the combined toxicities in the tumor.
  • the second drug may be administered either in free form or it, too, may be administered as a conjugate with a similar carrier or in any other suitable form, including inclusion in delivery vehicles such as liposomes, nanoparticles, micelles, and the like.
  • a third drug that has non-overlapping toxicity with the second drug may be coadministered simultaneously or sequentially with said second drug.
  • both the first and second drug may be administered in the form of conjugates that are retained in the tumor by virtue of EPR either at the same time or at disparate times.
  • EPR electrospray induced senorizing hormone
  • the major concentration of each drug occurs in the tumor rather than being in contact with normal tissue.
  • the higher dosage levels of these drugs is experienced mainly in the tumor, and the administered conjugates along with released drug are rapidly cleared from the systemic circulation.
  • an additional conjugated form of an agent may be coadministered.
  • the carriers used in the method of the invention to administer at least the first agent in the first above-cited method and to release both the first and second agents in the second-noted method are carriers that are flexible in nature and have hydrodynamic radii of about 10 nm.
  • Suitable macromolecule carriers include polyethylene glycols (PEG) which may be linear or multi-armed and have molecular weights of 10-50 kD.
  • PEG polyethylene glycols
  • the carriers are multi-armed PEG with molecular weights of at least 20 kD.
  • linkers that release the agent by beta elimination reactions such as those described in detail in the above cited U.S. Pat. Nos. 8,680,315; 9,387,254; 8,754,190; 8,946,405; and 8,703,907 all incorporated herein by reference for their disclosures of not only the structure of useful linkers that release the agent by beta elimination, but also with respect to their disclosure of nanomolecular carriers useful in the present invention as well.
  • linkers include those cleavable by hydrolysis of esters, carbonates, or carbamates, by proteolysis of amides or by reduction of aromatic nitro groups by nitroreductase.
  • the subjects of the methods of the invention are typically human subjects, but the invention methods are also applicable in veterinary contexts including livestock and companion animals.
  • the methods are also suitable for animal models useful in the laboratory such as rats, mice, rabbits or other model systems preparatory to designing protocols for human use.
  • chemotherapeutic agents any combination of these may be selected as the first and second drug.
  • Agents that act additively or synergistically are preferred, for example combination of drugs wherein each inhibits DNA repair.
  • Topo 1 inhibitors Drugs that cause DNA damage, such as Topo 1 inhibitors, are particularly useful in treating tumors whose genome contains a mutation in a gene that normally aids in DNA repair.
  • these genes include BRCA1, BRCA2, ATM which encodes ataxia telangiectasia mutated (ATM) kinase and ATR which encodes Rad-3 related (ATR) kinase.
  • the invention includes identifying tumors that will show enhanced sensitivity to treatment with a Topo 1 inhibitor where the tumor-bearing subject's genome has at least one gene that has a mutation in BRCA1, BRCA2, ATM or ATR or other genes where mutation prevents or depresses the ability of the gene to enhance DNA repair.
  • the response may be further enhanced by inhibiting a second enzyme involved in DNA repair, such as a PARP inhibitor, which then causes a synthetic lethality that is amplified because of the high level of DNA breaks caused by the Topo inhibitor.
  • a second enzyme involved in DNA repair such as a PARP inhibitor
  • Agents include:
  • Cell cycle inhibitors or “cell cycle control inhibitors” these interfere with the progress of a cell through its normal cell cycle, the life span of a cell, from the mitosis that gives it origin to the events following mitosis that divides it into daughter cells;
  • Checkpoint inhibitors these interfere with the normal function of cell cycle checkpoints, e.g., the S/G2 checkpoint, G2/M checkpoint and G1/S checkpoint;
  • Topoisomerase Inhibitors such as camptothecins, which interfere with topoisomerase I or II activity, enzymes necessary for DNA replication and transcription;
  • Receptor tyrosine kinase inhibitors these interfere with the activity of growth factor receptors that possess tyrosine kinase activity
  • Antimetabolites such as gemcitabine or hydroxyurea, which closely resemble an essential metabolite and therefore interfere with physiological reactions involving it;
  • telomerase inhibitors these interfere with the activity of a telomerase, an enzyme that extends telomere length and extends the lifetime of the cell and its replicative capacity;
  • Cyclin-dependent kinase inhibitors these interfere with cyclin-dependent kinases that control the major steps between different phases of the cell cycle through phosphorylation of cell proteins such as histones, cytoskeletal proteins, transcription factors, tumor suppresser genes and the like;
  • Anti-angiogenic agents which interfere with the generation of new blood vessels or growth of existing blood vessels that occurs during tumor growth.
  • Preferred agents that may be used in combination include DNA damaging agents such as carboplatin, cisplatin, cyclophosphamide, doxorubicin, daunorubicin, epirubicin, mitomycin C, mitoxantrone; DNA repair inhibitors including 5-fluorouracil (5-FU) or FUDR, gemcitabine and methotrexate; topoisomerase I inhibitors such as camptothecin, irinotecan and topotecan; S/G2 or G2/M checkpoint inhibitors such as bleomycin, docetaxel, doxorubicin, etoposide, paclitaxel, vinblastine, vincristine, vindesine and vinorelbine; G1/early S checkpoint inhibitors; G2/M checkpoint inhibitors; receptor tyrosine kinase inhibitors such as genistein, trastuzumab, ZD1839; cytotoxic agents; apoptosis-inducing agents and cell
  • Exemplary combinations are DNA damaging agents in combination with DNA repair inhibitors, DNA damaging agents in combination with topoisomerase I or topoisomerase II inhibitors, topoisomerase I inhibitors in combination with S/G2 or G2/M checkpoint inhibitors, G1/S checkpoint inhibitors or CDK inhibitors in combination with G2/M checkpoint inhibitors, receptor tyrosine kinase inhibitors in combination with cytotoxic agents, apoptosis-inducing agents in combination with cytotoxic agents, apoptosis-inducing agents in combination with cell-cycle control inhibitors, G1/S or G2/M checkpoint inhibitors in combination with cytotoxic agents, topoisomerase I or II inhibitors in combination with DNA repair inhibitors, topoisomerase I or II inhibitors or telomerase inhibitors in combination with cell cycle control inhibitors, topoisomerase I inhibitors in combination with topoisomerase II inhibitors, and two cytotoxic agents in combination.
  • Exemplary specific agents include cisplatin (or carboplatin) and 5-FU (or FUDR), cisplatin (or carboplatin) and irinotecan, irinotecan and 5-FU (or FUDR), vinorelbine and cisplatin (or carboplatin), methotrexate and 5-FU (or FUDR), idarubicin and AraC, cisplatin (or carboplatin) and taxol, cisplatin (or carboplatin) and etoposide, cisplatin (or carboplatin) and topotecan, cisplatin (or carboplatin) and daunorubicin, cisplatin (or carboplatin) and doxorubicin, cisplatin (or carboplatin) and gemcitabine, oxaliplatin and 5-FU (or FUDR), gemcitabine and 5-FU (or FUDR), adriamycin and vinorel
  • exemplary second drugs include PARP inhibitors, mTOR inhibitors, trabectedin, cis-platinum, oxaliplatin, fluorouracil, temozolomide and vincristine all of which have been reported to be synergistic with SN-38.
  • Certain tumors are especially susceptible to treatment with PARP inhibitors and in these tumors, PARP inhibitors are favored as the combination drug.
  • Such tumors are also responsive to topoisomerase inhibitors, such as SN38, since inhibition of topoisomerase causes excess DNA damage that requires DNA repair that is deficient in these tumors.
  • These genes include BRCA1, BRCA2, ATM which encodes ataxia telangiectasia mutated (ATM) kinase and ATR which encodes Rad-3 related (ATR) kinase, among others.
  • the invention includes identifying tumors that have mutations in BRCA1, BRCA2, ATM or ATR or other genes where mutations prevent or depress the ability of the gene to enhance DNA repair and combining treatment with the invention SN38 conjugates with follow up treatment with for example PARP inhibitors, or other inhibitors of DNA repair. Because the drug accumulates and remains in the tumor after it is eliminated from the rest of the system, the toxicity of the SN38 is confined to the tumor and the system as a whole has only to deal with toxicity of the PARP inhibitor.
  • Some of the above listed drugs to be administered as second drugs may be administered in combination either sequentially or simultaneously provided their toxicities do not overlap.
  • the invention methods rely on the ability of the conjugates administered for the first agent in the first approach above and both the first and second agents in the second approach being subject to the EPR effect, it is important to confirm that this is in fact the case since tumors are heterogeneous and the particular carrier selected must be compatible with the pore structure of the vasculature in the solid tumor that resides in the subject in the sense that the EPR effect is present. Therefore, in some embodiments of the invention method, this is confirmed by administration either at the same time or separately of a conjugate of a label that is coupled non-releasably to the same carrier or a carrier with the same characteristics as that linked to the drug(s).
  • any detectable label e.g., fluorescent label
  • PET positron emission tomography
  • the non-releasable conjugate of the isotope is then monitored to detect whether preferential uptake and retention by the tumor is exhibited. If so, the method of the invention is employed. If the tumor fails to exhibit the EPR effect with the labeled non-releasable conjugate, the method of the invention is contraindicated.
  • the isotopes thus detectable are well known in the art as are means for coupling such isotopes to macromolecular carriers.
  • the imaging agent of the invention For imaging, a similar conjugate is used. As noted above, it is advantageous to design the imaging agent of the invention such that the diameter is approximately are 20 nanometers and to avoid excessive flexibility. This can be accomplished by using the multi-armed PEG polymers in the range of 40-60 kD. Although the number of arms associated with this polymer may range from 1-6, multi-armed PEGs of 3-5 arms, more preferably 4 arms are focused on herein.
  • n in formula (1) can vary from 1 to the number of arms associated with the polymer and it should be understood that in the compositions of the invention the value of n may not be the same for all of the individual imaging moieties in the composition.
  • n for a 4 armed PEG where n is 4, or in single chain PEG where n is 1, most of the individual “molecules” in a given composition will contain 4 or 1 as values of n respectively.
  • the chelator represents a desferrioxamine or a multidentate chelator comprised of a multiplicity of hydroxypyridinones, abbreviated herein “plur-hydroxypyridinone multidentates.”
  • a variety of such chelators are well known in the art and are described in detail, for example, in Ma, M. T. et al., Dalton Trans (2015) 44:4884-4900 and by Deri, M. A., J Med Chem (2014) 57:4849-4860. The description of these ligands in these documents is specifically incorporated herein by reference.
  • the covalent connector on Formula (1) may be a direct bond to the chelator or there may be intermediate linkers such as dipeptides or bifunctional linkers comprising 1-20 linking atoms.
  • Radioisotopes (I) useful in PET in the context of the present invention are known in the art, and particularly a subset preferred among those set forth in Table 3 of Smith, S. V.
  • the imaging agents of the invention contain carriers with the same characteristics as those carriers used in conjugating the drugs. These are then used to monitor the uptake of the conjugates by the solid tumor. This permits verification (or not) that the corresponding conjugates of drugs will exhibit an EPR effect.
  • An alternative to using separate therapeutic and imaging conjugates employs a hybrid conjugate of formula (2) for treatment and imaging of solid tumors which conjugate comprises a flexible carrier wherein the carrier is a nanoparticle or macromolecule each with a hydrodynamic radius of 5-50 nm which conjugate exhibits enhanced permeability and retention (EPR) in solid tumors so as to concentrate said conjugate in the tumor and wherein said carrier is releasably coupled to a therapeutic agent and also coupled to an imaging agent.
  • EPR enhanced permeability and retention
  • I is 89 Zr, 94 Tc, 101 In, 81 Rb, 66 Ga, 64 Cu, 62 Zn, 61 Cu or 52 Fe, and/or the PEG is a four armed polyethylene glycol of approximately 40 kD, and n is 1-4, and/or the chelator is desferrioxamine-B, and/or
  • the arms of the PEG is occupied by the imaging agent and at least one is occupied by the therapeutic agent.
  • the therapeutic agent may be SN38 or other topoisomerase inhibitor or any other suitable agent for tumor treatment that is benefited by accumulation in the tumor, such as a PARP or kinase inhibitor.
  • the imaging agents of the invention are also useful to identify subjects that harbor tumors or other tissue masses that are susceptible to treatment with therapeutic agents that exhibit the EPR effect.
  • the imaging agent may be administered to a subject and monitored to determine whether the tumor, for example, will, in fact, preferentially take up and retain entities of similar size.
  • chemotherapeutic agent agent
  • drug a drug
  • chemotherapeutic agent agent
  • drug a drug
  • the number cited will typically have error bars of plus-or-minus 10%, preferably plus-or-minus 5% and more preferably plus-or-minus 1%.
  • a range of 10-50 nm could include a range of 9-55 nm.
  • Hydrodynamic radius means the apparent Stokes radius the radius of a hard sphere that diffuses through solution at the same rate as the molecule in question as measured, for example, by gel permeation chromatography.
  • the subjects of the invention are typically human, but also include non-human animals such as laboratory models and veterinary subjects.
  • SN-38 is the topoisomerase I inhibitor that is the active drug released from the prodrug, irinotecan. Conjugates of SN-38 are described in WO 2015/051307. Two different conjugates of SN-38 were prepared: PLX038 and PLX038A. These conjugates couple the drug releasably to a four-armed PEG of 40 kD through a linker that effects release by ⁇ -elimination. The structure of PLX038 and PLX038A is shown below wherein “Mod” is CN in PLX038, and methyl sulfonyl in PLX038A.
  • the efficacy of a non-toxic dose of 20 nmol/kg of SN-38 in the form of PLX038 exceeds that of a toxic gastrointestinal dose of irinotecan control.
  • FIGS. 3A and 3B are graphs of the levels of the conjugate PLX038 and of SN-38 that has been released from the conjugate in the tumor at various dosage levels.
  • the level of PLX038 in the tumor (a left bar) is roughly 8 nmol/g while the concentration in the plasma (shown as the right bar) is barely detectable.
  • the left bar shows the concentration in the tumor as about 80 pm/g while, again, the right bar shows that in the circulation it is barely detectable.
  • the conjugate and free drug are not detected in the plasma, while the tumor shows significant concentrations of these moieties.
  • a dosing schedule in humans for a combination of PLX038 and a second drug (e.g., a PARP inhibitor) administered systemically is proposed wherein PLX038 is administered on day 1 whereby the conjugate accumulates in the tumor and releases the free drug. The conjugate and the free drug are concomitantly cleared from the system. After two half-lives of systemic clearance or 10 days, systemic PLX038 is reduced to 25% of its original concentration, which lies below its minimal effective and toxic levels. At this time the second drug, which is synergistic with SN-38 is administered orally for 20 days.
  • a second drug e.g., a PARP inhibitor
  • the EPR effect concentrates PLX038 in the tumor (dotted line), while the systemic PLX038 (solid line) is sufficiently low that any toxic effect is only to a second drug, which is administered as shown at 10 days. At that time, the concentration of the conjugate in the tumor is still above the minimum effective level but below the toxic level.
  • mice Because most xenograft tumor models use mice as hosts, it is desirable to adapt the protocols of the present invention to testing in mice. Adaptation is needed because the half-life of the PLX038 conjugate in the mouse is only about 24 hours, whereas in the rat it is about 48 hours and in humans about 6 hours. Because the more rapid elimination of PLX038 in mice occurs before substantial amounts of the SN-38 are released, a different conjugate of SN-38, PLX038A that has a higher cleavage rate, is used in murine experiments.
  • Linker cleavage is species independent. While 32% of PLX038 is converted to SN-38 over one half-life of the conjugate in humans, only 12% is converted in the rat and 6% in the mouse. For PLX038A, the cleavage half-life is 70 hours and 26% conversion to SN-38 over one half-life of the conjugate in the mouse occurs. This conjugate also can be administered intraperitoneally (IP) in mice with 100% bioavailability.
  • IP intraperitoneally
  • mice PLX038A still has a short t 1/2 of renal elimination so a single dose may not effect high tumor accumulation and longer exposure may be necessary to achieve this.
  • a multi-dose schedule for PLX038A in the mouse that simulates a single effective dose of the conjugate that gives high tumor accumulation in the rat is therefore used.
  • a single 200 mg/kg of PLX038 produced 61% inhibition of tumor growth with no gastrointestinal (GI) toxicity while irinotecan control that showed near-equal tumor inhibition showed significant GI toxicity.
  • GI gastrointestinal
  • irinotecan control that showed near-equal tumor inhibition showed significant GI toxicity.
  • FIG. 5 A dosing schedule for PLX038A in the mouse that would simulate the pharmacokinetics (PK) of PLX038 in the rat is shown in FIG. 5 .
  • Three daily decreasing doses of 152, 60 and 54 mmol/kg effectively simulate the rat PK profile of released SN-38 from PLX038.
  • the “effective” half-life of SN-38 in the schedule is over 2 days, whereas SN-38 from irinotecan in the mouse is 2 hours.
  • Table 1 The data supporting FIG. 5 are shown in Table 1.
  • HT29 xenografts The ability of HT29 xenografts to accumulate conjugate using the EPR effect is tested by injecting mice with one dose IP of 50 nmol of 40 kD four-armed PEG fluorescein per 100 g (15 nmol/mouse) to obtain about 10 ⁇ M in serum. Blood and tumor are sampled at various times (at 6, 24, 48 and 96 hours) and the level of fluorescein measured. (The tumor is excised and digested with sodium hydroxide for measurement.)
  • PLX038A is tested for tumor growth inhibition in a nude mouse HT29 tumor xenograft using the three-dose schedule developed in Example 3.
  • the nude mouse model with HT29 xenograft is treated with the three-dose schedule of PLX038A developed in Example 3 and at 14 days the mice were treated daily with oral administration of a PARP inhibitor.
  • a conjugate of PARP inhibitor analogous to PLX038A is administered daily to nude mice bearing HT29 tumors and tested vs. daily administration of free inhibitor.
  • PEG 40kDa -(DFB) 4 was prepared by reaction of PEG 40kDa (NH 2 ) 4 with p-isothiocyanatobenzyl-DFB (Perk, L. R., et al. Eur. J. Nucl. Med. Mol. I . (2010) 37:250-259; Fischer, G., et al., Molecules (2013) 18:6469-6490; and van de Watering, F. C., et al. Biomed. Res. Int . (2014) 2014:203601) (macrocyclics) as follows.
  • An alternative DFB reagent for conjugation is prepared by acylation of DFB with N 3 —(CH 2 ) n CO-HSE; the N 3 —(CH 2 ) n CO-DFB is reacted with cyclooctyne-derivatized-PEG 40kDa (NH 2 ) 4 by SPAAC.
  • Coupling to PET isotopes was performed by treatment of the PEGylated-DFB with 89 Zr oxalate followed by purification using size-exclusion chromatography (Perk, L. R., supra; and van de Watering, F. C., supra).
  • PEG 40kDa -(BzI 125 I) 4 is prepared by reacting the 125 I-azide shown below with a cyclooctyne-derivatized-PEG 40kDa (NH 2 ) 4 (prepared from MFCO-HSE+PEG 40kDa (NH 2 ) 4 ), which results in a clean high yield strain-promoted azide-alkyne cycloaddition (SPAAC) reaction.
  • SPAAC strain-promoted azide-alkyne cycloaddition
  • Preparation and radioiodination of the [ 125 ] iodobenzoyl-PEG-azide is shown below for stable iodination of macromolecules using SPAAC.
  • Azido-linker-SN38 having a cyano modulator prepared as described in PCT Publication W02015/051307.
  • PEG 40kDa -(DBCO) 4 A solution of 40-kDa 4-armed PEG-tetraamine (PTE400-PA, NOF; 10 umol amines), dibenzocyclooctyne-N-hydroxysuccinimidyl ester (DBCO-NHS, ClickChemistryTools; 5 mg, 12 umol), and N,N-diisopropylethylamine (2 uL, 12 umol) in 1 mL of acetonitrile was stirred for 1 h at ambient temperature. The mixture was evaporated to dryness, then redissolved in 1 mL of THF and precipitated by addition of 10 mL of MTBE. The resulting solid was collected, washed with MTBE, and dried to provide the product.
  • PTE400-PA NoF
  • DBCO-NHS dibenzocyclooctyne-N-hydroxysuccinimidyl ester
  • PEG 40kDa -(sDFB) 1 (rSN38) 3 A 1:3 mixture of stable-linker-DFB and releasable-linker-SN38 was coupled to PEG 40kDa (DBCO) 4 to yield a mixture that was predominantly PEG 40kDa (sDFB) 1 (rSN38) 3 and PEG 40kDa (rSN38) 4 by HPLC analysis. These were separated by preparative HPLC using a Phenomenex 300A 5 um Jupiter C18 column, 21.2 ⁇ 150 mm, with a 30-60% gradient of acetonitrile in water+0.1% TFA at 15 mL/min.
  • the concentrate was diluted to 6 mL with H 2 O (0.1% TFA) then purified by preparative C18 HPLC, two injections eluting with a linear gradient (35%-60%) of MeCN in H 2 O (0.1% TFA).
  • Fractions from the first eluting Fmoc-containing peak were analyzed by C18 HPLC, and clean, product-containing fractions were combined and concentrated to dryness. After removing volatiles under high vacuum for 30 min, the residue was dissolved in minimal THF ( ⁇ 1 mL) and added dropwise to 40 mL of 0° C. MTBE in a tared 50 mL Falcon tube.
  • Step 2 (Cyclooct-4-yn-1-yloxycarbonyl-NH) 3 —PEG 40kDa -NHFmoc.
  • the reaction mixture was concentrated to ⁇ 0.3 mL by rotary evaporation.
  • the concentrate was diluted with 1 mL of THF, and the solution was added dropwise to 40 mL of ice-cold MTBE in a tared 50 mL Falcon tube.
  • the mixture was kept on ice for 15 min then centrifuged (3500 ⁇ g, 1 min) and decanted.
  • the wet solid was washed with ice-cold MTBE (2 ⁇ 40 mL), centrifuged (3500 ⁇ g, 1 min) and decanted. Residual volatiles were removed under high vacuum for 20 min to provide the title compound (40 mg, 0.93 ⁇ mol, 66% yield) as a white powder.
  • Step 3 (Cyclooct-4-yn-1-yloxycarbonyl-NH) 3 -PEG 40kDa -NH 2 .
  • Step 4 (Cyclooct-4-yn-1-yloxycarbonyl-NH) 3 -PEG 40kDa -NHCSNH-phenyl-4-(NHCSNHDFB).
  • P-isothiocyanatobenzyl-desferrioxamine B (1.8 mg, 2.4 ⁇ mol; Macrocyclics) was added to a 50 mg/mL solution of (cyclooct-4-yn-1-yloxycarbonyl-NH) 3 -PEG 40kDa -NH 2 (1.36 mL, 1.6 ⁇ mol in DMF.
  • the reaction mixture was placed in a 37° C. water bath and monitored by C18 HPLC. After 4 h, PEG was precipitated by dropwise addition of the reaction solution to 40 mL of ice-cold MTBE in a tared 50 mL Falcon tube.
  • a 10 mM solution of stable azido-rucaparib (0.11 mL, 1.1 mol, 1.8 mM final concentration; prepared by reacting rucaparib with 6-azidohexyl succinimidyl carbonate according to the procedures of Santi et al., Proc. Natl. Acad. Sci.
  • reaction solution was concentrated by SpeedVac to 0.1 mL, diluted to 1.0 mL with H 2 O, and loaded onto a PD-Midi column. Elution with H 2 O yielded a cloudy fraction of excluded material that contained both unmodified and PEGylated drug-linker. The mixture was then dialyzed against MeOH (12-14 k MWCO).
  • the dialysate was concentrated to dryness, and residual volatiles were removed under high vacuum to provide the title compound (8.7 mg, 0.19 umol, 66% yield) as white film that contained 0.51 ⁇ mol of rucaparib as determined by A 355 and 0.19 umol of DFB as determined by A 490 of Fe 3+ -DFB.
  • hybrid SN38/DFB and alternative hybrid drug/DFB conjugates are coupled to 89 Zr by the methods set forth in Example 5.
  • mice bearing HT-29 human xenografts and normal mice are treated with conjugates PEG-PET isotopes which are similar in size and shape to the drug conjugates of Examples 1-4.
  • HT-29 Tumor bearing mice and normal control mice are treated with ⁇ 200 uCi/mouse, and PET-imaging is performed at varying times to determine the amount and rates of accumulation.
  • a signal is observable at ⁇ 1 uCi/cc so the tumor is easily visualized as long as the background tissue does not accumulate the tracer.
  • the loss of isotope is followed as the reagent is cleared from the body. Rates of a) tumor accumulation of the PEG-isotope (quantitative PET imaging), b) vascular elimination (serum radioactivity), c) systemic elimination (whole body radioactivity) and d) tumor elimination (quantitative PET imaging) are thus determined.
  • tumor-bearing mice are treated with varying amounts of the PEG 40kDa -isotope to determine the maximal amount of nanoparticle that can accumulate.
  • PET scanning is used to simulate the behavior of an agent coupled to the same or similar carrier to evaluate the parameters appropriate for the drug administration protocol.
  • the % ID/g uptake (uptake of PEG 40kDa -DFB- 89 Zr) in tumors was 15 and 20% at 24- and 48 h, respectively, while organs other than liver had ⁇ 3% uptake.
  • MicroPET/CT studies showed high accumulation of 89 Zr-DFB-PEG 40 in MX-1 tumors as early as 24h while accumulation in healthy tissue was nearly background. The imaging data corroborated the increased accumulation in tumor from 24 to 48h. However, there was heterogeneous uptake in the tumor, possibly suggesting necrosis of this rapidly growing tumor.
  • the experiment was repeated the slower growing HT-29 tumor. Given the lower tumor to blood ratios and limited clearance at early time points in MX-1 tumors (1.1 ⁇ 0.2 [24 h]-1.2 ⁇ 0.1 [48 h]) the uptake in the HT-29 tumors was studied at 72 h and 120 h. Mice (n 8) were injected with 160 ⁇ Ci (8.4 nmol) of 89 Zr-DEB-PEG 40 and microPET/CT images were obtained at 72- and 120h. Mice were euthanized at 72- and 120h for ex-vivo biodistribution studies. HT-29 tumors were clearly visualized on the microPET/CT at 72h and 120h ( FIG.
  • FIG. 6A is an MIP image of PEG-SN-38) 3 -DFB 89 Zr in a single flank tumor-bearing mouse.
  • FIG. 6E shows biodistribution of PEG-(SN-38) 3 -DFB- 89 Zr (black) vs PEG-DFB- 89 Zr (grey) at 72h.
  • mice bearing HT29 tumors Five mice were used in the study and each was injected with 250-290 ⁇ Ci of the conjugate in 100 ⁇ l saline. Two of the mice were imaged at one hour post injection. After 24 hours, two mice, (one that had been imaged at one hour and an additional mouse) were imaged and then sacrificed to perform distribution studies. At 48 hours, two mice were imaged (one of the mice that was imaged at one hour and one additional mouse) and these were also sacrificed along with the remaining mouse and a distribution study performed.
  • FIGS. 7A-7C show the results of these studies. Shown in FIG. 7A , the label was present in the tumor at all of the times measured. As shown in FIG. 7B , the % of the injected dose (ID) per gram of individual organs was significant in most organs, although bone, spleen and tumor had the highest levels. As shown in FIG. 7C when computed as the percentage of the injected dose per organ, rather than as per gram of organ, accumulation in the tumor was dramatically higher, especially at 48 hours, as compared to other organs. Only liver showed a significant accumulation which dropped over the time period of 24-48 hours. Thus, the imaging agent confirms that the conjugate is selectively accumulated in the tumor as compared to other organs.
  • Example 8 The experiments of Example 8 were repeated using 4-branched PEG 40kDa -DFB- 89 Zr (Example 5), 4-armed PEG 40kDa -(DFB- 89 Zr) 4 (Example 5), and 4-armed PEG 40kDa -(DFB- 89 Zr) 1 (SN38) 3 (Example 6) in both MX-1 and HT-29 xenografts.
  • PET imaging was used to measure accumulation of 89 Zr in tumor, heart, liver, and kidney at 1, 24, 48, 72, 96, and 216 h post-dose.
  • the resulting data (expressed as decay-corrected percent of the total dose) were analyzed using a membrane-limited tissue distribution model according to the methods of Li et al., Intl. J. Nanomedicine (2012) 7: 1345-56. A compartment for the remaining tissues was included in order to match measured blood levels in the absence of more specific tissue analyses. Blood data were fit using a total clearance equal to the sum of the diffusion coefficients from blood into the organs (k, Table 2) and the elimination rate constant calculated from a plasma half-life of 20 hours.
  • FIG. 8 shows the distribution of 89 Zr in HT-29 xenografts
  • FIG. 9 shows the distribution of 89 Zr in MX-1 xenografts.
  • the pharmacokinetics/biodistribution of the imaging agent PEG 40kDa -DFB 89 Zr is compared with that of PEG-SN-38.
  • SN-38 is the active metabolite of irinotecan (CPT-11) a widely used anticancer agent.
  • CPT-11 irinotecan
  • PEGSN-38 is a conjugate of 4 arm PEG 40kDa with 4 equivalents of SN-38, giving PEG 40kDa (SN-38) 4 (Santi D V, et al., J. of Med. Chem . (2014) 57(6):2303-2314).
  • PEGSN-38 is in dose escalation in Phase 1 trials and shows a long t 1/2, ⁇ of 6 days.
  • Xenograft mice are prepared by implantation of 10 6 to 10 7 HT29 cells into the NSG mouse flank, and maintained until the tumors are ⁇ 200 mm 3 .
  • Time vs activity curves from microPET/CT images, blood, tumor and main organs are used to determine the accumulation/elimination rates of PEG 40kDa -DFB- 89 Zr in the tumor, the elimination rate from the blood and body, and the temporal activity distribution in the remainder of the mouse.
  • Increasing concentrations of PEG 40kDa -DFB- 89 Zr increase the rate of accumulation, with no effect on the first-order elimination from tumors.
  • Varying doses of the unlabeled PEG ⁇ (SN-38) 4 conjugate are injected into animals. From preclinical toxicology studies of PEG ⁇ (SN-38), the dose to provide 50% tumor growth inhibition (TGI) in the HT-29 tumor/nude rate was 150 mg/kg. From allometric scaling, 50% TGI in the mouse should be 280 mg/kg. A target dose for measurable growth inhibition (e.g. ⁇ 50% TGI) is verified.
  • TGI tumor growth inhibition
  • a mixture of PEG ⁇ (SN-38) 4 and PEG-(DFB- 89 Zr) is prepared that suitable for both a) achieving the therapeutic target dose, and b) monitoring tumor uptake/elimination kinetics of PEG-(DFB- 89 Zr) measured by PET over 10 days, as described above. Tissues are removed to quantify biodistribution, blood sampling. Total SN-38 content of tumors is measured by HPLC of NaOH-digested tumor and blood samples at various times (Santi, et al. (supra)). The PEG ⁇ (SN-38) 4 /PEG-(DFB- 89 Zr) ratio is determined at various time points to verify either an identity of drug/isotope of the ratio vs time or other relationship of tumor uptake of two components.
  • the % ID/g tumor of PEG-(DFB- 89 Zr) that corresponds to a therapeutic dose of PEG ⁇ (SN-38) 4 is established. High-uptake tumors are identified that accumulate sufficient PEG ⁇ (SN-38) 4 to achieve a therapeutic dose.
  • the subjects who will benefit from an EPR effect of a conjugated SN-38 are identified by an initial administration of the imaging agent of the invention.
  • the SN38 conjugate designated PLX038A in Example 1 and abbreviated here as PEG-SN38 is used in this Example.
  • mice having 5 mice in each group bearing MX-1 tumor xenographs were injected with vehicle or with a single dose of either vehicle, 137 mole/kg irinotecan (0.137/g or ⁇ 4 mole per mouse) or with 120 mole/kg PEG-SN38 qdx x 1d (single dose). Tumor volume was measured as a function of time. At 42 days, the group that received vehicle was treated with 120 ⁇ mole/kg of PEG-SN28. The results are shown in FIG. 10 .
  • mice with untreated tumors that showed tumor growth even as large as 1.7 cm 3 a single MTD dose of PEGSN38 shrank these tumors.
  • MX-1 xenografts The MX-1 cell line was obtained from Charles River Labs (Frederick, Md.). Ovejera A A et al. Ann Clin Lab Sci (1978) 8:50-6. Cells were cultured in RPMI-1640, 10% FBS and 1% 2 mM L-glutamine at 37° C. in 95% air/5% CO 2 atmosphere.
  • NCr nude mice Female NCr nude mice (N CrTac:NCr-Foxn1 mi ; ⁇ 6-7 weeks old) from Taconic Bioscience (Cambridge City, Ind.) were housed at the UCSF Preclinical Therapeutics Core vivarium (San Francisco, Calif.). All animal studies were carried out in accordance with UCSF Institutional Animal Care and Use Committee. Tumor xenografts were established by subcutaneous injection with MX-1 tumor cells (2 ⁇ 10 6 cells in 100 ⁇ I of serum free medium mixed 1:1 with Matrigel) into the right flank of female NCr nude mice.
  • tumor xenografts reached 1000-1500 mm 3 in donor mice, they were resected, cut into even-size fragments ( ⁇ 2.5 ⁇ 2.5 ⁇ 2.5 mm in size), embedded in Matrigel and re-implanted via subcutaneous trocar implantation in receiver mice.
  • Solutions of PLX038A (1.02 mM SN38; 0.26 mM PLX038A conjugate) were prepared in pH 5 isotonic acetate and sterile filtered (0.2 um) before use.
  • Solutions of BMN673 (52 ⁇ M) were prepared in 10% dimethylacetamide/5% Solutol HS15/85% 1 ⁇ PBS and were sterile filtered (0.2 um) before use.
  • mice received vehicle, a single dose of PLX038A (14.7 mL/kg i.p., 15 ⁇ mol/kg), daily doses of BMN673 (7.72 mL/kg p.o., 0.4 umol/kg), or a combination of PLX038A and BMN673 at the same doses.
  • daily BMN673 dosing began on the same day ( FIG. 11A ) or after a 4-day delay ( FIG. 11B ) after dosing PLX038A.
  • event-free survival was enhanced synergistically with the combination vs PLX038A and TLZ individually.

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