Classifications

• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
  • G01N33/574—Immunoassay; Biospecific binding assay; Materials therefor for cancer
  • G01N33/57407—Specifically defined cancers
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/47—Quinolines; Isoquinolines
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
  • C12Q1/00—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions
  • C12Q1/68—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving nucleic acids
  • C12Q1/6876—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes
  • C12Q1/6883—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for diseases caused by alterations of genetic material
  • C12Q1/6886—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for diseases caused by alterations of genetic material for cancer
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
  • G01N33/574—Immunoassay; Biospecific binding assay; Materials therefor for cancer
  • G01N33/57407—Specifically defined cancers
  • G01N33/57438—Specifically defined cancers of liver, pancreas or kidney
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
  • C12Q2600/00—Oligonucleotides characterized by their use
  • C12Q2600/106—Pharmacogenomics, i.e. genetic variability in individual responses to drugs and drug metabolism
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
  • C12Q2600/00—Oligonucleotides characterized by their use
  • C12Q2600/156—Polymorphic or mutational markers

Definitions

• the present invention relates generally to biomarkers and thyroid and kidney cancer.
• kinase inhibitors have been developed as antitumor agents.
• a group of compounds having inhibitory activity against receptor tyrosine kinases such as vascular endothelial growth factor receptor (VEGFR)
• VEGFR vascular endothelial growth factor receptor
• Lenvatinib mesylate is an oral tyrosine kinase inhibitor targeting VEGFR1- 3, fibroblast growth factor receptor (FGFR) 1-4, rearranged during transfection receptor (RET), KIT, and platelet-derived growth factor receptor (PDGFR).
• RET transfection receptor
• PDGFR platelet-derived growth factor receptor
• biomarkers that can be used to predict the response of a subject to an antitumor agent prior to administration thereof are greatly needed.
• the present application is based, at least in part, on the identification of biomarkers that are predictive of a thyroid or a kidney cancer subject's responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• lenvatinib mesylate e.g., lenvatinib mesylate.
• a mutation(s) in one or more of the genes NRAS, KRAS, VHL, BRAF, ERBB2, PTEN, and MET is indicative that a given thyroid or kidney cancer subject will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate.
• the ratio of thyroglobulin levels pre- and post-treatment with a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof can be useful in determining the likelihood that a subject having differentiated thyroid cancer will respond to continued therapy with the lenvatinib compound.
• the expression level of certain proteins can also be a useful predictor of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the combination of these two classes biomarkers (mutations and blood biomarkers) or three classes biomarkers (mutations, thyroglobulin, and blood biomarkers) can provide for even stronger predictions of the likelihood that a subject having thyroid or kidney cancer will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the application also provides methods for evaluating whether to continue treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) for a subject having thyroid or kidney cancer.
• lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• Low or high levels of certain proteins e.g., those listed in Table 3
• lenvatinib mesylate e.g., lenvatinib mesylate
• lower ratios of thyroglobulin levels post/pre-treatment with lenvatinib or a
• pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• control ratios from samples of patients who are known to not respond to such therapy can be useful in assessing/evaluating whether the test subject will benefit from continued therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• biomarkers and compositions described herein are useful, for example, in identifying and/or selecting a patient or a subset of patients having thyroid or kidney cancer that could benefit from treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the methods described herein are useful, for example, in selecting appropriate treatment modalities (e.g., therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate)) for a subject suffering from, suspected of having, or at risk of developing a thyroid or kidney cancer.
• the methods allow a health care practitioner to determine whether to continue with a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) or change therapies and use a different treatment.
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) or change therapies and use a different treatment.
• the disclosure provides a method of predicting the response of a subject having, suspected of having, or at risk of developing, a thyroid cancer or a kidney cancer to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the method involves providing a biological sample obtained from the subject and detecting the presence of a mutation in at least one gene selected from the group consisting of RAS, VHL, and BRAF in the biological sample.
• RAS is KRAS or NRAS.
• the mutation in at least one gene is a mutation listed in Table 1.
• the mutation in at least one gene is a mutation listed in Table 2.
• the mutation in RAS is selected from the group consisting of KRAS Q61R, KRAS G12R, NRAS Q61P, and NRAS Q61R.
• the method of this aspect further involves detecting the presence of a mutation in at least one gene selected from the group consisting of ERBB2, PTEN, and MET in the biological sample, wherein the presence of a mutated RAS and a mutation in at least one of ERBB2, PTEN, and MET is even more strongly predictive that the subject will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the method further comprises the step of determining the expression level of at least one gene selected from the group consisting of ANGPT2, VEGFA, FLT4, CCL3, and CCL4.
• the application provides another method of predicting the response of a subject having, suspected of having, or at risk of developing, a differentiated thyroid cancer to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• This method can also be used to evaluate/assess the benefit of continued administration of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the method involves providing a first blood sample obtained from the subject before the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof; providing a second blood sample obtained from the subject after initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof; measuring the concentration of thyroglobulin in the first blood sample and the second blood sample; and calculating the ratio (second/first) of the concentrations of thyroglobulin.
• a reduced ratio, as compared to a control, of the concentration of thyroglobulin in the blood samples is predictive that the subject will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof
• an increased ratio, as compared to a control, of the concentration of thyroglobulin in the blood samples is predictive that the subject will respond less effectively to the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof than a subject having a reduced ratio, as compared to a control, of the concentration of thyroglobulin in the blood samples.
• the second blood sample is obtained from the subject 1 week to 9 months after the initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the second blood sample is obtained from the subject 2 weeks to 9 months after the initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof. In another embodiment, the second blood sample is obtained from the subject 4 weeks to 6 months after the initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof. In a further embodiment, the second blood sample is obtained from the subject 4 days to 2 weeks after the initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the disclosure provides another method of predicting the response of a subject having, suspected of having, or at risk of developing, a thyroid cancer or a kidney cancer to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• This method involves providing a biological sample obtained from the subject before the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof; and measuring the concentration of at least one protein selected from the group consisting of ANGPT2, VEGFA, IFNG, KDR (soluble VEGFR2), FLT4 (soluble VEGFR3), IL6, PDGFAB, CSF3 (G-CSF), CCL3 (MIP-la), CCL4 (MIP- 16), FGF2, and IL13 in the biological sample.
• a reduced concentration, as compared to a control, of ANGPT2, VEGFA, IFNG, or soluble KDR (soluble VEGFR2), and/or an increased concentration, as compared to a control, of IL-6, IL-13, PDGFAB, CSF3 (G- CSF), CCL3 (MIP-la), CCL4 (MIP-16), FLT4 (soluble VEGFR3), or FGF2 is indicative that the subject will respond to the therapy comprising lenvatinib or a
• the concentration of at least two genes is measured.
• the two genes are selected from the group consisting of VEGFA, ANGPT2, and CSF3; or IL13, CCL3 and CCL4.
• the concentration of at least three genes is measured.
• the concentration of at least four genes is measured.
• the disclosure provides another method of predicting the response of a subject having, suspected of having, or at risk of developing, a thyroid cancer or a kidney cancer to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• This method can also be used to evaluate/assess the benefit of continued administration of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the method involves providing a biological sample obtained from the subject after initiation of the therapy comprising lenvatinib or a
• the sample is obtained about 15 days after initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof. In one embodiment, the sample is obtained about 29 days or any first day of each treatment cycle (four weeks per cycle) after initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the disclosure provides another method of predicting the response of a subject having, suspected of having, or at risk of developing, a thyroid cancer or a kidney cancer to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• This method can also be used to evaluate/assess the benefit of continued administration of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the method involves providing a first biological sample obtained from the subject before the therapy comprising lenvatinib or a
• pharmaceutically acceptable salt thereof measuring the concentration of at least one protein selected from the group consisting of CCL5, FLT3LG, IL12(p40), EGF, PDGF- BB, PDGF-AA, CSF2, FLTl, TEK, HGF, VEGFA, IL6, CSF3, FIGF, IL1RN, CCL11, ILIA, TGFA, PGF, PDGF-AB, IL10, and FGF2, in the first and the second biological samples; and calculating the ratio (second / first) of the concentrations of the protein.
• at least one protein selected from the group consisting of CCL5, FLT3LG, IL12(p40), EGF, PDGF- BB, PDGF-AA, CSF2, FLTl, TEK, HGF, VEGFA, IL6, CSF3, FIGF, IL1RN, CCL11, ILIA, TGFA, PGF, PDGF-AB, IL10, and FGF2, in the first and the second biological samples;
• a reduced ratio, as compared to a control, of the concentration of CCL5, FLT3LG, IL12(p40), EGF, PDGF-BB, PDGF-AA, CSF3, FLTl, TEK, HGF, VEGFA, or IL6, and an increased ratio, as compared to a control, of the concentration of CSF2, FIGF, IL1RN, CCL11, ILIA, TGFA, PGF, PDGF AB, IL10, or FGF2 is predictive that the subject will respond to the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the sample is obtained about 15 days after initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the sample is obtained about 29 days or any first day of each treatment cycle (four weeks per cycle) after initiation of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the disclosure provides a method of treating a thyroid or kidney cancer, the method including the step of administering to a subject in need thereof an effective amount of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof, wherein the subject has been identified as having a mutation that is associated with responsiveness to this therapy, and/or expressing a level or having an expression ratio of a biomarker that is associated with responsiveness to this therapy, and/or, for the case of thyroid cancer, having an expression ratio of thyroglobulin that is associated with responsiveness to this therapy.
• the disclosure provides a method of predicting responsiveness of a subject having, suspected of having, or at risk of developing a thyroid or kidney cancer.
• the method involves assessing the mutational status of NRAS and the pre- treatment concentrations of ANGPT2 in a biological sample(s) obtained from the subject.
• the presence of a mutation in NRAS e.g., a NRAS mutation listed in Table 1 or 2
• concentrations of ANGPT2 when entered into the following prediction formula: (0.00075l)*(Ang2) + (2.69)*iXNRAS,WT) - (3.92) ⁇ 0.716, where function D is defined in detailed description section, that satisfy the formula, are even more strongly predictive of the subject being responsive to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) than a subject having either of these biomarkers individually (slopes, insertions and cut-off value in the formula can be differently optimized when a different population of the sample is analyzed.).
• the disclosure provides a method of predicting
• the method involves assessing the mutational status of NRAS or KRAS and the pre-treatment concentrations of ANGPT2 in a biological sample(s) obtained from the subject.
• a mutation in NRAS or KRAS e.g., a NRAS mutation or a KRAS mutation listed in Table 1 or 2
• concentrations of ANGPT2 when entered into the following prediction formula :
• the lenvatinib or a pharmaceutically acceptable salt thereof is lenvatinib mesylate.
• the thyroid cancer is a differentiated thyroid cancer.
• the thyroid cancer is a medullary thyroid cancer.
• the thyroid cancer is a papillary thyroid cancer.
• the thyroid cancer is a follicular thyroid cancer.
• the thyroid cancer is a Hurthle ell thyroid cancer.
• the thyroid cancer is an advanced radioiodine-refractory differentiated thyroid cancer.
• the kidney cancer is renal cell carcinoma.
• the subject is a human.
• the biological sample is selected from the group consisting of a blood sample, circulating tumor cells, circulating DNA, a plasma sample, a serum sample, a urine sample, a thyroid sample, a thyroid nodule sample, a kidney sample, and a tumor sample.
• the method further includes communicating the test results to the subject's health care provider.
• the method further includes modifying the subject's medical record to indicate that the subject is likely or not likely to respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• the record is created on a computer readable medium.
• the method further includes prescribing a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof for the subject if the biomarker expression profile is predictive that the subject will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof. In some embodiments, the method further includes
• the method further comprises selecting a subject having, or at risk of developing, a cancer that would benefit from treatment comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• Fig. 1 is a schematic diagram of progression free survival (PFS) of patients with mutations in NRAS alone or with mutations in either NRAS or KRAS.
• PFS progression free survival
• Fig. 2 is a schematic diagram of the change in thyroglobulin levels after E7080 treatment.
• PR refers to median values among groups of patients showing partial response to E7080 therapy.
• Opters refers to median values among groups of patients having stable disease or progressive disease after E7080 therapy.
• This disclosure provides methods and compositions for predicting the response of a thyroid or kidney cancer subject (such as a human patient) to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the disclosure provides predictive biomarkers (e.g., protein expression levels and/or gene mutations) to identify those subjects having, suspected of having, or at risk of developing, thyroid (e.g., differentiated thyroid cancer) or kidney cancer (e.g., renal cell carcinoma), for whom administering a therapy comprising lenvatinib or a
• the disclosure provides biomarkers that are useful to evaluate/assess continued treatment of thyroid or kidney cancer subjects with a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the biomarkers, compositions, and methods described herein are useful in selecting appropriate therapeutic modalities (e.g., a lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) therapy) for subjects suffering from thyroid cancer or kidney cancer.
• this application provides methods of selecting patients having, suspected of having, or at risk of developing, thyroid or kidney cancer that could benefit from a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) as well as methods of treatment.
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) as well as methods of treatment.
• CTCs circulating tumor cells
• circulating DNA refers to DNA that is present in increased amounts in plasma or serum of cancer patients. Cancer patients have higher levels of circulating DNA than healthy controls (Leon et al., Cancer Res., 37 : 646-650 (1977); Chuang et al., Head & Neck, 229-234 (2010)).
• decreased/reduced expression level means an expression level that is lower than the expression level in a control.
• Elevated expression level means an expression level that is higher than the expression level in a control.
• nucleic acid and “polynucleotide” are used interchangeably herein, and refer to both RNA and DNA, including cDNA, genomic DNA, synthetic DNA, and DNA (or RNA) containing nucleic acid analogs. Polynucleotides can have any three- dimensional structure. A nucleic acid can be double-stranded or single-stranded (i.e., a sense strand or an antisense strand).
• Non-limiting examples of polynucleotides include genes, gene fragments, exons, introns, messenger RNA (mRNA), transfer RNA, ribosomal RNA, siRNA, micro-RNA, ribozymes, cDNA, recombinant polynucleotides, branched polynucleotides, plasmids, vectors, isolated DNA of any sequence, isolated RNA of any sequence, nucleic acid probes, and primers, as well as nucleic acid analogs.
• mRNA messenger RNA
• transfer RNA transfer RNA
• ribosomal RNA siRNA
• micro-RNA micro-RNA
• ribozymes cDNA
• recombinant polynucleotides branched polynucleotides
• plasmids vectors, isolated DNA of any sequence, isolated RNA of any sequence, nucleic acid probes, and primers, as well as nucleic acid analogs.
• salts include, but are not limited to, inorganic acid addition salt such as hydrochloric acid salt, sulfuric acid salt, carbonic acid salt, bicarnobate salt, hydrobromic acid salt and hydriodic acid salt; organic carboxylic acid addition salt such as acetic acid salt, maleic acid salt, lactic acid salt, tartaric acid salt and trifluoroacetic acid salt; organic sulfonic acid addition salt such as methanesulfonic acid salt, hydroxymethanesulfonic acid salt, hydroxyethanesulfonic acid salt, benzenesulfonic acid salt, toluenesulfonic acid salt and taurine salt; amine addition salt such as trimethylamine salt, triethylamine salt, pyridine salt, procaine salt, picoline salt, dicyclohexylamine salt, ⁇ , ⁇ '-dibenzylethylenediamine salt, N
• the pharmaceutically acceptable salt is a methanesulfonic acid salt ("mesylate").
• the methanesulfonic acid salt form (i.e., the mesylate) of 4-(3-chloro-4-(cyclopropylaminocarbonyl)aminophenoxy)-7- methoxy-6-quinolinecarboxamide is disclosed in US Patent 7,612,208, which is incorporated by reference herein in its entirety.
• Polypeptide and “protein” are used interchangeably herein and mean any peptide-linked chain of amino acids, regardless of length or post-translational modification.
• a polypeptide described herein is “isolated” when it constitutes at least 60%, by weight, of the total protein in a preparation, e.g., 60% of the total protein in a sample.
• a polypeptide described herein consists of at least 75%, at least 90%, or at least 99%, by weight, of the total protein in a preparation.
• the term "responds/responsive to a therapy” means that the subject administered with the therapy shows a positive response to the therapy provided.
• a positive response are : a decrease in tumor size, a decrease in metastasis of a tumor, or an increased period of survival after treatment.
• subject means a mammal, including but not limited to, a human, a chimpanzee, an orangutan, a gorilla, a baboon, a monkey, a mouse, a rat, a pig, a horse, a dog, and a cow.
• compositions 1 and 2 in the context of the amino acid sequence of the protein encoded by the respective genes.
• V600_K601>E amino acids VK are replaced by E;
• lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate.
• the subject can have a single mutation (e.g., NRAS Q61P) or multiple mutations in the same gene (e.g., NRAS G12D and NRAS Q61R); or single mutations in multiple genes (e.g., BRAF V600E, NRAS Q61R, KRAS G12R, and VHL
• KRAS G12R, KRAS Q61R; and VHL P81S are useful in predicting responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• lenvatinib a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the mutation(s) is/are in NRAS.
• mutations that are predictive of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof are NRAS Q61P and NRAS Q61R.
• the mutation(s) is/are in NRAS and/or KRAS.
• KRAS mutations that are predictive of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof e.g.,
• lenvatinib mesylate are KRAS G12R and KRAS Q61R.
• the mutation(s) is/are in NRAS and/or KRAS and/or VHL.
• VHL mutation that is predictive of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) is P81S.
• the mutation(s) is/are in NRAS and/or KRAS and/or BRAF.
• a non- limiting example of a BRAF mutation that is predictive of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) is BRAF V600E.
• the mutation(s) is/are in NRAS and/or KRAS and/or BRAF and/or VHL.
• genes other than, or in addition to, NRAS, KRAS, VHL and/or BRAF can also be predictive of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• Non-limiting examples of such genes include ERBB2, PTEN and MET.
• Non-limiting examples of mutations in these genes that can be predictive of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) include ERBB2 S779_P780insVGS, PTEN N323fs*2 and MET T1010I.T992I.
• the subject has, is suspected of having, or is at risk of developing a thyroid cancer (e.g., differentiated thyroid cancer such as papillary or follicular thyroid cancer).
• a thyroid cancer e.g., differentiated thyroid cancer such as papillary or follicular thyroid cancer.
• the subject has, is suspected of having, or is at risk of developing a kidney cancer (e.g., renal cell carcinoma).
• Nucleic acid isolated from biological samples obtained from the subject can be analyzed for the presence of one or more of the mutations listed in Table 1 and/or Table 2. Methods of identifying mutations in a nucleic acid are well known in the art. One method of assessing whether a subject has a mutation in any of the genes of interest is the method described in Example 1, specifically, the use of Sequenom's OncoCartaTM mutation panels.
• SMMD simultaneous multiple mutation detection
• the proteins of interest can also be isolated from the biological samples from the subject and analyzed for the presence of mutations such as those disclosed above.
• Methods of protein sequencing are well known in the art. Non-limiting examples of such methods include mass spectrometry and the Edman degradation reaction.
• Protein sequencing can be carried out in both the form of whole-protein analysis or analysis of enzymatically produced peptides by mass spectrometry (see, Chait, Science. 314(5796) : 65"6 (2006)).
• Tandem mass spectrometry such as collision-induced dissociation (CID) (4), is a key technique for protein or peptide sequencing.
• CID collision-induced dissociation
• gas-phase peptide/protein ions which are generated by ion source are internally heated by multiple collisions with rare gas atoms. This leads to peptide backbone fragmentation of the C-N bond resulting in a generation of series of fragment ions.
• the sequence information can be read from the series of fragment ions.
• the biological samples that are used to obtain the nucleic acid or protein for analysis include, but are not limited to, a blood sample, a plasma sample, a serum sample, circulating tumor cells, circulating DNA, a urine sample, a thyroid tissue sample, a thyroid nodule sample, a renal tissue sample, or a tumor sample.
• Thyroglobulin as a Biomarker for Responsiveness to Therapy Comprising Lenvatinib or a Pharmaceutically Acceptable Salt Thereof
• thyroglobulin can also be used as an effective biomarker.
• Thyroglobulin is the major protein found in the thyroid colloid and is central to thyroid physiology, functioning both as a pro-hormone and a storage site for thyroid hormones.
• the expression level of thyroglobulin can be used to determine whether a subject (e.g., one having, suspected of having, or at risk of developing differentiated thyroid cancer) will be more likely or less likely to respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the expression level of thyroglobulin can also be used to assess or evaluate whether a subject already being administered a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) should continue or terminate the therapy.
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) should continue or terminate the therapy.
• a biological sample e.g., blood, serum, or plasma sample
• lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• concentration of thyroglobulin after administration of lenvatinib or a pharmaceutically acceptable salt thereof / concentration of thyroglobulin before administration of lenvatinib or a pharmaceutically acceptable salt thereof is calculated.
• the subject is determined to be likely to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), whereas if the ratio of the samples from the test subject is greater than or about the same as (at least 90% but less than 100% of) that of the control, the subject is determined to be less likely to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate). If the subject is predicted to respond to treatment, the therapy with lenvatinib or a pharmaceutically acceptable salt thereof is recommended to be continued.
• lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• control means samples obtained pre- and post-treatment with lenvatinib or a pharmaceutically acceptable salt thereof from the same source (e.g., blood, serum or plasma sample) as that of the test samples and that are taken at the same, or substantially the same, time points from a control subject(s) as the test samples, from a subject (or subjects) who has not responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• control includes samples obtained in the past (pre- and post-treatment with the therapy) and used as a reference for future comparisons to test samples taken from subjects for which therapeutic responsiveness is to be predicted.
• control may be pre-established by an analysis of thyroglobulin expression pre-and post-treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) in one or more subjects that have not responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• This pre-established reference ratio (which may be an average or median ratio taken from multiple subjects that have not responded to the therapy) may then be used for the "control" ratio in the comparison with the test sample.
• control may alternatively be pre-established by an analysis of
• thyroglobulin expression in one or more subjects that have responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate.
• This pre-established reference ratio (which may be an average or median ratio taken from multiple subjects that have responded to the therapy) may then be used as the "control" ratio in the comparison with the test sample.
• the subject is predicted to respond to a therapy comprising lenvatinib or a
• thyroglobulin levels are comparable to or lower than, for example is lower than, the same as, or about the same as (at least 90% but less than 100% of), the pre-established reference ratio.
• the first biological sample can be taken at any time point prior to treatment with the therapy lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the first biological sample may be taken minutes, hours, days, weeks, or months before initiation of the therapy, or substantially at the same time as the initiation of the therapy.
• the second biological sample can also be taken from the subject at any time point after initiation of treatment with the therapy lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the second biological sample can be taken minutes, hours, days, weeks, or months after treatment with the therapy lenvatinib or a pharmaceutically acceptable salt thereof.
• Non-limiting examples of the time points when the second biological sample is taken include : 1 week to 9 months, 2 weeks to 9 months, 3 weeks to 9 months after, 4 weeks to 9 months after, 1 day to 2 weeks after, 2 days to 2 weeks after, 3 days to 2 weeks after, 4 days to 2 weeks after, 5 days to 2 weeks after, 6 days to 2 weeks after, 1 week to 2 weeks after, 1 week to 3 weeks after, 1 week to 4 weeks after, and 1 week to 5 weeks after, initiation of treatment with the therapy lenvatinib or a pharmaceutically acceptable salt thereof.
• the thyroglobulin levels can be determined either by measuring the levels of mRNA or protein levels. Methods of measuring mRNA and protein levels are well known in the art (see, e.g., Sambrook J, Fritsch EF, Maniatis T, eds. (1989). Molecular Cloning: A Laboratory Manual, 2nd ed. (Woodbury, NY Cold Spring Harbor Laboratory Press; Real-time PCR applications guide. Bio-Rad Bulletin 5279 (catalog #170-9799)).
• a subject is determined to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), if the subject shows a partial response post treatment with the therapy.
• Partial Response means at least 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline summed LD.
• a subject is determined to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), if the subject shows tumor shrinkage post-treatment with the therapy.
• Tuor shrinkage means percent change of sum of diameters of target lesions, taking as reference the baseline sum diameters.
• a subject is determined to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), if the subject shows progression free survival.
• Progression Free Survival refers to the period from start date of treatment to the last date before entering Progressive Disease (PD) status.
• PD means at least 20% increase in the sum of the LD of target lesions, taking as reference the smallest summed LD recorded since the treatment started, or the appearance of one or more new lesions.
• a larger decrease in thyroglobulin levels post-treatment from pre-treatment levels compared to a control is predictive of a partial response to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) in differentiated thyroid cancer patients.
• a decrease in thyroglobulin levels about 28 days (e.g., 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 days) after treatment with a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) is predictive of progression free survival in differentiated thyroid cancer patients.
• a decrease in thyreoglobulin levels about 56 days after, about 84 days after, about 112 days after, and about 140 days after treatment with a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) is predictive of tumor shrinkage in differentiated thyroid cancer patients.
• genes have been identified whose expression levels (e.g., mRNA or protein expression levels) are useful in predicting responsiveness of a subject to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate). These genes as identified by Gene ID, related URL, protein ID and UniProtKB Accession Nos. are listed in Table 3.
• FIGF 2277 www.ncbi.nlm.nih.gov/gene/2277 VEGFD (78) 043915
• PDGF-AA (alternative symbol PDGFAA); homo dimer of PDGFA
• PDGF-AB (alternative symbol PDGFAB); hetero dimer of PDGFA and PDGFB
• PDGF-BB (alternative symbol PDGFBB); homo dimer of PDGFB
• IL-12p70 hetero dimer of IL12A(p35) and IL12B(p40)
• a low expression (e.g., mRNA or protein expression) level (compared to a
• control includes a sample (from the same tissue) obtained from a subject who is known to not respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• control also includes a sample obtained in the past and used as a reference for future comparisons to test samples taken from subjects for which therapeutic responsiveness is to be predicted.
• the "control" expression level for a particular gene in a particular cell type or tissue may be pre-established by an analysis of gene expression in one or more subjects that have not responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate). This pre-established reference value (which may be an average or median expression level taken from multiple subjects that have responded to the therapy) may then be used for the "control" expression level in the comparison with the test sample.
• control expression level for a particular gene in a particular cell type or tissue may alternatively be pre-established by an analysis of gene expression in one or more subjects that have responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• This pre-established reference value (which may be an average or median expression level taken from multiple subjects that have responded to the therapy) may then be used as the "control" expression level in the comparison with the test sample.
• the subject is predicted to respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) if the expression level of the gene being analyzed is comparable to or lower than, for example is lower than, the same as, or about the same as (at least 85% but less than 100% of), the pre- established reference.
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) if the expression level of the gene being analyzed is comparable to or lower than, for example is lower than, the same as, or about the same as (at least 85% but less than 100% of), the pre- established reference.
• a high expression (e.g., mRNA or protein expression) level (compared to a control) of certain genes listed in Table 3 is predictive that a subject will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate.
• high concentrations (compared to a control) of PDGF-AB, FGF2, CSF3, IL6, IL13, FLT4, CCL3, and CCL4 in a biological sample obtained from a subject prior to treatment with the therapy are predictive that a given subject will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• control is identical to that described in the paragraph above, except that when the "control" expression level for a particular gene in a particular cell type or tissue is alternatively pre-established by an analysis of gene expression in one or more subjects that have responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), the subject is predicted to respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) if the expression level of the gene being analyzed is comparable to or higher than, for example is higher than, the same as, or about the same as (at least 85% but less than 100% of), the pre-established reference.
• lenvatinib mesylate e.g., lenvatinib mesylate
• subjects be administered with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) for short periods of time to determine whether the administered therapy will be effective for the subject.
• the determination of effectiveness of the therapy is made based on the expression (e.g., mRNA or protein expression) levels of certain genes in biological samples obtained from these subjects at different time points post-treatment. Based on the expression levels of these genes, one can predict whether the subject will respond to continued treatment.
• these methods are useful in assessing or evaluating whether it is advisable to continue administration of lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• low concentrations (compared to a control) of certain genes, e.g., ANGPT2 and/or IL13 about 5 days to about 18 days after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) are predictive that the subject will have a beneficial clinical outcome (e.g., tumor response and/or tumor shrinkage) upon continued therapy with lenvatinib compounds.
• high concentrations (compared to a control) of certain genes e.g., IL10 and/or CXCL12 about 5 days to about 18 days after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) are also predictive that the subject will have a beneficial clinical outcome (e.g., tumor response and/or tumor shrinkage) upon continued therapy with lenvatinib compounds.
• low concentrations (compared to a control) of certain genes, e.g., VEGFA, IL6, and/or PGF about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) are predictive that the subject will have a beneficial clinical outcome (e.g., tumor response and/or tumor shrinkage) upon continued therapy with lenvatinib compounds.
• high concentrations (compared to a control) of certain genes e.g., CCL5 about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) are predictive that the subject will have a beneficial clinical outcome (e.g., tumor response and/or tumor shrinkage) upon continued therapy with lenvatinib compounds.
• the ratio of the expression (e.g., mRNA or protein expression) level of certain genes post-treatment over pre-treatment with lenvantib or a pharmaceutically acceptable salt thereof (compared to a control) can also be useful in predicting whether a subject will have a beneficial clinical outcome (e.g., best overall response, tumor shrinkage, progression free survival) upon continued therapy with lenvatinib compounds.
• a beneficial clinical outcome e.g., best overall response, tumor shrinkage, progression free survival
• a reduced ratio, as compared to a control, of the expression level of certain genes e.g., CCL5, FLT3LG, IL12(p40), EGF, PDGF-BB, PDGF-AA, CSF3, FLT1, TEK, HGF, VEGFA, or IL6 is indicative that the subject will respond to the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• an increased ratio, as compared to a control, of the concentration of certain genes, e.g., CSF2, FIGF, ILIRN, CCLll, ILIA, TGFA, PGF, PDGF AB, IL10, or FGF2 is predictive that the subject will respond to the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• a reduced ratio (compared to a control) of the expression level of certain genes, e.g., CCL5, FLT3LG based on expression about 5 days to about 18 days after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene prior to initiation of this therapy is indicative that the subject will have progression free survival.
• An increased ratio (compared to a control) of the expression level of certain genes, e.g., CSF3 or FGF2 based on expression about 5 days to about 18 days after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene prior to initiation of this therapy is indicative that the subject will have tumor response.
• An increased ratio (compared to a control) of the expression level of certain genes, e.g., CSF3, IL10 or FGF2 based on expression about 5 days to about 18 days after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene prior to initiation of this therapy is indicative that the subject will show tumor shrinkage.
• An increased ratio (compared to a control) of the expression level of certain genes, e.g., FIGF, ILIRN, PDGFAB or IL10 based on expression about 5 days to about 18 days after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene prior to initiation of this therapy is indicative that the subject will have progression free survival.
• certain genes e.g., FLT3LG, IL12, EGF, PDGFBB, PDGFAA, CSF3, or FLT1 based on expression about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene prior to initiation
• certain genes e.g., CCL11 based on expression about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene prior to initiation of this therapy is indicative that the subject will exhibit tumor response.
• An increased ratio of the expression level of certain genes, e.g., ILIA or TGFA based on expression about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene prior to initiation of this therapy is predictive that the subject will exhibit tumor shrinkage.
• certain genes e.g., FLT1, TEK, VEGFA, or IL6 based on expression about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene about 5 days to about 18 days after initiation of this therapy is indicative that the subject will exhibit tumor shrinkage.
• certain genes e.g., TEK, HGF, or VEGFA based on expression about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene about 5 days to about 18 days after initiation of this therapy is predictive that the subject will show the best overall response.
• An increased ratio of the expression level of certain genes, e.g., PGF based on expression about 5 weeks (e.g., 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks) after initiation of therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and the expression level of the same gene about 5 days to about 18 days after initiation of this therapy is indicative that the subject will exhibit tumor shrinkage, whereas an increased ratio under the same conditions of e.g., FGF2 is predictive of the subject exhibiting a tumor response.
• the progression free survival observed above can be, for example, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months, or about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 12 months, about 13 months, about 14 months, about 15 months, about 15 months, about 17 months, about 18 months, about 19 months, about 20 months, about 21 months, about 22 months, about 23 months, or about 24 months.
• control includes samples obtained from the same source (e.g., blood, serum or plasma sample) as that of the test samples and that are taken at the same, or substantially the same, time points as the test samples, from a subject (or subjects) who has not responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• control includes samples obtained in the past (pre- and post-treatment with the therapy) and used as a reference for future comparisons to test samples taken from subjects for which therapeutic responsiveness is to be predicted.
• control may be a pre-established ratio of the expression of the gene of interest pre-and post-treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) in one or more subjects that have not responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• This pre- established reference ratio (which may be an average or median ratio taken from multiple subjects that have not responded to the therapy) may then be used for the "control" ratio in the comparison with the test sample.
• control may alternatively be pre-established by an analysis of expression of the gene of interest in one or more subjects who have responded to treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• This pre-established reference ratio (which may be an average or median ratio taken from multiple subjects that have responded to the therapy) may then be used as the "control" ratio in the comparison with the test sample.
• the subject is predicted to respond to a therapy comprising lenvatinib or a
• any of the above biomarkers may be assessed in combination to determine whether a subject will respond to, or benefit from continued, administration of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• any one or more of the mutation biomarkers may be assessed in combination with thyroglobulin expression ratios and/or expression levels or expression ratios of cytokine, chemokine, or angiogenic factors, and/or histological analysis.
• a mutational biomarker(s) is assessed in combination with histological analysis.
• a mutational biomarker(s) is assessed in combination with thyroglobulin expression ratios.
• a mutational biomarker(s) is assessed in combination with expression levels or expression ratios of one or more cytokine, chemokine, or angiogenic factors.
• the mutational status of NRAS is assessed in the biological sample obtained from the subject and considered in combination with pre-treatment concentrations of ANGPT2.
• the mutational status of NRAS or KRAS is assessed in the biological sample obtained from the subject and considered in combination with pre-treatment concentrations of ANGPT2.
• Such combinatorial biomarker analyses provide even stronger predictive value than studying individual biomarkers, and are useful, for example, in predicting responsiveness of a subject to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• Statistical analysis can be used to determine which markers when used in combination are better associated with a desired clinical outcome than the individual markers.
• a non-limiting example of such an analysis is provided in Example 4 of this application.
• pre-treatment The combination of the expression levels of VEGFA and ANGPT2 prior to initiation of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate)
• pre-treatment can be a better predictor of response to the therapy than each of these individual blood biomarkers.
• concentrations of VEGFA and ANGPT2 in a subject when entered into the following prediction formula :
• pre-treatment a mutation(s) and the expression levels of VEGFA and MlPlb prior to initiation of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate)
• pre-treatment can also be a better predictor of response to the therapy than each of these individual mutational and blood biomarkers.
• the sample from the subject has a mutation in NRAS (e.g., one of those listed in Table 1 or 2) and the pre-treatment concentrations of VEGFA and MlPlb in a subject when entered into the following prediction formula : (-0.025)*(MIPlb) + (-0.00616)*(VEGFA100) + (3.32)*ZXNRAS, WT) - (-0.52) ⁇ 1.81
• the function Dig, s is 1 when mutation status of gene(s) ⁇ is status s, and 0 when ⁇ is not s.
• the status s can be "WT” (wild type) or "MU” (mutation).
• mutation status is "MU” if one or more genes have mutation and "WT” only for the case that all genes are wild-type)
• the sample from the subject has a mutation in NRAS (e.g., one of those listed in Table 1 or 2) and the pre-treatment concentrations of VEGFA, MlPlb, and sVEGFR3 in a subject when entered into the following prediction formula :
• the sample from the subject has a mutation in NRAS (e.g., one of those listed in Table 1 or 2) and the pre-treatment concentrations of VEGFA, MlPlb, sVEGFR3, and Ang2 in a subject when entered into the following prediction formula :
• NRAS e.g., one of those listed in Table 1 or 2
• pre-treatment concentrations of Ang2 in a subject when entered into the following prediction formula :
• NRAS e.g., one of those listed in Table 1 or 2
• pre-treatment concentrations of ANG2(90) in a subject when entered into the following prediction formula :
• ⁇ 0.633 render this formula true (i.e. if the value is ⁇ 0.633 (e.g., 0.5)), then the subject is predicted to have a stronger clinical outcome (e.g., progression free survival) with the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) than subjects who have wild type NRAS and whose pre-treatment concentrations of ANG2(90) do not satisfy the formula (slopes, insertions and cut-off value in the formula can be differently optimized when different population of the sample is analyzed.).
• a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• the sample from the subject has a mutation in NRAS, KRAS, or BRAF (e.g., one of those listed in Table 1 or 2) and the pre-treatment concentrations of MlPla in a subject when entered into the following prediction formula :
• ⁇ -0.0348 render this formula true (i.e. if the value is ⁇ -0.0348 (e.g., -1.0)), then the subject is predicted to have a stronger clinical outcome (e.g., progression free survival) with the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) than subjects who have wild type NRAS or KRAS or BRAF and whose pre-treatment concentrations of MlPla do not satisfy the formula (slopes, insertions and cut-off value in the formula can be differently optimized when different population of the sample is analyzed.).
• a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• the sample from the subject has a mutation in NRAS, KRAS, or BRAF (e.g., one of those listed in Table 1 or 2) and the pre-treatment concentrations of IL6, VEGFA, MlPla, and MlPlb in a subject when entered into the following prediction formula :
• the subject is predicted to have a stronger clinical outcome (e.g., progression free survival) with the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) than subjects who have wild type NRAS or KRAS or BRAF and whose pre-treatment concentrations of IL6, VEGFA, MlPla, and MlPlb do not satisfy the formula (slopes, insertions and cut-off value in the formula can be differently optimized when different population of the sample is analyzed.).
• a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• Suitable biological samples for the methods described herein include any biological fluid, cell, tissue, or fraction thereof, which includes analyte biomolecules of interest such as nucleic acid (e.g., DNA or mRNA) or protein.
• a biological sample can be, for example, a specimen obtained from a subject (e.g., a mammal such as a human) or can be derived from such a subject.
• a sample can be a tissue section obtained by biopsy, or cells that are placed in or adapted to tissue culture.
• a biological sample can also be a biological fluid such as urine, blood, plasma, serum, saliva, semen, sputum, cerebral spinal fluid, tears, or mucus, or such a sample absorbed onto a substrate (e.g., glass, polymer, paper).
• a biological sample can also include a thyroid tissue sample, a renal tissue sample, a tumor sample, circulating tumor cells, and circulating DNA.
• the biological sample is a tumor cell(s) or a cell(s) obtained from a region of the subject suspected of containing a tumor or a pre ⁇ cancerous lesion.
• the biological sample may be a thyroid tumor sample or a renal tumor sample.
• a biological sample can be further fractionated, if desired, to a fraction containing particular cell types.
• a blood sample can be fractionated into serum or into fractions containing particular types of blood cells such as red blood cells or white blood cells (leukocytes).
• a sample can be a combination of samples from a subject such as a combination of a tissue and fluid sample.
• the biological samples can be obtained from a subject, e.g., a subject having, suspected of having, or at risk of developing, a cancer.
• the subject has a thyroid cancer.
• the subject has a differentiated thyroid cancer (e.g., papillary thyroid cancer, follicular thyroid cancer).
• the subject has a medullary thyroid cancer.
• the subject has a kidney cancer.
• the subject has a renal cell carcinoma.
• Any suitable methods for obtaining the biological samples can be employed, although exemplary methods include, e.g., phlebotomy, swab (e.g., buccal swab), or fine needle aspirate biopsy procedure.
• Non-limiting examples of tissues susceptible to fine needle aspiration include lymph node, lung, thyroid, breast, skin, and liver. Samples can also be collected, e.g., by microdissection (e.g., laser capture microdissection (LCM) or laser microdissection (LMD)).
• microdissection e.g., laser capture microdissection (LCM) or laser microdissection (LMD)
• a biological sample can be further contacted with one or more additional agents such as appropriate buffers and/or inhibitors, including nuclease, protease and phosphatase inhibitors, which preserve or minimize changes in the molecules (e.g., nucleic acids or proteins) in the sample.
• additional agents such as appropriate buffers and/or inhibitors, including nuclease, protease and phosphatase inhibitors, which preserve or minimize changes in the molecules (e.g., nucleic acids or proteins) in the sample.
• Such inhibitors include, for example, chelators such as ethylenediamine tetraacetic acid (EDTA), ethylene glycol bis(P-aminoethyl ether) ⁇ , ⁇ , ⁇ , ⁇ -tetraacetic acid (EGTA), protease inhibitors such as phenylmethylsulfonyl fluoride (PMSF), aprotinin, leupeptin, antipain and the like, and phosphatase inhibitors such as phosphate, sodium fluoride, vanadate and the like.
• chelators such as ethylenediamine tetraacetic acid (EDTA), ethylene glycol bis(P-aminoethyl ether) ⁇ , ⁇ , ⁇ , ⁇ -tetraacetic acid (EGTA), protease inhibitors such as phenylmethylsulfonyl fluoride (PMSF), aprotinin, leupeptin, antipain and the like, and phosphatase inhibitors such as phosphat
• a sample also can be processed to eliminate or minimize the presence of interfering substances.
• a biological sample can be fractionated or purified to remove one or more materials that are not of interest. Methods of fractionating or purifying a biological sample include, but are not limited to, chromatographic methods such as liquid chromatography, ion-exchange
• a sample can be in a variety of physical states.
• a sample can be a liquid or solid, can be dissolved or suspended in a liquid, can be in an emulsion or gel, or can be absorbed onto a material.
• Gene expression can be detected as, e.g., protein or mRNA expression of a target gene. That is, the presence or expression level (amount) of a gene can be determined by detecting and/or measuring the level of mRNA or protein expression of the gene. In some embodiments, gene expression can be detected as the activity of a protein encoded by a gene such as a gene depicted in Table 3.
• mRNA expression can be determined using Northern blot or dot blot analysis, reverse transcriptase-PCR (RT-PCR; e.g., quantitative RT-PCR), in situ hybridization (e.g., quantitative in situ hybridization) or nucleic acid array (e.g., oligonucleotide arrays or gene chips) analysis. Details of such methods are described below and in, e.g., Sambrook et al., Molecular Cloning: A
• the presence or amount of one or more discrete mRNA populations in a biological sample can be determined by isolating total mRNA from the biological sample (see, e.g., Sambrook et al. (supra) and U.S. Patent No. 6,812,341) and subjecting the isolated mRNA to agarose gel electrophoresis to separate the mRNA by size. The size-separated mRNAs are then transferred (e.g., by diffusion) to a solid support such as a nitrocellulose membrane.
• the presence or amount of one or more mRNA populations in the biological sample can then be determined using one or more detectably-labeled-polynucleotide probes, complementary to the mRNA sequence of interest, which bind to and thus render detectable their corresponding mRNA populations.
• Detectable-labels include, e.g., fluorescent (e.g., umbelliferone, fluorescein, fluorescein isothiocyanate, rhodamine, dichlorotriazinylamine fluorescein, dansyl chloride, allophycocyanin (APC), or phycoerythrin), luminescent (e.g., europium, terbium, QdotTM nanoparticles supplied by the Quantum Dot Corporation, Palo Alto, CA), radiological (e.g., 1251, 1311, 35S, 32P, 33P, or 3H), and enzymatic (horseradish peroxidase, alkaline phosphatase, beta-galactosidase, or acetylcholinesterase) labels.
• fluorescent e.g., umbelliferone, fluorescein, fluorescein isothiocyanate, rhodamine, dichlorotriazin
• the presence or amount of discrete populations of mRNA (e.g., mRNA encoded by one or more genes depicted in Table 3) in a biological sample can be determined using nucleic acid (or oligonucleotide) arrays (e.g., an array described below under "Arrays and Kits").
• nucleic acid (or oligonucleotide) arrays e.g., an array described below under "Arrays and Kits”
• isolated mRNA from a biological sample can be amplified using RT-PCR with, e.g., random hexamer or oligo(dT)-primer mediated first strand synthesis. The amplicons can be fragmented into shorter segments.
• the RT-PCR step can be used to detectably-label the amplicons, or, optionally, the amplicons can be detectably-labeled subsequent to the RT-PCR step.
• the detectable-label can be enzymatically (e.g., by nick-translation or kinase such as T4 polynucleotide kinase) or chemically conjugated to the amplicons using any of a variety of suitable techniques (see, e.g., Sambrook et al., supra).
• the detectably-labeled-amplicons are then contacted with a plurality of polynucleotide probe sets, each set containing one or more of a polynucleotide (e.g., an oligonucleotide) probe specific for (and capable of binding to) a corresponding amplicon, and where the plurality contains many probe sets each corresponding to a different amplicon.
• a polynucleotide e.g., an oligonucleotide
• the probe sets are bound to a solid support and the position of each probe set is predetermined on the solid support.
• the binding of a detectably-labeled amplicon to a corresponding probe of a probe set indicates the presence or amount of a target mRNA in the biological sample. Additional methods for detecting mRNA expression using nucleic acid arrays are described in, e.g., U.S. Patent Nos. 5,445,934; 6,027,880; 6,057,100; 6,156,501; 6,261,776; and 6,576,424; the disclosures of each of which are incorporated herein by reference in their entirety.
• Methods of detecting and/or for quantifying a detectable label depend on the nature of the label.
• the products of reactions catalyzed by appropriate enzymes can be, without limitation, fluorescent, luminescent, or radioactive or they may absorb visible or ultraviolet light.
• detectors suitable for detecting such detectable labels include, without limitation, x-ray film, radioactivity counters, scintillation counters, spectrophotometers, colorimeters, fluorometers, luminometers, and densitometers.
• the expression of a gene can also be determined by detecting and/or measuring expression of a protein encoded by the gene.
• Methods of determining protein expression are well known in the art.
• a generally used method involves the use of antibodies specific for the target protein of interest.
• methods of determining protein expression include, but are not limited to, western blot or dot blot analysis, immunohistochemistry (e.g., quantitative immunohistochemistry), immunocytochemistry, enzyme-linked immunosorbent assay (ELISA), enzyme-linked immunosorbent spot (ELISPOT; Coligan, J. E., et al., eds. (1995) Current Protocols in Immunology. Wiley, New York), or antibody array analysis (see, e.g., U.S. Publication Nos.
• the presence or amount of protein expression of a gene can be determined using a western blotting technique.
• a lysate can be prepared from a biological sample, or the biological sample itself, can be contacted with Laemmli buffer and subjected to sodium-dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE). SDS-PAGE-resolved proteins, separated by size, can then be transferred to a filter membrane (e.g., nitrocellulose) and subjected to immunoblotting techniques using a detectably-labeled antibody specific to the protein of interest. The presence or amount of bound detectably-labeled antibody indicates the presence or amount of protein in the biological sample.
• a filter membrane e.g., nitrocellulose
• an immunoassay can be used for detecting and/or measuring the protein expression of a gene (e.g., a gene depicted in Table 3).
• a gene e.g., a gene depicted in Table 3
• an immunoassay can be performed with an antibody that bears a detection moiety (e.g., a fluorescent agent or enzyme).
• Proteins from a biological sample can be conjugated directly to a solid-phase matrix (e.g., a multi-well assay plate, nitrocellulose, agarose, sepharose, encoded particles, or magnetic beads) or it can be conjugated to a first member of a specific binding pair (e.g., biotin or streptavidin) that attaches to a solid-phase matrix upon binding to a second member of the specific binding pair (e.g., streptavidin or biotin).
• a specific binding pair e.g., biotin or streptavidin
• Such attachment to a solid-phase matrix allows the proteins to be purified away from other interfering or irrelevant components of the biological sample prior to contact with the detection antibody and also allows for subsequent washing of unbound antibody.
• the presence or amount of bound detectably-labeled antibody indicates the presence or amount of protein in the biological sample.
• the present disclosure includes polyclonal antibodies, as well as monoclonal antibodies.
• an intact protein or its partial peptide may be used as the antigen for immunization.
• partial peptides of the proteins for example, the amino (N)-terminal fragment of the protein and the carboxy (C)-terminal fragment can be given.
• a gene encoding a protein of interest or a fragment thereof is inserted into a known expression vector, and, by transforming the host cells with the vector described herein, the desired protein or a fragment thereof is recovered from outside or inside the host cells using standard methods.
• This protein can be used as the sensitizing antigen.
• cells expressing the protein, cell lysates, or a chemically synthesized protein of the invention may be also used as a sensitizing antigen.
• the mammal that is immunized by the sensitizing antigen is not restricted; however, it is preferable to select animals by considering the compatibility with the parent cells used in cell fusion.
• animals belonging to the orders rodentia, lagomorpha, or primates are used.
• animals belonging to the order of rodentia that may be used include, for example, mice, rats, and hamsters.
• animals belonging to the order of lagomorpha that may be used include, for example, rabbits.
• animals belonging to the order of primates that may be used include, for example, monkeys.
• monkeys to be used include the infraorder catarrhini (old world monkeys), for example, Macaca fascicularis, rhesus monkeys, sacred baboons, and chimpanzees.
• the sensitizing antigen is injected intraperitoneally or subcutaneously into mammals.
• the solution is emulsified and injected into the mammal.
• the sensitizing antigen suitably mixed with Freund's incomplete adjuvant is preferably given several times every 4 to 21 days.
• a suitable carrier can also be used when immunizing and animal with the sensitizing antigen. After the immunization, the elevation in the level of serum antibody is detected by usual methods.
• Polyclonal antibodies against the proteins of the present disclosure can be prepared as follows. After verifying that the desired serum antibody level has been reached, blood is withdrawn from the mammal sensitized with antigen. Serum is isolated from this blood using conventional methods. The serum containing the polyclonal antibody may be used as the polyclonal antibody, or according to needs, the polyclonal antibody-containing fraction may be further isolated from the serum. For example, a fraction of antibodies that specifically recognize the protein of the invention may be prepared by using an affinity column to which the protein is coupled. Then, the fraction may be further purified by using a Protein A or Protein G column in order to prepare immunoglobulin G or M.
• immunocytes are taken from the mammal and used for cell fusion.
• splenocytes can be mentioned as preferable immunocytes.
• parent cells fused with the above immunocytes mammalian myeloma cells are preferably used. More preferably, myeloma cells that have acquired the feature, which can be used to distinguish fusion cells by agents, are used as the parent cell.
• the cell fusion between the above immunocytes and myeloma cells can be conducted according to known methods, for example, the method by Milstein et al. (Galfre et al., Methods Enzymol. 73:3-46, 1981).
• the hybridoma obtained from cell fusion is selected by culturing the cells in a standard selection medium, for example, HAT culture medium (medium containing hypoxanthine, aminopterin, and thymidine).
• HAT culture medium medium containing hypoxanthine, aminopterin, and thymidine.
• the culture in this HAT medium is continued for a period sufficient enough for cells (non-fusion cells) other than the objective hybridoma to perish, usually from a few days to a few weeks.
• the usual limiting dilution method is carried out, and the hybridoma producing the objective antibody is screened and cloned.
• a hybridoma producing the objective human antibodies having the activity to bind to proteins can be obtained by the method of sensitizing human lymphocytes, for example, human lymphocytes infected with the EB virus, with proteins, protein-expressing cells, or lysates thereof in vitro and fusing the sensitized lymphocytes with myeloma cells derived from human, for example, U266, having a permanent cell division ability.
• the monoclonal antibodies obtained by transplanting the obtained hybridomas into the abdominal cavity of a mouse and extracting ascites can be purified by, for example, ammonium sulfate precipitation, protein A or protein G column, DEAE ion exchange chromatography, an affinity column to which the protein of the present disclosure is coupled, and so on.
• Monoclonal antibodies can be also obtained as recombinant antibodies produced by using the genetic engineering technique (see, for example, Borrebaeck C.A.K. and Larrick, J.W., THERAPEUTIC MONOCLONAL ANTIBODIES, Published in the United Kingdom by MACMILLAN PUBLISHERS LTD (1990)).
• Recombinant antibodies are produced by cloning the encoding DNA from immunocytes, such as hybridoma or antibody-producing sensitized lymphocytes, incorporating into a suitable vector, and introducing this vector into a host to produce the antibody.
• the present disclosure encompasses such recombinant antibodies as well.
• Antibodies or antibody fragments specific for a protein encoded by one or more biomarkers can also be generated by in vitro methods such as phage display.
• the antibody of the present disclosure may be an antibody fragment or modified-antibody, so long as it binds to a protein encoded by a biomarker of the invention.
• Fab, F (ab') 2, Fv, or single chain Fv (scFv) in which the H chain Fv and the L chain Fv are suitably linked by a linker can be given as antibody fragments.
• antibody fragments are generated by treating antibodies with enzymes, for example, papain or pepsin.
• they may be generated by constructing a gene encoding an antibody fragment, introducing this into an expression vector, and expressing this vector in suitable host cells (see, for example, Co et al., J. Immunol, 152:2968-2976, 1994; Better et al., Methods Enzymol, 178:476-496, 1989; Pluckthun et al., Methods Enzymol, 178:497-515, 1989; Lamoyi, Methods Enzymol, 121:652-663, 1986; Rousseaux et al., Methods Enzymol, 121:663-669, 1986; Bird et al., Trends Biotechnol, 9: 132-137, 1991).
• the antibodies may be conjugated to various molecules, such as polyethylene glycol (PEG), fluorescent substances, radioactive substances, and luminescent substances.
• PEG polyethylene glycol
• Methods to attach such moieties to an antibody are already established and conventional in the field (see, e.g., US 5,057,313 and 5,156,840).
• Examples of methods that assay the antigen -binding activity of the antibodies include, for example, measurement of absorbance, enzyme-linked immunosorbent assay (ELISA), enzyme immunoassay (EIA), radioimmunoassay (RIA), and/or immunofluorescence.
• ELISA enzyme-linked immunosorbent assay
• EIA enzyme immunoassay
• RIA radioimmunoassay
• immunofluorescence when using ELISA, a protein encoded by a biomarker of the invention is added to a plate coated with the antibodies of the present disclosure, and then, the antibody sample, for example, culture supernatants of antibody-producing cells, or purified antibodies are added.
• a protein fragment for example, a fragment comprising a C-terminus, or a fragment comprising an N-terminus may be used.
• BIAcore Pharmacia
• the antibody of the invention and a sample presumed to contain a protein of the invention are contacted, and the protein encoded by a biomarker of the invention is detected or assayed by detecting or assaying the immune complex formed between the above-mentioned antibody and the protein.
• Mass spectrometry based quantitation assay methods for example, but not limited to, multiple reaction monitoring (MRM)-based approaches in combination with stable-isotope labeled internal standards, are an alternative to immunoassays for quantitative measurement of proteins. These approaches do not require the use of antibodies and so the analysis can be performed in a cost- and time- efficient manner (see, for example, Addona et al., Nat. Biotechnol., 27:633-641, 2009; Kuzyk et al., Mol. Cell Proteomics, 8:1860-1877, 2009; Paulovich et al., Proteomics Clin. Appl, 2:1386- 1402, 2008).
• MRM offers superior multiplexing capabilities, allowing for the simultaneous quantification of numerous proteins in parallel. The basic theory of these methods has been well-established and widely utilized for drug metabolism and pharmacokinetics analysis of small molecules.
• Methods for detecting or measuring gene expression can optionally be performed in formats that allow for rapid preparation, processing, and analysis of multiple samples. This can be, for example, in multi-welled assay plates (e.g., 96 wells or 386 wells) or arrays (e.g., nucleic acid chips or protein chips).
• Stock solutions for various reagents can be provided manually or robotically, and subsequent sample preparation (e.g., RT-PCR, labeling, or cell fixation), pipetting, diluting, mixing, distribution, washing, incubating (e.g., hybridization), sample readout, data collection (optical data) and/or analysis (computer aided image analysis) can be done robotically using commercially available analysis software, robotics, and detection instrumentation capable of detecting the signal generated from the assay. Examples of such detectors include, but are not limited to, spectrophotometers, luminometers, fluorimeters, and devices that measure radioisotope decay.
• Exemplary high- throughput cell-based assays can utilize ArrayScan® VTI HCS Reader or KineticScan® HCS Reader technology (Cellomics Inc., Pittsburg, PA).
• the expression level of two genes, three genes, four genes, five genes, six genes, seven genes, eight genes, nine genes, 10 genes, 11 genes, 12 genes, 13 genes, 14 genes, 15 genes, 16 genes, 17 genes, 18 genes, 19 genes, 20 genes, 21 genes, 22 genes, 23 genes, at least 24 genes, at least 25 genes or more, or at least two genes, at least three genes, at least four genes, at least five genes, at least six genes, at least seven genes, at least eight genes, at least nine genes, at least 10 genes, at least 11 genes, at least 12 genes, at least 13 genes, at least 14 genes, at least 15 genes, at least 16 genes, at least 17 genes, at least 18 genes, at least 19 genes, at least 20 genes, at least 21 genes, at least 22 genes, at least 23 genes, at least 24 genes, or at least 25 genes or more can be assessed and/or measured.
• any part of the nucleic acid sequence of the genes can be used, e.g., as hybridization polynucleotide probes or primers (e.g., for amplification or reverse transcription).
• the probes and primers can be oligonucleotides of sufficient length to provide specific hybridization to an RNA , DNA, cDNA, or fragments thereof derived from a biological sample.
• varying hybridization conditions can be employed to achieve varying degrees of selectivity of a probe or primer towards target sequence.
• the primers and probes can be detectably- labeled with reagents that facilitate detection (e.g., fluorescent labels, chemical labels (see, e.g., U.S. Patent Nos. 4,582,789 and 4,563,417), or modified bases).
• reagents e.g., fluorescent labels, chemical labels (see, e.g., U.S. Patent Nos. 4,582,789 and 4,563,417), or modified bases).
• nucleic acid molecule In order for a nucleic acid molecule to serve as a primer or probe it need only be sufficiently complementary in sequence to be able to form a stable double-stranded structure under the particular hybridization conditions (e.g., solvent and salt concentrations) employed.
• particular hybridization conditions e.g., solvent and salt concentrations
• Hybridization can be used to assess homology between two nucleic acid sequences.
• a nucleic acid sequence described herein, or a fragment thereof can be used as a hybridization probe according to standard hybridization techniques.
• the hybridization of a probe of interest e.g., a probe containing a portion of a nucleotide sequence described herein or its complement
• DNA, RNA, cDNA, or fragments thereof from a test source is an indication of the presence of DNA or RNA corresponding to the probe in the test source.
• Hybridization conditions are known to those skilled in the art and can be found in Current Protocols in Molecular Biology, John Wiley & Sons, N.Y., 6.3.1-6.3.6, 1991.
• Moderate hybridization conditions are defined as hybridization in 2X sodium chloride/sodium citrate (SSC) at 30°C, followed by a wash in 1 X SSC, 0.1% SDS at 50°C.
• Highly stringent conditions are defined as hybridization in 6X SSC at 45°C, followed by a wash in 0.2 X SSC, 0.1% SDS at 65°C.
• Primers can be used in in a variety of PCR-type methods. For example, polymerase chain reaction (PCR) techniques can be used to amplify specific sequences from DNA as well as RNA, including sequences from total genomic DNA or total cellular RNA.
• the PCR primers are designed to flank the region that one is interested in amplifying. Primers can be located near the 5' end, the 3' end or anywhere within the nucleotide sequence that is to be amplified.
• the amplicon length is dictated by the experimental goals. For qPCR, the target length is closer to 100 bp and for standard PCR, it is near 500 bp.
• PCR primers can be chemically synthesized, either as a single nucleic acid molecule (e.g., using automated DNA synthesis in the 3' to 5' direction using phosphoramidite technology) or as a series of oligonucleotides.
• one or more pairs of long oligonucleotides can be synthesized that contain the desired sequence, with each pair containing a short segment of complementarity (e.g., about 15 nucleotides) such that a duplex is formed when the oligonucleotide pair is annealed.
• DNA polymerase is used to extend the oligonucleotides, resulting in a single, double-stranded nucleic acid molecule per oligonucleotide pair.
• nucleic acid sequences or fragments thereof e.g., amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids, amino acids
• oligonucleotide probes can be used in nucleic acid arrays (such as the nucleic acid arrays described below under "Arrays") for detection and/or quantitation of gene expression.
• the methods described herein can involve, assessing the expression level (e.g., mRNA or protein expression level) of one or more genes (e.g., one or more genes depicted in Table 3), wherein the expression level of one or more of the genes predicts the response of a subject to treatment comprising a lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• “Assessing” can include, e.g., comparing the expression of one or more genes in a test biological sample with a known or a control expression level (e.g., in a reference biological sample) of the particular gene(s) of interest.
• the expression level of one or more genes in a test biological sample can be compared to the corresponding expression levels in a subject who has responded or failed to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), or an average or median expression level of multiple (e.g., two, three, four, five, six, seven, eight, nine, 10, 15, 20, 25, 30, 35, or 40 or more) subjects, of the same species, who have responded or have failed to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• lenvatinib mesylate e.g., lenvatinib mesylate
• Assessing can also include determining if the expression level of one or more genes (e.g., one or more genes as depicted in Table 3) falls within a range of values predetermined as predictive of responsiveness of a subject to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate). In some embodiments, assessing can be, or include, determining if the expression of one or more genes (e.g., one or more of the genes depicted in Table 3) falls above or below a predetermined cut-off value.
• a cut-off value is typically an expression level of a gene, or ratio of the expression level of a gene with the expression level of another gene, above or below which is considered predictive of responsiveness of a subject to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a reference expression level of a gene e.g., a gene depicted in Table 3
• a cut-off value is identified as a cut-off value, above or below of which is predictive of responsiveness to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• cut-off values are not absolute in that clinical correlations can still remain significant over a range of values on either side of the cutoff; however, it is possible to select an optimal cut-off value (e.g. varying H- scores) of expression levels of genes for a particular sample types. Cut-off values determined for use in the methods described herein can be compared with, e.g., published ranges of expression levels but can be individualized to the methodology used and patient population. It is understood that improvements in optimal cut-off values could be determined depending on the sophistication of statistical methods used and on the number and source of samples used to determine reference level values for the different genes and sample types. Therefore, established cut-off values can be adjusted up or down, on the basis of periodic re-evaluations or changes in methodology or population distribution.
• the reference expression level of one or more genes can be determined by a variety of methods.
• the reference level can be determined by comparison of the expression level of a gene of interest in, e.g., populations of subjects (e.g., patients) that are responsive to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) or not responsive to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof.
• This can be accomplished, for example, by histogram analysis, in which an entire cohort of patients are graphically presented, wherein a first axis represents the expression level of a gene and a second axis represents the number of subjects in the cohort whose sample contain one or more expression levels at a given amount.
• the reference level can be a single number, equally applicable to every subject, or the reference level can vary, according to specific subpopulations of subjects. For example, older subjects can have a different reference level than younger subjects for the same metabolic disorder.
• a subject with more advanced disease e.g., a more advanced form of a disease treatable by lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate)
• lenvatinib mesylate can have a different reference value than one with a milder form of the disease.
• the methods described herein can also be used to generate a lenvatinib (e.g., lenvatinib mesylate) therapy response profile for a subject.
• the profile can include information that indicates whether one or more of the mutations such as those listed in Tables 1 and 2 are present in a sample from the subject; and/or information that indicates the expression level of one or more genes (e.g., one or more genes depicted in Table 3); and /or the expression ratio of thyroglobulin in a sample (e.g., plasma, serum) of the subject post/pre-treatment with lenvatinib or a pharmaceutically acceptable salt thereof; and/or the histological analysis of any tumors (e.g., whether a thyroid cancer is a FTC or PTC).
• a sample e.g., plasma, serum
• a lenvatinib therapy response profile can include the expression level of one or more additional genes and/or other proteomic markers, serum markers, or clinical markers.
• the response profiles described herein can contain information on the expression or expression level of at least two, at least three, at least four, at least five, at least six, at least seven, at least eight, at least nine, at least 10, at least 11, at least 12, at least 13, at least 14, at least 15, at least 16, at least 17, at least 18, at least 19, at least 20, at least 21, at least 22, at least 23, at least 24, or at least 25 genes listed in Table 3.
• the response profiles described herein can also contain information on the presence of mutations (if any) and the nature of the mutation (s) in any one or more of the following genes: NRAS, KRAS, VHL, BRAF, ERBB2, PTEN and MET.
• the resultant information (lenvatinib therapy response profile) can be used for predicting the response of a subject (e.g., a human patient) to a treatment comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the response profiles can be used in predicting the response of a subject to a variety of therapies and/or a variety of disease states since, e.g., the expression levels of one or more of the genes (e.g., one or more of the genes depicted in Table 3), the mutations, the thyroglobulin levels, and/or the histological data examined can be indicative of such responses or disorders, whether or not physiologic or behavioral symptoms of the disorder have become apparent.
• the expression levels of one or more of the genes e.g., one or more of the genes depicted in Table 3
• the mutations, the thyroglobulin levels, and/or the histological data examined can be indicative of such responses or disorders, whether or not physiologic or behavioral symptoms of the disorder have become apparent.
• a lenvatinib (e.g., lenvatinib mesylate) response profile can be in electronic form (e.g., an electronic patient record stored on a computer or other electronic (computer-readable) media such as a DVD, CD, or floppy disk) or written form.
• the lenvatinib (e.g., lenvatinib mesylate) response profile can also include information for several (e.g., two, three, four, five, 10, 20, 30, 50, or 100 or more) subjects (e.g., human patients).
• Such multi-subject response profiles can be used, e.g., in analyses (e.g., statistical analyses) of particular characteristics of subject cohorts.
• pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• responsiveness is any decrease in the disease state as compared to pre-treatment
• non-responsiveness is the lack of any change in the disease state as compared to pre-treatment.
• Responsiveness of a subject e.g., a human
• a cancer can be classified based on one or more of a number of objective clinical indicia such as, but not limited to, tumor size, Clinical Benefit (CB), Overall Survival (OS), Progression Free Survival (PFS), Disease Control Rate (DCR), Time-To-Response (TTR), Tumor Shrinkage (TS), or Tumor Response (TR).
• CB Clinical Benefit
• OS Overall Survival
• PFS Progression Free Survival
• DCR Disease Control Rate
• TTR Tumor Shrinkage
• TR Tumor Response
• Chronic benefit refers to having one of the following statuses— Complete Response (CR), Partial Response (PR); or Stable Disease (SD) with 6 months or more progression free survival (PFS).
• Complete Response means complete disappearance of all target lesions.
• Partial Response means at least 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline summed LD.
• Progressive Disease means at least 20% increase in the sum of the LD of target lesions, taking as reference the smallest summed LD recorded since the treatment started, or the appearance of one or more new lesions.
• Stable Disease means neither sufficient shrinkage of the target lesions to qualify for PR nor sufficient increase to qualify for progressive disease (PD), taking as reference the smallest summed LD since the treatment started.
• OS Global System for Mobile communications
• Randomization means randomization of a patient into a test group or a control group when therapy plan for a patient is determined.
• PFS Progression Free Survival
• DCR Disease Control Rate
• TTR Time-To-Response
• CR or PR criteria for response
• Tumor shrinkage means percent change of sum of diameters of target lesions, taking as reference the baseline sum diameters.
• TR Tumor response
• PR Partial Response
• SD Stable Disease
• PD Progressive Disease
• the methods disclosed herein enable the assessment of a subject for responsiveness to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• lenvatinib mesylate a pharmaceutically acceptable salt thereof
• lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the methods of this disclosure also enable the classification of subjects into groups of subjects that are more likely to benefit, and groups of subjects that are less likely to benefit, from treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate.
• the ability to select such subjects from a pool of subjects who are being considered for treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) is beneficial for effective treatment.
• the methods of this disclosure can also be used to determine whether to continue treatment with lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) after administering this therapy for a short period of time and determining based on the expression profile of one or more of the biomarkers described above post-treatment or post-treatment versus pre-treatment whether this therapy is more likely or less likely to benefit the patient.
• Lenvatinib or a pharmaceutically acceptable salt thereof shows potent anti-tumor effects in xenograft models of various tumors by inhibiting angiogenesis.
• the subjects who are considered for treatment with lenvatinib or a pharmaceutically acceptable salt thereof include, but are not limited to, subjects having, suspected of having, or likely to develop a thyroid cancer or a kidney cancer (e.g., renal cell carcinoma).
• thyroid cancer is a cancerous tumor or growth located within the thyroid gland. It is the most common endocrine cancer and is one of the few cancers that has increased in incidence rates over recent years. It occurs in all age groups from children through seniors.
• the American Cancer Society estimates that there were about 44,670 new cases of thyroid cancer in the U.S. in 2010. Of these new cases, about 33,930 were in women and about 10,740 in men. About 1,690 people (960 women and 730 men) died of thyroid cancer in 2010. Many patients, especially in the early stages of thyroid cancer, do not experience symptoms.
• thyroid cancer there are several types of thyroid cancer : papillary, follicular, medullary, anaplastic, and variants.
• Papillary carcinoma is the most common type accounting for approximately 85% of all thyroid cancers, and usually affects women of childbearing age. It spreads slowly and is the least dangerous type of thyroid cancer.
• Follicular carcinoma accounts for about 10% of all cases and is more likely to come back and spread.
• Medullary carcinoma is a cancer of nonthyroid cells that are normally present in the thyroid gland. This form of the thyroid cancer tends to occur in families.
• Anaplastic carcinoma also called giant and spindle cell cancer
• Anaplastic carcinoma is the most dangerous form of thyroid cancer. It is rare, and does not respond to radioiodine therapy. Anaplastic carcinoma spreads quickly and invades nearby structures such as the windpipe (trachea), causing breathing difficulties. Variants include tall cell, insular, columnar, and Hurthle cell.
• Lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• the subject to be treated with lenvatinib or a pharmaceutically acceptable salt thereof has, is suspected of having, or is likely to develop a differentiated thyroid cancer.
• the subject to be treated with lenvatinib or a pharmaceutically acceptable salt thereof has, is suspected of having, or is likely to develop a medullary thyroid cancer.
• the subject to be treated with lenvatinib or a pharmaceutically acceptable salt thereof has, is suspected of having, or is likely to develop a papillary thyroid cancer.
• the subject to be treated with lenvatinib or a pharmaceutically acceptable salt thereof has, is suspected of having, or is likely to develop a follicular thyroid cancer.
• the subject to be treated with lenvatinib or a pharmaceutically acceptable salt thereof has, is suspected of having, or is likely to develop a Hurthle ell thyroid cancer.
• Kidney cancer is usually defined as a cancer that originates in the kidney.
• the two most common types of kidney cancer, reflecting their location within the kidney, are renal cell carcinoma (RCC, also known as hypernephroma) and urothelial cell carcinoma (UCC) of the renal pelvis.
• RCC renal cell carcinoma
• UTC urothelial cell carcinoma
• kidney cancer Other, less common types include : Squamous cell carcinoma, Juxtaglomerular cell tumor (reninoma), Angiomyolipoma, Renal oncocytoma, Bellini duct carcinoma, Clear- cell sarcoma of the kidney, Mesoblastic nephroma, Wilms' tumor, and mixed epithelial stromal tumor.
• RCC is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products.
• RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases. It is also known to be the most lethal of all the genitourinary tumors.
• Initial treatment is most commonly a radical or partial nephrectomy and remains the mainstay of curative treatment. Where the tumor is confined to the renal parenchyma, the 5-year survival rate is 60-70%, but this is lowered considerably where metastases have spread. It is resistant to radiation therapy and chemotherapy, although some cases respond to immunotherapy.
• Lenvatinib or a pharmaceutically acceptable salt thereof can be used to treat a subject having, suspected of having, or likely to develop any of the above-described kidney cancers.
• the subject to be treated with lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• the subject can then be administered an effective amount of the lenvatinib compound (e.g., lenvatinib mesylate).
• an effective amount of the compound can suitably be determined by a health care practitioner taking into account, for example, the characteristics of the patient (age, sex, weight, race, etc.), the progression of the disease, and prior exposure to the drug.
• the subject can then be optionally administered a therapy that does not comprise lenvatinib.
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate)
• the subject can then be optionally administered a therapy that does not comprise lenvatinib.
• These therapies include, but are not limited to, radioactive iodine, doxorubicin, carboplatin, cisplatin, paclitaxel, sorafenib, docetaxel, trastumab, interleukin-2, interferon, everolimus, sunitinib, pazopanib, vandetanib, and "standard of care” treatment (i.e., prevailing standard of care as determined by the health care practitioner or as specified in the clinical study) such as investigational drugs and chemotherapy.
• a biological sample used in a methods described herein can be obtained from a subject (e.g., a human) of any age, including a child, an adolescent, or an adult, such as an adult having, or suspected of having, a disease (e.g., papillary thyroid cancer, renal cell carcinoma) treatable by lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• the methods can also be applied to individuals at risk of developing a cancer treatable by lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• Such individuals include those who have (i) a family history of (a genetic predisposition for) such disorders or (ii) one or more risk factors for developing such disorders.
• lenvatinib mesylate After classifying or selecting a subject based on whether the subject will be more likely or less likely to respond to lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), a medical practitioner (e.g., a doctor) can administer the appropriate therapeutic modality to the subject.
• a medical practitioner e.g., a doctor
• Methods of administering lenvatinib therapies are well known in the art.
• any therapy described herein can include one or more additional therapeutic agents. That is, any therapy described herein can be co ⁇ administered (administered in combination) with one or more additional therapeutic agents such as, but not limited to, doxorubicin, carboplatin, cisplatin, paclitaxel, docetaxel, trastumab, interleukin-2, interferon and everolimus.
• additional therapeutic agents such as, but not limited to, doxorubicin, carboplatin, cisplatin, paclitaxel, docetaxel, trastumab, interleukin-2, interferon and everolimus.
• any therapy described herein can include one or more agents for treating, for example, pain, nausea, and/or one or more side-effects of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• Combination therapies can be, e.g., co-administration of a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and one or more additional therapeutic agents
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) and one or more additional therapeutic agents
• lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• one or more additional therapeutic agents can be administered at the same time or a lenvatinib compound (e.g., lenvatinib mesylate) can be administered first in time and the one or more additional therapeutic agents administered second in time.
• the one or more additional therapeutic agents can be administered first in time and lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) administered second in time.
• the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof can replace or augment a previously or currently administered therapy.
• administration of the one non-lenvatinib therapies can cease or diminish, e.g., be administered at lower levels.
• Administration of the previous therapy can be maintained while the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) is administered.
• a previous therapy can be maintained until the level of the therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) reaches a level sufficient to provide a therapeutic effect.
• Nucleic acid arrays including the nucleic acid biomarkers disclosed herein are useful in, e.g., detecting gene expression and/or measuring gene expression levels.
• the arrays are also useful for e.g., in predicting the response of a subject to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), for identifying subjects who can benefit from a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), and for steering subjects who would not likely benefit from a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate) to other cancer therapies.
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof e.g., lenvatinib mesylate
• An array is an orderly arrangement of samples where matching of known and unknown DNA samples is done based on base pairing rules (e.g., Adenosine pairs with Thymine or Uracil; Guanosine pairs with Cytosine).
• a typical microarray experiment involves the hybridization of an mRNA, a cDNA molecule, or fragments thereof, to a DNA template from which it is originated or derived. Many DNA samples are used to construct an array.
• An array experiment makes use of common assay systems such as microplates or standard blotting membranes. The sample spot sizes are typically less than 200 microns in diameter and the array usually contains thousands of spots.
• spotted samples known as probes (with known identity) are immobilized on a substrate (e.g., a microscope glass slides, silicon chips, nylon membrane).
• the spots can be DNA, cDNA, or oligonucleotides. These are used to determine
• An experiment with a single DNA chip can provide information on thousands of genes simultaneously.
• An orderly arrangement of the probes on the support is important as the location of each spot on the array is used for the identification of a gene.
• the amount of mRNA bound to each site on the array indicates the expression level of the various genes that are included on the array.
• cDNA microarrays are made with long double-stranded DNA molecules generated by enzymatic reactions such as PCR (Schena,M. et al., Science, 270:467-470 (1995)), while oligonucleotide microarrays employ oligonucleotide probes spotted by either robotic deposition or in situ synthesis on a substrate
• kits include probes that can be used to identify or detect any of the biomarkers of Table 3.
• the kits include primers that can be used to amplify the region containing any of the mutations listed in Table 1 and /or Table 2.
• kits include any of the nucleic acid arrays described herein.
• the kits include antibodies that can be used to detect thyreoglobulin or to detect any of the biomarkers of Table 3 or their expression or expression levels.
• the kits include probes and antibodies that can be used to identify or detect any of the biomarkers of Table 3 or their expression or expression levels.
• the kits can, optionally, contain instructions for detecting and/or measuring the level of one or more genes in a biological sample.
• kits can optionally include, e.g., a control biological sample or control labeled-amplicon set containing known amounts of one or more amplicons recognized by nucleic acid probes of the array.
• the control can be an insert (e.g., a paper insert or electronic medium such as a CD, DVD, or floppy disk) containing expression level ranges of one or more genes predictive of a response to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• kits can include one or more reagents for processing a biological sample.
• a kit can include reagents for isolating a protein from a biological sample and/or reagents for detecting the presence and/or amount of a protein in a biological sample (e.g., an antibody that binds to the protein that is the subject of the detection assay and/or an antibody that binds the antibody that binds to the protein).
• kits can include a software package for analyzing the results of, e.g., a microarray analysis or expression profile.
• kits can also include one or more antibodies for detecting the protein expression of any of the genes described herein.
• a kit can include (or in some cases consist of) a plurality of antibodies capable of specifically binding to one or more proteins encoded by any of the genes depicted in Table 3 and optionally, instructions for detecting the one or more proteins and/or a detection antibody comprising a detectably-labeled antibody that is capable of binding to at least one antibody of the plurality.
• kits can include antibodies that recognize one, at least two, at least three, at least four, at least five, at least six, at least seven, at least eight, at least nine, at least 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45 or 46 proteins encoded by genes depicted in Table 3.
• kits described herein can also, optionally, include instructions for administering a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate), where the expression level of one or more genes detectable by the array predicts that a subject will respond to a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate).
• a therapy comprising lenvatinib or a pharmaceutically acceptable salt thereof (e.g., lenvatinib mesylate)
• lenvatinib mesylate e.g., lenvatinib mesylate
• FFPE formalin fixed, paraffin embedded tissues
• Sequenom's OncoCartaTM Panels are a set of pre-designed and pre-validated assays for efficient mutation screening.
• OncoCartaTM Panel vl.O genes and the number of mutations are : ABL1 (14); AKT1 (7); AKT2 (2); BRAF (25); CDK4 (2); EGFR (40); ERBB2 (9); FGFR1 (2); FGRF3 (7); FLT3 (3); HRAS (10); JAK2 (l); KIT (32); KRAS (16); MET (5); NRAS (19); PDGFRA (ll); PIK3CA (14); and RET (6).
• OncoCartaTM Panel v3.0 genes and the number of mutations are: ABL1 (2) AKT1 (l); APC (12); BRAF (19); CDKN2A (7); CSF1R (6); CTTNB1 (28); EGFR (32); ERBB2 (2); FLT3 (3); HRAS
• OncoCartaTM Panel v3.0 genes and the number of mutations are : ABL1 (2) AKT1 (l); APC (12); BRAF (19); CDKN2A (7); CSF1R (6); CTTNB1 (28); EGFR (32); ERBB2 (2); FLT3 (3); HRAS (2); JAK3 (3); KIT (3); KRAS (5); MET (6); MLH1 (1); MYC (6); PDGFRA (ll); PIK3CA (4); PTEN (14); RBI (ll); RET (13); SRC (1); STKll (12); P53 (7); and VH1 (7).
• DNA was amplified using the OncoCartaTM PCR primer pools, unincorporated nucleotides were inactivated by shrimp alkaline phosphatase (SAP), and a single base extension reaction was performed using extension primers that hybridize immediately adjacent to the mutations and a custom mixture of nucleotides. Salts were removed by the addition of a cation exchange resin. Multiplexed reactions were spotted onto the SpectroChipII, and mutations, if present, were resolved by MALDPTOF on the Compact Mass Spectrometer (Sequenom®, San Diego, CA).
• SAP shrimp alkaline phosphatase
• the OncoCartaTM Panel vl.O (Sequenom®, San Diego, CA) consists of 24 pools of primer pairs and 24 pools of extension primers, and has the capacity to detect 225 mutations in 19 genes.
• the OncoCartaTM Panel v 3.0 consists of 24 pools of primer pairs and 24 pools of extension primers, and has the capacity to detect 218 mutations in 26 genes. Each pool consists of 5-9 primer pairs in the PCR reaction.
• Two types of assays have been designed in the OncoCarta panel, referred to as simple and complex. The simple assays are those in which a single assay is able to detect the amino acid changes at that codon.
• the complex assays are those that require more than one assay to identify codon changes or deletions and insertion, and thus are able to detect multiple different amino acid substitutions or deletions.
• An example of a complex assay involves the use of the KRAS_1 and KRAS_2 assays, which interrogates 2 different nucleotide positions within codon 12 and together identify all codon 12 amino acid changes.
• the mutant allele has the codon CGT (Arginine) in contrast to the wild type allele which has the GGT (Glycine) codon. So, the first nucleotide of codon 12 needs to be "C” and second nucleotide needs to be "G".
• the KRAS_2 assay reveals which nucleotide is incorporated into the first nucleotide of the codon 12, and the KRAS_1 assay is for the second nucleotide. Together, the data from these two assays detects the G12R substitution.
• BRAF_16 assay for the first nucleotide of the codon 600
• BRAF_15 for the second nucleotide
• A For the VHL P81S mutation, the mutant allele has TCG (Serine) whereas the wild type allele has CCG (Proline).
• the VHL_498 assay reveals which nucleotide is incorporated into the first nucleotide of the codon 81.
• the KRAS_7 assay discriminates the mutant allele (CGA, Arginine) from the wild type allele (CAA, Glutamine) by examining nucleotide variation in the second position of the codon.
• CGA mutant allele
• CAA wild type allele
• NRAS codon 61 there are three known mutations, Q61L (CAA to CTA), Q61R (CAA to CGA) and Q61P (CAA to CCA).
• the NRAS_6 assay detects nucleotide variation in the second position of the codon. Even more complex assays are also included in OncoCartaTM, which interrogate insertions and deletions within the EGFR gene.
• E7080 Thyroid Cancer trial each Cycle is 28 days (4 weeks) so Day 1-28 is cycle l; Day 29 is Day 1 of Cycle 2; and Day 57 is Day 1 of Cycle 3. Blood samples were collected for pharmacokinetic (PK) analysis on Cycle 1 Days 1 and 8, Cycle 2 Day 1, and Cycle 3 Day 1.
• PK pharmacokinetic
• PK parameter was used as a covariate in Cox proportional hazards model.
• CR Complete Response
• PR Partial Response
• SD Stable Disease
• PD Progressive Disease
• CB Clinical benefit
• CR Complete Response
• PR Partial Response
• SD Stable Disease
• Partial Response means at least 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline summed LD.
• Progressive Disease means at least 20% increase in the sum of the LD of target lesions, taking as reference the smallest summed LD recorded since the treatment started, or the appearance of one or more new lesions.
• “Stable Disease” means neither sufficient shrinkage of the target lesions to qualify for PR nor sufficient increase to qualify for progressive disease (PD), taking as reference the smallest summed LD since the treatment started.
• PFS Progression Free Survival
• Tumor shrinkage means percent change of sum of diameters of target lesions, taking as reference the baseline sum diameters.
• Genbank® accession number for: BRAF is NM_004333.3; for NRAS is NM_002524.2; for KRAS is NM_033360.2 (variant A) and NM_004985.3 (variant B); and for VHL is NM_000551.2 (variant l) and NM_198156.1 (variant 2).
• the association of gene mutations with progression free survival of treated patients was analyzed first by performing Logrank test and then using Cox proportional hazards model with or without covariates.
• the covariate used are the following PK parameters : cycle 1 dayl Cmax (E7080 concentration 2 hr after dosing on cycle 1 dayl : MAXl); cyclel dayl Ctrough (E7080 concentration before dosing on cyclel day 8 : MINl); cycle2 dayl Cmax (E7080 concentration 2 hrs after dosing on cycle2 day 1 ⁇ MAX2); cycle2 dayl Ctrough (E7080 concentration before dosing on cycle 2 day i:MIN2).
• thyroglobulin levels are predictive of whether patients respond to treatment with E7080 using three criteria of clinical response : tumor response, tumor shrinkage, and progression free survival.
• the serum for the thyroglobulin assays was collected within 72 hours prior to Day 1 of all cycles. 24 mg of E7080 was administered orally, daily continuously in 28-day cycles. Serum samples from 58 patients were used for thyroglobulin measurements. 6 mL of blood was drawn into red top tubes and let to clot at room temperature for at least 30 min. Within 60 minutes of sample collection, the tubes were centrifuged for 15 minutes at 20-25°C at lOOOx g. The supernatant was drawn without disturbing the pellet, put into sample tubes with serum filter and shipped frozen to the central lab for testing on the day of collection.
• the level of thyroglobulm was detected by a solid-phase, chemiluminescent immunometric assay (IMMULITE 2000 Thyroglobulm Assay System, Siemens) following standard operating procedure.
• serum thyroglobulm was captured by beads coated with anti- thyroglobulin antibody and detected using anti-thyroglobulin antibody linked to alkaline phosphatase.
• the level of serum thyroglobulm was calculated from a standard curve generated with lyophilized thyroglobulm. Serum thyroglobulin was stable for up to 2 months when stored frozen for the assay. The sensitivity of this assay was 0.2ng/ml.
• Example 3 Cytokine, Chemokine, and Angiogenic Factors (Blood Biomarkers) as Predictive and Response Biomarkers of E7080
• Purpose-' Angiogenesis is regulated by signaling through multiple growth factor receptors, such as VEGF and FGF receptor.
• VEGF receptor signaling is also associated with immune cell function.
• the purpose of this analysis was to measure cytokine, chemokine and angiogenic factors (collectively referred to herein as "blood biomarkers") in serum samples obtained from patients in clinical trials at both pre- and post- treatment with E7080 and to identify blood biomarkers which can be used to predict whether patients will respond to treatment with E7080.
• blood biomarkers cytokine, chemokine and angiogenic factors
• three criteria of response were employed, namely : tumor response, % of tumor shrinkage and progression free survival.
• TR Tumor response
• PR Partial Response
• SD Stable Disease
• PD Progressive Disease
• Serum samples received E7080 at a dose of 24mg oral once daily in 28 day cycles. Serum samples were collected at Cycle 1 Day 1 (pre-treatment), Cycle 1 Day 8 and Cycle 2 Day8 (i.e., day 36 post-treatment). 7.5 mL of blood was drawn into serum stainless steel tube (SST) and let to clot at room temperature for at least 30 min. Within 60 minutes of sample collection, the tubes were centrifuged for 10 minutes at 20"25°C at 1400x g. The supernatant was drawn without disturbing the pellet and the serum was mixed and divided into two sample tubes and stored frozen (-70°C) at an upright position until further treatment for analysis. Serum samples from 58 patients were used for blood biomarker analysis.
• SST serum stainless steel tube
• Serum from Cycle 1 day 1 (baseline), cycle 1 day 8, and cycle 2 day 8 were used in this analysis.
• the association of progression free survival with or without a covariate was analyzed.
• the covariates used are the following PK parameters : cycle 1 dayl Cmax (E7080 concentration 2 hr after dosing on cycle 1 dayl : MAXl); cyclel dayl Ctrough (E7080 concentration before dosing on cyclel day 8 : MINl); cycle2 dayl Cmax (E7080 concentration 2 hrs after dosing on cycle2 day 1 ⁇ MAX2); cycle2 dayl Ctrough (E7080 concentration before dosing on cycle 2 day 1 ⁇ MIN2).
• Serum samples were tested in batch format where all timepoints from the same subject were assayed on the same day. On the day of assay, samples were removed from -80°C and allowed to thaw and reach room temperature. The serum samples were tested using the following commercial assay kits as per the
• Human Soluble Tie-2 ELISA (R&D Systems Cat. No. DTE200), Human Angiopoietin-1 ELISA (R&D Systems Cat. No. DANG10), Human FGF23 ELISA, Human SDF-la ELISA.
• Human Angiopoietin-2 ELISA (R&D Systems Cat. No. DANG20), Human Soluble Receptor Multiplex (Millipore Cat. No. HSCR-32K; sVEGF Rl, sVEGF R2 and sVEGF R3 only), Human Cytokine/Chemokine Panel I Multiplex (Millipore Cat. No.
• MPXHCYTO60K MPXHCYTO60K; IL-la, IL- ⁇ , IL-lra, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12p40, IL-12p70, IL-13, IL-15, IL-17, sCD40L, EGF, Eotaxin, FGF-2, G-CSF, GM-CSF, IFN- ⁇ , IP- 10, MCP-1, ⁇ - ⁇ , ⁇ - ⁇ , PDGF-AA, RANTES, TGF-a, TNF-a and VEGF only) and Human Growth Factor Multiplex (Origene TruPLEX Cat. No. AM100096; PDGF-AB, PDGF-BB, FGF4, VEGFD, FGF2, EGF, HGF, FLT3LG, ANGPT2, PGF and VEGFA).
• the ELISA plates were measured using a Molecular Devices UVmax kinetic microplate reader with SoftMax Pro 5.2 software.
• the multiplex assays were performed using the Bio-Rad BkrPlex system with BkrPlex Manager 4.1 software. Final protein concentrations (pg/mL) were calculated from the standard curve for each assay. Depending on the assay, serum samples may have been diluted in assay buffer prior to testing. In these cases, protein concentrations were multiplied by the dilution factor.
• Concentration of 4 factors (ANG-2, PDGF-AB, sVEGFR2, and VEGF) in 5 assays were significantly associated with tumor shrinkage at pre-treatment. These studies indicated that lower concentrations of these 4 factors can predict larger tumor shrinkage, while higher concentration of PDGF-AB might predict larger tumor shrinkage. Concentration of 3 factors (IL-13, PGF, and VEGF) in 4 assays at either 1 week or 5 weeks after treatments with E7080 were significantly associated with tumor shrinkage. These studies showed that lower concentrations of these IL-13, PGF, and VEGF are predictive of larger tumor shrinkage at indicated time points.
• Cox proportional hazard model was performed to identify blood biomarkers that predict progression free survival by either concentrations or ratio (changes in expression levels) of factors.
• Pharmacokinetic (PK) parameter was used as a covariate in Cox proportional hazards model.
• Low concentrations of ANG-2 and VEGF at cycle 1 dayl, or a low ratio of IL-12(p40) at cycle2 day8 compared to cyclel dayl were significantly associated to longer PFS, indicating that these factors can be used as biomarkers for prediction or response to E7080 therapy (Table 12).
• Cox proportional hazard model with PK parameter demonstrated that high concentrations of 7 factors (GCSF, MlPlb, FGF2, MlPla, IL6, IL13, and sVEGFR3) at pre-treatment can be predictive of longer PFS; whereas, low concentrations of ANG-2 at pre-treatment can be predictive of longer PFS.
• Cox proportional hazard model with PK parameter demonstrated that low ratios of 7 factors (FLT3LG, RANTES, GCSF, sVEGFRl, EGF, PDGF-BB, PDGF-AA) are predictive of better PFS and that high ratios of 4 factors (VEGFD, IL10, IL1RA, PDGF-AB) are predictive of better PFS.
• factors such as mutations, thyroglobulin, blood biomarkers that better associate with clinical outcomes, such as progression free survival (PFS) than a single factor and to predict those clinical outcomes.
• PFS progression free survival
• Each patient has his/her own hazard value for each model, so that patients can be assigned into two groups when a threshold of hazard is given for a model.
• log rank test of progression free survival was performed to test difference of survival curves between two groups (low hazard and high hazard).
• the best threshold of hazard for each model of combination of factors was identified by sweeping threshold to calculate log rank test p-values and finding a threshold that minimized the smoothed curve constructed from the p-values, which was similar to the approach described in U. Abel, J. Berger and H. Wiebelt, "CRITLEVEL: An Exploratory Procedure for the Evaluation of Quantitative Prognostic Factors", Methods Inf.
• the best thresholds of the models divided patients into high and low hazard groups. Patients are predicted as longer PFS when their hazard value is lower than the threshold.
• Group (2) NRAS mu or KRAS mu plus ANG-2;
• Group (3) NRAS mu or KRAS mu or VHL mu
• biomarkers either gene mutations or blood biomarkers or combination among blood biomarkers predicted PFS better than as a single biomarker based on prediction models after determining combinations of them using the Cox proportional hazard model. Biomarker combinations that were found by this analysis may be used to predict clinical outcomes such as PFS with E7080 and response to E7080 treatment.
• Tissue samples are obtained at surgery before the patients had received any therapy comprising E7080 and were routinely processed with formalin fixed, paraffin embedded tissues (FFPE).
• FFPE formalin fixed, paraffin embedded tissues
• the protocol that is used is approved by the institutional review board, and informed consent is obtained from each subject.
• Tumor tissue samples from X patients, for which tissues are available, will be used for mutation analysis.
• DNA is isolated from FFPE tumor blocks collected from patients participating in the trial. Genomic DNA is extracted from two to five 10 micron unstained sections by deparaffinization and Qiagen DNA Mini Kit Tissue Protocol with minor modification.
• a sequencing technology such as the SEQUENOM® (San Diego, CA) platform and the OncoCartaTM Panel vl.O and OncoCartaTM Panel v3.0 described in Example 1, semiconductor sequencing such as Ion Torrent PGM, High Resolution Melt Analysis, or classical Sanger sequencing is used.
• E7080 The period during which a patient takes E7080 is artificially divided into different Cycles for ease of evaluation and tracking. Patients receive E7080 at a dose of 24mg orally once daily in 28 day cycles either alone or in combination with everolimus (E7080 and/or everolimus).
• each Cycle is 28 days (4 weeks) so Day 1-28 is cycle l; Day 29 is Day 1 of Cycle 2; and Day 57 is Day 1 of Cycle 3.
• Blood samples are collected for pharmacokinetic (PK) analysis on Cycle 1 Days 1, Cycle 2 Day 1, and Cycle 3 Day 1.
• a total of 6 samples per patient are collected as follows : Cycle 1 Day V immediately prior to the dose of E7080, and 2 to 8 hours following the first dose of E7080 (post-dose); Cycle 2 Day 1 ' ⁇ immediately prior to the dose of E7080 and 2 to 8 hours following the first dose of E7080 (post-dose); Cycle 3 Day V immediately prior to the dose of E7080 and 2 to 8 hours following the first dose of E7080 (post-dose).
• PK parameter is used as a covariate in Cox proportional hazards model.
• CB Clinical benefit
• CR Complete Response
• PR Partial Response
• SD Stable Disease
• Partial Response means at least 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline summed LD.
• Progressive Disease means at least 20% increase in the sum of the LD of target lesions, taking as reference the smallest summed LD recorded since the treatment started, or the appearance of one or more new lesions.
• “Stable Disease” means neither sufficient shrinkage of the target lesions to qualify for PR nor sufficient increase to qualify for progressive disease (PD), taking as reference the smallest summed LD since the treatment started.
• PFS Progression Free Survival
• TS Tumor shrinkage
• TR Tumor response
• PR Partial Response
• SD Stable Disease
• PD Progressive Disease
• Example 6 Blood Biomarkers as Predictive and Response Biomarkers of E7080 Either Alone or in Combination With Everolimus in RCC Subjects
• Purpose- The purpose of this analysis is to measure cytokine, chemokine and angiogenic factors (collectively referred to herein as "blood biomarkers") in blood samples obtained from patients in clinical trials at both pre- and post-treatment with E7080 and/or everolimus and to identify blood biomarkers which can be used to predict whether renal cell carcinoma patients will respond or fail to respond to treatment with E7080.
• blood biomarkers cytokine, chemokine and angiogenic factors
• Serum samples from patients are used for blood biomarker analysis. Serum from Cycle 1 day 1 (baseline), cycle 1 day 15, pre-dose sample from Dayl of each subsequent cycle and serum sample when the patient comes off treatment are used in this analysis. The association of progression free survival with or without a covariate is analyzed.
• the covariates used are the following PK parameters: cycle 1 dayl Cmax (E7080 concentration 2 hrs to 8 hrs after dosing on cycle 1 dayl : MAXl); cycle2 dayl Cmax (E7080 concentration 2 hrs to 8hrs after dosing on cycle2 day 1 ⁇ MAX2); cycle2 dayl Ctrough (E7080 concentration before dosing on cycle 2 day i:MIN2).
• Serum samples are tested in batch format where all timepoints from the same subject are assayed on the same day. On the day of assay, samples are removed from -80°C and allowed to thaw and reach room temperature. The serum samples are tested using the following commercial assay kits as per the manufacturer's instructions : Human Soluble Tie-2 ELISA (R&D Systems Cat. No. DTE200), Human Angiopoietin- 1 ELISA (R&D Systems Cat. No. DANG10), Human Angiopoietin-2 ELISA (R&D Systems Cat. No. DANG20), Human Soluble Receptor Multiplex (Millipore Cat. No.
• the ELISA plates are measured using a Molecular Devices UVmax kinetic microplate reader with SoftMax Pro 5.2 software.
• the multiplex assays are performed using the BkrRad BkrPlex system with BkrPlex Manager 4.1 software. Final protein concentrations (pg/mL) are calculated from the standard curve for each assay.
• serum samples may be diluted in assay buffer prior to testing.
• protein concentrations are multiplied by the dilution factor.
• BOR Best Overall Response
• CB Clinical benefit
• CR Complete Response
• PR Partial Response
• SD Stable Disease
• “Complete Response” means complete disappearance of all target lesions.
• “Partial Response” means at least 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline summed LD.
• Progressive Disease means at least 20% increase in the sum of the LD of target lesions, taking as reference the smallest summed LD recorded since the treatment started, or the appearance of one or more new lesions.
• “Stable Disease” means neither sufficient shrinkage of the target lesions to qualify for PR nor sufficient increase to qualify for progressive disease (PD), taking as reference the smallest summed LD since the treatment started.
• PFS Progression Free Survival
• TS Tumor shrinkage
• TR Tumor response
• PR Partial Response
• SD Stable Disease
• PD Progressive Disease
• Purpose- The purpose of this analysis is to identify combinations of factors, such as mutations, and levels or expression ratios of cytokine, chemokine and angiogenic factors, that better associate with progression free survival (PFS) than a single factor and to predict clinical outcomes, such as PFS and TS, in RCC patients.
• factors such as mutations, and levels or expression ratios of cytokine, chemokine and angiogenic factors, that better associate with progression free survival (PFS) than a single factor and to predict clinical outcomes, such as PFS and TS, in RCC patients.
• Each patient has his/her own hazard value for each model, so that patients can be assigned into two groups when a threshold of hazard is given for a model.
• log rank test of progression free survival is performed to test difference of survival curves between two groups (low hazard and high hazard).
• the best threshold of hazard for each model of combination of factors is identified by sweeping threshold to calculate log rank test p-values and finding a threshold that minimizes the smoothed curve constructed from the p-values, which is similar to the approach described in U. Abel, J. Berger and H. Wiebelt, "CRITLEVEL: An Exploratory Procedure for the Evaluation of Quantitative Prognostic Factors", Methods Inf. Medicine, 23(3): 154-6(1984).
• the best thresholds of the models divides patients into high and low hazard groups.
• the criteria of patient prediction of longer PFS are defined as a hazard value calculated by hazard function that is lower than the threshold.

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