WO2016168451A1 - Compositions for improving the pharmacokinetics and therapeutic index of cancer treatment - Google Patents

Abstract

Provided are methods for improving the pharmacokinetics of drug therapy, in one aspect methods are provided for co-administration of a liposomally encapsulated, PEGylated, or protein-conjugated drug via a parenteral route and the same drug in free (non-encapsulated PEGylated, or protein-conjugated) form via an enteral or parenteral route, in another aspect, methods are provided for treating a cancer in a patient by co-administering liposomal irinotecan and free irinotecan, optionally in further combination with additional therapeutic agents.

Description

COMPOSITIONS FOR IMPROVING THE PHARMACOKINETICS AND THERAPEUTIC INDEX OF CANCER TREATMENT

CROSS REFERENCE TO RELATED APPLICATIONS;

0β.11 This application claims the benefit of U.S. Provisional Application No. 62/147389, filed

April 14, 2015, the disclosure of which is hereby incorporated by reference in its entirety.

[0002] Colorectal cancer accounts for 10 to 15 percent of all cancers and is the second leading cause of cancer .deaths in Western countries. Approximately half of .the patients develop

metastatic disease. The prognosis, for these patients is poor, even though palliative chemotherapy has been able- to prolong survival and improve the quality of life over best supporti ve care.

Accordingly, there remains a critical need to further ^'improve therapies so as to prolong patients' li ves whiie maintain ing quality of life, particularly in the case of colorectal cancers that often are.

or become, resistant to current therapeutic modalities.

SUMMARY

\%M ] Provided are methods of Improving the pharmacokinetic profile of a drug treatment in a patient (e.g. , a hitman patient), the methods comprisin administering to the patient a

therapeutically effective amount of the drug, Wherein the therapeutically effective amount is administered as a first, amount of the drug administered to the patient parenteraliy in a sustained release dosage form and a second amount of the same drug co-administering to the patient

enterally or parenteraliy- in an immediate release dosage form, Beneficially, the first amount combined with the second amount equals a therapeutically effective amount of the drug. The 'drug maybe administered in doses (each dose comprising the first amount and the second

amount) separated by an interval of a day or more, or a week, two weeks, or three weeks, or a month or more-, in some embodiments, the first amount of the drag i administered parenteraliy in a form (e.g., a liposomaily -encapsulated- form) thai provides sustained release, and the same drag is co-administered parenteraliy in the second amount, e.g., at the same interval, such that the pharmacokinetic profile is improved. Beneficially, the drug reaches therapeutic levels at a site of action faster than if administered only in the sustained release (e.g., liposomaily encapsulated) form, and maintains therapeutic levels at the site of action longer than if administered at the same intervals only in the immediate release form.

0084] The immediate release form may be a free (non-encapsulated. non-PEGylated, and.non- protem-conjiigated) form, and the sustained release dosage form may be a liposomaily encapsulated, PEGylated, or protein-conjugated (e.g., albumin-conjugated) form. Such. coadministration _.results in improvement of the pharmacokinetic profile of the drug, or in improvement of the therapeutic index (efficacy to safety ratio) of the drug, or in therapeutic synergy, as compared to administration, to matched patients of the first amount and the second amount -as a combined amount in the sustained release injectable dosage form.

[0005] The uneneapsulated dru and the drug in sustained release dosage form (e.g., liposomally encapsulated, PEGylated.,. or protein-conjugated form) may be administered sequentially or simultaneously. The sustained release and immediate release dosage forms may both be comprised -within a singl formulation for simultaneous injection, in one embodiment, the second amount of the immediate release injectable dosage form is at least 10% of the first amount of the sustained release injectable dosage form. The. drug, may be an anti-cancer drug. In one embodiment, the sustained release dosage form is in a liposomal, hyaluronate, or PEGylated form and the immediate release dosage form is in the form of a hydrochloride or other salt solution, or analogs or derivatives thereof.

|00O6) In various embodiments the drug is an anti-cancer drug. The anti-cancer drug may be selected from a topoisomerase inhibitor (e.g., a topoisomerase I. inhibitor or a topoisomerase if inhibitor), an anti-microtubule agent (e.g.. a taxane, a yi-nca alkaloid, -a vinca alkaloid derivative), an anti-metabolite (e.g.,. an anti-foiate. a fluoropyrimidine, a deoxynucleoside analogue, or a thlopurine), a platinum salt, an alkylating agent (e.g., a nitrogen mustard, a nitrosourea, a tetrazine, a aziridine, an organoplatinum agent, procarbazine -or hexamethylmelami-ne), an anti- angiogenic agent, or a cytotoxic, antibiotic. The topoisomerase I inhibitor may be, e.g., eamptoihecin, irinotecan, S -38. or topoieean; the topoisomerase II inhibitor may be , e.g., pixantrone, mitoxantrone, or an anthracycline (e.g., doxorubicin, daunorubicin, bleomycin, daciinomycin, epjrubicin, or Idarubiein) or it may be, e.g., etoposide or teniposide; the taxane -may be, e.g.. paciitaxel, doeetaxei, cabazitaxel, or tesetaxei, the vinca alkaloid is, e.g., vincristine, vinblastine, or vinore!hme, the platinum salt may be, e.g., oxaliplatm, eisplatin or. earboplatm, the alkylating agent may be. e.g., bendamusiine, busulfan, eanrmstme, ehlonnbucil, cyclophosphamide, ifbstamide, lomustine. meehiorethamine, melphalan, streptazocin, thiotepa. or uraniustine, the anti-metabolite may be, e.g., 5--FIX capecitabme, cytarab.ine, gemcitabine, methotrexate, pemetrexed, or tegafur, and the anti-angiogenic agent may be, e.g., bevacteumab. The liposomally encapsulated irinoieean may be irinotecan suerosofate liposome injection (nai- I L 0NIVY.DE™, MM-3 8).

[0807] Exemplary combinations include: liposomal irinotecan (e.g., IViM-398 or !HL-305) coadministered with SN-38 or free irinotecan (e.g., CA PTOSAR®): hyaiuronate irinotecan (HA- irinotecan) coadministered -with SN-38 or irinotecan; PEGylated irinotecan (e.g,₅ NKTR-102) co-administered with SN-38 or irinotecan; eyclodexirin camptothecin (e.g., CRLXI Q!) coadministered with camptothccin or PEGylate SN-38 (e.g., N 102 or EZN22Q8) coadministered with SN-38 or irinotecan.. Liposomal doxorubicin (e.g.,. D0X1L®. CAELYX®. YOCET®) co-administered with doxorubicin; liposomal daunorubiein (e.g.,

DAtiNOSOMB®} co-administered with daunorubiein, bleomycin, dactmornyciu, epirubiei idarub.icin,_. or mitoxantrone. Albumin conjugated paditaxel (e.g.. ABRAXANE®) coadministered with pacliiaxel; liposomal doeetaxel -co-administered with doeetaxel;. cyclodextrin doeetaxel co-administered with doeetaxel; PEGylated doeetaxel co-adminisiered with doeetaxel. Liposomal vincristine (e.g., !VlARQIBO©) co-administered with -vincristine; liposomal vhiorelbine co-adminisiered with vinorelbme; liposornai vinblastine co-administered with vinblastine. Liposomal or PEOyiated or protein-conjugated oxaHplatin co-administered with pxaliplatm liposomal or PEGylated or protein-conjugated cisplatih co-administered with cisplatin; liposomal or PEGyiaied or protein-conjugated earhoplatin. co-administered with carboplatin.

[0M8j Also provided are methods for treating cancers (tumors, e.g., unresectable tumors), in a patient (e.g., a human patient) comprising co-administering to the- patient liposomal irinotecan (e.g., O VYDE™) and free irinotecan (i ., in an neneapsulated solution or suspension, e.g., CAK TO$AR®)_S optionally in combination with co-administration of 5-fluorouracil (5-FU) and ieueovorin, optionally in further combination with eo -administration of bevaci umab. according to particular clinical dosage regimens providing effective amounts of each drug. Compositions adapted for use in such methods also are provided.

[6009J in one aspect, a method for treatment (e.g., effective treatment) of a cancer (e.g., an unresectable cancer) in a patient is provided, the method comprising: administering to the patient an effective amount of irinotecan. where the effective amount is comprised by a combination of liposomal, irinotecan co-administered with tree (non-encapsulated) irinotecan. wherein the method comprises at least one cycle, wherein the cycle is a period of two weeks, and wherein fo each cycle the liposomal, irinotecan is administered to patients at a dose of 60 mg ra² or 80 mg/ra², .and the fee -irinotecan is administered to patients -.at a dose of 90 mg/m^J or 120 mg/m^?. ^' 0010] In one embodiment, the cancer is a gastrointestinal cancer, e.g., colorectal cancer (C.R.C). in: another embodiment, the cancer is metastatic C C. In another embodiment, the cancer is pancreatic cancer. In yet another embodiment the patient previously has been treated for the cancer with first line standard of care therapy. [0011] in another aspect a method for treatment of CRC (optionally unresectable advanced CRC) in a patient is provided, the method comprising: co-admtoistraiing to a patient an effective amount of each, liposomal irinoteean, free irinoteean, 5-fluoroumcil (5~Fl^j), leucovorin, and optionally hevaekumab, wherein the method comprises at least one cycle of co-administration, wherei a cycle i a period of two weeks, and wherein for each cycle;

[0012] (a) liposomal irinoteean is administered once to patients, at a dose of 60

{0013] (b) free irinoteean is administered once to patients at a dose of 90 mg/m" or

1.20 mg/n ;

(o) leucovorin is administered once to patients at a dos of 400 mg/m^";

100.151 «} 5-FU is administered once to patients at a dose of 2400 mg m"; and

[00I6J (e) bevacizumab is optionall administered once t patients at a dose of 5 rag/kg or 10 mg kg.

[0Θ17] in one embodiment, the liposomal Irinoteean is admi istered intravenously over 90 minutes, in another embodiment the 5-FU is administered intravenously over 46 hours. In .another embodiment, the leucovorin is- administered intravenously over 2 hours, la another embodiment, the bevacizumab Is administered intravenously over 30-90· minutes. In another embodiment, the liposomal irinoteean is administered intravenously over 60 minutes or 90 minutes, in another embodiment, the: tree irinoteean is administered intravenously over 6-0 minutes.

{0018] in other embodiments, the liposomal irinoteean is administered prior to the free irinoteean. In one embodiment, the leucovorin and 5-FU are administered sequentially. The leucovorin and 5-fiuorouracil may be administered after ihe two formulations of irinoteean, with the leucovorin administered before the 5-FU, In another embodiment, the bevacizumab is administered prior to the liposomal irinoteean, the free irinoteean. -the leucovorin. and the 5-FU.

[0019] In still other embodiments, treating the patient results in a positive outcome, wherein the positive outcome is pathologic, complete response (pCR), complete response (CR). partial response .(PR) or stable disease (SD). In one embodiment, the combination therapy^' with liposomal irinoteean, free irinoteean,_.5-FU and leucovorin results in therapeutic- syner y,

[0020] in further embodiments, the liposomal irinoteean is formulated as irinoteean liposome injection (MM-398, O VY^'DE.™). MM-398 ma also be referred to as irinoteean HC1 liposome injection because irinoteean HC1 is the active pharmaceutical ingredient that Is. osed t load ^•irinoteean into liposomes containing triethylammonium sucrose oetasulfate to prepare MM-398 liposomes. This nomenclature may be used even though the hydrochloride ion of the irinoteean HCT reacts with the triethylamrnoni m ion of the triethylammonium sucrose oetasulfateto yield triemylammomum chloride (triei hylamine hydrochloride) which may diffuse .out of the liposomes, leaving irinotecan suerosofaie entrapped within the MM- 398 liposomes.

0β21| in another aspect, a formulation of liposomal irinoteean (e.g., MM-3 8) is provided for co-administration with free irinoteean in at least one cycle, wherein the cycle is. two weeks, and wherein:

[0022} (a) liposomal irinoteean is administered at a dose of 60 or 80 rag/ ²; and

[0023] (b) free irinoteean is administered^' at a dose of 90 or 120 mg/m^*.

[0024] In. another aspect, a formulation of liposomal irinoteean is provided for co-administration with free Irinoteean, 5-fluorouracil (5-FLJ), leucovorin, and bevacizumab in at least one cycle is: provided, wherein the cycle ^'is. two weeks, and wherein:

100251 (a) liposomal irinoteean. is administered at a dose of 60 or ^"80 mg/nr

Ι0Θ26] (b) free irinoteean is -administered at a dose of 90 or 120 mg nr;

[0027] (c) leucovorin. is .administered at a dose of 400 mg/m^*;

[0028] (d) 5-fluorouracil is. administered at a dose of 2400 ing/m² and

[0029} (v) bevacizumab is administered at a dose of 5 mg kg.

(0030] Optionally, the liposomal irinoteean is administered intravenously over 90.minutes, and/or the 5-FU is administered intravenously over 46 hours, and/or the leucovorin is administered intravenously over 2 hours. In an alternate embodiment, the liposomal irinoteean is administered intravenously over 6 minutes or 9.0 minutes and/or the free irinoteean is administered intravenously over 60 minutes:.

[0031] In another aspect, the camptothecin topoisomerase I inhibitor is ^' irinoteean and the sustained release dosage form is in a liposomal, hyaiuronate, or PEGylated form, and the immediate release dosage form is in the form of an irinoteean hydrochloride .solution or its analogs or derivatives. In one embodiment, a cycle is a period of two weeks, and for each coadministration:

[0032] (a) the liposomal irinoteean sucroso.fate is administered at a dose range between 60 and 100 mg/m^a;

[ 033| (b) the irinoteean hydrochloride is administered at -a dose range between 90 and 1.80 mg/m^"';;

[0034] (c) the leucovorin is administered at a dose of 400 mg/nv^':;

[0035] (d) the S-fluorouracil is administered at a dose o 2400 rag/m ; and

[0036] (e) the bevacizumab is co-administered at a dose of 5 mg/kg Q2W or 1.0 mg/kg Q2w or 15 mg/kg Q3W. [0037] in another aspect, a kit for treating CRC (e.g., unresectable CRC, metastatic CRC, or metastatic unresectable CRC) in a patient is provided, the kit comprising a first container, and within the first container, a second container and a third container, the second container holding a dose of liposomal irinotecan and the third container holding a dose of free irinotecan. The kit optionally further comprising _. ^'instructions^' for using liposomal irinotecan, free irinotecan, and optionally 5-FlI and ieucovorin. and optionally bevaclzuma , as described herein,

[0038] An MM-398 PBGylated liposome encapsulating irinotecan and sucrose octasuipbate can be used in a method of treating unresectable, advanced cancer in a human patient, the method comprising administration to the human patient once every two weeks in a treatment cycle.

BRIEF DESCRIPTION OF THE DRAWINGS

| 03*>1 Figures 1.A.- IC -summarize MM-39S pharmacokinetic parameter in an HI -29 xenograft study,

[0040 j Figures :1A and I B are graphs showing plasma irinotecan and SN-38 le^'vel-s, respectively, following f ee irinotecan and MM-398 administrations. Figure IC is a graph showing iniratumor levels of irinotecan and SN-3S levels following different ^'doses of MM-398.

DETAILED DESCRIPTION

[00 11 Definitions

[0642] The term "patient" is human patient.

[8643] The term "effective treatment" refers to treatment producing a beneficial effect, e.g., amelioration of at least one symptom, of a disease or disorder. A beneficial effect can take the form of an improvement over baseline, i.e., an improvement over a measurement or observation made prior to initiation of therapy according: to the .method. A beneficial effect can also take the form of arresting, slowing, retarding, or stabilizing of a deleterious progression of a marker of a ^'cancer. Effective treatment may refer to alleviation of at least one symptom of a cancer. Such effective treatment may, e.g.. reduce patient pain, reduce the size and/or number of lesions, may reduce or prevent metastasis of a cancer tumor, and or may slow growth of a cancer tumor. Effective treatment with a drug or composition may: (i) reduce the number of cancer cells; (li) reduce tumor size; (hi) inhibit, retard, slow to some -extent and may stop cancer ceil Infiltration into peripheral organs; (iv) inhibit (i.e., slow to some extent and may stop) tumor metastasis; (v) inhibit -tumor growth; (vi) prevent or delay occurrence and/or recurrence of tumor; and/or (vii) relieve to some extent one or more of the symptoms associated with the cancer,

$0 4] The terms "combination therapy,^'' "co-administration,^" or "co-administered"^' (or minor variations of these terms) include simultaneous, admin stration of at least two therapeutic agents to a patient or their ^'sequential administration within a time period during which the first administered therapeutic agent is still present in the patient when, the second administered therapeutic agent Is administered.

00 51 The term ^monotherapy" refers to administering a single drug preparation, containing a single dr ug to treat a disease or disorder in the absence of co-administration of any other drug or therapeutic preparation to treat the same disease or disorder.

[0040] "Dosage" refers to parameters for administering a drug preparation in defined quantities per unit time (e.g., per hour, per day, per^■week, per month, etc.) to a patient. Such parameters include, e.g., the quantity of drug In each dose, or .administration. Such parameters also include the configuration of each dose, which may he administered as one or more units, e.g., each taken at a single administration, e.g., injected (e.g., as an nfusion or a bolus). Such parameters further include frequency of administration of separate doses, which frequency may change over time.

[0047] "Dosage form" ^'refers to the form and/or formulation in which a. drug is provided for use, e.g. a free aqueous solution, an aqueous suspension, a liposomal suspension, a single dose vial, a pill, a capsule, etc.

[0048] ''Dose" refers to an amount of a drug gi ven in a single administration.

[0049] The terms "resistant^'" and ''refractory" refer to tumor cells that continue to grow or divide during treatment with a therapeutic agent. Such cell may have responded (e.g., by not growing or dividing) to a therapeutic agent .initially, but subsequently exhibited a reduction -of responsiveness during treatment.

[0050] "Therapeutic synergy" refers to a. phenomenon where treatment of patients^' with a combination of therapeutic agents (e.g., eo-ad mini strati on of a combination of different drugs or co-administration of a combination, of different formulations of the same drug) manifests a therapeutically superior outcome to the outcome achieved by each, individual constituent of the combination used at its optimum dose, in this context, a therapeutically Superior outcome is one in which the patients either a) exhibit fewer incidences of adverse events while receiving a therapeutic benefit that is equal to or greater than that where Indi vidual constituents of the combination are each administered a monotherapy at the same dose as in the combination, or b) do not exhibit dose-limiting toxicities while receiving a therapeutic benefit that is greater than that of treatment with each individual constituen of the combination when each constituent is administered in at the same doses in the^■ combination^) as is administered as individual components, in xenograft models, a combination, used at its maximum tolerated dose, in which each of the constituents will be present at a dose generally not exceeding its individual maximum tolerated dose, manifests therapeutic, synergy- when decrease i tumor growth achieved by

? administration of the com ination is greater than the value of the decrease in tumor growth of the best constituent when the constituent is administered alone.

OSI f II Improving the pharmacokinetic profile of drug treatment

0852} ^encapsulated -drugs typically provide rapid exposure to high drug levels., but often do not sustain exposure, over a. long time period. In a complementary fashion, encapsulation of a drug-can. he engineered so as to provide a sustained release .-pharmacokinetic pro fi le, sustainin exposure tor a prolonged period of time. Such an encapsulated drug may, however, take longer to reach therapeutic levels at the she of action than the free drug.

{0053} III Irinotecan and MM-398

[0054} Irinotecan is ($)-4_s 1 1 -dieihyi~3 U 2, 14-tetra^^_^

eamptoth.ee in derivative topoisomerase I inhibitor

|0Θ55] MM-398 (see, e.g., US 8, 147,867) is a stable liposomal formulation also known as irinotecan liposome injection, irinotecan sucrose octasui fate salt liposome injection, or irinotecan sucrosofate. liposome -injectiou (also referred to as PEP02, and ONiVYDE™). MM-398 may be provided as a sterile, injectable parenteral aqueous liquid for intravenous injection. The required ^•amount -of MM-398 may be diluted, e.g., in 250 mi, of 5% dextrose injection USP.and infused, e.g., over a 90 minute period,

{0O56J An MM-398 liposome is a -unilamellar lipid bilayer vesicle of 80- 1.40 nrn in diameter that encapsulates an aqueous space which -contains irinotecan compfexed in a .geiated or precipitated state as a salt with sucrose oetasiiliate. The lipid membrane of the liposome is comprised of phosphatidylcholine, cholesterol, and a poiyemyleneglycoi-derivatfeed phosphatidyl- eihanolamine in the amount of approximately one po!yemyleneglyeol (PEG) molecule for 200 phospholipid molecules. This stable liposomal formulation of irinotecan has several attributes that provide an improved therapeutic index. The controlled and sustained release improves activity of the schedule-dependent drug_, irinotecan b increasing duration of exposure of -_.tumor tissue to drug (either or both -of irinotecan aud its more active-metabolite, -SM.-38). an. attribute that allows drug to be present in a higher proportion of cells during the- S-pbase of the cell cycle, when DNA unwinding (mediated by topoisomsrase) is required as a preliminar step in the DNA replication, process.

{0057) The long circulating- pharmacokinetics and high intravascular drug retention of liposomes (e.g., the MM-398 liposomes) can provide additional benefits, such as those stemming, from enhanced permeability and retention (EP.R). In tumors and certain other sites of pathology (e.g., sites of infection, inflammation, or both), the normal integrity of the vasculature (capillaries in particular) is; compromised, resulting in vascular permeability that allows leakage out of the capillar lumen of nano-particulates such as liposomes,, which may then be retained and accumulate at the site of leakage. Such, enhanced permeability and retention may thus promote preferential delivery and accumulation of liposomes within tumors and sites of inflammation or infection. EPR of M -398 may result in a. subsequent depot effect, where liposomes accumulate (e.g., in tumor associated, macrophages), which can metabolize irinotecan, converting it locally to the substantially more cytotoxic SN-38) and release drug as they break- down. This preferential local bioact.vatio.tt and delivery is believed to result in Increased exposure at cancer cells within the tumor and reduced drug exposure elsewhere (e.g., at potential sites of toxicity).

(0958] IV. 3-Fhmmumcrl (5-FU). and Leucovorm,

§59 5-Fiuorouracil is a pyrimidine antagonist that interferes with nucleic acid biosynthesis. The deoxyrihonucieotlde of the drug inhibits thymidilate synthetase, thus inhibiting the formation -ofthymkSylic acid -from deoxyuridyiic acid, thus interfering in the synthesis of DNA. It also interferes with RNA synthesis.

[0068] Leucovorin can potentiate the cytotoxic efibcts of fluorinated pyrlmsdines (e.g., 5-FU and fi-oxuridine). For example, after 5-FU is activated within the cell, it becomes associated with a folate eofactor, and mediates cytotoxicity by inhibiting the enzyme th m dilate synthetase. Leucovorin can increase the folate pool, thereby increasing the bindin of folate eofactor and active 5-FU with thymidilate synthetase, resulting in increased cytotoxicity.

j¾Q61J ¥. Bevackum b

[8062] Bevackumab is a recombinant humanized monoclonal antibody- that blocks angiogenesis by inhibiting vascular endothelial growth factor A (VEGF-A). VEGF-A is a cytokine that stimulates angiogenesis in a variety of diseases, especially in cancer. Bevacizumab . is administered at a dose of 5 mg/kg, or 10 mg/kg typically Q2 W, or 15 mg/kg, typically Q3W. imm] VI Administration

106641 Liposomal irinotecan is administered intravenously in combination with coadministration, of free . irinotecan, and optionally in further combination with eo-administration of 5~fluarouracii (5-FU), and leucovorin. which optionally are co-administered in further combination with bevacizumab. In one embodiment, free irinotecan is administered prior to liposomal irinotecan. in another embodiment, -free irinotecan and liposomal irinotecan are administered prior to 5-FU and leucovorin. in. another embodiment, leucovorin is administered prior to 5-FU. In another embodiment, bevackumab is administered prior to liposomal irinotecan, free irinotecan, leucovorin, and 5-fluorouraeiL In another embodiment, liposomal

Irinotecan is administered intravenously over 60 minutes or 90 minutes, in another embodiment free irinoteeao is administered intravenously over 60 minutes, in another embodiment, 5-Fij is administered intravenously over 46 hours, in another embodiment, leucovorin is administered intravenously over 2 hours, in another embodiment bevacixumab and leucovorin are each administered over 120 minutes. I another embodiment bevacizumab is administered over 30-90 minutes. In various embodiments the liposomal irinotecan is MM-398.

|O 65) ViL Patient Populations

0066] The compositions and methods disclosed herein are useful for the treatment of patients with a variety cancers including unresectable cancers and cancers that are refractory or resistant to other anti-cancer treatments.

0067] CRC

J006S| in one embodiment, a patient treated using the methods and compositions disclosed herein has histologically proven carcinoma.

[0069) The patient treated may have advanced or metastatic disease not suitable for complete surgical resection (e.g., unresectable cancer).

[8070] The patient treated may have colorectal cancer (CRC).

(007IJ The patient treated may have unresectable or metastatic CRC.

[0072] The CRC may be adenocarcinoma, squamous cell carcinoma, leiomyosarcoma,: carcinoid tumor, or gastrointestinal stromal tumor.

[0673| In. various of the CRC embodiments, the patient has at least one, or all, of;

[0 174] a, histologically proven carcinoma,

[0075)^' b. documented advanced or metastatic disease not suitable for complete surgical resection

[0076] c. Measurable lesions according to RECiS v l J criteria

10077] d. ECOG performance status 0 ~ 1

flTSj e. bone marrow reserves as evidenced by:

{0-079] « ANC≥ I .5 x 1 Q^v L without the use of hematopoietic growth .factor

[0080) * platelets > 100 x 10⁹ L

fO081] * hemoglobin > 9 g/dL (may be transfused to maintain or exceed this, level)

»82] f international Normalized Ratio (INK) <1 .5; aPTT<S .5 x UNL; EXEPT THAT: patients on full anticoagulation due to VTE must have an in-range 1NR (between 2 and 3).

(00831 §- adequate renal function as evidenced by:

[00841 * serum creatin ne: < i 50 pmol/l (0685] ·^» calculated creatinine clearance >5G.ml/rnin. (recommendation: to be calculated according to the MDRD formula)

[0086] h. total bilirubin <1 ,0 x upper normal limit (UL ^[). or

[0087] i. normal ECG, or ECG without any clinically significant findings.

j^'8088] la -various of the CRC embodiments, the patient does not have one or more of:

00S9j a. Active central nervous system metastases (e.g., indicated by clinical symptoms, cerebral edema, steroid requirement, or progressive disease)

jW90] b. Bone-only disease

[00911 c Clinically significant gastrointestinal disorder (other than CRC) including hepatic disorders, bleeding, inflammation, Gl obstruction, or diarrhea > grade 1

0092 d. Patients re ractory to irinotecan (i.e. prior exposure to irinotecan-based

^•therapy with progressive disease as best response)

[0993] e. Known DLT responses to irinotecan

[0094] f. Patients known -to be homozygous for UGT1 A l *28

[0095] g. History of any second malignancy in. the last 3 years; patients with prior history of ih-situ cancer or basal, or squamous cell skin cancer are eligible. Patients with a history of other malignancies^' are eligible if they have been -continuously disease-tree for at least

3 year

[0096] h. Prior exposure to M -398

[0097] i. Known hypersensitivity- to any of the components of M-398, or other liposomal products

[0098] j. Concurrent illnesses that would he a relative contraindication, to trial participation such as active cardiac or li ver disease

[0099] « Severe arterial thromboembolic events (myocardial infarction, unstable angina pectoris, stroke) less than 6 months before inclusion

[00100] · NY^'HA Class HI or IV congestive heart failure, ventricular arrhythmias

[00101]^' k. Active infection or an unexplained fever >38.5°C during screening visits or on the first scheduled day of dosing fat the discretion of the investigator,; patients with tumor fever may be enrolled}., which in the investigator^'s opinion might compromise the patient's rtici ation in the trial or affect the study outcome

[00102J k Prior chemotherap administered within 3 weeks, or within a time interval less than at least 5 half-lives of the agent, whichever is longer, prior to the first scheduled day of dosing in this study |β0103] m. Uncontrolled hypertension (defined as persistent systolic blood pressure > 150 mraHg and/or diastolic biood pressure >i00 rnmBg), or history of hypertensive crisis, or hypertensive encephalopathy

f 00164] n. Received radiation therapy in the last. 14 days

001.051 .o« Major surgery or traumatic injury within the las 28 days

jlOI.QS] p. Any other medical or social condition deemed by the Investigator to. be likely to interfere with a patient's ability to sign _.informed consent, cooperate and participate in the study, or interfere wi th the interpretation of the .results

[06107] q. Pregnant or breast feeding; females of child-bearing potential must test negative for pregnancy .at. the time, of enrollment based on a urine or serum pregnancy test. Both male and female -patients of reproductive potential must agree to use a reliable method of birth control, during the study and For3 months following the last dose of study drug,

jOOMSj r. Concomitant administration use with St John Worth,

001β9-| s. Concomitant administration of live attenuated virus vaccine such as yellow fever vaccine

Ϊ0ΘΠΘ] In other embodiments, the patient has a pancreatic cancer, e.g., an exocrine pancreatic cancer. In one such embodiment, the pancreatic cancer selected from the group consisting of acinar ceil carcinoma, adenocarcinoma, adenosquamous carcinoma, giant cell tumor, intraductal papil!ary-mueinous neoplasm (ΪΡ.ΜΝ), .mucinous cystadenocarcmoma, panereatcbiastoma, serous c stadenoearcinoma, and solid and pseudopapiilary tumors. A. patient treated may have recurrent or persistent pancreatic cancer following primary chemotherapy. The patient with pancreatic cancer may have had previousl been treated with and. failed at least one platinum- based chemotherapy regimen for management of primary or recurrent disease, e.g., a -chemotherapy regimen comprising oxalip latin, carbopiatin, cisplatm, or another organopiatinum compound. Alternately, the patient with, pancreatic cancer may have failed prior treatment with gemcitabine or become resistant to gemc-itabine.

leOilll VIII. Combination T re®?

[0011:2} According to this ^'invention, a drug in iipospmally encapsulated form and the same drug in unencapsulated and unmodified (free) .form are co-administered, to a patient in need thereof. Such co-administration improves the pharmacokinetic profile of the drug in the patient. The: patient may have cancer. Th drug may he irinotecan.

[0 113] In one embodiment, liposomal irinotecan is co-administered with free irinotecan to patients .having cancer, according to a particular clinical, dosage regimen, such as those described herein. In another embodiment, the patien ts have -unresectable cancer. In another embodiment, the patients have colon cancer. In another embodiment, the. patients have unresectable -colon cancer,

{MI 14] In another embodiment, liposomal irinotecan is co-administered to a cancer patient In combination with free irinotecan, 5-fluorouracH (5-FU), leucovorin, and (optionally) bevacizumab. Administration of each of these combinations is to a pattent having -cancer, according to a particular clinical dosage regimen, such as those described herein. The liposomal irinotecan ma be MM-398. The patient may have unresectable cancer. The patient may have CRC. The CRC may be unresectable. The patient may have metastatic cancer. The patient may have metastatic CRCr. The patient may have unresectable metastatic CRC,

[001151 Liposomal, irinotecan may be co-administered to patients having pancreatic cancer in combination with free irinotecan, S-Duorouraci!: (5-FU) and ieuc-Qvori.u, according to a particular clinical dosage regimen, such as those described herein.

[68116] In all of the foregoing embodiments, an exemplary liposomal irinotecan is MM- 398. Liposomal Irinotecan can be simultaneously or sequentially administered with free irinotecan. Alternatively, liposomal irinotecan can be e-o-adro mistered with free Irinotecan, 5- FU and leucovorin, wherein liposomal irinotecan, 5-FU and leucovorin are -each formulated for separate administration and are administered sequentially. For example, liposomal -and free_: Irinotecan can. he administered first followed by (e.g., immediately followed by) the

administration of the leucovorin and then 5-FU. in another embodiment, tree irinotecan and liposomal irinotecan are administered prior to 5-FlJ, leucovorin, and bevacizumab,. In another embodiment, bevacizumab is administered prior to liposomal irinotecan, free irinotecan, leucovorin, and 5-tluorouraciI.

[001 IT] Liposomal irinotecan, free irinotecan, 5-FU, leucovorin, and bevacizumab. may each be separately formulated for intravenous administration. In .an exemplary embodiment the patient is administered effective therapy comprising administration, of each of liposomal irinotecan. free irinotecan, 5-fIuorouracII (5-FU). and leucovorin. wherein the treatment comprises at least one cycle, wherein the cycle is a period of 2 weeks, and wherein for each cycle: (a) liposomal irinotecan is administered at a dose of 60 or 80 rog/m¾ (b) free Irinotecan is administered at a dose of 90 or 120 m /nr: (e) leucovorin Is administered at a dose of 400

and (d) 5-fluo.rouraeii is administered at a dose of 2400 rng/hr. The therapy may further comprise administration of bevacizumab at a dose of 5 mg kg or 10 rag/kg.

OI 18} Alternately, the patient is administered effective therapy comprising

administration of each of liposomal irinotecan and free irinotecan without administration of leucovorin or 5-FU, and optionall without administratio of bevacizumab, wherein the treatment comprises at least one cycle, wherein the cycle is a period of 2 weeks, and whe ein for each cycle: (a) liposomal irinotecan is administered at a dose of 60 or SO mg/nv⁴; (b) free irinotecan is administered at a dose of 90 or 120 mg/nr.

00119] DC Outcomes

[00120] Preferably, co-administration of liposomal irinotecan and free, irinotecan exhibits therapeutic synergy, or the c -administration of liposomal irinotecan, free irinotecan,. 5- fluorouracil (S-FU): and leucovorin exhibits therapeutic synergy, or the coadministration of liposomal irinotecan, free irinQteean, 5-f!uoroura.cii (5-FU), leucovorin and bevacizumab exhibits therapeutic synergy ,

{00121 Such coadministration of these combinations produces a additive o

.superadd itive effect on suppressing tumor growth, as compared to monotherapy wit iiposome- eneapsuiated irinotecan alone or treatment with the other preparations in the absence of liposomal irinotecan therapy. By "additive" is meant a result that is _.greater in extent than the best separate result achieved by monotherapy with each individual component, whil

"superadditive" is used to indicate a result that exceeds in extent the sum of such separate results, in one embodiment, the additive effect is measured as slowing or stopping of tumor growth. The additive effect can also be measured as, e.g., reduction in sfce of a tumor, reduction of tumor mitotic index, reduction in number of metastatic lesions ove time, increase in overall response rate, or increase In -median or overall ^'-survival or In the frequenc and/or duration of symptom- free or symptom -reduced periods.

(M122| One non -limiting example Of a measure by which effectiveness of a therapeutic treatment can be. quantified is by calculating the log 10 cell kill, which is determined according to the following equation:

100123] log! 0 cell kill - T C (days)/3.32 * I^'d

[00124] in which T C represents the delay in growth of the cells, which is the average time, in. days, for the tumors of the treated group (T) and the tumors of the control group (C) to have reached a predetermined value (1 g, or 10 ml.,, for ex-ample), and Td represents the time, in days necessary for the volume of the tumor to double in the control animals. When applying this measure,, a product is considered to be active if log 10 ceil kill is greater than or equal to 0.7 and a product is considered to be very active . if log 10 cell kill is greater than 2.8, Using this measure, a combinat ion, used, a its own maximum tolerated close, in which each of the constituents is present at a dose generally less than, or equal to its maximum tolerated dose, exhibits therapeutic synergy when the ioglO ceil kill is greater than the value of the log 10 cell kill of the bes constituent when it is admin istered alone, in an exemplary case, the log 10 cell kill of the combination exceeds the value -of the log 10 cell kill . of the best constituent of the combination- b at least 0.1 log cell kill at least. 0.5 log cell kill, or at least. 1.0 log cell kill

[09125] Responses to therapy may include:

[001261 Pathologic complete response (pCR): absence of invasive cancer in the breast and lymph nodes following primary systemic treatmen

[00127] Complete Response (CM.): Disappearance o f al l target lesions. An pathological lymph nodes (whether target or non-target) which has reduction in short axis to <Ϊ0 mm;

[00128] Partial Response (PR): At least 30% decrease in. the sum of dimensions of target lesions, taking as reference the baseline sum diameters;

[00129] Stable Disease (SD): Neither sufficient shrinkage to qualify for partial response, nor sufficient increase to qualify^' for progressive disease, taking as reference the. smallest sum diameters while on study; or

1001301 Meanwhile, non-CR on -PD denotes a persistence of one or more non-target lesion(s) and/or maintenanc of tumor marker level above the normal limits.

[0013IJ Progressive Disease (PD) denotes at least a 20% increase in the sum of dimensions of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on. study), I.n addition to th relative increase of 20%, the sum must also demonstrate an absolute increase, of 5 mm. ^'Fhe appearance of one or more new lesions is also considered progression;

00132] In exemplary outcomes,, patients treated according to the .methods disclosed herein may experience improvement in at least one sign of cancer.

[00133] In one embodiment the patient so treated exhibits pCR, CR, PR, or SD.

[00134] In another embodiment, the patient so treated exhibits tumor shrinkage and/or decrease in growth rate, i.e., suppression of tumor growth. In another embodiment tumor eel! proliferation is- reduced or inhibited, hi yet another embodiment, one or more of the following-can occur: the number of cancer cells can be reduced; tumor size can be reduced; cancer cell Infiltration into peripheral organs can be inhibited, retarded, slowed, or stopped; tumor metastasis can be slowed or inhibited; tumor growth can be inhibited; recurrence of tumor can be prevented or delayed; one or more of the symptoms associated with cancer can be relieved to some extent.

[00135] In other embodiments, such improvement is measured by a reduction in the q uantity and/or size of measurable tum or lesions.

[00136] In some embodiments, coadministration of effective amounts of liposomal irinotecan and tree irinotecan according to any of the methods provided herein produce at least one therapeutic effect selected -from the group consisting of reduction in size of a tumor, reduction in number of metastatic lesions .appearing over time, complete remission, partial remission, stable disease, increase in overall response rate, or a pathologic complete response. In some embodiments, the provided methods of treatment, produce a comparable clinical benefit rate (CB - CR+ PR+ SD > 6 months) better than that achieved by the same combinations of anti-cancer -agents administered without concomitant MM-398 administration., In other embodiments, the improvement of clinical benefit rate is about 20% 20%, 30%, 40%, 50%, 60 , 70%, 80% or more compared to the same combinations of anti-ca nc er agents administered without concomitant MM-398- administration.

100137] In other embodiments, co-administration of effective amounts of liposomal irinoiec.an, free notecan, 5-FlJ, leueovorin. and bevacizumah according to any of the methods provided herein produce at least one therapeutic effect selected from the group consisting of reduction in size of a tumor, reduction in size of a unresectable colorectal tumor, reduction in number of metastatic lesions appearing overtime, complete remission, partial remission, stable disease, increase in overall response rate, -or a. pathologic com lete response, in some embodiments, the provided methods of treatment produce a comparable clinical, benefit rate (CBR = CR+ PR÷ SD > 6 months) better than that achieved by the same combinations of anticancer agents administered without concomitant MM-398 administration, in other embodiments, the improvement of clinical benefit rate is about 20% 20%, 30%, 40%, 50%, 60%, 70%, 80% or more compared to the same combinations of anti-cancer agents administered without concomitant MM-398 administration.

[08138] The following examples are illustrative and should not be construed as limiting the- scope of this disclosure in any way; many variations and equivalents will become apparent to those skilled in the art upon reading the present disclosure,

[00139] EXAMPLES

[00140] Example 1 : MM-398 Pre-Clinieal. Pharmacokinetics

[00141] Pharmacokinetic properties of free irinotecan and MM-398 were evaluated In an

HT-29 colon subcutaneous xenograft model. Tumor bearing mice were injected with different doses of MM-398 (5, 1.0, 20mg fcg) an following a single injection, plasm -and tissue samples were collected at various time points (1, 4, 8, 24, 8. 72, 168hours). WPLC analysis was used to measure the levels of the irinotecan and its metabolite SN-38 in these samples. The PK profile of

MM-398 was compared with that of free irinotecan (at .10 and 4Qmg kg).

[001.42] Both irinotecan and SN-38 are cleared very rapidly (within 8 hours) from the plasma following free irinotecan administration. However, MM-398 clearance is considerably slower with a half-life of approximately 48 hours as shown in Figure 1 A ; as >90% of irinotecan is encapsulated throughout ^" the plasma, irinoteean levels: are reflective of MM-398

concentration. SN38 plasma exposure is also greater though Cm_.ax levels are reduced following MM-398 administration, suggesting the advantage of the irinoteean liposomal formulation in prolonging exposure and half-life (Figure IB). Both irinoteean and SN-38 accumulate in tissues for extended time (at least ! week after MM-398 administration). Also, the accumulation was observed to be dose-dependent (Figure 1€),

|8 i 43] Activation of irinoteean to SN38 by the Hver is the primary path tor SN38 tumoral accumulation, when free irinoteean is administered, in contrast, these, data suggest that accumulation of MM-398 in the tumor and subsequent liposome breakdown and local conversion of irinoteean t SN38 is responsible for the enhanced tumor exposure of SN38 when MM-398 is administered. Current research is focused on. identifying cell types located in the tumor responsible for liposomal breakdown and activation of MM-398.

[001 4] Example 2: A Phase 1 study of MM-398; plus irinoteean in unresectable advanced cancer,

[00145]^' Objectives

[00 6] The primary objective of this study is to determine the safety, f olerability and range of tolera ted combination doses, and to defi ne the recommended dose (RD) for furthe evaluation in a phase 11 study. 1) To. determine the safety, toicrability and range of tolerated combination dose. 2) To define the recommended dose (RD) for further evaluation in -a phase II study.

[06147! The secondary objectives of this study are: To describe the pharmacokinetics of MM-398 plus irinoteean combination therapy (group A). To describe the pharmacokinetics of MM-398 plus irinoteean. and LV/5-.FU combination therapy (group B), To determine the clinical activity of MM-398 plus irinoteean combination therapy (group A). To. determine the clinical activity of MM-398 plus irinoteean and LV/5-FU combination therapy (group B).

[00148] Exploratory objectives_. of this study are to evaluate the pharmacodynamic, response in colorectal tumors following combination therapy, correlations- between potential tissue and plasma serum pharmacodynafnjc markers (Tumor Associated Macrophages (TAM), tumor irinoteean, tumor SN-38, tumor SN38G levels, plasma cytokines, plasma apolipoproteins or other plasma components), and tumor response, -drug- clearance and safety.

[00149] Trial^' Design

[00150] This is a dose-escalation and therapeutic exploratory .phase I multi-center, open label study of MM-398 plus irinoteean patients with unresectable- advanced cancer.

[80151] This study will enroll approximately 6-36 patients In two groups.. [00152] « Group A, patients with unresectable advanced non-colorectal cancer who would receive MM-39S and free irinoteean every two weeks (q2w),

[00153] · Group B, patients with metastatic colorectal. -cancer who -would receive MM- 398 and tree irinoteean co-administered with bevacizumab 5mg kg_s leucovorih-400 rag/'n 2 h infusion and 5-Fluorouracil 2400 -mg m² 46-h infusion, every two weeks.

[00154] There are three periods to this study; 1) Screening Period (up to 28 days):

Patients undergo screening assessments to determine ^'the eligibilit for the study^'. 2} MM-398 treatment Period (CI Dl ntil intolerable toxicity and/or progression): Patients receive treatment every 2 weeks and undergo biopsies and other required assessments. 3} FetfQW-Hp Period ^•Patients are assessed 30 days after their last dose of MM-398 for .final safety assessments, and every 2 months thereafter for overall survival follow-up.

[00155] Dose-Limiting Toxicity-

[60156] Dose-limiting toxicities (DLT) are defined as any of the following events that are possibly, probably or definitely attributable to the combination, of MM-398 and irinotecan, and are considered to be dinicaHy significan DLTs for the purposes of dose-escalation are evaluated during a 28-day period following the first dose of the study treatment. This includes the two treatment cycles. Each treatment cycle is 2 weeks. Toxicities are graded and documented according the NCI CTCAE (v4.0).

[00157] oH-heniatoiogical dose-limiting toxicity is defined as:

[00158] & Any Grade 3 or Grade 4 non-hematological toxicity with, the specific exclusion of:

[001591 © Grade 3 nausea, vomitins, diarrhea- mucositis stamatitis that responds to maximal supportive treatments) within 3 days;

[00160] o Grade 3 liver enzyme elevation, including ALT/A T GGT^' that returns to Grade <1 or baseline prior to the time for the nex treatment cycle; and

[001.61] ø Grade 3 fever or infection

100162] « Allergic reactions that necessitate discontinuation of study drug.

[00163] Hematological .dose-limiting toxicity is defined as:

[00164] · Grade 4 neutropenia (absolute neutrophil eont. ANC) for > 7 days. Platelet count <10.000/mm^'3 on 2 separate days or requiring a platelet transfusion on 2 separate days within a 7 day period

[00165] · Toxicity that causes a delay of > 14 days between treatment cycles,

[0016.6] * Febrile neutropenia despite G-CSF secondary prophylaxis

[00167] Dose Escalatio and Definition of Maximum Tolerated Base

I S The objective of the dose escalation, is to define_., with a limited number of patients, the safety and toxicity ^'characteristics -of MM»3^'9S given with free irinotecan. Dose escalation will follow a 3*3 dose, escalation procedure as described in Table 4. Evaluation of safety data format least 3 patients who have completed 28 days of dosing on study is required prior to defining a new dose and starting the next cohort. After the last patient in each cohort completes the DLT evaluation period, the safety data, including labs, ail adverse events (AEs) and any other relevant data collected, is assessed, Dostng will proceed to the next level after agreement between the Investigators, Sponsor and Medical Monitor. Patients are enrolled in cohorts of 3 for each dose level. Dose escalation proceeds between each cohort and no intra- patient dose escalation is allowed. If none of the first 3 patients experiences DLT. then dose escalation proceeds for the next cohort of patients. If 1 of 3 patients develop DLT, the cohort is expanded to 6 patients, i f no more than I of the 6 patients experience DLT, then escalation to the next dose level occurs. If 2 of 3 or 2 of 6 patients develop DLT at a certain dose level, the dose escalation is withheld and the prior dose level is verified as^' maximum tolerated dose (MTD). A minimum of 6 evalnabk patients -are treated at the MTD dose level and no more than 1 of the 6 patients should experience DLT at this dose level. If the highest dose level is evaluated without a DLT in the initial. 3 patients, than an additional 3 patients are enrolled, if no more than 1. of 6 patients experience DLT at the highest dose level, than this is declared the MTD.

treated previously at that dose. I 2 of 3 Dose escalation is. stopped. This dose level is declared to have

exceeded the MID. Three (3) additional patients are entered at the (Text lowest dose level if only 3 patients were treated previously at that dose.

Highest dose level,

producing < 1 DLT out

of 6 patients

100170 The final MID after sequential M -398 and CPU ! dose escalations will be considered as the recommended dose for the Phase II study. Patients who experience a DLT are discontinued from the study. Patients who are non-com pliant with study procedures, or discontinue from the study during the DLT evaluation period for reasons other than toxicity, are replaced.

{00171} Efficacy

00172 ] Tumor responses are evaluated every 8 weeks after start of treatment. The modified Response Evaluation Criteria in Solid tumors (RECIST version 1.1 ; Eisenhauen, E. A., et l (2009% EJC 45(2), 22S-47) is for this study for objective tumor response assessment, including, confirmation; of response within 28 days. The best overall response is the best response recorded from the start of treatment until treatment failure, taking as reference for progressive disease the smallest measurements recorded since the treatment started. Survival is assessed from the date of randomization to the date of patient death, due to any cause, or to the last date the patient was known to be alive. Patients^' who were not reported as having died at the time of the analysis are censored using the date they were last known to be alive. PFS (progression-free survival) is the time from the date of first dose of study drug to the date of progressive disease (RECIST criteria) or death (any cause). Death is regarded as a progression event in those patients. Patients without documented objective progression at the time of the final analy sis are censored at the date of their last objective tumor assessment.

[0ø 173 } Patient, opulation

1001.74} Patients must fulfill ail of the following criteria to be eligible for the study.

[00175} Inclusion criteria:

[001.76} a. Age. 18 - 75 years

{00.177} b. Histologically proven carcinoma

£001 8} c. Documented advanced or metastatic disease not suitable for complete surgical resection $0179} d , Measurable lesions according to REC1ST v 1.1 criteria

[60180] s. ECOCs performance status 0 - I

£ Bone marrow reserves as evidenced by:

• ANC > 1.5 x 1 ⁽ffL without the use of hematopoietic growth factors [00183] * platelets > 100 x iOvL

[00184] * hemoglobin > 9 g/dL (may be transfused to maintain or exceed this level)

[001851 g. international Normalized Ratio (INR.) < 1.5: aPTT <i .5 x^'UNL;.

EXEMPTION: patients o ^'Mi anticoagulation due to V^'TE must have an in -range INR (usually between 2 and 3).

[00186] h. Adequate renal function as evidenced by:

[00187] « serum creatinine: < 150 μήκ>1/1

[00188] * calculated creatinine clearance > 50nil½in. (recommendation: to be calculated according to the MDRD formula)

[00189] i.. total bilirubin < 1.0 x upper normal limit f ULN)

[0.0190] j . Normal ECG or ECO without any clinically significant findings

[0001] k, Regular follow-up feasible. A registered patient must be treated and followed at the participating^, center.

[00192) l- Able to understand and sign an informed consent (or have a legal representative who is able to do so)

[80193] m. Registration, in a national health care system (CMC included for France).

[00194] Exclusion Criteria :

(00195) a. Active central nervous system metastases (indicated by clinical symptoms, cerebral edema, steroid requirement, or progressive disease)

[00196] b. Bone-only disease

[08197] c. Clinically significant gastrointestinal disorder including hepatic disorders, bleeding, inflammation. G I obstruction, or diarrhea > grade 1

[80198] d. Patients refractory to iriuotecan {i.e. prior exposure to irinotecan -based therapy with progressive disease as best response)

[00199] e. Known QLT responses to irinotecan

[00200] f. Patients known to be homozygous for UGTI A S. *28

[0020.1] g. History of any second malignancy in the last 3 years; patients with prior history of in-situ cancer or basal or squamous ceil skin cancer are eligible. Patients with a history of other malignancies are eligible if they have been .continuously disease-free for at least 3 years

[00202) h. Prior exposure to MM-398

|002Q3J i. Known hypersensitivity to any of the components of MM-398, or other .liposomal products

[00204] j. Concurrent illnesses thai would be a relative contraindication to trial participation, such as active cardiac or liver disease

[00205] #. Severe arterial .thromboembolic events (myocardial infarction, unstable angina pectoris, stroke) less than 6 months before inclusion

[00206] · NYHA Class HI or IV congestive heart failure, ventricular arrhythmias

[00207] k. Active infection or an unexplained fever > 38.5°C during screening visits or^' n the first scheduled, day of dosing (at the discretion of the investigator, patients with tumor fever may be enrolled), which in the investigator's opinion might compromise the patient's participation in the trial or affect the study outcome

[00208] 1. Prior chemotherapy administered within 3 weeks, or within a time interval less than at feast 5 half-lives of the agent, whichever is longer, prior to the .first scheduled day of dosing in this study

[00209] m. Uncontrolled hypertension (defined as persistent systolic blood pressure >150 rnmBg and/or diastolic blood pressure > 100 tnmHg), or history of hypertensive crisis, o hypertensive encephalopathy

[00210] o. Received radiation therapy in the last 14 days

[00211] o. Major surgery or traumatic injury within the last. 28 days

[00212] p.- Any other medical or social condition deemed by the investigator to be- likely to- interfere with a patient's ability to -sign informed consent, cooperate and participate. n the study, or interfere with the interpretation of the results

[00213} q. Pregnant or breast feeding; females of child-bearing potential must test negative for pregnancy at the time of enrollment based on a .urine or serum pregnancy test Both male and female patients of reproductive potential roust agree to use a reliable method of birth control, during the study and for 3 mouths following the last dose of study drug.

[00214] r. Concomitant administration use with St John Worth

(00215] s. Concomitant administration of live attenuated viru vaccine such as yellow fever vaccine

[00216] Stud Treatment Discontinuation (00 17] Patients may withdraw or be withdrawn from the study at any time -and for any reason. Some possible reasons for early withdrawal include, ^'but are not limited to, the following: Progressive neoplastic -disease. An adverse event which precludes further participation.

Development. of an intercurrent medical condition or need for concern iiant treatment mat precludes further participation. Noncompliance -with the protocol. Patient withdraws consent. In vestigator removes the patient from the trial in the best interest of the patient. Study

termination by the Sponsor. Use of prohibited concomitant medications. Lost to follow up.

[00218] All procedures and evaluations required by the 30 day follow u visit are completed when a patient is discontinued from treatment, and the patients should continue to be foliowed-up for overall survival. All patients who discontinue the trial as a result of an adverse event must be followed until resolution or stabilization of the adverse event,

[O02J ] Treatment Period

$0220] The treatment phase consists of 5 dose levels. A "3 ÷ 3" design is utilized.

Patients will be treated until disease progression or unacceptable toxicity. Each dose cohort starts with 3 patients. 0LT evaluation period is during- cycle 1 and 2 (28-days period).

Insotecan dose levels 60 or 80 rog/nr diluted in 250 mi NaOl 0.9%, 1 hour infusion,

MM-398 dose levels 90 or 120 rag/m' diluted in 250 m l dextrose 5%, .90 minute infusion. The MM-398 infusion time may he reduced to 1 hour starting with cycle 2 if no acute- infusion reaction has occurred in cycle 1. Group B. patients with metastatic colorectal cancer, will receive q2w treatment with Jeucovorin 400

4⁽>hr infusion and bevacizumab 5mg 30-90 minute infusion, in addition to irinotecan and MM-398.

[00221] Schedule and ^'Dose Modiikatkm.s

(00222] Specific dose modifications for irinotecan/ M- 8

{00223] Patients are discontinued from study-treatment if they:

[00224] · Experience a DLT

[00225] ® Experience any of the toxicities defined below that do not resolve to baseline within 1 days after the planned start of next treatment cycle

[00226] « Require more than one dose reduction

(00227] Patients who meet the above criteria are allowed to continue in the study if the patient is receiving clinical benefit. Once a dos has! been reduced, it cannot, be escalated back to the previous level if Grade 3 (> 3 days) or Grade 4 therapy-associated diarrhea Is experienced by a patient: despite maximal use of anfi-diarrheal medications, the dose of irinotecan/MM-398 is reduced to the next lower dose level as defined in stage 1 for subsequent cycles, if Grade 3 (> 3 days) or Grade 4 diarrhea is documented despite maxim l use of anti-diarrheai drugs, prophylactic, antibiotics, and the dose reductions, the patient comes off protocol therapy. Patients who have Grade 3 or 4 thrombocytopenia receive subsequent cycles at the next. lower dose level. Re-treatment at these lower doses is initiated when thrombocytopenia has normalized to Grade.2 or better. Patients who have Grade 4 neutropenia of > 7 days duration or febrile neutropenia, receive subsequent cycles at the next lower dose level and may recei ve prophylactic myeloid growth, factor treatment Retreatment at these lowe doses is initiated when the neutropenia has normalized to Grade 2 or better. For non-hematoiogical toxic ity, that meets the definition of a DLT, other than, those specifically listed above, subsequent cycle of therapy is administered at the next lower dose level

(09228] Management of ^'Infusion Reactions

00229 Therapy modifications for patients who develop infusional reactions to MM-398 follow procedures outlined in Table 5:

100230} Ta le 2: Therapy Modification After lafustoa Reactions to MM-398

without urticaria, allergy* equivalent), bronehodilators for bronchospasms,..and other related ede-ma iuig ioedeni , medications as medically indicated. Hospital admission is hypotension considered,

o Discon i I nue MM-398 treat m en i

Grade 4 o Stop infusion .immediately and remove the infusion tube

Anaphylaxis o Administer diphenhydramine hydrochloride 1 mg/kg (max

50mg) IV, dexamethasone 0.2 mg/kg (max l Omg) IV (or equivalent), and other anaphylaxis medications as indicated. Epinephrine or bronchodilators should be administered as indicated. Hospital admission for observation may be indicated o Discontinue MM-3 8 treatment

180231] ox .adaptation for S~flmreumcU [(Group B)

Type of Toxicity 5-FU C. Infusion. Doses (mg/m'/course)

NCI CTC Grade NCI CTC Grade

Hemoglobin, (any grade) none

Neutrophils Gr 3-4 and/or Platelets Gr .2-4 2000

Nausea and/or Vomiting Grade 4 despite 2000

p.re~m education

Diarrhea Grade - 3-4 2000

Stomatitis Grade 3-4 2000

Heart Grade 1 Stop treatment

Skin Grade 3 or 4 2000

Allergy Contact the medical coordinator for specific case

Neurocerebellar Stop treatment

Local Tolerance (any Grade) none

Alopecia (any Grade) none

Other Toxicity clearly drug related:

- Grade 1 and 2 none

- Grade 3 2000

- Grade 4 Stop i gme adaptation for ^mci^um k smM

10 2331 Dose, of bevacizumab will not be reduced nor escalated. If serious bevacizumab reiated toxicity, be vacfemnab will be suspended 'temporarily or definitively. Any grade 3 toxicity attributable ie Bevacizumab will require treatment with Bevacizumab to be modified or discontinued, if toxicity resolves to < grade 1 within 4 weeks, treatment will be restarted {on scheduled days). No dose reductions of Bevacizumab are permitted_.. Missed doses of

Bevacizumab and combination chemotherapy will not be made up. Any patient who develops any one of the following toxicities attributable to Bevacizumab should not receive: further Bevacizumab: Grade 4 toxicity; Grade 3 toxicity that does not resolve to grade 1 or less within 4 weeks; Arterial thromboembolic events; Gastrointestinal perforation. The schedule of study drug administration will be modified in the event of certain grades of adverse events, s summarized in the foil owin Table.

[«6234] Table 3; Dme Modification ofBe ciz mb

Event Action to Be Taken 1

Proteiauria * First eccarreisee of proteinuria:

Adjustment of Bevaeizumab administration for proteinuria will occur according to. the following guidelines:

o <2+ (dipstick): Administer Bevaeizumab as scheduled, NO additional evaluation is required.

o 2+ , 3* and 4+ proteinuria (dipstick)-: Administer Bevaeizumab as scheduled ^'and collect 24-hour urine to determine the total protein within 3 days prior to the next scheduled dose:

* 24-hour proteinuria 2g: Administer Bevaeizumab as scheduled. Repeat dipstick is required before each scheduled administration of Bevaeizumab.

* 24-hour proteinuria >2g: Bevaeizumab treatment should be withheld pending next 24 hour total protein.

·· Repeat 24-hour urine protein <2g: Administer Bevaeizumab as schedule. 24-hour protein should be further monitored prior to each administration of Bevaeizumab until k has decreased to <l.g 24-hour.

- Repeat 24-hour urine protein >2g: Bevaeizumab dose should be withheld until 24-hour protein has decreased to <2g. 24-hour protein should be further monitored prior to each administration of Bevaeizumab until it has decreased to <ig/24-hour.

Second and subsequent occurrence of < 3+ proteinuria (dipstick): Administer Bevaeizumab as scheduled and .no further 24-hour urine protein is requi ed.

Hypersensitivity

reaction

Hypersensitivity » Treat patient (antihistanunics, corticosteroids) j reaction attributable to

« Discontinue Bevaeizumab j ■Bevaeizumab grade 3 or

grade 4

Gastrointestinal * Discontinue Bevaeizumab

perforation

Gastrointestinal

perforation or

dehiscence

Hypertension j Patients should be- monitored for the development or worsening of hypertension via frequent blood pressure measurement. Daily home monitoring is encouraged. Blood pressure measurements should occu Actio to Be Taken

after the patient has been m a resting position for > 5 minutes. Repeat measurement of blood pressure for verification should b undertaken ^'if the initial reading is > 140 rnmHg systolic and/or > 90 rnmHg diastolic blood pressure,

• Grade 1 hypertension: Asymptomatic, transient (<24 hrs) increase by >20 rnmHg (diastolic} or to >150/100 mmHg if previously within normal range. Intervention not indicated,

« Grade 2 hypertension: Recurrent or persistent (>24 hr) or symptomatic increase by 20 rnmHg (diastolic) or Co >15Q/100 | rnmHg if previously within normal range. Monotherapy of anti-j hvpertensive -may be ^'indicated. Once controlled to <l50/10o l rnmHg, patients may continue Bevaektimab therapy. |

* Grade- 3 hypertension: Requiring more than one anti-hypertensive or more intensive therapy than previously. Bevacizumab should be withheld for persistent or symptomatic hypertension and should be permanently discontinued if BP is not controlled.

• Grade 4 hypertension: Occurrence of grade 4 hypertension should lead to permanent discontinuation of Bevacizu-mab. All doses of antihypertensive medicines should be recorded at ail visits.

Wouad. Healing Bevacizumab therap should not be initiated for at least 28 days Complications following major surgery or until the surgical wound is fully healed, hi patients who experience wound healing complications during j Bevacizumab- treatment, Bevacizumab should be withheld until the ! wound is fully healed, Bevacizumab therapy should be withheld for i elective surgery. j

00235J Concomitant ^'Therapy |O0236j All concurrent medical conditions and complications of the underlying

.malignancy are treated with discretion according to acceptable local standards of medical care. Patients receive analgesics, -antiemetics, antibiotics, anti-pyretics. and blood products as necessary. Although warfarin-type anticoagulant therapies are permitted,, careful monitoring of coagulation parameters is imperative, in order to avoid complications of any possible drug interactions. All .concomitant medications, including transfusions of blood products, are recorded on the appropriate case report form, Oexametbasone and a 5-HT3 blocker (e.g., ondansetron or granisetron) are administered to all patients as premedication unless

contraindicated for the individual patient. Antiemetics are prescribed as clinically indicated during the study period. Use of granulocyte colony-stimulating factors (G-CSF) is permitted to treat, patients: with, neutropenia or neutropenic fever. Prophylactic use of G-CSF Is permitted only in those patients who have had at least one episode of grade 3 or 4 neutropenia or neutropenic lever while receiving study therapy or have: had documented grade 3 or 4 neutropenia or neutropenic fever while receiving prior anii-neoplastie therapy. Acute diarrhea and abdominal cramps, developing_, during or -within 24 hours after MM-398 administration, can occur as past, of a cholinergic syndrome. The syndrome is treated with atropine. Prophylactic or therapeutic administration of atropine is considered in patients experiencing cholinergic symptoms during the study unless clinically contraindicated.

100237] Diarrhea can be debilitating and on. rare occasions is potentially life-threatening. Guidelines developed by an A SCO panel for treating chemotherapy-induced diarrhea have been published (Benson AB, et ah. (2004), I Clin. Oncol 2004: 22:2918-2926 and adler, S., et ah (1998), .1. Clin. Oncol. 1998; 16(9): 3169-3178). Suggested pharmacological approaches include: Oral loperamide administered as an initial 4-mg dose followed by 2-nig doses every 2 hours for irinotecan induced diarrhea; 2mg every 4 hours for 5-FU induced diarrhea. During the night, the patient can take 4mg every 4 hours for Irinotecan induced diarrhea. Continue until diarrhea-free for 12 hours. This dose and regimen is moderately effective. Do not exceed 16mg per day. f 00238| If loperamide fails to control diarrhea within 24hours of onset then the use of octreotide is considered, administered at doses ranging from 100 micrograms twice daily to 500 .micrograms three times daily, with a maximum tolerated dose of 2000 micrograms three times daily in a 5-day regimen. [00239 Antibiotics such as .-cetpodoxim .and eefbdme are considered for patients who develop Grade 3 or 4 gastrointestinal (Gl) toxicity following irmoieean→^'-SvlM-3.98 therapy [42.]. The antibiotic are started 5 days prior to the start of M-398 therapy only if the patient experienced Grade 3 or 4 colitis, dehydration, diarrhea, abdominal pain, weight loss or vomiting during prior therapy with MM-398, If it is not feasible. fo -start cetpodoxime or ceOxime 5 days prior to therapy with M -398, give at least ! full day of eefpodoxirrse or cefixi .e> prior to the start of MM-398 course. Patients are advised to drink water copiously throughout treatment (>2l/day).

[00240] Surgical excision of the lesions is allowed under the following conditions;

[00241] Pre v ious assessment of tumoral response at least after 4 cycles of treatmen (2 months).

[602 21 intent to achieve a complete surgical resection (R0), After R0 or Rl secondary surgery (complete resection), patients will be removed_, from the study. In ease of incomplete resection (R2), the patient remains in the study and should receive therapy according to treatment allocation..

[992431 Prok ibited therapy

[00244] The following drugs are noted in the irinotecan prescribing information as interacting with irinotecan: St. John's Wort. CYP3A4-inducing anticonvulsants (e.g., phcnytom,_. phenobarbital, and carhamazepme), ketoconazole, itraconazole, iroleandomycin, erythromycin,, diltiazem- and verapamil. Treatment with these agents and any other tha interac with, irinoteoan, is avoided wherever possible,

[00245] MM-398

[09246] MM-39S Is irinotecan (also known as CPT- 1 1 } encapsulated in a nanofiposomal drug delivery system in the form of the sucrose oetasdfate: salt of Irinotecan. it is supplied as sterile, single-use vials containing 9.5 ml, of M -398 at a concentration of 5 mg/ni^'L. The vials ^•contain a 0.5 m^'L excess to facilitate the withdrawal of the label amount iron^'s, each 10 niL vial. [00247] The labels carry required regulatory instructions. The frequenc at which the M-398 is supplied to each, individual center is adapted to the enrollment rate of the center and takes into consideration the expiry date of the MM-398, The MM-398 is shipped to the Hospital Pharmacist in accordance with local requirements. Upon receipt of MM-39S, the Pharmacist inventories the MM-398 and completes the shipping form. MM-398 must be stored in a .secured limited-access refrigeration at 2 to 8°C, with protection from light. Light protection is not required during infusion. MM-398 is not to be frozen. Responsible individuals should inspect vial contents for particulate matter before and alter they withdraw- the drug product from a vial into a syringe. The Hospital Pharmacist is responsible for the appropriate storage of the MM-398 at the study center. MM-398 must be diluted prior to administration. The diluted solution is physically and chemically stable for 6 hours at room temperature ;{ i 5-30°C ), but it is preferred to be stored at refrigerated tem eratures (2-8 "C), and protected from light. The diluted solution must not be frozen. Because of possible microbial contamination during dilution, it is advisable to use the- diluted solution within 24 hours if refrigerated (2-8°C}_; and -within 6 hours if kept at room temperature (15-30°€). MM-398 is administered by intravenous (IV) infusion over 90 minutes, at a dose of 60- J 00 mg/m² every two weeks. The first Cycle Day l is a fixed day;

subsequent doses are administered on the first day of each cycle. +/~ 2 days. Prior to

administration, the appropriate dose of MM-398 is diluted in 5% Dextrose Injection solution (D5.W) to a final volume of about 250mL. Care is taken not to use in-line filters or any diluents other than DS W. MM-398 is not mixed with other drugs prior- to infusion.

[00248] The actual dose of MM-398 io be administered is- determined by calculating the patient's body surface area at the beginning of each, cycle. A -Η·^'- 5% variance in the calculated total dose allows for ease of dose administration. MM-398 vials are single-use vials and unused portions of a vial are not stored for future use. The 90 minutes infusion period may be prolonged because -of acute infusion-associated reactions or any other clinical -needs. The infusion time can- be reduced to 1 hour from cycle 2 if no acute infusion reaction has occurred in cycle 1. A ll patients are pre-medicated prior to MM-398 infusion with standard doses of dexaroethasone and a 5-HT3 antagonist or other antt-emetic(s) according to standard institutional practices for irinotecan administration. Atropine may be prescribed prophy iaetleally for patients who experienced acute cholinergic: symptoms in previous cycles.

[00249] Free Mnot c n. {00250 irinoiecan HC1 is a well-known product, and available on the market as a sterile aqueous solution - see irinoieean HC1 (CAMPTOSA ®) U.S. Package Insert Irinoteean is administered in accordance with, standard procedures. For storage conditions one should follow the standard procedures for this compound. Other drugs should are not added to the infusion solution, Irinoteean Is adroinistered by intravenous (IV) in.fusi.on over 60 minutes -at a dose of 90- 150 gmr every two weeks. It is .recommended that patients receive premedication with antiemetic agents per standard institutional practices. Prophylactic or therapeutic administration of atropine Is considered in patients experiencing cholinergic symptoms.

1802511 Drug Infusion Extravasation

[00252] Should extravasation of the study drug at the infusion site occur, the steps below are to be followed: I . IV is discontinued. 2. Infiltration is treated according to institutional guidelines fo infiltration of a non-caustic agent,

106253] Study Assessments

(O0254J A medical history includes all pertinent prior medical conditions, surgeries or other medical procedures. Physical examination includes a careful assessment of all body systems, including the skin; central and peripheral nervous system; eyes, ears, nose and throat; respiratory and cardiovascular -systems; abdomen and extremities. Particular attention is made to areas of possible neoplastic involvement Vital signs include weight, resting blood pressure, pulse, respiratory rate and temperature. The Eastern cooperative oncology group (EC OG) Performance Score, is obtained by questioning the patient about their functional capabilities. A 12 lead ECG includes a description of the cardiac rate, rhythm, interval durations and an overall impression. Tumor response is evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, to establish disease progression by computed tomography or MRI. In addition, other radiographic or scintigraphic procedures (such as radionuclide bone scans), are; performed to assess sites, of neoplastic involvement The same method of assessment is used throughout the study. Investigators select target and non-target lesions in accordance with RECIST vl .1 guidelines (Eisenhauer, E. A., et al. (2009), EJC, 45(2), 228-47). Follow up measurements and response confirmation are in accordance with these guidelines. In the event the patient discontinues study treatment for reasons other than disease progression, a rumor assessment_, is completed as soon -as possible relative to the date of study termination, unless performed within the prior 4 weeks, to ensure disease _.progression is not present and to assess overall disease status. In such patients, this assessment occurs no later than the date of the 30 day follow up visit and future assessments continue to take place every 8 weeks during the follow-up. period until objective disease progression or commencement of new ami -neoplastic therapy.

[0025S;| Laboratory Procedures

[00256] A complete blood count includes a white blood count (WBC) and differential, hemoglobin, hematocrit and platelet count. Serum chemistry includes electrolytes (sodium, potassium, chloride and bicarbonate). BUN, serum creatinine, glucose, bilirubin, AST, ALT, alkaline phosphatase, lactate dehydrogenase, uric acid, total protein, albumin, calcium, magnesium and phosphate. Whole blood and plasma are collected to potentially identify factors that may correlate with tumor response and resistance to MM -398. Examples of potential analyses include cytokine levels (e.g. MCSPi, and IL-6), growth factor markers (e.g. IGF I and EGFR family receptors and iigands) and enzyme levels (e.g. MP9). UGTI A family polymorphism may also be tested for either or both of UGTI A 1*28 and UGTI A 1*6 allele status. The tumor marker CEA is analyzed by the local lab. A coagulation profile includes a partial thromboplastin time and an international normalized ratio. A urinalysis includes descriptions of color and clarity; pH specific gravity ; and analyses of blood, gl ucose, ketones and total protein; A microscopic examination of the urine, to include WBC, RBC, bacteria and casts is performed if the urinalysis is abnormal. A urine or serum pregnancy test is obtained for all. females of ehildbearing potential Exemp female patients will include those who have undergone a bilateral oophorectomy or hysterectomy or who are menopausal (defined as absence of a menstrual cycle for at least 12 consecutive months). Plasma samples are collected during Cycle 1 to determine the levels of MM-398/irihotecan. S -3-8 and SN.-38G (5N-38 glucuronide, a less active metabolite of SN-38. levels of which may vary with UGTI A 1 allele status). SN-3SG/SN- 38 concentration ratio may be calculated. This ratio may be useful to guide dose adjustments of irinotecan. The P time-points are outlined in the tables below. Optional iimepomts can be considered. Additional anaiytes which may impact the pharmacokinetics of MM-39S are also measured from these samples for further analysis on clearance-related issues, if they occur, sueh as iipid-binding proteins. |O0257| Table 4: Summary of P Tia-epoists ia Treatises! .and FoMo -Up Phases

$02381 Tissue Coltectton

{00259] A biopsy is performed (primary tumor or metastatic lesion), if clinically appropriate during the first treatment cycle (day 3), in order to isolate tumor tissue for further analysis of pharmacodynamics. A minimum of three passes is required to isolate tumor material for further analysis. If the tumor biopsy is not feasible during cycle i. both plasma sample and tumor biopsy may be performed during cycle 2 (day 3). Archived FFPE tumor blocks or unstained paraffin slides containing tumor tissue, prepared at the time of initial diagnosis and at the time of metastasis (if available), are -collected from each patient.

00260] Image Da Collection

[90261 ¾ CT imaging data is used for evaluation of ECIST vi .1 criteria. Volumetric analysis can be performed independently. Assessment of image density and CT heterogeneity or other advanced analysis strategies can be performed, as well.

{96262] Overall Survival Post Study Fottow-up $0263] Overall survival data is collected after a patient completes the 30 day follow-up visit even- 2 months (4·/- 1 week) from the date of the 30 day follow-up visit. All patients are foliowed-up until death or study closure, whichever occurs first

[80264] Adverse Event .Reporting

{06265] Adverse Event An adverse event is any untoward medical-occurrence in a patient administered a pharmaceutical product and which does not necessarily have to have a causa! relationship with this treatment. An adverse event can therefore be any unfavorable and

unintended sign, including abnormal laboratory findings, symptoms, or diseases temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product. Worsening of a medical condition for which the efficacy of the study drug is bein evaluated is considered an adverse event

00266] Unexpected Adverse Even!. An unexpected adverse event is one for which the nature or severity of the event is not consisten t with the applicable product information, e.g., the Investigator's Brochure,

|00267] Serious Adverse Event A serious adverse event (SAE) is an untoward medical occurrence that at any dose that: Results in death. Is life-threatening (an event in which the patient was at risk of death at the time of the event; it does not refer to an event which

hypothetically might have caused death if it were more severe). Requires in-patient

hospitalization or prolongation of existing hospitalization. Results in persistent or significant disability/incapacity. Is a congenital anomaly or birth defect. An SAE Is also any other important medical event thai may not be immediately life-threatening or result in death or hospitalization but may jeopardize the patient or may require intervention to prevent one of the other outcomes listed above. Examples of such events are intensive treatment in an emergency room for allergic bronchospasm; blood dyscrassas or convulsions that do not result in hospitalization; or

development of drug dependenc or drug abuse. The term "seve e- ' is often used to describe the Intensity (severity) of an event. The event itself may be of relatively minor medical significance (such as a severe headache). This is not the same as "serious", which is based on patient/event outcome or action criteria usually associated with events that pose a threat to a. patient's life or functioning.

100268] Documenting Advers Events Adverse event reporting begins on the date the patient provides Informed consent to participate in the study. Information Is elicited regarding the occurrence of adverse events through open-ended questioning of the patient, physical examination and revie of laboratory results. All adverse events, whether serious or not are- recorded in the source documents and the adverse event page of the case report form (except as noted below). All new events, as well as those that worsen in intensity or frequency relative to baseline, which ^'occur after first administration of study drug through 30 days following the last dose of study drug, are recorded. Adverse events are followed through resolution, where possible. Adverse events that are ongoing at the time of treatment discontinuation are followed through the 30 day follow up assessment. However, new adverse events related to MM-39S and/or irinoiecan must be reported any time the investigator becomes aware of such an event, even if this occurrence is more than 30 days after the last dose of study drug. Laboratory, vita! signs or BCG abnormalities are recorded as Adverse Events only if they are medically relevant; s mptomatic, requiring corrective treatment, leading to discontinuation and/or fulfilling a seriousness criterion.

[00269] information reported in the description of each adverse event includes:

[00270] · A medical diagnosis of the event (if a medical diagnosis cannot be determined, a description of each sign or symptom characterizing the even are recorded)

100271] · The date of onset of the event

[00272! ss The date of resolution of the event

(602731 ·· A determination of whether the event is serious or not

0 2?4| * Action taken: none; change in the study drug administration (e.g., temporary interruption in dosing)' drug treatment required; non-drug treatment required;

hospitalization or prolongation of hospitalization required (complete serious adverse event page)^; diagnostic procedure ^'performed; patient discontinued -from the study (complete Final Visit

Section of the case report form)

[00275] · Outcome: resolved without sequelae; resolved with sequelae; event, resolving; event ongoing; patient died (notify the Sponsor immediately, and complete the Serious Adverse Event page and the Final Visit section of the case report form)

{00276} Reporting Serious Adverse Events Any SAEs occurring during the screening period are reported only if they are believed to be related to a protocol procedure. Ail fatal or life-threatenin adverse events or adverse event of special interest are reported. Within 24 hours of the event, the Serious Adverse Event Form is faxed to the appropriate contact whether full information regarding the event is known or not. Additional follow-up is required if complete information is not known. Source documentation of ail examinations, diagnostic procedures, etc.. which were completed with respect to the event are included with the SAE form.

[00277] In case of accidental or intentional overdose of any study drug, even if asymptomatic or not fulfilling; a seriousness criterion, the overdose is to be reported immediately (within. 1 working day) using the: AE and SAE forms. Overdose will he defined as > .133% of planned dose.

[002.78] Determining t e Severity, mid Relaiedmss of Adverse Events Each adverse event is graded according to the NCI CTCAE Version 4.0(14 June 2010 v,4.03 reference), which may be found at http:/7evs.nci,nih.gov ftp i CTCAE AbouUsrml. For events not listed, in the CTCAE, severit is designated as mild, moderate, severe or life threatening or fatal which correspond to Grades 1, 2, 3, 4 and 5, respectively on the NCI CTCAE, with the following definitions: MM: an event not resulting in disability or incapacity and which resolves without intervention;

[Θ0279] Moderate: an event not resulting in disability or incapacity but which requires intervention; Severe: an event resulting in temporary disability or incapacity and which requires intervention; Life-threatening: an event In which the patient, was at risk of death at the time of the event; Fatal; an went that results in the death of the patient.

[00286] The. Investigator will attempt to determine If an adverse event is in some way related to the use of the study drug, This relationship is described as follows Usilikeiy: The event is clearly due to causes distinct from, the use of the study drug, such as a documente preexisting condition, the effect of a concomitant medication a new condition which, based on the pathophysiology of the condition, and the pharmacology of t he study drug, would be unlikely related to the use of the study drug; Possible: The event follows a reasonable temporal sequence from administration of the study drug and the event follows a known response pattern to the studv dr g BUT the event could have been produced bv an intercurrent medical condition which, based on the pathophysiology of the condition, and the pharmacology of the study drug, would be unlikely related to the use of the study drug or the event could be the effect of a concomitant medication; Probable: ^'The. event follows a reasonable temporal sequence from administration of the study drug and the event follow a known response pattern to the study drag AND the event cannot have been reasonably explained by an intercurrent medical condition^' which or the event cannot be the effect of a concomitant medication; Definite: The event follows a reasonable temporal sequence -from administration of .be study drug, the event follows a known response pattern to the study drug and based on the known pharmacology of the study ^'drug, the event is clearly related, to the effect of the study -drag; U known ; Based on the evidence available, causality cannot be ascribed.

100281] Statistical Ct side tkms

|00282] General Statistical Considerations The primary objective of this dose-escalation study is to assess the safety and toierabi!ity ofMM-398 in combination with, free irinotecan and to determine the recommended dose (RD) for further studies sing this combination, when administered in patients with unresectable advanced cancer. Descriptive statistics are utilized for safety, efficacy, and pharmacokinetic parameters. Categorical variables are summarized by frequency distributions (number and percen tages of patients) and continuous variables are summarized by descriptive statistics (mean. -standard deviation, median, minimum, maximum). Ail data are summarized by M -398 irinofecan dose cohorts. The study population for safety and efficacy analyses is defined as all patients enrolled in tbe study who receive at least a partial infusion of MM-39S. Patients who exit the study prior to receiving study medication or who withdraw in Cycle 1 for reasons unrelated to drag toxicity re replaced.

[06283] Deierminatiot! of Sample Size Dose Escalation Phase

(0628 ] Approximatel 5 dosin cohorts are evaluated. In this scenario, the minimum number of patients treated is 18 (5 cohorts x 3 ÷ 3 patients) and the maximum number of patients treated Is 30 (5 cohorts x 6 patients). The exact number of patients depends on the observed safety profile, which determines the number of patients per dose level, as well, as the number of dose escalations required to meet MTD. Escalation to the nest dose cohort depends on the background toxicity rate (i.e., probability of DLT at a given dose). The proposed plan for dose escalation provides at least 90% probability that dose escalation proceeds al doses associated with DLT probability of <10%. Table.9 shows the probability of escalation from cohort to cohort with various toxicity rates.

[06285] Table 8: Probabilities of Dose Escalation

(00286] Treatment Assignment ami Blinding This is a dose-escaiatiorL open-label study. Therefore, no randomization, or blinding procedures is performed. Sequential cohort of patients are treated at each dose with the dose escalation scheme described above.

[08287] Statistical Analysis Disposition of patients is presented by center and overal 1 per MM-398 containing dose cohorts as patients are entered, treated, .withdrawn and ©valuable for efficacy and for safety. Demographic characteristics of patients are summarized by MM-398 dose cohort using descriptive statistics. The tumor response achieved is assessed per REC1ST vi.L The overall response rate (CR.+P ), as well as the rates for the individual categories of response (i.e., CR, PR, SD, and PD), are estimated by the percent of patients achieving these criteria by dose cohort when possible and overall- he percent of patients who achieve clinical benefit of response (CR + PR + SD), the median duration of response, and the median progression- free survival are displayed per dose cohort and overall Response rate per treatment arm -are presented with corresponding 95% CI calculated using the binomial distribution.

Progression-free survival and overall surv val are estimated using the Kaplan and Meier method.

[09288] Anal^ysis of Safety and Adverse Events All patients who receive any amount of any of the study drugs- re included in the final -summaries and listings of safety data. Ail safety analyses are performed by dose level, treatment cycle and week, where appropriate, Summary tables present the number of patients observed with treatment-emergent adverse events and corresponding percentages by dose cohort. The denominator used to calculate incidence percentages consists of patients receiving at least one dose of MM-398 in that cohort. Within each summary table, the AEs are categorized by MedD A body system and preferred term. Additional subcategories are based on event intensity (severity graded according to CTCAE v4.0) and relationship to study drug. Emphasis in the analysis will be placed on AEs classified as dose limiting. Deaths and SAEs are tabulated on a per-patient basis. Frequencies of adverse events are also summarized by bod system and organs. Laboratory data is presented by dose cohort and visit. Abnormal laboratory values are assessed according to NCI CTCAE v4.0 where possible.

[60289] Other analyses Pharmacokinetic parameters are derived from blood PK samples and are analyzed using descriptive statistics, including the median, mean and 95% confidence intervals around parameter estimates by dose level All PK parameters include C_max,- T»&_x, AUG (area under the concentration curve), clearance, volume of distribution at steady state (Vd_ss). and the terminal elimination hal f-life. Estimation of the pharmacokinetic parameters is performed using standard non-compartmental methods. Spearman pair ise correlations are computed between the following measurements-: Tumor associated acrophage levels. Tumor irin.oteean levels. Tumor SN-38 and SN38G levels. Graphical and regression methods are used to explore potential relationships among correlated measurements. In addition, relationships between pharmacodynamics markers and efficacy response are evaluated in an exploratory manner. Analyses -of pharmacodynamics markers include all patients with available data.

[00290] Endnotes

[00291] While the invention has been described in connection with specific embodiments thereof, it will be understood that it is capable of further modifications and this application is intended to cover any variations, uses, or adaptations of the Invention following, in general, the principles of the invention and including such departures from the present disclosure that come within known or customary practice within the art to which the. invention pertains and may be applied to the essential features set forth herein. The disclosure of each and every US, international, or other patent or patent application or publication referred to herein is hereby incorporated herein by reference in its entirety.

Claims

What is claimed Is;

1. A method of treating a cancer in a patient, the method compr sing administering to the patient a therapeutically effective amount of an anti-cancer drug, wherein the therapeuticall effective amount is administered by coadministration to the patient of a) a first amount of the drug in a sustained releas injectable dosage form and h) a second amount of the drug in an immediate release injectable dosage form,.

2. A drug in a sustained release injectable dosage form for use in a first amount for coadministration in combination with a second amount of the drug in an immediate release injectable dosage form, wherein the first amount combined with the second amount equal a therapeutically effective amount of the drug,

3. The method of claim 1. or the drug in a sustained release injectable dosage form of claim 2, wherein the co-administration, yields an improved therapeutic index, improved

pharmacokinetic profile, or therapeutic, synergy, as compared to administration to matched patients of the first amount and the second amount as a combined amount, wherein the combined amount is in the sustained release injectable dosage form.

4. The method of claim 1 , or the drug; in a sustained release injectable dosage form of clai 2, wherein the sustained release and immediate release dosage forms are both comprised within a single- formulation and are thereby injected together, and wherein the second amount is at least

10% of the first amount.

5. The method of claim 1, or the drug in a sustained release injectable dosage form of claim 2, wherein the sustained release and immediate release dosage, forms of the drug are comprised within separate fbrmuiations and are mixed and injected together simultaneously,, or are injected separately, said separate injections being performed simultaneously or sequentially.

6. The method of claim 5 wherein, the sequential, administrations do not overlap and thereby do not include a period of simultaneous administration. 7^, A .method of treating a cancer in a patient the method comprising co-administering liposomal iiinotecan and free irmotecan to the patient, wherein the eo-adtn»«s$ering is carried oat in at least 1 cycle, wherein the cycle is a period of 2 weeks, and wherein for .each, cycle:

(a) liposomal irinotecan is administered, once at a dose of 60 or 80 mg/n ; and

(b) free notecan- is administered once at a dose of 90 or 120 ra¾/m².

S. The method of claim, 7 wherein the cancer is an unresectable cancer.

9. The method of claim 7 or claim 8„ wherein the cancer is colorectal cancer.

10. The method of any one of claims 7-9, further comprising coadministering !eucovorin and 5- fluorourapil to the patient once in each cycle.

11. The method of claim 10, wherein for each, cycle:

(c) ieucQvorin is administered at a. dose of 00 mg/n ;

(d) S-f!uorowracil is administered at a dose of 2400 mg/m"^'.

.12. The method of any one of claims 7-1 1 , further comprising .administering be vacizumab: to the patient.

13, The method of claim 1 . wherein the bevacizurnah is administered once per- cycle by infusion at a- dose, of 5 mg/kg or 1-0 rng kg.

14. The method of any one of claims 7-13. wherein the cancer is. metastatic colorectal cancer.

1.5. The .method of any one of claims 12-14, wherein bevacizumab is administered intravenously over 30-90 minutes.

16. The method of any one of claims 10-15, wherein S-fiuorouiadil is administered intravenously over 46 hours.

17. The method of any one of claims 10-16. wherein ieucovorin is administered intravenously over 2 hours.

18. A method of treating unresectable advanced colorectal cancer in a patient, the method comprising co-administering each of liposomal irinotecan and tree irinotecan to the patient, wherein the method comprises at least ! cycle, wherein the cycle is a period of 2 weeks, and wherein once for each cycle:

(a) the liposomal irinotecan is administered at a dose of 60 or 80 nig nr:

(b) the free irinotecan is administered at a dose of 90 or 120 mg/rrA

19. The method of claim 18, wherein the method further comprises co-administering each of leucovo in and 5-fluorouracil to the patient, wherein once for each cycle:

(c) leucovorin s administered at. a dose of 400 mg/m²;

(d) 5-fluerouraeii is administered at a dose of 2400 mg/mA

20. The method of claim 19, wherein the method further comprises co-administering

bevaeizumab to the patient, wherein once for each cycle;

(e) bevacixumah is administered at a dose of 5 mg/^'kg.

21. The method of anv one of the preceding claims, wherein the liposomal irinotecan is

administered intravenously over 90 minutes and the free irinotecan is administered intravenously over 60 minutes, optionally wherein, in each cycle, the free irinotecan is administered prior to the liposomal irinotecan,

22.. The method of anv one of claims 7-21 , wherein, in each cycle, the free irinotecan and the liposomal irinotecan are administered prior to the 5-fluorouracil.

23. The method of any one of claims 7-22. wherein, in each cycle, the leucovorin is

administered prior to administration of the 5-fluoroaracii.

24. The method of any one of claims 7-23, wherein, in each cy cle, the liposomal irinotecan and the free irinotecan are administered prior to the leucovorin, and the 5-fluorouracii.

25. The method of anv one of the preceding claims, wherein, in each cycle, the liposomal irinotecan is irinotecan sucrosefate liposome injection (irinotecan liposome injection M -398).

26. A formulation of liposomal irinotecan for co-adm i nistration with, free irinotecan, beyacizuraab, leucovorm, and 5-fluorouracil in af least one. cycle, wherein the cycle is a period of 2 weeks, and wherein, once in each cycle:

(a) liposomal irinotecan is. administered at a dose of 60 or 80 mg/m²;

(b) free -Irinotecan is administered at a dose of 90 or 120 mg/m²;

(c) leucovorm is administered at a dose of 400 mg/m²;

(d) 5~fl orouraci1 is administered at a dose of 2400 mg m'; and

'(e) ^'bevacizuraab is administered at a dose of 5 mg kg.

27. A formulation of liposomal irinotecan for co -administration with, free irinotecan, irs at least one cycle,, wherein the cycle is a period of 2 weeks, and wherein, once- in each cycle:

(a) liposomal irinotecan is administered at a dose of 60 or 80 mg/m^";

(b) free Irinotecan is administered at a dose of 90 or 120 mg/m^

28. The formulation of claim 19 or 20. wherein the liposomal irinotecan is administered

intravenously over 60 minutes or 90 minutes,

29. The formulation of any one of claims 26-28, wherein the free irinotecan -Is administered intravenously over 60 minutes.

30. Re ormulation of any one of claims 26 or ^'28-30, wherein the bevacizuraab is administered intravenously over 3-0-90 minutes.

31. The formulation of any one of claims 26 or 28-30, wherein the 5-ftuoroui¾eiI is administered intravenously over 46 hours,

32. The fbrmuia on of any one of claims 26 or 28-3 1 , wherein the leucovorin is administered intravenously over 2 hours.

33. The formulation of any one of claims 26-3 1 , wherein the liposomal formulation of irinotecan Is Irinotecan sucrosofate liposome injection (M -398).

34. A kit for treating a cancer in a human patient, the kit comprisin a first container holding a second container -and a. third container and._. (optionally) instructions, the second container comprising a dose of liposomal irinotecan the third container comprising a dose of fee irinotecan, and the instructions calling for co-administering the liposomal irinotecan and the free irinotecan to a cancer patient.

35. The method, drug or formulation of any of claims 1-2 or 4-34, wherein the co-administration results in an improved therapeutic index, or improved pharmacokinetics, or in therapeutic synergy.

36. A method of improving the pharmacokinetic profi le of a drug treatment, the method

comprising administering the drag enterallyor parenteral^' in doses separated by an interval of a day or more, or a week, or two weeks, or three weeks, or a month or more, in unencapsuiaied form, and co-administering the .same drug parenteral iy at the same ^'interval in a liposomal!}-' encapsulated injectable form, such that the pharmacokinetic profile is- improved in that the drug reaches ^'therapeutic levels, at a site of action faster than if administered only n the encapsulated form, and maintains therapeutic levels at the site of action longer t han if administered at the same intervals only in the unencapsulated form,

37. The method of claim 36, wherein the unencapsulated drug and the iiposomail encapsulated drug arc administered sequentially or simultaneously.

38. The method of claim 37, wherein the dru is an anti-cancer drug selected from a

topoisomerase 1 inhibitor, a topoisomerase If inhibitor, a raxane, a vinea alkaloid, a platinum salt, an alkylating agent, or an anti-metabolite.

39. The method of claim 38 wherein the topoisomerase I inhibitor is irinotecan, S -38 or

topotecan, the topoisomerase Π inhibitor is an anthracycl me, teniposide, or etoposide, the taxane is paelitaxel, doeetaxel, cabaxitaxei, or tesetaxei, the vinea alkaloid is vincristine, vinblastine, or vmore!bine. the platinum salt is oxalipiatin, cisplatin or earboplatin, the alkylating agent is bendamustme, busuifan, carraustine, chlormbucil, cyclophosphamide, ifosiamidc. lomustine, meehiorethantine, melphaiau. streptazoem, thiotepa, or uiamustine, and the anti-metabolite is 5-FU, capecitabine, eytarabine, gemcitabine, methotrexate, pem.eirex.ed, or tegafur ,

40. The method of claim 39, wherein the anthrac-ycline is doxorubicin., daunoruhiein, bleomycin, dact omycm, epinibicm, idarubictn, mitomycin, or mitoxantrone.

41. The method of any one of claims 36-40. wherein the- interval is two weeks.

42. The method of any one of claims 36-41, wherein the co-administration of the drug in

uneneapsuiaied form and of the same- drug in liposomal iy encapsulated form produces an improved therapeutic index, or improved ^' harmacokinetics, or therapeutic synergy.

43. A method of treating a -cancer in a. patient, the method comprising at least one cycle of coadministration of 1} a- chemotherapeutie agent that is a sustained release dosage form and 2) of the same chemotherapeutie agent that is an immediate release dosage form, wherein the coadministration of both, dosage forms provide an improved therapeutic index, or improved pharmacokinetics, or therapeutic synergy.

44. The method of claim 43 wherein the two dosage forms are both comprised -within a single formulation and are thereby injected together,

45. The method of ciaim 43 wherein the two dosage forms of the chemotherapeutie agent are comprised within separate formulations and are -mixed and injected together simultaneously or are injected -separately, -said separate injections being performed simultaneously or -sequentially.

46. The method of claim 45 wherein the ..sequential administrations do not overlap and thereby do not include. a period of simultaneous administration.

47. The method of any one of claims 39-46 wherein the chemotherapeutie agent is an alkylating agent, an anti-metabolite, an anti-microtubule agent, a topoisomerase inhibitor or a cytotoxic antibiotic.

48. The. method of claim 47 wherein the alkylating agent is a nitrogen mustard, a nitrosourea, a tetrazine, an aziridine, an organoplatinum agent, procarbazine or hexamethylmelamine.

49. The method of claim 47 wherein the anti-metabolite is an anti- folate, a fluoropyrimidine, a deoxynucleoside analogue, or a thiopurine.

50. The method of claim 47 wherein the anti-rnierotubuie agent is a taxane, a vlnea alkaloid or yinca alkaloid derivative,

51. The method of claim 47 wherein the topoisomerase inhibitor is a eamptoiheem.

topoisomerase 1 inhibitor or a topoisomerase !,i inhibitor.

52. The method of claim 54 wherein the caraptotheein topoisomerase 1 inhibitor is topotecan or irinotecan.

53. The method of claim 52 wherein the^■camptotheein. topoisomerase i inhibitor is irinotecan and the sustained release dosage form, is in a liposomal, byaUironate, or PEGylaied form, and the Immediate release dosage form is in the form of an irinoteca hydrochloride s lution or its analogs or derivatives.

54. The method of claim 53 wherein the sustained release dosage form is liposomal irinotecan sucrosofate and, for each cycle of co-administration:

(a) the liposomal Mnotecan sucrosofate is administered at a dose range between 60 and 100 mg/rrT and

(b) the irinotecan hydrochloride is administered at a dose range between 90 and 180 mg/ro\

55. The method of claim 54 com rising at least a second cycle, wherein the cycles are at. two week intervals.

56. The method of claim 54, further comprising coadministration of an effective amount of each of leucovorm (foHnic acid) and 5-flurouraciL.

57. The method of claim 47, further comprising co-administration of an effective amount of each of leucovorm and 5-tlurouraci!.

58. The method of claim 57, wherein, in each cycle of coadministration, the leucovorin is administered at a dose of 4.00 mg/m² and the 5-fhiorouraeiI is administered at a dose of 2400 mg/m'.

59. The method of any one of cl aims 36-58, the method further .comprising co-administering an effective amount of an ami-angiogeme agent to the patient.

60. The method of claim 59 wherei n the anti-angiogenic agent, is bevaeizumab,

61. The method of claim 60 -wherein the bevaeizumab is coadministered at a dose of 5 mg/kg Q2W or 10^' mg kg Q2w or 15· mg/kg Q3W.

62. The method of claim 38, wherei n the fopoisom.erase. 1 inhibitor is j.rinotecan and the liposom LI encapsulated irinqtecan is irinotecan sucrosofate liposome injection (MM-398),