Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/496—Non-condensed piperazines containing further heterocyclic rings, e.g. rifampin, thiothixene or sparfloxacin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/63—Compounds containing para-N-benzenesulfonyl-N-groups, e.g. sulfanilamide, p-nitrobenzenesulfonyl hydrazide
  • A61K31/635—Compounds containing para-N-benzenesulfonyl-N-groups, e.g. sulfanilamide, p-nitrobenzenesulfonyl hydrazide having a heterocyclic ring, e.g. sulfadiazine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K39/395—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum
  • A61K39/39533—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals
  • A61K39/3955—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals against proteinaceous materials, e.g. enzymes, hormones, lymphokines
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K51/00—Preparations containing radioactive substances for use in therapy or testing in vivo
  • A61K51/02—Preparations containing radioactive substances for use in therapy or testing in vivo characterised by the carrier, i.e. characterised by the agent or material covalently linked or complexing the radioactive nucleus
  • A61K51/04—Organic compounds
  • A61K51/08—Peptides, e.g. proteins, carriers being peptides, polyamino acids, proteins
  • A61K51/10—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody
  • A61K51/1027—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody against receptors, cell-surface antigens or cell-surface determinants
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K51/00—Preparations containing radioactive substances for use in therapy or testing in vivo
  • A61K51/02—Preparations containing radioactive substances for use in therapy or testing in vivo characterised by the carrier, i.e. characterised by the agent or material covalently linked or complexing the radioactive nucleus
  • A61K51/04—Organic compounds
  • A61K51/08—Peptides, e.g. proteins, carriers being peptides, polyamino acids, proteins
  • A61K51/10—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody
  • A61K51/1045—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody against animal or human tumor cells or tumor cell determinants
  • A61K51/1069—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody against animal or human tumor cells or tumor cell determinants the tumor cell being from blood cells, e.g. the cancer being a myeloma
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K51/00—Preparations containing radioactive substances for use in therapy or testing in vivo
  • A61K51/02—Preparations containing radioactive substances for use in therapy or testing in vivo characterised by the carrier, i.e. characterised by the agent or material covalently linked or complexing the radioactive nucleus
  • A61K51/04—Organic compounds
  • A61K51/08—Peptides, e.g. proteins, carriers being peptides, polyamino acids, proteins
  • A61K51/10—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody
  • A61K51/1093—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody conjugates with carriers being antibodies
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K51/00—Preparations containing radioactive substances for use in therapy or testing in vivo
  • A61K51/02—Preparations containing radioactive substances for use in therapy or testing in vivo characterised by the carrier, i.e. characterised by the agent or material covalently linked or complexing the radioactive nucleus
  • A61K51/04—Organic compounds
  • A61K51/08—Peptides, e.g. proteins, carriers being peptides, polyamino acids, proteins
  • A61K51/10—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody
  • A61K51/1093—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody conjugates with carriers being antibodies
  • A61K51/1096—Antibodies or immunoglobulins; Fragments thereof, the carrier being an antibody, an immunoglobulin or a fragment thereof, e.g. a camelised human single domain antibody or the Fc fragment of an antibody conjugates with carriers being antibodies radioimmunotoxins, i.e. conjugates being structurally as defined in A61K51/1093, and including a radioactive nucleus for use in radiotherapeutic applications
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P35/00—Antineoplastic agents
  • A61P35/02—Antineoplastic agents specific for leukemia
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/28—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
  • C07K16/2803—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against the immunoglobulin superfamily
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/545—Medicinal preparations containing antigens or antibodies characterised by the dose, timing or administration schedule
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/20—Immunoglobulins specific features characterized by taxonomic origin
  • C07K2317/24—Immunoglobulins specific features characterized by taxonomic origin containing regions, domains or residues from different species, e.g. chimeric, humanized or veneered

Definitions

• the present invention relates to treating a subject afflicted with cancer using a therapeutically effective regimen of a BCL-2 inhibitor in conjunction with an alpha-emitting isotope-labeled agent that targets cancer cells in the subject.
• BCL-2 inhibitors have potential for treating malignancies.
• One such BCL-2 inhibitor is venetoclax, a drug that has been approved for treating chronic lymphocytic leukemia (“CLL”) (1 ).
• CLL chronic lymphocytic leukemia
• Venetoclax binds to the BH3-binding groove of BCL-2, displacing pro-apoptotic proteins like BIM to initiate mitochondrial outer membrane permeabilization (“MOMP"), the release of cytochrome c, and caspase activation, ultimately resulting in programmed cancer cell death (i.e., apoptosis) (2).
• Apoptosis is a mechanism of cell death in cancer cells, in addition to necrosis and autophagy (3).
• venetoclax would facilitate programed cell death of cancer cells and thus improve cancer patient outcomes.
• apoptosis is a complex pathway. Cancer cells can develop various mechanisms to circumvent and/or abrogate a given treatment strategy intended to cause apoptotic death (4) (as presented in Figure 1 of that reference).
• X-linked XIAP can abrogate the blocking of BCL-2.
• XIAP is a well-characterized inhibitor of apoptosis proteins (lAPs) (5). Indeed, the majority of human cancers harbor high levels of lAPs such as XIAP (6).
• FIG. 7 Other possible mechanisms of circumventing the effect of BCL-2 inhibitors can be seen in Figure 7. These include blocking activation of caspase 8 to prevent the downstream activity of venetoclax on the BAX/BCL-2 axis. Also, stimulating or un-blocking one part of the apoptotic pathway may not be sufficient to cause apoptosis, as pro-apoptotic stimuli are still needed to trigger an apoptotic pathway (7), (8). Consequently, not all cancer cells respond to BCL-2 inhibitors. In one venetoclax trial, for example, the complete response rate (including complete responses with incomplete marrow recovery) was 7.5%, even though a majority of patients (79.4%) had some level of response to venetoclax (2). In addition, venetoclax has a significant myelosuppressive effect on neutrophils, with 40% of patients experiencing grade 3 and/or 4 neutropenia (2).
• Radiation is a recognized way to treat cancer. It is known that cellular effects of radiation include cell cycle arrest, mutation, apoptosis, necrosis and autophagy (9). Radiation-related mediators of cellular damage include: (i) direct LED (linear energy deposition); (ii) ROS (reactive oxygen species); and (iii) RNS (reactive nitrogen species) (9).
• DNA damage 9 (e.g., double-strand DNA breaks (most efficient), single- strand DNA breaks (less efficient, repairable), DNA base damage (least efficient, repairable), and DNA crosslinks);
• direct effects on the apoptotic cascade e.g., direct activation of caspases, and damage to lAPs
• bystander effects i.e., damage or killing of cells not directly damaged by radiation, which damage or killing occurs through mediation via gap junction communication and/or cytokines from target cells
• mice treated with a combination of venetoclax and 90 Y-based radioimmunotherapy had better survival rates compared to mice treated with either venetoclax or the radioimmunotherapy alone. Survival outcomes in xenografted mouse cohorts are shown in Figure 8.
• Xenografted mice had small tumor masses in Fred Hutchinson Cancer Research Center experiments. Diffuse large B-cell lymphoma ("DLBCL") tumor xenografts were treated at a volume of 50 mm 3 , implying a tumor diameter of under 0.5 cm. For DLBCL patients in an MD Anderson study, ⁇ 25% of patients had tumor diameters greater than 7 cm (13). In large xenografted tumors in rats, it was found that in tumors larger than 3.5 cm 3 , baseline hypoxia was greater than 80%, while tumors smaller than 2.5 cm 3 had baseline hypoxia of ⁇ 20% (14). Hypoxia confers resistance to irradiation by lowering the creation of ROS (15), (16), (17). High tumor burden with hypoxic areas in human disease would significantly abrogate beta radiation-induced ROS and RNS. Another such factor is the range of feasible dose levels. In mouse
• mice typically receive doses of drug weight per body weight that cannot be applied to humans.
• the mice were treated with doses of 800 Ci and 1 ,200 Ci per mouse (whereby 800 Ci was used in combination with venetoclax). Eight hundred Ci in a mouse would correspond to 3,000 mCi in an average human.
• Zevalin ® 90 Y-RIT, ibritumomab tiuxetan
• This invention provides a method for treating a subject afflicted with cancer, comprising administering to the subject (i) a BCL-2 inhibitor in conjunction with (ii) an alpha-emitting isotope-labeled agent that targets cancer cells in the subject, wherein the amounts of the BCL-2 inhibitor and labeled agent, when administered in conjunction with one another, are therapeutically effective.
• This invention also provides a method for treating a human subject afflicted with acute myeloid leukemia, comprising administering to the subject (i) venetoclax in conjunction with (ii) 225 Ac-labeled HuM195, wherein the amounts of venetoclax and 225 Ac-labeled HuM195, when administered in conjunction with one another, are therapeutically effective.
• This invention further provides a method for inducing the death of a cancer cell, comprising contacting the cell with (i) a BCL-2 inhibitor in conjunction with (ii) an alpha-emitting isotope-labeled agent that targets the cancer cell, wherein the amounts of BCL-2 inhibitor and labeled agent, when concurrently contacted with the cell, are effective to induce the cell's death.
• this invention also provides a method for inducing the death of an acute myeloid leukemic cell, comprising contacting the cell with (i) venetociax in conjunction with (ii) 225 Ac-labeled HuM195, wherein the amounts of venetociax and 225 Ac-labeled HuM195, when concurrently contacted with the cell, are effective to induce the cell's death.
• This figure shows a schematic diagram of the expression plasm ids for HuM195.
• the humanized VL and VH exons of HuM195 are flanked by Xbal sites.
• the VL exon was inserted into mammalian expression vector pVk, and the VH exon into pVgl (Co, et al., J. Immunol. 148: 1 149-1 154, 1992).
• This figure shows the complete sequence of the HuM195 light chain gene cloned in pVk between the Xbal and BamHI sites.
• the nucleotide number indicates its position in the plasmid pVk-HuM195.
• the VL and CK exons are translated in single letter code; the dot indicates the translation termination codon.
• the mature light chain begins at the double-underlined aspartic acid (D).
• the intron sequence is in italics.
• the polyA signal is underlined.
• This figure shows the complete sequence of the HuM195 heavy chain gene cloned in pVgl between the Xbal and BamHI sites.
• the nucleotide number indicates its position in the plasmid pVg1 -HuM195.
• the VH, CH1 , H, CH2 and CH3 exons are translated in single letter code; the dot indicates the translation termination codon.
• the mature heavy chain begins at the double- underlined glutamine (Q).
• the intron sequences are in italics.
• the polyA signal is underlined.
• This figure shows a dosing protocol for 225 Ac-Lintuzumab ( 225 Ac-HuM195) treatment of AML.
• This figure shows a schematic of apoptotic cell death and mechanisms of cancer cells resistance to apoptosis (modified from (4)).
• This figure shows a diagram of survival of xenografted mice treated with venetoclax alone, targeted beta radioimmunotherapy alone, and a
• This figure shows a comparison between beta and alpha radiation
• alpha radiation is significantly more potent than beta radiation ( ⁇ 700 times); causes more dsDNA breaks than beta radiation; does not depend on tissue oxygenation and the cell division phase; and can overcome cellular resistance to beta and gamma radiation and cytotoxic chemotherapy.
• This invention provides methods for treating a subject afflicted with cancer. These methods comprise administering to the subject two types of agents in conjunction with one another.
• the first type of agent is a BCL-2 inhibitor such as venetoclax.
• the second type is an alpha-emitting isotope-labeled agent, such as 225 Ac-labeled HuM195, that targets cancer cells in the subject.
• administer means to deliver the agent to a subject's body via any known method.
• Specific modes of administration include, without limitation, intravenous, oral, sublingual, transdermal, subcutaneous, intraperitoneal, intrathecal and intra-tumoral administration.
• injectable drug delivery systems include solutions, suspensions, gels, microspheres and polymeric injectables, and can comprise excipients such as solubility-altering agents (e.g., ethanol, propylene glycol and sucrose) and polymers (e.g., polycaprylactones and PLGA's).
• solubility-altering agents e.g., ethanol, propylene glycol and sucrose
• polymers e.g., polycaprylactones and PLGA's.
• agent whether in reference to a BCL-2 inhibitor or an alpha-emitting isotope-labeled agent, can be any type of compound or composition useful for such purpose.
• agents include, without limitation, antibodies, other protein-based drugs, peptides, nucleic acids, carbohydrates and small molecules drugs.
• alpha-emitting isotope includes, without limitation, 225 Ac, 213 Bi and 213 Po.
• Methods for affixing an alpha-emitting isotope to an antibody i.e., “labeling" an antibody with an alpha-emitting isotope are well known.
• the term "antibody” includes, without limitation, (a) an immunoglobulin molecule comprising two heavy chains and two light chains and which recognizes an antigen; (b) polyclonal and monoclonal immunoglobulin molecules; (c) monovalent and divalent fragments thereof, and (d) bi-specific forms thereof.
• Immunoglobulin molecules may derive from any of the commonly known classes, including but not limited to IgA, secretory IgA, IgG and IgM.
• IgG subclasses are also well known to those in the art and include, but are not limited to, human lgG1 , lgG2, lgG3 and lgG4.
• Antibodies can be both naturally occurring and non-naturally occurring.
• antibodies include chimeric antibodies, wholly synthetic antibodies, single chain antibodies, and fragments thereof.
• Antibodies may be human, humanized or nonhuman.
• an "anti-CD33 antibody” is an antibody that binds to any available epitope of CD33. In one embodiment, the anti-CD33 antibody binds to the epitope recognized by the antibody HuM195.
• the term “burden”, when used in connection with a cancerous cell, means quantity. So, a cancerous cell “burden” means the quantity of cancerous cells. Cancerous cells have a burden with respect to their tissue of origin (i.e., the primary site of disease), such as the "bone marrow blast burden” in the case of AML. Cancerous cells also have a burden with respect to one or more tissues other than those of origin, such as the blast burden in blood, liver and spleen in the case of AML.
• peripheral burden relates to such cells.
• the peripheral burden of cancerous cells such as blasts in the case of AML
• the "peripheral blast burden” can be measured as the total blast population outside of the bone marrow, or the total blast population of the blood, spleen and liver combined, or simply the blast population of the blood as measured in cells per unit volume.
• peripheral cancerous cell burden e.g., peripheral blast burden
• the term “peripheral cancerous cell burden” refers to the cancerous cell population of the blood as measured in cells per unit volume (e.g., cells/ ⁇ ). This blood- based measurement is a useful proxy for the more cumbersome
• a peripheral cancerous cell burden in a subject is "high” if, when the subject is administered an agent (e.g., an antibody) targeting a hematologic malignancy-associated antigen at the maximum safe dose, the agent does not reach the primary site of disease in a sufficient amount to bind to more than 90% of its target antigens at that site.
• a peripheral cancerous cell burden in a subject is "low” if, when the subject is administered an agent (e.g., an antibody) targeting a hematologic malignancy-associated antigen at the maximum safe dose, the agent reaches the primary site of disease in a sufficient amount to bind to more than 90% of its target antigens at that site.
• examples of low peripheral blast burden are those yielding blood blast burdens at or below 1 ,000 blast cells/ ⁇ , at or below 500 blast cells/ ⁇ , at or below 400 blast cells/ ⁇ , at or below 300 blast cells/ ⁇ , at or below 200 blast cells/ ⁇ , at or below 100 blast cells/ ⁇ , and at or below 50 blast cells/ ⁇ .
• a “hematologic malignancy”, also known as a blood cancer, is a cancer that originates in blood-forming tissue, such as the bone marrow or other cells of the immune system.
• Hematologic malignancies include, without limitation, leukemias (such as AML, acute prornye!ocytic leukemia, acute lymphoblastic leukemia, acute mixed lineage leukemia, chronic myeloid leukemia, chronic lymphocytic leukemia, hairy ceil leukemia and large granular lymphocytic leukemia), myeiodysplastic syndrome (MDS), myeloproliferative disorders (polycythemia vera, essential thrombocytosis, primary myelofibrosis and chronic myeloid leukemia), lymphomas, multiple myeloma, and MGUS and similar disorders.
• leukemias such as AML, acute prornye!ocytic leukemia, acute lymphoblastic leukemia, acute mixed lineage leuk
• a "hematologic malignancy-associated antigen” can be, for example, a protein and/or carbohydrate marker found exclusively or predominantly on the surface of a cancer cell associated with that particular malignancy.
• hematologic malignancy-associated antigens include, without limitation, CD20, CD33, CD38, CD45, CD52, CD123 and CD319.
• the antibody "HuM195” also known as lintuzumab) is known, as are methods of making it.
• methods of labeling HuM195 with 225 Ac are known. These methods are exemplified, for example, in Scheinberg, et al., U.S.
• administering to a subject a BCL-2 inhibitor "in conjunction with" an alpha-emitting isotope-labeled agent that targets cancer cells in the subject means administering the BCL-2 inhibitor before, during or after administration of the labeled agent.
• This administration includes, without limitation, the following scenarios: (i) the BCL-2 inhibitor is administered first (e.g., orally once per day for 21 days, 28 days, 35 days, 42 days, 49 days, or a longer period during which the cancer being treated does not progress and during which the BCL-2 inhibitor does not cause unacceptable toxicity), and the labeled agent is administered second (e.g., intravenously in a single dose or a plurality of doses over a period of weeks); (ii) the BCL-2 inhibitor is administered concurrently with the labeled agent (e.g., the BCL-2 inhibitor is administered orally once per day for n days, and the labeled agent is administered intravenously in a single dose on one of days 2 through n-1 of the BCL-2 inhibitor regimen); (iii) the BCL-2 inhibitor is administered concurrently with the labeled agent (e.g., the BCL-2 inhibitor is administered orally for a duration of greater than one month (e.g., orally once per day for 35 days, 42 days, 49
• the labeled agent is administered first (e.g., intravenously in a single dose or a plurality of doses over a period of weeks), and the BCL-2 inhibitor is administered second (e.g., orally once per day for 21 days, 28 days, 35 days, 42 days, 49 days, or a longer period during which the cancer being treated does not progress and during which the BCL-2 inhibitor does not cause unacceptable toxicity). Additional permutations are provided below in the Examples section.
• the term "subject" includes, without limitation, a mammal such as a human, a non-human primate, a dog, a cat, a horse, a sheep, a goat, a cow, a rabbit, a pig, a rat and a mouse.
• the subject can be of any age.
• the subject can be 60 years or older, 65 or older, 70 or older, 75 or older, 80 or older, 85 or older, or 90 or older.
• the subject can be 50 years or younger, 45 or younger, 40 or younger, 35 or younger, 30 or younger, 25 or younger, or 20 or younger.
• the subject can be newly diagnosed, or relapsed and/or refractory, or in remission.
• a "sub-saturating dose" of an agent targeting an antigen (e.g., CD33) or marker (e.g., BCL-2) is one that introduces into the subject's body fewer target antigen-binding sites (e.g., Fab's) than there are target antigens, or fewer target marker-binding sites (e.g., venetoclax molecules) than there are target markers, as applicable.
• target antigen-binding sites e.g., Fab's
• target marker-binding sites e.g., venetoclax molecules
• a sub-saturating dose of an agent targeting a hematologic malignancy-associated antigen is one where the ratio of target antigen- binding sites to target antigens is less than or equal to 9: 10. In another embodiment, the ratio of target antigen-binding sites to target antigens is less than or equal to 1 :2, less than or equal to 1 :5, less than or equal to 1 : 10, less than or equal to 1 :20, or less than or equal to 1 : 100.
• a sub-saturating dose is one that introduces into the subject's body fewer BCL-2-binding sites than there are BCL-2 proteins.
• a sub-saturating dose of a BCL-2 inhibitor is one where the ratio of inhibitor to BCL-2 protein is less than or equal to 9: 10.
• the ratio of target antigen-binding sites to target antigens is less than or equal to 1 :2, less than or equal to 1 :5, less than or equal to 1 : 10, less than or equal to 1 :20, or less than or equal to 1 : 100.
• a "sub-saturating dose" of a BCL-2 inhibitor is a dose lower than the inhibitor's maximum approved dose in humans (e.g., below 400 mg per day, below 300 mg per day, below 200 mg per day, below 100 mg per day, below 50 mg per day, or below 10 mg per day).
• a sub-saturating dose of an agent targeting a hematologic malignancy-associated antigen is one where the ratio of total (i.e., labeled and unlabeled) target antigen-binding sites to target antigens is less than or equal to 9: 10 (and can be less than or equal to 1 :2, less than or equal to 1 :5, less than or equal to 1 : 10, less than or equal to 1 :20, or less than or equal to 1 : 100).
• a sub-saturating dose of an agent targeting a hematologic malignancy-associated antigen is one where the ratio of labeled target antigen-binding sites to target antigens is less than or equal to 9: 10 (and can be less than or equal to 1 :2, less than or equal to 1 :5, less than or equal to 1 : 10, less than or equal to 1 :20, or less than or equal to 1 : 100).
• Sub-saturating doses of labeled agent used in connection with this invention include, for example, a single administration, and two or more administrations (i.e., fractions).
• the amount administered in each dose can be measured, for example, by labeled radiation activity (e.g., pCi/kg) or antibody weight (e.g., g/kg or pg/m 2 ).
• human dosing regimens include the following, without limitation: (i) 2 x ⁇ 0.5 pCi/kg, 2 x 0.5 Ci/kg, 2 x 1 .0 pCi/kg, 2 x 1 .5 pCi/kg, or 2 x 2.0 pCi/kg, where the fractions are administered one week apart; (ii) ⁇ 0.5 pCi/kg, or from 0.5 Ci/kg to 10 Ci/kg; (iii) 2 x ⁇ 7.5 pg/kg, 2 x 7.5 pg/kg, 2 x 10 pg/kg, or 2 x 12.5 pg/kg, where the fractions are administered one week apart; or (iv) ⁇ 15 pg/kg, or from 15 g/kg to 50 g/kg.
• treating a subject afflicted with a disorder shall include, without limitation, (i) slowing, stopping or reversing the disorder's progression,
• treating a subject afflicted with a disorder means (i) reversing the disorder's progression, ideally to the point of eliminating the disorder, and/or (ii) reversing the progression of the disorder's symptoms, ideally to the point of eliminating the symptoms, and/or (iii) reducing or eliminating the likelihood of relapse (i.e., consolidation, which is a common goal of post- remission therapy for AML and, ideally, results in the destruction of any remaining leukemia cells).
• the treatment of hematologic malignancy can be measured according to a number of clinical endpoints. These include, without limitation, survival time (such as weeks, months or years of improved survival time, e.g., one, two or more months' of additional survival time), and response status (such as complete remission (CR), complete remission with incomplete platelet recovery (CRp), complete remission with incomplete peripheral blood recovery (CRi), morphologic leukemia-free state (MLFS) and partial remission (PR)).
• survival time such as weeks, months or years of improved survival time, e.g., one, two or more months' of additional survival time
• response status such as complete remission (CR), complete remission with incomplete platelet recovery (CRp), complete remission with incomplete peripheral blood recovery (CRi), morphologic leukemia-free state (MLFS) and partial remission (PR)).
• treatment of hematologic malignancy can be measured in terms of remission. Included here are the following non-limiting examples.
• CRi Morphologic complete remission with incomplete blood count recovery
• ANC may be ⁇ 1 ,000/mcl and/or platelet count ⁇ 100,000/mcl.
• PR Partial remission
• ANC > 1 ,000/mcl, platelet count > 100,000/mcl, and at least a 50% decrease in the percentage of marrow aspirate blasts to 5-25%, or marrow blasts ⁇ 5% with persistent Auer rods.
• This invention employs the use of alpha particles. These particles induce apoptosis in target cells, e.g., leukemic cells (10), (19).
• Alpha-emitters and beta-emitters induce apoptosis with different efficiencies at comparable activities in leukemic cells (10).
• Alpha particles can overcome doxorubicin- resistance, CD95-resistance, and radio-resistance to beta-irradiation and gamma-irradiation in leukemic cells (10).
• the particles induce apoptosis via: (i) double-strand DNA breaks (20), (21 ); (ii) activation of caspases; (iii) the fact that [ 213 Bi]anti-CD45 activates caspases 2, 3, 8 and 9 through the
• this invention provides a first therapeutic method.
• This first method is for treating a subject afflicted with cancer, comprising administering to the subject (i) a BCL-2 inhibitor in conjunction with (ii) an alpha-emitting isotope-labeled agent that targets cancer cells in the subject, wherein the amounts of the BCL-2 inhibitor and labeled agent, when administered in conjunction with one another, are therapeutically effective.
• This invention also provides a second therapeutic method.
• This second method is for treating a human subject afflicted with acute myeloid leukemia, comprising administering to the subject (i) venetoclax in conjunction with (ii) 225 Ac-labeled HuM195, wherein the amounts of venetoclax and 225 Ac-labeled HuM195, when administered in conjunction with one another, are
• the subject is human.
• the cancer is a hematologic malignancy, and preferably is a leukemia such as acute myeloid leukemia.
• the BCL-2 inhibitor is venetoclax.
• the alpha-emitting isotope-labeled agent is an anti-CD33 antibody labeled with an alpha-emitting isotope, ideally ⁇ Ac- labeled HuM195.
• the BCL-2 inhibitor, the labeled agent, or both are preferably administered (i) in sub-saturating doses, and/or (ii) in doses that are less than (and/or shorter duration than) those presently prescribed on their respective labels.
• the subject's peripheral blast burden is preferably low, and the methods preferably do not cause unacceptable levels of neutropenia.
• This invention provides a third method.
• This third method is for inducing the death of a cancer cell, comprising contacting the cell with (i) a BCL-2 inhibitor in conjunction with (ii) an alpha-emitting isotope-labeled agent that targets the cancer cell, wherein the amounts of BCL-2 inhibitor and labeled agent, when concurrently contacted with the cell, are effective to induce the cell's death.
• the cancer cell is a human cancer cell.
• the cancer cell is a hematologic cell, and preferably is a leukemic cell such as an acute myeloid leukemic cell.
• the BCL-2 inhibitor is venetoclax.
• the alpha-emitting isotope-labeled agent is an anti- CD33 antibody labeled with an alpha-emitting isotope, ideally 225 Ac-labeled HuM195.
• This invention also provides a fourth method.
• This fourth method is for inducing the death of an acute myeloid leukemic cell, comprising contacting the cell with (i) venetoclax in conjunction with (ii) 225 Ac-labeled HuM195, wherein the amounts of venetoclax and 225 Ac-labeled HuM195, when concurrently contacted with the cell, are effective to induce the cell's death.
• this invention provides two articles of manufacture.
• the first article comprises (i) a BCL-2 inhibitor (e.g., venetociax) and (ii) a label instructing the user (e.g., the patient or healthcare provider) to treat a subject afflicted with cancer (e.g., acute myeloid leukemia) by administering the BCL-2 inhibitor to the subject in conjunction with an alpha-emitting isotope-labeled agent that targets cancer cells in the subject (e.g., 225 Ac-labeled HuM195), wherein the amounts of the BCL-2 inhibitor and labeled agent, when administered in conjunction with one another, are therapeutically effective.
• the second article comprises (i) an alpha-emitting isotope-labeled agent that targets cancer cells (e.g.
• a label instructing the user to treat a subject afflicted with cancer e.g., acute myeloid leukemia
• a subject afflicted with cancer e.g., acute myeloid leukemia
• a BCL-2 inhibitor e.g., venetociax
• a PRIT-based method comprises the steps of (i) administering a monoclonal antibody labeled with a marker (e.g., streptavidin), (ii) then administering a suitable clearing agent (e.g., a biotin galactose clearing agent), and (iii) administering an alpha-emitting isotope-labeled agent that specifically binds to the marker (e.g., 225 Ac-labeled biotin).
• a marker e.g., streptavidin
• a suitable clearing agent e.g., a biotin galactose clearing agent
• an alpha-emitting isotope-labeled agent that specifically binds to the marker (e.g., 225 Ac-labeled biotin).
• 225 Ac-Lintuzumab includes three key components; humanized monoclonal antibody HuM195 (generic name, lintuzumab), the alpha-emitting radioisotope 225 Ac, and the bi-functional chelate 2-(p-isothiocyanatobenzyl)-1 ,4,7, 10- tetraazacyclododecane-1 ,4,7, 10-tetraacetic acid (p-SCN-Bn-DOTA).
• HuM195 is radiolabeled using the bi-functional chelate p- SCN-Bn-DOTA that binds to 225 Ac and that is covalently attached to the IgG via a lysine residue on the antibody.
• Example 2 - p-SCN-Bn-DOTA DOTA, 2-(4-lsothiocyanatobenzyl)-1 ,4,7, 10-tetraazacyclododecane tetraacetic acid (Macrocyclics item code B205-GMP) is synthesized by a multi-step organic synthesis that is fully described in U.S. Patent No. 4,923,985.
• the procedure involves radiolabeling the bi-functional chelate, p- SCN-Bn-DOTA, with the radioisotope 225 Ac, followed by binding of the radiolabeled p-SCN-Bn-DOTA to the antibody (HuM195).
• the construct, 225 Ac-p-SCN-Bn-DOTA-HuM195 is purified using 10 DG size exclusion chromatography and eluted with 1 % human serum albumin (HSA).
• HSA human serum albumin
• the resulting drug product, Ac 225 -Lintuzumab is then passed through a 0.2 pm sterilizing filter.
• the 225 Ac is assayed to confirm the level of activity and is reconstituted to the desired activity concentration with hydrochloric acid.
• a vial of lyophilized p-SCN-Bn-DOTA is reconstituted with metal-free water to a concentration of 10 mg/mL.
• 0.02 ml of ascorbic acid solution (150 mg/mL) and 0.05 ml of reconstituted p-SCN-Bn-DOTA are added and the pH adjusted to between 5 and 5.5 with 2M
• TMAA tetramethylammonium acetate
• the labeling efficiency of the 225 Ac-p-SCN-Bn-DOTA is greater than 95%.
• the final product is purified by size exclusion chromatography using 10DG resin and eluted with 2 ml of 1 % HSA. Typical reaction yields are 10%.
• Venetoclax is sold by Genentech (San Francisco, CA) under the brand name VenclextaTM. According to the FDA's VenclextaTM label, this drug "is a BCL-2 inhibitor indicated for the treatment of patients with chronic lymphocytic leukemia (CLL) with 17p deletion ... who have received at least one prior therapy.” VenclextaTM is sold in tablet form at 10 mg, 50 mg and 100 mg.
• the ramp-up dosing schedule is as follows: week 1 , 20mg/day; week 2, 50mg/day; week 3, 100mg/day; week 4, 200mg/day; and week 5 and beyond,
• This dosing regimen is referred to herein as the "normal" human dosing regimen for venetoclax, regardless of the disorder treated. Any dosing regimen having a shorter duration (e.g., 21 days) or involving the
• a "reduced” human dosing regimen administration of less venetoclax (e.g., 20mg/day for a total of 21 days) is referred to herein as a "reduced” human dosing regimen.
• the terms "normal” human dosing regimen and “reduced” human dosing regimen also apply, mutatis mutandis, to any other BCL-2 inhibitor with respect to its approved or otherwise customary dosing regimen.
• a "normal” murine dosing regimen and a “reduced” murine dosing regimen each being commensurate with mouse body weight and tumor xenograft size.
• the "normal” murine dosing regimen has a duration of at least 21 days.
• the "normal" human dosing regimen (regardless of the disorder treated), as this term is used herein, includes either of the following: (i) 2 x 2.0 pCi/kg, where the fractions are administered one week apart; and (ii) 4.0 Ci/kg when delivered in a single administration. Any dosing regimen involving the administration of less 225 Ac-HuM195 (e.g., 2.0 Ci/kg when delivered in a single administration) is referred to herein as a "reduced" human dosing regimen (which may also be considered a sub- saturating dose).
• normal human dosing regimen and reduced human dosing regimen also apply, mutatis mutandis, to any other alpha- emitting isotope-labeled agent with respect to its approved or otherwise customary dosing regimen. Also envisioned is a "normal” murine dosing regimen and a “reduced” murine dosing regimen, each being commensurate with mouse body weight and tumor xenograft size.
• a human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to its normal dosing regimen (i.e., for at least five weeks), followed by intravenous administration of 225 Ac- HuM195 according to its normal dosing regimen (either single or fractional administration).
• the first (and only, if applicable) dose of 225 Ac-HuM195 is administered on the same day as, or one day following, the last dose of venetoclax.
• the treatment of an experimental mouse model according to the treatment regimen in this scenario whereby the appropriate dosing regimens are commensurate with mouse body weight and tumor xenograft size.
• a human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to its normal dosing regimen (i.e., for at least five weeks), followed by intravenous administration of a reduced dosing regimen of 225 Ac-HuM195 (either single or fractional administration).
• a reduced dosing regimen of 225 Ac-HuM195 either single or fractional administration.
• the first (and only, if applicable) dose of 225 Ac-HuM195 is administered on the same day as, or one day following, the last dose of venetoclax.
• the reduced dosing regimen of 225 Ac- HuM195 is (i) 2 x 0.5 ⁇ /kg, 2 x 1 .0 ⁇ /kg, or 2 x 1 .5 ⁇ /kg, where the fractions are administered one week apart; or (ii) 1 x 0.5 pCi/kg, 1 x 1.0
• Ci/kg 1 x 2.0 pCi/kg, or 1 x 3.0 pCi/kg, for a single administration.
• a human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to a reduced dosing regimen, followed by intravenous administration of the normal dosing regimen of 225 Ac- HuM195 (either single or fractional administration).
• the first (and only, if applicable) dose of 225 Ac-HuM195 is administered on the same day as, or one day following, the last dose of venetoclax.
• the reduced dosing regimen of venetoclax is one of the following: (i) 20 mg once daily for 7 days; (ii) 20 mg once daily for 14 days; (iii) 20 mg once daily for 21 days; (iv) 50 mg once daily for 7 days; (v) 50 mg once daily for 14 days; (vi) 50 mg once daily for 21 days; (vii) 100 mg once daily for 7 days; (viii) 100 mg once daily for 14 days; (ix) 100 mg once daily for 21 days; (x) 200 mg once daily for 7 days; (xi) 200 mg once daily for 14 days; (xii) 200 mg once daily for 21 days; (xiii) 400 mg once daily for 7 days; and (xiv) week 1 at 20mg/day, week 2 at 50mg/day and week 3 at 100mg/day.
• a human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to a reduced dosing regimen, followed by intravenous administration of a reduced dosing regimen of 225 Ac- HuM195 (either single or fractional administration).
• a reduced dosing regimen of 225 Ac- HuM195 either single or fractional administration.
• the first (and only, if applicable) dose of 225 Ac-HuM195 is administered on the same day as, or one day following, the last dose of venetoclax.
• the reduced dosing regimen of venetoclax is one of (i) 20 mg once daily for 7 days; (ii) 20 mg once daily for 14 days; (iii) 20 mg once daily for 21 days; (iv) 50 mg once daily for 7 days; (v) 50 mg once daily for 14 days; (vi) 50 mg once daily for 21 days; (vii) 100 mg once daily for 7 days; (viii) 100 mg once daily for 14 days; (ix) 100 mg once daily for 21 days; (x) 200 mg once daily for 7 days; (xi) 200 mg once daily for 14 days; (xii) 200 mg once daily for 21 days; (xiii) 400 mg once daily for 7 days; and (xiv) week 1 at 20mg/day, week 2 at 50mg/day and week 3 at 100mg/day; and (b) the reduced dosing regimen of 225 Ac-HuM195 is one of (i) 2 x 0.5 pCi/kg, 2 x 1 .0 pCi
• Example 1 1 - Dosing Scenario V for 225 Ac-HuM195 and Venetoclax A human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to its normal dosing regimen (i.e., for at least five weeks), and 225 Ac-HuM195 is intravenously administered according to its normal single dose regimen during the course of the venetoclax dosing regimen.
• the single dose of 225 Ac- HuM195 is administered (a) on day 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 of the venetoclax dosing regimen, or (b) on the last day of, the penultimate day of, or 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 days prior to the last day of, the venetoclax dosing regimen.
• a human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to its normal dosing regimen (i.e., for at least five weeks), and 225 Ac-HuM195 is intravenously administered according to a reduced single dose regimen during the course of the venetoclax dosing regimen.
• the single dose of 225 Ac- HuM195 is administered (a) on day 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 of the venetoclax dosing regimen, or (b) on the last day of, the penultimate day of, or 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 days prior to the last day of, the venetoclax dosing regimen.
• the reduced dosing regimen of 225 Ac- HuM195 is (i) 2 x 0.5 pCi/kg, 2 x 1 .0 ⁇ /kg, or 2 x 1 .5 ⁇ /kg, where the fractions are administered one week apart; or (ii) 1 x 0.5 pCi/kg, 1 x 1.0 pCi/kg, 1 x 2.0 pCi/kg, or 1 x 3.0 pCi/kg, for a single administration.
• a human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to a reduced dosing regimen
• 225 Ac-HuM195 is intravenously administered according to its normal single dose regimen during the course of the venetoclax dosing regimen.
• the single dose of 225 Ac-HuM195 is administered (a) on day 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 of the venetoclax dosing regimen, or (b) on the last day of, the penultimate day of, or 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 days prior to the last day of, the venetoclax dosing regimen.
• the reduced dosing regimen of venetoclax is one of the following: (i) 20 mg once daily for 7 days; (ii) 20 mg once daily for 14 days; (iii) 20 mg once daily for 21 days; (iv) 50 mg once daily for 7 days; (v) 50 mg once daily for 14 days; (vi) 50 mg once daily for 21 days; (vii) 100 mg once daily for 7 days; (viii) 100 mg once daily for 14 days; (ix) 100 mg once daily for 21 days; (x) 200 mg once daily for 7 days; (xi) 200 mg once daily for 14 days; (xii) 200 mg once daily for 21 days; (xiii) 400 mg once daily for 7 days; and (xiv) week 1 at 20mg/day, week 2 at 50mg/day and week 3 at 10Omg/day.
• Example 14 Dosing Scenario VIII for 225 Ac-HuM195 and Venetoclax A human AML patient is treated according to the following regimen.
• Venetoclax is orally administered according to a reduced dosing regimen
• 225 Ac-HuM195 is intravenously administered according to a reduced single dose regimen during the course of the venetoclax dosing regimen.
• the single dose of 225 Ac-HuM195 is administered (a) on day 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 of the venetoclax dosing regimen, or (b) on the last day of, the penultimate day of, or 2, 3, 4, 5, 6, 7, 8, 9, 10, 1 1 , 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 days prior to the last day of, the venetoclax dosing regimen.
• the reduced dosing regimen of venetoclax is one of (i) 20 mg once daily for 7 days; (ii) 20 mg once daily for 14 days; (iii) 20 mg once daily for 21 days; (iv) 50 mg once daily for 7 days; (v) 50 mg once daily for 14 days; (vi) 50 mg once daily for 21 days; (vii) 100 mg once daily for 7 days; (viii) 100 mg once daily for 14 days; (ix) 100 mg once daily for 21 days; (x) 200 mg once daily for 7 days; (xi) 200 mg once daily for 14 days; (xii) 200 mg once daily for 21 days; (xiii) 400 mg once daily for 7 days; and (xiv) week 1 at 20mg/day, week 2 at 50mg/day and week 3 at 100mg/day; and (b) the reduced dosing regimen of 225 Ac-HuM195 is one of (i) 2 x 0.5 pCi/kg, 2 x 1 .0 ⁇ /kg

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