WO2023245249A1

WO2023245249A1 - Treatment of melanoma

Info

Publication number: WO2023245249A1
Application number: PCT/AU2023/050569
Authority: WO
Inventors: Daniel Tillett
Original assignee: Race Oncology Ltd
Priority date: 2022-06-22
Filing date: 2023-06-22
Publication date: 2023-12-28
Also published as: WO2023245248A1

Abstract

The present invention provides methods for treating patients with melanoma, the method comprising administering to the patient a therapeutically effective amount of a protein kinase inhibitor and a therapeutically effective amount of at least a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof. Also provided by the present invention are pharmaceutical compositions and kits for the treatment of melanoma as well as the use of such compositions for the manufacture of medicaments for the treatment of melanoma.

Description

TREATMENT OF MELANOMA FIELD OF THE INVENTION [0001] This invention is directed to the use of bisantrene in combination with targeted agents to treat melanoma, including advanced melanoma and in patients who show resistance to targeted therapy. These combinations include protein kinase inhibitors and immune checkpoint inhibitors indicated for use in patients with melanoma. The present invention also contemplates pharmaceutical compositions and kits for such treatments, as well as the use of such compositions for the manufacture of medicaments for such treatments. BACKGROUND OF THE INVENTION [0002] Melanoma is a dangerous form of skin cancer that begins in cells called melanocytes. While melanoma is less frequent than other skin cancers such as basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), melanoma is typically more dangerous because of its ability to metastasize to other organs if not detected and treated at an early stage. [0003] Risk factors that are associated with a higher incidence of melanoma include: a fair complexion (including fair skin that burns or freckles easily, blue or green eyes, and blonde or red hair); exposure to sunlight and other sources of ultraviolet (UV) energy; a prior history of sunburns that caused blistering (especially in childhood); having large moles, many small moles, or moles that look different from normal moles; a family history of unusual moles or melanoma; a personal history of skin cancer; genetic syndromes such as xeroderma pigmentosum; other environmental exposures, including to radiation and some chemicals; a weakened immune system; older age; and male sex. [0004] In 2020, an estimated 196,060 cases of melanoma are expected to be diagnosed in the U.S. While the estimated five-year survival rate for patients whose melanoma is detected early is about 99%, an estimated 6,850 people (4,610 men and 2,240 women) are expected to die of melanoma in the U.S. in 2020. Similar rates of melanoma and deaths are seen in other regions off the world with large populations of people with fair complexion include Australia, New Zealand, South America, South Africa and Europe. [0005] Melanoma can be treated very effectively by surgical removal if identified at an early stage (Stage 0), but once the melanoma has spread into the dermis or beyond (Stage I and greater), treatment becomes more difficult. While some melanomas respond to conventional cancer treatment options such as chemotherapy and radiation, many are resistant to such treatments especially those that are advanced (Stages III & IV). Newer targeted treatments such as the BRAF inhibitors (for example, trametinib, encorafenib, binimetinib, vemurafinib) have proven effective in melanoma, however, the majority of the patients treated with an inhibitor of mutant BRAF eventually suffer relapse, treatment resistance, and disease progression. [0006] Recent breakthroughs in immunotherapy, including anti-PD-1 and PD-L1 checkpoint blockade therapy, have benefitted a growing number of melanoma patients. Despite this advance more than half of these patients do not show a durable response to immunotherapy. Multiple mechanisms, such as driver mutations, epigenetic changes, tumor plasticity, and immunosuppression, all mediate resistance to immunotherapy. [0007] At present, there are no approved treatments that can overcome targeted treatment resistance in melanoma patients. Therefore, there is a need for new treatments that can enhance the effectiveness of targeted agents and improve treatment outcomes. SUMMARY OF THE INVENTION [0008] The present invention provides a new paradigm for treating melanoma by the administration of bisantrene in combination with a targeted agent, for example a protein kinase inhibitor or immune checkpoint inhibitor. This meets the need for new treatments that improve the clinical outcomes of patients with melanoma, especially patients who show resistance to current targeted therapies. [0009] Bisantrene is an antineoplastic agent that has multiple mechanisms of action, including DNA intercalation, inhibition of topoisomerase and the fat mass and obesity-associated protein (FTO), and activation of the immune system. [0010] Surprisingly, it has been found through the course of these studies that bisantrene and pharmaceutically acceptable salts thereof act synergistically with protein kinase inhibitors against melanoma cells. [0011] One aspect of the invention therefore provides a method of treating a patient with melanoma, said method comprising administering to said patient a therapeutically effective amount of a targeted agent, which may be a protein kinase inhibitor, and a therapeutically effective amount of at least a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof. [0012] According to certain embodiments the protein kinase inhibitor inhibits one or more of RAS, MEK and BRAF. [0013] According to certain embodiments, the at least one protein kinase inhibitor is selected from the group consisting of: (a) binimetinib (b) cobimetinib (c) dabrafenib (d) encorafenib (e) trametinib (f) vemurafenib [0014] According to certain embodiments, the at least one protein kinase inhibitor is selected from the group consisting of: (a) binimetinib (b) cobimetinib (c) vemurafenib [0015] According to certain embodiments, the second agent is bisantrene or a pharmaceutically acceptable salt thereof. [0016] According to certain embodiments, the method comprises administering to a patient a therapeutically effective amount of one protein kinase inhibitor and a therapeutically effective amount of bisantrene or a pharmaceutically acceptable salt thereof. [0017] According to certain embodiments, the method comprises treatment of protein kinase inhibitor resistant melanoma. [0018] According to certain embodiments, the method may further comprise administration of at least one additional therapeutic agent, optionally a checkpoint inhibitor drug or an immunomodulator for the treatment melanoma. In certain embodiments the at least one additional therapeutic agent may be selected from the group consisting of: ipilimumab; nivolumab; nivolumab and relatlimab-rmbw; pembrolizumab; talimogene laherparepvec; tebentafusp-tebn; interleukin-2; and proleukin. [0019] According to certain embodiments, the method may comprise administering said at least one protein kinase inhibitor to said patient prior to, simultaneously with, or after administration of said second agent to said patient. [0020] According to other embodiments, the method may comprise administering said at least one protein kinase inhibitor and the second agent to said patient at the same time, optionally in a single composition. [0021] According to certain embodiments, the treatment has synergistic results against melanoma compared to a method wherein said at least one protein kinase or said second agent is administered alone. In certain embodiments, the dose of said at least one protein kinase inhibitor is at least 20% lower than the dose required of said at least one protein kinase inhibitor agent when administered without said second agent to achieve the same targeted outcome. [0022] Another aspect of the invention provides a pharmaceutical composition for the treatment of melanoma by embodiments of treatment methods as described above, said compositions comprising at least one protein kinase inhibitor, which may be a tyrosine kinase inhibitor, as described above, and a second agent as described above comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof. Said compositions may comprise further active agents as described above. [0023] Another aspect of the invention provides the use of a composition according to the invention, as described above, for the manufacture of a medicament for the treatment of advanced melanoma, optionally protein kinase inhibitor resistant melanoma in a patient. [0024] Yet another aspect of the invention provides a kit for the treatment of melanoma, optionally protein kinase inhibitor resistant melanoma by embodiments of methods of the present invention, as described above, said kit comprising at least one protein kinase inhibitor, optionally a tyrosine kinase inhibitor, as described above, and at least a second agent as described above, said second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof. Kits according to the present invention may comprise instructions for administering said at least one protein kinase inhibitor to said patient prior to, simultaneously with, or after administering said second agent to said patient. Alternatively, kits according to the present invention may comprise instructions for administering said at least one protein kinase inhibitor and the second agent to said patient at the same time. BRIEF DESCRIPTION OF THE DRAWINGS [0025] The following invention will become better understood with reference to the specification, appended claims, and accompanying drawings, where: [0026] Figure 1 shows the sensitivity of primary melanoma cells derived from patients receiving BRAF inhibitor therapy prior to (Pre) and following (Post) clinical resistance to BRAF inhibition to treatment with bisantrene. [0027] Figures 2 to 4 show Webb synergy analyses of bisantrene-cobimetinib, bisantrene -binimetinib or bisantrene -vemurafinib drug combinations in Mel-RMu cells, IgR3 cells and A375 melanoma cells respectively. Cell viability in response to different dose ranges of: (A) cobimetinib; (B) binimetinib; or (C) vemurafenib in combination with bisantrene, as indicated. Experimental data is shown for each drug alone and the combinations. The ‘Expected value’ is calculated using the method of Webb and shows the expected value if the drug combination was additive. Therefore any experimental values below this line are considered synergistic. At or near the line is additive; and above the line is antagonistic. Webb analysis for: (D) cobimetinib; (E) binimetinib; or (F) vemurafenib in combination with bisantrene where a result of <-0.1 indicates synergy (*); between -0.1 to 0.1 is additive (&); and >0.1 is antagonistic (#). [0028] Figure 5 shows the effects of bisantrene, vemurafenib or bisantrene- vemurafeninb combination on IgR3 subcutaneous tumor growth in a NOD/SCID xenografted mouse model. Bisantrene was dosed at 15 mg/kg every second day, vemurafenib was dosed daily for 6 consecutive days out of 7. (A) Average tumor volume for each treatment group. The triangle represents a significant difference between combination and vemurafenib (2-way ANOVA, Tukey’s test for multiple comparisons). Asterix represent significant difference between combination and all other groups. (B) Representative appearance of individual mice and excised tumors at endpoint for each treatment group. [0029] Figure 6 shows bisantrene and a targeted agent combination trial design to enhance targeted agent activity in melanoma. DETAILED DESCRIPTION OF THE INVENTION [0030] The present disclosure relates to improve targeted agent activity in melanoma patients, comprising administration of an effective amount of a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof., optionally bisantrene or a pharmaceutically acceptable salt thereof, in combination with said targeted agent. [0031] Bisantrene is an unusual agent with direct cytotoxic action as well as genomic and immunologic methods of action including as a potent inhibitor (IC50142 nM) of the fat mass and obesity-associated protein (FTO), an RNA N6- methyladenosine (m⁶A) demethylase (Su, R., Dong, L., Li, Y., Gao, M., Han, L., Wunderlich, M., et al. (2020). Targeting FTO Suppresses Cancer Stem Cell Maintenance and Immune Evasion. Cancer Cell, 38(1), 79–96.e11). The chemical name for bisantrene is 9, 10-anthracenedicarboxaldehyde-bis [(4, 5-dihydro-1H- imidazole-2-yl) hydrazine] dihydrochloride, and it was originally classed as an anthracycline-like chemotherapeutic agent. As used herein, the term “bisantrene” refers to bisantrene or any pharmacologically compatible salt form, not only bisantrene dihydrochloride, unless the dihydrochloride or another specific pharmacologically compatible salt form is specifically indicated. Typically, the pharmacologically compatible salt form of bisantrene is bisantrene dihydrochloride for most pharmacological applications. Bisantrene has a planar structure based around a resonant aromatic ring structure that intercalates within the helices of DNA and disrupts various functions, including replication, presumably due to a strong inhibitory effect on the enzyme topoisomerase II. It was found that bisantrene could kill tumor cells in clonogenic assays and intercalate with DNA, where it inhibits both DNA and RNA synthesis. It was found that while inactive orally, intravenously (IV), intraperitoneally (IP), or subcutaneously (SC), the drug was effective in cancer models using colon 26, Lewis lung, Ridgway osteosarcoma, B16, Lieberman plasma cell, P388 or L1210 cancer cells. Activity in clonogenic assays from tissue samples isolated from 684 patients was seen in breast, small cell lung, large cell lung, squamous cell lung, ovarian, pancreatic, renal, adrenal, head and neck, sarcoma, gastric, lymphoma and melanoma tumor cells, but not in colorectal cancer. Importantly, a lack of cross resistance with Adriamycin (doxorubicin) and mitoxantrone was found. [0032] Bisantrene has immunologic properties that might be responsible for some of its activities, and which may make this agent a useful tool in the combinatorial treatment of cancer in conjunction with newer immunotherapeutic agents. Subsequent to treatment with bisantrene, treated with bisantrene, and for 4 weeks thereafter, macrophages could be isolated from peritoneal exudate that had cytostatic anti-proliferative functionality in cultures of P815 (mastocytoma) tumor cells. Moreover, the supernatants from bisantrene activated macrophages also had a protective cytostatic effect in the tumor cell cultures. Further work revealed that macrophages activated with bisantrene and adoptively transferred to mice with EL-4 lymphomas more than doubled their median survival time, with 7 of 10 mice in the group being cured. Multiple administrations of activated macrophages were more effective than a single administration. Recent studies have identified that bisantrene suppresses immune checkpoint gene expression and immune evasion via enzymatic inhibition of the FTO RNA demethylase activity as described in R. Su. et al., “Targeting FTO Suppresses Cancer Stem Cell Maintenance and Immune Evasion”. Cancer Cell, 38(1), 79–96.e11 (2020). [0033] Bisantrene has also been found to have non-immunologic telomeric effects. Bisantrene binds to DNA at a site called a G-quadruplex, in which 4 guanines are associated by folding. Stabilization of the G-quadruplex can interfere with telomere- telomerase interaction and thus inhibit the activity of telomerase in various ways, including the displacement of telomerase binding proteins. Since the level of topoisomerase II inhibition does not always correlate with cytotoxic efficacy, alternative mechanisms may play a role in the actions of bisantrene. Analogs of bisantrene have been made in an attempt to improve upon the anti-telomerase activity; these analogs are described further below. Human melanoma (SK-Mel5) and colon cancer (LoVo) tumor cells were observed to lose their proliferative ability in the presence of these agents. Apoptosis was not observed; however a loss of immortality was seen, with treated cells reacquiring the ability to become senescent, age, and die. [0034] As detailed above, in addition to direct antineoplastic effects related to the activity of bisantrene as a DNA intercalator, bisantrene also possesses other mechanisms of action, including immunopotentiation. These mechanisms are described in: (i) N.R. West et al., “Tumor-Infiltrating Lymphocytes Predict Response to Anthracycline-Based Chemotherapy in Estrogen-Resistant Breast Cancer,” Breast Canc. Res.13: R126 (2011), which concludes that the level of tumor-infiltrating lymphocytes is correlated with a response to the administration of anthracycline- based agents; the markers associated with tumor-infiltrating lymphocytes (TIL) include CD19, CD3D, CD48, GZMB, LCK, MS4A1, PRF1, and SELL; (ii) L. Zitvogel et al., “Immunological Aspects of Cancer Chemotherapy,” Nature Rev. Immunol.8: 59-73 (2008), which states that DNA damage, such as that produced by intercalating agents such as bisantrene, induces the expression of NKG2D ligands on tumor cells in an ATM-dependent and CHK1-dependent (but p53-independent) manner; NKG2D is an activating receptor that is involved in tumor immunosurveillance by NK cells, NKT cells, γδ T cells and resting (in mice) and/or activated (in humans) CD8⁺ T cells, and also states that anthracycline-based agents may act as immunostimulators, particularly in combination with IL-12; such agents also promote HMGB1 release and activate T cells; (iii) D.V. Krysko et al., “TLR2 and TLR9 Are Sensors of Apoptosis in a Mouse Model of Doxorubicin-Induced Acute Inflammation,” Cell Death Different. 18: 1316-1325 (2011), which states that anthracycline-based antibiotics induce an immunogenic form of apoptosis that has immunostimulatory properties mediated by MyD88, TLR2, and TLR9; (iv) C. Ferraro et al., “Anthracyclines Trigger Apoptosis of Both G0-G1 and Cycling Peripheral Blood Lymphocytes and Induce Massive Deletion of Mature T and B Cells,” Cancer Res.60: 1901-1907 (2000), which stated that anthracyclines induce apoptosis and ceramide production, as well as activate caspase-3 in resting and cycling cells; the apoptosis induced is independent from CD95-L/CD95 and TNF/TNF-R; (v) K. Lee et al., “Anthracycline Chemotherapy Inhibits HIF-1 Transcriptional Activity and Tumor-Induced Mobilization of Circulating Angiogenic Cells,” Proc. Natl. Acad. Sci. USA 106: 2353-2358 (2009), which provides another antineoplastic mechanism for anthracycline-based antibiotics, namely inhibition of HIF-1 mediated gene transcription, which, in turn, inhibits transcription of VEGF required for angiogenesis; HIF-1 also activates transcription of genes encoding glucose transporter GLUT1 and hexokinases HK1 and HK2, which are required for the high level of glucose uptake and phosphorylation that is observed in metastatic cancer cells, and pyruvate dehydrogenase kinase 1 (PDK1), which shunts pyruvate away from the mitochondria, thereby increasing lactate production; patients with HIF-1 ^ overexpression based on immunohistochemical results were suggested to be good candidates for treatment with anthracycline- based antibiotics; and (vi) R. Su et al., “Targeting FTO Suppresses Cancer Stem Cell Maintenance and Immune Evasion.” Cancer Cell, 38(1), 79–96.e11 (2020), which identified a new mechanism of action of bisantrene via the inhibition of the FTO enzyme. Inhibition of FTO was found to enhance immunotherapy response via suppression of immune checkpoint gene expression. [0035] Several clinical trials have investigated the pharmacokinetics of bisantrene in humans. In one trial of patients given a 90 min infusion at 260 mg/m² a biphasic elimination with an initial half-life of 65 ± 15 min, a terminal half-life of 1142 ± 226 min, and a steady state volume of distribution (Vdss) of 1845 L/m². Plasma clearance in this trial was 735 mL/min/m², with 11.3% of the administered dose excreted unchanged in the urine in 24 h. In another trial, doses of 80-250 mg/m² were assessed, and the initial and terminal half-lives were 0.6 h and 24.7 h, respectively, with a clearance of 1045.5 ± 51.0 mL/kg/h and a calculated volume of distribution of 42.1 ± 5.9 L/kg. In this study only 3.4 ± 1.1% of the administered dose was found in the urine over 96 h. In three other single dose studies triphasic elimination was reported, one with t^½ ^, ^, and ^ of 3.44 min, 1.33 h and 26.13 h, respectively, another was 3 min, 1 h, and 8 h respectively, and the last revealed clearances of 0.1 h, 1.9 h and 43.9 h, respectively, in one report a large volume of distribution (687 L/m²) was interpreted as tissue sequestration of the drug with a subsequent depot effect, in a 72 h infusion study, a plasma concentration of 12 ± 6 ng/ml was observed at a dose of 56 mg/m² while a dose of 260 mg/m² resulted in a plasma concentration of 55 ± 8 ng/mL. In this trial plasma clearance was 1306 ± 179 mL/min/m² with urinary excretion of 4.6% of the dose in 24 h. Finally, in another study, a 5-day schedule of 60 min infusions revealed a to a and p of 0.9 and 9.7 h, respectively with 7.1% of the dose excreted in the urine.

[0036] The structure of bisantrene dihydrochloride is shown in Formula (I)

(I).

[0037] Bisantrene dihydrochloride is a tricyclic aromatic compound with the chemical name, 9,10-anthracenedicarboxaldehyde bis[(4,5-dihydro~1 H-imidazol-2- yljhydrazine] dihydrochloride. The molecular formula of bisantrene hydrochloride is C22H22N8 • 2HCI and the molecular weight, 471.4 g/mol. The alkylimidazole side chains are very basic and, at physiologic pH, are positively charged. This is believed to facilitate electrostatic attractions to negatively charged ribose phosphate groups in DNA and RNA.

[Q03S] Bisantrene is typically administered intravenously, either centrally or peripherally.

[0039] Various formulations suitable for use in the administration of bisantrene or derivatives or analogs thereof are known in the art. United States Patent No. 4,784,845 to Desai ef a/. discloses a composition of mater for delivery of a hydrophobic drug (i.e., bisantrene or a derivative or analog thereof) comprising: (I) the hydrophobic drug; (ii) an oleaginous vehicle or oil phase that is substantially free of butylated hydroxyanisole (BHA) or butylated hydroxytoluene (BHT); (iii) a co- surfactant or emulsifier; (iv) a co-surfactant or auxiliary emulsifier; and (v) benzyl alcohol as a co-solvent. United States Patent No.4,816,247 by Desai et al. discloses a composition of matter for delivery by intravenous, intramuscular, or intraarticular routes of hydrophobic drugs (such as bisantrene or a derivative or analog thereof) comprising: (i) the hydrophobic drug; (ii) a pharmaceutically acceptable oleaginous vehicle or oil selected from the group consisting of: (a) naturally occurring vegetable oils and (b) semisynthetic mono-, di-, and triglycerides, wherein the oleaginous vehicle or oil is free of BHT or BHA; (iii) a surfactant or emulsifier; (iv) a co-surfactant or emulsifier; (v) an ion-pair former selected from C6-C20 saturated or unsaturated aliphatic acids when the hydrophobic drug is basic and a pharmaceutically acceptable aromatic amine when the hydrophobic drug is acidic; and (vi) water. United States Patent No.5,000,886 to Lawter et al. and United States Patent No. 5,143,661 to Lawter et al. disclose compositions for delivery of pharmaceutical agents such as bisantrene or a derivative or analog thereof comprising a microcapsule, wherein the microcapsule includes a hardening agent that is a volatile silicone fluid. United States Patent No.5,070,082 to Murdock et al., United States Patent No.5,077,282 to Murdock et al., and United States Patent No.5,077,283 to Murdock et al. disclose prodrug forms of poorly soluble hydrophobic drugs, including bisantrene and derivatives and analogs, that are salts of a phosphoramidic acid. United States Patent No.5,116,827 to Murdock et al. and United States Patent No. 5,212,291 to Murdock et al. disclose prodrug forms of poorly soluble hydrophobic drugs, including bisantrene and derivatives and analogs, that are quinolinecarboxylic acid derivatives. United States Patent No.5,378,456 to Tsou includes compositions containing an anthracene antitumor agent, such as bisantrene or a derivative or analog thereof, in which the bisantrene or derivative or analog thereof is conjugated to or admixed with a divinyl ether-maleic acid (MVE) copolymer. United States Patent No.5,609,867 to Tsou discloses polymeric 1,4-bis derivatives of bisantrene and copolymers of bisantrene and another monomer, such as a dianhydride. [0040] Methods and compositions described herein can use a derivative or analog of bisantrene in place of bisantrene itself. Derivatives and analogs of bisantrene are described in US Patents 10,500,19 and 10,548,876, by Garner et al. Methods for treating melanoma [0041] Surprisingly, it has been found through the course of these studies that bisantrene and pharmaceutically acceptable salts thereof act synergistically with protein kinase inhibitors against melanoma cells. It is contemplated that derivatives of bisantrene possessing substantially the same activity will also act synergistically with protein kinases in methods and compositions according to the present invention. [0042] Thus, one aspect of the invention is a method of treating melanoma comprising administration to a patient in need thereof of a therapeutically effective quantity of bisantrene or therapeutically acceptable salt thereof, or a therapeutically effective quantity of a derivative or analog of bisantrene or therapeutically acceptable salt thereof, said derivative or analog or salt thereof having substantially the same activity against melanoma cells. In some embodiments, the bisantrene (or in some cases, the derivative or analog of bisantrene) can be administered together with a therapeutically effective quantity of at least one additional therapeutic agent for treating melanoma. Targeted therapeutic agents that have been FDA approved for treating melanoma include: binimetinib, cobimetinib, dabrafenib, encorafenib, trametinib, and vemurafenib. [0043] The protein kinase inhibitor may inhibit one or more potential protein kinase targets associated with melanoma. According to certain embodiments, the protein kinase inhibitor inhibits at least one or more of RAS, MEK and BRAF. According to certain embodiments, the protein kinase inhibitor inhibits BRAF. [0044] According to certain embodiments at least one protein kinase inhibitor is selected from the group consisting of: binimetinib, cobimetinib, dabrafenib, encorafenib, trametinib, and vemurafenib. [0045] According to specific embodiments at least one protein kinase inhibitor is selected from the group consisting of: binimetinib, cobimetinib and trametinib. [0046] According to more specific embodiments at least one protein kinase inhibitor is selected from the group consisting of: dabrafenib, encorafenib and vemurafenib. [0047] According to still more specific embodiments at least one protein kinase inhibitor is selected from the group consisting of: binimetinib, cobimetinib and vemurafenib. [0048] According to even more specific embodiments the protein kinase inhibitor is vemurafenib. [0049] According to specific embodiments of the present invention, the second agent is bisantrene or a pharmaceutically acceptable salt thereof. [0050] According to certain embodiments, the bisantrene can be administered as a drug compound or as a component of a pharmaceutical composition, as discussed further below. [0051] According to certain specific embodiments, the method comprises administering to said patient a therapeutically effective amount of one protein kinase inhibitor and a therapeutically effective amount of bisantrene or a pharmaceutically acceptable salt thereof. [0052] The pharmaceutical compositions and medicaments of the present invention may be administered to a subject by standard enteral or parenteral routes, including, but not limited to, injection (such as intravenous, subcutaneous, intramuscular, bolus, etc.), or by, for example, topical, oral, sublingual, nasal, pulmonary, otic, rectal or vaginal administration routes. In some embodiments, pharmaceutical compositions according to the invention may be administered to a subject by themselves or in combination with other pharmaceutical composition(s). In the latter case, the administration may be simultaneous or sequential, or administration of the pharmaceutical composition(s) may be independent of one another. [0053] In certain embodiments bisantrene (or derivative, or pharmaceutically acceptable salt of either) is administered intravenously, either centrally or peripherally, including by intramuscular, subcutaneous and/or intradermal injection. [0054] In general, the pharmaceutical compositions and medicaments of the present invention can be administered in a manner compatible with the route of administration and physical characteristics of the subject (including health status) and in such a way that the desired effect(s) are induced (i.e. therapeutically effective and/or preventative). For example, the appropriate dosage may depend on a variety of factors including, but not limited to, a subject’s physical characteristics (e.g. age, weight, sex), whether the composition or medicament is being used as single agent, the progression (i.e. pathological state) of the disease or disorder being treated, and other factors readily apparent to those of ordinary skill in the art. [0055] Suitable dosages, dosage frequencies, dosage durations, and routes of administration for chemotherapeutic agents are known in the art. As suggested by Figure 6, bisantrene, derivatives of bisantrene, or pharmaceutically acceptable salts of either can be administered in the same pharmaceutical composition as a protein kinase inhibitor, in a separate composition as, but simultaneously with the protein kinase inhibitor, or at a different time. If the bisantrene, derivative of bisantrene, or pharmaceutically acceptable salt of bisantrene or derivative of bisantrene, is administered at a different time than the protein kinase inhibitor, it can either be administered before or after the protein kinase inhibitor and/or at different timings, being administered according to different timing and/or frequency regimes. One of ordinary skill in the art can determine a suitable schedule for administration based on variables such as the age, weight, and sex of the subject, the susceptibility of the subject to side effects of the active agents, genetic markers, the dose of active agent(s), the subject’s history with prior active agent(s), and other pharmacokinetic parameters such as heart, liver or kidney function. [0056] The methods and compositions provided herein enable a subject to receive a therapy more frequently without having the dosage regimen significantly altered by the risk of side-effects, such as cardiotoxicity. The dose(s) of a protein kinase inhibitor and bisantrene, derivative of bisantrene, or pharmaceutically acceptable salt of bisantrene or derivative of bisantrene, may be administered to a subject in one or more doses per day. In some cases, the daily dose of the chemotherapeutic agent may be administered together with bisantrene, derivative of bisantrene, or pharmaceutically acceptable salt of either, in a single dose. [0057] The pharmaceutical compositions described herein may be administered to a patient one or more times per day. In some cases, the pharmaceutical composition may be administered to a patient once per day. In some cases, the pharmaceutical composition may be administered to a patient at least 2 times, 3 times, 4 times 5 times, or 6 times per day. For example, a pharmaceutical composition may be administered to a patient 3 times per day. [0058] In methods described herein, suitable dosages of bisantrene (or a derivative of bisantrene, or a pharmaceutically acceptable salt of either) can be determined by one of ordinary skill in the art. The selected dosage level depends upon a variety of pharmacokinetic factors including the amount of active agent(s) being administered, the route of administration, the time of administration, the rate of excretion of the particular compound being employed, the severity of the condition, other health considerations affecting the subject, and the status of liver and kidney function of the subject. It also depends on the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular therapeutic agent employed, as well as the age, weight, condition, general health and prior medical history of the subject being treated, and like factors. Methods for determining optimal dosages are described in the art, e.g., Remington: The Science and Practice of Pharmacy, Mack Publishing Co., 20^th ed., 2000, and Gilman et al., (Eds), (1990), “Goodman And Gilman's: The Pharmacological Bases of Therapeutics”, Pergamon Press. Optimal dosages for a given set of conditions can be ascertained by those skilled in the art using conventional dosage-determination tests in view of the experimental data for an agent. [0059] According to certain embodiments, administration of bisantrene is performed at a dosage of from about 0.1 mg/m²/day to about 400 mg/m²/day, such as from about 0.2 mg/m²/day to about 300 mg/m²/day, from about 0.5 mg/m²/day to about 200 mg/m²/day, from about 0.5 mg/m²/day to about 100 mg/m²/day, from about 0.5 mg/m²/day to about 50 mg/m²/day, from about 0.5 mg/m²/day to about 30 mg/m²/day, from about 0.5 mg/m²/day to about 20 mg/m²/day, from about 1.0 mg/m²/day to about 10 mg/m²/day, from about 1.0 mg/m²/day to about 8 mg/m²/day, about 1 mg/m²/day, about 2 mg/m²/day, about 3 mg/m²/day, about 4 mg/m²/day, about 5 mg/m²/day, about 6 mg/m²/day, about 7 mg/m²/day, or about 10 mg/m²/day. In some embodiments, bisantrene is administered daily or weekly, once every two weeks, once every three weeks, once every four weeks, over a period of, for example, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 21 days, 28 days, 35 days, 42 days, 49 days, 56 days or 63 days. In certain embodiments, bisantrene is administered once or multiple times over a period of 28 days, optionally once or multiple times daily or weekly, once every two weeks, once every three weeks, once every four weeks, at a dosage of about 20-50 mg/m²/28 days. Administration of pharmaceutically acceptable salts of bisantrene or derivatives or pharmaceutically acceptable salts thereof may be performed at similar dosage rates, adjusted for molar equivalence. [0060] Dosing regimens for protein kinase inhibitors will depend on the particular protein kinase inhibitor, and have been published for known protein kinase inhibitors, including for treatment of melanoma. In addition, suitable dosages of a given protein kinase inhibitor can be readily determined by one of ordinary skill in the art using known approaches and techniques as discussed above in relation to bisantrene. [0061] According to certain embodiments, and as a result of the synergistic biologic activity observed when bisantrene (or derivative of bisantrene, or a pharmaceutically acceptable salt of either) is administered with a protein kinase inhibitor, a therapeutic outcome may be achieved more effectively for a given dose rate for that protein kinase inhibitor. This biologic activity of the bisantrene (or derivative of bisantrene, or a pharmaceutically acceptable salt of either) may also allow for use, or expanded use of protein kinase inhibitors which at normal dosages may have deleterious side- effects, such as cardiotoxicity. [0062] Alternatively, when administered in combination with bisantrene (or derivative of bisantrene, or a pharmaceutically acceptable salt of either), the protein kinase inhibitor may be administered to a patient at a lower dosage than it would normally be administered, over a longer period while maintaining a comparable ongoing therapeutic outcome. This is particularly important for active agents with deleterious side-effects, such as cardiotoxicity. Thus, in certain embodiments of methods according to the present invention, when administered in combination with bisantrene (or derivative of bisantrene, or a pharmaceutically acceptable salt of either), the protein kinase inhibitor may be administered at a rate which is significantly lower than the recommended dosage rate for that protein kinase inhibitor when administered alone, such as at a rate which is at least 10%, 20%, 30%, 40%, 50%, 60% or 70% lower than the dosage rate for that protein kinase inhibitor when administered alone. Additional active agents [0063] Programmed cell death 1 ligand 1 (PD-L1) and its receptor programmed cell death 1 (PD-1) regulate the activation of immune cells. Checkpoint inhibitors can assist in suppressing this regulation, allowing immune cells to destroy tumors. An emerging strategy is the combination of checkpoint inhibitors with protein kinase inhibitors, especially protein kinase inhibitors that target mutant BRAF, an oncogene involved in immunosuppression in melanoma patients. Known checkpoint inhibitors include antibodies and small molecules that target PD-1 or PD-L1. [0064] The FDA has approved two PD-1 inhibitors (nivolumab and pembrolizumab), one CTLA-4 inhibitor (ipilimumab) and one PD-1/LAG3 inhibitor combination (nivolumab and relatlimab) for use in melanoma. Other PD-1/ PD-L1 immune checkpoint inhibitors of potential consideration include avelumab, atezolizumab, bevacizumab, cemiplimab, dostarlimab, and durvalumab. [0065] In addition, some studies have shown that protein kinase inhibitors can themselves stimulate immune responses against tumors, which may in turn result in synergistic responses when combined with checkpoint inhibitors. [0066] Similarly, immunomodulators such as cytokines that regulate immune cell maturation, growth and activation, including interleukin-2 (Aldesleukin/ Proleukin), interferon alpha-2a, interferon alpha-2b (and Peginterferon alpha-2b), and Granulocyte-macrophage colony-stimulating factor (GM-CSF) have also been approved for treatment of various cancers via immunostimulation. Interleukin-2 (or the recombinant human version Aldesleukin/ Proleukin) has been approved for the treatment of melanoma. [0067] Thus, methods according to the present invention may further comprise administration of at least one additional therapeutic agent for the treatment of melanoma. [0068] According to certain embodiments the additional therapeutic agent is a checkpoint inhibitor or an immunomodulator such as those discussed above. According to certain embodiments the at least one additional therapeutic agent comprises a checkpoint inhibitor selected from the group comprising nivolumab, pembrolizumab, avelumab, ipilimumab, atezolizumab, bevacizumab, cemiplimab, dostarlimab, and durvalumab or an immunomodulator selected from interleukin-2 (Aldesleukin/ Proleukin), interferon alpha-2a, interferon alpha-2b (and Peginterferon alpha-2b), and GM-CSF. According to certain embodiments, the at least one additional therapeutic agent comprises a checkpoint inhibitor selected from the group comprising nivolumab, pembrolizumab, ipilimumab and nivolumab/relatlimab combinations. According to certain embodiments the at least one additional therapeutic agent comprises interleukin-2 (Aldesleukin/ Proleukin). [0069] Suitable dosages, dosage frequencies, dosage durations, and routes of administration for these additional agents are known in the art. As suggested by Figure 6, these additional agents can either be administered simultaneously with the bisantrene or the derivative or analog of bisantrene, or at a different time than the bisantrene or the derivative or analog of bisantrene. If the additional agent is administered at a different time than the bisantrene or the derivative or analog of bisantrene, it can either be administered before or after the bisantrene or the derivative or analog of bisantrene and/or at different timings, being administered according to different timing and/or frequency regimes. Similarly, and independently of bisantrene considerations, these additional agents can either be administered simultaneously with the protein kinase inhibitor, or at a different time than the protein kinase inhibitor. If the additional agent is administered at a different time than the protein kinase inhibitor, it can either be administered before or after the protein kinase inhibitor and/or at different timings, being administered according to different timing and/or frequency regimes. One of ordinary skill in the art can determine a suitable schedule for administration based on variables such as the age, weight, and sex of the patient, the severity of the cancer, genetic markers such as further described below, and pharmacokinetic parameters such as liver and kidney function. [0070] Yet another aspect of the invention is a pharmaceutical composition formulated for the treatment of melanoma comprising: (1) bisantrene or a derivative or analog of bisantrene; and (2) at least one pharmaceutically acceptable excipient. In one embodiment, the composition comprises a therapeutically effective quantity of bisantrene or a derivative or analog of bisantrene. Pharmaceutical compositions for the treatment of melanoma [0071] The present invention also provides pharmaceutical compositions for the treatment of melanoma comprising at least one targeted agent, such as a protein kinase inhibitor, as described above, and a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof. As described above, the compositions of the invention may comprise an additional agent selected from checkpoint inhibitors and immunomodulators. [0072] According to certain embodiments the protein kinase inhibitor is a tyrosine kinase inhibitor. According to certain embodiments, the protein kinase inhibitor inhibits at least one or more of RAS, MEK and BRAF. According to certain embodiments, the protein kinase inhibitor inhibits BRAF. [0073] According to certain embodiments at least one protein kinase inhibitor is selected from the group consisting of: binimetinib, cobimetinib, dabrafenib, encorafenib, trametinib, and vemurafenib. [0074] According to specific embodiments of the present invention, at least one protein kinase inhibitor is selected from the group consisting of: binimetinib, cobimetinib and vemurafenib. [0075] According to specific embodiments of the present invention, the second agent is bisantrene or a pharmaceutically acceptable salt thereof. [0076] According to specific embodiments of the present invention, the composition may comprise a therapeutically effective amount of one protein kinase inhibitor and a therapeutically effective amount of bisantrene or a pharmaceutically acceptable salt thereof. [0077] Compositions according to the present invention may further comprise administration of at least one additional therapeutic agent for the treatment melanoma. [0078] According to certain embodiments the additional therapeutic agent is a checkpoint inhibitor or an immunomodulator such as those discussed above. According to certain embodiments the at least one additional therapeutic agent comprises a checkpoint inhibitor selected from the group comprising nivolumab, pembrolizumab, avelumab, ipilimumab, atezolizumab, bevacizumab, cemiplimab, dostarlimab, relatlimab, and durvalumab or an immunomodulator selected from interleukin-2 (Aldesleukin/ Proleukin®), interferon alpha-2a, interferon alpha-2b (and Peginterferon alpha-2b), and GM-CSF. According to certain embodiments, at least one additional therapeutic agent comprises a checkpoint inhibitor selected from the group comprising nivolumab, pembrolizumab, ipilimumab and nivolumab/relatlimab combinations. According to certain embodiments the at least one additional therapeutic agent comprises interleukin-2 (Aldesleukin/ Proleukin). [0079] Compositions according to the present invention may be administered by any route, and in a form suitable for that route, as known in the art. Thus, compositions according to the present invention may be adapted for administration by enteral or parenteral routes, including by injection (such as intravenous, subcutaneous, intramuscular, bolus, etc.), or by, for example, topical, oral, sublingual, nasal, pulmonary, otic, rectal or vaginal administration routes. [0080] Typically, the pharmaceutical compositions described herein include at least one pharmaceutically acceptable carrier or excipient and/or diluents. For preparing the pharmaceutical compositions and medicaments, inert, pharmaceutically acceptable carriers can be either solid or liquid. Liquid form preparations include solutions, suspensions and emulsions, for example water or water-propylene glycol solutions for parenteral injection. Also included are solid form preparations, such as tablets, or amorphous or crystalline powders, including lyophilized preparations, that are intended to be converted, shortly before use, to liquid form preparations for either oral or injection administration. Such liquid forms include solutions, suspensions and emulsions. Examples of pharmaceutically acceptable carriers and methods of manufacture for various compositions may be found in, for example, “Remington: The Science and Practice of Pharmacy”, Mack Publishing Co., 20^th ed., 2000, and Gilman et al., (Eds), (1990), “Goodman And Gilman's: The Pharmacological Bases of Therapeutics”, Pergamon Press. [0081] Pharmaceutically acceptable carriers and excipients include: (i) a liquid carrier; (ii) an isotonic agent; (iii) a wetting or emulsifying agent; (iv) a preservative; (v) a buffer; (vi) an acidifying agent; (vii) an antioxidant; (viii) an alkalinizing agent; (ix) a carrying agent; (x) a chelating agent; (xi) a coloring agent; (xii) a complexing agent; (xiii) a solvent; (xiv) a suspending and/or viscosity-increasing agent; (xv) an oil; (xvi) a penetration enhancer; (xvii) a polymer; (xviii) a stiffening agent; (xix) a protein; (xx) a carbohydrate; (xxi) a bulking agent; and (xxii) a lubricating agent. [0082] Other pharmaceutically acceptable carriers and excipients known in the art may be used. [0083] The carriers, diluents, excipients and adjuvants must be “acceptable” in terms of being compatible with the other ingredients of the composition or medicament, and are generally not deleterious to the subject thereof. Non-limiting examples of pharmaceutically acceptable carriers or diluents are demineralised or distilled water; saline solution; vegetable-based oils such as peanut oil, safflower oil, olive oil, cottonseed oil, maize oil; sesame oils such as peanut oil, safflower oil, olive oil, cottonseed oil, maize oil, sesame oil, arachis oil or coconut oil; silicone oils, including polysiloxanes, such as methyl polysiloxane, phenyl polysiloxane and methylphenyl polysolpoxane; volatile silicones; mineral oils such as liquid paraffin, soft paraffin or squalane; cellulose derivatives such as methyl cellulose, ethyl cellulose, carboxymethylcellulose, sodium carboxymethylcellulose or hydroxylpropyl- methylcellulose; lower alkanols, for example ethanol or isopropanol; lower aralkanols; lower polyalkylene glycols or lower alkylene glycols, for example polyethylene glycol, polypropylene glycol, ethylene glycol, propylene glycol, 1,3- butylene glycol or glycerin; fatty acid esters such as isopropyl palmitate, isopropyl myristate or ethyl oleate; polyvinylpyrolidone; agar; gum tragacanth or gum acacia, and petroleum jelly. Typically, the carrier or carriers will form from about 10% to about 99.9% by weight of the composition, vaccine or medicament. [0084] For administration as an injectable solution or suspension, non-toxic parenterally acceptable diluents or carriers can include, Ringer’s solution, isotonic saline, phosphate buffered saline, ethanol and 1,2 propylene glycol. Methods for preparing parenterally administrable pharmaceutical compositions and medicaments are apparent to those of ordinary skill in the art, and are described in more detail in, for example, “Remington: The Science and Practice of Pharmacy”, Mack Publishing Co., 20^th ed., 2000, and Gilman et al., (Eds), (1990), “Goodman And Gilman's: The Pharmacological Bases of Therapeutics”, Pergamon Press. [0085] For oral administration, some examples of suitable carriers, diluents, excipients and adjuvants include peanut oil, liquid paraffin, sodium carboxymethylcellulose, methylcellulose, sodium alginate, gum acacia, gum tragacanth, dextrose, sucrose, sorbitol, mannitol, gelatin and lecithin. In addition these oral formulations may contain suitable flavouring and colourings agents. When used in capsule form the capsules may be coated with compounds such as glyceryl monostearate or glyceryl stearate which delay disintegration. [0086] Solid forms for oral administration may contain binders acceptable in human and veterinary pharmaceutical practice, sweeteners, disintegrating agents, diluents, flavourings, coating agents, preservatives, lubricants and/or time delay agents. Suitable binders include gum acacia, gelatine, corn starch, gum tragacanth, sodium alginate, carboxymethylcellulose or polyethylene glycol. Suitable sweeteners include sucrose, lactose, glucose, aspartame or saccharine. Suitable disintegrating agents include corn starch, methylcellulose, polyvinylpyrrolidone, guar gum, xanthan gum, bentonite, alginic acid or agar. Suitable diluents include lactose, sorbitol, mannitol, dextrose, kaolin, cellulose, calcium carbonate, calcium silicate or dicalcium phosphate. Suitable flavouring agents include peppermint oil, oil of wintergreen, cherry, orange or raspberry flavouring. Suitable coating agents include polymers or copolymers of acrylic acid and/or methacrylic acid and/or their esters, waxes, fatty alcohols, zein, shellac or gluten. Suitable preservatives include sodium benzoate, vitamin E, alpha-tocopherol, ascorbic acid, methyl paraben, propyl paraben or sodium bisulphite. Suitable lubricants include magnesium stearate, stearic acid, sodium oleate, sodium chloride or talc. Suitable time delay agents include glyceryl monostearate or glyceryl distearate. [0087] Liquid forms for oral administration may contain, in addition to the above agents, a liquid carrier. Suitable liquid carriers include water, oils such as olive oil, peanut oil, sesame oil, sunflower oil, safflower oil, arachis oil, coconut oil, liquid paraffin, ethylene glycol, propylene glycol, polyethylene glycol, ethanol, propanol, isopropanol, glycerol, fatty alcohols, triglycerides or mixtures thereof. [0088] Suspensions for oral administration may further comprise dispersing agents and/or suspending agents. Suitable suspending agents include sodium carboxymethylcellulose, methylcellulose, hydroxypropylmethyl-cellulose, poly-vinyl- pyrrolidone, sodium alginate or acetyl alcohol. Suitable dispersing agents include lecithin, polyoxyethylene esters of fatty acids such as stearic acid, polyoxyethylene sorbitol mono- or di-oleate, -stearate or- laurate, polyoxyethylene sorbitan mono- or di-oleate, -stearate or -laurate and the like. [0089] In certain embodiments, the pharmaceutical composition may comprise a liposome. A liposomal formulation suitable for bisantrene or a cardioprotective derivative thereof comprises small unilamellar or multilamellar liposomes of size range between 0.01 and 100 ^M, and between about 50-95% liposome-entrapped bisantrene, composed of hydrogenated soy phosphatidylcholine, distearoyl phosphatidylglycerol, and cholesterol of natural or synthetic origin lipids, in aqueous solution which can be reconstituted from a lyophilized form to an injectable liposome suspension. The composition is prepared by reconstituting a lyophilized bisantrene/liposome composition to a liposome concentrate, then diluting the concentrate for parenteral administration for the treatment of melanoma. [0090] In yet another embodiment, the pharmaceutical composition may comprise a complex with a beta-cyclodextrin. A liposomal formulation suitable for bisantrene, a therapeutically active derivative of bisantrene, or a pharmaceutically acceptable salt of bisantrene or derivative thereof, comprises a complex formed in aqueous solution which may be reconstituted from a lyophilized form to an injectable suspension. One such composition is prepared by reconstituting a lyophilized bisantrene/beta- cyclodextrin composition to a concentrate, then diluting the concentrate for parenteral administration. Beta-cyclodextrin complexes and methods for preparing such complexes are known in the art and are described in, for example, WO 2019/073296 by Rothman. [0091] Various formulations suitable for use in the administration of bisantrene, a therapeutically active derivative of bisantrene, or a pharmaceutically acceptable salt of bisantrene or derivative thereof, are known in the art. United States Patent No. 4,784,845 to Desai et al. discloses a composition for delivery of a hydrophobic drug comprising: (i) the hydrophobic drug; (ii) an oleaginous vehicle or oil phase that is substantially free of butylated hydroxyanisole (BHA) or butylated hydroxytoluene (BHT); (iii) a co-surfactant or emulsifier; (iv) a co-surfactant or auxiliary emulsifier; and (v) benzyl alcohol as a co-solvent. United States Patent No.4,816,247 by Desai et al. discloses a composition for delivery by intravenous, intramuscular, or intraarticular routes of hydrophobic drugs (such as bisantrene or analog thereof) comprising: (i) the hydrophobic drug; (ii) a pharmaceutically acceptable oleaginous vehicle or oil selected from the group consisting of: (a) naturally occurring vegetable oils and (b) semisynthetic mono-, di-, and triglycerides, wherein the oleaginous vehicle or oil is free of BHT or BHA; (iii) a surfactant or emulsifier; (iv) a co-surfactant or emulsifier; (v) an ion-pair former selected from C6-C20 saturated or unsaturated aliphatic acids when the hydrophobic drug is basic and a pharmaceutically acceptable aromatic amine when the hydrophobic drug is acidic; and (vi) water. [0092] According to certain embodiments, compositions according to the present invention may be adapted for administration of bisantrene at a dosage of from about 0.1 mg/m²/day to about 100 mg/m²/day, such as from about 0.2 mg/m²/day to about 50 mg/m²/day, from about 0.5 mg/m²/day to about 20 mg/m²/day, from about 1.0 mg/m²/day to about 10 mg/m²/day, from about 1.0 mg/m²/day to about 8 mg/m²/day, about 1 mg/m²/day, about 2 mg/m²/day, about 3 mg/m²/day, about 4 mg/m²/day, about 5 mg/m²/day, about 6 mg/m²/day, about 7 mg/m²/day, or about 10 mg/m²/day. In some embodiments, compositions according to the present invention may be adapted for administration of bisantrene once or multiple times daily or weekly, once every two weeks, once every three weeks, once every four weeks, over a period of, for example, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 21 days, 28 days, 35 days, 42 days, 49 days, 56 days or 63 days. In certain embodiments, compositions according to the present invention may be adapted for administration of bisantrene over a period of 28 days, optionally once or multiple times daily or weekly, once every two weeks, once every three weeks, once every four weeks, at a dosage of about 20-50 mg/m²/28 days. Compositions according to the present invention comprising pharmaceutically acceptable salts of bisantrene or therapeutically active derivatives or pharmaceutically acceptable salts thereof may be adapted to deliver similar dosage rates, adjusted for molar equivalence. [0093] Dosing regimens for protein kinase inhibitors will depend on the particular protein kinase inhibitor, and have been published for known protein kinase inhibitors, including for treatment of melanoma. In addition, suitable dosages of a given protein kinase inhibitor can be readily determined by one of ordinary skill in the art using known approaches and techniques as discussed above in relation to bisantrene. Compositions according to the invention may be formulated to include the protein kinase(s) at their recommended dosage rates, or different dosage rates as discussed below. [0094] According to certain embodiments, and as a result of the synergistic biologic activity observed when bisantrene (or derivative of bisantrene, or a pharmaceutically acceptable salt of either) is administered with a protein kinase inhibitor, the dosage of protein kinase in a composition according to the present invention may be lower than it would be when administered to a patient by itself. This is particularly important for active agents with deleterious side-effects, such as cardiotoxicity. Thus, in certain embodiments of compositions according to the present invention, the protein kinase inhibitor may be included in the composition at a dosage which is significantly lower than the recommended dosage rate for that protein kinase inhibitor when administered alone, such as at a rate which is at least 10%, 20%, 30%, 40%, 50%, 60% or 70% lower than the dosage rate for that protein kinase inhibitor when administered alone. [0095] Similarly, where compositions according to the present invention include an additional therapeutic agent, being a checkpoint inhibitor and/or an immunomodulator, that additional therapeutic agent may be included in the composition at its known recommended rate(s) for the treatment of melanoma, or even lower rates if synergy amongst the components is determined. Uses of compositions for the manufacture of medicaments for the treatment of melanoma [0096] The present invention also provides uses of compositions according to the invention for the manufacture of a medicament for the treatment of melanoma, especially protein kinase resistant melanoma in a patient. [0097] The parameters for such manufacture, including protein kinase inhibitors, bisantrene, bisantrene derivatives and salts thereof, as well as checkpoint inhibitors and immunomodulators as optional additional therapeutic agent(s), and dosages/dosing for all actives, dosage forms and other components are described above. Kits for the treatment of melanoma [0098] The present invention also provides kits for the treatment of melanoma, especially protein kinase resistant melanoma, the kit comprising at least one protein kinase inhibitor and at least a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof. [0099] The parameters for such kits, including protein kinase inhibitors, bisantrene, bisantrene derivatives and salts thereof, as well as checkpoint inhibitors and immunomodulators as optional additional therapeutic agent(s), and dosages/dosing for all actives, dosage forms and other components are described above. [0100] In some cases, the kit may also comprise vials, tubes, needles, packaging, or other materials. [0101] Kits with unit doses of one or more of the active agents described herein, usually in injectable doses, are provided. Such kits may include containers containing unit doses, informational package inserts describing the use and attendant benefits of the drugs in treating the disease, and optionally appliance(s) or device(s) for delivery of the composition. [0102] The kit may further comprise any device suitable for administration of the composition. For example, a kit may comprise a needle suitable for intravenous administration. [0103] In some cases, kits may be provided with instructions. The instructions may be provided in the kit or they may be accessed electronically. The instructions may provide information on how to use the compositions of the present disclosure. The instructions may further provide information on how to use the devices of the present disclosure. The instructions may provide information on how to perform the methods of the disclosure. In some cases, the instructions may provide dosing information. The instructions may provide drug information such as the mechanism of action, the formulation of the drug, adverse risks, contraindications, and the like. In some cases, the kit is purchased by a physician or health care provider for administration at a clinic or hospital. In some cases, the kit is purchased by a laboratory and used for screening candidate compounds. [0104] Preferred forms of the present invention will now be described, by way of example only, with reference to the following examples, including comparative data, and which are not to be taken to be limiting to the scope or spirit of the invention in any way. EXAMPLES Example 1: Bisantrene IC50 curves and time courses in melanoma cell lines and patient isolates [0105] All melanoma cell lines were grown in DMEM with 5% foetal calf serum and incubated at 37°C. Cells were grown to 70% to 80% confluence and were detached using trypsinisation and passaged. [0106] The effects of bisantrene on cell viability was assayed using a 7-step dilution series in the range 0.1 nM-100 µM. Melanoma cell lines or patient isolates were plated on a 96-well plate at a concentration of 1x10⁴ cells/well and were treated with bisantrene in triplicate at each concentration with comparison to vehicle controls. Cell viability was assessed 72 h post-treatment using the VisionBlue™ Quick Cell Viability Assay kit (Abcam, Cambridgeshire, UK). IC50 curves were determined using the inhibitor vs normalized response, four parameter non-linear regression analysis in GraphPad PRISM v9. [0107] The emergence of drug resistance in melanoma patients receiving BRAF- targeting drugs is a primary contributor to treatment failure and disease progression. Options for secondary treatments following BRAF-inhibitor resistance remain limited, creating a desperate need for new agents able effectively kills melanoma cells following treatment failure. [0108] Administration of bisantrene to primary tumor isolates taken from two BRAF- positive melanoma patients taken prior to and after the emergence of treatment resistance in vitro demonstrated modest decreases in cytotoxic activity (Figure 1). These results demonstrate that bisantrene is able to effectively kill melanoma cells irrespective of sensitivity to BRAF-targeting drugs. Example 2: Combined BRAF inhibitor and bisantrene melanoma cell treatments and Webb Analyses thereof [0109] Melanoma cells were plated on a 96-well plate as described in Example 2. 2D synergy modeling was performed by treating cells with increasing doses of bisantrene (0 nM to 250 nM) and/or increasing doses of MEK (cobimetinib or binimetinib) or BRAF inhibitors (vemurafenib) (0 nM to 30 nM) (Sigma Aldrich, Missouri, USA,). Cell proliferation was determined 72 h post-treatment, and values normalized to vehicle controls followed by Webb analysis. [0110] Synergy analysis of the drug treatments combination were assessed using the fraction product method of Webb (Webb J (1963), “Effect of more than one inhibitor” In: Hochster E.R., Quastel J. (eds). “Enzymes and metabolic inhibitors”, Academic Press: New York) using SynergyFinder 2.0 software (Ianevski A, Giri AK, Aittokallio T (2020): “SynergyFinder 2.0: visual analytics of multi‐drug combination synergies”, Nucleic Acids Res., 48(W1):W488‐W493). [0111] Fractional Product Method of Webb: Webb, in 1963 (Webb J (1963), “Effect of more than one inhibitor” In: Hochster E.R., Quastel J. (eds). “Enzymes and metabolic inhibitors”, Academic Press: New York), introduced a method that was later termed the “fractional product” method (Chou T‐C. (2020), “Theoretical Basis, Experimental Design, and Computerized Simulation of Synergism and Antagonism in Drug Combination Studies”, Pharmacological Reviews, 58(3):621‐681). It estimates the expected additive effect of two drugs using the fractional product of the effect of each drug alone, i.e.: 1 – Fa(Drug1 + Drug2) = (1 ‐ FaDrug1)*(1 – FaDrug2) Where Fa = the fraction of cells affected, expressed as a decimal. [0112] An observed Fa(Drug1+Drug2) value greater than the expected Fa(Drug1+Drug2) value result indicates synergy, whereas an observed Fa(Drug1+Drug2) lower than the expected value indicates antagonism. The method of Webb therefore takes into account the potency of each drug at a particular dose, however does not consider the shape of the dose‐response curve as a whole. The result is considered as: ^ Result values <‐0.1 indicates synergy ^ Result values between ‐0.1 and 0.1 indicate additivity ^ Result values >0.1 indicates antagonism [0113] Webb synergy analysis was used to assess the effects of bisantrene/BRAF inhibitor cotreatment in the mutant BRAF melanoma cell lines IgR3 and A375, and BRAF wildtype Mel-RMu primary cells, revealing synergy across multiple drug doses for bisantrene and BRAF inhibitors cobimetinib, binimetinib and vemurafenib (Fig.2- 4). The strongest synergy was observed for bisantrene in combination with cobimetinib, with synergism also seen with binimetinib and cobimetinib in two of the three cell lines tested. In particular, high dose combinations of bisantrene and vemurafenib produced robust synergistic killing in both A375 and Mel-RMu cells. Example 3: Combination treatment in BRAF-mutant xenograft models [0114] In order to assess the efficacy of bisantrene/BRAF inhibitor combinations in melanoma bisantrene was combined with the commonly used BRAF inhibitor vemurafenib in NOD/SCID mice engrafted with human BRAF-mutated IgR3 melanoma cells. The combination of 15 mg/kg bisantrene IV every second day with 30 mg/kg vemurafenib PO six days out of every seven produced a significantly larger decrease in volume of subcutaneously engrafted tumors relative to either matched dose bisantrene or vemurafenib-alone from Day 29 until study endpoint (Figure 5). Significant decreases in tumor volume were also seen from Day 24 until study endpoint for vemurafenib, bisantrene and the bisantrene/vemurafenib combination when compared to vehicle treated animals. These results demonstrate that bisantrene is able to potentiate the efficacy of BRAF-targeted therapy in vivo. [0115] NOD/SCID mice (Jackson Labs, ARC, Western Australia) were acclimated for 7 days before the commencement of experiments. Mice were xenografted with the BRAF-mutant cell line IgR3 (1x10⁶ cells in 200 µL) supplemented with 20% Matrigel™ (Corning Life Sciences, New York, USA). After the development of tumors approximately 11 days post xenografting, mice were treated with the BRAF-inhibitor vemurafenib (suspended in 0.5% w/v methylcellulose, 0.2% w/v Tween-80) 6 days per week (30 mg/kg oral gavage) and/or bisantrene every second day (15 mg/kg, intravenous injection). Mouse body weight and tumor growth were monitored daily using calipers (Vernier caliper). Mice were euthanised on study day 30, or when their tumor burden exceeded a volume of 2000 mm³ as determined using the Length x Width x Width/2 approach. Significant differences between groups were calculated using the 2-way ANOVA with Tukey’s test for multiple comparisons tool in GraphPad PRISM v9. ADVANTAGES OF THE INVENTION [0116] The present invention provides a new paradigm for treating of melanoma by the administration of bisantrene, an antineoplastic agent that has multiple mechanisms of action, including DNA intercalation, inhibition of topoisomerase, inhibition of the Fat and obesity associated protein (FTO), and activation of the immune system. Bisantrene is well tolerated and, in particular, shows lower cardiotoxicity that is characteristic of other anthracene and anthracycline derivatives. Bisantrene can be used together with other therapeutic agents that are used for the treatment of melanoma. [0117] Methods according to the present invention possess industrial applicability for the preparation of a medicament for the treatment of melanoma or for the use of the agents described herein for the treatment of melanoma, and compositions according to the present invention possess industrial applicability as pharmaceutical compositions for the treatment of melanoma. [0118] The inventions illustratively described herein can suitably be practiced in the absence of any element or elements, limitation or limitations, not specifically disclosed herein. Thus, for example, the terms “comprising,” “including,” “containing,” etc. shall be read expansively and without limitation. As used herein the use of the term “comprising” as a transitional phrase in claims is intended to include therein the use of the transitional phrases “consisting essentially of” or “consisting of” if the narrower transitional phrases are not expressly excluded. Additionally, the terms and expressions employed herein have been used as terms of description and not of limitation, and there is no intention in the use of such terms and expressions of excluding any equivalents of the future shown and described or any portion thereof, and it is recognized that various modifications are possible within the scope of the invention claimed. Thus, it should be understood that although the present invention has been specifically disclosed by preferred embodiments and optional features, modification and variation of the inventions herein disclosed can be resorted by those skilled in the art, and that such modifications and variations are considered to be within the scope of the inventions disclosed herein. The inventions have been described broadly and generically herein. Each of the narrower species and subgeneric groupings falling within the scope of the generic disclosure also form part of these inventions. This includes the generic description of each invention with a proviso or negative limitation removing any subject matter from the genus, regardless of whether or not the excised materials specifically resided therein.

Claims

Claims:

1 . A method of treating a patient with melanoma, said method comprising administering to said patient a therapeutically effective amount of at least one targeted agent and an effective amount of at least a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof.

2. The method of claim 1 , wherein said targeted agent is a protein kinase inhibitor.

3. The method of claim 1 or claim 2, wherein said protein kinase inhibitor inhibits one or more of RAS, MEK and BRAF.

4. The method of claim 2, wherein said protein kinase inhibitor is selected from the group consisting of:

(a) binimetinib

(b) cobimetinib

(c) dabrafenib

(d) encorafenib

(e) trametinib

(f) vemurafenib

5. The method of claim 2, wherein said protein kinase inhibitor is selected from the group consisting of:

(a) binimetinib

(b) cobimetinib

(c) vemurafenib

6. The method of any one of claims 1 to 5, wherein said second agent is bisantrene or a pharmaceutically acceptable salt thereof.

7. The method of any one of claims 1 to 6 which comprises administering to said patient a therapeutically effective amount of one protein kinase inhibitor and a therapeutically effective amount of bisantrene or a pharmaceutically acceptable salt thereof.

8. The method of any one of claims 1 to 7 which comprises treatment of advanced melanoma, optionally protein kinase inhibitor resistant melanoma.

9. The method of any one of claims 1 to 8, further comprising administration of at least one additional therapeutic agent for the treatment of advanced melanoma, optionally protein kinase inhibitor resistant melanoma.

10. The method of claim 9, wherein the additional therapeutic agent is a checkpoint inhibitor drug or an immunomodulator.

11. The method of claim 10, wherein the at least one additional therapeutic agent is selected from the group consisting of:

(a) ipilimumab;

(b) nivolumab;

(c) nivolumab and relatlimab-rmbw;

(d) pembrolizumab;

(e) talimogene laherparepvec;

(f) tebentafusp-tebn;

(g) interleukin-2; and

(h) proleukin.

12. The method of any one of claims 1 to 11 comprising administering said at least one protein kinase inhibitor to said patient prior to, simultaneously with, or after administration of said second agent to said patient.

13. The method of any one of claims 1 to 11 , wherein said at least one protein kinase inhibitor and the second agent are administered to said patient at the same time, optionally in a single composition.

14. The method of any one of claims 1 to 13, wherein the dose of said at least one protein kinase inhibitor is at least 20% lower than the dose required of said at least one protein kinase inhibitor agent when administered without said second agent to achieve the same targeted outcome.

15. A pharmaceutical composition for the treatment of melanoma comprising at least one protein kinase inhibitor and a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof.

16. The composition of claim 15, wherein said targeted agent is a protein kinase inhibitor.

17. The composition of claim 16, wherein said protein kinase inhibitor inhibits one or more of RAS, MEK and BRAF.

18. The composition of claim 16, wherein said at least one protein kinase inhibitor is selected from the group consisting of:

(a) binimetinib

(b) cobimetinib

(c) dabrafenib

(d) encorafenib

(e) trametinib

(f) vemurafenib

19. The composition of claim 16, wherein said at least one protein kinase inhibitor is selected from the group consisting of:

(a) binimetinib

(b) cobimetinib

(c) vemurafenib

20. The composition of any one of claims 15 to 19, further comprising at least one additional therapeutic agent for the treatment of advanced melanoma, optionally protein kinase inhibitor resistant melanoma.

21. The composition of claim 20, wherein the additional therapeutic agent is a checkpoint inhibitor drug or an immunomodulator, optionally selected from the group consisting of:

(a) ipilimumab;

(b) nivolumab;

(c) nivolumab and relatlimab-rmbw;

(d) pembrolizumab;

(e) talimogene laherparepvec;

(f) tebentafusp-tebn;

(g) interleukin-2; and

(h) proleukin.

22. The composition of any one of claims 15 to 21 , wherein said second agent is bisantrene or a pharmaceutically acceptable salt thereof.

23. The composition of any one of claims 15 to 22 which comprises a therapeutically effective amount of one protein kinase inhibitor and a therapeutically effective amount of bisantrene or a pharmaceutically acceptable salt thereof.

24. The composition of any one of claims 15 to 23 for the treatment of advanced melanoma, optionally protein kinase inhibitor resistant melanoma.

25. Use of a composition according to any one of claims 15 to 24 for the manufacture of a medicament for the treatment of melanoma in a patient.

26. The use of claim 25, wherein said medicament is for the treatment of advanced melanoma, optionally protein kinase inhibitor resistant melanoma.

27. The use of claim 25 or claim 26, wherein said medicament comprises one protein kinase inhibitor and bisantrene or a pharmaceutically acceptable salt thereof.

28. A kit for the treatment of melanoma, said kit comprising at least one targeted agent and at least a second agent comprising bisantrene or a derivative thereof, or a pharmaceutically acceptable salt of bisantrene or derivative thereof.

29. The kit of claim 28, wherein said at least one targeted agent is a protein kinase inhibitor.

30. The kit of claim 29, wherein said at least one protein kinase inhibitor inhibits one or more of RAS, MEK and BRAF.

31. The kit of claim 29 wherein said at least one protein kinase inhibitor is selected from the group consisting of:

(a) binimetinib

(b) cobimetinib

(c) dabrafenib

(d) encorafenib

(e) trametinib

(f) vemurafenib

32. The kit of any one of claims 28 to 31 , wherein said second agent is bisantrene or a pharmaceutically acceptable salt thereof.

33. The kit of any one of claims 28 to 31 which comprises one protein kinase inhibitor and bisantrene or a pharmaceutically acceptable salt thereof.

34. The kit of any one of claims 28 to 33, further comprising at least one additional therapeutic agent for the treatment of melanoma.

35. The kit of claim 34, wherein the additional therapeutic agent is a checkpoint inhibitor drug or an immunomodulator, optionally selected from the group consisting of:

(a) ipilimumab;

(b) nivolumab;

(c) nivolumab and relatlimab-rmbw;

(d) pembrolizumab; (e) talimogene laherparepvec;

(f) tebentafusp-tebn;

(g) interleukin-2; and

(h) proleukin.

36. The kit of any one of claims 28 to 35 for the treatment of advanced melanoma, optionally protein kinase inhibitor resistant melanoma.