Note: Descriptions are shown in the official language in which they were submitted.
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TREATMENT OF ADVANCED METASTATIC CANCER
FIELD OF THE INVENTION
This invention relates to treatment of advanced metastatic cancer, in
particular,
advanced hepatocellular carcinoma, comprising administration of an A3AR
ligand.
BACKGROUND OF THE INVENTION
Primary liver cancer, and specifically hepatocellular carcinoma (HCC), is a
major global health problem due to its incidence, associated mortality, and
lack of
effective treatment modalities, particularly for patients with moderate or
advanced
hepatic dysfunction.
Patients with advanced HCC and Child¨Pugh B (CPB) cirrhosis have a
borderline liver function, and therefore the benefit of any therapy might be
offset by the
decline in their liver function. The only curative option for these patients
involves
successful downstaging and liver transplantation. However, this approach is
appropriate
only for a minority of patients and is further limited by the restricted
number of livers
available for transplantation [Granito A., and Bolondi L. Lancet Oncol.
2017;18: e101¨
e1121. The most common treatment for HCC and CPB is the multikinase inhibitor
sorafenib, which is approved by the US Food and Drug Administration (FDA) for
advanced HCC regardless of liver function.
CPB patients are generally excluded from clinical studies due to their poor
prognosis and low expected response rate [Llovet J.M., et al. J. Natl. Cancer
Inst. 2008;
100:698-7111. Clearly, therapies for HCC and CPB cirrhosis are still needed.
The Gi protein-coupled A3 adenosine receptor (A3AR) is overexpressed in
different types of solid tumors, including melanoma, breast, colon, and
prostate cancer,
and HCC, whereas low receptor expression is found in adjacent normal tissues
[Bar-
Yehuda S., et al. Int. J. Oncol. 2008; 33:287-2951.
Namodenoson, generically known as CI-IB-MECA, is a highly selective orally
bioavailable A3AR agonist that induces an apoptotic effect towards HCC in
syngeneic
orthotopic and xenograft experimental animal models [Cohen S., et al., J. Cell
Physiol. 2011; 226:2438-24471.
Date Recue/Date Received 2021-12-29
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In an open-label phase I/II trial, the safety and efficacy of namodenoson were
assessed in patients with advanced unresectable HCC, 67% of whom failed prior
sorafenib treatment. Median overall survival (OS) was 7.8 months for the whole
study
population, and for CPB patients (28%), it was 8.1 months. Namodenoson was
safe and
well-tolerated, and a direct correlation between A3AR expression levels at
baseline and
tumor response to namodenoson was found [Stemmer S.M., et al. Oncologist.
2013;
18:25-26].
SUMMARY OF THE INVENTION
In a first of its aspects, the present invention provides an A3 adenosine
receptor
(A3AR) ligand for use in the treatment of an advanced solid tumor in a
mammalian
subject.
In another aspect, the present invention provides a pharmaceutical composition
comprising an A3AR ligand, and a pharmaceutically acceptable carrier or
diluent,
wherein said pharmaceutical composition is for treating an advanced solid
tumor in a
mammalian subject.
In an embodiment, said advanced solid tumor is advanced hepatocellular
carcinoma.
In an embodiment, said advanced solid tumor is metastatic hepatocellular
carcinoma.
In an embodiment, said subject has advanced hepatocellular carcinoma with
Child¨Pugh B (CPB) cirrhosis score of 7 (CPB7), Child¨Pugh B (CPB) cirrhosis
score
of 8 (CPB8), or Child¨Pugh B (CPB) cirrhosis score of 9 (CPB9).
In an embodiment, said A3AR ligand is an A3AR agonist or an A3AR allosteric
modulator.
In some embodiments, said A3AR agonist is selected from the group consisting
of N6-2- (4-aminophenyl)ethyladenosine (APNEA), N6-(4-amino-3-iodobenzyl)
adenos ine-5'-(N-methy luronami de) (AB-MECA), N6-(3-iodobenzy1)-adenosine-5'-
N-
methyluronamide (IB-MECA) and 2-chloro-N6-(3-iodobenzy1)- adenosine-5'-N-
methyluronamide (Cl-IB-MECA, namodenoson).
Date Recue/Date Received 2021-12-29
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In some embodiments, said A3AR allosteric modulator is selected from the group
consisting of:
N-(3,4-Dichloro-pheny1)-2-cyclopenty1-1H-imidazo[4,5-c] quinolin-4-amine;
N-(3,4-Dichloro-pheny1)-2-cyclohepty1-1H-imidazo[4,5-c] quinolin-4-amine;
N-(3,4-Dichloro-pheny1)-2-cyclobuty1-1H-imidazo[4,5-clquinolin-4-amine; and
N-(3,4-Dichloro-pheny1)-2-cyclohexy1-1H-imidazo [4,5-c] quinolin-4-amine.
In an embodiment, the treatment further comprises administration of an
additional
therapeutic agent.
In some embodiments, said additional therapeutic agent is an anti-cancer drug,
e.g., a monoclonal antibody and/or a multi-kinase inhibitor.
In some embodiments, said A3AR ligand is administered once daily, twice daily,
or thrice daily.
In an embodiment, said A3AR ligand is administered every 12 hours throughout
the treatment period.
In an embodiment, said A3AR ligand is administered in a continuous manner.
In an embodiment, said treatment period is divided into cycles (e.g., 4-week
cycles).
In an embodiment, said mammalian subject is a human subject.
In some embodiments, said A3AR ligand is administered at an amount of
50 g/kg-10mg/kg body weight, preferably 100 g/kg-5 mg/Kg body weight, or
200 g/kg-lmg/Kg body weight.
In a specific embodiment, said A3AR ligand is CI-IB-MECA which is
administered orally in a dose of 1-50mg, preferably 5-30 mg twice daily.
In a specific embodiment, said subject received the A3AR ligand as a second-
line
therapy.
In a specific embodiment, said administration is for a treatment period of at
least
9 months, at least 10 months, at least one year, at least 2 years, at least 3
years, at least 4
years or at least 5 years.
Date Recue/Date Received 2021-12-29
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In another aspect, the present invention provides a method of increasing
overall
survival of subjects with advanced HCC and a CPB7 score, said method comprises
administering an A3AR ligand (e.g., CI-IB-MECA) to said subject.
In a specific embodiment, said increase in overall survival is measured after
a
treatment period of 9 months, 10 months, 12 months or more, and wherein said
treatment comprises administration of the A3AR ligand (e.g., CI-IB-MECA)
orally in a
dose of 1-50mg, preferably 5-30 mg twice daily.
In another aspect, the present invention provides a kit comprising:
(a) a pharmaceutical composition comprising an A3AR ligand as described
above;
(b) instructions for administration of the pharmaceutical composition for the
treatment of a subject with an advanced solid tumor.
BRIEF DESCRIPTION OF THE DRAWINGS
In order to understand the invention and to see how it may be carried out in
practice, a preferred embodiment will now be described, by way of non-limiting
example only, with reference to the accompanying drawings, in which:
Fig. 1 is a graph showing comparison of 12-month Overall Survival (OS) Rate
in Patients with Child-Pugh Score 7 (Namodenoson 25 mg BID vs placebo).
DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS
The present invention is based on the surprising finding that a patient with
advanced HCC with CPB that was treated with namodenoson (CI-IB-MECA) showed
unprecedent results and complete remission of the cancer after 5 years of
treatment. The
patient was included in a randomized, placebo-controlled, phase II study
evaluating the
efficacy/safety of namodenoson versus placebo in advanced HCC CPB patients.
Moreover, the phase II study showed a surprising efficacy of namodenoson in
increasing 12-months overall survival rate of the treated patients.
Date Recue/Date Received 2021-12-29
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The invention is described in the following detailed description with
reference to
therapeutic methods for the treatment of advanced solid tumors, in particular,
HCC with
CPB involving administration of an A3AR ligand to a subject in need of same.
As used in the specification and claims, the forms "a", "an" and "the" include
singular as well as plural references unless the context clearly dictates
otherwise. For
example, the term "an A3AR ligand' includes one or more ligands.
Further, as used herein, the term "comprising" is intended to mean that the
method
or composition includes the recited elements but does not exclude others.
Similarly,
"consisting essentially of is used to define methods and compositions that
include the
recited elements but exclude other elements that may have an essential
significant
therapeutic activity towards joint inflammation. For example, a composition
consisting
essentially of an A3AR ligand will not include or include only insignificant
amounts
(amounts that will have an insignificant effect on joint inflammation) of
other active
ingredients that have such an activity. Also, a composition consisting
essentially of the
A3AR ligand as defined herein would not exclude trace contaminants from the
isolation
and purification method, pharmaceutically acceptable carriers, such as
phosphate buffered
saline, excipients, preservatives, and the like. "Consisting of shall mean
excluding more
than trace elements of other elements. Embodiments defined by each of these
transition
terms are within the scope of this invention.
Further, all numerical values, e.g., concentration or dose or ranges thereof,
are
approximations which are varied (+) or (-) by up to 20%, at times by up to 10%
of the
stated values. It is to be understood, even if not always explicitly stated
that all numerical
designations are preceded by the term "about". It also is to be understood,
although not
always explicitly stated, that the reagents described herein are merely
exemplary and that
equivalents of such are known in the art.
There is provided by the present invention a method of treating an advanced
solid
tumor said method comprising administering to a mammalian subject in need
thereof an
A3 adenosine receptor (A3AR) ligand or a pharmaceutical composition comprising
said
A3AR ligand.
In a specific embodiment, the advanced solid tumor is advanced hepatocellular
carcinoma (HCC).
Date Recue/Date Received 2021-12-29
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In the context of the present invention the term "treatment" comprises
treating
an advanced solid tumor, e.g., advanced HCC by administering a therapeutically
effective amount of an A3AR ligand to achieve a desired therapeutic effect.
The desired
therapeutic effect may include, without being limited thereto, complete, or
partial
reversal of disease symptoms, clearing of the cancer lesions, increasing
survival,
achieving disappearance of ascites, normal liver function, and the
disappearance of
peritoneal carcinomatosis.
As used herein the term "advanced solid tumor" refers to a malignant solid
neoplasm that has spread extensively to other anatomic sites or is no longer
responding to
treatment. Non-limiting examples of malignant solid neoplasms include
carcinomas (e.g.,
adenocarcinoma, breast carcinoma, ovarian carcinoma, non-small cell lung
cancer,
bladder cancer, prostate cancer, colon cancer, hepatocellular carcinoma,
squamous cell
carcinoma or glioma), and sarcomas (e.g., bone, tendon, cartilage, muscle, or
fat
sarcomas).
As used herein the term "advanced hepatocellular carcinoma" refers to an
advanced (metastatic) liver cancer which has spread either to the lymph nodes
or to other
organs. At such a stage the cancer is widespread and generally cannot be
removed by
surgery.
In an embodiment, the present invention concerns patients with hepatocellular
carcinoma which is associated with cirrhosis. The cirrhotic state of the liver
can be
assessed using the Child-Pugh scoring system (also known as the Child-Pugh-
Turcotte
score) that was designed to predict mortality in cirrhosis patients. This
scoring system
breaks down patients into three categories: A - good hepatic function, B -
moderately
impaired hepatic function, and C - advanced hepatic dysfunction. The scoring
system uses
five clinical and laboratory criteria to categorize patients: serum bilirubin,
serum albumin,
ascites, neurological disorder (encephalopathy), and prothrombin time, each of
these
criteria being defined using a numerical value which together define the
severity
of cirrhosis:
= Child-Pugh A: 5 to 6 points
= Child-Pugh B: 7 to 9 points
Date Recue/Date Received 2021-12-29
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= Child-Pugh C: 10 to 15 points
In accordance with the invention, the subject may have advanced hepatocellular
carcinoma with Child¨Pugh B cirrhosis score of 7 to 9 points, namely
Child¨Pugh B
(CPB) cirrhosis score of 7 (CPB7), Child¨Pugh B (CPB) cirrhosis score of 8
(CPB8), or
Child¨Pugh B (CPB) cirrhosis score of 9 (CPB9).
In accordance with one embodiment of the invention the subjects are treated
with
the A3AR ligand as a second-line therapy, namely the subjects were previously
treated
with another anti-cancer drug and the therapy failed. In other words, in some
embodiments, the subjects in accordance with the present invention are
patients with
advanced HCC with CPS7-CPS9 score who failed other treatment regimens.
In an embodiment, the present invention provides a method of increasing
overall
survival of patients with advanced HCC with a CPB7 score.
In a specific embodiment, said increase is a 12-months or more increase in
overall survival.
As used herein, the term "an A3 adenosine receptor (A3AR) ligand" encompasses
A3AR agonists as well as A3AR allosteric modulators.
A3AR agonists are known in the art and are readily available. Generally, an
A3AR
agonist is any compound that is capable of specifically binding to the
adenosine A3
receptor ('A3R'), thereby fully or partially activating said receptor thereby
yielding a
therapeutic effect (e.g., an anti-arthritic effect). The A3AR agonist is thus
a molecule that
exerts its prime effect through the binding and activation of the A3AR. This
means that at
the doses it is being administered it essentially binds to and activates only
the A3R.
In an embodiment, the A3AR agonist has a binding affinity (K) to the human
A3AR of less than 1000 nM, desirably less than 500 nM, advantageously less 200
nM and
even less than 100 nM, typically less than 50 nM, preferably less than 20 nM,
more
preferably less than 10 nM and ideally less than 5 nM. The lower the K, the
lower the dose
of the A3AR agonist (that may be used) that will be effective in activating
the A3R and thus
achieving a therapeutic effect.
It should be noted that some A3AR agonists can also interact with and activate
other receptors with lower affinities (namely a higher Ki). A molecule will be
considered
an A3AR agonist in the context of the invention (namely a molecule that exerts
its prime
Date Recue/Date Received 2021-12-29
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effect through the binding and activation A3R) if its affinity to the A3R is
at least 3 times
(i.e., its Ki to the A3R is at least 3 times lower), preferably 10 times,
desirably 20 times and
most preferably at least 50 times larger than the affinity to any other of the
adenosine
receptors.
The affinity of A3AR agonists to the human A3R as well as its relative
affinity to
the other human adenosine receptors can be determined by various assays, such
as a
binding assay. Examples of binding assays include providing membranes or cells
having
the receptor and measuring the ability of the A3AR agonist to displace a bound
radioactive
agonist; utilizing cells that display the respective human adenosine receptor
and
measuring, in a functional assay, the ability of the A3AR agonist to activate
or deactivate
downstream signaling events such as the effect on adenylate cyclase measured
through
increase or decrease of the cAMP level; etc. Clearly, if the administered
level of an A3AR
agonist is increased such that its blood level reaches a level approaching
that of the Ki of
the other adenosine receptors, activation of these receptors may occur
following such
administration, in addition to activation of the A3R. An A3AR agonist is thus
preferably
administered at a dose such that the blood level that will be attained will
give rise to
essentially only A3R activation.
The characteristic of some adenosine A3AR agonists and methods of their
preparation are described in detail in, inter alia, US 5,688,774; US
5,773,423;
US 5,573,772; US 5,443,836; US 6,048,865; WO
95/02604; WO 99/20284;
WO 99/06053; WO 97/27173 and WO 01/19360, all of which are incorporated herein
by
reference.
The following examples are specified in US 5,688,774 at column 4, lines 67-
column 6, line 16; column 5, lines 40-45; column 6, lines 21-42; column 7,
lines 1-11;
column 7, lines 34-36; and column 7, lines 60-61:
N6-(3-iodobenzy1)-9-methyladenine;
N6-(3-iodobenzy1)-9-hydroxyethyladenine;
R¨N6-(3-iodobenzy1)-9-(2,3-dihydroxypropyl)adenine;
5¨N6-(3-iodobenzy1)-9-(2,3-dihydroxypropyl)adenine;
N6-(3-iodobenzyladenin-9-yl)acetic acid;
N6-(3-iodobenzy1)-9-(3-cyanopropyl)adenine;
Date Recue/Date Received 2021-12-29
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2-chioro-N6-(3-iodobenzy1)-9-methy1adenine;
2-amino-N6-(3-iodobenzy1)-9-methy1adenine;
2-hydrazido-N6-(3-iodobenzy1)-9-methy1adenine;
N6-(3-iodobenzy1)-2-methy1amino-9-methy1adenine;
2-dimethy1amino-N6-(3-iodobenzy1)-9-methy1adenine;
N6-(3-iodobenzy1)-9-methyl-2-propy1aminoadenine;
2-hexy1amino-N6-(3-iodobenzy1)-9-methy1adenine;
N6-(3-iodobenzy1)-2-methoxy-9-methy1adenine;
N6-(3-iodobenzy1)-9-methyl-2-methy1thioadenine;
N6-(3-iodobenzy1)-9-methyl-2-(4-pyridy1thio)adenine;
(1S, 2R, 3S, 4R)-4-(6-amino-2-pheny1ethy1amino-9H-purin-9-y1)cyclopentane-1,2
,3-trio1;
(1S, 2R, 3S, 4R)-4-(6-amino-2-ch1oro-9H-purin-9-y1) cyciopentane-1,2,3-trio1;
( )-942a,3a-dihydroxy-4f3-(N-methy1carbamoy1)cyc1opent-13-y1)]-N6-(3-
iodobenzy1)-adenine;
2-ch1oro-9-(2'-amino-2',3'-dideoxy-P-D-5'-methy1-arabino-furonamido)-N6-(3-
iodobenzypadenine;
2-ch1oro-9-(2',3'-dideoxy-2'-fluoro-P-D-5'-methy1-arabino
furonamido)-N6-(3-
iodobenzypadenine;
9-(2-acety1-3-deoxy-P-D-5-methy1-ribofuronamido)-2-ch1oro-N6(3-
iodobenzypadenine;
2-ch1oro-9-(3-deoxy-2-methanesulfony1-P-D-5-methy1-ribofuronamido)-N6-(3-
iodobenzypadenine;
2-ch1oro-9-(3-deoxy-P-D-5-methy1-ribofuronamido)-N6-(3-iodobenzypadenine;
2-ch1oro-9-(3,5-1,1,3,3-tetraisopropy1disi1oxy1-P-D-5-ribofuranosy1)-N6-(3-
iodobenzypadenine;
2-ch1oro-9-(2',3'-0-thiocarbony1-P-D-5-methy1-ribofuronamido)-N6-(3-
iodobenzypadenine;
Date Recue/Date Received 2021-12-29
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9-(2-phenoxythiocarbony1-3-deoxy-P-D-5-methyl-ribofuronamido)-2-chloro-N6-
(3-iodobenzyl)adenine;
1-(6-benzylamino-9H-purin-9-y1)-1-deoxy-N,4-dimethyl-P-D-
ribofuranosiduronamide;
2-chloro-9-(2,3-dideoxy-P-D-5-methyl-ribofuronamido)-N6 benzyladenine;
2-chloro-9-(2'-azido-2',3'-dideoxy-P-D-5'-methyl-arabino-furonamido)- N6-
benzyladenine;
2-chloro-9-(P-D-erythrofuranoside)-N6-(3-iodobenzypadenine;
N6-(benzodioxanemethyl)adenosine;
1-(6-furfurylamino-9H-purin-9-y1)-1-deoxy-N-methyl-P-D-
ribofuranosiduronamide;
N643-(L-prolylamino)benzylladenosine-5'-N-methyluronamide;
N643-(P-alanylamino)benzylladenosine-5'-N-methyluronamide;
N643-(N-T-Boc-P-alanylamino)benzylladenosine-S-N-methyluronami de
6-(N-phenylhydrazinyl)purine-9-P-ribofuranoside-5'-N-methyluronamide;
6-(0-phenylhydroxylamino)purine-9-P-ribofuranoside-5'-N-methyluronami de;
9-(P-D-2',3'-dideoxyerythrofuranosyl)-N6-[(3-P-alanylamino)benzylladenosine;
9-(3-D-erythrofuranoside)-2-methylamino-N6-(3-iodobenzypadenine;
2-chloro-N-(3-iodobenzy1)-9-(2-tetrahydrofury1)-9H-purin-6-amine;
2-chloro-(2'-deoxy-6'-thio-L-arabinosyl)adenine; and
2-chloro-(6'-thio-L-arabinosyl)adenine.
In US 5,773,423 at column 6, line 39, to column 7, line 14, specifically
disclosed
are compounds which include the formula:
Date Recue/Date Received 2021-12-29
- 1 1 -
Rs
1
NH
N--.........5N
8 < 2
'X1 N9 ----3
N
0 R2
OH OH
wherein
X1 is R aRbNC(=0), wherein Ra and Rb may be the same or different and are
selected from the group consisting of hydrogen, Ci-Cio alkyl, amino, Ci-Cio
haloalkyl, Ci-
Cio aminoalkyl, and C3-C10 cycloalkyl;
R2 is selected from the group consisting of hydrogen, halo, Ci-Cio alkyoxy,
amino,
C2-C10 alkenyl, and C2-C10 alkynyl; and
R5 is selected from the group consisting of R- and S-1-phenylethyl, an
unsubstituted benzyl group, and a benzyl group substituted in one or more
positions with a
substituent selected from the group consisting of Ci-Cio alkyl, amino, halo,
Ci-Cio
haloalkyl, nitro, hydroxy, acetamido, Ci-Cio alkoxy, and sulfo.
More specific compounds include those of the above formula wherein Ra and Rb
may be the same or different and are selected from the group consisting of
hydrogen and
Ci-Cio alkyl, particularly when R2 is hydrogen or halo, especially hydrogen.
Additional specific compounds are those compounds wherein Ra is hydrogen and
R2 is hydrogen, particularly when R5 is unsubstituted benzyl.
More specific compounds are such compounds wherein Rb is a Ci-Cio alkyl or C3-
C10 cycloalkyl, particularly a Ci-Cio alkyl, and more particularly methyl.
Especially specific are those compounds where Ra is hydrogen, Rb is Ci-Cio
alkyl
or C3-C10 cycloalkyl, and R5 is R- or S-1-phenylethyl or a benzyl substituted
in one or
more positions with a substituent selected from the group consisting of halo,
amino,
Date Recue/Date Received 2021-12-29
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acetamido, Ci-Cio haloalkyl, and sulfo, where the sulfo derivative is a salt,
such as a
triethylammonium salt.
An example of an especially preferred compound disclosed in US 5,773,423 is IB-
MECA. In addition, those compounds in which R2 is a C2-C10 alkenylene of the
formula
Rd¨C=C¨ where Rd is a C1-C8 alkyl are particularly noted in this publication.
Also
specific are those compounds wherein R2 is other than hydrogen, particularly
those
wherein 112 is halo, Ci-Cio alkylamino, or Ci-Cio alkylthio, and, more
preferably, when
additionally Ra is hydrogen, Rb is a Ci-Cio alkyl, and/or 115 is a substituted
benzyl.
Such specifically disclosed compounds include 2-chloro-1\16-(3-iodobenzy1)-945-
(methylamido)-(3-D-ribofuranosyll-adenine, N6-
(3-iodobenzy1)-2-methylamino-9-[5-
(methylamido)-(3-D-ribofuranosyll-adenine, and N6-(3-iodobenzy1)-2-methylthio-
945-
(methylamido)-(3-D-ribofuranosyll-adenine.
Further US 5,773,423 discloses at column 7, line 60, through column 8, line 6,
A3AR agonists as modified xanthine-7-ribosides having the formula:
R8
N--.........43x
8(79 2
N \
R9 1
...._..---5
5'R6 N
p. R7
' 1
0
OH OH
wherein
Xis 0;
R6 is RaRbNC(=0), wherein Ra and Rb may be the same or different and are
selected from the group consisting of hydrogen, Ci-Cio alkyl, amino, Ci-Cio
haloalkyl, Ci-
Cio aminoalkyl, and C3-C10 cycloalkyl;
R7 and R8 may be the same or different and are selected from the group
consisting
of Ci-Cio alkyl, R- and 5-1-phenylethyl, an unsubstituted benzyl group, and a
benzyl group
Date Recue/Date Received 2021-12-29
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substituted in one or more positions with a substituent selected from the
group consisting
of Ci-Cio alkyl, amino, halo, Ci-Cio haloalkyl, nitro, hydroxy, acetamido, Ci-
Cio alkoxy,
and sulfo; and
R9 is selected from the group consisting of halo, benzyl, phenyl, and C3-C10
cycloalkyl.
WO 99/06053 discloses in examples 19-33 compounds selected from:
N6-(4-biphenyl-carbonylamino)-adenosine-5'-N-ethyluronamide;
N6-(2,4-dichlorobenzyl-carbonylamino)-adenosine-5'-N-ethyluronamide;
N6-(4-methoxyphenyl-carbonylamino)-adenosine-5'-N-ethyluronamide;
N6-(4-chlorophenyl-carbonylamino)-adenosine-S-N-ethyluronamide;
N6-(phenyl-carbonylamino)-adenosine-5'-N-ethyluronamide;
N6-(benzylcarbamoylamino)-adenosine-5 '-N-ethyluronamide;
N6-(4-sulfonamido-phenylcarbamoy1)-adenosine-S-N-ethyluronamide;
N6-(4-acetyl-phenylcarbamoy1)-adenosine-5'-N-ethyluronamide;
N6-((R)-a-phenylethylcarbamoy1)-adenosine-5'-N-ethyluronamide;
N6-((S)- a-phenylethylcarbamoy1)-adenosine-5'-N-ethyluronamide;
N6-(5-methyl-isoxazol-3-yl-carbamoy1)-adenosine-5'-N-ethyluronamide;
N6-(1,3,4-thiadiazol-2-yl-carbamoy1)-adenosine-S-N- ethyluronamide;
N6-(4-n-propoxy-phenylcarbamoy1)- adenosine-5'-N-ethyluronamide;
N6-bis-(4-nitrophenylcarbamoy1)-adenosine-5'-N-ethyluronamide; and
N6-bis-(5-chloro-pyridin-2-yl-carbamoy1)-adenosine-5'-N-ethyluronamide.
According to one embodiment of the invention, the A3AR agonist is a compound
that exerts its prime effect through the binding and activation of the
adenosine A3AR and is
a purine derivative falling within the scope of the general formula (I):
R13
N-.........>
N
<
N N (I)
I R12
R11
Date Recue/Date Received 2021-12-29
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wherein,
- Rii represents an alkyl, hydroxyalkyl, carboxyalkyl or cyanoalkyl or a
group of
the following general formula (II):
Y
X12 (II)
X13 X14
in which:
- Y represents oxygen, sulfur or CH2;
XII represents H, alkyl, ReRfNC(=0)- or HORg-, wherein
- Re and le may be the same or different and are selected from the group
consisting of hydrogen, alkyl, amino, haloalkyl, aminoalkyl, BOC-
aminoalkyl, and cycloalkyl or are joined together to form a heterocyclic
ring containing two to five carbon atoms; and
- Rg is selected from the group consisting of alkyl, amino, haloalkyl,
aminoalkyl, BOC-aminoalkyl, and cycloalkyl;
X12 is H, hydroxyl, alkylamino, alkylamido or hydroxyalkyl;
- Xi3 and Xi4 represent independently hydrogen, hydroxyl, amino, amido,
azido, halo, alkyl, alkoxy, carboxy, nitrilo, nitro, trifluoro, aryl, alkaryl,
thio,
thioester, thioether, -000Ph, -0C(=S)0Ph or both X13 and X14 are oxygens
connected to >C=S to form a 5-membered ring, or X12 and Xi3 form the ring of
formula (III):
0 ___________________
R'S/ \
1 (III)
0\
/
R"Si-0
where R' and R" represent independently an alkyl group;
- Ri2 is selected from the group consisting of hydrogen, halo, alkylether,
amino,
hydrazido, alkylamino, alkoxy, thioalkoxy, pyridylthio, alkenyl; alkynyl,
thio, and
alkylthio; and
- Ri3 is a group of the formula ¨NR15R16 wherein
Date Recue/Date Received 2021-12-29
- 15 -
- R15 is a hydrogen atom or a group selected from alkyl, substituted alkyl
or aryl-
NH-C(Z)-, with Z being 0, S, or NW with Re having the above meanings; wherein
when
R15 is hydrogen than
- R16 is selected from the group consisting of R- and S-1-phenylethyl,
benzyl,
phenylethyl or anilide groups unsubstituted or substituted in one or more
positions with a
substituent selected from the group consisting of alkyl, amino, halo,
haloalkyl, nitro,
hydroxyl, acetoamido, alkoxy, and sulfonic acid or a salt thereof;
benzodioxanemethyl,
furury 1, L-propylalanyl- aminobenzyl, 13-alany lami no-
.. benzyl, .. T-B 0C-13-
alanylaminobenzyl, phenylamino, carbamoyl, phenoxy or cycloalkyl; or R16 is a
group of
the following formula:
0 0
(_...
N NH2
H il
or when R15 is an alkyl or aryl-NH-C(Z)-, then, Ri6 is selected from the group
consisting of heteroaryl-NRa-C(Z)-, heteroaryl-C(Z)-, alkaryl-NRa-C(Z)-,
alkaryl-C(Z)-,
aryl-NR-C(Z)- and aryl-C(Z)-; Z representing an oxygen, sulfor or amine;
or a physiologically acceptable salt of the above compound.
According to one preferred embodiment, the A3AR agonist is a nucleoside
derivative
of the general formula (IV):
R5
1
NH
N
< --------1 N
I (IV)
Xi N N
R2
(0
Nf
OH OH
Date Recue/Date Received 2021-12-29
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wherein Xi, R2' and R5 are as defined above, and physiologically acceptable
salts of
said compound.
The non-cyclic carbohydrate groups (e.g., alkyl, alkenyl, alkynyl, alkoxy,
aralkyl,
alkaryl, alkylamine, etc) forming part of the substituent of the compounds of
the present
invention are either branched or unbranched, preferably containing from one or
two to
twelve carbon atoms.
A specific group of A3AR agonists are the N6-benzyladenosine-5'-uronamide
derivatives. Some preferred N6-benzyladenosine-5'-uronamide derivatives are N6-
2-(4-
aminophenypethyladenosine (APNEA), N6-(4-amino-3- iodobenzyl) adenosine-5'-(N-
methy luronami de) (AB-MECA) and 1-deoxy -1- {6- [( {3-iodophenyl} methyl)ami
n(3+ 9H-
purine-9-yll-N-methyl- P-D-ribofuranuronamide (IB-MECA) and 2-chloro-N6-(3-
iodobenzyl)adenosine- 5'-N-methlyuronamide (Cl-IB-MECA).
According to another embodiment, the A3AR agonist may be an oxide derivative
of adenosine, such as N6-benzyladenosine-5'-N-alkyluronamide-M-oxide or N6-
benzyladenosine-5'-N-dialkyluronamide-M-oxide, wherein the 2-purine position
may be
substituted with an alkoxy, amino, alkenyl, alkynyl or halogen.
When referring to an "A3AR allosteric modulator" or "A3ARM" it is to be
understood as referring to the positive regulation, activation or increase of
the receptor
activity by binding of the allosteric modulator at the receptor's allosteric
site which may
be different from the binding site of the endogenous ligand or agonist
thereof.
In one example, "modulation" denotes an effect of the A3AR ligand on the
receptor exhibited by an increase of at least 15% in the efficacy of the A3
adenosine
receptor by binding of the compound to the allosteric site of the receptor
and/or by a
decrease in dissociation rate of adenosine or an A3AR agonist to the
orthosteric binding
site.
In one example, the modulation is by an A3AR allosteric modulator (A3ARAM)
that is an imidazoquinoline derivative.
In one example, the A3ARAM, or imidazoquinoline derivative has the following
general formula (V):
Date Recue/Date Received 2021-12-29
- 17 -
H , Ri
\ N /
N
N 1
1 ) __ R2
N
\H
(V)
wherein:
Ri represents an aryl or alkaryl being optionally substituted at the
aromatic ring with one or more substituents selected from the group consisting
of Ci-Cio alkyl, halo, Ci-Cio alkanol, hydroxyl, Ci-Cio acyl, Ci-Cio alkoxyl;
Ci-
Cio-alkoxycarbony, Ci-Cio alkoxylalkyl; Ci-Cio thioalkoxy; Ci-Cio alkylether,
amino, hydrazido, Ci-Cio alkylamino, pyridylthio, C2-C10 alkenyl; C2-C10
alkynyl, thio, Ci-Cio alkylthio, acetoamido, sulfonic acid; or said
substituents
can form together a cycloalkyl or cycloalkenyl fused to said aryl, the
cycloalkyl
or cycloalkenyl optionally comprising one or more heteroatoms; provided that
said aryl is not an unsubstituted phenyl group;
R2 represents hydrogen or a substituent selected from the group
consisting of Ci-Cio alkyl, C2-C10 alkenyl; C2-C10 alkynyl, C4-C10 cycloalkyl,
C4-C10 cycloalkenyl, a five to seven membered heterocyclic aromatic ring, C5-
C15 fused cycloalkyl, bicyclic aromatic or heteroaromatic rings; Ci-Cio
alkylether, amino, hydrazido, Ci-Cio alkylamino, Ci-Cio alkoxy, Ci-Cio-
alkoxycarbony, Ci-Cio alkanol, Ci-Cio acyl, Ci-Cio thioalkoxy, pyridylthio,
thio,
and Ci-Cio alkylthio, acetoamido and sulfonic acid;
and pharmaceutically acceptable salts thereof.
According to some embodiments, the Ri substituent in the A3ARAM has the
following general formula (VI):
X2
1
¨(CH2),, Xi (VI)
Date Recue/Date Received 2021-12-29
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wherein n is 0 or an integer selected from 1-5; preferably, n is 0, 1 or 2;
and
- Xi and X2 which may be the same or different, are selected
from
hydrogen halogen, alkyl, alkanol or alkoxy, indanyl, pyrroline provided that
when said n is 0, Xi and X2 are not hydrogen.
In yet some further examples, Ri in A3ARAM is a substituent having the above
formula (VI), wherein Xi or X2, which may be the same or different, are
selected from
hydrogen, chloro, methoxy, methanol or a substituent having the formulae (Via)
or (Vlb):
\
X
/
N
\
H
(VIa) (VIb)
wherein Y is selected from N or CH.
In some yet further examples R2 in A3ARAM is selected from H, Ci-io alkyl, Ca-
lo
cycloalkyl, the alkyl chain may be a straight or branched or form a four to
seven
membered cycloalkyl ring.
In one example, R2 in A3ARAM is selected from a five to seven membered
heterocyclic aromatic ring.
In some examples, R2 substituents in A3ARAM are selected from H, n-pentyl, or
a
five membered heterocyclic aromatic ring having the following formula (VII):
3
z
(VII)
wherein Z is selected from 0, S or NH, preferably 0.
In accordance with one example, R2 in the A3ARAM comprises one or more fused
rings, particularly so as to form bicyclic substituents.
Non-limiting examples of bicyclic compounds which may be used to form the
substituents in the context of the A3ARAM comprise bicyclo[2.2.11heptane,
bicyclo[4.1.01heptane, bicyclo[4.1.01heptan-3-carboxylic acid,
bicyclo[3.1.01hexan-3-
Date Recue/Date Received 2021-12-29
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carboxylic acid, bicyclo[4.1.0]heptan-2-carboxylic acid, bicyclo[3.1.0]hexan-2-
carboxylic
acid, and bicyclo[2.2.1]heptan-2-carboxylic acid.
In accordance with yet some other examples, R2 in A3ARAM is selected from
2-cyclohexene and 3-cyclohexene.
Specific imidazoquinoline derivatives which can be used as allosteric
modulators
of the A3AR are listed below:
N-(4 -Methyl-pheny1)-2-cyclopenty 1- 1H-imidazo [4,5 -c] quinolin-4 -amine
N-(4 -Methoxy-pheny1)-2-cyclopentyl- 1H-imidazo [4,5 -c] quinolin-4-amine
N-(3 ,4-Dichloro-phenyl)-2 -cyclopentyl- 1H-imidazo [4,5 -c] quinolin-4-amine
N-(4 -Chloro-pheny1)-2 -cyclopenty 1- 1H-imidazo [4,5 -c] quinolin-4-amine
N-(3 -Methanol-phenyl)-2 -cyclopenty1-1H-imidazo [4,5 -c] quinolin-4-amine
N-([3 ,4 -clIndan)-2 -cyclopentyl- 1H-imidazo [4,5-c] quinolin-4-amine
N-(1H-indazol-6-y1)-2 -cyclopentyl- 1H-imi dazo [4,5 -c] quinolin-4-amine
N-(4 -Methoxy-benzy1)-2-cyclopenty1-1H-imidazo [4,5-c] quinolin-4-amine
N-(1H-Indo1-6-y1)-2-cyclopentyl- 1H-imi dazo [4,5 -c] quinolin-4 -amine
N-(B enzy1)-2-cyclopenty 1- 1H-imidazo [4,5-c] quinolin-4 -amine
N-(Phenylethyl)-2-cyclopenty1- 1H-imidazo [4,5 -c] quinolin-4 -amine
N-(3 ,4-Dichloro-pheny1)-2-cyclohepty1- 1H-imi dazo [4,5-c] quinolin-4 -amine
N-(3 ,4-Dichloro-phenyl)-2 -furyl- 1H-imidazo [4,5 -c] quinolin-4 -amine
N-(3 ,4-Dichloro-phenyl)-2 -cyclobuty1-1H-imidazo [4,5-c] quinolin-4-amine
N-(3 ,4-Dichloro-phenyl)-2 -cyclohexy1-1H-imidazo [4,5-c] quinolin-4-amine
N-(3 ,4-Dichloro-phenyl)-2 -- 1H-imidazo [4,5 -c] quinolin-4 -amine
N-(3 ,4-Dichloro-phenyl)-2 -pentyl- 1H-imidazo [4,5 -c] qui nolin-4 -amine.
The above imidazoquinoline derivatives are regarded as allosteric modulators
as
they were shown to have, on the one hand, reduced affinity, if any, to the
orthosteric
binding sites of the Ai and A2A, A2B adenosine receptors and reduced affinity
to the
orthosteric binding site of the A3 adenosine receptor, and on the other hand,
high affinity to
the allosteric site of the A3 adenosine receptor [International Patent
Application No.
W007/089507, incorporated herein by reference].
A specifically preferred imidazoquinoline derivative in accordance with the
present disclosure is N-(3,4-Dichloro-pheny1)-2-cyclohexy1-1H-imidazo [4,5-
clquinolin-
Date Recue/Date Received 2021-12-29
- 20 -
4-amine (also referred to at times by the abbreviation LUF6000 or CF602),
being an
A3AR allosteric modulator.
In the context of the general formulae disclosed herein, the following meaning
for
the various terms is to be considered:
The term "alkyl" is used herein to refer to a linear or branched hydrocarbon
chain
having from 1 to 10 carbon atoms and more preferably 1 to 6 carbon atoms
including, but
not limited to, methyl, ethyl, n-propyl, isopropyl, n-butyl, t-butyl, n-
heptyl, octyl and the
like.
Similarly, the terms "alkenyl" and "alkynyl" denote a linear or branched
hydrocarbon chain having, respectively, from 2 to 10, or from 3 to 10 carbon
atoms and
more preferably 2 to 6 or 3 to 6 carbon atoms, the alkenyl or alkynyl having
at least one
unsaturated bond.
The alkyl, alkenyl or alkynyl substituents may be substituted with a
heteroatom
containing group. Thus, it should be understood that while not explicitly
stated, any of the
alkyl modifications defined hereinabove and below, such as alkylthio, alkoxy,
akanol,
alkylamine etc, also include the corresponding alkenyl or alkynyl
modifications, such as,
akenylthio, akenyloxy, alkenol, alkenylamine, or respectively, akynylthio,
alkynyloxy,
alkynol, alkynylamine.
The term "aryl" denotes an unsaturated aromatic carbocyclic group of from 5 to
14
carbon atoms having a single ring (e. g., phenyl) or multiple condensed rings
(e. g.,
naphthyl or anthryl). Preferred aryls include phenyl, indanyl, benzimidazole.
The term "alkaryl" refers to -alkylene-aryl groups preferably having from 1 to
10
carbon atoms in the alkylene moiety and from 6 to 14 carbon atoms in the aryl
moiety.
Such alkaryl groups are exemplified by benzyl, phenethyl and the like.
The term "Substituted aryl" refers to an aromatic moiety which is substituted
with
from 1 to 3 substituents as defined above. A variety of substituents are
possible, as
appreciated by those versed in the art. Nonetheless, some preferred
substituents include,
without being limited thereto, halogen, (substituted) amino, nitro, cyano,
alkyl, alkoxy,
acyloxy or alkanol, sulphonyl, sulphynyl.
The term "Halo" or "halogen" refers to fluoro, chloro, bromo and iodo,
preferably
to chloro.
Date Recue/Date Received 2021-12-29
-21 -
The term "acyl" refers to the groups H-C(0)- as well as alkyl-C(0)-.
The term "alkanol" refers to the group -COH as well as alk-OH, "alk" denoting
an
alkylene, alkenylene or alkynylene chain.
The term "alkoxy" is used herein to mean -0-alkyl, including, but not limited
to,
methoxy, ethoxy, propoxy, isopropoxy, n-butoxy and the like.
The term "alkylthio" is used herein to mean -S-alkyl, including, but not
limited to,
methylthio, ethylthio, n-propylthio, isopropylthio, n-butylthio and the like.
The term "alkoxyalkyl" is used herein to mean -alkyl-0-alkyl, including, but
not
limited to, methoxymethyl, ethoxymethyl, n-propoxymethyl, isopropoxymethyl, n-
butoxymethyl, isobutoxymethyl, t-butoxymethyl and the like.
The term "cycloalkyl" is used herein to mean cyclic hydrocarbon radicals
including, but not limited to, cyclopropyl, cyclobutyl, cyclopentyl,
cyclohexyl, cycloheptyl
and the like.
The term "alkoxycarbonyl" is used herein to mean -C(0)0-alkyl, including, but
not limited to, methoxycarbonyl, ethoxycarbonyl, propoxycarbonyl and the like.
The term "fused cycloalkyl" is used herein to mean any compound or substituent
comprising at least two aliphatic rings which are connected at a single atom
(to form a
spirocyclic moiety), at two mutually bonded atoms or across a sequence of
atoms
(bridgehead). The fused rings may include any bicyclic, tricyclic as well as
polycyclic
moieties. Bicyclic substituents are preferred in accordance with some
embodiments of the
present disclosure.
The present disclosure also makes use of physiologically acceptable salts of
an
A3AR selective ligand, such as the above-described compounds. A -
physiologically
acceptable salt" refers to any non-toxic alkali metal, alkaline earth metal,
and ammonium
salt commonly used in the pharmaceutical industry, including the sodium,
potassium,
lithium, calcium, magnesium, barium ammonium and protamine zinc salts, which
are
prepared by methods known in the art. The term also includes non-toxic acid
addition salts,
which are generally prepared by reacting the ligand with a suitable organic or
inorganic
acid. The acid addition salts are those which retain the biological
effectiveness and
qualitative properties of the free bases, and which are not toxic or otherwise
undesirable.
Examples include, inter alia, acids derived from mineral acids, hydrochloric,
hydrobromic,
Date Recue/Date Received 2021-12-29
- 22 -
sulfuric, nitric, phosphoric, metaphosphoric and the like. Organic acids
include, inter alia,
tartaric, acetic, propionic, citric, malic, malonic, lactic, fumaric, benzoic,
cinnamic,
mandelic, glycolic, gluconic, pyruvic, succinic salicylic and arylsulphonic,
e.g., p-
toluenesulphonic, acids.
The A3AR ligand can be administered in a single dose (one time medication) or
as a continuous treatment. In one example, the A3AR ligand is used for long
term
treatment.
In the context of the present disclosure, long term treatment is to be
understood
to encompass a treatment window lasting for at least a period of days, weeks,
months, or
even years, until discontinuation for example due to intolerance, withdrawal
of consent,
or death. Though continuous, the treatment period may be divided into cycles
(e.g., 4-
week cycles) for the purpose of data recording. In an embodiment, the A3AR
ligand is
administered every 12 h until discontinuation.
Further in the context of some examples of the present disclosure long term
treatment encompasses chronic treatment, e.g., long term daily administration
(once,
twice, or thrice daily) at times even without an envisaged end point for the
treatment. In
some examples, the long-term treatment comprises at least one week of daily
administration of the A3AR ligand, at times, one-month daily treatment, at
times, at
least 2, 3, 4, 5, 6, or even 12 months of daily administration of the ligand,
at times at
least 1, 2, 3, 4, 5, 6 or more years of daily administration of the ligand.
In an embodiment, the treatment period is a long term treatment lasting for at
least one year.
The A3AR ligand is administered in amounts which are sufficient to achieve a
therapeutic anti-cancer effect. As will be appreciated, the amount of the A3AR
ligand will
depend on the severity of the disease, the intended therapeutic regimen, and
the desired
therapeutic dose. By way of example, where the dose is 50 mg per day and the
desired
administration regimen is 2 daily administrations, the amount of the active
agent in the
pharmaceutical composition will be 25 mg.
An amount effective to achieve the desired effect is determined by
considerations
known in the art. An "effective amount" for purposes herein must be effective
to achieve a
therapeutic effect, the therapeutic effect being as defined hereinbefore.
Date Recue/Date Received 2021-12-29
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It is appreciated that the effective amount depends on a variety of factors
including
the affinity of the chosen A3AR agonist to the A3AR, its distribution profile
within the
body, a variety of pharmacological parameters such as half life in the body,
on undesired
side effects, if any, on factors such as age and gender of the subject to be
treated, etc. The
effective amount is typically tested in clinical studies having the aim of
finding the
effective dose range, the maximal tolerated dose, and the optimal dose. The
manner of
conducting such clinical studies is well known to a person versed in the art
of clinical
development.
In accordance with one embodiment of the invention, the administration of A3AR
agonist is preferably daily administration, between once and a few times a
day, preferably
once or twice a day, the dose in each administration being in the range of
between about 1
to about 1000Kg/kg body weight, preferably 50 g/kg-10mg/kg body weight,
preferably
100 g/kg-5 mg/Kg body weight, or 200 g/kg-lmg/Kg body weight.
In some embodiments, the A3AR ligand is CI-IB-MECA administered orally in a
dose of 1-50mg, preferably 5-30 mg twice daily.
In a specific embodiment, the advanced solid tumor is advanced HCC, the A3AR
agonist is CI-IB-MECA (namodenoson) and the dose is 25 mg given orally every
12 hours
(i.e., twice a day).
The A3AR agonist is formulated in a pharmaceutical composition. A
"composition" in the context of the invention is intended to mean a
combination of the
active agent(s), together or separately, with a pharmaceutically acceptable
carrier as well as
other additives. The carrier may at times have the effect of improving the
delivery or
penetration of the active ingredient to the target tissue, improving the
stability of the drug,
slowing clearance rates, imparting slow-release properties, reducing undesired
side effects
etc. The carrier may also be a substance that stabilizes the formulation
(e.g., a
preservative). For examples of carriers, stabilizers, and adjuvants, see E.W.
Martin,
REMINGTONS PHARMACEUTICAL SCIENCES, MacK Pub Co (June 1990).
The term -pharmaceutically acceptable carrier" in the context of the present
invention denotes any one of inert, non-toxic materials, which do not react
with the A3AR
agonist, and which can be added to formulations as diluents, carriers or to
give form or
consistency to the formulation.
Date Recue/Date Received 2021-12-29
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The composition of the present invention is administered and dosed in
accordance
with good medical practice, taking into consideration the clinical condition
of the
individual patient, the site and method of administration, scheduling of
administration,
patient age, sex, body weight and other factors known to medical
practitioners. The choice
of carrier will be determined in part by the specific active ingredient, as
well as by the
specific method used to administer the composition. Accordingly, there is a
wide variety of
suitable pharmaceutical compositions of the present invention.
As noted above, the therapeutic use of an A3AR agonist may at times be in
combination with other anti-cancer drugs such monoclonal antibodies (e.g., the
antibody
atezolizumab alone or in combination with bevacizumab, or the VEGFR2 inhibitor
ramucirumab, the anti-PD1 receptor monoclonal antibodies pembrolizumab and
nivolumab, alone or in combination with the anti CTLA-4 antibody ipilimumab),
and
multi-kinase inhibitors (e.g., sorafenib, regorafenib, cabozantinib or
lenvatinib). In such
a combination treatment the other drug and the A3AR agonist may be given to
patients
at the same time or at different times, depending on the dosing schedule of
each of the
drugs.
The invention has been described in an illustrative manner, and it is to be
understood that the terminology which has been used, is intended to be a
description rather
than a limitation. Obviously, many modifications and variations of the present
invention
are possible in view of the above teaching. It is therefore, to be understood
that within the
scope of the appended claims, the invention may be practiced otherwise than as
specifically described hereinafter.
EXEMPLARY EMBODIMENTS
Study Participants
The study population consisted of patients aged >18 years with advanced
stage/treatment-refractory HCC and CPB cirrhosis who did not tolerate
sorafenib or
whose disease had previously progressed on sorafenib treatment. The diagnosis
of HCC
in subjects without underlying cirrhosis at the time of diagnosis required
cytology
and/or histology; for subjects with underlying cirrhosis at the time of
diagnosis, HCC
diagnosis was established according to the American Association for the Study
of Liver
Date Recue/Date Received 2021-12-29
- 25 -
Diseases practice guidelines algorithm [Marrero J.A., et al., Hepatology.
2018; 68:723-
7501 For subjects who had tolerated sorafenib, >3 weeks of prior treatment was
required, terminating at >2 weeks before study entry. Inclusion criteria
included: ECOG
PS < 2; having CPB cirrhosis (i.e., CP score 7-9); aspartate aminotransferase
(AST) and
alanine aminotransferase (ALT) levels < 5 times the upper limit of normal
(ULN); total
bilirubin, <3.0 mg/dL; serum albumin, >2.8 g/dL; prothrombin time (PT), <6 s
longer
than control; serum creatinine, <2.0 mg/dL; absolute neutrophil count, >1500 x
109/L;
and platelet count, >75,000 x 109/L. Exclusion criteria included: the presence
of hepatic
encephalopathy; and gastrointestinal hemorrhage requiring transfusion
occurring within
the past 4 weeks.
Study Design and Treatment
This was a multicenter, randomized, double-blind, placebo-controlled clinical
trial
(ClinicalTrials.gov identifier NCT02128958). The trial was conducted at 15
sites in
Israel, Europe, and the United States.
Subjects were enrolled by the participating centers and were randomly assigned
2:1,
using a central randomization schedule generated by an independent
biostatistician with
no stratification prior to randomization. Patients were randomized to either
namodenoson (C1-IB-MECA) 25 mg or matching placebo, administered orally every
12
hours until discontinuation due to intolerance, withdrawal of consent, or
death. Though
treatment was administered in a continuous manner, the treatment period was
divided
into 4-week cycles for the purpose of data recording. No crossover was
initially
allowed; however, by protocol amendment, patients that continued with blinded
treatment were offered namodenoson (25 mg twice daily) upon unblinding of the
treatment assignments. All study site personnel were blinded to patients'
treatment
throughout the study period.
The study was approved by all relevant national regulatory authorities and
local Ethics
Committees/Institutional Review Boards. The study was conducted in accordance
with
the Declaration of Helsinki, and written informed consent was obtained from
all the
patients.
Date Recue/Date Received 2021-12-29
- 26 -
Assessments
The primary endpoint of the study was overall survival (OS). Secondary
endpoints were
progression-free survival (PFS), overall response rate (ORR), disease control
rate
(DCR), and safety. As in advanced HCC, PFS was found to be moderately
correlated
with OS; PFS is a reasonable secondary endpoint in this disease [Llovet J.M.,
et al., J.
Hepatol. 2019, 70:1262-12771. Disease response assessment was evaluated
locally by 2
independent blinded radiologists using Response Evaluation Criteria in Solid
Tumors
(RECIST) version 1.1 [Eisenhauer E.A., et al. Eur. J. Cancer. 2009; 45:228-
2471.
Tumor status was assessed at baseline and every 8 weeks thereafter by computed
tomography scan or magnetic resonance imaging. Safety was monitored through
assessments of AEs using the US National Cancer Institute's Common Terminology
Criteria for Adverse Events (CTCAE) v4.03. Changes from baseline in vital
signs,
clinical laboratory parameters, electrocardiograms, physical examinations, and
ECOG
PS were also assessed. AFP levels were assessed at baseline and every 4 weeks
thereafter, as were laboratory parameters associated with hepatic dysfunction
and
cirrhosis, such as serum ALT, AST, bilirubin, and albumin levels, PT, and
international
normalized ratio. ALBI scores were calculated from the albumin and bilirubin
levels, as
previously described [Johnson P.J., et al. J. Clin. Oncol. 2015; 33:550-5581.
Biomarker Studies
Another secondary objective was to evaluate the relationship between white
blood cell
(WBC) A3AR expression (which has been suggested to mirror the expression in
HCC
tumor cells [Bar-Yehuda S., et al. Int. J. Oncol. 2008; 33:287-2951) as
assessed at
baseline and every cycle thereafter at selected study centers, (n = 53
patients) and
clinical response. A3AR mRNA expression in WBC was determined from blood
collected to a PAXgene RNA tube (Qiagen, Venlo, The Netherlands), using the
QuantiGene Plex 2.0 assay (Thermo Fisher, Waltham, MA, USA). 13-actin was
used as
a reference control, and the oligonucleotide probe sets were designed by
Thermo Fisher.
Luminescence from each specific probe set was captured by GloMax Multi
(Promega,
Madison, WI, USA). A3AR was expressed in units, where 1 unit was defined as
the
mean of A3AR expression in healthy subjects (n = 50). Healthy subjects were 20-
70
years of age with no known illness and no prior treatment.
Date Recue/Date Received 2021-12-29
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Statistical Analysis
Power calculation determined that 75 deaths, assuming a hazard ratio of 0.5,
would
provide 80% power for the log-rank test at a significance level of 0.05.
Primary efficacy
analyses were performed on the ITT population. Descriptive statistics were
used to
summarize patient/tumor characteristics and safety. Kaplan¨Meier curves were
used to
estimate OS/PFS, and between comparisons were performed using log-rank tests.
The
Cox proportional hazards regression model was used to assess the impact of
covariates.
ORR/DCR were determined using the normal approximation to the binomial
distribution by treatment. The statistical analysis plan was amended prior to
unblinding
to include subgroup analysis by CP score. All statistical tests were 2-sided,
and p < 0.05
was considered statistically significant. Statistical analyses were conducted
using SAS
9.4 (SAS Institute Inc., Cary, NC, USA).
Example 1
In a phase II blinded, randomized, placebo-controlled study, the namodenoson
dose evaluated was oral 25 mg BID (twice daily) and the population consisted
of 78
patients with advanced HCC and CPB cirrhosis who received namodenoson as
second-
line therapy. Patients were randomized 2:1 to receive namodenoson 25 mg BID (n
= 50)
or placebo (n = 28).
No treatment-related deaths were reported. Also, no patients withdrew from the
study and no dose reductions were attributable to namodenoson. Importantly, no
hepatotoxicity was reported and liver function tests demonstrated no adverse
namodenoson-related effect. Mean serum albumin levels and albumin-bilirubin
(ALBI)
scores also did not change significantly in both arms throughout the study.
Only one
grade 3 treatment-related AE was reported (hyponatremia).
Analysis of initial results
With respect to anti-tumor efficacy, the primary trial endpoint of OS
superiority
over placebo was not met; median OS was 4.1 and 4.3 months for namodenoson and
placebo, respectively (hazard ratio [HR], 0.82; 95% confidence interval [CI]
0.49-1.38;
p = 0.46). Similarly, there was no superiority with respect to progression-
free survival
(PFS). Within the CBP patients included in the study, the patients with Child-
Pugh
score 7 (the least severe form of hepatic dysfunction within the CPB category)
were the
largest group (34 patients in the namodenoson arm and 22 patients in the
placebo arm).
Date Recue/Date Received 2021-12-29
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Preplanned analysis in which patients were evaluated by Child-Pugh subgroups
demonstrated nonsignificant differences in OS and PFS for patients with Child-
Pugh
score 7. In this subcategory, the median OS was 6.9 in the namodenoson group
vs 4.3
months in the placebo group (HR, 0.81; 95% CI 0.45-1.43; p = 0.46). The median
PFS
was 3.5 months vs 1.9 months (HR, 0.89; 95% CI 0.51-1.55; p = 0.67). In
patients with
Child-Pugh score 8 (13 patients; 7 namodenoson-treated and 6 placebo-treated),
OS and
PFS were similar between the namodenoson and placebo arms and were overall
shorter
than those reported for the subgroup of patients with Child-Pugh score 7 (OS:
3.3 vs 3.4
months, for the namodenoson and placebo arms respectively; HR, 0.88; 95% CI
0.28-2.77, p = 0.83. PFS: 2.1 vs 1.9 months, respectively; HR, 0.71; 95% CI
0.23-2.17,
p = 0.53). The median OS and PFS values for the 9 patients with Child-Pugh
Score 9,
who were all in the namodenoson arm, were 3.5 and 2.2 months, respectively,
similar to
those in patients with Child-Pugh score 8. Exploratory analysis comparing OS
by
treatment arm and stratification by gender, alfa-fetoprotein levels, Eastern
Cooperative
Oncology Group (ECOG) Performance Status (PS), HPB, and HPC status,
locoregional
therapy, extrahepatic spread status, and portal vein thrombosis status found
no
statistically significant differences between the study arms in any of the
subgroups,
which could be attributed, in part, to the relatively small sample size in
some of the
groups.
Analysis of long-term treatment
However, in contrast with the initial results, the difference in the 12-month
OS
rate was statistically significant (44% and 18% in the namodenoson and placebo
arms,
respectively; p = 0.028) (Figure 1).
Analysis of the response in all patients for whom at least 1 post-baseline
assessment was available (55 patients; 34 namodenoson-treated and 21 placebo-
treated)
revealed that one patient in the namodenson group experienced CR, and that PR
was
achieved by 3 patients (9%) in the namodenson group vs none in the placebo
group
(Table 1). In the 3 patients who experienced PR, the duration of response was
2, 6, and
26 months.
Date Recue/Date Received 2021-12-29
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Table 1: Best Observed Responses (RECIST 1.1) by Treatment Arm
Namodenoson Placebo
Response, n (%) n = 34 n = 21
CR 1 (2.94%) 0 (0.0%)
PR 3 (8.8%) 0 (0.0%)
SD 17 (50.0%) 10 (47.6%)
PD 14(41.2%) 11(52.4%)
As shown in Table 1 above one patient showed a complete response. This
patient was treated for 5 years under the Open Label Extension program of the
Phase II
study of Namodenoson in the treatment of hepatocellular carcinoma (HCC) and
experienced a Complete Response (CR) to namodenoson, meaning that all cancer
lesions have cleared.
Under treatment with namodenoson (25 mg administered orally twice a day), the
patient who had advanced metastatic HCC with underlying Child Pugh B7 (CPB7)
cirrhosis has now survived five years. As indicated by a scan of the patient's
chest,
abdomen, and pelvis the clinical benefits of treatment have included the
disappearance
of ascites, normal liver function, and the disappearance of peritoneal
carcinomatosis
leading to complete clearance of all cancer lesions.
Date Recue/Date Received 2021-12-29
