AU2024231397A1 - Therapy for bladder cancer - Google Patents

Abstract

The present invention relates to the treatment of bladder cancer. In particular, it relates to a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of therapy for bladder cancer, wherein said method comprises instillation of said composition into the bladder of a patient, and wherein said method is not a method of photodynamic therapy.

Description

THERAPY FOR BLADDER CANCER

Technical field

This invention relates to a therapy for bladder cancer. More particularly, it relates to a therapy for bladder cancer in which hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, is instilled into a patient’s bladder without carrying out photodynamic therapy (PDT).

Such therapy finds use as a therapeutic treatment for bladder cancer and as a prophylactic treatment to prevent its recurrence. It may be used as a stand-alone therapy, or as an adjuvant or neoadjuvant therapy in combination with other therapies and/or surgical procedures, such as radiotherapy, chemotherapy, immunotherapy, transurethral resection (TUR), or a radical cystectomy.

Background of the invention

Bladder cancer is the ninth most common cancer diagnosis worldwide, with more than 330,000 new cases each year and more than 130,000 deaths per year. At any point in time, 2.7 million people have a history of urinary bladder cancer.

The diagnosis of bladder cancer ultimately depends on cystoscopic examination of the bladder (cystoscopy) and histological evaluation of the resected tissue. At the initial diagnosis of bladder cancer, 70% of cases are diagnosed as non-muscle invasive bladder cancer (NMIBC) and approximately 30% as muscle invasive bladder cancer (MIBC).

If a bladder tumor has been detected during cystoscopy, the patient will undergo transurethral resection (TUR), i.e. a procedure where the bladder is visualized through the urethra and tumors and lesions are resected. In the case of NMIBC, such a resection is to completely remove the tumor. In the case of MIBC, such a resection is of a palliative nature. Apart from the resection of the tumor, the TUR is also carried out to enable a correct histological diagnosis of the bladder cancer based on examination of the resected tumor/tumor biopsies by a pathologist. For patients with MIBC, the standard treatment is radical cystectomy, i.e. removal of the bladder and adjacent organs, that is prostate and seminal vesicles in men, and uterus and adnexa in women. It also includes the dissection of regional lymph nodes. Cystectomy is also advocated in patients with NMIBC who are at high risk of progression, i.e. patients having multiple recurrent high-grade tumors or highgrade T1 tumors, or high-grade tumors with concurrent carcinoma-in-situ (CIS). Further, cystectomy is advocated in patients with NMIBC who have received Bacillus Calmette-Guerin (BCG) immunotherapy but where such treatment has failed.

Despite being the gold standard for MIBC treatment and advocated in patients with certain types of NMIBC, radical cystectomy only provides a 5-year survival in about 50% of patients. In order to improve these unsatisfactory results, the use of neoadjuvant therapies (i.e. therapies prior to the main treatment which is the cystectomy) has been explored since the 1980s. Currently, neoadjuvant radiotherapy and neoadjuvant chemotherapy is used.

With neoadjuvant radiotherapy, down staging of the cancer after radiotherapy takes about 4-6 weeks. However, a delay of surgery in patients with locally advanced bladder cancer beyond 90 days has shown to cause a significant increase in extravesical disease (81 vs. 52%). Neoadjuvant radiotherapy is not recommended according to the current European guidelines on MIBC since no data exist to support that neoadjuvant radiotherapy for operable MIBC increases survival.

Neoadjuvant chemotherapy has many advantages including that chemotherapy is delivered at the earliest time-point, when the burden of micrometastatic disease is expected to be low; that tolerability of chemotherapy is expected to be better before cystectomy rather than after; and that, hypothetically, patients with micrometastatic disease might respond to neoadjuvant therapy and reveal favorable pathological status determined mainly by negative lymph node status and negative surgical margins. Neoadjuvant cisplatin-containing chemotherapy has been shown to significantly improve survival (5% absolute improvement in survival at 5 years). However, as stated above, delayed cystectomy may compromise the outcome in patients who are not sensitive to chemotherapy and, generally, pre-operative anemia and neuropathy is more common in patients receiving neoadjuvant chemotherapy prior to cystectomy. The current European guidelines on MIBC state that “... neoadjuvant chemotherapy has its limitations regarding patient selection, current development of surgical technique, and current chemotherapy combinations.” Hence, there is room for improvement in neoadjuvant therapies for bladder cancer patients who are scheduled for a cystectomy, i.e. bladder cancer patients diagnosed with MIBC or NMIBC who are at high risk of progression, including multiple recurrent high-grade tumors or high-grade T1 tumors or highgrade tumors with concurrent carcinoma-in-situ (CIS).

For patients with NMIBC, the standard treatment is resection of the tumor by TUR. Instillation into the bladder of a composition comprising HAL, or a pharmaceutically acceptable salt thereof, and exposing the inside of the bladder to blue light may be used to improve visualization of bladder cancer during cystoscopy and/or TUR. As a standard procedure, cystoscopy and TUR are performed using white light. However, since the use of white light can lead to missing lesions that are present but not visible, photodynamic diagnosis/detection (PDD) is often used in such procedures. In general, PDD involves the administration of a photosensitizer or a precursor thereof (which collectively may be referred to herein as a "photosensitizing agent") to an area of interest. The photosensitizer or precursor thereof is taken up into the cells, where a precursor of a photosensitizer is converted into a photosensitizer. Upon exposure of the area of interest to light of a suitable wavelength, the photosensitizer is activated (i.e. excited) and, upon relaxation to its ground state, fluorescence occurs and is detected.

Hexyl 5-ALA ester (hexaminolevulinate, HAL) and its salts are known precursors of photosensitizers. HAL preferably penetrates rapidly proliferating cells, e.g. tumor cells, where it is converted into porphyrins (e.g. protoporphyrin IX, “PpIX”), which are photosensitizers. Upon blue-light activation, the porphyrins are activated and, upon relaxation to their ground state, emit red light and thus enable specific and accurate visualization of the tumor. Hexvix® (Photocure ASA, Norway), marketed in the US and Canada as Cysview®, is a commercially available approved drug that comprises HAL and is used in PDD in cystoscopy and TUR procedures.

In patients with NMIBC, HAL-guided cystoscopy and TUR has increased detection of both papillary tumors and flat carcinoma-in-situ (CIS) lesions, the latter of which are difficult to detect with white light alone. HAL-guided TUR of bladder cancer in patients with NMIBC has further reduced the rate of residual tumors after such procedures and has led to superior recurrence free survival (RFS) rates and prolonged RFS intervals compared to white light TUR alone (see Rink M, et al. Eur Urol 4(64), 2013, 624). Existing European guidelines on NMIBC and several expert groups consensus statements recommend the use of HAL-guided TUR in various settings of management of NMIBC and some even recommend its use in all NMIBC patients at initial TUR (see Witjes JA, et al., Eur Urol 1(66), 2014, 863).

Although a TaT1 tumor can be completely resected by HAL-guided TUR, and HAL- guided TUR favorably affects recurrence rate, these tumors may recur and progress to muscle invasive bladder cancer in a limited number of cases. It is therefore necessary to consider adjuvant therapy, i.e. adjuvant chemotherapy or adjuvant chemotherapy and adjuvant immunotherapy, in all patients. The choice of therapy may be considered differently according to what risk is acceptable for the individual patient. Usually, a patient will receive one immediate, post-TUR instillation of chemotherapy into the bladder. The need for further adjuvant intravesical therapy depends on the patients’ prognosis. In patients with a low risk of tumor recurrence, a single immediate instillation reduces the risk of recurrence and is considered as the standard treatment, i.e. no further treatment is given in these patients before recurrence. For other patients, however, a single immediate instillation remains an incomplete treatment because the likelihood of recurrence and/or progression is considerable. There is no single chemotherapy drug that is superior with regard to efficacy; mitomycin C, epirubicin, and doxorubicin have all shown a beneficial effect. However, mitomycin C (MMC) is often the drug of choice.

According to EAU guidelines for the treatment of NMIBC, in patients with TaT1 tumors at intermediate or high risk of recurrence and intermediate or high risk of progression, one immediate instillation of chemotherapy should be followed by a minimum one year of Bacillus Calmette-Guerin (BCG) immunotherapy, or by further instillations of chemotherapy. In patients with bladder CIS, intravesical BCG for at least one year is indicated. Assuming that maintenance therapy with BCG is necessary for optimal efficacy, the issue of BCG toxicity becomes more relevant. As a result of the more pronounced side effects of BCG compared to intravescial chemotherapy, there is still a reluctance about the use of BCG. Deaths due to BCG sepsis and the high frequency of BCG-induced cystitis and allergic reactions have compromised its use. In addition, treatment failure of BCG is not uncommon.

Photodynamic therapy (PDT) has also been suggested for the treatment of bladder cancer and clinical studies have been carried out to investigate efficacy and safety of such treatment. Similar to PDD, PDT involves the administration of a photosensitizing agent to an area of interest followed by activation of the photosensitizer by light of a suitable wavelength to elicit a PDT effect (i.e. photoactivating light). The therapeutic effect of PDT is based on a phototoxic reaction: the photosensitizing agent is taken up into the cells where, if the agent is a precursor of a photosensitizer, the precursor is converted into a photosensitizer. Upon exposure of the area of interest to photoactivating light, the photosensitizer is activated, i.e. excited from a ground singlet state to an excited singlet state. It then undergoes intersystem crossing to a longer-lived excited triplet state. One of the few chemical species present in tissue with a ground triplet state is molecular oxygen. When the activated photosensitizer and an oxygen molecule are in proximity, an energy transfer can take place that allows the activated photosensitizer to relax to its ground singlet state, and create an excited singlet state oxygen molecule. Singlet oxygen is a very aggressive chemical species and will rapidly react with any nearby biomolecules. Ultimately, these reactions will kill cells, i.e. cancer cells.

HAL and its salts have been suggested for use in PDT of bladder cancer (see for instance US 2005/0031541, Example 21). HAL and its salts have also been proposed for use in PDT for bladder cancer in which HAL is instilled into the bladder of a patient and the inside of the bladder is exposed to blue light (see WO 2017/103285 and US 2019/0022404), for use in a neoadjuvant therapy for bladder cancer in a patient scheduled for a cystectomy in which HAL is instilled into the patient’s bladder and the inside of the bladder is exposed to light (WO 2017/103283 and US 2018/0369379), and for use in therapy of bladder cancer in which a combination of HAL and anti-PD-L1 and/or anti-PD-1 -antibodies is instilled into the bladder of a patient and the inside of the bladder is exposed to light (WO 2017/103280). Bader et al., Urol. Oncol. Seminars and Original Investigations 31, 2013, 1178-1183, have carried out HAL PDT using solutions of HAL (8 mM and 16 mM). Irradiation was carried out with white light from a xenon bulb and transmitted into the bladder via a glass fiber inserted into the working channel of a cystoscope. Photoactivating light is employed in all of these earlier methods of PDT using HAL and its salts.

The disadvantage of some of the PDT methods described above is that specially designed equipment, which is not commercially available, is needed to carry out the procedure. Furthermore, the use of light fibers and placement of the tip of the light fibers in the center of the bladder is complicated and cumbersome. The location of the fiber tip needs to be verified by ultrasound or the PDT procedure needs to be interrupted to make sure that the fiber tip is still in the center and does not touch the bladder wall, which could lead to injuries. Furthermore, side-effects are frequent and, depending on the PDT parameters used, may take a long time before they are resolved.

Hence there remains a need for alternative (e.g. improved) methods for the management of bladder cancer.

As discussed in Saleh Al-Omari, Biophys. Rev. (2013) 5:305-311, researchers have reported on the dark toxicity of certain photosensitizing agents in cell lines. Dark toxicity refers to the cytotoxicity of photosensitizing agents towards cancerous cells in the absence of light illumination. None of the studies described by Saleh Al- Omari in this article relate to HAL (or 5-ALA or a 5-ALA derivative) and all studies investigate dark toxicity in cell cultures.

In Example 21 of US 2015/0191419, dark toxicity of HAL is determined in WiDr cells derived from a primary adenocarcinoma of the rectosigmoid colon. HAL is added to the cell culture medium in concentrations of 0.001 to 1 mM. A weak cell toxicity is observed in the range of 0.3 to 1 mM with a minimum cell survival rate of 85%, i.e. only 15% or less were killed. Neither Saleh Al-Omari nor US 2015/0191419 reports any investigation of the dark toxicity of HAL in a bladder cancer cell line. Studies carried out in cell lines in vitro, i.e. on isolated tumor cells, differ from the reality in a patient (e.g. in a bladder cancer patient) in which a tumor is surrounded by a tumor microenvironment that can impact efficacy of any treatment. Known dark toxicity studies thus reveal nothing with respect to the dark toxicity of HAL or its salts towards a bladder tumor in a patient.

US 2013/0158293 relates to enhancers for cancer thermotherapy comprising 5-ALA and 5-ALA derivatives. Thermotherapy is a treatment method which takes advantage of the fact that cancer cells are heat-sensitive compared to normal cells and thus inhibits proliferation of the cancer cells. At a temperature of 42°C (i.e. above body temperature), 5-ALA is shown to exhibit an anti-cancer effect in various cell lines in the absence of photodynamic therapy, i.e. without light illumination. However, no results are provided with respect to HAL or any of its salts (or any other 5-ALA derivative such as a 5-ALA ester). Further, there is no reference in this document to the potential treatment of bladder cancer.

Summary of the invention

As evidenced herein, the Applicant has now surprisingly found that intravesical (i.e. inside the bladder) administration of hexyl 5-ALA ester (HAL) is effective to eradicate tumors in the bladder, or to reduce their proliferation, in the absence of photodynamic therapy, i.e. in the absence of photoactivating light. As a result of this finding, the Applicant proposes that HAL, or its pharmaceutically acceptable salts, are used as a therapy to treat bladder cancer or to reduce its recurrence without the combined use of photoactivating light. Whilst not wishing to be bound by theory, it is postulated that the therapy according to the invention may be effective to stimulate the patient’s immune system thereby not only fighting the bladder cancer, but also reducing its rate of recurrence following treatment

The therapy described herein may be combined with other methods of treatment for bladder cancer, including surgical procedures, chemotherapy and/or immunotherapy. As such, its use as an adjuvant or neoadjuvant therapy in the management of bladder cancer is also proposed. Since the therapy is performed in the absence of photoactivating light, it addresses the problems associated with conventional methods of PDT in which the delivery of light inside the patient’s bladder may be complicated and cumbersome, and which require the use of specially designed equipment to carry out the PDT. Furthermore, the use of HAL or its pharmaceutically acceptable salts without photoactivating light is expected to be well tolerated by patients with minimal side effects.

In one aspect, the invention thus provides a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of therapy for bladder cancer, wherein said method comprises instillation of said composition into the bladder of a patient, and wherein said method is not a method of photodynamic therapy.

In another aspect, the invention provides a method of therapy for bladder cancer, said method comprising the step of instillation into the bladder of a patient a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, and wherein said method is not a method of photodynamic therapy.

Detailed description of the invention

Definitions

As used herein, the term “photodynamic therapy” or “PDT” refers to a treatment involving the combined use of: (i) a photosensitizing agent; and (ii) photoactivating light, i.e. light of an appropriate wavelength to activate the photosensitizer and convert it into a therapeutically active form. The photosensitizing agent may be a photosensitizer or it may be a precursor of a photosensitizer. In some cases, the photosensitizing agent is a precursor of a photosensitizer that may be administered to the patient and is converted in vivo to a photosensitizer. Hexyl 5-ALA ester (HAL) is an example of a precursor of the photosensitizer protoporphyrin IX (“PpIX”). PDT involves administration of the photosensitizing agent to the treatment area which is then exposed to photoactivating light. The photosensitizer is therapeutically inactive until it is exposed to photoactivating light. It is only after exposure to photoactivating light (i.e. “photoactivation”) that the photosensitizer is converted into a therapeutically active form. Light which is capable of activating the photosensitizer and converting it into a therapeutically active form (i.e.

“photoactivating light”) is thus an essential component of any method of photodynamic therapy. As will be understood, the nature of the photoactivating light will vary depending on the photosensitizer. In order to achieve the desired photoactivation and thus the intended therapeutic effect, the light must be provided at a certain dose (i.e. the light dose), and at a suitable, defined wavelength and fluence rate.

As used herein, the term "cancer" refers to cells undergoing abnormal proliferation. Growth of such cells typically causes the formation of a tumor. The term “tumor”, as used herein, refers to an abnormal mass of tissue containing cancerous cells. Cancerous cells may be benign, pre-malignant or malignant. Such cells may be invasive and/or have the ability to metastasize to other locations in the body. The term cancer, as used herein, includes cancerous growths, tumors, and their metastases.

As used herein, the term “metastasis” refers to the spread of malignant tumor cells from one organ or part of the body to another non-adjacent organ or part of the body. Cancer cells may break away from a primary tumor, enter the lymphatic and blood systems and circulate to other parts of the body (e.g. to normal tissues). Here they may settle and grow within the normal tissues. When tumor cells metastasize, the new tumors may be referred to as metastatic cancer.

As used herein, the term “bladder cancer” refers to cancer that arises from the tissues of the bladder. Bladder cancer is classified by the extent of spread of the cancer (i.e. staged) and graded based on how abnormal and aggressive the cells appear under the microscope. Staging is usually performed with transurethral resection of the bladder tumor (TUR) and radiologic imaging (e.g. CT or MRI). Papillary tumors confined to the mucosa or which invade the lamina propria are classified as Ta or T1. Flat lesions that do not invade the basement membrane of the bladder mucosa are termed Tis (in situ). All three categories (Tis, Ta and T1) are grouped together as non-muscular invasive disease for therapeutic purposes, i.e. as non-muscle invasive bladder cancer (NMIBC). Tumors in the remaining categories (T2, T3 and T4) are termed muscular-invasive disease, i.e. muscle- invasive bladder cancer (MIBC).

As used herein, “treatment” refers to the reduction, alleviation or elimination, of a disease. It includes palliative treatment, i.e. treatment intended to minimise, or partially or completely inhibit the development of the disease. In the context of the invention, the disease is bladder cancer.

As used herein, “prevention” refers to absolute prevention, i.e. maintenance of normal levels with reference to the extent or appearance of a particular symptom of the disease, or to reduction or alleviation of the extent or timing (e.g. delaying) of the onset of that symptom.

By “a pharmaceutical composition” is meant a composition in any form suitable to be used for a medical purpose.

As used herein, a “therapeutically effective amount” relates to an amount that will lead to the desired therapeutic effect, i.e. a therapeutic or prophylactic amount of an agent which is effective to achieve its intended purpose. Such an amount may be provided by a single administration or by multiple (e.g. repeated) administration of any of the agents described herein. For example, several dosages of the agents described herein may need to be administered to make up the “therapeutically effective amount” that will lead to the desired therapeutic effect. While individual patient needs may vary, determination of optimal ranges for effective amounts of the agents herein described is within the capability of one skilled in the art. Generally, the dosage regimen for treating a disease with any of the agents described herein may be selected by those skilled in the art in accordance with a variety of factors including the extent and severity of the disease.

As used herein, the term “patient” refers to a human subject under the treatment of a clinician.

As used herein, the term “hexyl 5-ALA ester” (HAL) denotes n-hexyl aminolevulinate, i.e. n-hexyl 5-amino-4-oxo-pentanoate. As used herein, the term “pharmaceutically acceptable salt” denotes a salt that is suitable for and fulfils the requirements related to for instance safety, bioavailability and tolerability (see for instance P. H. Stahl et al. (eds.) Handbook of Pharmaceutical Salts, Publisher Helvetica Chimica Acta, Zurich, 2002).

As used herein, the term “adjuvant therapy” refers to the administration of a therapeutic or prophylactic agent in addition to the main treatment for the disease.

As used herein, the term “neoadjuvant therapy” refers to the administration of a therapeutic or prophylactic agent before (i.e. prior to) to the main treatment for the disease.

The therapy for bladder cancer according to the invention is not a method of photodynamic therapy, i.e. it does not rely on the activation of the photosensitizer by photoactivating light. It may alternatively be referred to as “non-photodynamic”. In contrast to known methods involving the use of HAL or its salts in the treatment of bladder cancer, the therapy herein described relies on the effect of HAL or its pharmaceutically acceptable salts in the absence of photoactivating light. The therapy does not involve the delivery of photoactivating light to the inside of the patient’s bladder subsequent to intravesical (i.e. inside the bladder) administration of HAL or one of its pharmaceutically acceptable salts.

The composition for use in the invention is able to suppress or delay tumor growth and/or prevent recurrence of tumors in a patient’s bladder without the need to carry out photodynamic therapy to achieve this therapeutic effect. Specifically, the composition is used in a method which does not involve the use of photoactivating light capable of producing a therapeutically active form of the photosensitizer PpIX in vivo.

Wavelengths of light that are generally considered suitable to produce a therapeutically active form of the photosensitizer PpIX in vivo following the administration of HAL or a pharmaceutically acceptable salt thereof include: white light, i.e. visible light having wavelengths of from about 350 to about 700 nm; blue light, i.e. light having a wavelength of from about 360 to about 450 nm; and red light, i.e. light having a wavelength of from about 600 to about 670 nm. The method of therapy according to the invention is performed without exposing the inside of the patient’s bladder to white light, blue light or red light, or any combination thereof in which two or more wavelengths of light are used either simultaneously (i.e. at the same time) or sequentially (i.e. subsequent to one another). Light doses that are given during irradiation of the inside of the bladder with white and/or red and/or blue light during PDT may vary. Typically, these may be in the range from 0.01 to 100 J/cm². Fluence rates that are used during irradiation of the inside of the bladder with white and/or red and/or blue light during PDT may vary. Duration of light exposure in conventional methods of PDT will vary. Typically, the light may be provided for a period of about 10 to 30 minutes.

In some embodiments, the therapy for bladder cancer according to the invention is performed without the application of heat, i.e. it is not a method of thermotherapy in which the patient’s bladder is subjected to heating. In one embodiment, the therapy is carried out at body temperature, for example at a temperature in the range of from about 35°C to about 38°C, e.g. from about 36°C to about 37°C.

The composition comprising HAL, or a pharmaceutically acceptable salt thereof, for use in the invention is instilled into the patient’s bladder, preferably through a catheter. Preferably, the composition is retained in the bladder for a predetermined period of time. The patient’s bladder will preferably be empty at the time of instillation and, if necessary, may be evacuated prior to instillation of the composition.

Once instilled into the patient’s bladder, the composition may be retained in the bladder for a predetermined period of time. A suitable period of time may readily be determined by those skilled in the art. The composition may, for example, be left in the bladder for a period of from about 10 minutes to about 3 hours, preferably from about 20 minutes to about 2 hours, more preferably from about 30 minutes to 1 hour. Advantageously, the composition may be retained in the patient’s bladder for no less than about 30 minutes or no less than about 1 hour. At the end of this period, the bladder is evacuated. If the patient cannot retain the composition for a suitable period of time, for example for about 10 minutes, or for about 20 minutes, or for about 30 minutes, or for about 1 hour, the instillation procedure may be repeated. In one embodiment, the composition is instilled into the patient’s bladder through a catheter and is left in the bladder for about 30 minutes or for about 1 hour. The bladder is then evacuated.

The composition for use in the invention comprises hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof. The synthesis of hexyl 5-ALA ester is known in the art. It may, for example, be prepared as described in WO 96/28412, the entire contents of which are incorporated herein by reference. For example, hexyl 5-ALA ester may be prepared by reaction of 5-ALA with hexanol in the presence of a catalyst, such as an acid. Alternatively, hexyl 5-ALA ester hydrochloride is commercially available, e.g. in the form of Hexvix® (available from Photocure ASA, for example) or Cysview® (available from Photocure Inc., for example).

The hexyl 5-ALA ester for use in the invention may be employed in the form of a pharmaceutically acceptable salt. Such salts are preferably acid addition salts with pharmaceutically acceptable organic or inorganic acids. Suitable acids include, for example, hydrochloric, nitric, hydrobromic, phosphoric, sulfuric, sulfonic acid and sulfonic acid derivatives. Such salts of ALA-esters are described in WO 2005/092838, the entire contents of which are incorporated herein by reference. A preferred acid addition salt of HAL for use in the invention is the hydrochloride salt. Synthetic procedures for salt formation are conventional in the art and are for instance described in WO 2005/092838.

The composition will contain HAL or a pharmaceutically acceptable salt in a therapeutically effective amount. Appropriate concentrations can readily be determined by those skilled in the art. Conveniently, the concentration is in the range of 0.1 to 5% by weight of the total weight of the composition, or the equivalent concentration of a pharmaceutically acceptable salt of HAL, preferably 0.15 to 3.5%, and most preferably 0.17%, which corresponds to e.g. 0.2% HAL hydrochloride (8 mM).

The composition for use in the invention is a pharmaceutical composition and may comprise pharmaceutically acceptable carriers or excipients, such as stabilizers. The composition is preferably a liquid composition, more preferably a suspension or even more preferably a solution of HAL in a liquid carrier. Preferred liquid carriers include water and aqueous solutions, for example aqueous buffers.

In one embodiment, the composition for use in the invention is an aqueous solution of HAL or a pharmaceutically acceptable salt thereof.

In one embodiment, the composition for use in the invention is a solution of HAL, or a pharmaceutically acceptable salt thereof, in an aqueous buffer such as an aqueous phosphate buffer. In one embodiment, the composition for use in the invention comprises an aqueous phosphate buffer comprising disodium phosphate dihydrate, potassium dihydrogen phosphate, sodium chloride, hydrochloric acid, sodium hydroxide and water.

In one embodiment, the composition for use in the invention is an aqueous solution of HAL hydrochloride. For example, the composition may be a solution of HAL hydrochloride in an aqueous buffer.

If the composition for use in the invention is a liquid composition comprising water, the pH of said composition is preferably in the range of 4.5 to 7.5, more preferably in the range of 5.7 to 7.2.

In one embodiment, HAL or the pharmaceutically acceptable salt thereof is provided in a lyophilized form, and is reconstituted in a liquid carrier, preferably in water or an aqueous solution, most preferably in an aqueous buffer, prior to use.

In one embodiment, the composition for use of the invention is Hexvix®, i.e. a solution of HAL hydrochloride (2 mg/ml; 8 mM) in an aqueous buffer comprising disodium phosphate dihydrate, potassium dihydrogen phosphate, sodium chloride, hydrochloric acid, sodium hydroxide and water.

The amount of the composition to be instilled into the patient’s bladder may vary according to the patient’s bladder volume. A suitable amount may readily be determined by those skilled in the art. In general, a volume of about 50 ml of the composition may be suitable. For example, a volume of about 50 ml of a composition comprising 0.2% HAL hydrochloride (8 mM) is suitable and sufficient.

The use of a volume of about 50 ml of Hexvix® is considered to be suitable.

In one embodiment, the composition for instillation into the patient’s bladder is a solution comprising 2 mg/ml HAL hydrochloride.

In one embodiment, the composition for use in the invention may further comprise anti-PD-L1 antibodies and/or anti-PD-1 antibodies. Anti-PD-L1 is a monoclonal antibody designed to interfere with a protein called PD-L1 (programmed deathligand 1). Anti-PD-L1 targets PD-L1 expressed on cancer cells and tumorinfiltrating immune cells, preventing it from binding to PD-1 and B7.1 on the surface of T cells. By inhibiting PD-L1 , anti-PD-L1 may enable the activation of T cells, restoring their ability to effectively detect and attack bladder cancer cells. Anti-PD-1 is a monoclonal antibody that binds to the PD-1 (programmed death receptor-1) protein, which is present at high levels in many cancer types, e.g. bladder cancer. By competitively blocking the interaction with PD-1 receptors, it is believed that anti- PD-1 thereby restores anti-cancer T-cell responses. Thus, anti-PD-L1 antibodies and anti-PD-1 antibodies target different components of the same interaction mechanism between immune cells (specifically killer T cells) and cancer cells, but have a similar therapeutic effect: anti-PD-L1 antibodies target PD-L1 expressed on cancer cells while anti-PD-1 antibodies target the other half of this mechanism, i.e. PD-1), which is expressed on killer T cells. As will be understood, the anti-PD-L1 antibodies and anti-PD-1 antibodies referred to herein act to inhibit PD-L1 and PD- 1 , respectively. Accordingly, these may also be referred to as antagonizing anti- PD-L1 antibodies and antagonizing anti-PD-1 antibodies.

In another aspect the invention thus provides a composition for use in a method of therapy for bladder cancer, wherein said composition comprises: (i) hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof; and (ii) anti-PD-L1 antibodies and/or anti-PD-1 antibodies, and said method comprises instillation of said composition into the bladder of a patient, and further wherein said method is not a method of photodynamic therapy.

In another aspect, the invention provides a method of therapy for bladder cancer, said method comprising the step of instillation into the bladder of a patient a composition comprising: (i) hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof; and (ii) anti-PD-L1 antibodies and/or anti-PD-1 antibodies, and wherein said method is not a method of photodynamic therapy.

Preferred anti-PD-L1 antibodies for use in the invention are those by Roche, preferably MPDL3280A. Such anti-PD-L1 antibodies are described in

WO 2010/077634, WO 2013/019906 and WO 2013/181452, the entire contents of which are incorporated herein by reference.

Preferred anti-PD-1 antibodies for use in the invention are those by Merck, preferably pembrolizumab (Keytruda). Such anti-PD-1 antibodies are described in WO 2008/156712, WO 2009/114335 and WO 2013/079174, the entire contents of which are incorporated herein by reference.

Other preferred anti-PD-1 antibodies that find use in the invention are those by Bristol-Myers Squibb, preferably nivolumab (Opdivo). Such anti-PD-1 antibodies are described in WO 2004/004771 , the entire content of which is incorporated herein by reference.

Where the composition for use in the invention additionally comprises anti-PD-L1 antibodies and/or anti-PD-1 antibodies, these will be present in a therapeutically effective amount. The precise amount will depend on various factors such as the chosen anti-PD-L1 antibodies and/or anti-PD-1 antibodies, whether the therapy is intended for the treatment and/or prevention of bladder cancer, if the therapy is a stand-alone therapy or is intended to be carried out as an adjuvant or neoadjuvant therapy in combination with other therapies and/or surgical procedures such as those herein described, etc. A therapeutically effective amount of the anti-PD-L1 antibodies and/or anti-PD-1 antibodies can readily be determined by those skilled in the art taking account of such factors.

The method of therapy for bladder cancer according to the invention can be used in the treatment of bladder cancer. For use in such treatment, the composition is administered to a patient in need thereof, i.e. a patient diagnosed with bladder cancer. The bladder cancer may be non-muscular invasive bladder cancer (NMIBC), or muscular invasive bladder cancer (MIBC).

In one embodiment, the bladder cancer is MIBC in which the cancer has entered the muscle layer of the bladder.

In one embodiment, the bladder cancer is NMIBC in which the cancer has not entered the muscle layer of the bladder. This cancer appears as papillary tumors and flat lesions (carcinoma-in-situ, CIS).

In one embodiment, the bladder cancer is NMIBC with a high risk of progression, for example including multiple recurrent high-grade tumors or high-grade T1 tumors or high-grade tumors with concurrent carcinoma-in-situ (CIS).

For use in the treatment of bladder cancer, the therapy according to the invention may be carried out once, or repeatedly, depending on the extent and aggression of the cancer. For example, it may be carried out 2 or more times, e.g. 3, 4, 5, 6, 7, 8, 9 or 10 times, with a period between the treatments. In some cases, it may be carried out more than 10 times. The period between treatments may vary, but may for example range from about 4 days to 4 weeks, e.g., it may be 1 , 2 or 3 weeks. In some embodiments, the therapy according to the invention is carried out repeatedly in the form of an induction therapy followed by a maintenance therapy. In some embodiments, the induction therapy comprises carrying out the method of therapy according to the invention 2 or more times, e.g. 3, 4, 5, 6, 7, 8, 9 or 10 times, such as 5, 6, 7 or 8 times, with a period between the treatments of 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 , 12, 13 or 14 days, such as 6, 7, 8, 9 or 10 days. For example, the induction therapy may comprise carrying out the method of therapy according to the invention once a week for a period of about 6 weeks. In some embodiments, the maintenance therapy comprises carrying out the method of therapy according to the invention once a week for a period of 2, 3 or 4 weeks. Such maintenance therapy may be performed once, twice, three or 4 times a year.

The method of therapy for bladder cancer according to the invention can be used as a stand-alone bladder cancer treatment. Preferably, it can be used as an adjuvant therapy in the treatment of bladder cancer, i.e. in addition to a primary (i.e. main) therapy for bladder cancer.

In a further embodiment, the invention thus provides a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of adjuvant therapy for bladder cancer, wherein said method comprises instillation of said composition into the bladder of a patient, and wherein said method is not a method of photodynamic therapy.

In another embodiment, the invention provides a method of adjuvant therapy for bladder cancer, said method comprising the instillation into the bladder of a patient a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, wherein said method is not a method of photodynamic therapy.

The adjuvant therapy according to the invention can be carried out prior to, simultaneously, or after the main treatment for the disease (i.e. bladder cancer). The main treatment for the bladder cancer will be dependent on the patient’s diagnosis, for example whether they have been diagnosed with NMIBC or with MIBC.

For patients with NMIBC, e.g. who have TaT1 tumors with low risk of recurrence and progression, or TaT1 tumors with intermediate or high risk of recurrence and intermediate risk of progression or CIS, the main treatment for such patients will typically be a transurethral resection (TUR), i.e. a procedure in which a cystoscope is used to visualize the inside of the bladder through the urethra in order to detect and identify tumors and lesions and to resect such tumors and lesions. The adjuvant therapy according to the invention may be carried out either prior to or after TUR, or it may be carried out both prior to and after TUR.

In one embodiment, the invention thus provides a composition comprising hexyl 5- ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of adjuvant therapy for bladder cancer, wherein said method comprises instillation of said composition into the bladder of a bladder cancer patient, wherein said patient has undergone TUR and/or will undergo TUR, and wherein said method is not a method of photodynamic therapy.

In another embodiment, the invention provides a method of adjuvant therapy for bladder cancer in a bladder cancer patient who has undergone TUR and/or will undergo TUR, said method comprising the instillation into the bladder of said patient a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, wherein said method is not a method of photodynamic therapy.

In one embodiment, the method of therapy of the invention is carried out as an adjuvant therapy to TUR in patients in need of such treatment, i.e. patients who are diagnosed with NMIBC or patients who are suspected of having NMIBC.

In one embodiment, the adjuvant therapy of the invention may be carried out subsequent to a TUR. When carried out after a TUR, the adjuvant therapy for treating NMIBC will comprise instillation into the bladder of a patient having undergone TUR of a composition comprising hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof. In one embodiment, the adjuvant therapy of the invention is carried out directly after the TUR. In another embodiment, the adjuvant therapy of the invention is carried out as a separate procedure after the TUR, for example after some days, weeks or months following the TUR procedure. For example, the adjuvant therapy of the invention may be carried out after 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 days or more, or after 1 , 2, 3, 4 or 5 weeks or more, or after 1 , 2, 3, 4, 5 or 6 months.

In another embodiment, the adjuvant therapy of the invention may be carried out prior to a TUR. When carried out prior to a TUR, the adjuvant therapy for treating a patient who is suspected of having NMIBC will comprise instillation into the bladder of such a patient a composition comprising hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof. In one embodiment, the adjuvant therapy of the invention is carried out directly prior to the TUR. In another embodiment, the adjuvant therapy of the invention is carried out as a separate procedure prior to the TUR, for example some days, weeks or months prior to the TUR procedure. For example, the adjuvant therapy of the invention may be carried out 1 , 2, 3, 4, 5, 6, 7, 8, 9 or 10 days or more, or 1 , 2, 3, 4 or 5 weeks or more, or 1 , 2, 3, 4, 5 or 6 months prior to the TUR.

Any conventional TUR procedure for the treatment of NMIBC or suspected NMIBC may be used as the main treatment. Such a procedure may involve photodynamic detection of lesions in the bladder, for example using HAL or a pharmaceutically acceptable salt thereof with blue light. The TUR procedure typically comprises the use of a cystoscope and exposure of the inside of the patient’s bladder to white light from the cystoscope for a visual inspection to detect and identify lesions, followed by resection of said lesions. In some cases, the TUR procedure may involve the photodynamic detection (PDD) of lesions. If the TUR procedure involves photodynamic detection of lesions, the TUR procedure may comprise: a) instillation of a composition comprising hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof into the bladder of a patient; b) exposing the inside of said bladder to white light for a visual inspection followed by exposing said inside of the bladder to blue light for fluorescence detection of lesions; c) exposing the bladder to white light for resection of said lesions; and d) optionally monitoring the completeness of the resection by exposing said inside of the bladder again to blue light for fluorescence detection of residual lesions.

In one embodiment, the invention thus provides a composition comprising hexyl 5- ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of treating NMIBC by carrying out a transurethral resection of NMIBC and, subsequently, carrying out an adjuvant therapy comprising instillation of said composition into the bladder, wherein said adjuvant therapy is not a method of photodynamic therapy.

In another embodiment, the invention provides a method of treating NMIBC in a patient in need thereof, said method comprising carrying out a transurethral resection of NMIBC and, subsequently, carrying out an adjuvant therapy comprising instillation into the bladder of said patient a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, wherein said adjuvant therapy is not a method of photodynamic therapy. In yet another embodiment, the invention provides a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of treating a patient suspected of having NMIBC, said method comprising carrying out an adjuvant therapy comprising instillation of said composition into the bladder of said patient, wherein said adjuvant therapy is not a method of photodynamic therapy, and subsequently carrying out a transurethral resection of NMIBC.

In yet another embodiment, the invention provides a method of treating a patient suspected of having NMIBC, said method comprising carrying out an adjuvant therapy comprising instillation into the bladder of said patient a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, wherein said adjuvant therapy is not a method of photodynamic therapy, and subsequently carrying out a transurethral resection of NMIBC.

In yet another embodiment, the invention provides a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of treating a patient suspected of having NMIBC or diagnosed with NMIBC, said method comprising: a) carrying out an adjuvant therapy comprising instillation of said composition into the bladder of said patient, wherein said adjuvant therapy is not a method of photodynamic therapy; b) subsequently carrying out a transurethral resection of NMIBC; and c) subsequently carrying out a further adjuvant therapy according to step a).

In another embodiment, the invention provides a method of treating a patient suspected of having NMIBC or diagnosed with NMIBC, said method comprising: a) carrying out an adjuvant therapy comprising instillation into the bladder of said patient a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, wherein said adjuvant therapy is not a method of photodynamic therapy; b) carrying out a transurethral resection of NMIBC; and c) subsequently carrying out a further adjuvant therapy according to step a).

The adjuvant therapy for NMIBC or suspected NMIBC according to the invention may be carried out once or repeatedly. For example, it may be carried out 2 or more times, e.g. 3, 4, 5, 6, 7, 8, 9 or 10 times, or more than 10 times, with a period between each treatment of several days or weeks, e.g. 4 days to 4 weeks, or 1 , 2 or 3 weeks.

The therapy according to the invention may alternatively be used as an adjuvant therapy in the treatment of bladder cancer in combination with radiotherapy, chemotherapy and/or immunotherapy treatments.

In one embodiment, the therapy for treating NMIBC of the invention can be used in combination with chemotherapy, e.g. systemic or intravesical administration of suitable chemotherapeutic agents for NMIBC, such as cisplatin, methotrexate, vinblastine, valrubicin, adriamycin or mitomycin C and/or in combination with suitable immunotherapeutic agents for NMIBC, such as systemic administration of anticancer vaccines or intravesical administration of Bacillus Calmette-Guerin (BCG).

Alternatively, the adjuvant therapy for treating NMIBC according to the invention may replace or partially replace other adjuvant therapies like chemotherapy and/or immunotherapy. In one embodiment, the adjuvant therapy according to the invention replaces or partially replaces other adjuvant therapies which are intravesically administered, e.g. mitomycin and/or BCG. In one embodiment, the adjuvant therapy for treating NMIBC according to the invention partially or fully replaces BCG. BCG treatment is usually started a few weeks after a transurethral resection of NMIBC and is given once a week for 6 weeks, optionally followed by a maintenance period in which it is given, e.g. once a week for three weeks at the three-, six- and 12-month marks. The adjuvant therapy according to the invention may replace 1, 2, 3, 4, 5 or all 6 of such BCG treatments and/or the maintenance BCG treatments.

Up to 40% of patients with NMIBC will fail intravesical BCG therapy. The vast majority of low-grade NMIBC are prone to recur but very rarely progress. Failure after intravesical BCG in these patients is usually superficial and low-grade, and such patients can be managed with intravesical regimens, including repeated BCG, BCG plus cytokines, intravesical chemotherapy, thermochemotherapy or new immunotherapeutic modalities. At the other end of the spectrum, failure to respond to BCG in high-risk T1 bladder cancer and/or carcinoma in situ is more problematic, since those tumors often have the potential to progress to muscle invasion. In these cases, radical cystectomy remains the mainstay after BCG failure. Full replacement of BCG by the adjuvant therapy according to the invention may be used in BCG refractory NMIBC patients, i.e. patients where BCG therapy does not lead to the desired treatment success.

In one embodiment, the invention thus provides an adjuvant therapy for treating NMIBC in BCG refractory patients, comprising instillation of a composition comprising hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof into the bladder of a BCG refractory patient, wherein said adjuvant therapy is not a method of photodynamic therapy.

For patients with MIBC, the main treatment is radical cystectomy, i.e. removal of the bladder and, if applicable, adjacent organs, i.e. prostate and seminal vesicles in men, and uterus and adnexa in women, including the dissection of regional lymph nodes. Cystectomy is also advocated in patients with NMIBC who are at high risk of progression, i.e. patients having multiple recurrent high-grade tumors or highgrade T1 tumors or high-grade tumors with concurrent carcinoma-in-situ (CIS). Further, cystectomy is advocated in patients with NMIBC who have received BCG immunotherapy but where such treatment has failed. For patients who are scheduled for a cystectomy, the therapy according to the invention may be carried out as a neoadjuvant therapy, i.e. prior to the main treatment which is a cystectomy.

In one embodiment, the therapy of the invention is thus a neoadjuvant therapy for a bladder cancer patient who is scheduled for a cystectomy. Such a patient is one for whom a decision has already been taken by a physician that a cystectomy will be performed, i.e. the patient will undergo a procedure to remove the bladder within a pre-determined and relatively short period of time from carrying out the neoadjuvant therapy. As will be understood, such a patient is one in whom the cancer has already advanced to a stage where there is no alternative but to carry out a cystectomy. The patient may either have MIBC or they may have NMIBC which is at high risk of progression. For such a patient, the standard treatment will be a cystectomy. Thus, in one embodiment, the therapy of the invention is carried out as a neoadjuvant therapy to cystectomy, i.e. prior to such a cystectomy, in a patient who is in need of such treatment, for example a patient who has been diagnosed with MIBC.

In one embodiment, the invention thus provides a composition comprising hexyl 5- ALA ester (HAL) or a pharmaceutically acceptable salt thereof for use in a method of neoadjuvant therapy for bladder cancer in a bladder cancer patient who is scheduled for a cystectomy, said method comprising instillation of the composition into the bladder of said patient, and wherein said neoadjuvant therapy is not a method of photodynamic therapy.

In another embodiment, the invention provides a method of neoadjuvant therapy for bladder cancer in a bladder cancer patient who is scheduled for a cystectomy, said method comprising instillation into the bladder of said patient a composition comprising hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof, and wherein said neoadjuvant therapy is not a method of photodynamic therapy.

In one embodiment, the invention provides a composition comprising hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof for use in a method of treating MIBC in a patient, said method comprising: a) neoadjuvant therapy in which said composition is instilled into the bladder of said patient and wherein said neoadjuvant therapy is not a method of photodynamic therapy; and b) carrying out a cystectomy.

In another embodiment, the invention provides a method of treating MIBC in a patient, said method comprising: a) neoadjuvant therapy in which a composition comprising hexyl 5-ALA ester (HAL) or a pharmaceutically acceptable salt thereof is instilled into the bladder of said patient and wherein said neoadjuvant therapy is not a method of photodynamic therapy; and b) carrying out a cystectomy.

The time period between the neoadjuvant therapy of the invention and the cystectomy may vary but is preferably zero to 6 weeks, e.g. zero to 1 , 2, 3, 4, 5 or 6 weeks, more preferably zero to 3 weeks, e.g. 1 or 2 weeks. “Zero” means that the cystectomy is carried out directly after the neoadjuvant therapy according to the invention.

The neoadjuvant therapy can be carried out repeatedly prior to the cystectomy. For example, it may be carried out 2 or more times, e.g. 3, 4, 5, 6, 7, 8, 9 or 10 times, or more than 10 times. The period between each treatment may be several days or weeks, e.g. 4 days to 4 weeks, or 1 , 2 or 3 weeks.

The neoadjuvant therapy of the invention can be carried out in combination with other neoadjuvant therapies, for example prior to, simultaneously, or after other neoadjuvant therapies, such as neoadjuvant radiotherapy, neoadjuvant chemotherapy, and neoadjuvant immunotherapy. Examples of neoadjuvant therapies include neoadjuvant chemotherapy (intravesical instillation or systemic administration) of cisplatin, methotrexate, vinblastine, valurubicin, adriamycin, mitomycin C, or combinations thereof, and neoadjuvant immunotherapy (intravesical instillation or systemic administration) of BCG.

After the cystectomy, the patient may receive systemic adjuvant chemotherapy with e.g. cisplatin, methotrexate, vinblastine, adriamycin, gemcitabine, doxorubicin, epirubicin, cyclophosphamide or combinations thereof. Alternatively, or in addition thereto, the patient may receive systemic adjuvant immunotherapy with e.g. anti- PD-L1 antibodies and/or anti-PD-1 antibodies. Suitable anti-PD-L1 antibodies and/or anti-PD-1 antibodies include those as herein described in respect of the composition for use in the invention. Formulations suitable for parenteral (e.g. subcutaneous) or intravenous administration are described in WO 2010/077634, WO 2013/019906 and WO 2013/181452 (for anti-PD-L1 antibodies) and in WO 2004/004771 , WO 2008/156712, WO 2009/114335 and WO 2013/079174 (for anti-PD-1 antibodies). The entire contents of these documents are incorporated herein by reference.

The adjuvant or neoadjuvant therapies according to the method of the invention have several advantages compared to neoadjuvant radiotherapy, (neo)adjuvant chemotherapy and (neo)adjuvant immunotherapy, where nausea, vomiting, fatigue, anemia, damage to epithelial surfaces, intestinal discomfort/gastrointestinal stress, nephrotoxicity, neurotoxicity, swelling, depression of the immune system and infertility are well-known and common adverse effects. In contrary thereto, the most reported adverse reactions to HAL (in the form of HexvixO/Cysview®) were transient and mild to moderate in intensity. The most frequently reported adverse reactions from clinical studies with Hexvix®/Cysview® were bladder spasm, reported by 2.4 % of the patients, dysuria by 1.8%, bladder pain by 1.7 % and hematuria by 1.7% of the patients.

In addition, HAL has a highly favorable metabolic profile compared to chemotherapeutics, e.g. cisplatin. HAL interferes with the body’s own heme biosynthetic pathway and leads of accumulation of porphyrins, particularly PpIX which is the last intermediate in heme synthesis. Since such porphyrins are compounds which naturally occur in the body, there is a “natural process” in the body for degrading (metabolizing) and excreting degraded heme.

The invention is illustrated further by way of the following non-limiting Example.

Example

Example 1 - Therapeutic efficacy of intravesical HAL instillation into the bladder of tumor-bearing rats

Method:

The rat bladder carcinoma cell line AY-27 was used to establish superficial bladder tumors in Female Fischer rats (purchased from Charles River Laboratories, Chatillon-sur-Chalronne, France) weighing 150-175 g as described in Frangois et al., J. Urol. 190(2), 2013, 731-736. The animals were used in the experiments 5 days after tumor cell inoculation.

Lyophilized HAL (in the form of Hexvix® powder) was dissolved in RPMI medium without serum to a final concentration of 2 mg/ml (8 mM) immediately before instillation. pH of the resulting solution was 6.8. 0.5 ml of the solution was instilled into the rat bladder, left in the bladder for about 1 hour and then evacuated. The bladder was washed three times with PBS. No HAL was instilled into bladders of the rats in the control groups. The treatments were performed at normal body temperature. The rats were sacrificed 12, 30 or 60 days after treatment by an overdose of pentobarbital. Bladders were removed from the animals and transferred into vials with formaldehyde (4%) for a minimum of 4 hours. Then the bladder was cut into 4 parts and fixed for 48 hours. Following different cycles of dehydration with gradients of ethanol and xylene, the bladder tissue was embedded into paraffin. Paraffin embedded sections of 5 pm were cut and stained with haematoxylin-eosin- safran (HES) for histology assessment.

Results:

Therapeutic efficacy at day 12, 30 or 60 after tumor inoculation was determined by histology as extent of tumor regression. According to tumor regression extent, rats were divided into 4 groups:

• No response (“NR”): muscle-invasive tumor.

• Moderate response (“MR”): several areas of few tumor cells or islets of tumor cells.

• Near complete response (“Near CR”): singular islet of tumor cells or isolated tumor cells.

• Complete response (“CR”): no tumor cells.

A good anti-tumor effect was defined as the sum of “Near CR” and “CR”.

Results are provided in Table 1 , showing the therapeutic efficacy of a treatment comprising the bladder instillation of HAL into rats having bladder cancer compared to a control group, wherein such treatment is performed in the absence of photoactivating light: Table 1

Various embodiments of the invention are as follows:

Embodiment 1: A method of therapy for bladder cancer, said method comprising the step of instillation into the bladder of a patient a composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, and wherein said method is not a method of photodynamic therapy.

Embodiment 2: The method according to Embodiment 1 , wherein said method is carried out at body temperature.

Embodiment 3: The method according to Embodiment 1 or 2, wherein said patient is a human.

Embodiment 4: The method according to any one of Embodiments 1 to 3, wherein said method is performed in the absence of photoactivating light.

Embodiment 5: The method according to Embodiment 4, wherein said photoactivating light is white light, blue light, red light or any combination thereof.

Embodiment 6: The method according to any one of Embodiments 1 to 5, wherein said composition is instilled into the bladder of the patient through a catheter and is left in the bladder for a period of from about 10 minutes to about 3 hours. Embodiment 7: The method according to any one of Embodiments 1 to 6, wherein the concentration of HAL in the composition is in the range from 0.1 to 5% by weight based on the total weight of the composition, or the equivalent concentration of a pharmaceutically acceptable salt of HAL.

Embodiment 8: The method according to any one of Embodiments 1 to 7, wherein said composition is an aqueous solution of HAL or a pharmaceutically acceptable salt thereof, preferably a solution of HAL or a pharmaceutically acceptable salt thereof in an aqueous buffer, more preferably a solution of HAL or a pharmaceutically acceptable salt thereof in a phosphate buffer.

Embodiment 9: The method according to Embodiment 8, wherein the pH of said composition is in the range of 4.5 to 7.5, preferably in the range of 5.7 to 7.2.

Embodiment 10: The method according to any one of Embodiments 1 to 9, wherein said composition is a solution of 2 mg/ml HAL hydrochloride in an aqueous buffer comprising disodium phosphate dihydrate, potassium dihydrogen phosphate, sodium chloride, hydrochloric acid, sodium hydroxide and water.

Embodiment 11 : The method according to any one of Embodiments 1 to 10, wherein said bladder cancer is muscular invasive bladder cancer (MIBC).

Embodiment 12: The method according to any one of Embodiments 1 to 10, wherein said bladder cancer is non-muscular invasive bladder cancer (NMIBC).

Embodiment 13: The method according to Embodiment 12, wherein said bladder cancer is NMIBC with a high risk of progression.

Embodiment 14: The method according to any one of Embodiments 1 to 13, wherein said method is carried out in a bladder cancer patient who has undergone a transurethral resection.

Embodiment 15: The method according to any one of Embodiments 1 to 14 for the prevention of recurrence of said bladder cancer. Embodiment 16: The method according to any one of Embodiments 1 to 13, wherein said method is an adjuvant therapy, preferably wherein said bladder cancer is NMIBC and said method is carried out prior to or after a transurethral resection of NMIBC.

Embodiment 17: The method according to Embodiment 16, wherein said bladder cancer is NMIBC and said method is carried out after a transurethral resection of NMIBC.

Embodiment 18: The method according to Embodiment 16 or 17, wherein said method replaces or partially replaces other adjuvant therapies for the treatment of bladder cancer, preferably wherein said other adjuvant therapies are chemotherapy and/or immunotherapy, for example BCG treatment.

Embodiment 19: The method according to any one of Embodiments 1 to 13, wherein said method is a neoadjuvant therapy, preferably wherein said bladder cancer is MIBC and said method is carried out prior to a cystectomy.

Embodiment 20: Use of hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, in the manufacture of a medicament for the treatment of bladder cancer, wherein said medicament is instilled into the bladder of a patient, and wherein said treatment is not photodynamic therapy.

Embodiment 21: Use according to Embodiment 20, wherein said treatment is carried out at body temperature.

Embodiment 22: Use according to Embodiment 20 or 21 , wherein said patient is a human.

Embodiment 23: Use according to any one of Embodiments 20 to 22, wherein said treatment is performed in the absence of photoactivating light.

Embodiment 24: Use according to Embodiment 23, wherein said photoactivating light is white light, blue light, red light or any combination thereof. Embodiment 25: Use according to any one of Embodiments 20 to 24, wherein said medicament is instilled into the bladder of the patient through a catheter and is left in the bladder for a period of from about 10 minutes to about 3 hours.

Embodiment 26: Use according to any one of Embodiments 20 to 25, wherein the concentration of HAL in the medicament is in the range from 0.1 to 5% by weight based on the total weight of the medicament, or the equivalent concentration of a pharmaceutically acceptable salt of HAL.

Embodiment 27: Use according to any one of Embodiments 20 to 26, wherein said medicament is an aqueous solution of HAL or a pharmaceutically acceptable salt thereof, preferably a solution of HAL or a pharmaceutically acceptable salt thereof in an aqueous buffer, more preferably a solution of HAL or a pharmaceutically acceptable salt thereof in a phosphate buffer.

Embodiment 28: Use according to Embodiment 27, wherein the pH of said medicament is in the range of 4.5 to 7.5, preferably in the range of 5.7 to 7.2.

Embodiment 29: Use according to any one of Embodiments 20 to 28, wherein said medicament is a solution of 2 mg/ml HAL hydrochloride in an aqueous buffer comprising disodium phosphate dihydrate, potassium dihydrogen phosphate, sodium chloride, hydrochloric acid, sodium hydroxide and water.

Embodiment 30: Use according to any one of Embodiments 20 to 29, wherein said bladder cancer is muscular invasive bladder cancer (MIBC).

Embodiment 31: Use according to any one of Embodiments 20 to 29, wherein said bladder cancer is non-muscular invasive bladder cancer (NMIBC).

Embodiment 32: Use according to Embodiment 31, wherein said bladder cancer is NMIBC with a high risk of progression. Embodiment 33: Use according to any one of Embodiments 20 to 32, wherein said treatment is carried out in a bladder cancer patient who has undergone a transurethral resection.

Embodiment 34: Use according to any one of Embodiments 20 to 33, wherein said treatment is for the prevention of recurrence of said bladder cancer.

Embodiment 35: Use according to any one of Embodiments 20 to 32 wherein said treatment is an adjuvant therapy, preferably wherein said bladder cancer is NMIBC and said treatment is carried out prior to or after a transurethral resection of NMIBC.

Embodiment 36: Use according to Embodiment 35, wherein said bladder cancer is NMIBC and said treatment is carried out after a transurethral resection of NMIBC.

Embodiment 37: Use according to Embodiment 35 or 36, wherein said treatment replaces or partially replaces other adjuvant therapies for the treatment of bladder cancer, preferably wherein said other adjuvant therapies are chemotherapy and/or immunotherapy, for example BCG treatment.

Embodiment 38: Use according to any one of Embodiments 20 to 32, wherein said treatment is a neoadjuvant therapy, preferably wherein said bladder cancer is MIBC and said treatment is carried out prior to a cystectomy.

Claims

Claims:

1. A composition comprising hexyl 5-ALA ester (HAL), or a pharmaceutically acceptable salt thereof, for use in a method of therapy for bladder cancer, wherein said method comprises instillation of said composition into the bladder of a patient, and wherein said method is not a method of photodynamic therapy.

2. A composition for use as claimed in claim 1 , wherein said method is carried out at body temperature.

3. A composition for use as claimed in claim 1 or claim 2, wherein said patient is a human.

4. A composition for use as claimed in any one of the preceding claims, wherein said method of therapy is performed in the absence of photoactivating light.

5. A composition for use as claimed in claim 4, wherein said photoactivating light is white light, blue light, red light, or any combination thereof.

6. A composition for use as claimed in any one of the preceding claims, wherein said composition is instilled into the bladder of the patient through a catheter and is left in the bladder for a period of from about 10 minutes to about 3 hours.

7. A composition for use as claimed in any one of the preceding claims, wherein the concentration of HAL in the composition is in the range from 0.1 to 5% by weight based on the total weight of the composition, or the equivalent concentration of a pharmaceutically acceptable salt of HAL.

8. A composition for use as claimed in any one of the preceding claims, wherein said composition is an aqueous solution of HAL or a pharmaceutically acceptable salt thereof, preferably a solution of HAL or a pharmaceutically acceptable salt thereof in an aqueous buffer, more preferably a solution of HAL or a pharmaceutically acceptable salt thereof in a phosphate buffer.

9. A composition for use as claimed in claim 8, wherein the pH of said composition is in the range of 4.5 to 7.5, preferably in the range of 5.7 to 7.2.

10. A composition for use as claimed in any one of the preceding claims, wherein said composition is a solution of 2 mg/ml HAL hydrochloride in an aqueous buffer comprising disodium phosphate dihydrate, potassium dihydrogen phosphate, sodium chloride, hydrochloric acid, sodium hydroxide and water.

11. A composition for use as claimed in any one of the preceding claims, wherein said bladder cancer is muscular invasive bladder cancer (MIBC).

12. A composition for use as claimed in any one of claims 1 to 10, wherein said bladder cancer is non-muscular invasive bladder cancer (NMIBC).

13. A composition for use as claimed in claim 12, wherein said bladder cancer is NMIBC with a high risk of progression.

14. A composition for use as claimed in any one of the preceding claims, wherein said method of therapy is carried out in a bladder cancer patient who has undergone a transurethral resection.

15. A composition for use as claimed in any one of the preceding claims in the prevention of recurrence of said bladder cancer.

16. A composition for use as claimed in any one of claims 1 to 13, wherein said method of therapy is an adjuvant therapy, preferably wherein said bladder cancer is NMIBC and said method of therapy is carried out prior to or after a transurethral resection of NMIBC.

17. A composition for use as claimed in claim 16, wherein said bladder cancer is NMIBC and said method of therapy is carried out after a transurethral resection of NMIBC.

18. A composition for use as claimed in claim 16 or claim 17, wherein said method of therapy replaces or partially replaces other adjuvant therapies for the treatment of bladder cancer, preferably wherein said other adjuvant therapies are chemotherapy and/or immunotherapy, for example BCG treatment.

19. A composition for use as claimed in any one of claims 1 to 13, wherein said method of therapy is a neoadjuvant therapy, preferably wherein said bladder cancer is MIBC and said method of therapy is carried out prior to a cystectomy.