WO2025188940A1 - Thiostrepton therapies, dosing regimens, patient populations, and combination therapies - Google Patents

Abstract

Disclosed herein are methods of administering thiostrepton with anti-cancer agents to treat cancers such as mesothelioma, lung cancer and ovarian cancer.

Description

THIOSTREPTON THERAPIES, DOSING REGIMENS, PATIENT POPULATIONS, AND COMBINATION THERAPIES

CROSS-REFERENCE TO RELATED APPLCIATIONS

This application claims the benefit of priority to U.S. Provisional Patent Application No. 63/561,934, filed on March 6, 2024, which is hereby incorporated by reference in its entirety.

BACKGROUND

Thiostrepton (TS) is a cyclic oligopeptide antibiotic that is also known by other names such as Bryamycin, Thiactin, alaninamide, HR4S203Y18, etc. Thiostrepton has the structure below: or a pharmaceutically acceptable salt thereof. Recent studies have shown that thiostrepton also has promising anticancer activity in addition to its antibiotic properties. There remains a need for safe and effective methods of administering thiostrepton for treating cancer.

Malignant pleural effusion (MPE) is a condition whereby excess fluid accumulates in the pleural cavity, caused by direct pleural tumor invasion, resulting in increased permeability of the pleural microvessels and involvement of local lymph nodes causing reduced fluid reabsorption. MPE is defined by the presence of malignant cells in the pleural fluid and advanced malignancy. There are 100,000 new cases of MPE yearly in Europe, and in the United Kingdom 40,000 people per year are affected. It is estimated that up to 50% of patients with metastatic malignancy will develop a pleural effusion, either at the time of diagnosis, or during the evolution of their cancer. The most common etiologies for MPE are lung, breast, gastric, ovarian, and other cancers, in order of decreasing frequency. The four most frequent malignancies account for over 70% of all MPE. Malignant mesothelioma is the most common primary pleural malignancy associated with a pleural effusion.

Despite recent advances in technologies and a greater understanding of the disease, the prognosis of MPE remains poor with a median overall survival of 3 to 12 months. The principal therapeutic modalities for MPE include thoracentesis and pleurodesis for symptom control and chemotherapy and/or radiotherapy directed at the underlying malignancy.

While multiple therapeutic approaches are available for MPE, and a number of direct antitumor strategies have been attempted, no intrapleural management of MPE exploiting intrinsic tumoral oxidative stress has been previously described.

SUMMARY

In certain embodiments, provided herein are methods of treating pleural disease, such as malignant pleural effusion, comprising administering to a human subject in need thereof a first amount of thiostrepton and a second amount of an anti-cancer agent, wherein the first amount of thiostrepton and the second amount of the anti-cancer agent, taken together, are therapeutically effective; and the first amount of thiostrepton is from about 40 mg to about 500 mg, thereby treating the pleural disease.

In certain embodiments, provided herein are methods of treating cancer, comprising administering to a human subject in need thereof thiostrepton in a single dose of about 40 mg to about 500 mg once every other week or in a single dose of about 40 mg to about 500 mg once every three weeks, thereby treating the cancer.

In certain embodiments, provided herein are methods of treating cancer, comprising administering to a human subject in need thereof thiostrepton in a single dose of about 40 mg to about 500 mg once per week, or in a single dose of about 40 mg to about 500 mg once every other week, or in a single dose of about 40 mg to about 500 mg once every three weeks, wherein, prior to receiving a first single dose of thiostrepton, the subject has not received first line systemic therapy for the cancer, thereby treating the cancer.

In certain embodiments, provided herein are methods of treating cancer, comprising administering to a human subject in need thereof a first amount of thiostrepton and a second amount of an anti-cancer agent, wherein the first amount of thiostrepton and the second amount of the anti-cancer agent, taken together, are therapeutically effective; and the first amount of thiostrepton is from about 40 mg to about 500 mg, thereby treating the cancer.

BRIEF DESCRIPTIONS OF THE DRAWING

FIG. 1 depicts a Swimmer’s plot showing the initial outcomes for patients treated with TS in a window of opportunity (WoO) study.

DETAILED DESCRIPTION

Overview

Pleural disease usually manifests as recurrent and symptomatic malignant pleural effusion(s). Thiostrepton can treat local pleural disease, but it is not expected to impact the systemic growth or spread of solid tumors that have metastasized to the pleura from elsewhere. The target population for use of thiostrepton in solid tumors is patients whose pleural disease is expected to be life-limiting or quality of life-limiting, i.e. locally symptomatic and therefore presenting a clinical problem due to their pleural disease. The vast majority of patients with pleural metastases from solid tumors are metastatic non-small cell lung cancers (NSCLC) and breast cancers (MBC). Ovarian cancers can metastasize to pleura, and the presence of pleural effusion in such patients confers a negative prognostic impact, with a short overall survival. To permit testing of TS in such patients, systemic control of disease is also required to complement any local effects. A single-agent systemic standard of care common to the types of tumors that cause pleural disease is required to provide a consistent approach and allow adequate assessment of the impact of TS.

Paclitaxel is an approved agent in advanced/metastatic NSCLC [Paclitaxel SMPC], and patients not eligible for platinum doublet therapy (e.g. due to poor performance status or concurrent illness) may receive single agent paclitaxel per NICE and other clinical guidelines. In MBC, paclitaxel is approved for single agent use in patients whose disease has failed to respond adequately to standard treatment with anthracyclines or in whom anthracycline therapy has not been appropriate. In second line ovarian cancer, paclitaxel is indicated for treatment of metastatic carcinoma of the ovary after failure of standard therapy with platinum-containing preparations. Pharmaceutical Compositions and Formulations

The compositions and methods described herein may be utilized to treat an individual in need thereof. The term “pharmaceutical composition” means a composition that comprises thiostrepton and at least one pharmaceutically acceptable carrier. The terms “active compound” and “active ingredient” refer to thiostrepton. In certain embodiments, the individual is a mammal such as a human, or a non-human mammal. In certain preferred embodiments, the subject or the mammal is a human. When administered to an animal, such as a human, the composition or the compound is preferably administered as a pharmaceutical composition comprising, for example, an active compound described herein and a pharmaceutically acceptable carrier. Pharmaceutically acceptable carriers are well-known in the art and include, as a non-limiting example, aqueous solutions such as water or physiologically buffered saline or other solvents or vehicles such as glycols, glycerol, oils such as olive oil, or injectable organic esters. In preferred embodiments, when such pharmaceutical compositions are for human administration, particularly for invasive routes of administration (i.e., routes, such as injection or implantation, that circumvent transport or diffusion through an epithelial barrier), the aqueous solution is pyrogen-free, or substantially pyrogen-free. The excipients can be chosen, for example, to effect delayed release of an agent or to selectively target one or more cells, tissues or organs. The pharmaceutical composition can be in dosage unit form such as tablet, capsule (including sprinkle capsule and gelatin capsule), granule, lyophile for reconstitution, powder, solution, syrup, suppository, injection or the like. The composition can also be present in a transdermal delivery system, e.g., a skin patch. The composition can also be present in a solution suitable for topical administration, such as a lotion, cream, or ointment.

A pharmaceutically acceptable carrier can contain physiologically acceptable agents that act, for example, to stabilize, increase solubility or to increase the absorption of an active compound such as an active compound described herein. Such physiologically acceptable agents include, for example, carbohydrates, such as glucose, sucrose or dextrans, antioxidants, such as ascorbic acid or glutathione, chelating agents, low molecular weight proteins or other stabilizers or excipients. The choice of a pharmaceutically acceptable carrier, including a physiologically acceptable agent, depends, for example, on the route of administration of the composition. The preparation or pharmaceutical composition can be a self-emulsifying drug delivery system or a self-microemulsifying drug delivery system. The pharmaceutical composition (preparation) also can be a liposome or other polymer matrix, which can have incorporated therein, for example, a compound described herein. Liposomes, for example, which comprise phospholipids or other lipids, are nontoxic, physiologically acceptable and metabolizable carriers that are relatively simple to make and administer.

The phrase "pharmaceutically acceptable" is employed herein to refer to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.

The phrase "pharmaceutically acceptable carrier" as used herein means a pharmaceutically acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, solvent or encapsulating material. Each carrier must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not injurious to the patient. Some examples of materials which can serve as pharmaceutically acceptable carriers include: (1) sugars, such as lactose, glucose and sucrose; (2) starches, such as corn starch and potato starch; (3) cellulose, and its derivatives, such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; (4) powdered tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients, such as cocoa butter and suppository waxes; (9) oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil and soybean oil; (10) glycols, such as propylene glycol; (11) polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; (12) esters, such as ethyl oleate and ethyl laurate; (13) agar; (14) buffering agents, such as magnesium hydroxide and aluminum hydroxide; (15) alginic acid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer’s solution; (19) ethyl alcohol; (20) phosphate buffer solutions; and (21) other non-toxic compatible substances employed in pharmaceutical formulations.

A pharmaceutical composition (preparation) can be administered to a subject by any of a number of routes of administration including, for example, intraperitoneally; intrapleurally; subcutaneously; intratumorally; orally (for example, drenches as in aqueous or non-aqueous solutions or suspensions, tablets, capsules (including sprinkle capsules and gelatin capsules), boluses, powders, granules, pastes for application to the tongue); absorption through the oral mucosa (e.g., sublingually); transdermally (for example as a patch applied to the skin); and topically (for example, as a cream, ointment or spray applied to the skin). The compound may also be formulated for inhalation. In some embodiments, the pharmaceutical composition is administered locally. In some embodiments, the pharmaceutical composition is administered by a catheter, a tube, or a needle. In certain embodiments, a compound may be simply dissolved or suspended in sterile water. Details of appropriate routes of administration and compositions suitable for same can be found in, for example, U.S. Pat. Nos. 6,110,973, 5,763,493, 5,731,000, 5,541,231, 5,427,798, 5,358,970 and 4,172,896, as well as in patents cited therein.

The formulations may conveniently be presented in unit dosage form and may be prepared by any methods well known in the art of pharmacy. The amount of active ingredient that can be combined with a carrier material to produce a single dosage form will vary depending upon the host being treated, the particular mode of administration. The amount of active ingredient that can be combined with a carrier material to produce a single dosage form will generally be that amount of the compound that produces a therapeutic effect.

Methods of preparing these formulations or compositions include the step of bringing into association an active compound, such as thiostrepton, with the carrier and, optionally, one or more accessory ingredients. In general, the formulations are prepared by uniformly and intimately bringing into association a compound described herein with liquid carriers, or finely divided solid carriers, or both, and then, if necessary, shaping the product.

Liquid dosage forms include pharmaceutically acceptable emulsions, lyophiles for reconstitution, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active ingredient, the liquid dosage forms may contain inert diluents commonly used in the art, such as, for example, water or other solvents, cyclodextrins and derivatives thereof, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof.

Besides inert diluents, the liquid compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, coloring, perfuming and preservative agents.

Suspensions, in addition to the active compounds, may contain suspending agents as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.

The phrases "parenteral administration" and "administered parenterally" as used herein means modes of administration other than enteral and topical administration, usually by injection, and includes, without limitation, intraperitoneal, intrapleural, subcutaneous, intratumoral, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, transtracheal, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal and intrasternal injection and infusion. In some embodiments, the pharmaceutical composition is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally. Pharmaceutical compositions suitable for parenteral administration comprise one or more active compounds in combination with one or more pharmaceutically acceptable sterile isotonic aqueous or nonaqueous solutions, dispersions, suspensions or emulsions, or sterile powders which may be reconstituted into sterile injectable solutions or dispersions just prior to use, which may contain antioxidants, buffers, bacteriostats, solutes which render the formulation isotonic with the blood of the intended recipient or suspending or thickening agents.

Examples of suitable aqueous and nonaqueous carriers that may be employed in the pharmaceutical compositions described herein include water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, and the like), and suitable mixtures thereof, vegetable oils, such as olive oil, and injectable organic esters, such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of coating materials, such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants.

These compositions may also contain adjuvants such as preservatives, wetting agents, emulsifying agents and dispersing agents. Prevention of the action of microorganisms may be ensured by the inclusion of various antibacterial and antifungal agents, for example, paraben, chlorobutanol, phenol sorbic acid, and the like. It may also be desirable to include isotonic agents, such as sugars, sodium chloride, and the like into the compositions. In addition, prolonged absorption of the injectable pharmaceutical form may be brought about by the inclusion of agents that delay absorption such as aluminum monostearate and gelatin.

In some cases, in order to prolong the effect of a drug, it is desirable to slow the absorption of the drug after injection, for example, subcutaneous injection. This may be accomplished by the use of a liquid suspension of crystalline or amorphous material having poor water solubility. The rate of absorption of the drug then depends upon its rate of dissolution, which, in turn, may depend upon crystal size and crystalline form. Alternatively, delayed absorption of a parenterally administered drug form may be accomplished by dissolving or suspending the drug in an oil vehicle.

Injectable depot forms are made by forming microencapsulated matrices of the subject compounds in biodegradable polymers such as polylactide-polyglycolide. Depending on the ratio of drug to polymer, and the nature of the particular polymer employed, the rate of drug release can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly( anhydrides). Depot injectable formulations are also prepared by entrapping the drug in liposomes or microemulsions that are compatible with body tissue.

For use in the methods described herein, active compounds can be given per se or as a pharmaceutical composition containing, for example, 0.1 to 99.5% (more preferably, 0.5 to 90%) of active ingredient in combination with a pharmaceutically acceptable carrier.

Methods of introduction may also be provided by rechargeable or biodegradable devices. Various slow-release polymeric devices have been developed and tested in vivo in recent years for the controlled delivery of drugs, including proteinaceous biopharmaceuticals. A variety of biocompatible polymers (including hydrogels), including both biodegradable and non-degradable polymers, can be used to form an implant for the sustained release of a compound at a particular target site.

Actual dosage levels of the active ingredients in the pharmaceutical compositions may be varied so as to obtain an amount of the active ingredient that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient.

The selected dosage level will depend upon a variety of factors including the activity of the particular compound or combination of compounds employed, or the ester, salt or amide thereof, the route of administration, the time of administration, the rate of excretion of the particular compound(s) being employed, the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular compound(s) employed, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and like factors well known in the medical arts.

A physician or veterinarian having ordinary skill in the art can readily determine and prescribe the therapeutically effective amount of the pharmaceutical composition required. For example, the physician or veterinarian could start doses of the pharmaceutical composition or compound at levels lower than that required in order to achieve the desired therapeutic effect and gradually increase the dosage until the desired effect is achieved. By “therapeutically effective amount” is meant the concentration of a compound that is sufficient to elicit the desired therapeutic effect. It is generally understood that the effective amount of the compound will vary according to the weight, sex, age, and medical history of the subject. Other factors that influence the effective amount may include, but are not limited to, the severity of the patient’s condition, the disorder being treated, the stability of the compound, and, if desired, another type of therapeutic agent being administered with the compound described herein. A larger total dose can be delivered by multiple administrations of the agent. Methods to determine efficacy and dosage are known to those skilled in the art (Isselbacher et al. (1996) Harrison’s Principles of Internal Medicine 13 ed., 1814-1882, herein incorporated by reference).

In general, a suitable dose of an active compound used in the compositions and methods described herein will be that amount of the compound that is the lowest dose effective to produce a therapeutic effect. Such an effective dose will generally depend upon the factors described above.

If desired, the effective dose of the active compound may be administered as one, two, three, four, five, six or more sub-doses administered separately at appropriate intervals, optionally, in unit dosage forms. In some embodiments, thiostrepton is administered once a week. In certain embodiments, thiostrepton is administered for two, three, four, five or six consecutive weeks. In some embodiments, thiostrepton is administered every other week, once every three weeks, or once every four weeks at a rate of once or twice each week.

The patient receiving this treatment is any animal in need, including primates, in particular humans; and other mammals such as equines, cattle, swine, sheep, cats, and dogs; poultry; and pets in general.

In certain embodiments, compounds described herein may be used alone or conjointly administered with another type of therapeutic agent.

The present disclosure includes the use of pharmaceutically acceptable salts of compounds described herein in the compositions and methods described herein. In certain embodiments, contemplated salts include, but are not limited to, alkyl, dialkyl, trialkyl or tetra-alkyl ammonium salts. In certain embodiments, contemplated salts include, but are not limited to, L-arginine, benenthamine, benzathine, betaine, calcium hydroxide, choline, deanol, diethanolamine, diethylamine, 2-(diethylamino)ethanol, ethanolamine, ethylenediamine, N-methylglucamine, hydrabamine, IH-imidazole, lithium, L-lysine, magnesium, 4-(2-hydroxyethyl)morpholine, piperazine, potassium, l-(2- hydroxyethyljpyrrolidine, sodium, triethanolamine, tromethamine, and zinc salts. In certain embodiments, contemplated salts include, but are not limited to, Na, Ca, K, Mg, Zn or other metal salts. In certain embodiments, contemplated salts include, but are not limited to, 1- hydroxy-2-naphthoic acid, 2,2-dichloroacetic acid, 2-hydroxyethanesulfonic acid, 2- oxoglutaric acid, 4- acetamidobenzoic acid, 4-aminosalicylic acid, acetic acid, adipic acid, 1- ascorbic acid, 1-aspartic acid, benzenesulfonic acid, benzoic acid, (+)-camphoric acid, (+)- camphor- 10-sulfonic acid, capric acid (decanoic acid), caproic acid (hexanoic acid), caprylic acid (octanoic acid), carbonic acid, cinnamic acid, citric acid, cyclamic acid, dodecylsulfuric acid, ethane- 1 ,2-disulfonic acid, ethanesulfonic acid, formic acid, fumaric acid, galactaric acid, gentisic acid, d glucoheptonic acid, d gluconic acid, d glucuronic acid, glutamic acid, glutaric acid, glycerophosphoric acid, glycolic acid, hippuric acid, hydrobromic acid, hydrochloric acid, isobutyric acid, lactic acid, lactobionic acid, lauric acid, maleic acid, 1- malic acid, malonic acid, mandelic acid, methanesulfonic acid , naphthalene- 1,5-disulfonic acid, naphthalene-2-sulfonic acid, nicotinic acid, nitric acid, oleic acid, oxalic acid, palmitic acid, pamoic acid, phosphoric acid, propionic acid, 1-pyroglutamic acid, salicylic acid, sebacic acid, stearic acid, succinic acid, sulfuric acid, 1 tartaric acid, thiocyanic acid, p- toluenesulfonic acid, trifluoroacetic acid, and undecylenic acid salts.

The pharmaceutically acceptable acid addition salts can also exist as various solvates, such as with water, methanol, ethanol, dimethylformamide, and the like. Mixtures of such solvates can also be prepared. The source of such solvate can be from the solvent of crystallization, inherent in the solvent of preparation or crystallization, or adventitious to such solvent.

Wetting agents, emulsifiers and lubricants, such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, release agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the compositions.

Examples of pharmaceutically acceptable antioxidants include: (1) water-soluble antioxidants, such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal-chelating agents, such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like.

Synergism and Augmentation

The term “synergistic” refers to a combination that is more effective than the additive effects of any two or more single agents. A synergistic effect may enable the effective treatment of a disease using lower amounts (doses) of individual therapy. The lower doses result in lower toxicity without reduced efficacy. In addition, a synergistic effect can result in improved efficacy. Finally, synergy may result in an improved reduction of disease as compared to any single therapy. Combination therapy can allow for the product of lower doses of the first therapeutic or the second therapeutic agent (referred to as “apparent one-way synergy” herein), or lower doses of both therapeutic agents (referred to as “two-way synergy” herein) than would normally be required when either drug is used alone.

Combination therapy can allow for the product of lower doses of any one of the therapeutic agents (referred to as “apparent one-way synergy” herein), or lower doses of all therapeutic agents than would normally be required when any drug is used alone.

In certain embodiments, the synergism exhibited between one or more therapeutic agent(s) and the remaining therapeutic agent(s) is such that the dosage of one of the therapeutic agents would be sub-therapeutic if administered without the dosage of the other therapeutic agents.

The terms “augmentation” or “augment” refer to combinations where one of the compounds increases or enhances therapeutic effects of another compound or compounds administered to a patient. In some instances, augmentation can result in improving the efficacy, tolerability, or safety, or any combination thereof, of a particular therapy.

In certain embodiments, described herein are methods comprising administering a therapeutically effective dose of one or more therapeutic agent(s) together with a dose of another therapeutic agent effective to augment the therapeutic effect of the one or more therapeutic agent(s). In other words, described herein are methods of augmenting the therapeutic effect in a patient of one or more therapeutic agent(s) by administering another therapeutic agent to the patient.

In certain embodiments, described herein are synergistic combinations of one or more therapeutic agent(s) in an amount sufficient to render a therapeutic effect together with the remaining therapeutic agent(s). For example, in certain embodiments a therapeutic effect is attained which is at least about 2 (or at least about 4, 6, 8, or 10) times greater than that obtained with the dose of the one or more therapeutic agent(s) alone. In certain embodiments, the synergistic combination provides a therapeutic effect which is up to about 20, 30 or 40 times greater than that obtained with the dose of the one or more therapeutic agent(s) alone. In such embodiments, the synergistic combinations display what is referred to herein as an “apparent one-way synergy,” meaning that the dose of the remaining therapeutic agent(s) synergistically potentiates the effect of the one or more therapeutic agent(s), but the dose of the one or more therapeutic agent(s) does not appear to significantly potentiate the effect of the remaining therapeutic agent(s). In certain embodiments, the combination of active agents exhibits two-way synergism, meaning that the second therapeutic agent potentiates the effect of the first therapeutic agent, and the first therapeutic agent potentiates the effect of the second therapeutic agent. Thus, other embodiments of the invention relate to combinations of a second therapeutic agent and a first therapeutic agent where the dose of each drug is reduced due to the synergism between the drugs, and the therapeutic effect derived from the combination of drugs in reduced doses is enhanced. The two-way synergism is not always readily apparent in actual dosages due to the potency ratio of the first therapeutic agent to the second therapeutic agent. For instance, two-way synergism can be difficult to detect when one therapeutic agent displays much greater therapeutic potency relative to the other therapeutic agent.

The synergistic effects of combination therapy may be evaluated by biological activity assays. For example, the therapeutic agents are mixed at molar ratios designed to give approximately equipotent therapeutic effects based on the EC90 values. Then, three different molar ratios are used for each combination to allow for variability in the estimates of relative potency. These molar ratios are maintained throughout the dilution series. The corresponding monotherapies are also evaluated in parallel to the combination treatments using the standard primary assay format. A comparison of the therapeutic effect of the combination treatment to the therapeutic effect of the monotherapy gives a measure of the synergistic effect. Further details on the design of combination analyses can be found in B E Korba (1996) Antiviral Res. 29:49. Analysis of synergism, additivity, or antagonism can be determined by analysis of the aforementioned data using the CalcuSyn™ program (Biosoft, Inc.). This program evaluates drug interactions by use of the widely accepted method of Chou and Talalay combined with a statistically evaluation using the Monte Carlo statistical package. The data are displayed in several different formats including median-effect and dose-effects plots, isobolograms, and combination index [CI] plots with standard deviations. For the latter analysis, a CI greater than 1.0 indicates antagonism and a CI less than 1.0 indicates synergism.

The methods described herein present the opportunity for obtaining relief from moderate to severe cases of disease. Due to the synergistic or additive or augmented effects provided by the inventive combination of the first and second therapeutic agent, it may be possible to use reduced dosages of each of therapeutic agent. Due to the synergistic or additive or augmented effects provided by the inventive combination of the first, second, and third therapeutic agents, it may be possible to use reduced dosages of each of therapeutic agent. By using lesser amounts of drugs, the side effects associated with each may be reduced in number and degree. Moreover, the combinations avoid side effects to which some patients are particularly sensitive.

Definitions

Unless otherwise defined herein, scientific and technical terms used in this application shall have the meanings that are commonly understood by those of ordinary skill in the art. Generally, nomenclature used in connection with, and techniques of, chemistry, cell and tissue culture, molecular biology, cell and cancer biology, neurobiology, neurochemistry, virology, immunology, microbiology, pharmacology, genetics and protein and nucleic acid chemistry, described herein, are those well-known and commonly used in the art.

The methods and techniques of the present disclosure are generally performed, unless otherwise indicated, according to conventional methods well known in the art and as described in various general and more specific references that are cited and discussed throughout this specification.

All of the above, and any other publications, patents and published patent applications referred to in this application are specifically incorporated by reference herein. In case of conflict, the present specification, including its specific definitions, will control.

The term “agent” is used herein to denote a chemical compound (such as an organic or inorganic compound, a mixture of chemical compounds), a biological macromolecule (such as a nucleic acid, an antibody, including parts thereof as well as humanized, chimeric and human antibodies and monoclonal antibodies, a protein or portion thereof, e.g., a peptide, a lipid, a carbohydrate), or an extract made from biological materials such as bacteria, plants, fungi, or animal (particularly mammalian) cells or tissues. Agents include, for example, agents whose structure is known, and those whose structure is not known.

A “patient,” “subject,” or “individual” are used interchangeably and refer to either a human or a non-human animal. These terms include mammals, such as humans, primates, livestock animals (including bovines, porcines, etc.), companion animals (e.g., canines, felines, etc.) and rodents (e.g., mice and rats). A subject may be male or female. In some embodiments, the subject is greater than 18 years old. In certain embodiments, a subject preferably has an ECOG (Eastern Cooperative Oncology Group) score of 0-1. In certain embodiments, a patient may have a histological diagnosis of MPE caused by nonmesothelioma solid tumour or mesothelioma. In some embodiments, the patient has received at least one prior standard of care treatment regimen, with documented progression and no approved alternative available. In some embodiments, the patient has resolution of all acute reversible toxic effects of prior therapy to Grade <1. In certain embodiments, the patient has a paraffin block of his or her most recent biopsy. In some embodiments, the patient has adequate organ function as defined by lab values before administration of thiostrepton. In some embodiments, the subject is postmenopausal, surgically sterile, or using effective birth control.

In some embodiments, the patient has not had prior systemic anti-cancer or radiation therapy before administration of thiostrepton. In some embodiments, the patient has not had surgery within 3 weeks or within 5 half-lives before administration of thiostrepton. In some embodiments, the patient has not had treatment with an investigational product/device within 30 days before administration of thiostrepton. In certain embodiments, the patient has not had a previous malignancy other than the cancer to be treated before administration of thiostrepton. In certain embodiments, the patient does not have tumors or loculations that would render intrapleural administration incomplete or ineffective. In certain embodiments, the patient does not have a known hypersensitivity to thiostrepton or a pharmaceutical composition excipient. In some embodiments, the patient does not have any surgical or medical condition that is likely to interfere with thiostrepton treatment. In some embodiments, the patient does not have human immunodeficiency virus (HIV) or active infection with hepatitis B; or hepatitis C in absence of a sustained virologic response. In certain embodiments, the patient is not pregnant or breast-feeding. In some embodiments, the patient does not have a symptomatic or unstable CNS tumour or metastases or carcinomatous meningitis. In some embodiments, the patient has not used systemic corticosteroids within 15 days before administration of thiostrepton or other immunosuppressive drugs within 3 weeks before administration of thiostrepton.

“Treating” a condition or patient refers to taking steps to obtain beneficial or desired results, including clinical results. As used herein, and as well understood in the art, “treatment” is an approach for obtaining beneficial or desired results, including clinical results. Beneficial or desired clinical results can include, but are not limited to, alleviation or amelioration of one or more symptoms or conditions, diminishment of extent of disease, stabilized (i.e. not worsening) state of disease, preventing spread of disease, delay or slowing of disease progression, amelioration or palliation of the disease state, and remission (whether partial or total), whether detectable or undetectable. “Treatment” can also mean prolonging survival as compared to expected survival if not receiving treatment. The term “preventing” is art-recognized, and when used in relation to a condition, such as a local recurrence (e.g., pain), a disease such as cancer, a syndrome complex such as heart failure or any other medical condition, is well understood in the art, and includes administration of a composition which reduces the frequency of, or delays the onset of, symptoms of a medical condition in a subject relative to a subject which does not receive the composition. Thus, prevention of cancer includes, for example, reducing the number of detectable cancerous growths in a population of patients receiving a prophylactic treatment relative to an untreated control population, and/or delaying the appearance of detectable cancerous growths in a treated population versus an untreated control population, e.g., by a statistically and/or clinically significant amount.

“Administering” or “administration of’ a substance, a compound or an agent to a subject can be carried out using one of a variety of methods known to those skilled in the art. For example, a compound or an agent can be administered intraperitoneally, intrapleurally, subcutaneously, intratumorally, intravenously, arterially, intradermally, intramuscularly, subcutaneously, ocularly, sublingually, orally (by ingestion), intranasally (by inhalation), intraspinally, intracerebrally, and transdermally (by absorption, e.g., through a skin duct). A compound or agent can also appropriately be introduced by rechargeable or biodegradable polymeric devices or other devices, e.g., patches and pumps, or formulations, which provide for the extended, slow or controlled release of the compound or agent. Administering can also be performed, for example, once, a plurality of times, and/or over one or more extended periods.

The term “advanced cancer,” as used herein, is used to describe cancer that is unlikely to be cured. Some advanced cancers may be controlled for many years with treatment and are thought of as a chronic illness. Treatment may be given to help shrink the tumor, slow the growth of cancer cells, relieve symptoms, or help a person live longer. Advanced cancer may also be used to describe cancer that has spread from where it first started to nearby tissue, lymph nodes, or other parts of the body.

In certain embodiments, administration of thiostrepton or any of the pharmaceutical compositions comprising thiostrepton disclosed herein can be carried out using an indwelling intraperitoneal catheter (IPC). In some embodiments, administration occurs once a week or twice a week, preferably once a week. In some embodiments, the methods further comprise removing liquid from a pleural effusion, for example, before administration of thiostrepton. In certain embodiments, after administration of thiostrepton, the IPC is secured until the next dosing time point. In certain embodiments, the single dose amount of thiostrepton ranges from about 45 mg to about 500 mg. In some embodiments, the single dose amount of thiostrepton ranges from about 90 mg to about 450 mg. In preferred embodiments, the single dose is selected from about 45 mg, about 90 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg. In some embodiments, the single dose is administered to the subject once per week, for example, for at least 3 weeks.

In some embodiments, the single dose of thiostrepton may be increased every three week period, for example, such that the patient at weeks 1-3 is dosed at 90 mg once each week, then optionally at weeks 4-6 is dosed at 180 mg once each week, then optionally at weeks 7-9 is dosed at 270 mg once each week, then optionally at weeks 10-12 is dosed at 360 mg once each week, and finally optionally at weeks 13-15 is dosed at 450 mg once each week. Each patient may complete any or all of the 3-week sessions. In some embodiments, the dosing regimen may be paused, halted, or the patient may move to a lower dose, for example, in the event of toxicity or an adverse event.

In some embodiments, the methods further comprise obtaining a tumour biopsy from the patient before administering thiostrepton. In some embodiments, the methods further comprise obtaining a tumour biopsy after administration of the third dose of thiostrepton.

In other embodiments, the pharmaceutical composition comprises from about 5 mg thiostrepton/mL to about 50 mg thiostrepton/mL. In some embodiments, the pharmaceutical composition comprises about 10 mg thiostrepton/mL, about 20 mg thiostrepton/mL, about 30 mg thiostrepton/mL, about 40 mg thiostrepton/mL and about 50 mg thiostrepton/mL. In a preferred embodiment, the pharmaceutical composition comprises 20 mg thiostrepton/mL.

Appropriate methods of administering a substance, a compound or an agent to a subject will also depend, for example, on the age and/or the physical condition of the subject and the chemical and biological properties of the compound or agent (e.g., solubility, digestibility, bioavailability, stability and toxicity). In some embodiments, a compound or an agent is administered orally, e.g., to a subject by ingestion. In some embodiments, the orally administered compound or agent is in an extended release or slow release formulation, or administered using a device for such slow or extended release.

As used herein, the phrase “conjoint administration” refers to any form of administration of two or more different therapeutic agents such that the second agent is administered while the previously administered therapeutic agent is still effective in the body (e.g., when at least 5% of drug product is detectable systemically with industry acceptable methodology, or when the two agents are simultaneously effective in the patient, which may include synergistic effects of the two agents). For example, the different therapeutic compounds can be administered either in the same formulation or in separate formulations, either concomitantly or sequentially. In certain embodiments, the different therapeutic compounds can be administered within one hour, 12 hours, 24 hours, 36 hours, 48 hours, 72 hours, or a week of one another. Thus, an individual who receives such treatment can benefit from a combined effect of different therapeutic agents.

In some embodiments, a first single dose in one week is the same amount as a second single dose administered in a different week. In certain embodiments, a first single dose is administered for 3 weeks, followed by administration of a second single dose for the next 3 weeks, wherein the first single dose and the second single dose are different. In some embodiments, the second single dose is greater than the first single dose. In other embodiments, the second single dose is less than the first single dose.

A “therapeutically effective amount” or a “therapeutically effective dose” of a compound or other agent described herein is an amount of a drug or an agent that, when administered to a subject will have the intended therapeutic effect. The full therapeutic effect does not necessarily occur by administration of one dose of such a drug or agent, and may occur only after administration of a series of doses (multiple consecutive doses). Thus, a therapeutically effective amount may be administered in one or more administrations. The precise effective amount needed for a subject will depend upon, for example, the subject’s size, health and age, and the nature and extent of the condition being treated, such as cancer.

As used herein, the terms “optional” or “optionally” mean that the subsequently described event or circumstance may occur or may not occur, and that the description includes instances where the event or circumstance occurs as well as instances in which it does not.

The term “modulate” as used herein includes the inhibition or suppression of a function or activity (such as cell proliferation) as well as the enhancement of a function or activity.

The phrase “pharmaceutically acceptable” is art-recognized. In certain embodiments, the term includes compositions, excipients, adjuvants, polymers and other materials and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio. In certain embodiments, disclosed herein are methods of treating a cancer (e.g., solid tumor or hematological cancer) comprising administering to a subject in need thereof a therapeutically effective amount of any of the compounds described herein, or a composition of that compound. In certain embodiments, the cancer (solid tumor or hematological) is selected from lung, breast, prostate, melanoma, esophageal, leukemia, cervical, liver, colon, gastric, colorectal, glioblastoma, head and neck, pancreatic, mesothelioma, and ovarian. In certain embodiments, the cancer is selected from mesothelioma, lung, ovarian, and breast. In some embodiments, the cancer is malignant mesothelioma.

Methods

In certain embodiments, described herein are methods of treating malignant pleural effusion, comprising administering to a human subject in need thereof a first amount of thiostrepton and a second amount of an anti-cancer agent, wherein the first amount of thiostrepton and the second amount of the anti-cancer agent, taken together, are therapeutically effective; and the first amount of thiostrepton is from about 40 mg to about 500 mg, thereby treating the malignant pleural effusion. In certain embodiments, the first amount of thiostrepton and the second amount of the anti-cancer agent treat the malignant pleural effusion in a synergistic manner.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally. In certain embodiments, thiostrepton is administered by a catheter, a tube, or a needle, preferably by an indwelling intraperitoneal catheter (IPC).

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is administered weekly. In certain embodiments, the first amount of thiostrepton is administered once every other week. In certain embodiments, the first amount of thiostrepton is administered once every 3 weeks.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once per week.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every other week. In certain embodiments, the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every three weeks. In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

In certain embodiments, the subject has a solid tumor, for example, a solid tumor selected from lung, breast, prostate, melanoma, esophageal, cervical, liver, colon, gastric, colorectal, glioblastoma, head and neck, pancreatic, and ovarian, preferably wherein the solid tumor is selected from breast cancer, ovarian cancer, and non-small cell lung cancer, even more preferably wherein the solid tumor is lung cancer. In certain embodiments, the lung cancer is an adenocarcinoma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the solid tumor is metastatic.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has received at least 1 prior standard of care treatment regimen for the solid tumor. In certain embodiments, the subject has received at least 1 prior standard of care treatment regimen for the solid tumor, the solid tumor is advanced and unresectable and has progressed since the 1 prior standard of care treatment, and there is no approved lifeextending alternative available.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has mesothelioma. In certain embodiments, the mesothelioma is malignant mesothelioma, for example, malignant pleural mesothelioma. In certain embodiments, the mesothelioma is malignant epitheloid pleural mesothelioma. In certain embodiments, wherein the mesothelioma is malignant peritoneal mesothelioma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not have mesothelioma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the anti-cancer agent is a taxane, for example, wherein the taxane is paclitaxel. In certain embodiments, the paclitaxel is administered at least once per month, for example, the paclitaxel is administered about every 3 weeks, or the paclitaxel is administered weekly. In certain embodiments, the paclitaxel is administered intravenously. In certain embodiments, the second amount of paclitaxel is from about 100 mg/m² to about 220 mg/m².

In certain embodiments, the disclosure relates to methods of treating cancer, comprising administering to a human subject in need thereof thiostrepton in a single dose of about 40 mg to about 500 mg once every other week or in a single dose of about 40 mg to about 500 mg once every three weeks, thereby treating the cancer. In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has a malignant pleural effusion.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally. In certain embodiments, the thiostrepton is administered by a catheter, a tube, or a needle, preferably by an indwelling intraperitoneal catheter (IPC).

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered once every other week.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered once every 3 weeks.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the single dose is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the cancer is a solid tumor, for example, a solid tumor selected from lung, breast, prostate, melanoma, esophageal, cervical, liver, colon, gastric, colorectal, glioblastoma, head and neck, pancreatic, and ovarian, preferably wherein the solid tumor is selected from breast cancer, ovarian cancer, and non-small cell lung cancer, even more preferably wherein the solid tumor is lung cancer. In certain embodiments, the lung cancer is an adenocarcinoma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the solid tumor is metastatic.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has received at least 1 prior standard of care treatment regimen for the solid tumor, the solid tumor is advanced and unresectable and has progressed since the 1 prior standard of care treatment, and there is no approved life-extending alternative available.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the cancer is mesothelioma. In certain embodiments, the mesothelioma is malignant mesothelioma, for example, malignant pleural mesothelioma. In certain embodiments, the mesothelioma is malignant epitheloid pleural mesothelioma. In certain embodiments, the mesothelioma is malignant peritoneal mesothelioma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not have mesothelioma. In certain embodiments, the disclosure relates to methods of treating cancer, comprising administering to a human subject in need thereof thiostrepton in a single dose of about 40 mg to about 500 mg once per week, or in a single dose of about 40 mg to about 500 mg once every other week, or in a single dose of about 40 mg to about 500 mg once every three weeks, wherein, prior to receiving a first single dose of thiostrepton, the subject has not received first line systemic therapy for the cancer, thereby treating the cancer.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has a malignant pleural effusion.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally. In certain embodiments, the thiostrepton is administered by a catheter, a tube, or a needle, preferably by an indwelling intraperitoneal catheter (IPC).

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered once per week.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered once every other week.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered once every 3 weeks.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the single dose is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the cancer is a solid tumor, for example, a solid tumor selected from lung, breast, prostate, melanoma, esophageal, cervical, liver, colon, gastric, colorectal, glioblastoma, head and neck, pancreatic, and ovarian, preferably wherein the solid tumor is selected from breast cancer, ovarian cancer, and non-small cell lung cancer, even more preferably wherein the solid tumor is lung cancer. In certain embodiments, the lung cancer is an adenocarcinoma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the solid tumor is metastatic.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the cancer is mesothelioma. In certain embodiments, the mesothelioma is malignant mesothelioma, for example, malignant pleural mesothelioma. In certain embodiments, the mesothelioma is malignant epitheloid pleural mesothelioma. In certain embodiments, the mesothelioma is malignant peritoneal mesothelioma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not have mesothelioma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein comprising co-administering a taxane to the subject, wherein, taken together, the thiostrepton and the taxane are therapeutically effective. In certain embodiments, the taxane is paclitaxel. In certain embodiments, paclitaxel is administered at least once per month, for example, the paclitaxel is administered about every 3 weeks, or the paclitaxel is administered weekly. In certain embodiments, the paclitaxel is administered intravenously. In certain embodiments, about 100 mg/m² to about 220 mg/m² of paclitaxel is administered.

In certain embodiments, the disclosure relates to methods of treating cancer, comprising administering to a human subject in need thereof a first amount of thiostrepton and a second amount of an anti-cancer agent, wherein the first amount of thiostrepton and the second amount of the anti-cancer agent, taken together, are therapeutically effective; and the first amount of thiostrepton is from about 40 mg to about 500 mg, thereby treating the cancer. In certain embodiments, the first amount of thiostrepton and the second amount of the anticancer agent treat the cancer in a synergistic manner.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has a malignant pleural effusion.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally. In certain embodiments, the thiostrepton is administered by a catheter, a tube, or a needle, preferably by an indwelling intraperitoneal catheter (IPC).

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is administered weekly.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is administered once every other week.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is administered once every 3 weeks.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once per week. In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every other week.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every three weeks.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the first amount is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the cancer is a solid tumor, for example, a solid tumor selected from lung, breast, prostate, melanoma, esophageal, cervical, liver, colon, gastric, colorectal, glioblastoma, head and neck, pancreatic, and ovarian, preferably wherein the solid tumor is selected from breast cancer, ovarian cancer, and non-small cell lung cancer, even more preferably wherein the solid tumor is lung cancer. In certain embodiments, the lung cancer is an adenocarcinoma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the solid tumor is metastatic.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has received at least 1 prior standard of care treatment regimen for the solid tumor.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has received at least 1 prior standard of care treatment regimen for the solid tumor, the solid tumor is advanced and unresectable and has progressed since the 1 prior standard of care treatment, and there is no approved life-extending alternative available.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has mesothelioma. In certain embodiments, the mesothelioma is malignant mesothelioma, for example, malignant pleural mesothelioma. In certain embodiments, the mesothelioma is malignant epitheloid pleural mesothelioma. In certain embodiments, the mesothelioma is malignant peritoneal mesothelioma.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not have mesothelioma. In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the anti-cancer agent is a taxane. In certain embodiments, the taxane is paclitaxel. In certain embodiments, the paclitaxel is administered at least once per month, for example, the paclitaxel is administered about every 3 weeks, or the paclitaxel is administered weekly. In certain embodiments, the paclitaxel is administered intravenously. In certain embodiments, the second amount of paclitaxel is from about 100 mg/m² to about 220 mg/m².

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject experiences progression free survival for at least 12 weeks after administration of a first dose of thiostrepton. In certain embodiments, the subject experiences progression free survival for at least 18 weeks after administration of a first dose of thiostrepton. In certain embodiments, the subject experiences progression free survival for at least 24 weeks after administration of a first dose of thiostrepton.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject experiences partial response for at least 12 weeks after administration of a first dose of thiostrepton. In certain embodiments, the subject experiences partial response for at least 18 weeks after administration of a first dose of thiostrepton. In certain embodiments, the subject experiences partial response for at least 24 weeks after administration of a first dose of thiostrepton.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject experiences stable disease for at least 12 weeks after administration of a first dose of thiostrepton. In certain embodiments, the subject experiences stable disease for at least 18 weeks after administration of a first dose of thiostrepton. In certain embodiments, the subject experiences stable disease for at least 24 weeks after administration of a first dose of thiostrepton.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the volume of pleural effusion is reduced 10 weeks after administration of a first dose of thiostrepton relative to the volume of pleural effusion before administration of thiostrepton. In certain embodiments, the volume of pleural effusion is reduced 5 weeks after administration of a first dose of thiostrepton relative to the volume of pleural effusion before administration of thiostrepton. In certain embodiments, wherein the volume of pleural effusion is reduced 1 week after administration of a first dose of thiostrepton relative to the volume of pleural effusion before administration of thiostrepton.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the volume of pleural effusion is about 30% less than the volume of pleural effusion before administration of thiostrepton. In certain embodiments, the volume of pleural effusion is about 60% less than the volume of pleural effusion before administration of thiostrepton. In certain embodiments, wherein the volume of pleural effusion is about 90% less than the volume of pleural effusion before administration of thiostrepton.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject is at least 18 years old.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject has a pleural space that is accessible.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not have a hematological malignancy.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not experience grade 4 neutropenia with a duration of > 7 days.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not experience febrile neutropenia.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not experience grade 4 anemia refractory to transfusion with a duration of > 7 days.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not experience grade 4 thrombocytopenia lasting greater than 7 days.

In certain embodiments, the disclosure relates to any one of the methods described herein, wherein the subject does not experience grade 3/4 thrombocytopenia with bleeding.

EXAMPLES

Inclusion Criteria

A patient was eligible for inclusion in this study only if all the following criteria were met:

1. Male or female > 18 years old.

2. Eastern Cooperative Oncology Group (ECOG) performance status 0-1.

3. Histological diagnosis of solid tumor/mesothelioma with MPE.

Expansion Cohort 2: a. only patients with breast cancer, ovarian cancer or non-small cell lung cancer. b. patients for whom paclitaxel was a recommended SoC therapy. c. no contraindications to paclitaxel.

4. Patients with a disease burden that were predominantly pleural, and a pleural space that was accessible.

5. Dose Escalation and Expansion Cohorts 1 and 2:

MPE (non- mesothelioma): patients must have received at least 1 prior standard of care treatment regimen for advanced, unresectable malignancy, with documented progression.

Dose Escalation and Expansion Cohort 3:

MPE mesothelioma: patients must have received at least 1 prior standard of care treatment regimen for advanced, unresectable malignancy, with documented progression and there is no approved life extending alternative available.

Expansion Cohort 4:

MPE mesothelioma ‘window of opportunity’ (WoO): patients were treatment naive, have refused or not be immediately requiring of systemic therapy and for whom drainage was planned immediately while further treatment options were arranged. It must be documented for each patient that protocol participation did not affect their subsequent ability to access standard systemic first line therapy due to TS being a local therapy.6. Resolution of all acute reversible toxic effects of prior therapy or surgical procedure to Grade <1 (except alopecia).

7. For dose escalation: Archival paraffin block, ideally from the patient’s most recent biopsy, were provided prior to the first dose of study therapy, if sufficient tissue was available.

For dose expansion cohorts: fresh tumor biopsy must be obtained. a. Patients enrolled in the mesothelioma expansion phase were requested to undergo a tumor biopsy during the screening period and after the third dose. b. Patients enrolled in the non-mesothelioma expansion phase were requested to undergo a tumor biopsy during the screening period and after the third dose only if medically feasible.

8. Adequate organ function as defined by the following criteria: ^aIf on anticoagulants, value must have been within prophylactic range for condition under consideration

9. If not postmenopausal or surgically sterile, patients must have been willing to practice at least one of the following highly effective methods of birth control (defined as having a low failure rate, i.e., less than 1% per year) for at least a (partner’s) menstrual cycle before and for

4 months after last study drug administration: a. True abstinence, when this is in line with the preferred and usual lifestyle of the patient, from sexual intercourse with a member of the opposite sex; b. Sexual intercourse with vasectomized male/sterilized female partner; c. Hormonal female contraceptive (oral, parenteral, intravaginal, implantable or transdermal) for at least 3 consecutive months prior to investigational product administration (when not clinically contraindicated as in breast, ovarian and endometrial cancers); d. Use of an intrauterine contraceptive device.

10. Willingness and ability to comply with scheduled visits, treatment plan, laboratory tests, and other trial procedures.

Exclusion Criteria

Patients meeting any of the following exclusion criteria at screening were not enrolled in the study:

11. Last dose of prior anti-cancer therapies: a. Systemic anti-cancer therapy within 3 weeks or 5 half-lives prior to study entry, whichever was shorter. b. Thoracic radiation therapy or significant surgery within 3 weeks prior to study entry. Localized palliative radiotherapy for pain control in non-target lesions was allowed during the screening period. c. Received an investigational product or had been treated with an investigational device within 30 days prior to first drug administration or planned to participate in any other clinical trial while on this study.

12. Previous or concurrent malignancy that would have prevented evaluation of the primary endpoint (e.g., relapsed/refractory hematological malignancy).

13. Patients whose extent of tumor or loculations would have rendered intrapleural administration incomplete and/or ineffective.

14. Known hypersensitivity to the active ingredient or any excipient contained in the drug formulation.

15. History or clinical evidence of any surgical or medical condition which the investigator and/or medical monitor judged as likely to interfere with the results of the study or pose an additional risk in participating, e.g., rapidly progressive or uncontrolled disease involving a major organ system — vascular, cardiac, pulmonary, gastrointestinal, gynecologic, hematologic, neurologic, neoplastic, renal, endocrine, or an immunodeficiency, or clinically significant active psychiatric or abuse disorders.

16. Active infection with human immunodeficiency virus (HIV) and CD4+ T-cell count

< 350/pL. Patients not on established anti-retroviral therapy for at least four weeks prior to first dose of study drug and having a detectable HIV viral load. Testing was not required for eligibility. 17. Active infection with hepatitis B (surface antigen); or infection with hepatitis C in absence of sustained virologic response.

Testing was not required for eligibility.

18. Pregnant or breast-feeding patients.

19. Patients with symptomatic or unstable central nervous system (CNS) primary tumor or metastases and/or carcinomatous meningitis. Patients with documented treated CNS metastases stable off steroids may be enrolled at the discretion of the investigator.

20. Therapeutic oral anticoagulation for a thromboembolic event (prophylactic anticoagulation is allowed as long as patient could undergo catheter placement and biopsy). Low molecular weight heparin (LMWH) was allowed on condition that it was medically acceptable to interrupt LMWH therapy for all invasive procedures.

21. Use of systemic corticosteroids to treat inflammatory or autoimmune symptoms within

15 days or other immunosuppressive drugs within 3 weeks prior to start of the study. Inhaled and topical corticosteroids were permitted. Up to 10 mg/day prednisone or equivalent was permitted.

Dose and Route of Administration

TS solution was supplied in 30 mL glass vials with rubber stopper with a TS concentration of 3 mg/mL. Formulation: Vitamin E-TPGS (d-a-tocopheryl polyethylene glycol 1000 succinate). Strength: 3.0 mg TS/mL micellar solution.

Each patient received TS as a solution for pleural infusion through an indwelling IP catheter, administered as a single dose on day 1 (+/- 1 day) of each week of a treatment cycle (cycle = 21 days, 3 drug administrations).

The starting dose for TS was 90 mg.

Total injected volume depended on the dose cohort but did not exceed 150 mL at the highest dose.

Arm 2 MPE (non-mesothelioma) in combination with paclitaxel:

Paclitaxel was administered as a systemic therapy per SoC and the approved labeling based on the primary tumor type being treated. It was prepared and administered per the prescribing information (SmPC). See, Paclitaxel Summary of Product Characteristics, 2023 at https://www.medicines.org.Uk/emc/product/3891/smpc/print#INDICATIONS

The treatment schedule for expansion Arm 2 MPE (non-mesothelioma) in combination with paclitaxel of the clinical study:

*Paclitaxel can be administered QW per investigators discretion

Paclitaxel was given on Day 2 of thiostrepton cycle 1 , then Q3W. Subsequent cycles could be administered on the same day as TS administration.

Safety Assessments

The NCI CTCAE, v5.0 was used for grading toxicities. Safety assessments included adverse events (AEs), serious adverse events (SAEs), physical examinations (PEs), vital sign measurements, Eastern Cooperative Oncology Group (ECOG) status, clinical safety laboratory evaluations (hematology, serum chemistry and hepatic panels, coagulation and urinalysis) and electrocardiograms (ECG).

Additionally, IP catheter assessment (insertion site, patency, catheter placement) was evaluated.

The AE/SAE reporting period for a patient enrolled in the study began when the patient provided signed informed consent and continued through 30 days after the last dose of study drug. All AE/SAEs that occurred in enrolled patients during the AE/SAE reporting period specified in the protocol were recorded, regardless of the relationship of the AE/SAE to study drug. Concomitant medications were recorded throughout the AE/SAE reporting period.

Efficacy Assessments

RECIST 1.1 was used in this study for assessment of tumor response (objective response rate; ORR) for non-mesothelioma tumors. Computed tomography (CT) was the preferred imaging technique in this study. However, positron emission tomography (PET)/CT or magnetic resonance imaging (MRI) may be utilized, as per RECIST 1.1. The same imaging modality that was used at baseline should be used for subsequent imaging evaluations. Imaging assessment was performed at baseline and day 43 (+/-3 days), then every 2 cycles until PD by the same imaging modality at each timepoint. Responses were confirmed per RECIST 1.1. A radiological assessment of a complete response (CR) or partial response (PR) required confirmatory imaging at least 4 weeks after the initial assessment of response was observed.

Revised modified RECIST 1.1 (mRECIST 1.1) was used in this study for assessment of tumor response for patients with malignant mesothelioma.

Additional efficacy assessments could include disease control rate (DCR) and progression-free survival (PFS).

FIG. 1 depicts a Swimmer’s plot showing the initial outcomes for patients treated with TS in a window of opportunity (WoO) study. These data show that treatment naive patients exhibited progression free survival for up to 24 weeks when dosed with 45 or 90 mg of TS.

INCORPORATION BY REFERENCE

All publications and patents mentioned herein are hereby incorporated by reference in their entirety as if each individual publication or patent was specifically and individually indicated to be incorporated by reference. In case of conflict, the present application, including any definitions herein, will control.

EQUIVALENTS

The foregoing written specification is considered to be sufficient to enable one skilled in the art to practice the invention. The present invention is not to be limited in scope by examples provided, since the examples are intended as a single illustration of one aspect of the invention and other functionally equivalent embodiments are within the scope of the invention. Various modifications of the invention in addition to those shown and described herein will become apparent to those skilled in the art from the foregoing description and fall within the scope of the appended claims. The advantages and objects of the invention are not necessarily encompassed by each embodiment of the invention.

Claims

We claim:

1. A method of treating malignant pleural effusion, comprising administering to a human subject in need thereof a first amount of thiostrepton and a second amount of an anti-cancer agent, wherein the first amount of thiostrepton and the second amount of the anti-cancer agent, taken together, are therapeutically effective; and the first amount of thiostrepton is from about 40 mg to about 500 mg, thereby treating the malignant pleural effusion.

2. The method of claim 1, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally.

3. The method of any one of the preceding claims, wherein the thiostrepton is administered by a catheter, a tube, or a needle.

4. The method of any one of the preceding claims, wherein the thiostrepton is administered by an indwelling intraperitoneal catheter (IPC).

5. The method of any one of the preceding claims, wherein the first amount of thiostrepton is administered weekly.

6. The method of any one of claims 1-4, wherein the first amount of thiostrepton is administered once every other week.

7. The method of any one of claims 1-4, wherein the first amount of thiostrepton is administered once every 3 weeks.

8. The method of any one of claims 1-4, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once per week.

9. The method of any one of claims 1-4, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every other week.

10. The method of any one of claims 1-4, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every three weeks.

11. The method of any one of claims 1-10, wherein the first amount is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

12. The method of any one of the preceding claims, wherein the subject has a solid tumor.

13. The method of claim 12, wherein the solid tumor is selected from lung, breast, prostate, melanoma, esophageal, cervical, liver, colon, gastric, colorectal, glioblastoma, head and neck, pancreatic, and ovarian.

14. The method of claim 12, wherein the solid tumor is selected from breast cancer, ovarian cancer, and non- small cell lung cancer.

15. The method of claim 12, wherein the solid tumor is lung cancer.

16. The method of claim 15, wherein the lung cancer is an adenocarcinoma.

17. The method of any one of claims 12-16, wherein the solid tumor is metastatic.

18. The method of any one of claims 12-17, wherein the subject has received at least

1 prior standard of care treatment regimen for the solid tumor.

19. The method of any one of claims 12-18, wherein the subject has received at least

1 prior standard of care treatment regimen for the solid tumor, the solid tumor is advanced and unresectable and has progressed since the 1 prior standard of care treatment, and there is no approved life-extending alternative available.

20. The method of any one of claims 1-19, wherein the subject does not have mesothelioma.

21. The method of any one of the preceding claims, wherein the anti-cancer agent is a taxane.

22. The method of claim 21, wherein the taxane is paclitaxel.

23. The method of claim 22, wherein the paclitaxel is administered at least once per month.

24. The method of claim 23, wherein the paclitaxel is administered about every 3 weeks.

25. The method of claim 23, wherein the paclitaxel is administered weekly.

26. The method of any one of claims 22-25, wherein the paclitaxel is administered intravenously.

27. The method of any one of claims 22-26, wherein the second amount of paclitaxel is from about 100 mg/m² to about 220 mg/m².

28. A method of treating cancer, comprising administering to a human subject in need thereof thiostrepton in a single dose of about 40 mg to about 500 mg once every other week or in a single dose of about 40 mg to about 500 mg once every three weeks, thereby treating the cancer.

29. The method of claim 28, wherein the subject has a malignant pleural effusion.

30. The method of any one of claims 28-29, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally.

31. The method of any one of claims 28-30, wherein the thiostrepton is administered by a catheter, a tube, or a needle.

32. The method of any one of claims 28-31, wherein the thiostrepton is administered by an indwelling intraperitoneal catheter (IPC).

33. The method of any one of claims 28-32, wherein the thiostrepton is administered once every other week.

34. The method of any one of claims 28-32, wherein the thiostrepton is administered once every 3 weeks.

35. The method of any one of claims 28-34, wherein the single dose is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

36. The method of any one of claims 28-35, wherein the cancer is mesothelioma.

37. The method of claim 36, wherein the mesothelioma is malignant mesothelioma.

38. The method of claim 37, wherein the mesothelioma is malignant pleural mesothelioma.

39. The method of claim 38, wherein the mesothelioma is malignant epitheloid pleural mesothelioma.

40. The method of claim 39, wherein the mesothelioma is malignant peritoneal mesothelioma.

41. A method of treating cancer, comprising administering to a human subject in need thereof thiostrepton in a single dose of about 40 mg to about 500 mg once per week, or in a single dose of about 40 mg to about 500 mg once every other week, or in a single dose of about 40 mg to about 500 mg once every three weeks, wherein, prior to receiving a first single dose of thiostrepton, the subject has not received first line systemic therapy for the cancer, thereby treating the cancer.

42. The method of claim 41, wherein the subject has a malignant pleural effusion.

43. The method of any one of claims 41-42, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally.

44. The method of any one of claims 41-43, wherein the thiostrepton is administered by a catheter, a tube, or a needle.

45. The method of any one of claims 41-44, wherein the thiostrepton is administered by an indwelling intraperitoneal catheter (IPC).

46. The method of any one of claims 41-45, wherein the thiostrepton is administered once per week.

47. The method of any one of claims 41-45, wherein the thiostrepton is administered once every other week.

48. The method of any one of claims 41-45, wherein the thiostrepton is administered once every 3 weeks.

49. The method of any one of claims 41-48, wherein the single dose is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

50. The method of any one of claims 41-49, wherein the cancer is mesothelioma.

51. The method of claim 50, wherein the mesothelioma is malignant mesothelioma.

52. The method of claim 51 , wherein the mesothelioma is malignant pleural mesothelioma.

53. The method of claim 52, wherein the mesothelioma is malignant epitheloid pleural mesothelioma.

54. The method of claim 53, wherein the mesothelioma is malignant peritoneal mesothelioma.

55. A method of treating cancer, comprising administering to a human subject in need thereof a first amount of thiostrepton and a second amount of an anti-cancer agent, wherein the first amount of thiostrepton and the second amount of the anti-cancer agent, taken together, are therapeutically effective; and the first amount of thiostrepton is from about 40 mg to about 500 mg, thereby treating the cancer.

56. The method of claim 55, wherein the subject has a malignant pleural effusion.

57. The method of any one of claims 55-56, wherein the thiostrepton is administered intraperitoneally, intrapleurally, subcutaneously, or intratumorally.

58. The method of any one of claims 55-57, wherein the thiostrepton is administered by a catheter, a tube, or a needle.

59. The method of any one of claims 55-58, wherein the thiostrepton is administered by an indwelling intraperitoneal catheter (IPC).

60. The method of any one of claims 55-59, wherein the first amount of thiostrepton is administered weekly.

61. The method of any one of claims 55-59, wherein the first amount of thiostrepton is administered once every other week.

62. The method of any one of claims 55-59, wherein the first amount of thiostrepton is administered once every 3 weeks.

63. The method of any one of claims 55-59, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once per week.

64. The method of any one of claims 55-59, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every other week.

65. The method of any one of claims 55-59, wherein the first amount of thiostrepton is a single dose of about 40 mg to about 500 mg once every three weeks.

66. The method of any one of claims 55-65, wherein the first amount is selected from about 45 mg, about 90 mg, about 120 mg, about 180 mg, about 270 mg, about 360 mg, and about 450 mg.

67. The method of any one of claims 55-66, wherein the cancer is a solid tumor.

68. The method of claim 67, wherein the solid tumor is selected from lung, breast, prostate, melanoma, esophageal, cervical, liver, colon, gastric, colorectal, glioblastoma, head and neck, pancreatic, and ovarian.

69. The method of claim 67, wherein the solid tumor is selected from breast cancer, ovarian cancer, and non- small cell lung cancer.

70. The method of claim 67, wherein the solid tumor is lung cancer.

71. The method of claim 70, wherein the lung cancer is an adenocarcinoma.

72. The method of any one of claims 67-71, wherein the solid tumor is metastatic.

73. The method of any one of claims 67-72, wherein the subject has received at least

1 prior standard of care treatment regimen for the solid tumor.

74. The method of any one of claims 67-72, wherein the subject has received at least

1 prior standard of care treatment regimen for the solid tumor, the solid tumor is advanced and unresectable and has progressed since the 1 prior standard of care treatment, and there is no approved life-extending alternative available.

75. The method of any one of claims 55-74, wherein the subject does not have mesothelioma.

76. The method of any one of claims 55-75, wherein the anti-cancer agent is a taxane.

77. The method of claim 76, wherein the taxane is paclitaxel.

78. The method of claim 77, wherein the paclitaxel is administered at least once per month.

79. The method of claim 78, wherein the paclitaxel is administered about every 3 weeks.

80. The method of claim 78, wherein the paclitaxel is administered weekly.

81. The method of any one of claims 77-80, wherein the paclitaxel is administered intravenously.

82. The method of any one of claims 77-81, wherein the second amount of paclitaxel is from about 100 mg/m² to about 220 mg/m².