WO2025228595A1 - Use of compound ia in the treatment of cancers including combination therapy with atezolizumab. - Google Patents

Abstract

The present invention relates to therapeutic treatment of cancer, particularly mesothelioma, using Compound IA as single agent or in combination therapy using Compound IA and atezolizumab.

Description

TITLE Use of Compound IA in the treatment of cancers including combination therapy with atezolizumab. FIELD OF THE INVENTION The present invention relates to therapeutic treatment of cancer, particularly mesothelioma, using Compound IA as single agent or in combination therapy using Compound IA and atezolizumab. BACKGROUND TO THE INVENTION Malignant pleural mesothelioma (MPM), an aggressive tumor of the pleural surface, mainly associates with asbestos exposure. Most case detections occur at advanced stages due to its long latency period -frequently longer than 30 years- and challenging diagnosis. MPM is classified in three histotypes: epithelioid carcinoma (50 to 60% of cases), associated with a favourable prognosis; sarcomatoid carcinoma (10% of cases), drug-resistant and associated with a worse prognosis, and biphasic carcinoma (30 to 40% of cases) in which, variable proportion of the tumor presents one of the other two histotypes. Regardless of these histotypes, current available treatments are limited and have mild clinical benefit, which offer overall survival (OS) rates between 12 to 36 months. First-line (1L) standard treatment is platinum-based combined with pemetrexed chemotherapy, with or without bevacizumab. MPM microenvironment is highly infiltrated by immunosuppressive cells which justifies the exploratory evaluation of treatments based on the immune checkpoint inhibitors (ICI). In the past, it was demonstrated improved OS in patients treated with the combination of anti-PD-1 with anti- CTLA-4 compared to standard 1L chemotherapy. However, and despite efforts made with different therapeutic approaches, a second-line (2L) therapy has not yet been approved. The wide genomic heterogeneity present in MPM may help explain the lack of an effective targeted therapy. Most frequent mutations in MPM, i.e., BAP1, CDKN2A, NF2, TP53 and SETD2, are tumor suppressor inactivating genes. Mutations in BAP1 tend to accelerate asbestos-induced MPM in mice and have been associated with multi-cancer-related syndromes. Thus, deubiquitinase-related tumor suppression may be potentially relevant as a promising DNA- interacting agent-based therapy for MPM. Ecteinascidins are exceedingly potent antitumor agents isolated from the marine tunicate Ecteinascidia turbinata. WO2018/197663 describes synthetic ecteinascidin compounds including Compound IA which is described as compound 39-S with the following formula: Compound IA demonstrated in vitro activity against non-small cell lung cancer (NSCLC), colorectal adenocarcinoma, breast adenocarcinoma, pancreas adenocarcinoma, prostate adenocarcinoma, melanoma, and prostate carcinoma cell lines and in vivo activity in fibrosarcoma, melanoma, breast adenocarcinoma, NSCLC, ovarian carcinoma, gastric carcinoma, small cell lung cancer (SCLC), and prostatic carcinoma xenograft models. This compound can be synthesized using the synthetic route disclosed in WO2018/197663. Despite the positive results obtained in clinical applications in chemotherapy, there is a need for further effective cancer therapies. SUMMARY OF THE INVENTION In a first aspect, the invention provides Compound IA, which is a compound of formula I, for use in the treatment of malignant mesothelioma. In an embodiment, Compound IA is not administered in combination with a topoisomerase I inhibitor. In an embodiment, Compound IA, is administered as monotherapy. In an embodiment, the malignant mesothelioma is malignant pleural mesothelioma. In a preferred embodiment, the malignant mesothelioma is malignant peritoneal mesothelioma. In another preferred embodiment, the malignant mesothelioma is epithelioid mesothelioma. In a further preferred embodiment, the malignant mesothelioma is sarcomatoid mesothelioma. In a further preferred embodiment, the malignant mesothelioma is biphasic mesothelioma. In another embodiment, the malignant mesothelioma is progressive. In another embodiment, the malignant mesothelioma has progressed from first-line therapy, preferably standard first-line therapy. In a preferred embodiment, the first-line therapy also includes radiotherapy. In a preferred embodiment, the radiotherapy is administered prior to or subsequent to administration of Compound IA, preferably at least an hour, three hours, five hours, 12 hours, a day, a week, a month, more preferably several months (e.g. up to three months) prior or subsequent to administration of Compound IA. In a further aspect, the invention provides a pharmaceutical package comprising Compound IA, together with instructions for treating malignant mesothelioma in monotherapy as defined herein. In a further aspect, the invention provides Compound IA which is a compound of formula I, for use in the treatment of malignant mesothelioma, wherein in said treatment Compound IA is administered in combination with atezolizumab to a patient in need thereof. In an embodiment, the malignant mesothelioma is malignant pleural mesothelioma. In a preferred embodiment, the malignant mesothelioma is malignant peritoneal mesothelioma. In another preferred embodiment, the malignant mesothelioma is epithelioid mesothelioma. In a further preferred embodiment, the malignant mesothelioma is sarcomatoid mesothelioma. In a further preferred embodiment, the malignant mesothelioma is biphasic mesothelioma. In another embodiment, the malignant mesothelioma is progressive. A further aspect of the invention provides a pharmaceutical package comprising Compound IA, together with instructions for treating malignant mesothelioma in combination with atezolizumab, as defined herein. A further aspect of the invention provides Compound IA, which is a compound of formula I, for use in the treatment of cancer, wherein in said treatment Compound IA is administered in combination with atezolizumab to a patient in need thereof, as defined herein. In an embodiment, the cancer is a solid tumor. In another embodiment, the solid tumor is selected from neuroendocrine tumor, gastrointestinal cancer, lung cancer, sarcoma, gynaecological cancer, breast cancer, malignant pleural mesothelioma, extrapulmonary small cell carcinoma, adrenocortical carcinoma, adenoid cystic carcinoma, skin cancer, genitourinary tract tumors, microsatellite instability (MSI) solid tumors, head and neck squamous cell carcinoma. In a preferred embodiment, the solid tumor is selected from melanoma, Merkel cell carcinoma, urothelial bladder carcinoma, clear cell renal carcinoma, prostate adenocarcinoma, esophageal carcinoma, gastric adenocarcinoma, hepatocarcinoma, non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), epithelial ovarian carcinoma (including primary peritoneal disease and/or fallopian tube carcinomas and/or endometrial adenocarcinomas), endometrial carcinoma, carcinoma of cervix, triple negative breast cancer, liposarcoma, leiomyosarcoma, synovial sarcoma and Ewing sarcoma. In a preferred embodiment, the solid tumor is endometrial cancer. In a preferred embodiment, the solid tumor is non-small cell lung cancer. In another preferred embodiment, the solid tumor is gastric cancer. In another preferred embodiment, the solid tumor is melanoma. In a more preferred embodiment, the solid tumor is malignant mesothelioma. In another preferred embodiment, the malignant mesothelioma is malignant pleural mesothelioma. In another preferred embodiment, the malignant mesothelioma is malignant peritoneal mesothelioma. In another preferred embodiment, malignant mesothelioma is epithelioid mesothelioma. In another preferred embodiment, wherein the malignant mesothelioma is sarcomatoid mesothelioma. In another preferred embodiment, the malignant mesothelioma is biphasic mesothelioma. In another embodiment, the malignant mesothelioma is progressive. In a further aspect, the invention provides a pharmaceutical package comprising Compound IA, together with instructions for its use in combination with atezolizumab for treating cancer. In embodiments, Compound IA is in the form of a pharmaceutically acceptable salt or ester. BRIEF DESCRIPTION OF THE FIGURES Figure 1A. In vitro IC50 median values (2L) of cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA determined in 12 patient-derived histotypes of MPM (epithelioid: square; sarcomatoid: circle; biphasic: diamond) with BAP1 positive (solid symbol) and BAP1 negative (open symbol). Results are mean of 4 independent experiments. Figure 1B. In vitro IC10 median values (2L) of cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA determined in 12 patient-derived histotypes of MPM (epithelioid: square; sarcomatoid: circle; biphasic: diamond) with BAP1 positive (solid symbol) and BAP1 negative (open symbol). Results are mean of 4 independent experiments. Figure 2. Histograms showing the percentage of total DNA in the tail of COMET assay in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA at IC50 for 24 h. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3A. Representative immunoblot images of the indicated proteins belonging to the cGAS/STING pathway, in MPM#1 (epithelioid, BAP1 positive: Epi, BAP+) and MPM#7 (sarcomatoid, BAP1 negative: Sar, BAP-), treated or not (-) with cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), and Compound IA at their IC⁵⁰ for 24 h, actin was used as a loading control. The figure is representative of 1 out of 3 experiments. Figure 3B. Activation of NF-kB after the treatment indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). **p<0.01, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX Figure 3C. Pro-inflammatory IFN-β levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3D. Pro-inflammatory CXCL5 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3E. Pro-inflammatory CXCL10 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3F. Pro-inflammatory TNF-α levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3G. Pro-inflammatory IL-6 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 3H. Pro-inflammatory IL-12 levels released in the supernatant of MPM cell cultures after the treatments indicated in Figure 3A. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4A. Percentage of cells positive for surface calreticulin (CRT) measured by flow-cytometry. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4B. ATP release measured by a chemiluminescent- based assay. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4C. HMGB1 release measured by ELISA. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4D. Phagocytized MPM cells counted by flow cytometry. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4E. Percentage of CD8⁺CD107a⁺INFγ⁺ cells, as index of cytotoxic T-lymphocyte activation. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. Figure 4F. Percentage of annexin V-FITC⁺/PI⁺ MPM cells, as index of tumor cells immunokilling by CD8⁺T-lymphocytes, measured by flow cytometry. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). *p<0.05, ***p<0.001: vs untreated cells; °°°p<0.001: vs Pt+PMX. DETAILED DESCRIPTION OF THE INVENTION In the present application, a number of general terms and phrases are used, which should be interpreted as follows. The term “treating”, as used herein, unless otherwise indicated, means reversing, attenuating, alleviating or inhibiting the progress of the disease or condition to which such term applies, or one or more symptoms of such disorder or condition. The term “treatment”, as used herein, unless otherwise indicated, refers to the act of treating as “treating” is defined immediately above. "Patient" includes a living organism that is treated with a compound of the present invention, including a mammal, such as a human, other primates, sports animals, animals of commercial interest such as cattle, farm animals such as horses, or pets such as dogs and cats. Preferably, the subject is a human. In the present application, by “cancer” it is meant to include tumors, neoplasias and any other malignant disease having as cause malignant tissue or cells. “Malignant mesothelioma” is a disease in which malignant (cancer) cells are found in the pleura (the thin layer of tissue that lines the chest cavity and covers the lungs) or the peritoneum (the thin layer of tissue that lines the abdomen and covers most of the organs in the abdomen). Malignant mesothelioma may also form in the heart or testicles, but this is rare. The four types of mesothelioma are therefore pleural (lung lining), peritoneal (abdominal lining), pericardial (heart sac) and testicular. Mesothelioma can also be identified by three cancer cell types: epithelioid, sarcomatoid and biphasic, and can therefore be defined as epithelioid mesothelioma (epithelioid cells), sarcomatoid mesothelioma (sarcomatoid cells) or biphasic mesothelioma (epithelioid and sarcomatoid cells). Pleural is the most common mesothelioma. Approximately 70% to 75% of cases occur in the pleura. Peritoneal disease accounts for 10% to 20% of mesothelioma cases. There is less research available on peritoneal compared to pleural; however, the prognosis for this tumor type is better. Pericardial Mesothelioma is extremely rare. Around 200 cases are reported in medical literature. Testicular mesothelioma develops in the lining of the testes. This form of mesothelioma is the rarest. Less than 100 cases are reported in the medical literature. The three mesothelioma cell varieties are epithelial, sarcomatoid and biphasic. Biphasic is a mix of the first two cell types. Different mesothelioma tumors respond differently to treatment. Epithelial or epithelioid cells typically respond the best to treatment, and sarcomatoid cells are typically more resistant to treatment. Epithelioid mesothelioma makes up approximately 70% to 75% of all cases of asbestos-related mesothelioma cancers. Epithelioid cell typically has the best prognosis. It tends to be less aggressive and doesn’t spread as quickly as sarcomatoid and biphasic cell disease. About 50% of pleural disease is epithelioid. Around 75% of peritoneal tumors are made up of epithelioid cells. Sarcomatoid is the least common mesothelioma cell category. It is typically the most aggressive and difficult to treat. It accounts for around 10% to 20% of all mesothelioma diagnoses. About 20% of pleural tumors are sarcomatoid, while only 1% of peritoneal mesothelioma are sarcomatous. Biphasic mesothelioma refers to tumors that contain epithelial and sarcomatoid cells. Life expectancy after diagnosis with biphasic mesothelioma depends upon which cell predominates in the tumor. More epithelioid cells generally mean a better prognosis. If the tumor is mostly sarcomatous, it is harder to treat and life expectancy is shorter. Around 30% of pleural and 25% of peritoneal tumors are biphasic cell. Table 1. Prevalence of Mesothelioma Tumors by Cell Type Cell type Pleural Peritoneal epithelioid 50% to 60% 75% to 90% biphasic 30% to 40% 25% sarcomatoid 10% 1% Based on the limited number of cases reported in the medical literature, pericardial mesothelioma exhibits roughly equal distribution of the three mesothelioma cell types. Approximately two-thirds of testicular mesothelioma cases are epithelioid cell. The rest of testicular cases are biphasic. Only one case of purely sarcomatoid cell disease is reported for testicular mesothelioma. The present invention is preferably the use of Compound IA as single agent or in combination with another drug for the treatment of malignant pleural mesothelioma (MPM). The malignant mesothelioma to be treated may be epithelioid. The malignant mesothelioma to be treated may be sarcomatoid. The malignant mesothelioma to be treated may be biphasic. “Progressive malignant mesothelioma” is where the disease has progressed after first-line therapy. In an embodiment, the present invention is directed to treatment of patients who experience progression after standard treatment. “First-line therapy” means the initial treatment given to the patient. Standard first line therapy of malignant mesothelioma is typically platinum-pemetrexed chemotherapy with or without surgery, and potentially additional radiotherapy. Thus, standard first-line therapy may comprise platinum- pemetrexed chemotherapy, platinum-pemetrexed chemotherapy and surgery, platinum- pemetrexed chemotherapy and radiotherapy or platinum-pemetrexed chemotherapy and surgery plus radiotherapy. Progressive therapy according to the present invention may therefore be after platinum- pemetrexed chemotherapy with or without surgery, and potentially additional radiotherapy. “Monotherapy” means the patient is treated with Compound IA as the sole chemotherapeutic agent and not in combination. For example, the patient is treated with Compound IA alone and not Compound IA in combination with a platinum agent, for example cisplatin. Compound IA monotherapy does not, however, preclude the patient from other medicaments such as, for example, an anti-emetic. In embodiments, Compound IA monotherapy may include radiotherapy. Sarcomas are rare cancers that develop in the muscle, bone, nerves, cartilage, tendons, blood vessels and the fatty and fibrous tissues. They can affect almost any part of the body, on the inside or the outside. Sarcomas commonly affect the arms, legs and trunk. They also appear in the stomach and intestines as well as behind the abdomen (retroperitoneal sarcomas) and the female reproductive system (gynecological sarcomas). Bone sarcomas affect less than 500 people in the UK each year, making it a very rare form of cancer. Not all bone cancers will be sarcomas. “Soft-tissue sarcoma” can affect any part of the body. They develop in supporting or connective tissue such as the muscle, nerves, fatty tissue, and blood vessels. Unless detected at an early stage when the tumor can be removed by surgery there is currently no cure for soft tissue sarcoma. Approximately 16% of patients with soft tissue sarcoma have advanced stage (metastatic) disease. For these patients, the relative 5 year survival rate is 16% (American Cancer Society). There are more than 50 different types of soft tissue sarcomas, including: Leiomyosarcoma is a type of cancer that starts in smooth muscle tissue. These tumors often start in the abdomen, but they can also start in other parts of the body, such as the arms or legs, or in the uterus. Liposarcomas are malignant tumors of fat tissue. They can start anywhere in the body, but they most often start in the thigh, behind the knee, and inside the back of the abdomen. They occur mostly in adults between 50 and 65 years old. Synovial sarcoma is a malignant tumor of the tissue around joints. The most common locations are the hip, knee, ankle, and shoulder. This tumor is more common in children and young adults, but it can occur in older people. The “Ewing family of tumors” is a group of cancers that start in the bones or nearby soft tissues that share some common features. These tumors can develop at any age, but they are most common in the early teen years. The main types of Ewing tumors are: Ewing sarcoma of bone: most Ewing tumors occur in the bones. The most common sites are: the pelvis (hip bones), the chest wall (such as the ribs or shoulder blades), or the legs, mainly in the middle of the long bones. Extraosseous Ewing tumors can occur almost anywhere. Extraosseous Ewing tumor (EOE): Extraosseous Ewing tumors start in soft tissues around bones, but they look and act very much like Ewing sarcomas in bones. They are also known as extraskeletal Ewing sarcomas. “Carcinosarcoma” is a malignant tumor that is a mixture of carcinoma (cancer of epithelial tissue, which is skin and tissue that lines or covers the internal organs) and sarcoma (cancer of connective tissue, such as bone, cartilage, and fat). Clear cell sarcoma is a rare cancer that often starts in tendons of the arms or legs. Under the microscope, it has some features of malignant melanoma, a type of cancer that starts in pigment- producing skin cells. How cancers with these features start in parts of the body other than the skin is not known. Desmoplastic small round cell tumor is a rare sarcoma of teens and young adults. It's found most often in the abdomen. Epithelioid sarcoma most often starts in tissues under the skin of the hands, forearms, feet, or lower legs. Teens and young adults are often affected. Fibromyxoid sarcoma, low-grade is a slow-growing cancer that most often starts as a painless growth in the trunk or arms and legs (particularly the thigh). It is more common in young to middle aged adults. It is sometimes called an Evans’ tumor Gastrointestinal stromal tumor (GIST) is a type of sarcoma that starts in the digestive tract. Kaposi sarcoma is a type of sarcoma that starts in the cells lining lymph or blood vessels. Malignant peripheral nerve sheath tumors include neurofibrosarcomas, malignant schwannomas, and neurogenic sarcomas. These are sarcomas that start in the cells that surround a nerve. Myxofibrosarcomas, low-grade are most often found in the arms and legs of elderly patients. They are most common in or just under the skin and there might be more than one tumor. Rhabdomyosarcoma is the most common type of soft tissue sarcoma seen in children. Undifferentiated pleomorphic sarcoma (UPS) was once called malignant fibrous histiocytoma (MFH). It's most often found in the arms or legs. Less often, it can start inside at the back of the abdomen (the retroperitoneum). This sarcoma is most common in older adults. It mostly tends to grow into other tissues around the place it started, but it can spread to distant parts of the body. Intermediate soft tissue tumors may grow and invade nearby tissues and organs, but they tend to not spread to other parts of the body. Infantile fibrosarcoma is the most common soft tissue sarcoma in children under one year of age. It tends to be slow-growing and is less likely to spread to other organs than adult fibrosarcomas. Adult fibrosarcoma usually affects fibrous tissue in the legs, arms, or trunk. “Endometrial carcinoma” is a cancer that forms in the tissue lining the uterus. Most endometrial cancers are adenocarcinomas (cancers that begin in cells that make and release mucus and other fluids). There are various types of endometrial carcinomas including adenocarcinoma (particularly endometrioid cancer), uterine carcinosarcoma, squamous cell carcinoma, small cell carcinoma, transitional carcinoma or serous carcinoma. Clear-cell carcinoma, mucinous adenocarcinoma, undifferentiated carcinoma, dedifferentiated carcinoma, and serous adenocarcinoma are less common types of endometrial adenocarcinomas. They tend to grow and spread faster than most types of endometrial cancer. Most endometrial cancers are adenocarcinomas, and endometrioid cancer is the most common type of adenocarcinoma. Endometrioid cancers start in gland cells. Some of these cancers have squamous cells (squamous cells are flat, thin cells), as well as glandular cells. There are many sub-types of endometrioid cancers including: adenocarcinoma, (with squamous differentiation), adenoacanthoma, adenosquamous (or mixed cell), secretory carcinoma, ciliated carcinoma, and villoglandular adenocarcinoma. Cervical cancer starts in the cells lining the cervix. The main types of cervical cancers are squamous cell carcinoma and adenocarcinoma. “Ovarian cancer” includes epithelial ovarian carcinoma, primary peritoneal disease, fallopian tube carcinomas, or ovarian germ cell tumors. “Epithelial ovarian tumors” start in the outer surface of the ovaries. These tumors can be benign, borderline, or malignant. Epithelial ovarian tumors that are benign don’t spread and usually don’t lead to serious illness. There are several types of benign epithelial tumors including serous cystadenomas, mucinous cystadenomas, and Brenner tumors. When looked at in the lab, some ovarian epithelial tumors don’t clearly appear to be cancerous and are known as borderline epithelial ovarian cancer. The two most common types are atypical proliferative serous carcinoma and atypical proliferative mucinous carcinoma. Primary peritoneal carcinoma (PPC) is a rare cancer closely related to epithelial ovarian cancer. At surgery, it looks the same as an epithelial ovarian cancer that has spread through the abdomen. Other names for this cancer include extra-ovarian (meaning outside the ovary) primary peritoneal carcinoma (EOPPC) and serous surface papillary carcinoma. PPC appears to start in the cells lining the inside of the fallopian tubes. Fallopian tube cancer is another rare cancer that is similar to epithelial ovarian cancer but begins in the fallopian tube. Like PPC, fallopian tube cancer and ovarian cancer have similar symptoms. Most ovarian germ cell tumors are benign, but <2% of ovarian cancers are germ cell tumors. There are several subtypes of germ cell tumors. The most common germ cell tumors are teratomas, dysgerminomas, endodermal sinus tumors, and choriocarcinomas. Germ cell tumors can also be a mix of more than a single subtype. Teratomas are germ cell tumors which have a benign form called mature teratoma and a cancerous form called immature teratoma. Immature teratomas occur in girls and young women, usually younger than 18. These are rare cancers that contain cells that look like those from embryonic or fetal tissues such as connective tissue, respiratory passages, and brain. Dysgerminoma is rare, but it is the most common ovarian germ cell cancer. It usually affects women in their teens and twenties. Endodermal sinus tumor (yolk sac tumor) and choriocarcinoma are very rare tumors which typically affect girls and young women. They tend to grow and spread rapidly but are usually very sensitive to chemotherapy. The ovarian cancers according to embodiments of the present invention may be selected regardless of platinum sensitivity. Breast cancer is a kind of cancer that begins as a growth of cells in the breast tissue. The most common type of breast cancer is ductal carcinoma, which begins in the lining of the milk ducts. Another type of breast cancer is lobular carcinoma, which begins in the lobules of the breast. Invasive breast cancer is breast cancer that has spread from where it began in the breast ducts or lobules to surrounding normal tissue. Triple negative breast cancer is a type of breast cancer. Around 15 out of 100 (around 15%) breast cancers are of this type. Triple negative breast cancers are cancers whose cells don’t have receptors for the hormones oestrogen and progesterone and/or a protein called Human Epidermal Growth Factor Receptor 2 (HER2). Urothelial carcinoma (also called transitional cell carcinoma) is cancer that begins in the urothelial cells, which line the urethra, bladder, ureters, renal pelvis, and some other organs. Almost all bladder cancers are urothelial carcinomas. Clear cell renal cell carcinoma, or ccRCC, is a type of kidney cancer. In adults, ccRCC is the most common type of kidney cancer, and makes up about 80% of all renal cell carcinoma cases. Hepatocellular carcinoma is also called hepatoma or HCC. This type of liver cancer develops from the main liver cells called hepatocytes. It's the most common type of primary liver cancer. Squamous cell carcinoma of the head and neck is a cancer that begins in squamous cells (thin, flat cells that form the surface of the skin, eyes, various internal organs, and the lining of hollow organs and ducts of some glands). Squamous cell carcinoma of the head and neck includes cancers of the nasal cavity, sinuses, lips, mouth, salivary glands, throat, and larynx (voice box). Most head and neck cancers are squamous cell carcinomas. Lung cancer is a disease in which malignant (cancer) cells form in the tissues of the lung. The two major types of lung cancer are small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). SCLC comprises only about 13-15% of all lung cancers at diagnosis; however, SCLC is the more aggressive form of lung cancer. With SCLC, the cancer cells tend to grow quickly and travel to other parts of the body, or metastasize, more easily. The median survival of patients with untreated SCLC is two to four months. The most common regimens include cisplatin or carboplatin and etoposide. Unfortunately, despite the 40-90% response rate to first-line chemotherapy, long-term survival is unusual because patients develop resistance to chemotherapy and relapse. The overall expected mean survival after disease relapse without treatment was typically two to four months. “Pancreatic adenocarcinoma” is a disease in which malignant (cancer) cells are found in the tissues of the pancreas. Pancreatic cancer can develop from two kinds of cells in the pancreas: exocrine cells and neuroendocrine cells, such as islet cells. The exocrine type is more common and is usually found at an advanced stage. Pancreatic neuroendocrine tumors (islet cell tumors) are less common but have a better prognosis (discussed separately below). The most common type of pancreatic cancer, adenocarcinoma of the pancreas, starts when exocrine cells in the pancreas start to grow out of control. Exocrine cancers are by far the most common type of pancreas cancer. About 95% of cancers of the exocrine pancreas are adenocarcinomas. These cancers usually start in the ducts of the pancreas. Less often, they develop from the cells that make the pancreatic enzymes, in which case they are called acinar cell carcinomas. Other, less common exocrine cancers include adenosquamous carcinomas, squamous cell carcinomas, signet ring cell carcinomas, undifferentiated carcinomas, and undifferentiated carcinomas with giant cells. Ampullary cancer (carcinoma of the ampulla of Vater) is a cancer which starts in the ampulla of Vater. Ampullary cancers often block the bile duct while they are still small and have not spread far. This blockage causes bile to build up in the body, which leads to yellowing of the skin and eyes (jaundice). “GEP-NET” is a rare type of tumor that can form in the pancreas or in other parts of the gastrointestinal tract, including the stomach, small intestine, colon, rectum, and appendix. GEP- NETs usually form in cells that secrete hormones. Some of these tumors make extra amounts of hormones and other substances that may cause signs and symptoms of disease, including a condition called carcinoid syndrome. GEP-NETs may be benign or malignant. They are sometimes called carcinoid tumors or islet cell tumors. Also called gastroenteropancreatic neuroendocrine tumor. Pancreatic NETs are classified based on whether they are functioning (making hormones that cause symptoms) or non-functioning (not making hormones). Functioning NETs: About half of pancreatic NETs make hormones that are released into the blood and cause symptoms. These are called functioning NETs. Each one is named for the type of hormone the tumor cells make. Insulinomas come from cells that make insulin; glucagonomas come from cells that make glucagon; gastrinomas come from cells that make gastrin; somatostatinomas come from cells that make somatostatin; VIPomas come from cells that make vasoactive intestinal peptide (VIP); ACTH-secreting tumors come from cells that make adrenocorticotropic hormone (ACTH). Most (up to 70%) functioning NETs are insulinomas. The other types are much less common. Non-functioning NETs: These tumors don’t make enough excess hormones to cause symptoms. Because they don’t make excess hormones that cause symptoms, they can often grow quite large before they're found. Symptoms that may occur when they grow to a large size include abdominal (belly) pain, lack of appetite, and weight loss. Carcinoid tumors: These NETs are much more common in other parts of the digestive system, although rarely they can start in the pancreas. These tumors often make serotonin. “Gastric carcinoma” is a cancer that forms in tissues lining the stomach. Risk factors include smoking, infection with H. pylori bacteria, and certain inherited conditions. “Colorectal carcinoma (CRC)” is a cancer that develops in the colon (the longest part of the large intestine) and/or the rectum (the last several inches of the large intestine before the anus). Colorectal cancer often begins as a growth called a polyp inside the colon or rectum. Most colorectal cancers are adenocarcinomas. These cancers start in cells that make mucus to lubricate the inside of the colon and rectum. Some sub-types of adenocarcinomas, such as signet ring and mucinous, may have a worse prognosis than other subtypes of adenocarcinomas. Prostate cancer is a type of cancer arising from the prostate gland. The most common type is adenocarcinoma of the prostate. Melanoma is a form of cancer that begins in melanocytes. It may begin in a mole (skin melanoma), but can also begin in other pigmented tissues, such as in the eye or in the intestines. Merkel cell carcinoma is a rare type of skin cancer that usually appears as a flesh-colored or bluish-red nodule, often on the face, head or neck. Compound IA is a synthetic compound under clinical investigation. Compound IA was first disclosed in WO2018/197663 (as compound 39-S), the contents of which are herein incorporated by reference. Compound IA can be prepared following the synthesis set out in WO2018/197663. The structure for Compound IA is: . In embodiments, Compound IA is in the form of a pharmaceutically acceptable salt or ester. The terms “pharmaceutically acceptable salt” and “ester” refers to any pharmaceutically acceptable salt or ester which, upon administration to the patient is capable of providing (directly or indirectly) a compound as described herein. However, it will be appreciated that non- pharmaceutically acceptable salts also fall within the scope of the invention since those may be useful in the preparation of pharmaceutically acceptable salts. The preparation of salts can be carried out by methods known in the art. For instance, pharmaceutically acceptable salts of the compounds provided herein are synthesized from the parent compounds, which contain a basic or acidic moiety, by conventional chemical methods. Generally, such salts are, for example, prepared by reacting the free acid or base of these compounds with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent or in a mixture of both. Generally, nonaqueous media like ether, ethyl acetate, ethanol, 2-propanol or acetonitrile are preferred. Examples of the acid addition salts include mineral acid addition salts such as, for example, hydrochloride, hydrobromide, hydroiodide, sulfate, nitrate, phosphate, and organic acid addition salts such as, for example, acetate, trifluoroacetate, maleate, fumarate, citrate, oxalate, succinate, tartrate, malate, mandelate, methanesulfonate and p-toluenesulfonate. Examples of the alkali addition salts include inorganic salts such as, for example, sodium, potassium, calcium and ammonium salts, and organic alkali salts such as, for example, ethylenediamine, ethanolamine, N,N- dialkylenethanolamine, triethanolamine and basic amino acids salts. The compounds of the invention may be in crystalline or amorphous form either as free compounds or as solvates (e.g. hydrates) and it is intended that all forms are within the scope of the present invention. Methods of solvation are generally known within the art. In addition, compounds referred to herein may exist in isotopically-labelled forms. All pharmaceutically acceptable salts, esters and isotopically labelled forms of the compounds referred to herein, and mixtures thereof, are considered within the scope of the present invention. Atezolizumab (MPDL3280A) is a humanized lgG1 monoclonal antibody consisting of two heavy chains (448 amino acid residues each) and two light claims (214 amino acid residues each) and is produced in Chinese hamster ovary cells. Atezolizumab targets human PD-L1 and inhibits its interaction with its receptors, programmed cell death protein 1 (PD-1) and B7.1 (CD80, B7-1). Both of these interactions are reported to provide inhibitory signals to T cells. Atezolizumab is approved in USA and Europe for the treatment of patients with metastatic NSCLC whose disease progressed during or following platinum-containing chemotherapy. “Radiotherapy” means that in a further embodiment of the present invention, the patient in need of said treatment is given radiation therapy with (including prior to, during or after) treatment with Compound IA. In embodiments of the present invention, the patient is treated with Compound IA and radiotherapy. In an embodiment, the radiation therapy is administered prior or subsequent to administration of Compound IA, preferably at least an hour, three hours, five hours, 12 hours, a day, a week, a month, more preferably several months (e.g. up to three months) prior or subsequent to administration of Compound IA. The preferred route of administration is parenteral administration including, but not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, intracerebral, intraventricular, intrathecal, intravaginal or transdermal. The preferred mode of administration is left to the discretion of the practitioner, and will depend in part upon the site of the medical condition. The invention will now be described further with reference to the following examples. EXAMPLES Example 1: in vitro antiproliferative activity of Compound IA and in malignant pleural mesothelioma (MPM) cancer cells Twelve primary MPM cell lines (Table 2) derived from patients with different histology, BAP1 status and clinical administered treatments were evaluated for in vitro activity of cisplatin+pemetrexed (Pt+ PMX), lurbinectedin (L), and Compound IA. Table 2. Malignant pleural mesothelioma primary samples, clinical features and treatments. APN=Anonymized Patient Number; OS means Overall Survival; M=male; F=female; C=carboplatin; P=pemetrexed; G=gemcitabine; T=trabectedin. Treatments APN Histotype BAP1 Gender Age Asbestos OS (years) exposure Surgery e 2^nd (months) 1^st-lin - line #¹ Epithelioid + M 78 Possible No Palliative No 6 #² Epithelioid - F 74 Yes No C+P No 13 #³ Epithelioid + M 70 Yes Yes No No 3 #⁴ Epithelioid + M 79 Possible No C+P G 16 #⁵ Epithelioid + M 68 Yes No C+P P 9 #⁶ Sarcomatoid + M 69 Yes No C+P T 10 #⁷ Sarcomatoid - M 77 Yes No No No 3 #⁸ Sarcomatoid - M 61 Yes Yes No No 7 #⁹ Biphasic - M 65 No No C+P No 11 ^#10 Biphasic - M 55 Possible No C+P T 10 ^#11 Biphasic + F 69 Yes Yes C+P G 14 ^#12 Biphasic - F 80 Yes No C+P T 5 Compound-induced antitumor activity was assessed by the crystal violet proliferation assay as described by Riganti et al., J. Natl. Cancer Inst.2015. Inhibition concentrations (IC⁵⁰ and IC¹⁰) were calculated with GraphPad Prism software, v.9.4.1 (GraphPad Software Inc., La Jolla, CA, USA). 2×10³ cells/well were seeded into 96-well plates and incubated for 72 hours with increasing concentrations of Pt+PMX (0.1 nM to 100 nM), lurbinectedin, and Compound IA (both, 0.01 nM to 100 nM). Lurbinectedin, Compound IA, as well as the combination Pt+PMX (1^st-line clinical treatment) induced a concentration-dependent decrease in cell viability in a panel of twelve 2D-cultures of patient-derived MPM, independent of histotype or BAP1 status. In these experiments, while the median IC⁵⁰ for Pt+PMX was 6.0 nM, those obtained with lurbinectedin, and Compound IA were 0.1 nM, and 0.17 nM, respectively, thus showing 60-, and 35-fold higher in vitro potency than Pt+PMX. A very similar activity relationship was found with the IC10 values, whose mean values were calculated as 2.5, 0.045, and 0.065 nM for Pt+PMX, lurbinectedin, and Compound IA, respectively, the latter two compounds being thus 56-, and 39-fold more active in vitro than Pt+PMX (Table 3 and 4; Fig.1A and 1B). Table 3. In vitro activity (IC10, nM) of cisplatin plus pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA in a panel of 12 patient-derived MPM cells. IC10 APN Histotype BAP1 Pt+PMX L Compound IA #1 Epithelioid + 0.3±0.2 0.05±0.01 0.09±0.03 #2 Epithelioid - 1.5±0.3 0.01±0.005 0.003±0.001 #3 Epithelioid + 0.9±0.4 0.03±0.02 0.003±0.005 #4 Epithelioid + 2.5±0.7 0.04±0.002 0.001±0.002 IC10 APN Histotype BAP1 Pt+PMX L Compound IA #5 Epithelioid + 3.3±0.6 0.07±0.02 0.003±0.001 #6 Sarcomatoid + 1.9±0.4 0.13±0.04 0.17±0.05 #7 Sarcomatoid - 4.5±1.1 0.05±0.02 0.06±0.02 #8 Sarcomatoid - 5.1±0.7 0.04±0.01 0.04±0.01 #9 Biphasic - 2.5±0.4 0.03±0.01 0.07±0.01 #10 Biphasic - 5.6±0.9 0.54±0.74 0.56±0.07 #11 Biphasic + 2.3±0.5 0.07±0.02 0.08±0.02 #12 Biphasic - 3.1±0.5 0.04±0.01 0.08±0.02 Table 4. In vitro activity (IC50, nM) of cisplatin plus pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA in a panel of 12 patient-derived MPM cells. Values represent mean±SD of 3 independent experiments. APN=Anonymized patient number. IC50 APN Histotype BAP1 Pt+PMX L Compound IA #1 Epithelioid + 1.7±0.5 0.6±0.2 0.4±0.3 #2 Epithelioid - 2.9±0.7 0.07±0.03 0.02±0.007 #3 Epithelioid + 1.2±0.5 0.06±0.02 0.01±0.0033 #4 Epithelioid + 5.6±0.4 0.05±0.001 0.02±0.003 #5 Epithelioid + 4.7±0.8 0.06±0.002 0.04±0.03 #6 Sarcomatoid + 4.4±0.6 0.5±0.08 0.54±0.08 #7 Sarcomatoid - 9.8±1.4 0.11±0.008 0.21±0.04 #8 Sarcomatoid - 6.4±1.1 0.09±0.04 0.24±0.07 #9 Biphasic - 6.7±1.4 0.12±0.05 0.13±0.03 #10 Biphasic - 9.4±1.1 0.85±0.12 0.23±0.04 #11 Biphasic + 10.3±1.7 0.11±0.4 0.11±0.03 #12 Biphasic - 8.7±1.5 0.3±0.07 0.34±0.08 Major different results were obtained in long-term experiments with Pt+PMX as compared with either lurbinectedin and Compound IA. In long-term assays, cells (4×10³/well) were incubated with Pt+PMX, lurbinectedin, and Compound IA at their corresponding IC10 and the exposure to the compounds were maintained for 10 weeks according to the following schedule: 4-week treatment-on; 2-week treatment-off; 4- week treatment-on. Pt+PMX induced heterogeneous effect after the first treatment period, with cell viability percentages ranging from 32 ± 14% (APN#3; histotype epithelioid, BAP1 positive) to 78 ± 14% (APN#12; histotype biphasic, BAP1 negative). After treatment interruption for 2 weeks followed by the second treatment period, most cultures experienced a rebound in cell viability, suggesting a strong possibility of induction of resistance to Pt+PMX treatment (median cell viability, 63 ± 12%) on week 10. However, lurbinectedin, and mainly, Compound IA induced a continuous and strong decrease in MPM cell viability, unaffected by the 2-week period without treatment. At the end of the experimental period (week 10), the cell viability median values for lurbinectedin, and Compound IA were 12 ± 4%, and 5 ± 3%, respectively, resulting in a very low potential for the induction to treatment resistance, regardless of the histotype and BAP1 status of tested MPM cell. Example 2: in vitro cell invasion impairment with Compound IA in malignant pleural mesothelioma (MPM) cancer cells In the wound healing assay, MPM cells were scratched (at a density of 90–100% of confluence in 6-well plates) using a 200-µl sterile tip, washed twice with phosphate buffered saline (PBS), and incubated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA at their corresponding IC50. Cell migration was monitored by contrast phase microscopy at 0, 24 and 48 hours. The percentage of migrated cells (number of cells counted within the scratch/number of seeded cells) was calculated using ImageJ software and results are shown in Table 5. Table 5. Percentage of migrated cells in wound healing assay at 24h and 48h in MPM cells incubated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA. untreated Pt+PMX L Compound IA %migrated cells 24h 45±8 21±4 11±5 5±3 %migrated cells 48h 73±9 48±9 16±8 6±3 Pt+PMX induced a modest effect at 24 hours (comparing treated vs untreated migrated cells; p<0.05) and 48 hours (p<0.05) of incubation. However, a strong and very highly statistically significant reduction in the percentage of migrated cells was observed (p<0.001 vs untreated cultures) with lurbinectedin and Compound IA with the percentages obtained with Compound IA being statistically much lower than with lurbinectedin. A similar result pattern in invasion was observed (Table 6). In the Transwell invasion assay, re- suspended MPM cells in 0.45% type VII low melting and 10% FBS- supplemented agarose were coated on a 0.9% agarose layer in the upper chamber of 6-well transwell plates (1x10⁵ cells/plate). Then, they were diluted in complete medium, and incubated for three weeks with Pt+PMX, lurbinectedin, and Compound IA at their corresponding IC¹⁰. Afterwards, cells in the bottom chamber were stained by crystal violet, images acquired by contrast phase microscopy, absorbance measured (Cytation 3 Imaging Reader, Bio-tek Instruments), quantification performed and the percentage of migrated cells/field (number of cells in the bottom chamber versus number of cells seeded in the upper chamber) calculated. Table 6. Percentage of migrated cells/field in invasion assay in MPM cells incubated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA. untreated Pt+PMX L Compound IA %migrated cells/field 786±205 452 ± 103 108±25 15±5 A very highly statistically significant reduction (p<0.001) in the number of cells migrated after incubation with lurbinectedin, and Compound IA compared to untreated or Pt+PMX was observed. Notably, Compound IA induced a lower cell migration than lurbinectedin (p<0.001). Example 3: cell cycle analysis and apoptosis quantitation on mesothelioma cancer cells treated with Compound IA For both assays, cells were plated in 6-well plates (1.2×10⁵ cells/well) and treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA at their IC50 for 24 hours. Once the incubation period finalized, cells were washed with PBS, treated with RNAse (167 μg/mL) and stained propidium iodide (33 μg/mL for 15 min at room temperature -RT-). Samples were analyzed by FACSCalibur flow cytometer (Becton Dickinson, Franklin Lanes, NJ, USA) and calculated using CellQuest (Becton Dickinson). For the quantitation of apoptosis, floating and adherent cells were washed with PBS and stained with the Annexin V-FITC Apoptosis Detection Kit (Sigma). Percentage of necro-apoptotic (Annexin V FITC⁺/PI⁺) cells was measured by FACSCalibur flow cytometer and calculated using CellQuest program. The following Table 7 summarizes the results on the possible cell cycle perturbations after 24 h exposure to to cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA at their corresponding IC50 in a panel of 12 patient-derived MPM cells. Values represent the percentage (%) of cells in each phase of the cell cycle. It is shown the mean±SD of 3 independent experiments. a=p<0.05, c=p<0.001: vs untreated cells; APN=Anonymized patient number. Table 7. Cell cycle Untreated Pt+ Compound phase PMX L IA Sub-G1 4±2 6±3 22±4 c 22±4 c G0/G1 65±11 69±12 _53±12 51±12 S-phase 4±2 6±3 _{14±4 c} 23±5 c G2/M 21±5 16±4 _{9±4 a} 5±3 a Lurbinectedin or Compound IA induced a clear increase in the S-phase population in MPM cells that was statistically higher (p<0.001) to that recorded in untreated or Pt+PMX-treated cells. In agreement, a decrease in the G2/M population was also observed, as well as an increase in the subG1 population. Taken together, these results are likely due to DNA damage and mitotic arrest leading to an increase in the percentage of necro-apoptotic cells (Table 8) that was recorded in lurbinectedin, and Compound IA, all highly statistically (p<0.001) greater than that induced by Pt+PMX or found in untreated cultures. Table 8. Percentage of necro-apoptotic cells (% Annex V+PI+cells) produced under treatment with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA versus untreated cells. Untreated Pt+PMX L Compound IA % necro-apoptotic cells 5±2 6±3 46±6 53±7 Example 4: Effects on DNA, STING pathway, NF-κB, and pro-inflammatory cytokines with Compound IA The transcriptome profile (Table 9) in MPM cells exposed to the different tested compounds was analyzed. The heat map showed that lurbinectedin and Compound IA induced down-regulation of DNA damage sensors (e.g., ABL1, BRACA1 and TP53) and up-regulation of repair machinery protein expressions (e.g., ATR, ATM, CHEK1, CHEK2, PRKDC and RAD51), all resulting unaltered after Pt+PMX treatment. Table 9. The expression pattern of DNA damage genes up-regulated (with values of level of expression from about 5 to about 25) and down-regulated (with values of level of expression from about 2.5 to about 0.25) in MPM cell lines after a 24 h treatment with cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), Compound IA (Comp. IA) at their IC50 for 24 h, was shown as mRNA abundance versus a pool of housekeeping gens (n=3 independent experiments, in triplicates).

Compound IA induced a statistically significant (p<0.001) increase in DNA in the tailed COMET assay (Table 10) compared to untreated and Pt+PMX-treated cells (Fig.2) regardless of BAP1 status. Taken together, these results strongly suggest that Compound IA induces DNA damage and genome instability. Table 10. Comet assay results for cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA versus untreated cells. Untreated Pt+PMX L Compound IA %DNA damage in COMET tail 2±1 21±11 59±11 78±12 In contrast to Pt+PMX, incubation of MPM cells with lurbinectedin and Compound IA induced activation of the cGAS/STING pathway resulting in an increase of STING as well as activated and phosphorylated TBK1/IRF3 and IKKβ proteins (Fig. 3A), resulting in statistically significant (p<0.001) increases in NF-κB transcription (Fig. 3B, Table 11) as well as the levels of proinflammatory cytokines, namely INF-β, TNF-α, CXCL5, CXCL10, IL-6 and Il-12 (Fig.3C to 3H). Table 11. Activation of cGAS/STING pathway by incubation of MPM cells with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA versus untreated cells. Untreated Pt+PMX L Compound IA NF-κB (U/mg prot) 0.3±0.1 1.2±0.4 5.2±0.8 6.5±1.4 INF-β (pg/ml) 89±23 154±36 489±54 547±57 TNF-α (pg/ml) 502±65 985±265 1721±239 1398±345 CXCL5 (pg/ml) 38±12 78±14 182±24 282±33 CXCL10 (pg/ml) 87±14 234±45 453±44 504±72 IL-6 (pg/ml) 45±14 178±29 278±39 309±41 Il-12 (pg/ml) 56±13 178±28 231±29 309±31 Example 5: Compound IA induces immunogenic cell death and immune killing by CD8+T- lymphocytes, and reshape the immune-environment of MPM cells To investigate whether Compound IA was able to increase MPM recognition by immune cells, three classical parameters (Table 12, Fig. 4A-4C) of immunogenic cell death (ICD) were measured namely, pre-apoptotic translocation of calreticulin (CRT) on cell surface, extracellular release of adenosine triphosphate (ATP) and, high mobility group 1 box protein (HMGB1) in MPM- PBMC co-cultures. Table 12. Values of calreticulin, extracellular release of adenosine triphosphate and, high mobility group 1 box protein in MPM-PBMC co-cultures treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA versus untreated cells. Untreated Pt+PMX L Compound IA Calreticulin (%positive cells) 3±2 7±4 29±6 37±7 ATP (pmol/ml) 0.7±0.09 1.2±0.4 3.4±0.7 3.1±0.6 HMGB1 (pg/ml) 102±19 298±78 1871±182 2451±201 Pt + PMX combination only elicited a small increase in HMGB1, while lurbinectedin (L) and Compound IA increased all three parameters. Consistent with these results, lurbinectedin-treated cells were more phagocytized by DCs (Table 13; Fig.4D). Table 13. Values of phagocytosis in in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA versus untreated cells. Untreated Pt+PMX L Compound IA Phagocytosis 1±0.7 2±1 5±1.3 6±2.5 Moreover, the CD8⁺T-lymphocytes co-incubated with DCs that have phagocytized MPM cells (previously treated with either lurbinectedin and Compound IA) were more endorsed with cytotoxic properties, as indicated by the highest percentage of CD8+CD107a+INFγ+T-cells (Table 14; Fig.4E). Table 14. Values of CD8 activation in in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA versus untreated cells. Untreated Pt+PMX L Compound IA CD8 activation (%CD8-Cd107a+IFNƔ+ 3.4±1.1 7.3±2.2 21.4±3.6 26.4±4.1 cells) In these settings, MPM cells were more significantly killed with activated CD8+T-lymphocytes than with Pt+PMX (Table 15, Fig.4F). Table 15. Values of tumor immune killig in MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L) and Compound IA versus untreated cells. Untreated Pt+PMX L Compound IA Tumor immune killing (%Annexin V+PI+ 3.2±1.2 7.4±2.1 21.4±3.9 37.8±5.8 MPM cells) In parallel, we investigated whether MPM cells treatment with lurbinectedin and Compound IA changes the immune-suppressive phenotype that is typically induced by these cells. For this aim, PBMC from healthy volunteers were co-incubated 5 days with MPM cells, previously grown 24 h in drug-free medium (untreated), cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), and Compound IA at their IC50. Then, PBMC were collected and immunophentyped by flow cytometry. The immune-phenotype analysis of PBMC suggested that Pt + PMX did not generate any change, while lurbinectedin and Compound IA increased NK cells and decreased Treg cells and myeloid- derived suppressor cells (Mo MDSC)(Table 16).

Ta ble 16. Immunophenotype of PBMC after 5 day-incubation with MPM cells. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). a p<0.05: vs untreated cells; d p<0.05: vs Pt+PMX. Untreated Pt+PMX L Compound IA T^{-helper lymphocytes (CD3+CD4+) 42.3±8.1 40.2±6.7 34.6±5.4 33.4±4.9} T-cytotoxic lymphocytes (CD3+CD8+) 10.3±2.3 11.3±3.4 15.6±4.1 18.7±7.1 NK (CD56+CD335+) 2.6±0.8 2.1±1.1 3.5±1.3 5.1±0.8 a ,d Treg (CD4+CD25+CD127low) 5.4±1.2 4.5±1.5 5.2±1.4 3.1±0.6 a M^{onocytes (CD14+) 27.5±2.9 25.3±5.8 18.7±5.6 18.9±8.4} Macrophages (CD14+CD68+) 32.3±6.7 30.5±4.5 27.4±5.7 24.5±4.9 Gr-MDSC (CD11b+CD14+CD15+HLA-DR- cells) 4.2±1.4 2.3±1.5 2.1±0.8 2.5±1.5 Mo-MDSC (CD11b+CD14+CD15lowHLA- 13.4±4.5 10.4±4.5 6.4±2.6 DR-cells) 7.5±2.5 a Notably, MPM cells treated with lurbinectedin (L), and Compound IA displayed a reduced expression of ICP ligands PD-L1 and LAG-3. Additionally, ICPs expression on CD8⁺ and CD4⁺T- lymphocytes plays a key role in MPM-induced immune suppression. Hence, CD4⁺T-helper cells, CD8⁺T-cytotoxic cells and NK cells were collected after a 5 day- co-culture with MPM cells previously treated with Pt + PMX, lurbinectedin or Compound IA measuring then the levels of ICPs (PD-1, TIM-3, LAG-3, CTLA-4, HVEM, TIGIT) and immuno- senescence markers (CD160, CD57). Particularly, MPM cells were grown 24 h in drug-free medium (untreated), cisplatin+permetrexed (Pt+PMX), lurbinectedin (L), and Compound IA at their IC50. Then, an aliquot was used to quantify the expression of ICP ligands by flow cytometry. A second aliquot was washed and incubated 5 days with the PBMC of healthy donors. After this, ICP and immune-senescence markers were evaluated by flow cytometry on isolated CD4+T-helper lymphocytes, CD8+T-cytotoxic lymphocytes and NK cells. In CD4⁺T-lymphocytes, Compound IA produced a small reduction of LAG-3 and CD57 (p<0.05). Furthermore, in CD8⁺T-cells, lurbinectedin and Compound IA reduced PD-1, LAG-3 and CD57, while in NK cells they decreased PD-1 and CD57 (for all parameters: p<0.05). Conversely, standard treatment of Pt + PMX did not produce any significant change (Table 17). Table 17. ICP/ICP ligands and immune-senescence expression on T-lymphocytes and MPM cells treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), and Compound IA. Data are expressed as means±SD of 12 MPM samples (n=3 independent experiments, in duplicates). a p<0.05: vs untreated cells; d p<0.05: vs Pt+PMX. Untreated Pt+PMX L Compound IA PD-L1 14.5±3.5 10.9±3.4 7.8±3.1 a 7.6±1.3 a PD-L2 8.9±3.2 7.5±1.7 8.4±1.5 8.1±1.8 TIM-3 7.8±2.1 6.9±1.4 7.3±0.8 5.1±1.9 LAG-3 10.3±2.4 9.1±1.8 6.3±1.4 a 5.8±1.8 a PD-1 2.4±1.5 3.4±0.9 2.7±1.7 2.4±0.7 TIM-3 5.4±2.0 4.9±3.4 3.4±1.1 3.4±1.3 LAG-3 9.8±3.1 7.9±3.2 5.6±2.3 4.4±0.7 a CTLA-4 6.7±3.5 6.1±3.1 7.2±4.3 6.1±1.9 HVEM 3.4±2.5 2.9±1.2 2.8±1.2 2.1±1.1 TIGIT 3.9±1.2 2.5±1.1 4.1±0.8 3.2±1.1 CD160 4.8±2.4 4.5±2.1 2.4±1.6 2.9±1.7 CD57 12.7±3.6 10.8±3.1 7.2±2.1 4.3±1.2 a,d PD-1 43.7±10.9 34.5±9.1 27.8±8.3 a 28.9±7.3 a TIM-3 5.4±1.6 4.6±1.3 5.1±1.5 4.8±1.1 LAG-3 9.8±1.8 7.8±1.9 5.6±1.4 a 4.9±0.8 a CTLA-4 4.3±1.3 4.3±2.1 5.4±1.4 4.6±1.2 HVEM 2.1±1.8 2.8±1.4 2.4±1.2 2.6±0.8 TIGIT 6.7±1.9 6.6±1.1 5.8±1.6 5.9±0.8 CD160 7.6±2.1 6.5±2.1 4.9±1.8 5.6±1.3 C^D57 39.9±7.8 32.9±5.9 21.4±3.8 a,d 21.3±6.3 a,d PD-1 26.3±4.9 29.8±5.6 13.8±2.5 a,d 13.4±3.2 a,d TIM-3 6.7±2.1 6.5±1.4 5.9±1.8 7.5±3.4 LAG-3 4.9±1.1 4.7±1.1 5.9±1.4 5.4±1.3 CTLA-4 4.5±1.2 5.6±1.2 5.8±1.5 5.2±1.9 HVEM 4.3±0.9 4.5±2.3 4.9±1.8 4.3±1.3 TIGIT 5.6±1.2 4.3±1.1 5.6±1.4 6.3±1.1 CD160 9.8±1.3 8.5±1.8 7.6±2.1 8.9±1.9 CD57 25.7±2.4 19.8±4.5 17.8±3.4 a 11.4±2.9 a Data suggest that the treatment with lurbinectedin or Compound IA qualitatively and quantitatively changed the immune cells to a more anti-tumor than tumor tolerant/immunosuppressive phenotype. Example 6: Compound IA increased the efficacy of atezolizumab in immune-PDX models of malignant pleural mesothelioma (MPM) The decrease of PD-L1 on MPM cells and PD-1 in co-cultured T-lymphocytes constituted the rationale for testing the combination of lurbinectedin, and Compound IA with an ICI targeting the PD- 1/PD-L1 axis. A platform of Hu-NSG mice, bearing an active human immune system, and two MPMs representative of the best case of an epitheliod histotype, BAP1 positive, and a worst case of a sarcomatoid histotype, BAP1 negative was set up. MPM PDX#1 (epithelioid, BAP1 positive) and MPM PDX#7 (sarcomatoid, BAP1 negative) were subcutaneously (s.c.) injected (1x10⁷ cells) in the right flank of 6-week-old female NOD SCID-γ (NSG) mice engrafted with human hematopoietic CD34⁺ cells (herein referred as humanized Hu- CD34⁺ NSG mice; The Jackson Laboratories, Bar Harbor, MA, USA) or in NSG mice. Animals were housed (5/cage) under 12 hours light/dark cycle, with food and water ad libitum. Calliper measurements of the tumor diameters were made daily, and tumor volumes calculated according to (LxW²)/2, where L and W were the length and width tumor, respectively. Animal weights were monitored throughout the study. When tumors reached a volume of ca. 50 mm³, animals (n=4/group) were randomly allocated in the experimental groups: vehicle (0.1 mL saline solution); cisplatin (5 mg/kg)+pemetrexed (100 mg/kg) (Pt+PMX); lurbinectedin (L, 0.18 mg/kg); atezolizumab (A, 10 mg/kg); Compound IA (0.9 mg/kg); lurbinectedin (0.18 mg/kg)+atezolizumab (10 mg/kg) (L+A); Compound IA (0.9 mg/kg)+atezolizumab (10 mg/kg) (Compound IA+A). All compounds were intravenously (i.v.) administered, except for vehicle and atezolizumab (intraperitoneal). Regardless of compound administration (single agent or combination), the schedule was one dose per week for three consecutive weeks except for atezolizumab, which was administered twice a week for three consecutive weeks. Animals were euthanized with zolazepam: xylazine (0.2 mL/kg: 16 mg/kg) on day 49 after randomization. Tumors were removed, digested with 1 mg/mL collagenase (Sigma) and 0.2 mg/mL hyaluronidase (Sigma) for 1 hour at 37°C and filtered (70-μm cell strainer) to obtain a single cell suspension. Infiltrating immune cells were collected by centrifugation on Ficoll-Hypaque density gradient and immunostained as detailed above. Cells were quantified with Guava^® easyCyte flow cytometer and InCyte software. Table 18. Median tumor volume evaluation in MPM xenografts (PDX#1) in NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), Compound IA and combination of Compound IA and atezolizumab (Compound IA+A). Median tumor volume (mm³) DAYS Compound Compound Vehicle Pt+PMX L A L+A IA IA+A 0 49.0 54.0 49.5 51.0 46.5 49.5 49.5 4 169.0 172.5 156.0 194.0 136.5 106.0 94.5 7 320.5 316.5 207.0 281.0 235.0 169.5 145.5 10 572.0 471.5 425.5 513.5 397.0 232.0 232.0 14 636.5 636.5 475.0 647.5 473.5 333.0 310.0 17 769.5 722.0 507.5 819.5 513.5 427.5 420.0 21 918.5 806.0 542.5 1024.0 568.5 520.0 525.5 Table 19. Median tumor volume evaluation in MPM xenografts (PDX#7) in NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), Compound IA and combination of Compound IA and atezolizumab (Compound IA+A). Median tumor volume (mm³) DAYS Compound Compound Vehicle Pt+PMX L A L+A IA IA+A 0 55.5 50.0 48.5 51.5 49.5 47.0 52.5 4 168.0 180.5 178.0 207.0 123.5 93.5 91.0 7 336.5 273.0 240.5 342.0 239.0 144.0 141.0 10 530.5 427.0 440.0 488.0 441.0 225.5 199.5 14 697.5 597.5 509.0 657.0 493.0 305.0 304.0 17 959.5 695.0 583.0 919.5 562.0 407.5 367.0 21 1034.0 810.0 633.0 1110.5 659.5 548.0 549.5 The combination of Pt + PMX was poorly effective in reducing tumor growth (Tables 18 and 19). On Day 21 (one week after the last administration), the treatment of patient derived xenografts PDX#1 or PDX#7 bearing NSG mice with either lurbinectedin, or Compound IA resulted in a statistically significant reduction (p<0.05) of the median tumor volume as compared to in vehicle- treated animals. As expected, atezoluzimab treatment resulted in no antitumoral activity in this mouse strain. In humanized Hu-CD34⁺ NSG mice xenografted with either PDX#1 or PDX#7 (Tables 20 and 21), lurbinectedin, and Compound IA as single agents also induced a strong antitumor effect, which was very similar to that observed in NSG xenografted mice (described above). In these humanized mice, atezoluzimab treatment induced a strong and statistically significant reduction in tumor volume in comparison to vehicle-treated mice. Table 20. Median tumor volume evaluation in MPM xenografts (PDX#1) in Hu-CD34⁺NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), Compound IA and combination of Compound IA and atezolizumab (Compound IA+A). Median tumor volume (mm³) DAYS Compound Compound Vehicle Pt+PMX L A L+A IA IA+A 0 50.0 46.5 49.5 49.5 49.0 50.0 50.5 4 139.5 164.5 133.0 139.5 88.0 100.0 80.0 7 218.0 198.0 161.5 190.0 107.0 138.5 97.5 10 491.0 495.5 267.0 293.5 196.5 240.5 116.5 14 588.0 651.5 371.5 377.0 245.5 300.0 146.5 17 755.0 817.0 407.0 464.0 269.0 310.5 217.5 21 959.0 949.5 493.5 511.5 299.5 400.5 281.0 Table 21. Median tumor volume evaluation in MPM xenografts (PDX#7) in Hu-CD34⁺NSG mice treated with cisplatin+pemetrexed (Pt+PMX), lurbinectedin (L), atezolizumab (A), combination of lurbinectedin and atezolizumab (L+A), Compound IA and combination of Compound IA and atezolizumab (Compound IA+A). Median tumor volume (mm³) DAYS Compound Compound Vehicle Pt+PMX L A L+A IA IA+A 0 47.0 49.5 50.0 51.0 53.0 49.5 51.5 4 149.5 153.0 147.5 138.0 103.0 117.0 100.5 7 228.0 186.0 182.0 216.0 105.5 145.0 123.0 10 503.5 502.0 267.0 234.0 145.0 192.5 156.0 14 671.5 626.5 255.0 339.0 205.5 228.5 205.0 17 803.5 777.0 367.0 405.5 277.0 288.0 213.5 21 959.0 957.5 502.0 452.5 285.5 345.0 232.0 Additionally, atezoluzimab combined with either lurbinectedin, or Compound IA, significantly improved the antitumor effect obtained with atezoluzimab as a single agent. These results were even stronger in PDX#7, the most clinically aggressive tumor. A significant increase in the anti-tumor CD8+T-lymphocytes and NK cells, as well as a reduction in the immune-suppressive populations Mo-MDSC and TAM2 was detected when the quantitative immune-infiltrating of both PDXs were exposed to atezolizumab plus lurbinectedin, or atezolizumab and Compound IA, CD8⁺T-lymphocytes and NK cells were analyzed. However, none of the treatments induced changes in CD4⁺T-lymphocytes, Treg cells, TAM1 or Gr-MDSC (Table 22).

Table 22. Quantification of the immune-infiltrating cells in excised MPM#1 implanted in Hu-NSG mice. Data are expressed as means±SD (n=4 mice/group). a=p<0.05, b=p<0.01, c=p<0.001: vs untreated cells; d=p<0.05, e=p<0.01,f=p<0.001: vs Pt+PMX. Comp. Comp. Vehicle Pt+PMX L A L+A IA IA+A T-helper lymphocytes 43.0±12.3 51.0±18.3 62.0±13.1 48.2±5.8 41.2±7.0 40.3±7.9 49.8±14.7 (CD3+CD4+) T-cytotoxic 33.0±4 36.8±6.2 34.0±2.9 41.5±3.4 lymphocytes 19.0±7.9 20.5±6.9 22.0±2.9 b b,d b,e c,f (CD3+CD8+) NK (CD56+CD335+ 2.8±1.7 3.5±1.3 4.5±1.3 2.7±0.9 5.0±0.8 a 4.5±1.7 6.0±1.4 a ) Treg (CD4+CD25+C 4.0±8.0 4.5±1.3 5.0±1.8 4.7±0.9 4.8±1.5 4.3±1 3.5±1.3 D127low) TAM1 (CD68+CD86+i 31.8±10.0 45.5±2.6 40.3±6.8 29.7±6.8 26.3±4.3 26.3±7.3 27.5±5.1 NOS+) TAM2 25.0±6.4 15.0±1.8 (CD68+CD206+ 40.5±5.4 30.5±4.5 34.3±7.7 42.2±7.1 30.3±6.4 b c,f Arg1+) Gr-MDSC (CD11b+CD14+ 9.8±2.2 12.3±3.1 9.5±2.6 10.2±3.5 8.3±2.5 7.5±2.1 8.0±3.7 CD15+HLA-DR- cells) Mo-MDSC (CD11b+CD14+ 4.8±1.5 15.0±5.1 15.8±2.2 9.0±1.8 15.0±2.1 9.3±1.7 5.5±2.4 c,f CD15lowHLA- c,f DR-cells) In PDX#7, the most clinically aggressive tumor, the combination of atezolizumab+lurbinectedin or atezolizumab+Compound IA produced even stronger effects: it increased lymphoid (CD8⁺T- lymphocytes and NK cells) and myeloid (TAM1) anti-tumor cells; decreased the immune-tolerant populations (TAM2, Gr-MDSC, Mo-MDSC) (Table 23), recapitulating the immune-phenotype observed in MPM-PBMC co-cultures. Table 23. Quantification of the immune-infiltrating cells in excised MPM#7 implanted in Hu-NSG mice. Data are expressed as means±SD (n=4 mice/group). a=p<0.05, b=p<0.01, c=p<0.001: vs untreated cells; d=p<0.05, e=p<0.01,f=p<0.001: vs Pt+PMX. L+A Comp. IA Comp. Vehicle Pt+PMX L A IA+A T-helper lymphocytes 47.3±12.9 47.5±4.7 56.8±7.1 53±11.5 50.5±8.4 44.3±12.5 44.8±16.5 (CD3+CD4+) T-cytotoxic lymphocytes 18.05±4.8 24.0±2.4 37.0±3.9 38.5±5.3 33.8±3.1 37.3±8.5 c,f 26.2±5.3 (CD3+CD8+) c,f c,e c,e NK (CD56+CD335+ _{2.5±1.3 2.8±1.0} ^5.0 6.0±1.4 8.0±2.2 a^±1.4 _3.0±1.8 ^6.5 b^± ,d^1.3 b,e c,f ) Treg (CD4+CD25+C 4.5±1.3 3.3±1.0 4.5±1.3 3.7±1.7 4.3±1.0 3.8±2.4 4.3±2.8 D127low) TAM1 (CD68+CD86+i _{21.5±5.1 25.0±7.3} ^36.8 33.2±5.7 39.5±4.0 39.3±5.5 42.8±5.1 a^±4.0 a b,d c,f c,f NOS+) TAM2 (CD68+CD206+ _{40.3±6.2 37.0±4.7} ^29. b³ 29.5±5.9 ,^± d^3.9 _31.5±9.4 ^18.8 c,^± f^5.0 b,d 1.8±5.1 c,f Arg1+) Gr-MDSC (CD11b+CD14+ CD15+HLA-DR- _{9.0±3.2 8.3±3.3 6.5±1.9 9.7±3.7} ^4.8 a^± ,d^1.7 _6.8±1.7 ^4.8 a,^± d^1.7 cells) Mo-MDSC (CD11b+CD14+ CD15lowHLA- ^{18.5±5.2 20.0±7.1 14.8±2.6 20.7±4.8 12.5±3.9 13.5±2.4} _{7.0±1.8 b,e} DR-cells) Although Compound IA produced similar effects when used as single agents, the widest changes in immune-infiltrating cells were produced by its combination with atezolizumab. Conclusion Compound IA induced cytotoxicity in MPM cells independently from histological origin or BAP1 status. With an IC50 in the low nanomolar range, it is more potent than 1L (first line) treatment Pt + PMX. Moreover, Compound IA strongly reduced MPM cell migration and invasion. MPM is a highly invasive tumor and no pharmacological agents block MPM cell invasion: Compound IA may represent the first prototypical drug in this perspective, once tested in proper orthotopic MPM animal models. Another relevant aspect of this drug is its ability to induce long-term control of cell proliferation. Most MPM patients become resistant to the 1L treatment and no 2L (second line) treatments have been successful at clinical level so far. Long-term proliferation assays based on a 4-week period of drug exposure followed by a 2-week interruption and a second 4-week exposure to the previous drugs, showed a great variability in the efficacy of Pt + PMX among patient-derived cell lines. Remarkably, Compound IA particularly showed no re- growth during the treatment break period and the second exposure. This trend indicates that the cells did not acquire resistance towards Compound IA, and/or that persister cells are irreversibly damaged and unable to proliferate. The main mechanism of cytotoxicity induced by Compound IA is the DNA damage, an event that has two distinct but interconnected effects: the direct killing of MPM cell and the increased priming of MPM cell for immune-killing. Besides arresting cell proliferation, Compound IA produced a huge amount of double-strand fragmented DNA, not prevented by the increase in specific genes of DNA repair system. In analyzed patient-derived cell lines, the scarcely effective combination Pt + PMX produced only minor variations in these genes, while Compound IA increased them, notwithstanding a certain inter-patient variability. Furthermore, because of Compound IA induction of cGAS/STING pathway, it promotes beneficial effects on MPM immune-environment. Thanks to its ability of producing irreversible double- stranded DNA fragments that activates the cGAS/STING pathway, Compound IA emerged as a powerful inducer of immunogenic cell death (ICD) in MPM. The ICD induced by Compound IA was paralleled by a moderate increase in CD8+T-cells and NK cells in MPM-PBMC co-cultures, particularly with Compound IA, which was the strongest antitumor agent in our setting. This quantitative change in immune-population is indeed typical of cGAS/STING pathway agonists. The combinations with atezolizumab showed a significant effect over atezolizumab alone in humanized (i.e. immunocompetent) mice. This fact indicated that the anti-tumor effects are in part due to the engagement of the host immune system against the tumor. Consistently, the analysis of the immune-infiltrate recapitulated the immune-phenotype of MPM-PBMC co-cultures, confirming that Compound IA increased CD8+T-cells and NK cells, and decreased Mo-MDSCs. Additionally, they reduced M2-polarized macrophages, further eliminating a typical pro-tumoral population detected in MPM microenvironment and necessary to initiate MPM tumorigenesis, favoring its progression. In summary, the preclinical data shows that Compound IA is useful in the treatment of malignant pleural mesothelioma (MPM). The data also shows that the combination of Compound IA and atezolizumab is effective. The data shows that Compound IA alone and Compound IA in combination with atezolizumab effectively treats cancer, with data demonstrating effectiveness in malignant mesothelioma (MPM). References - Janes et al., Perspectives on the Treatment of Malignant Pleural Mesothelioma, N. Engl. J. Med.2021, 385, 1207-1218 - Cinausero et al., Chemotherapy treatment in malignant pleural mesothelioma: a difficult history, J. Thor. Dis, 2018, 304-310 - Zalcman et al., Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial, Lancet, 2016, 387, 1405-1414 - Hiltbrunner et al., Tumor Immune Microenvironment and Genetic Alterations in Mesothelioma, 2021, Front Oncol., 2021, doi: 10.3389/fonc.2021.660039. - Ceresoli et al, Immune checkpoint inhibitors in mesothelioma: a turning point, 2021, 397, 348-349 - Leal et al., what's Current and What's New in Mesothelioma?, Clin. Onc., 2022 Nov;34(11):771-780. - Cantini et al., Emerging treatments for malignant pleural mesothelioma: where are we heading? Oncol., 2020, 10 - Hiltbrunner et al., Genomic landscape of pleural and peritoneal mesothelioma tumours, 2022, 127, 1997-2005 - Santamaria Nunez G, et al.. Lurbinectedin Specifically Triggers the Degradation of Phosphorylated RNA Polymerase II and the Formation of DNA Breaks in Cancer Cells. Mol Cancer Ther (2016) 15(10):2399–412. - WO2021043949 - WO2018/197663 - WO2022/2434482 - Galluzzi et al., Consensus guidelines for the definition, detection and interpretation of immunogenic cell death, J Immunother Cancer. 2020 Mar;8(1):e000337. doi: 10.1136/jitc-2019-000337. - Riganti et al, Bromodomain inhibition exerts its therapeutic potential in malignant pleural mesothelioma by promoting immunogenic cell death and changing the tumor immune- environment. Oncoimmunology. 2017 Nov 27;7(3):e1398874. doi: 10.1080/2162402X.2017. - Salaroglio et al, Potential Diagnostic and Prognostic Role of Microenvironment in Malignant Pleural Mesothelioma, J Thorac Oncol .2019 Aug;14(8):1458-1471. - Terenziani et al., Immunotherapeutic approaches in malignant pleural mesothelioma, Cancers, 2021, 13. - NCT05841563 - AEMPS 2023-508644-22-00 - Press release PharmaMar 28/02/2024 - Press release PharmaMar 26/10/2023 - Press release PharmaMar 26/04/2023 - Financial report PharmaMar 28/02/2022 - Financial report PharmaMar 28/10/2021 - Napoli F. et al., Pathological Characterization of Tumor Immune Microenvironment (TIME) in Malignant Pleural Mesothelioma. Cancers (Basel).2021,13(11):2564. - Wu L. et al., Defining and targeting tumor-associated macrophages in malignant mesothelioma. Proc Natl Acad Sci U S A.2023 Feb 28;120(9):e2210836120. - Ferrara, Circulating T-cell Immunosenescence in Patients with Advanced Non-small Cell Lung Cancer Treated with Single-agent PD-1/PD-L1 Inhibitors or Platinum-based Chemotherapy., Clin Cancer Res 2021, 27(2):492-503. - Gu at el, Enhancing anti-tumor immunity through liposomal oxaliplatin and localized immunotherapy via STING activation. J Control Release.2023;357:531-54 - Taieb, Deficient mismatch repair/microsatellite unstable colorectal cancer: Diagnosis, prognosis and treatment. Eur J Cancer.2022, 175:136-157 - Liu, On-demand integrated nano-engager converting cold tumors to hot via increased DNA damage and dual immune checkpoint inhibition. Acta Pharm Sin B. 2023, 13(4):1740-1754 - Gemelli M, Immune Checkpoint Inhibitors in Malignant Pleural Mesothelioma: A Systematic Review and Meta-Analysis. Cancers (Basel).2022;14(24):6063. - Kepp O, Lurbinectedin: an FDA-approved inducer of immunogenic cell death for the treatment of small-cell lung cancer. Oncoimmunology.2020;9(1):1795995. - Chee SJ, Evaluating the effect of immune cells on the outcome of patients with mesothelioma. Br J Cancer.2017;117(9):1341-1348. - Miselis NR, Kinetics of host cell recruitment during dissemination of diffuse malignant peritoneal mesothelioma. Cancer Microenviron.2010;4(1):39-50. - Guo X, Immunotherapy vs. Chemotherapy in Subsequent Treatment of Malignant Pleural Mesothelioma: Which Is Better? J Clin Med.2023;12(7):2531. - Tagliamento M, Meta-Analysis on the Combination of Chemotherapy With Programmed Death-Ligand 1 and Programmed Cell Death Protein 1 Blockade as First-Line Treatment for Unresectable Pleural Mesothelioma. J Thorac Oncol.2024;19(1):166-172. - Knelson Eh. Et al., Activation of Tumor-Cell STING Primes NK-Cell Therapy. Cancer Immunol Res.2022 Aug 3;10(8):947-961. - Aoki M. et al., IRF3 Knockout Results in Partial or Complete Rejection of Murine Mesothelioma. J Clin Med.2021 Nov 7;10(21):5196. - Cantini L, Emerging Treatments for Malignant Pleural Mesothelioma: Where Are We Heading? Front Oncol.2020;10:343. - Hiltbrunner S, Genomic landscape of pleural and peritoneal mesothelioma tumours. Br J Cancer.2022;127(11):1997-2005. - Leal JF, PM01183, a new DNA minor groove covalent binder with potent in vitro and in vivo anti-tumour activity. Br J Pharmacol.2010;161(5):1099-110. - Harlow ML, Lurbinectedin Inactivates the Ewing Sarcoma Oncoprotein EWS-FLI1 by Redistributing It within the Nucleus. Cancer Res.2016;76(22):6657-6668. - Belgiovine C, Lurbinectedin reduces tumour-associated macrophages and the inflammatory tumour microenvironment in preclinical models. Br J Cancer. 2017;117(5):628-638. - Farago A, ATLANTIS: a Phase III study of lurbinectedin/doxorubicin versus topotecan or cyclophosphamide/doxorubicin/vincristine in patients with small-cell lung cancer who have failed one prior platinum-containing line. Future Oncol.2019;15(3):231-239. - Cote GM, A phase II multi-strata study of lurbinectedin as a single agent or in combination with conventional chemotherapy in metastatic and/or unresectable sarcomas. Eur J Cancer.2020;126:21-32. - Gaillard S, Lurbinectedin versus pegylated liposomal doxorubicin or topotecan in patients with platinum-resistant ovarian cancer: A multicenter, randomized, controlled, open-label phase 3 study (CORAIL). Gynecol Oncol.2021;163(2):237-245. - Kristeleit R, Doxorubicin plus lurbinectedin in patients with advanced endometrial cancer: results from an expanded phase I study. Int J Gynecol Cancer.2021;31(11):1428-1436. - Poveda A, A phase I dose-finding, pharmacokinetics and genotyping study of olaparib and lurbinectedin in patients with advanced solid tumors. Sci Rep.2021;11(1):4433. - Mark M, Long-term benefit of lurbinectedin as palliative chemotherapy in progressive malignant pleural mesothelioma (MPM): final efficacy and translational data of the SAKK 17/16 study. ESMO Open.2022;7(3):100446. - Mark M, Long-term benefit of lurbinectedin as palliative chemotherapy in progressive malignant pleural mesothelioma (MPM): final efficacy and translational data of the SAKK 17/16 study. ESMO Open.2022;7(3):100446. - Trigo J, Lurbinectedin as second-line treatment for patients with small-cell lung cancer: a single-arm, open-label, phase 2 basket trial. Lancet Oncol. 2020;21(5):645-654. Epub 2020 Mar 27. Erratum in: Lancet Oncol.2020;21(12):e553. - Milosevic V, Wnt/IL-1β/IL-8 autocrine circuitries control chemoresistance in mesothelioma initiating cells by inducing ABCB5. Int J Cancer.2020;146(1):192-207. - Riganti C, The role of C/EBP-β LIP in multidrug resistance. J Natl Cancer Inst. 2015;107(5):djv046. - Freyria FS, Hematite nanoparticles larger than 90 nm show no sign of toxicity in terms of lactate dehydrogenase release, nitric oxide generation, apoptosis, and comet assay in murine alveolar macrophages and human lung epithelial cells. Chem Res Toxicol. 2012;25(4):850-61. - Kopecka J, Loss of C/EBP-β LIP drives cisplatin resistance in malignant pleural mesothelioma. Lung Cancer.2018;120:34-45. - Obeid M, Calreticulin exposure dictates the immunogenicity of cancer cell death. Nat Med.2007;13(1):54-61. - Salaroglio IC, Mitochondrial ROS drive resistance to chemotherapy and immune-killing in hypoxic non-small cell lung cancer. J Exp Clin Cancer Res.2022;41(1):243. - Vogelzang NJ, Phase III Study of Pemetrexed in Combination With Cisplatin Versus Cisplatin Alone in Patients With Malignant Pleural Mesothelioma. J Clin Oncol. 2023;41(12):2125-2133. - Nowak AK, Durvalumab with first-line chemotherapy in previously untreated malignant pleural mesothelioma (DREAM): a multicentre, single-arm, phase 2 trial with a safety run- in. Lancet Oncol.2020;21(9):1213-1223. - Anobile DP, Evaluation of the Preclinical Efficacy of Lurbinectedin in Malignant Pleural Mesothelioma. Cancers (Basel).2021;13(10):2332. - Kwon J, BAP1 as a guardian of genome stability: implications in human cancer. Exp Mol Med.2023;55(4):745-754. - Bellini A, Relapse Patterns and Tailored Treatment Strategies for Malignant Pleural Mesothelioma Recurrence after Multimodality Therapy. J Clin Med.2021;10(5):1134. - Shi Y, Starvation-induced activation of ATM/Chk2/p53 signaling sensitizes cancer cells to cisplatin. BMC Cancer.2012 Dec 4;12:571. - Salaroglio, I C, Ecteinascidin synthetic analogues: a new class of selective inhibitors of transcription, exerting immunogenic cell death in refractory malignant pleural mesothelioma. J. Exp. Clin. Cancer Res.2024, 43(1):327. - Eudrat 2021000415-13.

Claims

CLAIMS 1. Compound IA, which is a compound of formula I: for use in the treatment of malignant mesothelioma.

2. Compound IA for use according to claim 1, wherein Compound IA is not administered in combination with a topoisomerase I inhibitor.

3. Compound IA for use according to claim 1 or 2, wherein Compound IA is administered as a monotherapy.

4. Compound IA for use according to any one of claims 1 to 3, wherein the malignant mesothelioma is malignant pleural mesothelioma.

5. Compound IA for use according to any one of claims 1 to 3, wherein the malignant mesothelioma is malignant peritoneal mesothelioma.

6. Compound IA for use according to any one of claims 1 to 5, wherein the malignant mesothelioma is epithelioid mesothelioma.

7. Compound IA for use according to any one of claims 1 to 5, wherein the malignant mesothelioma is sarcomatoid mesothelioma.

8. Compound IA for use according to any one of claims 1 to 5, wherein the malignant mesothelioma is biphasic mesothelioma.

9. Compound IA for use according to any one of claims 1 to 8, wherein the malignant mesothelioma is progressive.

10. Compound IA for use according to any one of claims 1 to 9, wherein Compound IA is in the form of a pharmaceutically acceptable salt or ester.

11. Compound IA, which is a compound of formula I: , for use in the treatment of malignant mesothelioma, wherein in said treatment Compound IA is administered in combination with atezolizumab to a patient in need thereof.

12. Compound IA for use according to claim 11, wherein the malignant mesothelioma is malignant pleural mesothelioma.

13. Compound IA for use according to claim 11, wherein the malignant mesothelioma is malignant peritoneal mesothelioma.

14. Compound IA for use according to any one of claims 11 to 13, wherein the malignant mesothelioma is epithelioid mesothelioma.

15. Compound IA for use according to any one of claims 11 to 13, wherein the malignant mesothelioma is sarcomatoid mesothelioma.

16. Compound IA for use according to any one of claims 11 to 13, wherein the malignant mesothelioma is biphasic mesothelioma.

17. Compound IA for use according to any one of claims 11 to 16, wherein the malignant mesothelioma is progressive.

18. Compound IA for use according to any one of claims 11 to 17, wherein Compound IA is in the form of a pharmaceutically acceptable salt or ester.

19. Compound IA, which is a compound of formula I: for use in the treatment of cancer, wherein in said treatment Compound IA is administered in combination with atezolizumab to a patient in need thereof.

20. Compound IA for use according to claim 19, wherein the cancer is a solid tumor.

21. Compound IA for use according to claim 20, wherein the solid tumor is selected from neuroendocrine tumor, gastrointestinal cancer, lung cancer, sarcoma, gynaecological cancer, breast cancer, malignant mesothelioma, extrapulmonary small cell carcinoma, adrenocortical carcinoma, adenoid cystic carcinoma, skin cancer, genitourinary tract tumors, microsatellite instability (MSI) solid tumors, head and neck squamous cell carcinoma.

22. Compound IA for use according to claim 21, wherein the solid tumor is malignant mesothelioma.

23. Compound IA for use according to claim 22, wherein the malignant mesothelioma is malignant pleural mesothelioma.

24. Compound IA for use according to claim 22, wherein the malignant mesothelioma is malignant peritoneal mesothelioma.

25. Compound IA for use according to any one of claims 22 to 24, wherein the malignant mesothelioma is epithelioid mesothelioma.

26. Compound IA for use according to any one of claims 22 to 24, wherein the malignant mesothelioma is sarcomatoid mesothelioma.

27. Compound IA for use according to any one of claims 22 to 24, wherein the malignant mesothelioma is biphasic mesothelioma.

28. Compound IA for use according to any one of claims 22 to 27, wherein the malignant mesothelioma is progressive.

29. Compound IA for use according to any one of claims 22 to 28, wherein Compound IA is in the form of a pharmaceutically acceptable salt or ester.