MXPA01003074A - Chemotherapy of cancer with acetyldinaline in combination with gemcitabine, capecitabine or cisplatin - Google Patents

Abstract

Acetyldinaline in combination with gemcitabine, a pharmaceutically acceptable salt thereof, capecitabine, or cisplatin is synergistic for treating cancer.

Description

CHEMOTHERAPY FOR TREATING CANCER WITH ACETILDINALINE IN COMBINATION WITH GEMCITABIN A. CAPECITABINE OR CISPLATINE FIELD OF THE INVENTION The invention relates to a method for treating tumors using a combination of known oncolytic agents. The use of these agents together provides unexpectedly greater efficacy than using the agents alone. BACKGROUND OF THE INVENTION Chemotherapy for cancer has advanced dramatically in recent years. Many tumors can effectively be treated using compounds that are either naturally occurring products or synthetic agents. Chemotherapy for cancer very often involves the use of a combination of agents, generally as a means to provide greater therapeutic effects and to reduce the toxic effects that are very often encountered with individual agents when used alone. A unique combination of known oncolytic agents showing a dramatic synergistic effect has now been discovered. The combination uses the agent acetyldinaline, along with either gemcitabine, capecitabine or cisplatin. The combination is especially effective in treating patients with solid tumors, especially non-small cell lung cancer and other advanced solid tumors. Acetyldinaline is 4-acetylamino-N- (2'-aminophenyl) -benzamide. It is also known as CI-994. It is described in U.S. Patent No. 5,137,918, which is incorporated herein by reference for its teachings on how to make acetyldinaline, how to formulate it in dosage form, and how to treat cancers such as colon cancer and adenocarcinomas. It is also described in US Pat. No. 5,795,909 as a possible conjugate for the treatment of cancer. Gemcitabine is the generic name assigned to 2'-deoxy-2'-2'-difluoro-cytidine. It can be obtained commercially as the monohydrochloride salt and as the β-isomer. It is also known chemically as 1- (4-amino-2-ono-1 H-pyrimidin-1-yl) -2-deoxy-2,2-difluororibose. Gemcitabine is described in U.S. Patent Nos. 4,808,614 and 5,464,826, which are incorporated herein by reference for their teachings on how to synthesize, formulate and utilize gemcitabine to treat susceptible neoplasms. The commercial formulation of gemcitabine hydrochloride as indicated as first-line treatment for patients with locally advanced (unresected Stage II or Stage III) or metastatic (Stage IV) adenocarcinoma of the pancreas, and is commonly used in patients previously treated with fluorouracil.

Capecitabine is a fluoropyrimidine carbamate with antineoplastic activity. It is a systemic prodrug that is administered orally of 5'-deoxy-5-fluouridine (5'-DFUR) which is converted to 5-fluorouracil. The chemical name for capecitabine is 5'-deoxy-5-fluoro-N - [(pentyloxy) carbonyl] -cytidine. It is marketed in the United States under the name of Xeloda ™ (Roche Laboratories). It is indicated for the treatment of patients with metastatic breast cancer and colorectal tumors. It is usually given for 14 days, followed by a rest period of 7 days during each 21-day cycle. Capecitabine is described in U.S. Patent No. 5,472,949. Cisplatin is the generic name for cis-diaminodichloroplatinum and is described in US Patent No. 5,562,925, which is incorporated herein by reference. Cisplatin is commercially available and is indicated for testicular and ovarian metastatic tumors, as well as advanced bladder cancer. An object of this invention is to provide a method for treating cancers, especially advanced solid tumors, with a combination comprising acetyldinaline together with either gemcitabine, capecitabine or cisplatin. A further object is to provide a composition comprising synergistic amounts of acetyldinaline and gemcitabine, synergistic amounts of acetyldinaline and capecitabine, and synergistic amounts of acetyldinaline and cisplatin.

PREVIOUS ART This invention relates to a synergistic combination of antineoplastic agents, and to a method of treating tumors comprising administering the combination. The invention more particularly provides a composition comprising, as a first component, acetyldinaline, and as a second component, either gemcitabine, capecitabine or cisplatin. Gemcitabine is preferably used as a pharmaceutically acceptable acid addition salt. The compositions of this invention consist essentially of the above active ingredients, or suitable salts thereof, together with common excipients, diluents and carriers. A preferred composition comprises acetyldinaline, together with gemcitabine hydrochloride. Another preferred combination is acetyldinaline and cisplatin. In a further embodiment of the invention, there is provided a method of treating cancer comprising administering to an animal in need of treatment an effective amount of a combination of acetyldinaline and either cisplatin or gemcitabine, preferably as a salt such as the hydrochloride.

A preferred method includes the treatment of solid tumors. Another preferred method employs an antitumor amount of acetyldinaline and an effective amount of gemcitabine hydrochloride, capecitabine or cisplatin to treat susceptible cancers, including non-small cell lung cancer (NSCLC), breast cancer, ovarian cancer, head cancer and neck, myelomas, prostate cancer and pancreatic cancer. Another embodiment of the invention is an assembly comprising in one compartment a dose of acetyldinaline, and in another compartment a dose of gemcitabine, or a pharmaceutically acceptable salt thereof. Another embodiment is a set comprising in one compartment a dose of acetyldinaline, and in another compartment a dose of capecitabine or cisplatin.

DESCRIPTION OF THE DRAWINGS Figure 1 shows the reduction of the growth rate of tumors implanted in mice after several oral doses of acetyldinaline (CI-994). A-Effect of CI-994 against LC12 squamous cell lung carcinoma; B-control; C-Size Evaluation; D-Tumor Implant of Daily Placement; E-control; F-Medium Tumor Size (mg).

Figure 2 shows the reduction in growth rate in tumors transplanted into mice after several interperitoneal injections of gemcitabine hydrochloride. A-Effect of Gemcitabine against Squamous Cell Lung Carcinoma LC12, B-Control, C-Tumor Implant of Daily Placement; D-Size Evaluation, E-Control, Gemcitabine, IP d10, 113, 16, 19, G-Medium Tumor Size (mg). Figure 3 shows the reduction of the growth rate of the transplanted tumors in mice after various combinations of doses of acetyldinaline and gemcitabine hydrochloride (both agents supplied at the same time). A-Effect of CI-994 in Combination with Gemcitabine against Squamous Cell Lung Carcinoma TC12, B-Control, C-Gemcitabine, IP d10, 113, 16, 19, D-Combo, d10-14, 17-21, 24-28, E-Size of Evaluation, F-Control, G-Tumor Implant of Daily Placement; H-Medium Tumor Size (mg). Figure 4 shows the reduction in the growth rate of the tumors transplanted in mice after various combinations of doses of acetyldinaline and gemcitabine hydrochloride (gemcitabine is first supplied, followed by a dose with CI-994). A-Effect of CI-994 in Combination with Gemcitabine against Squamous Cell Lung Carcinoma TC12, B-Control, C-Gemcitabine, IP d10, 113, 16, 19, D-Combo, d 10-14, 17-21 , 24-28, E-Control, F-Implant Tumor of Daily Placement; G-Medium Tumor Size (mg). Figure 5 shows the synergy of CI-994 and gemcitabine in human ovarian carcinoma cells. A-Combination of Ci-994 / Gemcitabine in OVCAR-4 cells. B- Mut.Excl., C-S¡n Excl., D-Fraction Affected (Fa), E-Index of Combination (Cl). Figure 6 shows the synergy of CI-994 and cisplatin in cancer of human ovarian carcinoma. A-Combination of Cl-994 in 4 cells-Ovocar, B-Mut.Excl., C-Sin Excl., D-Fraction Affected (Fa), E-Index of Combination (Cl).

DETAILED DESCRIPTION OF THE INVENTION The compounds that are used in the method of this invention will be administered in a dose commonly used clinically. Said doses will be calculated in a normal manner, for example in the body surface area. Acetyldinaline will be administered, for example, in doses of about 1.0 mg / m2 to about gm / m2, preferably from about 2.0 mg / m2 to about 10.0 mg / m2. Ideally, acetyldinaline will be administered in doses that will produce plasma levels of about 5 to about 100 μg / mL. Acetyldinaline is typically administered orally, for example, as capsules having active ingredient in the amounts of 2.5, 5 and 25 mg per capsule. Acetyldinaline will be administered daily at approximately the same dose levels throughout the treatment period, typically 15 to 30 days. Multiple treatment periods can be practiced, as dictated by the doctor and the particular patient and the condition being treated. Gemcitabine will also be administered in doses that can be compared to those routinely used clinically. For example, the initial dose of gemcitabine, typically as the hydrochloride salt, will be about 1000 mg / m2 body surface area. This product is routinely formulated as a sterile solution and is administered by intravenous infusion, generally over a period of approximately 30 minutes, with approximately 2 to 4 weekly doses, with repeated courses approximately every 28 to 30 days. The dose of 1000 mg / m2 can be given for up to 7 weeks, according to this treatment regimen, or until undesirable side effects are observed. Other forms of salts can be used if desired, for example, the hydrobromide, monophosphate, sulfate, malonate, citrate and succinate can be easily prepared. Capecitabine for monotherapy is generally administered orally at a dose of approximately 2500 mg / m2 daily for 2 weeks, followed by a rest period of 1 week. The product is commercially supplied in 150 mg and 500 mg tablets. The tablets are administered in a ratio of approximately 1 to 4 times a day during the period of treatment. The daily doses of capecitabine will vary from about 1000 mg / m2 to about 3500 mg / m2 per day in the combinations of this invention. Cisplatin is generally formulated as a sterile solution to be injected, and is routinely administered in doses of about 10 to 100 mg / m2, given intravenously daily for about 5 to 6 days. Alternatively, cisplatin can be administered as a single dose of approximately 50 to 100 mg / m2. This cycle can be repeated for approximately every 4 to 8 weeks. The combinations provided in this invention have been evaluated in several test systems, and the data can be analyzed using a standard program to quantify the synergy, addition and antagonisms between anticancer agents. The program preferably used is that described by Chou and Talalay, in "New Avenues in Developmental Cancer Chemotherapy \ Academic Press, 1987, Chapter 2. The method is based on the principle of average effect of the law of mass-action using a kinetic system The equation is simple and describes the relationship between dose and effect independently of the shape of the dose-effect curve.Two basic equations are the pillars of this methodology. Only drug in the simplest possible form, the average effect equation derived by Chou is given by: f./fu = (D / D m D = Dm [fa / (l-fa)] l / m where the right side represents the dose and the left side represents the effect, where fa and fu are the affected and unaffected fractions, respectively. D is the dose, Dm is the average effect dose that the power means, and m is a coefficient that signifies the shape of the dose / effect curve. From this equation, Chou and Talalay derive the general equation for two or more drugs: where m = 1 for first-order Michaelis-Menten type kinetics and m > 1 (or m < 1) is for the Hill type kinetics of higher order (or lower order). When alpha = 0, the third term on the right side disappears and when alpha = 1, the third term is retained. Alpha = 0 is used for mutually exclusive drugs and alpha = 1 is used for mutually non-exclusive drugs. For drugs that have the same or similar modes of action, the effects of both drugs are mutually exclusive. For drugs that have different modes of action or act independently, the effects of both drugs are mutually exclusive. An affected fraction diagram (Fa) against the combination index (Cl) res called the Fa-CI diagram. This diagram indicates the synergy, addition or antagonism of two drugs at different levels of effect in a mixture that is serially diluted. If several mixtures are made, it is possible to calculate the optimum combination ratio for maximum synergy. Different levels of effect usually provide different degrees of synergy, addition or antagonism. The values C I < 1 indicate synergy; the values C I > 1 indicate antagonism, and Cl values that are one or that oscillate between an indicated addition. For anticancer agents, synergy at high levels of effect (Fa) is clinically more relevant than synergy at low levels of F .. Gemcitabine, as a monohydrochloride, is routinely used clinically, and is well suited as a single agent for a frontal line treatment in patients with advanced pancreatic cancer or NSCLC. It is also routinely used in combination with other known antineoplastic agents, most notably cisplatin. However, synergistic combinations have not been reported so far.

While acetyldinaline (CI-994) has not been tested for chemical use, it has nevertheless been evaluated in several clinical trials. In one study, patients were treated using a dose escalation scheme that increased both the daily dose and the duration of treatment; most patients had received extensive prior chemotherapy. The maximum tolerated dose (MTD) was 15 mg / m2 / day when the duration of treatment was 14 consecutive days. To allow a longer treatment, lower doses were studied. Using an 8-week schedule of continuous daily therapy, followed by a two-week "drug suspension", the MTD was 8 mg / m2 / day. The toxicity that limits the dose was thrombocytopenia or neutropenia, usually occurring one month after the start of therapy. Blood tests had a tendency to stabilize even with continuous treatment and recover quickly when treatment is discontinued. There was no evidence of cumulative toxicity after repeated courses and prolonged exposures to CI-994. Other toxicities included nausea, vomiting, diarrhea, anorexia, fatigue, mucositis, headache, dehydration, increases in renal and hepatic puncture test values. The responses included a partial response in a highly pretreated patient with NSCLC and a smaller response in one patient each with NSCLC renal cell cancer.

An additional Phase 1 study was conducted in patients with recurrent acute leukemia or other hematological disorders using a 5-day high-dose schedule once a day. The MTD was 135 mg / m / day. The toxicity that limits the dose was an acute CNS toxicity manifested as sedative effects and somnolence. Other adverse effects included nausea, vomiting, hypotension resulting from dehydration, hypocalcemia, headaches and in one patient, watery pancreatitis, pyramidal syndrome characterized by hyperreflexia and bilateral Babinski reflexes, and sepsis. Hematological toxicities could not be evaluated in this patient population. Two patients with AML developed tumor lysis syndrome, resulting in one death. Transient decreases in peripheral white blood cell counts were noted. A Phase 2 program with CI-994, used as a single agent, is currently underway. The dose regimen is 8 mg / m2 given orally on a daily basis. More than 100 patients have been treated, including patients with non-small cell lung cancer, renal cell cancer, pancreatic cancer, head and neck cancer, ovarian cancer, myeloma, prostate cancer and breast cancer. Some patients have tolerated dose increases of up to 10mg / m2, while some patients had to discontinue treatment due to thrombocytopenia, and were then restarted with CI-994 at lower doses. Adverse effects have been similar to those observed in the Phase I chronic dose protocol. Thrombocytopenia has been the dose-limiting toxicity. Uncommon neurological adverse events that include paresthesias, confusion and hallucinations have been reported. Objective responses have been obtained in patients with non-small cell lung cancer. Clinical benefits have been reported in patients with renal cell cancer. In the Phase 1 study of solid tumor, the doses of CI-994 were administered orally after a fasting period, and blood samples were collected for pharmacokinetic analyzes. Preliminary results indicate that the maximum blood level is achieved approximately 1 or 2 hours after ingestion, and that the terminal half-life elimination of CI-994 is approximately 15 hours. The maximum plasma concentrations of CI-994 achieved with the increase in dose levels were less than proportional to the dose. The terminal elimination of the half-life and the apparent release rate were independent of the dose administered. An additional object of this study was to determine if the ingestion of CI-994 with food affected its speed or degree of absorption. Twelve fasting patients were supplied with a single dose of CI-994, 8 mg / m2. One week later, the same patients were given the same dose of Cl-994 with a normal meal. Analysis of pharmacokinetic data revealed that CI-994 can be taken independently of meals. No mass / route balance elimination studies in humans have been carried out. Animal studies indicate that the main route of elimination is by renal excretion, with 80% and 62% of radiolabelled drug appearing in the urine of monkeys and rats, respectively, at 24 hours. 0 The following detailed examples further establish the synergy between CI-994 and either gemcitabine, capecitabine, or cisplatin.

EXAMPLE 1 5! The synergistic combinations provided by this invention have been evaluated in chemotherapy studies, standard using female BALB / C mice with weights of 18 to 20 grams. On Day 0 of the test, each mouse was! surgically implanted (subcutaneously) with a Q fragment of a lung carcinoma tumor with squamous cells LC-j 12 weighing approximately 30 mg. The mice were Heavy weekly, and tumor size (width and length in mm) was measured three times per week with standard calibers.

' The mass of the tumor for each animal was calculated according to the formula: (a x b2) Mass = where "a" is the width of the tumor in mm, and "b" is the length in mm. The evaluation of the TC anticancer activity, where "T" and "C" are the average times (in days) required for the treated tumors and the control (respectively) to reach a predetermined size of 750 mg (the "evaluation size"). "). Acetyldinaline was suspended in 0.5% aqueous methyl cellulose and several doses were administered orally in 0.5 mL of volumes. Gemcitabine hydrochloride was dissolved in 5% aqueous output and administered intraperitoneally at various dose levels in 0.5 mL injections. The animals were divided into 4 groups. One group served as a control and did not receive drug treatment. One group (Figure 1) was further divided into four subgroups, each of which received oral doses of acetyldinaline at a specific level of active drug (15 mg / kg, 30 mg / kg, 45 mg / kg, and 60 mg / kg). kg). acetyldinaline was administered daily on Days 10-14 (Day 0 being when the tumor was implanted), Days 17-21, and Days 24-28. Figure 1 shows that acetyldinaline delays the growth of the implanted tumor at all dose levels, compared to untreated controls. Tumors in untreated controls exhibited significant growth, starting on Day 10. At doses of 30 and 45 mg / kg of acetyldinaline, significant tumor growth did not start until approximately on Day 24. At 60 mg / kg, growth was delayed for 33 days. Figure 2 shows the effects of gemcitabine hydrochloride at 40 and 80 mg / kg, administered IP on Days 10, 13, 16 and 19. Tumor growth was substantially inhibited for 25 days at 40 mg / kg, and approximately 32 days at 80 mg / kg. (Controls showed significant growth starting on Day 10). Figure 3 shows the examples of various combinations of doses of acetyldinaline and gemcitabine hydrochloride (e.g., 15 mg / kg of acetyldinaline with 40 mg / kg of gemcitabine hydrochloride, 15/80, 30/40, 30/80 and 45/20). The test animals were implanted with an LC12 squamous cell lung carcinoma, and were divided into four subgroups, each subgroup receiving a different dose of the combination therapy. Acetyldinaline was administered orally at the doses indicated on Days 10-14 (for example, 15 mg / kg daily), Days 17-21 and Days 24-28. The gemcitabine hydrochloride was administered IP on Days 10, 13, 16 and 19. The results in Figure 3 establish a dramatic and synergistic reduction in tumor growth for all drug combination doses. In the combination of 15 mg / kg of acetyldinaline and 40 mg / kg of gemcitabine, there was no substantial growth of the implanted tumor until Day 28 (tumors in controls initiated substantial growth on Day 10). In combination doses of 15/80, 30/40, 30/80 and 45/20 (acetyldinaline / gemcitabine), tumor growth was substantially inhibited for the total 60-day period of the test. Figure 4 shows the results of a combination study carried out for 75 days. All the test animals were implanted with an LC12 squamous cell lung carcinoma. The animals selected to receive the test drugs were divided into four subgroups. One subgroup received 15 mg / kg of acetyldinaline in combination with 80 mg / kg of gemcitabine. A second subgroup received the combination in a dose of 15 mg / kg / 160 mg / kg. The third subgroup received the combination in a dose of 30 mg / kg of acetyldinaline with 80 mg / kg of gemcitabine. The four subgroup received the combination of 45 mg / kg / 80 mg / kg. Acetyldinaline was administered orally to each test group on Days 26-30, 33-37 and 40-44. Gemcitabine was administered IP on Days 10, 13, 16 and 19. Figure 4 shows that tumors in untreated controls initiated growth on day 11 after implantation, and reached 750 mg (the "evaluation size"). ") on Days 18. In comparison, tumors in animals treated with 15 mg / kg of acetyldinaline and 80 mg / kg of gemcitabine showed very little growth until Day 35, and did not reach the valuation size until Day 42 Tumors in animals with doses of 30 mg / kg / 80 mg / kg combination started growth on Day 35, but did not reach the evaluation size of 750 mg until Day 52. Tumors in animals dosed with 15 mg / kg / 160 mg / kg combination, as well as the combination of 45 mg / kg / 80 mg / kg, showed growth, even on Day 75 when the test ended. The data presented in Figures 2 and 4 establish that the combination of acetyldinaline and gemcitabine is surprisingly active in reducing the growth rate of tumors in animals. The ability of these agents when used together establish that the combination is synergistic as an antitumor agent.

EXAMPLE 2 Because the synergistic effects observed with the combination of acetyldinaline and gemcitabine (shown in Figures 2 and 4) were surprisingly dramatic, the experiment described above in Example 1 was repeated with additional doses of acetyldinaline. Table 1 below shows the activity of CI-944 and gemcitabine, alone or in combination, in the mouse lung tumor model LC-12 when tested in accordance with the procedure of Example 1.

TABLE 1 Antitumor Effect of the Combination of CI-994 and Gemcitabine in the Mouse Tumor Model LC-12 CI-994 Gemcitabins Deaths% in Weight Antitumor Effect Dose'1 Schedule Dose 'Toxic Hours of Changeb CR PRU T-Ce NetolO Death Record' 7. 5 11-15, 18-22,25-29 0 0/6 +4 1/6 0/6 2.4 -1.2 15 0 0/6 +10 0/6 0/6 0.4 -1.4 30 0 0/6 +1 0/6 0/6 1.6 -1.3 60 0 0/6 -9 3/6 0/6 7.8 -0.8 or 80 11, 14, 17.20 0/6 +1 1/6 0/6 15.4 0.5 or 160 0 / 6 -3 0/6 1/6 24.0 1.2 7.5 11-15,18-22,25-29 80 11, 14,17.20 0/6 +8 2/6 0/6 23.5 0.4 15 80 0/6 +7 2/6 1/6 23.8 0.5 30 80 0/6 +8 5/6 0/6 37.0 1.5 60 80 3/6 -8 Toxic Toxic Toxic Toxic 7.5 11-15, 18-22,25-29 160 11.14 , 17.20 0/6 3/6 0/6 25.6 0.6 15 160 0/6 4/6 1/6 29.8 0.9 30 160 0/6 5/6 1/6 > 82.6 > 5.0 60 160 0/6 Toxic Toxic Toxic Toxic at Dose in mg / kg / day. b Weight loss is the maximum view during treatment; an increase in weight is the weight seen at the end of the treatment c Complete response (CR) tumor that can not be detected at the end of the study d Partial response (PR) represents a tumor that decreased by 50% more during the study, e The difference in days for treated tumors (t) and control (C) reached 750 mg. f The net 10 tumor cell death record was calculated from the T-C.z value EXAMPLE 3 The procedure of Example 1 was followed to evaluate the antitumor activity of the combinations of CI-994 and cisplatin in combination with the individual agents alone. The results are presented in table 2. The table shows that treatment with 60 mg / kg / day of CI-994 elicited two complete responses from 10 test animals, while cisplatin alone at 2 mg / kg / day failed to provoke any complete response. The combination, however, elicited a complete response of 70%, mainly complete responses in 7 out of 10 treated animals. The T-C effect was even more dramatic, ranging from 8.7 and 2.4 for the monotherapy treatments, to 84.2 for the combination treatment.

? TABLE 2. Antitumor Effect of the Combination of CI-994 and Cisplatin in the Mouse Lung Tumor Model LC-12 CI-994 Gemcitabine Deaths% in Weight Antitumor Effect Dose "Schedule Dose '1 Schedule Toxic of Change" CR' PRU TC Register PNetolO of Death * 0 - 0 - 0/10 +15 0/10 0/10 - - 7.5 11-15,18-22,25-29 0 - 0/10 +9 0/10 0/10 -1.4 0 15 0 ~ 0 / 10 +11 0/10 0/10 -1.9 0 30 0 ~ 0/10 +11 0/10 0/10 4.3 -0.8 60 0 - 0/10 +11 2/10 0/10 8.7 -0.5 0 1 11-15 0/10 +13 0/10 0/10 2.6 -0.1 0 - 2 0/10 +12 0/10 0 / 10 2.4 -0.1 7.5 11-15,18-22,25-29 1 11-15 0/10 +4 0/10 0/10 2.0 -0.9 1 0/10 +4 1/10 0/10 8.2 -0.6 1 0/10 +3 4/10 2/10 6.7 -0.7 60 1 0/10 +2 7/10 1/10 12.7 -0.3 7.5 11-15,18-22,25-29 2 11-15 0/10 + 1 1/10 0/10 10.0 -0.5 2 0/10.? 3/10 0/10 17.0 -0.1 2 0/10 -l 5/10 1/10 20.6 0.2 60 2 0/10 -14 7/10 3/10 84.2 3.8 a Dose in mg / kg / day. b Weight loss is the maximum view during treatment; an increase in weight is the weight seen at the end of treatment c Complete response (CR) tumor that can not be detected at the end of study d Partial response (PR) represents a tumor that decreased by 50% more during the study, e The difference in days for treated (t) and control (C) tumors will reach 750 mg. f The net 10 tumor cell death record was calculated from the T-C value.

EXAMPLE 4 The general procedure of Example 1 was followed to evaluate CI-994 and capecitabine, alone and in combination, against a colon tumor. The test was carried out as described in Example 1, except that a fragment of tumor of color C26 was surgically implanted in the mice, instead of the lung tumor LC-12 that was used in the previous examples. Table 3 reports the results of monotherapy with specific doses of CI-994, and with capecitabine (Xeloda ™), and with a combination therapy in which the animals were first dosed with capecitabine (on Days 3-7 and 10- 14), followed by a dosage with CI-994 (on Days 17-21, 24-28 and 31-35). The data in Table 3 establish that none of the animals that received CI-994 alone were tumor free at the end of the trial, that 30% (3 of 10) of the animals that received capecitabine alone were free of the tumor, and that 70% (7 of 10) animals that received the combination of CI-994 plus capecitabine were tumor-free. Table 4 presents the trials of the same assay, except that the combination agents CI-994 and capecitabine were both administered simultaneously on Days 3-7 and 10-14. Doses with CI-994 continued on Days 17-21, while capecitabine therapy was stopped on Day 14.

TABLE 3 Antitumor Effect of the Combination of CI-994 and Xeioda in the Mouse Colon Tumor Model C26: Effect of Xeioda Treatment Followed by Treatment with CI-994 against Early Stage Tumor Cl-994 Xelod to Deaths% in Weight Antitumor Effect% Dose Free "Schedule Dose" Toxic Schedule of Change. CRC PRd T-Ce (add.) NetolO Record of Death e Tumor 7.5 17-21,24-28,31-35 0 0/10 -5 Early Stage Early Stage 3.1 -1.3 0/10 15 0 - 0 / 10 -9 Stage "Early Early Stage 6.7 -1.0 0/10 30 0 1/10 -16 Early Stage Early Stage 8.4 -0.8 0/10 60 0 0/10 -10 Early Stage Early Stage 10.1 -0.7 0/10 0 500 3-7, 10-14 0/10 -0.2 Early Stage Early Stage 13.8 0.2 2/10 0 - 750 1/10 -18 Early Stage Early Stage 20.7 0.8 3/10 7.5 17-21,24-28,31-35 500 3-7, 10-14 0/10 -1 Early Stage Early Stage 13.7 (16.9) -0.4 3/10 15 500 0/10 -1 Early Stage Early Stage 17.3 (20.5) -0.1 4/10 30 500 0 / 10 -4 Early Stage Early Stage 18.3 (22.2) 0.0 3/10 60 500 0/10 -4 Early Stage Early Stage 20.4 (23.9) 0.2 6/10 7.5 17-21.24-28.31-35 750 3-7 , 10-14 1/10 -13 Early Stage Early Stage 19] (23.8) 0.1 4/10 15 750 2 / ios -15 Early Stage Early Stage 29.8 (27. 0.4 2/10 30 750 1/10 -10 Early Stage Early Stage 5 g nn 2.3 7/10 60 750 6/10 Toxic Stage Tem prana Early Stage TOXIC TOXIC TOXIC a Dosage in mg / kg / day. b Weight loss is the maximum view during treatment; an increase in weight is the weight seen at the end of treatment, c Complete response (CR) tumor that can not be detected at the end of the study. This was an early stage test; therefore, the CRs could not be calculated d Partial response (PR) represents a tumor that decreased by 50% more during the study. This was an early stage test; therefore, the PRs could not be calculated e The difference in days for the treated and control tumors reached 750 mg. The values in parentheses represent the T-C values for an additional antitumor effect, f The net register 10 of tumor cell death was calculated from the T-C value. g It is presumed that a death was due to a dosing error by tube.

¿. { TABLE 4 Antitumor Effect of the Combination of CI-994 and Xeioda in the Mouse Tumor Model of C26 Mouse: Simultaneous Treatment Effect with CI-994 and Xeioda Against Early Stage Tumor CI-994 Xeioda Deaths in Weight Antitumor Effect Dosage "Dosage Schedule" Toxic Schedules of Change "CRC PRd T-Ce (add.) NetolO Record of Death *% Tumor-Free 7. 5 3-7, 10-14, 17-21 0 - 0/10 +5 Early Stage Early Stage 1.6 -2.2 0/10 0 - 0/9 -8 Early Stage Early Stage 1.0 -2.3 0/9 0 - 0/9 • II Early Stage Early Stage 4.6 -1.8 0/9 60 0 - 0/9 • 12 Early Stage Early Stage 4.8 -1.8 0/9 0 500 3-7, 10-14 0/10 +2 Early Stage Early Stage 15.2 0.6 0/10 0 - 750 0/10 -12 Early Stage Early Stage 20.4 1.3 1/10 7.5 3-7. 10-14, 17-21 500 3-7, 10-14 0/10 +6 Early Stage Early Stage 15.4 (16.8) -0.4 0/10 15 500 0/10 +6 Early Stage Early Stage 14.5 (16.2) -0.5 1/10 500 0/10 -11 Early Stage Early Stage 14.2 (19.8) -0.5 0/10 60 500 0/10 -8 Early Stage Early Stage 18.1 (20.0) 0.0 1/10 7.5 3-7, 10-14, 17- 21 750 3-7, 10-14 0/10 -11 Early Stage Early Stage 19.1 (22.0) 0.2 0/10 750 0/10 -7 Early Stage Early Stage 16.9 (21.4) -0.2 2/10 750 0/10 -14 Early Stage Early Stage 17.4 (25.0) -0.1 0/10 60 750 1/10 -18 Early Stage Early Stage 16.4 (25.2) -0.2 0/10 Early Stage Early Stage at Dosage in mg / kg / day. b Weight loss is the maximum view during treatment; an increase in weight is the weight seen at the end of treatment, c Complete response (CR) tumor that can not be detected at the end of the study. This was an early stage test; therefore, the CRs could not be calculated ? d Partial response (PR) represents a tumor that decreased by 50% more during the study. This was an early stage test; therefore, the PRs could not be calculated e The difference in days for the treated and control tumors reached 750 mg. The values in parentheses represent the T-C values for an additional antitumor effect. f The net 10 tumor cell death record was calculated from the T-C value.

EXAMPLE 5 The combinations of CI-994 plus gemcitabine, and of Cl-994 plus cisplatin, were evaluated in human ovarian carcinoma cells, and the data were analyzed according to the Chou and Talalay program which states that both combinations are synergistic.

Human Ovary Ovcar-4 Ovcar-4 human ovarian carcinoma cells were implanted in 96-well culture plates in an RPMI 1640 culture medium implemented with 20% fetal bovine serum and 10 μg / gL insulin. Several concentrations of CI-994 and either cisplantin or gemcitabine were added together 24 hours after the cells were initially implanted in the culture plates and allowed to attach. The effect of CI-994, gemcitabine or cisplatin alone or in combination on a proliferation of Ovcar-4 was determined after 96 hours of incubation at 37 ° C using the RSB assay as previously described (Skehan P., Stoneng R , Scudiero D, et al., New colorimetric cytotocity assay for anticancer drug screening, J. Nati, Cancer Inst. 1990; 82: 1107-1112). The combined chemotherapy data were analyzed using a Biosoft program, "Dose Effect Analysis with Microcomputers for IBM PC", which is a standard program to quantify the synergy, addition and antagonisms between anticancer agents, and is based on an average effect principle. the law of mass-action using a kinetic enzyme system model described by Chou and Talalay. The diagrams of the affected fraction (Fa) against the combination index (Cl) are called Fa-CI diagrams. These diagrams indicate the synergy, addition, or antagonism of two drugs at different levels of effect in a mixture that is diluted serially. If several mixtures are made, it is possible to calculate the optimum combination ratio for maximum synergy. Different levels of effect usually provide different degrees of synergy, addition or antagonism. The Cl values < 1 indicate synergy; the values C I > 1 indicate antagonisms and values that oscillate between 1 as a straight line indicate addition. Figures 5 and 6 show representative Fa-CI diagrams for CI-994 plus gemcitabine (Figure 5), and CI-994 plus cisplatin (Figure 6). In both diagrams, Cl values over the entire Fa range are less than one, indicating synergy for drug combinations.

CLINICAL EVALUATION OF COMBINATION THERAPY This is a Phase 1 multicentre open label study of CI-994 delivered in combination with gemcitabine to patients with advanced solid tumors. The objectives of this study are to determine, (1) the maximum tolerated dose (MTD), (2) the recommended Phase 2 dose, (3) pharmacokinetics, (4) safety profile, (5) observe an antitumor activity for IC. -994 when given in combination with gemcitabine to patients with advanced solid tumors. The endpoint of primary efficacy is to obtain either a partial response either (PR) or a complete response (CR). Endpoints include time for PR or CR, duration of PR or CR, and survival. Gemcitabine is administered as an intravenous infusion in 30 minutes on Days 1, 8 and 15 in a 28-day course of treatment, using an initial dose of 1000 mg / m2. CI-994 is administered orally as an area dose for 21 days in a 28-day course, starting on Day 1. Patients can receive subsequent courses of treatment based on individual tolerance and response to therapy. Patients whose diseases do not respond or who develop intolerable adverse effects discontinued the study treatment. The initial dose level of CI-994 is 4mg / m2. A minimum of 3 patients will be treated with each dose level. The dose levels are increased by 2 mg / m2 until the BAT is reached. Ten additional patients are treated at the recommended dose levels for the Phase 2 studies, which are expected to be BAT or a dose level below the BAT. Once a patient starts a study treatment, the addition of another cancer treatment will confuse the evaluation of safety and efficacy and therefore will not be allowed. This restriction affects the addition of cytotoxic, hormonal, and immunological systemic agents while the patient is in the treatment phase of this protocol. Patients who require palliative radiotherapy while in the study are generally considered to have a progressive disease and, unless there is compelling information to the contrary, they should be discontinued from the study medication. Patients who develop new brain metastases during the study may interrupt the treatment to receive a cranial irradiation course, after being restored to the study medication after a recovery period of at least 1 week. Antiemetics can be used at the discretion of the investigator to prevent and / or treat nausea or vomiting. Every effort should be made to ensure that nausea and vomiting are controlled, since these conditions can prevent a patient from taking or absorbing the oral dose of CI-994. This issue is particularly relevant on Days 1, 8 and 15, when gemcitabine is also administered. Because CI-994 caused sedative effects and somnolence at a higher dose in the Phase 1 program, antiemetics should be used that are less likely to cause these side effects. Colony stimulation factors can be used at the discretion of the investigator to treat episodes of severe myelosuppression that are complicated by infection, but which should not otherwise be used to support low blood counts or maintain dose intensity. If the criteria for a complete response (CR) are met, administer 2 additional courses of treatment beyond CR confirmation and then fully re-assess the patient's disease status. If the patient is considered clinically free of the disease at that time, discontinue the gemcitabine and continue administering CI-994 for an additional 3 months, using the same dose and schedule (3 weeks if / 1 week not). At that time, I once again completely re-evaluate the patient's disease status. If the patient is still in CR, the investigator should assess the risk and potential benefits of continuing treatment with CI-994.

Treatment Courses A course of treatment consists of gemcitabine given intravenously on Days 1, 8 and 15 of a 28-day course plus CI-994 provided daily orally, beginning on Day 1, for 21 days of a 28-day course. The courses must be repeated on Day 29 if there has been an adequate recovery of the adverse cases and myelosuppression, defined as non-hematological parameters of Grade < .1, platelet count > _100,000 / μL, and neutrophil count absorb > _1500 / μL. Subsequent courses may be delayed at weekly intervals of up to 3 weeks. If no recovery has occurred on Day 50, the study medication should be discontinued in the patients.

Dosage of Gemcitabine The initial dose of gemcitabine in each course is 1000 mg / m2, given as a 30-minute intravenous infusion. Dose adjustments may be required during a course of treatment. Follow the manufacturer's recommendations for information regarding preparation and administration.

CI-994 Dosage Levels The doses of CI-994 are calculated based on body surface area (BSA) and should be rounded to the nearest available capsule strength. CI-994 is available in capsule potencies of 2.5.5 and 25 mg. Doses can be taken independently of meals. The initial dose level of CI-994 is 4 mg / m2. Subsequent dose levels will be increased (or decreased if necessary) by a fixed increase of 2 mg / m2 until the BAT is determined. Individual patients may not receive dose escalations of gemcitabine or CI-994 in subsequent courses. Patients may receive a lower dose of CI-994 in a subsequent course if toxicities that limit the dose occur. Three new patients will be evaluated at each new dose level. The minimum time that should be followed in these patients should be four weeks before a new dose level can be opened (unless the treatment is interrupted earlier and the patient is recovering from adverse effects). If none of these 3 patients experience a toxicity that limits the dose, the next higher dose level will open. If a patient develops a toxicity that limits the dose, three more patients will be included in the dose level. Yes > 2 of 6 patients experience toxicity that limits the dose at the same level, that dose level will be considered as BAT. A patient with evaluation capacity is defined as one who has received 3 weekly doses of gemcitabine plus at least 80% of the doses of CI-994, (> 17 doses), or a patient whose course of treatment was discontinued before or did not comply (< 17 doses), due to the adverse effects related to the treatment. A patient who took less than 17 doses of CI-994 or did not complete the course of treatment due to reasons unrelated to treatment (eg, missed appointments, had insufficient CI-994 supply, developed a coexisting medical condition that the patient was unable to swallow the capsules, developed a rapidly progressive disease) is not considered as a patient with evaluation capacity for the tolerance of that dose level. Patients have been encouraged to take their dose of Cl-994 at approximately the same time of day. However, a variation of up to 12 hours in either direction is allowed for any given dose, preferable to failing the dose of a day. If a patient does not take a full day's dose, they should be instructed not to duplicate "the next day's dose". If a patient vomits at any time after taking the dose of Cl-994, he should be instructed not to "duplicate" it but to take up doses subsequent to the next day as prescribed. On Days 1, 8 and 15, the dose of CI-994 should be given 2 hours before the dose of gemcitabine, to ensure maximum absorption in case the patient develops vomiting after the dose of gemcitabine. Once BAT is determined, 10 additional patients will be treated at the Phase 2 dose level, which is expected to be BAT or a dose level below the BAT.

Dose Adjustments During a Course The continuation of gemcitabine and CI-994 during a course depends on the tolerance of the patient and the hematological parameters. Reduced doses of gemcitabine may be required on Days 8 and 15, as recommended by the manufacturer and as shown in the following table. The dose of CI-994 should not be increased or decreased during a course of treatment, although an early termination may be required as will be described below. If both study medications should be discontinued before completing the course, do not complete the course, instead assist the patient in their recovery, and then start another course using a reduced dose of CI-994.

The gemcitabine settings shown in the previous table are based on the results of that day. For example, on Day 8 take a CBC and review the results. Determine if the dose should be continued. If so, have the patient take the dose of CI-994. Two hours later, supply the dose of gemcitabine, which if necessary, has been reduced. The decision to discontinue the dose of CI-994 during a course is based on adverse effects or haematological results at any time. Example: A patient has a platelet count on Day 11 of 45,000 / μL. Instruct the patient to stop taking the CI-994 capsules (and return all the study medication containers to the site). Obtain other CBCs on Day 15. If the platelet count on Day 15 is 50,000 to 99,000 / μL, administer 75% of the calculated dose of gemcitabine but not restore the dose of CI-994. If the platelet count on Day 15 remains below 50,000μL, it is not removed with calculated gemcitabine. Consider that this course is completed and help the patient recover. In any case, the patient may receive a subsequent course of treatment using the same initial dose of gemcitabine (1000 mg / m2) and a dose of CI-994 that has been reduced by 2 mg / m.

Drug Formulation and Stability Gemcitabine is obtained at the site from commercial sources. Follow the manufacturer's recommendations for preparation, administration, stability and storage conditions.

CI-994 is formulated in gelatin capsules that appear identically to contain 2.5, 5, or 25 mg of the study drug, plus inactive ingredients of lactose, corn starch, and talc or polyethylene glycol 6000. Store at room temperature controlled, . The above data establish an unstably favorable interaction between acetyldinaline and gemcitabine, and between acetyldinaline and cisplatin. Accordingly, this invention provides a method for treating susceptible neoplasms which comprises administering acetyldylanine in a regimen together with either gemcitabine, a pharmaceutically acceptable salt thereof, or cisplatin. The combination will generally include each active ingredient packaged separately, thereby avoiding any interaction between the agents prior to administration. If desired, individually packaged drugs can be placed in a single carton as a whole, with this providing convenience for the physician. Neoplasms susceptible to be treated according to this invention include solid tumors, especially advanced solid tumors and non-small cell lung cancer, as well as renal cell cancer, pancreatic cancer, head and neck cancer, ovarian cancer, myeloma. , prostate cancer, and breast cancer.

Claims (20)

1. A combination of antineoplastic agents comprising an anti-tumor amount of acetyldinaline and an anti-tumor amount of gemcitabine, a pharmaceutically acceptable salt thereof, capecitabine or cisplatin.

2. The combination of compliance with the claim 1, characterized in that acetyldinaline is formulated as a capsule.

3. The combination of compliance with the claim 2, characterized in that it comprises gemcitabine or a pharmaceutically acceptable salt thereof, formulated as a sterile solution for an intravenous infusion.

4. The combination according to claim 3, characterized in that it comprises gemcitabine monohydrochloride.

5. The combination of compliance with the claim 3, characterized in that it comprises gemcitabine monohydrobromide.

6. The combination of compliance with the claim 2, characterized in that it comprises cisplatin.

7. The combination according to claim 2, characterized in that it comprises capecitabine.

8. A method for treating cancer comprising administering to an animal in need of treatment an anti-tumor amount of the combination according to claim 1.

9. The method according to claim 8, characterized in that the cancer treated is lung cancer. of not small cell.

The method according to claim 9, characterized in that it comprises administering acetyldinaline in combination with gemcitabine monohydrochloride.

11. The method according to claim 9, characterized in that it comprises administering acetyldinaline in combination with cisplatin.

12. The method according to claim 9, characterized in that it comprises administering acetyldinaline in combination with capecitabine.

13. The method according to claim 8, characterized in that the cancer treated is prostate cancer.

The method according to claim 13, characterized in that it comprises administering acetyldinaline in combination with gemcitabine monohydrochloride.

15. The method according to claim 13, characterized in that it comprises administering acetyldinaline in combination with cisplatin.

16. The method according to claim 13, characterized in that it comprises administering acetyldinaline in combination with capecitabine.

17. The method according to claim 8, characterized in that the cancer treated is a locally advanced (non-resectable Stage II or Stage III) or metastatic (stage IV) adenocarcinoma or adenocarcinoma of the pancreas.

18. A pool comprising acetyldinaline in a compartment and gemcitabine or a pharmaceutically acceptable salt thereof in a second compartment.

19. A set comprising acetyldinaline in one compartment and cisplatin in a second compartment.

20. An assembly comprising acetyldinaline in a capecitabine compartment in a second compartment.