WO2018045256A1

WO2018045256A1 - Combination of an erbb3 inhibitor, topoisomerase i inhibitor, and an alkylating agent to treat cancer

Info

Publication number: WO2018045256A1
Application number: PCT/US2017/049798
Authority: WO
Inventors: Michael CURLEY; Chrystal U. Louis
Original assignee: Merrimack Pharmaceuticals, Inc.
Priority date: 2016-09-02
Filing date: 2017-09-01
Publication date: 2018-03-08

Abstract

Provided are methods for treating cancer (e.g., Ewing sarcoma) using a combination of an IGF-lR/ErbB3 inhibitor (e.g., istiratumab), topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide).

Description

COMBINATION OF AN ERBB3 INHIBITOR, TOPOISOMERASE I INHIBITOR, AND AN ALKYLATING AGENT TO TREAT CANCER

RELATED APPLICATIONS

This application claims priority to U.S. Provisional Application No. 62/383,086, filed

September 2, 2016. The contents of the aforementioned application are hereby incorporated by reference.

FIELD

Provided are methods of treating patient with cancer with targeted therapies alone in combination with chemotherapies. Additionally, methods of determining whether the patient is likely to respond to a treatment with the aforementioned combinations are described. BACKGROUND

Cancer therapy has advanced with the use of targeted agents that have significantly increased the utility of traditional chemotherapies as part of combination regimens. Most of the successes have been observed in those cancer subtypes in which a specific oncogenic protein is mutated, such as EGF receptor (EGFR), BRAF, or ALK, or the expression is amplified, such as ErbB2 in breast and gastric cancer. However, many patients never respond to these combination regimens or become refractory, suggesting the existence of

uncharacterized tumor survival mechanisms. Although inhibition of IGF-IR was expected to eliminate a key resistance mechanism to anticancer therapies, clinical results to date have been disappointing. It has previously been established that adaptive v-erb-b2 erythroblastic leukemia viral oncogene homolog 3 (ErbB3) signaling activated by its ligand heregulin is a key factor limiting the utility of anti-IGF-lR agents. A series of biomolecules have been invented that co-inhibit IGF-IR and ErbB3, including a bispecific tetravalent antibody, MM- 141. MM- 141 is a polyvalent bispecific antibody (PBA) that co-blocks IGF-1 and heregulin- induced signaling and induces degradation of receptor complexes containing IGF-IR and ErbB3, including their respective heterodimers with insulin receptor and with ErbB2. MM- 141 is disclosed in U.S. Patent No. 8,476,409, which also discloses a number of other novel PBAs that, like MM- 141, bind specifically to human IGF-IR and to human ErbB3 and are potent inhibitors of tumor cell proliferation and of signal transduction through their actions on either or (typically, as for MM- 141) both of IGF-1R and ErbB3. The invention of such co- inhibitory biomolecules has resulted in a need for new approaches to combination therapies for cancer. The present invention addresses these needs and provides other benefits. SUMMARY

Provided herein are compositions comprising, and methods for use of PB As. It has now been discovered that co-administration of such a PBA (e.g., MM- 141, as described below) with one or more additional anti-cancer agents, such as irinotecan and/or

temozolomide, exhibits therapeutic synergy.

Accordingly, provided are methods for the treatment of a cancer in a human patient (a

"subject") wherein the methods comprise administering to the subject a therapeutically effective amount of an IGF-1R and ErbB3 co-inhibitor biomolecule. Treatment according to the present disclosure in any of its embodiments may be carried out by administering an effective amount of a bispecific anti-IGF-lR and anti-ErbB3 antibody to the patient, where the patient is given a single loading dose of at least 10 mg/kg of the bispecific antibody followed administration of one or more maintenance doses given at intervals. The intervals between doses are intervals of at least three days. In some embodiments, the intervals are every fourteen days or every twenty-one days.

The doses administered may range from 1 mg/kg to 60 mg/kg of the bispecific antibody. In some embodiments, the loading dose is greater than the maintenance dose. The loading dose may from 12 mg/kg to 20 mg/kg, from 20 mg/kg to 40 mg/kg, or from 40 mg/kg to 60 mg/kg. In some embodiments the loading dose is about 12 mg/kg, 20 mg/kg, 40 mg/kg, or 60 mg/kg. In other embodiments the maintenance dose is about 6 mg/kg, 12 mg/kg, 20 mg/kg, 30 mg/kg, 40 mg/kg, 50 mg/kg or 60 mg/kg.

In other embodiments, a fixed dose of the bispecific anti-IGF-lR and anti-ErbB3 antibody is administered, rather than a body mass-based dose. In one embodiment, a dose of 2.8 grams is administered to the patient every two weeks (Q2W). In other embodiments, a dose of 2.24 grams Q2W, 1.96 grams Q2W, 1.4 grams Q1W, 1.4 grams Q1W x 3 with 1W off, 40 mg/kg Q2W, or 20 mg/kg Q1W is administered.

In some embodiments, the patient has a pancreatic cancer, renal cell carcinoma,

Ewing's sarcoma, non-small cell lung cancer, gastrointestinal neuroendocrine cancer, estrogen receptor-positive locally advanced or metastatic cancer, ovarian cancer (e.g., high- grade serous ovarian cancer), colorectal cancer, endometrial cancer, or glioblastoma. In one embodiment, the patient has a cancer that is refractory to one or more anti-cancer agents, e.g., gemcitabine or sunitinib.

In one embodiment the bispecific anti-IGF- lR and anti-ErbB3 antibody has an anti- IGF-1R module selected from the group consisting of SF, P4, M78, and M57. In another embodiment the bispecific anti-IGF- lR and anti-ErbB3 antibody has an anti-ErbB3 module selected from the group consisting of C8, PI, Ml .3, M27, P6, and B69. In one embodiment, the bispecific anti-IGF- lR and anti-ErbB3 antibody is P4-G1-M1.3. In another embodiment, the bispecific anti-IGF- lR and anti-ErbB3 antibody is P4-G1-C8.

In some embodiments, co-administration of the additional anti-cancer agent or agents has an additive or superadditive effect on suppressing tumor growth, as compared to administration of the bispecific anti-IGF-lR and anti-ErbB3 antibody alone or the one or more additional anti-cancer agents alone, wherein the effect on suppressing tumor growth is measured in a mouse xenograft model using BxPC-3, Caki- 1, SK-ES-1, A549, NCI/ADR- RES, BT-474, DU145, or MCF7 cells.

Also provided are compositions for use in the treatment of a cancer, or for the manufacture of a medicament for the treatment of cancer, said composition comprising a bispecific anti-IGF- lR and anti-ErbB3 antibody to be administered to a patient requiring treatment of a cancer, the administration comprising administering to the patient a single loading dose of at least 10 mg/kg of the bispecific antibody followed by administration of one or more maintenance doses given at intervals. The intervals between doses are intervals of at least three days. In some embodiments, the intervals are every fourteen days or every twenty-one days.

In some embodiments, the compositions comprise a loading dose that is greater than the maintenance dose. The loading dose may from 12 mg/kg to 20 mg/kg, from 20 mg/kg to 40 mg/kg, or from 40 mg/kg to 60 mg/kg. In some embodiments the loading dose is about 12 mg/kg, 20 mg/kg, 40 mg/kg, or 60 mg/kg. In other embodiments the maintenance dose is about 6 mg/kg, 12 mg/kg, 20 mg/kg, 30 mg/kg, 40 mg/kg, 50 mg/kg, or 60 mg/kg.

In some embodiments the patient has a pancreatic cancer, a KRAS mutant pancreatic cancer, renal cell carcinoma, Ewing's sarcoma, non-small cell lung cancer, gastrointestinal neuroendocrine cancer, estrogen receptor-positive locally advanced or metastatic cancer, ovarian cancer (e.g., high-grade serous ovarian cancer), colorectal cancer, endometrial cancer, or glioblastoma. In one embodiment, the patient has a cancer that is refractory to one or more anti-cancer agents, e.g., gemcitabine or sunitinib. In one aspect, a patient has a cancer and is selected for treatment with a bispecific anti-IGF-lR and anti-ErbB3 antibody, e.g., MM- 141, only if the patient has a serum concentration (level) of free IGF- 1 (i.e., IGF- 1 in serum that is not bound to an IGF-1 binding protein) that is above the population median level of free IGF- 1 for patients with that type of cancer. In one embodiment, the patient has a pancreatic cancer and has a serum level of free IGF-1 that is above the pancreatic cancer population median level of 0.39 ng/ml of free serum IGF-1. Alternately, the serum concentration of free IGF-1 is 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.5, 4, 4.5, 5, 6.5, or 6 times the lower limit of detection for a particular assay, i.e., the assay described in Example 5. Alternately, the patient is treated with MM- 141 only if the patient's serum free IGF- 1 level meets a cutoff determined for the same type and stage of cancer as the patient. In one embodiment, the cutoff is above the population median level (i.e., the median level in a population of cancer patients with the same type of cancer as the patient). In another embodiment, the cutoff is below the population median level. In one embodiment, the cutoff is about 20%, about 15%, about 10%, or about 5% below or above the population median level.

In one embodiment, the bispecific anti-IGF-lR and anti-ErbB3 antibody comprises an anti-IGF-lR module selected from the group consisting of SF, P4, M78, and M57. In another embodiment the bispecific anti-IGF- lR and anti-ErbB3 antibody comprises an anti-ErbB3 module selected from the group consisting of C8, PI, Ml .3, M27, P6, and B69. In one embodiment, the bispecific anti-IGF- lR and anti-ErbB3 antibody is P4-G1-M1.3. In another embodiment, the bispecific anti-IGF- lR and anti-ErbB3 antibody is P4-G1-C8.

Also provided are kits comprising a therapeutically effective amount of a bispecific anti-IGF-lR and anti-ErbB3 antibody and a pharmaceutically-acceptable carrier, and further comprising instructions to a practitioner, wherein the instructions comprise dosages and administration schedules for the bispecific anti-IGF- lR and anti-ErbB3 antibody. In one embodiment, the kit includes multiple packages each containing a single dose amount of the antibody. In another embodiment, the kit provides infusion devices for administration of the bispecific anti-IGF- lR and anti-ErbB3 antibody. In another embodiment, the kit further comprises an effective amount of at least one additional anti-cancer agent.

Further provided herein are compositions and methods for treating cancer (e.g., Ewing sarcoma) in a human patient, comprising administering to the patient a particular combination of agents, i.e., an ErbB3 and/or IGF-1R inhibitor (e.g., istiratumab)), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide), as well as administration of the agents according to a particular clinical dosage regimen (i.e., at a particular dose amount and according to a specific dosing schedule).

In one embodiment, an ErbB3 inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein. In another embodiment, an IGF-1R inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein. In another embodiment, an ErB3 inhibitor and IGF- 1R inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein. In another embodiment, a bispecific inhibitor

(e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein.

In one embodiment, the ErB3 inhibitor is an antibody. In a particular embodiment, the anti-ErbB3 antibody is a bispecific antibody antagonist of IGF-IR and ErbB3, e.g., having two pairs of polypeptide chains, each pair of said two pairs comprising a heavy chain joined to a light chain by at least one heavy-light chain bond, wherein each light chain comprises the amino acid sequence set forth in SEQ ID NO: l and each heavy chain comprises the amino acid sequence set forth in SEQ ID NO:2. In one embodiment, the bispecific antibody further comprises a linker having the amino acid sequence set forth in SEQ ID NO:3. In another embodiment, the ErbB3 inhibitor is a small molecule, such as a small molecule tyrosine kinase inhibitors (TKIs).

In one embodiment, the IGF- IR inhibitor is an antibody. In a particular embodiment, the anti-IGF- lR antibody is a bispecific antibody antagonist of IGF-IR and ErbB3. In one embodiment, the bispecific antibody is a polyvalent bispecific antibody having two pairs of polypeptide chains, each pair of said two pairs comprising a heavy chain joined to a light chain by at least one heavy-light chain bond, wherein each light chain comprises the amino acid sequence set forth in SEQ ID NO: l and each heavy chain comprises the amino acid sequence set forth in SEQ ID NO:2. In one embodiment, the bispecific antibody further comprises a linker having the amino acid sequence set forth in SEQ ID NO:3. In a particular embodiment, the antibody is istiratumab. In another embodiment, the IGF- IR inhibitor is a small molecule.

In one embodiment, the cancer is a solid tumor, such as a sarcoma, carcinoma, or lymphoma. In another embodiment, the cancer is a sarcoma selected from the group consisting of a Ewing family tumor (e.g., Ewing sarcoma, primitive neuroectodermal tumor, or Askin tumor), Osteosarcoma, or Rhabdomyosarcoma. In another embodiment, the solid tumor is NSCLC, an ovarian tumor, a glioblastoma, a glioma, or a neuroblastoma. In another embodiment, the cancer is a relapsed or refractory tumor. In another embodiment, the cancer is a cancer associated with IGF-1, IGF- 1R, or ErbB3. In a particular embodiment, the cancer is Ewing sarcoma. In another embodiment, the cancer is selected from the group consisting of sarcoma (e.g. Ewing family tumor (e.g., Ewing's sarcoma, primitive neuroectodermal tumor, or Askin tumor), rhabdomyosarcoma, osteosarcoma, myelosarcoma, chondrosarcoma, liposarcoma, leiomyosarcoma, soft tissue sarcoma), lung cancer (e.g. non-small cell lung cancer and small cell lung cancer), bronchus, prostate, breast , pancreas, gastrointestinal cancer, colon, rectum, colon carcinoma, colorectal adenoma, thyroid, liver, intrahepatic bile duct, hepatocellular, adrenal gland, stomach, gastric, glioma (e.g., adult, childhood brain stem, childhood cerebral astrocytoma, childhood visual pathway and hypothalamic), glioblastoma, endometrial, melanoma, kidney, renal pelvis, urinary bladder, uterine corpus, uterine cervix, vagina, ovary (e.g., high-grade serous ovarian cancer), multiple myeloma, esophagus, brain (e.g., brain stem glioma, cerebellar astrocytoma, cerebral

astrocytoma/malignant glioma, ependymoma, meduloblastoma, supratentorial primitive neuroectodermal tumors, visual pathway and hypothalamic glioma), lip and oral cavity and pharynx, larynx, small intestine, melanoma, villous colon adenoma, a neoplasia, a neoplasia of epithelial character, lymphomas (e.g., AIDS-related, Burkitt's, cutaneous T-cell, Hodgkin, non-Hodgkin, and primary central nervous system), a mammary carcinoma, basal cell carcinoma, squamous cell carcinoma, actinic keratosis, tumor diseases, including solid tumors, a tumor of the neck or head, polycythemia vera, essential thrombocythemia, myelofibrosis with myeloid metaplasia, Waldenstrom's macroglobulinemia, adrenocortical carcinoma, AIDS-related cancers, childhood cerebellar astrocytoma, childhood cerebellar astrocytoma, basal cell carcinoma, extrahepatic bile duct cancer, malignant fibrous histiocytoma bone cancer, bronchial adenomas/carcinoids, carcinoid tumor, gastrointestinal carcinoid tumor, primary central nervous system, cerebellar astrocytoma, childhood cancers, ependymoma, extracranial germ cell tumor, extragonadal germ cell tumor, extrahepatic bile duct cancer, intraocular melanoma eye cancer, retinoblastoma eye cancer, gallbladder cancer, gastrointestinal carcinoid tumor, germ cell tumors (e.g., extracranial, extragonadal, and ovarian), gestational trophoblastic tumor, hepatocellular cancer, hypopharyngeal cancer, hypothalamic and visual pathway glioma, islet cell carcinoma (endocrine pancreas), laryngeal cancer, malignant fibrous histiocytoma of bone/osteosarcoma, meduloblastoma, mesothelioma, metastatic squamous neck cancer with occult primary, multiple endocrine neoplasia syndrome, multiple myeloma/plasma cell neoplasm, mycosis fungoides, nasal cavity and paranasal sinus cancer, nasopharyngeal cancer, neuroblastoma, oral cancer, oropharyngeal cancer, ovarian epithelial cancer, ovarian germ cell tumor, ovarian low malignant potential tumor, islet cell pancreatic cancer, parathyroid cancer,

pheochromocytoma, pineoblastoma, pituitary tumor, pleuropulmonary blastoma, ureter transitional cell cancer, retinoblastoma, rhabdomyosarcoma, salivary gland cancer, Sezary syndrome, non-melanoma skin cancer, Merkel cell carcinoma, squamous cell carcinoma, testicular cancer, thymoma, gestational trophoblastic tumor, and Wilms' tumor. The cancer may be a primary tumor; the tumor may be a metastatic tumor. The cancer may be pancreatic cancer, ovarian cancer (e.g., high-grade serous ovarian cancer, platinum resistant ovarian cancer, or high-grade serous platinum resistant ovarian cancer), sorafenib-naive or sorafenib- refractory hepatocellular carcinoma, parathyroid cancer, sarcoma, lung cancer, or breast cancer. The cancer may be a KRAS mutant cancer (e.g., a KRAS mutant pancreatic cancer).

In one embodiment, the inhibitor (e.g., istiratumab), the topoisomerase I inhibitor (e.g., irinotecan), and the alkyating agent (e.g., temozolomide) are each administered in a separate formulation or a separate unit dosage form. In another embodiment, the inhibitor (e.g., istiratumab), the topoisomerase I inhibitor (e.g., irinotecan), and the alkyating agent (e.g., temozolomide) are administered simultaneously or sequentially. In another

embodiment, the inhibitor (e.g., istiratumab) and topoisomerase I inhibitor (e.g., irinotecan) are administered intravenously. In another embodiment, the alkyating agent (e.g., temozolomide) is administered orally.

In one embodiment, the inhibitor (e.g., an ErbB3 inhibitor or IGF-1R inhibitor), topoisomerase I inhibitor, and alkylating agent are administered according to a particular regimen (e.g., dosing regimen) to treat cancer (e.g., Ewing sarcoma).

In one embodiment, istiratumab is administered intravenously at a dose of 40 mg/kg every two weeks. In another embodiment, istiratumab is administered intravenously at a fixed dose of 2.8 g every two weeks.

In one embodiment, irinotecan is administered intravenously at a dose of 50 mg/m² on days 1-5 every three weeks and temozolomide is administered orally at a dose of 75- 100 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle). In another embodiment, irinotecan is administered intravenously at a dose of 50 mg/m² on days 1-5 every three weeks and temozolomide is administered orally at a dose of 125 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle).

In another embodiment, irinotecan is administered intravenously at a dose of 25- 100 mg/m², 25-150 mg/m², 50-100 mg/m², 75- 100 mg/m², 100- 125 mg/m², or 125- 150 mg/m² on days 1-5 every three weeks and temozolomide is administered orally at a dose of 125 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle).

In another embodiment, irinotecan is administered intravenously at a dose of 10 mg/m², 20 mg/m², or 25 mg/m² on days 1-5 and 8- 12 every three weeks and temozolomide is administered orally at a dose of 50-100 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle).

In another embodiment, irinotecan is administered intravenously at a dose of 5-40 mg/m², 10-40 mg/m², 20-40 mg/m², 30-40 mg/m², 10-50 mg/m², 20-50 mg/m², 30-50 mg/m², or 40-60 mg/m² on days 1-5 and 8- 12 every three weeks and temozolomide is administered orally at a dose of 25- 100 mg/m², 25- 150 mg/m², 50-100 mg/m², 50- 125 mg/m², 50-150 mg/m², 75- 100 mg/m², or 75-150 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle). In one embodiment, the irinotecan is irinotecan sucrosofate liposome injection (e.g., Onivyde®). In one embodiment, the irinotecan sucrosofate liposome injection is administered intravenously at a dose of 35-50 mg/m² every two weeks and temozolomide is administered orally at a dose of 25-100 mg/m², 25-150 mg/m², 50- 100 mg/m², 50-125 mg/m², 50- 150 mg/m², 75-100 mg/m², 75- 150 mg/m², 100- 150 mg/m²,125-150 mg/m², or 125 mg/m² on days 1-5 every three weeks. In another embodiment, the irinotecan

sucrosofate liposome injection is intravenously at a dose of 50-70 mg/m² every two weeks and temozolomide is administered orally at a dose of 25- 100 mg/m², 25- 150 mg/m², 50-100 mg/m², 50- 125 mg/m², 50-150 mg/m², 75- 100 mg/m², or 75- 150 mg/m², or 125 mg/m² on days 1-5 every three weeks.

In another embodiment, provided is the use of istiratumab, irinotecan, and

temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma. In another embodiment, provided is istiratumab, irinotecan, and

temozolomide for use in the treatment of a patient having Ewing sarcoma. In another embodiment, provided is istiratumab for use in the treatment of a patient having Ewing sarcoma, wherein the treatment further comprises administering irinotecan and

temozolomide. In another embodiment, provided is irinotecan for use in the treatment of a patient having Ewing sarcoma, wherein the treatment further comprises administering istiratumab and temozolomide. In another embodiment, provided is temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein the treatment further comprises administering istiratumab and irinotecan.

In another embodiment, a method of treating a patient having Ewing sarcoma is provided, comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(B) irinotecan intravenously at a dose of 50 mg/m² on days 1-5 every three weeks; and

(C) temozolomide orally at a dose of 75-100 mg/m² on days 1-5 every three weeks. In another embodiment, provided is the use of istiratumab, irinotecan, and

temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, or istiratumab, irinotecan, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

(A) istiratumab is administered intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(B) irinotecan is administered intravenously at a dose of 50 mg/m² on days 1-5 every three weeks; and

(C) temozolomide is administerd orally at a dose of 75-100 mg/m² on days 1-5 every three weeks. In another embodiment, a method of treating a patient having Ewing sarcoma is provided, comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 125 mg/m² on days 1-5 every three weeks. In another embodiment, provided is the use of istiratumab, irinotecan, and

(C) temozolomide is administered orally at a dose of 125 mg/m² on days 1-5 every three weeks. In another embodiment, a method of treating a patient having Ewing sarcoma is provided, comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(B) irinotecan intravenously at a dose of 10 mg/m², 20 mg/m², or 25 mg/m² on days 1- 5 and 8-12 every three weeks; and

(C) temozolomide orally at a dose of 50-100 mg/m² on days 1-5 every three weeks. In another embodiment, provided is the use of istiratumab, irinotecan, and

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 50-100 mg/m² on days 1-5 every three weeks. In another embodiment, a method of treating a patient having Ewing sarcoma is provided, comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(B) irinotecan sucrosofate liposome injection (e.g., Onivyde®) intravenously at a dose of 35-50 mg/m² or 50-70 mg/m² every two weeks; and

(C) temozolomide orally at a dose of 75-100 mg/m² on days 1-5 every three weeks. In another embodiment, provided is the use of istiratumab, irinotecan sucrosulfate liposome injection, and temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, or istiratumab, irinotecan sucrosulfate liposome injection, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

(B) irinotecan sucrosofate liposome injection (e.g., Onivyde®) is administered

intravenously at a dose of 35-50 mg/m² or 50-70 mg/m² every two weeks; and

(C) temozolomide is administered orally at a dose of 75- 100 mg/m² on days 1-5 every three weeks.

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks; (B) irinotecan sucrosofate liposome injection (e.g., Onivyde®) intravenously at a dose of 35-50 mg/m² or 50-70 mg/m² every two weeks; and

(C) temozolomide orally at a dose of 125 mg/m² on days 1-5 every three weeks.

In another embodiment, provided is the use of istiratumab, irinotecan sucrosulfate liposome injection, and temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, or istiratumab, irinotecan sucrosulfate liposome injection, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

(B) irinotecan sucrosofate liposome injection (e.g., Onivyde®) is administered

intravenously at a dose of 35-50 mg/m² or 50-70 mg/m² every two weeks; and (C) temozolomide is administered orally at a dose of 125 mg/m² on days 1-5 every three weeks.

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks ;

(C) temozolomide orally at a dose of 50-100 mg/m² on days 1-5 every three weeks. In another embodiment, provided is the use of istiratumab, irinotecan sucrosulfate liposome injection, and temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, or istiratumab, irinotecan sucrosulfate liposome injection, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks ;

(C) temozolomide orally at a dose of 50-100 mg/m² on days 1-5 every three weeks. In one embodiment, the treatment cycle for istiratumab is a two week cycle. In another embodiment, the treatment cycle for irinotecan and temozolomide is a three week cycle. In another embodiment, the treatment cycle for irinotecan sucrosofate liposome injection (e.g., Onivyde®) is a two week cycle. In one embodiment the treatment cycle for istiratumab overlaps with the the treatment cycle for irinotecan and temozolomide. In one embodiment, an additional antineoplastic agent is administered, along with the inhibitor (e.g., istiratumab), topoisomerase I inhibitor (e.g., irinotecan), and alkylating agent (e.g., temozolomide), during treatment. In another embodiment, no more than three antineoplastic agents are administered during treatment. In another embodiment, no more than two other antineoplastic agents are administered during treatment. In another embodiment, no more than one other antineoplastic agent is administered during

treatment. In another embodiment, no other antineoplastic agent is administered during treatment.

Also provided are kits that include an inhibitor (e.g., istiratumab), topoisomerase I inhibitor (e.g., irinotecan), and alkyating agent (e.g., temozolomide) in therapeutically effective amounts adapted for use in the methods described herein. In one embodiment, the kit comprises: a dose of an inhibitor (e.g., istiratumab), topoisomerase I inhibitor (e.g., irinotecan), and alkyating agent (e.g., temozolomide) and instructions for using the inhibitor, topoisomerase I inhibitor, and alkyating agent in the methods described herein.

BRIEF DESCRIPTION OF THE DRAWINGS

Figures 1A-1D show clinical pharmacodynamic (PD) effects of MM- 141 treatment on serum total IGF-1 levels and pharmacokinetic (PK) analysis of serum MM- 141 levels for monotherapy dose levels of 6 mg/kg q7d (Figure 1A), 12 mg/kg q7d (Figure IB), 20 mg/kg q7d (Figure 1C) and 40 mg/kg ql4d (Figure ID). q7d = qw, ql4d = q2w. The y-axis represents either MM- 141 in serum in μg/ml (top) or total serum IGF-1 in mg/dL (bottom).

The x-axis labeling indicates time in hours in relation to each cycle (C) and week (W) of dosing, with FUP_30D indicating a 30 day follow-up.

Figure 2 shows the pre- (top panels) and post- (bottom panels) MM- 141 treatment levels of ErbB3 (left panels) and IGF-IR (right panels), as detected by

immunohistochemistry, in hepatocellular carcinoma tumor biopsies taken from a patient enrolled in an MM- 141 Phase 1 clinical trial.

Figures 3A-3D show the effects of MM- 141 on surface expression levels of IGF-IR

(Figure 3 A) and ErbB3 (Figure 3B) compared to the effects of a monospecific IGF- IR antibody and a monospecific ErbB3 antibody, as measured by ELISA. In addition, treatment with MM- 141 leads to increased degradation of IGF-IR (Figure 3C) and ErbB3 (Figure 3D) receptors, as evidenced by enhanced receptor ubiquitination, measured using

immunoprecipitation and immunoblotting assays in vitro. Figures 4A and 4B show the distribution of free IGF-1 in serum (i.e., IGF-1 not bound by one or more of six IGF-1 binding proteins). Figure 4A shows the distribution in serum taken from Stage 3 and Stage 4 pancreatic cancer patients. Each column represents a single serum sample. Figure 4B shows that Phase 1 breast cancer patients who have a level of free serum IGF-1 above a cutpoint are able to stay on study longer, and thus receive more therapeutic doses of MM-141, than patients whose level of free serum IGF-1 was below the cutpoint.

Figure 5 shows modeling of the steady state exposure of MM-141 administered at different dosing schedules. Average, maximal and minimal steady state concentrations of MM-141 were modeled on the basis of Phase 1 PK data. The 2.8 g Q2W regimen was indicated to have similar exposures to the 40 mg/kg Q2W regimen and the 2.24 g Q2W regimen was indicated to yield smaller exposures than the 20 mg/kg QW regimen.

Figure 6 shows the mean surface receptor expression of EGFR, HER2, ErbB3, IGF- IR, and insulin receptor (INSR) on 6 Ewing sarcoma cell lines (A-673, Hs 822. T, Hs 869. T, RD-ES, SK-ES-1, and SK-N-DW), as measured by quantitative flow cytometry.

Figure 7 shows the effect of treatment of Ewing sarcoma cell lines with different concentrations of SN-38, temozolomide, and MM-141 in vitro, expressed as percent cell proliferation normalized to no-treatment control, as measured by Cell TitreGlo assay.

Figure 8 shows the effect of treatment with MM-141 and the ligands IGF-1 and heregulin (HRG), alone or in combination, on Ewing sarcoma cell line proliferation in vitro, as measured by Cell TitreGlo assay.

Figure 9 shows the effect of treatment with MM-141, IGF-1, and HRG, alone or in combination, on expression of cellular proteins (IGF-IR, pIGF-lR, pAKT (S473), pS6 (S240, S244), pERK, and beta actin in Ewing sarcoma cell lines, as measured by immunoblotting.

Figure 10 shows the effects of treatment with PBS, istiratumab (MM-141), a combination of irinotecan and temozolomide (IRI-TEM), and a combination of IRI-TEM + istiratumab (MM-141) on the growth of RD-ES tumors in vivo. Additionally, the effect of treatment with a combination of irinotecan and temozolomide (IRI-TEM) and a combination of IRI-TEM + istiratumab (MM-141) on the growth of RD-ES tumors previously treated with a combination of IRI-TEM is evaluated after a 4 week period of no treatment. DETAILED DESCRIPTION

Methods and Compositions

Methods of combination therapy and combination compositions for treating cancer in a patient are provided. In these methods, the cancer patient is treated with both a bispecific anti-IGF-lR and anti-ErbB3 antibody and one or more additional anti-cancer agents selected, e.g., from an mTOR inhibitor, a PI3K inhibitor, and an antimetabolite.

As used herein, "anti-cancer agent" (also referred to as an "antineoplastic agent") refers to agents that have the functional property of inhibiting the development or progression of a neoplasm in a human, particularly a malignant (cancerous) lesion, such as a carcinoma, sarcoma, lymphoma, or leukemia. Inhibition of metastasis is frequently a property of antineoplastic agents.

As used herein, the term "administer" or "administration" refers to the act of injecting or otherwise physically delivering a substance as it exists outside the body (e.g., a

formulation of the molecules disclosed herein) into a patient, such as by mucosal, intradermal, intravenous, intramuscular delivery and/or any other method of physical delivery described herein or known in the art. When a disease, or a symptom thereof, is being treated, administration of the substance typically occurs after the onset of the disease or symptoms thereof. When a disease, or symptoms thereof, is being prevented, administration of the substance typically occurs before the onset of the disease or symptoms thereof.

The terms "combination therapy," "co-administration," "co-administered" or

"concurrent administration" (or minor variations of these terms) include simultaneous administration of at least two therapeutic agents to a patient or their sequential administration within a time period during which the first administered therapeutic agent is still present in the patient (e.g., in the patient's plasma or serum) when the second administered therapeutic agent is administered.

The term "monotherapy" refers to administering a single drug to treat a disease or disorder in the absence of co-administration of any other therapeutic agent that is being administered to treat the same disease or disorder.

"Additional anti-cancer agent" is used herein to indicate any drug that is useful for the treatment of a malignant pancreatic tumor other than a drug that inhibits heregulin binding to ErbB2/ErbB3 heterodimer.

"Dosage" refers to parameters for administering a drug in defined quantities per unit time (e.g., per hour, per day, per week, per month, etc.) to a patient. Such parameters include, e.g., the size of each dose. Such parameters also include the configuration of each dose, which may be administered as one or more units, e.g., as one or more administrations, e.g., either or both of orally (e.g., as one, two, three or more pills, capsules, etc.) or injected (e.g., as a bolus or infusion). Dosage sizes may also relate to doses that are administered continuously (e.g., as an intravenous infusion over a period of minutes or hours). Such parameters further include frequency of administration of separate doses, which frequency may change over time.

"Dose" refers to an amount of a drug given in a single administration.

Some drugs are dosed according to body weight (mg/kg) or body surface area (BSA) (mg/m²). As used herein, a "body surface area (BSA)-based dose" refers to a dose of an agent that is adjusted to the body-surface area (BSA) of the individual patient. Various calculations have been published to arrive at the BSA without direct measurement, the most widely used of which is the Du Bois formula (see Du Bois D, Du Bois EF (Jun 1916) Archives of Internal Medicine 17 (6): 863-71; and Verbraecken, J. et al. (Apr 2006). Metabolism— Clinical and Experimental 55 (4): 515-24). Other exemplary BSA formulas include the Mosteller formula (Mosteller RD. N Engl J Med., 1987; 317: 1098), the Haycock formula (Haycock GB, et al., Pediatr 1978, 93:62-66), the Gehan and George formula (Gehan EA, George SL, Cancer Chemother Rep 1970, 54:225-235), the Boyd formula (Current, JD (1998), The Internet Journal of Anesthesiology 2 (2); and Boyd, Edith (1935), University of Minnesota. The Institute of Child Welfare, Monograph Series, No. x. London: Oxford University Press), the Fujimoto formula (Fujimoto S, et al., Nippon Eiseigaku Zasshi 1968;5:443-50), the Takahira formula (Fujimoto S, et al., Nippon Eiseigaku Zasshi 1968;5:443-50), and the Schlich formula (Schlich E, et al., Ernahrungs Umschau 2010;57: 178-183).

Other drugs are dosed according to a "fixed dose." As used herein, the terms "fixed dose", "flat dose", and "flat- fixed dose" are used interchangeably and refer to a dose that is administered to a patient without regard for the weight or body surface area (BSA) of the patient. The fixed or flat dose is therefore not provided as a mg/kg dose, but rather as an absolute amount of the agent.

As used herein, the terms "treat," "treating," and "treatment" refer to therapeutic or preventative measures described herein. The methods of "treatment" employ administration to a subject, the combination disclosed herein in order to prevent, cure, delay, reduce the severity of, or ameliorate one or more symptoms of the disease or disorder or recurring disease or disorder, or in order to prolong the survival of a subject beyond that expected in the absence of such treatment.

As used herein, the term "agent," refers to an active molecule, e.g., a therapeutic protein, e.g., a drug.

As used herein, "effective treatment" refers to treatment producing a beneficial effect, e.g., amelioration of at least one symptom of a disease or disorder. A beneficial effect can take the form of an improvement over baseline, i.e., an improvement over a measurement or observation made prior to initiation of therapy according to the method. Effective treatment may refer to alleviation of at least one symptom of cancer.

"Effective amount" refers to an amount (administered in one or more doses) of an antibody, protein, or additional therapeutic agent, which amount is sufficient to provide effective treatment, e.g., an amount of an agent that provides the desired biological, therapeutic, and/or prophylactic result. That result can be reduction, amelioration, palliation, lessening, delaying, and/or alleviation of one or more of the signs, symptoms, or causes of a disease, or any other desired alteration of a biological system. An effective amount can be administered in one or more administrations.

As used herein, "sample", "tumor cell sample," "cancer cell sample", "patient sample", or "sample from a patient", as used herein, is meant a sample comprising tumor cells from the patient. Such a sample may be, e.g., from a biopsy of a tumor, a tissue sample, or circulating tumor cells from the blood.

As used herein, the term "subject" or "patient" is a human patient (e.g., a patient having cancer).

"ErbB3"and "HER3" refer to ErbB3 protein, as described in U.S. Pat. No. 5,480,968. The human ErbB3 protein sequence is set forth herein as SEQ ID NO:7 and is also shown in SEQ ID NO:4 of U.S. Pat. No. 5,480,968, wherein the first 19 amino acids (aas) correspond to the leader sequence that is cleaved from the mature protein. ErbB3 is a member of the ErbB family of receptors, other members of which include ErbB l (EGFR), ErbB2

(HER2/Neu) and ErbB4. While ErbB3 itself lacks tyrosine kinase activity, but is itself phosphorylated upon dimerization of ErbB3 with another ErbB family receptor, e.g., ErbB 1 (EGFR), ErbB2 and ErbB4, which are receptor tyrosine kinases. Ligands for the ErbB family receptors include heregulin (HRG), betacellulin (BTC), epidermal growth factor (EGF), heparin-binding epidermal growth factor (HB-EGF), transforming growth factor alpha (TGF- α ), amphiregulin (AR), epigen (EPG), and epiregulin (EPR). The aa sequence of human ErbB3 is provided at Genbank Accession No. NP_001973.2 (receptor tyrosine-protein kinase erbB-3 isoform 1 precursor) and is assigned Gene ID: 2065.

"IGF-1R" or "IGF1R" refers to the receptor for insulin-like growth factor 1 (IGF-1, formerly known as somatomedin C). IGF-1R also binds to, and is activated by, insulin-like growth factor 2 (IGF-2). IGF1-R is a receptor tyrosine kinase, which, upon activation by IGF-1 or IGF-2, is auto-phosphorylated. The aa sequence of human IGF-1R precursor is provided at Genbank Accession No. NP_000866 and is assigned Gene ID: 3480.

"Module" refers to a structurally and/or functionally distinct part of a PBA, such a binding site (e.g., an scFv domain or a Fab domain) and the Ig constant domain. Modules provided herein can be rearranged (by recombining sequences encoding them, either by recombining nucleic acids or by complete or fractional de novo synthesis of new

polynucleotides) in numerous combinations with other modules to produce a wide variety of PBAs as disclosed herein. For example, an "SF" module refers to the binding site "SF," i.e., comprising at least the CDRs of the SF VH and SF VL domains. A "C8" module refers to the binding site "C 8."

"PBA" refers to a polyvalent bispecific antibody, an artificial hybrid protein comprising at least two different binding moieties or domains and thus at least two different binding sites (e.g., two different antibody binding sites), wherein one or more of the pluralities of the binding sites are covalently linked, e.g., via peptide bonds, to each other. A preferred PBA described herein is an anti-IGF-lR+anti-ErbB3 PBA (e.g., as disclosed in

U.S. Patent No. 8,476,409), which is a polyvalent bispecific antibody that comprises one or more first binding sites binding specifically to human IGF-1R protein, and one or more second binding sites binding specifically to human ErbB3 protein. An anti-IGF-lR+anti- ErbB3 PBA is so named regardless of the relative orientations of the anti-IGF-lR and anti- ErbB3 binding sites in the molecule, whereas when the PBA name comprises two antigens separated by a slash (/) the antigen to the left of the slash is amino terminal to the antigen to the right of the slash. A PBA may be a bivalent binding protein, a trivalent binding protein, a tetravalent binding protein, or a binding protein with more than 4 binding sites. An exemplary PBA is a tetravalent bispecific antibody, i.e., an antibody that has 4 binding sites, but binds to only two different antigens or epitopes. Exemplary bispecific antibodies are tetravalent "anti-IGF-lR/anti-ErbB3" PBAs and "anti-ErbB3 /anti- IGF-1R" PBAs.

Typically the N-terminal binding sites of a tetravalent PBA are Fabs and the C-terminal binding sites are scFvs. Exemplary IGF-lR+ErbB3 PBAs comprising IgGl constant regions each comprise two joined essentially identical subunits, each subunit comprising a heavy and a light chain that are disulfide bonded to each other, (SEQ ID NOs hereinafter refer to sequences set forth in U.S. Patent No. 8,476,409, which is herein incorporated by reference in its entirety) e.g., M7-G1-M78 (SEQ ID NO: 284 and SEQ ID NO: 262 are the heavy and light chain, respectively), P4-G1-M1.3 (SEQ ID NO: 226 and SEQ ID NO: 204 are the heavy and light chain, respectively), and P4-G1-C8 (SEQ ID NO: 222 and SEQ ID NO: 204 are the heavy and light chain, respectively), are exemplary embodiments of such IgGl- (scFv)₂ proteins. When the immunoglobulin constant regions are those of IgG2, the protein is referred to as an IgG2-(scFv)₂. Other exemplary IGF-lR+ErbB3 PBAs comprising IgGl constant regions include (as described in U.S. Patent No. 8,476,409) SF-G1-P1,SF-G1- M1.3, SF-G1-M27, SF-G1-P6, SF-G1-B69, P4-G1-C8, P4-G1-P1, P4-G1-M1.3, P4-G1- M27, P4-G1-P6, P4-G1-B69, M78-G1-C8, M78-G1-P1, M78-G1-M1.3, M78-G1-M27, M78-G1-P6, M78-G1-B69, M57-G1-C8, M57-G1-P1, M57-G1-M1.3, M57-G1-M27, M57- G1-P6, M57-G1-B69, P1-G1-P4, P1-G1-M57, P1-G1-M78, M27-G1-P4, M27-G1-M57, M27-G1-M78, M7-G1-P4, M7-G1-M57, M7-G1-M78, B72-G1-P4, B72-G1-M57, B72-G1- M78, B60-G1-P4, B60-G1-M57, B60-G1-M78, P4M-G1-M1.3, P4M-G1-C8, P33M-G1- M1.3, P33M-G1-C8, P4M-G1-P6L, P33M-G1-P6L, P1-G1-M76.

The heavy and light chain sequences of M7-G1-M78, P4-G1-M1.3, and P4-G1-C8 are listed below:

M7-G1-M78 Heavy chain (SEQ ID NO: 4)

E VQLVES GGGLVQPGRS LRLS C A AS GFTFDD Y AMHW VRQ APGKGLEW VS GI S WDS GS VG Y ADS VKGRFTIS RDN AKNS LYLQMNS LRAEDT ALY YC ARDLG YNQW WEGFD YWGQGTLVT VS S AS TKGPS VFPLAPS S KS TS GGT A ALGCLVKD YFPEP VT V S WNS G ALTS G VHTFP A VLQS S GLYS LS S V VT VPS S S LGTQT YICN VNHKPS NTKVDK KVEPKSCDKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDP EVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSN KALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWES NGQPENN YKTTPP VLDS DGS FFLYS KLT VD KS RWQQGN VFS C S VMHE ALHNHYTQ KSLSLSPGGGGGSGGGGSGGGGSEVQLLQSGGGLVQPGGSLRLSCAASGFDFSSYP MHW VRQ APGKGLEW VGS IS S S GG ATP Y ADS VKGRFTIS RDNS KNTLYLQMNS LRPE DTAVYYCAKDFYTILTGNAFDMWGQGTSVTVSSASTGGGGSGGGGSGGGGSGGG GS DIQMTQS PS S LS AS LGDRVTITCR AS QGIS S YLA W YQQKPGK APKLLIY AS S TRQS G VPS RFS GS GS GTDFTLTIS S LQPEDS GT Y YC QQ YW AFPLTFGGGTKVEIKRT M7-G1-M78 Light chain (SEQ ID NO: 5)

SSELTQDPAVSVALGQTVRITCQGDSLRSYYASWYQQKPGQAPVLVIYGKNN RPS GIPDRFS GS S S GNT ASLTITGAQAEDEAD YYCNSRDTPGNKW VFGGGTKVT VIG QPKAAPSVTLFPPSSEELQANKATLVCLVSDFYPGAVTVAWKADGSPVKVGVETTK PS KQS NNKY A AS S YLS LTPEQWKS HRS YS CR VTHEGS T VEKT V AP AEC S

P4-G1-M1.3 Heavy chain (SEQ ID NO: 2)

E VQLLQS GGGLVQPGGS LRLS C A AS GFMFS R YPMHW VRQ APGKGLE W VGS IS GS G GATPYADS VKGRFTIS RDNS KNTLYLQMNS LRAEDT A VYYC AKDFYQILTGNAFD Y WGQGTT VT VS S AS TKGPS VFPLAPS S KS TS GGT A ALGCLVKD YFPEP VT VS WNS G A LTS G VHTFP A VLQS S GLYS LS S V VT VPS S S LGTQT YICN VNHKPS NTKVDKKVEPKS CDKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFN WYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPA PIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPE NNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLS PGGGGGSGGGGSGGGGS Q VQLVQS GGGLVQPGGS LRLS C A AS GFTFDD Y AMHW V RQAPGKGLEWVAGISWDSGSTGYADSVKGRFTISRDNAKNSLYLQMNSLRAEDTA LYYC ARDLGA YQWVEGFD YWGQGTLVTVS S ASTGGGGS GGGGS GGGGS GGGGS S YELTQDPAVSVALGQTVRITCQGDSLRSYYASWYQQKPGQAPVLVIYGKNNRPSGI PDRFS GS TS GNS AS LTITG AQ AEDE AD Y YCNS RDS PGNQW VFGGGTKVT VLG

P4-G1-M1.3 and P4-G1-C8 Light chain (SEQ ID NO: 1)

DIQMTQS PS S LS AS LGDRVTITCR AS QGIS S YLA W YQQKPGKAPKLLIY AKSTLQS G VPSRFS GS GS GTDFTLTIS S LQPEDS AT YYCQQYWTFPLTFGGGTKVEIKRTVAAPS V FIFPPSDEQLKSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDS T YS LS S TLTLS KAD YEKHKV Y ACE VTHQGLS S P VTKS FNRGEC

P4-G1-C8 Heavy chain (SEQ ID NO: 6)

E VQLLQS GGGLVQPGGS LRLS C A AS GFMFS R YPMHW VRQ APGKGLE W VGS IS GS G GATPYADS VKGRFTIS RDNS KNTLYLQMNS LRAEDT A VYYC AKDFYQILTGNAFD Y WGQGTT VTVS S AS TKGPS VFPLAPS S KS TS GGT A ALGCLVKD YFPEP VTVS WNS G A LTS G VHTFP A VLQS S GLYS LS S V VT VPS S S LGTQT YICN VNHKPS NTKVDKKVEPKS CDKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFN WYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPA PIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPE NNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLS PGGGGGSGGGGSGGGGS Q VQLVQS GGGLVQPGGS LRLS C A AS GFTFDD Y AMHW V RQ APGKGLEW V AGIS WNS GS IG Y ADS VKGRFTIS RDN AKNS LYLQMNS LRPEDT A V Y YC ARDLG YNQW VEGFD YWGQGTLVT VS SASTGGGGSGGGGSGGGGSGGGGSSY ELTQDPAVSVALGQTVRITCQGDSLRSYYASWYQQKPGQAPVLVIYGKNNRPSGIP DRFS GS TS GNS AS LTITG AQ AEDE AD Y YCNS RDS S GNHW VFGGGTKVT VLG

"MM- 141" or "istiratumab" refers to a recombinant fully human bispecific anti-IGF- 1R and anti-ErbB3 tetravalent antibody (also known as PBA P4-G1-M1.3). The complete tetrameric structure of the IgGl -based molecule is composed of two heavy chains (720 amino acids each) and two kappa light chains (214 amino acids each) held together by intrachain and inter-chain disulfide bonds. The variable regions of the heavy and light chains encode anti-IGF-lR modules. The C-terminus of the heavy chain encodes anti- ErbB3 scFv modules. MM-141-P5G5 is the designation for Master Cell Bank which produces MM- 141. Istiratumab has two pairs of polypeptide chains, each pair of said two pairs comprising a heavy chain joined to a light chain by at least one heavy-light chain bond, wherein each light chain comprises the amino acid sequence set forth in SEQ ID NO: 1 and each heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 2. SEQ ID NOs: 1 and 2 correspond to SEQ ID NOs: 204 and 226, respectively, as set forth in U.S. Patent No. 8,476,409 (which is herein incorporated by reference in its entirety). In one embodiment, istiratumab comprises a linker having the amino acid sequence set forth in

SEQ ID NO: 3, which corresponds to SEQ ID NO: 53 as set forth in PCT/US2010/052712 (which is herein incorporated by reference in its entirety).

Combination Therapies with Additional Anti-Cancer Agents

As herein provided, PBAs (e.g., P4-G1-M1.3) are co-administered with one or more additional anti-cancer agents (e.g., an mTOR inhibitor, a PI3K inhibitor, an antimetabolite, a topoisomerase inhibitor, and an alkylating agent), to provide effective treatment to human patients having a cancer (e.g., pancreatic, ovarian, lung, colon, head and neck, and

esophageal cancers). Additional anti-cancer agents suitable for combination with anti-ErbB3 antibodies may include, but are not limited to, pyrimidine antimetabolites, mTOR inhibitors, pan-mTOR inhibitors, phosphoinositide-3-kinase (PI3K) inhibitors, MEK inhibitors, taxanes, and nanoliposomal irinotecan (e.g., MM-398). As used herein, "topoisomerase inhibitors" refer to agents designed to interfere with the action of topoisomerase enzymes (topoisomerase I and II), which are enzymes that control the changes in DNA structure by catalyzing the breaking and rejoining of the phosphodiester backbone of DNA strands during the normal cell cycle. Topoisomerase inhibitors are often divided according to which type of enzyme it inhibits. Topoisomerase I inhibitors include, but are not limited to, irinotecan, topotecan, camptothecin, and lamellarin D, and all target type IB topoisomerases. Topoisomerase II inhibitors include, but are not limited to, etoposide (VP-16), teniposide, doxorubicin, daunorubicin, mitoxantrone, amsacrine, ellipticines, aurintricarboxylic acid, and HU-331, a quinolone synthesized from cannabidiol. In some embodiments of the methods and compositions disclosed herein, the topoisomerase inhibitor is a topoisomerase I inhibitor (e.g., irinotecan, nanoliposomal irinotecan, topotecan, camptothecin, indotecan, indimitecan, or SN-38).

Irinotecan HC1 (Camptosar® or Campto®) is a topoisomerase 1 -inhibitor, mainly used in the treatment of colon cancer. It is often used in the FOLFIRI regimen, consisting of infusion of 5-fluorouracil, leucovorin, and irinotecan (CAS No. 100286-90-6).

Nanoliposomal irinotecan (irinotecan sucrosofate liposome injection: MM-398 also disclosed as MM-398 or Onivyde®) is a stable nanoliposomal formulation of irinotecan. MM-398 is described, e.g., in U.S. Patent No. 8, 147,867. The nanoliposomal encapsulation improves the pharmacokinetics of irinotecan and results in a lower C_max, longer half-life, and higher levels of irinotecan and SN-38 in tumor tissue compared with standard irinotecan. Nal-IRI is approved by the FDA under the brand name ONIVYDE, in combination with 5- FU and leucovorin in gemcitabine refractory pancreatic adenocarcinoma. MM-398 may be administered, for example, on day 1 of the cycle at a dose of 120 mg/m², except if the patient is homozygous for allele UGT1A1*, wherein nanoliposomal irinotecan is administered on day 1 of cycle 1 at a dose of 80 mg/m². The required amount of MM-398 may be diluted, e.g., in 500 mL of 5% dextrose injection USP and infused over a 90 minute period.

Topotecan (Hycamtin®) is a chemotherapeutic agent that is a topoisomerase inhibitor. It can be used to treat ovarian cancer, cervical cancer, lung cancer, neuroblastomas, brainstem gliomas, and Ewing's sarcoma (CAS No. 123948-87-8).

Camptothecin (CPT) is a cytotoxic quinoline alkaloid which inhibits the DNA enzyme topoisomerase I (topo I). CPT has a planar pentacyclic ring structure, that includes a pyrrolo[3,4-P]-quinoline moiety (rings A, B and C), conjugated pyridone moiety (ring D) and one chiral center at position 20 within the alpha-hydroxy lactone ring with (S) configuration (the E-ring).

Indotecan (also known as LPM400) is a selective and potent topoisomerase I inhibitor, which as an indenoisoquinoline structure.

Indimitecan (also known as LMP776) is a topoisomerase I inhibitor.

SN38 is an antineoplastic drug. It is the active metabolite of irinotecan (an analog of camptothecin - a topoisomerase I inhibitor), but has 1000 times more activity than irinotecan itself. SN38 is formed via hydrolysis of irinotecan by carboxylesterases and metabolized via glucuronidation by UGT1A1.

As used herein, "alkylating agents" refers to a class of antineoplastic or anticancer drugs which act by inhibiting the transcription of DNA into RNA and thereby stopping the protein synthesis. Alkylating agents substitute alkyl groups for hydrogen atoms on DNA, resulting in the formation of cross links within the DNA chain and thereby resulting in cytotoxic, mutagenic, and carcinogenic effects. This action occurs in all cells, but alkylating agents have their primary effect on rapidly dividing cells (such as cancer cells), which do not have time for DNA repair. The end result of the alkylation process results in the misreading of the DNA code and the inhibition of DNA, RNA, and protein synthesis and the triggering of programmed cell death (apoptosis) in rapidly proliferating tumor cells. The alkylating agents are generally separated into six classes: (1) the nitrogen mustards (e.g.,

mechlorethamine, cyclophosphamide, ifosfamide, melphalan and chlorambucil] (2) ethylenamine and methylenamine derivatives (e.g., altretamine and thiotepa), (3) alkyl sulfonates (e.g., busulfan), (4) nitrosoureas (e.g., carmustine and lomustine), (5) triazenes (e.g., dacarbazine, procarbazine, and temozolomide), and (6) the platinum-containing antineoplastic agents (e.g., cisplatin, carboplatin, and oxaliplatin), which are referred to as platinum coordination complexes. These antineoplastic drugs are usually classified as alkylating agents, although they do not alkylate DNA, but cause covalent DNA adducts by a different means. In some embodiments of the methods and compositions disclosed herein, the alkylating agent is a triazene (e.g., dacarbazine, procarbazine, or temozolomide).

Temozolomide (Temodar®) is an oral chemotherapy drug. It is an alkylating agent used as a treatment of some brain cancers; as a second-line treatment for astrocytoma and a first-line treatment for glioblastoma multiforme. Temodar® contains temozolomide, an imidazotetrazine derivative. The chemical name of temozolomide is 3,4-dihydro-3-methyl-4- oxoimidazo[5,l-d]-as-tetrazine-8-carboxamide. Temodar® is a white to light tan/light pink powder with a molecular formula of C6H6N602 and a molecular weight of 194.15. The molecule is stable at acidic pH (<5) and labile at pH >7. Temodar® can be administered orally or intravenously. The prodrug, temozolomide, is rapidly hydrolyzed to the active 5-(3- methyltriazen-l-yl) imidazole-4-carboxamide (MTIC) at neutral and alkaline pH values, with hydrolysis taking place even faster at alkaline pH. Each Temodar® capsule for oral use contains either 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, or 250 mg of temozolomide. Each vial of Temodar® for injection contains 100 mg of sterile and pyrogen-free temozolomide lyophilized powder for intravenous injection. The inactive ingredients are: mannitol (600 mg), L- threonine (160 mg), polysorbate 80 (120 mg), sodium citrate dihydrate (235 mg), and hydrochloric acid (160 mg). Temozolomide is not directly active but undergoes rapid nonenzymatic conversion at physiologic pH to the reactive compound 5-(3-methyltriazen-l- yl)-imidazole-4-carboxamide (MTIC). The cytotoxicity of MTIC is thought to be primarily due to alkylation ofDNA. Alkylation (methylation) occurs mainly at the 06 and N7 positions of guanine.

Mitozolomide is a prodrug of imidazotetrazine alkylating agent with antineoplastic property. Mitozolomide undergoes ring opening upon the nucleophilic attack at C-4 by an activated molecule of water within the major groove of DNA. The resulting bioactive mono- alkyltriazene species are capable of alkylating nucleophilic residues in the immediate vicinity such as N-7 and/or 0-6 sites of guanine, thereby causing intra- or inter-stranded DNA cross- links and triggering apoptosis. Temozolomide is a less toxic analogue of mitozolomide.

Dacarbazine (also known as DTIC) is an intravenously administered alkylating agent used in the therapy of Hodgkin disease and malignant melanoma. Dacarbazine (da kar' ba zeen) is a triazene analogue of 5-aminoimidazole-4-carboxamide, a precursor in purine biosynthesis. Dacarbazine is popularly known as DTIC and was approved for use in the United States in 1975. Current indications include Hodgkin lymphoma and metastatic malignant melanoma usually in combination with other antineoplastic agents. Dacarbazine is available for injection in vials of 10 mg/mL and the recommended dose varies by indication and body weight (2 to 4.5 mg/kg/day or 150 mg/meter-squared/day). Dacarbazine is given by intravenous infusion typically for five to ten days in cycles of every 3 to 4 weeks.

Procarbazine hydrochloride (Matulane®), a hydrazine derivative antineoplastic agent, is available as capsules containing the equivalent of 50 mg procarbazine as the hydrochloride. Chemically, procarbazine hydrochloride is N-isopropyl-a-(2-methylhydrazino)-p-toluamide monohydrochloride . Altretamine (Hexalen®) is an alkylating antineoplastic agent that was approved by the U.S. FDA in 1990. It is indicated for use as a single agent in the palliative treatment of patients with persistent or recurrent ovarian cancer following first-line therapy with cisplatin and/or alkylating agent-based combination. It is not considered a first-line treatment, but it can be useful as salvage therapy.

Cisplatin (Platinol®) is the prototype platinum coordination complex classified as an alkylating agent and used intravenously in the treatment of several forms of cancer. Cisplatin is an inorganic, water soluble complex containing a central platinum atom surrounded by 2 chlorine atoms and ammonia moieties in the cis position in the horizontal plane. Cisplatin forms irreversible covalent links with DNA, causing cross linking of DNA chains as well as breaks in the DNA chain and missense mutations. The DNA injury triggers cell death and inhibits RNA and protein synthesis, particularly in rapidly dividing cells. Cisplatin has activity against multiple tumor types and was approved for use by the United States in 1978. Current indications include testicular, ovarian, and bladder cancer. It is also used in combination with other agents in head and neck, breast, lung, and colon cancer. Cisplatin is administered parenterally and is available in 50 and 100 mg vials in generic forms and under the brand name Platinol.

Carboplatin is a cisplatin analog with a carboxy-cyclobutane moiety instead of the chloride atoms which makes it more stable and perhaps less toxic than cisplatin. Carboplatin acts as an alkylating agent causing cross linking between and within DNA strands, leading to inhibition of DNA, RNA, and protein synthesis and the triggering of programmed cell death, mostly in rapidly dividing cells. Carboplatin was approved for use in cancer chemotherapy in the United States in 1989. It is currently indicated for advanced ovarian carcinoma, but is also used in other solid tumors including lung and head and neck cancer. Carboplatin is available in a powder or aqueous solution for injection in 50, 150 and 450 mg amounts generic ally and under the brand name Paraplatin.

Oxaliplatin (Eloxatin®) is a cisplatin analog with a tetravalent platinum molecule which is referred to as a platinum coordination complex. Oxaliplatin acts as an alkylating agent causing cross linking between and within DNA strands leading to inhibition of DNA, RNA, and protein synthesis and the triggering of programmed cell death, mostly in rapidly dividing cells. Oxaliplatin was approved for use in cancer chemotherapy in the United States in 2002. Its current indications are colorectal carcinoma and it is usually administered in combination with other agents such as 5-fluorouracil (5-FU), irinotecan, or capecitabine. Oxaliplatin is available in an aqueous solution for injection in 50, 100, and 200 mg vials in generic forms and under the brand name Eloxatin.

Satraplatin (also known as JM216) is an orally bioavailable platinum

chemotherapeutic agent under development for several cancer types, including hormone - refractory prostate cancer (HRPC).

Nedaplatin (Aqupla®) is a platinum-based antineoplastic drug which is used for cancer chemotherapy. The complex consists of two ammine ligands and the dianion derived from glycolic acid.

Triplatin tetranitrate (also known as BBR3464) is a platinum-based cytotoxic drug that acts by forming adducts with cellular DNA, preventing DNA transcription and replication, thereby inducing apoptosis.

In one embodiment, an ErbB3 inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein. In another embodiment, an IGF-1R inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein. In another embodiment, an ErB3 inhibitor and IGF-1R inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein. In another embodiment, a bispecific inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) are administered according to the methods described herein.

In one embodiment, the ErB3 inhibitor is an antibody. For example, Ab#3, Ab #14, Ab #17, Ab # 19 (described in U.S. 7,846,440), or seribantumab (also known as "MM-121 " and "Ab#6" and described in WO 2008/100624 and US Patent No. 7,846,440), can be used. Additional art-recognized anti-ErbB3 antibodies which can be used include those disclosed in US 7,285,649; US20200310557; US20100255010, as well as antibodies IB4C3 and 2D1D12 (U3 Pharma Ag), both of which are described in e.g., US2004/0197332; anti-ErbB3 antibody referred to as AMG888 (U3-1287 - U3 Pharma Ag and Amgen); and monoclonal antibody 8B8, described in US 5,968,511. In another particular embodiment, the anti-ErbB3 antibody is patritumab. In another embodiment, the anti-ErbB3 antibody is a bispecific antibody antagonist of IGF-IR and ErbB3, e.g., having two pairs of polypeptide chains, each pair of said two pairs comprising a heavy chain joined to a light chain by at least one heavy-light chain bond, wherein each light chain comprises the amino acid sequence set forth in SEQ ID NO: l and each heavy chain comprises the amino acid sequence set forth in SEQ ID NO:2. In one embodiment, the bispecific antibody further comprises a linker having the amino acid sequence set forth in SEQ ID NO:3. In another embodiment, the ErbB3 inhibitor is a small molecule, such as a small molecule tyrosine kinase inhibitors (TKIs) (e.g., gefitinib (Iressa®) or erlotinib (Tarceva®).

In one embodiment, the IGF- 1R inhibitor is an antibody. For example, any of the anti-IGF-lR antibodies recited in Chen et al. (Chin. J.Cancer. 2013 May; 32(5): 242-252) including, but not limited to cixutumumab (EVIC-A12; ImClone), figitumumab (CP-751,871 ; Pfizer), dalotuzumab (MK-0646; h7C10) Pierre Fabre and Merck), ganitumab (AMG 479; Amgen), R1507 (Roche), SCH 717454 (19D12; Schering Plough), AVE1642 (EM164;

ImmunoGen/Sanofi), and BIIB022 (Biogen-IDEC), can be used. In another embodiment, the anti-IGF-lR antibody is a bispecific antibody antagonist of IGF-IR and ErbB3. In one embodiment, the bispecific antibody is a polyvalent bispecific antibody having two pairs of polypeptide chains, each pair of said two pairs comprising a heavy chain joined to a light chain by at least one heavy-light chain bond, wherein each light chain comprises the amino acid sequence set forth in SEQ ID NO: l and each heavy chain comprises the amino acid sequence set forth in SEQ ID NO:2. In one embodiment, the bispecific antibody further comprises a linker having the amino acid sequence set forth in SEQ ID NO:3. In a particular embodiment, the antibody is istiratumab (also known as "MM-141 " and "P4-G1-M1.3 "). In another embodiment, the IGF-IR inhibitor is a small molecule, such as any one of the IGF- IR tyrosine kinase inhibitors recited in Chen et al. (Chin. J. Cancer. 2013 May; 32(5): 242- 252) including, but not limited to linsitinib (OSI-906; OSI), BMS-754807 (BMS), BVP 51004 (Biovitrum), XL228 (Exelixis), and INSM- 18 (NDGA)-

In one embodiment, an additional antineoplastic agent is administered during treatment. In another embodiment, no more than three antineoplastic agents are administered during treatment. In another embodiment, no more than two other antineoplastic agents are administered during treatment. In another embodiment, no more than one other

antineoplastic agent is administered during treatment. In another embodiment, no other antineoplastic agent is administered during treatment.

Dosage Regimens

Provided herein are methods for treating cancer (e.g., Ewing sarcoma) in a human patient, comprising administering to the patient a particular combination of agents, i.e., an ErbB3 and/or IGF- 1R inhibitor (e.g., istiratumab), a topoisomerase I inhibitor (e.g., irinotecan), and an alkylating agent (e.g., temozolomide) according to a particular clinical dosage regimen (i.e., at a particular dose amount and according to a specific dosing schedule).

In one embodiment, the inhibitor (e.g., istiratumab), the topoisomerase I inhibitor

(e.g., irinotecan), and the alkyating agent (e.g., temozolomide) are each administered in a separate formulation or a separate unit dosage form. In another embodiment, the inhibitor (e.g., istiratumab), the topoisomerase I inhibitor (e.g., irinotecan), and the alkyating agent (e.g., temozolomide) are administered simultaneously or sequentially. In another

embodiment, the inhibitor (e.g., istiratumab), and topoisomerase I inhibitor (e.g., irinotecan) are administered intravenously. In another embodiment, the alkyating agent (e.g., temozolomide) is administered orally.

In one embodiment, irinotecan and temozolomide are administered according the regimen described in DuBois et al. (J. Clin. Oncol. 2016 Apr 20;34(12): 1368-75), the contents of which are expressly incorporated herein by reference. For example, in one embodiment, irinotecan is administered intravenously at a dose of 50 mg/m² on days 1-5 every three weeks and temozolomide is administered orally at a dose of 75- 100 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle).

In another embodiment, irinotecan and temozolomide are administered according the regimen described in Raciborska et al. (Pediatr. Blood Cancer, 2013 Oct; 60(10): 1621-5), the contents of which are expressly incorporated herein by reference. For example, in one embodiment, irinotecan is administered intravenously at a dose of 50 mg/m² on days 1-5 every three weeks and temozolomide is administered orally at a dose of 125 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle).

In another embodiment, irinotecan and temozolomide are administered according the regimen described in Casey et al. (Pediatr. Blood Cancer, 2009 ;53: 1029-1034), the contents of which are expressly incorporated herein by reference. For example, in one embodiment, irinotecan is administered intravenously at a dose of 10 mg/m², 20 mg/m², or 25 mg/m² on days 1-5 and 8- 12 every three weeks and temozolomide is administered orally at a dose of 50-100 mg/m² on days 1-5 every three weeks (e.g., a 21 day treatment cycle). In one embodiment, the irinotecan is irinotecan sucrosofate liposome injection (e.g., Onivyde®). In one embodiment, irinotecan sucrosofate liposome injection is administered according to the Onivyde® prescription guidelines. For example, in one embodiment, the irinotecan sucrosofate liposome injection is administered intravenously at a dose of 35-50 mg/m² every two weeks and temozolomide is administered orally at a dose of 50-100 mg/m², 75-100 mg/m², or 125 mg/m² on days 1-5 every three weeks. In another embodiment, the irinotecan sucrosofate liposome injection is intravenously at a dose of 50-70 mg/m² every two weeks and temozolomide is administered orally at a dose of 50-100 mg/m², 75- 100 mg/m², or 125 mg/m² on days 1-5 every three weeks cycle.

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 75-100 mg/m² on days 1-5 every three weeks. In another embodiment, a method of treating a patient having Ewing sarcoma is provided, comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 125 mg/m² on days 1-5 every three weeks.

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 50-100 mg/m² on days 1-5 every three weeks.

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 75-100 mg/m² on days 1-5 every three weeks. In another embodiment, a method of treating a patient having Ewing sarcoma is provided, comprising administering to the patient : (A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 125 mg/m² on days 1-5 every three weeks. In another embodiment, a method of treating a patient having Ewing sarcoma is provided, comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks ;

Outcomes

As shown in the Examples herein, co-administration of an anti-ErbB3 antibody with one or more additional therapeutic agents (e.g., everolimus, temsirolimus, sirolimus, XL147, gemcitabine, 5-fluorouracil, and cytarabine) provides improved efficacy compared to treatment with the antibody alone or with the one or more additional therapeutic agents in the absence of antibody therapy. Preferably, a combination of an anti-ErbB3 antibody with one or more additional therapeutic agents exhibits therapeutic synergy.

"Therapeutic synergy" refers to a phenomenon where treatment of patients with a combination of therapeutic agents manifests a therapeutically superior outcome to the outcome achieved by each individual constituent of the combination used at its optimum dose (T. H. Corbett et al., 1982, Cancer Treatment Reports, 66, 1187). In this context, a therapeutically superior outcome is one in which the patients either a) exhibit fewer incidences of adverse events while receiving a therapeutic benefit that is equal to or greater than that where individual constituents of the combination are each administered as monotherapy at the same dose as in the combination, or b) do not exhibit dose-limiting toxicities while receiving a therapeutic benefit that is greater than that of treatment with each individual constituent of the combination when each constituent is administered in at the same doses in the combination(s) as is administered as individual components. In xenograft models, a combination, used at its maximum tolerated dose, in which each of the constituents will be present at a dose generally not exceeding its individual maximum tolerated dose, manifests therapeutic synergy when decrease in tumor growth achieved by administration of the combination is greater than the value of the decrease in tumor growth of the best constituent when the constituent is administered alone.

Thus, in combination, the components of such combinations have an additive or superadditive effect on suppressing tumor growth, as compared to monotherapy with the PBA or treatment with the chemotherapeutic(s) in the absence of antibody therapy. By

"additive" is meant a result that is greater in extent (e.g., in the degree of reduction of tumor mitotic index or of tumor growth or in the degree of tumor shrinkage or the frequency and/or duration of symptom-free or symptom-reduced periods) than the best separate result achieved by monotherapy with each individual component, while "superadditive" is used to indicate a result that exceeds in extent the sum of such separate results. In one embodiment, the additive effect is measured as slowing or stopping of tumor growth. The additive effect can also be measured as, e.g., reduction in size of a tumor, reduction of tumor mitotic index, reduction in number of metastatic lesions over time, increase in overall response rate, or increase in median or overall survival.

One non-limiting example of a measure by which effectiveness of a therapeutic treatment can be quantified is by calculating the log 10 cell kill, which is determined according to the following equation:

loglO cell kill = T C (days)/3.32 x Td in which T C represents the delay in growth of the cells, which is the average time, in days, for the tumors of the treated group (T) and the tumors of the control group (C) to have reached a predetermined value (1 g, or 10 mL, for example), and Td represents the time, in days necessary for the volume of the tumor to double in the control animals. When applying this measure, a product is considered to be active if log 10 cell kill is greater than or equal to 0.7 and a product is considered to be very active if loglO cell kill is greater than 2.8. Using this measure, a combination, used at its own maximum tolerated dose, in which each of the constituents is present at a dose generally less than or equal to its maximum tolerated dose, exhibits therapeutic synergy when the log 10 cell kill is greater than the value of the log 10 cell kill of the best constituent when it is administered alone. In an exemplary case, the log 10 cell kill of the combination exceeds the value of the loglO cell kill of the best constituent of the combination by at least 0.1 log cell kill, at least 0.5 log cell kill, or at least 1.0 log cell kill. Kits and Unit Dosage Forms

Further provided are kits that include a pharmaceutical composition containing a bispecific anti-IGF- lR and anti-ErbB3 antibody (e.g., istiratumab), including a

pharmaceutically-acceptable carrier, in a therapeutically effective amount adapted for use in the preceding methods. The kits include instructions to allow a practitioner (e.g., a physician, nurse, or physician's assistant) to administer the composition contained therein to treat an ErbB2 expressing cancer.

Preferably, the kits include multiple packages of the single-dose pharmaceutical composition(s) containing an effective amount of a bispecific anti-IGF-lR and anti-ErbB3 antibody for a single administration in accordance with the methods provided above.

Optionally, instruments or devices necessary for administering the pharmaceutical composition(s) may be included in the kits. For instance, a kit may provide one or more pre- filled syringes containing an amount of a bispecific anti-IGF- lR and anti-ErbB3 antibody that is about 100 times the dose in mg/kg indicated for administration in the above methods.

Furthermore, the kits may also include additional components such as instructions or administration schedules for a patient suffering from a cancer to use the pharmaceutical composition(s) containing a bispecific anti-IGF- lR and anti-ErbB3 antibody.

Also provided are kits that include an inhibitor (e.g., istiratumab), topoisomerase I inhibitor (e.g., irinotecan), and alkyating agent (e.g., temozolomide) in therapeutically effective amounts adapted for use in the methods described herein. In one embodiment, the kit comprises: a dose of an inhibitor (e.g., istiratumab), topoisomerase I inhibitor (e.g., irinotecan), and alkyating agent (e.g., temozolomide), and instructions for using the inhibitor, topoisomerase I inhibitor, and alkyating agent in the methods described herein.

It will be apparent to those skilled in the art that various modifications and variations can be made in the compositions, methods, and kits of the present invention without departing from the spirit or scope of the invention. Thus, it is intended that the present invention cover the modifications and variations of this invention provided they come within the scope of the appended claims and their equivalents.

EXAMPLES

The following Examples should not be construed as limiting the scope of this disclosure. Unless specifically stated, all commercial antibodies used for western blotting the following Examples were provided by Cell Signaling Technologies and, in all western blots, signal was normalized to beta-Actin levels detected by western blot as a loading control. Where treatments of cancer in patients are set forth in the Examples below, the cancer to be treated is Ewing sarcoma, pancreatic cancer, ovarian cancer (e.g., high-grade serous ovarian cancer), sorafenib-naive or sorafenib-refractory hepatocellular carcinoma, parathyroid cancer, sarcoma, lung cancer, or breast cancer. Where measured in xenograft studies, tumors were measured bi-weekly using digital calipers, and volumes (mm³) were calculated according to the formula: π/6 x (length x width x width).

Example 1:

This Example discloses the results of treatment of patients with solid tumors in a

Phase 1 dose escalation study with MM-141 administered as monotherapy. 15 patients were dosed with MM-141 monotherapy at 6 mg/kg (n=3), 12 mg/kg (n=4), 20 mg/kg (n=4) q7d, or 40 mg/kg (n=4) ql4d. No dose-limiting toxicities were observed at any of these dose levels. Adverse events that were reported with a frequency >15% included: vomiting (7/15), nausea (6/15), fatigue (4/15), abdominal pain (4/15), increased AP (4/15), dyspnea (4/15), diarrhea (3/15), anemia (3/15), increased AST (3/15), and rash (3/15). Pharmacokinetic (PK), and pharmacodynamic (PD) analysis of MM-141 as monotherapy are shown in Figures l(A-D). Half -lives (T ½) for each dose level were in the ranges of 2.4-6.3 days (6 mg kg), 2.1-2.9 days (12 mg/kg), 3.3-3.4 days (20 mg kg) and 3.2-9.9 days (40 mg/kg). increases in serum total IGF- 1 levels in response to M - 141 dosing were seen in each cohort with greater magnitude as dosing escalated. Total IGF-1 increased approximately two-fold in 1/3 patient samples analyzed in each of the 6 mg/kg and 12 mg/kg cohorts. At 20 mg/kg all patient samples exhibited approximately a two-fold increase in total IGF-1, and at 40 mg/kg all patient samples exhibited approximately two to four fold increases in total IGF-1. The safety, tolerability, PK and PD profiles support weekly and biweekly MM-141 dosing. Disease stabilization was observed in patients with Ewing' s Sarcoma (1) and parotid gland carcinoma (1). Recommended dose levels for MM-141 Phase 2 study were established as 20 mg/kg q7d and 40 mg/kg ql4d.

Serum for PK and PD analysis was prepared by drawing whole blood into red top tubes, clotting 30 minutes at 4-8°C and spinning down in a refrigerated centrifuge. Serum was aliquotted and frozen immediately after centrifugation. PD analysis of total IGF- 1 in serum was performed using Human IGF-I Quantikine® ELISA Kit (R&D Systems,

Minneapolis, MN) according to the manufacturer's instructions. For the PK analysis, in brief, ELISA plates were plates were coated with IGF-1R (R&D Systems) in PBS and incubated overnight at 4°C. Plates were washed, blocked, and then samples and standards were added to plates and incubated for 2hr at room temperature. Plates were washed and ErbB3-His was added for lhr at room temperature. Plates were washed and anti-His-HRP (Abeam, Cambridge, MA) was added for lhr at room temperature. Plates were developed using TMB and STOP solution and absorbance was read at 450nM. PK parameters were analyzed using descriptive statistics including the median, mean, and 95% confidence intervals around parameter estimates by dose level. All PK parameters included Cmax, Tmax, AUC (area under the concentration curve), clearance, volume of distribution at steady state (Vdss), and the terminal elimination half-life. Estimation of the PK parameters was performed using standard non-compartmental methods.

Example 2:

This Example provides actual clinical administration parameters (including dosage and administration) and preliminary results for an ongoing MM-141phase 1 clinical trial treating tumors in human cancer patients.

Methods: This is a Phase 1 dose-escalation study evaluating safety, tolerability, pharmacokinetic (PK), and pharmacodynamic (PD) properties of MM- 141 as monotherapy (Arm A, n=15) and in combination with everolimus (Arm B) or with nab-paclitaxel and gemcitabine (Arm C , n= 11 ) .

Table 1: Clinical Trial Design

6B MTD + 10

Cohort A: solid tumors Cohort B: ER/1 ^JR+ breast cancer

Cohort C: pancreatic cancer Cohort D: hepatocellular carcinoma

a: dosage is in mg/kg

b: dosage is in mg

c: dosage is in mg/m²

Three HCC patients in the Arm A 4D expansion cohort received MM- 141 as a monotherapy at a weekly dose of 20 mg/kg. These patients underwent mandatory pre- treatment and optional post-treatment biopsies. Patients in the dose-escalation portion of Arm C received MM- 141 at a weekly dose of 12 or 20 mg/kg in combination with weekly nab- paclitaxel (125 mg/m²) and gemcitabine (1000 mg/m²) (3 weeks on, 1 week off). Enrollment in Arm B (MM- 141 in combination with everolimus) is ongoing.

Key inclusion criteria include cytologically or histologically confirmed advanced malignant solid tumors for which no curative therapy exists that has recurred or progressed following standard therapy; a body mass index between 18 and 32.5; measurable disease according to RECIST vl. l; and no insulin-dependent or uncontrolled diabetes.

Key primary and secondary objectives include determination of the maximum tolerated dose or recommended Phase 2 dose of MM- 141 as a single agent, in combination with everolimus, and in combination with nab-paclitaxel and gemcitabine based on the safety, tolerability, PK, and PD; determination of the adverse event profile; and determination of the pharmacokinetic and immunogenicity parameters.

This study features a standard "3+3 design followed by additional expansion cohorts and combination arms. MM-141 is dosed weekly or bi-weekly for four week cycles. There is a four week dose-limiting toxicity (DLT) evaluation period prior to escalating to the next cohort.

Key study requirements are that patients are tested for free serum IGF-1 at screening; cohort 4D comprises mandatory pre-treatment biopsies and optional post-treatment biopsies; treatment arm B includes mandatory pre-treatment biopsies and mandatory post-treatment biopsies; patients are scanned every eight weeks; and the patients participate in daily glucose monitoring.

Preliminary Results: Fifteen patients with advanced solid tumors were enrolled into the dose escalation portion of Arm A. No DLTs were observed at any of the studied dose levels. The safety, tolerability, PK and PD profile support weekly and bi-weekly MM-141 dosing. The Arm A expansion cohort 4D enrolled 3 patients with sorafenib-refractory HCC. The analysis of pre- and post-treatment biopsies confirmed that IGF-1R and ErbB3 are expressed in patients previously exposed to sorafenib, and their levels are decreased after MM- 141 exposure. Eleven patients with advanced solid tumors were enrolled into Arm C, combining MM- 141 with nab-paclitaxel and gemcitabine. One DLT of grade 3 abdominal cramping was seen at the MM- 141 dose of 20 mg/kg weekly. An additional 3 patients were enrolled at that dose level and no further DLTs were seen.

Example 3:

Figure 2 shows the pre- (top panels) and post- (bottom panels) MM- 141 treatment levels of ErbB3 (left panels) and IGF-1R (right panels), as detected by

Formalin fixed, paraffin embedded biopsy samples were sectioned at 5 μιη, processed and stained for IGF-1R (Gl 1 clone detection antibody, Ventana) and ErbB3 (clone D22 antibody, Cell Signaling Technology). Down-regulation of both ErbB3 and IGF-1R following one month of MM- 141 treatment is plainly evident in these (vertically) matched sections.

Example 4:

Treatment with MM- 141 decreases the expression levels of IGF-1R and ErbB3 receptors to a greater extent than do individual monospecific antibodies targeting either IGF- lR or ErbB3.

Cell lysates were harvested four hours post-treatment with antibodies as indicated in Figures 3A and 3B (50 nM of each antibody) and changes in receptor expression were measured by ELISA. All ELISA measurements are normalized to vehicle (PBS) treatment, and these measurements are expressed relative to a vehicle treated control value of 1.

In addition, the following experiments were performed, to investigate the mechanism of degradation of IGF-1R and ErbB3 receptors associated with MM-141 treatment.

Following 2 hours pre-treatment with 1 μΜ epoxomicin (a selective proteasome inhibitor), CFPAC-1 pancreatic cancer cells were treated with 500 nM MM-141 or vehicle for 20 minutes. Cell lysates were immunoprecipitated (IP) with an IGF-1R (Figure 3C) or ErbB3 (Figure 3D) antibody, and then immunoblotted (IB) for IGF-1R, ErbB3, or ubiquitin protein (Ub) expression by western blotting.

The results indicate that MM- 141 -induced IGF-1R and ErbB3 receptor

downregulation is associated with induction of ubiquitination.

Example 5:

This Example shows that patients with high levels of free serum IGF-1 were able to remain on study longer than patients with lower levels of free serum IGF- 1.

The assay used in this Example employs a novel receptor-capture based qualitative sandwich ELISA in the 96-well format. Free IGF-1 receptor is immobilized on each well of the microtiter plate. A series of standards, controls, and samples are pipetted into the wells and any free serumIGF-1 present is bound by the immobilized receptor. After washing away any unbound substances, a rabbit monoclonal antibody ((Cell Signaling Technology, Cat # 9750)), specific for the anti-human IGF-1, is added to the wells, followed by another wash to remove any unbound substances. An enzyme-linked polyclonal anti-rabbit IgG HRP conjugate (Anti-Rabbit IgG, HRP-Linked antibody, Cell Signaling Technology, Catalog No. 7074) is added to the wells, followed by another wash to remove any unbound antibody- enzyme reagent. A 3,3', 5, 5' - tetramethylbenzidine (TMB) substrate solution is added to the wells and color develops in proportion to the amount of Free IGF-1 bound in the initial step. The color development is stopped and the intensity of the color is measured. The optical density (OD) of each well of the ELISA plate is measured spectrophotometrically at a wavelength of 450 nm. A distribution of free serum IGF-1 in serum from pancreatic cancer patients is shown in Figure 4 A and summarized in Table 4 below. As the data in Table 2 show, median levels of free IGF-1 are higher in serum from Stage 3 pancreatic cancer patients, similar to what is seen in tissue samples from such patients. Approximately 60% of samples are expected to be HIGH (above cutpoint) regardless of the stage of cancer progression.

Table 2: Distribution of Free Serum IGF

All (n=155) 0.70

% Above Cutpoint

Stage 3 61%

Stage 4 56%

All 59%

Results: Pre-treatment serum detection of free IGF-1 was seen in 5 of 7 (71.4%) patients who stayed on study long enough to receive more than two cycles of MM- 141. These data support prospective selection of patients who have levels of free serum IGF-1 above 0.39 ng/niL to receive MM- 141.

Retrospective analysis of the free IGF-1 found that in breast cancer patients, two patients with levels above the cutpoint remained on study longer and received at least twice the number of MM- 141 doses as compared to those patients with levels below the cutpoint (Figure 4B).

Example 6:

This Example discloses selection of a fixed-dose treatment regimen for MM- 141. To evaluate the difference between weight-based and fixed-dose regimens, a simulation study was conducted by comparing pharmacokinetics of these treatment options. Post-hoc estimates of PK parameters from each of the patients on the Phase 1 clinical study

(see Example 2) were used in the simulation.

Population pharmacokinetic analyses of MM 141 were performed based on

pharmacokinetic data from patients treated with MM-141 monotherapy (n=13, 4 dose levels).

The model was a two-compartmental model (ADVAN3) with covariate structure that includes relationship between weight-clearance and sex-clearance. Parameter estimates of the two-compartmental models and the associations were obtained from MM 141 PK data.

The inter-individual variabilities and residuals were assumed to be the same as those estimated from previously reported anti-ErbB3 antibody data; these assumed values were comparable to other antibodies. The residual followed a linear and proportional model. The simulation was performed by assuming a distribution of weight and sex as observed in patients in previously reported anti-ErbB3 antibody studies. The comparisons of dose regimens were controlled for inter-individual variability by applying multiple dose regimens for each simulated patient. The reported values were assumed to be at steady state. The models were as specified below.

CL = THETA(1)*EXP( ET A( 1 )+THET A(5 )* (WEIGHT/MEDWGT- 1 ) - THETA(6)*(SEX-

D) ;

VI = THETA(2)*EXP( ETA(2))

Q= THETA(3)

V2 = THETA(4) where THETA(.) were fixed effect estimates, and ETA(.) were random effect estimates, MEDWGT was the median weight (=72), CL= clearance, Vl= volume,

Q=intercompartmental clearance, V2= volume of second compartment.

Preparation of dataset was performed in SAS (ENTERPRISE GUIDE 5.1) and R version 3.0.2. Population pharmacokinetic analysis was performed in NONMEM 7, using interface from PERL SPEAKS NONMEM (PSN). Post-NONMEM analysis was performed in R using XPOSE4 package version 4.5.0.

The simulation results showed comparable variability between both fixed-dosing and weight-based dosing regimens, suggesting there were no significant differences expected with a transition to a fixed-dosing schedule. Based on the model from patients treated on the monotherapy arm, a weight-based dosing of 40 mg/kg Q2W and a corresponding fixed dose of 2.8 grams Q2W had comparable maximum, minimum, average steady-state concentration levels, and variability; therefore 2.8 grams Q2W was the dose chosen for this Phase 2 study.

In order to evaluate a variety of MM- 141 fixed-dosing options, a simulation study was conducted comparing the simulation pharmacokinetics (averaged and minimum

concentration) of different dose concentrations (Figure 5): 2.8 grams Q2W, 2.24 grams Q2W, 1.96 grams Q2W, 1.4 grams Q1W, 1.4 grams Q1W x 3 with 1W off, 40 mg/kg Q2W, and 20 mg/kg Q1W. A dosing regimen of 2.8 grams Q2W is predicted to have a comparable imum concentration (Cmax) to 40 mg/kg Q2W, the highest dose level tested on the weight-based monotherapy dosing regimens. An alternative regimen of 2.24 grams Q2W is predicted to have a comparable Cmax to 20 mg/kg Q1W. The 2.24 grams Q2W dose had a predicted lower comparable minimum concentration (Cmin) to 20 mg/kg Q1W, but of the options tested, it was also predicted to provide the greatest number of patients with trough levels above 50 mg/L. Example 7:

This Example discloses a method of treatment of patients with cancer (e.g. Ewing sarcoma, pancreatic cancer, ovarian cancer, hepatocellular carcinoma, parathyroid cancer, sarcoma, lung cancer or breast cancer) with istiratumab (MM-141), wherein the therapeutic effect of irinotecan + temozolomide (IRI-TEM) is enhanced in combination with istiratumab compared to IRI-TEM alone. Patients are dosed with fixed doses of irinotecan and temozolomide. Irinotecan is administered at 10-50 mg/m² intravenously on days 1 to 5 or in a protracted dosing schedule of 5 days each week for 2 weeks, every 3 weeks. Temozolomide is administered at 100-125 mg/m² orally 1 hour before irinotecan on days 1 to 5. Istiratumab is administered at 1.96 - 2.8 grams intravenously every two weeks.

Example 8:

The cell surface signaling receptor proteins EGFR, HER2, ErbB3, insulin receptor (INSR), and IGF-IR are expressed at different levels in a panel of Ewing sarcoma (EWS) cell lines (Figure 6). These cell lines also display differential sensitivity to treatment with SN-38 (the active metabolite of irinotecan), temozolomide and MM-141, as tested in in vitro cell proliferation assays (Figure 7). Additionally, these cell lines are differentially sensitive to treatment with the ligands, IGF-1 and HRG; treatment with istiratumab, alone and in combination with ligand, can inhibit basal and ligand activated cell proliferation (Figure 8) and expression of IGF-IR, pAKT and pS6 (Figure 9). Moreover, in an in vivo model of

EWS, co-treatment of istiratumab + IRI-TEM significantly inhibits tumor growth compared to single agent treatments and significantly delays the time to tumor progression (Figure 10).

As shown in Figure 6, low passage EWS cell lines (A-673, Hs 822.T, Hs 869.T, RD- ES, SK-ES-1, and SK-N-DW) were propagated in vitro for 1 week, harvested by trypsin treatment, and aliquoted (100,000 cells/well) prior to staining with Alexa-647 conjugated antibodies [anti-EGFR (cetuximab), anti-HER2 (trastuzumab), anti-ErbB3 (in-house generated), anti-insulin receptor (BD 559954), and anti-IGF-lR (cixitumumab)] to measure the surface expression of these proteins using a FACS Canto. Absolute quantification of target receptor numbers was achieved using Quantum™ Simply Cellular® beads (Bangs Laboratories, Indiana, USA).

In Figure 7, A-673, RD-ES, SK-ES-1, and SK-N-MC cells were plated (5000 cells/well) independently in 3D 96 well plates overnight in 10% FBS containing culture media; the following day, different wells of cells were treated with different doses of SN-38 (0.0064 - 500 nM), temozolomide (6.4 nM - 500 mM), and istiratumab [MM-141 (0.0128 - ΙΟΟΟηΜ)]. Cell proliferation in all wells was measured after 5 days of treatment using Cell TiterGlo assay (Promega).

As outlined in Figure 8, A-673, RD-ES, SK-ES-1, and SK-N-MC cells were plated (5000 cells/well) independently in 3D 96 well plates overnight in 5% FBS containing culture media; the following day, different wells of cells were treated with IGF-1 (50 nM), HRG (5 nM), or MM-141 (250 nM), alone or in combination. Cell proliferation in all wells was measured after 5 days of treatment using Cell TiterGlo assay (Promega).

In Figure 9, A-673, RD-ES, SK-ES-1, and SK-N-MC cells were seeded (150,000 cells/well) independently in 12 well cell culture plates overnight in 5% FBS containing culture media. The next day, the cells were serum starved by adding an equal volume of 0% FBS containing media (final serum concentration = 2.5%) for 24 hours, followed by addition of MM-141 (250 nM), IGF-1 (50nM), HRG (5 nM), or combinations thereof for 4 hours. Following incubation, cells were harvested, protein lysates generated and subjected to immunoblotting for phosphorylated IGF- 1R (pIGF- 1R), total IGF- 1R, pAKT, pERK, pS6, and beta actin.

The results of the in vivo efficacy study in a model of EWS are set forth in Figure 10. Tumors were established by inoculating female SCID-Beige mice subcutaneously with 8xl0⁶ RD-ES cells, suspended 1: 1 in 200 μΐ_^ of Matrigel® Matrix Basement Membrane mix (Corning, Corning, NY): unsupplemented culture media. When tumor volumes reached approximately 100-250 mm³ (Day 14), mice were randomized into study groups with equivalent average starting tumor volume per group maintained across all groups.

Mice (10/group) were treated (starting on Day 14) with PBS vehicle (black line;

200μΕ, i.p., Q2W); istiratumab (red line; 30 mg/kg, in PBS, i.p., Q2W); IRI-TEM (blue line; irinotecan [0.2 mg/kg, in 0.9% saline, i.p., dosed on days 1-5 of each week {QDx5}] and temozolomide [5 mg/kg, in citrate buffer, via oral gavage {PO}, QDx5]); or the combination of IRI-TEM + istiratumab (dosed as outlined above for the monotherapies). Tumor volume changes were calculated twice weekly using the formula (PI/6 (length x width x width), with tumor dimensions determined by caliper measurement. The tumor growth rate of the IRI- TEM + istiratumab treated mice was significantly different ( <0.05) on Day 35 post- treatment initiation (indicated by the "number 1"), therefore drug treatment was stopped in all groups to evaluate the effect of a drug treatment "holiday" on tumor re-growth. After stopping all drug treatments, tumors in the IRI-TEM treated mouse group re-grew rapidly, reaching an group average tumor volume of -2000 mm³ on Day 60 post-treatment initiation; in contrast, the tumors in the mice treated with IRI-TEM + istiratumab re-grew at a significantly slower rate, only reaching a similar group average tumor volume at Day 112 post-treatment initiation (and 77 days since stopping treatment).

To test whether tumors previously treated with IRI-TEM were still sensitive to re- treatment, mice in this group were re-randomized (5/group) on Day 63 (indicated by the "number 2") to receive IRI-TEM (dashed line) or IRI-TEM + istiratumab (dashed line), as previously dosed for the study. Following 3 weeks of re-treatment, tumor growth had stabilized in both treatment groups. At this point (Day 84; indicated by the "number 3"), drug treatment was again stopped to evaluate the effect of a second "drug holiday" on tumor growth. The tumors re-grew in both groups. However, unexpectedly, the tumors grew at a slower rate in mice that had been re-treated with IRI-TEM + istiratumab.

Taken together, these data indicate that co-treatment of istiratumab + IRI-TEM significantly inhibits tumor growth compared to single agent treatments and significantly delays the time to tumor progression in an in vivo model of Ewing Sarcoma.

Equivalents and Incorporation by reference

Those skilled in the art will recognize, or be able to ascertain and implement using no more than routine experimentation, many equivalents of the specific embodiments described herein. Such equivalents are intended to be encompassed by the following claims. Any combinations of the embodiments disclosed in the dependent claims are contemplated to be within the scope of the disclosure. The disclosure of each and every U.S. and foreign patent and pending patent application and publication referred to herein is specifically incorporated by reference herein in its entirety for all purposes.

Table 3. Summary of sequences

Linker of polyvalent EPKSCDKTHTCPPCPAPELLGGPSVFLFPPKPKDT bispecific antibody LMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVE P4-G1-M1.3 (MM-141) VHN AKTKPREEQ YNS T YRV VS VLT VLHQD WLN

GKE YKC KVS NKALP APIEKTIS K AKGQPREPQ V Y TLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWES NGQPENN YKTTPP VLDS DGS FFLYS KLT VD KS R WQQGNVFSCSVMHEALHNHYTQKSLSLSPGGG GGSGGGGSGGGGS

M7-G1-M78 Heavy chain E VQLVES GGGLVQPGRS LRLS C A AS GFTFDD Y A

MHWVRQAPGKGLEWVSGISWDSGSVGYADSV KGRFTIS RDN AKNS LYLQMNS LR AEDT ALY YC A RDLGYNQWWEGFDYWGQGTLVTVSSASTKGPS VFPLAPS S KSTS GGT AALGCLVKD YFPEPVTVS W NSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSS LGTQTYICNVNHKPSNTKVDKKVEPKSCDKTHT CPPCP APELLGGPS VFLFPPKPKDTLMIS RTPE VT CVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPR EEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVS NKALP APIEKTIS KAKGQPREPQVYTLPPSREEM TKNQ VS LTCLVKGFYPS DIA VEWES NGQPENN Y KTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFS CSVMHEALHNHYTQKSLSLSPGGGGGSGGGGS GGGGSEVQLLQSGGGLVQPGGSLRLSCAASGFD FS S YPMHW VRQ APGKGLEW VGS IS S S GG ATP Y A DS VKGRFTIS RDNS KNTLYLQMNS LRPEDT A V Y YC AKDF YTILTGN AFDMWGQGTS VT VS S AS TGG GGSGGGGSGGGGSGGGGSDIQMTQSPSSLSASL GDRVTITCR AS QGIS S YLA W YQQKPGKAPKLLIY AS STRQS GVPSRFS GS GS GTDFTLTIS S LQPEDS G TYYCQQYWAFPLTFGGGTKVEIKRT M7-G1-M78 Light chain SSELTQDPAVSVALGQTVRITCQGDSLRSYYAS W YQQKPGQAPVLVIYGKNNRPS GIPDRFS GS S S G NTASLTITGAQAEDEADYYCNSRDTPGNKWVFG GGTKVT VIGQPKA APS VTLFPPS S EELQ ANKATL VCLVSDFYPGAVTVAWKADGSPVKVGVETTKP S KQS NNKY A AS S YLS LTPEQWKS HRS YS CRVTH EGSTVEKTVAPAECS

P4-G1-C8 Heavy chain E VQLLQS GGGLVQPGGS LRLS C A AS GFMFS R YP

MHW VRQ APGKGLE W VGS IS GS GG ATP Y ADS VK GRFTIS RDNS KNTLYLQMNS LRAEDT A V Y YC AK DFYQILTGN AFD YWGQGTT VT VS S AS TKGPS VF PLAPS S KSTS GGT AALGCLVKD YFPEPVTVS WNS G ALTS G VHTFP A VLQS S GLYS LS S V VT VPS S S LG TQTYICNVNHKPSNTKVDKKVEPKSCDKTHTCP PCP APELLGGPS VFLFPPKPKDTLMIS RTPE VTC V VVDVSHEDPEVKFNWYVDGVEVHNAKTKPREE Q YNS T YR V VS VLT VLHQD WLNGKE YKC KVS NK ALPAPIEKTISKAKGQPREPQVYTLPPSREEMTK NQVSLTCLVKGFYPSDIAVEWESNGQPENNYKT TPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCS VMHE ALHNH YTQKS LSLSPGGGGGSGGGGSGG GGS Q VQLVQS GGGLVQPGGS LRLS C A AS GFTFD DYAMHWVRQAPGKGLEWVAGISWNSGSIGYA DS VKGRFTIS RDN AKNS LYLQMNS LRPEDT A V Y YC ARDLG YNQW VEGFD YWGQGTLVT VS S AS TG GGGSGGGGSGGGGSGGGGSS YELTQDP A VS V A LGQT VRITC QGDS LRS Y Y AS W YQQKPGQ AP VLV IYGKNNRPS GIPDRFS GS TS GNS AS LTITG AQ AED EAD YYCNSRDS S GNHW VFGGGTKVT VLG

ErbB3 protein SEVGNSQAVCPGTLNGLSVTGDAENQYQTLYKL

YERCEVVMGNLEIVLTGHNADLSFLQWIREVTG

YVLVAMNEFSTLPLPNLRVVRGTQVYDGKFAIF VMLN YNTNS S H ALRQLRLTQLTEILS GG V YIEKN

DKLCHMDTIDWRDIVRDRDAEIVVKDNGRSCPP

CHEVCKGRCWGPGSEDCQTLTKTICAPQCNGHC

FGPNPNQCCHDECAGGCSGPQDTDCFACRHFND

SGACVPRCPQPLVYNKLTFQLEPNPHTKYQYGG

VCVASCPHNFVVDQTSCVRACPPDKMEVDKNG

LKMCEPCGGLCPKACEGTGSGSRFQTVDSSNID

GFVNCTKILGNLDFLITQGDPWHKIPALDP

EKLNVFRTVREITGYLNIQSWPPHMHNFSVFSNL

TTIGGRS LYNRGFS LLIMKNLN VTS LGFRS LKEIS

AGRIYISANRQLCYHHSLNWTKVLRGPTEERLDI

KHNRPRRDC VAEGKVCDPLCS S GGC WGPGPGQ

CLSCRNYSRGGVCVTHCNFLNGEPREFAHEAEC

FSCHPECQPMEGTATCNGSGSDTCAQCAHFRDG

PHCVSSCPHGVLGAKGPIYKYPDVQNECRPCHE

NCTQGCKGPELQDCLGQTLVLIGKTHLTMALTV

IAGLVVIFMMLGGTFLYWRGRRIQNKRAMRRY

LERGES IEPLDPS EKANKVLARIFKETELRS LKVL

GS GVFGT VHKGVWIPEGESIKIP VCIKVIEDKS GR

QS FQ A VTDHMLAIGS LDH AHIVRLLGLCPGS S LQ

LVTQYLPLGSLLDHVRQHRGALGPQLLLNWGV

QIAKGMYYLEEHGMVHRNLAARNVLLKSPSQV

QVADFGVADLLPPDDKQLLYSEAKTPIKWMALE

S IHFGKYTHQS D VWS YG VT VWELMTFG AEP Y A

GLRLAEVPDLLEKGERLAQPQICTIDVYMVMVK

CWMIDENIRPTFKELANEFTRMARDPPRYLVIKR

ESGPGIAPGPEPHGLTNKKLEEVELEPELDLDLD

LE AEEDNLATTTLGS ALS LP VGTLNRPRGS QS LL

SPSS G YMPMNQGNLGES CQES A VS GS S ERCPRP

VS LHPMPRGCLAS ES S EGH VTGS E AELQEK VS M

CRS RS RS RS PRPRGDS A YHS QRHS LLTP VTPLS PP

GLEEED VNG Y VMPDTHLKGTPS S REGTLS S VGL S S VLGTEEEDEDEE YE YMNRRRRHS PPHPPRPS S LEELG YE YMD VGS DLS AS LGS TQS CPLHP VPIMP TAGTTPDEDYEYMNRQRDGGGPGGDYAAMGA CPASEQGYEEMRAFQGPGHQAPHVHYARLKTL RS LE ATDS AFDNPD Y WHS RLFPKAN AQRT

Claims

What is claimed is:

1. A method of treating a patient having Ewing sarcoma comprising administering to the patient effective amounts of istiratumab, irinotecan, and temozolomide.

2. Use of istiratumab, irinotecan, and temozolomide for the manufacture of a

medicament for the treatment of a patient having Ewing sarcoma. 3. Istiratumab, irinotecan, and temozolomide for use in the treatment of a patient having Ewing sarcoma.

4. Istiratumab for use in the treatment of a patient having Ewing sarcoma, wherein the treatment further comprises administering irinotecan and temozolomide.

5. Irinotecan for use in the treatment of a patient having Ewing sarcoma, wherein the treatment further comprises administering istiratumab and temozolomide.

6. Temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein the treatment further comprises administering istiratumab and irinotecan.

7. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-6, wherein istiratumab, irinotecan, and temozolomide are each administered in a separate formulation or a separate unit dosage form.

8. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-7, wherein istiratumab and irinotecan are administered intravenously and

temozolomide is administered orally. 9. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-8, wherein istiratumab, irinotecan, and temozolomide are administered

simultaneously or sequentially.

10. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-9, wherein istiratumab is administered intravenously at a dose of 40 mg/kg every two weeks. 11. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-9, wherein istiratumab is administered intravenously at a fixed dose of 2.8 g every two weeks.

12. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-11, wherein irinotecan is administered intravenously at a dose of 50 mg/m² on days

1-5 every three weeks and temozolomide is administered orally at a dose of 75-100 mg/m² on days 1-5 every three weeks.

13. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-11, wherein irinotecan is administered intravenously at a dose of 50 mg/m² on days

1-5 every three weeks and temozolomide is administered orally at a dose of 125 mg/m² on days 1-5 every three weeks.

14. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-11, wherein irinotecan is administered intravenously at a dose of 10 mg/m², 20 mg/m², or 25 mg/m² on days 1-5 and 8-12 every three weeks and temozolomide is administered orally at a dose of 50-100 mg/m² on days 1-5 every three weeks.

15. The method of claim 14, wherein irinotecan is administered intravenously at a dose of 10 mg/m² on days 1-5 and 8-12 every three weeks.

16. The method, use, or istiratumab, irinotecan and/or temozolomide for use of claim 14, wherein irinotecan is administered intravenously at a dose of 20 mg/m² on days 1-5 and 8-12 every three weeks.

17. The method, use, or istiratumab, irinotecan and/or temozolomide for use of claim 14, wherein irinotecan is administered intravenously at a dose of 25 mg/m² on days 1-5 and 8-12 every three weeks.

18. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-17, wherein the irinotecan is irinotecan sucrosofate liposome injection.

19. The method, use, or istiratumab, irinotecan and/or temozolomide for use of any one of claims 1-17, wherein the irinotecan is Onivyde®.

20. The method, use, or istiratumab, irinotecan and/or temozolomide for use of claim 18, wherein the irinotecan sucrosofate liposome injection is administered intravenously at a dose of 35-50 mg/m² every two weeks and temozolomide is administered orally at a dose of 25- 100 mg/m², 25-150 mg/m², 50-100 mg/m², 50-125 mg/m², 50-150 mg/m², 75-100 mg/m², 75- 150 mg/m², 100-150 mg/m²,125-150 mg/m², or 125 mg/m² on days 1-5 every three weeks.

21. The method, use, or istiratumab, irinotecan and/or temozolomide for use of claim 18, wherein the irinotecan sucrosofate liposome injection is administered intravenously at a dose of 50-70 mg/m² every two weeks and temozolomide is administered orally at a dose of 25- 100 mg/m², 25-150 mg/m², 50-100 mg/m², 50-125 mg/m², 50-150 mg/m², 75-100 mg/m², 75- 150 mg/m², 100-150 mg/m²,125-150 mg/m², or 125 mg/m² on days 1-5 every three weeks.

22. A method of treating a patient having Ewing sarcoma comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 75-100 mg/m² on days 1-5 every three weeks. 23. Use of istiratumab, irinotecan, and temozolomide for the manufacture of a

medicament for the treatment of a patient having Ewing sarcoma, wherein:

(C) temozolomide is administerd orally at a dose of 75-100 mg/m² on days 1-5 every three weeks.

24. Istiratumab, irinotecan, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

(C) temozolomide is administerd orally at a dose of 75-100 mg/m² on days 1-5 every three weeks. 25. A method of treating a patient having Ewing sarcoma comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 125 mg/m² on days 1-5 every three weeks.

26. Use of istiratumab, irinotecan, and temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, wherein:

(C) temozolomide is administered orally at a dose of 125 mg/m² on days 1-5 every three weeks.

27. Istiratumab, irinotecan, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 125 mg/m² on days 1-5 every three weeks.

28. A method of treating a patient having Ewing sarcoma comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks; (B) irinotecan intravenously at a dose of 10 mg/m², 20 mg/m², or 25 mg/m² on days 1- 5 and 8-12 every three weeks; and

29. Use of istiratumab, irinotecan, and temozolomide for the manufacture of a

medicament for the treatment of a patient having Ewing sarcoma, wherein:

(B) irinotecan is administered intravenously at a dose of 10 mg/m², 20 mg/m², or 25 mg/m² on days 1-5 and 8-12 every three weeks; and

(C) temozolomide is administered orally at a dose of 50-100 mg/m² on days 1-5 every three weeks.

Istiratumab, irinotecan, and temozolomide for use in the treatment of a patient having sarcoma, wherein:

31. A method of treating a patient having Ewing sarcoma comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(B) irinotecan sucrosofate liposome injection intravenously at a dose of 35-50 mg/m² or 50-70 mg/m² every two weeks; and

(C) temozolomide orally at a dose of 75-100 mg/m² on days 1-5 every three weeks.

32. Use of istiratumab, irinotecan sucrosofate liposome injection, and temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, wherein: (A) istiratumab is administered intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(B) irinotecan sucrosofate liposome injection is administered intravenously at a dose of 35-50 mg/m² or 50-70 mg/m² every two weeks; and

(C) temozolomide is administered orally at a dose of 75-100 mg/m² on days 1-5 every three weeks.

33. Istiratumab, irinotecan sucrosofate liposome injection, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

34. A method of treating a patient having Ewing sarcoma comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(C) temozolomide orally at a dose of 125 mg/m² on days 1-5 every three weeks.

35. Use of istiratumab, irinotecan sucrosofate liposome injection, and temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, wherein:

36. Istiratumab, irinotecan sucrosofate liposome injection, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

37. A method of treating a patient having Ewing sarcoma comprising administering to the patient:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

(B) irinotecan sucrosofate liposome injection administered intravenously at a dose of 35-50 mg/m² or 50-70 mg/m² every two weeks; and

38. Use of istiratumab, irinotecan sucrosofate liposome injection, and temozolomide for the manufacture of a medicament for the treatment of a patient having Ewing sarcoma, wherein:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

39. Istiratumab, irinotecan sucrosofate liposome injection, and temozolomide for use in the treatment of a patient having Ewing sarcoma, wherein:

(A) istiratumab intravenously at a dose of 40 mg/kg or 2.8 g every two weeks;

40. The method, use, or istiratumab, irinotecan sucrosofate liposome injection, and temozolomide for use of any one of claims 31-39, wherein the irinotecan sucrosofate liposome injection is Onivyde®.