Cancer therapy with a parvovirus combined with bevacizumab

Abstract

Described is a pharmaceutical composition comprising (a) a parvovirus and (b) bevacizumab and the use of said composition for treatment of cancer, e.g., a solid tumor.

Claims

1. A method for treating a brain tumor comprising administering a pharmaceutical combination containing (a) a parvovirus in combination with (b) bevacizumab, wherein said parvovirus is H-1 (H-1PV).

2. The method according to claim 1 wherein the pharmaceutical combination containing (a) the parvovirus and (b) bevacizumab is formulated for intratumoral or intravenous administration, and bevacizumab is formulated for intravenous administration.

3. The method according to claim 1 wherein the parvovirus and bevacizumab are sequentially administered.

4. The method according to claim 1 wherein the brain tumor is a solid brain tumor and/or cancer initiating stem cells.

5. The method according to claim 1 wherein the brain tumor is resistant to parvovirus cytotoxicity.

6. The method according to claim 1 wherein the brain tumor is a glioma or recurrent glioblastoma multiforme.

7. The method according to claim 1 wherein the parvovirus and/or bevacizumab are administered by intratumoral or intravenous administration.

8. A kit comprising a first container, a second container and a package insert, wherein the first container comprises at least one dose of a pharmaceutical composition containing parvovirus H-1, the second container comprises at least one dose of a pharmaceutical composition comprising bevacizumab, and the package insert comprises instructions for treating an individual having a brain tumor using the pharmaceutical composition(s).

9. The kit of claim 8, wherein the brain tumor is a glioma or recurrent glioblastoma multiforme.

Description

BRIEF DESCRIPTION OF THE FIGURES

(1) FIG. 1: Trial Design of Clinical Phase I/IIa Study

(2) FIG. 2: Compassionate Use of H-1 PV with Avastin in Patient 2-04

(3) FIG. 3: Compassionate Use of H-1 PV with Avastin in Patient 5-14

(4) FIG. 4: EliSpot Data of Patient 2-04 Pool 1 & Pool 2: Glioblastoma multiforme (GBM)specific peptides Pool 3 & Pool 4: Parvovirus H-1 specific peptidesNS1 and VP

(5) The present invention provides a pharmaceutical composition containing (a) parvovirus H-1 in combination with (b) bevacizumab.

(6) Preferably, in said pharmaceutical composition the parvovirus H-1 and bevacizumab are present in an effective dose and combined with a pharmaceutically acceptable carrier. Pharmaceutically acceptable is meant to encompass any carrier, which does not interfere with the effectiveness of the biological activity of the active ingredients and that is not toxic to the patient to whom it is administered. Examples of suitable pharmaceutical carriers are well known in the art and include phosphate buffered saline solutions, water, emulsions, such as oil/water emulsions, various types of wetting agents, sterile solutions etc. Such carriers can be formulated by conventional methods and can be administered to the subject at an effective dose.

(7) The term parvovirus as used herein comprises wild-type or modified replication-competent derivatives thereof, as well as related viruses or vectors based on such viruses or derivatives. Suitable parvoviruses, derivatives, etc. as well as cells which can be used for actively producing said parvoviruses and which are useful for therapy, are readily determinable within the skill of the art based on the disclosure herein, without undue empirical effort.

(8) An effective dose refers to amounts of the active ingredients that are sufficient to affect the course and the severity of the disease, leading to the reduction or remission of such pathology. An effective dose useful for treating and/or preventing these diseases or disorders may be determined using methods known to one skilled in the art.

(9) Additional pharmaceutically compatible carriers can include gels, bioasorbable matrix materials, implantation elements containing the therapeutic agent, or any other suitable vehicle, delivery or dispensing means or material(s).

(10) Administration of the compounds may be effected by different ways, e.g. by intravenous, intraperetoneal, subcutaneous, intramuscular, topical, intratumoral or intradermal administration. The route of administration, of course, depends on the kind of therapy and the kind of compounds contained in the pharmaceutical composition. The dosage regimen of the parvovirus and bevacizumab is readily determinable within the skill of the art, by the attending physician based an patient data, observations and other clinical factors, including for example the patient's size, body surface area, age, sex, the particular parvovirus, the particular inhibitor etc. to be administered, the time and route of administration, the tumor type and characteristics, general health of the patient, and other drug therapies to which the patient is being subjected. As regards bevacizumab reference is made to the package insert and patient information sheet which are incorporated by reference herewith.

(11) If the parvovirus in the combination with bevacizumab according to the invention comprises infectious virus particles with the ability to penetrate through the blood-brain barrier, treatment can be performed or at least initiated by intravenous injection of the virus. However, a preferred route of administration is intratumoral administration.

(12) Since long-term intravenous treatment is susceptible to becoming inefficient as a result of the formation of neutral-izing antibodies to the virus, different modes of administration can be adopted after an initial regimen intravenous viral administration, or such different administration techniques, e.g., intracranial or intratumoral virus administration, can be alternatively used throughout the entire course of parvoviral treatment.

(13) As another specific administration technique, the parvovirus (virus, vector and/or cell agent) can be administered to the patient from a source implanted in the patient. For example, a catheter, e.g., of silicone or other biocompatible material, can be connected to a small subcutaneous reservoir (Rickham reservoir) installed in the patient during tumor removal or by a separate procedure, to permit the parvovirus composition to be injected locally at various times without further surgical intervention. The parvovirus or derived vectors can also be injected into the tumor by stereotactic surgical techniques or by neuronavigation targeting techniques.

(14) Administration of the parvovirus can also be performed by continuous infusion of viral particles or fluids containing viral particles through implanted catheters at low flow rates using suitable pump systems, e.g., peristaltic infusion pumps or convection enhanced delivery (CED) pumps.

(15) A yet another method of administration of the parvovirus composition is from an implanted article constructed and arranged to dispense the parvovirus to the desired cancer tissue. For example, wafers can be employed that have been impregnated with the parvovirus H-1, wherein the wafer is attached to the edges of the resection cavity at the conclusion of surgical tumor removal. Multiple wafers can be employed in such therapeutic intervention. Cells that actively produce the parvovirus H-1, or H-1 based vectors, can be injected into the tumor or into the tumoral cavity after tumor removal.

(16) The therapy with the compound combination is useful for the therapeutic treatment of cancer, in particular (but not exclusively) brain tumor, pancreatic carcinoma, cervical carcinoma, lung cancer, head and neck cancer, breast cancer or colon cancer and can significantly improve the prognosis of said diseases. It can also allow the clinical use of the virus and/or bevacizumab at lower therapeutic doses preserving or even enhancing anticancer efficacy while increasing safety and reducing and/or avoiding side effects. In view of the strong synergistic effect between the parvovirus and bevacizumab it is possible to foresee the reduction of the therapeutic doses, e.g. half or a third of the previously used single component doses are preserving the desired therapeutic effect. In view of the reduced doses (severe) side effects may be reduced or even avoided.

(17) Parvovirus infection effects killing of tumor cells but does not harm normal cells and such infection can, for example, be carried out by intracerebral use of a suitable parvovirus, e.g., parvovirus H-1, or a related virus or vectors based on such viruses, to effect tumor-specific therapy without adverse neurological or other side effects.

(18) The present invention also relates to the use of (a) a parvovirus H-1 and (b) bevacizumab for the preparation of (a) pharmaceutical composition(s) or combination for the treatment of cancer.

(19) The mode of administration of (a) and (b) may be simultaneously or sequentially, wherein, preferably, (a) and (b) are sequentially (or separately) administered. This means that (a) and (b) may be provided in a single unit dosage form for being taken together or as separate entities (e.g. in separate containers) to be administered simultaneously or with a certain time difference. This time difference may be between 1 hour and 1 week, preferably between 12 hours and 3 days. In addition, it is possible to administer the parvovirus via another administration way than bevacizumab. In this regard it may be advantageous to administer either the parvovirus or bevacizumab intratumoraly and the other systemically or orally. In a particular preferred embodiment the parvovirus is administered intratumoraly and bevacizumab intravenously. Preferably, the parvovirus and bevacizumab are administered as separate compounds. Concomitant treatment with the two agents is also possible.

(20) In one preferred embodiment of the present invention, the combination of agents is utilized in the treatment of solid tumours and its metastasis'. Examples are brain tumour, pancreatic carcinoma, cervical carcinoma, lung cancer, head and neck cancer, breast cancer or colon cancer. In a preferred embodiment these tumours are resistant to parvovirus toxicity.

(21) In a further preferred embodiment these tumour to be treated are recurrent tumours. A particular advantage of the pharmaceutical composition of the present invention is that even cancer initiating stem cells can be successfully treated. This has a positive effect as regards the avoidance of the recurrence of the tumours and metastasis formation.

(22) According to the present the parvovirus of the composition is parvovirus H-1 (H-1PV).

(23) Patients treatable by the combination of agents according to the invention include humans as well as non-human animals. Examples of the latter include, without limitation, animals such as cows, sheep, pigs, horses, dogs, and cats.

(24) The present invention further concerns a kit which comprises a first container, a second container and a package insert, wherein the first container comprises at least one dose of a pharmaceutical composition containing parvovirus H-1, the second container comprises at least one dose of a pharmaceutical composition comprising bevacizumab, and the package insert comprises instructions for treating an individual having cancer using the pharmaceutical composition(s).

(25) In the present invention it has been shown for the first time that the combinatorial use of parvovirus H-1PV and bevacizumab may be a valid approach against cancer, in particular gliomas and pancreatic carcinomas.

(26) As regards the treatment of brain tumors, unlike other oncolytic viruses, H-1PV was shown to cross the blood-brain barrier and to infect intracerebral tumors. This offers the chance of boosting the initial local therapy by consecutive intravenous administrations or for interval retreatment without the necessity of craniotomy.

(27) In general, the parvovirus H-1PV is considered to evoke an anticancer vaccination effect based on release of tumor-associated antigens and subsequent immunostimulation. This could lead to long-term effects in prevention of disease relapse, potentially adding to initial oncolysis. This effect is enhanced by using bevacizumab which is an anti-VEGF antibody and acts as an anti-angiogenic agent. In other words, the bevacizumab reduces or normalizes the formation of new blood vessels around the tumor as well as it reduces the immune-inhibitory effects of VEGF. This combination of effects renders the tumor more susceptible to the immune system, in particular after previous therapy with the parvovirus. Patients examples show that this combination therapy leads to either remission or stable disease, even when these patients suffered from progressive recurrent GBM.

(28) The below example explains the invention in more detail.

EXAMPLE 1

Bevacizumab Potentiates the Oncolytic Activity of H-1PV in a Synergistic Manner

(29) A clinical phase I/IIa trial on 18 patients suffering from recurrent malignant gliomas was initiated. This trial aims to investigate the safety, biodistribution, maximum tolerated dose and signs of anti-tumor activity of parvovirus H-1. According to preclinical data the parvovirus will not only include intratumoral virus application but also intravenous treatment.

(30) The application of parvovirus H-1 (GMP-grade preparation) was performed in 2 groups of 12 (group I) and 6 patients (group II). The route of administration differs between group 1 and group 2 (FIG. 1).

(31) Within each group the mode of application is identical, but the dose will be increased if no dose limiting events are observed. In group I the parvovirus H-1 (also called investigational medicinal product; IMP) was administered in four dose levels and in group II in 2 dose levels (Table 1).

(32) TABLE-US-00001 TABLE 1 Dose schedule for both study groups Escalation Level Study Time Dose and route of administration Duration GROUP I Level 1 Total dose: 1 10.sup.6 pfu Day 1 5 10.sup.5 pfu, intratumoral (via catheter) 15 minutes Day 10 5 10.sup.5 pfu, intracerebal (direct injection at multiple locations of resection wall) 15-30 minutes Level 2 Total dose: 5 10.sup.7 pfu Day 1 2.5 10.sup.7 pfu, intratumoral (via catheter) 15 minutes Day 10 2.5 10.sup.7 pfu, intracerebal (direct injection at multiple locations of resection wall) 15-30 minutes Level 3 Total dose: 1 10.sup.9 pfu Day 1 5 10.sup.8 pfu, intratumoral (via catheter) 15 minutes Day 10 5 10.sup.8 pfu, intracerebral (direct injection at multiple locations of resection wall) 15-30 minutes Level 4 Total dose: 5 10.sup.9 pfu Day 1 2.5 10.sup.9 pfu, intratumoral (via catheter) 15 minutes Day 10 2.5 10.sup.9 pfu, intracerebal (direct injection at multiple locations of resection wall) 15-30 minutes GROUP II Level 2 Total dose: 5 10.sup.7 Day 1-5 0.5 10.sup.7 pfu, intravenous infusion 2 hours Day 10 2.5 10.sup.7 pfu, intracerebral (direct injection at multiple locations of resection wall) 15-30 minutes Level 3 Total dose: 1 10.sup.9 pfu Day 1-5 1 10.sup.8 pfu, intravenous infusion 2 hours Day 10 5 10.sup.8 pfu, intracerebral (direct injection at multiple locations of resection wall) 15-30 minutes

(33) In group 1 the patients received the IMP on day 1 via image guided injection into the tumor tissue. On this day the patient is injected with 50% of the intended overall dose. After an observation period of 9 days the tumor was resected on day 10. After tumor removal the second half of the dose was administered into the walls of the resection cavity by direct injection. With this injection during open surgery the administration of the IMP is completed and no additional virus application was performed.

(34) In group 2 the initial administration of the IMP was via the intravenous route. Subjects received 50% of the intended dose by 5 infusions on days 1 to 5, each infusion containing 10% of the total dose. After the last infusion on day 5 there is an observation period until day 9 and on day 10 tumor resection was performed as in group 1. In analogy to group 1, patients receive the second half of the dose by injection in the tissue surrounding the tumor cavity after tumor removal and no further virus injections were performed in each individual during the course of the trial.

(35) 6 patients requested another H-1PV injection on the basis of a compassionate use agreement during resection of tumor recurrence: Group I Level 1 (intratumoral): 2 patients Group I Level 2 (intratumoral): 1 patient Group I Level 3 (intratumoral): 1 patient Group II Level 3 (intravenous): 2 patients

(36) After tumor resection virus was reapplied in the walls of the tumor cavity, whereas all patients received the same dose of virus of 510.sup.8 PFU.

(37) As a part of the compassionate use program that started in 2013 these patients received after the resection of the tumor recurrence a treatment with bevacizumab.

(38) The below summary (Table 2) of the survival data shows the interesting result that in 5 of 6 patients so far the time between second virus injection and second recurrence or dealth (PFS2) was longer than the time between first virus injection and first recurrence (PFS1). This is untypical for glioblastoma multiforme and a very surprising result.

(39) TABLE-US-00002 TABLE 2 (results received as of February 2015) Tu S OS PFS1 PFS2 DG ID ccm t/st m PV-R1 CU-R2 DG1 1-01 1.0 total 27.4 12.6 14.2 1-03 3.7 total 25.7 9.0 15.7 DG2 2-04 1.8 total 34.9 8.0 21.8 DG3 3-08 13.1 total 16.4 4.3 11.6 DG3 5-13 15.2 >90% 11.3 6.0 4.0 5-14 5.8 >95% 11.8 4.0 6.6 DG: dose group (level), Tu: tumor size, S: surgery, t: total, st: subtotal, m: month, OS: overall survival (month), PFS: progression free survival (month), PFS1: start virotherapy, first viral injection - recurrence, PFS2: start compassionate use, second virus injection - recurrence or death

(40) The treatment regimen (all treatments 1.2E9 pfu single dose IMP) in the year 2015 was for

(41) Patient 5-13: i.v. treatment on Sep. 2, 2015; peritumoral on Sep. 3, 2015

(42) Patient 5-14: i.v. treatment on Aug. 31, 2015; i.a. treatment on Sep. 1, 2015

(43) 1-2 weeks after the virus administration the patients received again Avastin in a dosage regimen according to the package insert.

(44) Recent Reassessment of the Patients Showed the Following Results:

(45) Patient 1-01: unchanged

(46) Patient 1-03: unchanged

(47) Patient 2-04: OS 40.9 months; patient has died; PFS2 24.2 months

(48) Patient 3-08: unchanged

(49) Patient 5-13: OS 21.3 months; patient has died; PFS2 14 months

(50) Patient 5-14: OS 24.1 months; PFS2 18.4 months; patient is still alive

(51) In the above Table 2 the first four patients (1-01, 1-03, 2-04, 3-08) are from the intratumoral treatment group (Group I) and the last two patients (5-13 and 5-14) are from the intravenous treatment group (Group II).

(52) 4 patients responded extremely favorably on the combination of repeated H-1PV injection followed by therapy with bevacicumab. 2 of the 4 patients [2-04 and 5-14] went into remission or stable disease. These data suggest a possible immune stimulation by repeated H-1PV injection, which possibly enhances the effects of bevacicumab.

(53) For the two patients 2-04 and 5-13 the treatment protocol and MRI scans are shown in FIGS. 2 and 3.

(54) The EliSpot Data of patient 2-04 are shown in FIG. 4. It is absolutely surprising that CTL-responses against virus specific NS1 peptides (Poll3; Parvo NS) occur at day 625.

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