CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of U.S. Application No. 15/809,427, filed November 10, 2017, which is incorporated by reference herein in its entirety.

STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

[0002] This invention was made with government support under OD024576 and CA197078 awarded by the National Institutes of Health. The government has certain rights in the invention.

FIELD OF THE DISCLOSURE

[0003] This disclosure relates generally to methods of treating cancer. In particular, the disclosure is directed to methods of treating a cancer comprising one or more malignant solid tumors in a subject by (1) systemically administering to the subject an immunomodulatory dose of a targeted radiotherapy (TRT) agent, such as a radioactive metal chelate compound, a radiohalogenated compound, radiolabeled antibody, or a radiosiotope that is differentially taken up by and retained within solid tumor tissue; and (2) systemically administering to the subject one or more immunostimulatory agents, such as one or more immune checkpoint inhibitors.

BACKGROUND

[0004] Current cancer treatment typically involves systemic chemotherapy whereby non-targeted small molecule or antibody directed cytotoxic agents preferentially enter, or bind to (in the case of antibody directed agents) and kill cancer cells by a variety of mechanisms. External beam radiation therapy (xRT), which is often combined with chemotherapy, kills cancer cells by inducing nuclear DNA double strand breaks resulting in cell-cycle death. Unlike systemic chemotherapy, xRT depends on the ability to accurately determine the anatomic location of the tumor. Surgical resection of tumors also depends on the ability to see the tumor and on complete removal, since residual tumor cells will quickly reestablish the tumor following surgery. Surgery and xRT are generally limited to the local treatment of malignant tumors and thus are limited in treating disseminated or metastatic disease, which is why chemotherapy is often used in conjunction with these treatment modalities. Although systemic chemotherapy is capable of reaching many distant metastatic sites, with the possible exception of brain metastases, for all too many patients, responses are typically short-lived (months to several years) and ultimately result in tumor recurrence.

[0005] Because the body's natural immune system is also capable of destroying cancer cells following their recognition, immunologic approaches are rapidly becoming more prevalent in cancer treatment paradigms. However, some cancer cells, and to a greater extent cancer stem cells, manage to initially avoid immune-surveillance and actually acquire the ability to evolve and ultimately survive by remaining relatively immune invisible [Gaipi et al, Immunotherapy 6:597-610, 2014].

[0006] One specific immunologic approach that is being increasingly investigated is "in situ vaccination," a strategy that seeks to enhance tumor immunogenicity, generate tumor infiltrating lymphocytes (TIL) and drive a systemic anti-tumor immune response directed against "unvaccinated," disseminated tumors. In in situ vaccination, a malignant solid tumor is injected with (or treated with) one or more agents that facilitate the release of tumor antigens while simultaneously providing pro-inflammatory signals to reverse the immune-tolerizing microenvironment of the tumor [Pierce et al, Human Vaccines & Immunotherapoeutics 11(8): 1901 -1909, 2015; Marabelle et al, Clin. Cancer Res.

20(7): 1747-56, 2014; Morris et al, Cancer Res; 76(13); 3929-41, 2016], [0007] A second and quite different approach is systemically-administered immunotherapy. In systemically-administered immunotherapy, an immunostimulatory agent, such as an immune checkpoint inhibitor, is administered to circulate through the entire body (e.g., intravenously), rather than being locally injected into the tumor. Such agents can be used to treat tumors in which an anti-tumor immune response is present, but has been "exhausted" or rendered ineffective. In the case of checkpoint inhibitors, the tumor cells express "checkpoint ligands" or other checkpoint molecules that interact with "checkpoint receptors" on the existing anti-tumor immune cells, triggering the inactivation of these cells. By blocking this interaction, systemically-administered checkpoint inhibitors turn on the exhausted, pre-existing immune response in cancer patients, facilitating a more effective attack on the cancer cells by the patient's own immune system.

[0008] Although recent data from clinical trials and pre-clinical models illustrate the potential of these approaches, there is a great need in the art for s stemically- administered immunotherapy methods exhibiting improved systemic efficacy.

[0009] Radiation hormesis is a decades-old hypothesis that low doses of ionizing RT can be beneficial by stimulating the activation of natural protective repair mechanisms that are not activated in the absence of ionizing RT [Cameron and Moulder, Med. Phys. 25: 1407, 1998]. The reserve repair mechanisms are hypothesized to be sufficiently effective when stimulated as to not only cancel the detrimental effects of ionizing RT but also inhibit disease not related to RT exposure. Perhaps related, the abscopal effect is a phenomenon reported in the 1950's, whereby, xRT treatment of one tumor actually causes shrinkage of another tumor outside the RT treatment area. Although rare, this phenomenon is thought to be dependent on activation of the immune system. Together, hormesis and the abscopal effect support the potential interaction and stimulation of the immune system by low dosage (immune stimulatory but non-cytotoxic) RT, which may then be combined with other immunologic approaches, such as systemically-administered immunotherapy.

[0010] We have previously published that the combination of local xRT + in situ vaccination and/or systemic checkpoint inhibitor immunotherapy are potently synergistic in treating large established tumors in mice, when there is a single tumor present [Morris et al, Cancer Res; 76(13); 3929-41, 2016]. However, we have surprisingly discovered that the combination of in situ vaccination and xRT does not result in inhibited tumor growth in the presence of a second, non-radiated tumor. Apparently, the non-radiated tumor exhibits a dampening effect (which we have designated as "concomitant immune tolerance") on the immunomodulatory effect of the xRT and in situ vaccine on the radiated tumor.

[0011] This concomitant immune tolerance can be overcome, enabling efficacy of in situ vaccination, when xRT is given to all areas of tumor. However, xRT cannot be effectively used in combination with in situ vaccination methods in the presence of multiple tumors, particularly if the tumors are not few in number, or if the location of one or more of the tumors is not precisely known, or if it is not feasible to deliver xRT to all sites of tumor. Furthermore, administering xRT to all tumor sites in patients with metastatic disease would likely result in systemic immune suppression, defeating the central purpose of systemically-administered immunotherapy.

[0012] Accordingly, in combination with systemically-administered immunotherapy, there is a need for improved methods of delivering an immunomodulatory dose of RT to all tumors within a subject, regardless of their number and anatomic location.

BRIEF SUMMARY

[0013] We have previously shown that certain alkylphosphocholine analogs are preferentially taken up and retained by malignant solid tumor cells. In U.S. Patent Publication No. 2014/0030187, which is incorporated by reference herein in its entirety, Weichert et al. disclose using analogs of the base compound 18-(p-iodophenyl)octadecyl phosphocholine (NM404; see Figure 1) for detecting and locating, as well as for treating, a variety of malignant solid tumors. If the iodo moiety is an imaging-optimized radionuclide, such as iodine-124 ([ ¹²⁴ I]-NM404), the analog can be used in positron emission tomography-computed tomography (PET/CT) or single-photon emission computed tomography (SPECT) imaging of solid tumors. Alternatively, if the iodo moiety is a radionuclide optimized for delivering therapeutic doses of RT to the solid tumors cells in which the analog is taken up, such as iodine-125 or iodine-131 ([ ¹²⁵ I]- NM404 or [ ¹³¹ I]-NM404), the analog can be used to treat the solid tumors. [0014] Such analogs not only target a wide variety of solid tumor types in vivo, but also undergo prolonged selective retention in tumor cells, thus affording high potential as RT agents. Moreover, tumor uptake is limited to malignant cancer and not premalignant or benign lesions.

[0015] However, there are metal isotopes that have better properties for optimized imaging and/or RT than the radioactive iodine isotopes used in the previously disclosed alkylphosphocholine analogs. For example, as an imaging isotope, 1-124 suffers from poor positron output (only about 24% of the emissions are positrons), and it suffers further from a confounding gamma emission (600 KeV), which actually interferes with normal 511 KeV PET detection. Certain positron emitting metals have better imaging characteristics. As another example, as an RT isotope, 1-131 produces other non- therapeutic emissions at other energies, which add undesired radiation dosimetry to neighboring normal tissue, including bone marrow. The beta particle range of 1-131 is also quite long, which contributes to off target toxicity. Several metallic radiotherapy isotopes offer a cleaner emission profile and shorter pathlength and thus less potential toxicity.

[0016] We have developed improved alkylphosphocholine analogs that include a chelated radioactive metal isotope instead of a radioactive iodine isotope (see, e.g., U.S. Patent Publication No. 2018/0022768, which is incorporated by reference herein in its entirety). The analogs include the same backbone as the previously disclosed

radioiodinated compounds, so they are still selectively taken up and retained in tumor cells. However, the chelated radioactive metal isotope provides improved emissions for imaging and/or radiotherapy applications. Such agents are well suited for delivering a sub-cytotoxic but immunomodulatory dose of ionizing RT to all malignant tumors present within a subject, regardless of whether their number and locations are known.

[0017] Accordingly, in a first aspect, the disclosure encompasses a method of treating a cancer comprising one or more malignant solid tumors in a subject. The method includes the steps of systemically administering to the subject (a) an immunomodulatory dose of a targeted radiotherapy (TRT) agent that is differentially taken up by and retained within the malignant solid tumor tissue; and (b) one or more immunostimulatory agents. [0018] In some embodiments, the one or more immunostimulatory agents are immune checkpoint inhibitors capable of targeting one or more checkpoint molecules.

[0019] Non-limiting examples of the one or more immune checkpoint inhibitors include agents that are capable of targeting one or more of the following checkpoint molecules: A2AR (adenosine A2a receptor), BTLA (B and T lymphocyte attenuator), CTLA4 (cytotoxic T lymphocyte-associated protein 4), KIR (killer cell immunoglobulin- like receptor), LAG3 (Lymphocyte Activation Gene 3), PD-1 (programmed death receptor 1), PD-L1 (programmed death ligand 1), CD40 (cluster of differentiation 40), CD27 (cluster of differentiation 27), CD28 (cluster of differentiation 28), CD137 (cluster of differentiation 137), OX40 (CD134; cluster of differentiation 134), OX40L (OX40 ligand; cluster of differentiation 252), GITR (glucocorticoid-induced tumor necrosis factor receptor-related protein), GITRL (glucocorticoid-induced tumor necrosis factor receptor-related protein ligand), ICOS (inducible T-cell costimulatory), ICOSL (inducible T-cell costimulatory ligand), B7H3 (CD276; cluster of differentiation 276), B7H4 (VTCN1; V-set domain-containing T-cell activation inhibitor 1), IDO (Indoleamine 2,3- dioxygenase), TIM-3 (T-cell Immunoglobulin domain and Mucin domain 3), Gal-9 (galectin-9), or VISTA (V-domain Ig suppressor of T cell activation).

[0020] In some embodiments, the one or more immune checkpoint inhibitors include one or more anti-immune checkpoint molecule antibodies. In some such embodiments, the one or more anti-immune checkpoint molecule antibodies include at least one monoclonal antibody.

[0021] In some embodiments, the one or more immune checkpoint inhibitors include one or more small molecules capable of inhibiting or blocking one or more immune checkpoint molecules. Non-limiting examples of such small molecule checkpoint inhibitors include CA-170 and CA-327, which both target PD-L1.

[0022] In some embodiments, the one or more anti-immune checkpoint molecule antibodies include an anti-CTLA4 antibody, an anti-PD-1 antibody, an anti-PD-Ll antibody, an anti-LAG3 antibody, an anti-KIR antibody, an anti-A2AR antibody, and anti-BTLA antibody, an anti-CD40 antibody, an anti-CD27 antibody, an anti-CD28 antibody, an anti-CD 137 antibody, an anti-OX40 antibody, an anti-OX40L antibody, an anti-GITR antibody, an anti-GITRL antibody, an anti-ICOS antibody, an anti-ICOSL antibody, an anti-B7H3 antibody, an anti-B7H4 antibody, an anti-IDO antibody, an anti-

TIM-3 antibody, an anti-Gal-9 antibody, or an anti-VISTA antibody.

[0023] In some embodiments, the TRT agent is metaiodobenzylguanidine (MIBG), where the iodine atom in the MIBG is a radioactive iodine isotope.

[0024] In some embodiments, the TRT agent is a radiolabeled tumor-targeting antibody.

[0025] In some embodiments, the TRT agent is radioactive isotope of radium, such as

Ra-223.

[0026] In some embodiments, the TRT agent is a radioactive phospholipid ether metal chelate having the formula:

or a salt thereof. Ri includes a chelating agent that is chelated to a metal atom, wherein the metal atom is an alpha, beta or Auger emitting metal isotope with a half-life of greater than 6 hours and less than 30 days; a is 0 or 1; n is an integer from 12 to 30; m is 0 or 1; Y is -H, -OH, -COOH, -COOX, -OCOX, or -OX, wherein X is an alkyl or an aryl; R ₂ is -N ⁺ H ₃ , -N ⁺ H ₂ Z, -N ⁺ HZ ₂ , or -N ⁺ Z ₃ , wherein each Z is independently an alkyl or an aroalkyl; and b is 1 or 2. Non-limiting examples of metal isotopes that could be used include Sc-47, Lu-177, Y-90, Ho-166, Re-186, Re-188, Cu-67, Au-199, Rh-105, Ra-223, Ac-225, Pb-212, or Th-227.

[0027] In some embodiments, the chelating agent is 1,4,7, 10-tetraazacy clododecane- 1,4,7-triacetic acid (D03A) or one of its derivatives; l,4,7-triazacyclononane-l,4-diacetic acid (NOD A) or one of its derivatives; l,4,7-triazacyclononane-l,4,7-triacetic acid (NOTA) or one of its derivatives; 1,4,7, 10-tetraazacyclododecane-1, 4,7, 10-tetraacetic acid (DOTA) or one of its derivatives; l,4,7-triazacyclononane, l-glutaric acid-4,7- diacetic acid (NODAGA) or one of its derivatives; 1,4,7, 10-tetraazacy clodecane, l- glutaric acid-4,7,10-triacetic acid (DOTAGA) or one of its derivatives; 1,4,8, 11- tetraazacyclotetradecane-l,4,8, l l-tetraacetic acid (TETA) or one of its derivatives; 1,4,8, 1 l-tetraazabicyclo[6.6.2]hexadecane-4, 11-diacetic acid (CB-TE2A) or one of its derivatives; diethylene triamine pentaacetic acid (DTP A), its diester, or one of its derivatives; 2-cyclohexyl diethylene triamine pentaacetic acid (CHX-A"-DTPA) or one of its derivatives; deforoxamine (DFO) or one of its derivatives; l,2-[[6-carboxypyridin- 2-yl]methylamino]ethane (FTidedpa) or one of its derivatives; and DADA or one of its derivatives, wherein DADA comprises the structure:

[0028] In some embodiments, a is 1 (aliphatic aryl-alkyl chain). In other

embodiments, a is 0 (aliphatic alkyl chain).

[0029] In some embodiments, m is 1 (acylphospholipid series). In some such embodiments, n is an integer between 12 and 20. In some embodiments, Y is -OCOX, -COOX or -OX.

[0030] In some embodiments, X is -CH2CH3 or -CH3.

[0031] In some embodiments, m is 0 (alkylphospholipid series).

[0032] In some embodiments, b is 1.

[0033] In some embodiments, n is 18.

[0034] In some embodiments, R2 is -N ⁺ Z ₃ . In some such embodiments, each Z is independently -CH2CH3 or -CH ₃ . In some such embodiments, each Z is -CH ₃ . e embodiments, the chelating agent chelated to the metal atom is:

[0036] In some embodiments, the radioactive phospholipid ether metal chelate is of the following compounds, wherein the selected compound is chelated to the metal atom:

HO

-(CH ₂ )i 80POCH2CH ₂ NMe3

O

Θ

HO





e ₃

Me ₃ CH ₂ ) ₁₈ OPOCH ₂ CH ₂ NMe ₃

0

-N N ©

H0 ₂ C ) ( C0 ₂ H

H0 ₂ C C0 ₂ H C0 ₂ H CH ₂ CH ₂ NMe ₃ Me ₃

[0037] In some embodiments, in the phospholipid ether metal chelate structure, a is 1, b is 1, m is 0, n is 18, and R2 is -N ⁺ (CH3)3. In some such embodiments, the phospholipid ether metal chelate is M600 chelated to the metal atom, such as (but not limited to) ⁹⁰ Y- M600. [0038] In some embodiments, the TRT agent is a radiohalogenated phospholipid ether having the formula:

OC H ₂

or a salt thereof. Ri comprises a radioactive halogen isotope; a is 0 or 1; n is an integer from 12 to 30; m is 0 or 1; Y is selected from the group consisting of -H, -OH, -COOH, - COOX, -OX, and -OCOX, wherein X is an alkyl or an arylalkyl; and R2 is selected from the group consisting of -N ⁺ H ₃ , -N ⁺ H ₂ Z, -N ⁺ HZ ₂ , and -N ⁺ Z ₃ , wherein each Z is independently an alkyl or an aryl.

[0039] In some embodiments, the radioactive halogen isotope is ¹²³ 1, ¹²⁴ 1, ¹²⁵ I, ¹³¹ I,

211 At, ⁷⁶ Br, or ⁷⁷ Br.

[0040] In some embodiments, a is 1 and m is 0.

[0041] In some embodiments, n is 18.

[0042] In some embodiments, R ₂ is -N ⁺ (CH ₃ ) ₃ . In some such embodiments, a is 1, m is 0, and n is 18. In some such embodiments, the radioactive halogen isotope is ¹²³ I, ¹²⁴ I, ¹²⁵ I, or ¹³¹ I (the radiohalogenated phospholipid ether is [ ¹²³ I]- M404, [ ¹²⁴ I]- M404, [ ¹²⁵ I]- M404, [ ¹³¹ I]- M404, [ ²¹¹ At]- M404, [ ⁷⁶ Br]- M404, or [ ⁷⁷ Br]- M404).

[0043] In some embodiments, the TRT agent, the immunostimulatory agent, or both, are administered intravenously.

[0044] In some embodiments, the subject is a human.

[0045] Non-limiting examples of the cancers presenting as malignant solid tumors that can be treated using the method include melanoma, neuroblastoma, lung cancer, adrenal cancer, colon cancer, colorectal cancer, ovarian cancer, prostate cancer, liver cancer, subcutaneous cancer, squamous cell cancer of the skin or head or neck, intestinal cancer, retinoblastoma, cervical cancer, glioma, breast cancer, pancreatic cancer, soft tissue sarcoma, Ewings sarcoma, rhabdomyosarcoma, osteosarcoma, Wilms' tumor, and pediatric brain tumors. [0046] In some embodiments, the cancer is treated without administering to the subject an antibody to a tumor antigen that is not a checkpoint molecule.

[0047] In some embodiments, an anti-GD2 antibody is not adminstered to the subject.

[0048] In a second aspect, the disclosure encompasses the use of a TRT agent and one or more immunostimulatory agents for treating a cancer comprising one or more malignant solid tumors in a subject, as further described above.

[0049] In a third aspect, the disclosure encompasses the use of a TRT agent and/or one or more immunostimulatory agents for the manufacture of a medicament treating a cancer comprising one or more malignant solid tumors in a subject, as further described above.

[0050] Other objects, features and advantages of the present invention will become apparent after review of the specification, claims and drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0051] The patent or application file contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee.

[0052] Fig. 1 shows the chemical structure of the base compound 18- (p-iodophenyl) octadecyl phosphocholine ( M404).

[0053] Fig. 2A is a graph showing that xRT + IT-IC elicits in situ tumor vaccination. More specifically, Fig. 2A shows tumor growth curves that show synergy between xRT and IT-hul4.18-IL2. 71% (22/31) of mice treated with xRT + IT-IC are rendered disease- free.

[0054] Fig. 2B is another graph showing that xRT + IT-IC elicits in situ tumor vaccination. More specifically, Fig. 2B shows Kaplan-Meier survival curves that show synergy between xRT and IT-hul4.18-IL2. 71% (22/31) of mice treated with xRT + IT- IC are rendered disease-free.

[0055] Fig. 2C is another graph showing that xRT + IT-IC elicits in situ tumor vaccination. More specifically, Fig. 2C shows that 90% of the treated mice reject subsequent engraftment with B78 melanoma.

[0056] Fig. 3 is a graph demonstrating concomitant immune tolerance. Primary tumor response is shown. A distant un-treated tumor suppresses response to xRT + IT-IC in a 2- tumor B78 melanoma model, and this suppression can be overcome be radiating the second tumor.

[0057] Fig. 4 is a graph showing that concomitant immune tolerance is due to Tregs. Primary tumor response is shown. A distant un-treated tumor suppresses response to xRT + IT-IC in a 2-tumor B78 melanoma model and this suppression can be overcome by depleting Tregs (using transgenic DEREG mice that express diphtheria toxin receptors on their Tregs, and thus depleting Tregs by administering diphtheria toxin).

[0058] Fig. 5 is an image showing selective uptake of ¹²⁴ I- M404 by B78 melanoma. A mouse bearing a ~200mm ³ B78 tumor received IV ¹²⁴ I- M404 and had serial PET/CT scans done. This image at 71h shows selective uptake by the tumor with some residual background uptake by the heart and liver.

[0059] Fig. 6 is a graph demonstrating that in situ vaccination can be elicited in the presence of residual levels of molecular targeted radiation therapy (TRT). Treatment with combined xRT + IT-IC is equally effective in the presence or absence of 3 μθ ¹³¹ I- M404. This approximates the residual activity of TRT that will be present when we deliver xRT (dO) followed by IT-IC (d6-10), as described in Example 4.

[0060] Fig. 7 shows a time course MRI image of a tumor-bearing mouse following injection of Gd- M600 showing enhancement of the tumor (T) by 24 hours.

[0061] Fig. 8A is a graph showing tumor-specific inhibition of primary tumor response to the combination of local RT+IT-IC by a distant untreated tumor in murine melanoma and pancreatic tumor models. C57BL/6 mice bearing a syngeneic,

disialoganglioside-expressing (GD2+), primary flank tumor +/- a secondary tumor on the contralateral flank were treated to the primary tumor only, as indicated, with xRT on day "1" and intra-tumor (IT) injection of 50 meg of the anti-GD2 immunocytokine (IC), hul4.18-IL2 (a fusion of anti-GD2 mAb and IL2), on day 6-10. Mean primary tumor volumes are displayed in Fig. 8A. More specifically, Fig. 8A shows that in mice bearing a primary B78 melanoma tumor, the presence of an untreated secondary B78 tumor antagonized primary tumor response to RT+IT-IC. We describe this effect as

"concomitant immune tolerance" - an antagonistic effect of a non-treated distant tumor on the local response of a treated tumor to xRT + IT-IC. [0062] Fig. 8B is another graph showing tumor-specific inhibition of primary tumor response to the combination of local RT+IT-IC by a distant untreated tumor in murine melanoma and pancreatic tumor models. C57BL/6 mice bearing a syngeneic,

disialoganglioside-expressing (GD2+), primary flank tumor +/- a secondary tumor on the contralateral flank were treated to the primary tumor only, as indicated, with xRT on day "1" and intra-tumor (IT) injection of 50 meg of the anti-GD2 immunocytokine (IC), hul4.18-IL2 (a fusion of anti-GD2 mAb and IL2), on day 6-10. More specifically, Fig. 8B shows Kaplan-Meier survival curves for mice plus replicate experiments. Nearly all mice were euthanized due to primary tumor progression.

[0063] Fig. 8C is another graph showing tumor-specific inhibition of primary tumor response to the combination of local RT+IT-IC by a distant untreated tumor in murine melanoma and pancreatic tumor models. C57BL/6 mice bearing a syngeneic,

disialoganglioside-expressing (GD2+), primary flank tumor +/- a secondary tumor on the contralateral flank were treated to the primary tumor only, as indicated, with xRT on day "1" and intra-tumor (IT) injection of 50 meg of the anti-GD2 immunocytokine (IC), hul4.18-IL2 (a fusion of anti-GD2 mAb and IL2), on day 6-10. More specifically, Fig. 8C shows that in mice bearing a primary Panc02-GD2+ pancreatic tumor, with or without a secondary Panc02-GD2- tumor on the opposite flank, the presence of an untreated Panc02 secondary tumor suppressed the response of a primary Panc02-GD2+ tumor to RT+IT-IC.

[0064] Fig. 8D is another graph showing tumor-specific inhibition of primary tumor response to the combination of local RT+IT-IC by a distant untreated tumor in murine melanoma and pancreatic tumor models. C57BL/6 mice bearing a syngeneic,

disialoganglioside-expressing (GD2+), primary flank tumor +/- a secondary tumor on the contralateral flank were treated to the primary tumor only, as indicated, with xRT on day "1" and intra-tumor (IT) injection of 50 meg of the anti-GD2 immunocytokine (IC), hul4.18-IL2 (a fusion of anti-GD2 mAb and IL2), on day 6-10. More specifically, Fig. 8D shows that in mice bearing a primary B78 melanoma tumor, a secondary B78 tumor suppressed primary tumor response to RT+IT-IC but a secondary Panc02-GD2+ pancreatic tumor did not exert this effect. [0065] Fig. 8E is another graph showing tumor-specific inhibition of primary tumor response to the combination of local RT+IT-IC by a distant untreated tumor in murine melanoma and pancreatic tumor models. C57BL/6 mice bearing a syngeneic,

disialoganglioside-expressing (GD2+), primary flank tumor +/- a secondary tumor on the contralateral flank were treated to the primary tumor only, as indicated, with xRT on day "1" and intra-tumor (IT) injection of 50 meg of the anti-GD2 immunocytokine (IC), hul4.18-IL2 (a fusion of anti-GD2 mAb and IL2), on day 6-10. More specifically, Fig. 8E shows that in mice bearing a primary Panc02-GD2+ tumor a secondary Panc02-GD2- tumor suppressed primary tumor response to combined xRT and IT-hul4.18-IL2, while a B78 secondary tumor did not. n=number of mice per group. NS=non-significant, ***p<0.001.

[0066] Fig. 9A includes immunohistochemistry images (left and center) and graphs (right) showing that concomitant immune tolerance is circumvented by specific depletion of regulator T cells (Tregs). More specifically, Fig. 9A shows immunohistochemistry for the Treg marker, FoxP3 (representative 400x images are shown) for tumors evaluated on day 6 after xRT in mice with one (Fig. 9A, leftmost panels Al and A2) or two (Fig. 9A _^ center panels A3 and A4) tumors. Mice received no xRT, or xRT only to the primary tumor. The primary tumor is shown in Fig. 9A, panels_Al-A3 and the secondary is shown in Fig. 9A _a panel A4. Small arrows point out some of the FoxP3+ cells (brown nuclei = FoxP3+, blue = hematoxylin counterstain). The graphs on the right display blinded quantification of FoxP3+ cells per 200x field, corresponding to the conditions shown in Fig. 9A, panels Al, A2, A3 and A4, respectively.

[0067] Fig. 9B is another graph showing that concomitant immune tolerance is circumvented by specific depletion of regulator T cells (Tregs). More specifically, Fig. 9B shows that DEREG mice express diphtheria toxin receptor under control of the Treg- specific FoxP3 promoter, enabling specific depletion of Tregs upon IP injection of diphtheria toxin. DEREG mice bearing primary and secondary B78 melanoma tumors were treated with xRT+IT-IC to the primary tumor and IP injection of either diphtheria toxin or PBS (the first of replicate experiments are shown). Concomitant immune tolerance is eliminated following depletion of Tregs in these mice, resulting in improved (Fig. 9B) primary tumor response. n=number of mice per group. **p<0.0\, ***p<0.00\ . [0068] Fig. 9C is another graph showing that concomitant immune tolerance is circumvented by specific depletion of regulator T cells (Tregs). More specifically, Fig. 9C shows that DEREG mice express diphtheria toxin receptor under control of the Treg- specific FoxP3 promoter, enabling specific depletion of Tregs upon IP injection of diphtheria toxin. DEREG mice bearing primary and secondary B78 melanoma tumors were treated with xRT+IT-IC to the primary tumor and IP injection of either diphtheria toxin or PBS (the first of replicate experiments are shown). Concomitant immune tolerance is eliminated following depletion of Tregs in these mice, resulting in improved (Fig. 9C) secondary tumor response. n=number of mice per group. **/><0.01,

***/?<0.001.

[0069] Fig. 10A and is a graph showing that concomitant immune tolerance is overcome by delivering xRT to both tumor sites. In mice bearing primary and secondary B78 tumors, the secondary tumor suppresses primary tumor response to primary tumor treatment with xRT + IT-IC. This is overcome by delivering 12 Gy xRT to both the primary and secondary tumors and IT-IC to the primary tumor, resulting in improved (Fig. 10A) primary tumor response (the first of replicate experiments is shown) from replicate experiments. n=number of mice per group. **p<0.01, ***/?<0.001.

[0070] Fig. 10B is another graph showing that concomitant immune tolerance is overcome by delivering xRT to both tumor sites. In mice bearing primary and secondary B78 tumors, the secondary tumor suppresses primary tumor response to primary tumor treatment with xRT + IT-IC. This is overcome by delivering 12 Gy xRT to both the primary and secondary tumors and IT-IC to the primary tumor, resulting in improved (Fig. 10B) aggregate animal survival from replicate experiments. n=number of mice per group. **p<0.0\, ***/ 0.001.

[0071] Fig. 11 A is a graph showing that low dose xRT alone does not elicit in situ vaccination but does overcome concomitant immune tolerance when delivered to distant tumor sites together with 12 Gy + IT-IC treatment of an in situ vaccine site. More specifically, Fig. 11 A shows that in mice bearing a primary B78 tumor only, 12 Gy + IT- IC elicits in situ vaccination (as shown previously) and results in complete tumor regression in most mice (4/6 in this experiment) and a memory immune response (Morris, Cancer Res, 2016). On the other hand no animals exhibit complete tumor regression following either IT-IC alone or low dose (2 Gy) xRT + IT-IC (0/6 in both groups) p<0.05.

[0072] Fig. 1 IB is another graph showing that low dose xRT alone does not elicit in situ vaccination but does overcome concomitant immune tolerance when delivered to distant tumor sites together with 12 Gy + IT-IC treatment of an in situ vaccine site. More specifically, Fig. 1 IB shows that in mice bearing a primary and secondary B78 melanoma tumor, low dose xRT (2 Gy or 5 Gy) delivered to the secondary tumor is comparable to 12 Gy in its capacity to overcome concomitant immune tolerance at the primary tumor.

[0073] Fig. 11C is another graph showing that low dose xRT alone does not elicit in situ vaccination but does overcome concomitant immune tolerance when delivered to distant tumor sites together with 12 Gy + IT-IC treatment of an in situ vaccine site. More specifically, Fig. 11C shows that in these same animals, it is apparent that overcoming concomitant immune tolerance by delivery of low dose xRT to the secondary tumor rescues a systemic response to IT-IC immunotherapy. In this context, when xRT is delivered to all tumor sites then IT-IC injection of the primary tumor triggers a systemic anti-tumor effect that renders secondary tumor response to 2 Gy or 5 Gy greater than the response to 12 Gy xRT in absence of primary tumor IT-IC injection.

[0074] Fig. 12A is a PET image showing that low dose TRT with ¹³¹ I- M404 effectively depletes tumor infiltrating FoxP3+ Tregs without systemic leukopenia or depletion of tumor infiltrating CD8+ effector T cells. In most clinical scenarios, it is not feasible to deliver external beam, even low dose, to all tumor sites without eliciting marked bone marrow depletion and leukopenia that would result in immunosuppression. Here we tested whether TRT could be administered systemically to specifically deplete tumor infiltrating suppressive immune cells (Tregs), without triggering systemic immune cell depletion and leukopenia. More specifically, Fig. 12A shows dosimetry studies in this B78 melanoma tumor model using positron-emitting ¹²⁴ I- M404 confirm tumor- selective uptake of M404. C57BL/6 mice bearing B78 tumors were treated with 60 iC ¹³¹ I- M404. This activity approximates the amount of ¹³¹ I- M404 necessary to deliver ~ 2 Gy TRT to a B78 tumor. Peripheral blood and tumor samples were collected in untreated control mice (designated "C") and at 8 day intervals (Tl = d8, T2 = dl6, T3 = d24, T4 = d32) thereafter.

[0075] Fig. 12B is a bar graph showing that low dose TRT with ¹³¹ I- M404 effectively depletes tumor infiltrating FoxP3+ Tregs without systemic leukopenia or depletion of tumor infiltrating CD8+ effector T cells. In most clinical scenarios, it is not feasible to deliver external beam, even low dose, to all tumor sites without eliciting marked bone marrow depletion and leukopenia that would result in immunosuppression. Here we tested whether TRT could be administered systemically to specifically deplete tumor infiltrating suppressive immune cells (Tregs), without triggering systemic immune cell depletion and leukopenia. More specifically, Fig. 12B shows that this dose of TRT did not result in any significant systemic leukopenia _^

[0076] Fig. 12C is another bar graph showing that low dose TRT with ¹³¹ I- M404 effectively depletes tumor infiltrating FoxP3+ Tregs without systemic leukopenia or depletion of tumor infiltrating CD8+ effector T cells. In most clinical scenarios, it is not feasible to deliver external beam, even low dose, to all tumor sites without eliciting marked bone marrow depletion and leukopenia that would result in immunosuppression. Here we tested whether TRT could be administered systemically to specifically deplete tumor infiltrating suppressive immune cells (Tregs), without triggering systemic immune cell depletion and leukopenia. More specifically, Fig. 12C shows that this dose of TRT did not significantly affect the level of tumor infiltrating CD8+ effector T cells (ANOVA p=0.25).

[0077] Fig. 12D is another bar graph showing that low dose TRT with ¹³¹ I-NM404 effectively depletes tumor infiltrating FoxP3+ Tregs without systemic leukopenia or depletion of tumor infiltrating CD8+ effector T cells. In most clinical scenarios, it is not feasible to deliver external beam, even low dose, to all tumor sites without eliciting marked bone marrow depletion and leukopenia that would result in immunosuppression. Here we tested whether TRT could be administered systemically to specifically deplete tumor infiltrating suppressive immune cells (Tregs), without triggering systemic immune cell depletion and leukopenia. More specifically, Fig. 12D shows that tumor infiltrating FoxP3+ Tregs were significantly depleted by this dose of TRT (ANOVA p=0.03; * p<0.05). [0078] Fig. 13 A is a graph showing that low dose TRT with ¹³¹ I- M404 effectively overcomes concomitant immune tolerance and rescues the systemic anti-tumor effect of in situ vaccination. Given the capacity of low dose ¹³¹ I- M404 TRT to deplete tumor- infiltrating Tregs without rendering a mouse leukopenic, we tested whether low dose ^{13 l} l- M404 might effectively overcome concomitant immune tolerance. C57BL/6 mice bearing two B78 tumors were treated with 60-mcCi ¹³¹ I- M404 on day 1 ( M404), as indicated. After one half-life (day 8), animals received 12 Gy xRT or no xRT to the primary tumor (in situ vaccine site). Control mice receiving no ¹³¹ I- M404 were treated to the secondary tumor as indicated (0, 2, or 12 Gy). Mice received daily IT injections of IC to the primary tumor (in situ vaccine site), as indicated, on days 13-17. More specifically, Fig. 13 A shows that primary tumor response is shown and demonstrates that administration of low dose TRT effectively overcomes concomitant immune tolerance and rescues the systemic anti-tumor effect of in situ vaccination.

[0079] Fig. 13B is another graph showing that low dose TRT with ¹³¹ I- M404 effectively overcomes concomitant immune tolerance and rescues the systemic antitumor effect of in situ vaccination. Given the capacity of low dose ¹³¹ I- M404 TRT to deplete tumor-infiltrating Tregs without rendering a mouse leukopenic, we tested whether low dose ¹³¹ I- M404 might effectively overcome concomitant immune tolerance.

C57BL/6 mice bearing two B78 tumors were treated with 60-mcCi ¹³¹ I- M404 on day 1 ( M404), as indicated. After one half-life (day 8), animals received 12 Gy xRT or no xRT to the primary tumor (in situ vaccine site). Control mice receiving no ¹³¹ I- M404 were treated to the secondary tumor as indicated (0, 2, or 12 Gy). Mice received daily IT injections of IC to the primary tumor (in situ vaccine site), as indicated, on days 13-17. More specifically, Fig. 13B shows that secondary tumor response is shown and demonstrates that administration of low dose TRT effectively overcomes concomitant immune tolerance and rescues the systemic anti-tumor effect of in situ vaccination.

[0080] Figure 14 shows the chemical structure of an exemplary alkylphosphocholine metal chelate ( ⁶⁴ Cu- M600). Other metals may be used in place of ⁶⁴ Cu.

[0081] Figure 15 is a PET/CT image of two single tumor B78 mice from a scan taken 48 hours post-injection with ⁸⁶ Y- M600. [0082] Figure 16 is a PET/CT image of two two-tumor B78 mice from a scan taken 48 hours post-injection with ⁸⁶ Y- M600.

[0083] Figure 17 includes PET/CT images for a U87MG mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁶⁴ Cu- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0084] Figure 18 includes PET/CT images for a 4T1 mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁶⁴ Cu- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0085] Figure 19 includes PET/CT images for an HCT-116 mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁶⁴ Cu- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0086] Figure 20 includes PET/CT images for an A549 mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁶⁴ Cu- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0087] Figure 21 includes PET/CT images for a PC-3 mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁶⁴ Cu- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0088] Figure 22 includes PET/CT images for an HT-29 mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁶⁴ Cu- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0089] Figure 23 includes PET/CT images for a MiaPaca mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁶⁴ Cu- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right). [0090] Figure 24 includes PET/CT images for a 4T1 mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁸⁶ Y- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0091] Figure 25 includes PET/CT images for a 4T1 mouse from scans taken 3 hours (left panel), 24 hours (center panel) and 48 hours (right panel) post-injection with ⁸⁹ Zr- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0092] Figure 26 includes PET/CT images for an HT-29 mouse from scans taken 4 hours (left panel) and 1 day (right panel) post-injection with ⁵² Mn- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown on far right).

[0093] Figure 27 includes PET/CT images for a PC-3 mouse from scans taken 4 hours (left panel) and 1 day (right panel) post-injection with ⁵² Mn- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown to the right of each image).

[0094] Figure 28 includes PET/CT images for an HT-29 mouse from scans taken 2 days (left panel), 3 days (second panel from the left), 5 days (second panel form the right) and 7 days (right panel) post-injection with ⁵² Mn- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown to the right of the images).

[0095] Figure 29 includes PET/CT images for a PC-3 mouse from scans taken 2 days (left panel), 3 days (second panel from the left), 5 days (second panel form the right) and 7 days (right panel) post-injection with ⁵² Mn- M600. The images show tissue activity calculated as a percent of injected dose/g tissue (%ID/g, scale shown to the right of the images).

[0096] Figure 30 is a graph showing PET quantitative region of interest data (chelate uptake as a function of time) for 4T1 tumor tissue in 4T1 mice injected with ⁸⁶ Y-NM600, ⁶⁴ Cu-NM600 and ⁸⁹ Zr- M-600. [0097] Figure 31 is a graph showing PET quantitative region of interest data (chelate uptake as a function of time) for heart tissue in 4T1 mice injected with ⁸⁶ Y- M600, ⁶⁴ Cu- M600 and ⁸⁹ Zr- M-600.

[0098] Figure 32 is a graph showing PET quantitative region of interest data (chelate uptake as a function of time) for liver tissue in 4T1 mice injected with ⁸⁶ Y- M600, ⁶⁴ Cu- M600 and ⁸⁹ Zr- M-600.

[0099] Figure 33 is a graph showing PET quantitative region of interest data (chelate uptake as a function of time) for whole body in 4T1 mice injected with ⁸⁶ Y-NM600, ⁶⁴ Cu-NM600 and ⁸⁹ Zr- M-600.

[00100] Figure 32 is a bar graph illustrating ex vivo chelate biodistribution in healthy and tumor tissues in 4T1 mice 48 hours ( ⁸⁶ Y- M600, ⁶⁴ Cu- M600, ⁸⁹ Zr- M-600 and ¹⁷⁷ Lu-NM600) and 96 hours ( ¹⁷⁷ Lu- M600) post-injection of the metal chelates.

[00101] Figure 35 shows the chemical structure of an exemplary alkylphosphocholine metal chelate ( ¹⁷⁷ Lu- M600). Other metals may be used in place of ¹⁷⁷ Lu.

[00102] Figure 36 is an audioradiographic image of three B78 mice taken 48 hours after injection with ⁹⁰ Y- M600. Xenografted B78 tumors are seen as large dark spots at the lower right of each mouse image.

[00103] Figure 37 is an audioradiographic image of three B78 mice taken 96 hours after injection with ⁹⁰ Y- M600. Xenografted B78 tumors are seen as large dark spots at the lower right of each mouse image.

[00104] Figure 38 is an audioradiographic image of a B78 mouse taken on day 5 after injection with ¹⁷⁷ Lu- M600. Xenografted B78 tumors are seen as two dark spots at the bottom of the mouse image.

[00105] Figure 39 is an audioradiographic image of a B78 mouse taken on day 13 after injection with ¹⁷⁷ Lu- M600. Xenografted B78 tumors are seen as two dark spots at the bottom of the mouse image.

[00106] Figure 39 is an audioradiographic image of a B78 mouse taken on day 13 after injection with ¹⁷⁷ Lu- M600. Xenografted B78 tumors are seen as two dark spots at the bottom of the mouse image. [00107] Figure 40 is an audioradiographic image of a MiaPaca mouse taken 10 days after injection with ¹⁷⁷ Lu-NM600. The location of the xenografted MiaPaca tumor is indicated by the arrow and dashed circle.

[00108] Figure 41 is an audioradiographic image of three 4T1 mice taken 48 hours after injection with ¹⁷⁷ Lu-NM600. The locations of the xenografted 4T1 tumors are indicated by the arrows and dashed circles.

[00109] Figure 42 is an audioradiographic image of three 4T1 mice taken 96 hours after injection with ¹⁷⁷ Lu-NM600. The locations of the xenografted 4T1 tumors are indicated by the dashed circles.

[00110] Figure 43 is an audioradiographic image of three 4T1 mice taken 4 hours after injection with ⁹⁰ Y- M600. The locations of the xenografted 4T1 tumors are indicated by the arrows and dashed circles.

[00111] Figure 44 is an audioradiographic image of three 4T1 mice taken 48 hours after injection with ⁹⁰ Y- M600. The xenografted 4T1 tumors are seen as large dark spots on the lower right of each mouse image.

[00112] Figure 45 is an audioradiographic image of three 4T1 mice taken 96 hours after injection with ⁹⁰ Y- M600. The xenografted 4T1 tumors are seen as large dark spots on the lower right of each mouse image.

[00113] Figure 46 is a graph illustrating the radiotherapeutic effect of ⁹⁰ Y- M600 at two different doses (150 μθ and 300 μθ) in a B78 xenograft mouse model, versus a control (excipient only). Data is presented as measured tumor volume in mm ³ as a function of time in days after injection.

[00114] Figure 47 is a graph illustrating the radiotherapeutic effect of a single 500 μθ dose of ¹⁷⁷ Lu-NM600 in a B78 xenograft mouse model, versus a control (excipient only). Data is presented as measured tumor volume in mm ³ as a function of time in days after injection.

[00115] Figure 48 is a graph illustrating the radiotherapeutic effect of a single 400 μθ dose of ¹⁷⁷ Lu- M600 in a MiaPaca xenograft mouse model, versus a control (excipient only). Data is presented as measured tumor volume in mm ³ as a function of time in days after injection. [00116] Figure 49 is a graph illustrating the radiotherapeutic effect of a single 500 μϋι ^' dose of ¹⁷⁷ Lu-NM600 in a 4T1 xenograft mouse model, versus a control (excipient only). Data is presented as measured tumor volume in mm ³ as a function of time in days after injection. * P < 0.05; ** P < 0.01; *** P < 0.001.

[00117] Figure 50 is a graph illustrating the radiotherapeutic effect of two serial doses of ¹⁷⁷ Lu-NM600 (500 μΠ and 250 μθ) in a 4T1 xenograft mouse model, versus a control (excipient only). Data is presented as measured tumor volume in mm ³ as a function of time in days after injection.

[00118] Figure 51 is a graph illustrating the radiotherapeutic effect of ¹⁷⁷ Lu- M600 at two different doses (500 μθ and 250 μθ) in a 4T1 xenograft mouse model, versus a control (excipient only). Data is presented as measured tumor volume in mm ³ as a function of time in days after injection.

[00119] Figure 52 is a graph illustrating the impact of tumor mass on the comparative therapeutic efficacy of ⁹⁰ Y- M600 and ¹³¹ I- M404 in conventional TRT.

[00120] Figure 53 is a bar graph comparing average albumin binding energies of three different metal chelate analogs of M404, along with an amine analog. For comparison, the binding energy of I- M404 is shown as a dotted line.

[00121] Figure 54 is a graph illustrating tumor volume (mm ³ ) as a function of time (days) in B78 melanoma flank tumor mice treated with anti-CTLA4 immune checkpoint inhibitor (CTLA4) and/or varying doses (25 μθ, 50 μθ, or 100 μθ) of the targeted radiotherapy (TRT) agent Y90- M600. Control mice were administered vehicle without anti-CTLA4 or the TRT agent (PBS). After Day 18, combination treatment with 50 or 100 μα of Y90- M600 with anti-CTLA4 had significantly (p < 0.05 by ANOVA) reduced tumor growth compared to PBS, Y90-NM600 alone, or anti-CTLA4 alone. The 25 Y90- M600 combination treatment group with anti-CTLA-4 had an intermediate growth delay response that showed a trend towards dose response.

[00122] Figure 55 is a graph showing aggregate animal survival for mice administered a combination of TRT (50 μϋϊ Y90- M600) and checkpoint blockade (anti-CTLA4), compared to mice administered TRT alone, checkpoint blockade alone (anti-CTLA4), or PBS vehicle. [00123] Figure 56 is a graph showing aggregate animal survival for mice administered three different combinations of TRT (25 μθ, 50 μθ, and 100 μθ Y90- M600) with checkpoint blockade (anti-CTLA4).

[00124] Figure 57 is a graph illustrating tumor volume (mm ³ ) as a function of time (days) in B78 melanoma flank tumor mice treated with anti-CTLA4 immune checkpoint inhibitor (CTLA4) and/or varying doses (25 μθ, 50 μθ, or 100 μθ) of the molecularly targeted radiotherapy (MTRT) agent ⁹⁰ Y- M600. Control mice were administered vehicle without anti-CTLA4 or the MTRT agent (PBS). Combination treatment with 50 or 100 μα of ⁹⁰ Y-NM600 with anti-CTLA4 had significantly (p < 0.05 by ANOVA) reduced tumor growth compared to PBS, ⁹⁰ Y- M600 alone, or anti-CTLA4 alone.

[00125] Figure 58 is a graph showing aggregate animal survival for B78 melanoma flank tumor mice treated with anti-CTLA4 immune checkpoint inhibitor (CTLA4) and/or varying doses (25 μθ, 50 μθ, or 100 μθ) of the molecularly targeted radiotherapy (MTRT) agent ⁹⁰ Y- M600. Mice administered a combination of MTRT (50 μϋϊ ⁹⁰ Y- M600 or 100 μθ ⁹⁰ Y- M600) and checkpoint blockade (anti-CTLA4) exhibited significantly increased survival as compared to other groups.

[00126] Figure 59 is a graph illustrating tumor volume (mm ³ ) as a function of time (days) in NXS2 neuroblastoma tumor mice treated with anti-CTLA4 immune checkpoint inhibitor (CTLA4) and/or 50 μθ of the molecularly targeted radiotherapy (MTRT) agent ⁹⁰ Y- M600. Control mice were administered vehicle without anti-CTLA4 or the TRT agent (PBS). Combination treatment of ⁹⁰ Y- M600 MTRT with anti-CTLA4 had significantly reduced tumor growth compared to PBS, ⁹⁰ Y- M600 alone, or anti-CTLA4 alone.

[00127] Figure 60 is a graph illustrating tumor volume (mm ³ ) as a function of time (days) in 4T1 breast cancer tumor mice treated with anti-CTLA4 immune checkpoint inhibitor (CTLA4) and/or 50 μθ of the molecularly targeted radiotherapy (MTRT) agent ⁹⁰ Y- M600. Control mice were administered vehicle without anti-CTLA4 or the TRT agent (PBS). Combination treatment of ⁹⁰ Y- M600 MTRT with anti-CTLA4 had significantly reduced tumor growth compared to PBS, ⁹⁰ Y- M600 alone, or anti-CTLA4 alone. [00128] Figure 61 is a graph illustrating tumor volume (mm ) as a function of time (days) for the irradiated primary B78 tumor in B78 melanoma flank tumor mice having both primary and secondary (distant) tumors. Mice were treated with various combinations of EBRT of the primary tumor only (12 Gy, secondary tumor was shielded), anti-CTLA4 immune checkpoint inhibitor (CTLA4) and/or 50 μθ of the molecularly targeted radiotherapy (MTRT) agent ⁹⁰ Y- M600. Combination treatment of 12 Gy EBRT, ⁹⁰ Y- M600 MTRT, and anti-CTLA4 caused significantly reduced primary tumor growth compared to other groups.

[00129] Figure 62 is a graph illustrating tumor volume (mm ³ ) as a function of time (days) for the shielded secondary (distant) B78 tumor in B78 melanoma flank tumor mice having both primary and secondary tumors. Mice were treated with various combinations of EBRT of the primary tumor only (12 Gy, secondary tumor was shielded), anti-CTLA4 immune checkpoint inhibitor (CTLA4) and/or 50 μθ of the molecularly targeted radiotherapy (MTRT) agent ⁹⁰ Y-NM600. Combination treatment of EBRT to the primary tumor, ⁹⁰ Y- M600 MTRT, and anti-CTLA4 caused significantly reduced secondary tumor growth compared to other groups.

DETAILED DESCRIPTION

I. IN GENERAL

[00130] It is understood that this disclosure is not limited to the particular

methodology, protocols, materials, and reagents described, as these may vary. The terminology used herein is for the purpose of describing particular embodiments only, and is not intended to limit the scope of the present invention, which will be limited only by any later-filed nonprovisional applications.

[00131] As used herein and in the appended claims, the singular forms "a", "an", and "the" include plural reference unless the context clearly dictates otherwise. As well, the terms "a" (or "an"), "one or more" and "at least one" can be used interchangeably herein. The terms "comprising" and variations thereof do not have a limiting meaning where these terms appear in the description and claims. Accordingly, the terms "comprising", "including", and "having" can be used interchangeably. [00132] Unless defined otherwise, all technical and scientific terms used herein have the same meanings as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All publications and patents specifically mentioned herein are incorporated by reference for all purposes including describing and disclosing the chemicals, instruments, statistical analysis and

methodologies which are reported in the publications which might be used in connection with the invention. All references cited in this specification are to be taken as indicative of the level of skill in the art.

[00133] The terminology as set forth herein is for description of the embodiments only and should not be construed as limiting of the invention as a whole. Unless otherwise specified, "a," "an," "the," and "at least one" are used interchangeably and mean one or more than one.

[00134] The disclosure is inclusive of the compounds described herein (including intermediates) in any of their pharmaceutically acceptable forms, including isomers (e.g., diastereomers and enantiomers), tautomers, salts, solvates, polymorphs, prodrugs, and the like. In particular, if a compound is optically active, the invention specifically includes each of the compound's enantiomers as well as racemic mixtures of the enantiomers. It should be understood that the term "compound" includes any or all of such forms, whether explicitly stated or not (although at times, "salts" are explicitly stated).

[00135] "Pharmaceutically acceptable" as used herein means that the compound or composition or carrier is suitable for administration to a subject to achieve the treatments described herein, without unduly deleterious side effects in light of the necessity of the treatment.

[00136] The term "effective amount," as used herein, refers to the amount of the compounds or dosages that will elicit the biological or medical response of a subject, tissue or cell that is being sought by the researcher, veterinarian, medical doctor or other clinician.

[00137] As used herein, "pharmaceutically-acceptable carrier" includes any and all dry powder, solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic agents, absorption delaying agents, and the like. Pharmaceutically-acceptable carriers are materials, useful for the purpose of administering the compounds in the method of the present invention, which are preferably non-toxic, and may be solid, liquid, or gaseous materials, which are otherwise inert and pharmaceutically acceptable, and are compatible with the compounds of the present invention. Examples of such carriers include, without limitation, various lactose, mannitol, oils such as corn oil, buffers such as PBS, saline, polyethylene glycol, glycerin, polypropylene glycol, dimethylsulfoxide, an amide such as dimethylacetamide, a protein such as albumin, and a detergent such as Tween 80, mono- and oligopolysaccharides such as glucose, lactose, cyclodextrins and starch.

[00138] The term "administering" or "administration," as used herein, refers to providing the compound or pharmaceutical composition of the invention to a subject suffering from or at risk of the diseases or conditions to be treated or prevented.

[00139] A route of administration in pharmacology is the path by which a drug is taken into the body. Routes of administration may be generally classified by the location at which the substance is applied. Common examples may include oral and intravenous administration. Routes can also be classified based on where the target of action is.

Action may be topical (local), enteral (system-wide effect, but delivered through the gastrointestinal tract), or parenteral (systemic action, but delivered by routes other than the GI tract), via lung by inhalation.

[00140] In an enteral administration, the desired effect is systemic (non-local), substance is given via the digestive tract. In a parenteral administration, the desired effect is systemic, and substance is given by routes other than the digestive tract.

[00141] Enteral administration may be administration that involves any part of the gastrointestinal tract and has systemic effects. The examples may include those by mouth (orally), many drugs as tablets, capsules, or drops, those by gastric feeding tube, duodenal feeding tube, or gastrostomy, many drugs and enteral nutrition, and those rectally, various drugs in suppository.

[00142] Examples of parenteral administrations may include intravenous (into a vein), e.g. many drugs, total parenteral nutrition intra-arterial (into an artery), e.g., vasodilator drugs in the treatment of vasospasm and thrombolytic drugs for treatment of embolism, intraosseous infusion (into the bone marrow), intra-muscular, intracerebral (into the brain parenchyma), intracerebroventricular (into cerebral ventricular system), intrathecal (an injection into the spinal canal), and subcutaneous (under the skin). Among them, intraosseous infusion is, in effect, an indirect intravenous access because the bone marrow drains directly into the venous system. Intraosseous infusion may be

occasionally used for drugs and fluids in emergency medicine and pediatrics when intravenous access is difficult.

[00143] The following abbreviations are used in this disclosure: ADCC, Antibody dependent cell-mediated cytotoxicity; anti-CTL4, an antibody that targets cytotoxic T lymphocyte-associated antigen 4 (CTLA4), which is found on cytotoxic T lymphocytes (CTLs); B16, A melanoma syngeneic to C57B1/6 mice; B78, A variant of B 16 that expresses GD2, due to transfection with GD2 synthase; D, day; Hul4.18-IL2, The primary immunocytokine (reacts against GD2) used in the studies disclosed in the examples; IC, Immunocytokine (a fusion protein of a tumor-reactive mAb linked to IL2); ICI, immune checkpoint inhibitor; IL2, Interleukin 2; IT, Intratumoral; IV, Intravenous; mAb, Monoclonal antibody; MAHA, Mouse anti-human antibody; M404, used to designate the phospholipid ether shown in Figure 1, which is selectively taken up by most tumors and used for TRT in the studies disclosed in the examples; M600, used to designate the phospholipid ether shown in Figure 14, which can be chelated with any metal, and which is also selectively taken up by most tumors and used for TRT in the studies disclosed in the examples; NXS2, A neuroblastoma syngeneic to AJ mice;

Panc02-GD2, A pancreatic cancer syngeneic to C57B1/6 mice, expressing GD2, due to transfection with GD2 synthase; PLE, Phospholipid ether; RT, Radiation therapy; TRT, Targeted radiotherapy; W, week; 9464D-GD2, A neuroblastoma syngeneic to C57B1/6 mice, expressing GD2, due to transfection with GD2 synthase.

II. THE INVENTION

[00144] This disclosure is directed to methods of treating any cancer that presents as one or more malignant solid tumors. The disclosed methods combine two treatment steps, with an unexpected synergy resulting in a much improved effect against the malignant solid tumors. Specifically, an immunomodulatory dose of a radioactive phospholipid metal chelate compound or radiohalogenated phospholipid compound that is differentially taken up by and retained within malignant solid tumor tissue is

administered to the patient, and further immunomodulation is performed by systemically administering (e.g., by IV injection) a composition that includes one or more agents capable of stimulating specific immune cells, either with or without additional xRT to at least one of the malignant solid tumors being treated with immune-stimulating agents.

[00145] The immunomodulatory dose of the radioactive phospholipid metal chelate or radiohalogenated compound likely reduces Treg levels (and other immune-suppressive elements) and prevents the immune system dampening (concomitant immune tolerance) that occurs when xRT is used against a tumor and one or more additional tumors are not radiated, although an understanding of the mechanism is not necessary to practice the invention and the invention is not limited to any particular mechanism of action.

A. Systemically-administered immunotherapy: immune checkpoint

inhibitors as exemplary immunostimulatory agents.

[00146] In direct contrast to methods of immunostimulation by administering an immunomodulatory agent directly into a tumor (such as intratumoral immunization by in situ vaccination, as illustrated in some of the examples below), systemically-administered immunotherapy is performed by administering an immunostimulatory agent systemically. The immunostimulatory agent circulates through the whole body of the subject, stimulating the body's natural immune response.

[00147] Immune checkpoint inhibitors are non-limiting examples of such

immunostimulatory agents. Activated T cells express multiple immune co-inhibitory receptors, such as lymphocyte-activation gene 3 (LAG-3), programmed cell death protein 1 (PD-1), and cytotoxic T-lymphocyte-associated protein 4 (CTLA4). These and other immune checkpoint molecules have been shown to modulate T cell responses to tumor antigens in the tumor microenvironment through unique and non-redundant pathways.

[00148] More specifically, cancer growth is partly mediated by immune suppression induced by cancers. Tumors can activate suppressive immune checkpoint pathways in order to diminish the general immune response to the tumor. Accordingly, blockade of key immune checkpoint pathways can induce anti-tumor immunity, facilitated by the patient's own immune system. [00149] CTLA4 was the first immune checkpoint molecule to be clinically targeted, by administering CTLA4-targeting (anti-CLA4) mAbs. To date, the most promising immune checkpoint inhibitor strategies for the treatment of cancers involve administering mAbs targeting CTLA-4 and/or PD-1/PD-L1. Other immune checkpoint inhibitor strategies are currently in development, and the disclosed combination method is not limited to targeting any specific immune checkpoint pathway.

[00150] A series of reviews covering checkpoint inhibitors and cancer immunotherapy was recently published in volume 276 of Immunological Reviews. These reviews, including the introductory overview, Sharpe, A.H., "Introduction to checkpoint inhibitors and cancer immunotherapy," Immunol Rev. 276 (4 March 2017): 5-8, are incorporated by reference herein in their entirety.

B. Immunomodulatory dose of a radioactive phospholipid metal chelate compound

[00151] The radioactive phospholipid metal chelate compound used should selectively target a wide range of solid tumor cell types, such that the RT emitted by the metal isotope chelated to the metal chelate compound is directed to malignant solid tumor tissue without substantially exposing other tissue types to the emitted RT. The radioactive metal isotope included in the radioactive phospholipid metal chelate compound may be any radioactive metal isotope known to emit ionizing RT in a form that would result in immunostimulation of the cells that take up the compound. Non-limiting examples of radioactive metal isotopes that could be used include Lu-177, Y-90, Ho-166, Re-186, Re- 188, Cu-67, Au-199, Rh-105, Ra-223, Ac-225, Pb-212, or Th-227.

[00152] The immunomodulatory RT dose (as opposed to injected dose) of the radioactive phospholipid metal chelate compound is much less than the dose that would be used for conventional RT against malignant solid tumors. Specifically, the dose should be sufficient to stimulate a response in immune cells within the tumor

microenvironment (likely by reducing immune-suppressing Treg levels and other immunosuppressive cells or molecules), while not ablating the desired immune cells that are responsible for the immunostimulatory effect. [00153] The proper immunomodulatory dose can be calculated from imaging data obtained after administering a "detection-facilitating" dose of a radioactive metal chelate compound. The detection-facilitating dose may be quite different than the

immunomodulatory dose, and the radioactive metal isotope that is chelated into the radioactive metal chelate compound may be different (although the rest of the compound structure should be the same). The radioactive metal isotope used in the detection step and dosimetry calculations may be any radioactive metal isotope known to emit RT in a form that is readily detectable by conventional imaging means. Non-limiting examples of "conventional imaging means" include gamma ray detection, PET scanning, and SPECT scanning. Non-limiting examples of radioactive metal isotopes that could be used include Ga-66, Cu-64, Y-86, Co-55, Zr-89, Sr-83, Mn-52, As-72, Sc-44, Ga-67, In-I l l, or Tc-99m.

C. Metal chelates of PLE analogs

[00154] The disclosed structures utilize an alkylphosphocholine (APC) carrier backbone. Once synthesized, the agents should harbor formulation properties that render them suitable for injection while retaining tumor selectivity as was demonstrated previously with the related radiohalogenated compounds. The disclosed structures include a chelating moiety to which the radioactive metal isotope will chelate to produce the final imaging or therapeutic agent.

D. Methods of Synthesizing Exemplary M-PLE Analogs

[00155] Proposed synthesis of compound 1 is shown below. The first step of the synthesis is similar to described in Org Synth, 2008, 85, 10-14. The synthesis is started from cyclen which is converted into D03 A tris-Bn ester. This intermediate is then conjugated with NM404 in the presence of the base and Pd catalyst. Finally, benzyl protecting groups are removed by the catalytic hydrogenation.

[00156] Synthesis of compound 2 is shown below. It begins with D03 A tris-Bn ester which is alkylated with 3-(bromo-prop-l-ynyl)-trimethylsilane. After alkylation, the trimethylsilyl group is removed and the intermediate acetylene is coupled with M404 by the Sonogashira reaction. The benzyl groups are removed and the triple bond is hydrogenated simultaneously in the last step of the synthesis.

43 [00157] Compounds 5 and 6 can be synthesized from same precursors, DTPA dianhydride and 18-p-(3 -hydroxy ethyl-phenyl)-octadecyl phosphocholine as shown schemes below.

DTPA dianhydride

[00158] NOTA-NM404 conjugates can be synthesized in an analogous manner. One example of NOTA- M404 conjugate 7:

7

E. Dosage Forms and Administration Methods

[00159] For the synergistic targeted RT, any route of administration may be suitable. In one embodiment, the disclosed alkylphosphocholine analogs may be administered to the subject via intravenous injection. In another embodiment, the disclosed

alkylphosphocholine analogs may be administered to the subject via any other suitable systemic deliveries, such as parenteral, intranasal, sublingual, rectal, or transdermal administrations.

[00160] In another embodiment, the disclosed alkylphosphocholine analogs may be administered to the subject via nasal systems or mouth through, e.g., inhalation.

[00161] In another embodiment, the disclosed alkylphosphocholine analogs may be administered to the subject via intraperitoneal injection or IP injection.

[00162] In certain embodiments, the disclosed alkylphosphocholine analogs may be provided as pharmaceutically acceptable salts. Other salts may, however, be useful in the preparation of the alkylphosphocholine analogs or of their pharmaceutically acceptable salts. Suitable pharmaceutically acceptable salts include, without limitation, acid addition salts which may, for example, be formed by mixing a solution of the

alkylphosphocholine analog with a solution of a pharmaceutically acceptable acid such as hydrochloric acid, sulfuric acid, methanesulfonic acid, fumaric acid, maleic acid, succinic acid, acetic acid, benzoic acid, oxalic acid, citric acid, tartaric acid, carbonic acid or phosphoric acid.

[00163] Where the disclosed alkylphosphocholine analogs have at least one asymmetric center, they may accordingly exist as enantiomers. Where the disclosed alkylphosphocholine analogs possess two or more asymmetric centers, they may additionally exist as diastereoisomers. It is to be understood that all such isomers and mixtures thereof in any proportion are encompassed within the scope of the present disclosure.

[00164] The disclosure also includes methods of using pharmaceutical compositions comprising one or more of the disclosed alkylphosphocholine analogs in association with a pharmaceutically acceptable carrier. Preferably these compositions are in unit dosage forms such as tablets, pills, capsules, powders, granules, sterile parenteral solutions or suspensions, metered aerosol or liquid sprays, drops, ampoules, auto-injector devices or suppositories; for parenteral, intranasal, sublingual or rectal administration, or for administration by inhalation or insufflation.

[00165] For preparing solid compositions such as tablets, the principal active ingredient is mixed with a pharmaceutically acceptable carrier, e.g. conventional tableting ingredients such as corn starch, lactose, sucrose, sorbitol, talc, stearic acid, magnesium stearate, dicalcium phosphate or gums, and other pharmaceutical diluents, e.g. water, to form a solid preformulation composition containing a homogeneous mixture for a compound of the present invention, or a pharmaceutically acceptable salt thereof. When referring to these preformulation compositions as homogeneous, it is meant that the active ingredient is dispersed evenly throughout the composition so that the composition may be easily subdivided into equally effective unit dosage forms such as tablets, pills and capsules. This solid pre-formulation composition is then subdivided into unit dosage forms of the type described above containing from 0.1 to about 500 mg of the active ingredient of the present invention. Typical unit dosage forms contain from 1 to 100 mg, for example, 1, 2, 5, 10, 25, 50 or 100 mg, of the active ingredient. The tablets or pills of the novel composition can be coated or otherwise compounded to provide a dosage affording the advantage of prolonged action. For example, the tablet or pill can comprise an inner dosage and an outer dosage component, the latter being in the form of an envelope over the former. The two components can be separated by an enteric layer which, serves to resist disintegration in the stomach and permits the inner component to pass intact into the duodenum or to be delayed in release. A variety of materials can be used for such enteric layers or coatings, such materials including a number of polymeric acids and mixtures of polymeric acids with such materials as shellac, cetyl alcohol and cellulose acetate.

[00166] The liquid forms in which the alkylphosphocholine analogs may be incorporated for administration orally or by injection include aqueous solutions, suitably flavored syrups, aqueous or oil suspensions, and flavored emulsions with edible oils such as cottonseed oil, sesame oil, coconut oil or peanut oil, as well as elixirs and similar pharmaceutical vehicles. Suitable dispersing or suspending agents for aqueous suspensions include synthetic and natural gums such as tragacanth, acacia, alginate, dextran, sodium caboxymethylcellulose, methylcellulose, polyvinylpyrrolidone or gelatin.

[00167] The disclosed alkylphosphocholine analogs are particularly useful when formulated in the form of a pharmaceutical injectable dosage, including in combination with an injectable carrier system. As used herein, injectable and infusion dosage forms (i.e., parenteral dosage forms) include, but are not limited to, liposomal injectables or a lipid bilayer vesicle having phospholipids that encapsulate an active drug substance. Injection includes a sterile preparation intended for parenteral use.

[00168] Five distinct classes of injections exist as defined by the USP: emulsions, lipids, powders, solutions and suspensions. Emulsion injection includes an emulsion comprising a sterile, pyrogen-free preparation intended to be administered parenterally. Lipid complex and powder for solution injection are sterile preparations intended for reconstitution to form a solution for parenteral use. Powder for suspension injection is a sterile preparation intended for reconstitution to form a suspension for parenteral use. Powder lyophilized for liposomal suspension injection is a sterile freeze dried preparation intended for reconstitution for parenteral use that is formulated in a manner allowing incorporation of liposomes, such as a lipid bilayer vesicle having phospholipids used to encapsulate an active drug substance within a lipid bilayer or in an aqueous space, whereby the formulation may be formed upon reconstitution. Powder lyophilized for solution injection is a dosage form intended for the solution prepared by lyophilization ("freeze drying"), whereby the process involves removing water from products in a frozen state at extremely low pressures, and whereby subsequent addition of liquid creates a solution that conforms in all respects to the requirements for injections. Powder lyophilized for suspension injection is a liquid preparation intended for parenteral use that contains solids suspended in a suitable fluid medium, and it conforms in all respects to the requirements for Sterile Suspensions, whereby the medicinal agents intended for the suspension are prepared by lyophilization. Solution injection involves a liquid preparation containing one or more drug substances dissolved in a suitable solvent or mixture of mutually miscible solvents that is suitable for injection.

[00169] Solution concentrate injection involves a sterile preparation for parenteral use that, upon addition of suitable solvents, yields a solution conforming in all respects to the requirements for injections. Suspension injection involves a liquid preparation (suitable for injection) containing solid particles dispersed throughout a liquid phase, whereby the particles are insoluble, and whereby an oil phase is dispersed throughout an aqueous phase or vice-versa. Suspension liposomal injection is a liquid preparation (suitable for injection) having an oil phase dispersed throughout an aqueous phase in such a manner that liposomes (a lipid bilayer vesicle usually containing phospholipids used to encapsulate an active drug substance either within a lipid bilayer or in an aqueous space) are formed. Suspension sonicated injection is a liquid preparation (suitable for injection) containing solid particles dispersed throughout a liquid phase, whereby the particles are insoluble. In addition, the product may be sonicated as a gas is bubbled through the suspension resulting in the formation of microspheres by the solid particles.

[00170] The parenteral carrier system includes one or more pharmaceutically suitable excipients, such as solvents and co-solvents, solubilizing agents, wetting agents, suspending agents, thickening agents, emulsifying agents, chelating agents, buffers, pH adjusters, antioxidants, reducing agents, antimicrobial preservatives, bulking agents, protectants, tonicity adjusters, and special additives.

[00171] The following examples are offered for illustrative purposes only, and are not intended to limit the scope of the present invention in any way. Indeed, various modifications of the invention in addition to those shown and described herein will become apparent to those skilled in the art from the foregoing description and the following examples and fall within the scope of the appended claims. III. EXAMPLES

Introduction to the Examples

[00172] These examples demonstrate the potential of bringing together two very distinct cutting-edge disciplines in cancer treatment research, capitalizing on an unexpected and very potent synergy. These disciplines are: 1) systemically administered TRT; and 2) locally directed, antibody-mediated cancer immunotherapy or systemically administered cancer immunotherapy. The data presented herein suggest that powerful synergy results from combining these approaches. Together, these two strategies can be used to destroy visible macroscopic tumor in a way that enables the destroyed cancer cells to function as a potent immunostimulator that creates tumor-specific T cell immunity able to eradicate persistent residual metastatic disease, for any type of solid tumor in any location.

[00173] Our ongoing preclinical work has shown that combination of tumor-specific mAb with IL2 (to activate innate immune cells) results in augmented antibody-dependent cell-mediated cytotoxicity (ADCC) [1,2]; a process that has already been translated into clinical benefit for children with neuroblastoma [3]. Recent preclinical data demonstrate more potent antitumor efficacy when the mAb-IL2 fusion protein is injected

intratumorally (IT) [4,5]. Remarkably, large tumors that do not respond to these mAb/IL2 injections and continue growing if treated only with local xRT, can be completely eradicated if the xRT is combined with the mAb/IL2 treatment. Most mice are cured and develop T cell memory that rejects re-challenge with similar tumor cells [6];

demonstrating that the combined xRT + mAb/IL2 is acting as a potent "in situ" anticancer vaccine.

[00174] A key limitation is that if there is another macroscopic tumor present in these animals when they receive xRT+ mAb/IL2 treatment to the primary (first) tumor, the second tumor will continue to grow and, to our surprise, suppress the immune response, preventing any shrinkage of the 1 ^st treated tumor. This "concomitant immune tolerance" results, in part, from suppressive regulatory T cells (Tregs) in the 2 ^nd tumor. Delivering RT alone to both tumors has minimal anti-tumor effect, but does deplete these Tregs. Thus, when first tumors are treated with xRT + mAb/IL2, the addition of RT to the second tumor circumvents this immune tolerance, enabling eradication of both tumors [7]. These observations indicate a limitation of in situ tumor vaccination in the metastatic setting, but also suggest a robust capacity of RT to overcome this limitation.

[00175] xRT cannot typically be delivered to all metastatic sites without prohibitive normal tissue toxicity and immune suppression. Yet not delivering xRT to all sites of macroscopic disease may leave inhibitory immune lineages intact, which are capable of suppressing the immunologic response to our local xRT + mAb/IL2 immunotherapy. What is needed, therefore, is a means to deliver RT to all tumor sites in a cancer patient in a targeted manner.

[00176] We have developed TRT vehicles capable of targeting systemically administered RT to both primary and metastatic cancers. One such TRT agent, ¹³¹ I- M404, an intravenously (IV) administered phospholipid ether (PLE) analog, has shown nearly universal tumor targeting properties in over 60 in vivo cancer and cancer stem cell models. This agent is currently being evaluated clinically in multiple imaging and therapy trials [8,9]. A systemic injection of ¹³¹ I- M404 localizes in all tumors regardless of anatomic location and internally provide sufficient RT to ablate intratumoral

immunosuppressive pathways that can prevent development of an effective, tumor- eradicating, immune response. The unique attributes of this approach are the near universal tumor targeting capability of M404, as well as the ability to deliver immunomodulatory sub-lethal doses of RT to all tumor sites, something that is not typically feasible with xRT. What is new about this is that our TRT Agents may immuno- modulate all tumors regardless of anatomic location, overcoming concomitant tolerance, which will result in a long-term in situ tumor vaccination effect following local xRT followed by injection of a tumor specific mAb + IL2. As an increasing number of tumor specific mAbs are becoming approved for clinical use, this combination strategy provides an expanded approach for any tumor type that can be targeted by a tumor-reactive mAb. Furthermore, the approach can be readily generalized to all in situ tumor vaccination strategies.

[00177] Recently, we have discovered that the iodine in ¹³¹ I- M404 can be substituted with chelators capable of carrying a wide variety of metallic imaging (MRI and PET) and TRT radiotherapy moieties. In these examples, we describe how to assess the ability of ¹³¹ I- M404 (and thus, the related metal chelate analogs) to initiate the systemic immunomodulatory response necessary to enable combined xRT + immunotherapy treatment to induce a potent radioimmune-facilitated response against cancerous solid timuors. A similar approach can be used for combined PLE analog-delivered TRT with other immunotherapy methods used against cancerous solid tumors. For example, we have illustrated below that the combination method can use an immunodulation step that is quite different from local in situ tumor vaccination: the systemic administration of an immunostumulatory agent such as an immune checkpoint inhibitor.

[00178] In sum, we disclose herein therapeutic and research processes that combine two different methods from seemingly disconnected cancer therapy disciplines into a single unified treatment. The data presented in these examples indicate that the two methods can be synergistically combined to effectively eliminate malignant solid tumors and to prevent tumor recurrence.

[00179] In Example 1, we present background data from our B78 GD2+ model in support of the method.

[00180] In Example 2, we provide guidance for determining the dose of xRT needed for optimal in situ vaccine effect to a primary tumor, and the lowest dose of xRT to a distant tumor needed to prevent concomitant immune tolerance.

[00181] In Example 3, we provide guidance for determining the ¹³¹ I- M404 dosing that approximates the required dosing of xRT to metastases, as determined in Example 2, and subsequently evaluating the effects of that ¹³¹ I- M404 dose on in vivo immune function. Such guidance can be similarly applied when using the disclosed radioactive phospholipid metal chelate compounds as the TRT agent.

[00182] In Example 4, we provide guidance for using data from Examples 2 and 3 to design/test/develop a regimen of ¹³¹ I- M404 + local xRT + IT-mAb/IL2 in mice bearing two or more tumors in order to destroy the locally treated tumors and induce T-cell mediated eradication of all distant tumors. Critical issues of TRT and xRT dose and time are optimized for antitumor efficacy. Again, such guidance can be similarly applied when using the disclosed radioactive phospholipid metal chelate compounds as the TRT agent.

[00183] In Example 5, we provide an exemplary synthesis that also finds use to the synthesis of analogous compounds chelating radioactive metal isotopes. [00184] In Example 6, we demonstrate that an analog having a chelating agent and chelated metal substituted for the iodine moiety of M404 (Gd- M600) is taken up by (and can be imaged in) solid tumor tissue, thus providing proof of concept for using the disclosed metal chelates as a TRT agent.

[00185] In Examples 7, 8, 9 and 10, we provide information and specific data from experimental studies performed in accordance with the guidance of Examples 1-4.

[00186] In Examples 11 and 12, we demonstrate that additional analogs having a chelating agents and chelated metals substituted for the iodine moiety of M404 are taken up by, and can be imaged in, and can be used therapeutically for TRT in a range of solid tumor in vivo models, thus providing additional proof of concept for using the disclosed metal chelates as TRT agents in the disclosed methods.

[00187] In Example 13, we discuss how dosimetry in combination with known radiosensitivities can be used by the skilled artisan to optimize treatment dosages for any solid tumors.

[00188] In Example 14, we discuss differences and advantages in using

alkylphosphocholine metal chelates in the disclosed methods, rather than the iodinated compounds exemplified in Examples 1-4 and 7-10.

[00189] In Examples 15 and 16, we demonstrate that TRT in combination with systemically-administered immunotherapy, rather than in situ vaccination, is also effective is treating solid tumors. The immunostimulatory agent that is systemically administered may be an immune checkpoint blocker or inhibitor (in this case, anti- CTLA4).

Example 1: Background Supporting Data

[00190] The Sondel lab has shown that tumor-specific mAb + IL2 activates innate immune cells to mediate ADCC in mice [2], with clinical benefit for children with neuroblastoma [3]. In mice, IV administration of the hul4.18-IL2 is more potent than IV administration of anti-GD2 mAb + IL2 [2, 10]. This can provide dramatic antitumor effects against very small recently established GD2+ tumors or very small microscopic metastases, potentially accounting for the clinical use of this approach in patients in remission but at great risk for relapse [3]. More potent antitumor efficacy against measurable, macroscopic tumors [i.e. ~ 50 mm GD2+ tumors] can be achieved when the IC is injected intratumorally (IT-IC) rather than IV [4,5].

[00191] We are now focusing on ways to provide benefit in the setting of much larger, macroscopic tumors. Mice bearing a moderately large (200 mm ³ ) B78 melanoma tumor, established five weeks earlier, show no response to IV-IC, and are slowed in their growth by IT-IC, but the tumors continue to grow. These same 200 mm ³ tumors also grow after 12 Gy of xRT. In contrast, when the IT-IC and xRT are combined, 73% of the animals become tumor-free and appear cured of their disease (Figs. 2A and 2B). These mice then show T-cell mediated rejection of rechallenge with the same tumor (Fig. 2C). Thus IT-IC + xRT synergize, inducing the tumor to become an "in situ tumor vaccine" [6].

[00192] In order to simulate clinical metastases, we inoculate mice with B78 in one flank on d-1, and the other flank at week 2. At week 5, the first tumor is 200 mm ³ , and the second is 50 mm ³ . We anticipated that xRT + IT-IC would destroy the first tumor and that the resultant T cell response would then destroy the second. However, adding IT-IC to the xRT had virtually no effect on either the 50 mm ³ tumor or the 200 mm ³ tumor (Fig. 3). This demonstrated a key limitation to the therapy we delivered; namely, if there is another tumor present when these mice receive xRT + IT-IC to the first tumor, the second tumor will cause a systemic tumor- specific concomitant immune tolerance effect, preventing any shrinkage of either tumor. Importantly, we have found that local xRT (12 Gy) to the first and second tumor simultaneously, abrogates this tolerance effect, allowing IT-IC to the first tumor to induce an immune response that eradicates both tumors in most mice (Fig. 4) [7]. Recent data, using a Treg depleting mAb (not shown) or transgenic mice that allow selective Treg depletion (Fig. 4) [7], demonstrate that this immune tolerance is mediated, in part, by regulatory T cells (Tregs); RT to the first and second tumors partially deplete these Tregs, potentially explaining how irradiating both tumors circumvents the tolerance effect [7].

[00193] While local xRT to both the first and second tumors circumvents tolerance, clinical metastatic disease is often in several locations. All macroscopic metastatic disease must receive RT to block immune tolerance and enable xRT + IT-IC to effectively eradicate all tumor sites. However, delivery of 12 Gy xRT to all sites of disease may be akin to "total body RT" with major dose-dependent (potentially lethal) toxicity and profound systemic immune suppression.

[00194] Previously, the Weichert lab has pioneered the development of TRT, in order to deliver RT to all systemic tumor sites, while minimizing "off-target" RT to normal tissue (especially marrow and immune tissue).

[00195] Based on the finding that tumor cells contain an overabundance of phospholipid ethers (PLE) [11], we synthesized over thirty radioiodinated PLE analogs in hopes of identifying analogs that would selectively target tumors [12]. One of these, M404, not only displayed near universal tumor uptake in all but three of over 70 in vivo models examined regardless of anatomic location, including brain metastases and cancer stem cells, but also underwent prolonged selective retention once it entered tumor cells [8]. These diapeutic PLE analogs are unique in that they avoid premalignant and inflammatory lesions. Surface membrane lipid rafts, which are overexpressed on cancer cells relative to normal cells, serve as portals of entry for PLE's, including M404, into cancer and cancer stem cells [8]. Radioiodinated M404 (1-124 and 1-131), which has now been evaluated in five phase 1 and 2 PET imaging trials and three phase 1 TRT radiotherapy trials, respectively, affords similar tumor uptake and retention properties in over a dozen human cancer types [8]. Excellent tumor uptake in the cancer models relevant to these examples (the B78 GD2+ murine melanoma) have been confirmed with ¹²⁴ I- M404 PET imaging (Fig. 5).

Example 2: Determining Dosages of xRT

[00196] Our data suggest these four hypotheses: (1) the dose of xRT we have used to treat a single tumor causes modest direct in vivo tumor death and increases susceptibility to immune mediated death (via both ADCC and T cells); (2) the strong T-cell response provided by the addition of IT-IC, but not IT mAb, suggests that mAb binding to radiated tumor cells, in the presence of IL2, facilitates antigen presentation and augmented induction of adaptive immunity; (3) the presence of a second tumor prevents the xRT + IT-IC to the first tumor from causing virtually any anti-tumor effect, due to tolerance caused largely by the systemic actions of immunosuppressive cells present in the second tumor [such as Tregs and possibly myeloid derived suppressor cells (MDSC)]; this tolerance can be circumvented by depletion of Tregs (Fig. 4) or irradiating the second tumor (Fig. 3); (4) the dose of RT needed at the second tumor to circumvent tolerance might be much lower than the xRT dose needed for the first tumor to become an "in situ vaccine" [14].

[00197] Optimizing xRT dose for the primary ("in situ vaccine") tumor site.

[00198] Our in vivo studies of xRT + IT-IC have focused on one dose of 12 Gy to the first tumor. This is based on our data showing that in vitro RT induces a dose-dependent functional upregulation of Fas on B78 tumor cells (nearing peak at >12 Gy), coupled to our in vivo data demonstrating our in situ vaccine effect of xRT + IT-IC requires mice with functional Fas-L (6). We conducted in vivo pilot studies prior to selecting the 12 Gy dose, which showed higher dose (16 Gy) or increased fractionation flank RT had toxicity (dermatitis, ulceration, and late limb edema) and no improvement in tumor response. While we chose a 12 Gy single fraction of xRT for our in vivo studies, as we move towards clinical translation, it will be beneficial to better understand the mechanism of the local xRT effect and its dose requirements, in order to safely and effectively induce the in situ vaccine effect.

[00199] Our mouse data (Figs. 2A, 2B and 2C) show that we can induce a potent vaccine effect with 12 Gy xRT + IT-IC, even though 12 Gy of xRT alone causes no shrinkage of the tumor; it merely slows the progressive growth. It is contemplated that we might see just as potent an in situ vaccine effect using lower doses of RT. To test this, we will evaluate a range of xRT doses (from 4 - 16 Gy) as a single fraction in mice bearing a ~ 200 mm ³ B78 tumor, followed by our standard IT-IC regimen (50 mcg/d on days 6-10). We will determine which xRT doses give optimal tumor eradication and T-cell memory, when combined with IT-IC. If doses lower than 12 Gy are less toxic and show

comparable efficacy, such lower doses would be better targets for our xRT dose to the "in situ vaccine" site in Examples 3 and 4. Similar approaches may be used to optimize dosing for particular targets or subjects.

[00200] Optimizing xRT dose at a distant tumor to prevent tolerance from blocking "in situ vaccination."

[00201] Treating both the first and second tumors with 12 Gy (Fig. 3) enables IT-IC to the first tumor to induce a potent response that eradicates both tumors. Our goal is to be able to accomplish this same in situ vaccine effect by providing xRT + IT-IC to a single tumor while using the minimal RT dose necessary at metastatic sites to circumvent tolerance. We recognize that xRT itself, especially if widespread, can be

myelo/immunosuppressive. This is why we are pursuing TRT in Examples 3 and 4. Even though it is targeted, TRT does have some systemic delivery of RT. In order to minimize the systemic immune suppression from TRT, we wish to give as low of a dose of TRT as is needed to effectively inhibit the tumor-induced immune tolerance, while not causing systemic RT-induced global immune suppression. Therefore, it is best to select the lowest dose of xRT needed to be delivered to the distant tumor in order to enable a higher xRT dose to the first tumor to function as an in situ vaccine when combined with IT-IC to the first tumor.

[00202] As an exemplary optimization experiment, mice bearing a 200 mm ³ first B78 tumor and a -50 mm ³ second B78 tumor will receive 12 Gy of xRT to the first tumor on day-0 (~5 weeks after implantation of the first B78 tumor). This will be followed by our standard regimen of IT-IC on days 6-10. Separate groups of mice will receive varying doses of xRT to the second tumor. Based on data from the lab of B. Johnson

demonstrating that a total body xRT of 3 Gy can prevent an immunosuppressive effect in a myeloma model (15), we will evaluate doses of 0, 1, 5 and 8 Gy (in addition to the 12 Gy dose we know is effective). We will see if doses substantially less than 12 Gy to the second tumor can be as effective as the full 12 Gy dose at eliminating the immune tolerance.

[00203] Once we have selected the critical dose of xRT where we lose the beneficial effect, we will perform subsequent analyses to better optimize the critical dose. For example, if 5 Gy is as effective as 12 Gy, but 1 Gy is not much better than 0 Gy, we would then compare 2, 3, and 4 Gy to identify the critical lowest effective RT dose needed to eliminate tolerance and obtain efficacy in this two tumor model, receiving 12 Gy + IT-IC to the first tumor.

[00204] Repeat studies are then be done to confirm if this lowest effective dose to the second tumor still enables an effective in situ vaccine when the dose to the first is the lowest effective dose in the 1 -tumor model (tested in Example 2, above) rather than the 12 Gy dose. In summary, the studies of Example 2 optimize what the lowest xRT doses are for the first and second tumors, without losing the efficacy we have demonstrated with 12 Gy to both.

[00205] Initiating studies of required xRT dose to first and second tumors in mice bearing tumors other than B78.

[00206] To allow our mouse studies to suggest more clinical generalizability, we will initiate analyses of RT + IT-IC in additional models of GD2+ tumors. We have published on IT-IC with hul4.18-IL2 IC in AJ mice bearing the GD2+ NXS2 neuroblastoma [5]. We are also evaluating IT-IC with this same IC in C57BL/6 mice bearing the GD2+ 9464D-GD2 neuroblastoma, and the Panc02-GD2 pancreatic cancer that express GD2 via our insertion of the gene for GD2 synthase. As for Example 2, for each model we will determine the lowest effective xRT dose needed to the primary and the secondary tumors to retain the in situ vaccine effect.

Example 3:

Determining Dosage of ¹³¹ I-NM404 and Evaluating Effects on Immune Function Dosimetry with TRT and immunesuppression from TRT in C57BL/6 mice.

[00207] ¹³¹ I- M404 has shown selective uptake in vitro in >95% of tumor lines (human and mouse), with poor uptake by non-malignant cells, and with similar tumor specificity seen in vivo. This includes selective uptake in vivo with the B78 tumor (Fig. 5). In our preliminary dosimetry study, we gave ¹²⁴ I- M404 to C57BL/6 mice and characterized the time course of TRT exposure by serial PET/CT imaging (as in Fig. 5). Monte Carlo dosimetry calculations [16-18] based on this study indicated that ~ 60 μθ of ¹³¹ I- M404 would be needed to deliver ~ 3 Gy to an established B78 tumor over a four week period of decay. After those four weeks, the remaining TRT dose to the B78 tumor would be less than 0.25 Gy. We will replicate the data we obtained in our 2-tumor model using xRT (Fig. 3), but use the lowest possible dose of targeted ¹³¹ I- M404 TRT to enable effective elimination of tumor-induced tolerance at all sites of distant disease. However, unlike xRT, which delivers all dose in minutes and is then done, TRT deposits dose over time, depending upon both the biological and physical half-life of the targeted isotope (8 day t½ for ¹³¹ I). We want an initial TRT effect at the distant tumor sites to eradicate immune tolerance; however we want the immunosuppressive TRT effect to then be minimal when we give the IT-IC to induce ADCC and the in situ vaccine antitumor effects. This is essential to allow full tumor destruction at all sites.

[00208] Using the dosimetry calculations from our preliminary data, we estimated that a dose of 3 μθί of ¹³¹ I- M404, should deliver an equivalent of -0.2 Gy to the tumor site, a dose that we hypothesized should not be immunosuppressive and should not prevent lymphocyte-mediated tumor destruction. As noted above, this is the dose we estimated would remain yet to be delivered 28 days after an initial ¹³¹ I- M404 dose of 60 μθ. We thus evaluated groups of mice bearing a single 200 mm ³ B78 tumor. On day 0, all mice got 12 Gy xRT to their tumor, and on days 6-10, all got 50 mcg/d of IT-IC. One group also got 3 μθ of ¹³¹ I- M404 on d-0 (-0.2 Gy). Fig. 6 shows that the group receiving the ¹³¹ I- M404 had the same degree of tumor eradication as the group without ¹³¹ I- M404, demonstrating that this low dose of "residual" TRT in the tumor does not block immune mediated destruction by the RT + IT-IC in situ vaccine. We thus hypothesize that if we use an initial dose of 60 μθ of ¹³¹ I- M404 TRT on day -22, it would effectively block the tolerogenic effect of distant tumors, yet enable xRT on day 0 and IT-IC on days 6-10 (28d after the TRT) to the first tumor to function as an in situ vaccine, inducing an adaptive response that then eradicates all tumors.

[00209] The experiments outlined in this example optimize the dose relationships tested in Fig. 6. In our 1 -tumor B78 model, we will test a range of doses of ¹³¹ I- M404 TRT to select the best TRT dose that results in enough unwanted systemic immune suppression to interfere with the desired in situ vaccine effect (and thereby slow or prevent eradication of the first tumor). This is important to Example 4, as it allows us to make sure the residual radioactivity of the TRT has decayed to less than this value at the time we initiate IT-IC to the first tumor in mice with distant disease. We will also evaluate the kinetics of the TRT response after varying TRT doses to select an optimal time period for how long we should wait after the "tolerance-preventing TRT dose" is given to animals with multiple tumors to allow the RT + IT-IC treatment of the first tumor to still induce the in situ vaccine effect and eradicate the primary as well as distant tumors.

[00210] Related studies will also look at what dose of TRT, given as single agent treatment, are most beneficial to cause slowing, versus shrinkage, versus eradication of a single B78 tumor. The dose of TRT that is most beneficial to eliminate the tumor-induced immune tolerance will be substantially less than the TRT dose needed to actually induce complete tumor destruction (from the TRT alone).

[00211] Finally, once the effects of various optimized doses of TRT are determined in the 1 -tumor model, we will evaluate the subtle immune-suppressive effects of TRT, by evaluating sera from these subject for their immune response to the human IgG component of the IC. We have shown that immunocompetent mice generate a readily quantified level of Mouse Anti -Human Antibody (MAHA) following treatment with these humanized ICs (19). We will use this as a means of determining at what dose we are seeing the TRT cause a detectible dose-dependent decrease in the strength of the murine immune response, to gauge the overall immunosuppressive effects from the systemic doses of RT these mice will receive from this TRT. The low TRT dose that we will need to block the tumor-induced immune tolerance will cause minimal systemic immune suppression.

Example 4: Developing an optimal Regimen of ¹³¹ I-NM404 + local xRT + IT- mAb IL2 in Mice Bearing Two or More Tumors

[00212] Testing the efficacy of TRT + RT + IT-IC in the 2-tumor B78 model.

[00213] The dose and timing information learned from the studies outlined in

Examples 2 and 3 will provide the information we need to optimize TRT dosing and timing required for efficacy in our 2-tumor model. C57BL/6 mice will be inoculated with B78 in the left (L) and right (R) flanks simultaneously. Each tumor should be ~ 50 mm ³ after two weeks and ~ 200 mm ³ after five weeks. If we assume that our dosimetry calculations in Example 3 suggest that we need to deliver 60 μθ of TRT to approximate 3 Gy RT to the second tumor (to block the immune tolerance), our external beam xRT studies predict that this dose should have minimal slowing effect on tumor growth. We would plan to treat different groups of mice with 30, 60 or 90 μθ at the 2 w time point (when the tumors are ~ 50 mm ³ ). Three weeks later the tumors should be ~ 200 mm ³ ; at that time we will give xRT (dose determined as outlined in Example 2) followed six days later (~ 28 d after the TRT) by five daily injections of IT-IC to the tumor in the L flank, to induce the in situ vaccine effect. Control mice would get no TRT, and only the xRT and IT-IC to the L flank, anticipating no in situ vaccine due to tolerance from the distant tumor. A separate group would get local xRT to both tumors and IT-IC to the L flank, anticipating eradication of both tumors via the in situ vaccine effect. Another group get TRT + IT-IC, but without local xRT, anticipating an incomplete vaccine effect.

[00214] Follow-up experiments further evaluate varying doses of TRT and variations in the timing between the TRT and the local xRT + IT-IC to the primary tumor (L flank). The readouts will be: (A) eradication of the primary tumor; (B) eradication of the secondary tumor; and (C) systemic immune suppression, via ELISA analyses of the MAHA response. Our goal is to identify optimal TRT dose and timing with a particular subject and disease model, to add to the local xRT + IT-IC regimen that can eradicate both tumors in most subject, while minimizing systemic immunosuppression (as measured by MAHA response).

[00215] Optimizing TRT + xRT + IT-IC in mice bearing more than two B78 tumors.

[00216] This section of Example 4 is most analogous to the relevant clinical setting; namely, patients with an injectable tumor that could be used as an in situ vaccine site, but with multiple distant metastases that could each be causing tumor-induced immune tolerance. These studies will replicate the conditions found to be most effective in the first part of Example 4 (above). The important difference is that these subject will each have four separate tumors, in L and R flanks, and L and R para-scapular regions. The TRT is given at the dose and timing found most effective in the studies outlined in the first section of Example 4, with xRT + IT-IC subsequently given only to the L-flank lesion. The goal here is to select TRT dose and timing issues to enable most effective in situ vaccine, because the TRT would effectively eliminate the tumor-induced immune tolerance caused by the three sites not getting xRT. The measure of efficacy is elimination of all four tumors in most subjects. Modifications in TRT dose and timing are tested in order to generate an optimized regimen that is most effective. Such a regimen finds use in the clinic for patients with multiple distant metastases, that could not all be irradiated via external beam, but could be irradiated via TRT, when combined with local xRT + IT-IC to the "in situ vaccine" site. Example 5: Synthesis of metal chelated NM600

[00217] In this Example, we show the synthetic scheme used to synthesize one exemplary phospholipid chelate, Gd- M600. Analogs incorporating various radioactive isotopes could be synthesized in a similar manner, where the radioactive isotope in questions is substituted for Gd.

[00218] Scheme for synthesizing Gd- M600 (the disclosed radioactive metal isotopes could be substituted for Gd): cyclen

{01273789.DOCX / }62

Example 6: In vivo Imaging Proof of Concept

[00219] In this example, we demonstrate the successful in vivo MRI imaging of a tumor, using Gd-NM600 as the MRI contrast agent. The data demonstrates that the backbone phospholipid and chelating agent are taken up and retained by solid tumors, demonstrating that such chelates incorporating various radioactive metals, as disclosed herein, would exhibit similar properties

[00220] For proof-of-concept in vivo imaging of tumor uptake of the Gd-NM404 agent, nude athymic mouse with a flank A549 tumor (non small cell lung cancer) xenograft was scanned. The Gd-NM600 agent (2.7 mg) was delivered via tail vein injection. Mice were anesthetized and scanning performed prior to contrast administration and at 1, 4, 24, 48, and 72 hours following contrast delivery. Imaging was performed on a 4.7T Varian preclinical MRI scanner with a volume quadrature coil. Tl-weighted images were acquired at all imaging time points using a fast spin echo scan with the following pulse sequence parameters: repetition time (TR) = 206 ms, echo spacing = 9 ms, echo train length = 2, effective echo time (TE) = 9 ms, 10 averages, with a 40x40 mm ² field of view, 192x192 matrix, 10 slices of thickness 1mm each.

[00221] As seen in Figure 7, MRI imaging of the tumor was significantly enhanced by 24 hours post-injection.

[00222] These results demonstrate that the differential uptake and retention of alkylphosphocholine analogs is maintained for the metal chelated analogs disclosed herein. Thus, the disclosed metal chelates can readily be applied to clinical therapeutic and imaging applications.

Example 7: Experiments determining the dose of xRT needed for optimal in situ vaccine effect to a primary tumor, and the lowest dose of xRT to a distant tumor needed to prevent concomitant immune tolerance

[00223] As a follow-up to Examples 1-4, dose titration experiments, evaluating a variety of xRT doses, to mice with 1 or 2 tumors have been performed. The first goal has been to test the dose of xRT needed in mice with one tumor to facilitate synergy and an situ vaccine" with IT-IC, tumor-reactive mAb linked to IL2. Initial experiments have confirmed our prior observation that 12 Gy RT alone does not eradicate or even regress the growth of established B78 melanoma tumors (0% complete regression), whereas 12 Gy + IT-IC results in complete regression of most B78 tumors (66%) in mice bearing a single tumor. On the other hand, 2 Gy + IT-IC slows tumor progression compared to IT-IC alone (mean tumor size day 32 = 472 mm ³ vs 1214 mm ³ , respectively) but did not render any mice disease free (0% complete regression).

[00224] In our "2 -tumor model", we have previously shown that treatment of one "primary" tumor with xRT + IT-IC is not effective in treating either the treated primary tumor or the untreated "secondary" tumor. In fact, in this 2-tumor model we have observed that the presence of the second tumor eliminates the efficacy of IT-IC injection following xRT. We have designated this phenomenon as "concomitant immune tolerance" (CIT), and demonstrated that this results, at least in part, from T regulatory cells (Tregs) in the distant (non-irradiated) secondary tumor, which circulate systemically and repopulate the xRT-treated /IT-IC injected primary tumor. These Tregs that return to the primary tumor appear to interfere with the desired situ vaccine" effect.

[00225] We have now confirmed our prior observation that CIT can be overcome by delivering 12 Gy xRT to both the primary and the secondary tumor. Importantly, given that Tregs are quite sensitive to RT, we hypothesized that a lower dose of RT could be delivered to the secondary tumor in order to overcome CIT and rescue response to in situ vaccination at the primary tumor (primary tumor treated with 12 Gy + IT-IC). We have now tested this and observed that xRT doses of 2 Gy or 5 Gy to the secondary tumor are comparable to 12 Gy in their capacity to blunt CIT and rescue response to primary tumor treatment with 12 Gy + IT-IC. These important experiments have been repeated in duplicate, and suggest (as hypothesized) that the dose of xRT that must be given to distant tumors to prevent CIT is much less than the dose needed at the IT-IC injected primary tumor site for the purpose of generating an in situ vaccine effect.

[00226] This supports our overarching hypothesis in this disclosure, and suggests that in animals bearing multiple tumors we will be able to deliver a relatively low dose of RT to all sites of disease using the targeted radiotherapeutic (TRT) NM600, and thereby overcome CIT when this is combined with local xRT and IT-IC injection of a single tumor site (the in situ vaccine site). Example 8: Experiments determining the ¹³¹ I-NM404 dosing that approximates the required dosing of xRT to metastases, as determined above, and then evaluating the effects of that ¹³¹ I-NM404 dose on in vivo immune function

[00227] Based on the preliminary data described above in Examples 1-4, studies have been done to move these concepts into in vivo testing using TRT. Dosimetry studies have been performed on mice bearing 1 or 2 B78 tumors (the tumor model that we have used to demonstrate best our in situ vaccine approach and the hurdle of CIT). This was done in order to estimate the amount of ^{1 1} I-NM404 that would be needed to approximate ~ 2 Gy of xRT.

[00228] In order to then determine if a ~2 Gy equivalent dose of ^m I-NM404 would have the desired effects against intratumor lymphoid cells (particularly Tregs), 2 separate approaches have been pursued. First, we administered this dose of ^m I- NM404 to mice bearing a radiosensitive lymphoma tumor, which exhibits comparable NM404 uptake to B78 tumors. Following this we have documented potent lymphoid tumor shrinkage/dose-dependent inhibition under conditions that did not cause either substantial shrinkage/slowing of the B78 tumor or any evident depletion of circulating lymphoid cells (as gauged by peripheral complete blood counts). These data are consistent with the fact that lymphoid cells are much more sensitive to low-dose RT than are typical solid tumor cells, and suggest that selective uptake of TRT in tumor may enable intratumor lymphoid cell depletion without systemic lymphopenia. These studies also suggest that such a lymphoid tumor could serve as an in vivo biological "dosimeter" for identifying and monitoring the effect of TRT on intratumor lymphoid cells.

[00229] A second approach involved treating mice with B78 tumors with these same doses of ^m I-NM404. These animals were then sacrificed at half-life (8d) intervals, and after sufficient delay for radioactive decay, the tumors were stained for the presence of effector T cells and Tregs by immunohistochemistry Intriguingly, the animals receiving ^{1 1} I-NM404 in this initial experiment showed no systemic lymphopenia at any time point (by peripheral complete blood count) but did show a decrease in intratumor FoxP3+ Tregs at 2 half-lifes following TRT administration. At this 2-half-life time point, we also observed a decrease in intratumor effector CD8+ T cells. Importantly, however at subsequent 3 and 4 half-life time points we observed an increase in intratumor CD8+ effector T cells but a further decline in the levels of intratumor Tregs, both compared to untreated baseline and2 ^nd half-life levels. This observation again supports our hypothesis that it will be feasible to use TRT to overcome Treg-mediated CIT in order to rescue an in situ vaccine effect in animals bearing multiple tumors.

[00230] Finally, to characterizing the immunological effects of TRT on the immune cells within tumors, we have treated B78 bearing mice with ^m I-NM404 and collected tumor tissue at pretreatment and at half-life (8d) intervals thereafter. These tissues were then analyzed by RT-PCR for gene expression of a panel of immune signatures. The results indicate that TRT treatment alone causes striking changes in expression of tumor cell markers of immunsusceptibility and in genes normally expressed only by immune cells, with the latter showing a clear time course of decreased expression followed by rebound over-expression.

Example 9: Experiments using data from Examples 5 and 6 to develop a regimen of ¹³¹ I-NM404 + local xRT + IT-mAb/IL2 in mice bearing two or more tumors and induce T-cell mediated eradication of all distant tumors

[00231] This Example illustrates treating animals bearing tumors in at least 2 locations. Our strategy involves using xRT and local IT-IC at the in situ vaccine site, in combination with TRT systemically to inhibit CIT, in order to obtain enhanced anti-tumor immune activity at all tumor sites. Critical issues of TRT and xRT dose and timing will be optimized for antitumor efficacy.

[00232] Using the data summarized in Examples 7 and 8, a study was done in mice bearing 2 separate B78 tumors. Mice received the estimated required systemic ^{1 1} \- NM404 dose followed by xRT and local immunotherapy to the in situ vaccine site. With appropriate controls, this dose of ^{1 1} I-NM404 did appear to attenuate CIT, as desired in mice with 2 tumors. In addition, in mice with one tumor, this TRT dose did not appear to interfere with the local in situ vaccine effect (as hypothesized and desired). Further testing, and modification of some of the experimental variables, is underway in order to try to maximize the desired effect of blocking CIT without suppressing the in situ vaccine effect. More details regarding these experiments are disclosed in Example 10 below. Example 10: Data from mice bearing two or more tumors

[00233] Tumor-specific inhibition of primary tumor response to the combination of local xRT+IT-IC by a distant untreated tumor in murine melanoma and pancreatic tumor models.

[00234] C57BL/6 mice bearing a syngeneic, GD2+ primary flank tumor +/- a secondary tumor on the contralateral flank were treated to the primary tumor only, as indicated, with xRT on day "1" and IT injection of 50 meg of the anti-GD2 IC, hul4.18- IL2 on day 6-10.

[00235] In mice bearing a primary B78 melanoma tumor, the presence of an untreated secondary B78 tumor antagonized primary tumor response to xRT+IT-IC (Figure 8A). We describe this effect as "concomitant immune tolerance" - an antagonistic effect of a non-treated distant tumor on the local response of a treated tumor to xRT + IT-IC. Kaplan-Meier survival curves were obtained for these mice plus replicate experiments (Figure 8B). Nearly all mice were euthanized due to primary tumor progression.

[00236] In mice bearing a primary Panc02-GD2+ pancreatic tumor, with or without a secondary Panc02-GD2- tumor on the opposite flank, the presence of an untreated Panc02 secondary tumor suppressed the response of a primary Panc02-GD2+ tumor to xRT+IT-IC (Figure 8C). In mice bearing a primary B78 melanoma tumor, a secondary B78 tumor suppressed primary tumor response to xRT+IT-IC but a secondary Panc02- GD2+ pancreatic tumor did not exert this effect (Figure 8D). In mice bearing a primary Panc02-GD2+ tumor a secondary Panc02-GD2- tumor suppressed primary tumor response to combined xRT and IT-hul4.18-IL2, while a B78 secondary tumor did not (Figure 8E).

[00237] Concomitant immune tolerance is circumvented by specific depletion of regulator T cells (Tregs).

[00238] Immunohistochemistry images were obtained for the Treg marker, FoxP3 for tumors evaluated on day 6 after xRT in mice with one or two tumors (Figure 9A). Mice received no xRT, or xRT only to the primary tumor. DEREG mice express diphtheria toxin receptor under control of the Treg-specific FoxP3 promoter, enabling specific depletion of Tregs upon IP injection of diphtheria toxin (Figures 9B and 9C). DEREG mice bearing primary and secondary B78 melanoma tumors were treated with xRT+IT-IC to the primary tumor and IP injection of either diphtheria toxin or PBS. Concomitant immune tolerance is eliminated following depletion of Tregs in these mice, resulting in improved primary (Figure 9B) and secondary (Figure 9C) tumor response.

[00239] Concomitant immune tolerance is overcome by delivering xRT to both tumor sites.

[00240] In mice bearing primary and secondary B78 tumors, the secondary tumor suppresses primary tumor response to primary tumor treatment with xRT + IT-IC. This is overcome by delivering 12 Gy xRT to both the primary and secondary tumors and IT-IC to the primary tumor, resulting in improved primary tumor response (Figure 10A) and aggregate animal survival (Figure 10B) from replicate experiments.

[00241] Low dose xRT alone does not elicit in situ vaccination but does overcome concomitant immune tolerance when delivered to distant tumor sites together with 12 Gy + IT-IC treatment of an in situ vaccine site.

[00242] In mice bearing a primary B78 tumor only, 12 Gy + IT-IC elicits in situ vaccination (as shown previously) and results in complete tumor regression in most mice (Figure 11 A) and a memory immune response (Morris, Cancer Res, 2016). On the other hand no animals exhibit complete tumor regression following either IT-IC alone or low dose (2 Gy) xRT + IT-IC (0/6 in both groups) p<0.05.

[00243] In mice bearing a primary and secondary B78 melanoma tumor, low dose xRT (2 Gy or 5 Gy) delivered to the secondary tumor is comparable to 12 Gy in its capacity to overcome concomitant immune tolerance at the primary tumor (Figure 1 IB). In these same animals, it is apparent that overcoming concomitant immune tolerance by delivery of low dose xRT to the secondary tumor rescues a systemic response to IT-IC immunotherapy (Figure 11C). In this context, when RT is delivered to all tumor sites then IT-IC injection of the primary tumor triggers a systemic antitumor effect that renders secondary tumor response to 2 Gy or 5 Gy greater than the response to 12 Gy RT in absence of primary tumor IT-IC injection.

[00244] Low dose TRT with ¹³¹ I-NM404 effectively depletes tumor infiltrating FoxP3+ Tregs without systemic leukopenia or depletion of tumor infiltrating CD8+ effector T cells.

[00245] In most clinical scenarios, it is not feasible to deliver external beam, even low dose, to all tumor sites without eliciting marked bone marrow depletion and leukopenia that would result in immunosuppression. Here we tested whether TRT could be administered systemically to specifically deplete tumor infiltrating suppressive immune cells (Tregs), without triggering systemic immune cell depletion and leukopenia. Dosimetry studies in this B78 melanoma tumor model were performed using positron-emitting ¹²⁴ I-NM404 confirm tumor-selective uptake of NM404 (Figure 12 A). C57BL/6 mice bearing B78 tumors were treated with 60 μθ ^{1 1} I-NM404. This activity approximates the amount of ^m I-NM404 necessary to deliver ~ 2 Gy TRT to a B78 tumor. Peripheral blood and tumor samples were collected in untreated control mice (C) and at 8 day intervals (Tl = d8, T2 = dl6, T3 = d24, T4 = d32) thereafter. This dose of TRT did not result in any significant systemic leukopenia (Figure 12B) and did not significantly affect the level of tumor infiltrating CD8+ effector T cells (Figure 12C). However, tumor infiltrating FoxP3+ Tregs were significantly depleted by this dose of TRT (Figure 12D).

[00246] Low dose TRT with ¹³¹ I-NM404 effectively overcomes concomitant immune tolerance and rescues the systemic anti-tumor effect of in situ vaccination.

[00247] Given the capacity of low dose ^m I-NM404 TRT to deplete tumor- infiltrating Tregs without rendering a mouse leukopenic, we tested whether low dose ^{1 1} I-NM404 might effectively overcome concomitant immune tolerance. C57BL/6 mice bearing two B78 tumors were treated with 60-μΟ ^m I-NM404 on day 1 (NM404), as indicated. After one half-life (day 8), animals received 12 Gy xRT or no xRT to the primary tumor (in situ vaccine site). Control mice receiving no ^{1 X} I- NM404 were treated to the secondary tumor as indicated (0, 2, or 12 Gy). Mice received daily IT injections of IC to the primary tumor (in situ vaccine site), as indicated, on days 13-17. Primary tumor (Figure 13A) and secondary tumor (Figure 13B) response demonstrates that administration of low dose TRT effectively overcomes concomitant immune tolerance and rescues the systemic anti-tumor effect of in situ vaccination.

References Cited in the Examples 1-4 and 7-10:

[1] Hank JA, Robinson RR, Surfus J, Mueller BM, Reisfeld RA, Cheung N-K and Sondel PM. Augmentation of antibody dependent cell mediated cytotoxicity following in vivo therapy with recombinant Interleukin-2. Cancer Res. 50:5234-9. 1990.

[2] Neal ZC, Yang JC, Rakhmilevich AL, Buhtoiarov I, Lum HE, Imboden M, Hank JA, Lode HN, Reisfeld RA, Gillies SD, Sondel PM. Enhanced activity of hul4.18-IL2 IC against the murine NXS2 neuroblastoma when combined with IL2 therapy. Clin Cancer Res. 2004 Jul 15;10(14):4839-47.

[3] Yu AL, Gilman AL, Ozkaynak MF, London WB, Kreissman S, Chen H, Smith M, Anderson B, Villablanca J, Matthay KK, Shimada H, Grupp SA, Seeger R, Reynolds CP, Buxton A, Reisfeld RA, Gillies SD, Cohn SL, Maris JM, Sondel PM. Anti-GD2 antibody with GM-CSF, interleukin-2, and isotretinoin for neuroblastoma. N Engl J. Med. 2010 Sep 30;363(14): 1324-34.

[4] Johnson EE, Yamane BH, Lum HD, Buhtoiarov IN, Rakhmilevich AL, Mahvi DM, Gillies SD, Sondel, PM. Radiofrequency Ablation Combined with KS-IL2 IC (EMD 273066) Results in an Enhanced Anti-tumor Effect Against Murine Colon Adenocarcinoma. Clin Cancer Res. 2009 Aug l ;15(15):4875-84.

[5] Yang RK, Kalogriopoulos NA, Rakhmilevich AL, Ranheim EA, Seo S, Kim KM, Alderson KL, Gan J, Reisfeld RA, Gillies SD, Hank JA, Sondel PM. Intratumoral hul4.18-IL2 (IC) Induces Local and Systemic Antitumor Effects that Involve Both Activated T- and NK cells as well as Enhanced IC Retention. J Immunol. 2012 Sep l ;189(5):2656-64.

[6] Morris ZS, Emily I. Guy EI, Francis DM, Gressett MM, Carmichael LL, Yang RK, Armstrong EA, Huang S, Navid F, Gillies SD, Korman A, Hank JA,

Rakhmilevich AL, Harari PM, Sondel PM. Combining Local Radiation and tumor- specific antibody or IC to elicit in situ tumor vaccination. Cancer Research, e-pub ahead of print, 2016. [7] Morris ZS, G.E., Francis DM, Gressett MM, Armstrong EA, Huan S, Gillies SD, Korman AJ, Hank JA, Rakhmilevich AL, Harari PM, and Sondel PM., IC augments local and abscopal response to radiation and CTLA-4 checkpoint inhibition in a murine melanoma model. Am. Soc.Therapeutic Radiation Oncology. Abstract accepted Oct. 2015 (and selected as the meeting's winning abstract in the basic— translational science category).

[8] Weichert JP, Clark PA, Kandela IK, Vaccaro AM, Clarke W, Longino MA, Pinchuk AN, Farhoud M, Swanson KI, Floberg JM, Grudzinski J, Titz B, Traynor AM, Chen HE, Hall LT, Pazoles CJ, Pickhardt PJ, Kuo JS. Alkylphosphocholine Analogs for Broad Spectrum Cancer Imaging and Therapy. Science Translational Medicine 6, 240ra75, 1-10. 2014.

[9] Morris ZS, JP Weichert, J Sakera, EA Armstrong, A Besemer, B Bednarz, R Kimple, PM Harari. Therapeutic combination of radiolabeled NM404 with external beam radiation in head and neck cancer model systems. Radiotherapy and Oncology. J. Radiation Oncology, DOI: 10.1016. 2015.

[10] Lode HN, Xiang R, Dreier T, Varki NM, Gillies SD, Reisfeld RA. Natural killer cell-mediated eradication of neuroblastoma metastases to bone marrow by targeted interleukin-2 therapy. Blood 91(5), 1706-1715. 1998.

[11] Snyder F, Wood R. Alkyl and alk-l-enyl ethers of glycerol in lipids from normal and neoplastic human tissues. Cancer Res 29, 251-257. 1969.

[12] Pinchuk AN, Rampy MA, Longino MA, Skinner RW, Gross MD, Weichert JP, Counsell RE, Synthesis and structure-activity relationship effects on the tumor avidity of radioiodinated phospholipid ether analogues. J Med Chem 49, 2155- 2165. 2006.

[13] Swanson KI, Clark PA, Pinchuk AN, Longino MA, Farhoud M, Weichert JP, Kuo JS. Initial Studies on Novel Cancer-Selective Alkylphosphocholine Analogs CLR1501 and CLR1502 for Fluorescence-guided Neurosurgery. Neurosurgery. 76(2): 115-123. 2015.

[14] Filatenkov A, Baker J, Mueller AM, Kenkel J, Ahn GO, Dutt S, Zhang N, Kohrt H, Jensen K, Dejbakhsh- Jones S, Shizuru JA, Negrin RN, Engleman EG, Strober S. Ablative Tumor Radiation Can Change the Tumor Immune Cell Microenvironment to Induce Durable Complete Remissions. Clin Cancer Res. 21 :3727-39. 2015.

[15] Jing W, Gershan JA, Weber J, Tlomak D, McOlash L, Sabatos-Peyton C, Johnson BD. Combined immune checkpoint protein blockade and low dose whole body irradiation as immunotherapy for myeloma. J Immunother Cancer. 3:2.

2015.

[16] Bednarz B., Besemer A., Yang Y. A Monte Carlo-Based Small Animal Dosimetry Platform for Pre-Clinical Trials: Proof of Concept. Med. Phys. 39, 3899. 2012.

[17] Besemer et al. Towards Personalized Dosimetry Using Diapeutic Radiopharmaceuticals. Med. Phys. 40, 382. 2013.

[18] Besemer A. and Bednarz B. Validation of a patient-specific Monte Carlo targeted radionuclide therapy dosimetry platform. Med. Phys. 41, 303. 2014.

[19] Imboden M, Murphy KR, Rakhmilevich AL, Neal ZC, Xiang R, Reisfeld RA, Gillies SD and Sondel PM. The level of MHC Class I expression on murine adenocarcinoma can change the antitumor effector mechanism of immunocytokine therapy. Cancer Res. 61 : 1500-7. 2001.

Example 11:

In vivo uptake of multiple NM600 metal chelates in mice xenografted with eight different solid tumor types, demonstrated by PET imaging

[00248] In this example, we demonstrate the differential uptake of NM600 chelated with four different metals in a range of solid tumors in vivo, as demonstrated by PET/CT imaging of such tumors. These data provide additional support for the use of metal chelated alkylphosphocholine analogs as TRT agents for eliminating tumor- induced immune tolerance, as disclosed herein. The structure of NM600 is shown in Figure 14, as an example species chelated with ⁶⁴ Cu ( ⁶⁴ Cu-NM600); however, any metal can be readily chelated to NM600.

[00249] Specifically, mice were each xenografted with one of eight different solid tumor cell lines (B78 (melanoma), U87MG (glioblastoma), 4T1 (breast carcinoma), HCT-116 (colorectal carcinoma), A549 (lung carcinoma), PC-3 (prostate carcinoma), HT-29 (colorectal adenocarcinoma), or MiaPaca (pancreatic carcinoma). For each of the xenografted mice, cell suspension containing tumor cells was inoculated into subcutaneous tissue of one or both flanks of the mouse. Once xenograft tumors reached a minimum size, each mouse was injected with between 150-300 μθ of

64 89 86 52

NM600 radiolabeled with Cu, Zr, Y, or Mn via lateral tail vein injection. After an uptake period, PET imaging was performed in an Inveon micro PET/CT. Right before each scan, mice were anesthetized with isoflurane (2%) and placed in a prone position in the scanner. Longitudinal 40-80 million coincidence event static PET scans were acquired at 3, 12, 24, and 48 hours post-injection of the radiotracer and the images were reconstructed using an OSEM3D/MAP reconstruction algorithm.

[00250] Figure 15 shows the resulting images 48 hours post-injection-for single- tumor B78 mice injected with ⁸⁶ Y-NM600; Figure 16 shows the resulting images 48 hours post-injection-for two-tumor B78 mice injected with ⁸⁶ Y-NM600; Figure 17 shows the resulting images 3, 24 and 48 hours post-injection for a U87MG mouse injected with ⁶⁴ Cu-NM600; Figure 18 shows the resulting images 3, 24 and 48 hours post-injection for a 4T1 mouse injected with ⁶⁴ Cu-NM600; Figure 19 shows the resulting images 3, 24 and 48 hours post-injection for an HCT-116 mouse injected with ⁶⁴ Cu-NM600; Figure 20 shows the resulting images 3, 24 and 48 hours post- injection for an A549 mouse injected with ⁶⁴ Cu-NM600; Figure 21 shows the resulting images 3, 24 and 48 hours post-injection for a PC-3 mouse injected with Cu-NM600; Figure 22 shows the resulting images 3, 24 and 48 hours post-injection for a HT-29 mouse injected with ⁶⁴ Cu-NM600; Figure 23 shows the resulting images 3, 24 and 48 hours post-injection for a MiaPaca mouse injected with ⁶⁴ Cu-NM600; Figure 24 shows the resulting images 3, 24 and 48 hours post-injection for a 4T1 mouse injected with ⁸⁶ Y-NM600; Figure 25 shows the resulting images 3, 24 and 48 hours post-injection for a 4T1 mouse injected with ⁸⁹ Zr-NM600.

[00251] For HT-29 and PC3 mice injected with ⁵² Mn-NM600, PET images were obtained at 4 hours, and one day post-injection (Figure 26 for HT-29; Figure 27 for PC3), as well as on days 2, 3, 5 and 7 post-injection (Figure 28 for HT-29; Figure 29 for PC-3).

[00252] As seen in Figures 15-29, the scanned mice produced PET/CT three- dimensional volume renderings showing cumulative absorbed dose distribution concentrated in the xenografted tumor. The results confirm the differential uptake of metal chelated NM600 into the xenografted solid tumor tissue, and demonstrate the potential use of NM600 analogs incorporating radioactive metal isotopes in the disclosed treatment methods.

[00253] Quantitative region-of-interest analysis of the images was performed by manually contouring the tumor and other organs of interest. Quantitative data was expressed as percent injected doe per gram of tissue (%ID/g). Exemplary data show that 4T1 tumor tissue increased its uptake over time and effectively retained all three tested NM600 chelates ( ⁸⁶ Y-NM600, ⁶⁴ Cu-NM600 and ⁸⁹ Zr-NM600, see Figure 30), while healthy heart (Figure 31), liver (Figure 32) and whole body tissue (Figure 33) all exhibited significantly decreased uptake/retention over time.

[00254] Ex vivo biodistribution analysis was performed after the last longitudinal PET scan. Mice were euthanized and tissues harvested, wet-weighed, and counted in an automatic gamma counter (Wizard 2480, Perkin Elmer). Exemplary

biodistribution data show significant uptake and retention in tumor tissue (4T1) for different NM-600 chelates ( ⁸⁶ Y-NM600, ⁶⁴ Cu-NM600, ⁸⁹ Zr-NM600 and ¹⁷⁷ Lu- NM600, see Figure 34),

[00255] Together, these results demonstrate that the disclosed metal chelates can readily be used for the TRT step of the disclosed treatment methods. Example 12:

Demonstrating anti-tumor activity and tumor autoradiography with two different NM600 metal chelates against multiple solid tumor types in xenografted mice

[00256] In this example, using three different solid tumor models, we show that alkylphosphocholine metal chelate analogs can be effectively used to facilitate conventional TRT. These results further demonstrate the potential for using the metal chelates in the TRT step of the presently disclosed treatment methods.

[00257] B78, MiaPaca and 4T1 subcutaneous flank xenografts were induced in mice, as described previously. Subsequently, the mice were administered therapeutic doses (250-500 μ(¾ of ⁹⁰ Y-NM600, ¹⁷⁷ Lu-NM600, or a control solution via lateral tail vein injection.

[00258] Planar 2D phosphor images of the biodistribution of the agent were taken using a Cyclone Phosphorimager (Perkin Elmer). Mice were anesthetized and place in direct contact with the phosphor plate in a supine position, where they remained for a period of 15-30 min; plates were then read in the phosphorimager. Various images were recorded between 4 and 96 h post-injection of the radioactive dose. The resulting autoradiography images demonstrate rapid and selective uptake and long term retention of the chelates in all of the solid tumor tissues types tested (see Figures 40, 41, 42, 43, 44 and 45).

[00259] Tumor response was assessed by comparing tumor growth of the treated vs. control mice. Tumor volume was determined by measuring tumor's length and width with calipers and calculating the volume using the formula for the volume of the ellipsoid. Mice weight was also recorded. Humane endpoints were defined as: tumor volume >2500 m ³ or significant weight lost below 13 g.

[00260] As seen in Figures 46, 47, 48, 49, 50 and 51, the results demonstrate that the two tested NM600 chelates had a statistically significant in vivo therapeutic effect when compared with the control, resulting in decreased mean tumor volumes for double doses of ¹⁷⁷ Lu-NM600 in 4T1 xenografts (see Fig. 50), and reducing growth to near zero or slowing the growth rate of MiaPaca, 4T1 or B78 xenografts given a single dose of ¹⁷⁷ Lu-NM600 (see Figures 47, 48, and 49) or B78 or 4T1 xenografts given a single dose of ⁹⁰ Y-NM600 (see Figures 46 and 51). [00261] These results further demonstrate the efficacy of using the disclosed alkylphosphocholine metal chelates to deliver TRT to effectively treat solid tumors of various types.

Example 13:

Coupling radiation dosimetry and radiosensitivity index to predict TRT response in a wide range of solid tumor types

[00262] In this example, we discuss factors for determining chelate dosages appropriate for the TRT step of the disclosed methods in a range of solid tumor types.

[00263] Estimation of tumor absorbed doses

[00264] Whether the amount of ¹⁷⁷ Lu/ ⁹⁰ Y-NM600 that is administered is immuno- stimulatory or cytotoxic depends on the tumor absorbed dose. The diapeutic property of NM600, that ⁶⁴ Cu/ ⁸⁶ Y-NM600 can be used as an imaging surrogate for therapeutic metals ¹⁷⁷ Lu/ ⁹⁰ Y-NM600, respectively, was leveraged to estimate tumor dosimetry. Ultimately, ⁶⁴ Cu/ ⁸⁶ Y-NM600 PET/CT was used to quantitatively measure in vivo biodistribution and estimate radiation dosimetry which can help identify dose limiting organs and potential tumor efficacy of ¹⁷⁷ Lu/ ⁹⁰ Y-NM600 TRT.

[00265] The general concept is as follows: (1) the concentration of ⁶⁴ Cu/ ⁸⁶ Y- NM600 within the tumor is quantified over time using longitudinal PET/CT imaging, (2) the concentration of ⁶⁴ Cu/ ⁸⁶ Y-NM600 is decay corrected to account for the difference in decay rates between the ⁶⁴ Cu/ ⁸⁶ Y-NM600 and ¹⁷⁷ Lu/ ⁹⁰ Y-NM600, (3) the concentration of ¹⁷⁷ Lu/ ⁹⁰ Y-NM600 within the tumor is time-integrated to compute the cumulative activity, or total number of decays, (4) the deposition of the radionuclide decays is modeled within the tumor and quantified.

[00266] Steps (1) through (3) can be performed with any medical image processing software package whereas step (4) requires sophisticated radiation dosimetry software. OLINDA/EXM (Stabin, Sparks and Crowe 2005) is a dosimetry estimation software with 510(k) approval that uses the formalism developed by the Medical Internal Radiation Dose (MIRD) committee of the Society for Nuclear Medicine (Bolch et al, 2009). The MIRD approach estimates the mean absorbed dose received by a tissue or organ due to the radiation emitted from within the organ itself or from another source organ. The simplest form of the MIRD equation,

D (t - s) = A _s S(t - s), gives the absorbed dose, D [mGy], to a target region t from the radionuclide activity within a source region s. The radionuclide activity of s is expressed as a cumulated activity A _s which is the total number of radionuclide decays given in units of MBq-s. The S-factor, S(t <- s) [mGy/ MBq-s], is the fraction of the energy released by one radionuclide decay within the source region s which is deposited within the target region t normalized by the mass of the target region t, m _t . The S-factor is a tabulated value calculated using Monte Carlo in a set of standard phantoms and organs.

Typically, we are concerned with the dose per unit of injected activity, D

[mGy/MBq]. The equation is written in terms of the residence time, r _ft ,[MBq- s/MBqinj],

As

th =

inj

which is the ratio of the cumulative activity and the injection activity, A _in j [MBq], as

[00267] In the case of calculating tumor dosimetry, OLINDA/EXM models the tumor as an isolated unit density sphere whose volume was estimated from the tumor region of interest (ROI) created as part of step (1). The concentration of NM600 (%ID/g) within the tumor was determined at each time point and decay corrected. Cumulative activity was then calculated by integrating the concentrations over all time using trapezoidal piecewise integration.

[00268] Radiation dosimetry results for many cell lines are shown in Table 1. This information can be used to estimate the absorbed dose for radiotherapy studies aimed to either eradicate tumors or stimulate the immune system.

Table 1: Dosimetry estimates for both ¹⁷⁷ Lu-NM600 and ⁹⁰ Y-NM600 (Gy/MBq _inj ) using either ⁶ Cu-NM600 or ⁸⁶ Y-NM600 PET imaging as a surrogate

[00269] Radiosensitivity Index to Predict Dose-response

[00270] Intrinsic radiosensitivity is a crucial factor underlying radiotherapy response; and, knowing it a priori for a cancer type could help predict how it may respond to radiation from TRT. However, since there is no method for its routine assessment in tumors, radiosensitivity is measured as the surviving fraction (between 0 and 1) following irradiation with 2 Gy (SF2) by clonogenic assay. The relative radiosensitivity of cancer cell phenotypes ranges from those that have very low radiosensitivities (pancreas, colorectal, glioma and breast) to those with high radiosensitivities (lymphomas). Cancers can be categorized or ranked by their radiosensitivity indices (Table 2).

[00271] If we can demonstrate good tumor uptake and growth inhibition with APC metal chelates in a highly radiosensitive tumor like lymphoma and in a highly radiation resistant tumor like glioma, breast, pancreatic or colorectal, then it can be implied that these agents would be effective against any tumor with an SF2 value between that of lymphoma and glioma (0.3-0.82) if they are able to target the tumor in vivo. It would also be expected then that the radiation dose needed to eradicate glioma tumor cells would be higher than that needed to treat the more radiosensitive lymphoma cells.

[00272] We currently have in vivo imaging to confirm tumor selectivity and therapy response (tumor growth inhibition) data in all the tumor cell lines listed in Table 2. In some cases, it may be necessary to give multiple doses of the APC chelates to elicit sufficient cancer cell kill. By using quantitative imaging coupled with radiation dosimetry calculation, we can estimate the tumor absorbed dose necessary to either kill the cancer cells (higher doses) or stimulate the immune system, as disclosed herein (lower doses).

[00273] Coupling dosimetry estimates for a variety of cancer cell lines (Table 1) with their respective radiosensitivity indices (Table 2) supports the establishment of a dose response landscape for NM600. By knowing the tumor targeting characteristics and efficacy of NM600 within a series of cell lines, it is possible to estimate the absorbed tumor dose and potential efficacy of cell lines with similar radiosensitivity indices. Furthermore, treatment doses can be linearly scaled according to Table 1, depending on the desired outcome of tumor eradication or immuno-stimulation (as disclosed herein).

Table 2: Relative Radiosensitivity of Cancer Cells

³ Taghian, Alphonse, et al. "In vivo radiation sensitivity of glioblastoma multiforme." International Journal of Radiation Oncology* Biology* Physics 32.1 (1995): 99-104.

' ^■ Ramsay, J., R. Ward, and N. M. Bleeben. "Radiosensitivity testing of human malignant gliomas." International Journal of Radiation Oncology* Biology* Physics 24.4 (1992): 67 680.

³ Fertil, B., and E. P. Malaise. "Intrinsic radiosensitivity of human cell lines is correlated w radioresponsiveness of human tumors: analysis of 101 published survival curves." International Journal of Radiation Oncology* Biology* Physics 11.9 (1985): 1699-1707. ⁴ Woliin, Michael, et al. "Radio sensitivity of human prostate cancer and malignant melanoma cell lines." Radiotherapy and Oncology 15.3 (1989): 285-293.

⁵ Kodym, Elisabeth, et al. "The small-molecule CDK inhibitor, SNS-032, enhances cellular radiosensitivity in quiescent and hypoxic non-small cell lung cancer cells." Lung Cancer 66.1 (2009): 37-47.

⁶ lJnkel, Steffen, Claus Belka, and Kirsten Lauber. "On the analysis of clonogenic survival data: Statistical alternatives to the linear-quadratic model." Radiation Oncology 11.1 (2016): 11.

⁷ EP Malaise, Patrick J. Deschavanne, and Bernard Fertil. "intrinsic radiosensitivity of human cells." Advances in radiation biology 15 (2016): 37-70.

⁸ Siles, E., et al. "Relationship between p53 status and radiosensitivity in human tumour cell lines. " British journal of cancer 73,5 (1996): 581-588.

[00274] References cited in Example 13:

[00275] Bolch, W. E., K. F. Eckerman, G. Sgouros, and S. R. Thomas. 2009. "MIRD Pamphlet No. 21 : A Generalized Schema for Radiopharmaceutical

Dosimetry—Standardization of Nomenclature. " Journal of Nuclear Medicine 50 (3): 477-84. doi: 10.2967/jnumed.108.056036.

[00276] Stabin, M G, R B Sparks, and E Crowe. 2005. "OLINDA/EXM: The Second-Generation Personal Computer Software for Intemal Dose Assessment in Nuclear Medicine." JNucl Med 46 (6): 1023-27.

Example 14:

Advantages of and differences when using alkylphosphocholine metal chelates in place of radioiodinated compounds, such as those exemplified in Examples 1-4 and 7-10

[00277] In this example, we discuss the advantages of using APC metal chelates instead of radioiodinated compounds (the compounds exemplified in Examples 1-4 and 7-10). We also discuss factors to be considered by the skilled artisan when optimizing dosages of metal chelates to be used in the TRT step of the disclosed methods.

[00278] Chelates permit the use of a wide variety of stable or radioactive metal ions for imaging and therapy. They can be conjugated with a wide variety of alpha, beta, Auger, gamma and positron emitters whereas iodine is limited to one positron (1-124), one beta (1-131), one gamma (1-123) and 1 Auger (1-125) isotope.

[00279] Metal Isotopes are diapeutically more efficacious than 1-131 and 1-124.

[00280] Lu-177 has fewer high energy gammas which make it more favorable for SPECT imaging and dosimetry. However, its beta energy is slightly less than 1-131, making it more ideal for treating smaller tumors.

[00281] 1-131 and Lu-177 are comparable in therapeutic efficacy "horse power", but there is significantly less contribution to the overall dose from gamma-emissions for Lu-177. In the case of Y-90, there is negligible contribution to the radiation dose from gamma-emissions.

[00282] Relative to 1-131, Y-90 is more efficacious for killing cancer cells by conventional TRT than 1-131, as seen in Figure 52 and discussed further below.

[00283] The Committee on Medical Internal Radiation Dose (MIRD) develops standard methods, models, assumptions, and mathematical schema for assessing internal radiation doses from administered radiopharmaceuticals. The MIRD approach, which simplifies the problem of assessing radiation dose for many different radionuclides, has been implemented in the widely used 510(k) approved software, OLINDA/EXMl. Along with its many standard anthropomorphic phantoms, OLINDA/EXM has a Spheres Model which can be used to approximate tumor doses. The Spheres Model assumes homogeneous distribution of a radiopharmaceutical within unit-density spheres of a range of tumor masses (0.01 - 6,000 g).

[00284] Using this standard model, we compared Y-90 to 1-131 in terms of radiation dose normalized by administered radioactivity. The results of this comparison, for tumor masses between 1 to 100 g, are displayed in Figure 52. Note that the Y-90-to-I- 131 ratio reaches 4 for a 4 g tumor, and remains between 4.0 and 4.2 up to a 100 g tumor, strongly suggesting that on a mCi per mCi basis that Y-90 is between 3.6 and 4.1 times as cytotoxic as 1-131 in tumors up to lOg in size, and about 4.1 times more effective in tumors greater than 10 grams in size.

[00285] Different Pharmacokinetic Properties

[00286] Unlike iodinated analogs, APC chelates are too large to fit into known albumin binding pockets in the plasma and therefore exhibit different in vivo pharmacokinetic and biodistribution profiles (see Figure 53). Lower binding energies lead to larger fractions of free molecule in the plasma which affords more rapid tumor uptake. Some APC chelates are cleared via the renal system, whereas iodinated analogs are eliminated through the hepatobiliary system. APC chelates also accumulate in tumors and clear from the blood much quicker than iodinated analog. Faster blood clearance is directly associated with lower bone marrow and off-target toxicity of therapeutic radiopharmaceuticals.

[00287] These differences in PK and biodistribution profiles lead to differing dose limiting organ toxicity and ultimate utility. Moving from hematological toxicity to renal or liver for dose limiting toxicity would increase the utility of radiometal chelates for TRT.

[00288] Moreover, the pharmacokinetic profile of the APC chelates can easily be manipulated by minor changes in the structure of the chelate (e.g. chelate charge). The choice of chelators is vast. Faster clearance from normal tissues improves imaging contrast and therapeutic windows, resulting in higher maximum tolerable doses.

[00289] APC chelates possess different physico-chemical characteristics than iodinated analogs. They are much more water-soluble, and therefore do not need surfactants to render them suitable for intravenous injection. APC chelates are based on ionic binding of the metal to the chelate, whereas iodinated compounds form covalent bonds with their carrier molecules. In vivo de-iodination is quite common in alkyl iodides whereas chelates tend to be extremely stable in vivo.

[00290] Once de-iodination occurs, free iodide rapidly accumulates in the thyroid with a very long subsequent excretion half-life, whereas free radiometals are in general excreted from the body or detoxified much more quickly.

[00291] In vivo biodistribution of APC chelates can be quite different depending on the metal ion so the metal and chelate also both contribute to the tumor targeting characteristics of the APC. Not all chelates target tumors. Tumor targeting depends on the cumulative properties of the APC carrier, the type of chelate (linear chelates undergo rapid renal elimination whereas macrocyclic chelates undergo hepatobiliary excretion), and the metal ion. Even slight changes in chelate structure result in significant variations on the in vivo properties. Simple changes in isotope can result in changes in tumor targeting larger than 50%.

[00292] Radioactive APC-metal chelates are easily radiolabeled in nearly quantitative (>98%) yields under facile conditions, whereas radioiodination yields of iodinated analogs are much lower (typically about 50% for 1-131 and 60% for 1-124). Moreover, high specific activities can be achieved with chelates. Synthesis can be done using a radiolabeling kit in any nuclear pharmacy without the requirement of sophisticated ventilation equipment or training. Radioiodination must be done in a fume hood fitted with effluent monitoring equipment due to the volatility of radioactive iodine during the labeling reaction.

[00293] Imaging agents don't necessarily make good therapy agents and vice versa.

[00294] It cannot be assumed that because there is good tumor uptake with an imaging agent that it implies that therapy is obvious. In addition to having good tumor uptake, a therapy agent needs to have prolonged tumor retention relative to normal tissues and must be cleared from the blood quickly in order to lower bone marrow exposure and associated toxicity. Iodinated analogs have prolonged blood residence resulting in dose limiting bone marrow toxicity. In contrast, our APC chelates exhibit much faster blood clearance kinetics most likely, as stated above, due to lower albumin binding in the plasma.

[00295] Finally, due to the short path length and physical nature of metallic beta- and alpha-emitters relative to Iodine- 131, there are no exposure concerns for health care workers or family members following injection. Patients undergoing 1-131 therapy often have to be held for some time (up to a week) in a lead shielded room prior to being released from the hospital. Patients injected with radioactive alpha and beta-emitting APC chelates will not be required to remain hospitalized. Example 15:

TRT delivered by Y90-NM600 in combination with administering an anti-CLA4 immune checkpoint inhibitor synergistically inhibits cancer in an //; vivo melanoma model

[00296] In this example, we demonstrate the efficacy of the disclosed combination method, where the in vivo immunization is performed by systemically administering an immune checkpoint inhibitor (an anti-CTLA4 antibody), and the TRT is performed by systemically administering the ⁹⁰ Y-NM600 chelate used in previous examples.

[00297] B78 melanoma subcutaneous flank xenografts were implanted in male C57BL/6 mice, as described previously. Subsequently, the mice were randomized to be to be treated with varying doses (25 μ(¾ 50 μ(¾ or 100 μ(¾ of ⁹⁰ Y-NM600 (Day 1), both with and without anti-CTLA4 antibody (an immune-checkpoint inhibitor) (200 μg on Days 4, 7, and 11) (n=6 for each experimental group). Both agents were administered by via lateral tail vein injection (i.e., intravenously). Control groups of PBS treatment alone and anti-CTLA4 alone were also included. Tumors were measured with calipers twice a week, and animal survival was monitored for 60 days.

[00298] As shown in Figure 54, the three combination therapies (anti-CTLA4 + ⁹⁰ Y-NM600 at three different dosages) showed substantial tumor growth inhibition, as compared to any of the single therapies (anti-CTLA4 or ⁹⁰ Y-NM600 alone at three different dosages) or the PBS control. After Day 18, combination treatment with 50 or 100 μθί of ⁹⁰ Y-NM600 with anti-CTLA4 had significantly (p < 0.05 by ANOVA) reduced tumor growth compared to PBS, ⁹⁰ Y-NM600 alone, or anti-CTLA4 alone. The 25 μθί ⁹⁰ Y-NM600 combination treatment group with anti-CTLA-4 had an intermediate growth delay response that showed a trend towards dose response.

[00299] As seen in Figure 55, mice treated with 50 μθί of ⁹⁰ Y-NM600 combined with anti-CTLA4 exhibited significantly greater aggregate survival than mice treated with TRT alone or PBS vehicle (p < 0.05). The log rank was p = 0.06 for the combination treatmnent, as compared to anti-CTLA4 alone.

[00300] As seen in Figure 56, all three combination treatments significantly improved survival. Significantly, there were 6/12 (50%) complete responders in the combination TRT + CTLA4 arms at therapeutic 50 and 100 μθί doses of ⁹⁰ Y-NM600, as compared to 0/24 complete responders in the non-combination control arms (PBS, TRT alone at 50 μ(¾ TRT alone at 100 μ(¾ and anti-CTLA4 alone). [00301] These results illustrate the therapeutic potential of combining the use of a molecular targeted radiotherapeutic agent with any agent that causes immune checkpoint inhibition (ICI). The results show that a combination of molecularly targeted TRT and an ICI affords a synergistic effect, relative to treatment with each agent alone. In addition to demonstrating significant tumor regression, the combined method also has the potential to generate immunologic memory and ultimately afford a potent in situ cancer vaccine effect that prevents tumor recurrence.

Example 16:

Utilization of Molecular Targeted Radiotherapy to Enhance the Efficacy of Systemic Checkpoint Inhibition in Metastatic Cancer Models

[00302] In this follow-up to Example 15, we provide greatly expanded supporting data demonstrating the efficacy of the disclosed method combining systemically administering an immune checkpoint inhibitor and TRT performed by systemically administering the ⁹⁰ Y-NM600 chelate used in previous examples. Efficacy is demonstrated in mouse melanoma, neuroblastoma and breast cancer models, as well as in multiple tumor melanoma models having disseminated "cold" tumors.

[00303] Clinical studies demonstrate that a subset of patients treated with immune checkpoint inhibitors (ICIs) experience durable and complete response (CR) at all disease sites. However, ICIs are not typically effective in patients with

immunologically "cold" tumors characterized by low levels of T cell infiltrate and/or few mutation-created neo-antigens. In this example, we demonstrate using the disclosed combination method to stimulate an immune response in such tumors and to enhance response in "hot" tumors. More specifically, we enhanced the efficacy of systemic ICI by combining it with systemic molecular targeted radiotherapy (MTRT), which can deliver immunostimulatory low dose radiation to all sites of disease without causing resultant systemic lymphodepletion that would be counterproductive in generating an anti-tumor immunotherapy response.

[00304] Methods:

[00305] For tumor uptake studies of MTRT, flank tumors (n = 3 for each of B78 melanoma and Panc02) were established by injection of l-2xl0 ⁶ cells in 100 PBS into C57BL/6 mice on an approved IACUC protocol. Both B78 and Panc02 tumors are poor to moderately immunogenic, slow growing, radio-resistant tumor lines and this profile makes them useful for studies of MTRT where slow growth permits time for MTRT decay and radio-resistance plus poor immunogenicity enables testing for cooperative improvements in efficacy with combined MTRT + ICI.

[00306] After tumors were well established, approximately 5 weeks after injection, animals were treated with a dose of IV ⁸⁶ Y-NM600 and serial PET/CT images were collected at 1,2, and 3 days after MTRT injection. PET uptake values were compared to areas of background activity including the heart and liver. A paired t-test was performed to test for significant differences in ⁸⁶ Y-NM600 uptake between background organs and tumor sites.

[00307] To demonstrate the ability of ⁹⁰ Y-NM600 and/or ICI to decrease immunosuppressive Treg cell populations within B78 Melanoma flank tumors, we generated flank tumor models (n = 4 for each group) of B78 melanoma. MTRT (50 μ(¾, anti-CTLA4 (200 μg Days 4,7,10), MTRT and CTLA4, and PBS placebo control were our treatment groups. The effect of treatment on tumor immune cell populations was examined at day 1, 7, and 14 after radiation or saline placebo delivery by harvesting tumor tissue and freezing one portion for histology and saving another portion for quantitative PCR. The rest of the tumor sample was prepped for mRNA and RT-PCR analysis. Quantitative RT-PCR was used to evaluate changes in tumor cell expression of immune susceptibility markers (e.g. Fas, MHC-I, and PD- LI).

[00308] For efficacy studies, 2 bilateral flank tumors models of B78 melanoma were generated in C57BL/6 mice. Once tumors grew to 80-120 mm ³ , they were randomized into the following treatment groups: anti-CTLA-4 alone at 200 μg IP on days 4, 7, 10, ⁹⁰ Y-NM600 IV (50 μ(¾ on day 1 and anti-CTLA4, 12 Gy whole body radiation (EBRT) and anti-CTLA4, 12 Gy EBRT + 50 μθί 90Y-NM600, 12 Gy EBRT + 50 μθί 90Y-NM600 and anti-CTLA4. Tumor measurements were made twice a week for 30 days, and survival was tracked to 60 days with a euthanasia endpoint of 15 mm diameter for tumor burden.

[00309] Mice with complete response to therapy were re-challenged with 2x10 ⁶ B78 or lxl 0 ⁶ Panc02 cells to the opposite flank 90 days after MTRT and then again at 120 days with Panc02 (only for B78) and B16 melanoma to test for tumor specific immune memory response.

[00310] Results:

[00311] The selective uptake of our MTRT agent, ⁹⁰ Y-NM600, was confirmed in both B78 and Panc02 tumor models. For B78 melanoma, tumor uptake of 90Y- NM600 demonstrated that after initial injection the majority of the agent was in the blood pool as expected, however by 48 hours after injection the majority of the agent was retained in the tumor or organs of elimination (liver, kidney). Gamma counts of tissue sections taken at Day 48 confirms PET imaging uptake values with higher radioactivity counts in tumor tissue that increase over time with lower values in marrow spaces that decrease over time. Monte Carlo dosimetry performed as a collaborative effort shows that approximately 2-3 Gy are delivered over the life of the MTRT agent when our experimental dose of 50 μθί is delivered. PET uptake and tissue biodistribution studies in Panc02 pancreatic cancer also demonstrated increased uptake and retention of ⁹⁰ Y-NM600 in tumor tissue compared to marrow tissue at 72 hours.

[00312] To study the effect of treatment on tumor immune cell populations, tumor tissue samples were collected at various time points after radiation. At Day 14 after MTRT treatment (50 μθί ⁹⁰ Y-NM600), we found that combination MTRT and anti- CTLA4 significantly increases effector/suppressive immune t-cell ratios as determined by the CD4/FoxP3 and CD8/FoxP3 infiltrates in tumor tissue.

Quantitative PCR (qPCR) studies of gene expression also showed increased inflammatory gene expression including genes that are part of the stimulator of interferon gene pathway (STING). Levels of Mxl, IFNa, ΙΡΝβ, and PDL1, which are all downstream of STING activation, were upregulated compared to PBS control.

[00313] We next established a single B78 R flank tumor in mice and once they reached approximately 80 mm ³ , randomized them into 25, 50, and 100 uCi MTRT dose treatment groups given on Day 1 with and without anti CTLA4 given on days 4,7, and 10, as well as PBS and anti CTLA4 alone as controls. We found that combination MTRT at 50 and 100 uCi dose levels and anti-CTLA4 demonstrated significantly improved tumor growth delay (Figure 57) and survival (Figure 58) compared to other groups. At 25 uCi of MTRT there was an intermediate response. Additionally, the only mice that had a complete response to therapy were in the combination therapy groups with 66%, 33, and 16% of the animals in the 50 uCi, 100, and 25 uCi MTRT dose groups. All mice that had a complete response at Day 60 after MTRT injection were challenged with B78 cells on the contralateral flank and there was a 100% rejection rate compared to naive controls, demonstrating that our treatment was able to generate an immune memory response. [00314] This study has since been replicated showing similar trends and survival across both studies showed a significantly improved overall survival in mice treated with combination MTRT (50, 100 uCi) and anti-CTLA4 compared to other groups by log rank test.

[00315] We next extended this study to similar mouse models of neuroblastoma (NXS2) and breast cancer (4T1). As seen in Figure 59 (NXS2) and in Figure 60 (4T1), the CTLA4 MTRT combination again was the only group demonstrating significantly reduced tumor growth (in fact, tumor volume reduction).

[00316] Next, we extended the study to demonstrate improved response rates in mice with multiple bulky tumors. We designed a study MTRT treatment in a two- tumor mouse model, the goal being to treat mice with multiple bulky tumors, which would correspond to a patient with bulky metastatic disease at multiple sites. For this experiment, we examined if MTRT can improve response rates over the current clinical paradigm of delivering EBRT to one site in combination with immune checkpoint blockade.

[00317] Two-tumor models of Panc02 and B78 melanoma were established. First in B78 melanoma, traditional immunosensitizing EBRT (12 Gy) to a primary site of disease (secondary site shielded) was combined with anti-CTLA4 and compared to radiation alone, MTRT and anti-CTLA4, or combination treatment with EBRT to a primary site with MTRT to all sites and anti-CTLA4. Tumor growth curves show that triple combination treatment results in improved tumor regression of both primary (Figure 61) and secondary (Figure 62) tumors compared to other groups. Additionally, survival was significantly improved with triple combination treatment (p < 0.01) compared to dual combination treatment groups. Triple combination treatment resulted in a 40% complete response rate (16% CR in MTRT + anti-CTLA4, 0% other groups) with all responding animals having tumor specific immune memory to B78 or related B16 melanoma.

[00318] Finally, we simulated advanced multi-site "cold" cancers (i.e., multi-site tumors that do not provoke a strong immune system response, and thus are largely resistant to checkpoint inhibition) using a mouse model having two distant macrospcopic tumors and disseminated microscopic metastases.

[00319] To form the large primary tumor, mice were injected in one flank with 2 x 10 ⁶ B78 melanoma tumor cells. To form the small secondary tumor, twelve days later, mice were injected in the opposite flank with 5 x 10 ⁵ B78 melanoma tumor cells. Seventeen days after this (Day 1), to create the disseminated metastases, mice were injected intravenously with 2 x 10 ⁵ B16 melanoma cells.

[00320] Mice were the exposed to various single or combination treatments: PBS control injection; MTRT, 50 μθί IV on Day 1 ; ICI, Anti-CTL A4/PD 1 on Days 4, 7 and 10; In Situ Vaccine (IS), 12 Gy local RT on Day 1 + intratumoral injection of anti-GD2 mAb and IL2 on Days 6-10. Tested single and combination treatments were PBS, MTRT, ICI, IS, MTRT + ICI, MTRT + IS, ICI + IS, and MTRT + IS + ICI. Beginning on Day 60, mice were monitored for tumor growth and animal survival, and tumor-free mice were rechallenged with B78 on Day 90.

[00321] On Day 90, less than 20% of the ICI mice survived, while about half of the MTRT + IS and the ICI + IS mice survived (the MTRT + IS had a somewhat higher survival rate). Surprisingly, the MTRT + IS mice were 100 % alive (the survival rate was zero for all the other groups). Notably, 83% of these mice were found to be tumor-free, exhibiting complete remission (CR) with immune cell memory (i.e., were cured), while the remainder retained an uncontrolled secondary tumor.

[00322] We also confirmed uptake and dose delivery in a variety of other cancers, including neuroblastoma (NXS2, 9464D), rhabdomyosarcoma (M3-9-M), high grade glioma, lewis lung carcinoma, and head and neck cancer (MOC-2). In addition to tumor uptake and dosimetry, toxicity analysis was conducted, and no radiation-induced marrow toxicity (as measured by seum white cells or lymphocytes) was observed at our therapeutic radiation dose of 50 μθί (2-3 Gy tumor dose). We have also irradiated mice with both external beam and varying doses of 90Y-NM600 and collected histology stained with IHC as well as tissue for mRNA analysis by PCR. Data from these studies show upregulation of the interferon signaling pathway with 50 μθ of 90Y-NM600 as well as increased PDL1 expression. In addition, we have found that tumor infiltrating regulatory T-cells are reduced wuth molecularly targeted radiotherapy.

[00323] In sum, our findings from this study suggest that low dose NM600 MTRT can enhance abscopal response in tumors when combined with checkpoint blockade. Notably, the NM600 MTRT radiotherapeutic delivery agent demonstrates the ability to improve response in "cold" tumors that normally do not respond to immune checkpoint blockade alone. In addition, a relatively low MTRT dose, 50 μCi (2.5 Gy tumor dose) is sufficient to achieve immunostimulatory effects to enhance ICI efficacy without systemic lymphodepletion. MTRT can be added to single site EBRT and checkpoint blockade to achieve greater tumor response and cure rates at both local and distant tumor sites. Our results show that MTRT has great potential to improve therapeutic efficacy of immunotherapy treatments in patients.

Conclusion to the Examples

[00324] These examples illustrate an anti-cancer strategy based on the synergistic and widely applicable combination of targeted systemic delivery of radiotherapy with systemic delivery of an immunostimulatory agent, such as an immune checkpoint inhibitor. As the disclosed metal chelated and radiohalogenated alkylphosphocholine analogs can target cancers of virtually any histology, the systemic administration of immune checkpoint-targeting mAbs or small molecules (immune checkpoint inhibitors) finds use for virtually any cancer type (tumor reactive mAbs are approved or in clinical testing for nearly all cancer histological types). Accordingly, the clinical translation of the two different combined strategies have wide application for virtually all high risk cancers.

[00325] Other embodiments and uses of the invention will be apparent to those skilled in the art from consideration from the specification and practice of the invention disclosed herein. All references cited herein for any reason, including all journal citations and U.S. /foreign patents and patent applications, are specifically and entirely incorporated herein by reference. It is understood that the invention is not confined to the specific reagents, formulations, reaction conditions, etc., herein illustrated and described, but embraces such modified forms thereof as come within the scope of the following claims.