TREATMENT OF CANCER

RELATED APPLICATIONS

This application claims priority to, and the benefit of, U.S. application Serial No. 62/728,492, filed September 7, 2018, the content of which is hereby incorporated by reference in its entirety.

SEQUENCE LISTING

The instant application contains a Sequence Listing which has been submitted electronically in ASCII format and is hereby incorporated by reference in its entirety. Said ASCII copy, created on August 27, 2019, is named PAT058207-WO-PCT_SL.txt and is 63,862 bytes in size.

FIELD OF THE INVENTION

The present invention relates to use of a STING agonist or a combination of therapeutic compounds useful for the treatment of cancer. In particular, the invention relates to combination therapies comprising at least (a) the STING agonist COMPOUND A (dithio- Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]) or a pharmaceutically acceptable salt thereof and (b) one or more PD- 1 or CTLA-4 checkpoint inhibitors, suitably selected from spartalizumab, nivolumab and ipilimumab.

BACKGROUND

Development of effective antitumor immunity requires activation and expansion of a stable and self-renewing population of tumor antigen-specific effector T cells. One approach to promote priming of specific CD8 ⁺ T cell responses is to inject immune modulators directly into the tumor, with the intent of reestablishing immune surveillance conditions in the tumor microenvironment (TME) that favor the development of effective systemic tumor-specific immunity and tumor destruction of both injected and distal untreated lesions.

Spontaneous shrinkage of melanoma lesions in humans is correlated with a type I IFN transcription profile in the TME and infiltration of lymphocytes, indicative of innate immune recognition of the tumor. Substantial evidence indicates that tumor infiltrating lymphocytes (TILs) are correlated with favorable prognosis in diverse malignancies. The presence of activated T cells in the TME, known as a T cell-inflamed tumor immunophenotype (tumors presenting with significant TILs), is also predictive of a positive clinical outcome in response to several immunotherapy strategies (Galon et al (2012) J Transl Med 10:205; Postow el al (2012) Am Soc Clin Oncol Educ Book 76-83, doi: l0. l4694/edbook_am.20l5.35.76.; Wolchok et al (2013) N Engl J Med 369(2): 122-133). The interaction between antitumor T cells and APCs play a critical role in the development of antitumor T cell immunity and is modulated through competing stimulatory and inhibitory molecules (Wolchok and Saenger (2008) The Oncologist 13 (4): 2-9). CD28 and CTLA-4, two surface proteins on T cells, play important roles in the regulation of immune activation and tolerance. CD28 facilitates and maintains a T cell response, partly through increased cytokine expression (Chambers and Allison (1999) Opin Cell Biol 11(2):203-210) mediated by interaction with its primary ligands B7-1 and B7- 2 on the surface of the APCs. CTLA-4 signaling inhibits T cell activation, particularly during strong T cell responses. CTLA-4 blockade, using anti-CTLA-4 antibody therapy, has been shown to suppress inhibitory signals resulting in the generation of an antitumor T cell response. The inhibition of CTLA-4 shifts the immune system balance toward T cell activation, resulting in rejection of tumors by the host. As such, CTLA-4 is essential to the downregulation of autoreactive and potentially destructive peripheral T cell responses. Treating patients with a CTLA-4 inhibitor can broaden the diversity of the peripheral T cell receptor repertoire following CTLA-4 blockade which has been associated with antitumor activity (Buchbinder and Desai (2016 ) Am J Clin Oncol 39:98-106; Robert etal (2014) Clin Cancer Res 20(9):2424- 2432).

The Programmed Death 1 (PD-l) protein is an inhibitory member of the CD28/CTLA- 4 family of T cell regulators (Okazaki etal. (2002) Curr Opin Immunol 14: 391779-82; Bennett et al. (2003) J. Immunol. 170:711-8). PD-l is expressed on activated B cells, T cells, and monocytes.

Two ligands for PD-l have been identified, PD-L1 (B7-H1) and PD-L2 (B7-DC), that have been shown to downregulate T cell activation upon binding to PD-l (Freeman et al. (2000) J. Exp. Med. 192: 1027-34; Carter et al. (2002) Eur. J. Immunol. 32:634-43). PD-L1 is abundant in a variety of human cancers (Dong et al. (2002) Nat. Med. 8:787-9) and it has been proposed that PD-L1 expressing tumor cells interact with PD-l expressing T-cells, which can lead to, e.g., a decrease in tumor infiltrating lymphocytes, a decrease in T-cell receptor mediated proliferation, and/or immune evasion by cancerous cells (Dong et al. (2003) J. Mol. Med. 81 :281-7; Blank et al. (2005) Cancer Immunol. Immunother. 54:307-314; Konishi et al. (2004) Clin. Cancer Res. 10:5094-100). Immune suppression can be reversed by inhibiting the local interaction of PD-l with PD-L1 or PD-L2.

Immunotherapies employing checkpoint inhibitors currently in development have started to offer significant benefit to cancer patients, including those for whom conventional treatments are ineffective. However, although T cells attack and destroy tumor cells, tumors are able to inhibit T cell activation thereby escaping immune surveillance. In the setting of anti- PD- 1 therapy, treatment failure is associated with upregulation of alternate immune checkpoint inhibitors that act to limit the antitumor immune response (Koyama et al (2016) Nat Commun 7(1): 10501), suggesting that many patients treated with single agent inhibitors do not benefit adequately from treatment.

There is thus the need for developing novel combination therapies which are effective, safe and/or well tolerated. A therapy which results in durable and sustained responses in a clinical setting is also needed.

SUMMARY

In one aspect, the present invention relates to a method for the treatment of cancer. The method comprises administering to a patient in need thereof (a) a dose (e.g., a daily dose, a weekly dose, etc.) of about 50 pg to about 10,000 pg (e.g., 400 pg to about 10,000 pg) of COMPOUND A (dithio-Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, and (b) one or more PD-l or CTLA-4 checkpoint inhibitors, suitably or preferably selected from nivolumab, spartalizumab and ipilimumab, wherein COMPOUND A, or the pharmaceutically acceptable salt thereof, is administered intratumorally or intravesically. The method comprises the separate or sequential administration of (a) a dose (e.g., a daily dose, a weekly dose, etc.) of about 400 pg to about 10,000 pg of Compound A (dithio-Rp,Rp-cyclic- [A(2’,5’)pA(3’5’)p]) or a pharmaceutically acceptable salt thereof, and (b) one or more PD-l or CTLA-4 checkpoint inhibitors, suitably or preferably selected from nivolumab, spartalizumab and ipilimumab, for the treatment of cancer, e.g., a solid cancer or lymphoma, including, but not limited to, melanoma, e.g., metastatic melanoma, breast cancer, e.g., triple negative breast cancer (TNBC), squamous cell carcinoma (SCC), lymphoma, e.g., Hodgkin lymphoma, Merkel cell carcinoma, uveal melanoma, renal cell cancer (RCC), colorectal cancer (CRC), e.g., microsatellite stable (MSS) colorectal cancer (CRC), ovarian cancer, pancreas cancer, or head and neck cancer e.g., head and neck squamous cell carcinoma (HNSCC).

COMPOUND A is the compound with the following structure:

Also provided herein is a method for the treatment of cancer, wherein the cancer is PD- 1 inhibitor refractory or relapsed metastatic melanoma, and wherein a) Compound A (dithio- Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]) or a pharmaceutically acceptable salt thereof is administered intratumorally at a dose (e.g., a daily dose, a weekly dose, etc.) of about 400 pg to about 10,000 pg on day 1 and optionally on about day 8 of a 21 -day treatment cycle and b) ipilimumab is administered intravenously at a dose of about 3 mg/kg on day 1 of a 21 -day treatment cycle. “About” in this context refers to +/- one day. Day 8 is preferred.

Also provided herein is a method for the treatment of cancer, wherein the cancer is solid tumor or lymphoma, and wherein a) Compound A (dithio-Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]) or a pharmaceutically acceptable salt thereof is administered intratumorally or intravesically at a dose (e.g., a daily dose, a weekly dose, etc.) of about 50 pg to about 10,000 pg on day 1 and optionally on about day 8 and/or about day 15 of a 28 -day treatment cycle and b) spartalizumab is administered intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle.

Also provided herein is a method for the treatment of cancer, wherein the cancer is solid tumor or lymphoma, and wherein a) Compound A (dithio-Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]) or a pharmaceutically acceptable salt thereof is administered intratumorally or intravesically at a dose of about 50 pg to about 10,000 pg on day 1 and optionally on about day 8 and day about 15 of a 28-day treatment cycle and b) nivolumab is administered intravenously at a dose of about 480 mg on day 1 of a 28-day treatment cycle.

Also provided is a pharmaceutical combination for use in the treatment of cancer comprising (a) COMPOUND A (dithio-Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof and (b) one or more checkpoint inhibitors selected from nivolumab, spartalizumab and ipilimumab, and wherein COMPOUND A or the pharmaceutically acceptable salt thereof is administered to a patient in need thereof at a dose (e.g., a daily dose, a weekly dose, etc.) of about 400 pg to about 10,000 pg, and wherein COMPOUND A or the pharmaceutically acceptable salt thereof is administered intratumorally or intravesically.

Also provided is a method for the treatment of cancer comprising administering to a patient in need thereof a dose (e.g., a daily dose, a weekly dose, etc.) of about 300 pg to about 10,000 pg (e.g., about 400-10,000 pg) of COMPOUND A (dithio-Rp,Rp-cyclic- [A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, intratumorally or intravesically. In embodiments, the cancer is, e.g., a solid cancer or lymphoma, including, but not limited to, melanoma, e.g., metastatic melanoma, breast cancer, e.g., triple negative breast cancer (TNBC), squamous cell carcinoma (SCC), lymphoma, e.g., Hodgkin lymphoma, Merkel cell carcinoma, uveal melanoma, renal cell cancer (RCC), colorectal cancer (CRC), e.g., microsatellite stable (MSS) colorectal cancer (CRC), ovarian cancer, pancreas cancer, bladder cancer, or head and neck cancer e.g., head and neck squamous cell carcinoma (HNSCC).

Other features, objects, and advantages of the invention will be apparent from the description and drawings, and from the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1 illustrates the study design on anti-tumor activity of Compound A in combination with an anti-CTUA-4 antibody in B16 Melanoma mouse model.

Figure 2 is a plot of tumor volume over time. C57BU/6 mice were implanted with 5 10 ⁴ B 16.F10 melanoma cells on the right flank at Day 0. Flank tumors were treated intratumorally (“IT”) on day 17, 20 and 24 with COMPOUND A (50 pg), or HBSS vehicle control (n = 8). Mice were treated IP on days 20, and 24 with anti-CTUA4 (clone 9D9, 100 pg) or IgG isotype control (100 pg). Results are shown as mean tumor volume ± SEM. Two-way ANOVA of mean at day 41, * P < 0.05.

Figures 3A and 3B illustrate the systemic IFN-b concentrations as PD biomarker. Figure 3A is a plot demonstrating change of IFN-b concentrations at 6 hours post-treatment versus pre-dose. Figure 3B is PK/PD analysis of IFN-b concentration change from pre-dose by AUCiast (which is the area under the concentration-time curve from time zero to time of last measurable concentration). GENERAL DEFINITIONS

In order that the present invention may be more readily understood, certain terms are first defined. Additional definitions are set forth throughout the detailed description. As used herein, the following definitions shall apply unless otherwise indicated. The abbreviations used herein have their conventional meaning within the chemical and biological arts. The chemical structures set forth herein are constructed according to the standard rules of chemical valency known in the chemical arts.

The term“comprising”,“including”,“having”, or“containing” means“including but not limited to” as well as“consisting of’, e.g. a composition“comprising” X may consist exclusively of X or may include something additional e.g. X + Y. Additionally, whenever “comprising” or another open-ended term is used in an embodiment, it is to be understood that the same embodiment can be more narrowly claimed using the intermediate term“consisting essentially of’ or the closed term“consisting of’.

As used herein, the articles "a" and "an" refer to one or to more than one (e.g., to at least one) of the grammatical object of the article.

The term "or" is used herein to mean, and is used interchangeably with, the term "and/or", unless context clearly indicates otherwise.

"About" and "approximately" shall generally mean an acceptable degree of error for the quantity measured given the nature or precision of the measurements, or when used in connection with a numerical value, means that a collection or range of values is included. Exemplary degrees of error are within 20 percent (%), more typically, within 10%, of a given value or range of values. This usage of“about” recognizes that the precise amount in a given dosage form may differ slightly from an intended amount for various reasons without materially affecting the in vivo effect of the administered therapeutic agent. For example, when referring to the dose of COMPOUND A or a checkpoint inhibitor in a combination therapy as described herein,“about X” includes a range of values that are ±20%, ±10%, ±5%, ±2%, ±1%, ±0.5%, ±0.2%, or ±0.1% of X, where X is a numerical value of the intended dose. In one embodiment, the term“about” refers to a range of values which are 10% more or less than the specified value. In another embodiment, the term“about” refers to a range of values which are 5% more or less than the specified value. In another embodiment, the term“about” refers to a range of values which are 1% more or less than the specified value.

Recitation of ranges of values are merely intended to serve as a shorthand method of referring individually to each separate value falling within the range, unless otherwise indicated herein, and each separate value is incorporated into the specification as if it were individually recited herein. A range used herein, unless otherwise specified, includes the two limits of the range. For example, the terms“between X and Y” and“range from X to Y, are inclusive of X and Y and the integers there between. On the other hand, when a series of individual values are referred to in the disclosure, any range including any of the two individual values as the two end points is also conceived in this disclosure. For example, the expression“a dose of about 800 pg, 1,200 pg, 1,600 pg, 2,000 pg, 2,400 pg, 2,800 pg, or 3,200 pg” can also mean “a dose ranging from 800 to 1,200 pg”,“a dose ranging from 1,200 to 2,400 pg”, or“a dose ranging from 800 to 3,200 pg”.

As used herein, the terms“treat”,“treatment” and“treating” refer to the reduction or amelioration of the progression, severity and/or duration of a disorder, e.g., a proliferative disorder, such as a cancer, or the amelioration of one or more symptoms (preferably, one or more discernible symptoms) of the disorder resulting from the administration of one or more therapeutic agents. In other embodiments the terms“treat”,“treatment” and“treating” refer to the reduction or stabilization of the progression of a proliferative disorder, such as a cancer, either physically by, e.g., reduction or stabilization of a discernible symptom, physiologically by, e.g., reduction or stabilization of a physical parameter, or both. In certain embodiments, the terms“treat,”“treatment” and“treating” refer to the amelioration of at least one measurable physical parameter of a proliferative disorder, such as a cancer, such as reduction or stabilization of tumor size or reduction or stabilization of cancerous cell count or reduction or stabilization of rate of cancer cell infiltration into peripheral organs or reduction or stabilization of tumor metastasis or reduction or stabilization of tumor growth, not necessarily discernible by the patient. Such“treatment” therefore may result in the slowing, interrupting, arresting, controlling, delaying the onset (i.e., the period prior to clinical manifestation of a disease), reducing the risk of developing or worsening or stopping of the progression of a proliferative disorder, such as a cancer, as described herein, but does not necessarily indicate a total elimination of the proliferative disorder, such as a cancer, or the total elimination of symptoms of the proliferative disorder, such as a cancer.

As used herein, the term“administering” is intended to refer to a method of giving a dosage of a pharmaceutically active ingredient, e.g., COMPOUND A or a checkpoint inhibitor as described herein, to a subject in need thereof.

As used herein the term“therapeutic agent” is understood to mean a substance that produces a desired effect in a tissue, system, animal, mammal, human, or other subject. It is also to be understood that a“therapeutic agent” may be a single compound or a combination or composition of two or more compounds.

The term“pharmaceutically acceptable” as used herein refers to those compounds, materials, compositions and/or dosage forms, which are, within the scope of sound medical judgment, suitable for contact with the tissues of a subject, e.g. a mammal or human, without excessive toxicity, irritation, allergic response and other problems or complications commensurate with a reasonable benefit/risk ratio.

By“a combination” or“in combination with” it is not intended to imply that the therapy or the therapeutic agents (e.g., COMPOUND A or a pharmaceutically acceptable salt thereof, or a checkpoint inhibitor, such as ipilimumab, spartalizumab, nivolumab, etc.) must be physically mixed or administered at the same time and/or formulated for delivery together, although these methods of delivery are within the scope described herein. A therapeutic agent in these combinations can be administered concurrently with, prior to, or subsequent to, one or more other additional therapies or therapeutic agents. The therapeutic agents can be administered in any order. In general, each agent will be administered at a dose and/or on a time schedule determined for that agent. It will further be appreciated that the therapeutic agents utilized in this combination may be administered together in a single composition or administered separately in different compositions. In general, it is expected that additional therapeutic agents utilized in combination be utilized at levels that do not exceed the levels at which they are utilized individually. In some embodiments, the levels utilized in combination will be lower than those utilized as single-agent therapeutics.

The combinations of the invention have therapeutic or protective functions or both. For example, these molecules may be administered to a human subject, to treat and/or prevent a variety of disorders, such as cancers as described herein.

The terms“combination therapy” and“therapeutic combination” refer to treatments in which the therapeutic agents, e.g., COMPOUND A, or a pharmaceutically acceptable salt thereof, and at least one checkpoint inhibitor, suitably selected from PD-l inhibitor or CTUA- 4 inhibitor, and optionally additional therapeutic agents, are administered to a patient in a coordinated manner, in order to treat a therapeutic condition or disorder described herein. Such administration encompasses co-administration of these therapeutic agents in separate formulations (e.g., capsules and/or intravenous formulations) for each active ingredient. In addition, such administration also encompasses use of each type of therapeutic agent in a sequential or separate manner, either at approximately the same time or at different times. The therapeutic agents are administered to the same patient as part of the same course of therapy. As such, the therapeutic agents of the combination therapy can be given jointly, separately or sequentially in such time intervals that they prefer such that the subject, especially human, to be treated, still show an (preferably synergistic) interaction (joint therapeutic effect). Whether this is the case can, inter alia, be determined by following the blood levels of the compounds, showing that both compounds are present in the blood of the human to be treated at least during certain time intervals. The treatment regimen will provide beneficial effects in treating the conditions or disorders, suitably cancer, as described herein.

The term“synergistic effect” as used herein, refers to action of two or more agents such as, for example, COMPOUND A, or a pharmaceutically acceptable salt thereof, and one or more checkpoint inhibitors, preferably selected from a PD- 1 inhibitor or a CTLA-4 inhibitor, suitably or preferably selected from ipilimumab, spartalizumab, and nivolumab, to produce an effect, for example, slowing the symptomatic progression of cancer or symptoms thereof, which is greater than the simple addition of the effects of each drug administered by themselves.

The term“non-fixed combination” or“kit of parts” means that the therapeutic agents of the combination of the invention are both administered to a patient as separate entities either simultaneously, concurrently or sequentially with no specific time limits, wherein such administration provides therapeutically effective levels of the two compounds in the body of a subject in need thereof. The latter also applies to cocktail therapy, e.g., the administration of three or more active ingredients.

The term“separate use”, as used herein, is meant in particular an administration of at least two active ingredients at the same time or at substantially the same time by different routes and/or different formulations.

By “sequential use” is meant administration of at least two active ingredients at different times, the administration route being identical or different. More particularly by a sequential administration method is meant according to which the whole administration of one of the active ingredients is carried out before administration of the other or others commences.

As used herein, the terms "treatment regimen", "dosing protocol", and "dosing regimen" are used interchangeably to refer to the dose and timing of administration of each therapeutic agent in a combination therapy as disclosed herein. The dosing regimen defines the amount of a drug and the number and frequency of its administrations over a specified period of time that is employed in the treatment of a disease. The term“dose” refers to a specified amount of a drug administered. The term“daily dose” or“dose per day” refers to a specified amount of a drug administered in one day. This term does not imply that the drug administration has to occur every day on consecutive days or only one administration per day. The“daily dose” may be the amount administered into one lesion per day or the total amount per day if administered into multiple lesions (e.g., 2, 3, 4, 5, or 6 lesions). Similarly, the term“weekly dose” or“dose per week” refers to a specified amount of a drug administered in one week and this term does not imply that the drug administration has to occur only once per week or to occur on consecutive days of the week or on consecutive weeks.

The term“pharmaceutical composition” is defined herein to refer to a mixture or solution containing at least one therapeutic agent to be administered to a subject, e.g., a mammal or human, in order or treat a particular disease or condition affecting the subject. The present pharmaceutical combinations can be formulated in suitable pharmaceutical compositions for enteral or parenteral administration, such as sugar-coated tablets, tablets, capsules or suppositories, or ampoules. If not indicated otherwise, these are prepared in a manner known per se, for example by means of various conventional mixing, comminution, direct compression, granulating, sugar-coating, dissolving, lyophilizing processes, or fabrication techniques readily apparent to those skilled in the art. It will be appreciated that the unit content of a combination partner contained in an individual dose of each dosage form need not in itself constitute an effective amount since the necessary effective amount may be reached by administration of a plurality of dosage units. The pharmaceutical composition may contain, from about 0.1 % to about 99.9%, preferably from about 1 % to about 60 %, of the therapeutic agent(s). One of ordinary skill in the art may select one or more of the aforementioned carriers with respect to the particular desired properties of the dosage form by routine experimentation and without any undue burden. The amount of each carriers used may vary within ranges conventional in the art. The pharmaceutical compositions provided herein may be in the form of a sterile injectable preparation, such as a sterile injectable aqueous or oleaginous suspension. This suspension may be formulated according to the known art using those suitable dispersing or wetting agents and suspending agents which have been mentioned above. The sterile injectable preparation may also be a sterile injectable solution or suspension in a non-toxic parenterally acceptable diluent or solvent such as a solution in l,3-butane-diol or prepared as a lyophilized powder. Among the acceptable vehicles and solvents that may be employed are water, Ringer's solution and isotonic sodium chloride solution. In addition, sterile fixed oils may conventionally be employed as a solvent or suspending medium. For this purpose, any bland fixed oil may be employed including synthetic mono- or diglycerides. In addition, fatty acids such as oleic acid may likewise be used in the preparation of injectables.

As noted, the compositions described herein are preferably formulated as pharmaceutical compositions for parenteral or enteral delivery. A typical pharmaceutical composition for administration to an animal subject comprises a pharmaceutically acceptable vehicle such as aqueous solutions, non-toxic excipients, including salts, preservatives, buffers and the like. See, e.g., Remington's Pharmaceutical Sciences, !5th Ed.. Easton ed., Mack Publishing Co., pp 1405-1412 and 1461- 1487 (1975); The National Formulary XIV. !4th Ed.. American Pharmaceutical Association, Washington, DC (1975). Examples of non-aqueous solvents are propylene glycol, polyethylene glycol, vegetable oil and injectable organic esters such as ethyloleate. Aqueous carriers include water, alcoholic/aqueous solutions, saline solutions, parenteral vehicles such as sodium chloride, Ringer's dextrose, etc. Intravenous vehicles include fluid and nutrient replenishers. Preservatives include antimicrobial agents, anti-oxidants, chelating agents and inert gases. The pH and exact concentration of the various components the pharmaceutical composition are adjusted according to routine skills in the art.

Pharmaceutical compositions may be presented in unit dose forms containing a predetermined amount of active ingredient per unit dose. In certain embodiments, the unit dose includes one or more vehicles such that each vehicle includes an effective amount of at least one of the therapeutic agents along with pharmaceutically acceptable carriers and excipients. In some embodiments, the unit dose is one or more tablets, capsules, pills, injections, infusions, patches, or the like, administered to the patient at the same time. As is known to those skilled in the art, the amount of active ingredient per dose will depend on the condition being treated, the route of administration and the age, weight and condition of the patient. Preferred unit dosage compositions are those containing a daily dose or sub-dose, or an appropriate fraction thereof, of an active ingredient. Furthermore, such pharmaceutical compositions may be prepared by any of the methods well known in the pharmacy art. As used herein, the term "unit dose" or "unit dosage" refers to a physically discrete unit that contains a predetermined quantity of active ingredient, e.g., COMPOUND A or a pharmaceutically acceptable salt thereof, calculated to produce a desired therapeutic effect. The unit dose or unit dosage may be in the form of an injectable solution, tablet, capsule, sachet, etc. referred to herein as a "unit dosage form". The pharmaceutical compositions described herein may include a“therapeutically effective amount” or “effective amount” of a compound disclosed herein. The term “pharmaceutically effective amount”, “therapeutically effective amount” or “clinically effective amount” of a combination of therapeutic agents is an amount sufficient, at dosages and for periods of time necessary, to provide an observable or clinically significant improvement over the baseline of clinically observable signs and symptoms of the disorders treated with the combination. A therapeutically effective amount may vary according to factors such as the disease state, age, sex, and weight of the individual. A therapeutically effective amount is also one in which any toxic or detrimental effects of the therapeutic agents are outweighed by therapeutically beneficial effects. A "therapeutically effective amount" preferably modulates a measurable parameter, such as tumor growth rate or disease progression in a desired manner. The ability of a compound to modulate a measurable parameter may be evaluated in an animal model system predictive of efficacy in human tumors to help establish suitable dosing levels and schedules. Alternatively, this property of a composition may be evaluated by examining the ability of the compound to modulate an undesired parameter by using in vitro assays known to the skilled practitioner.

As used herein, the term“cancer” refers to a disease characterized by the undesired and uncontrolled growth of aberrant cells and is meant to include all types of cancerous growths or oncogenic processes, metastatic tissues or malignantly transformed cells, tissues, or organs, irrespective of histopathological type or stage of invasiveness. Cancer cells can spread locally or through the bloodstream and lymphatic system to other parts of the body. As used herein, the term“cancer” or“tumor” includes premalignant, as well as malignant cancers and tumors. The term“cancer” is used herein to mean a broad spectrum of tumors, including all solid tumors and lymphomas.

The term“subject” or“patient” as used herein is intended to include animals, which are capable of suffering from or afflicted with a cancer or any disorder involving, directly or indirectly, a cancer. Examples of subjects include mammals, e.g., humans, apes, monkeys, dogs, cows, horses, pigs, sheep, goats, cats, mice, rabbits, rats, and transgenic non-human animals. In an embodiment, the subject is a human, e.g., a human suffering from, at risk of suffering from, or potentially capable of suffering from a proliferative disease, such as cancer and who would benefit from treatment. In some embodiments, the subject is a human patient in need of enhancement of an immune response. The methods and compositions described herein are suitable for treating human patients having a disorder that can be treated by modulating (e.g., augmenting or inhibiting) an immune response.

As used herein, the term "immune response" relates to any one or more of the following: specific immune response, non-specific immune response, both specific and non-specific response, innate response, primary immune response, adaptive immunity, secondary immune response, memory immune response, immune cell activation, immune cell-proliferation, immune cell differentiation, and cytokine expression.

As used herein, a subject is“in need of’ a treatment if such subject (patient) would benefit biologically, medically or in quality of life from such treatment.

As used herein, "RECIST 1.1 Response Criteria" means the definitions set forth in Eisenhauer, E.A. et al., Eur. J. Cancer 45:228-247 (2009) for target lesions or non-target lesions, as appropriate based on the context in which response is being measured.

As used herein, %T/C refers to the percent change in tumor volume in a treated (e.g., treated with COMPOUND A or COMPOUND A in combination with a checkpoint inhibitor) versus control animal (e.g., treated with standard of care or treated with control vehicle).

The term“inhibition,”“inhibitor,” or“antagonist” includes a reduction in a certain parameter, e.g., an activity, of a given molecule, e.g., an immune checkpoint inhibitor, e.g., an inhibitor of PD-l or an inhibitor of CTLA-4. For example, inhibition of an activity, e.g., a PD- 1 or CTLA-4 activity, of at least 5%, 10%, 20%, 30%, 40% or more is included by this term. Thus, inhibition can be, but need not be 100%.

The term “activation,” “activator,” or“agonist” includes an increase in a certain parameter, e.g., an activity, of a given molecule, e.g., a costimulatory molecule. For example, increase of an activity, e.g., a costimulatory activity, of at least 5%, 10%, 25%, 50%, 75% or more is included by this term.

As used herein,“salts” (which, what is meant by“or salts thereof’ or“or a salt thereof’), can be present alone or in mixture with free compounds of the combination of the invention, e.g., COMPOUND A, and are preferably pharmaceutically acceptable salts. Such salts are formed, for example, by modifying the parent compound via converting an existing acid or base moiety to its salt form.

Lists of suitable salts can be found, e.g., in“Remington's Pharmaceutical Sciences”, 20th ed., Mack Publishing Company, Easton, Pa., (1985); and in“Handbook of Pharmaceutical Salts: Properties, Selection, and Use” by Stahl and Wermuth (Wiley-VCH, Weinheim, Germany, 2002). In some embodiments, the pharmaceutically acceptable salt of Compound A is selected from the group consisting of the sodium, potassium, calcium, magnesium, zinc, aluminum, ammonium, diethylamine, isopropylamine, olamine, benzathine, benethamine, tromethamine (2-amino-2-(hydroxymethyl)propane-l,3-diol), morpholine, epolamine, piperidine, piperazine, picoline, dicyclohexylamine, N,N’-dibenzylethylenediamine, 2- hydroxyethylamine, tri-(2-hydroxyethyl)amine, chloroprocaine, choline, deanol, imidazole, diethanolamine, ethylenediamine, meglumine (N-methylglucamine), procaine, dibenzylpiperidine, dehydroabietylamine, glucamine, collidine, quinine, quinolone, erbumine, lysine and arginine salt. The invention includes within its scope all possible stoichiometric and non-stoichiometric forms of the salts of Compound A. In some embodiments, the pharmaceutically acceptable salt of Compound A is the disodium salt.

For isolation or purification purposes it is also possible to use pharmaceutically unacceptable salts, for example picrates or perchlorates. For therapeutic use, only pharmaceutically acceptable salts or free compounds are employed (where applicable in the form of pharmaceutical preparations), and these are therefore preferred. The salts of compounds used in the combination of the invention are preferably pharmaceutically acceptable salts. Unless otherwise specified, or clearly indicated by the text, reference to therapeutic agents useful in the pharmaceutical combination provided herein includes both the free acid or base from of the compounds, and all pharmaceutically acceptable salts of the compounds.

As used herein, the term "antibody molecule" refers to a protein, e.g., an immunoglobulin chain or fragment thereof, comprising at least one immunoglobulin variable domain sequence. The term“antibody molecule” includes, for example, a monoclonal antibody (including a full length antibody which has an immunoglobulin Fc region). In an embodiment, an antibody molecule comprises a full length antibody, or a full length immunoglobulin chain. In an embodiment, an antibody molecule comprises an antigen binding or functional fragment of a full length antibody, or a full length immunoglobulin chain. In an embodiment, an antibody molecule is a multispecific antibody molecule, e.g., it comprises a plurality of immunoglobulin variable domain sequences, wherein a first immunoglobulin variable domain sequence of the plurality has binding specificity for a first epitope and a second immunoglobulin variable domain sequence of the plurality has binding specificity for a second epitope. In an embodiment, a multispecific antibody molecule is a bispecific antibody molecule. A bispecific antibody has specificity for no more than two antigens. A bispecific antibody molecule is characterized by a first immunoglobulin variable domain sequence which has binding specificity for a first epitope and a second immunoglobulin variable domain sequence that has binding specificity for a second epitope.

In an embodiment, an antibody molecule is a monospecific antibody molecule and binds a single epitope, e.g. , a monospecific antibody molecule having a plurality of immunoglobulin variable domain sequences, each of which binds the same epitope.

In an embodiment, an antibody molecule comprises a diabody, and a single-chain molecule, as well as an antigen-binding fragment of an antibody (e.g., Fab, F(ab’)2, and Fv). For example, an antibody molecule can include a heavy (H) chain variable domain sequence (abbreviated herein as VH), and a light (L) chain variable domain sequence (abbreviated herein as VL). In an embodiment an antibody molecule comprises or consists of a heavy chain and a light chain (referred to herein as a half antibody). In another example, an antibody molecule includes two heavy (H) chain variable domain sequences and two light (L) chain variable domain sequence, thereby forming two antigen binding sites, such as Fab, Fab’, F(ab’)2, Fc, Fd, Fd’, Fv, single chain antibodies (scFv for example), single variable domain antibodies, diabodies (Dab) (bivalent and bispecific), and chimeric (e.g. , humanized) antibodies, which may be produced by the modification of whole antibodies or those synthesized de novo using recombinant DNA technologies. These functional antibody fragments retain the ability to selectively bind with their respective antigen or receptor. Antibodies and antibody fragments can be from any class of antibodies including, but not limited to, IgG, IgA, IgM, IgD, and IgE, and from any subclass (e.g., IgGl, IgG2, IgG3, and IgG4) of antibodies. The preparation of antibody molecules can be monoclonal or polyclonal. An antibody molecule can also be a human, humanized, CDR-grafied, or in vitro generated antibody. The antibody can have a heavy chain constant region chosen from, e.g., IgGl, IgG2, IgG3, or IgG4. The antibody can also have a light chain chosen from, e.g., kappa or lambda. The term“immunoglobulin” (Ig) is used interchangeably with the term“antibody” herein.

Examples of antigen-binding fragments of an antibody molecule include: (i) a Fab fragment, a monovalent fragment consisting of the VL, VH, CL and CH1 domains; (ii) a F(ab')2 fragment, a bivalent fragment comprising two Fab fragments linked by a disulfide bridge at the hinge region; (iii) a Fd fragment consisting of the VH and CH1 domains; (iv) a Fv fragment consisting of the VL and VH domains of a single arm of an antibody, (v) a diabody (dAb) fragment, which consists of a VH domain; (vi) a camelid or camelized variable domain; (vii) a single chain Fv (scFv), see e.g., Bird el al. (1988) Science 242:423-426; and Huston el al. (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883); (viii) a single domain antibody. These antibody fragments are obtained using conventional techniques known to those with skill in the art, and the fragments are screened for utility in the same manner as are intact antibodies.

The term“antibody” includes intact molecules as well as functional fragments thereof. Constant regions of the antibodies can be altered, e.g., mutated, to modify the properties of the antibody (e.g., to increase or decrease one or more of: Fc receptor binding, antibody glycosylation, the number of cysteine residues, effector cell function, or complement function).

The VH and VL regions can be subdivided into regions of hypervariability, termed "complementarity determining regions" (CDR), interspersed with regions that are more conserved, termed "framework regions" (FR or FW). The extent of the framework region and CDRs has been precisely defined by a number of methods (see, Rabat, E. A., el al. (1991) Sequences of Proteins of Immunological Interest, Fifth Edition, U.S. Department of Health and Human Services, NIH Publication No. 91-3242; Chothia, C. etal. (1987) J. Mol. Biol. 196:901- 917; and the AbM definition used by Oxford Molecular's AbM antibody modeling software. See, generally, e.g. , Protein Sequence and Structure Analysis of Antibody Variable Domains. In: Antibody Engineering Lab Manual (Ed.: Duebel, S. and Kontermann, R., Springer-Verlag, Heidelberg).

The terms“complementarity determining region,” and“CDR,” as used herein refer to the sequences of amino acids within antibody variable regions which confer antigen specificity and binding affinity. In general, there are three CDRs in each heavy chain variable region (HCDR1, HCDR2, HCDR3) and three CDRs in each light chain variable region (LCDR1, LCDR2, LCDR3).

The precise amino acid sequence boundaries of a given CDR can be determined using any of a number of well-known schemes, including those described by Rabat et al. (1991), “Sequences of Proteins of Immunological Interest,” 5th Ed. Public Health Service, National Institutes of Health, Bethesda, MD (“Rabat” numbering scheme), Al-Lazikani et al , (1997) JMB 273,927-948 (“Chothia” numbering scheme).

Generally, unless specifically indicated, the checkpoint inhibitor antibody molecules set forth herein can include any combination of one or more Rabat CDRs and/or Chothia hypervariable loops, e.g., described in Table 1, Table 2 or Table 3.

As used herein, an“immunoglobulin variable domain sequence” refers to an amino acid sequence which can form the structure of an immunoglobulin variable domain. For example, the sequence may include all or part of the amino acid sequence of a naturally-occurring variable domain. For example, the sequence may or may not include one, two, or more N- or C-terminal amino acids, or may include other alterations that are compatible with formation of the protein structure.

The terms "monoclonal antibody" or "monoclonal antibody composition" as used herein refer to a preparation of antibody molecules of single molecular composition. A monoclonal antibody composition displays a single binding specificity and affinity for a particular epitope. A monoclonal antibody can be made by hybridoma technology or by methods that do not use hybridoma technology (e.g., recombinant methods).

A humanized or CDR-grafted antibody will have at least one or two but generally all three recipient CDRs (of heavy and or light immunoglobulin chains) replaced with a donor CDR. The antibody may be replaced with at least a portion of a non-human CDR or only some of the CDRs may be replaced with non-human CDRs. It is only necessary to replace the number of CDRs required for binding of the humanized antibody to PD-l or to CTLA-4. Preferably, the donor will be a rodent antibody, e.g., a rat or mouse antibody, and the recipient will be a human framework or a human consensus framework. Typically, the immunoglobulin providing the CDRs is called the "donor" and the immunoglobulin providing the framework is called the "acceptor". In one embodiment, the donor immunoglobulin is a non-human (e.g., rodent). The acceptor framework is a naturally-occurring (e.g., a human) framework or a consensus framework, or a sequence about 85% or higher, preferably 90%, 95%, 99% or higher identical thereto

All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g. "such as”) provided herein is intended merely to better illuminate the invention and does not pose a limitation on the scope of the invention otherwise claimed.

DETAILED DESCRIPTION

In addition to checkpoint inhibitor therapies, another potential immune therapy for cancers and for other cell-proliferation disorders is related to the immune system response to certain danger signals associated with cellular or tissue damage. The innate immune system has no antigen specificity but does respond to a variety of effector mechanisms, such as the damage-associated molecular patterns (DAMPs) or pathogen-associated molecular patterns (PAMPs), such as those associated with opsonization, phagocytosis, activation of the complement system, and production of soluble bioactive molecules such as cytokines or chemokines. The cyclic-di-nucleotides (CDNs) cyclic-di-AMP (produced by Listeria monocytogenes and other bacteria) and its analogs cyclic-di-GMP and cyclic -GMP-AMP are recognized by the host cell as a pathogen associated molecular pattern (PAMP), which bind to the pathogen recognition receptor (PRR) known as Stimulator of INterferon Genes (STING). Free cytosolic DNA and RNA are also among these PAMPs and DAMPs. It has recently been demonstrated that the main sensor for cytosolic DNA is cGAS (cyclic GMP-AMP synthase). Upon recognition of cytosolic DNA, cGAS catalyzes the generation of the cyclic-dinucleotide 2'-3' cGAMP, an atypical second messenger that strongly binds to the ER-transmembrane adaptor protein STING. A conformational change is undergone by cGAMP-bound STING, which translocates to a perinuclear compartment and induces the activation of critical transcription factors IRF-3 and NF-kB. This leads to a strong induction of type I interferons and production of pro-inflammatory cytokines such as IL-6, TNF-a and IFN-g, leading to the development of an adaptive protective pathogen-specific immune response consisting of both antigen-specific CD4 ⁺ and CD8 ⁺ T cells as well as pathogen-specific antibodies.

These type I interferons and pro-inflammatory cytokines strongly potentiate T-cell activation by enhancing the ability of dendritic cells and macrophages to uptake, process, present and cross-present antigens to T-cells. Type I interferons can significantly enhance anti tumor immune responses by inducing activation of both the adaptive and innate immune cells. Finally, tumor invasiveness may be inhibited by interferons by modulating enzyme expression related to tissue remodeling. Examples of cyclic purine dinucleotides are described in some detail in, e.g., U.S. Patent Nos. 7,709458 and 7,592,326; W02007/054279; and Yan et al, Bioorg. Med. Chem Lett. 18: 5631 (2008), each of which is hereby incorporated by reference.

The present invention is based partially on the surprising finding that the combination of a STING agonist, e.g., COMPOUND A or a pharmaceutically acceptable salt thereof, and one or more checkpoint inhibitors, e.g., an anti -PD- 1 antibody or an anti-CTLA-4 antibody, leads to early and robust antitumor responses from the immunoactivation of STING agonism and the long-term benefit of immunotherapy.

The combinations disclosed herein can result in one or more of: an increase in antigen presentation, an increase in effector cell function (e.g., one or more of T cell proliferation, IFN- g secretion or cytolytic function), inhibition of regulatory T cell function, an effect on the activity of multiple cell types, such as regulatory T cell, effector T cells and NK cells), an increase in tumor infiltrating lymphocytes, an increase in T-cell receptor mediated proliferation, and a decrease in immune evasion by cancerous cells. Accordingly, in one embodiment, a method of modulating an immune response in a subject is provided. The method comprises administering to the subject a combination according to the methods disclosed herein (e.g., a combination comprising a therapeutically effective amount of an anti-PD-l antibody molecule and a therapeutically effective amount of COMPOUND A or a pharmaceutically acceptable salt thereof), such that the immune response in the subject is modulated. In one embodiment, the antibody molecule enhances, stimulates or increases the immune response in the subject. The subject can be a mammal, e.g., a primate, preferably a higher primate, e.g., a human (e.g., a patient having, or at risk of having, a disorder described herein). In one embodiment, the subject is in need of enhancing an immune response. In one embodiment, the subject has, or is at risk of, having a proliferative disorder described herein, e.g., a cancer, as described herein.

It has been found that intratumoral injection of COMPOUND A in combination with a checkpoint inhibitor, e.g., an anti-PD-l antibody or an anti-CTUA-4 antibody in humans with diverse malignancies resulted in clinical systemic anti-tumor responses.

It has also been found that the combination of a STING agonist, e.g., COMPOUND A or a pharmaceutically acceptable salt thereof, and a checkpoint inhibitor, e.g., an anti-PD-l antibody or an anti-CTUA-4 antibody, primes the immune system locally and relieves systemic immune suppression through inhibition of the immune checkpoint pathway. Patients with poorly immunogenic tumors who do not benefit from checkpoint inhibition alone mount a stronger immune response upon activation of the STING pathway, due to the enhanced cross presentation, which leads to increased activation of TIUs. Similarly, patients with immunogenic tumors, who may or may not benefit from checkpoint inhibition, may experience an even stronger immune response and subsequently improved clinical benefit.

STING Agonist

As used herein, "stimulator of interferon genes (STING)" is also known as "endoplasmic reticulum interferon stimulator (ERIS)", "mediator of IRF3 activation (MITA)", "MPYS" or "transmembrane protein 173 (TM173)". STING is a transmembrane receptor protein and is encoded by the gene TMEM173 in human. In response to viral infection, STING activates STAT6 (signal transducer and activator of transcription 6) to induce (Tin-ty pe). increase (IU-12), or decrease (IU-10) production of various cytokines, including the chemokines CCU2, CCU20, and CCU26 (Chen et al, 2011). COMPOUND A, which is dithio-Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p], or a pharmaceutically acceptable salt thereof, is a synthetic cyclic dinucleotide (CDN) molecule comprised of two adenosine purine nucleotides that can initiate a productive anti-tumor immune response through the STING pathway when delivered to the tumor microenvironment by acting on tumor-resident dendritic cells (DC) and other cell populations. STING-mediated induction of the innate immune response leads to the production of critical IFNs, cytokines and chemokines resulting in the priming of APC and CD8 ⁺ T cells (Woo el al (2014) J Immunity 41:830-842). Intratumoral injections of COMPOUND A in tumor-bearing mice resulted in significant local and abscopal antitumor efficacy that was completely dependent on host STING (Corrales et al (2015) Cell Reports 11 : 1018-1030).

COMPOUND A, a STING agonist, may therefore be useful in treating (e.g., one or more of reducing, inhibiting, or delaying progression) a proliferative disease, particularly a cancer, particularly a solid tumor or lymphoma.

In a particularly preferred embodiment, the STING agonist is COMPOUND A, or a pharmaceutically acceptable salt thereof.

COMPOUND A has the following structure:

COMPOUND A is disclosed in WO2014/189805, which is incorporated herein by reference in its entirety.

COMPOUND A (also referred to herein as“Compound A”) is also known by the name of dithio-Rp,Rp-cyclic- [A(2’ ,5’ )pA(3’ 5’ )p] .

In a preferred embodiment, the pharmaceutically acceptable salt of COMPOUND A is a disodium salt.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered, e.g., as a single agent, at a dose of about 300 pg to about 10,000 pg (e.g., per injection or per day or per administration) for treating cancer in a subject in need thereof. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 300 pg to about 5,000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 300 pg to about 2000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 300 pg to about 1000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg to about 10,000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg to about 7000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg to about 4000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 1000 pg to about 5000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 5000 pg to about 10,000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 250 pg, about 300 pg, about 350 pg, about 400 pg, about 450 pg, about 500 pg about 550 pg, about 600 pg, about 650 pg, about 700 pg, about 750 pg, about 800 pg, about 850 pg, about 900 pg, about 950 pg, about 1000 pg, about 1050 pg, about 1100 pg, about 1150 pg, about 1200 pg, about 1250 pg, about 1300 pg, about 1350 pg, about 1400 pg, about 1450 pg, about 1500 pg, about 1550 pg, about 1600 pg, about 1650 pg, about 1700 pg, about 1750 pg, about 1800 pg, about 1850 pg, about 1900 pg, about 1950 pg, about 2000 pg, about 2050 pg, about 2100 pg, about 2150 pg, about 2200 pg, about 2250 pg, about 2300 pg, about 2350 pg, about 2400 pg, about 2450 pg, about 2500 pg, about 2550 pg, about 2600 pg, about 2650 pg, about 2700 pg, about 2750 pg, about 2800 pg, about 2850 pg, about 2900 pg, about 2950 pg, about 3000 pg, about 3050 pg, about 3100 pg, about 3150 pg, about 3200 pg, 3250 pg, about 3300 pg, about 3350 pg, about 3400 pg, about 3450 pg, about 3500 pg, about 3550 pg, about 3600 pg, about 3650 pg, about 3700 pg, about 3750 pg, about 3800 pg, about 3850 pg, about 3900 pg, about 3950 pg, about 4000 pg, about 4500 pg, about 5000 pg, about 5500 pg, about 6000 pg, about 6500 pg, about 7000 pg, about 7500 pg, about 8000 pg, about 8500 pg, about 9000 pg, about 9500 pg, about 9600 pg, or about 10,000 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 800 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 1600 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 3200 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 6400 pg. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 9600 pg.

Checkpoint inhibitors

Based on the mechanism of action of COMPOUND A, a combination with a checkpoint inhibitor, e.g., an antibody molecule (e.g., ahumanized antibody molecule or ahuman antibody molecule) that binds to Programmed Death 1 (PD-l) and blocks the binding of PD-l to PD-U1 and/or PD-U2 or an antibody molecule (e.g., a humanized antibody molecule or a human antibody molecule) that binds to CTUA-4 and blocks the binding of CTUA-4 to CD80 and/or CD86, especially the exemplary antibody molecules as described below, can be useful in the treatment of patients with cancer, in particular with solid cancer or lymphoma. In one embodiment, the use of a PD- 1 inhibitor in the combination inhibits, reduces or neutralizes one or more activities of PD-l, resulting in blockade or reduction of an immune checkpoint. Thus, such combinations comprising (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, and (b) at least one or more PD-l inhibitor can be used to treat or prevent disorders where enhancing an immune response in a subject is desired.

PD-l is a CD28/CTUA-4 family member expressed, e.g., on activated CD4 ⁺ and CD8 ⁺ T cells, Tregs, and B cells. It negatively regulates effector T cell signaling and function. PD-l is induced on tumor-infiltrating T cells, and can result in functional exhaustion or dysfunction (Keir et al. (2008) Anna. Rev. Immunol. 26:677-704; Pardoll et al. (2012) Nat Rev Cancer l2(4):252-64). PD-l delivers a coinhibitory signal upon binding to either of its two ligands, Programmed Death-Uigand 1 (PD-U1) or Programmed Death-Uigand 2 (PD-U2). PD-U1 is expressed on a number of cell types, including T cells, natural killer (NK) cells, macrophages, dendritic cells (DCs), B cells, epithelial cells, vascular endothelial cells, as well as many types of tumors. High expression of PD-U1 on murine and human tumors has been linked to poor clinical outcomes in a variety of cancers (Keir et al. (2008) Annu. Rev. Immunol. 26:677-704; Pardoll et al. (2012) Nat Rev Cancer l2(4):252-64). PD-U2 is expressed on dendritic cells, macrophages, and some tumors. Blockade of the PD-l pathway has been pre -clinically and clinically validated for cancer immunotherapy. Both preclinical and clinical studies have demonstrated that anti -PD-l blockade can restore activity of effector T cells and results in robust anti-tumor response. Blockade of the PD-l pathway can be effected with an antibody, an antigen binding fragment thereof, an immunoadhesin, a fusion protein, or oligopeptide of PD-l, PD-L1 and/or PD-L2.

As used herein, the term “Programmed Death 1” or “PD-l” includes isoforms, mammalian, e.g., human PD-l, species homologs of human PD-l, and analogs comprising at least one common epitope with PD-l . The amino acid sequence of PD-l, e.g., human PD-l, is known in the art, e.g., Shinohara T et al. (1994) Genomics 23(3):704-6; Finger LR, et al. Gene (1997) 197(1-2): 177-87.

In one embodiment, the antibody molecule binds to a mammalian, e.g., human, PD-l . For example, the antibody molecule binds specifically to an epitope, e.g., linear or conformational epitope on PD- 1.

PD-l Inhibitors

In certain embodiments, COMPOUND A as described herein is administered in combination with a PD-l inhibitor. In some embodiments, the PD-l inhibitor is chosen from spartalizumab (PDR001, Novartis), nivolumab (Bristol-Myers Squibb), pembrolizumab (Merck & Co), pidilizumab (CureTech), MEDI0680 (Medimmune), cemiplimab (REGN2810, Regeneron), TSR-042 (Tesaro), PF-06801591 (Pfizer), tislelizumab (BGB-A317, Beigene), BGB-108 (Beigene), INCSHR1210 (Incyte), or AMP-224 (Amplimmune).

In one embodiment, the anti -PD-l antibody molecule is spartalizumab (Novartis), also known as PDR001 or PDR-001. Spartalizumab (PDR001) is a high-affinity, ligand-blocking, humanized anti -PD-l IgG4 antibody that blocks the binding of PD-L 1 and PD-L2 to PD-l .

In one embodiment, the PD-l inhibitor is an anti-PD-l antibody molecule. In one embodiment, the PD-l inhibitor is an anti-PD-l antibody molecule as described in US 2015/0210769, published on July 30, 2015, entitled“Antibody Molecules to PD-l and Uses Thereof,” incorporated by reference in its entirety. In one embodiment, the PD-l inhibitor is spartalizumab (corresponding to BAP049-Clone-E, also known as PDR001) as disclosed in US 2015/0210769, incorporated by reference in its entirety. In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of spartalizumab, e.g., as disclosed in Table 1.

In one embodiment, the anti-PD-l antibody molecule comprises at least one, two, three, four, five or six complementarity determining regions (CDRs) (or collectively all of the CDRs) from a heavy and light chain variable region comprising an amino acid sequence shown in Table 1 (e.g. , from the heavy and light chain variable region sequences of BAP049-Clone-E or BAP049-Clone-B disclosed in Table 1), or encoded by a nucleotide sequence shown in Table 1. In some embodiments, the CDRs are according to the Kabat definition (e.g., as set out in Table 1). In some embodiments, the CDRs are according to the Chothia definition (e.g., as set out in Table 1). In some embodiments, the CDRs are according to the combined CDR definitions of both Kabat and Chothia (e.g., as set out in Table 1). In one embodiment, the combination of Kabat and Chothia CDR of VH CDR1 comprises the amino acid sequence GYTFTTYWMH (SEQ ID NO: 543). In one embodiment, one or more of the CDRs (or collectively all of the CDRs) have one, two, three, four, five, six or more changes, e.g., amino acid substitutions (e.g., conservative amino acid substitutions) or deletions, relative to an amino acid sequence shown in Table 1, or encoded by a nucleotide sequence shown in Table 1.

In one embodiment, the anti -PD- 1 antibody molecule comprises a heavy chain variable region (VH) comprising a VHCDR1 amino acid sequence of SEQ ID NO: 501, a VHCDR2 amino acid sequence of SEQ ID NO: 502, and a VHCDR3 amino acid sequence of SEQ ID NO: 503; and a light chain variable region (VL) comprising a VLCDR1 amino acid sequence of SEQ ID NO: 510, a VLCDR2 amino acid sequence of SEQ ID NO: 511, and a VLCDR3 amino acid sequence of SEQ ID NO: 512, each disclosed in Table 1.

In one embodiment, the antibody molecule comprises a VH comprising a VHCDR1 encoded by the nucleotide sequence of SEQ ID NO: 524, a VHCDR2 encoded by the nucleotide sequence of SEQ ID NO: 525, and a VHCDR3 encoded by the nucleotide sequence of SEQ ID NO: 526; and a VL comprising a VLCDR1 encoded by the nucleotide sequence of SEQ ID NO: 529, a VLCDR2 encoded by the nucleotide sequence of SEQ ID NO: 530, and a VLCDR3 encoded by the nucleotide sequence of SEQ ID NO: 531, each disclosed in Table 1.

In one embodiment, the anti -PD- 1 antibody molecule comprises a VH comprising the amino acid sequence of SEQ ID NO: 506, or an amino acid sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 506. In one embodiment, the anti-PD-l antibody molecule comprises a VL comprising the amino acid sequence of SEQ ID NO: 520, or an amino acid sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 520. In one embodiment, the anti-PD- 1 antibody molecule comprises a VL comprising the amino acid sequence of SEQ ID NO: 516, or an amino acid sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 516. In one embodiment, the anti-PD-l antibody molecule comprises a VH comprising the amino acid sequence of SEQ ID NO: 506 and a VL comprising the amino acid sequence of SEQ ID NO: 520. In one embodiment, the anti-PD-l antibody molecule comprises a VH comprising the amino acid sequence of SEQ ID NO: 506 and a VL comprising the amino acid sequence of SEQ ID NO: 516.

In one embodiment, the antibody molecule comprises a VH encoded by the nucleotide sequence of SEQ ID NO: 507, or a nucleotide sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 507. In one embodiment, the antibody molecule comprises a VL encoded by the nucleotide sequence of SEQ ID NO: 521 or 517, or a nucleotide sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 521 or 517. In one embodiment, the antibody molecule comprises a VH encoded by the nucleotide sequence of SEQ ID NO: 507 and a VL encoded by the nucleotide sequence of SEQ ID NO: 521 or 517.

In one embodiment, the anti -PD- 1 antibody molecule comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 508, or an amino acid sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 508. In one embodiment, the anti- PD-l antibody molecule comprises a light chain comprising the amino acid sequence of SEQ ID NO: 522, or an amino acid sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 522. In one embodiment, the anti-PD-l antibody molecule comprises a light chain comprising the amino acid sequence of SEQ ID NO: 518, or an amino acid sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 518. In one embodiment, the anti-PD-l antibody molecule comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 508 and a light chain comprising the amino acid sequence of SEQ ID NO: 522. In one embodiment, the anti-PD-l antibody molecule comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 508 and a light chain comprising the amino acid sequence of SEQ ID NO: 518.

In one embodiment, the antibody molecule comprises a heavy chain encoded by the nucleotide sequence of SEQ ID NO: 509, or a nucleotide sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 509. In one embodiment, the antibody molecule comprises a light chain encoded by the nucleotide sequence of SEQ ID NO: 523 or 519, or a nucleotide sequence at least 85%, 90%, 95%, or 99% identical or higher to SEQ ID NO: 523 or 519. In one embodiment, the antibody molecule comprises a heavy chain encoded by the nucleotide sequence of SEQ ID NO: 509 and a light chain encoded by the nucleotide sequence of SEQ ID NO: 523 or 519.

The antibody molecules described herein can be made by vectors, host cells, and methods described in US 2015/0210769, incorporated by reference in its entirety. Table 1. Amino acid and nucleotide sequences of exemplary anti-PD-1 antibody molecules

Other Exemplary PD- 1 Inhibitors

In one embodiment, the anti -PD- 1 antibody molecule is Nivolumab (Bristol-Myers Squibb), also known as MDX-l 106, MDX-l 106-04, ONO-4538, BMS-936558, or OPDIVO®. Nivolumab (Opdivo®) is a fully human IgG4 monoclonal antibody (mAb) binding PD-l, thereby blocking the binding of PD-L1 and PD-L2 to PD-l. Opdivo® is approved for the treatment of various cancers, including unresectable or metastatic melanoma, renal cell carcinoma, Hodgkin lymphoma, Recurrent or metastatic squamous cell carcinoma of the head and neck (HNSCC), and Microsatellite instability-high (MSI-H) metastatic colorectal cancer (CRC). Nivolumab (clone 5C4) and other anti-PD-l antibodies are disclosed in US 8,008,449 and WO 2006/121168, incorporated by reference in their entirety. In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of Nivolumab, e.g., as disclosed in Table 2.

In one embodiment, the anti-PD-l antibody molecule is Pembrolizumab (Merck & Co), also known as Lambrolizumab, MK-3475, MK03475, SCH-900475, or KEYTRUDA®. Pembrolizumab and other anti-PD-l antibodies are disclosed in Hamid, O. et al. (2013) New England Journal of Medicine 369 (2): 134-44, US 8,354,509, and WO 2009/114335, incorporated by reference in their entirety. In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of Pembrolizumab, e.g., as disclosed in Table 2.

In one embodiment, the anti -PD- 1 antibody molecule is Pidilizumab (CureTech), also known as CT-011. Pidilizumab and other anti -PD- 1 antibodies are disclosed in Rosenblatt, J. etal. (2011) J Immunotherapy 34(5): 409-18, US 7,695,715, US 7,332,582, and US 8,686,119, incorporated by reference in their entirety. In one embodiment, the anti -PD- 1 antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of Pidilizumab, e.g., as disclosed in Table 2.

In one embodiment, the anti -PD- 1 antibody molecule is MEDI0680 (Medimmune), also known as AMP-514. MEDI0680 and other anti -PD- 1 antibodies are disclosed in US 9,205, 148 and WO 2012/145493, incorporated by reference in their entirety. In one embodiment, the anti -PD- 1 antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of MEDI0680.

In one embodiment, the anti-PD-l antibody molecule is cemiplimab , also known as REGN2810 (Regeneron). In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of cemiplimab (REGN2810).

In one embodiment, the anti-PD-l antibody molecule is PF-06801591 (Pfizer). In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of PF-06801591.

In one embodiment, the anti-PD-l antibody molecule is tislelizumab, also known as BGB-A317 or BGB-108 (Beigene). In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of tislelizumab (BGB-A317) or BGB-108.

In one embodiment, the anti-PD-l antibody molecule is INCSHR1210 (Incyte), also known as INCSHR01210 or SHR-1210. In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of INCSHR1210.

In one embodiment, the anti-PD-l antibody molecule is TSR-042 (Tesaro), also known as ANB011. In one embodiment, the anti-PD-l antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of TSR-042.

Further known anti-PD-l antibodies include those described, e.g., in WO 2015/112800, WO 2016/092419, WO 2015/085847, WO 2014/179664, WO 2014/194302, WO 2014/209804, WO 2015/200119, WO 2018/020476, US 8,735,553, US 7,488,802, US 8,927,697, US 8,993,731, and US 9,102,727, incorporated by reference in their entirety.

In one embodiment, the anti-PD-l antibody is an antibody that competes for binding with, and/or binds to the same epitope on PD-l as one of the anti-PD-l antibodies described herein.

In one embodiment, the PD-l inhibitor is a peptide that inhibits the PD-l signaling pathway, e.g., as described in US 8,907,053, incorporated by reference in its entirety. In one embodiment, the PD-l inhibitor is an immunoadhesin (e.g., an immunoadhesin comprising an extracellular or PD-l binding portion of PD-U1 or PD-U2 fused to a constant region (e.g., an Fc region of an immunoglobulin sequence). In one embodiment, the PD-l inhibitor is AMP- 224 (B7-DCIg (Amplimmune), e.g., disclosed in WO 2010/027827 and WO 2011/066342, incorporated by reference in their entirety).

Table 2. Amino acid sequences of other exemplary anti-PD-1 antibody molecules

CTLA-4 Inhibitors

In certain embodiments, COMPOUND A as described herein is administered in combination with a CTLA-4 inhibitor. In one embodiment, the checkpoint inhibitor is an anti- CTLA-4 antibody molecule.

In one embodiment, the anti-CTLA-4 antibody molecule is Ipilimumab. Ipilimumab (Y ervoy®) is a fully human IgGl monoclonal antibody (mAb) binding CTLA-4, also known as MDX-010 (CAS No. 477202-00-9) that binds to human CTLA4 and prevent its interaction with CD80 and CD86. Ipilimumab activates the immune system by targeting CTLA-4, a protein receptor that downregulates the immune system. Y ervoy® is approved for the treatment of unresectable or metastatic melanoma. The antibody ipilimumab and other anti-CTLA-4 antibodies are disclosed in US 6,984,720, herein incorporated by reference. In one embodiment, the anti-CTLA-4 antibody molecule comprises one or more of the CDR sequences (or collectively all of the CDR sequences), the heavy chain or light chain variable region sequence, or the heavy chain or light chain sequence of ipilimumab, e.g., as disclosed in Table 3.

Table 3. Amino acid sequence of ipilimumab

COMBINATION THERAPY

In a first aspect, provided is a method for the treatment of cancer comprising administering to a patient in need thereof (a) a dose (e.g., a daily dose, a weekly dose, etc.) of about 400 pg to about 10,000 pg of COMPOUND A (dithio-Rp,Rp-cyclic- [A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, and (b) one or more checkpoint inhibitors, preferably selected from the group consisting of ipilimumab, spartalizumab and nivolumab, and wherein administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral, peri-tumoral or into the tumor draining lymph node(s).

In a second aspect, provided herein is a method for the treatment of cancer comprising administering to a patient in need thereof (a) a dose (e.g., a daily dose, a weekly dose, etc.) of about 400 pg to about 10,000 pg of COMPOUND A (dithio-Rp,Rp-cyclic-

[A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, and (b) ipilimumab, and wherein administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral, peri-tumoral or into the tumor-draining lymph node(s). In a third aspect, provided herein is a method for the treatment of cancer comprising administering to a patient in need thereof (a) a dose (e.g., a daily dose, a weekly dose, etc.) of about 50 pg to about 10,000 pg of COMPOUND A (dithio-Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, and (b) one or more PD-l checkpoint inhibitors, and wherein administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral, peri-tumoral or into the tumor-draining lymph node(s).

In one embodiment, the PD-l inhibitor is selected from the group consisting of spartalizumab, nivolumab, pembrolizumab, pidilizumab, MEDI0680, cemiplimab, TSR-042, PF-06801591, tislelizumab, BGB-108, INCSHR1210, or AMP-224. In a preferred embodiment, the PD-l inhibitor is spartalizumab or nivolumab.

Accordingly, in one embodiment provided herein is a method for the treatment of cancer comprising administering to a patient in need thereof (a) a dose (e.g., a daily dose, a weekly dose, etc.) of about 50 pg to about 10,000 pg of COMPOUND A (dithio-Rp,Rp-cyclic- [A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, and (b) spartalizumab, and wherein administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral, peri-tumoral or into the tumor-draining lymph node(s).

Accordingly, in one embodiment provided herein is a method for the treatment of cancer comprising administering to a patient in need thereof (a) a dose (e.g., a daily dose, a weekly dose, etc.) of about 50 pg to about 10,000 pg of COMPOUND A (dithio-Rp,Rp-cyclic- [A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, and (b) nivolumab, and wherein administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral, peri-tumoral or into the tumor-draining lymph node(s).

In one embodiment, the methods described herein are for first-line treatment in a patient in need thereof with cancer. In one embodiment, the cancer is treatment naive. In another embodiment, the methods described herein are for second-line or third-line treatment in a patient in need thereof with cancer, for example following treatment with a checkpoint inhibitor as monotherapy, or following treatment with chemotherapy or following treatment with a checkpoint inhibitor in combination with standard of care (e.g., platinum based therapy or targeted therapy or other chemotherapy) for said cancer. In one embodiment, the methods described herein are for the treatment of PD-l inhibitor refractory or relapsed cancer. In one embodiment, the methods described herein are for the treatment of PD-1/PD-U1 inhibitor naive cancer. As used herein, the term“first-line treatment” means that a patient has not been treated previously with a biotherapeutic or chemotherapeutic agent, targeted therapy, or hormonal therapy, i.e., is treatment-naive.

As used herein, the term“second-line or third-line treatment” means treatment of a patient that has been treated previously with a biotherapeutic (e.g., checkpoint inhibitor) agent, chemotherapeutic agent (e.g., platinum-based therapy), targeted therapy (e.g., BRAF/MEK inhibitors), and/or hormonal therapy and has failed to achieve a sustained response after prior therapy, i.e., said patient is treatment-experienced.

As used herein, the term“PD- 1 inhibitor refractory” means that a patient is refractory to PD-l inhibitors.

As used herein, the term“PD- 1 inhibitor relapsed” means that a patient has relapsed or progressed after an initial response to a PD-l inhibitor.

As used herein, the term“PD-l inhibitor refractory or relapsed” means that a patient is refractory to PD-l inhibitor or has relapsed or progressed after an initial response to PD-l inhibitor”.

As used herein, the term“checkpoint inhibitor refractory or relapsed (R/R)” means that a patient is refractory to checkpoint inhibitor or has relapsed or progressed after an initial response to checkpoint inhibitor”.

As used herein, the term“PD-1/PD-L1 inhibitor naive cancer” means that a patient has not been treated previously with a PD-l and/or PD-L1 inhibitor for treatment of that patient’s cancer.

In one embodiment, the methods described herein may also be used prior to or following surgery to remove a tumor and may be used prior to, during, or after radiation treatment.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 50 pg to about 10,000 pg (e.g., per injection or per day or per administration) in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 100 pg to about 10,000 pg (e.g., per injection or per day or per administration) in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 200 pg to about 10,000 pg (e.g., per injection or per day or per administration) in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 250 mg to about 10,000 mg (e.g., per injection or per day or per administration) in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 300 pg to about 10,000 pg (e.g., per injection or per day or per administration) in combination with one or more checkpoint inhibitors for treating cancer in a subject in need thereof. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 200 pg to about 5,000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 200 pg to about 2000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 200 pg to about 1000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg to about 10,000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg to about 7000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg to about 4000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 1000 pg to about 5000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 5000 pg to about 10,000 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 50 pg, about 100 pg, about 150 pg, about 200 pg, about 250 pg, about 300 pg, about 350 pg, about 400 pg, about 450 pg, about 500 pg about 550 pg, about 600 pg, about 650 pg, about 700 pg, about 750 pg, about 800 pg, about 850 pg, about 900 pg, about 950 pg, about 1000 pg, about 1050 pg, about 1100 pg, about 1150 pg, about 1200 pg, 1250 pg, about 1300 pg, about 1350 pg, about 1400 pg, about 1450 pg, about 1500 pg, about 1550 pg, about 1600 pg, about 1650 pg, about 1700 pg about

1750 pg, about 1800 pg, about 1850 pg, about 1900 pg, about 1950 pg, about 2000 pg, about

2050 pg, about 2100 pg, about 2150 pg, about 2200 pg, about 2250 pg, about 2300 pg, about

2350 pg, about 2400 pg, about 2450 pg, about 2500 pg, about 3000 pg, about 3050 pg, about

3100 pg, about 3150 pg, about 3200 pg, 3250 pg, about 3300 pg, about 3350 pg, about 3400 mg, about 3450 mg, about 3500 mg, about 3550 mg, about 3600 mg, about 3650 mg, about 3700 mg about 3750 mg, about 3800 mg, about 3850 mg, about 3900 mg, about 3950 mg, about 4000 mg, about 4500 mg, about 5000 mg, about 5500 mg, about 6000 mg, about 6500 mg, about 7000 mg, about 7500 mg, about 8000 mg, about 8500 mg, about 9000 mg, about 9500 mg, or about 10,000 mg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 50 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 100 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 200 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 400 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 800 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 1600 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 3200 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 6400 pg in combination with one or more checkpoint inhibitors. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered at a dose of about 9600 pg in combination with one or more checkpoint inhibitors.

The dosages quoted herein may apply to the administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, per lesion or per day or per administration.

In some embodiments, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered non-parenterally or parenterally. In some embodiments, the administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is subcutaneous, intramuscular, intravenous, intradermal, intravesical, mucosal, vaginal, cervical, peri-tumoral, intra-tumoral, or intranode (lymph node), e.g., in the nearest lymph node(s) or directly into the tumor-draining lymph node(s). In one embodiment, the administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral, peri-tumoral, or directly into the tumor-draining lymph node(s). In a preferred embodiment, the administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral.

In another preferred embodiment, the administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is by intra-tumoral visceral injection.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered into one tumor lesion. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered into the same tumor lesion on each day of administration. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered into a single lesion on each day of administration. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered into a single lesion on each day of administration per treatment cycle. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered into multiple lesions (e.g., 2, 3, 4, 5, or 6 lesions) on each day of administration per treatment cycle. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered into the same multiple lesions on each day of administration per treatment cycle. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, or a composition comprising COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered into different one or more lesions on each day of administration per treatment cycle. Suitably, the dose of COMPOUND A, or a pharmaceutically acceptable salt thereof, administered per lesion may be between about 50 pg and 10,000 pg, with the total daily dose of COMPOUND A, or a pharmaceutically acceptable salt thereof, not exceeding about 10,000 pg. Suitably, the dose of COMPOUND A, or a pharmaceutically acceptable salt thereof, administered per lesion may be between about 50 pg and 10,000 pg, with the total weekly dose of COMPOUND A, or a pharmaceutically acceptable salt thereof, not exceeding about 10,000 pg. In one embodiment, a dose of about 200 pg of COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered per lesion, e.g., per day or per week. In one embodiment, a dose of about 400 pg of COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered per lesion, e.g., per day or per week. In one embodiment, a dose of about 800 pg of COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered per lesion, e.g., per day or per week. In one embodiment, a dose of about 1600 pg of COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered per lesion, e.g., per day or per week. In one embodiment, a dose of about 3200 pg of COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered per lesion, e.g., per day or per week. In one embodiment, a dose of about 6400 pg of COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered per lesion, e.g., per day or per week. In one embodiment, a dose of about 9600 pg of COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered per lesion, e.g., per day or per week.

In some embodiments, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1 only of a 21 -day treatment cycle.

In some embodiments, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1 and on day 8 of a 21 -day treatment cycle.

In some embodiments, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1 only of a 28 -day treatment cycle.

In some embodiments, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1 and day 15 of a 28-day treatment cycle.

In some embodiments, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1, day 8, and day 15 of a 28-day treatment cycle.

In some embodiments, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1, day 8, day 15, and day 21 of a 28-day treatment cycle. For example, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for treating a bladder disorder (e.g., bladder cancer).

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 21 -day treatment cycles.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1 and day 8 of a 21 -day treatment cycle for at least one, at least two, at least three, at least four, at least five, or at least six 2l-day treatment cycles. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 21 -day treatment cycles, followed by administration once per month for at least one month, at least two months, at least three months, at least four months, at least five months, at least six months, at least seven months, at least eight months, at least nine months, at least ten months, at least 11 months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 21 -day treatment cycles, followed by administration once every four weeks for at least one month, at least two months, at least three months, at least four months, at least five months, at least six months, at least seven months, at least eight months, at least nine months, at least ten months, at least 11 months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 21 -day treatment cycles, followed by administration once every three weeks for at least one month, at least two months, at least three months, at least four months, at least five months, at least six months, at least seven months, at least eight months, at least nine months, at least ten months, at least 11 months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 21 -day treatment cycles, followed by administration once every 8 weeks for at least two months, at least four months, at least six months, at least eight months, at least ten months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 21 -day treatment cycles, followed by administration once every 12 weeks for at least three months, at least six months, at least nine months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 28-day treatment cycles.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered on day 1, day 8, and day 15 of a 28-day treatment cycle for at least one, at least two, at least three, at least four, at least five, or at least six 28-day treatment cycles. In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 28-day treatment cycles, followed by administration once per month for at least one month, at least two months, at least three months, at least four months, at least five months, at least six months, at least seven months, at least eight months, at least nine months, at least ten months, at least 11 months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 28-day treatment cycles, followed by administration once every four weeks for at least one month, at least two months, at least three months, at least four months, at least five months, at least six months, at least seven months, at least eight months, at least nine months, at least ten months, at least 11 months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 28-day treatment cycles, followed by administration once every three weeks for at least one month, at least two months, at least three months, at least four months, at least five months, at least six months, at least seven months, at least eight months, at least nine months, at least ten months, at least 11 months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 28-day treatment cycles, followed by administration once every 8 weeks for at least two months, at least four months, at least six months, at least eight months, at least ten months, or at least 12 months.

In one embodiment, COMPOUND A, or a pharmaceutically acceptable salt thereof, is administered for at least one, at least two, at least three, at least four, at least five, or at least six 28-day treatment cycles, followed by administration once every 12 weeks for at least three months, at least six months, at least nine months, or at least 12 months.

COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered as a single dose per lesion or per day or per administration or COMPOUND A, or a pharmaceutically acceptable salt thereof, may be administered in multiple doses per lesion or per day or per administration.

In another embodiment, provided is a method for the treatment of cancer comprising administering to a patient in need thereof (a) a dose (e.g., a daily dose or weekly dose) of about 50 mg to about 10,000 mg of COMPOUND A (dithio-Rp,Rp-cyclic-[A(2’,5’)pA(3’5’)p]), or a pharmaceutically acceptable salt thereof, (b) one or more checkpoint inhibitors, preferably selected from nivolumab, ipilimumab and spartalizumab, and (c) at least one further therapeutic agent, and wherein administration of COMPOUND A, or a pharmaceutically acceptable salt thereof, is intra-tumoral, peri -tumoral or into the tumor-draining lymph node(s). In one embodiment, the at least one further therapeutic agent includes, but is not limited to, one or more of standard of care treatment (e.g., for a cancer), targeted therapy (e.g., for cancer), an antibody molecule (e.g., for cancer), an immunomodulator (e.g., a checkpoint inhibitor, an activator of a costimulatory molecule or an inhibitor of a costimulatory molecule); a vaccine, e.g., a therapeutic cancer vaccine.

The methods described herein are useful in the treatment of cancerous disorders. Examples of cancerous disorders include, but are not limited to, solid tumors, hematological cancers, soft tissue tumors, and metastatic lesions. Examples of solid tumors include malignancies, e.g., sarcomas, lymphomas, and carcinomas (including adenocarcinomas and squamous cell carcinomas), of the various organ systems, such as those affecting liver, lung, breast, lymphoid, gastrointestinal (e.g., colon), genitourinary tract (e.g., renal, urothelial, or bladder cells), prostate, CNS (e.g., brain, neural, or glial cells), skin, pancreas, and pharynx. Adenocarcinomas include malignancies, such as most colon cancers, rectal cancer, renal-cell carcinoma, liver cancer, non-small cell carcinoma of the lung, cancer of the small intestine, and cancer of the esophagus. Squamous cell carcinomas include malignancies, e.g., in the lung, esophagus, skin, head and neck region, oral cavity (e.g., gingiva), anus, and cervix. Metastatic lesions of the aforementioned cancers can also be treated or prevented using the methods of the invention.

Exemplary cancers whose growth can be inhibited using the methods, as disclosed herein, include cancers typically responsive to immunotherapy. Non-limiting examples of typical cancers for treatment include skin cancer (e.g., a Merkel cell carcinoma or a melanoma, e.g., a cutaneous melanoma), breast cancer (e.g., a metastatic breast carcinoma or a stage IV breast carcinoma, e.g., a triple negative breast cancer (TNBC)), squamous cell carcinoma, lymphoma, an eye cancer (e.g., uveal melanoma), kidney cancer (e.g., renal cell carcinoma), colorectal cancer (e.g., relapsed colorectal cancer or metastatic colorectal cancer, e.g., a microsatellite unstable colorectal cancer, a microsatellite stable colorectal cancer, a mismatch repair proficient colorectal cancer, or a mismatch repair deficient colorectal cancer), ovarian cancer, pancreatic cancer or head and neck cancer (e.g., squamous cell carcinoma of the head and neck). The methods as disclosed herein are also useful for treating metastatic lesions associated with the aforementioned cancers. Additionally, refractory or recurrent or relapsed malignancies can be treated using methods as described herein. In some embodiments, the cancer is a metastatic cancer. In other embodiments, the cancer is an advanced cancer. In other embodiments, the cancer is a relapsed or refractory cancer. In one embodiment, the cancer is advanced/metastatic solid tumor. In another embodiment, the cancer is advanced/metastatic lymphoma.

In certain embodiments, the cancer is a solid tumor or a lymphoma. In one embodiment, the cancer is a solid tumor. In some embodiments, the cancer is a skin cancer, e.g., a melanoma (e.g., a cutaneous melanoma, a non-cutaneous melanoma, a stage II-IV melanoma, an HLA- A2 positive melanoma, an unresectable melanoma, or a metastatic melanoma), or a Merkel cell carcinoma. In one embodiment, the cancer is a melanoma. In one embodiment, the cancer is an advanced stage melanoma. In another embodiment, the cancer is metastatic melanoma. In another embodiment, the cancer is PD-l inhibitor refractory or relapsed (R/R) metastatic melanoma. In another embodiment, the cancer is checkpoint inhibitor refractory or relapsed (R/R) metastatic melanoma. In one embodiment, the cancer is cutaneous melanoma. In one embodiment, the cancer is non-cutaneous melanoma. In one embodiment, the cancer is visceral metastatic melanoma. In one embodiment, the cancer is a Merkel cell carcinoma. In some embodiments, the cancer is a breast cancer, e.g., a metastatic breast carcinoma or a stage IV breast carcinoma, e.g., a triple negative breast cancer (TNBC). In one embodiment, the cancer is triple negative breast cancer. In one embodiment, the cancer is metastatic triple negative breast cancer. In another embodiment, the cancer is metastatic triple negative breast cancer that has progressed on prior therapy, e.g., prior chemotherapy with or without checkpoint inhibitors, such as PD-l or PD-L1 inhibitors. In some embodiments, the cancer is a cervical cancer (e.g., a squamous cell carcinoma of the cervix). In some embodiments, the cancer is a colorectal cancer, e.g., a relapsed colorectal cancer or a metastatic colorectal cancer, e.g., a microsatellite unstable colorectal cancer, a microsatellite stable colorectal cancer, a mismatch repair proficient colorectal cancer, or a mismatch repair deficient colorectal cancer. In one embodiment, the cancer is a microsatellite instability-high colorectal cancer (MSI-high CRC) or a microsatellite stable colorectal cancer (MSS CRC). In one embodiment, the cancer is a microsatellite stable (MSS) colorectal cancer (CRC). In one embodiment, the cancer is a sarcoma. In one embodiment, the cancer is esophageal cancer. In one embodiment, the cancer is gastric cancer. In some embodiments, the cancer is an ovarian cancer. In some embodiments, the cancer is a pancreatic cancer, e.g., an advanced pancreatic cancer. In some embodiments, the cancer is a renal cancer, e.g., a renal cell carcinoma (RCC) (e.g., a metastatic renal cell carcinoma) or a treatment-naive metastatic kidney cancer. In some embodiments, the cancer is a head and neck cancer (e.g., an HPV positive or negative squamous cell cancer of the head and neck (SCCHN)). In one embodiment, the cancer is a head and neck squamous cell carcinoma (HNSCC). In another embodiment, the cancer is an advanced/metastatic head and neck squamous cell carcinoma (HNSCC). In another embodiment, the cancer is recurrent head and neck squamous cell carcinoma. In one embodiment, the cancer is a SCC of the scalp. In some embodiments, the cancer is a lymphoma, e.g., a Hodgkin lymphoma (HL) or a diffuse large B cell lymphoma (DLBCL) (e.g., a relapsed or refractory HL or DLBCL) or a non- Hodgkin lymphoma. In one embodiment, the cancer is lymphoma. In one embodiment, the cancer is extranodal lymphoma. In another embodiment, the cancer is Hodgkin lymphoma. In another embodiment, the cancer is non-Hodgkin lymphoma.

In some embodiments, treatment according to the methods described herein results in the improvement of at least one of overall response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). Overall response rate (ORR) is the proportion of patients with a best overall response of complete response (CR) or partial response (PR). Disease control rate (DCR) is the proportion of patients with a best overall response of CR or partial response (PR) or stable disease (SD). Progression-free survival (PFS) is the time from date of randomization/start of treatment to the date of event defined as the first documented progression or death due to any cause. Overall survival (OS) is defined as the time from date of randomization/start of treatment to date of death due to any cause.

In one embodiment, the methods as disclosed herein increases median PFS compared to patients not receiving the treatment as put forth herein, i.e., patients receiving standard of care. In one embodiment, the methods as disclosed herein increases median OS compared to patients not receiving the treatment as put forth herein, i.e., patients receiving standard of care. The treatment regimen as described herein that is effective to treat a cancer patient may vary according to factors such as the disease state, age, and weight of the patient, and the ability of the therapy to elicit an anti-cancer response in the subject.

Further specific embodiments of the invention include:

In one embodiment, provided is a method for the treatment of visceral metastatic melanoma comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 400 pg to about 10,000 mg intratumorally on day 1 only of a 21 -day treatment cycle and (b) ipilimumab intravenously at a dose of about 3 mg/kg on day 1 of a 21 -day treatment cycle.

In one embodiment, provided is a method for treating visceral metastatic melanoma comprising administering to in a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally on day 1 only of a 28-day treatment cycle and (b) one or more PD-l checkpoint inhibitors, preferably spartalizumab or nivolumab, intravenously on day 1 of a 28- day treatment cycle.

In one embodiment, provided is a method of treating PD-l inhibitor refractory or relapsed metastatic melanoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose of about 400 pg to about 10,000 pg intratumorally on day 1 of a 21 -day treatment cycle and (b) ipilimumab intravenously at a dose of about 3 mg/kg on day 1 of a 21 -day treatment cycle.

In another embodiment, provided is a method of treating PD-l inhibitor refractory or relapsed metastatic melanoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 400 pg to about 10,000 pg intratumorally on day 1 and on day 8 of a 21 -day treatment cycle and (b) ipilimumab intravenously at a dose of about 3 mg/kg on day 1 of a 21 -day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically at on day 1 of a 28-day treatment cycle and (b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, day 8 and day 15 of a 28-day treatment cycle and (b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating triple negative breast cancer (e.g., anti -PD-l -naive TNBC), comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 mg to about 10,000 mg intratumorally (e.g., from about 400 mg to about 6,400 mg, e.g., about 800 mg, 1,200 mg, 1,600 mg, 2,000 mg, 2,400 mg, 2,800 mg, or 3,200 mg) on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and (b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating bladder cancer, comprising administering, e.g., intravesically, to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intravesically (e.g., from about 400 pg to about 6,400 pg, e.g., about 800 pg, 1,200 pg, 1,600 pg, 2,000 pg, 2,400 pg, 2,800 pg, or 3,200 pg) on day 1, and optionally on day 8, day 15, and day 21 of a 28-day treatment cycle and (b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle. For example, in treating bladder cancer, COMPOUND A, or a pharmaceutically acceptable salt thereof, is intravesically administered only on day 1 of a 28-day treatment cycle, only on day 1 of a 35-day treatment cycle, or only on day 1 of a 42-day treatment cycle. As another example, in treating bladder cancer, COMPOUND A, or a pharmaceutically acceptable salt thereof, is intravesically administered only on day 1, day 8, day 15, and day 21 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating recurrent or metastatic head and neck squamous cell carcinoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28 -day treatment cycle.

In one embodiment, provided is a method of treating unresectable or metastatic melanoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and (b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating microsatellite stable colorectal cancer (MSS CRC), comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and (b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating cancer, wherein said cancer is solid tumor or lymphoma with one or more visceral lesion, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, day 8 and day 15 of a 28-day treatment cycle and (b) spartalizumab intravenously at a dose of about 400 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1 of a 28-day treatment cycle and (b) nivolumab intravenously at a dose of about 480 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, day 8 and day 15 of a 28-day treatment cycle and (b) nivolumab intravenously at a dose of about 480 mg on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and (b) an anti -PD- 1 antibody selected from the group consisting of pembrolizumab, pidilizumab, MEDI0680 (Medimmune), cemiplimab, TSR-042 (Tesaro), PF- 06801591 (Pfizer), tislelizumab, BGB-108 (Beigene), INCSHR1210 (Incyte), and AMP-224 (Amplimmune), for example, on day 1 of a 28-day treatment cycle, on day 1 of a 21 -day treatment cycle, or on day 1 of a l4-day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and (b) an anti -PD- 1 antibody selected from the group consisting of pembrolizumab, pidilizumab, MEDI0680 (Medimmune), cemiplimab, TSR-042 (Tesaro), PF- 06801591 (Pfizer), tislelizumab, BGB-108 (Beigene), INCSHR1210 (Incyte), and AMP-224 (Amplimmune) on day 1 of a 28-day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 of a 21 -day treatment cycle and (b) an anti -PD- 1 antibody selected from the group consisting of pembrolizumab, pidilizumab, MEDI0680 (Medimmune), cemiplimab, TSR-042 (Tesaro), PF- 06801591 (Pfizer), tislelizumab, BGB-108 (Beigene), INCSHR1210 (Incyte), and AMP-224 (Amplimmune) on day 1 of a 2l-day treatment cycle. For example, in one embodiment, provided is a method of treating head and neck squamous cell carcinoma (HNSCC, e.g., recurrent or metastatic HNSCC), comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 400 pg to about 6,400 pg (e.g., 800 pg, 1,200 pg, 1,600 pg, 2,000 pg, 2,400 pg, 2,800 pg, or 3,200 pg) intratumorally on day 1 and day 8 of a 21 -day treatment cycle and (b) about 200 mg pembrolizumab on day 1 of a 21 -day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 of a l4-day treatment cycle and (b) an anti -PD- 1 antibody selected from the group consisting of pembrolizumab, pidilizumab, MEDI0680 (Medimmune), cemiplimab, TSR-042 (Tesaro), PF- 06801591 (Pfizer), tislelizumab, BGB-108 (Beigene), INCSHR1210 (Incyte), and AMP-224 (Amplimmune) on day 1 of a 14-day treatment cycle.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 of a 21 -day treatment cycle and (b) a checkpoint inhibitor on day 1 of a 21 -day treatment cycle for at least one, at least two, at least three, at least four, at least five or at least six 21 -day treatment cycles, followed by administration of the checkpoint inhibitor once every six weeks, once every nine weeks, once every twelve weeks or once every sixteen weeks. In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and on day 8 of a 21 -day treatment cycle and (b) a checkpoint inhibitor on day 1 of a 21 -day treatment cycle for at least one, at least two, at least three, at least four, at least five or at least six 21 -day treatment cycles, followed by administration of the checkpoint inhibitor once every six weeks, once every nine weeks, once every twelve weeks or once every sixteen weeks.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and on day 8 of a 21 -day treatment cycle and (b) ipilimumab on day 1 of a 2l-day treatment cycle for at least one, at least two, at least three, at least four, at least five or at least six 21 -day treatment cycles, followed by administration of the checkpoint inhibitor once every six weeks, once every nine weeks, once every twelve weeks or once every sixteen weeks.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and (b) a checkpoint inhibitor on day 1 of a 28-day treatment cycle for at least one, at least two, at least three, at least four, at least five or at least six 28-day treatment cycles, followed by administration of the checkpoint inhibitor once every six weeks, once every nine weeks, once every twelve weeks or once every sixteen weeks.

In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 and day 15 of a

28-day treatment cycle and (b) spartalizumab on day 1 of a 28-day treatment cycle for at least one, at least two, at least three, at least four, at least five or at least six 28-day treatment cycles, followed by administration of the checkpoint inhibitor once every six weeks, once every nine weeks, once every twelve weeks or once every sixteen weeks. In one embodiment, provided is a method of treating solid tumor or lymphoma, comprising administering to a patient in need thereof (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, at a dose (e.g., a daily dose) of about 50 pg to about 10,000 pg intratumorally or intravesically on day 1, and optionally on day 8 and day 15 of a 28-day treatment cycle and (b) nivolumab on day 1 of a 28-day treatment cycle for at least one, at least two, at least three, at least four, at least five or at least six 28-day treatment cycles, followed by administration of the checkpoint inhibitor once every six weeks, once every nine weeks, once every twelve weeks or once every sixteen weeks.

Also provided herein is a commercial package kit or a non-fixed combination comprising as active ingredients (a) COMPOUND A, or a pharmaceutically acceptable salt thereof, and (b) one or more checkpoint inhibitors, suitably selected from the group consisting of nivolumab, spartalizumab and ipilimumab, optionally together with instructions for separate or sequential administration of said pharmaceutical combination to a patient in need thereof for use in the treatment of a cancer comprising administering intratumorally or intravesically a daily dose or weekly dose of about 400 pg to about 10,000 pg COMPOUND A, or a pharmaceutically acceptable salt thereof, to a patient in need thereof.

Additional embodiments include pharmaceutical compositions, combinations, and uses of the methods set forth above, wherein it is to be understood that each embodiment may be combined with one or more other embodiments, to the extent that such a combination is consistent with the description of the embodiments. It is further to be understood that the embodiments provided above are understood to include all embodiments, including such embodiments as result from combinations of embodiments.

EXAMPLES

The Examples below are set forth to aid in the understanding of the inventions but are not intended to, and should not be construed to, limit its scope in any way.

Example 1: A Phase lb, open label, multicenter study of the safety and efficacy of COMPOUND A administered by intratumoral injection with spartalizumab (PDR001) to patients with advanced/metastatic solid tumors or lymphomas

This is a phase I, multi-center, open-label study of COMPOUND A in combination with spartalizumab (PDR001) in adult patients with solid tumors or lymphomas who may or may not have received prior immunotherapy. There are two parts in the study: dose escalation/dose confirmation and dose expansion.

Dose escalation/dose confirmation part

Patients were treated with COMPOUND A via intratumoral injection in combination with a fixed intravenous dose of spartalizumab (PDR001), to determine safety, tolerability and the maximum tolerated dose (MTD) and/or recommended dose for expansion (RDE) of the combination.

There are three groups:

Group A: Dose escalation in solid tumor or lymphoma patients with cutaneous or subcutaneous accessible lesions. Patients received 400mg spartalizumab (PDR001) intravenously (i.v.) as a fixed dose administered on day 1 of each 28 day cycle. COMPOUND A was administered via intratumoral injection on days 1, 8 and 15 of each 28-day cycle.

Group B: Dose escalation in solid tumor or lymphoma patients with cutaneous or subcutaneous accessible lesions. Patients received 400mg spartalizumab (PDR001) i.v. as a fixed dose and COMPOUND A administered on day 1 only of each 28-day cycle.

Group C: Dose confirmation in solid tumor patients with visceral lesions accessible by ultrasound (US) or computed tomography (CT) guidance or endoscopically accessible lesions. Patients receive spartalizumab (PDR001) i.v. as a fixed dose and COMPOUND A is administered on day 1 only of each 28-day cycle as a fixed dose at the MTD/RDE determined in Group B.

Inclusion criteria

Patients eligible for inclusion in this study have to meet all of the following criteria: Written informed consent must be obtained prior to any procedures that are not part of standard of care.

• Male or female > 18 years.

• Patients must have measurable disease as determined by RECIST vl.l (for solid tumors) or Cheson criteria (for lymphomas) (Cheson et al (2014) J Clin Oncol 32(27):3059-68).

• Patients must have at least two sites of disease amenable to biopsy and be a candidate for tumor biopsy according to the treating institution’s guidelines. Patient must be willing to undergo new tumor biopsies at screening and during therapy on the study according to the treating institution’s own guidelines and requirements for such procedure. Exceptions may be considered after documented discussions.

• Patients must have two lesions amenable to biopsy: one injected lesion (Ll) must be >10 millimeters (mm) and <100 mm in longest diameter, and accessible for intratumoral injection. For Group C, a visceral lesion amenable to intratumoral injection (using ultrasound or CT guidance) is required.

• The injected lesion (Ll) must be an accessible cutaneous or subcutaneous lesion for baseline and on-treatment biopsies.

• The second (distal) lesion (L2) must be an accessible cutaneous or subcutaneous lesion for baseline and on-treatment biopsy and must be distinct from the injected lesion.

• Tumors encasing major vascular structures such as the carotid artery or tumors in locations that are at high risk for adverse events (i.e. pneumothorax), are not considered appropriate for intratumoral injection.

• Dose escalation/dose confirmation part of study: Patients with advanced/metastatic solid tumors or lymphomas, who have progressed despite standard therapy or are intolerant to standard therapy, for whom no standard therapy exists or for whom standard therapy is not reasonably effective.

• Dose expansion part of study: Patients with melanoma, HNSCC or other accessible solid tumors and lymphomas, who have progressed despite standard therapy or are intolerant of standard therapy, for whom no standard therapy exists or for whom standard therapy is not reasonably effective. In addition, patients with injectable visceral lesions who have MSS CRC or other solid tumors with accessible visceral lesions, who have progressed despite standard therapy or are intolerant of standard therapy, for whom no standard therapy exists or for whom standard therapy is not reasonably effective.

• Eastern Cooperative Oncology Group (ECOG) Performance Status < 1.

Study treatment

The study treatment is the combination of COMPOUND A and spartalizumab

(PDR001).

Table 4. Dose and treatment schedule

Dosing regimen

A treatment cycle is defined as 28 days for the purpose of scheduling procedures and evaluations. The first dose of study drug is Cycle l-Day 1 (C1D1) and defines the patient’s treatment cycle for the study. The last day of each treatment cycle is day 28 (D28). Spartalizumab (PDR001) is administered as a 30 minute infusion or up to two hours, if clinically indicated. The intratumoral injection is given as soon as possible following the completion of the infusion. The intratumoral injection of COMPOUND A should take no more than 5 minutes to complete.

Group C is administered spartalizumab (PDR001) i.v. followed by COMPOUND A intratumorally in a visceral lesion on day 1 of each 28 day cycle. The intratumoral injection is given as soon as possible following the completion of the infusion. The intratumoral injection of COMPOUND A is performed by experienced interventional personnel using US or CT guidance or using endoscopic techniques into a visceral lesion on day 1 of each cycle.

Prior to the intratumoral injection of COMPOUND A, the longest diameter of the injected lesion will be measured and the injection volume is based on the size of that lesion (Table 5). As another example, the injection volume is a fixed volume for different sizes of lesions. The dose of COMPOUND A is administered as described in Table 4.

Table 5. COMPOUND A injection volume

Efficacy objectives

All efficacy endpoints are defined and analyzed based on tumor assessment by RECIST 1.1 (primary) and irRC (secondary). All efficacy endpoints for lymphoma patients are defined and analyzed based on Cheson (2014) criteria. Efficacy endpoints include best overall response (BOR), objective response rate (ORR), disease control rate (DCR), progression free survival (PFS), duration of response (DOR) and time to response (TTR). For irRC, the key difference in the assessments of these endpoints is the requirement for confirmation of PD no less than 4 weeks after the criteria for PD are first met. The date of the first of these two assessments is then the date of confirmed progression. For patients who have ended study without a valid confirmation assessment, for the purposes of analysis the single assessment of PD will be treated as a confirmed PD.

The immune-related response criteria (irRC) use unidimensional measurements to assess tumor response and are an adaptation of the original irRC (Wolchok el al (2009) Clin Cancer Res; 15:7412-20; Nishino et al (2013) Clin Cancer Res; 19:3936-3943). The primary difference between irRC and RECIST 1.1 is the definition of progressive disease. The definitions of baseline target/non target lesions, number of lesions selected at baseline, the criteria for lesion measurement method of evaluation of response and definition of response are the same for irRC and RECIST 1.1. In irRC a new lesion does not automatically indicate progressive disease. New measurable lesions are added to the sum of diameters of the previously existing target lesions, and the sum of diameters is followed at each subsequent tumor assessment. New measureable lesions are defined using the same criteria as for baseline target lesions in RECIST vl . l . New measurable lesions shall be prioritized according to size, and the largest lesions shall be selected as new measurable lesions. Up to five new measurable lesions (and a maximum of two per organ) are allowed in total and will be included in the overall tumor assessment. Non-target lesions (baseline and new non-measurable lesions) are used primarily for determination of Complete Response (CR). The RECIST vl. l definitions for the assessment of non-target lesions apply. A CR requires that all non-target lesions disappear (both those present at baseline and any new non-measurable lesions that have appeared during the study). If after worsening a non-target lesion becomes measurable, it should still be followed as a non-target lesion. Worsening of non-target lesions and new non- measurable lesions only indicate disease progression if there is unequivocal evidence of disease progression. To assess tumor response, the sum of diameters for all target lesions is calculated (at baseline and throughout the study). The diameters of any new measurable lesions are included in the sum of diameters at each assessment to provide the total tumor burden. At each assessment, percent change in the sum of diameters is calculated and compared to baseline or to nadir in order to evaluate the target lesion response (including new measurable lesions). This evaluation combined with the status of non-target lesions (baseline and new non- measurable lesions) is then used to determinate the overall lesion response. The thresholds for irPR and irPD assessment are the same as for RECIST vl . l . In irRC, the overall response is primarily based on target lesions (baseline and new measurable lesions). The non-target lesions only contribute to define irCR, and irPD in the case of unequivocal progression, as shown below in Table 6.

Like in RECIST 1.1, irCR and irPR must be confirmed at a new assessment after at least 4 weeks. Unlike RECIST 1.1, irPD also requires confirmation at a new assessment after at least 4 weeks.

The irRC response categories are defined as follows:

• irCR: Disappearance of all non-nodal target lesions and non-target lesions in two consecutive observations not less than 4 weeks apart. In addition, any pathological lymph nodes assigned as target lesions must have a reduction in short axis to <10 mm. (Sum of diameters may be greater than zero at the time of CR, if nodal lesions are included as target lesions).

• irPR: At least a 30% decrease in the sum of diameters of all target lesions including new measurable lesions in two consecutive observations not less than 4 weeks apart, taking as reference the baseline sum of diameters.

• irPD: At least a 20% increase in the sum of diameters of all measured target lesions including new measurable lesions. The irPD must be confirmed in a second evaluation not less than 4 weeks later, taking as reference the smallest sum of diameter of all target lesions recorded at or after baseline (nadir). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. Worsening of non-target lesions (existing or new) only indicates PD when there is unequivocal evidence of progression, confirmed in a second evaluation not less than 4 weeks later.

• irSD: Neither a sufficient shrinkage to qualify for irPR or irCR, nor an increase in lesions which would qualify for irPD.

• Unknown (UNK): Progression has not been documented and one or more target lesions or new measurable lesions observed at earlier assessment have not been/could not be assessed, or have been assessed using a method significantly different from baseline (target lesions) or assessment of first occurrence (for new measurable lesions) that prevents reasonable comparison to the prior assessments.

Table 6. Overall response at each assessment

* the diameter of new measurable lesions is included in the calculation of the sum of diameters,

a to be confirmed after at least 4 weeks, ^b from baseline, ^c from nadir

Results

Group A: COMPOUND A at the dose indicated in Table 7 on day 1, day 8 and day 15 of every 28-day cycle and 400 mg spartalizumab (PDR001) on day 1 of every 28-day cycle

Group B: COMPOUND A at the dose indicated in Table 7 on day 1 of every 28-day cycle and 400 mg spartalizumab (PDR001) on day 1 of every 28-day cycle

Table 7. Number of patients and cancer type per cohort

Tumors were evaluated before treatment according to the dose and treatment schedule detailed in Table 4 as well as on day 1 of cycle 3 (evaluation 1), day 1 of cycle 5 (evaluation 2), day 1 of cycle 7 (evaluation 3), day 1 of cycle 9 (evaluation 4), and day 1 of cycle 11 (evaluation 5) as indicated.

•Cohort 1A

Patient 1 : Cutaneous melanoma (PD1-R/R) with PR, ongoing 30 weeks

o 42 year old female with melanoma

o Prior therapy included pembrolizumab (4 months with CR), trametinib/dabrafenib (9 months with CR), nivolumab/ipilimumab (3 months with SD), nivolumab/ BMS IDOi (2 months with SD)

o Baseline imaging revealed liver metastases, hilar, inguinal and pelvic lymphadenopathy Table 8. Tumor measurements of patient 1

TL1 =Target Lesion 1, TL2=Target Lesion 2, TL3=Target Lesion 3, TL4=Target Lesion 4, TL5=Target Lesion 5

Patient 2: triple negative breast cancer (TNBC) with PR, ongoing 35 weeks o 64 year old female with TNBC with history of prior hyperthyroidism (not on treatment) o No prior immunotherapy

Table 9. Tumor measurements of patient 2

TL1 =Target Lesion 1, TL2=Target Lesion 2, TL3=Tar get Lesion 3, TL4=Target Lesion 4 •Cohort 1B

Patient 3: SCC of the scalp with resolution of injectable lesions and continued with single agent spartalizumab; now off study due to adverse event

Table 10. Tumor measurements of patient 3

TLl =Target Lesion 1, TL2=Target Lesion 2

Patient 4: Ovarian cancer (PD1-R/R) with SD 6 cycles now off with PD

Table 11. Tumor measurements of patient 4

TL1 =Target Lesion 1, TL2=Target Lesion 2, TL3=Tar get Lesion 3, TL4=Target Lesion 4 •Cohort 2 A

- Patient 5: Hodgkin’s lymphoma (PD1-R/R) with SD, ongoing 19 weeks

Table 12. Tumor measurements of patient 5

TL1 =Target Lesion 1, TL2=Target Lesion 2, TL3=Target Lesion 3, TL4=Target Lesion 4, TL5=Target Lesion 5, LTP=longest transverse diameter, LPD= longest perpendicular diameter - Patient 6: Melanoma with PR of locoregional disease, ongoing 15 weeks o 93 year old female with cutaneous melanoma

o Prior therapy included Tvec only

o Baseline imaging revealed right hilar, and right axillary adenopathy

o Clinical lesions on the right distal forearm

Table 13. Tumor measurements of patient 6

TL1 =Target Lesion 1, TL2=Target Lesion 2

As of April 5, 2019 data cut-off (based on findings from 83 enrolled patients, with 53 patients in the weekly group, i.e., Group A, and 30 patients in the monthly group, i.e., Group B or C):

• Five patients treated in the weekly dosing schedule group achieved confirmed responses, one of which was a complete response (CR) in anti-PD-l -naive TNBC, two were partial responses (PRs) in anti-PD-l -naive TNBC, and two were PRs in previously immunotherapy- treated melanoma. Among the five confirmed responders in the weekly group, the median was a 73 percent maximum reduction in the sum of the target lesion diameters.

• Eight of the 11 enrolled TNBC patients were evaluable for efficacy. Of the eight TNBC patients evaluable for efficacy, one anti-PD-l naive TNBC patient achieved a CR and two anti- PD-l naive TNBC patients achieved partial responses (PRs), and the three patients are continuing to receive treatment. Of the three unevaluable TNBC patients, one patient discontinued the study early due to toxicity (pneumonitis) and the two remaining patients are too early for assessment.

• Twenty-five of the 35 melanoma patients were radiologically evaluable for efficacy. Of the 25 melanoma patients radiologically evaluable for efficacy, two previously immunotherapy-treated melanoma patients achieved PRs. Nine melanoma patients achieved stable disease (SD). Of the 10 unevaluable melanoma patients, seven patients were ongoing as of the data cut-off and were too early for assessments, two patients discontinued due to clinical progression and one patient chose to start another treatment.

• In the weekly group, 12 patients achieved SD, including five patients who maintained SD for five months or more. The SD patients had the following tumor types: sarcoma, melanoma (7), squamous cell carcinoma of the skin, breast, lymphoma and head and neck. Eight patients with SD received prior immunotherapy.

• In the monthly group, six patients achieved SD, including five patients who maintained SD for five months or more. The SD patients had the following tumor types: cutaneous melanoma, head and neck, ovarian (2), uveal melanoma and breast. Five patients with SD received prior immunotherapy.

It has been observed that the combination of COMPOUND A and spartalizumab was generally well tolerated in patients with solid tumors or lymphomas, with no dose-limiting toxicities reported as of the data cut-off. The combination has demonstrated anti -tumor activity in PD-l-naive TNBC and PD-l-relapsed/refractory melanoma. Systemic IFN-b concentrations appeared to increase with increasing exposure to COMPOUND A (see Figure 3). Other cytokines detected (IP-10, MCP-l, and IF-6) did not demonstrate significant dose dependency and/or PK/PD relationships (IF-6: interleukin-6; IP-10: interferon gamma-induced protein 10; and MCP-l : monocyte chemoattractant protein 1).

Example 2: A Phase I, open label, multicenter study of the safety and efficacy of COMPOUND A administered by intratumoral injection as a single agent or in combination with ipilimumab to patients with advanced/metastatic disease

This study is a Phase I, first-in-human (FIH), multi-center, open-label study of COMPOUND A as a single agent in patients with advanced/metastatic solid tumors and COMPOUND A in combination with ipilimumab in patients with in patients with metastatic melanoma who are relapsed/refractory (R/R) to PD-l inhibitors.

This study consists of a dose escalation part and a dose expansion part.

Dose escalation

Group A includes patients with advanced/metastatic solid tumors or lymphomas with cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by ultrasound (US) guidance. Patients are administered COMPOUND A as a single agent, via intratumoral injection on days 1, 8 and 15 of each 28 day cycle

Group B includes patients with metastatic melanoma with cutaneous, SC and/or nodal lesions who are R/R to PD-l inhibitors. Patients receive ipilimumab, i.v., on day 1 of each 21 day cycle for the first 4 cycles and COMPOUND A, via intratumoral injection, on days 1 and 8 of each 2 l-day cycle. After the first four cycles, patients with SD/PR/CR may continue to receive COMPOUND A on days 1 and 8 of each cycle and ipilimumab maintenance on day 1, every 12 weeks, until disease progression.

Dose expansion

There are four groups:

Group 1 includes patients with UV-induced cancers that have cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by US guidance.

Group 2 includes patients with non UV-induced cancers that have cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by US guidance.

Group 3 includes patients with metastatic melanoma that is R/Rto PD-l inhibitors. Patients must have cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by US guidance. COMPOUND A is administered on days 1 and 8 of every 21 day cycle and ipilimumab is administered on day 1 of each 21 day cycle through cycle 4. Patients may continue on maintenance ipilimumab on day 1 every 12 weeks thereafter if they have SD/PR/CR.

Group 4 includes patients with metastatic melanoma that is R/Rto PD-l inhibitors. Patients must have US, CT, or endoscopically accessible visceral lesions. COMPOUND A is administered on day 1 of every 21 day cycle and ipilimumab is administered on day 1 of each 21 day cycle for the first four cycles. After the first four cycles, patients with SD/PR/CR may continue to receive COMPOUND A on day 1 of each 21 -day cycle and ipilimumab maintenance on day 1 every 12 weeks, until disease progression.

Inclusion criteria

Patients eligible for inclusion in this study have to meet all of the following criteria: Written informed consent must be obtained prior to any procedures that are not part of standard of care.

• Male or female >18 years.

• Patients must have measurable disease as determined by RECIST vl.l (for solid tumors) or Cheson 2014 criteria (for lymphomas).

• Patients must have at least two sites of disease amenable to biopsy and be a candidate for tumor biopsy according to the treating institution’s guidelines. Patient must be willing to undergo new tumor biopsies at screening and during therapy on the study according to the treating institution’s own guidelines and requirements for such procedure. Exceptions may be considered after documented discussions. • Patients must have two lesions amenable to biopsy: one injected lesion (Ll) must be >10 millimeters (mm) and <100 mm in longest diameter, and accessible for intratumoral injection.

• The injected lesion (Ll) must be an accessible cutaneous or subcutaneous lesion for baseline and on-treatment biopsies. In dose expansion, the injected lesion can be an accessible cutaneous or subcutaneous lesion or a visceral lesion.

• The second (distal) lesion (L2) must be an accessible cutaneous or subcutaneous lesion for baseline and on-treatment biopsy and must be distinct from the injected lesion.

• Tumors encasing major vascular structures such as the carotid artery or tumors in locations that are at high risk for adverse events (i.e. pneumothorax), are not considered appropriate for intratumoral injection.

• Dose escalation part of study includes patients with:

o advanced/metastatic solid tumors or lymphomas with cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by US guidance o metastatic melanoma who are R/R to PD- 1 inhibitors with cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by US guidance o progressive disease despite standard therapy or are intolerant to standard therapy or for whom no standard therapy exists

o no prior anti-CTLA-4 therapy (this only applies to patients treated with COMPOUND A in combination with ipilimumab

• Dose expansion part of study will include patients with:

o UV- and non-UV-induced cancers with cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by US guidance

o Patients with metastatic melanoma who are R/R to PD-l inhibitors with cutaneous, SC and/or nodal lesions that are visible, palpable or detectable by US guidance or with visceral lesions that are accessible by US, CT or endoscopic techniques

o progressive disease despite standard therapy or are intolerant of standard therapy or for whom no standard therapy exists

o Patients must not have received prior anti-CTLA-4 therapy (this only applies to patients treated with COMPOUND A in combination with ipilimumab).

o PD-l refractory is defined as progressive disease at the first radiological imaging assessment after initiation of an anti -PD-l -directed therapy and PD-l relapsed is defined as any PD- 1 -treated patient with progression that did not meet the definition ofPD-l refractory.

• Eastern Cooperative Oncology Group (ECOG) Performance Status <1.

Study treatment

The study treatment is COMPOUND A as a single agent or the combination of

COMPOUND A and ipilimumab.

Table 14. Dose and treatment schedule

Dosing regimen

A treatment cycle is defined as 28 days for patients receiving COMPOUND A as a single agent and 21 days for patients receiving COMPOUND A in combination with ipilimumab for the purpose of scheduling procedures and evaluations. The treatment cycle calendar is continuous. There is no break in administration of study treatment between cycles.

The first dose of COMPOUND A is Cycle 1 Day 1 (C1D1) and defines the patient’s treatment cycle for the study. The last day of each treatment cycle is day 28 for patients receiving COMPOUND A, as a single agent, and day 21 for patients receiving COMPOUND A in combination with ipilimumab. COMPOUND A is administered via intratumoral injection. Ipilimumab (3mg/kg) is administered as an i.v. infusion, given over 90 minutes. The intratumoral injection of COMPOUND A should be given as soon as possible following the completion of the ipilimumab infusion.

Prior to the intratumoral injection of COMPOUND A on day 1 of each cycle, the longest diameter of the injected lesion will be measured and the injection volume is based on the size of that lesion (Table 15). As another example, the injection volume is a fixed volume for different sizes of lesions. The dose of COMPOUND A is administered as described in Table 14.

Table 15. COMPOUND A injection volume

In patients with multiple cutaneous, SC or nodal lesions, the same lesion should be injected until an on-treatment biopsy of that lesion has been obtained (Cycle 2 between days 18 and 25) for patients receiving COMPOUND A as a single agent. In patients with multiple cutaneous, SC or nodal lesions or visceral lesions, the same lesion should be injected until an on-treatment biopsy of that lesion has been obtained (Cycle 2 between days 12 and 18) for patients receiving COMPOUND A in combination with ipilimumab. If the first injected lesion shows signs of significant regression that precludes the ability to reinject the lesion, other accessible lesions may be injected after documented discussions. Injection of treatment into visceral lesions should be performed by a qualified interventional radiologist with experience in US and CT guided techniques. Some lesions may be best accessed using endoscopic techniques by qualified endoscopists. In patients with multiple accessible lesions, the same lesion should be injected until an on-treatment biopsy of that lesion has been obtained (Cycle 2 between days 12 and 18). If the first injected lesion shows signs of significant regression that precludes the ability to reinject the lesion, other accessible lesions may be injected after documented discussions. Efficacy objectives

The evaluations of tumor responses are based on criteria according to irRC (see criteria in example 1), RECIST vl. l (European Journal of Cancer, Vol.45: 228-47), or Cheson (2014) for lymphoma patients.

• For solid tumors, BOR is defined as the best response recorded from the start of the treatment until disease progression/recurrence as defined for irRC, RECIST vl.l. For lymphomas, BOR will be analyzed both as the best response recorded from the start of treatment until disease progression/recurrence as defined by Cheson 2014 criteria and as best response recorded at any time on treatment. CR and PRs must be confirmed by repeat assessments that should be performed not less than 4 weeks after the criteria for response are first met. Additionally, for irRC, progressive disease should be confirmed in a similar manner.

· ORR, defined as the proportion of patients with best overall response of CR or PR.

• For irRC, PFS is defined as the time from the date of start of treatment to the date of the first documented and confirmed progression, or death due to any cause. Progressive disease should be confirmed by a repeat assessment that should be performed not less than 4 weeks after the criteria for progression are first met. The date of progression will then be the date of the first of these two assessments. For patients without a confirmation assessment, and with no subsequent assessments of SD, or better, a single assessment will be used as date of progression. If a patient has not had an event, PFS will be censored at the date of the last adequate tumor evaluation.

• For RECIST vl .1, PFS is defined as the time from the date of start of treatment to the date of the first documented progression or death due to any cause.

• For Cheson 2014, PFS is defined as the time from the date of start of treatment to the date of the first documented progression or death due to any cause.

• DOR, defined for responder as the time between the date of first documented response (CR or PR) and the date of first documented progression or death due to underlying cancer. If progression or death due to underlying cancer has not occurred, then the patient is censored at the date of last adequate tumor assessment.

• DCR, defined as the proportion of patients with best overall response of CR or PR or SD.

Table 16. Response criteria for target lesions

¹ Sum of Diameter (SOD) for CR may not be zero when nodal lesions are part of target lesions, ² Following an initial CR, a PD cannot be assigned if all non-nodal target lesions are still not present and all nodal lesions are <10 mm in size. In this case, the target lesion response is CR. Table 17. Response criteria for non-target lesions

Example 3A: A Phase lb/II, open label, multicenter study of the safety and efficacy of COMPOUND A administered by intratumoral injection in combination with nivolumab to patients with advanced cancer

This study is a Phase II, multi-center, open-label study of COMPOUND A in combination with nivolumab in patients with PD- 1/PD-L1 -naive recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) or treatment-naive unresectable or metastatic melanoma.

There are two groups:

Group 1 includes patients with PD- 1/PD-L1 -naive recurrent or metastatic SCCHN. Patients receive 480 mg nivolumab, i.v., on day 1 of each 28-day cycle and COMPOUND A, via intratumoral injection, on days 1, 8 and 15 of each 28-day cycle at a dose of e.g., 200 pg, 400 pg, or 800 pg per lesion per day.

Group 2 includes patients with treatment naive unresectable or metastatic melanoma. Patients receive 480 mg nivolumab, i.v., on day 1 of each 28-day cycle and COMPOUND A, via intratumoral injection, on days 1, 8 and 15 of each 28-day cycle at a dose of e.g., 200 pg, 400 pg, or 800 pg per lesion per day.

Inclusion criteria

Patients eligible for inclusion in this study have to meet all of the following criteria: Written informed consent must be obtained prior to any procedures that are not part of standard of care.

• Male or female >18 years.

• If SCCHN: Histological or cytological confirmation of recurrent or metastatic SCCHN that has progressed on or after a platinum-based therapy

• If melanoma: Histological or cytological confirmation of unresectable (Stage IIIB/C/IIID or metastatic (Stage IV) melanoma (per American Joint Committee on Cancer Staging, 8th ed)

• Patients must have at least one site of measurable disease as determined by RECIST v 1.1 (for solid tumors) :

o Superficial (i.e., cutaneous, subcutaneous and/or nodal) lesion

o lesion must be >10 millimeters (mm) and <100 mm in longest diameter; nodal lesions must be >15 mm (post-biopsy) at short axis. o Lesion accessible for intratumoral injection: Tumors encasing major vascular structures such as the carotid artery or tumors in locations that are at high risk for adverse events (i.e. pneumothorax), are not considered appropriate for intratumoral injection.

· Eastern Cooperative Oncology Group (ECOG) Performance Status <1.

Exclusion criteria

• Prior treatment with an anti-PD-l, anti-PD-Ll, anti-CTLA-4, or any other antibody or drug targeting T cell co-stimulation or checkpoint pathways, either alone or as part of a combination regimen

• Prior anti -cancer therapy with an oncolytic virus, pattern recognition receptor (e.g. toll- like receptor) agonist, or STING agonist

• Received more than 3 prior lines of treatment for SCCHN in the advanced/metastatic setting

• Prior anti-cancer chemotherapy, targeted small molecule therapy, or monoclonal antibody within 4 weeks prior the first dose of study treatment

Study treatment

The study treatment is the combination of COMPOUND A and nivolumab.

Table 18a. Dose and treatment schedule

1 total dose level assumes maximum number of four (4) lesions are injected; total dose varies by subject depending on number of accessible target lesions, but does not exceed 2400 meg. All designated lesions are injected on every dosing day.

Efficacy Variables and Analyses All efficacy endpoints are defined and analyzed according to RECIST vl .1 (Eisenhauer et al. (2009) Eur J Cancer, 45: 228-47) (primary evaluation) and iRECIST (Seymour et al. (2017) Lancet Oncol, 18: el43-e52) (secondary evaluation).

Primary efficacy endpoints are:

For SCCHN

• ORR (CR and PR) according to RECIST v 1.1

For melanoma: Occurrence of CR per RECIST vl .1

Secondary endpoints are:

For SCCHN: Occurrence of CR per RECIST 1.1

• ORR (CR and PR) per iRECIST

For Melanoma

• ORR (CR and PR) per RECIST 1.1

• Occurrence of CR per iRECIST

Additional endpoints in each indication are progression-free survival (PFS) (time from first dose of study drug to first documentation of disease progression or death due to any cause), duration of response (DOR) (time from first tumor assessment that supports the subject’s objective disease response to the time of disease progression or death due to any cause), disease control rate (DCR) (subjects with CR, PR, or stable disease (SD)), duration of disease control (DODC) (time from first tumor assessment that supports the subject’s disease control (CR, PR, SD) to the time of disease progression or death due to any cause), and overall survival (OS) (time from first dose of study drug until date of death due to any cause). Estimates of progression-free survival and overall survival are assessed using Kaplan-Meier methodology.

Example 3B: A Phase II, open label, multicenter study of the safety and efficacy of COMPOUND A administered by intratumoral injection in combination with pembrolizumab to patients with advanced cancer

This study is a Phase II, multi-center, open-label study of COMPOUND A in combination with pembrolizumab in the first-line setting in adult patients with PD-L1 positive recurrent or metastatic head and neck squamous cell carcinoma (HNSCC).

Examples of Inclusion criteria

Patients eligible for inclusion in this study have to meet all of the following criteria: Writen informed consent must be obtained prior to any procedures that are not part of standard of care.

• Male or female >18 years.

• Histological or cytological confirmation of recurrent or metastatic HNSCC

• Measurable disease as determined by RECIST vl .1

• PD-L1 positive (defined as combined positive score [CPS] ^ 1 using the Dako PD-L1 22C3 pharmDx companion diagnostic assay)

• At least one lesion that is:

o Superficial (e.g., cutaneous, subcutaneous) and/or nodal

o >10 millimeters (mm) and <100 mm in longest diameter; nodal lesions must be >15 mm (post-biopsy) at short axis.

o Lesion accessible for intratumoral injection: Tumors encasing or abuting major vascular structures (such as the carotid artery) or tumors in locations that are at high risk for adverse events (i.e. pneumothorax, brain lesions), are not considered appropriate for intratumoral injection. An irradiated mass cannot be used for intratumoral injection unless radiotherapy was completed at least 28 days prior to first dose of study drug and/or the lesion demonstrates evidence of growth (metabolically active by positive positron emission tomography or an unambiguous increase in size)

o Amenable to baseline and on-treatment biopsy.

• Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 or 1.

Examples of Exclusion criteria

• Diagnosis of recurrent or metastatic carcinoma of the nasopharynx, squamous cell carcinoma of unknown primary histology; or salivary gland or non-squamous histologies (e.g. mucosal melanoma).

• Prior systemic anti-cancer therapy (use of chemotherapeutic agents, targeted small molecules, immunotherapy, or monoclonal antibodies) for the treatment of recurrent or metastatic HNSCC with certain exceptions.

• Symptomatic or untreated leptomeningeal disease.

• Radiotherapy within 2 weeks of the first dose of study drug, except for palliative radiotherapy to a limited field, such as for the treatment of bone pain or a focally painful tumor mass. • Participation in an interventional, investigational trial where an intervention was received within 4 weeks of the first dose of study drug.

• Diagnosis of immunodeficiency or receiving chronic systemic steroid therapy (>10 mg/day prednisone or equivalent) or any immunosuppressive therapy within 7 days prior to the first dose of study drug. Topical (<class III), inhaled, nasal and ophthalmic steroids are allowed except in the anatomic location of injected and non-injected lesions.

• Receipt of any live vaccines within 4 weeks prior to first dose of study drug.

• Use of hematopoietic colony-stimulating growth factors [e.g. granulocyte colony- stimulating factor (G-CSF), GM-CSF, macrophage colony-stimulating factor (M-

CSF)], thrombopoietin mimetics or erythroid stimulating agents <2 weeks prior to first dose of study drug. Erythroid stimulating agents may be maintained if initiated more than 4 weeks prior to the first dose of study drug and the dose is stable.

• Active infection (viral, bacterial, or fungal) requiring systemic therapy.

• Active, known, or suspected autoimmune disease or a documented history of autoimmune disease, except vitiligo or resolved childhood asthma/atopy.

Study treatment

The study treatment is the combination of COMPOUND A and pembrolizumab.

Table 18b. Dose and treatment schedule

¹ total dose level assumes maximum number of two (2) lesions are injected; total dose varies by subject depending on number of accessible target lesions, but does not exceed 1600 meg. All designated lesions are injected on every dosing day.

Efficacy Variables and Analyses

All efficacy endpoints are defined and analyzed according to RECIST vl .1 (Eisenhauer et al. (2009) Eur J Cancer, 45: 228-47) (primary evaluation) and iRECIST (Seymour et al. (2017) Lancet Oncol, 18: el43-e52) (secondary evaluation). Occurrence of objective response (complete and partial response), duration of response, occurrence of disease control (complete response, partial response, and stable disease), and duration of disease control will be summarized. Estimates of progression-free survival and overall survival will be assessed using the Kaplan-Meier method.

Primary efficacy endpoints are:

• ORR (CR and PR) according to RECIST v 1.1

Secondary endpoints are:

• overall survival (OS) (time from first dose of study drug until date of death due to any cause)

• progression-free survival (PFS) (time from first dose of study drug to first documentation of disease progression or death due to any cause)

• duration of response (DOR) (time from first tumor assessment that supports the subject’s objective disease response to the time of disease progression or death due to any cause)

• disease control rate (DCR) (subjects with CR, PR, or stable disease (SD))

• duration of disease control (DODC) (time from first tumor assessment that supports the subject’s disease control (CR, PR, SD) to the time of disease progression or death due to any cause)

• ORR (CR and PR) per iRECIST

Examnle 4: Anti-tumor activity of COMPOUND A in combination with an anti- CTLA-4 antibody in B16 Melanoma mouse model

Female C57BL/6 mice (Charles River Laboratories) and were acclimated to laboratory conditions for at least 72 hours before the start of the study.

B16.F10 melanoma cells were purchased from ATCC (Manassas, VA) and thawed at passage 4 into a 15 cm cell culture dish. Cells were maintained at 37°C with 5% C02 in DMEM media containing L-glutamine (Hyclone), with 10% heat-inactivated FCS, IX penicillin and streptomycin (Hyclone). Upon reaching confluence, cells were washed with IX DPBS, harvested with 0.25% Trypsin-EDTA, and washed with DMEM media. Cells were centrifuged at 400 x g for 5 min and resuspended in IX DPBS to a concentration of 5xl0 ⁵ cells/mL for flank tumor implantation. 5 x 10 ⁴ cells were implanted by subcutaneous injection on the right flank of mice. Mice with 17-day old established flank tumors (tumor volume of about 75-100 mm ³ ) were treated with 50 pg Compound A or HBSS (Hy clone) vehicle control by IT injection on days 17, 20 and 24 as well as two IP injections of 100 pg mouse specific anti-CTLA4 antibody 9D9 (Bio X cell) or isotype control IgG (Bio X cell) on days 20 and 24 (see Figure 1 and Table 19).

Table 19. Study design

*mouse anti-CTLA4, ** Tumor did not take in one of eight mice

IT injections were initiated when tumors grew to between 75-100 mm ³ (day 17). On day 17, 20 and 24 all groups of mice were administered a single intratumoral (IT) injection of 40 pL HBSS vehicle, or 40 pL COMPOUND A as described in Table 20 below.

Table 20. COMPOUND A Dosing

All groups of mice were administered intraperitoneal (IP) injections of 100 pL of antibody (polyclonal Rat IgG (isotype control) or anti -mouse CTLA4 (9D9)) on day 20 and day 24 as described in Table 21 below. Table 21. Antibody Dosing

Tumor measurements were performed twice weekly using electronic calipers (Fowler, Newton, MA). Tumor volume was calculated using the modified ellipsoid formula l/2(length x width ² ). Mice were euthanized if tumor size reached >20% of body weight or became necrotic.

The purpose of this study was to evaluate the potential synergy of anti-CTLA4 administration in combination with COMPOUND A given intratumorally (IT). C57BL/6 mice bearing established B16.F10 flank tumors received a single IT injection into the right flank tumor on day 17, 20 and 24 with 50 pg COMPOUND A or HBSS control (see Table 19 and Table 20). Groups of mice received injections of either 100 pg isotype control IgG or anti- CTUA4 IP on day 20 and 24 (see Table 19 and Table 21).

In groups administered control IgG IP, significant tumor inhibition (day 24, 12.4% T/C) was observed for the COMPOUND A group (Group 3), compared to the control HBSS IT group (Group 1) for the primary tumor (day 24, P < 0.0001) (Figure 2). The addition of anti- CTUA4 in the HBSS IT group (Group 2) compared to IgG control did not have a significant impact on overall tumor control (day 24, 41.7% T/C). Combining COMPOUND A administered IT with anti-CTUA4 administered IP (Group 4) elicited more inhibition of the injected, primary tumor (day 24, 3.71% T/C) compared to COMPOUND A administered IT with IgG control IP (Group 3) (Figure 2).

Administration of COMPOUND A IT demonstrated potent antitumor activity. This was significantly enhanced by the addition of anti-CTUA4 (see Figure 2), demonstrating that anti- CTUA4 can significantly enhance the anti-tumor activity of COMPOUND A, and when administered together offers a potent anti -tumor regimen for aggressive tumors. Example 5: Anti-tumor activity of COMPOUND A as a single agent or in combination with an anti-PD-1 antibody in multiple mouse tumor models

Intratumoral injection of COMPOUND A induces a potent antitumor immune response and significant tumor regression in multiple mouse tumor models, including B16.F10 (B 16) melanoma, 4T1 mammary carcinoma, and CT26 colon carcinoma. Treatment with COMPOUND A inhibited the primary treated tumor and primed an effective systemic CD8+ Tcell immune response that significantly inhibited the growth of distal, untreated lesions, or conferred protection against autologous tumor challenge. In the B 16 model, induction of CD8+ T cell immunity and antitumor efficacy by COMPOUND A was shown to be completely STING dependent. In addition, when COMPOUND A was given as a subcutaneous injection in the 4T1 mammary carcinoma model, no tumor efficacy was noted. These results demonstrate that direct activation of tumor resident APCs through the STING pathway is important for cross-presentation of tumor-specific CD8+ T cells and tumor destruction.

The combination of COMPOUND A and anti-PD-l antibody has been evaluated in the MC38 colon carcinoma and the 4T1 mammary carcinoma syngeneic mouse tumor models and demonstrated enhanced anti-tumor immunity and tumor regression as compared to treatment with MIW815 or anti-PD-l antibody alone. A study in the MC38 colon carcinoma model evaluated a single intratumoral injection of COMPOUND A in combination with the mouse anti-PD-l antibody administered intraperitoneally twice weekly. Results demonstrated partial tumor control with either COMPOUND A or anti-PD-l antibody alone, and complete tumor control when COMPOUND A was combined with anti-PD-l antibody. In the 4T1 mammary carcinoma model bearing two flank tumors, COMPOUND A was administered by single intratumoral injection and combined with a twice weekly regimen of anti-PD-l antibody. These data demonstrated partial control of the distal, uninjected tumor with COMPOUND A alone, and complete primary and distal tumor clearance from COMPOUND A in combination with anti-PD-l antibody. The combined efficacy was evident when anti-PD-l antibody was administered at the time of COMPOUND A intratumoral treatment, not when anti-PD-l antibody treatment was delayed by three days. Control of the primary and distal tumors by the combination of COMPOUND A and anti-PD-l antibody were dependent on CD8+ DCs and T cells, and required intratumoral injection of COMPOUND A; subcutaneous injection of the STING agonist was not efficacious. These results demonstrate that the combination of direct activation of the STING pathway with COMPOUND A and immune checkpoint blockade with anti-PD-l antibody significantly enhances anti -tumor immunity and tumor regression in mice. INCORPORATION BY REFERENCE

All publications, patents, and Accession numbers mentioned herein are hereby incorporated by reference in their entirety as if each individual publication or patent was specifically and individually indicated to be incorporated by reference.

EQUIVALENTS

While specific embodiments of the subject invention have been discussed, the above specification is illustrative and not restrictive. Many variations of the invention will become apparent to those skilled in the art upon review of this specification and the claims below. The full scope of the invention should be determined by reference to the claims, along with their full scope of equivalents, and the specification, along with such variations.