WO2025250276A1 - Methods for treatment of non-small cell lung cancers - Google Patents

Abstract

The presently claimed and described technology relate to method of treating non-small-cell lung cancer (NSCLC) in a subject in need thereof, the method comprising administering an effective amount of (S)-N- (4-amino-6-methyl-5- (quinolin-3-yl)-8,9-dihydropyrimido[5,4-b]indolizin-8-yl)acrylamide (Compound 1) or a salt thereof, wherein the subject has previously been treated with amivantamab and/or chemotherapy.

Description

METHODS FOR TREATMENT OF NON-SMALL CELL LUNG CANCERS

BACKGROUND

[0001] Among cancer-related deaths, deaths from lung cancer are the most common in the world, and approximately 80% to 85% of lung cancers are classified as non-small cell lung cancer (NSCLS). See Ferlay J, Colombet M, Soeijomataram I, et al. Cancer statistics for the year 2020: An overview. Int J Cancer. 2021;149:778-789; American Cancer Society. What ls Non-Small Cell Lung Cancer? https://www.cancer.org/cancer/non-small-cell-lung-cancer/about/what-is- non- small-cell-lung-cancer. html. Accessed: January 8, 2023.

[0002] Over the past decade, cancer treatment has seen a shift towards targeted therapy and immunotherapy. However, the success of targeted therapy relies significantly on the specific gene mutations present in tumor tissue. National Comprehensive Cancer Network (NCCN) Guidelines recommend genetic testing panels for NSCLC that include epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), HER2, ROS1, BRAF, TP53, FGFR1, PIK3CA, NTRK, MET, RET, ERBB2, and KRAS, with the predominant gene mutations in NSCLC being EGFR, ERBB2, and KRAS, with over 60% of individuals with NSCLC displaying two or more mutations simultaneously.

[0003] Despite recent progress in the development of NSCLC targeted therapies, there remains a significant need for well-tolerated therapies and treatment regimens for individuals with NSCL cancer progression after at least one prior treatment with an anti-cancer agent or chemotherapy.

BRIEF SUMMARY

[0004] (S)-N-(4-amino-6-methyl-5-(quinolin-3-yl)-8,9-dihydropyrimido[5,4-b]indolizin-8- yl)acrylamide (Compound 1) is an irreversible oral EGFR TKI with a unique pyrrolopyrimidine structural scaffold distinct from other EGFR ex20ins TKIs (which use quinazoline and pyrimidine scaffolds). [0005] Compound 1 (also known as CLN-081, TAS-6417 or Zipalertinib) has the following structure:

[0006] Compound 1 potently inhibits cell growth and EGFR signaling in EGFR ex20ins- mutant human cancer cell lines with improved selectivity for ex20ins-mutant versus WT EGFR. Additionally, unlike many other approved and investigational ex20ins TKIs, Compound 1 does not inhibit WT or mutant HER2. On the basis of these preclinical data, the inventors investigated the safety, tolerability, antitumor activity, and pharmacokinetics (PK) of Compound 1 in this phase l/2a study.

[0007] One aspect of the disclosure is a method of treating non-small-cell lung cancer (NSCLC) in a subject in need thereof, the method comprising administering an effective amount of (S)-N-(4-amino-6-methyl-5-(quinolin-3-yl)-8,9-dihydropyrimido[5,4-b]indolizin-8- yljacrylamide (Compound 1) or a salt thereof, wherein the subject has previously been treated with amivantamab.

[0008] In an aspect, the subject failed to respond to amivantamab; or the subject had disease progression after administration of amivantamab.

[0009] In an aspect, the subject was also previously treated with chemotherapy. In an aspect, the subject was also treated with mobocertinib, poziotinib, and/or sunvozertinib.

[0010] One aspect of the disclosure is a method of treating non-small-cell lung cancer (NSCLC) in a subject in need thereof, the method comprising administering an effective amount of (S)-N-(4-amino-6-methyl-5-(quinolin-3-yl)-8,9-dihydropyrimido[5,4-b]indolizin-8- yljacrylamide (Compound 1 ) or a salt thereof, wherein the subj ect has previously been treated with chemotherapy. [0011 ] In an aspect, the subject failed to respond to chemotherapy; or the subject had disease progression after administration of chemotherapy.

[0012] In an aspect, the subject was also previously treated with amivantamab. In an aspect, the subject was also treated with mobocertinib, poziotinib, and/or sunvozertinib.

[0013] In an aspect, the effective amount is a therapeutically effective or pharmaceutically effective amount. In an aspect, an effective amount of Compound 1 or a salt thereof is administered orally at least twice a day. In an aspect, the effective amount is about 50 mg of Compound 1 or a salt thereof, alternatively about 75 mg of Compound 1 or a salt thereof, alternatively about 100 mg of Compound 1 or a salt thereof, alternatively about 125 mg of Compound 1 or a salt thereof, or alternatively about 150 mg of Compound 1 or a salt thereof.

[0014] In an aspect, the subject has at least one mutation in non-small cell lung cancer, alternatively at least two mutations, or alternatively at least three mutations. In an aspect, the mutation is selected from the group consisting of an epidermal growth factor receptor (EGFR) mutation, a HER2 mutation, a TP53 mutation, a KRAS mutation, a MET mutation, an anaplastic lymphoma kinase (ALK) mutation, a ROS1 mutation, a BRAE mutation, a FGFR1 mutation, a PIK3CA mutation, a RET mutation, a NTRK mutation, and a ERBB2 mutation.

[0015] In an aspect, the at least one mutation is an EGFR mutation. In an aspect, the EGFR mutation is an exon 20 insertions (ex20ins).

[0016] In an aspect, the at least one EGFR mutation is selected from the group consisting of D770_N771insX, V769_D770insX, H773_V774insX, P772_H773insX, N771_P772insX, A763_Y764insX, V774_C775insX, D761_E762insX, A767_S768insX, S768_V769insX, Y764 V765insX, V765 M766insX, A763 Y764insFQEA, A767 S768insTLA, S768_V769insVAS, S768_V769insAWT, V769_D770insGV, V769_D770insCV,

V769_D770insDNV, V769_D770insGSV, V769_D770insGVV, V769_D770insMASVD, V769_D770insASV, V769_D770insGE, V769_D770delInsDGEL, D770_N771insSVD,

D770_N771insNPG, D770_N771insKH, D770_N771insGNPH, D770_N771insAPW,

D770_N771insD, D770_N771insDG, D770delinsGY, D770_N771insGL, D770_N771insN, D770_N771insNPH, D770_N771insSVP, D770_N771insSVQ, D770_N771insMATP,

D770_N771insG, D770_N771insY, D770_N771insGF, D770_N771insGT, delD770insGY, N771_P772insH, N771_P772insN, delN771insGY, delN771insGF, N771delinsGY, N771_P772insRH, P772_H773insPR, P772_H773insYNP, P772_H773insX, P772_H773insDPH, P772_H773insDNP, P772_H773insQV, P772_H773insTPH, P772_H773insN, P772_H773insV, P772_H773insNP, P772_H773insNPH, H773_V774insH, H773 V774insNPH, H773 V774insPH, H773 V774insGNPH, H773 V774insG, H773_V774insGH, H773_V774insAH, H773_V774delInsLM, H773_V774delInsTY, and V774_C775insHV.

[0017] In an aspect, the subject has advanced or metastatic EGFR ex20ins mutant NSCLC.

[0018] These and other advantages, aspects, and novel features of the present disclosure, as well as details of an illustrated embodiment thereof, will be more fully understood from the following description and drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0019] Various aspects of the present disclosure will now be described, by way of example only, with reference to the attached Figures, wherein:

[0020] FIG. 1 is a graph depicting the efficacy of Compound 1 (TAS6417) in a mouse model of Amivantamab pre-treatment.

[0021] FIG. 2 is a summary of patient demographics module C ami overall.

[0022] FIG. 3 is a summary of the best overall tumor response based on investigator assessment per RECITS vl.1 .

[0023] FIG. 4 is a waterfall plot for the best change from baseline in target lesions.

[0024] FIG. 5 is a swim plot for study treatment duration.

[0025] FIG. 6 is a Kaplan Meier plot of progression free survival based on RECITS vl .1.

[0026] FIG. 7 is a summary of treatment-related adverse events of any grade observed in >

10% of patients.

[0027] FIG. 8 is a summary of grade 3 treatment-related adverse events in > 2 patients.

[0028] FIG. 9 shows a flow diagram depicting the analysis groups. The efficacy analysis includes patients treated with oral zipalertinib 100 mg twice daily prior to or on April 25, 2024 (>~8 months before database lock on December 10, 2024); Patients with prior platinum-based chemotherapy without prior EGFR ex20ins-targeted therapy; and Patients who progressed on amivantamab with or without prior mobocertinib and/or other ex20ins agents.

[0029] FIG. 10 is a graph depicting the best change from baseline in target lesions.

[0030] FIGS. 11A and 11B are graphs depicting duration of response per independent central review in the primary efficacy population (FIG. 11 A) and among patients with brain metastasis (FIG. 11B).

[0031] FIGS. 12A and 12B are graphs depicting median progression-free survival per independent central review (FIG. 12A) and median overall survival (FIG. 12B). Progression-free survival was defined as the time between the day of the first dose of zipalertinib to the first documentation of progressive disease or death, whichever occurred earliest. Overall survival was defined as the time between the day of the first dose of zipalertinib until the date of death due to any cause.

DETAILED DESCRIPTION

[0032] I. Introduction

[0033] NSCLC is known to have high rates of somatic mutation and genomic rearrangement. These genes include EGFR, ALK, HER2, ROS1, BRAF, TP53, FGFR1, PIK3CA, NTRK, MET, RET, ERBB2, and KRAS. Up to 23% of all NSCLC involve the EGFR gene mutation and EGFR exon 20 insertions (ex20ins), comprise approximately 10% of EGFR mutations in NSCLC. EGFR ex20ins are a diverse group of mutations that are structurally distinct from the more common EGFR exon 19 deletions and exon 21 L858R point mutations.

[0034] The EGFR is a transmembrane glycoprotein and belongs to the ErbB family of tyrosine kinase receptors. The erythroblastosis oncogene B (ErbB) receptor family includes four receptor tyrosine kinases: EGFR/HERl/ErbB 1 , HER2/ErbB2, HER3/ErbB3, and HER4/ErbB4. These 4 receptors are activated via homodimerization, heterodimerization, and possibly higher-order oligomers, resulting in autophosphorylation of tyrosine residues within the cytoplasmic domain of the receptors, thereby activating a variety of signaling pathways, including Ras and phosphoinositide 3-kinase (PBK). Activating mutations in the EGFR kinase domain induce ligandindependent constitutive activation and subsequent downstream molecule phosphorylation, leading to cancer cell growth and survival. Aberrations in EGFR are found in many cancer types, and therefore much research has been focused on identifying inhibitors capable of regulating the kinase activity of these receptors. However, cancers harboring certain types of aberrations within the ErbB receptor family have proven difficult to treat, leaving patients harboring these cancer types with no or limited treatment options.

[0035] Among NSCLC patients with EGFR mutations, approximately 4-10% of patients have EGFR exon 20 insertion (ex20ins) mutations, with 46% of patients having EGFR exon 19 deletion (ex 19del) mutations and 38% of patients having the EGFR L858R point mutation. Various tyrosine kinase inhibitors (TKIs) targeting EGFR mutations have been developed as anticancer agents, such as gefitinib, erlotinib, and afatinib, for patients with NSCLC harboring activating EGFR mutations (including exon 19 deletions and L858R), and osimertinib for patients with EGFR exon 19 deletions, exon 21 L858R mutations, and T790M acquired resistance mutations. However, these TKIs targeting the classical EGFR mutations have little to no efficacy in NSCLC harboring EGFR ex20ins.

[0036] Platinum-based chemotherapy is the standard of care for the first-line treatment of patients with advanced or metastatic NSCLC in whom targeted therapy treatment options are not indicated or available. In patients with advanced or metastatic NSCLC harboring EGFR ex20ins mutations, current lung cancer treatment guidelines recommend standard platinum-based chemotherapy to treat patients in the front-line setting. This regimen is preferred due to low response rates against EGFR ex20ins mutation patients with single agent first-, second-, and third- generation EGFR TKIs. Real world evidence analysis of overall survival (OS) and progression- free survival (PFS) outcomes indicate that patients having advanced NSCLC with EGFR ex20ins mutations have better outcomes with front-line platinum-based chemotherapy as compared to standard EGFR TKIs. However, outcomes for these patients remain poor regardless of treatment in subsequent lines of therapy.

[0037] Amivantamab is approved for use in patients with NSCLC with EGFR ex20ins and other investigational agents are in development. However, currently available EGFR ex20ins- specific TKIs such as mobocertinib cause frequent rash and diarrhea because of the narrow therapeutic window between inhibition of EGFR ex20ins and wild-type (WT) EGFR. Amivantamab, a bispecific antibody targeting EGFR and mesenchymal-epithelial transition factor (MET), requires intravenous administration and causes frequent infusion reactions (IRRs). [0038] However, despite recent progress in the development of EGFR ex20ins-targeting therapies, there remains a significant need for novel treatment regimen for individuals that have been previously treated with chemotherapy and/or anti-cancer agents. The unmet medical need remains for effective and well -tolerated therapies for patients with previously treated recurrent or metastatic NSCLC harboring EGFR ex20ins mutations. The inventors have unexpectantly found that in patients with disease progression after amivantamab or chemotherapy treatment, Compound 1 has demonstrated efficacy that is at least comparable with, if not exceeding, other EGFR ex20ins- targeted agents, including both mobocertinib and amivantamab.

[0039] Compound 1, is an oral, irreversible, selective inhibitor of Epidermal Growth Factor EGFR exon 20 insertions (ex20ins) with a unique pyrrolopyrimidine structural scaffold distinct from other EGFR ex20ins TKIs (which use quinazoline and pyrimidine scaffolds). Compound 1 potently inhibits cell growth and EGFR signaling in EGFR ex20ins-mutant human cancer cell lines with improved selectivity for ex20ins-mutant versus WT EGFR. Additionally, unlike many other approved and investigational ex20ins TKIs, Compound 1 does not inhibit WT or mutant HER2.

[0040] While the development of effective therapies targeting EGFR ex20ins has been limited by EGFR-mediated toxicities, the safety profile of Compound 1 observed to date appears consistent with its high in vitro selectivity for ex20ins-mutant versus WT EGFR. TRAEs have generally been reversible and manageable with standard supportive care. Diarrhea was observed in 30% of patients across all dose levels, with only two cases of grade 3 diarrhea, both at the highest dose level tested. Antidiarrheal prophylaxis was not required and symptoms were well managed with standard antidiarrheal therapies. Although dermatologic toxicities were more common, with 80% of patients across all dose levels experiencing rash, these were also predominantly low grade. Only one patient (at the 150 mg dose level) experienced grade 3 rash. Dermatologic toxicities observed with Compound 1 have been well managed with conventional supportive care (topical antibiotics and/or corticosteroids, and in a smaller number of patients, oral antibiotics, antihistamines, or corticosteroids).

[0041] The safety profile of Compound 1 appears to compare favorably with that of other EGFR ex20ins-directed therapies. For example, any -grade diarrhea occurred in 91% of patients treated with mobocertinib, 92% with poziotinib, and 54% with sunvozertinib, with over 20% of patients experiencing grade >3 diarrhea with mobocertinib and pozotinib. Although amivantamab causes less diarrhea, dermatologic toxicities including rash (84%) are more common and IRRs occur in 64% of patients. Taken together, the results indicate that Compound 1 may represent a more tolerable oral treatment option for patients with EGFR exon 20 insertion mutations than other currently available agents.

[0042] The ORR (38.4%) and mPFS (10 months) observed with Compound 1, in particular the activity observed in the largest expansion cohort of 100 mg twice a day; suggest that its efficacy may be at least comparable with, if not exceeding, other EGFR ex20ins-targeted agents, including both mobocertinib and amivantamab. Among 81 patients treated with amivantamab on the CHRYSALIS trial, the confirmed ORR was 40% and the mPFS was 8.3 months (95% CI, 6.5 to 10.9). Similarly, mobocertinib led to an ORR of 28% and an mPFS of months. Moreover, the inventors saw responses to Compound 1 in ex20ins TKLpretreated patients.

[0043] Additional clinical data has been obtained for a wider patient pool and across a longer time period in the REZILIENT1 (NCT04036682) study, a phase VII, open-label, multicenter trial to evaluate the safety and efficacy of oral zipalertinib in patients with locally advanced or metastatic EGFR ex20ins NSCLC who have previously received platinum-based chemotherapy. Evidenced by a confirmed ORR of 35.2% in the primary efficacy population, rapid and durable responses, with a median duration of response more than 8 months. The overall CBR was 64.2%, and median PFS and OS were 9.4 and 31.4 months, respectively, with a survival rate 69.3% at 12 months after the first dose of zipalertinib.

[0044] The ORR in patients who had received prior platinum-based chemotherapy without ex20ins-targeted therapy was 40.0%, with a median DOR and PFS of 8.8 and 9.4 months, respectively. These findings are similar to those observed in the phase I CHRYSALIS trial of amivantamab monotherapy, in which the confirmed ORR was 40% and the median DOR and PFS were 11.1 and 8.3 months, respectively. The results also compare favorably with those observed with mobocertinib or poziotinib, which showed confirmed ORRs of 28% and 31%, respectively and were comparable to those recently reported for sunvozertinib (confirmed ORR, 41%) and furmonertinib (41-50%).28, 29

[0045] Exploratory subgroup analysis showed that patients who had received prior treatment with amivantamab alone achieved an ORR of 30.0%, supporting the potential efficacy of zipalertinib in the post-amivantamab setting. Observing comparable efficacy of zipalertinib in patients who received prior amivantamab alone and those who received platinum-based chemotherapy without any prior ex20ins-targeted therapy suggests a lack of cross resistance between the two agents and has important implications regarding treatment sequencing. By comparison, limited activity (ORR, 14.3%) was observed in the subgroup who received prior amivantamab and other ex20ins-targeted therapies. Although little is known regarding resistance to EGFR TKIs in patients with EGFR ex20ins NSCLC this observation may reflect accumulation of resistance mutations that confer cross resistance, resulting from selective pressure under prior EGFR TKI treatment.

[0046] The management of CNS metastases in patients with NSCLC remains a critical unmet need, particularly among patients with EGFR ex20ins, where the prognosis is particularly unfavorable. It is notable, therefore, that zipalertinib demonstrated promising systemic efficacy (ORR, 30.9%) in patients with asymptomatic, stable CNS metastases. This finding is in line with anecdotal cases of intracranial activity in the same study and provides preliminary evidence that zipalertinib may be active in this patient population. The activity of zipalertinib in patients with active or untreated brain metastases therefore warrants further investigation.

[0047] The safety profile of zipalertinib was consistent with previously reported data25 and with the toxicities associated with other EGFR TKIs with the most common TRAEs being low- grade dermatologic toxicities. Treatment with zipalertinib appeared to result in a lower occurrence of any-grade/grade >3 treatment-related diarrhea (26%/2%) than observed in previous studies of mobocertinib (91 %/21%) and poziotinib (92%/22%), with similar findings for rash (30%/2% with zipalertinib vs 45%/0% with mobocertinib and 90%/34% with poziotinib, respectively). Both AEs are known on-target toxicities associated with EGFR TKIs.33, 34 The incidence of grade >3 treatment-related diarrhea with zipalertinib was also lower than reported for sunvozertinib in a phase II study in patients with platinum-pretreated EGFR ex20ins NSCLC. Pneumonitis, another class effect of EGFR TKIs was among the most common grade >3 TRAEs with zipalertinib (2.5% of patients). However, it is notable that almost half of patients had received prior anti-PD-(L)! therapy, which has been shown to increase the likelihood of severe immune-related AEs, including pneumonitis, with subsequent EGFR- TKI therapy.

[0048] TRAEs with zipalertinib were generally reversible and manageable with dose modifications and/or supportive care, as reflected in the low rates of treatment discontinuation (8.2%). Tn totality, these findings support the overall tolerability of zipalertinib in patients with previously treated EGFR ex20ins NSCLC, particularly when considered in the context of other EGFR TKIs, where the broader therapeutic window of zipalertinib offers the potential to maximize therapeutic efficacy while minimizing the diarrhea and rash associated with wildtype EGFR inhibition. Although zipalertinib had similar efficacy to that observed previously with amivantamab monotherapy, the safety profiles of the two agents differ. Amivantamab is associated with infusion-related reactions, as well as toxicities related to MET inhibition, such as hypoalbuminemia and peripheral edema which are not observed with zipalertinib; however, patients treated with amivantamab still experience the GI and dermatologic toxicities associated with EGFR inhibition.

[0049] II. Definitions

[0050] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the methods described herein belong. Any reference to standard methods (e.g., ASTM, TAPPI, AATCC, etc.) refers to the most recent available version of the method at the time of filing of this disclosure unless otherwise indicated.

[0051] For any method disclosed herein that includes discrete steps, the steps may be conducted in any feasible order. And, as appropriate, any combination of two or more steps may be conducted simultaneously.

[0052] All headings are for the convenience of the reader and should not be used to limit the meaning of the text that follows the heading, unless so specified.

[0053] The words "preferred" and "preferably" refer to embodiments of the invention that may afford certain benefits, under certain circumstances. However, other embodiments may also be preferred, under the same or other circumstances. Furthermore, the recitation of one or more preferred embodiments does not imply that other embodiments are not useful and is not intended to exclude other embodiments from the scope of the invention.

[0054] The term "comprises" and variations thereof do not have a limiting meaning where these terms appear in the description and claims. Such terms will be understood to imply the inclusion of a stated step or element or group of steps or elements but not the exclusion of any other step or element or group of steps or elements.

[0055] By "consisting of is meant including, and limited to, whatever follows the phrase "consisting of." Thus, the phrase "consisting of indicates that the listed elements are required or mandatory, and that no other elements may be present. By "consisting essentially of is meant including any elements listed after the phrase, and limited to other elements that do not interfere with or contribute to the activity or action specified in the disclosure for the listed elements. Thus, the phrase "consisting essentially of indicates that the listed elements are required or mandatory, but that other elements are optional and may or may not be present depending upon whether or not they materially affect the activity or action of the listed elements.

[0056] The singular form "a", "an" and "the" include plural referents unless the context clearly dictates otherwise. These articles refer to one or to more than one (i.e., to at least one). As used herein, the term "or" is generally employed in its usual sense including "and/or" unless the content clearly dictates otherwise. The term "and/or" means any one or more of the items in the list joined by "and/or". As an example, "x and/or y" means any element of the three-element set {(x), (y), (x, y)}. In other words, "x and/or y" means "one or both of x and y". As another example, "x, y, and/or z" means any element of the seven-element set {(x), (y), (z), (x, y), (x, z), (y, z), (x, y, z)}. In other words, "x, y and/or z" means "one or more of x, y and z".

[0057] Where ranges are given, endpoints include all numbers subsumed within that range (e.g., 1 to 5 includes 1, 1.5, 2, 2.75, 3, 3.80, 4, 5, etc.). Furthermore, unless otherwise indicated or otherwise evident from the context and understanding of one of ordinary skill in the art, values that are expressed as ranges can assume any specific value or subrange within the stated ranges in different embodiments of the disclosure, to the tenth of the unit of the lower limit of the range, unless the context clearly dictates otherwise. Herein, "up to" a number (for example, up to 50) includes the number (for example, 50). The term "in the range" or "within a range" (and similar statements) includes the endpoints of the stated range.

[0058] Reference throughout this specification to "one aspect,” "an aspect,” "certain aspects," or "some aspects," etc., means that a particular feature, configuration, composition, or characteristic described in connection with the aspect is included in at least one aspect of the disclosure. Thus, the appearances of such phrases in various places throughout this specification are not necessarily referring to the same embodiment of the disclosure. Furthermore, the particular features, configurations, compositions, or characteristics may be combined in any suitable manner in one or more aspects.

[0059] Unless otherwise indicated, all numbers expressing quantities of components, molecular weights, and so forth used in the specification and claims are to be understood as being modified in all instances by the term "about." As used herein in connection with a measured quantity, the term "about" refers to that variation in the measured quantity as would be expected by the skilled artisan making the measurement and exercising a level of care commensurate with the objective of the measurement and the precision of the measuring equipment used. The term "about" as used in connection with a numerical value throughout the specification and the claims denotes an interval of accuracy, familiar and acceptable to a person skilled in the art. In general, such interval of accuracy is +/-10%. Accordingly, unless otherwise indicated to the contrary, the numerical parameters set forth in the specification and claims are approximations that may vary depending upon the desired properties sought to be obtained by the present invention. At the very least, and not as an attempt to limit the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques.

[0060] Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the invention are approximations, the numerical values set forth in the specific examples are reported as precisely as possible. All numerical values, however, inherently contain a range necessarily resulting from the standard deviation found in their respective testing measurements.

[0061] The term "exemplary" means serving as a non-limiting example, instance, or illustration. As utilized herein, the terms "e.g.," and "for example" set off lists of one or more nonlimiting aspects, examples, instances, or illustrations.

[0062] As used herein, the term "substantially" refers to the qualitative condition of exhibiting total or near-total extent or degree of a characteristic or property of interest. Biological and chemical phenomena rarely, if ever, go to completion and/or proceed to completeness or achieve or avoid an absolute result. The term "substantially" is therefore used herein to capture the potential lack of completeness inherent in many biological and chemical phenomena. For example, "substantially" may refer to being within at least about 20%, alternatively at least about 10%, alternatively at least about 5% of a characteristic or property of interest.

[0063] As used herein, “antagonist” and “inhibitor” are used interchangeably, and they refer to a compound or agent having the ability to inhibit a biological function of a target protein or polypeptide, such as by inhibiting the activity or expression of the target protein or polypeptide. Accordingly, the terms “antagonist” and “inhibitor” are defined in the context of the biological role of the target protein or polypeptide. While some antagonists herein specifically interact with (e g., bind to) the target, compounds that inhibit a biological activity of the target protein or polypeptide by interacting with other members of the signal transduction pathway of that target protein or polypeptide are also specifically included within this definition. Non-limiting examples of biological activity inhibited by an antagonist include those associated with the development, growth, or spread of a tumor, or an undesired immune response as manifested in autoimmune disease.

[0064] As used herein, “anti-cancer agent”, “anti-tumor agent” or “chemotherapeutic agent” refers to any agent useful in the treatment of a neoplastic condition. One class of anti-cancer agents comprises chemotherapeutic agents. “Chemotherapy” means the administration of one or more chemotherapeutic drugs and/or other agents to a cancer patient by various methods, including intravenous, oral, intramuscular, intraperitoneal, intravesical, subcutaneous, transdermal, buccal, or inhalation or in the form of a suppository.

[0065] As used herein, “cell proliferation” refers to a phenomenon by which the cell number has changed as a result of cell division. This term also encompasses cell growth by which the cell morphology has changed (e.g., increased in size) consistent with a proliferative signal.

[0066] As used herein, “administration” of a disclosed compound encompasses the delivery to a subject of a compound as described herein, or a prodrug or other pharmaceutically acceptable derivative thereof, using any suitable formulation or route of administration, as discussed herein. [0067] As used herein, “co-administration,” “administered in combination with,” and their grammatical equivalents, as used herein, encompasses administration of two or more agents to a subject such that both agents and/or their metabolites are present in the subject at the same time. Co-administration includes simultaneous administration in separate compositions, administration at different times in separate compositions, or administration in a single fixed dose composition in which both agents are present.

[0068] As used herein, “selective inhibition” or “selectively inhibit” as applied to a biologically active agent refers to the agent's ability to selectively reduce the target signaling activity as compared to off-target signaling activity, via direct or indirect interaction with the target. For example, a compound that selectively inhibits exon 20 mutant EGFR over wild-type EGFR has an activity of at least about 2*against the mutated EGFR relative to the compound's activity against the wild-type EGFR isoform (e.g., at least about 3*, about 5x, about 10*, about 20*, about 50*, or about 100x).

[0069] As used herein, “in vivo” refers to an event that takes place in a subject's body. In vivo also includes events occurring in rodents, such as rats, mice, guinea pigs, and the like.

[0070] As used herein, “in vitro” refers to an event that takes places outside of a subject's body. For example, an in vitro assay encompasses any assay conducted outside of a subject. In vitro assays encompass cell-based assays in which cells, alive or dead, are employed. In vitro assays also encompass a cell-free assay in which no intact cells are employed.

[0071] As used herein, “therapeutic effect” encompasses a therapeutic benefit as described above. A “prophylactic effect” includes delaying or eliminating the appearance of a disease or condition, delaying or eliminating the onset of symptoms of a disease or condition, slowing, halting, or reversing the progression of a disease or condition, or any combination thereof.

[0072] The invention is defined in the claims. However, below is a non-exhaustive listing of non- limiting exemplary aspects. Any one or more of the features of these aspects may be combined with any one or more features of another example, embodiment, or aspect described herein.

[0073] III. Methods of Treatment of NSCLC

[0074] An exemplary embodiment of the present disclosure involves administering Compound 1 or its pharmaceutically acceptable salt to a subject with NSCLC who has previously undergone at least one systemic treatment.

[0075] Examples of systemic treatments include, but are not limited to, treatment with one or more EGFR inhibitor(s) (i.e., EGFR inhibitors other than Compound 1, such as gefitinib, erlotinib, afatinib, dacomitinib, osimertinib, amivantamab, mobocertinib, poziotinib, and/or sunvozertinib), platinum anticancer agents, or both. Systemic treatment does not include local treatment such as localized or limited tumor rescission.

[0076] Before commencing treatment, determination may be made as to whether the subject has one or more aberrations in EGFR, as described below. Thus, the methods may involve a prescreening step to determine whether the subject has an aberration in EGFR and is a good candidate for treatment. The aberration(s) may be determined from family history of cancers involving the aberration(s), by genotyping the subject or analyzing any biological sample from the subject including blood or tumor samples taken from the subject using assays such as those described hereinafter, or from historical records or previous testing performed on the subject. If the subject is determined to be EGFR-positive, and to harbor one or more aberrations therein such as those described in the present disclosure, treatment with Compound 1 is appropriate.

[0077] In an exemplary embodiment, the disclosure provides methods for treating non-smallcell lung cancer (NSCLC) in a subject who was previously been treated with amivantamab. In another exemplary embodiment, the disclosure provides methods for treating non-small-cell lung cancer (NSCLC) in a subject who was previously been treated with chemotherapy.

[0078] As used herein, the terms “subject”, “individual”, and “patient” are interchangeable, and relate to vertebrates, preferably mammals. For example, mammals in the context of the disclosure are humans, non-human primates, domesticated animals such as dogs, cats, sheep, cattle, goats, pigs, horses, etc., laboratory animals such as mice, rats, rabbits, guinea pigs, etc., as well as animals in captivity such as animals in zoos. The term "animal" as used herein includes humans. The term "subject" may also include a patient, i.e., an animal, having a disease. In exemplary aspects, a subject, individual, or patient refers to a human (e.g., a man, a woman, or a child).

[0079] NSCLC is the most common form of lung cancer and is histologically divided into adenocarcinoma, squamous cell carcinoma (SCC) and large cell carcinoma. In an aspect, the method includes administering an effective amount of (S)-N- (4-amino-6-methyl-5- (quinolin-3- yl)-8,9-dihydropyrimido[5,4-b]indolizin-8- yl)acrylamide (Compound 1) or a salt thereof. Compound 1 may also be referred to as CLN-081, TAS-6417 and/or Zipalertinib. [0080] Compound 1 has the following structure:

[0082] The chemical synthesis and chemical properties of Compound 1 have been described in U.S. Patent No. 9,650,386, which is fully incorporated by reference herein. Compound 1 is a potent, and highly selective EGFR-TKI (as described in PCT Publication No. WO 2018/079310, which is fully incorporated by reference herein).

[0083] In some aspects, the salt of Compound l is a pharmaceutically acceptable salt. The term “pharmaceutically acceptable salt” refers to those salts which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of subjects without undue toxicity, irritation, allergic response and the like, and are commensurate with a reasonable benefit/risk ratio. Pharmaceutically acceptable salts are well known in the art. For example, Berge et al. describes pharmaceutically acceptable salts in detail in J. Pharmaceutical Sciences (1977) 66: 1-19. Pharmaceutically acceptable salts of the compounds provided herein include those derived from suitable inorganic and organic acids and bases. Examples of pharmaceutically acceptable, nontoxic acid addition salts are salts of an amino group formed with inorganic acids such as hydrochloric acid, hydrobromic acid, phosphoric acid, sulfuric acid and perchloric acid or with organic acids such as acetic acid, oxalic acid, maleic acid, tartaric acid, citric acid, succinic acid or malonic acid or by using other methods used in the art such as ion exchange. Other pharmaceutically acceptable salts include adipate, alginate, ascorbate, aspartate, benzenesulfonate, besylate, benzoate, bisulfate, borate, butyrate, camphorate, camphorsulfonate, citrate, cyclopentanepropionate, di gluconate, dodecyl sulfate, ethanesulfonate, formate, fumarate, glucoheptonate, glycerophosphate, gluconate, hemisulfate, heptanoate, hexanoate, hydroiodide, 2-hydroxy- ethanesulfonate, lactobionate, lactate, laurate, lauryl sulfate, malate, maleate, malonate, methanesulfonate, 2-naphthalenesulfonate, nicotinate, nitrate, oleate, oxalate, palmitate, pamoate, pectinate, persulfate, 3-phenylpropionate, phosphate, picrate, pivalate, propionate, stearate, succinate, sulfate, tartrate, thiocyanate, p-toluenesulfonate, undecanoate, valerate salts, and the like. In some embodiments, organic acids from which salts can be derived include, for example, acetic acid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, lactic acid, trifluoracetic acid, maleic acid, malonic acid, succinic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid, and the like.

[0084] In certain embodiments, the pharmaceutically acceptable salt is a succinate salt, fumarate salt, hippurate salt, oxalate salt, mesylate salt, tosylate salt, sulfate salt, hydrochloride salt, or hydrobromide salt.

[0085] A "disease", as used herein, is a state of health of a subject wherein the subject cannot maintain homeostasis, and wherein if the disease is not ameliorated, the subject's health continues to deteriorate. In contrast, a "disorder" is a state of health in which the subject is able to maintain homeostasis, but in which the subject's state of health is less favorable than it would be in the absence of the disorder. Left untreated, a disorder does not necessarily cause a further decrease in the subject's state of health. A disease or disorder is "alleviated" if the severity of a sign or symptom of the disease or disorder, the frequency with which such a sign or symptom is experienced by a subject, or both, is reduced.

[0086] The terms “treat”, “treating”, or “treatment” refer to administering to a subject a compound or pharmaceutical composition disclosed herein to partially or completely alleviate, inhibit, ameliorate, or relieve the disease or disorder from which the subject is suffering. This means any manner in which one or more of the symptoms of a disease or disorder are ameliorated or otherwise beneficially altered. As used herein, amelioration of the symptoms of a particular disease or disorder refers to any lessening, whether permanent or temporary, lasting or transient, that can be attributed to or associated with treatment by the compounds, compositions, and methods of the present disclosure. For example, treating a subject can mean eliminating or reducing the clinical signs of a disease or disorder in the subject; arrest, inhibit, or slow the progression of the disease or disorder in the subject; and/or decrease the number, frequency, or severity of clinical symptoms and/or recurrence of the disease or disorder in the subject who currently has or who previously had the disease or disorder. In particular, the terms “treatment of a disease” and “treating a disease” include curing, shortening in duration, ameliorating, slowing down, inhibiting progression or worsening, or delaying the onset of clinical symptoms in a subject who has the disease or disorder.

[0087] The terms “prophylactic”, “preventive”, “preventing”, and “prevention” refer to a decrease in the occurrence of a disease or disorder, or a decrease in the risk of acquiring a disease or its associated symptoms in a subject. The prevention can be complete, e.g., the total absence of the disease or disorder) or partial, e.g., the occurrence of the disease or disorder in a subject is less than, occurs later than, or develops more slowly than that which would have occurred without the disclosed compounds, compositions, and methods.

[0088] As used herein, the term “preventing a disease” in a subject means, for example, to stop the development of one or more clinical symptoms of a disease or disorder in a subject before they occur or are detectable. Preferably, the disease or disorder does not develop at all, i.e., no symptoms of the disease or disorder are detectable. In some aspects, it can also mean delaying or slowing of the development of one or more symptoms of the disease or disorder. Alternatively, or in addition, it can mean decreasing the severity of one or more subsequently developed symptoms.

[0089] In some aspects, the treatment is given to a subject who the subject failed to respond to amivantamab or had disease progression after administration of amivantamab. A subject who failed to respond to a treatment, also known as non-responsive or lack of respond, does not exhibit any alleviate, inhibit, ameliorate, or relieve from the disease or disorder from which the subject is suffering after the administration of the treatment. “Disease progression” in a subject means, for example, that the course of the disease becomes worse or spreads through the body. In some aspects, the subject was also previously treated with chemotherapy.

[0090] In some aspects, the treatment is given to a subject who the subject failed to respond to chemotherapy or had disease progression after administration of chemotherapy. In some aspects, the subject was also previously treated with amivantamab.

[0091] In other aspects, the subject was also treated with mobocertinib, poziotinib, and/or sunvozertinib. [0092] In some embodiments, the subject has at least one mutation in non-small cell lung cancer, alternatively at least two mutations, or alternatively at least three mutations.

[0093] In an aspect, the mutation is selected from the group consisting of an epidermal growth factor receptor (EGFR) mutation, a HER2 mutation, a TP53 mutation, a KRAS mutation, a MET mutation, an anaplastic lymphoma kinase (ALK) mutation, a ROS1 mutation, a BRAE mutation, a FGFR1 mutation, a PZK3CA mutation, a RET mutation, a NTRK mutation, and a ERBB2 mutation.

[0094] EGFR, KRAS, and FGFR1 are the most common mutations in subjects with NSCLC, with the majority having two or more mutations. EGRF and KRAS mutations are more common in adenocarcinoma type of NSCLC, while FGFR1 is more common in squamous carcinoma type NSCLC. ROS1 and ALK gene mutations tend to present in younger non-smoking subjects.

[0095] Unless specified otherwise, any reference to EGFR amino acid sequence information is based on human wild-type EGFR isoform a, which is accessible from the National Center for Biotechnology Information (NCBI) Protein Database as Accession No. NP_005219.2, P00533.2, etc. Isoforms of EGFR are also known by those of ordinary skill in the art, and the present disclosure also encompasses those isoforms. With regard to mutations in EGFR discussed herein, it should be understood that the alteration in the isoform may be located in a different position from the position identified for EGFR due to deletion or insertion of an amino acid(s) in the isoform, but that the alteration in the isoform nevertheless corresponds to the position identified for EGFR.

[0096] In some embodiments, the at least one mutation is an EGFR mutation.

[0097] EGFR mutations may be located in the tyrosine kinase domain of EGFR, including, but not limited to, one or more of: exon 18 (in the region of 688-728); exon 19 (in the region of 729- 761); exon 20 (in the region of 762-823); and exon 21 (in the region of 824- 875).

[0098] EGFR exon 18 mutations may include, but are not limited to, point mutations such as E709Xor G719X(where X is an arbitrary amino acid), exemplified by E709K, E709A, E709G, G719A, G719S, and G719C, deletion mutations, and deletion insertion mutations, for example deletion of glutamic acid at position 709 and threonine at position 710 and insertion of aspartic acid (DelE709_T710insD), and the like.

[0099] EGFR exon 19 mutations may include, but are not limited to, "classical" Exon 19 deletion mutations of at least three amino acid residues, as well as deletion insertion mutations, for example DelE746_A750 (deletion of glutamic acid at position 746 to alanine at position 750), DelL747_P753insS (deletion of leucine at position 747 to proline at position 753 and insertion of serine), DelE746_T751insA, DelE746_S752insD, DelL747_T751, DelL747_A750insP, and the like.

[0100] EGFR exon 20 mutations may include, but are not limited to, point mutations such as T790M, S768I, V769M, and H773R, deletion mutations, and insertion mutations. Compound 1 or its pharmaceutically acceptable salts have been found to be surprisingly active in cancers harboring one or more EGFR exon 20 insertion mutations.

[0101] EGFR exon 20 insertion mutations are found with relatively high prevalence in NSCLC as well as sinonasal squamous cell carcinoma (SNSCC), are associated with de novo resistance to current clinically available EGFR inhibitors. In some embodiments, the EGFR exon 20 insertion mutations are the preferred targets for treatment.

[0102] EGFR exon 20 insertion mutations may be heterogeneous in-frame insertions of between 1-7 amino acids (indicated as "insX") across a span of about 15 amino acids (D761- C775) in exon 20, for example D761 E762insX (insertion of between 1-7 amino acid residues "X" in between aspartic acid at position 761 and glutamic acid at position 762), A763_Y764insX, Y764_V765insX, V765_M766insX, A767_S768insX, S768_V769insX, V769_D770insX, D770_N771insX, N771_P772insX, P772_H773insX, H773_V774insX, and V774_C775insX.

[0103] Also included are deletion insertion mutations, such as DelD770insX (deletion of aspartic acid at position 770 and insertion of 1-7 amino acids "X") and DelN771insX (Simon Vyse and Paul H. Huang, Targeting EGFR exon 20 insertion mutations in non-small cell lung cancer. Signal Transduct Target Ther. 2019 Mar 8;4:5).

[0104] Specific examples of EGFR exon 20 insertion mutations include, but are not limited to, A763_Y764insFQEA, A763_Y764insTLA, Y764_V765insHH, A767_S768insASV, S768dupSVD, S768_V769insVAS, S768_V769insAWT, V769_D770insGV, V769_D770insCV, V769_D770insDNV, V769_D770insGSV, V769_D770insGVV, V769_D770insMASVD, V769 D770insASV, V769 D770insGE, V769 D770dellnsDGEL, V769 D770insASV, D770_N771insSVD, D770_N771insNPG, D770_N771insKH, D770_N771insGNPH, D770_N771insAPW, D770_N771insD, D770_N771insDG, D770delinsGY, D770_N771insGL, D770_N771insN, D770_N771insNPH, D770_N771insSVP, D770_N771insSVQ, D770_N771insMATP, D770_N771insG, D770_N771insY, D770_N771insGF, D770_N771insGT, D770_N771insSVG, DelD770insGY, DelD770insVG, N771_P772insH, N771_P772insV, N771_P772insN, DelN771insGY, DelN771insTH, delN771insGF, N771delinsGY, N771_P772insRH, P772_H773insPR, P772_H773insYNP, P772_H773insX, P772_H773insDPH, P772_H773insQV, P772_H773insTPH, P772_H773insN, P772_H773insV, P772_H773insNP, P772_H773insDNP, P772_H773insPNP, P772_H773insNPH, H773_V774insNPH, H773_V774insPH, H773_V774insGNPH, H773_V774insG, 24 H773_V774insGH,

H773_V774insAH, H773_V774insH, H773_V774delinsLM, H773_V774delinsTY, and V774_C775insHV.

[0105] In some aspects, the subject has advanced or metastatic EGFR ex20ins mutant NSCLC. Advanced or metastatic NSCLC patients with EGFR Exon 20 insertion mutations have a worse prognosis compared to those with other common mutations.

[0106] While cancers at various stages and resectabilities may respond to the disclosed treatment, the methods herein may be particularly useful in the treatment of unresectable or advanced (stage III, "locally advanced") and metastatic (stage IV) disease, "recurrent," "resistant", and "refractory" cancers-cancer that heretofore has failed to respond to medical treatment. "Recurrent" cancers are cancers that have recurred (come back), usually after a period of time during which the cancer could not be detected. The cancer may come back to the same place as the original (primary) tumor or to another place in the body. "Refractory" cancers may present as resistance/intractability from the start. "Resistant" cancers may present following the acquisition of resistance/intractability by the cancer cells during the course of prior therapy, and thus can include relapsed cancer that responds initially to treatment, but returns, often in a more aggressive/resistant form. Resistant cancers may also be described as having "secondary resistance", "acquired resistance", or similar term. For example, the cancer may be a recurrent, resistant, or refractory EGFR -positive cancer, preferably a recurrent, resistant, or refractory cancer in which EGFR is genetically amplified and/or overexpressed. Example cancer types may include, but are not limited to, recurrent, resistant, or refractory EGFR-positive NSCLC. Particularly relevant to the present disclosure of cancers which are locally advanced and/or which have metastasized to the brain of the subject.

[0107] Subjects with a recurrent, resistant, or refractory cancer who have previously undergone at least one treatment regimen with one or more anticancer agents may be treated with Compound 1 or its pharmaceutically acceptable salt. In some cases, the recurrent, resistant, or refractory cancer may have acquired resistance to, or intractability from, the prior treatment regimen(s). For example, a subject with a EGFR- positive cancer treated previously with one or more anticancer agents, and that failed to respond to or relapsed from the prior treatment(s) with the anticancer agent(s), may develop resistance/intractability as a result of exposure of the cancer to the anticancer agent(s).

[0108] Resistance/intractability may manifest in the cancer in the form of EGFR aberrations e.g., overexpression and/or mutations, or any other cancer driver alterations that result in loss-of- function of tumor suppressor genes/proteins or gain-of-function alterations in oncogenes/oncogene-encoded proteins.

[0109] Dosing Regimens

[0110] In an aspect, the effective amount of Compound 1 administered is a therapeutically effective or pharmaceutically effective amount. As used herein, “effective amount” or “therapeutically effective amount” refers to that amount of a compound or pharmaceutical composition described herein that is sufficient to affect the intended application including, but not limited to, disease treatment, as illustrated below. In some embodiments, the amount that is effective for detectable killing or inhibition of the growth or spread of cancer cells, the size or number of tumors, or other measure of the level, stage, progression or severity of the cancer. The therapeutically effective amount can vary depending upon the intended application (in vitro or in vivo), or the subject and disease condition being treated, e.g., the weight and age of the subject, the severity of the disease condition, the manner of administration and the like. The term also applies to a dose that will induce a particular response in target cells, e.g., reduction of cell migration.

[0111] The dosage amount and treatment duration are dependent on factors, such as bioavailability of a drug, administration mode, toxicity of a drug, gender, age, lifestyle, body weight, the use of other drugs and dietary supplements, the disease stage, tolerance and resistance of the body to the administered drug, etc., and then determined and adjusted accordingly. An appropriate dosage amount may differ from one individual to another. An appropriate dosage amount in any individual case may be determined using techniques, such as dose escalation.

[0112] The subject having a NSCLC can be treated with Compound 1 or its pharmaceutically acceptable salt at dose levels of from about 10 mg/day, from about 15 mg/day, from about 20 mg/day, from about 30 mg/day, from about 40 mg/day, from about 50 mg/day, from about 60 mg/day, from about 80 mg/day, from about 100 mg/day, from about 125 mg/day, from about 140 mg/day and up to about 500 mg/day, up to about 480 mg/day, up to about 450 mg/day, up to about 400 mg/day, up to about 350 mg/day, up to about 300 mg/day, up to about 250 mg/day, up to about 240 mg/day, up to about 200 mg/day, up to about 150 mg/day. The dosing level may be varied within the ranges such as from about 10 mg/day to about 500 mg/day, from about 20 mg/day to about 300 mg/day, and from about 30 mg to about 150 mg/day. In one embodiment, the dosing level is about 100 mg/day.

[0113] The administration dose level can be changed during an administration schedule, for example, the administration can begin with low dose for some time and then increased, or, the administration can begin with high dose for some time and then decreased. The dosing can be continuous (daily; 7 days of administration in a week) or intermittent (alternating one or more dosing days with one or more non-dosing days, such as 4 days-on/3 days-oft), for example, depending the pharmacokinetics and a particular patient's clearance/accumulation of the drug. The dosing schedule should be selected using sound medical judgement. Daily administration is preferred. The dosing may be performed every other day (QOD), once per day (QD), twice per day (BID) or more than twice per day (TID, etc.), with doses of about 30 to 150 mg/day being preferred.

[0114] The daily dose may be administered as a single dose or multiple individual divided doses. For example, one (1) tablet, containing 50 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the patient once per day (QD) for a total dose of 50 mg/day. In another example, two (2) tablets, each containing 50 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the patient once per day (QD) for a total dose of 100 mg/day. In another example, one (1) tablet, containing 50 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the patient twice per day (BID) for a total dose of 100 mg/day. In another example, two (2) tablets, each containing 50 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the patient twice per day (BID) for a total dose of 200 mg/day. In another example, three (3) tablets, each tablet containing 10 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the subject once per day (QD) for a total dose of 30 mg/day. In another example, three (3) tablets, each tablet containing 20 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the subject twice per day (BID) for a total dose of 120 mg/day. The multiple individual divided doses can be equal in terms of the amount of Compound 1 or its pharmaceutically acceptable salt or can contain different amounts of Compound 1 or its pharmaceutically acceptable salt. For example, one (1) tablet, containing 50 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the patient as a first dose in a day and two (2) tablets, each containing 50 mg of Compound 1 or its pharmaceutically acceptable salt, may be administered to the patient as a second dose in a day, for a total dose of 150 mg/day.

[0115] In certain aspects, an effective amount of Compound 1 or a salt thereof is administered orally at least twice a day. In some embodiments, the effective amount administered is about 30 mg of Compound 1 or a salt thereof. In some embodiments, the effective amount administered is about 45 mg of Compound 1 or a salt thereof. In some embodiments, the effective amount administered is about 65 mg of Compound 1 or a salt thereof. In some embodiments, the effective amount administered is about 100 mg of Compound 1 or a salt thereof. In some embodiments, the effective amount administered is about 150 mg of Compound 1 or a salt thereof.

[0116] In some embodiments, the method comprises administering to the subject twice daily (e g., every 12 hours) a dose between about 30 mg and about 150 mg of Compound 1 (e.g., between about 30 mg and about 145 mg, between about 30 mg and about 140 mg, between about 30 mg and about 135 mg, between about 30 mg and about 130 mg, between about 30 mg and about 125 mg, between about 30 mg and about 120 mg, between about 30 mg and about 115 mg, between about 30 mg and about 110 mg or between about 30 mg and about 105 mg).

[0117] In some embodiments, the method comprises administering to the subject twice daily (e.g., every 12 hours) a dose of about 30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg, about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 85 mg, about 90 mg, about 95 mg, about 100 mg, about 105 mg, about 110 mg, about 115 mg, about 120 mg, about 125 mg, about 130 mg, about 135 mg, about 140 mg, about 145 mg or about 150 mg.

[0118] In some embodiments, the method comprises administering to the subject twice daily (e g., every 12 hours) a dosebetween about 30 mg and about 100 mg of Compound 1 (e.g., between about 30 mg and about 95 mg, between about 30 mg and about 90 mg, between about 30 mg and about 85 mg, between about 30 mg and about 80 mg, between about 30 mg and about 75 mg, between about 30 mg and about 70 mg, between about 30 mg and about 65 mg, between about 30 mg and about 60 mg or between about 30 mg and about 55 mg).

[0119] In some embodiments, the method comprises administering to the subject twice daily (e g., every 12 hours) a dose of about 30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg, about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 85 mg or about 90 mg of Compound 1.

[0120] In some embodiments, the method comprises administering to the subject twice daily (e.g., every 12 hours) a dose of about 30 mg, about 45 mg, about 65 mg, about 100 mg or about 150 mg of Compound 1.

[0121] In some embodiments, the method comprises administering to the subject twice daily (e.g., every 12 hours) a dose of about 30 mg of Compound 1.

[0122] In some embodiments, the method comprises administering to the subject twice daily (e.g., every 12 hours) a dose of about 45 mg of Compound 1.

[0123] In some embodiments, the method comprises administering to the subject twice daily (e.g., every 12 hours) a dose of about 65 mg of Compound 1. [0124] In some embodiments, the method comprises administering to the subject twice daily (e.g., every 12 hours) a dose of about 100 mg of Compound 1.

[0125] In some embodiments, the method comprises administering to the subject twice daily (e.g., every 12 hours) a dose of about 150 mg of Compound 1.

[0126] The dosing whether continuous or intermittent is continued for a particular treatment cycle, typically at least a 21 -day cycle, which can be repeated with or without a drug holiday. Longer or shorter cycles can also be used such as 7 days, 14 days, 18 days, 24 days, 28 days, 35 days, 42 days, or any range therebetween. In certain embodiments, Compound 1 is administered in 21 -day cycles.

[0127] The treatment cycle may be repeated without a drug holiday or with a drug holiday depending upon the subject. A treatment cycle of alternating and consecutive days can be used. For instance, a dosing schedule of sequential 7- day periods may be used where each period comprises alternating 4 days-on and 3 days-off. Here, this schedule would involve dosing on days 1, 3, 5, 7, 8, 10, 12, 14, 15, 17, 19, 21, and so on. Other schedules are possible depending upon the presence or absence of adverse events, response of the cancer to the treatment, patient convenience, and the like. An "adverse event" refers to any unfavorable or unintended illness or symptom thereof occurring in a patient to whom a drug has been administered. It does not matter whether there is a causal relationship with the drug or not.

[0128] In some embodiments, Compound 1 is administered in consecutive 21-day cycles (e.g., without a pause between the end of one cycle and the beginning of the next cycle).

[0129] In some embodiments Compound 1 is administered until disease progression, unacceptable toxicity, or voluntary discontinuation by subject or physician.

[0130] The larger doses are usually given intermittently with doses up to about 150 mg usually given continuously (daily). Compound 1 may be dosed using an up-titration regimen, whereby a subject is started with a low dose for a certain period of time (e.g., 2 weeks) and then the dose is escalated. The dose may be up-titrated until either a target or maximum dose is reached or the subject experiences adverse events at which point the escalation is stopped and the drug dosing is reduced to a previous dose where the adverse event was not experienced or was not serious enough to require stoppage of the treatment. A subject that experiences an adverse event may also be managed with dosing interruptions (e.g., a drug holiday), if deemed appropriate. Typical dosing for the continuous regimen may be 30, 45, 60, 75, 100, or 150 mg/day but higher or lower doses may be used depending on the subject's response to the treatment and presence or absence of adverse events. If a dose is well -tolerated, the dose can be increased. The continuous administration may be continued for one treatment cycle, e.g., 21 days, the treatment cycle may then be repeated, as desired. In some embodiments, only one treatment cycle is performed. In some embodiments, up to 10 treatment cycles are performed. In general, any number of treatment cycles can be performed, for example 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 treatment cycles can be performed. A drug holiday can be included in between any treatment cycles. A treatment regimen can include treatment cycles between which a drug holiday is included and treatment cycles between which a drug holiday is not included.

[0131] Compound 1 or its pharmaceutically acceptable salt may be specially formulated for administration in solid or liquid form, including those adapted for the following: (1) oral administration, for example, drenches (aqueous or non-aqueous solutions or suspensions), tablets or capsules, e.g., those targeted for buccal, sublingual, and systemic absorption, boluses, powders, granules, syrups, pastes for application to the tongue; (2) parenteral administration, for example, by subcutaneous, intramuscular, intravenous or epidural injection as, for example, a sterile solution or suspension, or sustained release formulation; (3) topical application/transdermal administration, for example, as a cream, ointment, or a controlled release patch or spray applied to the skin; (4) intravaginally or intrarectally, for example, as a pessary, cream or foam; or (5) nasally. In the case of Compound 1 or its pharmaceutically acceptable salt, an oral formulation is preferable.

[0132] Formulations can be prepared using a pharmaceutically acceptable carrier or the like by using known formulation methods. Pharmaceutically acceptable carriers are those materials, compositions, or vehicles, such as a liquid or solid fdler, diluent, excipient, manufacturing aid (e.g., lubricant, talc magnesium, calcium or zinc stearate, or steric acid), or solvent encapsulating material, involved in carrying or transporting the subject compound from one organ, or portion of the body, to another organ, or portion of the body. Each carrier must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not injurious to the subject. Some examples of materials which can serve as pharmaceutically acceptable carriers include: (1) sugars, such as lactose, glucose and sucrose; (2) starches, such as com starch and potato starch; (3) cellulose, and its derivatives, such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; (4) powdered tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients, such as cocoa butter and suppository waxes; (9) oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, com oil and soybean oil; (10) glycols, such as propylene glycol; (11) polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; (12) esters, such as ethyl oleate and ethyl laurate; (13) agar; (14) buffering agents, such as magnesium hydroxide and aluminum hydroxide; (15) alginic acid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer's solution; (19) ethyl alcohol; (20) pH buffered solutions; (21) polyesters, polycarbonates and/or polyanhydrides; and (22) other non-toxic compatible substances employed in pharmaceutical formulations, such as cyclodextrins, liposomes, and micelle forming agents, e.g., bile acids.

[0133] Pharmaceutically acceptable carriers may be categorized as various general-purpose agents such as excipients, binders, disintegrating agents, lubricants, diluents, dissolution aids, suspending agents, swelling agents, isotonic agents, pH adjusters, buffers, stabilizers, colorants, flavoring agents, corrigents, and the like.

[0134] Examples of excipients include, but are not limited to, lactose, sucrose, D-mannitol, glucose, starch (com starch), calcium carbonate, kaolin, microcrystalline cellulose, and silicic acid anhydride.

[0135] Examples of binders include, but are not limited to, water, ethanol, 1 -propanol, 2- propanol, simple syrup, liquid glucose, liquid a-starch, liquid gelatin, D-mannitol, carboxymethyl cellulose, hydroxypropyl cellulose (e.g., low viscosity hydroxypropyl cellulose), hydroxypropyl methylcellulose (hypromellose), hydroxypropyl starch, methyl cellulose, ethyl cellulose, shellac, calcium phosphate, polyvinylpyrrolidone.

[0136] Examples of disintegrants include, but are not limited to, low-substituted hydroxypropyl cellulose, dry starch, partially pregelatinized starch, crystalline cellulose, carmellose sodium, carmellose calcium, D-mannitol, crospovidone, croscarmellose sodium, sodium alginate, agar powder, sodium hydrogen carbonate, calcium carbonate, sodium lauryl sulfate, stearic acid monoglyceride, and lactose.

[0137] Examples of lubricants include, but are not limited to, hydrogenated oil, sucrose fatty acid ester, sodium lauryl sulfate, stearic acid, purified talc, sodium stearate, magnesium stearate, borax, and polyethylene glycol. [0138] Examples of colorants include, but are not limited to, edible yellow No. 5 dye, edible blue No. 2 dye, edible lake dye, iron sesquioxide, yellow sesquioxide, and titanium dioxide.

[0139] Examples of sweetening/flavoring agents include, but are not limited to, aspartame, saccharin (as sodium, potassium or calcium saccharin), cyclamate (as a sodium, potassium or calcium salt), sucralose, acesulfame-K, thaumatin, neohisperidin, dihydrochalcone, ammoniated glycyrrhizin, dextrose, maltodextrin, fructose, levulose, sucrose, glucose, wild orange peel, citric acid, tartaric acid, oil of wintergreen, oil of peppermint, oil of spearmint, oil of sassafras, oil of clove, cinnamon, anethole, menthol, thymol, eugenol, eucalyptol, lemon, lime, and lemon-lime. [0140] If desired, an enteric coating or a coating to increase the persistence of effects can be provided by methods desirable for oral preparations. Examples of such coating agents include hydroxypropyl methylcellulose, ethyl cellulose, hydroxymethyl cellulose, hydroxypropyl cellulose, polyethylene glycol, and Tween 80 (registered trademark).

[0141] Compound 1 or its pharmaceutically acceptable salt are preferably formulated in solid dosage form for oral administration, such as in the form of capsules, tablets, pills, dragees, powders, granules, troches, and the like, with preference given to film-coated tablets. Compound 1 or its pharmaceutically acceptable salt may be mixed with one or more pharmaceutically acceptable carriers such as sodium citrate or dicalcium phosphate, and/or any of the following: (1) fillers or extenders, such as starches, lactose, sucrose, glucose, mannitol, and/or silicic acid; (2) binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; (3) humectants, such as glycerol; (4) disintegrating agents, such as agar- agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; (5) solution retarding agents, such as paraffin; (6) absorption accelerators, such as quaternary ammonium compounds and surfactants, such as poloxamer and sodium lauryl sulfate; (7) wetting agents, such as, for example, cetyl alcohol, glycerol monostearate, and non-ionic surfactants (e.g., fatty acid esters of sorbitan and polyalkolyated fatty acid esters of sorbitan such as Tween 80 (registered trademark); (8) absorbents, such as kaolin and bentonite clay; (9) lubricants, such as talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, zinc stearate, sodium stearate, stearic acid, and mixtures thereof; (10) coloring agents; and (11) controlled release agents such as crospovidone or ethyl cellulose. In the case of capsules, tablets and pills, the formulations may also comprise buffering agents. Solid compositions of a similar type may also be employed as fillers in soft and hard shelled gelatin capsules using such excipients as lactose or milk sugars, as well as high molecular weight polyethylene glycols and the like.

[0142] A tablet may be made by compression or molding, optionally with one or more accessory ingredients. Compressed tablets may be prepared using binder (for example, gelatin or hydroxypropyl methylcellulose), lubricant, inert diluent, preservative, disintegrant (for example, sodium starch glycolate or cross-linked sodium carboxymethyl cellulose), surface active or dispersing agent. Molded tablets may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent. The tablets, and other solid dosage forms may optionally be scored or prepared with coatings and shells, such as enteric coatings and other coatings well known in the pharmaceutical formulating art. One example coating formulation may include hypromellose, polyethylene glycol, titanium dioxide, and optionally a coloring agent. They may also be formulated so as to provide slow or controlled release of the active ingredient therein using, for example, hydroxypropylmethyl cellulose in varying proportions to provide the desired release profile, other polymer matrices, liposomes and/or microspheres. They may be formulated for rapid release, e.g., freeze-dried. They may be sterilized by, for example, filtration through a bacteria retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved in sterile water, or some other sterile injectable medium immediately before use. These formulations may also optionally contain opacifying agents and may be of a composition that they release the active ingredient(s) only, or preferentially, in a certain portion of the gastrointestinal tract, optionally, in a delayed manner. Examples of embedding compositions which can be used include polymeric substances and waxes. The active ingredient can also be in micro-encapsulated form, if appropriate, with one or more of the above described excipients.

[0143] Compound 1 or its pharmaceutically acceptable salt may be formulated for parenteral administration, for intravenous, subcutaneous, intraperitoneal, intramuscular, intravascular, or infusion administration, by combining Compound 1 or its pharmaceutically acceptable salt with one or more pharmaceutically acceptable sterile isotonic aqueous or non- aqueous solutions, dispersions, suspensions or emulsions, or sterile powders which may be reconstituted into sterile injectable solutions or dispersions just prior to use, which may contain sugars, alcohols, antioxidants, buffers, bacteriostats, solutes which render the formulation isotonic with the blood of the intended recipient or suspending or thickening agents. Examples of suitable aqueous and non-aqueous carriers which may be employed include water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, and the like), and suitable mixtures thereof, vegetable oils, such as olive oil, and injectable organic esters, such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of coating materials, such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants. These compositions may also contain adjuvants such as preservatives, wetting agents, emulsifying agents, dispersing agents, pH regulators, stabilizers, local anesthetics, etc. Prevention of the action of microorganisms upon the subject compounds may be ensured by the inclusion of various antibacterial and antifungal agents, for example, paraben, chlorobutanol, phenol sorbic acid, and the like. It may also be desirable to include isotonic agents, such as sugars, sodium chloride, and the like into the compositions. In addition, prolonged absorption of the injectable pharmaceutical form may be brought about by the inclusion of agents which delay absorption such as aluminum monostearate and gelatin.

[0144] Compound 1 or its pharmaceutically acceptable salt can be combined with one or more anticancer agents. Examples of anticancer agents include chemotherapeutic agents (e.g., cytotoxic agents), immunotherapeutic agents, hormonal and anti-hormonal agents, targeted therapy agents, and anti-angiogenesis agents. Many anti-cancer agents can be classified within one or more of these groups. While certain anticancer agents have been categorized within a specific group(s) or subgroup(s) herein, many of these agents can also be listed within one or more other group(s) or subgroup(s), as would be presently understood in the art. The anticancer agent is not particularly limited, and examples thereof include, but are not limited to, a chemotherapeutic agent, a mitotic inhibitor, a plant alkaloid, an alkylating agent, an anti-metabolite, a platinum analog, an enzyme, a topoisomerase inhibitor, a retinoid, an aziridine, an antibiotic, a hormonal agent, an anti- hormonal agent, an anti-estrogen, an anti- androgen, an anti-adrenal, an androgen, a targeted therapy agent, an immunotherapeutic agent, a biological response modifier, a cytokine inhibitor, a tumor vaccine, a monoclonal antibody, an immune checkpoint inhibitor, an anti-PD-I agent, an anti-PD-LI agent, a colony-stimulating factor, an immunomodulator, an immunomodulatory imide (IMiD), an anti-CTLA4 agent, an anti-LAGl agent, an anti-OX40 agent, a GITR agonist, a CAR- T cell, a BiTE, a signal transduction inhibitor, a growth factor inhibitor, a tyrosine kinase inhibitor, an EGFR inhibitor, a HER2 inhibitor, a histone deacetylase (HDAC) inhibitor, a proteasome inhibitor, a cell-cycle inhibitor, an anti-angiogenesis agent, a matrix-metalloproteinase (MJ\1P) inhibitor, a hepatocyte growth factor inhibitor, a TOR inhibitor, a KDR inhibitor, a VEGF inhibitor, a HIF-la inhibitor a HIF-2a inhibitor, a fibroblast growth factor (FGF) inhibitor, a RAF inhibitor, a MEK inhibitor, an ERK inhibitor, a PBK inhibitor, an AKT inhibitor, an MCL-1 inhibitor, a BCL-2 inhibitor, an SHP2 inhibitor, a BRAF-inhibitor, a RAS inhibitor, a gene expression modulator, an autophagy inhibitor, an apoptosis inducer, an antiproliferative agent, and a glycolysis inhibitor.

[0145] As discussed below in the examples, zipalertinib demonstrated clinically meaningful efficacy with a manageable safety profile in patients with EGFR exon20ins NSCLC who received prior platinum-based chemotherapy, including in those who received prior amivantamab.

[0146] Zipalertinib demonstrated clinically meaningful efficacy and a manageable safety profile in patients with EGFR ex20ins NSCLC who have received prior platinum-based chemotherapy, including those who received prior amivantamab. Overall, the findings support further evaluation of zipalertinib as a potential treatment option for patients with EGFRex20ins NSCLC after progression on platinum-based chemotherapy, including those who are unresponsive to or experience disease progression on amivantamab.

[0147] The safety and efficacy of zipalertinib as first-line therapy in combination with standard platinum-based chemotherapy in patients with locally advanced or metastatic EGFR ex20ins NSCLC is being investigated in the phase III REZILIENT3 trial (NCT05973773).

[0148] The presently described technology and its advantages will be better understood by reference to the following examples. These examples are provided to describe specific implementations of the present technology. By providing these specific examples, it is not intended limit the scope and spirit of the present technology. It will be understood by those skilled in the art that the full scope of the presently described technology encompasses the subject matter defined by the claims appending this specification, and any alterations, modifications, or equivalents of those claims.

[0149] EXAMPLES [0150] Example 1. Evaluation of TAS6417 efficacy in xenograft model harboring EGER exon20 insertion mutation (insSVD) after recurrent of Amivantamab 10 mg/kg/day or 30 mg/kg/day treatment

[0151] Method : NCI-H1975 EGFRD770_N771 insSVD (H1975insSVD) was transplanted at 5* 10⁶ cells/mouse into the flank of male BALB/cA Jcl-nu mice. Amivantamab was administered intraperitoneally at 10 mg/kg or 30 mg/kg twice a week. TAS6417 was orally administered at 200 mg/kg every day.

[0152] Vehicles and compounds: TAS6417 was mixed in 0.1 mol/L hydrochloric acid to generate a suspension. The amivantamab was diluted in saline to generate a suspension.

[0153] The TAS6417 efficacy was examined in the model of amivantamab pre-treatment. H1975ins SVD cells were implanted into the flank of mice. The amivantamab was administered intraperitoneally at 10 mg/kg twice a week from the time the tumor volume reaches about 200 mm³. The tumor temporarily regressed but re-grew to about 500 mm³, amivantamab -relapsed tumors, were randomly stratified into two groups of five animals per group to ensure uniform mean tumor volume. TAS6417 was administered orally at a dose of 200 mg/kg daily to one mice group, and the other continued to receive amivantamab intraperitoneally at 10 mg/kg twice a week as a control group. TAS6417 resulted in a significant reduction in tumor growth compared amivantamab administered intraperitoneally at 10 mg/kg twice a week (Aspin-Welch p-value < 0.05) (FIG. 1). The amivantamab was administered intraperitoneally at 30 mg/kg twice a week. The tumor temporarily regressed but re-grew to about 500 mm³, amivantamab-relapsed tumors, were randomly stratified into two groups of six animals per group to ensure uniform mean tumor volume. TAS6417 was administered orally at a dose of 200 mg/kg daily to one mice group, and the other continued to receive amivantamab intraperitoneally at 30 mg/kg twice a week as a control group. TAS6417 resulted in a significant reduction in tumor growth compared amivantamab administered intraperitoneally at 30 mg/kg twice a week (Aspin-Welch p-value < 0.001) The group of the 30mg/kg dose of amivantamab were the similar result as that of the lOmg/kg dose (data not shown).

[0154] Example 2: Safety and Antitumor Activity of Zipalertinib in N SCLC Patients with EGFR Exon 20 Insertion (ex20ins) Mutations Who Received Prior Amivantamab [0155] Study Design and Patients

[0156] Zipalertinib (CLN-081, TAS6417) is a novel EGFR TKI which demonstrated a confirmed objective response rate (ORR) of 41% and manageable safety in a phase l/2a study in patients with ex20ins NSCLC after prior platinum-containing chemotherapy (JCO 2023). Here we present data from the phase 2b REZILIENT1 study of zipalertinib cohort C patients with EGFR ex20ins mutant NSCLC that progressed after prior amivantamab.

[0157] Methods: Patients that had progressed after at least 1 prior treatment including amivantamab were enrolled to receive zipalertinib at 100 mg oral twice daily. Tumor response was assessed by the investigator per RECTST vl .1 . Stable, asymptomatic, or treated brain metastases were allowed.

[0158] Results: As of the 29 March 2024 data cut-off (DCO), 45 patients had been enrolled with median age of 62 years (33-85), median lines of prior therapy 3 (1-6), prior platinum-based chemotherapy 43 patients (96%), prior anti-PDl/Ll 20 patients (44%), prior EGFR TKIs 22 patients (49%), and history of brain metastasis 22 patients (49%).

[0159] FIG. 2 is a summary of patient demographics module C ami overall. Module C Ami Overall are Patients that progressed on amivantamab with or without prior mobocertinib and/or other ex20ins drugs (excluding patients that received mobocertinib and/or other exon20ins drugs only, but no amivantamab). FIG. 3 depicts a summary of the best overall tumor response based on investigator assessment per RECITS vl. l. This includes all treated patients with measurable disease at baseline who have received at least one dose of zipalertinib and had one of the following: at least two on treatment tumor assessments, death, or discontinuation due to disease progression (either clinical or per RECIST vl.l based on Investigator Assessment) NE=not evaluable, NA=Not applicable. FIG. 4 is a waterfall plot for the best change from baseline in target lesions. Efficacy population includes all treated patients with measurable disease at baseline who received at least one dose of zipalertinib and had one of the following: 1) at least two on treatment tumor assessments, 2) death, or 3) discontinuation due to disease progression (either clinical or per RECIST vl.l based on Investigator Assessment). Positive change in tumor size indicates tumor growth which negative change in tumor size indicates tumor reduction. If the dimension was recorded as “TOO SMAL TO MEASURE”, a default value of 5mm was assigned. If dimension is recorded as “INDTERMTNATE”, the value from the previous assessment is assigned. Ami only includes patients receiving only prior amivantamab, Ami+ex20ins drug includes patients receiving prior amivantamab and mobocertinib or other EGFR exon 20 insertion (ex20ins) targeted tyrosine kinase inhibitors (TKIs).

[0160] FIG. 5 is a swim plot for study treatment duration. The study treatment duration is the end of treatment date - first dose date+1. For subjects still ongoing, the study duration is the data cutoff date - the first dose date+1. Ami only includes patients receiving only prior amivantamab, Ami+ex20ins drug includes patients receiving prior amivantamab and mobocertinib or other EGFR exon 20 insertion (ex20ins) targeted tyrosine kinase inhibitors (TKIs). FIG. 6 is a Kaplan Meier plot of progression free survival based on RECITS vl.l. Ami only includes patients receiving only prior amivantamab, Ami+ex20ins drug includes patients receiving prior amivantamab and mobocertinib or other EGFR exon 20 insertion (ex20ins) targeted tyrosine kinase inhibitors (TKIs), Ami overall includes both patient populations (excluding patients that received mobocertinib and/or other ex20ins drugs only, but no amivantamab).

[0161] Treatment-related AEs (TRAEs) occurring in > 10% of patients were rash (38%), paronychia (36%), anemia (24%), dry skin (20%), dermatitis acneiform (16%), nausea (16%), and stomatitis (11%). Grade 3 TRAEs were reported in 14 patients (31%): occurring in >2 patients included anemia (4), rash (3), and pneumonitis/ILD (3). There were no grade 4 or 5 TRAEs. TRAEs leading to dose reductions and discontinuations occurred in 3 patients (7%) each. At DCO, 30 patients were evaluable for response (at least 2 on treatment assessments or PD/death), of which 1 pt (3%) had CR, 11 patients (37%) had partial response (PR), and 15 (50%) had stable disease (SD). The ORR was 40% and disease control rate (CR + PR + SD) was 90%. Median duration of response was not yet estimable and median PFS was 9.7 months. FIG. 7 is a summary of treatment-related adverse events of any grade observed in > 10% of patients. FIG. 8 is a summary of grade 3 treatment-related adverse events in > 2 patients.

[0162] Conclusions: This is the first report to systematically characterize the anti-tumor activity of a new irreversible and selective EGFR ex20ins TKI, in heavily treated patients with NSCLC harboring EGFR ex20ins mutations who have received prior amivantamab. In this amivantamab resistant setting, zipalertinib demonstrated promising efficacy, similar to patients that progressed after platinum-based chemotherapy alone and had a manageable safety profile.

[0163] Example 3. Safety and Antitumor Activity of Zipalertinib in N SCLC Patients with EGFR Exon 20 Insertion (ex20ins) Mutations Who Received Prior Amivantamab and Platinum-Containing Chemotherapy

[0164] Study Design and Patients

[0165] Zipalertinib (CLN-081, TAS6417) is a novel EGFR TKI which demonstrated a confirmed objective response rate (ORR) of 41% and manageable safety in a phase l/2a study in patients with ex20ins NSCLC after prior platinum-containing chemotherapy (JCO 2023). Here we present data from the REZILIENT1 (NCT04036682) study, a phase I/II, open-label, multicenter trial to evaluate the safety and efficacy of oral zipalertinib in patients with locally advanced or metastatic EGFR ex20ins NSCLC who have previously received platinum-based chemotherapy. The data described here is for patients who received zipalertinib 100 mg twice daily as part of the trial.

[0166] Eligible patients were aged >18 years with locally advanced or metastatic NSCLC and documented EGFR ex20ins mutation. Patients were required to have measurable disease per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST vl .1), an Eastern Cooperative Oncology Group performance status of 0/1, and adequate organ function. Patient must have received prior treatment with platinum-based chemotherapy in the recurrent/metastatic setting unless contraindicated or declined by the patient, with no restrictions on the number of previous therapies. Prior EGFR TKIs were permitted if completed more than 8 days or 5 times the terminal phase half-life, whichever was longer, prior to the first dose of zipalertinib. Prior treatment with an agent approved by local regulatory authorities for the treatment of EGFR ex20ins mutant NSCLC (e.g., amivantamab) was allowed in a subset of patients enrolled to explore the safety and efficacy of zipalertinib 100 mg twice daily after progression on EGFR ex20ins-targeted therapy. Patients with central nervous system (CNS) metastases were eligible if they were asymptomatic, treated with surgery and/or radiation (if clinically indicated), and stable (not requiring steroids or on a stable or decreasing dose for >4 weeks prior to the first dose of zipalertinib). The study was conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki and was reviewed and approved by the institutional review board at each participating site. All patients provided written informed consent.

[0167] Study procedures

[0168] Zipalertinib was self-administered with or without food at a dose of 100 mg twice daily, at approximately the same time each day and with approximately 12 hours between doses. Dose interruption was allowed in the presence of clinically significant toxicity, and treatment could be discontinued or resumed (with or without a maximum of one dose reduction to 50 mg twice daily) depending on the severity of the AE.

[0169] Tumor imaging was performed at baseline, at 6 weeks after initiation of treatment, and at 9-week intervals thereafter, and response evaluation was conducted using RECIST vl. l. AEs were monitored throughout the study and until 28 days after treatment discontinuation or initiation of a new anti-cancer therapy and were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 5.

[0170] End Points: The primary end points were objective response rate (ORR) and duration of response (DOR), as determined by independent central review (ICR) per RECIST vl.l. Secondary end points included investigator-assessed ORR and DOR, disease control rate (DCR), clinical benefit rate (CBR), progression-free survival (PFS) determined by ICR and by investigator assessment, overall survival (OS), antitumor activity in patients with known CNS disease, and safety and tolerability.

[0171] Statistical Analysis: The safety analysis set included all patients who received at least one dose of zipalertinib 100 mg twice daily, and the primary efficacy population included all patients who received at least one dose of zipalertinib 100 mg twice daily and started treatment prior to or on April 25, 2024 (i.e., had at least ~8 months follow-up before the data cutoff of December 10, 2024).

[0172] Including 176 patients in the efficacy analysis would provide >99% power to demonstrate that the lower bound value of the 95% confidence interval (CI) for the observed ORR was >20% (historical control).26, 27 ORR was defined as the proportion of patients who achieved a confirmed complete response (CR) or partial response (PR) per RECIST vl. l during the study and was assessed using the point estimate and 95% two-sided exact CI (Clopper-Pearson method). DOR was defined as the time between the first response and the date of the first documented progressive disease (PD), death, or, in the absence of PD/death, last disease assessment. The nonparametric Kaplan-Meier method was used to estimate DOR, PFS and OS curves and rates. Exploratory subgroup analyses were performed in patients who received prior amivantamab with or without other EGFR ex20ins-targeted therapy, and by CNS involvement at baseline. All statistical analyses were performed using SAS, Version 9.4.

[0173] RESULTS:

[0174] Patient Population

[0175] In total, 244 patients were enrolled and treated with zipalertinib 100 mg twice daily (FIG. 9). At the data cutoff, 62.3% of patients had permanently discontinued treatment with zipalertinib, most commonly due to disease progression (32.8%) or AEs (16.8% [treatment-related in 8.2%]; FIG. 9). In total, 43.9% of patients discontinued the study, including 32.0% of patients who died.

[0176] Baseline demographics and disease characteristics were similar between patients previously treated with platinum-based chemotherapy without ex20ins-targeted therapy (n=143) and those who had received prior ex20ins-targeted therapy (n=101), except for a slightly younger age, higher prevalence of baseline CNS metastases, and a higher number of prior treatment lines in the latter subgroup (Table 1).

Table 1. Baseline Patient Demographics and Disease Characteristics

CNS, central nervous system; ECOG, Eastern Cooperative Oncology Group; PD-(L)1, programmed death (ligand) ^a NSCLC or adenocarcinoma with squamous features. ^bthe patient was mistakenly assigned to prior platinum chemotherapy, should be in prior amivantamab.

[0177] Most patients (96.3%) had received prior systemic therapy, mostly as first- or second- line treatment (70.9% of patients). Among the 93.4% of patients who had received prior chemotherapy, the most common agents included pemetrexed, carboplatin, and cisplatin (84.0%, 79.5%, and 22.1% of patients); 46.3% of patients had received prior immunotherapy, all of whom received a programmed death (ligand) 1 (PD-[L]1) inhibitor, with or without another immunotherapy.

[0178] Among patients who received prior platinum-based chemotherapy without ex20ins- targeted therapy, 37 patients (25.9%) had received prior targeted therapy, most commonly osimertinib (9.1%). Among patients who had received prior ex20ins-targeted therapy, 83 patients (82.2%) had received either amivantamab only (n=53) or amivantamab and another EGFR ex20ins-targeted therapy (n=30) such as mobocertinib, BLU-451, poziotinib, or sunvozertinib (Table 1; FIG. 9).

[0179] Efficacy

[0180] Of the 244 treated patients, 176 patients were included in the primary efficacy population, comprising 125 patients treated with prior platinum-based chemotherapy without EGFR ex20ins-targeted therapy and 51 patients who had received prior amivantamab, with or without chemotherapy. Of these 51 patients, 21 had also received another ex20ins-targeted therapy.

[0181] The confirmed ORR per ICR was 35.2% (95% CI, 28.2 to 42.8), including one patient with a CR, and 61 patients with a PR (Table 2; FIG. 10). Table 2. Best Overall Response per Independent Central Review

Patients were evaluable for response if they had received at least one dose of zipalertinib and had at least one postdose tumor assessment or had discontinued prior to the first efficacy assessment due to clinical disease progression or toxicity. ^aPatients with brain metastasis included 44 patients with prior platinum-based chemotherapy without ex20ins-targeted therapy and 24 patients with prior platinum-based chemotherapy and ex20ins-targeted therapy;

' Response confirmed >4 weeks after response first noted; ^cPatient had PR only at last tumor assessment visit;

'Proportion of patients with confirmed CR or PR; ' Proportion of patients with CR, PR or SD; ‘Proportion of patients with CR, PR, or with SD lasting >24 weeks. BOR, best overall response; CBR. clinical benefit rate; CI. confidence interval; CR, complete response; DCR, disease control rate; ORR. objective response rate; PD. progressive disease; PR, partial response; SD, stable disease.

[0182] The median DOR per ICR was 8.8 months overall (95% CI, 8.3 to 12.7), and the investigator-assessed median DOR was 9.9 months (95% CI, 8.3 to 29.0). The DCR was 89.2% (95% CI, 83.7 to 93.4), and the CBR was 64.2% (95% CI, 56.6 to 71.3). The ORR, DCR, and CBR per investigator assessment was 38.1% (95% CI, 30.9 to 45.7), 90.9% (95% CI, 85.7 to 94.7), and 67.0% (95% CI, 59.6 to 73.9), respectively (Table 3).

Table 3. Best Overall Response per Investigator Assessment

“Response confirmed >4 weeks after response first noted; ^bPatient had PR only at last tumor assessment visit; “Proportion of patients with confirmed CR or PR; Proportion of patients with CR, PR or SD; “Proportion of patients with CR. PR. or with SD lasting >24 weeks. BOR. best overall response; CBR. clinical benefit rate; CI. confidence interval; CR, complete response; DCR, disease control rate: DOR. duration of response; ORR. objective response rate; PD, progressive disease; PR, partial response; SD. stable disease.

[0183] Overall, the median time to response per ICR and investigator was 44.0 days (range, 31-295) and 42.0 days (range, 31-862), respectively.

[0184] Among the 125 patients who received prior platinum -based chemotherapy without prior EGFR ex20ins-targeted therapy, the confirmed ORR per ICR and investigator assessment was 40.0% (95% CI, 31.3 to 49.1) and 40.8% (95% CI, 32.1 to 49.9), respectively (Tables 2 and 3). The median DOR was 8.8 months (95% CI, 8.3 to 12.7; FIG 11 A) per ICR and 10.4 months (95% CI, 8.3 to 29.0) per investigator assessment.

[0185] Efficacy was also explored in patients who received prior amivantamab treatment with or without other EGFR ex20ins-targeted therapy. Among all 51 patients, the confirmed ORR per ICR was 23.5% (95% CI, 12.8 to 37.5) and the median DOR was 8.5 months (95% CI, 4.2 to 14.8; Table 3, FIG 11 A). The confirmed ORR per ICR in patients who received prior amivantamab alone (n=30) or with another ex20ins-targeted therapy (n=21) was 30.0% (95% CI, 14.7 to 49.4) and 14.3% (95% CI, 3.0 to 36.3), respectively. Clinical outcomes by prior amivantamab treatment per investigator assessment are summarized in Table 3.

[0186] Among 68 patients with baseline brain metastasis, the confirmed systemic ORR per ICR was 30.9% (95% CI, 20.2 to 43.3), comprising one patient with a CR and 20 patients with a PR. The median DOR was 8.3 months (95% CI, 4.2 to 9.9). The DCR and CBR were 88.2% (95% CI, 78.1 to 94.8) and 55.9% (95% CI, 43.3 to 67.9), respectively (Table 2, FIG. 1 IB).

[0187] Overall, the median PFS per ICR was 9.4 months (95% CI, 7.4 to 10.0), and the median OS was 31.4 months (95% CI, 16.3 to not estimable [NE]) (FIGS. 12A and 12B). Landmark 6- and 12-month disease free rates were 63.8% and 29.9% for PFS, and survival rates were 84.1% and 69.3% for OS, respectively. Median PFS and OS in patients with brain metastasis were 7.3 months (95% CI, 5.3 to 9.5) and 16.4 months (95% Cl, 11.1 to 36.9), respectively. [0188] Safety and Tolerability

[0189] At the time of data cutoff, of the 244 patients, the median duration of treatment exposure was 6.4 months (range, 0.03-51.8), and patients had received a mean relative dose intensity of 83.5%.

[0190] Almost all patients had at least one treatment-emergent AE (99.2%), with 223 patients (91.4%) having a treatment-related AE (TRAE; grade >3 in 29.5% of patients) (Table 4).

Table 4. Safety Summary ^aTRAEs leading to discontinuation included pneumonitis (n=9). and interstitial lung disease, neutrophil count decreased, platelet count decreased, pneumonia paronychia, erythema multiforme, rash, and Stevens-Johnson syndrome (n=l each). TEAE, treatment-emergent adverse event; TRAE, treatment-related adverse event.

[0191] The most common any-grade TRAEs (reported in >20% of patients) were paronychia (38.5%), rash (30.3%), dermatitis acneiform (24.6%), dry skin (24.6%), diarrhea (21.7%), and stomatitis (20.1%). Anemia was the most common grade >3 TRAE, reported in 17 (7.0%) patients; other common grade >3 TRAEs (reported in >5 patients) comprised pneumonitis and rash (n=6 for both), and alanine aminotransferase increased, diarrhea, and platelet count decreased (each n=5) (Table 5).

Table 5. Grade >3 Treatment- related Adverse Events Reported in >2 Patients

TRAE, treatment-related adverse event.

[0192] Serious TRAEs were reported in 22 patients (9.0%), most commonly pneumonitis (n=7; 2.9%), followed by anemia, decreased appetite, hypoxia, and rash (all n=2; 0.8%). There were two TRAEs leading to death (pneumonitis and hypoxia).

[0193] Dose modification due to TRAEs occurred in 103 patients (42.2%), including 35 patients (14.3%) with a dose reduction and 96 patients (39.3%) with a dose interruption. TRAEs led to treatment discontinuation in 20 patients (8.2%) overall.

[0194] References

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[0144] All features disclosed in the specification, including the claims, abstracts, and drawings, and all the steps in any method or process disclosed, may be combined in any combination, except combinations where at least some of such features and/or steps are mutually exclusive. Each feature disclosed in the specification, including the claims, abstract, and drawings, can be replaced by alternative features serving the same, equivalent or similar purpose, unless expressly stated otherwise. Thus, unless expressly stated otherwise, each feature disclosed is one example only of a generic series of equivalent or similar features.

[0145] It will be understood that while the invention has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the invention, which is defined by the scope of the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims.

Claims

CLAIMS What is Claimed is:

1. A method of treating non-small-cell lung cancer (NSCLC) in a subject in need thereof, the method comprising administering an effective amount of (S)-N- (4-amino-6- methyl-5- (quinolin-3-yl)-8,9-dihydropyrimido[5,4-b]indolizin-8- yljacrylamide (Compound 1) or a salt thereof, wherein the subject has previously been treated with amivantamab.

2. The method of claim 1, wherein the subject failed to respond to amivantamab; or the subject had disease progression after administration of amivantamab.

3. The method of any claim 1 or claim 2, wherein the subject was also previously treated with chemotherapy.

4. The method of any one of the preceding claims, wherein the subject was also treated with mobocertinib, poziotinib, and/or sunvozertinib.

5. The method of any one of the preceding claims, wherein the effective amount is a therapeutically effective or pharmaceutically effective amount.

6. The method of any one of the preceding claims, wherein an effective amount of Compound 1 or a salt thereof is administered orally at least twice a day.

7. The method of claim 6, wherein the effective amount is about 50 mg of Compound 1 or a salt thereof, alternatively about 75 mg of Compound 1 or a salt thereof, alternatively about thereof, or alternatively about 150 mg of Compound 1 or a salt thereof.

8. The method of any one of the preceding claims, the subject has at least one mutation in non-small cell lung cancer, alternatively at least two mutations, or alternatively at least three mutations.

9. The method of claim 8, wherein the mutation is selected from the group consisting of an epidermal growth factor receptor (EGFR) mutation, a HER2 mutation, a TP53 mutation, a KRAS mutation, a MET mutation, an anaplastic lymphoma kinase (ALK) mutation, a ROSl mutation, a BRAF mutation, a FGFRl mutation, a PIK3CA mutation, a RET mutation, a NTRK mutation, and a ERBB2 mutation.

10. The method of claim 9, wherein the at least one mutation is an EGFR mutation.

11 . The method of claim 10, wherein the EGFR mutation is an exon 20 insertions (ex20ins).

12. The method of any one of claims 9 to 11, wherein the at least one EGFR mutation is selected from the group consisting of D770_N771insX, V769_D770insX, H773_V774insX, P772_H773insX, N771_P772insX, A763_Y764insX, V774_C775insX, D761_E762insX, A767_S768insX, S768_V769insX, Y764_V765insX, V765_M766insX, A763_Y764insFQEA, A767_S768insTLA, S768_V769insVAS, S768_V769insAWT, V769_D770insGV, V769_D770insCV, V769_D770insDNV, V769_D770insGSV, V769_D770insGVV, V769_D770insMASVD, V769_D770insASV, V769_D770insGE, V769_D770delInsDGEL, D770_N771insSVD, D770_N771insNPG, D770_N771insKH, D770_N771insGNPH, D770_N771insAPW, D770_N771insD, D770_N771insDG, D770delinsGY, D770_N771insGL, D770_N771insN, D770_N771insNPH, D770_N771insSVP, D770_N771insSVQ, D770_N771insMATP, D770_N771insG, D770_N771insY, D770_N771insGF, D770_N771insGT, delD770insGY, N771_P772insH, N771_P772insN, delN771insGY, delN771insGF, N771delinsGY, N771_P772insRH, P772_H773insPR, P772_H773insYNP, P772_H773insX, P772_H773insDPH, P772_H773insDNP, P772_H773insQV, P772_H773insTPH, P772_H773insN, P772_H773insV, P772_H773insNP, P772_H773insNPH, H773_V774insH, H773_V774insNPH, H773_V774insPH, H773_V774insGNPH, H773_V774insG, H773_V774insGH, H773_V774insAH, H773_V774delInsLM, H773_V774delInsTY, and V774_C775insHV.

13. The method of any one of claims 9 to 12, wherein the subject has advanced or metastatic EGFR ex20ins mutant NSCLC.

14. A method of treating non-small-cell lung cancer (NSCLC) in a subject in need thereof, the method comprising administering an effective amount of (S)-N- (4-amino-6- methyl-5- (quinolin-3-yl)-8,9-dihydropyrimido[5,4-b]indolizin-8- yl)acrylamide (Compound 1) or a salt thereof, wherein the subject has previously been treated with chemotherapy.

15. The method of claim 14, wherein the subject failed to respond to chemotherapy; or the subject had disease progression after administration of chemotherapy.

16. The method of claim 14 or claim 15, wherein the subject was also previously treated with amivantamab.

17. The method of any one of claims 14 to 16, wherein the subject was also treated with mobocertinib, poziotinib, and/or sunvozertinib.

18. The method of any one of claims 14 to 17, wherein the effective amount is a therapeutically effective or pharmaceutically effective amount.

19. The method of any one of claims 14 to 18, wherein an effective amount of Compound 1 or a salt thereof is administered orally at least twice a day.

20. The method of claim 19, wherein the effective amount is about 50 mg of Compound 1 or a salt thereof, alternatively about 75 mg of Compound 1 or a salt thereof, alternatively about 100 mg of Compound 1 or a salt thereof, alternatively about 125 mg of Compound 1 or a salt thereof, or alternatively about 150 mg of Compound 1 or a salt thereof.

21. The method of any one of claims 14 to 20, the subject has at least one mutation in non-small cell lung cancer, alternatively at least two mutations, or alternatively at least three mutations.

22. The method of claim 21, wherein the mutation is selected from the group consisting of an epidermal growth factor receptor (EGFR) mutation, a HER2 mutation, a TP53 mutation, a KRAS mutation, a MET mutation, an anaplastic lymphoma kinase (ALK) mutation, a ROSl mutation, a BRAF mutation, a FGFRl mutation, a PIK3C A mutation, a RET mutation, a NTRK mutation, and a ERBB2 mutation.

23. The method of claim 22, wherein the at least one mutation is an EGFR mutation.

24. The method of claim 23, wherein the EGFR mutation is an exon 20 insertions (ex20ins).

25. The method of any one of claims 21 to 24, wherein the at least one EGFR mutation is selected from the group consisting of D770_N771insX, V769_D770insX, H773_V774insX, P772_H773insX, N771_P772insX, A763_Y764insX, V774_C775insX, D761_E762insX, A767 S768insX, S768 V769insX, Y764 V765insX, V765 M766insX, A763_Y764insFQEA, A767_S768insTLA, S768_V769insVAS, S768_V769insAWT, V769_D770insGV, V769_D770insCV, V769_D770insDNV, V769_D770insGSV, V769_D770insGVV, V769_D770insMASVD, V769_D770insASV, V769_D770insGE, V769_D770delInsDGEL, D770_N771insSVD, D770_N771insNPG, D770_N771insKH, D770_N771insGNPH, D770_N771insAPW, D770_N771insD, D770_N771insDG, D770delinsGY, D770_N771insGL, D770_N771insN, D770_N771insNPH,

D770_N77 tins SVP, D770_N771insSVQ, D770_N771insMATP, D770_N771insG, D770_N771insY, D770_N771insGF, D770_N771insGT, delD770insGY, N771_P772insH, N771_P772insN, delN771insGY, delN771insGF, N771delinsGY, N771_P772insRH, P772_H773insPR, P772_H773insYNP, P772_H773insX, P772_H773insDPH, P772_H773insDNP, P772_H773insQV, P772_H773insTPH, P772_H773insN, P772_H773insV, P772_H773insNP, P772_H773insNPH, H773_V774insH, H773_V774insNPH, H773_V774insPH, H773_V774insGNPH, H773_V774insG, H773_V774insGH, H773_V774insAH, H773_V774delInsLM, H773_V774delInsTY, and V774_C775insHV.

26. The method of any one of claims 22 to 25, wherein the subject has advanced or metastatic EGFR ex20ins mutant NSCLC.

27. A method of treating non-small-cell lung cancer (NSCLC) in a subject in need thereof, the method comprising administering an effective amount of (S)-N- (4-amino-6- methyl-5- (quinolin-3-yl)-8,9-dihydropyrimido[5,4-b]indolizin-8- yljacrylamide (Compound 1) or a salt thereof, wherein the subject has previously been treated with at least one member selected from the group comprising pemetrexed, carboplatin, cisplatin, programmed death ligand 1 .