Methods for treatment of non-small cell lung cancer

BACKGROUND OF THE INVENTION

Cancer is the second leading cause of death in the United States, exceeded only by heart disease. (Cancer Facts and Figures 2004, American Cancer Society, Inc.) Despite recent advances in cancer diagnosis and treatment, surgery and radiotherapy may be curative if a cancer is found early, but current drug therapies for metastatic disease are mostly palliative and seldom offer a long-term cure. Even with new chemotherapies entering the market, the need continues for new drugs effective in monotherapy or in combination with existing agents as first line therapy, and as second and third line therapies in treatment of resistant tumors.

Cancer cells are by definition heterogeneous. For example, within a single tissue or cell type, multiple mutational `mechanisms` may lead to the development of cancer. As such, heterogeneity frequently exists between cancer cells taken from tumors of the same tissue and same histiotype that have originated in different individuals. Frequently observed mutational `mechanisms` associated with some cancers may differ between one tissue type and another (e.g., frequently observed mutational `mechanisms` leading to colon cancer may differ from frequently observed `mechanisms` leading to leukemias). It is therefore often difficult to predict whether a particular cancer will respond to a particular chemotherapeutic agent. (Cancer Medicine, 5th Edition, Bast et al. eds., B. C. Decker Inc., Hamilton, Ontario).

Despite recent advances in treatment, non-small cell lung cancer (NSCLC) remains the leading global cause of cancer-related death. The majority of patients have advanced disease at diagnosis, with a median survival of 10 to 12 months with aggressive therapy. Recent efforts focus on targeted therapeutics or treatments that specifically inhibit vital signaling pathways. However, drug resistance and cancer progression invariably develop. Accordingly, new compounds and methods for treating non-small cell lung cancer (NSCLC) are needed. The present invention addresses these needs.

SUMMARY OF THE INVENTION

The present invention provides a method of treating non-small cell lung cancer in a subject in need thereof, the method comprising administering to said subject a therapeutically effective amount of composition comprising a compound of formula III, IIIa, IVa, IVb, Va, or Vb, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, in combination with, a therapeutically effective amount of a composition comprising an epidermal growth factor tyrosine kinase inhibitor, wherein the non-small cell lung cancer is treated.

The compound of formula III, IIIa, IVa, IVb, Va, or Vb or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be (+)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3-y- l)pyrrolidine-2,5-dione, (-)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3-y- l)pyrrolidine-2,5-dione, (+)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, or (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof. Preferably, the compound is (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof. Most preferably, the compound is (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione.

The epidermal growth factor tyrosine kinase inhibitor can be gefitinib, lapatinib, cetuximab, erlotinib, panitumumab, PKI-166, canertinib, matuzumab or EKB-569, or a combination thereof. Preferably, the epidermal growth factor tyrosine kinase inhibitor is erlotinib.

The composition comprising (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered simultaneously with the composition comprising an epidermal growth factor tyrosine kinase inhibitor. The composition comprising (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered preceding administration of the composition comprising an epidermal growth factor tyrosine kinase inhibitor. The composition comprising (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered following administration of the composition comprising an epidermal growth factor tyrosine kinase inhibitor. The composition can comprise one or more pharmaceutically acceptable carriers or excipients.

The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-ind- ol-3-yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered at a dose range between 0.1 mg/day to 10 g/day. The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl) pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered at a dose range between 0.5 mg/day to 5 g/day. The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2, 5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered at a dose range between 1 mg/day to 1 g/day. Preferably, the (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, is administered at a maximal daily dose of 720 mg. More preferably, the (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, is administered at a dose of 360 mg, provided twice a day. The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered intravenously, orally or intraperitoneally. Preferably, the (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, is administered orally.

The epidermal growth factor tyrosine kinase inhibitor can be administered at a dose range between 0.1 mg/day to 10 g/day. The epidermal growth factor tyrosine kinase inhibitor can be administered at a dose range between 0.5 mg/day to 5 g/day. The epidermal growth factor tyrosine kinase inhibitor can be administered at a dose range between 1 mg/day to 1 g/day. Preferably, the epidermal growth factor tyrosine kinase inhibitor is administered at a maximal daily dose of 150 mg. More preferably, the growth factor tyrosine kinase inhibitor is administered at a dose of 150 mg, one per day. The growth factor tyrosine kinase inhibitor can be administered intravenously, orally or intraperitoneally. Preferably, the growth factor tyrosine kinase inhibitor is administered orally.

The method of treating non-small cell lung cancer can include a reduction in tumor size, reduction in tumor burden, reduction in tumor volume, reduction in tumor number, reduction or inhibition of metastatic cancer cell invasion, or any combination thereof.

The non-small cell lung cancer cells can contain DNA encoding c-Met. The non-small cell lung cancer cells can have increased c-Met gene copy number or increased c-Met activity, or both.

The subject can have a KRAS mutation or an epidermal growth factor receptor mutation, or both. Preferably, the subject is a mammal. More preferably, the subject is a human. In some embodiments, the subject was not previously treated with epidermal growth factor inhibitor (EGFR-naive).

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 this invention belongs. In the specification, the singular forms also include the plural unless the context clearly dictates otherwise. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents and other references mentioned herein are incorporated by reference. The references cited herein are not admitted to be prior art to the claimed invention. In the case of conflict, the present specification, including definitions, will control. In addition, the materials, methods and examples are illustrative only and are not intended to be limiting.

Other features and advantages of the invention will be apparent from the following detailed description and claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a CONSORT diagram of patient enrollment.

FIGS. 2A and 2B are schematics showing patients tested for molecular characteristics and overlap of findings. FIG. 2A is a Venn diagram illustrating the overlap of patients with sufficient tumor tissue for testing for EGFR mutations, KRAS mutations and MET gene copy number. FIG. 2B is a Venn diagram illustrating tumors that tested positive for each of these variables.

FIG. 3A-F is a series of Kaplan-Meier plots. FIG. 3A shows Progression-free survival (PFS) in the intent-to-treat (IIT) population. FIG. 3B shows Overall Survival (OS) in the IIT population. FIG. 3C shows PFS in the non-squamous cell histology population. FIG. 3D shows OS in the non-squamous cell histology population. FIG. 3E shows PFS in patients with EGFR wild-type status. FIG. 3F shows PFS in patients with KRAS mutation-positive status.

FIG. 4A-B are Kaplan-Meier plots. FIG. 4A shows the time-to-development of new metastatic disease among the intent-to-treat population. FIG. 4B shows the time-to-development of new metastatic disease among the non-squamous cell histology population.

DETAILED DESCRIPTION OF THE INVENTION

1. Methods of Treatment

The present invention provides a method of treating non-small cell lung cancer in a subject in need thereof, the method comprising administering to said subject a therapeutically effective amount of composition comprising a compound of formula III, IIIa, IVa, IVb, Va, or Vb, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, in combination with, a therapeutically effective amount of a composition comprising an epidermal growth factor tyrosine kinase inhibitor, wherein the non-small cell lung cancer is treated.

The compound of formula III, IIIa, IVa, IVb, Va, or Vb or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be (+)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3-y- l)pyrrolidine-2,5-dione, (-)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3-y- l)pyrrolidine-2,5-dione, (+)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl) pyrrolidine-2,5-dione, or (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof. Preferably, the compound is (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof. Most preferably, the compound is (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione.

Exemplary EGFR inhibitors include, but are not limited to, gefitinib (Iressa); lapatinib (Tykerb); cetuximab (Erbitux); erlotinib (Tarceva); panitumumab (Vectibix); PKI-166; canertinib (CI-1033); matuzumab (Emd7200) or EKB-569. Preferably, the epidermal growth factor tyrosine kinase inhibitor is erlotinib.

The composition comprising (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered simultaneously with the composition comprising an epidermal growth factor tyrosine kinase inhibitor. The composition comprising (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered preceding administration of the composition comprising an epidermal growth factor tyrosine kinase inhibitor. The composition comprising (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered following administration of the composition comprising an epidermal growth factor tyrosine kinase inhibitor. The composition can comprise one or more pharmaceutically acceptable carriers or excipients.

The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-ind- ol-3-yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered at a dose range between 0.1 mg/day to 10 g/day. The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered at a dose range between 0.5 mg/day to 5 g/day. The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered at a dose range between 1 mg/day to 1 g/day. Preferably, the (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, is administered at a maximal daily dose of 720 mg. More preferably, the (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, is administered at a dose of 360 mg, provided twice a day. The (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, can be administered intravenously, orally or intraperitoneally. Preferably, the (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione or a pharmaceutically acceptable salt, prodrug or metabolite thereof, is administered orally.

The epidermal growth factor tyrosine kinase inhibitor can be administered at a dose range between 0.1 mg/day to 10 g/day. The epidermal growth factor tyrosine kinase inhibitor can be administered at a dose range between 0.5 mg/day to 5 g/day. The epidermal growth factor tyrosine kinase inhibitor can be administered at a dose range between 1 mg/day to 1 g/day. Preferably, the epidermal growth factor tyrosine kinase inhibitor is administered at a maximal daily dose of 150 mg. More preferably, the growth factor tyrosine kinase inhibitor is administered at a dose of 150 mg, one per day. The growth factor tyrosine kinase inhibitor can be administered intravenously, orally or intraperitoneally. Preferably, the growth factor tyrosine kinase inhibitor is administered orally.

The method of treating non-small cell lung cancer can include a reduction in tumor size, reduction in tumor volume, reduction in tumor number, reduction or inhibition of metastatic cancer cell invasion, decrease in number of metastatic lesions, or any combination thereof.

The non-small cell lung cancer cells can contain DNA encoding c-Met. The non-small cell lung cancer cells can have increased c-Met gene copy number or increased c-Met activity, or both.

The subject can have a KRAS mutation or an epidermal growth factor receptor mutation, or both. Preferably, the subject is a mammal. More preferably, the subject is a human. In some embodiments, the subject was not previously treated with epidermal growth factor inhibitor (EGFR-naive).

The methods of the present invention can further include the administration of at least a third chemotherapeutic agent (also referred to as an anti-neoplastic agent or anti-proliferative agent) can be an alkylating agent; an antibiotic; an anti-metabolite; a detoxifying agent; an interferon; a polyclonal or monoclonal antibody; an EGFR inhibitor; a HER2 inhibitor; a histone deacetylase inhibitor; a hormone; a mitotic inhibitor; an MTOR inhibitor; a multi-kinase inhibitor; a serine/threonine kinase inhibitor; a tyrosine kinase inhibitors; a VEGF/VEGFR inhibitor; a taxane or taxane derivative, an aromatase inhibitor, an anthracycline, a microtubule targeting drug, a topoisomerase poison drug, an inhibitor of a molecular target or enzyme (e.g., a kinase inhibitor), a cytidine analogue drug or any chemotherapeutic, anti-neoplastic or anti-proliferative agent listed in www.cancer.org/docroot/cdg/cdg.sub.--0.asp.

Exemplary alkylating agents include, but are not limited to, cyclophosphamide (Cytoxan; Neosar); chlorambucil (Leukeran); melphalan (Alkeran); carmustine (BiCNU); busulfan (Busulfex); lomustine (CeeNU); dacarbazine (DTIC-Dome); oxaliplatin (Eloxatin); carmustine (Gliadel); ifosfamide (Ifex); mechlorethamine (Mustargen); busulfan (Myleran); carboplatin (Paraplatin); cisplatin (CDDP; Platinol); temozolomide (Temodar); thiotepa (Thioplex); bendamustine (Treanda); or streptozocin (Zanosar).

Exemplary antibiotics include, but are not limited to, doxorubicin (Adriamycin); doxorubicin liposomal (Doxil); mitoxantrone (Novantrone); bleomycin (Blenoxane); daunorubicin (Cerubidine); daunorubicin liposomal (DaunoXome); dactinomycin (Cosmegen); epirubicin (Ellence); idarubicin (Idamycin); plicamycin (Mithracin); mitomycin (Mutamycin); pentostatin (Nipent); or valrubicin (Valstar).

Exemplary anti-metabolites include, but are not limited to, fluorouracil (Adrucil); capecitabine (Xeloda); hydroxyurea (Hydrea); mercaptopurine (Purinethol); pemetrexed (Alimta); fludarabine (Fludara); nelarabine (Arranon); cladribine (Cladribine Novaplus); clofarabine (Clolar); cytarabine (Cytosar-U); decitabine (Dacogen); cytarabine liposomal (DepoCyt); hydroxyurea (Droxia); pralatrexate (Folotyn); floxuridine (FUDR); gemcitabine (Gemzar); cladribine (Leustatin); fludarabine (Oforta); methotrexate (MTX; Rheumatrex); methotrexate (Trexall); thioguanine (Tabloid); TS-1 or cytarabine (Tarabine PFS).

Exemplary detoxifying agents include, but are not limited to, amifostine (Ethyol) or mesna (Mesnex).

Exemplary interferons include, but are not limited to, interferon alfa-2b (Intron A) or interferon alfa-2a (Roferon-A).

Exemplary polyclonal or monoclonal antibodies include, but are not limited to, trastuzumab (Herceptin); ofatumumab (Arzerra); bevacizumab (Avastin); rituximab (Rituxan); cetuximab (Erbitux); panitumumab (Vectibix); tositumomab/iodine, tositumomab (Bexxar); alemtuzumab (Campath); ibritumomab (In-111 Zevalin); gemtuzumab (Mylotarg); eculizumab (Soliris); ibritumomab (Y-90 Zevalin); denosumab or ibritumomab (Zevalin).

Exemplary EGFR inhibitors include, but are not limited to, gefitinib (Iressa); lapatinib (Tykerb); cetuximab (Erbitux); erlotinib (Tarceva); panitumumab (Vectibix); PKI-166; canertinib (CI-1033); matuzumab (Emd7200) or EKB-569.

Exemplary HER2 inhibitors include, but are not limited to, trastuzumab (Herceptin); lapatinib (Tykerb) or AC-480.

Histone Deacetylase Inhibitors include, but are not limited to, vorinostat (Zolinza)

Exemplary hormones include, but are not limited to, tamoxifen (Soltamox; Nolvadex); raloxifene (Evista); megestrol (Megace); leuprolide (Lupron; Lupron Depot; Eligard; Viadur); fulvestrant (Faslodex); letrozole (Femara); triptorelin (Trelstar LA; Trelstar Depot); exemestane (Aromasin); goserelin (Zoladex); bicalutamide (Casodex); anastrozole (Arimidex); fluoxymesterone (Androxy; Halotestin); medroxyprogesterone (Provera; Depo-Provera); estramustine (Emcyt); flutamide (Eulexin); toremifene (Fareston); degarelix (Firmagon); nilutamide (Nilandron); abarelix (Plenaxis); or testolactone (Teslac).

Exemplary mitotic inhibitors include, but are not limited to, paclitaxel (Taxol; Onxol; Abraxane); docetaxel (Taxotere); vincristine (Oncovin; Vincasar PFS); vinblastine (Velban); etoposide (Toposar; Etopophos; VePesid); teniposide (Vumon); ixabepilone (Ixempra); nocodazole; epothilone; vinorelbine (Navelbine); camptothecin (CPT); irinotecan (Camptosar); topotecan (Hycamtin); amsacrine or lamellarin D (LAM-D).

Exemplary mTOR inhibitors include, but are not limited to, everolimus (Afinitor) or temsirolimus (Torisel); rapamune, ridaforolimus; or AP23573.

Exemplary kinase inhibitors include, but are not limited to, Bevacizumab (targets VEGF), BIBW 2992 (targets EGFR and Erb2), Cetuximab/Erbitux (targets Erb1), Imatinib/Gleevic (targets Bcr-Abl, PDGFRs and c-Kit), Trastuzumab (targets Erb2), Gefitinib/Iressa (targets EGFR), Ranibizumab (targets VEGF), Pegaptanib (targets VEGF), Erlotinib/Tarceva (targets Erb1), Nilotinib (targets Bcr-Abl), Lapatinib (targets Erb1 and Erb2/Her2), GW-572016/lapatinib ditosylate (targets HER2/Erb2), Panitumumab/Vectibix (targets EGFR), Vandetinib (targets RET/VEGFR), E7080 (multiple targets including RET and VEGFR), Herceptin (targets HER2/Erb2), PKI-166 (targets EGFR), Canertinib/CI-1033 (targets EGFR), Sunitinib/SU-11464/Sutent (targets EGFR and FLT3), Matuzumab/Emd7200 (targets EGFR), EKB-569 (targets EGFR), Zd6474 (targets EGFR and VEGFR), PKC-412 (targets VEGR and FLT3), Vatalanib/Ptk787/ZK222584 (targets VEGR), CEP-701 (targets FLT3), SU5614 (targets FLT3), MLN518 (targets FLT3), XL999 (targets FLT3), VX-322 (targets FLT3), Azd0530 (targets SRC), BMS-354825 (targets SRC), SKI-606 (targets SRC), CP-690 (targets JAK), AG-490 (targets JAK), WHI-P154 (targets JAK), WHI-P131 (targets JAK), sorafenib/Nexavar (targets RAF kinase, VEGFR-1, VEGFR-2, VEGFR-3, PDGFR-.beta., KIT, FLT-3, and RET), Dasatinib/Sprycel (BCR/Abl and Src), AC-220 (targets Flt3), AC-480 (targets all HER proteins, "pan-HER"), Motesanib diphosphate (targets VEGF1-3, PDGFR, and c-kit), Denosumab (targets RANKL, inhibits SRC), AMG888 (targets HER3), and AP24534 (multiple targets including Flt3).

Exemplary multi-kinase inhibitors include, but are not limited to, sorafenib (Nexavar); sunitinib (Sutent); BIBW 2992; E7080; Zd6474; PKC-412; motesanib; or AP24534.

Exemplary serine/threonine kinase inhibitors include, but are not limited to, eril/easudil hydrochloride; Rapamune (targets mTOR/FRAP1); Deforolimus (targets mTOR); Certican/Everolimus (targets mTOR/FRAP1); AP23573 (targets mTOR/FRAP1); Eril/Fasudil hydrochloride (targets RHO); Flavopiridol (targets CDK); Seliciclib/CYC202/Roscovitrine (targets CDKs); SNS-032/BMS-387032 (targets CDKs); Ruboxistaurin (targets PKC); Pkc412 (targets PKC); Bryostatin (targets PKC); KAI-9803 (targets PKC); SF1126 (targets PI3K); VX-680 (targets Aurora kinase); Azd1152 (targets Aurora kinase); Arry-142886/AZD-6244 (targets MAP/MEK); SCIO-469 (targets MAP/MEK); GW681323 (targets MAP/MEK); CC-401 (targets JNK); CEP-1347 (targets JNK); and PD 332991 (targets CDKs).

Exemplary tyrosine kinase inhibitors include, but are not limited to, erlotinib (Tarceva); gefitinib (Iressa); imatinib (Gleevec); sorafenib (Nexavar); sunitinib (Sutent); trastuzumab (Herceptin); bevacizumab (Avastin); rituximab (Rituxan); lapatinib (Tykerb); cetuximab (Erbitux); panitumumab (Vectibix); everolimus (Afinitor); alemtuzumab (Campath); gemtuzumab (Mylotarg); temsirolimus (Torisel); pazopanib (Votrient); dasatinib (Sprycel); nilotinib (Tasigna); vatalanib (Ptk787; ZK222584); CEP-701; SU5614; MLN518; XL999; VX-322; Azd0530; BMS-354825; SKI-606 CP-690; AG-490; WHI-P154; WHI-P131; AC-220; or AMG888.

Exemplary VEGF/VEGFR inhibitors include, but are not limited to, bevacizumab (Avastin); sorafenib (Nexavar); sunitinib (Sutent); ranibizumab; pegaptanib; or vandetinib.

Exemplary aromatase inhibitors include, but are not limited to, aminoglutethimide, testolactone (Teslac), anastrozole (Arimidex), Letrozole (Femara), exemestane (Aromasin), Vorozole (Rivizor), Formestane (Lentaron), Fadrozole (Afema), 4-androstene-3,6,17-trione (6-OXO), 1,4,6-androstatrien-3,17-dione (ATD), and 4-hydroxyandrostenedione.

Exemplary anthracyclines include, but are not limited to, daunorubicin (Daunomycin), doxorubicin (Adriamycin), epirubicin, idarubicin, and valrubicin.

Exemplary cytidine analogs include, but are not limited to, gemcitabine, azacytidine (e.g., 5-azacytidine), and cytosine arabinoside (cytarabin, araC, Cytosar).

Exemplary microtubule targeting drugs include, but are not limited to, paclitaxel, docetaxel, vincristin, vinblastin, nocodazole, epothilones and navelbine.

Exemplary topoisomerase poison drugs include, but are not limited to, teniposide, etoposide, adriamycin, camptothecin, daunorubicin, dactinomycin, mitoxantrone, amsacrine, epirubicin and idarubicin.

Exemplary taxanes or taxane derivatives include, but are not limited to, paclitaxel and docetaxel.

Exemplary general chemotherapeutic, anti-neoplastic, anti-proliferative agents include, but are not limited to, altretamine (Hexalen); isotretinoin (Accutane; Amnesteem; Claravis; Sotret); tretinoin (Vesanoid); azacitidine (Vidaza); bortezomib (Velcade) asparaginase (Elspar); levamisole (Ergamisol); mitotane (Lysodren); procarbazine (Matulane); pegaspargase (Oncaspar); denileukin diftitox (Ontak); porfimer (Photofrin); aldesleukin (Proleukin); lenalidomide (Revlimid); bexarotene (Targretin); thalidomide (Thalomid); temsirolimus (Torisel); arsenic trioxide (Trisenox); verteporfin (Visudyne); mimosine (Leucenol); (1M tegafur--0.4 M 5-chloro-2,4-dihydroxypyrimidine--1 M potassium oxonate) or statins (e.g., lovastatin, atorvastatin, cerivastatin, fluvastatin, mevastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin).

A compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, can be incorporated into pharmaceutical compositions suitable for administration. Such compositions typically comprise the compound (i.e. including the active compound), and a pharmaceutically acceptable excipient or carrier. As used herein, "pharmaceutically acceptable excipient" or "pharmaceutically acceptable carrier" is intended to include any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like, compatible with pharmaceutical administration. Suitable carriers are described in the most recent edition of Remington's Pharmaceutical Sciences, a standard reference text in the field. Preferred examples of such carriers or diluents include, but are not limited to, water, saline, ringer's solutions, dextrose solution, and 5% human serum albumin.

Pharmaceutically acceptable carriers include solid carriers such as lactose, terra alba, sucrose, talc, gelatin, agar, pectin, acacia, magnesium stearate, stearic acid and the like. Exemplary liquid carriers include syrup, peanut oil, olive oil, water and the like. Similarly, the carrier or diluent may include time-delay material known in the art, such as glyceryl monostearate or glyceryl distearate, alone or with a wax, ethylcellulose, hydroxypropylmethylcellulose, methylmethacrylate or the like. Other fillers, excipients, flavorants, and other additives such as are known in the art may also be included in a pharmaceutical composition according to this invention. Liposomes and non-aqueous vehicles such as fixed oils may also be used. The use of such media and agents for pharmaceutically active substances is well known in the art. Except insofar as any conventional media or agent is incompatible with the active compound, use thereof in the compositions is contemplated. Supplementary active compounds can also be incorporated into the compositions.

In one aspect, a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, is administered in a suitable dosage form prepared by combining a therapeutically effective amount (e.g., an efficacious level sufficient to achieve the desired therapeutic effect through inhibition of tumor growth, killing of tumor cells, treatment or prevention of cell proliferative disorders, etc.) of a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, (as an active ingredient) with standard pharmaceutical carriers or diluents according to conventional procedures (i.e., by producing a pharmaceutical composition of the invention). These procedures may involve mixing, granulating, and compressing or dissolving the ingredients as appropriate to attain the desired preparation.

As used herein, a "subject" can be any mammal, e.g., a human, a primate, mouse, rat, dog, cat, cow, horse, pig, sheep, goat, camel. In a preferred aspect, the subject is a human.

As used herein, a "subject in need thereof" is a subject having a cell proliferative disorder, or a subject having an increased risk of developing a cell proliferative disorder relative to the population at large. In one aspect, a subject in need thereof has a precancerous condition. In a preferred aspect, a subject in need thereof has cancer.

In addition to methods of treating non-small cell lung cancer, the present invention provides methods of treating a cell proliferative disorder in a subject in need thereof, the method comprising administering to said subject a therapeutically effective amount of composition comprising a compound of formula III, IIIa, IVa, IVb, Va, or Vb, or a pharmaceutically acceptable salt, prodrug or metabolite thereof, in combination with, a therapeutically effective amount of a composition comprising an epidermal growth factor tyrosine kinase inhibitor, wherein the cell proliferative disorder is treated. Preferably, the subject in need thereof has a KRAS mutation or an epidermal growth factor receptor mutation, or both

As used herein, the term "cell proliferative disorder" refers to conditions in which unregulated or abnormal growth, or both, of cells can lead to the development of an unwanted condition or disease, which may or may not be cancerous. Exemplary cell proliferative disorders of the invention encompass a variety of conditions wherein cell division is deregulated. Exemplary cell proliferative disorder include, but are not limited to, neoplasms, benign tumors, malignant tumors, pre-cancerous conditions, in situ tumors, encapsulated tumors, metastatic tumors, liquid tumors, solid tumors, immunological tumors, hematological tumors, cancers, carcinomas, leukemias, lymphomas, sarcomas, and rapidly dividing cells. The term "rapidly dividing cell" as used herein is defined as any cell that divides at a rate that exceeds or is greater than what is expected or observed among neighboring or juxtaposed cells within the same tissue. A cell proliferative disorder includes a precancer or a precancerous condition. A cell proliferative disorder includes cancer. Preferably, the methods provided herein are used to treat or alleviate a symptom of cancer. The term "cancer" includes solid tumors, as well as, hematologic tumors and/or malignancies. A "precancer cell" or "precancerous cell" is a cell manifesting a cell proliferative disorder that is a precancer or a precancerous condition. A "cancer cell" or "cancerous cell" is a cell manifesting a cell proliferative disorder that is a cancer. Any reproducible means of measurement may be used to identify cancer cells or precancerous cells. Cancer cells or precancerous cells can be identified by histological typing or grading of a tissue sample (e.g., a biopsy sample). Cancer cells or precancerous cells can be identified through the use of appropriate molecular markers.

Exemplary non-cancerous conditions or disorders include, but are not limited to, rheumatoid arthritis; inflammation; autoimmune disease; lymphoproliferative conditions; acromegaly; rheumatoid spondylitis; osteoarthritis; gout, other arthritic conditions; sepsis; septic shock; endotoxic shock; gram-negative sepsis; toxic shock syndrome; asthma; adult respiratory distress syndrome; chronic obstructive pulmonary disease; chronic pulmonary inflammation; inflammatory bowel disease; Crohn's disease; psoriasis; eczema; ulcerative colitis; pancreatic fibrosis; hepatic fibrosis; acute and chronic renal disease; irritable bowel syndrome; pyresis; restenosis; cerebral malaria; stroke and ischemic injury; neural trauma; Alzheimer's disease; Huntington's disease; Parkinson's disease; acute and chronic pain; allergic rhinitis; allergic conjunctivitis; chronic heart failure; acute coronary syndrome; cachexia; malaria; leprosy; leishmaniasis; Lyme disease; Reiter's syndrome; acute synovitis; muscle degeneration, bursitis; tendonitis; tenosynovitis; herniated, ruptures, or prolapsed intervertebral disk syndrome; osteopetrosis; thrombosis; restenosis; silicosis; pulmonary sarcosis; bone resorption diseases, such as osteoporosis; graft-versus-host reaction; Multiple Sclerosis; lupus; fibromyalgia; AIDS and other viral diseases such as Herpes Zoster, Herpes Simplex I or II, influenza virus and cytomegalovirus; and diabetes mellitus.

Exemplary cancers include, but are not limited to, adrenocortical carcinoma, AIDS-related cancers, AIDS-related lymphoma, anal cancer, anorectal cancer, cancer of the anal canal, appendix cancer, childhood cerebellar astrocytoma, childhood cerebral astrocytoma, basal cell carcinoma, skin cancer (non-melanoma), biliary cancer, extrahepatic bile duct cancer, intrahepatic bile duct cancer, bladder cancer, urinary bladder cancer, bone and joint cancer, osteosarcoma and malignant fibrous histiocytoma, brain cancer, brain tumor, brain stem glioma, cerebellar astrocytoma, cerebral astrocytoma/malignant glioma, ependymoma, medulloblastoma, supratentorial primitive neuroectodeimal tumors, visual pathway and hypothalamic glioma, breast cancer, bronchial adenomas/carcinoids, carcinoid tumor, gastrointestinal, nervous system cancer, nervous system lymphoma, central nervous system cancer, central nervous system lymphoma, cervical cancer, childhood cancers, chronic lymphocytic leukemia, chronic myelogenous leukemia, chronic myeloproliferative disorders, colon cancer, colorectal cancer, cutaneous T-cell lymphoma, lymphoid neoplasm, mycosis fungoides, Seziary Syndrome, endometrial cancer, esophageal cancer, extracranial germ cell tumor, extragonadal germ cell tumor, extrahepatic bile duct cancer, eye cancer, intraocular melanoma, retinoblastoma, gallbladder cancer, gastric (stomach) cancer, gastrointestinal carcinoid tumor, gastrointestinal stromal tumor (GIST), germ cell tumor, ovarian germ cell tumor, gestational trophoblastic tumor glioma, head and neck cancer, hepatocellular (liver) cancer, Hodgkin lymphoma, hypopharyngeal cancer, intraocular melanoma, ocular cancer, islet cell tumors (endocrine pancreas), Kaposi's sarcoma, kidney cancer, renal cancer, laryngeal cancer, acute lymphoblastic leukemia, acute myeloid leukemia, chronic lymphocytic leukemia, chronic myelogenous leukemia, hairy cell leukemia, lip and oral cavity cancer, liver cancer, lung cancer, non-small cell lung cancer, small cell lung cancer, AIDS-related lymphoma, non-Hodgkin lymphoma, primary central nervous system lymphoma, Waldenstram macroglobulinemia, medulloblastoma, melanoma, intraocular (eye) melanoma, merkel cell carcinoma, mesothelioma malignant, mesothelioma, metastatic squamous neck cancer, mouth cancer, cancer of the tongue, multiple endocrine neoplasia syndrome, mycosis fungoides, myelodysplastic syndromes, myelodysplastic/myeloproliferative diseases, chronic myelogenous leukemia, acute myeloid leukemia, multiple myeloma, chronic myeloproliferative disorders, nasopharyngeal cancer, neuroblastoma, oral cancer, oral cavity cancer, oropharyngeal cancer, ovarian cancer, ovarian epithelial cancer, ovarian low malignant potential tumor, pancreatic cancer, islet cell pancreatic cancer, paranasal sinus and nasal cavity cancer, parathyroid cancer, penile cancer, pharyngeal cancer, pheochromocytoma, pineoblastoma and supratentorial primitive neuroectodermal tumors, pituitary tumor, plasma cell neoplasm/multiple myeloma, pleuropulmonary blastoma, prostate cancer, rectal cancer, renal pelvis and ureter, transitional cell cancer, retinoblastoma, rhabdomyosarcoma, salivary gland cancer, ewing family of sarcoma tumors, Kaposi Sarcoma, uterine cancer, uterine sarcoma, skin cancer (non-melanoma), skin cancer (melanoma), merkel cell skin carcinoma, small intestine cancer, soft tissue sarcoma, squamous cell carcinoma, stomach (gastric) cancer, supratentorial primitive neuroectodermal tumors, testicular cancer, throat cancer, thymoma, thymoma and thymic carcinoma, thyroid cancer, transitional cell cancer of the renal pelvis and ureter and other urinary organs, gestational trophoblastic tumor, urethral cancer, endometrial uterine cancer, uterine sarcoma, uterine corpus cancer, vaginal cancer, vulvar cancer, and Wilm's Tumor.

A "cell proliferative disorder of the hematologic system" is a cell proliferative disorder involving cells of the hematologic system. In one aspect, a cell proliferative disorder of the hematologic system includes lymphoma, leukemia, myeloid neoplasms, mast cell neoplasms, myelodysplasia, benign monoclonal gammopathy, lymphomatoid granulomatosis, lymphomatoid papulosis, polycythemia vera, chronic myelocytic leukemia, agnogenic myeloid metaplasia, and essential thrombocythemia. In another aspect, a cell proliferative disorder of the hematologic system includes hyperplasia, dysplasia, and metaplasia of cells of the hematologic system. In a preferred aspect, compositions of the present invention may be used to treat a cancer selected from the group consisting of a hematologic cancer of the present invention or a hematologic cell proliferative disorder of the present invention. In one aspect, a hematologic cancer of the present invention includes multiple myeloma, lymphoma (including Hodgkin's lymphoma, non-Hodgkin's lymphoma, childhood lymphomas, and lymphomas of lymphocytic and cutaneous origin), leukemia (including childhood leukemia, hairy-cell leukemia, acute lymphocytic leukemia, acute myelocytic leukemia, chronic lymphocytic leukemia, chronic myelocytic leukemia, chronic myelogenous leukemia, and mast cell leukemia), myeloid neoplasms and mast cell neoplasms.

A "cell proliferative disorder of the lung" is a cell proliferative disorder involving cells of the lung. In one aspect, cell proliferative disorders of the lung include all forms of cell proliferative disorders affecting lung cells. In one aspect, cell proliferative disorders of the lung include lung cancer, a precancer or precancerous condition of the lung, benign growths or lesions of the lung, and malignant growths or lesions of the lung, and metastatic lesions in tissue and organs in the body other than the lung. In a preferred aspect, compositions of the present invention may be used to treat lung cancer or cell proliferative disorders of the lung. In one aspect, lung cancer includes all forms of cancer of the lung. In another aspect, lung cancer includes malignant lung neoplasms, carcinoma in situ, typical carcinoid tumors, and atypical carcinoid tumors. In another aspect, lung cancer includes small cell lung cancer ("SCLC"), non-small cell lung cancer ("NSCLC"), squamous cell carcinoma, adenocarcinoma, small cell carcinoma, large cell carcinoma, adenosquamous cell carcinoma, and mesothelioma. In another aspect, lung cancer includes "scar carcinoma," bronchioalveolar carcinoma, giant cell carcinoma, spindle cell carcinoma, and large cell neuroendocrine carcinoma. In another aspect, lung cancer includes lung neoplasms having histologic and ultrastructual heterogeneity (e.g., mixed cell types).

In one aspect, cell proliferative disorders of the lung include all forms of cell proliferative disorders affecting lung cells. In one aspect, cell proliferative disorders of the lung include lung cancer, precancerous conditions of the lung. In one aspect, cell proliferative disorders of the lung include hyperplasia, metaplasia, and dysplasia of the lung. In another aspect, cell proliferative disorders of the lung include asbestos-induced hyperplasia, squamous metaplasia, and benign reactive mesothelial metaplasia. In another aspect, cell proliferative disorders of the lung include replacement of columnar epithelium with stratified squamous epithelium, and mucosal dysplasia. In another aspect, individuals exposed to inhaled injurious environmental agents such as cigarette smoke and asbestos may be at increased risk for developing cell proliferative disorders of the lung. In another aspect, prior lung diseases that may predispose individuals to development of cell proliferative disorders of the lung include chronic interstitial lung disease, necrotizing pulmonary disease, scleroderma, rheumatoid disease, sarcoidosis, interstitial pneumonitis, tuberculosis, repeated pneumonias, idiopathic pulmonary fibrosis, granulomata, asbestosis, fibrosing alveolitis, and Hodgkin's disease.

A "cell proliferative disorder of the colon" is a cell proliferative disorder involving cells of the colon. In a preferred aspect, the cell proliferative disorder of the colon is colon cancer. In a preferred aspect, compositions of the present invention may be used to treat colon cancer or cell proliferative disorders of the colon. In one aspect, colon cancer includes all forms of cancer of the colon. In another aspect, colon cancer includes sporadic and hereditary colon cancers. In another aspect, colon cancer includes malignant colon neoplasms, carcinoma in situ, typical carcinoid tumors, and atypical carcinoid tumors. In another aspect, colon cancer includes adenocarcinoma, squamous cell carcinoma, and adenosquamous cell carcinoma. In another aspect, colon cancer is associated with a hereditary syndrome selected from the group consisting of hereditary nonpolyposis colorectal cancer, familial adenomatous polyposis, Gardner's syndrome, Peutz-Jeghers syndrome, Turcot's syndrome and juvenile polyposis. In another aspect, colon cancer is caused by a hereditary syndrome selected from the group consisting of hereditary nonpolyposis colorectal cancer, familial adenomatous polyposis, Gardner's syndrome, Peutz-Jeghers syndrome, Turcot's syndrome and juvenile polyposis.

In one aspect, cell proliferative disorders of the colon include all forms of cell proliferative disorders affecting colon cells. In one aspect, cell proliferative disorders of the colon include colon cancer, precancerous conditions of the colon, adenomatous polyps of the colon and metachronous lesions of the colon. In one aspect, a cell proliferative disorder of the colon includes adenoma. In one aspect, cell proliferative disorders of the colon are characterized by hyperplasia, metaplasia, and dysplasia of the colon. In another aspect, prior colon diseases that may predispose individuals to development of cell proliferative disorders of the colon include prior colon cancer. In another aspect, current disease that may predispose individuals to development of cell proliferative disorders of the colon include Crohn's disease and ulcerative colitis. In one aspect, a cell proliferative disorder of the colon is associated with a mutation in a gene selected from the group consisting of p53, ras, FAP and DCC. In another aspect, an individual has an elevated risk of developing a cell proliferative disorder of the colon due to the presence of a mutation in a gene selected from the group consisting of p53, ras, FAP and DCC.

A "cell proliferative disorder of the prostate" is a cell proliferative disorder involving cells of the prostate. In one aspect, cell proliferative disorders of the prostate include all forms of cell proliferative disorders affecting prostate cells. In one aspect, cell proliferative disorders of the prostate include prostate cancer, a precancer or precancerous condition of the prostate, benign growths or lesions of the prostate, and malignant growths or lesions of the prostate, and metastatic lesions in tissue and organs in the body other than the prostate. In another aspect, cell proliferative disorders of the prostate include hyperplasia, metaplasia, and dysplasia of the prostate.

A "cell proliferative disorder of the skin" is a cell proliferative disorder involving cells of the skin. In one aspect, cell proliferative disorders of the skin include all forms of cell proliferative disorders affecting skin cells. In one aspect, cell proliferative disorders of the skin include a precancer or precancerous condition of the skin, benign growths or lesions of the skin, melanoma, malignant melanoma and other malignant growths or lesions of the skin, and metastatic lesions in tissue and organs in the body other than the skin. In another aspect, cell proliferative disorders of the skin include hyperplasia, metaplasia, psoriasis, and dysplasia of the skin.

A "cell proliferative disorder of the ovary" is a cell proliferative disorder involving cells of the ovary. In one aspect, cell proliferative disorders of the ovary include all forms of cell proliferative disorders affecting cells of the ovary. In one aspect, cell proliferative disorders of the ovary include a precancer or precancerous condition of the ovary, benign growths or lesions of the ovary, ovarian cancer, malignant growths or lesions of the ovary, and metastatic lesions in tissue and organs in the body other than the ovary. In another aspect, cell proliferative disorders of the ovary include hyperplasia, metaplasia, and dysplasia of cells of the ovary.

A "cell proliferative disorder of the breast" is a cell proliferative disorder involving cells of the breast. In one aspect, cell proliferative disorders of the breast include all forms of cell proliferative disorders affecting breast cells. In one aspect, cell proliferative disorders of the breast include breast cancer, a precancer or precancerous condition of the breast, benign growths or lesions of the breast, and malignant growths or lesions of the breast, and metastatic lesions in tissue and organs in the body other than the breast. In another aspect, cell proliferative disorders of the breast include hyperplasia, metaplasia, and dysplasia of the breast.

In one aspect, a cell proliferative disorder of the breast is a precancerous condition of the breast. In one aspect, compositions of the present invention may be used to treat a precancerous condition of the breast. In one aspect, a precancerous condition of the breast includes atypical hyperplasia of the breast, ductal carcinoma in situ (DCIS), intraductal carcinoma, lobular carcinoma in situ (LCIS), lobular neoplasia, and stage 0 or grade 0 growth or lesion of the breast (e.g., stage 0 or grade 0 breast cancer, or carcinoma in situ). In another aspect, a precancerous condition of the breast has been staged according to the TNM classification scheme as accepted by the American Joint Committee on Cancer (AJCC), where the primary tumor (T) has been assigned a stage of T0 or Tis; and where the regional lymph nodes (N) have been assigned a stage of N0; and where distant metastasis (M) has been assigned a stage of M0.

In a preferred aspect, the cell proliferative disorder of the breast is breast cancer. In a preferred aspect, compositions of the present invention may be used to treat breast cancer. In one aspect, breast cancer includes all forms of cancer of the breast. In one aspect, breast cancer includes primary epithelial breast cancers. In another aspect, breast cancer includes cancers in which the breast is involved by other tumors such as lymphoma, sarcoma or melanoma. In another aspect, breast cancer includes carcinoma of the breast, ductal carcinoma of the breast, lobular carcinoma of the breast, undifferentiated carcinoma of the breast, cystosarcoma phyllodes of the breast, angiosarcoma of the breast, and primary lymphoma of the breast. In one aspect, breast cancer includes Stage I, II, IIIA, IIIB, IIIC and IV breast cancer. In one aspect, ductal carcinoma of the breast includes invasive carcinoma, invasive carcinoma in situ with predominant intraductal component, inflammatory breast cancer, and a ductal carcinoma of the breast with a histologic type selected from the group consisting of comedo, mucinous (colloid), medullary, medullary with lymphcytic infiltrate, papillary, scirrhous, and tubular. In one aspect, lobular carcinoma of the breast includes invasive lobular carcinoma with predominant in situ component, invasive lobular carcinoma, and infiltrating lobular carcinoma. In one aspect, breast cancer includes Paget's disease, Paget's disease with intraductal carcinoma, and Paget's disease with invasive ductal carcinoma. In another aspect, breast cancer includes breast neoplasms having histologic and ultrastructual heterogeneity (e.g., mixed cell types).

In a preferred aspect, a compound of the present invention may be used to treat breast cancer. In one aspect, a breast cancer that is to be treated includes familial breast cancer. In another aspect, a breast cancer that is to be treated includes sporadic breast cancer. In one aspect, a breast cancer that is to be treated has arisen in a male subject. In one aspect, a breast cancer that is to be treated has arisen in a female subject. In one aspect, a breast cancer that is to be treated has arisen in a premenopausal female subject or a postmenopausal female subject. In one aspect, a breast cancer that is to be treated has arisen in a subject equal to or older than 30 years old, or a subject younger than 30 years old. In one aspect, a breast cancer that is to be treated has arisen in a subject equal to or older than 50 years old, or a subject younger than 50 years old. In one aspect, a breast cancer that is to be treated has arisen in a subject equal to or older than 70 years old, or a subject younger than 70 years old.

In one aspect, a breast cancer that is to be treated has been typed to identify a familial or spontaneous mutation in BRCA1, BRCA2, or p53. In one aspect, a breast cancer that is to be treated has been typed as having a HER2/neu gene amplification, as overexpressing HER2/neu, or as having a low, intermediate or high level of HER2/neu expression. In another aspect, a breast cancer that is to be treated has been typed for a marker selected from the group consisting of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor-2, Ki-67, CA15-3, CA 27-29, and c-Met. In one aspect, a breast cancer that is to be treated has been typed as ER-unknown, ER-rich or ER-poor. In another aspect, a breast cancer that is to be treated has been typed as ER-negative or ER-positive. ER-typing of a breast cancer may be performed by any reproducible means. In a preferred aspect, ER-typing of a breast cancer may be performed as set forth in Onkologie 27: 175-179 (2004). In one aspect, a breast cancer that is to be treated has been typed as PR-unknown, PR-rich or PR-poor. In another aspect, a breast cancer that is to be treated has been typed as PR-negative or PR-positive. In another aspect, a breast cancer that is to be treated has been typed as receptor positive or receptor negative. In one aspect, a breast cancer that is to be treated has been typed as being associated with elevated blood levels of CA 15-3, or CA 27-29, or both.

In one aspect, a breast cancer that is to be treated includes a localized tumor of the breast. In one aspect, a breast cancer that is to be treated includes a tumor of the breast that is associated with a negative sentinel lymph node (SLN) biopsy. In one aspect, a breast cancer that is to be treated includes a tumor of the breast that is associated with a positive sentinel lymph node (SLN) biopsy. In another aspect, a breast cancer that is to be treated includes a tumor of the breast that is associated with one or more positive auxiliary lymph nodes, where the auxiliary lymph nodes have been staged by any applicable method. In another aspect, a breast cancer that is to be treated includes a tumor of the breast that has been typed as having nodal negative status (e.g., node-negative) or nodal positive status (e.g., node-positive). In another aspect, a breast cancer that is to be treated includes a tumor of the breast that has metastasized to other locations in the body. In one aspect, a breast cancer that is to be treated is classified as having metastasized to a location selected from the group consisting of bone, lung, liver, or brain. In another aspect a breast cancer that is to be treated is classified according to a characteristic selected from the group consisting of metastatic, localized, regional, local-regional, locally advanced, distant, multicentric, bilateral, ipsilateral, contralateral, newly diagnosed, recurrent, and inoperable.

In one aspect, a compound of the present invention may be used to treat or prevent a cell proliferative disorder of the breast, or to treat or prevent breast cancer, in a subject having an increased risk of developing breast cancer relative to the population at large. In one aspect, a subject with an increased risk of developing breast cancer relative to the population at large is a female subject with a family history or personal history of breast cancer. In another aspect, a subject with an increased risk of developing breast cancer relative to the population at large is a female subject having a germ-line or spontaneous mutation in BRCA1 or BRCA2, or both. In one aspect, a subject with an increased risk of developing breast cancer relative to the population at large is a female subject with a family history of breast cancer and a germ-line or spontaneous mutation in BRCA1 or BRCA2, or both. In another aspect, a subject with an increased risk of developing breast cancer relative to the population at large is a female who is greater than 30 years old, greater than 40 years old, greater than 50 years old, greater than 60 years old, greater than 70 years old, greater than 80 years old, or greater than 90 years old. In one aspect, a subject with an increased risk of developing breast cancer relative to the population at large is a subject with atypical hyperplasia of the breast, ductal carcinoma in situ (DCIS), intraductal carcinoma, lobular carcinoma in situ (LCIS), lobular neoplasia, or a stage 0 growth or lesion of the breast (e.g., stage 0 or grade 0 breast cancer, or carcinoma in situ).

In another aspect, a breast cancer that is to be treated has been histologically graded according to the Scarff-Bloom-Richardson system, wherein a breast tumor has been assigned a mitosis count score of 1, 2, or 3; a nuclear pleiomorphism score of 1, 2, or 3; a tubule formation score of 1, 2, or 3; and a total Scarff-Bloom-Richardson score of between 3 and 9. In another aspect, a breast cancer that is to be treated has been assigned a tumor grade according to the International Consensus Panel on the Treatment of Breast Cancer selected from the group consisting of grade 1, grade 1-2, grade 2, grade 2-3, or grade 3.

In one aspect, a cancer that is to be treated has been staged according to the American Joint Committee on Cancer (AJCC) TNM classification system, where the tumor (T) has been assigned a stage of TX, T1, T1mic, T1a, T1b, T1c, T2, T3, T4, T4a, T4b, T4c, or T4d; and where the regional lymph nodes (N) have been assigned a stage of NX, N0, N1, N2, N2a, N2b, N3, N3a, N3b, or N3c; and where distant metastasis (M) has been assigned a stage of MX, M0, or M1. In another aspect, a cancer that is to be treated has been staged according to an American Joint Committee on Cancer (AJCC) classification as Stage I, Stage IIA, Stage IIB, Stage IIIA, Stage IIIB, Stage IIIC, or Stage IV. In another aspect, a cancer that is to be treated has been assigned a grade according to an AJCC classification as Grade GX (e.g., grade cannot be assessed), Grade 1, Grade 2, Grade 3 or Grade 4. In another aspect, a cancer that is to be treated has been staged according to an AJCC pathologic classification (pN) of pNX, pN0, PN0 (I-), PN0 (I+), PN0 (mol-), PN0 (mol+), PN1, PN1(mi), PN1a, PN1b, PN1c, pN2, pN2a, pN2b, pN3, pN3a, pN3b, or pN3c.

In one aspect, a cancer that is to be treated includes a tumor that has been determined to be less than or equal to about 2 centimeters in diameter. In another aspect, a cancer that is to be treated includes a tumor that has been determined to be from about 2 to about 5 centimeters in diameter. In another aspect, a cancer that is to be treated includes a tumor that has been determined to be greater than or equal to about 3 centimeters in diameter. In another aspect, a cancer that is to be treated includes a tumor that has been determined to be greater than 5 centimeters in diameter. In another aspect, a cancer that is to be treated is classified by microscopic appearance as well differentiated, moderately differentiated, poorly differentiated, or undifferentiated. In another aspect, a cancer that is to be treated is classified by microscopic appearance with respect to mitosis count (e.g., amount of cell division) or nuclear pleiomorphism (e.g., change in cells). In another aspect, a cancer that is to be treated is classified by microscopic appearance as being associated with areas of necrosis (e.g., areas of dying or degenerating cells). In one aspect, a cancer that is to be treated is classified as having an abnormal karyotype, having an abnormal number of chromosomes, or having one or more chromosomes that are abnormal in appearance. In one aspect, a cancer that is to be treated is classified as being aneuploid, triploid, tetraploid, or as having an altered ploidy. In one aspect, a cancer that is to be treated is classified as having a chromosomal translocation, or a deletion or duplication of an entire chromosome, or a region of deletion, duplication or amplification of a portion of a chromosome.

In one aspect, a cancer that is to be treated is evaluated by DNA cytometry, flow cytometry, or image cytometry. In one aspect, a cancer that is to be treated has been typed as having 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% of cells in the synthesis stage of cell division (e.g., in S phase of cell division). In one aspect, a cancer that is to be treated has been typed as having a low S-phase fraction or a high S-phase fraction.

As used herein, a "normal cell" is a cell that cannot be classified as part of a "cell proliferative disorder." In one aspect, a normal cell lacks unregulated or abnormal growth, or both, that can lead to the development of an unwanted condition or disease. Preferably, a normal cell possesses normally functioning cell cycle checkpoint control mechanisms.

As used herein, "contacting a cell" refers to a condition in which a compound or other composition of matter is in direct contact with a cell, or is close enough to induce a desired biological effect in a cell.

As used herein, "candidate compound" refers to a compound of the present invention that has been or will be tested in one or more in vitro or in vivo biological assays, in order to determine if that compound is likely to elicit a desired biological or medical response in a cell, tissue, system, animal or human that is being sought by a researcher or clinician. In a preferred aspect, the biological or medical response is treatment of cancer. In another aspect, the biological or medical response is treatment or prevention of a cell proliferative disorder. In one aspect, in vitro or in vivo biological assays include, but are not limited to, enzymatic activity assays, electrophoretic mobility shift assays, reporter gene assays, in vitro cell viability assays, and the assays.

As used herein, "monotherapy" refers to administration of a single active or therapeutic compound to a subject in need thereof. Preferably, monotherapy will involve administration of a therapeutically effective amount of an active compound. Monotherapy may be contrasted with combination therapy, in which a combination of multiple active compounds is administered, preferably with each component of the combination present in a therapeutically effective amount. In one aspect, montherapy with a compound of the present invention is more effective than combination therapy in inducing a desired biological effect.

As used herein, "treating" describes the management and care of a patient for the purpose of combating a disease, condition, or disorder and includes decreasing or alleviating the symptoms or complications, or eliminating the disease, condition or disorder.

As used herein, "preventing" describes stopping the onset of the symptoms or complications of the disease, condition or disorder.

In one aspect, treating cancer results in a reduction in size of a tumor. A reduction in size of a tumor may also be referred to as "tumor regression." Preferably, after treatment, tumor size is reduced by 5% or greater relative to its size prior to treatment; more preferably, tumor size is reduced by 10% or greater; more preferably, reduced by 20% or greater; more preferably, reduced by 30% or greater; more preferably, reduced by 40% or greater; even more preferably, reduced by 50% or greater; and most preferably, reduced by greater than 75% or greater. Size of a tumor may be measured by any reproducible means of measurement. In a preferred aspect, size of a tumor may be measured as a diameter of the tumor.

In another aspect, treating cancer results in a reduction in tumor volume. Preferably, after treatment, tumor volume is reduced by 5% or greater relative to its size prior to treatment; more preferably, tumor volume is reduced by 10% or greater; more preferably, reduced by 20% or greater; more preferably, reduced by 30% or greater; more preferably, reduced by 40% or greater; even more preferably, reduced by 50% or greater; and most preferably, reduced by greater than 75% or greater. Tumor volume may be measured by any reproducible means of measurement.

In another aspect, treating cancer results in a decrease in number of tumors. Preferably, after treatment, tumor number is reduced by 5% or greater relative to number prior to treatment; more preferably, tumor number is reduced by 10% or greater; more preferably, reduced by 20% or greater; more preferably, reduced by 30% or greater; more preferably, reduced by 40% or greater; even more preferably, reduced by 50% or greater; and most preferably, reduced by greater than 75%. Number of tumors may be measured by any reproducible means of measurement. In a preferred aspect, number of tumors may be measured by counting tumors visible to the naked eye or at a specified magnification. In a preferred aspect, the specified magnification is 2.times., 3.times., 4.times., 5.times., 10.times., or 50.times..

In another aspect, treating cancer results in a decrease in number of metastatic lesions in other tissues or organs distant from the primary tumor site. Preferably, after treatment, the number of metastatic lesions is reduced by 5% or greater relative to number prior to treatment; more preferably, the number of metastatic lesions is reduced by 10% or greater; more preferably, reduced by 20% or greater; more preferably, reduced by 30% or greater; more preferably, reduced by 40% or greater; even more preferably, reduced by 50% or greater; and most preferably, reduced by greater than 75%. The number of metastatic lesions may be measured by any reproducible means of measurement. In a preferred aspect, the number of metastatic lesions may be measured by counting metastatic lesions visible to the naked eye or at a specified magnification. In a preferred aspect, the specified magnification is 2.times., 3.times., 4.times., 5.times., 10.times., or 50.times..

In another aspect, treating cancer results in an increase in average survival time of a population of treated subjects in comparison to a population receiving carrier alone. Preferably, the average survival time is increased by more than 30 days; more preferably, by more than 60 days; more preferably, by more than 90 days; and most preferably, by more than 120 days. An increase in average survival time of a population may be measured by any reproducible means. In a preferred aspect, an increase in average survival time of a population may be measured, for example, by calculating for a population the average length of survival following initiation of treatment with an active compound. In another preferred aspect, an increase in average survival time of a population may also be measured, for example, by calculating for a population the average length of survival following completion of a first round of treatment with an active compound.

In another aspect, treating cancer results in an increase in average survival time of a population of treated subjects in comparison to a population of untreated subjects. Preferably, the average survival time is increased by more than 30 days; more preferably, by more than 60 days; more preferably, by more than 90 days; and most preferably, by more than 120 days. An increase in average survival time of a population may be measured by any reproducible means. In a preferred aspect, an increase in average survival time of a population may be measured, for example, by calculating for a population the average length of survival following initiation of treatment with an active compound. In another preferred aspect, an increase in average survival time of a population may also be measured, for example, by calculating for a population the average length of survival following completion of a first round of treatment with an active compound.

In another aspect, treating cancer results in increase in average survival time of a population of treated subjects in comparison to a population receiving monotherapy with a drug that is not a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof. Preferably, the average survival time is increased by more than 30 days; more preferably, by more than 60 days; more preferably, by more than 90 days; and most preferably, by more than 120 days. An increase in average survival time of a population may be measured by any reproducible means. In a preferred aspect, an increase in average survival time of a population may be measured, for example, by calculating for a population the average length of survival following initiation of treatment with an active compound. In another preferred aspect, an increase in average survival time of a population may also be measured, for example, by calculating for a population the average length of survival following completion of a first round of treatment with an active compound.

In another aspect, treating cancer results in a decrease in the mortality rate of a population of treated subjects in comparison to a population receiving carrier alone. In another aspect, treating cancer results in a decrease in the mortality rate of a population of treated subjects in comparison to an untreated population. In a further aspect, treating cancer results a decrease in the mortality rate of a population of treated subjects in comparison to a population receiving monotherapy with a drug that is not a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof. Preferably, the mortality rate is decreased by more than 2%; more preferably, by more than 5%; more preferably, by more than 10%; and most preferably, by more than 25%. In a preferred aspect, a decrease in the mortality rate of a population of treated subjects may be measured by any reproducible means. In another preferred aspect, a decrease in the mortality rate of a population may be measured, for example, by calculating for a population the average number of disease-related deaths per unit time following initiation of treatment with an active compound. In another preferred aspect, a decrease in the mortality rate of a population may also be measured, for example, by calculating for a population the average number of disease-related deaths per unit time following completion of a first round of treatment with an active compound.

In another aspect, treating cancer results in a decrease in tumor growth rate. Preferably, after treatment, tumor growth rate is reduced by at least 5% relative to number prior to treatment; more preferably, tumor growth rate is reduced by at least 10%; more preferably, reduced by at least 20%; more preferably, reduced by at least 30%; more preferably, reduced by at least 40%; more preferably, reduced by at least 50%; even more preferably, reduced by at least 50%; and most preferably, reduced by at least 75%. Tumor growth rate may be measured by any reproducible means of measurement. In a preferred aspect, tumor growth rate is measured according to a change in tumor diameter per unit time.

In another aspect, treating cancer results in a decrease in tumor regrowth. Preferably, after treatment, tumor regrowth is less than 5%; more preferably, tumor regrowth is less than 10%; more preferably, less than 20%; more preferably, less than 30%; more preferably, less than 40%; more preferably, less than 50%; even more preferably, less than 50%; and most preferably, less than 75%. Tumor regrowth may be measured by any reproducible means of measurement. In a preferred aspect, tumor regrowth is measured, for example, by measuring an increase in the diameter of a tumor after a prior tumor shrinkage that followed treatment. In another preferred aspect, a decrease in tumor regrowth is indicated by failure of tumors to reoccur after treatment has stopped.

In another aspect, treating or preventing a cell proliferative disorder results in a reduction in the rate of cellular proliferation. Preferably, after treatment, the rate of cellular proliferation is reduced by at least 5%; more preferably, by at least 10%; more preferably, by at least 20%; more preferably, by at least 30%; more preferably, by at least 40%; more preferably, by at least 50%; even more preferably, by at least 50%; and most preferably, by at least 75%. The rate of cellular proliferation may be measured by any reproducible means of measurement. In a preferred aspect, the rate of cellular proliferation is measured, for example, by measuring the number of dividing cells in a tissue sample per unit time.

In another aspect, treating or preventing a cell proliferative disorder results in a reduction in the proportion of proliferating cells. Preferably, after treatment, the proportion of proliferating cells is reduced by at least 5%; more preferably, by at least 10%; more preferably, by at least 20%; more preferably, by at least 30%; more preferably, by at least 40%; more preferably, by at least 50%; even more preferably, by at least 50%; and most preferably, by at least 75%. The proportion of proliferating cells may be measured by any reproducible means of measurement. In a preferred aspect, the proportion of proliferating cells is measured, for example, by quantifying the number of dividing cells relative to the number of nondividing cells in a tissue sample. In another preferred aspect, the proportion of proliferating cells is equivalent to the mitotic index.

In another aspect, treating or preventing a cell proliferative disorder results in a decrease in size of an area or zone of cellular proliferation. Preferably, after treatment, size of an area or zone of cellular proliferation is reduced by at least 5% relative to its size prior to treatment; more preferably, reduced by at least 10%; more preferably, reduced by at least 20%; more preferably, reduced by at least 30%; more preferably, reduced by at least 40%; more preferably, reduced by at least 50%; even more preferably, reduced by at least 50%; and most preferably, reduced by at least 75%. Size of an area or zone of cellular proliferation may be measured by any reproducible means of measurement. In a preferred aspect, size of an area or zone of cellular proliferation may be measured as a diameter or width of an area or zone of cellular proliferation.

In another aspect, treating or preventing a cell proliferative disorder results in a decrease in the number or proportion of cells having an abnormal appearance or morphology. Preferably, after treatment, the number of cells having an abnormal morphology is reduced by at least 5% relative to its size prior to treatment; more preferably, reduced by at least 10%; more preferably, reduced by at least 20%; more preferably, reduced by at least 30%; more preferably, reduced by at least 40%; more preferably, reduced by at least 50%; even more preferably, reduced by at least 50%; and most preferably, reduced by at least 75%. An abnormal cellular appearance or morphology may be measured by any reproducible means of measurement. In one aspect, an abnormal cellular morphology is measured by microscopy, e.g., using an inverted tissue culture microscope. In one aspect, an abnormal cellular morphology takes the form of nuclear pleiomorphism.

As used herein, the term "selectively" means tending to occur at a higher frequency in one population than in another population. In one aspect, the compared populations are cell populations. In a preferred aspect, a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, acts selectively on a cancer or precancerous cell but not on a normal cell. In another preferred aspect, a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, acts selectively to modulate one molecular target (e.g., c-Met) but does not significantly modulate another molecular target (e.g., Protein Kinase C). In another preferred aspect, the invention provides a method for selectively inhibiting the activity of an enzyme, such as a kinase. Preferably, an event occurs selectively in population A relative to population B if it occurs greater than two times more frequently in population A as compared to population B. More preferably, an event occurs selectively if it occurs greater than five times more frequently in population A. More preferably, an event occurs selectively if it occurs greater than ten times more frequently in population A; more preferably, greater than fifty times; even more preferably, greater than 100 times; and most preferably, greater than 1000 times more frequently in population A as compared to population B. For example, cell death would be said to occur selectively in cancer cells if it occurred greater than twice as frequently in cancer cells as compared to normal cells.

In a preferred aspect, a compound of the present invention or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, modulates the activity of a molecular target (e.g., c-Met). In one aspect, modulating refers to stimulating or inhibiting an activity of a molecular target. Preferably, a compound of the present invention modulates the activity of a molecular target if it stimulates or inhibits the activity of the molecular target by at least 2-fold relative to the activity of the molecular target under the same conditions but lacking only the presence of said compound. More preferably, a compound of the present invention modulates the activity of a molecular target if it stimulates or inhibits the activity of the molecular target by at least 5-fold, at least 10-fold, at least 20-fold, at least 50-fold, at least 100-fold relative to the activity of the molecular target under the same conditions but lacking only the presence of said compound. The activity of a molecular target may be measured by any reproducible means. The activity of a molecular target may be measured in vitro or in vivo. For example, the activity of a molecular target may be measured in vitro by an enzymatic activity assay or a DNA binding assay, or the activity of a molecular target may be measured in vivo by assaying for expression of a reporter gene.

In one aspect, a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, does not significantly modulate the activity of a molecular target if the addition of the compound does not stimulate or inhibit the activity of the molecular target by greater than 10% relative to the activity of the molecular target under the same conditions but lacking only the presence of said compound. In a preferred aspect, a compound of the present invention does not significantly modulate the activity of Protein Kinase C.

As used herein, the term "isozyme selective" means preferential inhibition or stimulation of a first isoform of an enzyme in comparison to a second isoform of an enzyme (e.g., preferential inhibition or stimulation of a kinase isozyme alpha in comparison to a kinase isozyme beta). Preferably, a compound of the present invention demonstrates a minimum of a four fold differential, preferably a ten fold differential, more preferably a fifty fold differential, in the dosage required to achieve a biological effect. Preferably, a compound of the present invention demonstrates this differential across the range of inhibition, and the differential is exemplified at the IC.sub.50, i.e., a 50% inhibition, for a molecular target of interest.

In a preferred embodiment, administering a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, to a cell or a subject in need thereof results in modulation (i.e., stimulation or inhibition) of an activity of c-Met. As used herein, an activity of c-Met refers to any biological function or activity that is carried out by c-Met. For example, a function of c-Met includes phosphorylation of downstream target proteins. Other functions of c-Met include autophosphorylation, binding of adaptor proteins such as Gab-1, Grb-2, Shc, SHP2 and c-Cbl, and activation of signal transducers such as Ras, Src, PI3K, PLC-.gamma., STATs, ERK1 and 2 and FAK. c-Met knockdown has been shown to inhibit cancer cell growth in a cell-type-specific manner. MDA-MB-231, NCI-H661, NCI-H441, MIA PaCa-2, HT29 and MKN-45 human cancer cells. c-Met knockdown induces caspase-dependent apoptosis in a cell type-specific manner. Thus, the present invention is directed to the treatment of cell proliferative disorders where the cells express c-Met at high levels or express active c-Met.

In a preferred embodiment, administering a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, to a cell or a subject in need thereof results in modulation (i.e., stimulation or inhibition) of an activity of ERK 1 or ERK 2, or both. As used herein, an activity of ERK 1 or ERK 2 refers to any biological function or activity that is carried out by ERK 1 or ERK 2. For example, a function of ERK 1 or ERK 2 includes phosphorylation of downstream target proteins.

In one aspect, activating refers to placing a composition of matter (e.g., protein or nucleic acid) in a state suitable for carrying out a desired biological function. In one aspect, a composition of matter capable of being activated also has an unactivated state. In one aspect, an activated composition of matter may have an inhibitory or stimulatory biological function, or both.

In one aspect, elevation refers to an increase in a desired biological activity of a composition of matter (e.g., a protein or a nucleic acid). In one aspect, elevation may occur through an increase in concentration of a composition of matter.

As used herein, "a cell cycle checkpoint pathway" refers to a biochemical pathway that is involved in modulation of a cell cycle checkpoint. A cell cycle checkpoint pathway may have stimulatory or inhibitory effects, or both, on one or more functions comprising a cell cycle checkpoint. A cell cycle checkpoint pathway is comprised of at least two compositions of matter, preferably proteins, both of which contribute to modulation of a cell cycle checkpoint. A cell cycle checkpoint pathway may be activated through an activation of one or more members of the cell cycle checkpoint pathway. Preferably, a cell cycle checkpoint pathway is a biochemical signaling pathway.

As used herein, "cell cycle checkpoint regulator" refers to a composition of matter that can function, at least in part, in modulation of a cell cycle checkpoint. A cell cycle checkpoint regulator may have stimulatory or inhibitory effects, or both, on one or more functions comprising a cell cycle checkpoint. In one aspect, a cell cycle checkpoint regulator is a protein. In another aspect, a cell cycle checkpoint regulator is not a protein.

In one aspect, treating cancer or a cell proliferative disorder results in cell death, and preferably, cell death results in a decrease of at least 10% in number of cells in a population. More preferably, cell death means a decrease of at least 20%; more preferably, a decrease of at least 30%; more preferably, a decrease of at least 40%; more preferably, a decrease of at least 50%; most preferably, a decrease of at least 75%. Number of cells in a population may be measured by any reproducible means. In one aspect, number of cells in a population is measured by fluorescence activated cell sorting (FACS). In another aspect, number of cells in a population is measured by immunofluorescence microscopy. In another aspect, number of cells in a population is measured by light microscopy. In another aspect, methods of measuring cell death are as shown in Li et al., (2003) Proc Natl Acad Sci U S A. 100(5): 2674-8. In an aspect, cell death occurs by apoptosis.

In a preferred aspect, an effective amount of a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof is not significantly cytotoxic to normal cells. A therapeutically effective amount of a compound is not significantly cytotoxic to normal cells if administration of the compound in a therapeutically effective amount does not induce cell death in greater than 10% of normal cells. A therapeutically effective amount of a compound does not significantly affect the viability of normal cells if administration of the compound in a therapeutically effective amount does not induce cell death in greater than 10% of normal cells. In an aspect, cell death occurs by apoptosis.

In one aspect, contacting a cell with a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, induces or activates cell death selectively in cancer cells. Preferably, administering to a subject in need thereof a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, induces or activates cell death selectively in cancer cells. In another aspect, contacting a cell with a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, induces cell death selectively in one or more cells affected by a cell proliferative disorder. Preferably, administering to a subject in need thereof a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof, induces cell death selectively in one or more cells affected by a cell proliferative disorder. In a preferred aspect, the present invention relates to a method of treating or preventing cancer by administering a compound of the present invention, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof to a subject in need thereof, where administration of the compound, or a pharmaceutically acceptable salt, prodrug, metabolite, analog or derivative thereof results in one or more of the following: accumulation of cells in G1 and/or S phase of the cell cycle, cytotoxicity via cell death in cancer cells without a significant amount of cell death in normal cells, antitumor activity in animals with a therapeutic index of at least 2, and activation of a cell cycle checkpoint. As used herein, "therapeutic index" is the maximum tolerated dose divided by the efficacious dose. One skilled in the art may refer to general reference texts for detailed descriptions of known techniques discussed herein or equivalent techniques. These texts include Ausubel et al., Current Protocols in Molecular Biology, John Wiley and Sons, Inc. (2005); Sambrook et al., Molecular Cloning, A Laboratory Manual (3d ed.), Cold Spring Harbor Press, Cold Spring Harbor, New York (2000); Coligan et al., Current Protocols in Immunology, John Wiley & Sons, N.Y.; Enna et al., Current Protocols in Pharmacology, John Wiley & Sons, N.Y.; Fingl et al., The Pharmacological Basis of Therapeutics (1975), Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pa., 18th edition (1990). These texts can, of course, also be referred to in making or using an aspect of the invention.

2. Pyrroloquinolinyl-pyrrole-2,5-diones and pyrroloquinolinyl-pyrrolidine-2,5-diones

The pyrroloquinolinyl-pyrrole-2,5-dione compounds of formula III and IIIa are:

##STR00001## where: R1, R2 and R3 are independently selected from the group consisting of hydrogen, F, Cl, Br, I, --NR5R6, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, --O--(C.sub.1-C.sub.6) alkyl, --O--(C.sub.1-C.sub.6) substituted alkyl, --O--(C.sub.3-C.sub.9) cycloalkyl, and --O--(C.sub.3-C.sub.9) substituted cycloalkyl, aryl, heteroaryl, heterocyclyl; R4 is independently selected from the group consisting of hydrogen, --(C.sub.1-C.sub.6) alkyl, --CH.sub.2R7; R5, R6 are independently selected from the group consisting of hydrogen, and --(C.sub.1-C.sub.6) alkyl; R7 is independently selected from the group consisting of --O--P(.dbd.O)(OH).sub.2, --O--P(.dbd.O)(--OH)(--O--(C.sub.1-C.sub.6) alkyl), --O--P(.dbd.O)(--O--(C.sub.1-C.sub.6) alkyl).sub.2, --O--P(.dbd.O)(--OH) (--O--(CH.sub.2)-phenyl), --O--P(.dbd.O)(--O--(CH.sub.2)-phenyl).sub.2, a carboxylic acid group, an amino carboxylic acid group and a peptide; Q is selected from the group consisting of aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl; X is selected from the group consisting of --(CH.sub.2)--, --(NR8)--, S, and O; R8 is independently selected from the group consisting of hydrogen, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, and --O--(C.sub.1-C.sub.6) alkyl, --C(.dbd.O)--O--(C.sub.1-C.sub.6) alkyl and --C(.dbd.O)--O--(C.sub.1-C.sub.6) substituted alkyl; Y is selected from the group consisting of --(CH.sub.2)-- or a bond; wherein said aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl groups may be substituted with one or more substituents independently selected from the group consisting of F, Cl, Br, I, --NR5R6, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, --O--(C.sub.1-C.sub.6) alkyl, --O--(C.sub.1-C.sub.6) substituted alkyl, --O--(C.sub.3-C.sub.9) cycloalkyl, --O--(C.sub.3-C.sub.9) substituted cycloalkyl, -aryl, -aryl-(C.sub.1-C.sub.6) alkyl, -aryl--O--(C.sub.1-C.sub.6) alkyl, --O-aryl, --O--(C.sub.1-C.sub.4) alkyl-aryl, heteroaryl, heterocyclyl, --O--(C.sub.1-C.sub.4) alkyl-heterocycle, and --(S(.dbd.O).sub.2)--(C.sub.1-C.sub.6) alkyl; and m is 1 or 2.

For the compound of formula IIIa, Q is selected from the group consisting of aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl, provided that when R4 is hydrogen, or (C.sub.1-C.sub.4) alkyl, Q is not 3-indolyl or substituted 3-indolyl.

The pyrroloquinolinyl-pyrrolidine-2,5-dione compounds of formula IVa, IVb, Va, or Vb, are:

##STR00002## where: R1, R2 and R3 are independently selected from the group consisting of hydrogen, F, Cl, Br, I, --NR5R6, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, --O--(C.sub.1-C.sub.6) alkyl, --O--(C.sub.1-C.sub.6) substituted alkyl, --O--(C.sub.3-C.sub.9) cycloalkyl, and --O--(C.sub.3-C.sub.9) substituted cycloalkyl, aryl, heteroaryl, heterocyclyl; R4 is independently selected from the group consisting of hydrogen, --(C.sub.1-C.sub.6) alkyl, --CH.sub.2R7; R5, R6 are independently selected from the group consisting of hydrogen, and --(C.sub.1-C.sub.6) alkyl; R7 is independently selected from the group consisting of --O--P(.dbd.O)(OH).sub.2, --O--P(.dbd.O)(--OH)(--O--(C.sub.1-C.sub.6) alkyl), --O--P(.dbd.O)(--O--(C.sub.1-C.sub.6) alkyl).sub.2, --O--P(.dbd.O)(--OH) (--O--(CH.sub.2)-phenyl), --O--P(.dbd.O)(--O--(CH.sub.2)-phenyl).sub.2, a carboxylic acid group, an amino carboxylic acid group and a peptide; Q is selected from the group consisting of aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl; X is selected from the group consisting of --(CH.sub.2)--, --(NR8)--, S, and O; R8 is independently selected from the group consisting of hydrogen, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3--C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, and --O--(C.sub.1-C.sub.6) alkyl, --C(.dbd.O)--O--(C.sub.1-C.sub.6) alkyl and --C(.dbd.O)--O--(C.sub.1-C.sub.6) substituted alkyl; Y is selected from the group consisting of --(CH.sub.2)-- or a bond; wherein said aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl groups may be substituted with one or more substituents independently selected from the group consisting of F, Cl, Br, I, --NR5R6, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, --O--(C.sub.1-C.sub.6) alkyl, --O--(C.sub.1-C.sub.6) substituted alkyl, --O--(C.sub.3-C.sub.9) cycloalkyl, --O--(C3-C.sub.9) substituted cycloalkyl, -aryl, -aryl--(C.sub.1-C.sub.6) alkyl, -aryl-O--(C.sub.1-C.sub.6) alkyl, --O-aryl, --O--(C1-C4) alkyl-aryl, heteroaryl, heterocyclyl, --O--(C.sub.1-C.sub.4) alkyl-heterocycle, and --(S(.dbd.O).sub.2)--(C.sub.1-C.sub.6) alkyl; and m is 1 or 2.

Examples of preparation of a compound of formula III, IIIa, IVa, IVb, Va or Vb (including (+)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3-y- l)pyrrolidine-2,5-dione, (-)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3-y- l)pyrrolidine-2,5-dione, (+)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione, and (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione) and methods of using such compounds, are described in PCT publication number WO 06/086484 and in PCT publication number WO 10/093789, each of which is incorporated by reference in its entirety for all purposes.

2.1. Definitions

The term "alkyl" refers to radicals containing carbon and hydrogen, without unsaturation. Alkyl radicals can be straight or branched. Exemplary alkyl radicals include, without limitation, methyl, ethyl, propyl, isopropyl, hexyl, t-butyl, sec-butyl and the like. Alkyl groups may be denoted by a range, thus, for example, a (C.sub.1-C.sub.6) alkyl group is an alkyl group having from one to six carbon atoms in the straight or branched alkyl backbone. Substituted and unsubstituted alkyl groups may independently be (C.sub.1-C.sub.5) alkyl, (C.sub.1-C.sub.6) alkyl, (C.sub.1-C.sub.10) alkyl, (C.sub.3-C.sub.10) alkyl, or (C.sub.5-C.sub.10) alkyl. Unless expressly stated, the term "alkyl" does not include "cycloalkyl."

A "cycloalkyl" group refers to a cyclic alkyl group having the indicated number of carbon atoms in the "ring portion," where the "ring portion" may consist of one or more ring structures either as fused, spiro, or bridged ring structures. For example, a C3 to C6 cycloalkyl group (e.g., (C.sub.3-C.sub.6) cycloalkyl) is a ring structure having between 3 and 6 carbon atoms in the ring. When no range is given, then cycloalkyl has between three and nine carbon atoms ((C.sub.3-C.sub.9) cycloalkyl) in the ring portion. Exemplary cycloalkyl groups include, but are not limited to cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, and adamantyl. Preferred cycloalkyl groups have three, four, five, six, seven, eight, nine, or from three to nine carbon atoms in the ring structure.

The term substituted alkyl and substituted cycloalkyl, refer to alkyl and cycloalkyl groups, as defined above, substituted with one or more substituents independently selected from the group consisting of fluorine, aryl, heteroaryl, --O--(C.sub.1-C.sub.6) alkyl, and --NR5R6, where R5 and R6 are independently selected from the group consisting of hydrogen and --(C.sub.1--C.sub.6) alkyl.

The term "aryl" refers to an aromatic carbocyclic group, having one, two, or three aromatic rings. Exemplary aryl groups include, without limitation, phenyl, naphthyl, and the like. Aryl groups include one, two, or three aromatic rings structures fused with one or more additional non-aromatic carbocyclic or heterocyclic rings having from 4-9 members. Examples of fused aryl groups include benzocyclobutanyl, indanyl, tetrahydronapthylenyl, 1,2,3,4-tetrahydrophenanthrenyl, tetrahydroanthracenyl, 1,4-dihydro-1,4-methanonaphthalenyl, benzodioxolyl.

The term "heteroaryl" refers to a heteroaromatic (heteroaryl) group having one, two, or three aromatic rings containing from 1-4 heteroatoms (such as nitrogen, sulfur, or oxygen) in the aromatic ring. Heteroaryl groups include one, two, or three aromatic rings structures containing from 1-4 heteroatoms fused with one or more additional non-aromatic rings having from 4-9 members. Heteroaryl groups containing a single type of hetroatom in the aromatic ring are denoted by the type of hetero atom they contain, thus, nitrogen-containing heteroaryl, oxygen-containing heteroaryl and sulfur-containing heteroaryl denote heteroaromatic groups containing one or more nitrogen, oxygen or sulfur atoms respectively. Exemplary heteroaryl groups include, without limitation, pyridyl, pyrimidinyl, triazolyl, quinolyl, quinazolinyl, thiazolyl, benzo[b]thiophenyl, furanyl, imidazolyl, indolyl, and the like.

The terms "heterocyclyl" or "heterocycle" refers to either saturated or unsaturated, stable non-aromatic ring structures that may be fused, spiro or bridged to form additional rings. Each heterocycle consists of one or more carbon atoms and from one to four heteroatoms selected from the group consisting of nitrogen, oxygen and sulfur. "Heterocyclyl" or "heterocycle" include stable non-aromatic 3-7 membered monocyclic heterocyclic ring structures and 8-11 membered bicyclic heterocyclic ring structures. A heterocyclyl radical may be attached at any endocyclic carbon or nitrogen atom that results in the creation of a stable structure. Preferred heterocycles include 3-7 membered monocyclic heterocycles (more preferably 5-7-membered monocyclic heterocycles) and 8-10 membered bicyclic heterocycles. Examples of such groups include piperidinyl, piperazinyl, pyranyl, pyrrolidinyl, morpholinyl, thiomorpholinyl, oxopiperidinyl, oxopyrrolidinyl, oxoazepinyl, azepinyl, isoxozolyl, tetrahydropyranyl, tetrahydrofuranyl, dioxolyl, dioxinyl, oxathiolyl, dithiolyl, sulfolanyl, dioxanyl, dioxolanyl, tetahydrofurodihydrofuranyl, tetrahydropyranodihydro-furanyl, dihydropyranyl, tetrahydrofurofuranyl, tetrahydropyranofuran, quinuclidinyl (1-azabicyclo[2.2.2]octanyl) and tropanyl (8-methyl-8-azabicyclo[3.2.1]octanyl).

For the purpose of the Q substituent, the term "substituted 3-indolyl" refers to a 3-indolyl group substituted with one or more substituents selected from the group consisting of: F, Cl, Br, I, --NR5R6, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, --O--(C.sub.1-C.sub.6) alkyl, --O--(C.sub.1-C.sub.6) substituted alkyl, --O--(C.sub.3--C.sub.9) cycloalkyl, --O--(C.sub.3-C.sub.9) substituted cycloalkyl, -aryl, -aryl--(C.sub.1-C.sub.6) alkyl, -aryl--O--(C.sub.1-C.sub.6) alkyl, --O-aryl, --O--(C.sub.1-C.sub.4) alkyl-aryl, heteroaryl, heterocyclyl, --O--(C.sub.1-C.sub.4) alkyl-heterocycle, and --(S(.dbd.O).sub.2)--(C.sub.1--C.sub.6) alkyl; where R5, R6 are independently selected from the group consisting of hydrogen, and --(C.sub.1-C.sub.6) alkyl.

For the purposes of the R7 substituent, the term "carboxylic acid group" refers to a group of the form --O--C(.dbd.O)--(C.sub.1-C.sub.6) alkyl, --O--C(.dbd.O)--(C.sub.3-C.sub.9) cycloalkyl, --O--C(.dbd.O)-aryl, --O--C(.dbd.O)-heteroaryl, --O--C(.dbd.O)-heterocycle, --O--C(.dbd.O)--(C.sub.1-C.sub.6) alkyl-aryl, --O--C(.dbd.O)--(C.sub.1-C.sub.6) alkyl-heteroaryl, or --O--C(.dbd.O)--(C.sub.1-C.sub.6) alkyl-heterocycle. Included in "carboxylic acid group" are groups of the form --O--C(.dbd.O)--(C.sub.1C.sub.6) alkyl, --O--C(.dbd.O)--(C.sub.3-C.sub.9) cycloalkyl, --O--C(.dbd.O)-aryl, --O--C(.dbd.O)-heteroaryl, --O--C(.dbd.O)-heterocycle, --O--C(.dbd.O)--(C.sub.1C.sub.6) alkyl-aryl, --O--C(.dbd.O)-(C.sub.1-C.sub.6) alkyl-heteroaryl, or --O--C(.dbd.O)--(C.sub.1-C.sub.6) alkyl-heterocycle substituted with one or more substituent independently selected from the group consisting of: F, Cl, Br, I, --OH, --SH, --NR5R6, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, --O--(C.sub.1-C.sub.6) alkyl, --O--(C.sub.1-C.sub.6) substituted alkyl, --S--(C.sub.1-C.sub.6) alkyl, --O--(C.sub.3-C.sub.9) cycloalkyl, --O--(C.sub.3-C.sub.9) substituted cycloalkyl, -aryl, --O-aryl, --O--(C.sub.1-C.sub.4) alkyl-aryl, heteroaryl, heterocyclyl, --O--(C.sub.1-C.sub.4) alkyl-heterocycle, --(S(.dbd.O).sub.2)--(C.sub.1-C.sub.6) alkyl, --NH--C(.dbd.NH)--NH.sub.2 (i.e., guanido), --COOH, and --C(.dbd.O)--NR5R6, where R5 and R6 are independently selected from the group consisting of hydrogen, and --(C.sub.1-C.sub.6) alkyl. In addition, for the purposes of the R7 substituent the term "amino carboxylic acid group" refers to a carboxylic acid group, including carboxylic acid groups substituted with one or more of the above-stated substituents, which bears one or more independently selected amino groups of the form --NR5R6 where R5 and R6 are independently selected from the group consisting of hydrogen and (C1-C6) alkyl.

In one embodiment of this invention, R7 is an alpha amino or imino acid, including but not limited to alanine, arginine, asparagine, aspartic acid, cysteine, glutamine, glutamic acid, glycine, histidine, isoleucine, leucine, lysine, methionine, phenylalanine, proline, serine, threonine, tryptophan, tyrosine, valine or stereoisomers or racemic mixtures thereof. In another embodiment the of the invention, R7 is alpha amino or imino acid selected from the group consisting of L-alanine, L-arginine, L-asparagine, L-aspartic acid, L-cysteine, L-glutamine, L-glutamic acid, L-glycine, L-histidine, L-isoleucine, L-leucine, L-lysine, L-methionine, L-phenylalanine, L-proline, L-serine, L-threonine, L-tryptophan, L-tyrosine, and L-valine.

For the purposes of the R7 substituent, the term "peptide" refers to a dipeptide, tripeptide, tetrapeptide or pentapeptide, which release two, three, four, or five amino or imino acids (e.g., proline) respectively upon hydrolysis. For the purpose of R7, peptides are linked to the remainder of the molecule through an ester linkage. In one embodiment, peptides of R7 are comprised of alpha amino or imino acid, including but not limited to alanine, arginine, asparagine, aspartic acid, cysteine, glutamine, glutamic acid, glycine, histidine, isoleucine, leucine, lysine, methionine, phenylalanine, proline, serine, threonine, tryptophan, tyrosine, valine or stereoisomers or racemic mixtures thereof; and in a more preferred version of this embodiment, the carboxyl group involved in the ester linkage is the carboxyl terminal COOH group of the peptide, as opposed to a side chain carboxyl. In another embodiment the of the invention, R7 is alpha amino or imino acid selected from the group consisting of L-alanine, L-arginine, L-asparagine, L-aspartic acid, L-cysteine, L-glutamine, L-glutamic acid, L-glycine, L-histidine, L-isoleucine, L-leucine, L-lysine, L-methionine, L-phenylalanine, L-proline, L-serine, L-threonine, L-tryptophan, L-tyrosine, and L-valine; and in a more preferred version of this preferred embodiment, the carboxyl group involved in the ester linkage is the carboxyl terminal COOH group of the peptide, as opposed to a side chain carboxyl.

2.2. Preferred Compounds

Included in the preferred embodiments are compounds of formula III, IIIa, IVa, IVb, Va, or Vb, wherein Q is selected from the group consisting of aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl, provided that Q is not 3-indolyl or a substituted 3-indolyl. In other preferred embodiments Q is selected from the group consisting of aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl, provided that when R4 is hydrogen, cycloalkyl, or alkyl, Q is not 3-indolyl or a substituted 3-indolyl. In still other preferred embodiments Q is selected from the group consisting of aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl, provided that when R4 is hydrogen, (C.sub.3-C.sub.4) cycloalkyl, or (C.sub.1-C.sub.4) alkyl, Q is not 3-indolyl or substituted 3-indolyl. In another preferred embodiment Q is 3-indolyl or a substituted 3-indolyl provided that R4 is not hydrogen, cycloalkyl, or alkyl. In still another preferred embodiment Q is 3-indolyl or a substituted 3-indolyl provided that R4 is not hydrogen, (C.sub.3-C.sub.4) cycloalkyl, or (C.sub.1-C.sub.4) alkyl.

Other preferred embodiments include compounds of formula III, IIIa, IVa, IVb, Va, or Vb where R4 is --CH.sub.2R7. These compounds may serve as prodrug forms of the corresponding compounds of formula III, IIIa, IVa, IVb, Va, or Vb where R4 is H. The prodrug form is cleaved by hydrolysis to release the corresponding compound where R4 is H. The hydrolysis may occur by enzymatic or nonenzymatic routes that produce the corresponding hydroxymethylene derivative, which upon subsequent hydrolysis, result in the release of compounds where R4 is H. In one such preferred embodiment R4 is --CH.sub.2R7, where R7 is --O--P(.dbd.O)(OH).sub.2, --O--P(.dbd.O)(--OH)(--O(C.sub.1-C.sub.6)alkyl), or --O--P(.dbd.O)(--O(C.sub.1-C.sub.6)alkyl).sub.2. In one embodiment where R7 is --O--P(.dbd.O)(--O(C.sub.1-C.sub.6)alkyl).sub.2, the alkyl groups are independently selected. In another preferred embodiment, R4 is --CH.sub.2R7, where R7 is a carboxylic acid group or an amino carboxylic acid group. In still another preferred embodiment R7 is a peptide; where in a more preferred embodiment the peptide is linked through an ester bond formed with the carboxyl terminal COOH group of the peptide chain to the remainder of the compound. In other preferred separate and independent embodiments of compounds of formula III, IIIa, IVa, IVb, Va, or Vb where R4 is --CH.sub.2R7 and R7 is a peptide, the peptide may be a dipeptide, a tripeptide, a tetrapeptide or a pentapeptide. Preferred amino acid compositions for peptides of the R7 functionality are described above.

Embodiments of compounds of formula III, IIIa, IVa, IVb, Va, or Vb include those where X is selected from the group consisting of --(NR8)--, S, and O, where R8 is independently selected from the group consisting of hydrogen, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, and --O--(C.sub.1-C.sub.6) alkyl. Other embodiments of compounds of formula III, IIIa, IVa, IVb, Va, or Vb include those where X is --CH.sub.2--. In other embodiments of compounds of formula III, IIIa, IVa, IVb, Va, or Vb, X is oxygen (O). In other embodiments of compounds of formula III, IIIa, IVa, IVb, Va, or Vb, X is sulfur (S). In still other embodiments of compounds of formula III, IIIa, IVa, IVb, Va, or Vb, X is --(NR8)--, where R8 is independently selected from the group consisting of hydrogen, --(C.sub.1-C.sub.6) alkyl, --(C.sub.1-C.sub.6) substituted alkyl, --(C.sub.3-C.sub.9) cycloalkyl, --(C.sub.3-C.sub.9) substituted cycloalkyl, and --O--(C.sub.1-C.sub.6) alkyl.

Other preferred embodiments of the invention include compounds of formula III or IIIa, where Q is a heteroaryl or an optionally substituted heteroaryl group. In four separate alternative preferred embodiments of compounds of formula III or IIIa, Q is an optionally substituted monocyclic heteroaryl group, an optionally substituted bicyclic heteroaryl group, an optionally substituted bicyclic heteroaryl group with the proviso that the bicyclic heteroaryl group is not an indolyl group or a substituted indolyl, or an optionally substituted tricyclic heteroaryl group. Optional substituents, when present, are independently selected from those recited for aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl.

Included in the preferred embodiments of the invention are compounds of formula IVa, IVb, Va, or Vb, where Q is a heteroaryl or an optionally substituted heteroaryl group. In four separate alternative preferred embodiments of compounds of formula IVa, IVb, Va, or Vb, Q is an optionally substituted monocyclic heteroaryl group, an optionally substituted bicyclic heteroaryl group, an optionally substituted bicyclic heteroaryl group with the proviso that the bicyclic heteroaryl group is not indolyl, or an optionally substituted tricyclic heteroaryl group. In a more preferred embodiment, Q is an optionally substituted nitrogen-containing heteroaryl group. In a related embodiment, Q is an optionally substituted indolyl. Optional substituents, when present are independently selected from those recited for aryl, heteroaryl, --O-aryl, --S-aryl, --O-heteroaryl, and --S-heteroaryl.

Preferred embodiments of the invention include mixtures of compounds of formula IVa and IVb, including racemic mixtures. In another preferred embodiment, the compounds of formula IVa and IVb are the separate enantiomers of (.+-.)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-- 3-yl)pyrrolidine-2,5-dione. In this embodiment the preparation of (.+-.)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-- 3-yl)pyrrolidine-2,5-dione is prepared as a mixture beginning with the starting materials 1,2,3,4-tetrahydroquinoline and indole-3-acetamide. The 1,2,3,4-tetrahydroquinoline is converted into 5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl) oxoacetic acid methyl ester as described in PCT publication number WO 06/086484. The 5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl) oxoacetic acid methyl ester is reacted with indole-3-acetamide as described in PCT publication number WO 06/086484, to yield 3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3-yl)pyrrol- e-2,5-dione. The mixture of (.+-.)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-- 3-yl)pyrrolidine-2,5-dione is then prepared by catalytic hydrogenation as described in PCT publication number WO 06/086484.

Preferred embodiments of the invention also include mixtures of compounds of formula Va and Vb, including racemic mixtures. In another preferred embodiment, the compounds of Va and Vb are the separate enantiomers of (.+-.)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indo- l-3-yl)pyrrolidine-2,5-dione. In this embodiment, the compounds are prepared as a mixture by first preparing (.+-.)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-- 3-yl)pyrrolidine-2,5-dione, as described above. The mixture of cis compounds is then treated with a mixture of potassium tert-butoxide in tert-butanol to obtain a mixture of (.+-.)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indo- l-3-yl)pyrrolidine-2,5-dione as described in PCT publication number WO 06/086484.

The chemical structures of (.+-.)-cis-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-- 3-yl)pyrrolidine-2,5-dione are:

##STR00003## and (.+-.)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1ij]quinolin-1-yl)-4-(1H-indol- -3-yl)pyrrolidine-2,5-dione are:

##STR00004##

All stereoisomers of the compounds of the instant invention are contemplated, either in admixture or in pure or substantially pure form, including crystalline forms of racemic mixtures and crystalline forms of individual isomers. The definition of the compounds according to the invention embraces all possible stereoisomers (e.g., the R and S configurations for each asymmetric center) and their mixtures. It very particularly embraces the racemic forms and the isolated optical isomers having a specified activity. The racemic forms can be resolved by physical methods, such as, for example, fractional crystallization, separation or crystallization of diastereomeric derivatives, separation by chiral column chromatography or supercritical fluid chromatography. The individual optical isomers can be obtained from the racemates by conventional methods, such as, for example, salt formation with an optically active acid followed by crystallization. Furthermore, all geometric isomers, such as E- and Z-configurations at a double bond, are within the scope of the invention unless otherwise stated. Certain compounds of this invention may exist in tautomeric forms. All such tautomeric forms of the compounds are considered to be within the scope of this invention unless otherwise stated. The present invention also includes one or more regioisomeric mixtures of an analog or derivative.

As used herein, the term "salt" is a pharmaceutically acceptable salt and can include acid addition salts including hydrochlorides, hydrobromides, phosphates, sulphates, hydrogen sulphates, alkylsulphonates, arylsulphonates, acetates, benzoates, citrates, maleates, fumarates, succinates, lactates, and tartrates; alkali metal cations such as Na.sup.+, K.sup.+, Li.sup.+, alkali earth metal salts such as Mg or Ca, or organic amine salts.

As used herein, the term "metabolite" means a product of metabolism of a compound of the present invention, or a pharmaceutically acceptable salt, analog or derivative thereof, that exhibits a similar activity in vivo to said compound.

As used herein, the term "prodrug" means a compound of the present invention covalently linked to one or more pro-moieties, such as an amino acid moiety or other water solubilizing moiety. A compound of the present invention may be released from the pro-moiety via hydrolytic, oxidative, and/or enzymatic release mechanisms. In an embodiment, a prodrug composition of the present invention exhibits the added benefit of increased aqueous solubility, improved stability, and improved pharmacokinetic profiles. The pro-moiety may be selected to obtain desired prodrug characteristics. For example, the pro-moiety, e.g., an amino acid moiety or other water solubilizing moiety such as phosphate within R4, may be selected based on solubility, stability, bioavailability, and/or in vivo delivery or uptake.

3. The Pharmaceutical Compositions and Formulations

A pharmaceutical composition of the invention is formulated to be compatible with its intended route of administration. Examples of routes of administration include parenteral, e.g., intravenous, intradermal, subcutaneous, oral (e.g., inhalation), transdermal (topical), and transmucosal administration. Solutions or suspensions used for parenteral, intradermal, or subcutaneous application can include the following components: a sterile diluent such as water for injection, saline solution, fixed oils, polyethylene glycols, glycerine, propylene glycol or other synthetic solvents; antibacterial agents such as benzyl alcohol or methyl parabens; antioxidants such as ascorbic acid or sodium bisulfate; chelating agents such as ethylenediaminetetraacetic acid; buffers such as acetates, citrates or phosphates, and agents for the adjustment of tonicity such as sodium chloride or dextrose. The pH can be adjusted with acids or bases, such as hydrochloric acid or sodium hydroxide. The parenteral preparation can be enclosed in ampoules, disposable syringes or multiple dose vials made of glass or plastic

A compound or pharmaceutical composition of the invention can be administered to a subject in many of the well-known methods currently used for chemotherapeutic treatment. For example, for treatment of cancers, a compound of the invention may be injected directly into tumors, injected into the blood stream or body cavities or taken orally or applied through the skin with patches. The dose chosen should be sufficient to constitute effective treatment but not so high as to cause unacceptable side effects. The state of the disease condition (e.g., cancer, precancer, and the like) and the health of the patient should preferably be closely monitored during and for a reasonable period after treatment.

The term "therapeutically effective amount," as used herein, refers to an amount of a pharmaceutical agent to treat, ameliorate, or prevent an identified disease or condition, or to exhibit a detectable therapeutic or inhibitory effect. The effect can be detected by any assay method known in the art. The precise effective amount for a subject will depend upon the subject's body weight, size, and health; the nature and extent of the condition; and the therapeutic or combination of therapeutics selected for administration. Therapeutically effective amounts for a given situation can be determined by routine experimentation that is within the skill and judgment of the clinician. In a preferred aspect, the disease or condition to be treated is cancer. In another aspect, the disease or condition to be treated is a cell proliferative disorder.

For any compound, the therapeutically effective amount can be estimated initially either in cell culture assays, e.g., of neoplastic cells, or in animal models, usually rats, mice, rabbits, dogs, or pigs. The animal model may also be used to determine the appropriate concentration range and route of administration. Such information can then be used to determine useful doses and routes for administration in humans. Therapeutic/prophylactic efficacy and toxicity may be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., ED.sub.50 (the dose therapeutically effective in 50% of the population) and LD.sub.50 (the dose lethal to 50% of the population). The dose ratio between toxic and therapeutic effects is the therapeutic index, and it can be expressed as the ratio, LD.sub.50/ED.sub.50. Pharmaceutical compositions that exhibit large therapeutic indices are preferred. The dosage may vary within this range depending upon the dosage form employed, sensitivity of the patient, and the route of administration.

Dosage and administration are adjusted to provide sufficient levels of the active agent(s) or to maintain the desired effect. Factors which may be taken into account include the severity of the disease state, general health of the subject, age, weight, and gender of the subject, diet, time and frequency of administration, drug combination(s), reaction sensitivities, and tolerance/response to therapy. Long-acting pharmaceutical compositions may be administered every 3 to 4 days, every week, or once every two weeks depending on half-life and clearance rate of the particular formulation.

The pharmaceutical compositions containing active compounds of the present invention may be manufactured in a manner that is generally known, e.g., by means of conventional mixing, dissolving, granulating, dragee-making, levigating, emulsifying, encapsulating, entrapping, or lyophilizing processes. Pharmaceutical compositions may be formulated in a conventional manner using one or more pharmaceutically acceptable carriers comprising excipients and/or auxiliaries that facilitate processing of the active compounds into preparations that can be used pharmaceutically. Of course, the appropriate formulation is dependent upon the route of administration chosen.

Pharmaceutical compositions suitable for injectable use include sterile aqueous solutions (where water soluble) or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersion. For intravenous administration, suitable carriers include physiological saline, bacteriostatic water, Cremophor ELTM (BASF, Parsippany, N.J.) or phosphate buffered saline (PBS). In all cases, the composition must be sterile and should be fluid to the extent that easy syringeability exists. It must be stable under the conditions of manufacture and storage and must be preserved against the contaminating action of microorganisms such as bacteria and fungi. The carrier can be a solvent or dispersion medium containing, for example, water, ethanol, polyol (for example, glycerol, propylene glycol, and liquid polyethylene glycol, and the like), and suitable mixtures thereof. The proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersion and by the use of surfactants. Prevention of the action of microorganisms can be achieved by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, ascorbic acid, thimerosal, and the like. In many cases, it will be preferable to include isotonic agents, for example, sugars, polyalcohols such as manitol, sorbitol, sodium chloride in the composition. Prolonged absorption of the injectable compositions can be brought about by including in the composition an agent which delays absorption, for example, aluminum monostearate and gelatin.

Sterile injectable solutions can be prepared by incorporating the active compound in the required amount in an appropriate solvent with one or a combination of ingredients enumerated above, as required, followed by filtered sterilization. Generally, dispersions are prepared by incorporating the active compound into a sterile vehicle that contains a basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, methods of preparation are vacuum drying and freeze-drying that yields a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof.

Oral compositions generally include an inert diluent or an edible pharmaceutically acceptable carrier. They can be enclosed in gelatin capsules or compressed into tablets. For the purpose of oral therapeutic administration, the active compound can be incorporated with excipients and used in the form of tablets, troches, or capsules. Oral compositions can also be prepared using a fluid carrier for use as a mouthwash, wherein the compound in the fluid carrier is applied orally and swished and expectorated or swallowed. Pharmaceutically compatible binding agents, and/or adjuvant materials can be included as part of the composition. The tablets, pills, capsules, troches and the like can contain any of the following ingredients, or compounds of a similar nature: a binder such as microcrystalline cellulose, gum tragacanth or gelatin; an excipient such as starch or lactose, a disintegrating agent such as alginic acid, Primogel, or corn starch; a lubricant such as magnesium stearate or Sterotes; a glidant such as colloidal silicon dioxide; a sweetening agent such as sucrose or saccharin; or a flavoring agent such as peppermint, methyl salicylate, or orange flavoring.

For administration by inhalation, the compounds are delivered in the form of an aerosol spray from pressured container or dispenser, which contains a suitable propellant, e.g., a gas such as carbon dioxide, or a nebulizer.

Systemic administration can also be by transmucosal or transdermal means. For transmucosal or transdermal administration, penetrants appropriate to the barrier to be permeated are used in the formulation. Such penetrants are generally known in the art, and include, for example, for transmucosal administration, detergents, bile salts, and fusidic acid derivatives. Transmucosal administration can be accomplished through the use of nasal sprays or suppositories. For transdermal administration, the active compounds are formulated into ointments, salves, gels, or creams as generally known in the art.

In one aspect, the active compounds are prepared with pharmaceutically acceptable carriers that will protect the compound against rapid elimination from the body, such as a controlled release formulation, including implants and microencapsulated delivery systems. Biodegradable, biocompatible polymers can be used, such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid. Methods for preparation of such formulations will be apparent to those skilled in the art. The materials can also be obtained commercially from Alza Corporation and Nova Pharmaceuticals, Inc. Liposomal suspensions (including liposomes targeted to infected cells with monoclonal antibodies to viral antigens) can also be used as pharmaceutically acceptable carriers. These can be prepared according to methods known to those skilled in the art, for example, as described in U.S. Pat. No. 4,522,811.

It is especially advantageous to formulate oral or parenteral compositions in dosage unit form for ease of administration and uniformity of dosage. Dosage unit form as used herein refers to physically discrete units suited as unitary dosages for the subject to be treated; each unit containing a predetermined quantity of active compound calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier. The specification for the dosage unit forms of the invention are dictated by and directly dependent on the unique characteristics of the active compound and the particular therapeutic effect to be achieved.

In therapeutic applications, the dosages of the pharmaceutical compositions used in accordance with the invention vary depending on the agent, the age, weight, and clinical condition of the recipient patient, and the experience and judgment of the clinician or practitioner administering the therapy, among other factors affecting the selected dosage. Generally, the dose should be sufficient to result in slowing, and preferably regressing, the growth of the tumors and also preferably causing complete regression of the cancer. Dosages can range from about 0.01 mg/kg per day to about 3000 mg/kg per day. In preferred aspects, dosages can range from about 1 mg/kg per day to about 1000 mg/kg per day. In an aspect, the dose will be in the range of about 0.1 mg/day to about 50 g/day; about 0.1 mg/day to about 25 g/day; about 0.1 mg/day to about 10 g/day; about 0.1 mg to about 3 g/day; or about 0.1 mg to about 1 g/day, in single, divided, or continuous doses (which dose may be adjusted for the patient's weight in kg, body surface area in m.sup.2, and age in years). An effective amount of a pharmaceutical agent is that which provides an objectively identifiable improvement as noted by the clinician or other qualified observer. For example, regression of a tumor in a patient may be measured with reference to the diameter of a tumor. Decrease in the diameter of a tumor indicates regression. Regression is also indicated by failure of tumors to reoccur after treatment has stopped. As used herein, the term "dosage effective manner" refers to amount of an active compound to produce the desired biological effect in a subject or cell.

Preferably, (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione is administered at dosage of 360 mg, twice a day, for a maximal daily dosage of 720 mg. (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl) pyrrolidine-2,5-dione is optionally administered to subjects or patients at an initial dosage of 10 mg twice daily for a maximal daily dose of 20 mg, with dosage escalation to administration of 360 mg twice daily for a maximal daily dosage of 720 mg. Preferred dosage forms of (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione include, but are not limited to, caplets, tablets, pills, and freeze-dried powder. For instance, a subject or patient is administered one 360 mg caplet twice a day, or alternatively, two 180 mg caplets, twice a day, for a maximal daily dosage of 720 mg. (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5-dione caplets or tablets are also formulated in 60 mg doses.

The pharmaceutical compositions can include co-formulations of any of the compounds described herein.

The pharmaceutical compositions can be included in a container, pack, or dispenser together with instructions for administration.

EXAMPLES

Examples are provided below to further illustrate different features of the present invention. The examples also illustrate useful methodology for practicing the invention. These examples do not limit the claimed invention.

Materials and Methods: Unless otherwise stated, the following materials and methods apply to the biological assays described herein.

Patients were recruited from 33 centers in 6 countries in North America and Europe. Eligible patients had advanced NSCLC previously treated with at least one chemotherapy regimen but naive to EGFR TKI therapy. Patients were required to have radiographically-measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST) 1.0 guidelines. (Therasse P, et al. J Natl Cancer Inst. 92(3):205-216, 2000). Central nervous system metastases needed to be stable, and adequate end-organ function and performance status (PS; 0-1 on the Eastern Cooperative Oncology Group scale) were required. Tumor blocks or ten unstained archival tumor tissue slides for molecular analyses were mandatory.

Study Design and Treatment: In this double-blind, randomized phase II study, patients were assigned to receive oral erlotinib, 150 mg daily, plus a placebo capsule twice daily (EP arm), or erlotinib plus oral (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5,-dione (tivantinib) 360 mg twice daily (ET arm). Randomization was performed according to a dynamic allocation procedure designed to minimize imbalances in gender, age, smoking status, histology, performance status, prior chemotherapy, best response to prior chemotherapy, and study site. Treatment was administered continuously, although divided into 28-day cycles, until progressive disease or unacceptable toxicity occurred. At the time of progression, patients still suitable for further protocol therapy were unblinded and, if assigned to EP, crossed-over to ET treatment.

End Points and Statistical Considerations: The primary end point of the trial was comparison of progression-free survival (PFS) between treatment arms in an intent-to-treat (ITT) analysis using the Kaplan-Meier method and log-rank test. PFS was calculated as the time from first dose until disease progression per RECIST 1.0 or death from any cause. Tumor status was assessed with computed tomography every eight weeks (2 cycles). An independent central, blinded radiology review was performed post-hoc to compare with investigator-assessed PFS in a sensitivity analysis. The study was powered to detect a 1.5 month improvement in PFS in the ET arm beyond the 2.2 month PFS projected for the EP arm (estimated from the erlotinib arm of the randomized phase III BR.21 study). (Shepherd FA, et al. N Engl J Med. 353(2):123-132, 2005). Assuming a two-sided .alpha.=0.025 and 80% power, the sample size was calculated to be 154 patients. The primary analysis was scheduled to occur after 120 PFS events; no interim analysis was scheduled. Patients who were alive and progression-free at the time of analysis were censored at their last radiographic evaluation.

Secondary end points included a prespecified proportional hazards model for PFS and overall survival (OS) in the ITT population including key clinical and molecular variables on the basis of a stepwise selection procedure with significance for inclusion set at 0.2 or to include at least the three most significant covariates. Other secondary endpoints included comparison of PFS and OS between treatment arms among patients with specific clinical or biomarker signatures (e.g. EGFR or KRAS mutations, and MET or EGFR amplification), determination of response rates by RECIST 1.0, evaluation of post-progression response to ET among patients crossed-over from EP and characterization of the safety of the ET combination regimen. Adverse effects were classified using National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) v3.0 criteria and were assessed on days 1 and 15 of each cycle. (NCI. Common terminology criteria for adverse events (CTCAE) version 3.0 Aug. 9, 2006). In addition, exploratory post-hoc proportional hazards models were constructed for time to development of new metastatic lesions, which was calculated from the first treatment dose until the appearance of a new site of disease as prospectively collected by investigators on all restaging radiographs under RECIST guidelines.

Molecular analyses were performed centrally by Canis Life Sciences (Phoenix, Ariz.). EGFR and KRAS mutations were detected by utilizing direct sequencing of exons 18 to 21 and DxS PCR kit (DxS Ltd., Farnham, UK). MET gene copy number (GCN) was determined by fluorescent in situ hybridization (FISH) with probes for the MET loci and for CEP7 (control) and was assessed as MET:CEP7 ratio and total number of copies per cell, evaluated at different cutoff points (most commonly .gtoreq.4 copies in .gtoreq.40% of cells). Given that EGFR and MET both reside on chromosome 7, EGFR was assessed by FISH using standard Colorado criteria (gene amplification plus high polysomy) (Cappuzzo F, et al. J Natl Cancer Inst. 97(9):643-655, 2005) but was not a prespecified subgroup of interest.

The Chou algorithm was employed to calculate the Combination Index (CI) which is shown in Table 1.

TABLE-US-00001 TABLE 1 Criteria for Combination Index (CI) CI .ltoreq. 0.3 Strong Synergy 0.3 < CI .ltoreq. 0.85 Synergy 0.85 < CI .ltoreq. 1.2 Additive 1.2 < CI .ltoreq. 3.3 Antagonism CI .gtoreq. 3.3 Strong Antagonism

Combination indices were determined according to the method of Chou. (Chou, T. -C. 1991. The median-effect principle and the combination index for quantitation of synergism and antagonism, p. 61-102. In T. -C. Chou and D. C. Rideout (ed.), Synergism and antagonism in chemotherapy. Academic Press, San Diego, Calif.).

Example 1

Combination of c-Met Inhibitors with Erlotinib for the Treatment of Non-Small Cell Lung Cancer

Patients: One hundred seventy-three patients were recruited between October 2008 and September 2009 (FIG. 1). Six patients were enrolled but not treated. Accordingly, 83 subjects were treated with EP and 84 with ET. The study population had a mean age of 63 years and was primarily made up of white (95%), male (60%), current or former smokers (79%), with adenocarcinoma (60%) and one prior chemotherapy regimen (60%, Table 2). The arms were well-balanced in terms of clinical characteristics.

TABLE-US-00002 TABLE 2 Patient and Tumor Characteristics Total ET Arm EP Arm (N = 167) (n = 84) (n = 83) Characteristic No. % No. % No. % Age, years Median 63 64 62 Range 23-89 32-81 23-89 Gender Female 67 40 33 39 34 41 Male 100 60 51 61 49 59 White race 158 95 78 93 80 96 Smoking status Current 34 20 12 14 22 27 Former 98 59 55 65 43 52 Never 35 21 17 20 18 22 Stage IIIB 19 11 8 10 11 13 IV 148 89 76 91 72 87 Histology Adenocarcinoma and BAC 101 60 47 56 54 65 Squamous cell 50 30 26 31 24 29 Other 16 10 11 13 5 6 Performance status* 0 40 24 23 27 17 20 1 126 75 60 71 66 80 Not known 1 1 1 1 0 0 Time since diagnosis, months* Median 11 10 12 Range <1-165 <1-165 2-84 No. of prior chemotherapies 1 101 60 50 60 51 61 >1 66 40 34 40 32 39 Best response to prior chemotherapy* Partial response 67 42 35 43 32 42 Stable disease 63 40 31 38 32 42 Progressive disease 28 18 15 19 13 17 EGFR mutation 116 57 59 Mutant 17 15 6 11 11 19 Wild type 99 85 51 89 48 81 KRAS mutation 109 59 50 Mutant 15 14 10 17 5 10 Wild type 94 86 49 83 45 90 EGFR GCN.dagger. 141 73 68 FISH positive 78 55 38 52 40 59 FISH negative 63 45 35 48 28 41 MET GCN 141 73 68 ~4 37 26 19 26 18 26 <3 73 52 38 52 35 52 Abbreviations: BAC, bronchioloalveolar carcinoma; EP, erlotinib plus placebo; ET, erlotinib plus tivantinib; FISH, fluorescent in situ hybridization; GCN, gene copy number. Denotes variable that had incomplete information for a small portion of patients. .dagger.Positive status is defined as 4 copies in 40% of cells, a gene to chromosome ratio per cell of 2 overall scored nuclei, the presence of tight gene clusters In 10% of cells, or 15 copies of EGFR per cell in 10% of cells.

Molecular Analyses: Tumor tissue was required from all patients. Molecular analyses were performed after study entry; therefore, results were not factored into the random assignment. Material collected was adequate for EGFR mutation analysis in 70% of cases, KRAS mutation analysis in 65% of cases, and MET FISH in 84% of cases (FIG. 2A). No significant differences in patient or tumor characteristics between those with sufficient material for molecular analyses and the overall population were observed (Table 3).

TABLE-US-00003 TABLE 3 Characteristics of Patients With Sufficient Tumor for Genotyping EGFR KRAS MET All Mutation Mutation GCN Patients (n = 116) (n = 109) (n = 141) (N = 167) Characteristic No. % No. % No. % No. % Age, years Mean 62.0 61.2 62.0 62.5 Range 23-89 23-86 23-89 23-89 Male 67 58 63 58 85 60 100 60 White 111 96 104 95 134 95 158 95 Stage at study entry IIIB 13 11 12 11 15 11 19 11 IV 103 89 97 89 126 89 148 89 Time from diagnosis; months Median 11.2 10.9 11.6 11.3 Range 1.9-130.3 0.4-167.5 0.4-167.5 0.4-167.5 Current/former 88 76 87 80 114 81 132 79 smoker Tumor histology Adenocarcinoma 65 56 58 53 79 56 98 59 Squamous cell 39 34 38 35 47 33 50 30 Abbreviation: GCN, gene copy number.

The incidence of EGFR mutations was 15% (exact mutations detailed in Table 4), and there was a near doubling of patients with EGFR mutation-positive disease randomly assigned to EP compared with ET (11 v 6) (Table 2). The incidence of KRAS mutations was 14%, and twice as many patients were randomly assigned to ET compared with EP (10 v 5). Only three patients had MET:CEP7 ratios greater than 2. MET GCN was elevated (4 copies) in 37 patients (26%) and was balanced well between treatment arms FIG. 2B depicts the overlap of molecular findings. EGFR FISH was positive in 78 (55%) patients; all those with MET GCN also had EGFR-high polysomy.

TABLE-US-00004 TABLE 4 Types of Mutations Identified Mutation Type No. % EGFR 17 Exon 19 deletion 12 71 L858R, exon 21 2 12 R776C, exon 20 1 6 P772S, exon 20 1 6 Exon 20 insertion 1 6 KRAS 15 Codon 12, 35G->A 6 40 Codon 12, 35G->T 5 33 Codon 12, 34G->C 2 13 Codon 12, 34G->T 1 7 Codon 12, 35G->C 1 7

PFS and OS: At the time of PFS analysis, median follow-up was 11 months and 122 PFS events had occurred, including 106 progressions and 16 deaths. The median PFS was 2.3 months for EP and 3.8 months for ET (FIG. 3A), with a hazard ratio (HR) of 0.81 (95% CI, 0.57 to 1.16; p=0.24). The proportional hazards model yielded an adjusted PFS HR of 0.68 (95% CI, 0.47 to 0.98; p<0.05) (Table 4). As prespecified, this model used stepwise inclusion to select covariates, and the included variables were male sex, one prior chemotherapy regimen, progressive disease as best prior response, longer than 6 months since diagnosis, and EGFR wild-type status. PFS was also analyzed using central radiology review in place of investigator assessments and yielded similar results of median PFS 3.6 and 2.0 months in the ET and EP arms, respectively (HR, 0.74; 95% CI, 0.51 to 1.06; P=.09).

At the time of OS analysis, median follow-up was 14 months, and 105 patients had died. Median OS was 8.5 months for ET and 6.9 months for EP (HR, 0.87; 95% CI, 0.59 to 1.27; P=0.47) (FIG. 3B). The proportional hazards model developed for the PFS analysis resulted in an adjusted OS HR of 0.87 (95% CI, 0.59 to 1.29; P=0.50).

TABLE-US-00005 TABLE 4 No. Patients Univariate Hazard Ratio Multivariate Hazard Ratio Factor/Subgroup (ET/EP) HR (95% CI).sup.(1) p-value HR (95% CI).sup.(2) p-value Treatment Group 84/83 0.81 (0..57 to- 1.15) 0.243 0.68 (0.47 to 0.98) 0.038 Sex Male 51/49 0.85 (0.54 to 1.34) 0.482 1.47 (1.0 to 2.16) 0.050 Female 33/34 0.74 (0.41 to 1.32) 0.306 Age <60 years 30/32 0.75 (0.43 to 1.32) 0.322 1.30 (0.90 to 1.90) 0.167 .gtoreq.60 years 54/51 0.84 (0.52 to 1.33) 0.454 Histology Squamous 26/24 1.05 (0.56 to 1.99) 0.870 NI Non-squamous 58/59 0.71 (0.46 to 1.10) 0.123 Baseline ECOG PS score 0 23/17 0.84 (0.40 to 1.77) 0.639 NI 1 60/66 0.74 (0.49 to 1.12) 0.156 Prior chemotherapy regimens 1 50/51 0.72 (0.45 to 1.16) 0.177 0.55 (0.37 to 0.83) 0.005 >1 34/32 0.98 (0.56 to 1.70) 0.937 Best prior response.sup.(3) CR, PR, SD 66/64 0.91 (0.61 to 1.37) 0.667 NA PD 15/13 0.30 (0.12 to 0.79) 0.015 NA Smoking history Previous/current smoker 67/65 0.83 (0.56 to 1.23) 0.344 NI Never smoker 17/18 0.76 (0.33 to 1.76) 0.516 CNS mets CNS mets at baseline 12/11 0.94 (0.35 to 2.55) 0.904 NI No CNS mets at baseline 72/72 0.79 (0.54 to 1.16) 0.232 Time since diagnosis <6 months 18/12 1.00 (0.41 to 2.46) 0.994 Reference 6-12 months 32/31 0.55 (0.32 to 0.96) 0.037 NI >12 months (or missing) 34/40 0.91 (0.52 to 1.61) 0.755 0.47 (0.31 to 0.73) <0.001 Site location U.S. 28/26 0.92 (0.49 to 1.74) 0.805 NA Non-U.S. 56/57 0.77 (0.50 to 1.18) 0.228 MET GCN.sup.(4) <4 54/50 0.86 (0.55 to 1.35) 0.523 NI .gtoreq.4 19/18 0.71 (0.33 to 1.54) 0.387 NI EGFR mutation.sup.(4) Mutant 6/11 1.23 (0.34 to 4.44) 0.747 NI Wild type 51/48 0.70 (0.44 to 1.10) 0.125 1.97 (1.32 to 2.92) <0.001 KRAS mutation.sup.(4) Mutant 10/5 0.18 (0.05 to 0.70) 0.013 1.61 (0.80 to 3.23) 0.183 Wild type 49/45 1.01 (0.63 to 1.60) 0.977 NI Abbreviations: Complete Response (CR); Easter Cooperative Oncology Group (ECOG); Erlotinib plus Placebo (EP); Erlotinib plub Tivantinib (ET); Gene Copy Number (GCN); Hazard Ratio (HR); Metastases (mets); Factor was not a candidate for inclusion in the model (NA); Factor was a candidate for inclusion in the model but did not qualify per the stepwise criteria (NI); Progressive Disease (PD); Partial Response (PR); Performance Status (PS); Stable Disease (SD). .sup.(1)Univariate treatment HRs are not corrected for any other variables and are restricted to the specified subgroup of patients. .sup.(2)Multivariate HRs are derived from the final stratified Cox regression model (stepwise procedure). .sup.(3)Reference is Unknown/NA .sup.(4)Reference is No result. NOTE: HRs < 1.0 favor treatment with ET

Preplanned exploratory survival analyses were performed to examine outcomes according to tumor histology and molecular characteristics. Among patients with nonsquamous histology (n=117), there was a trend toward benefit from ET in both PFS (HR, 0.71; 95% CI, 0.46 to 1.10; P=0.12; FIG. 3C) and OS (HR, 0.72; 95% CI, 0.44 to 1.17; P=0.18; FIG. 3D). Applying the proportional hazards model generated for the ITT population to patients with nonsquamous histology in a hypothesis-generating analysis revealed an adjusted PFS HR of 0.61 (95% CI, 0.39 to 0.98; P=0.04) and an adjusted OS HR of 0.58 (95% CI, 0.34 to 0.99; P=0.04) for patients with nonsquamous histology. Patients with EGFR wild-type tumors (n=99) demonstrated a trend toward benefit from ET in PFS (HR, 0.70; 95% CI, 0.44 to 1.10; P=0.12; FIG. 3E) and OS (HR, 0.76; 95% CI, 0.48 to 1.22; P=0.25). Among the small number of patients with KRAS mutations (n=15), there was a significant benefit in PFS (HR, 0.18; 95% CI, 0.05 to 0.70; P<0.01; interaction P=0.006; FIG. 3F) and OS (HR, 0.43; 95% CI, 0.12 to 1.50; P=0.17). Finally, patients with increased MET GCN demonstrated a trend toward benefit from ET; benefit grew in magnitude as the copy number cutoff rose but never reached statistical significance. Specifically, patients with MET GCN 2, 3, 4, and 5 revealed PFS HRs of 0.92, 0.75, 0.71, and 0.42, respectively (Table 5). A similar although not as vigorous trend was observed in OS comparisons within the same populations (Table 5). Of note, there was no evidence that ET was worse than EP in patients with low MET GCN (<2 or <3) in this cohort.

TABLE-US-00006 TABLE 5 PFS and OS According to MET GCN Status PFS OS No. of Median Median Patients (months) (months) MET GCN ET EP ET EP Hazard Ratio 95% CI P ET EP Hazard Ratio 95% CI P <2 7 9 3.77 2.73 0.35 0.09 to 1.39 .12 9.73 8.23 0.73 0.18 to 2.96 .66 <3 38 35 3.20 1.90 0.86 0.50 to 1.46 .58 6.87 5.87 0.84 0.48 to 1.46 .52 <4 54 50 3.63 1.90 0.86 0.55 to 1.35 .52 7.57 6.70 0.95 0.58 to 1.53 .83 <5 65 56 3.50 1.90 0.92 0.61 to 1.39 .69 8.33 6.70 0.91 0.59 to 1.42 .68 >2 66 59 3.53 1.97 0.92 0.62 to 1.39 .72 7.87 6.80 0.88 0.57 to 1.35 .56 >3 35 33 3.77 3.50 0.75 0.43 to 1.31 .31 8.57 8.27 0.90 0.49 to 1.63 .72 >4 19 18 3.60 3.57 0.71 0.33 to 1.54 .39 8.33 7.53 0.76 0.34 to 1.71 .51 >5 8 12 5.63 3.57 0.42 0.13 to 1.31 .12 9.33 7.53 0.70 0.22 to 1.98 .46 Abbreviations: EP, erlotinib plus placebo; ET, erlotinib plus tivantinib; GCN, gene copy number; PFS, progression-free survival; OS, overall survival.

Given that MET is implicated in cancer cell metastasis, time-to-development of new metastatic lesions as categorized by independent radiologists was explored. The treatment anus were balanced well in terms of both the number and type of follow-up scans obtained. Among the ITT population, EP patients had a median time-to-new metastatic lesions of 3.6 months compared to 7.3 months for ET patients (HR 0.49; 95% CI, 0.31 to 0.78; p<0.01) (FIG. 4A). This effect was more pronounced in patients with nonsquamous histology (median time to metastatic disease was 3.6 months for EP and 11.0 months for ET (HR 0.46; 95% CI, 0.26 to 0.82; p<0.01) (FIG. 4B).

The objective response rate (ORR) in evaluable patients consisted entirely of partial responses (PR) and was 7% (5 of 72) in the EP arm and 10% (7 of 74) in the ET arm (p=not significant). The seven responding patients in the ET arm included three patients with EGFR mutations, one patient with EGFR wild-type status, and three patients with indeterminate EGFR status; the five responding patients in the EP arm included four patients with EGFR mutations and one patient with indeterminate EGFR status. Overall, 35 patients (42%) treated with EP were eligible for and agreeable to additional treatment at progression and crossed over to treatment with ET. Twenty-six patients were eligible for response assessment after crossing over, and two (8%) of 26 experienced PR, which was confirmed by repeat scans as per RECIST guidelines. At baseline, one of the two cross-over responders was positive for EGFR mutation and KRAS wild-type and displayed MET GCN greater than 5; the other had indeterminate EGFR status, had KRAS wild-type, and displayed MET GCN greater than 4.

Toxicity: In general, therapy was well tolerated. As is typical with erlotinib-based therapy, low grade rash and diarrhea were the most frequent toxicities. There was no significant increase in the rates of overall or serious adverse events on ET compared with EP, including neutropenia (Table 6). Thirty-eight patients died within 30 days of treatment (21 on EP, 17 on ET).

TABLE-US-00007 TABLE 6 Adverse Events ET EP Grades Grades All Grades 3-5 All Grades 3-5 P Adverse Event No. % No. % No. % No. % All Grades Grades 3-5 Alopecia 7 8.3 0 0.0 4 4.8 0 0.0 .54 NA Anemia 12 14.3 5 6.0 11 13.3 6 7.2 1.00 .77 Anorexia 24 28.6 0 0.0 28 33.7 1 1.2 .51 .50 Constipation 11 13.1 0 0.0 17 20.5 0 0.0 .22 NA Dehydration 8 9.5 4 4.8 5 6.0 3 3.6 .57 1.00 Dermatitis, acneiform 9 10.7 1 1.2 15 18.1 1 1.2 .19 1.00 Diarrhea 40 47.6 6 7.1 45 54.2 6 7.2 .44 1.00 Dry skin 19 22.6 0 0.0 21 25.3 1 1.2 .72 .50 Dysphagia 2 2.4 0 0.0 3 3.6 1 1.2 .68 .50 Dyspnea 19 22.6 6 7.1 22 26.5 11 13.3 .59 .21 Electrocardiogram QT interval prolonged 1 1.2 0 0.0 1 1.2 1 1.2 1.00 .50 Fatigue 28 33.3 4 4.8 31 37.3 5 6.0 .63 .75 Febrile neutropenia 0 0.0 0 0.0 1 1.2 1 1.2 .50 .50 Interstitial lung disease 1 1.2 0 1.2 1 1.2 0 0.0 1.00 NA Liver function test abnormal 1 1.2 0 1.2 1 1.2 0 0.0 1.00 NA Lymphopenia 1 1.2 1 1.2 3 3.6 1 1.2 .37 1.00 Mucosal inflammation 5 6.0 0 6.0 5 6.0 1 1.2 1.00 .50 Nausea 22 26.2 1 1.2 23 27.7 4 4.8 .86 .21 Neutropenia 5 6.0 4 4.8 3 3.6 2 2.4 .72 .68 Pruritus 19 22.6 0 0.0 14 16.9 2 2.4 .44 .25 Pulmonary embolism 4 4.8 4 4.8 7 8.4 5 6.0 .37 .75 Pyrexia 4 4.8 0 0.0 10 12.0 2 2.4 .10 .25 Rash 55 65.5 8 9.5 44 53.0 6 7.2 .12 .78 Renal failure 0 0.0 0 0.0 5 6.0 2 2.4 .03 .25 Acute 0 0.0 0 0.0 3 3.6 3 3.6 .12 .12 Chronic 0 0.0 0 0.0 2 2.4 0 0.0 .25 NA Sepsis 1 1.2 1 1.2 1 1.2 1 1.2 1.00 1.00 Stomatitis 4 4.8 0 0.0 2 2.4 0 0.0 .68 NA Thrombocytopenia 0 0.0 0 0.0 2 2.4 0 0.0 .25 NA Vomiting 22 26.2 3 3.6 12 14.5 1 1.2 .08 .62 Weight decrease 10 11.9 2 2.4 13 15.7 0 0.0 .51 .50 Abbreviations: EP, erlotinib plus placebo; ET, erlotinib plus tivantinib; NA, not applicable.

This is the first large randomized clinical trial of a MET-targeted inhibitor to be reported in NSCLC. Erlotinib was studied with placebo (EP arm) compared to erlotinib plus the specific MET inhibitor (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5,-dione (tivantinib) (ET arm) and discovered that PFS was not significantly different between the groups. A preplanned adjus eri analysis accounting for demographic and molecular imbalances between the arms showed prolonged PFS in the ET arm (adjusted HR, 0.68; 95% CI, 0.47 to 0.98; P=0.04). The ET combination was well tolerated without significantly increased adverse effects compared with EP. In addition, ET demonstrated increased efficacy among patients with KRAS mutations (interaction p=0.006).

Erlotinib is particularly active in NSCLC patients with EGFR mutations (Pao W, Miller V, Zakowski M, et al. EGF receptor gene mutations are common in lung cancers from "never smokers" and are associated with sensitivity of tumors to gefitinib and erlotinib. Proc Natl Acad Sci U S A. 2004;101(36):13306-13311 and Rosell R, Moran T, Queralt C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. N Engl J Med. 2009;361(10):958-967). Yet even in unselected NSCLC patients previously treated with chemotherapy, erlotinib yields a response rate of 9% and improved survival compared to placebo, especially among those with adenocarcinoma (HR 0.8; 95% CI, 0.6 to 0.9). (Shepherd F A, Rodrigues Pereira J, Ciuleanu T, et al. Erlotinib in previously treated non-small-cell lung cancer. N Engl J Med. 2005;353(2):123-132). In contrast, KRAS mutations confer inherent resistance to erlotinib, and may even be associated with harm from EGFR TKI therapy (Massarelli E, Varella-Garcia M, Tang X, et al. KRAS mutation is an important predictor of resistance to therapy with epidermal growth factor receptor tyrosine kinase inhibitors in non-small-cell lung cancer. Clin Cancer Res. 2007;13(10):2890-2896 and Jackman D M, Miller V A, Cioffredi L A, et al. Impact of epidermal growth factor receptor and KRAS mutations on clinical outcomes in previously untreated non-small cell lung cancer patients: results of an online tumor registry of clinical trials. Clin Cancer Res. 2009;15(16):5267-5273). In this study, the 17 patients with known EGFR-mutant NSCLC were, by chance, allocated nearly 2:1 to the EP arm, whereas the 15 with known KRAS mutations were allocated 2:1 to ET. Both of these imbalances may have predisposed the ET arm to worse performance compared to the placebo arm. In this regard, subgroup analysis indicated a benefit of ET in patients with KRAS mutations, which suggests that (--)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-- 3-yl)pyrrolidine-2,5,-dione (tivantinib) may have the ability to widen the scope of patients benefitting from erlotinib-based treatment.

Additionally, the study population was TKI-naive and thus a large population of MET-amplified cancer was neither expected nor observed. However, at least one patient with both an EGFR mutation and MET GCN greater than 5 was assigned to the placebo arm that crossed-over to ET upon progression and achieved a post-crossover response, indicating that (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5,-dione (tivantinib) and erlotinib can also be utilized in EGFR mutation-positive NSCLC.

Several clinical studies demonstrate that increased MET GCN is a poor prognostic factor in NSCLC, and can be expected to occur in 5 to 12% of patients (Cappuzzo F, Marchetti A, Skokan M, et al. Increased MET gene copy number negatively affects survival of surgically resected non-small-cell lung cancer patients. J Clin Oncol. 2009;27(10):1667-1674 and Go H, Jeon Y K, Park H J, Sung S W, Seo J W, Chung D H. High MET gene copy number leads to shorter survival in patients with non-small cell lung cancer. J Thorac Oncol. 2010;5(3):305-313). A MET copy number .gtoreq.4 in 37 (26%) of 141 patients, and copy number .gtoreq.5 in 20 (14%) was observed. The data reveal no evidence that elevated GCN predicted poor outcome among patients treated with EP, but a consistent trend toward benefit from ET was observed in the small cohort with increased MET GCN.

The exploratory analysis of time-to-development of new metastatic disease was also provocative, given the importance of MET signaling in disruption of cancer intercellular bonds and mobilization of cells outside their native location (Birchmeier C, Birchmeier W, Gherardi E, Vande Woude G F. Met, metastasis, motility and more. Nat Rev Mol Cell Biol. 2003;4(12):915-925 and Comoglio P M, Giordano S, Trusolino L. Drug development of MET inhibitors: targeting oncogene addiction and expedience. Nat Rev Drug Discov. 2008;7(6):504-516). A significant 3.7 month delay in the development of new metastatic disease among the ITT patients treated with ET and a significant 7.4 month delay among patients with non-squamous histology who were treated with ET was observed.

The data demonstrated that when (-)-trans-3-(5,6-dihydro-4H-pyrrolo[3,2,1-ij]quinolin-1-yl)-4-(1H-indol-3- -yl)pyrrolidine-2,5,-dione (tivantinib), a selective inhibitor of c-MET, when given in combination with an EGFR inhibitor, such as erlotinib, to patients with NSCLC who have had prior chemotherapy but who are EGFR TKI naive, the combination prolonged PFS, extended OS, and delayed metastases when compared with either treatment alone. In this phase II trial, particular benefit was observed among patients with KRAS mutations