ANTITUMOR COMBINATION INCLUDING
AVE8062 AND SORAFENIB
The present invention relates to an antitumour combination that combines AVE8062 and
sorafenib that is effective in the treatment of cancers, more particularly of solid tumours.
[Prior art]
WO 2007/077309 describes the combination between the antivascular agent AVE8062 (or VDA,
Vascular Disrupting Agent) and the antiangiogenic agent VEGF Trap.
WO 99910779 describes the AVE8062 / platinum salt combination.
WO 2004/037258 describes the combination of AVE8062 with various antitumour agents chosen
from taxanes (taxol, taxotere), alkylating agents (cyclophosphamide, isosfamide, etc. ),
antimetabolites (5-FU, cytarabine, etc.), epidophylloptoxin, antibiotics (doxorubicin, etc.), and
vinca alkaloids.
EP 1407784 describes the AVE8062 / dexamethasone combination.
On the website www.clinicaltrials.gov, the patient recruitment phase for the Phase I study of the
combretastatin CA4P / Avastin combination ("Safety study of increasing doses of combretastatin
in combination with Bevacizumab (Avastin) in patients with advanced solid tumours") is described.
It is specified that the patients excluded are those who have already undergone a treatment
based on a VEGF or VEGFR inhibitor such as sorafenib or sutent ("exclusion criteria: prior
therapy with CA4P or bevacizumab, or other agents which target vascular endothelial growth
factor (VEGF) or VEGFR signaling such as Sorafenib and Sutent").
In the file on Nexavar available on the website of the EMEA
(http://www.emea.europa.eu/humandocs/PDFs/EPAR/nexavar/H-690-PI-fr.pdf), it is indicated that
Nexavar® (sorafenib tosylate) may be combined with various anticancer agents such as
gemcitabine, oxaliplatin, doxorubicin, irinotecan or docetaxel.

[Brief description of the invention]
The invention relates to an antitumour pharmaceutical combination comprising AVE8062 of
formula:
and sorafenib of formula:
these two antitumour agents
possibly being in the base form or in the form of a salt of a pharmaceutically acceptable acid. The
combination comprises an effective amount of AVE8062 and an effective amount of sorafenib.
The combination is intended to be administered to a patient during a cycle comprising an
administration of AVE8062 that marks the beginning of said cycle and several administrations of
sorafenib, the combination being staggered over time and not concomitant, the AVE8062 being
administered before the very first administration of sorafenib. The AVE8062 may be administered
the same day as the sorafenib with a time delay of 1 to 4 hours before the very first administration
of sorafenib. The AVE8062 may also be administered the day before the very first administration
of sorafenib, more particularly with a time delay of at least 24 hours. The cycle is repeated, the
interval between two administrations of AVE8062 ranging from 1 to 4 weeks.
The invention also relates to the use of AVE8062 and sorafenib for the preparation of the
antitumour combination described above.
[Description of the invention]
definitions
• pharmaceutically acceptable acid: organic or inorganic acid having a low toxicity (see
"Pharmaceutical salts" J.Pharm.Sci. 1977, 66,1-19);
• effective amount: amount of a pharmaceutical compound that produces an effect on the
treated tumour.

Regarding AVE8062, this belongs to the family of combretastatins and has the formula:

It is an antivascular agent (or VDA, Vascular Disrupting Agent). It has the chemical name: (Z)-N-
[2-methoxy-5-[2-(3,4,5-trimethoxyphenyl)vinyl]phenyl]-L-serinamide. This compound, which is
described in EP 731085 B1, may be prepared according to the method described in WO
03/084919. AVE8062 may be administered in base form (cf. above formula) or in the form of a
salt of a pharmaceutically acceptable acid, for example in the form of the hydrochloride,
represented below:
Once administered, AVE8062 releases in vivo the active metabolite (Z)-1-(3-amino-4-
methoxyphenyl)-2-(3,4,5-trimethoxyphenyl)ethene, which has the formula:

It is therefore also possible to substitute, for AVE8062, another combretastatin of formula:

in base form or in the form of a salt of a pharmaceutically acceptable acid, in which Y represents
an amino acid, which releases in vivo this metabolite.
Regarding sorafenib, this is sold by Bayer Healthcare under the trademark Nexavar®. Sorafenib
is a multikinase inhibitor that targets VEGF and BRAF receptors which has the chemical formula:


and has the chemical name: 4-[4-[[4-chloro-3-(trifluoromethyl)phenyl]carbamoylamino]
phenoxy]-N-methylpyridine-2-carboxamide. It is an antiangiogenic agent. This compound is
described in WO 00/42012 and WO 00/41698. Sorafenib may be administered in base form (cf.
formula above) or in the form of a salt of a pharmaceutically acceptable acid, for example in
tosylate form.
Regarding the combination, this consists in combining, in the form of two separate
pharmaceutical preparations, AVE8062 and sorafenib.
The combination is administered repeatedly in a course of several cycles according to a protocol
that depends on the nature and on the stage of the cancer to be treated and also on the patient to
be treated (age, weight, previous treatment(s), etc.). Each cycle begins with the administration of
AVE8062 and comprises, in addition to this, several administrations of sorafenib (one cycle is
therefore characterized by an administration of AVE8062 that marks the beginning of said cycle
and several administrations of sorafenib). The AVE8062 is administered to a patient in an
intermittent pattern with an interval between two administrations (duration of one cycle) which
may range from 1 to 4 weeks, for example 3 weeks (comment: in the case of tests on mice, the
administration interval of AVE8062 was 4 or 5 days). Sorafenib may itself be administered to a
+patient in a daily pattern over a certain duration of the cycle. Sorafenib may optionally be
administered up to the end of one cycle.
The mode of administration may be the parenteral route and/or oral route and depends on the
galenic form use for the antitumour agent. By the parenteral route, the antitumour agent may be
administered intravenously as a bolus or prepared in an intravenous infusion bag, with
pharmaceutically acceptable vectors, by various methods known to a person skilled in the art.
According to one particular mode, the AVE8062 is administered parenterally, such as via
intravenous administration, as a bolus or via infusion, and the sorafenib is administered orally.
One galenic form of AVE8062 suitable for parenteral administration is that where the AVE8062 is
in solution in water. One galenic form of sorafenib suitable for oral administration is, for example,
that sold under the trademark Nexavar® in the form of tablets containing 274 mg of sorafenib in
sorafenib tosylate form (equivalent to 200 mg of active principle).

The doses of AVE8062 and of sorafenib administered each time to a patient depend on various
parameters such as the nature and the stage of the cancer to be treated and also on the patient
to be treated (age, weight, previous treatment(s), etc.). The AVE8062 may be administered at a
tolerated dose between 5 and 100, 5 and 60, 10 and 50, 20 and 42 or 20 and 40 mg/m2
(weight/body surface area, dose defined for each administration). The sorafenib may itself be
administered at a tolerated dose between 200 and 600 mg, or 300 and 500 mg (dose defined for
each administration). The sorafenib may be taken two times a day at a dose of active principle of
200 mg, which corresponds to a daily dose of 400 mg. Furthermore, according to the product
instructions, it is recommended to take this product at least one hour before or two hours after a
meal.
The combination is effective in the treatment of cancers, more particularly of solid tumours in
general, more particularly of a sarcoma, lung, ovarian, kidney or liver cancers.
It has been observed that a better efficacy in the treatment of the tumour is obtained when, in the
course of one cycle, the administration of the two antitumour agents is staggered overtime and is
not concomitant, the AVE8062 being administered before the very first administration of the
sorafenib.
According to one particular mode, the AVE8062 is administered the same day and with a time
delay of 1 to 4 hours before the very first administration of sorafenib. A cycle example: day D1:
infusion of AVE8062 and, 1 to 4 hours after the infusion, sorafenib is taken orally (e.g. in the form
of two doses of sorafenib); day D2 to D14: sorafenib is taken orally (e.g. in the form of two doses
of sorafenib), then the cycle is repeated at D1 +3 weeks.
According to another particular mode, the AVE8062 is administered the day before the very first
administration of sorafenib. More particularly, the time delay between the administration of the
AVE8062 and the very first administration of sorafenib is at least 24 hours. Cycle example: day
D1: infusion of AVE8062; day D2 after a time delay of at least 24 hours: sorafenib is taken orally
(e.g. in the form of two doses of sorafenib); day D3 to D14: sorafenib is taken orally (e.g. in the
form of two doses of sorafenib), then the cycle is repeated at D1 + 3 weeks.
The efficacy of a combination can be demonstrated by determining its therapeutic synergy. A
combination manifests therapeutic synergy if it is therapeutically superior to the best agent used
alone at its optimum dose (T.H. Corbett et al., Cancer Treatment Reports 1982, 66, 1187). The

efficacy of a combination can also be demonstrated by comparing the maximum tolerated dose of
the combination with the maximum tolerated dose of each of the separate constituents in the
study in question. This efficacy can be quantified by the log10 cell kill, which is determined by the
following formula:
log10 cell kill = T-C (days)/3.32 x Td
in which T-C represents the tumour growth delay, which is the mean time, in days, required by
the treatment-group tumours (T) to reach a predetermined value (1 g for example) and for the
control-group tumours (C) to reach the same value, and Td represents the time, in days,
necessary for the volume of the control-group tumours to double during the exponential phase of
tumour growth (T.H. Corbett et al. Cancer, 1977, 40, 2660-2680; F.M. Schabel et al., Cancer
Drug Development, Part B, Methods in Cancer Research 1979, 17, 3-51, New York, Academic
Press Inc.). A product is considered to be active if the log10 cell kill is greater than or equal to 0.7.
A product is considered to be highly active if the log10 is greater than 2.8. When the treatment
time is at least equal to 10 days, and/or is different between the two agents evaluated in the
combination, it is possible to calculate the net log cell kill:
net log10 cell kill = (T-C in days) - (treatment time in days)/3.32 x Td.
The activity in this case is acknowledged for a net log cell kill that is positive (>0). A cytostatic
activity corresponds to a net log cell kill of 0, that is to say that the treatment time is equal to the
duration of the antitumour effect.
The combination, used at its own maximum tolerated dose, in which each of the constituents is
present at a dose that generally does not exceed its maximum tolerated dose, will show
therapeutic synergy when the log10 cell kill is at least 1 log10 greater than the value of the log10
cell kill of the best constituent when the latter is administered alone.
[Examples]
Antitumor effect and tests
The efficacy of the combinations on solid tumours can be determined experimentally in the
following way: the animals subjected to the experiment are female SCID mice which are
bilaterally grafted subcutaneously with 30 to 60 mg of a fragment of NCI-H460 (ATCC#HTB-177)
human non-small cell lung tumour at day 0. In the case of an early tumour treatment, the
implanted animals are distributed randomly in various groups which are, or are not (controls),
intended to receive the treatment(s). Where it is a question of treatment of advanced tumours, the
animals bearing tumours that have reached a predefined tumour size greater than 150 mg are
distributed in the various treatment and control groups in such a way that the tumour size range is

comparable from one group to the other. The animals which do not bear tumours can also be
subjected to the same treatments as the animals bearing tumours, so that it is possible to
dissociate the toxic effect from the specific effect on the tumour. Generally, the chemotherapy
begins from 3 to 22 days after the graft, depending on the type of tumour and the desired tumour
size. The animals are observed and weighed every day. A dose which induces a weight loss of
20% or more at the lowest point (average of the group) or a mortality of 10% or more is
considered to be toxic. The tumour activity is evaluated at the highest non-toxic dose, or at the
highest dose tested, within the context of a non-cytotoxic agent.
The tumours are measured 2 or 3 times a week until the tumour reaches approximately 2 g or
until the animal dies, if this occurs before the tumour reaches 2 g. The animals are autopsied
when they are sacrificed.
The antitumor activity is determined in accordance with various recorded parameters, such as the
dose (mg/kg), the method of administration, the administration time, the toxicity and the log10 cell
kill, which depends on the tumour growth delay and also on the tumour doubling time.
Within the context of the following studies, the AVE8062, in hydrochloride form, is formulated in
water with 0.9% NaCI. The sorafenib is formulated with 12.5% of ethanol, 12.5% of polysorbate
80 and 75% of 5% glucose in water.
Study 1: Sorafenib administered simultaneously with AVE8062 (Table \)
The AVE8062 was administered intravenously on days 9 and 13 post tumour implantation. The
sorafenib was administered orally from day 9 to day 24. When the two agents were administered
in combination, the same schedules were used as for the agents alone, the combination of the
two agents having been carried out simultaneously on days 9 and 13.
The tumour doubling time was two days.
The median tumour weight at the start of the treatments was 219 to 234 mg, the control having
reached a tumour weight of 1000 mg, 12.8 days after the tumour grafting.
The highest evaluated dose (HED) of AVE80S2 is 58 mg/kg per injection, i.e. a total dose of 116
mg/kg. At this dose, AVE8062 is active with 0.9 log1D cell kill (log cell kill), 1/6 partial regression
(PR = 50% regression of the initial tumour size) being obtained at this dose.

The sorafenib, at its highest dose tested (HDT) of 62 mg/kg per administration, i.e. a total dose of
992 mg/kg, is also active with 2.3 log cell kill. However, the sorafenib did not have a cytostatic
activity at this dose (-0.1 net log cell kill), the tumour having escaped treatment.
The highest non-toxic dose (HNTD) of the combination was determined at the dose of 36 mg/kg
per administration of AVE8062 combined with that of 62 mg/kg per administration of sorafenib,
higher doses of the combination having been found to be toxic. At this HNTD, the combination is
active with 2.4 log cell kill, and 0.0 net log cell kill. However, no partial regression was observed
at this dose. Lower doses of the combination are also active (2.2 to 2.5 log cell kill), without
inducing tumour regression either.
In conclusion, the concomitant administration of AVE8062 and of sorafenib is active, maintaining
at least the therapeutic gain of each of the two agents alone. Furthermore, it has been possible to
observe that this activity is maintained at several dose levels only for the combination.
Study 2: Sorafenib adminisered 1 h after AVE8062 in the combination (Table II)
The AVE8062 was administered intravenously on days 10 and 14 post tumour implantantion. The
sorafenib was administered orally from day 10 to day 14. The two agents were administered in
combination, according to the same schedules as those used for the agents alone, but the
administration of sorafenib having been staggered one hour after the administration of the
AVE8062.
The tumour doubling time was 1.6 days.
The median tumour weight at the start of the treatments was 431 to 458 mg, the control having
reached a tumour weight of 1500 mg, 13.2 days after tumour grafting.
The 2 highest doses of AVE8062 were toxic and the highest non-toxic dose (HNTD) is
22.3 mg/kg per injection, i.e. a total dose of 44.6 mg/kg. At this dose, AVE8062 is active with
1.1 log10 cell kill (log cell kill), without inducing tumour regression.
Sorafenib, at its highest dose tested (HDT) of 100 mg/kg per administration, i.e. a total dose of
447.4 mg/kg, is also active with 1.1 log cell kill.
The HNTD of the combination was determined at the dose of 58 mg/kg per administration of
AVE8062 combined with that of 38.4 mg/kg per administration of sorafenib, the higher doses of
the combination having been found to be toxic. At this HNTD, the combination is active with 2.1

log cell kill, i.e. 1 log cell kill more than the agents alone, 1.1 log cell kill for each). Furthermore,
50% (3/6) of partial regressions (PR = 50% regression of the initial tumour size) was obtained at
this dose. Five lower doses of the combination are also active, with a log cell kill of 1.9 to 1.5, and
inducing PR at 4 dose levels.
In conclusion, the combination of AVE8062 with sorafenib administered 1 h later, induces more
tumour regressions than each of the agents alone, a therapeutic synergy being observed at the
HNTD.
Study 3: Sorafenib administered 24 h after AVE8062 in the combination (Table 111)
The AVE8062 was administered intravenously on days 9 and 14 post implantation of the
NCI-H460 pulmonary tumour in female SCID mice. The sorafenib was administered orally from
day 9 to day 20. When the 2 agents were administered in combination, the same schedules were
used as for the agents alone, but the administrations of sorafenib were started 24 hours after that
of AVE8062.
The tumour doubling time was 1.5 days.
The median tumour weight at the start of the treatments was 217 to 235 mg, the control having
reached a tumour weight of 1000 mg, 13.6 jours after tumour grafting.
The highest non-toxic dose (HNTD) of the AVE8062 is 36 mg/kg per injection, i.e. a total dose of
72 mg/kg. At this dose, AVE8062 is active with 1.7 log10 cell kill (log cell kill) without inducing
tumour regression.
Sorafenib, at its highest dose tested (HDT) of 100 mg/kg per administration, i.e. a total dose of
1213.3 mg/kg, is also active with 2.4 log cell kill. However, sorafenib did not have a cytostatic
activity at this dose (-0.4 net log cell kill), the tumour having escaped treatment.
The HNTD of the combination was determined at the dose of 36 mg/kg per administration of
AVE8062 combined with that of 100 mg/kg per administration of sorafenib, the higher doses of
the combination having been found to be toxic. At this HNTD, the combination is highly active
with 3.1 log cell kill, and 0.3 net log cell kill. Furthermore, 50% (3/6) of partial regressions (PR =
50% regression of the initial tumour size) and 16% (1/6) of complete regression (CR = regression
below the palpable limit of 63 mg) were obtained at this dose. Lower doses of the combination
are also active (2.6 to 3 log cell kill), and induce PR at 5 dose levels and CR at 2 dose levels.

In conclusion, this combination, which uses a sequence during which sorafenib is administered
after AVE8062, induces complete and/or partial tumour regressions, which is not observed for the
agents alone. These regressions, in combination, are observed at several dose levels. The log10
cell kill in combination is systematically higher than that observed in monotherapy.
In conclusion, for these 3 studies, staggering the administration of sorafenib by at least 1 hour
after the administration of AVE8062, gives a therapeutic gain compared to the administration of
the two antitumour agents when they are administered alone. Expanding this interval up to at
least 24 hours increases this therapeutic advantage.

CLAIMS
Antitumour pharmaceutical combination comprising AVE8062 of formula:

antitumour agents possibly being in the base form or in the form of a salt of a
pharmaceutically acceptable acid.
Combination according to Claim 1, comprising an effective amount of AVE8062
and an effective amount of sorafenib.
Combination according to Claim 1 or 2, in which the AVE8062 is in hydrochloride
form and/or the sorafenib is in tosylate form.
Combination according to Claims 1 to 3, intended to be administered to a patient
during a cycle comprising an administration of AVE8062 that marks the
beginning of said cycle and several administrations of sorafenib, characterized in
that the combination is staggered over time and is not concomitant, the AVE8062
being administered before the very first administration of sorafenib.
Combination according to Claim 4, in which the AVE8062 is administered the
same day as the sorafenib with a time delay of 1 to 4 hours before the very first
administration of sorafenib.
Combination according to Claim 4, in which the AVE8062 is administered the
day before the very first administration of sorafenib.

5. Combination according to Claim 4, in which the AVE80S2 is administered the
same day as the sorafenib with a time delay of 1 to 4 hours before the very first
administration of sorafenib.
G. Combination according to Claim 4, in which the AVE8062 is administered the
day before the very first administration of sorafenib.
7. Combination according to Claim 6, in which the time delay between the
administration of the AVE8062 and the very 1st administration of sorafenib is at
least 24 hours.
8. Combination according to one of Claims 4 to 7, in which the cycle is repeated,
the interval between two administrations of AVE8062 ranging from 1 to 4 weeks.
9. Combination according to one of Claims 1 to 8, in which the AVE8062 is
administered parenterally and/or the sorafenib orally.
10. Combination according to one of Claims 1 to 9, intended for the treatment of a
solid tumour, more particularly a sarcoma, lung, ovarian, kidney or liver cancers.
11. Use of AVE8062 and of sorafenib for the preparation of an antitumour
combination as described in one of Claims 1 to 10.

The invention relates to a pharmaceutical antitumor combination including AVE8062 of formula (I) and sorafenib
of formula (II), wherein both of said antitumor agents can be in the form of a base or pharmaceutically acceptable acid salt.