# Patent

## Title
CD47 blockade therapy by HDAC inhibitors

## Abstract

CD47+ disease cells such as cancer cells are treated using a combination of CD47 blockade drug and a histone deacetylase (HDAC) inhibitor. The anti-cancer effect of one drug enhances the anti-cancer effect of the other. Specific combinations include SIRPαFc as CD47 blockade drug, and one of depsipeptide and romidepsin as HDAC inhibitor. These combinations are useful particularly to treat blood cancers including lymphomas, leukemias and myelomas.

## Background
CROSS-REFERENCE
This application claims the benefit under 35 USC § 119(e) from U.S. Provisional patent application Ser. No. 62/416,968, filed Nov. 3, 2016, which is incorporated herein by reference in its entirety.


FIELD
This disclosure relates to methods and uses of a drug that blocks the CD47/SIRPα interaction. More particularly, the disclosure relates to methods and uses that, in combination, are useful for improving cancer therapy.
BACKGROUND
Cancer cells are targeted for destruction by antibodies that bind to cancer cell antigens, and through recruitment and activation of macrophages by way of Fc receptor binding to the Fc portion of that antibody. Binding between CD47 on cancer cells and SIRPα on macrophages transmits a “don't eat me” signal that enables many tumour cells to escape destruction by macrophages. It has been shown that inhibition of the CD47/SIRPα interaction (CD47 blockade) will allow macrophages to “see” and destroy the target CD47+ cancer cell. The use of SIRPα to treat cancer by CD47 blockade is described in WO2010/130053.
Trillium Therapeutics' WO2014/094122 describes a protein drug that inhibits the interaction between CD47 and SIRPα. This CD47 blockade drug is a form of human SIRPα that incorporates a particular region of its extracellular domain linked with a particularly useful form of an IgG1-based Fc region. In this form, the SIRPαFc drug shows dramatic effects on the viability of cancer cells that present with a CD47+ phenotype. The effect is seen particularly on acute myelogenous leukemia (AML) cells, and many other types of cancer. A soluble form of SIRP having significantly altered primary structure and potent CD47 binding affinity is described in WO2013/109752.
Other CD47 blockade drugs have been described, and these include various CD47 antibodies (see for instance Stanford's U.S. Pat. No. 8,562,997, and InhibRx′ WO2014/123580), each comprising different antigen binding sites but having, in common, the ability to compete with endogenous SIRPα for binding to CD47, to interact with macrophages and, ultimately, to increase CD47+ disease cell depletion. These CD47 antibodies have activities in vivo that are quite different from those intrinsic to drugs that incorporate SIRPα structure. The latter, for instance, display negligible binding to red blood cells whereas the opposite property in CD47 antibodies, and in high affinity SIRPα variants, creates a need for strategies that accommodate a drug “sink” that follows administration.
Still other agents are proposed for use in blocking the CD47/SIRPα axis. These include CD47Fc proteins described in Viral Logic's WO2010/083253, and SIRPα antibodies as described in University Health Network's WO2013/056352, Eberhard's U.S. Pat. No. 6,913,894, and elsewhere.
The CD47 blockade approach in anti-cancer drug development shows great promise. There is a need to provide methods and means for improving the effect of these drugs, and in particular for improving the effect of the CD47 blockade drugs that incorporate CD47-binding forms of SIRPα.
SUMMARY
It is now shown that the anti-cancer effect of CD47 blockade therapy is improved when combined with an agent that inhibits histone deacetylase (HDAC) activity. More particularly, significant improvement in cancer cell vitality and/or depletion is seen when CD47+ cancer cells are treated with a CD47 blockade drug, such as a SIRPα-based drug or an anti-CD47 antibody, in combination with an HDAC inhibitor and particularly with romidepsin and related compounds. The two drugs cooperate in their effects on cancer cells, and cause the depletion of more cancer cells than can be accounted for by their individual effects. In related terms, the HDAC inhibitor is effective to enhance the anti-cancer activity of the CD47 blockade drug.
In one aspect, there is provided a method for treating a subject presenting with CD47+ disease cells, comprising administering a combination comprising a CD47-binding form of SIRPα and an HDAC inhibitor, such as romidepsin.
In a related aspect, there is provided the use of a CD47 blockade drug, such as a SIRPα-based drug, in combination with an HDAC inhibitor for the treatment of a subject presenting with CD47+ disease cells such as cancer.
In another aspect there is provided a pharmaceutical combination comprising a CD47 blockade drug and HDAC inhibitor for use in the treatment of CD47+ disease cells.
There is also provided, in another aspect, a kit comprising a pharmaceutical combination comprising a CD47 blockade drug, such as a soluble SIRPα-based drug, and an HDAC inhibitor, together with instructions teaching their use in the treatment method herein described of CD47+ disease cells.
In a specific embodiment, the combination of the CD47 blockade drug and HDAC inhibitor is for use in the treatment of cancer, including a blood cancer such as a myeloma, a lymphoma or a leukemia.
Other features and advantages of the present disclosure will become apparent from the following detailed description. It should be understood, however, that the detailed description and the specific examples while indicating preferred embodiments of the disclosure are given by way of illustration only, since various changes and modifications within the spirit and scope of the disclosure will become apparent to those skilled in the art from this detailed description.



BRIEF REFERENCE TO THE DRAWINGS
FIG. 1 shows results when the multiple myeloma cell lines MM1s and H929 are cultured in the presence of the HDAC inhibitor Romidepsin (at 1, 5 or 10 nM) for 48 hours. Cells are then washed; macrophages and SIRPαFc [TTI-621] (at 1, 5 or 100 nM) or Control Fc are added and the mixture is then subjected to the phagocytosis assay described below. As shown in FIG. 1, culturing MM1s (A) and H929 (B) in Romidepsin for 48 hours results increased SIRPαFc-mediated phagocytosis.
FIG. 2 shows additional results when the multiple myeloma cell lines MM1.S and the cutaneous T-cell lymphoma line HH are cultured in the presence of the HDAC inhibitor Romidepsin (10 nM) for 48 hours. Cells are then washed; macrophages and 100 nM SIRPαFc (IgG1), SIRPαFc (IgG4), SIRPαFc (CV1) (IgG4 mut), CD47 monoclonal antibody (mAb) or Control Fc are added and the mixture is then subjected to the phagocytosis assay described herein. As shown in FIG. 2, culturing MM1.S (A) and HH (B) in Romidepsin for 48 hours results in increased phagocytosis mediated by a variety of CD47 blockade drugs.



DETAILED DESCRIPTION
The present disclosure provides methods, uses, combinations and kits useful for treating subjects that present with disease cells that have a CD47+ phenotype. In this method, subjects receive a combination of a CD47 blockade drug which preferably is a CD47-binding form of SIRPα, and a histone deacetylase (HDAC) inhibitor. The effect of this combination is superior to the effects of either agent alone. This is a statistically significant effect, or benefit, that results particularly when the CD47 blockade drug is a CD47-binding SIRPαFc-based agent. The effect is also seen when the CD47 blockade drug is a CD47-binding antibody. The effect is pronounced when the CD47+ disease cells are CD47+ cancer cells and tumours.
In one aspect, there is provided a method for treating a subject with CD47+ disease cells, comprising administering an effective amount of a drug combination comprising a CD47 blockade drug and a HDAC inhibitor.
In a related aspect, there is provided a use of a CD47 blockade drug in combination with a HDAC inhibitor for the treatment of a subject with CD47+ disease cells.
In another aspect, there is provided a combination comprising a CD47 blockade drug and HDAC inhibitor for use in the treatment of a CD47+ disease.
In a further aspect, there is provided a kit comprising a combination comprising a CD47 blockade drug and HDAC inhibitor together with instructions for the use in the treatment of CD47+ disease cells.
The term CD47+ disease cells means cells having the phenotype CD47+ and are associated with a disease. Cells that are CD47+ can be identified using the methods disclosed herein. In one embodiment, the CD47+ disease cells are cancer cells.
As used herein, a CD47 blockade drug is a drug or agent that interferes with and dampens or blocks signal transmission that results when CD47 interacts with macrophage-presented SIRPα. Also included are CD47-binding agents that block interaction between SIRPα and CD47. CD47-binding forms of human SIRPα are the preferred CD47 blockade drugs for use in the combination herein disclosed. These drugs are based on the CD47-binding extracellular region of human SIRPα. They comprise at least a part of the extracellular region sufficient to confer effective CD47 binding affinity and specificity. So-called “soluble” forms of SIRPα, lacking the membrane anchoring component, are useful and are described in the literature and include those referenced in Novartis' WO 2010/070047, and Stanford's WO2013/109752, and Trillium Therapeutics' WO2014/094122. The CD47 blockade drug can also be a bispecific Fc fusion protein that includes a CD47 binding site.
In a preferred embodiment, the soluble form of SIRPα is an Fc fusion. More particularly, the CD47 blockade drug suitably comprises a CD47-binding part of the human SIRPα protein, in a form fused directly, or indirectly, with an antibody constant region, or Fc (fragment crystallisable) Unless otherwise stated, the term “human SIRPα” as used herein refers to a wild type, endogenous, mature form of human SIRPα. In humans, the SIRPα protein is found in two major forms. One form, the variant 1 or V1 form, has the amino acid sequence set out as NCBI RefSeq NP 542970.1 (residues 27-504 constitute the mature form). Another form, the variant 2 or V2 form, differs by 13 amino acids and has the amino acid sequence set out in GenBank as CAA71403.1 (residues 30-504 constitute the mature form). These two forms of SIRPα constitute about 80% of the forms of SIRPα present in humans, and both are embraced herein by the term “human SIRPα”. Also embraced by the term “human SIRPα” are the minor forms thereof that are endogenous to humans and have the same property of triggering signal transduction through CD47 upon binding thereto. The present disclosure is directed most particularly to the drug combinations that include the human SIRP variant 2 form, or V2.
In the present drug combination, useful SIRPαFc fusion proteins comprise one, such as only one, of the three so-called immunoglobulin (Ig) domains that lie within the extracellular region of human SIRPα. More particularly, the present SIRPαFc proteins incorporate at least residues 32-137 of human SIRPα (a 106-mer), which constitute and define the IgV domain of the V2 form according to current nomenclature. This SIRPα sequence, shown below, is referenced herein as SEQ ID No.1.







[SEQ ID No. 1]


EELQVIQPDKSVSVAAGESAILHCTVTSLIPVGPIQWFRGAGPAREL


 


IYNQKEGHFPRVTTVSESTKRENMDFSISISNITPADAGTYYCVKFR


 


KGSPDTEFKSGA






In a preferred embodiment, the SIRPαFc fusion proteins incorporate the IgV domain as defined by SEQ ID No.1, and additional, flanking residues contiguous within the SIRPα sequence. This preferred form of the IgV domain, represented by residues 31-148 of the V2 form of human SIRPα, is a 118-mer having SEQ ID No. 2 shown below:







[SEQ ID No. 2]


EEELQVIQPDKSVSVAAGESAILHCTVTSLIPVGPIQWFRGAGPARE


 


LIYNQKEGHFPRVTTVSESTKRENMDFSISISNITPADAGTYYCVKF


 


RKGSPDTEFKSGAGTELSVRAKPS






Desirable SIRPα fusion proteins incorporate an Fc region that preferably also has effector function. Fc refers to “fragment crystallisable” and represents the constant region of an antibody comprised principally of the heavy chain constant region and components within the hinge region. An Fc component “having effector function” is an Fc component having at least some natural or engineered function, such as at least some contribution to antibody-dependent cellular cytotoxicity or some ability to fix complement. Also, the Fc will at least bind to Fc receptors. These properties can be revealed using assays established for this purpose. Functional assays include the standard chromium release assay that detects target cell lysis. By this definition, an Fc region that is wild type IgG1 or IgG4 has effector function, whereas the Fc region of a human IgG4 mutated to alter effector function, such as by incorporation of an alteration series that includes Pro233, Val234, Ala235 and deletion of Gly236 (EU), is considered not to have effector function. In a preferred embodiment, the Fc is based on human antibodies of the IgG1 isotype. The Fc region of these antibodies will be readily identifiable to those skilled in the art. In embodiments, the Fc region includes the lower hinge-CH2-CH3 domains.
In a specific embodiment, the Fc region is based on the amino acid sequence of a human IgG1 set out as P01857 in UniProtKB/Swiss-Prot, residues 104-330, and has the amino acid sequence shown below and referenced herein as SEQ ID No.3:







[SEQ ID No. 3]


DKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVS


 


HEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWL


 


NGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSRDELTKN


 


QVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYS


 


KLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK*






Thus, in embodiments, the Fc region has either a wild type or consensus sequence of an IgG1 constant region. In alternative embodiments, the Fc region incorporated in the fusion protein is derived from any IgG1 antibody having a typical effector-active constant region. The sequences of such Fc regions can correspond, for example, with the Fc regions of any of the following IgG1 sequences (all referenced from GenBank), for example: BAG65283 (residues 242-473), BAC04226.1 (residues 247-478), BAC05014.1 (residues 240-471), CAC20454.1 (residues 99-320), BAC05016.1 (residues 238-469), BAC85350.1 (residues 243-474), BAC85529.1 (residues 244-475), and BAC85429.1 (residues (238-469).
In the alternative, the Fc region can be a wild type or consensus sequence of an IgG2 or IgG3 sequence, examples thereof being shown below:

    
    
        a human IgG2, for example:
    
    









(SEQ ID No. 4)


APPVAGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVQFNWY


 


VDGVEVHNAKTKPREEQFNSTFRVVSVLTVVHQDWLNGKEYKCKVSN


 


KGLPAPIEKTISKTKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGF


 


YPSDISVEWESNGQPENNYKTTPPMLDSDGSFFLYSKLTVDKSRWQQ


 


GNVFSCSVMHEALHNHYTQKSLSLSPGK,






as comprised in P01859 of the UniProtKB/Swiss-Prot database;

    
    
        a human IgG3, for example:
    
    









(SEQ ID No. 5)


APELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVQFKW


 


YVDGVEVHNAKTKPREEQYNSTFRVVSVLTVLHQDWLNGKEYKCKVS


 


NKALPAPIEKTISKTKGQPREPQVYTLPPSREEMTKNQVSLTCLVKG


 


FYPSDIAVEWESSGQPENNYNTTPPMLDSDGSFFLYSKLTVDKSRWQ


 


QGNIFSCSVMHEALHNRFTQKSLSLSPGK,






as comprised in P01860 of the UniProtKB/Swiss-Prot database.

In other embodiments, the Fc region has a sequence of a wild type human IgG4 constant region. In alternative embodiments, the Fc region incorporated in the fusion protein is derived from any IgG4 antibody having a constant region with effector activity that is present but, naturally, is significantly less potent than the IgG1 Fc region. The sequences of such Fc regions can correspond, for example, with the Fc regions of any of the following IgG4 sequences: P01861 (residues 99-327) from UniProtKB/Swiss-Prot and CAC20457.1 (residues 99-327) from GenBank.
In a specific embodiment, the Fc region is based on the amino acid sequence of a human IgG4 set out as P01861 in UniProtKB/Swiss-Prot, residues 99-327, and has the amino acid sequence shown below and referenced herein as SEQ ID No.6:







[SEQ ID No. 6]


ESKYGPPCPSCPAPEFLGGPSVFLFPPKPKDTLMISRTPEVTCVVVD


 


VSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQD


 


WLNGKEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMT


 


KNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFL


 


YSRLTVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLGK






In embodiments, the Fc region incorporates one or more alterations, usually not more than about 10, e.g., up to 5 such alterations, including amino acid substitutions that affect certain Fc properties. In one specific and preferred embodiment, the Fc region incorporates an alteration at position 228 (EU numbering), in which the serine at this position is substituted by a proline (S228P), thereby to stabilize the disulfide linkage within the Fc dimer. Other alterations within the Fc region can include substitutions that alter glycosylation, such as substitution of Asn297 by glycine or alanine; half-life enhancing alterations such as T252L, T253S, and T256F as taught in U.S. 62/777,375, and many others. Particularly useful are those alterations that enhance Fc properties while remaining silent with respect to conformation, e.g., retaining Fc receptor binding.
In a specific embodiment, and in the case where the Fc component is an IgG4 Fc, the Fc incorporates at least the S228P mutation, and has the amino acid sequence set out below and referenced herein as SEQ ID No. 7:







[SEQ ID No. 7]


ESKYGPPCPPCPAPEFLGGPSVFLFPPKPKDTLMISRTPEVTCVVVD


 


VSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQD


 


WLNGKEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMT


 


KNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFL


 


YSRLTVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLGK






The CD47 blockade drug used in the combination is thus preferably a SIRP fusion protein useful to inhibit the binding of human SIRPα with human CD47, thereby to inhibit or reduce transmission of the signal mediated via SIRPα-bound CD47, the fusion protein comprising a human SIRPα component and, fused therewith, an Fc component, wherein the SIRPα component comprises or consists of a single IgV domain of human SIRPα V2 and the Fc component is the constant region of a human IgG having effector function.
In one embodiment, the fusion protein comprises a SIRPα component consisting at least of residues 32-137 of the V2 form of wild type human SIRPα, i.e., SEQ ID No.1. In a preferred embodiment, the SIRPα component consists of residues 31-148 of the V2 form of human SIRPα, i.e., SEQ ID No. 2. In another embodiment, the Fc component is the Fc component of the human IgG1 designated P01857, and in a specific embodiment has the amino acid sequence that incorporates the lower hinge-CH2-CH3 region thereof i.e., SEQ ID No.3.
In a preferred embodiment, therefore, the SIRPαFc fusion protein is provided and used in a secreted dimeric fusion form, wherein the fusion protein incorporates a SIRPα component having SEQ ID No.1 and preferably SEQ ID No, 2 and, fused therewith, an Fc region having effector function and having SEQ ID No.3. When the SIRPα component is SEQ ID No. 1, this fusion protein comprises SEQ ID No.8, shown below:







[SEQ ID No. 8]


EEELQVIQPDKSVSVAAGESAILHCTVTSLIPVGPIQWFRGAGPARE


 


LIYNQKEGHFPRVTTVSESTKRENMDFSISISNITPADAGTYYCVKF


 


RKGSPDTEFKSGAGTELSVRAKPSDKTHTCPPCPAPELLGGPSVFLF


 


PPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTK


 


PREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTIS


 


KAKGQPREPQVYTLPPSRDELTKNQVSLTCLVKGFYPSDIAVEWESN


 


GQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEA


 


LHNHYTQKSLSLSPGK*






When the SIRPα component is SEQ ID No. 2, this fusion protein comprises SEQ ID No. 9, shown below:







[SEQ ID No. 9]


EEELQVIQPDKSVSVAAGESAILHCTVTSLIPVGPIQWFRGAGPARE


 


LIYNQKEGHFPRVTTVSESTKRENMDFSISISNITPADAGTYYCVKF


 


RKGSPDTEFKSGAGTELSVRAKPSDKTHTCPPCPAPELLGGPSVFLF


 


PPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTK


 


PREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTIS


 


KAKGQPREPQVYTLPPSRDELTKNQVSLTCLVKGFYPSDIAVEWESN


 


GQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEA


 


LHNHYTQKSLSLSPGK






In alternative embodiments, the Fc component of the fusion protein is based on an IgG4, and preferably an IgG4 that incorporates the S228P mutation. In the case where the fusion protein incorporates the preferred SIRPα IgV domain of SEQ ID No.2, the resulting IgG4-based SIRPα-Fc protein has SEQ ID No. 10, shown below:







[SEQ ID No. 10]


EEELQVIQPDKSVSVAAGESAILHCTVTSLIPVGPIQWFRGAGPARE


 


LIYNQKEGHFPRVTTVSESTKRENMDFSISISNITPADAGTYYCVKF


 


RKGSPDTEFKSGAGTELSVRAKPSESKYGPPCPPCPAPEFLGGPSVF


 


LFPPKPKDTLMISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAK


 


TKPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKT


 


ISKAKGQPREPQVYTLPPSQEEMTKNQVSLTCLVKGFYPSDIAVEWE


 


SNGQPENNYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVMH


 


EALHNHYTQKSLSLSLGK






In preferred embodiment, the fusion protein comprises, as the SIRPα IgV domain of the fusion protein, a sequence that has/comprises SEQ ID No.2. A preferred SIRPαFc is SEQ ID No.9. Another preferred SIRPαFc has/comprises SEQ ID No.10. The SIRPα sequence incorporated within the CD47 blockade drug can be varied, as described in the literature. That is, useful substitutions within SIRPα include one or more of the following: L4V/I, V6I/L, A21V, V27I/L, 131T/S/F, E47V/L, K53R, E54Q, H56P/R, S66T/G, K68R, V92I, F94V/L, V63I, and/or F103V. In embodiments, these variants can incorporate a set of amino acid substitutions, such as V6I+V27I+I31 F+E47V+K53R+E54Q+H56P+S66T+V92I. CD47-binding SIRPα variants of this type can be used either per se or as Fc fusions.
In embodiments, the CD47 blockade drug is a variant of human SIRPα having higher binding affinity for human CD47 than wild type SIRPα. In a specific embodiment, the variant SIRPα has the sequence shown in SEQ ID No. 11:







[SEQ ID No. 11]


EEELQIIQPDKSVSVAAGESAILHCTITSLFPVGPIQWFRGAGPARV


 


LIYNQRQGPFPRVTTVSETTKRENMDFSISISNITPADAGTYYCIKF


 


RKGSPDTEFKSGAGTELSVRAKP






This SIRPα variant comprises the following amino acid substitutions relative to wild type SIRPα:
V6I+V27I+I31 F+E47V+K53R+E54Q+H56P+S66T+V92I. In a specific embodiment, this variant SIRPα sequence can be fused with a mutated IgG4 Fc region including a Ser228Pro (EU) having virtually no effector function, to yield a CD47 blockade drug having the sequence shown in SEQ ID No. 12:







[SEQ ID No. 12]


EEELQIIQPDKSVSVAAGESAILHCTITSLFPVGPIQWFRGAGPARV


 


LIYNQRQGPFPRVTTVSETTKRENMDFSISISNITPADAGTYYCIKF


 


RKGSPDTEFKSGAGTELSVRAKPSESKYGPPCPPCPAPPVAGPSVFL


 


FPPKPKDTLMISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAKT


 


KPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKTI


 


SKAKGQPREPQVYTLPPSQEEMTKNQVSLTCLVKGFYPSDIAVEWES


 


NGQPENNYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVMHE


 


ALHNHYTQKSLSLSLGK*






Still other types of CD47 blockade drugs can be used in the present method and combination, instead of or in addition to the SIRPα-based drugs. These other drugs include particularly the CD47 antibodies, which bind to CD47 and antagonize the interaction with SIRPα. By blocking that interaction, and because of the Fc region of the antibody, the effect of the CD47 antibodies can be similar to the effect of the SIRPα-based Fc fusion drugs. Examples of CD47 antibodies are described in the literature such as Chugai's US2008/0107654; Stanford's WO2009/091601; InhibRx WO2013/119714, Celgene's WO2016/109415; and Janssen's WO2016/081423. Because these antibodies bind red blood cells, a dosing regimen that takes this into account has been developed and is described in WO2014/149477. The properties of a useful antibody include simply the ability to bind to CD47 in a way that ultimately inhibits signaling by SIRPα, i.e., as an antagonist.
In one embodiment, the CD47 blockade drug is an anti-CD47 antibody that is a chimeric, humanized, human or otherwise recombinant, monoclonal or polyclonal antibody based on the sequence of antibody B6H12 known from the literature and including the sequences:
Amino acid sequence of B6H12 heavy chain variable region







[SEQ ID No. 13]


EVQLVESGGDLVKPGGSLKLSCAASGFTFSGYGMSWVRQTPDKRLEW


 


VATITSGGTYTYYPDSVKGRFTISRDNAKNTLYLQIDSLKSEDTAIY


 


FCARSLAGNAMDYWGQGTSVTVSS






Amino acid sequence of B6H12 light chain variable region







[SEQ ID No. 14]


DIVMTQSPATLSVTPGDRVSLSCRASQTISDYLHWYQQKSHESPRLL


 


IKFASQSISGIPSRFSGSGSGSDFTLSINSVEPEDVGVYYCQNGHGF


 


PRTFGGGTKLEIK






A full sequence for this antibody and the CDR sequences therein, are available from FIG. 1 in US21030142786, the entire contents of which are incorporated herein by reference.
Other CD47 blockade drugs include CD47Fc proteins, as taught by Viral Logic in WO2010/083253 and by Stanford in U.S. Pat. No. 8,377,448), as well as SIRPα antibodies, as described in UHN's WO2013/056352, Stanford's WO2016/022971, Eberhard's U.S. Pat. No. 6,913,894, and elsewhere. These particular CD47 blockade drugs are not ideal, because they bind to the SIRPα which is presented by most cells in the body. CD47 on the other hand is presented only on macrophages and on a limited variety of other cell types, thus limiting the effects of CD47 binding agents to those cells and tissues.
In a SIRPαFc fusion protein, the SIRPα component and the Fc component are fused, either directly or indirectly, to provide a single chain polypeptide that is ultimately produced as a dimer in which the single chain polypeptides are coupled through intrachain disulfide bonds formed within the Fc region. The nature of the fusing region is not critical. The fusion may be direct between the two components, with the SIRP component constituting the N-terminal end of the fusion and the Fc component constituting the C-terminal end. Alternatively, the fusion may be indirect, through a linker comprised of one or more amino acids, desirably genetically encoded amino acids, such as two, three, four, five, six, seven, eight, nine or ten amino acids, or any number of amino acids between 5 and 100 amino acids, such as between 5 and 50, 5 and 30 or 5 and 20 amino acids. A linker may comprise a peptide that is encoded by DNA constituting a restriction site, such as a BamHI, ClaI, EcoRI, HindIII, PstI, SalI and XhoI site and the like.
The linker amino acids typically and desirably have some flexibility to allow the Fc and the SIRP components to adopt their active conformations. Residues that allow for such flexibility typically are Gly, Asn and Ser, so that virtually any combination of these residues (and particularly Gly and Ser) within a linker is likely to provide the desired linking effect. In one example, such a linker is based on the so-called G45 sequence (Gly-Gly-Gly-Gly-Ser) (SEQ ID No. 15) which may repeat as (G4S)n where n is 1, 2, 3 or more, or is based on (Gly)n, (Ser)n, (Ser-Gly)n or (Gly-Ser)n and the like. In another embodiment, the linker is GTELSVRAKPS (SEQ ID No.16). This sequence constitutes SIRPα sequence that C-terminally flanks the IgV domain (it being understood that this flanking sequence could be considered either a linker or a different form of the IgV domain when coupled with the IgV minimal sequence described above). It is necessary only that the fusing region or linker permits the components to adopt their active conformations, and this can be achieved by any form of linker useful in the art.
As noted, the CD47 blockade drug such as a SIRPαFc fusion is useful to inhibit interaction between SIRPα and CD47, thereby to block signalling across this axis. Stimulation of SIRPα on macrophages by CD47 is known to inhibit macrophage-mediated phagocytosis by deactivating myosin-II and the contractile cytoskeletal activity involved in pulling a target into a macrophage. Activation of this cascade is therefore important for the survival of CD47+ disease cells, and blocking this pathway enables macrophages to eradicate or at least reduce the CD47+ disease cell population.
The term “CD47+” is used with reference to the phenotype of cells targeted for binding by the present CD47 blockade drugs. Cells that are CD47+ can be identified by flow cytometry using CD47 antibody as the affinity ligand. CD47 antibodies that are labeled appropriately are available commercially for this use (for example, the antibody product of clone B6H12 is available from BD Biosciences). The cells examined for CD47 phenotype can include standard tumour biopsy samples including particularly blood samples taken from the subject suspected of harbouring endogenous CD47+ cancer cells. CD47 disease cells of particular interest as targets for therapy with the present drug combination are those that “over-express” CD47. These CD47+ cells typically are disease cells, and present CD47 at a density on their surface that exceeds the normal CD47 density for a cell of a given type. CD47 overexpression will vary across different cell types, but is meant herein to refer to any CD47 level that is determined, for instance by flow cytometry or by immunostaining or by gene expression analysis or the like, to be greater than the level measurable on a counterpart cell having a CD47 phenotype that is normal for that cell type.
The present drug combination comprises both a CD47 blockade drug that preferably comprises a soluble form of a SIRPα-based drug, as just described, and an inhibitor of histone deacetylase.
Histone deacetylases (HDACs) are a group of enzymes that facilitates the removal of acetyl groups (deacetylation) from lysine residues on histone and non-histone proteins. HDACs regulate chromatin structure and transcription by erasing acetyl groups on histones. Deacetylation of non-histone proteins regulates a range of cellular processes. Human have 18 known HDACs divided in to 4 classes (Class I, II, III and IV).
HDAC inhibitors interfere with the deacetylation process, by inhibiting the enzyme activity of HDACs. These have been described as “epigenetic modifiers” because of their regulation of post-translational modifications. The anti-tumor mechanisms of HDACi are not fully understood, but have been shown to affect a wide range of cellular processes, for example leading to the induction of cell death, cell cycle arrest, and differentiation and inhibition of invasion and migration. HDAC inhibitors are divided into at least four structural classes: hydroxamates, cyclic peptides (depsipeptides), aliphatic acids and benzamides. The selectivity of the compounds varies. Pan-HDACi (non-selective), class-selective and isotype selective inhibitors have been described, resulting in different, often non-redundant anti-tumor effects and target specificity.
In embodiments, the HDAC inhibitor used in the drug combination is a depsipeptide. These are non-ribosomal peptides cyclized via an ester bond. They can contain non-protein amino acids. They include the cyclotetrapeptides that include apicidin and romidepsin, as well as Spiruchostatin A, etamycin, papuamide, neamphamide A, callipeltin A and mirabamides A-D. In particular embodiments, the HDAC inhibitor used in the pharmaceutical combination is a depsipeptide that inhibits the enzymatic activity of HDACs belonging to Class I, such as HDAC1, HDAC2, HDAC3 and HDAC8. These
In a preferred embodiment, the HDAC inhibitor in the present combination is romidepsin, a depsipeptide that is a potent inhibitor of Class I HDACs, having the structure shown below:




Other HDAC inhibitors include compounds such as those listed below in Table 1:










TABLE 1





Compound
Class
Compound
Class







Romidepsin (Istodax ®)
depsipeptide
Trapoxin B
cyclic tetrapeptide


Spiruchostatin A
depsipeptide
Apicidin
Cyclic peptide


etamycin
depsipeptide
Valproic acid Mg
Aliphatic acid


Trichostatin A
hydroxamate
Mocetinostat
benzamide


Belinostat (Beleodaq ®)
hydroxamate
CI994
benzamide


Panobinostat (Farydak ®)
hydroxamate
Entinostat
benzamide


Dacinostat (LAQ824)
hydroxamate
HBI-8000
benzamide


Rocilinostat (ACY-1215)
hydroxamate
4SC-202
benzamide


Abexinostat (PCI24781)
hydroxamate
chidamide
Benzamide


Pracinostat (SB939)
hydroxamate
sulforaphane


Resminostat (4SC-201)
hydroxamate
trasquinimod


Givinostat (ITF2357)
hydroxamate
NCH51


Quisinostat (JNJ-26481585)
hydroxamate
KD 5170


CUDC-101
hydroxamate
RG2833


AR-42 (HDAC-42)
hydroxamate
diaminozide


CHR-2845, CHR-3996
hydroxamate
CHAPS


SB939
hydroxamate
parthenolide


M344
hydroxamate
apistatin


tubacin
hydroxamate
Tubastatin A




Tacediniline




Kevetrin




Sirtuin family









In a specific embodiment of the present method, the CD47 blockade drug is used in combination with romidepsin. As noted, romidepsin is marketed under the trademark Istodax® and is provided as a lyophilized powder for intravenous injection. It is supplied as a kit which includes a sterile, lyophilized powder in a single-use vial containing 10 mg of romidepsin and 20 mg of carrier, povidone. Each kit also provides one sterile vial containing 2 mL of diluent (80% propylene glycol, and 20% dehydrated alcohol), for reconstitution in 0.9% saline. Established dosing is 14 mg/m2 with intravenous administrations on days 1, 8 and 15 of a 28 day cycle. It can be used in this same manner for purposes of the present disclosure, although cooperation with the CD47 blockade drug should permit the use of a reduced romidepsin dose or dosing frequency. It is used particularly for the treatment of blood cancers such as forms of T cell lymphoma including peripheral and cutaneous, and can be used for this purpose when combined with CD47 blockade drug.
Each drug included in the combination can be formulated separately for use in combination. The drugs are said to be used “in combination” when, in a recipient of both drugs, the effect of one drug enhances or at least influences the effect of the other drug.
The two drugs in the combination cooperate to provide an effect on target CD47+ cells that is greater than the effect of either drug alone. This benefit manifests as a statistically significant improvement in a given parameter of target cell fitness or vitality. For instance, a benefit in CD47+ cancer cells, when exposed to a combination of CD47 blockade drug and HDAC inhibitor, could be a statistically significant decrease in the number of living cancer cells (hence a depletion), relative to non-treatment, or a decrease in the number or size of cancer cells or tumours, or an improvement in the endogenous location or distribution of any particular tumour type. In embodiments, the improvement resulting from treatment with the drug combination can manifest as an effect that is at least additive and desirably synergistic, relative to results obtained when only a single agent or an agent combination is used.
In use, each drug in the combination can be formulated as it would be for monotherapy, in terms of dosage size and form and regimen. In this regard, the improvement resulting from their combined use may permit the use of somewhat reduced dosage sizes or frequencies, as would be revealed in an appropriately controlled clinical trial.
The mechanism by which an HDAC inhibitor contributes to the activity of a CD47 blockade drug, in the present combination, is not known. The HDAC inhibitors likely have a direct activity on some tumour cells, and preliminary data suggest that treatment of tumor cells with these inhibitors results in upregulation of pro-phagocytic (“eat-me”) signals on the surface of some tumor cells.
In this approach, each drug is provided in a dosage form comprising a pharmaceutically acceptable carrier, and in a therapeutically effective amount. As used herein, “pharmaceutically acceptable carrier” means any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like that are physiologically compatible and useful in the art of protein/antibody formulation. Examples of pharmaceutically acceptable carriers include one or more of water, saline, phosphate buffered saline, dextrose, glycerol, ethanol and the like, as well as combinations thereof. In many cases, it will be preferable to include isotonic agents, for example, sugars, polyalcohols such as mannitol, sorbitol, or sodium chloride in the composition. Pharmaceutically acceptable carriers may further comprise minor amounts of auxiliary substances such as wetting or emulsifying agents, preservatives or buffers, which enhance the shelf life or effectiveness of the pharmacological agent. Each of the CD47 blockade drug, e.g., SIRPαFc fusion protein, and the HDAC inhibitor is formulated using practices standard in the art of therapeutics formulation. Solutions that are suitable for intravenous administration, such as by injection or infusion, are particularly useful. The HDAC inhibitor will of course be formulated as permitted by the regulatory agencies when it is a drug approved for use in humans.
Sterile solutions can be prepared by incorporating the active compound in the required amount in an appropriate solvent with one or a combination of ingredients noted above, as required, followed by sterilization microfiltration. 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 are vacuum drying and freeze-drying (lyophilization) that yield a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof.
As used herein, “effective amount” refers to an amount effective, at dosages and for a particular period of time necessary, to achieve the desired therapeutic result. A therapeutically effective amount of each drug in the combination may vary according to factors such as the disease state, age, sex, and weight of the individual, and the ability of the drug to elicit a desired response in the recipient. A therapeutically effective amount is also one in which any toxic or detrimental effects of the pharmacological agent are outweighed by the therapeutically beneficial effects. The HDAC inhibitor will of course be formulated in amounts that are suitable for patient dosing, as permitted by the regulatory agencies that have approved its use in humans. In use, each drug in the combination thus is formulated as it would be for monotherapy, in terms of dosage size and form and regimen. In this regard, the cooperation/benefit resulting from their combined use may permit the use of somewhat reduced dosage sizes or frequencies, as would be revealed in an appropriately controlled clinical trial.
The SIRPαFc fusion protein can be administered to the subject through any of the routes established for protein delivery, in particular intravenous, intradermal, intratumoural and subcutaneous injection or infusion, or by oral or nasal administration.
The drugs in the present combination can be administered sequentially or, essentially at the same time. In embodiments, the HDAC inhibitor is given before administration of the CD47 blockade drug, e.g., SIRPαFc. In the alternative, the HDAC inhibitor can be given after or during administration of the CD47 blockade drug, e.g., SIRPαFc. Thus, in embodiments, the subject undergoing therapy is a subject already treated with one of the combination drugs, such as the HDAC inhibitor, that is then treated with the other of the combination drugs, such as the CD47 blockade drug.
Dosing regimens are adjusted to provide the optimum desired response (e.g., a therapeutic response). For example, a single bolus of each drug may be administered, or several divided doses may be administered over time or the dose may be proportionally reduced or increased as indicated by the therapeutic situation. It is especially advantageous to formulate parenteral compositions in unit dosage form for ease of administration and uniformity of dosage. “Unit dosage form” as used herein refers to physically discrete units suited as unitary dosages for the subjects to be treated; each unit contains a predetermined quantity of active compound calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier.
The drugs can be formulated in combination, so that the combination can be introduced to the recipient in one administration, e.g., one injection or one infusion bag. Alternatively, the drugs can be combined as separate units that are provided together in a single package, and with instructions for the use thereof according to the present method. In another embodiment, an article of manufacture containing the SIRPαFc drug and HDAC inhibitor combination in an amount useful for the treatment of the disorders described herein is provided. The article of manufacture comprises one or both drugs of the present antibody drug combination, as well as a container and a label. Suitable containers include, for example, bottles, vials, syringes, and test tubes. The containers may be formed from a variety of materials such as glass or plastic. The container holds a composition which is effective for treating the condition and may have a sterile access port (for example the container may be an intravenous solution bag or vial having a stopper pierceable by a hypodermic injection needle). The label on or associated with the container indicates that the composition is used in combination with another CD47 blockade drug in accordance with the present disclosure, thereby to elicit a synergistic effect on the CD47+ disease cells. The article of manufacture may further comprise a second container comprising a pharmaceutically-acceptable buffer, such as phosphate-buffered saline, Ringer's solution and dextrose solution. It may further include other matters desirable from a commercial and use standpoint, including other buffers, diluents, filters, needles, syringes, and package inserts with instructions for use.
For administration the dose for the CD47 blockade drug will be within the range from about 0.0001 to 100 mg/kg, and more usually 0.01 to 5 mg/kg, of the host body weight. For example SIRPαFc dosages can be 0.3 mg/kg body weight, 1 mg/kg body weight, 3 mg/kg body weight, 5 mg/kg body weight or 10 mg/kg body weight or within the range of 0.1-100 mg/kg. When the CD47 blockade drug is a SIRPαFc fusion protein of SEQ ID No.9, the dose can be about 1-5 mg per injection, such as intratumoural injection.
The SIRPαFc protein displays negligible binding to red blood cells. There is accordingly no need to account for an RBC “sink” when dosing with the drug combination. Relative to other CD47 blockade drugs that are bound by RBCs, it is estimated that the present SIRPαFc fusion can be effective at doses that are less than half the doses required for drugs that become RBC-bound, such as CD47 antibodies. Moreover, the SIRPα-Fc fusion protein is a dedicated antagonist of the SIRPα-mediated signal, as it displays negligible CD47 agonism when binding thereto. There is accordingly no need, when establishing medically useful unit dosing regimens, to account for any stimulation induced by the drug.
The drug combination is useful to treat a variety of CD47+ disease cells. These include particularly CD47+ cancer cells, including liquid and solid tumours. Solid tumours can be treated with the present drug combination, to reduce the size, number, distribution or growth rate thereof and to control growth of cancer stem cells. Such solid tumours include CD47+ tumours in bladder, brain, breast, lung, colon, ovary, prostate, liver and other tissues as well. In one embodiment, the drug combination can used to inhibit the growth or proliferation of hematological cancers. As used herein, “hematological cancer” refers to a cancer of the blood, and includes leukemia, lymphoma and myeloma among others. “Leukemia” refers to a cancer of the blood, in which too many white blood cells that are ineffective in fighting infection are made, thus crowding out the other parts that make up the blood, such as platelets and red blood cells. It is understood that cases of leukemia are classified as acute or chronic. Certain forms of leukemia may be, by way of example, acute lymphocytic leukemia (ALL); acute myeloid leukemia (AML); chronic lymphocytic leukemia (CLL); chronic myelogenous leukemia (CML); myeloproliferative disorder/neoplasm (MPDS); and myelodysplastic syndrome. “Lymphoma” may refer to a Hodgkin's lymphoma, both indolent and aggressive non-Hodgkin's lymphoma, cutaneous T cell lymphoma (CTCL), Burkitt's lymphoma, Mantle cell lymphoma (MCL) and follicular lymphoma (small cell and large cell), among others. Myelomas include multiple myeloma (MM), giant cell myeloma, heavy-chain myeloma, and light chain myeloma and Bence-Jones myeloma.
In some embodiments, the hematological cancer treated with the drug combination is a CD47+ leukemia, preferably selected from acute lymphocytic leukemia, acute myeloid leukemia, chronic lymphocytic leukemia, chronic myelogenous leukemia, and myelodysplastic syndrome, preferably, human acute myeloid leukemia.
In other embodiments, the hematological cancer treated with the drug combination is a CD47+ lymphoma or myeloma selected from Hodgkin's lymphoma, both indolent and aggressive non-Hodgkin's lymphoma, diffuse large cell lymphoma (DLBCL), mantle cell lymphoma, T cell lymphoma including mycosis fungoides, Sezary's syndrome, Burkitt's lymphoma, follicular lymphoma (small cell and large cell), multiple myeloma (MM), giant cell myeloma, heavy-chain myeloma, and light chain or Bence-Jones myeloma as well as leimyosarcoma.
In a specific embodiment, the cancer treated with the present combination is multiple myeloma. In another specific embodiment, the targeted cancer is mantle cell lymphoma. In a further embodiment, the cancer treated with the present combination is relapsed or refractory Hodgkin's lymphoma. In another specific embodiment, the CD47 blockade drug is SIRPαFc. In a further specific embodiment the HDAC inhibitor is romidepsin.
In still other embodiments, romidepsin is used in combination with SIRPαFc, such as SEQ ID No.9 or SEQ ID No.10, such as for the treatment of cutaneous T cell lymphoma or multiple myeloma. In another embodiment, the combination is used to treat a T cell lymphoma such as mycosis fungoides or Sezary's syndrome.
Thus, in specific embodiments, there is provided the use of a CD47 blockade drug in combination with an HDAC inhibitor for the treatment of a particular CD47+ cancer, wherein:

    
    
        i) the CD47 blockade drug is SIRPαFc of SEQ ID No.9 and the HDAC inhibitor is romidepsin, such as for the treatment of a cancer that is cutaneous T cell lymphoma or multiple myeloma or relapsed or refractory Hodgkin's lymphoma;
        ii) the CD47 blockade drug is SIRPαFc of SEQ ID No.10 and the HDAC inhibitor is romidepsin, such as for the treatment of a cancer that is cutaneous T cell lymphoma or multiple myeloma or relapsed or refractory Hodgkin's lymphoma;
        iii) the CD47 blockade drug is anti-CD47 antibody and the HDAC inhibitor is romidepsin, such as for the treatment of a cancer that is cutaneous T cell lymphoma or multiple myeloma.
    
    


It will be appreciated that other CD47 blockade drugs can be used in combination with HDAC inhibitors. Desirable combinations will show a statistically significant improvement in cancer cell response. This can be demonstrated as a statistically significant improvement in HDAC inhibitor activity caused by combination with a CD47 blockade drug, or vice versa, where statistical significance is shown as noted in the examples that follow and desirably, provides a p value >0.05 and more desirably >0.01 such as >0.001.
The combination therapy, comprising CD47 blockade and HDAC inhibition can also be exploited together with any other agent or modality useful in the treatment of the targeted indication, such as surgery as in adjuvant therapy, or with additional chemotherapy as in neoadjuvant therapy.
The following non-limiting examples are illustrative of the present disclosure.
EXAMPLES
Heparinized whole blood was obtained from normal healthy human donors (Biological Specialty Corporation) and informed consent was obtained from all donors. Peripheral blood mononuclear cells (PBMCs) were isolated over Ficoll-Paque Plus density gradient (GE Healthcare) and CD14+ monocytes were isolated from PBMCs by positive selection using CD14 antibody-coated MicroBead separation (Miltenyi Biotec). Monocytes were differentiated into macrophages by culturing for seven days in X-Vivo-15 media (Lonza) supplemented with M-CSF (PeproTech). 24 hours prior to the phagocytosis assay, macrophages were primed with IFN-γ (PeproTech). 48 hours prior to the phagocytosis assay, Romidepsin (1, 5 or 10 nM) was added to tumor cells. On the day of the phagocytosis assay, macrophages were co-cultured with a violet proliferation dye 450 (VPD450)-labeled human multiple myeloma cell lines (MM1s or H929) in the presence of 1, 5 or 100 nM human SIRPαFc (V region of human SIRPα variant 2 fused with IgG1 Fc), 100 nM control Fc [human IgG1 Fc region (hinge-CH2-CH3)] for two hours. Phagocytosis was assessed as 30% VPD450+ cells of live, single CD14+CD11b+ macrophages by flow cytometry. Results shown in FIGS. 1 and 2 are representative of two independent experiments.
Results are shown in FIG. 1 and are duplicates from a single experiment. Results shown in FIG. 2 reveal the effects of a wider array of CD47 blockade drugs used in combination with romidepsin. For FIG. 2, methods were the following:
Macrophages were prepared from human peripheral blood mononuclear cells (PBMCs) obtained from healthy donors (BioreclamationIVT); informed consent was obtained from all donors. CD14+ monocytes were isolated by positive selection using the EasySep® human monocyte isolation kit (Stemcell Technologies). Monocytes were differentiated into macrophages by culturing the cells in X-VIVO 15 media (Lonza) supplemented with human m-CSF (PeproTech) for 10 days. Macrophages were primed with human IFNγ (PeproTech) one day prior to the phagocytosis assay. 48 hours prior to the phagocytosis assay, 10 nM Romidepsin was added to tumor cells. On the day of the phagocytosis assay, macrophages were co-cultured with a violet proliferation dye 450 (VPD450)-labeled human cell lines (MM1.S or HH) in the presence 100 nM human SIRPαFc (IgG1, SEQ ID No.9), SIRPαFc (IgG4, SEQ ID No.10), SIRPαFc (CV1, (IgG4 mut, SEQ ID No. 12), CD47 monoclonal antibody B6H12 (mAb, SEQ ID Nos. 13 and 14) or Control Fc for two hours. Phagocytosis was assessed as % VPD450+ cells of live, single CD14+CD11b+ macrophages by flow cytometry. Statistical significance was calculated by unpaired t-test using GraphPad Prism software comparing untreated vs romidepsin treated cells.
While the present disclosure has been described with reference to what are presently considered to be the preferred examples, it is to be understood that the disclosure is not limited to the disclosed examples. To the contrary, the disclosure is intended to cover various modifications and equivalent arrangements included within the spirit and scope of the appended claims.
All publications, patents and patent applications are herein incorporated by reference in their entirety to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated by reference in its entirety.

## Claims

1. A method of treating a subject presenting with CD47+ disease cells, the method comprising administering a combination of a CD47 blockade drug and a histone deacetylase (HDAC) inhibitor.

2. The method according to claim 1, wherein the HDAC inhibitor is a depsipeptide.

3. The method according to claim 2, wherein the HDAC inhibitor is romidepsin.

4. The method according to claim 1, wherein the CD47 blockade drug comprises a CD47-binding form of human SIRPα.

5. The method according to claim 4, wherein the CD47-binding form of human SIRPα is a CD47-binding fragment of human SIRPα.

6. The method according to claim 5, wherein the CD47-binding fragment of human SIRPα comprises the V region of human SIRPα.

7. The method according to claim 1, wherein the CD47 blockade drug is an Fc fusion protein comprising the V region of soluble human SIRPα variant 2.

8. The method according to claim 7, wherein the Fc fusion protein comprising soluble SIRPα comprises SEQ ID No. 9.

9. The method according to claim 7, wherein the Fc fusion protein comprising soluble SIRPα comprises SEQ ID No. 10.

10. The method according to claim 1, wherein the CD47 blockade drug comprises soluble SIRPα having one or more amino acid substitutions selected from L4V/I, V6I/L, A21V, V27I/L, 131T/S/F, E47V/L, K53R, E54Q, H56P/R, S66T/G, K68R, V92I, F94V/L, V63I, and F103V.

11. The method according to claim 1, wherein the CD47 blockade drug is an anti-CD47 antibody.

12. The method according to claim 1, wherein the CD47+ disease cells are cancer cells.

13. The method according to claim 12 wherein the cancer cells are blood cancer cells or solid tumour cells.

14. The method according to claim 12, wherein the disease cells are cells of a cancer type selected from acute lymphocytic leukemia (ALL); acute myeloid leukemia (AML); chronic lymphocytic leukemia (CLL); chronic myelogenous leukemia (CML); myeloproliferative disorder/neoplasm (MPDS); and myelodysplastic syndrome.

15. The method according to claim 12, wherein the cancer is a lymphoma selected from a Hodgkin's lymphoma, both indolent and aggressive non-Hodgkin's lymphoma, Burkitt's lymphoma, and follicular lymphoma (small cell and large cell).

16. The method according to claim 12, wherein the cancer is a myeloma selected from multiple myeloma (MM), giant cell myeloma, heavy-chain myeloma, and light chain or Bence-Jones myeloma.

17. The method according to claim 1, wherein the HDAC inhibitor is for use in a subject that has already received the CD47 blockade drug.