Patent Description:
The polycomb family negatively regulates gene expression through chromatin control mediated by histone modification. Enhancer of zeste homologue <NUM>/<NUM> (EZH1/<NUM>) is an active center of polycomb repressive complex <NUM> (PRC2), which tri-methylates histone H3K27. EZH1 and EZH2 mutually compensate each other's functions and maintain an epigenome within a cell. Inhibition of EZH2 reduces the methylation level at H3K27 of a whole cell; however, the effect is limited by the compensation effect of EZH1. If EZH1 and EZH2 are simultaneously inhibited, methylation is more effectively eliminated (Non Patent Literature <NUM>). Abnormalities of components of PRC2 cause cancer and functional abnormalities of stem cells. Particularly, abnormalities of the EZH2 gene and elevated expression thereof induce accumulation of methylated H3K27me3, which is identified in many cancers. Studies have been aggressively conducted focusing on EZH2 as a new molecular target for cancer (Non Patent Literatures <NUM>, <NUM>).

An EZH1/<NUM> dual inhibitor, (2R)-<NUM>-chloro-<NUM>-[trans-<NUM>-(dimethylamino)cyclohexyl]-N-[(<NUM>,<NUM>-dimethyl-<NUM>-oxo-<NUM>,<NUM>-dihydropyridin-<NUM>-yl)methyl]-<NUM>,<NUM>-dimethyl-<NUM>,<NUM>-benzodioxol-<NUM>-carboxamide and a pharmaceutically acceptable salt thereof are known (Patent Literature <NUM>).

In terms of cancer therapy, it is known that therapies using a plurality of anticancer agents in combination are effective, and various studies (on combination therapy) have been actively conducted. However, it is extremely difficult to find a combination of medical agents exerting a combined effect, and a type of cancer on which the effect is exerted. The EZH1/<NUM> dual inhibitor according to the present invention, i.e., (2R)-<NUM>-chloro-<NUM>-[trans-<NUM>-(dimethylamino)cyclohexyl]-N-[(<NUM>,<NUM>-dimethyl-<NUM>-oxo-<NUM>,<NUM>-dihydropyridin-<NUM>-yl)methyl]-<NUM>,<NUM>-dimethyl-<NUM>,<NUM>-benzodioxol-<NUM>-carboxamide and a pharmaceutically acceptable salt thereof, has been disclosed in <CIT> and <CIT>, where it is also described in possible combination with a number of other medical agents. However, there is no literature reporting the combined use thereof with the specific medical agents according to the appended claims, and the effect of the combinations according to the present invention has not yet been disclosed.

An object of the present invention is to provide a combination drug having an EZH1/<NUM> dual inhibitor in combination with another medical agent and exerting an excellent anticancer effect.

The present inventors conducted intensive studies with a view to achieving the object. As a result, they found that an excellent anticancer effect can be exerted by using the EZH1/<NUM> dual inhibitor of formula (I) in combination with at least one second medical agent selected from azacitidine, SN-<NUM>, venetoclax, ibrutinib, lenalidomide, panobinostat, a pharmaceutically acceptable salt of any of the foregoing medical agents, an anti-PD-<NUM> antibody, an anti-PD-L1 antibody, an anti-CLTA-<NUM> antibody, and the medical agents involved in R-CHOP therapy. Based on the finding, the present invention was accomplished. The present invention relates to the following (<NUM>) to (<NUM>).

Owing to the present invention, an excellent anticancer effect can be exerted by using the EZH1/<NUM> dual inhibitor of formula (I), or a pharmaceutically acceptable salt thereof, in combination with at least one second medical agent selected from azacitidine, SN-<NUM>, venetoclax, ibrutinib, lenalidomide, panobinostat, a pharmaceutically acceptable salt of any of the foregoing medical agents, an anti-PD-<NUM> antibody, an anti-PD-L1 antibody, an anti-CLTA-<NUM> antibody, and the combination of medical agents involved in R-CHOP therapy.

The compound represented by the formula (I) of the present invention is (2R)-<NUM>-chloro-<NUM>-[trans-<NUM>-(dimethylamino)cyclohexyl]-N-[(<NUM>,<NUM>-dimethyl-<NUM>-oxo-<NUM>,<NUM>-dihydropyridin-<NUM>-yl)methyl]-<NUM>,<NUM>-dimethyl-<NUM>,<NUM>-benzodioxol-<NUM>-carboxamide, also known as valemetostat. The compound represented by the formula (I) can be produced, for example, in accordance with a method described in Example <NUM> of <CIT>.

A pharmaceutically acceptable salt of the compound represented by the formula (I) of the present invention is most preferably (2R)-<NUM>-chloro-<NUM>-[trans-<NUM>-(dimethylamino)cyclohexyl]-N-[(<NUM>,<NUM>-dimethyl-<NUM>-oxo-<NUM>,<NUM>-dihydropyridin-<NUM>-yl)methyl]-<NUM>,<NUM>-dimethyl-<NUM>,<NUM>-benzodioxol-<NUM>-carboxamide p-toluenesulfonate (hereinafter referred to as "Compound A").

In the present invention, the "immune checkpoint inhibitor" refers to a medical agent exerting an anticancer effect by blocking the immunosuppressive escape mechanism by an immune checkpoint molecule to proliferate and activate T cells. The immune checkpoint inhibitor that can be used in the present invention include an anti-PD-<NUM> antibody, an anti-PD-L1 antibody and an anti-CTLA-<NUM> antibody. Specific examples of the medical agent include nivolumab, pembrolizumab, avelumab, atezolizumab, durvalumab and ipilimumab.

"CHOP therapy" refers to a chemotherapy for cancer, by administering cyclophosphamide, doxorubicin, vincristine and prednisolone in combination. The medical agents involved in CHOP therapy refer to these four medical agents. It is used for treating, for example, malignant lymphoma.

In the present invention, "R-CHOP therapy" refers to a chemotherapy for cancer, by administering rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone in combination. The combination of medical agents involved in R-CHOP therapy refers to these five medical agents. It is used for treating, for example, malignant lymphoma.

It is suggested that EZH1 and/or EZH2 are involved in, e.g., proliferation of cancer and survival. Because of this, the present invention is preferably used for cancer in which the expression levels of EZH1 and/or EZH2 are increased and/or cancer having a mutation(s) in EZH1 and/or EZH2.

Whether the expression levels of EZH1 and/or EZH2 are increased or not can be determined by analyzing, e.g., the expression levels of EZH1 and/or EZH2 in a test tissue (collected by, for example, blood sampling or biopsy) of a patient by e.g., western blot, ELISA, northern blot, quantitative PCR, DNA tip tissue immunostaining and/or a commonly known method using pathological techniques.

Whether or not a mutation is present in EZH1 and/or EZH2 can be determined by examining the nucleotide sequence of genomic DNA.

In the present invention, "cancer" refers to a whole group of malignant tumors.

Cancer can be classified into "solid cancer" and "hematological cancer". Solid cancer can be classified into "epithelial cell cancer" and "non-epithelial cell cancer". Epithelial cell cancer is derived from epithelial cells. Examples thereof include lung cancer, gastric cancer, liver cancer, kidney cancer, prostate cancer, pancreatic cancer, colorectal cancer, breast cancer and ovarian cancer. Non-epithelial cell cancer is derived from non-epithelial cells such as bone and muscle. Examples thereof include osteosarcoma, chondrosarcoma and rhabdomyosarcoma. Hematological cancer is derived from a hematopoietic organ and can be classified into, e.g., malignant lymphoma, leukemia and multiple myeloma. In hematological cancer, a pathological condition, which is sometimes classified into a precancerous stage, such as myelodysplastic syndrome, is also included.

Malignant lymphoma can be classified into, for example, Hodgkin's lymphoma and non-Hodgkin's lymphoma. Examples of the non-Hodgkin's lymphoma include mantle cell lymphoma (also referred to as MCL), diffuse large B-cell lymphoma, (also referred to as DLBCL), adult T-cell leukemia/lymphoma (also referred to as ATLL) and peripheral T-cell lymphoma (also referred to as PTCL).

Leukemia is classified into, for example, acute myelogenous leukemia (also referred to as AML), chronic myelogenous leukemia (also referred to as CML), acute lymphoid leukemia (also referred to as ALL), chronic lymphoid leukemia (also referred to as CLL), and myelodysplastic syndromes (also referred to as MDS).

The type of cancer to be treated by the present invention is not particularly limited as long as it is susceptible to the combination therapy of the present invention. For example, a hematological cancer such as leukemia, malignant lymphoma, multiple myeloma or myelodysplastic syndrome; brain tumor, head and neck cancer, esophageal cancer, gastric cancer, appendix cancer, colorectal cancer, anal cancer, gallbladder cancer, bile duct cancer, pancreatic cancer, gastrointestinal stromal tumor, lung cancer, liver cancer, mesothelioma, thyroid cancer, kidney cancer, prostate cancer, neuroendocrine tumor, melanoma, breast cancer, endometrial cancer, cervical cancer, ovarian cancer, osteosarcoma, soft tissue sarcoma, Kaposi's sarcoma, myoma, kidney cancer, bladder cancer or testicular cancer can be mentioned.

The hematological cancer to be treated by the present invention preferably includes leukemia, malignant lymphoma, multiple myeloma and myelodysplastic syndrome, and particularly preferably, acute myelogenous leukemia, non-Hodgkin's lymphoma and multiple myeloma.

The non-Hodgkin's lymphoma to be treated by the present invention preferably includes mantle cell lymphoma, diffuse large B-cell lymphoma, adult T cell leukemia/lymphoma and peripheral T cellular lymphoma.

The solid cancer to be treated by the present invention preferably includes lung cancer, gastric cancer and colorectal cancer.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and a medical agent containing azacitidine or a pharmaceutically acceptable salt thereof, can be used for, e.g., myelodysplastic syndrome.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and a medical agent containing SN-<NUM> or a pharmaceutically acceptable salt thereof, can be used for, e.g., lung cancer, cervical cancer, ovarian cancer, gastric cancer, colorectal cancer, breast cancer, skin cancer (including, for example, squamous cell cancer), malignant lymphoma, pancreatic cancer and pediatric cancer.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and a medical agent containing lenalidomide or a pharmaceutically acceptable salt thereof, can be used for hematological cancers. Of the hematological cancers, malignant lymphomas and myelodysplastic syndromes are preferred hematological cancers to which the combination is applied. Of the malignant lymphomas, non-Hodgkin's lymphoma is preferred as a malignant lymphoma to which the combination is applied. In another aspect, the combination can be used for solid cancers such as lung cancer, gastric cancer, pancreatic cancer, colorectal cancer, osteosarcoma, breast cancer and pediatric cancer.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and a medical agent containing venetoclax or a pharmaceutically acceptable salt thereof, can be used for hematological cancers. Of the hematological cancers, malignant lymphomas and myelodysplastic syndromes are preferred hematological cancers to which the combination is applied. Of the malignant lymphomas, non-Hodgkin's lymphoma is a preferred malignant lymphoma to which the combination is applied. In another aspect, the combination can be used for solid cancers such as lung cancer, gastric cancer, pancreatic cancer, colorectal cancer, osteosarcoma, breast cancer and pediatric cancer.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and a medical agent containing ibrutinib or a pharmaceutically acceptable salt thereof, can be used for hematological cancers. Of the hematological cancers, malignant lymphomas are preferred hematological cancers to which the combination is applied. Of the malignant lymphomas, non-Hodgkin's lymphoma is a preferred malignant lymphoma to which the combination is applied.

In another aspect, the combination can be used for solid cancers such as lung cancer, gastric cancer, pancreatic cancer, colorectal cancer, osteosarcoma, breast cancer and pediatric cancer.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and a medical agent containing panobinostat or a pharmaceutically acceptable salt thereof, can be used for, e.g., multiple myeloma.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and a medical agent containing an anti-PD-<NUM> antibody, an anti-PD-L1 antibody or an anti-CTLA-<NUM> antibody, can be used for hematological cancers. Of the hematological cancers, malignant lymphomas are preferred hematological cancers to which the combination is applied.

In another aspect, the combination can be used for solid cancers. Of the solid cancers, the composition is preferably used for skin cancer, gastric cancer, liver cancer, colorectal cancer, breast cancer, pancreatic cancer, cervical cancer, endometrial cancer, ovarian cancer, esophageal cancer, lung cancer, head and neck cancer and myelodysplastic syndrome.

In the present invention, a combination of a medical agent containing the compound represented by the formula (I) or a pharmaceutically acceptable salt thereof and the combination of medical agents involved in R-CHOP therapy, can be used for, e.g., hematological cancers. Of hematological cancers, malignant lymphomas are preferred hematological cancers to which the combination is applied. Of the malignant lymphomas, non-Hodgkin's lymphoma is a preferred malignant lymphoma to which the combination is applied.

In the present invention, the phrase "administered in combination" means that both types of medical agent are taken into the body of a subject within a predetermined period. A preparation containing both types of medical agent in a single formulation may be administered or two preparations containing respective types of medical agent may be administered separately. In the case of separate preparations, the timing of administration of them is not particularly limited. The preparations may be administered at the same time or different times with a time interval between them, or administered on different days.

If they are administered at different times or on different days, the order of administration is not particularly limited. Since the medical agents are administered in accordance with the administration methods respectively instructed, the administration times of them may coincide with each other or be mutually different. If they are separate preparations, the administration method (route of administration) of the preparations may be the same or different. Also, it is not necessary for the two types of medical agents to be present at the same time. It is sufficient that the two medical agents are taken and remain in the body for a certain period (for example, a month, preferably a week, further preferably a few days, even further preferably a day). Alternatively, when one of the preparations is administered, the other active ingredient may have disappeared from the body.

The pharmaceutical composition of the present invention may be used in combination with another antitumor agent and another therapy (for example, radiation therapy, immunotherapy).

In the present invention, "pharmaceutically acceptable salt" refers to a salt which has no significant toxicity and can be used as a pharmaceutical composition. A salt can be formed by reacting a compound having an acidic substituent with a base. Examples of the salt include, but are not limited to, alkali metal salts such as a sodium salt, a potassium salt and a lithium salt; alkaline earth metal salts such as a calcium salt and a magnesium salt; metal salts such as an aluminum salt and an iron salt; inorganic salts such as an ammonium salt; amine salts such as organic salts including a tert-butylamine salt, a tert-octylamine salt, a dibenzylamine salt, a morpholine salt, a glucosamine salt, a phenylglycine alkyl ester salt, an ethylenediamine salt, a N-methylglucamine salt, a guanidine salt, a diethylamine salt, a triethylamine salt, a dicyclohexylamine salt, a N,N' -dibenzylethylenediamine salt, a chloroprocaine salt, a procaine salt, a diethanolamine salt, a N-benzylphenethylamine salt, a piperazine salt, a tetramethylammonium salt and a tris (hydroxymethyl) amino methane salt; and amino acid salts such as a glycine salt, a lysine salt, an arginine salt, an ornithine salt, a glutamate and an aspartate.

A salt can be also formed by reacting a compound having a basic substituent with an acid. Examples of the salt include halide acid salts such as a hydrofluoride, a hydrochloride, a hydrobromide and a hydroiodide; inorganic acid salts such as a nitrate, a perchlorate, a sulfate and a phosphate; C<NUM>-C<NUM> alkyl sulfonates such as methanesulfonate, trifluoromethanesulfonate and ethane sulfonate; arylsulfonates such as benzenesulfonate and p-toluenesulfonate; organic acid salts such as an acetate, a malate, a fumarate, a succinate, a citrate, an ascorbate, a tartrate, an oxalate, an adipate and a maleate; and amino acid salts such as a glycine salt, a lysine salt, an arginine salt, an ornithine salt, a glutamate and an aspartate.

In the present invention, when the compound represented by the formula (I), the at least one second medical agent and pharmaceutically acceptable salts of these medical agents are allowed to stand still in the air or recrystallize, they sometimes incorporate water molecule(s) to form hydrates. The hydrates are also included in the present invention.

In the present invention, when the compound represented by the formula (I), the at least one second medical agent and pharmaceutically acceptable salts of these medical agents are allowed to stand still in a solvent or recrystallize, they sometimes absorb the solvent to form solvates. Such solvates are also included in the present invention.

In the present invention, if the compound represented by the formula (I), the at least one second medical agent and pharmaceutically acceptable salts of these medical agents are prepared into pharmaceutical compositions, examples of pharmaceutically acceptable carriers to be used in the compositions include, but are not limited to, sterilized water, saline, a vegetable oil, a solvent, a base, an emulsifier, a suspension, a surfactant, a stabilizer, a seasoning agent, an aromatic substance, an excipient, a vehicle, a preservative, a binder, a diluent, an isotonic agent, a soothing agent, a thickening agent, a disintegrant, a buffering agent, a coating agent, a lubricant, a colorant, a sweetener, a viscous agent, a flavoring agent and a dissolution aid (or other additives). The compound of the present invention or a pharmaceutically acceptable salt thereof may be formed into various dosage forms, such as a tablet, a powder, a granule, a capsule and a liquid, depending on the therapeutic purpose; and may be administered, for example, by a delivery system using liposomes. To the liposomes, the aforementioned auxiliary parts (e.g., antibody, a ligand) that enhance therapeutically useful properties can be added.

For administration to a patient, either oral administration or parenteral administration can be employed. Examples of parenteral administration include intravenous administration, intraarterial administration, intramuscular administration, intrathoracic administration, intraperitoneal administration and direct administration to a target site (for example, tumor).

The dosage amount is not particularly limited as long as it is an effective amount for treating a target disease and appropriately selected depending on the age, body weight, symptom, health condition and disease progression of the patient. The frequency of administration is not particularly limited and can be appropriately selected depending on the purpose. For example, the dosage amount per day is administered once a day or divided into a plurality of doses and administered separately. When the medical agent of the present invention is administered to a human, the dosage amount of an active ingredient ranges from about <NUM>/kg (body weight) to about <NUM>/kg (body weight), and preferably, about <NUM>/kg (body weight) to about <NUM>/kg (body weight). For administration to a human, the dosage amount per day is preferably administered once a day or divided into <NUM> to <NUM> portions, which are administered separately at appropriate intervals.

Note that, in the present invention, the compound represented by the formula (I), the at least one second medical agent and pharmaceutically acceptable salts of these medical agents may each be prepared into a reagent for use in assays and, if necessary, other components acceptable for use in assays, such as sterilized water, saline, a buffering agent and/or a preservative, can be added. The reagent is administered to a target (e.g., cells, fractionated cells, tissue, experimental animal) according to purpose, in a dosage amount in accordance with the purpose, to suppress the growth of a tumor.

The present invention will be more specifically described by way of Examples; however the scope of the present invention is not limited by these. The examples according to the present invention are those relating to the combination of Compound A with a second medical agent selected from azacitidine, SN-<NUM>, venetoclax, ibrutinib, lenalidomide, panobinostat, a pharmaceutically acceptable salt of any of the foregoing medical agents, an anti-PD-<NUM> antibody, an anti-PD-L1 antibody, an anti-CLTA-<NUM> antibody, and the combination of medical agents involved in R-CHOP therapy. All other combinations are reference examples and are not encompassed by the present invention. The same applies to the figures.

(Experimental Example <NUM>) Evaluation of cell growth inhibitory activity by combined use of Compound A and a second medical agent.

Cell strains listed in Table <NUM> and Table <NUM> were seeded in cell culture plates (for example, <NUM>-well culture plates). DMSO solutions of Compound A diluted to different concentrations or DMSO alone were added such that the concentration of the solvent was <NUM>%. The cells were cultured for <NUM> days. During the culturing, at intervals of about <NUM> days or <NUM> days depending on cell proliferation, subculturing was appropriately carried out. In the subculturing, DMSO solutions of Compound A diluted to different concentrations or DMSO alone were added to fresh medium at the same concentration as in initiation of the study.

The cell strains cultured in the above conditions were seeded in <NUM>-well assay plates and the cells were cultured under a combination of the following conditions:.

During the culturing period, the culture conditions were <NUM> and <NUM>% CO<NUM>. On the day when the cells were seeded in a <NUM>-well assay plate (day of seeding) and <NUM> days later (day of evaluation), a reaction was carried out using CellTiter-Glo <NUM> Assay reagent (Promega KK. , #G9241) in accordance with the manual attached thereto. Thereafter, the amount of light emitted from each of the wells was measured by a plate reader (EnVision, PerkinElmer Co. Based on the luminescence of the sample addition group (TS) and the DMSO addition group (CS) for each treatment condition measured on the day of seeding; and the luminescence of the sample addition group (T) and the DMSO addition group (C) for each treatment condition measured on the day of evaluation, the cell growth inhibition rate was calculated in accordance with the following expression: <MAT>.

Note that, if the number of cells of a sample addition group on the day of evaluation was lower than that of the day of seeding (T < TS), the cell-killing effect was calculated in accordance with the following expression: <MAT>.

The cell growth inhibition rate and cell killing rate obtained by calculation were fitted to the Sigmoid Emax model to calculate <NUM>% cell growth inhibitory concentration of each of Compound A alone, a second medical agent alone, and Compound A-second medical agent combinations at different concentrations.

Based on the <NUM>% cell growth inhibitory concentrations (Compound A alone: D1, second medical agent alone: D2, Compound A when used in combination: d1, second medical agent when used in combination: d2) calculated, the combination index (CI) was calculated in accordance with the following expression: <MAT> Determination was based on the criteria: if CI < <NUM>, a synergetic effect is present; if CI = <NUM>, an additive effect is present; and if CI > <NUM>, an antagonist effect is present (refer to <NPL>).

The results are shown in Table <NUM> and Table <NUM>. A synergetic effect was confirmed in all cancer types.

Human diffuse large B-cell lymphoma KARPAS-<NUM> cells were transplanted into the subcutaneous tissue of the right abdomen of each female SCID mouse (Day <NUM>). Twenty days later, the mice were divided into groups based on estimated tumor volumes (major axis × minor axis × minor axis/<NUM>). To the mice of a Compound A administration group, Compound A (dosage selection: <NUM>/kg/day) was orally administered once a day for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). To the mice of a CHOP therapy group, cyclophosphamide (dosage selection: <NUM>/kg), doxorubicin (dosage selection: <NUM>/kg), and vincristine (dosage selection: <NUM>/kg) were administered by tail vein injection once on Day <NUM> (QD × <NUM>); and prednisone (dosage selection: <NUM>/kg) was orally administered once a day for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). Also, a combination test was carried out by using these in combination. The results are shown in <FIG>.

Compared to Compound A alone and CHOP therapy alone, a combination of Compound A and CHOP therapy exerted an excellent antitumor effect.

Human diffuse large B-cell lymphoma KARPAS-<NUM> cells were transplanted into the subcutaneous tissue of the right abdomen of each female SCID mouse (Day <NUM>). Twenty one days later, the mice were divided into groups based on estimated tumor volumes. To the mice of a Compound A administration group, Compound A (dosage selection: <NUM>/kg/day) was orally administered once a day for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). To the mice of an R-CHOP therapy group, rituximab (dosage selection: <NUM>/kg), was administered by tail vein injection once on Day <NUM> (QD × <NUM>); cyclophosphamide (dosage selection: <NUM>/kg), doxorubicin (dosage selection: <NUM>/kg) and vincristine (dosage selection: <NUM>/kg), were administered by tail vein injection once on Day <NUM> (QD × <NUM>); and prednisone (dosage selection: <NUM>/kg) was orally administered once a day for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). Also, a combination test was carried out by using these in combination. The results are shown in <FIG>.

Compared to Compound A alone and R-CHOP therapy alone, a combination of Compound A and R-CHOP therapy exerted an excellent antitumor effect.

Human diffuse large B-cell lymphoma WSU-DLCL2 cells were transplanted into the subcutaneous tissue of the right abdomen of each female SCID mouse (Day <NUM>). Fifteen days later, the mice were divided into groups based on estimated tumor volumes. The mice of a Compound A administration group were allowed to take a feed mix containing <NUM>% of Compound A at discretion for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). To the mice of a rituximab administration group, rituximab (dosage selection: <NUM>/kg) was administered by tail vein injection once on Day <NUM> (QD × <NUM>). Also, a combination test was carried out by using these in combination. The results are shown in <FIG>. Compared to Compound A alone and rituximab alone, a combination of Compound A and rituximab exerted an excellent antitumor effect.

The anti-PD-<NUM> antibody, anti-PD-L1 antibody and anti-CTLA-<NUM> antibody used herein were all manufactured by Bio X cell. Mouse B cellular lymphoma A20 cells were transplanted into the subcutaneous tissue of the right abdomen of each female Balb/c mouse (Day <NUM>). To the mice of a Compound A administration group, Compound A (dosage selection: <NUM>/kg/day) was orally administered once a day for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). To the mice of an anti-PD-<NUM> antibody administration group, an anti-PD-<NUM> antibody (dosage selection: <NUM>/kg) was administered by tail vein injection on Day <NUM>, <NUM> and <NUM>. Also, a combination test was carried out by using these in combination. The results are shown in <FIG>. To the mice of an anti-PD-L1 antibody administration group, an anti-PD-L1 antibody (dosage selection: <NUM>/kg) was administered by tail vein injection on Day <NUM>, <NUM> and <NUM>. Also, a combination test was carried out by using Compound A and the anti-PD-L1 antibody in combination. The results are shown in <FIG>. To the mice of an anti-CTLA-<NUM> antibody administration group, an anti-CTLA-<NUM> antibody (dosage selection: <NUM>/kg) was administered by tail vein injection on Day <NUM>, <NUM> and <NUM>. Also, a combination test was carried out by using Compound A and the anti-CTLA-<NUM> antibody in combination. The results are shown in <FIG>. Compared to Compound A alone, the anti-PD-<NUM> antibody, anti-PD-L1 antibody, and anti-CTLA-<NUM> antibody alone, a combination of Compound A and each of the antibodies exerted an excellent antitumor effect.

Human acute myelogenous leukemia MV-<NUM>-<NUM> cells were transplanted into the tail vein of each female NOG mouse (Day <NUM>). To the mice of a Compound A administration group, Compound A (dosage selection: <NUM>/kg/day) was orally administered once a day for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). To the mice of a <NUM>-azacitidine group, <NUM>-azacitidine (dosage selection: <NUM>/kg) was administered by tail vein injection for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). Also, a combination test was carried out by using these in combination. The results are shown in <FIG>.

Compared to Compound A alone and <NUM>-azacitidine alone, a combination of Compound A and <NUM>-azacitidine exerted an excellent life prolongation.

Human small cell lung cancer NCI-H446 cells were transplanted into the subcutaneous tissue of the right abdomen of each female SCID mouse (Day <NUM>). Twenty one days later, the mice were divided into groups based on estimated tumor volumes. To the mice of a Compound A administration group, Compound A (dosage selection: <NUM>/kg/day) was orally administered once a day for <NUM> consecutive days from Day <NUM> to Day <NUM> (QD × <NUM>). To the mice of an irinotecan (CPT-<NUM>) administration group, irinotecan (dosage selection: <NUM>/kg) was administered by tail vein injection once on Day <NUM> (QD × <NUM>). Also, a combination test was carried out by using these in combination. The results are shown in <FIG>.

Compared to Compound A alone and irinotecan alone, a combination of Compound A and irinotecan exerted an excellent antitumor effect.

Claim 1:
A compound represented by the following formula (I) or a pharmaceutically acceptable salt thereof for use in therapy,
<CHM>
wherein the compound represented by formula (I) or pharmaceutically acceptable salt thereof is administered in combination with at least one second medical agent selected from azacitidine, SN-<NUM>, venetoclax, ibrutinib, lenalidomide, panobinostat, a pharmaceutically acceptable salt of any of the foregoing medical agents, an anti-PD-<NUM> antibody, an anti-PD-L1 antibody, an anti-CLTA-<NUM> antibody, and the combination of medical agents involved in R-CHOP therapy.