US 2013 0196938A1 (19) United States (12) Patent Application Publication (10) Pub. No.: US 2013/0196938 A1 GREEN et al. (43) Pub. Date: Aug. 1, 2013

(54) COMBINATION COMPRISING CNDAC (52) U.S. Cl. (2-CYANO-2-DEOXY-N4-PALMITOYL-1- CPC ...... A61 K3I/7068 (2013.01); A61 K3I/7048 BETA-D-ARABINOFURANOSYL-CYTOSINE) (2013.01); A61K 45/06 (2013.01); A61 K AND A CYTOTOXCAGENT 31/4375 (2013.01) USPC ...... 514/27: 514/49 (71) Applicant: Cyclacel Limited, London (GB) (57) ABSTRACT (72) Inventors: Simon Richard GREEN, Dundee (GB); prisingA first aspect 2-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabinofura of the invention relates to a combination com Ian Neil FLEMING, Angus (GB) nosyl-cytosine, or a metabolite thereof, or a pharmaceutically acceptable salt thereof, and a cytotoxic agent selected from: (73) Assignee: CYCLACEL LIMITED, London (GB) (a) a HDAC inhibitor; and (b) a selected from , and SN-38, or a (21) Appl. No.: 13/709,883 thereof. A second aspect relates to a pharmaceutical product comprising (i) 2'-cyano-2'-deoxy-N-palmitoyl-1-(B-D-ara (22) Filed: Dec. 10, 2012 binofuranosyl-cytosine, or a metabolite thereof, or a pharma ceutically acceptable salt thereof, and (ii) a cytotoxic agent selected from: (a) a HDAC inhibitor; and (b) a topoisomerase Related U.S. Application Data inhibitor selected from etoposide, topotecan and SN-38, or a (63) Continuation of application No. 12/517,196, filed on prodrug thereof, as a combined preparation for simultaneous, Nov. 19, 2009, now Pat. No. 8,349,792, filed as appli sequential or separate use in therapy. A third aspect relates to cation No. PCT/GB07/04883 on Dec. 19, 2007. a method of treating a proliferative disorder, said method comprising simultaneously, separately or sequentially (30) Foreign Application Priority Data administering to a subject 2'-cyano-2'-deoxy-N-palmitoyl 1-B-D-arabinofuranosyl-cytosine, or a metabolite thereof, or Dec. 19, 2006 (GB) ...... O625283.7 a pharmaceutically acceptable salt thereof, and a cytotoxic agent selected from: (a) a HDAC inhibitor; and (b) a topoi Publication Classification Somerase inhibitor selected from etoposide, topotecan and SN-38, or a prodrug thereof. A fourth aspect of the invention (51) Int. Cl. relates to the use of a subject 2'-cyano-2'-deoxy-N-palmi A6 IK3I/7068 (2006.01) toyl-1-B-D-arabinofuranosyl-cytosine, or a metabolite A6 IK 45/06 (2006.01) thereof, or a pharmaceutically acceptable salt thereof, in the A6 IK3I/4375 (2006.01) preparation of a medicament for treating cutaneous T-cell A6 IK3I/7048 (2006.01) lymphoma (CTCL). Patent Application Publication Aug. 1, 2013 Sheet 1 of 5 US 2013/0196938A1

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COMBINATION COMPRISING CNDAC 0006 EP 536936 (Sankyo Company Limited) discloses (2-CYANO-2'-DEOXY-N4-PALMITOYL-1-BETA various 2'-cyano-2'-deoxy-derivatives of 1-?3-D-arabinofura D-ARABINOFURANOSYL-CYTOSINE) AND A nosylcytosine which have been shown to exhibit valuable CYTOTOXCAGENT anti-tumour activity. One particular compound disclosed in EP 536936 is 2'-cyano-2'-deoxy-N-palmitoyl-1-(B-D-ara 0001. The present invention relates to a combination suit binofuranosylcytosine (referred to hereinafter as "sapacitab able for the treatment of proliferative disorders. ine'), this compound is currently under further investigation. 0007 Sapacitabine, also known as CYC682 and 1-(2-C- BACKGROUND TO THE INVENTION cyano-2-dioxy-3-D-arabino-pentofuranosyl)-N'-palmitoyl 0002 The therapeutic use of pyrimidine nucleosides in the cytosine (Hanaoka, K., et al. Int. J. Cancer, 1999:82:226-236; treatment of proliferative disorders has been well docu Donehower R, et al., Proc Am Soc Clin Oncol, 2000: abstract mented in the art. By way of example, commercially available 764; Burch, PA, etal, Proc AmSoc. Clin Oncol, 2001: abstract antitumor agents of the pyrimidine series include 5-fluorou 364), is an orally administered novel 2’-deoxycytidine anti racil (Duschinsky, R., et al., J. Am. Chem. Soc., 79, 4559 metabolite prodrug of the nucleoside CNDAC, 1-(2-C-cyano (1957)), (Hiller, S.A., et al., Dokl. Akad. Nauk USSR, 2-deoxy-3-D-arabino-pentafuranosyl)-cytosine. 176,332 (1967)), UFT (Fujii, S., et al., Gann, 69,763 (1978)), (Hoshi, A., et al., Gann, 67, 725 (1976)), Doxyflu ridine (Cook, A. F., et al., J. Med. Chem., 22, 1330 (1979)), (Evance, J. S., et al., Proc. Soc. Exp. Bio. Med., 106. 350 (1961)), Ancytabine (Hoshi, A., et al., Gann, 63, 353, (1972)) and Enocytabine (Aoshima, M., et al., Cancer Res., 36,2726 (1976)). 0003 Nucleoside analogues that show antimetabolic activity in cancer cells have been Successfully used in the treatment of various human malignancies. Nucleosides Such as 1-beta-D-arabinofuranosylcytosine (Ara-C), and play an important role in the treatment of , while is extensively used in the treat ment of many types of solid tumors. These compounds are metabolized in a similar manner to endogenous nucleosides Sapacitabine and nucleotides. Active metabolites interfere with the denovo synthesis of nucleosides and nucleotides and/or inhibit DNA chain elongation after being incorporated into DNA strands, acting as chain terminators. Furthermore, nucleoside antime tabolites incorporated into DNA strands induce strand-breaks that may eventually result in induction of apoptosis. 0004 Nucleoside target one or more spe cific enzyme(s) (Galmarini et al. Nucleoside analogues and nucleobases in cancer treatment. Lancet Oncol. 2002 July; 3(7):415-24: Review). The mode of inhibitory action on tar get enzymes may differ between nucleoside antimetabolites, which have the same nucleoside base, such as Ara-C and gemcitabine. Although both nucleosides are phosphorylated by deoxycytidine kinase and are also good Substrates of cyti dine deaminase, only gemcitabine shows antitumor activity 0008 Sapacitabine has a unique mode of action over other against Solid tumors. This Suggests that there are differences nucleoside metabolites such as gemcitabine in that it has a in the pharmacological activity of these nucleoside antime spontaneous DNA strand breaking action, resulting in potent tabolites, which may reflect different modes of action on anti-tumour activity in a variety of cell lines, Xenograft and target molecules. metastatic cancer model (Hanaoka et al., 1999: Kaneko et al. 0005. It has been shown that dCK deficiency is associated 1997; Wu et al., 2003). Because of its unique mode of action, with resistance to Ara-C in various cell and animal models sapacitabine causes a block at the G2/M phase of the cell (Galmarini et al. In vivo mechanisms of resistance to cytara cycle rather than in S phase of the , which is seen for bine in acute myeloid leukaemia, Br J Haematol. 2002 June; gemcitabine and ara-C (AZuma et al 2001). 117(4):860-8). Alterations in expression of the dCK gene or 0009 Sapacitabine has been the focus of a number of significant decrease in the activity of this enzyme in Ara-C- studies in view of its oral bioavailability and its improved treated AML patients have also been correlated with clinical activity over gemcitabine (the leading marketed nucleoside outcome. These data are consistent with the concept that analogue) and 5-FU (a widely-used drug) intracellular phosphorylation of Ara-C by dCK is essential for based on preclinical data in Solid tumours. Recently, investi cytotoxicity in cellular models and in patients. Deficiency of gators reported that Sapacitabine exhibited Strong anticancer hENT1 in blast cell plasma membranes has also been sug activity in a model of colon cancer. In the same model, Sapa gested as a mechanism of cellular resistance to Ara-C. Other citabine was found to be superior to either gemcitabine or authors have suggested that mechanisms of drug resistance to 5-FU in terms of increasing Survival and also preventing the Ara-C are associated with increased levels of Ara-C catabolic spread of colon cancer metastases to the liver (Wu M. et al. enzymes such as CDA. Cancer Research, 2003:63:2477-2482). To date, phase I data US 2013/0196938 A1 Aug. 1, 2013 from patients with a variety of cancers suggest that sapacit and (b) a topoisomerase inhibitor selected from etoposide, abine is well tolerated in humans, with myelosuppression as topotecan and SN-38, or a prodrug thereof. the dose limiting . 0019. A seventh aspect relates to the use of a cytotoxic 0010. It well established in the art that active pharmaceu agent selected from: (a) a HDAC inhibitor; and (b) a topoi tical agents can often be administered in combination in order Somerase inhibitor selected from etoposide, topotecan and to optimise the treatment regime. For example, combinations SN-38, or a prodrug thereof, in the preparation of a medica comprising a CDK inhibitor and 1-(2-C-cyano-2-dioxy-f-D- ment for the treatment of a proliferative disorder, wherein arabino-pentofuranosyl)-N4-palmitoyl cytosine, or a said treatment comprises simultaneously, separately or metabolite thereof, and their use in the treatment of prolifera sequentially administering to a subject 2'-cyano-2'-deoxy tive disorders are disclosed in WO 2005/053699 (Cyclacel N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, O a Limited). metabolite thereof, or a pharmaceutically acceptable salt 0011. The present invention seeks to provide new combi thereof. nations of known pharmaceutical agents that are particularly 0020. An eighth aspect relates to a kit of parts comprising: suitable for the treatment of proliferative disorders, especially I0021 (i) 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-ara cancer. More specifically, the invention relates to combina binofuranosyl-cytosine, or a metabolite thereof, or a tions comprising 2'-cyano-2'-deoxy-N'-palmitoyl-1-B-D- pharmaceutically acceptable salt thereof, optionally arabinofuranosyl-cytosine, or a metabolite thereof, or a phar admixed with a pharmaceutically acceptable diluent, maceutically acceptable Salt thereof, with various cytotoxic excipient or carrier; and drugs. 0022 (ii) a cytotoxic agent selected from: (a) a HDAC I0012. Although 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D- inhibitor; and (b) a topoisomerase inhibitor selected arabinofuranosyl-cytosine and these cytotoxic drugs are well from etoposide, topotecan and SN-38, or a prodrug established in the art as individual therapeutic agents, to date thereof, optionally admixed with a pharmaceutically there has been no suggestion that the specific combinations acceptable diluent, excipient or carrier. claimed herein would be effective in the treatment of cancer. 0023. A ninth aspect of the invention relates to the use of 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabinofuranosyl STATEMENT OF THE INVENTION cytosine, or a metabolite thereof, or a pharmaceutically 0013. A first aspect of the invention relates to a combina acceptable salt thereof, in the preparation of a medicament for tion comprising 2'-cyano-2'-deoxy-N-palmitoyl-1-?3-D-ara treating cutaneous T-cell lymphoma (CTCL). binofuranosyl-cytosine, or a metabolite thereof, or a pharma 0024. A tenth aspect of the invention relates to a method of ceutically acceptable salt thereof, and a cytotoxic agent treating cutaneous T-cell lymphoma (CTCL) in a Subject, said selected from: (a) a HDAC inhibitor; and (b) a topoisomerase method comprising administering to said Subject a therapeu inhibitor selected from etoposide, topotecan and SN-38, or a tically effective amount of 2'-cyano-2'-deoxy-N-palmitoyl prodrug thereof. 1-B-D-arabinofuranosyl-cytosine, or a metabolite thereof, or 0014. A second aspect relates to a pharmaceutical compo a pharmaceutically acceptable salt thereof. sition comprising a combination according to the invention and a pharmaceutically acceptable carrier, diluent or excipi DETAILED DESCRIPTION ent. 0025. The preferred embodiments set out below are appli 0015. A third aspect relates to a pharmaceutical product cable to all the above-mentioned aspects of the invention. comprising (i) 2'-cyano-2'-deoxy-N-palmitoyl-1-?3-D-ara 0026. The present invention relates to the use of 2'-cyano binofuranosyl-cytosine, or a metabolite thereof, or a pharma 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or ceutically acceptable salt thereof, and (ii) a cytotoxic agent a metabolite thereof, (i) in combination with various other selected from: (a) a HDAC inhibitor; and (b) a topoisomerase therapeutic agents in the treatment of cutaneous T-cell lym inhibitor selected from etoposide, topotecan and SN-38, or a phoma (CTCL), or (ii) in monotherapy in the treatment of prodrug thereof, as a combined preparation for simultaneous, cutaneous T-cell lymphoma (CTCL). sequential or separate use in therapy. 0027. In one preferred embodiment, the metabolite of 0016 A fourth aspect relates to a method of treating a 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabinofuranosyl proliferative disorder, said method comprising simulta cytosine is 1-(2-C-cyano-2-deoxy-B-D-arabino-pentafurano neously, separately or sequentially administering to a subject syl)-cytosine (otherwise known as CNDAC). 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabinofuranosyl 0028. As mentioned above, one aspect of the present cytosine, or a metabolite thereof, or a pharmaceutically invention relates to a combination comprising 2'-cyano-2'- acceptable salt thereof, and a cytotoxic agent selected from: deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or a (a) a HDAC inhibitor; and (b) a topoisomerase inhibitor metabolite thereof, or a pharmaceutically acceptable salt selected from etoposide, topotecan and SN-38, or a prodrug thereof, and a selected cytotoxic agent which is a HDAC thereof. inhibitor. 0017. A fifth aspect relates to the use of a combination 0029. Histones are small positively charged proteins that according to the invention in the preparation of a medicament are rich in basic amino acids (positively charged at physi for treating a proliferative disorder. ological pH). There are five main types of histones namely, 0018. A sixth aspect relates to the use of 2'-cyano-2'- H1, H2A, H2B, H3, and H4, which exhibit a high degree of deoxy-N-palmitoyl-1-B-D-arabinofuranosyl-cytosine, or a structural similarity. metabolite thereof, or a pharmaceutically acceptable salt 0030. Histones are not found in eubacteria (e.g., E. coli), thereof, in the preparation of a medicament for the treatment although the DNA of these bacteria is associated with other of a proliferative disorder, wherein said treatment comprises proteins that presumably function like histones to package the simultaneously, separately or sequentially administering to a DNA within the bacterial cell. Archaebacteria, however, do subject a cytotoxic agent selected from: (a) a HDAC inhibitor; contain histones that package their DNAS instructures similar US 2013/0196938 A1 Aug. 1, 2013

to eukaryotic chromatin (G. M. Cooper, “The Cell—A deoxy-N-palmitoyl-1-B-D-arabinofuranosyl-cytosine, or a Molecular Approach”, 2" Edition, Chapter II). metabolite thereof, or a pharmaceutically acceptable salt 0031. The majority of histones are synthesized during the thereof, and a cytotoxic agent which is a topoisomerase S phase of the cell cycle, and newly synthesized histones inhibitor selected from etoposide, topotecan and SN-38, or a quickly enter the nucleus to become associated with DNA. prodrug thereof. Within minutes of its synthesis, new DNA becomes associ 0047 DNA molecules can coil and bend in space, leading ated with histones in nucleosomal structures. to changes in topology, including formation of negative or positive Supercoils. The enzymes that control the topology of 0032. The amino-terminal tail domains of histones may be DNA function at several different steps in replication in both enzymatically modified by post-translational addition of prokaryotic and eukaryotic cells. There are two classes of methyl (to lysine and arginine groups), acetyl (to lysine topoisomerases namely, topoisomerase I and topoisomerase groups), or phosphate groups (to serine groups) (Spencer et II. Thus, in one preferred embodiment, the topoisomerase al, Gene, 1999, 240(1), 1). This results in a reduction of the inhibitor is a topoisomerase I inhibitor, whereas in another net positive charge of the histone which, consequently, may preferred embodiment, the topoisomerase inhibitor is a topoi weaken the binding of the histone to DNA. somerase II inhibitor. 0033 Studies of histone deacetylators (HDACs), as well 0048 Type I topoisomerases relax DNA by nicking and as the compounds which inhibit HDACs, have elucidated the then closing one strand of duplex DNA. Type II topoi mechanisms through which some disease states act. For Somerases change DNA topology by breaking and rejoining example, in the search for novel anti-malarial compounds, the double-stranded DNA (Molecular Cell Biology, 4" Edition, naturally occurring apicidin was shown to inhibit the in vitro Eds. H. Lodish et al., 2000, WHFreeman & Company). Topoi growth of Pfalciparum by hyperacetylating histones (K. T. somerase inhibitors are believed to bind to DNA, the topoi Andrews et al. Int. J. Parasitol., 2000, 30(6), 761). Somerase, or either molecule at or near the region of the 0034. HDACs are therefore believed to be associated with enzyme involved in the formation of the DNA-protein cova a number of different diseases which include proliferative lent linkage (Holland & Frei Cancer Medicine 6, Eds. Kufeet disorders such as (Linetal, Nature, 1998,391,811), al, 2003, BC Decker Inc.) melanomas/squamous cell carcinomas (Gillenwater et al. Int. 0049. In one highly preferred embodiment, the topoi J. Cancer, 1998, 75217; Saunders etal, Cancer Res., 1999, 59, somerase inhibitor is SN-38, or a prodrug thereof. 399), breast cancer, prostrate cancer, bladder cancer (Gel 0050 SN-38 (+)-(4S)-4,11-diethyl-4,9-dihydroxy-1H mettietal, Mol. Cell Biol., 1998, 18,7185; Wang etal, PNAS, pyrano.3',4':6.7-indolizino 1,2-biquinoline-3,14(4H,12H)- 1998,951, 10860) and colon cancer (C.A. Hassig, et al., 1997, dione, also known as 7-ethyl-10-hydroxy-20(S)-camptoth Chem. Biol. 4, 783: S.Y. Archer et al., PNAS, 1998, 95(12), ecin, has the structure shown below. 6791). 0035) To date, there has been no disclosure of the specific combinations claimed in the present application, let alone any Suggestion that they would be therapeutically useful in the treatment of cancers such as cutaneous T-cell lymphoma (CTCL) and non-small cell lung cancer (NSCLC). 0036. In one preferred embodiment, the HDAC inhibitoris selected from Sodium butyrate, or a prodrug thereof. Suberoy lanilide hydramic acid (SAHA), sodium valproate, valproic acid, trichostatin A (TSA), PXD101, LAQ824, MS-275, SN-38 CI-994, SB939, MGCD0103, and depsipeptide. 0037. In a particularly preferred embodiment of the inven 005.1 SN-38 is the active metabolite of (also tion, the HDAC inhibitor is sodium butyrate, or a prodrug known as CPT-11) which is a hemisynthetic, water-soluble thereof. derivative of used for the treatment of cancer, 0038. In a highly preferred embodiment, the prodrug of i.e. CPT-11 is a prodrug of SN-38 that is metabolized to its sodium butyrate is pivaloyloxymethylbutyrate. active form, SN-38. In a highly preferred embodiment, the 0039. In another particularly preferred embodiment, the combination of the invention comprises a prodrug of SN-38. HDAC inhibitor is suberoylanilide hydramic acid (SAHA). Preferably, the prodrug is irinotecan. 0040. In yet another particularly preferred embodiment, the HDAC inhibitor is sodium valproate or valproic acid. 0041. In another particularly preferred embodiment, the HDAC inhibitor is trichostatin A (TSA). 0042. In one highly preferred embodiment, the combina tion comprises Sapacitabine and SAHA. 0043. In another highly preferred embodiment, the com bination comprises CNDAC and SAHA. 0044. In one highly preferred embodiment, the combina tion comprises Sapacitabine and sodium valproate or valproic acid. 0045. In another highly preferred embodiment, the com bination comprises CNDAC and sodium valproate or valproic acid. Irinotecan 0046. As mentioned above, another aspect of the present invention relates to a combination comprising 2'-cyano-2'- US 2013/0196938 A1 Aug. 1, 2013

0052 Irinotecan is a DNA topoisomerase I inhibitor that induces double strand breaks. Irinotecan is converted in vivo into its active form SN-38, with cytotoxic effects exerted through its binding to and inhibition of the DNA-associated HO nuclear enzyme topoisomerase I (top1), thus stabilizing top1 DNA cleavable ternary complexes (Tanizawa, A. etal, J. Natl. Cancer Inst., 86: 836-42, 1994). This impedes the DNA religation reaction and results in DNA double-strand breaks, eventually leading to apoptosis (Kjeldsen, E. et al., J. Mol. Biol., 228: 1025-30, 1992). 0053 Irinotecan is approved for use in the treatment of patients with advanced colorectal cancer (i) in combination with 5- and folinic acid in patients without prior Topotecan for advanced disease; and (ii) as a single agent in patients who have failed to respond to an established 5-fluorouracil containing treatment regimen. 0059. It has the molecular formula CHNOs-HCl and a molecular weight of 457.9. It is soluble in water and melts 0054. In another preferred embodiment, the topoi with decomposition at 213° to 218°C. Somerase inhibitor is etoposide. 0060 Topoisomerase I relieves torsional strain in DNA by 0055 Etoposide 4'-demethylepipodophyllotoxin 9-4,6- inducing reversible single strand breaks. Topotecan binds to O—(R)-ethylidene-3-D-gluco-pyranoside is a semisyn the topoisomerase I-DNA complex and prevents religation of these single strand breaks. The cytotoxicity of topotecan is thetic derivative of podophyllotoxin, a toxin found in the thought to be due to double strand DNA damage produced American May apple. Etoposide has the chemical structure during DNA synthesis, when replication enzymes interact shown below: with the ternary complex formed by topotecan, topoi somerase I, and DNA. Mammalian cells cannot efficiently repair these double strand breaks. 0061. To date, there has been no suggestion of administer ing a combination comprising Sapacitabine, or a metabolite thereof, or a pharmaceutically acceptable salt thereof, and a cytotoxic agent selected from: (a) a HDAC inhibitor; and (b) a topoisomerase inhibitor selected from etoposide, topotecan and SN-38, or a prodrug thereof. 0062 Many anti-cancer agents are given incombination in order to optimise the treatment regime. The effect of drug combinations is inherently unpredictable and there is often a propensity for one drug to partially or completely inhibit the effects of the other. OMe 0063. The present invention is based on the surprising observation that administering a combination comprising Sapacitabine, or a metabolite, or a pharmaceutically accept OH able salt thereof, and a cytotoxic agent, either simultaneously, separately or sequentially, does not lead to any significant or Etoposide dramatic adverse interaction between the two agents. 0064. The unexpected absence of any such antagonistic interaction is critical for clinical applications. 0065 Preferably, the combination of the invention is a 0056 Etoposide is approved for use in combination with synergistic combination comprising a sapacitabine, or a other approved chemotherapeutic agents (i) in patients with metabolite, or a pharmaceutically acceptable salt thereof and refractory testicular tumours who have already received the cytotoxic agent, i.e. the combination has a synergistic appropriate Surgical, chemotherapeutic and radiotherapeutic effect. therapy; and (ii) in patients as the first line treatment of small 0066. In a preferred embodiment, the combination of cell lung cancer (Source: www.rxlist.com). Sapacitabine, or metabolite thereof, or pharmaceutically 0057. In another preferred embodiment, the topoi acceptable salt thereof, and the cytotoxic agent produces an Somerase inhibitor is topotecan. enhanced effect as compared to either drug administered alone. The Surprising nature of this observation is in contrast 0058 Topotecan hydrochloride is a semi-synthetic deriva to that expected on the basis of the prior art. Advantageously, tive of camptothecin and is an anti-tumor drug with topoi a synergistic interaction may allow for lower doses of each Somerase I-inhibitory activity. Topotecan has the structure component to be administered to a patient, thereby decreasing shown below and the chemical name (S)-10-(dimethy the toxicity of chemotherapy, whilst producing and/or main lamino)methyl-4-ethyl-4,9-dihydroxy-1H-pyrano.3',4':6.7 taining the same therapeutic effect. Thus, in a particularly indolizino 1.2-biquinoline-3,14-(4H, 12H)-dione monohy preferred embodiment, each component can be administered drochloride. in a sub-therapeutic amount. US 2013/0196938 A1 Aug. 1, 2013

0067. In another preferred embodiment, sapacitabine, or 0076. In one preferred embodiment, sapacitabine, or a metabolite thereof, or a pharmaceutically acceptable salt metabolite thereof, or a pharmaceutically acceptable salt thereof, and the cytotoxic agent interact in a manner So as to thereof, and the cytotoxic agent are administered simulta alleviate or eliminate adverse side effects associated with the neously. use of the individual components in monotherapy, or associ 0077. In another aspect, the present invention relates to the ated with their use in known combinations. use of a cytotoxic agent selected from: (a) a HDAC inhibitor; 0068. As mentioned above, one aspect of the invention and (b) a topoisomerase inhibitor selected from etoposide, relates to a pharmaceutical product comprising (i) 2'-cyano topotecan and SN-38, or a prodrug thereof, in the preparation 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or of a medicament for the treatment of a proliferative disorder, a metabolite thereof, or a pharmaceutically acceptable salt wherein said treatment comprises simultaneously, separately thereof, and (ii) a cytotoxic agent selected from: (a) a HDAC or sequentially administering to a subject 2'-cyano-2'-deoxy inhibitor; and (b) a topoisomerase inhibitor selected from N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, O a etoposide, topotecan and SN-38, or a prodrug thereof, as a metabolite thereof, or a pharmaceutically acceptable salt combined preparation for simultaneous, sequential or sepa thereof. rate use in therapy. 0078. In one preferred embodiment, the cytotoxic agent 0069. The combination comprising 2'-cyano-2'-deoxy and Sapacitabine, or a metabolite thereof, or a pharmaceuti N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, O a cally acceptable salt thereof, are administered simultaneously metabolite thereof, or a pharmaceutically acceptable salt or sequentially. thereof, and the cytotoxic agent may be administered simul 0079. In one highly preferred embodiment, the cytotoxic taneously, sequentially or separately (as part of a dosing agent is administered at least 2 hours, more preferably at least regime). 4 hours, even more preferably at least 8 hours, even more 0070. As used herein, “simultaneously' is used to mean preferably still at least 12 or 24 or 48 hours before sapacitab that the two agents are administered concurrently. Thus, ine, or a metabolite thereof, or a pharmaceutically acceptable administration “sequentially may permit one agent to be salt thereof. In one particularly preferred embodiment, the administered within 5 minutes, 10 minutes or a matter of cytotoxic agent is administered at least 24 hours before Sapa hours after the other provided the circulatory half-life of the citabine, or a metabolite thereof, or a pharmaceutically first administered agentis Such that they are both concurrently acceptable salt thereof. present in therapeutically effective amounts. The time delay 0080. In another preferred embodiment, the cytotoxic between administration of the components will vary depend agent and 2'-cyano-2'-deoxy-N'-palmitoyl-1-B-D-arabino ing on the exact nature of the components, the interaction furanosyl-cytosine, or a metabolite thereof, or a pharmaceu therebetween, and their respective half-lives. tically acceptable Salt thereof, are administered simulta 0071. In contrast to “sequentially”, “separately' is used neously. herein to mean that the gap between administering one agent I0081. Another aspect of the invention relates to a method and the other is significant i.e. the first administered agent of treating a proliferative disorder, said method comprising may no longer be present in the bloodstream in a therapeuti simultaneously, separately or sequentially administering to a cally effective amount when the secondagent is administered. subject 2'-cyano-2'-deoxy-N-palmitoyl-1-?3-D-arabinofura 0072. In one preferred embodiment, the second agent is nosyl-cytosine, or a metabolite thereof, or a pharmaceutically administered at least 2 hours, more preferably at least 4 hours, acceptable salt thereof, and a cytotoxic agent selected from: even more preferably at least 8 hours, even more preferably (a) a HDAC inhibitor; and (b) a topoisomerase inhibitor still at least 12 or 24 or 48 hours after the first agent. In one selected from etoposide, topotecan and SN-38, or a prodrug particularly preferred embodiment, the second agent is thereof. administered at least 24 hours after the first agent. I0082 Preferably, the subject is a mammal, more prefer 0073. One aspect the present invention relates to the use of 2'-cyano-2'-deoxy-N'-palmitoyl-1-B-D-arabinofuranosyl ably a human. cytosine, or a metabolite thereof, or a pharmaceutically I0083. In one preferred embodiment, sapacitabine, or a acceptable salt thereof, in the preparation of a medicament for metabolite thereof, or a pharmaceutically acceptable salt the treatment of a proliferative disorder, wherein said treat thereof, and the cytotoxic agent are each administered in a ment comprises simultaneously, sequentially or separately therapeutically effective amount with respect to the indi administering to a Subject a cytotoxic agent selected from (a) vidual components. a HDAC inhibitor; and (b) a topoisomerase inhibitor selected I0084. In an alternative preferred embodiment, sapacitab from etoposide, topotecan and SN-38, or a prodrug thereof. ine, or a metabolite thereof, or a pharmaceutically acceptable 0074 Preferably, sapacitabine, or a metabolite thereof, or salt thereof, and the cytotoxic agent are each administered in a pharmaceutically acceptable salt thereof, and the cytotoxic a sub-therapeutically effective amount with respect to the agent are administered sequentially or separately. individual components. 0075 Preferably, sapacitabine, or a metabolite thereof, or I0085. The term “sub-therapeutically effective amount” a pharmaceutically acceptable salt thereof, is administered at means an amount that is lower than that typically required to least 2 hours, more preferably at least 4 hours, even more produce a therapeutic effect with respect to treatment with preferably at least 8 hours, even more preferably still at least Sapacitabine, or a metabolite thereof, or a pharmaceutically 12 or 24 or 48 hours before the cytotoxic agent. In one acceptable salt thereof, or the cytotoxic agent alone. particularly preferred embodiment, Sapacitabine, or a I0086. In a particularly preferred embodiment, sapacitab metabolite thereof, or a pharmaceutically acceptable salt ine, or a metabolite thereof, or a pharmaceutically acceptable thereof, is administered at least 24 hours before the cytotoxic salt thereof, and the cytotoxic agent are administered simul agent. taneously. US 2013/0196938 A1 Aug. 1, 2013

0087. In another particularly preferred embodiment, sapa Chemotherapy is generally only used when CTLC is citabine, or a metabolite thereof, or a pharmaceutically advanced. CTLC responds well to chemotherapy, but the acceptable salt thereof, are administered sequentially or sepa effects are short lived. Other treatments under investigation rately. include interferon, Denileukin (Ontak), Campath 1H (Alem 0088. In a highly preferred embodiment, sapacitabine, or a tuzumub), and Depsipeptide (FK228). metabolite thereof, or a pharmaceutically acceptable salt 0100. In another particularly preferred embodiment, the thereof, is administered sequentially or separately prior to the cancer is lung cancer, more preferably non-small cell lung cytotoxic agent. cancer (NSCLC) or small cell lung cancer (SCLC), even more 0089. In another highly preferred embodiment, the cyto preferably NSCLC. toxic agent is administered sequentially or separately prior to 0101. In another particularly preferred embodiment, the Sapacitabine, or a metabolite thereof, or a pharmaceutically cancer is colorectal cancer. acceptable salt thereof. 0102. In one preferred embodiment, the proliferative dis 0090 Another aspect relates to the use of a combination of order is a leukaemia. Preferably, the leukemia is selected from the present invention in the preparation of a medicament for acute myelogenous leukemia (AML), acute lymphocytic leu treating a proliferative disorder. kemia (ALL), chronic myelogenous leukemia (CML) and 0091. As used herein, the phrase “preparation of a medi chronic lymphocytic leukemia (CLL). cament includes the use of one or more of the above 0103) In one highly preferred embodiment, the cytotoxic described components directly as the medicament or in any agent is suberoylanilide hydramic acid (SAHA) and the pro stage of the manufacture of such a medicament. liferative disorder is non-Hodgkin’s lymphoma or lung can C. Proliferative Disorder 0104. In another highly preferred embodiment, the cyto 0092. The term “proliferative disorder is used herein in a toxic agent is sodium butyrate and the proliferative disorder is broad sense to include any disorder that requires control of the lung cancer. cell cycle, for example cardiovascular disorders such as res 0105. In yet another highly preferred embodiment, the tenosis and cardiomyopathy, auto-immune disorders such as cytotoxic agent is irinotecan and the proliferative disorder is glomerulonephritis and rheumatoid arthritis, dermatological colorectal cancer. disorders such as psoriasis, anti-inflammatory, anti-fungal, 0106. In another particularly preferred embodiment, the antiparasitic disorders such as malaria, emphysema and cytotoxic agent is irinotecan and the proliferative disorder is alopecia. In these disorders, the compounds of the present lung cancer. invention may induce apoptosis or maintain stasis within the 0107. In another preferred embodiment, the cytotoxic desired cells as required. agentis etoposide and the proliferative disorder is lung cancer 0093. In respect of all of the above aspects and embodi or testicular cancer. ments, preferably the proliferative disorder is cancer. 0108. In a particularly preferred embodiment, the cyto 0094. In one particularly preferred embodiment, the can toxic agent is etoposide and the proliferative disorder is lung cer is lymphoma, preferably non-Hodgkin’s lymphoma, CaCC. more preferably cutaneous T-cell lymphoma (CTCL). 0109. In one highly preferred embodiment, the combina 0095 Cutaneous T cell lymphoma (CTCL; also known as tion comprises sapacitabine and SAHA, and the proliferative Mycosis fungoides, Sezary syndrome or reticulum cell sar disorder is selected from NSCLC, AML and CTCL. coma of the skin) is a particular rare type of lymphoma in 0110. In another preferred embodiment, the combination which cancerous T cells grow within the skin. comprises Sapacitabine and Sodium valproate, and the prolif 0.096 CTLC is a rare condition with no known cause. erative disorder is selected from CTCL and AML. There are only about 4 cases diagnosed for every million 0111. In another preferred embodiment, the combination people and most patients are between 40 and 60 years old. The comprises CNDAC and topotecan, and the proliferative dis condition is twice as common in men and slightly more com order is small cell lung cancer (SCLC). mon in black people. It can only be definitely diagnosed by 0112. In one highly preferred embodiment, the combina taking a biopsy and examining under a microscope for can tion comprises CNDAC and SAHA, and the proliferative cerous T cells. disorder is selected from NSCLC and AML. In one especially 0097. There are four main stages of the condition. Stage 1 preferred embodiment, the proliferative disorder is AML, and affects only the skin; in stage 2, the lymph nodes are enlarged, for this particular embodiment, CNDAC pre-treatment is but there is no sign of cancer inside them; in stage 3, there are even more preferred. lymphoma cells in the lymph nodes; and in stage 4, the 0113. In another preferred embodiment, the combination lymphoma has spread to body organs. comprises CNDAC and sodium valproate, and the prolifera 0098. The prognosis of CTCL depends on how wide tive disorder is selected from CTCL and AML. spread the disease is. If less than 10% of the skin is affected, 0114. Another aspect of the invention relates to the use of there is a good chance of complete cure or long term control. 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabinofuranosyl If more than 10% of the skin is involved, or if the lymphoma cytosine, or a metabolite thereof, or a pharmaceutically has spread to the lymph nodes or a body organ, then the acceptable salt thereof, in the preparation of a medicament for disease is usually incurable, but can still be controlled with treating cutaneous T-cell lymphoma (CTCL). long term treatment. 0115 Similarly, the invention further relates to a method 0099 Treatment of CTCL depends on the stage of the of treating cutaneous T-cell lymphoma (CTCL) in a Subject, disease at diagnosis. Conventional treatments to date include said method comprising administering to said subject athera topical chemotherapy, treatment with ultraviolet light peutically effective amount of 2'-cyano-2'-deoxy-N-palmi (PUVA; psoralen ultraviolet treatment), radiotherapy, elec toyl-1-B-D-arabinofuranosyl-cytosine, or a metabolite tron beam therapy (EBT) and oral or injected chemotherapy. thereof, or a pharmaceutically acceptable salt thereof. US 2013/0196938 A1 Aug. 1, 2013

0116. In one preferred embodiment of the invention, the administration to a human or mammalian Subject. Such rever 2'-cyano-2'-deoxy-N'-palmitoyl-1-B-D-arabinofuranosyl sion is usually performed by an enzyme naturally present in cytosine, or a metabolite thereof, or a pharmaceutically Such subject, though it is possible for a second agent to be acceptable salt thereof is administered in combination with a administered together with Such a prodrugin order to perform pharmaceutically acceptable carrier, diluent or excipient. the reversion in vivo. Examples of such modifications include 0117. In one preferred embodiment of the invention, the esters (for example, any of those described above), wherein 2'-cyano-2'-deoxy-N'-palmitoyl-1-B-D-arabinofuranosyl the reversion may be carried out be an esterase etc. Other such cytosine, or a metabolite thereof, or a pharmaceutically systems will be well known to those skilled in the art. acceptable salt thereof is administered in combination with I0128 By way of example, in one preferred embodiment, one or more other antiproliferative agents. the prodrug of sodium butyrate is pivaloyloxymethyl butyrate. Preferably, the prodrug of SN-38 is irinotecan. Pharmaceutical Compositions Salts/Esters 0118. In a particularly preferred embodiment, the pharma ceutical product of the invention is in the form of a pharma I0129. The agents of the present invention can be present as ceutical composition comprising a pharmaceutically accept salts or esters, in particular pharmaceutically acceptable salts able carrier, diluent or excipient. OresterS. 0119 Even though the compounds of the present inven 0.130 Pharmaceutically acceptable salts of the agents of tion (including their pharmaceutically acceptable salts, esters the invention include suitable acid addition or base salts and pharmaceutically acceptable Solvates) can be adminis thereof. A review of suitable pharmaceutical salts may be tered alone, they will generally be administered in admixture found in Berge et al, J Pharm Sci, 66, 1-19 (1977). Salts are with a pharmaceutical carrier, excipient or diluent, particu formed, for example with strong inorganic acids such as larly for human therapy. The pharmaceutical compositions mineral acids, e.g. Sulphuric acid, phosphoric acid or hydro may be for human or animal usage in human and Veterinary halic acids; with strong organic carboxylic acids, such as medicine. alkanecarboxylic acids of 1 to 4 carbon atoms which are 0120 Examples of such suitable excipients for the various unsubstituted or Substituted (e.g., by halogen). Such as acetic different forms of pharmaceutical compositions described acid; with Saturated or unsaturated dicarboxylic acids, for herein may be found in the “Handbook of Pharmaceutical example oxalic, malonic, Succinic, maleic, fumaric, phthalic Excipients', 2' “Edition, (1994), Edited by A Wade and PJ or tetraphthalic; with hydroxycarboxylic acids, for example Weller. ascorbic, glycolic, lactic, malic, tartaric or citric acid, with aminoacids, for example aspartic or glutamic acid; with ben 0121 Acceptable carriers or diluents for therapeutic use Zoic acid; or with organic sulfonic acids, Such as (C1-C4)- are well known in the pharmaceutical art, and are described, alkyl- or aryl-sulfonic acids which are unsubstituted or sub for example, in Remington's Pharmaceutical Sciences, Mack stituted (for example, by a halogen) Such as methane- or Publishing Co. (A. R. Gennaro edit. 1985). p-toluene Sulfonic acid. 0122 Examples of suitable carriers include lactose, I0131 Esters are formed either using organic acids or alco starch, glucose, methyl cellulose, magnesium Stearate, man hols/hydroxides, depending on the functional group being nitol, sorbitol and the like. Examples of suitable diluents esterified. Organic acids include carboxylic acids, such as include ethanol, glycerol and water. alkanecarboxylic acids of 1 to 12 carbon atoms which are 0123. The choice of pharmaceutical carrier, excipient or unsubstituted or Substituted (e.g., by halogen). Such as acetic diluent can be selected with regard to the intended route of acid; with Saturated or unsaturated dicarboxylic acid, for administration and standard pharmaceutical practice. The example oxalic, malonic, Succinic, maleic, fumaric, phthalic pharmaceutical compositions may comprise as, or in addition or tetraphthalic; with hydroxycarboxylic acids, for example to, the carrier, excipient or diluent any suitable binder(s), ascorbic, glycolic, lactic, malic, tartaric or citric acid; with lubricant(s), Suspending agent(s), coating agent(s), solubilis aminoacids, for example aspartic or glutamic acid; with ben ing agent(s). Zoic acid; or with organic sulfonic acids, Such as (C1-C4)- 0.124 Examples of suitable binders include starch, gelatin, alkyl- or aryl-sulfonic acids which are unsubstituted or sub natural Sugars Such as glucose, anhydrous lactose, free-flow stituted (for example, by a halogen) Such as methane- or lactose, beta-lactose, corn Sweeteners, natural and synthetic p-toluene sulfonic acid. Suitable hydroxides include inor gums, such as acacia, tragacanth or sodium alginate, car ganic hydroxides, such as sodium hydroxide, potassium boxymethyl cellulose and polyethylene glycol. hydroxide, calcium hydroxide, aluminium hydroxide. Alco 0.125 Examples of suitable lubricants include sodium ole hols include alkanealcohols of 1-12 carbonatoms which may ate, Sodium Stearate, magnesium Stearate, sodium benzoate, be unsubstituted or Substituted, e.g. by a halogen). Sodium acetate, sodium chloride and the like. 0126 Preservatives, stabilizers, dyes and even flavoring Enantiomers/Tautomers agents may be provided in the pharmaceutical composition. Examples of preservatives include Sodium benzoate, Sorbic 0.132. The invention also includes where appropriate all acid and esters of p-hydroxybenzoic acid. Antioxidants and enantiomers and tautomers of the agents. The man skilled in Suspending agents may be also used. the art will recognise compounds that possess optical prop erties (one or more chiral carbon atoms) or tautomeric char acteristics. The corresponding enantiomers and/or tautomers may be isolated/prepared by methods known in the art. 0127. The invention further includes agents of the present invention in prodrug form. Such prodrugs are generally com Stereo and Geometric Isomers pounds wherein one or more appropriate groups have been 0.133 Some of the agents of the invention may exist as modified such that the modification may be reversed upon Stereoisomers and/or geometric isomers—e.g. they may pos US 2013/0196938 A1 Aug. 1, 2013

sess one or more asymmetric and/or geometric centres and so ally, intrathecally, Subcutaneously, intradermally, intraperito may exist in two or more stereoisomeric and/or geometric neally or intramuscularly, and which are prepared from sterile forms. The present invention contemplates the use of all the or sterilisable solutions. The pharmaceutical compositions of individual Stereoisomers and geometric isomers of those the present invention may also be in form of Suppositories, inhibitor agents, and mixtures thereof. The terms used in the pessaries, Suspensions, emulsions, lotions, ointments, claims encompass these forms, provided said forms retain the creams, gels, sprays, Solutions or dusting powders. appropriate functional activity (though not necessarily to the 0140. An alternative means of transdermal administration same degree). is by use of a skin patch. For example, the active ingredient 0134. The present invention also includes all suitable iso can be incorporated into a cream consisting of an aqueous topic variations of the agent or pharmaceutically acceptable emulsion of polyethylene glycols or liquid paraffin. The salts thereof. An isotopic variation of an agent of the present active ingredient can also be incorporated, at a concentration invention or a pharmaceutically acceptable salt thereof is of between 1 and 10% by weight, into an ointment consisting defined as one in which at least one atom is replaced by an of a white wax or white soft paraffin base together with such atom having the same atomic number but an atomic mass stabilisers and preservatives as may be required. different from the atomic mass usually found in nature. 0141 Injectable forms may contain between 10-1000 mg. Examples of isotopes that can be incorporated into the agent preferably between 10-500 mg. ofactive ingredient per dose. and pharmaceutically acceptable salts thereof include iso 0.142 Compositions may be formulated in unit dosage topes of hydrogen, carbon, nitrogen, oxygen, phosphorus, form, i.e., in the form of discrete portions containing a unit sulphur, fluorine and chlorine such as 2H,3H, 13C, 14C, 15.N. dose, or a multiple or sub-unit of a unit dose. 17O, 18O,31P 32P 35S, 18F and 36C1, respectively. Certain 0143. In a preferred embodiment, sapacitabine is admin isotopic variations of the agent and pharmaceutically accept istered orally. able salts thereof, for example, those in which a radioactive 0144. In another preferred embodiment, irinotecan is isotope Such as 3H or 14C is incorporated, are useful in drug administered intravenously. and/or substrate tissue distribution studies. Tritiated, i.e., 3H, 0145. In yet another preferred embodiment, etoposide is and carbon-14, i.e., 14C, isotopes are particularly preferred administered orally or intravenously. for their ease of preparation and detectability. Further, sub stitution with isotopes such as deuterium, i.e., 2H, may afford Dosage certain therapeutic advantages resulting from greater meta 0146 A person of ordinary skill in the art can easily deter bolic stability, for example, increased in vivo half-life or mine an appropriate dose of one of the instant compositions to reduced dosage requirements and hence may be preferred in administer to a Subject without undue experimentation. Typi Some circumstances. Isotopic variations of the agent of the cally, a physician will determine the actual dosage which will present invention and pharmaceutically acceptable salts be most suitable for an individual patient and it will depend on thereof of this invention can generally be prepared by con a variety of factors including the activity of the specific com ventional procedures using appropriate isotopic variations of pound employed, the metabolic stability and length of action Suitable reagents. of that compound, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug Solvates combination, the severity of the particular condition, and the 0135 The present invention also includes solvate forms of individual undergoing therapy. The dosages disclosed herein the agents of the present invention. The terms used in the are exemplary of the average case. There can of course be claims encompass these forms. individual instances where higher or lower dosage ranges are merited, and Such are within the scope of this invention. Polymorphs 0147 Depending upon the need, the agent may be admin 0136. The invention furthermore relates to agents of the istered at a dose of from 0.1 to 30 mg/kg body weight, such as present invention in their various crystalline forms, polymor from 2 to 20 mg/kg, more preferably from 0.1 to 1 mg/kg phic forms and (an)hydrous forms. It is well established body weight. within the pharmaceutical industry that chemical compounds 0.148. By way of guidance, sapacitabine is typically may be isolated in any of such forms by slightly varying the administered in accordance to a physician's direction at dos method of purification and or isolation form the solvents used ages between 0.05 to 5 g for an adult human patient. Prefer in the synthetic preparation of such compounds. ably, the dosage is between 1 and 120 mg/m body surface orally. The doses can be given 5 days a week for 4 weeks, or Administration 3 days a week for 4 weeks. Sapacitabine may also be admin istered at dosages between 1 and 500 mg per dose twice a day. 0.137 The pharmaceutical compositions of the present Preferably, these doses may be given in a treatment cycle invention may be adapted for oral, rectal, vaginal, parenteral, which comprises administering Sapacitabine for 2 to about 6 intramuscular, intraperitoneal, intraarterial, intrathecal, intra days per week, for 2 weeks out of 3 weeks. More preferably, bronchial, Subcutaneous, intradermal, intravenous, nasal, the sapacitabine may be given from 3 to 5 days per week for buccal or Sublingual routes of administration. two weeks with 1 week rest. Even more preferably, the sapa 0138 For oral administration, particular use is made of citabine may be given for 3, 4 or 5 consecutive days per week compressed tablets, pills, tablets, gellules, drops, and cap for two weeks with 1 week rest. Alternatively, the sapacitab sules. Preferably, these compositions contain from 1 to 2000 ine may be in a treatment cycle which comprises administer mg and more preferably from 50-1000 mg. of active ingredi ing sapacitabine for 7 days or 14 days every 21 days, more ent per dose. preferably for 7 consecutive days or 14 consecutive days 0.139. Otherforms of administration comprise solutions or every 21 days, even more preferably for 7 consecutive days emulsions which may be injected intravenously, intraarteri followed by two weeks rest. Dosages and frequency of appli US 2013/0196938 A1 Aug. 1, 2013 cation are typically adapted to the general medical condition 0158 Optionally, the kit of parts may further comprise a of the patient and to the severity of the adverse effects caused, means for facilitating compliance with a particular dosing in particular to those caused to the hematopoietic, hepatic and regimen, for example, instructions indicating when, how, and to the renal system. The total daily dose of sapacitabine can be how frequently the unit dosage forms of each component administered as a single dose or divided into separate dosages should be taken. preferably administered two, three or four time a day. 0159. The present invention is further described by way of 0149. By way of guidance, the cytotoxic agent is typically example, and with reference to the following figures, administered in accordance with a physician's direction at wherein: dosages between the approved dosages for said cytotoxic (0160 FIG. 1 shows that CNDAC and SAHA induce a agent. Said dosages are available from the Summary of Prod dose-dependent increase in Sub-G1 Hut 78 cells. uct Characteristics for each agent which may be obtained 0.161 FIG. 2 shows Xenograft data from the combinations from the manufacturer or from the literature e.g. www.emea. of sapacitabine with either irinotectan (CPT-11) or SAHA. In eu.int/htmS/human?eparta-Zepar.htm. each column, the symbols represent the individual mice and 0150 Preferably, where the cytotoxic agent is etoposide, it the line represents the average for that group. The error bars is administered by infusion, more preferably, intravenous represent the standard error of the mean. The data was infusion. Preferably, the etoposide is administered in a dosage obtained 22 days after the start of the treatment. This time of from 100 to 120 mg/m/day via continuous infusion over point was immediately after the 21 day treatment regimes 30 to 60 minutes. have been completed. 0151. Preferably, where the cytotoxic agent is irinotecan, (0162 FIG. 3 shows that CNDAC and SAHA induce a it is administered by infusion into a peripheral or central vein, synergistic increase in Hut 78 cells with a sub-G1 DNA con more preferably by intravenous infusion. Preferably, the tent (% total cells vs treatment). irinotecan is administered in a dosage of from 100-400 0163 FIG. 4 shows Annexin V staining in dead and apo mg/m, more preferably from 150-350 mg/m, even more ptotic cells (cell number 96 vs treatment). The staining indi preferably from 150-200 mg/m. Preferably, the irinotecanis cates that CNDAC and SAHA induce an additive increase in administered over a 30 to 90 minute period. dead/dying Hut 78 cells. 0152 Preferably, where the cytotoxic agent is topotecan, it (0164 FIG. 5 shows the analysis of CNDAC/SAHA com is administered in oral or intravenous forms. For the oral form bination by Western Blotting in Hut 78 cells. PI and annexin V the recommended dose is 2.3 mg/m/day once daily for 5 staining indicate that CNDAC/SAHA combination causes a consecutive days repeated every 21 days. For the intravenous weak synergistic increase in cell death in Hut 78 cells. form the recommended dose is 1.5 mg/m2 by intravenous 0.165 FIG. 6 shows the number of mice vs days after infusion over 30 minutes daily for 5 consecutive days, starting innoculuation for various treatment combinations in P388 on day 1 of a 21-day course. mouse model (vehicle (control), CYC682 20 mg/kg PO 0153. By way of guidance, the HDAC inhibitor is typically QDx5x2, SAHA 75 mg/kg IP QDx12, or CYC682+SAHA). administered in accordance with a physicians direction. Piv anex (pivaloyloxymethylbutyrate) is typically administered EXAMPLES at about 2.34 g/m per day. Pivanex is preferably administered intravenously. Suberoylanilide hydroxamic acid (SAHA) is Material and Methods typically administered from about 100-600 mg per day. Sub eroylanilide hydroxamic acid (SAHA) is preferably admin 0166 CNDAC was supplied by Cyclacel Ltd. (Dundee, istered orally. Valproic acid is typically administered from UK). Etoposide was supplied by Sigma. SN-38 was supplied about 10 to 60 mg/kg when administered orally, or from about by Abatra technology Co Ltd., Xi'an, China. Irinotectan was 10 to 150 mg/kg when administered intravenously. The total supplied by Pfizer. Sodium butyrate, valproic acid and daily dose of HDAC inhibitor can be administered as a single Sodium valproate were obtained from Sigma; trichostatin A dose or divided into separate dosages preferably administered (TSA) was obtained from AG Scientific, Inc.; SAHA was obtained from Toronto Research Chemicals, Inc. Cell lines two, three or four time a day. H1299, H460, Hut 78, MV4-11, HL-60 and PL-21 were Kit of Parts obtained from ATCC. 0154) A further aspect of the invention relates to a kit of Preparation of Sapacitabine parts comprising: (O155 (i) 2'-cyano-2'-deoxy-N-palmitoyl-1-(B-D-ara 0.167 Sapacitabine was prepared in accordance with the binofuranosyl-cytosine, or a metabolite thereof, or a methodology described in Examples 1 and 2 of EP536936 in pharmaceutically acceptable salt thereof, optionally the name of Sankyo Company Limited. admixed with a pharmaceutically acceptable diluent, excipient or carrier, and Cell Culture 0156 (ii) a cytotoxic agent selected from: (a) a HDAC 0168 Experiments were carried out in 96-well plates and inhibitor; and (b) a topoisomerase inhibitor selected the cell lines seeded at a density of 2500/well for H1299, from etoposide, topotecan and SN-38, or a prodrug 2500/well or 3000/well for H460, 5000/well for HL-60 cells, thereof, optionally admixed with a pharmaceutically and 8,000 cells/well for Hut 78, MV4-11 and PL-21 cells. In acceptable diluent, excipient or carrier. the solid tumour cell lines (H460 and H1299) 24 h treatment 0157 Preferably, sapacitabine, or a metabolite thereof, or and 72 h treatment ICs values were determined for each a pharmaceutically acceptable salt thereof, and the cytotoxic compound using the Alamar blue assay, whereas only 72 h agent are each in unit dosage form. Preferably, the kit of parts ICso values were obtained in the suspension cell lines (Hut78, contains a plurality of unit dosage forms of each component, MV4-11, HL60 and PL21). Each compound was then tested i.e. of components (i) and (ii) above. in combination with CNDAC using three different treatment US 2013/0196938 A1 Aug. 1, 2013

regimes: concomitant, CNDAC pre-treatment followed by and for multiple diluted, fixed-ratio combinations, using the HDAC inhibitor/topoisomerase inhibitor and CNDAC treat equation: f/f(C/C)", wheref, is the cell fraction affected ment after pre-treatment with HDAC inhibitor/topoisomerase by the drug concentration C (e.g., 0.9 if cell growth is inhib inhibitor. In Hut 78 cells, a concomitant treatment regime was ited by 90%), f is the unaffected fraction, C is the drug employed, after pre-treatment with CNDAC, SAHA or drug concentration, ICs the concentration required for a half free medium for 24 h. maximal effect (i.e., 50% inhibition of cell growth), and m is the sigmoidicity coefficient of the concentration-effect curve. Calcusyn Drug Combination Protocol On the basis of the slope of the curve for each drug in a 0169 Slightly different variations of the combination pro combination, it can be determined whether the drugs have tocol were used in the different cell lines tested, since some mutually nonexclusive effects (e.g., independent or interac cell lines do not adhere to the plates, making aspiration of tive modes of action). impracticable. 0.174. The combination index (CI) is then determined by 0170 For the concomitant treatment regime in H460 and the equation: H1299 cells, 2-fold serial dilutions of CNDAC, HDAC inhibitor/topoisomerase inhibitor, or both drugs simulta neously were added to cells 24 h after plating, and left for 72 h at 37°C. In the pre-treatment regimes, the first drug was where (CX) is the concentration of drug 1 required to produce added 2 h after cells were plated, and left for 24 h. Medium an X percent effect of that drug alone, and (C), the concen was aspirated and replaced with fresh medium containing the tration of drug 1 required to produce the same X percent effect second drug, and incubated for 72h. The two controls for each in combination with (C). If the mode of action of the drugs is sequential treatment involved substituting one of the drug mutually exclusive or nonexclusive, then C. is 0 or 1, respec treatments with medium. A similar protocol was used in tively. CI values will be calculated with this equation using Hutt.8 cells, although the medium aspiration step was omitted different values off (i.e., for different degrees of cell growth (as the pre-treatment drug could not be removed from these inhibition). CI values of <1 indicate synergy, the value of 1 cells, since it is a suspension cell line). AML cell lines (HL60, indicates additive effects, and values > 1 indicate antagonism. MV4-11, PL21): Combination analysis was carried out Data were analyzed on an IBM-PC computer using concen essentially as described for Hut 78 cells, except the 72 h drug tration-effect analysis for microcomputer software (Biosoft, incubation period was reduced to 48 h in the AML cell lines, Cambridge, UK). For statistical analysis and graphs we will to compensate for their fast growth rate. use Instat and Prism software (GraphPad, San Diego, USA). 0171 After drug treatment, the cell number in each well The dose-effect relationships for the drugs tested, alone or in was then estimated by incubating the cells for 1 h in medium paired combinations, were Subjected to median-effect plot containing 10% alamar blue (Roche, Lewes, East Sussex, analysis to determine their relative potency (ICs), shape (m), U.K.) and reading the absorbance at 544-595 nm. Drug inter and conformity (r) in each selected cell line. As stated above, actions were analysed using the commercial software pack the ICso and m values were respectively used to calculate age Calcusyn, which is based on the median effect model of synergism and antagonism on the basis of the CI equation. Chou and Talalay (Chou, T. C. & Talalay, P. (1984) Adv. Results were expressed as the meantstandard deviation of at Enzyme Regul. 22, 27-55. Quantatative analysis of dose least 3 experiments performed in duplicate. In each experi effect relationships: the combined effects of multiple drugs or ment, cells were exposed to the paired combinations for 48 enzyme inhibitors). A Combination Index (C.I.) of 1 indi hours as described above. Means and standard deviations cated an additive drug interaction, whereas a C.I. greater than were compared using Student's t-test (two-sided p value). 1 was antagonistic and a score lower than 1 was synergistic. Western Blotting Analysis Flow Cytometry 0.175 Protein lysates were generated from 10 cm plates 0172 Hut 78 cells were seeded in 10 cm plates at approxi that were seeded at approximately 5x10 cells/well, in mately 5x10 cells/plate and left to settle for 2 h. CNDAC, medium containing 10% FCS. Cells were incubated with SAHA or both drugs were added at the indicated concentra CNDAC, SAHA, or both compounds at the indicated concen tions for the times shown (16-72 h treatment). After treat trations and times prior to harvest. Cells were collected by ment, cells were harvested and cell cycle analysis was carried centrifugation (5 minx2,000 g), washed once with ice-cold our. Cells were pelleted by centrifugation, washed twice in buffer A (50 mM HEPES, pH 7.0, 20 mM NaCl, 1 mM DTT, PBS and then fixed overnight in 70% (v/v) ethanol at -20°C. protease inhibitors, 10 mM Sodium pyrophosphate, 10 mM Cells were stained with 50 ug/ml propidium iodide for 20 min Sodium Fluoride and 1 mM Sodium Orthovanadate), and and the DNA content analysed on the flow cytometer. resuspended in 0.3 ml of the same buffer. Cells were lysed by Annexin V staining was performed as indicated in manufac Sonication (2x3 Sbursts with probe Sonicator), and the protein turers instructions, on live, non-fixed cells. concentration of each tube determined using the BCA assay. Statistical Analysis and Determination of Synergistic Lysates (20-30 ug protein loaded/well) were resolved on Bis Activity Tris gels containing 10 or 12% acrylamide and transferred to nitrocellulose for analysis by western blotting. Membranes 0173 Effects of drug combinations were evaluated using were blocked for 1 h at room temperature in PBS containing the Chou and Talalay method which is based on the median 0.02% (v/v) Tween 20 and 5% (w/v) fat-free dried milk. effect principle (Chou TC, Talalay P. Quantitative analysis of Antibody incubations were carried out overnight at 2-8°C. in dose-effect relationships: the combined effects of multiple PBS containing 0.02%(v/v) Tween 20 (PBST) containing 3% drugs or enzyme inhibitors. Adv Enzyme Regul. 1984; 22:27 (w/v) dried milk. Nitrocellulose membranes were probed 55). This involves plotting dose-effect curves for each drug with the following antibodies: US 2013/0196938 A1 Aug. 1, 2013

CNDAC and SAHA Induce a Time-Dependent Increase in Sub-G1 Hut78 Cells dilution Antibody Source target protein used 0181 FIG. 4 shows that CNDAC and SAHA induce a time-dependent increase in sub-G1 Hut 78 cells. Hut 78 cells Cleaved PARP BD Pharmingen Cleaved PARP 1:500 Acetyl-Histone H4 Upstate Acetylated Histone H4 1:1000 were incubated with 1xIC50 CNDAC, 1xIC50 SAHA, or XIAP Cell Signalling XIAP 1:1000 1XIC50 CNDAC+SAHA for 16, 24, 48 or 72 h. 1XIC50 McI-1 (S-19) Santa Cruz McI-1 1:1000 values are 0.36 uM for CNDAC and 0.46 uM for SAHA in Survivin AbCam Survivin 1:500 Hut78 cells. After treatment, cells were then harvested, H2AX Upstate H2AX 1:2OOO pser139 H2AX Upstate pser139 in H2AX 1:2OOO stained with propidium iodide and their DNA content analy pser317 Chk1 Cell signalling pser317 in Chk1 1:1000 sed by flow cytometry. SAHA alone had little effect on the RADS1 Neomarkers RADS1 1:250 cell cycle and induced a small increase in Sub-G1 cells (<2n DNA) which are usually dead or undergoing apoptosis. CNDAC treatment induced a time-dependent increase in sub (0176 Membranes were then washed three times in PBST, G1 cells that became apparent by 48 h treatment and included and then incubated for 1 h with the appropriate horseradish almost 30% of the cell population by 72 h. CNDAC and peroxidase-conjugated secondary antibody (Perbio) at 1:5. SAHA produced a synergistic increase in sub-G1 cells that 000 dilution. Finally, the membranes were washed three was apparent by 48 hand involved approximately 70% of the times in PBST prior to development using an enhanced cell population by 72 h. These data indicate that CNDAC and chemiluminescence kit (Amersham Corporation, Bucking SAHA induce a synergistic increase in cells that are dead or hamshire, U.K.) or the Millipore Immobilon HRP substrate. dying and that this effect is significant by 48 h treatment time CNDAC treatment also induced a discrete population of cells Results in the DNA content that contained 2-3n DNA (S-phase), which could either represent a sub-population of S-phase Antiproliferative Effect of CNDAC and SAHA Against a cells or cells that are dying from (4n DNA). If the Cutaneous T-Cell Lymphoma Cell Line (Hut 78) latter explanation is correct, then CNDAC probably induces a 0177 Table 1 shows the effect of CNDAC and SAHA greater proportion of dead/dying cells than is shown in FIG. 4. against the cutaneous T-cell lymphoma (CTCL) cell line Overall, these data suggest that the CNDAC/SAHA combi Hutt.8 cells using three different treatment regimes. The nation either induces a synergistic or additive increase in cells Combination Index values from each drug treatment are that are dead or dying. shown for ED50, ED75 and ED90 values (the point on the Antiproliferative Effects of CNDAC and SAHA Against curve where 50%, 75% and 90% of the cells have been killed). Non-Small Cell Lung Cancer Cells (H460 and H1299) Data are the average of three independent experiments. 0182 Table 2 shows the effects of CNDAC and SAHA 0.178 These results demonstrate that CNDAC and SAHA against H460 and H1299 cells. CNDAC was tested using are highly synergistic in Hutt.8 cells, with all three treatment three different treatment regimes. The Combination Index regimes tested. Pretreatment with either SAHA or CNDAC values from each drug treatment are shown for ED50, ED75 appears to slightly enhance the concomitant treatment and ED90 values (the point on the curve where 50%, 75% and regime. These data demonstrate that combining CNDAC with 90% of the cells have been killed). Data are the average of at SAHA may be a promising treatment regime for treating least two independent experiments. These results demon Cutaneous T-cell Lymphoma (CTCL) cells. strate that CNDAC and SAHA are synergistic in H1299 cells, 0179. In view of the difficulties in working with a sus with all three treatment regimes tested. These data Suggest pended cell line, one drug was tested prior to a combination of that combining CNDAC with SAHA may produce a useful the two drugs. This method is equivalent to first testing one treatment regime for treating non-Small cell lung cancer drug and then the other drug in a situation where the half-life (NSCLC) cell lines. of the first drug is such that the first drug is still present when the second drug is applied. Antiproliferative Effects of CNDAC and Sodium Butyrate Against Non-Small Cell Lung Cancer Cells (H460 and CNDAC and SAHA Induce a Dose-Dependent Increase in H1299) Sub-G1 Hut 78 Cells 0183 Table 3 shows the effects of CNDAC and sodium butyrate against H460 and H1299 cells. These results dem 0180 FIG. 1 shows that CNDAC and SAHA induce a onstrate that CNDAC and butyrate generate moderate to dose-dependent increase in sub-G1 Hut 78 cells. Hut 78 cells strong synergy in H460 and H1299 cells, with all three treat were incubated with 0.5X-2xIC50 CNDAC, 0.5-2xIC50 ment regimes, showing positive drug interactions. In particu SAHA, or 0.5-2xIC50 CNDAC+SAHA for 72 h. 1XIC50 lar, the results demonstrate that CNDAC pretreatment and values are 0.36 uM for CNDAC and 0.46 uM for SAHA in concomitant treatment regimes are synergistic in H460 cells. Hutt.8 cells. After drug treatment, cells were then harvested, In H1299 cells, butyrate pre-treatment produced a synergistic stained with propidium iodide and their DNA content analy drug interaction. These data Suggest that combining CNDAC sed by flow cytometry. SAHA alone had little effect on the with butyrate may produce a useful treatment regime for cell cycle, except at 2xIC50, where it induced a small increase treating non-small cell lung cancer (NSCLC) cell lines. in sub-G1 cells (those that contain less DNA than normal diploid cells), which are usually dead or undergoing apopto Antiproliferative Effects of CNDAC and Topoisomerase sis. CNDAC treatment induced a dose-dependent increase in Inhibitors Against Non-Small Cell Lung Cancer Cells (H460 Sub-G1 cells, which was synergistically enhanced by inclu and H1299) sion of SAHA. These data indicate that CNDAC and SAHA (0.184 Table 4 shows the effects of CNDAC and topoi induce a synergistic increase in cells that are dead or dying. somerase inhibitors against H460 and US 2013/0196938 A1 Aug. 1, 2013

0185. H1299 cells. These results demonstrate that com harvested and the resulting cell lysates analysed by western bining CNDAC with the topoisomerase inhibitors etoposide, blotting with the indicated antibodies. Data are representative or SN38 (active agent derived from irinotecan) generates of two independent experiments (FIG. 5). SAHA treatment synergy in H1299 cells. ED50, 75 and 90 are when 50, 75 and induced an increase in Acetyl-histone H4, confirming that the 90% of the cell population has been killed. These data suggest HDAC inhibitor is active in this experiment. The combination that combining CNDAC with a topoisomerase inhibitor may induced an additive/synergistic increase in cleaved PARP, produce a useful treatment regime for treating non-small cell which is consistent with the annexin V data presented above lung cancer (NSCLC) cell lines. (FIG. 4). The increase in apoptosis may be induced by down regulation of anti-apoptotic proteins, since CNDAC caused a CNDAC and HDAC Inhibitors in Combination in Acute decrease in Mcl-1, and the combination resulted in down Myeloid Leukaemia (AML) Cell Lines regulation of XIAP and survivin. CNDAC induced an 0186 CNDAC was tested in combination with the indi increase in H2AX phosphorylation at serine 139, which was cated HDAC inhibitors in the AML cell lines HL60, PL21 and significantly enhanced by inclusion of SAHA. Phosphoryla MV4-11, using three different treatment regimes (Tables 5 tion of H2AX at serine 139 is indicative of double strand and 6). The Combination Index values from each drug treat DNA breaks, and these results suggest that SAHA and ment are shown for ED50, ED75 and ED90 values (the point CNDAC cause a synergistic increase in this form of DNA on the curve where 50%, 75% and 90% of the cells have been damage. Homologous recombination is one of the major killed). Data are the average of three independent experi repair pathways for double strand DNA breaks, and RAD51 mentS. plays a key role in homologous recombination. Therefore, it 0187 CNDAC and SAHA generated moderate to strong is possible that the downregulation of RAD51 induced by this synergy in all three cell lines tested, with little evidence of any combination could play a role in explaining the Synergy antagonism between the compounds. CNDAC pre-treatment between these agents, since it would result in decreased repair was marginally the best treatment regime for this combina of double-strand DNA breaks, one of the most deleterious tion. types of DNA damage. 0188 CNDAC and valproate also produced moderate to Sapacitabine and SAHA in p388 Xenograft strong synergy in all three AML cell lines. With this combi nation, there was no evidence that any treatment regime was 0.192 The p388 mouse leukaemiaxenograft assesses drug optimal. combinations by the survival times of the mice in the various (0189 These results support the idea of combining treatment arms. In this model, SAHA had very little effect on CNDAC with HDAC inhibitors in AML cell lines, since most survival, compared to the vehicle control (see FIG. 6). On the of the combinations generated Synergy, with no significant other hand, CYC682 caused a significant increase in the antagonism observed. In addition, Valproate and SAHA pro survival time. The CYC682/SAHA combination produced an duced comparable data when combined with CNDAC, argu additive increase in survival, at worst. These data provide ing that the observed synergy is a result of combining evidence that the CYC682/SAHA combination is at least CNDAC with an HDAC inhibitor, and not due to the unique additive in the p388 xenograft model. properties of a specific HDAC inhibitor. In Vivo Studies CNDAC and SAHA Induce an Additive Increase in Apoptotic/Dead Hut 78 Cells 0193 Female mice (nu/nu) were obtained from Harlan. Animals were injected subcutaneously with ~1x10" H358 0.190 Hut78 cells were incubated with IC50 CNDAC, cells/mouse at a single site on their flanks. Tumours were SAHA or CNDAC+SAHA for 24 h, 48 h or 72 h. Cells were allowed to grow to ~127 mm before being pair-matched by then harvested, stained with annexin V and analysed on the tumour size into treatment groups (10 mice/group). One flow cytometer. Data are representative of two independent group was treated with Sapacitabine (15 mg/kg) once daily by experiments. Annexin V labels live cells that are undergoing oral gavage for five consecutive days followed by a two day apoptosis or already dead. SAHA treatment induced a negli break; the treatment was then repeated for a total of three gible increase in dead/dying cells. FIG.3 shows that CNDAC cycles. Irinotecan (50 mg/kg) was treated once weekly by single agent treatment and the combination both produced a intraperitoneal injection for three weeks. SAHA (50 mg/kg) time-dependent increase in apoptotic/dead cells. Moreover, was dosed once daily by oral gavage for 21 consecutive days. CNDAC treatment and the combination produced a similar All dosing started on day 1 with the irinotecan treatment increase in the proportion of apoptotic/dead cells that was being given 12 hr prior to the sapacitabine and SAHA treat comparable in magnitude to the sub-G1 peak observed with ments; all combination dosing was based on equivalent the combination (FIG. 3). Taken together, these data Suggest schedules to the single agent treatments. As a control one that the PI staining in FIG.3 underestimated the proportion of group of mice were dosed with the same vehicle/schedule as sub-G1 cells induced by CNDAC treatment, and that the sapacitabine (2.5% DMA 9.75% Emulphor). Mice to were combination only induced an additive increase in apoptotic weighed at least twice a week to assess toxicity of the treat cells. The synergy detected in the calcusyn analysis (Table 1) ments and the tumours were measured with calipers at least is therefore likely to be mainly due to inhibition of cell pro twice a week to determine tumour growth. The tumour mea liferation. Surements were converted into Volumes using the formula: tumour volume (mm)-width (mm)xlength (mm)x0.52. The Analysis of CNDAC and SAHA Combination by Western percent tumour growth inhibition was determined with the Blotting in Hut 78 Cells formula: 1-(Change intreated tumour Volume?change in con (0191 Hut78 cells were treated with 1xIC50 CNDAC, trol tumour volume)x100%. Statistical significance was SAHA or CNDAC+SAHA for the indicated times. Cells were determined using a two sided unpaired Students T-test. US 2013/0196938 A1 Aug. 1, 2013

Results TABLE 3 0194 The results from these xenograft experiments are Analysis of CNDAC and sodium butyrate in combination in H460 and shown in FIG. 2. At day 22 the vehicle control had a mean H1299 cells. Data are the average of three (H460) or two (H1299) tumour volume of 517 mm while the irinotecan and sapac independent experiments. itabine dosed animals had mean volumes of 225 and 229 mm Sodium respectively demonstrating that both compounds had activity CNDAC Butyrate resulting in ~75% tumour growth inhibition (% TGI). The Cell Line Pretreatment Pretreatment Concomitant combination of the two agents had a mean tumour Volume of 151 mm (94% TGI), demonstrating that the combination is H460 ED50 O.8 O.99 1.00 beneficial. (n = 3) ED75 O.71 O.89 O.78 ED90 O.65 O.83 O.64 0.195. In contrast, SAHA had no effect on tumour growth, H1299 ED50 2.19 O.36 O.85 having an equivalent mean tumour Volume to the control (n = 2) ED75 O.61 O48 O.93 group (517 mm). The combination of sapacitabine and ED90 1.OO 1.04 1.57 SAHA had a mean tumour volume of 168 mm (89% TGI), since this is Smaller than the Sapacitabine alone treatment, it Suggests that the combination is having a synergistic effect on TABLE 4 tumour growth. Analysis of CNDAC in combination with a topoisomerase inhibitor in 0196. Various modifications and variations of the inven H460 and H1299 cells. Data are the average of three independent tion will be apparent to those skilled in the art without depart experiments. ing from the scope and spirit of the invention. Although the CNDAC Etoposide invention has been described in connection with specific pre Cell Line' Pretreatment Pretreatment Concomitant ferred embodiments, it should be understood that the inven H460 ED50' O.S1 O.65 O.S3 tion as claimed should not be unduly limited to such specific (n = 3) ED75' O.89 O.78 O.93 embodiments. Indeed, various modifications of the described ED90' 1.63 1.OS 2.05 modes for carrying out the invention which are obvious to CNDAC SN38 those skilled in the relevant fields are intended to be covered Cell Line Pretreatment Pretreatment Concomitant by the present invention. H1299 ED50 O.S8 O.S3 O45 (n = 3) ED75 1.51 O.66 1.17 TABLE 1. ED90 4.29 1.03 3.75

Analysis of 1-(2-C-cyano-2-deoxy--D-arabino-pentafuranosyl)- cytosine (CNDAC) and suberoylanilide hydramic acid (SAHA). TABLE 5 Data are the average of three independent experiments. Analysis of CNDAC in combination with SAHA in MV4-11, HL-60 and PL-21 cells. Data are the average of two CNDAC. SAHA independent experiments.

CNDAC- CNDAC- CNDAC CNDAC SAHA Cell Line SAHA SAHA SAHA Cell Line Effect pretreatment pretreatment Concomitant MV4-11 ED50 1.19 O.87 1.04 Hutf8 ED50 O.66 O.64 O.99 (n = 3) ED75 O.86 O.77 O.86 ED90 O.68 0.73 O.77 (n = 3) ED75 O.S6 O.47 0.7 HL60 ED50 1.18 1.31 1.2 ED90 O.48 O.36 O.S1 (n = 3) ED75 O.76 0.97 0.97 ED90 O.S3 O.89 O.98 PL21 ED50 O.99 1.12 1.29 (n = 3) ED75 O.71 O.87 0.97 ED90 O.S3 0.7 0.73 TABLE 2 Analysis of CNDAC and SAHA in combination in H460 and H1299 cells. Data are the average of three (H460) or two TABLE 6 H1299) independent experiments. Analysis of CNDAC in combination with valproate in MV4-11, HL-60 CNDAC SAHA and PL-21 cells. Data are the average of two independent experiments. Cell Line Pretreatment Pretreatment Concomitant CNDAC Valproate H460 ED50 O.93 1.63 O.85 Cell Line Effect pretreatment pretreatment Concomitant (n = 3) ED75 O.91 1.58 O.99 MV4-11 ED50 1.34 1.06 O.69 ED90 O.94 1.57 1.18 (n = 3) ED75 O.86 0.79 O.64 H1299 ED50 2.24 O.66 O.63 ED90 O.61 O.64 O.64 (n = 2) ED75 O42 O.84 O.S9 HL60 ED50 1.93 1.43 1.16 ED90 O.6 1.9 O.99 (n = 3) ED75 1.27 1.08 O.83 US 2013/0196938 A1 Aug. 1, 2013

TABLE 6-continued 37. A method of treating a proliferative disorder, said method comprising simultaneously, separately or sequen Analysis of CNDAC in combination with valproate in MV4-11, HL-60 tially administering to a subject 2'-cyano-2'-deoxy-N-palmi and PL-21 cells. Data are the average of two independent experiments. toyl-1-B-D-arabinofuranosyl-cytosine, or a metabolite or CNDAC Valproate pharmaceutically acceptable salt thereof, and a cytotoxic Cell Line Effect pretreatment pretreatment Concomitant agent, wherein the cytotoxic agent is either an HDAC inhibi PL21 ED50 1.OS 1.26 1.68 tor or a topoisomerase inhibitor selected from the group con (n = 3) ED75 O.85 O.96 1.16 sisting of etoposide, topotecan, and SN-38, and a prodrug ED90 0.79 O.81 O.89 thereof. 38. A method according to claim 37 wherein the 2'-cyano 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or 1. A combination comprising 2-cyano-2'-deoxy-N-palmi metabolite, or pharmaceutically acceptable salt thereof, and toyl-1-?3-D-arabinofuranosyl-cytosine, or a metabolite or the cytotoxic agent are each administered in a therapeutically pharmaceutically acceptable salt thereof, and a cytotoxic effective amount with respect to the individual components. agent, wherein the cytotoxic agent is either selected an HDAC 39. A method according to claim 37 wherein the 2'-cyano inhibitor or a topoisomerase inhibitor selected from the group 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or consisting of etoposide, topotecan, irinotecan, SN-38, and a metabolite or pharmaceutically acceptable salt thereof, and prodrug thereof. the cytotoxic agent are each administered in a sub-therapeu 2-8. (canceled) tically effective amount with respect to the individual com 9. A combination according to claim 1 wherein the topoi ponents. somerase inhibitor is SN-38 or a prodrug thereof. 40. A method according to claim 37 wherein the 2'-cyano 10. (canceled) 2'-deoxy-N4-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or 11. A combination according to claim 9 wherein the pro metabolite or pharmaceutically acceptable salt thereof, and drug of SN-38 is inrinotecan. the cytotoxic agent are administered simultaneously. 12. A combination according to claim 1 wherein the topi 41. A method according to claim 37 wherein the 2'-cyano Somerase inhibitor is etoposide or toptecan. 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or 13. The combination according to claim 1 wherein the metabolite or pharmaceutically acceptable salt thereof, and metabolite of 2'-cyano-2'-deoxy-N-palmitoyl-1-?3-D-ara the cytotoxic agent are administered sequentially or sepa binofuranosyl-cytosine is 1-(2-C-cyano-2-deoxy-3-D-ara rately. bino-pentafuranosyl)-cytosine (CNDAC). 42. A method according to claim 41 wherein the 2'-cyano 14. A combination according to claim 1 further comprising 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or a pharmaceutically acceptable carrier, diluent or excipient. metabolite or pharmaceutically acceptable salt thereof, and 15. A pharmaceutical product comprising (i) 2'-cyano-2'- the cytotoxic agent is administered sequentially or separately deoxy-N-palmitoyl-1-B-D-arabinofuranosyl-cytosine, or a prior to the cytotoxic agent. metabolite or pharmaceutically acceptable salt thereof, and 43. A method according to claim 41 wherein the cytotoxic (ii) a cytotoxic agent, wherein the cytotoxic agent is eitheran agent is administered sequentially or separately prior to the HDAC inhibitor or a topoisomerase inhibitor selected from 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabinofuranosyl the group consisting of etoposide, topotecan, irinotecan, cytosine, or metabolite or pharmaceutically acceptable salt SN-38, and a prodrug thereof. thereof. 16. A pharmaceutical product according to claim 15 44. A method claim 37 wherein the metabolite of 2'-cyano wherein the 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabino 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine is furanosyl-cytosine, or a metabolite or pharmaceutically 1-(2-C-cyano-2-deoxy-B-D-arabino-pentafuranosyl)-cy acceptable salt thereof, and the cytotoxic agent are formu tosine. lated for simultaneous administration. 45. A method claim 37, wherein the proliferative disorder 17. A pharmaceutical product according to claim 15 is cancer or lymphoma. wherein the 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabino 46. A method according to claim 45, wherein the cancer or furanosyl-cytosine, or a metabolite or pharmaceutically lymphoma is selected from the group consisting of non acceptable salt thereof, and the cytotoxic agent are formu Hodgkin’s lymphoma, cutaneous T-cell lymphoma (CTCL), lated for separate or sequential administration. lung cancer, non-Small cell lung cancer (NSCLC), Small cell 18-23. (canceled) lung cancer (SCLC), leukemia and acute myelogenous leu 24. A pharmaceutical product according to claim 15 kemia (AML). wherein the topoisomerase inhibitor is SN-38, or a prodrug 47-66. (canceled) thereof. 67. A kit of parts comprising: 25. A pharmaceutical product according to claim 24 (i) 2'-cyano-2'-deoxy-N-palmitoyl-1-B-D-arabinofurano wherein the prodrug of SN-38 is irinotecan. Syl-cytosine, or a metabolite thereof, or pharmaceuti 26. A pharmaceutical product according to claim 15 cally acceptable salt thereof, optionally admixed with a wherein the topoisomerase inhibitor is etoposide or toptecan. pharmaceutically acceptable diluent, excipient or car 27. A pharmaceutical product according to claim 15 rier; and wherein the metabolite of 2'-cyano-2'-deoxy-N-palmitoyl (ii) a cytotoxic agent selected from: (a) a HDAC inhibitor; 1-B-D-arabinofuranosyl-cytosine is 1-(2-C-cyano-2-deoxy and (b) a topoisomnerase inhibitor selected from etopo B-D-arabino-pentafuranosyl)-cytosine. side, topotecan and SN-38, or a prodrug thereof, option 28. A pharmaceutical product according to claim 15 further ally admixed with a pharmaceutically acceptable dilu comprising a pharmaceutical carrier, diluent or excipient. ent, excipient or carrier. 29-36. (canceled) 68. (canceled) US 2013/0196938 A1 Aug. 1, 2013 15

69. A method of treating cutaneous T-cell lymphoma (CTCL) in a subject, said method comprising administering to said Subject atherapeutically effective amount of 2'-cyano 2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cytosine, or a metabolite thereof, or a pharmaceutically acceptable salt thereof. 70. The method according to claim 69 wherein the 2'-cy ano-2'-deoxy-N-palmitoyl-1-?3-D-arabinofuranosyl-cy tosine, or a metabolite thereof, or a pharmaceutically accept able salt thereof is administered in combination with a pharmaceutically acceptable carrier, diluent or excipient. 71. The method according to claim 69 wherein the 2'-cy ano-2'-deoxy-N'-palmitoyl-1-B-D-arabinofuranosyl-cy tosine, or a metabolite thereof, or a pharmaceutically accept able salt thereof is administered in combination with one or more other antiproliferative agents. 72-73. (canceled)