TW202432192A - Methods for treating glioblastoma - Google Patents

Abstract

The present disclosure is directed to methods of treating glioblastoma in a subject in need thereof comprising administering to said subject a therapeutically effective amount of a radiopharmaceutical compound with GRPR antagonist moiety, preferably [177Lu]Lu-NeoB, in combination with radiotherapy, and optionally, with a therapeutically effective amount of an alkylating agent, preferably temozolomide.

Description

Methods for treating glioblastoma

The present invention relates to methods for treating glioblastoma in a subject in need thereof, wherein a therapeutically effective amount of a radiopharmaceutical compound comprising a GRPR antagonist moiety, such as [ ¹⁷⁷ Lu]Lu-NeoB, is administered to the subject in combination with radiation therapy and, if necessary, other adjuvant therapy.

Glioblastoma (GBM) is the most common and aggressive type of primary brain tumor, and despite extensive efforts to develop new treatment options, mortality remains high.

The overall age-adjusted incidence of glioblastoma in the United States is 3.22 per 100,000 people, with the highest incidence between the ages of 75 and 79. The incidence is higher in males and increases with increasing age at diagnosis. Glioblastoma contributes disproportionately to morbidity and mortality, with an overall 5-year relative survival rate of only 6.8%, which varies by age at diagnosis and sex (Wen et al. 2020, Neuro Oncol; 22(8):1073-1113).

Survival rates for patients diagnosed with neuroglioblastoma remain low, with a median overall survival of approximately 15–18 months. Neuroglioblastoma has one of the lowest long-term survival rates among malignant brain tumors (Ostrom QT, Cioffi G, Gittleman H, et al. (2019) CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2012-2016. Neuro Oncol; 12(S5):1-10). Once glioblastoma recurs, the estimated median overall survival (OS) is in the range of 3.5–6 months (Wen PY, Weller M, Lee EQ et al. (2020) Glioblastoma in adults: a Society for Neuro-Oncology (SNO) and European Society of Neuro-Oncology (EANO) consensus review on current management and future directions. Neuro Oncol; 22(8):1073-113).

The current standard of care (SoC) for newly diagnosed neuroglioblastoma includes the alkylating agent temozolomide in combination with radiation therapy, a treatment that was approved in 2005 based on the results of a large randomized phase III trial comparing radiation therapy with radiation therapy followed by daily temozolomide followed by maintenance temozolomide alone. The results showed statistically significant improvements in progression-free survival (PFS) and overall survival (OS), with median PFS of 6.9 months in the radiotherapy + temozolomide group and 5 months in the radiotherapy group (P < 0.001), and median OS of 14.6 months and 12.1 months, respectively (P < 0.001) (Stupp et al. 2005, N Engl J Med; 352(10):987-96).

Several studies have been conducted using radiation therapy and temozolomide to improve standard of care. A phase 3 trial of bevacizumab, a VEGF inhibitor, in newly diagnosed glioblastoma showed an improvement in PFS but no corresponding improvement in OS, and on this basis, bevacizumab was not approved for the treatment of patients newly diagnosed with glioblastoma. (Iwamoto et al. 2009, Neurology; 73(15):1200-6)

Trials combining immunotherapy with standard of care are being conducted in the setting of new diagnoses. Combined with radiotherapy in patients with newly diagnosed glioblastoma with unmethylated MGMT promoter status (CheckMate-498) (Omuro et al. 2022, Radiotherapy Combined With Nivolumab or Temozolomide for Newly Diagnosed Glioblastoma With Unmethylated MGMT Promoter: An International Randomized Phase 3 Trial. Neuro Oncol.) and in patients with methylated MGMT promoter status (CheckMate-548) (Lim et al. 2022, Phase 3 Trial of Chemoradiotherapy With Temozolomide Plus Nivolumab or Placebo for Newly Diagnosed Glioblastoma With Methylated MGMT Promoter [Phase 3 Trial of Chemoradiation Combined with Temozolomide Plus Nivolumab or Placebo]. Neuro Oncol [Neuro-Oncology] Phase 3 trials with the PD-1 inhibitor nivolumab (NIVO) combined with standard-of-care radiation therapy and temozolomide (vs. SoC) have failed to show improvement in overall survival. CheckMate-498 showed that the median OS (mOS) was 13.4 months for patients treated with NIVO + RT and 14.9 months for those in the temozolomide + RT group (HR, 1.31; P = .0037). Patients with methylated MGMT promoter status included in CheckMate-548 showed mOS of 28.9 months in the NIVO + RT + temozolomide group and 32.1 months in the placebo + RT + temozolomide group (HR, 1.1).

The use of alternating electric fields (TTF, tumor treating fields) as an adjunct to temozolomide maintenance in newly diagnosed neuroglioblastoma was approved in the United States and several European Union countries based on the results of a phase 3 trial in which median OS and PFS were significantly prolonged. The median overall survival was 20.9 months in the TTField-temozolomide group vs 16.0 months in the temozolomide-alone group (HR, 0.63; P < .001) (Stupp et al., JAMA [Journal of the American Medical Association], 2017; 318(23):2306-2316). Despite the positive phase 3 results, the use of TTF remains controversial and is not widely used in Europe (Lassman et al. 2020, Current usage of tumor treating fields for glioblastoma. Neurooncol Adv; 2(1):vdaa069).

Current guidelines still recommend RT and concomitant temozolomide followed by maintenance temozolomide for newly diagnosed glioblastoma (Nabors et al. 2020, J Natl Compr Canc Netw; 18(11):1537-1570; Weller et al. 2021, Nat Rev Clin Oncol; 18(3):170-186).

Therefore, there remains a need to provide improved clinical treatments for glioblastoma.

Gastrin-releasing peptide (GRP) is a mammalian pyrin-like peptide that regulates many biological responses in the central and enteric nervous systems (Flores et al. 2010, Brain Res Bull; 82(1-2):95-8). GRP acts through specific membrane G protein-coupled receptors (GRPRs) that are overexpressed in a variety of cancers, including glioma/neuroglioblastoma (Flores et al. 2010, Brain Res Bull; 82(1-2):95-8).

NeoB peptides are next-generation leucophyllotoxin analogs that bind to GRPR with high affinity (half-maximal inhibitory concentration ( IC50 ) 1-2 nM, Nock et al. J. Nucl. Med . 2017; 58(1):75-80) and show low internalization, consistent with the antagonistic behavior of the peptide. NeoB peptides contain a DOTA metal chelator in their structure, which allows radiolabeling with different radionuclides, including gallium-68 (for PET imaging), yttrium-177 (for radionuclide therapy), and other relevant radionuclides, which enables the therapeutic diagnostic use of NeoB without affecting receptor affinity, internalization properties, or biodistribution. In nonclinical models, [ ⁶⁸ Ga]Ga-NeoB and [ ¹⁷⁷ Lu]-Lu NeoB have been shown to have high affinity for GRPR overexpressed in breast tumors, prostate tumors, gastrointestinal stromal tumors (GISTs), and gliomas (including neuroglioblastomas) (Flores et al. 2010, supra, Morgat et al., J. Nucl. Med . 2017 ;58(9):1401-1407) and low internalization after binding to specific receptors.

The ability of the radiolabeled compounds to target GRPR-expressing tumors has been demonstrated in in vivo imaging and biodistribution studies in tumor models. [ ^177Lu ]Lu-NeoB is rapidly cleared from the blood and is rapidly eliminated through the renal system with no retention in the kidney. Background radioactivity was observed in tissues expressing GRPR (primarily the pancreas), however this background radioactivity decreased over time, consistent with a GRPR antagonist profile. In contrast, tumor remanence is persistent, with uptake detectable up to 7 days after injection ⁽ Kaloudi A, Lymperis E, Giarika A, Dalm S, Orlandi F, Barbato D, Tedesco M, Maina T, de Jong M, Nock BA. NeoBOMB1, a GRPR-Antagonist for Breast Cancer Theragnostics: First Results of a Preclinical Study with [ ^67Ga ]NeoBOMB1 in T-47D Cells and Tumor-Bearing Mice. Molecules. 2017 Nov 11;22(11):1950. doi: 10.3390/molecules22111950.PMID: 29137110; PMCID: PMC6150197).

The present disclosure provides a method for treating glioblastoma in a subject in need thereof by administering to the subject a therapeutically effective amount of a radiopharmaceutical compound in combination with radiation therapy and optionally temozolomide, wherein the radiopharmaceutical compound is a compound having formula (I) or a pharmaceutically acceptable salt thereof: C-S-P (I) wherein: C is a chelating moiety, P is a GRP receptor antagonist moiety, S is an optional spacer covalently linking C and P, and wherein the radiopharmaceutical compound is labeled with a radionuclide M.

The present disclosure provides, in various aspects as summarized below: 1. A method for treating glioblastoma in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a radiopharmaceutical compound in combination with radiotherapy, wherein the radiopharmaceutical compound is a compound having formula (I) or a pharmaceutically acceptable salt thereof: C-S-P (I) wherein: C is a chelating moiety, P is a GRP receptor antagonist moiety, S is an optional spacer covalently linking C and P, and wherein the radiopharmaceutical compound is labeled with a radionuclide M.

2. The method as described in embodiment 1, wherein the method further comprises administering a therapeutically effective amount of an alkylating agent.

3. The method as described in embodiment 2, wherein the alkylating agent is temozolomide.

4. The method of embodiment 2 or 3, wherein the alkylating agent, preferably temozolomide, is administered concomitantly with radiation therapy at a dose of 50 to 100 mg/m²/day, preferably about 75 mg/m²/day, daily during the induction period, typically for a period of 4 to 8 weeks, preferably 6 weeks.

5. The method as described in embodiment 4, wherein the alkylating agent, preferably temozolomide, is administered daily during the maintenance period after the induction period after radiotherapy at a dose of 50 to 400 mg/m²/day, preferably 75 to 300 mg/m²/day, and more preferably 150 to 200 mg/m²/day, for 5 consecutive days, followed by a 2-day rest, once every 28 days, for a period of 20 to 28 weeks, preferably 24 weeks.

6. A method as described in any one of embodiments 2-5, wherein the radiotherapy and the alkylating agent, preferably temozolomide, are both started on the same day, for example 7 to 10 days after the first administration of the radiopharmaceutical compound.

7. A method as described in any one of embodiments 2-6, wherein the alkylating agent, preferably temozolomide, is administered concomitantly with the radiotherapy during the induction period without interruption.

8. The method of any one of embodiments 2-7, wherein the alkylating agent, preferably temozolomide, is administered daily in a first dose during concomitant administration with the radiation therapy, for example for a period of 6 consecutive weeks.

9. The method according to any one of embodiments 1 to 8, wherein the radionuclide M is selected from ⁹⁰ Y, ¹³¹ I, ¹²¹ Sn, ¹⁸⁶ Re, ¹⁸⁸ Re, ⁶⁴ Cu, ⁶⁷ Cu, ⁵⁹ Fe, ⁸⁹ Sr, ¹⁹⁸ Au, ²⁰³ Hg, ²¹² Pb, ¹⁶⁵ Dy, ¹⁰³ Ru, ¹⁴⁹ Tb, ¹⁶¹ Tb, ²¹³ Bi, ¹⁶⁶ Ho, ^{165 Er, 169 Er} , ¹⁵³ Sm, ¹⁷⁷ Lu, ²¹³ Bi, ²²³ Ra, ²²⁵ Ac, ²²⁷ Ac, ²²⁷ Th, ²¹¹ At, ⁶⁷ Cu, ¹⁸⁶ Re, ¹⁸⁸ Re, ¹⁶¹ Tb, ¹⁷⁵ Yb, ¹⁰⁵ Rh, ¹⁶⁶ Dy, ¹⁹⁹ Au, ⁴⁴ Sc, ¹⁴⁹ Pm, ¹⁵¹ Pm, ¹⁴² Pr, ¹⁴³ Pr, ⁷⁶ As, ¹¹¹ Ag and ⁴⁷ Sc.

10. The method according to embodiment 9, wherein M is ¹⁷⁷ Lu.

11. The method according to any one of embodiments 1 to 10, wherein C is obtained by grafting to S or P, and C is selected from the following chelating agents: 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) (Titan), qutan, 1,4,7,10-tetraazacyclododecane, 1 (pentanedioic acid)-4,7,10-triacetic acid (DOTAGA), diethylenetriaminepentaacetic acid (DTPA), aminetriacetic acid (NTA), ethylenediaminetetraacetic acid (EDTA), 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetra ... Cyclododecane-1,4,7-triacetic acid (DO3A), triethylenetetramine (TETA), 1,4,7-triazacyclononane-1,4,7-triacetic acid (NOTA), NOTAGA, 1-(1,3-carboxypropyl)-4,7-carboxymethyl-1,4,7-triazacyclononane (NODAGA), NODASA, NODAPA, and 1,4-bis(carboxymethyl)-6-[bis(carboxymethyl)]amino-6-methylperhydro-1,4-diazepine (AAZTA, such as AAZTA5).

12. The method of embodiment 11, wherein C has the formula, .

13. The method according to any one of embodiments 1 to 12, wherein P has the general formula DPhe-Gln-Trp-Ala-Val-Gly-His-Z, wherein Z is selected from Leu-ψ(CH ₂ N)-Pro-NH ₂ and NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ or Z is wherein X is NH(amide) and R2 is (CH ₂ -CH(CH ₃ ) ₂ , and R1 and R2 are the same or are (CH ₂ N)-Pro-NH ₂ .

14. The method according to embodiment 13, wherein P is DPhe-Gln-Trp-Ala-Val-Gly-His-NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ .

15. The method according to any one of embodiments 1 to 14, wherein the compound of formula (I) is a compound of formula (II) (II) wherein C and P are as defined in any one of claims 1 and 11-14, and wherein the chelating moiety C is complexed with the radionuclide M.

16. The method of any one of embodiments 1-15, wherein the radiopharmaceutical compound is M-NeoB having the following formula (III): (III), or a pharmaceutically acceptable salt thereof, wherein M is a radioactive nuclide, preferably M is ¹⁷⁷ Lu.

17. The method of any one of embodiments 1-16, wherein the radiopharmaceutical compound is administered 1 to 10 times/treatment, preferably 4 to 10 times/treatment, and more preferably 6 to 8 times/treatment.

18. The method as described in embodiment 17, wherein the treatment with the radiopharmaceutical compound includes an administration interval of 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks or even 6 weeks, preferably 3 or 4 weeks, and more preferably once every 4 weeks.

19.    The method as described in any of embodiments 1-18, wherein the radiopharmaceutical compound is administered to the subject in multiple treatments, preferably 2-3 treatments, with a 2-12 month pause between treatments.

20. The method of any one of embodiments 1-19, wherein the radiopharmaceutical compound is administered at a dose in the range of 0.925 GBq (25 mCi) to 29.6 GBq (800 mCi), preferably 1.48 GBq (40 mCi) to 18.5 GBq (500 mCi), preferably 1.85 GBq (50 mCi) to 14.8 GBq (400 mCi), more preferably 3.7 GBq (100 mCi) to 11.1 GBq (300 mCi), even more preferably about 3.7 GBq (100 mCi), about 5.55 GBq (150 mCi), about 7.4 GBq (200 mCi), about 9.25 GBq (250 mCi), or about 11.1 GBq (300 mCi).

21. A method as described in any of embodiments 1-20, wherein the radiation therapy comprises irradiating the subject with a total dose of 40-80 Gy, for example 60 Gy.

22. The method of any one of embodiments 1-21, wherein the radiotherapy is administered at a dose of 1 Gy to 4 Gy/day, preferably about 2 Gy/day, during a period of 3 to 7 days per week, preferably about 5 days per week, and during a period of 4 to 8 weeks, preferably 6 weeks.

23. A method as described in any of embodiments 1-22, wherein the radiation therapy begins 7-10 days after the first administration of the radiopharmaceutical compound.

24.    The method as described in any of embodiments 1-23, wherein the subject is newly diagnosed with glioblastoma.

25. A method as described in any one of embodiments 1-24, wherein the subject is selected from subjects having a positive methylated O-6-methylguanine-DNA methyltransferase promoter state.

26. A method as described in any of embodiments 1-25, wherein the radiation therapy is whole brain irradiation.

27.      A method as described in any of embodiments 1-26, wherein the subject has been imaged by SPECT/CT or PET/CT or SPECT/MRI, PET/MRI prior to any surgery, for example two weeks before the start of the treatment, using the same radiopharmaceutical compound as defined for the treatment, but using an alternative radionuclide or contrast agent suitable for imaging, preferably 68-gallium, 67-gallium or 64-copper, more preferably 68-gallium, selected based on detection of the radionuclide in imaging scans of the tumor area.

28. The method as described in embodiment 27, wherein the subject is selected from subjects who show the presence of alternative radionuclides or contrast agent enhancement, such as gadum enhancement, in a PET/MRI scan of the tumor area prior to any surgery.

29. A method as described in any of embodiments 1-28, wherein the subject is newly diagnosed with glioblastoma and has a positive methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject in combination with radiotherapy and an alkylating agent, preferably temozolomide, wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before starting radiotherapy.

30. A method as described in any of embodiments 1-28, wherein the subject is newly diagnosed with neuroglioblastoma and has a negative methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject at least 6 times in combination with radiotherapy and further in combination with temozolomide, and wherein the interval between two administrations of the radiopharmaceutical compound is 4 weeks, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before the start of radiotherapy and temozolomide.

31. The method of embodiment 29 or 30, wherein the radiopharmaceutical compound is M-NeoB having the formula: Among them, M is ¹⁷⁷ Lu.

32. The method of any one of embodiments 1-30, wherein the radiopharmaceutical compound is M-NeoB having the formula: wherein M is ¹⁷⁷ Lu and the radiopharmaceutical compound is administered by intravenous infusion at a concentration of 370 MBq/mL.

33.    A radiopharmaceutical compound for use in a method of treating glioblastoma in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of the radiopharmaceutical compound in combination with radiation therapy, wherein the radiopharmaceutical compound is a compound having formula (I) or a pharmaceutically acceptable salt thereof: C-S-P  (I) wherein: C is a chelating moiety, P is a GRP receptor antagonist moiety, S is an optional spacer covalently linking C and P, and wherein the radiopharmaceutical compound is labeled with a radionuclide M.

34. A radiopharmaceutical compound for use as described in embodiment 33, wherein the method further comprises administering a therapeutically effective amount of an alkylating agent.

35. A radiopharmaceutical compound for use as described in embodiment 34, wherein the alkylating agent is temozolomide.

36. A radiopharmaceutical compound for use as described in embodiment 34 or 35, wherein the alkylating agent, preferably temozolomide, is administered daily during the induction period at a dose of 50 to 100 mg/m²/day, preferably about 75 mg/m²/day, typically for a period of 4 to 8 weeks, preferably 6 weeks.

37. A radiopharmaceutical compound for use as described in embodiment 36, wherein the alkylating agent, preferably temozolomide, is administered daily during the maintenance period after the induction period at a dose of 50 to 400 mg/m²/day, preferably 75 to 300 mg/m²/day, more preferably 150 to 200 mg/m²/day, for 5 consecutive days, followed by a 2-day rest, once every 28 days, for a period of 20 to 28 weeks, preferably 24 weeks.

38. A radiopharmaceutical compound for use as described in any of embodiments 34-37, wherein radiotherapy and the alkylating agent, preferably temozolomide, are both started on the same day, for example 7 to 10 days after the first administration of the radiopharmaceutical compound.

39. A radiopharmaceutical compound for use as described in any of embodiments 34-38, wherein the alkylating agent, preferably temozolomide, is administered concomitantly with the radiotherapy during the induction period without interruption.

40. A radiopharmaceutical compound for use as described in any of embodiments 34-39, wherein the alkylating agent, preferably temozolomide, is administered in a first dose daily during concomitant administration with the radiation therapy, for example for a period of 6 consecutive weeks.

41. A radiopharmaceutical compound for use as described in any one of embodiments 33 to 40, wherein the radionuclide M is selected from ⁹⁰ Y, ¹³¹ I, ¹²¹ Sn, ¹⁸⁶ Re, ¹⁸⁸ Re, ⁶⁴ Cu, ⁶⁷ Cu, ⁵⁹ Fe, ⁸⁹ Sr, ¹⁹⁸ Au, ²⁰³ Hg, ²¹² Pb, ¹⁶⁵ Dy, ¹⁰³ Ru, ¹⁴⁹ Tb, ¹⁶¹ Tb, ²¹³ Bi, ¹⁶⁶ Ho, ¹⁶⁵ Er, ¹⁶⁹ Er, ¹⁵³ Sm, ¹⁷⁷ Lu, ²¹³ Bi, ²²³ Ra, ²²⁵ Ac, ²²⁷ Ac, ²²⁷ Th, ²¹¹ At, ⁶⁷ Cu, ¹⁸⁶ Re, ¹⁸⁸ Re, ¹⁶¹ Tb, ¹⁷⁵ Yb, ¹⁰⁵ Rh, ¹⁶⁶ Dy, ¹⁹⁹ Au, ⁴⁴ Sc, ¹⁴⁹ Pm, ¹⁵¹ Pm, ¹⁴² Pr, ¹⁴³ Pr, ⁷⁶ As, ¹¹¹ Ag and ⁴⁷ Sc.

42. The radiopharmaceutical compound for use as described in embodiment 41, wherein M is ¹⁷⁷ Lu.

43. A radiopharmaceutical compound for use as described in any one of embodiments 33-42, wherein C is obtained by grafting to S or P, and C is selected from the following chelating agents: 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) (Titan), qutan, 1,4,7,10-tetraazacyclododecane, 1 (glutaric acid)-4,7,10-triacetic acid (DOTAGA), diethylenetriaminepentaacetic acid (DTPA), aminetriacetic acid (NTA), ethylenediaminetetraacetic acid (EDTA), 1,4,7, 10-Tetraazacyclododecane-1,4,7-triacetic acid (DO3A), triethylenetetramine (TETA), 1,4,7-triazacyclononane-1,4,7-triacetic acid (NOTA), NOTAGA, 1-(1,3-carboxypropyl)-4,7-carboxymethyl-1,4,7-triazacyclononane (NODAGA), NODASA, NODAPA, and 1,4-bis(carboxymethyl)-6-[bis(carboxymethyl)]amino-6-methylperhydro-1,4-diazepine (AAZTA, such as AAZTA5).

44. The radiopharmaceutical compound for use as described in embodiment 43, wherein C has the following formula: .

45. A radiopharmaceutical compound for use as described in any one of embodiments 33-44, wherein P has the general formula DPhe-Gln-Trp-Ala-Val-Gly-His-Z wherein Z is selected from Leu-ψ(CH ₂ N)-Pro-NH ₂ and NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ or Z is wherein X is NH(amide) and R2 is (CH ₂ -CH(CH ₃ ) ₂ , and R1 and R2 are the same or are (CH ₂ N)-Pro-NH ₂ .

46. The radiopharmaceutical compound for use as described in embodiment 45, wherein P is DPhe-Gln-Trp-Ala-Val-Gly-His-NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ .

47. The radiopharmaceutical compound for use as described in any one of embodiments 33-46, wherein the compound of formula (I) is a compound of formula (II) (II) wherein C and P are as defined in claim 1, and wherein the chelating moiety C is complexed with the radionuclide M.

48. A radiopharmaceutical compound for use as described in any one of embodiments 33-47, wherein the radiopharmaceutical compound is M-NeoB having the following formula (III): (III), or a pharmaceutically acceptable salt thereof, wherein M is a radioactive nuclide, preferably M is ¹⁷⁷ Lu.

49. A radiopharmaceutical compound for use as described in any one of embodiments 33-48, wherein the radiopharmaceutical compound is administered 1 to 10 times/treatment, preferably 4 to 10 times/treatment, and more preferably 6 to 8 times/treatment.

50. A radiopharmaceutical compound for use as described in embodiment 49, wherein treatment with the radiopharmaceutical compound includes an administration interval of 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks or even 6 weeks, preferably 3 or 4 weeks, and more preferably once every 4 weeks.

51. A radiopharmaceutical compound for use as described in any of embodiments 33-50, wherein the radiopharmaceutical compound is administered to the subject in multiple treatments, preferably 2-3 treatments, with a pause of 2-12 months between treatments.

52. A radiopharmaceutical compound for use as described in any of embodiments 33-51, wherein the radiopharmaceutical compound is administered in an amount within the range of 0.925 GBq (25 mCi) to 29.6 GBq (800 mCi), preferably 1.48 GBq (40 mCi) to 18.5 GBq (500 mCi), preferably 1.85 GBq (50 mCi) to 14.8 GBq (400 mCi), more preferably 3.7 GBq (100 mCi) to 11.1 GBq (300 mCi), even more preferably about 3.7 GBq (100 mCi), about 5.55 GBq (150 mCi), about 7.4 GBq (200 mCi), about 9.25 GBq (250 mCi), or about 11.1 GBq (300 mCi). mCi), or about 11.1 GBq (300 mCi).

53. A radiopharmaceutical compound for use as described in any of embodiments 33-52, wherein the radiotherapy comprises irradiating the subject with a total dose of 40-80 Gy, for example 60 Gy.

54. A radiopharmaceutical compound for use as described in any of embodiments 33-53, wherein the radiotherapy is performed at a dose of 1 Gy to 4 Gy/day, preferably about 2 Gy/day, during a period of 3 to 7 days, preferably about 5 days per week, and during a period of 4 to 8 weeks, preferably 6 weeks.

55. A radiopharmaceutical compound for use as described in any of embodiments 33-54, wherein the radiotherapy begins 7-10 days after the first administration of the radiopharmaceutical compound.

56. A radiopharmaceutical compound for use as described in any of embodiments 33-55, wherein the subject is newly diagnosed with glioblastoma.

57. A radiopharmaceutical compound for use as described in any of embodiments 33-56, wherein the subject is selected from subjects having a positive methylated O-6-methylguanine-DNA methyltransferase promoter state.

58. A radiopharmaceutical compound for use as described in any of embodiments 33-57, wherein the radiation therapy is whole brain irradiation.

59. A radiopharmaceutical compound for use as described in any of embodiments 33-58, wherein the subject has been imaged by SPECT/CT or PET/CT or SPECT/MRI, PET/MRI prior to any surgery, e.g., two weeks prior to the start of the treatment, using the same radiopharmaceutical compound as defined for the treatment but using an alternative radionuclide or contrast agent suitable for imaging, preferably 68-gallium, 67-gallium or 64-copper, more preferably 68-gallium, selected based on detection of the radionuclide in an imaging scan of the tumor area.

60. A radiopharmaceutical compound for use as described in embodiment 59, wherein the subject is selected from subjects who show the presence of surrogate radionuclides or contrast enhancement, such as gadum enhancement, in a PET/MRI scan of the tumor area prior to any surgery.

61. A radiopharmaceutical compound for use as described in any of embodiments 33-60, wherein the subject is newly diagnosed with glioblastoma and has a positive methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject in combination with radiotherapy and an alkylating agent, preferably temozolomide, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before starting radiotherapy.

62. A radiopharmaceutical compound for use as described in any of embodiments 33-60, wherein the subject is newly diagnosed with glioblastoma and has a negative methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject at least 6 times in combination with radiotherapy and further in combination with temozolomide, and wherein the interval between two administrations of the radiopharmaceutical compound is 4 weeks, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before the start of radiotherapy and temozolomide.

63. The radiopharmaceutical compound for use as described in embodiment 61 or 62, wherein the radiopharmaceutical compound is M-NeoB having the following formula: Among them, M is ¹⁷⁷ Lu.

64. A radiopharmaceutical compound for use as described in any one of embodiments 1-62, wherein the radiopharmaceutical compound is M-NeoB having the formula: wherein M is ¹⁷⁷ Lu and the radiopharmaceutical compound is administered by intravenous infusion at a concentration of 370 MBq/mL.

65.    Use of a radiopharmaceutical compound in the manufacture of a drug for use in a method of treating glioblastoma in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of the radiopharmaceutical compound in combination with radiotherapy, wherein the radiopharmaceutical compound is a compound having formula (I) or a pharmaceutically acceptable salt thereof: C-S-P (I) wherein: C is a chelating moiety, P is a GRP receptor antagonist moiety, S is an optional spacer covalently linking C and P, and wherein the radiopharmaceutical compound is labeled with a radionuclide M.

66. The use as described in embodiment 65, wherein the method further comprises administering a therapeutically effective amount of an alkylating agent.

67. The use as described in embodiment 66, wherein the alkylating agent is temozolomide.

68. The use as described in embodiment 66 or 67, wherein the alkylating agent, preferably temozolomide, is administered daily during the induction period at a dose of 50 to 100 mg/m²/day, preferably about 75 mg/m²/day, typically for a period of 4 to 8 weeks, preferably 6 weeks.

69. The use as described in embodiment 68, wherein the alkylating agent, preferably temozolomide, is administered daily during the maintenance period after the induction period at a dose of 50 to 400 mg/m²/day, preferably 75 to 300 mg/m²/day, more preferably 150 to 200 mg/m²/day, for 5 consecutive days, followed by a 2-day rest, once every 28 days, for a period of 20 to 28 weeks, preferably 24 weeks.

70. The use as described in any of embodiments 66-69, wherein radiotherapy and the alkylating agent, preferably temozolomide, are started on the same day, for example 7 to 10 days after the first administration of the radiopharmaceutical compound.

71. The use as described in any of embodiments 66-70, wherein the alkylating agent, preferably temozolomide, is administered concomitantly with the radiotherapy during the induction period without interruption.

72. The use as described in any of embodiments 66-71, wherein the alkylating agent, preferably temozolomide, is administered in a first dose daily during the period of concomitant administration with the radiation therapy, for example for a period of 6 consecutive weeks.

73. The use according to any one of embodiments 65 to 72, wherein the radionuclide M is selected from ⁹⁰ Y, ¹³¹ I, ¹²¹ Sn, ¹⁸⁶ Re, ¹⁸⁸ Re, ⁶⁴ Cu, ⁶⁷ Cu, ⁵⁹ Fe, ⁸⁹ Sr, ¹⁹⁸ Au, ²⁰³ Hg, ²¹² Pb, ¹⁶⁵ Dy, ¹⁰³ Ru, ¹⁴⁹ Tb, ¹⁶¹ Tb, ²¹³ Bi, ¹⁶⁶ Ho, ^{165 Er, 169 Er} , ¹⁵³ Sm, ¹⁷⁷ Lu, ²¹³ Bi, ²²³ Ra, ²²⁵ Ac, ²²⁷ Ac, ²²⁷ Th, ²¹¹ At, ⁶⁷ Cu, ¹⁸⁶ Re, ¹⁸⁸ Re, ¹⁶¹ Tb, ¹⁷⁵ Yb, ¹⁰⁵ Rh, ¹⁶⁶ Dy, ¹⁹⁹ Au, ⁴⁴ Sc, ¹⁴⁹ Pm, ¹⁵¹ Pm, ¹⁴² Pr, ¹⁴³ Pr, ⁷⁶ As, ¹¹¹ Ag and ⁴⁷ Sc.

74. The use as described in embodiment 73, wherein M is ¹⁷⁷ Lu.

75. The use as described in any one of embodiments 65-73, wherein C is obtained by grafting to S or P, and C is selected from the following chelating agents: 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) (Titan), Qutan, 1,4,7,10-tetraazacyclododecane, 1 (pentanedioic acid)-4,7,10-triacetic acid (DOTAGA), diethylenetriaminepentaacetic acid (DTPA), aminetriacetic acid (NTA), ethylenediaminetetraacetic acid (EDTA), 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetra ... Cyclododecane-1,4,7-triacetic acid (DO3A), triethylenetetramine (TETA), 1,4,7-triazacyclononane-1,4,7-triacetic acid (NOTA), NOTAGA, 1-(1,3-carboxypropyl)-4,7-carboxymethyl-1,4,7-triazacyclononane (NODAGA), NODASA, NODAPA, and 1,4-bis(carboxymethyl)-6-[bis(carboxymethyl)]amino-6-methylperhydro-1,4-diazepine (AAZTA, such as AAZTA5).

76. The use according to embodiment 75, wherein C has the formula, .

77. The use according to any one of embodiments 65-76, wherein P has the general formula DPhe-Gln-Trp-Ala-Val-Gly-His-Z, wherein Z is selected from Leu-ψ(CH ₂ N)-Pro-NH ₂ and NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ or Z is wherein X is NH(amide) and R2 is (CH ₂ -CH(CH ₃ ) ₂ , and R1 and R2 are the same or are (CH ₂ N)-Pro-NH ₂ .

78. The use according to embodiment 77, wherein P is DPhe-Gln-Trp-Ala-Val-Gly-His-NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ .

79. The use according to any one of embodiments 65-78, wherein the compound of formula (I) is a compound of formula (II) (II) wherein C and P are as defined in any one of claims 65 and 75-78, and wherein the chelating moiety C is complexed with the radionuclide M.

80. The use according to any one of embodiments 65-79, wherein the radiopharmaceutical is M-NeoB having the following formula (III): (III), or a pharmaceutically acceptable salt thereof, wherein M is a radioactive nuclide, preferably M is ¹⁷⁷ Lu.

81. The use as described in any one of embodiments 65-80, wherein the radiopharmaceutical compound is administered 1 to 10 times/treatment, preferably 4 to 10 times/treatment, and more preferably 6 to 8 times/treatment.

82. The use as described in embodiment 81, wherein the treatment with the radiopharmaceutical compound includes an administration interval of 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks or even 6 weeks, preferably 3 or 4 weeks, and more preferably once every 4 weeks.

83. The use as described in any of embodiments 65-82, wherein the radiopharmaceutical compound is administered to the subject in multiple treatments, preferably 2-3 treatments, with a pause of 2-12 months between treatments.

84. The use as described in any of embodiments 65-83, wherein the radiopharmaceutical compound is administered in an amount within the range of 0.925 GBq (25 mCi) to 29.6 GBq (800 mCi), preferably 1.48 GBq (40 mCi) to 18.5 GBq (500 mCi), preferably 1.85 GBq (50 mCi) to 14.8 GBq (400 mCi), more preferably 3.7 GBq (100 mCi) to 11.1 GBq (300 mCi), even more preferably about 3.7 GBq (100 mCi), about 5.55 GBq (150 mCi), about 7.4 GBq (200 mCi), about 9.25 GBq (250 mCi), or about 11.1 GBq (300 mCi).

85. The use as described in any of embodiments 65-84, wherein the radiotherapy comprises irradiating the subject with a total dose of 40-80 Gy, for example 60 Gy.

86. The use as described in any of embodiments 65-85, wherein the radiotherapy is performed at a dose of 1 Gy to 4 Gy/day, preferably about 2 Gy/day, during a period of 3 to 7 days per week, preferably about 5 days per week, and during a period of 4 to 8 weeks, preferably 6 weeks.

87. The use as described in any of embodiments 65-86, wherein the radiotherapy begins 7-10 days after the first administration of the radiopharmaceutical compound.

88. The use as described in any of embodiments 65-87, wherein the subject is newly diagnosed with glioblastoma.

89. The use as described in any one of embodiments 65-88, wherein the subject is selected from subjects having a positive methylated O-6-methylguanine-DNA methyltransferase promoter state.

90. The use as described in any of embodiments 65-89, wherein the radiation therapy is whole brain irradiation.

91. The use as described in any of embodiments 65-90, wherein the subject has been imaged by SPECT/CT or PET/CT or SPECT/MRI, PET/MRI prior to any surgery, for example two weeks before the start of the treatment, using the same radiopharmaceutical compound as defined for the treatment, but using an alternative radionuclide or contrast agent suitable for imaging, preferably 68-gallium, 67-gallium or 64-copper, more preferably 68-gallium, selected based on detection of the radionuclide in imaging scans of the tumor area.

92. The use as described in embodiment 91, wherein the subject is selected from subjects who show the presence of alternative radionuclides or contrast agent enhancement, such as gadum enhancement, in a PET/MRI scan of the tumor area prior to any surgery.

93. The use as described in any of embodiments 65-92, wherein the subject is newly diagnosed with glioblastoma and has a positive methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject in combination with radiotherapy and an alkylating agent, preferably temozolomide, wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before starting radiotherapy.

94. The use as described in any of embodiments 65-92, wherein the subject is newly diagnosed with neuroglioblastoma and has a negative methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is combined with radiotherapy and further administered to the subject in combination with temozolomide at least 6 times, and wherein the interval between two administrations of the radiopharmaceutical compound is 4 weeks, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before the start of radiotherapy and temozolomide.

95. The use according to embodiment 93 or 94, wherein the radiopharmaceutical compound is M-NeoB having the following formula: Among them, M is ¹⁷⁷ Lu.

96. The use according to any one of embodiments 1-94, wherein the radiopharmaceutical compound is M-NeoB having the following formula: wherein M is ¹⁷⁷ Lu and the radiopharmaceutical compound is administered by intravenous infusion at a concentration of 370 MBq/mL.

According to one aspect of the present disclosure, it has been discovered that the combination of radiopharmaceuticals, radiation therapy and optionally other treatments, such as alkylating agents, such as temozolomide, in the treatment methods of the present disclosure are at least additive or, preferably, synergistic.

The present disclosure relates to a method for treating glioblastoma in a subject in need thereof by administering to the subject a therapeutically effective amount of a radiopharmaceutical compound in combination with radiation therapy and, optionally, an alkylating agent, preferably temozolomide. General Definitions

Unless otherwise indicated herein or clearly contradicted by context, the use of the articles "a and an" and "the" in the specification and claims should be interpreted to include both the singular and the plural. Unless otherwise indicated, the terms "comprising," "having," "being of," "including," and "containing" should be interpreted as open terms (i.e., meaning "including but not limited to"), unless otherwise indicated. In addition, whenever "comprising" or another open term is used in an embodiment, it should be understood that the intermediate term "consisting essentially of" or the closed term "consisting of" can be used to more narrowly claim the same embodiment.

The term "about" or "approximately" as used herein means that the following values may vary by ± 20%, preferably ± 10%, more preferably ± 5%, even more preferably ± 2%, even more preferably ± 1%.

As used herein, the term "treating" or "treatment" includes treatment that alleviates, reduces or relieves at least one symptom of a subject or delays the progression of a disease. For example, treatment may be the reduction of one or more symptoms of a disorder or the complete eradication of a disorder (such as cancer). Within the meaning of the present disclosure, the term "treatment" also means preventing the disease, delaying the onset of the disease (i.e., the period of time before the clinical manifestation of the disease), and/or reducing the risk of the disease developing or worsening. As used herein, in the context of the disclosed combination therapies, the term "treatment" encompasses the administration of a radiopharmaceutical compound, optionally in combination with radiation therapy and/or an alkylating agent. Such treatment may involve one or more administrations of the radiopharmaceutical compound over a defined period of time.

As used herein, "glioblastoma" refers to an aggressive brain tumor that is a grade IV astrocytoma brain tumor. The term neuroglioblastoma also includes its variants gliosarcoma, giant cell neuroglioblastoma, and small cell neuroglioblastoma. Because the cells in this tumor vary in size and shape, i.e., they are pleomorphic, neuroglioblastoma is also called glioblastoma pleomorphica (GBM).

As used herein, the term "radiopharmaceutical" or "radiopharmaceutical compound" refers to a pharmaceutical compound labeled with a radionuclide element, typically of a metallic nature. Such radiopharmaceutical compounds have a binding affinity for a specific marker on a target cell, such as a receptor or tumor antigen, and thus include a target ligand (or target binding moiety). Radiopharmaceutical compounds can be used as contrast agents in imaging techniques, such as PET scans or MRI scans, or as therapeutic agents in nuclear medicine, also known as radioligand therapy (RLT) or PRRT (peptide receptor radionuclide therapy).

In line with the International System of Units, "MBq" is the abbreviation of the unit of radioactivity "megabecquerel".

As used herein, "PET" stands for positron emission tomography.

As used herein, "SPECT" stands for single photon emission computed tomography.

As used herein, "MRI" stands for magnetic resonance imaging.

As used herein, "CT" stands for computerized tomography.

The terms "tumor" and "cancer" are used interchangeably herein, e.g., both terms encompass solid and liquid tumors, e.g., diffuse or circulating tumors. As used herein, the terms "cancer" or "tumor" include pre-malignant and malignant cancers and tumors and benign cancers. The term "cancer" as used herein includes primary malignancies or tumors (e.g., those whose cells have not migrated to a site in the subject other than the original malignant tumor or tumor site) and secondary malignancies or tumors (e.g., those arising from metastasis (malignant cells or tumor cells migrate to a second site different from the original tumor site)).

As used herein, the phrase "therapeutically effective amount" of a compound refers to an amount of the compound that will elicit a desired therapeutic response in at least one subpopulation of subjects, e.g., improving symptoms, alleviating symptoms, slowing or delaying disease progression, or preventing disease, at a reasonable benefit/risk ratio applicable to any medical treatment.

As used herein, the term "subject" or "patient" is intended to include animals that are capable of or suffer from cancer or any disorder directly or indirectly related to cancer. Examples of subjects include mammals, such as humans, apes, monkeys, dogs, cows, horses, pigs, sheep, goats, cats, mice, rabbits, rats, and transgenic non-human animals. In one embodiment, the subject is a human, such as a human who has cancer, is at risk of cancer, or may be susceptible to cancer.

"Combination therapy" refers to a therapy that includes administration of a fixed combination in the form of one dosage unit, or a therapy in which a radiopharmaceutical compound as disclosed herein and a combination partner, e.g., another drug as explained below, such as an alkylating agent and/or radiation therapy, can be administered simultaneously or separately, i.e., separately within a time interval, especially where such time intervals allow the combination partner and/or the combination radiation therapy to show a cooperative effect (e.g., a synergistic effect) with the radiopharmaceutical compound. The individual components can be packaged in a kit or separately. One or both components (e.g., powders or liquids) can be reconstituted or diluted to the desired dose prior to administration.

As used herein, the terms "co-administration" or "combination administration" and the like are also intended to encompass administration of selected combination partners, such as a radiopharmaceutical compound and an alkylating agent, to a single subject (e.g., a patient) in need thereof, and are intended to include treatment regimens in which the agents are not necessarily administered by the same route of administration or administered simultaneously.

In chemical formulas, the wavy line = ...

The radiopharmaceutical compound used in the method disclosed herein is a compound having formula (I) or a pharmaceutically acceptable salt thereof: C-S-P (I) wherein: C is a chelating moiety; S is an optional spacer covalently linking C and P; P is a GRP receptor binding moiety covalently linked to C directly or indirectly via S, wherein the compound is labeled with a radionuclide M.

M is selected from radioactive isotopes useful in nuclear medicine. Examples of such radioactive isotopes include, but are not limited to, ⁹⁰ Y, ¹³¹ I, ¹²¹ Sn, ¹⁸⁶ Re, ¹⁸⁸ Re, ^{64 Cu, 67 Cu} , ⁵⁹ Fe, ⁸⁹ Sr, ¹⁹⁸ Au, ²⁰³ Hg, ²¹² Pb, ¹⁶⁵ Dy, ¹⁰³ Ru, ¹⁴⁹ Tb, ¹⁶¹ Tb, ²¹³ Bi, ¹⁶⁶ Ho, ¹⁶⁵ Er, ¹⁶⁹ Er, ¹⁵³ Sm, ¹⁷⁷ Lu, ²¹³ Bi, ²²³ Ra, ²²⁵ Ac, ²²⁷ Ac, ²²⁷ Th, ²¹¹ At, ⁶⁷ Cu, ¹⁸⁶ Re, ¹⁸⁸ Re, ¹⁶¹ Tb, ¹⁷⁵ Yb, ¹⁰⁵ Rh, ¹⁶⁶ Dy, ¹⁹⁹ Au, ⁴⁴ Sc, ^{149 Preferably , M is 177 Lu .}

In certain embodiments, M is associated with a chelating moiety.

Preferred GRP receptor binding compounds are GRP receptor antagonist compounds. Examples of GRP receptor antagonist compounds include RM2, SB3, RM26, BAY-864367, CB-TE2A-AE06, or Pro-BOMB1.

In a preferred embodiment, P is a GRP receptor antagonist portion having the general formula: Xaa1-Xaa2-Xaa3-Xaa4-Xaa5-Xaa6-Xaa7-Z; wherein Xaa1 is absent or selected from the group consisting of the following amino acid residues: Asn, Thr, Phe, 3-(2-thienyl)alanine (Thi), 4-chlorophenylalanine (Cpa), α-naphthylalanine (α-Nal), β-naphthylalanine (β-Nal), 1,2,3,4-tetrahydronorhalman-3-carboxylic acid (Tpi), Tyr, 3-iodotyrosine (oI-Tyr), Trp and pentafluorophenylalanine (5-F-Phe) (all L-isomers or D-isomers); preferably D-Phe, Xaa2 is Gln, Asn or His; preferably Gln, Xaa3 is Trp or 1,2,3,4-tetrahydronorhalman-3-carboxylic acid (Tpi); preferably Trp, Xaa4 is Ala, Ser or Val; preferably Ala, Xaa5 is Val, Ser or Thr; preferably Val, Xaa6 is Gly, sarcosine (Sar), D-Ala, or β-Ala; preferably Gly, Xaa7 is His or (3-methyl)histidine (3-Me)His; preferably His, Z is selected from -NHOH, -NHNH2, -NH-alkyl, -N(alkyl)2, and -O-alkyl, or Z is wherein X is NH (amide) or O (ester), and R1 and R2 are the same or different and are selected from proton, optionally substituted alkyl, optionally substituted alkyl ether, aryl, aryl ether or alkyl-, halogen, hydroxyl, hydroxyalkyl, amine, amino, amide or amide-substituted aryl or heteroaryl groups.

According to an embodiment, P is DPhe-Gln-Trp-Ala-Val-Gly-His-Z; wherein Z is as defined above.

According to an embodiment, P is DPhe-Gln-Trp-Ala-Val-Gly-His-Z, wherein Z is selected from Leu-ψ(CH ₂ N)-Pro-NH ₂ and NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ or Z is wherein X is NH(amide) and R2 is CH(CH ₂ -CH(CH ₃ ) ₂ , and R1 and R2 are the same or different (CH 2 N)-Pro-NH 2 .

As used herein, the term "chelating moiety" refers to an organic moiety comprising a functional group capable of forming a non-covalent bond with a radionuclide M, thereby forming a stable radionuclide complex.

In the context of the present disclosure, the chelating moiety can be obtained by grafting a chelating agent to S or P, wherein the chelating agent is selected from the following list: 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) (Titan), Tritan, 1,4,7,10-tetraazacyclododecane, 1 (pentanedioic acid)-4,7,10-triacetic acid (DOTAGA), diethylenetriaminepentaacetic acid (DTPA), aminetriacetic acid (NTA), ethylenediaminetetraacetic acid (EDTA), 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetra ... Cyclododecane-1,4,7-triacetic acid (DO3A), triethylenetetramine (TETA), 1,4,7-triazacyclononane-1,4,7-triacetic acid (NOTA), NOTAGA, 1-(1,3-carboxypropyl)-4,7-carboxymethyl-1,4,7-triazacyclononane (NODAGA), NODASA, NODAPA, and 1,4-bis(carboxymethyl)-6-[bis(carboxymethyl)]amino-6-methylperhydro-1,4-diazepine (AAZTA, such as AAZTA5).

In a particular embodiment, the chelating moiety C has the formula, , where the wavy bond represents the attachment point of the chelator to the spacer S or to the GRP receptor antagonist P.

This chelating moiety is directly linked to the GRP receptor antagonist moiety, or is linked via a linker molecule or also referred to herein as a spacer S. The one or more connecting bonds are covalent or non-covalent bonds between the GRP receptor antagonist (and the spacer) and the chelating moiety, preferably the one or more bonds are covalent bonds.

The chelating moiety C is typically bonded to the N-terminus of the peptide derivative formula disclosed above, optionally via a spacer S, such as DPhe-Gln-Trp-Ala-Val-Gly-His-Z.

In a specific embodiment, the spacer S is selected from the group consisting of: a) an aromatic group containing a residue having any formula: ; b) a dicarboxylic acid, ω-aminocarboxylic acid, ω-diaminocarboxylic acid or diamine derivative having any of the following formulae: wherein each n independently represents an integer from 0 to 12, for example n = 0, 1, 2, 3 or 4; c) PEG spacers having various chain lengths, in particular PEG spacers selected from any of the following formulae: wherein m is an integer from 1 to 36, for example m = 1, 2, 3 or 4, and p is an integer from 0 to 5, for example p = 0 or 1; d) β-amino acid residues, either as a single chain or as homologous chains of various chain lengths or as heterologous chains of various chain lengths, in particular: ; and/or e) any combination of one or more of a, b, c and/or d.

According to a preferred embodiment, the radiopharmaceutical compound used in the treatment method disclosed herein is selected from the group consisting of radiolabeled compounds having the following formula: wherein C and P are as defined above, and M is a radioactive isotope complexed with the chelating moiety, preferably M is selected from ¹⁷⁷ Lu.

Preferably, the radiopharmaceutical compound used according to the present disclosure is a compound having the following formula (II): (II) wherein C and P are as defined above and C is complexed with the radionuclide M.

According to a particularly preferred embodiment, the radiopharmaceutical compound for use in the method of treatment is M-NeoB having the formula (III): (III), wherein M is as defined above, preferably M is ¹⁷⁷ Lu.

The radiopharmaceutical compound [ ¹⁷⁷ Lu]Lu-NeoB refers to a compound having the formula (III), wherein M is ¹⁷⁷ Lu.

According to an embodiment, the radiopharmaceutical compound is a radiolabeled NeoB2 having the formula (IV): (IV), wherein M is as defined above, preferably ¹⁷⁷ Lu.

According to another specific embodiment, the radiopharmaceutical compound used according to the present disclosure is a compound of formula (I), which is a ProBOMB1 having the following formula (V): (V) It is radiolabeled with M, preferably ¹⁷⁷ Lu.

Many embodiments of the present disclosure encompass combination therapies that preferably utilize [ ¹⁷⁷ Lu]Lu-NeoB as the radiopharmaceutical compound.

The radiopharmaceutical compound is used to treat glioblastoma in a subject in need thereof, wherein a therapeutically effective amount of the radiopharmaceutical compound is administered to the subject.

The individual components or their precursors, typically unlabeled NeoB, may be packaged in a kit or individually. One or both components (e.g., powder or liquid) may be reconstituted or diluted to the desired dosage prior to administration.

In certain embodiments, the radiopharmaceutical compounds for use in the disclosed combination therapies can be formulated as previously described, for example, as described in WO2021/052960. Typically, the combination therapy comprises administering a drug composition consisting of: (a) a complex formed by (ai) a radionuclide ¹⁷⁷ lutetium ( ¹⁷⁷ Lu), and (aii) NeoB having formula (III): (III); and; (b) gentian acid or a salt thereof and ascorbic acid or a salt thereof; (c) polyethylene glycol 15 hydroxystearate, if necessary; (d) acetate buffer; (e) water for injection, and (f) at least one other pharmaceutically acceptable excipient, such as a chelating agent, such as DTPA. Synthesis of compounds of formula (I), (II), (III), (IV) and (V)

Compounds of formula (I), (II), (III), (IV) and (V) can be synthesized using the method disclosed in the following reference: " Positron Emission Tomography Imaging of the Gastrin-Releasing Peptide Receptor with a Novel Bombesin Analogue " ACS Omega 2019, 4, 1470-1478 .

Further information on the synthesis of compounds of formula (V) can be found in WO2021/0608051. Radiotherapy as used in combination therapy

In one embodiment, a method of treating glioblastoma in a subject in need thereof comprises the step of irradiating the subject with an effective dose of ionizing radiation (ie, radiation therapy).

As used herein, the term "radiation therapy" is used to treat neoplastic diseases with irradiation corresponding to ionizing radiation. The energy deposited by ionizing radiation damages or destroys cells in the treated area (target tissue) by damaging the genetic material of the cells, making them unable to continue to grow.

In certain embodiments, the methods of the present disclosure include exposing a tumor to be treated to an effective dose of ionizing radiation, wherein the ionizing radiation is photons, such as X-rays. Depending on how much energy they have, radiation can be used to destroy cancer cells on the surface of the body or deeper in the body. The higher the energy of the X-ray beam, the deeper the X-rays can penetrate into the target tissue. Linear accelerators and electron induction accelerators produce X-rays with increasing energy. Using a machine to focus radiation (such as X-rays) on the cancer site is called external beam radiation therapy.

In an alternative embodiment of the treatment method according to the present disclosure, gamma rays are used. Gamma rays are produced spontaneously when certain elements (such as radium, uranium and cobalt-60) release radiation when they decompose or decay.

Ionizing radiation is typically in the range of 2 keV to 25,000 keV, especially 2 keV to 6,000 keV (6 MeV) or 2 keV to 1,500 keV (e.g., from a cobalt-60 source).

Those skilled in the art of radiotherapy know how to determine appropriate dosing and administration schedules based on the nature of the disease and the patient's constitution. In particular, they know how to assess dose-limiting toxicity (DLT) and how to determine the maximum tolerated dose (MTD) accordingly.

The amount of radiation used in radiation therapy is measured in Gray (Gy) and varies depending on the type and stage of cancer being treated. Typical total doses for solid tumors range from 20 to 120 Gy for curative cases. Radiation oncologists consider many other factors when choosing a dose, including whether the patient is receiving chemotherapy, the patient's comorbidities, whether radiation therapy is given before or after surgery, and how successful the surgery was.

The total dose is typically fractionated (spread out over time). The dose and schedule (ionizing radiation, fractionated dose, fractionated delivery schedule, planning and delivery of total dose alone or in combination with other anticancer agents, etc.) are defined for any disease/anatomical site/disease stage patient background/age and constitute the standard of care for any given situation.

A typical conventional fractionation schedule for adults using the methods of the present disclosure may be 1 Gy to 4 Gy/day, preferably about 2 Gy/day, during a period of 3 to 7 days per week, preferably about 5 days per week, during a period of 4 to 8 weeks, preferably about 6 weeks. In a specific embodiment, the radiation therapy consists of exposing the subject to a total dose of 50 to 70 Gy, for example 60 Gy of ionizing radiation.

In other specific embodiments, the subject is exposed to a dose of about 2 to 12 Gy of ionizing radiation per fraction, and the total dose is preferably administered in up to 6 fractions. In other words, the radiation therapy is performed for 5 consecutive days, followed by 2 days of rest, for 6 consecutive weeks.

Preferably, the subjects will be exposed to the standard of care for treating patients with neuroglioblastoma in combination with temozolomide. This standard of care involves subjecting the subjects to a dose of 2 Gy/day for 5 days, followed by 2 days of rest, for 6 consecutive weeks, for a total dose of 60 Gy.

In certain embodiments where the subject suffers from glioblastoma, the radiation therapy used in the methods disclosed herein is whole brain radiation therapy (WBRT). Alkylating agents as used in combination therapy

The method of treating glioblastoma in a subject in need thereof optionally comprises administering to the subject a radiopharmaceutical compound in combination with radiation therapy and a therapeutically effective amount of an alkylating agent, preferably temozolomide.

Alkylating agents are classified into different classes, including: 1. Nitrogen mustards: such as dichloromethane (mechlorethamine), chlorambucil, cyclophosphamide (Cytoxan®), effulgamide, and chlorambucil; 2. Nitrosoureas: such as streptozotocin, carmustine (BCNU), and lomustine; 3. Alkyl sulfonates: busulfan; 4. Trioxanes: dacarbazine (DTIC) and temozolomide (Temodar®); and 5. Ethylenediamines: thiotepa and hexamethylmelamine (ATM).

As used herein, "temozolomide" refers to a triazine-type alkylating agent, and more particularly refers to a compound having the formula 3,4-dihydro-3-methyl-4-oxoimidazo[5,1-d][1,2,3,5]tetrazolamide-8-carboxamide and its pharmaceutically acceptable salts (CAS No. 85622-93-1). Alkylating agents directly damage DNA (the genetic material in every cell) to prevent cells from multiplying. These drugs act at all stages of the cell cycle and are used to treat many different cancers, including neuroglioblastoma, leukemia, lymphoma, Hodgkin's disease, multiple myeloma and sarcoma, as well as lung, breast and ovarian cancers.

In one embodiment, the alkylating agent, preferably temozolomide, is administered daily during the induction period at a dose of 50 to 100 mg/m²/day, preferably about 75 mg/m²/day, for a period of 4 to 8 weeks, preferably 6 weeks.

As used herein, "induction period" refers to the period of time during which the alkylating agent, preferably temozolomide, is administered to the subject concomitantly with radiation therapy. The induction period may have a duration of up to 11 weeks, for example, from day 1 of week 1 to day 7 of week 11.

Concomitant treatment of glioblastoma with temozolomide and radiation therapy is the standard of care, and temozolomide may be administered according to the prescribing information of the combination therapy disclosed herein.

In one embodiment, both the radiotherapy and the alkylating agent, preferably temozolomide, are started on the same day. In one aspect, the alkylating agent, preferably temozolomide, is administered daily concomitantly with the radiotherapy without interruption. As in a more specific embodiment, both the radiotherapy and the alkylating agent, preferably temozolomide, are started on the same day, 7 to 10 days after the first administration of the radiopharmaceutical compound.

For example, temozolomide is first administered in week 2 and continues until the end of week 7 at a dose of 75 mg/m2/day from the first to the last day of radiation therapy (external beam radiation therapy).

In certain embodiments, the alkylating agent, preferably temozolomide, is administered daily at a first dosing schedule during a period of concomitant administration with radiation therapy (induction period), e.g., for a period of 6 weeks, and is administered at a second dosing schedule during a maintenance period following concomitant administration with radiation therapy, e.g., for a period of up to 24 weeks.

As used herein, "maintenance phase" refers to a period of time beginning after the induction phase or concomitant administration of radiation therapy, with an increase in dose compared to the induction phase dose, e.g., on Day 1 of Week 12, and lasting up to 25 weeks.

In a specific embodiment, during the maintenance period, the alkylating agent, preferably temozolomide, can be administered daily at a dose of 50 to 400 mg/m²/day, preferably 75 to 300 mg/m²/day, more preferably 150 to 200 mg/m²/day, for 5 consecutive days, followed by 2 days of rest, once every 28 days, for a period of 20 to 28 weeks, preferably 24 weeks.

In certain embodiments, the temozolomide dose is increased during the maintenance treatment period. For the same patient, if 150 mg/m2 temozolomide is well tolerated, the temozolomide dose is 150 mg/m2 for 5 days at week 12 and 200 mg/m2 for 5 days each at weeks 16, 20, 24, 28, and 32. More generally, one can follow the approved prescribing information. Combination Therapy

In a specific embodiment, a method of treating glioblastoma in a subject in need thereof comprises administering to the subject a therapeutically effective amount of a radiopharmaceutical compound as described above, preferably [ ¹⁷⁷ Lu]Lu-NeoB, in combination with radiation therapy.

In another embodiment, the present disclosure relates to a method for treating glioblastoma in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of the radiopharmaceutical compound as described above, preferably [ ¹⁷⁷ Lu]Lu-NeoB in combination with radiation therapy and further in combination with a therapeutically effective amount of an alkylating agent, preferably temozolomide.

The present disclosure also relates to the use of a radiopharmaceutical compound in the preparation of a medicament for treating glioblastoma in a subject in need thereof, wherein a therapeutically effective amount of the radiopharmaceutical compound, such as [ ¹⁷⁷ Lu]Lu-NeoB, is administered to the subject simultaneously, separately or sequentially in combination with radiation therapy and, if necessary, a therapeutically effective amount of an alkylating agent, preferably temozolomide.

In various embodiments of the present disclosure, the combination therapy comprises jointly (i) administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising a radiopharmaceutical compound (e.g., [ ¹⁷⁷ Lu]Lu-NeoB); and (ii) irradiating the subject with a therapeutically effective amount of ionizing radiation, and (iii) administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising an alkylating agent, preferably temozolomide.

As used herein, the term "combined" means that the therapeutic agent and the ionizing radiation can be administered separately within a time interval (e.g., in a time-staggered manner, especially in a specific order within such time interval) to show a (preferably synergistic) interaction (i.e., a combined therapeutic effect).

In various embodiments of the disclosure, a combination administration wherein the radiopharmaceutical compound (eg, ¹⁷⁷ Lu-NeoB) and radiation therapy are administered simultaneously or separately within a time interval, particularly where such time intervals allow the combination partners to exhibit a cooperative (eg, synergistic) effect.

In one embodiment, the radiopharmaceutical compound (eg, [ ¹⁷⁷ Lu]Lu-NeoB) is administered 1 to 20 days, preferably 3 to 15 days, more preferably 7 to 10 days prior to the start of radiation therapy.

Administration of the radiopharmaceutical compound may include an administration interval of 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks or even 6 weeks, preferably 3 or 4 weeks, and more preferably once every 4 weeks.

In a specific embodiment, the radiopharmaceutical compound (e.g., [ ^177Lu ]Lu-NeoB) is administered to the subject at least 6 times in combination with radiotherapy and further in combination with temozolomide, and wherein the administration interval between two administrations of the radiopharmaceutical compound is 4 weeks, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before the start of radiotherapy and temozolomide.

In certain embodiments, the radiopharmaceutical compound (e.g., [ ¹⁷⁷ Lu]Lu-NeoB) is administered at a dose in the range of 0.925 GBq (25 mCi) to 29.6 GBq (800 mCi), preferably 1.48 GBq (40 mCi) to 18.5 GBq (500 mCi), preferably 1.85 GBq (50 mCi) to 14.8 GBq (400 mCi), more preferably 3.7 GBq (100 mCi) to 11.1 GBq (300 mCi), even more preferably about 3.7 GBq (100 mCi), about 5.55 GBq (150 mCi), about 7.4 GBq (200 mCi), about 9.25 GBq (250 mCi), or about 11.1 GBq (300 mCi). GBq (300 mCi), e.g., about 5.55 GBq (150 mCi) to about 9.25 GBq (250 mCi).

In certain embodiments, the radiopharmaceutical compound (e.g., [ ¹⁷⁷ Lu]Lu-NeoB) is administered 1 to 10 times/treatment, preferably 4 to 10 times/treatment, and more preferably 6 to 8 times/treatment. For example, the radiopharmaceutical compound (e.g., [ ¹⁷⁷ Lu]Lu-NeoB) is preferably administered 6 to 10 times in a dose range of 5.55 GBq (150 mCi) to 9.25 GBq (250 mCi), once every 4 weeks.

A particularly preferred treatment regimen for combination therapy is shown in Figure 1.

Advantageously, in certain embodiments, the combination of treatment with a radiopharmaceutical compound (e.g., [ ^177Lu ]Lu-NeoB) and radiation therapy and, optionally, an alkylating agent (e.g., temozolomide) increases the overall survival of the subject by at least 10%, 20%, 30%, 40%, or at least 50%, compared to radiation therapy alone or the combination of radiation therapy and an alkylating agent (e.g., temozolomide).

"Overall survival" (OS) is defined herein as the time from the date of the first dose to the date of death of a participant in the clinical study due to any cause, such as disclosed in Example 1. If a participant is not known to have died, overall survival is censored at the latest date that the participant is known to be alive (on or before the cutoff date). OS distribution will be estimated using the Kaplan-Meier method.

In certain embodiments, the combination of treatment with a radiopharmaceutical compound (e.g., [ ^177Lu ]Lu-NeoB) and radiation therapy and, optionally, an alkylating agent (e.g., temozolomide) also increases progression-free survival by at least 10%, 20%, 30%, 40%, or at least 50%, compared to radiation therapy alone or the combination of radiation therapy and an alkylating agent (e.g., temozolomide).

As used herein, the term "progression-free survival" (PFS) is defined as the time from the date of the first dose to the date of confirmed progression or death from any cause according to a modified RANO. If no PFS events were observed, PFS was censored at the data cutoff date and the date of the last adequate tumor assessment before the start of new antitumor therapy, whichever came first. PFS distributions were estimated using the Kaplan-Meier method.

In certain aspects, administration of a composition comprising a radiopharmaceutical compound (e.g., [ ^177Lu ]Lu-NeoB) to a subject eligible for such treatment can inhibit, delay, and/or reduce tumor growth in the subject. In certain aspects, tumor growth is delayed by at least 50%, 60%, 70%, or 80% compared to an untreated control subject. In certain aspects, tumor growth is delayed by at least 80% compared to an untreated control subject. In certain aspects, tumor growth is delayed by at least 50%, 60%, 70%, or 80% compared to the predicted growth of a tumor without treatment. In certain aspects, tumor growth is delayed by at least 80% compared to the predicted growth of a tumor without treatment. Assessment of tumor volume in glioblastoma can be determined by using the modified Response Assessment in Neuro-Oncology (mRANO) criteria, which are adapted from, for example, the International Brain Tumor Imaging Protocol, allowing for 2D and volumetric measurements of enhancing tumors in clinical trials. For additional details, refer to the mRANO criteria (Ellingson BM, Wen PY, Cloughesy TF. Modified Criteria for Radiographic Response Assessment in Glioblastoma Clinical Trials. Neurotherapeutics. 2017 Apr;14(2):307-320. doi: 10.1007/s13311-016-0507-6. PMID: 28108885; PMCID: PMC5398984).

In certain aspects, administration of a composition comprising a radiopharmaceutical compound (e.g., [ ^177Lu ]Lu-NeoB) to a subject eligible for such treatment can increase the subject's length of survival. In certain aspects, the increase in survival is compared to an untreated control subject or a control subject receiving standard of care treatment (e.g., a combination of radiation therapy and temozolomide for patients newly diagnosed with neuroglioblastoma). In certain aspects, the increase in survival is compared to the predicted length of survival for a subject receiving standard of care treatment. In certain aspects, the length of survival is increased by at least 3-fold, 4-fold, or 5-fold as compared to an untreated control subject or a control subject receiving standard of care treatment (such as a combination of radiation therapy and temozolomide for patients newly diagnosed with glioblastoma). In certain aspects, the length of survival is increased by at least one week, two weeks, one month, two months, three months, six months, one year, two years, or three years as compared to a control subject receiving standard of care treatment (such as a combination of radiation therapy and temozolomide for patients newly diagnosed with glioblastoma). In certain aspects, the survival length is increased by at least one month, two months, or three months compared to the predicted survival length of a subject receiving standard of care treatment, such as a combination of radiation therapy and temozolomide in patients newly diagnosed with glioblastoma.

In certain embodiments of the present disclosure, the glioblastoma is a GRPR-positive disease.

In a particular embodiment, subjects are selected for treatment by: SPECT/CT or PET/CT or SPECT/MRI, PET/MRI imaging, using the same compound as defined for said treatment, but wherein M is an alternative radioactive metal or contrast agent suitable for imaging, i.e., an imaging radiopharmaceutical compound, based on the detection of said radionuclide in an imaging scan of the tumor area post-operatively.

Typical radioactive metals suitable for use as contrast agents in imaging include the following: ¹¹¹ In, ^133m In, ^99m Tc, ^94m Tc, ⁶⁷ Ga, ⁶⁶ Ga, ⁶⁸ Ga, ⁵² Fe, ⁷² As, ⁹⁷ Ru, ²⁰³ Pb, ⁶² Cu, ⁶⁴ Cu, ⁶¹ Cu, ¹⁷⁷ Lu, ⁸⁶ Y, ⁵¹ Cr, ^52m Mn, ¹⁵⁷ Gd, ¹⁶⁹ Yb, ¹⁷² Tm, ^117m Sn, ¹²³ I, ¹²⁴ I, ¹²⁵ I, ¹⁸ F, Al ¹⁸ F, ¹⁵² Tb, ¹⁵⁵ Tb, ⁸² Rb, ⁸⁹ Zr, ⁴³ Sc, ⁴⁴ Sc.

According to a preferred embodiment, the radioactive metal suitable for imaging is ⁶⁷ Ga, ⁶⁸ Ga or ⁶⁴ Cu, preferably ⁶⁸ Ga.

In one embodiment, subjects are selected by assessing ⁶⁸ Ga-NeoB uptake in the tumor region (e.g., whole brain) by PET/CT or PET/MRI scanning.

In certain embodiments, the subject eligible for combination therapy is selected from subjects who demonstrate the presence of surrogate radionuclides or contrast enhancement, such as gadoid enhancement, on a postoperative PET/MRI scan of the tumor area.

Typically, a PET scan using a radiopharmaceutical compound labeled with a radiometal suitable for imaging (eg, [ ^68Ga ]Ga-NeoB) can be performed at least 3 days prior to the first administration of the radiopharmaceutical compound for combination therapy.

Therefore, the present disclosure also relates to a method for determining whether a human subject with neuroglioblastoma can be selected for a combination therapy as disclosed herein, the method comprising the following steps: 1.  Administering an effective amount of an imaging radiopharmaceutical compound as a contrast agent to image the uptake of the radiopharmaceutical compound, 2.  Obtaining an image scan by PET/MRI or PET/CT of the patient, and 3.  Comparing with a control image scan.

The purpose of the above selection method is to select patients with GRPR-positive tumors, i.e., which patients are better responders to the combination therapy of the present disclosure. GRPR-positive tumors can be advantageously detected by assessing the uptake of the imaging radiopharmaceutical compound by PET/MRI or PET/CT imaging after injection of the imaging radiopharmaceutical compound as a contrast agent.

As used herein, a good responder is a patient selected from a patient population that shows a statistically better response to treatment than a random patient population (i.e., a population not selected by the selection step of the method of the invention) and/or a patient population that shows fewer side effects of treatment than a random patient population (i.e., a population not selected by the selection step of the method of the invention).

In one aspect, [ ^68Ga ]Ga-NeoB is provided in a kit. The kit can consist of 2 sterile vials as a single dose product: Vial 1: NeoB (active ingredient), 50 μg, powder for solution for injection, to be reconstituted with a solution of gallium chloride-68 (68GaCl3) in HCl eluted from a 68Ge/68Ga generator; Vial 2: reaction buffer. Add vial 2 to the reconstituted vial 1.

An example of such a kit is disclosed in WO 2021053040.

Based on the current activity provided by the generator and the physical decay of the radionuclide (half-life = 68 min), the volume of [ ⁶⁸ Ga]Ga-NeoB solution to be injected corresponding to the amount of radioactivity to be administered was calculated according to the estimated injection time.

In one embodiment, subject selection is performed 10 to 18 days, preferably about 14 days, prior to the first administration of the radiopharmaceutical compound.

In certain embodiments, the imaging radiopharmaceutical is administered as a single intravenous dose of 150 to 250 MBq (4.1-6.8 mCi).

Then, images of the subject's body are obtained by PET/MRI or PET/CT imaging, and the images are compared with control images to identify whether lesions identified by conventional imaging (e.g., by MRI, CT, SPECT, or PET) are also identified by uptake by the imaging radiopharmaceutical compound (i.e., [ ^68Ga ]Ga-NeoB uptake). Typically, PET/MRI or PET/CT imaging is performed 30 to 120 minutes, preferably 60 to 90 minutes, after the imaging radiopharmaceutical compound is intravenously administered to the subject.

In a specific embodiment of the method, the subject selected for the combination therapy of the present disclosure satisfies the following criteria: at least 10%, preferably more than 20%, preferably more than 30%, preferably more than 40%, preferably more than 50%, preferably more than 60%, preferably more than 70%, preferably more than 80% of the lesions detected by conventional imaging of the subject (e.g., by MRI, CT, SPECT or PET) are also identified by imaging radiopharmaceutical compound uptake (e.g., [ ^68Ga ]Ga-NeoB uptake), as determined by PET/MRI or PET/CT imaging in the subject.

In certain embodiments, the term "lesion" refers to a measurable tumor lesion according to the modified RANO criteria, as defined in Ellingson BM, Wen PY, Cloughesy TF. Modified Criteria for Radiographic Response Assessment in Glioblastoma Clinical Trials . Neurotherapeutics . 2017 Apr ; 14 (2):307-320. doi: 10.1007/s13311-016-0507-6. PMID: 28108885; PMCID: PMC5398984 .

Pathological conditions, including brain tumors such as neuroglioblastoma, and chemical or physical stimuli such as surgery, radiation therapy or certain chemotherapeutic agents, may increase the permeability of the blood-brain barrier (BBB), thereby disrupting its integrity (Chen et al., Front. Pharmacol. 2019; 10:86; Deeken and Löscher, Clin. Cancer Res ., 2007; 13(6):1663-74). Thus, in one aspect, the subject is selected from a subject newly diagnosed with neuroglioblastoma and exhibiting blood-brain barrier (BBB) disruption, for example as determined by conventional gadolinium contrast enhancement on magnetic resonance imaging (MRI).

In one aspect, the subject is newly diagnosed with glioblastoma or has recurrent glioblastoma.

Methylation of the O6-methylguanine-DNA methyltransferase (MGMT) promoter has been extensively studied as a predictive and prognostic biomarker for glioblastoma. Methylation of the MGMT promoter results in loss of MGMT protein expression, which reduces DNA repair activity in glioma cells and subsequently leads to sensitivity to alkylating agents such as TMZ (Hegi et al. 2005, N Engl J Med; 352(10):997-1003, Nabors et al. 2020, J Natl Compr Canc Netw; 18(11):1537-1570). Interestingly, MGMT promoter methylation has also been shown to be associated with improved outcome of radiotherapy in glioblastoma in the absence of adjuvant alkylating chemotherapy (Rivera et al. 2010, Neuro Oncol; 12(2):116-21).

Thus, in certain embodiments, subjects are further selected by assessing their methylated O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status. Typically, subjects receiving an alkylating agent, preferably temozolomide, and a combination therapy as disclosed herein can be advantageously selected from subjects with a positive MGMT promoter status. Methods for determining the MGMT promoter status of a subject are disclosed, for example, in Mansouri, Alireza et al. ("MGMT promoter methylation status testing to guide therapy for glioblastoma: refining the approach based on emerging evidence and current challenges." Neuro-oncology Vol. 21, 2 (2019): 167-178. doi:10.1093/neuonc/noy132)

In certain aspects, in such selected subjects having a methylated MGMT promoter, a radiopharmaceutical compound (e.g., [ ^177Lu ]Lu-NeoB) can be administered in combination with concomitant radiation therapy and an alkylating agent, preferably temozolomide, during an induction period, followed by administration of the radiopharmaceutical complex in combination with an alkylating agent, preferably temozolomide, during a maintenance period.

For example, in certain embodiments, the subject is newly diagnosed with neuroglioblastoma and has a positive methylated O-6-methylguanine-DNA methyltransferase promoter state, and the radiopharmaceutical compound, preferably [ ^177Lu ]Lu-NeoB, is administered to the subject in combination with radiation therapy and an alkylating agent, preferably temozolomide.

In a specific embodiment, the subject is newly diagnosed with neuroglioblastoma and has a positive methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject at least 6 times in combination with radiation therapy and further in combination with temozolomide, and wherein the administration interval between two administrations of the radiopharmaceutical compound is 4 weeks, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before the start of radiation therapy and temozolomide.

In a specific embodiment, the subject is newly diagnosed with neuroglioblastoma and has a positive methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject at least 6 times in combination with radiotherapy and further in combination with temozolomide, and wherein the interval between administrations of the radiopharmaceutical compound is 4 weeks, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before the start of radiotherapy and temozolomide, and The alkylating agent, preferably temozolomide, is administered daily during the period of concomitant administration with radiotherapy (induction period) at a first dosing schedule, for example, for a period of 6 weeks, and is administered during the maintenance period after concomitant administration with radiotherapy at a second dosing schedule, for example, for a period of up to 24 weeks.

Preferably, temozolomide is administered one week prior to administration of the radiopharmaceutical compound (typically [ ^177Lu ]Lu-NeoB) during the maintenance treatment period.

Suitable dosing regimens of alkylating agents, particularly temozolomide, during the induction and maintenance phases are disclosed, for example, in the previous section related to alkylating agents used in combination therapy.

Hereinafter, other aspects of the combination therapy disclosed herein are described in more detail and with specific reference to the Examples, however, such Examples are not intended to limit the present invention. Examples Example 1 : Clinical Study for the Treatment of Glioblastoma Subjects Provided herein is a protocol example describing a Phase Ib dose-finding study evaluating the safety and activity of [ ^177Lu ]Lu- NeoB in combination with radiation therapy and temozolomide in subjects newly diagnosed with glioblastoma with either methylated or unmethylated promoter status of MGMT. Short title Phase 1b dose-finding study evaluating the safety and activity of [177Lu]Lu-NeoB in combination with radiation therapy and temozolomide in subjects newly diagnosed with glioblastoma with either MGMT methylated or unmethylated promoter status Sponsors and clinical stage Novartis, Phase Ib Study Type intervention Purpose This study aimed to investigate different doses of [ ^177Lu ]Lu-NeoB in combination with radiotherapy (RT) and temozolomide (TMZ) in participants newly diagnosed with glioblastoma (GBM) with methylated or unmethylated promoter status, to evaluate the safety and efficacy of [ ^177Lu ]Lu-NeoB in combination with SoC to identify a recommended dose, and also to investigate the safety of the PET imaging agent [ ^68Ga ]Ga-NeoB and characterize its uptake in the tumor area. One or more primary goals Dose-escalation phase: to identify the recommended dose (RD) of [177Lu]Lu-NeoB in combination with RT and TMZ in participants newly diagnosed with GBMDose -expansion phase: to further characterize the safety and tolerability of [ ^177Lu ]Lu-NeoB RD in combination with RT and TMZ in participants newly diagnosed with GBM Secondary Goals In dose escalation: characterize the safety and tolerability of [ ^177Lu ]Lu-NeoB in combination with RT and TMZ In dose escalation and dose expansion: characterize the PK and biodistribution (dosimetry) of [ ^177Lu ]Lu-NeoB in combination with RT and TMZ In dose expansion: evaluate the preliminary antitumor activity of [ ^177Lu ]Lu-NeoB in combination with RT and TMZ in patients treated with RD In dose escalation and dose expansion: evaluate the safety and tolerability of [ ^68Ga ]Ga-NeoB Trial Design: 1. Single-arm, Phase Ib, multicenter, dose-finding study in expansion phase 2. Newly diagnosed neuroglioblastoma 3. Open label 4. Allocation to dose escalation and expansion queues 5. Review Group: Dose Escalation Committee and Study Steering Committee Brief Overview:

Glioblastoma (GBM) is the most common and aggressive type of primary brain tumor with a high mortality rate. The current standard of care (SoC) for newly diagnosed GBM includes the alkylating agent temozolomide (TMZ) in combination with radiation therapy (RT). The hypothesis of this study is to improve patient outcomes by combining the current standard of care with the radioligand therapy [ ^177Lu ]Lu-NeoB. Patients included in this trial will be treated with the standard regimen of TMZ and RT in combination with [ ^177Lu ]Lu-NeoB every 4 weeks for up to 32 weeks. In special circumstances, if patients tolerate and benefit from [ ^177Lu ]Lu-NeoB, they can receive up to 10 doses, allowing treatment to be continued for up to 37 weeks. During this time period, regular safety and efficacy assessments are planned to be performed weekly. The primary objectives of this trial are to estimate the recommended dose of [ ^177Lu ]Lu-NeoB in combination with TMZ and RT in participants newly diagnosed with GBM and to characterize the safety and tolerability of this treatment. Therefore, patients will be enrolled and treated at increasing dose levels, and all available data will be used to determine the recommended dose. In the expansion cohort, additional patients will be treated to further characterize safety and tolerability, and preliminary efficacy data will be collected from this cohort. Contrast-enhanced MRI assessments are recommended to be repeated every 8 weeks, and the effects of study treatment on patient-reported symptoms and tolerability will be assessed using a patient-reported outcome (PRO) questionnaire. All patients will be visited for up to an additional 5 years following treatment for safety, disease progression, and survival. Study Treatments and Treatment Modalities:

In this study, the term "study drug" refers to [ ⁶⁸ Ga]Ga-NeoB, used as a radioligand imaging compound to explore the expression of GRPR, and [ ¹⁷⁷ Lu]Lu-NeoB, used as a radioligand therapy. The term "study treatment" refers to the combination of [ ¹⁷⁷ Lu]Lu-NeoB, temozolomide (TMZ), and radiation therapy (RT).

Study Duration: During the 60-month visit period (starting from the last dose of study treatment), participants will be monitored for safety (8 weeks after the last dose of [ ^177Lu ]Lu-NeoB and 4 weeks after the last dose of TMZ) and for efficacy every 8 weeks with contrast-enhanced MRI until disease progression is confirmed. Survival visits will be monitored every 12 weeks thereafter.

Duration of Treatment: [ ^177Lu ]Lu-NeoB is given every 4 weeks, starting on Day 1 of Week 1, for a maximum of 6 doses. In special cases, if patients tolerate and benefit from [ ^177Lu ]Lu-NeoB, they may receive up to 4 additional doses.

Treatments of Interest: The term "study drug" refers to [ ⁶⁸ Ga]Ga-NeoB, used as a radioligand imaging compound to explore the expression of GRPR, and [ ¹⁷⁷ Lu]Lu-NeoB, used as a radioligand therapy. The term "study treatment" refers to the combination of [ ¹⁷⁷ Lu]Lu-NeoB, radiation therapy (RT), and temozolomide (TMS).

Number of Participants: Approximately 42 participants will be included, with a maximum of 21 participants in the dose escalation phase and approximately 15 participants in the dose expansion phase. Key Inclusion Criteria: 1. Must provide signed informed consent prior to study participation 2. Histologically confirmed glioblastoma according to WHO classification established after surgical resection or biopsy 3. Adequate bone marrow and organ function as defined by the following laboratory values obtained ≤ 14 days prior to receiving study treatment 4. Presence of gadolinium enhancement in the tumor area on preoperative MRI 5. Karnofsky performance status ≥ 60% Key Exclusion Criteria 6. Additional, concomitant, or active therapy for glioblastoma outside of this study 7. Administration of a radiopharmaceutical with therapeutic intent within a time period corresponding to 10 half-lives of the radionuclide used prior to injection of [ ⁶⁸ Ga]Ga-NeoB 8. History or current diagnosis of impaired cardiac function 9. History of another active malignant tumor within 3 years before study entry 10. Known hypersensitivity reaction to any study treatment, its formulations or dacarbazine Treatment Group:

[ ^177Lu ]Lu-NeoB will be given every 4 weeks, starting on Day 1 of Week 1, for a maximum of 6 doses. Participants who tolerate and benefit from [ ^177Lu ]Lu-NeoB may receive up to 10 doses. TMZ and RT administration will begin 7 to 10 days after the first dose of [ ^177Lu ]Lu-NeoB.

TMZ will be administered orally at a dose of 75 mg/m2/day during the concomitant period of RT according to the approved prescribing information. RT will be delivered at a dose of 2 Gy/day, 5 days per week (followed by 2 days of rest) for 6 consecutive weeks. Example 2 : Rationale for the Study Non-clinical Biodistribution and Drug Metabolism and Pharmacokinetics

The biodistribution of [ ^177Lu ]Lu-NeoB has been evaluated in vivo in healthy mice and in tumor-bearing models. NeoB is rapidly cleared from the blood and eliminated via the renal system with no retention in vivo. Background radioactivity observed in tissues expressing GRPR (primarily the pancreas) decreased over time, as expected for an antagonist. In contrast, tumor uptake remained high at all time points evaluated, resulting in an increased tumor/background ratio.

Pathological conditions, including brain tumors (i.e., neuroglioblastoma) as well as chemical or physical stimuli such as surgery, RT, and certain chemotherapeutic agents, may increase blood-brain barrier (BBB) permeability, thereby disrupting its integrity (Chen et al. 2019 supra, Deeken and Löscher 2007 supra). In brain tumors, BBB dysfunction has been detected on conventional gadolinium contrast-enhanced magnetic resonance imaging ( MRI ) (Sarkaria et al., Neuro. Oncol ., 2018 Jan 22;20(2):184-191). In this study, participants who show contrast enhancement on MRI will be selected to ensure that the BBB is disrupted and that the study agent [ ^177Lu ]Lu-NeoB can permeate through. In addition, [ ¹⁷⁷ Lu]Lu-NeoB will be administered concomitantly with chemotherapy and radiotherapy.

[ ^177Lu ]Lu-NeoB induces cell damage primarily through free radical formation in GRPR-positive tumors and their adjacent cells.

Based on the results of in vitro drug-drug interaction (DDI) studies, [ ^177Lu ]Lu-NeoB is not considered to have the potential for CYP- or transporter-mediated drug-drug interactions .

Nonclinical studies were performed using a nonradioactive surrogate [ ^175Lu ]Lu-NeoB formulation and supported the absence of pharmacological activity of the NeoB peptide. No adverse effects were observed in safety pharmacology studies. Similarly, no signs of toxicity were reported after acute or repeated administration of [ ^175Lu ]Lu-NeoB, confirming the safety of the nonradioactive molecule. Clinical Experience with [ ^177Lu ]Lu-NeoB

NeoRay (EUDRACT No. 2018-004727-37) is an ongoing Phase I/IIa, open-label, multicenter study evaluating the safety, tolerability, systemic distribution, radiation dosimetry, and antitumor activity of [ ^177Lu ]Lu-NeoB administered in patients with advanced solid tumors known to overexpress GRPR.

In the NeoRay study, as of October 11, 2022, [ ^177Lu ]Lu-NeoB has been administered to 11 patients. Patients included in the first cohort received a first dose (Cycle 1) of 1.85 GBq (50 millicuries (mCi)) of [ ^177Lu ]Lu-NeoB. Based on the clinical dosimetry in Cycle 1, patients were dosed to 150 mCi [ ^177Lu ]Lu-NeoB starting in Cycle 2. Each treatment cycle had a duration of 6 weeks.

Dose level 1 (50 mCi in cycle 1 and 150 mCi in subsequent cycles) was evaluated in 3 patients with breast cancer, prostate cancer, and GIST cancer, respectively. 2 patients received 2 cycles, and 1 patient received 6 cycles. Overall treatment was well tolerated, with no dose-limiting toxicities (DLTs) or SAEs reported.

Dose level 2 evaluated 300 mCi per cycle and enrolled 4 patients, 2 with prostate cancer and 2 with GIST. 2 patients received 1 cycle, 1 patient received 2 cycles, and 1 patient received 3 cycles. 2 of the 4 enrolled patients experienced DLTs (grade 3 anemia in both patients and grade 3 encephalopathy in 1 patient). All of these events resolved. One of the grade 3 anemia events occurred in a patient with prostate cancer who had extensive bone metastases at screening and persistent grade 2 anemia (for which the subject also received red blood cell transfusions before starting treatment); the patient developed grade 3 anemia on day 36 after the transfusion and subsequently developed grade 4 thrombocytopenia while in the midst of progressive disease; the patient discontinued treatment, with anemia temporarily improving to grade 2 with supportive therapy, and death, which continued with grade 4 thrombocytopenia, was due to progressive disease. Two DLTs were recorded in one patient affected by GIST (grade 3 anemia and grade 3 encephalopathy), with onset within one week after the first treatment dose. The patient had extensive hip metastases and grade 1 anemia at baseline. The patient was noted to have left facial paralysis and mental alterations with grade 2 vomiting and grade 3 hyponatremia; a brain MRI ruled out stroke and brain metastases. Three days later, the patient also developed seizures. The patient was being treated with very high doses of diazepam, which was discontinued a few days after the [ ^177Lu ]Lu-NeoB infusion, raising suspicion of withdrawal syndrome as a confounding factor. No other significant toxicities were reported, and the patient received only one [ ^177Lu ]Lu-NeoB infusion.

DLTs were observed at dose level 2 and the dose was reduced to 250 mCi (dose level 3) per protocol decision. Dose level 3 was evaluated in 4 patients (2 affected by GIST, 1 affected by prostate cancer, and 1 affected by glioblastoma). The glioblastoma patient received 3 cycles, one of the GIST patients received 2 cycles and both patients discontinued treatment due to disease progression, while the other 2 patients (GIST and prostate cancer) each received 2 cycles and treatment is ongoing. Overall treatment was well tolerated with most reported AEs being mild/moderate, and no DLTs and SAEs were reported.

At the dose levels evaluated, two prolonged disease stabilizations were observed: approximately one year for GIST patients and five months for prostate cancer patients.

Of the 11 treated patients in the study, 3 patients completed treatment, 2 patients discontinued treatment due to AEs, 3 discontinued treatment due to progressive disease (PD), 1 patient decided to stop treatment, and 2 patients are ongoing treatment.

Preliminary blood radioactivity PK of [ ^177Lu ]Lu-NeoB from NeoRay showed rapid elimination from the systemic circulation, with a geometric mean elimination half-life of approximately 60-80 hours and a mean effective half-life of approximately 48 hours. Radio-HPLC data showed signs of metabolism in the systemic circulation and urine (probably pharmacologically inactive metabolites that are unable to bind to receptors), however cumulative excretion of activity indicated that the radioactivity was primarily (average ≥ 80%) excreted via the kidney within 24-48 hours.

Preliminary dosimetry results demonstrate favorable biodistribution and low uptake in organs considered at risk due to GRPR expression (e.g., pancreas) or due to RLT (e.g., red bone marrow) and excretion pathway (e.g., kidney). The dose-normalized mean absorbed dose in Gy/GBq (rounded to 2 significant figures) (± SD, n = 10) across all studied dose levels was 0.11 ± 0.059 (kidney), 0.019 ± 0.0066 (red bone marrow), 0.063 ± 0.038 (pancreas), 0.011 ± 0.0034 (testis, n = 7), 0.021 ± 0.0077 (ovary, n = 3), and 0.72 ± 0.94 (all tumor lesions, n = 18).

Based on the safety and biodistribution profile at 250 mCi, a protocol-based decision was made to re-escalate to 300 mCi. The study is ongoing and enrolling patients to receive the 300 mCi dose level per cycle. Study updates as of June 7, 2023

As of June 7, 2023, [177Lu]Lu-NeoB has been administered to 17 patients according to Table 1. Patients included in the first cohort received a first dose (Cycle 1) of 50 mCi (1.85 GBq) of [177Lu]Lu-NeoB. In dose level (DL) 1, patients were escalated to 150 mCi [177Lu]Lu-NeoB based on clinical dosing in Cycle 1. [ Table 1]. Patients included in the cohort in NeoRay

DL1 (50 mCi in cycle 1 and 150 mCi in subsequent cycles) did not result in any significant toxicity (no serious adverse events (SAEs)). The breast cancer patient included in this cohort was a 54-year-old female first diagnosed with stage IV HR+/HER2+ invasive ductal carcinoma with multiple bone metastases in May 2018. The patient had received prior mastectomy, radiation therapy, and multiple lines of therapy (including palbociclib + ET, trastuzumab, pertuzumab, fulvestrant, capecitabine, and everolimus + ixemestane) before inclusion in the study. The patient discontinued study treatment after 2 doses of [ ^177Lu ]Lu-NeoB due to disease progression.

In the second cohort of patients who received dose level 2 (300 mCi), 2 of 4 enrolled patients experienced dose-limiting toxicities (DLTs) (grade 3 anemia in both patients and grade 3 encephalopathy in one patient). All of these events have resolved.

A DLT was observed at dose level 2, and a protocol-based decision was made to reduce the dose to 250 mCi (dose level 3).

Dose level 3 was initially evaluated in 4 patients at 250 mCi, and treatment was generally well tolerated with most reported AEs being mild/moderate, and no DLTs and SAEs reported.

Given the overall favorable safety profile on DL3, the decision was made to re-escalate the dose in queue 4 to 300 mCi. Only one patient with GBM was enrolled and experienced moderate (grade 2) nausea, severe (grade 3) vomiting, and ‘neurological decline’ (grade 3) (preferable term: neurologic impairment) 5 days after the first dose of study treatment, leading to hospitalization the next day. All events were considered by the investigator to be serious and possibly related to [ ^177Lu ]Lu-NeoB. Neurological decline met the definition of a DLT. New events of grade 2 nausea and grade 3 vomiting were experienced 12 days after the first dose of study treatment, while the AE of neurologic impairment worsened to grade 4. Although the nausea and vomiting events resolved rapidly on the second day, the neurologic events worsened to Grade 4 despite increased dexamethasone therapy, leading to discontinuation of treatment and continuing at the time of the patient’s death by active euthanasia. Considering that the first patient treated in this new cohort experienced a DLT (neurologic decline) at 300 mCi, and considering that 2 other patients in the previous cohort experienced DLTs (anemia and encephalopathy) at 300 mCi (DL2), the dose was reduced to 250 mCi (DL3) per protocol, and cohort 5 was opened for enrollment.

As of June 7, 2023, a total of 5 patients were enrolled in Cohort 5 at the 250 mCi dose (DL3), 4 of whom had GIST and 1 had prostate cancer indications. No patient in Cohort 5 experienced any DLT or SAE. Reported AEs were mild or moderate in severity. Laboratory abnormalities ≥ Grade 2 were not clinically significant.

Among the dose levels evaluated, two prolonged disease stabilizations (approximately one year in GIST patients and five months in prostate cancer patients) were observed in cohort 1 (50 mCi and 150 mCi).

Of the 17 treated patients in the study, 4 patients completed treatment, 2 patients discontinued treatment due to AEs, 7 patients discontinued treatment due to PD, 3 patients discontinued treatment due to investigator/patient decision, and 1 patient is ongoing treatment.

Preliminary blood radiopharmacokinetics of [ ¹⁷⁷ Lu]Lu-NeoB from NeoRay showed rapid elimination from the systemic circulation, with a geometric mean elimination half-life of approximately 55-80 h, and a mean effective half-life of approximately 44 h. Radio-HPLC data showed signs of metabolism in the systemic circulation and urine (probably pharmacologically inactive metabolites that are unable to bind to receptors), and cumulative excretion of activity indicating that the radioactivity is still primarily (average ≥ 80%) excreted via the kidney within 24-48 hours. Metabolites in plasma will be studied.

Preliminary dosimetry results demonstrate favorable biodistribution and low uptake in organs considered at risk due to GRPR expression (e.g., pancreas) or due to RLT (e.g., red bone marrow) and excretion pathway (e.g., kidney). The observed dose-normalized mean absorbed dose in Gy/GBq from all cohorts (rounded to 2 significant figures) (± SD, n = 13) was 0.10 ± 0.056 (kidney), 0.018 ± 0.0076 (red bone marrow), 0.056 ± 0.038 (pancreas), 0.011 ± 0.0041 (testis, n = 10), 0.021 ± 0.0094 (ovary, n = 3), and 0.53 ± 0.84 (all tumor lesions, n = 28).

Given the overall favorable safety profile of DL3, the decision was made to re-escalate the dose in queue 4 to 300 mCi. Only one patient with GBM was enrolled and experienced moderate (grade 2) nausea, severe (grade 3) vomiting, and 'neurological decline' (grade 3) (PT: neurologic impairment) 5 days after the first dose of study treatment, leading to hospitalization on the second day. All events were considered by the investigator to be serious and possibly related to [ ^177Lu ]Lu-NeoB. Neurological decline met the definition of a DLT. Considering that the first patient treated in this new cohort experienced a DLT (neurological decline) at 300 mCi, and considering that 2 other patients in the previous cohort experienced DLTs (anemia and encephalopathy) at 300 mCi (DL2), the dose was reduced to 250 mCi (DL3) per protocol. As of January 29, 2023, enrollment of patients in cohort 5 at 250 mCi is ongoing, and 2 additional patients affected by GIST (6 total) have received 1 cycle of [177Lu]Lu-NeoB at this DL with no reported DLTs.

The generated Phase I dosing data demonstrated a favorable [ ¹⁷⁷ Lu]Lu-NeoB organ dosing spectrum with a large safety margin compared to the EBRT threshold, even at high cumulative activity. Therefore, based on the safety and tolerability data observed at the dose levels tested, the MTD was established to be 250 mCi every 6 weeks. Novartis AG and the participating investigators announce that the recommended Phase II dose (RP2D) is 250 mCi and will be further tested in the Phase IIa portion of the FIH study CAAA603A12101. Clinical Experience with [ ⁶⁸ Ga]Ga-NeoB

[ ^68Ga ]Ga-NeoB has demonstrated favorable technical and diagnostic performance in both preclinical and clinical studies to identify malignant tumors expressing GRPR, with good image quality and ease of interpretation. The [ ^68Ga ]Ga-NeoB PET agent has been evaluated in two completed clinical trials and is currently being evaluated in one ongoing trial: A Phase I/IIa clinical trial (MITIGATE; EudraCT number 2016-002053-38) designed to evaluate the safety, biodistribution, dosimetry, and preliminary diagnostic performance of [ ^68Ga ]Ga-NeoB in patients with advanced GIST pretreated with tyrosine kinase inhibitors. [ ⁶⁸ Ga]Ga-NeoB was well tolerated in all 9 participants, and no adverse events related to [ ⁶⁸ Ga]Ga-NeoB were reported. Radiation exposure was low due to rapid clearance from the kidney and blood. Biodistribution showed high [ ⁶⁸ Ga]Ga-NeoB uptake in the pancreas, followed by the kidney and liver. Rapid, visually moderate to high tumor-specific uptake was identified in lesions expressing GRPR.

A phase II clinical trial (NeoFIND; EudraCT number 2017-003432-37) evaluated the preliminary diagnostic performance of [ ^68Ga ]Ga-NeoB in 19 patients with breast cancer (n = 5), prostate cancer (n = 5), colorectal cancer (n = 5), non-small cell lung cancer (n = 3), and small cell lung cancer (n = 1). The safety profile of [ ^68Ga ]Ga-NeoB was confirmed in this study. The results indicated that there was variable [ ^68Ga ]Ga-NeoB uptake in tumor lesions, with breast cancer patients having the highest number of lesions showing visually moderate to high uptake.

[ ⁶⁸ Ga]Ga-NeoB is currently used in the ongoing Phase I/IIa NeoRay study (EudraCT number 2018-004727-37) as an imaging agent in patients selected for treatment with [ ¹⁷⁷ Lu]Lu-NeoB. As of October 11, 2022, 41 patients have received [ ⁶⁸ Ga]Ga-NeoB and no safety issues related to [ ⁶⁸ Ga]Ga-NeoB have been reported, with doses of 150-250 MBq administered.

In this study, [ ⁶⁸ Ga]Ga-NeoB will be explored as a positron emission tomography (PET) agent for imaging tumor regions before treatment with [ ¹⁷⁷ Lu]Lu-NeoB and during disease progression. Rationale for targeting GRPR in glioblastoma

The presence of GRPR has been confirmed in various glioma cell lines (Sharif et al., Mol. Cell Endocrinol , 1997; 130:119-130; Farias CB et al., Oncology , 2008; 75(1-2):27-31). Immunohistochemical ( IHC ) staining studies evaluated the expression of GRPR in gliomas of different WHO grades as well as in normal human brain (34 samples from glioma patients (24 of which were glioblastoma multiforme) and 9 samples of normal brain tissue from 9 autopsies were selected). GRPR was detected in 100% of the samples analyzed. High GRPR expression was also observed in tumor endothelial cells. GRPR was not detected in glial cells of normal brain tissue samples; 10%–50% of neuronal cells showed varying degrees of GRPR expression (Flores et al., 2010, Brain Res Bull; 82(1-2):95-8).

Dynamic PET imaging studies were performed using the [ ^68Ga ]Ga-bellofugin analog [ ^68Ga ]Ga-BZH3 in patients with a high suspicion of recurrent glioma. All three WHO grade IV astrocytomas showed visibly increased [ ^68Ga ]Ga-BZH3 uptake (Dimitrakopoulou-Strauss et al., Clin. Nucl. Med ., 2011 Feb;36(2):101-8). Another imaging study evaluated receptor expression levels in glioma patients using the GRPR-targeted, ^68Ga -labeled bellofugin (BBN) peptide derivative PET tracer NOTA-Aca-BBN (denoted [ ^68Ga ]Ga-BBN). Twelve patients diagnosed with glioma by contrast-enhanced MRI underwent PET/CT after injection of [ ^68Ga ]Ga-BBN. Within one week, the tumors were surgically resected, and tumor samples were stained for GRPR by IHC and correlated with the PET/CT results. In the 12 patients with glioma (glioblastoma multiforme, n = 2), all MRI-identified lesions showed high signal intensity on [ ^68Ga ]Ga-BBN PET/CT. The tumor-to-background ratios based on the maximum SUV and the mean SUV were 24.0 ± 8.85 and 13.4 ± 4.54, respectively, with normal brain tissue as the background. IHC staining confirmed a positive correlation between SUV and GRPR expression levels (r2 = 0.71, P < 0.001). No significant difference in SUV was found between lesions of different WHO grades (Zhang et al., J. Nucl. Med ., 2018 Jun;59(6):922-928).

In conclusion, GRPR was highly expressed in glioblastoma multiforme samples by IHC staining. In addition, imaging studies using ^68Ga -labeled BBN analogs showed robust uptake in patients with high-grade gliomas, including GBM. For radiosensitive tumors like glioblastoma, delivery of radiation in combination with current SoCs (RT and TMZ) by targeting specific receptors overexpressed in glioblastoma cancer cells may improve treatment outcomes in subjects newly diagnosed with glioblastoma and therefore warrant further study. The ultimate treatment goal for this patient population is to prolong survival, but current treatment alternatives offer limited benefit.

In some embodiments, the combination of the disclosed GRPR radiopharmaceuticals with radiation and optionally other agents provides a synergistic effect for treating glioblastoma.

The dose escalation phase started with 100 mCi (3.7 GBq) of [ ^177Lu ]Lu-NeoB every 4 weeks (Q4W). Based on data from NeoRay 50 mCi (Cycle 1) + 150 mCi, [ ^177Lu ]Lu-NeoB Q6W was well tolerated as a monotherapy with no DLTs and G3/4 adverse events. The absorbed radiation doses to critical organs (kidney, pancreas, red bone marrow, testis, ovary) were low, indicating a low risk of radiation-related toxicity from a single administration.

GBM is an aggressive and rapidly growing tumor with high mortality and low long-term survival rates, and rapid disease progression (i.e., less than 7 months in newly diagnosed patients). Therefore, [ ^177Lu ]Lu-NeoB will be administered at a shorter interval of Q4W compared to the Q6W schedule in the NeoRay first-in-human study. The shorter interval will enable administration of sufficient cycles of radioligand therapy to achieve a potentially effective cumulative dose over an appropriate period of time.

Although the contribution of [ ^177Lu ]Lu-NeoB frequency to safety has not been fully investigated, safety reviews of blood laboratory parameters over time after [ ^177Lu ]Lu-NeoB administration showed no trend toward decrease or worsening of hematological parameters. Therefore, there is no need to allow a recovery period between administrations, and there are no data to suggest that a higher frequency of administration will enhance the safety of a single administration, especially because the radioactivity associated with [ ^177Lu ]Lu-NeoB is rapidly cleared from the body. Therefore, Q4W is considered an acceptable frequency of administration for [ ^177Lu ]Lu-NeoB.

Based on the above information and given that [ ^177Lu ]Lu-NeoB will be used in combination with RT and TMZ and that the dosing frequency will be reduced to Q4W days compared to Q6W in monotherapy (NeoRay study), the study will be initiated with a dose of 100 mCi.

In this study, [ ^177Lu ]Lu-NeoB was administered 6 times every 4 weeks. Based on currently available dosimetric data from the three study dose levels (150 mCi, 250 mCi, and 300 mCi) in the FIH study, the mean cumulative absorbed doses in the kidney, pancreas, red bone marrow, testis, and ovary were significantly below the external beam radiation therapy (EBRT) threshold. The margin for 6 cycles of 11.1 GBq (300 mCi) [ ¹⁷⁷ Lu]Lu-NeoB (the highest radiation dose studied to date) is approximately 9–10 times that of the pancreas (40 Gy EBRT threshold; ICRP 118 et al. 2012), approximately 1.6 times that of the red bone marrow (2 Gy EBRT threshold; Howard et al. 2017), 1.3–2 times that of the testis and ovary (1 Gy and 3 Gy EBRT thresholds; De Felice et al., 2019; Husseinzadeh et al., 1994; Chambers SK), and 3 times that of the kidney (23 Gy EBRT threshold; Emami et al. 1991, Emami 2013, ICRP 2012). The calculations are based on the average absorbed doses cited in chapter 2.2 and the EBRT thresholds mentioned above. The lower the starting dose, the higher the margin proportionally.

However, these EBRT limitations may be overly conservative in their application to RLT due to the inherent differences between external beam radiation therapy and radionuclide therapy, including different dose rates and fractionation schedules, uneven absorbed dose distribution, and the potential for different radiobiological mechanisms of cytotoxicity leading to different biological effects (Wessels et al. 2008, J Nucl Med; 49(11):1884-99; Bergsma et al. 2016 Eur J Nucl Med Mol Imaging; 43(3):453-63; Bergsma et al. 2016, Eur J Nucl Med Mol Imaging; 43(10):1802-11). In fact, there is growing evidence that a biologically effective dose (BED) of approximately 40 Gy is safe for the kidney in the case of 177Lu-labeled RLT, with a conversion factor of 1.09 for converting absorbed dose to BED (Bodei, 2008, Eur J Nucl Med Mol Imaging; 35(10):1847-56; Schäfer 2022, Extensive 177Lu-PSMA Radioligand Therapy Can Lead to Radiation Nephropathy with a Renal Thrombotic Microangiopathy-like Picture. Eur Urol). Therefore, even beyond 6 cycles, there may be minimal concern about radiation-induced toxicity because organs may be able to tolerate higher radiation doses.

Based on the above evidence, administration beyond 6 cycles is warranted. Therefore, in this study, 4 additional administrations of [ ^177Lu ]Lu-NeoB beyond the planned 6 administrations could be considered based on individual benefit-risk assessment by the treating physician and agreement with the study participant, based on treatment tolerability, clinical benefit, and participant willingness to continue taking [ ^177Lu ]Lu-NeoB, and agreement with the sponsor.

For each of the 4 additional [ ^177Lu ]Lu-NeoB administrations beyond the 6 doses, the investigator should determine: • whether the participant shows evidence of disease stability or response (i.e., radiographic or clinical assessment), • whether the participant does not show any signs or symptoms of clinical worsening • whether the participant tolerates the [ ^177Lu ]Lu-NeoB treatment well, with no documented [ ^177Lu ]Lu-NeoB-related SAEs that are not resolved before the next [ ^177Lu ]Lu-NeoB dose and lead to treatment discontinuation.

If the patient meets all of the above criteria and agrees to continue further treatment with [ ^177Lu ]Lu-NeoB, the investigator may administer up to 4 additional (i.e., up to a total of 10) [ ^177Lu ]Lu-NeoB administrations in consultation with the sponsor. Study Treatment

In this clinical study, the term “investigational drug” refers to [ ⁶⁸ Ga]Ga-NeoB, used as a radioligand imaging compound to explore the expression of GRPR, and [ ¹⁷⁷ Lu]Lu-NeoB, used as a radioligand therapy.

The term "study treatment" refers to the combination of [ ^177Lu ]Lu-NeoB, temozolomide (TMZ), and radiation therapy (RT). Study / control drug (name/strength) Drug dosage form Investment channels [ ¹⁷⁷ Lu]Lu-NeoB 370MBq/mL (10 mCi/mL) Radiopharmaceutical solutions for infusion Intravenous use [ ⁶⁸ Ga]Ga-NeoB (50 ug) Available as a set Intravenous use For the preparation of [68Ga]Ga-NeoB radiopharmaceuticals or as ready-to-use radiopharmaceutical solutions for injection Temozolomide (TMZ) Capsules/lyophilized powder in single-dose vials for reconstitution*. Oral use/intravenous use [ ^177Lu ]Lu-NeoB

[ ¹⁷⁷ Lu]Lu-NeoB is a sterile radiopharmaceutical supplied as a ready-to-use solution for infusion containing [ ¹⁷⁷ Lu]Lu-NeoB with a volumetric activity of 370 megabecquerels (MBq)/mL at a reference date and time (calibration time (tc)). The starting dose level of [ ¹⁷⁷ Lu]Lu-NeoB is 100 mCi.

[ ^177Lu ]Lu-NeoB is given every 4 weeks, starting on Day 1 of Week 1, for a maximum of 6 doses. In special circumstances, if patients tolerate and benefit from [ ^177Lu ]Lu-NeoB, they may receive up to 10 doses, with additional details outlined in Section 4.3. [ ^177Lu ]Lu-NeoB does not allow for intravenous dose escalation in patients.

TMZ and RT administration will begin 7 to 10 days after the first dose of [ ^177Lu ]Lu-NeoB. TMZ will be administered orally at a dose of 75 mg/m2/day during the concomitant period of RT according to the approved prescribing information.

RT will be delivered at a dose of 2 Gy/day, 5 days per week (followed by 2 days of rest) for 6 consecutive weeks, for a total dose of 60 Gy (without interruption).

During the maintenance treatment period, the TMZ dose will be increased in patients. For the same patient, if 150 mg/m2 TMZ treatment is well tolerated, the TMZ dose will be 150 mg/m2 for 5 days at Week 12 and 200 mg/m2 for 5 days each at Weeks 16, 20, 24, 28, and 32. For additional information, refer to the approved prescribing information. [ ^68Ga ]Ga-NeoB

The radiopharmaceutical kit for [ ⁶⁸ Ga]Ga-NeoB contains 50 μg of NeoB. In this study, [ ⁶⁸ Ga]Ga-NeoB will be used as an imaging agent for PET/CT or PET/MRI.

After radiolabeling with Ga-68, [ ⁶⁸ Ga]Ga-NeoB will be used for positron emission tomography (PET) to localize GRPR-positive tumors.

[ ⁶⁸ Ga]Ga-NeoB will be administered as a single intravenous (iv) dose with an activity of 150 to 250 MBq (4.1-6.8 mCi).

After reconstitution, [ ⁶⁸ Ga]Ga-NeoB will be administered by slow intravenous injection. Images should be acquired 120 ± 30 min after intravenous administration. Eligibility

Participants will be evaluated for study inclusion and exclusion criteria and safety assessments. If values outside the normal range are observed in the screening laboratory results, a repeat laboratory evaluation will be allowed. If the repeat laboratory results fall within the normal range for the laboratory, they will be used for enrollment eligibility testing.

During the screening period, images and results of gadolinium-enhanced MRI performed during routine preoperative workup will be required for eligibility assessment and will be collected in the clinical database. In addition, results of postoperative MRI will also be collected.

During the screening period, [ ⁶⁸ Ga]Ga-NeoB PET/CT (or PET/MRI) must be performed within a 2-week interval after surgery/biopsy and at least 3 days before administration of study drug [ ¹⁷⁷ Lu]Lu-NeoB. [ ⁶⁸ Ga]Ga-NeoB PET/CT will not be used for eligibility assessment but for exploratory purposes. [ ⁶⁸ Ga]Ga-NeoB PET scan

[ ⁶⁸ Ga]Ga-NeoB PET/CT or PET/MRI will be performed at baseline, at least 2 weeks after surgery/biopsy of tumor lesions, and at least 3 days before the first dose of [ ¹⁷⁷ Lu]Lu-NeoB. In the event of progressive disease, PET/CT or PET/MRI will be performed to evaluate GRPR expression in the tumor.

The PET/CT or PET/MRI will be a brain-specific acquisition performed 120 ± 30 minutes after injection of 150-250 MBq (4.1-6.8 mCi) of radiotracer. The PET scans will be read locally by the same local radiologist/nuclear medicine physician throughout the study whenever possible.

[ ^68Ga ]Ga-NeoB uptake in the tumor region (guided by postoperative MRI findings at baseline and by MRI findings confirming disease progression on PET scans obtained during progressive disease) will be assessed visually and semiquantitatively. Visual assessment will record the pattern (focal or diffuse, homogeneous or heterogeneous) and extent of uptake (mild, moderate, or high). Semiquantitative assessment will include maximum SUV, mean SUV, and uptake to background ratio (UBR). Background activity will be considered as uptake within healthy brain parenchyma areas (e.g., contralateral hemisphere, if preserved).

without

[Figure 1] shows the treatment options proposed for clinical research.

without

Claims (32)

A method for treating glioblastoma in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a radiopharmaceutical compound in combination with radiotherapy, wherein the radiopharmaceutical compound is a compound having formula (I) or a pharmaceutically acceptable salt thereof: C-S-P     (I) wherein: C is a chelating moiety, P is a GRP receptor antagonist moiety, S is an optional spacer covalently linking C and P, and wherein the radiopharmaceutical compound is labeled with a radionuclide M. The method of claim 1, further comprising administering a therapeutically effective amount of an alkylating agent. The method of claim 2, wherein the alkylating agent is temozolomide. The method of claim 2 or 3, wherein the alkylating agent, preferably temozolomide, is administered concomitantly with radiation therapy at a dose of 50 to 100 mg/m²/day, preferably about 75 mg/m²/day, daily during the induction period, typically for a period of 4 to 8 weeks, preferably 6 weeks. The method of claim 4, wherein the alkylating agent, preferably temozolomide, is administered daily during the maintenance period after the induction period after radiotherapy at a dose of 50 to 400 mg/m²/day, preferably 75 to 300 mg/m²/day, more preferably 150 to 200 mg/m²/day, for 5 consecutive days, followed by a 2-day rest, once every 28 days, for a period of 20 to 28 weeks, preferably 24 weeks. The method of any one of claims 2-5, wherein the radiation therapy and the alkylating agent, preferably temozolomide, are both started on the same day, for example 7 to 10 days after the first administration of the radiopharmaceutical compound. The method of any one of claims 2-6, wherein the alkylating agent, preferably temozolomide, is administered concomitantly with the radiation therapy during the induction period without interruption. The method of any one of claims 2-7, wherein the alkylating agent, preferably temozolomide, is administered daily in a first dose during concomitant administration with the radiation therapy, for example, over a period of 6 consecutive weeks. ¹⁸⁸ Re, ⁶⁴ Cu, ⁶⁷ Cu, ⁵⁹ Fe, ⁸⁹ Sr, ^{198 Au} , ²⁰³ Hg, ²¹² Pb, ¹⁶⁵ Dy, ¹⁰³ Ru, ¹⁴⁹ Tb, ¹⁶¹ Tb, ²¹³ Bi ^{, 166} Ho, ¹⁶⁵ Er, ¹⁶⁹ Er, ¹⁵³ Sm, ¹⁷⁷ Lu, ²¹³ Bi, 223 Ra, ²²⁵ Ac, ²²⁷ Ac, ^{227 Th} , ²¹¹ At, ⁶⁷ Cu, ^{186 Re} , ¹⁸⁸ Re, ¹⁶¹ Tb, ¹⁷⁵ Yb, ^{105 Rh} , ¹⁶⁶ Dy, ¹⁹⁹ Au, ⁴⁴ Sc, ¹⁴⁹ Pm, ¹⁵¹ Pm, ¹⁴² Pr, ¹⁴³ Pr, ⁷⁶ As, ¹¹¹ Ag and ⁴⁷ Sc. The method of claim 9, wherein M is ¹⁷⁷ Lu. The method of any one of claims 1 to 10, wherein C is obtained by grafting to S or P, and C is selected from the following chelating agents: 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) (Titan), qutan, 1,4,7,10-tetraazacyclododecane, 1 (glutaric acid)-4,7,10-triacetic acid (DOTAGA), diethylenetriaminepentaacetic acid (DTPA), aminetriacetic acid (NTA), ethylenediaminetetraacetic acid (EDTA), 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetra ... Cyclododecane-1,4,7-triacetic acid (DO3A), triethylenetetramine (TETA), 1,4,7-triazacyclononane-1,4,7-triacetic acid (NOTA), NOTAGA, 1-(1,3-carboxypropyl)-4,7-carboxymethyl-1,4,7-triazacyclononane (NODAGA), NODASA, NODAPA, and 1,4-bis(carboxymethyl)-6-[bis(carboxymethyl)]amino-6-methylperhydro-1,4-diazepine (AAZTA, such as AAZTA5). The method of claim 11, wherein C has the formula, . The method of any one of claims 1 to 12, wherein P has the general formula DPhe-Gln-Trp-Ala-Val-Gly-His-Z, wherein Z is selected from Leu-ψ(CH ₂ N)-Pro-NH ₂ and NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ or Z is wherein X is NH(amide) and R2 is (CH ₂ -CH(CH ₃ ) ₂ , and R1 and R2 are the same or are (CH ₂ N)-Pro-NH ₂ . The method of claim 13, wherein P is DPhe-Gln-Trp-Ala-Val-Gly-His-NH-CH(CH ₂ -CH(CH ₃ ) ₂ ) ₂ . The method of any one of claims 1 to 14, wherein the compound of formula (I) is a compound of formula (II) (II) wherein C and P are as defined in any one of claims 1 and 11-14, and wherein the chelating moiety C is complexed with the radionuclide M. The method of any one of claims 1 to 15, wherein the radiopharmaceutical compound is M-NeoB having the following formula (III): (III), or a pharmaceutically acceptable salt thereof, wherein M is a radioactive nuclide, preferably M is ¹⁷⁷ Lu. The method of any one of claims 1-16, wherein the radiopharmaceutical compound is administered 1 to 10 times/treatment, preferably 4 to 10 times/treatment, and more preferably 6 to 8 times/treatment. The method of claim 17, wherein treatment with the radiopharmaceutical compound comprises an administration interval of 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks or even 6 weeks, preferably 3 or 4 weeks, and more preferably once every 4 weeks. The method of any one of claims 1-18, wherein the radiopharmaceutical compound is administered to the subject in multiple treatments, preferably 2-3 treatments, with a 2-12 month pause between treatments. The method of any one of claims 1-19, wherein the radiopharmaceutical compound is administered at a dose in the range of 0.925 GBq (25 mCi) to 29.6 GBq (800 mCi), preferably 1.48 GBq (40 mCi) to 18.5 GBq (500 mCi), preferably 1.85 GBq (50 mCi) to 14.8 GBq (400 mCi), more preferably 3.7 GBq (100 mCi) to 11.1 GBq (300 mCi), even more preferably about 3.7 GBq (100 mCi), about 5.55 GBq (150 mCi), about 7.4 GBq (200 mCi), about 9.25 GBq (250 mCi), or about 11.1 GBq (300 mCi). mCi). The method of any one of claims 1-20, wherein the radiation therapy comprises irradiating the subject with a total dose of 40-80 Gy, such as 60 Gy. The method of any one of claims 1-21, wherein the radiation therapy is administered at a dose of 1 Gy to 4 Gy/day, preferably about 2 Gy/day, during a period of 3 to 7 days per week, preferably about 5 days per week, during a period of 4 to 8 weeks, preferably 6 weeks. The method of any one of claims 1-22, wherein the radiation therapy begins 7-10 days after the first administration of the radiopharmaceutical compound. The method of any one of claims 1-23, wherein the subject is newly diagnosed with glioblastoma. The method of any one of claims 1-24, wherein the subject is selected from subjects having a positive methylated O-6-methylguanine-DNA methyltransferase promoter state. The method of any one of claims 1-25, wherein the radiation therapy is whole brain irradiation. A method as described in any of claims 1-26, wherein the subject has been imaged by SPECT/CT or PET/CT or SPECT/MRI, PET/MRI prior to any surgery, for example two weeks before the start of the treatment, using the same radiopharmaceutical compound as defined for the treatment, but using an alternative radionuclide or contrast agent suitable for imaging, preferably 68-gallium, 67-gallium or 64-copper, more preferably 68-gallium, selected based on detection of the radionuclide in imaging scans of the tumor area. The method of claim 27, wherein the subject is selected from subjects who show the presence of surrogate radionuclide or contrast agent enhancement, such as gadum enhancement, in the tumor area on a PET/MRI scan prior to any surgery. The method of any of claims 1-28, wherein the subject is newly diagnosed with glioblastoma and has a positive methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject in combination with radiation therapy and an alkylating agent, preferably temozolomide, wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before starting radiation therapy. The method of any one of claims 1-28, wherein the subject is newly diagnosed with neuroglioblastoma and has a negative methylated O-6-methylguanine-DNA methyltransferase promoter state, wherein the radiopharmaceutical compound is administered to the subject at least 6 times in combination with radiation therapy and further in combination with temozolomide, and wherein the interval between administrations of the radiopharmaceutical compound is 4 weeks, and wherein the first dose of the radiopharmaceutical compound is preferably administered 7 to 10 days before the start of radiation therapy and temozolomide. The method of claim 29 or 30, wherein the radiopharmaceutical compound is M-NeoB having the formula: Among them, M is ¹⁷⁷ Lu. The method of any one of claims 1-30, wherein the radiopharmaceutical compound is M-NeoB having the formula: wherein M is ¹⁷⁷ Lu and the radiopharmaceutical compound is administered by intravenous infusion at a concentration of 370 MBq/mL.