CDK6

ROCKVILLE, Md. and SUZHOU, China, April 7, 2024 /PRNewswire/ -- Ascentage Pharma (6855.HK), a global biopharmaceutical company engaged in developing novel therapies for cancer, age-related diseases, and chronic hepatitis B (CHB), announced today that it releases the latest results from three preclinical studies of its novel drug candidates olverembatinib, MDM2-p53 inhibitor alrizomadlin (R&D Code: APG-115), FAK/ALK/ROS1 tyrosine kinase inhibitor APG-2449, and embryonic ectoderm development (EED) inhibitor APG-5918, at the 2024 American Association of Cancer Research Annual Meeting (AACR 2024). This year's AACR annual meeting will be held from April 5-10 2024, in San Diego, California, USA. "We are pleased to present the preclinical research data of four assets in our pipeline at the AACR 2024. The results provided essential support for the potential clinical development and therapeutic combinations of these compounds in SDH-deficient neoplasms, prostate cancer, and ovarian cancer," said Dr. Yifan Zhai, Chief Medical Officer of Ascentage Pharma. "Moving forward, we will continue to advance these programs toward the clinical stage in order to bring more treatment options to patients in need." The details of these three preclinical studies are as follows: Olverembatinib, a novel multikinase inhibitor, demonstrates superior antitumor activity in succinate dehydrogenase (SDH)-deficient neoplasms Abstract#: 1971 Time: Monday April 8, 2024, 9:00 AM - 12:30 PM (Pacific Time) Introduction: Succinate dehydrogenase (SDH) – deficient (dSDH) neoplasms are identified by the loss of immunohistochemical expression of SDHB due to the bi-allelic inactivation of any of the four components of mitochondrial SDH complex (SDH A-D). Succinate accumulation, due to SDH deficiency, is involved in tumorigenesis of different types of cancers including gastrointestinal stromal tumor (GIST), paraganglioma, pheochromocytoma, renal cell carcinoma, pituitary adenomas, and pancreatic neuroendocrine tumors. The prognosis of patients with dSDH neoplasia, especially GIST, is poor and approved tyrosine kinase inhibitors (TKIs) have limited efficacy. There is a high unmet medical need for these patients. Olverembatinib, a novel multi-kinase inhibitor, targets a broad spectrum of kinases and has demonstrated promising efficacy in dSDH GIST patients in an ongoing phase I clinical trial. In this study, we assessed antitumor effects of olverembatinib in preclinical models of dSDH cancers and dSDH GIST primary tumor cells, and explored potential mechanisms of action. Conclusions: Olverembatinib showed superior anti-tumor activity in dSDH cell lines in vitro and human dSDH GIST primary tumor cells ex vivo. Olverembatinib, as a multi-target kinase inhibitor, exerted antitumor effects by modulating multiple signaling pathways including hypoxia, angiogenesis, apoptosis, proliferation, and survival, which are involved in tumorigenesis of dSDH cancers. Olverembatinib demonstrated more potent in vivo antitumor activity in mice bearing PC12#5F7 (SDHB KD) xenograft tumors than other TKIs. Western blot analysis in tumor tissues collected from mice further confirmed the modulation of the signal pathways by olverembatinib observed in cell lines. In summary, the results provide a rationale for future clinical development of olverembatinib in dSDH cancers. Embryonic ectoderm development (EED) inhibitor APG-5918 (EEDi-5273) and MDM2 inhibitor alrizomadlin (APG-115) synergistically inhibit tumor growth in preclinical models of prostate cancer (PCa) Abstract#: 3223 Time: Monday April 8, 2024, 1:30 PM - 5:00 PM (Pacific Time) Introduction: Prostate cancer (PCa) is one of the most frequently diagnosed malignancies among elderly males. Androgen deprivation therapy (ADT) with or without androgen receptor (AR) inhibitors is widely used as initial treatment for advanced PCa. However, most ADT-treated patients eventually develop castration-resistant prostate cancer (CRPC), which is in urgent need of novel therapies. Polycomb repressive complexes 2 (PRC2) dysregulation is common in PCa and correlates with poor prognosis. PRC2 mediates histone H3 lysine 27 tri-methylation (H3K27me3), a repressive epigenetic marker for gene transcription. embryonic ectoderm development (EED), a PRC2 core component, is crucial for histone methyltransferase activity through direct binding to H3K27me3. MDM2, a negative regulator of the tumor suppressor p53, is frequently amplified or overexpressed in PCa, and associated with poor clinical outcomes and metastasis. The aim of this study was to evaluate antitumor activity and molecular mechanisms of the investigational, clinical-stage EED inhibitor APG-5918/EEDi-5273 and MDM2 selective inhibitor alrizomadlin (APG-115) in PCa preclinical models Conclusions: In PCa preclinical models, the combination of APG-5918 and alrizomadlin synergistically inhibited cellular proliferation and induced cellular apoptosis. APG-5918 in combination with alrizomadlin synergistically enhanced antitumor activity in PCa xenograft models in vivo. Mechanistically, PD analysis revealed that APG-5918 downregulated the oncogenic DNA methylation factors (UHRF1, DNMT1) and histone methylation marker H3K27me3. Alrizomadlin markedly downregulated UHRF1 and DNMT1, and upregulated p53 and p21 expression. Combined treatment further enhanced downregulation of DNMT1, UHRF1, cell cycle pathway proteins (pRb, CDK6), antiapoptotic protein MCL-1, and synergistically increased cleavage of PARP-1, a marker of apoptosis. Therefore, the findings provide a scientific rationale for future clinical development of APG-5918 and alrizomadlin to treat patients with PCa. APG-2449, a novel focal adhesion kinase (FAK) inhibitor, inhibits metastasis and enhances the antitumor efficacy of PEGylated liposome doxorubicin (PLD) in epithelial ovarian cancer (EOC) Abstract#: 4569 Time: Tuesday April 9, 2024, 9:00 AM - 12:30 PM (Pacific Time) Introduction: Ovarian cancer is among the leading causes of cancer-related death in women, and most cases are diagnosed at later stages with distant metastasis. FAK overexpression or activation occurs in a substantial proportion of epithelial ovarian cancers (EOCs) and is predictive of poor clinical outcomes. FAK plays an important role in cell migration and chemoresistance, rendering FAK inhibition a promising treatment approach to reduce metastasis of tumor cells and sensitize them to chemotherapy. FAK is therefore emerging as a potential treatment target. The aim of this study was to evaluate the antitumor efficacy of investigational APG-2449, a novel FAK inhibitor, combined with PLD, a commonly used chemotherapy, in relapsed or refractory ovarian cancer. Conclusions: APG-2449 combined with doxorubicin showed synergistic antiproliferative effects in both platinum-resistant and platinum-sensitive ovarian cancer cell lines. FAK inhibition via APG-2449 alone attenuated migration of ovarian cancer cells in a dose-dependent manner. APG-2449 in combination with PLD showed enhanced antitumor activity in platinum-resistant OVCAR-3 ovarian cancer CDX model. The combination regimen prolonged ascites-free and survival times in the ID8-Luc peritoneal syngeneic model. These promising results support the future clinical development of this combination treatment for ovarian cancer. About Ascentage Pharma Ascentage Pharma (6855.HK) is a globally focused biopharmaceutical company engaged in developing novel therapies for cancers, chronic hepatitis B, and age-related diseases. On October 28, 2019, Ascentage Pharma was listed on the Main Board of the Stock Exchange of Hong Kong Limited with the stock code 6855.HK. Ascentage Pharma focuses on developing therapeutics that inhibit protein-protein interactions to restore apoptosis, or programmed cell death. The company has built a pipeline of 9 clinical drug candidates, including novel, highly potent Bcl-2, and dual Bcl-2/Bcl-xL inhibitors, as well as candidates aimed at IAP and MDM2-p53 pathways, and next-generation tyrosine kinase inhibitors (TKIs). Ascentage Pharma is also the only company in the world with active clinical programs targeting all three known classes of key apoptosis regulators. The company is conducting more than 40 Phase I/II clinical trials in the US, Australia, Europe, and China. Ascentage Pharma has been designated for multiple Major National R&D Projects, including five Major New Drug Projects, one New Drug Incubator status, four Innovative Drug Programs, and one Major Project for the Prevention and Treatment of Infectious Diseases. Olverembatinib, the company's core drug candidate developed for the treatment of drug-resistant chronic myeloid leukemia (CML) and the company's first approved product, has been granted Priority Review Designations and Breakthrough Therapy Designations by the Center for Drug Evaluation (CDE) of China National Medical Products Administration (NMPA). To date, the drug had been included into the China 2022 National Reimbursement Drug List (NRDL). Furthermore, olverembatinib has been granted an Orphan Drug Designation (ODD) and a Fast Track Designation (FTD) by the US FDA, and an Orphan Designation by the EMA of the EU. To date, Ascentage Pharma has obtained a total of 16 ODDs from the US FDA and 1 Orphan Designation from the EMA of the EU for 4 of the company's investigational drug candidates. Leveraging its robust R&D capabilities, Ascentage Pharma has built a portfolio of global intellectual property rights and entered into global partnerships with numerous renowned biotechnology and pharmaceutical companies and research institutes such as UNITY Biotechnology, MD Anderson Cancer Center, Mayo Clinic, Dana-Farber Cancer Institute, MSD, and AstraZeneca. The company has built a talented team with global experience in the discovery and development of innovative drugs and is setting up its world-class commercial manufacturing and Sales & Marketing teams. One pivotal aim of Ascentage Pharma is to continuously strengthen its R&D capabilities and accelerate its clinical development programs, in order to fulfil its mission of addressing unmet clinical needs in China and around the world for the benefit of more patients. Forward-Looking Statements The forward-looking statements made in this article relate only to the events or information as of the date on which the statements are made in this article. Except as required by law, Ascentage Pharma undertakes no obligation to update or revise publicly any forward-looking statements, whether as a result of new information, future events, or otherwise, after the date on which the statements are made or to reflect the occurrence of unanticipated events. You should read this article completely and with the understanding that our actual future results or performance may be materially different from what we expect. In this article, statements of, or references to, our intentions or those of any of our Directors or our Company are made as of the date of this article. Any of these intentions may alter in light of future development. SOURCE Ascentage Pharma

摘要细胞周期机制失调与细胞周期蛋白依赖性激酶 (CDK) 失调有关，是癌症的明确特征，最终促进异常增殖，促进肿瘤发生和疾病发展。对此，在过去几十年中开发了几种 CDK 抑制剂 (CDKI)（第1、2和3代CDKI）来抑制癌细胞增殖。第1代和第2代 CDKIs 因其特异性有限、毒性大，用于肿瘤患者的治疗未受到临床广泛关注。然而，最近开发的联合策略使我们能够降低这些 CDKI 的毒性和副作用，为其在临床环境中的潜在应用铺平了道路。第3代 CDKIs 在临床前和临床水平上产生了最有希望的结果，推动其进入针对多种恶性肿瘤，尤其是乳腺癌的临床试验晚期阶段，并彻底改变了传统的治疗策略。本综述讨论了第1、2和3代 CDKI 中研究最多的候选药物、其基本作用机制、既往失败的原因及其目前治疗不同恶性肿瘤的临床开发。简要总结了最近的临床试验结果和开发第三代 FDA 批准的选择性 CDK4/6 抑制剂（对抗最普遍的癌症）的进展。总的来说，这篇综述将提供从过去到现在 CDKIs 的透彻知识，让研究人员重新思考和开发创新的癌症治疗方案。细胞周期的进展在很大程度上依赖于CDKs，CDKs的失调与细胞周期失调和异常增殖有关，这是癌细胞的两个关键标志。在过去的几十年里已经开发了多种 CDKIs 来抑制癌细胞增殖。早期生成的 CDKI 显示出异常的抗癌活性，但其显著的毒性和有限的选择性使人们对其治疗用途产生怀疑。而第3代 CDKIs 则以相对较低的毒性和较高的特异性，产生了最有前景的临床结果，推动其进入针对多种恶性肿瘤，特别是针对乳腺癌的临床试验的晚期阶段，并彻底改变了传统的治疗策略。1.引言非程序性增殖是癌细胞的关键标志之一。癌细胞的非程序性增殖直接或间接由失调的细胞周期蛋白依赖性激酶 (CDKs) 介导Unscheduled proliferation is one of the key hallmarks of cancer cells. Unscheduled proliferation in cancer cells is mediated directly or indirectly by dysregulated cyclindependent kinases (CDKs)。细胞周期早期 CDKs 的表达形成了细胞增殖的条件。实现 CDKs 在细胞周期进程中的潜力，在过去的几十年里，多种 CDK 抑制剂 (CDKIs) 被开发用于阻断癌细胞增殖。包括第1、2、3代CDKI。尽管第1和第2种 CDKI 在临床前和临床研究（程度较轻）中显示出显著的抗肿瘤疗效，但由于其特异性较低和毒性严重，这些抑制剂在癌症患者的治疗中未受到太多临床关注。近年来联合治疗策略的发展使降低前一代 CDKI 的毒性和副作用成为可能，为其在临床环境中的应用开辟了可能。与第1代和第2代 CDKI 相比，在开发第3代 CDKI 的临床方面取得了显著进展。临床前和临床结果表明，这些选择性 CDK4/6 抑制剂可以显著降低多种恶性肿瘤的进展。其中4种抑制剂palbociclib、ribociclib、abemaciclib和 trilaciclib 已被 FDA 批准用于治疗不同的癌症，单独使用或与已确立的疗法联合使用。本综述讨论了第1、2和3代 CDKI 中研究最多的候选药物、其基本作用方式、既往失败的原因以及多发性恶性肿瘤管理的近期临床开发。此外，简要总结了 FDA 批准的第三代选择性 CDK4/6 抑制剂治疗最普遍癌症的最新临床试验结果和进展。1.1.CDK和细胞周期进程CDKs 是在细胞周期进程和转录调控过程中催化蛋白磷酸化的酶家族。CDKs的催化活性需要被称为细胞周期蛋白的调控伴侣的结合。几种 CDKs 和细胞周期蛋白已在不同物种中被鉴定识别，只有特异性的 CDK-细胞周期蛋白相互作用被认为控制细胞周期进程，即通过G1、S、G2和 M 期。在哺乳动物中，目前公认的模型是基于生化证据，其中 G1 至 S 期转变由 CDK4 或 CDK6 与D1、D2和 D3 细胞周期蛋白结合控制。在细胞周期早期，有丝分裂前信号增加细胞周期蛋白 D 的表达，细胞周期蛋白 D 结合并激活CDK4/6，最终激活CDK2/cyclin E。CDK4/CDK6使 Rb 蛋白磷酸化，CDK2进一步磷酸化Rb。在细胞周期蛋白-CDK4/6 复合物存在的情况下，Rb的过度磷酸化阻断 E2F 结合，使细胞进入 S 期，在那里发生 DNA 合成。当CDK2/cyclin A 磷酸化E2F1，阻断其 DNA 结合能力时，S期终止。CDK1与细胞周期蛋白 B 结合完成有丝分裂过程。据报道，CDK3与细胞周期蛋白 C 结合可使Rb 磷酸化，导致从 G0 期退出。也有报道 CDK3 有助于进入 S 期，部分是通过激活转录因子 E2F 家族成员，但其作用与 CDK2 不同。这些事件的概述和图形表示见图1.除了直接驱动细胞周期进程的CDKs（如CDK4、CDK6、CDK2、CDK1和CDK3）外，还揭示了一个控制转录的 CDKs 家族，其中包括CDK7、CDK8、CDK9、CDK10、CDK11、CDK12、CDK13等。在特殊组织环境中具有有丝分裂后功能的CDK，如CDK5，也已被确定。每个CDK 的重要性及其对细胞周期调控的贡献的细节已经在各种报告中讨论过。在本节中，我们打算概述调节哺乳动物细胞周期的 CDK 家族重要成员。鉴于 CDKs 在哺乳动物细胞细胞周期调控中发挥的至关重要的功能，所有恶性肿瘤都具有某些损害细胞周期正常控制的特征可能并不令人惊讶。这就是为什么在过去的30年里，多种靶向 CDKs 活性的药物不断进化，并在临床试验中进行了测试的原因。在最近的时代，选择性靶向 CDK 家族两个关键成员 (CDK4/6) 活性的最先进药物已成为现代癌症治疗的支柱。在下面的章节中，简要回顾了第1、2和3代靶向 CDK 活性 (CDKIs) 药物中研究最多的候选药物，它们最近在临床上开发用于治疗多种恶性肿瘤，它们的基本作用方式及其过去失败的原因，以及振兴它们用于癌症治疗的策略。图1.CDK家族蛋白及其相互作用的伴侣参与调节细胞周期进程。促有丝分裂信号在细胞周期早期促进细胞周期蛋白 D 的合成，细胞周期蛋白 D 结合并激活CDK4/6，随后激活CDK2/cyclin E。CDK4/CDK6使 Rb 蛋白磷酸化，CDK2进一步使 Rb 过度磷酸化。Rb的过度磷酸化阻止E2F 结合，使细胞进入 S 期，在那里发生 DNA 合成。在 S 期接近结束时，CDK2/细胞周期蛋白 A 磷酸化E2F1，阻止其与 DNA 结合并终止 S 期。CDK1与细胞周期蛋白 B 偶联完成有丝分裂过程。CDK3与细胞周期蛋白 C 结合使 Rb磷酸化，导致从 G0 期退出。除了这些直接驱动细胞周期进程的CDK 外，还发现了CDK7、CDK8、CDK9、CDK10、CDK11、CDK12、CDK13和 CDK19 等其他CDK，并证实参与转录调控。2.靶向各种恶性肿瘤的 CDKI进展2.1.第一代 CDKI一旦探索了 CDKs 在各种癌症中的治疗潜力，就会进化出 CDKIs 开发的研究。最初，多种 CDKI 被称为第一代CDKI，包括olomoucine、flavopiridol和roscovitine，被开发为潜在的癌症治疗药物，并在大量临床试验中进行了试验。然而，由于其相对于其类似物的亲和力有限且毒性严重，其中一些第一代CDKI（如olomoucine）尽管在临床前研究中对癌细胞具有相当大的抑制作用，但仍无法用于临床研究。相比之下，flavopiridol和 roscovitine 这两种第一代 CDKI 在研究方面引起了最大的关注，正在用于 I/II 期临床研究。2.2. FlavopiridolFlavopiridol 是研究最广泛的第一代CDKI，也是首次用于临床研究。Flavopiridol最初被发现是表皮生长因子受体的抑制剂，在多个实验模型中已被证明可以抑制各种癌症的生长，但后来，观察到其对CDK1、CDK2、CDK4、CDK6、CDK7和 CDK9 的抑制活性强于对表皮生长因子受体的抑制活性（图2）flavopiridol的初步临床试验始于1994年，作为慢性淋巴细胞白血病和急性髓系白血病的一线联合治疗。此后，根据最大的临床试验数据库 (www.clinicaltrials.gov)flavopiridol已经在67项临床试验中进行了测试，该药主要用于治疗包括淋巴瘤、急性髓性白血病、前列腺癌和胃癌在内的多种癌症。flavopiridol的早期试验证明，在体外足以抑制细胞增殖和 CDK 活化的浓度可在人体中安全获得。此外，这些静脉注射 flavopiridol 的初步临床试验表明对多种癌症有效，如非霍奇金淋巴瘤和前列腺癌、结肠癌、肾癌和胃癌。然而，在这些研究期间，观察到严重的不良反应，如分泌性腹泻和促炎状态伴低血压，导致该药物的进一步临床开发停止。联合治疗策略的最新发展使其能够降低与强效药物相关的毒性和副作用，从而改善其在临床环境中的应用。在相同的背景下，已对各种药物与 flavopiridol 联合使用进行了检查，以降低 flavopiridol 在临床上的严重不良反应。例如，在 I 期临床研究中，食管癌、肺癌和前列腺癌均对序贯紫杉醇和favopiridol治疗有良好的反应。几项 I 期临床研究已经证明了联合使用 favopiridol 和多西他赛对抗转移性乳腺癌、多种非血液系统癌症和晚期实体瘤的巨大潜力。还进行了多项使用favopiridol的 II 期临床研究。其中许多在多种癌症中有中度至显著的结果，而另一些则产生了不令人满意的结果，需要对其他联合策略进行更多的实验。这些晚期临床研究的详细信息总结见表1。图2.总结了多年来开发的研究最广泛的第1、2和3代CDKI、其化学结构及其靶向的重要CDK。表1.部分第一代和第二代CDKI 的晚期临床试验概述2.3. RoscovitineRoscovitine 是一种基于嘌呤的CDKI，也是第一代 CDKI 之一，将在多种癌症的临床试验中进行探索。这种抑制剂已经证明了它能够结合和抑制 CDK 家族的多个成员，包括CDK1、CDK2、CDK5、CDK7和CDK9，即使在微摩尔浓度下 (2) 临床前研究了Roscovitine对多种癌细胞系和移植瘤模型的抑制作用，显示Roscovitine的抑制作用多通过细胞周期阻滞和凋亡诱导介导。此后，开展了几项以roscovitine 为单一药物的 I 期和 II 期临床试验，但结果未能给科学界留下明显的印象。使用 roscovitine 的 I 期临床试验证明没有客观的肿瘤反应，即使一些患者 (8/21) 达到了疾病稳定。另一项 I 期临床研究发现，各种类型恶性肿瘤个体的部分缓解和肿瘤稳定。还进行了一项 II 期临床试验，研究口服 roscovitine 治疗非小细胞肺癌的有效性；然而，这项研究被关闭，没有数据被披露 (NCT00372073)。与 flavopiridol 相似，roscovitine最近在临床水平上与常规治疗联合使用。最近完成的一项 I 期临床研究采用了sapacitibine和Roscovitine联合治疗BRCA（乳腺癌基因）肿瘤，研究显示出潜在的协同效应，导致细胞周期停滞和肿瘤细胞凋亡。根据这项研究，将 roscovitine 与 sapacitibine 联合使用增加了其总体疗效并降低了其细胞毒性，表明未来采用联合策略的研究可能会提高 roscovitine 的治疗疗效。使用 roscovitine 单药或联合治疗多种癌症的 II 期临床研究总结见表1。2.4.第二代 CDKI考虑到第一代 CDKI 抑制剂的细胞毒性和低选择性，已开发了几种第二代CDKI，并在各种临床研究中进行了试验。这些化合物包括多种化合物，如dinaciclib、AT7519、CYC065、P276–00、TG02、roniclib、RGB-286638、PHA793887、ZK-304709、P1446A-05、R547、SNS-032、AZD5438、AG-024322和PHA-848125。然而，并非所有研究均在早期临床研究之外进展，并在晚期临床研究中产生了令人满意的结果。例如，由于申办方公司的商业决定，停止了P276–00的临床试验。3项 I 期研究评估了AZD5438（一种对CDK1、CDK2和 CDK9 具有选择性的抑制剂）以不同给药方案给药时的临床安全性、耐受性、药代动力学和药效学，观察到耐受性较差，停止了其临床开发。R547是一种CDK1、CDK2和 CDK4 抑制剂，对CDK7、GSK3a和 GSK3b 的疗效较低，2007年在一项 I 期研究中进行了研究，但尽管声称毒性可控，但并未进一步进展。使用 SNS-032 抑制剂启动了两项 I 期临床试验，据称 SNS-032 抑制剂对CDK2、CDK7和 CDK9 具有选择性；然而，这些研究未进行随访。P1446A-05、ZK-304709和RGB-286638 的 I 期或 II 期研究也已终止。另一方面，三种第二代CDKI，即dinaciclib、AT7519和CYC065，在临床前水平进行了相当多的研究后，能够进入晚期临床试验。下面，我们分别对这3个第二代 CDKI 进行了详细的讨论。2.5. DinaciclibDinaciclib 是研究最广泛的第二代CDKI，主要被开发为一种非常有效的CDK1、CDK2、CDK5和 CDK9 抑制剂 (图2) 对CDK4、CDK6、CDK7的活性降低。在基于细胞的实验中，与早期世代相比，dinaciclib在抑制 RB 磷酸化方面表现出更大的有效性。此外，dinaciclib在超过100种多种肿瘤类型的肿瘤细胞系中阻止了细胞周期的进展，并在各种异种移植模型中引起植入的实体瘤消退。Dinaciclib在48例晚期实体瘤患者中进行了 I 期试验，这些患者每周接受一次2小时静脉输注，持续3周。直立性低血压和尿酸升高是记录的剂量限制性毒性；然而，总体而言，治疗耐受良好，在10例患者中观察到疾病稳定。在乳腺癌和非小细胞肺癌患者中进行了 dinaciclib 的 II 期试验，但在两项研究中，与标准治疗相比，dinaciclib导致疾病进展时间更短，因此试验被叫停。鉴于第一代 CDKI flavopiridol 在复发性和难治性慢性淋巴细胞白血病中观察到令人鼓舞的结果，还在该患者人群中研究了 dinaciclib 的治疗疗效。令人惊讶的是，54%的 dinaciclib 治疗患者出现缓解；然而，血细胞减少症和肿瘤溶解综合征被观察为不良后果。这表明 dinaciclib 可能对某些血液癌症的治疗有效，flavopiridol也证实了对这些癌症的疗效。设计了一项随访 III 期试验，在接受 dinaciclib 与 ofatumumab 治疗的复发/难治性慢性淋巴细胞白血病患者中，将无进展生存期 (PFS) 作为主要终点（ORR，部分缓解+完全缓解）和总生存期 (OS) 进行比较。PFS、ORR和 OS 的结果显示，dinaciclib对慢性淋巴细胞白血病的疗效优于ofatumumab，但由于样本量太小，无法进行统计分析。接受 dinaciclib 或 ofatumumab 治疗的患者的中位 PFS 分别为13.7个月和5.9个月。接受 dinaciclib 治疗的患者的 ORR 为40.0%，接受 ofatumumab 治疗的患者的 ORR 为8.3%。所有这些均为部分缓解。共有35.0%的 dinaciclib 患者和45.8%的 ofatumumab 患者能够使其疾病免于恶化。Dinaciclib患者的中位 OS 为21.2个月，而ofatumumab患者的中位 OS 为16.7个月。还使用了不同的组合策略来增强 dinaciclib 的效率并降低其毒性。例如，在一项 I 期随机递增3+3研究中，复发性/难治性慢性淋巴细胞白血病患者接受了dinaciclib+利妥昔单抗治疗。根据这项试验的研究结果，dinaciclib联合利妥昔单抗的耐受性良好，在复发/难治性慢性淋巴细胞白血病患者中表现出临床活性。同时进行了一项以 MYC 过表达作为反应预测因子的 dinaciclib 联合 pembrolizumab 治疗晚期三阴性乳腺癌 (TNBC) 患者的 Ib 期研究，结果在2020年 ASCO 年会上公布。晚期TNBC 患者除接受设定剂量的帕博利珠单抗 200 mg 每21天一次给药外，还在第1天和第8天接受 dinaciclib IV 给药。采用剂量限制性毒性 (DLT) 率为25%的毒性概率区间设计增加 Dinaciclib 的剂量，并对基线肿瘤组织进行MYC IHC，以确定临床反应。在本研究中，入组了32例患者（中位年龄53岁，中位既往治疗线数为2，13例患者 (41%) 既往患有ER+乳腺癌）。剂量递增阶段招募了18例无 DLT 的患者；33 mg/m2是推荐的 II 期剂量 (RP2D)。剂量扩展研究增加了14例患者，剂量为33 mg/m2，使实验得出结论。结果显示所有患者均发生3级不良事件 (AE)，包括发热(12.5%)、疲乏 (12.5%)、中性粒细胞减少(37.5%)、转氨酶炎性升高 (3.2%) 和神经肌肉无力(3.2%)。疲乏 (63%)、腹泻 (63%)、恶心 (63%) 和中性粒细胞减少症 (53%) 是最常见的所有等级不良反应。在初步疗效分析中观察到临床获益率为47%，c-MYC高表达与临床缓解显著相关，需要进一步验证 c-MYC 作为联合治疗缓解的预测标志物。在这些令人鼓舞的结果之后，正在进行一些进一步的晚期临床试验，采用 dinaciclib 单药或与其他药物联合治疗各种癌症。表2总结了这些研究。表2.正在进行的palbociclib 单药或联合治疗晚期临床试验列表2.6. AT7519Dinaciclib为发现AT7519铺平了道路，AT7519是另一种对CDK1、CDK2、CDK4、CDK5、CDK6和CDK9表现出抑制活性的抑制剂（图2）与dinaciclib相似，这种抑制剂在多种人癌细胞系中表现出令人鼓舞的疗效，即使在纳摩尔浓度下也是如此。在一项探索AT7519生物学特征的研究中，AT7519显示可诱导人肿瘤细胞的细胞周期停滞和随后的细胞凋亡。在同一研究中，在人结直肠癌异种移植模型中观察到显著的肿瘤消退，证明了显著的抗癌有效性。同样，Dolman等人于2015年发表的一项临床前研究。表明AT7519作为治疗MYCN扩增的高危神经母细胞瘤患者的潜在疗法。在最近的一项临床前研究中发现，纳摩尔浓度的AT7519通过阻止G2/M期细胞并诱导细胞凋亡，大大抑制鼻咽癌的生长。I期临床试验已被用于研究AT7519是否能有效治疗晚期难治性实体瘤或非霍奇金淋巴瘤个体。共有34例患者参加本试验，其中32例接受所有4个剂量水平的治疗。粘膜炎、发热性中性粒细胞减少症、皮疹、疲乏和低钾血症是观察到的一些剂量限制性毒性。在19例可评价疗效的患者中，10例的最佳缓解为疾病稳定。II期推荐剂量为27.0 mg/m2。还进行了一项使用AT7519治疗复发性套细胞淋巴瘤和复发性难治性慢性淋巴细胞白血病的II期临床试验。然而，在16个月期间仅累积了7例患者的预后。因此，试验提前结束。在一项I/II期开放性多中心研究中，还在既往接受过多发性骨髓瘤治疗的患者中研究了AT7519M单药治疗和与硼替佐米联合治疗。在本研究中，AT7519M和硼替佐米全剂量有效联合给药，患者组对该治疗耐受良好。AT7519M和硼替佐米的最大耐受剂量分别为21 mg/m2和1.3 mg/m2。在接受过硼替佐米预治疗或硼替佐米难治的部分患者中，AT7519M与硼替佐米联合给药产生了显著缓解（33%PR）；然而，AT7519M单药治疗后未观察到显著疗效。此外，2016年4月启动了一项使用onalespib和AT7519治疗转移性或不能手术的实体瘤患者的I期临床试验，目前正在进行中。本研究的主要目的是确定onalespib和AT7519 M联合治疗晚期、转移性和不可切除的恶性实体瘤的安全性、耐受性和最大耐受剂量。表1包含此类临床研究的更多信息。2.7.FadraciclibFadraciclib(CYC065) 也是一种第二代CDKI，来源于 roscovitine 和CCT068127。这种抑制剂对CDK2、CDK5和 CDK9 表现出很强的效力(图2)。在急性髓系白血病和急性淋巴细胞白血病的临床前模型中，表明 CYC065 通过抑制CDK9 限制白血病细胞系的增殖和存活，从而降低 RNA 聚合酶Ⅱ介导的转录和 MCL1 表达，从而引发细胞凋亡。此外，CYC065可通过促进细胞周期进程和抑制分化，降低 MEIS1 的表达，MEIS1是混合谱系白血病干细胞发生和维持所必需的转录辅因子。同样，另一项临床前研究探索了 CYC065 对 AML 和混合谱系白血病的治疗潜力。发现相关癌细胞系对这种抑制剂极为敏感，导致这些癌细胞快速凋亡。此外，同一研究表明，小鼠经口给予 CYC065 可使 AML 肿瘤生长减少90%以上。考虑到这种新兴的强效 CDKI 令人鼓舞的结果，单独使用这种抑制剂或与 venetoclax 联合使用的不同 I/II 期临床试验正在包括复发性/难治性急性髓系白血病 (AML)、慢性淋巴细胞白血病和多发性实体瘤在内的多种恶性肿瘤中进行。这些 I/II 期临床试验的详细信息见表1。2.8.第三代 CDKI绝大多数来自第1代和第2代的 CDKIs 在其分子靶点上没有选择性（图2）阻止这些早期一代 CDKIs 在临床方面完全开发的主要障碍是对其作用的潜在机制缺乏坚实的理解。就众多第1代和第2代 CDKI 的治疗疗效而言，尚不清楚哪些 CDK 在体内条件下受到抑制，以及通过何种机制受到抑制。此外，由于其中许多早期 CDKI 靶向正常细胞增殖和存活所必需的多种蛋白，如 CDK1 和CDK9，因此这些药物在晚期临床研究中的进一步开发也受到其无法区分癌组织和健康组织的限制。归因于这些早期生成 CDKI 的缺点意味着，改善对特定 CDK 的选择性对于CDKI 作为癌症治疗药物的有效开发至关重要。因此，开发了特异性靶向 CDK 4 和 CDK6 的选择性更强、毒性更小的第三代CDKI。这些药物包括palbociclib、ribociclib、abemaciclib和最近开发的trilaciclib。这些都是口服选择性 CDK 4/6 抑制剂，可阻止 RB 的磷酸化，引起 G1 期阻滞和肿瘤细胞的衰老。它们似乎具有相似的临床作用和相似的化学结构（图2）这些第3代 CDKIs 被认为是迄今发现的最耐人寻味、最有前景的 CDKIs 家族，彻底改变了几种侵袭性恶性肿瘤的治疗。已对 CDK 4 和 CDK6 抑制剂在癌症中的作用以及palbociclib、ribociclib、abemaciclib和 trilaciclib 的药理学特性进行了广泛研究。下面简要概述这些新一代 CDKI 治疗多种恶性肿瘤的最新临床发展。2.9. PalbociclibPalbociclib是研究最广泛的第三代CDKI之一。口服生物可利用的palbociclib由辉瑞开发，并于2015年2月获得FDA的批准。Palbociclib是一种CDK4/6抑制剂，IC50（抑制浓度）为9-15 nmol/L，通过与ATP（三磷酸腺苷）口袋结合发挥作用。重要的是，它对任何其他激酶都没有任何作用。CDK4/6激酶及其共调节伴侣细胞周期蛋白D促进G1-S转换，因此，在RB蛋白磷酸化和E2F转录因子被激活的细胞中，阻断这一步可抑制细胞周期进程。Palbociclib在多种类型癌症的各种临床前研究中显示出良好的结果。例如，在人肝癌细胞系中，palbociclib通过诱导可逆性细胞周期停滞来抑制细胞生长。在亚微摩尔剂量下，发现80%的口腔鳞状细胞癌细胞系对palbociclib敏感。在40种卵巢癌细胞系中发现了palbociclib的浓度依赖性抗增殖作用，但各细胞系之间的作用差异很大。通过降低Rb磷酸化，palbociclib能够成功地将多种肿瘤细胞（包括HT29、Colo205和DLD1等）阻滞在G1细胞周期阶段。在不同癌症类型的异种移植小鼠模型中也观察到相似的结果。例如，palbociclib在ApcMin小鼠体内可有效给药，抑制肿瘤细胞生长，而对正常上皮细胞无影响。在小鼠异种移植模型中进行试验时，Palbociclib对多种肿瘤（包括乳腺癌）具有抗肿瘤活性。此外，已证实palbociclib可通过阻断c-Jun/COX-2通路抑制乳腺癌细胞迁移和侵袭以及上皮间质转化和转移。在获得关于palbociclib疗效的令人鼓舞的临床前结果后，在不同的人类癌症类型中使用palbociclib单药和与其他疗法联合进行了多项I/II/III期临床研究，包括胰腺神经内分泌癌（NCT02806648）、卵巢癌（NCT03936270）、转移性胰腺导管腺癌（NCT02501902）、转移性结直肠癌（NCT03446157）以及KRAS突变的非小细胞肺癌和实体瘤（NCT02022982）。尽管palbociclib正在几种不同的癌症中进行研究，但最令人鼓舞的发现是在乳腺癌中。这是palbociclib大多数晚期临床研究（II/III期）在乳腺癌患者中进行的主要依据。在综述的单独章节中记录了这些临床研究的结局（第三代CDKI治疗乳腺癌的临床研究的最新突破），并将其列于表2中。2.10. Abemaciclib礼来公司实验室的研究人员首次确定 abemaciclib 是一种抗肿瘤药物，也是 CDK4 和 CDK6 的双重抑制剂。后来研究表明，abemaciclib是 CDK4 和 CDK6 ATP 结合结构域的竞争性抑制剂，对 CDK4 的疗效是 CDK6 的14倍。根据其生物活性和对 CDK4/细胞周期蛋白 D1 和CDK6/细胞周期蛋白复合物的极特异性抑制选择Abemaciclib。与 palbociclib 相似，未检测到对其他必需细胞周期相关激酶的活性。IC50值是 palbociclib 和 ribociclib 的1/5（将在下文讨论），因此，abemaciclib对 CDK4/细胞周期蛋白 D1 复合物的选择性更高。在 abemaciclib 治疗多种癌症（包括结直肠癌、肺癌、胶质母细胞瘤和血癌）的临床前表征期间，、 abemaciclib 即使在纳摩尔浓度下也能通过抑制 Rb 蛋白磷酸化抑制 CDK4 和CDK6，引起 G1 期阻滞，增殖变慢。Abemaciclib连续给药时耐受性良好，在肿瘤异种移植模型中评价时显示出显著的剂量依赖性抗癌疗效，导致肿瘤体积减少70%。基于临床前研究中获得的非常有前景的结果，abemaciclib进入了临床开发阶段。进行了一项 I 期多中心研究，以评估 abemaciclib 单药治疗多种晚期恶性肿瘤的安全性、药代动力学特征、药效学作用和抗肿瘤活性，包括乳腺癌、非小细胞肺癌、胶质母细胞瘤、黑色素瘤和结直肠癌。本研究共纳入225例患者：剂量递增队列33例，肿瘤特异性队列192例。3级疲乏是研究期间观察到的剂量限制性毒性。最大耐受剂量为200 mg/12 h。胃肠道、肾脏或造血系统影响和疲乏是最常见的不良事件。既往接受过治疗的乳腺癌、非小细胞肺癌和黑色素瘤患者均获得了放射学缓解。激素受体阳性乳腺癌的总缓解率为31%；然而，61%的患者出现缓解或疾病稳定持续6个月或更短时间。在另一项 I 期研究中，接受 abemaciclib 单药或联合氟维司群或其他抗激素治疗的HR+转移性乳腺癌患者显示出有利的药代动力学和毒性特征，其中腹泻、中性粒细胞减少症、恶心和疲乏是最常见的3级治疗相关副作用。未记录到4级事件或发热性中性粒细胞减少症。接受abemaciclib+氟维司群治疗的HR+转移性乳腺癌患者组表现出最有前景的结局，在平均接受过4次既往全身治疗的患者中，62%证实了部分缓解。这些发现引发了 II 期和 III 期临床研究的开始。在 MONARCH 1 临床 II 期试验中，研究了 abemaciclib 单药在内分泌治疗后疾病进展且既往接受过化疗的难治性HR +/HER2-转移性乳腺癌患者中的抗肿瘤活性，在 MONARCH III 期试验中，在内分泌治疗后疾病进展的HR +/HER2晚期乳腺癌患者中评价了 abemaciclib 与氟维司群的联合用药。综述的后面部分详细讨论了这些临床试验的结果。由于其在HR +/HER2晚期乳腺癌中的显著临床结果，目前正在多项正在进行的 i/II/III 期临床试验中对该抑制剂单药或与其他已确定的癌症疗法联合治疗多种恶性肿瘤进行临床研究。例如，在头颈部鳞状细胞癌 (NCT03655444)、转移性肾细胞癌 (NCT03905889)、胆道癌 (NCT04003896)、胶质瘤 (NCT05413304)、骨和软组织癌 (NCT04040205)、转移性或局部晚期间变性/未分化甲状腺癌 (NCT04552769) 和子宫内膜癌 (NCT04393285) 中。这些正在进行的临床研究的结果可能为各种流行癌症的新型、有效的治疗方式铺平道路。2.11. RibociclibRibociclib 由诺华国际公司开发，2017年获得 FDA 批准，与来曲唑联合使用时，可用于晚期乳腺癌患者的治疗。与其他第三代 CDK 抑制剂一样，Ribociclib是一种口服生物可利用的小分子药物，可特异性抑制CDK4/6，从而降低视网膜母细胞瘤蛋白磷酸化，阻止细胞周期进程并将细胞周期阻滞在 G1期。已证明 Ribociclib 可降低细胞周期蛋白 D1 和 CDK4 复合物以及细胞周期蛋白 D3 和 CDK6 复合物的结合，对CDK4 的选择性是 CDK6 的4倍。在肺癌细胞系和原发性肿瘤组织中进行的 CDK4/6 抑制剂活性的化学蛋白质组学研究表明，ribociclib对 CDK4 和 CDK6 的选择性远高于palbociclib，后者已被证实可与两倍多的激酶发生相互作用。在一项癌细胞系广泛研究中，分析了 ribociclib 对超过500种细胞系的活性，其显示出剂量依赖性抗肿瘤活性，与各种肿瘤细胞系中的 CDK4/6 抑制具有良好的相关性；但在神经母细胞瘤细胞系中的作用更为明显。另一项探索ribociclib 治疗作用的研究发现，ribociclib治疗与神经母细胞瘤细胞系来源的异种移植动物模型中磷酸化Rb、Ki67和细胞增殖的减少有关，导致整个治疗过程中肿瘤生长显著延迟。这些令人鼓舞的临床前方面的结果与其他在多种癌症类型中的结果一起，单独或与标准疗法一起，导致研究人员在 I/II/III 期临床试验中探索这种第三代抑制剂的作用。在美国和欧洲以及日本进行了第一项 I 期临床试验，检查了 ribociclib 单药治疗多种 Rb 阳性晚期实体瘤和淋巴瘤的有效性。使用 ribociclib 作为单药，这些探索性临床试验表明在 Rb 阳性恶性肿瘤中具有可接受的安全性特征和早期临床有效性，支持在临床环境中进一步探索该药物。从那时起，ribociclib成为多种肿瘤类型的多项 I/II 期临床试验的主题，包括 BRAFV600 和 NRAS 突变黑色素瘤 (NCT01777776，NCT01781572)、非小细胞肺癌、头颈部鳞状细胞癌、食管鳞状细胞癌、胃肠道间质瘤和结直肠癌 (NCT04000529)、畸胎瘤 (NCT02300987)、脂肪肉瘤 (NCT03096912)、骨髓纤维化 (NCT02370706)、卵巢癌 (NCT03056833) 和子宫内膜癌 (NCT03008408)。然而，最先进的临床试验正在研究 ribociclib 与几种常规疗法联合治疗HR+乳腺癌。这些高级临床研究的详细信息包含在本综述的后续章节中。2.12. TrilaciclibTrilaciclib 是G1 Therapeutics（原名G-Zero Therapeutics）开发的最新第三代短暂性 CDK 4/6 抑制剂，与化疗联合用于治疗癌症，尤其是小细胞肺癌和TNBC，具有骨髓保护、潜在抗肿瘤疗效和安全性获益。CDK控制细胞周期进程，trilaciclib诱导骨髓中增殖的造血干祖细胞发生一过性、可逆性 G1 细胞周期阻滞，保护其免受化疗损伤。2021年02月12日，FDA首次批准 trilaciclib 在含铂/依托泊苷方案或含托泊替康方案治疗广泛期小细胞肺癌 (ES-SCLC) 前给药可降低成人化疗诱导的骨髓抑制风险。多项研究表明，trilaciclib是一种非常有效、具有选择性和可逆性的CDK 4和 CDK6 抑制剂。用 trilaciclib 处理24 小时的正常成纤维细胞系产生了显著和一过性的 G1 细胞周期停滞。同一研究发现，在化疗前给予 trilaciclib 可减CDK4/6 依赖性细胞的凋亡，表明瞬时 trilaciclib 可引起这些细胞的 G1 细胞周期停滞，并降低与骨髓抑制相关的细胞毒性化疗药物的体外毒性。在小鼠同基因肿瘤模型中，在化疗加免疫检查点抑制剂方案中添加 trilaciclib 改善了抗肿瘤有效性，部分是通过改变肿瘤微环境中 T 细胞亚型的增殖和组成。在健康志愿者的首次人体 I 期临床试验中，96或 192 mg/m2 trilaciclib 单次给药以剂量依赖性方式抑制了CD45 +/CD3+淋巴细胞的增殖。此外，在 24 h 时，trilaciclib增加了骨髓造血干细胞和祖细胞的 G1 细胞群，在 32 h 时部分恢复，并且对于研究中评估的所有骨髓祖细胞亚群，G1期细胞的比例增加。此外，最近开展了一项 II 期试验，评估 trilaciclib 联合化疗方案吉西他滨和卡铂（GC方案）治疗复发性或转移性 TNBC 的疗效。本研究的结果表明，在标准 GC 治疗的基础上加用 trilaciclib 可显著增加生存率。除这些试验外，正在对晚期/转移性膀胱癌 (NCT04887831)、乳腺癌（NCT04799249、NCT05113966和NCT05112536）、结直肠癌 (NCT04607668) 和小细胞肺癌 (NCT04902885) 进行额外的 II/III/IV 期临床研究。希望这些先进的正在进行的临床试验的发现可能为多种常见恶性肿瘤的创新、成功的治疗方法铺平道路。2.12.1.过去和现在对CDKIs 的挑战如前所述，在过去的几十年里，已经开发了三代 CDK 抑制剂 (CDKIs)。尽管第1和第2代 CDKI 在临床前和临床研究（程度较轻）中显示出显著的抗肿瘤活性，但由于许多原因，这些抑制剂在癌症患者的治疗中未获得太多的治疗关注。阻碍早期一代 CDKI 进一步临床开发的主要因素之一是其缺乏选择性，从而导致毒性增加。由于这些早期生成的 CDKI 靶向几种CDK，尚不清楚这些早期生成的 CDKI 特异性靶向哪种CDK，尚不确定这些早期生成抑制剂治疗作用的基础机制。同样方面的另一个因素是抑制对正常细胞生理活动很重要的必需CDK，包括增殖、存活、检查点激活、DNA修复和复制。这导致正常细胞的细胞毒性水平更高。另一方面，第3代或选择性CDKI（CDK4/6抑制剂）尚未遇到这些问题，使其取得最令人鼓舞的结果，进行晚期临床试验，并获得 FDA 批准。然而，尽管在临床方面取得了显著的成功，但固有和获得性耐药对其更广泛的使用构成了重大挑战。临床上，据报告，只有一部分接受治疗的患者对晚期 CDKI 产生应答，而其他患者表现出固有耐药性，无法从这些药物中获益，通常转换为化疗。同时，一些患者最初从治疗中获益，但后来获得了对这些 CDKI 的耐药性。多项研究试图探讨耐药的相关机制，发现 RB 的基因丢失和突变、细胞周期的各种关键调控因子如p16、CCNDI、CCNE1、E2F、CDK2、CDK4、CDK6、CDK7、CDK9的扩增、参与细胞存活和增殖的关键通路的激活，如 FGFR 通路、PI3K/AKT/mTOR通路、ER/PR的表达缺失、CDKI耐药的免疫相关机制、癌细胞内的代谢改变、药物诱导的基质功能改变等是 CDKI 治疗耐药的重要可能机制。这些机制最近在多篇报道中进行了详细介绍。尽管发表了过多的临床前研究，但 CDKI 耐药机制与临床验证的明确背景尚待研究。这突出了该课题临床和临床前研究的重大差距。迫切需要对耐药机制进行更彻底的研究，发现生物标志物来识别可能或可能不会从这组药物中获益的个体，并采用不同的抑制剂/药物来对抗 CDKI 耐药的组合策略。2.12.2.第三代 CDKIs对抗乳腺癌临床研究的最新突破乳腺癌已超过肺癌成为全球发病率最高的癌症。HR+/HER2-乳腺癌是最常见的乳腺癌亚型，占所有乳腺癌病例的70%以上。内分泌治疗 (ET) 在辅助和转移背景下对该亚型乳腺癌均高度有效。尽管有这种有效的疗法，但仍有一部分辅助治疗患者会因无法治愈的转移性疾病而复发，这可能与内分泌治疗产生耐药性有关。HR+转移性乳腺癌患者最终对进一步内分泌治疗产生完全耐药性，预示着向持续终生化疗的转变。因此，在辅助和转移背景下改善内分泌治疗的疗效将对许多乳腺癌患者产生非凡的获益，是未满足的医疗需求。目前正在开发多种靶向作用于细胞生长和控制关键通路的新药，以提高内分泌治疗对HR+乳腺癌的疗效。考虑到细胞周期失控导致非限制性生长（癌症的典型标志）和CDK在细胞周期调控中的潜在作用，在过去几十年中开发了多种靶向不同 CDK 的CDKI，以阻断癌细胞增殖，如本综述前面部分所述，并总结于图2中。针对晚期乳腺癌亚型已经取得了最大程度的成功。事实上，CDKIs作为乳腺癌治疗药物的临床前和临床研究结果都彻底改变了乳腺癌的治疗方式。几篇杰出的报道详细介绍了 CDKIs 在乳腺癌治疗中的临床前和早期临床效果。总结 CDKIs 在乳腺癌治疗中最先进的临床研究的最新成果，重点介绍现代一代CDKIs。2.12.3.palbociclib治疗乳腺癌的临床开发Palbociclib是首个临床可用的CDK4/6抑制剂，并于2015年2月获得FDA加速批准，联合来曲唑用于ER+和HER2-转移性乳腺癌绝经后女性患者的一线治疗。Palbociclib首次在两项I期单药治疗剂量递增研究中进行了评估，包括74例晚期癌症患者。在这些研究中，Palbociclib的剂量限制性毒性是骨髓抑制/中性粒细胞减少症，具有可逆性和非累积性。研究期间，共有69%的患者发生任何级别的中性粒细胞减少。疲乏、恶心、腹泻、呕吐、便秘和皮疹是最常见的非血液学毒性。选择125 mg/天给药3周停药1周的II期剂量，因为其耐受性增加。还对Palbociclib与紫杉醇每周一次联合治疗进行了研究；由于中性粒细胞减少症的发生率和需要减少剂量，故确定Palbociclib剂量为100 mg，给药3天，停药4天，以进行进一步研究。然后在II期试验中使用Palbociclib。一项在28例所有亚型的治疗前转移性乳腺癌患者中进行的palbociclib单药治疗II期试验发现，临床获益率（PR+SD>6个月）为21%，最常见的3/4级毒性仅限于中性粒细胞减少症和血小板减少症。在I期安全性导入期后进行了PALOMA-1 II期研究，该研究将患有激素受体阳性HER2-转移性乳腺癌的绝经后个体随机分配至来曲唑组或来曲唑+palbociclib组。将患者分为2个队列（队列1，N =6；队列2，N =99）。未选择队列1作为生物标志物，而评价了队列2的细胞周期蛋白D扩增和/或p16缺失。根据试验的最终报告，总研究组的主要终点PFS从来曲唑单药的10.2个月改善至来曲唑和palbociclib联合治疗的20.2个月，缓解率从33%增加至43%。加用palbociclib改善了两组的生存期；但是，生物标志物的表达与更好的结局之间没有明确的相关性。该研究显示了palbociclib的总体、可控毒性特征。PALOMA-2是一项随机III期研究，主要设计用于验证PALOMA-1的结果。在该试验中，666例女性患者按2:1的比例随机接受palbociclib+来曲唑或安慰剂+来曲唑。大约一半的个体之前接受过新辅助或辅助化疗，一半之前接受过辅助内分泌治疗。palbociclib-来曲唑组和安慰剂-来曲唑组的中位PFS分别为24.8个月和14.5个月。亚组分析显示所有指定组的获益一致。palbociclib–来曲唑组和安慰剂–来曲唑组的临床获益率（完全或部分缓解，或疾病稳定至少24周）分别为84.9%和70.3%。此后，设计了PALOMA-3，这是一项III期研究，旨在探索palbociclib+氟维司群在通常更年轻和风险更高的既往经治晚期HR +/HER2–乳腺癌患者中的作用。在本试验中，如果早期内分泌治疗后癌症复发或进展，且大多数患者已绝经，则有资格入组研究。共计521例患者按2:1的比例随机接受palbociclib或匹配安慰剂+氟维司群治疗。palbociclib+氟维司群组和安慰剂+氟维司群组的中位PFS分别为11.2个月和4.6个月。更新后的OS分析表明，palbociclib+氟维司群组的中位OS为34.8个月，而安慰剂+氟维司群组的中位OS为28.0个月。还在亚洲患者中进行了PALOMA-4临床研究，以检查来曲唑与palbociclib联用的有效性和安全性。随机分配患者（来曲唑和palbociclib，N =169；来曲唑和安慰剂，N =171）。OS的中位随访时间为52.8个月。截至数据截止日期（2020年8月31日），来曲唑和palbociclib组的中位PFS为21.5个月，安慰剂和来曲唑组为13.9个月，所有患者的ORR分别为37.3%和31.6%。与安慰剂组和来曲唑组相比，来曲唑组和palbociclib组中最常见的3/4级不良事件是中性粒细胞减少症、白细胞减少症、血小板减少症和贫血。PALOMA-4进一步验证了来曲唑和palbociclib作为ER+/HER2-晚期乳腺癌绝经后亚洲女性患者一线治疗的疗效和安全性。除了上文讨论的临床研究外，许多评价palbociclib单药或联合治疗对转移性和早期乳腺癌疗效的晚期临床试验正在进行中。例如，2017年6月开始了一项palbociclib靶向治疗转移性乳腺癌的随机、开放性、III期临床研究，主要目的是证明palbociclib联合抗HER2治疗+内分泌治疗在改善激素受体阳性/HER2 +转移性乳腺癌受试者的结局方面优于单独的抗HER2治疗+内分泌治疗。另一项于2018年启动的III期临床研究考察了激素受体HR+/HER2-晚期或转移性乳腺癌患者在他莫昔芬基础上加用palbociclib与单用他莫昔芬相比的疗效，不考虑绝经状态。此外，正在进行一项IV期临床研究，以验证palbociclib联合内分泌治疗与化疗相比可改善转移性乳腺癌患者的至治疗失败时间。本研究的目的是提供1级证据，证明palbociclib+内分泌治疗是需要一线治疗的转移性乳腺癌患者的治疗选择，不仅与内分泌治疗相比，而且与化疗联合或不联合内分泌维持治疗相比。这些晚期临床试验的更多详情见表4。预期这些正在进行的试验中的新临床证据可以阐明palbociclib在晚期乳腺癌治疗中的意义。2.12.4.ribociclib治疗乳腺癌的临床开发2017年3月13日，FDA批准ribociclib联合芳香化酶抑制剂（AI）作为HR+/HER2-晚期乳腺癌绝经后女性的一线治疗。2017年8月24日，欧盟委员会批准该药用于相同用途。这些批准主要基于MONALEESA临床试验项目的结果，其中包括MONALEESA-2、MONALEESA-3和MONALEESA-7试验。这些临床研究的主要目的是评价来曲唑联合ribociclib作为转移性或复发性HR+/HER2-乳腺癌绝经后女性患者的一线治疗。在MONALEESA 2临床研究中，668例患者以双盲方式随机接受ribociclib或安慰剂口服给药3周，停药1周，随后每4周为1周期，同时连续接受来曲唑治疗。患者必须有可测量的疾病或≥1个溶骨性病变，并根据是否存在内脏转移进行分类。Ribociclib的起始剂量为600 mg，即3片200 mg片剂。这项于2021年发表的临床研究的最新结果显示，在中位随访79.7个月后，ribociclib联合来曲唑与安慰剂联合来曲唑相比，OS增加具有统计学意义（中位数，63.9个月vs. 51.4个月）。研究人员表示，这是第一项在绝经后HR+/HER2-晚期乳腺癌患者中证明第三代CDKI具有统计学显著和临床重要OS优势的研究。MONALEESA 3试验在726例既往仅接受过一线内分泌治疗的晚期乳腺癌绝经后女性或男性患者中比较了氟维司群+ribociclib与氟维司群+安慰剂。这些试验的更新OS结果（于2021年在美国临床肿瘤学会年会上公布）表明，在中位随访时间延长至56.3个月后，ribociclib+氟维司群在HR+/HER-晚期乳腺癌绝经后患者中保留了OS获益，并且该获益在大多数患者亚组和治疗环境中保持不变。ribociclib联合氟维司群和氟维司群单药组的中位OS分别为53.7个月和41.5个月。与氟维司群单药治疗相比，ribociclib+氟维司群延迟了后续化疗的必要性，并改善了无化疗生存期。在MONALEESA-7试验中，研究人员使用各种联合治疗的ribociclib来评估绝经前/围绝经期晚期HR+/HER2-乳腺癌患者。在该试验中，患者接受ribociclib+他莫昔芬（每日20 mg）、安慰剂+他莫昔芬或ribociclib+芳香化酶抑制剂（来曲唑每日2.5 mg或阿那曲唑每日1 mg）、安慰剂+芳香化酶抑制剂治疗。此外，MONALEESA-7研究中的所有受试者在每个28天周期的第1天接受戈舍瑞林3.6 mg皮下给药，以抑制卵巢功能。中位随访53.5个月后，本研究的最新OS数据表明，与安慰剂+内分泌治疗相比，ribociclib联合内分泌治疗改善了OS（中位数，58.7个月vs. 48.0个月）。与安慰剂联合非甾体类芳香化酶抑制剂相比，ribociclib联合非甾体类芳香化酶抑制剂也改善了OS获益（中位数，58.7 vs. 47.7个月）。这些更新结果进一步表明，在延长随访超过4年后，在绝经前/围绝经期患者中，与单独内分泌治疗相比，ribociclib+内分泌治疗继续表现出临床相关的OS获益。此外，目前正在进行多项临床试验，以进一步研究ribociclib联合多种乳腺癌治疗的疗效。例如，一项II期、多中心、随机、开放性研究于2019年启动，预计于2025年完成。本研究的目的是检查400 mg ribociclib联合非甾体类芳香化酶抑制剂治疗既往未接受过任何治疗的绝经前和绝经后HR+/HER2-乳腺癌女性的安全性和有效性（NCT03822468）。另一项在原发性可手术HR+/HER2乳腺癌（2/3级，II期）男性和女性患者中开展的II期、开放性、多中心国际试验于2022年5月开始，旨在评价对新辅助ribociclib和来曲唑治疗有生物反应的患者接受非化疗治疗的安全性和长期疗效（NCT05296746）。HARMONIA是一项国际、多中心、随机、开放标签、III期研究，于2022年3月开始。本研究的主要目的是证明ribociclib联合内分泌治疗（来曲唑或氟维司群）在延长晚期HR+/HER2-和HER2富集乳腺癌患者的无进展生存期方面优于palbociclib联合内分泌治疗（来曲唑或氟维司群）（NCT05207709）。该研究将从全球约80家研究中心入组约456例HER2富集疾病患者。关于更多使用ribociclib的临床试验的详细信息见表3。表3.正在进行的ribociclib 单药或联合治疗的晚期临床试验列表2.12.5.abemaciclib治疗乳腺癌的临床开发Abemaciclib也是第三代CDKI，与palbociclib和ribociclib相比，具有独特的毒性特征，这可能是由于其对CDK4的抑制作用高于CDK6以及可能对CDK9的抑制作用。最初，由于JPBA I期研究的有希望的发现，FDA授予abemaciclib突破性疗法认定。随后，在2017年9月28日，FDA批准该抑制剂用于HR+/HER2-晚期乳腺癌患者的两种不同治疗环境。设置1为内分泌治疗和化疗治疗后疾病进展后的单药治疗，设置2为内分泌治疗后疾病进展后与氟维司群联合治疗。JPBA是一项大型、多中心Ib期研究，在33例患者中进行初始剂量递增，随后为扩展期，涉及192例特定恶性肿瘤患者，如乳腺癌、胶质母细胞瘤、肺癌、黑色素瘤和结直肠癌。在该剂量递增试验中，abemaciclib的最高耐受剂量确定为200 mg每日两次；与palbociclib和ribociclib不同，其在连续给药方案中耐受性良好。3级疲乏被确定为剂量限制性毒性。疲乏和胃肠道、肾脏或造血系统毒性是研究期间观察到的最常见治疗不良反应。还观察到骨髓抑制；但发生率低于palbociclib和ribociclib，仅10%的患者发生3/4级中性粒细胞减少症。试验中1例受试者被诊断为发热性中性粒细胞减少症。11%的患者发生1/2级肌酐升高，但这可能不是实际肾脏疾病损害的体征，因为药物影响肌酐肾小管分泌。2个乳腺癌队列被纳入研究的扩展期。Abemaciclib单药连续给药治疗47例既往接受过大量治疗的乳腺癌患者，不考虑其ER或HER2状态。在接受早期内分泌治疗时出现疾病进展的47例患者中，10例患者的治疗方案中还添加了Abemaciclib。在HR-乳腺癌患者中未观察到缓解；然而，31%的HR+患者对治疗有缓解，临床获益率为61%。此外，在由19例广泛预治疗转移性HR+乳腺癌患者组成的小型队列中，abemaciclib 200 mg每日两次与氟维司群联合治疗显示，可测量疾病患者的缓解率为36%，所有个体的临床获益比为63%。I期试验的有前景的结果使abemaciclib在HR+乳腺癌组中的研究得以扩展。单臂II期MONARCH 1试验的结果为FDA批准abemaciclib单药治疗奠定了基础。II期MONARCH 1研究招募并治疗了132例晚期HR+/HER2-乳腺癌患者，这些患者均接受过内分泌治疗和化疗（200 mg abemaciclib每日两次）。尽管存在耐药患者人群，其中大多数有内脏转移，但临床获益率达到42.4%。此外，在涉及abemaciclib、MONARCH 2和MONARCH 3的两项III期试验中招募了乳腺癌患者。MONARCH 2 III期研究在内分泌治疗后进展的晚期HR+/HER2-乳腺癌女性患者中比较了abemaciclib（150 mg，每日两次）联合氟维司群（500 mg）与安慰剂联合氟维司群的影响。在abemaciclib组中观察到的中位PFS为16.4个月，而安慰剂组为9.3个月。在可测量疾病患者中，abemaciclib组的ORR为48.1%，安慰剂组为21.3%。与安慰剂组相比，腹泻、中性粒细胞减少症、疲乏和恶心是abemaciclib组中最常见的不良反应。中性粒细胞减少症、白细胞减少症和腹泻是abemaciclib组最常报告的3级或4级不良事件。Abemaciclib正在MONARCH 3 III期研究中进行测试，该研究正在招募既往未接受过任何全身治疗的HR+/HER2晚期乳腺癌绝经后患者。共计493例绝经后女性被随机分配接受abemaciclib（150 mg，每日两次，连续给药）+芳香化酶抑制剂（阿那曲唑1 mg或来曲唑2.5 mg，每日一次）或安慰剂+芳香化酶抑制剂。MONARCH 3是唯一纳入绝经后患者的研究，而MONARCH 1和MONARCH 2没有描述患者的绝经状态。根据2022年欧洲肿瘤内科学会（ESMO）大会上公布的III期MONARCH 3试验的预定第二次期中分析的最新结果，在芳香化酶抑制剂（NSAI）中加用abemaciclib可使激素受体HR+/HER2-晚期乳腺癌患者的中位总生存期延长12.6个月。经确定，安全性结果与abemaciclib的既往观察结果一致。此外，多项I/II/III/IV期临床试验正在检查abemaciclib联合众多成功乳腺癌疗法的有效性。例如，探索abemaciclib联合芳香化酶抑制剂对HR+/HER2-晚期乳腺癌患者影响的II期临床研究（HERMIONE-7）于2020年1月启动。本试验将评估abemaciclib联合芳香化酶抑制剂在接受高剂量氟维司群预治疗的转移性乳腺癌患者中的临床获益率。预计共有121例患者入组研究（NCT04227327）。2021年2月，启动了一项新的临床研究阶段，以研究氟维司群联合abemaciclib联合或不联合氟维司群治疗ER+和Her2-转移性乳腺癌的影响。本试验的目的是确定将abemaciclib给药延迟一个月是否比从开始使用氟维司群和abemaciclib治疗既往治疗后进展的ER+/HER2-乳腺癌更成功（NCT05305924）。2022年4月，宣布了一项IV期临床研究，探索abemaciclib联合内分泌治疗在激素受体阳性HER2局部进展或转移性乳腺癌中的获益，重点是副作用控制（MINERVA，NCT05362760）。本研究旨在评价abemaciclib联合芳香化酶抑制剂或氟维司群作为一线治疗在绝经前和绝经后转移性HER2 +/HER2-乳腺癌患者中的安全性、疗效和生活质量。其他多项使用abemaciclib的临床试验也正在进行中。这些试验的详细信息见表4。表4.正在进行的Abemaciclib 单药或联合治疗晚期临床试验列表2.12.6.trilaciclib治疗乳腺癌的临床开发Trilaciclib 是最新的第三代 CDK 4/6 抑制剂，最近在美国获批用于治疗小细胞肺癌患者，以减少化疗带来的骨髓抑制。根据 trilaciclib 开发者 G1 Therapeutics 的新闻稿，FDA已授予 trilaciclib 快速通道资格认定，与化疗联用治疗局部晚期或转移性 TNBC 患者（新闻发布）。G1 Therapeutics,Inc.（2021年07月19日）。快速通道是 FDA 设计的一个流程，旨在促进药物的开发和加快审查，以治疗严重疾病并填补未满足的医疗需求。尽管已报告 trilaciclib 是一种基于细胞的CDK 44/6 的非常强效、选择性和可逆性抑制剂，但目前仅有少数临床试验正在研究其治疗 TNBC 的疗效。例如，在一项随机 II 期研究中，在吉西他滨和卡铂给药前静脉给予trilaciclib，并在 TNBC 患者中与单独化疗进行比较。本研究的目的是在102例既往接受过不超过2个疗程化疗的TNBC 患者中研究 trilaciclib 的骨髓保护作用。第1组在第1天和第8天给予 1000 mg/m2 吉西他滨和卡铂，第2组在第1天和第8天给予吉西他滨和卡铂以及240 mg/m2 trilaciclib，第3组在第2天和第9天给予吉西他滨和卡铂，第1、2、8和9天给予trilaciclib，21天为一个周期。记录的骨髓抑制水平无明显差异。尽管 OS 不是研究的主要终点，但结果具有显著性，第1组的 OS 为12.6个月，第2组为20.1个月，第3组为17.8个月。贫血、血小板减少症和中性粒细胞减少症是研究期间观察到的最常见副作用。鉴于这些发现，目前正在开展多项随机 II/III 期研究。例如，正在进行一项 III 期、多中心、随机、双盲、安慰剂对照研究，在接受首次或第二次治疗的局部晚期、不可切除或转移性 TNBC 患者中比较在吉西他滨和卡铂给药前给予 trilaciclib 与安慰剂的安全性和有效性 (PRESERVE 2，NCT04799249)。目前正在进行另一项 II 期、多中心、开放性、单臂研究，以评估在既往接受过至少2种治疗（其中至少1种治疗为转移性疾病）的不可切除、局部晚期或转移性 TNBC 患者中，在 sacituzumab govitecan-hziy 给药前给予trilaciclib 的安全性和疗效 (NCT05113966)。此外，正在启动一项 II 期临床研究，以评估 trilaciclib 联合标准治疗在早期 TNBC 新辅助治疗背景下的作用机制以及安全性和有效性 (NCT05112536)。关于使用 trilaciclib 治疗晚期乳腺癌的最新正在进行的临床试验的更多详细信息见表5。表5.正在进行的Trilaciclib 单药或联合治疗的晚期临床试验列表2.12.7.未来展望和结论在过去的几十年中，CDKI研发领域见证了晚期癌症疗法方面的兴奋和乐观的一面，增长迅速，由此产生了一批具有多种抑制靶点的市售药物，对多种癌症具有多样化的抑制靶点。这篇综述只涵盖了经过相当多研究和临床评价的 CDKIs 的一个部分，其他大量 CDKIs 现在正在开发中。尽管早期开发的CDKIs（第一代和第二代抑制剂）在临床前和一定程度上在临床研究中表现出了显着的抗肿瘤疗效，但由于其特异性低、副作用严重，这些抑制剂用于癌症患者的治疗在临床方面并没有受到太多的关注。现在正在这方面进行一些临床试验，以确定联合治疗和优化这些第1代和第2代 CDKI 是否会产生任何有希望的结果。与第一代和第二代 CDKI 相比，开发第三代CDKI（palbociclib、ribociclib、abemaciclib和trilaciclib）取得了很大进展。临床前和临床结果表明，这些选择性 CDK 4/6抑制剂可减少多种恶性肿瘤的进展，在乳腺癌中具有突出的活性。为此，这4种 CDK 4/6 抑制剂中有3种获得FDA 批准，1种处于晚期乳腺癌治疗的快速通道资格认定。乳腺癌晚期临床研究的临床数据目前表明，作为单药治疗的疗效，以及在内分泌/化疗的基础上加用 CDK 4/6 抑制剂治疗晚期乳腺癌的获益。然而，这些药物联合内分泌/化疗的结果似乎更有前景。这些抑制剂进一步开发方式的主要障碍是一致的毒性信号、缺乏预测性生物标志物和耐药性。在这方面，正在进行多次尝试。进一步深入研究降低相关毒性、探索预测的生物标志物和确定 CDK 4/6 抑制的原发性或继发性耐药机制，可能为这些抑制剂的治疗应用提供创新的生物医学依据。内容来源：https://www-sciencedirect-com.libproxy1.nus.edu.sg/science/article/pii/S1044579X22002607#fig0005声明：发表/转载本文仅仅是出于传播信息的需要，并不意味着代表本公众号观点或证实其内容的真实性。据此内容作出的任何判断，后果自负。若有侵权，告知必删！长按关注本公众号   粉丝群/投稿/授权/广告等请联系公众号助手 觉得本文好看，请点这里↓

Advanced oncology pipeline in mid- and late-stage with plans to have ten or more potentially registrational oncology trials running by the end of 2024 Aiming for first oncology launch in 2026 and ten indication approvals by 2030 as part of BioNTech's strategy to develop combinatorial and synergistic therapeutic approaches Entered strategic collaborations with Biotheus, DualityBio, Medilink and OncoC4 to complement clinical oncology pipeline with innovative antibody-drug conjugate (ADC) and immuno-modulatory programs Annemarie Hanekamp appointed as Chief Commercial Officer effective July 1, 2024 Delivered over 400 million COVID-19 vaccine doses worldwide in 2023, including successfully launched XBB.1.5 variant-adapted monovalent COVID-19 vaccine Progressed three infectious disease vaccine candidates into clinical evaluation, leveraging BioNTech's mRNA technology and expertise Fourth quarter and full year 2023 revenues of €1.5 billion and €3.8 billion, respectively Full year net profit of €0.9 billion and fully diluted earnings per share of €3.83 ($4.141) Strong financial position with €17.7 billion in cash, cash equivalents and security investments 2024 revenue guidance of €2.5 billion to €3.1 billion Conference call and webcast scheduled for March 20, 2024, at 8:00 a.m. ET (1:00 p.m. CET) MAINZ, Germany, March 20, 2024 (GLOBE NEWSWIRE) -- BioNTech SE (Nasdaq: BNTX, “BioNTech” or “the Company”) today reported financial results for the three months and full year ended December 31, 2023, and provided an update on its corporate progress. “2023 was another year of good performance for BioNTech. We have maintained our leading position in the COVID-19 vaccine market which lays the foundation for establishing a sustainable respiratory vaccines business. In oncology, we have strengthened our core competencies by entering into several partnerships and have made numerous clinical advances. Today, our oncology pipeline encompasses multiple candidates in mid- and late-stage clinical development, including investigational ADCs, mRNA vaccines and innovative immunotherapies,” said Prof. Ugur Sahin, M.D., CEO and Co-Founder of BioNTech. “Our goal is to achieve product approvals in ten oncological indications by 2030 and with this improve the treatment options for patients around the globe.” Financial Review for the Fourth Quarter and Full Year 2023 Financial Results in millions €, except per share data Fourth Quarter 2023 Fourth Quarter 2022 Full Year 2023 Full Year 2022 Total Revenues 1,479.0 4,278.3 3,819.0 17,310.6 Net Profit 457.9 2,278.7 930.3 9,434.4 Diluted Earnings per Share 1.90 9.26 3.83 37.77 Total revenues reported were €1,479.0 million for the three months ended December 31, 2023, compared to €4,278.3 million for the comparative prior year period. For the year ended December 31, 2023, total revenues were €3,819.0 million, compared to €17,310.6 million for the comparative prior year period. Inventory write-downs by BioNTech's collaboration partner Pfizer, Inc. (“Pfizer”) reduced BioNTech's revenues by €291.3 million and €906.7 million for the three and twelve months ended December 31, 2023, respectively. Cost of sales were €179.1 million for the three months ended December 31, 2023, compared to €183.5 million for the comparative prior year period. For the year ended December 31, 2023, cost of sales were €599.8 million, compared to €2,995.0 million for the comparative prior year period. The change was mainly caused by the decrease in COVID-19 vaccine sales. Research and development (R&D) expenses were €577.8 million for the three months ended December 31, 2023, compared to €509.8 million for the comparative prior year period. For the year ended December 31, 2023, research and development expenses were €1,783.1 million, compared to €1,537.0 million for the comparative prior year period. R&D expenses are mainly influenced by progressing clinical studies for pipeline candidates as well as by our newly acquired product candidates and the development of variant-adapted COVID-19 vaccines. The increase was further driven by an increase in wages, benefits and social security expenses resulting from an increase in headcount. General and administrative (G&A) expenses reached €124.3 million for the three months ended December 31, 2023, compared to €119.9 million for the comparative prior year period. For the year ended December 31, 2023, G&A expenses were €495.0 million, compared to €481.7 million for the comparative prior year period. G&A expenses were mainly influenced by increased expenses for IT services as well as by wages, benefits and social security expenses resulting from an increase in headcount. Income taxes were accrued in an amount of €205.3 million for the three months ended December 31, 2023, compared to €893.9 million accrued for the comparative prior year period. For the year ended December 31, 2023, income taxes were accrued with an amount of €255.8 million, compared to €3,519.7 million accrued for the comparative prior year period. The derived annual effective income tax rate for the year ended December 31, 2023, was 21.6%. Net profit was €457.9 million for the three months ended December 31, 2023, compared to €2,278.7 million for the comparative prior year period. For the year ended December 31, 2023, net profit was €930.3 million, compared to €9,434.4 million net profit for the comparative prior year period. Cash and cash equivalents as well as security investments2as of December 31, 2023, reached €17,653.4 million, comprising €11,663.7 million cash and cash equivalents and €5,989.0 million security investments, respectively. Diluted earnings per share was €1.90 for the three months ended December 31, 2023, compared to diluted earnings per share of €9.26 for the comparative prior year period. For the year ended December 31, 2023, diluted earnings per share were €3.83, compared to €37.77 diluted earnings per share for the comparative prior year period. Shares outstanding as of December 31, 2023, were 237,725,735, excluding 10,826,465 shares held in treasury. In March 2023, the Management Board and Supervisory Board authorized the 2023 share repurchase program, under which BioNTech was permitted to purchase ADSs, each representing one ordinary share, with a value of up to $0.5 billion, which started June 2, 2023, and concluded on September 18, 2023. During the three months ended December 31, 2023, 114,513 ADSs were repurchased under the share repurchase program at an average price of $112.22 (€105.07), for total consideration of $12.9 million (€12.0 million). For the year ended December 31, 2023, a total of 4,646,965 ADSs were repurchased related to the 2023 program at an average price of $107.58 (€98.24), for total consideration of $0.5 billion (€456.5 million). “In 2023, we strengthened our financial position while concurrently progressing our clinical pipeline of immunotherapies and executing acquisitions and collaborations. Looking ahead to 2024, we will maintain a prudent capital allocation strategy as we invest and execute in our maturing pipeline and prepare for our first potential oncology launches,” said Jens Holstein, CFO of BioNTech. “Our COVID-19 vaccine franchise is expected to remain an important cash contributor in 2024. We believe our solid financial position will enable us to push forward with our long-term strategy to develop novel therapies against cancer, infectious and other severe diseases thereby generating added value for patients, society, investors and the Company.” Outlook for the 2024 Financial Year The Company's outlook contains the following components: Total revenues for the 2024 financial year €2.5 billion - €3.1 billion BioNTech expects group revenue for the full 2024 financial year to be in the range of €2.5 - €3.1 billion. The range reflects certain assumptions, including, but not limited to, expectations regarding: the timing and grant of regulatory approvals and recommendations, COVID-19 vaccine uptake and price levels, inventory write-downs by BioNTech's collaboration partner Pfizer that would negatively influence the Company's revenues, seasonal variations in SARS-CoV-2 circulation and vaccination uptake which are expected to lead to demand peaks in the autumn and winter compared to other seasons, revenues from a pandemic preparedness contract with the German government as well as revenues from BioNTech Group service businesses, namely InstaDeep, JPT Peptide Technologies GmbH and in Idar-Oberstein at BioNTech Innovative Manufacturing Services GmbH. Generally, the Company continues to remain largely dependent on revenues generated in its collaboration partner’s territories in 2024. Planned 2024 Financial Year Expenses and Capex3: R&D expenses4 €2.4 billion - €2.6 billion SG&A expenses5 €700 million - €800 million Capital expenditures for operating activities €400 million - €500 million BioNTech expects to continue to focus investments on R&D and scaling the business for commercial readiness in oncology, while continuing to be cost disciplined. Strategic capital allocation will continue to be an important driver of the Company's trajectory. As part of BioNTech's strategy, the Company may continue to evaluate appropriate corporate development opportunities with the aim of driving sustainable long-term growth and create future value. The full audited consolidated financial statements as of and for the year ended December 31, 2023, can be found in BioNTech’s Annual Report on Form 20-F for the period ended December 31, 2023, filed today with the United States Securities and Exchange Commission (“SEC”) and available at (the “Annual Report”). Endnotes 1 Calculated applying the average foreign exchange rate for the year ended December 31, 2023, as published by the German Central Bank (Deutsche Bundesbank). 2 The contractual settlement of the gross profit share has a temporal offset of more than one calendar quarter. As Pfizer’s financial quarter for subsidiaries outside the United States differs from BioNTech's, it creates an additional time lag between the recognition of revenues and the payment receipt. 3 Numbers reflect current base case projections and are calculated based on constant currency rates, and exclude external risks that are not yet known and/or quantifiable, including, but not limited to, the effects of ongoing and/or future legal disputes or related activity. 4 Numbers include effects identified from additional collaborations or potential M&A transactions to the extent disclosed and are subject to update due to future developments. 5 Anticipated expenses related to external legal advice in connection with certain legal litigations are not reflected in SG&A but in other operating expenses. Guidance does not include and may be impacted by potential payments resulting from the outcomes of ongoing or future legal disputes or related activity, such as judgments or settlements. Operational Review of the Fourth Quarter 2023, Key Post Period-End Events and 2024 Outlook Omicron XBB.1.5-adapted Monovalent COVID-19 Vaccine (COMIRNATY®) BioNTech and Pfizer developed, manufactured and delivered their Omicron XBB.1.5-adapted monovalent COVID-19 vaccine, which has received multiple regulatory approvals, including full approvals, authorizations for emergency or temporary use, or marketing authorizations in more than 40 countries and regions. In 2023, BioNTech and Pfizer delivered more than 400 million COVID-19 vaccine doses worldwide. COVID-19 – Influenza Combination Vaccine Program BNT162b2 + BNT161 is an mRNA-based combination vaccine program against COVID-19 and influenza being developed in collaboration with Pfizer. Topline data from the Phase 1/2 trial (NCT05596734) demonstrated robust immune responses to influenza A, influenza B, and SARS-CoV-2 strains and that the safety pro the candidates was consistent with that of the companies’ COVID-19 vaccine. A Phase 3 clinical trial (NCT06178991) was initiated in December 2023. Select Oncology Pipeline Highlights BioNTech's vision for oncology is to bring novel therapies to patients and address the continuum of cancer treatment, from early to late lines. Addressing root causes of cancer treatment failure such as cancer heterogeneity and interindividual variability is the core of its strategy. To augment anti-tumor activity and to counteract resistance mechanisms, BioNTech seeks to combine compounds with non-overlapping, synergistic mechanisms of action. In 2023, the Company’s pipeline continued to mature, with various programs advancing towards later stages of development. BioNTech’s oncology pipeline currently contains 10 ongoing Phase 2 and 3 trials. In 2024, the Company expects to continue building its pipeline towards its planned first oncology launch in 2026. BioNTech aims to have ten indication approvals by 2030. Antibody-Drug Conjugate (ADC) Programs BNT323/DB-1303 is an ADC candidate targeting Human Epidermal Growth Factor 2 (HER2) that is being developed in collaboration with Duality Biologics (Suzhou) Co. Ltd. (“DualityBio”). An ongoing randomized, multi-center, open-label Phase 3 clinical trial (NCT06018337) is recruiting to evaluate BNT323/DB1303 versus the investigator's choice of chemotherapy in advanced or metastatic Hormone Receptor (HR)+, HER2-low breast cancer subjects whose disease has progressed on at least two lines of prior endocrine therapy or within six months of first-line endocrine therapy + cyclin-dependent kinase 4/6 (CDK4/6) inhibitor therapy without prior chemotherapy. The first patient was dosed in January 2024 and the trial aims to enroll 532 patients. A potentially registrational single-arm trial enrolling HER2-expressing (immunohistochemistry score (“IHC”) 3+, 2+, 1+ or in situ hybridization (“ISH”)-positivet) patients with endometrial carcinoma is ongoing and plans to enroIl 140 patients. In December 2023, the U.S. Food and Drug Administration (“FDA”) granted Breakthrough Therapy designation for BNT323/DB-1303 for the potential treatment of advanced endometrial cancer in patients whose disease progressed on or after treatment with immune-checkpoint inhibitors. First-in-human data from the ongoing Phase 1/2 trial (NCT05150691) were presented at medical conferences in 2023, indicating a manageable safety pro anti-tumor activity in patients with heavily pretreated HER2-expressing solid tumors, including breast and endometrial cancer. Data from this trial informed the decision to further evaluate this candidate in these indications in the aforementioned studies. Additional trials with registrational potential are planned to be initiated in 2024. BNT325/DB-1305 is an ADC candidate targeting Trophoblast Cell-surface Antigen 2 (“TROP2”) that is being developed in collaboration with DualityBio. Data from the ongoing Phase 1/2 clinical trial (NCT05438329) were presented at the 2023 European Society for Medical Oncology (“ESMO”) Annual Meeting. The dose range with manageable safety pro determined. Encouraging preliminary activity was observed in heavily pretreated patients with advanced/metastatic solid tumors. In November 2023, two new cohorts were added to the study: one to evaluate BNT325/DB-1305 monotherapy in cervical cancer, and one to assess the combination of BNT325/DB-1305 with pembrolizumab in non-small cell lung cancer (“NSCLC”). In January 2024, BioNTech and DualityBio received Fast Track designation for BNT325/DB-1305 from the FDA for the treatment of patients with platinum-resistant ovarian epithelial, fallopian tube, or primary peritoneal cancer who have received one to three prior systemic treatment regimens. Next-Generation Immune Checkpoint Immunomodulator Programs BNT316/ONC-392 (gotistobart) is an anti-CTLA-4 monoclonal antibody candidate being developed in collaboration with OncoC4, Inc. (“OncoC4”). In June 2023, a Phase 3 clinical trial (NCT05671510) was initiated to evaluate BNT316/ONC-392 (monotherapy in patients with metastatic NSCLC whose disease progressed on anti-PD-1/PD-L1 antibody-based therapy. In November 2023, clinical data from the ongoing Phase 1/2 trial (NCT04140526) were presented at the Society for Immunotherapy of Cancer (”SITC”) Annual Meeting in which BNT316/ONC-392 was observed to have a manageable safety profile. The data also included encouraging clinical activity observations in patients with immunotherapy-resistant NSCLC, which informed the decision to proceed the Phase 3 clinical trial. In December 2023, the first patient was dosed in a Phase 1/2 clinical trial (NCT05682443) to evaluate the efficacy and safety of BNT316/ONC-392 in combination with the radioligand therapy, lutetium (177Lu) vipivotide tetraxetan in patients with metastatic castration-resistant prostate cancer (“mCRPC”) who have progressed on an androgen receptor pathway inhibitor. BNT311/GEN1046 (acasunlimab) is a potential first-in-class bispecific antibody candidate combining PD-L1 checkpoint inhibition with 4-1BB costimulatory activation that is being developed in collaboration with Genmab S/A (“Genmab”). Based on emerging clinical data, the companies are engaging with health authorities on the design of a Phase 3 trial in second-line NSCLC. The companies intend to share initial data at a medical conference in the first half of 2024 from an ongoing Phase 2 randomized, open-label clinical trial (NCT05117242) evaluating BNT311/GEN1046 as monotherapy and in combination with pembrolizumab in patients with relapsed/refractory metastatic NSCLC and a tumor PD-L1 expression of tumor proportion score of ≥1% after treatment with standard-of-care therapy with an immune-checkpoint inhibitor. The primary endpoint is objective response rate according to Response Evaluation Criteria in Solid Tumors (“RECIST v1.1”). Secondary endpoints include duration of response, time to response, progression-free survival, overall survival and safety. BNT312/GEN1042 is a potential first-in-class bispecific antibody candidate designed to induce conditional immune activation by crosslinking CD40 and 4-1BB positive cells that is being developed in collaboration with Genmab. The companies intend to share updated data at a medical conference in the second half of 2024 from an ongoing Phase 1/2 dose-escalation clinical trial (NCT04083599) with expansion cohorts evaluating safety and anti-tumor activity of BNT312/GEN1042 as monotherapy and in combination therapies in patients with solid tumors. The companies also expect to determine next steps for this program in 2024. BNT327/PM8002 is an anti-VEGF-A antibody candidate fused to a humanized anti-PD-L1 VHH that is being developed in collaboration with Biotheus Inc. (“Biotheus”). BNT327/PM8002 is currently being evaluated in Phase 1 and Phase 2/3 clinical trials in China to assess the efficacy and safety of the candidate as a monotherapy or in combination with chemotherapy in various indications, including in first line small-cell lung cancer (“SCLC”) and second-line Epidermal Growth Factor Receptor (“EGFR”)-mutated NSCLC. Data from a Phase 1/2 clinical trial in advanced solid tumors presented in 2023 indicate that BNT327/PM8002 monotherapy may have antitumor activity and a manageable safety profile. Data from Phase 2 trials in patients with SCLC and triple-negative breast cancer (“TNBC”) presented in 2023 indicate that BNT327/PM8002 in combination with chemotherapy may have encouraging antitumor activity and an acceptable toxicity pro second and first-line therapy, respectively. An Investigational New Drug (“IND”) application has been accepted by the FDA for further studies in the United States. Global trials are planned to start in 2024. Cancer Vaccine Programs BNT116 is based on BioNTech’s FixVac platform, and is a wholly owned, systemically administered, off-the-shelf uridine mRNA-lipoplex based cancer vaccine candidate encoding six shared lung cancer associated antigens. BNT116 is being evaluated for the treatment of advanced NSCLC. A randomized, controlled Phase 2 clinical trial (NCT05557591) is ongoing to evaluate BNT116 in combination with cemiplimab versus cemiplimab alone as first-line treatment in patients with advanced NSCLC whose tumors express PD-L1 in ≥ 50% of tumor cells. In November 2023, data from the ongoing Phase 1 clinical trial (NCT05142189) evaluating the safety, tolerability and preliminary efficacy of BNT116 alone and in combination with cemiplimab or chemotherapy were presented at the 2023 SITC Annual Meeting. BNT116 was observed to be generally well tolerated with an expected safety pro monotherapy and in combination with cemiplimab. In heavily pretreated NSCLC patients, early clinical activity was observed with treatment with BNT116 with the addition of cemiplimab from cycle 3 onward. Additional data from a different cohort of this Phase 1 clinical trial evaluating BNT116 in combination with docetaxel in patients with NSCLC that progressed on prior anti-PD(L)-1 therapy will be presented at the 2024 American Association of Cancer Research ("AACR") Annual Meeting in April 2024. Autogene cevumeran (BNT122) is an uridine mRNA-lipoplex based cancer vaccine candidate for individualized neoantigen-specific immunotherapy ("iNeST") being developed in collaboration with Genentech, Inc. ("Genentech"), a member of the Roche Group (“Roche”). In October 2023, BioNTech announced the initiation of a Phase 2 trial (NCT05968326) evaluating the efficacy and safety of BNT122 in combination with the anti-PD-L1 immune checkpoint inhibitor atezolizumab and standard of care chemotherapy in patients with resected pancreatic ductal adenocarcinoma ("PDAC"). Follow-up data from the investigator-initiated Phase 1 trial in patients with resected PDAC which informed and motivated the Phase 2 trial, are due to be presented at the AACR Annual Meeting in April 2024. The results of the Phase 1 trial were published in Nature (Rojas et al., Nature 2023). An additional Phase 2 clinical trial is planned to be initiated as early as 2024. Cell Therapy Programs BNT211 is a CAR-T cell product candidate targeting Claudin-6 ("CLDN6")-positive solid tumors that is combined with a CAR-T cell-amplifying RNA vaccine ("CARVac") encoding CLDN6. An open-label, multi-center Phase 1/2 dose escalation and dose expansion basket trial (NCT04503278) evaluating CLDN6 CAR-T cells with or without a CLDN6 CARVac in CLDN6-positive relapsed or refractory advanced solid tumors, including ovarian and testicular cancers, is ongoing. Data from this trial were reported at several conferences, including ASCO and ESMO 2023. Encouraging signs of activity were observed. In several patients treated with CARVac, an increased persistence of CLDN6 CAR-T cells was observed. The rate of treatment-dependent adverse event was dose-dependent and further evaluation is ongoing to determine the CLDN6 CAR T dose with manageable safety. A pivotal Phase 2 clinical trial in relapsed/refractory germ cell tumors is planned to start in 2024. Select Infectious Disease Pipeline Highlights Beyond BioNTech’s portfolio of variant-adapted, next-generation and combination respiratory programs, the Company is developing vaccine modalities against multiple pathogens that pose a threat to public health and have a significant global health burden. In 2023, BioNTech initiated three first-in-human Phase 1 clinical trials leveraging its proprietary mRNA prophylactic vaccine technology. These trials are for vaccine candidates addressing shingles (NCT05703607), tuberculosis (NCT05537038, Germany and NCT05547464, Republic of South Africa), and mpox (NCT05988203). Corporate Update for 2023 and Key Post Period-End Events In 2023, BioNTech strategically forged a series of complementary agreements and collaborations, including: The acquisition of its long-time strategic collaboration partner, InstaDeep Ltd (“InstaDeep”), which provides BioNTech with capabilities to leverage artificial intelligence (AI) and machine learning (ML) technologies across its therapeutic platforms and operations. With this acquisition, BioNTech has added industry-leading AI and ML capabilities and approximately 290 highly skilled professionals to its organization. InstaDeep is operating as a London-based subsidiary of BioNTech. New collaborations with DualityBio and MediLink Therapeutics (Suzhou) Co., Ltd. ("MediLink") which expanded BioNTech's technology base into ADCs, and collaborations with OncoC4 and Biotheus that have complemented the Company's pipeline with mid-to-late-stage novel immunomodulators. A strategic partnership with the Government of the United Kingdom ("UK") aiming to lead to personalized mRNA cancer immunotherapies reaching up to 10,000 patients by 2030. BioNTech also plans to invest in a research and development hub in Cambridge, UK, which is expected to employ more than 70 additional highly skilled scientists. A multi-year strategic partnership with the State of Victoria, Australia, to set up and operate a clinical-scale mRNA manufacturing facility through its BioNTainers, BioNTech’s modular, state-of-the-art mRNA manufacturing solution, and to establish an mRNA Innovation Center in Melbourne. Over the last 12 months, BioNTech expanded its organization in Asia, Africa, North America, Australia and Europe. The Company increased its research and development and production capabilities and completed construction of its first proprietary plasmid DNA manufacturing facility in Marburg, Germany. BioNTech also delivered and set up the first BioNTainer for its site in Kigali, Rwanda. In February 2024, BioNTech entered into a strategic collaboration with Autolus Therapeutics plc ("Autolus") aimed at advancing both companies’ autologous CAR-T programs towards commercialization, pending regulatory authorizations. The collaboration also grants BioNTech the option to access a suite of Autolus’ target binders and cell programming technologies to support BioNTech’s development of in vivo cell therapy and ADC candidates. In March 2024, BioNTech announced that Sean Marett, Chief Business and Commercial Officer, will retire as planned from the Management Board of BioNTech. As of July 1, 2024, Sean Marett will continue as a specialist advisor to the Company at least until the end of the year. As announced earlier today, Annemarie Hanekamp will be joining the Company's Management Board as Chief Commercial Officer on July 1, 2024. Sean Marett’s responsibilities as Chief Business Officer are being gradually transferred to James Ryan, Ph.D., Chief Legal Officer, who joined the Management Board in September 2023 and who will also take on the role as Chief Business Officer of BioNTech at the end of the transition phase and upon Sean Marett’s retirement. Environmental, Social, and Governance (ESG) In February 2024, the Company’s near-term science-based emissions reduction targets were approved by the Science Based Targets initiative (“SBTi”). This validation underscores the ambitious nature of BioNTech’s scope 1 and scope 2 climate targets and is intended to align with the United Nations' Paris Climate Agreement to limit global warming to 1.5 degrees Celsius above pre-industrial levels. More information on BioNTech’s Scope 1, 2 and 3 targets can be found in the Company's press release dated February 12, 2024. BioNTech's performance on environmental, social, and governance matters is regularly assessed by external rating agencies. The Institutional Shareholder Services Group ("ISS") currently assigns BioNTech a "Prime" ESG rating: the Company has received an overall corporate rating of B-, which is among the top 10% of all rated companies in the pharmaceutical and biotechnology sector. In the ISS Governance Quality Score, BioNTech stands at 5 on a risk scale of 1 (low risk) to 10 (high risk). S&P Global Ratings has rated BioNTech in the S&P Corporate Sustainability Assessment 2023 ("CSA") with an S&P Global CSA score of 45 (2022: 32) out of 100. Morningstar Sustainalytics has given BioNTech a Sustainalytics ESG rating of 24.1 (2022: 22.3), which corresponds to a "medium risk", the third of five risk levels (negligible, low, medium, high and severe). BioNTech publishes its ESG report (Sustainability Report 2023) today, March 20, 2024. The report is being made available on the Investors' section of BioNTech’s website. Upcoming Investor and Analyst Events Annual General Meeting: May 17, 2024 Innovation Series (Digital & AI Day): October 1, 2024 Innovation Series: November 14, 2024 Conference Call and Webcast Information BioNTech invites investors and the general public to join a conference call and webcast with investment analysts today, March 20, 2024, at 8:00 a.m. ET (1:00 p.m. CET) to report its financial results and provide a corporate update for the fourth quarter and financial year 2023. To access the live conference call via telephone, please register via this link. Once registered, dial-in numbers and a pin number will be provided. The slide presentation and audio of the webcast will be available via this link. Participants may also access the slides and the webcast of the conference call via the “Events & Presentations” page of the Investors' section of the Company’s website at . A replay of the webcast will be available shortly after the conclusion of the call and archived on the Company’s website for 30 days following the call. About BioNTech Biopharmaceutical New Technologies (BioNTech) is a global next generation immunotherapy company pioneering novel therapies for cancer and other serious diseases. BioNTech exploits a wide array of computational discovery and therapeutic drug platforms for the rapid development of novel biopharmaceuticals. Its broad portfolio of oncology product candidates includes individualized and off-the-shelf mRNA-based therapies, innovative chimeric antigen receptor (CAR) T cells, several protein-based therapeutics, including bispecific immune checkpoint modulators, targeted cancer antibodies and antibody-drug conjugate (ADC) therapeutics, as well as small molecules. Based on its deep expertise in mRNA vaccine development and in-house manufacturing capabilities, BioNTech and its collaborators are developing multiple mRNA vaccine candidates for a range of infectious diseases alongside its diverse oncology pipeline. BioNTech has established a broad set of relationships with multiple global and specialized pharmaceutical collaborators, including Biotheus, DualityBio, Fosun Pharma, Genentech, a member of the Roche Group, Genevant, Genmab, OncoC4, Pfizer and Regeneron. For more information, please visit . Forward-Looking Statements This press release contains forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, as amended, including, but not limited to, statements concerning: BioNTech's expected revenues and net profit related to sales of BioNTech's COVID-19 vaccine, referred to as COMIRNATY where approved for use under full or conditional marketing authorization, in territories controlled by BioNTech's collaboration partners, particularly for those figures that are derived from preliminary estimates provided by BioNTech's partners; the rate and degree of market acceptance of BioNTech's COVID-19 vaccine and, if approved, BioNTech's investigational medicines; expectations regarding anticipated changes in COVID-19 vaccine demand, including changes to the ordering environment and expected regulatory recommendations to adapt vaccines to address new variants or sublineages; the initiation, timing, progress, results, and cost of BioNTech's research and development programs, including those relating to additional formulations of BioNTech's COVID-19 vaccine, and BioNTech's current and future preclinical studies and clinical trials, including statements regarding the timing of initiation, enrollment, and completion of studies or trials and related preparatory work and the availability of results, and the timing and outcome of applications for regulatory approvals and marketing authorizations; BioNTech's expectations with respect to its intellectual property; the impact of BioNTech's collaboration and licensing agreements and its acquisition of InstaDeep Ltd.; the development, nature and feasibility of sustainable vaccine production and supply solutions; and BioNTech's estimates of revenues, research and development expenses, cost of sales, general and administrative expenses, and capital expenditures for operating activities. In some cases, forward-looking statements can be identified by terminology such as “will,” “may,” “should,” “expects,” “intends,” “plans,” “aims,” “anticipates,” “believes,” “estimates,” “predicts,” “potential,” “continue,” or the negative of these terms or other comparable terminology, although not all forward-looking statements contain these words. The forward-looking statements in this press release are neither promises nor guarantees, and you should not place undue reliance on these forward-looking statements because they involve known and unknown risks, uncertainties, and other factors, many of which are beyond BioNTech’s control and which could cause actual results to differ materially from those expressed or implied by these forward-looking statements. These risks and uncertainties include, but are not limited to: BioNTech's pricing and coverage negotiations regarding its COVID-19 vaccine with governmental authorities, private health insurers and other third-party payors after BioNTech's initial sales to national governments; the future commercial demand and medical need for initial or booster doses of a COVID-19 vaccine; competition from other COVID-19 vaccines or related to BioNTech's other product candidates, including those with different mechanisms of action and different manufacturing and distribution constraints, on the basis of, among other things, efficacy, cost, convenience of storage and distribution, breadth of approved use, side-effect pro durability of immune response; the timing of and BioNTech's ability to obtain and maintain regulatory approval for BioNTech's product candidates; the ability of BioNTech’s COVID-19 vaccines to prevent COVID-19 caused by emerging virus variants; BioNTech's and its counterparties’ ability to manage and source necessary energy resources; BioNTech's ability to identify research opportunities and discover and develop investigational medicines; the ability and willingness of BioNTech's third-party collaborators to continue research and development activities relating to BioNTech's development candidates and investigational medicines; the impact of the COVID-19 pandemic on BioNTech's development programs, supply chain, collaborators and financial performance; unforeseen safety issues and potential claims that are alleged to arise from the use of BioNTech's COVID-19 vaccine and other products and product candidates developed or manufactured by BioNTech; BioNTech's and its collaborators’ ability to commercialize and market BioNTech's COVID-19 vaccine and, if approved, its product candidates; BioNTech's ability to manage its development and expansion; regulatory developments in the United States and other countries; BioNTech's ability to effectively scale its production capabilities and manufacture its products, including target COVID-19 vaccine production levels, and product candidates; risks relating to the global financial system and markets; and other factors not known to BioNTech at this time. You should review the risks and uncertainties described under the heading “Risk Factors” in BioNTech's Annual Report on Form 20-F for the year ended December 31, 2023 and in subsequent filings made by BioNTech with the SEC, which are available on the SEC’s website at . Except as required by law, BioNTech disclaims any intention or responsibility for updating or revising any forward-looking statements contained in this press release in the event of new information, future developments or otherwise. These forward-looking statements are based on BioNTech’s current expectations and speak only as of the date hereof. CONTACTS Investor Relations Victoria Meissner, M.D. +1 617 528 8293 Investors@biontech.de Media Relations Jasmina Alatovic +49 (0)6131 9084 1513 Media@biontech.de Statements of Profit or Loss Three months ended December 31, Years ended December 31, 2023 2022 2023 2022 2021 (in millions €, except per share data) (unaudited) (unaudited) Revenues Commercial revenues 1,478.9 4,271.3 3,815.5 17,194.6 18,874.0 Research & development revenues 0.1 7.0 3.5 116.0 102.7 Total revenues 1,479.0 4,278.3 3,819.0 17,310.6 18,976.7 Cost of sales (179.1) (183.5) (599.8) (2,995.0) (2,911.5) Research and development expenses (577.8) (509.8) (1,783.1) (1,537.0) (949.2) Sales and marketing expenses (18.0) (14.6) (62.7) (59.5) (50.4) General and administrative expenses (124.3) (119.9) (495.0) (481.7) (276.8) Other operating expenses (1) (57.6) (379.2) (293.0) (410.0) (103.4) Other operating income (1) 4.0 221.6 105.0 815.3 598.4 Operating income 526.2 3,292.9 690.4 12,642.7 15,283.8 Finance income 162.2 38.8 519.6 330.3 67.7 Finance expenses (25.2) (159.1) (23.9) (18.9) (305.1) Profit before tax 663.2 3,172.6 1,186.1 12,954.1 15,046.4 Income taxes (205.3) (893.9) (255.8) (3,519.7) (4,753.9) Profit for the period 457.9 2,278.7 930.3 9,434.4 10,292.5 Earnings per share Basic earnings for the period per share 1.91 9.38 3.87 38.78 42.18 Diluted earnings for the period per share 1.90 9.26 3.83 37.77 39.63 (1) Adjustments to prior-year figures due to change in functional allocation of general and administrative expenses and other operating expenses Statements of Financial Position December 31, December 31, (in millions €) 2023 2022 Assets Non-current assets Goodwill 362.5 61.2 Other intangible assets 804.1 158.5 Property, plant and equipment 757.2 609.2 Right-of-use assets 214.4 211.9 Other financial assets 1,176.1 80.2 Other non-financial assets 83.4 6.5 Deferred tax assets 81.3 229.6 Total non-current assets 3,479.0 1,357.1 Current assets Inventories 357.7 439.6 Trade and other receivables 2,155.7 7,145.6 Contract assets 4.9 — Other financial assets 4,885.3 189.4 Other non-financial assets 280.9 271.9 Income tax assets 179.1 0.4 Cash and cash equivalents 11,663.7 13,875.1 Total current assets 19,527.3 21,922.0 Total assets 23,006.3 23,279.1 Equity and liabilities Equity Share capital 248.6 248.6 Capital reserve 1,229.4 1,828.2 Treasury shares (10.8) (5.3) Retained earnings 19,763.3 18,833.0 Other reserves (984.6) (848.9) Total equity 20,245.9 20,055.6 Non-current liabilities Lease liabilities, loans and borrowings 191.0 176.2 Other financial liabilities 38.8 6.1 Income tax liabilities — 10.4 Provisions 8.8 8.6 Contract liabilities 398.5 48.4 Other non-financial liabilities 13.1 17.0 Deferred tax liabilities 39.7 6.2 Total non-current liabilities 689.9 272.9 Current liabilities Lease liabilities, loans and borrowings 28.1 36.0 Trade payables and other payables 354.0 204.1 Other financial liabilities 415.2 785.1 Refund liabilities — 24.4 Income tax liabilities 525.5 595.9 Provisions 269.3 367.2 Contract liabilities 353.3 77.1 Other non-financial liabilities 125.1 860.8 Total current liabilities 2,070.5 2,950.6 Total liabilities 2,760.4 3,223.5 Total equity and liabilities 23,006.3 23,279.1 Statements of Cash Flows Three months ended December 31, Years ended December 31, 2023 2022 2023 2022 2021 (in millions €) (unaudited) (unaudited) Operating activities Profit for the period 457.9 2,278.7 930.3 9,434.4 10,292.5 Income taxes 205.3 893.9 255.8 3,519.7 4,753.9 Profit before tax 663.2 3,172.6 1,186.1 12,954.1 15,046.4 Adjustments to reconcile profit before tax to net cash flows: Depreciation and amortization of property, plant, equipment, intangible assets and right-of-use assets 78.8 29.0 183.4 123.3 75.2 Share-based payment expenses 14.2 22.2 51.4 108.6 93.9 Net foreign exchange differences 66.3 847.8 (298.0) 625.5 (387.5) Loss on disposal of property, plant and equipment 0.2 0.2 3.8 0.6 4.6 Finance income excluding foreign exchange differences (162.2) (38.8) (519.6) (265.3) (1.5) Finance expense excluding foreign exchange differences 3.4 2.1 7.9 18.9 305.2 Movements in government grants 5.4 0.3 2.4 0.3 (89.0) Net (gain) / loss on derivative instruments at fair value through profit or loss (21.2) (323.3) 175.5 (241.0) 57.3 Working capital adjustments: Decrease / (increase) in trade and other receivables, contract assets and other assets (288.0) (646.8) 5,374.0 4,369.9 (11,808.1) Decrease / (increase) in inventories 58.0 (144.8) 81.9 62.9 (438.4) Increase in trade payables, other financial liabilities, other liabilities, contract liabilities, refund liabilities and provisions 412.8 (674.6) 118.9 85.7 1,516.1 Interest received and realized gains from cash and cash equivalents 91.8 22.8 258.2 29.3 1.2 Interest paid and realized losses from cash and cash equivalents (1.7) (5.0) (5.4) (21.5) (12.2) Income tax paid (65.1) (1,387.4) (482.9) (4,222.1) (3,457.9) Share-based payments (5.0) (47.1) (766.2) (51.8) (13.4) Net cash flows from operating activities 850.9 829.2 5,371.4 13,577.4 889.7 Investing activities Purchase of property, plant and equipment (83.8) (136.6) (249.4) (329.2) (127.5) Proceeds from sale of property, plant and equipment 0.1 0.2 (0.7) 0.6 3.4 Purchase of intangible assets and right-of-use assets (106.5) (7.9) (455.4) (34.1) (26.5) Acquisition of subsidiaries and businesses, net of cash acquired — — (336.9) — (20.8) Investment in other financial assets (3,418.2) (16.7) (7,128.4) (47.8) (19.5) Proceeds from maturity of other financial assets 913.3 — 1,216.3 375.2 (375.2) Net cash flows used in investing activities (2,695.1) (161.0) (6,954.5) (35.3) (566.1) Financing activities Proceeds from issuance of share capital and treasury shares, net of costs — — — 110.5 160.9 Proceeds from loans and borrowings 0.2 0.2 0.3 0.8 — Repayment of loans and borrowings — — (0.1) (18.8) (52.6) Payments related to lease liabilities (12.3) (9.2) (40.3) (41.1) (14.1) Share repurchase program (0.8) (55.7) (738.5) (986.4) — Dividends — — — (484.3) — Net cash flows from / (used in) financing activities (12.9) (64.7) (778.6) (1,419.3) 94.2 Net increase / (decrease) in cash and cash equivalents (1,857.1) 603.5 (2,361.7) 12,122.8 417.8 Change in cash and cash equivalents resulting from exchange rate differences (15.4) (152.1) (14.5) 60.1 64.7 Cash and cash equivalents at the beginning of the period 13,495.8 13,423.7 13,875.1 1,692.7 1,210.2 Cash and cash equivalents as of December 31 11,663.7 13,875.1 11,663.7 13,875.1 1,692.7