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Mastrangelo S, Romano A, Attinà G, Maurizi P, Ruggiero A. Timing and chemotherapy association for 131-I-MIBG treatment in high-risk neuroblastoma. Biochem Pharmacol 2023; 216:115802. [PMID: 37696454 DOI: 10.1016/j.bcp.2023.115802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
Prognosis of high-risk neuroblastoma is dismal, despite intensive induction chemotherapy, surgery, high-dose chemotherapy, radiotherapy, and maintenance. Patients who do not achieve a complete metastatic response, with clearance of bone marrow and skeletal NB infiltration, after induction have a significantly lowersurvival rate. Thus, it's necessary to further intensifytreatment during this phase. 131-I-metaiodobenzylguanidine (131-I-MIBG) is a radioactive compound highly effective against neuroblastoma, with32% response rate in relapsed/resistant cases, and only hematological toxicity. 131-I-MIBG wasutilized at different doses in single or multiple administrations, before autologous transplant or combinedwith high-dose chemotherapy. Subsequently, it was added to consolidationin patients with advanced NB after induction, but an independent contribution against neuroblastoma and for myelotoxicity is difficult to determine. Despiteresults of a 2008 paper demonstratedefficacy and mild hematological toxicity of 131-I-MIBG at diagnosis, no center had included it with intensive chemotherapy in first-line treatment protocols. In our institution, at diagnosis, 131-I-MIBG was included in a 5-chemotherapy drug combination and administered on day-10, at doses up to 18.3 mCi/kg. Almost 87% of objective responses were observed 50 days from start with acceptable hematological toxicity. In this paper, we review the literature data regarding 131-I-MIBG treatment for neuroblastoma, and report on doses and combinations used, tumor responses and toxicity. 131-I-MIBG is very effective against neuroblastoma, in particular if given to patients at diagnosis and in combination with chemotherapy, and it should be included in all induction regimens to improve early responses rates and consequently long-term survival.
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Affiliation(s)
- Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Gemelli, 8, 00168 Rome, Italy.
| | - Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Gemelli, 8, 00168 Rome, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Gemelli, 8, 00168 Rome, Italy
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Olgun N, Cecen E, Ince D, Kizmazoglu D, Baysal B, Onal A, Ozdogan O, Guleryuz H, Cetingoz R, Demiral A, Olguner M, Celik A, Kamer S, Ozer E, Altun Z, Aktas S. Dinutuximab beta plus conventional chemotherapy for relapsed/refractory high-risk neuroblastoma: A single-center experience. Front Oncol 2022; 12:1041443. [PMID: 36620564 PMCID: PMC9816792 DOI: 10.3389/fonc.2022.1041443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Background Relapsed/refractory high-risk neuroblastoma has a dismal prognosis. Anti-GD2-mediated chemo-immunotherapy has a notable anti-tumor activity in patients with relapsed/refractory high-risk neuroblastoma. The purpose of this study was to analyze the efficacy and safety of the combination of immunotherapy with dinutuximab beta (DB) and chemotherapy in patients with relapsed/refractory high-risk neuroblastoma. Methods All patients received the Turkish Pediatric Oncology Group NB 2009 national protocol for HR-NB treatment at the time of diagnosis. Salvage treatments were administered after progression or relapse. The patients who could not achieve remission in primary or metastatic sites were included in the study. The most common chemotherapy scheme was irinotecan and temozolomide. DB was administered intravenously for 10 days through continuous infusion with 10 mg/m2 per day. The patients received 2 to 14 successive cycles with duration of 28 days each. Disease assessment was performed after cycles 2, 4, and 6 and every 2 to 3 cycles thereafter. Results Between January 2020 and March 2022, nineteen patients received a total of 125 cycles of DB and chemotherapy. Objective responses were achieved in 12/19 (63%) patients, including complete remission in 6/19 and partial response in 6/19. Stable disease was observed in two patients. The remaining five patients developed bone/bone marrow and soft tissue progression after 2-4 cycles of treatment. The most common Grade ≥3 toxicities were leukopenia, thrombocytopenia, hypertransaminasemia, fever, rash/itching and capillary leak syndrome, respectively. Conclusion Our study results suggest that DB-based chemo-immunotherapy seems to be suitable with encouraging response rates in patients with relapsed/refractory high-risk neuroblastoma.
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Affiliation(s)
- Nur Olgun
- Department of Pediatric Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye,*Correspondence: Nur Olgun,
| | - Emre Cecen
- Department of Pediatric Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye
| | - Dilek Ince
- Department of Pediatric Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye
| | - Deniz Kizmazoglu
- Department of Pediatric Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye
| | - Birsen Baysal
- Department of Pediatric Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye
| | - Ayse Onal
- Department of Pediatric Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye
| | - Ozhan Ozdogan
- Department of Nuclear Medicine, Dokuz Eylul University School of Medicine, Izmir, Türkiye
| | - Handan Guleryuz
- Department of Radiology, Dokuz Eylul University School of Medicine, Izmir, Türkiye
| | - Riza Cetingoz
- Department of Radiation Oncology, Dokuz Eylul University School of Medicine, Izmir, Türkiye
| | - Ayse Demiral
- Department of Radiation Oncology, Dokuz Eylul University School of Medicine, Izmir, Türkiye
| | - Mustafa Olguner
- Department of Pediatric Surgery, Dokuz Eylul University School of Medicine, Izmir, Türkiye
| | - Ahmet Celik
- Department of Pediatric Surgery, Ege University School of Medicine, Izmir, Türkiye
| | - Serra Kamer
- Department of Radiation Oncology, Ege University School of Medicine, Izmir, Türkiye
| | - Erdener Ozer
- Department of Pathology, Dokuz Eylul University School of Medicine, Izmir, Türkiye
| | - Zekiye Altun
- Department of Basic Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye
| | - Safiye Aktas
- Department of Basic Oncology, Dokuz Eylul University Institute of Oncology, Izmir, Türkiye
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3
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Desai AV, Applebaum MA, Karrison TG, Oppong A, Yuan C, Berg KR, MacQuarrie K, Sokol E, Hall AG, Pinto N, Wolfe I, Mody R, Shusterman S, Smith V, Foster JH, Nassin M, LaBelle JL, Bagatell R, Cohn SL. Efficacy of post-induction therapy for high-risk neuroblastoma patients with end-induction residual disease. Cancer 2022; 128:2967-2977. [PMID: 35665495 PMCID: PMC10764281 DOI: 10.1002/cncr.34263] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/17/2022] [Accepted: 01/31/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND High-risk neuroblastoma patients with end-induction residual disease commonly receive post-induction therapy in an effort to increase survival by improving the response before autologous stem cell transplantation (ASCT). The authors conducted a multicenter, retrospective study to investigate the efficacy of this approach. METHODS Patients diagnosed between 2008 and 2018 without progressive disease with a partial response or worse at end-induction were stratified according to the post-induction treatment: 1) no additional therapy before ASCT (cohort 1), 2) post-induction "bridge" therapy before ASCT (cohort 2), and 3) post-induction therapy without ASCT (cohort 3). χ2 tests were used to compare patient characteristics. Three-year event-free survival (EFS) and overall survival (OS) were estimated by the Kaplan-Meier method and survival curves were compared by log-rank test. RESULTS The study cohort consisted of 201 patients: cohort 1 (n = 123), cohort 2 (n = 51), and cohort 3 (n = 27). Although the end-induction response was better for cohort 1 than cohorts 2 and 3, the outcomes for cohorts 1 and 2 were not significantly different (P = .77 for EFS and P = .85 for OS). Inferior outcomes were observed for cohort 3 (P < .001 for EFS and P = .06 for OS). Among patients with end-induction stable metastatic disease, 3-year EFS was significantly improved for cohort 2 versus cohort 1 (P = .04). Cohort 3 patients with a complete response at metastatic sites after post-induction therapy had significantly better 3-year EFS than those with residual metastatic disease (P = .01). CONCLUSIONS Prospective studies to confirm the benefits of bridge treatment and the prognostic significance of metastatic response observed in this study are warranted.
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Affiliation(s)
- Ami V. Desai
- Department of Pediatrics, University of Chicago, Chicago, IL
| | | | | | - Akosua Oppong
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Cindy Yuan
- Department of Radiology, University of Chicago, Chicago, IL
| | - Katherine R. Berg
- Children’s Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA
| | - Kyle MacQuarrie
- Ann and Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, IL
| | - Elizabeth Sokol
- Ann and Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, IL
| | - Anurekha G. Hall
- Seattle Children’s Hospital and University of Washington, Seattle, WA
| | - Navin Pinto
- Seattle Children’s Hospital and University of Washington, Seattle, WA
| | - Ian Wolfe
- C.S Mott Children’s Hospital and University of Michigan, Ann Arbor, MI
| | - Rajen Mody
- C.S Mott Children’s Hospital and University of Michigan, Ann Arbor, MI
| | - Suzanne Shusterman
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Valeria Smith
- Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | | | - Michele Nassin
- Department of Pediatrics, University of Chicago, Chicago, IL
| | | | - Rochelle Bagatell
- Children’s Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA
| | - Susan L. Cohn
- Department of Pediatrics, University of Chicago, Chicago, IL
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Mechanisms, Characteristics, and Treatment of Neuropathic Pain and Peripheral Neuropathy Associated with Dinutuximab in Neuroblastoma Patients. Int J Mol Sci 2021; 22:ijms222312648. [PMID: 34884452 PMCID: PMC8657961 DOI: 10.3390/ijms222312648] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/13/2021] [Accepted: 11/18/2021] [Indexed: 12/21/2022] Open
Abstract
Prognosis of metastatic neuroblastoma is very poor. Its treatment includes induction chemotherapy, surgery, high-dose chemotherapy, radiotherapy, and maintenance with retinoic acid, associated with the anti-GD2 monoclonal antibody (ch14.18) dinutuximab. Immunotherapy determined a significant improvement in survival rate and is also utilized in relapsed and resistant neuroblastoma patients. Five courses of dinutuximab 100 mg/m2 are usually administered as a 10-day continuous infusion or over 5 consecutive days every 5 weeks. Dinutuximab targets the disialoganglioside GD2, which is highly expressed on neuroblastoma cells and minimally present on the surface of normal human neurons, peripheral pain fibers, and skin melanocytes. Anti GD2 antibodies bind to surface GD2 and determine the lysis of neuroblastoma cells induced by immune response via the antibody-dependent cellular cytotoxicity and the complement-dependent cytotoxicity. Dinutuximab has significant side effects, including neuropathic pain, peripheral neuropathy, hypersensitivity reactions, capillary leak syndrome, photophobia, and hypotension. The most important side effect is neuropathic pain, which is triggered by the same antibody–antigen immune response, but generates ectopic activity in axons, which results in hyperalgesia and spontaneous pain. Pain can be severe especially in the first courses of dinutuximab infusion, and requires the administration of gabapentin and continuous morphine infusion. This paper will focus on the incidence, mechanisms, characteristics, and treatment of neuropathic pain and peripheral neuropathy due to dinutuximab administration in neuroblastoma patients.
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Gu J, Huang H, Liu C, Jiang B, Li M, Liu L, Zhang S. Pinocembrin inhibited cardiomyocyte pyroptosis against doxorubicin-induced cardiac dysfunction via regulating Nrf2/Sirt3 signaling pathway. Int Immunopharmacol 2021; 95:107533. [PMID: 33752080 DOI: 10.1016/j.intimp.2021.107533] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 01/25/2023]
Abstract
Doxorubicin (DOX) is a potent chemotherapeutic drug but the clinical use was limited by its dose-dependent cardiotoxicity. Pinocembrin (PCB), a flavonoid originally isolated from honeybee propolis and rhizomes of Boesenbergia pandurate displays diverse biological activities. However, the role of PCB in DOX-induced cardiac injury and its underlying molecular mechanism are not fully elucidated. The present study was designed to evaluate the protective role of PCB in a DOX-induced cardiotoxicity in vivo and in vitro. Our results revealed that PCB administration greatly improved cardiac function and reduced cardiac fibrosis manifested by LVEF, LVFS, LVIDd, LVIDs, and myocardial fibrotic area which were impaired by DOX treatment. The cardiac injury evidenced by LDH and CK-MB activities were reduced while the levels of IL-1β and IL-18 were decreased following PCB treatment compared to DOX-treated mice. Mechanically, our present results showed that PCB significantly inhibited DOX-induced cardiomyocyte pyroptosis via activating Nrf2/Sirt3 signal pathway. Furthermore, the inhibition of Nrf2 in H9c2 cells abolished the protective role of PCB against DOX-induced cell toxicity, which was at least partly via upregulation of NLRP3-mediated pyroptosis. In conclusion, our study clearly demonstrated that PCB reduced cardiomyocyte pyroptosis to protect hearts from DOX-induced cardiotoxicity through activation of Nrf2/Sirt3 signal pathway.
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Affiliation(s)
- Jiwei Gu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Hui Huang
- Department of Cardiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Chunlian Liu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Bo Jiang
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Mingliang Li
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Li Liu
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Shuya Zhang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Ningxia Medical University, Yinchuan 750004, China.
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Jain R, Trehan A, Menon P, Kapoor R, Kakkar N, Radhika S, Saxena AK, Mittal BR, Varma N, Samujh R, Bansal D. Survival in patients with high-risk neuroblastoma treated without autologous stem cell transplant or dinutuximab beta. Pediatr Hematol Oncol 2021; 38:291-304. [PMID: 33622164 DOI: 10.1080/08880018.2020.1850955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The majority of patients with high-risk neuroblastoma (HR-NB) in low- and middle-income countries (LMIC) do not have access to autologous stem cell transplant (ASCT) and dinutuximab. Consolidation with nonmyeloablative chemotherapy is not well-defined, and the outcomes are variable. We report a single-center outcome of patients with HR-NB, treated with nonmyeloablative consolidation. A tabulated compilation of similar reports is included. A retrospective chart review of patients with HR-NB was performed from January 2009 till June 2016. Patients were treated on the backbone of HR-NBL1/SIOPEN protocol. Treatment included induction with rapid-COJEC, surgery, followed by consolidation. Consolidation involved 4 cycles of topotecan, vincristine, and doxorubicin (TVD) instead of ASCT. Infusion of vincristine and doxorubicin were modified for ease and to enable administration in the clinic. Subsequent treatment included radiotherapy to the primary tumor and differentiation therapy with isotretinoin. Over 7½ years, 28 patients with HR-NB were treated. Two (7%) patients had therapy-related mortality. A relapse or disease progression occurred in 11 (39%) patients at a median duration of 17 months (IQR: 5, 18). Treatment abandonment was observed in 4 (14%) patients. The median follow-up of disease-free patients was 49 months (IQR: 45, 79). Patients with relapse were not treated further. A 4-year EFS of 29.3% was observed when 4-cycles of TVD were administered instead of ASCT in patients with HR-NB. The study and the review will aid decision-making for care of patients in LMIC while considering the options of treatment for HR-NB if access to ACST and dinutuximab is lacking.
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Affiliation(s)
- Richa Jain
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prema Menon
- Department of Pediatric Surgery, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kapoor
- Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nandita Kakkar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Srinivasan Radhika
- Department of Cytopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akshay Kumar Saxena
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ram Samujh
- Department of Pediatric Surgery, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gene Expression Signature of Acquired Chemoresistance in Neuroblastoma Cells. Int J Mol Sci 2020; 21:ijms21186811. [PMID: 32948088 PMCID: PMC7555742 DOI: 10.3390/ijms21186811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 01/14/2023] Open
Abstract
Drug resistance of childhood cancer neuroblastoma is a serious clinical problem. Patients with relapsed disease have a poor prognosis despite intense treatment. In the present study, we aimed to identify chemoresistance gene expression signatures in vincristine resistant neuroblastoma cells. We found that vincristine-resistant neuroblastoma cells formed larger clones and survived under reduced serum conditions as compared with non-resistant parental cells. To identify the possible mechanisms underlying vincristine resistance in neuroblastoma cells, we investigated the expression profiles of genes known to be involved in cancer drug resistance. This specific gene expression patterns could predict the behavior of a tumor in response to chemotherapy and for predicting the prognosis of high-risk neuroblastoma patients. Our signature could help chemoresistant neuroblastoma patients in avoiding useless and harmful chemotherapy cycles.
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Alfei S, Marengo B, Zuccari G, Turrini F, Domenicotti C. Dendrimer Nanodevices and Gallic Acid as Novel Strategies to Fight Chemoresistance in Neuroblastoma Cells. NANOMATERIALS (BASEL, SWITZERLAND) 2020; 10:E1243. [PMID: 32604768 PMCID: PMC7353457 DOI: 10.3390/nano10061243] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 01/15/2023]
Abstract
Human neuroblastoma (NB), a pediatric tumor inclined to relapse, after an initial response to therapy, usually develops resistance. Since several chemotherapeutics exert anticancer effect by increasing reactive oxygen species (ROS), NB cells overproduce antioxidant compounds becoming drugs-resistant. A strategy to sensitize NB cells to chemotherapy involves reducing their antioxidant defenses and inducing ROS overproduction. Concerning this, although affected by several issues that limit their clinical application, antioxidant/pro-oxidant polyphenols, such as gallic acid (GA), showed pro-oxidant anti-cancer effects and low toxicity for healthy cells, in several kind of tumors, not including NB. Herein, for the first time, free GA, two GA-dendrimers, and the dendrimer adopted as GA reservoir were tested on both sensitive and chemoresistant NB cells. The dendrimer device, administered at the dose previously found active versus sensitive NB cells, induced ROS-mediated death also in chemoresistant cells. Free GA proved a dose-dependent ROS-mediated cytotoxicity on both cell populations. Intriguingly, when administered in dendrimer formulations at a dose not cytotoxic for NB cells, GA nullified any pro-oxidant activity of dendrimer. Unfortunately, due to GA, nanoformulations were inactive on NB cells, but GA resized in nanoparticles showed considerable ability in counteracting, at low dose, ROS production and oxidative stress, herein induced by the dendrimer.
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Affiliation(s)
- Silvana Alfei
- Department of Pharmacy (DiFAR), University of Genoa, Viale Cembrano, 16148 Genoa, Italy; (G.Z.); (F.T.)
| | - Barbara Marengo
- Department of Experimental Medicine—DIMES, University of Genoa, Via Alberti L.B., 16132 Genoa, Italy; (B.M.); (C.D.)
| | - Guendalina Zuccari
- Department of Pharmacy (DiFAR), University of Genoa, Viale Cembrano, 16148 Genoa, Italy; (G.Z.); (F.T.)
| | - Federica Turrini
- Department of Pharmacy (DiFAR), University of Genoa, Viale Cembrano, 16148 Genoa, Italy; (G.Z.); (F.T.)
| | - Cinzia Domenicotti
- Department of Experimental Medicine—DIMES, University of Genoa, Via Alberti L.B., 16132 Genoa, Italy; (B.M.); (C.D.)
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Herd F, Basta NO, McNally RJQ, Tweddle DA. A systematic review of re-induction chemotherapy for children with relapsed high-risk neuroblastoma. Eur J Cancer 2019; 111:50-58. [PMID: 30822684 PMCID: PMC6458963 DOI: 10.1016/j.ejca.2018.12.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/28/2018] [Accepted: 12/28/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite aggressive multimodal therapy, >50% of children with high-risk neuroblastoma (HRNB) relapse. Survival after relapse is rare, and no consensus currently exists on the most effective therapy. OBJECTIVE To conduct a systematic review of the literature on effectiveness of re-induction chemotherapy in children with relapsed HRNB. METHODS Database searches were performed to identify studies looking at response to 1st line chemotherapy for children >12 months at diagnosis with first relapse of HRNB. Studies not reporting separate outcomes for HRNB patients or of refractory patients only were excluded. Two independent reviewers extracted the data and assessed study quality using a modified Newcastle-Ottawa tool. RESULTS Nine studies were identified fitting the inclusion criteria. All except one were single arm cohorts, and two were retrospective database reviews from single centres. One was a multicentre randomised controlled trial. All used a version of the validated International Neuroblastoma Response Criteria with 8 recording best ever response and 1 at a specified time, and 5 had central review. The proportion of relapsed patients varied from 24 to 100% with 30-93% receiving upfront myeloablative therapy. The response rate varied from 6 to 64%; however, because of heterogeneity, studies were not directly comparable, and no single treatment emerged as the most effective re-induction therapy. CONCLUSIONS To date, there is no clear superior re-induction therapy for 1st relapse of HRNB. Randomised controlled trials with separate arms for relapsed versus refractory disease are needed to determine optimal re-induction chemotherapy to act as a backbone for testing newer targeted agents.
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Affiliation(s)
- Fiona Herd
- Department of Paediatric Oncology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
| | - Nermine O Basta
- Institute of Health & Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, United Kingdom
| | - Richard J Q McNally
- Institute of Health & Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, United Kingdom
| | - Deborah A Tweddle
- Department of Paediatric Oncology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle, NE1 4LP, UK; Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Level 6 Herschel Building, Brewery Lane, Newcastle upon Tyne, NE1 7RU, UK.
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Novel Therapies for Relapsed and Refractory Neuroblastoma. CHILDREN-BASEL 2018; 5:children5110148. [PMID: 30384486 PMCID: PMC6262328 DOI: 10.3390/children5110148] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/23/2018] [Accepted: 10/23/2018] [Indexed: 12/17/2022]
Abstract
While recent increases in our understanding of the biology of neuroblastoma have allowed for more precise risk stratification and improved outcomes for many patients, children with high-risk neuroblastoma continue to suffer from frequent disease relapse, and despite recent advances in our understanding of neuroblastoma pathogenesis, the outcomes for children with relapsed neuroblastoma remain poor. These children with relapsed neuroblastoma, therefore, continue to need novel treatment strategies based on a better understanding of neuroblastoma biology to improve outcomes. The discovery of new tumor targets and the development of novel antibody- and cell-mediated immunotherapy agents have led to a large number of clinical trials for children with relapsed neuroblastoma, and additional clinical trials using molecular and genetic tumor profiling to target tumor-specific aberrations are ongoing. Combinations of these new therapeutic modalities with current treatment regimens will likely be needed to improve the outcomes of children with relapsed and refractory neuroblastoma.
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11
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Colla R, Izzotti A, De Ciucis C, Fenoglio D, Ravera S, Speciale A, Ricciarelli R, Furfaro AL, Pulliero A, Passalacqua M, Traverso N, Pronzato MA, Domenicotti C, Marengo B. Glutathione-mediated antioxidant response and aerobic metabolism: two crucial factors involved in determining the multi-drug resistance of high-risk neuroblastoma. Oncotarget 2018; 7:70715-70737. [PMID: 27683112 PMCID: PMC5342585 DOI: 10.18632/oncotarget.12209] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 09/13/2016] [Indexed: 12/24/2022] Open
Abstract
Neuroblastoma, a paediatric malignant tumor, is initially sensitive to etoposide, a drug to which many patients develop chemoresistance. In order to investigate the molecular mechanisms responsible for etoposide chemoresistance, HTLA-230, a human MYCN-amplified neuroblastoma cell line, was chronically treated with etoposide at a concentration that in vitro mimics the clinically-used dose. The selected cells (HTLA-Chr) acquire multi-drug resistance (MDR), becoming less sensitive than parental cells to high doses of etoposide or doxorubicin. MDR is due to several mechanisms that together contribute to maintaining non-toxic levels of H2O2. In fact, HTLA-Chr cells, while having an efficient aerobic metabolism, are also characterized by an up-regulation of catalase activity and higher levels of reduced glutathione (GSH), a thiol antioxidant compound. The combination of such mechanisms contributes to prevent membrane lipoperoxidation and cell death. Treatment of HTLA-Chr cells with L-Buthionine-sulfoximine, an inhibitor of GSH biosynthesis, markedly reduces their tumorigenic potential that is instead enhanced by the exposure to N-Acetylcysteine, able to promote GSH synthesis. Collectively, these results demonstrate that GSH and GSH-related responses play a crucial role in the acquisition of MDR and suggest that GSH level monitoring is an efficient strategy to early identify the onset of drug resistance and to control the patient's response to therapy.
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Affiliation(s)
- Renata Colla
- Department of Experimental Medicine, University of Genova, Genova, Italy
| | - Alberto Izzotti
- Department of Health Sciences, University of Genova, Genova, Italy.,IRCCS AOU San Martino IST Genova, Genova, Italy
| | - Chiara De Ciucis
- Department of Experimental Medicine, University of Genova, Genova, Italy
| | - Daniela Fenoglio
- Center of Excellence for Biomedical Research, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Silvia Ravera
- Department of Pharmacy, University of Genova, Genova, Italy
| | - Andrea Speciale
- Department of Experimental Medicine, University of Genova, Genova, Italy
| | | | | | | | - Mario Passalacqua
- Department of Experimental Medicine, University of Genova, Genova, Italy
| | - Nicola Traverso
- Department of Experimental Medicine, University of Genova, Genova, Italy
| | | | - Cinzia Domenicotti
- Department of Experimental Medicine, University of Genova, Genova, Italy
| | - Barbara Marengo
- Department of Experimental Medicine, University of Genova, Genova, Italy
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12
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Amoroso L, Erminio G, Makin G, Pearson ADJ, Brock P, Valteau-Couanet D, Castel V, Pasquet M, Laureys G, Thomas C, Luksch R, Ladenstein R, Haupt R, Garaventa A. Topotecan-Vincristine-Doxorubicin in Stage 4 High-Risk Neuroblastoma Patients Failing to Achieve a Complete Metastatic Response to Rapid COJEC: A SIOPEN Study. Cancer Res Treat 2018; 50:148-155. [PMID: 28324923 PMCID: PMC5784636 DOI: 10.4143/crt.2016.511] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 03/09/2017] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Metastatic response to induction therapy for high-risk neuroblastoma is a prognostic factor. In the International Society of Paediatric Oncology Europe Neuroblastoma (SIOPEN) HR-NBL-1 protocol, only patients with metastatic complete response (CR) or partial response (PR) with ≤ three abnormal skeletal areas on iodine 123-metaiodobenzylguanidine ([123I]mIBG) scintigraphy and no bone marrow disease proceed to high dose therapy (HDT). In this study, topotecan-vincristine-doxorubicin (TVD) was evaluated in patients failing to achieve these criteria, with the aim of improving the metastatic response rate. MATERIALS AND METHODS Patients with metastatic high-risk neuroblastoma who had not achieved the SIOPEN criteria for HDT after induction received two courses of topotecan 1.5 mg/m2/day for 5 days, followed by a 48-hour infusion of vincristine, 2 mg/m2, and doxorubicin, 45 mg/m2. RESULTS Sixty-three patients were eligible and evaluable. Following two courses of TVD, four (6.4%) patients had an overall CR, while 28 (44.4%) had a PR with a combined response rate of 50.8% (95% confidence interval [CI], 37.9 to 63.6). Of these, 23 patients achieved a metastatic CR or a PR with ≤ 3 mIBG skeletal areas and no bone marrow disease (36.5%; 95% CI, 24.7 to 49.6) and were eligible to receive HDT. Toxicity was mostly haematological, affecting 106 of the 126 courses (84.1%; 95% CI, 76.5 to 90.0), and dose reduction was necessary in six patients. Stomatitis was the second most common nonhematological toxicity, occurring in 20 patients (31.7%). CONCLUSION TVD was effective in improving the response rate of high-risk neuroblastoma patients after induction with COJEC enabling them to proceed to HDT. However, the long-term benefits of TVD needs to be determined in randomized clinical trials.
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Affiliation(s)
| | - Giovanni Erminio
- Epidemiology and Biostatistics Unit, Istituto Giannina Gaslini, Genova, Italy
| | - Guy Makin
- Institute of Cancer Sciences, Manchester Cancer Research Centre, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Andrew D. J. Pearson
- Divisions of Cancer Therapeutics and Clinical Studies, Institute of Cancer Research and Children and Young People’s Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Penelope Brock
- Paediatric Oncology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Victoria Castel
- Paediatric Oncology, Hospital Universitario La Fe, Valencia, Spain
| | - Marlène Pasquet
- Department of Hematology-Oncology Hopital des Enfants, Toulouse, France
| | - Genevieve Laureys
- Department of Paediatric Hematology, Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Caroline Thomas
- Pediatric Intensive Care and Onco-Hematology Units, Nantes Hospital, Nantes, France
| | - Roberto Luksch
- Department of Paediatric Oncology, Istituto Nazionale Tumori, Milan, Italy
| | - Ruth Ladenstein
- Children’s Cancer Research Institute, St. Anna Children’s Hospital, Vienna, Austria
| | - Riccardo Haupt
- Epidemiology and Biostatistics Unit, Istituto Giannina Gaslini, Genova, Italy
| | | | - SIOPEN Group
- Paediatric Oncology, Istituto Giannina Gaslini, Genova, Italy
- Epidemiology and Biostatistics Unit, Istituto Giannina Gaslini, Genova, Italy
- Institute of Cancer Sciences, Manchester Cancer Research Centre, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Divisions of Cancer Therapeutics and Clinical Studies, Institute of Cancer Research and Children and Young People’s Unit, The Royal Marsden NHS Foundation Trust, London, UK
- Paediatric Oncology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Paediatric Oncology, Institute Gustave Roussy, Villejuif, France
- Paediatric Oncology, Hospital Universitario La Fe, Valencia, Spain
- Department of Hematology-Oncology Hopital des Enfants, Toulouse, France
- Department of Paediatric Hematology, Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
- Pediatric Intensive Care and Onco-Hematology Units, Nantes Hospital, Nantes, France
- Department of Paediatric Oncology, Istituto Nazionale Tumori, Milan, Italy
- Children’s Cancer Research Institute, St. Anna Children’s Hospital, Vienna, Austria
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13
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Risum S, Knigge U, Langer SW. Hitherto unseen survival in an ALK-positive-patient with advanced stage adult ganglioneuroblastoma treated with personalized medicine. Clin Case Rep 2017; 5:2085-2087. [PMID: 29225862 PMCID: PMC5715430 DOI: 10.1002/ccr3.1262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 07/28/2017] [Accepted: 08/07/2017] [Indexed: 02/02/2023] Open
Abstract
Survival of stage 4 ganglioneuroblastoma (GNB) patients is poor; no reports exist of patients surviving up to 5 years (1, 2). We report the clinical and therapeutic course of a patient with stage 4 GNB surviving beyond expectations due to a multimodal treatment approach incorporating new technologies in cancer diagnostic and treatment.
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Affiliation(s)
- Signe Risum
- Department of Oncology ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, Copenhagen University Hospital Copenhagen DK-2100 Denmark
| | - Ulrich Knigge
- Department of Endocrinology ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, Copenhagen University Hospital Copenhagen DK-2100 Denmark
| | - Seppo W Langer
- Department of Oncology ENETS Neuroendocrine Tumor Centre of Excellence Rigshospitalet, Copenhagen University Hospital Copenhagen DK-2100 Denmark
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14
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Amoroso L, Haupt R, Garaventa A, Ponzoni M. Investigational drugs in phase II clinical trials for the treatment of neuroblastoma. Expert Opin Investig Drugs 2017; 26:1281-1293. [PMID: 28906153 DOI: 10.1080/13543784.2017.1380625] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Neuroblastoma (NB) is an embryonal tumor originating from undifferentiated neural crest cell, highly heterogeneous ranging from spontaneous regression to progression despite multimodal treatments. Approximately, 20% of patients are refractory to frontline therapy and 50% will relapse/progress after an initial response. The overall five year survival for high-risk neuroblastoma ranges from 35-45%. Despite enhanced understanding of NB biology and the addition of myeloablative chemotherapy, isotretinoin and immunotherapy, survival for high risk NB remains less than 50%. Areas covered: This review summarizes and gives a critical overview of phase II trials investigating therapies for relapsed-refractory and high risk neuroblastoma. Expert opinion: Several novel molecules have been developed and are currently under investigation for the treatment of NB. The trend of novel targeted agents is one towards individualized, tailored therapy, based on the molecular and biological differences that characterize tumors that seem similar based solely on histological analysis. The task of developing new molecules is particularly difficult for NB, given the recurrent development of new patterns of drug resistance. However, even if current research is focused towards identifying the best treatments for each children and young adult with a NB defined disease, a deeper knowledge of the molecular biology and genetics is needed.
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Affiliation(s)
- Loredana Amoroso
- a Department of Pediatric Oncology , Istituto G.Gaslini , Genova , Italy
| | - Riccardo Haupt
- b Epidemiology and Biostatistics Unit , Istituto G.Gaslini , Genova , Italy
| | - Alberto Garaventa
- a Department of Pediatric Oncology , Istituto G.Gaslini , Genova , Italy
| | - Mirco Ponzoni
- c Experimental Therapy Unit in Oncology , Istituto G. Gaslini , Genova , Italy
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15
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Ladenstein R, Lambert B, Pötschger U, Castellani MR, Lewington V, Bar-Sever Z, Oudoux A, Śliwińska A, Taborska K, Biassoni L, Yanik GA, Naranjo A, Parisi MT, Shulkin BL, Nadel H, Gelfand MJ, Matthay KK, Park JR, Kreissman SG, Valteau-Couanet D, Boubaker A. Validation of the mIBG skeletal SIOPEN scoring method in two independent high-risk neuroblastoma populations: the SIOPEN/HR-NBL1 and COG-A3973 trials. Eur J Nucl Med Mol Imaging 2017; 45:292-305. [PMID: 28940046 DOI: 10.1007/s00259-017-3829-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/03/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Validation of the prognostic value of the SIOPEN mIBG skeletal scoring system in two independent stage 4, mIBG avid, high-risk neuroblastoma populations. RESULTS The semi-quantitative SIOPEN score evaluates skeletal meta-iodobenzylguanidine (mIBG) uptake on a 0-6 scale in 12 anatomical regions. Evaluable mIBG scans from 216 COG-A3973 and 341 SIOPEN/HR-NBL1 trial patients were reviewed pre- and post-induction chemotherapy. The prognostic value of skeletal scores for 5-year event free survival (5 yr.-EFS) was tested in the source and validation cohorts. At diagnosis, both cohorts showed a gradual non-linear increase in risk with cumulative scores. Several approaches were explored to test the relationship between score and EFS. Ultimately, a cutoff score of ≤3 was the most useful predictor across trials. A SIOPEN score ≤ 3 pre-induction was found in 15% SIOPEN patients and in 22% of COG patients and increased post-induction to 60% in SIOPEN patients and to 73% in COG patients. Baseline 5 yr.-EFS rates in the SIOPEN/HR-NBL1 cohort for scores ≤3 were 47% ± 7% versus 26% ± 3% for higher scores at diagnosis (p < 0.007) and 36% ± 4% versus 14% ± 4% (p < 0.001) for scores obtained post-induction. The COG-A3973 showed 5 yr.-EFS rates for scores ≤3 of 51% ± 7% versus 34% ± 4% for higher scores (p < 0.001) at diagnosis and 43% ± 5% versus 16% ± 6% (p = 0.004) for post-induction scores. Hazard ratios (HR) significantly favoured patients with scores ≤3 after adjustment for age and MYCN-amplification. Optimal outcomes were recorded in patients who achieved complete skeletal response. CONCLUSIONS Validation in two independent cohorts confirms the prognostic value of the SIOPEN skeletal score. In particular, patients with an absolute SIOPEN score > 3 after induction have very poor outcomes and should be considered for alternative therapeutic strategies.
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Affiliation(s)
- Ruth Ladenstein
- Children's Cancer Research Institute, Zimmermannplatz 10, 1090, Vienna, Austria. .,Medical University, Department of Paediatrics, Vienna, Austria.
| | - Bieke Lambert
- Radiology and Nuclear Medicine, Ghent University, Ghent, Belgium
| | - Ulrike Pötschger
- Children's Cancer Research Institute, Zimmermannplatz 10, 1090, Vienna, Austria
| | - Maria-Rita Castellani
- Nuclear Medicine Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Zvi Bar-Sever
- Schneider Children's Medical Center of Israel, Petah-Tikva, Israel
| | - Aurore Oudoux
- Department of Nuclear Medicine Lille, Oscar Lambret Center, Lille, France
| | | | | | - Lorenzo Biassoni
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Arlene Naranjo
- Children's Oncology Group Statistics and Data Center, University of Florida, Gainesville, FL, USA
| | - Marguerite T Parisi
- Department of Radiology, University of Washington School of Medicine/ Seattle Children's Hospital, Seattle, WA, USA
| | - Barry L Shulkin
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Helen Nadel
- Department of Radiology, BC Children's Hospital, Vancouver, BC, Canada
| | - Michael J Gelfand
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katherine K Matthay
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Julie R Park
- Department of Pediatrics, University of Washington School of Medicine/ Seattle Children's Hospital, Seattle, WA, USA
| | - Susan G Kreissman
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Dominique Valteau-Couanet
- Pediatric and Adolescent Oncology, Gustave Roussy Institute, Université Paris-Sud, Villejuif, France
| | - Ariane Boubaker
- Institute of Radiology, Clinique de La Source, Lausanne, Switzerland
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16
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Mody R, Naranjo A, Van Ryn C, Yu AL, London WB, Shulkin BL, Parisi MT, Servaes SEN, Diccianni MB, Sondel PM, Bender JG, Maris JM, Park JR, Bagatell R. Irinotecan-temozolomide with temsirolimus or dinutuximab in children with refractory or relapsed neuroblastoma (COG ANBL1221): an open-label, randomised, phase 2 trial. Lancet Oncol 2017; 18:946-957. [PMID: 28549783 DOI: 10.1016/s1470-2045(17)30355-8] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Outcomes for children with relapsed and refractory neuroblastoma are dismal. The combination of irinotecan and temozolomide has activity in these patients, and its acceptable toxicity profile makes it an excellent backbone for study of new agents. We aimed to test the addition of temsirolimus or dinutuximab to irinotecan-temozolomide in patients with relapsed or refractory neuroblastoma. METHODS For this open-label, randomised, phase 2 selection design trial of the Children's Oncology Group (COG; ANBL1221), patients had to have histological verification of neuroblastoma or ganglioneuroblastoma at diagnosis or have tumour cells in bone marrow with increased urinary catecholamine concentrations at diagnosis. Patients of any age were eligible at first designation of relapse or progression, or first designation of refractory disease, provided organ function requirements were met. Patients previously treated for refractory or relapsed disease were ineligible. Computer-based randomisation with sequence generation defined by permuted block randomisation (block size two) was used to randomly assign patients (1:1) to irinotecan and temozolomide plus either temsirolimus or dinutuximab, stratified by disease category, previous exposure to anti-GD2 antibody therapy, and tumour MYCN amplification status. Patients in both groups received oral temozolomide (100 mg/m2 per dose) and intravenous irinotecan (50 mg/m2 per dose) on days 1-5 of 21-day cycles. Patients in the temsirolimus group also received intravenous temsirolimus (35 mg/m2 per dose) on days 1 and 8, whereas those in the dinutuximab group received intravenous dinutuximab (17·5 mg/m2 per day or 25 mg/m2 per day) on days 2-5 plus granulocyte macrophage colony-stimulating factor (250 μg/m2 per dose) subcutaneously on days 6-12. Patients were given up to a maximum of 17 cycles of treatment. The primary endpoint was the proportion of patients achieving an objective (complete or partial) response by central review after six cycles of treatment, analysed by intention to treat. Patients, families, and those administering treatment were aware of group assignment. This study is registered with ClinicalTrials.gov, number NCT01767194, and follow-up of the initial cohort is ongoing. FINDINGS Between Feb 22, 2013, and March 23, 2015, 36 patients from 27 COG member institutions were enrolled on this groupwide study. One patient was ineligible (alanine aminotransferase concentration was above the required range). Of the remaining 35 patients, 18 were randomly assigned to irinotecan-temozolomide-temsirolimus and 17 to irinotecan-temozolomide-dinutuximab. Median follow-up was 1·26 years (IQR 0·68-1·61) among all eligible participants. Of the 18 patients assigned to irinotecan-temozolomide-temsirolimus, one patient (6%; 95% CI 0·0-16·1) achieved a partial response. Of the 17 patients assigned to irinotecan-temozolomide-dinutuximab, nine (53%; 95% CI 29·2-76·7) had objective responses, including four partial responses and five complete responses. The most common grade 3 or worse adverse events in the temsirolimus group were neutropenia (eight [44%] of 18 patients), anaemia (six [33%]), thrombocytopenia (five [28%]), increased alanine aminotransferase (five [28%]), and hypokalaemia (four [22%]). One of the 17 patients assigned to the dinutuximab group refused treatment after randomisation; the most common grade 3 or worse adverse events in the remaining 16 patients evaluable for safety were pain (seven [44%] of 16), hypokalaemia (six [38%]), neutropenia (four [25%]), thrombocytopenia (four [25%]), anaemia (four [25%]), fever and infection (four [25%]), and hypoxia (four [25%]); one patient had grade 4 hypoxia related to therapy that met protocol-defined criteria for unacceptable toxicity. No deaths attributed to protocol therapy occurred. INTERPRETATION Irinotecan-temozolomide-dinutuximab met protocol-defined criteria for selection as the combination meriting further study whereas irinotecan-temozolomide-temsirolimus did not. Irinotecan-temozolomide-dinutuximab shows notable anti-tumour activity in patients with relapsed or refractory neuroblastoma. Further evaluation of biomarkers in a larger cohort of patients might identify those most likely to respond to this chemoimmunotherapeutic regimen. FUNDING National Cancer Institute.
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Affiliation(s)
- Rajen Mody
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Arlene Naranjo
- Children's Oncology Group Statistics and Data Center, University of Florida, Gainesville, FL, USA
| | - Collin Van Ryn
- Children's Oncology Group Statistics and Data Center, University of Florida, Gainesville, FL, USA
| | - Alice L Yu
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA; Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taoyuan, Taiwan
| | - Wendy B London
- Dana-Farber Cancer Institute and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Barry L Shulkin
- St Jude Children's Research Hospital and the University of Tennessee Health Science Center, University of Tennessee, Memphis, TN, USA
| | | | - Sabah-E-Noor Servaes
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mitchell B Diccianni
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Paul M Sondel
- Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | - Julia G Bender
- Columbia University Medical Center, Columbia University, New York, NY, USA
| | - John M Maris
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie R Park
- Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Rochelle Bagatell
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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17
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Ladenstein R, Pötschger U, Pearson ADJ, Brock P, Luksch R, Castel V, Yaniv I, Papadakis V, Laureys G, Malis J, Balwierz W, Ruud E, Kogner P, Schroeder H, de Lacerda AF, Beck-Popovic M, Bician P, Garami M, Trahair T, Canete A, Ambros PF, Holmes K, Gaze M, Schreier G, Garaventa A, Vassal G, Michon J, Valteau-Couanet D. Busulfan and melphalan versus carboplatin, etoposide, and melphalan as high-dose chemotherapy for high-risk neuroblastoma (HR-NBL1/SIOPEN): an international, randomised, multi-arm, open-label, phase 3 trial. Lancet Oncol 2017; 18:500-514. [PMID: 28259608 DOI: 10.1016/s1470-2045(17)30070-0] [Citation(s) in RCA: 213] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 11/03/2016] [Accepted: 11/04/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND High-dose chemotherapy with haemopoietic stem-cell rescue improves event-free survival in patients with high-risk neuroblastoma; however, which regimen has the greatest patient benefit has not been established. We aimed to assess event-free survival after high-dose chemotherapy with busulfan and melphalan compared with carboplatin, etoposide, and melphalan. METHODS We did an international, randomised, multi-arm, open-label, phase 3 cooperative group clinical trial of patients with high-risk neuroblastoma at 128 institutions in 18 countries that included an open-label randomised arm in which high-dose chemotherapy regimens were compared. Patients (age 1-20 years) with neuroblastoma were eligible to be randomly assigned if they had completed a multidrug induction regimen (cisplatin, carboplatin, cyclophosphamide, vincristine, and etoposide with or without topotecan, vincristine, and doxorubicin) and achieved an adequate disease response. Patients were randomly assigned (1:1) to busulfan and melphalan or to carboplatin, etoposide, and melphalan by minimisation, balancing age at diagnosis, stage, MYCN amplification, and national cooperative clinical group between groups. The busulfan and melphalan regimen comprised oral busulfan (150 mg/m2 given on 4 days consecutively in four equal doses); after Nov 8, 2007, intravenous busulfan was given (0·8-1·2 mg/kg per dose for 16 doses according to patient weight). After 24 h, an intravenous melphalan dose (140 mg/m2) was given. Doses of busulfan and melphalan were modified according to bodyweight. The carboplatin, etoposide, and melphalan regimen consisted of carboplatin continuous infusion of area under the plasma concentration-time curve 4·1 mg/mL per min per day for 4 days, etoposide continuous infusion of 338 mg/m2 per day for 4 days, and melphalan 70 mg/m2 per day for 3 days, with doses for all three drugs modified according to bodyweight and glomerular filtration rate. Stem-cell rescue was given after the last dose of high-dose chemotherapy, at least 24 h after melphalan in patients who received busulfan and melphalan and at least 72 h after carboplatin etoposide, and melphalan. All patients received subsequent local radiotherapy to the primary tumour site followed by maintenance therapy. The primary endpoint was 3-year event-free survival, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01704716, and EudraCT, number 2006-001489-17. FINDINGS Between June 24, 2002, and Oct 8, 2010, 1347 patients were enrolled and 676 were eligible for random allocation, 598 (88%) of whom were randomly assigned: 296 to busulfan and melphalan and 302 to carboplatin, etoposide, and melphalan. Median follow-up was 7·2 years (IQR 5·3-9·2). At 3 years, 146 of 296 patients in the busulfan and melphalan group and 188 of 302 in the carboplatin, etoposide, and melphalan group had an event; 3-year event-free survival was 50% (95% CI 45-56) versus 38% (32-43; p=0·0005). Nine patients in the busulfan and melphalan group and 11 in the carboplatin, etoposide, and melphalan group had died without relapse by 5 years. Severe life-threatening toxicities occurred in 13 (4%) patients who received busulfan and melphalan and 29 (10%) who received carboplatin, etoposide, and melphalan. The most frequent grade 3-4 adverse events were general condition (74 [26%] of 281 in the busulfan and melphalan group vs 103 [38%] of 270 in the carboplatin, etoposide, and melphalan group), infection (55 [19%] of 283 vs 74 [27%] of 271), and stomatitis (138 [49%] of 284 vs 162 [59%] of 273); 60 (22%) of 267 patients in the busulfan and melphalan group had Bearman grades 1-3 veno-occlusive disease versus 21 (9%) of 239 in the carboplatin, etoposide, and melphalan group. INTERPRETATION Busulfan and melphalan improved event-free survival in children with high-risk neuroblastoma with an adequate response to induction treatment and caused fewer severe adverse events than did carboplatin, etoposide, and melphalan. Busulfan and melphalan should thus be considered standard high-dose chemotherapy and ongoing randomised studies will continue to aim to optimise treatment for high-risk neuroblastoma. FUNDING European Commission 5th Framework Grant and the St Anna Kinderkrebsforschung.
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Affiliation(s)
- Ruth Ladenstein
- Children's Cancer Research Institute (CCRI)-S(2)IRP: Studies and Statistics for Integrated Research and Projects, Medical University, Vienna, Austria; St Anna Children's Hospital and Department of Paediatrics of the Medical University, Vienna, Austria.
| | - Ulrike Pötschger
- Children's Cancer Research Institute (CCRI)-S(2)IRP: Studies and Statistics for Integrated Research and Projects, Medical University, Vienna, Austria
| | - Andrew D J Pearson
- Paediatric and Adolescent Drug Development Team, Oak Centre for Children and Young People, Institute of Cancer Research, Royal Marsden Hospital, Sutton, UK
| | - Penelope Brock
- Department Paediatric Oncology, Great Ormond Street Hospital, London, UK
| | - Roberto Luksch
- Dipartimento di Ematologia e Onco-ematologia Pediatrica, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Victoria Castel
- Pediatric Oncology Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - Isaac Yaniv
- Sackler Faculty of Medicine, Tel Aviv University, Schneider Children's Medical Center of Israel, Petach, Tikvah, Israel
| | - Vassilios Papadakis
- Department of Paediatric Haematology-Oncology, Agia Sofia Children's Hospital Athens, Athens, Greece
| | - Geneviève Laureys
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation University Hospital Ghent, Ghent, Belgium
| | - Josef Malis
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague, Czech Republic
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Ellen Ruud
- Department of Paediatric Medicine, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Per Kogner
- Department of Women's and Children's Health, Karolinska Institutet, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Schroeder
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Ana Forjaz de Lacerda
- Department of Paediatric and Adolescent Oncology, Portuguese Institute of Oncology, Lisbon, Portugal
| | - Maja Beck-Popovic
- Department of Pediatrics and Pediatric Surgery, Pediatric Haematology Oncology Unit, University Hospital Lausanne, Lausanne, Switzerland
| | - Pavel Bician
- Clinic of Pediatric Oncology and Hematology, University Children's Hospital, Banska Bystrica, Slovakia
| | - Miklós Garami
- Second Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Toby Trahair
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Adela Canete
- Pediatric Oncology Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - Peter F Ambros
- Children's Cancer Research Institute Department of Tumour Biology, Medical University, Vienna, Austria
| | - Keith Holmes
- Department Paediatric Surgery, St Georges Hospital, London, UK
| | - Mark Gaze
- Department of Oncology, University College Hospital, London, UK
| | - Günter Schreier
- Center for Health and Bioresources, AIT Austrian Institute of Technology, Graz, Austria
| | | | - Gilles Vassal
- Children and Adolescent Oncology Department, Gustave Roussy, Paris-Sud University, Paris, France
| | - Jean Michon
- Children, Adolescent and Young Adults Department, Institut Curie, Paris, France
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18
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Whittle SB, Smith V, Doherty E, Zhao S, McCarty S, Zage PE. Overview and recent advances in the treatment of neuroblastoma. Expert Rev Anticancer Ther 2017; 17:369-386. [PMID: 28142287 DOI: 10.1080/14737140.2017.1285230] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Children with neuroblastoma have widely divergent outcomes, ranging from cure in >90% of patients with low risk disease to <50% for those with high risk disease. Recent research has shed light on the biology of neuroblastoma, allowing for more accurate risk stratification and treatment reduction in many cases, although newer treatment strategies for children with high-risk and relapsed neuroblastoma are needed to improve outcomes. Areas covered: Neuroblastoma epidemiology, diagnosis, risk stratification, and recent advances in treatment of both newly diagnosed and relapsed neuroblastoma. Expert commentary: The identification of newer tumor targets and of novel cell-mediated immunotherapy agents may lead to novel therapeutic approaches, and clinical trials for regimens designed to target individual genetic aberrations in tumors are underway. A combination of therapeutic modalities will likely be required to improve survival and cure rates for patients with high-risk neuroblastoma.
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Affiliation(s)
- Sarah B Whittle
- a Department of Pediatrics, Section of Hematology-Oncology , Texas Children's Cancer and Hematology Centers, Baylor College of Medicine , Houston , TX , USA
| | - Valeria Smith
- a Department of Pediatrics, Section of Hematology-Oncology , Texas Children's Cancer and Hematology Centers, Baylor College of Medicine , Houston , TX , USA
| | - Erin Doherty
- a Department of Pediatrics, Section of Hematology-Oncology , Texas Children's Cancer and Hematology Centers, Baylor College of Medicine , Houston , TX , USA
| | - Sibo Zhao
- a Department of Pediatrics, Section of Hematology-Oncology , Texas Children's Cancer and Hematology Centers, Baylor College of Medicine , Houston , TX , USA
| | - Scott McCarty
- b Department of Pediatrics, Division of Hematology-Oncology , University of California San Diego, La Jolla, CA and Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital , San Diego , CA , USA
| | - Peter E Zage
- b Department of Pediatrics, Division of Hematology-Oncology , University of California San Diego, La Jolla, CA and Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital , San Diego , CA , USA
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19
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Moreno L, Rubie H, Varo A, Le Deley MC, Amoroso L, Chevance A, Garaventa A, Gambart M, Bautista F, Valteau-Couanet D, Geoerger B, Vassal G, Paoletti X, Pearson ADJ. Outcome of children with relapsed or refractory neuroblastoma: A meta-analysis of ITCC/SIOPEN European phase II clinical trials. Pediatr Blood Cancer 2017; 64:25-31. [PMID: 27555472 DOI: 10.1002/pbc.26192] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 06/14/2016] [Accepted: 07/05/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Few randomized trials have been conducted in children with relapsed/refractory neuroblastoma and data about outcomes including progression-free survival (PFS) in these patients are scarce. PROCEDURE A meta-analysis of three phase II studies of children with relapsed/refractory neuroblastoma conducted in Europe (temozolomide, topotecan-vincristine-doxorubicin and topotecan-temozolomide) was performed. Individual patient data with extended follow-up were collected from the trial databases after publication to describe trial outcomes (response rate, clinical benefit ratio, duration of treatment, PFS, and overall survival [OS]). Characteristics of subjects with relapsed/refractory neuroblastoma were compared. RESULTS Data from 71 children and adolescents with relapsed/refractory neuroblastoma were collected. Response definitions were not homogeneous in the three trials. Patients were on study for a median of 3.5 months (interquartile range [IQR] 1.9-6.2). Of those, 35.2% achieved a complete or partial response, 26.3% experienced a response after more than two cycles, and 23.9% received more than six cycles. Median PFS from study entry for all, refractory, and relapsed patients was 6.4 ± 1.0, 12.5 ± 6.8, and 5.7 ± 1.0 months, respectively (P = 0.006). Median OS from study entry for all, refractory, and relapsed patients was 16.1 ± 4.3, 27.9 ± 20.2, and 11.0 ± 1.6 months, respectively (P = 0.03). CONCLUSIONS Baseline data for response rate, clinical benefit ratio, duration of treatment, PFS, and OS were provided. Two subpopulations (relapsed/refractory) were clearly distinct and should be included in the interpretation of all trials. These results should help informing the design of forthcoming studies in relapsed/refractory neuroblastoma.
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Affiliation(s)
- Lucas Moreno
- HNJ-CNIO Clinical Research Unit, Hospital Universitario Niño Jesus, Madrid, Spain
| | | | - Amalia Varo
- HNJ-CNIO Clinical Research Unit, Hospital Universitario Niño Jesus, Madrid, Spain
| | - Marie Cecile Le Deley
- Universite Paris-Saclay, Univ. Paris-Sud, CESP, INSERM, Gustave Roussy, Villejuif, France
| | | | | | - Alberto Garaventa
- Department of Pediatric Hemato-Oncology, Istituto Gianina, Gaslini, Genova
| | | | - Francisco Bautista
- HNJ-CNIO Clinical Research Unit, Hospital Universitario Niño Jesus, Madrid, Spain
| | | | - Birgit Geoerger
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | - Gilles Vassal
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
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20
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Abstract
Neuroblastoma is the most common extracranial solid tumour occurring in childhood and has a diverse clinical presentation and course depending on the tumour biology. Unique features of these neuroendocrine tumours are the early age of onset, the high frequency of metastatic disease at diagnosis and the tendency for spontaneous regression of tumours in infancy. The most malignant tumours have amplification of the MYCN oncogene (encoding a transcription factor), which is usually associated with poor survival, even in localized disease. Although transgenic mouse models have shown that MYCN overexpression can be a tumour-initiating factor, many other cooperating genes and tumour suppressor genes are still under investigation and might also have a role in tumour development. Segmental chromosome alterations are frequent in neuroblastoma and are associated with worse outcome. The rare familial neuroblastomas are usually associated with germline mutations in ALK, which is mutated in 10-15% of primary tumours, and provides a potential therapeutic target. Risk-stratified therapy has facilitated the reduction of therapy for children with low-risk and intermediate-risk disease. Advances in therapy for patients with high-risk disease include intensive induction chemotherapy and myeloablative chemotherapy, followed by the treatment of minimal residual disease using differentiation therapy and immunotherapy; these have improved 5-year overall survival to 50%. Currently, new approaches targeting the noradrenaline transporter, genetic pathways and the tumour microenvironment hold promise for further improvements in survival and long-term quality of life.
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21
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Kushner BH, Ostrovnaya I, Cheung IY, Kuk D, Modak S, Kramer K, Roberts SS, Basu EM, Yataghene K, Cheung NKV. Lack of survival advantage with autologous stem-cell transplantation in high-risk neuroblastoma consolidated by anti-GD2 immunotherapy and isotretinoin. Oncotarget 2016; 7:4155-66. [PMID: 26623730 PMCID: PMC4826196 DOI: 10.18632/oncotarget.6393] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/09/2015] [Indexed: 11/25/2022] Open
Abstract
Since 2003, high-risk neuroblastoma (HR-NB) patients at our center received anti-GD2 antibody 3F8/GM-CSF + isotretinoin – but not myeloablative therapy with autologous stem-cell transplantation (ASCT). Post-ASCT patients referred from elsewhere also received 3F8/GM-CSF + isotretinoin. We therefore accrued a study population of two groups treated during the same period and whose consolidative therapy, aside from ASCT, was identical. We analyzed patients enrolled in 1st complete/very good partial remission (CR/VGPR). Their event-free survival (EFS) and overall survival (OS) were calculated from study entry. Large study size allowed robust statistical analyses of key prognosticators including MYCN amplification, minimal residual disease (MRD), FCGR2A polymorphisms, and killer immunoglobulin-like receptor genotypes of natural killer cells. The 170 study patients included 60 enrolled following ASCT and 110 following conventional chemotherapy. The two cohorts had similar clinical and biological features. Five-year rates for ASCT and non-ASCT patients were, respectively: EFS 65% vs. 51% (p = .128), and OS 76% vs. 75% (p = .975). In multivariate analysis, ASCT was not prognostic and only MRD-negativity after two cycles of 3F8/GM-CSF correlated with significantly improved EFS and OS. Although a trend towards better EFS is seen with ASCT, OS is near identical. Cure rates may be similar, as close surveillance detects localized relapse and effective salvage treatments are applied. ASCT may not be needed to improve outcome when anti-GD2 immunotherapy is used for consolidation after dose-intensive conventional chemotherapy.
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Irina Ostrovnaya
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Irene Y Cheung
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Deborah Kuk
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Shakeel Modak
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Kim Kramer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Stephen S Roberts
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ellen M Basu
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Karima Yataghene
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Nai-Kong V Cheung
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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22
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Proust-Houdemont S, Pasqualini C, Blanchard P, Dufour C, Benhamou E, Goma G, Semeraro M, Raquin MA, Hartmann O, Valteau-Couanet D. Busulfan-melphalan in high-risk neuroblastoma: the 30-year experience of a single institution. Bone Marrow Transplant 2016; 51:1076-81. [PMID: 27042850 DOI: 10.1038/bmt.2016.75] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/10/2016] [Accepted: 02/19/2016] [Indexed: 11/09/2022]
Abstract
High-dose chemotherapy (HDC) was investigated in high-risk neuroblastoma (HR-NBL) to reduce the risk of relapse. We report the results of the 30-year experience of a cohort of patients with HR-NBL treated with high-dose (HD) busulfan (Bu)-containing regimens. From 1980 to 2009, 215 patients aged >1 year with stage 4 NBL were treated with HD Bu-containing regimens at Gustave Roussy. These data were prospectively recorded in the Pediatric Transplantation Database. The median age at diagnosis was 40 months (12-218 months). All patients had a stage 4 neuroblastoma. NMYC amplification was displayed in 24% of the tumors. The hematopoietic support consisted of bone marrow or PBSCs in 46% and 49% of patients, respectively. The 5-year event-free survival and overall survival rates of the whole cohort were 35.1% and 40%, respectively. Age at diagnosis, bone marrow involvement and tumor response after induction chemotherapy were significant prognostic factors. Toxicity was manageable and decreased over time, owing to both PBSC administration and better supportive care. Based on this experience, HD Bu-melphalan (Mel) has been implemented in Europe and compared with Carboplatin-Etoposide-Mel in the European SIOP Neuroblastoma (SIOPEN)/HR-NBL randomized protocol. It has now become the standard HDC in the SIOPEN HR strategy.
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Affiliation(s)
- S Proust-Houdemont
- Department of Pediatric Oncology, Centre Hospitalier Universitaire, Angers, France
| | - C Pasqualini
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | - P Blanchard
- Biostatistics and Epidemiology Unit, Gustave Roussy, Villejuif, France
| | - C Dufour
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | - E Benhamou
- Biostatistics and Epidemiology Unit, Gustave Roussy, Villejuif, France
| | - G Goma
- Biostatistics and Epidemiology Unit, Gustave Roussy, Villejuif, France
| | - M Semeraro
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | - M-A Raquin
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | - O Hartmann
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | - D Valteau-Couanet
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
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23
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Reed DR, Mascarenhas L, Manning K, Hale GA, Goldberg J, Gill J, Sandler E, Isakoff MS, Smith T, Caracciolo J, Lush RM, Juan TH, Lee JK, Neuger AM, Sullivan DM. Pediatric phase I trial of oral sorafenib and topotecan in refractory or recurrent pediatric solid malignancies. Cancer Med 2015; 5:294-303. [PMID: 26714427 PMCID: PMC4735769 DOI: 10.1002/cam4.598] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/02/2015] [Accepted: 11/05/2015] [Indexed: 12/22/2022] Open
Abstract
Targeted kinase inhibitors and camptothecins have shown preclinical and clinical activity in several cancers. This trial evaluated the maximum tolerated dose (MTD) and dose‐limiting toxicities of sorafenib and topotecan administered orally in pediatric patients with relapsed solid tumors. Sorafenib was administered twice daily and topotecan once daily on days 1–5 and 8–12 of each 28‐day course. The study utilized a standard 3 + 3 dose escalation design. Three dose levels (DL) were evaluated: (1) sorafenib 150 mg/m2 and topotecan 1 mg/m2; (2) sorafenib 150 mg/m2 and topotecan 1.4 mg/m2; and (3) sorafenib 200 mg/m2 and topotecan 1.4 mg/m2. Pharmacokinetics were ascertained and treatment response assessed. Thirteen patients were enrolled. DL2 was the determined MTD. Grade 4 thrombocytopenia delaying therapy for >7 days was observed in one of six patients on DL2, and grade 4 neutropenia that delayed therapy in two of three patients on DL3. A patient with preexisting cardiac failure controlled with medication developed a transient drop in the left ventricular ejection fraction that improved when sorafenib was withheld. Sorafenib exposure with or without topotecan was comparable, and the concentration‐time profiles for topotecan alone and in combination with sorafenib were similar. One objective response was noted in a patient with fibromatosis. We determined MTD to be sorafenib 150 mg/m2 twice daily orally on days 1–28 combined with topotecan 1.4 mg/m2 once daily on days 1–5 and 8–12. While these doses are 1 DL below the MTD of the agents individually, pharmacokinetic studies suggested adequate drug exposure without drug interactions. The combination had limited activity in the population studied.
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Affiliation(s)
- Damon R Reed
- Sarcoma Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.,Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.,Adolescent and Young Adult Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.,All Children's Hospital, Johns Hopkins Medicine, St. Petersburg, Florida
| | - Leo Mascarenhas
- Division of Hematology, Oncology, Blood and Marrow Transplantation, Department of Pediatrics, Children's Hospital of Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kathleen Manning
- Sarcoma Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Gregory A Hale
- All Children's Hospital, Johns Hopkins Medicine, St. Petersburg, Florida
| | | | - Jonathan Gill
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Eric Sandler
- Nemours Children's Cancer Center, Jacksonville, Florida
| | | | - Tiffany Smith
- Sarcoma Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jamie Caracciolo
- Department of Diagnostic Imaging, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard M Lush
- Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Tzu-Hua Juan
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jae K Lee
- Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.,Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Anthony M Neuger
- Translational Research Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Daniel M Sullivan
- Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.,Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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24
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Bolzacchini E, Martinelli B, Pinotti G. Adult onset of ganglioneuroblastoma of the adrenal gland: case report and review of the literature. Surg Case Rep 2015; 1:79. [PMID: 26380803 PMCID: PMC4567593 DOI: 10.1186/s40792-015-0062-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 07/03/2015] [Indexed: 11/10/2022] Open
Abstract
Ganglioneuroblastoma (GBN) is a malignant neoplasm of the autonomic nervous system. Adult onset of ganglioneuroblastoma is extremely rare. Only 16 cases have been reported in English literature, to date. Surgery represents the first-line therapy for the treatment of ganglioneuroblastoma. Radiation therapy is indicated in patients with localized unresectable disease. Chemotherapy is reserved for metastatic disease. We present the case of a 63-year-old man affected by ganglioneuroblastoma of the adrenal gland. The diagnosis was made incidentally. The tumor, measuring 5 × 3 cm, was successfully surgically removed.
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Affiliation(s)
- Elena Bolzacchini
- U.O Oncologia Medica, Azienda ospedaliero-universitaria Ospedale di Circolo e Fondazione Macchi, Viale Borri, 57, 21100 Varese, Italy
| | - Barbara Martinelli
- U.O Oncologia Medica, Azienda ospedaliero-universitaria Ospedale di Circolo e Fondazione Macchi, Viale Borri, 57, 21100 Varese, Italy
| | - Graziella Pinotti
- U.O Oncologia Medica, Azienda ospedaliero-universitaria Ospedale di Circolo e Fondazione Macchi, Viale Borri, 57, 21100 Varese, Italy
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25
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Kushner BH, Ostrovnaya I, Cheung IY, Kuk D, Kramer K, Modak S, Yataghene K, Cheung NK. Prolonged progression-free survival after consolidating second or later remissions of neuroblastoma with Anti-G D2 immunotherapy and isotretinoin: a prospective Phase II study. Oncoimmunology 2015; 4:e1016704. [PMID: 26140243 DOI: 10.1080/2162402x.2015.1016704] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 10/23/2022] Open
Abstract
Relapse of high-risk neuroblastoma (HR-NB) is deemed invariably fatal yet increasing numbers of HR-NB patients achieve a second complete/very good partial remission (CR/VGPR), hence the urgency to find a successful consolidative therapy. Identifying efficacy in patients without assessable disease, however, is problematic. We report the first study providing outcome data for this group of patients with poor prognosis. To prevent another relapse, HR-NB patients in second or later CR/VGPR received the anti-GD2 murine antibody 3F8 plus granulocyte-macrophage colony-stimulating factor plus isotretinoin in a Phase II trial. Upon meeting the target aim for progression-free survival (PFS) in the initial cohort of 33 patients, the trial was amended to allow patients who developed human anti-mouse antibody (HAMA) to receive rituximab to ablate HAMA with or without low-dose maintenance chemotherapy until immunotherapy could resume. For the total of 101 study patients, 5-year PFS and overall survival (OS) rates were 33% ± 5% and 48% ± 5%, respectively. Among the 33 long-term progression-free survivors, 19 had MYCN amplification, 19 had previously received anti-GD2 immunotherapy plus isotretinoin (as first-line therapy), and 15 never received maintenance chemotherapy. In a multivariate analysis of prognostic factors, only absence of minimal residual disease in bone marrow after 2 cycles of immunotherapy and before initiation of isotretinoin or anti-HAMA therapy was significantly favorable for both PFS and OS. Therefore, long-term PFS is possible for HR-NB patients who achieve at least a second CR/VGPR and receive consolidation that includes anti-GD2 immunotherapy plus isotretinoin, even if the patients received these biological treatments before relapse. Results from this prospective study will aid in the development of future Phase II studies for this growing ultra high-risk patient population.
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Key Words
- ASCT, autologous stem-cell transplantation
- BM, bone marrow
- CNS, central nervous system
- CR, complete remission
- GM-CSF, granulocyte-macrophage colony-stimulating factor
- HAMA, human anti-mouse antibody
- HR-NB: high-risk neuroblastoma
- INRC, International Neuroblastoma Response Criteria
- INRG, International Neuroblastoma Risk Group
- MIBG, metaiodobenzylguanidine
- MRD, minimal residual disease
- OS, overall survival
- PD, progressive disease
- PFS, progression-free survival
- VGPR, very good partial remission
- anti-GD2 antibody
- immunotherapy
- mAb, monoclonal antibody
- minimal residual disease
- salvage
- second remission
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics; Memorial Sloan-Kettering Cancer Center ; New York, NY USA
| | - Irina Ostrovnaya
- Department of Epidemiology and Biostatistics; Memorial Sloan Kettering Cancer Center ; New York, NY USA
| | - Irene Y Cheung
- Department of Pediatrics; Memorial Sloan-Kettering Cancer Center ; New York, NY USA
| | - Deborah Kuk
- Department of Epidemiology and Biostatistics; Memorial Sloan Kettering Cancer Center ; New York, NY USA
| | - Kim Kramer
- Department of Pediatrics; Memorial Sloan-Kettering Cancer Center ; New York, NY USA
| | - Shakeel Modak
- Department of Pediatrics; Memorial Sloan-Kettering Cancer Center ; New York, NY USA
| | - Karima Yataghene
- Department of Pediatrics; Memorial Sloan-Kettering Cancer Center ; New York, NY USA
| | - N K Cheung
- Department of Pediatrics; Memorial Sloan-Kettering Cancer Center ; New York, NY USA
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26
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Additional Therapies to Improve Metastatic Response to Induction Therapy in Children With High-risk Neuroblastoma. J Pediatr Hematol Oncol 2015. [PMID: 26201036 DOI: 10.1097/mph.0000000000000308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Children with high-risk neuroblastoma who fail to achieve adequate metastatic response after induction chemotherapy have dismal outcome and new therapeutic strategies are needed. However, timing of introduction of novel agents still remains under discussion. Given an increase in number of phase I-II studies of molecularly targeted drugs in neuroblastoma, it is crucial to determine, as early as possible, which patients may be suitable candidates for new therapeutic strategies. This single-center retrospective analysis of patients with high-risk neuroblastoma showed that the addition of conventional chemotherapy improved the quality of metastatic response only for the group of patients with partial response. It is therefore proposed to develop stratification criteria for those patients very unlikely to benefit from a plethora of additional lines of treatment, but might benefit from introduction of novel agents.
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27
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Abstract
Neuroblastoma (NB) is the third most common pediatric cancer. Although NB accounts for 7% of pediatric malignancies, it is responsible for more than 10% of childhood cancer-related mortality. Prognosis and treatment are determined by clinical and biological risk factors. Estimated 5-year survival rates for patients with non-high-risk and high-risk NB are more than 90% and less than 50%, respectively. Recent clinical trials have continued to reduce therapy for patients with non-high-risk NB, including the most favorable subsets who are often followed with observation approaches. In contrast, high-risk patients are treated aggressively with chemotherapy, radiation, surgery, and myeloablative and immunotherapies.
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28
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Tran HC, Marachelian A, Venkatramani R, Jubran RF, Mascarenhas L. Oxaliplatin and Doxorubicin for relapsed or refractory high-risk neuroblastoma. Pediatr Hematol Oncol 2015; 32:26-31. [PMID: 25551355 DOI: 10.3109/08880018.2014.983624] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with relapsed or refractory neuroblastoma have poor long-term survival. New therapeutic regimens are needed. Doxorubicin and cisplatin are commonly used in the treatment of high-risk neuroblastoma. Oxaliplatin, a platinum compound with a 1,2-diaminocyclohexan carrier ligand, is more potent than cisplatin with less nephrotoxicity and ototoxicity. We treated seven relapsed/refractory neuroblastoma patients using oxaliplatin (105-130 mg/m(2)) and doxorubicin (60-75 mg/m(2)) together with dexrazoxane (10 mg/mg of doxorubicin) administered intravenously every three weeks. Prolonged thrombocytopenia causing treatment delay was observed when oxaliplatin was administered at 130 mg/m(2). A reduced dose of oxaliplatin 105 mg/m(2) on day 1 with doxorubicin at 20 mg/m(2)/dose on days 1-3 was well tolerated. Sensory neuropathies were mild and transient. No cardiotoxicity was noted despite all patients having a history of prior anthracycline exposure. Best responses included 1 complete response, 1 partial response, 1 mixed response, 3 stable diseases. In our cohort of heavily pretreated relapsed and refractory neuroblastoma patients, the combination of oxaliplatin and doxorubicin demonstrated anti-tumor activity and merits further investigation.
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Affiliation(s)
- Hung C Tran
- 2Division of Hematology/Oncology/BMT, Children's Hospital Los Angeles , Los Angeles, California , USA
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29
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Nhan T, Burgess A, Lilge L, Hynynen K. Modeling localized delivery of Doxorubicin to the brain following focused ultrasound enhanced blood-brain barrier permeability. Phys Med Biol 2014; 59:5987-6004. [PMID: 25230100 DOI: 10.1088/0031-9155/59/20/5987] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Doxorubicin (Dox) is a well-established chemotherapeutic agent, however it has limited efficacy in treating brain malignancies due to the presence of the blood-brain barrier (BBB). Recent preclinical studies have demonstrated that focused ultrasound induced BBB disruption (BBBD) enables efficient delivery of Dox to the brain. For future treatment planning of BBBD-based drug delivery, it is crucial to establish a mathematical framework to predict the effect of transient BBB permeability enhancement on the spatiotemporal distribution of Dox at the targeted area. The constructed model considers Dox concentrations within three compartments (plasma, extracellular, intracellular) that are governed by various transport processes (e.g. diffusion in interstitial space, exchange across vessel wall, clearance by cerebral spinal fluid, uptake by brain cells). By examining several clinical treatment aspects (e.g. sonication scheme, permeability enhancement, injection mode), our simulation results support the experimental findings of optimal interval delay between two consecutive sonications and therapeutically-sufficient intracellular concentration with respect to transfer constant Ktrans range of 0.01-0.03 min(-1). Finally, the model suggests that infusion over a short duration (20-60 min) should be employed along with single-sonication or multiple-sonication at 10 min interval to ensure maximum delivery to the intracellular compartment while attaining minimal cardiotoxicity via suppressing peak plasma concentration.
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Affiliation(s)
- Tam Nhan
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada. Medical Biophysics, University of Toronto, Toronto, ON, Canada
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Kushner BH, Modak S, Kramer K, LaQuaglia MP, Yataghene K, Basu EM, Roberts SS, Cheung NKV. Striking dichotomy in outcome of MYCN-amplified neuroblastoma in the contemporary era. Cancer 2014; 120:2050-9. [PMID: 24691684 DOI: 10.1002/cncr.28687] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/21/2014] [Accepted: 02/24/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND The authors exploited a large database to investigate the outcomes of patients with high-risk neuroblastoma in the contemporary era. METHODS All patients with high-risk neuroblastoma aged <12 years who were treated during induction at the authors' institution from 2000 through 2011 were studied, including 118 patients with MYCN-amplified [MYCN(+)] disease and 127 patients aged >18 months with MYCN-nonamplified [MYCN(-)] stage 4 disease. RESULTS A complete response/very good partial response (CR/VGPR) to induction was correlated with significantly superior event-free survival (EFS) (P < .001) and overall survival (OS) (P < .001) compared with a partial response or less. Patients with MYCN(+) and MYCN(-) disease had similar rates of CR/VGPR to induction (P = .366), and those with MYCN(+) and MYCN(-) disease who attained a CR/VGPR had similar EFS (P = .346) and OS (P = .542). In contrast, only MYCN(+) patients had progressive disease as a response to induction (P < .001), and early death from progressive disease (<366 days after diagnosis) was significantly more common (P < .001) among those with MYCN(+) disease. Overall, among patients who had a partial response or less, MYCN(+) patients had significantly inferior EFS (P < .001) and OS (P < .001) compared with MYCN(-) patients, which accounted for the significantly worse EFS (P = .008) and OS (P = .002) for the entire MYCN(+) cohort versus the MYCN(-) cohort. CONCLUSIONS Patients with MYCN(-), high-risk neuroblastoma display a broad, continuous spectrum with regard to response and outcome, whereas MYCN(+) patients either have an excellent response to induction associated with good long-term outcome or develop early progressive disease with a poor outcome. This extreme dichotomy in the clinical course of MYCN(+) patients points to underlying biologic differences with MYCN(+) neuroblastoma, the elucidation of which may have far-reaching implications, including improved risk classification at diagnosis and the identification of targets for treatment.
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
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Rapid screening of novel agents for combination therapy in sarcomas. Sarcoma 2013; 2013:365723. [PMID: 24282374 PMCID: PMC3824404 DOI: 10.1155/2013/365723] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 09/04/2013] [Accepted: 09/05/2013] [Indexed: 01/22/2023] Open
Abstract
For patients with sarcoma, metastatic disease remains very difficult to cure, and outcomes remain less than optimal. Treatment options have not largely changed, although some promising gains have been made with single agents in specific subtypes with the use of targeted agents. Here, we developed a system to investigate synergy of combinations of targeted and cytotoxic agents in a panel of sarcoma cell lines. Agents were investigated alone and in combination with varying dose ratios. Dose-response curves were analyzed for synergy using methods derived from Chou and Talalay (1984). A promising combination, dasatinib and triciribine, was explored in a murine model using the A673 cell line, and tumors were evaluated by MRI and histology for therapy effect. We found that histone deacetylase inhibitors were synergistic with etoposide, dasatinib, and Akt inhibitors across cell lines. Sorafenib and topotecan demonstrated a mixed response. Our systematic drug screening method allowed us to screen a large number of combinations of sarcoma agents. This method can be easily modified to accommodate other cell line models, and confirmatory assays, such as animal experiments, can provide excellent preclinical data to inform clinical trials for these rare malignancies.
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Ashraf K, Shaikh F, Gibson P, Baruchel S, Irwin MS. Treatment with topotecan plus cyclophosphamide in children with first relapse of neuroblastoma. Pediatr Blood Cancer 2013; 60:1636-41. [PMID: 23650219 DOI: 10.1002/pbc.24587] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 04/07/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND Reports of responses and toxicities of salvage therapies for relapsed neuroblastoma are rare and often confounded by effects of additional treatments. Our objective was to describe the outcomes and toxicities for a topotecan and cyclophosphamide (TOPO/CTX) regimen for first relapse or progression of high-risk neuroblastoma. METHODS We retrospectively reviewed charts of relapsed or refractory neuroblastoma patients treated between 1999 and 2009 with our standard-of-care outpatient TOPO/CTX (0.75 and 250 mg/m(2) /day × 5 days q3-4 weeks). RESULTS Twenty-seven patients received 343 cycles of TOPO/CTX (median 10 cycles per patient, range 1-32). Most patients (N = 25) had undergone autologous stem cell transplantation. Seventeen (63%) patients had an objective response (CR + PR + MR). The 3-year progression-free survival (PFS) after relapse was 11 ± 6% and 3-year overall survival (OS) after relapse was 33 ± 9%. The median PFS was 1.2 years and the median OS was 2.3 years. Five patients are alive with follow-up of 3.1-5.5 years. Shorter time from diagnosis to relapse (6-18 months) was associated with shorter OS. The majority of patients experienced chemotherapy delays, transfusions, and febrile neutropenia, including eight bacterial infections. The mean number of hospitalized days was less than one per cycle. CONCLUSIONS TOPO/CTX was well tolerated and resulted in response rates and PFS similar to those reported for patients treated on COG 9462. Our study provides additional toxicity, historical endpoints, and time-to-progression data against which new agents and combination therapies using TOPO/CTX as a backbone can be measured.
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Affiliation(s)
- Kaleem Ashraf
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
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Di Giannatale A, Dias-Gastellier N, Devos A, Mc Hugh K, Boubaker A, Courbon F, Verschuur A, Ducassoul S, Malekzadeh K, Casanova M, Amoroso L, Chastagner P, Zwaan CM, Munzer C, Aerts I, Landman-Parker J, Riccardi R, Le Deley MC, Geoerger B, Rubie H. Phase II study of temozolomide in combination with topotecan (TOTEM) in relapsed or refractory neuroblastoma: a European Innovative Therapies for Children with Cancer-SIOP-European Neuroblastoma study. Eur J Cancer 2013; 50:170-7. [PMID: 24021349 DOI: 10.1016/j.ejca.2013.08.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 08/07/2013] [Accepted: 08/12/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess objective response rate (ORR) after two cycles of temozolomide in combination with topotecan (TOTEM) in children with refractory or relapsed neuroblastoma. PATIENTS AND METHODS This multicenter, non-randomised, phase II study included children with neuroblastoma according to a two-stage Simon design. Eligibility criteria included relapsed or refractory, measurable or metaiodobenzylguanidine (mIBG) evaluable disease, no more than two lines of prior treatment. Temozolomide was administered orally at 150mg/m(2) followed by topotecan at 0.75mg/m(2) intravenously for five consecutive days every 28days. Tumour response was assessed every two cycles according to International Neuroblastoma Response Criteria (INRC), and reviewed independently. RESULTS Thirty-eight patients were enroled and treated in 15 European centres with a median age of 5.4years. Partial tumour response after two cycles was observed in 7 out of 38 evaluable patients [ORR 18%, 95% confidence interval (CI) 8-34%]. The best ORR whatever the time of evaluation was 24% (95% CI, 11-40%) with a median response duration of 8.5months. Tumour control rate (complete response (CR)+partial response (PR)+mixed response (MR)+stable disease (SD)) was 68% (95% CI, 63-90%). The 12-months Progression-Free and Overall Survival were 42% and 58% respectively. Among 213 treatment cycles (median 4, range 1-12 per patient) the most common treatment-related toxicities were haematologic. Grade 3/4 neutropenia occurred in 62% of courses in 89% of patients, grade 3/4 thrombocytopenia in 47% of courses in 71% of patients; three patients (8%) had febrile neutropenia. CONCLUSION Temozolomide-Topotecan combination results in very encouraging ORR and tumour control in children with heavily pretreated recurrent and refractory neuroblastoma with favourable toxicity profile.
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Affiliation(s)
- Angela Di Giannatale
- Institut Gustave Roussy, Université Paris-Sud, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Nathalie Dias-Gastellier
- Institut Gustave Roussy, Université Paris-Sud, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Annick Devos
- Sophia Children's Hospital/Erasmus MC Rotterdam, 60 Dr. Molewaterplein, 3015 GJ Rotterdam, The Netherlands
| | - Kieran Mc Hugh
- Great Ormond Street Hospital, 34 Great Ormond Street, Bloomsbury, London WC1N 3JH, United Kingdom
| | - Ariane Boubaker
- Centre Hospitalier Universitaire Vaudois, 46 Rue du Bugnon, 1011 Lausanne, Switzerland
| | - Frederic Courbon
- Institut Claudius Regaud, 20-24 Rue du pont Saint-Pierre, 31052 Toulouse Cedex, France
| | - Arnaud Verschuur
- Hôpital de la Timone, 264 Rue Saint Pierre, 13385 Marseille Cedex 5, France
| | - Stéphane Ducassoul
- Centre Hospitalier Pellegrin Hôpital des Enfants, Place Amélie Raba-Léon, 33076 Bordeaux, France
| | - Katty Malekzadeh
- Institut Gustave Roussy, Université Paris-Sud, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Michela Casanova
- Fondazione IRCCS Istituto Nazionale Tumori, 1 Via Venezian, 20133 Milano, Italy
| | - Loredana Amoroso
- Istituto Giannina Gaslini, 5 Via Gerolamo Gaslini, 16147 Genova, Italy
| | | | - Christian M Zwaan
- Sophia Children's Hospital/Erasmus MC Rotterdam, 60 Dr. Molewaterplein, 3015 GJ Rotterdam, The Netherlands
| | - Caroline Munzer
- Hôpital des Enfants, 330 Avenue de Grande Bretagne, 31059 Toulouse Cedex 9, France
| | - Isabelle Aerts
- Universita Cattolica, Gemelli, Largo A. Gemelli 8, 00168 Roma, Italy
| | | | - Riccardo Riccardi
- Hôpital d'Enfants Armand-Trousseau, 26 Avenue du Docteur Arnold Netter, 75571 Paris, France
| | - Marie-Cecile Le Deley
- Institut Gustave Roussy, Université Paris-Sud, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Birgit Geoerger
- Institut Gustave Roussy, Université Paris-Sud, 114 Rue Edouard Vaillant, 94805 Villejuif, France
| | - Hervé Rubie
- Hôpital des Enfants, 330 Avenue de Grande Bretagne, 31059 Toulouse Cedex 9, France.
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Current and future strategies for relapsed neuroblastoma: challenges on the road to precision therapy. J Pediatr Hematol Oncol 2013; 35:337-47. [PMID: 23703550 DOI: 10.1097/mph.0b013e318299d637] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
More than half of the patients with high-risk neuroblastoma (NB) will relapse despite intensive multimodal therapy, with an additional 10% to 20% refractory to induction chemotherapy. Management of these patients is challenging, given disease heterogeneity, resistance, and organ toxicity including poor hematological reserve. This review will discuss the current treatment options and consider novel therapies on the horizon. Cytotoxic chemotherapy regimens for relapse and refractory NB typically center on the use of the camptothecins, topotecan and irinotecan, in combination with agents such as cyclophosphamide and temozolomide, with objective responses but poor long-term survival. I-meta-iodobenzylguanidine therapy is also effective for relapsed patients with meta-iodobenzylguanidine-avid disease, with objective responses in a third of cases. Immunotherapy with anti-GD2 has recently been incorporated into upfront therapy, but its role in the relapse setting remains uncertain, especially for patients with bulky disease. Future cell-based immunotherapies and other approaches may be able to overcome this limitation. Finally, many novel molecularly targeted agents are in development, some of which show specific promise for NB. Successful incorporation of these agents will require combinations with conventional cytotoxic chemotherapies, as well as the development of predictive biomarkers, to ultimately personalize approaches to patients with "targetable" molecular abnormalities.
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Abstract
INTRODUCTION Neuroblastoma accounts for 8 - 10% of pediatric cancers and is responsible for 15% of childhood cancer deaths. Despite multimodality treatment, the overall survival (OS) and event-free survival (EFS) in high-risk patients remain suboptimal. More than half of children diagnosed with high-risk neuroblastoma either do not respond to conventional therapies or relapse after treatment. AREAS COVERED This review discusses about the unmet medical needs for new therapeutic options against high-risk neuroblastoma. New drugs and therapeutic strategies that are under development in clinical trials, which are currently recruiting patients. EXPERT OPINION There is a need to improve the response rate of induction chemotherapy, which is not effective in a third of patients and also the other components of the current treatment, little efficacious in avoiding the relapses. Few drugs have been introduced as upfront therapy in the last years. Topotecan, irinotecan and temozolomide are expected to improve the response in high-risk neuroblastoma, but their impact on OS and EFS is unknown. Anti-GD2 antibodies combined with other immunomodulators (IL-2, GM-CSF) are an important advance in the treatment of these children. Nevertheless, the hope is put in the new drugs directed to molecular targets of neuroblastoma. Anti-angiogenic drugs, ALK antagonist and PI3K/Akt/mTOR inhibitors are among the most promising.
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Affiliation(s)
- Victoria Castel
- Unidad de Oncología Pediátrica, Hospital Universitario y Politécnico La Fe, Torre G, 2° Planta, Bulevar Sur s/n, 46026 Valencia, Spain.
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Gains J, Mandeville H, Cork N, Brock P, Gaze M. Ten challenges in the management of neuroblastoma. Future Oncol 2013; 8:839-58. [PMID: 22830404 DOI: 10.2217/fon.12.70] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Neuroblastoma is a complex disease with many contradictions and challenges. It is, by and large, a cancer of babies and preschool children, but it does occur, albeit increasingly rarely, in older children, adolescents and young adults. The prognosis is very variable, with outcome related to age, stage and molecular pathology. Neuroblastoma may behave in an almost benign way, with spontaneous regression in some infants, but the majority of older patients have high-risk disease, which is usually fatal, despite best current treatments. As a rare disease, international collaboration is essential to run clinical trials of adequate statistical power to answer important questions in a reasonable time frame. High-risk disease requires multimodality therapy including chemotherapy, surgery and radiotherapy as well as biological and immunological treatments for optimal outcomes. Innovative treatment approaches, sometimes associated with appreciable toxicity, offer hope for the future but, despite parental wishes, cannot be generally implemented without adequate assessment in clinical trials.
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Affiliation(s)
- Jennifer Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
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5-day/5-drug myeloablative outpatient regimen for resistant neuroblastoma. Bone Marrow Transplant 2012; 48:642-5. [PMID: 23085829 DOI: 10.1038/bmt.2012.202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
5-day/5-drug (5D/5D) is a novel high-dose regimen administered with autologous hematopoietic SCT (HSCT). It was designed to maximize cytoreduction via high dosing of synergistically interacting agents, while minimizing morbidity in patients with resistant neuroblastoma (NB) and ineligible for clinical trials due to myelosuppression from previous therapy. 5D/5D comprises carboplatin 500 mg/m(2)/day on days 1-2, irinotecan 50 mg/m(2)/day on days 1-3, temozolomide 250 mg/m(2)/day on days 1-3, etoposide 200 mg/m(2)/day on days 3-5 and cyclophosphamide 70 mg/kg/day on days 4-5. HSCT is on day 8. Sixteen patients received 21 courses. Treatment was in the outpatient clinic. Responses were noted against progressive disease (PD) that had developed while patients were off, or receiving only low-dose, chemotherapy but not against PD that emerged despite high-dose chemotherapy. Responses were also seen in patients with PD or stable disease after (131)I-metaiodobenzylguanidine therapy. Grade 3 toxicities were limited to transient elevations in liver enzymes (three courses) and hyponatremia (one course). Bacteremia occurred in 2/21 (10%) courses. Hematological recovery allowed patients to be enrolled on clinical trials. In conclusion, 5D/5D (including HSCT) spares vital organs, entails modest morbidity, shows activity against resistant NB and helps patients meet eligibility requirements for formal clinical trials.
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Kushner BH, Modak S, Kramer K, Basu EM, Roberts SS, Cheung NKV. Ifosfamide, carboplatin, and etoposide for neuroblastoma. Cancer 2012; 119:665-71. [DOI: 10.1002/cncr.27783] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 07/05/2012] [Accepted: 07/13/2012] [Indexed: 11/10/2022]
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Brutti P, Gubbiotti S, Sambucini V. An extension of the single threshold design for monitoring efficacy and safety in phase II clinical trials. Stat Med 2011; 30:1648-64. [DOI: 10.1002/sim.4229] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 01/24/2011] [Indexed: 11/10/2022]
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Simon T, Berthold F, Borkhardt A, Kremens B, De Carolis B, Hero B. Treatment and outcomes of patients with relapsed, high-risk neuroblastoma: results of German trials. Pediatr Blood Cancer 2011; 56:578-83. [PMID: 21298742 DOI: 10.1002/pbc.22693] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 05/17/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND The prognosis of high-risk neuroblastoma patients has improved over the last decades. However, many patients experience relapse after successful initial treatment. We retrospectively analyzed the long-term outcome of relapsed patients of three consecutive national neuroblastoma trials. METHODS Patients were included when they fulfilled all of the following criteria: Age at diagnosis being 1 year or older, first diagnosis between 1990 and 2007, stage 4 disease or stage 3 neuroblastoma with MYCN amplification, and relapse or progression after successful first-line autologous stem cell transplantation (ASCT). RESULTS A total of 451 high-risk neuroblastoma patients 1 year or older underwent ASCT during first-line treatment, 253 experienced recurrence of disease, 158 received salvage chemotherapy, and 23 of them finally underwent a second ASCT. These 23 patients had a better median survival (2.08 years) and 3-year survival rate from recurrence (43.5 ± 10.9%) compared to 74 patients who had no second chemotherapy (median survival 0.24 years, 3-year survival rate 4.0 ± 2.6%) and 135 patients who underwent second-line chemotherapy but did not undergo second ASCT (median survival of 0.89 years, 3-year survival rate 9.6 ± 2.8%, P < 0.001). By February 2010, 3/23 patients were in complete remission, 3/23 in very good partial remission, 1/23 in partial remission, 14/23 patients died of disease after successful second ASCT, and 2/23 died of complications due to second ASCT. CONCLUSION Intensive second-line therapy is feasible. A small subgroup of relapsed high-risk neuroblastoma patients may benefit from intensive relapse chemotherapy and second ASCT. The potential of long-term survival justifies clinical trials on intensive second-line treatment.
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Affiliation(s)
- Thorsten Simon
- Department of Pediatric Oncology and Hematology, Children's Hospital, University of Cologne, Cologne, Germany.
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Kushner BH, Kramer K, Modak S, Cheung NKV. High-dose carboplatin-irinotecan-temozolomide: treatment option for neuroblastoma resistant to topotecan. Pediatr Blood Cancer 2011; 56:403-8. [PMID: 21049517 DOI: 10.1002/pbc.22855] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND We report a retrospective study of a novel regimen for neuroblastoma (NB) resistant to standard induction or salvage chemotherapy which now routinely includes topotecan. PATIENTS AND METHODS Forty-five patients received carboplatin (500 mg/m(2)/day, 2×)-irinotecan (50 mg/m(2)/day, 5×)-temozolomide (250 mg/m(2)/day, 5×) (HD-CIT). Only one course was planned. Patients with thrombocytopenia indicative of poor bone marrow (BM) reserve resulting from extensive prior therapy received peripheral blood stem cells (PBSCs) post-HD-CIT. RESULTS Modest acute toxicity allowed outpatient treatment. Low-grade diarrhea was common; there was no mucositis, nephrotoxicity, or cardiotoxicity. Myelosuppression was prolonged but uncomplicated. The absolute neutrophil count reached 500/µl on days 20-30 (median, 25) in 25 patients with satisfactory BM reserve, and on days 9-14 (median, 11) post-PBSC infusion. Anti-NB activity was common against refractory (non-progressing) disease or new relapse occurring off therapy (68% objective response rate), but not against disease progressing on therapy. Seven of 26 patients treated for refractory NB are progression-free and in complete remission following subsequent therapy, including anti-G(D2) immunotherapy, at ≥ 29+ months post-HD-CIT. CONCLUSIONS HD-CIT is appealing as salvage or consolidative therapy because of anti-NB activity and modest non-hematologic toxicity. PBSC support is unnecessary when BM reserve is intact. The wide antineoplastic activity of its three components and their potential for activity against disease in the central nervous system support applicability to other cancers.
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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Abdel Rahman H, Moussa EA, Zekri WZ, El Debawy E, Mostafa NE, Yones A, Ezzat S, El Rahman Rayan A. Did salvage ICE chemotherapy improve the outcome in primary resistant/relapsing stage III/IV neuroblastoma? J Egypt Natl Canc Inst 2011; 23:47-53. [DOI: 10.1016/j.jnci.2011.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 02/09/2011] [Indexed: 11/24/2022] Open
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Bellanti F, Kågedal B, Della Pasqua O. Do pharmacokinetic polymorphisms explain treatment failure in high-risk patients with neuroblastoma? Eur J Clin Pharmacol 2011; 67 Suppl 1:87-107. [PMID: 21287160 PMCID: PMC3112027 DOI: 10.1007/s00228-010-0966-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 11/27/2010] [Indexed: 12/30/2022]
Abstract
PURPOSE Neuroblastoma is the most common extracranial solid tumour in childhood. It accounts for 15% of all paediatric oncology deaths. In the last few decades, improvement in treatment outcome for high-risk patients has not occurred, with an overall survival rate <30-40%. Many reasons may account for such a low survival rate. The aim of this review is to evaluate whether pharmacogenetic factors can explain treatment failure in neuroblastoma. METHODS A literature search based on PubMed's database Medical Subject Headings (MeSH) was performed to retrieve all pertinent publications on current treatment options and new classes of drugs under investigation. One hundred and fifty-eight articles wer reviewed, and relevant data were extracted and summarised. RESULTS AND CONCLUSIONS Few of the large number of polymorphisms identified thus far showed an effect on pharmacokinetics that could be considered clinically relevant. Despite their clinical relevance, none of the single nucleotide polymorphisms (SNPs) investigated can explain treatment failure. These findings seem to reflect the clinical context in which anti-tumour drugs are used, i.e. in combination with multimodal therapy. In addition, many pharmacogenetic studies did not assess (differences in) drug exposure, which could contribute to explaining pharmacogenetic associations. Furthermore, it remains unclear whether the significant activity of new drugs on different neuroblastoma cell lines translates into clinical efficacy, irrespective of resistance or myelocytomatosis viral related oncogene, neuroblastoma derived (MYCN) amplification. Elucidation of the clinical role of pharmacogenetic factors in the treatment of neuroblastoma demands an integrated pharmacokinetic-pharmacodynamic approach to the analysis of treatment response data.
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Affiliation(s)
- Francesco Bellanti
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
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De Ioris MA, Castellano A, Ilari I, Garganese MC, Natali G, Inserra A, De Vito R, Ravà L, De Pasquale MD, Locatelli F, Donfrancesco A, Jenkner A. Short topotecan-based induction regimen in newly diagnosed high-risk neuroblastoma. Eur J Cancer 2010; 47:572-8. [PMID: 21112775 DOI: 10.1016/j.ejca.2010.10.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 10/25/2010] [Accepted: 10/27/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE Topotecan is an active drug in relapsed neuroblastoma. We investigated the efficacy and toxicity of a topotecan-based induction regimen in newly diagnosed neuroblastoma. METHODS Patients older than 1 year with either metastatic or localised stage 2-3 MYCN-amplified neuroblastoma received 2 courses of high-dose topotecan (HD-TPT) 6mg/m(2) and high-dose cyclophosphamide (HD-CPM) 140 mg/kg, followed by 2 courses of ifosfamide, carboplatin and etoposide (ICE) every 28 days. After surgery on primary tumour, a fifth course with vincristine, doxorubicin and CPM was given, followed by high-dose chemotherapy with stem cell support. Response was assessed in accordance with the International Neuroblastoma Response Criteria. RESULTS Of 35 consecutive patients, 33 had metastatic disease. The median length of induction phase was 133 days (range 91-207) and time to high-dose chemotherapy was 208 days (range 156-285). The median tumour volume reduction was 55% after two HD-TPT/HD-CPM courses and 80% after four courses. Radical surgery was performed in 16/27 patients after chemotherapy. After the fifth course, 29/34 patients (85%) had achieved a partial remission (12) or a CR/very good partial remission (17). CR of metastases was achieved in 13/32 (41%) and bone marrow was in complete remission in 16/24 patients (67%). Grade 4 neutropenia and/or thrombocytopenia occurred in 100% of HD-TPT/HD-CPM and in 95% of ICE courses, while non-haematological toxicities were manageable. CONCLUSIONS These data indicate that our induction regimen is feasible and well tolerated. A major response rate of 85% with 41% complete metastatic response confirms this regimen as effective induction in high-risk neuroblastoma.
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High-dose cyclophosphamide-irinotecan-vincristine for primary refractory neuroblastoma. Eur J Cancer 2010; 47:84-9. [PMID: 20934323 DOI: 10.1016/j.ejca.2010.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/03/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND We used a novel regimen for neuroblastoma (NB) that had responded inadequately to standard chemotherapy which now includes topotecan in induction or second-line therapy. PATIENTS AND METHODS We retrospectively studied 38 patients who received one or two courses of high-dose cyclophosphamide (140 mg/kg)-irinotecan (CPT-11) (250 mg/m(2))-vincristine (HD-CCV) as treatment for NB that had responded incompletely to induction but had never progressed. Treatment was outpatient and was preceded and followed by extent-of-disease and toxicity evaluations because the patients were being considered for enrolment on formal protocols. Progression-free survival (PFS) was calculated from day 1 of HD-CCV. RESULTS Common toxicities were grade 4 myelosuppression and grade 2 diarrhoea. Responses--5 complete (CR), 3 partial (PR), 4 mixed (MR)--occurred in 12/28 (43%) patients treated ≤9 months, and in 1/10 (10%) patients treated >10 months, from diagnosis. HD-CCV was the initial salvage regimen after topotecan-containing induction in 5 patients, achieving 1 CR, 1 MR and 3 stable disease (NR). HD-CCV produced responses (2 PR, 3 MR) in all 5 patients previously treated with CPT-11/ temozolomide. In contrast, all 6 patients treated post-HD-CCV with CPT-11/temozolomide had NR to the latter. Post-HD-CCV treatments included immunotherapy, targeted radiotherapy and/or chemotherapy. PFS was 64% (±8%) at 24 months, with 20 patients progression-free at 2+-to-36+ (median 16+) months and 10 in first CR at 9+-to-36+ (median 16+) months. CONCLUSIONS HD-CCV offers a treatment option against topotecan-resistant NB. Results support the concept that combining CPT-11 with very high doses of alkylators can yield greater antitumour effect.
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Rubie H, Geoerger B, Frappaz D, Schmitt A, Leblond P, Ndiaye A, Aerts I, Deley MCL, Gentet JC, Paci A, Chastagner P, Dias N, Djafari L, Pasquet M, Chatelut E, Landman-Parker J, Corradini N, Vassal G. Phase I study of topotecan in combination with temozolomide (TOTEM) in relapsed or refractory paediatric solid tumours. Eur J Cancer 2010; 46:2763-70. [PMID: 20558056 DOI: 10.1016/j.ejca.2010.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 04/08/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate maximum tolerated dose and recommended dose (RD) for phase II studies of topotecan (TPT) combined with temozolomide (TMZ) (TOTEM) in children and adolescents with relapsed or refractory solid malignancies. PATIENTS AND METHODS Multicentre, phase I study with a standard '3+3' design in five dose increments. Eligible patients: aged 6 months to 21 years, diagnosis of a solid malignancy failed at least 2 previous lines of therapy. TMZ was administered orally, starting at 100 mg/m(2)/d, and TPT intravenously over 30 min, starting at 0.75 mg/m(2)/d over 5 consecutive days every 28 d. A pharmacokinetics analysis was performed on Day 1 and Day 5 of cycle 1. RESULTS Between February and October 2007, 16 patients were treated. The median age was 8.5 years (range, 3-19 years). Dose-limiting toxicity (grade 4 neutropenia and/or thrombocytopenia lasting more than 7 d) during the first cycle occurred in 2 of 3 patients at level 3 (TMZ 150 mg/m(2)/d and TPT 1.0 mg/m(2)/d) and was always manageable. Confirmed complete and partial responses were observed in 4 patients (25%), three with metastatic neuroblastoma and one with high-grade glioma. Seven patients had a stable disease. Pharmacokinetic data show a wide inter-individual variability. No significant differences were observed between plasma TMZ and TPT concentrations on Day 1 and Day 5 indicating the absence of pharmacokinetic interaction between the drugs. CONCLUSIONS The RD for the combination is TMZ 150 mg/m(2)/d and TPT 0.75 mg/m(2)/d with dose-limiting haematological toxicity. The observed activity deserves further evaluation in paediatric malignancies.
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Pastorino F, Loi M, Sapra P, Becherini P, Cilli M, Emionite L, Ribatti D, Greenberger LM, Horak ID, Ponzoni M. Tumor Regression and Curability of Preclinical Neuroblastoma Models by PEGylated SN38 (EZN-2208), a Novel Topoisomerase I Inhibitor. Clin Cancer Res 2010; 16:4809-21. [DOI: 10.1158/1078-0432.ccr-10-1354] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Affiliation(s)
- John M Maris
- Center for Childhood Cancer Research, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, and Abramson Family Cancer Research Institute, Philadelphia, PA 19104-4318, USA.
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Kushner BH, Kramer K, Modak S, Qin LX, Cheung NKV. Differential impact of high-dose cyclophosphamide, topotecan, and vincristine in clinical subsets of patients with chemoresistant neuroblastoma. Cancer 2010; 116:3054-60. [DOI: 10.1002/cncr.25232] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Neuroblastoma, the most common extracranial pediatric solid tumor remains a clinical enigma with outcomes ranging from cure in >90% of patients with locoregional tumors with little to no cytotoxic therapy, to <30% for those >18months of age at diagnosis with metastatic disease despite aggressive multimodality therapy. Age, stage and amplification of the MYCN oncogene are the most validated prognostic markers. Recent research has shed light on the biology of neuroblastoma allowing more accurate stratification of patients which has permitted reducing or withholding cytotoxic therapy without affecting outcome for low-risk patients. However, for children with high-risk disease, the development of newer therapeutic strategies is necessary. Current surgery and radiotherapy techniques in conjunction with induction chemotherapy have greatly reduced the risk of local relapse. However, refractory or recurrent osteomedullary disease occurs in most patients with high-risk neuroblastoma. Toxicity limits for high-dose chemotherapy appear to have been reached without further clinical benefit. Neuroblastoma is the first pediatric cancer for which monoclonal-antibody-based immunotherapy has been shown to be effective, particularly for metastatic osteomedullary disease. Radioimmunotherapy appears to be a critical component of a recent, successful regimen for treating patients who relapse in the central nervous system, a possible sanctuary site. Efforts are under way to refine and enhance antibody-based immunotherapy and to determine its optimal use. The identification of newer tumor targets and the harnessing of cell-mediated immunotherapy may generate novel therapeutic approaches. It is likely that a combination of therapeutic modalities will be required to improve survival and cure rates.
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