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Pearson AD, DuBois SG, Macy ME, de Rojas T, Donoghue M, Weiner S, Knoderer H, Bernardi R, Buenger V, Canaud G, Cantley L, Chung J, Fox E, Friend J, Glade-Bender J, Gorbatchevsky I, Gore L, Gupta A, Hawkins DS, Juric D, Lang LA, Leach D, Liaw D, Lesa G, Ligas F, Lindberg G, Lindberg W, Ludwinski D, Marshall L, Mazar A, McDonough J, Nysom K, Ours C, Pappo A, Parsons DW, Rosenfeld A, Scobie N, Smith M, Taylor D, Weigel B, Weinstein A, Karres D, Vassal G. Paediatric strategy forum for medicinal product development of PI3-K, mTOR, AKT and GSK3β inhibitors in children and adolescents with cancer. Eur J Cancer 2024; 207:114145. [PMID: 38936103 DOI: 10.1016/j.ejca.2024.114145] [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: 11/23/2023] [Revised: 05/16/2024] [Accepted: 05/27/2024] [Indexed: 06/29/2024]
Abstract
Phosphatidylinositol 3-kinase (PI3-K) signalling pathway is a crucial path in cancer for cell survival and thus represents an intriguing target for new paediatric anti-cancer drugs. However, the unique clinical toxicities of targeting this pathway (resulting in hyperglycaemia) difficulties combining with chemotherapy, rarity of mutations in childhood tumours and concomitant mutations have resulted in major barriers to clinical translation of these inhibitors in treating both adults and children. Mutations in PIK3CA predict response to PI3-K inhibitors in adult cancers. The same mutations occur in children as in adults, but they are significantly less frequent in paediatrics. In children, high-grade gliomas, especially diffuse midline gliomas (DMG), have the highest incidence of PIK3CA mutations. New mutation-specific PI3-K inhibitors reduce toxicity from on-target PI3-Kα wild-type activity. The mTOR inhibitor everolimus is approved for subependymal giant cell astrocytomas. In paediatric cancers, mTOR inhibitors have been predominantly evaluated by academia, without an overall strategy, in empiric, mutation-agnostic clinical trials with very low response rates to monotherapy. Therefore, future trials of single agent or combination strategies of mTOR inhibitors in childhood cancer should be supported by very strong biological rationale and preclinical data. Further preclinical evaluation of glycogen synthase kinase-3 beta inhibitors is required. Similarly, even where there is an AKT mutation (∼0.1 %), the role of AKT inhibitors in paediatric cancers remains unclear. Patient advocates strongly urged analysing and conserving data from every child participating in a clinical trial. A priority is to evaluate mutation-specific, central nervous system-penetrant PI3-K inhibitors in children with DMG in a rational biological combination. The choice of combination, should be based on the genomic landscape e.g. PTEN loss and resistance mechanisms supported by preclinical data. However, in view of the very rare populations involved, innovative regulatory approaches are needed to generate data for an indication.
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Affiliation(s)
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, USA
| | | | | | | | | | | | - Ronald Bernardi
- Genentech, A Member of the Roche Group, South San Francisco, CA USA
| | - Vickie Buenger
- Coalition Against Childhood Cancer (CAC2), Philadelphia, USA
| | | | | | - John Chung
- Bayer Healthcare Pharmaceuticals, Whippany, NJ, USA
| | | | | | | | | | | | - Abha Gupta
- The Hospital for Sick Children (SickKids), Princess Margaret Hospital Toronto, Canada
| | | | | | - Leigh Anna Lang
- Rally Foundation for Childhood Cancer Research, Atlanta, GA, USA
| | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), the Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), the Netherlands
| | | | | | | | - Lynley Marshall
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Joe McDonough
- The Andrew McDonough B+ Foundation, Wilmington, DE, USA
| | | | - Christopher Ours
- National Human Genome Research Institute/National Institutes of Health, MD, USA
| | | | | | | | | | | | | | | | - Amy Weinstein
- Pediatric Brain Tumor Foundation of the US, Atlanta, USA
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), the Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe, Belgium; Gustave Roussy Cancer Centre, Paris, France
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2
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Hlavackova E, Krenova Z, Kerekes A, Slanina P, Vlkova M. B cell subsets reconstitution and immunoglobulin levels in children and adolescents with B non-Hodgkin lymphoma after treatment with single anti CD20 agent dose included in chemotherapeutic protocols: single center experience and review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:167-176. [PMID: 37227099 DOI: 10.5507/bp.2023.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 05/10/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND RTX, an anti-CD20 monoclonal antibody, added to chemotherapy has proven to be effective in children and adolescents with high-grade, high-risk and matured non-Hodgkin lymphoma. RTX leads to prompt CD19+ B lymphocyte depletion. However, despite preserved immunoglobulin production by long-lived plasmablasts after treatment, patients remain at risk of prolonged hypogammaglobulinemia. Further, there are few general guidelines for immunology laboratories and clinical feature monitoring after B cell-targeted therapies. The aim of this paper is to describe B cell reconstitution and immunoglobulin levels after pediatric B-NHL protocols, that included a single RTX dose and to review the literature. METHODS A retrospective single-center study on the impact of a single RTX dose included in a chemotherapeutic pediatric B Non-Hodgkin Lymphoma (B-NHL) treatment protocols. Immunology laboratory and clinical features were evaluated over an eight hundred days follow-up (FU) period, after completing B-NHL treatment. RESULTS Nineteen patients (fifteen Burkitt lymphoma, three Diffuse large B cell lymphoma, and one Marginal zone B cell lymphoma) fulfilled the inclusion criteria. Initiation of B cell subset reconstitution occurred a median of three months after B-NHL treatment. Naïve and transitional B cells declined over the FU in contrast to the marginal zone and the switched memory B cell increase. The percentage of patients with IgG, IgA, and IgM hypogammaglobulinemia declined consistently over the FU. Prolonged IgG hypogammaglobulinemia was detectable in 9%, IgM in 13%, and IgA in 25%. All revaccinated patients responded to protein-based vaccines by specific IgG antibody production increase. Following antibiotic prophylaxes, none of the patients with hypogammaglobulinemia manifested with either a severe or opportunistic infection course. CONCLUSION The addition of a single RTX dose to the chemotherapeutic treatment protocols was not shown to increase the risk of developing secondary antibody deficiency in B-NHL pediatric patients. Observed prolonged hypogammaglobulinemia remained clinically silent. However interdisciplinary agreement on regular long-term immunology FU after anti-CD20 agent treatment is required.
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Affiliation(s)
- Eva Hlavackova
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Zdenka Krenova
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Arpad Kerekes
- Department of Pediatric Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Czech Republic
| | - Peter Slanina
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marcela Vlkova
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital in Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Pearson ADJ, de Rojas T, Karres D, Reaman G, Scobie N, Fox E, Lesa G, Ligas F, Norga K, Nysom K, Pappo A, Weigel B, Weiner SL, Vassal G. Impact of ACCELERATE Paediatric Strategy Forums: a review of the value of multi-stakeholder meetings in oncology drug development. J Natl Cancer Inst 2024; 116:200-207. [PMID: 37975877 PMCID: PMC10852613 DOI: 10.1093/jnci/djad239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
In a landscape of an increasing number of products and histology and age agnostic trials for rare patient cancer, prioritization of products is required. Paediatric Strategy Forums, organized by ACCELERATE and the European Medicines Agency with participation of the US Food and Drug Administration, are multi-stakeholder meetings that share information to best inform pediatric drug development strategies and subsequent clinical trial decisions. Academia, industry, regulators, and patient advocates are equal members, with patient advocates highlighting unmet needs of children and adolescents with cancer. The 11 Paediatric Strategy Forums since 2017 have made specific and general conclusions to accelerate drug development. Conclusions on product prioritization meetings, as well as global master protocols, have been outputs of these meetings. Forums have provided information for regulatory discussions and decisions by industry to facilitate development of high-priority products; for example, 62% of high-priority assets (agreed at a Forum) in contrast to 5% of those assets not considered high priority have been the subject of a Paediatric Investigational Plan or Written Request. Where there are multiple products of the same class, Forums have recommended a focused and sequential approach. Class prioritization resulted in an increase in waivers for non-prioritized B-cell products (44% to 75%) and a decrease in monotherapy trials, proposed in Paediatric Investigation Plans (PIP) submissions of checkpoint inhibitors from 53% to 19%. Strategy Forums could play a role in defining unmet medical needs. Multi-stakeholder forums, such as the Paediatric Strategy Forum, serve as a model to improve collaboration in the oncology drug development paradigm.
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Affiliation(s)
| | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Gregory Reaman
- US Food and Drug Administration (FDA), Silver Spring, MD, USA
| | | | - Elizabeth Fox
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium
- Paediatric Committee of the European Medicines Agency, (EMA), Amsterdam, The Netherlands
- Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children’s Research Hospital, Memphis, TN, USA
| | | | | | - Gilles Vassal
- ACCELERATE, Brussels, Belgium, Europe
- Gustave Roussy Cancer Centre, Paris, France
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4
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Uguen M, Hilton M, Farid-Kapadia M, Datye A, Chohan S, Carlucci C, Dixon M, Elze M, Chen Y, Cheung KWK, Sane R, Zheng M, Choi Y. Advancing drug development in pediatric oncology, a focus on cancer biology and targeted therapies: iMATRIX platform. J Biopharm Stat 2023; 33:800-811. [PMID: 36637189 DOI: 10.1080/10543406.2022.2162071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/09/2022] [Indexed: 01/14/2023]
Abstract
With the development of novel treatment therapies as well as evolving and innovative approaches to conduct clinical trials, the landscape of pediatric oncology drug development has dramatically changed in recent years. Despite this change, approvals for new drugs and labeling updates to ensure availability of proper treatment for pediatric patients with cancer remain slow. The context of drug development in pediatric tumors has also changed with regulatory initiatives in the US and Europe, creating a great need for faster development of novel drugs. Today, conventional study designs have been replaced or complemented by novel clinical trial designs, such as master protocols and platform trials, to optimize cancer drug development and enable faster regulatory approval. The iMATRIX platform is a mechanism-of-action (MOA)-based phase 1/2 trial framework for concurrently studying multiple molecules across a range of relevant pediatric tumor types, taking into account the biology of each pediatric tumor type. Six studies have been conducted, ongoing, or planned on the iMATRIX platform - investigating atezolizumab, cobimetinib, entrectinib, idasanutlin, alectinib, and glofitamab. A brief overview of study designs and characteristics are shared in this article, along with learnings from them.
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Affiliation(s)
- Marianne Uguen
- Data and Statistical Sciences, F. Hoffmann-La Roche, Ltd, Basel, Switzerland
| | - Magalie Hilton
- Data and Statistical Sciences, F. Hoffmann-La Roche, Ltd, Basel, Switzerland
| | | | - Asim Datye
- Data and Statistical Sciences, F. Hoffmann-La Roche, Ltd, Mississauga, Canada
| | - Saibah Chohan
- Data and Statistical Sciences, F. Hoffmann-La Roche, Ltd, Mississauga, Canada
| | - Claudia Carlucci
- Data and Statistical Sciences, Roche Products Limited, Welwyn Garden City, UK
| | - Mark Dixon
- Data and Statistical Sciences, Roche Products Limited, Welwyn Garden City, UK
| | - Markus Elze
- Data and Statistical Sciences, F. Hoffmann-La Roche, Ltd, Basel, Switzerland
| | - Yingjia Chen
- Product Development Safety, Genentech Inc, South San Francisco, United States
| | | | - Rucha Sane
- Clinical Pharmacology, Genentech Inc, South San Francisco, United States
| | - Maoxia Zheng
- Data and Statistical Sciences, Genentech Inc, South San Francisco, CA, USA
| | - YounJeong Choi
- Data and Statistical Sciences, Genentech Inc, South San Francisco, CA, USA
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Pearson ADJ, Federico S, Gatz SA, Ortiz M, Lesa G, Scobie N, Gounaris I, Weiner SL, Weigel B, Unger TJ, Stewart E, Smith M, Slotkin EK, Reaman G, Pappo A, Nysom K, Norga K, McDonough J, Marshall LV, Ludwinski D, Ligas F, Karres D, Kool M, Horner TJ, Henssen A, Heenen D, Hawkins DS, Gore L, Bender JG, Galluzzo S, Fox E, de Rojas T, Davies BR, Chakrabarti J, Carmichael J, Bradford D, Blanc P, Bernardi R, Benchetrit S, Akindele K, Vassal G. Paediatric Strategy Forum for medicinal product development of DNA damage response pathway inhibitors in children and adolescents with cancer: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2023; 190:112950. [PMID: 37441939 DOI: 10.1016/j.ejca.2023.112950] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
DNA damage response inhibitors have a potentially important therapeutic role in paediatric cancers; however, their optimal use, including patient selection and combination strategy, remains unknown. Moreover, there is an imbalance between the number of drugs with diverse mechanisms of action and the limited number of paediatric patients available to be enrolled in early-phase trials, so prioritisation and a strategy are essential. While PARP inhibitors targeting homologous recombination-deficient tumours have been used primarily in the treatment of adult cancers with BRCA1/2 mutations, BRCA1/2 mutations occur infrequently in childhood tumours, and therefore, a specific response hypothesis is required. Combinations with targeted radiotherapy, ATR inhibitors, or antibody drug conjugates with DNA topoisomerase I inhibitor-related warheads warrant evaluation. Additional monotherapy trials of PARP inhibitors with the same mechanism of action are not recommended. PARP1-specific inhibitors and PARP inhibitors with very good central nervous system penetration also deserve evaluation. ATR, ATM, DNA-PK, CHK1, WEE1, DNA polymerase theta and PKMYT1 inhibitors are early in paediatric development. There should be an overall coordinated strategy for their development. Therefore, an academia/industry consensus of the relevant biomarkers will be established and a focused meeting on ATR inhibitors (as proof of principle) held. CHK1 inhibitors have demonstrated activity in desmoplastic small round cell tumours and have a potential role in the treatment of other paediatric malignancies, such as neuroblastoma and Ewing sarcoma. Access to CHK1 inhibitors for paediatric clinical trials is a high priority. The three key elements in evaluating these inhibitors in children are (1) innovative trial design (design driven by a clear hypothesis with the intent to further investigate responders and non-responders with detailed retrospective molecular analyses to generate a revised or new hypothesis); (2) biomarker selection and (3) rational combination therapy, which is limited by overlapping toxicity. To maximally benefit children with cancer, investigators should work collaboratively to learn the lessons from the past and apply them to future studies. Plans should be based on the relevant biology, with a focus on simultaneous and parallel research in preclinical and clinical settings, and an overall integrated and collaborative strategy.
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Affiliation(s)
- Andrew D J Pearson
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium.
| | - Sara Federico
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Susanne A Gatz
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Michael Ortiz
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | | | - Ioannis Gounaris
- Merck Serono Ltd (an affiliate of Merck KGaA, Darmstadt, Germany), Feltham, UK
| | | | | | - T J Unger
- Repare Therapeutics, Cambridge, MA, USA
| | | | | | | | - Gregory Reaman
- US Food and Drug Administration, Silver Springs, MD, USA
| | - Alberto Pappo
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency (EMA), Amsterdam, the Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - Joe McDonough
- The Andrew McDonough B+ Foundation, Wilmington, DE, USA
| | - Lynley V Marshall
- The Royal Marsden NHS Foundation Hospital, The Institute of Cancer Research, Sutton, Surrey, UK
| | | | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Amsterdam, the Netherlands
| | - Marcel Kool
- Hopp Children's Cancer Center, Heidelberg, Germany
| | | | | | | | - Douglas S Hawkins
- Seattle Children's Hospital, Seattle, WA, USA; Children's Oncology Group, Seattle, WA, USA
| | - Lia Gore
- Children's Hospital Colorado, Aurora, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Elizabeth Fox
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Teresa de Rojas
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium
| | | | | | - Juliet Carmichael
- The Royal Marsden NHS Foundation Hospital, The Institute of Cancer Research, Sutton, Surrey, UK
| | - Diana Bradford
- US Food and Drug Administration, Silver Springs, MD, USA
| | | | - Ronald Bernardi
- Genentech, a Member of the Roche Group, South San Francisco, CA, USA
| | - Sylvie Benchetrit
- National Agency for the Safety of Medicine and Health Products, Paris, France
| | | | - Gilles Vassal
- ACCELERATE, c/o BLSI, Clos Chapelle-aux-Champs 30, Bte 1.30.30 BE-1200 Brussels, Belgium; Gustave Roussy Cancer Centre, Paris, France
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6
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Chu Y, Gardenswartz A, Diorio C, Marks LJ, Lowe E, Teachey DT, Cairo MS. Cellular and humoral immunotherapy in children, adolescents and young adults with non-Hodgkin lymphoma. Best Pract Res Clin Haematol 2023; 36:101442. [PMID: 36907635 DOI: 10.1016/j.beha.2023.101442] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
The prognosis is dismal (2-year overall survival less than 25%) for childhood, adolescent, and young adult (CAYA) with relapsed and/or refractory (R/R) non-Hodgkin lymphoma (NHL). Novel targeted therapies are desperately needed for this poor-risk population. CD19, CD20, CD22, CD79a, CD38, CD30, LMP1 and LMP2 are attractive targets for immunotherapy in CAYA patients with R/R NHL. Novel anti-CD20 monoclonal antibodies, anti-CD38 monoclonal antibody, antibody drug conjugates and T and natural killer (NK)-cell bispecific and trispecific engagers are being investigated in the R/R setting and are changing the landscape of NHL therapy. A variety of cellular immunotherapies such as viral activated cytotoxic T-lymphocyte, chimeric antigen receptor (CAR) T-cells, NK and CAR NK-cells have been investigated and provide alternative options for CAYA patients with R/R NHL. Here, we provide an update and clinical practice guidance of utilizing these cellular and humoral immunotherapies in CAYA patients with R/R NHL.
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Affiliation(s)
- Yaya Chu
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | | | - Caroline Diorio
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lianna J Marks
- Division of Pediatric Hematology and Oncology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eric Lowe
- Division of Pediatric Hematology-Oncology, Children's Hospital of the Kings Daughter, Norfolk, VA, USA
| | - David T Teachey
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mitchell S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA; Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY, USA; Department of Medicine, New York Medical College, Valhalla, NY, USA; Department of Pathology, Microbiology and Immunology, New York Medical College, Valhalla, NY, USA; Department of Cell Biology, New York Medical College, Valhalla, NY, USA; Department of Anatomy, New York Medical College, Valhalla, NY, USA.
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7
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Beishuizen A, Mellgren K, Andrés M, Auperin A, Bacon CM, Bomken S, Burke GAA, Burkhardt B, Brugieres L, Chiang AKS, Damm-Welk C, d'Amore E, Horibe K, Kabickova E, Khanam T, Kontny U, Klapper W, Lamant L, Le Deley MC, Loeffen J, Macintyre E, Mann G, Meyer-Wentrup F, Michgehl U, Minard-Colin V, Mussolin L, Oschlies I, Patte C, Pillon M, Reiter A, Rigaud C, Roncery L, Salaverria I, Simonitsch-Klupp I, Uyttebroeck A, Verdu-Amoros J, Williams D, Woessmann W, Wotherspoon A, Wrobel G, Zimmermann M, Attarbaschi A, Turner SD. Improving outcomes of childhood and young adult non-Hodgkin lymphoma: 25 years of research and collaboration within the framework of the European Intergroup for Childhood Non-Hodgkin Lymphoma. Lancet Haematol 2023; 10:e213-e224. [PMID: 36858678 DOI: 10.1016/s2352-3026(22)00374-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/01/2022] [Accepted: 11/18/2022] [Indexed: 03/03/2023]
Abstract
The European Intergroup for Childhood Non-Hodgkin Lymphoma (EICNHL) was established 25 years ago with the goal to facilitate clinical trials and research collaborations in the field both within Europe and worldwide. Since its inception, much progress has been made whereby major improvements in outcomes have been achieved. In this Review, we describe the different diagnostic entities of non-Hodgkin lymphoma in children and young adults describing key features of each entity and outlining clinical achievements made in the context of the EICNHL framework. Furthermore, we provide an overview of advances in biopathology with an emphasis on the role of biological studies and how they have shaped available treatments. Finally, for each entity, we describe future goals, upcoming clinical trials, and highlight areas of research that require our focus going forward.
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Affiliation(s)
- Auke Beishuizen
- Division of Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands; The Netherlands and Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Karin Mellgren
- Department of Paediatric Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mara Andrés
- Department of Pediatric Oncology, University Hospital Le Fe, Valencia, Spain
| | - Anne Auperin
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Chris M Bacon
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Wolfson Childhood Cancer Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Simon Bomken
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Wolfson Childhood Cancer Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - G A Amos Burke
- Department of Paediatric Haematology, Oncology and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Birgit Burkhardt
- Department of Pediatric Hematology, Oncology, and BMT, University Hospital Muenster, Münster, Germany
| | - Laurence Brugieres
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Alan K S Chiang
- Department of Pediatrics & AdolescentMedicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Christine Damm-Welk
- Pediatric Hematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Emanuele d'Amore
- Department of Pathological Anatomy, San Bortolo Hospital, Vicenza, Italy
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Edita Kabickova
- Department of Pediatric Hematology and Oncology, Charles University & University Hospital Motol, Prague, Czech Republic
| | - Tasneem Khanam
- Department of Paediatric Haematology, Oncology and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Udo Kontny
- Section of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatric and Adolescent Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Wolfram Klapper
- Institute of Pathology, Hematopathology Section, University of Schleswig-Holstein, Kiel, Germany
| | - Laurence Lamant
- Université Toulouse III-Paul Sabatier, Laboratoire d'Excellence Toulouse Cancer-TOUCAN, Équipe Labellisée La Ligue Contre Le Cancer, Inserm, Toulouse, France
| | | | - Jan Loeffen
- Division of Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Elizabeth Macintyre
- Onco-hematology, Université Paris Cité and Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georg Mann
- Pediatric Hematology and Oncology, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Friederike Meyer-Wentrup
- Division of Hemato-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Ulf Michgehl
- Department of Paediatric Haematology, Oncology and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Veronique Minard-Colin
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Lara Mussolin
- Istituto di Ricerca Pediatrica Città della Speranza, Padua, Italy; Pediatric Hematology, Oncology and Stem Cell Transplant Division, Maternal and Child Health Department, Padova University Hospital, Padova, Italy
| | - Ilske Oschlies
- Institute of Pathology, Hematopathology Section, University of Schleswig-Holstein, Kiel, Germany
| | - Catherine Patte
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Marta Pillon
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Maternal and Child Health Department, Padova University Hospital, Padova, Italy
| | - Alfred Reiter
- Department of Pediatric Hematology and Oncology, Justus Liebig-University Giessen, Giessen, Germany
| | - Charlotte Rigaud
- Department of Pediatric Hematology, Oncology, and BMT, University Hospital Muenster, Münster, Germany
| | - Leila Roncery
- St Anna Children's Hospital, Department of Paediatric Haematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Itziar Salaverria
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Anne Uyttebroeck
- Department of Pediatric Hematology and Oncology, University Hospital Leuven,KU Leuven, Leuven, Belgium
| | - Jaime Verdu-Amoros
- Department of Pediatric Hematology and Oncology, University Hospital Valencia, Valencia, Spain
| | - Denise Williams
- Wolfson Childhood Cancer Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Wilhelm Woessmann
- Pediatric Hematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | | | - Grazyna Wrobel
- Bone Marrow Transplantation and Pediatric Hematology and Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - Martin Zimmermann
- Hannover Medical School, Department of Pediatric Hematology and Oncology, Hannover, Germany
| | - Andishe Attarbaschi
- St Anna Children's Hospital, Department of Paediatric Haematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Suzanne D Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK; Central European Institute for Technology, Masaryk University, Brno, Czech Republic.
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8
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Lasala R, Santoleri F, Zanon D, Romagnoli A, Abrate P, Costantini A, Musicco F. Available information about paediatric use of onco-haematological drugs authorized by EMA since 2016. J Oncol Pharm Pract 2023; 29:83-87. [PMID: 34693799 DOI: 10.1177/10781552211053251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The treatment options available to children with cancer are limited. This is why for more than 10 years, the European Medicine Agency (EMA) has stated that all drugs to be marketed must be tested on the paediatric population in accordance with the Paediatric Investigation Plan (PIP). The objective of this study is to make a cross sectional analysis of the information related to the use of cancer drugs authorised on the European market in the paediatric population. METHOD The European Public Assessment Reports and PIPs have been considered. The following data were extracted for onco-haematological drugs approved since 2016: paediatric indications, information about the paediatric population in the Summary of Product Characteristics (SmPC) and presence and characteristics of PIPs. A descriptive analysis of the characteristics of the drugs was made from the point of view of the paediatric population. RESULTS Forty-eight drugs with onco-haematological indications have been authorised for marketing since 2016, 7 (15%) of these have paediatric indications. Two (4%) drugs have no paediatric indication but have information related to the paediatric population within SmPC. Forty-one (85%) drugs have no reference to the paediatric population in SmPC. Seventeen (35%) drugs out of 48 do not have PIPs and 11 have been granted a waiver to present the results of paediatric studies. The other 19 active ingredients have a total of 28 PIPs. CONCLUSION AND RELEVANCE Most of the onco-haematological drugs approved by EMA since 2016 have neither paediatric indications nor mentions about paediatric use in SmPC. PIPs represent an opportunity, but demand for the paediatric population is still huge.
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Affiliation(s)
| | | | - Davide Zanon
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health - IRCCS 18705"Burlo Garofolo", Trieste, Italy
| | - Alessia Romagnoli
- Hospital Pharmacy of "Santo Spirito" General Hospital, Pescara, Italy
| | | | | | - Felice Musicco
- Hospital Pharmacy, 18659IFO Regina Elena San Gallicano, Rome, Italy
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9
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López C, Burkhardt B, Chan JKC, Leoncini L, Mbulaiteye SM, Ogwang MD, Orem J, Rochford R, Roschewski M, Siebert R. Burkitt lymphoma. Nat Rev Dis Primers 2022; 8:78. [PMID: 36522349 DOI: 10.1038/s41572-022-00404-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 12/16/2022]
Abstract
Burkitt lymphoma (BL) is an aggressive form of B cell lymphoma that can affect children and adults. The study of BL led to the identification of the first recurrent chromosomal aberration in lymphoma, t(8;14)(q24;q32), and subsequent discovery of the central role of MYC and Epstein-Barr virus (EBV) in tumorigenesis. Most patients with BL are cured with chemotherapy but those with relapsed or refractory disease usually die of lymphoma. Historically, endemic BL, non-endemic sporadic BL and the immunodeficiency-associated BL have been recognized, but differentiation of these epidemiological variants is confounded by the frequency of EBV positivity. Subtyping into EBV+ and EBV- BL might better describe the biological heterogeneity of the disease. Phenotypically resembling germinal centre B cells, all types of BL are characterized by dysregulation of MYC due to enhancer activation via juxtaposition with one of the three immunoglobulin loci. Additional molecular changes commonly affect B cell receptor and sphingosine-1-phosphate signalling, proliferation, survival and SWI-SNF chromatin remodelling. BL is diagnosed on the basis of morphology and high expression of MYC. BL can be effectively treated in children and adolescents with short durations of high dose-intensity multiagent chemotherapy regimens. Adults are more susceptible to toxic effects but are effectively treated with chemotherapy, including modified versions of paediatric regimens. The outcomes in patients with BL are good in high-income countries with low mortality and few late effects, but in low-income and middle-income countries, BL is diagnosed late and is usually treated with less-effective regimens affecting the overall good outcomes in patients with this lymphoma.
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Affiliation(s)
- Cristina López
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Institute of Human Genetics, Ulm University and Ulm University Medical Center, Ulm, Germany
| | - Birgit Burkhardt
- Non-Hodgkin's Lymphoma Berlin-Frankfurt-Münster (NHL-BFM) Study Center and Paediatric Hematology, Oncology and BMT, University Hospital Muenster, Muenster, Germany
| | - John K C Chan
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Lorenzo Leoncini
- Section of Pathology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Sam M Mbulaiteye
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, USA
| | | | | | - Rosemary Rochford
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Reiner Siebert
- Institute of Human Genetics, Ulm University and Ulm University Medical Center, Ulm, Germany.
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10
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Pearson AD, Allen C, Fangusaro J, Hutter C, Witt O, Weiner S, Reaman G, Russo M, Bandopadhayay P, Ahsan S, Barone A, Barry E, de Rojas T, Fisher M, Fox E, Bender JG, Gore L, Hargrave D, Hawkins D, Kreider B, Langseth AJ, Lesa G, Ligas F, Marotti M, Marshall LV, Nasri K, Norga K, Nysom K, Pappo A, Rossato G, Scobie N, Smith M, Stieglitz E, Weigel B, Weinstein A, Viana R, Karres D, Vassal G. Paediatric Strategy Forum for medicinal product development in mitogen-activated protein kinase pathway inhibitors: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2022; 177:120-142. [PMID: 36335782 DOI: 10.1016/j.ejca.2022.09.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 01/06/2023]
Abstract
As the mitogen-activated protein kinase (MAPK) signalling pathway is activated in many paediatric cancers, it is an important therapeutic target. Currently, a range of targeted MAPK pathway inhibitors are being developed in adults. However, MAPK signals through many cascades and feedback loops and perturbing the MAPK pathway may have substantial influence on other pathways as well as normal development. In view of these issues, the ninth Paediatric Strategy Forum focused on MAPK inhibitors. Development of MAPK pathway inhibitors to date has been predominantly driven by adult indications such as malignant melanoma. However, these inhibitors may also target unmet needs in paediatric low-grade gliomas, high-grade gliomas, Langerhans cell histiocytosis, juvenile myelomonocytic leukaemia and several other paediatric conditions. Although MAPK inhibitors have demonstrated activity in paediatric cancer, the response rates and duration of responses needs improvement and better documentation. The rapid development and evaluation of combination approaches, based on a deep understanding of biology, is required to optimise responses and to avoid paradoxical tumour growth and other unintended consequences including severe toxicity. Better inhibitors with higher central nervous systempenetration for primary brain tumours and cancers with a propensity for central nervous system metastases need to be studied to determine if they are more effective than agents currently being used, and the optimum duration of therapy with MAPK inhibition needs to be determined. Systematic and coordinated clinical investigations to inform future treatment strategies with MAPK inhibitors, rather than use outside of clinical trials, are needed to fully assess the risks and benefits of these single agents and combination strategies in both front-line and in the refractory/relapse settings. Platform trials could address the investigation of multiple similar products and combinations. Accelerating the introduction of MAPK inhibitors into front-line paediatric studies is a priority, as is ensuring that these studies generate data appropriate for scientific and regulatory purposes. Early discussions with regulators are crucial, particularly if external controls are considered as randomised control trials in small patient populations can be challenging. Functional end-points specific to the populations in which they are studied, such as visual acuity, motor and neuro psychological function are important, as these outcomes are often more reflective of benefit for lower grade tumours (such as paediatric low-grade glioma and plexiform neurofibroma) and should be included in initial study designs for paediatric low-grade glioma. Early prospective discussions and agreements with regulators are necessary. Long-term follow-up of patients receiving MAPK inhibitors is crucial in view of their prolonged administration and the important involvement of this pathway in normal development. Further rational development, with a detailed understanding of biology of this class of products, is crucial to ensure they provide optimal benefit while minimising toxicity to children and adolescents with cancer.
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Affiliation(s)
| | - Carl Allen
- Texas Children Hospital, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA
| | - Jason Fangusaro
- Children's Healthcare of Atlanta, USA; Emory University School of Medicine, Atlanta, USA
| | - Caroline Hutter
- St. Anna Children's Hospital, Vienna, Austria; Children's Cancer Research Institute, Vienna, Austria
| | - Olaf Witt
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany; Heidelberg University Hospital, Heidelberg, Germany; German Cancer Research Center, Heidelberg, Germany
| | | | | | | | - Pratiti Bandopadhayay
- Department of Pediatrics, Harvard Medical School, Broad Institute, USA; Dana-Farber/Boston Children's Cancer and Blood Disorders Center, USA
| | | | - Amy Barone
- US Food and Drug Administration, Silver Springs, USA
| | - Elly Barry
- Day One Biopharmaceuticals, San Francisco, USA
| | | | - Michael Fisher
- The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Elizabeth Fox
- St Jude Children's Research Hospital, Tennessee, USA
| | | | - Lia Gore
- Children's Hospital Colorado, USA; University of Colorado, USA
| | - Darren Hargrave
- UCL Great Ormond Street Institute of Child Health, London UK
| | - Doug Hawkins
- Seattle Children's Hospital, USA; Children's Oncology Group, Seattle, USA
| | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | | | - Lynley V Marshall
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | | | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency, (EMA), Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children's Research Hospital, Tennessee, USA
| | | | | | | | | | | | | | - Ruth Viana
- Alexion Pharmaceuticals, Zurich, Switzerland
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency (EMA), Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, Paris, France
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11
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Karres D, Lesa G, Ligas F, Benchetrit S, Galluzzo S, Van Malderen K, Sterba J, van Dartel M, Renard M, Sisovsky P, Wang S, Norga K. European regulatory strategy for supporting childhood cancer therapy developments. Eur J Cancer 2022; 177:25-29. [PMID: 36323049 DOI: 10.1016/j.ejca.2022.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/02/2022] [Accepted: 09/23/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Regulatory decisions on paediatric investigation plans (PIPs) aim at making effective and safe medicines timely available for children with high unmet medical need. At the same time, scientific knowledge progresses continuously leading frequently to the identification of new molecular targets in the therapeutic area of oncology. This, together with further efforts to optimise next generation medicines, results in novel innovative products in development pipelines. In the context of global regulatory development requirements for these growing pipelines of innovative products (e.g. US RACE for children Act), it is an increasing challenge to complete development efforts in paediatric oncology, a therapeutic area of rare and life-threatening diseases with high unmet needs. OBJECTIVE Regulators recognise feasibility challenges of the regulatory obligations in this context. Here, we explain the EU regulatory decision making strategy applied to paediatric oncology, which aims fostering evidence generation to support developments based on needs and robust science. Because there is a plethora of products under development within given classes of or within cancer types, priorities need to be identified and updated as evidence evolves. This also includes identifying the need for third or fourth generation products to secure focused and accelerated drug development. CONCLUSION An agreed PIP, as a plan, is a living document which can be modified in light of new evidence. For this to be successful, input from the various relevant stakeholders, i.e. patients/parents, clinicians and investigators is required. To efficiently obtain this input, the EMA is co-organising with ACCELERATE oncology stakeholder engagement platform meetings.
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Affiliation(s)
- Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands.
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Sylvie Benchetrit
- Agence Nationale de Sécurité Du Médicament et des Produits de Santé (ANSM), Paris, France; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Sara Galluzzo
- Italian Medicines Agency (AIFA), Rome, Italy; Scientific Advice Working Party and Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Karen Van Malderen
- Federal Agency for Medicines and Health Products (FAMHP), Brussels, Belgium; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Jaroslav Sterba
- Department of Pediatric Oncology, University Hospital Brno, And Faculty of Medicine, Masaryk University, International Clinical Research Center, St Anne's University Hospital, Brno, Czech Republic; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Maaike van Dartel
- College Ter Beoordeling van Geneesmiddelen, Utrecht, Netherlands; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Marleen Renard
- University Hospitals Leuven, Leuven, Belgium; Federal Agency for Medicines and Health Products (FAMHP), Brussels, Belgium; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Peter Sisovsky
- State Institute for Drug Control, Bratislava, Slovakia; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Siri Wang
- Norwegian Medicines Agency, Oslo, Norway; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands
| | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products (FAMHP), Brussels, Belgium
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12
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Pearson ADJ, de Rojas T, Karres D, Reaman G, Scobie N, Fox E, Lesa G, Ligas F, Norga K, Nysom K, Pappo A, Weigel B, Weiner S, Vassal G. ACCELERATE Paediatric Strategy Forums: an advance for oncological drug development? Lancet Oncol 2022; 23:1354-1357. [PMID: 36328007 DOI: 10.1016/s1470-2045(22)00619-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency, Amsterdam, Netherlands
| | | | | | - Elizabeth Fox
- St Jude Children's Research Hospital, Memphis, TN, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency, Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Division, European Medicines Agency, Amsterdam, Netherlands
| | - Koen Norga
- Antwerp University Hospital, Antwerp, Belgium; Paediatric Committee of the European Medicines Agency, Amsterdam, Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | | | - Alberto Pappo
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Gilles Vassal
- ACCELERATE, 1200 Brussels, Belgium; Gustave Roussy Cancer Centre, Paris, France
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13
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Paediatric Strategy Forum for medicinal product development of multi-targeted kinase inhibitors in bone sarcomas: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2022; 173:71-90. [PMID: 35863108 DOI: 10.1016/j.ejca.2022.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/26/2022] [Accepted: 06/12/2022] [Indexed: 12/27/2022]
Abstract
The eighth Paediatric Strategy Forum focused on multi-targeted kinase inhibitors (mTKIs) in osteosarcoma and Ewing sarcoma. The development of curative, innovative products in these tumours is a high priority and addresses unmet needs in children, adolescents and adults. Despite clinical and investigational use of mTKIs, efficacy in patients with bone tumours has not been definitively demonstrated. Randomised studies, currently being planned or in progress, in front-line and relapse settings will inform the further development of this class of product. It is crucial that these are rapidly initiated to generate robust data to support international collaborative efforts. The experience to date has generally indicated that the safety profile of mTKIs as monotherapy, and in combination with chemotherapy or other targeted therapy, is consistent with that of adults and that toxicity is manageable. Increasing understanding of relevant predictive biomarkers and tumour biology is absolutely critical to further develop this class of products. Biospecimen samples for correlative studies and biomarker development should be shared, and a joint academic-industry consortium created. This would result in an integrated collection of serial tumour tissues and a systematic retrospective and prospective analyses of these samples to ensure robust assessment of biologic effect of mTKIs. To support access for children to benefit from these novel therapies, clinical trials should be designed with sufficient scientific rationale to support regulatory and payer requirements. To achieve this, early dialogue between academia, industry, regulators, and patient advocates is essential. Evaluating feasibility of combination strategies and then undertaking a randomised trial in the same protocol accelerates drug development. Where possible, clinical trials and development should include children, adolescents, and adults less than 40 years. To respond to emerging science, in approximately 12 months, a multi-stakeholder group will meet and review available data to determine future directions and priorities.
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14
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Burkhardt B, Michgehl U, Rohde J, Erdmann T, Berning P, Reutter K, Rohde M, Borkhardt A, Burmeister T, Dave S, Tzankov A, Dugas M, Sandmann S, Fend F, Finger J, Mueller S, Gökbuget N, Haferlach T, Kern W, Hartmann W, Klapper W, Oschlies I, Richter J, Kontny U, Lutz M, Maecker-Kolhoff B, Ott G, Rosenwald A, Siebert R, von Stackelberg A, Strahm B, Woessmann W, Zimmermann M, Zapukhlyak M, Grau M, Lenz G. Clinical relevance of molecular characteristics in Burkitt lymphoma differs according to age. Nat Commun 2022; 13:3881. [PMID: 35794096 PMCID: PMC9259584 DOI: 10.1038/s41467-022-31355-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 06/13/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractWhile survival has improved for Burkitt lymphoma patients, potential differences in outcome between pediatric and adult patients remain unclear. In both age groups, survival remains poor at relapse. Therefore, we conducted a comparative study in a large pediatric cohort, including 191 cases and 97 samples from adults. While TP53 and CCND3 mutation frequencies are not age related, samples from pediatric patients showed a higher frequency of mutations in ID3, DDX3X, ARID1A and SMARCA4, while several genes such as BCL2 and YY1AP1 are almost exclusively mutated in adult patients. An unbiased analysis reveals a transition of the mutational profile between 25 and 40 years of age. Survival analysis in the pediatric cohort confirms that TP53 mutations are significantly associated with higher incidence of relapse (25 ± 4% versus 6 ± 2%, p-value 0.0002). This identifies a promising molecular marker for relapse incidence in pediatric BL which will be used in future clinical trials.
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15
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ACCELERATE – Five years accelerating cancer drug development for children and adolescents. Eur J Cancer 2022; 166:145-164. [DOI: 10.1016/j.ejca.2022.01.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/06/2022] [Accepted: 01/17/2022] [Indexed: 02/06/2023]
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16
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Brivio E, Baruchel A, Beishuizen A, Bourquin JP, Brown PA, Cooper T, Gore L, Kolb EA, Locatelli F, Maude SL, Mussai FJ, Vormoor-Bürger B, Vormoor J, von Stackelberg A, Zwaan CM. Targeted inhibitors and antibody immunotherapies: Novel therapies for paediatric leukaemia and lymphoma. Eur J Cancer 2022; 164:1-17. [PMID: 35121370 DOI: 10.1016/j.ejca.2021.12.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/16/2021] [Accepted: 12/21/2021] [Indexed: 12/19/2022]
Abstract
Despite improved outcomes achieved in the last decades for children with newly diagnosed leukaemia and lymphoma, treatment of patients with refractory/relapsed disease remains a challenge. The cure rate is still unsatisfactory and often achieved at the cost of significant morbidity. Exploring treatment with novel agents should offer less toxic therapeutic options, without compromising efficacy. Bispecific and antibody-drug conjugates targeting CD19 and CD22 (blinatumomab and inotuzumab ozogamicin) play an important role in the treatment of relapsed and refractory B-cell precursor acute lymphoblastic leukaemia (BCP-ALL); antibodies targeting CD123 and CD38 are also under investigation for acute myeloid leukaemia (AML) and T-ALL, respectively. Targeted therapy with small molecules is of primary importance for specific genetic subtypes, such as BCR-ABL-positive ALL, FLT3-ITD AML and anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma. KMT2A-directed targeted therapy with menin inhibitors holds promise to be of relevance in KMT2A-rearranged leukaemias, known to have dismal prognosis. Target inhibition in cellular pathways such as BCL-2, RAS, MEK, Bruton's tyrosine kinase, JAK-STAT or CDK4/CDK6 inhibition may be suitable for different diseases with common mutated pathways. Nevertheless, development and approval of new agents for paediatric cancers lags behind adult therapeutic options. New regulations were implemented to accelerate drug development for children. Considering the number of oncology medicinal products available for adults and the rarity of paediatric cancers, prioritisation based on scientific evidence and medical need, as well as international collaboration, is critical. Herein, we review the current status of drug development for children with leukaemia and lymphoma, excluding cellular therapy despite its well-known significance.
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Affiliation(s)
- Erica Brivio
- Princess Ma´xima Center for Pediatric Oncology, Utrecht, the Netherlands; Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - André Baruchel
- Hématologie-Immunologie Pédiatrique, Hoˆ pital Universitaire Robert Debré (APHP) and Université de Paris, Paris, France
| | - Auke Beishuizen
- Princess Ma´xima Center for Pediatric Oncology, Utrecht, the Netherlands; Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jean-Pierre Bourquin
- Department of Oncology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Patrick A Brown
- Departments of Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd Cooper
- Aflac Cancer and Blood Disorders Center/Children's Healthcare of Atlanta/Emory University, Atlanta, GA, USA
| | - Lia Gore
- University of Colorado School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, USA
| | - E Anders Kolb
- Nemours Center for Cancer and Blood Disorders, Nemours/Alfred I DuPont Hospital for Children, Wilmington, DE, USA
| | - Franco Locatelli
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Sapienza, University of Rome, Italy
| | - Shannon L Maude
- Division of Oncology, Department of Pediatrics, Center for Childhood Cancer Research, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Francis J Mussai
- Institute for Immunology and Immunotherapy, Cancer Research UK Birmingham Centre, The University of Birmingham, Birmingham, United Kingdom
| | | | - Josef Vormoor
- Princess Ma´xima Center for Pediatric Oncology, Utrecht, the Netherlands; University Medical Center, Utrecht, the Netherlands; Newcastle University, Newcastle, UK
| | | | - C Michel Zwaan
- Princess Ma´xima Center for Pediatric Oncology, Utrecht, the Netherlands; Pediatric Oncology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; The Innovative Therapies for Children with Cancer Consortium, Paris, France.
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17
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Genomic abnormalities of TP53 define distinct risk groups of paediatric B-cell non-Hodgkin lymphoma. Leukemia 2022; 36:781-789. [PMID: 34675373 PMCID: PMC8885412 DOI: 10.1038/s41375-021-01444-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 09/26/2021] [Accepted: 09/29/2021] [Indexed: 11/09/2022]
Abstract
Children with B-cell non-Hodgkin lymphoma (B-NHL) have an excellent chance of survival, however, current clinical risk stratification places as many as half of patients in a high-risk group receiving very intensive chemo-immunotherapy. TP53 alterations are associated with adverse outcome in many malignancies; however, whilst common in paediatric B-NHL, their utility as a risk classifier is unknown. We evaluated the clinical significance of TP53 abnormalities (mutations, deletion and/or copy number neutral loss of heterozygosity) in a large UK paediatric B-NHL cohort and determined their impact on survival. TP53 abnormalities were present in 54.7% of cases and were independently associated with a significantly inferior survival compared to those without a TP53 abnormality (PFS 70.0% vs 100%, p < 0.001, OS 78.0% vs 100%, p = 0.002). Moreover, amongst patients clinically defined as high-risk (stage III with high LDH or stage IV), those without a TP53 abnormality have superior survival compared to those with TP53 abnormalities (PFS 100% vs 55.6%, p = 0.005, OS 100% vs 66.7%, p = 0.019). Biallelic TP53 abnormalities were either maintained from the presentation or acquired at progression in all paired diagnosis/progression Burkitt lymphoma cases. TP53 abnormalities thus define clinical risk groups within paediatric B-NHL and offer a novel molecular risk stratifier, allowing more personalised treatment protocols.
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Pearson AD, Rossig C, Mackall C, Shah NN, Baruchel A, Reaman G, Ricafort R, Heenen D, Bassan A, Berntgen M, Bird N, Bleickardt E, Bouchkouj N, Bross P, Brownstein C, Cohen SB, de Rojas T, Ehrlich L, Fox E, Gottschalk S, Hanssens L, Hawkins DS, Horak ID, Taylor DH, Johnson C, Karres D, Ligas F, Ludwinski D, Mamonkin M, Marshall L, Masouleh BK, Matloub Y, Maude S, McDonough J, Minard-Colin V, Norga K, Nysom K, Pappo A, Pearce L, Pieters R, Pule M, Quintás-Cardama A, Richardson N, Schüßler-Lenz M, Scobie N, Sersch MA, Smith MA, Sterba J, Tasian SK, Weigel B, Weiner SL, Zwaan CM, Lesa G, Vassal G. Paediatric Strategy Forum for medicinal product development of chimeric antigen receptor T-cells in children and adolescents with cancer: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2021; 160:112-133. [PMID: 34840026 DOI: 10.1016/j.ejca.2021.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/13/2021] [Indexed: 12/30/2022]
Abstract
The seventh multi-stakeholder Paediatric Strategy Forum focused on chimeric antigen receptor (CAR) T-cells for children and adolescents with cancer. The development of CAR T-cells for patients with haematological malignancies, especially B-cell precursor acute lymphoblastic leukaemia (BCP-ALL), has been spectacular. However, currently, there are scientific, clinical and logistical challenges for use of CAR T-cells in BCP-ALL and other paediatric malignancies, particularly in acute myeloid leukaemia (AML), lymphomas and solid tumours. The aims of the Forum were to summarise the current landscape of CAR T-cell therapy development in paediatrics, too identify current challenges and future directions, with consideration of other immune effector modalities and ascertain the best strategies to accelerate their development and availability to children. Although the effect is of limited duration in about half of the patients, anti-CD19 CAR T-cells produce high response rates in relapsed/refractory BCP-ALL and this has highlighted previously unknown mechanisms of relapse. CAR T-cell treatment as first- or second-line therapy could also potentially benefit patients whose disease has high-risk features associated with relapse and failure of conventional therapies. Identifying patients with very early and early relapse in whom CAR T-cell therapy may replace haematopoietic stem cell transplantation and be definitive therapy versus those in whom it provides a more effective bridge to haematopoietic stem cell transplantation is a very high priority. Development of approaches to improve persistence, either by improving T cell fitness or using more humanised/fully humanised products and co-targeting of multiple antigens to prevent antigen escape, could potentially further optimise therapy. Many differences exist between paediatric B-cell non-Hodgkin lymphomas (B-NHL) and BCP-ALL. In view of the very small patient numbers with relapsed lymphoma, careful prioritisation is needed to evaluate CAR T-cells in children with Burkitt lymphoma, primary mediastinal B cell lymphoma and other NHL subtypes. Combination trials of alternative targets to CD19 (CD20 or CD22) should also be explored as a priority to improve efficacy in this population. Development of CD30 CAR T-cell immunotherapy strategies in patients with relapsed/refractory Hodgkin lymphoma will likely be most efficiently accomplished by joint paediatric and adult trials. CAR T-cell approaches are early in development for AML and T-ALL, given the unique challenges of successful immunotherapy actualisation in these diseases. At this time, CD33 and CD123 appear to be the most universal targets in AML and CD7 in T-ALL. The results of ongoing or planned first-in-human studies are required to facilitate further understanding. There are promising early results in solid tumours, particularly with GD2 targeting cell therapies in neuroblastoma and central nervous system gliomas that represent significant unmet clinical needs. Further understanding of biology is critical to success. The comparative benefits of autologous versus allogeneic CAR T-cells, T-cells engineered with T cell receptors T-cells engineered with T cell receptor fusion constructs, CAR Natural Killer (NK)-cell products, bispecific T-cell engager antibodies and antibody-drug conjugates require evaluation in paediatric malignancies. Early and proactive academia and multi-company engagement are mandatory to advance cellular immunotherapies in paediatric oncology. Regulatory advice should be sought very early in the design and preparation of clinical trials of innovative medicines, for which regulatory approval may ultimately be sought. Aligning strategic, scientific, regulatory, health technology and funding requirements from the inception of a clinical trial is especially important as these are very expensive therapies. The model for drug development for cell therapy in paediatric oncology could also involve a 'later stage handoff' to industry after early development in academic hands. Finally, and very importantly, strategies must evolve to ensure appropriate ease of access for children who need and could potentially benefit from these therapies.
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Affiliation(s)
| | - Claudia Rossig
- University Children´s Hospital Muenster, Pediatric Hematology and Oncology, Germany
| | - Crystal Mackall
- Department of Pediatrics and Medicine, Stanford University, Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, CA, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, National Cancer Institute, USA
| | - Andre Baruchel
- Hôpital Universitaire Robert Debré (APHP) and Université de Paris, France
| | | | | | | | | | - Michael Berntgen
- Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | - Lynley Marshall
- The Royal Marsden Hospital and the Institute of Cancer Research, London, UK
| | | | | | - Shannon Maude
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | - Veronique Minard-Colin
- Department of Pediatric and Adolescent Oncology, INSERM U1015, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products, Belgium
| | | | | | | | - Rob Pieters
- Princess Maxima Center for Pediatric Oncology, Netherlands
| | | | | | | | - Martina Schüßler-Lenz
- Chair of CAT (Committee for Advanced Therapies), European Medicines Agency (EMA), Amsterdam, Netherlands; Paul-Ehrlich-Institut, Germany
| | | | | | | | - Jaroslav Sterba
- University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Sarah K Tasian
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | | | - Christian Michel Zwaan
- Princess Maxima Center for Pediatric Oncology, Netherlands; Haematological Malignancies Co-Chair Innovative Therapies for Children with Cancer Consortium (ITCC), Europe; Erasmus University Medical Center Rotterdam, Netherlands
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe; Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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19
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Pearson ADJ, Barry E, Mossé YP, Ligas F, Bird N, de Rojas T, Zimmerman ZF, Wilner K, Woessmann W, Weiner S, Weigel B, Venkatramani R, Valteau D, Trahair T, Smith M, Singh S, Selvaggi G, Scobie N, Schleiermacher G, Richardson N, Park J, Nysom K, Norga K, Merino M, McDonough J, Matloub Y, Marshall LV, Lowe E, Lesa G, Irwin M, Karres D, Gajjar A, Doz F, Fox E, DuBois SG, Donoghue M, Casanova M, Caron H, Buenger V, Bradford D, Blanc P, Barone A, Reaman G, Vassal G. Second Paediatric Strategy Forum for anaplastic lymphoma kinase (ALK) inhibition in paediatric malignancies: ACCELERATE in collaboration with the European Medicines Agency with the participation of the Food and Drug Administration. Eur J Cancer 2021; 157:198-213. [PMID: 34536944 DOI: 10.1016/j.ejca.2021.08.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/12/2021] [Accepted: 08/14/2021] [Indexed: 12/28/2022]
Abstract
The first (2017) and sixth (2021) multistakeholder Paediatric Strategy Forums focused on anaplastic lymphoma kinase (ALK) inhibition in paediatric malignancies. ALK is an important oncogene and target in several paediatric tumours (anaplastic large cell lymphoma [ALCL], inflammatory myofibroblastic tumour [IMT], neuroblastoma and hemispheric gliomas in infants and young children) with unmet therapeutic needs. ALK tyrosine kinase inhibitors have been demonstrated to be active both in ALK fusion-kinase positive ALCL and IMT. ALK alterations differ, with fusions occurring in ALCL, IMT and gliomas, and activating mutations and amplification in neuroblastoma. While there are many ALK inhibitors in development, the number of children diagnosed with ALK driven malignancies is very small. The objectives of this ALK Forum were to (i) Describe current knowledge of ALK biology in childhood cancers; (ii) Provide an overview of the development of ALK inhibitors for children; (iii) Identify the unmet needs taking into account planned or current ongoing trials; (iv) Conclude how second/third-generation inhibitors could be evaluated and prioritised; (v) Identify lessons learnt from the experience with ALK inhibitors to accelerate the paediatric development of other anti-cancer targeted agents in the new regulatory environments. There has been progress over the last four years, with more trials of ALK inhibitors opened in paediatrics and more regulatory submissions. In January 2021, the US Food and Drug Administration approved crizotinib for the treatment of paediatric and young adult patients with relapsed or refractory ALCL and there are paediatric investigation plans (PIPs) for brigatinib and for crizotinib in ALCL and IMT. In ALCL, the current goal is to investigate the inclusion of ALK inhibitors in front-line therapy with the aim of decreasing toxicity with higher/similar efficacy compared to present first-line therapies. For IMT, the focus is to develop a joint prospective trial with one product in children, adolescents and adults, taking advantage of the common biology across the age spectrum. As approximately 50% of IMTs are ALK-positive, molecular analysis is required to identify patients to be treated with an ALK inhibitor. For neuroblastoma, crizotinib has not shown robust anti-tumour activity. A focused and sequential development of ALK inhibitors with very good central nervous system (CNS) penetration in CNS tumours with ALK fusions should be undertaken. The Forum reinforced the strong need for global academic collaboration, very early involvement of regulators with studies seeking possible registration and early academia-multicompany engagement. Innovations in study design and conduct and the use of 'real-world data' supporting development in these rare sub-groups of patients for whom randomised clinical trials are not feasible are important initiatives. A focused and sequenced development strategy, where one product is evaluated first with other products being assessed sequentially, is applicable for ALK inhibitors and other medicinal products in children.
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Affiliation(s)
| | | | - Yael P Mossé
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Division of Oncology and Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, USA
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products, Belgium
| | | | | | | | - Lynley V Marshall
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, UK
| | - Eric Lowe
- Children's Hospital of the King's Daughters, USA
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, France
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20
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Barry E, Walsh JA, Weinrich SL, Beaupre D, Blasi E, Arenson DR, Jacobs IA. Navigating the Regulatory Landscape to Develop Pediatric Oncology Drugs: Expert Opinion Recommendations. Paediatr Drugs 2021; 23:381-394. [PMID: 34173206 PMCID: PMC8275539 DOI: 10.1007/s40272-021-00455-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/30/2022]
Abstract
Regulatory changes have been enacted in the United States (US) and European Union (EU) to encourage the development of new treatments for pediatric cancer. Here, we review some of the factors that have hampered the development of pediatric cancer treatments and provide a comparison of the US and EU regulations implemented to address this clinical need. We then provide some recommendations for each stage of the oncology drug development pathway to help researchers maximize their chance of successful drug development while complying with regulations. A key recommendation is the engagement of key stakeholders such as regulatory authorities, pediatric oncologists, academic researchers, patient advocacy groups, and a Pediatric Expert Group early in the drug development process. During drug target selection, sponsors are encouraged to consult the Food and Drug Administration (FDA), European Medicines Agency (EMA), and the FDA target list, in addition to relevant US and European consortia that have been established to characterize and prioritize oncology drug targets. Sponsors also need to carefully consider the resourcing requirements for preclinical testing, which include ensuring appropriate access to the most relevant databases, clinical samples, and preclinical models (cell lines and animal models). During clinical development, sponsors can account for the pharmacodynamic (PD)/pharmacokinetic (PK) considerations specific to a pediatric population by developing pediatric formulations, selecting suitable PD endpoints, and employing sparse PK sampling or modeling/simulation of drug exposures where appropriate. Additional clinical considerations include the specific design of the clinical trial, the potential inclusion of children in adult trials, and the value of cooperative group trials.
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21
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Treatment and Outcome Analysis of 639 Relapsed Non-Hodgkin Lymphomas in Children and Adolescents and Resulting Treatment Recommendations. Cancers (Basel) 2021; 13:cancers13092075. [PMID: 33923026 PMCID: PMC8123268 DOI: 10.3390/cancers13092075] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/18/2021] [Accepted: 04/22/2021] [Indexed: 12/23/2022] Open
Abstract
Simple Summary Despite very poor survival, controversies remain in the treatment for refractory or relapsed non-Hodgkin lymphoma (r/r NHL) in children and adolescents. The current project identifies and reports international experience on re-induction treatment of r/r NHL, hematopoietic stem cell transplantation, risk factors associated with outcome, and suggests treatment recommendations. Abstract Despite poor survival, controversies remain in the treatment for refractory or relapsed pediatric non-Hodgkin lymphoma (r/r NHL). The current project aimed to collect international experience on the re-induction treatment of r/r NHL, hematopoietic stem cell transplantation (HSCT), risk factors associated with outcome, and to suggest treatment recommendations. Inclusion criteria were (i) refractory disease, disease progression or relapse of any NHL subtype except anaplastic large cell lymphoma, (ii) age < 18 years at initial diagnosis, (iii) diagnosis in/after January 2000. Data from 639 eligible patients were evaluable. The eight-year probability of overall survival was 34 ± 2% with highly significant differences according to NHL subtypes: 28 ± 3% for 254 Burkitt lymphoma/leukemia, 50 ± 6% for 98 diffuse large B-cell lymphomas, 57 ± 8% for 41 primary mediastinal large B-cell lymphomas, 27 ± 3% for 177 T-lymphoblastic lymphomas, 52 ± 10% for 34 precursor-B-cell lymphoblastic lymphomas and 30 ± 9% for 35 patients with rare NHL subtypes. Subtype-specific factors associated with survival and treatment recommendations are suggested. There were no survivors without HSCT, except in few very small subgroups. Conclusions: There is an urgent need to further improve survival in r/r NHL. The current study provides the largest real-world series, which underlines the role of HSCT and suggests treatment recommendations.
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22
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Laetsch TW, DuBois SG, Bender JG, Macy ME, Moreno L. Opportunities and Challenges in Drug Development for Pediatric Cancers. Cancer Discov 2021; 11:545-559. [PMID: 33277309 PMCID: PMC7933059 DOI: 10.1158/2159-8290.cd-20-0779] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/08/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022]
Abstract
The use of targeted small-molecule therapeutics and immunotherapeutics has been limited to date in pediatric oncology. Recently, the number of pediatric approvals has risen, and regulatory initiatives in the United States and Europe have aimed to increase the study of novel anticancer therapies in children. Challenges of drug development in children include the rarity of individual cancer diagnoses and the high prevalence of difficult-to-drug targets, including transcription factors and epigenetic regulators. Ongoing pediatric adaptation of biomarker-driven trial designs and further exploration of agents targeting non-kinase drivers constitute high-priority objectives for future pediatric oncology drug development. SIGNIFICANCE: Increasing attention to drug development for children with cancer by regulators and pharmaceutical companies holds the promise of accelerating the availability of new therapies for children with cancer, potentially improving survival and decreasing the acute and chronic toxicities of therapy. However, unique approaches are necessary to study novel therapies in children that take into account low patient numbers, the pediatric cancer genomic landscape and tumor microenvironment, and the need for pediatric formulations. It is also critical to evaluate the potential for unique toxicities in growing hosts without affecting the pace of discovery for children with these life-threatening diseases.
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Affiliation(s)
- Theodore W Laetsch
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and Abramson Cancer Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts
| | | | - Margaret E Macy
- Children's Hospital Colorado and University of Colorado, Denver, Colorado
| | - Lucas Moreno
- Division of Pediatric Hematology and Oncology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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23
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Forde S, Matthews JD, Jahangiri L, Lee LC, Prokoph N, Malcolm TIM, Giger OT, Bell N, Blair H, O'Marcaigh A, Smith O, Kenner L, Bomken S, Burke GAA, Turner SD. Paediatric Burkitt lymphoma patient-derived xenografts capture disease characteristics over time and are a model for therapy. Br J Haematol 2021; 192:354-365. [PMID: 32880915 DOI: 10.1111/bjh.17043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/26/2020] [Indexed: 12/28/2022]
Abstract
Burkitt lymphoma (BL) accounts for almost two-thirds of all B-cell non-Hodgkin lymphoma (B-NHL) in children and adolescents and is characterised by a MYC translocation and rapid cell turnover. Intensive chemotherapeutic regimens have been developed in recent decades, including the lymphomes malins B (LMB) protocol, which have resulted in a survival rate in excess of 90%. Recent clinical trials have focused on immunochemotherapy, with the addition of rituximab to chemotherapeutic backbones, showing encouraging results. Despite these advances, relapse and refractory disease occurs in up to 10% of patients and salvage options for these carry a dismal prognosis. Efforts to better understand the molecular and functional characteristics driving relapse and refractory disease may help improve this prognosis. This study has established a paediatric BL patient-derived xenograft (PDX) resource which captures and maintains tumour heterogeneity, may be used to better characterise tumours and identify cell populations responsible for therapy resistance.
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Affiliation(s)
- Sorcha Forde
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Jamie D Matthews
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Leila Jahangiri
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK.,Department of Life Sciences, Birmingham City University, Birmingham, UK
| | - Liam C Lee
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Nina Prokoph
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Tim I M Malcolm
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Olivier T Giger
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Natalie Bell
- Wolfson Childhood Cancer Research Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Blair
- Wolfson Childhood Cancer Research Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Owen Smith
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Lukas Kenner
- Department of Pathology, Medical University of Vienna, Vienna, Austria.,Unit of Laboratory Animal Pathology, University of Veterinary Medicine Vienna, Vienna, Austria.,Christian Doppler Laboratory for Applied Metabolomics, Vienna, Austria
| | - Simon Bomken
- Wolfson Childhood Cancer Research Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,The Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Gladstone A A Burke
- Department of Paediatric Oncology and Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Suzanne D Turner
- Division of Cellular and Molecular Pathology, Department of Pathology, University of Cambridge, Cambridge, UK.,Central European Institute of Technology, Masaryk University, Brno, Czech Republic
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24
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Pearson ADJ, Karres D, Reaman G, DuBois SG, Knox L, Scobie N, Vassal G. The RACE to accelerate drug development for children with cancer. THE LANCET. CHILD & ADOLESCENT HEALTH 2020; 4:714-716. [PMID: 32822672 DOI: 10.1016/s2352-4642(20)30247-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 06/11/2023]
Affiliation(s)
| | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency, Amsterdam, Netherlands
| | | | - Steven G DuBois
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Nicole Scobie
- Zoé4life, Sullens, Switzerland; Childhood Cancer International, Europe
| | - Gilles Vassal
- ACCELERATE, Europe; Gustave Roussy Cancer Centre, Villejuif, France
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25
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Pearson AD, Stegmaier K, Bourdeaut F, Reaman G, Heenen D, Meyers ML, Armstrong SA, Brown P, De Carvalho D, Jabado N, Marshall L, Rivera M, Smith M, Adamson PC, Barone A, Baumann C, Blackman S, Buenger V, Donoghue M, Duncan AD, Fox E, Gadbaw B, Hattersley M, Ho P, Jacobs I, Kelly MJ, Kieran M, Lesa G, Ligas F, Ludwinski D, McDonough J, Nikolova Z, Norga K, Senderowicz A, Taube T, Weiner S, Karres D, Vassal G. Paediatric Strategy Forum for medicinal product development of epigenetic modifiers for children: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2020; 139:135-148. [PMID: 32992153 DOI: 10.1016/j.ejca.2020.08.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 12/27/2022]
Abstract
The fifth multistakeholder Paediatric Strategy Forum focussed on epigenetic modifier therapies for children and adolescents with cancer. As most mutations in paediatric malignancies influence chromatin-associated proteins or transcription and paediatric cancers are driven by developmental gene expression programs, targeting epigenetic mechanisms is predicted to be a very important therapeutic approach in paediatric cancer. The Research to Accelerate Cures and Equity (RACE) for Children Act FDARA amendments to section 505B of the FD&C Act was implemented in August 2020, and as there are many epigenetic targets on the FDA Paediatric Molecular Targets List, clinical evaluation of epigenetic modifiers in paediatric cancers should be considered early in drug development. Companies are also required to submit to the EMA paediatric investigation plans aiming to ensure that the necessary data to support the authorisation of a medicine for children in EU are of high quality and ethically researched. The specific aims of the forum were i) to identify epigenetic targets or mechanisms of action associated with epigenetic modification relevant to paediatric cancers and ii) to define the landscape for paediatric drug development of epigenetic modifier therapies. DNA methyltransferase inhibitors/hypomethylating agents and histone deacetylase inhibitors were largely excluded from discussion as the aim was to discuss those targets for which therapeutic agents are currently in early paediatric and adult development. Epigenetics is an evolving field and could be highly relevant to many paediatric cancers; the biology is multifaceted and new targets are frequently emerging. Targeting epigenetic mechanisms in paediatric malignancy has in most circumstances yet to reach or extend beyond clinical proof of concept, as many targets do not yet have available investigational drugs developed. Eight classes of medicinal products were discussed and prioritised based on the existing level of science to support early evaluation in children: inhibitors of menin, DOT1L, EZH2, EED, BET, PRMT5 and LSD1 and a retinoic acid receptor alpha agonist. Menin inhibitors should be moved rapidly into paediatric development, in view of their biological rationale, strong preclinical activity and ability to fulfil an unmet clinical need. A combination approach is critical for successful utilisation of any epigenetic modifiers (e.g. EZH2 and EED) and exploration of the optimum combination(s) should be supported by preclinical research and, where possible, molecular biomarker validation in advance of clinical translation. A follow-up multistakeholder meeting focussing on BET inhibitors will be held to define how to prioritise the multiple compounds in clinical development that could be evaluated in children with cancer. As epigenetic modifiers are relatively early in development in paediatrics, there is a clear opportunity to shape the landscape of therapies targeting the epigenome in order that efficient and optimum plans for their evaluation in children and adolescents are developed in a timely manner.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Lynley Marshall
- Royal Marsden NHS Foundation Trust/Institute of Cancer Research, UK
| | | | | | - Peter C Adamson
- Sanofi US, Emeritus Professor of Paediatrics and Pharmacology, Perelman School of Medicine, University of Pennsylvania, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products, Belgium
| | | | | | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
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26
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Hwang TJ, Orenstein L, DuBois SG, Janeway KA, Bourgeois FT. Pediatric Trials for Cancer Therapies With Targets Potentially Relevant to Pediatric Cancers. J Natl Cancer Inst 2020; 112:224-228. [PMID: 31665394 DOI: 10.1093/jnci/djz207] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 09/30/2019] [Accepted: 10/16/2019] [Indexed: 01/23/2023] Open
Abstract
The Research to Accelerate Cures and Equity (RACE) for Children Act was enacted in 2017 to authorize the US Food and Drug Administration (FDA) to require pediatric studies for new cancer drugs that have a molecular target relevant to the growth or progression of a pediatric cancer. To assess the possible scope of this new policy, we examined all 78 adult cancer drugs approved by the FDA from 2007 to 2017. Only 17 (21.8%) drugs received any pediatric labeling information. Based on the FDA's Pediatric Molecular Target List, we found that the RACE Act could have increased the proportion of cancer drugs potentially subject to pediatric study requirements from 0% to 78.2%. However, the actual effect of the legislation will depend on how often regulators require pediatric trials and on timely completion of such trials.
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Affiliation(s)
- Thomas J Hwang
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Liat Orenstein
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Katherine A Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Florence T Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
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Moreno L, Barone G, DuBois SG, Molenaar J, Fischer M, Schulte J, Eggert A, Schleiermacher G, Speleman F, Chesler L, Geoerger B, Hogarty MD, Irwin MS, Bird N, Blanchard GB, Buckland S, Caron H, Davis S, De Wilde B, Deubzer HE, Dolman E, Eilers M, George RE, George S, Jaroslav Š, Maris JM, Marshall L, Merchant M, Mortimer P, Owens C, Philpott A, Poon E, Shay JW, Tonelli R, Valteau-Couanet D, Vassal G, Park JR, Pearson ADJ. Accelerating drug development for neuroblastoma: Summary of the Second Neuroblastoma Drug Development Strategy forum from Innovative Therapies for Children with Cancer and International Society of Paediatric Oncology Europe Neuroblastoma. Eur J Cancer 2020; 136:52-68. [PMID: 32653773 DOI: 10.1016/j.ejca.2020.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/16/2020] [Accepted: 05/12/2020] [Indexed: 01/18/2023]
Abstract
Only one class of targeted agents (anti-GD2 antibodies) has been incorporated into front-line therapy for neuroblastoma since the 1980s. The Neuroblastoma New Drug Development Strategy (NDDS) initiative commenced in 2012 to accelerate the development of new drugs for neuroblastoma. Advances have occurred, with eight of nine high-priority targets being evaluated in paediatric trials including anaplastic lymphoma kinase inhibitors being investigated in front-line, but significant challenges remain. This article reports the conclusions of the second NDDS forum, which expanded across the Atlantic to further develop the initiative. Pre-clinical and clinical data for 40 genetic targets and mechanisms of action were prioritised and drugs were identified for early-phase trials. Strategies to develop drugs targeting TERT, telomere maintenance, ATRX, alternative lengthening of telomeres (ALT), BRIP1 and RRM2 as well as direct targeting of MYCN are high priority and should be championed for drug discovery. Promising pre-clinical data suggest that targeting of ALT by ATM or PARP inhibition may be potential strategies. Drugs targeting CDK2/9, CDK7, ATR and telomere maintenance should enter paediatric clinical development rapidly. Optimising the response to anti-GD2 by combinations with chemotherapy, targeted agents and other immunological targets are crucial. Delivering this strategy in the face of small patient cohorts, genomically defined subpopulations and a large number of permutations of combination trials, demands even greater international collaboration. In conclusion, the NDDS provides an internationally agreed, biologically driven selection of prioritised genetic targets and drugs. Improvements in the strategy for conducting trials in neuroblastoma will accelerate bringing these new drugs more rapidly to front-line therapy.
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Affiliation(s)
- Lucas Moreno
- Paediatric Haematology & Oncology Division, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Giuseppe Barone
- Department of Paediatric Oncology, Great Ormond Street Hospital for Children, London, UK
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA, USA
| | - Jan Molenaar
- Princess Máxima Centre for Paediatric Oncology, Utrecht, The Netherlands
| | - Matthias Fischer
- Experimental Pediatric Oncology, University Children's Hospital, Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Johannes Schulte
- Department of Pediatric Oncology & Hematology, Charité University Hospital, Berlin, Germany
| | - Angelika Eggert
- Department of Pediatric Oncology & Hematology, Charité University Hospital, Berlin, Germany; German Cancer Consortium (DKTK Berlin), Berlin, Germany; Berlin Institute of Health (BIH), Berlin, Germany
| | - Gudrun Schleiermacher
- SIREDO, Department of Paediatric, Adolescents and Young Adults Oncology and INSERM U830, Institut Curie, Paris, France
| | - Frank Speleman
- Center for Medical Genetics Ghent (CMGG), Department of Biomolecular Medicine, Cancer Research Institute Ghent (CRIG), Belgium
| | - Louis Chesler
- Paediatric Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK; Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
| | - Birgit Geoerger
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Center, University Paris-Saclay & Inserm U1015, Villejuif, France
| | - Michael D Hogarty
- Division of Oncology, Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, USA
| | - Meredith S Irwin
- Department of Paediatrics, Medical Biophysics and Laboratory Medicine & Pathobiology, The Hospital for Sick Kids, Toronto, Canada
| | - Nick Bird
- Solving Kids' Cancer, UK and National Cancer Research Institute Children's Cancer & Leukaemia Clinical Studies Group, UK
| | - Guy B Blanchard
- Neuroblastoma UK & Department of Physiology, Development & Neuroscience, University of Cambridge, UK
| | | | | | | | - Bram De Wilde
- Center for Medical Genetics Ghent (CMGG), Department of Biomolecular Medicine, Cancer Research Institute Ghent (CRIG), Belgium
| | - Hedwig E Deubzer
- Center for Molecular Medicine Cologne (CMMC), Medical Faculty, University of Cologne, Cologne, Germany
| | - Emmy Dolman
- Department of Translational Research, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Martin Eilers
- Department of Biochemistry and Molecular Biology, University of Wuerzburg, Germany
| | - Rani E George
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA, USA
| | - Sally George
- Paediatric Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK; Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
| | - Štěrba Jaroslav
- Pediatric Oncology Department, University Hospital Brno, School of Medicine Masaryk University Brno, Regional Centre for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, ICRC Brno, St Anna University Hospital Brno, Czech Republic
| | - John M Maris
- Division of Oncology, Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, USA
| | - Lynley Marshall
- Paediatric Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK; Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
| | - Melinda Merchant
- Astrazeneca, Early Clinical Projects, Oncology Translation Medicines Unit, Innovative Medicines Unit, Cambridge, UK
| | - Peter Mortimer
- Astrazeneca, Early Clinical Projects, Oncology Translation Medicines Unit, Innovative Medicines Unit, Cambridge, UK
| | - Cormac Owens
- Department of Paediatric Haemaology/Oncology, Our Lady's Children's Hospital, Dublin, Ireland
| | | | - Evon Poon
- Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
| | - Jerry W Shay
- Department of Cell Biology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Roberto Tonelli
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Dominique Valteau-Couanet
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Center, University Paris-Saclay & Inserm U1015, Villejuif, France
| | - Gilles Vassal
- Department of Clinical Research, Gustave Roussy, Paris-Sud University, Paris, France
| | - Julie R Park
- Department of Pediatrics, University of Washington School of Medicine and Center for Clinical and Translational Research, Seattle Children's Hospital, USA
| | - Andrew D J Pearson
- Paediatric Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK; Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
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Harker-Murray PD, Pommert L, Barth MJ. Novel Therapies Potentially Available for Pediatric B-Cell Non-Hodgkin Lymphoma. J Natl Compr Canc Netw 2020; 18:1125-1134. [PMID: 32755987 DOI: 10.6004/jnccn.2020.7608] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022]
Abstract
Burkitt lymphoma, diffuse large B-cell lymphoma (DLBCL), and primary mediastinal B-cell lymphoma are the most common aggressive pediatric mature B-cell non-Hodgkin lymphomas (B-NHLs). Despite excellent survival with current chemotherapy regimens, therapy for Burkitt lymphoma and DLBCL has a high incidence of short- and long-term toxicities. Patients who experience relapse generally have a very poor prognosis. Therefore, novel approaches using targeted therapies to reduce toxicities and improve outcomes in the relapse setting are needed. The addition of rituximab, a monoclonal antibody against CD20, to upfront therapy has improved survival outcomes for high-risk patients and may allow decreased total chemotherapy in those with low-risk disease. Antibody-drug conjugates have been combined with chemotherapy in relapsed/refractory (R/R) NHL, and multiple antibody-drug conjugates are in development. Additionally, bispecific T-cell-engaging antibody constructs and autologous CAR T-cells have been successful in the treatment of R/R acute leukemias and are now being applied to R/R B-NHL with some successes. PD-L1 and PD-L2 on tumor cells can be targeted with checkpoint inhibitors, which restore T-cell-mediated immunity and antitumor responses and can be added to conventional chemotherapy and immune-directed therapies to augment responses. Lastly, trials of small molecule inhibitors targeting cell signaling pathways in NHL subtypes are underway. This article reviews many of the targeted therapies under development that could be considered for future trials in R/R pediatric mature B-NHL.
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Affiliation(s)
| | - Lauren Pommert
- Pediatric Oncology, Midwest Children's Cancer Center, Milwaukee, Wisconsin; and
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Pearson ADJ, Zwaan CM, Kolb EA, Karres D, Guillot J, Kim SY, Marshall L, Tasian SK, Smith M, Cooper T, Adamson PC, Barry E, Benettaib B, Binlich F, Borgman A, Brivio E, Capdeville R, Delgado D, Faller D, Fogelstrand L, Fraenkel PG, Hasle H, Heenen D, Kaspers G, Kieran M, Klusmann JH, Lesa G, Ligas F, Mappa S, Mohamed H, Moore A, Morris J, Nottage K, Reinhardt D, Scobie N, Simko S, Winkler T, Norga K, Reaman G, Vassal G. Paediatric Strategy Forum for medicinal product development for acute myeloid leukaemia in children and adolescents: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2020; 136:116-129. [PMID: 32688206 PMCID: PMC7789799 DOI: 10.1016/j.ejca.2020.04.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Purpose: The current standard-of-care for front-line therapy for acute myeloid leukaemia (AML) results in short-term and long-term toxicity, but still approximately 40% of children relapse. Therefore, there is a major need to accelerate the evaluation of innovative medicines, yet drug development continues to be adult-focused. Furthermore, the large number of competing agents in rare patient populations requires coordinated prioritisation, within the global regulatory framework and cooperative group initiatives. Methods: The fourth multi-stakeholder Paediatric Strategy Forum focused on AML in children and adolescents. Results: CD123 is a high priority target and the paediatric development should be accelerated as a proof-of-concept. Efforts must be coordinated, however, as there are a limited number of studies that can be delivered. Studies of FLT3 inhibitors in agreed paediatric investigation plans present challenges to be completed because they require enrolment of a larger number of patients than actually exist. A consensus was developed by industry and academia of optimised clinical trials. For AML with rare mutations that are more frequent in adolescents than in children, adult trials should enrol adolescents and when scientifically justified, efficacy data could be extrapolated. Methodologies and definitions of minimal residual disease need to be standardised internationally and validated as a new response criterion. Industry supported, academic sponsored platform trials could identify products to be further developed. The Leukaemia and Lymphoma Society PedAL/EUpAL initiative has the potential to be a major advance in the field. Conclusion: These initiatives continue to accelerate drug development for children with AML and ultimately improve clinical outcomes.
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Affiliation(s)
| | - C Michel Zwaan
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Julie Guillot
- Fred Hutchinson Cancer Research Center, Leukaemia Lymphoma Society, Target Paediatric AML, USA
| | | | - Lynley Marshall
- Royal Marsden Hospital, The Institute of Cancer Research, UK
| | - Sarah K Tasian
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, USA
| | - Malcolm Smith
- National Institutes of Health, National Cancer Institute, USA
| | | | - Peter C Adamson
- Sanofi US, Emeritus Professor of Paediatrics & Pharmacology, Perelman School of Medicine, University of Pennsylvania, USA
| | | | | | | | | | - Erica Brivio
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | | | - Linda Fogelstrand
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Denmark
| | | | - Gertjan Kaspers
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Giovanni Lesa
- European Medicines Agency, Amsterdam, the Netherlands
| | - Franca Ligas
- European Medicines Agency, Amsterdam, the Netherlands
| | | | | | - Andrew Moore
- Queensland Children's Hospital, Brisbane, Australia
| | | | | | | | | | | | | | - Koen Norga
- Universitair Ziekenhuis Antwerpen, FAMHP, Belgium
| | | | - Gilles Vassal
- ACCELERATE/ITCC, Belgium; Gustave Roussy Cancer Centre, France
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30
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Karres D, Lesa G, Ligas F, Annunen P, van Dartel M, Demolis P, Galluzzo S, Herold R, van Criekingen OK, Stoyanova-Beninska V, Norga K. Can a Multistakeholder Prioritization Structure Support Regulatory Decision Making? A Review of Pediatric Oncology Strategy Forums Reflecting on Challenges and Opportunities of this Concept. Clin Pharmacol Ther 2020; 108:553-556. [PMID: 32559312 DOI: 10.1002/cpt.1939] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/23/2020] [Indexed: 11/07/2022]
Abstract
Timely and successful drug development for rare cancer populations, such as pediatric oncology, requires consolidated efforts in the spirit of shared responsibility. In order to advance tailored development efforts, the concept of multistakeholder Strategy Forum involving industry, academia, patient organizations, and regulators has been developed. In this study, we review the first five pediatric oncology Strategy Forums co-organized by the European Medicines Agency between 2017 and 2020, reflecting on the outcomes and the evolution of the concept over time and providing an outline of how a "safe space" for multistakeholder engagement facilitated by regulators could be of potential value beyond pediatric oncology drug development.
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Affiliation(s)
- Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Pia Annunen
- Finnish Medicines Agency (Fimea), Helsinki, Finland
- EMA's Paediatric Committee (PDCO), Amsterdam, The Netherlands
| | - Maaike van Dartel
- EMA's Paediatric Committee (PDCO), Amsterdam, The Netherlands
- Medicines Evaluation Board (CBG-MEB), Utrecht, The Netherlands
| | - Pierre Demolis
- Agence nationale de sécurité du médicament et des produits de santé (ANSM), SAINT-DENIS CEDEX, France
- EMA's Scientific Advice Working Party, Amsterdam, The Netherlands
| | - Sara Galluzzo
- EMA's Paediatric Committee (PDCO), Amsterdam, The Netherlands
- Italian Medicine Agency (AIFA), Rome, Italy
| | - Ralf Herold
- Oncology and Haematology Office, Human Medicines Division, European Medicines Agency (EMA), The Netherlands
| | | | - Violeta Stoyanova-Beninska
- Medicines Evaluation Board (CBG-MEB), Utrecht, The Netherlands
- EMA's Committee for Orphan Medicinal Products (COMP), Amsterdam, The Netherlands
| | - Koen Norga
- EMA's Paediatric Committee (PDCO), Amsterdam, The Netherlands
- Federal Agency for Medicines and Health Products (FAMHP), Brussels, Belgium
- EMA's Committee for Medicinal Products for Human Use (CHMP), Amsterdam, The Netherlands
- Paediatric Oncology, Antwerp University Hospital, Edegem, Belgium
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31
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Minard-Colin V, Aupérin A, Pillon M, Burke GAA, Barkauskas DA, Wheatley K, Delgado RF, Alexander S, Uyttebroeck A, Bollard CM, Zsiros J, Csoka M, Kazanowska B, Chiang AK, Miles RR, Wotherspoon A, Adamson PC, Vassal G, Patte C, Gross TG. Rituximab for High-Risk, Mature B-Cell Non-Hodgkin's Lymphoma in Children. N Engl J Med 2020; 382:2207-2219. [PMID: 32492302 PMCID: PMC7720281 DOI: 10.1056/nejmoa1915315] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Rituximab added to chemotherapy prolongs survival among adults with B-cell cancer. Data on its efficacy and safety in children with high-grade, mature B-cell non-Hodgkin's lymphoma are limited. METHODS We conducted an open-label, international, randomized, phase 3 trial involving patients younger than 18 years of age with high-risk, mature B-cell non-Hodgkin's lymphoma (stage III with an elevated lactate dehydrogenase level or stage IV) or acute leukemia to compare the addition of six doses of rituximab to standard lymphomes malins B (LMB) chemotherapy with standard LMB chemotherapy alone. The primary end point was event-free survival. Overall survival and toxic effects were also assessed. RESULTS Analyses were based on 328 patients who underwent randomization (164 patients per group); 85.7% of the patients had Burkitt's lymphoma. The median follow-up was 39.9 months. Events were observed in 10 patients in the rituximab-chemotherapy group and in 28 in the chemotherapy group. Event-free survival at 3 years was 93.9% (95% confidence interval [CI], 89.1 to 96.7) in the rituximab-chemotherapy group and 82.3% (95% CI, 75.7 to 87.5) in the chemotherapy group (hazard ratio for primary refractory disease or first occurrence of progression, relapse after response, death from any cause, or second cancer, 0.32; 95% CI, 0.15 to 0.66; one-sided P = 0.00096, which reached the significance level required for this analysis). Eight patients in the rituximab-chemotherapy group died (4 deaths were disease-related, 3 were treatment-related, and 1 was from a second cancer), as did 20 in the chemotherapy group (17 deaths were disease-related, and 3 were treatment-related) (hazard ratio, 0.36; 95% CI, 0.16 to 0.82). The incidence of acute adverse events of grade 4 or higher after prephase treatment was 33.3% in the rituximab-chemotherapy group and 24.2% in the chemotherapy group (P = 0.07); events were related mainly to febrile neutropenia and infection. Approximately twice as many patients in the rituximab-chemotherapy group as in the chemotherapy group had a low IgG level 1 year after trial inclusion. CONCLUSIONS Rituximab added to standard LMB chemotherapy markedly prolonged event-free survival and overall survival among children and adolescents with high-grade, high-risk, mature B-cell non-Hodgkin's lymphoma and was associated with a higher incidence of hypogammaglobulinemia and, potentially, more episodes of infection. (Funded by the Clinical Research Hospital Program of the French Ministry of Health and others; ClinicalTrials.gov number, NCT01516580.).
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Affiliation(s)
- Véronique Minard-Colin
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Anne Aupérin
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Marta Pillon
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - G A Amos Burke
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Donald A Barkauskas
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Keith Wheatley
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Rafael F Delgado
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Sarah Alexander
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Anne Uyttebroeck
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Catherine M Bollard
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - József Zsiros
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Monika Csoka
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Bernarda Kazanowska
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Alan K Chiang
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Rodney R Miles
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Andrew Wotherspoon
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Peter C Adamson
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Gilles Vassal
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Catherine Patte
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
| | - Thomas G Gross
- From the Departments of Pediatric and Adolescent Oncology (V.M.-C., C.P.) and Clinical Research (G.V.), INSERM Unité 1015 (V.M.-C.), and the Unit of Biostatistics and Epidemiology and INSERM Unité 1018 (A.A.), Gustave Roussy, Université Paris-Saclay, Villejuif, France; the Department of Pediatric Hematology and Oncology, University of Padua, Padua, Italy (M.P.); the Department of Paediatric Haematology, Oncology, and Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (G.A.A.B.), Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham (K.W.), and the Department of Histopathology, Royal Marsden NHS Foundation Trust, London (A.W.) - all in the United Kingdom; the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (D.A.B.); the Department of Pediatric Hematology and Oncology, University of Valencia, Valencia, Spain (R.F.D.); the Division of Haematology-Oncology, Hospital for Sick Children, Toronto (S.A.); the Department of Pediatric Hematology and Oncology, University Hospitals Leuven, Leuven, Belgium (A.U.); the Center for Cancer and Immunology Research, Children's National Health System and George Washington University, Washington, DC (C.M.B.); Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands (J.Z.); the Department of Pediatric Hematology and Oncology, Semmelweis University, Budapest, Hungary (M.C.); the Department of Pediatric Bone Marrow Transplantation, Oncology, and Hematology, Wroclaw Medical University, Wroclaw, Poland (B.K.); the Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong (A.K.C.); the Department of Pathology, University of Utah, Salt Lake City (R.R.M.); Children's Hospital of Philadelphia, Philadelphia (P.C.A.); and the National Cancer Institute, Center for Global Health, Rockville, MD (T.G.G.)
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Moreno L, DuBois SG, Marshall LV, Fox E, Carceller F, Pearson AD. How to address challenges and opportunities in pediatric cancer drug development? Expert Opin Drug Discov 2020; 15:869-872. [PMID: 32421361 DOI: 10.1080/17460441.2020.1767064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Lucas Moreno
- Division of Pediatric Hematology and Oncology. Hospital Universitari Vall d'Hebron , Barcelona, Spain
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School , Boston, MA, USA
| | - Lynley V Marshall
- Pediatric and Adolescent Oncology Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust , London, UK.,Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research , London, UK
| | - Elizabeth Fox
- Department of Oncology, St. Jude Children's Research Hospital , Memphis, TN, USA
| | - Fernando Carceller
- Pediatric and Adolescent Oncology Drug Development, Children & Young People's Unit, The Royal Marsden NHS Foundation Trust , London, UK.,Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research , London, UK
| | - Andrew Dj Pearson
- Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research , London, UK
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Choi JY. Immunotherapy in Pediatric Solid Tumors. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2020. [DOI: 10.15264/cpho.2020.27.1.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jung Yoon Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Seoul, Korea
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Pearson ADJ, Rossig C, Lesa G, Diede SJ, Weiner S, Anderson J, Gray J, Geoerger B, Minard-Colin V, Marshall LV, Smith M, Sondel P, Bajars M, Baldazzi C, Barry E, Blackman S, Blanc P, Capdeville R, Caron H, Cole PD, Jiménez JC, Demolis P, Donoghue M, Elgadi M, Gajewski T, Galluzzo S, Ilaria R, Jenkner A, Karres D, Kieran M, Ligas F, Lowy I, Meyers M, Oprea C, Peddareddigari VGR, Sterba J, Stockman PK, Suenaert P, Tabori U, van Tilburg C, Yancey T, Weigel B, Norga K, Reaman G, Vassal G. ACCELERATE and European Medicines Agency Paediatric Strategy Forum for medicinal product development of checkpoint inhibitors for use in combination therapy in paediatric patients. Eur J Cancer 2020; 127:52-66. [PMID: 31986450 DOI: 10.1016/j.ejca.2019.12.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/23/2019] [Indexed: 12/21/2022]
Abstract
The third multistakeholder Paediatric Strategy Forum organised by ACCELERATE and the European Medicines Agency focused on immune checkpoint inhibitors for use in combination therapy in children and adolescents. As immune checkpoint inhibitors, both as monotherapy and in combinations have shown impressive success in some adult malignancies and early phase trials in children of single agent checkpoint inhibitors have now been completed, it seemed an appropriate time to consider opportunities for paediatric studies of checkpoint inhibitors used in combination. Among paediatric patients, early clinical studies of checkpoint inhibitors used as monotherapy have demonstrated a high rate of activity, including complete responses, in Hodgkin lymphoma and hypermutant paediatric tumours. Activity has been very limited, however, in more common malignancies of childhood and adolescence. Furthermore, apart from tumour mutational burden, no other predictive biomarker for monotherapy activity in paediatric tumours has been identified. Based on these observations, there is collective agreement that there is no scientific rationale for children to be enrolled in new monotherapy trials of additional checkpoint inhibitors with the same mechanism of action of agents already studied (e.g. anti-PD1, anti-PDL1 anti-CTLA-4) unless additional scientific knowledge supporting a different approach becomes available. This shared perspective, based on scientific evidence and supported by paediatric oncology cooperative groups, should inform companies on whether a paediatric development plan is justified. This could then be proposed to regulators through the available regulatory tools. Generally, an academic-industry consensus on the scientific merits of a proposal before submission of a paediatric investigational plan would be of great benefit to determine which studies have the highest probability of generating new insights. There is already a rationale for the evaluation of combinations of checkpoint inhibitors with other agents in paediatric Hodgkin lymphoma and hypermutated tumours in view of the activity shown as single agents. In paediatric tumours where no single agent activity has been observed in multiple clinical trials of anti-PD1, anti-PDL1 and anti-CTLA-4 agents as monotherapy, combinations of checkpoint inhibitors with other treatment modalities should be explored when a scientific rationale indicates that they could be efficacious in paediatric cancers and not because these combinations are being evaluated in adults. Immunotherapy in the form of engineered proteins (e.g. monoclonal antibodies and T cell engaging agents) and cellular products (e.g. CAR T cells) has great therapeutic potential for benefit in paediatric cancer. The major challenge for developing checkpoint inhibitors for paediatric cancers is the lack of neoantigens (based on mutations) and corresponding antigen-specific T cells. Progress critically depends on understanding the immune macroenvironment and microenvironment and the ability of the adaptive immune system to recognise paediatric cancers in the absence of high neoantigen burden. Future clinical studies of checkpoint inhibitors in children need to build upon strong biological hypotheses that take into account the distinctive immunobiology of childhood cancers in comparison to that of checkpoint inhibitor responsive adult cancers.
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Affiliation(s)
| | - Claudia Rossig
- University Children´s Hospital Muenster, Pediatric Hematology and Oncology, Germany
| | - Giovanni Lesa
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, Amsterdam, the Netherlands
| | | | | | - John Anderson
- UCL Great Ormond Street Institute of Child Health, UK
| | | | | | | | | | | | - Paul Sondel
- The University of Wisconsin, Madison WI, USA
| | | | | | | | | | | | | | | | | | - Jorge Camarero Jiménez
- Agencia Espanola de Medicamentos y Productos Sanitarios and European Medicines Agency, Committee for Medicinal Products for Human Use, Amsterdam, the Netherlands
| | - Pierre Demolis
- Agence Nationale de Sécurité du Médicament et des Produits de Santé and European Medicines Agency, Scientific Advice Working Party and Oncology Working Party, Amsterdam, the Netherlands
| | | | | | | | - Sara Galluzzo
- Agenzia Italiana del Farmaco and European Medicines Agency, Paediatric Committee, Amsterdam, the Netherlands
| | | | - Alessandro Jenkner
- Ospedale Pediatrico Bambino Gesù and European Medicines Agency, Paediatric Committee, Amsterdam, the Netherlands
| | - Dominik Karres
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, Amsterdam, the Netherlands
| | | | - Franca Ligas
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, Amsterdam, the Netherlands
| | | | | | | | | | - Jaroslav Sterba
- University Hospital Brno and European Medicines Agency, Paediatric Committee, Amsterdam, the Netherlands
| | | | | | - Uri Tabori
- Hospital for Sick Children, Toronto, Canada
| | - Cornelis van Tilburg
- KiTZ Clinical Trial Unit, Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ) and Heidelberg University Hospital, Heidelberg, Germany
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Abstract
PURPOSE OF REVIEW We provide an overview of the current landscape of drug development relevant to childhood cancers. We present recent and ongoing efforts to identify therapeutic targets in pediatric cancers. We describe efforts to improve the approach to clinical trials and highlight the role regulatory changes and multistakeholder platforms play in advancing pediatric cancer drug development. RECENT FINDINGS Expanding knowledge of the genetic landscape of pediatric malignancies through clinical genomics studies has yielded an increasing number of potential targets for intervention. In parallel, new therapies for children with cancer have shifted from cytotoxic agents to targeted therapy, with examples of striking activity in patients with tumors driven by oncogenic kinase fusions. Innovative trial designs and recent governmental policies provide opportunities for accelerating development of targeted therapies in pediatric oncology. SUMMARY Novel treatment strategies in pediatric oncology increasingly utilize molecularly targeted agents either as monotherapy or in combination with conventional cytotoxic agents. The interplay between new target identification, efforts to improve clinical trial design and new government regulations relevant to pediatric cancer drug development has the potential to advance novel agents into frontline care of children with cancer.
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