Phase I study of oral irinotecan and temozolomide in children with relapsed high-risk neuroblastoma: A New Approach to Neuroblastoma Therapy (NANT) Consortium study

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Background: Irinotecan (IRN) and temozolomide (TEM) have single-agent activity and schedule-dependent synergy against neuroblastoma. Because intravenous IRN is costly and inconvenient, especially with protracted scheduling common in pediatric trials, we sought to determine the maximum tolerated dose (MTD) of oral IRN combined with TEM in children with recurrent/resistant high-risk neuroblastoma, using the antibiotic cefixime to reduce IRN-associated diarrhea. Methods: Patients received oral TEM on days 1–5 and oral IRN on days 1–5 and 8–12, with courses repeated every 21 days. Oral cefixime 8 mg/kg (max 400 mg/day) was started on day -5 and continued daily. Results: Fifteen patients (median age 7 years, range 2–22) with a median of 3.5 previous treatment regimens were evaluable for toxicity and have to date received 71 courses (median 2, range 1–19+). Neutropenia and thrombocytopenia were dose-limiting in the first 6 patients, and TEM was reduced from 100 to 75 mg/m2/day for all subsequent patients. IRN was then escalated from 30 to 60 mg/m2/day. First-course grade 3 diarrhea was dose-limiting in 1 of 6 patients treated at the IRN MTD of 60 mg/m2/day. Other toxicities were mild and reversible. No grade 4 therapy-related toxicity occurred in 27 courses administered at the MTD. The median SN-38 lactone AUC at this dose was 72 ng*hr/ml, similar to that reported with protracted intravenous IRN at the single-agent MTD. Of 14 patients evaluable for response, one with measurable nodal disease had a very good partial response through 6 courses. Six additional patients had stable disease for a median of 7.5 courses (range 6–19+). Two patients remain on study after 10 and 19 courses. Conclusions: This combination was well tolerated in heavily-pretreated children with resistant neuroblastoma, and 7 (50%) of 14 evaluable patients had response/stable disease for 6 or more courses in this Phase I trial. This all-oral regimen was feasible and resulted in favorable SN-38-lactone exposures. The dose recommended for further study in this patient population is TEM 75 mg/m2/day plus IRN 60 mg/m2/day when given with cefixime.

No significant financial relationships to disclose.

Acute left main coronary artery occlusion. Survival following emergent coronary bypass

Emergent aortocoronary bypass surgery for acute myocardial infarction is controversial. We describe a patient with total occlusion of the left main coronary artery associated with acute anterior wall infarction and refractory cardiogenic shock. The patient underwent successful emergent coronary bypass surgery to manage refractory cardiogenic shock. He has subsequently experienced a prolonged survival (60 months postsurgery). This report suggests that emergent aortocoronary bypass surgery should be considered in patients with acute myocardial infarction with refractory cardiogenic shock in whom other forms of reperfusion are unsuccessful.