Dr Hammoud Mofid Hospital 2/22/2019

High-Risk Neuroblastoma treatment Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

INTRODUCTION Outcome for patients with advanced-stage neuroblastoma or those whose tumors exhibit unfavorable biologic characteristics such as MYCN gene amplification is poor, with survival of only 20% to 35%. Achievement of complete tumor response following induction therapy is associated with improved survival, and escalation in chemotherapy dose intensity improves initial tumor response. Dr Hammoud Mofid Hospital 2/22/2019

However, recent multicenter trials of dose- intensive chemotherapy induction regimens reveal response rates of only 52% to 75%. An alternative strategy is to incorporate new agents with non–crossresistant mechanisms of cytotoxicity into induction therapy. This led to our testing the feasibility of adding cyclophosphamide and topotecan to a backbone dose-intensive induction regimen. Topotecan, an inhibitor of topoisomerase I, has activity against neuroblastoma, potentiates the effects of other DNA damaging agents, and demonstrates a non–cross-resistant mechanism of action. Topotecan has a toxicity profile most notable for dose limiting myelosuppression and can be safely combined with cyclophosphamide. Dr Hammoud Mofid Hospital 2/22/2019

A randomized study of topotecan alone versus topotecan- cyclophosphamide in patients with recurrent neuroblastoma demonstrated a trend toward improved response rate (19% v 32%, respectively), decreased rate of grades 3 or 4 infectious complications, and increased time to tumor progression following topotecan-cyclophosphamide therapy. Early clinical trials estimated a topotecan maximum-tolerated dose of 0.75mg/m2/d daily for 5 days when combined with cyclophosphamide. Xenograft models predict that a higher topotecan systemic exposure (52 to 88 ng/mL/hr), achieved by topotecan dosages of 1.0 to 1.6 mg/m2/d will improve antineuroblastoma tumor activity and support further topotecan dose intensification. We report the feasibility of incorporating dose-intensive topotecan plus cyclophosphamide (TopoCy) into a conventional chemotherapy backbone as a novel induction regimen for newly diagnosed patients with high-risk neuroblastoma. Dr Hammoud Mofid Hospital 2/22/2019

Pharmacokinetically guided topotecan dosing was used to achieve the optimal topotecan systemic exposure suggested by preclinical models. The feasibility of peripheral-blood stem cell (PBSC) mobilization, in vivo PBSC tumor purging following TopoCy, tumor response, and survival rates were determined. Dr Hammoud Mofid Hospital 2/22/2019

Patient Selection PATIENTS AND METHODS Patients had a diagnosis of neuroblastoma or ganglioneuroblastoma verified by histology or demonstration of clumps of tumor cells in bone marrow with increased urinary catecholamine metabolites. Diagnosis, staging, and response assessments were performed according to International Neuroblastoma Staging System (INSS) criteria. Centralized analysis of MYCN gene amplification (defined as more than 10 copies) by fluorescent in situ hybridization and Shimada histology classification was performed. Dr Hammoud Mofid Hospital 2/22/2019

High-risk neuroblastoma included patients with: Patients < 30 years of age at initial diagnosis and without prior systemic therapy were enrolled at one of five participating Children’s Oncology Group (COG) institutions. High-risk neuroblastoma included patients with: INSS stage 3, age>365 days with MYCN amplification and/or unfavorable histology; INSS stage 3, 4, or 4S and age less than 365 days old with MYCN amplification; INSS stage 4 and age>547 days old; INSS stage 4, and age 365 to 547 days old with MYCN amplification, unfavorable histology, and/or diploidy; and age>365 days initially with INSS stage 1, 2, or 4S that progressed to stage 4 without interval chemotherapy. Dr Hammoud Mofid Hospital 2/22/2019

The study protocol and consent forms were approved by each participating hospital’s institutional review board, and signed informed consent was obtained from the patient or parents or guardian, as appropriate, after neuroblastoma diagnosis was confirmed. The protocol was activated on March 29, 2004, and was closed to accrual on November 30, 2005. Dr Hammoud Mofid Hospital 2/22/2019

Treatment Protocol therapy consisted of three phases: induction, consolidation, and maintenance . Induction included six cycles of chemotherapy administered every 21 days or thereafter when absolute neutrophil count (ANC) was > 750/L and platelet count was > 75,000/. Granulocyte colony stimulating factor 5 micg/kg/d was administered 24 hours after completion of chemotherapy until ANC was more than 1,500/L. Doses were based on body-surface area for those who weighed morethan 12 kg oronweight (kg) for those who weighed<12 kg. Topotecan dose was adjusted to achieve a topotecan lactone systemic exposure (ie, area under the curve [AUC]) of 50 to 70 ng/mL/hr. PBSC harvest occurred after cycle 2 or later, if clinically indicated. Surgical resection of residual primary tumor or sites of regional dissemination (nodal disease) occurred after cycle 5. Dr Hammoud Mofid Hospital 2/22/2019

at least partial response (PR) at the end of induction, Patients with : at least partial response (PR) at the end of induction, PBSC product of > 1.5 * 10(6) CD34 cells/kg without evidence of tumor contamination as documented by immunocytochemical a cardiac shortening fraction of > 28% or ejection fraction > 55%, a creatinine clearance or glomerular filtration rate > 60 mL/min/1.73 m2, and serum creatinine less than 1.5 mg/dL proceeded to consolidation chemotherapy (carboplatin, etoposide, and melphalan). Onday 0, PBSCs were infused, and daily granulocyte colony-stimulating factor (5 micg/kg/d) was administered until engraftment (ANC>2,000X3 days). External beam radiotherapy (21.6 Gy in 1.8 Gy fractions) beginning > 28 days following PBSC infusion was administered to the presurgical gross tumor volume and sites of residual disease on the basis of computed tomography scan, magnetic resonance imaging, and/or meta iodo benzyl quanadine (MIBG) scans performed at the end of induction. Maintenance isotretinoin began after day 66 after PBSC infusion and after radiation therapy for 6 months duration. Dr Hammoud Mofid Hospital 2/22/2019

Adverse events were assessed by National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) v3.0. The treating institutions assessed tumor response by using the INSS response criteria for chest, abdomen, or pelvic computed tomography scan, magnetic resonance imaging evaluation, iodine-123 [123I]-MIBG scintigraphy, urinary catecholamine levels, and bone marrow aspirate and biopsy obtained from bilateral iliac crests. Response assessments occurred after induction cycle 2 and at end of induction, consolidation, and maintenance. Patients were followed until they met the criteria for being off study (death, loss to follow-up, entry into another COG therapeutic study, withdrawal of consent for further data submission, or secondary malignancy). Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

RESULTS Patients’ Characteristics Thirty-one patients were enrolled onto the study and all met eligibility requirements (Table 1). The majority of patients were male (81%) and age>18 months (84%), with median age at diagnosis of 30 months (range, 10 months to 9 years). One patient progressed to INSS stage 4 from stage 1 following only surgical resection, three patients had stage 3, and 27 patients had stage 4 neuroblastoma. Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Stem-Cell Harvest PBSCs were successfully collected in 30 patients (> 1.5 * 10(6) CD34+ cells/kg). One patient had disease progression before PBSC collection and went off therapy. Median PBSC collection was 31.1* 10(6) CD34+ cells/kg cells/kg collected over a median of 1 day (range, 1 to 3 days), with 27 collections occurring before cycle 3. Three patients had less than 4 * 10(6) CD34+ cells/kgcells/kg collected; one patient had CD34+ cells/kg collected following cycle 5 of induction at the physician’s discretion. Dr Hammoud Mofid Hospital 2/22/2019

Toxicities No DLTs or deaths related to toxicity occurred during induction. Only one patient required a dose reduction of more than 25% of the intended chemotherapy doses (in cycle 6) because of prolonged myelosuppression. The majority of patients experienced grade 3 or 4 hematopoietic toxicity and febrile neutropenia throughout induction. Mucositis involving the oropharnyx or lower intestinal tract and documented infections were more common during cycles 3 to 6 (30% and 46.7%, respectively) compared with cycles 1 and 2 (9.7% and 9.7%, respectively). Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Feasiblity In summary of the primary end point, all of the induction feasibility rules were met: delivery of intended cycles, no deaths related to toxicity or DLTs, and sufficient PBSC collection with no detectable tumor contamination. Dr Hammoud Mofid Hospital 2/22/2019

Responses A best overall response of complete response (CR), very good partial response (VGPR), or partial response (PR) was achieved in 12 (40%) of 30 evaluated patients following two cycles of induction, 26 (83.8%) of 31 at end of induction, and 21 (87.5%) of 24 at completion of consolidation. Twenty-four patients proceeded to consolidation. The reasons for removing patients from protocol therapy before consolidation were progression (n=1), physician discretion (n = 2), less than PR to induction (n =2), prolonged delay in beginning consolidation due to viral infection (n = 1), and parental refusal (n=1). Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Survival Analysis Fourteen of the 31 patients were alive at last follow-up. Sixteen patients relapsed or progressed, and thirteen of those subsequently died. Four of the 17 deaths on this study were first events. Causes of death included disease (n=15) and stem-cell transplantation– related complications (n=2). The median follow-up time for the 11 patients who did not experience an event was 4.5 years (range, 2.0 to 5.4 years). The overall 3-year EFS and OS rates were 37.8% +/- 9.4% and 57.1% +/- 9.4%, respectively (Fig 2). No statistically significant difference in outcome was found by patient characteristics Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

DISCUSSION The MSKCC regimen’s initial induction cycles— high-dose cyclophosphamide plus doxorubicin and vincristine— cause significant mucosal and infectious toxicities similar to those observed during ANBL02P1 cycles 3 to 6. In comparison, dose intensive TopoCy rarely caused severe mucositis and documented infection and did not limit the ability to deliver the subsequent intended dose-intensive chemotherapy. Dr Hammoud Mofid Hospital 2/22/2019

The use of myeloablative consolidation chemotherapy and autologous bone marrow infusion improves EFS of high-risk neuroblastoma. PBSCs carry less burden of collection and are less likely to contain tumor cells than bone marrow although the optimal timing of PBSC collection remains controversial. Dr Hammoud Mofid Hospital 2/22/2019

Our study confirmed prior results from Bensihom et al that sufficient PBSC cells without tumor contamination can be harvested after two cycles of chemotherapy. Dr Hammoud Mofid Hospital 2/22/2019

Sufficient numbers of stem cells were harvested for a minimum of two PBSC infusions in all but one patient, which was essential when planning the current COG tandem transplantation study. The occurrence of secondary malignancy following intensive neuroblastoma therapy may be related to the mutagenic potential of induction alkylator or topoisomerase 1 inhibitor chemotherapy, further providing a rationale for earlier PBSC harvest. Dr Hammoud Mofid Hospital 2/22/2019

ANBL02P1 induction regimen, patients achieved an overall response rate of 84% and 15 (48%) of 31 patients achieved CR or VGPR. Dr Hammoud Mofid Hospital 2/22/2019

The tolerability of the topotecan-containing induction regimen provides a backbone regimen on which to add such agents. Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019

Dr Hammoud Mofid Hospital 2/22/2019