Interleukin 2 with anti-GD2 antibody ch14.18/CHO (dinutuximab beta) in patients with high-risk neuroblastoma (HR-NBL1/SIOPEN): a multicentre, randomised, phase 3 trial
Immunotherapy with the chimeric anti-GD2 monoclonal antibodydinutuximab, combined with alternating granulocyte-macrophage colony-stimulating factor and intravenous interleukin-2 (IL-2), improves survival in patients with high-risk neuroblastoma. We aimed to assess event-free survival after treatment with ch14.18/CHO (dinutuximab beta) and subcutaneous IL-2, compared with dinutuximab beta alone in children and young people with high-risk neuroblastoma.
Methods
We did an international, open-label, phase 3, randomised, controlled trial in patients with high-risk neuroblastoma at 104 institutions in 12 countries. Eligible patients were aged 1–20 years and had MYCN-amplified neuroblastoma with stages 2, 3, or 4S, or stage 4 neuroblastoma of any MYCN status, according to the International Neuroblastoma Staging System. Patients were eligible if they had been enrolled at diagnosis in the HR-NBL1/SIOPEN trial, had completed the multidrug induction regimen (cisplatin, carboplatin, cyclophosphamide, vincristine, and etoposide, with or without topotecan, vincristine, and doxorubicin), had achieved a disease response that fulfilled prespecified criteria, had received high-dose therapy (busulfan and melphalan or carboplatin, etoposide, and melphalan) and had received radiotherapy to the primary tumour site. In this component of the trial, patients were randomly assigned (1:1) to receive dinutuximab beta (20 mg/m2 per day as an 8 h infusion for 5 consecutive days) or dinutuximab beta plus subcutaneous IL-2 (6 × 106 IU/m2 per day on days 1–5 and days 8–12 of each cycle) with the minimisation method to balance randomisation for national groups and type of high-dose therapy. All participants received oral isotretinoin (160 mg/m2 per day for 2 weeks) before the first immunotherapy cycle and after each immunotherapy cycle, for six cycles. The primary endpoint was 3-year event-free survival, analysed by intention to treat. This trial was registered with ClinicalTrials.gov, number NCT01704716, and EudraCT, number 2006-001489-17, and recruitment to this randomisation is closed.
Findings
Between Oct 22, 2009, and Aug 12, 2013, 422 patients were eligible to participate in the immunotherapy randomisation, of whom 406 (96%) were randomly assigned to a treatment group (n=200 to dinutuximab beta and n=206 to dinutuximab beta with subcutaneous IL-2). Median follow-up was 4·7 years (IQR 3·9–5·3). Because of toxicity, 117 (62%) of 188 patients assigned to dinutuximab beta and subcutaneous IL-2 received their allocated treatment, by contrast with 160 (87%) of 183 patients who received dinutuximab beta alone (p<0·0001). 3-year event-free survival was 56% (95% CI 49–63) with dinutuximab beta (83 patients had an event) and 60% (53–66) with dinutuximab beta and subcutaneous IL-2 (80 patients had an event; p=0·76). Four patients died of toxicity (n=2 in each group); one patient in each group while receiving immunotherapy (n=1 congestive heart failure and pulmonary hypertension due to capillary leak syndrome; n=1 infection-related acute respiratory distress syndrome), and one patient in each group after five cycles of immunotherapy (n=1 fungal infection and multi-organ failure; n=1 pulmonary fibrosis). The most common grade 3–4 adverse events were hypersensitivity reactions (19 [10%] of 185 patients in the dinutuximab beta group vs 39 [20%] of 191 patients in the dinutuximab plus subcutaneous IL-2 group), capillary leak (five [4%] of 119 vs 19 [15%] of 125), fever (25 [14%] of 185 vs 76 [40%] of 190), infection (47 [25%] of 185 vs 64 [33%] of 191), immunotherapy-related pain (19 [16%] of 122 vs 32 [26%] of 124), and impaired general condition (30 [16%] of 185 vs 78 [41%] of 192).
Interpretation
There is no evidence that addition of subcutaneous IL-2 to immunotherapy with dinutuximab beta, given as an 8 h infusion, improved outcomes in patients with high-risk neuroblastoma who had responded to standard induction and consolidation treatment. Subcutaneous IL-2 with dinutuximab beta was associated with greater toxicity than dinutuximab beta alone. Dinutuximab beta and isotretinoin without subcutaneous IL-2 should thus be considered the standard of care until results of ongoing randomised trials using a modified schedule of dinutuximab beta and subcutaneous IL-2 are available.
Funding
European Commission 5th Frame Work Grant, St. Anna Kinderkrebsforschung, Fondation ARC pour la recherche sur le Cancer.
Introduction
Neuroblastoma is a paediatric extracranial malignancy of the sympathetic nervous system that is responsible for 12% of childhood cancer deaths.1, 2 High-risk neuroblastoma, which is defined by the presence of metastatic disease in children older than 12 or 18 months2 or the MYCN amplification (MNA) in patients of any age, is associated with 5-year survival of only 40%.3, 4 Current therapeutic approaches consist of intensive induction,5, 6 high-dose chemotherapy, and autologous stem-cell rescue as consolidation treatment,4, 7 and isotretinoin for minimal residual disease therapy. Treatment with the human and mouse chimeric antibody ch14.18, directed against disialoganglioside GD2, has been developed as an important option in the treatment phase for patients with minimal residual disease.8, 9 GD2 is expressed on most neuroblastoma cells, and in normal human tissues is only expressed by neurons, skin melanocytes, and peripheral sensory nerve fibres, which make GD2 a suitable target for immunotherapy.8
In Europe, ch14.18 was recloned in Chinese hamster ovary (CHO) cells (dinutuximab beta)10 and made available for clinical trials of the International Society of Paediatric Oncology Europe Neuroblastoma (SIOPEN) group. A phase 1 study of dinutuximab beta11 showed tolerability and activity in a regimen of 20 mg/m2 given by an 8 h infusion on 5 consecutive days.
Research in context
Evidence before this study
Preclinical and preliminary clinical data indicate that monoclonal antibodies against the tumour-associated disialoganglioside GD2 have activity against neuroblastoma, which was enhanced when the monoclonal antibody (ch14.18) was combined with either granulocyte-macrophage colony- stimulating factor (GM-CSF) or interleukin 2 (IL-2). A randomised front-line trial in patients with high-risk neuroblastoma comparing the addition of ch14.18 derived from SP2/0 hybridoma cells (ch14.18/SP2/0, dinutuximab), GM-CSF, and IL-2 to standard of care (oral isotretinoin), versus isotretinoin alone in residual disease therapy, showed a survival benefit in the immunotherapy group. However, the role of cytokines in this context remained unclear. The International Society of Paediatric Oncology European Neuroblastoma Group recloned ch14.18 in Chinese hamster ovary cells (ch14.18/CHO, dinutuximab beta) and investigated its safety and tolerability. Because IL-2 has the ability to increase the number of natural killer cells and to enhance antibody-dependent cell-mediated cytotoxicity, we decided to study the combination of IL-2 with dinutuximab beta to assess the effect on survival. A feasible, safe, and effective dose for subcutaneous IL-2 had been established in a phase 1/2 trial. We searched PubMed on Jan 15, 2002, and Oct 1, 2007, for all publications with the terms “neuroblastoma”, “randomised”, and “chimeric anti-GD2 antibody” with no language or date restrictions. We found one trial, which compared the addition of a monoclonal antibody against GD2, added to chemotherapy in the relapse setting. We did not find any randomised trials comparing different immunotherapy regimens in front-line patients during residual disease.
Added value of this study
The addition of subcutaneous IL-2 (6 x 106 IU/m2) to dinutuximab beta (5 x 20 mg/m2 per day, in an 8 h infusion) in patients with high-risk neuroblastoma who had responded to induction and consolidation treatment did not increase event-free survival or overall survival, suggesting that this combination in this schedule has no therapeutic benefit. Furthermore, we noted an increased inflammatory toxicity profile in the group receiving IL-2. Dinutuximab beta with isotretinoin was associated with objective responses in patients with residual, evaluable disease. This study adds information to optimise therapeutic schedules that use monoclonal antibodies against GD2, and highlights the respective contributions of cytokine and antibody to efficacy and toxicity.
Implications of all the available evidence
Monoclonal antibodies against the tumour-associated disialoganglioside GD2 improve survival in patients with high-risk neuroblastoma. However, the addition of subcutaneous IL-2 to dinutuximab beta did not improve outcomes and increased toxicity. Further clinical trials of different dosing schedules and combinations are required to optimise the benefit of immunotherapy with anti-GD2 monoclonal antibodies in high-risk neuroblastoma.
On March 15, 2006, SIOPEN started a randomised trial (HR-NBL1/SIOPEN) comparing dinutuximab beta and isotretinoin with isotretinoin alone in children with high-risk neuroblastoma who had received dose-intensive induction, surgical excision of the primary tumour, high-dose chemotherapy followed by autologous stem-cell rescue, and local radiotherapy. However, on April 15, 2007, the Children's Oncology Group first became aware of the early results of their ANBL0032 study (NCT00026312) and later reported that the addition of a ch14.18 antibody produced in SP2/0 cells (dinutuximab), combined with cytokines (granulocyte–macrophage colony-stimulating factor [GM-CSF] and interleukin 2 [IL-2]), in addition to isotretinoin, improved 2-year event-free survival by 20% and overall survival by 11% in patients with high-risk neuroblastoma.8 In this three-drug regimen the individual contribution to efficacy of each of the drugs was unknown, and the combination was associated with substantial toxicity, including pain, fever, allergic reactions, and capillary leak syndrome.
In view of these results, continuation of the SIOPEN trial comparing dinutuximab beta and isotretinoin to isotretinoin alone was deemed neither feasible nor ethical. Clinical and preclinical data suggested that IL-2 in addition to ch14.18 had a positive immunomodulatory effect.12 Because subcutaneous IL-2 (6 × 106 IU/m2 per day) was associated with mild toxicity and little discomfort in adults and could be administered in an outpatient setting,13 SIOPEN adopted this schedule in a dose-finding study and showed that the regimen of 6 × 106 IU/m2 per day of subcutaneous IL-2 was acceptable in children with high-risk neuroblastoma when administered on 5 consecutive days in five intermittent courses over 3 months.14 Additionally, GM-CSF was neither licensed nor available in Europe, so the HR-NBL1/SIOPEN trial was amended to randomly assign patients to receive either dinutuximab beta and subcutaneous IL-214 with oral isotretinoin or dinutuximab beta with oral isotretinoin, to investigate the role of subcutaneous IL-2 in improving event-free survival in children with high-risk neuroblastoma.
Section snippets
Study design and participants
The HR-NBL1/SIOPEN trial is an international, randomised, open-label, phase 3 trial. The protocol is available online.
Recruitment to all randomised study groups is closed. Results from two randomisations have been published (prophylactic granulocyte colony-stimulating factor during induction; busulfan and melphalan vs carboplatin, etoposide, and melphalan as high-dose chemotherapy6, 7), with two more awaiting data maturity before publication (continuous infusion of dinutuximab beta with or
Results
Between Oct 22, 2009, and Aug 12, 2013, 422 (68%) of 621 patients who had been recruited at SIOPEN member centres and were participating in the HR-NBL1/SIOPEN trial were eligible for random allocation to immunotherapy, of whom 406 (96%) were randomly assigned (n=200 to receive dinutuximab beta, n=206 to receive dinutuximab beta with subcutaneous IL-2; figure 1; appendix pp 2–5). Assignment to immunotherapy was closed after the calculated sample size was reached and data were released by the
Discussion
In this open-label, phase 3, randomised trial, we compared dinutuximab beta and oral isotretinoin to dinutuximab beta combined with subcutaneous IL-2 and oral isotretinoin in patients with high-risk neuroblastoma who responded to induction and consolidation therapy. The addition of subcutaneous IL-2 to dinutuximab beta, in the dose and schedule administered, did not increase event-free survival or overall survival and was associated with increased toxicity.
Evidence for an age cutoff greater than 365 days for neuroblastoma risk group stratification in the Children's Oncology Group
J Clin Oncol
(2005)
D Valteau-Couanet et al.
Long-term results of the combination of the N7 induction chemotherapy and the busulfan-melphalan high dose chemotherapy
Pediatr Blood Cancer
(2014)
KK Matthay et al.
Long-term results for children with high-risk neuroblastoma treated on a randomized trial of myeloablative therapy followed by 13-cis-retinoic acid: a children's oncology group study
J Clin Oncol
(2009)
R Ladenstein et al.
Randomized trial of prophylactic granulocyte colony-stimulating factor during rapid COJEC induction in pediatric patients with high-risk neuroblastoma: the European HR-NBL1/SIOPEN study
J Clin Oncol
(2010)
AL Yu et al.
Anti-GD2 antibody with GM-CSF, interleukin-2, and isotretinoin for neuroblastoma
N Engl J Med
(2010)
N-K V Cheung et al.
Neuroblastoma: developmental biology, cancer genomics and immunotherapy
Nat Rev Cancer
(2013)
R Ladenstein et al.
Ch14.18 antibody produced in CHO cells in relapsed or refractory stage 4 neuroblastoma patients: a SIOPEN phase 1 study
MAbs
(2013)
BM Mueller et al.
Enhancement of antibody-dependent cytotoxicity with a chimeric anti-GD2 antibody
J Immunol
(1990)
NJ Meropol et al.
Daily subcutaneous injection of low-dose interleukin 2 expands natural killer cells in vivo without significant toxicity
Clin Cancer Res
(1996)
R Ladenstein et al.
Dose finding study for the use of subcutaneous recombinant interleukin-2 to augment natural killer cell numbers in an outpatient setting for stage 4 neuroblastoma after megatherapy and autologous stem-cell reinfusion
A basic mathematical model for IL-2-based cancer immunotherapy is proposed and studied. Our analysis shows that the outcome of therapy is mainly determined by three parameters, the relative death rate of CD T cells, the relative death rate of CD T cells, and the dose of IL-2 treatment. Minimal equilibrium tumor size can be reached with a large dose of IL-2 in the case that CD T cells die out. However, in cases where CD and CD T cells persist, the final tumor size is independent of the IL-2 dose and is given by the relative death rate of CD T cells. Two groups of in silico clinical trials show some short-term behaviors of IL-2 treatment. IL-2 administration can slow the proliferation of CD T cells, while high doses for a short period of time over several days transiently increase the population of CD T cells during treatment before it recedes to its equilibrium. IL-2 administration for a short period of time over many days suppresses the tumor population for a longer time before approaching its steady-state levels. This implies that intermittent administration of IL-2 may be a good strategy for controlling tumor size.
Addition of anti-GD2 antibodies to temozolomide-based chemotherapy has demonstrated increased antitumor activity and progression-free survival in patients with relapsed/progressive high-risk neuroblastoma. However, chemo-immunotherapy is not yet approved for this indication. This study presents the chemo-immunotherapy experience in patients with relapsed/progressive high-risk neuroblastoma treated within the off-label use program of the Neuroblastoma Committee of the French Society of Pediatric Oncology (SFCE).
Dinutuximab beta (dB) was administered alongside temozolomide-topotecan (TOTEM) or temozolomide-irinotecan (TEMIRI) at first disease relapse/progression or topotecan-cyclophosphamide (TopoCyclo) at further relapse/progression. Real-world data on demographics, treatment, antitumor activity and safety was collected from all patients after inclusion in SACHA-France (NCT04477681), a prospective national registry, which documents safety and efficacy data on innovative anticancer therapies prescribed to patients ≤ 25 years old as compassionate or off-label use.
Between February 2021 and July 2023, 39 patients with confirmed relapsed/progressive high-risk neuroblastoma (median age 6 years, range 1–24) were treated with dB+TopoCyclo (n = 24) or dB+TOTEM/TEMIRI (n = 15) across 17 centers. In total, 163 chemo-immunotherapy cycles were administered, main toxicities were mild or moderate, with higher incidence of hematological adverse drug reactions with dB+TopoCyclo than dB+TOTEM/TEMIRI. Objective response rate was 42% for dB+TopoCyclo (CI95% 22–63%) and 40% for dB+TOTEM/TEMIRI (CI95% 16–68%).
Similar objective response rates for dB+TopoCyclo and dB+TOTEM/TEMIRI in patients with relapsed/progressive high-risk neuroblastoma emphasize the importance of chemo-immunotherapy, irrespective of the chemotherapy backbone.
Metronomic chemotherapy refers to the consistent and regular administration of low-dose chemotherapeutic agents over an extended period, with minimal or no extended drug-free intervals. The effectiveness of metronomic chemotherapy is derived from its capacity to impede tumor angiogenesis and foster antitumor immune responses, rather than merely interrupting tumor cell mitosis. Metronomic chemotherapy has been applied in the treatment of neuroblastoma for decades, including patients with newly diagnosed high-risk neuroblastoma and relapsed or refractory neuroblastoma. In the modern era of neuroblastoma treatment, metronomic chemotherapy remains a viable option for maintenance therapy in newly diagnosed neuroblastoma patients without access to autologous stem cell transplantation or immunotherapy, especially in resource-limited regions. For relapsed or refractory patients, metronomic chemotherapy is a suitable alternative for individuals intolerant to intensified treatments or receiving palliative care. Cyclophosphamide, etoposide, vinca alkaloids, and celecoxib constitute the primary components of current metronomic chemotherapy. Given the need for additional research to determine the optimal regimen, comprehensive studies must be conducted to explore and establish standardized metronomic chemotherapy protocols. Additionally, investigating potential biomarkers and clinical prognostic factors is imperative for future advancements in this field.
Chimeric antigen receptor (CAR) T cell therapy is a medical breakthrough in the treatment of B cell malignancies. There is intensive focus on developing solid tumor-targeted CAR-T cell therapies. Although clinically approved CAR-T cell therapies target B cell lineage antigens, solid tumor targets include neoantigens and tumor-associated antigens (TAAs) with diverse roles in tumor biology. Multiple early-stage clinical trials now report encouraging signs of efficacy for CAR-T cell therapies that target solid tumors. We review the landscape of solid tumor target antigens from the perspective of cancer biology and gene regulation, together with emerging clinical data for CAR-T cells targeting these antigens. We then discuss emerging synthetic biology strategies and their application in the clinical development of novel cellular immunotherapies.
This study evaluated the abdominal aortic diameter in high-risk neuroblastoma (NB) patients and the risk of aortic narrowing following intensive treatment.
We measured the aortic diameter at four specific levels of the abdominal aorta (diaphragmatic crus, celiac axis, and the root of the superior (SMA) and inferior (IMA) mesenteric arteries) on contrast CT scans. The control group consisted of 56 children with non-oncologic disorders, while the NB group included 35 patients with high-risk abdominal NB. We used regression analysis of age and aortic diameter to determine the regression formula for each level in each group and performed intergroup comparisons using t-test.
We evaluated a total of 160 contrast-enhanced CTs performed in the 35 eligible cases. The aortic diameter of pretreated NB patients was not significantly different from the controls. After receiving any treatment, the aortic diameter was significantly smaller in the NB group (p < 0.01 each). Patients who underwent radical surgery, particularly gross total resection (n = 26), had smaller aortic diameters at all levels compared to controls (p < 0.01 each). Patients treated with radiotherapy (RT) had smaller aortic diameters than controls. External beam radiotherapy (EBRT) patients (n = 24) had smaller aortic diameters at all levels except the celiac axis (crus, SMA, IMA; p < 0.01 each), and intraoperative radiotherapy (IORT) ± EBRT patients (n = 5) had smaller aortic diameters at all levels (p < 0.01 each).
Patients with NB may experience impaired development of the abdominal aorta after multimodal therapy, particularly after RT. Close observation and long-term follow-up is essential to monitor for catastrophic vascular complications.
