Dinutuximab for the Treatment of Pediatric Patients with High-Risk Neuroblastoma

Expert Review of Clinical Pharmacology

ISSN: 1751-2433 (Print) 1751-2441 (Online) Journal homepage: http://www.tandfonline.com/loi/ierj20

Dinutuximab for the treatment of pediatric patients with high-risk neuroblastoma

Jaume Mora

To cite this article: Jaume Mora (2016): Dinutuximab for the treatment of pediatric patients with high-risk neuroblastoma, Expert Review of Clinical Pharmacology, DOI: 10.1586/17512433.2016.1160775

To link to this article: http://dx.doi.org/10.1586/17512433.2016.1160775

Accepted author version posted online: 02 Mar 2016. Published online: 21 Mar 2016.

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Download by: [Hospital Sant Joan de Deu], [Jaume Mora] Date: 30 March 2016, At: 23:12 EXPERT REVIEW OF CLINICAL PHARMACOLOGY, 2016 http://dx.doi.org/10.1586/17512433.2016.1160775

DRUG PROFILE Dinutuximab for the treatment of pediatric patients with high-risk neuroblastoma Jaume Mora Department of Pediatric Onco-Hematology and Developmental Tumor Biology Laboratory, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, Barcelona, Spain

ABSTRACT ARTICLE HISTORY Neuroblastoma (NB) is the most common extra cranial solid tumor of childhood, with 60% of patients Received 14 December 2015 presenting with high risk (HR) NB by means of clinical, pathological and biological features. The 5-year Accepted 29 February 2016 survival rate for HR-NB remains below 40%, with the majority of patients suffering relapse from Published online chemorefractory tumor. Immunotherapy is the main strategy against minimal residual disease and 21 March 2016 clinical experience has mostly focused on monoclonal antibodies (MoAb) against the glycolipid dis- KEYWORDS ialoganglioside GD2. Three anti-GD2 antibodies have been tested in the clinic including murine 14G2a, Neuroblastoma; anti-GD2 human-mouse chimeric ch14.18 and 3F8. Anti-GD2 MoAb induces cellular cytoxicity against NB and is immunotherapy; most effective when effector cells like natural killer cells, granulocytes and macrophages are amplified dinutuximab; GM-CSF; by cytokines. The combination of cytokines IL-2 and GM-CSF with the anti-GD2 MoAb ch14.18 Interleukin 2; chimeric (Dinutuximab) has shown a significant improvement in outcome for HR-NB. The FDA and EMA antibodies; orphan drugs; ’ approved dinutuximab (UnituxinR) in 2015 for the treatment of patients with HR-NB who achieved at children s cancer; Unituxin least a partial response after multimodality therapy.

Disease background Immunotherapy Neuroblastoma (NB) is the most common extracranial solid Immunotherapy has been tested over the last 3 decades as a tumor of childhood, with 50–60% of patients presenting potential strategy against systemic MRD. Most of the clinical with high-risk (HR) NB by means of clinical, pathological, experience with immunotherapy of NB has focused on mono- and biological features [1]. Currently, therapy for HR-NB clonal antibodies (MoAbs) against NB cell membrane antigens includes induction treatment with chemotherapy and sur- including cell adhesion molecules NCAM and L1-CAM, B7-H3 gery, consolidation therapy with high-dose multi-agent glycoproteins targeted by the 8H9 MoAb and the glycolipids chemotherapy rescued with autologous stem cell trans- GD2, GD3, and GM3 [18–22]. In 1985, Cheung and colleagues plantation (ASCT) and radiation therapy, and maintenance described for the first time four MoAbs against, at the time, an therapy to manage minimal residual disease (MRD). unknown glycolipid antigen on the surface of human NB cells Intensive induction chemotherapy and aggressive surgery [23]. The murine IgG3 anti-GD2 MoAb 3F8 was initially devel- have improved remission rates in young patients [2–4]; oped by undergoing subsequent extensive preclinical testing results have been modest in adolescents in whom NB is eventually being the first anti-GD2 MoAb to be administered especially chemoresistant [5,6]. Despite intensive multimo- to patients with HR-NB [24]. dal therapy, long-term survival rates for HR-NB remain at GD2 is a ganglioside which are acidic glycolipids found on 30–40%. The complete eradication of NB is rarely achieved the outer cell membrane. They are concentrated in nervous and the majority of patients with HR-NB suffer a relapse tissues where they serve as membrane receptors for viruses Downloaded by [Hospital Sant Joan de Deu], [Jaume Mora] at 23:12 30 March 2016 from chemorefractory residual tumor cells [7]. and are important for cell adhesion [25,26]. GD2 is biosynthe- Postsurgical use of local radiotherapy helps control MRD in sized from precursor gangliosides GD3/GM3 by the β-1,4-N- the primary site [8]. Myeloablative therapy with ASCT has been acetyl-galactosaminyltransferase (GD2 synthase) [27] and is the most common approach for eradicating MRD in distant expressed in most NB regardless of stage, and is highly abun- sites [9]. A randomized CCG study yielded improved results dant, with an estimated 5–10 million molecules/cell (Figure 1) using total body irradiation (TBI) within the cytoreductive regi- [29]. Therapeutic responses were obtained in Phase I and II men of ASCT [10]. Due to toxicity concerns, TBI is no longer studies of different anti-GD2 MoAbs such as 3F8, murine IgG2 used [11–14], nonetheless ASCT has become the standard MoAb 14G2a, and human-mouse chimeric MoAb ch14.18 approach for MRD management in HR-NB. Extensive experi- [24,30–36]. Ch14.18 was constructed by combining the vari- ence, however, has shown an uncertain benefit of ASCT for able regions of original murine IgG3 anti-GD2 MoAb 14.18 and refractory NB, and recent updates of overall survival (OS) data the constant regions of human IgG1 (Figure 2)[38]. In a Phase appear to question the effectiveness of ASCT for MRD control I clinical trial reported by Yu and colleagues, 10 HR-NB in HR-NB patients [15–17]. patients received a total of 19 courses of anti-GD2 MoAb

rarely noted at low dosages [35]. The pain associated with anti- GD2 therapy is similar to other neuropathic pain syndromes and is relatively opioid-resistant. Other toxicities include hypo- natremia, hypokalemia, nausea, vomiting, diarrhea, serum sick- ness, and occasional changes in pupil reaction to light and accommodation [42,43].

Anti-GD2 immunotherapy and cytokines By activating ADCC to kill NB, anti-GD2 MoAbs are most efficient when effector cell populations including natural killer (NK), granulocytes, and macrophages are amplified by cytokines (Figure 3). Since NK cells and granulocytes are effectors for ADCC, the cytokines IL-2 and GM-CSF were administered in combination with anti-GD2 MoAbs to enhance their activity. GM-CSF has been shown both in vitro and in vivo to enhance antitumor immunity through direct activation of Figure 1. Neuroblastoma tissue cryosection (5 µm) immunofluorescence staining of the cytoplasmic membrane (in green) with anti-GD2 antibody (1:800; BD, monocytes, macrophages, dendritic cells, and ADCC [57], and US). Intense and universal staining of all neuroblastic cells is seen reflecting the indirect T-cell activation via tumor necrosis factor, interferon, estimated 5–10 million GD2 molecules per cell. Nuclei counterstaining per- and IL-1 (Figure 3)[44,46–49,57,58]. GM-CSF may enhance formed with 406-diamino-2-phenylindole (DAPI), showing in blue. For protocol details see Acosta S. et al [28]. functions of cells critical for immune activation against tumor cells, alone or with other cytokines or MoAbs, making it an important agent in cancer biotherapy. GM-CSF-dependent ADCC was studied in 34 patients with a variety of tumors post-ASCT including 3 with NB [50]. A significant increase in monocyte-mediated ADCC following GM- CSF therapy was documented. GM-CSF has the potential for amplifying anti-GD2 MoAb antitumor activity in patients via its effects on granulocytes and tissue-based macrophages. Granulocyte production is only transiently suppressed with chemotherapy and GM-CSF increases numbers of circulating neutrophils and eosinophils but does not affect complement Figure 2. Schema depicting the composition of different monoclonal antibodies levels, and is well tolerated [45]. Granulocytes from patients (MoAb). Murine (in red) IgG2a 14G2a is a switch (from original IgG3b) variant of the receiving chemotherapy and from normal volunteers are effec- murine anti-GD2 MoAb 14.18. Chimeric Ch14.18 was constructed by combining the tive in mounting ADCC against NB cells via non-oxidative variable regions of original murine (in red) IgG3b anti-GD2 MoAb 14.18 and the – constant regions of human (in blue) IgG1. The original murine IgG3 MoAb 3F8 (not mechanisms, and GM-CSF enhances this cytotoxicity [44,46 shown) was recently humanized (hu3F8) based on complementarity determining 50]. Eosinophilic infiltration of some cancers has favorable region grafting technology (consult reference [37]) and is currently in Phase I/II prognostic significance, and eosinophils exhibit potent antitu- clinical trials. The human IgG molecule is shown in blue. mor activity in animal models. Activated monocytes-macrophages efficiently phagocytose NB cells and exposure in vitro or in vivo to GM-CSF primes monocytes-macrophages for ch14.18 at doses of 10–200 mg/m2/course. One partial greater antineoplastic cytotoxicity [44,46–49]. GM-CSF response (PR) and four mixed responses were observed in enhances the proliferation, maturation, and function of anti- Downloaded by [Hospital Sant Joan de Deu], [Jaume Mora] at 23:12 30 March 2016 nine evaluable patients [35]. Another Phase I trial of ch14.18 gen-presenting cells. This includes antigen processing and by Handgretinger et al. used 30–50 mg/m2/day × 5 days/ presentation by macrophages and dendritic cells effects that course, and two complete and two PR in nine patients were might promote induction, or antitumor activity, of an idiotypic reported [39]. network [44,46–49]. The biological activities of the anti-GD2 MoAb ch14.18 in Importantly, the addition of GM-CSF to anti-GD2 MoAbs vivo have been demonstrated by the capacity of post-infusion has led to remarkable responses in patients with refractory sera to mediate complement dependent cytotoxicity [35]and NB [57,59,60]. The analysis of 53 patients with bone marrow antibody-dependent cellular cytoxicity (ADCC) [40,41]. (BM) disease refractory to conventional treatment showed that Pharmacokinetic and immunological studies showed the differ- 85% achieved BM complete remission (CR) and 9/14 had ences between the anti-GD2 MoAbs; for instance ch14.18 has a normalization of MIBG scans after therapy with MoAb longer plasma half-life [33,42] and less immunogenicity when 3F8 + GM-CSF [60]. Toxicities were similar to those observed compared to the murine MoAb 14G2a (Figure 2). However, with Phase I studies of MoAb 3F8 alone. Subsequently, a Phase toxicities of all anti-GD2 MoAbs were similar in all early studies II trial compared the efficacy of intravenous (iv) versus sub- [31,32,34,35,43]. The most common toxicities include difficult to cutaneous (sc) GM-CSF in combination with MoAb 3F8 in treat pain, tachycardia, hypertension, hypotension, fever, and patients with refractory NB. sc GM-CSF showed better efficacy urticaria. Many of these toxicities are dose-dependent and are as compared to iv administration. Retrospective review of the EXPERT REVIEW OF CLINICAL PHARMACOLOGY 3

Figure 3. Anti-GD2 immunotherapy of neuroblastoma based on the innate immune system. In the presence of anti-GD2 MoAbs neuroblastoma cells become susceptible to natural killer (NK) cell mediated antibody-dependent cell mediated cytotoxicity (ADCC); granulocyte mediated ADCC; and monocyte-macrophage mediated cytotoxicity. GM-CSF enhances antitumor immunity through direct activation of (monocytes) macrophages, dendritic cells and granulocytes [44]. GM-CSF increases the numbers of circulating neutrophils and eosinophils [45] and GM-CSF enhances the ADCC of granulocytes against neuroblastoma cells [43,45–49]. IL-2 activates NK cells generating lymphokine-activated killer (LAK) cells augmenting ADCC [41,51–56].

experience with MoAb 3F8 plus sc GM-CSF and oral cis-reti- that overall, the reports using IL-2 for the treatment of HR-NB noic acid (CRA) showed a 5-year progression-free survival (PFS) were feasibility and toxicity studies in the post-ASCT setting rate of 62% and OS of 81% in patients with HR-NB treated in and were not designed to answer antitumor efficacy first remission [60]. Nevertheless, a final proof of the contribu- [57,58,61–64]. The most recent data challenge the use of IL- tion of GM-CSF has not been tested in a randomized trial. 2 on the basis of a randomized trial using long-term infusion IL-2 (Aldesleukin) causes activation of NK cells, generation of cho14.18 combined with or without sc IL-2 for relapsed or of lymphokine-activated killer cells and augments ADCC refractory NB patients [65]. The addition of IL-2 increased (Figure 3)[41,51–56]. An early Phase II trial with IL-2 showed pain and did not enhance anti-GD2 cytotoxicity which there- a modest antitumor effect as a single agent [61]. IL-2 was fore did not support the use of IL-2 as a co-stimulatory administered to children with refractory solid tumors and no cytokine for anti-NB purposes. antitumor effects were observed in children with sarcomas or NB, whereas one of five children with renal cell carcinoma had CR. IL-2 was administered post-ASCT in a variety of The convincing proof of anti-GD2 immunotherapy diseases including NB [56,62] to eradicate the residual malignant cells via immune activation. At the time, the CCG-0935 Although MoAb 3F8 plus sc GM-CSF and oral CRA without IL-2 Phase I study of MoAb ch14.18 + GM-CSF [57] was amended in a series of single-arm studies showed an unprecedented to substitute IL-2 for GM-GSF in alternate cycles [58]. After PFS and OS among patients with HR-NB [60], the definitive engraftment, patients were given ch14.18 at 40 mg/m2 with proof of efficacy for anti-GD2 immunotherapy could not be GM-CSF (Courses 1 and 3) or 20 mg/m2 with IL-2 (Course 2). ascertained until a randomized control study was carried out. However, an increase in toxicities was observed including The Cooperative German Neuroblastoma trials NB90 and NB97 Downloaded by [Hospital Sant Joan de Deu], [Jaume Mora] at 23:12 30 March 2016 pain,fever,capillaryleak,O2 requirement due to capillary with the antibody ch14.18 showed initially controversial leak, hypotension, mild reversible increased hepatic transa- results. Antibody ch14.18 was applied as consolidation treat- minases, and infection. Subsequently, the antibody dose was ment in pilot patients of the NB90 and all HR patients of the changed to 25 mg/m2 for both the GM-CSF and IL-2 cycles NB97 trials. Early analysis did not demonstrate reduction of and the IL-2 dose was reduced in an attempt to decrease the event-free survival (EFS) [43]. A longer follow-up analysis, capillary leak. A total of 25 patients were enrolled. The MTD however, suggested a benefit of antibody ch14.18-based con- of MoAb ch14.18 was determined to be 25 mg/m2/day for solidation therapy compared to no consolidation therapy on 4 days alternated with 4.5 × 106 U/m2/day of IL-2 for 4 days. EFS and OS [66]. The 9-year EFS rates were 41%, 31%, and 32% IL-2 was also administered at a dose of 3 × 106 U/m2/day for for ch14.18, NB90 maintenance chemotherapy, and no conso- 4daysstarting1weekbeforeMoAb ch14.18. Two patients lidation, respectively (p = 0.098). Antibody ch14.18 treatment experienced dose-limiting toxicity due to ch14.18 and IL-2. as consolidation improved the long-term outcome compared Common toxicities included pain, fever, nausea, emesis, diar- to no additional therapy (p = 0.038) [66]. rhea, urticaria, mild elevation of hepatic transaminases, capil- In 2010, the Children’s Oncology Group (COG) reported a lary leak syndrome, and hypotension. These findings randomized Phase 3 study in which 226 patients with HR-NB in indicated that MoAb ch14.18 in combination with IL-2 was remission after ASCT were randomized to receive immunother- tolerable in the early post-ASCT period. It is relevant to note apy or CRA alone [67]. Patients on the immunotherapy arm 4 J. MORA

received MoAb ch14.18 at 25 mg/m2/day for four consecutive from the vial and the exact volume for the 17.5 mg/m2/day days in five consecutive 4-week cycles; GM-CSF at 250 µg/m2/ dose injected into a 100 mL bag of 0.9% sodium chloride. The day for 14 days (starting 3 days before ch14.18) in cycles 1, 3, supplied dinutuximab does not require filtration during pre- and 5; IL-2 at 3.0 × 106 IU/m2/day for 4 days in week 1 and at paration nor does it need to be protected from light during 4.5 × 106 IU/m2/day in week 2; and CRA at 160 mg/m2/day in administration. Vials should be stored in the original container the last 2 weeks of all six cycles. Patients in the standard tightly closed at 2–8°C. Dinutuximab is stable at room tem- chemotherapy group received CRA at 160 mg/m2/day in the perature for at least 24 h when diluted to a concentration last 2 weeks of all six cycles. At a median follow-up of 2.1 years, between 0.044 and 0.56 mg/mL; however, the final dosage MoAb ch14.18 recipients (n = 113) had significantly higher EFS form should be prepared immediately prior to administration rates (66 vs. 46%; p = 0.01) and OS rates (86 vs. 75%; p =0.02) as there is a maximum infusion time of 20 h. The minimum compared with standard therapy recipients (n = 113). Since infusion time is 10 h. Stability data were conducted utilizing an then, a Phase 3 safety trial (NCT01041638; ANBL0931) in newly iv bag composed of polyvinyl chloride and bis(2-ethylhexyl) diagnosed HR-NB patients who achieved at least PR to induc- phthalate (DEHP). No data are available on the stability of tion therapy and received consolidation with ASCT (n =105) dinutuximab in polypropylene syringes and polyolefin iv was conducted with maintenance treatment for all patients bags (freeflex®), within the range of 0.044–0.56 mg/mL [71]. with MoAb ch14.18 (5 cycles) in combination with GM-CSF The pharmacokinetics of ch14.18 was assessed in a Phase I (cycles 1, 3, 5), IL-2 (cycles 2, 4), and CRA (6 cycles). Updates trial in 10 children with NB and 1 adult with osteosarcoma from the original data have shown a consistent 2-year EFS and [34], and a pharmacokinetic analysis of 14 children [72] parti- OS rates of 74% and 84%, respectively [68]. However, the 4-year cipating in the pivotal Phase 3 trial [67]. A population pharma- (from randomization) EFS rate was not anymore significant cokinetic analysis was based on a clinical study (NCT01592045) (p = 0.1) but the 4-year OS rate still remained significantly in 27 children with HR-NB who received 5 cycles of treatment improved (p = 0.02) with immunotherapy [69]. with dinutuximab 17.5 mg/m2/day as an iv infusion over 10–20 h for four consecutive days every 28 days in combination with GM-CSF, IL-2, and CRA. In this study, the observed From chimeric MoAb ch14.18 to dinutuximab maximum plasma concentration of dinutuximab was (unituxin®) 11.5 mcg/mL, mean volume of distribution at steady state In July 2010, United Therapeutics Corporation (UTC) initiated a 5.4 L, clearance 0.21 L/day (which increased with body size) Cooperative Research and Development Agreement (CRADA) with a terminal elimination half-life 10 days [73]. with the National Cancer Institute (NCI), USA to collaborate on the late-stage development and commercialization of MoAB Expert commentary ch14.18. As such, under the CRADA, UTC had exclusive rights to the technical information required to manufacture compar- It has taken precisely 30 years from the discovery of anti-GD2 able MoAb ch14.18 in the murine myeloma cell line SP2/0. antibodies in 1985 by Cheung and colleagues [23] to the US and Since then, UTC has developed the manufacturing process to EU regulatory agencies approval of dinutuximab in 2015. produce MoAb ch14.18 (named dinutuximab) comparable to Although we should congratulate this extraordinary advance that from the NCI and on a commercial scale [70]. UTC has for a rare, orphan disease with such poor prognosis, many issues sponsored one Phase 2 study with dinutuximab in combina- remain unresolved with several uncertainties for the future. tion with GM-CSF, IL-2, and CRA for HR-NB patients, Protocol Dinutuximab has been approved in combination with GM- DIV-NB-201, designed to compare the pharmacokinetic profile CSF, IL-2, and CRA in the context of post-ASCT. Recently, an of ch14.18 manufactured by two independent facilities; UTC update of the initially reported long-term OS advantage for and NCI. This study also compared the safety and toxicity ASCT in the randomized CCG study [15] was shown to no profile of UTC-manufactured dinutuximab versus NCI-manu- longer support the OS advantage for ASCT [16]. Therefore, factured ch14.18. On 10 March 2015, the US FDA and on the the corrected results do not support the long-standing recom- Downloaded by [Hospital Sant Joan de Deu], [Jaume Mora] at 23:12 30 March 2016 14 August 2015, the European Medicines Agency (EMA)- mendation of ASCT as the systemic consolidative treatment approved iv dinutuximab, in combination with GM-CSF, IL-2, for HR-NB patients. In this context, the value of immunother- and CRA for the treatment of pediatric patients with HR-NB apy as the sole modality for managing MRD should be who achieved at least PR with prior first-line multi agent, revisited. multimodality therapy. Dinutuximab is now Unituxin®, a regis- The role of each of the cytokines with which dinutuximab tered trademark from UTC. has been approved remains to be clarified. IL-2 has not shown The recommended dosage of dinutuximab is 17.5 mg/m2/ antitumor activity when used as a single agent against NB and day administered iv over 10–20 h for four consecutive days for the significant toxicity associated to its use should promote a maximum of 5 cycles. The infusion of dinutuximab is to be reevaluation. No studies have been performed using dinutux- initiated at a rate of 0.875 mg/m2/h over 30 min and the rate imab and GM-CSF alone; therefore, a study of sc GM-CSF alone can be increased gradually, as tolerated, to the maximum rate with dinutuximab would be of great interest. Furthermore, of 1.75 mg/m2/h. Unituxin® is supplied as a sterile solution in cytokines such as IL-15 have shown similar immune activity single-dose vials containing 17.5 mg/5 mL (3.5 mg/mL) in profiles as of IL-2 and do not cause capillary leak syndrome 20 mM histidine, 150 mM NaCl, 0.05% Tween 20 at pH 6.8. [74]. Future developments should include combinations of Dinutuximab should be diluted with 0.9% sodium chloride for dinutuximab with selected new cytokines with a better toxi- injection prior to iv infusion and the required dose withdrawn city profile to enhance ADCC. EXPERT REVIEW OF CLINICAL PHARMACOLOGY 5

The Phase III study showing improved 2-year EFS and ● Anti-GD2 MoAb activate ADCC to kill NB response more reported in 2010 has been updated by the COG investigators efficiently when effector cell populations of the innate [68,69]. The improvement in EFS appears to decline over time immune system are amplified by cytokines. and the final results on OS are still pending of longer follow-up. ● MoAb ch14.18 (Dinutuximab) is a chimeric anti-GD2 anti- On the other hand, improved OS of HR-NB patients experiencing body produced in the murine myeloma cell line SP2/0. multiple recurrences is currently possible if an active surveillance ● In the first trimester of 2015, the EMA and the FDA program to detect earlier and smaller relapses is implemented. approved dinutuximab, in combination with GM-CSF, IL-2, Therefore, long-term OS may now become a better endpoint to and CRA, for the treatment of pediatric patients with HR-NB. evaluate results for HR-NB than EFS, since the equivalence ● Unituxin® is the registered trademark from United between relapse and lethality may no longer hold true. In this Therapeutics Company. context, the importance of anti-GD2 immunotherapy in improv- Dinutuximab is the first and only approved drug so far for ing OS remains to be formally definitively proven. the treatment of neuroblastoma. Last, but not least, the market price of dinutuximab in the USA was recently set at $150,000 per treatment (five cycles). This is, by Financial and competing interests disclosure all means an abusive cost for a drug that has been developed at the expense of tax-payers in academic centers in the USA. The The author has no relevant affiliations or financial involvement with any market price is now being negotiated in Europe, country by organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes country, but it will not be cheap. The consequences of such are employment, consultancies, honoraria, stock ownership or options, expert multiple, including that most children worldwide will remain testimony, grants or patents received or pending, or royalties. excluded from access to this ‘novel’ therapy. Protecting children is to make sure they readily have access to the best treatments for deadly diseases like HR-NB and it should be a priority of References governments to avoid unethical prices for orphan diseases. Papers of special note have been highlighted as: • of interest •• of considerable interest Five-year view 1. Maris JM, Hogarty MD, Bagatell R, et al. Neuroblastoma. Lancet. 2007;369:2106–2120. Cancer Immunotherapy has revolutionized the adult cancer 2. Pearson ADJ, Craft AW, Pinkerton CR, et al. High-dose rapid sche- field in recent years and was labeled the year discovery in dule chemotherapy for disseminated neuroblastoma. Eur J Cancer. 2013. Drugs targeting specific processes of the T-cell func- 1992;28A:1654–1659. tion have been developed and shown extraordinary anti- 3. Kushner BH, LaQuaglia MP, Bonilla MA, et al. Highly effective tumor effects in selected tumor types, mainly melanoma. induction therapy for stage 4 neuroblastoma in children over one year of age. J Clin Oncol. 1994;12:2607–2613. The so-called immune checkpoint inhibitors represent the 4. La Quaglia MP, Kushner BH, Heller G, et al. Stage 4 neuroblastoma first in class type of drugs that can be developed to modify diagnosed at more than one year of age: Gross total resection and T-cell response against cancer cells. It is said that immunol- clinical outcome. J Pediatr Surg. 1994;29:1162–1166. ogy has come to an age where it meets oncology and all the 5. Franks LM, Bollen A, Seeger RC, et al. Neuroblastoma in adults and understanding that has been gathered over the past adolescents. An indolent course with poor survival. Cancer. 1997;79:2028–2035. 30 years studying anti-GD2 immunotherapy will help in 6. Kushner BH, Cohn SL, Matthay KK, et al. Treatment of neuroblas- devising better and more potent agents against pediatric toma. In: Cheung NKV and Cohn SL. Neuroblastoma. Heidelberg: tumors. We have learnt that native immunotherapy is criti- Springer-Verlag. 2005. p. 173–192. cally distinct from adoptive immunotherapy and a child’s 7. Cheung NK, Dyer MA. Neuroblastoma: developmental biology, immune system relies heavily on the innate system. The cancer genomics and immunotherapy. Nat Rev Cancer. 2013;13:397–411. anti-GD2 MoAb experience has been the leading spear in •• The most recent update of the fundamental biological features this field which I predict will rapidly provide more potent

Downloaded by [Hospital Sant Joan de Deu], [Jaume Mora] at 23:12 30 March 2016 relevant for the treatment of neuroblastoma. and less toxic agents. The recent initial description of potent 8. Kushner BH, Wolden S, LaQuaglia MP, et al. Hyperfractionated low- bivalent GD2 and CD3-bispecific antibodies to redirect T dose (21 Gy) radiotherapy for high-risk neuroblastoma following – cells for enhanced anti-GD2 therapy is one such exam- intensive chemotherapy and surgery. J Clin Oncol. 2001;19:2821 2828. ple [75]. 9. Grupp SA, Asgharzadeh S, Yanik GA. Neuroblastoma: issues in transplantation. Biology Blood Marrow Transplantation. J Am Soc Blood Marrow Transplant. 2012;18:S92–100. Key issues 10. Matthay KK, Villablanca JG, Seeger RC, et al. Treatment of high-risk ● Neuroblastoma is the most common extra cranial solid neuroblastoma with intensive chemotherapy, radiotherapy, auto- – logous bone marrow transplantation, and 13-cis-retinoic acid. tumor of childhood, with 50 60% of patients presenting Children’s Cancer Group. N Engl J Med. 1999;341:1165–1173. with HR features. 11. Park JR, Scott JR, Stewart CF, et al. Pilot induction regimen incor- ● The complete eradication of NB is rarely achieved with porating pharmacokinetically guided topotecan for treatment of conventional multimodality therapy and the majority of newly diagnosed high-risk neuroblastoma: a Children’s Oncology – patients with HR-NB will relapse from chemorefractory resi- Group study. J Clin Oncol. 2011;29:4351 4357. 12. Kreissman SG, Seeger RC, Matthay KK, et al. Purged versus non- dual tumor cells. purged peripheral blood stem-cell transplantation for high risk ● Anti-GD2 MoAb immunotherapy has become a clinically neuroblastoma (COG A3973): a randomised phase 3 trial. Lancet relevant strategy against chemorefractory MRD. Oncol. 2013;14:999–1008. 6 J. MORA

13. Seif AE, Naranjo A, Baker DL, et al. A pilot study of tandem high- 31. Kushner BH, Kramer K, Cheung NKV. Phase II trial of the anti-G(D2) dose chemotherapy with stem cell rescue as consolidation for monoclonal antibody 3F8 and granulocyte macrophage colony-sti- high-risk neuroblastoma: Children’s Oncology Group study mulating factor for neuroblastoma. J Clin Oncol. 2001;19:4189–4194. ANBL00P1. Bone Marrow Transplant. 2013;48:947–952. 32. Handgretinger R, Baader P, Dopfer R, et al. A phase I study of 14. Ladenstein R, Potschger U, Hartman O, et al. 28 years of high-dose neuroblastoma with the anti-ganglioside GD2 antibody 14.G2a. therapy and SCT for neuroblastoma in Europe: lessons from more Cancer Immunol Immunother. 1992;35:199–204. than 4000 procedures. Bone Marrow Transplant. 2008;41S:S118– 33. Murray JL, Cunningham JE, Brewer H, et al. Phase I trial of murine 127. monoclonal antibody 14G2a administered by prolonged intrave- 15. Matthay KK, Reynolds CP, Seeger RC, et al. Long-term results for nous infusion in patients with neuroectodermal tumors. J Clin children with high-risk neuroblastoma treated on a randomized Oncol. 1994;12:184–193. trial of myeloablative therapy followed by 13-cisretinoic acid: a 34. Uttenreuther-Fischer MM, Huang CS, Reisfeld RA, et al. children’s oncology group study. J Clin Oncol. 2009;27:1007–1013. Pharmacokinetics of anti-ganglioside GD2 mAb 14G2a in a phase 16. Errata. J Clin Oncol. 2014;32:1862–1863. I trial in pediatric cancer patients. Cancer Immunol Immunother. •• In a surprisingly brief format, the COG authors of the 2009 1995;41:29–36. article by Matthay et al. updating the results from the rando- 35. Yu A, Uttenreuther-Fischer M, Huang C-S, et al. Phase I trial of a mized trial of myeloablative therapy stated that the p-values human-mouse chimeric anti-disialoganglioside monoclonal anti- were calculated in error. The consequences of this many errors body ch14.18 in patients with refractory neuroblastoma and osteo- have been enormous. sarcoma. J Clin Oncol. 1998;16:2169–2180. 17. Yalçin B, Kremer LC, van Dalen EC. Cochrane Database Syst Rev. 36. Kremens B, Hero B, Esser J, et al. Ocular symptoms in children 2015 Oct 5;10:CD006301. doi:10.1002/14651858.CD006301. pub4. treated with human-mouse chimeric anti-GD2 mAb ch14.18 for Review.PMID:26436598 High-dose chemotherapy and autologous neuroblastoma. Cancer Immunol Immunother. 2002;51:107–110. haematopoietic stem cell rescue for children with high-risk neuro- 37. Cheung NK, Guo H, Hu J, et al. Humanizing murine IgG3 anti-GD2 blastoma. The Cochrane database of systematic reviews. 2013; 8: antibody m3F8 substantially improves antibody dependent cell- CD006301. mediated cytotoxicity while retaining targeting in vivo. • A systematic review of the available data regarding myeloa- OncoImmunology. 2012;1:477–486. blative therapy for HR-NB management concluding that it 38. Gillies SD, Lo K-M, Wesolowski J. High-level expression of chimeric appears to work in terms of event-free survival but not for antibodies using adapted cDNA variable region cassettes. J overall survival. Immunol Methods. 1989;125:191–202. 18. Lipinski M, Hirsch MR, Deagostini-Bazin H, et al. Characterization of 39. Handgretinger R, Anderson K, Lang P, et al. A phase I study of neural cell adhesion molecules (NCAM) expressed by Ewing and human/mouse chimeric anti-ganglioside GD2 antibody ch14.18 in neuroblastoma cell lines. Int J Cancer. 1987;40:81–86. patients with neuroblastoma. Eur J Cancer. 1995;31A:261–267. 19. Grunberg J, Novak-Hofer I, Honer M, et al. In vivo evaluation of 40. Albertini MR, Hank JA, Schiller JH, et al. Phase II trial of chimeric 177Lu- and 67/64Cu-labeled recombinant fragments of antibody anti-GD2 antibody plus interleukin-2 for melanoma patients. Clinic chCE7 for radioimmunotherapy and PET imaging of L1- Can Res. 1997;3:1277–1288. CAMpositive tumors. Clin Cancer Res. 2005;11:5112–5120. 41. Hank J, Surfus J, Gan J, et al. Treatment of neuroblastoma patients 20. Modak S, Kramer K, Gultekin SH, et al. Monoclonal antibody 8H9 with antiganglioside GD2 antibody plus Interleukin-2 induces anti- targets a novel cell surface antigen expressed by a wide spectrum body dependent cellular cytotoxicity against neuroblastoma of human solid tumors. Cancer Res. 2001;61:4048–4054. detected in vitro. J Immunother. 1994;15:29–37. 21. Smolarz K, Waters W, Sieverts H, et al. Immunoscintigraphy with Tc- 42. Uttenreuther-Fischer MM, Huang C-S, Yu AL. Pharmacokinetics of 99m-labeled monoclonal antibody BW575 compared with I-123 human/mouse chimeric anti-GD2 MAb ch14.18 in a phase I trial of MIBG scintigraphy in neuroblastoma. Radiology. 1989;173:152–153. neuroblastoma patients. Cancer Immunol Immunother. 1996;41:331– 22. Hakomori S. Tumor-associated carbohydrate antigens defining 338. tumor malignancy: basis for development of anti-cancer vaccines. 43. Simon T, Hero B, Faldum A, et al. Consolidation treatment with Adv Exp Med Biol. 2001;491:369–402. chimeric anti-GD2 antibody ch14.18 in children older than 1 year 23. Cheung NK, Saarinen UM, Neely JE, et al. Monoclonal antibodies to with metastatic neuroblastoma. J Clin Oncol. 2004;22:3549–3557. a glycolipid antigen on human neuroblastoma cells. Cancer Res. 44. Munn DH, Cheung NK. Phagocytosis of tumor cells by human 1985;45:2642–2649. monocytes cultured in recombinant macrophage colony-stimulat- • First historical description of anti-GD2 monoclonal antibodies ing factor. J Exp Med. 1990;172:231–237. produced injecting neuroblastoma into Balb/c mice and spleen 45. Mujoo K, Kipps TJ, Yang HM, et al. Functional properties and effect cells fused to a mouse myeloma cell line SP/2. on growth suppression of human neuroblastoma tumors by iso- 24. Cheung NK, Lazarus H, Miraldi FD, et al. Ganglioside GD2 specific type switch variants of monoclonal antiganglioside GD2 antibody

Downloaded by [Hospital Sant Joan de Deu], [Jaume Mora] at 23:12 30 March 2016 monoclonal antibody 3F8: a phase I study in patients with neuro- 14.18. Cancer Res. 1989;49:2857–2861. blastoma and malignant melanoma. J Clin Oncol. 1987 ;5:1430–1440. 46. Dallegri F, Ballestrero L, Ottonello L, et al. Defective antibody 25. Bullens RW, O’Hanlon GM, Wagner E, et al. Roles of complex gang- dependent tumor cell lysis by neutrophils from cancer patients. liosides at the neuromuscular junction. Ann NY Acad Sci. Clin Exp Immunol. 1989;77:58–61. 2003;998:401–403. 47. Barker E, Reisfeld RA. A mechanism for neutrophil-mediated lysis of 26. Hakomori S, Igarashi Y. Functional role of glycosphingolipids in cell human neuroblastoma cells. Cancer Res. 1993;53:362–367. recognition and signaling. J Biochem. 1995;118:1091–1103. 48. Yu AL, Uttenreuther MM, Kamps A, et al. Combined use of a 27. Furukawa K, Soejima H, Niikawa N, et al. Genomic organization and human-mouse chimeric anti-GD2 (ch14.18) and GM-CSF in the chromosomal assignment of the human B1,4-N acetyl galactos- treatment of refractory neuroblastoma. Antibody aminyltransferase gene. J Biol Chem. 1996;271:20836–20844. Immunoconjugates and Radiopharmaceuticals. 1995;8:12. 28. Acosta S, Mayol G, Rodríguez E, et al. Identification of tumoral glial 49. Honsik CJ, Gundram J, Reisfeld RA. Lymphokine-activated killer precursor cells in neuroblastoma. Cancer Letters. 2011;312:73–81. cells targeted by monoclonal antibodies to the disialogangliosides 29. Wu Z, Schwartz E, Seeger RC, et al. Expression of GD2 ganglioside GD2 and GD3 specifically lyse human tumor cells of neuroectoder- by untreated primary human neuroblastomas. Cancer Res. mal origin. Proc Natl Acad Sci USA. 1986;83:7893–7897. 1986;46:440–443. 50. Nagler A, Shur I, Barak V, et al. Granulocyte-macrophage colony- 30. Cheung NK, Kushner BH, Yeh SD, et al. 3F8 monoclonal antibody stimulating factor dependent monocyte-mediated cytotoxicity treatment of patients with stage 4 neuroblastoma: a phase II study. post-autologous bone marrow transplantation. Leukemia Res. Int J Oncol. 1998;12:1299–1306. 1996;20:637–643. EXPERT REVIEW OF CLINICAL PHARMACOLOGY 7

51. Hank JA, Robinson RR, Surfus J, et al. Augmentation of antibody 63. Marti F, Pardo N, Peiro M, et al. Progression of natural immunity dependent cell mediated cytotoxicity follow in vivo therapy with during one-year treatment of residual disease in neuroblastoma recombinant interleukin-2. Cancer Res. 1990;50:5234–4239. patients with high doses of interleukin-2 after autologous bone 52. Frost JD, Hank JA, Reaman GH, et al. A phase I/IB trial of murine marrow transplantation. Exp Hematol. 1995;23:1445–1452. monoclonal anti-GD2 antibody 14.G2a plus interleukin-2 in chil- 64. Valteau-Couanet D, Rubie H, Mersse V, et al. Phase I-II study of dren with refractory neuroblastoma: a report of the Children’s interleukin-2 after high-dose chemotherapy and autologous bone Cancer Group. Cancer Immunol Immunother. 1997;80:317–333. marrow transplantation in poorly responding neuroblastoma. Bone 53. Lotze MT, Grimme EA, M A, et al. Lysis of fresh and cultured Marrow Transplant. 1995;16:515–520. autologous tumor by human lymphocytes cultured in T cell growth 65. Lode HN, Siebert N, Eger C, et al. Interleukin-2 adds toxicity but no factor. Cancer Res. 1981;41:4420–4425. measurable activity in relapsed/refractory neuroblastoma patients 54. Grimm EA, Mazumder A, Z HZ, et al. Lymphokine activated killer treated with long term infusion of anti-GD2 antibody ch14.18/CHO. cell phenomenon: lysis of NK resistant fresh solid tumor cells by IL- Pediatr Blood Cancer. 2015;62:S4. Abstract PD-057 2 activated autologous human peripheral blood lymphocytes. J Exp 66. Simon T, Hero B, Faldum A, et al. Long term outcome of high-risk Med. 1982;155:1823–1841. neuroblastoma patients after immunotherapy with antibody 55. Hank JA, Kohler PC, Weil-Hillman G, et al. In vivo induction of the ch14.18 or oral metronomic chemotherapy. BMC Cancer. lymphokine-activated killer phenomenon: interleukin-2-dependent 2011;11:21. human non-major histocompatibility complex-restricted cytotoxi- 67. Yu AL, Gilman AL, Ozkaynak MF, et al. Anti-GD2 antibody with GM- city generated in vivo during administration of human recombi- CSF, interleukin-2, and isotretinoin for neuroblastoma. N Engl J nant interleukin-2. Cancer Res. 1988;48:1965–1971. Med. 2010;363:1324–1334. 56. Ladenstein R, Pötschger U, Siabalis D, et al. Dose finding study for •• The formal proof of a large randomized clinical trial showing the use of subcutaneous recombinant interleukin-2 to augment improved outcome for patients treated with anti-GD2-based natural killer cell numbers in an outpatient setting for stage 4 immunotherapy. neuroblastoma after megatherapy and autologous stem-cell rein- 68. Ozkaynak MF, Gilman AL, Yu AL, et al. A comprehensive safety trial fusion. J Clin Oncol. 2011;29:441–448. of chimeric antibody 14.18 (ch14.18) with GM-CSF, IL-2, and iso- 57. Ozkaynak MF, Seeger R, Bauer M, et al. A Phase I study of ch14.18 with tretinoin in high-risk neuroblastoma patients following myeloabla- GM-CSF in children with neuroblastoma following autologous BMT. tive therapy: A Children’s Oncology Group study. J Clin Oncol. Children’s Cancer Group Study. J Clin Oncol. 2000;18:4077–4085. 2014;32(15 Suppl 1). 2014 ASCO Annual Meeting Abstracts. 58. Gilman AL, Ozkaynak MF, Matthay KK, et al. Phase I study of Abstract no. 10044. ch14.18 with granulocyte-macrophage colony stimulating factor 69. Yu AL, Gilman AL, Ozkaynak MF, et al. Update of outcome for high- and interleukin-2 in children with neuroblastoma after autologous risk neuroblastoma treated on a randomized trial of chimeric anti- bone marrow transplantation or stem-cell rescue: a report from the GD2 antibody (ch14.18) + GM-CSF/IL2 immunotherapy in 1st Children’s Oncology Group. J Clin Oncol. 2009;27(1):85–91. response: A Children’s Oncology Group study. Abstract PL013. 59. Yu AL, Batova A, Alvarado C, et al. Usefulness of a chimeric anti- Advances in Neuroblastoma Research Congress Cologne; 2014 May GD2 (ch14.18) and GM-CSF for refractory neuroblastoma: a POG 13th–16th;. 108. phase II study [abstract]. Proc Am Soc Clin Oncol. 1997;16:1846. 70. Investigational medicinal product (IMP; UTC NSC 764038). Research 60. Cheung NK, Cheung IY, Kushner BH, et al. Murine anti-GD2 monoclonal Triangle Park (NC): United Therapeutics Corporation; 2013. antibody 3F8 combined with granulocyte-macrophage colony-stimu- 71. Safety Data Sheet for Dinutuximab [Internet]. Research Triangle lating factor and 13-cis-retinoic acid in high-risk patients with stage 4 Park (NC): United Therapeutics Corporation. [cited 2015 Oct 15]. neuroblastoma in first remission. J Clin Oncol. 2012;30:3264–3270. Available from: https://www.unituxin.com/safety-profile • The summary update of the MSKCC experience from 1988 to 72. Desai AV, Fox E, Smith LM, et al. Pharmacokinetics of the chimeric 2008 using the murine 3F8 anti-GD2 MoAb. anti-GD2 antibody, ch14.18, in children with high-risk neuroblas- 61. Bauer M, Reaman GH, Hank JA, et al. A phase II trial of human toma. Cancer Chemother Pharmacol. 2014;74:1047–1055. recombinant interleukin-2 administered as a 4-day continuous infu- 73. United Therapeutics Corporation. UnituxinTM: US prescribing infor- sion for children with refractory neuroblastoma, non-Hodgkin’s lym- mation. 2015 [Cited 2015 15 October]. http://www.accessdata.fda. phoma, sarcoma, renal cell carcinoma, and malignant melanoma. A gov/drugsatfda_docs/label/2015/125516s000lbl.pdf. Children’s Cancer Group Study. Cancer. 1995;75:2959–2965. 74. Steel JC, Waldmann TA, Morris JC. Interleukin-15 biology and its 62. Michon J, Negrier S, Coze C, et al. Administration of high-dose therapeutic implications in cancer. Trends Pharmacol Sci. recombinant interleukin 2 after autologous bone marrow trans- 2012;33:35–41. plantation in patients with neuroblastoma: toxicity, efficacy and 75. Xu H, Cheng M, Guo H, et al. Retargeting T cells to GD2 pentasac- survival. A Lyon-Marseille-Curie-east of France Group study. Prog charide on human tumors using Bispecific humanized antibody. Clin Biol Res. 1994;385:293–300. Cancer Immunol Res. 2015;3:266–277. Downloaded by [Hospital Sant Joan de Deu], [Jaume Mora] at 23:12 30 March 2016