Risk-adapted local therapy and intensive chemotherapy in patients with high-risk rhabdomyosarcoma

10031

Background: Outcomes for patients with metastatic RMS remain poor. Dose escalation of radiation may reduce risk of local failure, and maintenance therapy has prolonged survival in intermediate risk patients. We investigated a multimodal chemotherapeutic regimen with risk adapted local therapy and the addition of maintenance therapy following intensive chemotherapy to improve the outcome for patients with high-risk RMS. Methods: We conducted a phase 2 multi-center trial for patients with newly diagnosed high-risk (stage 4) RMS. Patients received 54 weeks of chemotherapy (vincristine/irinotecan, interval compressed vincristine/doxorubicin/cyclophosphamide and ifosfamide/etoposide, and vincristine/dactinomycin/cyclophosphamide) followed by 4 cycles of anti-angiogenic maintenance therapy (bevacizumab, sorafenib, cyclophosphamide). Primary tumor local control consisted of surgery and photon/proton radiation therapy (RT) dependent on the degree of resection (negative margin – no RT, positive margin – 36 GyRBE, unresected ≤5cm – 50.4 GyRBE, unresected > 5cm – 59.4 GyRBE). RT was administered at Week 4 or 20 based on size/location, and to radiographically visible (non-CR) sites of metastatic disease at end of treatment. Results: Thirty-nine eligible patients with high-risk RMS (64% FOXO1 fusion positive, 74% with nodal disease, 67% Oberlin score > 1) were enrolled. Two of 13 patients with Oberlin score ≤ 1 were FOXO1 fusion positive whereas 23 of 26 patients with Oberlin score > 1 were fusion positive. Seventeen patients received maintenance therapy as planned (progression, n = 12; received alternate maintenance regimen, n = 4; other, n = 6) with a median of 4 cycles (range 1-4). Common toxicities of maintenance included palmar-plantar erythrodysesthesia (n = 9), rash (n = 7), and cystitis (n = 6). At a median follow-up of 43.5 months for survivors, 3-year EFS was 29.5% (95% CI 15.4-45.1%). Fusion positive status significantly predicted EFS (negative, 60.6% vs. positive, 9.6%, p = 0.019), whereas low Oberlin score approached significance for EFS (≤1, 56.6% vs. > 1, 16.4%, p = 0.064). The cumulative incidence of local failure was 17.5% (95% CI 6.9-32.2%). Twenty-one patients achieved CR of all metastatic sites and did not receive metastatic site RT. Of those, 7 experienced disease recurrence in a pre-existing metastatic soft tissue site. Among 4 patients who received metastatic site RT at the end of treatment, one patient experienced disease recurrence in a pre-existing metastatic site. Conclusions: The addition of maintenance therapy to intensive chemotherapy and risk adapted radiotherapy did not improve EFS in this population. Consolidative radiation should be considered for soft tissue metastatic sites regardless of radiographic response. Clinical trial information: NCT01871766.

Late health outcomes in survivors of Wilms tumor: A report from the St. Jude Lifetime (SJLIFE) cohort study

10038

Background: We aimed to characterize late health, neurocognitive, and physical performance outcomes among survivors of Wilms tumor. Methods: Wilms tumor survivors (n = 280), ≥ 5 years from diagnosis, participating in SJLIFE were clinically assessed along with a community control sample (n = 625). Health outcomes were graded per a modified Common Terminology Criteria for Adverse Events (grade 1 [mild] to grade 4 [life threatening]). Standardized neurocognitive testing was graded using age-adjusted z-scores. Aerobic function (six-minute walk), mobility (timed up and go) and flexibility (sit and reach) were assessed. Associations between treatment exposures and prevalent conditions were examined by multivariable logistic regression, adjusted for current age, sex and race. Results: Survivors (59% female, 73% white), median age 3 years (range 0-15) at diagnosis and 31 years (9-58) at evaluation, were comprehensively evaluated on the St. Jude campus. Two-thirds (67%) were treated with doxorubicin (median dose 175 mg/m2 range 52-490), 167 (60%) received abdominal radiation (median dose 12 Gy range 8.8-61.2) and 25% received chest radiation (12 Gy range 9-44). By age 40 years, survivors averaged 12.7 (95% confidence interval [CI] 11.7-13.8) grade 1-4 and 7.5 (CI 6.7-8.2) grade 2-4 conditions, compared to 4.2 (CI 3.9-4.6) and 2.3 (CI 2.1-2.5), respectively, among controls. The most prevalent medical conditions (grade ≥ 2) are reported in the table. Abnormal glucose metabolism was associated with abdominal radiation (relative risk [RR] 5.1 CI 1.4-19.0); restrictive pulmonary defects with chest radiation (RR 24.0 CI 3.2-180); and cardiomyopathy (RR 15.6 CI 1.9-128), pulmonary diffusion (RR 4.5 CI 1.3-15.1), and chronic kidney disease (RR 4.5 CI 1.3-16.1) with doxorubicin exposure. Survivors had a three-fold higher risk (standardized incidence ratio 3.5, CI 2.2-6.6) for subsequent neoplasms. Impairments (grade ≥ 2) in executive function (20% vs. 12%), attention (17% vs. 9%), memory (21% vs. 10%), and processing speed (20% vs. 8%) were more frequent in survivors than controls (p < 0.05). Impairments in aerobic function (13.6%), mobility (13.6%), and flexibility (11.1%) were higher than expected (p < 0.01). Significant associations were not identified between treatment exposures and neurocognitive or physical performance outcomes. Conclusions: Systematic clinical assessment identified a significant burden of chronic health conditions and previously unrecognized neurocognitive and physical performance limitations in survivors of Wilms tumor.[Table: see text]

Early response rates and Curie scores at end of induction: An update from a phase II study of an anti-GD2 monoclonal antibody (mAb) with chemotherapy (CT) in newly diagnosed patients (pts) with high-risk (HR) neuroblastoma (NB)

10534

Background: We are conducting a Phase II trial of the anti-GD2 mAb hu14.18K322A given concomitantly with CT in newly diagnosed pts with HR NB. Our primary objective is to compare the response rate (RR; defined as ≥ PR) after two courses of CT with cyclophosphamide (CTX)/topotecan (TPT) and hu14.18K322A with GM-CSF and IL-2 to the RR reported by Park et al. (JCO 29:4351, 2011), using identical CT with GCSF only, in a two-stage group sequential design. Semiquantitative MIBG scoring (Curie; CS) has been shown to be a prognostic indicator of outcome in pts with HR NB (Yanik et al, J Nucl Med, 2013), particularly, those with CS > 2 at end of induction (EoI) CT have inferior outcomes. Here we update the RR and report the CS at EoI CT. Methods: Pts received induction CT (6 cycles) as described by Park et al, with the addition of hu14.18K332A (on d 2-5; 40mg/m2/d x 4d), daily sc GM-CSF and sc IL-2 (1 x 106 IU/m2/dose) qod x 6. 123I-MIBG scans and scoring (CS) were obtained on all pts at diagnosis, after second course of CT and at EoI. Results: 42 evaluable pts completed the first two courses of CT (24 male, median age 2.9 yrs (range 6 m -15.2 yrs), 36 INSS 4, 19 MYCNamplified); 40/42 evaluable pts had measurable reductions in primary tumor volume after two courses of CT (median 79%, average 69%, range +5 – 100%). Responses (≥ PR) after two courses were seen in 32/42 (76.2%; 95% CI 61.3 – 87.9%); No mAb dose-reductions were made but 20/43 (47%) pts had infusion times extended. The development of human anti-human antibody reactivity (HAHA) to hu14.18K322A in the first 22 pts is minimal. Of the 36 INSS 4 pts, 1 withdrew prior to EoI and 2 are too early. The median CS at diagnosis for the 33 stage 4 pts who have completed induction CT was 18 (range 1 – 28). At EoI the median CS was 0 (range 0 -23); 29/33 INSS 4 pts had EoI CS ≤ 2. Conclusions: The addition of hu14.18K322A to two courses of CTX/TPT significantly improves the RR compared to two courses of CTX/TPT alone (32/42 vs 12/30 as reported by Park et al,; P = 0.000004). The improved median CS of the stage 4 patients from 18 at diagnosis to 0 at EoI suggest the improvement in early RR may translate into improved EFS as well. Clinical trial information: NCT01857934.

Patients with retinoblastoma and chromosome 13q deletions have increased chemotherapy-related toxicities

BACKGROUND

A total of 5-10% of patients with retinoblastoma (RB) harbor deletion of the long arm (q) chromosome 13 (13q-). The treatment-related toxicities in this population have not been described.

METHODS

Sixty-eight RB patients on a single institutional protocol (RET5) from 2005 to 2010 were reviewed. Genetic screening identified 11 patients (seven female) with 13q-. Patients with early (Reese-Ellsworth [R-E] group I-III) disease (6/23 with 13q-) received eight courses of vincristine/carboplatin (VC). Patients with advanced (R-E group IV-V) bilateral disease (2/27 with 13q-) received two courses of vincristine/topotecan (VT) followed by nine courses of alternating VT/VC. Patients undergoing upfront enucleation received histopathology-based chemotherapy: intermediate risk (2/8 with 13q-) or high risk (1/10 with 13q-). Dose reductions were mandated for >7 day delay in two consecutive courses following hematologic toxicity. Grades 3 and 4 hematologic, infectious, and gastrointestinal toxicities were compared between RET5 patients with and without 13q-.

RESULTS

Demographics were similar between groups. When present, prolonged neutropenia (median 7 days, range 0-14 days) delayed chemotherapy and resulted in more frequent dose reductions among 13q- patients (5/11) than non-13q- patients (4/57) (P < 0.01). GI toxicity was similar between groups (5/11 13q- vs. 13/57 non-13q-; P = 0.14), but halted chemotherapy in one 13q- patient. Infectious complications and disease outcomes were similar between groups. At follow-up, all patients are alive (median 6.1 years, range 7.6 months-9.5 years).

CONCLUSIONS

13q- RB patients had a higher incidence of neutropenia requiring chemotherapy dose reductions, but did not have increased treatment failure.

Bilateral internal hemipelvectomy for osteosarcoma in a pediatric patient previously treated for rhabdomyosarcoma

The surgical treatment of malignant bone tumors involving the pelvis represents a great challenge in terms of local control. Internal hemipelvectomy is a major surgical procedure that involves the resection of the entire hemipelvis or of a portion of the hemipelvis with preservation of the ipsilateral extremity. The need for a bilateral internal hemipelvectomy is an extraordinary situation. We describe the case of an 11-year-old girl with a primary diagnosis of rhabdomyosarcoma of the bladder at the age of two years who subsequently developed a right pelvis osteosarcoma at the age of six years and a left pelvis osteosarcoma at the age of nine years. She ultimately underwent sequential bilateral internal hemipelvectomies and she postoperatively ambulates without an assist device.

Comprehensive preclinical testing for neuroblastoma using orthotopic xenografts of a patient tumor

e13584

Background: Neuroblastoma is an aggressive malignancy that accounts for 15% of pediatric cancer deaths. There are limited well characterized neuroblastoma models for use in preclinical trials. We characterized a human neuroblastoma orthotopic xenograft, performed comprehensive preclinical studies, and evaluated the pharmacokinetics of drugs targeting the PI3K pathway. Methods: Tumor tissue (MAST3) was obtained from a 2 year old with stage IV metastatic MYCN amplified neuroblastoma. Using ultrasound guidance, MAST3 cells were injected into the para-adrenal space of nod-scid mice. Tumors were monitored for growth with routine ultrasound and passaged. The initial patient tumor (MAST3) and tumor from each passage were extensively analyzed including: histology, electron microscopy (EM), gene expression profiling, single nucleotide polymorphism (SNP ) microarrays, whole genome sequencing (WGS), and spectral karyotyping (SKY). Using this orthotopic xenograft model, a randomized preclinical trial was conducted to evaluate the response to standard chemotherapeutic agents. Pharmacokinetic studies of oral BEZ-235, BKM-120, OSI-906 and everolimus were conducted. Results: Analysis of the histology, EM, gene expression profiling, SNP microarrays, WGS, and SKY showed minimal variability between the MAST3 tumor and the passaged tumors in the orthotopic xenografts. Notably, MAST3 metastasized to the liver, lung and spleen in vivo. Administering standard chemotherapeutic agents every 3 weeks for a total of 6 courses, we observed a significant response in 40% of treated mice. Further ongoing preclinical trials will evaluate the comparative efficacy of IGFR/PI3K/mTOR molecular targeted therapies. Conclusions: We developed the first well characterized neuroblastoma orthotopic xenograft. Our comprehensive characterization of this xenograft indicates that it retains many of the molecular, cellular and genetic properties of the primary lesion. A preclinical trial using standard chemotherapeutic agents has provided a valuable baseline for comparison with novel therapeutics and will inform our selection of the most promising agents to move into clinical trials.

SYK expression in metastatic retinoblastoma

e13544

Background: Retinoblastoma is an aggressive childhood cancer of the retina. While more than 90% of patients are cured when tumor is confined to the globe, for up to half of children in developing countries with advanced tumor at diagnosis, retinoblastoma remains a lethal disease. Recent whole-genome sequencing demonstrated that the retinoblastoma genome is relatively stable (Zhang et al). However, RB1 loss is associated with epigenetic deregulation of several cancer pathways. Significantly, the proto-oncogene SYK, spleen tyrosine kinase, which has no role in normal eye development, is upregulated in retinoblastoma and required for tumor cell survival (Zhang et al). Immunohistochemical (IHC) studies showed that SYK is ubiquitously overexpressed in intraocular retinoblastoma, whereas it is absent in normal retina. The purpose of this study is to investigate whether SYK overexpression persists in metastatic retinoblastoma. Methods: From 1962-2011, seven metastatic retinoblastoma tumor specimens (excluding bone marrow or cerebrospinal fluid) from six retinoblastoma patients were retrieved from the Pathology Archives in our institution. Morphology and supportive IHC, to include immunopositivity for synaptophysin and immunonegativity for cytokeratins, confirmed the diagnosis of metastatic retinoblastoma in each case. IHC for SYK was performed according to the previously published technique (Zhang et al). Results: Tumors occurred in two male and four female patients with seven metastatic retinoblastoma samples in scalp, lymph node, neck, ovary and bone (femur). By IHC, all seven metastatic retinoblastoma tumor samples were positive for SYK. Conclusions: This is the first report of SYK overexpression in metastatic retinoblastoma. Drugs targeting SYK are already in clinical trials for adults with leukemia and rheumatoid arthritis, and preclinical efficacy in vitro and in vivo has been established. Moving from bench to bedside with this epigenetically targeted agent warrants further investigation.