Neuroblastoma relapse is one of the greatest challenges to complete cure for children with high-risk disease. At least 40% of high-risk neuroblastoma patients will experience cancer relapse 4 years after intense treatment, which includes a combination of chemotherapy, surgery, irradiation and the self-transplantation of stem cells (consolidation therapy).
To overcome this problem improved maintenance therapy is needed. These are therapies administered to patients after the end of the initial treatment to prevent tumour relapse. Frequently, maintenance therapy for neuroblastoma includes immunotherapies such as antibodies against GD-2 and cytokines and 13-cis-retinoic acid. Although these therapies have some positive effects, the rate of relapse is still high. Therefore, other options to prevent relapse are needed.
Recently, a phase II clinical trial evaluated the effect of Difluoromethylornithine (DFMO) on event-free survival (EFS) and overall survival (OS) of high-risk neuroblastoma patients1. Event-free survival means the length of time that the patient remains free of cancer after the end of treatment, while overall survival means the length of time that the patient is alive after the diagnosis or the start of treatment. The measurement of event-free survival and overall survival provides a good indication of the treatment effect.
In this clinical trial report the therapy efficacy on 81 patients that received immunotherapy treatment with dinutuximab and started DFMO maintenance therapy at least 120 days after completion of treatment were compared to the efficacy (based on medical records) from a group of 76 patients that got the same treatment but without the maintenance with DFMO.
DFMO inhibit the ornithine decarboxylase pathway, which is related to cell growth and decreased cell death, thus preventing cells to become cancerous and tumour progression. The results demonstrated that maintenance therapy with DFMO provided 85% of 5-year event-free survival compared to 65% for no-DFMO maintenance therapy, and 95% 5-year OS compared to 81% no-DFMO therapy2.
In conclusion, this study results suggest a benefit provided by the DFMO therapy in preventing neuroblastoma relapse. The researchers suggest that early therapy with DFMO may further improve these results. Therefore, more clinical trials evaluating this possibility are being conducted3,4.
Written by Luiza Erthal
References
1. SaulnierSholler, G. A Phase II Preventative Trial of DFMO (Eflornithine HCl) as a Single Agent in Patients With High Risk Neuroblastoma in Remission. https://clinicaltrials.gov/ct2/show/NCT02395666 (2020).
2. Lewis, E. C. et al. A subset analysis of a phase II trial evaluating the use of DFMO as maintenance therapy for high‐risk neuroblastoma. Int. J. Cancer 147, 3152–3159 (2020).
3. SaulnierSholler, G. Phase II Trial of Eflornithine (DFMO) and Etoposide for Relapsed/Refractory Neuroblastoma. https://clinicaltrials.gov/ct2/show/NCT04301843 (2021).
4. SaulnierSholler, G. NMTT- Neuroblastoma Maintenance Therapy Trial Using Difluoromethylornithine (DFMO). https://clinicaltrials.gov/ct2/show/NCT02679144 (2021).
Immunotherapies are treatments that stimulate the patient’s immune system to help it to fight cancer. This type of treatment is gaining more attention in neuroblastoma due to the possibility to combine it with other therapies, potentially, generating fewer side effects.
Clinical trials are research protocols performed in patients to evaluate whether a new treatment is safe and effective. This type of research can also compare standard treatments with new treatment options as well as investigate new combinations of drugs. Clinical trials occur in phases comprising phase I (safety), phase 2 (safety and efficacy), phase 3 (safety, efficacy and comparison with standard treatments for the specific disease).
According to a search performed on November 14th, 2021, there are 594 clinical trials for neuroblastoma at clinicaltrials.gov, a clinical trial database from the United States (US). From these, 173 are recruiting or active trials and 15 are related to immunotherapies. Generally, these are initial trials evaluating treatment combinations using chemotherapy, cell transplants and immunotherapy, including antibodies and vaccines.
Trials for antibodies
The most explored target for immunotherapy in neuroblastoma is the GD2, a molecule present in the surface of neuroblastoma cells that can be used to combat the tumour. Indeed, antibodies that bind to GD2 called dinutuximab and naxitamab are approved for use in the US to treat neuroblastoma1,2.
A clinical trial in the US and Canada is recruiting patients to evaluate the combination of dinutuximab with another antibody called Magrolimab in patients with neuroblastoma that do not respond to or come back after treatment3. This is an initial trial (Phase 1), which aims to determine the best doses and side effects of this combination.
Racotumomab, an antibody that binds to N-glycolyl GM3, a molecule that is highly expressed in the surface of neuroblastoma cells, is being evaluated in high-risk neuroblastoma5. The study aims to determine the immune response generated by the drug and the related toxicity.
Trials for vaccines
A trial from Dana-Farber Cancer Institute is recruiting patients to study the GVAX Vaccine and its combination with the antibodies, nivolumab and ipilimumab, that stimulates T-cells to attack the cancer 6. The vaccine is produced with neuroblastoma cells from the patient. The study will evaluate the dose and safety of the combination treatment.
Another trial is evaluating the use of a modified neuroblastoma cell vaccine in combination with low doses of chemotherapy (Cytoxan/Cyclophosphamide)7. A vaccination scheme comprising 8 doses of vaccine and cycles of oral chemotherapy is planned and patients will be closely monitored through the vaccination period to evaluate side effects and disease status. This study is ongoing and will follow the patients for 15 years after completing the vaccination scheme.
Trials for cell therapy
A trial evaluating the use of modified T-cells (CART-T-cell) to recognise GD2- neuroblastoma cells in combination with chemotherapies (cyclophosphamide and fludarabine) and an antibody (Pembrolizumab) is ongoing8. The combination is based on previous studies that have demonstrated the longer time presence of CAR T-cell in the blood of patients after intravenous infusion of chemotherapy. Moreover, the antibody will help to stimulate the patient immune system. The trial aims to determine the highest dose possible for the combination treatment generating fewer side effects.
Another Phase I immunotherapy trial for neuroblastoma aims to compare the treatment with dinutuximab and lenalidomide (drugs that support the immune system) and Natural Killer (NK) cells from the patient9. The NK cells can kill cancer cells while the two immunotherapeutic drugs activate the NK cells. This study will determine the safest dose of cells to be used in combination with the drugs.
Conclusion
Considering some of the clinical trials in progress that uses immunotherapy to treat neuroblastoma, we can conclude that this therapy modality holds great promise to advance and potentially serve as a new treatment option to improve neuroblastoma patients’ survival and quality of life.
Written by Luiza Erthal
References
1. Drugs Approved for Neuroblastoma – National Cancer Institute. https://www.cancer.gov/about-cancer/treatment/drugs/neuroblastoma (2011).
2. Memorial Sloan Kettering Cancer Center. Expanded Access Use of Naxitamab/GM-CSF Immunotherapy for Consolidation of Complete Remission or Relapsed/Refractory High-Risk Neuroblastoma. https://clinicaltrials.gov/ct2/show/NCT04501757 (2021).
3. National Cancer Institute (NCI). Phase 1 Trial of Hu5F9-G4 (Magrolimab) Combined With Dinutuximab in Children and Young Adults With Relapsed and Refractory Neuroblastoma or Relapsed Osteosarcoma. https://clinicaltrials.gov/ct2/show/NCT04751383 (2021).
4. Memorial Sloan Kettering Cancer Center. Hu3F8/GM-CSF Immunotherapy Plus Isotretinoin for Consolidation of First Remission of Patients With High-Risk Neuroblastoma: A Phase II Study. https://clinicaltrials.gov/ct2/show/NCT03033303 (2020).
5. Laboratorio Elea Phoenix S.A. Open-label, Multicenter, Phase II Immunotherapy Study With Racotumomab in Patients With High-risk Neuroblastoma. https://clinicaltrials.gov/ct2/show/NCT02998983 (2021).
6. Collins, N. B. A Phase 1 Study of Combination Nivolumab and Ipilimumab With Irradiated GM-CSF Secreting Autologous Neuroblastoma Cell Vaccine (GVAX) for Relapsed or Refractory Neuroblastoma. https://clinicaltrials.gov/ct2/show/NCT04239040 (2021).
7. Heczey, A. A Phase I/II Study Using Allogeneic Tumor Cell Vaccination With Oral Metronomic Cytoxan in Patients With High-Risk Neuroblastoma (ATOMIC). https://clinicaltrials.gov/ct2/show/study/NCT01192555 (2021).
8. Heczey, A. Autologous Activated T-Cells Transduced With A 3rd Generation GD-2 Chimeric Antigen Receptor And iCaspase9 Safety Switch Administered To Patients With Relapsed Or Refractory Neuroblastoma (GRAIN). https://clinicaltrials.gov/ct2/show/NCT01822652 (2021).
9. New Approaches to Neuroblastoma Therapy Consortium. A Phase I Dose Escalation Study of Autologous Expanded Natural Killer (NK) Cells for Immunotherapy of Relapsed Refractory Neuroblastoma With Dinutuximab +/- Lenalidomide. https://clinicaltrials.gov/ct2/show/NCT02573896 (2021).
And the story began with a meeting of fantastic 7 at the very beginning of Dublin Mountains Way in Tallaght at 6.30 am on September 25th. The spirit, cheer, backpacks with essentials and branded tops were on, Strava was launched and we swiftly headed off.
It was quiet, dark and cheering. No one was on the streets, a few cars passed by. We took towards Bohernabreena reservoir through the sleepy estates of Tallaght, sensing the sunset. Clouds were low and the highest peaks in the Dublin Mountains including Seefingan, Corrig and the highest, Kippure were in the mist. Nevertheless, we were full of energy and hopes to see it later.
Cheat chats and jokes were here and there, we walked in small dynamic groups recalling our pre-covid life and stories that happened during the lockdown. A mix of newbies and maturating research students. We met some in person for the first time since the COVID restrictions admitting that our visual senses are extremely important to memorise a person and recognise him/her on the next occasion. We were enjoying this face-to-face communication and our team re-connection.
The first 8 km flew in a flash. We stopped for our breakfast in Dublin Mountains. The grass was wet, the sky was blue. Mountains started to draw their shape through the clouds. Yoghurts, fruits, bars immediately disappeared in our stomachs. Everyone was happy to lighten their backpack. Every little helps!
A few plasters were glued, and we continued on at a very good pace. The sky was changing with sunny spells. We travelled around Spinkeen and Killakee at their base doing up and downhills and verifying our route with the hiking app. At the 20 km mark, we stopped for lunch. Sandwiches, grapes, mandarines and sweets were shared and eaten and then polished with chocolates from the recent Nadiya’s home trip. Jellies left untouched.
At 25 km, our blisters reminded us of being humans. Our pace slowed down and we started a very mild ascent to Tibradden Mountain leaving the Pine Forest or Tibradden Wood behind. We climbed further to Fairy Castle, the highest point on the Dublin Mountains Way (537m). Throughout the entire way, Dublin showed its best views of the Phoenix Park and the Pope Cross, house roofs, Aviva Stadium, two Chimneys, Dublin Port… The scenery was fascinating and breathtaking. We saw Howth and Dun Laoghaire, Sugar Loaf… We met groups of Germans, French, Irish and many others.
At Three Rocks Mountain/Fairy Castle, we started our descent and entered Tiknock forest. This part was steep. We crossed the Gap Mountain Bike Adventure Park to reach Glencullen. Got lost at the end but just for a sec and reached the Glencullen junction at 2.30pm. It took us 8 hours with walks and stops from start to finish to complete the 30 km challenge in a day. We got tired but felt happy and satisfied.
We aimed to raise awareness of childhood cancer in general and neuroblastoma in particular as well as honour children with cancer, their parents, siblings, friends and careers, doctors and nurses, volunteers in the hospitals and researchers working to find cancer weaknesses and develop new treatments that are friendly to patients and target cancer aggressiveness.
We will count our tally in the coming days and transfer it to three wonderful charities that support childhood cancer research.
Here are our plans. This year we have upped the challenge, taking on the Dublin Mountain’s Way in a Day ⛰ We will hike through the Dublin Mountains from Tallaght to Glencullen, and maybe even all the way to Shankill on September 25th! Our challenge is not only to do #DMW in a Day & support three wonderful charities CMRF Crumlin/National Children’s Research Centre, Neuroblastoma UK and the Conor Foley Neuroblastoma Cancer Research Foundation but also beat our past fundraising records! If we raise 2K+, we’ll do 30km in a day. If 3K+ then 42km! Can u challenge us? All funds raised will go to the 3 selected charities. Every donation big or small is hugely appreciated!
Every 100th cancer patient is a child. Cancer is the 2nd most common cause of death among children after accidents.
Childhood cancer is an umbrella term for many other types of this disease. Every September, many charities, researchers and parents of children with cancer work hard to raise awareness of this cancer. You may learn more about kids with cancer, their loving families, the doctors and caregivers who looking after them and treating them, the young survivors of cancer and those kids and teens who lost their battle, and the scientists who working hard to find a way to stop childhood cancer.
This year our research team will hike Dublin MountainWay in One Day on the 25th of September 2021 whatever the weather in honour of Childhood Cancer Awareness Month. For every one euro donated to research only 1 cent of this goes to ALL childhood health conditions including cancer. Therefore, the donations we receive will be split equally among some wonderful children’s charities. These charities include the Conor Foley Neuroblastoma Research Foundation (CFNRF), Neuroblastoma UK (NBUK), Children’s Research & Medical Foundation (CRMF) Crumlin.
If you would like to get involved in this amazing challenge and help us raise vital funds for childhood cancers, you can contribute to our fundraising page:
We will work closely with the Conor Foley Neuroblastoma Cancer Research Foundation – a research charity led by the family who lost their child to neuroblastoma. An inspirational example of never giving up.
We will continue to dissect neuroblastoma biology using innovative platforms such as tumour-on-chip and 3D scaffold-based models in collaboration with our colleagues in the Tissue Engineering Research Group at RCSI and the Fraunhofer Project Centre at DCU.
This announcement is timely to celebrate Childhood Cancer Awareness Month in September.
Two talented and dedicated young scientists are joining our team. In 4 years time, we will have another pic of their graduation on the same stairs.
Last month we set ourselves the “10 Laps 10km” challenge for Childhood Cancer Awareness.
Now we have closed the GoFundMe and counted the charity buckets. We are delighted to announce we raised a grand total of €1419! We are over the moon with this sum, as 2020 required a very different kind of fundraiser than previous years.
Our three chosen charities: Children’s Health Foundation Crumlin (formerly CMRF), the Conor Foley Neuroblastoma Cancer Research Foundation, and Neuroblastoma UK, will each receive just over €470.
We’d like to say big thank you to everyone who donated. It will make a huge difference for these charities, this year especially, paving the way to better treatment options for children with cancer in the future.
The new norm, new challenges, new excitement and new achievements! We all proud to say that we completed 10K Vhi Womens Mini marathon socially distanced. Our paces were so different that distancing came absolutely natural. We ran it individually but were a team mentally. Even the capricious Irish weather was our ally. The Sun was bright. The air was fresh and crispy.
This was an individual challenge #POWEROF10: just you and the trail. 10 laps around St Stephen’s Green park were to make the target 10K in aid of Childhood Cancer Awareness Month. The celebration of life, therapeutical advancements, the strength of little patients battling their cancer and their families, doctors and carers who are supporting them in their journey. The emphasis on the gaps in available treatments and diagnosis and the importance of research that needs funding.
Personally, my 10K were split into two parts. The first 4K were full of arguments with my body. Why didn’t I like to do laps? Could I complete 10K? Was I fit to do it? Keep going! No walking – better slow jogging. Did one lap make 1K? Should I do a longer lap instead? And so on and so forth. Then, the second part kicked in. My body stopped arguing and began to enjoy it. I noticed beautiful Autumn colours on the trees, people walking around with a cup of coffee or chatting away, saw my team members overtaking me, and our volunteers counting our laps. People on the street and in the park were cheering us up. What a wonderful and fulfilling day!
As Catherine says: “The 10 Laps 10km challenge was tough! Like many people, I took up running casually during the lockdown, however, I never did more than a couple of kilometres at once, so I was absolutely not prepared for running 10. But the cheers from our socially distanced spectators and all the online support we received meant I got through it. Also knowing what a positive impact this challenge could have for the future of childhood cancer treatment provided plenty of motivation to finish the race 💛🎗”
10K by 6 team members socially distanced. #POWEROF10. Go Gold! Let’s reach 1.5k in donations!
Our Go Fund Me page is still open until this Sunday (October 11th midnight) if you wish to support us.
Our team is expanding – we are welcome our new PhD student Ellen King!Her project will add another dimension to neuroblastoma research. She will look into potential targets on the surface of neuroblastoma cells resistant to therapy and investigate how we can strengthen the patient immune systemresponse.
Like everyone, my current workspace looks very different from what it normally looks like. I have just joined the Cancer Bioengineering Group as a PhD student in the midst of the pandemic. Certain moments like induction day or meeting my new lab mates, will all be done virtually due to the pandemic. Luckily, I have spent the last year working as a research assistant at RCSI and this has taken away all the stresses of finding my way around a new campus and indeed making friends. Without a doubt, the transition is and will be a strange one but the excitement and enthusiasm haven’t gone anywhere!
Recently, my days as a researcher have been spent at my lovely, newly-built (with the help of IKEA instructions) home desk. And as the picture I have standing proudly beside my laptop says, there really is no place like home. I feel very lucky to be able to safely work from home and continue my research while so many people are now without jobs or are risking their lives to keep people safe during the pandemic.
“NÍL AON TINTEÁN MAR DO THINTEÁN FÉIN” – THERE IS NO FIRESIDE LIKE YOUR OWN
Most days I wake up early and go for a run along the lovely canal beside my house. This is a great way to wake up my brain and is also great preparation for our virtual VHI mini-marathon on the 7th of October 2020 in honour of Childhood Cancer Awareness Month. I start work at around 9am, which at the moment is mostly research, reading papers and writing a literature review in preparation for my return to the lab soon. I miss the experimental side of my research and am really excited to start this new exciting project.
Today marks the start of Childhood Cancer Awareness Month.
Three girls fountain in Mainz Germany
I like this photo of a lovely fountain capturing 3 girls under umbrellas (Drei-Mädchen-Brunnen) in Ballplatz Mainz. It is about a happy childhood; every child deserves a happy childhood. So, I select it again to support #ChildhoodCancerAwarnessMonth.
Childhood cancer is an umbrella term for many other types of this disease. This month is a big channel to support and learn more about kids with cancer, their loving families, the doctors and caregivers who looking after them and treating them, the young survivors of cancer and those kids and teens who lost their battle, and the scientists who working hard to find a way to stop childhood cancer.
When it comes to a disease, we have to acknowledge that children are not little adults. They are constantly developing. So their diseases have a different way to progress and respond to treatment. This is very true for childhood cancers. For example, children diagnosed with neuroblastoma before a 1.5 years old mark will do better than older children.
Every 100th cancer patient is a child. Cancer is the 2nd most common cause of death among children after accidents. The most common types of childhood cancer are:
Leukaemia and lymphoma (blood cancers)
Brain and other central nervous system tumours
Muscle cancer (rhabdomyosarcoma)
Kidney cancer (Wilms tumour)
Neuroblastoma (tumour of the non-central nervous system)
Bone cancer (osteosarcoma)
Testicular and ovarian tumours (gonadal germ cell tumours)
