Bevacizumab, Irinotecan, or Topotecan Added to Temozolomide for Children With Relapsed and Refractory Neuroblastoma: Results of the ITCC-SIOPEN BEACON-Neuroblastoma Trial

Purpose Outcomes for children with relapsed and refractory high-risk neuroblastoma (RR-HRNB) remain dismal. The BEACON Neuroblastoma trial (EudraCT 2012-000072-42) evaluated three backbone chemotherapy regimens and the addition of the antiangiogenic agent bevacizumab (B). Materials and Methods Patients age 1-21 years with RR-HRNB with adequate organ function and performance status were randomly assigned in a 3 × 2 factorial design to temozolomide (T), irinotecan-temozolomide (IT), or topotecan-temozolomide (TTo) with or without B. The primary end point was best overall response (complete or partial) rate (ORR) during the first six courses, by RECIST or International Neuroblastoma Response Criteria for patients with measurable or evaluable disease, respectively. Safety, progression-free survival (PFS), and overall survival (OS) time were secondary end points. Results One hundred sixty patients with RR-HRNB were included. For B random assignment (n = 160), the ORR was 26% (95% CI, 17 to 37) with B and 18% (95% CI, 10 to 28) without B (risk ratio [RR], 1.52 [95% CI, 0.83 to 2.77]; P = .17). Adjusted hazard ratio for PFS and OS were 0.89 (95% CI, 0.63 to 1.27) and 1.01 (95% CI, 0.70 to 1.45), respectively. For irinotecan ([I]; n = 121) and topotecan (n = 60) random assignments, RRs for ORR were 0.94 and 1.22, respectively. A potential interaction between I and B was identified. For patients in the bevacizumab-irinotecan-temozolomide (BIT) arm, the ORR was 23% (95% CI, 10 to 42), and the 1-year PFS estimate was 0.67 (95% CI, 0.47 to 0.80). Conclusion The addition of B met protocol-defined success criteria for ORR and appeared to improve PFS. Within this phase II trial, BIT showed signals of antitumor activity with acceptable tolerability. Future trials will confirm these results in the chemoimmunotherapy era

Pancreatoblastoma in Children: The Expert/Partner Diagnostic and Therapeutic Recommendations

Background and Aims: Pancreatoblastoma (PBL) is a rare malignant epithelial pancreatic neoplasm affecting typically young children. Complete surgical resection is the mainstay of treatment but optimal therapeutic protocol has to be established. Methods: We present international consensus recommendations for the management of pediatric PBL, established by the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT) within EUfunded PARTNER (Paediatric Rare Tumors Network-European Registry) project. The Consensus Conference Standard Operating Procedure methodology was adopted to grade the levels of evidence and strength of recommendations. Results: Pancreatoblastoma can involve any part of pancreas and is usually diagnosed in advanced stages. Serum alpha-fetoprotein is often elevated reflecting tumor burden [Level IV; Grade A]. Histopathological examination is mandatory for diagnosis. Preoperative radiologic work-up should include abdominal MRI and chest CT [IV; A]. Complete surgical resection with negative margins (R0) is the cornerstone of treatment [IV; A] and should be performed in experienced centers. We recommend 2 courses of PLADO (cisplatin, doxorubicine) after R0 surgery and 4 PLADO in case of microscopic residues (R1) or resected involved lymph nodes. In unresectable and metastatic PBL, neo-adjuvant PLADO (2-6 courses) is advised [IV; B]. Feasibility of complete resection should be evaluated every 2 courses. In case of inadequate response, ICE (ifosfamide, carboplatin, etoposide) [IV; C] or VAC (vincristine, dactinomycine, cyclophosphamide) regimens are alternatives [V; C]. The impact of radiotherapy in incompletely resected PBL remains unproven, and potential side effects in young children have to be considered. Long-term monitoring of pancreatic, auditory, cardiac and renal functions is mandatory [IV; B]. Conclusions: The prognosis is usually favorable in completely resected pediatric PBL. Unresectable and/or metastatic PBL may become amenable to complete delayed surgery after neo-adjuvant PLADO chemotherapy. Discussion in multidisciplinary teams with oncologists and surgeons and enrolment of patients in the national or European database are mandatory. EU Funding: PARTNER GA n.777336 - 3rdHP (2014-2020

Shedding a Light on the Challenges of Adolescents and Young Adults with Rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is a typical tumour of childhood but can occur at any age. Several studies have reported that adolescent and young adult (AYA) patients with RMS have poorer survival than do younger patients. This review discusses the specific challenges in AYA patients with pediatric-type RMS, exploring possible underlying factors which may influence different outcomes. Reasons for AYA survival gap are likely multifactorial, and might be related to differences in tumor biology and intrinsic aggressiveness, or differences in clinical management (that could include patient referral patterns, time to diagnosis, enrolment into clinical trials, the adequacy and intensity of treatment), as well as patient factors (including physiology and comorbidity that may influence treatment tolerability, drug pharmacokinetics and efficacy). However, improved survival has been reported in the most recent studies for AYA patients treated on pediatric RMS protocols. Different strategies may help to further improve outcome, such as supporting trans-age academic societies and national/international collaborations; developing specific clinical trials without upper age limit; defining integrated and comprehensive approach to AYA patients, including the genomic aspects; establishing multidisciplinary tumor boards with involvement of both pediatric and adult oncologists to discuss all pediatric-type RMS patients; developing dedicated projects with specific treatment recommendations and registry/database

Phase I/II Study of the WEE1 Inhibitor Adavosertib (AZD1775) in Combination with Carboplatin in Children with Advanced Malignancies: Arm C of the AcSé-ESMART Trial

International audienceAbstract Purpose: AcSé-ESMART Arm C aimed to define the recommended dose and activity of the WEE1 inhibitor adavosertib in combination with carboplatin in children and young adults with molecularly enriched recurrent/refractory malignancies. Patients and Methods: Adavosertib was administered orally, twice every day on Days 1 to 3 and carboplatin intravenously on Day 1 of a 21-day cycle, starting at 100 mg/m2/dose and AUC 5, respectively. Patients were enriched for molecular alterations in cell cycle and/or homologous recombination (HR). Results: Twenty patients (median age: 14.0 years; range: 3.4–23.5) were included; 18 received 69 treatment cycles. Dose-limiting toxicities were prolonged grade 4 neutropenia and grade 3/4 thrombocytopenia requiring transfusions, leading to two de-escalations to adavosertib 75 mg/m2/dose and carboplatin AUC 4; no recommended phase II dose was defined. Main treatment-related toxicities were hematologic and gastrointestinal. Adavosertib exposure in children was equivalent to that in adults; both doses achieved the cell kill target. Overall response rate was 11% (95% confidence interval, 0.0–25.6) with partial responses in 2 patients with neuroblastoma. One patient with medulloblastoma experienced unconfirmed partial response and 5 patients had stable disease beyond four cycles. Seven of these eight patients with clinical benefit had alterations in HR, replication stress, and/or RAS pathway genes with or without TP53 alterations, whereas TP53 pathway alterations alone (8/10) or no relevant alterations (2/10) were present in the 10 patients without benefit. Conclusions: Adavosertib–carboplatin combination exhibited significant hematologic toxicity. Activity signals and identified potential biomarkers suggest further studies with less hematotoxic DNA-damaging therapy in molecularly enriched pediatric cancers