Antitumor Activity of Hu14.18-IL2 in Patients With Relapsed/Refractory Neuroblastoma: A Children's Oncology Group (COG) Phase II Study

Article (PDF Available)inJournal of Clinical Oncology 28(33):4969-75 · October 2010with46 Reads
DOI: 10.1200/JCO.2009.27.8861 · Source: PubMed
Abstract
The hu14.18-IL2 fusion protein consists of interleukin-2 molecularly linked to a humanized monoclonal antibody that recognizes the GD2 disialoganglioside expressed on neuroblastoma cells. This phase II study assessed the antitumor activity of hu14.18-IL2 in two strata of patients with recurrent or refractory neuroblastoma. Hu14.18-IL2 was given intravenously (12 mg/m(2)/daily) for 3 days every 4 weeks for patients with disease measurable by standard radiographic criteria (stratum 1) and for patients with disease evaluable only by [(123)I]metaiodobenzylguanidine (MIBG) scintigraphy and/or bone marrow (BM) histology (stratum 2). Response was established by independent radiology review as well as BM histology and immunocytology, and durability was assessed by repeat evaluation after more than 3 weeks. Thirty-nine patients were enrolled (36 evaluable). No responses were seen in stratum 1 (n = 13). Of 23 evaluable patients in stratum 2, five patients (21.7%) responded; all had a complete response (CR) of 9, 13, 20, 30, and 35+ months duration. Grade 3 and 4 nonhematologic toxicities included capillary leak, hypoxia, pain, rash, allergic reaction, elevated transaminases, and hyperbilirubinemia. Two patients required dopamine for hypotension, and one patient required ventilatory support for hypoxia. Most toxicities were reversible within a few days of completing a treatment course and were expected based on phase I results. Patients with disease evaluable only by MIBG and/or BM histology had a 21.7% CR rate to hu14.8-IL2, whereas patients with bulky disease did not respond. Hu14.18-IL2 warrants further testing in children with nonbulky high-risk neuroblastoma.
Antitumor Activity of Hu14.18-IL2 in Patients With
Relapsed/Refractory Neuroblastoma: A Children’s Oncology
Group (COG) Phase II Study
Suzanne Shusterman, Wendy B. London, Stephen D. Gillies, Jacquelyn A. Hank, Stephan D. Voss,
Robert C. Seeger, C. Patrick Reynolds, Jennifer Kimball, Mark R. Albertini, Barrett Wagner, Jacek Gan,
Jens Eickhoff, Kenneth B. DeSantes, Susan L. Cohn, Toby Hecht, Brian Gadbaw, Ralph A. Reisfeld,
John M. Maris, and Paul M. Sondel
From the Dana-Farber Cancer Institute and
Children’s Hospital Boston, Boston; Chil-
dren’s Oncology Group Statistics and Data
Center, Gainesville, FL; Provenance Biop-
harmaceuticals, Waltham, MA; University
of Wisconsin Carbone Cancer Center,
Madison WI; Children’s Hospital of Los
Angeles, Los Angeles; The Scripps
Research Institute, La Jolla, CA; University
of Texas, Lubbock, TX; University of
Chicago, Chicago, IL; National Cancer Insti-
tute, Biologic Resources Branch, Frederick,
MD; and The Children’s Hospital of Phila-
delphia, Philadelphia, PA.
Submitted January 12, 2010; accepted
August 20, 2010; published online ahead of
print at www.jco.org on October 4, 2010.
Supported by National Institutes of Health
(NIH)/National Cancer Institute (NCI) Grant
No. U10CA98543 (Children’s Oncology
Group [COG] Group Chair), NIH/NCI Grant
No. U10 CA98413 (COG Statistics and
Data Center), and NIH/NCI Grants No.
R01-CA-32685-25, CA87025, CA81403,
and RR03186, and grants from the
Midwest Athletes for Childhood Cancer
Fund, the Crawdaddy Foundation, and The
Evan Dunbar Foundation. Hu14.18-IL2
(EMD 273063) was produced through a
Material Cooperative Research and Devel-
opment Agreement between the NCI and
Merck KGaA.
Presented in part at the 44th Annual Meet-
ing of the American Society of Clinical
Oncology, May 30-June 3, 2008, Chicago,
IL (J Clin Oncol 26:132s, 2008 [suppl; abstr
3002]).
Terms in blue are defined in the glossary,
found at the end of this article and online
at www.jco.org.
Authors’ disclosures of potential conflicts
of interest and author contributions are
found at the end of this article.
Clinical Trials repository link available on
JCO.org.
Corresponding author: Paul M. Sondel,
MD, PhD, Department of Pediatrics, 4159
MACC Fund Childhood Cancer Research
Wing, Wisconsin Institute of Medical
Research, UW-Madison, 1111 Highland
Ave, Madison WI, 53792; e-mail:
pmsondel@humonc.wisc.edu.
© 2010 by American Society of Clinical
Oncology
0732-183X/10/2833-4969/$20.00
DOI: 10.1200/JCO.2009.27.8861
ABSTRACT
Purpose
The hu14.18-IL2 fusion protein consists of interleukin-2 molecularly linked to a humanized
monoclonal antibody that recognizes the GD2 disialoganglioside expressed on neuroblastoma
cells. This phase II study assessed the antitumor activity of hu14.18-IL2 in two strata of patients
with recurrent or refractory neuroblastoma.
Patients and Methods
Hu14.18-IL2 was given intravenously (12 mg/m
2
/daily) for 3 days every 4 weeks for patients with
disease measurable by standard radiographic criteria (stratum 1) and for patients with disease
evaluable only by [
123
I]metaiodobenzylguanidine (MIBG) scintigraphy and/or bone marrow (BM)
histology (stratum 2). Response was established by independent radiology review as well as BM
histology and immunocytology, and durability was assessed by repeat evaluation after more than
3 weeks.
Results
Thirty-nine patients were enrolled (36 evaluable). No responses were seen in stratum 1 (n 13).
Of 23 evaluable patients in stratum 2, five patients (21.7%) responded; all had a complete
response (CR) of 9, 13, 20, 30, and 35 months duration. Grade 3 and 4 nonhematologic toxicities
included capillary leak, hypoxia, pain, rash, allergic reaction, elevated transaminases, and hyper-
bilirubinemia. Two patients required dopamine for hypotension, and one patient required ventila-
tory support for hypoxia. Most toxicities were reversible within a few days of completing a
treatment course and were expected based on phase I results.
Conclusion
Patients with disease evaluable only by MIBG and/or BM histology had a 21.7% CR rate to
hu14.8-IL2, whereas patients with bulky disease did not respond. Hu14.18-IL2 warrants further
testing in children with nonbulky high-risk neuroblastoma.
J Clin Oncol 28:4969-4975. © 2010 by American Society of Clinical Oncology
INTRODUCTION
Most children with neuroblastoma present with
metastatic disease and/or high-risk features.
1,2
Despite multimodal intensive induction and con-
solidation therapy that provides responses for ap-
proximately 80% of patients, fewer than 40% of
patients with high-risk disease are cured.
2,3
The ma-
jority of responding patients eventually die from
recurrent disease, indicating that they still harbor
viable neuroblastoma after front-line therapy.
The GD2 disialoganglioside is expressed on
most neuroblastomas and melanomas and weakly
on peripheral nerves.
4-6
Clinical trials using murine
(3F8 and 14.G2a) and chimeric (ch14.18) anti-GD2
monoclonal antibodies (mAbs) have shown con-
trollable toxicity (including pain and fever), but rare
antitumor effects against measurable disease.
7-11
Preclinical data suggest in vivo activity is mediated
by antibody-dependent cell-mediated cytotoxicity
(ADCC) and is most effective in the minimal resid-
ual disease setting.
12-15
ADCC may be enhanced by
interleukin-2 (IL-2), which activates natural killer
(NK) cells,
16,17
and by granulocyte-macrophage
colony-stimulating factor (GM-CSF), which acti-
vates neutrophils and macrophages.
18
Clinical trials
have administered anti-GD2 mAbs together with
IL-2 and/or GM-CSF.
19-26
Recently a Children’s
JOURNAL OF CLINICAL ONCOLOGY
ORIGINAL REPORT
VOLUME 28 NUMBER 33 NOVEMBER 20 2010
© 2010 by American Society of Clinical Oncology
4969
Oncology Group (COG) phase III trial in patients with high-risk
neuroblastoma showed a 66% versus 46% (P .01) advantage in
event-free survival (EFS) and a 86% versus 75% (P .02) advantage in
overall survival (OS) using a regimen of ch14.18 plus GM-CSF plus
IL-2 and isotretinoin versus isotretinoin alone.
27
The hu14.18-IL2 fusion protein consists of the humanized
14.18 anti-GD2 mAb linked to IL-2.
28
Hu14.18-IL2 localizes to
GD2-positive tumor cell surfaces via the mAb component. The
IL-2 component binds to and activates both NK and T cells via
their IL-2 receptors, whereas the Fc end triggers ADCC and
complement-dependent cytotoxicity (Buhtoiarov et al, manu-
script submitted for publication).
28-30
Hu14.18-IL2 has preclinical
activity in neuroblastoma-bearing mice via NK-mediated effects,
especially when there is a smaller tumor burden.
14,31
In mice
hu14.18-IL2 has superior antitumor activity compared with
ch14.18 mAb combined with IL-2.
13,32
Phase I testing of hu14.18-IL2 demonstrated biologic activity,
clinical tolerability, and a maximum-tolerated dose of 12 mg/m
2
/d for
3 days.
33,34
Dose-limiting toxicities (DLT) included hypotension and
allergic reactions.
The primary objective of this study was to determine the antitu-
mor activity of hu14.18-IL2 in subjects with measurable disease and
subjects with disease evaluable only by [
123
I]metaiodobenzylguani-
dine (MIBG) scintigraphy and/or bone marrow (BM) histology.
PATIENTS AND METHODS
Eligibility
Patients with recurrent or refractory neuroblastoma (age, 12 months to
22 years) were eligible. Primary refractory disease (persistent tumor after
front-line therapy) required a biopsy demonstrating viable tumor. There were
no prior therapy limitations. Eligibility required organ function, performance
status, recovery from prior therapy, and life expectancy standard for COG
phase II trials. Patients with CNS disease were excluded, as were patients
requiring immunosuppression. Institutional review board–approved in-
formed consent (and assent when applicable) was obtained for all patients.
Study Design
This phase II, single-arm trial evaluated the activity of hu14.18-IL2 sep-
arately for two patient strata. Stratum 1 included patients with disease measur-
able by computed tomography and/or magnetic resonance imaging using
standard radiographic criteria. Stratum 2 included patients with disease evalu-
able only by
123
I-MIBG scintigraphy and/or BM histology.
Hu14.18-IL2 (EMD 273063) was supplied collaboratively by the Na-
tional Cancer Institute (Bethesda, MD) as well as EMD Pharmaceuticals
(Durham, NC) and Merck KGaA (Darmstadt, Germany). Hu14.18-IL2 (12
mg/m
2
/dose) was administered on an inpatient basis as a 4-hour intravenous
infusion over 3 consecutive days. Patients received indomethacin (0.5 mg/kg/
dose, every 6 hours). Treatment cycles were 28 days. Toxicities were graded by
the National Cancer Institute Common Toxicity Criteria (v3.0). DLT was
defined as any grade 3 or worse toxicity, with certain reversible exceptions
identified in the phase I studies.
33,34
Treatment was held for DLT and restarted
at 50% of the previous dose once toxicity resolved. Disease evaluations were
done every two courses.
35
Treatment was continued for four courses in the
absence of progressive disease or drug intolerance. Subsequent treatment
could continue for two courses after reaching a complete response (CR).
Evaluation of Response
All patients who completed two or more courses of hu14.18-IL2 or
who had an event (relapse or progressive disease) were evaluable for
response. All responses were confirmed by independent radiology review
and marrow immunocytology.
The International Neuroblastoma Response Criteria were used to define
response.
36
For measurable disease, response was determined using the Re-
sponse Evaluation Criteria in Solid Tumors (RECIST). Response for stratum 2
patients was determined as follows:
MIBG response. Patients graded locally with CR or partial response
(PR) for MIBG were scored by central review using the Curie scale.
37
CR was
defined by complete resolution of all MIBG-avid lesions.
BM response. For patients who entered with BM disease (neuroblas-
toma identified in the BM aspirate and/or biopsy by the local pathologist
using standard histology), CR was defined as no tumor cells detectable by
morphology and immunocytologic analysis on two subsequent bilateral
BM aspirates/biopsies done 3 weeks apart. Progressive disease (PD) was
defined as 25% tumor in the marrow and a doubling in the percentage of
tumor. Stable disease (SD) was defined as persistence of disease that does
not meet criteria for CR or PR. Patients who cleared morphologic tumor
but still had immunocytochemistry-detectible tumor (sensitive to 1 tumor
cell in 1 10
5
nucleated cells)
35
were classified as having SD.
Immunologic Monitoring
Absolute lymphocyte counts were determined at each institution pre-
treatment and on days 1, 3, 4, 8, and 15 of each course. Serum samples were
obtained pretreatment, immediately after treatment on days 1 and 3, and on
days 4 and 8 of each course. These were analyzed for hu14.18-IL2 levels,
anti-hu14.18-IL2 antibody, and soluble IL-2 receptor (sIL2R).
38,39
Statistical Considerations
The primary end point of this study was response. Responders were
defined as evaluable patients who demonstrated a best overall response of CR,
very good partial response, or PR. Using a one-stage rule, if four or more
Table 1. Patient Characteristics by Stratum
Characteristic
Stratum 1
(n 15)
Stratum 2
(n 24)†
Total
(n 39)
No. % No. % No. %
Eligible patients 15 100 24 100 39 100
Patients evaluable for toxicity 14 93 24 100 38 97
Patients evaluable for response 13 87 23 96 36 92
Age at diagnosis, months
18 000000
18 15 100 24 100 39 100
INSS stage
1, 2, 3, 4s 0 0 2 8 2 5
4 11 7315 6326 67
Unknown 4 27 7 29 11 28
MYCN status
Not amplified 7 47 11 46 18 46
Amplified 4 27 2 8 6 15
Unknown 4 27 11 46 15 38
Ploidy
Hyperdiploid 6 40 10 42 16 41
Diploid 4 27 3 12 7 18
Unknown 5 33 11 46 16 41
Histology
Favorable 0 0 0 0 0 0
Unfavorable 9 60 11 46 20 51
Unknown 6 40 13 54 19 49
No. of courses administered
Total 35 76 110
Median 2 2.5 2
Range 1-6 1-6 1-6
Abbreviation: INSS, International Neuroblastoma Staging System.
Disease measurable by standard radiographic criteria.
†Disease evaluable only by iodine-123 metaiodobenzylguanidine and/or bone
marrow histology.
Shusterman et al
4970 © 2010 by American Society of Clinical Oncology
J
OURNAL OF CLINICAL ONCOLOGY
patients responded of the first 20 evaluable in a given stratum, the regimen was
considered effective.
A two-stage rule was used to monitor for an excessive number of unac-
ceptable DLTs, where unacceptable was defined as a requirement for pressor
and/or ventilator support due to acute vascular leak syndrome. Secondary
analyses of EFS and OS were performed as intent to treat. For EFS, time to
event was from enrollment until first occurrence of relapse, progression, death,
or secondary malignancy or until last contact if no event was observed. For OS,
the event was death. Survival estimates (Kaplan-Meier) were calculated
40
and
reported with SEs.
41
Estimates of the mean value of biologic correlates are presented the SE.
A paired t test was used to test the change from baseline to a subsequent time
point. A two-sample t test was used to compare the level of a particular biologic
correlate for responders versus nonresponders. A nonparametric Spearman’s
rank correlation analysis was performed to test for association between
hu14.18-IL2 levels and anti-hu14.18-IL2 antibody response (both the bridging
and the binding assays). All analyses were performed using SAS software
version 9.2 (SAS Institute, Cary, NC). P values less than .05 were considered
statistically significant.
RESULTS
Patient Characteristics
A total of 39 patients (all eligible) were enrolled, 15 in stratum 1
and 24 in stratum 2 (Table 1). The 15 patients in stratum 1 received a
total of 35 treatment courses (median, two courses), and the 24 pa-
tients in stratum 2 received a total of 76 courses (median, 2.5 courses).
Response and Outcome
Two patients in stratum 1 were not evaluable for response. One
received no treatment due to parental choice, and the other received
only one dose of drug secondary to vascular leak and hypotension. Of
the 13 evaluable patients in stratum 1, there were no responders: three
had SD and 10 had PD. One patient in stratum 2 was taken off study
secondary to anaphylaxis during cycle 1 and was not evaluable for
response, leaving 23 evaluable stratum 2 patients. In the first 20 evalu-
able stratum 2 patients, there were five responders, all with CR (Table
2). The statistical criterion for activity required at least four responders
in stratum 2, and this boundary was exceeded. Of the 23 evaluable
stratum 2 patients, five patients had a CR, four patients had SD, and 14
had PD, for an overall response and CR rate of 21.7% (95% CI, 5%
to 37%).
Three of the patients with CR (Table 3) enrolled with disease in
the BM only. One patient had a single MIBG-avid lesion in the right
tibia, and the final responder had BM disease as well as multiple
MIBG-avid sites. This was the first relapse for four of the five patients
who had previously been in a complete remission after myeloablative
chemotherapy and autologous stem-cell transplantation (ASCT). Pa-
tient 29 had primary refractory neuroblastoma and enrolled with
persistent disease 2 months after treatment with
131
I-MIBG and my-
eloablative therapy with autologous stem-cell rescue. Four of these five
patients received six cycles of therapy, and one (patient 10) stopped
therapy after four cycles due to DLT. Two of the responders received
isotretinoin after the completion of protocol-determined therapy.
Four of the patients achieved CR after two cycles of hu14.18-IL2
treatment. Patient 29 had a negative MIBG scan and negative BM
morphology after two cycles of treatment but remained positive by
immunocytology. Both the BM morphology and immunocytology
were clear after four treatment cycles. All five patients had a prolonged
CR, and patient 29 remains in CR at 35 months (additional clinical
details for these patients are provided in Appendix Table A1, on-
line only).
In addition to the five CRs, two additional patients in stratum 2
who were scored as having SD for protocol-defined agent activity
showed suggestion of improvement and are presented here descrip-
tively (patients 3 and 21 in Appendix Table A1). One patient went on
study with multiple MIBG-avid sites and biopsy-proven bone and
marrow disease after ASCT. This patient showed clearing of marrow
disease and had a decrease in MIBG avidity that was close to, but did
not meet, the definition of PR by central review. The other patient
went on study with MIBG-avid disease and BM biopsies showing 10%
to 15% replacement with neuroblastoma. After four courses of treat-
ment, despite a CR by MIBG scintigraphy, the overall response was SD
because of substantial improvement, but incomplete clearing in
the BM.
The overall (n 39) 1-year EFS and OS were 26% 10% and
63% 11%, respectively, with the curves going much lower after 1
year (Fig 1A). For stratum 1 (n 15) and stratum 2 (n 24), both the
Table 2. Response Summary
Stratum
No. of
Evaluable
Patients
No. of
Responders
Level of Response
CR VGPR PR SD PD
1(n 15) 13 0 0 0 0 3 10
2(n 24) 23 5 5 0 0 4 14
Abbreviations: CR, complete response; VGPR, very good partial response;
PR, partial response; SD, stable disease; PD, progressive disease.
Table 3. Response Details
Patient Disease at Study Entry Courses Dose Reduction Required Response Time to Event
(months)
2 Bone marrow 6 No CR 13†
10 Bone marrow 4 Yes CR 9
22 MIBG (1 site) 6 Yes CR 20†
27 Bone marrow 6 No CR 30
29 Bone marrow, MIBG (multiple sites) 6 No CR No event‡
Abbreviations: CR, complete response; MIBG, iodine-123 metaiodobenzylguanidine.
Time to progression from start of therapy.
†Patient received cis-retinoic acid after the completion of hu14.18-IL2.
‡Patient in remission for 35 months at last follow-up.
Phase II Clinical Activity of Hu14.18-IL2 in Neuroblastoma
www.jco.org © 2010 by American Society of Clinical Oncology 4971
EFS (Fig 1B) and OS (Fig 1C) curves trend to similar low values after
1 year.
Toxicity
Of the 38 patients evaluable for toxicity, eight received only one
course of therapy: six due to PD and two due to DLT. The grade 3 and
4 toxicities observed over all treatment courses are listed in Table 4.
Most toxicities were self-limited and resolved within a few days of the
last dose of hu14.18-IL2 for that treatment course.
Two patients had unacceptable DLTs. One developed grade 3
hypotension after the first dose of hu14.18-IL2 in course 1 and re-
quired treatment with dopamine for 24 hours. The other developed
capillary leak and hypoxia that required pressors and ventilator sup-
port for 2 weeks. This toxicity developed after the final dose of
hu14.18-IL2 during course 2. In retrospect, this patient had two prior
episodes requiring ventilator support because of capillary leak after
ASCT 1 year prior. After this event, the protocol was amended to
exclude patients with a prior history of ventilator support related to
lung injury. All DLTs are listed in Table 5.
Correlative Studies
Stratum 1 and stratum 2 patients were combined for these cor-
relative analyses.
Hu14.18-IL2 levels. The mean change in the serum hu14.18-IL2
level from baseline (course 1, day 1, before first dose) to (1) the day 1
peak value was 2.4 0.9
g/mL (n 36) and (2) the day 3 peak value
was 2.1 0.8
g/mL (n 31). During course 1, the change from
baseline to day 3 was less than the change from baseline to day 1
(P .001); this was true for all courses (courses 1 through 6). Within the
36 patients evaluable for response, for each time point (day 1 peak, day 3
peak) and course (1 through 6), the hu14.18-IL2 peak levels for respond-
ers (n 5) were similar to those of nonresponders (P .15 at each time).
Absolute lymphocyte count. As noted previously,
34
subjects
showed a significant (P .001) decrease in their absolute lymphocyte
count (ALC) with hu14.18-IL2 treatment (course 1, baseline to day 3
decrease of 830 940 cells/
L[n 29]; baseline to day 4 decrease of
710 770 cells/
L[n 25]). Although this drop in ALC is scored as
hematologic toxicity, it actually represents immune activation and
margination of lymphocytes, a known effect of IL-2.
42
This transient
lymphopenia (Appendix Fig A1, online only) is followed by lympho-
cytosis consistent with immune activation (course 1, baseline to day 8
increase (P .001) of 2,360 2,160 cells/
L[n 26]). A similar
A
0
OS
EFS
Survival (%)
Time After Enrollment (Years)
100
80
60
40
20
1 2 3
B
0
Stratum 2
Stratum 1
Stratum 2
Stratum 1
Event-Free Survival (%)
Time After Enrollment (Years)
100
80
60
40
20
1 2 3
C
0
Overall Survival (%)
Time After Enrollment (Years)
100
80
60
40
20
1 2 3
4
1
12
10
2
5
Fig 1. (A) Event-free survival (EFS) and overall survival (OS) for all patients; (B)
EFS for stratum 1 and stratum 2; (C) OS for stratum 1 and stratum 2. The
numbers alongside each curve, at the 1-year time point, indicate the number of
patients corresponding to that curve at the 1-year time point.
Table 4. Grade 3 and 4 Toxicities for All Courses of Therapy
Toxicity
No. of Patients
(n 38)
Incidence of
Toxicity (%)
Acute vascular leak syndrome 12 31.6
Allergic reaction/hypersensitivity 4 10.5
ALT elevation 8 21.1
AST elevation 9 23.7
Bilirubin 8 21.1
Fever (without neutropenia) 15 39.5
Hemoglobin 9 23.7
Hypokalemia 4 10.5
Hyponatremia 2 5.3
Hypotension 6 15.8
Infection (catheter-related) with
ANC 1,000/
L 5 13.2
Leukocytes 9 23.7
Lymphocytes 15 39.5
Neutrophils 13 34.2
Pain (head/headache) 4 10.5
Pain (other) 12 31.6
Platelets 16 42.1
Pleural effusion (nonmalignant) 2 5.3
Pneumonitis/pulmonary infiltrates 2 5.3
Rash 2 5.3
Urticaria 2 5.3
Abbreviation: ANC, absolute neutrophil count.
Number of patients reporting at least one grade 3 or 4 toxicity over all
courses. Treatment was not initiated in one patient.
Shusterman et al
4972 © 2010 by American Society of Clinical Oncology
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pattern of somewhat smaller ALC decreases from baseline to days 3
and 4 was seen in subsequent courses; the decreases in courses 5 and 6
were not significant.
sIL2R levels. As noted previously,
34
there was a significant in-
crease in sIL2R levels at all courses from baseline to days 4 and 8
(P .0001 for courses 1 through 3; P .01 for courses 4 through
6). sIL2R values in courses 2, 3, 5, and 6 were higher than on
corresponding days in course 1. Within the 36 patients evaluable
for response, 31 reported an sIL2R level on day 4 of course 1: the
five responders had a mean sIL2R of 17,006 6,277 pg/mL versus
11,104 4,372 pg/mL for the 26 not responding (P .015). In a
comparison of sIL2R levels for the patients with a DLT versus those
without a DLT, there was no association.
Anti-hu14.18-IL2 antibody response. Of 36 evaluable patients, 13
patients developed an anti-idiotypic antibody against hu14.18-IL2
based on the bridging assay, and 16 developed an anti-idiotypic anti-
body based on the binding inhibition assay.
38,39
However, there was
no apparent effect of this anti-idiotypic antibody response on the in
vivo level of hu14.18-IL2. Specifically, there was no significant associ-
ation of the level of anti-idiotypic antibody developed after course 1
(or after course 2) with any detectible decrease in peak hu14.18-IL2
level seen on day 1 of course 2 versus the level seen on day 1 of course
1. This is in contrast to the decrease in hu14.18-IL2 levels from course
1, day 1, to course 2, day 1, for those patients with a strong anti-
idiotypic antibody response in our past phase I trials (where most
patients received lower doses).
39
Furthermore, there was no associa-
tion of anti-idiotypic antibody response (by either of these assays) with
antitumor effect for the five CRs.
All of the correlative analyses described above comparing the five
patients in CR with the others were repeated, comparing the seven
“improved” patients (ie, the five patients with CRs plus the two pa-
tients in stratum 2 who were scored as having SD, but showed clinical
improvement in BM and or MIBG [patients 3 and 21 in Appendix
Table A1]) versus the other patients. For this comparison, no statisti-
cally significant associations were found between hu14.18-IL2 levels,
sIL2R levels, or anti-idiotypic antibody response with antitumor ac-
tivity. Furthermore, no significant associations were found between
response and factors at diagnosis (age, stage, MYCN, ploidy, or histo-
logic grade; Appendix Table A1).
DISCUSSION
This study demonstrates antitumor activity of hu14.18-IL2 in patients
with relapsed/refractory neuroblastoma with stratum 2 disease. Five
(of 23 evaluable) stratum 2 patients had a durable CR to therapy, and
two additional patients showed evidence of improvement. Although
this study did not collect data specifically quantifying disease burden at
enrollment, there is the suggestion from their clinical descriptions that
the five responders began treatment with relatively small but clearly
evaluable tumor burdens: limited MIBG-avid lesions (rather than
diffuse skeletal MIBG avidity) and partial contamination of marrow
with tumor cells (rather than marrow replacement). Even so, all re-
sponders had a poor clinical prognosis after being refractory to or
relapsing after frontline therapy. In contrast, none of the 15 patients
entered into stratum 1 showed evidence of antitumor activity. This
trial was not designed or powered to test for a difference in the re-
sponse rate between stratum 1 and 2; however, five CRs of 23 evaluable
patients in stratum 2 compared with 0 of 13 patients in stratum 1 has
a P value of .089. If one includes in this analysis the two additional
stratum 2 patients with SD but descriptive improvement (patients 3
and 21 in Appendix Table A1), the difference is significant between the
strata (P .029). These results are consistent with preclinical data
showing that the efficacy of hu14.18-IL2 is best seen when used in the
minimal residual disease setting.
14
The clinical toxicities seen in this study were consistent with those
previously reported for hu14.18-IL2
33,34
and for anti-GD2 mAb plus
IL-2.
19-21,25
Most toxicities resolved within days; only three patients
had their therapy discontinued because of toxicity.
Evidence for immune activation was seen as changes in sIL2R
levels and lymphocytosis. Neither of these were correlated with anti-
tumor response or with toxicity. Although there was a significant
increase in sIL2R levels in the five responders compared with the
others, this correlation was not seen when the two “improved” patients
Table 5. Dose-Limiting Toxicity
Patient Course Toxicity Result
3 2 Grade 3 hypoxia, pneumonitis/pulmonary infiltrates Tolerated courses 3-6 at 50% dosing
4 2 Grade 4 acute vascular leak Therapy discontinued due to toxicity
10 3 Grade 3 acute vascular leak Course 4 at 50% dosing, discontinued day 2
13 1 Grade 3 acute vascular leak and hypotension Therapy discontinued due to toxicity
14 2 Grade 3 hyperbilirubinemia Course 3 50% dosing, course 4 25% dosing
18 1 Grade 3 transaminitis Tolerated course 2 at full dose
19 3 Grade 3 transaminitis Tolerated course 4 at 50% dosing
21 4 Grade 3 transaminitis Repeat toxicity course 5 at 50% dosing
22 4 Grade 3 hyperbilirubinemia Tolerated course 5 at 50% dosing and course 6 at 75% dosing
24 1 Grade 3 transaminitis Tolerated courses 2-4 at 50% dosing
26 1 Grade 3 hyperbilirubinemia Tolerated course 2 at 50% dosing
31 2 Grade 3 hypotension Off study end of course due to PD
32 1 Grade 4 allergic reaction Therapy discontinued due to toxicity
34 2 Grade 3 hypotension Tolerated course 3 at 50% dosing and course 4 at 75% dosing
37 1 Grade 3 transaminitis Tolerated course 2 at 50% dosing
38 2 Grade 3 acute vascular leak Tolerated courses 3-6 at 50% dosing
Abbreviation: PD, progressive disease.
Dosing in violation of the protocol.
Phase II Clinical Activity of Hu14.18-IL2 in Neuroblastoma
www.jco.org © 2010 by American Society of Clinical Oncology 4973
were included in the analysis. Anti-idiotypic antibody was detected in 13
and 16 of 36 patients using two different assays. This anti-idiotypic anti-
body was not correlated with antitumor activity, in contrast to clinical
response correlations with human antimouse antibody detection re-
ported in other studies.
43,44
This may be due in part to low statistical power
in this study. Furthermore, the anti-hu14.18-IL2 responses we detected
did not seem to have functional significance in that they were not associ-
ated with a subsequent decrease in hu14.18-IL2 levels. This suggests that
the anti-idiotypic antibodies detected were not sufficiently strong to im-
pact the function of the circulating hu14.18-IL2.
The results of this study support further development of
hu14.18-IL2 in patients with recurrent or refractory neuroblastoma
with disease evaluable only by
123
I-MIBG scintigraphy and/or BM
histology. A successor study is being planned to confirm efficacy in
stratum 2 patients and quantify the disease burden in patients before
and after treatment to better define which patients are most likely to
respond to hu14.18-IL2 (see Appendix, online only).
Finally, given the efficacy recently demonstrated for the regimen
of ch14.18 mAb plus IL-2 plus GM-CSF for children with high-risk
neuroblastoma who have achieved response (CR, very good PR, or
PR) to their initial induction and consolidation treatment
27
and the
superiority of ch14.18-IL2 over ch14.18 plus IL-2 as separate mol-
ecules in preclinical studies (Buhtoiarov et al, manuscript submit-
ted for publication; Gubbels et al, manuscript submitted for
publication),
28-30
we hypothesize that hu14.18-IL2 may be more ef-
fective than ch14.18 plus IL-2 in this same clinical setting. Thus the
COG is planning to randomly compare a regimen of hu14.18-IL2 plus
GM-CSF plus isotretinoin versus the now “standard” regimen of
ch14.18 plus GM-CSF plus IL-2 plus isotretinoin in a phase III study
for newly diagnosed patients with high-risk neuroblastoma who have
achieved response to their front-line therapy.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
OF INTEREST
Although all authors completed the disclosure declaration, the following
author(s) indicated a financial or other interest that is relevant to the subject
matter under consideration in this article. Certain relationships marked
with a “U” are those for which no compensation was received; those
relationships marked with a “C” were compensated. For a detailed
description of the disclosure categories, or for more information about
ASCO’s conflict of interest policy, please refer to the Author Disclosure
Declaration and the Disclosures of Potential Conflicts of Interest section in
Information for Contributors.
Employment or Leadership Position: Stephen D. Gillies, Merck Serono
(C) Consultant or Advisory Role: None Stock Ownership: None
Honoraria: None Research Funding: Mark R. Albertini, EMD
Pharmaceuticals Expert Testimony: None Other Remuneration: None
AUTHOR CONTRIBUTIONS
Conception and design: Suzanne Shusterman, Wendy B. London,
Stephen D. Gillies, C. Patrick Reynolds, John M. Maris, Paul M. Sondel
Administrative support: Jennifer Kimball
Provision of study materials or patients: Stephen D. Gillies, Toby
Hecht, John M. Maris, Paul M. Sondel
Collection and assembly of data: Suzanne Shusterman, Wendy B.
London, Jacquelyn A. Hank, Barrett Wagner, Jacek Gan, Brian Gadbaw,
Paul M. Sondel
Data analysis and interpretation: Suzanne Shusterman, Wendy B.
London, Jacquelyn A. Hank, Stephan D. Voss, Mark R. Albertini, Barrett
Wagner, Jacek Gan, Jens Eickhoff, Brian Gadbaw, John M. Maris,
Paul M. Sondel
Manuscript writing: Suzanne Shusterman, Wendy B. London, Stephen
D. Gillies, Jacquelyn A. Hank, Stephan D. Voss, Robert C. Seeger, C.
Patrick Reynolds, Jennifer Kimball, Mark R. Albertini, Barrett Wagner,
Jacek Gan, Jens Eickhoff, Kenneth B. DeSantes, Susan L. Cohn, Toby
Hecht, Brian Gadbaw, Ralph A. Reisfeld, John M. Maris, and
Paul M. Sondel
Final approval of manuscript: Suzanne Shusterman, Wendy B. London,
Stephen D. Gillies, Jacquelyn A. Hank, Stephan D. Voss, Robert C.
Seeger, C. Patrick Reynolds, Jennifer Kimball, Mark R. Albertini, Barrett
Wagner, Jacek Gan, Jens Eickhoff, Kenneth B. DeSantes, Susan L. Cohn,
Toby Hecht, Brian Gadbaw, Ralph A. Reisfeld, John M. Maris, and Paul
M. Sondel
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■■■
Glossary Terms
Monoclonal antibody: An antibody that is secreted from
a single clone of an antibody-forming cell. Large quantities of
monoclonal antibodies are produced from hybridomas, which
are produced by fusing single antibody-forming cells to tumor
cells. The process is initiated when a mouse is immunized ini-
tially against a particular antigen, stimulating the production
of antibodies targeted to different epitopes of the antigen.
Antibody-forming cells are subsequently isolated from the
spleen. By fusing each antibody-forming cell to tumor cells,
hybridomas can be generated each with a different specificity
and targeted against a different epitope of the antigen
ADCC (antibody-dependent cell-mediated
cytotoxicity):
a mechanism of cell-mediated immunity whereby
an effector cell of the immune system actively lyses a target cell that
has been bound by specific antibodies.
Hu14.18-IL2: an immunocytokine, which is a fusion protein,
comprised of one molecule of humanized anti-GD2 monoclonal an-
tibody, with an intact molecule of human interleukin-2 on the car-
boxy terminus of each immunoglobulin G heavy chain.
MIBG Scintigraphy: a nuclear medicine scan using iodine-123
metaiodobenzylguanidine (MIBG) scintigraphy to identify neuro-
blastoma or pheochromocytoma lesions.
Phase II Clinical Activity of Hu14.18-IL2 in Neuroblastoma
www.jco.org © 2010 by American Society of Clinical Oncology 4975
    • "fusion was engineered and used in Phase I and II clinical trials [66,67], with a 21% response rate in patients with minimal disease, but no response in patients with bulky disease of soft-tissue tumors [67,68]. Observed toxicities were similar to what is observed with IL-2 alone, including capillary leak syndrome and abnormal liver functions [44,67]. Phase II clinical trial of hu14.18-IL-2 for both melanoma (NCT00590824) [68] and for neuroblastoma (NCT01334515) have been completed. "
    [Show abstract] [Hide abstract] ABSTRACT: Ganglioside GD2 is highly expressed on neuroectoderm-derived tumors and sarcomas, including neuroblastoma, retinoblastoma, melanoma, small cell lung cancer, brain tumors, osteosarcoma, rhabdomyosarcoma, Ewing's sarcoma in children and adolescents, as well as liposarcoma, fibrosarcoma, leiomyosarcoma and other soft tissue sarcomas in adults. Since GD2 expression in normal tissues is restricted to the brain, which is inaccessible to circulating antibodies, and in selected peripheral nerves and melanocytes, it was deemed a suitable target for systemic tumor immunotherapy. Anti-GD2 antibodies have been actively tested in clinical trials for neuroblastoma for over the past two decades, with proven safety and efficacy. The main limitations have been acute pain toxicity associated with GD2 expression on peripheral nerve fibers and the inability of antibodies to treat bulky tumor. Several strategies have been developed to reduce pain toxicity, including bypassing complement activation, using blocking antibodies, or targeting of O-acetyl-GD2 derivative that is not expressed on peripheral nerves. To enhance anti-tumor efficacy, anti-GD2 monoclonal antibodies and fragments have been engineered into immunocytokines, immunotoxins, antibody drug conjugates, radiolabeled antibodies, targeted nanoparticles, T-cell engaging bispecific antibodies, and chimeric antigen receptors. The challenges of these approaches will be reviewed to build a perspective for next generation anti-GD2 therapeutics in cancer therapy.
    Full-text · Article · Nov 2013
    • "Db diabody, GM-CSF granulocyte-macrophage colonystimulating factor, IFN interferon, IL interleukin, RD IL-15Rasushi? domain, scDb single chain diabody, scFv single chain variable fragment, scIL single chain interleukin, TNFSF tumor necrosis factor superfamily D. Müller neuroblastoma patients [17, 18]. The latter presented less bulky disease at treatment start, suggesting further application of the fusion protein in clinical settings of minimal residual disease. "
    [Show abstract] [Hide abstract] ABSTRACT: Treatment with cytokines holds great potential for cancer immunotherapy, but is generally restricted by systemic toxicity. Tumor-directed targeting in the form of antibody fusion proteins appears to be an attractive strategy to overcome this problem. In the last twenty years, continuous efforts in developing appropriate molecules have retrieved a variety of antibody fusion proteins that reveal promising therapeutic effects in preclinical studies. Currently, several candidates are in clinical evaluation. Here, recent developments exploring diverse antibody formats, tumor targets and cytokines of different families as well as strategies addressing cytokine modification or presentation are discussed and clinical trials summarized at a glance. Thus, antibody-cytokine fusion proteins are becoming progressively improving immunologic reagents that raise expectations mainly for combinatorial cancer therapies.
    Article · Sep 2013
    • "Surprisingly, statistical analysis showed a positive correlation between sEPCR and CD3, CD8 and a negative correlation between CD56 (NK cells), CD29 (integrin β-1, present on all blood cells), CD294 (TH2 cells), and the immune cells containing IL-2, IL-17a, IL-10 and IL-21. IL-2 is one of a multitude of cytokines produced by lymphocytes and monocytes that trigger a cascade of immune reactions ( 33 ) . IL-10 inhibits the synthesis of pro-inflammatory cytokines such as IFN-γ, IL-2 and TNFα. "
    [Show abstract] [Hide abstract] ABSTRACT: In spite of the growing importance of endothelial protein C receptor/active protein C (EPCR/aPC) in tumor biology, their impact on immunological homeostasis remains largely unexplored. The objective of this study was to assess whether soluble plasma endothelial protein C receptor (sEPCR), which is a regulator of circulating aPC, is involved in innate immune response in cancer patients. In the Ovcar-3 ovarian cancer line, the role of aPC in secretion of cytokines was analyzed. In parallel, in 33 patients, with a diagnosis of ovarian epithelial cancer, sEPCR was quantified, blood immune cell phenotypes were determined by flow cytometry and plasma cytokines were evaluated using a protein array. Spearman's rank correlation coefficients (r) and coefficient significance was determined by a statistical hypothesis test (α=0.05). Our results show that i) aPC induced the secretion of several cytokines in Ovcar-3 cells; ii) 61% of patients exhibited a concentration of plasma sEPCR well above the baseline (normal plasma level, 100±28 ng/ml); iii) comparing immune cell phenotypes in patients having a normal level of sEPCR with those having a high level of sEPCR, it was found that sEPCR levels were correlated with high intensity of cells expressing CD45ra, CD3, CD8, CD25 and low intensity of cells expressing CD56 (NK cells), CD294 (TH2 cells), IL-2, IL-10, IL-17a (TH17 cells), IL-21 (TH21 cells) and CD29 markers (r ≥0.60); and iv) high levels of sEPCR correlate with high levels of plasma bioactive proteins such as insulin-like growth factor-2 (IGFII), IL-13rα, macrophage inflammatory protein (MIP1α) and matrix metalloproteinase-7 (MMP-7) that have already been proposed as biomarkers for ovarian cancer and particularly those with poor prognosis. In conclusion, sEPCR produced by ovarian cancer cells, by modulating circulating aPC, influences the secretory behavior of tumor cells (cytokines and interleukins). Consequently, sEPCR in turn acts on the innate immune response by decreasing effector cells such as natural killer and T helper cells (TH2, TH17 and TH21).
    Full-text · Article · Jul 2013
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