Dinutuximab (Unituxin)

Number: 0895

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

1. Criteria for Initial Approval

   Neuroblastoma

   1. Aetna considers dinutuximab (Unituxin) medically necessary, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) [sargramostim (Leukine)], interleukin-2 (IL-2) [aldesleukin (Proleukin)], and 13-cis-retinoic acid (RA) (isotretinoin), for the treatment of high-risk neuroblastoma when all of the following criteria are met:

      1. Member is less than 21 years of age; and
      2. Member has achieved at least a partial response to prior first-line multiagent, multimodality therapy that includes induction combination chemotherapy and maximum feasible surgical resection; and
      3. Member has previously had both of the following therapies:
         
         
         1. Myeloablative consolidation chemotherapy followed by autologous stem cell transplant; and
         2. Radiation therapy to residual soft tissue disease.

   2. Aetna considers dinutiximab (Unituxin) medically necessary as chemoimmunotherapy in combination with temozolomide, irinotecan, and sargramostim in members less than 21 years of age for the treatment of neuroblastoma when either of the following criteria are met:

      1. Following induction for high risk disease with either:

         a. Minor response or stable disease (as bridging therapy to standard consolidation); or
         b. Progressive disease; or
      
      2. For progressive disease following consolidation for high risk disease.

   3. Aetna considers dinutiximab (Unituxin) medically necessary for post-consolidation therapy in combination with sargramostim and isotretinoin following consolidation for high risk disease and full disease evaluation with no disease progression in members less than 21 years of age for the treatment of neuroblastoma.

   Aetna considers all other indications as experimental, investigational, or unproven.

2. Continuation of Therapy

   Aetna considers continuation of dinutuximab (Unituxin) therapy (up to a maximum of 5 cycles) medicallly necessary for an indication listed in Section I when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Dosage and Administration

Dinutuximab (Unituxin) is supplied as a 17.5 mg/5 mL (3.5 mg/mL) solution for injection, single-use vial for intravenous infusion. 

The recommended dosing is as follows:

Neuroblastoma

Dinutuximab (Unituxin) is administered as 17.5 mg/m² /day as an intravenous infusion over 10 to 20 hours for 4 consecutive days for a maximum of 5 cycles. Consult the Prescribing Information for dosing administration schedule and required pre-treatment and guidelines for pain management.

Source: United Therapeutics, 2020

Experimental, Investigational, or Unproven

Aetna considers dinutuximab (Unituxin) experimental, investigational, or unproven for all other indications including the following (not an all-inclusive list) because its effectiveness for these indications has not been established:

• Ewing sarcoma
• Ewing-like sarcoma
• Glioblastoma multiforme
• Lung cancer (e.g., small cell lung cancer)
• Osteosarcoma
• Triple-negative breast cancer.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Other CPT codes related to the CPB:
96365	Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
96366	each additional hour (List separately in addition to code for primary procedure)
96401 - 96450	Chemotherapy administration
HCPCS codes covered if selection criteria are met:
Dinutuximab (Unituxin) - no specific code:
Other HCPCS codes related to the CPB:
Irinotecan -no specific code
J2820	Injection, sargramostim (GM-CSF), 50 mcg
J9015	Injection, aldesleukin, per single use vial
J9328	Injection, temozolomide, 1 mg
ICD-10 codes covered if selection criteria are met:
C74.00 - C74.92	Malignant neoplasm of adrenal gland [neuroblastoma]
ICD-10 codes not covered if selection criteria are met:
C34.00 - C34.82	Malignant neoplasm of bronchus and lung [small cell lung cancer]
C40.00 - C41.9	Malignant neoplasm of bone and articular cartilage of limbs [osteosarcoma] [Ewing sarcoma, Ewing-like sarcoma]
C50.011 - C50.929	Malignant neoplasm of breast [triple-negative breast cancer]
C71.0 - C71.9	Malignant neoplasm of brain [glioblastoma multiforme]

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Background

U.S. Food and Drug Administration (FDA)-Approved Indications

• Unituxin, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2), and 13-cis-retinoic acid (RA), is indicated for the treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response to prior first-line multiagent, multimodality therapy.

Compendial Uses

• Neuroblastoma

Neuroblastoma is a tumor derived from primitive cells of the sympathetic nervous system and is the most common extracranial tumor in childhood, the second most common solid tumor in childhood, the most common cancer in infancy, Neuroblastoma makes up approximately 8% of the total number of children's cancers (NIHR HSC, 2014)with an annual incidence in the United States of approximately 700 patients, of whom 50% are diagnosed as having high-risk disease (United Therapeutics, 2015).

Treatment of neuroblastoma depends on risk category, which is determined according to the age of the child, the size and position of the tumor, stage, the tumor biology and whether the neuroblastoma has spread (NIHR HSC, 2014). Based on various prognostic factors and the International Neuroblastoma Staging System (INSS), children are classified into 3 different risk groups: low, intermediate, and high. High-risk neuroblastoma is characterized by age (>1 year), disseminated disease, MYCN oncogene amplification, and/or unfavourable histopathologic findings; approximately 40% of children with neuroblastoma are classified as high-risk.

Unituxin (dinutuximab) is a disialoganglioside, GD2-binding chimeric monoclonal antibody (formerly ch14.18), composed of a combination of mouse and human DNA, which binds to the glycolipid GD2. This glycolipid is expressed on neuroblastoma cells and on normal cells of neuroectodermal origin, including the central nervous system and peripheral nerves. Unituxin (dinutuximab) binds to cell surface GD2 and induces cell lysis of GD2‐expressing cells through antibody‐dependent cell‐mediated cytotoxicity and complement‐dependent cytotoxicity and is part of an immunotherapeutic regimen to treat pediatric high-risk neuroblastoma (United Therapeutics, 2015).

In 2015, dinutuximab (Unituxin) was approved by the FDA for use, in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2 (IL-2), and 13-cis-retinoic acid (RA), for the treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response to prior first-line multiagent, multimodality therapy (FDA, 2015). In clinical trials for FDA approval, dinutuximab was used in pediatric patients with high‐risk neuroblastoma who have previously received induction chemotherapy and achieved at least a partial response, followed by myeloablative therapy and autologous stem cell transplantation (ASCT). 

The FDA approval was based on demonstration of improved event-free survival (EFS) and overall survival (OS) in a multicenter, open-label, randomized trial (ANBL0032) in pediatric patients with high-risk neuroblastoma, conducted by the Children's Oncology Group (COG) (United Therapeutics, 2015).  All patients had received prior therapy consisting of induction combination chemotherapy, maximum feasible surgical resection, myeloablative consolidation chemotherapy followed by autologous stem cell transplant, and radiation therapy to residual soft tissue disease. Patients were required to have achieved at least a partial response prior to autologous stem cell transplantation, have no evidence of disease progression following completion of front-line multi-modality therapy, have adequate pulmonary function (no dyspnea at rest and peripheral arterial oxygen saturation of at least 94% on room air), adequate hepatic function (total bilirubin < 1.5 x the upper limit of normal and ALT < 5 x the upper limit of normal), adequate cardiac function (shortening fraction of > 30% by echocardiogram, or if shortening fraction abnormal, ejection fraction of 55% by gated radionuclide study), and adequate renal function (glomerular filtration rate at least 70 mL/min/1.73 m2). Patients with systemic infections or a requirement for concomitant systemic corticosteroids or immunosuppressant usage were not eligible for enrollment.

The trial randomized (1:1) 226 patients to either the dinutuximab/13-cis-retinoic acid (RA) arm or the RA alone arm.  Patients in each arm received six cycles of treatment.  The dinutuximab/RA arm consisted of dinutuximab in combination with granulocyte macrophage-colony stimulating factor and RA (cycles 1, 3, and 5), dinutuximab in combination with interleukin-2 and RA (cycles 2 and 4), and RA (cycle 6).  Patients were 11 months to 15 years of age (median age 3.8 years). 

The major efficacy outcome measure was investigator-assessed EFS, defined as the time from randomization to the first occurrence of relapse, progressive disease, secondary malignancy, or death (United Therapeutics, 2015).  At the seventh interim analysis, an improvement in EFS [HR 0.57 (95% CI: 0.37, 0.89); p = 0.01, log-rank test] was demonstrated and four remaining patients undergoing treatment on the RA arm crossed over to receive dinutuximab/RA.  The median EFS was not reached (3.4 years, NR) in the dinutuximab/RA arm and was 1.9 years (1.3, NR) in the RA arm.  An analysis of overall survival (OS) conducted three years later documented an improvement in OS in the dinutuximab/RA arm compared to the RA arm [HR 0.58 (95% CI: 0.37, 0.91)].  At the time of this survival analysis, median OS had not been reached in either arm. 

The most common serious adverse reactions (greater than or equal to 5%) are infections, infusion reactions, hypokalemia, hypotension, pain, fever, and capillary leak syndrome (United Therapeutics, 2015). 

The most common adverse drug reactions (greater than or equal to 25%) in dinutuximab/RA compared with RA alone are pain (85% vs. 16%), pyrexia (72% vs. 27%), thrombocytopenia (66% vs. 43%), lymphopenia (62% vs. 36%), infusion reactions (60% vs. 9%), hypotension (60% vs. 3%), hyponatremia (58% vs. 12%), increased alanine aminotransferase (56% vs. 31%), anemia (51% vs. 22%), vomiting (46% vs. 19%), diarrhea (43% vs. 15%), hypokalemia (43% vs. 4%), capillary leak syndrome (40% vs. 1%), neutropenia (39% vs. 16%), urticaria (37% vs. 3%), hypoalbuminemia (33% vs. 3%), increased aspartate aminotransferase (28% vs. 7%), and hypocalcemia (27% vs. 0%) (United Therapeutics, 2015).

Dinutuximab causes severe neuropathic pain in the majority of patients (United Therapeutics, 2017). Intravenous opioid should be administered prior to, during, and for 2 hours following completion of the dinutuximab infusion. Severe (Grade 3) peripheral sensory neuropathy ranged from 2% to 9% in patients with neuroblastoma. In clinical studies of dinutuximab and related GD2-binding antibodies, severe motor neuropathy was observed in adults.  Resolution of motor neuropathy was not documented in all cases. Dinutuximab should be discontinued for severe unresponsive pain, severe sensory neuropathy, or moderate to severe peripheral motor neuropathy.

Black Box Warnings

• Infusion Reactions: Life‐threatening infusion adverse reactions occurred in 26% of patients treated with Unituxin. Administer required prehydration and premedication including antihistamines prior to each Unituxin infusion. Immediately interrupt for severe infusion reactions and permanently discontinue for anaphylaxis.
• Neurotoxicity: Unituxin causes serious neurologic adverse reactions including neuropathic pain and peripheral neuropathy. Administer intravenous opioid prior to, during, and for 2 hours following completion of the Unituxin infusion. In clinical studies of patients with high-risk neuroblastoma, Grade 3 peripheral sensory neuropathy occurred in 2% to 9% of patients. In clinical studies of Unituxin and related GD2-binding antibodies, severe motor neuropathy has occurred. Resolution of motor neuropathy did not occur in all cases. Discontinue Unituxin for severe unresponsive pain, severe sensory neuropathy, and moderate to severe peripheral motor neuropathy.

Warnings and Precautions

• Neurological Disorders of the Eye: Interrupt Unituxin for dilated pupil with sluggish light reflex or other visual disturbances and permanently discontinue Unituxin for recurrent eye disorders or loss of vision.
• Prolonged Urinary Retention and Transverse Myelitis: Permanently discontinue Unituxin and institute supportive care.
• Reversible Posterior Leukoencephalopathy Syndrome (RPLS): Permanently discontinue Unituxin and institute supportive care for signs and symptoms of RPLS.
• Capillary Leak Syndrome and Hypotension: Cases of severe (Grade 3 to 5) capillary leak syndrome occurred in the Unituxin/RA group. Grade 3 or 4 hypotension occurred in 16% patients in the Unituxin/RA group compared to no patients in the RA group. Administer required prehydration and monitor patients closely during treatment. Depending upon severity, manage by interruption, infusion rate reduction, or permanent discontinuation.
• Infection: Sepsis occurred in 18% patients in the Unituxin/RA group and in 9% patients in the RA group. Interrupt until resolution of systemic infection.
• Bone Marrow Suppression: Severe (Grade 3 or 4) thrombocytopenia, anemia, neutropenia, and febrile neutropenia occurred more commonly in patients in the Unituxin/RA group. Monitor peripheral blood counts during Unituxin therapy. 
• Electrolyte Abnormalities: Cases of patients receiving Unituxin developed syndrome of inappropriate antidiuretic hormone secretion resulting in severe hyponatremia.
• Atypical Hemolytic Uremic Syndrome: Hemolytic uremic syndrome in the absence of documented infection and resulting in renal insufficiency, electrolyte abnormalities, anemia, and hypertension occurred in 2 patients following receipt of the first cycle of Unituxin. Atypical hemolytic uremic syndrome recurred following rechallenge with Unituxin in one patient. Permanently discontinue Unituxin and institute supportive management.
• Embryo-Fetal toxicity: May cause fetal harm. Advise of the potential risk to a fetus and to use effective contraception.

Recommended Dose Adjustments

• In the event of mild to moderate adverse reactions such as transient rash, fever, rigors, and localized urticaria that respond promptly to symptomatic treatment:
  
  
  • Onset of reaction: Reduce Unituxin infusion rate to 50% of the previous rate and monitor closely.
  • After resolution: Gradually increase infusion rate up to a maximum rate of 1.75 mg/m²/hour.
    
    
• In the event of prolonged or severe adverse reactions such as mild bronchospasm without other symptoms, angioedema that does not affect the airway:
  
  
  • Onset of reaction: Immediately interrupt Unituxin.
  • After resolution: If signs and symptoms resolve rapidly, resume Unituxin at 50% of the previous rate and observe closely.
  • Second recurrence: Permanently discontinue Unituxin.

Unituxin has not been studied in patients with renal or hepatic impairment. The safety and effectiveness of Unituxin in geriatric patients have not been established (United Therapeutics, 2017).

Ewing Sarcoma/Ewing-Like Sarcoma

Spasov et al (2022) stated that despite multi-modal therapy, the prognosis of patients with metastatic Ewing sarcoma (ES) remains poor, with new treatments urgently needed.  The disialoganglioside GD2, a well-established tumor-associated antigen, is expressed in 40 % to 90 % of ES cells, making it a suitable therapeutic target.  In a retrospective, case-series study, these investigators reported the findings of 3 cases with newly diagnosed, metastatic, GD2-positive ES or Ewing-like sarcoma treated with dinutuximab beta in addition to standard chemotherapeutic regimens.  Treatment was well-tolerated, and all patients achieved complete remission (CR), without evidence of relapse.  The authors concluded that 1st-line anti-GD2 immunotherapy in patients with metastatic, GD2-positive ES or Ewing-like sarcoma represents a promising therapeutic option that warrants further clinical evaluation.

The authors stated that this case-series study had several drawbacks, including its retrospective design, the small patient number (n = 3), and the short follow-up duration (ranging from 14 to 19 months).  These researchers stated that these findings, in addition to previous results achieved with anti-GD2 therapy in neuroblastoma, suggested that a treatment approach combining anti-GD2 immunotherapy and chemotherapy might be worth examining in a wider clinical study in patients with ES and/or ELS, especially those with metastatic disease.

Small Cell Lung Cancer

Edelman et al (2022) stated that topotecan is approved as 2nd-line treatment for small cell lung cancer (SCLC). Irinotecan is also frequently used given its more convenient schedule and superior tolerability. Pre-clinical studies support disialoganglioside (GD2) as an SCLC target and the combination of dinutuximab, an anti-GD2 antibody, plus irinotecan in this setting. In a randomized, phase-III clinical trial, these researchers examined dinutuximab/irinotecan versus irinotecan or topotecan as 2nd-line therapy in relapsed/refractory (RR) SCLC. Patients with RR SCLC and Eastern Cooperative Oncology Group(ECOG) performance status (PS) 0 to 1 were randomized 2:2:1 to receive dinutuximab 16 to 17.5 mg/m2 intravenous (IV)/irinotecan 350 mg/m2 IV (day 1), irinotecan 350 mg/m2 IV (day 1), or topotecan 1.5 mg/m2 IV (days 1 to 5) in 21-day cycles. The primary endpoint was OS; secondary endpoints were progression-free survival (PFS), objective response rate (ORR; complete response [CR] + partial response [PR]), and clinical benefit rate (CBR; CR + PR + stable disease [SD]). Safety/tolerability were also evaluated. A total of 471 patients were randomized to dinutuximab/irinotecan (n = 187), irinotecan (n = 190), or topotecan (n = 94). Age, sex, PS, prior therapies, and metastatic disease sites were similar between groups. Survival and response rates were not improved for patients receiving dinutuximab/irinotecan versus those receiving irinotecan or topotecan (median OS of 6.9 versus 7.0 versus 7.4 months; p = 0.3132; median PFS of 3.5 versus 3.0 versus 3.4 months; p = 0.3482); ORR of 17.1 % versus 18.9 % versus 20.2 % (p = 0.8043); and CBR of 67.4 % versus 58.9 % versus 68.1 % (p = 0.0989), respectively. Grade 3/4 adverse events (AEs; 5 % or higher receiving dinutuximab/irinotecan) included neutropenia, anemia, diarrhea, and asthenia. The authors concluded that dinutuximab/irinotecan treatment did not result in improved OS in RR SCLC versus irinotecan alone. Irinotecan administered every 21 days demonstrated comparable activity to topotecan administered daily × 5 every 21 days.

Triple-Negative Breast Cancer

Ly et al (2021) noted that triple-negative breast cancer (TNBC) is the most aggressive BC subtype with no effective standard therapy. Breast cancer stem-like cells (BCSCs) in primary TNBCs are reported to be responsible for metastatic spread of the disease and resistance to chemotherapy; however, no available therapeutic tools target BCSCs.  These researchers previously reported that the ganglioside GD2 is highly expressed on BCSCs and that inhibition of its expression hampers TNBC growth; thus, they hypothesized that the anti-GD2 antibody dinutuximab (ch14.18) targets GD2+ BCSCs and inhibits TNBC growth.  These investigators tested their hypothesis – they first determined GD2 expression via immunohistochemistry in frozen primary tumor samples from patients with TNBC (n = 89).  Then, they examined the effects of dinutuximab on TNBC cell adhesion, migration, and mammosphere formation in-vitro and on tumor growth in-vivo using TNBC cell-line and patient-derived xenograft (PDX) models.  These researchers found that GD2 was expressed in approximately 60 % of primary TNBC tumors at variable levels and was associated with worse OS of patients with TNBC (p = 0.002).  GD2 was found to be expressed in tumors and stroma, but normal ducts and lobules in adjacent tissues have shown low or no GD2 staining, indicating that GD2 is potentially a novel biomarker for tumor and its micro-environment.  Treatment with dinutuximab significantly decreased adhesion and migration of MDA-MB-231 and SUM159 TNBC cells.  Moreover, dinutuximab treatment inhibited mTOR signaling, which has been shown to be regulated by GD2 in BCSCs.  Dinutuximab also reduced tumor growth in nude mice bearing TNBC cell-line xenografts.  Finally, dinutuximab in combination with activated natural killer (NK) cells inhibited tumor growth in a TNBC PDX model and improved OS of tumor-bearing mice.  The authors concluded that dinutuximab successfully eliminated GD2+ cells and reduced tumor growth in both in-vivo models.  These researchers stated that these findings provided proof-of-concept for the criticality of GD2 in BCSCs and demonstrated the potential of dinutuximab as a novel therapeutic agent for the treatment of TNBC.

Shao et al (2022) stated that TNBC is a heterogeneous disease characterized by lack of hormone receptor expression and is known for high rates of recurrence, distant metastases, and poor clinical outcomes.  TNBC cells lack targetable receptors; hence, there is an urgent need for targetable markers for the disease.  BCSCs are a fraction of cells in primary tumors that are associated with tumorigenesis, metastasis, and resistance to chemotherapy; therefore, targeting BCSCs is an effective approach for preventing cancer metastatic spread and sensitizing tumors to chemotherapy.  The CD44hi CD24lo phenotype is a well-established phenotype for identification of BCSCs; however, CD44 and CD24 are not targetable markers owing to their expression in normal tissues.  The ganglioside GD2 has been shown to be up-regulated in primary TNBC tumors compared with normal breast tissue and has been shown to identify BCSCs.  These investigators discussed GD2 as a BCSC- and tumor-specific marker in TNBC; epithelial-to-mesenchymal transition and the signaling pathways that are up-stream and down-stream of GD2 and the role of these pathways in tumorigenesis and metastasis in TNBC; direct and indirect approaches for targeting GD2; and ongoing clinical trials and treatments directed against GD2 as well as future directions for these strategies.  Dinutuximab is one of the key words listed in this study.

Other Cancers

Ploessi and colleagues (2016) reviewed the pharmacology, pharmacokinetics, safety, effectiveness, dosage and administration, and formulary considerations for dinutuximab.  Medline was searched (1964 to January 2016) using the terms ch14.18, dinutuximab, immunotherapy, and neuroblastoma.  Other information was identified from package insert, Biologics License Application, abstracts, news releases, and ClinicalTrials.gov.  Identified English-language articles were reviewed.  Selected studies included phase I through III.  High-risk neuroblastoma is primarily a childhood cancer with 5-year survival rates of 40 % to 50 %.  Treatment for high-risk neuroblastoma includes induction chemotherapy, surgery, myeloablative chemotherapy with autologous hematopoietic stem cell transplant, and radiation therapy.  For patients achieving clinical remission, limited treatments exist for preventing relapse.  Dinutuximab is approved in combination with GM-CSF, aldesleukin, and isotretinoin for maintenance treatment of pediatric patients with high-risk neuroblastoma who achieve at least a partial response (PR) to 1st-line multi-agent, multi-modality therapy.  In phase III clinical trials, dinutuximab increased 2-year EFS and OS when compared to standard treatment.  Severe adverse effects of dinutuximab include pain, hypersensitivity reactions, capillary leak syndrome, and hypotension.  The authors concluded that dinutuximab is the 1st anti-GD2 monoclonal antibody (MAb) approved in combination with GM-CSF, IL-2, and RA for maintenance treatment of pediatric patients with high-risk neuroblastoma who achieve at least a PR to 1st-line multi-agent, multi-modality therapy.  They stated that ongoing research will determine if dinutuximab could be used earlier in treatment, in non-responders to initial therapies, in combination with chemotherapy, or in other cancers.

1. a phase-II trial: “Dinutuximab in Combination With Sargramostim in Treating Patients With Recurrent Osteosarcoma” (last verified September 2017), and
2. a phase II/III trial: “Dinutuximab and Irinotecan Versus Irinotecan to Treat Subjects With Relapsed or Refractory Small Cell Lung Cancer” (last verified August 2017). 

Both trials are currently recruiting subjects.

Glioblastoma Multiforme

Marx and colleagues (2020) stated that disialoganglioside GD2 is expressed by glioblastoma multiforme (GBM) cells representing a promising target for anti-GD2 immunotherapeutic approaches. The investigators examined the anti-tumor efficacy of dinutuximab beta (DB) against GBM. Expression levels of GD2 and complement regulatory proteins (CRP; CD46, CD55 and CD59) on well-known and newly established primary tumor originated GBM cell lines were analyzed by flow cytometry. Ab-dependent cellular (ADCC) and complement-dependent cytotoxicity (CDC) mediated by DB against GBM cells were determined by a non-radioactive calcein-AM-based assay. Analysis of primary GBM cells revealed a heterogeneous GD2 expression that varied between the cell lines analyzed with higher expression levels in the tumor surface compared to the core originated cells. Both GD2-positive and -negative tumor cells were detected in every cell line analyzed. In contrast to CDC, ADCC mediated by DB was observed against the majority of GBM cells.  Importantly, CDC-resistant cells showed high expression of the CRP CD46, CD55 and CD59. The authors concluded that these findings showed anti-tumor effects mediated by DB against GBM cells providing a rationale for a GD2-directed immunotherapy against GBM. Due to high CRP expression, a combining of GD2-targeting with CRP blockade might be a further therapeutic option for GBM.

Nivolumab and Dinutuximab for the Treatment of Relapsed / Refractory Neuroblastoma

Ehlert and colleagues (2020) noted that in the past 10 years, immunotherapy approaches with checkpoint inhibitors were approved for patients with certain malignant diseases such as melanoma or Hodgkin lymphoma. In pre-clinical models, DB resulted in an up-regulation of the programmed cell death protein 1 (PD-1) checkpoint in neuroblastoma (NB) cell lines and a combined treatment of DB with a murine anti-PD-1 checkpoint inhibitor showed a synergistic effect in a NB mouse model.  These researchers presented the findings of 2 patients who were admitted with refractory metastatic NB.  In the 4-year old girl, NB was diagnosed in 2013.  She completed her 1st-line therapy with a 1st remission in 2015, but suffered a relapse in 2017.  Treatment with chemotherapy and DB resulted in progressive disease after transient improvement.  In the 17-year old young man, NB was first diagnosed in April 2010.  After 2 local relapses in 2011 and 2014, a metastatic relapse and a large abdominal tumor bulk were found in 2018.  Despite transient improvement with multi-modal therapy, progressive metastatic disease was observed in May 2019.  Both patients had a satisfactory quality of life (QOL).  Thus, treatment with DB and nivolumab was carried out – in the girl from October 2018 until August 2019; in the young man since June 2019.  Tolerance to treatment was excellent.  The girl continued to be in complete remission 6 months after therapy was stopped.  In the young man, the soft tissue lesions disappeared completely, the skeletal lesions regressed substantially after 9 months of his still ongoing treatment.  The authors concluded that the combination of DB with nivolumab resulted in complete and a very good PR in 2 patients and may be a promising strategy for relapsed/refractory NB.  Moreover, these researchers stated that prospective trials are needed to examine the role of this novel approach in a larger number of patients.

Combined Dinutuximab and Granulocyte-Macrophage Colony-Stimulating Factor for the Treatment of Osteosarcoma

Hingorani et al (2022) stated that novel effective therapies are urgently needed in recurrent osteosarcoma; GD2 is expressed in human osteosarcoma tumors and cell lines. In a single-arm, phase-II clinical trial, these researchers examined disease control rate (DCR) in patients with recurrent osteosarcoma treated with dinutuximab plus cytokine therapy as compared to historical outcomes. This study enrolled patients with recurrent pulmonary osteosarcoma in complete surgical remission. Subjects received up to 5 cycles of dinutuximab (70 mg/m2/cycle) with granulocyte-macrophage colony-stimulating factor (GM-CSF). Two different dinutuximab infusion schedules were studied: 35 mg/m2/day over 20 hours (2 days) and 17.5 mg/m2/day over 10 hours (4 days). Primary endpoint was DCR, defined as a proportion of patients who were event-free at 12 months from enrolment. The historical benchmark was 12-month DCR of 20 % (95 % CI: 10 % to 34 %). Dinutuximab would be considered effective if greater than or equal to 16/39 patients remained event free. Secondary objectives included toxicity evaluation and pharmacokinetics. A total of 39 eligible patients were included in the outcome analysis. Dinutuximab did not show evidence of effectiveness as 11/39 patients remained event-free for a DCR of 28.2 % (95 % CI: 15 % to 44.9 %); 1 of 136 administered therapy cycles met criteria for unacceptable toxicity when a patient experienced sudden death of unknown cause. Other grade-3 or higher toxicities included pain, diarrhea, hypoxia, and hypotension. Pharmacokinetic parameters were similar in the 2 schedules. The authors concluded that the combination of dinutuximab with GM-CSF did not significantly improve DCR in recurrent osteosarcoma. Dinutuximab toxicity and pharmacokinetics in adolescent and young adult osteosarcoma patients were similar to younger patients. These researchers stated that other strategies for targeting GD2 in osteosarcoma are being developed.

Combined Dinutuximab and Interleukin-2 for the Treatment of Relapsed Neuroblastoma

Flaadt et al (2023) stated that patients with relapsed high-risk neuroblastoma (rHR-NB) have a poor prognosis. In a multi-center, phase-I/II clinical trial, these researchers hypothesized that graft-versus-neuroblastoma effects could be elicited by transplantation of haploidentical stem cells (haplo-SCT) exploiting cytotoxic functions of natural killer cells and their activation by the anti-GD2 antibody dinutuximab beta (DB). These investigators examined safety, feasibility, and outcomes of immunotherapy with DB plus subcutaneous interleukin-2 (scIL2) following haplo-SCT in patients with rHR-NB. Patients aged 1 to 21 years underwent T-/B-cell-depleted haplo-SCT followed by DB and scIL2. The primary endpoint “success of treatment” encompassed patients receiving 6 cycles, being alive 180 days after end of trial treatment without progressive disease, unacceptable toxicity, acute graft-versus-host-disease (GvHD) of grade-3 or higher, or extensive chronic GvHD. A total of 70 patients were screened, and 68 were eligible for immunotherapy. Median number of DB cycles was 6 (range, of 1 to 9). Median number of scIL2 cycles was 3 (1 to 6). The primary endpoint was met by 37 patients (54.4 %). Median observation time was 7.8 years. 5-year EFS and OS from start of trial treatment were 43 % (95 % CI: 31 to 55) and 53 % (95 % CI: 41 to 65), respectively. 5-year EFS among patients in CR (52 %; 95 % CI: 31 to 69) or PR (44 %; 95 % CI: 27 to 60) before immunotherapy were significantly better compared with patients with non-response/mixed response/progressive disease (13 %; 95 % CI: 1 to 42; p = 0.026). ORR in 43 patients with evidence of disease after haplo-SCT was 51 % (22 patients), with 15 achieving CR (35 %); and 2 patients developed GvHD grade-2 and grade-3 each. No unexpected AEs occurred. The authors concluded that DB therapy after haplo-SCT in patients with rHR-NB was feasible, with low-risk of inducing GvHD, and resulted in long-term remissions likely attributable to increased anti-neuroblastoma activity by donor-derived effector cells. Moreover, these researchers stated that further prospective and randomized trials are needed to examine the contribution of each component of the approach, and larger cohorts are needed to allow better risk stratification and patient selection.

Dinutuximab Combined with Chemotherapy for the Treatment of Relapsed or Refractory Neuroblastoma

Olgun et al (2022) stated that relapsed/refractory (r/r) high-risk neuroblastoma has a dismal prognosis. A nti-GD2-mediated chemo-immunotherapy has a notable anti-tumor activity in patients with r/r high-risk neuroblastoma.  In a retrospective, single-center study, these researchers examined the safety and effectiveness of the combination of immunotherapy with dinutuximab beta (DB) and chemotherapy in patients with r/r high-risk neuroblastoma.  All patients received the Turkish Pediatric Oncology Group NB 2009 national protocol for HR-NB treatment at the time of diagnosis.  Salvage treatments were given following progression or relapse.  Patients who could not achieve remission in primary or metastatic sites were included in the study.  The most common chemotherapy scheme was irinotecan and temozolomide.  DB was given intravenously for 10 days via continuous infusion with 10 mg/m2 per day.  Subjects received 2 to 14 successive cycles with duration of 28 days each.  Disease assessment was carried out after cycles 2, 4, and 6 and every 2 to 3 cycles thereafter.  Between January 2020 and March 2022, a total of 19 patients received a total of 125 cycles of DB and chemotherapy.  Objective responses were achieved in 12/19 (63 %) patients, including CR in 6/19 and PR in 6/19; stable disease (SD) was observed in 2 patients.  The remaining 5 patients developed bone/bone marrow and soft tissue progression after 2 to 4 cycles of treatment.  The most common grade-3 or higher toxicities were leukopenia, thrombocytopenia, hypertransaminsemia, fever, rash/itching and capillary leak syndrome, respectively.  The authors concluded that the findings of this study suggested that DB-based chemo-immunotherapy appeared to be suitable with encouraging response rates in patients with r/r high-risk neuroblastoma.  Moreover, these researchers stated that further prospective, large, multi-center studies are needed to confirm these preliminary findings.

The authors stated that this study had several drawbacks.  This trial was carried out in a single-center setting.  The other drawbacks were the relatively small size of the cohort (n = 19), retrospective design, short follow-up period (median of 11 months [range of 6 to 26 months]), and lack of comparison group.

Wieczorek et al (2023) noted that prognosis in children with r/r high-risk neuroblastoma is poor.  Only a minority of patients obtain remission when treated with 2nd-line chemotherapy regimens.  Chemotherapy combined with anti-GD2 antibodies has previously been shown to increase response and survival rates.  In a retrospective study, these researchers analyzed a cohort of 25 patients with r/r high-risk neuroblastoma who were treated with irinotecan/temozolomide chemotherapy in combination with the anti-GD2 antibody dinutuximab beta.  The therapy resulted in an objective response rate (ORR) of 64 %, with 32 % of patients achieving a CR.  Response to treatment was observed in patients with refractory disease (n = 5) and those with first (n = 12) or consecutive (n = 8) relapses, including patients with progressing disease.  In 4 patients, best response was achieved after more than 5 cycles, suggesting that some patients may benefit from prolonged chemotherapy and dinutuximab beta treatment.  A total of 14 of the 25 patients had previously received dinutuximab beta, 4 of whom achieved CR; and 6 PR (ORR of 71 %).  The therapy was well-tolerated, even in heavily pre-treated patients and those who had previously received dinutuximab beta treatment.  Toxicities were comparable to those previously reported for the individual therapies, and no discontinuations due to toxicities occurred.  The authors concluded that combined chemotherapy plus dinutuximab beta is a promising therapeutic option for patients with r/r high-risk neuroblastoma and should be further investigated in clinical studies.

The authors stated that the drawbacks of this trial included its retrospective nature and the heterogeneity of the patient population.  As the treatment was not planned prospectively, the number of cycles and treatment following chemo-immunotherapy was dependent on clinical decisions, which might have influenced the results.  Furthermore, this cohort had a much higher number of relapsed than refractory patients, which may have also affected response rates.  Moreover, patients with actively progressing disease as well as patients with disease stabilized with other treatments were included.  In future prospective studies, these patient groups should be analyzed separately.

Lode et al (2023) stated that dinutuximab beta is approved for the maintenance treatment of high-risk neuroblastoma.  Dinutuximab beta combined with different chemotherapy regimens is being examined in various clinical settings.  These researchers carried out a retrospective clinical chart review of 25 patients with r/r neuroblastoma who had failed 1 or more 2nd-line therapy and received compassionate use treatment with dinutuximab beta long-term infusion combined with the induction chemotherapy regimens N5 (cisplatin, etoposide, vindesine) and N6 (vincristine, dacarbazine, ifosfamide, doxorubicin) recommended by the German Pediatric Oncology and Hematology Group [GPOH] guidelines.  The treatment did not result in any unexpected severe toxicities or in any major treatment delays.  Grade-3/4 pain was reported by 4/25 patients in cycle 1, decreasing to 0/9 patients in cycles 3 and 4.  The median follow-up was 0.6 years.  The best response in this group was 48 % (12/25 patients), which included 3 patients with minor responses.  At 1 year, the estimated EFS was 27 % (95 % CI: 8 to 47) and OS was 44 % (95 % CI: 24 to 65).  The authors concluded that combining long-term infusion of dinutuximab beta with N5 and N6 chemotherapy showed an acceptable safety profile and encouraging objective response rates in heavily pre-treated patients with high-risk neuroblastoma, warranting further evaluation in clinical trials.

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