High risk neuroblastoma (HRNB) accounts for 15% of all pediatric cancer deaths. Despite aggressive therapy approximately half of patients will relapse, typically with only transient responses to second-line therapy. This study evaluated the ornithine decarboxylase inhibitor difluoromethylornithine (DFMO) as maintenance therapy to prevent relapse following completion of standard therapy (Stratum 1) or after salvage therapy for relapsed/refractory disease (Stratum 2). This Phase II single agent, single arm multicenter study enrolled from June 2012 to February 2016. Subjects received 2 years of oral DFMO (750 ± 250 mg/m2 twice daily). Event free survival (EFS) and overall survival (OS) were determined on an intention-to-treat (ITT) basis. 101 subjects enrolled on Stratum 1 and 100 were eligible for ITT analysis; two-year EFS was 84% (±4%) and OS 97% (±2%). 39 subjects enrolled on Stratum 2, with a two-year EFS of 54% (±8%) and OS 84% (±6%). DFMO was well tolerated. The median survival time is not yet defined for either stratum. DFMO maintenance therapy for HRNB in remission is safe and associated with high EFS and OS. Targeting ODC represents a novel therapeutic mechanism that may provide a new strategy for preventing relapse in children with HRNB.

LIN28 has emerged as an oncogenic driver in a number of cancers, including neuroblastoma (NB). Overexpression of LIN28 correlates with poor outcome in NB, therefore drugs that impact the LIN28/Let-7 pathway could be beneficial in treating NB patients. The LIN28/Let-7 pathway affects many cellular processes including the regulation of cancer stem cells and glycolytic metabolism. Polyamines, regulated by ornithine decarboxylase (ODC) modulate eIF-5A which is a direct regulator of the LIN28/Let-7 axis. We propose that therapy inhibiting ODC will restore balance to the LIN28/Let-7 axis, suppress glycolytic metabolism, and decrease MYCN protein expression in NB. Difluoromethylornithine (DFMO) is an inhibitor of ODC in clinical trials for children with NB. In vitro experiments using NB cell lines, BE(2)-C, SMS-KCNR, and CHLA90 show that DFMO treatment reduced LIN28B and MYCN protein levels and increased Let-7 miRNA and decreased neurosphere formation. Glycolytic metabolic activity decreased with DFMO treatment in vivo. Additionally, sensitivity to DFMO treatment correlated with LIN28B overexpression (BE(2)-C>SMS-KCNR>CHLA90). This is the first study to demonstrate that DFMO treatment restores balance to the LIN28/Let-7 axis and inhibits glycolytic metabolism and neurosphere formation in NB and that PET scans may be a meaningful imaging tool to evaluate the therapeutic effects of DFMO treatment.

Neuroblastoma is a sympathetic nervous system tumor, primarily presenting in children under 6 years of age. The long-term prognosis for patients with high-risk neuroblastoma (HRNB) remains poor despite aggressive multimodal therapy. This report provides an update to a phase II trial evaluating DFMO as maintenance therapy in HRNB. Event-free survival (EFS) and overall survival (OS) of 81 subjects with HRNB treated with standard COG induction, consolidation and immunotherapy followed by 2 years of DFMO on the NMTRC003/003b Phase II trial were compared to a historical cohort of 76 HRNB patients treated at Beat Childhood Cancer Research Consortium (BCC) hospitals who were disease-free after completion of standard upfront therapy and did not receive DFMO. The 2-and 5-year EFS were 86.4%

Choroid plexus carcinomas (CPCs) are rare, aggressive pediatric brain tumors with no established curative therapy for relapsed disease, and poor survival rates. TP53 Mutation or dysfunction correlates with poor or no survival outcome in CPCs. Here, we report the case of a 4 month-old female who presented with disseminated CPC. After initial response to tumor resection and adjuvant-chemotherapy, the tumor recurred and metastasized with no response to aggressive relapse therapy suggesting genetic predisposition. This patient was then enrolled to a Molecular Guided Therapy Clinical Trial. Genomic profiling of patient tumor and normal sample identified a TP53 germline mutation with loss of heterozygosity, somatic mutations including IDH2, and aberrant activation of biological pathways. The mutations were not targetable for therapy. However, targeting the altered biological pathways (mTOR, PDGFRB, FGF2, HDAC) guided identification of possibly beneficial treatment with a combination of sirolimus, thalidomide, sunitinib, and vorinostat. This therapy led to 92% reduction in tumor size with no serious adverse events, excellent quality of life and long term survival.

Catechol-O-methyltransferase (COMT) is an enzyme that inactivates dopamine and other catecholamines by O-methylation. Tolcapone, a drug commonly used in the treatment of Parkinson's disease, is a potent inhibitor of COMT and previous studies indicate that Tolcapone increases the bioavailability of dopamine in cells. In this study, we demonstrate that Tolcapone kills neuroblastoma (NB) cells in preclinical models by inhibition of COMT. Treating four established NB cells lines (SMS-KCNR, SH-SY5Y, BE(2)-C, CHLA-90) and two primary NB cell lines with Tolcapone for 48 h decreased cell viability in a dose-dependent manner, with IncuCyte imaging and Western blotting indicating that cell death was due to caspase-3-mediated apoptosis. Tolcapone also increased ROS while simultaneously decreasing ATP-per-cell in NB cells. Additionally, COMT was inhibited by siRNA in NB cells and showed similar increases in apoptotic markers compared to Tolcapone. In vivo xenograft models displayed inhibition of tumor growth and a significant decrease in time-to-event in mice treated with Tolcapone compared to untreated mice. These results indicate that Tolcapone is cytotoxic to neuroblastoma cells and invite further studies into Tolcapone as a promising novel therapy for the treatment of neuroblastoma. Cancer Medicine Open Access 1342

Neuroblastoma (NB) is the most common childhood cancer arising from the nervous system. Many high-risk neuroblastoma (HRNB) patients develop relapse after initial response to induction treatment and overall long term survival remains poor (less than 60%), emphasizing the need for new therapeutic approaches and more effective treatments. Combination therapies present a favorable approach to improve efficacy, decrease toxicity, and reduce development of drug resistance. Difluoromethylornithine (DFMO) has shown promise in recent clinical trials as a therapeutic agent in treating HRNB. Proteasomes are known to play an important role in tumor cell growth. Bortezomib was the first proteasome inhibitor shown to have anticancer activity clinically. In this study we explore the mechanistic and therapeutic effects of the novel drug combination of DFMO and bortezomib in NB. Cell proliferation studies demonstrated synergistic inhibition of NB cell growth. Bortezomib induced cleaved caspase-3 apoptotic pathway whereas DFMO induced a cytostatic effect on NB cells. Western blot analyses demonstrated down regulation of MYCN, LIN28 and NF-kB in response to DFMO and bortezomib, pathways that are important in cancer stem cells. A decrease in ATP-per-cell when treated with combination therapy suggests inhibition of glycolytic metabolism in NB cells. DFMO as a single agent or in combination with bortezomib significantly reduced tumor growth in xenograft mice. Given the lack of effective treatments, DFMO coupled with bortezomib offers a potential new therapeutic treatment for children with NB.

Background: Pediatric cancer is the leading cause of death by disease in children in the US. Significant advances have been made in survival in the past 30 years and genomic understanding of tumors is underway. Gains in the identification of biomarkers, drug targets, and the molecular characterization of cancer are due to improved technology including gene sequencing, proteomics, and epigenetics. Still, this remains limited primarily to large academic centers and patients with high risk/metastatic disease experience < 30% survival. Phase 1/2 trials not based on precision medicine result in poor response rates (<10%). Therefore, genomic understanding of tumors and molecular targeted therapies with aims of reaching all children and reducing toxicity while improving efficacy is needed. Methods: The Signature Study is an IRB-approved biology study that seeks to perform genomic analysis, high throughput (HTP) drug testing, and creation of patient derived xenograft (PDX) models of all pediatric cancer patients diagnosed/relapsed at Helen DeVos Children’s Hospital. Patients are consented, clinical history is collected in RedCap, and tumors are collected flash frozen and in cell culture media. Blood is collected for germline analysis. Tumors are analyzed through gene expression arrays, DNA panels and exomes and RNA sequencing. Tumors in cell culture are used for generation of primary patient cell lines (confirmed by IHC and STR) and immediate injection into NSG mice for PDX models. Cell lines undergo HTP drug testing using the Prestwick and NCI drug libraries, novel therapeutics and combinations. Results: Enrollment has increased since inception in 2011 with now >50 patients/year; a total of 284 pediatric tumors collected representing over 30 tumor types. The most common diagnosis is neuroblastoma, followed by medulloblastoma, osteosarcoma, and rhabdomyosarcoma. Sequencing for genomic analysis has been performed on 166 tumors to identify mutations, fusions, CNV, and deletions. To date 184 have been grown as primary patient cell lines and 75 as PDX models. Over 60 samples have been evaluated in HTP drug testing. Genomic analysis of cultured tumor cells has been correlated with response to drug libraries to establish correlative predictive markers for therapeutic decision making to be tested in clinical trials. The study stores remaining tissue, cell lines, and PDX models for additional future research. Conclusion: This study shows it is feasible for a mid-sized hospital system to coordinate and collect tumors for genomic analysis in real time for clinical decision making in the future. This resource is an integrated TransMed database system which is a powerful resource which correlates clinical outcomes, therapies, genomic sequencing, PDX models and HTP drug testing used to answer research questions of biomarkers, biological characterization, drug sensitivity, and driver pathways within and between pediatric cancers. Citation Format: Elizabeth VanSickle, Ping Zhao, Deanna Mitchell, Jessica Foley, Julie Steinbrecher, Maria Rich, Abhinav Nagulapally, Jeff Bond, William Hendricks, Giselle Saulnier Sholler. The Signature Study: Molecular analysis of pediatric tumors with establishment of tumor models in a biology study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4869. doi:10.1158/1538-7445.AM2017-4869

Background: Overexpression of LIN28 correlates with poor outcome in neuroblastoma (NB). The LIN28/Let-7 axis affects many cellular processes including cell differentiation and glycolytic metabolism. MYCN overexpression correlates with decreased Let-7 miRNA which results in an increase in LIN28 protein. Recent studies have shown that ODC inhibition decreases LIN28 levels. We propose that therapy targeting ODC will affect the LIN28/Let-7 axis, thus suppressing the glycolytic metabolic activity of NB tumor cells. We also propose that cells overexpressing LIN28 will have greater sensitivity to Difluoromethylornithine (DFMO) treatment which inhibits ODC and decreases cellular polyamines. Methods: Two MYCN high-expression cell lines, BE(2)-C and SMS-KCNR, and one MYCN low-expression cell line, CHLA90, were grown in RPMI-1640 medium with 10% fetal bovine serum for 24 hours prior to treatment with DFMO. Cells were treated with 5 mM or 10 mM DFMO from 48-96 hours followed by cell viability assay, ATP per cell, and western blot analysis and 6 hours for qPCR analysis. Cell viability was measured using Calcein AM fluorescence assay. IC50 values were calculated using GraphPad software. ATP per cell was measured by combining Cell Titer GLO luminescence assay with CyQuant fluorescence assay. Western blot analysis was used to measure LIN28B and MYCN protein levels. TaqMan PCR reagents were used to measure Let-7 miRNA levels using qPCR analysis. SMS-KCNR cells were injected subcutaneously into nude mice for in vivo xenograft studies. Mice were drugged with 2% DFMO in drinking water when tumors reached 200mm3. Tumor volumes were measured using both caliper and micro-CT, and tumor glycolytic metabolism was determined by Maximum Standard Uptake Value (SUVMax) in the tumors through longitudinal 18F-FDG micro PET/CT scans on days 19 and 32. Results: treatment with high and low dose DFMO resulted in decreased LIN28B protein levels in all three cell lines at 48, 72, and 96 hours timepoints. MYCN protein levels decreased in MYCN high-expression cell lines, BE(2)-C and SMS-KCNR, with high and low dose DFMO treatments, but did not change in MYCN low-expression cell line CHLA90. Let-7 miRNA levels were increased in both MYCN high-expression cell lines after 6 hours of high dose DFMO treatment and no change was seen in CHLA90 cells. Sensitivity to DFMO correlated with LIN28B expression levels in all three cell lines (BE(2)-C>SMS-KCNR>CHLA90). BE(2)-C cells were most sensitive to DFMO treatment with an IC50 of 3.01 mM followed by SMS-KCNR cells (10.61 mM), and CHLA90 cells, which showed resistance (25.76 mM). In addition, ATP per cell levels were most significantly reduced in BE(2)-C cells after treatment with DFMO followed by SMS-KCNR and CHLA90 cells. In vivo 18F-FDG PET/CT studies showed decreased SUVMax in the DFMO treatment group indicating reduced glycolytic metabolism. Conclusions: Treatment with DFMO reverses the LIN28/Let-7 axis with a decrease in LIN28B protein expression and an increase in Let-7 miRNA expression. This axis has been shown to play a role in metabolic activity of cells. Decreased metabolic activity and decreased tumor growth is seen in NB cells both in vitro and in vivo following DFMO treatment. NB cell lines with higher levels of LIN28B and MYCN expression are more sensitive to DFMO treatment. These studies suggest that targeting of the LIN28/Let-7 pathway may offer a new method of treating neuroblastoma. Citation Format: Ann Kendzicky, Maria Rich, Anderson Peck, Zhao Ping, Elizabeth VanSickle, Heather McClung, Anthony Chang, Giselle Sholler. Difluoromethylornithine treatment affects the LIN28/Let-7 axis resulting in reduced glycolytic metabolism in neuroblastoma. [abstract]. In: Proceedings of the AACR Special Conference on Pediatric Cancer at the Crossroads: Translating Discovery into Improved Outcomes; Nov 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;74(20 Suppl):Abstract nr B54.