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

Abstract

Purpose: Outcomes for children with relapsed and refractory high-risk neuroblastoma (RR-HRNB) remain dismal. The BEACON Neuroblastoma trial (EudraCT 2012-000072-42) evaluated three backbone chemotherapy regimens and the addition of the antiangiogenic agent bevacizumab (B).

Materials and methods: Patients age 1-21 years with RR-HRNB with adequate organ function and performance status were randomly assigned in a 3 × 2 factorial design to temozolomide (T), irinotecan-temozolomide (IT), or topotecan-temozolomide (TTo) with or without B. The primary end point was best overall response (complete or partial) rate (ORR) during the first six courses, by RECIST or International Neuroblastoma Response Criteria for patients with measurable or evaluable disease, respectively. Safety, progression-free survival (PFS), and overall survival (OS) time were secondary end points.

Results: One hundred sixty patients with RR-HRNB were included. For B random assignment (n = 160), the ORR was 26% (95% CI, 17 to 37) with B and 18% (95% CI, 10 to 28) without B (risk ratio [RR], 1.52 [95% CI, 0.83 to 2.77]; P = .17). Adjusted hazard ratio for PFS and OS were 0.89 (95% CI, 0.63 to 1.27) and 1.01 (95% CI, 0.70 to 1.45), respectively. For irinotecan ([I]; n = 121) and topotecan (n = 60) random assignments, RRs for ORR were 0.94 and 1.22, respectively. A potential interaction between I and B was identified. For patients in the bevacizumab-irinotecan-temozolomide (BIT) arm, the ORR was 23% (95% CI, 10 to 42), and the 1-year PFS estimate was 0.67 (95% CI, 0.47 to 0.80).

Conclusion: The addition of B met protocol-defined success criteria for ORR and appeared to improve PFS. Within this phase II trial, BIT showed signals of antitumor activity with acceptable tolerability. Future trials will confirm these results in the chemoimmunotherapy era.

Trial registration: ClinicalTrials.gov NCT02308527.

FIG 1.

CONSORT diagram of the BEACON Neuroblastoma trial. AE, adverse event; B, bevacizumab; BT, bevacizumab-temozolomide; BIT, bevacizumab-irinotecan-temozolomide; BTTo, bevacizumab-topotecan-temozolomide; DMC, Data Monitoring Committee; I, irinotecan; IT, irinotecan-temozolomide; PD, progressive disease; PFS, progression-free survival; T, temozolomide; TTo, topotecan-temozolomide.

FIG 2.

Survival analysis in the BEACON Neuroblastoma trial. Left panels show progression-free survival and right panels show overall survival. (A and B) Bevacizumab random assignment. (C and D) Irinotecan random assignment (T [no irinotecan] v IT [irinotecan]). (E and F) Topotecan random assignment (T [no topotecan] v TTo [topotecan]). (G and H) Survival for all trial arms. BT, bevacizumab-temozolomide; BIT, bevacizumab-irinotecan-temozolomide; BTTo, bevacizumab-topotecan-temozolomide; IT, irinotecan-temozolomide; OS, overall survival; PFS, progression-free survival; T, temozolomide; TTo, topotecan-temozolomide.