Pain mitigation and management strategies for anti-GD2 infusions: An expert consensus.

Monoclonal antibodies (mAbs) targeting disialoganglioside 2 (GD2) are an important treatment advance for high-risk neuroblastoma, including in patients with refractory or relapsed disease. Dinutuximab and dinutuximab beta are administered for ≥8 hours (and up to 10 days for dinutuximab beta), whereas naxitamab is administered over 0.5 to 2 hours as tolerated. As acute pain is a class effect of anti-GD2 mAbs, effective pain management is crucial to successful treatment. Here, we provide an overview of current pain-management strategies for anti-GD2 mAb infusions, with a focus on strategies suitable for naxitamab infusions, which cause a more rapid onset of often severe pain. We discuss opioid analgesics, ketamine, gabapentin, and other similar agents and nonpharmacologic approaches. Potential future pain-management options are also discussed, in addition to the use of sedatives to reduce the anxiety that may be associated with infusion-related pain. In this expert consensus paper, specific guidance for pain management during naxitamab infusions is provided, as these infusions are administered over 0.5 to 2 hours and may not need overnight hospitalization based on the physician's assessment, and require rapid-onset analgesia options suitable for potential outpatient administration.

Progression-Free Survival and Patterns of Response in Patients With Relapsed High-Risk Neuroblastoma Treated With Irinotecan/Temozolomide/Dinutuximab/Granulocyte-Macrophage Colony-Stimulating Factor.

PURPOSE: Although chemoimmunotherapy is widely used for treatment of children with relapsed high-risk neuroblastoma (HRNB), little is known about timing, duration, and evolution of response after irinotecan/temozolomide/dinutuximab/granulocyte-macrophage colony-stimulating factor (I/T/DIN/GM-CSF) therapy. PATIENTS AND METHODS: Patients eligible for this retrospective study were age < 30 years at diagnosis of HRNB and received ≥ 1 cycle of I/T/DIN/GM-CSF for relapsed or progressive disease. Patients with primary refractory disease who progressed through induction were excluded. Responses were evaluated using the International Neuroblastoma Response Criteria. RESULTS: One hundred forty-six patients were included. Tumors were MYCN-amplified in 50 of 134 (37%). Seventy-one patients (49%) had an objective response to I/T/DIN/GM-CSF (objective response; 29% complete response, 14% partial response [PR], 5% minor response [MR], 21% stable disease [SD], and 30% progressive disease). Of patients with SD or better at first post-I/T/DIN/GM-CSF disease evaluation, 22% had an improved response per International Neuroblastoma Response Criteria on subsequent evaluation (13% of patients with initial SD, 33% with MR, and 41% with PR). Patients received a median of 4.5 (range, 1-31) cycles. The median progression-free survival (PFS) was 13.1 months, and the 1-year PFS and 2-year PFS were 50% and 28%, respectively. The median duration of response was 15.9 months; the median PFS off all anticancer therapy was 10.4 months after discontinuation of I/T/DIN/GM-CSF. CONCLUSION: Approximately half of patients receiving I/T/DIN/GM-CSF for relapsed HRNB had objective responses. Patients with initial SD were unlikely to have an objective response, but > 1 of 3 patients with MR/PR on first evaluation ultimately had complete response. I/T/DIN/GM-CSF was associated with extended PFS in responders both during and after discontinuation of treatment. This study establishes a new comparator for response and survival in patients with relapsed HRNB.

Residual meta-iodobenzyl guanidine (MIBG) positivity following therapy for metastatic neuroblastoma: Patient characteristics, imaging, and outcome.

BACKGROUND: Meta-iodobenzylguanidine(MIBG) scans are used to detect neuroblastoma metastatic lesions at diagnosis and during posttreatment surveillance. MIBG positivity following induction chemotherapy correlates with poor outcome; however, there are reports of patients with progression-free survival despite MIBG positivity at the end of therapy. The factors distinguishing these survivors from patients who progress or relapse are unclear. FDG-positron-emission tomography (PET) scans can also detect metastatic lesions at diagnosis; however, their role in posttherapy surveillance is less well studied. METHODS: We performed a retrospective analysis of International Neuroblastoma Staging System (INSS) stage 4 patients to identify those with residual MIBG-avid metastatic lesions on end-of-therapy scans without prior progression. Data collected included age, disease sites, histopathology, biomarkers, treatment, imaging studies, and response. RESULTS: Eleven of 265 patients met inclusion criteria. At diagnosis three of 11 patients were classified as intermediate and eight of 11 high risk; nine of 11 had documented marrow involvement. Histologic classification was favorable for four of 10 and MYCN amplification was detected in zero of 11 cases. The median time with persistent MIBG positivity following treatment was 1.5 years. Seven patients had at least one PET scan with low or background activity. Biopsies of three of three MIBG-avid residual lesions showed differentiation. All patients remain alive with no disease progression at a median of 4.0 years since end of therapy. CONCLUSION: Persistently MIBG-avid metastatic lesions in subsets of patients following completion of therapy may not represent active disease that will progress. Further studies are needed to determine whether MYCN status or other biomarkers, and/or PET scans, may help identify patients with residual inactive MIBG lesions who require no further therapy.

Theranostics in Neuroblastoma.

Theranostics combines diagnosis and targeted therapy, achieved by the use of the same or similar molecules labeled with different radiopharmaceuticals or identical with different dosages. One of the best examples is the use of metaiodobenzylguanidine (MIBG). In the management of neuroblastoma-the most common extracranial solid tumor in children. MIBG has utility not only for diagnosis, risk-stratification, and response monitoring but also for cancer therapy, particularly in the setting of relapsed/refractory disease. Improved techniques and new emerging radiopharmaceuticals likely will strengthen the role of nuclear medicine in the management of neuroblastoma.

Edema hemorrágico agudo da infância: uma vasculite com bom prognóstico / Acute hemorrhagic edema of infancy: a vasculitis with good prognosis

OBJETIVOS: Relatar dois casos de edema hemorrágico agudo da infância, que consiste numa vasculite rara, caracterizada por lesões cutâneas purpúricas e edema periférico, sem envolvimento sistêmico (excetuando- se a febre), que tem início súbito, curso benigno e evolui espontaneamente para a cura. DESCRIÇÃO DOS CASOS: Os autores apresentam dois casos de crianças do sexo masculino, com 11 e 12 meses de idade, que foram atendidos no serviço de urgência por febre e lesões purpúricas exuberantes de agravamento progressivo. O diagnóstico de edema hemorrágico agudo da infância foi feito por exclusão e sustentado pelo fato de que, apesar da impressionante apresentação cutânea, ambos os lactentes apresentavam um ótimo estado geral e a tríade clássica desta entidade: febre, edema e lesões purpúricas da face, orelhas e extremidades. Houve regressão total das lesões cutâneas em aproximadamente uma semana, sem sequelas em ambos os casos. CONCLUSÕES: Existem pouco mais de 100 casos publicados mundialmente de edema hemorrágico agudo da infância. A raridade dessa vasculite pode dever-se a um subdiagnóstico ou diagnóstico equivocado de outras vasculites leucocitoclásticas, principalmente a Púrpura de HenochSchönlein. Além desta, existem outras doenças a considerar no diagnóstico diferencial, como meningococemia, doença de Kawasaki e eritema multiforme, que apresentam similaridades, mas ao mesmo tempo características distintas que permitem excluí-las. É fundamental o diagnóstico oportuno do edema hemorrágico agudo da infância, de modo a evitar exames complementares e terapêuticas desnecessárias, além de tranquilizar a família quanto ao bom prognóstico da doença.

AIMS: To report two cases of acute hemorrhagic edema of infancy, a rare vasculitis characterized by purpuric skin lesions and peripheral edema without systemic involvement (excluding fever), which has a sudden onset and an usually benign course, with spontaneous resolution. CASES DESCRIPTION: The authors describe two cases of male infants, 11 and 12 months old, who were admitted to the emergency department with fever and progressively worsening purpuric lesions. The diagnosis of acute hemorrhagic edema of infancy was made by exclusion and sustained by the fact that, despite the impressive skin presentation, both infants had a good general state and presented the classic triad of this entity: fever, peripheral edema, and purpuric lesions on the face, ears and extremities. Both boys presented total regression of the lesions in about one week, without sequelae. CONCLUSIONS: There are just over 100 cases of hemorrhagic edema of infancy reported worldwide. The rarity of this vasculitis may be due to underdiagnosis or mistaken diagnosis of other leukocytoclastic vasculitis, mostly Henoch-Schönlein purpura. In addition to this, there are other conditions to consider in the differential diagnosis, such as meningococcemia, Kawasaki disease and erythema multiforme, which have similarities, but at the same time distinctive features that allow to exclude them. Timely diagnosis of acute hemorrhagic edema of childhood is crucial to avoid unnecessary therapies and supplementary tests, as well as to reassure the family about the good prognosis of the disease.