Hu14.18K322A, Irinotecan, Temozolomide and Sargramostim with or without N-803 for the Treatment of Relapsed or Refractory Neuroblastoma

Inclusion Criteria

• Patients must be =< 30 at the time of enrollment on study
• Patients must have had histologic verification of neuroblastoma or demonstration of neuroblastoma cells in the bone marrow with elevated urinary or serum catecholamines (i.e., > 2 x upper limit of normal [ULN]), at the time of initial diagnosis
• Patients must have high-risk neuroblastoma according to Children's Oncology Group (COG) risk classification at the time of study registration. Patients whose disease was initially considered low or intermediate risk but were then reclassified as high-risk neuroblastoma prior to enrollment are also eligible
• Patients must have at least ONE (recurrent/progressive, refractory, or persistent) of the following: * Recurrent/progressive disease after the diagnosis of high-risk neuroblastoma at any time prior to enrollment regardless of response to frontline therapy. (Note that this excludes patients initially considered low or intermediate risk that progressed to high-risk disease but have not progressed after the diagnosis of high-risk neuroblastoma) * Refractory disease: A best overall response of no response/stable disease since diagnosis of high-risk neuroblastoma AND after at least 4 cycles of induction therapy * Persistent disease: A best overall response of partial response since diagnosis of high-risk neuroblastoma AND after at least 4 cycles of induction therapy
• Patients must have at least ONE of the following (lesions may have received prior radiation therapy as long as they meet the other criteria listed below) based on institutional assessment: * Bone sites ** MIBG avid tumors: patients must meet one of the following criteria: *** Patients with recurrent/progressive or refractory disease: **** Must have at least one MIBG avid bone site on planar imaging OR **** Must have ≥ 2 lesions on single photon emission computed tomography (SPECT)/CT. A biopsy is not required unless the above imaging criteria are not met *** Patients with persistent disease: **** If a patient has 3 or more MIBG avid bone lesions, then no biopsy is required **** If a patient has only 1 or 2 MIBG avid bone lesion sites, then biopsy confirmation of neuroblastoma and/or ganglioneuroblastoma in at least one MIBG avid site present at the time of enrollment is required. Bone lesions may be biopsied at any time point prior to enrollment ** For MIBG non-avid tumors, patients must have at least an fludeoxyglucose F-18 (FDG)-PET avid site and meet the following criteria: *** Biopsy confirmation of neuroblastoma and/or ganglioneuroblastoma at any time prior to enrollment of at least one FDG-PET avid site * Bone marrow ** Any amount of tumor cells in the bone marrow (including neuroblasts, mature and maturing ganglion cells) done at the time of study enrollment based on routine morphology and/or immunohistochemistry in at least one sample from bilateral aspirates and biopsies. NOTE: Patients with bone marrow disease only will be eligible if they have more than 5% disease involvement (documented neuroblastoma cells) in at least one sample from bilateral bone marrow biopsies * Soft tissue sites ** At least one soft tissue lesion that meets criteria for a TARGET lesion as defined by: *** SIZE: Lesion can be accurately measured in at least one dimension with a longest diameter ≥ 10 mm, or for discrete lymph nodes ≥ 15mm on short axis. Lesions meeting size criteria will be considered measurable *** In addition to size, a lesion needs to meet ONE of the following criteria except for patients with parenchymal central nervous system (CNS) lesions which will only need to meet size criteria: **** For MIBG avid tumors: lesion must be MIBG avid and meet one of the following criteria: ***** For patients with recurrent/progressive or refractory disease: no biopsy is required ***** For patients with persistent disease: ****** If a patient has 3 or more MIBG avid soft tissue lesions, then no biopsy is required. ****** If a patient has only 1 or 2 MIBG avid soft tissue lesion sites) then biopsy confirmation of neuroblastoma and/or ganglioneuroblastoma in at least one MIBG avid site present at the time of enrollment is required. Soft tissue lesions may be biopsied at any time point prior to enrollment **** For MIBG non-avid tumors patient must have at least one FDG avid site and meet the following criteria: ***** Biopsy confirmation of neuroblastoma and/or ganglioneuroblastoma from a lesion at any time prior to enrollment of at least one FDG-PET avid site ***** At least one non-target soft tissue lesion that is not measurable but had a biopsy positive for neuroblastoma and/or ganglioneuroblastoma at any time prior to enrollment OR is MIBG avid on planar imaging
• Patients with elevated catecholamines (i.e., > 2 x ULN) only are NOT eligible for this study
• Patients must have Lansky (≤ 16 years) or Karnofsky (> 16 years) score of ≥ 50 * Note: Patients who are unable to walk because of paralysis, but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing the performance score
• Patients who have previously received anti-GD2 monoclonal antibodies are eligible unless they have had progressive disease while actively receiving prior anti-GD2. Patients must have fully recovered from the acute toxic effects of all prior chemotherapy, immunotherapy, or radiotherapy prior to study registration. Patients must not have received the therapies indicated below within the specified time period prior to registration on this study as follows: * Myelosuppressive chemotherapy ≤ 14 days ** This includes cytotoxic agents given on a low dose metronomic regimen as well as retinoids * Biologic antineoplastic (anti-neoplastic agents) ≤ 7 days ** Anti-cancer agents not known to be myelosuppressive (e.g., not associated with reduced platelet or absolute neutrophil counts [ANC] counts) ** This includes cytotoxic agents given on a low dose metronomic regimen as well as retinoids * Monoclonal antibodies ≤ 7 days or 3 half-lives whichever is longer, but no longer than 30 days (with recovery of any associated toxicities) * Cellular therapy (e.g., modified T cells, natural killer [NK] cells, dendritic cells, etc.) ≤ 21 days and with recovery of all associated toxicities * Small port radiation ≤ 7 days * Large field radiation therapy ≤ 12 weeks ** i.e., total body irradiation, craniospinal, whole abdominal, total lung, > 50% marrow space * Other substantial bone marrow radiation ≤ 6 weeks * 131 iodine [I]-MIBG therapy ≤ 6 weeks * Autologous stem cell infusion following myeloablative therapy ≤ 6 weeks ** Patients who have received an autologous stem cell infusion to support non-myeloablative therapy (such as 131I-MIBG) are eligible at any time as long as they meet the other criteria for eligibility * Any other investigational agents (covered under another investigational new drug [IND]) ≤ 14 days
• Patients must not have received the concomitant medications indicated below within the specified time period prior to study registration or planned treatment start date on this study as follows: * No other anti-cancer agents or radiotherapy at time of study registration or while on study * No short-acting hematopoietic growth factors within 7 days of blood draw documenting eligibility and no long-acting hematopoietic growth factors within 14 days of blood draw documenting eligibility * Patients must not have received 0.5 mg/kg/day (prednisone equivalent) doses of systemic steroids for at least 7 days prior to study enrollment ** Inhaled steroids are permitted to treat reactive airways ** ≤ 2mg/kg of hydrocortisone or equivalent is permitted as blood product premedication to avoid allergic reactions ** Physiologic hydrocortisone dosing is permitted for patients with known adrenal insufficiency * The use of dexamethasone as an antiemetic is not permitted * Irinotecan is a substrate for CYP3A4 (major) and CYP2B6 (major). Patients who have received drugs that are strong inducers or inhibitors of CYP3A4 within 7 days prior to study enrollment are not eligible. The use of strong inducers or inhibitors of CYP3A4 and CYP2B6 (e.g., carbamazepine) should be avoided for the duration of protocol therapy. Consult drug information references for further information. In addition, concomitant use of breast cancer resistance protein (BCRP) inhibitors (cyclosporine, eltrombopag, gefitinib), and UGT1A1 inhibitors (diclofenac, ketoconazole, probenecid, silibinin, nilotinib, and atazanavir) should be avoided due to potential increased risk of irinotecan toxicity ** Moderate inducers or inhibitors of CYP3A4 should also be avoided during protocol therapy if reasonable alternatives exist
• ANC ≥ 750/uL, (no short-acting hematopoietic growth factors ≤ 7 days of blood draw documenting eligibility and no long-acting hematopoietic growth factors ≤ 14 days of blood draw documenting eligibility) * Regardless of bone marrow disease involvement
• Platelet count ≥ 75,000/uL, transfusion independent (no platelet transfusions ≤ 7 days of blood draw documenting eligibility) * Regardless of bone marrow disease involvement
• Age-adjusted serum creatinine ≤ 1.5 ULN for age * 1 to < 2 years: Male 0.6 mg/dL, female 0.6 mg/dL * 2 to < 6 years: Male 0.8 mg/dL, female 0.8 mg/dL * 6 to < 10 years: Male 1 mg/dL, female 1 mg/dL * 10 to < 13 years: Male 1.2 mg/dL, female 1.2 mg/dL * 13 to < 16 years: Male 1.5 mg/dL, female 1.4 mg/dL * ≥ 16 years: Male 1.7 mg/dL, female 1.4 mg/dL
• Total bilirubin ≤ 1.5 x ULN for age
• Serum glutamic pyruvic transaminase (SGPT) (alanine aminotransferase [ALT]) ≤ 225 U/L (≤ 5 x ULN). Note that for ALT, the upper limit of normal for all sites is defined as 45 U/L
• Shortening fraction of ≥ 27% by ECHO, or ejection fraction of ≥ 50% by ECHO or gated radionuclide study
• No evidence of dyspnea at rest, no exercise intolerance
• Patients with a history of CNS disease must have no clinical or radiological evidence of active CNS disease at the time of study enrollment
• Patients with seizure disorders may be enrolled if seizures are well controlled on anti-seizure medications
• CNS toxicity ≤ grade 2
• All post-menarchal females must have a negative serum or urine beta-human chorionic gonadotropin (HCG) ≤ 7 days prior to registration. Male and female subjects of reproductive age and childbearing potential must agree to use two acceptable methods of birth control (i.e., intra-uterine device, diaphragm with spermicide, condom with spermicide, or abstinence) or to abstain from heterosexual intercourse for the duration of their participation in the study
• Patients with a history of intraparenchymal or leptomeningeal based CNS disease must have no clinical or radiological evidence of active CNS disease at the time of study enrollment * Patients with skull-based tumors with direct intracranial extension are eligible as long as there are no neurologic signs or symptoms related to the lesion
• OPTIONAL PRO/SDOH FAMILY EXPERIENCE SURVEY: Patients =< 18 years old
• OPTIONAL PRO/SDOH FAMILY EXPERIENCE SURVEY: Caregivers > 18 years old
• OPTIONAL PRO/SDOH FAMILY EXPERIENCE SURVEY: Caregivers and/or patients must be able to speak and read English or Spanish

Exclusion Criteria

• Pregnancy, breast feeding, or unwillingness to use effective contraception during the study will not be entered on this study due to risks of fetal and teratogenic adverse events. Females of childbearing potential must have a negative pregnancy test to be eligible for this study
• Patients who, in the opinion of the investigator, may not be able to comply with the safety monitoring requirements of the study
• Patients with disease of any major organ system that would compromise their ability to withstand therapy
• Patients who have undergone a prior allogeneic stem cell or solid organ transplant
• Patients who are on hemodialysis
• Patients with an active or uncontrolled infection. Patients on prolonged antifungal therapy are still eligible if they are culture negative, afebrile, and meet other organ function criteria
• Known history of human immunodeficiency virus (HIV) infection, hepatitis B, or hepatitis C. Testing is not required in the absence of clinical findings or suspicion
• Patients who require or are likely to require pharmacologic doses of systemic corticosteroids while receiving treatment on this study are ineligible. The only exception is for patients known to require 2 mg/kg or less of hydrocortisone (or an equivalent dose of an alternative corticosteroid) as premedication for blood product administration in order to avoid allergic transfusion reactions. The use of conventional doses of inhaled steroids for the treatment of reactive airway disease is permitted, as is the use of physiologic doses of steroids for patients with known adrenal insufficiency
• Patients on any other immunosuppressive medications (e.g., cyclosporine, tacrolimus) are not eligible
• Patients must not have received enzyme-inducing anticonvulsants including phenytoin, phenobarbital, or carbamazepine for at least 7 days prior to study enrollment. Patients receiving non-enzyme inducing anticonvulsants such as gabapentin, valproic acid, or levetiracetam will be eligible
• Patients who have received drugs that are strong inducers or inhibitors of CYP3A4 within 7 days prior to study enrollment are not eligible
• Patients must not have been diagnosed with myelodysplastic syndrome or with any malignancy other than neuroblastoma
• Patients with symptoms of congestive heart failure are not eligible
• Patients must not have > grade 2 diarrhea
• Patients with a history of progressive disease while receiving therapy per ANBL1221
• Patients with a history of grade 4 allergic reactions to anti-GD2 antibodies or reactions that required permanent discontinuation of the anti-GD2 therapy are not eligible