Key Points
Question
Does oral β-glucan administered early during GD2/GD3 ganglioside vaccine priming improve IgG antibody titer and seroconversion rates associated with improved survival among patients with high-risk neuroblastoma?
Findings
This phase 2 randomized clinical trial of 107 patients with high-risk neuroblastoma found that additional β-glucan during vaccine priming increased antibody titer without added toxic effects. Because the β-glucan receptor, dectin-1 single nucleotide polymorphism (SNP) rs3901533 strongly influenced antibody response, the identical genotype frequency in both study groups may explain their comparable seroconversion rates; understanding the effects on survival will require a longer follow-up.
Meaning
The findings of this phase 2 trial indicate that adding oral β-glucan during vaccine priming increases anti-GD2 IgG1 titer among genetic responders without added toxic effects; however, alternative adjuvants independent of dectin-1 SNP, such as CpG oligodeoxynucleotides—designed to activate toll-like receptor 9—may be needed to enhance seroconversion.
Abstract
Importance
Among patients with high-risk relapsed metastatic neuroblastoma, oral β-glucan adjuvant during GD2/GD3 ganglioside vaccine boost has stimulated IgG antibody response, which was associated with improved survival; however, the effectiveness of oral β-glucan during the vaccine priming phase remains unproven.
Objective
To isolate the adjuvant effect of oral β-glucan on antibody response to GD2/GD3 ganglioside vaccine in patients with high-risk neuroblastoma.
Design, Setting, and Participants
In this phase 2 randomized clinical trial, enrolled patients with high-risk neuroblastoma were randomized to 2 groups to receive the GD2/GD3 vaccine at a large cancer center in a major metropolitan area from October 2018 to September 2020. Data were analyzed from October 7, 2021, to February 28, 2022.
Interventions
Eligible patients receiving GD2/GD3 vaccine were randomly assigned to group 1 (n = 54) to receive no β-glucan or group 2 (n = 53) to receive an oral β-glucan regimen during the first 5 weeks of vaccine priming. From week 6 onwards, all 107 patients received oral β-glucan during vaccine boost for 1 year or until disease progression.
Main Outcomes and Measures
Primary end point was comparison of anti-GD2 IgG1 response before vaccine injection 6 (week 32) in group 1 vs group 2. Seroconversion rate and the association of antibody titer with β-glucan receptor dectin-1 single nucleotide polymorphism (SNP) rs3901533 were also assessed.
Results
In all, 107 patients with high-risk neuroblastoma were randomized to the 2 groups: 54 patients (median [range] age, 5.2 [1.0-17.3] years; 28 [52%] male and 26 [48%] female) in group 1; and 53 patients (median [range] age, 6.2 [1.9-18.4] years; 25 [47%] male and 28 [53%] female) in group 2; both groups were also comparable in their first remission status at study entry (70% vs 70%). Adding oral β-glucan during the first 5 weeks of vaccine priming elicited a higher anti-GD2 IgG1 antibody response in group 2 (1.80; 90% CI, 0.12-3.39; P = .08; planned type I error, 0.10). Anti-GD2 IgG1 titer of 230 ng/mL or greater by week 8 was associated with statistically favorable PFS. Antibody titer correlated significantly with dectin-1 SNP. The genotype frequency, seroconversion rates, and vaccine-related toxic effects were similar in the 2 groups.
Conclusions and Relevance
This phase 2 randomized clinical trial found that adding oral β-glucan during vaccine priming increased anti-GD2 IgG1 titer among genetic responders without added toxic effects. Because responder dectin-1 SNP was identical in the 2 randomized groups, no difference was detected in seroconversion rates. Alternative or additional adjuvants may be needed to enhance seroconversion.
Trial Registration
ClinicalTrials.gov Identifier: NCT00911560
This phase 2 randomized clinical trial evaluates the effect of β-glucan administered during vaccine priming on antibody titer and seroconversion rates at a large cancer center in children with high-risk neuroblastoma.
Introduction
Carbohydrate conjugate vaccines have proven to be effective for pneumococcal infections worldwide,1,2,3 while similar strategies have been much less efficacious for human cancers.4,5 With the recent clinical proof of objective tumor responses for antidisialoganglioside GD2 immunoglobulin G (anti-GD2 IgG) antibodies (ie, dinutuximab, naxitamab) and their approval from the US Food and Drug Administration, a rationale for revisiting failed ganglioside vaccines for human cancers has emerged. Ganglioside GM2,6,7 GD2,8 GD3,9 anti-GD3 anti-idiotype,10 GloboH,11,12 and the pentavalent vaccine13 could stimulate antibody responses in patients. However, the antibody titers were low with the predominance of immunoglobulin M (IgM) over IgG, which was ascribed to the low immunogenicity of carbohydrates, or the insufficiency of helper T cell response. To boost helper T cells, carbohydrate haptens were conjugated to immunogenic protein scaffolds, such as keyhole limpet hemocyanin (KLH)14 or diphtheria toxin CRM197,15 plus combining with subcutaneous immune stimulant QS-21 or monophosphoryl lipid A.16,17,18 Unfortunately, the antibody induced in these conjugate cancer vaccine trials was still mostly IgM,19 failing to show appreciable clinical benefit.12,20,21,22 To explore optimal adjuvants for human vaccines was most urgent,23 in light of the need among populations that are immune disadvantaged, including children,24 older adults,25 and immune-compromised individuals.
A promising oral adjuvant is β-glucan, which is found in many foods, such as mushrooms, oats, rice, barley, seaweed, baker’s yeast, and fungi. These are polymers containing a backbone of β-1,3-linked and β-1,4-D-glucose molecules with 1,6-linked side chains.26,27 The frequency and hinge structure of the side chains determine its immunomodulatory effect. The β-glucans of fungal or yeast origin are normally insoluble in water, but can become soluble with acid hydrolysis or derivatization using charged groups, such as phosphate, sulfate, amine, and carboxymethyl.28 They provide the pathogen-associated molecular patterns recognized by the immune system; β-glucans bind dectin-1 receptor (C-type lectin domain family 7 member A [CLEC7A]) on dendritic cells and macrophages29,30 and exert immune adjuvant properties in preclinical models.31,32 In humans, CLEC7A single nucleotide polymorphisms (SNPs) were associated with susceptibility to and severity of invasive fungal infections.33,34 Orally administered β-glucan has been shown to enhance the antitumor effect of monoclonal antibodies.35,36,37 The exact mechanism of how orally administered β-glucan exerts these effects is not fully understood given that these polymers are not digested or easily absorbed.
Different β-glucan preparations have vastly different properties.38 We tested a special gel formulation of yeast-erived β-glucan in mice and were able to show a strong adjuvant effect in enhancing antiganglioside antibody response.39 The safety and adjuvant effect when given orally was demonstrated in a phase 1 trial.40 After oral administration to patients, β-glucan was measurable in the blood.40 Previous preclinical studies found β-glucan localizing in macrophages and transported to the spleen, the lymph nodes, and the bone marrow.41 Within the bone marrow, macrophages degraded β-glucan further into smaller soluble fragments that were taken up by the complement receptor 3 of marginated granulocytes.41 This systemic activation of innate cells by β-glucan served as the working model for the GD2/GD3 bivalent vaccine strategy.42
A gel formulation of yeast β-glucan was first tested as an oral adjuvant in a phase 1 trial43 and evaluated for efficacy in a phase 2 ganglioside vaccine study in patients with high-risk neuroblastoma (HR-NB) who had prior disease progression.44 In the phase 2 study, the association of antibody titer with dectin-1 SNP highlighted a connection between oral β-glucan and the dendritic cells.40,44 The addition of oral β-glucan was associated with a 4-fold higher peak anti-GD2 IgG1 antibody titer when compared with prior vaccine trials with no β-glucan.8 Anti-GD2 IgG1 titer was also correlated with improved progression-free survival (PFS) and overall survival (OS) in multivariable analyses. Despite having robust antibody response, patients experienced no pain or neuropathic adverse effects that are often seen among patients treated with intravenous anti-GD2 monoclonal antibodies. To isolate the effect of oral β-glucan in this vaccine formulation, we used a randomized clinical trial (RCT) design to test its inclusion vs absence in the initial priming window of GD2/GD3 vaccination to evaluate whether starting oral β-glucan 5 weeks earlier could heighten the magnitude of antibody response and the rate of seroconversion.
Methods
This RCT was reviewed and approved by the Institutional Review Board of Memorial Sloan Kettering Cancer Center (No. 05-075). Written informed consent was obtained from the patients or their guardians. The study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.
Patient Inclusion Criteria
Patients with high-risk neuroblastoma (HR-NB) were defined by risk-related treatment guidelines and the International Neuroblastoma Staging System45—ie, stage 4 diagnosed at 18 months of age or older or MYCN-amplified at any age (stage 3 with unresectable primary tumor or stage 4 or 4S). Eligible patients had to be in clinical remission per the International Neuroblastoma Response Criteria,45 with absolute lymphocyte and neutrophil counts of 500/μL or higher and have major organ toxic effects of grade 3 or lower per the Memorial Sloan Kettering Cancer Center trial protocol 05-075 (Supplement 1). All patients in this analysis had not received any GD2/GD3 vaccine previously.
Study Design
The GD2/GD3 vaccine treatment schedule and the source of vaccine and β-glucan were identical to those in the phase 1 and 2 trials.43,44 Patients with HR-NB in remission were randomized into 2 groups (Figure 1 and eFigure 1 in Supplement 2): group 1 did not receive β-glucan in the first 5 weeks, and group 2 received the oral β-glucan regimen (40 mg/kg/d for 14 days on, then 14 days off) starting at week 1.
Figure 1. CONSORT Diagram of Study Participants.
From week 6 onwards, all 107 patients received β-glucan regimen for 1 year or until disease progression. Seven subcutaneous vaccine injections (weeks 1, 2, 3, 8, 20, 32, and 52) were administered. Each injection consisted of 30 μg of GD2 and 30ug of GD3, which were stabilized as lactones, conjugated to KLH, and then mixed with OPT-821 (an analog of QS-21) at 150 μg/m2.43 The randomization was detailed in the trial protocol (Supplement 1) and stratified by first or second remission status. Primary end point was the comparison of anti-GD2 IgG1 titer before vaccine injection 6 at 32 weeks between the 2 groups. To demonstrate a significant difference equal to 0.8 × SDs, a total of 27 patients per group was required to achieve a 10% type I error and 90% power. Secondary end points were PFS and OS to assess the effectiveness of this vaccine treatment. Toxic effects were evaluated and scored using Common Terminology Criteria for Adverse Events, version 3.0 (US National Cancer Institute) for 24 months after starting treatment or until disease progression, whichever was first.
Disease Evaluation
Computed tomography and/or magnetic resonance imaging plus scintigraphic studies (123I-metaiodobenzylguanidine scan) were performed at enrollment and then every 10 to 12 weeks through 24 months. We assessed bone marrow aspirates and biopsy specimens from bilateral posterior and anterior iliac crests and pooled heparinized aspirates for minimal residual disease (MRD). The response was evaluated using the International Criteria for Neuroblastoma Diagnosis, Staging, and Response to Treatment.45
Blood Collection and Serum Antivaccine Antibody by ELISA
Patients had blood drawn pretreatment and at approximately weeks 3, 8, 20, 32, and 52. Serum samples were collected and frozen at −20 °C for batch analyses and quantified by ELISA (enzyme-linked immunosorbent assay). Assays for the detection of IgG1 and IgM against GD2, IgG1 against GD3, and IgG1 against KLH have been detailed previously.44 Anti-GD2 IgG2 and anti-GD2 IgG3 were measured in assays similar to the anti-GD2 IgG1 ELISA, using hu3F8-IgG2 or hu3F8-IgG3 as the standard plus the addition of peroxidase-conjugated mouse antihuman IgG2 Fc specific or antihuman IgG3 hinge specific as the secondary antibody.
MRD Detection
Quantitative reverse transcription-polymerase chain reaction to detect bone marrow MRD was used as previously described.46 Dectin-1 (CLEC7A) polymorphism genotyping of rs3901533 was described previously44 using DNA extracted from patient’s peripheral blood mononuclear cells or bone marrow.
Statistical Analysis
As planned in the trial protocol (Supplement 1), the primary end point of anti-GD2 IgG1 at 32 weeks was analyzed using a linear regression on the log-transformed titer (logarithm of anti-GD2 IgG1 titer+0.1) stratified by the remission status at protocol entry. Without assuming normal distribution of the titer levels, Wilcoxon rank sum test was used to compare 2 groups at each time point; and Wilcoxon signed rank tests, to compare titers at different time points. Kruskal-Wallis and Mann-Whitney tests were used for association studies between antibody titer at week 8 of vaccine injection 4 and dectin-1 SNP. Using the Kaplan-Meier method, survival rates using time from either the first dose of vaccine or from week 8 through disease progression or death or through death only were estimated (PFS and OS, respectively), and compared using the log rank test. Patients alive without event were censored on the date of last follow-up. Survival rates were given as mean (SE). The potential follow-up duration was estimated using the reverse Kaplan-Meier method.47
Statistical tests were 2-tailed. Because the type I error of the trial was 0.10; P < .10 was considered to be significant. Data analyses were performed from October 7, 2021, to February 28, 2022, using R, version 4.1.0 (R Foundation for Statistical Computing).
Results
The study enrolled and evaluated 107 patients to first-time vaccine treatment in 2 groups from October 2018 to September 2020: 54 patients (median [range] age, 5.2 [1.0-17.3] years; 28 [52%] male and 26 [48%] female) in group 1 and 53 patients (median [range] age, 6.2 [1.9-18.4] years; 25 [47%] male and 28 [53%] female) in group 2. Additional patient characteristics, by group, are available in the Table. Disease status at study entry in both groups was the same: 70% of patients were in their first clinical remission and 30% had a prior history of disease progression. All patients except 2 patients in group 1 and 1 patient in group 2 had received anti-GD2 mAb (dinutuximab/naxitamab) immunotherapy before vaccine enrollment. Results of all available bone marrow samples were negative for MRD before vaccine enrollment.
Table. Patient Characteristics and Survival Outcome Among Patients With High-Risk Neuroblastoma .
| Characteristic | Group 1, No. (%) | Group 2, No. (%) |
|---|---|---|
| Patients, No. | 54 (100) | 53 (100) |
| Sex | ||
| Male | 28 (52) | 25 (47) |
| Female | 26 (48) | 28 (53) |
| Median (range) age at study entry, y | 5.2 (1.0-17.3) | 6.2 (1.9-18.4) |
| Neuroblastoma stage | ||
| 3 | 0 | 2 (4) |
| 4 | 54 (100) | 51 (96) |
| Disease status at study entry | ||
| First CR | 38 (70) | 37 (70) |
| Second CR with prior PD | 16 (30) | 16 (30) |
| First time registration to vaccine | 54 (100) | 53 (100) |
| Received anti-GD2 mAb just before vaccine | ||
| Dinutuximab | 22 (41) | 21 (40) |
| Naxitamab | 30 (56) | 31 (58) |
| None | 2 (3) | 1 (2) |
| Time to PD after vaccine, mo | ||
| <12 | 14 | 14 |
| 12-24 | 0 | 3 |
| 24-30 | 0 | 1 |
| Disease event, No. | 15a | 18 |
| Survival event, No. | 3 | 2 |
Abbreviations: CR, clinical remission; PD, progressive disease.
One patient died without disease progression.
Comparison of Antivaccine Antibody Response
Patients in group 2, who received β-glucan during the 5-week vaccine priming phase, had higher anti-GD2 IgG1 antibody response compared with group 1; the difference achieved statistical significance at week 20 and remained significant through week 52 (Figure 2). The primary end point of this trial was a comparison of anti-GD2 IgG1 titer at 32 weeks between the 2 groups. Using the predetermined 0.10 threshold for P values, the primary end point was met: the coefficient for the log titer level in group 2 compared with group 1 adjusted on remission status was 1.80 (90% CI, 0.12-3.39; P = .08). For anti-GD2 IgM, no statistical difference was observed after the first 8 weeks of treatment, whereas significance was only observed at week 20 for anti-GD3 IgG1 response (Figure 2).
Figure 2. Comparison of Antibody Titer Response Among 107 Patients With High-Risk Neuroblastoma Randomized to Begin Receiving β-Glucan at Week 1 (Group 2) vs Week 6 (Group 1).
The box plots used Tukey convention showing the median, Q1, Q3, and outliers; the whiskers extend up to 1.5 times the IQR. Wilcoxon signed-rank test was used for statistical comparison; P < .10 was deemed significant to achieve a 10% type I error rate and 90% power.
A Cox model using p-spline was used to investigate a nonlinear relationship between anti-GD2 IgG1 titer by week 8 (after the initiation of β-glucan in both groups) and PFS. On the corresponding hazard ratio (HR) plot, the HR line crossed 1 when titer equaled 230 ng/mL, defined as the threshold associated with better PFS. Induction of titer above 230 ng/mL was found to be associated with favorable PFS (Figure 3A; P = .05).
Figure 3. Induction of High Anti-GD2 IgG1 Titer by Week 8 Associated With Favorable PFS.
Titer was dichotomized when titer equaled 230 ng/mL. Correlation between antibody titer at week 8 of vaccine injection 4 and SNP rs3901533 of dectin-1 polymorphism; statistical analyses were performed using Mann-Whitney test. PFS indicates progression-free survival; SNP, single nucleotide polymorphisms.
Patients were defined as seronegative when their anti-GD2 IgG1 titer spanning their entire vaccine treatment was below the detection of limit of the assay. The seropositivity rate was 78% in group 1 and 83% in group 2, which was not statistically different by Fisher exact test (P = .63). Having an overall higher titer in group 2 did not translate to more patients becoming seropositive. Using sera collected at week 52, IgG2 and IgG3 subclasses against GD2 were measured (eTable 1 in Supplement 2). Comparison between the 2 groups showed that the distribution of titers for both IgG2 and IgG3 was not statistically different between the 2 groups; their titers were much lower than those of IgG1.
Antibody Response and Dectin-1 SNP rs3901533
Patients in both groups had identical genotype frequency in dectin-1 SNP rs3901533, the receptor for β-glucan (eTable 2 in Supplement 2). This SNP was previously shown to be associated with IgG1 titer against GD2 and GD3.44 Similar findings were recapitulated in this study. Patients with genotype C/C had significantly lower antibody titer at week 8 of vaccine injection 4 than those carrying either A/A or A/C genotype (P = .01; Figure 3B). In contrast, anti-GD2 IgM titer was not associated with this SNP (P = .24). When all patients were stratified with respect to their anti-GD2 IgG1 seroconversion status, C/C genotype was found among 38% of seropositive patients vs 70% of seronegative patients (P = .01).
Patient Outcomes
The median follow-up period was 20.3 months. No significant difference was found in PFS or OS between groups 1 and 2 (Figure 4); however, very few events were observed for OS, which underpowered the analysis. At 2 years, the PFS (SE) among group 1 was 72% (6%), and OS was 91% (6%), whereas PFS of group 2 was 66% (8%) and OS was 96% (3%) from starting vaccine treatment. When PFS was stratified by remission status in each randomization group (eFigure 2A and 2B in Supplement 2), the group 2 patients who had prior disease progression (≥ second clinical recurrence) before vaccine had statistically poorer PFS than the patients in group 2 who had first clinical recurrence; 8 of 18 patients (44%) who relapsed in group 2 had prior disease progression before vaccine treatment. In contrast, 4 of 14 (29%) patients who relapsed in group 1 had prior disease progression, confirming prior disease progression as an important adverse prognostic variable.44 Understanding how late relapse affected both groups would require a longer clinical follow-up period. It was noted that there was no statistical difference in PFS and OS when patients were stratified according to dectin-1 SNP rs3901533 (eFigure 3A and 3B in Supplement 2).
Figure 4. Survival Outcomes Among Patients With High-Risk Neuroblastoma Who Began Receiving β-Glucan at Week 1 (Group 2) vs at Week 6 (Group 1).
Shaded areas represent SEs.
Toxic Effects
None of the patients experienced neuropathic pain or neuropathy. All except 2 patients (1 in each group) experienced some reportable adverse events (eTable 3A in Supplement 2); 13% experienced grade 3 or 4 toxic effects, with no evidence of a difference between the 2 groups. Specifically, there were 2 episodes of grade 3 urticaria in the same patient on different dates, and 1 grade 3 catheter-related infection. The rest of grade 3 or 4 toxic effects were due to declines in white blood cells, absolute neutrophil counts, absolute lymphocyte counts, platelets, and hemoglobin among patients with myelotoxicity from prior chemotherapy. Grade 3 low potassium and grade 3 high or low glucose were all reversible (eTable 3B in Supplement 2). Grade 2 or lower toxic effects consisted of occasional local reactions at the injection sites—eg, erythema, pain, edema—as well as occasional systemic reactions—eg, fever, pain, vomiting, cough, diarrhea, hyperglycemia, abnormal complete blood count.
Discussion
Ganglioside cancer vaccines have been previously shown to be ineffective because of insufficient IgG response. Vaccine adjuvants have the potential to overcome this deficiency. The ideal vaccine adjuvant should increase antibody response titer and seroconversion rate. It should generate sustained immunological memory and increase the speed of initial immune response.48 Beyond efficacy, the optimal adjuvant should also emphasize safety without long-term adverse effects, allowing broad access and conducive to patient tolerance and compliance. The QS21 at maximal tolerated doses and other adjuvants have failed to induce a protective IgG response. Finding an alternative or complementary adjuvant is critical. There are advantages to having adjuvants produced by facile synthetic chemistry or by extraction from natural products that are compatible with vaccines and other adjuvants. The ability to administer vaccines and immune potentiators without physical or immunological interference is critically important.49
In preclinical models, different β-glucan-containing extracts have shown immune effects on cancer.50,51 However, to our knowledge, no RCT had successfully demonstrated a clear benefit of β-glucan as an adjuvant on cancer control and their mechanisms of action in patients had remained largely unexplored. In this RCT of ganglioside GD2/GD3 vaccine, a gel formulation of yeast β-glucan was used to stimulate IgG1 response against GD2, GD3, and KLH, as well IgM against GD2. It was notable that by administering β-glucan early during the priming phase (group 2), the anti-GD2 IgG1 antibody response in vaccinated patients was statistically higher than in the control (group 1). Moreover, high antibody response (≥230 ng/mL) by week 8 of vaccine correlated significantly with PFS, similar to our previous observation among patients with prior progression who received the same vaccine regimen as those in group 1.44 Finding a consensus protective anti-GD2 IgG1 titer as a surrogate measure of efficacy—analogous to the one adopted by the World Health Organization for pneumococcal conjugate vaccines52—could expedite further optimization of ganglioside vaccine and adjuvants.
The correlation of seroconversion with the dectin-1 SNP rs3901533 in this study and in the previous trial44 strongly implicates the role of macrophages or dendritic cells in this β-glucan effect on innate immunity and/or antibody class switch. Human antibody response class switches are irreversible and proceed from upstream classes to downstream classes, according to the order of the IgH constant region loci on the chromosome.53 The dominant class switch pathway includes IgM to IgG3, then IgG1, IgA1, and finally IgG2 (approximately 85%). Downstream classes are predominantly produced via indirect switches from IgG1 to IgA1 or IgG2 (approximately 92%).54
In this trial, when the IgG subclass of anti-GD2 antibody was analyzed using sera from week 52, the antibody titers between the 2 groups were similar but low for both IgG2 and IgG3 subclasses. The glucan effect appeared to dominate the class switch from IgM to IgG1. The apparent genetic association of glucan effect might limit its benefit to only a subset of patients carrying the appropriate SNPs, but it should also serve as a biomarker for prognostics and patient selection.
Limitations
Small sample size is a major limitation for RCTs of rare diseases, including the present study, resulting in P values being set at a 0.10 threshold. Because compliance of oral β-glucan may often be difficult, even among a highly committed patient population, steps are being taken to reduce the number of days patients receive β-glucan to coincide with the days when vaccine is given.
Conclusions
This RCT of β-glucan found that starting β-glucan early, before week 6 (priming period), vs starting glucan after week 6 enhanced anti-GD2 IgG1 response significantly from week 20 onward without added toxic effects. Treatment with β-glucan fulfills many of the benchmarks of an effective adjuvant. It increases the antibody response to ganglioside vaccine, with proven safety in children after a median follow-up of more than 10 years.43 It is sourced from the widely available baker’s yeast, inexpensive and biodegradable. Its oral route of administration should be highly compatible and codeliverable with subcutaneous or intravenous vaccines without physical interference. Being tasteless and odorless, it is well tolerated as an oral agent.
Unfortunately, this additional β-glucan did not increase the seroconversion rate in this RCT. A plausible explanation was the genetic influence of dectin-1 SNP on the β-glucan effect. To overcome this deficiency, additional adjuvants independent of dectin-1 SNP may be beneficial, a concept being tested in an RCT that includes granulocyte-macrophage colony stimulating factor, given its safety and efficacy record when combined with anti-GD2 monoclonal antibodies in the treatment of HR-NB in children.55,56
Trial Protocol
eFigure 1. Treatment schema with oral β-glucan randomization to Group 1 and Group 2
eFigure 2A. Progression-free survival stratified by remission status in randomization Group 1 (No β-glucan until wk6)
eFigure 2B. Progression-free survival stratified by remission status in randomization Group 2 (β-glucan at wk1)
eFigure 3A. Progression-free survival stratified by dectin-1 SNP rs3901533 among all patients
eFigure 3B. Overall survival stratified by dectin-1 SNP rs3901533 among all patients
eTable 1. Anti-GD2 subclass antibody titers as assessed at week 52
eTable 2. Genotype frequency of dectin-1 SNP rs3901533 among all patients
eTable 3A. Adverse event by toxic effect grade
eTable 3B. Grade 3 or 4 toxic effects (N=14 patients)
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Trial Protocol
eFigure 1. Treatment schema with oral β-glucan randomization to Group 1 and Group 2
eFigure 2A. Progression-free survival stratified by remission status in randomization Group 1 (No β-glucan until wk6)
eFigure 2B. Progression-free survival stratified by remission status in randomization Group 2 (β-glucan at wk1)
eFigure 3A. Progression-free survival stratified by dectin-1 SNP rs3901533 among all patients
eFigure 3B. Overall survival stratified by dectin-1 SNP rs3901533 among all patients
eTable 1. Anti-GD2 subclass antibody titers as assessed at week 52
eTable 2. Genotype frequency of dectin-1 SNP rs3901533 among all patients
eTable 3A. Adverse event by toxic effect grade
eTable 3B. Grade 3 or 4 toxic effects (N=14 patients)
Data Sharing Statement