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Only one class of targeted agents (anti-GD2 antibodies) has been incorporated into front-line therapy for neuroblastoma since the 1980s. The Neuroblastoma New Drug Development Strategy (NDDS) initiative commenced in 2012 to accelerate the development of new drugs for neuroblastoma. Advances have occurred, with eight of nine high-priority targets being evaluated in paediatric trials including anaplastic lymphoma kinase inhibitors being investigated in front-line, but significant challenges remain. This article reports the conclusions of the second NDDS forum, which expanded across the Atlantic to further develop the initiative. Pre-clinical and clinical data for 40 genetic targets and mechanisms of action were prioritised and drugs were identified for early-phase trials. Strategies to develop drugs targeting TERT, telomere maintenance, ATRX, alternative lengthening of telomeres (ALT), BRIP1 and RRM2 as well as direct targeting of MYCN are high priority and should be championed for drug discovery. Promising pre-clinical data suggest that targeting of ALT by ATM or PARP inhibition may be potential strategies. Drugs targeting CDK2/9, CDK7, ATR and telomere maintenance should enter paediatric clinical development rapidly. Optimising the response to anti-GD2 by combinations with chemotherapy, targeted agents and other immunological targets are crucial. Delivering this strategy in the face of small patient cohorts, genomically defined subpopulations and a large number of permutations of combination trials, demands even greater international collaboration. In conclusion, the NDDS provides an internationally agreed, biologically driven selection of prioritised genetic targets and drugs. Improvements in the strategy for conducting trials in neuroblastoma will accelerate bringing these new drugs more rapidly to front-line therapy. (C) 2020 Elsevier Ltd. All rights reserved.

Only one class of targeted agents (anti-GD2 antibodies) has been incorporated into front-line therapy for neuroblastoma since the 1980s. The Neuroblastoma New Drug Development Strategy (NDDS) initiative commenced in 2012 to accelerate the development of new drugs for neuroblastoma. Advances have occurred, with eight of nine high-priority targets being evaluated in paediatric trials including anaplastic lymphoma kinase inhibitors being investigated in front-line, but significant challenges remain. This article reports the conclusions of the second NDDS forum, which expanded across the Atlantic to further develop the initiative. Pre-clinical and clinical data for 40 genetic targets and mechanisms of action were prioritised and drugs were identified for early-phase trials. Strategies to develop drugs targeting TERT, telomere maintenance, ATRX, alternative lengthening of telomeres (ALT), BRIP1 and RRM2 as well as direct targeting of MYCN are high priority and should be championed for drug discovery. Promising pre-clinical data suggest that targeting of ALT by ATM or PARP inhibition may be potential strategies. Drugs targeting CDK2/9, CDK7, ATR and telomere maintenance should enter paediatric clinical development rapidly. Optimising the response to anti-GD2 by combinations with chemotherapy, targeted agents and other immunological targets are crucial. Delivering this strategy in the face of small patient cohorts, genomically defined subpopulations and a large number of permutations of combination trials, demands even greater international collaboration. In conclusion, the NDDS provides an internationally agreed, biologically driven selection of prioritised genetic targets and drugs. Improvements in the strategy for conducting trials in neuroblastoma will accelerate bringing these new drugs more rapidly to front-line therapy.

// Francesco Maria Calabrese 1, * , Rosanna Clima 2, * , Piero Pignataro 3, 4 , Vito Alessandro Lasorsa 3, 4 , Michael D. Hogarty 5 , Aurora Castellano 6 , Massimo Conte 7 , Gian Paolo Tonini 8 , Achille Iolascon 3, 4 , Giuseppe Gasparre 2, # , Mario Capasso 3, 4, 9, # 1 Department of Biology, University of Bari “Aldo Moro”, Bari, Italy 2 Department of Medical and Surgical Sciences-DIMEC, Medical Genetics Unit, University of Bologna, Bologna, Italy 3 Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy 4 CEINGE Biotecnologie Avanzate, Napoli, Italy 5 Department of Pediatrics, Division of Oncology, Children’s Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, USA 6 Paediatric Haematology/Oncology Department, IRCCS, Ospedale Pediatrico Bambino Gesu, Rome, Italy 7 Oncology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy 8 Pediatric Research Institute (IRP) – Fondazione Citta della Speranza, Neuroblastoma Laboratory, Padua, Italy 9 IRCCS SDN, Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy * These authors contributed equally to this work # Co-last authors Correspondence to: Mario Capasso, email: mario.capasso@unina.it Keywords: neuroblastoma, mitochondrial DNA mutations, WES, somatic mutations, germline mutations Received: April 21, 2016 Accepted: June 09, 2016 Published: June 24, 2016 ABSTRACT Background: Neuroblastoma, a tumor of the developing sympathetic nervous system, is a common childhood neoplasm that is often lethal. Mitochondrial DNA (mtDNA) mutations have been found in most tumors including neuroblastoma. We extracted mtDNA data from a cohort of neuroblastoma samples that had undergone Whole Exome Sequencing (WES) and also used snap-frozen samples in which mtDNA was entirely sequenced by Sanger technology. We next undertook the challenge of determining those mutations that are relevant to, or arisen during tumor development. The bioinformatics pipeline used to extract mitochondrial variants from matched tumor/blood samples was enriched by a set of filters inclusive of heteroplasmic fraction, nucleotide variability, and in silico prediction of pathogenicity. Results: Our in silico multistep workflow applied both on WES and Sanger-sequenced neuroblastoma samples, allowed us to identify a limited burden of somatic and germline mitochondrial mutations with a potential pathogenic impact. Conclusions: The few singleton germline and somatic mitochondrial mutations emerged, according to our in silico analysis, do not appear to impact on the development of neuroblastoma. Our findings are consistent with the hypothesis that most mitochondrial somatic mutations can be considered as ‘passengers’ and consequently have no discernible effect in this type of cancer.

// Vito Alessandro Lasorsa 1,2 , Daniela Formicola 1,2 , Piero Pignataro 1,2 , Flora Cimmino 1,2 , Francesco Maria Calabrese 3 , Jaume Mora 4 , Maria Rosaria Esposito 5 , Marcella Pantile 5 , Carlo Zanon 5 , Marilena De Mariano 6 , Luca Longo 6 , Michael D. Hogarty 7 , Carmen de Torres 4 , Gian Paolo Tonini 5 , Achille Iolascon 1,2 and Mario Capasso 1,2,8 1 University of Naples Federico II, Department of Molecular Medicine and Medical Biotechnology, Naples, Italy 2 CEINGE Biotecnolgie Avanzate, Naples, Italy 3 University of Bari, Department of Biology, Bari, Italy 4 Hospital Sant Joan de Deu, Developmental Tumor Biology Laboratory and Department of Oncology, Esplugues de Llobregat, Barcelona, Spain 5 Pediatric Research Institute (IRP), Fondazione Citta della Speranza, Neuroblastoma Laboratory, Padua, Italy 6 U.O.C. Bioterapie, IRCCS AOU San Martino-IST, National Cancer Research Institute, Genoa, Italy 7 Children’s Hospital of Philadelphia, Division of Oncology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America 8 IRCCS SDN, Istituto di Ricerca Diagnostica e Nucleare, Naples, Italy Correspondence: Mario Capasso, email: // Flora Cimmino, email: // Keywords : NGS, neuroblastoma, high risk, somatic mutation, cancer driver genes Received : December 22, 2015 Accepted : February 09, 2016 Published : March 18, 2016 Abstract The spectrum of somatic mutation of the most aggressive forms of neuroblastoma is not completely determined. We sought to identify potential cancer drivers in clinically aggressive neuroblastoma. Whole exome sequencing was conducted on 17 germline and tumor DNA samples from high-risk patients with adverse events within 36 months from diagnosis (HR-Event3) to identify somatic mutations and deep targeted sequencing of 134 genes selected from the initial screening in additional 48 germline and tumor pairs (62.5% HR-Event3 and high-risk patients), 17 HR-Event3 tumors and 17 human-derived neuroblastoma cell lines. We revealed 22 significantly mutated genes, many of which implicated in cancer progression. Fifteen genes (68.2%) were highly expressed in neuroblastoma supporting their involvement in the disease. CHD9 , a cancer driver gene, was the most significantly altered (4.0% of cases) after ALK . Other genes ( PTK2 , NAV3 , NAV1 , FZD1 and ATRX ), expressed in neuroblastoma and involved in cell invasion and migration were mutated at frequency ranged from 4% to 2%. Focal adhesion and regulation of actin cytoskeleton pathways, were frequently disrupted (14.1% of cases) thus suggesting potential novel therapeutic strategies to prevent disease progression. Notably BARD1 , CHEK2 and AXIN2 were enriched in rare, potentially pathogenic, germline variants. In summary, whole exome and deep targeted sequencing identified novel cancer genes of clinically aggressive neuroblastoma. Our analyses show pathway-level implications of infrequently mutated genes in leading neuroblastoma progression.