Polyamine Inhibition with DFMO: Shifting the Paradigm in Neuroblastoma Therapy

Neuroblastoma is a common childhood malignancy, and high-risk presentations, including an MYCN amplified status, continue to result in poor survival. Difluoromethylornithine (DFMO) is a new and well-tolerated treatment for high-risk neuroblastoma. This review article discusses preclinical and clinical data that resulted in the establishment of DFMO as a treatment for neuroblastoma. The review of preclinical data includes a summary of the contribution of polyamine synthetic pathways to high-risk neuroblastoma, the effect that MYCN has on polyamine synthetic pathways, and the proposed mechanism by which DFMO inhibits tumorigenesis. This understanding has led to the discussion of various preclinical combination therapies that may result in a synergistic therapeutic response for high-risk neuroblastoma. We review the clinical trials that show the successful treatment of high-risk neuroblastoma with DFMO, including comparative analysis and traditional neuroblastoma trials using propensity score matching. We review the regulatory path by which DFMO gained approval from the Federal Drug Administration for use as a maintenance therapy following the traditional high-risk neuroblastoma therapy. Finally, we discuss the role of DFMO in future clinical research for neuroblastoma and additional pediatric cancers.