Vincristine, Dactinomycin, and Cyclophosphamide With or Without Radiation Therapy in Treating Patients With Newly Diagnosed Low-Risk Rhabdomyosarcoma

Phase 3

Completed

Conditions: Adult Rhabdomyosarcoma
Embryonal Childhood Rhabdomyosarcoma
Embryonal-botryoid Childhood Rhabdomyosarcoma
Previously Untreated Childhood Rhabdomyosarcoma

Interventions: Procedure: conventional surgery
Drug: dactinomycin
Drug: vincristine sulfate
Drug: cyclophosphamide
Radiation: radiation therapy

Registration Number: NCT00075582

Lead Sponsor: Children's Oncology Group

Brief Summary: This phase III trial is studying how well combination chemotherapy and radiation therapy work in treating patients with newly diagnosed low-risk rhabdomyosarcoma. Drugs used in chemotherapy, such as vincristine, dactinomycin, and cyclophosphamide, work in different ways to stop tumor cells from dividing so they stop growing or die. Radiation therapy uses high-energy x-rays to damage tumor cells. Combining chemotherapy with radiation therapy may kill more tumor cells. It is not yet known which treatment regimen is more effective in treating low-risk rhabdomyosarcoma.

Detailed Description: PRIMARY OBJECTIVES:

I. Determine the failure-free survival of patients with newly diagnosed low-risk rhabdomyosarcoma treated with vincristine (V), dactinomycin (A), cyclophosphamide (C), and radiotherapy.

SECONDARY OBJECTIVES:

I. Determine local control rates in patients treated with this regimen. II. Determine the rate of second-look surgery in patients with bulk residual tumor at diagnosis (clinical group III) and the proportion of second-look surgeries that render patients treated with this regimen tumor-free or with microscopic tumor only and evaluate the pathologic significance of that residual tumor.

III. Determine the local control rates in patients with clinical group III disease treated with response-adjusted radiotherapy doses after second-look surgical resection.

OUTLINE: This is a nonrandomized, multicenter study. Patients are assigned to 1 of 2 treatment regimens according to disease stage and clinical group.

REGIMEN I (subset 1 patients) \[closed to accrual as of 08/13/2010: Patients receive VAC chemotherapy comprising vincristine IV over 1 minute on day 1 of weeks 1-9 and dactinomycin IV over 1 minute and cyclophosphamide IV over 1 hour on day 1 of weeks 1, 4, 7, and 10; VA chemotherapy comprising vincristine IV over 1 minute on day 1 of weeks 13-21 and dactinomycin\* IV over 1 minute on day 1 of weeks 13, 16, 19, and 22; and radiotherapy\*\*, 5 days a week, beginning on week 13 and continuing for 4-7 weeks, depending on prescribed dose.

REGIMEN II (subset 2 patients)\[closed to accrual as of 9/23/2011\]: Patients receive VAC chemotherapy and radiotherapy\*\* as in regimen I and VA chemotherapy comprising vincristine IV over 1 minute on day 1 of weeks 13-21, 25-33, and 37-45 and dactinomycin\* IV over 1 minute on day 1 of weeks 13, 16, 19, 22, 25, 28, 31, 34, 37, 40, 43, and 46. Patients with clinical group III disease may undergo second-look surgery at week 13 followed by response-adjusted radiotherapy, and continued VA\* chemotherapy. In both regimens, treatment continues in the absence of disease progression or unacceptable toxicity.

NOTE: \*For both regimens, dactinomycin is omitted during radiotherapy.

NOTE: \*\*Clinical Group I tumors and those with Clinical Group III uterine/cervix primary disease with negative nodes who have undergone a complete resection (i.e. hysterectomy) at Week 13 do not receive radiotherapy at Week 13

Patients are followed up every 3 months for 1 year, every 4 months for 2 years, every 6 months for 1 year, and then annually thereafter.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 390

Inclusion Criteria

Histologically confirmed newly diagnosed embryonal rhabdomyosarcoma (RMS), botryoid or spindle cell variants of embryonal RMS, or embryonal ectomesenchymoma, meeting criteria for 1 of the following subsets:
- Subset 1, defined by meeting 1 of the following criteria (closed to accrual as of 08/13/2010):
  - Stage 1 and clinical group I (completely resected) or II (microscopic residual disease and/or regional lymph node involvement) disease
  - Stage 1 and clinical group III (gross residual disease) disease arising in the orbit
  - Stage 2 and clinical group I or II disease
- Subset 2, defined by meeting 1 of the following criteria (closed to accrual as of 09/23/2011):
  - Stage 1 and clinical group III disease arising in a non-orbit site
  - Stage 3 and clinical group I or II disease
Prior staging ipsilateral retroperitoneal lymph node dissection required for all patients age 10 and over with paratesticular tumors and patients under 10 years of age with clinically or radiographically involved lymph nodes (except when extensive lymph node involvement is identified by imaging studies)
- If there is extensive gross node involvement only confirmatory node biopsy is recommended and the patient is classified as Clinical Group III
Prior regional lymph node sampling required for patients with extremity tumors
None of the following diagnoses:
- Intermediate-risk embryonal RMS
- Metastatic embryonal RMS
- Alveolar RMS
- Undifferentiated sarcoma
- RMS not otherwise specified (NOS)
- Other soft tissue sarcoma, including sarcoma NOS
Prior enrollment on clinical trial COG-D9902
Performance status - ECOG 0-2
Performance status - Karnofsky 50-100% (≥ 16 years old)
Performance status - Lansky 50-100% (< 16 years old)
Absolute neutrophil count at least 750/mm^3
Platelet count at least 75,000/mm^3 (transfusion independent)
Bilirubin no greater than 1.5 times upper limit of normal (ULN)*
Creatinine* based on age/gender as follows:
- No greater than 0.8 mg/dL for patients age 5 and under
- No greater than 1.0 mg/dL for patients age 6 to 9
- No greater than 1.2 mg/dL for patients age 10 to 12
- No greater than 1.4 mg/dL for female patients age 13 and over
- No greater than 1.5 mg/dL for male patients age 13 to 15
- No greater than 1.7 mg/dL for male patients age 16 and over
Creatinine clearance* or radioisotope glomerular filtration rate at least 70 mL/min/1.73 m^2
Not pregnant or nursing
Negative pregnancy test
Fertile patients must use effective contraception
No uncontrolled infection
No prior chemotherapy (except for patients treated on the related intermediate-risk study)
Prior steroids allowed
No prior radiotherapy

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Regimen I (chemotherapy, radiotherapy)	vincristine sulfate	Patients receive VAC chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 1-9 and dactinomycin IV over 1 minute and cyclophosphamide IV over 1 hour on day 1 of weeks 1, 4, 7, and 10; VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, and 22 (dactinomycin is omitted during radiation therapy); and radiation therapy, 5 days a week, beginning on week 13 and continuing for 4-7 weeks, depending on prescribed dose. Some patients do not receive radiation therapy; some start it at week 24. (closed to accrual as of 08/13/2010)
Regimen I (chemotherapy, radiotherapy)	radiation therapy	Patients receive VAC chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 1-9 and dactinomycin IV over 1 minute and cyclophosphamide IV over 1 hour on day 1 of weeks 1, 4, 7, and 10; VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, and 22 (dactinomycin is omitted during radiation therapy); and radiation therapy, 5 days a week, beginning on week 13 and continuing for 4-7 weeks, depending on prescribed dose. Some patients do not receive radiation therapy; some start it at week 24. (closed to accrual as of 08/13/2010)
Regimen II (chemotherapy, radiotherapy, surgery)	conventional surgery	Patients receive VAC chemotherapy and radiation therapy as in regimen I and VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21, 25-33, and 37-45 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, 22, 25, 28, 31, 34, 37, 40, 43, and 46 (dactinomycin is omitted during radiation therapy). Some patients do not receive radiation therapy; some start it at week 13 and some at week 24. Some patients have conventional surgery (second-look) at Week 13 (closed to accrual as of 9/23/2011).
Regimen II (chemotherapy, radiotherapy, surgery)	dactinomycin	Patients receive VAC chemotherapy and radiation therapy as in regimen I and VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21, 25-33, and 37-45 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, 22, 25, 28, 31, 34, 37, 40, 43, and 46 (dactinomycin is omitted during radiation therapy). Some patients do not receive radiation therapy; some start it at week 13 and some at week 24. Some patients have conventional surgery (second-look) at Week 13 (closed to accrual as of 9/23/2011).
Regimen II (chemotherapy, radiotherapy, surgery)	cyclophosphamide	Patients receive VAC chemotherapy and radiation therapy as in regimen I and VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21, 25-33, and 37-45 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, 22, 25, 28, 31, 34, 37, 40, 43, and 46 (dactinomycin is omitted during radiation therapy). Some patients do not receive radiation therapy; some start it at week 13 and some at week 24. Some patients have conventional surgery (second-look) at Week 13 (closed to accrual as of 9/23/2011).
Regimen II (chemotherapy, radiotherapy, surgery)	vincristine sulfate	Patients receive VAC chemotherapy and radiation therapy as in regimen I and VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21, 25-33, and 37-45 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, 22, 25, 28, 31, 34, 37, 40, 43, and 46 (dactinomycin is omitted during radiation therapy). Some patients do not receive radiation therapy; some start it at week 13 and some at week 24. Some patients have conventional surgery (second-look) at Week 13 (closed to accrual as of 9/23/2011).
Regimen II (chemotherapy, radiotherapy, surgery)	radiation therapy	Patients receive VAC chemotherapy and radiation therapy as in regimen I and VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21, 25-33, and 37-45 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, 22, 25, 28, 31, 34, 37, 40, 43, and 46 (dactinomycin is omitted during radiation therapy). Some patients do not receive radiation therapy; some start it at week 13 and some at week 24. Some patients have conventional surgery (second-look) at Week 13 (closed to accrual as of 9/23/2011).
Regimen I (chemotherapy, radiotherapy)	dactinomycin	Patients receive VAC chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 1-9 and dactinomycin IV over 1 minute and cyclophosphamide IV over 1 hour on day 1 of weeks 1, 4, 7, and 10; VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, and 22 (dactinomycin is omitted during radiation therapy); and radiation therapy, 5 days a week, beginning on week 13 and continuing for 4-7 weeks, depending on prescribed dose. Some patients do not receive radiation therapy; some start it at week 24. (closed to accrual as of 08/13/2010)
Regimen I (chemotherapy, radiotherapy)	cyclophosphamide	Patients receive VAC chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 1-9 and dactinomycin IV over 1 minute and cyclophosphamide IV over 1 hour on day 1 of weeks 1, 4, 7, and 10; VA chemotherapy comprising vincristine sulfate IV over 1 minute on day 1 of weeks 13-21 and dactinomycin IV over 1 minute on day 1 of weeks 13, 16, 19, and 22 (dactinomycin is omitted during radiation therapy); and radiation therapy, 5 days a week, beginning on week 13 and continuing for 4-7 weeks, depending on prescribed dose. Some patients do not receive radiation therapy; some start it at week 24. (closed to accrual as of 08/13/2010)

Primary Outcome Measures

Name	Time	Method
Percentage of Patients With Stage 1, Clinical Group IIB or C (Node Positive) or Stage 2 Failure Free at 5 Years Following Study Entry	From enrollment up to 5 years	Kaplan Meier estimate of failure free survival at 5 years, where failure free survival is defined as the time to relapse, progression, second malignancy, and death whichever occurs first.
Percentage of Patients With Low-risk Rhabdomyosarcoma in Subset 2 Failure Free at 5 Years Following Study Entry	From enrollment up to 5 years	Kaplan Meier estimate of failure free survival at 5 years, where failure free survival is defined as the time to relapse, progression, second malignancy, and death whichever occurs first.
Percentage of Patients With Low-risk Rhabdomyosarcoma in Subset 1 Failure Free at 5 Years Following Study Entry	From enrollment up to 5 years	Kaplan Meier estimate of failure free survival at 5 years, where failure free survival is defined as the time to relapse, progression, second malignancy, and death whichever occurs first.

Secondary Outcome Measures

Name	Time	Method
Cumulative Incidence of Patients Who Receive Reduced Doses of Radiation Therapy	From enrollment up to 5 years	The local failure rate will be estimated using cumulative incidence curves.
Percentage of Patients With Delayed Surgical Procedures	At 13 weeks after induction	The decision to perform second-look surgery should be based on the physical examination and imaging studies at Week 12 and should only be considered if a reasonable functional and cosmetic result is anticipated.
Cumulative Incidence of Group III Patients Who Received With Reduced Radiotherapy Dose	From enrollment up to 20 weeks	The local failure rate will be estimated using cumulative incidence curves for Group III patients who received reduced doses of radiation therapy after second look surgical resection.

Trial Locations

Locations (163): Driscoll Children's Hospital
🇺🇸
Corpus Christi, Texas, United States
West Virginia University Charleston
🇺🇸
Charleston, West Virginia, United States
University of Chicago Comprehensive Cancer Center
🇺🇸
Chicago, Illinois, United States
University of Illinois
🇺🇸
Chicago, Illinois, United States
Childrens Memorial Hospital
🇺🇸
Chicago, Illinois, United States
Children's Hospital of Pittsburgh of UPMC
🇺🇸
Pittsburgh, Pennsylvania, United States
Dana-Farber Cancer Institute
🇺🇸
Boston, Massachusetts, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸
Miami, Florida, United States
Miami Children's Hospital
🇺🇸
Miami, Florida, United States
Baptist Hospital of Miami
🇺🇸
Miami, Florida, United States
Indiana University Medical Center
🇺🇸
Indianapolis, Indiana, United States
Baylor College of Medicine
🇺🇸
Houston, Texas, United States
M D Anderson Cancer Center
🇺🇸
Houston, Texas, United States
Nevada Cancer Research Foundation CCOP
🇺🇸
Las Vegas, Nevada, United States
Cincinnati Children's Hospital Medical Center
🇺🇸
Cincinnati, Ohio, United States
University of Minnesota Medical Center-Fairview
🇺🇸
Minneapolis, Minnesota, United States
Children's Hospitals and Clinics of Minnesota - Minneapolis
🇺🇸
Minneapolis, Minnesota, United States
University of California San Francisco Medical Center-Parnassus
🇺🇸
San Francisco, California, United States
Vanderbilt-Ingram Cancer Center
🇺🇸
Nashville, Tennessee, United States
Methodist Children's Hospital of South Texas
🇺🇸
San Antonio, Texas, United States
University of Virginia
🇺🇸
Charlottesville, Virginia, United States
Children's National Medical Center
🇺🇸
Washington, District of Columbia, United States
Southern Illinois University
🇺🇸
Springfield, Illinois, United States
University of Mississippi Medical Center
🇺🇸
Jackson, Mississippi, United States
University of Rochester
🇺🇸
Rochester, New York, United States
Children's Hospital Los Angeles
🇺🇸
Los Angeles, California, United States
Swiss Pediatric Oncology Group - Lausanne
🇨🇭
Lausanne, Switzerland
Sinai Hospital of Baltimore
🇺🇸
Baltimore, Maryland, United States
Janeway Child Health Centre
🇨🇦
Saint John's, Newfoundland and Labrador, Canada
British Columbia Children's Hospital
🇨🇦
Vancouver, British Columbia, Canada
Children's Hospital of Eastern Ontario
🇨🇦
Ottawa, Ontario, Canada
Centre Hospitalier Universitaire de Quebec
🇨🇦
Ste-Foy, Quebec, Canada
Rocky Mountain Hospital for Children-Presbyterian Saint Luke's Medical Center
🇺🇸
Denver, Colorado, United States
Mayo Clinic
🇺🇸
Rochester, Minnesota, United States
Children's Hospital and Medical Center of Omaha
🇺🇸
Omaha, Nebraska, United States
University of Nebraska Medical Center
🇺🇸
Omaha, Nebraska, United States
Legacy Emanuel Hospital and Health Center
🇺🇸
Portland, Oregon, United States
Oregon Health and Science University
🇺🇸
Portland, Oregon, United States
Midwest Children's Cancer Center
🇺🇸
Milwaukee, Wisconsin, United States
Children's Hospital Medical Center of Akron
🇺🇸
Akron, Ohio, United States
Albany Medical Center
🇺🇸
Albany, New York, United States
Geisinger Medical Center
🇺🇸
Danville, Pennsylvania, United States
Wayne State University
🇺🇸
Detroit, Michigan, United States
Children's Hospital of Philadelphia
🇺🇸
Philadelphia, Pennsylvania, United States
Medical City Dallas Hospital
🇺🇸
Dallas, Texas, United States
University of Vermont
🇺🇸
Burlington, Vermont, United States
Cardinal Glennon Children's Medical Center
🇺🇸
Saint Louis, Missouri, United States
Rainbow Babies and Childrens Hospital
🇺🇸
Cleveland, Ohio, United States
Nationwide Children's Hospital
🇺🇸
Columbus, Ohio, United States
T C Thompson Children's Hospital
🇺🇸
Chattanooga, Tennessee, United States
University of Texas Health Science Center at San Antonio
🇺🇸
San Antonio, Texas, United States
Primary Children's Medical Center
🇺🇸
Salt Lake City, Utah, United States
The Children's Medical Center of Dayton
🇺🇸
Dayton, Ohio, United States
Scott and White Memorial Hospital
🇺🇸
Temple, Texas, United States
Advocate Lutheran General Hospital
🇺🇸
Park Ridge, Illinois, United States
Lehigh Valley Hospital - Muhlenberg
🇺🇸
Bethlehem, Pennsylvania, United States
Cook Children's Medical Center
🇺🇸
Fort Worth, Texas, United States
Royal Brisbane and Women's Hospital
🇦🇺
Herston, Queensland, Australia
Women's and Children's Hospital-Adelaide
🇦🇺
North Adelaide, South Australia, Australia
Hospital for Sick Children
🇨🇦
Toronto, Ontario, Canada
Swiss Pediatric Oncology Group - Geneva
🇨🇭
Geneva, Switzerland
New York Medical College
🇺🇸
Valhalla, New York, United States
Sydney West Area Health Service-Westmead Hospital
🇦🇺
Westmead, New South Wales, Australia
Hurley Medical Center
🇺🇸
Flint, Michigan, United States
Children's Hospital Colorado
🇺🇸
Aurora, Colorado, United States
Saint Joseph Children's Hospital of Tampa
🇺🇸
Tampa, Florida, United States
C S Mott Children's Hospital
🇺🇸
Ann Arbor, Michigan, United States
UC Davis Comprehensive Cancer Center
🇺🇸
Sacramento, California, United States
Wake Forest University Health Sciences
🇺🇸
Winston-Salem, North Carolina, United States
Saint Luke's Mountain States Tumor Institute
🇺🇸
Boise, Idaho, United States
Cleveland Clinic Foundation
🇺🇸
Cleveland, Ohio, United States
University of Arkansas for Medical Sciences
🇺🇸
Little Rock, Arkansas, United States
University of Alabama at Birmingham
🇺🇸
Birmingham, Alabama, United States
Children's Oncology Group
🇺🇸
Arcadia, California, United States
University of Arizona Health Sciences Center
🇺🇸
Tucson, Arizona, United States
Phoenix Childrens Hospital
🇺🇸
Phoenix, Arizona, United States
Loma Linda University Medical Center
🇺🇸
Loma Linda, California, United States
Southern California Permanente Medical Group
🇺🇸
Downey, California, United States
Children's Hospital Central California
🇺🇸
Madera, California, United States
Cedars-Sinai Medical Center
🇺🇸
Los Angeles, California, United States
Miller Children's Hospital
🇺🇸
Long Beach, California, United States
Rady Children's Hospital - San Diego
🇺🇸
San Diego, California, United States
Lucile Packard Children's Hospital Stanford University
🇺🇸
Palo Alto, California, United States
Childrens Hospital of Orange County
🇺🇸
Orange, California, United States
Children's Hospital and Research Center at Oakland
🇺🇸
Oakland, California, United States
Kaiser Permanente-Oakland
🇺🇸
Oakland, California, United States
Broward Health Medical Center
🇺🇸
Fort Lauderdale, Florida, United States
Memorial Healthcare System - Joe DiMaggio Children's Hospital
🇺🇸
Hollywood, Florida, United States
Nemours Children's Clinic - Pensacola
🇺🇸
Pensacola, Florida, United States
All Children's Hospital
🇺🇸
Saint Petersburg, Florida, United States
Children's Healthcare of Atlanta - Egleston
🇺🇸
Atlanta, Georgia, United States
Saint Mary's Hospital
🇺🇸
West Palm Beach, Florida, United States
Memorial Health University Medical Center
🇺🇸
Savannah, Georgia, United States
Nemours Children's Clinic - Jacksonville
🇺🇸
Jacksonville, Florida, United States
Saint Jude Midwest Affiliate
🇺🇸
Peoria, Illinois, United States
Advocate Hope Children's Hospital
🇺🇸
Oak Lawn, Illinois, United States
University of Iowa Hospitals and Clinics
🇺🇸
Iowa City, Iowa, United States
Eastern Maine Medical Center
🇺🇸
Bangor, Maine, United States
University of Maryland Greenebaum Cancer Center
🇺🇸
Baltimore, Maryland, United States
Maine Children's Cancer Program
🇺🇸
Scarborough, Maine, United States
Massachusetts General Hospital Cancer Center
🇺🇸
Boston, Massachusetts, United States
Johns Hopkins University
🇺🇸
Baltimore, Maryland, United States
Baystate Medical Center
🇺🇸
Springfield, Massachusetts, United States
Michigan State University - Breslin Cancer Center
🇺🇸
Lansing, Michigan, United States
Helen DeVos Children's Hospital at Spectrum Health
🇺🇸
Grand Rapids, Michigan, United States
William Beaumont Hospital
🇺🇸
Royal Oak, Michigan, United States
Washington University School of Medicine
🇺🇸
Saint Louis, Missouri, United States
Dartmouth Hitchcock Medical Center
🇺🇸
Lebanon, New Hampshire, United States
Hackensack University Medical Center
🇺🇸
Hackensack, New Jersey, United States
UMDNJ - Robert Wood Johnson University Hospital
🇺🇸
New Brunswick, New Jersey, United States
Newark Beth Israel Medical Center
🇺🇸
Newark, New Jersey, United States
The Steven and Alexandra Cohen Children's Medical Center of New York
🇺🇸
New Hyde Park, New York, United States
Brooklyn Hospital Center
🇺🇸
Brooklyn, New York, United States
Roswell Park Cancer Institute
🇺🇸
Buffalo, New York, United States
Mount Sinai Medical Center
🇺🇸
New York, New York, United States
Columbia University Medical Center
🇺🇸
New York, New York, United States
Memorial Sloan Kettering Cancer Center
🇺🇸
New York, New York, United States
Mission Hospitals Inc
🇺🇸
Asheville, North Carolina, United States
State University of New York Upstate Medical University
🇺🇸
Syracuse, New York, United States
Presbyterian Hospital
🇺🇸
Charlotte, North Carolina, United States
Penn State Hershey Children's Hospital
🇺🇸
Hershey, Pennsylvania, United States
Saint Christopher's Hospital for Children
🇺🇸
Philadelphia, Pennsylvania, United States
Greenville Cancer Treatment Center
🇺🇸
Greenville, South Carolina, United States
East Tennessee Childrens Hospital
🇺🇸
Knoxville, Tennessee, United States
St. Jude Children's Research Hospital
🇺🇸
Memphis, Tennessee, United States
University of Texas Southwestern Medical Center
🇺🇸
Dallas, Texas, United States
Covenant Children's Hospital
🇺🇸
Lubbock, Texas, United States
Childrens Hospital-King's Daughters
🇺🇸
Norfolk, Virginia, United States
Inova Fairfax Hospital
🇺🇸
Falls Church, Virginia, United States
Seattle Children's Hospital
🇺🇸
Seattle, Washington, United States
Providence Sacred Heart Medical Center and Children's Hospital
🇺🇸
Spokane, Washington, United States
Royal Children's Hospital
🇦🇺
Parkville, Victoria, Australia
Saint Vincent Hospital
🇺🇸
Green Bay, Wisconsin, United States
Sydney Children's Hospital
🇦🇺
Randwick, New South Wales, Australia
The Children's Hospital at Westmead
🇦🇺
Sydney, New South Wales, Australia
Princess Margaret Hospital for Children
🇦🇺
Perth, Western Australia, Australia
Alberta Children's Hospital
🇨🇦
Calgary, Alberta, Canada
CancerCare Manitoba
🇨🇦
Winnipeg, Manitoba, Canada
Chedoke-McMaster Hospitals
🇨🇦
Hamilton, Ontario, Canada
The Montreal Children's Hospital of the MUHC
🇨🇦
Montreal, Quebec, Canada
Cancer Centre of Southeastern Ontario at Kingston General Hospital
🇨🇦
Kingston, Ontario, Canada
Allan Blair Cancer Centre
🇨🇦
Regina, Saskatchewan, Canada
Starship Children's Hospital
🇳🇿
Grafton, Auckland, New Zealand
Hospital Sainte-Justine
🇨🇦
Montreal, Quebec, Canada
Christchurch Hospital
🇳🇿
Christchurch, New Zealand
San Jorge Children's Hospital
🇵🇷
Santurce, Puerto Rico
Connecticut Children's Medical Center
🇺🇸
Hartford, Connecticut, United States
M D Anderson Cancer Center- Orlando
🇺🇸
Orlando, Florida, United States
Kosair Children's Hospital
🇺🇸
Louisville, Kentucky, United States
The Childrens Mercy Hospital
🇺🇸
Kansas City, Missouri, United States
University of North Carolina
🇺🇸
Chapel Hill, North Carolina, United States
Medical University of South Carolina
🇺🇸
Charleston, South Carolina, United States
University of Hawaii
🇺🇸
Honolulu, Hawaii, United States
Tripler Army Medical Center
🇺🇸
Honolulu, Hawaii, United States
Raymond Blank Children's Hospital
🇺🇸
Des Moines, Iowa, United States
University of Kentucky
🇺🇸
Lexington, Kentucky, United States
Tulane University Health Sciences Center
🇺🇸
New Orleans, Louisiana, United States
Children's Hospital-Main Campus
🇺🇸
New Orleans, Louisiana, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
Virginia Commonwealth University
🇺🇸
Richmond, Virginia, United States
University of Wisconsin Hospital and Clinics
🇺🇸
Madison, Wisconsin, United States
University of Alberta Hospital
🇨🇦
Edmonton, Alberta, Canada
Montefiore Medical Center
🇺🇸
Bronx, New York, United States