Combination Chemotherapy and Surgery in Treating Young Patients With Wilms Tumor

Phase 3

Active, not recruiting

Conditions: Stage III Kidney Wilms Tumor
Adult Kidney Wilms Tumor
Beckwith-Wiedemann Syndrome
Childhood Kidney Wilms Tumor
Rhabdoid Tumor of the Kidney
Stage V Kidney Wilms Tumor
Diffuse Hyperplastic Perilobar Nephroblastomatosis
Stage II Kidney Wilms Tumor
Stage I Kidney Wilms Tumor
Stage IV Kidney Wilms Tumor

Interventions: Biological: Dactinomycin
Drug: Doxorubicin Hydrochloride
Radiation: Radiation Therapy
Procedure: Therapeutic Conventional Surgery
Drug: Vincristine Sulfate

Registration Number: NCT00945009

Lead Sponsor: Children's Oncology Group

Brief Summary: This phase III trial studies how well combination chemotherapy and surgery work in treating young patients with Wilms tumor. Drugs used in chemotherapy work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving more than one drug (combination chemotherapy) may kill more tumor cells. Giving combination chemotherapy before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. Giving it after surgery may kill any tumor cells that remain after surgery.

Detailed Description: OBJECTIVES:

I. To improve 4-year event-free survival (EFS) to 73% for young patients with bilateral Wilms tumor (BWT).

II. To prevent complete removal of at least one kidney in 50% of patients with BWT by using prenephrectomy 3-drug chemotherapy induction with vincristine (vincristine sulfate), dactinomycin, and doxorubicin (doxorubicin hydrochloride).

III. To evaluate the efficacy of chemotherapy in preserving renal units in children with diffuse hyperplastic perilobar nephroblastomatosis (DHPLN) and preventing Wilms tumor development.

IV. To facilitate partial nephrectomy in lieu of nephrectomy in 25% of children with unilateral tumors and aniridia, Beckwith-Wiedemann syndrome (BWS), hemihypertrophy or other overgrowth syndromes, by using prenephrectomy 2-drug chemotherapy induction with vincristine and dactinomycin.

V. To have 75% of patients with BWT undergo definitive surgical treatment by 12 weeks after initiation of chemotherapy.

OUTLINE: Patients are assigned to 1 of 3 arms.

ARM 1 (Bilateral Wilms Tumors): Patients start with three drug chemotherapy (Regimen VAD; vincristine, dactinomycin and doxorubicin) and are evaluated and six and 12 weeks for feasibility of undergoing a partial nephrectomy/renal sparing surgery. At week 12 definitive surgery takes place followed by chemotherapy and radiation therapy based on histology and stage. Treatment continues for 25 or 31 weeks depending on histology. Patients are followed for up to 10 years following end of therapy.

ARM 2 (Unilateral High Risk tumors bilaterally predisposed): Patients start with either 2 drug or three drug chemotherapy (Regimen VA, VAD) and are evaluated a 6 and 12 weeks for feasibility of undergoing a partial nephrectomy. At week 12 definitive surgery takes place followed by chemotherapy.

ARM 3 (DHPLN): Patients with this rare disease are diagnosed based on cross-sectional imaging characteristics and undergo 2 drug chemotherapy (Regimen;VA). Patients are reassessed at 6 weeks and 12 weeks. If disease has responded or stayed stable chemotherapy is completed for 19 weeks (Regimen EE4A). If disease has progress a biopsy is performed to assess histology and adjust therapy based on the biopsy. This therapy may include, nephrectomy, chemotherapy or radiation therapy.

VAD REGIMEN: Patients receive vincristine sulfate intravenously (IV) over 1 minute on days 1, 8, 15, 22, 29, and 36 (weeks 1-6) and dactinomycin IV and doxorubicin hydrochloride IV over 15-120 minutes on days 1 and 22 (weeks 1 and 4).

EE4A REGIMEN: Patients receive vincristine sulfate IV over 1 minute on days 1, 8, 15, 22, 29, and 36 (weeks 1-6) and dactinomycin IV over 1-5 minutes on days 1 and 22 (weeks 1 and 4).

After completion of study treatment, patients are followed up periodically for 10 years.

Recruitment & Eligibility

Status: ACTIVE_NOT_RECRUITING

Sex: All

Target Recruitment: 249

Inclusion Criteria

The patient must have one of the following conditions to be eligible:
- Synchronous bilateral Wilms tumors**; or
- Unilateral Wilms tumor and aniridia, Beckwith-Wiedemann Syndrome, idiopathic hemihypertrophy, Simpson-Golabi-Behmel-Syndrome, Denys-Drash Syndrome or other associated genitourinary anomalies associated with bilateral Wilms tumor, such as hypospadias and undescended testis (to be eligible, these patients must not undergo any nephrectomy at diagnosis; note-horseshoe kidney is not associated with bilateral Wilms tumor and these patients should go on the appropriate unilateral Wilms tumor study); or
- Multicentric Wilms tumor (any age) (to be eligible, these patients must not undergo any nephrectomy at diagnosis); or
- Unilateral Wilms tumor with contralateral nephrogenic rest(s) (any size) in a child under one year of age (to be eligible, these patients must not undergo any nephrectomy at diagnosis); or
- Diffuse hyperplastic perilobar nephroblastomatosis (unilateral or bilateral) defined by central radiological review; or
- Wilms tumor arising in a solitary kidney (patients with metachronous Wilms tumor are not eligible)
  - The AREN0534 study uses the guideline that Wilms tumor with a single lesion 1 cm or greater in the contralateral kidney or multiple lesions (of any size) in the contralateral kidney should be treated on the synchronous bilateral Wilms tumor stratum; patients with an isolated lesion less than 1 cm in the contralateral kidney should be treated on the appropriate study for unilateral Wilms tumor OR on the unilateral Wilms tumor/contralateral nephrogenic rest stratum of this study if they have not undergone nephrectomy and are under one year of age
- Loss of heterozygosity (LOH) results-which are used in the unilateral Wilms tumor studies-are not a requirement for enrollment on AREN0534; blood samples can be submitted but will not be used to direct AREN0534 therapy
Specimens/materials must be submitted for central review by day 7; for enrollment on AREN0534, unless a biopsy was done, the submission requirements at enrollment on AREN03B2 refer to imaging studies; tissue samples are only required if a surgical procedure (biopsy or nephrectomy) was performed at the time of enrollment on AREN03B2
Patients must begin protocol therapy on AREN0534 by day 14 following surgery or diagnosis by initial computed tomography (CT)/magnetic resonance imaging (MRI), unless medically contraindicated
Karnofsky performance status must be >= 50% for patients > 16 years of age and Lansky performance status must be >= 50% (for patients =< 16 years of age
Patients must not have received systemic chemotherapy or radiation therapy prior to treatment on this study
Patients with unilateral Wilms tumor and aniridia, Beckwith-Wiedemann Syndrome, idiopathic hemihypertrophy, Simpson-Golabi-Behmel-Syndrome, Denys-Drash Syndrome or other associated genitourinary anomalies; or multicentric or unilateral Wilms tumor with contralateral nephrogenic rest(s) (any size) in a child under 1 year of age who undergo a nephrectomy at diagnosis are not eligible for this study and should be directed to a unilateral Wilms tumor study
Total bilirubin =< 1.5 times upper limit of normal (ULN) for age
Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST]) or serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase [ALT]) < 2.5 times upper limit of normal (ULN) for age
Shortening fraction >= 27% by echocardiogram, OR ejection fraction >= 50% by radionuclide angiogram
- (Cardiac function does not need to be assessed in patients who will not receive doxorubicin as part of their initial therapy on this study [i.e., patients who start on regimen EE-4A])
Female patients of childbearing age must have a negative pregnancy test
Female patients who are lactating must agree to stop breastfeeding
Sexually active patients of childbearing potential must agree to use effective contraception
All patients and/or their parents or legal guardians must sign a written informed consent
All institutional, Food and Drug Administration (FDA), and National Cancer Institute (NCI) requirements for human studies must be met
No concurrent aprepitant

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm 2 (Unilateral High Risk tumors bilaterally predisposed)	Vincristine Sulfate	Patients start with either 2 drug or three drug chemotherapy (Regimen VA, VAD) and are evaluated a 6 and 12 weeks for feasibility of undergoing a partial nephrectomy. At week 12 definitive surgery takes place followed by chemotherapy.
Arm 1 (Bilateral Wilms Tumors)	Therapeutic Conventional Surgery	Patients start with three drug chemotherapy (Regimen VAD; vincristine, dactinomycin and doxorubicin) and are evaluated and six and 12 weeks for feasibility of undergoing a partial nephrectomy/renal sparing surgery. At week 12 definitive surgery takes place followed by chemotherapy and radiation therapy based on histology and stage. Treatment continues for 25 or 31 weeks depending on histology. Patients are followed for up to 10 years following end of therapy.
Arm 2 (Unilateral High Risk tumors bilaterally predisposed)	Dactinomycin	Patients start with either 2 drug or three drug chemotherapy (Regimen VA, VAD) and are evaluated a 6 and 12 weeks for feasibility of undergoing a partial nephrectomy. At week 12 definitive surgery takes place followed by chemotherapy.
Arm 3 (DHPLN)	Radiation Therapy	Patients with this rare disease are diagnosed based on cross-sectional imaging characteristics and undergo 2 drug chemotherapy (Regimen;VA). Patients are reassessed at 6 weeks and 12 weeks. If disease has responded or stayed stable chemotherapy is completed for 19 weeks (Regimen EE4A). If disease has progress a biopsy is performed to assess histology and adjust therapy based on the biopsy. This therapy may include, nephrectomy, chemotherapy or radiation therapy.
Arm 2 (Unilateral High Risk tumors bilaterally predisposed)	Radiation Therapy	Patients start with either 2 drug or three drug chemotherapy (Regimen VA, VAD) and are evaluated a 6 and 12 weeks for feasibility of undergoing a partial nephrectomy. At week 12 definitive surgery takes place followed by chemotherapy.
Arm 2 (Unilateral High Risk tumors bilaterally predisposed)	Therapeutic Conventional Surgery	Patients start with either 2 drug or three drug chemotherapy (Regimen VA, VAD) and are evaluated a 6 and 12 weeks for feasibility of undergoing a partial nephrectomy. At week 12 definitive surgery takes place followed by chemotherapy.
Arm 1 (Bilateral Wilms Tumors)	Radiation Therapy	Patients start with three drug chemotherapy (Regimen VAD; vincristine, dactinomycin and doxorubicin) and are evaluated and six and 12 weeks for feasibility of undergoing a partial nephrectomy/renal sparing surgery. At week 12 definitive surgery takes place followed by chemotherapy and radiation therapy based on histology and stage. Treatment continues for 25 or 31 weeks depending on histology. Patients are followed for up to 10 years following end of therapy.
Arm 1 (Bilateral Wilms Tumors)	Dactinomycin	Patients start with three drug chemotherapy (Regimen VAD; vincristine, dactinomycin and doxorubicin) and are evaluated and six and 12 weeks for feasibility of undergoing a partial nephrectomy/renal sparing surgery. At week 12 definitive surgery takes place followed by chemotherapy and radiation therapy based on histology and stage. Treatment continues for 25 or 31 weeks depending on histology. Patients are followed for up to 10 years following end of therapy.
Arm 1 (Bilateral Wilms Tumors)	Vincristine Sulfate	Patients start with three drug chemotherapy (Regimen VAD; vincristine, dactinomycin and doxorubicin) and are evaluated and six and 12 weeks for feasibility of undergoing a partial nephrectomy/renal sparing surgery. At week 12 definitive surgery takes place followed by chemotherapy and radiation therapy based on histology and stage. Treatment continues for 25 or 31 weeks depending on histology. Patients are followed for up to 10 years following end of therapy.
Arm 3 (DHPLN)	Dactinomycin	Patients with this rare disease are diagnosed based on cross-sectional imaging characteristics and undergo 2 drug chemotherapy (Regimen;VA). Patients are reassessed at 6 weeks and 12 weeks. If disease has responded or stayed stable chemotherapy is completed for 19 weeks (Regimen EE4A). If disease has progress a biopsy is performed to assess histology and adjust therapy based on the biopsy. This therapy may include, nephrectomy, chemotherapy or radiation therapy.
Arm 3 (DHPLN)	Therapeutic Conventional Surgery	Patients with this rare disease are diagnosed based on cross-sectional imaging characteristics and undergo 2 drug chemotherapy (Regimen;VA). Patients are reassessed at 6 weeks and 12 weeks. If disease has responded or stayed stable chemotherapy is completed for 19 weeks (Regimen EE4A). If disease has progress a biopsy is performed to assess histology and adjust therapy based on the biopsy. This therapy may include, nephrectomy, chemotherapy or radiation therapy.
Arm 3 (DHPLN)	Vincristine Sulfate	Patients with this rare disease are diagnosed based on cross-sectional imaging characteristics and undergo 2 drug chemotherapy (Regimen;VA). Patients are reassessed at 6 weeks and 12 weeks. If disease has responded or stayed stable chemotherapy is completed for 19 weeks (Regimen EE4A). If disease has progress a biopsy is performed to assess histology and adjust therapy based on the biopsy. This therapy may include, nephrectomy, chemotherapy or radiation therapy.
Arm 1 (Bilateral Wilms Tumors)	Doxorubicin Hydrochloride	Patients start with three drug chemotherapy (Regimen VAD; vincristine, dactinomycin and doxorubicin) and are evaluated and six and 12 weeks for feasibility of undergoing a partial nephrectomy/renal sparing surgery. At week 12 definitive surgery takes place followed by chemotherapy and radiation therapy based on histology and stage. Treatment continues for 25 or 31 weeks depending on histology. Patients are followed for up to 10 years following end of therapy.
Arm 2 (Unilateral High Risk tumors bilaterally predisposed)	Doxorubicin Hydrochloride	Patients start with either 2 drug or three drug chemotherapy (Regimen VA, VAD) and are evaluated a 6 and 12 weeks for feasibility of undergoing a partial nephrectomy. At week 12 definitive surgery takes place followed by chemotherapy.
Arm 3 (DHPLN)	Doxorubicin Hydrochloride	Patients with this rare disease are diagnosed based on cross-sectional imaging characteristics and undergo 2 drug chemotherapy (Regimen;VA). Patients are reassessed at 6 weeks and 12 weeks. If disease has responded or stayed stable chemotherapy is completed for 19 weeks (Regimen EE4A). If disease has progress a biopsy is performed to assess histology and adjust therapy based on the biopsy. This therapy may include, nephrectomy, chemotherapy or radiation therapy.

Primary Outcome Measures

Name	Time	Method
Event-Free Survival (EFS)	4 years from study enrollment	Probability of no relapse, secondary malignancy, or death whichever occurs first
Kidney Preservation After Preoperative Chemotherapy	12 weeks from study entry	Prevention of complete removal of at least one kidney in 50% of patients with bilateral Wilms tumor (BWT).
Number of Patients Without Complete Removal of at Least One Kidney	12 weeks from the study entry	To evaluate the efficacy of chemotherapy in preserving renal units in children with diffuse hyperplastic perilobar nephroblastomatosis (DHPLN) and preventing Wilms tumor development.
Percentage of Patients Who Experienced Partial Nephrectomy After Preoperative Chemotherapy	12 weeks from study entry	Percentage of patients who experienced partial nephrectomy in lieu of nephrectomy in 25% of children with unilateral tumors and aniridia, Beckwith-Wiedemann syndrome (BWS), hemihypertrophy or other overgrowth syndromes, by using prenephrectomy 2-drug chemotherapy induction with vincristine and dactinomycin.
Percentage of Patients Who Had Definitive Surgical Treatment	12 weeks from study entry	Percentage of Bilateral Wilms Tumor (BWT) patients who undergo definitive surgery by week 12 after initiation of chemotherapy.

Secondary Outcome Measures

Name	Time	Method

Trial Locations

Locations (169): Royal Children's Hospital-Brisbane
🇦🇺
Herston, Queensland, Australia
Saint Barnabas Medical Center
🇺🇸
Livingston, New Jersey, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸
Dallas, Texas, United States
Saint Christopher's Hospital for Children
🇺🇸
Philadelphia, Pennsylvania, United States
Hospital for Sick Children
🇨🇦
Toronto, Ontario, Canada
Royal Brisbane and Women's Hospital
🇦🇺
Herston, Queensland, Australia
Children's Healthcare of Atlanta - Egleston
🇺🇸
Atlanta, Georgia, United States
Nationwide Children's Hospital
🇺🇸
Columbus, Ohio, United States
Children's Hospital Medical Center of Akron
🇺🇸
Akron, Ohio, United States
Banner University Medical Center - Tucson
🇺🇸
Tucson, Arizona, United States
Arkansas Children's Hospital
🇺🇸
Little Rock, Arkansas, United States
Children's Hospital Los Angeles
🇺🇸
Los Angeles, California, United States
Hackensack University Medical Center
🇺🇸
Hackensack, New Jersey, United States
Kingston Health Sciences Centre
🇨🇦
Kingston, Ontario, Canada
Rainbow Babies and Childrens Hospital
🇺🇸
Cleveland, Ohio, United States
Baylor College of Medicine/Dan L Duncan Comprehensive Cancer Center
🇺🇸
Houston, Texas, United States
Seattle Children's Hospital
🇺🇸
Seattle, Washington, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸
Miami, Florida, United States
Riley Hospital for Children
🇺🇸
Indianapolis, Indiana, United States
Summerlin Hospital Medical Center
🇺🇸
Las Vegas, Nevada, United States
Alliance for Childhood Diseases/Cure 4 the Kids Foundation
🇺🇸
Las Vegas, Nevada, United States
Nevada Cancer Research Foundation NCORP
🇺🇸
Las Vegas, Nevada, United States
Children's Hospitals and Clinics of Minnesota - Minneapolis
🇺🇸
Minneapolis, Minnesota, United States
University of Minnesota/Masonic Cancer Center
🇺🇸
Minneapolis, Minnesota, United States
Duke University Medical Center
🇺🇸
Durham, North Carolina, United States
Kaiser Permanente-Oakland
🇺🇸
Oakland, California, United States
Rady Children's Hospital - San Diego
🇺🇸
San Diego, California, United States
Saint Jude Midwest Affiliate
🇺🇸
Peoria, Illinois, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
Mission Hospital
🇺🇸
Asheville, North Carolina, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
Cincinnati Children's Hospital Medical Center
🇺🇸
Cincinnati, Ohio, United States
Children's Hospital of Philadelphia
🇺🇸
Philadelphia, Pennsylvania, United States
Madigan Army Medical Center
🇺🇸
Tacoma, Washington, United States
Blank Children's Hospital
🇺🇸
Des Moines, Iowa, United States
UCSF Medical Center-Parnassus
🇺🇸
San Francisco, California, United States
UCSF Medical Center-Mission Bay
🇺🇸
San Francisco, California, United States
Primary Children's Hospital
🇺🇸
Salt Lake City, Utah, United States
Sanford Broadway Medical Center
🇺🇸
Fargo, North Dakota, United States
Princess Margaret Hospital for Children
🇦🇺
Perth, Western Australia, Australia
CancerCare Manitoba
🇨🇦
Winnipeg, Manitoba, Canada
University of Rochester
🇺🇸
Rochester, New York, United States
University of Mississippi Medical Center
🇺🇸
Jackson, Mississippi, United States
Washington University School of Medicine
🇺🇸
Saint Louis, Missouri, United States
University of Alabama at Birmingham Cancer Center
🇺🇸
Birmingham, Alabama, United States
Children's Hospital of Alabama
🇺🇸
Birmingham, Alabama, United States
Phoenix Childrens Hospital
🇺🇸
Phoenix, Arizona, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Rocky Mountain Hospital for Children-Presbyterian Saint Luke's Medical Center
🇺🇸
Denver, Colorado, United States
Legacy Emanuel Children's Hospital
🇺🇸
Portland, Oregon, United States
Legacy Emanuel Hospital and Health Center
🇺🇸
Portland, Oregon, United States
Children's Hospital Colorado
🇺🇸
Aurora, Colorado, United States
Saint Joseph's Hospital/Children's Hospital-Tampa
🇺🇸
Tampa, Florida, United States
Walter Reed National Military Medical Center
🇺🇸
Bethesda, Maryland, United States
Mayo Clinic in Rochester
🇺🇸
Rochester, Minnesota, United States
Children's Hospital of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States
AdventHealth Orlando
🇺🇸
Orlando, Florida, United States
C S Mott Children's Hospital
🇺🇸
Ann Arbor, Michigan, United States
Nemours Children's Clinic - Orlando
🇺🇸
Orlando, Florida, United States
University of California Davis Comprehensive Cancer Center
🇺🇸
Sacramento, California, United States
Arnold Palmer Hospital for Children
🇺🇸
Orlando, Florida, United States
Orlando Health Cancer Institute
🇺🇸
Orlando, Florida, United States
Nemours Children's Hospital
🇺🇸
Orlando, Florida, United States
Wake Forest University Health Sciences
🇺🇸
Winston-Salem, North Carolina, United States
Kaiser Permanente Downey Medical Center
🇺🇸
Downey, California, United States
University of Arkansas for Medical Sciences
🇺🇸
Little Rock, Arkansas, United States
Loma Linda University Medical Center
🇺🇸
Loma Linda, California, United States
Miller Children's and Women's Hospital Long Beach
🇺🇸
Long Beach, California, United States
Valley Children's Hospital
🇺🇸
Madera, California, United States
UCSF Benioff Children's Hospital Oakland
🇺🇸
Oakland, California, United States
Lucile Packard Children's Hospital Stanford University
🇺🇸
Palo Alto, California, United States
Connecticut Children's Medical Center
🇺🇸
Hartford, Connecticut, United States
MedStar Georgetown University Hospital
🇺🇸
Washington, District of Columbia, United States
Alfred I duPont Hospital for Children
🇺🇸
Wilmington, Delaware, United States
Children's National Medical Center
🇺🇸
Washington, District of Columbia, United States
Lee Memorial Health System
🇺🇸
Fort Myers, Florida, United States
Nemours Children's Clinic-Jacksonville
🇺🇸
Jacksonville, Florida, United States
Miami Cancer Institute
🇺🇸
Miami, Florida, United States
Nemours Children's Clinic - Pensacola
🇺🇸
Pensacola, Florida, United States
Johns Hopkins All Children's Hospital
🇺🇸
Saint Petersburg, Florida, United States
Augusta University Medical Center
🇺🇸
Augusta, Georgia, United States
Memorial Health University Medical Center
🇺🇸
Savannah, Georgia, United States
Lurie Children's Hospital-Chicago
🇺🇸
Chicago, Illinois, United States
Sinai Hospital of Baltimore
🇺🇸
Baltimore, Maryland, 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
Dana-Farber Cancer Institute
🇺🇸
Boston, Massachusetts, United States
Tufts Children's Hospital
🇺🇸
Boston, Massachusetts, United States
Helen DeVos Children's Hospital at Spectrum Health
🇺🇸
Grand Rapids, Michigan, United States
Michigan State University Clinical Center
🇺🇸
East Lansing, Michigan, United States
Bronson Methodist Hospital
🇺🇸
Kalamazoo, Michigan, United States
Sunrise Hospital and Medical Center
🇺🇸
Las Vegas, Nevada, United States
Saint Peter's University Hospital
🇺🇸
New Brunswick, New Jersey, United States
Morristown Medical Center
🇺🇸
Morristown, New Jersey, United States
Rutgers Cancer Institute of New Jersey-Robert Wood Johnson University Hospital
🇺🇸
New Brunswick, New Jersey, United States
Overlook Hospital
🇺🇸
Summit, New Jersey, United States
Roswell Park Cancer Institute
🇺🇸
Buffalo, New York, United States
NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center
🇺🇸
New York, New York, United States
Memorial Sloan Kettering Cancer Center
🇺🇸
New York, New York, United States
State University of New York Upstate Medical University
🇺🇸
Syracuse, New York, United States
Novant Health Presbyterian Medical Center
🇺🇸
Charlotte, North Carolina, United States
Carolinas Medical Center/Levine Cancer Institute
🇺🇸
Charlotte, North Carolina, United States
Cleveland Clinic Foundation
🇺🇸
Cleveland, Ohio, United States
ProMedica Toledo Hospital/Russell J Ebeid Children's Hospital
🇺🇸
Toledo, Ohio, United States
Mercy Children's Hospital
🇺🇸
Toledo, Ohio, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Lehigh Valley Hospital - Muhlenberg
🇺🇸
Bethlehem, Pennsylvania, United States
BI-LO Charities Children's Cancer Center
🇺🇸
Greenville, South Carolina, United States
Children's Hospital of Pittsburgh of UPMC
🇺🇸
Pittsburgh, Pennsylvania, United States
Prisma Health Richland Hospital
🇺🇸
Columbia, South Carolina, United States
East Tennessee Childrens Hospital
🇺🇸
Knoxville, Tennessee, United States
Greenville Cancer Treatment Center
🇺🇸
Greenville, South Carolina, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸
Sioux Falls, South Dakota, United States
Saint Jude Children's Research Hospital
🇺🇸
Memphis, Tennessee, United States
Texas Tech University Health Sciences Center-Amarillo
🇺🇸
Amarillo, Texas, United States
Brooke Army Medical Center
🇺🇸
Fort Sam Houston, Texas, United States
Driscoll Children's Hospital
🇺🇸
Corpus Christi, Texas, United States
Medical City Dallas Hospital
🇺🇸
Dallas, Texas, United States
Covenant Children's Hospital
🇺🇸
Lubbock, Texas, United States
University of Texas Health Science Center at San Antonio
🇺🇸
San Antonio, Texas, United States
University of Vermont and State Agricultural College
🇺🇸
Burlington, Vermont, United States
Methodist Children's Hospital of South Texas
🇺🇸
San Antonio, Texas, United States
Children's Hospital of The King's Daughters
🇺🇸
Norfolk, Virginia, United States
University of Virginia Cancer Center
🇺🇸
Charlottesville, Virginia, United States
Mary Bridge Children's Hospital and Health Center
🇺🇸
Tacoma, Washington, United States
Providence Sacred Heart Medical Center and Children's Hospital
🇺🇸
Spokane, Washington, United States
West Virginia University Charleston Division
🇺🇸
Charleston, West Virginia, United States
Marshfield Medical Center-Marshfield
🇺🇸
Marshfield, Wisconsin, United States
Sydney Children's Hospital
🇦🇺
Randwick, New South Wales, Australia
The Children's Hospital at Westmead
🇦🇺
Westmead, New South Wales, Australia
Queensland Children's Hospital
🇦🇺
South Brisbane, Queensland, Australia
Women's and Children's Hospital-Adelaide
🇦🇺
North Adelaide, South Australia, Australia
Alberta Children's Hospital
🇨🇦
Calgary, Alberta, Canada
British Columbia Children's Hospital
🇨🇦
Vancouver, British Columbia, Canada
IWK Health Centre
🇨🇦
Halifax, Nova Scotia, Canada
McMaster Children's Hospital at Hamilton Health Sciences
🇨🇦
Hamilton, Ontario, Canada
Children's Hospital of Eastern Ontario
🇨🇦
Ottawa, Ontario, Canada
The Montreal Children's Hospital of the MUHC
🇨🇦
Montreal, Quebec, Canada
CHU de Quebec-Centre Hospitalier de l'Universite Laval (CHUL)
🇨🇦
Quebec, Canada
Centre Hospitalier Universitaire Sainte-Justine
🇨🇦
Montreal, Quebec, Canada
Saskatoon Cancer Centre
🇨🇦
Saskatoon, Saskatchewan, Canada
Christchurch Hospital
🇳🇿
Christchurch, New Zealand
Starship Children's Hospital
🇳🇿
Grafton, Auckland, New Zealand
Schneider Children's Medical Center of Israel
🇮🇱
Petah Tikua, Israel
San Jorge Children's Hospital
🇵🇷
San Juan, Puerto Rico
Norton Children's Hospital
🇺🇸
Louisville, Kentucky, United States
Children's Mercy Hospitals and Clinics
🇺🇸
Kansas City, Missouri, United States
UNC Lineberger Comprehensive Cancer Center
🇺🇸
Chapel Hill, North Carolina, United States
Mount Sinai Hospital
🇺🇸
New York, New York, United States
Cook Children's Medical Center
🇺🇸
Fort Worth, Texas, United States
NYU Winthrop Hospital
🇺🇸
Mineola, New York, United States
Saint Mary's Hospital
🇺🇸
West Palm Beach, Florida, United States
Golisano Children's Hospital of Southwest Florida
🇺🇸
Fort Myers, Florida, United States
Newark Beth Israel Medical Center
🇺🇸
Newark, New Jersey, United States
Dartmouth Hitchcock Medical Center/Dartmouth Cancer Center
🇺🇸
Lebanon, New Hampshire, United States
Kalamazoo Center for Medical Studies
🇺🇸
Kalamazoo, Michigan, United States
Memorial Regional Hospital/Joe DiMaggio Children's Hospital
🇺🇸
Hollywood, Florida, United States
Penn State Children's Hospital
🇺🇸
Hershey, Pennsylvania, United States
Saint Vincent Hospital Cancer Center Green Bay
🇺🇸
Green Bay, Wisconsin, United States
Dayton Children's Hospital
🇺🇸
Dayton, Ohio, United States
Broward Health Medical Center
🇺🇸
Fort Lauderdale, Florida, United States
Saint Luke's Cancer Institute - Boise
🇺🇸
Boise, Idaho, United States
University of Kentucky/Markey Cancer Center
🇺🇸
Lexington, Kentucky, United States
Tulane University School of Medicine
🇺🇸
New Orleans, Louisiana, United States
Children's Hospital New Orleans
🇺🇸
New Orleans, Louisiana, United States
Montefiore Medical Center - Moses Campus
🇺🇸
Bronx, New York, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸
Richmond, Virginia, United States
Children's Hospital of Orange County
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Orange, California, United States