Erdafitinib in Treating Patients With Relapsed or Refractory Advanced Solid Tumors, Non-Hodgkin Lymphoma, or Histiocytic Disorders With FGFR Mutations (A Pediatric MATCH Treatment Trial)

Sponsor

National Cancer Institute (NCI) (NIH)

Overall Status

Suspended

CT.gov ID

NCT03210714

Collaborator

(none)

Enrollment

118

Locations

Arm

85.8

Anticipated Duration (Months)

0.4

Patients Per Site

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

This phase II Pediatric MATCH trial studies how well erdafitinib works in treating patients with solid tumors, non-Hodgkin lymphoma, or histiocytic disorders that have spread to other places in the body and have come back or do not respond to treatment with FGFR mutations. Erdafitinib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth.

Condition or Disease	Intervention/Treatment	Phase
Advanced Malignant Solid Neoplasm Ann Arbor Stage III Childhood Non-Hodgkin Lymphoma Ann Arbor Stage IV Childhood Non-Hodgkin Lymphoma Low Grade Glioma Malignant Glioma Recurrent Childhood Ependymoma Recurrent Childhood Malignant Germ Cell Tumor Recurrent Childhood Medulloblastoma Recurrent Childhood Non-Hodgkin Lymphoma Recurrent Childhood Rhabdomyosarcoma Recurrent Childhood Soft Tissue Sarcoma Recurrent Ewing Sarcoma/Peripheral Primitive Neuroectodermal Tumor Recurrent Hepatoblastoma Recurrent Langerhans Cell Histiocytosis Recurrent Malignant Solid Neoplasm Recurrent Neuroblastoma Recurrent Osteosarcoma Recurrent Primary Central Nervous System Neoplasm Refractory Langerhans Cell Histiocytosis Refractory Malignant Solid Neoplasm Refractory Neuroblastoma Refractory Non-Hodgkin Lymphoma Refractory Primary Central Nervous System Neoplasm Rhabdoid Tumor Stage III Soft Tissue Sarcoma AJCC v7 Stage IV Soft Tissue Sarcoma AJCC v7 Wilms Tumor	Drug: Erdafitinib Other: Laboratory Biomarker Analysis Other: Pharmacological Study	Phase 2

Detailed Description

PRIMARY OBJECTIVE:

To determine the objective response rate (ORR; complete response + partial response) in pediatric patients treated with erdafitinib with advanced solid tumors (including central nervous system [CNS] tumors), non-Hodgkin lymphomas or histiocytic disorders that harbor genetic alterations in the FGFR1/2/3/4 pathway.

SECONDARY OBJECTIVES:

To estimate the progression free survival in pediatric patients treated with erdafitinib with advanced solid tumors (including CNS tumors), non-Hodgkin lymphomas or histiocytic disorders that harbor genetic alterations in the FGFR1/2/3/4.
To obtain information about the tolerability of erdafitinib in children with relapsed or refractory cancer.
To provide preliminary estimates of the pharmacokinetics of erdafitinib in children with relapsed or refractory cancer.

EXPLORATORY OBJECTIVE:

To explore approaches to profiling changes in tumor genomics over time through evaluation of circulating tumor deoxyribonucleic acid (DNA).

OUTLINE:

Patients receive erdafitinib orally (PO) once daily (QD) on days 1-28 of each cycle. Treatment repeats every 28 days for up to 26 cycles (2 years) in the absence of disease progression or unacceptable toxicity.

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

Study Design

Study Type:

Interventional

Anticipated Enrollment :

49 participants

Allocation:

N/A

Intervention Model:

Single Group Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

NCI-COG Pediatric MATCH (Molecular Analysis for Therapy Choice) - Phase 2 Subprotocol of Erdafitinib in Patients With Tumors Harboring FGFR1/2/3/4 Alterations

Actual Study Start Date :

Nov 6, 2017

Anticipated Primary Completion Date :

Dec 31, 2024

Anticipated Study Completion Date :

Dec 31, 2024

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Treatment (erdafitinib) Patients receive erdafitinib PO QD on days 1-28 of each cycle. Treatment repeats every 28 days for up to 26 cycles (2 years) in the absence of disease progression or unacceptable toxicity.	Drug: Erdafitinib Given PO Other Names: Balversa JNJ-42756493 Other: Laboratory Biomarker Analysis Correlative studies Other: Pharmacological Study Correlative studies

Arm

Intervention/Treatment

Experimental: Treatment (erdafitinib)

Patients receive erdafitinib PO QD on days 1-28 of each cycle. Treatment repeats every 28 days for up to 26 cycles (2 years) in the absence of disease progression or unacceptable toxicity.

Drug: Erdafitinib

Given PO

Other Names:

Balversa

JNJ-42756493

Other: Laboratory Biomarker Analysis

Correlative studies

Other: Pharmacological Study

Correlative studies

Outcome Measures

Primary Outcome Measures

Response rate [From enrollment to the end of treatment, up to 2 years]
Response rates will be calculated as the percent of evaluable patients who are responders, and confidence intervals will be constructed using the Wilson score interval method.

Secondary Outcome Measures

Incidence of adverse events [From enrollment to the end of treatment, up to 2 years]
Graded by National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0. Toxicity tables will be constructed to summarize the observed incidence by type of toxicity and grade. A patient will be counted only once for a given toxicity for the worst grade of that toxicity reported for that patient.
Progression free survival (PFS) [From the initiation of protocol treatment to the occurrence of any of the following events: disease progression or disease recurrence or death from any cause, assessed up to 3 years]
PFS along with the confidence intervals will be estimated using the Kaplan-Meier method.
Pharmacokinetic (PK) parameters [Cycle 2 day 1]
A descriptive analysis of PK parameters will be performed to define systemic exposure, drug clearance, and other pharmacokinetic parameters. The PK parameters will be summarized with simple summary statistics, including means, medians, ranges, and standard deviations (if numbers and distribution permit).

Other Outcome Measures

Changes in tumor genomic profile [Up to 3 years]
A descriptive analysis will be performed and will be summarized with simple summary statistics. All of these analyses will be descriptive in nature.

Eligibility Criteria

Criteria

Ages Eligible for Study:

12 Months to 21 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Patient must have enrolled onto APEC1621SC and must have been given a treatment assignment to molecular analysis for therapy choice (MATCH) to APEC1621B based on the presence of an actionable mutation as defined in APEC1621SC
Patients must have a body surface area >= 0.53 m^2 at enrollment
Patients must have radiographically measurable disease at the time of study enrollment; patients with neuroblastoma who do not have measurable disease but have metaiodobenzylguanidine (MIBG) positive (+) evaluable disease are eligible; measurable disease in patients with CNS involvement is defined as lesion that is at minimum 10 mm in one dimension on standard magnetic resonance imaging (MRI) or computed tomography (CT)
Note: The following do not qualify as measurable disease:
Malignant fluid collections (e.g., ascites, pleural effusions)
Bone marrow infiltration except that detected by MIBG scan for neuroblastoma
Lesions only detected by nuclear medicine studies (e.g., bone, gallium or positron emission tomography [PET] scans) except as noted for neuroblastoma
Elevated tumor markers in plasma or cerebrospinal fluid (CSF)
Previously radiated lesions that have not demonstrated clear progression post radiation
Leptomeningeal lesions that do not meet the measurement requirements for Response Evaluation Criteria in Solid Tumors (RECIST) 1.1
Karnofsky >= 50% for patients > 16 years of age and Lansky >= 50 for patients =< 16 years of age; Note: neurologic deficits in patients with CNS tumors must have been stable for at least 7 days prior to study enrollment; patients who are unable to walk because of paralysis, but who are up in a wheelchair, will be considered ambulatory for the purpose of assessing the performance score
Patients must have fully recovered from the acute toxic effects of all prior anti-cancer therapy and must meet the following minimum duration from prior anti-cancer directed therapy prior to enrollment; if after the required timeframe, the numerical eligibility criteria are met, e.g. blood count criteria, the patient is considered to have recovered adequately
Cytotoxic chemotherapy or other anti-cancer agents known to be myelosuppressive;

= 21 days after the last dose of cytotoxic or myelosuppressive chemotherapy (42 days if prior nitrosourea)

Anti-cancer agents not known to be myelosuppressive (e.g. not associated with reduced platelet or absolute neutrophil count [ANC] counts): >= 7 days after the last dose of agent
Antibodies: >= 21 days must have elapsed from infusion of last dose of antibody, and toxicity related to prior antibody therapy must be recovered to grade =< 1
Corticosteroids: if used to modify immune adverse events related to prior therapy, >= 14 days must have elapsed since last dose of corticosteroid
Hematopoietic growth factors: >= 14 days after the last dose of a long-acting growth factor (e.g. pegfilgrastim) or 7 days for short-acting growth factor; for growth factors that have known adverse events occurring beyond 7 days after administration, this period must be extended beyond the time during which adverse events are known to occur; the duration of this interval must be discussed with the study chair and the study-assigned research coordinator
Interleukins, interferons and cytokines (other than hematopoietic growth factors): >= 21 days after the completion of interleukins, interferon or cytokines (other than hematopoietic growth factors)
Stem cell infusions (with or without total body irradiation [TBI]):
Allogeneic (non-autologous) bone marrow or stem cell transplant, or any stem cell infusion including donor lymphocyte infusion (DLI) or boost infusion:

= 84 days after infusion and no evidence of graft versus host disease (GVHD)

Autologous stem cell infusion including boost infusion: >= 42 days
Cellular therapy: >= 42 days after the completion of any type of cellular therapy (e.g. modified T cells, natural killer [NK] cells, dendritic cells, etc.)
X-ray therapy (XRT)/external beam irradiation including protons: >= 14 days after local XRT; >= 150 days after TBI, craniospinal XRT or if radiation to >= 50% of the pelvis; >= 42 days if other substantial bone marrow (BM) radiation
Note: radiation may not be delivered to "measurable disease" tumor site(s) being used to follow response to subprotocol treatment
Radiopharmaceutical therapy (e.g., radiolabeled antibody, iobenguane I-131 [131I-MIBG]): >= 42 days after systemically administered radiopharmaceutical therapy
Patients must not have received prior exposure to erdafitinib or another FGFR inhibitor such as (but not limited to) AZD4547, BGJ398, BAY1163877, LY2874455
For patients with solid tumors without known bone marrow involvement:
Peripheral absolute neutrophil count (ANC) >= 1000/mm^3
Platelet count >= 100,000/mm^3 (transfusion independent, defined as not receiving platelet transfusions for at least 7 days prior to enrollment)
Hemoglobin >= 8.0 g/dL at baseline (may receive red blood cell [RBC] transfusions)
Patients with known bone marrow metastatic disease will be eligible for study provided they meet the blood counts (may receive platelet or packed [p]RBC transfusions provided they are not known to be refractory to red cell or platelet transfusions); these patients will not be evaluable for hematologic toxicity
Creatinine clearance or radioisotope glomerular filtration rate (GFR) >= 70 ml/min/1.73 m^2 or a serum creatinine based on age/gender as follows:
Age: 1 to < 2 years; maximum serum creatinine (mg/dL): male 0.6; female 0.6
Age: 2 to < 6 years; maximum serum creatinine (mg/dL): male 0.8; female 0.8
Age: 6 to < 10 years; maximum serum creatinine (mg/dL): male 1; female 1
Age: 10 to < 13 years; maximum serum creatinine (mg/dL): male 1.2; female 1.2
Age: 13 to < 16 years; maximum serum creatinine (mg/dL): male 1.5; female 1.4
Age: >= 16 years; maximum serum creatinine (mg/dL): male 1.7; female 1.4
Bilirubin (sum of conjugated + unconjugated) =< 1.5 x upper limit of normal (ULN) for age
Serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase [ALT]) =< 135 U/L; (for the purpose of this study, the ULN for SGPT is 45 U/L)
Serum albumin >= 2 g/dL
Corrected QT (QTc) interval =< 480 milliseconds
Pulse oximetry > 94% on room air if there is clinical indication for determination (e.g. dyspnea at rest)
Patients must be able to swallow intact tablets
All patients and/or their parents or legally authorized representatives must sign a written informed consent; assent, when appropriate, will be obtained according to institutional guidelines

Exclusion Criteria:

Pregnant or breast-feeding women will not be entered on this study due to risks of fetal and teratogenic adverse events as seen in animal studies; pregnancy tests must be obtained in girls who are post-menarchal; males or females of reproductive potential may not participate unless they have agreed to use an effective contraceptive method, while receiving study treatment and for 3 months after the last dose of erdafitinib; male subjects (with a partner of child-bearing potential) must use a condom with spermicide when sexually active and must not donate sperm from the first dose of study drug until 3 months after the last dose of study drug
Concomitant medications
Corticosteroids: patients receiving corticosteroids who have not been on a stable or decreasing dose of corticosteroid for at least 7 days prior to enrollment are not eligible; if used to modify immune adverse events related to prior therapy,

= 14 days must have elapsed since last dose of corticosteroid

Investigational drugs: patients who are currently receiving another investigational drug are not eligible
Anti-cancer agents: patients who are currently receiving other anti-cancer agents are not eligible
Anti-GVHD agents post-transplant: patients who are receiving cyclosporine, tacrolimus or other agents to prevent graft-versus-host disease post bone marrow transplant are not eligible for this trial
CYP3A4 agents: patients who are currently receiving drugs that are strong inducers or inhibitors of CYP3A4 are not eligible; Note: CYP3A4 inducing anti-epileptic drugs and dexamethasone for CNS tumors or metastases, on a stable dose, are allowed
CYP2C9 agents: patients who are currently receiving drugs that are strong inducers or moderate inhibitors of CYP2C9 are not eligible
Patients who have an uncontrolled infection are not eligible
Patients who have received a prior solid organ transplantation are not eligible
Patients who in the opinion of the investigator may not be able to comply with the safety monitoring requirements of the study are not eligible
A history of cardiovascular diseases: unstable angina, myocardial infarction, or known congestive heart failure class IIIV within the preceding 12 months; cerebrovascular accident or transient ischemic attack within the preceding 3 months, pulmonary embolism within the preceding 2 months
A history of any of the following: sustained ventricular tachycardia, ventricular fibrillation, torsades de pointes, cardiac arrest, Mobitz II second degree heart block or third degree heart block; known presence of dilated, hypertrophic, or restrictive cardiomyopathy
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements
Patients with significant ophthalmologic conditions (uncontrolled glaucoma, central serous retinopathy, history of retinal vein occlusion or retinal detachment, excluding patients with longstanding findings secondary to existing conditions) are not eligible, to be confirmed with baseline ophthalmologic exam; all patients must have a baseline ophthalmologic exam, including fundoscopy to confirm no significant ophthalmologic conditions are present

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Children's Hospital of Alabama	Birmingham	Alabama	United States	35233
2	Providence Alaska Medical Center	Anchorage	Alaska	United States	99508
3	Banner Children's at Desert	Mesa	Arizona	United States	85202
4	Banner University Medical Center - Tucson	Tucson	Arizona	United States	85719
5	Arkansas Children's Hospital	Little Rock	Arkansas	United States	72202-3591
6	Kaiser Permanente Downey Medical Center	Downey	California	United States	90242
7	Loma Linda University Medical Center	Loma Linda	California	United States	92354
8	Miller Children's and Women's Hospital Long Beach	Long Beach	California	United States	90806
9	Children's Hospital Los Angeles	Los Angeles	California	United States	90027
10	Cedars Sinai Medical Center	Los Angeles	California	United States	90048
11	Valley Children's Hospital	Madera	California	United States	93636
12	UCSF Benioff Children's Hospital Oakland	Oakland	California	United States	94609
13	Kaiser Permanente-Oakland	Oakland	California	United States	94611
14	University of California Davis Comprehensive Cancer Center	Sacramento	California	United States	95817
15	UCSF Medical Center-Mission Bay	San Francisco	California	United States	94158
16	Children's Hospital Colorado	Aurora	Colorado	United States	80045
17	Rocky Mountain Hospital for Children-Presbyterian Saint Luke's Medical Center	Denver	Colorado	United States	80218
18	Yale University	New Haven	Connecticut	United States	06520
19	Alfred I duPont Hospital for Children	Wilmington	Delaware	United States	19803
20	Children's National Medical Center	Washington	District of Columbia	United States	20010
21	University of Florida Health Science Center - Gainesville	Gainesville	Florida	United States	32610
22	Memorial Regional Hospital/Joe DiMaggio Children's Hospital	Hollywood	Florida	United States	33021
23	Nemours Children's Clinic-Jacksonville	Jacksonville	Florida	United States	32207
24	University of Miami Miller School of Medicine-Sylvester Cancer Center	Miami	Florida	United States	33136
25	Nicklaus Children's Hospital	Miami	Florida	United States	33155
26	AdventHealth Orlando	Orlando	Florida	United States	32803
27	Arnold Palmer Hospital for Children	Orlando	Florida	United States	32806
28	Nemours Children's Hospital	Orlando	Florida	United States	32827
29	Johns Hopkins All Children's Hospital	Saint Petersburg	Florida	United States	33701
30	Saint Joseph's Hospital/Children's Hospital-Tampa	Tampa	Florida	United States	33607
31	Saint Mary's Hospital	West Palm Beach	Florida	United States	33407
32	Children's Healthcare of Atlanta - Egleston	Atlanta	Georgia	United States	30322
33	Saint Luke's Cancer Institute - Boise	Boise	Idaho	United States	83712
34	Lurie Children's Hospital-Chicago	Chicago	Illinois	United States	60611
35	University of Chicago Comprehensive Cancer Center	Chicago	Illinois	United States	60637
36	Saint Jude Midwest Affiliate	Peoria	Illinois	United States	61637
37	Southern Illinois University School of Medicine	Springfield	Illinois	United States	62702
38	Riley Hospital for Children	Indianapolis	Indiana	United States	46202
39	Saint Vincent Hospital and Health Care Center	Indianapolis	Indiana	United States	46260
40	Blank Children's Hospital	Des Moines	Iowa	United States	50309
41	University of Iowa/Holden Comprehensive Cancer Center	Iowa City	Iowa	United States	52242
42	University of Kentucky/Markey Cancer Center	Lexington	Kentucky	United States	40536
43	Norton Children's Hospital	Louisville	Kentucky	United States	40202
44	Children's Hospital New Orleans	New Orleans	Louisiana	United States	70118
45	Ochsner Medical Center Jefferson	New Orleans	Louisiana	United States	70121
46	Eastern Maine Medical Center	Bangor	Maine	United States	04401
47	Sinai Hospital of Baltimore	Baltimore	Maryland	United States	21215
48	Johns Hopkins University/Sidney Kimmel Cancer Center	Baltimore	Maryland	United States	21287
49	C S Mott Children's Hospital	Ann Arbor	Michigan	United States	48109
50	Michigan State University Clinical Center	East Lansing	Michigan	United States	48824-7016
51	Helen DeVos Children's Hospital at Spectrum Health	Grand Rapids	Michigan	United States	49503
52	Bronson Methodist Hospital	Kalamazoo	Michigan	United States	49007
53	Children's Hospitals and Clinics of Minnesota - Minneapolis	Minneapolis	Minnesota	United States	55404
54	University of Minnesota/Masonic Cancer Center	Minneapolis	Minnesota	United States	55455
55	Mayo Clinic in Rochester	Rochester	Minnesota	United States	55905
56	University of Mississippi Medical Center	Jackson	Mississippi	United States	39216
57	Children's Mercy Hospitals and Clinics	Kansas City	Missouri	United States	64108
58	Cardinal Glennon Children's Medical Center	Saint Louis	Missouri	United States	63104
59	Washington University School of Medicine	Saint Louis	Missouri	United States	63110
60	Mercy Hospital Saint Louis	Saint Louis	Missouri	United States	63141
61	Children's Hospital and Medical Center of Omaha	Omaha	Nebraska	United States	68114
62	University of Nebraska Medical Center	Omaha	Nebraska	United States	68198
63	Hackensack University Medical Center	Hackensack	New Jersey	United States	07601
64	Morristown Medical Center	Morristown	New Jersey	United States	07960
65	Saint Peter's University Hospital	New Brunswick	New Jersey	United States	08901
66	Albany Medical Center	Albany	New York	United States	12208
67	Montefiore Medical Center - Moses Campus	Bronx	New York	United States	10467
68	Roswell Park Cancer Institute	Buffalo	New York	United States	14263
69	The Steven and Alexandra Cohen Children's Medical Center of New York	New Hyde Park	New York	United States	11040
70	NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center	New York	New York	United States	10032
71	Memorial Sloan Kettering Cancer Center	New York	New York	United States	10065
72	NYP/Weill Cornell Medical Center	New York	New York	United States	10065
73	University of Rochester	Rochester	New York	United States	14642
74	State University of New York Upstate Medical University	Syracuse	New York	United States	13210
75	Mission Hospital	Asheville	North Carolina	United States	28801
76	Carolinas Medical Center/Levine Cancer Institute	Charlotte	North Carolina	United States	28203
77	Duke University Medical Center	Durham	North Carolina	United States	27710
78	Sanford Broadway Medical Center	Fargo	North Dakota	United States	58122
79	Cincinnati Children's Hospital Medical Center	Cincinnati	Ohio	United States	45229
80	Rainbow Babies and Childrens Hospital	Cleveland	Ohio	United States	44106
81	Nationwide Children's Hospital	Columbus	Ohio	United States	43205
82	Dayton Children's Hospital	Dayton	Ohio	United States	45404
83	ProMedica Toledo Hospital/Russell J Ebeid Children's Hospital	Toledo	Ohio	United States	43606
84	University of Oklahoma Health Sciences Center	Oklahoma City	Oklahoma	United States	73104
85	Legacy Emanuel Children's Hospital	Portland	Oregon	United States	97227
86	Oregon Health and Science University	Portland	Oregon	United States	97239
87	Geisinger Medical Center	Danville	Pennsylvania	United States	17822
88	Children's Hospital of Philadelphia	Philadelphia	Pennsylvania	United States	19104
89	Children's Hospital of Pittsburgh of UPMC	Pittsburgh	Pennsylvania	United States	15224
90	Prisma Health Richland Hospital	Columbia	South Carolina	United States	29203
91	BI-LO Charities Children's Cancer Center	Greenville	South Carolina	United States	29605
92	Sanford USD Medical Center - Sioux Falls	Sioux Falls	South Dakota	United States	57117-5134
93	East Tennessee Childrens Hospital	Knoxville	Tennessee	United States	37916
94	Saint Jude Children's Research Hospital	Memphis	Tennessee	United States	38105
95	The Children's Hospital at TriStar Centennial	Nashville	Tennessee	United States	37203
96	Vanderbilt University/Ingram Cancer Center	Nashville	Tennessee	United States	37232
97	Dell Children's Medical Center of Central Texas	Austin	Texas	United States	78723
98	Medical City Dallas Hospital	Dallas	Texas	United States	75230
99	UT Southwestern/Simmons Cancer Center-Dallas	Dallas	Texas	United States	75390
100	Cook Children's Medical Center	Fort Worth	Texas	United States	76104
101	Baylor College of Medicine/Dan L Duncan Comprehensive Cancer Center	Houston	Texas	United States	77030
102	M D Anderson Cancer Center	Houston	Texas	United States	77030
103	Children's Hospital of San Antonio	San Antonio	Texas	United States	78207
104	Methodist Children's Hospital of South Texas	San Antonio	Texas	United States	78229
105	University of Texas Health Science Center at San Antonio	San Antonio	Texas	United States	78229
106	Scott and White Memorial Hospital	Temple	Texas	United States	76508
107	Primary Children's Hospital	Salt Lake City	Utah	United States	84113
108	University of Vermont and State Agricultural College	Burlington	Vermont	United States	05405
109	Children's Hospital of The King's Daughters	Norfolk	Virginia	United States	23507
110	Virginia Commonwealth University/Massey Cancer Center	Richmond	Virginia	United States	23298
111	Seattle Children's Hospital	Seattle	Washington	United States	98105
112	Providence Sacred Heart Medical Center and Children's Hospital	Spokane	Washington	United States	99204
113	Madigan Army Medical Center	Tacoma	Washington	United States	98431
114	West Virginia University Healthcare	Morgantown	West Virginia	United States	26506
115	University of Wisconsin Carbone Cancer Center	Madison	Wisconsin	United States	53792
116	Children's Hospital of Wisconsin	Milwaukee	Wisconsin	United States	53226
117	San Jorge Children's Hospital	San Juan		Puerto Rico	00912
118	University Pediatric Hospital	San Juan		Puerto Rico	00926