Surgery in Treating Children With Neuroblastoma

Sponsor

Children's Oncology Group (Other)

Overall Status

Completed

CT.gov ID

NCT00003119

Collaborator

National Cancer Institute (NCI) (NIH)

968

Enrollment

235

Locations

Arms

Duration (Months)

4.1

Patients Per Site

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

RATIONALE: Surgery alone may be effective in treating children with neuroblastoma.

PURPOSE: Phase III trial to study the effectiveness of surgery alone in treating children who have neuroblastoma.

Condition or Disease	Intervention/Treatment	Phase
Neuroblastoma	Biological: filgrastim Biological: sargramostim Drug: carboplatin Drug: cyclophosphamide Drug: doxorubicin hydrochloride Drug: etoposide Procedure: adjuvant therapy Procedure: conventional surgery Radiation: radiation therapy	Phase 3

Detailed Description

OBJECTIVES:

To determine if asymptomatic patients with low-risk neuroblastoma treated with surgery alone will have a 3-year survival rate of 95%.
Estimate the response and 3-year event-free survival rates of symptomatic patients treated with chemotherapy.
Estimate the event-free survival and overall survival rates in patients who relapse or progress after initial treatment with surgery alone.
Determine the acute and chronic toxic effects associated with treating low-risk neuroblastoma with surgery alone or surgery and chemotherapy.

OUTLINE: This is a multicenter study. Patients are stratified according to disease stage, MYCN status, age, and histology.

Patients undergo primary tumor resection and biopsy of regional nodes. Patients with at least 50% of the tumor resected are followed monthly for 3 months, every 3 months for 9 months, every 6 months for one year, and then annually thereafter.

Regimen I

Patients with clinically symptomatic (e.g., respiratory distress, spinal cord compromise with or without neurologic deficit, inferior vena cava compression with renal or bowel ischemia, intractable vomiting due to gastrointestinal obstruction, genitourinary obstruction, or coagulopathy) low-risk neuroblastoma or who have less than 50% of the primary tumor resected receive 4 different courses of chemotherapy.
Course 1: Patients receive carboplatin IV over 1 hour followed by etoposide IV over 2 hours on day 0 and etoposide only on days 1 and 2.
Course 2: Patients receive carboplatin IV over 1 hour, cyclophosphamide IV over 1 hour, and doxorubicin IV over 15-60 minutes on day 1.
Course 3: Patients receive cyclophosphamide IV over 1 hour followed by etoposide IV over 2 hours on day 0 and etoposide only on days 1 and 2.
Course 4: Patients receive carboplatin IV over 1 hour and etoposide IV over 2 hours followed by doxorubicin IV over 15-60 minutes on day 0 and etoposide only on days 1 and

Regimen II

Patients who progress to or recur with unfavorable biology intermediate-risk disease receive an additional 4 courses of chemotherapy.
Course 5: Patients receive treatment as in course 3 above.
Course 6: Patients receive treatment as in course 2 above.
Course 7: Patients receive treatment as in course 1 above.
Course 8: Patients receive cyclophosphamide IV over 1 hour followed by doxorubicin IV over 15-60 minutes on day 1.

All infants under 60 days of age receive filgrastim (G-CSF) or sargramostim (GM-CSF) subcutaneously beginning 24 to 36 hours after chemotherapy and continuing until blood counts recover.

Courses in both regimens repeat every 3 weeks in the absence of unacceptable toxicity.

Patients at risk for symptomatic spinal cord compression may also receive chemotherapy. Patients experiencing progressive or recurrent disease after observation undergo repeat surgery and/or chemotherapy as above. Patients with clinically symptomatic disease may also undergo radiotherapy if response to chemotherapy is not rapid.

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

PROJECTED ACCRUAL: A total of 820 patients will be accrued for this study within 4 years.

Study Design

Study Type:

Interventional

Actual Enrollment :

968 participants

Allocation:

N/A

Intervention Model:

Single Group Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

Primary Surgical Therapy for Biologically Defined Low-Risk Neuroblastoma: A Pediatric Oncology Group/Children's Cancer Group Intergroup Study

Study Start Date :

Mar 1, 1998

Actual Primary Completion Date :

Mar 1, 2006

Actual Study Completion Date :

Mar 1, 2006

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Treatment 1 - Asymptomatic - no immediate chemotherapy	Procedure: conventional surgery Radiation: radiation therapy
Experimental: Symptomatic - immediate chemotherapy	Biological: filgrastim Biological: sargramostim Drug: carboplatin Drug: cyclophosphamide Drug: doxorubicin hydrochloride Drug: etoposide Procedure: adjuvant therapy Procedure: conventional surgery Radiation: radiation therapy

Arm

Intervention/Treatment

Experimental: Treatment 1 - Asymptomatic - no immediate chemotherapy

Procedure: conventional surgery

Radiation: radiation therapy

Experimental: Symptomatic - immediate chemotherapy

Biological: filgrastim

Biological: sargramostim

Drug: carboplatin

Drug: cyclophosphamide

Drug: doxorubicin hydrochloride

Drug: etoposide

Procedure: adjuvant therapy

Procedure: conventional surgery

Radiation: radiation therapy

Outcome Measures

Primary Outcome Measures

Estimate the 3 year survival rate for low risk asymptomatic stage 2A/2B patients who are treated with surgery alone []
The primary objective is to estimate the 3 year survival rate for low risk asymptomatic stage 2A/2B patients who are treated with surgery alone. Under the assumption that about 90% of the low risk 2A/2B patients will be asymptomatic, and 10% of these will be lost to follow up, the projected sample size will enable estimation of the survival rate with a standard error less than .03. This sample size will also provide sufficient power for the sequential monitoring plan (see below) for this subgroup of patients.

Eligibility Criteria

Criteria

Ages Eligible for Study:

N/A to 21 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

DISEASE CHARACTERISTICS:

Histologically proven low-risk neuroblastoma (excluding ganglioneuroma)
International Neuroblastoma Staging System (INSS) stage 1 in all patients
INSS stage 2A or 2B in patients less than 365 days of age
INSS stage 2A or 2B tumor with nonamplified MYCN with any Shimada histology in patients ages 1 to 20 years
INSS stage 2A or 2B tumor with amplified MYCN with Shimada favorable histology in patients ages 1 to 20 years
INSS stage 4S tumors with nonamplified MYCN, Shimada favorable histology, and a DNA index not equal to 1 in patients less than 365 days of age
Immediate chemotherapy allowed prior to biopsy for patients with intradural extension and/or emergent paresis if biopsy performed within 96 hours
Must have no abnormal organ function unless due to neuroblastoma
Concurrent registration on companion biology study (protocol COG-ANBL00B1) or its successor

PATIENT CHARACTERISTICS:

Age:

Under 21

Performance status:

Not specified

Life expectancy:

Not specified

Hematopoietic:

Not specified

Hepatic:

Bilirubin less than 1.5 times normal
SGOT or SGPT less than 2.5 times normal

Renal:

Creatinine less than 1.5 times normal

Cardiovascular:

Shortening fraction greater than 27% by echocardiogram OR
Ejection fraction greater than 47% by radionuclide angiogram

PRIOR CONCURRENT THERAPY:

Biologic therapy:

No prior immunotherapy

Chemotherapy:

See Disease Characteristics

Endocrine therapy:

No prior hormonal therapy

Radiotherapy:

No prior radiotherapy

Surgery:

Prior surgery allowed

Other:

No other prior therapy

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	University of Alabama at Birmingham Comprehensive Cancer Center	Birmingham	Alabama	United States	35233
2	University of South Alabama Cancer Research Institute	Mobile	Alabama	United States	36604
3	Phoenix Children's Hospital	Phoenix	Arizona	United States	85016
4	Arizona Cancer Center at University of Arizona Health Sciences Center	Tucson	Arizona	United States	85724
5	Arkansas Cancer Research Center at University of Arkansas for Medical Sciences	Little Rock	Arkansas	United States	72205
6	Southern California Permanente Medical Group	Downey	California	United States	90242
7	City of Hope Comprehensive Cancer Center	Duarte	California	United States	91010-3000
8	Rebecca and John Moores UCSD Cancer Center	La Jolla	California	United States	92093-0658
9	Loma Linda University Cancer Institute at Loma Linda University Medical Center	Loma Linda	California	United States	92354
10	Jonathan Jaques Children's Cancer Center at Miller Children's Hospital	Long Beach	California	United States	90801-1428
11	Children's Hospital Los Angeles	Los Angeles	California	United States	90027-0700
12	Cedars-Sinai Comprehensive Cancer Center at Cedars-Sinai Medical Center	Los Angeles	California	United States	90048
13	Jonsson Comprehensive Cancer Center, UCLA	Los Angeles	California	United States	90095-1781
14	Children's Hospital Central California	Madera	California	United States	93638-8762
15	Children's Hospital and Research Center at Oakland	Oakland	California	United States	94609-1809
16	Chao Family Comprehensive Cancer Center at University of California Irvine Cancer Center	Orange	California	United States	92868
17	Children's Hospital of Orange County	Orange	California	United States	92868
18	Lucile Packard Children's Hospital at Stanford University Medical Center	Palo Alto	California	United States	94304
19	Sutter Cancer Center	Sacramento	California	United States	95816
20	University of California Davis Cancer Center	Sacramento	California	United States	95817
21	Kaiser Permanente Medical Center - Sacramento	Sacramento	California	United States	95825
22	Kaiser Permanente Medical Center/Kaiser Foundation Hospital - San Diego	San Diego	California	United States	92120
23	Children's Hospital and Health Center, San Diego	San Diego	California	United States	92123-4282
24	UCSF Comprehensive Cancer Center	San Francisco	California	United States	94143
25	Santa Barbara Cottage Hospital	Santa Barbara	California	United States	93102
26	Kaiser Permanente Medical Center - Santa Clara	Santa Clara	California	United States	95051-5386
27	David Grant Medical Center	Travis Air Force Base	California	United States	94535
28	Children's Hospital of Denver	Denver	Colorado	United States	80218-1088
29	Presbyterian - St. Luke's Medical Center	Denver	Colorado	United States	80218
30	University of Connecticut Comprehensive Cancer Center at University of Connecticut Health Center	Farmington	Connecticut	United States	06360-7106
31	Yale Comprehensive Cancer Center	New Haven	Connecticut	United States	06520-8028
32	Alfred I. duPont Hospital for Children	Wilmington	Delaware	United States	19899
33	Lombardi Cancer Center at Georgetown University Medical Center	Washington	District of Columbia	United States	20007
34	Children's National Medical Center	Washington	District of Columbia	United States	20010-2970
35	Broward General Medical Center	Fort Lauderdale	Florida	United States	33316
36	Children's Hospital of Southwest Florida	Fort Myers	Florida	United States	33908
37	Shands Cancer Center at the University of Florida Health Science Center	Gainesville	Florida	United States	32610-0296
38	Joe DiMaggio Children's Hospital at Memorial	Hollywood	Florida	United States	33021
39	Nemours Children's Clinic	Jacksonville	Florida	United States	32207
40	Jackson Memorial Hospital	Miami	Florida	United States	33136
41	Miami Children's Hospital	Miami	Florida	United States	33155
42	Baptist-South Miami Regional Cancer Program	Miami	Florida	United States	33176-2197
43	Florida Hospital Cancer Institute	Orlando	Florida	United States	32804
44	Nemours Children's Clinic-Orlando	Orlando	Florida	United States	32806
45	Sacred Heart Children's Hospital	Pensacola	Florida	United States	32504
46	All Children's Hospital	St. Petersburg	Florida	United States	33701
47	St. Joseph's Children's Hospital	Tampa	Florida	United States	33677-4227
48	St. Mary's Hospital	West Palm Beach	Florida	United States	33407
49	AFLAC Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta - Scottish Rite Campus	Atlanta	Georgia	United States	30342
50	MBCCOP-Medical College of Georgia Cancer Center	Augusta	Georgia	United States	30912-4000
51	Medical Center of Central Georgia	Macon	Georgia	United States	31201
52	Curtis & Elizabeth Anderson Cancer Institute at Memorial Health University Medical Center	Savannah	Georgia	United States	31405
53	Cancer Research Center of Hawaii	Honolulu	Hawaii	United States	96813
54	MBCCOP - Hawaii	Honolulu	Hawaii	United States	96813
55	Tripler Army Medical Center	Honolulu	Hawaii	United States	96859-5000
56	Mountain States Tumor Institute - Boise	Boise	Idaho	United States	83712
57	University of Chicago Cancer Research Center	Chicago	Illinois	United States	60601
58	Rush University Medical Center	Chicago	Illinois	United States	60612
59	University of Illinois Medical Center	Chicago	Illinois	United States	60612
60	Children's Memorial Hospital - Chicago	Chicago	Illinois	United States	60614
61	Advocate Hope Children's Hospital	Oak Lawn	Illinois	United States	60453
62	Lutheran General Cancer Care Center	Park Ridge	Illinois	United States	60068-1174
63	Saint Jude Midwest Affiliate	Peoria	Illinois	United States	61637
64	Southern Illinois University School of Medicine	Springfield	Illinois	United States	62794-9658
65	Riley Children Cancer Center at Riley Hospital for Children	Indianapolis	Indiana	United States	46202-5225
66	St. Vincent Hospitals and Health Care Centers	Indianapolis	Indiana	United States	46260
67	Blank Children's Hospital	Des Moines	Iowa	United States	50308
68	John Stoddard Cancer Center at Iowa Methodist Medical Center	Des Moines	Iowa	United States	50309
69	Holden Comprehensive Cancer Center at University of Iowa	Iowa City	Iowa	United States	52242-1009
70	Wesley Medical Center	Wichita	Kansas	United States	67214
71	Markey Cancer Center at University of Kentucky Chandler Medical Center	Lexington	Kentucky	United States	40536-0284
72	Kosair Children's Hospital	Louisville	Kentucky	United States	40202-3830
73	MBCCOP - LSU Health Sciences Center	New Orleans	Louisiana	United States	70112
74	Tulane Cancer Center at Tulane University Hospital and Clinic	New Orleans	Louisiana	United States	70112
75	Children's Hospital of New Orleans	New Orleans	Louisiana	United States	70118
76	Ochsner Clinic Foundation	New Orleans	Louisiana	United States	70121
77	Eastern Maine Medical Center	Bangor	Maine	United States	04401
78	Maine Children's Cancer Program	Scarborough	Maine	United States	04074-9308
79	Greenebaum Cancer Center at University of Maryland Medical Center	Baltimore	Maryland	United States	21201-1595
80	Alvin and Lois Lapidus Cancer Institute at Sinai Hospital	Baltimore	Maryland	United States	21225
81	Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins	Baltimore	Maryland	United States	21231-2410
82	Walter Reed Army Medical Center	Silver Spring	Maryland	United States	20910
83	Floating Hospital for Children	Boston	Massachusetts	United States	02111
84	Dana-Farber/Harvard Cancer Center at Dana Farber Cancer Institute	Boston	Massachusetts	United States	02115
85	Baystate Regional Cancer Program at Baystate Medical Center	Springfield	Massachusetts	United States	01107
86	UMASS Memorial Cancer Center - University Campus	Worcester	Massachusetts	United States	01655
87	University of Michigan Comprehensive Cancer Center	Ann Arbor	Michigan	United States	48109-0914
88	Children's Hospital of Michigan	Detroit	Michigan	United States	48201
89	Josephine Ford Cancer Center at Henry Ford Health System	Detroit	Michigan	United States	48202
90	Van Elslander Cancer Center at St. John Hospital and Medical Center	Detroit	Michigan	United States	48236
91	Hurley Medical Center	Flint	Michigan	United States	48503
92	Spectrum Health and DeVos Children's Hospital	Grand Rapids	Michigan	United States	49503
93	Bronson Methodist Hospital	Kalamazoo	Michigan	United States	49007-5364
94	Breslin Cancer Center at Ingham Regional Medical Center	Lansing	Michigan	United States	48910
95	CCOP - Beaumont	Royal Oak	Michigan	United States	48073-6769
96	William Beaumont Hospital - Royal Oak	Royal Oak	Michigan	United States	48073-6769
97	St. Mary's - Duluth Clinic Cancer Center	Duluth	Minnesota	United States	55805
98	Children's Hospitals and Clinics - Minneapolis	Minneapolis	Minnesota	United States	55404
99	Mayo Clinic Cancer Center	Rochester	Minnesota	United States	55905
100	Children's Hospitals and Clinics - Minnesota	Saint Paul	Minnesota	United States	55102
101	University of Mississippi Medical Center	Jackson	Mississippi	United States	39216-4505
102	Children's Mercy Hospital	Kansas City	Missouri	United States	64108
103	Cardinal Glennon Children's Hospital	Saint Louis	Missouri	United States	63104
104	St. Louis Children's Hospital	Saint Louis	Missouri	United States	63110
105	Children's Hospital of Omaha	Omaha	Nebraska	United States	68114
106	UNMC Eppley Cancer Center at the University of Nebraska Medical Center	Omaha	Nebraska	United States	68198-2168
107	Sunrise Hospital and Medical Center	Las Vegas	Nevada	United States	89109
108	Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center	Lebanon	New Hampshire	United States	03756
109	Cancer Center at Hackensack University Medical Center	Hackensack	New Jersey	United States	07601
110	Cancer Institute of New Jersey at Robert Wood Johnson University Hospital	New Brunswick	New Jersey	United States	08903
111	Newark Beth Israel Medical Center	Newark	New Jersey	United States	07112-2094
112	St. Joseph's Hospital and Medical Center	Paterson	New Jersey	United States	07503
113	Valerie Fund Children's Center at Atlantic Health	Summit	New Jersey	United States	07901
114	University of New Mexico Cancer Research and Treatment Center	Albuquerque	New Mexico	United States	87131
115	Cancer Center of Albany Medical Center	Albany	New York	United States	12208
116	Albert Einstein Clinical Cancer Center	Bronx	New York	United States	10461
117	Brooklyn Hospital Center	Brooklyn	New York	United States	11201-5493
118	SUNY Downstate Medical Center	Brooklyn	New York	United States	11203
119	Brookdale University Hospital and Medical Center	Brooklyn	New York	United States	11212
120	Comprehensive Cancer Center at Maimonides Medical Center	Brooklyn	New York	United States	11219
121	Schneider Children's Hospital	New Hyde Park	New York	United States	11042
122	Memorial Sloan-Kettering Cancer Center	New York	New York	United States	10021
123	New York Weill Cornell Cancer Center at Cornell University	New York	New York	United States	10021
124	Mount Sinai School of Medicine	New York	New York	United States	10029
125	Herbert Irving Comprehensive Cancer Center at Columbia University	New York	New York	United States	10032
126	James P. Wilmot Cancer Center at University of Rochester Medical Center	Rochester	New York	United States	14642
127	Long Island Cancer Center at Stony Brook University Hospital	Stony Brook	New York	United States	11794
128	SUNY Upstate Medical University Hospital	Syracuse	New York	United States	13210
129	New York Medical College	Valhalla	New York	United States	10595
130	Mission Hospitals	Asheville	North Carolina	United States	28801
131	Lineberger Comprehensive Cancer Center at University of North Carolina - Chapel Hill	Chapel Hill	North Carolina	United States	27599-7295
132	Blumenthal Cancer Center at Carolinas Medical Center	Charlotte	North Carolina	United States	28232-2861
133	Presbyterian Healthcare	Charlotte	North Carolina	United States	28233
134	Duke Comprehensive Cancer Center	Durham	North Carolina	United States	27710
135	Leo W. Jenkins Cancer Center of University Health Systems of Eastern Carolina	Greenville	North Carolina	United States	27858-4354
136	Comprehensive Cancer Center at Wake Forest University	Winston-Salem	North Carolina	United States	27157-1081
137	Dakota Cancer Institute at Innovis Health - Dakota Clinic	Fargo	North Dakota	United States	58103-4940
138	Children's Hospital Medical Center of Akron	Akron	Ohio	United States	44308-1062
139	Cincinnati Children's Hospital Medical Center	Cincinnati	Ohio	United States	45229-3039
140	Ireland Cancer Center at University Hospitals of Cleveland and Case Western Reserve University	Cleveland	Ohio	United States	44106-5065
141	Cleveland Clinic Taussig Cancer Center	Cleveland	Ohio	United States	44195
142	Columbus Children's Hospital	Columbus	Ohio	United States	43205-2696
143	Children's Medical Center - Dayton	Dayton	Ohio	United States	45404
144	Toledo Children's Hospital	Toledo	Ohio	United States	43601
145	St. Vincent Mercy Medical Center	Toledo	Ohio	United States	43608
146	Forum Health-Tod Childrens Hospital	Youngstown	Ohio	United States	44501
147	Children's Hospital at Oklahoma University Medical Center	Oklahoma City	Oklahoma	United States	73104
148	CCOP - Oklahoma	Tulsa	Oklahoma	United States	74136
149	Natalie Warren Bryant Cancer Center	Tulsa	Oklahoma	United States	74136
150	CCOP - Columbia River Oncology Program	Portland	Oregon	United States	97225
151	Legacy Emanuel Hospital and Health Center & Children's Hospital	Portland	Oregon	United States	97227
152	Doernbecher Children's Hospital at Oregon Health & Science University	Portland	Oregon	United States	97239-3098
153	Geisinger Medical Center	Danville	Pennsylvania	United States	17822-1320
154	Penn State Cancer Institute at Milton S. Hershey Medical Center	Hershey	Pennsylvania	United States	17033
155	Children's Hospital of Philadelphia	Philadelphia	Pennsylvania	United States	19104
156	St. Christopher's Hospital for Children	Philadelphia	Pennsylvania	United States	19134-1095
157	Children's Hospital of Pittsburgh	Pittsburgh	Pennsylvania	United States	15213-2583
158	Rhode Island Hospital	Providence	Rhode Island	United States	02903
159	Hollings Cancer Center at Medical University of South Carolina	Charleston	South Carolina	United States	29425-0721
160	Palmetto Health South Carolina Cancer Center	Columbia	South Carolina	United States	29203
161	Children's Hospital of Greenville Hospital System	Greenville	South Carolina	United States	29605
162	Avera Cancer Institute	Sioux Falls	South Dakota	United States	57105-1080
163	Sioux Valley Hospital at University of South Dakota Medical Center	Sioux Falls	South Dakota	United States	57117-5039
164	East Tennessee State University Cancer Center at Johnson City Medical Center	Johnson City	Tennessee	United States	37614-0622
165	East Tennessee Children's Hospital	Knoxville	Tennessee	United States	37901
166	St. Jude Children's Research Hospital	Memphis	Tennessee	United States	38105-2794
167	Vanderbilt Children's Hospital	Nashville	Tennessee	United States	37232-6310
168	Texas Tech University Health Sciences Center School of Medicine	Amarillo	Texas	United States	79106
169	Children's Hospital of Austin	Austin	Texas	United States	78701
170	Medical City Dallas Hospital	Dallas	Texas	United States	75230
171	Simmons Cancer Center at University of Texas Southwestern Medical Center - Dallas	Dallas	Texas	United States	75390-9063
172	Cook Children's Medical Center - Fort Worth	Fort Worth	Texas	United States	76104
173	University of Texas Medical Branch	Galveston	Texas	United States	77555-0361
174	University of Texas - MD Anderson Cancer Center	Houston	Texas	United States	77030-4009
175	Baylor College of Medicine	Houston	Texas	United States	77030
176	San Antonio Military Pediatric Cancer and Blood Disorders Center	Lackland Air Force Base	Texas	United States	78236
177	Covenant Children's Hospital	Lubbock	Texas	United States	79410
178	University of Texas Health Science Center at San Antonio	San Antonio	Texas	United States	78207
179	MBCCOP - South Texas Pediatrics	San Antonio	Texas	United States	78229-3900
180	Methodist Cancer Center at Methodist Specialty and Transplant Hospital	San Antonio	Texas	United States	78229-3902
181	CCOP - Scott and White Hospital	Temple	Texas	United States	76508
182	Center for Cancer Prevention and Care at Scott and White Clinic	Temple	Texas	United States	76508
183	Huntsman Cancer Institute	Salt Lake City	Utah	United States	84112
184	Vermont Cancer Center at University of Vermont	Burlington	Vermont	United States	05401-3498
185	Cancer Center at the University of Virginia	Charlottesville	Virginia	United States	22908
186	Inova Fairfax Hospital	Falls Church	Virginia	United States	22042-3300
187	Children's Hospital of the King's Daughters	Norfolk	Virginia	United States	23507
188	Naval Medical Center, Portsmouth	Portsmouth	Virginia	United States	23708-5100
189	Massey Cancer Center at Virginia Commonwealth University	Richmond	Virginia	United States	23298-0121
190	Carilion Medical Center for Children	Roanoke	Virginia	United States	24029
191	Children's Hospital and Regional Medical Center - Seattle	Seattle	Washington	United States	98105
192	Fred Hutchinson Cancer Research Center	Seattle	Washington	United States	98109-1024
193	Group Health Central Hospital	Seattle	Washington	United States	98112
194	Deaconess Medical Center	Spokane	Washington	United States	99210-0248
195	Mary Bridge Children's Hospital and Health Center	Tacoma	Washington	United States	98415-0299
196	Madigan Army Medical Center	Tacoma	Washington	United States	98431-5000
197	West Virginia University - Robert C. Byrd Health Sciences Center - Charleston Division	Charleston	West Virginia	United States	25302
198	Cabell Huntington Hospital	Huntington	West Virginia	United States	25701
199	West Virginia University Hospitals	Morgantown	West Virginia	United States	26506-9300
200	Bellin Memorial Hospital	Green Bay	Wisconsin	United States	54301
201	CCOP - St. Vincent Hospital Cancer Center, Green Bay	Green Bay	Wisconsin	United States	54301
202	St. Vincent Hospital	Green Bay	Wisconsin	United States	54307-9070
203	Gundersen Lutheran Cancer Center at Gundersen Lutheran Medical Center	La Crosse	Wisconsin	United States	54601
204	University of Wisconsin Comprehensive Cancer Center	Madison	Wisconsin	United States	53792-6164
205	Marshfield Clinic	Marshfield	Wisconsin	United States	54449-5772
206	CCOP - Marshfield Clinic Research Foundation	Marshfield	Wisconsin	United States	54449
207	Midwest Children's Cancer Center	Milwaukee	Wisconsin	United States	53226
208	Sydney Children's Hospital	Randwick	New South Wales	Australia	2031
209	Children's Hospital at Westmead	Westmead	New South Wales	Australia	2145
210	Royal Children's Hospital	Brisbane	Queensland	Australia	4029
211	Women's and Children's Hospital	North Adelaide	South Australia	Australia	5006
212	Royal Children's Hospital	Parkville	Victoria	Australia	3052
213	Princess Margaret Hospital for Children	Perth	Western Australia	Australia	6001
214	Alberta Children's Hospital	Calgary	Alberta	Canada	T2T 5C7
215	Cross Cancer Institute	Edmonton	Alberta	Canada	T6G 1Z2
216	British Columbia Children's Hospital	Vancouver	British Columbia	Canada	V6H 3V4
217	CancerCare Manitoba	Winnipeg	Manitoba	Canada	R3E 0V9
218	Janeway Children's Health and Rehabilitation Centre	St. John's	Newfoundland and Labrador	Canada	A1B 3V6
219	IWK Health Centre	Halifax	Nova Scotia	Canada	B3J 3G9
220	McMaster Children's Hospital at Hamilton Health Sciences	Hamilton	Ontario	Canada	L8S 4J9
221	Children's Hospital of Western Ontario	London	Ontario	Canada	N6C 2V5
222	Children's Hospital of Eastern Ontario	Ottawa	Ontario	Canada	K1H 8L1
223	Hospital for Sick Children	Toronto	Ontario	Canada	M5G 1X8
224	Montreal Children's Hospital at McGill University Health Center	Montreal	Quebec	Canada	H3G 1A4
225	Hopital Sainte Justine	Montreal	Quebec	Canada	H3T 1C5
226	Centre de Recherche du Centre Hospitalier de l'Universite Laval	Sainte Foy	Quebec	Canada	GIV 4G2
227	Allan Blair Cancer Centre at Pasqua Hospital	Regina	Saskatchewan	Canada	S4T 7T1
228	Saskatoon Cancer Centre	Saskatoon	Saskatchewan	Canada	S7N 4H4
229	Academisch Ziekenhuis Groningen	Groningen		Netherlands	9700 RB
230	Starship Children's Health	Auckland		New Zealand
231	Puerto Rico Cancer Center at University of Puerto Rico - Medical Sciences Campus	San Juan		Puerto Rico	00936-5067
232	San Jorge Childrens Hospital	Santurce		Puerto Rico	00912
233	Swiss Pediatric Oncology Group Bern	Bern		Switzerland	CH 3010
234	Swiss Pediatric Oncology Group Geneva	Geneva		Switzerland	CH 1211
235	Swiss Pediatric Oncology Group Lausanne	Lausanne		Switzerland	CH 1011