Sponsor Protocol N°: CSET EudraCT N°: PHASE I / II STUDY ... · Laboratoire d'Anatomie Pathologique C.H.U Rangueil (Bât. L3) 1 Avenue Jean Poulhès 31400 TOULOUSE Tel : 05 61 32

HR MB – 5 CSET 2012/xxxxx

12 June 2012 Version 1.0 – Confidential Page 1 of 91

Sponsor Protocol N°: CSET

EudraCT N°:

PHASE I / II STUDY OF SEQUENTIAL HIGH-DOSE CHEMOTHERAPY WITH STEM CELL SUPPORT IN

CHILDREN YOUNGER THAN 5 YEARS OF AGE WITH HIGH-RISK MEDULLOBLASTOMA

Abbreviated Protocol Title: HR MB - 5

Version n° 1.0 – 12/06/2012

COORDINATING INVESTIGATOR

Coordinating Investigator: Dr Christelle DUFOUR Address: 114 rue Edouard Vaillant – 94805 Villejuif Phone: 01 42 11 42 47 Fax: 01 42 11 52 75 Email: [email protected]

SPONSOR

Institut Gustave Roussy

114, rue Edouard Vaillant

94 805 Villejuif

France

Signature of the Clinical Research Department Directeur:

Date :



STUDY CONTACTS

Name and Address Telephone Number/Fax Number

Sponsor Institut Gustave Roussy 114 rue Edouard Vaillant F-94805 Villejuif Cedex

Coordinating Investigator

Dr Christelle DUFOUR Département de pédiatrie Institut Gustave Roussy

Tel: 01 42 11 42 47 fax: 01 42 11 52 75 [email protected]

Co-coordinating investigator

Dr Nicolas ANDRE Hôpital pour enfants la Timone Hématologie &Oncologie Pédiatrique Avenue Jean Moulin 13385 Marseille cedex

Tel : 04 91 38 68 21 Fax : 04 91 38 68 32 [email protected]

Inclusion management/ Statistician/Data manager

Statistician : Dr Marie-Cécile LE DELEY Institut Gustave Roussy Data manager: Katty MALEKZADEH

Tel: 01 42 11 54 44 [email protected] Tel : 01 42 11 41 96 Fax : 01 42 11 52 58 [email protected]

Monitoring Thibaud MOTREFF Institut Gustave Roussy


Pharmacovigilance Dr Salim LAGHOUATI UFPV - DRCT Institut Gustave Roussy


Pharmacy Dr Sylvie DEMIRDJAN Institut Gustave Roussy


Anatomical pathology

Pr. Marie-Bernadette DELISLE Laboratoire d'Anatomie Pathologique C.H.U Rangueil (Bât. L3) 1 Avenue Jean Poulhès 31400 TOULOUSE

Tel : 05 61 32 27 05 Fax. 05 61 32 20 84 [email protected]

Radiotherapy

Dr. Christian CARRIE Département Radiothérapie Centre Léon Bérard, 28 rue Laennec 69373 LYON Cedex 08

Tel : 04 78 78 26 52 Fax: 04 78 78 51 40 [email protected]

Radiotherapy

Dr Laetitia PADOVANI Hopital de la Timone 264 rue St Pierre 13005 Marseille

[email protected]

Radiology Pr. Anne GEOFFRAY Imagerie médicale – Fondation Lenval. 57 avenue de la Californie 06200 NICE

Tel : 04 92 03 03 11 Tel : 04 92 03 03 12 Fax: 04 92 03 04 35 [email protected]



Surgery

Pr Matthieu VINCHON Hôpital Roger Salengro Rue du Pr. Emile Laine 59037 LILLE Cedex


Rehabilitation

Docteur Mathilde CHEVIGNARD Hôpitaux de Saint Maurice 14, rue du val d'Osne 94415 Saint Maurice cedex

Tél : 01 43 96 63 40 [email protected]

Pharmacokinetics – pharmacogenetic Busulfan

Dr Angelo PACI Service de pharmacologie et d’analyse du médicament Institut Gustave Roussy


Pharmacokinetics – pharmacogenetic Cyclophosphamide

Dr Gareth VEAL Northern Institute for Cancer Research Paul O’Gorman Building North Terrace Newcastle upon Tyne NE2 4AD United Kingdom

Tel : +44 (0)191 246 4332 Fax: +44 (0)191 222 3452 [email protected]



SYNOPSIS – PROTOCOL N° (CSET)

A) IDENTIFICATION OF CLINICAL TRIAL EudraCT NUMBER: VERSION AND DATE : 1.0 12/06/2012 STUDY TITLE: PHASE I / II STUDY OF SEQUENTIAL HIGH-DOSE CHEMOTHE RAPY WITH STEM CELL SUPPORT IN CHILDREN YOUNGER THAN 5 YEARS OF AGE WITH HIGH-RISK MEDULLOBLASTOMA ABBREVIATED TITLE : HR MB-5

COORDINATING INVESTIGATOR : Dr Christelle DUFOUR

Total France

NUMBER OF CENTRES: 28 28

NUMBER OF PATIENTS : 50 50

B) IDENTIFICATION OF SPONSOR Institut Gustave Roussy 114 rue Edouard Vaillant – 94 805 VILLEJUIF FRANCE Tel.: 01 42 11 48 84 Fax: 01 42 1162 90

C) GENERAL INFORMATION ON STUDY INDICATION: High-risk medulloblastoma

METHODOLOGY: Multicentre, non-randomised, Phase I/II Trial, using a Bayesian design

PRIMARY OBJECTIVES : Phase II: To assess the efficacy in terms of Event Free Survival (EFS) of the strategy intended to treat children younger than 5 years of age suffering from high-risk medulloblastoma with sequential high-dose chemotherapy without radiotherapy. Phase I: To determine the Maximum Tolerated Dose (MTD) of cyclophosphamide in combination with a fixed dose of busilvex in children with high-risk medulloblastoma who are in complete response after the intensification phase. SECONDARY OBJECTIVES :

• To assess feasibility and efficacy of a strategy without radiotherapy by estimating the rate of patients alive free of disease without having received radiation therapy

• To assess efficacy of this strategy in terms of Overall Survival (OS) • To assess the proportion of radiological tumour response (complete and partial response)

of VP16-Carboplatin courses • To assess the proportion of patients achieving complete response after 2 courses of

VP16-carboplatine followed by 2 courses of thiotepa • To characterize the pharmacokinetics of cyclophosphamide – busilvex combination

(Phase I) • To assess efficacy, feasibility and tolerance of salvage treatment • To evaluate the acute toxicity of this therapeutic strategy, overall and by treatment phase



(induction / intensification / consolidation) • To evaluate the prognostic value of some immunohistochemical markers on the risk of

relapse or progression • To evaluate neurocognitive development of patients within 10 years after the end of

treatment INCLUSION CRITERIA:

• Histological diagnosis of medulloblastoma with no INI-1 loss • High risk medulloblastoma defined by at least one of the following conditions:

• Newly diagnosed classical metastatic medulloblastoma • Newly diagnosed anaplastic/large cell medulloblastoma • Newly diagnosed medulloblastoma with amplification of c-myc or N-myc

• Age at study entry less than 5 years of age • Weight > 8 kgs • Ability to comply with requirements for submission of materials for central review • Nutritional and general status compatible with this therapy, Lansky play score ≥ 30% • Estimated life expectancy ≥3 months • No organ toxicity other than alopecia and neurological symptoms due to disease (grade

>2 according to NCI-CTC v4 grading system) • No prior irradiation or chemotherapy (except VP16 – CBP) • Written informed consent from parents or legal guardian

INCLUSION CRITERIA FOR THE PHASE I PART OF THE STUDY: • Complete response after intensification phase confirmed by central review • Adequate hepatic and renal function

NON-INCLUSION CRITERIA :

• Desmoplastic medulloblastoma • Atypical Teratoid rhabdoid tumour • Uncontrolled active or symptomatic intracranial hypertension before chemotherapy

treatment • Patient incapable of undergoing medical follow-up



D) DESCRIPTION OF STUDY TREATMENTS

TREATMENT DURATION : 6 to 12 months depending on the response

E) STATISTICAL CONSIDERATIONS PRIMARY ENDPOINT:

• For the whole study: Event-free survival • For the Phase I part of the study: Dose-Limiting Toxicity

SECONDARY ENDPOINTS: • Radiotherapy-free survival without event • Overall survival • Response (complete and partial response) to conventional chemotherapy assessed after

the first two courses • Complete response to induction and intensification phases assessed after the two

courses of thiotepa • Toxicity according to NCI-CTC v4 grading system, in particular after the course of

cyclophosphamide in combination with busilvex to estimate the maximum tolerated dose of cyclophosphamide in this setting (phase I part).

• Pharmacokinetics of cyclophosphamide and Busilvex • Response to salvage treatment • Cognitive assessments

TRIAL DESIGN The trial includes i) the evaluation of the efficacy of a treatment strategy, designed as a phase II trial, and ii) a dose-finding part. The Phase II trial is an open label, non-randomized, multicentre trial without control group. A Bayesian approach will be used to analyse the EFS, assuming a cure model. We will use three prior distributions of the EFS; (1) an enthusiastic prior distribution, (2) a pessimistic prior distribution, and (3) a non-informative prior distribution. As the patient outcomes in the trial will be recorded, the subsequent distribution of the outcome probability under experimental treatment will be computed by applying Bayes’ theorem, which yields an estimated EFS probability with a



95% credibility interval (measure of Bayesian precision). Interim analyses are planned to monitor the efficacy data (early stopping rules for futility or inefficacy). The final analysis of efficacy will be made on an intention to treat basis, including all recruited patients, 3 years after recruitment of the last patient. Due to the uncertainty on the dose of cyclophosphamide that can be given in combination with busilvex for the last chemotherapy course in patients in complete response after intensification chemotherapy treatment, a dose-finding subtrial will be performed to address this issue (Phase I part). The dose escalation of cyclophosphamide will be performed using the Continual Reassessment Method in a Bayesian framework. SAMPLE SIZE Phase II part: In theory, Bayesian approach does not need to define a sample size in advance in order to obtain reliable results. However considering classical frequentist approach, 50 patients would be required if we had used a one-sample logrank test, with the following assumptions: statistical power of 0.85 for a 3-year improvement of 20% compared to historical data; type I error rate (one-sided) of 0.05. This sample size is reasonable considering possible accrual. We thus decided to recruit about 50 patients in the trial. Phase I part: All the patients in complete response after intensification chemotherapy treatment, eligible for the consolidation course of cyclophosphamide-busilvex course, will be included in the phase I part of the trial. They will be treated at the best current estimate of the MTD. Approximately 50% of the patients entering the trial are expected to be recruited in the phase I. ACCRUAL PERIOD: 5 YEARS

TREATMENT PERIOD: 6 TO 12 MONTHS

FOLLOW-UP PERIOD FOR THE MAIN ENDPOINT: 3 years OVERALL DURATION OF STUDY : 9 YEARS



TABLE OF CONTENTS 1. INTRODUCTION AND RATIONAL OF THE STUDY ............. ................................................13 1.1 Information on the disease.........................................................................................................13

1.1.1 Medulloblastoma.................................................................................................................................... 13

1.1.2 Biology of medulloblastoma................................................................................................................... 13

1.1.3 Stratification of medulloblastoma........................................................................................................... 15 1.2 Information on treatments in medulloblastoma...........................................................................15

1.2.1 Induction chemotherapy ............................................................................................................................ 17

1.2.2 Intensification chemotherapy..................................................................................................................... 18

1.2.3 Consolidation chemotherapy..................................................................................................................... 19

1.2.4 Salvage treatment ..................................................................................................................................... 20

2. STUDY OBJECTIVES................................... .........................................................................24 Primary objective .............................................................................................................................24 Secondary objectives ......................................................................................................................25

3. STUDY DESIGN ....................................................................................................................25 Study centres ..................................................................................................................................25 Study period ....................................................................................................................................26

4. SELECTION OF PATIENTS .............................. ....................................................................26 4.1 Inclusion criteria for the study ....................................................................................................26 4.2 Non-inclusion criteria .................................................................................................................27 4.3 Inclusion criteria for the Phase I part of the study ......................................................................27

5. PATIENT REGISTRATION ............................... .....................................................................27

6. TREATMENTS.......................................................................................................................28 6.1 Surgery......................................................................................................................................29

6.1.1 Initial surgery for patients treated at diagnosis...................................................................................... 29

6.1.2 Secondary surgery .................................................................................................................................... 30 6.2 Induction phase .........................................................................................................................30

6.2.1 Drug administration ................................................................................................................................... 30

6.2.2 Patient monitoring...................................................................................................................................... 31

6.2.3 Concomitant therapies .............................................................................................................................. 31 6.3 Intensification phase..................................................................................................................31


6.3.2. Dose adaptation ....................................................................................................................................... 32


6.3.4 Concomitant therapies .............................................................................................................................. 32 6.4 Consolidation phase: Phase I ....................................................................................................32



6.4.4 Concomitant therapies .............................................................................................................................. 34 6.5 Salvage treatment .....................................................................................................................35

6.5.1 Salvage treatment’s first step: TEMIRI...................................................................................................... 36



6.5.2 Chemo-radiotherapy.................................................................................................................................. 36

6.5.3 Maintenance treatment.............................................................................................................................. 40 6.6 Treatment Discontinuation .........................................................................................................40

7. BASELINE AND FOLLOW-UP ASSESSMENTS................. ..................................................41 7.1 Baseline assessments ...............................................................................................................41 7.2 Follow-up assessments during treatment and at the end of treatment .......................................43 7.3 Follow-up assessments after treatment .....................................................................................45

8. PK / PD / PG STUDIES..........................................................................................................45

8.1 BUSULFAN .................................................................................................................................................. 46

9. EVALUATION CRITERIA ................................ ......................................................................48 9.1 Primary endpoint .......................................................................................................................48 9.2 Secondary endpoints .................................................................................................................49

10. STATISTICAL CONSIDERATIONS ......................... ..............................................................50 10.1 Study design............................................................................................................................50 10.2 Sample size .............................................................................................................................51 10.3 Statistical analysis ...................................................................................................................52

10.3.1 Analysis of the main endpoint ................................................................................................................. 52

10.3.2 Others analyses....................................................................................................................................... 53

10.3.3 Phase I analyses ..................................................................................................................................... 54 10.4 Analysed population ................................................................................................................55 10.5 Monitoring of toxicity and stopping rules ..................................................................................55

10.5.1 Toxic death .............................................................................................................................................. 55

10.5.2 Severe toxicity ......................................................................................................................................... 56

11. ADVERSE EVENT COLLECTION & REPORTING............... .................................................57 11.1 Definition .................................................................................................................................57 11.2 Recording and assessing adverse events................................................................................59 11.3 Intensity criteria .......................................................................................................................61 11.4 Reporting of serious adverse events........................................................................................61 11.5 Follow-up.................................................................................................................................63 11.6 Information given to investigators, ethics committee and regulatory authority ..........................63

12. INDEPENDENT DATA MONITORING COMMITTEE.............. ...............................................64

13. STUDY DISCONTINUATION .................................................................................................64

14. ETHICAL AND REGULATORY ASPECTS..................... .......................................................65 14.1 Rules and regulations ..............................................................................................................65 14.2 Committee for the Protection of Persons (CPP) – Competent Authority...................................65 14.3 Information and Consent of Participants ..................................................................................66 14.4 Principal Investigator Responsibilities ......................................................................................66

15. DATA COLLECTION .................................... .........................................................................67

16. QUALITY ASSURANCE - MONITORING ..................... .........................................................67 16.1 Monitoring................................................................................................................................67 16.2 Central review..........................................................................................................................68

16.2.1 Central radiological review ...................................................................................................................... 68



16.2.2 Central histology review .......................................................................................................................... 68

17. DATA OWNERSHIP / PUBLICATION POLICY ................ .....................................................68

REFERENCES................................................................................................................................70

APPENDIX A: LANSKY SCALE........................... ..........................................................................76

APPENDIX B: PERIPHERAL STEM CELL COLLECTION........ .....................................................77

APPENDIX C: IMAGING PROCEDURES..................... ..................................................................78

APPENDIX D: BUSILVEX (IV BUSULFAN) SAMPLING SHEET ...................... ..........................81

APPENDIX E : CYCLOPHOSPHAMIDE PHARMACOKINETICS SAMP LING SHEET ..................83

APPENDIX F: CLASSIFICATION CTC-AE (VERSION 4.0).... ........................................................85

APPENDIX G: TOXICITY AFTER HIGH DOSE CHEMOTHERAPY ( BEARMAN GRADING) ........86

APPENDIX H: STATISTICAL MODEL, SPECIFIC RULES AND O PERATING CHARACTERISTICS OF PHASE I DESIGN.................. .................................................................87



List of abbreviations ALAT: Alanine Amino Transferase

ANSM: French competent authority (Agence nationale de sécurité du medicament et des produits de santé)

ASAT: Aspartate Amino Transferase

ASCT: Autologous Stem Cell Transplantation

AT/RT: Atypical Teratoid/Rhabdoid Tumour

CCE: Carboplatin – Cyclophosphamide - Etoposide

CNS : Central Nervous System

CPP: French ethic committee (Comité de Protection des Personnes)

CR: Complete Response

CRA: Clinical Research Assistant

CRF: Case Report Form

CSF: Cerebrospinal Fluid

CSI: Craniospinal Irradiation

CT: Computed Tomography

CTV: Clinical Target Volume

DLT: Dose Limiting Toxicity

DRR’s: Digitally Reconstructed Radiographs

EFS: Event Free Survival

G-CSF: Granulocyte Colony-Stimulating Factor

GTV: Gross Tumour Volume

HDCT: High-Dose ChemoTherapy

HDM: High-Dose Melphalan

IGR: Institut Gustave Roussy

ITT: Intent-to-Treat

MB: Medulloblastoma

MRI: Magnetic Resonance Image

MTD: Maximum Tolerated Dose

NCI-CTCAE V4: NCI Common Terminology Criteria for Adverse Events version 4.0

OS: Overall Survival

PBSC: Peripheral Blood Stem Cells

PD: Progressive Disease

PF: Posterior Fossa



PFS: Progression-Free Survival

PNET: Primitive NeuroEctodermal Tumours

PR: Partial Response

PTV: Planning Target Volume

SAE: Serious Adverse Event

SD: Stable Disease

TMA: Tissue Micro-Array

VOD: Hepatic Veno occlusive Disease



1. INTRODUCTION AND RATIONAL OF THE STUDY

1.1 Information on the disease

1.1.1 Medulloblastoma

Medulloblastoma (MB) is one of the most common malignant brain tumours during

childhood accounting for a 5-year overall survival at 70% to 80% for standard-risk

patients, and a 5-year survival of 55% to 76% for high-risk patients [1].

MB and other central nervous system (CNS) embryonic tumours are usually classified

according to their location within the CNS, and their histological features. The WHO

classification [2] identifies 5 histological variants: (a) the classical variant MB, in which

the cells occasionally display features of neuroblastic differentiation; (b) desmoplastic

MB, in which tumour cells commonly show neurocytic differentiation, and are

surrounded by a collagen-rich extracellular matrix; (c) large-cell / anaplastic MB,

associated with poor prognosis and short survival; and finally (d) the melanotic and (e)

medullomyoblastoma variants, which are less common [1].

1.1.2 Biology of medulloblastoma

Medulloblastoma (MB) is a heterogeneous disease at the molecular level and no

diagnostic cytogenetic or molecular abnormality has been identified. Nonetheless, a

series of major non-random molecular genetic abnormalities have been identified in

the human disease, which (i) have furthered our understanding of the molecular

mechanisms underlying its pathogenesis and (ii) offer significant potential for improved

treatment stratification and/or the identification of novel therapeutic targets. In

particular, a number of consistent chromosomal abnormalities have been identified, as

well as critical oncogenes and tumour suppressor genes, and an involvement for

specific molecular pathways.

Genomic abnormalities

Numerous studies have been performed on medulloblastoma though they often

involved only limited retrospective series. The two most frequently recurring

abnormalities are the loss of the short arm of chromosome 17 and the amplification of

the MYC (C, N and L-myc oncogenes).

The loss of the short arm of chromosome 17 is the most frequently described genetic

abnormality in MB, and may occur in up to 40 - 50% of the tumours investigated [3].

Although a limited number of studies have reported a significantly worse prognosis in



the case of tumours with loss of 17p [4, 5], this has not been confirmed by all

investigators [6, 7]. However, these studies only enrolled a small number of patients or

used different techniques with heterogeneous levels of sensitivity to detect losses of

the 17p allele, therefore definitive conclusions are difficult to interpret.

A literature search suggests that approximately 6% of MB present an amplification of

the MYC oncogenes. Several studies have reported that these oncogenes are

predictors of a poor prognosis [8-10].

Sonic Hedgehog (SHH) Signalling

Aberrant SHH pathway activation by genetic mutation occurs in at least 15% of MB,

based on estimated from genetic data, and arises through mutations affecting multiple

alternative pathway components. In addition to PTCH1 mutations (〜 10% of cases),

SMO activating mutations have been reported in 〜 5% of cases. SUFU mutations

have also been described, although their incidence and involvement are likely to be

lower than initially reported (0-10% of cases) [11, 12]. Aberrant SHH pathway

activation appears to be associated with the development of the nodular/desmoplastic

MB histological sub-type. Similarly, PTCH mutations, deletion of chromosome 9q

elements, and SHH-associated gene expression profiles occur preferentially and in a

significant proportion (30-40%) of sporadic nodular / desmoplastic MB [12, 13].

However, the relationship between SHH defects and nodular/desmoplastic MB is not

absolute and up of 50% of SHH subgroup MBs are not nodular/desmoplastic [14].

Abnormalities of the Wnt/APC/betacatenin pathway

Cases of MB have been observed in patients with a personal or familial anamnesis of

familial polyposis of the colon, involving a hereditary mutation of the APC gene [15].

The incidence of abnormalities of this gene in sporadic forms of MB is under

investigation [16]. Wnt MBs can occur at all ages, but are uncommon in infants [14].

Investigation of this signal transduction pathway should be a priority as it was recently

shown that nuclear accumulation of β-catenin in MB tumour specimens was associated

with a favourable outcome [17]. There are metastatic cases with abnormalities of the

betacatenin route with an apparently better prognosis.



Molecular subgroups of medulloblastoma: the current consensus.

On the basis of the published literature and some unpublished data presented at a

recent consensus conference, four molecular subgroups were identified in childhood

MB [14] : Wnt, SHH, group 3 and group 4. The Wnt and SHH were named for the

signalling pathways thought to play prominent roles in the pathogenesis of that

subgroup. Group 3 tumours are mostly « classic » MB and are found in infants and

children. Group 3 tumours have high incidence of large/anaplastic MB and, are very

frequently metastatic. The molecular Group 4 tumours are not currently clear. While

SHH subgroup tumours have high levels of amplification of MYCN, and Wnt subgroup

and Group 3 have high levels MYC expression, whereas Group 4 tumours have

relatively low expression of both MYC and MYCN, apart from the few cases that have

MYCN amplification.

1.1.3 Stratification of medulloblastoma

Based on the clinical, histopathologic and molecular criteria, patients affected by MB

may be categorized as high-risk, standard-risk and low-risk patients. The clinical

criteria followed are: extent of tumour resection and Chang metastasis staging groups

[18]. Low-risk patients are those with β-catenin-nucleopositive tumours without

metastatic disease and undergoing complete or near complete tumour resection

(largest diameter <1.5 cm2 of residual tumour on postoperative magnetic resonance

image (MRI)). High-risk medulloblastomas are defined as metastatic disease,

uncompleted resected disease, large-cell / anaplastic phenotype or MYC amplification.

Patients not fulfilling these criteria are considered standard-risk.

The 5-year survival rate of high risk MB is less than 55% [19, 20]. So far, the clinical

staging has helped to design treatment and predict prognosis.

1.2 Information on treatments in medulloblastoma

Treatment of very young children (< 3 years of age) with MB and sPNET is particularly

challenging because of the aggressive nature of these tumours and the potential long-

term sequelae related to treatment [21]. Disease-free survival for those brain tumours

in children younger than 4 years old is associated with a survival rate of less than 20%

[22]. Furthermore, late effects of therapy, in particular radiation therapy, on cognitive

function have been substantial among children treated for brain tumours at a young

age [23, 24]. Previous trials found potential for delaying and, in some cases, avoiding



radiation therapy in treatment of young children with malignant brain tumours. The

possibility to cure MB without craniospinal radiotherapy was suggested in a pilot study

published in 1997 [25] and secondly in two large US prospective trials [26, 27] where

selected patients were cured by chemotherapy without any craniospinal radiotherapy.

In the BBSFOP protocol, the 5-year progression-free survival (PFS) and overall

survival (OS) in children who had no post-operative radiological residual disease and

no metastases was 29% and 73% respectively, and most of these children did not

receive any craniospinal radiation [28]. These findings are consistent with those of

others studies [29, 30] also including patients less than 3 years old cured without any

radiotherapy. The OS rates in localised disease could reach those observed in older

children despite omission or reduction radiotherapy and allowed us to treat them

upfront with chemotherapy alone. Metastatic disease in this age group is also a

challenging situation with a low rate of survival. In BBSFOP protocol, the 5-year PFS

and OS was 13% and 13%, respectively, in children with metastatic disease [28].

Strategies delaying the schedule of radiation therapy, usually using high dose

chemotherapies, are widely used to optimize the cure rate of these young children with

disseminated MB.

A small number of studies have evaluated the use of high-dose chemotherapy (HDCT)

with autologous stem cell transplantation (ASCT) and delayed radiation to improve

survival and minimize treatment-related sequelae. Perez et al. describe the outcome of

a small homogeneous group of children that were treated with HDCT followed by

ASCT: 7 children received HDCT with ASCT and 5/7 are alive without sequelae.

Disease-free survival was 71.4% with a median follow-up of only 21 months [31].

Mason et al. [32] evaluated HDCT with ASCT in children less than 6 years of age with

newly diagnosed malignant brain tumours (“Head start I protocol”), of whom 27 were

children with MB or sPNET. Patients received 5 cycles of induction chemotherapy

followed by consolidation chemotherapy. The 2-year OS rate was around 60%, while

event-free survival (EFS) rate from diagnosis and consolidation was reported to be 40

and 50%, respectively. The 3-year PFS was 49% [33].

In our previous study, 19 patients younger than 5 years with high-risk MB were

planned to receive two courses of carboplatin and etoposide, followed by two courses

of high-dose melphalan (HDM) and one course of high-dose busulfan-thiotepa

combination. The last three courses were followed by rescue by ASCT. Irradiation

limited to the posterior fossa was then performed. Six of the nineteen children treated



according to this protocol are presently alive in first remission with a median follow-up

of 9 years. However, the visceral toxicity of the third course was severe and

inacceptable with 3 toxic deaths related to multiorgan failure and 11/18 (61%) cases of

hepatic veno-occlusive disease [34]. The high visceral toxicity observed led to modify

the treatment schedule. To reduce the alkylating agents’ toxicity, we introduced

between each high-dose melphalan course, a course of cisplatin and we omitted

Busulfan. Then, the treatment schedule (PNET HR) included, in absence of disease

progression after two courses of carboplatin and etoposide, five sequential

conventional and HDC followed by ASCT, i.e. melphalan, cisplatin twice each and

thiotepa. In case of persisting residual tumour, surgical excision was performed if

possible. Treatment was then completed by age-adapted craniospinal irradiation, and

not restricted to posterior fossa as in the previous protocol. The preliminary results

were encouraging. At last-update, 39 patients were evaluable. Among the 24 children

who completed procedure, 14 were in complete remission at the end of chemotherapy

and 12 were still alive without disease with a median follow-up of 30 months. The 3-

year EFS and OS were 48% and 52%, respectively [35]. This study suggests that pre-

HDCT tumour status is important for outcome: the 3-year OS was 59% in patients who

achieved partial or complete response after the induction chemotherapy. Similarly, the

3-year EFS of patients who were in complete response at the end of intensive

chemotherapy was 90%. These findings are consistent with others studies [33, 36].

These results demonstrated that children with disseminated medulloblastoma could be

also treated with HDCT avoiding radiotherapy if complete response is achieved before

radiation therapy. For patients who do not achieve a partial response initially, VP16-

Carboplatin, HDCT with ASCT may not be adequate and additional, possibly targeted,

therapies should be considered. In this study, sequential high-dose chemotherapy will

be used to treat children with high-risk medulloblastoma without radiotherapy in case

of CR.

1.2.1 Induction chemotherapy

Carboplatin alone has been proven to be effective in this tumour type [37]. Etoposide is

often used in combination with other anticancer drugs, and more particularly in

tumours of neuroectodermal origin. A phase II study evaluated the antitumor activity of

the Carboplatin - Etoposide combination in 26 children with high-risk medulloblastoma.

The response rate after two courses was 72 +/- 10% with an acceptable safety [38]. In



our previous study, PNET HR regimen, the response rate of Etoposide-Carboplatin

was 54% [35].

1.2.2 Intensification chemotherapy

Alkylating agents appear to be the most appropriate class of drugs for use in a high-

dose setting since they are the most active drugs against CNS tumours along with

platinum derivatives. A step linear-log relationship characterizes them. Thiotepa and its

major metabolite, TEPA, reach the CSF at concentrations approximately equivalent to

their plasma concentrations [39]. They display in vitro activity against MB with a steep

dose-response curve [40].

Fagioli et al. reported a 3-year PFS of 31% in a cohort of 12 patients treated with

HDCT consisting of thiotepa and etoposide [41]. Chi et al. reported 3-years PFS of

49% for 21 patients with newly HR MB treated with HDCT (carboplatin, thiotepa,

etoposide) [33]. More recently, Thorarinsdottir et al. [42] evaluated HDCT with ASCT in

children less than 4 years with malignant central nervous system tumours, 9 of whom

were children with MB or sPNET. Patients received 3 cycles of induction

chemotherapy with vincristine, etoposide, cisplatin and cyclophosphamide, 3 weeks

apart, followed by 3 cycles of HDCT of thiotepa – carboplatin combination with ASCT.

The 2-year EFS was 52.2%.

Sung et al. [36] described 25 children with newly diagnosed HR or relapsed

MB/sPNET. After induction chemotherapy, children received tandem double HDCT

with cyclophosphamide and melphalan for the first HDCT and carboplatin, etoposide

and thiotepa for the second. The 3-year EFS in patients initially intended to receive

double HDCT and single HDCT was 66% and 40%, respectively. For patients in CR or

PR at first HDCT, 3-year EFS was 88.9% in tandem double HDCT group, and 44.4% in

single group, respectively (p = 0.037). These findings suggest that increased dose

intensity without significant toxicity in second HDCT may have contributed to the

improved survival in tandem double HDCT group.

An investigative pilot study was carried out at the Gustave Roussy Institute between

September 1996 and October 2005, in order to treat children aged over 5 years with

high-risk medulloblastoma or supratentorial PNET. The protocol included 2 courses of

conventional chemotherapy combining etoposide (500mg/m²) and carboplatin

(800mg/m²) followed by double dose-intensive chemotherapy (melphalan 100 mg/m²

or thiotepa 600 mg/m²) with stem cell rescue. If a tumour residue persisted at the end



of this chemotherapy, the tumour was resected whenever possible. Craniospinal

irradiation was scheduled 45 days after the second intensification: 55 Gy to the primary

site, 30 Gy supratentorially and 36 Gy to the cord axis. A total of 26 children were

enrolled in this trial, including 19 metastatic medulloblastomas and 7 supratentorial

PNET. The median age at diagnosis was 8 years (5 – 14.4 years). Seventeen of these

21 children received melphalan and 9, thiotepa. The 3-year EFS after Melphalan

regimen and Thiotepa were 36.5% and 66.7%, respectively (p =0.01) [34].

In view of these results, we prefer to use high-dose thiotepa chemotherapy.

1.2.3 Consolidation chemotherapy

Cyclophosphamide

Cyclophosphamide has proven activity against many childhood solid tumours and

malignant tumours. High-dose cyclophosphamide has been demonstrated to be

effective in newly diagnosed MB [43]. Gajjar et al. recently showed a new approach:

patients with high-risk MB underwent craniospinal radiotherapy (36 Gy to 39.6 Gy)

with a three-dimensional conformal boost to the tumour bed( total 55.8 Gy) followed by

4 courses of high-dose cyclophosphamide with stem-cell rescue support to overcome

haematological toxic effect after radiotherapy [44]. They reported 5-year EFS of 83%

for the average risk patients and 70% for the HR patients. These results seem to be

excellent looking at the EFS compared with most published trials.

Busulfan

Busulfan crosses the blood-brain barrier with a CSF to plasma ratio of 1.39 when

administered at a dose of 600 mg/m2; and its tumour activity against MB xenografts has

been demonstrated in athymic nude mice [45]. The busulfan-thiotepa combination

efficiently induced a 75% response rate and cured patients with a local relapse without

additional craniospinal irradiation [46]. Ridola et al. [47] reported the outcome of 39

young children with local MB recurrence or progression after conventional

chemotherapy treated by HDCT with busulfan-thiotepa combination followed by local

irradiation. The 5-year EFS was 68.8%. Acute toxicity was manageable, and

characterised mainly by a significant percentage of hepatic veno-occlusive (VOD)

disease in 33% patients. None of the children died of liver toxicity. The liver toxicity is

reportedly caused mainly by busulfan but can be modified by the accompanying drug

[48].



Chemotherapy combining busulfan and cyclophosphamide was identified as a major

VOD risk factor. Pharmacological studies have demonstrated a correlation between

busulfan exposure and the incidence of VOD following the busulfan-cyclophosphamide

combination [49]. Sageghi et al. [50] studied the effect of administration order of

busulfan and cyclophosphamide as a conditioning regimen for hematopoietic stem cell

transplantation in a mouse model. They showed that inverting the order of busulfan-

cyclophosphamide to cyclophosphamide-busulfan not only decreased conditioning-

related toxicity significantly, but also allowed the same level of donor hematopoietic

stem cell engraftment. A clinical trial using cyclophosphamide-busulfan as a

myeloablative conditioning regimen for HSCT was performed and the results were

compared with those of a historical control of patients with a conventional busulfan-

cyclophosphamide conditioning regimen. Significantly less hepatic toxicity was

observed in patients treated with cyclophosphamide-busulfan, and neutrophil recovery

did not differ from that in patients treated with busulfan-cyclophosphamide [51].

Cacchione et al. demonstrated that etoposide-carcoplatin combination administered

before HDCT can be a significant risk factor for the subsequent development of VOD

[52].

According to these data, we considered it is justified to use the cyclophosphamide -

busilvex combination. Due to potential toxicity of this combination after chemotherapy

containing alkylating agent, we plan a phase I study in order to determine the

Maximum Tolerated Dose (MTD) of cyclophosphamide in combination with a fixed

dose of busilvex. It is likely that the rate and the severity of VOD could be decreased

by refinement of the use of intravenous busulfan form (Busilvex) [53] and the

prophylactic use of defibrotide [54].

1.2.4 Salvage treatment

Temozolomide (TEMODAL®)

Temozolomide (TEMODAL®) has an excellent bioavailability after oral administration

with satisfactory CNS concentrations. Several paediatric trials have led to the

conclusion that temozolomide was an active drug in refractory or relapsing

medulloblastoma. First, two phase I trials [55, 56] showed efficacy in

medulloblastoma/PNET and allowed determination of the maximum tolerated dose of

Temozolomide in children (1000mg/m²/cycle). An Italian Phase II multicentre study



showed that this molecule was effective in medulloblastoma relapses [57]. In this

study, Temozolomide was administered for 5 consecutive days, every 28 days with

dosages adjusted according to prior treatment. Treatment was continued until tumour

progression or for a maximum of 36 cycles. A total of 34 patients with metastatic MB

(32) or PNET (2) were enrolled in this study. The observed responses were 6 CR, 7 PR

and 3 minor effects, resulting in an overall 47% response rate with an acceptable

toxicity. The 6-month PFS was 67% for responding patients. Elsewhere, Nicholson and

al. reported a phase II study of temozolomide (150mg/m²/day for 5 days every 4 weeks

in children and adolescents with recurrent central nervous system tumours: 3 PR and 1

CR were observed in the medulloblastoma/primitive neuroectodermal tumour (PNET)

cohort [58]. Wang et al. reported their experience with 8 children, including four with

medulloblastoma (MB), three with atypical teratoid/rhabdoid tumour (AT/RT) and one

with supratentorial primitive neuroectodermal tumour, whose tumours recurred after

surgery and radiotherapy [59]. They all received daily oral temozolomide (150

mg/m2/day) once for five consecutive days in a 28-day cycle. The median PFS of the

eight patients was 15.7 months (range from 0 to 59 months). Complete response was

achieved in one patient with MB associated with a long lasting PFS of 26 months.

These data support the use of temozolomide for the salvage treatment of children with

refractory medulloblastoma.

Irinotecan (Hycantin®)

Irinotecan (Hycantin®) is an inhibitor of topoisomerase I and has demonstrated safety

and efficacy as a single agent in paediatric solid and CNS tumours with various

schedules. Importantly, the studies provided indications that protracted administration

such as daily x 5 for 2 weeks every 3-4 weeks/cycle could be administered safely and

were feasible.

According to Turner et al., 2 of 3 patients with medulloblastoma/primitive

neuroectodermal tumour had stable disease for 9 and 13 months. Toxicity was mainly

myelosuppression, with 12 out of 22 patients (50%) suffering from grade II-IV

neutropenia [60].

From these data and from preliminary data concerning efficacy in phase I studies,

irinotecan as a single agent can be considered as an active agent in recurrent

medulloblastoma.



Temozolomide (Temodal®)-Irinotecan (Hycantin®) co mbination

The combination of temozolomide with irinotecan has been well evaluated in children.

Wagner and colleagues investigated the combination of protracted irinotecan and

temozolomide in a phase I study of paediatric patients with refractory solid tumours

using a 28-day cycle [61]. Twelve heavily pre-treated patients received 56 cycles of

oral temozolomide at 100 mg/m2/d for 5 consecutive days combined with intravenous

irinotecan given daily for 5 consecutive days for two consecutive weeks at either 10

mg/m2/d or 15 mg/m2/day. Two patients experienced DLT (Dose Limiting Toxicity) at the

15 mg/m2/d dose level (grade 4 diarrhoea and bacteraemia with grade 2 neutropenia),

while no DLT was experienced at the 10 mg/m2/d dose level. No pharmacokinetic

interaction was observed. One CR, 2 PR, and one minor response were observed in

patients with Ewing sarcoma and neuroblastoma. The MTD with this schedule for oral

temozolomide and intravenous irinotecan were 100 mg/m2/d and 10 mg/m2/day,

respectively [61]. Elsewhere, based on their previous phase I study, Wagner et al.

reported on the combination of temozolomide and irinotecan in 16 patients with

advanced Ewing sarcoma [62]. The patients received oral temozolomide 100 mg/m2/d

on 5 consecutive days plus intravenous irinotecan 10–20 mg/m2/d on 5 consecutive

days for 2 consecutive weeks with cycles repeated every 3 to 4 weeks. Sixteen

patients received a total of 95 cycles with a median of 5 cycles per patient. One CR, 3

PR and 3 minor responses were obtained. The median duration of response was 30

weeks. The 21-day cycles were tolerable and no more toxic that the 28-day cycles.

Myelosuppression was minimal, even in previously heavily treated patients. Grade 3-4

diarrhoea occurred in 11% of the cycles and was related to the higher (20 mg/m2/day)

irinotecan dose [62].

Recently, Wagner et al. reported a phase I study of oral irinotecan combined with

temozolomide in children with recurrent/resistant high-risk neuroblastoma [63]. Patients

received oral temozolomide on days 1 through 5 combined with oral irinotecan on days

1 through 5 and 8 through 12 in 3-week courses. Significantly, daily oral cefixime was

used to reduce irinotecan-associated diarrhoea. The dosages recommended for further

study in this patient population are temozolomide 75 mg/m2/d plus irinotecan 60

mg/m2/d when administered with cefixime. First-course grade 3 diarrhoea was dose-

limiting in one out of six patients treated at the irinotecan MTD of 60 mg/m2/d. Other

toxicities were mild and reversible [63].

Thus, paediatric data are consistent with a good tolerance of the combination as well



as a promising activity in relapsing paediatric tumours.

Most importantly, the ITCC recently conducted a phase II study investigating the role of

the temozolomide-irinotecan combination in refractory or relapsing medulloblastoma.

Temozolomide is given at a dose of 100 mg/m2/day on days 1-5 (the dose was

increased to 125 mg/m2/day in cycle 2 if the patient did not experience ≥ grade 3

toxicity of any kind) and Irinotecan 10 mg/m2/day on days 1-5 and days 8-12 every

three weeks. Grill et al. have reported intermediate analysis on 40 patients (Grill,

ASCO, 2009). 19 patients were available for response assessment through a central

review and 7 patients had confirmed PR, 4 patients had SD and 8 patients had PD.

The irinotecan-temozolomide combination has promising activity in heavily pre-treated

patients with relapsed/refractory medulloblastoma and at the same time it is well

tolerated in patients with recurrent or refractory childhood medulloblastoma,

haematological toxicity was the main toxicity primarily in patients with prior cranio-

spinal irradiation.

Etoposide

Etoposide (Celltop®) is an inhibitor of topoisomerase II. Daily low dose etoposide

treatment is a known effective palliative approach for patients with refractory

medulloblastoma in whom chronic oral etoposide could induce response and stable

disease lasting over 6 months in more than 60% of the patients [64, 65]. Recently,

continuous low dose daily etoposide (25 mg/m² D1-D21) has been shown to be quite

effective in refractory medulloblastoma when used along with ablative carboplatin and

thiotepa with stem cell rescue. Indeed, none of the survivors required additional

salvage irradiation [66].

A phase I/II pilot study used oral etoposide given concurrently with radiotherapy

followed by dose-intensive adjuvant chemotherapy in children with HR MB [67]. During

craniospinal radiation, patient received daily oral etoposide 21 out of 28 days. 47

patients were included in this study. The dose level was reduced to 35 mg/m2/day due

to the toxicity, and 34 patients were treated in this way. The most common adverse

event was gastrointestinal toxicity. The proportion of objective response (CR+PR)

postchemoradiotherapy was 88% [67].



According to these data, we propose to use oral etoposide concurrently with

craniospinal irradiation followed by 6 cycles of temozolomide for patients who do not

achieve response to chemotherapy.

Radiotherapy

The neurocognitive sequelae associated with radiotherapy in younger patients have

prevented oncologists from using irradiation in children younger than 3 years of age

until recently. However, for some of children with recurrent CNS Brain tumours without

upfront radiotherapy (majority of medulloblastoma) encouraging results of long-term

survival were reported after salvage regimen including irradiation either before or

immediately after HDCT [68-70]. In the St Jude’s study, 7 children younger than 3

years of age had a significantly better PFS (57%) than 20 children older than 3 years

of age. Of these 7 younger children, the 4 long-term survivors underwent irradiation as

part of salvage therapy with HDCT. Conventional craniospinal irradiation (CSI) is

responsible for the deleterious effect on the developing brain of very young children.

Nevertheless the efficacy of radiotherapy with reduced - dose and reduced - volume

led to propose an adapted-risk radiotherapy for refractory or recurrence high-risk MB of

younger children taking into account the age, the initial disease status and the nature

of recurrence. Goldwein et al. reported in 10 children younger than 5 years of age with

non-metastatic MB an actuarial survival rate at 6 years of 70% with sustained

Intellectual quotient scores in the normal range using a treatment with chemotherapy

and 18 Gy CSI [71]. Dufour et al. reported a pilot study using 5 sequential courses of

HDCT followed by age-adapted CSI with doses from 18 to 35 Gy and the OS rate of 34

patients younger than 5 years was 50% at 30 months [35].

2. STUDY OBJECTIVES

Primary objective

Phase II part: To assess efficacy in terms of Event Free Survival (EFS) of the strategy

intended to treat children younger than 5 years of age with high-risk medulloblastoma

with sequential high-dose chemotherapy without radiotherapy.

Phase I part: To determine the Maximum Tolerated Dose (MTD) of cyclophosphamide

in combination with a fixed dose of busilvex in children with high-risk medulloblastoma

who are in complete response after the intensification phase



Secondary objectives

- To assess feasibility and efficacy of a strategy without radiotherapy by estimating the rate of patients alive free of disease without having received radiation therapy.

- To assess efficacy of this strategy in terms of Overall Survival (OS).

- To evaluate the effectiveness of the different treatment phases:

o Evaluation of the initial conventional chemotherapy based on the proportion of patients in complete or partial radiological response after the second induction VP16-Carboplatin course.

o Evaluation of induction and intensification chemotherapy based on the proportion of patients achieving a complete response after the second course of thiotepa

- To characterize the pharmacokinetics of cyclophosphamide – busilvex combination (Phase I)

- To assess the efficacy, feasibility and tolerance of salvage treatment

- To evaluate the acute toxicity of this therapeutic strategy, overall and per treatment phase (induction / intensification / consolidation/salvage treatment).

- To evaluate the prognostic value of some immunohistochemical markers on the risk of relapse or progression

- To evaluate neurocognitive development of patients within 10 years after the end of treatment.

3. STUDY DESIGN

The study is a multicentre, non-randomised, phase I/II trial using a Bayesian design.

The evaluation of the efficacy of the whole treatment strategy is designed as an open

label, non-randomised, multicentre trial without control group Phase II trial, with a

Bayesian analysis. No interim analysis is planned.

A Phase I dose-finding study is planned to identify the Maximum Tolerated Dose

(MTD) of cyclophosphamide in combination with a fixed dose of busilvex in children

who are in complete response after the intensification phase, using a Bayesian

Continual Reassessment Method (CRM).

Study centres

Patients will be accepted for registration into the trial from any SFCE centre

authorized. Due to toxicity, patients will undergo the intensification and consolidation

phases in only 7 centres:

- CHU de la Timone (Marseille)

- CHU Toulouse, Hopital d’enfants (Toulouse)



- CHR Brabois (Nancy)

- IHOP (Lyon)

- Centre Oscar Lambret (Lille)

- Institut Curie (Paris)

- Institut Gustave Roussy (Villejuif)

Study period

The planned duration of the enrolment is 5 years. The planned duration of the study

(i.e. equal to the enrolment period with the treatment period plus the follow-up for the

main efficacy analysis) is 9 years.

4. SELECTION OF PATIENTS

4.1 Inclusion criteria for the study

1) Histological diagnostic of medulloblastoma with no INI-1 loss

2) High-risk medulloblastoma defined by at least one of the following conditions:

- Newly diagnosed metastatic classical medulloblastoma defined by the presence of metastasis and/or positive cerebrospinal fluid cytology

- Newly diagnosed medulloblastoma with amplification of MYC oncogenes whatever the risk criteria (localized or metastatic, complete or incomplete resection)

- Newly anaplastic and/or large cell medulloblastoma irrespective of the other risk criteria (localised or metastatic, complete or incomplete resection).

3) Age on enrolment in study entry less than 5 years

4) Weight > 8 kgs

5) Ability to comply with requirements for submission of materials for central review

6) Nutritional and general status compatible with this therapy, Lansky play score > 30% (appendix A)

7) Estimated life expectancy > 3 month

8) No organ toxicity other than alopecia and neurological symptoms due to disease (Grade > 2 according to NCI-CTC grading system, version 4.0)

9) No prior irradiation or chemotherapy (except VP16 – CBP)

10) Written informed consent from parents or legal guardian.



4.2 Non-inclusion criteria

1) Desmoplastic medulloblastoma

2) AT/RT

3) Uncontrolled active or symptomatic intracranial hypertension before chemotherapy treatment

4) Patients incapable of undergoing medical follow-up for geographical, social or mental reasons

5) Relapse of medulloblastoma

4.3 Inclusion criteria for the Phase I part of the study

1) Complete response after the intensification phase confirmed by central review

2) Adequate hepatic function:

- Serum bilirubin < 2.5 x ULN for age

- ASAT and ALAT < 2.5 x ULN

3) Adequate renal function:

- Creatinine < 1.5 x ULN for age; If serum creatinine is > 1.5 ULN of age,

then creatinine clearance (or radioisotope GFR) must be >

70 ml/min/1.73 m2

5. PATIENT REGISTRATION

Study entry: The registration will be performed after initial biopsy and/or surgery for

patients before start of study treatment. After signing the consent form and verifying

the eligibility criteria, eligible patients will be enrolled in the trial by faxing the

completed enrolment form (F1a) to the trial data manager at the Department of

Biostatistics and Epidemiology at the Gustave Roussy Institute. Patients may be

registered from 9 am to 5 pm, Monday to Friday, except on bank holidays. If there are

any problems, the data manager responsible for the trial or the data manager on call

may be contacted by telephone at: 01 42 11 49 00 (beeper).

After checking the study eligibility criteria, the data manager will send by fax to the

investigator the confirmation of patient enrolment with the patient study number. This

number must be used in all subsequent correspondence.

Treatment must begin within 30 days of registration in the trial.

Entry in the Phase I part: The patients in complete response confirmed by radiological

central review after the intensification course will be included in the dose-finding part of



the trial. The dose of cyclophosphamide to be allocated will be determined on the basis

of all the information currently available. The completed F1b form is to be sent to the

trial data manager.

6. TREATMENTS

The treatment plan consists of the following phases:

Before registration in the study:

- Surgical biopsy and/or resection

After registration, the initial planned treatment includes three phases:

- Induction

- Intensification

- Consolidation

For the patients requiring salvage treatment, the planned treatment includes also three phases:

- Second line induction

- Chemo-radiotherapy

- Maintenance

The different phases are followed by assessment of the tumour response, resectability

and remission status.



6.1 Surgery

6.1.1 Initial surgery for patients treated at diagn osis

The purpose of the initial surgical treatment is to treat intracranial hypertension when

this exists (using the method that the surgeon considers appropriate to the child's

clinical condition and status) and to conduct a more or less complete resection of the

tumour. The first goal of this resection is to allow histological diagnosis but also to

decompress the brainstem where necessary. At this stage of treatment, tumour

resection must not involve any excessive functional or vital risk to the child, or cause

complications that may delay or compromise the start of chemotherapy since the

priority is systemic treatment in a metastatic or high-risk disease. If a secondary lesion

is more easily accessible than the primary tumour, open sky or endoscopic biopsy of

this secondary lesion is a sufficient diagnostic criterion provided that all the

histopathologic and molecular studies may be carried out on these specimens. Early

postoperative MRI (before 72h) evaluates the existence and size of a local residue or,

where impossible, CT-scan immediately after surgery (< 48h) before and after contrast

agent injection, compared to the preoperative brain MRI imaging.



6.1.2 Secondary surgery

If a residue remains at the level of the primary tumour, complementary surgical

excision should be proposed whenever possible according to the radiological data and

the patient’s status. This intervention must be performed either after the induction or

after intensification phase, as soon as a normal platelet count is restored (platelets >

75,000 Giga/L with spontaneous rising platelet count).

6.2 Induction phase

Induction consisting of 2 courses of Etoposide-Carboplatin should start as rapidly as

possible after histological diagnosis. The second course should start on day 21 of the

previous course or thereafter when peripheral counts recover with an absolute

granulocyte ≥ 800/mm3 and platelet count ≥ 100 000/ mm3 during hematologic

reparation phase and within day 28. The second course should start at least 48 hours

after discontinuation of G-CSF.

Leukapheresis: Peripheral stem cells should be collected by leukapheresis during

neutropenia resolution after the second course of chemotherapy. At least 9 x106 CD34

cells/kg should be collected. The procedures for collecting peripheral blood stem cells

are described in appendix B.

6.2.1 Drug administration

Day 1 Day 2 Day 3 Day 4 Day 5

carboplatin 160 mg/m2 • • • • •

etoposide 100 mg/m2 • • • • •

Carboplatin 160 mg/m 2 Day 1 to day 5

as an intravenous infusion over 1 hour

Dilution in 5 % glucose saline or sodium

chloride 9 mg/ml (0.9%)

Etoposide 100 mg/m 2 Day 1 to day 5

as an intravenous infusion over 1 hour

Dilution in physiological saline or 5 % glucose

saline while not exceeding a concentration of



0.4 mg/ml etoposide in the infusion bottle.

6.2.2 Patient monitoring

A complete differential blood count will be carried out twice weekly from D7 of each

course and more often, if necessary, until haematological recovery.

6.2.3 Concomitant therapies

Antiemetic treatment with Setron should be systematically prescribed before the start

of chemotherapy and must be continued for 5 days.

To collect peripheral stem cells, treatment by G-CSF growth factor will be instituted on

day 9, at a dosage of 5 micrograms/kg/day, by the subcutaneous route. It should be

continued until collection of peripheral blood stem cells. If hospitalisation for febrile

neutropenia or other problem, GCSF can be administered intravenously

In the case of febrile neutropenia, patients must be hospitalised in the investigator’s

unit or in a nearby the patient’s home strictly controlled by the investigator.

6.3 Intensification phase

If partial or complete response confirmed by central radiological review is achieved

after conventional chemotherapy, the high-dose chemotherapy will be administered.

The time between courses shall be as short as possible when peripheral counts

recover with an absolute granulocyte ≥ 800/mm3, platelet count ≥ 75 000/ mm3 and

acquired platelet transfusion independence.

If the disease is stable or if progression occurs after the induction chemotherapy, the

patient should proceed to salvage treatment (cf. paragraph 6.5).


Day - 3 Day - 2 Day – 1 Day 0 thiotepa 200mg/m2 • • •

autologous stem cell rescue

(≥3 x 106 CD34/kg) •

Thiotepa 200 mg/m² Day-3 to day-1

As an intravenously infusion over 1 hour



dilution in 200 ml/m² of 5% glucose saline or sodium


Autologous stem cells will be infused intravenously 24 hours after the last

infusion of thiotepa on D0, not more than 60 to 90 minutes after thawing.

Hydration: start at the beginning of chemotherapy at a rate of 3 L/m2/day and

continue until the transfusion of autologous peripheral blood stem cell.

6.3.2. Dose adaptation

No dose adjustment is planned during the intensification phase.


Monitoring during the intensive chemotherapy phase is performed according to the

usual institutional practices.


Antiemetics chosen according to the normal procedures at each centre should be

administered 30 minutes before infusion of Thiotepa and repeated systematically.

G-CSF growth factors will be instituted on D5 after ASCT, at a dosage of 5

microgram/kg/day by the IV route and continued until the neutrophil count is greater

than 500 /mm3 on 2 samples collected at 24h intervals.

Care during the intensive chemotherapy phase is provided according to usual

institutional practices (bacteriological samples, antibiotic therapy, anti-CMV prevention

in CMV-positive patients, parenteral nutrition etc.).

Before the first course of high-dose chemotherapy, cryopreservation of gonads may be

proposed.

6.4 Consolidation phase: Phase I

The radiological response should be confirmed by the central review. If complete

response is achieved after the last course of high-dose thiotepa, one course of

cyclophosphamide-busilvex will be performed at day 28 of the previous course when

peripheral counts recover with an absolute granulocyte ≥ 800/mm3, platelet count ≥ 75

000/ mm3 and acquired platelet transfusion independence.

If complete response is not observed or if progression occurs after the intensification

phase, patient should proceed to salvage treatment.




D - 10 D - 9 D - 8 D - 7 D -6 D - 5 D - 4 D - 3 D - 2 D - 1 D 0

cyclophosphamide • • • •

Mesna • • • • •

Busilvex • • • •

clonazepam • • • • • •

autologous stem cell rescue

(≥3 x 106 CD34/kg) •

The dose of busilvex is fixed. The initial dose of cyclophosphamide will be equal to 20

mg/kg/ day. Four dose levels are planned.

Cyclophosphamide

Level 1 20 mg/kg/day




Busilvex

0.8 mg/kg/dose - 3.2 mg/kg/day

0.96 mg/kg/dose- 3.84 mg/kg/day



< 9 kgs

9 à < 16 kgs

16 à 23 kgs

> 23 à 34 kgs

> 34 kgs 0.64 mg/kg/dose



Cyclophosphamide will be administered as a 1-hour intravenously infusion on Day -

10 to day – 7. Cyclophosphamide should be diluted in 5% glucose saline or sodium


Hydration: start at a rate of 750 ml/m2 per 6 hours and continue until stem cell rescue.

Mesna (120% of dose of cyclophosphamide) will be started with the first infusion of

cyclophosphamide and will be continued until 24 hours after the last infusion of

cyclophosphamide

Busilvex is administered as a two-hour infusion every 6 hours over 4 consecutive

days (Day – 5 to day – 2) for a total of 16 doses, via central venous catheter.

Busilvex must be diluted prior infusion. A final concentration of approximately

05.mg/ml busulfan should be achieved.

Autologous stem cells will be infused intravenously on D0, not more than 60 to 90

minutes after thawing.

A careful record of fluid input and output should be kept during the administration of

course. If diuresis falls below 350 ml/m2 per 6 hours, furosemide should be given at 0.5

mg/kg to 1 mg/kg.


This course will be administered in a laminar flow single room. Monitoring during the

intensive chemotherapy phase is provided according to usual institutional practices.


Antiemetics chosen according to the normal procedures at each centre should be

administered before infusion of cyclophosphamide and repeated systematically.

Prophylactic therapy consisting of Clonazepam (0.1 mg/kg/day total dose) will be

administered one day prior to IV Busilvex administration and continued until 24 hours

after the last dose of IV Busilvex.

G-CSF growth factors will be instituted on D5 after ASCT, at a dosage of 5

microgram/kg/day by the IV route and continued until the neutrophil count is greater

than 500 /mm3 on 2 samples collected at 24h intervals.

Care during the intensive chemotherapy phase is provided according to usual

institutional practices (bacteriological samples, antibiotic therapy, anti-CMV prevention



in CMV-positive patients, parenteral nutrition). Prophylactic antifungal treatment with

ketaconazole, itraconazole or fluconazole should be avoided, because of the increased

risk of veno-occlusive disease in particular in association with busulfan. For proven

fungal infection, amphotericin would be used.

Defibrotide should be administered as prophylactic treatment for veno-occlusive

disease [72]. The treatment should be started on day 1 of the Cyclophosphamide-

Busilvex combination upon at day 30 after ASCT or upon discharge from inpatient

care. The dose is 25 mg/kg/day. Defibrotide is administered in 5% D-Glucose

(Dextrose) water to a maximum concentration of 20 mg per 1 ml given IV in 4 divided

doses (every 6 hours), each infused over 2 hours. The duration of infusion can be

reduced to a minimum of 30 minutes if venous access is limited.

6.5 Salvage treatment

The interval between the last course of chemotherapy and the beginning of the

salvage treatment shall be as short as possible when peripheral counts recover with an

absolute granulocyte ≥ 800/mm3, platelet count ≥ 100 000/ mm3 and acquired platelet

transfusion independence.



If progressive disease is observed during salvage treatment, patient should proceed to

phase I or II studies for recurrent and/or refractory MB.

6.5.1 Salvage treatment’s first step: TEMIRI

The induction phase will consist of 2 cycles of 21 days:

- Temozolomide 100 mg/m2/d on Days 1-5

- Irinotecan 10 mg/m2/d on Days 1-5 and Days 8-12

Temozolomide will be given orally, on an empty stomach, on Days 1-5 of repeated 3-

week cycles. Initially, irinotecan will be given intravenously over 1 hour on Days 1-5

and Days 8- 12. During Week 1 of each cycle, irinotecan will be given one hour after

the administration of temozolomide.

Haematological monitoring is required and a full blood count should be performed at

least once weekly. Hematopoietic growth factors must not be used.

6.5.2 Chemo-radiotherapy

Oral etoposide

Etoposide will be administered during the radiation treatment and should start on day

21 of the last cycle of temozolomide

The dosage is 35 mg/m2/day 21 days of 28 days. A single daily dose will be given. For

younger patients, pharmaceutical form of etoposide could be inappropriate and a

magistral prescription could be prepared in the pharmacy.

Haematological monitoring is required and a full blood count should be performed at

least once weekly. Hematopoietic growth factors must not be used.

In case of severe haematological toxicity, etoposide can be stopped, but radiation

therapy should be continued.

Radiation therapy

Radiation therapy should start on day 21 of the last course of temozolomide. In the

younger children < 3 years of age, radiation therapy should be performed under

general anaesthesia. Radiotherapy will consist of conventionally fractionated regimen

in a once daily schedule of 1.8 Gy per fraction and will deliver a total dose depending

on the age of children at the time of radiotherapy and at the maximal tolerable dose of



each anatomical site (supratentorial area, posterior fossa, spinal cord above or under

the terminal cone on spinal MRI (cf. table 1).

Whenever possible, target volume definition should be based on magnetic resonance

imaging (MRI). Image fusion (=coregistration) of the MRI scans and the planning CT

scan should be used for target volume definitions and especially posterior fossa. The

accuracy of image co-registration should remain within <0.5 cm. Post-chemotherapy or

post-operative imaging after resection is mandatory. CT-based 3-D treatment planning

using beam’-eye-view is mandatory.

CSI: craniospinal irradiation; PF: posterior fossa; M0: without metastasis; M1M2M3

with metastases; spinal cone (above or under)

The Gross Tumour Volume is defined by:

- The tumour bed in case of complete or subtotal removal includes all tissues in

contact with the tumour (it can shift and the GTV (Gross tumour volume) should take

the new position of the abnormalities on MRI scan),

Total Dose (Gy)

CSI PF Tumour Bed

Residue Metastatic site

M0 M1M2M3 Above cone

Under cone and

supratentorial

Age < 3 years

18 18 35 50 54 30 54

Age > 3 years

24 24 35 54 59.4 45 54



- The region of enhancement on postoperative CT/MRI (residue and metastatic

site).

The Clinical Target Volume is defined by a 5 mm volumetric expansion of the GTV.

The Posterior Fossa is delimited by the occipital foramen, the tentorium, the anterior

limit of brainstem and occipital bone.

The Planning Target Volume will take into account uncertainties of planning, setup and

repositioning. This margin should be based upon known departmental values but

usually be in order of 3 to 5 mm by volumetric expansion.

The tentorium and meninges should be considered as anatomical borders and limited

the PTV expansion.

Craniospinal volumes:

The Whole Brain must be included in cranial fields. Attention should be taken at the

ethmoidal level and at the craniospinal junction. The cervical spinal volume should be

included into lateral encephalic beams. The thyroid gland should be protected as much

as possible by a junction between the cord and encephala as down as possible. The

distance between the laryngeal shielding block and the second anterior vertebral body

must be at 5 mm. The inferior limit of CTV encompassing the dorsal and lumbar spinal

cord will be determined by MRI scan. It must encompass the entire medullar canal

including arachnoidal spaces and vertebral and sacral foramen (named as « bêche

sacree »).

Organs-at-risk:

All different organs-at-risk must be delineated: eyes, pituitary gland, optic chiasm, optic

nerves, lens, brainstem, inner ears, temporal, frontal lobes, hippocampic areas,

cervical cord, thyroid gland, kidneys.

Planning procedure:

The use of a Planning CT is mandatory with a maximum CT slice thickness of 3 mm in

order to obtain good quality of Digitally Reconstructed Radiographs (DRR’s) for cranial

volume and 10 mm for spinal volumes. Virtual simulation and planning with beams-

eye-views of each beam are mandatory. Planning should conform to ICRU50/62

criteria for target volume coverage, dose normalisation, homogeneity and dose

prescription and recording. Dose homogeneity requirements in the PTV shall be -5%,



+7% and the PTV should be encompassed by 95% isodose. The 90% isodose is

acceptable in close proximity to organ-at-risk. Dose-Volume- Histograms of target

volumes and organs-at-risk must be registered.

The patient will be treated in supine position for techniques such as tomotherapy and

IMRT arc therapy.

With linear accelerator and 3D conformal technique, the treatment must be delivered

with a linear accelerator with minimal photon beam energy of 4-6 MeV for cranial

beam, greater than 8 MeV for PF and tumour bed, photon beam energy of 4-6 MeV or

electron beam greater than 18 MV for spinal volume. All vertebral bodies should be

irradiated homogeneously (at least the isodose 80%). The different junctions between

cranial and spinal irradiations must be calculated and must be mobile when necessary.

All fields will be treated for each fraction. At least weekly, carries out treatment position

verification is carried out by portal imaging. Conformal radiotherapy or intensity-

modulated radiotherapy must be used to deliver boost dose to tumour bed, residue

and metastatic nodular lesion. Cobalt unit is not permitted.

Organs-at-risk must be spared in order not receive doses higher than the following:

pituitary gland 50 Gy, eyes, 45 Gy, optic chiasm 50 Gy, optic nerves 45 Gy, inner ears

45 Gy, lens 10 Gy.

Dose reporting and Quality control:

The isodose distributions will be calculated and printed for documentation in three

planes (transverse, coronal, and sagittal planes) through the isocentre. Isodose

distributions with marked PTV and CTV and isodose lines with maximal, volume 98%,

mean, median, minimal dose, volume 2%, 100%, 95%, 90%, 80%, 60%, 50%, 40%,

20% of the prescription dose should be reported for a reviewer to evaluate the

adequacy of target coverage. The following volumes should be calculated and

documented in cm3: GTV, CTV, PTV, Total volume of the brain without PTV, Volume

98% and 2% as well as HDV of target volumes and organs-at-risk. Weekly portal

imaging will be undertaken for set-up verification.

Radiotherapy control quality should be performed prior to the start of radiotherapy. The

national radiotherapy quality control panel is Dr Carrie (Centre Léon Bérard, Lyon), Dr

Padovani (CHU la Timone, Marseille) and Dr Bernier-Chastagner (CHU Nancy).

Planning documentation (treatment plan, conventional imaging or computer generated

dose distributions) should be submitted via Aquishare plateform.



6.5.3 Maintenance treatment

We also propose here to use temozolomide as a single agent for the maintenance

phase of the salvage treatment.

Maintenance treatment will be instituted as soon as the haematological criteria are

obtained, between 1 month and three months after the end of craniospinal irradiation.

Institution of this treatment after this period is ineffective. The haematological criteria

required to institute this course of maintenance treatment are:

- Leucocyte > 1500 G/L

- Absolute granulocyte > 800 G/L

- Platelets > 100 000 G/L

In cases of grade IV neutropenia or platelets bellow 50.000 G/L, the temozolomide

dosage may be reduced by 25%. Dose reduction can be performed no more than

twice.

Temozolomide will be given orally, on an empty stomach, at 150 mg/m2/d on Days 1-5,

every 28 days. A total of 6 cycles are scheduled. Antiemetics will be administered 30

minutes before each dose of temozolomide according to procedures, which depend on

practices at each centre. Haematological monitoring is required and a full blood count

should be performed once weekly. Hematopoietic growth factors must not be used.

6.6 Treatment Discontinuation

Treatment should be discontinued if this is considered to be in the best interest of the

patient. Treatment could be discontinued for the following reasons:

• Investigator’s decision: if this decision is made because of toxicity, a serious

adverse event, or a clinically significant laboratory value, appropriate measures

will be taken and the IGR will be notified immediately

• The parents or legal representative’s refusal, withdrawal of patient consent.

• The patient requires treatment with another therapeutic agent that has been

demonstrated to be effective for treatment of the study indication. In this case,

discontinuation from study treatment occurs immediately upon introduction of

the new agent.

• The investigator or sponsor, for significant safety or efficacy reason, stops the

study or stops the patient's participation in the study.

• Evidence of progressive disease exists.



• Life threatening toxicity.

• Treatment delay of more than 3 weeks for any reason except in cases of

obvious patient benefit in continuing the treatment.

Study discontinuation, must be reported to the IGR as soon as possible and

immediately in case of discontinuation related to a serious adverse event. The primary

reason and date of removal for all patients will be documented in the case report form.

The final evaluation required by the protocol will be performed at the time of study

discontinuation. Further follow-up should be reported. The investigator will attempt to

complete all discharge procedures at the time a patient is withdrawn from the

treatment.

7. BASELINE AND FOLLOW-UP ASSESSMENTS

7.1 Baseline assessments

Patients eligible for the trial and for whom the parents have signed their consent for

participation, must undergo a baseline examination not more than 15 days before the

start of induction chemotherapy.

▪ Clinical examination

• History of present illness, main medical and surgical history with collection of

previous treatments.

• Physical examination, including neurological examination

• Height, body weight, surface area and temperature

• Lansky-Play scale

Particular care shall be given to report tumour-related neurological signs for

subsequent determination of a possible clinical response.

▪ Imaging (cf. procedures appendix C)

• Preoperative cerebral magnetic resonance imaging (MRI) before and after

contrast injection.

• Spinal MRI with injection of contrast product which should be performed

whenever possible preoperatively, but it may also be performed post-

operatively.



• Post-operative cerebral MRI (or otherwise a CT-scan cf. above) before and

after contrast product injection and no later than 72 hours after and preferably

within 48h of the surgical procedure.

Central review of preoperative MRI imaging will be mandatory (cf. paragraph 16.2).

▪ Laboratory tests

• Full blood count, platelets

• Blood and 24-hour urine electrolytes: sodium, potassium, blood glucose,

calcium, phosphorus, magnesium, serum and urinary creatinine.

• ALAT, ASAT, alkaline phosphatases, gamma-GT, bilirubin

• Irregular agglutinin test, blood grouping with extensive phenotyping

• Viral serological tests (HBV, HCV, CMV, HSV, HIV 1+2)

▪ Cytological and histological examination

• Histological confirmation of diagnosis for patients treated at diagnosis (cf.

paragraph 16.2)

• Study of CSF cytospin collected by lumbar puncture between 7 and 15 days

after the surgical procedure, until CSF study become negative

▪ Translational research

An immunohistochemical study will be performed to refine the diagnosis and define the

value of probable markers of prognostic importance.

Five antibodies will be used: INI 1 (BAF47), MIB 1, beta-catenin, FSTL5 [73], p53 [74].

The first antibody (INI 1) will be used to define the diagnosis ruling out the rhabdoid

teratoid tumour diagnosis. The prognostic value of the latter markers remains to be

ascertained. The expression of these markers, which may be of prognostic value, will

be investigated in parallel by two laboratories. This double analysis will be integrated

within the scope of a quality procedure to evaluate the most suitable

immunohistochemistry method for the study of these markers and to compare these

techniques on very heterogeneous material (various types of fixative due to the varied

origins of the blocks). A tissue micro-array (TMA) will be carried out on this series of

tumours with the agreement of the local concerned pathologists. These TMA will allow

us to perform complementary studies.

We assume that neurofilament and synaptophysin are immunohistochemical markers,

which have been routinely applied by the pathologist who gave the initial diagnosis.



In order to carry out this study, a tissue block embedded in paraffin, representative of

the tumour, will be sent to Professor M.B. DELISLE who will carry out histological

review and the immunohistochemical study +/- TMA. Stained and unstained slides will

be sent from Toulouse to Professor D. FIGARELLA-BRANGER for a second reading

and a comparative immunohistochemical study. Blocks will be returned to the local

pathologist after preparing unstained slides and +/- TMA.

The following antibodies will be used for the immunohistochemistry study:

- INI 1 (clone BAF 47), Toulouse : BD Transduction Laboratories, 1/50 dilution,

- Beta-catenin (clone β-catenin-1), Toulouse : Dako, 1/400 dilution

- p53 (clone DO7), Toulouse : Dako, 1/100 dilution

- KI67 (clone MIB-1), Toulouse : Dako, 1/150 dilution

- FSTL5 (Mouse polyclonal antibody), Abnova, the dilution will be soon determined.

Frozen tumour specimens will be preserved for future biological studies.

▪ Neuropsychological evaluation

Neuropsychological tests will performed as soon as possible after surgery or study

entry, using Brunet-Lezine or Weschler scales, adapted to the age. This evaluation

should be performed before radiation therapy for patients treated with salvage

treatment.

7.2 Follow-up assessments during treatment and at t he end of treatment

Assessments during treatment and salvage treatment are summarised in table 1 and

2, respectively.

Follow-up assessments for the disease:

- MRI of all measurable sites will be performed after the second course of

conventional chemotherapy, after the second course of high-dose thiotepa

and after the course of cyclophosphamide-busilvex combination. Central

review MRI imaging after the conventional chemotherapy and after the

intensification phase will be mandatory in real time (cf. Paragraph 16.2).

- A study of the CSF cytology will be conducted after the second course of

conventional chemotherapy and after the last course of chemotherapy

(cyclophosphamide-Busilvex).



Follow-up assessments for the treatment:

- An echocardiography will be performed before leukapheresis.

- The safety of conventional chemotherapy (VP16-Carboplatin) courses will be

evaluated according to NCI-CTCAE V4 criteria (appendix D).

- The safety of high-dose chemotherapy courses will be assessed with the

Bearman grading system (appendix E).

- All examinations to detect treatment-related toxicity will be repeated

periodically until reversion of toxicity or until it is considered irreversible.

Table 1: Assessment during planned treatment

Registration Before VP-CBP

Before VP-CBP

Before Thiotepa1

Before Thiotepa2

Before Cyclophosphamide + Busilvex

After Cyclophosphamide + Busilvex

FBC/platelet X X X X X X X

Biochemistry(Blood and Urine)

X X X X X X X

Brain MRI X X X X

Spinal MRI X X X X

CSF cytology X X X X

Toxicity (NCI-CTC) X X

Toxicity (Bearman)

X X

Neuropsychological evaluation

X (as soon as possible after surgery or study entry) X

Table 2: Follow-up during salvage treatment

Before TEMERI1

Before TEMERI2

Before RT-CC

Before TMZ1

Before TMZ2 - 3

Before TMZ4

Before TMZ5-6

After TMZ

FBC/platelet X X X X X X X X

Biochemistry X X X X X X X X

Brain MRI X X X X X

Spinal MRI X X X X X

CSF cytology X X X

Toxicity (NCI-CTC) X X X X X X X X



7.3 Follow-up assessments after treatment

• Tumour

After treatment, a craniospinal MRI shall be performed every 3 months during the first

2 years following the end of the treatment, every 6 months during the following 2 years

and then every year for 5 years.

• Sequelae

- Neuropsychological evaluation: The neuropsychological evaluation will be conducted

prospectively and for a minimum duration of 5 years. It will be carried out at the end of

treatment and then at 1 year, 2 years, 3 years, 5 years, 7 years and 10 years after the

end of treatment. Tests appropriate to the child’s age will be performed to investigate

their cognitive functions (Brunet-Lezine or Weschler scales). The purpose is to screen

for any cognitive deficiencies, prescribe rehabilitation therapy when required and help

the children integrate in school. Neuropsychological evaluations of children treated

according to this protocol will be analysed in order to study the outcome of the cognitive

deficiencies and to determine their cause.

- Follow-up of sequelae: This follow-up will involve the collection of prospective data,

and will be carried out at the same times as the neuropsychological evaluation:

reading, writing, motor activity, laterality, epilepsy, cranial nerve involvement, sensory

deficiency, integration at school, specialised support.

- Endocrine follow-up: Monitoring will be mainly clinical and concern growth in weight

and height and pubertal development as well as fertility during late follow-up.

- General assessment after treatment to evaluate the sequelae of the entire treatment.

8. PK / PD / PG STUDIES

The clinical trial includes a multi-institution pharmacological study exploring

pharmacokinetics, pharmaco-dynamics and pharmacogenetics of two anticancer

drugs, cyclophosphamide and busulfan, using limited blood sampling strategies and

NONMEM programmes.

This PK/PD/PG study will be conducted according to Good Laboratory Practice:

- To study the PK/PD relationships between exposure to busulfan and

cyclophosphamide and severe toxicities other than VOD.

- To identify the AUCs of busulfan and cyclophosphamide that could be

prospectively targeted to reduce the risk of severe toxicity in high-dose combined



chemotherapy regimens including I.V. Busulfan (Busilvex) and

cyclophosphamide.

8.1 BUSULFAN

• Blood sampling/ assays (appendix D)

For all blood samples (2 ml), plasma will be separated at 0°C and stored at –20°C until

sample shipment. Samples should be sent to the reference laboratory as soon as

possible following collection, to avoid issues concerning sample stability.

Busulfan plasma levels will be assayed after doses 1 and 9, with three blood samples

withdrawn following these two doses (before administration and at 2.5 and 6 hours

after the START of infusion). In addition, plasma levels will be measured after dose 13,

with a single sample being taken 6 hours after the START of infusion.

Busulfan will be assayed by gas-chromatography with mass spectrometry in the

laboratory of Dr Angelo Paci (IGR, France).

Briefly, 0.2 ml (heparin) plasma is required for the analysis. Internal standard (1,5-bis

(methansulfonoxy) pentane) or Deuterium busulfan) is added along with 1 ml sodium

iodide (8M) and 0.4 ml n-heptane. A micro magnet is added to the screw cap tube. The

reaction is carried out at 70oC for 45 min under continuous magnet stirring. Then, the

organic phase (n-heptane) is taken to analysis in the GC system.

8.2 Cyclophosphamide

• Blood sampling (appendix E)

All patients must have a central venous catheter (single or multi-lumen catheter or

port-a-cath) in place in order for samples to be taken for pharmacokinetic analysis. No

samples will be taken by venipuncture. For patients with a double lumen line, samples

for pharmacokinetic analysis should be taken from a different lumen to that used for

infusion. For patients with a single lumen line, the line should be flushed with 10ml

normal saline prior to the withdrawal of blood samples. Wherever possible,

pharmacokinetic samples should be taken when clinical blood samples are obtained.

• Cyclophosphamide pharmacokinetics



Blood samples (2ml) will be taken and transferred to heparinised tubes after

administration of a single dose of cyclophosphamide on Day -9 at the following times:

prior to treatment, end of infusion, 1, 2, 4, 6 and 23 hours after the end of infusion (i.e.

immediately prior to infusion of cyclophosphamide on Day -8). Samples will be

immediately centrifuged for 5 min at 2,000 rpm and 4ºC, plasma transferred to clean

labelled tubes and frozen at -20ºC prior to transport to the Northern Institute for Cancer

Research, Newcastle, UK, for analysis (see below). Methods for measurement of

cyclophosphamide and its metabolites in plasma using LC/MS (liquid

chromatography/mass spectrometry) are established in the Northern Institute for

Cancer Research [75].

• Pharmacogenetic studies

An additional 5ml blood sample for DNA extraction will be taken pre-treatment and

transferred to an EDTA tube to be genotyped for the known functional polymorphisms

in CYP2B6, CYP2C9 and other metabolic enzymes in addition to the determination of

genetic variation in MDR. This whole blood sample will be stored at -20ºC prior to

transport to Newcastle for analysis (see below). The techniques for genotyping

individuals for these polymorphisms have been established in the Northern Institute for

Cancer Research [76].

• Transport of samples for analysis

Clearly labelled samples should be sent to Newcastle in a single package by overnight

courier (Monday – Wednesday), packed on dry ice in an insulated container, following

completion of all pharmacokinetic and pharmacogenetic sampling. The Northern

Institute for Cancer Research should be notified on the day that the samples are sent

(Gareth Veal/Julie Errington, Tel. +44 (0)191 246 4332 or +44 (0)191 246 4357).

Address for shipment of samples:

Gareth Veal /Julie Errington Contact numbers

Northern Institute for Cancer Research Gareth Veal: 0191 246 4332

Paul O’Gorman Building Julie Errington: 0191 246 4357

North Terrace Fax: 0191 222 3452

Newcastle upon Tyne Email: [email protected]



NE2 4AD [email protected]

• Pharmacokinetics and statistical analysis

The data obtained will be used to determine pharmacokinetic parameters such as area

under the plasma concentration-time curve (AUC), clearance and half-life (t½) for

cyclophosphamide in children with high-risk medulloblastoma following a single

intravenous dose. Pharmacokinetic modelling will then be carried out using these data

in conjunction with patient characteristics and clinical parameters in order to

investigate the key factors involved in determining individual exposure to parent drug

and metabolites within the defined patient population.

9. EVALUATION CRITERIA

9.1 Primary endpoint

The primary endpoint of the whole study is the Event-Free Survival (EFS). EFS is

defined by the time between registration and the first of the following events: disease

progression, relapse, secondary malignancy, death irrespective of the cause. Data will

be censored at the date of last follow-up visit for patients alive without disease

progression, relapse and secondary malignancy. As the trial aims at evaluating the

efficacy of the whole treatment strategy, patients who receive salvage treatment

because of an insufficient response to treatment (stable disease after the first two

induction courses, or partial response or stable disease after the two consolidation

courses) will not be considered as an event as long as there is no evidence of disease

progression. Patients who experience a disease progression at any stage of the

treatment will be counted as events in the EFS estimate.

The primary endpoint of the Phase I part of the trial is the Dose-Limiting Toxicity

defined as

- any grade 3 toxicity according to the Bearman grading system, in particular grade 3

veno-occlusive disease,

- or grade 2 or 3 pulmonary toxicity according to the Bearman grading system,

occurring in the 30 days following the autologous stem cell transplantation (DLT

observation period).



9.2 Secondary endpoints

1. Radiotherapy-free survival without event is defined as the time between the

registration in the study and the first event (i.e., progression, relapse, secondary

malignancy, death whatever the cause) or the beginning of radiotherapy. Data

will be censored at the date of last follow-up for patients alive without event and

without radiotherapy.

2. Overall survival defined by the time between enrolment in the study and the

death whatever the cause. Data will be censored at the date of last follow-up for

patients alive.

3. The response to induction and intensification chemotherapy will be evaluated in

patients with measurable disease on enrolment in the study. Patients with non

measurable disease will be considered as having progressive disease in case of

appearance of new lesion, at the primitive site or in metastatic sites. Otherwise,

they will be considered as stable or complete remission in case of no residual

disease. In patients with measurable disease, responses will be evaluated

according to the WHO criteria.

Complete response (CR): complete disappearance of all the measurable

disease by appropriate imaging of residual tumour or absence of residual

tumour in cerebrospinal fluid.

Partial response (PR): The reduction in size of all the tumours by at least 50%

as determined by the sum of the products of the two maximum perpendicular

diameters of each lesion, as compared to initial assessment.

Progressive disease (PD): increase in size of one or several lesions by more

than 25% or appearance of new lesions, as compared to the best response

assessment.

Stable disease (SD): All other cases.

4. Establishment of Pharmacokinetics of cyclophosphamide and busilvex when the

two drugs are combined.

5. The response to salvage treatment will be evaluated according to the WHO

criteria.

6. Toxicity will be assessed using the National Cancer Institute Common

Terminology Criteria for Adverse Events (NCI CTCAE v 4.0). Any grade IV



toxicity (except haematological) will be considered as severe toxicity. Toxic

death defined by a death not due to the disease, occurring during treatment or

after the end of the treatment, except if it can be proved that it is not related to

treatment.

7. Cognitive assessment at the end of treatment and then at 1 year, 2 years, 3

years, 5 years, 7 years and 10 years after the end of treatment. Cognitive

deficiencies will be assessed through neuropsychological tests appropriate to

the child’s age.

10. STATISTICAL CONSIDERATIONS

10.1 Study design

Phase II part

The survival of children less than 5 years of age with metastatic medulloblastoma

treated with standard treatment (surgery followed by conventional craniospinal

irradiation and chemotherapy) remains poor. Due to the low incidence of the disease, it

was not feasible to design a randomised study to assess the efficacy of this strategy

compared to conventional therapy including radiotherapy. Consequently a Phase II,

open label, non-randomised, multicentre trial will be achieved without control group,

using the 3-year EFS as efficacy endpoint.

In the previous study PNET HR, the observed 3-year EFS for patients with high-risk

medulloblastoma treated with sequential HDCT and age-adapted craniospinal

irradiation was 49%. However, there is some uncertainty regarding the null and

alternative hypotheses that should be considered to define a Simon’s or Fleming’s

design. This uncertainty led us to propose a Bayesian approach since such designs

may be more informative in terms of treatment effect estimate, allowing for several a

priori distribution of the considered outcome, compared to the classical test-driven

analyses using a single null hypothesis. Based on historical data, a cure model will be

used to model the EFS data.

Interim analyses will be performed, as soon as approximately half of the total expected

number of events will be observed (early stopping rules for futility or inefficacy).



Phase I part

This is a single arm phase I using the continual reassessment method (CRM) design to

determine the dose of cyclophosphamide to be recommended (Maximum Tolerated

Dose, MTD) when given in combination with busilvex. A CRM design with an empiric

dose-toxicity model in a Bayesian framework will be adopted for dose-finding in this

trial [77]. The CRM design has been shown to have better operating characteristics

than traditional “3+3” design in simulations [78]. Additionally we will use a slightly

modified CRM design (Doussau 2012) to increase the flexibility by allowing continuous

accrual with no trial suspensions, which are classically needed when the toxicity

assessment of the patient(s) previously recruited is not completed: an eligible patient

can be included in the trial at any time, without waiting for the evaluation of prior

patients. The model will be re-estimated considering all the complete toxicity

observations currently available. The patient will be treated at the best current estimate

of the MTD. Patients may eventually be treated at a dose below the dose

recommended by the model for safety reasons (see rules in Appendix I). This is

particularly appealing in the context of this trial where all the patients eligible for the

chemotherapy course of cyclophosphamide-busilvex should participate in the dose-

finding trial. See appendix for the operating characteristics of this design.

Decision for dose-escalation recommended by the model will be confirmed by the

study committee, after discussion of all toxicity data currently available.

The initial dose level of cyclophosphamide is 80 mg/kg. Four dose levels are planned.

Dose level 1 2 3 4

Cyclophosphamide dose (mg/kg) 80 120 160 200

10.2 Sample size Phase II part: In theory the Bayesian approach does not need to define a sample size

in advance in order to give reliable results. However, considering classical frequentist

approach, 50 patients would be required to provide a 85% power of a one-sample

logrank test [79] if the true 3-year EFS improvement was 20% compared to historical

data, using a one-sided test with a type-I error of 0.05 (27.2 events required). This



sample size is reasonable considering the possible accrual. We thus decided to recruit

about 50 patients in the trial.

Due to the low incidence of the disease and the selection of high-risk patients only

(around 10 patients per year included in the previous study), the accrual duration is

expected to be 5 years.

Phase I part: All the patients in complete response after intensification chemotherapy

treatment, eligible for the consolidation course of cyclophosphamide-busilvex course,

will be included in the phase I part of the trial. They will be treated at the best current

estimated MTD. The dose-finding part of the trial will be run until the end of the trial.

Approximately 50% of the patients entering the trial are expected to be recruited in the

phase I part (last chemotherapy course), leading to an estimated accrual of 25 patients

in the dose-finding part of the trial.

10.3 Statistical analysis

10.3.1 Analysis of the main endpoint

In the previous study PNET-HR including 38 patients with a medulloblastoma with a

median follow-up of 6.2 years, most of the events occurred in the first two years (1-

year and 2-year EFS at 62% and 52%, respectively), with few events after that (3-year

and 6-year EFS at 49% and 42%, respectively). The observed EFS distribution could

be modelled using a cure model, written as: S0(t) = π+ (1-π).{exp(-λ.t)}, with π = 0.435

and λ = 1.12, leading to a predicted EFS of 61.9%, 49.5%, 45.5% and 43.6% at 1, 2, 3

and 6 years respectively.

We plan to model the observed EFS data on the whole follow-up period using a cure

model assuming proportional hazards, written as follows:

S1(t) = S0(t)R, where R represents the treatment effect of the evaluated strategy

compared to the historical treatment. An a priori distribution of the parameter R will be

combined with its likelihood function given the observed data, to compute a posterior

distribution of the parameter. The posterior distribution of the 3-year EFS will then be

derived from the posterior distribution of the parameter R. We will use three prior

distributions of the parameter R; (1) one enthusiastic prior distribution, with an

expected R of 0.538, corresponding to an expected 3-year EFS of 65.5% (20%

increase of the 3-year EFS compared to historical data), (2) one pessimistic prior

distribution with an expected R of 1.162, corresponding to an expected EFS of 40%,



and (3) a non-informative prior distribution. As the patient outcomes in the trial will be

recorded, the subsequent distribution of the outcome probability under experimental

treatment will be computed by applying Bayes’ theorem, which yields an estimated 3-

year EFS probability with a 95% credibility interval (measure of Bayesian precision).

This approach allows us to estimate the probability that the 3-year EFS is above or

below certain thresholds: probability that 3-year EFS is below 20%, is below 40%, or is

above 60%...

The final efficacy analysis will be performed 3 years after the recruitment of the last

patient. Two interim analyses will be performed, when approximately 50% and 75% of

the total expected number of events will be observed (14 and 21 events). Early

termination of the trial will be discussed if the estimated probability that 3-year EFS >

60% is lower than 5% (early stopping rules for futility or inefficacy).

10.3.2 Others analyses

In addition to the Bayesian approach, the EFS curve will be estimated on the entire

follow-up period (8 years of follow-up expected for the first patient recruited in the

study) using the Kaplan Meier method, with 95% confidence intervals estimated using

the Rothman method. A one-sample log-rank test [79] will also be used to compare the

observed EFS to a fixed null outcome defined as S0(t) = π+ (1-π).{exp(-λ.t)}, with π =

0.435 and λ =1.12. We will compare the number of events observed in our sample to

that predicted using the theoretical cure model defined above. Testing will be done at

the 5% level of statistical significance (1-sided). The sample of 50 patients will provide

85% power to detect a true 3-year EFS of 65.4% (derived from S1(t) = S0(t)R with

R=0.538, leading to a 20% improvement of the 3-year EFS) and 90% power to detect

a true 3-year EFS of 68% (22.5% increase, R=0.506). Power would be 60% to detect a

true 3-year EFS of 60% (14.6% increase, R=0.647).

The curves of radiotherapy-free survival without event as well as the overall survival

curves will be estimated by the Kaplan Meier method, with confidence intervals

estimated using the Rothman method.

The response rate of the initial conventional chemotherapy will be estimated

considering complete or partial response after the 2 first conventional courses as

success. Patients who stop protocol treatment due to clinical progression, without



imaging confirming the progression, and patients who die before radiological

assessment will be considered as failures of conventional chemotherapy. Response

rate will be given with a 95% confidence interval (binomial distribution).

Repeated measurements of neurocognitive tests will be analysed to study the kinetic

of neurocognitive function using a linear mixed model.

In addition to the description of efficacy outcome and toxicity, a decision theory

approach will be developed to evaluate the benefice/risk ratio.

10.3.3 Phase I analyses

The recommended dose of cyclophosphamide as consolidation chemotherapy in the

strategy treatment for further consideration is defined as the dose level associated with

an estimated probability of dose-limiting toxicity (DLT) closest to the target of 0.30.

Dose-limiting toxicity is defined as any grade 3 toxicity according to the Bearman

grading system, in particular grade 3 veno-occlusive disease, or grade 2 or 3

pulmonary toxicity according to the Bearman grading system (See Appendix G),

occurring within 30 days following the autologous stem cell transplantation (DLT

observation period). An additional clause is that the MTD is a dose with no observed

grade 3 pulmonary toxicity (Bearman).

The estimated probability of dose-limiting toxicity will be based on a one-parameter

empirical power model in a Bayesian framework. The initial toxicity probabilities

guesses are 7%, 17%, 30%, and 44% of DLTs at dose levels 1 to 4, respectively. See

appendix I for further description of the model.

The dose-toxicity relationship is estimated for each new inclusion on the basis of

complete information for previous included patients. If complete information is not

available for all included patients, the estimate is based on all complete information,

ignoring incomplete information. If the model estimate recommends escalating to a

new dose level, we require that complete information about at least two patients at the

current dose level is known in order to escalate.

No dose skipping is allowed. That is, if a dose level i has not yet been explored, no

patient inclusion is allowed at a level >i. If the model estimate recommends escalating

to a level >i, inclusion is done at dose level i.



The toxicity target is 30% for veno-occlusive disease grade III and 0% for pulmonary

grade III toxicity according to the Bearman grading. In order to meet this constraint, the

observation of a pulmonary toxicity at dose level i leads to the closure of the dose level

i and all higher dose levels. See appendix I for the specific rules.

10.4 Analysed population

For the phase II evaluation, all efficacy analyses will be performed on the Intent-to-

Treat (ITT) population: all subjects will be taken into account including those who were

erroneously enrolled and those who did not comply with the protocol.

For the toxicity analyses, including the Phase I part of study, the treated population will

be considered (as per protocol).

The relationship between the dose of cyclophosphamide and the outcome may be

studied according to the number of patients allocated at the different dose-levels. This

exploratory analysis will be performed on the subgroup of patients in complete

remission after the intensification phase participating in the phase I part of the study.

For the phase I part, dose-toxicity relationship will be estimated in patients who receive

cyclophosphamide combined with busilvex.

10.5 Monitoring of toxicity and stopping rules

Severe toxicity including toxic deaths will be monitored continuously. The coordinating

data centre must be immediately informed about any events corresponding to the

definitions given below.

10.5.1 Toxic death

Toxic death is defined by a death other than death due to the disease occurring during

treatment or after the end of the treatment, except if it can be proved that it is not

related to treatment. The acceptable limit toxic death rate is based on the literature

data: observed toxic death rates range from 0% [80] to 5.4% [44]. The acceptable limit

toxic death percentage is therefore fixed at 5%. The nominal alpha risk is set at 15%

(i.e. risk of wrongly concluding that there are too many toxic deaths, i.e. of stopping the

trial for an unacceptable toxic death rate when this rate is in fact lower than 5%) and to

have an alpha function following a gamma law with gamma equal to 4 (leading to a



concave alpha function, i.e. high at the start, in order to be able to conclude early

about a “toxic death”) (ref “Early Stopping Rules in Clinical Trials Based on Sequential

Monitoring of Serious Adverse Events.” Med Decis Making. 2008 Dec 10.).

The stopping rules used to monitor toxic death rate are based on the estimation of the

toxic death rate with its appropriate confidence interval, estimated after occurrence of

each new toxic death (from the second toxic death).

The following scenario illustrates the method:

If the 2nd toxic death occurs:

� Among the first 9 patients, the observed toxic rate death is significantly higher

than the limit of acceptable toxic death rate (for example, 2/9=22%, 84.74%CI,

5.2 to 51%) and the Trial Safety Board could decide to stop the trial,

� After the 9th patient, the observed toxic death rate is not significantly higher

than the limit (for example, 2/10=20%, 83.6%CI, 4.9 to 47%); the trial will go on.

Similar rule applies for further deaths.

E.g., if the 2nd toxic death occurs at the 10th patient and the 3rd death occurs:

� Among the first 19 patients, the observed toxic rate death is significantly higher

than the limit of acceptable toxic death rate and the Trial Safety Board could

decide to stop the trial,

� After the 19th patients, the observed toxic death rate is not significantly higher

than the limit; the trial will go on.

10.5.2 Severe toxicity

Any grade IV toxicity (except haematological toxicity) will be monitored. The acceptable

severe toxicity rate limit is set at 20%. The method used to monitor severe toxicity is

similar used to monitor toxic deaths (ref “Early Stopping Rules in Clinical Trials Based

on Sequential Monitoring of Serious Adverse Events.” Med Decis Making. 2008 Dec

10.), with a nominal alpha risk equal to 15% and an alpha function following a gamma

law with gamma equal to 4.



The stopping rules used to monitor severe toxicity rate are based on the estimation of

the toxic death rate with its appropriate confidence interval, estimated after occurrence

of each new severe toxic event (from the second toxic event).

11. ADVERSE EVENT COLLECTION & REPORTING

11.1 Definition Adverse event (AE) An adverse event (AE) is any untoward medical occurrence in a patient or clinical trial

subject administered a medicinal product and which does not necessarily have a causal

relationship with this treatment. An AE can therefore be any unfavourable and unintended

sign (including an abnormal laboratory finding) symptom, or disease temporally associated

with the use of a medicinal product whether or not considered related to the medicinal

product.

Serious Adverse event (SAE) A serious adverse event (SAE) is any untoward medical occurrence that at any dose:

• Results in death;

• Is life-threatening

• Requires inpatient hospitalization or prolongation of existing hospitalization

• Results in persistent or significant disability/incapacity;

• Results in congenital anomaly/birth defect.

• Or is otherwise considered medically significant by the Investigator*

• Results in the development of a secondary malignant neoplasm

*Medical judgement should be exercised in deciding whether an AE is serious in other

situations. AEs that are not immediately life-threatening or do not result in death or

hospitalisation but may jeopardise the subject or may require intervention to prevent

one of the other outcomes listed in the SAE definition above, should be considered

serious.

If a patient dies as a result of a SAE any post-mortem findings including histopathology



should be provided.

An SAE judged either by the investigator and/or the sponsor as potentially related to a

study drug qualifies as Serious Adverse Drug Reaction (SADR).

SAEs that are related to the study drug and unexpected (ie, not previously described in

the reference document are termed as Suspected Unexpected Serious Adverse

Reactions (SUSARs).

Events not to be considered as SAEs Due to the seriousness of the disease in this study, certain conditions defined as SAEs will be excluded from expedited reporting on a SAE report form:

• AE (symptoms, signs) unequivocally related to tumour relapse or progression

that meet criteria for seriousness, must not be reported as a SAE (in case of

doubt, please report)

• A visit to the emergency room or other hospital department for less than 24

hours that does not result in admission (unless considered an “important

medical event” or a life-threatening event)

• Outpatient or same-day or ambulatory procedures

• Observation or short-stay units

• Hospitalization due to diagnostic procedures or standard supportive care (e.g.

implant of central venous catheter)

• A pre-planned hospitalization for a condition which existed at the start of study

drug and which did not worsen during the course of study drug treatment

• Social admission (e.g., subject has no place to sleep; hospice facilities)

• Administrative admission (e.g., for yearly physical examinations)

• Protocol-specified admission during a clinical trial (e.g., for a procedure required

by the study protocol or for clinical research)

• Optional admission not associated with a precipitating clinical AE (e.g., for

elective cosmetic surgery)



11.2 Recording and assessing adverse events

Any AE which occurs or comes to the attention of the investigator at any time during

the study, since consent is given, regardless of time elapsed since last study drug

administration, whether or not considered related to study drugs must be recorded in

the CRF.

If in any one subject the same AE occurs on several occasions, then the AE in

question must be documented and assessed anew each time.

For SAEs, a SAE report form (initial or follow up) must be completed in addition.

The following aspects must be recorded for each event in the CRF.

• A description of the AE in medical terms, not as reported by the subject;

• The date of onset (start date)

• The date of recovery (stop date)

• The grade as assessed by the investigator according to NCI-CTCAE scale,

version 4.0.

• Action taken on study drugs (e.g. none, medication discontinued, dose reduction, medication delayed, reduction of infusion rate…).

• Other action (none, corrective treatment given, surgery..).

• The outcome according to the following definitions: - Recovered with sequelae (if so specify nature of the sequelae). - Recovered without sequelae. - Ongoing - Change in toxicity grade/severity - Died.

• Seriousness: yes or no

• In addition, if the investigator determines a serious adverse event is associated with study procedures, the investigator must record this causal relationship in the source documents and CRF, as appropriate, and report such an assessment in accordance with the serious adverse event reporting requirements, if applicable.

• The causal relationship with study drugs as assessed by the investigator

The site investigator is responsible for assessing the relationship between the AE and

study drugs. Sites investigators must determine whether there is a reasonable



possibility that the study agent(s) caused or contributed to an AE/SAE. The

relationship assessment, based on clinical judgment, often relies the following:

• A temporal relationship between the event and the administration of the study

drug(s).

• A plausible biological mechanism for the agent to cause the AE/SAE

• Previous reports of similar AEs/SAEs associated with the study drug(s), or other

drug in the same class

• Recurrence of the AE/SAE after re-challenge or resolution after de-challenge

(drug withdrawal), if applicable

• Another possible aetiology for the AE/SAE (concomitant drug, concurrent

disease/condition, underlying cancer disease…)

The terms used to assess the relationship of an event to study drug(s) are:

• Related: there is a reasonable possibility that the AE/SAE may be related to the

study drug(s)/protocol

• Not related: there is not a reasonable possibility that the AE/SAE is related to

the study drug(s)/protocol

If there is insufficient or incomplete evidence to make a clinical judgement of the

casual relationship, the site investigator is allowed to qualify the event as ‘not

assessable’.

If new information becomes available, the relationship assessment of any AE/SAE

should be reviewed again and updated, as required.

The causality assessment given by the investigator will not be downgraded by the

Pharmacovigilance Unit. If the Pharmacovigilance Unit disagrees with the

investigator’s causality assessment, both, the opinion of the investigator and the

Pharmacovigilance Unit will be provided in the case report.



11.3 Intensity criteria

Intensity criteria must not be confused with criteria for seriousness, which serve as

guidelines for definition of reporting obligations.

Intensity of events will be estimated according to the NCI-CTCAE classification,

version 4.0 (toxicity score grade 1 to 5). Intensity of adverse events not listed in this

classification will be evaluated according to the following terms:

- Mild (grade 1): does not affect the patient's usual daily activity

- Moderate (grade 2): perturbs the patient's usual daily activity

- Severe (grade 3): prevents the patient carrying out his usual daily activities

- Very severe (grade 4): necessitates intensive care or is life-threatening

- Death (grade 5)

11.4 Reporting of serious adverse events

All Serious Adverse Events (SAE), related or not to study drugs, occurring at any time

during the study (since consent is given) and through 30 days after the last

administration of study drugs, independent of the circumstances or suspected cause,

must be reported, within 24 hours of knowledge by fax .

The investigator must fill in the SAE Form and assess the relationship to study drugs,

then send it signed and dated , within 24 hours of learning of its occurrence, even if it

does not appear to be treatment-related, to the: Pharmacovigilance Unit at IGR : +33

(0) 1 42 11 61 50.

Phone +33 (0) 1 42 11 61 00 (from 9 a.m to 6 p.m from Monday to Friday except

bank holidays). Emai: [email protected]

Serious Adverse drug Reactions (SADR) must be repor ted regardless of time elapsed since last study drug dose (no time limit).



Information collected in the SAE form is crucial to assess the case and for this reason

diligence in collecting as much verifiable and reliable information are of capital

importance. BOTH QUALITY and TIMELINES are key factors.

The investigator must provide any relevant information for the required 8 days follow

up report for any SAE which is fatal or life-threatening.

As far as possible, for each event, the following should be noted:

1) As clear a description as possible in medical terminology

2) Whether the event is expected or not

3) Its duration (start and end dates)

4) Action taken and the necessity for corrective treatment or not, action taken on study

drug(s) (delayed, dose reduction….)

5) Its intensity (grade 1-5), according to the NCI-CTCAE version 4.0

6) Its relationship to study drug(s), the underlying cancer disease, a concurrent

disease/condition, a concomitant drug/treatment, …..

7) Documentation of all co-medication and/or therapies

8) Documentation of all relevant medical history and/or co-existing diseases

9) The outcome (where applicable). For non fatal events, developments should be

followed up until either recovery or recovery of a previous state of health or until the

stabilization of possible after-effects.

The investigator must also attach the following to the serious adverse event report

form, wherever possible:

• A copy of the summary of hospitalization or prolongation of hospitalization

• A copy of the post-mortem report (if applicable)

• A copy of all relevant laboratory examinations and the dates on which these

examinations were carried out, including relevant negative results, as well as

normal laboratory ranges.

• All other document that he judges useful and relevant.



All these documents will remain anonymous.

The Pharmacovigilance Unit of IGR will assess the adverse event in terms of

seriousness, expectedness, severity (NCI-CTCAE v4.0) and relationship to the study

drug. All SAEs will be coded using MedDRA.

“Expectedness” will be assessed with regard to the valid SPC of XXXXXX

In case of Suspected Unexpected Serious Adverse Reaction (or SUSAR), a CIOMS-1

form will be sent by the sponsor to the French competent authority and ethic

Committee. The SUSARs will also be transmitted by the sponsor to the EMA

pharmacovigilance database (EUDRAVIGILANCE)

11.5 Follow-up

The investigator is responsible for the appropriate medical follow-up of patients until

resolution or stabilization of the adverse event or until the patient's death. This may

mean that follow-up should continue once the patien t has left the trial.

Follow up information about a previously reported serious adverse event must be

reported by the investigator to the Pharmacovigilance Unit within 24 hours of receiving

it (on the serious adverse event report form, by ticking the box marked Follow-up

N°…). The investigator also transmits the final rep ort at the time of resolution or

stabilization of the SAE.

11.6 Information given to investigators, ethics com mittee and regulatory authority

The Pharmacovigilance Unit sends all study investigators and the IDMC a copy of any

unexpected serious adverse reaction (SUSAR) and/or toxic death.

The Pharmacovigilance Unit also informs investigators, the IDMC, the ethics

committee and the competent authority of any information at its disposition that might



be relevant to patient safety and that might lead to an (unfavourable) reappraisal of the

benefit/risk ratio of the research, originating from other studies carried out on the same

products or according to the same methodology or from publication, spontaneous

notification or another authorized authority.

The sponsor will submit the Development Safety Update report (DSUR) within 60

days of the data lock point (date of the first authorisation of the concerned clinical)

to the French competent authority and Ethic Committee, according to national

legislation.

12. INDEPENDENT DATA MONITORING COMMITTEE

An Independent Data Monitoring Committee (IDMC) composed of x experts

(including one statistician) will monitor the progress of the study on ethical and

scientific grounds. The Committee will meet approximately every x months (by

meeting or conference call).

The role of the IDMC will be:

a) To review accrual rate

b) To monitor toxicity

c) To examine first stage analyses

d) Other

The IDMC may be asked to review a major modification to the study prior to its

implementation as a study amendment.

13. STUDY DISCONTINUATION

The study could be interrupted or terminated by the sponsor in agreement with the

coordinator and with the competent authority for the following reasons:

- Frequency and/or unexpected severity of the toxicity,

- Recruitment of patients too low,

- Poor quality of the data collected,



- Request of the Data Monitoring Committee

14. ETHICAL AND REGULATORY ASPECTS

14.1 Rules and regulations

The clinical trial is conducted in compliance with:

- The Huriet Law (n° 88-1138) of December 20, 1988 concerning the Protection of

Persons Undergoing Biomedical Research,

- The Public Healthcare Law (n° 2004-806) of August 9, 2004, a partial adaptation of

the European Directive (2001/20/EC) on the conduct of clinical trials,

- The Data Processing and Civil Liberties Law (n° 7 8-17) of January 6, 1978 modified

by Law n° 2004-801 of August 6, 2004 relative to th e protection of physical persons

with respect to the processing of personal information.

- Law n° 2002-303 of March 4, 2002 relative to pati ents’ rights and to the quality of the

healthcare system,

- Appendix 13 of the E. U. Guide to Good Manufacturing Practices (revised and

adopted in July 2003 by the European Commission),

- Article R5121-16 of the “Code de la Santé Publique” (Public Health Regulations)

concerning the labelling of trial products.

14.2 Committee for the Protection of Persons (CPP) – Competent Authority

This protocol was submitted to the XXXX Committee for the Protection of Persons

which gave its approval during the session on XX/XX/XXXX. This protocol has also

been approved by the ANSM [French Health Products Safety Agency] on

XX/XX/XXXX.

The Institut Gustave Roussy has taken out a legal liability insurance policy (N°124895).

The Institut Gustave Roussy will declare the date of the start and of the end of the trial

to the ANSM.

A final report on the trial will be written at the latest, 6 months after the end of the trial

(defined as the time of the main analysis) and sent to the competent authority and to

the CPP.

The Institut Gustave Roussy will keep records of essential trial documentation in the

Sponsor file for a minimum duration of 15 years after the end of the trial.



14.3 Information and Consent of Participants

Written informed consent is required prior enrolment in the study. This consent is

obtained once the investigator has informed the parents / legal guardian of the patient

during a consultation and after the person had been given sufficient time to think it

over.

Having read the information notice, the parents / legal guardian patient must date and

sign the consent form if they accept the participation of their child. The investigator

must also sign this consent form. The original consent form must be kept in the study

file by the investigator and the study participant should receive a copy.

14.4 Principal Investigator Responsibilities

The principal investigator of each establishment concerned promises to conduct the

clinical trial in compliance with the protocol that has been approved by the CPP and

the competent authority.

The principal investigator should not modify any aspect of the protocol without prior

written permission from the Sponsor or without the approval of the proposed

modifications by the CPP and the competent authority.

The Principal Investigator is responsible for:

- Providing the Sponsor with his/her CV as well as that of co-investigators,

- Identifying members of his/her team participating in the trial and defining their

responsibilities,

- Recruiting patients after receiving the Sponsor’s approval,

Each investigator is responsible for:

- Personally obtaining the informed consent form which has been dated and signed by

the participant in the research prior to any specific trial selection procedure,

- Regularly completing the case report form (CRF) for each patient included in the trial

and ensuring that the Clinical Research Assistant (CRA) mandated by the Sponsor has

direct access to source documents in order to validate information on the CRF,

- Dating, correcting and signing the corrections on the CRF for each patient included in

the trial,

- Accepting regular visits from a CRA and possibly visits from auditors mandated by the Sponsor or inspectors from the regulatory authorities.



All documentation concerning the trial (protocol, consent form, case report form,

investigator file, etc…), as well as the original documents (laboratory results, imaging

studies, medical consultation reports, clinical examination reports, etc.) is considered

confidential and should be kept in a safe place. The Principal Investigator should keep

data as well as a list of patient-identifying data for at least 15 years after the end of the

study.

15. DATA COLLECTION

Data are collected using a CRF. Data will be sent to the Data Manager after they have

been made anonymous by the CRA at the centres participating in the study. The data

for each phase must be sent within one month of the completion of each phase

(conventional chemotherapy, intensification, consolidation, salvage treatment, end of

treatment).

16. QUALITY ASSURANCE - MONITORING

In order to guarantee the authenticity and the credibility of the data in compliance with

good clinical practices, the Sponsor has implemented a quality assurance system that

includes:

- Trial management in accordance with the procedures at the Institut Gustave

Roussy,

- Quality control of data at the investigating site by the Sponsor’s CRA,

- Possible auditing of investigating centres,

- a central review of certain protocol criteria

16.1 Monitoring

Quality control on the site will be ensured by the Sponsor’s CRA.

The CRA must check that the investigator’s file exists and that it is updated.

The CRA must verify the consent forms, that subjects fulfil eligibility criteria, the validity

of evaluation criteria and treatment toxicity with the help of source documents



The CRA will check drug accountability and ensure that the drug accountability forms

are validated and signed by the in-house pharmacist before any request for

destruction.

16.2 Central review

16.2.1 Central radiological review

The cerebral and spinal MRI films recorded at the start of treatment, those conducted

after conventional chemotherapy, those conducted after the intensification phase, and

at the end of the treatment will be subject to central review and must be sent to Dr

Anne Geoffay (Medical imaging, Lenval Foundation, 57 avenue de la Californie, 06200

NICE) for subsequent second reading. The imaging after conventional chemotherapy

and the intensification phase must be sent in the real time to confirm the response.

In the event of tumour progression either during or after the end of treatment, the

imaging must be sent with the previous examinations in real time to confirm the failure

of treatment and validate the decision to withdraw the patient from the trial. The result

of this centralised review will be used as a study endpoint.

16.2.2 Central histology review

The initial biopsy from each patient enrolled in the study must undergo centralised

reading by Professor Marie-Bernadette Delisle (Laboratory of pathological anatomy

and cytology - Rangueil Hospital - 1, avenue du Professeur Jean Poulhès - TSA 50032

- 31059 Toulouse cedex 9). The protocol requires that the slides are sent for a second

reading.

17. DATA OWNERSHIP / PUBLICATION POLICY

The investigator promises, on his/her behalf as well as that of all the persons involved

in the conduct of the trial, to guarantee the confidentiality of all the information provided

by Institut Gustave Roussy until the publication of the results of the trial.

All publications, abstracts or presentations including the results of the trial require prior

approval by the Sponsor (Institut Gustave Roussy).



All oral presentations, manuscripts must include a section mentioning the Sponsor, the

investigators / institutions that participated in the trial, the cooperative groups, learned

societies which contributed to the conduct of the trial and the bodies which funded the

research.

The Study Investigator-Coordinator will write an article reporting on the results as soon

as possible after the final analysis and will be the first author of the publication.



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27. Geyer, J.R., et al., Survival of infants with primitive neuroectodermal tumors or malignant ependymomas of the CNS treated with eight drugs in 1 day: a report from the Childrens Cancer Group. J Clin Oncol, 1994. 12(8): p. 1607-15.

28. Grill, J., et al., Treatment of medulloblastoma with postoperative chemotherapy alone: an SFOP prospective trial in young children. Lancet Oncol, 2005. 6(8): p. 573-80.

29. Geyer, J.R., et al., Multiagent chemotherapy and deferred radiotherapy in infants with malignant brain tumors: a report from the Children's Cancer Group. J Clin Oncol, 2005. 23(30): p. 7621-31.

30. Rutkowski, S., et al., Treatment of early childhood medulloblastoma by postoperative chemotherapy alone. N Engl J Med, 2005. 352(10): p. 978-86.



31. Perez Martinez, A., et al., [High-dose chemotherapy with autologous stem cell rescue in children with high-risk and recurrent brain tumors]. An Pediatr (Barc), 2004. 61(1): p. 8-15.

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36. Sung, K.W., et al., High-dose chemotherapy and autologous stem cell rescue in children with newly diagnosed high-risk or relapsed medulloblastoma or supratentorial primitive neuroectodermal tumor. Pediatr Blood Cancer, 2007. 48(4): p. 408-15.

37. Bacha, D.M., et al., Phase I study of carboplatin (CBDCA) in children with cancer. Cancer Treat Rep, 1986. 70(7): p. 865-9.

38. Gentet, J.C., et al., Carboplatin and VP 16 in medulloblastoma: a phase II Study of the French Society of Pediatric Oncology (SFOP). Med Pediatr Oncol, 1994. 23(5): p. 422-7.

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40. Heideman, R.L., et al., High-dose chemotherapy and autologous bone marrow rescue followed by interstitial and external-beam radiotherapy in newly diagnosed pediatric malignant gliomas. J Clin Oncol, 1993. 11(8): p. 1458-65.

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44. Gajjar, A., et al., Risk-adapted craniospinal radiotherapy followed by high-dose chemotherapy and stem-cell rescue in children with newly diagnosed medulloblastoma (St Jude Medulloblastoma-96): long-term results from a prospective, multicentre trial. Lancet Oncol, 2006. 7(10): p. 813-20.



45. Boland, I., et al., Busulphan is active against neuroblastoma and medulloblastoma xenografts in athymic mice at clinically achievable plasma drug concentrations. Br J Cancer, 1999. 79(5-6): p. 787-92.

46. Dupuis-Girod, S., et al., [High-dose chemotherapy in relapse of medulloblastoma in young children]. Bull Cancer, 1997. 84(3): p. 264-72.

47. Ridola, V., et al., High-dose chemotherapy with autologous stem cell rescue followed by posterior fossa irradiation for local medulloblastoma recurrence or progression after conventional chemotherapy. Cancer, 2007. 110(1): p. 156-63.

48. Bouligand, J., et al., In children and adolescents, the pharmacodynamics of high-dose busulfan is dependent on the second alkylating agent used in the combined regimen (melphalan or thiotepa). Bone Marrow Transplant, 2003. 32(10): p. 979-86.

49. McCune, J.S., et al., Cyclophosphamide following targeted oral busulfan as conditioning for hematopoietic cell transplantation: pharmacokinetics, liver toxicity, and mortality. Biol Blood Marrow Transplant, 2007. 13(7): p. 853-62.

50. Sadeghi, B., et al., The effect of administration order of BU and CY on engraftment and toxicity in HSCT mouse model. Bone Marrow Transplant, 2008. 41(10): p. 895-904.

51. Kerbauy, F.R., et al., The effect of administration order of BU and CY on toxicity in hematopoietic SCT in humans. Bone Marrow Transplant, 2009. 43(11): p. 883-5.

52. Cacchione, A., et al., Risk factors for hepatic veno-occlusive disease: a retrospective unicentric study in 116 children autografted after a high-dose BU-thiotepa regimen. Bone Marrow Transplant, 2008. 42(7): p. 449-54.

53. Lee, J.H., et al., Decreased incidence of hepatic veno-occlusive disease and fewer hemostatic derangements associated with intravenous busulfan vs oral busulfan in adults conditioned with busulfan + cyclophosphamide for allogeneic bone marrow transplantation. Ann Hematol, 2005. 84(5): p. 321-30.

54. Richardson, P.G., et al., Multi-institutional use of defibrotide in 88 patients after stem cell transplantation with severe veno-occlusive disease and multisystem organ failure: response without significant toxicity in a high-risk population and factors predictive of outcome. Blood, 2002. 100(13): p. 4337-43.

55. Estlin, E.J., et al., Phase I study of temozolomide in paediatric patients with advanced cancer. United Kingdom Children's Cancer Study Group. Br J Cancer, 1998. 78(5): p. 652-61.

56. Nicholson, H.S., et al., Phase I study of temozolomide in children and adolescents with recurrent solid tumors: a report from the Children's Cancer Group. J Clin Oncol, 1998. 16(9): p. 3037-43.

57. Riccardi, R., et al. Antitumor activity of temozolomide in medulloblastoma - PNET. in 12th International Symposium on Pediatric Neuro-Oncology. 2006. Nara, Japon.

58. Nicholson, H.S., et al., Phase 2 study of temozolomide in children and adolescents with recurrent central nervous system tumors: a report from the Children's Oncology Group. Cancer, 2007. 110(7): p. 1542-50.



59. Wang, C.H., et al., Efficacy of temozolomide for recurrent embryonal brain tumors in children. Childs Nerv Syst, 2009. 25(5): p. 535-41.

60. Turner, C.D., et al., Phase II study of irinotecan (CPT-11) in children with high-risk malignant brain tumors: the Duke experience. Neuro Oncol, 2002. 4(2): p. 102-8.

61. Wagner, L.M., et al., Phase I trial of temozolomide and protracted irinotecan in pediatric patients with refractory solid tumors. Clin Cancer Res, 2004. 10(3): p. 840-8.

62. Wagner, L.M., et al., Temozolomide and intravenous irinotecan for treatment of advanced Ewing sarcoma. Pediatr Blood Cancer, 2007. 48(2): p. 132-9.

63. Wagner, L.M., et al., Phase I trial of oral irinotecan and temozolomide for children with relapsed high-risk neuroblastoma: a new approach to neuroblastoma therapy consortium study. J Clin Oncol, 2009. 27(8): p. 1290-6.

64. Ashley, D.M., et al., Response of recurrent medulloblastoma to low-dose oral etoposide. J Clin Oncol, 1996. 14(6): p. 1922-7.

65. Chamberlain, M.C. and P.A. Kormanik, Chronic oral VP-16 for recurrent medulloblastoma. Pediatr Neurol, 1997. 17(3): p. 230-4.

66. Grodman, H., L. Wolfe, and C. Kretschmar, Outcome of patients with recurrent medulloblastoma or central nervous system germinoma treated with low dose continuous intravenous etoposide along with dose-intensive chemotherapy followed by autologous hematopoietic stem cell rescue. Pediatr Blood Cancer, 2009. 53(1): p. 33-6.

67. Moghrabi, A., et al., A phase I/II feasibility study of oral etoposide given concurrently with radiotherapy followed with dose-intensive adjuvant chemotherapy for children with newly diagnosed high-risk medulloblastoma COG P9631. Neuro Oncol, 2008. 10(3): p. 476.

68. Bowers, D.C., et al., Impact of site of tumor recurrence upon survival for children with recurrent or progressive medulloblastoma. J Neurosurg, 2007. 107(1 Suppl): p. 5-10.

69. Dunkel, I.J., et al., High-dose carboplatin, thiotepa, and etoposide with autologous stem-cell rescue for patients with recurrent medulloblastoma. Children's Cancer Group. J Clin Oncol, 1998. 16(1): p. 222-8.

70. Dupuis-Girod, S., et al., Will high dose chemotherapy followed by autologous bone marrow transplantation supplant cranio-spinal irradiation in young children treated for medulloblastoma? J Neurooncol, 1996. 27(1): p. 87-98.

71. Goldwein, J.W., et al., Updated results of a pilot study of low dose craniospinal irradiation plus chemotherapy for children under five with cerebellar primitive neuroectodermal tumors (medulloblastoma). Int J Radiat Oncol Biol Phys, 1996. 34(4): p. 899-904.

72. Corbacioglu, S., et al., Defibrotide for prophylaxis of hepatic veno-occlusive disease in paediatric haemopoietic stem-cell transplantation: an open-label, phase 3, randomised controlled trial. Lancet, 2012. 379(9823): p. 1301-9.

73. Remke, M., et al., FSTL5 is a marker of poor prognosis in non-WNT/non-SHH medulloblastoma. J Clin Oncol, 2011. 29(29): p. 3852-61.



74. Gessi, M., et al., p53 expression predicts dismal outcome for medulloblastoma patients with metastatic disease. J Neurooncol, 2012. 106(1): p. 135-41.

75. Chinnaswamy, G., et al., Pharmacokinetics of cyclophosphamide and its metabolites in paediatric patients receiving high-dose myeloablative therapy. Eur J Cancer, 2011. 47(10): p. 1556-63.

76. Bray, B.C., S.T. Lanza, and L.M. Collins, Modeling Relations Among Discrete Developmental Processes: A General Approach to Associative Latent Transition Analysis. Struct Equ Modeling, 2010. 17(4): p. 541-569.

77. O'Quigley, J., M. Pepe, and L. Fisher, Continual reassessment method: a practical design for phase 1 clinical trials in cancer. Biometrics, 1990. 46(1): p. 33-48.

78. Ahn, C., An evaluation of phase I cancer clinical trial designs. Stat Med, 1998. 17(14): p. 1537-49.

79. Finkelstein, D.M., A. Muzikansky, and D.A. Schoenfeld, Comparing survival of a sample to that of a standard population. J Natl Cancer Inst, 2003. 95(19): p. 1434-9.

80. Massimino, M., et al., Supratentorial primitive neuroectodermal tumors (S-PNET) in children: A prospective experience with adjuvant intensive chemotherapy and hyperfractionated accelerated radiotherapy. Int J Radiat Oncol Biol Phys, 2006. 64(4): p. 1031-7.



APPENDIX A: LANSKY SCALE (Lansky et al., Cancer, 1987)

This questionnaire is designed to be filled in with the help of the parents according to the child’s daily life and is useful during the course of the disease.

100% Fully active, normal.

90% Minor restrictions in physically strenuous activity.

80% Active, but tires more quickly.

70% Both greater restriction of, and less time spent in, active play

60% Up and around but minimal active play, keeps busy with quieter activities.

50% Gets dressed, but lies around much of the day; no active play; able to participate in quiet play and activities.

40% Mostly in bed; participates in quiet activities.

30 % In bed; needs assistance even for quiet play.

20 % Often sleeping; play entirely limited to very passive activities.

10 % No play. Does not get out of bed.

0% Unresponsive.



APPENDIX B: PERIPHERAL STEM CELL COLLECTION

1/ COLLECTION OF PERIPHERAL BLOOD STEM CELLS (PBSC)

Approach

Collection of PBSC requires 2 venous access lines. A central venous line will be used if possible with a second peripheral access. If there is no solid peripheral venous line, a central indwelling catheter will be inserted and then removed after the end of leukapheresis. The diameter of the catheter must be adjusted according to patient body weight. The catheter will be chosen according to the practices in each centre, though it is important for at least one of the 2 catheters to be adapted to the high pressures generated by the pump used to collect whole blood.

Collection

Whole blood is collected from the venous access line and anticoagulated with citrate solution (ACDA). After separation of whole blood, the mononuclear cells layer is removed and the rest of the blood cells are returned to the patient. In parallel with mononuclear cells, plasma, red blood cells and platelets are collected leading to a reduction in haemoglobin concentration from 1 to 2 g/100ml and an approximately 30% reduction in platelet mass after each leukapheresis. Each leukapheresis will involve the processing of at least one and a half times the patient’s blood mass.

Possible complications

These will be prevented by a medical examination before each leukapheresis as well as follow-up by the leukapheresis operator and a doctor during collection.

In the event of hypovolemic malaise due to the extracorporeal volume (200 to 300 ml), the collection flow rate will be reduced or even stopped. If the malaise persists despite discontinuation of collection it may be necessary to infuse a macromolecular solution.

Citrated solutions may cause hypocalcaemia reactions. If paraesthesia or gastrointestinal disorders (nausea) occur, the citrate infusion rate should be reduced or a calcium salt used. In children weighing less than 20 kg, the intravenous administration of 1 g of calcium morning and evening is recommended throughout the duration of leukapheresis.

Heparin is not systematically administered though it may be necessary if there is a venous obstruction problem . A minimum haemoglobin concentration of 12g/100ml is required for satisfactory leukapheresis.

Blood products must be irradiated and the white blood cells removed.

Thrombocytopenia secondary to leukapheresis is transient and only requires platelet transfusion in the event of bleeding or disease.

2/ DEEP-FREEZING OF STEM CELLS

The PBSC must be frozen within 8 hours of collection.



APPENDIX C: IMAGING PROCEDURES

Imaging is essential to evaluate the initial tumour, any postoperative tumour residue

and its outcome after chemotherapy.

It must be possible to compare the different examinations and conduct a second

reading by other doctors during this trial.

The tumour and any post-operative residue should be measured in all 3 planes for the

calculation of tumour volume (a x b x c/2). 3D-volume calculations may be performed

additionally. These volume calculations are the basis for follow-up evaluation and

every effort should be made to ensure the highest possible accuracy

Cranial MRI:

The standard imaging plane for the brain should be the axial plane (aligned to the AC-

PC axis). Slice thickness should not exceed 4mm and must be adapted to the

individual problem. As the signal of a tumour depends on the field strength of the MRI

scanner the field strength must not be changed during the study.

For 1-1.5 Tesla MR scanners Sequences:

Pre-contrast Axial T1, T2 and PD or FLAIR

Coronal FLAIR

Post contrast Axial, coronal and sagittal T1

Axial DWI with ADC

Optional: 3D gradient echo T1 post contrast (particularly for computer guided surgical

planning); functional imaging (e.g. perfusion, MRS, DTI and any other individual local

imaging protocols).

For 3 Tesla MRI scanners:

The T1 imaging should be undertaken using a 3D-gradient echo T1 volume sequence

pre- and post-contrast in addition to a T1 SE or gradient echo sequence (e.g. in the

axial plane).

Spinal MRI:



Avoid 3T MRI for spinal imaging, as the image quality is often inferior to that of 1.5T

MR-scanners and more unpredictable. The entire dural sac must be fully visualised.

As only meningeal disease is of interest only sagittal post-contrast T1-weighted

sequences are necessary. Slice thickness must not e xceed 3 mm . The

physiological veins of the cord can be mistaken for dissemination nodules and

therefore axial slices without gaps (slice thickness can be chosen individually) are

essential for all suspicious areas . As fat suppression often leads to artefacts and is

not necessary for the delineation of meningeal disease it should not be used routinely.

Optional:

T2 TSE sequences (particularly when the primary tumour does not enhance or

minimally enhances) or fat suppression techniques.

Early postoperative imaging:

As non-specific intracranial enhancement is often seen after 3 days following surgery

the postoperative MRI must be obtained within this time. Optimal evaluation is made

within the first 48 hours following surgery, and therefore should be undertaken within

this period. However, even within this time false positive nodular enhancement can be

seen with haemostatic materials and after electrocoagulation and therefore the pre-

and post-contrast T1-weighted images need to be carefully evaluated in combination

with the signal intensities on the T2-weighted and FLAIR series. Comparability with the

preoperative MRI is essential for the detection of residual tumour. The size of a

possible residuum has to be measured in all three planes. If the residuum is best

visible on T2-weighted images a second plane incorporating a T2-weighted sequence

must be employed.

A residuum is considered to be any area of pathological signal and/or enhancement

comparable with the appearance of the pre-operative tumour.

For the evaluation of residual tumour seen on imaging the surgical report is often

valuable and should be available.

Sequences for cranial and spinal imaging see prescriptions for cranial and spinal MRI:

Spatial resolution for postoperative MR should definitely be increased, including

sequences with 1 to 2 mm slice thickness and 512 matrix. T2 sequences are

recommending.



Please note if spinal MRI is performed post-operatively:

Non-specific subdural and intradural enhancement and possible intradural blood

products may be identified on early post-operative imaging of the spine and must not

be mistaken for meningeal dissemination. Where there is on-going doubt or if intense

subdural enhancement is seen, the spinal MRI should be repeated after 2 weeks to

clarify the situation.



APPENDIX D: Busilvex (iv Busulfan) Sampling Sheet

DAY OF STUDY

DATE INITIALS HR-MB-5 STUDY No.

WEIGHT S.A GFR

BUSULFAN DOSE (mg):

INFUSION TIME START: FINISH:

(busulfan)

Samples to be taken for busulfan analysis.

Label all tubes with the patient initials, date of study and time of sample or sample number.

Sample number

Day of busulfan treatment

Time from START

busulfan

Time due

Time taken

1 Day 1 Pre-treatment

2 Day 1 2.5 h post-dose 1

3 Day 1 6 h post-dose 1

4 Day 3 Pre-dose 9

5 Day 3 2.5 h post-dose 9



2 ml of blood to be taken in a heparinised tube, centrifuge for 5 min at 2000rpm and 4°C.

Remove plasma and freeze at -20°C.

COMMENTS:



Samples to be sent by overnight courier, packed on dry ice in an insulated container.

Address for delivery :-

Angelo Paci

Institut de Cancérologie Gustave Roussy

Service de Pharmacologie et d’Analyse du Médicament

Bat ERP, niveau -1

114, rue Camille Desmoulins

94800 VILLEJUIF

FRANCE

Contact numbers:-

Angelo Paci : 00 33 1 42 11 47 30

Fax : 00 33 1 42 11 52 77

e mail : [email protected]



APPENDIX E : Cyclophosphamide Pharmacokinetics Sampling Sheet

STUDY CENTRE DATE OF STUDY

DATE OF BIRTH INITIALS *

(* first 3 letters of surname, first 2 letters of first name)

STUDY NUMBER TYPE OF CVC

WEIGHT S.A GFR (if available)

Cyclophosphamide Dose (mg)

Cyclophosphamide Infusion Start: ____:___ Finish: ____:___

Samples to be taken for analysis following intravenous administration of cyclophosphamide. Label all tubes with the patient initials, date of study and time of sample or sample number.

Sample number

Time from END of Cyclophosphamide Infusion

Time due

Time taken

1 Pre-treatment

2 End infusion

3 1 h

4 2 h

5 4 h

6 6 h

7 23 h (pre-dose 2)

2 ml of blood to be taken in a heparinised tube, immediately centrifuge for 5 min at 2,000rpm and 4°C. Freeze plasma at -20°C as soon a s possible.

/ /

/ /



Samples to be sent by overnight courier (Monday to Wednesday) packed on dry ice in an insulated container.

Address for delivery :-

Samples to be sent packed on dry ice in an insulated container to:

Gareth Veal /Julie Errington Contact numbers:-

Northern Institute for Cancer Research Gareth Veal: +44 (0)191 246 4332

Paul O’Gorman Building Julie Errington: +44 (0)191 246 4357

North Terrace Fax: +44 (0)191 222 3452

Newcastle upon Tyne Email : [email protected]

NE2 4AD [email protected]

United Kingdom



APPENDIX F: CLASSIFICATION CTC-AE (VERSION 4.0)

National Cancer Institute - Common Terminology Criteria for Adverse Events

(NCI-CTCAE, Version 4.0)

http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40

http://ctep.cancer.gov/


APPENDIX G: TOXICITY AFTER HIGH DOSE CHEMOTHERAPY ( BEARMAN GRADING)

Grade I Grade II Grade III

Cardiac Mild EKG abnormality, not requiring medical intervention; or noted heart enlargement on CXR with no clinical symptoms

Moderate EKG abnormalities requiring and responding to medical intervention; or requiring continuous monitoring without treatment, or congestive heart failure responsive to digitalis or diuretics.

Severe EKG abnormalities with no or only partial response to medical intervention; or heart failure with no or only minor response to medical intervention; or decrease in voltage by more than 50%.

Bladder Macroscopic haematuria after 2 days from last chemotherapy dose with no subjective symptoms of cystitis and not caused by infection.

Macroscopic haematuria after 7 days from last chemotherapy dose not caused by infection; or haematuria after 2 days with subjective symptoms of cystitis not caused by infection .

Haemorrhagic cystitis with frank blood, necessitating invasive local intervention with installation of sclerosing agents, nephrostomy or other surgical procedure.

Renal Increase in creatinine up to twice the baseline value (usually the last recorded before start of conditioning).

Increase in creatinine above twice baseline but not requiring dialysis.

Requirement of dialysis.

Pulmonary Dyspnoea without CXR changes not caused by infection or congestive heart failure; or CXR showing isolated infiltrate or mild interstitial changes without symptoms not caused by infection or congestive heart failure.

CXR with extensive localised infiltrate or moderate interstitial changes combined with dyspnoea and not caused by infection or CHF; or decrease of PO2 (>10% from baseline) but not requiring mechanical ventilation or >50% O2 on mask and not caused by infection or CHF.

Interstitial changes requiring mechanical ventilatory support or >50% oxygen on mask and not caused by infection or CHF.

Liver Mild hepatic dysfunction with 2.0 mg% � bilirubin 6.0mg%; or weight gain �2.5% and �5% from baseline, of noncardiac origin; or SGOT increase more than 2-fold but less than 5-fold from lowest preconditioning.

Moderate hepatic dysfunction with bilirubin �6mg% �20mg%, or SGOT increase � 5-fold from preconditioning ; or clinical ascites or image documented ascites �100ml, or weight gain �5% from baseline of noncardiac origin.

Severe hepatic dysfunction with bilirubin �20mg%; or hepatic encephalopathy; or ascites compromising respiratory function.

CNS Somnolence but the patient is easily arousable and orientated after arousal.

Somnolence with confusion after arousal, or other new objective CNS symptoms with no loss of consciousness not more easily explained by other medication, bleeding, or CNS infection.

Seizures or coma not explained (documented) by other medication, CNS infection, or bleeding.

Stomatitis Pain and/or ulceration not requiring a continuous IV narcotic drug.

Pain and/or ulceration requiring a continuous IV narcotic drug (morphine drip).

Severe ulceration and/or mucositis requiring preventive intubation; or resulting in documented aspiration pneumonia with or without intubation.

Digestive Watery stools � 500ml but �2,000ml every day not related to infection.

Watery stools �2,000ml every day not related to infection; or macroscopic haemorrhagic stools with no effect on cardiovascular status not caused by infection; or subileus not related to infection.

Ileus requiring nasogastric suction and/or surgery and not related to infection; or haemorrhagic enterocolitis affecting cardiovascular status and requiring transfusion.

Code promoteur CSET n°

Page 87 sur 91

APPENDIX H: STATISTICAL MODEL, SPECIFIC RULES AND OPERATING CHARACTERISTICS OF PHASE I DESIGN

Statistical model : A one-parameter empirical power model will be used to assess the

relation between the dose level and the probability of DLT: )exp(),( αα dpdF = where F(d,α) is

the estimated probability of DLT at dose-level d, pd is the prior probability of DLT at dose

level d, and α is the unknown parameter to be estimated by the model. The vector {p0d}

represent the initial guesses of toxicity probabilities, reflecting the clinicians’ prior belief.

The skeleton of initial guesses of toxicity probabilities {p0d} is numerically calibrated using

the Lee and Cheung approach (ref ClinTrials 2009) and using the getprior function of R,

ensuring good design’s operating characteristics. After discussion with the clinicians, the

delta defining the indifference interval was set at 0.7 (indifference interval: 0.23 to 0.37)

and the prior MTD (MTD0) at the 3rd dose level, meaning that the clinicians believe, a

priori, that the 3rd dose (1500 mg/m²) is probably the MTD. This yields a vector of prior

probabilities {p0k} equal to 0.07, 0.17, 0.30, and 0.44. The clinicians confirmed that it was

in accordance with their initial guesses.

A non-informative prior distribution Normal (0,1.34) has been assigned for α in the

Bayesian computation.

The simulation study below confirmed that the operating characteristics and the behaviour

of the model defined with these parameters were reasonable.

Specific rules:

a. No dose skipping in escalation.

b. No escalation if >1 DLT observed among < 3 patients.

c. If a grade 3 pulmonary toxicity is observed, the corresponding dose level will be

closed.

d. For the first two dose levels, the patients can be recruited with no minimal time

interval between successive inclusions. A safety period of one month will be used

for the first patients at dose levels 3 and 4, that is, a second patient will be treated

at the dose level 3 (or 4) only after the first patient treated at this dose has been

fully observed and no grade 3 pulmonary toxicity occurred.

e. At least two patients fully observed with no DLT are required at a given dose before

dose escalation.


Page 88 sur 91

Operating characteristics:

The operating characteristics of the proposed design were evaluated using the R crmsim

function written by Cheung, and considering five different scenarios (highly toxic,

moderately toxic, similar with prior probabilities, close to the probabilities but a little less

toxic, and little toxic) and with cohort sizes successively equal to 1, 2 or 3. Considering

that approximately 50% of all study patients should enter the phase I part of the trial, we

considered that the phase 1 trial would recruit a total of 24 patients for the simulation

study. The rules a. and b. were implemented in the simulation study.

For each case, 1000 trials were simulated. The Monte Carlo estimation of the percentage

of dose selection, the average number of patients treated at each dose level, the average

number of observed DLTs at each dose level demonstrated that the modified CRM design

can efficiently identify the MTD, with a reasonable probability of overdosing, and expose

few patients to toxicity. Results in terms of the distribution of dose selection were very

similar when the cohort size varied from 1 to 3. The tables below display the results for

cohorts of 1 patient. Additional results are available in appendix X (Plots of the results

according to the cohort size = 1, 2 or 3).

Figure 1: Scenarios studied


Page 89 sur 91

Table 1 : Operating characteristics for five differ ent scenarios for the probability of DLT per dose

The grey row represents the true MTD (proba(DLT) closest to the target of 0.30. Scenario 1 Dose Level Prior Prob

True Proba(DLT)

% of dose selection

Mean no of patients

Mean no of DLTs

80 7% 29% 0.51 12.0 3.5 120 17% 35% 0.33 6.8 2.4 160 30% 45% 0.14 3.7 1.6 200 44% 55% 0.02 1.4 0.8

Expected number of DLTs = 8.3 / trial Scenario 2 Dose Level Prior Prob

True Proba(DLT)

% of dose selection

Mean no of patients

Mean no of DLTs

80 7% 10% 0.06 4.1 0.4 120 17% 27% 0.48 8.9 2.4 160 30% 36% 0.37 7.3 2.6 200 44% 48% 0.09 3.6 1.8

Expected number of DLTs = 7.2 / trial Scenario 3: prior = true proba(DLT) Dose Level Prior Prob

True Proba(DLT)

% of dose selection

Mean no of patients

Mean no of DLTs

80 7% 7% 0.01 2.2 0.1 120 17% 17% 0.22 6.3 1.0 160 30% 30% 0.56 9.4 2.8 200 44% 44% 0.22 6.2 2.7


True Proba(DLT)

% of dose selection

Mean no of patients

Mean no of DLTs

80 7% 5% 0.00 1.7 0.1 120 17% 12% 0.11 4.5 0.5 160 30% 28% 0.48 8.6 2.4 200 44% 35% 0.41 9.2 3.2


True Proba(DLT)

% of dose selection

Mean no of patients

Mean no of DLTs

80 7% 1% 0.00 1.1 0.0 120 17% 5% 0.00 1.5 0.1 160 30% 10% 0.05 3.1 0.3 200 44% 20% 0.95 18.2 3.6

Expected number of DLTs = 4.0 / trial


Page 90 sur 91

Examples of behaviour of the step by step design (D L=Dose Level)

Escalation to DL2, if

- 0 DLT / 2 patients DL1

- 1 DLT / > 4 patients DL1


If 0 DLT / 2 (or 3) patients at DL1, then escalation at DL2. Escalation at DL3 if



(the model recommends DL3 if 0 DLT / 3 DL1 + 1 DLT / 3 DL2,

but rule b � 4 DL2 requested before escalation)


If 1 DLT / 4 patients at DL1, then escalation at DL2. Escalation at DL3 if



Very conservative approach if one DLT occurs at DL1.


Page 91 sur 91

Design performance according to the cohort size

Percentage of dose selection

Average number of patients treated at each

dose level

Average number of observed DLTs at each

dose level

Sce

nario

1

Percentage of dose selection according to cohort size, m

0

0.2

0.4

0.6

0.8

1

500 1000 1500 2000

Dose level

Pe

rce

nta

ge o

f se

lect

ion m=1

m=2m=3


0

0.2

0.4

0.6

0.8

1

500 1000 1500 2000

Dose level

Pe

rce

nta

ge o

f se

lect

ion m=1

m=2m=3


0

0.2

0.4

0.6

0.8

1

500 1000 1500 2000

Dose level

Pe

rce

nta

ge o

f se

lect

ion m=1

m=2m=3

Sce

nario

2


0

0.2

0.4

0.6

0.8

1

500 1000 1500 2000

Dose level

Pe

rce

nta

ge o

f se

lect

ion m=1

m=2m=3


0

0.2

0.4

0.6

0.8

1

500 1000 1500 2000

Dose level

Pe

rce

nta

ge o

f se

lect

ion m=1

m=2m=3

Number of DLTsaccording to cohort size, m

0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3

Sce

nario

3


0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3


0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3


0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3

Sce

nario

4


0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3


0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3

Number of DLTs according to cohort size, m

0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3

Sce

nario

5


0

0.2

0.4

0.6

0.8

1

500 1000 1500 2000

Dose level

Pe

rce

nta

ge o

f se

lect

ion m=1m=2m=3

Dose allocation in the trialaccording to cohort size, m

0

5

10

15

20

500 1000 1500 2000

Dose level

Num

ber o

f pat

ient

s

m=1m=2m=3


0

1

2

3

4

5

500 1000 1500 2000

Dose level

Nu

mb

er o

f DL

Ts

m=1m=2m=3

80 120 160 200 80 120 160 200 80 120 160 200

80 120 160 200 80 120 160 200 80 120 160 200

80 120 160 200 80 120 160 200 80 120 160 200

80 120 160 200 80 120 160 200 80 120 160 200

80 120 160 200 80 120 160 200 80 120 160 200

Documents

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