F Berthold1, A Faldum2, A Ernst3, J Boos4, D Dilloo5, A Eggert6, M Fischer7, M Frühwald8, G Henze9, T Klingebiel10, C Kratz11, B Kremens12, B Krug13, I Leuschner14, M Schmidt15, R Schmidt2, R Schumacher-Kuckelkorn16, D von Schweinitz17, F H Schilling18, J Theissen16, R Volland16, B Hero16, T Simon16. 1. Department of Pediatric Oncology and Hematology, University of Cologne, Cologne, Germany. Electronic address: frank.berthold@uk-koeln.de. 2. Institute of Medical Statistics and Clinical Research, University of Muenster, Muenster, Germany. 3. Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany. 4. Department of Pediatric Oncology and Hematology, University of Muenster, Muenster, Germany. 5. Department of Pediatric Oncology and Hematology, University of Bonn, Bonn, Germany. 6. Department of Pediatric Oncology and Hematology, Charité Universitätsmedizin Berlin and Berlin Institute of Health, Berlin, Germany. 7. Department of Experimental Pediatric Oncology and Center for Molecular Medicine, Medical Faculty, University of Cologne, Cologne, Germany. 8. Swabian Children's Cancer Center, Children's Hospital, University Hospital Augsburg, Augsburg, Germany. 9. Department of Pediatric Oncology and Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany. 10. Department of Children and Adolescents, University Hospital, Goethe University Frankfurt (Main), Frankfurt am Main, Germany. 11. Department of Pediatric Oncology and Hematology, Medicinal University, Hannover, Germany. 12. Department of Pediatric Oncology and Hematology, University of Essen, Essen, Germany. 13. Institute of Diagnostic and Interventional Radiology, University of Cologne, Cologne, Germany. 14. Children's Tumor Registry, Institute of Pathology, University of Kiel, Kiel, Germany. 15. Department of Nuclear Medicine, University of Cologne, Cologne, Germany. 16. Department of Pediatric Oncology and Hematology, University of Cologne, Cologne, Germany. 17. Department of Pediatric Surgery, University of Munich, Munich, Germany. 18. Department of Pediatric Oncology and Hematology, Olgahospital Stuttgart, Stuttgart, Germany.
Abstract
BACKGROUND: Long-term survival of high-risk neuroblastoma patients is still below 50% despite intensive multimodal treatment. This trial aimed to address whether the addition of two topotecan-containing chemotherapy courses compared to standard induction therapy improves event-free survival (EFS) of these patients. PATIENTS AND METHODS: An open-label, multicenter, prospective randomized controlled trial was carried out at 58 hospitals in Germany and Switzerland. Patients aged 1-21 years with stage 4 neuroblastoma and patients aged 6 months to 21 years with MYCN-amplified tumors were eligible. The primary endpoint was EFS. Patients were randomly assigned to standard induction therapy with six chemotherapy courses or to experimental induction chemotherapy starting with two additional courses of topotecan, cyclophosphamide, and etoposide followed by standard induction chemotherapy (eight courses in total). After induction chemotherapy, all patients received high-dose chemotherapy with autologous hematopoietic stem cell rescue and isotretinoin for consolidation. Radiotherapy was applied to patients with active tumors at the end of induction chemotherapy. RESULTS: Of 536 patients enrolled in the trial, 422 were randomly assigned to the control arm (n = 211) and the experimental arm (n = 211); the median follow-up time was 3.32 years (interquartile range 1.65-5.92). At data lock, the 3-year EFS of experimental and control patients was 34% and 32% [95% confidence Interval (CI) 28% to 40% and 26% to 38%; P = 0.258], respectively. Similarly, the 3-year overall survival of the patients did not differ [54% and 48% (95% CI 46% to 62% and 40% to 56%), respectively; P = 0.558]. The response to induction chemotherapy was not different between the arms. The median number of non-fatal toxicities per patient was higher in the experimental group while the median number of toxicities per chemotherapy course was not different. CONCLUSION: While the burden for the patients was increased by prolonging the induction chemotherapy and the toxicity, the addition of two topotecan-containing chemotherapy courses did not improve the EFS of high-risk neuroblastoma patients and thus cannot be recommended. CLINICAL TRIALS. GOV NUMBER: NCT number 03042429.
BACKGROUND: Long-term survival of high-risk neuroblastoma patients is still below 50% despite intensive multimodal treatment. This trial aimed to address whether the addition of two topotecan-containing chemotherapy courses compared to standard induction therapy improves event-free survival (EFS) of these patients. PATIENTS AND METHODS: An open-label, multicenter, prospective randomized controlled trial was carried out at 58 hospitals in Germany and Switzerland. Patients aged 1-21 years with stage 4 neuroblastoma and patients aged 6 months to 21 years with MYCN-amplified tumors were eligible. The primary endpoint was EFS. Patients were randomly assigned to standard induction therapy with six chemotherapy courses or to experimental induction chemotherapy starting with two additional courses of topotecan, cyclophosphamide, and etoposide followed by standard induction chemotherapy (eight courses in total). After induction chemotherapy, all patients received high-dose chemotherapy with autologous hematopoietic stem cell rescue and isotretinoin for consolidation. Radiotherapy was applied to patients with active tumors at the end of induction chemotherapy. RESULTS: Of 536 patients enrolled in the trial, 422 were randomly assigned to the control arm (n = 211) and the experimental arm (n = 211); the median follow-up time was 3.32 years (interquartile range 1.65-5.92). At data lock, the 3-year EFS of experimental and control patients was 34% and 32% [95% confidence Interval (CI) 28% to 40% and 26% to 38%; P = 0.258], respectively. Similarly, the 3-year overall survival of the patients did not differ [54% and 48% (95% CI 46% to 62% and 40% to 56%), respectively; P = 0.558]. The response to induction chemotherapy was not different between the arms. The median number of non-fatal toxicities per patient was higher in the experimental group while the median number of toxicities per chemotherapy course was not different. CONCLUSION: While the burden for the patients was increased by prolonging the induction chemotherapy and the toxicity, the addition of two topotecan-containing chemotherapy courses did not improve the EFS of high-risk neuroblastoma patients and thus cannot be recommended. CLINICAL TRIALS. GOV NUMBER: NCT number 03042429.
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