Autologous Transplant Followed by Allogeneic Transplant for High Risk Neuroblastoma

• To study the feasibility and toxicity of administering sequential MAT/AutoSCT and NAT/AlloSCT in patients with high-risk neuroblastoma. [ Time Frame: 1 year ] [ Designated as safety issue: Yes ]
• To determine the rate and durability of engraftment following NAT/AlloSCT from either a related donor or umbilical cord donor. [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• To determine the overall and disease free survival (DFS) of patients with high-risk neuroblastoma receiving sequential MAT/AutoSCT and NAT/AlloSCT. [ Time Frame: 5 years ] [ Designated as safety issue: No ]

• To determine the toxicity of a consolidation myeloablative chemotherapy of topotecan, carboplatin, and thiotepa. [ Time Frame: 1 year ] [ Designated as safety issue: Yes ]
• To determine the response rate of consolidation myeloablative chemotherapy of topotecan, carboplatin, and thiotepa in patients with measurable disease prior to MAT/AutoSCT. [ Time Frame: 6 months ] [ Designated as safety issue: No ]
• To determine the incidence of acute and chronic GVHD following NAT/AlloSCT and its relationship to DFS in patients with high-risk neuroblastoma. [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• To quantitate minimal residual disease status using immunocytochemistry, and RT PCR for GAGE and tyrosine hydroxylase. [ Time Frame: 1 year ] [ Designated as safety issue: No ]
• To determine immune reconstitution after NAT/AlloSCT in patients with high-risk neuroblastoma. [ Time Frame: 2 years ] [ Designated as safety issue: No ]

HYPOTHESIS: The combination of high dose induction chemotherapy, followed by consolidation with myeloablative therapy (MAT) and autologous stem cell transplant (AutoSCT), followed by immunotherapy with non-myeloablative therapy (NAT) and allogeneic stem cell transplant (AlloSCT) from either a related donor or umbilical cord donor, will be well tolerated, and provide information to develop future randomized trials testing the role of NAT/AlloSCT in patients with high-risk neuroblastoma after undergoing MAT/AutoSCT.

Despite the modest advances made over the past two decades with the addition of more intensive chemotherapy and high dose myeloablative therapy with allogeneic or autologous bone marrow transplantation, children with high-risk neuroblastoma continue to have an unsatisfactory long-term survival. The current survival for a child > 1 year of age at diagnosis with stage 4 neuroblastoma is only 20-35% 1,7. The overall treatment plan for high-risk patients with neuroblastoma will be:

Induction Therapy Intensive induction chemotherapy with the cardioprotectant dexrazoxane (Zinecard), vincristine, doxorubicin (Adriamycin), and cyclophosphamide (ZVAC), alternating with cisplatin and etoposide (CiE). Patients who receive induction chemotherapy on an alternate protocol and achieve a CR, VGPR, or PR will also be eligible for entry to receive consolidation therapy and AlloSCT immunotherapy after discussion and approval of the Principal Investigators ).

Consolidation Therapy with AutoSCT Consolidation therapy with a myeloablative preparative regimen of carboplatin, thiotepa, and topotecan (CaTT) followed by AutoSCT with PBSCs (CD34+ selection optional).

Immunotherapy with Non-myeloablative AlloSCT Immunotherapy with a non-myeloablative preparative regimen of busulfan and fludarabine followed by AlloSCT with either: (Arm A) a related donor (5/6 or 6/6 HLA matched); or (Arm B) an umbilical cord blood donor (unrelated 4/6, 5/6, or 6/6 HLA matched, or related 3/6, 4/6, 5/6, or 6/6 HLA matched). Patients with an umbilical cord blood donor will also receive Thymoglobulin (ATG-rabbit) during the preparative regimen. GVHD prophylaxis will consist of Tacrolimus and mycophenolate mofetil (MMF).

Maintenance Therapy Patients with a related donor who have persistent disease detected prior to NAT/AlloSCT will be assigned to Arm A1 and will receive two courses of DLI, followed by cis-RA for 6 cycles. Patients with a related donor with no persistent disease detected prior to NAT/AlloSCT will be assigned to Arm A2 and receive cis-RA for 6 cycles. Patients with an umbilical cord blood donor will receive cis-RA for 6 cycles.

Radiation Therapy Due to the potential risk of increased GVHD following radiation therapy, local radiation therapy to the primary tumor site (21 Gy) and metastatic sites, will be given after NAT/AlloSCT for patients on Arm A2 and Arm B, and prior to cis-RA therapy. Radiation therapy will be given following DLI in Arm A1, and prior to cis-RA therapy.

• Procedure: Related donor stem cell transplant
  Patients with a related donor will get reduced intensity transplant conditioning with busulfan and fludarabine.
• Procedure: unrelated cord blood transplant
  patients with an matched unrelated cord blood donor will get reduced intensity conditioning with busulfan, fludarabine, and ATG.

• Experimental: Arm A
  Related Donor
  Intervention: Procedure: Related donor stem cell transplant
• Experimental: Arm B
  Cord Blood donor
  Intervention: Procedure: unrelated cord blood transplant

Inclusion Criteria:

• Age be < 30 years of age at the time of initial diagnosis.
• Patients must have a diagnosis of neuroblastoma (ICD-O morphology 9500/3) verified by histology and/or demonstration of clumps of tumor cells in bone marrow with elevated urinary catecholamine metabolites. Patients with the following disease stages at diagnosis are eligible, if they meet the other specified criteria. The revised International Neuroblastoma Staging System (INSS) will be used to stage all patients 58. (See 14.3 for risk assignment).

• Patients with newly diagnosed neuroblastoma and age > 547 days with the following:

  • INSS Stage 4 neuroblastoma regardless of biologic factors
  • INSS Stage 2A/2B with MYCN amplification (> 10)
  • INSS Stage 3 with MYCN amplification (> 10) OR Unfavorable histology

• Patients with newly diagnosed neuroblastoma and age < 365 days with the following:

  * INSS Stage 3, 4, OR 4S neuroblastoma AND MYCN amplification (> 10).

• Patients with newly diagnosed Neuroblastoma and age 365 - <547 days with the following:

  • INSS Stage 3 with MYCN amplification (> 10)
  • INSS Stage 4 with MYCN amplification (> 10) OR with DNA Index (ploidy) = 1 OR with Unfavorable histology
• Patients > 365 days with INSS Stage 1, 2, and 4S who have progressed to Stage 4.
• Newly Diagnosed patients should be entered on this study within 4 weeks of diagnosis, or after receiving only one cycle of intermediate dose chemotherapy for patients initially treated on/according to the low or intermediate risk COG neuroblastoma studies, or within 4 weeks of progression to Stage 4 for INSS Stage 1, 2, 4S.
• Patients treated with alternative induction regimens and/or consolidation regimens (AutoSCT) who were not enrolled at diagnosis but who achieve a CR, VGPR, PR, or MR and meet all other criteria will be eligible for either the consolidation MAT/AutoSCT and NAT/AlloSCT immunotherapy or NAT/AlloSCT, which ever is clinically appropriate after discussion with the Principal Investigators.
• Liver Function: ALT and bilirubin < 3x normal
• Cardiac Function: Shortening fraction > 27%, or ejection fraction > 47%, no clinical congestive heart failure.
• Renal Function: Creatinine clearance and/or GFR > 60 ml/min/1.73m2.
• Hematologic Function: Patients must have adequate hematopoietic function (ANC > 1000/mm3 and platelets > 100,000/mm3) unless inadequate hematopoiesis documented to be due to bone marrow involvement with tumor (> 10% tumor infiltration).

Exclusion Criteria:

• Patients who are pregnant. Patients of childbearing potential must practice an effective method of birth control while participating on this study.