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Standard Risk B-precursor Acute Lymphoblastic Leukemia


Phase 3
1 Year
9 Years
Open (Enrolling)
Both
Leukemia

Thank you

Trial Information

Standard Risk B-precursor Acute Lymphoblastic Leukemia


OBJECTIVES:

Primary

- Compare event-free survival of pediatric patients with newly diagnosed, standard-risk
(SR)-average, B-precursor acute lymphoblastic leukemia (ALL) treated with induction
therapy followed by 1 of 4 intensified phases of post-induction therapy.

- Compare event-free survival of pediatric patients with SR-low ALL treated with
consolidation and interim maintenance therapy with or without additional pegaspargase.

Secondary

- Correlate day 29 minimal residual disease (MRD) status with event-free survival and
overall survival of patients treated with these regimens.

- Correlate early marrow response with day 29 MRD status in patients treated with these
regimens.

- Determine whether outcome is improved for SR-high patients by identifying these
patients by day 29 MRD status and subsequently treating these patients with a fully
augmented Berlin Frankfurt Munster regimen.

- Correlate relative contributions of genetic factors and early treatment response with
outcome in patients treated with these regimens.

OUTLINE: This is a 2-part, partially randomized, multicenter study. Patients are stratified
according to early response to study induction therapy (rapid early response [standard risk
(SR)-low or SR-average acute lymphoblastic leukemia (ALL)] vs slow early response [SR-high
ALL]). After completion of induction therapy but before proceeding to part II therapy,
patients are assigned to 1 of 3 groups based on stratification.

Part I

- Induction therapy: All patients receive cytarabine intrathecally (IT) on day 1;
vincristine IV on days 1, 8, 15, and 22; dexamethasone IV or orally twice daily on days
1-28; pegaspargase intramuscularly (IM) (may give IV over 1 to 2 hours) on day 4, 5, or
6; and methotrexate IT on days 8 and 29 (and days 15 and 22 for patients with CNS3
disease). Patients with Down syndrome (DS) receive oral leucovorin calcium at 48 and 60
hours after each dose of methotrexate IT .

Patients are assessed for response on day 29. Patients with M1 bone marrow AND minimal
residual disease (MRD) < 0.1% OR MRD ≥ 0.1% and < 1% proceed to therapy in part II. Patients
with M2 bone marrow OR M1 bone marrow AND MRD ≥ 1% proceed to extended induction therapy.
Patients with M3 bone marrow are removed from the study.

- Extended induction therapy: Patients receive dexamethasone IV or orally twice daily on
days 1-14; vincristine IV on days 1 and 8; pegaspargase IM on day 4, 5, or 6; and
daunorubicin hydrochloride IV over 15 minutes to 2 hours on day 1.

Patients with M1 bone marrow and MRD < 1% after extended induction therapy proceed to
therapy in part II. Patients with M2 or M3 bone marrow after extended induction therapy are
removed from the study.

Part II

- Group 1 (SR-low ALL): Patients are randomized to 1 of 2 treatment arms.

- Arm I:

- Standard consolidation therapy: Patients receive vincristine IV on day 1;
oral mercaptopurine on days 1-28; and methotrexate IT on days 1, 8, and 15.
Patients with Down syndrome (DS) receive oral leucovorin calcium at 48 and 60
hours after each dose of methotrexate IT.

- Standard interim maintenance therapy: Patients receive vincristine IV on days
1 and 29; dexamethasone IV or orally twice daily on days 1-5 and 29-33; oral
mercaptopurine on days 1-50; oral methotrexate on days 1, 8, 15, 22, 29, 36,
43, and 50; and methotrexate IT on day 29. Patients with DS receive oral
leucovorin calcium at 48 and 60 hours after each dose of methotrexate IT.

- Standard delayed intensification (DI) therapy: Patients receive vincristine
IV on days 1, 8, and 15; dexamethasone IV or orally twice daily on days 1-21;
doxorubicin hydrochloride IV over 15 minutes to 2 hours on days 1, 8, and 15;
pegaspargase IM on day 4, 5, or 6; cyclophosphamide IV over 30 minutes on day
29; cytarabine IV or subcutaneously (SC) on days 29-32 and 36-39; oral
thioguanine on days 29-42; and methotrexate IT on days 1 and 29. Patients
with DS receive dexamethasone IV or orally twice daily on days 1-7 and 15-21
and oral leucovorin calcium at 48 and 60 hours after each dose of
methotrexate IT.

- Arm II:

- Experimental consolidation therapy: Patients receive vincristine,
mercaptopurine, methotrexate, and leucovorin calcium as in arm I and
pegaspargase IM on days 1 and 22.

- Experimental interim maintenance therapy: Patients receive vincristine,
dexamethasone, mercaptopurine, oral methotrexate, and methotrexate IT as in
arm I and pegaspargase IM on days 15 and 36.

- Standard DI therapy: Patients receive standard DI therapy as in arm I.

- Group 2 (SR-average ALL): Patients are randomized to 1 of 4 treatment arms.

- Arm I: Patients receive standard consolidation therapy, standard interim
maintenance therapy, and standard DI therapy as in group 1, arm I.

- Arm II:

- Standard consolidation therapy: Patients receive standard consolidation
therapy as in group 1, arm I.

- Augmented interim maintenance therapy: Patients receive vincristine IV and
methotrexate IV on days 1, 11, 21, 31, and 41; pegaspargase IM on days 2 and
22; and methotrexate IT on days 1 and 31. Patients with DS receive oral
leucovorin calcium at 48 and 60 hours after each dose of methotrexate IT.

- Augmented DI therapy: Patients receive vincristine IV on days 1, 8, 15, 43,
and 50; dexamethasone IV or orally twice daily on days 1-21; doxorubicin
hydrochloride IV over 15 minutes to 2 hours on days 1, 8, and 15;
pegaspargase IM on day 4, 5, or 6 AND day 43; cyclophosphamide IV over 30
minutes on day 29; cytarabine IV or SC on days 29-32 and 36-39; oral
thioguanine on days 29-42; and methotrexate IT on days 1, 29, and 36.
Patients with DS receive dexamethasone on days 1-7 and 15-21 and oral
leucovorin calcium at 48 and 60 hours after each dose of methotrexate IT.

- Arm III:

- Intensified consolidation therapy: Patients receive cyclophosphamide IV over
30 minutes on days 1 and 29; cytarabine IV or SC on days 1-4, 8-11, 29-32,
and 36-39; oral mercaptopurine on days 1-14 and 29-42; vincristine IV on days
15, 22, 43, and 50; pegaspargase IM on days 15 and 43; and methotrexate IT on
days 1, 8, 15*, and 22*. Patients with DS receive oral leucovorin calcium at
48 and 60 hours after each dose of methotrexate IT*.

NOTE: *Patients with CNS3 disease at diagnosis do not receive methotrexate on days 15 and 22
or leucovorin calcium

- Standard interim maintenance therapy: Patients receive standard interim maintenance
therapy as in group 1, arm I.

- Standard DI therapy: Patients receive standard DI therapy as in group 1, arm I.

- Arm IV:

- Intensified consolidation therapy: Patients receive intensified consolidation therapy
as in group 2, arm III.

- Augmented interim maintenance therapy: Patients receive augmented interim maintenance
therapy as in group 2, arm II.

- Augmented DI therapy: Patients receive augmented DI therapy as in group 2, arm II.

- Group 3 (SR-high ALL): Patients receive the following therapy:

- Intensified consolidation therapy: Patients receive intensified consolidation
therapy as in group 2, arm III.

- Augmented interim maintenance* therapy: Patients receive augmented interim
maintenance therapy as in group 2, arm II. Treatment repeats every 56 days
for 2 courses.

NOTE: *As of Amendment #7, all SR-High patients currently receiving AIM 1 therapy should
complete this phase of therapy and proceed to ADI 1 therapy as originally planned including
Capizzi methotrexate during AIM 1. Upon completion of ADI 1, patients should receive a
second Interim Maintenance phase with high-dose methotrexate (IM HD) rather than Capizzi
methotrexate. Patients should then proceed to ADI 2 and then Maintenance.

- Augmented DI* therapy: Patients receive augmented DI therapy as in group 2, arm II.
Treatment repeats every 56 days for 2 courses**.

NOTE: *As of Amendment #7, all SR-High patients currently receiving ADI 1 therapy should
complete this phase of therapy as originally planned. Upon completion of ADI 1, patients
should receive a second Interim Maintenance phase with IM HD. Patients should then proceed
to ADI 2 and then Maintenance.

NOTE: **Patients with CNS3 disease at diagnosis also undergo cranial radiotherapy on days
29-33 and 36-40 during course 2 only; these patients do not receive methotrexate on day 36,
thioguanine, or leucovorin calcium.

- Maintenance therapy: All patients receive vincristine IV on days 1, 29, and 57; oral
dexamethasone twice daily on days 1-5, 29-33, and 57-61; oral methotrexate on days 8,
15, 22, 29, 36, 43, 50, 57, 64, 71, and 78; oral mercaptopurine on days 1-84; and
methotrexate IT* on day 1. Courses repeat every 84 days for a total of 2 years from the
start of interim maintenance therapy for female patients and 3 years from the start of
interim maintenance therapy for male patients.

NOTE: *SR-High or CNS3 patients should receive up to a maximum of 23 intrathecal treatments
for females and 26 intrathecal treatments for males.

After the completion of study treatment, patients are followed every 1-2 months for 2 years,
every 3 months for 1 year, and then every 6-12 months for 2 years.

PROJECTED ACCRUAL: A total of 3,381 patients (1,576 for group 1,278 for group 2, and 527 for
group 3) will be accrued for this study within 4.25 years.

Inclusion Criteria


DISEASE CHARACTERISTICS:

- Newly diagnosed B-precursor acute lymphoblastic leukemia

- Standard-risk (SR) disease meeting 1 of the following criteria:

- SR-average by age and WBC

- No unfavorable features

- Rapid early responder (RER) by day 15

- CNS 1 or 2

- Minimal residual disease (MRD) negative on day 29

- Trisomies of 4, 10, and 17 or TEL-AML1 translocation and RER and CNS2
allowed

- SR-low by age and WBC

- No unfavorable features

- RER by day 15

- MRD negative on day 29

- CNS1

- Favorable cytogenetics-trisomies of 4, 10, and 17 or TEL-AML
translocation

- SR-high

- Unfavorable features meeting ≥ 1 of the following criteria:

- MLL rearrangements and RER

- Steroid pretreatment

- CNS3

- Slow early responder by morphology or MRD

- Patients with Down syndrome are allowed

- Concurrently enrolled on COG-AALL03B1

PATIENT CHARACTERISTICS:

Age

- 1 to under 10

Performance status

- Not specified

Life expectancy

- Not specified

Hematopoietic

- Initial WBC < 50,000/mm^3

Hepatic

- Not specified

Renal

- Not specified

PRIOR CONCURRENT THERAPY:

Biologic therapy

- Not specified

Chemotherapy

- No prior cytotoxic chemotherapy except intrathecal cytarabine

Endocrine therapy

- Prior steroid therapy allowed at the discretion of the investigator

- No contraindication to additional asparaginase therapy after induction for the
standard risk-low study

Radiotherapy

- No concurrent intensity-modulated radiotherapy

Surgery

- Not specified

Type of Study:

Interventional

Study Design:

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment

Outcome Measure:

Event-free survival (EFS) for SR-average

Outcome Description:

All power calculations are based on the assumption of proportional hazards, and using the log rank test (alpha = 0.05) with four planned analyses of the data for interim monitoring purposes. The 95% confidence interval for EFS for standard risk-high will also be computed

Outcome Time Frame:

Up to 6 years

Safety Issue:

No

Principal Investigator

Kelly Maloney, MD

Investigator Role:

Study Chair

Investigator Affiliation:

Children's Hospital Colorado Center for Cancer and Blood Disorders

Authority:

United States: Federal Government

Study ID:

AALL0331

NCT ID:

NCT00103285

Start Date:

January 2005

Completion Date:

Related Keywords:

  • Leukemia
  • untreated childhood acute lymphoblastic leukemia
  • B-cell childhood acute lymphoblastic leukemia
  • Leukemia
  • Leukemia, Lymphoid
  • Precursor Cell Lymphoblastic Leukemia-Lymphoma

Name

Location

Roswell Park Cancer Institute Buffalo, New York  14263
Memorial Sloan-Kettering Cancer Center New York, New York  10021
Children's Hospital of Philadelphia Philadelphia, Pennsylvania  19104
Mayo Clinic Cancer Center Rochester, Minnesota  55905
Cardinal Bernardin Cancer Center at Loyola University Medical Center Maywood, Illinois  60153-5500
Walter Reed Army Medical Center Washington, District of Columbia  20307-5000
University of Chicago Cancer Research Center Chicago, Illinois  60637
Barbara Ann Karmanos Cancer Institute Detroit, Michigan  48201
Duke Comprehensive Cancer Center Durham, North Carolina  27710
Tripler Army Medical Center Honolulu, Hawaii  96859-5000
Hurley Medical Center Flint, Michigan  48503
Medical City Dallas Hospital Dallas, Texas  75230
University of Texas Health Science Center at San Antonio San Antonio, Texas  78284-7811
CCOP - Kalamazoo Kalamazoo, Michigan  49007-3731
Presbyterian - St. Luke's Medical Center Denver, Colorado  80218
Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center Farmington, Connecticut  06360-2875
Baystate Regional Cancer Program at D'Amour Center for Cancer Care Springfield, Massachusetts  01199
Van Elslander Cancer Center at St. John Hospital and Medical Center Grosse Pointe Woods, Michigan  48236
CCOP - MeritCare Hospital Fargo, North Dakota  58122
Natalie Warren Bryant Cancer Center at St. Francis Hospital Tulsa, Oklahoma  74136
Sanford Cancer Center at Sanford USD Medical Center Sioux Falls, South Dakota  57117-5039
Vanderbilt-Ingram Cancer Center Nashville, Tennessee  37232-6838
University of Wisconsin Paul P. Carbone Comprehensive Cancer Center Madison, Wisconsin  53792-6164
Marshfield Clinic - Marshfield Center Marshfield, Wisconsin  54449
Newark Beth Israel Medical Center Newark, New Jersey  07112
New York Medical College Valhalla, New York  10595
Holden Comprehensive Cancer Center at University of Iowa Iowa City, Iowa  52242-1002
UMASS Memorial Cancer Center - University Campus Worcester, Massachusetts  01605-2982
Ellis Fischel Cancer Center at University of Missouri - Columbia Columbia, Missouri  65203
Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire  03756-0002
Lineberger Comprehensive Cancer Center at University of North Carolina - Chapel Hill Chapel Hill, North Carolina  27599-7570
CCOP - Scott and White Hospital Temple, Texas  76508
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Baltimore, Maryland  21231-2410
Cancer Research Center of Hawaii Honolulu, Hawaii  96813
Cleveland Clinic Taussig Cancer Center Cleveland, Ohio  44195
Sutter Cancer Center Sacramento, California  95816
Children's Hospital of Orange County Orange, California  92668
Children's National Medical Center Washington, District of Columbia  20010-2970
Children's Mercy Hospital Kansas City, Missouri  64108
St. Joseph's Hospital and Medical Center Paterson, New Jersey  07503
Children's Hospital and Regional Medical Center - Seattle Seattle, Washington  98105
University of California Davis Cancer Center Sacramento, California  95817
Nemours Children's Clinic Jacksonville, Florida  32207
Miami Children's Hospital Miami, Florida  33155-4069
All Children's Hospital St. Petersburg, Florida  33701
Children's Memorial Hospital - Chicago Chicago, Illinois  60614
Saint Jude Midwest Affiliate Peoria, Illinois  61637
Children's Hospital of New Orleans New Orleans, Louisiana  70118
Cardinal Glennon Children's Hospital Saint Louis, Missouri  63104
Schneider Children's Hospital New Hyde Park, New York  11042
St. Christopher's Hospital for Children Philadelphia, Pennsylvania  19134-1095
Driscoll Children's Hospital Corpus Christi, Texas  78466
Cook Children's Medical Center - Fort Worth Fort Worth, Texas  76104
Inova Fairfax Hospital Falls Church, Virginia  22042-3300
City of Hope Comprehensive Cancer Center Duarte, California  91010
Fletcher Allen Health Care - University Health Center Campus Burlington, Vermont  05401
Phoenix Children's Hospital Phoenix, Arizona  85016-7710
Southern California Permanente Medical Group Downey, California  90242
Children's Hospital Central California Madera, California  93638-8762
Kosair Children's Hospital Louisville, Kentucky  40202-3830
Palmetto Health South Carolina Cancer Center Columbia, South Carolina  29203
East Tennessee Children's Hospital Knoxville, Tennessee  37901
Covenant Children's Hospital Lubbock, Texas  79410
Children's Hospital of the King's Daughters Norfolk, Virginia  23507
Midwest Children's Cancer Center at Children's Hospital of Wisconsin Milwaukee, Wisconsin  53226
Arizona Cancer Center at University of Arizona Health Sciences Center Tucson, Arizona  85724
Arkansas Cancer Research Center at University of Arkansas for Medical Sciences Little Rock, Arkansas  72205
Kansas Masonic Cancer Research Institute at the University of Kansas Medical Center Kansas City, Kansas  66160-7353
Blumenthal Cancer Center at Carolinas Medical Center Charlotte, North Carolina  28232-2861
Overlook Hospital Summit, New Jersey  07902-0220
Winthrop University Hospital Mineola, New York  11501
Loma Linda University Cancer Institute at Loma Linda University Medical Center Loma Linda, California  92354
Jonathan Jaques Children's Cancer Center at Miller Children's Hospital Long Beach, California  90801
Kaiser Permanente Medical Center - Oakland Sacramento, California  95825
Santa Barbara Cottage Children's Hospital Santa Barbara, California  93105
Yale Cancer Center New Haven, Connecticut  06520-8028
Lee Cancer Care of Lee Memorial Health System Fort Myers, Florida  33901
Broward General Medical Center Cancer Center Ft. Lauderdale, Florida  33316
University of Florida Shands Cancer Center Gainesville, Florida  32610-0232
Baptist-South Miami Regional Cancer Program Miami, Florida  33176
Nemours Children's Clinic - Orlando Orlando, Florida  32806
Florida Hospital Cancer Institute at Florida Hospital Orlando Orlando, Florida  32803-1273
Sacred Heart Cancer Center at Sacred Heart Hospital Pensacola, Florida  32504
St. Joseph's Cancer Institute at St. Joseph's Hospital Tampa, Florida  33607
Kaplan Cancer Center at St. Mary's Medical Center West Palm Beach, Florida  33407
Winship Cancer Institute of Emory University Atlanta, Georgia  30322
St. Vincent Indianapolis Hospital Indianapolis, Indiana  46260
Blank Children's Hospital Des Moines, Iowa  50309
Alvin and Lois Lapidus Cancer Institute at Sinai Hospital Baltimore, Maryland  21215
Floating Hospital for Children at Tufts - New England Medical Center Boston, Massachusetts  02111
Breslin Cancer Center at Ingham Regional Medical Center Lansing, Michigan  48910
Hackensack University Medical Center Cancer Center Hackensack, New Jersey  07601
Albert Einstein Cancer Center at Albert Einstein College of Medicine Bronx, New York  10461
NYU Cancer Institute at New York University Medical Center New York, New York  10016
Mount Sinai Medical Center New York, New York  10029
Stony Brook University Cancer Center Stony Brook, New York  11794-8174
SUNY Upstate Medical University Hospital Syracuse, New York  13210
Mission Hospitals - Memorial Campus Asheville, North Carolina  28801
Presbyterian Cancer Center at Presbyterian Hospital Charlotte, North Carolina  28233-3549
Wake Forest University Comprehensive Cancer Center Winston-Salem, North Carolina  27157-1096
Cincinnati Children's Hospital Medical Center Cincinnati, Ohio  45229-3039
Rainbow Babies and Children's Hospital Cleveland, Ohio  44106-5000
Medical University of Ohio Cancer Center Toledo, Ohio  43614
Toledo Hospital Toledo, Ohio  43606
Rhode Island Hospital Comprehensive Cancer Center Providence, Rhode Island  02903
Hollings Cancer Center at Medical University of South Carolina Charleston, South Carolina  29425
Texas Tech University Health Sciences Center School of Medicine - Amarillo Amarillo, Texas  79106
Simmons Comprehensive Cancer Center at University of Texas Southwestern Medical Center - Dallas Dallas, Texas  75390
Baylor University Medical Center - Houston Houston, Texas  77030-2399
Methodist Children's Hospital of South Texas San Antonio, Texas  78229-3993
Primary Children's Medical Center Salt Lake City, Utah  84113-1100
Naval Medical Center - Portsmouth Portsmouth, Virginia  23708-2197
Providence Cancer Center at Sacred Heart Medical Center Spokane, Washington  99220-2555
St. Vincent Hospital Regional Cancer Center Green Bay, Wisconsin  54307-3508
Saint Peter's University Hospital New Brunswick, New Jersey  08901-1780
William Beaumont Hospital - Royal Oak Campus Royal Oak, Michigan  48073
Greenebaum Cancer Center at University of Maryland Medical Center Baltimore, Maryland  21201
UNMC Eppley Cancer Center at the University of Nebraska Medical Center Omaha, Nebraska  68198-7680
Memorial Cancer Institute at Memorial Regional Hospital Hollywood, Florida  33021
New York Weill Cornell Cancer Center at Cornell University New York, New York  10021
University of South Alabama Mitchell Cancer Institute Mobile, Alabama  36604
Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center Los Angeles, California  90048-1865
Jonsson Comprehensive Cancer Center at UCLA Los Angeles, California  90095-1781
Childrens Hospital Los Angeles Los Angeles, California  90027
Children's Hospital and Research Center Oakland Oakland, California  94609
Rady Children's Hospital - San Diego San Diego, California  92123-4282
UCSF Helen Diller Family Comprehensive Cancer Center San Francisco, California  94115
Children's Hospital Center for Cancer and Blood Disorders Aurora, Colorado  80045
Alfred I. duPont Hospital for Children Wilmington, Delaware  19803
Lombardi Comprehensive Cancer Center at Georgetown University Medical Center Washington, District of Columbia  20007
M.D. Anderson Cancer Center at Orlando Orlando, Florida  32806
Curtis and Elizabeth Anderson Cancer Institute at Memorial Health University Medical Center Savannah, Georgia  31403-3089
Mountain States Tumor Institute at St. Luke's Regional Medical Center Boise, Idaho  83712-6297
University of Illinois Cancer Center Chicago, Illinois  60612-7243
Keyser Family Cancer Center at Advocate Hope Children's Hospital Oak Lawn, Illinois  60453
Advocate Lutheran General Cancer Care Center Park Ridge, Illinois  60068-1174
Simmons Cooper Cancer Institute Springfield, Illinois  62794-9677
Indiana University Melvin and Bren Simon Cancer Center Indianapolis, Indiana  46202-5289
Lucille P. Markey Cancer Center at University of Kentucky Lexington, Kentucky  40536-0093
Tulane Cancer Center Office of Clinical Research Alexandria, Louisiana  71315-3198
CancerCare of Maine at Eastern Maine Medical Center Bangor, Maine  04401
Maine Children's Cancer Program at Barbara Bush Children's Hospital Scarborough, Maine  04074-9308
C.S. Mott Children's Hospital at University of Michigan Medical Center Ann Arbor, Michigan  48109-0286
Butterworth Hospital at Spectrum Health Grand Rapids, Michigan  49503-2560
Masonic Cancer Center at University of Minnesota Minneapolis, Minnesota  55455
Children's Hospitals and Clinics of Minnesota - Minneapolis Minneapolis, Minnesota  55404
University of Mississippi Cancer Clinic Jackson, Mississippi  39216-4505
Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis St. Louis, Missouri  63110
Children's Hospital Omaha, Nebraska  68114-4113
CCOP - Nevada Cancer Research Foundation Las Vegas, Nevada  89109-2306
Cancer Institute of New Jersey at UMDNJ - Robert Wood Johnson Medical School New Brunswick, New Jersey  08903
University of New Mexico Cancer Center Albuquerque, New Mexico  87131-5636
Albany Medical Center Hospital Albany, New York  12208-3419
Akron Children's Hospital Akron, Ohio  44308-1062
Nationwide Children's Hospital Columbus, Ohio  43205-2696
Dayton Children's - Dayton Dayton, Ohio  45404-1815
Oklahoma University Cancer Institute Oklahoma City, Oklahoma  73104
Knight Cancer Institute at Oregon Health and Science University Portland, Oregon  97239-3098
Legacy Emanuel Hospital and Health Center and Children's Hospital Portland, Oregon  97227
Geisinger Cancer Institute at Geisinger Health Danville, Pennsylvania  17822-0001
Children's Hospital of Pittsburgh of UPMC Pittsburgh, Pennsylvania  15213
Dell Children's Medical Center of Central Texas Austin, Texas  78723
M. D. Anderson Cancer Center at University of Texas Houston, Texas  77030-4009
Virginia Commonwealth University Massey Cancer Center Richmond, Virginia  23298-0037
Carilion Medical Center for Children at Roanoke Community Hospital Roanoke, Virginia  24014
Madigan Army Medical Center - Tacoma Tacoma, Washington  98431
Mary Bridge Children's Hospital and Health Center - Tacoma Tacoma, Washington  98405
West Virginia University Health Sciences Center - Charleston Charleston, West Virginia  25302
University of Virginia Cancer Center Charlottesville, Virginia  22908
Massachusetts General Hospital Boston, Massachusetts  02114-2617
UAB Comprehensive Cancer Center Birmingham, Alabama  35294
Stanford Cancer Center Stanford, California  94305-5824
University of Miami Sylvester Comprehensive Cancer Center - Miami Miami, Florida  33136
Leo W. Jenkins Cancer Center at ECU Medical School Greenville, North Carolina  27834
Lehigh Valley Hospital - Muhlenberg Bethlehem, Pennsylvania  18017
Penn State Hershey Cancer Institute at Milton S. Hershey Medical Center Hershey, Pennsylvania  17033-0850
Greenville Hospital Cancer Center Greenville, South Carolina  29605
T.C. Thompson Children's Hospital Chattanooga, Tennessee  37403
Banner Desert Medical Center Mesa, Arizona  85202