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Risk-Based Treatment for Non-Rhabdomyosarcoma Soft Tissue Sarcomas (NRSTS) in Patients Under 30 Years of Age

Phase 3
29 Years
Open (Enrolling)
Adult Alveolar Soft-part Sarcoma, Adult Angiosarcoma, Adult Epithelioid Sarcoma, Adult Extraskeletal Chondrosarcoma, Adult Extraskeletal Osteosarcoma, Adult Fibrosarcoma, Adult Leiomyosarcoma, Adult Liposarcoma, Adult Malignant Fibrous Histiocytoma, Adult Malignant Hemangiopericytoma, Adult Malignant Mesenchymoma, Adult Neurofibrosarcoma, Adult Synovial Sarcoma, Childhood Alveolar Soft-part Sarcoma, Childhood Angiosarcoma, Childhood Epithelioid Sarcoma, Childhood Fibrosarcoma, Childhood Leiomyosarcoma, Childhood Liposarcoma, Childhood Malignant Mesenchymoma, Childhood Neurofibrosarcoma, Childhood Synovial Sarcoma, Chondrosarcoma, Dermatofibrosarcoma Protuberans, Localized Childhood Malignant Fibrous Histiocytoma of Bone, Metastatic Childhood Malignant Fibrous Histiocytoma of Bone, Metastatic Childhood Soft Tissue Sarcoma, Nonmetastatic Childhood Soft Tissue Sarcoma, Stage I Adult Soft Tissue Sarcoma, Stage II Adult Soft Tissue Sarcoma, Stage III Adult Soft Tissue Sarcoma, Stage IV Adult Soft Tissue Sarcoma

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Trial Information

Risk-Based Treatment for Non-Rhabdomyosarcoma Soft Tissue Sarcomas (NRSTS) in Patients Under 30 Years of Age


I. Define a risk-based treatment strategy comprising observation only, adjuvant
radiotherapy, or adjuvant chemoradiotherapy or neoadjuvant chemoradiotherapy, surgery, and
adjuvant chemotherapy with or without radiotherapy in young patients with
non-rhabdomyosarcoma soft tissue sarcoma (NRSTS).

II. Assess event-free and overall survival of patients treated with these regimens.

III. Assess the pattern of treatment failure in these patients.


I. Assess the feasibility of a neoadjuvant chemoradiotherapy approach in patients with - or
high-risk NRSTS.

II. Assess the imaging and pathologic responses to neoadjuvant chemoradiotherapy in patients
with intermediate- or high-risk NRSTS.

III. Correlate imaging and pathologic response with clinical outcomes in patients with
intermediate- or high-risk disease who undergo neoadjuvant chemoradiotherapy.

IV. Prospectively define clinical prognostic factors associated with event-free survival,
overall survival, local recurrence, and distant recurrence in these patients.

V. Correlate patient outcomes with findings of biologic studies performed on tissue
specimens collected on protocol COG-D9902 from these patients.

VI. Determine whether the diagnosis and histologic grade of NRSTS assigned by the enrolling
institution correlates with the diagnosis and histologic grade established by central expert
pathology reviewers.

VII. Compare the Pediatric Oncology Group (POG) and Fédération Nationale des Centres de
Lutte Contre le Cancer (French Federation of Cancer Centers [FNCLCC]) pathologic grading
systems to determine which better correlates with clinical outcomes.

OUTLINE: This is a multicenter study. Patients are divided into 3 risk groups according to
presence of metastatic disease (yes vs no), status of prior surgery (resected vs
unresected), grade of tumor (low vs high), and size of primary tumor (≤ 5 cm vs > 5 cm).
Patients are assigned to different treatment regimens based on disease extent (nonmetastatic
vs metastatic), tumor size (≤ 5 cm vs > 5 cm), extent of resection of primary tumor
(resected vs unresected), extent of resection of metastases (complete or microscopic
residual vs gross residual), microscopic tumor margins (negative vs positive), and tumor
grade (low vs high).

GROUP 1 (low risk [nonmetastatic, grossly resected disease, except high-grade tumor > 5
cm]): Patients with low-grade tumor with either negative or positive microscopic margins or
high-grade tumor ≤ 5 cm (in maximum diameter) with negative microscopic margins are assigned
to regimen A. Patients with high-grade tumor ≤ 5 cm (in maximum diameter) with positive
microscopic margins are assigned to regimen B.

REGIMEN A (observation only): Patients undergo observation only.

REGIMEN B (adjuvant radiotherapy): Beginning between 6-42 days after surgical resection,
patients undergo a total of 31 fractions of adjuvant radiotherapy.

GROUP 2 (intermediate risk [nonmetastatic, resected or unresected disease]): Patients with
grossly resected, high-grade tumor > 5 cm (in maximum diameter) are assigned to regimen C.
Patients with unresected tumor are assigned to regimen D.

REGIMEN C (adjuvant chemoradiotherapy): Patients receive ifosfamide IV over 3 hours on days
1-3 in weeks 1, 4, 7, 10, 13, and 16 and doxorubicin hydrochloride IV over 24 hours on days
1 and 2 in weeks 1, 4, 13, 16, and 19. Beginning in week 4, patients also undergo a total of
31 fractions of radiotherapy.

*NOTE: *Patients who receive brachytherapy will initiate radiotherapy in Week 1. If
brachytherapy is administered, chemotherapy should begin within 2 weeks of completion of
brachytherapy and the Weeks 1 and 19 doxorubicin should be given instead at Weeks 7 and 10.

REGIMEN D (neoadjuvant chemoradiotherapy, surgery, and adjuvant chemotherapy with or without
radiotherapy): Neoadjuvant chemoradiotherapy and surgery: Patients receive ifosfamide IV
over 3 hours on days 1-3 in weeks 1, 4, 7, and 10 and doxorubicin hydrochloride IV over 24
hours on days 1 and 2 in weeks 1 and 4. Beginning in week 4, patients also undergo a total
of 31 fractions of radiotherapy**. Patients undergo surgical resection in week 13.

NOTE: **Patients with primary hepatic tumors do not receive radiotherapy in week 4.

Adjuvant chemotherapy with or without radiotherapy: Patients receive ifosfamide IV over 3
hours on days 1-3 in weeks 16 and 19 and doxorubicin hydrochloride IV over 24 hours on days
1 and 2 in weeks 16, 19***, and 22. Beginning in week 16, patients achieving gross total
resection with positive microscopic margins undergo a total of 6 fractions of adjuvant
radiotherapy. Patients achieving less than total gross resection undergo a total of 11
fractions of adjuvant radiotherapy. Patients achieving total gross resection with negative
microscopic margins do not receive adjuvant radiotherapy.

NOTE: ***Patients who receive adjuvant radiotherapy in week 16 receive doxorubicin
hydrochloride in week 25 instead of week 19.

GROUP 3 (high risk [metastatic, resected, incompletely resected, or unresected disease]):
Patients with low-grade, all-sites resected tumor with either negative or positive
microscopic margins are assigned to receive treatment as in group 1 regimen A. Patients with
high-grade, grossly resected primary tumor, and metastatic disease are assigned to receive
treatment as in group 2 regimen C. Patients with unresected, high-grade metastatic tumor
are assigned to receive treatment as in group 2 regimen D.

In all groups, treatment continues in the absence of disease progression. After completing
study treatment, patients are followed periodically for at least 5 years.

Inclusion Criteria:

- Newly diagnosed non-rhabdomyosarcoma soft tissue sarcoma (STS), confirmed by central
pathology review via concurrent enrollment on protocol COG-D9902

- Metastatic or non metastatic disease

- Meets 1 of the following criteria:

- Intermediate (i.e., rarely metastasizing) or malignant STS, including any of the

- Adipocytic tumor, including liposarcoma of any of the following histology

- Dedifferentiated

- Myxoid

- Round cell

- Pleomorphic type

- Mixed-type

- Not otherwise specified (NOS)

- Fibroblastic/myofibroblastic tumors, including any of the following:

- Solitary fibrous tumor

- Hemangiopericytoma

- Low-grade myofibroblastic sarcoma

- Myxoinflammatory fibroblastic sarcoma

- Adult fibrosarcoma*

- Myxofibrosarcoma

- Low-grade fibromyxoid sarcoma or hyalinizing spindle-cell tumor

- Sclerosing epithelioid fibrosarcoma

- So-called fibrohistiocytic tumors, including any of the following:

- Plexiform fibrohistiocytic tumor

- Giant cell tumor of soft tissues

- Pleomorphic malignant fibrous histiocytoma (MFH)/undifferentiated
pleomorphic sarcoma

- Giant cell MFH/undifferentiated pleomorphic sarcoma with giant cells

- Inflammatory MFH/undifferentiated pleomorphic sarcoma with prominent

- Smooth muscle tumor (leiomyosarcoma)

- Pericytic [perivascular] tumor (malignant glomus tumor or glomangiosarcoma)

- Vascular tumor, including angiosarcoma

- Chondro-osseous tumors of any of the following types:

- Mesenchymal chondrosarcoma

- Extraskeletal osteosarcoma

- Tumors of uncertain differentiation, including any of the following:

- Angiomatoid fibrous histiocytoma

- Ossifying fibromyxoid tumor

- Myoepithelioma/parachordoma

- Synovial sarcoma

- Epithelioid sarcoma

- Alveolar soft-part sarcoma

- Clear cell sarcoma of soft tissue

- Extraskeletal myxoid chondrosarcoma ("chordoid type")

- Malignant mesenchymoma

- Neoplasms with perivascular epithelioid cell differentiation (PEComa)

- Clear cell myomelanocytic tumor

- Intimal sarcoma

- Malignant peripheral nerve sheath tumor

- Dermatofibrosarcoma protuberans meeting both of the following criteria:

- Non metastatic disease

- Tumor must be grossly resected prior to study enrollment

- Embryonal sarcoma of the liver

- Unclassified STS that is too undifferentiated to be placed in a specific
pathologic category (undifferentiated STS or STS NOS)

- Gross resection of the primary tumor ≤ 42 days prior to enrollment required except if
any of the following circumstances apply:

- Non metastatic high-grade tumor > 5 cm in maximal diameter and gross or
microscopic residual tumor is anticipated after resection

- Tumor of either high- or- low-grade that cannot be grossly excised without
unacceptable morbidity

- High-grade tumor with metastases

- Patients with metastatic low-grade tumor whose disease is amenable to gross
resection at all sites must undergo gross resection of all sites prior to
study entry

- Patients with a tumor recurrence after a gross total resection are not eligible

- Tumors arising in bone are not eligible

- Patients with epithelioid sarcoma, clear cell sarcoma, or clinical or radiologic
evidence of regional lymph node enlargement must undergo sentinel lymph node biopsies
or lymph node sampling to confirm the status of regional lymph nodes* NOTE: *Except
in cases where the study radiologist reviews the imaging and indicates that a biopsy
is not needed to confirm that the patient has lymph node involvement.

- If lymph node biopsies are positive for tumor (or the lymph nodes are classified
as positive by the study radiologist), formal lymph node dissection must be done
at the time of definitive surgery(prior to study entry for patients assigned to
study regimen C)

- Patients with metastatic disease must undergo a biopsy to confirm the presence of
metastatic tumor if all metastases are < 1 cm in maximal diameter (except in cases
where the study radiologist reviews the imaging and indicated that a biopsy is not
needed to confirm that the patient has metastatic disease)

- Lansky performance status (PS) 50-100% (for patients ≤ 16 years of age) OR Karnofsky
PS 50-100% (for patients > 16 years of age)

- Life expectancy ≥ 3 months

- Absolute neutrophil count ≥ 1,000/mm³*

- Platelet count ≥ 100,000/mm³*

- Creatinine clearance or radioisotope glomerular filtration rate ≥ 70 mL/min (≥ 40
mL/min for infants < 1 year of age)* or serum creatinine based on age and/or gender
as follows:

- 0.4 mg/dL (1 month to < 6 months of age)

- 0.5 mg/dL (6 months to < 1 year of age)

- 0.6 mg/dL (1 year to < 2 years of age)

- 0.8 mg/dL (2 years to < 6 years of age)

- 1.0 mg/dL (6 years to < 10 years of age)

- 1.2 mg/dL (10 years to < 13 years of age)

- 1.5 mg/dL (male) or 1.4 mg/dL (female) (13 years to < 16 years of age)

- 1.7 mg/dL (male) or 1.4 mg/dL (female) (≥ 16 years of age)

- Patients with urinary tract obstruction by tumor must meet the renal function
criteria listed above AND must have unimpeded urinary flow established via
decompression of the obstructed portion of the urinary tract

- Bilirubin ≤ 1.5 times upper limit of normal (ULN)*

- Shortening fraction ≥ 27% by echocardiogram* OR ejection fraction ≥ 50% by
radionuclide angiogram*

- Not pregnant or nursing (patients undergoing radiotherapy and/or chemotherapy)

- No nursing for ≥ 1 month after completion of study treatment in study regimens C
or D

- Fertile patients must use effective contraception during and for ≥ 1 month after
completion of study treatment

- Negative pregnancy test

- No evidence of dyspnea at rest*

- No exercise intolerance*

- Resting pulse oximetry reading > 94% on room air (for patients with respiratory

- No concurrent aprepitant during chemotherapy

- Prior treatment for cancer allowed provided the patient meet the prior therapy

- No prior anthracycline (e.g., doxorubicin or daunorubicin) or ifosfamide chemotherapy
for patients enrolled on arm C or arm D

- No prior radiotherapy to tumor-involved sites

Type of Study:


Study Design:

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

Outcome Measure:

Long-term survival for low-risk patients

Outcome Description:

A monitoring boundary located in some sense halfway between the O'Brien-Fleming and Pocock group sequential boundaries to monitor against the expected experience will be used. A procedure adapted from Woolson will be used.

Outcome Time Frame:

Up to 5 years

Safety Issue:


Principal Investigator

Sheri Spunt

Investigator Role:

Principal Investigator

Investigator Affiliation:

Children's Oncology Group


United States: Institutional Review Board

Study ID:




Start Date:

February 2007

Completion Date:

Related Keywords:

  • Adult Alveolar Soft-part Sarcoma
  • Adult Angiosarcoma
  • Adult Epithelioid Sarcoma
  • Adult Extraskeletal Chondrosarcoma
  • Adult Extraskeletal Osteosarcoma
  • Adult Fibrosarcoma
  • Adult Leiomyosarcoma
  • Adult Liposarcoma
  • Adult Malignant Fibrous Histiocytoma
  • Adult Malignant Hemangiopericytoma
  • Adult Malignant Mesenchymoma
  • Adult Neurofibrosarcoma
  • Adult Synovial Sarcoma
  • Childhood Alveolar Soft-part Sarcoma
  • Childhood Angiosarcoma
  • Childhood Epithelioid Sarcoma
  • Childhood Fibrosarcoma
  • Childhood Leiomyosarcoma
  • Childhood Liposarcoma
  • Childhood Malignant Mesenchymoma
  • Childhood Neurofibrosarcoma
  • Childhood Synovial Sarcoma
  • Chondrosarcoma
  • Dermatofibrosarcoma Protuberans
  • Localized Childhood Malignant Fibrous Histiocytoma of Bone
  • Metastatic Childhood Malignant Fibrous Histiocytoma of Bone
  • Metastatic Childhood Soft Tissue Sarcoma
  • Nonmetastatic Childhood Soft Tissue Sarcoma
  • Stage I Adult Soft Tissue Sarcoma
  • Stage II Adult Soft Tissue Sarcoma
  • Stage III Adult Soft Tissue Sarcoma
  • Stage IV Adult Soft Tissue Sarcoma
  • Histiocytoma
  • Histiocytoma, Benign Fibrous
  • Chondrosarcoma
  • Fibrosarcoma
  • Fibrosis
  • Hemangiopericytoma
  • Hemangiosarcoma
  • Leiomyosarcoma
  • Liposarcoma
  • Mesenchymoma
  • Osteosarcoma
  • Sarcoma, Synovial
  • Sarcoma
  • Dermatofibrosarcoma
  • Sarcoma, Alveolar Soft Part
  • Neurofibrosarcoma
  • Neurilemmoma
  • Histiocytoma, Malignant Fibrous
  • Liver Neoplasms



Baylor College of Medicine Houston, Texas  77030
Johns Hopkins University Baltimore, Maryland  21205
Cleveland Clinic Foundation Cleveland, Ohio  44195
Roswell Park Cancer Institute Buffalo, New York  14263
Mayo Clinic Rochester, Minnesota  55905
Children's Hospital of Philadelphia Philadelphia, Pennsylvania  19104
University of Iowa Hospitals and Clinics Iowa City, Iowa  52242
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Washington University School of Medicine Saint Louis, Missouri  63110
Tripler Army Medical Center Honolulu, Hawaii  96859-5000
Hurley Medical Center Flint, Michigan  48503
Rhode Island Hospital Providence, Rhode Island  02903
Medical City Dallas Hospital Dallas, Texas  75230
University of Texas Health Science Center at San Antonio San Antonio, Texas  78284-7811
Midwest Children's Cancer Center Milwaukee, Wisconsin  53226
Sinai Hospital of Baltimore Baltimore, Maryland  21225
Geisinger Medical Center Danville, Pennsylvania  17822-0001
Vanderbilt-Ingram Cancer Center Nashville, Tennessee  37232-6838
Loyola University Medical Center Maywood, Illinois  60153
Massachusetts General Hospital Cancer Center Boston, Massachusetts  02114
Marshfield Clinic Marshfield, Wisconsin  54449
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Baptist Hospital of Miami Miami, Florida  33176-2197
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University of Arkansas for Medical Sciences Little Rock, Arkansas  72205
Brooke Army Medical Center Fort Sam Houston, Texas  78234-6200
Madigan Army Medical Center Tacoma, Washington  98431-5048
Eastern Maine Medical Center Bangor, Maine  04401
University of Nebraska Medical Center Omaha, Nebraska  68198-3330
Hackensack University Medical Center Hackensack, New Jersey  07601
Children's Hospital Los Angeles Los Angeles, California  90027-0700
Children's National Medical Center Washington, District of Columbia  20010-2970
Miami Children's Hospital Miami, Florida  33155-4069
All Children's Hospital St. Petersburg, Florida  33701
Advocate Hope Children's Hospital Oak Lawn, Illinois  60453
Saint Jude Midwest Affiliate Peoria, Illinois  61637
Maine Children's Cancer Program Scarborough, Maine  04074-9308
Carolinas Medical Center Charlotte, North Carolina  28232-2861
University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma  73104
Legacy Emanuel Hospital and Health Center Portland, Oregon  97227
St. Jude Children's Research Hospital Memphis, Tennessee  38105-2794
Driscoll Children's Hospital Corpus Christi, Texas  78466
Scott and White Memorial Hospital Temple, Texas  76508
Inova Fairfax Hospital Falls Church, Virginia  22042-3300
Southern California Permanente Medical Group Downey, California  90242
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University of Wisconsin Hospital and Clinics Madison, Wisconsin  53792-0001
Overlook Hospital Summit, New Jersey  07902-0220
Mount Sinai Medical Center New York, New York  10029
Cincinnati Children's Hospital Medical Center Cincinnati, Ohio  45229-3039
Methodist Children's Hospital of South Texas San Antonio, Texas  78229-3993
Primary Children's Medical Center Salt Lake City, Utah  84113-1100
Montefiore Medical Center Bronx, New York  10467-2490
Saint Peter's University Hospital New Brunswick, New Jersey  08901-1780
Rady Children's Hospital - San Diego San Diego, California  92123-4282
Children's Hospitals and Clinics of Minnesota - Minneapolis Minneapolis, Minnesota  55404
University of New Mexico Cancer Center Albuquerque, New Mexico  87131-5636
Nationwide Children's Hospital Columbus, Ohio  43205-2696
Children's Hospital of Pittsburgh of UPMC Pittsburgh, Pennsylvania  15213
Dell Children's Medical Center of Central Texas Austin, Texas  78723
Children's Hospital and Research Center at Oakland Oakland, California  94609-1809
Mary Bridge Children's Hospital and Health Center Tacoma, Washington  98415-0299
City of Hope Medical Center Duarte, California  91010
Lehigh Valley Hospital - Muhlenberg Bethlehem, Pennsylvania  18017
Presbyterian Hospital Charlotte, North Carolina  28233-3549
Lee Memorial Health System Fort Myers, Florida  33902
University of Virginia Charlottesville, Virginia  22908
University of Alabama at Birmingham Birmingham, Alabama  35294-3300
Connecticut Children's Medical Center Hartford, Connecticut  06106
University of North Carolina Chapel Hill, North Carolina  27599
Duke University Medical Center Durham, North Carolina  27710
University of Florida Gainesville, Florida  32610-0277
University of Rochester Rochester, New York  14642
Nemours Children's Clinic - Pensacola Pensacola, Florida  32504
Helen DeVos Children's Hospital at Spectrum Health Grand Rapids, Michigan  49503
Yale University New Haven, Connecticut  06520
Wayne State University Detroit, Michigan  48202
Mercy Children's Hospital Toledo, Ohio  43608
Legacy Emanuel Children's Hospital Portland, Oregon  97227
University of Arizona Health Sciences Center Tucson, Arizona  85724
University of Massachusetts Medical School Worcester, Massachusetts  01605
Dartmouth Hitchcock Medical Center Lebanon, New Hampshire  03756
University Of Vermont Burlington,, Vermont  05403
Albany Medical Center Albany, New York  12208
University of Texas Southwestern Medical Center Dallas, Texas  
University of Kentucky Lexington, Kentucky  40536-0098
Oregon Health and Science University Portland, Oregon  97201
Tulane University Health Sciences Center New Orleans, Louisiana  70112
Virginia Commonwealth University Richmond, Virginia  
David Geffen School of Medicine at UCLA Los Angeles, California  90095
Florida Hospital Orlando, Florida  32803
Memorial Health University Medical Center Savannah, Georgia  31404
University of Chicago Comprehensive Cancer Center Chicago, Illinois  60637-1470
M D Anderson Cancer Center Houston, Texas  77030
Seattle Children's Hospital Seattle, Washington  98105
Wake Forest University Health Sciences Winston-Salem, North Carolina  27157
Childrens Memorial Hospital Chicago, Illinois  60614
Kaiser Permanente-Oakland Oakland, California  94611
M D Anderson Cancer Center- Orlando Orlando, Florida  32806
University of Hawaii Honolulu, Hawaii  96813
Saint Luke's Mountain States Tumor Institute Boise, Idaho  83712
Saint Vincent Hospital and Health Services Indianapolis, Indiana  46260
Saint John Hospital and Medical Center Detroit, Michigan  48236
Michigan State University - Breslin Cancer Center East Lansing, Michigan  48824-1313
Kalamazoo Center for Medical Studies Kalamazoo, Michigan  49008
Saint John's Mercy Medical Center Saint Louis, Missouri  63141
Nevada Cancer Research Foundation CCOP Las Vegas, Nevada  89106
New York University Langone Medical Center New York, New York  10016
Columbia University Medical Center New York, New York  10032
State University of New York Upstate Medical University Syracuse, New York  13210
Mission Hospitals Inc Asheville, North Carolina  28801
Saint Vincent Hospital Green Bay, Wisconsin  54301
University of Maryland Greenebaum Cancer Center Baltimore, Maryland  21201
University of Illinois Chicago, Illinois  60612
Stony Brook University Medical Center Stony Brook, New York  11794
Cook Children's Medical Center Fort Worth, Texas  76104
Memorial Healthcare System - Joe DiMaggio Children's Hospital Hollywood, Florida  33021
West Virginia University Charleston Charleston, West Virginia  25304
The Children's Medical Center of Dayton Dayton, Ohio  45404
Advocate Lutheran General Hospital Park Ridge, Illinois  60068
University of Miami Miller School of Medicine-Sylvester Cancer Center Miami, Florida  33136
University of Minnesota Medical Center-Fairview Minneapolis, Minnesota  55455
Children's Oncology Group Arcadia, California  91006-3776
C S Mott Children's Hospital Ann Arbor, Michigan  48109
Southern Illinois University Springfield, Illinois  62702
University Of Missouri-Columbia Columbia, Missouri  65212
Walter Reed National Military Medical Center Bethesda, Maryland  20889
Riley Hospital for Children Indianapolis, Indiana  46202
UMDNJ - Robert Wood Johnson University Hospital New Brunswick, New Jersey  08903
Phoenix Childrens Hospital Phoenix, Arizona  85016
Miller Children's Hospital Long Beach, California  90806
Childrens Hospital of Orange County Orange, California  92868-3874
Alfred I duPont Hospital for Children Wilmington, Delaware  19803
Nemours Children's Clinic - Jacksonville Jacksonville, Florida  32207-8426
Nemours Childrens Clinic - Orlando Orlando, Florida  32806
Saint Joseph Children's Hospital of Tampa Tampa, Florida  33607
Children's Healthcare of Atlanta - Egleston Atlanta, Georgia  30322
The Childrens Mercy Hospital Kansas City, Missouri  64108
Rainbow Babies and Childrens Hospital Cleveland, Ohio  44106
Penn State Hershey Children's Hospital Hershey, Pennsylvania  17033
Palmetto Health Richland Columbia, South Carolina  29203
East Tennessee Childrens Hospital Knoxville, Tennessee  37916
Saint Mary's Hospital West Palm Beach, Florida  33407
Saint Joseph's Regional Medical Center Paterson, New Jersey  07503
Texas Tech University Health Science Center-Amarillo Amarillo, Texas  79106
Childrens Hospital-King's Daughters Norfolk, Virginia  23507
Sanford Medical Center-Fargo Fargo, North Dakota  58122
Children's Hospital Colorado Aurora, Colorado  80045
Lucile Packard Children's Hospital Stanford University Palo Alto, California  94304
University of California San Francisco Medical Center-Parnassus San Francisco, California  94143
Rocky Mountain Hospital for Children-Presbyterian Saint Luke's Medical Center Denver, Colorado  80218
The Toledo Hospital/Toledo Children's Hospital Toledo, Ohio  43606
Greenville Cancer Treatment Center Greenville, South Carolina  29605
Sanford USD Medical Center - Sioux Falls Sioux Falls, South Dakota  57117-5134
T C Thompson Children's Hospital Chattanooga, Tennessee  37403
Providence Sacred Heart Medical Center and Children's Hospital Spokane, Washington  99204
Broward Health Medical Center Fort Lauderdale, Florida  33316
The Steven and Alexandra Cohen Children's Medical Center of New York New Hyde Park, New York  11040