Trial Information

Neuroblastoma Protocol 2005: Therapy for Children With Advanced Stage High-Risk Neuroblastoma

The study will have five parts or phases. In the first part the combination of irinotecan
and gefitinib will be studied. After that, patients who have responded well will have
surgery to remove the tumor. This will be followed by a third part which includes about nine
months of treatment with cisplatin, adriamycin, etoposide, cyclophosphamide, and topotecan.
The fourth part will be intensification with melphalan, etoposide and carboplatin and blood
stem cell rescue. During this part, radiation will also be given to the sites of the
disease. Finally, monthly treatments with oral retinoic acid, alternating with oral
topotecan, will be continued for a total of 16 months of maintenance. It is anticipated that
it will take about 2 years to complete this entire treatment plan.

This study has multiple therapeutic, pharmacologic, biologic, and diagnostic imaging
objectives:

- To estimate whether oral gefitinib with two courses of intravenous irinotecan will
decrease the incidence of fever/neutropenia, duration of hospitalization, duration of
intravenous antibiotics and numbers of platelet and RBC transfusions during the first
six weeks of treatment compared to the topotecan window in NB97.

- To estimate local control of primary site disease to this treatment plan.

- To estimate the overall survival and progression-free survival in patients treated with
this approach.

- To estimate the feasibility of resecting the primary tumor after two courses of
irinotecan and gefitinib.

- To evaluate the disposition of irinotecan and gefitinib in previously untreated
patients with neuroblastoma.

- To evaluate the disposition of intravenous and oral topotecan in previously untreated
patients with neuroblastoma.

- To evaluate the pharmacogenetic determinants of gefitinib and irinotecan
pharmacokinetics and pharmacodynamics (e.g., CYP3A4/5, UGT1A1, and ABCG2 (BCRP)
polymorphisms).

- To evaluate the pharmacogenetic determinants of topotecan pharmacokinetics and
pharmacodynamics (e.g., CYP3A4/5 and ABC transporter polymorphisms).

- To evaluate in tumor samples the molecular and cellular expression of EGFR, MRP4 and
ABCG2 (BCRP) utilizing appropriate laboratory techniques.

- To describe the relative frequency of positive bone marrow by sensitive MRD methods at
diagnosis, after window therapy, at the time of stem cell harvest, and at several time
points following the completion of intensification. These results will be compared
with timing and pattern of disease recurrence.

- To describe what percentage of primary or metastatic neuroblastomas have amplified
ICAM-2 and chromosome 17.

- To generate preliminary data regarding the potential use of ICAM-2 copy number as a
prognostic indicator in neuroblastoma.

- To determine the levels of the angiogenic factors VEGF and bFGF in the peripheral
circulation of patients at diagnosis, after window therapy, at the time of stem cell
harvest and at several time points following the completion of intensification. These
results will be compared with the degree of tumor response and the timing of disease
recurrence.

- To procure tumor samples for construction of tissue microarray blocks that will be
utilized in further biologic characterization of these tumors.

- To prospectively evaluate FDG PET imaging as a marker of disease at diagnosis, (pre and
post window therapy), prior to intensification, and at the completion of therapy.

- To generate preliminary data on the use of contrast enhanced ultrasound and magnetic
resonance imaging to evaluate changes in tumor vascularity at various timepoints in
therapy.

Details of Treatment Interventions:

Window Phase Irinotecan 15mg/m2 daily x 5 days for two weeks with daily oral gefitinib 112.5
mg/m2 daily x 12 days., followed by 9 day rest, then same course repeated. Subjects that
respond to window therapy receive the same course again instead of topotecan for Block 2,
course 6 (week 21) of induction.

Induction Therapy (following window):

Cyclophosphamide 1.5 gm/m2 daily x 2 I.V. day 1 & 2 Adriamycin 50 mg/m2 I.V. day 1 only
MESNA: 375 mg/m2 I.V. immediately following cyclophosphamide and at 3 and 6 hours
post-infusion.

Etoposide: 30 mg/m2 over 30 minutes, followed by etoposide 250 mg/m2/day x 3 days I.V. by
continuous infusion (days 2-5), given during induction therapy courses 1, 4, and 7.

Cisplatin 40 mg/m2/day x 5 I.V. over 1 hour (days 1-5) Etoposide 200 mg/m2/day x 3 I.V. over
1 hour (days 2, 3, 4), given during induction courses 2, 5, and 8.

IV topotecan adjusted to AUC 100 ± 20nghr/ml daily x 5 days for two weeks, during courses 3,
6 (for patients that do not respond to window), and 9 of induction.

Intensification:

Melphalan, Etopophos and carboplatin:Day -8, -7, -6, -5: Melphalan 45 mg/m2 IV Day -4:
Etopophos 40 mg/kg/day IV Day -4, -3, & -2: Carboplatin (AUC target 4.1) Day 0- infusion of
peripheral blood stem cells previously harvested by pheresis.

Maintenance:

13 cis-retinoic acid and oral topotecan courses:13-cis-retinoic acid 160 mg/m2/day divided
into two equal doses given orally BID x 14 days, followed by a 14 day rest. This will be
repeated x one. Subjects less or equal to 12 kg will be given 5.33 mg/kg/day divided BID.
These courses are alternated with 2 months of oral topotecan once daily for 5 days for 2
consecutive weeks at 1.8 mg/m2/day , or 0.06 mg/kg/day for patients less than 12 months old
(total of 10 doses) for a total of 16 courses (four, two-month courses of each).

Radiation therapy : Radiation therapy to the primary and metastatic disease sites will
follow peripheral blood stem cell transplant with the exception of any patient requiring
emergent radiation. External beam radiotherapy will be delivered to the primary site and
select metastatic sites. Radiotherapy is planned to be initiated four weeks following stem
cell reinfusion.

Surgery : After recovery from induction and re-evaluation of tumor status, subjects undergo
surgery for resection of the primary tumor mass and careful lymph node staging, if surgery
was not possible after the irinotecan and ZD1839 window.

Peripheral blood stem cell collection and infusion : After course 3, subjects undergo
peripheral blood stem cell (PBSC) harvest. If this is unsuccessful, harvesting will be done
with subsequent chemotherapy courses. Subjects are mobilized with filgrastim (10mcg/kg/day).
PBSC harvesting will be performed by leukapheresis if possible, bone marrow harvest if not.
Stem cells are stored and re-infused after intensification chemotherapy.