Childhood Renal Tumor Clinical Trial
— RANDOMETOfficial title:
Randomized Open-label Non-inferiority Phase 3 Clinical Trial for Patients With a Stage IV Childhood Renal Tumor, Comparing Upfront Vincristine, Actinomycin-D and Doxorubicin (Standard Arm) With Upfront Vincristine, Carboplatin and Etoposide (Experimental Arm)
Nephroblastoma (Wilms tumor, WT) is the most common renal tumor of childhood representing ±
6% of all childhood malignancies. The diagnosis is established on clinical and radiological
grounds. Metastases are visible on conventional imaging in at least 12% of nephroblastoma
patients; however, an additional ~15% of patients have nodules on CT-scan only. The treatment
consists of neoadjuvant (preoperative) chemotherapy, nephrectomy and risk-based adjuvant
chemotherapy ± radiation therapy (RT) to the flank and/or metastases. For truly localized
tumors, overall survival is > 85% (high risk histology excluded). Several high risk
biological characteristics have been identified: diffuse anaplasia, gain of 1q chromosome,
loss of heterozygosity 1p + 16q, blastemal residual volume.
For metastatic nephroblastoma, the standard neo-adjuvant chemotherapy includes 3 drugs:
vincristine, actinomycin-D and doxorubicin (VAD). Long-term survival is 82% (1). However, two
issues arise. First, the use of doxorubicin ± concomitant RT might be associated with cardiac
and pulmonary sequelae (4-17% of congestive heart failure) (2), and actinomycin-D is
associated with hepatic toxicity (3). Second, patients with "CT-only" nodules are treated
according to "localized disease". However, their outcome is poorer than that of truly
"localized disease" (4-6).
The efficacy of carboplatin and etoposide is known for a long time; these drugs are used as
second line treatment or for high-risk histology nephroblastoma. Therefore, an alternate
chemotherapy has been designed that combines drugs shown as highly efficacious in
nephroblastoma, i.e., Vincristine, Carboplatin and Etoposide (VCE). VCE has been used for the
treatment of other pediatric malignancies. For metastatic nephroblastoma, the switch from VAD
to VCE and the associated reduction of actinomycin-D and doxorubicin is expected to reduce
the chemotherapy-related long-term toxicity. In addition, VCE could potentially decrease the
rate of patients requiring pulmonary RT. Finally VCE may have a beneficial effect on tumor
high risk biological characteristics.
French patients with nephroblastoma have been treated for > 40 years according to SIOP
protocols collaborating in the SIOP Renal Tumour Study Group (SIOP-RTSG). This group has
designed an international randomized phase III clinical trial for the evaluation of VCE
versus VAD in patients with metastatic renal tumors (>>90% having nephroblastoma), in order
to decrease the long-term toxicity while at least preserving, if not improving, the treatment
efficacy. In addition, the issue of "CT-only" nodules and their adequate treatment needs to
be solved. In previous protocols, the treatment strategy was based on the diagnosis of
pulmonary metastases (~90% of all metastases) by conventional pulmonary X-ray. Central
Radiological Review (CRR) is planned for the initial staging using CT ± MRI, as it is
expected to more accurately detect patients with metastatic disease, including patients with
"CT-only" nodules. In addition, CRR will be set up for real-time response assessment during
treatment, in order to reliably determine who require pulmonary RT and which postoperative
chemotherapy.
Therefore, the main trial objectives are:
- Explore the non-inferiority (efficacy) of neoadjuvant VCE chemotherapy (experimental
arm) as compared to the standard arm with VAD.
- Provide central radiological review (CRR) at diagnosis and after neoadjuvant
chemotherapy in order to determine more precisely the appropriate treatment for each
patient.
The primary objective of the RCT is to investigate the metastatic complete response rate
(MetCR, including very good partial response (VGPR)) of neoadjuvant 6 weeks of VAD as
compared to neoadjuvant VCE in stage IV renal tumours using CRR. Several international
studies have shown that MetCR is a good surrogate endpoint for survival.
The postoperative treatment, secondary objectives as well as the intended methodology are
detailed in the research project.
The total number of patients is 406 patients for the entire phase III trial running in the 12
major SIOP countries (max 110 patients in France).
The expected trial duration is 5 years for accrual + 2 years follow-up (the overall 10-year
follow-up for long-term toxicity will be an independently funded ancillary study. This
duration is required for a reliable evaluation of the cardiac toxicity).
The results of the current trial should be useful for the future protocols for the treatment
of all patients with nephroblastoma (metastatic but also localized and bilateral).
The results of this RCT will be worthy for the entire international pediatric oncology
community and future patients throughout the world and will be communicated in scientific
congresses and high-level peer-reviewed journals.
| Status | Not yet recruiting |
| Enrollment | 110 |
| Est. completion date | January 1, 2027 |
| Est. primary completion date | July 1, 2026 |
| Accepts healthy volunteers | No |
| Gender | All |
| Age group | N/A to 17 Years |
| Eligibility |
Inclusion Criteria: - suffering from metastatic renal tumour at initial diagnosis - having at least one circumscript, non-calcified (pulmonary) nodule (or other lesion highly suspicious of metastasis according to criteria for metastatic disease) = 3 mm as determined by chest CT-scan and abdominal CT-scan/MRI. - Metastatic disease must be confirmed by central review. Exclusion Criteria: |
| Country | Name | City | State |
|---|---|---|---|
| n/a | |||
| Lead Sponsor | Collaborator |
|---|---|
| Assistance Publique Hopitaux De Marseille |
| Type | Measure | Description | Time frame | Safety issue |
|---|---|---|---|---|
| Primary | Metastatic response assessment by neoadjuvant chemotherapy only | percentage of patients with complete response (CR) or Very Good Partial Response (VGPR) of metastasis of nephroblastoma after 6 weeks of preoperative chemotherapy | 6 weeks | |
| Secondary | Secondary metastatic response assessment | percentage of patients after 6 weeks of preoperative chemotherapy achieving a CR after surgery of metastasis at time of nephrectomy | 6 weeks | |
| Secondary | Clinical outcome after treatment | stage of local tumor (for each arm) | 2 and 5 years | |
| Secondary | Histological response to preoperative treatment | stage distribution of local tumor histological subtype distribution of local tumor (low, intermediate or high risk (LR, IR, HR)) | 6 weeks |