Combination Chemotherapy Followed By Peripheral Stem Cell Transplant in Treating Young Patients With Newly Diagnosed Supratentorial Primitive Neuroectodermal Tumors or High-Risk Medulloblastoma

• Time to treatment failure defined as disease progression or recurrence, death from any cause, or occurrence of a second malignant neoplasm [ Time Frame: From baseline to up to 5 years ] [ Designated as safety issue: No ]

  The analysis of event-free survival (EFS) will be based on a proportional hazards, non-mixture parametric cure model (PCM).

  Partial stratification will be accomplished by separately estimating the scale parameter of the Weibull kernel function within each of the patient arms.

• Toxicity rates of acute, chronic, and late effects of the two intense regimens [ Time Frame: From the beginning of treatment to end of study, assessed up to 4 years ] [ Designated as safety issue: Yes ]
  Estimates will be obtained using life-table methods with an event defined as the first occurrence of toxicity. Patients who have progression or recurrence of disease will be censored in these analyses. Differences in incidence for treatment regimens will be tested with the log-rank test for overall pattern.
• Rates of gastrointestinal and nutritional toxicities [ Time Frame: In each course or treatment ] [ Designated as safety issue: Yes ]
  Rates of gastrointestinal and nutritional toxicities will be summarized using standard descriptive statistical methods. The two groups will be compared using a Chi-square test to detect a significant difference in complications between the two groups.
• Quality of life and neuropsychological (NP) scores as assessed by the Children Oncology Group (COG) Standard Neuropsychological and Behavioral Battery [ Time Frame: From baseline to up to 4 years ] [ Designated as safety issue: No ]
  Parent-report questionnaires will be completed to gather information about the patient's function, specifically in terms of attention, memory, executive abilities, and behavioral/social/emotional adaptation. Long-term effects of treatment on neuropsychological and quality of life outcomes will be primarily descriptive. Correlational analyses will be conducted, with Pearson product moment correlations computed for continuous data and chi-square analyses conducted for discrete data.
• Gene expression profiling by northern blotting or by gel electrophoresis [ Time Frame: At baseline ] [ Designated as safety issue: No ]
  The methods used by Golub and colleagues and Pomeroy and colleagues, as well as standard statistical techniques such as Cox regression analysis will be used in these analyses. Internal cross-validation procedures, such as the leave-one-out method, will be utilized in the training set to provide less-biased estimates of correct classification rates.

This randomized phase III trial is studying two different combination chemotherapy regimens to compare how well they work when given before a peripheral stem cell transplant in treating young patients with newly diagnosed supratentorial primitive neuroectodermal tumors or high-risk medulloblastoma. Drugs used in chemotherapy work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving more than one drug (combination chemotherapy) together with a peripheral stem cell transplant may allow more chemotherapy to be given so that more tumor cells are killed. It is not yet known which combination chemotherapy regimen is more effective when given before a peripheral stem cell transplant in treating supratentorial primitive neuroectodermal tumors or medulloblastoma.

PRIMARY OBJECTIVES:

I. Determine if treatment of pediatric patients with newly diagnosed supratentorial primitive neuroectodermal CNS tumors or high-risk medulloblastoma with intensive induction chemotherapy comprising vincristine, etoposide, cyclophosphamide, and cisplatin in combination with high-dose methotrexate and leucovorin calcium followed by consolidation chemotherapy comprising carboplatin and thiotepa and peripheral blood stem cell rescue results in a higher complete response rate then in patients treated with the same regimen without high-dose methotrexate and leucovorin calcium.

SECONDARY OBJECTIVES:

I. Determine whether biologic characterization of these tumors will refine therapeutic stratification separating atypical teratoid rhabdoid tumors from primitive neuroectodermal tumors (PNETs) and possibly identifying other markers of value for stratification within the group of PNETs.

II. Compare event-free survival and patterns of failure in patients treated with these regimens.

III. Compare the acute, chronic, and late effects of these regimens, particularly in terms of tolerance to the same consolidation regimen after treatment with 2 different induction regimens, in these patients.

IV. Compare the gastrointestinal and nutritional toxicities of these regimens in these patients.

V. Compare the quality of life outcomes in patients treated with these regimens.

VI. Compare the neuropsychological effects of these regimens in these patients.

OUTLINE: This is a randomized, multicenter study. Patients are stratified according to diagnosis* (M0 medulloblastoma with ≥ 1.5 cm² residual tumor vs M1 medulloblastoma [positive lumbar CSF cytology] vs M2, M3, or M4 medulloblastoma vs supratentorial PNET [any M-stage] vs M0 medulloblastoma < 8 months without residual disease or with < 1.5 cm² radiographic measurable residual tumor vs anaplastic M0 medulloblastoma without residual disease or with < 1.5 cm² radiographic measurable residual vs classic M0 (nondesmoplastic) medulloblastoma with < 1.5 cm² radiographic measurable residual tumor).

NOTE: *All diagnoses are for children < 36 months unless otherwise noted.

INDUCTION THERAPY: Patients are randomized to 1 of 2 induction treatment arms.

ARM I: Patients receive vincristine IV on days 1, 8, and 15; etoposide IV over 1 hour on days 1-3; cyclophosphamide IV over 1 hour on days 1 and 2; cisplatin IV over 6 hours on day 3; and filgrastim (G-CSF) IV or subcutaneously (SC) beginning on day 4 and continuing until blood counts recover. Treatment repeats every 3 weeks for 3 courses in the absence of disease progression or unacceptable toxicity.

ARM II: Patients receive vincristine IV on days 1, 8, and 15; high-dose methotrexate IV over 4 hours on day 1; and leucovorin calcium IV or orally every 6 hours beginning on day 2 and continuing until methotrexate levels are in a safe range. Once methotrexate levels are in a safe range, patients then receive etoposide IV over 1 hour on approximately days 4, 5, and 6, cyclophosphamide IV over 1 hour on approximately days 4 and 5, and cisplatin IV over 6 hours on approximately day 6. Patients also receive G-CSF IV or SC beginning 24 hours after the completion of chemotherapy and continuing until blood counts recover. Treatment repeats every 3 weeks for 3 courses in the absence of disease progression or unacceptable toxicity.

In both arms, patients with stable disease or partial response after induction therapy proceed to second-look surgery followed by consolidation therapy. Patients with a complete response after induction therapy proceed directly to consolidation therapy.

CONSOLIDATION THERAPY: Beginning no more than 6 weeks after completion of induction therapy, patients receive consolidation therapy comprising carboplatin IV over 2 hours and thiotepa IV over 2 hours on days 1 and 2 and G-CSF IV or SC beginning on day 54 and continuing until blood counts recover. Patients also receive autologous peripheral blood stem cells (PBSC) IV on day 4. Treatment repeats every 3 weeks for 3 courses in the absence of disease progression or unacceptable toxicity.

Blood and tissue samples are collected at baseline for correlative studies, including gene expression profiling, biological marker analysis (i.e., cMyc, ErbB2/ErbB4), comparative genome analysis, and mutation analysis.

After completion of study therapy, patients are followed up periodically for 4 years and then annually thereafter.

• Untreated Childhood Medulloblastoma
• Untreated Childhood Supratentorial Primitive Neuroectodermal Tumor

• Drug: etoposide
  Given IV
  Other Names:

  • EPEG
  • VP-16
  • VP-16-213
• Drug: cyclophosphamide
  Given IV
  Other Names:

  • CPM
  • CTX
  • Cytoxan
  • Endoxan
  • Endoxana
• Drug: cisplatin
  Given IV
  Other Names:

  • CACP
  • CDDP
  • CPDD
  • DDP
• Biological: filgrastim
  Given IV or SC
  Other Names:

  • G-CSF
  • Neupogen
• Drug: carboplatin
  Given IV
  Other Names:

  • Carboplat
  • CBDCA
  • JM-8
  • Paraplat
  • Paraplatin
• Drug: thiotepa
  Given IV
  Other Names:

  • Oncotiotepa
  • STEPA
  • TESPA
  • Tespamin
  • TSPA
• Drug: methotrexate
  Given IV
  Other Names:

  • amethopterin
  • Folex
  • methylaminopterin
  • Mexate
  • MTX
• Drug: leucovorin calcium
  Given IV or orally
  Other Names:

  • CF
  • CFR
  • LV
• Drug: vincristine sulfate
  Given IV
  Other Names:

  • leurocristine sulfate
  • VCR
  • Vincasar PFS
• Procedure: autologous hematopoietic stem cell transplantation
  Undergo autologous PBSC transplantation
• Other: laboratory biomarker analysis
  Correlative studies
• Procedure: quality-of-life assessment
  Ancillary studies
  Other Name: quality of life assessment

• Active Comparator: Arm I (induction+consolidation chemotherapy, autologous PBSC))

  Patients receive vincristine sulfate IV on days 1, 8, and 15; etoposide IV over 1 hour on days 1-3; cyclophosphamide IV over 1 hour on days 1 and 2; cisplatin IV over 6 hours on day 3. Treatment repeats every 3 weeks for 3 courses.

  Within 6 weeks after completion of induction therapy, patients receive consolidation therapy comprising carboplatin IV over 2 hours and thiotepa IV over 2 hours on days 1 and 2 and filgrastim (G-CSF) IV or SC beginning on day 54 and continuing until blood counts recover. Patients also receive autologous PBSC IV on day 4. Treatment repeats every 3 weeks for 3 courses in the absence of disease progression or unacceptable toxicity.

  Interventions:

  • Drug: etoposide
  • Drug: cyclophosphamide
  • Drug: cisplatin
  • Biological: filgrastim
  • Drug: carboplatin
  • Drug: thiotepa
  • Drug: vincristine sulfate
  • Procedure: autologous hematopoietic stem cell transplantation
  • Other: laboratory biomarker analysis
  • Procedure: quality-of-life assessment
• Experimental: Arm II (induction+consolidation chemotherapy, autologous PBSC)

  Patients receive vincristine sulfate IV on days 1, 8, and 15; high-dose methotrexate IV over 4 hours on day 1; and leucovorin calcium IV or orally every 6 hours beginning on day 2 and continuing until methotrexate levels are in a safe range. Patients then receive etoposide IV over 1 hour on approximately days 4, 5, and 6, cyclophosphamide IV over 1 hour on approximately days 4 and 5, and cisplatin IV over 6 hours on approximately day 6. Treatment repeats every 3 weeks for 3 courses.

  Within 6 weeks after completion of induction therapy, patients receive consolidation therapy comprising carboplatin IV over 2 hours and thiotepa IV over 2 hours on days 1 and 2 and filgrastim (G-CSF) IV or SC beginning on day 54 and continuing until blood counts recover. Patients also receive autologous PBSC IV on day 4. Treatment repeats every 3 weeks for 3 courses in the absence of disease progression or unacceptable toxicity.

  Interventions:

  • Drug: etoposide
  • Drug: cyclophosphamide
  • Drug: cisplatin
  • Biological: filgrastim
  • Drug: carboplatin
  • Drug: thiotepa
  • Drug: methotrexate
  • Drug: leucovorin calcium
  • Drug: vincristine sulfate
  • Procedure: autologous hematopoietic stem cell transplantation
  • Other: laboratory biomarker analysis
  • Procedure: quality-of-life assessment

Inclusion Criteria:

• Diagnosis of 1 of the following:

  • High-risk medulloblastoma defined by any of the following:

    • Residual disease > 1.5 cm²
    • Lumbar cerebral spinal fluid cytology positive for tumor cells by analysis of fluid collected either before definitive surgery or ≥ 10 days after definitive surgery unless contraindicated
    • M0 disease in children < 8 months of age at diagnosis
    • M2 or M3 metastatic disease by MRI
    • M4 disease
  • Supratentorial primitive neuroectodermal tumor (PNET)(any M-stage)
  • Anaplastic medulloblastoma regardless of M-stage or residual tumor
  • M0 classic, non-desmoplastic medulloblastoma (R1) with radiographically measurable residual disease < 1.5 cm^2
• MRI evidence of spinal disease
• Tumor must be negative for INI1 gene
• Has undergone definitive surgery within the past 31 days
• No atypical teratoid rhabdoid tumors
• Biological specimens must be available for correlative laboratory studies
• Life expectancy > 8 weeks
• Creatinine clearance or radioisotope glomerular filtration rate ≥ 60 mL/min
• Bilirubin ≤ 1.5 times upper limit of normal (ULN)
• AST and ALT < 2 times ULN
• Shortening fraction ≥ 27% by echocardiogram
• Ejection fraction ≥ 47% by radionuclide angiogram
• No evidence of dyspnea at rest
• Pulse oximetry > 94% on room air
• Absolute neutrophil count > 1,000/mm³
• Platelet count > 100,000/mm³ (transfusion independent)
• Hemoglobin > 8 g/dL (RBC transfusions allowed)
• Prior corticosteroids allowed
• No prior radiation therapy or chemotherapy