A Clinical and Molecular Risk-Directed Therapy for Newly Diagnosed Medulloblastoma

Condition(s) studied

Investigational drug(s) / intervention(s)

Craniospinal Irradiation with boost to the primary tumor site: All participants will undergo craniospinal irradiation (CSI) with boost to the primary tumor site. The dose given is based on the molecular and risk group as noted in the arm descriptions. The type of radiation used includes conformal radiation therapy (photons) or intensity modulated radiation therapy (IMRT) or proton beam therapy.

Cyclophosphamide: Route of Administration (ROA): Intravenously (IV)

Cisplatin: ROA: IV

Vincristine: ROA: IV

Vismodegib: ROA: Orally (PO)

Pemetrexed: ROA: IV

Gemcitabine: ROA: IV

Study summary

Historically, medulloblastoma treatment has been determined by the amount of leftover disease present after surgery, also known as clinical risk (standard vs. high risk). Recent studies have shown that medulloblastoma is made up of distinct molecular subgroups which respond differently to treatment. This suggests that clinical risk alone is not adequate to identify actual risk of recurrence. In order to address this, we will stratify medulloblastoma treatment in this phase II clinical trial based on both clinical risk (low, standard, intermediate, or high risk) and molecular subtype (WNT, SHH, or Non-WNT Non-SHH). This stratified clinical and molecular treatment approach will be used to evaluate the following:

* To find out if participants with low-risk WNT tumors can be treated with a lower dose of radiation to the brain and spine, and a lower dose of the chemotherapy drug cyclophosphamide while still achieving the same survival rate as past St. Jude studies with fewer side effects.
* To find out if adding targeted chemotherapy after standard chemotherapy will benefit participants with SHH positive tumors.
* To find out if adding new chemotherapy agents to the standard chemotherapy will improve the outcome for intermediate and high risk Non-WNT Non-SHH tumors.
* To define the cure rate for standard risk Non-WNT Non-SHH tumors treated with reduced dose cyclophosphamide and compare this to participants from the past St. Jude study.

All participants on this study will have surgery to remove as much of the primary tumor as safely possible, radiation therapy, and chemotherapy. The amount of radiation therapy and type of chemotherapy received will be determined by the participant's treatment stratum. Treatment stratum assignment will be based on the tumor's molecular subgroup assignment and clinical risk.

The participant will be assigned to one of three medulloblastoma subgroups determined by analysis of the tumor tissue for tumor biomarkers:

* WNT (Strata W): positive for WNT biomarkers
* SHH (Strata S): positive for SHH biomarkers
* Non-WNT Non-SHH, Failed, or Indeterminate (Strata N): negative for WNT and SHH biomarkers or results are indeterminable

Participants will then be assigned to a clinical risk group (low, standard, intermediate, or high) based on assessment of:

* How much tumor is left after surgery
* If the cancer has spread to other sites outside the brain \[i.e., to the spinal cord or within the fluid surrounding the spinal cord, called cerebrospinal fluid (CSF)\]
* The appearance of the tumor cells under the microscope
* Whether or not there are chromosomal abnormalities in the tumor, and if present, what type (also called cytogenetics analysis)

Eligibility

Primary outcome measure(s)

• Progression-free Survival in Stratum W1 — 2 years after diagnosis
  Progression-free survival (PFS) will be measured from diagnosis to the earliest of disease progression or death from any cause. Patients who have not experienced one of these events will be censored at their last date of contact.
• Progression-free Survival in Stratum N1 — 2 years after diagnosis
  Progression-free survival (PFS) will be measured from diagnosis to the earliest of disease progression or death from any cause. Patients who have not experienced one of these events will be censored at their last date of contact.
• Progression-free Survival in Stratum S1 Skeletally Mature Cohort — 2 years after diagnosis
  Progression-free survival (PFS) will be measured from diagnosis to the earliest of disease progression or death from any cause. Patients who have not experienced one of these events will be censored at their last date of contact. PFS in SJMB12 stratum S1 skeletally mature cohort will be compared to historical controls from SJMB03 as well as from another published cohort (Thompson et al., 2016) using log-rank test.
• Change in VO2 Peak Value — baseline and 12 weeks post-randomization
  To evaluate the effect of an aerobic training intervention on cardiopulmonary fitness.
• Change in Spatial Span Backward Standard Score — baseline and 10-12 weeks post baseline
  To assess the impact of a computer-based working memory intervention, relative to standard of care, on a performance-based measure of working memory.

Trial sites (23)

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