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Activated: October 1, 1995 Q9403{PRIVATE } Closed: Revised 4/97 Revised 9/97 Revised 3/01 Revised 9/01 Revised 3/04 NCI Version Date 6/8/04 Revised 3/09 Revised 1/10 Revised 12/13 Revised 12/18 Privileged Communication For Investigational Use Only

NATIONAL WILMS TUMOR LATE EFFECTS STUDY Page Study Coordinators 2 1.0 STUDY OBJECTIVES 4 2.0 BACKGROUND 4-9 3.0 PATIENT ELIGIBILITY 9-10 4.0 STUDY PROCEDURES 10-12 5.0 REPOSITORY 13 6.0 CODING OF MEDICAL CONDITIONS AND TREATMENT EXPOSURES 13 7.0 STATISTICAL CONSIDERATIONS 13-15 REFERENCES 16-21

APPENDICES

Appendix A: Adult Consent Form and Cover Letter, HIPAA Appendix B: Annual and Five Year mailings Appendix C: Forms used to ascertain Reproductive and Sexual Health Appendix D: Forms used to ascertain Familial Wilms Tumor Appendix E: Forms used to ascertain Targeted Late Conditions

Appendix F: Protocol for “National Wilms Tumor Saliva Collection Study” Appendix G: “Retrospective NCI Phantom-Monte Carlo Dosimetry for Late Effects in Wilms Tumor” Grant

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NWTS Late Effects Study Committee and Consultants Wendy Leisenring, ScD Principal Investigator Fred Hutchinson Cancer Research Center 1100 Fairview Avenue N, PO Box 19024, M2-B230 Seattle, WA 98109 Phone: 206-667-4374 Fax: 206-667-6358 email: wleisenr@fredhutch.org John Kalapurakal, MD Co-Investigator Northwestern Memorial Hospital Department of Radiation Oncology-Galter Pavilion 676 N St. Clair St. Chicago, IL 60611 Phone: 312-926-3761 Fax: 312-926-6374 email: j-kalapurakal@northwestern.edu Daniel M. Green, MD Consultant Department of Epidemiology and Cancer Control Saint Jude Children’s Research Hospital 262 Danny Thomas Pl. Mail Stop 735 Memphis, TN 38105-2794 Phone: 901-595-5915 Fax: 901-595-5845 email: daniel.green@stjude.org Vicki Huff, PhD Consultant Molecular Biologist Department of Molecular Genetics/Cancer Genetics MD Anderson Cancer Center 1515 Holcombe Boulevard, Unit 1010 Houston, TX 77030 Phone: 713-834-6384 Fax: 713-834-6380 email: vhuff@mdanderson.org NWTS Data & Statistical Center Data & Statistical Center Fred Hutchinson Cancer Research Center 1100 Fairview Avenue N / PO Box 19024 Seattle, WA 98109 Phone: 206-667-4842 Fax: 206-667-6623 web: www.nwtsg.org

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Key Abbreviations used in Protocol: NWTS National Wilms Tumor Study SMN Subsequent Malignant neoplasm WT1 First Wilms Tumor gene PLNR Perilobar Nephrogenic Rests ILNR Intralobar Nephrogenic Rests WAGR Wilms tumor, aniridia, genitourinary abnormalities and mental retardation LOH Loss of Heterozygosity DDS Denys-Drash NCI National Cancer Institute CCSS Childhood Cancer Survivor Study SIR Standardized Incidence Ratio 95% CI 95% Confidence Interval COG Children’s Oncology Group DSC Data and Statistics Center ASR Annual Status Reports APMHF Adult Patient Medical History Form FMHF Family and Medical History Form PE Physical Examination ACF Adult Consent Form IRB Institutional Review Board ICD International Classification of Disease ESRD End Stage Renal Disease CHF Congestive Heart Failure

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1.0 STUDY OBJECTIVES 1.1 To determine the incidence of life-threatening medical conditions in survivors of Wilms tumor,

specifically a) congestive heart failure; b) subsequent malignant neoplasms (SMNs); c) renal failure; and d) pulmonary fibrosis and interstitial lung disease. To relate the risks of these events to the type and amount of radiation and chemotherapy received;

1.2 To determine mortality rates in former Wilms tumor patients and to compare these with age, calendar

period, and sex-specific national population rates; 1.3 To determine the risks of serious pregnancy complications and other adverse reproductive events in

survivors of Wilms tumor, and to correlate their occurrence with the type and amount of radiation and chemotherapy received in childhood. To determine the rates of natality in former Wilms tumor patients and to compare these with national statistics and determine congenital anomalies in offspring;

1.4 To serve as a case-finding resource, identifying the most informative subgroups of Wilms tumor patients

for use by a) molecular biologists studying mutations in identified or prospective Wilms tumor genes including genes for familial Wilms tumor; and b) epidemiologists studying parental occupational exposures and other environmental risk factors;

1.5 To increase the number of NWTS survivors with available DNA to facilitate research on the association

of presence of germline WT1 mutation with ESRD among NWTS survivors without known associated WT1 associated congenital anomaly syndromes.

2.0 BACKGROUND

2.1 Genetic Epidemiology of Wilms Tumor 2.11 A Model for Childhood Cancer Wilms tumor is an important model for the study of fundamental mechanisms of carcinogenesis. Statistical study of the incidence and age at diagnosis of patients with retinoblastoma led Knudson to develop his famous two-hit model of carcinogenesis, which was subsequently extended to Wilms tumor. [1,2] The genetics of Wilms tumor are more complex than originally believed, however, with several genes now known to be involved in Wilms tumor genesis versus the single gene for retinoblastoma.[3] Epidemiological evidence suggests that some bilateral and multifocal Wilms tumors may arise from somatic mosaicism rather than a germ line mutation, contradicting a central tenet of the two-hit model. [4] Two distinct pathogenetic entities are identifiable on the basis of precursor lesions: perilobar nephrogenic rests (PLNR), which occur in association with growth anomalies; and intralobar nephrogenic rests (ILNR) which occur in association with WT1 mutations.[5] This provides phenotypic evidence for genetic heterogeneity.

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2.12 Wilms Tumor Genes The observation that the rare WAGR syndrome (Wilms tumor, aniridia, genitourinary abnormalities and mental retardation) was invariably associated with interstitial deletions of chromosome 11p13, and that tumor tissue at this same locus often displayed loss of heterozygosity (LOH), led ultimately to the cloning of the first Wilms tumor gene WT1. [6- 12] Ninety percent of patients with the even rarer Denys-Drash syndrome (DDS: male pseudohermaphroditism, protein-losing nephropathy and Wilms tumor; or males with only 2 of these 3 features; or females with the classically described nephropathy) harbor germ line mutations in WT1. Most are missense mutations resulting in single amino acid substitutions. [13-16] Microscopic examination of the kidney in patients with the WAGR and DDS syndromes often reveals ILNR. [17] The frequencies of germ line WT1 mutations in patients with bilateral Wilms tumor and of detectable WT1 mutations in Wilms tumor specimens are both low. Linkage at the WT1 locus has been excluded in most familial cases [18-22] The gene for Beckwith-Wiedemann syndrome (BWS: organ hypertrophy, hyperglossia, perinatal hypoglycemia, abdominal wall defects and propensity for embryonal tumors) maps to chromosome11p15.5. Here several genes (IGF2, p57KIP2, H19, KVLQT1) that regulate somatic growth are subject to dysregulated imprinting. This is the location for the putative second Wilms tumor gene, WT2, which has yet to be cloned. [23-29]

2.13 Familial Aggregation and Patterns of Inheritance The pattern of transmission for hereditary Wilms tumor is likely autosomal dominant with incomplete and variable penetrance and expressivity.[30-33] While some familial cases involve mutations in WT1, more are associated with the familial Wilms tumor genes FWT1 at 17q and FWT2 at 19q, for which fine scale mapping is currently underway. Further understanding of familial risk is essential for counseling the rapidly increasing pool of survivors and to provide valuable information to molecular biologists attempting to isolate the gene(s) responsible. 2.2 Long Term Consequences of Childhood Cancer Treatment Five year survival percentages for patients enrolled in National Wilms Tumor Study (NWTS) protocols were 79.7% for 1969-74 enrollees, 81.6% for 1975-1979, 86.3% for 1980-84, 88.6% for 1985-1989 and 90.4% for 1990-1995, and are among the highest for childhood cancer. Despite similar treatment, only some survivors develop late complications of therapy. Studies to date have identified several of the most serious complications. Specific disease, treatment and host related risk factors, however, require further investigation. The systematically treated and followed NWTS cohort is ideal for study of these questions. 2.21 Gonadal Function and Fertility The effect of radiation on reproductive function is dose and age dependent. [34-36] In an NCI study, Byrne and colleagues found relative fertility (compared with sibling controls) was 0.75 for female cancer survivors receiving sub-diaphragmatic radiation. For the subgroup of 29 Wilms tumor survivors, relative fertility was 1.47 (95% C.I. 0.81-2.65). Females treated in the pre-pubertal years did not experience premature menopause. [37, 38] Chiarelli and colleagues studied a similar Canadian cohort, of whom 46 had Wilms tumor. Women treated with abdominal-pelvic radiation without the use of alkylating agents had a relative risk of early menopause of 1.62 and a relative fertility of 0.77, neither of which was statistically significant.[39] Neither study included sufficient numbers of Wilms tumor patients for stable statistical results. In a 2009 analysis of the CCSS cohort with 5,149 female childhood cancer survivors, the relative risk of pregnancy was 0.81 (95% CI

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0.73, 0.90) compared to 1,441 sibling controls. Among survivors, exposure to ovarian or uterine radiation had a dose dependent effect on fertility, with a relative risk of 0.18 for >10Gy vs. ≤2.5 Gy. Wilms Tumor patients were not analyzed separately in this study. [36] Small studies of Wilms tumor survivors have indicated that ovaries or uterus may be decreased in size in those who received whole abdomen radiation therapy (RT). [40, 41] This may affect both fertility and pregnancy outcomes and requires additional study. Testicular radiation can cause azoospermia, due to scatter from abdominal-pelvic radiation. [42, 43] Studies with substantially larger numbers of patients are needed, however, to definitively investigate these issues. 2.22 Pregnancy Outcomes Adverse pregnancy outcomes have been reported in Wilms tumor survivors treated with abdominal radiation prior to 1980. [44-47] Rates of perinatal mortality and low birth weight were eight and four times higher, respectively, than among US white women. [47] Female survivors were four times more likely than sibling controls to have adverse outcomes such as low birth weight, preterm delivery, birth defects and neonatal death. This was not seen in the wives of male survivors. [44] A 2010 analysis of the NWTS cohort showed that women who receive flank radiation therapy as part of the treatment for unilateral WT are at increased risk of hypertension complicating pregnancy, fetal malposition, and premature labor. The offspring of these women are at risk for low birth weight and premature (ie, < 37 weeks gestation) birth. [48] Further follow-up of the NWTS cohort will increase the numbers of patient pregnancies available for such studies. 2.23 Second Malignant Neoplasms Survivors of childhood cancer are at increased risk of developing a second malignant neoplasm (SMN). The cumulative risk at 20 years varies between 3-10% over several studies and is 5-20 times greater than that expected in the general population. [49-58] The incidence of SMNs following Wilms tumor in NWTS patients was initially reported in 1988 for those patients enrolled between 1969 and 1982. Fifteen SMNs were identified among 2,438 patients. The observed (O) to expected (E) or standardized incidence ratio (SIR) was 8.5 (4.7-14.0). [59] The 4 patients who developed hepatocellular carcinoma all had right-sided tumors for which they received flank radiation. None had cirrhosis and neither of 2 tested had positive serology for Hepatitis B. Three of the 4 had a congenital anomaly or other heritable disease, suggesting the potential for an unstable genome. [60] These results were updated in 1996 based on follow-up through 1993 of 5,278 patients enrolled through 1991. A similar SIR of 8.4, with 43 SMNs, was observed [61] Dr. Breslow led a pooled analysis of combined North American (NWTS and CCSS), British and Nordic subjects with Wilms tumor to update and more precisely describe the risk of SMN, illustrating that cumulative incidence of solid tumors at age 40 was 6.7% in the cohort who was SMN free at age 15. SIRs for solid tumors and leukemias were 5.1 and 5.0, respectively. [57] Breast cancer was studied within the 2492 female participants in the NWTS cohort for whom 29 breast cancer events among 28 women were observed. This analysis illustrated a high risk of developing early Breast Cancer with elevated risks for subgroups who received chest RT (SIR 27.6; 95% CI, 16.1-44.2), only abdominal RT (SIR 6.0; 95% CI, 2.9-11.0). [58] Because of the long latency period for breast cancer and other solid tumors, survivors of Wilms tumor from the CCSS and NWTS cohorts continue to reach the ages at which substantial numbers of excess cancers may be expected. Large numbers of patients were treated with doxorubicin, a radiation sensitizer and topoisomerase II inhibitors, only after 1980. Continued follow-up is essential to determine the long term risk posed by doxorubicin.

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2.24 Contralateral Wilms Tumor Children with bilateral Wilms tumor, either at initial diagnosis or subsequently, have a lower overall survival and a higher incidence of renal failure. [62-64] Bilateral disease, whether synchronous or metachronous, is strongly associated with the precursors ILNR and PLNR.[5] Children who develop another Wilms tumor in the contralateral kidney are generally believed to have a genetic predisposition, in accordance with Knudson’s theory. Prediction of who these patients may be at the time of initial diagnosis is important to facilitate renal sparing surgery and follow-up by ultrasound. The NWTS study by Coppes and colleagues identified the joint presence of PLNR and ILNR, or the presence of PLNR in children diagnosed during the first year of life, as important risk factors. [65] These features did not predict all the future events, however, and further study is warranted to determine others. 2.25 Cardiac Toxicity Wilms tumor patients may have two risk factors for cardiac toxicity, exposure to doxorubicin and radiation (thoracic and left flank). Cardiac toxicity may be symptomatic or purely subclinical. [66-71] Cardiomyopathy risk from anthracyclines may be increased in females, those with higher cumulative doses, and younger age at diagnosis, and with longer follow-up time. [69-72] It is plausible to postulate that long-term survivors of Wilms tumor may be at uniquely increased risk of cardiac toxicity due to combination of radiation therapy and radiation sensitizing chemotherapeutic agents. The first NWTS study of cardiac toxicity demonstrated that risk of congestive heart failure persisted for 8-12 years or more from the time of anthracycline treatment. Since anthracycline was used more extensively in NWTS 3-4 that it had been earlier, continued follow-up is again essential in order to determine whether the risk may persist even longer than now believed. A recent pooled analysis led out by Dr. Eric Chow which included the NWTS cohort developed a risk prediction model for congestive heart failure by age 40, with risk scores based on anthracycline and chest radiation exposures to achieve an area under the receiver operating characteristics curve of 0.74. [73] This prompted additional analyses with the same combined cohort to better define conversion factors for calculating cumulative anthracycline doses, providing new data that an equivalence ratio for daunorubicin to doxorubicin in relation to late heart failure should be 0.5. [74] 2.26 Renal Failure Children with Wilms tumor are at risk of renal dysfunction and/or failure from a variety of potential mechanisms including radiation therapy, use of potentially nephrotoxic chemotherapy agents, and a theoretical risk due to hyperfiltration of the remaining nephrons following removal of a critical mass of renal tissue. [62, 75-77] There is a genetic component also. Patients with the Denys-Drash syndrome have a characteristic severe nephropathy believed to be due to a dominant negative effect of the WT1 mutation.[14] Hypertension may be a surrogate marker for some degree of renal dysfunction. Finkelstein and colleagues documented an increased incidence of diastolic hypertension among survivors of Wilms tumor, especially at younger ages. [78] In 1996, Ritchey and colleagues reported the spectrum of renal failure in 55 patients among 5,823 patients treated on NWTS 1-4. [64] The cumulative risk of renal failure at 16 years was 0.6% for all unilateral patients, and 13% for NWTS-3 bilateral patients. The most common etiologies of renal failure were bilateral nephrectomy for persistent or recurrent tumor, progressive tumor in the remaining kidney without nephrectomy, Denys-Drash syndrome and radiation nephritis. [64] A more recent NWTS report revealed that patients with the WAGR syndrome were at very high risk of renal failure after puberty. [79] The long term cumulative risks of

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renal failure for patients with a missense WT1 mutation (DDS) or a chromosomal deletion of WT1 (WAGR) were thus both in excess of 50%. More detailed study of the renal pathology in both syndromes is needed to determine whether it may have a common genetic origin. Further follow-up is also needed to determine whether other patient subgroups with possible WT1 mutations giving rise to less severe phenotypes, identified by the presence of genito-urinaryanomalies or ILNR, also have a high if not extreme incidence of renal failure. 2.27 Pulmonary function Delayed lung toxicity may occur after treatment with radiation or chemotherapy. [80, 81] While none of the chemotherapeutic agents used in Wilms tumor is known to induce pulmonary toxicity, doxorubicin and dactinomycin may augment the radiation effect. Both early interstitial lung disease and later occurring pulmonary fibrotic disease are seen after radiation therapy for other malignancies. [80, 82] It is therefore important to assess the incidence of this long-term effect in survivors of Wilms tumor, especially in those also at risk for cardiac dysfunction. 2.28 Mortality Among Survivors of Wilms Tumor From 1975-1999, there has been a dramatic decrease in childhood cancer mortality. [83] However, long-term sequelae may result in later cancer and non-cancer related mortality, including second malignancies, cardiac and pulmonary disease and infection. [84-91] For 4,972 5-year survivors of Wilms Tumor in the NWTS, the standardized mortality ratio, compared to the U.S. population age, sex and calendar year rates, was 24.3 (95% CI, 22.6 to 26.0) for the first 5 years, was 12.6 (95% CI, 10.0 to 15.7) for the next 5 years, and remained greater than 3.0 thereafter. [89] By identifying the treatment and host factors associated with the excess mortality, interventions may be developed and targeted for those at highest risk. Now that 90% of children with Wilms tumor are being cured, it is most important to focus attention on the duration and quality of life in the survivors.

TABLE 1: NWTS patients eligible for the Late Effects Study*

Year of Registration Studied Followed Total

1969-1974 306 167 4731975-1979 578 224 8021980-1984 1082 301 13831985-1989 821 715 15361990-1994 929 729 16581995-1999 1333 315 16482000-2002 810 117 927Total 5859 2568 8427 * Patients from US and Canadian institutions who survived two years from diagnosis

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2.3 Description of the NWTS Cohort 2.31 NWTS Study Population Five therapeutic studies have been completed: NWTS-1 (1969-1974), NWTS-2 (1975-1979), NWTS-3 (1980-1985), NWTS-4 (1986-1995), and NWTS-5 (1995-2002). Approximately 70-80% of the total national US incidence of Wilms tumor have been registered on these studies since 1980. There are a total of 9,424 subjects in this cohort, which constitutes the NWTS Data Repository. Table 1 shows patients treated on NWTS 1-5 who have survived 2 or more years and are therefore eligible for the Late Effects Study (N = 8,427). 2.32 Histopathology All patients on successive NWTS protocols are required to have slides submitted to the study pathology center for centralized review and since, 1980, for the presence, number and type of precursor lesions. This has been successful in 90% of all eligible NWTS-1, 91% of NWTS-2, 94% of NWTS-3, 97% of NWTS-4 and 99% of NWTS-5 patients. Tissue is archived for use in clinical or special research studies. In NWTS-5, a biology study was added to the therapeutic protocol. The NWTS Tissue Bank has biologic specimens for 72% of eligible patients. 2.33 Treatment Detailed therapy records were collected prospectively for all patients and entered into a computerized database at the NWTS for initial and, when applicable, retrieval therapy. Both randomized and historical comparison groups are available for evaluation of the effect of radiation and chemotherapy on the endpoints of interest. Radiation was part of standard treatment for all patients on NWTS-1, but is employed at much reduced doses for only 40% of patients on NWTS-4,5. 3.0 PATIENT ELIGIBILITY Patients previously registered on NWTS 1-5 constitute the members of our data Repository

(N=9,424). They are eligible for the Late Study if they have survived at least 2 years after diagnosis (N=8,427). All eligible patients for NWTS 1-4 have been enrolled.

3.1 NWTS-1 through NWTS-4: Registration procedures for entry onto NWTS-1 through NWTS-4 included

obtaining written consent from the patient's parents for participation in the study, including collection of follow-up data for an indefinite period. These patients were automatically eligible and enrolled in the Late Effects Study when they reached their second anniversary following diagnosis. There was no separate consent or registration for these patients.

3.2 Patients previously enrolled on NWTS-5 are eligible and are enrolled when the institution's original consent allowed for long term follow-up, these patients are automatically eligible for the Late Effects Study when they reach their second anniversary following diagnosis. Starting with the 9/01 revision of the protocol, NWTS-5 patients can be consented and thus registered on the Late Effects Study. Do not report the registration to COG. At the time the institution informs the NWTS Data and Statistics Center

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(DSC) of a newly consented patient it should also report the date of contact, the method of contact, and the status of the patient’s health. The DSC can then code a new date of follow-up which will be included in the report to COG. The DSC will report to COG quarterly.

3.3 As noted above, all NWTS 1-5 patients in the Randomized, Studied and Followed categories who have survived at least two years are eligible to be participants in the Late Effects Study. The procedures for achieving patient participation in the study differ for NWTS 1-4 vs 5 as described below.

3.31 Patients from National Wilms Tumor Studies 1-4

The institutions have received an NWTS Late Effects Study Information Sheet and a packet to be sent to the family that discusses the study and the schedule of forms. If the patient is no longer returning to the institution, a Release Authorization is solicited requesting that the DSC be authorized to trace and contact the family for continued follow-up

3.32 Patients from National Wilms Tumor Study 5

3.321 If the NWTS-5 consent provided for long-term follow-up, the institution need only inform the DSC that its patients are already consented, otherwise the institution will provide the consent to the patient.

3.322 If a patient is no longer returning to the institution, a Release Authorization is solicited requesting that the DSC be authorized to trace and contact the family for continued follow-up.

4.0 STUDY PROCEDURES The NWTS Data and Statistical Center (DSC) will provide institutions and families in direct contact with the

appropriate forms. NWTS Annual Status Reports (ASRs) should be submitted starting in year 2 to document patient contact.

At any time a patient relapses, flowsheets and complete clinical documentation must be submitted. 4.1 Copy of Current Institutional IRB Approval 4.2 Consent - The Data and Statistical Center (DSC) will request that the institution document consent for

NWTS-5 patients eligible for accrual to the Late Effect Study after the second anniversary following diagnosis.

4.3 Medical History Forms - Institutions are requested to present the Medical History Forms to families.

4.31 Adult Patient Medical History Form (APMHF) - This form is requested every five years,

from patients who are 18 years of age or older. 4.32 Family and Medical History Form (FMHF) - This form is requested every five years from the parents

of patients who are less than 18 years of age, as appropriate.

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4.4 NWTS Late Effects Study Physical Examination (PE) - This form is to be completed by the current physician of record for the patient every five years. It is mailed from the DSC to the current institution of record for patients remaining in follow-up by the institution, and directly to the family/patient for patients who are under direct follow-up by the DSC.

4.5 NWTS Late Effects Study Annual Status Report (ASR) - This form is requested at each yearly

anniversary (excluding the multiples of the fifth anniversary) after diagnosis. It is mailed from the DSC to the current institution of record for patients remaining in follow-up by the institution, and directly to the family/patient for patients who are under direct follow-up by the DSC. Participants have the option of completing the annual form and returning it to the DSC in the business reply envelope provided or of going to the website of SurveyMonkey.com to complete the form electronically in the area to which the DSC has access. The DSC will notify by email those participants who have notified us they prefer to complete electronic forms and have provided the DSC with their email addresses.

4.6 NWTS Adult Consent Form (ACF) - When each patient turns 18 years of age, the DSC solicits his/her

continuing consent for participation in the Late Effects Study. The ACF is sent to the institution, local physician, patient or patient's family at that time with a cover letter.

4.7 Pregnancy Questionnaire - Sent when a pregnancy is reported. 4.8 Special Studies

Special studies conducted as needed to meet our aims and as approved by the Hutch Institutional Review Board (IRB).

The Saliva Collection Substudy recently completed accrual to collect samples from a nested case-control study sample to examine associations of WT1 with end stage renal disease. See Protocol included in Appendix F.

To expand our ability to assess the effects of radiotherapy exposure to specific organs on health outcomes for, we have a grant collaboration with Dr. John Kalapurakal from Northwestern University to carry out detailed dosimetry estimation for our study patients who received radiation therapy, “Retrospective NCI Phantom-Monte Carlo Dosimetry for Late Effects in Wilms Tumor”. In addition, per the Aims of the that grant we have added an expanded Reproductive and Sexual Health Survey to augment the information we collect via other surveys for Objective 1.3. See Appendix C for survey and Appendix G for substudy details.

4.9 Requests for Medical Records

The key events monitored by the DSC include pregnancies and births, Wilms tumor in any family member, second malignant neoplasms, heart, lung, and renal disease and death. As soon as one of these events is ascertained, further details are requested from the appropriate source. When this entails going beyond the standard follow-up procedure to which the family already has consented as part of the therapeutic trial, appropriate authorization for release of medical information is solicited.

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4.91 Pregnancies and Births

A Pregnancy Questionnaire and authorization for Release of Medical Information are mailed to the NWTS patient as soon as the DSC learns about a pregnancy or birth. This covers items about the hospital where the birth took place, pregnancy complications and outcome, and birth defects, childhood illnesses and survival in the offspring. It requests an authorization for release of medical records on mother and child for access to the medical history of the pregnancy, delivery and early childhood. Once a child is known to have been born to the NWTS patient or partner, permission is sought to request annual updates on the health status of that child. Should sentinel events be detected, permission is sought for the release of additional medical records. The forms used in this process are shown in the Appendix.

4.92 Second Malignant Neoplasms and Organ System Failures

A copy of the pathology diagnosis or other clinical reports are requested for all identified second malignant neoplasms; only those SMNs with pathology confirmation are utilized in statistical analyses. Clinical records, reports of imaging studies and autopsy reports may also be requested. A similar procedure is followed to document identified cases of organ system failures. If such conditions are initially reported by the original institution, further details are requested directly from that institution just as they are for the clinical trial. If reported by the patient, the family or a local physician, however, permission for release of medical records is sought before approaching the physician/institution where the diagnosis was made. The forms sent to the family or (adult) patient that authorize the collection of such data are shown in the Appendix.

4.93 Relapse

In the event of a relapse in a patient in institutional contact, follow-up should be submitted monthly until a complete response is attained to the Data and Statistical Center. Whenever the patient develops recurrence or metastases, send the DSC the flow sheet giving the details of the relapse. If surgery is performed, a copy of the operative note and a copy of the pathology narrative should also be forwarded to the DSC. Events to be documented: progression or regression of disease, method of detection (radiology reports, surgeries, etc.), dates of each and treatment summary.

4.94 Death

In the event of the death of a patient the following information is requested: death certificate and/or clinical documentation.

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5.0 REPOSITORY

5.1 Repository

The NWTS Repository includes the patient characteristics, treatment and outcome data from the 9,424 patients who were treated on the 5 NWTS clinical trials. The NWTS has a long history of making its clinical trial available to qualified and approved researchers. Researchers requesting access to NWTS data must submit a research proposal to the NWTS. The NWTS PI reviews and approves. Any data files approved researchers receive are stripped of personal identifiers. For any approved projects The NWTS submits the completed repository form to the IRB with its annual submission.

6.0 CODING OF MEDICAL CONDITIONS AND TREATMENT EXPOSURES

6.1 Medical Conditions Specified medical conditions identified in NWTS survivors are coded in a record that contains (i)

date of diagnosis; (ii) 5-digit International Classification of Disease (ICD) code; (iii) 6-digit morphology/malignancy code for neoplasms (ICD); (iv) an alphanumeric description; (v) the initial and best source of information (pathology, clinical report, PE form, etc.). A dictionary of previously detected conditions with corresponding ICD codes is used by DSC staff as an adjunct to the ICD manuals.

6.2 Treatment Exposures Co-Investigators on this protocol with IRB approval at their institutions will have access to

medical reports to carry out radiation dosimetry and calculate cumulative chemotherapy exposures.

7.0 STATISTICAL CONSIDERATIONS

7.1 Sample Size and Study Design

7.11 Estimation and Comparison of Event Rates The methods of statistical analysis to be used in this study are those appropriate to the analysis of follow-up (cohort) studies more generally. They include estimation of incidence rates of major study endpoints, comparison of such rates with national standards (where available) and internal comparisons between different patient subgroups defined on the basis of their treatment, or on the basis of congenital anomalies and precursor lesions that may indicate different types of genetic predisposition. Relative risk regression analyses are used to model the incidence rates as a function of multiple quantitative or qualitative characteristics. Much of the relevant methodology was developed by the late Dr. Breslow, former PI of the NWTS Late Study, and his collaborator Dr. N.E. Day in a 1987 IARC monograph [92] which together with a volume on case-control studies [93] is now a standard source for statistical methods in epidemiology.

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7.12 Nested Case-Control and Case-Cohort Studies

For specific adverse events (such as pulmonary or cardiac toxicity) we would plan additional analyses using a nested case-control or case-cohort approach. This will permit the efficient abstraction, or if needed the collection and abstraction, of more extensive data than are already in the NWTS computerized data base. Cases are those who have had the endpoint of study (e.g. pulmonary fibrosis). Controls, without the endpoint of interest, are chosen randomly at a rate of 4 or more controls per case. Such an approach allows for approximately 80% efficiency relative to the analysis of all available controls and thus is quite cost-effective when an endpoint is rare and substantial additional data need to be collected or abstracted.

Methods for the design and analysis of stratified case-control and case-cohort studies that enable all the information already available in computer files, on both outcome and exposure, to be utilized in the most efficient way possible developed by Dr. Breslow will be employed.[94] The substantial gains that may be realized in comparison with more conventional designs and less efficient analyses were illustrated by application to NWTS prognostic factor studies.[95] Software is available for stratified case-cohort as well as stratified and nested case-control studies.[96]

7.13 Longitudinal (Repeated Measures) Data Analysis

Analysis of longitudinal data involving repeated measures on each patient will use methods for linear and nonlinear regression with random effects that explicitly model the correlation structure, as was done for the recently completed analysis of stature [97] as well as more robust methods based on generalized estimating equations. [98]

7.14 Number of Events and Power Calculations

We have accumulated over 150,000 person-years of observation as of September, 2018. Judging from the studies already successfully completed, this will be adequate to answer many questions of scientific interest. As the cohort ages, we have also accumulated increasing numbers of key events, which will allow more detailed analyses of treatment effects. Specifically, we have confirmed 250 SMN events, 172 end stage renal disease (ESRD) cases, 108 cardiomyopathy cases, 68 congestive heart failure (CHF) cases and 527 non-external causes of death in the cohort of which 272 were due to their Wilms tumor, 91 are related to an SMN and 32 are related to congestive heart failure. For SMNs, ESRD and cardiomyopathy, this will permit relative risks of 2.0 or less to be detected for most of the internal comparisons that one might contemplate, provided that the comparison groups are not extremely unbalanced (Table 2). For example, to determine whether patients treated with chemotherapy alone (no radiation) remain at increased risk of cancer since approximately 47% of the person years were contributed by patients who did not receive radiation, and their expected number of SMNs is at least 10.0. This is sufficient to detect a relative risk of 1.9 using a 5% test with 80% power (Table 7.3 of [92]). With the number of person-years observed currently, we have ample power to examine relative risks for a variety of subgroups

TABLE 2: Expected number of cases in the control group required to detect a difference with 5%

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significance and 80% power when the control group is K times the size of the exposed group (from Table 7.4 of [92])

Relative risk

K=1/10 K=1/5 K=1/2 K=1 K=2 K=5 K=10

2 11.3 12.3 15.1 20.0 29.6 58.6 107

3 3.9 4.2 5.2 6.7 9.9 19.5 35.0

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Appendix G: “Retrospective NCI Phantom‐Monte Carlo Dosimetry for Late Effects in Wilms Tumor” 

Grant 

RETROSPECTIVE NCI PHANTOM-MONTE CARLO DOSIMETRY FOR LATE EFFECTS IN WILMS TUMOR

SPECIFIC AIMS The National Wilms Tumor Study (NWTS) has studied the association between radiation therapy (RT) and several late effects among Wilms tumor (WT) survivors. However, RT was measured by prescribed doses to standard fields (flank, lungs, abdomen) rather than by three-dimensional (3D) target organ dosimetry. This study will, for the first time, perform 3D NCI phantom based treatment planning system and Monte-Carlo (MC) based retrospective dosimetry use the resulting doses to study the association between quantified RT exposure to specific organs and late effects.

SPECIFIC AIM 1: We will estimate RT doses to specific organs of 5000 irradiated NWTS subjects using the 3D NCI Phantom and TPS-MC dosimetry model. RT doses (mean dose, D30, D70) will be obtained for the following organs: total heart, ventricles, kidneys, lungs, chest wall, breasts, thyroid, liver, stomach, colon, ovaries, uterus, pelvis and testicles (APPENDIX 3).

SPECIFIC AIM 2: We will review and validate reproductive late effects (hypogonadism and infertility) in male and female survivors recorded in the NWTS database and conduct a prospective questionnaire-based cohort study to determine their prevalence among NWTS survivors. Ovarian failure in 143 patientsand infertility in 220 patients and male infertility in 42 patients were identified by the NWTS even though the LES was not specifically designed to ascertain and record these conditions. They were reported by the institution on flow sheets or by the patient/family on medical history forms and annual questionnaires for many decades of follow-up. All records for patients who have reported these conditions will be reviewed and conditions validated. The NWTS database will be thoroughly re-reviewed in order to identify as many patients as possible with these specific late effects for this study. A questionnaire developed by fertility experts that is designed to ascertain the history of occurrence of reproductive impairment will be sent to all patients known to be alive at last follow-up who have valid addresses. This will facilitate estimation of the prevalence of these late effects among current survivors (APPENDIX 4, 5).

SPECIFIC AIM 3: We will study the association between RT dose (mean dose, D30 and D70) estimated using the 3D NCI Phantom and TPS-MC dosimetry model and NWTS late effects. We will study the 5targeted late effects (target organs for dosimetry):CHF (Total heart, ventricles, myocardium); ESRD (Solitary or partial kidneys); Restrictive Pulmonary Disease (Lungs and chest wall); Adverse Pregnancy Outcomes (Ovaries, uterus and pelvis); Second Malignant Neoplasms (breast, thyroid, stomach, colon, liver, kidney) and reproductive impairment collected from Aim 2 in males (testes) and females (ovaries, uterus, pelvis) (TABLE 1, 5).

171

RESEARCH STRATEGY

PEDIATRIC CANCER SURVIVORSHIP AND RELEVANCE OF LATE EFFECTS STUDIES: The survival rates of childhood cancer patients have increased steadily. From 1969 until 2012 childhood cancer mortality rates have declined by 66%, and 5-year survival has increased from 58% to 83%. This level of improvement in cancer survival has been accomplished by systematic improvements in multimodality treatment and high rates of participation in clinical trials such as in the National Wilms Tumor Study (NWTS) (1). Despite improvements in survival, long-term (life-long) treatment-related toxicity is the most common cause of morbidity and mortality among cancer survivors. Radiation therapy (RT) is the single most important contributor to late toxicity in children. According to NCI and SEER the number of childhood cancer survivors is estimated to be more than 420,000 in 2013 and up to 500,000 by 2020. Currently about one of every 750 adults in the U.S is a survivor of childhood cancer (2-6).

STRENGTHS OF THE NWTS DATABASE The NWTS conducted 5 clinical trials that accrued 9236 Wilms tumor (WT) patients during 1969-2002 (7-13). The high survivorship (90%) makes WT ideal for the study of late effects after therapy. The NWTS database is a valuable NIH funded resource that provides us with a unique opportunity to conduct an accurate study of target organ RT dose and late toxicity. Its strengths include: 1) all patients were accrued on prospective national clinical protocols, 2) demographics and WT-related data were collected in a uniform manner, 3) multimodality treatment records including surgery, chemotherapy and RT details are available, 4) NWTS data are longitudinal; patients have been followed indefinitely from diagnosis for many decades, 5) treatment data have been monitored for accuracy by NWTS investigators, 6) RT fields have been consistent throughout all NWTS trials using simple AP-PA Fields (Flank, Whole Abdomen (WA) or Whole Lung). Further, these RT fields can be easily reconstructed unlike complex 3D conformal or IMRT treatment plans for other pediatric tumors. FIG. 1. STANDARD NWTS RT FIELDS (from NWTS report on breast cancer):- Axial CT scan (A) and digitally reconstructed radiographs (DRRs) with breast tissue contours of a 5 year-old girl.(B) DRR of a standard AP-PA whole-lung RT field. (C) DRR of a standard AP-PA whole-abdomen (WA) RT field. (D) DRR of a standard AP-PA left flank field (19), 7). While RT fields have been consistent, the indications for and dosages of RT were serially reduced: age-based dosing up to 40Gy in NWTS 1 and 2; 10-20Gy in NWTS 3; No RT in

stage I and II, 10Gy in NWTS 4-5 (stage III, IV patients), thus permitting dose-response (0-40Gy) analysis for late effects, 8) RT was randomized for some groups on NWTS1-3, creating variations in dose even for patients followed for comparable periods, 9) long-term follow up data on patients enrolled in the NWTS Late Effects Study (LES) are available. After excluding about 1459 patients who died and 335 who requested to be discontinued from study, 2529 are in current follow-up and 5002 have contributed information to the LES. Among 4186 patients enrolled before 1991, 2606 have been followed alive >20 years past diagnosis, 10) the NWTS database is the largest and most comprehensive database for children with WT. Other late effects studies like the Childhood Cancer Survivor Study (CCSS) do not have these advantages. Inadequate treatment records, retrospective patient selection and cross sectional design have hindered accurate inferences of temporality, causality and risk. The combination of a large long-term prospective database complemented by follow-up data from a questionnaire-based approach

makes NWTS ideal for such a comprehensive dosimetry study. Among 1182 WT survivors in the CCSS 756 are in the NWTS LES (14-16).

NWTS LATE-EFFECTS CHOSEN FOR THIS STUDY (Table 1, 5) Even though the cure rate of children with WT is >90%, the survivors remain at risk for death due to late toxicity >20 years later. The seminal NWTS publications were for 5 late effects targeted for data collection from patients (Second Malignant Neoplasms SMN, Congestive heart failure CHF, Restrictive Pulmonary disease RPD, End Stage Renal Disease ESRD, and Adverse Pregnancy Outcomes) (14, 17-29). In the NWTS report on 6185 patients followed from 1969-1995 the excess mortality risk compared to the general population was 24 fold for the first 5 years, 13 fold for the next 5 years and remained greater than 3 – 4 fold for the next 15 years. Among 5 year survivors 39% mortality was attributable to late toxicity (28). After 39, 461 personal years of observation for >5000 patients, the 15 year rate

Fig. 1

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of SMN was 1.6% and rising steadily. Abdominal RT increased SMN risk by 43% per 10Gy without doxorubicin (DOX) and 78% per 10Gy with DOX (29). A total of 2492 females from NWTS 1-4 (1969-1995) were followed from age 15 through 2013 and the median age at last contact was 27.3 years. The cumulative risk of breast cancer at age 40 years after chest RT, only abdominal RT, and no RT was 14.8%, 3.1% and 0.3% respectively (19). The 20 year rate of CHF was: 4.4% after initial treatment and 17.4% after treatment with doxorubicin for tumor relapse. The CHF relative risk (RR) was increased: in females (RR 4.5; P-value 0.004); doxorubicin (RR 3.3/100mg/m2; P-value <0.001); lung RT (RR 1.6/10Gy; P-value 0.037) and left abdominal RT (RR 1.8/10Gy; P-value 0.013). The CHF distribution was bimodal, a first wave during the first 3 years and a second wave 8-12 years later. The last event occurred at 24.3 years (NWTS 1, 2), 18.2 years (NWTS 1, 2 relapse patients) and 15.6 years (NWTS 3, 4) (18). In 6500 NWTS patients the 15 year incidence of RPD after initial lung RT, lung RT for relapse and no lung RT was 4%, 5.5% and <0.5% respectively (24). The 20 year rate of ESRD was 0.7% in non-syndromic unilateral WT, 3.1% in bilateral WT, 83% in Denys Drash syndrome and 43% in WAGR syndrome. For ESRD due to progressive bilateral WT at 3 years, the incidence was 4% in synchronous and 19.3% in metachronous bilateral WT. The effects of RT on ESRD have not been thoroughly studied (25-27). Regarding adverse pregnancy outcomes, analysis of 427 pregnancies of 20 weeks or longer and 421 live born infants, revealed that irradiated patients were at increased risk for early or threatened labor and fetal malposition and that their offspring were likely to be premature (<37 weeks gestation) and of low-birth weight (<2500 gms.). All these complications were significantly higher after flank RT dose >25Gy (20-22). Table 5 shows the multiple patient and multimodality treatment factors that correlated with these late effects. The NWTS has not analyzed in detail many other late effects such as reproductive impairment (infertility) that were not targeted in surveys, but which were recorded in the database from institution and patient reports. Ascertainment of reproductive impairment will likely be incomplete as it was not a specific aim of the LES, and will be completed as part of this study (AIM 2). Further, the numbers of such non-targeted events recorded are sufficient for meaningful RT-association studies (Table 1).

LIMITATIONS OF THE NWTS DATABASE The NWTS has consistently implicated higher RT doses, larger RT fields (WL, WA, left flank), and DOX as important causative factors for all these late effects (14, 17-29). However, these late effects were only correlated with RT fields and prescribed RT doses without target organ dosimetry. The RT-site and RT-dose dependence of these late effects using the prescribed RT information are shown in Table 1. Increasing doses to the flank appear to modify risks significantly (P<0.001) for all outcomes. For example, patients who received >25 Gy to the flank had a 10-fold increase in rates of both CHF and pulmonary disease as compared to those who received no RT (P<0.001). TABLE 1. NWTS LATE EFFECTS FOR CURRENT STUDY WITHOUT ANY TARGET ORGAN DOSIMETRY DATA BUT ONLY RELATION TO RT FIELDS AND DOSES

Table 1. CORRELATION OF NWTS PATIENTS’ TREATMENT AND LATE EFFECTS CHOSEN FOR THIS STUDY.* RT FIELD DOSES ONLY WITHOUT TARGET ORGAN DOSIMETRY Late effects responsible for mortality /morbidity Doxorubicin

Whole Abdomen

RT None

Flank <15 Gy

no Chest

Flank 15-<25 Gy no Chest

Flank >=25 Gy no Chest

Chest, No Flank

Chest + Flank

N = 4020 N =1128 N = 4420 N = 1941 N = 698 N = 713 N =253 N = 1211 SMN 122 (3.0%) 54 (4.8%) 59 (1.3%) 42 (2.2%) 25 (3.6%) 47 (6.6%) 10 (4.0%) 62 (5.1%) CHF 54 (1.3%) 16 (1.4%) 7 (0.2%) 7 (0.4%) 3 (0.4%) 16 (2.2%) 5 (2.0%) 31 (2.6%) ESRD** 37 (0.9%) 13 (1.2%) 72 (1.6%) 19 (1.0%) 18 (2.6%) 10 (1.4%) 2 (0.8%) 5 (0.4%) Pulmonary 52 (1.3%) 14 (1.2%) 4 (0.1%) 6 (0.3%) 3 (0.4%) 8 (1.1%) 14 (5.5%) 48 (4.0%) Pregnancy Complications 224 (5.6%) 30 (2.7%) 265 (6.0%) 71 (3.7%) 96 (13.8%) 114 (16.0%) 12 (4.7%) 80 (6.6%) Ovarian Failure 81 (2.0%) 91 (8.1%) 17 (0.4%) 26 (1.3%) 28 (4.0%) 36 (5.0%) 3 (1.2%) 33 (2.7%) Infertility 90 (2.2%) 65 (5.8%) 67 (1.5%) 24 (1.2%) 41 (5.9%) 49 (6.9%) 6 (2.4%) 33 (2.7%) *Columns labeled “None” through “Chest and Flank” are mutually exclusive, P value <0.001 for all outcomes. **Excludes ESRD due to progressive WT

LIMITATIONS TO THE STUDY RT-LATE EFFECTS IN CHILDREN Despite RT being the single most important contributor, there are significant limitations in our ability to accurately study RT-induced late toxicity from past treatments. The study of childhood normal tissue tolerance is more complex and challenging than in adults

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because: the underdeveloped and immature normal tissues are more vulnerable to RT injury; different normal tissues within a given RT field have different rates of growth and maturation and thus different RT sensitivity based on age; childhood tumors are generally treated with multimodality therapy including surgery, chemotherapy and RT, with a complex interplay between them for causality (Table 1, 5); different childhood tumors are treated with varying RT doses and chemotherapy regimens, thus making it difficult to act on conclusions of pooled data from multiple diagnoses for specific normal tissue effects; the latent period for late toxicity exceeds many decades as noted above, requiring careful follow up, maintenance of records etc. (5).

HOW TO BRIDGE THE KNOWLEDGE GAP BETWEEN PAST AND PRESENT. During the NWTS time period that represents the past RT technology (2D era) we did not have the capability for patient CT scan-based treatment planning, and dosimetry-archival expertise thus precluding meaningful 3D target organ dosimetry correlation for these late effects (Table 1, 5). However at the present time (3D era) the pediatric RT specialty has many novel technologies like IMRT, IGRT and proton therapy with robust 3D dosimetry and archival capability (QARC has 3D target organ dosimetry data on 896 WT children from first generation Children’s Oncology Group COG RT protocols). But we will need decades of follow-up and exhaustive late effects data after modern treatments before valid advanced dose-volume correlations can be made from present 3D dosimetry data (30-35). This proposed study using patient-matched NCI phantom (NCI-P) and treatment planning system (TPS) and Monte Carlo (MC) dosimetry for all 5000 NWTS subjects will provide a unique opportunity to combine the strengths of the past (very long-term toxicity data) and present (CT-based 3D treatment planning, IMRT, Protons to prevent toxicity), for the benefit of children currently being treated. QUANTEC reviewed published data on RT toxicity in adults and provided 3D organ dose-volume tolerance guidelines that are currently used in clinical practice (36). However there is not much data on 3D normal tissue RT tolerance in children. PENTEC (Pediatric Normal Tissue Effects in the Clinic) is a collaborative effort that is currently analyzing past published literature on 3D organ-RT tolerance in children (37). The main limitation for PENTEC is that the majority of past publications did not provide meaningful 3D dosimetry correlation with late effects. This dosimetry study can circumvent this limitation (See letter of support from PENTEC chair Dr. Louis Constine). For this reason, current COG protocols use mean and maximum dose limits without 3D tolerance guidelines (APPENDIX 1).

A).SIGNIFICANCE (See letters of support from Drs. Giulio D’Angio, Patrick Thomas and Peter Adamson)

A1).SIGNIFICANT IMPACT: FUTURE UTILITY OF THIS NCI FUNDED RESOURCE (NWTS DATABASE) While the NWTS has studied the association between RT and several important late effects noted above, the RT was measured by prescribed doses to standard fields and not based on target organ 3D dosimetry (Fig 1. Table 1, 5).This study using NCI-phantoms will help overcome this important limitation by providing detailed target organ dosimetry for all the 50+ pre-contoured phantom organs for all the 5000 NWTS patients. Further, this 3D multi-organ dosimetry data will greatly enhance the value of this long-standing NCI-funded effort for future epidemiologic studies for a larger number of many other non-targeted late effects in the database such as: (Total number of pts., number of pts. with DOX, number of pts. with RT, target organ shown in parenthesis) Spine disorders (739, 323, 660, bone-muscles); Chest-abdomen hypoplasia (380, 141, 345, muscles); Benign tumors (206, 92, 160, organs) Diabetes mellitus (129, 39, 88, pancreas); female breast hypoplasia (53, 18, 50, breast); heart valve disorders ( 77, 38, 59, heart valves); heart arrhythmias (58, 32, 37, AV node); Gall bladder disorders (137, 66, 91, gall bladder) and many more that are in the NWTS database.

A2). SIGNIFICANT IMPACT: GLOBAL DATA ON LATE EFFECTS AND RT CORRELATION IN PEDIATRIC ONCOLOGY The NWTS has the largest WT database in the world. We performed a literature review and compared the number of NWTS patients with late effects versus the number of WT patients from all other published reports combined: CHF and cardiomyopathy 184 vs. 34 (refs 38-43); ESRD 198 vs. 52 (refs 38, 41-45); SMN (239 vs. 197) (refs 38, 43, 56-68); Restrictive Pulmonary disease (83 vs. 24) (refs 38, 41, 43, 46); Pregnancy-related hypertension (171 vs. 0) (no published reports); Miscarriages/still births (374 vs. 88) (refs 47-55); Low birth weight (35 vs. 73 (refs 47-55); intrauterine growth retardation (35 vs. 0) (no published reports); Preterm labor (201 vs. 78) (refs 47-55); Fetal malposition (28 vs. 0) (no published reports); Ovarian failure (143 vs. 100) (refs 47-55, 69-80); Female Infertility (220 vs. 72) (refs 47-55, 69-80); Male Infertility (42 vs. 0) (No published reports).Though most CCSS WT patients are in the NWTS they were counted as non- NWTS patients.

A3).SIGNIFICANT IMPACT: 3D RT TOLERANCE DATA FOR WILMS TUMOR PROTOCOLS IN COG (APPENDIX 1) A comprehensive knowledge of 3D organ tolerance for late effects will help reduce organ RT

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exposure using modern technology and the future incidence of late effects. As stated above, COG currently does not have 3D guidelines for these effects. This knowledge will in turn help current generation of children receive safer RT treatments from and lower incidence of these late effects using modern technology such as IMRT or protons. (APPENDIX 1)For example: I) FUTURE CHF RISK REDUCTION IMRT DOSE VOLUME GUIDELINES: the NWTS LES data

linking CHF and lung RT led us to develop a cardiac sparing IMRT protocol that will be adopted in the next generation of COG renal tumor protocols (R21CA159547) (33-35).FIG. 2. CARDIAC SPARING IMRT TO REDUCE CHF Whole lung (WL) IMRT isodose lines 95% (blue), 75% (green) and 50% (yellow) on images of left (LV red) and

right ventricle (light blue) and lung PTV (purple) showing significant whole heart, LV and myocardial sparing with IMRT. Our group has further refined this technique to significantly reduce doses to the thyroid gland and breasts to reduce the risk of SMNs (33-35). II) FUTURE INFERTILITY AND HYPOGONADISM RISK REDUCTION RT GUIDELINES FOR COG: WT is the most common cancer requiring abdominal RT (Fig. 1, 3) and thus an important cause of RT-related infertility (47-55, 69-79). While 90-100% of girls after WA RT (25-30Gy) have ovarian failure (76-79, 83, 84), after flank RT (20-30Gy) majority have normal ovarian function (76-78). After WA RT (25-30Gy), girls had shorter uterine length, no endometrial response to exogenous hormones and no blood flow in the uterine arteries (72). In pre-pubertal girls, ovarian doses of 10-15Gy and >15Gy confers an intermediate and higher risk respectively for hypogonadism and infertility (47-55, 69-80, 84-87). In boys, testicular doses of >3Gy, 1-2Gy and 0.2-0.9Gy confers a high, intermediate and low risk respectively for infertility (77, 85-87). There are no published reports on hormonal or reproductive function after RT in male WT survivors. The NWTS has not examined the incidence of hypogonadism and infertility after treatment and this study will be the first. In a NWTS report on pregnancy outcomes after flank RT, higher prescribed doses >25Gy (without consideration of field length) led to increased rates of pregnancy induced hypertension, fetal malposition, premature labor and low birth weight off spring (20-22). The lack of patient-specific dosimetry led to the erroneous consideration that all flank fields delivered similar doses to the ovaries and uterus (21, 22). FIG. 3. NWTS RT FIELDS VS. TARGET ORGAN (OVARY-UTERUS) DOSIMETRY OF 2 GIRLS WITH INFERTILITY: A) #1- 35Gy to short left flank field lower edge 1cm above iliac crest (DRR A) and b) #2- 26.5Gy to longer left flank field lower edge 3cm below iliac crest (DRR B). Dose (cGy, x-axis) Volume (%, y-axis) Histograms (DVH) of A (solid lines) and B (dotted lines) of right ovary (red), left ovary (light blue), uterus (dark blue) are shown. This data demonstrates all flank fields are NOT the same and that proximity of the field to the target organs is more important than prescribed doses erroneously linked to late effects in past NWTS reports. III) DEVELOP LATE EFFECTS RISK REDUCTION AND MITIGATION STRATEGIES FOR COG In 2013 a COG report suggested that only 25% of children were referred at diagnosis for hormonal and fertility preservation (84). Currently, radiation oncologists are given no guidelines to either estimate or attempt to reduce ovarian or testicular doses

in WT patients (83).This dosimetry study will provide physicians, parents and survivors evidence-based guidelines for:1) prevalence of hypogonadism and infertility based on target organ dosimetry,2) dose reduction interventions such as: field length reduction (higher uterus and ovary dose due location in relation to field edge); oophoropexy; orchiopexy or testicular shielding; IMRT; proton therapy, 3) Mitigation strategies such as testicular cryopreservation and sperm banking in males 4) modern oncofertility advances such as serum anti-Mullerian hormone screening (89), ovarian cryopreservation for a) future re-implantation or b) in-vitro follicular maturation (IVM) and IVF in cases of ovarian tumor contamination (81-87, 89-92). The COG leadership on this study will prioritize adoption of these guidelines in future COG studies (see letters of support from COG).

Fig. 2

Fig. 3

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A4) SIGNIFICANT IMPACT: 3D RT TOLERANCE DATA FOR OTHER PEDIATRIC TUMORS IN COG PROTOCOLS The organ tolerance data (0-40Gy) in the neck, chest, abdomen and pelvis from WT fields for these late effects will help guide the selection of normal tissue dose-volume constraints (CHF, ESRD, Pulmonary, SMN, Pregnancy Outcomes and Infertility) for current COG protocols for Hodgkin lymphoma, rhabdomyosarcoma, neuroblastoma, Ewing Sarcoma and other tumors that arise in these sites (APPENDIX 1).

A5). SIGNIFICANT IMPACT: CURRENT COG LONG-TERM FOLLOW UP GUIDELINES An important application of accurate knowledge of target-organ dose correlation with late effects is that it can be used for risk-based screening of survivors for the early detection and mitigation of the impact of late effects on survival and quality of life. A recent NWTS report suggested revision of the COG breast cancer screening guidelines (currently only for RT > 20Gy) based on higher risk after lower RT (3-15Gy) doses to the breast after lung and flank RT (19). Likewise, this study could redefine current COG recommendations for threshold doses for many late effects including CHF (currently >20Gy), Hypogonadism and infertility (currently >5Gy pubertal, >10Gy prepubertal ovary) and colorectal cancer screening (currently colonoscopy recommended after RT >30Gy) (4).

A6). SIGNIFICANT IMPACT: IMPROVE ACCURACY OF RETROSPECTIVE DOSIMETRY FOR OTHER LARGE LATE EFFECTS STUDIES This study being the first to introduce 3D NCI phantom based TPS and Monte Carlo dosimetry has the potential to generate interest in other late effects studies in the U.S. and Europe to obtain more accurate 3D dosimetry correlation for late effects studies. This will enhance the utility and value of their data and significantly influence current and future RT treatments in children.

A7). SIGNIFICANT IMPACT: INCREASED RELEVANCE OF RETROSPECTIVE DOSIMETRY IN PEDIATRIC ONCOLOGY The CCSS is the largest NIH funded late effects study with > 100 publications in key journals using an older less robust mathematical phantom model in over 8000 children (93, 94). The CCSS data on SMNs and other late effects have led to the development of absolute risk prediction models for monitoring patients and has promoted the use of protons and IMRT respectively for children with brain tumors and Hodgkin’s disease (cardiac toxicity threshold mean heart dose >15Gy currently used in COG Hodgkin protocol AHOD1331) (95-98, 41, 57, 5). The Darby et al New England journal report on the ischemic heart disease risk after breast cancer RT has had a dramatic effect on the current management of breast cancer despite the fact that this report was based on a single patient CT scan dosimetry of a ‘typical’ patient representing >2000 patients (99). This report has promoted the use of heart dose reduction techniques with photons and proton therapy for left-sided breast cancer (100, 101).Thus the knowledge of RT risk factors from retrospective dosimetry studies while imperfect for many reasons including imprecise RT dose reconstruction has made valuable contributions towards improving our understanding of the genesis, prevention and mitigation of late effects in adult and pediatric oncology. As most late effects show a RT dose-response effect (NWTS Table 1) it is imperative that our discipline improve retrospective dosimetry techniques as proposed in this study to further enhance its relevance and improve the lives of children after RT.

A8) SIGNIFICANT IMPACT: FUTURE DOSIMETRY MODELS USING FUNCTIONAL SUB-REGIONS AS OPPOSED TO WHOLE ORGAN DOSIMETRY FOR LATE EFFECTS CORRELATION Retrospective dosimetry studies using older dose reconstruction methods such as CCSS (93, 94), Institut Gustave Roussy (40, 104, 105) and a single average patient CT scan for breast cancer (99) demonstrated the important correlation between mean heart dose and late cardiac effects: > 15Gy for CHF and other cardiac effects (97) and >5Gy (40) for cardiac mortality in children, and increased risk of major coronary events by 7.4%/Gy risk after breast cancer RT (99). Two recent French reports used computational phantoms and retrospective dosimetry after incorporating detailed cardiac anatomy models and coronary CT angiograms to study more precise RT correlation between functional anatomic sub-regions and late toxicity. They showed a 5 fold higher coronary artery dose compared to mean heart dose after breast cancer RT and suggested its use as a more sensitive marker for future studies (102). This group also merged patient CT scans and coronary CT angiograms into computational phantoms for retrospective dosimetry after childhood RT for Hodgkin’s lymphoma and found that the median dose to the

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coronary artery segment was more highly statistically significantly correlated with stenosis, while mean heart dose and mean coronary artery dose were not correlative (103). Given the precision of modern IGRT with IMRT and protons, integration of novel diagnostic radiology tools like cardiac MRI (as we propose to do for delineation of ventricular and myocardial anatomy) to computational phantom dosimetry will facilitate better understanding of RT-late effects relationships of functional sub-regions (future goal of dosimetry) as opposed to whole organs (in the past) and provide background data for targeted avoidance of these critical organ sub-regions. The cardiac sparing IMRT study (see A3, Fig. 2) utilized the help of cardiac radiologists to contour ventricles and myocardial volume for targeted-avoidance with IMRT as they are more relevant than whole heart for functional late effects like CHF.

B). INNOVATION

B1) THIS STUDY WILL FOR THE FIRST TIME USE THE ICRP RECOGNIZED NCI PHANTOM MODEL FOR LARGE SALCE RADIATION EPIDEMIOLOGY STUDIES Large late effects studies in the U.S. (CCSS) and Europe (French-UK group) have used different phantom dosimetry methods such as a mathematical phantom model by Stovall et al (CCSS) (93, 94) or the stylistic human anatomy by Diallo et al (French-UK group) (104), both using water phantom doses for organ dosimetry. Diallo et al also developed ICTA software with improved human anatomy based on a single adult person’s CT images (105). Anatomic inaccuracy and obtaining only multiple point dosimetry were the drawbacks of these models (Table 2, APPENDIX 2). NCI PHANTOMS (FIG. 4) Hybrid computational phantoms such as the NCI phantoms represent the newest generation of patient-dependent models that permit preservation of anatomic realism (organ shape, position and depth within the body) and anthropometric remodeling (scalability to model individual patient body morphometry) that was never available in the past. Two generations of NCI phantoms (106-108) were constructed and matched to anthropometric data from several sources including: International Commission on Radiological Protection (ICRP) # 89 (109); anthropometric percentile distributions from the U.S. National Health and Nutrition Examination Surveys (NHANES) III (1988-2004) and IV (1996-2006) comprising >67,000 persons including >27,000 children of varying ages (110); Anthrokids database of the U.S. Product Safety Commission (111); organ and tissue masses from ICRP #89 to within 1% (96); reference tissue densities and organ volumes from ICRU # 46 (112); and reference gastro-intestinal dimensions from ICRP # 100 (113). The second generation NCI phantom library consists of human models representing: (A) reference size individuals (12 newborn to adult males and females) and (B) body size-dependent individuals (351 height- and weight-dependent pediatric/adult males and females) after considering tripling of childhood obesity rates since 1980. Further, height and weight were chosen as the primary parameter for creating these models. All phantom anatomies are in DICOM-RT format with 50+ major organs already pre-contoured (108). This 3D model would be far superior to the CCSS phantoms as well as more time and cost-efficient than using patient-matched CT scans for 5000 patients (Table 2).

B2). THIS STUDY WILL IMPROVE THE ANATOMIC ACCURACY OF SELECTED ORGANS IN THE NCI PHANTOM MDOEL FOR BETTER ANATOMIC AND FUNCTIONAL LATE EFFECTS CORRELATION In the new generation of NCI phantoms, organ masses and percent differences between pre and post-voxelized values for the 5 primary organs were within +2.2%: liver (0.3-0.6%); heart wall (0.3-0.4%); kidneys (0.3-0.6%); thyroid (0.2-2%); spleen (0.2-0.7%) and bone marrow (0.9-1.8%). The NCI phantoms have also incorporated revisions per ICRP#89: to right and left lung models that showed 15% larger mass of right lung; and kidney models so that the renal pelvis with urine was excluded and only the renal cortex and medulla volumes would comport with renal parenchyma mass (108, 109). However, the human breast size was not sampled within the NHANES IV database (110). Our preliminary data also showed that the anatomic position of the uterus and ovaries was inaccurate as their location and size can vary based on the age of young girls (114). To improve the anatomic accuracy of the NCI phantoms for breast, ovaries and uterus, we will modify their existing organ contours (size, mass) and locations in the phantom based upon patient-matched CT/MRI data from QARC and Lurie Children’s radiology library; and published MRI data on ovarian and uterine anatomy (114). Further, we will use CT and cardiac MRI data from Lurie Children’s hospital library to improve the anatomic detail of the different cardiac sub-regions of the NCI phantoms (ventricles, myocardium) with help from expert cardiac radiologists on this study.

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TABLE 2: ADVANTAGES OF NCI PHANTOMS VS. EXISTING PHANTOM MODELS AND PATIENT MATCHED CT SCAN MODELS FOR 5000 PATIENTS (APPENDIX 2)

MATHEMATICAL PHANTOMS (CCSS, FRENCH STUDY)

NCI PHANTOM PATIENT MATCHED CT SCAN DOSIMETRY FOR 5000 PTS

*Inferior anatomic accuracy *Incapable of robust anthropometric remodeling

*Superior anatomic accuracy (Fig 4A-C) *Anthropometric remodeling capability

*Superior anatomic accuracy * No remodeling ability - obesity trends over time and lack of original subject CT scans limits accuracy of this model

*Phantoms matched by age/sex *Phantoms matched by Height/Weight/Age/Sex

*Patients matched by Height/Weight/Age/Sex

*Limited to few phantom only, relies on data extrapolation for other ages

*Not limited, allows for many body morphometry variations

*Limited to one matched CT scan and not average of multiple persons, thus less accurate

*Incompatible with RT planning systems

*Compatible with RT planning systems *Compatible with RT planning systems

*Can only obtain organ multiple point doses (2.5D) without 3D dose volume data – APPENDIX 2 *Monte Carlo dosimetry has not yet been performed

*3D Organ dose-volume histogram data *Availability of NIH supercomputing resource allows for efficient performance of large scale Monte Carlo dosimetry

*3D organ dose volume data can be obtained *Supercomputing availability will permit large scale Monte Carlo dosimetry

*Pre-contoured organs not available for large scale epidemiology studies

* Pre-contoured organs available for large scale epidemiology studies

*No organ contours, need manual entry for each CT - costly, labor intensive, for large studies

*Used for retrospective dosimetry *Best model for retrospective dosimetry *Best for patient-specific prospective dosimetry *Phantom models are outdated *INTERNATIONAL STANDARD MODEL *Never been used for large epidemiologic

studies

FIG. 4 NCI PHANTOM MATCHED FOR 83-MONTH OLD MALE NWTS PATIENT TPS PLAN: WA DRR (WA 10Gy plus Lt Flank 10Gy) thyroid (red), lungs (green), heart (magenta), breasts (khaki), liver (white), stomach (light blue), Rt kidney (dark blue), spleen (teal), right colon (yellow), left colon (orange), rectosigmoid (red), testes (purple). AXIAL CT IMAGE with isodose lines showing 10Gy (yellow), 8Gy (red) and 5Gy (orange) for breast, heart and lungs. DVH after WA (10Gy) plus Lt flank (20Gy) for all organs (refer to organ color codes).

B3).OTHER APPLICATIONS OF NCI PHANTOM MC MODEL: 1) ICRP standard for international radiation dosimetry studies; 2) UK National Health Service study of 178, 604 children that concluded that the use of CT scans to deliver cumulative doses of 50mGy and 60mGy may triple the risk of leukemia and brain tumors respectively (115); 3) Dutch Pediatric CT Study to define radiation exposure from CT scans and the risk for leukemia and brain tumors in 100,000 children (116); 4)Constructing a comprehensive international database of CT scan doses from UK ImPACT dose study, and CT-Expo dose calculation program and surveys performed by the US FDA and National Lung Screening Trial(117); 5)European epidemiological study of CT scan risk (EPI-CT study) (118); U.S. CT scan dose trends (119); Patient specific dosimetry in nuclear medicine (120) and proton therapy (121).

B4).THIS STUDY WILL USE MC DOSIMETRY FOR THE FIRST TIME IN LARGE SCALE

EPIDEMIOLOGY STUDIES The use of MC dosimetry in radiation oncology is not new, but its application for large epidemiology studies is a novel approach used in this study. We will adopt the MC dosimetry method developed by Dr. Lee at the NCI (122). We will use TPS for in-field and near -field and MC dosimetry for out-of-field organs. For each organ we will calculate the mean dose and dose to 30% (D30) and 70% (D70) of the organ volume. Accurate dose estimation whether in-filed or out-field is crucial in evaluating dose-response relationship for both tumor and organs at risk (OAR). While modern RT treatment planning systems (TPS) are

Fig. 4

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fairly accurate for estimating doses both in-field and near-field locations, it is not accurate for out-of-field dose measurements (123-127). Howell et al showed that commercial RT TPS (Eclipse) underestimated out-of-field doses by an average of 40% compared to water phantom measurements and this error was greater (up to 55%) at distances >11cm from edge of RT fields (127). Others have also reported that MC dose calculation algorithm measures out-of-field doses accurately (123-132). The main contributors for out-of-field doses are: a) machine head leakage, b) scatter through machine components, and d) internal tissue scatter. The majority of fields for WT patients employ simple large field sizes which range typically from 10x10 to 20x20cm. The variability of peripheral doses using MC dosimetry for large (>10x10cm2) fields between different linear accelerators has been shown to be acceptable for large scale epidemiology studies (133). This is due to the fact that for large field sizes, phantom scatter is the dominant method of energy deposition. In this study, MC dose calculations will be done by X-ray Voxel Monte Carlo (XVMC) codes to provide more accurate out-of-field dose calculations. Simulations were run on NCI Biowulf Linux cluster which has a 20,000+ core Linux cluster designed for high performance computing. A typical compute node consists of two Intel E5-2650v2 CPUs with 8 cores, 16 threads, and clock speed of 2.6 GHz. Most simulations were run using 16 cores, 32 threads. Calculation times for this configuration were 2.3 hrs. +/- 1.1 hrs. for patient CT scan-based dosimetry and 0.67 hrs. +/- 0.3 hrs. for the matched-NCI phantom cases for our pilot study (see below). This data shows that the plans on 5000 patients can be performed well within the timelines of this study. The MC simulations were run using the following parameters: ECUT=0.25MeV, ESTEPE=0.12, PCUT=0.05MeV. The KERMA approximations for the primary and secondary photons were 0.25MeV and 2.0Mev respectively. In this study, we will use TPS for measuring in-field and near-field (up to 5cm) doses and MC for estimating out-of-field doses. Dr. Lee has MC models for linear accelerator (LINAC) and Cobalt 60 machines that will enable dosimetry for most of the 5000 NWTS subjects. However, since there are no MC models for orthovoltage machines, we will not be able to do MC dosimetry on 62 patients. The IAEA list of phase space files (https://www-nds.iaea.org/phsp/photon1/) provides only limited number of LINAC models with different field sizes. The NCI MC program has head models from Varian, Elekta, Siemens, and Eldorado (Co-60) that will be applied in this study when the vendor is known. In all patients the energy of X-rays will be available. When vendor is not known, we will pick a Varian machine as reference. Uncertainty analysis will be conducted for different models for the same case to see how these parameters will change normal tissue doses and this data will be incorporated into the dosimetry and eventually into the risk analysis. This lack of knowledge of treatment machine vendor is common in ongoing epidemiological studies (Dr. Lee). FIG. 5 shows the fractional CAX dose profile plot along the axis of a 50cm water phantom on a log scale to highlight the differences between XVMC (blue) and TPS –(Pinnacle) (orange) for this Northwestern-NCI dosimetry project. The dose difference up to 10cm from field edge was negligible (<1%). Beyond 10cm there is a rapid fall-off of TPS dose as the primary TERMA does not extend past this distance. For distances beyond 10 cm (low dose region), MC doses were 88-98% higher than TPS. Even though these doses are low, this is an important factor to consider in epidemiology studies where the dose correlation for late effects has a linear no threshold (LNT) relationship (136). For distances up to 20 cm from the field edge, out-of-field doses have been validated with water phantom measurements to within 10% (Dr. Lee, NCI personal communication).

B5).PRELIMINARY DATA FROM NORTHWESTERN AND NCI TABLE 3, 4): FEASIBILITY AND ACCURACY OF NCI PHANTOM TPS AND MC DOSIMETRY (Dose Gy). Dr. Lee et al demonstrated the feasibility of using this model for retrospective MC dosimetry: conversion of phantom anatomy to DICOM images in TPS was validated by agreements in electron density to within 0.1-2%; DICOM-RT files were transferred from TPS directly to XVMC Monte Carlo transport code and mean organ doses from both calculations matched to within 7% for a sample of 3 patients (122). Northwestern and NCI data: We randomly selected 20 NWTS patients (10 male and 10 female) and obtained: 1) patient age-sex matched CT scans from QARC and 2) age-sex-height-weight matched NCI phantoms (NCI-P) from the phantom library (Dr. Lee). We performed 3D multi-organ RT treatment planning by recreating the original NWTS treatment fields and doses based on NWTS treatment records using 1) commercial TPS (Pinnacle 9.10) and 2) MC treatment planning at the NCI for these 20 CT and NCI-P data.

Fig. 5

179

We obtained dose-volume histograms (DVH) and 3D doses (mean, D30, D70) for heart, %heart volume receiving >5Gy (threshold dose for cardiac mortality in the French-UK Study (40), Left kidney, testes, ovary and thyroid

gland. We had 2 aims:1) Compare the anatomic accuracy of NCI phantoms (by comparing the 3D organ dosimetry data with both TPS and MC of NCI phantoms vs. patient CT scans; 2) Compare the accuracy of NCI MC dosimetry (by comparing organ MC vs.TPS dosimetry with both NCI-P and CT data. RESULTS (Tables 3, 4) for aim 1: Overall mean difference for mean dose (Gy) between patient-matched CT-organs vs. NCI phantom-organs using both TPS and MC was: 0.61Gy (0.01-2.87) for all organs; 2.54% (0-9.03%) for % heart volume >5Gy;for aim 2: Overall mean difference for mean dose (Gy) for all organs between TPS vs. MC dosimetry was: 0.17Gy (0.00-0.73) for in-field organs Blue; 0.32Gy (0.01-0.49) for organs <5cm Orange; 0.58Gy (0.02-1.91) for 5-10cm Green; and 0.24Gy (0.02-0.79) for >10cm from field edge Yellow; The mean dose for <5cm, 5-10cm, >10 cm organs was consistently higher for 90-100% of dose measurements with MC and for in-field organs TPS was higher in 60% of measurements. Statistical analysis was performed using Wilicoxon rank-sum test (NCI-P vs. CT scans) and Signed rank test (TPS vs. MC). There was NO significant difference between NCI phantom and CT dosimetry data for any of the organs with both TPS and MC dosimetry (P value 0.6-0.99). However, there WAS A significant

difference between TPS and MC dosimetry for both CT and NCI-phantom models: Left kidney CT(<0.0001) and NCI-P (<0.0001); heart CT (<0.0001) and NCI-P (<0.0001); Normalized heart % volume CT(0.005) and NCI-P (0.001); thyroid CT(<0.001) and NCI-P (<0.001); testes CT(0.02) and NCI-P (0.002); for corrected ovary CT(0.002) and NCI-P (P value 0.004). The position of the ovaries and uterus were inaccurate in NCI phantom model and ovarian doses varied by as much as 5.3 – 15.3Gy. For this analysis, the ovaries were re-contoured based on age-based MRI location guidelines for both NCI-P and CT models (114). This work utilized the high-performance computational capabilities of the Helix Linux computing system at the NIH. This data shows the feasibility and accuracy of this NCI phantom AND TPS-MC dosimetry for this study and these results were presented at the 2016 AAPM and 2016 Annual Meeting of ASTRO in Boston (134, 135). (Please see letter of support from Dr. Indra Das).

C).APPROACH C1).AIMS:SPECIFIC AIM 1: We will estimate RT doses to specific organs of 5000 irradiated NWTS subjects using the 3D NCI Phantom and TPS-MC dosimetry model. RT doses (mean

Male L-Kidney Heart Heart 5Gy Thyroid Testes

TPS MC TPS MC TPS MC TPS MC TPS MCNCI-P 39.66 39.40 9.40 9.69 39.67 42.63 0.25 0.46 1.99 2.74

CT 38.21 38.02 9.89 10.18 43.78 46.40 0.29 0.56 n/a n/a

NCI-P 39.27 40.04 5.66 6.08 21.45 23.02 0.29 0.37 0.38 0.43CT 40.21 40.61 5.17 5.48 17.25 18.83 0.30 0.34 0.29 0.31

NCI-P 2.70 2.81 0.97 1.06 0.00 0.00 0.13 0.17 0.25 0.38CT 1.90 1.83 0.86 0.96 0.00 0.00 0.15 0.12 0.27 0.40

NCI-P 31.08 30.86 9.75 10.13 43.05 49.69 0.62 0.77 2.63 3.31CT 29.62 29.31 10.21 10.50 44.33 47.88 0.20 0.65 n/a n/a

NCI-P 35.76 35.27 10.56 10.95 43.03 48.33 0.69 0.87 3.05 3.97CT 35.06 34.77 10.66 11.01 37.84 42.82 0.27 0.80 4.06 5.71

NCI-P 11.05 11.02 12.32 12.19 100.00 100.00 6.86 7.33 0.96 1.40CT 11.16 11.20 12.38 12.30 100.00 100.00 6.65 7.19 1.80 2.59

NCI-P 35.37 35.26 11.65 12.07 45.37 48.91 0.65 0.85 4.33 6.24CT 35.07 34.73 10.68 11.01 37.94 42.81 0.24 0.80 3.98 5.70

NCI-P 12.05 12.10 11.99 11.97 100.00 100.00 7.90 8.25 1.45 2.34CT 11.77 11.71 11.87 11.68 100.00 100.00 6.42 6.89 2.32 2.98

NCI-P 41.97 41.76 16.33 16.20 100.00 100.00 9.63 9.98 0.37 0.92CT 40.13 40.00 16.08 16.04 100.00 100.00 8.56 8.94 0.42 0.81

NCI-P 19.94 19.88 14.41 14.43 100.00 99.91 6.77 7.22 0.34 0.72CT 18.75 18.81 14.46 14.54 100.00 100.00 6.00 6.29 0.46 0.79

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dose, D30, D70) will be obtained for the following organs: total heart, ventricles, kidneys, lungs, chest wall, breasts, thyroid, liver, stomach, colon, ovaries, uterus, pelvis and testicles (APPENDIX 3).

C1).SPECIFIC AIM 2: We will review and validate the reproductive late effects (hypogonadism and infertility) in male and female survivors recorded in the NWTS database and conduct a prospective questionnaire-based cohort study to determine their prevalence among NWTS survivors. The NWTS identified ovarian failure in 143 and infertility in 220 females and male infertility in 42 patients from institution reports, flow sheets, medical history forms and annual questionnaires for many decades. The LES was not specifically designed to ascertain and record these conditions. All records for patients with these conditions will be reviewed and conditions validated. All NWTS patient records have been scanned into PDF files at the data and statistical center (DSC, Seattle) that can be reviewed and easily searched for key words by investigators remotely. A questionnaire developed by experts in Urology and OBGYN designed to ascertain the history of occurrence of reproductive impairment will be sent to all patients known to be alive at last follow-up . This will help estimate the prevalence of these late effects among current survivors (APPENDIX 4, 5).

C1).SPECIFIC AIM 3: We will study the association between RT dose (mean dose, D30 and D70) estimated using the 3D NCI Phantom and TPS-MC dosimetry model and NWTS late effects. We will study the 5 targeted late effects (target organs for dosimetry):CHF (Total heart, ventricles, myocardium); ESRD (Solitary or partial kidneys); Restrictive Pulmonary Disease (Lungs and chest wall); Adverse Pregnancy Outcomes (Ovaries, uterus and pelvis); Second Malignant Neoplasms (breast, thyroid, stomach, colon, liver, kidney) and reproductive impairment collected from Aim 2 in males (testes) and females (ovaries, uterus, pelvis) (TABLE 1, 5). Additionally RT modeling analysis for late effects will be performed by Dr. Berrington (NCI Radiation Epidemiology Branch).

C2). RT FIELD RECONSTRUCTION AND NCI PHANTOM TARGET ORGAN TPS AND MC DOSIMETRY: For each NWTS patient who received RT (approximately 5000 patients), a matched NCI phantom based on height, weight, age and sex will be selected from the phantom library and downloaded as DICOM files into the RT TPS (Pinnacle 9.10) at Northwestern. All target organs in aim 1 (Fig. 4, Appendix 3) are already pre-contoured or will be contoured per discussion above (breasts, heart chambers, myocardium, ovaries, uterus). The RT fields will be reconstructed on matched phantoms using patient-specific NWTS RT paper records (energy, machine, field size, total dose, RT field blocks and field diagrams). The RT fields for WT (flank, abdomen, lungs) have been standard for all NWTS and COG studies and are easy to reconstruct based on bony and soft tissue anatomy (lungs, diaphragm, spine and pelvis). The upper borders of the lung and flank/abdomen fields are typically 1cm above the lungs and at or above the diaphragm, respectively. The lower border selects itself based on RT dimensions from paper records (Fig. 1). Likewise, as in Fig. 1, the medial margin of the flank field is 1cm beyond the spine and lateral margin selects itself based on field width. The NWTS has RT portal films in about 500 (10%) of NWTS-3 patients archived at the QARC. These will be digitally copied and made available to the PI to improve the accuracy of RT field placement and error calculations (see below). After the phantom RT fields are reconstructed TPS target-organ dose calculations (mean, D30 and D70) will be performed at Northwestern. The RT parameters and phantom data will then be exported as DICOM RT files to the NIH for MC dose calculations as described above. The target organ MC dosimetry data will then be reviewed by physicists at both NCI and Northwestern for cross check and verification after comparing with NWTS prescriptions and commercial TPS dose calculations. After in-field (TPS), near field (TPS) and out-of-field dosimetry (MC data) has been cross checked and verified, the different target organ dose-volume data set will be sent to the NWTS DSC for statistical correlative analysis and to NCI REB for RT Statistical Modeling Analysis. C3). QUANTIFICATION AND CORRECTION OF DOSE UNCERTAINTIES Retrospective dosimetry will never be as accurate as prospective patient CT-based dosimetry. However, the use of NWTS database for obtaining patient-specific RT data, standard AP-PA WT fields and the use of NCI phantom-TPS/MC dosimetry will improve the accuracy of this study. While errors can still occur, they would likely be random and not systematic (93, 94). This study will be more accurate than any other retrospective dosimetry study from other late effect studies that mainly relied on 2.5 D phantoms with multiple point dosimetry and never used 3D phantom-MC dosimetry. Further, we will also perform an error analysis in order to better estimate dose measurement errors from any or all of these factors. For a pilot sample of 24 patients from NWTS-3 stratified by sex and age we will select one matched phantom for each patient. All these patients will have original portal films at QARC. Two sets of RT

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fields will be reconstructed: 1) based on RT diagram from NWTS paper records; and, 2) based on RT portal films. Thus for each phantom, a total of two RT plans will be performed and the various organ doses compared statistically. This error analysis will allow us to estimate the variability due to dosimetry errors from field placement within each age group. The estimated measures of variability and bias from this analysis will be incorporated into the final statistical analysis to improve the accuracy of the final results (see C5). For all the remaining NWTS-3 patients (#500) with original RT portal films, we will use digital copies to accurately reconstruct RT fields. C4). CORRECTION FOR ANATOMIC ERRORS As described in A8 (102, 103) in order to improve the anatomic accuracy of NCI phantoms we will conduct a study to improve the anatomic location and definition of the cardiac sub regions (ventricles, myocardium), breasts, uterus and ovaries, whose location and size can vary significantly with patient age (114). We will obtain 40 NWTS patient matched-CT chest (breasts), MRI abdomen/pelvis (ovaries, uterus) and published reports on ovarian location based on >300 girls (114) and cardiac MRI scans (heart sub regions) that uniformly represents between the 5th and 95th percentile age range of NWTS subjects (10 months-120 months) from QARC. A dedicated pediatric radiologist at Northwestern will contour these organs and we will modify existing contours on corresponding patient-matched NCI phantoms based on the accurate anatomic information obtained from age-matched co-registered CT/MRI scans. These corrected organ contours on NCI phantoms will be used for target organ dosimetry for all patients. This strategy will improve the anatomic accuracy of target organ dosimetry and enhance the value of correlative studies with specific late effects. C5). STATISTICAL CONSIDERATIONS AIM 1: We will carry out a small pilot error analysis study to evaluate potential measurement error in the dosimetry estimates (mean, D30 and D70) (C3) for the listed target organs for AIM 1 (C1, APPENDIX 3) and will use the resulting data to determine whether estimates from this pilot study would result in significantly different dose estimates compared to the larger study group. If there are significant differences, methods for calibrating the parameter estimates from our models will be utilized to correct them to avoid attenuation of parameter estimates towards the null (137, 138). AIM 2: The primary purpose is to collect a direct assessment of previously non-targeted reproductive outcomes using a questionnaire approach for all NWTS participants currently alive and in follow-up. The questionnaires have been developed for each gender (APPENDIX 4, 5). The staff at the DSC will mail them to eligible participants. Non-responders will be re-sent a new questionnaire twice after intervening 3 month intervals without returning a questionnaire. A database for the questionnaires will be developed and data from returned questionnaires will be hand entered and cross-checked for accuracy. We will also review patient records for the approximately 500 subjects who we have recorded as having experienced a reproductive impairment. These conditions will be confirmed and validated using consistent definitions. In addition to these subjects, a random sample of 500 subjects from those remaining who are not known to have any of the selected conditions will be taken and will be reviewed, with the hope that we will find few conditions that are not recorded in our database and thus, will be comfortable using non-reviewed subjects with confidence. If we do find a rate of events that suggests our electronic records are under ascertaining events, we will expand our chart review to include a larger selection of the population and will only include reviewed subjects in the analyses, along with their relevant sampling weights. AIM 3: We will utilize the full cohort of 9,236 NWTS subjects, with outcomes consisting of the five late effects, CHF, ESRD, Pulmonary disease, SMNs and Adverse Pregnancy Outcomes that are collected in a prospective and targeted fashion by the DSC as well as the non-targeted male and female reproductive impairment outcomes including hypogonadism and infertility, that will be collected in Aim 2. The primary goal of Aim 3 will be to ascertain the association between each outcome and the relevant target organs’ exposure to RT using NCI-phantom TPS AND MC calculated dose measures (mean dose, D30, D70). Outcomes for which date or age of onset is meaningful and available (SMN, CHF, ESRD, Pulmonary, some adverse pregnancy outcomes) will be analyzed as time to event outcomes using Cox proportional hazards models to evaluate RT dose-response effects. Outcomes that do not have a well-defined onset time (some adverse pregnancy and reproductive outcomes), will be defined as binary outcomes for each subject and analyzed using logistic regression models with adjustment for age or time since diagnosis, as appropriate. As described above, the primary risk factors of interest will include 3D RT doses to the relevant target organs (Appendix 3, e.g. ovaries, uterus and testes for reproductive outcomes) and will be the primary focus of modeling efforts. Before launching into model fitting, distributions of doses, both in univariate views and stratified by case status, will be summarized. Depending on patterns observed, categories of dose will be created for inclusion in models. Using categorical dose variables, regression models will be fit to evaluate the associations between exposure variable with each outcome, initially evaluating the impact of RT dose to each organ in separate models. Additional patient characteristics, in particular other key patient and treatment related factors (e.g. anthracycline exposures etc.) will be evaluated to

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determine confounding or synergistic effects as well as adjustments for demographic variables that may be important risk factors or confounding factors for RT therapy (TABLE 5). Risk factors will be included in final models if they either modify the association between RT dose and outcome by more than 10% or are significant risk factors themselves. Models with more than one organ RT dose may be fit, but care will be taken to evaluate and understand potential correlations between doses to adjacent organs, to avoid undue collinearity between risk factors within a single model. Where sufficient numbers of events occur, in addition to categorical dose models, more extensive dose-response models utilizing continuous forms of the RT doses will be fit to the data to more carefully explore the shape of the dose-response curves. We will use Epicure to fit a range of excess relative risk models using mean dose, D30 and D70 including linear, quadratic or exponential and also including potential plateau effects. Likelihood ratio tests will be used for comparisons between nested models to evaluate best-fitting and most parsimonious models. Finally, again where feasible, we plan to utilize predictiveness curves to summarize the predictive capability of the dose estimates for each outcome and relevant organ dose combination (139). These curves will plot the risk of an event as a function of the risk percentiles from the risk model and provide a useful metric for using dose measures as predictors to identify risk thresholds below which subjects are deemed at “low risk”TABLE 5. DESIGNATED PATIENT-RELATED AND MULTIMODALITY TREATMENT FACTORS OF INTEREST FOR EACH LATE EFFECT TO BE STUDIED Late Effect Outcome Risk Factors Target RT organ(s) Candidate

Non-RT treatments Other patient

characteristics* CHF and cardiomyopathy Heart, ventricles,

myocardium Anthracyclines Height, weight, diabetes

ESRD Kidney Surgery WT1 syndromes Pulmonary Lungs, chest wall Doxorubicin, alkylating agents Age, Sex SMN (selected) Breast, thyroid, stomach,

colon, liver, kidney Doxorubicin, Alkylating Agents Age, Sex

Hypertension complicating pregnancy Uterus, ovaries Anthracyclines Miscarriages / Still births Uterus, ovaries, pelvis Alkylating Agents Low Birth Weight Uterus, ovaries, pelvis Alkylating Agents height, weight Intrauterine growth retardation Uterus, ovaries, pelvis Alkylating Agents height, weight Preterm labor Uterus, ovaries, pelvis Alkylating Agents Height, weight Fetal malposition Uterus, ovaries, pelvis Alkylating Agents height, weight Ovarian failure Ovaries, uterus Alkylating Agents Infertility Ovaries, uterus Anthracyclines, Alkylating Agents Male infertility and hypogonadism Testicles Anthracyclines, Alkylating Agents *For all outcomes we will evaluate: Age at Diagnosis, Current Age, race, gender (unless all female) + listed additional factors

Power We focus our discussions of power on the available power for the associations to be evaluated in Aim 3. FIG. 6 illustrates the detectable relative risks (RRs) available with 80% power and type I error of 0.05 for a range of plausible outcome rates among a baseline group (e.g. unexposed or low-dose subjects) and a variety of

comparison group sizes relevant to evaluating RT dose effects. For e.g., if we were investigating a late effect with a prevalence of 1% among a non-irradiated group of subjects, for the simplest comparisons between exposed (N2=5000) subjects and unexposed (N1=4000), we would be able to detect an RR of at least 1.7. For dose-response evaluations, we evaluate potential power by considering the crude situation in which we might compare the upper quartile of exposed subjects (N2 ≈1000) vs. the lowest quartile (N1 ≈ 1000) and this would allow detection of an RR of 2.7 for a 1% outcome rate, falling to an RR of 1.8 when the baseline rate is 3%. These outcome rates and detectable RRs are clinically reasonable in the context of RT effects on late effects after cancer treatment.

Figure 6: Power to detect Relative Risks as a function of varying outcome rates among unexposed and for a range of comparative group sizes

.

11.5

22.5

33.5

4

11.5

22.5

33.5

4

.01 .05 .1 .15 .2 .25 .01 .05 .1 .15 .2 .25

N1=500 N1=1000

N1=2000 N1=4000500

100025005000

N2

Prevalence among Unexposed (P1)

Power=80%, =0.05Detectable Relative Risks (P2/P1)

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PROTECTION OF HUMAN SUBJECTS

Human Subjects Involvement and Characteristics

The study proposed in this application will be approved by the Northwestern University Institutional Review Board (IRB) and the Fred Hutchinson Cancer Research Center (FHCRC) and involves the continued follow up of a growing cohort of Wilms tumor (WT) survivors and their offspring. The study population includes patients enrolled on National Wilms Tumor Study (NWTS) clinical protocols during 1969-2002 by North American institutions and whose parents provided informed consent for their enrollment. The population is not restricted with respect to gender or race. The targeted participant enrollment is 9236, the number of patients who meet the above criteria, and the age range is expected to be 0-55 years. The only potentially vulnerable subpopulation is prisoners. Upon learning that a participant has been involuntarily incarcerated, the NWTS discontinues contacting the person, per our IRB regulations. The eligible offspring population includes all offspring born to participants. Offspring are enrolled as soon after birth as the NWTS receives parental or guardian consent to enroll their children. The age range is 0 to 18 years, and 1500 children are expected to be enrolled.

Collaborating sites involved in these proposed studies include the National Wilms Tumor Study, Fred Hutchinson Cancer Research Center, Seattle WA (Dr. Wendy Leisenring), Quality Assurance and Review Center (QARC) (Dr. T.J.Fitzgerald) in Providence RI, the and National Institute of Health (NIH) Radiation Epidemiology Branch, Bethesda MD. Patient identifiers may be shared with these collaborators as required by study activities. Anothercollaborator is the Childhood Cancer Survivor Study with whom we do not share NWTS identifiers.

1.2 Sources of Material The data are collected from participating institutions and directly from participants viamail and telephone, from participants via a secured website (Survey Monkey), and, with the participant’sauthorization, from copies of medical records provided by clinics and hospitals at which the participants/offspring have been seen. Data are kept in locked offices in a limited-access secure section of the Public Health Sciences building on the campus of the FHCRC. Only persons directly involved in the study have access to data that identify individual subjects. Data is maintained on a dedicated server housed in an access controlled server room. Data used for analysis are de-identified and stored on encrypted laptops per FHCRC Security Office mandate.

1.3 Potential Risks Since all data pertains to treatment and follow-up of WT patients, and no clinical procedures are planned for this study, there is minimal risk to the subjects. The primary risk to participants is unauthorized disclosure of confidential information, including medical. Some participants may feel uncomfortable answering questions on private or sensitive subjects such as medical conditions, pregnancy or other personal issues. They may decline to answer any question. Participants and families are advised that they can terminate study participation or limit their participation at any time without compromising their health care provision. There will be no drugs or experimental procedures tested in this protocol. There are no study related risks to unborn children.

1.4 Adequacy of Protection Against Risks1.4.1 Recruitment and Informed Consent Informed consent for extended follow-up was obtained by theregistering institution at the time of diagnosis for NWTS 1-4. Renewed consent, using an IRB consent formdescribing study risks and benefits, is requested by the DSC when the participant reaches 18 years of age.Institutions recruit participants enrolled on NWTS-5 for follow-up beyond 5 years from WT diagnosis using theirown IRB approved consent forms. The date consent was signed is coded. Consent for offspring is obtained from the parent or guardian. Family history data are obtained using questionnaires and consent forms approved by the FHCRC IRB.1.4.2 Protection Against Risk As per §1.3. above, the possibility of minimal risk to participants isacknowledged. To minimize risks to confidentiality, data management is protected as described in §1.2.Published data do not include participant identifiers. Should survivors be concerned about potential or real long-term effects noted in this study, personnel are available to provide guidance and access to additional counseling and care.

1.5 Potential Benefits Of The Proposed Research To The Subjects And Others The major potential benefit toparticipants is knowledge of potential late effects of WT and its treatment, so they can be appropriately monitored

184

and receive appropriate risk-directed clinical care. In addition, by collaboration with laboratory scientists, we are able to further the understanding of the genetics and pathophysiology of the disease, which can inform future preventive and therapeutic efforts.

1.6 Importance Of The Knowledge To Be Gained The study aids physicians, and thus future WT patients, in developing treatment strategies that carefully balance short term benefits and long term risk. Benefits of increased knowledge of genetic risk factors include more targeted genetic counseling.

Data Safety and Monitoring Plan.

Not applicable.

The proposed research does not meet the NIH definition of a clinical trial.

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INCLUSION OF WOMEN AND MINORITIES

All eligible women and minorities will be included in this study. Since 1980 the NWTS patient population covered 70 -80% of U.S. WT patients. The composition of the study population is similar to that of all survivors of childhood WT in the U.S. §(b) in Research Plan (PLEASE SEE PLANNED ENROLLMENT REPORT)

186

View Burden Statement OMB Number: 0925-0001 and 0925-0002Expiration Date: 10/31/2018

*Study Title (must beunique):

Retrospective NCI Phantom-Monte Carlo Dosimetry for Late Effects in Wilms Tumor

*Delayed Onset Study?Yes No

If study is not delayed onset, the following sections are required:

Enrollment TypePlanned

Cumulative(Actual)

Using an Existing Dataset orResource Yes No

Enrollment LocationDomestic Foreign

Clinical TrialYes No

NIH-Defined Phase III Clinical TrialYes No

Comments:

RacialCategories

Ethnic CategoriesNot Hispanic or Latino Hispanic or Latino Unknown/Not Reported Ethnicity Total

Female Male Unknown/NotReported Female Male Unknown/Not

Reported Female Male Unknown/NotReported

AmericanIndian/Alaska

Native9 6 2 1 18

Asian 27 23 7 5 62

NativeHawaiian orOther Pacific

Islander

2 4 2 1 9

Black orAfrican

American295 235 3 3 536

White 1833 1637 157 117 3744

More thanOne Race

6 5 2 1 14

Unknown orNot Reported

Total 2172 1910 173 128 4383

Report 1 of 1To ensure proper performance, pelase save frequently.

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INCLUSION OF CHILDREN Most subjects were children at the time of their original WT diagnosis and at the time of their enrollment on the LES. As children they were consented by their parents or guardians. While participants are minors, under the age of 18, forms are completed by and interviews are conducted with parents or guardians. Upon reaching the age of 18, participants are reconsented as adults.

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3. Mariotto AB, Rowland JH, Yabroff KR et al. Long-term survivors of childhood cancers in the United States. Cancer epidemiology, biomarkers and prevention: a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 2009; 18: 1033-40.

4. Landier W, Bhatia S, Eshelman DA et al. Development of risk-based guidelines for pediatric cancer survivors: the Children’s Oncology Group long-term follow-up guidelines from the Children’s OncologyGroup Late Effects Committee and Nursing discipline. J Clin Oncol 2004; 22: 4979-4990. PMID: 15576413

5. Oeffinger KC, Mertens AC, Sklar CA et al. Chronic health conditions in adult survivors of childhood cancer. The New Englad Journal of Medicine 2006; 355: 1572-1582.

6. Pediatric Radiation Oncology 5th edition. Halperin EC, Constine LS, Tarbell NJ, Kun LE eds. Lippincott Williams and Wilkins. 2011:353-396. Chapter 19. Friedman DL, Constine LS. Late Effects of Cancer treatment.

7. D’Angio GJ, Evans AE, Breslow N, et al: The treatment of Wilms’ tumor. Results of the National Wilms’ Tumor Study, Cancer 1976; 38:633-646. PMID: 184912

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