2.1 Treatment details
The treatment algorithm is illustrated in Figure 1. The induction was
with rapid COJEC as per the HR-NBL1/SIOPEN protocol.15The drugs in rapid COJEC included cisplatin, vincristine, carboplatin,
etoposide, and cyclophosphamide. Each cycle was administered at 10 days
interval, irrespective of count recovery. Granulocyte-colony stimulating
factor (G-CSF) was administered prophylactically after every cycle. A
reassessment was performed at the end of induction chemotherapy. As per
the international neuroblastoma response criteria, the response was
categorized as complete (CR), very good partial (VGPR), partial (PR),
mixed (MR), no response (NR), or progressive disease (PD) at primary and
metastatic sites.16 A favorable reassessment was
followed by surgical resection of the primary tumor. Consolidation was
with 4 cycles of TVD (Table 1). Each cycle of TVD was supported with
G-CSF. The subsequent cycle was administered at 21-28 days following
count recovery. TVD was administered either as in-patient or outpatient,
subject to the availability of beds. Infusion of vincristine and
doxorubicin was modified for ease and to enable administration in
daycare. Vincristine was administered as an intravenous push on days 5
and 6 instead of continuous 48-hours infusion recommended in the SIOPEN
protocol. Doxorubicin was administered as a 4-hours infusion on days 5
and 6 instead of a continuous 48-hours infusion. Consolidation
chemotherapy was followed by external beam radiotherapy to the tumor
bed, and differentiation therapy with six, 2-weekly cycles of
isotretinoin. No further therapy was offered to patients who had a
relapse or progressive disease.