Pediatric Precision Laboratory Advanced Neuroblastoma Therapy

A prospective open label, multicenter study to evaluate the feasibility and acute toxicity of using molecularly guided therapy in combination with standard therapy followed by a Randomized Controlled Trial of standard immunotherapy with or without DFMO followed by DFMO maintenance for Newly Diagnosed High-Risk Neuroblastoma.

Part A- CLOSED: 1. Diagnosis: Participants must have a diagnosis of neuroblastoma or ganglioneuroblastoma (nodular or intermixed) verified by histology or demonstration of clumps of tumor cells in bone marrow with elevated urinary catecholamine metabolites. Participants with the following disease stages at diagnosis are eligible, if they meet the other specified criteria: a) Participants with newly diagnosed neuroblastoma with INSS Stage 4 are eligible with the following: i. Age \> 18 months (\> 547 days) regardless of biologic features or ii. Age 12-18 months (365-547 days) with any of the following 3 unfavorable biologic features (MYCN amplification, unfavorable pathology and/or DNA index = 1) or iii. MYCN amplification (\> 4-fold increase in MYCN signals as compared to reference signals), regardless of age or additional biologic features. b) Participants with newly diagnosed neuroblastoma with INSS Stage 3 are eligible with the following: i. MYCN amplification (\> 4-fold increase in MYCN signals as compared to reference signals), regardless of age or additional biologic features or ii. Age \> 18 months (\> 547 days) with unfavorable pathology, regardless of MYCN status. c) Participants with newly diagnosed neuroblastoma with INSS Stage 2A/2B with MYCN amplification (\> 4-fold increase in MYCN signals as compared to reference signals), regardless of age or additional biologic features. 2. Participants must be age ≤ 21 years at initial diagnosis 3. Participants must not have had prior systemic therapy except for localized emergency radiation to sites of life-threatening or function-threatening disease and/or no more than 1 cycle of chemotherapy per a low or intermediate risk neuroblastoma regimen (as per P9641, A3961, ANBL0531, or similar) prior to determination of MYCN amplification status and histology. 4. Specimens will be obtained only in a non-significant risk manner and not solely for the purpose of investigational testing. 5. Ability to tolerate PBSC collection: No known contraindication to PBSC collection. Examples of contraindications would include a weight or size less than that determined to be feasible at the collecting institution, or a physical condition that would limit the ability of the child to undergo apheresis catheter placement (if necessary) and/or the apheresis procedure. Part A and B both- Part A CLOSED, Part B- OPEN: 6. Adequate Cardiac Function Defined As: 1. Shortening fraction of ≥ 27% by echocardiogram, or 2. Ejection fraction of ≥ 50% by radionuclide evaluation or echocardiogram. 7. Adequate liver function must be demonstrated, defined as: c. Total bilirubin ≤ 1.5 x upper limit of normal (ULN) for age AND d. ALT (SGPT) \< 10 x upper limit of normal (ULN) for age 8. ⦁ For participants \< 17 years old: estimated Glomerular Filtration rate (eGFR) as calculated from the Bedside Schwartz equation (in units of mL/min/1.73 m2) or via radioisotope GFR of ≥ 70 mL/min/1.73 m2. The Bedside Schwartz equation is: \[(0.413) X (Height in cm)\] / SCr ⦁ For participants ≥17 years old: estimated Glomerular Filtration rate (eGFR) as calculated from the Cockcroft and Gault formula (in units of mL/min/1.73 m2) or via radioisotope GFR of ≥ 70 mL/min/1.73 m2. The Cockcroft and Gault formula is: \[(140-age) x (Wt in kg) x (0.85 if female)\] / (72 x SCr) 9. A negative serum pregnancy test is required for female participants of child bearing potential (≥13 years of age or after onset of menses) 10. Post-pubertal study participants must be willing to use a highly effective contraceptive method (i.e., achieves a failure rate of \ 1) are not eligible. 2. Lactating females are not eligible unless they have agreed not to breastfeed their infants. 3. Participants receiving any investigational drug concurrently. 4. Participants with any other medical condition, including but not limited to malabsorption syndromes, mental illness or substance abuse, deemed by the Investigator to be likely to interfere with the interpretation of the results or which would interfere with a participant's ability to sign or the legal guardian's ability to sign the informed consent, and participant's ability to cooperate and participate in the study