Dinutuximab-beta and Chemotherapy in Newly Diagnosed High-Risk Neuroblastoma

Inclusion Criteria:

1. Must be 1 to 30 years of age at the time of initial diagnosis.
2. Must have histological verification of neuroblastoma or ganglioneuroblastoma, OR demonstration of neuroblastoma cells in the bone marrow with elevated urinary VMA at the time of initial diagnosis.
3. Must have newly diagnosed high-risk neuroblastoma according to the revised COG NBL risk classifier (version 2), defined as meeting at least ONE of the following:

   1. INRG Stage M: MYCN amplification (\> 4-fold increase), OR age 12 to \< 18 months without MYCN amplification but with unfavorable histology/DI = 1/SCA, OR age \> 18 months regardless of biologic features.
   2. INRG Stage MS: MYCN amplification, OR age 12 to \< 18 months without MYCN amplification but with unfavorable histology/DI = 1/SCA.
   3. INRG Stage L2: MYCN amplification, OR age 18 months to \< 5 years without MYCN amplification but with unfavorable histology, OR age ≥ 5 years without MYCN amplification but with unfavorable histology (undifferentiated or poorly differentiated tumor).
   4. INRG Stage L1: Tumor with incomplete resection and MYCN amplification.
   5. Patients \> 18 months of age initially diagnosed with INRG Stage L1, L2, or MS who are subsequently upgraded to high-risk disease.
4. Must have had no prior systemic therapy, or have only completed the first cycle of induction chemotherapy under the TPOG N2020-HR protocol.
5. Must have measurable disease, defined as at least ONE of the following (Note: Patients with elevated VMA only are NOT eligible):

   1. Measurable tumor on MRI or CT scan within 3 weeks prior to study entry (≥ 10 mm in at least one dimension) that is MIBG avid or demonstrates increased FDG/FDOPA uptake on PET scan.
   2. MIBG or FDG/FDOPA PET scan within 2 weeks prior to study entry with positive uptake at a minimum of one site.
6. ECOG Performance Status of 0, 1, or 2.
7. Adequate organ function, including:

   1. Renal: Creatinine clearance or estimated GFR ≥ 60 mL/min/1.73 m², or serum creatinine ≤ upper limit of normal (ULN) based on age/gender.
   2. Liver: Total bilirubin ≤ 1.5 x ULN for age AND SGPT (ALT) ≤ 5.0 x ULN (if liver tumor is present) or ≤ 3.0 x ULN (if no liver tumor).
   3. CNS: No clinical or radiological evidence of active CNS disease (well-controlled seizures allowed), and CNS toxicity ≤ Grade 2.
   4. Cardiac: Shortening fraction ≥ 27% or Ejection fraction ≥ 50% by ECHO or gated radionuclide study.
   5. Pulmonary: No dyspnea at rest, no exercise intolerance, no chronic oxygen requirement, and room air pulse oximetry \> 94%.
8. Must be enrolled on the TPOG N2020-GD2 protocol with completed informed consent forms, and be willing to proceed to standard therapy of high-risk neuroblastoma with a 10-year follow-up.

Exclusion Criteria:

1. Participation in other interventional clinical trials within 1 month.
2. Inability to obey the trial instructions.
3. Patients with bone marrow failure syndromes.
4. Current requirement for immunosuppressive medications (e.g., tacrolimus, cyclosporine, systemic corticosteroids for reasons other than prevention/treatment of acute allergic reactions or adrenal replacement therapy).
5. Females who are pregnant or breastfeeding (A pregnancy test is required for female patients of childbearing potential).

   1. Female patients who are pregnant are ineligible since fetal toxicities and teratogenic effects have been noted for several of the study drugs. A pregnancy test is required for female patients of childbearing potential.
   2. Lactating females who plan to breastfeed their infants.
   3. The subject or their partner is planning to conceive
   4. Sexually active patients of reproductive potential who have not agreed to use an effective contraceptive method during study therapy and for two months after the last dose of (ch14.18/CHO) (dinutuximab-β) are not eligible.