| E.1 Medical condition or disease under investigation | 
| E.1.1 | Medical condition(s) being investigated | 
| Stage IV childhood renal tumours |  | 
| E.1.1.1 | Medical condition in easily understood language | 
| Metastasized childhood  tumours in kidneys |  | 
| E.1.1.2 | Therapeutic area | Diseases [C] - Cancer [C04] | 
| MedDRA Classification | 
| E.1.3 | Condition being studied is a rare disease | No | 
| E.2 Objective of the trial | 
| E.2.1 | Main objective of the trial | 
| To determine non-inferiority of upfront 6 weeks of VCE to VAD in the overall metastatic response rate (MetRR) in newly diagnosed stage 4 WT. The MetRR will include the pulmonary response rate (PRR) and the response rate on non-pulmonary metastasis (NPRR). |  | 
| E.2.2 | Secondary objectives of the trial | 
| - acute toxicitiy of preoperative chemotherapy - histological composition and local stage distribution of the primary tumour
 - tumour volume reduction
 - EFS and OS after 2 and 5 years
 - short term and long term effects
 - role of molecular markers
 - assess and review the standard imaging criteria in use of pulmonary matastases
 - investigating the imaging characteristics of lung metastasis in routine chest imaging in correlation with outcome
 |  | 
| E.2.3 | Trial contains a sub-study | Yes | 
| E.2.3.1 | Full title, date and version of each sub-study and their related objectives | 
| The substudy are part of 1. Histologic and molecular response to preoperative treatment and outcome
 - Investigating the role of remaining blastema after pre-treatment wit VCE or VAD
 - Investigating the role of molecular markers
 
 2. Exploration of outcome and risk factor
 - To investigate a potential difference in outcome between males and females in both treatment arms at 2 and 5 years.
 - To investigate the potential difference in outcome for children <2 years, 2-4 years and >4 years in both treatment arms.
 - Investigating risk factors/Clinical outcome after treatment:
 
 3. Long term and acute sude effects
 - Percentage of patients suffering febrile grade 4 neutropenia during postoperative treatment
 - Percentage of patients suffering Grade 3 or 4 ALAT or bilirubin increase during postoperative treatment
 - Percentage of patients suffering from SOS during postoperative treatment according to EBMT criteria [48]
 - Percentage of patients with persistent CTCAE grade 3 and 4 ototoxicity (at the end of treatment and/or at 2 years after end of treatment) (=>= 30dB hearing loss in 2-4 kHZ area)
 - Percentage of patients with > grade I CTCAE left ventricular dysfunction at the end of treatment 2, 5 and 10 years (for 5 and 10 years)
 - Percentage of patients with second malignancy (within 2 years after end of treatment)
 
 |  | 
| E.3 | Principal inclusion criteria | 
| - Children <18 years at date of diagnosis and >3months - Patients suffering from metastatic renal tumour at initial diagnosis, having at least one circumscript, non-calcified (pulmonary) nodule (or other lesion highly suspicious of metastasis according to criteria for metastatic disease) ≥3 mm as determined by chest CT-scan and abdominal CT-scan/MRI (for radiological details please refer to section 12.8).
 - Metastatic childhood renal tumour must be confirmed by central review.
 - Signed informed consent form(s) prior to study entry according to national guidelines and GCP guidelines
 - Understand and voluntarily provide permission (subjects and when applicable, parental/legal representative(s)) to the ICF prior to conducting any study related assessments/procedures
 - Able to adhere to the study visit schedule and other protocol requirements
 - No pre-existing and ongoing cardiac malfunction disease (insufficiency, malign arrhythmias)
 - No pre-existing and ongoing liver function deficiency that is not controllable by substitution
 |  | 
| E.4 | Principal exclusion criteria | 
| - inability to be followed until two years after treatment - other chemotherapy prior to enrolment
 - Patient and/or parental/legal representative(s) denied randomization
 - primary nephrectomy
 - histology other than nephroblastoma if confirmed by upfront tumour biopsy/cutting needle biopsy
 - pregnancy or lactation
 - Fertile female with child bearing potential and fertile male subjects who refuse using highly effective contraceptive measures
 - Treated by any investigational agent in a clinical study within previous 4 weeks
 - hypersensitivity to the active substances or other excipients contained in the investigational medical products listed in the summary of product characteristics (SmPC) or Investigators Brochure (IB).
 - unwillingness to follow adequate supportive measures including transfusion of blood products if medically needed
 - inability to receive chemotherapy according to the protocol, this is particulary true for:
 a.	acute kidney failure needing dialysis treatment
 b.	pre-existing peripheral neuropathy
 - Active, uncontrolled life threatening Infection (e.g. Acute Hepatitis, Pneumonia, AIDS, Varizella)
 - known chromosomal instability/susceptibility (e.g. Fanconi Anemia, Nejjmegen Breakage Syndrome)
 - participation in other interventional trials (registration in observational non-interventional studies is acceptable)
 - age at start of treatment <3 months or >18 years
 - any other medical condition incompatible with the protocol treatment
 |  | 
| E.5 End points | 
| E.5.1 | Primary end point(s) | 
| Percentage of patients with radiologic complete response (CR) of any metastasis and/or Very Good Partial Response (VGPR) of lung metastasis of childhood renal tumours after 6 weeks of preoperative chemotherapy (Section 12.5 for definitions of metastatic response) |  | 
| E.5.1.1 | Timepoint(s) of evaluation of this end point | 
| 6 weeks after start of preoperative chemotherapy of the last patient |  | 
| E.5.2 | Secondary end point(s) | 
| - Radiologic response to preoperative treatment: Metastatic response assessment:
 - Percentage of patients after 6 weeks of preoperative chemotherapy achieving a CR after surgery of metastasis at time of nephrectomy
 - Percentage of patients with complete response +/- VGPR of (pulmonary) metastasis of nephroblastoma after 6 weeks of preoperative chemotherapy + 9 weeks adjuvant chemotherapy.
 - Percentage of patients with complete response +/- VGPR of (pulmonary) metastasis of nephroblastoma after preoperative chemotherapy + 9 weeks adjuvant chemotherapy + metastasectomy
 - Percentage of patients with remaining metastatic disease after surgery that achieve a CR at week 9 of adjuvant chemotherapy
 - Percentage of patients with complete response +/- VGPR of (pulmonary) metastasis of nephroblastoma at the end of adjuvant chemotherapy ± metastasectomy ± RT
 - Percentage of patients with radiologic complete response (CR) of any metastasis or Very Good Partial Response (VGPR) of lung metastasis of nephroblastoma after 6 weeks of preoperative chemotherapy of patients with remaining metastatic disease after surgery that achieve a CR at week 9 of adjuvant chemotherapy
 - Primary tumour volume shrinkage after 6 weeks of preoperative chemotherapy
 - Primary tumour volume after 6 weeks of preoperative chemotherapy
 - Number of metastases at diagnosis and after preoperative treatment
 - Maximum diameters of the largest metastases at diagnosis and after preoperative treatment
 
 - Histologic & molecular response to preoperative treatment:
 - Stage distribution of local tumour
 - Histologic subtype distribution of local tumour (LR, IR, HR)
 - Histologic subtype distribution of resected nodules/metastsis (LR, IR, HR)
 - Percentage of blastema and blastemal residual volume in local tumour
 - Percentage of patients with <10 ml of blastemal residual volume in resected nephroblastoma after 6 weeks of preoperative chemotherapy
 - Percentage of necrosis in local tumour
 - Percentage of patients with complete necrosis in resected nodules
 - Percentage of patients with 1q gain being in CR/VGPR in both arms.
 
 - Treatment burden, complications, side effects and toxicity:
 - Percentage of patients requiring pulmonary radiotherapy in first line
 - Percentage of patients suffering Grade 3 or 4 ALAT or bilirubin increase during preoperative treatment
 - Percentage of patients suffering from SOS during preoperative treatment according to EBMT criteria [48]
 - Percentage of patients suffering any Grade 4 or grade 5 toxicity during preoperative chemotherapy.
 - Overall duration of preoperative treatment per arm as determined as interval D1 – date of nephrectomy
 - Delay in timing of nephrectomy: % of patients with more than 8 weeks since start of preoperative chemotherapy because of toxicity
 - Percentage of (peri-)operative complications (haemorrhage, rupture, thromboembolism)
 - Outcome:
 - Event-free survival at 2 and 5 years for the whole cohort and according to study arm (VAD/VCE) and according to 1qGain
 - Overall survival at 2 and 5 years for the whole cohort and according to study arm (VAD/VCE) and according to 1qGain
 
 |  | 
| E.5.2.1 | Timepoint(s) of evaluation of this end point | 
| after surgery (6 weeks), 9 weeks after initiation of postoperative treatment (if applicable), at the end of overall treatment, 2 years and 5 years (if applicable) |  | 
| E.6 and E.7 Scope of the trial | 
| E.6 | Scope of the trial | 
| E.6.1 | Diagnosis | No | 
| E.6.2 | Prophylaxis | No | 
| E.6.3 | Therapy | Yes | 
| E.6.4 | Safety | Yes | 
| E.6.5 | Efficacy | Yes | 
| E.6.6 | Pharmacokinetic | No | 
| E.6.7 | Pharmacodynamic | No | 
| E.6.8 | Bioequivalence | No | 
| E.6.9 | Dose response | No | 
| E.6.10 | Pharmacogenetic | No | 
| E.6.11 | Pharmacogenomic | No | 
| E.6.12 | Pharmacoeconomic | No | 
| E.6.13 | Others | No | 
| E.7 | Trial type and phase | 
| E.7.1 | Human pharmacology (Phase I) | No | 
| E.7.1.1 | First administration to humans | No | 
| E.7.1.2 | Bioequivalence study | No | 
| E.7.1.3 | Other | No | 
| E.7.1.3.1 | Other trial type description |  | 
| E.7.2 | Therapeutic exploratory (Phase II) | No | 
| E.7.3 | Therapeutic confirmatory (Phase III) | Yes | 
| E.7.4 | Therapeutic use (Phase IV) | No | 
| E.8 Design of the trial | 
| E.8.1 | Controlled | Yes | 
| E.8.1.1 | Randomised | Yes | 
| E.8.1.2 | Open | Yes | 
| E.8.1.3 | Single blind | No | 
| E.8.1.4 | Double blind | No | 
| E.8.1.5 | Parallel group | No | 
| E.8.1.6 | Cross over | No | 
| E.8.1.7 | Other | No | 
| E.8.2 | Comparator of controlled trial | 
| E.8.2.1 | Other medicinal product(s) | Yes | 
| E.8.2.2 | Placebo | No | 
| E.8.2.3 | Other | No | 
| E.8.2.4 | Number of treatment arms in the trial | 2 | 
| E.8.3 | The trial involves single site in the Member State concerned | No | 
| E.8.4 | The trial involves multiple sites in the Member State concerned | Yes | 
| E.8.4.1 | Number of sites anticipated in Member State concerned | 47 | 
| E.8.5 | The trial involves multiple Member States | Yes | 
| E.8.5.1 | Number of sites anticipated in the EEA | 30 | 
| E.8.6 Trial involving sites outside the EEA | 
| E.8.6.1 | Trial being conducted both within and outside the EEA | Yes | 
| E.8.6.2 | Trial being conducted completely outside of the EEA | No | 
| E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned | 
| Brazil |  
| Holy See (Vatican City State) |  
| Austria |  
| Belgium |  
| Denmark |  
| France |  
| Germany |  
| Greece |  
| Hungary |  
| Ireland |  
| Italy |  
| Netherlands |  
| Norway |  
| Poland |  
| Portugal |  
| Spain |  
| Sweden |  
| Switzerland |  
| United Kingdom |  
| Czechia |  | 
| E.8.7 | Trial has a data monitoring committee | Yes | 
| E.8.8 | Definition of the end of the trial and justification where it is not the last
                        visit of the last subject undergoing the trial | 
| Last subject last visit, it is anticipated to be at the date patients were last known alive for two years after end of the treatment or date of death |  | 
| E.8.9 Initial estimate of the duration of the trial | 
| E.8.9.1 | In the Member State concerned years | 5 | 
| E.8.9.1 | In the Member State concerned months | 8 | 
| E.8.9.1 | In the Member State concerned days |  | 
| E.8.9.2 | In all countries concerned by the trial years | 5 | 
| E.8.9.2 | In all countries concerned by the trial months | 8 |