Total Therapy for Infants With Acute Lymphoblastic Leukemia (ALL) I
Phase: PHASE1
Conditions: Acute Lymphoblastic Leukemia
Sponsor: St. Jude Children's Research Hospital

TINI
Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
St. Jude
TINI CTG# - NCT02553460
IND# 127,270 (St. Jude sponsor)
Initial version dated: 05-06-2015. Resubmitted to CT-SRC 06-09-2015. Resubmitted to IRB 07-02-2015 and 08-17-
2015 (IRB approved: 08-25-2015)
Activation date: 10-20-2015
Amendment 1.0 dated: 11-30-2015. Resubmitted to CT-SRC 12-28-2015 and 01-07-2016. Resubmitted to IRB 01-28-
2016 (IRB approved: 01-28-2016) 
Amendment 2.0 dated: 03-29-2016. Resubmitted to IRB 05-19-2016, 06-30-2016 and 7-14-2016
(IRB approved: 07-26-2016) Activation date: 09-06-2016
Amendment 3.0 dated 02-10-2017. Resubmitted to IRB 03-28-2017 and 04-18-2017 (IRB approved: 04-26-2017) 
Activation date: 06-06-2017
Amendment 4.0 dated 08-19-2019. Resubmitted to CT-SRC on 09-13-2019 and 10-02-2019.  (IRB approved: 10-15-2019) 
Activation date: 12-12-2019
Amendment 5.0 dated 07-27-2020. (IRB approved: 10-26-2020) Activation date: 12-01-2020
Revision 5.1 date 10-21-2021  (IRB approved    )
TOTAL THERAPY FOR INFANTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) I
IND 127,270 (St. Jude Children’s Research Hospital)
Study Chair
Tanja A. Gruber, MD, PhD
Lucile Packard Children’s Hospital
Pediatric Hematology, Oncology, Stem Cell Transplant and Regenerative Medicine
1000 Welch Road Suite 300
Palo Alto, CA 94305
St. Jude Principal Investigator
Sima Jeha, MD
St. Jude Children’s Research Hospital
Department of Oncology/Leukemia Lymphoma Division
262 Danny Thomas Place
Memphis, TN 38105
Study Co-Chair
Paul S. Gaynon, MD
Children’s Hospital Los Angeles
Hematology/Oncology #54
Los Angeles, CA
Contents of this document may not be extracted without permission from the Principal Investigator.
St. Jude Children's Research Hospital
IRB NUMBER: Pro00005777
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Protocol document date: 10-21-2021
St. Jude Sub-Investigators
Cheng Cheng, PhD3
John K. Choi, MD, PhD2
Jennifer Pauley, PharmD4
Lu Wang, MD, PhD2
Paul G. Thomas, PhD5
Yinmei Zhou, MS3
1Department of Oncology, 2Department of Pathology, Department of Biostatistics, and  
4Department of Pharmaceutical Sciences and 5Department of Immunology
Collaborating Institutions and Sub-Investigators
Michael J. Absalon, MD, PhD
Erin Breese, MD, PhD
Dept of Hematology Oncology
Cincinnati Children’s Hospital Medical 
Center
Cincinnati, OH
Bruce C. Bostrom, MD
Yoav H. Messinger, MD
Michael Richards, MD
Dept of Hematology-Oncology
Children’s Hospital of Minnesota
Minneapolis, MN
Tanja A. Gruber, MD PhD
Norman J. Lacayo, MD
Pediatrics Hematology, Oncology, Stem Cell 
Transplant and Regenerative Medicine
Lucile Packard Children's Hospital, Stanford
Palo Alto, CA
Bill Hoon Chang, MD, PhD
Pediatric Hematology and Oncology
Doernbecher Children's Hospital
Oregon Health & Science University
Portland, OR
Kirk Schultz, MD
Pediatric Hematology/Oncology/BMT
BC Children’s Hospital, 
Vancouver, British Columbia
Uma Athale, MD, MSc, FAAP, FRCP(C), 
Department of Pediatric Oncology
Meret Henry, MD, PhD
Dept of Hematology Oncology
Children’s Hospital of Michigan
Detroit, MI
Duncan Stearns, MD
Pediatrics-Hematology and Oncology
Rainbow Babies and Children's Hospital
Case Western Reserve University 
Cleveland, OH
Deborah E. Schiff, MD
Hematology Oncology
 Rady Children’s Hospital-San Diego
San Diego, CA
Cecilia Fu, MD 
Hematology/Oncology 
Children’s Hospital Los Angeles
Los Angeles, CA
Ivan Kirov, MD
Dept of Hematology and Oncology
Children’s Hospital of Orange County
Orange, CA 92868
Henrique Bittencourt, MD, PhD
Yvan Samson, MD
Pediatric Hematology/Oncology
CHU Sainte- Justine
Montreal, Quebec
Victor Lewis, MD
Pediatric Oncology & Blood & Marrow 
Transplant
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Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
McMaster Children’s Hospital
Hamilton, Ontario
Lesleigh Abbott, MD, FRCP
Division of Hematology/Oncology
Children’s Hospital of Eastern Ontario
Ottawa, Ontario
Eric Lowe, MD
Department of Pediatric Hematology 
Oncology
Children’s Hospital-King's Daughters
Norfolk, VA
Sunil Desai, MD
Pediatric Hematology Oncology
Stollery Childrens Hospital
Edmonton, Alberta
Alberta Children’s Hospital
Calgary, Alberta
Catherine Vezina, MD
Oncology Pediatric
Montreal Children’s Hospital
Montreal, Quebec
Christine Bolen, MD
Pediatric Hematology Oncology
Novant Health Hemby Children's Hospital
Charlotte, NC
External Scientific Collaborator
Terzah M. Horton, MD, PhD
Hematology-Oncology
Texas Children’s Hospital
Baylor College of Medicine
Houston, TX
St. Jude Children's Research Hospital
IRB NUMBER: Pro00005777
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TINI
Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
Protocol summary
TINI:  Total Therapy for Infants with Acute Lymphoblastic Leukemia (ALL) I
Principal Investigator: Tanja A. Gruber, MD, PhD
IND holder: St. Jude Children’s Research Hospital, #127,270
Brief overview: Treatment will consist of 4 main phases: Remission Induction, Consolidation, 
Reinduction, and Maintenance. High risk patients will receive a Reintensification phase prior to 
transplant in first remission. Total duration of therapy is 22 months.
Intervention: 
Remission Induction
Drugs: Dexamethasone, mitoxantrone, PEG-asparaginase, bortezomib, vorinostat, 
cyclophosphamide, methotrexate, cytarabine, hydrocortisone, mercaptopurine
Procedure: Intrathecal chemotherapy
Consolidation Treatment
Drugs: Methotrexate, mercaptopurine, cytarabine, hydrocortisone
Procedure:  Intrathecal chemotherapy
Reinduction
Drugs: Dexamethasone, mitoxantrone, PEG-asparaginase, bortezomib, vorinostat, methotrexate, 
cytarabine, hydrocortisone
Procedure: Intrathecal chemotherapy
Reintensification
Drugs: Dexamethasone, cytarabine, etoposide, PEG-asparaginase, hydrocortisone, methotrexate
Procedure: Intrathecal chemotherapy
Maintenance
Drugs: Dexamethasone, vincristine, methotrexate, mercaptopurine, cytarabine, hydrocortisone
Procedure: Intrathecal chemotherapy
Study design: Non-randomized, multi-center feasibility/tolerability study.
Sample size: 50 evaluable participants in 7 years.
Data management: Data management and statistical analysis will be provided respectively by 
Clinical Research Informatics and the Comprehensive Cancer Center Hematological 
Malignancies Program and the Biostatistics Department at St. Jude Children’s Research Hospital.
Human subjects: The primary risk to participants in this research study is toxicity from the 
intensive, multi-agent chemotherapy. Participants are informed of this and other potential side 
effects during informed consent. Adverse events will be monitored, reported and treated 
appropriately.
St. Jude Children's Research Hospital
IRB NUMBER: Pro00005777
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Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
TINI Schema
DEX/PEG/MITO
Bortezomib/Vorinostat
HDMtx x4, 6MP
6MP/Mtx
VCR/DEX Pulses
SCT
Modified Protocol 1b
Induction
Induction 
Intensification
Consolidation
Reintensification/
Stem Cell Transplant
Reinduction
Maintenance
DEX/PEG/MITO
Bortezomib/Vorinostat
BFM 
HR3
MRD≤0.01%
End of 
Consol
MRD>0.01% End of Consol
SCT
MRD≤0.01%
End of Reind
MRD>0.01%  End of 
Reind
CART
OR
Consider SCT
St. Jude Children's Research Hospital
IRB NUMBER: Pro00005777
IRB APPROVAL DATE: 11/11/2021

TINI
Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
TABLE OF CONTENTS
1.0
OBJECTIVES 1
1.1
Primary Objectives ...........................................................................................................1
1.2
Secondary Objectives .......................................................................................................1
1.3
Exploratory Objectives .....................................................................................................1
2.0
BACKGROUND AND RATIONALE......................................................................................1
2.1
Background.......................................................................................................................1
2.2
Rationale...........................................................................................................................8
2.3
Background and Rationale for Correlative Research Studies.........................................12
3.0
ELIGIBILITY CRITERIA AND STUDY ENROLLMENT ..................................................14
3.1
Inclusion Criteria ............................................................................................................14
3.2
Exclusion Criteria ...........................................................................................................14
3.3
Research Participant Recruitment and Screening...........................................................15
3.4
Enrollment on Study at St. Jude .....................................................................................15
3.5
Enrollment on Study at Collaborating Sites ...................................................................15
4.0
TREATMENT PLAN..............................................................................................................16
4.1
Overview of Therapy......................................................................................................16
4.2
Remission Induction .......................................................................................................17
4.3
Consolidation Chemotherapy .........................................................................................22
4.4
Re-Induction Therapy.....................................................................................................25
4.5
Re-Intensification Therapy .............................................................................................27
4.6
Maintenance Chemotherapy ...........................................................................................29
5.0
DRUG/DEVICE/BIOLOGIC AGENT INFORMATION.......................................................31
5.1
Intrathecal Triples...........................................................................................................31
5.2
Dexamethasone (Decadron®, Hexadrol®, Dexone®, Dexameth®)..............................31
5.3
Mitoxantrone (Novantrone®, Mitozantrone) .................................................................33
5.4
Pegaspargase (PEG-asparaginase, Oncaspar®)..............................................................35
5.5
Asparaginase Erwinia Chrysanthemi (Erwinia chrysanthemi, Erwinase®, Erwinaze™, 
Crisantaspase).................................................................................................................37
5.6
Bortezomib (Velcade®, PS-341, MLN341, LDP-341)  IND# 127,270.........................39
5.7
Vorinostat (Zolinza®, Suberoylanidide Hydroxamic Acid, SAHA) IND# 127,270......42
5.8
Cyclophosphamide (Cytoxan®) .....................................................................................44
5.9
Mercaptopurine (6-MP; Purinethol®) ............................................................................46
5.10
Methotrexate - IV ...........................................................................................................47
5.11
Leucovorin Calcium (Wellcovorin®, folinic acid)..........................................................49
5.12
Cytarabine (Ara-C; Cytosar-U®) ...................................................................................50
5.13
Etoposide (VP-16, Vepesid®) and Etoposide Phosphate (Etophos®).............................52
5.14
VinCRIStine (Oncovin®)...............................................................................................54
5.15
Drug Shortages and Unavailability.................................................................................56
6.0
TREATMENT MODIFICATIONS.........................................................................................56
6.1
Renal Dysfunction ..........................................................................................................56
6.2
Hepatic Dysfunction .......................................................................................................57
6.3
Testicular Leukemia at Diagnosis ..................................................................................58
6.4
Vincristine Neurotoxicity ...............................................................................................58
6.5
Cytarabine Neurotoxicity................................................................................................60
6.6
Methotrexate Neurotoxicity............................................................................................60
6.7
Mitoxantrone Cardiac Toxicity.......................................................................................60
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Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
6.8
Bortezomib Neurotoxicity ..............................................................................................60
6.9
Venous Thromboembolism ............................................................................................62
6.10
Avascular Necrosis of Bone ...........................................................................................62
6.11
PEG-Asparaginase Dose Modifications .........................................................................62
6.12
Dexamethasone Dose Modifications ..............................................................................63
6.13
Management of Pancreatitis ...........................................................................................64
7.0
CONTINGENCY PLANS FOR REFRACTORY DISEASE OR RELAPSE ........................64
7.1
Increasing MRD During Consolidation..........................................................................64
7.2
Induction Failures ...........................................................................................................64
7.3
Hematologic Relapse......................................................................................................64
7.4
Extramedullary Relapse..................................................................................................65
8.0
REQUIRED EVALUATIONS, TESTS, AND OBSERVATIONS ........................................65
8.1
Pre-Study Evaluations ....................................................................................................65
8.2
Evaluations During Therapy...........................................................................................66
8.3
Long-Term Follow-up Evaluations ................................................................................68
9.0
EVALUATION CRITERIA....................................................................................................68
9.1
Response Criteria............................................................................................................68
9.2
Toxicity Evaluation Criteria ...........................................................................................68
10.0 SUPPORTIVE CARE..............................................................................................................69
10.1
Fever at Diagnosis ..........................................................................................................69
10.2
Metabolic Derangements................................................................................................69
10.3
Hyperleukocytosis ..........................................................................................................69
10.4
Skin Breakdown..............................................................................................................69
10.5
Avascular Necrosis of Bone ...........................................................................................70
10.6
Pancytopenias .................................................................................................................70
10.7
Nutritional Supplementation...........................................................................................70
10.8
Drug Interactions ............................................................................................................70
10.9
RSV Prophylaxis ............................................................................................................71
10.10 Mandatory Prophylactic Antibiotics During Periods of Prolonged Neutropenia...........71
11.0 CRITERIA FOR OFF STUDY AND OFF TREATMENT ....................................................72
11.1
Off-Study Criteria...........................................................................................................72
11.2
Off-Therapy Criteria.......................................................................................................72
12.0 SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS................................73
12.1
Reporting Adverse Experiences and Deaths to the IRB.................................................73
12.2
Reporting to Regulatory Affairs Office and FDA ..........................................................75
12.3
Recording Adverse Events and Serious Adverse Events ...............................................76
12.4
Process for Reporting AEs Between St. Jude and Collaborating Sites ..........................76
12.5
Data and Safety Monitoring Board.................................................................................77
13.0 DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY...................78
13.1
Data Collection ...............................................................................................................78
13.2
Data Collection Instructions for Collaborating Sites......................................................78
13.3
Study Monitoring............................................................................................................78
13.4
Confidentiality ................................................................................................................79
14.0 STATISTICAL CONSIDERATIONS.....................................................................................79
14.1
Primary Objective...........................................................................................................79
14.2
Statistical Analyses and Power for the Secondary Objectives .......................................83
14.3
Statistical Analyses for the Exploratory Objectives .......................................................84
15.0 OBTAINING INFORMED CONSENT..................................................................................85
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Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
15.1
Informed Consent Prior to Research Interventions ........................................................85
15.2
Consent at Enrollment ....................................................................................................85
15.3
Consent When English is Not the Primary Language ....................................................85
16.0 REFERENCES 86
APPENDICES
Appendix I:
Treatment/Evaluation Calendars
Appendix II:
Targeted Kinase Inhibitors and Inhibitors of Epigenetic Marks
Appendix III: Vorinostat Compounding
Appendix IV: Tests/Evaluations for Clinical Care and for Research
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1.0
OBJECTIVES
The overall aim of this study is to improve the cure rate of infants with acute lymphoblastic 
leukemia (ALL).
1.1
Primary Objectives
The primary objective is to determine the tolerability of incorporating bortezomib and 
vorinostat into an ALL chemotherapy backbone for newly diagnosed infants with ALL.
1.2
Secondary Objectives
1.2.1
To estimate the event-free survival and overall survival of infants with ALL who are 
treated with bortezomib and vorinostat in combination with an ALL chemotherapy 
backbone.
1.2.2
To measure minimal residual disease (MRD) positivity using both flow cytometry 
and PCR.
1.2.3
To compare end of induction, end of consolidation, and end of reinduction MRD 
levels to Interfant99.
1.3
Exploratory Objectives
1.3.1
To measure histone acetylation, ubiquitination, and methylation in leukemic blasts 
pre and post treatment with bortezomib and vorinostat.
1.3.2
Assess NF-kB activity and proteasome inhibition pre and post treatment with 
bortezomib.
1.3.3
To assess the prognostic value of MRD by deep sequencing.
1.3.4
Identify all genomic lesions by comprehensive whole genome, exome and 
transcriptome sequencing on all patients.
1.3.5
Evaluate the sensitivity of patient blasts in vitro to a panel of highly active agents 
identified by a high throughput drug screen on primary infant ALL specimens.
1.3.6
Identify subclones in patients with detectable minimal residual disease by next 
generation deep sequencing.
1.3.7
Determine clonal evolution of relapsed patients by next generation sequencing.
1.3.8
Study immune repertoire diversity over the course of treatment by deep sequencing of 
lymphocyte variable regions.
1.3.9
Describe methotrexate clearance in infants with ALL.
2.0
BACKGROUND AND RATIONALE
2.1
Background
Acute lymphoblastic leukemia (ALL) in infants less than 1 year of age is a rare, but deadly 
disease. While pediatric ALL patients greater than 1 year of age achieve a five year event 
free survival (EFS) of 85.6%, infants have a much poorer prognosis with a four year EFS of 
only 47% on the recent Interfant99 study.1,2 Importantly, outcomes for infant leukemia 
patients have not improved significantly over the last decade. The poor outcomes seen in this 
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subset of patients are believed to be a result of the unique biology of the leukemia cells, with 
approximately 80% of cases carrying a translocation that results in the rearrangement of 
MLL (MLLr) and its fusion to one of more than 40 different partner genes.3 Indeed, infants 
carrying MLLr had a significantly worse four year EFS in contrast to those lacking MLLr 
(36.9% vs. 74.1% P=0.0001).1 The presence of the MLLr has been documented in the 
neonatal blood spot prior to the development of overt leukemia, suggesting that this 
molecular event initiates disease and occurs in utero.4 Moreover, recent data have 
demonstrated that infant MLLr ALL cases have less than one copy number alterations 
(CNAs) / case, indicating that few secondary mutations are required for the full development 
of leukemia.5 Consistent with this interpretation, we recently completed whole genome DNA 
sequence analysis on leukemic blasts and matched non tumor tissue samples from 22 infant 
MLLr cases and identified a mean of only 3.5 structural variations (SVs) and 2.2 somatic 
single nucleotide variations (SNVs) and/or insertions/deletions (indels) per case - the lowest 
number of somatic mutations observed in 21 different pediatric cancers.6,7 These data suggest 
that the major driver of transformation in this leukemia subtype is the translocation encoded 
MLL fusion protein. Despite recent progress in defining the epigenetic alterations that result 
from the expression of the MLL fusion protein, these insights have only recently begun to be 
extrapolated into the development of new therapeutic approaches whose benefits have yet to 
be defined.8-11 Thus, there remains an urgent need for the development of alternative 
approaches to improve outcomes in these patients.
Due to this need for innovative therapy to improve outcomes, newly diagnosed infants 
carrying MLLr presenting to St. Jude Children’s Research Hospital (SJCRH) have been 
enrolled in the Total XVI (TOTXVI) protocol and given an intensified treatment regimen. 
This study incorporates clofarabine, a nucleoside analog, into a high-risk chemotherapy 
backbone. Clofarabine in combination with cyclophosphamide and etoposide is given twice: 
towards the end of induction and as part of reinduction I. Six infants have received this 
therapy thus far; in all patients the courses of clofarabine were well tolerated (Table 1; Jeha 
et al., unpublished). Based on presenting features, these patients would all be classified as 
Group 2 (Intermediate Risk) with a four year EFS of 44.8% on the Interfant99 protocol.1 Five 
patients remain in continuous complete remission; three of them have completed therapy. 
One patient died secondary to a severe RSV infection following a course of high dose 
cytarabine as part of reinduction II. While these numbers are small, the MRD data are 
extremely encouraging, as on Interfant 99, 70% of MLLr infants had MRD >0.01% after five 
weeks of therapy, and 40% continued to have >0.01% disease after nine weeks of therapy.12 
Similar to childhood ALL, MRD in infants has been shown to be a significant prognostic 
indicator on the Interfant99 trial.12 Consistent with their CCR status, all infants achieved 
MRD negative status within seven weeks of therapy (Table 1).
Infants presenting at less than six months of age with WBC >300/mm3 carried the worst 
prognosis on Interfant99, with a four year EFS of only 19.8%. Although none of the patients 
enrolled on TOTXVI have met this high-risk definition, we have had three 
relapsed/refractory infants referred to SJCRH. All three of these patients carried high risk 
features at diagnosis and had ≥5% leukemic blasts at the end of a five week induction 
course. These refractory patients received clofarabine containing courses at the time of 
relapse and failed to achieve durable responses (Table 2). This suggests that additional novel 
therapeutic approaches are necessary to target these high-risk patients. Based on 
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encouraging data in Phase I and II pediatric ALL trials, we treated these infants with the 
proteasome inhibitor bortezomib, in combination with a four drug chemotherapy 
backbone.13-15 Surprisingly, bortezomib demonstrated significant activity in all three of these 
high risk patients (Table 2; Gruber et al., unpublished).
 Table 1.  MLLr Infant Outcomes TOTXVI
1MRD as determined by flow cytometry, with a sensitivity of 0.01%; ND = Not Determined
2Duration of therapy is 2.5 years, consisting of induction (7 weeks), consolidation (8 weeks), and continuation (120 weeks). 
Table 2.  Response to Salvage Regimens in Relapsed/Refractory ALL Infants1
Patient
Age2
WBC2 (mm3)
Pre-Clofarabine
Post-Clofarabine3
Pre-Bortezomib
Post-Bortezomib4
1
3 mo
600
56%
75%
75%
3.23%
2
2 mo
1300
7.93%
85%
95%
7.93%
3
2 mo
264
97.57%
86%5
86%
1.384%
1As measured by flow cytometry on bone marrow aspirates
2At diagnosis
3Patients 1 and 3 received clofarabine in combination with high dose cytarabine and sorafenib;  Patient 2 received 
clofarabine in combination with etoposide, cyclophosphamide, and Natural Killer Cell infusions. 
4All patients received Bortezomib in combination with the MRC R3 relapsed induction chemotherapy backbone.  
Patients 1 and 2 received four doses of bortezomib, patient 3 received 6.
5Patient 3 received two courses of clofarabine, after the first she decreased to 2.885% however following the second 
she recovered with 86% blasts in the marrow.
To investigate the activity of bortezomib in this leukemia subset further, we established in 
vitro and in vivo assays to evaluate drug sensitivity of primary infant ALL patient samples 
(Figure 1a; Gruber et al., unpublished). We established 15 primary human infant MLLr 
leukemias as xenografts in NOD/SCID/ IL2Rnull (NSG) mice. These samples have 
undergone whole genome sequencing so that the presence or absence of genetic lesions can 
be correlated with response to targeted agents. All samples engrafted and expanded in NSG 
mice, leading to overt leukemia with a latency of 49 to 276 days. Purification of leukemic 
blasts from a single moribund mice yield on average 108 cells, providing sufficient material 
to screen large numbers of compounds. Moreover, we have established in vitro conditions 
that support growth in six of the patient specimens, allowing for a more accurate 
determination of drug sensitivity. Growth in vitro correlated with early onset of disease in 
NSG xenografts as well as younger age at presentation, allowing us to evaluate patient 
samples that represent aggressive high-risk disease (Figure 1b; Gruber et al., unpublished).
Induction MRD1
Age
WBC (mm3)
MLLr
CNS status
Day 15
Day 22
Day 49
Clinical status2
2 mo
54.4
MLL-AF4
CNS3
Neg
ND
Neg
Died in CR1 from RSV
5 mo
52
MLL-AF4
Traumatic 
Tap
Neg
ND
Neg
Alive CCR
Off Therapy 3/14
6 mo
411.9
MLL-
EPS15
Traumatic 
Tap Facial 
Palsy
1.274%
0.158%
Neg
Alive CCR
Continuation Wk 21
8 mo
31.1
MLL-AF10
CNS3+ 
Cranial 
Lesions
1.38%
0.45%
Neg
Alive CCR 
Off Therapy 12/10
8 mo
450
MLL-ENL
CNS2
0.01%
ND
Neg
Alive CCR 
Continuation Wk 98
10 mo
32.9
MLL-AF10
CNS1
13.7%
0.02%
Neg
Alive CCR 
Off Therapy 9/13
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Using this system, we tested bortezomib in addition to 29 other drugs, including standard 
ALL therapeutic agents as well as targeted kinase inhibitors and inhibitors of epigenetic 
marks (see Appendix II). Three classes of agents were active in this system: anthracyclines, 
histone deacetylase inhibitors (HDAC), and the proteasome inhibitor bortezomib (Table 3; 
Gruber et al., unpublished). In contrast to anthracyclines and HDAC inhibitors where IC50 
values were on par with those reported in the literature for primary childhood ALL samples, 
MLLr infant samples required 10-100 fold less bortezomib to induce cytotoxicity. These 
data suggest an enhanced sensitivity of MLLr infant ALL cells to bortezomib.
Table 3.  Drugs with Activity in Primary Infant ALL Samples*
Class
Drug
IC50 (uM)
Literature
Doxorubicin
0.41±0.38
0.054-4.35uM (90 1° ALL Cases)16
Daunorubicin
0.08±0.07
0.0053-1.05uM (157 1° ALL Cases)16
Anthracycline
Mitoxantrone
0.35±0.34
0.0015-0.444uM (112 1° ALL Cases)16
Vorinostat
3.11±1.29
0.55-1.78uM (5 ALL Cell Lines)17
HDAC Inhibitor
Panobinostat
0.63±1.46
0.0077-0.092uM (9 ALL Cell Lines)18
Proteasome Inhibitor
Bortezomib
0.002±0.0008
0.046-1.342uM (106 1° ALL Cases)19
*Only agents active against all 15 patient samples are shown.  IC50 values are from the 6 samples that 
proliferate in vitro (Figure 1b).  
Bortezomib has been shown to mediate responses through several mechanisms including 
NFkB inhibition, stabilization of cell cycle regulatory proteins, and induction of apoptosis.20 
Recently, proteasome inhibition has been demonstrated to lead to accumulated MLL fusion 
protein levels, triggering apoptosis and cell cycle arrest in MLL rearranged cell lines.21 To 
determine if NFkB inhibition also plays a role we evaluated cellular concentrations of the 
Figure 1.  Platform for High Throughput Drug Screening.  a) Study Design. Primary patient samples are 
injected into NSG recipient mice for expansion. Moribund mice are sacrificed, and human leukemia cells are 
purified for subsequent in vitro sensitivity studies. b) Growth Characteristics of Study Samples. Patient blasts 
purified from mice were grown in vitro in serum free media supplemented with cytokines on a collagen matrix 
and assessed for proliferation at 72 hours as determined by intracellular ATP concentrations. Correlation with 
disease latency in NSG and the age of the patient at presentation are shown.
a)
b)
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activated NFkB transcription factor, but failed to see decreased levels when cells were 
treated with bortezomib (data not shown). Bortezomib has also been shown to deregulate 
ubiquitin stores and deplete histone H2B ubiquitination (H2Bub), an epigenetic mark that is 
linked to histone methylation and expression.22 Recently, several groups have published 
reports demonstrating H2Bub is required for DOT1L activity and HOX gene expression.23-25 
We therefore evaluated histone H2B levels in MLLr cell lines and patient samples in the 
presence of bortezomib and confirmed depletion of this epigenetic mark (Figure 2a; Gruber 
et al., unpublished). Furthermore, genome wide chromatin immunoprecipitation sequencing 
(ChIPseq) of bortezomib treated cells demonstrated a decrease in histone 3 methylation at 
lysine residue 79 (H3K79me2) both genome wide and at MLL-AF4 target genes, the 
epigenetic mark imparted by DOT1L (Figure 2b; Gruber et al., unpublished). Consistent 
with these data, patient samples treated with bortezomib downregulated both the MLL gene 
expression signature and signatures of downstream targets such as cMYC (Figure 2b; 
Gruber et al., unpublished), suggesting that the MLL transcriptional program is inhibited in 
the presence of bortezomib.
a)
c)
Figure 2.  Bortezomib Depletes Histone H2B Ubiquitination and Downregulates the MLL gene 
expression program.  a) H2Bub levels. Shown is an MLLr cell line and a representative primary patient 
sample treated with bortezomib. Histones were extracted, run on a gel, and blotted for total H2B and 
ubiquitinated H2B. b) ChIPseq of H3K79me2 in untreated and bortezomib (BTZ) treated MLL-AF4 positive 
SEM cells. Read counts per million mapped reads are shown at all genes and MLL-AF4 target genes as 
previously described. TSS - transcriptional start site; TES – transcriptional end site.  c) GSEA of bortezomib 
treated patient samples. Patient samples were treated with bortezomib and subsequently underwent gene 
expression profiling. Gene set enrichment analysis was done on differentially expressed transcripts between 
treated and untreated cells. Shown are MLL and MYC gene signatures. NES, normalized enrichment score; 
FDR, false discovery rate. 
b)
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All three relapsed/refractory infants receiving bortezomib in combination with a four drug 
regimen had responses and were subsequently transplanted with either haploidentical or 
match unrelated donor transplants (Table 2). While the first two patients died of treatment 
related mortality, patient 3 achieved MRD negative status thirty days post-transplant 
following total body irradiation (TBI) conditioning with a cord blood donor. She remained 
in remission for 210 days post-transplant but subsequently relapsed, presenting with 
hyperleukocytosis. At that time she was reinduced with a five drug regimen including 
bortezomib, vorinostat, PEG asparaginase, dexamethasone, and mitoxantrone (Patient 3b, 
Table 4; Gruber et al., unpublished). With this single course she achieved MRD negative 
status by flow as well as deep sequencing (sensitivity 1:10,000 and 2:1,000,000 
respectively) following count recovery. She has subsequently been consolidated, undergone 
a second reinduction and is currently in maintenance. She remains MRD negative at greater 
than one year from the time of her relapse.  
We have subsequently treated eight additional relapsed MLLr leukemia patients that have 
failed one or more chemotherapy regimens with the combination of bortezomib, vorinostat, 
and mitoxantrone. Patients included ALL, AML and mixed lineage immunophenotypes. 
Combined, eight of nine MLLr patients have responded to this combination for an overall 
response rate of 88.9% (Table 4). This compares very favorably with recent relapsed ALL 
and AML trials that have reported CR rates between 40-65% using the same criteria of <5% 
leukemic blasts. 13,15,2613,15,26 Furthermore, the regimen was tolerated in this highly pretreated 
cohort that included patients post-transplant (Table 5). There was one Grade 5 toxicity 
secondary to a systemic adenoviral infection that was present prior to treatment. The patient 
tolerated the chemotherapy, however upon signs of count recovery, the patient worsened 
clinically and died secondary to cardiac failure.
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Table 4.  Clinical Activity of Bortezomib and Vorinostat in MLLr Leukemia 
Pre Treatment
Post Treatment
Chemo Doses
PBL
BMA1
PBL
BMA
Response2
Case
IP3
Age4
BTZ5
SAHA5
WBC
Blast
APC
Plt
Hgb
Blast
MRD
PCR6
WBC
Blast
APC
Plt
Hgb
Blast
MRD
PCR
1
ALL
7m
4
0
2.9
14%
2233
250
10.5
75%
94.9%
+++
0.3
0%
100
26
8.6
1%
3.23%
10-1
CRi
2
ALL
5m
4
0
92.9
95%
4400
63
8.5
ND
ND
ND
0.5
0%
300
45
7.4
12%
7.93%
10-3
PRi
3a7
ALL
10m
6
0
1.4
44%
182
22
8.3
83%
86%
10-2
2.7
0%
2619
209
10.2
0%
1.38%
10-3
CR
3b7
ALL
1.5y
8
12
83.5
73%
15865
255
10.9
83%
ND
10-1
2
0%
1320
60
11.1
2%
Neg
Neg
CRi
4
ALL
11y
8
12
3.1
4%
2046
52
9.3
74%
67%
+++
0.6
0%
90
30
9.3
60%
48.14%
+++
NR
5
AML
3.6y
6
12
0.8
0%
112
141
8
52%
68%
+++
1.9
0%
1121
99
8.9
0%
2%
10-1
CR
68
AML
1.6y
8
12
0.3
0%
100
73
10.4
46%6
23%
++
0.3
0%
100
28
9.6
26%
Neg
10-5
CRi
7
AML
9.25y
6
12
1.9
0%
798
175
10.2
8%
5.87%
ND
3.9
0%
3159
75
11.2
2%
Neg
10-4
CR
8
AML
2.3y
8
16
1.3
0%
1261
118
8.9
8%
12.8%
10-4
8.1
0%
8100
24
10.7
0%
0.28%
ND
CRi
9
Mixed
4.1y
6
12
1.6
3%
144
46
9.5
86%
78%
+++
0.4
0%
0
62
9.2
3%
0.997%
10-1
CRi
10
ALL
1.5y
8
16
15.6
2.3%
13104
204
10.3
46%
30.8%
++
3.1
0%
2852
183
8.1
0%
Neg
Neg
CR
11
ALL
17y
8
16
9.7
0%
7469
57
11.8
84%
ND
+++
0.1
0%
0
129
7.6
0%
Neg
Neg
CRi
1ND, not determined.
2Response criteria:  
CR <5% blasts by flow cytometry, ANC>500, Plts>75;  CRi <5% blasts by flow cytometry, ANC<500, Plts<75
PR 5-25% blasts by flow cytometry and a reduction of at least 50%, ANC>500, Plts>75;  PRi 5-25% blasts by flow cytometry and a reduction of at least 50%, ANC<500, Plts<75
3Immunophenotype by flow cytometry.
4Age at the time the chemotherapy course containing bortezomib and vorinostat were given.
5BTZ, bortezomib; SAHA, vorinostat.  Total number of doses given over the course of the treatment are indicated.  Patient 5 had two doses of bortezomib held secondary to neuropathy.
6PCR for the MLLr.  +++ strongly positive, ++positive.
7Patient 3 course a was pre-transplant, course b was post-transplant.
8Patient 6 had a severe systemic adenoviral infection prior to and post chemotherapy.  At the time of evaluation post treatment, while blasts were elevated, this was felt to be a recovering marrow given the negative MRD result 
by flow and PCR.
            Table 5.  Toxicity in MLLr Leukemia Patients Receiving Bortezomib and Vorinostat Containing Regimen
Chemo Doses
Case
IP
Age
BTZ
SAHA
Toxicity
Grade
1
ALL
7m
4
0
None
NA
2
ALL
5m
4
0
Fever and Neutropenia
3
3a
ALL
10m
6
0
VCR induced vocal cord paralysis
2
3b*
ALL
1.5y
8
12
Gram negative rod sepsis
Human metapneumovirus pneumonia
4
2
4
ALL
11y
8
12
None
NA
5
AML
3.6y
6
12
Urinary retention
2
6
AML
1.6y
8
12
Systemic adenovirus (pre-existing prior to initiation of treatment)
5
7
AML
9.25y
6
12
None
NA
8
AML
2.3y
8
16
None
NA
9*
Mixed
4.1y
6
12
Fungal infection (lungs and CNS)
VRE catheter related infection
4
2
10
ALL
1.5y
8
16
Upper respiratory infection 
Urinary retention
2
2
11*
ALL
17y
8
16
Neutropenic colitis
Enterococcus bacteremia
Fungal pneumonia
3
3
3
Patients receiving treatment upon relapse following one or more hematopoietic stem cell transplants are indicated with an asterisk (*).
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2.2
Rationale
2.2.1
Induction
Pre-clinical laboratory data and treatment of a small number of relapsed/refractory 
patients with MLLr demonstrates significant activity of bortezomib. H2Bub depletion, 
which silences the MLL transcriptional complex is reversible. Accordingly, responses in 
our first two patients that only received four doses of bortezomib were transient. We 
observed a more robust response with patient three who received six doses with her initial 
course. Vorinostat is synergistic with bortezomib in multiple models and demonstrated 
activity in our preclinical data.27 The addition of this drug in combination with 
bortezomib and standard chemotherapeutic agents led to MRD negativity by flow 
cytometry in five patients (Table 4). We therefore will incorporate both bortezomib and 
vorinostat into an induction backbone. The standard ALL induction regimen contains 
four drugs: a steroid, an anthracycline, vincristine, and asparaginase. Due to overlapping 
side effects with bortezomib and the under-recognized toxicity of vocal cord paralysis 
seen in infants, we have eliminated vincristine from our backbone. We do not feel this 
will compromise outcomes as it has been omitted in our ALL relapsed patients, 80% of 
whom (4/5) achieved CR/CRi. Furthermore, bortezomib has been shown to successfully 
replace vincristine in other hematologic malignancies.28 Bortezomib in combination with 
the standard induction backbone has been evaluated in the relapsed setting, however the 
addition of vorinostat to this combination has not.14,15 Therefore, we will use a 3+3 dose 
escalation phase for vorinostat, starting at 100mg/m2 per dose which is 55% of the 
defined pediatric maximum tolerated dose of 180mg/sqm.17  
Throughout treatment, patients will receive dexamethasone during times of steroid 
administration instead of prednisone. While evidence suggests that dexamethasone has 
superior cytotoxicity and CNS penetration compared to prednisone, prolonged continuous 
administration increases toxicity.29 We are therefore limiting the drug to 12 days total 
during induction. The schedule of dexamethasone has been altered to coincide with 
vorinostat/bortezomib administration. The alteration of dexamethasone will both limit 
dosing as well as provide synergy which has been demonstrated for these three classes of 
agents in laboratory studies.30 We have eliminated the prednisone prephase present in 
Interfant99 to bring up bortezomib and vorinostat on day 1 of treatment such that biologic 
correlate studies on the peripheral blood could be obtained that will be informative. 
Furthermore, patients with hyperleukocytosis will not run the risk of increasing WBC on 
prednisone monotherapy as they will receive additional chemotherapy upfront. 
Mitoxantrone has been chosen as our induction anthracycline based on data from the 
Medical Research Council (MRC) which found that it conferred a significant benefit in 
progression-free and overall survival in children with relapsed acute lymphoblastic 
leukemia as compared to idarubicin.13 Due to the high frequency of infants that present 
with hyperleukocytosis, mitoxantrone will be delayed until day 8 of our induction to 
allow for an initial reduction in tumor burden prior to its administration such that tumor 
lysis can be controlled.
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Although induction intensification with clofarabine was well tolerated on TOTXVI, we 
will replace this with a modified BFM based Protocol IB due to toxicity of clofarabine 
seen in the COG AALL1131 trial leading to closure of the clofarabine containing arm.  
Protocol 1B has been modified in that our patients will receive two weeks of this regimen 
as opposed to four. Furthermore, cyclophosphamide will be fractionated rather than 
administered as a single dose. Giving cyclophosphamide in this manner has improved 
end of induction MRD levels in TOTXVI when compared to TOTXV patients that 
received cyclophosphamide as a single dose (data not shown). Response to therapy will 
be assessed on day 22 to assess response to our study drugs, and at the end of induction 
intensification upon count recovery.  
TOTXV has proven that preventive cranial irradiation can be safely eliminated in 
childhood ALL irrespective of risk group with intensification of CNS-directed and 
systemic chemotherapy2. As the side effects of cranial irradiation are more profound in 
younger infants and patients with MLLr have a higher propensity of CNS relapse, we 
have continued to treat infants with intensified intrathecal (IT) chemotherapy on 
TOTXVI. Patients with CNS1 disease will receive weekly IT for a total of four doses 
while those with CNS2/3 disease will get two additional doses on days 4 and 11. The 
administration of leucovorin rescue at 24 and 30 hours post each IT is critical to prevent 
unwanted side effects such as seizures.
We recognize that the induction regimen is intensive. As such all patients are required to 
remain inpatient until count recovery following induction intensification with supportive 
care that includes prophylactic antibiotics. This is the current practice for children with 
AML and we feel the intensity of therapy and risk for infectious complications are on par 
if not greater than the pediatric AML population. In comparison to the COG infant trial 
AALL0631 pre-amendment, which experienced significant infectious toxicities, our 
cumulative anthracyclines, steroids, and vincristine dosing are less, while PEG 
asparaginase is equal (Table 6). Additionally, AALL0631 did not require an inpatient 
stay or prophylactic antibiotics other than trimethoprim/sulfamethoxazole (TMP/SMZ).  
For infants less than 30 days of age or less than 3 months of age and significantly 
premature, anthracyclines, PEG-asparaginase and cyclophosphamide during induction 
intensification will be administered at a 50% dose reduction. Using these measures, in 
addition to strict adherence of supportive care guidelines, we are confident the regimen 
will be well tolerated based on the number of infants we have treated at St. Jude.  
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Table 6.  Comparison of Infant Induction Regimens1
Interfant 99
AALL0631 Pre-amend
TINI
Drug
Details
Cum
Details
Cum
Details
Cum
Steroid2
Pred 60 mg/m2 d1-7
Dex 6 mg/m2 d8-29
1208 mg/m2
Pred 40 mg/m2 
d1-21
840/m2
Dex 10 mg/m2 
d1-4,8-11, 15-18
750 mg/m2
VCR
1.5 mg/m2
d8, 15, 22, 20
0.2 mg/kg
0.05 mg/kg d1, 15
0.03 mg/kg d8
0.13 mg/kg
NA
NA
Anthra3
Dauno 30 mg/m2 
d8,9
1.67 mg/kg
Dauno 2.6 mg/kg 
d1,2
4.33 mg/kg
Mito 0.27 mg/kg 
d8,9
2.16 mg/kg
PEG
Elspar 10,000 U/m2 
d15,18,22,25,29,33
60,000 U/m2
PEG 2500 U/m2 
d4
2500 U/m2
PEG 2500 U/m2 
d5
2500 U/m2
AraC
75 mg/m2 d8-21
1050 mg/m2
NA
NA
NA
NA
Bortez
NA
NA
NA
NA
0.043 mg/kg 
d1,4,8,11,15,18
0.258 
mg/kg
SAHA4
NA
NA
NA
NA
180 mg/m2 d1-4, 
8-11, 15-18
2160 
mg/m2
1Induction intensification is omitted from this table
25mg prednisone = 0.8mg dexamethasone conversion
3doxorubicin equivalents (daunorubicin=0.833, mitoxantrone=4);  mg/m2 dosing converted to mg/kg using the rule of 30.  
4Dose level 3 is shown in this table.  For dosing during the run in dose escalation phase, see section 4.2 and 14.1
2.2.2
Consolidation
Consolidation therapy is comprised of high dose methotrexate (HDMTX; average of 
5g/m2 over 24 hours) given every other week for 4 doses with leucovorin rescue. The 
feasibility and effectiveness of HDMTX at 5g/m2 has been documented in large number 
of patients treated on TOTXV in addition to the BFM and AIEOP cooperative studies. 
Specifically, outcomes in infants treated on BFM and POG regimens improved with the 
addition of HDMTX.31  Studies suggest that while HDMTX at 2.5g/m2 is sufficient for 
most ALL cases, non-hyperdiploid B lineage blasts accumulate more methotrexate 
polyglutamates with high dose than low dose methotrexate.32 The goal is to provide 
average therapeutic systemic exposure that is achieved with 5g/m2 while minimizing 
toxicity. Therefore, we will target dosing to a range of 65uM ± 20%. Using this approach 
on TOTXV we observed only 5.1% of courses with grade 3-4 mucositis (compared to as 
high as 44% of courses with BFMs administration of 5g/m2 without targeting). All 
patients will receive 5g/m2 over 24 hours for the first course and methotrexate levels will 
be drawn at 6, 23, 42, and every 24 hours thereafter from the start of infusion until the 
level is <0.1 uM.  Levels will be reported to the study chair following clearance and 
dosing recommendations will be given for the next course and each of the subsequent 
courses. This approach has been successful for the six infants treated on TOTXVI, with 
only one patient experiencing grade 3-4 mucositis during the first course and 
improvement with subsequent courses due to dosing modifications. It is recommended 
that patients achieving MRD negative status at the end of Consolidation not be referred to 
stem cell transplant in first remission. However, patients that are MRD positive during 
Consolidation but whom achieve MRD negative status at the end of Consolidation may 
be referred to stem cell transplant following Reinduction if the treating physician and the 
family agree that this is in the best interest of the patient.
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2.2.3
Reinduction
The inclusion of a reinduction phase has been demonstrated to improve outcomes in both 
low and high risk ALL.  
We have limited this regimen to one reinduction with the following rationale:

Infants on Interfant99 did not see an improvement in outcome for patients that 
received a second intensification phase.

Infants on Interfant99 that were MRD negative prior to the second intensification 
phase had a low rate of relapse (17% vs. 71% in MRD+ patients). Patients who 
remain MRD positive following reinduction on this protocol are eligible for 
transplant if a suitable donor is available. Thus, their therapy will be intensified 
accordingly.

Due to induction intensification, patients receive 134 days (~4.5 months) of 
intensive chemotherapy prior to maintenance on this protocol. By limiting 
reinduction courses to one, we hope to avoid the additional toxicity a second 
course would cause. Close monitoring of MRD as indicated above will allow us to 
identify patients at higher risk for relapse and these patients will go on to 
transplant following Reintensification.
The majority of infants that relapse, do so within a year of diagnosis. Therefore, to 
intensify therapy early in an attempt to eradicate persistent clones we will reinduce 
patients immediately following consolidation. The reinduction course is identical to 
induction with three exceptions: induction intensification has been eliminated, 
mitoxantrone has been moved up to day 1, and we have intensified PEG-asparaginase to 
include two doses. During the run in dose escalation phase, vorinostat dosing will the 
same as that received during induction (see section 4.4 and 14.1).
2.2.4
Reintensification
Patients with MRD > 0.01% on day 1 of Reinduction, OR patients with increasing MRD 
during Consolidation represent a high risk population that cannot be cured with 
chemotherapy alone. Patients that achieve MRD negative status following Reinduction 
may proceed directly to stem cell transplant if a suitable donor is available. Patients that 
remain MRD positive following Reinduction are considered upfront refractory and 
therefore may either receive chimeric antigen receptor (CAR) T cells if available, or 
proceed to a Reintensification phase followed by hematopoietic stem cell transplant.33 To 
introduce agents not yet seen during the treatment regimen, the BFM HR3 block, which 
includes high dose cytarabine and etoposide will be given34. All aspects of the 
hematopoietic stem cell transplant including but not limited to the conditioning regimen, 
donor selection, and GVHD prophylaxis will be at the discretion of the transplant 
physicians.
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2.2.5
Maintenance
Maintenance chemotherapy is comprised of the standard antimetabolite based regimen 
and vincristine and steroid pulses used in many pediatric cooperative group studies. 
Weekly low dose intravenous methotrexate will be held on weeks when patients get 
intrathecal therapy due to the risk of increased neurotoxicity when administered 
concurrently.35 80% of infants with MLLr ALL relapse within the first few years after 
diagnosis while on treatment; in keeping with this Interfant 99 treated non-high risk 
patients for 2 years duration from the date of diagnosis and observed few events for 
patients achieving MRD negative status at either 5 or 9 weeks into therapy.1,12 We have 
therefore limited the duration of maintenance chemotherapy to 20 cycles of 28 days each, 
for a total duration of therapy of 686 days = 1.9 years. Patients with CNS disease at 
diagnosis will receive more frequent intrathecal therapy than those who are CNS1.
2.2.6
Summary of TINI therapy
Total duration of therapy:  686 days = 1.9 years
Cumulative anthracyclines:  160 mg/m2 doxorubicin equivalents
ITMHA:  CNS1 – 17 doses, CNS2 – 20 doses, CNS3 – 23 doses
Study drugs:
Bortezomib:  12 doses
Vorinostat:  24 doses
2.3
Background and Rationale for Correlative Research Studies
2.3.1
Monitoring of MRD and Immune Repertoire
The current standard of care for MRD detection utilizes flow cytometry that carries  a 
sensitivity of 10-4. At St. Jude, we supplement this with quantitative RT-PCR detection 
of MLL fusion transcripts for cases that cannot be followed by flow cytometry or 
aspirates with hypocellular marrows where quantitation by flow is challenging due to 
limiting numbers of cells. Recently, next generation sequencing of T cell and B cell 
receptor variable regions has been used to monitor MRD with a sensitivity of up to 10-
6.36,37 The prognostic significance of MRD levels less than 10-4 have yet to be defined.  
We have established an in house assay to measure lymphocyte clonality by massive 
parallel next generation sequencing of rearranged immune receptor loci (both complete 
and partially rearranged alleles).  =We will utilize this assay to evaluate MRD status at 
multiple time points, correlate with flow cytometry and RT-PCR assays, and determine 
if there is a prognostic significance in this subtype of leukemia. As this is an 
exploratory aim and our assay is not CLIA-certified, deep sequencing results will not 
be reported back to families nor treating physicians and will be used for research 
purposes only.  
In addition to MRD detection, this technique allows the determination of immune 
diversity, providing a platform in which to monitor each patient’s lymphocyte repertoire. 
A diverse repertoire provides an individual with the ability to mount an immune response 
against an infectious agent. Infectious complications are a major source of morbidity and 
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mortality in infants with ALL and are felt to be a result of an immature immune system 
combined with immunosuppression secondary to chemotherapy. It is unclear, however, 
why some patients exhibit mild to moderate symptoms during an infection while others 
experience severe and often life threatening symptoms. We hypothesize that the diversity 
of a patient’s repertoire correlates with rate and severity of infectious complications. To 
evaluate this, we will obtain 2.5 ml of peripheral blood at multiple time points during 
therapy to measure and monitor lymphocyte repertoire over the course of treatment.
2.3.2
Next Generation Sequencing
Whole genome sequencing of MLLr infant ALL revealed a paucity of somatic mutations.  
None the less, activating mutations in tyrosine kinases/PI3K/RAS pathway genes were 
detected in 48% of cases.7 Surprisingly, however, these mutations were often present in 
only a minor sub-clone and were frequently lost at the time of relapse. Furthermore, in our 
small sample size we failed to identify any prognostic significance of these cooperating 
mutations in contrast to a previous report that identified RAS mutations as an independent 
predictor for poor outcome with a hazard ratio of 3.194.38 This may reflect our smaller 
sample size (48 vs. 109) or components of the treatment regimen received. To further 
define the genomic landscape and clarify the role of tyrosine kinase mutations we will 
comprehensively sequence leukemia cells from all patients enrolled by whole genome 
(WGS), whole exome (WES) and RNA sequencing (RNAseq). The use of WGS, which 
identifies all mutations in the genome (coding and noncoding regions) will provide us with 
sufficient mutant alleles to analyze persistent subclones in MRD positive patients by 
targeted capture with deep sequencing. Thus allowing us to correlate genetic composition 
with response to treatment at a higher sensitivity than standard overall outcome measures 
by identifying clones that demonstrate resistance to chemotherapeutic agents. Targeted 
capture and deep sequencing to identify persistent subclones using mutations identified at 
diagnosis will also be done. All next generation sequencing will be done in a research 
setting, and will not be used for clinical decision making as the significance and 
contribution to relapse remain unknown.
2.3.3
Measurement of Epigenetic Changes in Response to Bortezomib and Vorinostat
Our preclinical data demonstrates alterations in histone ubiquitination and methylation in 
response to treatment of cells with bortezomib. Additionally, vorinostat’s primary 
mechanism of action is through the inhibition of histone deacetylases. Therefore, to 
verify target inhibition and monitor the response of leukemic blasts to these agents, we 
will measure levels of histone acetylation, ubiquitination, and methylation by flow 
cytometry. Consenting patients will have peripheral blood specimens drawn prior to 
therapy, at 24 hours following administration of bortezomib and vorinostat and on day 
four.  
2.3.4
NFkB Activity and Proteasome Inhibition in Response to Bortezomib
Proteasome inhibition and NFkB activity will be assessed in peripheral blood before 
chemotherapy, 6h and 24h after bortezomib administration by ImageStream 
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cytometry.39,40 This technique allows a more sensitive measurement of NFkB activity and 
will evaluate proteasome target inhibition.
2.3.5
In Vitro Drug Sensitivity
We have established in vitro and in vivo assays to evaluate drug sensitivity of primary 
infant ALL patient samples as described in section 2.1. As proof of principle, we utilized 
this system to evaluate 30 chemotherapeutic agents. Our preliminary data suggests this 
system can identify compounds with clinical activity. We are currently using this system 
to screen >10,000 compounds including FDA approved drugs, known 
bioactives/scaffolds, as well as rare scaffolds and natural products. We will select 50-100 
compounds that have the greatest activity and test sensitivity of all patient samples 
received (including relapsed specimens). Agents with promise will then be selected for 
further study with a goal of identifying compounds that can be developed and brought to 
clinical trial in the relapsed setting.
3.0
ELIGIBILITY CRITERIA AND STUDY ENROLLMENT 
According to institutional and NIH policy, the study will accession research participants 
regardless of gender and ethnic background. Institutional experience confirms broad 
representation in this regard.
3.1
Inclusion Criteria
3.1.1
Patient is < 365 days of age at the time of diagnosis.
3.1.2
Patient has newly diagnosed acute lymphoblastic leukemia (ALL) or acute 
undifferentiated leukemia with ≥25% blasts in the bone marrow (M3), with or 
without extramedullary disease.  Patients with T-cell ALL are eligible.  Patients 
with bilineage or biphenotypic acute leukemia are eligible, provided the 
morphology and immunophenotype are predominantly lymphoid.
3.1.3
Limited prior therapy, including hydroxyurea for 72 hours or less, systemic 
glucocorticoids for one week or less, one dose of vincristine, and one dose of 
intrathecal chemotherapy.  
3.1.4
Written informed consent following Institutional Review Board, NCI, FDA, and 
OHRP Guidelines.  
3.2
Exclusion Criteria
3.2.1
Patients with prior therapy, other than therapy specified in 3.1.3.
3.2.2
Patients with mature B-cell ALL or acute myelogenous (AML).
3.2.3
Patients with Down syndrome.
3.2.4
Inability or unwillingness of legal guardian/representative to give written 
informed consent.
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3.3
Research Participant Recruitment and Screening
19 institutions will collaborate in the proposed project: St. Jude Children's Research 
Hospital (SJCRH), Children’s Hospital Los Angeles, Texas Children’s Hospital 
(correlative research only), Children’s Hospital of Minnesota, Rainbow Babies and 
Children's Hospital, Rady Children’s Hospital San Diego, Children’s Hospital of 
Michigan, Cincinnati Children’s Hospital and Medical Center, Lucile Packard Children's 
Hospital, Doernbecher Children's Hospital, Children’s Hospital of Orange County, 
Novant Health Hemby Children’s Hospital, Children’s Hospital-King’s Daughters, BC 
Children’s Hospital, CHU Sainte-Justine, McMaster Children’s Hospital, Alberta 
Children’s Hospital, Montreal Children’s Hospital, Children’s Hospital of Eastern 
Ontario, and Stollery Children’s Hospital Edmonton, Alberta.
3.4
Enrollment on Study at St. Jude
Eligibility will be reviewed for completeness and corrected by the study team. A research 
participant-specific consent form will be released for participant/parent signature.  
The study team will enter the Participant Eligibility checklist information into the central 
enrollment system and release the informed consent document. The signed consent form 
must be faxed  to 
 or scanned and emailed the Clinical Trials Operations 
(CTO) office at 
in order to complete enrolment.
To assist with enrollments and consent release, the CTO staff is available Monday 
through Friday. After hours, weekends, and holidays, the study team is referred to the 
CTO webpage for additional resources and instructions, Link:  
  
3.5
Enrollment on Study at Collaborating Sites
Before the collaborating or enrolling affiliate sites screen or enroll a study participant, the 
site completes a RIN request form and submits it to CTO by e-mail: 
 or fax 
 (follow fax by a phone call to 
 
 to ensure receipt). A RIN is an eight-digit automated number beginning with an 
“R”. Once the form is received, St. Jude will register the research participant and then 
email the RIN to the email address provided on your registration form. This will register 
the participant only; it will not enroll the participant on the study. After hours, holidays, 
and weekends the site RIN request will be answered by the Patient Registration team. 
To enroll the study participant, after the RIN is obtained, the site study team will 
complete an eligibility checklist and scan and email to the CTO at 
 or fax it to 
 (follow fax by a phone 
call to 
 to ensure receipt). Clinical Trials Operations (CTO) will enter the 
Eligibility Checklist information into the central enrollment system to officially enroll the 
participant on the trial. Collaborating sites are not required to forward a fully executed 
(signed) Informed Consent Form to St. Jude. 
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4.0
TREATMENT PLAN
4.1
Overview of Therapy
Phase
Treatment
ITMHA 1, 4*, 8, 11*,15, 22 (*CNS2/3) with leucovorin rescue
Dexamethasone 10mg/m2/day divided BID PO/NG/IV Days 1-4, 8-11, 15-18
Vorinostat see dose escalation plan PO/NG Days 1-4, 8-11, 15-18 
Bortezomib 0.043mg/kg/dose IV Days 1, 4, 8, 11, 15, 18
PEG-asparaginase 2500units/m2/dose IV Day 5
Mitoxantrone 0.27mg/kg/dose IV Days 8, 9
Cyclophosphamide 300mg/m2/dose IV Q12 hours x 4 doses Days 22-23
Cytarabine 75mg/m2 IV Days 23-26, 30-33
Induction
(~42 days)
6MP 50mg/m2 PO/NG Days 22-35
ITMHA Days 1, 15, 29, 43
HDMtx 5g/m2 IV (targeted to 65uM) Days 1, 15, 29, 43 
Consolidation
(~56 days)
6MP 25mg/m2 PO/NG Days 1-56
IT MHA Day 1, 15* (*CNS3)
Mitoxantrone 0.27mg/kg/dose IV Days 1, 2
PEG-asparaginase 2500units/m2/dose IV Days 3, 18
Dexamethasone 10mg/m2/day divided BID PO/NG/IV Days 1-4, 8-11, 15-18
Bortezomib 0.043mg/kg/dose IV Days 1, 4, 8, 11, 15, 18
Reinduction
(~36 days)
Vorinostat see dose escalation plan PO/NG Days 1-4, 8-11, 15-18
ITMHA Day 5
Dexamethasone 20mg/m2/day divided BID PO/NG/IV Days 1-5
Cytarabine 2g/m2/dose Q12H x 4 doses Days 1, 2
Etoposide 100mg/m2 Days 3-5 (see dosing table 4.5.3)
Reintensification
(~28 days)
If MRD>0.01% on 
Reinduction Day 1 OR 
increasing MRD 
during Consolidation
PEG-asparaginase 2500units/m2/dose IV Day 6
ITMHA Day 1* (*cycles 1-8 for CNS1; cycles 1-11 CNS2; cycles 1-13 for CNS3)
Decadron 6mg/m2/day divided BID PO/NG/IV Days 1-5
VCR 0.05mg/kg/dose IV Day 1
6MP 50mg/m2 PO/NG Days 1-28
Maintenance
(20 cycles, 
28 days each)
Methotrexate 40mg/m2/dose IV/IM/PO Days 1*, 8, 15, 22 (*cycles with no IT MHA 
only)
Weight and height measurements for dosing calculations should be done with each phase of 
therapy for the purpose of chemotherapy dosing calculations during that cycle of chemotherapy. 
Every effort should be made to record accurate measurements as small errors can result in 
significant dosing changes for patients less than 10kg. Within each phase, no dose adjustment is 
needed if changes in the patient’s BSA/dosing weight results in a change of less than 15% in the 
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drug dose. For patients that have a significant change in weight during a chemotherapy cycle 
requiring new dosing calculations, the new BSA/dosing weight should be double checked by 
another individual to verify accuracy.   
The timing and duration for administration for all agents are provided in the treatment phase 
sections as guidelines only. Variations in the timing and duration of chemotherapy infusions 
according to institutional practice or variations based on patient care needs are acceptable, as 
long as the treating investigator and/or PI determines that there was no impact on patient safety. 
These variations will not be considered protocol deviations, as long as the total dose is given 
within 10% of protocol specified dose calculated at the beginning of the treatment phase.
Complications during treatment may result in chemotherapy doses and/or procedures being held 
or delayed. These variations based on patient care needs are acceptable and will not be 
considered protocol deviations. Please contact the principal investigator for any questions 
regarding chemotherapy drug delays or omissions based on the clinical status of a patient.  
Efforts should be made to perform all procedures on the days specified in the protocol. 
Modifications due to scheduling difficulties, weekends and holidays, or the clinical status of a 
patient are acceptable and not considered protocol deviations.
4.2
Remission Induction
4.2.1
Remission Induction Intrathecal Chemotherapy
As a traumatic lumbar puncture at diagnosis may result in a poorer outcome and the need 
for extra intrathecal therapy subsequently, all diagnostic lumbar punctures will be 
performed by experienced personnel, preferably under general anesthesia or deep 
sedation. Triple intrathecal chemotherapy (MHA) will be administered immediately after 
cerebrospinal fluid is collected for diagnosis. 
Frequency and total number of triple intrathecal treatments for Remission Induction is 
based on the patient's risk of CNS relapse, as follows:

All patients will receive triple intrathecal treatment on days 1, 8, 15 and 22.

Patients with any of the following features will receive additional triple intrathecal 
treatment on days 4 and 11:
o
CNS3 status (i.e., ≥5 WBC/L of CSF with blasts or cranial nerve palsy)
o
CNS2 status (<5 WBC/L of CSF with blasts)
o
Traumatic LP (>10 RBC/L of CSF with blasts)
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Dose throughout the treatment protocol is based on age, as follows:
Age
Methotrexate (mg)
Hydrocortisone (mg)
Cytarabine (mg)
Volume (ml)*
< 12 months
6
12
18
6
12-23 months
8
16
24
8
24-35 months
10
20
30
10
> 36 months 
12
24
36
12
*Centers may use their institutional standard volumes for intrathecal chemotherapy provided the 
methotrexate, hydrocortisone, and cytarabine doses are as specified in the table.
Leucovorin rescue (5mg/m2/dose, max 5mg) PO or IV will be given at 24 and 30 hours 
after each triple intrathecal treatment during induction. Follow plasma methotrexate 
levels (starting 24 hours after intrathecal therapy and until level becomes undetectable) in 
patients with renal dysfunction or extra fluid in third space, and rescue with leucovorin 
according to PharmD recommendation. 
Intraventricular chemotherapy via Ommaya catheter may be used in place of intrathecal 
therapy delivered by LP. Intraventricular chemotherapy should be given according to the 
same schedule, but at 50% of the corresponding age-based doses for methotrexate 
and cytarabine that would be given by LP.  Hydrocortisone dosing does not require 
adjustment. We recommend using a total volume of 2 mL for patients less than 35 
months and 3 mL for 36 months or greater for chemotherapy administered via Ommaya 
catheter.
4.2.1
Dose Escalation Cohort
Vorinostat, initially at 100mg/m2/day will be administered on days 1-4, 8-11, and 15-18 
and escalated based on tolerability. A classical 3-on-3 dose escalation will be done as a 
run-in phase. Three patients will be enrolled sequentially at the 100mg/m2/day level.  At 
any of the first two dose levels (100mg/m2 or 150mg/m2), if no dose limiting toxicity 
(DLT) is observed then we will move on to the next higher does level; if there is 1 DLT 
then we will enroll 3 more patients at the same dose level, if there is no more DLTs we 
will then move to the next higher dose level, otherwise deem the current dose level too 
toxic and use the dosage at one level lower as the maximum tolerated dose (MTD). If at 
any dose level 2 or more DLTs occur, we will deem the current dose level too toxic and 
use the dosage at one level lower as the MTD. If the 100mg/m2 level is deemed 
intolerable (2/3 or 2/6 DLTs)  then  we move to dose level -1. If we escalate the dose to 
the highest dose level at 180mg/m2 and it is tolerated (0/3 or 1/6 DLT), then this dosage 
will be used for the remaining patients as the MTD.  Patients that are part of the dose 
escalation cohort will receive the same vorinostat dosing for induction and reinduction.  
Dose Level
Vorinostat Dosing
-1
75mg/m2/day
1*
100mg/m2/day
2
150mg/m2/day
3
180mg/m2/day
     *starting dose level
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4.2.1.1 Definitions of Dose-Limiting Toxicities (DLT)
Toxicities will be graded according the CTEP Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0. DLT is based on non-hematologic toxicities that 
occur during induction (planned for 42 days). All three subjects in a cohort must 
complete the DLT monitoring phase before accrual may resume during the dose 
escalation phase. Please note elective intubation for procedures and as a precaution in 
infants with hyperleukocytosis will not be considered a DLT.
Non-Hematologic DLT

Any Grade 5 event, unless the event is clearly and incontrovertibly due to 
extraneous causes or disease progression

Any Grade 4 event , unless the event is clearly and incontrovertibly due to 
extraneous causes or disease progression with the exception of the following:
o
Grade 4 infection or fever
o
Grade 4 elevation in hepatic transaminases, alkaline phosphatase, GGT, 
bilirubin, amylase, lipase, and triglycerides
o
Grade 4 electrolyte disturbances that resolve to < grade 3 within 24 hours.
o
Grade 4 electrolyte disturbances due to tumor lysis
o
Grade 4 hyperglycemia or hypoglycemia that resolve to < grade 3 within 
24 hours
o
Grade 4 intracranial hemorrhage secondary to hyperleukocytosis
o
Grade 4 pulmonary leukostasis syndrome
o
Grade 4 acute kidney injury due to tumor lysis 
o
Grade 4 seizures secondary to intrathecal chemotherapy
o
Grade 4 leukoencephalopathy secondary to intrathecal chemotherapy
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4.2.2
Remission Induction Chemotherapy
Agent
Dosage
Route
Days
# Doses
Mitoxantrone
(MITO)
0.27 mg/kg/dose
IV
Days 8, 9
2
PEG-asparaginase 
(PEG-ASP)
2500 international 
units/m2/dose
IV*
Day 5
1
Dexamethasone
(DEX)
10 mg/m2/day 
divided BID
PO/NG
(may give IV)
Days 1-4,8-11,15-
18
24
Bortezomib
(BORT)
0.043 mg/kg/dose
IV (may give subQ)
Days 1,4,8,11,15,18
6
Vorinostat
(VORINO)
see dose escalation 
plan
PO/NG
Days 1-4,8-11,15-
18
12
Cyclophosphamide
(CYCLO)
300 mg/m2/dose
IV Q12H
Days 22-23
4
Cytarabine
(ARAC)
75 mg/m2/dose
IV
Days 23-26,30-33
8
Mercaptopurine
(6MP)
50 mg/m2
PO/NG
22-35
14
* Intravenous is the preferred method of PEG-asparaginase administration as anaphylactic reactions are 
extremely rare in infants and intramuscular injection can lead to hematomas.  See Section 5.4 for 
intramuscular administration, if applicable.
Bone marrow exam will be performed at diagnosis, Day 22 and at end of Remission 
Induction upon count recovery with day 1 Consolidation procedures. Patients with residual 
leukemia identified on Day 22 should receive cyclophosphamide, mercaptopurine, and 
cytarabine as scheduled if their clinical condition permits, regardless of their ANC. For 
other patients, the treatment may be delayed for 3 to 7 days to allow some degree of 
hematopoietic recovery if APC (ANC + monocyte) <300/mm3. When possible, specimens 
should be shipped overnight Sunday-Thursday such that they are received by St. Jude 
Monday-Friday. If shipping on Friday or Saturday, please notify the study PI so that 
personnel can be called in to process the specimen on weekends and holidays. See section 
8.2 for acceptable alternate timing of bone marrow examinations.
4.2.2.1 Dose modifications for infants < 30 days of age or < 3 months of age and 
significantly premature, as defined by born at less than 35 weeks gestation.

Mitoxantrone and PEG-asparaginase will be at 50% dosing.

Cyclophosphamide will be at 50% dosing for patients less than 30 days of age at 
the time cyclophosphamide is due, or for infants that are less than 3 months of age 
that are significantly premature.
 
4.2.2.2 Cyclophosphamide administration
Patients should receive D5 0.45% NaCl at 2250 ml/m2/24 hours (=94ml/m2/hr) on days 
22-23 during cyclophosphamide administration. Hydration should be initiated 2 hours 
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prior to the first dose of cyclophosphamide and continued 12 hours after the final dose of 
cyclophosphamide. There is no need to measure urine specific gravity. 
Cyclophosphamide doses should be administered over 30 minutes. For patients with 
microscopic hematuria (or a history of microscopic hematuria), mesna may be given at 
20% of the cyclophosphamide dose immediately before (or mixed with) 
cyclophosphamide infusion, and again 4 and 8 hours after the start of the infusion. 
Alternatively, 60% of the cyclophosphamide dose may be given as an 8 hour continuous 
infusion beginning when cyclophosphamide infusion starts.
4.2.2.3 Vorinostat liquid administration
A suspension can be prepared locally by mixing 20 mL of OraPlus with the contents of 
twenty 100 mg vorinostat capsules in a 4 ounce glass bottle. After shaking for up to 3 
minutes to disperse, add 20 mL of OraSweet. Shake the container to disperse, resulting in 
a final concentration of 50 mg/mL. The suspension should be stored at room temperature 
for a maximum of 4 weeks.  Smaller volumes can be prepared to avoid wasting capsules.  
If the calculated dose can be accurately dispensed, then this dose should be administered.  
If the calculated dose cannot be accurately dispensed, then the dose may be rounded to 
the nearest 5 mg (0.1 mL) provided it is within 10% of the calculated dose. See also 
Appendix III.
4.2.2.4 Treatment modifications
Patients who have hyper leukocytosis, evidence of liver dysfunction at diagnosis 
secondary to leukemia infiltration, or are unable to initiate treatment for other clinical 
reasons may begin with steroid monotherapy until they are clinically stable to begin 
induction. The choice of steroid, dose, and duration of monotherapy are at the discretion 
of the treating physician and study team. For patients in which the treating physician is 
initiating steroid monotherapy, the principal and co-principal investigators should be 
notified of the reasons and rationale within 24 hours. Induction dexamethasone dosing will 
not be omitted in these patients, they will receive the full dosing schedule, e.g. this steroid 
administration will be in addition to induction chemotherapy.
See Section 6.0 for treatment modifications for mitoxantrone, bortezomib and PEG-
asparaginase.
4.2.2.5 Supportive care requirements:

Inpatient during Induction until signs of count recovery with a minimum ANC of 
200. We recommend an ANC of at least 300 for two consecutive days for 
discharge criteria, however this is at the discretion of the treating physician and 
therefore small differences in ANC values at the time of discharge will not be 
considered protocol deviations or violations.

IVIG for patients that have total immunoglobulin level of less than 400 mg/dL
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
Micafungin at treatment dosing (4mg/kg IV Q24 hours) or caspofungin at treatment 
dosing (see section 10.10) and cefepime at prophylactic dosing (50mg/kg IV Q12 
hours) for all patients until APC ≥500/mm3 for two consecutive days

Patients unable to receive cefepime due to drug shortage, allergy, or other cause 
should receive an alternative antibiotic with similar bacterial coverage. Patients who 
are discharged with an ANC of >200 but less than 500 may be sent out on oral 
levofloxacin without fungal coverage to facilitate a feasible outpatient regimen.

Synagis prophylaxis during RSV season

Patients with mucositis should be evaluated for herpes simplex infection and 
treated with acyclovir or famciclovir if work-up is positive

PCP prophylaxis with TMP/SMZ should begin on day 15 of induction therapy 
and continue until the patient is 3 months off therapy.  In patients who are allergic 
or who demonstrate significant cytopenias secondary to TMP/SMZ, intravenous 
pentamidine every 4 weeks may be substituted. Patients less than 2 months of age 
should receive pentamidine every 4 weeks as TMP/SMZ is contraindicated.

GM-CSF and/or G-CSF should not be administered to aid in count recovery. 
Growth factor administration is reserved for patients with severe infections that 
are not predicted to recover in the near future. Please contact the PI for approval 
prior to initiating.
4.2.2.6 End of Induction Response:  
A bone marrow aspirate will be performed at the end of remission induction upon count 
recovery with the day 1 consolidation LP. If the date falls on a Friday, week-end or 
holiday such that the bone marrow specimen will not be received by St. Jude Monday-
Friday, the procedure may be performed on closest working day that allows the specimen 
to be received during the work week. MRD level will be determined on this bone marrow 
sample.  
4.3
Consolidation Chemotherapy
Agent
Dosage
Route
Days
# Doses
High-dose 
Methotrexate
(HDMTX)
5g/m2 IV 
(targeted to 65uM)
IV
Days 1, 15, 29, 43
4
Mercaptopurine
(6MP)
25 mg/m2
PO/NG 
1-56
56
ITMHA
See section 4.2.1
IT
Days 1, 15, 29, 43
4
4.3.1
Criteria for Starting Consolidation
When ANC >500/mm3, WBC 1000/mm3, and platelet count 50 x 109/L, consolidation 
treatment will be started, comprised of high dose methotrexate (every other week for 4 
doses), daily mercaptopurine and IT chemotherapy on the same dates of high dose 
methotrexate (see section 5.3.4).  
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4.3.2
Mercaptopurine Administration
Mercaptopurine should be taken daily at approximately the same time. Due to recent data 
that commonly-practiced restrictions surrounding 6MP ingestion (i.e., taking medication 
only in the evening without food/dairy) might not influence outcome and the difficulty in 
withholding feeds in infants, these restrictive practices are not required.41 In patients for 
whom high dose methotrexate treatment is delayed, mercaptopurine may be continued 
until 14 days after the last course of high dose methotrexate. Mercaptopurine may be held 
in the presence of ANC <500/mm3, WBC <1,000/mm3, platelet count <50 x 109/L or 
grade 3 or 4 mucositis. Mercaptopurine may be resumed once mucositis has resolved. 
Dosage of mercaptopurine in subsequent courses may be reduced to 12.5 mg/m2/day in 
patients who have prolonged neutropenia after high dose methotrexate and 
mercaptopurine treatment.  
4.3.3
High-Dose Methotrexate (HDMTX) Administration
High-dose methotrexate (HDMTX) administration: Patients will receive 5 gm/m2, (or a 
dose targeted to achieve a steady-state plasma concentration of 65 uM) administered over 
24 hr intravenously. The subsequent courses of high dose methotrexate and intrathecal 
treatment will be delayed if ANC <500/mm3, WBC < 1000/mm3, platelet count < 50 x 
109/L, SGPT >500 U/L, total bilirubin >2 mg/dl and direct bilirubin >1.4 mg/dl, or 
mucositis is present. Sodium bicarbonate may be given orally at 1 gm/m2 every 6 hours 
or intravenously with pre-hydration fluid starting the day before high dose methotrexate.  
Methotrexate levels will be drawn at 6, 23, 42, and every 24 hours thereafter from the 
start of infusion until the level is <0.1 uM. Following each course, methotrexate levels 
will be evaluated by a St. Jude clinical pharmacist and a recommended dose will be given 
for the subsequent course to achieve the targeted concentration. Methotrexate levels, 
associated lab values, leucovorin dosing and adverse events during consolidation will be 
maintained in a targeting database within the department of pharmaceutical sciences at 
St. Jude Children’s Research Hospital for the purpose of exploratory objective 1.3.9. 
Pre-hydration: At least two hours before high dose methotrexate, prehydration IV fluid 
(D5W + 40 mEq NaHCO3/L + 20 mEq KCl/L) will be administered at the rate of 200 
ml/m2/hr. At start of prehydration, one IV dose of NaHCO3 (unless otherwise clinically 
indicated, 25 mEq/m2) will be given. Prehydration fluid may also be given overnight at a 
rate of at least 125 ml/m2/hr. High dose methotrexate treatment will follow, provided that 
urinary pH is >/=6.5; exceptions must be cleared with the pharmacokinetics service and 
the attending physician.
High-dose methotrexate infusion: A 10% methotrexate loading dose will be given over 1 
hour, followed immediately by maintenance infusion over 23 hours of the remaining 
90%. During the methotrexate infusion, patients should receive hydration fluid with D5W 
+ 40 mEq/L NaHCO3 + 20 mEq KCl/L at 100-150 ml/m2/hr. Urine pH will be monitored 
with each void during infusion. An IV bolus of 12 mEq/m2 NaHCO3 will be given if 
urine pH is 6.0; and 25 mEq/m2 will be given if urine pH is <6.0. Acetazolamide 500 
mg/m2 orally every 6 to 8 hours may be used if systemic alkalosis limits the 
administration of bicarbonate for urinary alkalinization. Patients with evidence of renal 
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dysfunction or delayed clearance during the methotrexate infusion may receive less than 
a 24 hour methotrexate infusion.
Leucovorin rescue: Leucovorin, 15 mg/m2 (IV or PO) will be started at 42 hours after the 
start of methotrexate and repeated every 6 hours for a total of three doses, as described 
Reiter, et al.30 The dosage of leucovorin will be increased in patients with high plasma 
methotrexate concentrations (>1.0 M at 42 hours) and continued until the methotrexate 
concentration is less than 0.10 M. Additional measures, such as hydration, 
hemoperfusion, or glucarpidase will be considered in patients with 42-hour methotrexate 
levels > 10M.  
Patients with a history of delayed Grade 3 or 4 gastrointestinal toxicity with prior 
methotrexate or a history of typhlitis with any chemotherapy, should have leucovorin 
continue for a minimum of 5, rather than 3 doses; those with early toxicity should have 
leucovorin begin at 36 hours with subsequent methotrexate and receive a minimum of 6 
rather than 3 doses; if toxicity recurs, the baseline leucovorin dosage should also be 
increased.
Leucovorin Dosing1,2
42 Hour MTX Level
Leucovorin Rescue
≤1 M
15mg/m2 q6h x 3 doses.
1.01-9.9 M
15mg/m2 q6h until MTX level <0.1M.
10-39.9 M
15mg/m2 q3h until MTX level <0.1M.  Consider glucarpidase2.
40-200 M
100mg/m2 q6h until MTX level <0.1M.  Consider glucarpidase2.
>200 M
1000mg/m2 q6h until MTX level <0.1M.  Consider 
glucarpidase3.
1If the 42 hour level is high, but then the patient “catches up” and the level falls to the expected value of <0.4 
M at 48 hours resume standard leucovorin and hydration as long as urine output remains satisfactory.
2Doses of LV may be increased outside of this table at the recommendation of the primary MD based on the 
clinical status of the patient.
3For patients who have markedly delayed MTX clearance secondary to renal dysfunction, consider using 
glucarpidase (carboxypeptidase G2, Voraxaze®). Glucarpidase is a commercially available agent designed 
to treat patients with excessive methotrexate levels and renal dysfunction. To obtain supplies of 
glucarpidase or for related questions, in the US, contact ASD Healthcare or Voraxaze® Customer Service 
at +1.855.7.VORAXAZE (+1.855.786.7292); available 24 hours/day, operating 365 days/year.
4.3.4
Intrathecal Chemotherapy 
All patients will receive triple intrathecal therapy every other week for four doses on 
Days 1, 15, 29, and 43 (dosages are based upon age, according to Section 4.2.1). The 
intrathecal treatment should be given on the same day of the high dose methotrexate 
administration. Consult the PI or Pharmacokinetics if the IT and high dose methotrexate 
become separated by more than 12 hours.
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4.3.5  Bone Marrow Examination
Patients that are MRD positive following induction will have bone marrow exams with 
each intrathecal/high dose methotrexate course. When possible, specimens should be 
shipped overnight Sunday-Thursday such that they are received by St. Jude Monday-
Friday. If shipping on Friday or Saturday, please notify the study PI so that personnel can 
be called in to process the specimen on weekends and holidays. See section 8.2 for 
acceptable alternate timing of bone marrow examinations. For patients that do not have a 
decrease in MRD levels during consolidation, the phase may be aborted and patients may 
proceed to reinduction provided they are clinically stable (see section 7.0).  
4.3.6
Interim Continuation Treatment
Interim continuation treatment will be given to the occasional patient who, upon attaining 
complete remission, are deemed unable to tolerate high dose methotrexate. Specific 
criteria to use interim continuation therapy include disseminated fungal infection 
requiring systemic antifungal therapy, recent development of cerebral thrombosis, or 
grade 3 or 4 renal or hepatic dysfunction. There may be other unforeseen reasons that 
warrant temporary withholding of high dose methotrexate.
Interim treatment will consist of oral mercaptopurine 50 mg/m2 per day (25 mg/m2 per 
day in those with ANC<500/mm3) and intravenous methotrexate 40 mg/m2 per week; 
intrathecal therapy may be given every other week during this period of time and 
continued during the subsequent high dose methotrexate treatment for a total of 4 doses. 
High dose methotrexate will be started when the patient’s physical condition allows. In 
the event that the interim therapy is longer than 4 weeks, an extra intrathecal therapy may 
be given with the last course of high dose methotrexate. Patients with a defective TPMT 
status may receive lower doses of mercaptopurine. 
4.4
Re-Induction Therapy
Agent
Dosage
Route
Days
# Doses
Mitoxantrone
(MITO)
0.27mg/kg/dose
IV
1, 2
2
PEG-asparaginase
(PEG-ASP)
2500 international 
units/dose
IV
3, 18
2
Dexamethasone
(DEX)
10 mg/m2/day
PO/NG 
divided BID
(may give IV)
1-4, 8-11, 15-18
24
Bortezomib
(BORT)
0.043 mg/kg/dose
IV
1, 4, 8, 11, 15, 18
6
Vorinostat
(VORINO)
see dose 
escalation plan
PO/NG
1-4, 8-11, 15-18
12
ITMHA
See section 4.2.1
IT
1, 15*
1 (*2 for CNS3 
or traumatic tap 
at diagnosis)
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4.4.1
Criteria for Starting Reinduction
Reinduction treatment begins after the completion of consolidation, provided that the 
ANC >500/mm3, WBC 1000/mm3, and platelet count 50 x 109/L as well as no 
evidence of grade 3 or 4 mucositis.
4.4.2
Bone Marrow Examination
A bone marrow will be done following count recovery prior to initiation of reinduction 
chemotherapy. When possible, specimens should be shipped overnight Sunday-Thursday 
such that they are received by St. Jude Monday-Friday. If shipping on Friday or Saturday, 
please notify the study PI so that personnel can be called in to process the specimen on 
weekends and holidays. See section 8.2 for acceptable alternate timing of bone marrow 
examinations.  
  
4.4.3
Dose Modifications
Patients >1 year of age at the time of Re-Induction AND >10kg will receive mitoxantrone 
at 8mg/m2/dose and bortezomib at 1.3mg/m2/dose.
4.4.4
Treatment Modifications
See section 6.0 for treatment modifications for mitoxantrone, bortezomib, and PEG-
asparaginase.
4.4.5
Intrathecal Treatment
Day 1 Intrathecal treatment will be followed by leucovorin rescue (5mg/m2/dose PO or 
IV, max 5mg) at 24 and 30 hours only in patients with prior CNS toxicities or in patients 
with WBC <1500/mm3 or ANC <500/mm3. CNS3 patients will receive an additional dose 
of intrathecal chemotherapy on day 15. Day 15 intrathecal treatment will be followed by 
leucovorin rescue (5mg/m2/dose PO or IV, max 5mg) at 24 and 30 hours as patients will 
be neutropenic at this time. See section 4.2.1 for dosing.  
4.4.6
Supportive Care Requirements

Inpatient during Reinduction until signs of count recovery with a minimum ANC 
of 200.  We recommend an ANC of at least 300 for two consecutive days for 
discharge criteria, however this is at the discretion of the treating physician and 
therefore small differences in ANC values at the time of discharge will not be 
considered protocol deviations or violations.

IVIG for patients that have total immunoglobulin level of less than 400 mg/dL

Micafungin at treatment dosing (4mg/kg IV Q24 hours) or caspofungin at 
treatment dosing (see section 10.10) and cefepime at prophylactic dosing (50mg/kg 
IV Q12 hours) for all patients until APC ≥500/mm3 for two consecutive days.  
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
Patients unable to receive cefepime due to drug shortage, allergy, or other cause 
should receive an alternative antibiotic with similar bacterial coverage. Patients 
who are discharged with an ANC of >200 but less than 500 may be sent out on oral 
levofloxacin without fungal coverage to facilitate a feasible outpatient regimen.

Synagis prophylaxis during RSV season.

Patients with mucositis should be evaluated for herpes simplex infection and 
treated with acyclovir or famciclovir if work-up is positive.

GM-CSF and/or G-CSF should not be administered to aid in count recovery. 
Growth factor administration is reserved for patients with severe infections that 
are not predicted to recover in the near future. Please contact the PI for approval 
prior to initiating.
4.5
Re-Intensification Therapy
Agent
Dosage
Route
Days
# Doses
Cytarabine
(ARAC)
2g/m2/dose Q12H 
IV
1, 2
4
Etoposide
(VP16)
100 mg/m2/dose*
IV
3-5
3
Dexamethasone
(DEX)
20 mg/m2/day
PO/NG
divided BID
(may give IV)
1-5
10
PEG-asparaginase
(PEG-ASP)
2500 international units/dose
IV
6
1
ITMHA
See section 4.2.1
IT
5
1
*See dosing table for etoposide, Section 4.5.3.
4.5.1
Criteria for Starting Reintensification
Patients with MRD >0.01% on day 1 of Reinduction, OR patients with increasing 
MRD during Consolidation are considered upfront refractory and at high risk for 
disease progression. Patients that achieve MRD negative status following 
reinduction may proceed directly to stem cell transplant. Patients that remain MRD 
positive are eligible for CAR T cells if available, or they may undergo a 
Reintensification phase following Reinduction and then proceed to hematopoietic 
stem cell transplant in first remission due to their high risk of relapse.  
Re-Intensification Treatment may begin after the completion of Reinduction, provided 
that the ANC >500/mm3, WBC 1000/mm3, and platelet count 50 x 109/L.  
4.5.2
Bone Marrow Examination
A bone marrow will be done following count recovery prior to initiation of 
Reintensification chemotherapy. When possible, specimens should be shipped overnight 
Sunday-Thursday such that they are received by St. Jude Monday-Friday. If shipping on 
Friday or Saturday, please notify the study PI so that personnel can be called in to process 
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the specimen on weekends and holidays. See section 8.2 for acceptable alternate timing 
of bone marrow examinations.  
4.5.3
Intrathecal Treatment
Intrathecal treatment will be followed by leucovorin rescue (5mg/m2/dose PO or IV, max 
5mg) at 24 and 30 hours only in patients with prior CNS toxicities or in patients with 
WBC <1500/mm3 or ANC <500/mm3. See section 4.2.1 for dosing.
4.5.3
Etoposide Administration

All intravenous doses should be given over 1-2 hours (maximum rate 100 
mg/sq.m/hour)

If infusion-related reaction occurs, may prolong infusion to 2-4 hours or substitute 
etoposide phosphate (Etoposphos™) and infuse it over 1-2 hours.

Patients with a body surface area < 0.6 m2 should receive standardized dosing as 
follows:
Standardized etoposide dosing
BSA (m2)
Dose (mg)
0.2-0.24
12
0.25-0.3
20
0.31-0.34
24
0.35-0.4
28
0.41-0.44
36
0.45-0.5
44
0.51-0.54
52
0.55-0.59
56
≥0.6
100/m2
4.5.4
Treatment Modifications
See section 6.0 for treatment modifications for PEG-asparaginase, etoposide, and cytarabine.
4.5.5
Supportive Care Requirements

Inpatient during Reintensification until signs of count recovery with a minimum 
ANC of 200. We recommend an ANC of at least 300 for two consecutive days for 
discharge criteria, however this is at the discretion of the treating physician and 
therefore small differences in ANC values at the time of discharge will not be 
considered protocol deviations or violations.

IVIG for patients that have total immunoglobulin level of less than 400 mg/dL

Micafungin at treatment dosing (4mg/kg IV Q24 hours) or caspofungin at treatment 
dosing (see section 10.10) and cefepime at prophylactic dosing (50mg/kg IV Q12 
hours) for all patients until APC ≥ 500/mm3 for two consecutive days.

Patients unable to receive cefepime due to drug shortage, allergy, or other cause 
should receive an alternative antibiotic with similar bacterial coverage. Patients that 
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are discharged with an ANC of >200 but less than 500 may be sent out on oral 
levofloxacin without fungal coverage to facilitate a feasible outpatient regimen. 

Synagis prophylaxis during RSV season

Patients with mucositis should be evaluated for herpes simplex infection and 
treated with acyclovir or famciclovir if work-up is positive.

GM-CSF and/or G-CSF should not be administered to aid in count recovery.  
Growth factor administration is reserved for patients with severe infections that 
are not predicted to recover in the near future. Please contact the PI for approval 
prior to initiating.
4.6
Maintenance Chemotherapy
20 Cycles;  One cycle = 28 days
Agent
Dosage
Route
Days
# Doses per 
cycle
Dexamethasone
(DEX)
6 mg/m2/day
PO/NG divided 
BID (may give IV)
1-5
10
VinCRIStine
(VCR)
1.5 mg/m2 (max 2 
mg) for patients > 1 
year and weighing 
>10 kg, or
0.05 mg/kg for 
patients < 1 year or 
weighing <10 kg
IV
1
1
Mercaptopurine
(6MP)
50 mg/m2
PO/NG 
1-28
28
Methotrexate
(MTX)
40 mg/m2
IV/IM/PO
1*,8,15,22
3 (4*)
ITMHA
See section 4.6.2
IT
1
1
*Methotrexate will be given on day 1 of cycles that do not have an intrathecal 
treatment. For CNS1 patients this is cycles 9-20, CNS2 patients cycles 12-20, and 
CNS3 or traumatic LP cycles 14-20.
4.6.1
Criteria for Starting Maintenance 
Treatment begins after the completion of Re-Induction, provided that the ANC 
500/mm3, WBC  1000/mm3 and platelet count  50 x 109/L as well as no evidence of 
grade 3 or 4 mucositis.
4.6.2
Intrathecal Treatment
Patients will receive intrathecal  treatments without leucovorin rescue during 
maintenance provided they are not neutropenic. Patients that are neutropenic should have 
the intrathecal treatment delayed until counts recover. 
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Frequency and total number of triple intrathecal treatments for Maintenance is based on 
the patient's risk of CNS relapse, as follows:

Patients with CNS1 status at diagnosis will receive triple intrathecal treatment on 
day 1 of cycles 1-8.

Patients with CNS2 status at diagnosis will receive triple intrathecal treatment on 
day 1 of cycles 1-11.

Patients with any of the following features at diagnosis will receive triple 
intrathecal treatment on day 1 of cycles 1-13:
o
CNS3 status (i.e., ≥5 WBC/L of CSF with blasts or cranial nerve palsy)
o
Traumatic LP (>10 RBC/L of CSF with blasts)
Dose is based on age, as follows:
Age
Methotrexate (mg)
Hydrocortisone (mg)
Cytarabine (mg)
Volume (ml)*
< 12 months
6
12
18
6
12-23 months
8
16
24
8
24-35 months
10
20
30
10
> 36 months
12
24
36
12
*Centers may use their institutional standard volumes for intrathecal chemotherapy provided the 
methotrexate, hydrocortisone, and cytarabine doses are as specified in the table.
4.6.3
Treatment Modifications
Patients > 1 year of age AND >10kg will receive vincristine at 1.5mg/m2/dose
Dexamethasone and vincristine should be given regardless of blood counts, provided that 
the patient is not sick. Methotrexate and mercaptopurine will be held if ANC <300/mm3, 
WBC <1000/mm3, or platelet count <50 x 109/L (see section 6.0 for other dose 
modifications). Dosage of treatment during maintenance should be titrated to keep WBC 
between 1800 and 3000/mm3, ANC between 500 and 1200/mm3, and platelet count ≥ 50 
x 109/L. Disproportionate dose reduction of one agent compared to another should be 
avoided unless clinically indicated. Frequent (e.g. weekly) changes of mercaptopurine 
doses should be avoided. Patients who receive mercaptopurine at a reduced dose for 
longer than 2 weeks should have a TGN level checked after at least 14 days of 
uninterrupted mercaptopurine if the plan is to continue at reduced doses to ensure 
therapeutic target is being achieved. 
4.6.4
Dose Modifications for Inadequate Myelosuppression
Patients who miss less than 25% of therapy but have persistently (>50% of time; not 
counting the week after dexamethasone/vincristine) high WBC (≥3 x 109/L) and high 
ANC (≥1200 x 109/L) should be counseled on compliance, particularly if 6TGN levels 
are <100 pmol/8x108 RBCs. If the WBC remains high, mercaptopurine and methotrexate 
doses should be increased by 30% (e.g. to 65mg/m2 and 50mg/m2 respectively), using a 
stepwise approach if needed. If patients have a TPMT defect, mercaptopurine dosage 
should not be increased unless the TGN levels are <100 pmol/8x108 RBCs.
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5.0
DRUG/DEVICE/BIOLOGIC AGENT INFORMATION 
Dose rounding will be allowed. For chemotherapy the resultant dose must be within 
±10% of the prescribed dose. For etoposide, please use standardized dosing table for 
patients with a body surface area of less than 0.6 m2, for patients with a body surface area 
of greater than or equal to 0.6 m2, dose rounding is allowed. For all other medications 
including but not limited to leucovorin and antibiotics, the resultant dose must be within 
±15% of the prescribed dose.
5.1
Intrathecal Triples
(ITMHA, methotrexate/hydrocortisone/cytarabine)
Source and pharmacology: The intrathecal route of administration of a drug produces 
more consistent CSF drug concentrations at relatively smaller doses because of the 
volume difference between the CSF and blood compartments (140 mL vs. 3500 mL in an 
adult). (The CSF volume of children after the first 3 years is equivalent to that of an 
adult). Drug half-lives are longer as well because clearance is related to flow rather than 
metabolism or protein binding. Intrathecal methotrexate has a biphasic elimination curve 
from the CSF with a t½ of 4.5 and 14 hours respectively. Following IT injection of 
cytarabine the elimination of the drug from the CSF is biphasic with a t½ of 1 and 3.4 
hours respectively which is 8-fold longer than the clearance from plasma. The 
elimination of hydrocortisone is similarly prolonged.
Formulation and stability: Methotrexate 25 mg/mL preservative free 2 mL vial or 
methotrexate 20 mg preservative free sterile powder for injection vial. Cytarabine 100 mg 
preservative free sterile powder for injection. Hydrocortisone sodium succinate100 mg 
vial sterile powder for injection.
Toxicity: Nausea, vomiting, fever, headache.
Guidelines for administration: Intrathecal, See Treatment Plan and Dosage Modification 
sections of the protocol.
Supplier: Commercially available. See individual drug package inserts for more detailed 
information
5.2
Dexamethasone (Decadron®, Hexadrol®, Dexone®, Dexameth®)
Source and pharmacology: Dexamethasone is a synthetic fluorinated glucocorticoid 
devoid of mineralocorticoid effects. Dexamethasone, 0.75 mg, has potent anti-
inflammatory activity equivalent to approximately 5 mg of prednisone. Glucocorticoids 
produce widespread and diverse physiologic effects on carbohydrate, protein, and lipid 
metabolism, electrolyte and water balance, functions of the cardiovascular system, 
kidney, skeletal muscle, and the nervous  systems. Glucocorticoids reduce the 
concentration of thymus-dependent lymphocytes (T-lymphocytes), monocytes, and 
eosinophils. Glucocorticoids selectively bind to the cortisol receptors on human lymphoid 
cells which are found in larger numbers on leukemic lymphoblasts. They also decrease 
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binding of immunoglobulin to cell surface receptors and inhibit the synthesis and/or 
release of interleukins, thereby decreasing T-lymphocyte blastogenesis and reducing 
expansion of the primary immune response. The specific cellular mechanisms that act to 
halt DNA synthesis are thought to be related to inhibition of glucose transport or 
phosphorylation, retardation of mitosis, and inhibition of protein synthesis. Elimination 
half-lives for the following age groups have been reported to be: infants and children 
under 2 years of age: 2.3 to 9.5 hours, 8 to 16 years: 2.82 to 7.5 hours, and adults (age not 
specified): 3 to 6 hours. The biologic half-life is 36-72 hours. It is primarily metabolized 
in the liver and excreted by the kidneys.
Toxicity:
Common
Happens to 21-100 
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Insomnia, 
hyperphagia
Gastritis
Hyperuricemia
Prompt:
Within 2-3 weeks, 
prior to the next 
course
Immunosuppression, 
personality changes 
(mood swings, 
euphoria, anxiety, 
depression), 
pituitary- adrenal 
axis suppression, 
acne (L)
Hyperglycemia, facial 
erythema, poor wound 
healing, infections (bacterial, 
fungal, parasitic, viral), 
edema
Pancreatitis (L), 
increased intraocular 
pressure (L), 
hypertension, 
psychosis, vertigo, 
headache
Delayed:
Any time later 
during therapy
Cushing’s syndrome 
(moon facies, 
truncal obesity)
Striae and thinning of the 
skin, easy bruising, muscle 
weakness, osteopenia
Spontaneous fractures 
(L), growth 
suppression, peptic 
ulcer and GI bleeding, 
pseudotumor cerebri 
(increased intracranial 
pressure with 
papilledema, 
headache), aseptic 
necrosis of the femoral 
and humeral heads (L), 
urolithiasis1 (L)
Late:
Any time after 
completion of 
treatment
Cataracts (may be reversible 
on discontinuation of 
dexamethasone in children)
Unknown 
frequency and 
timing:
Fetal and teratogenic toxicities: dexamethasone crosses the placenta with 54% 
metabolized by enzymes in the placenta. In animal studies, large doses of 
cortisol administered early in pregnancy produced cleft palate, stillborn fetuses, 
and decreased fetal size. Chronic maternal ingestion during the first trimester 
has shown a 1% incidence of cleft palate in humans. There are no reports of 
dexamethasone excretion into breast milk in humans; however, it is expected 
due to its low molecular weight that it would partition into breast milk.
1Mainly reported in pediatric patients with ALL. Howard SC et al. Urolithiasis in pediatric patients with 
acute lymphoblastic leukemia. Leukemia 2003; 17: 541-6.
(L) Toxicity may also occur later.
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Formulation and stability: Oral: Available in 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 
and 6 mg tablets; liquid formulations are available in 0.5 mg/5 mL and 1 mg/1 mL 
concentrations. Inactive ingredients vary depending on manufacturer but tablet 
formulations may include: calcium or magnesium stearate, corn starch, lactose, and 
various dyes. Liquid formulations may include: 5%-30% alcohol, benzoic acid, sorbitol, 
sodium saccharin, glycerin, purified water, and various dyes.
Injection:  Dexamethasone Sodium Phosphate Solution for Injection is available as 4 
mg/mL (1 mL, 5 mL, and 30 mL vials) and 10 mg/mL (1 mL and 10 mL vial sizes). Vials 
are available in multi-dose vials as well as unit of use vials and syringes. Inactive 
ingredients vary depending on manufacturer but include creatinine, sodium citrate, 
sodium hydroxide to adjust pH, Water for Injection, sodium sulfite, bisulfite and 
metabisulfite, methyl and propyl paraben, benzyl alcohol, and EDTA.
Guidelines for administration: Divided BID, PO/NG/IV; see Treatment and Dose 
Modifications section of the protocol. 
Supplier: Commercially available; see package insert for more detailed information.
5.3
Mitoxantrone (Novantrone®, Mitozantrone)
Source and pharmacology: Mitoxantrone is a substituted alkylaminoanthraquinone and is a 
potent inhibitor of DNA and RNA synthesis in vitro and binds strongly to DNA. 
Mitoxantrone most likely acts through intercalation between base pairs of the DNA double 
helix causing crosslinks and strand breaks. In addition, it is a topoisomerase II inhibitor, an 
enzyme responsible for uncoiling and repairing damaged DNA. It has a cytocidal effect on 
both proliferating and non-proliferating cultured human cells, suggesting lack of cell cycle 
phase specificity. The drug disappears rapidly from plasma (drug found only in the 3-
minute sample) and < 1% appears in the urine in 24 hours. The mean alpha half-life of 
mitoxantrone is 6 to 12 minutes, the mean beta half-life is 1.1 to 3.1 hours and the mean 
gamma (terminal or elimination) half-life is 23 to 215 hours (median approximately 75 
hours). Primary excretion is biliary with 25% appearing in the feces; renal excretion 
accounting for only 11% of the total dose. Mitoxantrone clearance is reduced by hepatic 
impairment. Patients with severe hepatic dysfunction (bilirubin > 3.4 mg/dL) have an AUC 
more than three times greater than that of patients with normal hepatic function receiving 
the same dose. Mitoxantrone is approximately 95% protein bound.
Toxicity:
Common
Happens to 21-100 
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Immediate:  
Within 1-2 days of 
receiving drug
Nausea, vomiting, 
diarrhea, fever, 
anorexia, green blue 
discoloration of the 
urine and/or sclera
Abdominal pain, back 
pain, headache, phlebitis, 
constipation
Anaphylaxis, angioedema, 
cardiac arrhythmias1 
(bradycardia), seizures, 
extravasation reactions 
rare but if occur can lead 
to: (erythema, swelling, 
pain, burning and/or blue 
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Common
Happens to 21-100 
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
discoloration of the skin 
and rarely tissue necrosis), 
tumor lysis
Prompt: 
Within 2-3 weeks, 
prior to the next 
course
Myelosuppression (L), 
mucositis /stomatitis, 
immunosuppression, 
alopecia, fatigue
Transient elevation of 
LFTs, pruritis with 
desquamation of the skin 
due to progressive dryness
Rash, conjunctivitis, (GI) 
hemorrhage, interstitial 
pneumonitis
Delayed:  
Any time later 
during therapy
Amenorrhea, 
menstrual disorders, 
temporary reduction in 
sperm count
Cardiotoxicity (decreased 
LVEF)2 (L)
CHF, hepatotoxicity
Late:  
Any time after 
completion of 
treatment
Secondary malignancy
Unknown 
frequency and 
timing:
Fetal toxicities and teratogenic effects of mitoxantrone have been noted in 
animals.  Toxicities include: low birth weight and prematurity. Mitoxantrone is 
excreted in human milk and significant concentrations (18 ng/mL) have been 
reported for 28 days after the last administration.
1 Rarely clinically significant.
2 Risk increases with chest radiation and prior anthracycline dosage.  (L) Toxicity may also occur later.
Formulation and stability: The concentrate is a sterile, non-pyrogenic, non-preserved, dark 
blue aqueous solution containing mitoxantrone hydrochloride equivalent to 2 mg/mL 
mitoxantrone free base, with sodium chloride (0.80% w/v), sodium acetate (0.005% w/v), 
and acetic acid (0.046% w/v) as inactive ingredients with 0.14 mEq of sodium per mL. 
Mitoxantrone is provided as 20 mg (10 mL), 25 mg (12.5 mL) and 30 mg (15 mL) vials. 
Store intact vials at 15°-25°C (59°-77°F). Undiluted mitoxantrone injection should be 
stored not longer than 7 days between 15°-25°C (59°-77°F) or 14 days under refrigeration. 
Refrigeration of the concentrate may result in a precipitate, which redissolves on warming 
to room temperature. DO NOT FREEZE.
Guidelines for administration: See Treatment and Dose Modifications sections of the 
protocol.
Mitoxantrone must be diluted prior to injection. DO NOT GIVE IV PUSH. The dose 
of mitoxantrone should be diluted in at least 50 mL or to a concentration ≤ 0.5 mg/mL with 
either NS or D5W. The dilution is stable at room temperature for 48 hours with no loss of 
potency. Admixture with heparin may result in precipitation. Mitoxantrone is an irritant: 
Care should be taken to avoid extravasation; the use of a central line is suggested. If it is 
known or suspected that subcutaneous extravasation has occurred, it is recommended that 
intermittent ice packs be placed over the area of extravasation and that the affected 
extremity be elevated. Because of the progressive nature of extravasation reactions, the 
area of injection should be frequently examined and surgery consultation obtained early if 
there is any sign of a local reaction.
Supplier:  Commercially available; see package insert for more detailed information.
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5.4
Pegaspargase (PEG-asparaginase, Oncaspar®)
Source and pharmacology: Pegaspargase is a modified version of the enzyme L-
asparaginase. L-asparaginase is modified by covalently conjugating units of 
monomethoxypolyethylene glycol (PEG), molecular weight of 5000, to the enzyme, 
forming the active ingredient PEG-L-asparaginase. The L-asparaginase (L-asparagine 
amidohydrolase, type EC-2, EC 3.5.1.1) used in the manufacture of Pegaspargase is 
derived from Escherichia coli, which is purchased in bulk from Merck, Sharp and Dohme.  
L-asparagine is a nonessential amino acid synthesized by the transamination of L-aspartic 
acid by a reaction catalyzed by the enzyme L-asparagine synthetase. The ability to 
synthesize asparagine is notably lacking in malignancies of lymphoid origin. Asparaginase 
depletes L-asparagine from leukemic cells (especially lymphoblasts) by catalyzing the 
conversion of L- asparagine to aspartic acid and ammonia. In predominately L-
asparaginase naive adult patients with leukemia and lymphoma, initial plasma levels of L-
asparaginase following intravenous administration of pegaspargase were determined. 
Apparent volume of distribution was equal to estimated plasma volume. L-asparaginase 
was measurable for at least 15 days following the initial treatment with Pegaspargase. The 
approximate t½ in adult patients is 5.73 days. The enzyme could not be detected in the 
urine. The half-life is independent of the dose administered, disease status, renal or hepatic 
function, age, or gender. In a study of newly diagnosed pediatric patients with ALL who 
received either a single intramuscular injection of pegaspargase (2500 IU/m2), E. coli L-
asparaginase (25000 IU/m2), or Erwinia (25000 IU/m2), the plasma half-lives for the three 
forms of L-asparaginase  were: 5.73 ± 3.24 days, 1.24 ± 0.17 days, and 0.65 ± 0.13 days 
respectively. The plasma half-life of pegaspargase is shortened in patients who are 
previously hypersensitive to native L-asparaginase as compared to non-hypersensitive 
patients. L- asparaginase is cleared by the reticuloendothelial system and very little is 
excreted in the urine or bile. Cerebrospinal fluid levels are < 1% of plasma levels.
Toxicity:
Common
Happens to 21-100 
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Allergic reactions (total 
likelihood of local, and 
or systemic reaction 
especially if previous 
hypersensitivity reaction 
to native asparaginase), 
pain at injection site, 
weakness, fatigue, 
diarrhea
Allergic reactions 
(total likelihood of 
local, and or systemic 
reaction if no 
previous 
hypersensitivity 
reaction to native 
asparaginase), rash
Anaphylaxis, 
hyper/hypotension, 
tachycardia, periorbital 
edema, chills, fever, 
dizziness, dyspnea, 
bronchospasm, lip edema, 
arthralgia, myalgia, 
urticaria, mild 
nausea/vomiting, 
abdominal pain, 
flatulence, somnolence, 
lethargy, headache, 
seizures (L), 
hyperuricemia
Prompt:  
Within 2-3 weeks, prior 
to the next course
Hyperammonemia (L), 
coagulation 
abnormalities with 
Hyperglycemia, 
abnormal liver 
function tests, 
Hemorrhage (L), DIC, 
thrombosis, anorexia, 
weight loss, CNS ischemic 
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Common
Happens to 21-100 
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
prolonged PTT, PT and 
bleeding times 
(secondary to decreased 
synthesis of fibrinogen, 
AT-III & other clotting 
factors) (L)
pancreatitis (L), 
increased serum 
lipase/amylase
attacks, edema, azotemia 
and decreased renal 
function, mild leukopenia, 
granulocytopenia, 
thrombocytopenia, 
pancytopenia, hemolytic 
anemia, infections (sepsis 
with/without septic shock, 
subacute bacterial 
endocarditis [SBE], URI), 
CNS changes including 
irritability, depression, 
confusion, EEG changes, 
hallucinations, coma and 
stupor, paresthesias, 
hypertriglyceridemia, 
hyperlipidemia, 
Parkinson-like syndrome 
with tremor and increase 
in muscular tone, 
hyperbilirubinemia, chest 
pain
Delayed:
Any time later during 
therapy
Renal failure, urinary 
frequency, hemorrhagic 
cystitis, elevated creatinine 
and BUN, fatty liver 
deposits, hepatomegaly, 
liver failure
Unknown 
frequency and 
timing:
Animal reproduction studies have not been conducted with pegaspargase. It is 
not known whether pegaspargase can cause fetal harm when administered to a 
pregnant woman or can affect reproduction capacity. However, fetal toxicities 
and teratogenic effects of asparaginase have been noted in animals. It is 
unknown whether the drug is excreted in breast milk.
(L)Toxicity may also occur later.
Formulation and stability: Each milliliter of pegaspargase contains: PEG-L-asparaginase 
750 IU  ± 20%, monobasic sodium phosphate, USP 1.20 mg ± 5% dibasic sodium 
phosphate, USP 5.58 mg ± 5%, sodium chloride, USP 8.50 mg ± 5% , Water for 
Injection, USP qs to 1 mL. The specific activity of pegaspargase is at least 85 IU per 
milligram protein. Available in 5 mL vials as Sterile Solution for Injection in ready to use 
single-use vials, preservative free. Keep refrigerated at 2°-8°C (36°-46°F). Do not use if 
stored at room temperature for more than 48 hours. DO NOT FREEZE. Do not use 
product if it is known to have been frozen. Freezing destroys activity, which cannot be 
detected visually.
Guidelines for administration: See Treatment and Dose Modifications sections of the 
protocol. Intravenous is the preferred method of administration as anaphylactic reactions 
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are extremely rare in infants and intramuscular injection can lead to hematomas. For I.M. 
administration, limit the volume at a single injection site to 2 mL; if the volume to be 
administered is >2 mL, use multiple injection sites I.V. infusion in 100 mL of D5W or NS 
through an infusion that is already running (can be TKO).
If the patient weighs ≥ 10 kg infuse PEG-asparaginase over 1 hour.
If the patient weighs < 10 kg infuse PEG-asparaginase over 2 hours.
Supplier: Commercially available; see package insert for more detailed information.
5.5
Asparaginase Erwinia Chrysanthemi (Erwinia chrysanthemi, Erwinase®, 
Erwinaze™, Crisantaspase)
To be used in case of allergy or intolerance to PEG-Asparaginase.
Source and pharmacology: L-asparagine is a nonessential amino acid synthesized by the 
transamination of L-aspartic acid by a reaction catalyzed by the enzyme L-asparagine 
synthetase. Neoplastic cells associated with acute lymphoblastic leukemia, acute myeloid 
leukemia and lymphoblastic lymphosarcoma are asparagine-dependent but lack 
asparagine synthetase activity. The administration of L-asparaginase produces an anti-
neoplastic effect by catalyzing asparagine into aspartic acid and ammonia. As a result, 
these cells lack the ability to produce the asparagine necessary for protein metabolism 
and survival. Deamination of glutamine may also play a role in the antineoplastic activity 
of asparaginase.
Asparaginase Erwinia chrysanthemi (Erwinaze™) is asparaginase derived from cultures 
of Erwinia chrysanthemi. L-asparaginase is a tetrameric enzyme; each of the four 
identical subunits has a molecular weight of approximately 35 kDa. Asparaginase 
Erwinia chrysanthemi is immunologically distinct from E. coli L-asparaginase and may 
allow continued asparaginase therapy when a hypersensitivity reaction occurs to 
Escherichia coli-derived asparaginase. The package labeling states that there is 
insufficient information to characterize the incidence of antibodies to asparaginase 
Erwinia chrysanthemi. Several factors are involved in immunogenicity assay results and 
the assessment of antibodies, including assay methodology, assay sensitivity and 
specificity, sample handling, timing of sample collection, concomitant medications, and 
the underlying disease state. The following data have been reported on each of the three 
preparations of asparaginase:
Clinical Pharmacology of 
Asparaginase Formulation
Elimination half-life (IM)
% Anti-Asparaginase Antibody 
positive patients
Native Escherichia Coli
26-30 hours
45-75
Pegylated-asparaginase
5.5-7 days
5-18
Erwinia Asparaginase
16 hours (7-13 hrs package insert)
30-50
From: Avramis, V; Panosyan, E; Pharmacokinetic/Pharmacodynamic Relationships of Asparaginase 
Formulations: The Past, the Present and Recommendations for the Future. Clin Pharmacokinet 2005; 44 
(4): 367-393.
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Effective asparaginase levels have been defined as activity of ≥ 0.1 International Units 
per mL. Clinical trials with asparaginase Erwinia chrysanthemi demonstrated that 100% 
of patients achieved effective asparaginase levels at 48 and 72 hours (n=35 and n=13, 
respectively) following the third total dose when given on a Monday, Wednesday, Friday 
schedule. No formal drug interaction studies have been performed with asparaginase 
Erwinia chrysanthemi.
Toxicity
Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Immediate:
Within 1-2 days 
of receiving drug
Allergic reactions, 
anaphylaxis, urticaria
Local injection site reactions, fever
Prompt:  
Within 2-3 weeks, 
prior to the next 
course
Pancreatitis, glucose intolerance, 
thrombosis, hemorrhage, transient 
ischemic attack, disseminated 
intravascular coagulation, 
hyperbilirubinemia, alanine 
aminotransferase increased, 
aspartate aminotransferase 
increased, hyperglycemia, 
hyperammonemia, vomiting, 
nausea, abdominal pain, headache, 
diarrhea, seizure
Unknown 
frequency 
and timing:
Fetal toxicities and teratogenic effects of L-asparaginase have been noted in 
animals. It is unknown whether the drug is excreted in breast milk. Adequate, well-
controlled studies of asparaginase Erwinia chrysanthemi have NOT been 
conducted. It is not known whether asparaginase Erwinia chrysanthemi will cause 
fetal harm or affect the ability to reproduce. It is not known if asparaginase Erwinia 
chrysanthemi is excreted into breast milk. The use of asparaginase Erwinia 
chrysanthemi should be avoided in pregnant or lactating patients.
(L) Toxicity may also occur later.
Formulation and stability: Asparaginase Erwinia chrysanthemi is supplied as a sterile, 
white lyophilized powder for reconstitution in a  clear glass vial with a 3 mL capacity. 
Each vial contains 10,000 International Units of asparaginase Erwinia chrysanthemi and 
the following inactive ingredients: glucose monohydrate (5.0 mg), sodium chloride (0.5 
mg). Store intact vials between 2°C and 8°C (36° to 46ºF). Protect from light.
Guidelines for administration: See Treatment and Dose Modification sections of the 
protocol. Intravenous (preferred) or intramuscular.
Use appropriate precautions for preparation of a hazardous agent. Visually inspect the 
powder in vial for foreign particles or discoloration prior to reconstitution. The contents 
of each vial should be reconstituted by slowly adding 1 mL or 2 mL of sterile, 
preservative-free NS to the inner vial wall. The final concentration is 10,000 International 
Units per mL when using 1 mL for reconstitution or 5,000 International Units per mL 
when using 2 mL for reconstitution. Gently mix or swirl the contents to dissolve the 
contents of the vial. Do not shake or invert the vial. The resulting solution should be clear 
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and colorless. Discard if any particulate matter or protein aggregates are visible.  
Withdraw the appropriate dosing volume into a polypropylene syringe within 15 minutes 
of reconstitution.  Polycarbonate luer-lok syringes from B-D (1 mL) are also acceptable 
(personal communication, EUSA Pharma). Discard any unused drug; do not save or use 
any unused drug remaining the in the vial.  
Administer the dose within a 4 hour time period from reconstitution. If the dose is 
not used within this time period, discard the dose. Do not freeze or refrigerate the 
reconstituted solution. If administering the dose IM, no more than 2 mL should be given 
at any one injection site. Doses larger than 2 mL should be divided and given in separate 
administration sites.
Supplier: Commercially available; see package insert for more detailed information.
5.6
Bortezomib (Velcade®, PS-341, MLN341, LDP-341)  IND# 127,270
Source and pharmacology: Bortezomib (PS-341) is a reversible inhibitor of the 
chymotrypsin-like activity of the 26S proteasome (a multicatalytic protease present in all 
eukaryotic cells). The 26S proteasome is a large protein complex that degrades proteins 
that have been conjugated to ubiquitin. The ubiquitin-proteasome pathway plays an 
essential role in regulating the intracellular concentration of specific proteins, and 
constitutes the major mechanism for intracellular protein degradation (80%). Those 
intracellular proteins that maintain homeostasis within cells include numerous regulatory 
proteins involved in cellular integrity, such as cell cycle control, cellular apoptosis, 
transcription factor activation, and tumor growth via ATP-dependent processes.  
Inhibition of the 26S proteasome prevents this targeted proteolysis, which can affect 
multiple signaling cascades within the cell. This disruption of normal homeostatic 
mechanisms can lead to cell death.  
The binding of bortezomib to human plasma proteins averages 83% over a concentration 
range of 100 to 1000 ng/mL. The mean elimination half-life of bortezomib after multiple 
dosing ranged from 40 to 193 hours after the 1 mg/m2 dose and 76 to 108 hours after the 
1.3 mg/m2 dose. In vitro studies with human liver microsomes and human cDNA-
expressed cytochrome P450 isozymes indicate that bortezomib is primarily oxidatively 
metabolized via cytochrome P450 enzymes 3A4, 2C19, and 1A2. Bortezomib 
metabolism by CYP 2D6 and 2C9 enzymes is minor. The major metabolic pathway is 
deboronation to form 2 deboronated metabolites that subsequently undergo hydroxylation 
to several metabolites. Deboronated bortezomib metabolites are inactive as 26S 
proteasome inhibitors.
In vitro and in vivo studies showed that green tea compounds, ascorbic acid (vitamin C) 
and other antioxidants, have the potential to significantly inhibit the activity of 
bortezomib. Green tea constituents, in particular epigallocatechin gallate (EGCG) and 
other polyphenols with 1,2-benzenediol moieties, effectively prevented tumor cell death 
induced by bortezomib both in vitro and in vivo. In multiple myeloma cell lines or mouse 
xenografts, EGCG directly reacted with bortezomib and blocked its proteasome 
inhibitory function. As a result, bortezomib could not trigger endoplasmic reticulum 
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stress or caspase-7 activation and could not induce tumor cell death. A more recent study 
investigated whether clinically relevant levels of EGCG or ascorbic acid could inhibit the 
antitumor activity of bortezomib in murine xenograft tumors. The addition of EGCG to 
bortezomib demonstrated no effect on tumor growth inhibition at lower concentrations of 
EGCG that the investigators compare to human dietary intake. Similar results were found 
for ascorbic acid at normal daily doses. When bortezomib was given concurrently with 
much higher concentrations of EGCG, the investigators found that all antitumor activity 
was eliminated. The authors concluded that there is no interaction between EGCG and 
ascorbic acid when plasma concentrations are commensurate with dietary oral intake.
Vitamin C, at concentrations achieved during vitamin supplementation, has also been 
shown to inhibit the activity of bortezomib both in vitro and in vivo. Direct binding 
between the hydroxyl group of vitamin C and the boronic acid of bortezomib reduced the 
affinity of the proteasome inhibitor for the chymotrypsin-like subunit of the proteasome. 
In addition, it was noted that besides vitamin C, other natural agents carrying a hydroxyl 
group, such as flavonoid compounds (quercetin among others), bind and inhibit the 
activity of bortezomib in vitro. 
To avoid the risk of any possible interaction it is recommended that green tea containing 
products and any supplemental products containing vitamin C, flavonoids or other 
antioxidants (e.g., vitamins, herbal supplements) be discontinued from at least 24 hours 
prior to the initiation of bortezomib through 72 hours after the last bortezomib dose. 
Injectable multivitamins used as a component of parenteral nutrition should also be 
avoided during this time period to minimize the risk of direct vitamin C inactivation of 
bortezomib. In addition, it is recommended that the total dietary intake of vitamin C not 
exceed the RDA for age. Normally balanced diets are acceptable; supplementation with 
high doses of vitamin C or injectable vitamin C should be avoided.
Toxicity:
Likely (>20%)
Less Likely (<20%)
Rare but Serious (<3%)
BLOOD AND LYMPHATIC SYSTEM DISORDERS
Anemia
CARDIAC DISORDERS
Heart failure
GASTROINTESTINAL DISORDERS
Constipation
Diarrhea
Nausea
Vomiting
Abdominal pain
Dyspepsia
Gastrointestinal hemorrhage
Ileus
Gastrointestinal perforation
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS
Fatigue
Fever
Chills
Edema limbs
INFECTIONS AND INFESTATIONS
Infections
INVESTIGATIONS
Thrombocytopenia
Neutropenia
Weight loss
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Likely (>20%)
Less Likely (<20%)
Rare but Serious (<3%)
METABOLISM AND NUTRITION DISORDERS
Anorexia
Dehydration
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS
Arthralgia
Back pain
Bone pain
Muscle spasms
Myalgia
Pain in extremity
NERVOUS SYSTEM DISORDERS
Peripheral motor neuropathy
Peripheral sensory 
neuropathy
Dizziness
Headache
Neuralgia
Paresthesia
Leukoencephalopathy
Reversible posterior 
leukoencephalopathy 
syndrome
PSYCHIATRIC DISORDERS
Anxiety
Insomnia
RENAL AND URINARY DISORDERS
Acute kidney injury
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS
Cough
Dyspnea
Pharyngeal mucositis
Adult respiratory distress 
syndrome
Pulmonary hypertension
SKIN AND SUBCUTANEOUS TISSUE DISORDERS
Maculo-papular rash
VASULAR DISORDERS
Hypotension
Formulation and stability: Bortezomib is supplied as a lyophilized powder in sterile vials 
containing 3.5 mg and 35 mg mannitol, USP. Unopened vials may be stored at controlled 
room temperature 25ºC (77ºF); excursions permitted from 15ºC to 30ºC (59ºF to 86ºF).  
Retain in original package to protect from light. Reconstitute bortezomib with 3.5 mL 
normal saline, USP. Each milliliter of solution will contain 1 mg of bortezomib at a pH of 
approximately 5 to 6. The drug solution is clear and colorless. Bortezomib contains no 
antimicrobial preservative. When reconstituted as directed, bortezomib may be stored at 
25°C (77°F). Reconstituted bortezomib should be administered within 8 hours of 
preparation. The reconstituted material may be stored in the original vial and/or the 
syringe prior to administration. The product may be stored for up to 8 hours in a syringe; 
however, total storage time for the reconstituted material must not exceed 8 hours when 
exposed to normal indoor lighting.
Guidelines for administration: See Treatment and Dose Modification Sections of the 
protocol. Bortezomib is to be given without further dilution as an IV push over 3 to 5 
seconds. Consecutive doses must be separated by at least 72 hours. Grapefruit and its juice 
should be avoided for the duration of treatment with bortezomib. 
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Special precautions: FOR INTRAVENOUS USE ONLY. The syringe containing 
bortezomib should be clearly labeled “For intravenous use only. Fatal if given by other 
routes.” Additional wording may be considered at the institution’s discretion. Three 
fatalities have been reported following accidental intrathecal administration of bortezomib. 
Special precautions should be employed to ensure that intravenous bortezomib and 
intrathecal medications are not inadvertently interchanged. 
For patients with neuropathy, bortezomib doses may be administered subcutaneously 
(concentration of 2.5 mg/mL) into the thigh or abdomen, rotating the injection site with 
each dose; injections at the same site within a single cycle were avoided. Administer at 
least 1 inch from an old site and never administer to tender, bruised, erythematous, or 
indurated sites. If injection site reaction occurs, the more dilute 1 mg/mL concentration 
may be used SubQ (or IV administration of 1 mg/mL concentration may be considered).
Supplier: Commercially available; see package insert for more detailed information.  
Agent Accountability: The Investigator, or a responsible party designated by the 
Investigator, must maintain a careful record of the inventory and disposition of bortezomib, 
as it is conducted under an IND.
5.7
Vorinostat (Zolinza®, Suberoylanidide Hydroxamic Acid, SAHA) IND# 
127,270
Source and pharmacology: Vorinostat also known as suberoylanilide hydroxamic acid 
(SAHA), is a histone deacetylase (HDAC) inhibitor. Its chemical name is N-hydroxy-N’-
phenyl-octane-1, 8-diotic acid diamide, N-hydroxy-N’-phenyl (9CI) octanediamide. The 
HDAC enzymes catalyze the removal of acetyl groups from the lysine residues of proteins, 
such as histones and transcription factors. In some cancer cells, there is an overexpression 
of HDACs or an abnormal recruitment of HDACs to oncogenic transcription factors 
causing hypoacetylation of core nucleosomal histones. Hypoacetylation of histones is 
associated with a condensed chromatin structure and repression of gene transcription. 
Vorinostat inhibits HDAC by binding directly to the catalytic pocket of HDAC1, HDAC2, 
and HDAC3 (Class I) and HDAC6 (Class II) enzymes. Inhibition of HDAC activity allows 
for the accumulation of acetylated histones. This accumulation influences the regulation of 
gene expression. In vitro, exposure of cultured transformed cell to vorinostat led to G1 or 
G2 phase cell-cycle arrest, apoptosis, or differentiation and demonstrated synergistic and 
additive activity in combination with other cancer therapies (including radiation, kinase 
inhibitors, cytotoxic agents, and differentiating agents). The mechanism of the 
antineoplastic effect of vorinostat has not been fully characterized.
After oral administration, vorinostat is rapidly absorbed, however, administration with a 
high-fat meal resulted in a 33% increase in the extent of absorption and a 2.5-hour delay 
in the rate of absorption compared to the fasted state. Vorinostat is approximately 71% 
bound to human plasma protein. It is extensively metabolized to inactive metabolites, 
primarily by glucuronidation and hydrolysis followed by beta-oxidation. The two 
metabolites, O-glucuronide of vorinostat and 4-anilino-4-oxobutanoic acid are 
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pharmacologically inactive. In vitro studies indicate that vorinostat is not metabolized by 
and does not inhibit the activity of cytochrome P-450 enzymes. Less than 1% of an 
administered dose is excreted unchanged in the urine. Approximately 35-52% of an oral 
dose of vorinostat is excreted in the urine as the two major metabolites. The mean 
terminal half-life of vorinostat and the O-glucuronide metabolite is approximately 2 
hours, while that of the 4-anilino-4-oxobutanoic acid metabolite it is 11 hours.
Prolongation of prothrombin time (PT) and International Normalized Ratio (INR) were 
observed in patients receiving vorinostat with coumarin-derivative anticoagulants (e.g., 
warfarin). Therefore, PT and INR should be monitored when coumarin-derivative 
anticoagulants are started or discontinued. 
When vorinostat was administered with other HDAC inhibitors (e.g., valproic acid), 
severe thrombocytopenia and gastrointestinal bleeding have been reported.
Toxicity:
Likely (>20%)
Less Likely (<20%)
Rare but Serious (<3%)
BLOOD AND LYMPHATIC SYSTEM DISORDERS
Anemia
GASTROINTESTINAL DISORDERS
Diarrhea
Nausea
Vomiting
Abdominal pain
Constipation
Dry mouth
Dyspepsia
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS
Fatigue
Fever
INFETIONS AND INFESTATIONS
Infection
INVESTIGATIONS
Alanine aminotransferase 
increased
Aspartate aminotransferase 
increased
Bilirubin increased
Creatinine increased
Lymphopenia
Neutropenia
Weight loss
White blood cell decreased
METABOLISM AND NUTRITION DISORDERS
Anorexia
Dehydration
Hyperglycemia
Hypocalcemia
Hypokalemia
Hypophosphatemia
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS
Muscle weakness
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Likely (>20%)
Less Likely (<20%)
Rare but Serious (<3%)
NERVOUS SYSTEM DISORDERS
Dizziness
Dysgeusia
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS
Cough
Dyspnea
SKIN AND SUBCUTANEOUS TISSUE DISORDERS
Alopecia
Skin necrosis
Prolongation of prothrombin time and International Normalized Ratio have been 
observed in patients using vorinostat concomitantly with coumarin-derivative 
anticoagulants.
Formulation and stability: Vorinostat is supplied as a white, opaque gelatin, size 3 capsule, 
containing 100 mg of vorinostat. The inactive ingredients in each capsule include 
icrocrystalline cellulose, sodium croscarmellose, and magnesium stearate. Vorinostat 100 
mg capsules are supplied in bottles containing 120 capsules.
Store vorinostat capsules at room temperature, 15 to 30ºC (59 to 86ºF). Do not store above 
30ºC and avoid exposure to excessive moisture.
Guidelines for administration: See Treatment and Dose Modification sections of the 
protocol. Vorinostat should be taken with food/breastmilk. The capsules should not be 
opened or crushed. A suspension can be prepared by the pharmacy (to prepare accurate 
doses) for patients that cannot swallow pills. Please see Appendix III for instructions on 
suspension preparation. Antacids such as proton pump inhibitors and H2 blockers are not 
contraindicated. Vorinostat may be administered with dexamethasone.  
Direct contact of the powder in vorinostat capsules with the skin or mucous membranes 
should be avoided. If such contact occurs, wash thoroughly. Clean powder spills from 
broken or damaged vorinostat capsules carefully minimizing inhalation. Wash spill area at 
least 3 times with ethyl alcohol, followed by water.
Supplier: Commercially available; see package insert for more detailed information.
Agent Accountability: The Investigator, or a responsible party designated by the 
Investigator, must maintain a careful record of the inventory and disposition of vorinostat, 
as it is conducted under an IND.
5.8
Cyclophosphamide (Cytoxan®)
Source and pharmacology: Cyclophosphamide is an alkylating agent related to nitrogen 
mustard. Cyclophosphamide is inactive until it is metabolized by P450 isoenzymes 
(CYP2B6, CYP2C9, and CYP3A4) in the liver to active compounds. The initial product is 
4-hydroxycyclophosphamide (4-HC) which is in equilibrium with aldophosphamide which 
spontaneously releases acrolein to produce phosphoramide mustard. Phosphoramide 
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mustard, which is an active bifunctional alkylating species, is 10 times more potent in vitro 
than is 4-HC and has been shown to produce interstrand DNA cross-link analogous to those 
produced by mechlorethamine. Approximately 70% of a dose of cyclophosphamide is 
excreted in the urine as the inactive carboxyphosphamide and 5-25% as unchanged drug. 
The plasma half-life ranges from 4.1 to 16 hours after IV administration.
Toxicity
Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Anorexia, nausea & 
vomiting (acute and 
delayed)
Abdominal discomfort, 
diarrhea
Transient blurred vision, 
nasal stuffiness with rapid 
administration, arrhythmias 
(rapid infusion), skin rash, 
anaphylaxis, SIADH
Prompt:  
Within 2-3 weeks, 
prior to the next 
course
Leukopenia, alopecia, 
immune suppression
Thrombocytopenia, 
anemia, hemorrhagic 
cystitis (L)
Cardiac toxicity with high 
dose (acute – CHF 
hemorrhagic myocarditis, 
myocardial necrosis) (L), 
hyperpigmentation, nail 
changes, impaired wound 
healing, infection 
secondary to immune 
suppression
Delayed:  
Any time later 
during therapy
Gonadal dysfunction: 
azoospermia or 
oligospermia (prolonged 
or permanent)1 (L)
Amenorrhea1
Gonadal dysfunction: 
ovarian failure1 (L), 
interstitial pneumonitis, 
pulmonary fibrosis2 (L)
Late:
Any time after 
completion of 
treatment
Secondary malignancy 
(ALL, ANLL, AML), 
bladder carcinoma (long 
term use > 2 years), bladder 
fibrosis
Unknown 
Frequency and 
Timing:
Fetal toxicities and teratogenic effects of cyclophosphamide (alone or in 
combination with other antineoplastic agents) have been noted in humans. 
Toxicities include: chromosomal abnormalities, multiple anomalies, 
pancytopenia, and low birth weight. Cyclophosphamide is excreted into breast 
milk. Cyclophosphamide is contraindicated during breast feeding because of 
reported cases of neutropenia in breast fed infants and the potential for serious 
adverse effects.
1 Dependent on dose, age, gender, and degree of pubertal development at time of treatment.
2 Risk increased with pulmonary chest irradiation and 
higher doses. (L) Toxicity may also occur later.
Formulation and stability: Cyclophosphamide for injection is available as powder for 
injection or lyophilized powder for injection in 500 mg, 1 g, and 2 g vials. The powder 
for injection contains 82 mg sodium bicarbonate/100 mg cyclophosphamide and the 
lyophilized powder for injection contains 75 mg mannitol/100 mg cyclophosphamide. 
Storage at or below 25ºC (77ºF) is recommended. The product will withstand brief 
exposures to temperatures up to 30ºC (86ºF).
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Guidelines for administration: See Treatment and Dose Modifications sections of the 
protocol.
Supplier: Commercially available; see package insert for more detailed information.
5.9
Mercaptopurine (6-MP; Purinethol®)
Source and pharmacology: Mercaptopurine is an analogue of the purine bases adenine and 
hypoxanthine. The main intracellular pathway for MP activation is catalyzed by the enzyme 
hypoxanthine-guanine phosphoribosyl transferase (HGPRT) which catalyzes the conversion 
of MP to several active nucleotide metabolites including thioinosinic acid, a ribonucleotide 
which can interfere with various metabolic reactions necessary for nucleic acid (RNA and 
DNA) biosynthesis. It can also cause pseudofeedback inhibition of the first step in de novo 
purine biosynthesis or convert to another ribonucleotide which can cause feedback inhibition. 
Mercaptopurine can be incorporated into DNA in the form of TG nucleotides as well and 
thus produce toxicity. The absorption of an oral dose of MP is incomplete and variable, with 
only about 16%-50% of an administered dose reaching the systemic circulation secondary to 
a first pass metabolism in the liver. Co-administration with cotrimoxazole (TMP/SMX) 
significantly reduces absorption of MP. After IV  administration, MP has a plasma half-life 
of 21 minutes in children. Approximately 19% is bound to protein. Mercaptopurine is well 
distributed into most body compartments except the CSF. (With high dose IV MP the CSF to 
plasma ratio is 0.15.) MP is metabolized by xanthine oxidase in the liver to 6-Thiouric acid 
an inactive metabolite. In patients receiving both MP and allopurinol (a xanthine oxidase 
inhibitor) the dose of MP must be reduced by 50-75%. Since TPMT, 6-thiopurine 
methyltransferase, is also one of the enzymes involved in the metabolism of MP, those 
individuals who have an inherited deficiency of the enzyme may be unusually sensitive to the 
myelosuppressive effects of MP and prone to develop rapid bone marrow suppression 
following the initiation of treatment. Mercaptopurine is excreted in urine as metabolites and 
some unchanged drug; about half an oral dose has been recovered in 24 hours. A small 
proportion is excreted over several weeks.
Toxicity:
Common
Happens to 21-100 
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Immediate: 
Within 1-2 days of 
receiving drug 
Anorexia, nausea, 
vomiting, diarrhea, 
malaise 
Urticaria, hyperuricemia 
Prompt: 
Within 2-3 weeks, prior to 
the next course 
Myelosuppression (L) 
Erythematous rash (L) 
Oral lesions resembling 
thrush, toxic hepatitis(L), 
increased AST/ALT 
hyperpigmentation (L), 
pancreatitis 
Delayed: 
Any time later during 
therapy, excluding the 
above conditions 
Oligospermia 
Hepatic fibrosis(L), 
hyperbilirubinemia, 
alopecia 
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Common
Happens to 21-100 
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Late: 
Any time after the 
completion of treatment 
Pulmonary fibrosis, 
secondary malignancies 
Unknown frequency 
and timing: 
Fetal toxicities and teratogenic effects of mercaptopurine have been noted in 
animals. Women receiving mercaptopurine in the first trimester of 
pregnancy have an increased incidence of abortion. It is unknown whether 
the drug is excreted in breast milk 
Formulation and stability: Mercaptopurine is available as a 50 mg tablet containing 
mercaptopurine and the inactive ingredients corn and potato starch, lactose, magnesium 
stearate, and stearic acid. Store at 15°-25°C (59°-77°F) in a dry place. Mercaptopurine is 
also available as an oral suspension in a concentration of 20 mg/mL (2000 mg/100 mL 
per bottle). The oral suspension is a pink to brown viscous liquid supplied in amber glass 
multiple-dose bottles with a child resistant closure. It should be stored at 15°-25°C (59°-
77°F) in a dry place. NOTE: the concentration of the commercially available suspension 
(20 mg/mL) and the compounded suspension (50 mg/mL) are NOT the same; doses 
should be prescribed in the milligrams required, not mL.
Guidelines for administration: See Treatment and Dose Modifications sections of protocol.
Supplier: Commercially available; see package insert for more detailed information.
5.10
Methotrexate – IV/IM/PO
Source and pharmacology: A folate analogue which reversibly inhibits dihydrofolate 
reductase, the enzyme that reduces folic acid to tetrahydrofolic acid. Inhibition of 
tetrahydrofolate formation limits the availability of one carbon fragments necessary for 
the synthesis of purines and the conversion of deoxyuridylate to thymidylate in the 
synthesis of DNA and cell reproduction. The polyglutamated metabolites of MTX also 
contribute to the cytotoxic effect of MTX on DNA repair and/or strand breaks. MTX 
cytotoxicity is highly dependent on the absolute drug concentration and the duration of 
drug exposure. MTX is actively transported across cell membranes. At serum 
methotrexate concentrations exceeding 0.1 µmol/mL, passive diffusion becomes a major 
means of intracellular transport of MTX. The drug is widely distributed throughout the 
body with the highest concentration in the kidney, liver, spleen, gallbladder and skin. 
Plasma concentrations following high dose IV MTX decline in a biphasic manner with an 
initial half-life of 1.5-3.5 hours, and a terminal half life of 8-15 hours. About 50% is 
bound to protein. MTX is excreted primarily by the kidneys via glomerular filtration and 
active secretion into the proximal tubules. Renal clearance usually equals or exceeds 
creatinine clearance. Small amounts are excreted in the feces. There is significant entero-
hepatic circulation of MTX. The distribution of MTX into third-space fluid collections, 
such as pleural effusions and ascitic fluid, can substantially alter MTX pharmacokinetics. 
The slow release of accumulated MTX from these third spaces over time prolongs the 
terminal half-life of the drug, leading to potentially increased clinical toxicity.
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Toxicity:
Common
Happens to 21-100
children out of every 
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5 children
out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Transaminase 
elevations
Nausea, vomiting, anorexia
Anaphylaxis, chills, fever, 
dizziness, malaise, 
drowsiness, blurred vision, 
acral erythema, urticaria, 
pruritis, toxic epidermal 
necrolysis, Stevens-Johnson 
Syndrome, tumor lysis 
syndrome, seizures, 
photosensitivity
Prompt:
Within 2-3 weeks, 
prior to the next 
course
Myelosuppression, 
stomatitis, gingivitis, 
photosensitivity, fatigue
Alopecia, folliculitis, acne, 
renal toxicity (ATN, 
increased creatinine/BUN, 
hematuria), enteritis, GI 
ulceration and bleeding, 
acute neurotoxicity 
(headache, drowsiness, 
aphasia, paresis, blurred 
vision, transient blindness, 
dysarthria, hemiparesis, 
Delayed:
Any time later during 
therapy, excluding the 
above conditions
Learning disability (L)
Pneumonitis, pulmonary 
fibrosis (L), hepatic fibrosis 
(L), osteonecrosis (L), 
leukoencephalopathy (L), 
pericarditis, pericardial 
effusions, hyperpigmentation 
of the nails
Late:
Any time after the 
completion of therapy
Progressive CNS 
deterioration
Unknown 
Frequency and 
Timing:
Methotrexate crosses the placenta.  Fetal toxicities and teratogenic effects of 
methotrexate have been noted in humans.  The toxicities include: congenital 
defects, chromosomal abnormalities, severe newborn myelosuppression, low 
birth weight, abortion, and fetal death.  Methotrexate is excreted into breast milk 
in low concentrations.
1May be enhanced by HDMTX and/or cranial irradiation.
(L) Toxicity may also occur later.
Formulation and stability: Methotrexate for Injection is available as a lyophilized powder 
for injection in 1000 mg vials. The powder for injection contains approximately 7 mEq 
sodium in the 1000 mg vial. Methotrexate for Injection is also available as a 25 mg/mL 
solution in 2, 4, 8, 10, and 40 mL preservative free vials and 2 and 10 mL vials with 
preservative. The 2, 4, 8, 10, and 40 mL solutions contain approximately 0.43, 0.86, 1.72, 
2.15, and 8.6 mEq sodium per vial, respectively. The preserved vials contain 0.9% benzyl 
alcohol as a preservative.
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Sterile methotrexate powder or solution is stable at 20º-25ºC (68º-77ºF); excursions 
permitted to 15º-30ºC (59º- 86 Fº). Protect from light.
Guidelines for administration: See Treatment and Dose Modifications sections of 
protocol. Leucovorin rescue may be necessary with certain doses of methotrexate.
For IV use: Powder for injection: Dilute 1000 mg vial with 19.4 mL of preservative free 
SWFI, D5W or NS to a 50 mg/mL concentration. The powder for injection may be 
further diluted in NS or dextrose containing solutions to a concentration of < 25mg/mL 
for IV use.
Do not use the preserved solution for high dose methotrexate administration due to 
risk of benzyl alcohol toxicity. Methotrexate dilutions are chemically stable for at least 7 
days at room temperature but contain no preservative and should be used within 24 hours. 
Diluted solutions especially those containing bicarbonate exposed to direct sunlight for 
periods exceeding 4 hours should be protected from light. High dose methotrexate 
requires alkalinization of the urine, adequate hydration and leucovorin rescue. Avoid 
probenecid, penicillins, cephalosporins, aspirin, proton pump inhibitors, and NSAIDS as 
renal excretion of MTX is inhibited by these agents.
Supplier: Commercially available; see package insert for further information.
5.11
Leucovorin Calcium (Wellcovorin®, folinic acid)
Source and pharmacology: Leucovorin is a mixture of the diastereoisomers of the 5-
formyl derivative of tetrahydrofolic acid (THF). The biologically active compound of the 
mixture is the (-)- l-isomer, known as Citrovorum factor or (-)- folinic acid. Leucovorin 
does not require reduction by the enzyme dihydrofolate reductase in order to participate 
in reactions utilizing folates as a source of “one-carbon” moieties. Administration of 
leucovorin can counteract the therapeutic and toxic effects of folic acid antagonists such 
as methotrexate, which act by inhibiting dihydrofolate reductase. In contrast, leucovorin 
can enhance the therapeutic and toxic effects of fluoropyrimidines used in cancer therapy, 
such as 5-fluorouracil. Leucovorin is readily converted to another reduced folate, 5,10-
methylenetetrahydrofolate, which acts to stabilize the binding of fluorodeoxyuridylic acid 
(an active metabolite of 5-FU) to thymidylate synthase and thereby enhances the 
inhibition of this enzyme. Peak serum levels of 5-methyl THF (an active metabolite) were 
reached at approximately 1.3-1.5 hours (IV/IM) and 2.3 hours for the oral form. The 
terminal half-life of total reduced folates was approximately 6.2 hours.  Following oral 
administration, leucovorin is rapidly absorbed and expands the serum pool of reduced 
folates. At a dose of 25 mg, almost 100% of the l-isomer (the biologically active form) 
but only 20% of the d-isomer is absorbed. Oral absorption of leucovorin is saturable at 
doses above 25 mg. The apparent bioavailability of leucovorin was 97% for 25 mg, 75% 
for 50 mg, and 37% for 100 mg doses. Both oral and parenteral leucovorin raise the CSF 
folate levels.
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Toxicity:
Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to <5
children out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Anaphylaxis, urticaria, 
seizure
Unknown 
frequency and 
timing:
Fetal toxicities and teratogenic effects of leucovorin in humans are unknown.  It 
is unknown whether the drug is excreted in breast milk.
Formulation and stability: Leucovorin calcium for injection is supplied as a sterile ready 
to use liquid and a sterile powder for injection. The 10 mg/mL preservative free liquid is 
available in 50 mL vials containing sodium chloride 400 mg/vial. Store preservative free 
liquid in the refrigerator at 2°-8°C (36°-46°F) protected from light. The powder for 
injection is available in 50 mg, 100 mg, 200 mg, and 350 mg vials. Store at room 
temperature 15°-25°C (59°-77°F) protected from light. Reconstitute the sterile powder 
with sterile water for injection or bacteriostatic water for injection to a concentration of 
10 mg/mL leucovorin calcium. Do not use diluents containing benzyl alcohol for doses 
> 10 mg/m² or in infants < 2 years of age or patients with allergy to benzyl alcohol. 
When Bacteriostatic Water is used, the reconstituted solution is good for 7 days. If 
reconstituted with SWFI, use solution immediately as it contains no preservative. One 
milligram of leucovorin calcium contains 0.004 mEq of leucovorin and 0.004 mEq of 
calcium.
The oral form of leucovorin is available as 5 mg, 10 mg, 15 mg, and 25 mg tablets. 
Inactive ingredients vary depending on manufacturer but tablet formulations may include: 
corn starch, dibasic calcium phosphate, magnesium stearate, pregelatinized starch, 
lactose, microcrystalline cellulose, and sodium starch glycolate.
Guidelines for administration: See Treatment and Dose Modifications sections of protocol.
Supplier: Commercially available; see package insert for further information.
5.12
Cytarabine (Ara-C; Cytosar-U®)
Source and pharmacology: Cytarabine appears to act through the inhibition of DNA 
polymerase. A limited, but significant, incorporation of cytarabine into both DNA and 
RNA has also been reported. It exhibits cell phase specificity, primarily killing cells 
undergoing DNA synthesis (S-phase) and under certain conditions blocking the progression 
of cells from the G1 phase to the S-phase. Cytarabine is metabolized by deoxycytidine 
kinase and other nucleotide kinases to the nucleotide triphosphate (Ara-CTP), an effective 
inhibitor of DNA polymerase. Ara-CTP is inactivated by a pyrimidine nucleoside 
deaminase, which converts it to the nontoxic uracil derivative (Ara-U). It appears that the 
balance of kinase and deaminase levels may be an important factor in determining 
sensitivity or resistance of the cell to cytarabine. It has an initial distributive phase t½ of 
about 10 minutes, with a secondary elimination phase t½ of about 1 to 3 hours. Peak levels 
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after intramuscular or subcutaneous administration of cytarabine occur about 20 to 60 
minutes after injection and are lower than IV administration. Intrathecally administered 
doses are metabolized and eliminated more slowly with a t½ of about 2 hours.
Toxicity:
Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to < 5
children out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Nausea, vomiting, 
anorexia
Flu-like symptoms with 
fever, rash
Ara-C syndrome (fever, 
myalgia, bone pain, 
occasionally chest pain, 
maculopapular rash, malaise, 
conjunctivitis), anaphylaxis
Prompt:
Within 2-3 weeks, 
prior to the next 
course
Myelosuppression 
(anemia, 
thrombocytopenia, 
leukopenia, 
megaloblastosis, 
reticulocytopenia), 
stomatitis, alopecia
Diarrhea, hypokalemia, 
hypocalcemia, 
hyperuricemia
Hepatotoxicity, sinusoidal 
obstruction syndrome (SOS, 
formerly VOD), urinary 
retention, renal dysfunction, 
pain and erythema of the 
palms and soles
Delayed:
Any time later 
during  therapy, 
excluding the above 
conditions
Asymptomatic nonoliguric 
rhabdomyolysis
Unknown 
frequency and 
timing:
Fetal toxicities and teratogenic effects of cytarabine have been noted in humans. It 
is unknown whether the drug is excreted in breast milk.
Formulation and stability: Cytarabine for Injection is available in vials of 100 mg, 500 
mg, 1 g, and 2 g containing a sterile powder for reconstitution. It is also available at a 20 
mg/mL concentration with benzyl alcohol (25 mL per vial) or as a preservative free 
solution (5 mL, 50 mL per vial), and at a 100 mg/mL concentration with benzyl alcohol 
(20 mL vial) or as preservative free solution (20 mL vial). Hydrochloric acid and/or 
sodium hydroxide may be added to adjust the pH. Store at 25°C (77°F); excursions 
permitted to 15°-30°C (59°-86°F). Cytarabine solutions should be protected from light.  
When reconstituted with Bacteriostatic Water for Injection, cytarabine is stable for 48 
hours at room temperature. Solutions reconstituted without a preservative should be used 
immediately. Discard if solution appears hazy. Diluted solutions in D5W or NS are stable 
for 8 days at room temperature; however, the diluted cytarabine should be used within 24 
hours for sterility concerns.
Guidelines for administration: See Treatment and Dose Modification sections of the 
protocol.
Supplier: Commercially available; see package insert for further information.
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5.13
Etoposide (VP-16, Vepesid®) and Etoposide Phosphate (Etophos®)
Source and pharmacology: A semisynthetic derivative of podophyllotoxin that forms a 
complex with topoisomerase II and DNA which results in single and double strand DNA 
breaks. Its main effect appears to be in the S and G2 phase of the cell cycle. The initial t½ 
is 1.5 hours and the mean terminal half-life is 4 to 11 hours. It is primarily excreted in the 
urine. In children, approximately 55% of the dose is excreted in the urine as etoposide in 
24 hours. The mean renal clearance of etoposide is 7 to 10 mL/min/m² or about 35% of 
the total body clearance over a dose range of 80 to 600 mg/m². Etoposide, therefore, is 
cleared by both renal and non renal processes, i.e., metabolism and biliary excretion. The 
effect of renal disease on plasma etoposide clearance is not known. Biliary excretion 
appears to be a minor route of etoposide elimination. Only 6% or less of an intravenous 
dose is recovered in the bile as etoposide. Metabolism accounts for most of the non renal 
clearance of etoposide.
The maximum plasma concentration and area under the concentration time curve (AUC) 
exhibit a high degree of patient variability. Etoposide is highly bound to plasma proteins 
(~94%), primarily serum albumin. Pharmacodynamic studies have shown that etoposide 
systemic exposure is related to toxicity. Preliminary data suggests that systemic exposure 
for unbound etoposide correlates better than total (bound and unbound) etoposide. There 
is poor diffusion into the CSF < 5%.
Etoposide phosphate is a water soluble ester of etoposide which is rapidly and completely 
converted to etoposide in plasma. Pharmacokinetic and pharmacodynamic data indicate 
that etoposide phosphate is bioequivalent to etoposide when it is administered in molar 
equivalent doses.  Etoposide phosphate will be used if the patient has drug reaction with 
etoposide.
Toxicity:
Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to < 5
children out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Nausea, vomiting
Anorexia
Transient hypotension 
during infusion; 
anaphylaxis (chills, fever, 
tachycardia, dyspnea, 
bronchospasm, 
hypotension)
Prompt:
Within 2-3 weeks, 
prior to next course
Myelosuppression 
(anemia, leukopenia), 
alopecia
Thrombocytopenia, 
diarrhea, abdominal 
pain, asthenia, malaise, 
rashes and urticaria
Peripheral neuropathy, 
mucositis, hepatotoxicity, 
chest pain, 
thrombophlebitis, 
congestive heart failure, 
Stevens-Johnson 
Syndrome, exfoliative 
dermatitis
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Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to < 5
children out of every 100
Delayed:
Any time later during 
therapy
Dystonia, ovarian failure, 
amenorrhea, anovulatory 
cycles, hypomenorrhea, 
onycholysis of nails
Late:
Any time after 
completion of 
treatment
Secondary malignancy 
(preleukemic or leukemic 
syndromes)
Unknown 
frequency and 
timing:
Fetal toxicities and teratogenic effects of etoposide have been noted in animals 
at 1/20th of the human dose. It is unknown whether the drug is excreted in 
breast milk.
Formulation and stability: Etoposide for Injection is available as a 20 mg/mL solution in 
sterile multiple dose vials (5 mL, 25 mL, or 50 mL each). The pH of the clear, nearly 
colorless to yellow liquid is 3 to 4. Each mL contains 20 mg etoposide, 2 mg citric 
acid, 30 mg benzyl alcohol, 80 mg modified polysorbate 80/tween 80, 650 mg 
polyethylene glycol 300, and 30.5 percent (v/v) alcohol. Vial headspace contains nitrogen. 
Unopened vials of etoposide are stable until expiration date on package at controlled 
room temperature (20˚-25˚C or 68˚- 77˚F).
Etoposide phosphate for injection is available for intravenous infusion as a sterile 
lyophilized powder in single-dose vials containing etoposide phosphate equivalent to 100 
mg etoposide, 32.7 mg sodium citrate USP, and 300 mg dextran 40. Etoposide 
phosphate must be stored under refrigeration (2°-8°C or 36°- 46°F). Unopened vials of 
etoposide phosphate are stable until the expiration date on the package.
Guidelines for administration: See Treatment and Dose Modification sections of the 
protocol.
Etoposide: Dilute etoposide to a final concentration ≤ 0.4 mg/mL in D5W or NS. 
Etoposide infusions are stable at room temperature for 96 hours when diluted to 
concentrations of 0.2 mg/mL; stability is 24 hours at room temperature with 
concentrations of  0.4 mg/mL. The time to  precipitation is highly unpredictable at 
concentrations > 0.4 mg/mL. Use in-line filter during infusion secondary to the risk of 
precipitate formation. However, the use of an in-line filter is not mandatory since 
etoposide precipitation is unlikely at concentrations of 0.1-0.4 mg/mL. Do not 
administer etoposide by rapid intravenous injection. Slow rate of administration if 
hypotension occurs.
Leaching of diethylhexyl phthalate (DEHP) from polyvinyl chloride (PVC) bags occurred 
with etoposide 0.4 mg/mL in NS. To avoid leaching, prepare the etoposide solution as 
close as possible, preferably within 4 hours, to the time of administration or alternatively 
as per institutional policy; glass or polyethylene-lined (non-PVC) containers and 
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polyethylene-lined tubing may be used to minimize exposure to DEHP.
Etoposide phosphate: Reconstitute the 100 mg vial with 5 or 10 mL of Sterile Water for 
Injection, D5W, NS, Bacteriostatic Water for Injection with Benzyl Alcohol, or 
Bacteriostatic Sodium Chloride for Injection with Benzyl Alcohol for a concentration 
equivalent to 20 mg/mL or 10 mg/mL etoposide equivalent (22.7 mg/mL or 11.4 mg/mL 
etoposide phosphate), respectively. Use diluents without benzyl alcohol for neonates and 
infants < 2 years of age or patients with hypersensitivity to benzyl alcohol.
When reconstituted as directed, etoposide phosphate solutions can be stored in glass or 
plastic containers under refrigeration for 7 days. When reconstituted with a diluent 
containing a bacteriostat, store at controlled room temperature for up to 48 hours. 
Following reconstitution with SWFI, D5W, or NS store at controlled room temperature for 
up to 24 hours.
Following reconstitution, etoposide phosphate may be further diluted to a concentration as 
low as 0.1 mg/mL of etoposide with D5W or NS. The diluted solution can be stored under 
refrigeration or at controlled room temperature for 24 hours.
Supplier: Commercially available; see package insert for more information.
5.14
VinCRIStine (Oncovin®)
Source and pharmacology: Vincristine is an alkaloid isolated from Vinca rosea Linn 
(periwinkle). It binds to tubulin, disrupting microtubules and inducing metaphase arrest. 
Its serum decay pattern is triphasic. The initial, middle, and terminal half-lives are 5 
minutes, 2.3 hours, and 85 hours respectively; however, the range of the terminal half-life 
in humans is from 19 to 155 hours. The liver is the major excretory organ in humans and 
animals; about 80% of an injected dose of vincristine sulfate appears in the feces and 
10% to 20% can be found in the urine. The p450 cytochrome involved with vincristine 
metabolism is CYP3A4. Within 15 to 30 minutes after injection, over 90% of the drug is 
distributed from the blood into tissue, where it remains tightly, but not irreversibly bound. 
It is excreted in the bile and feces. There is poor CSF penetration.
Toxicity:
Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to < 5
children out of every 100
Immediate:
Within 1-2 days of 
receiving drug
Jaw pain, headache
Extravasation (rare) but if 
occurs = local ulceration, 
shortness of breath, and 
bronchospasm
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Common
Happens to 21-100
children out of every 100
Occasional
Happens to 5-20
children out of every 100
Rare
Happens to < 5
children out of every 100
Prompt:
Within 2-3 weeks, 
prior to the next 
course
Alopecia, 
constipation
Weakness, abdominal 
pain, mild brief 
myelosuppression 
(leukopenia, 
thrombocytopenia, 
anemia)
Paralytic ileus, ptosis, diplopia, 
night blindness, hoarseness, 
vocal cord paralysis, SIADH, 
seizure, defective sweating
Delayed:
Any time later 
during therapy
Loss of deep tendon 
reflexes
Peripheral paresthesias 
including numbness, 
tingling and pain; 
clumsiness; wrist drop, 
foot drop, abnormal gait
Difficulty walking or inability 
to walk; sinusoidal obstruction 
syndrome (SOS, formerly 
VOD) (in combination); 
blindness, optic atrophy; 
urinary tract disorders 
(including bladder atony, 
dysuria, polyuria, nocturia, and 
urinary retention); autonomic 
neuropathy with postural 
hypotension; 8th cranial nerve 
damage with dizziness, 
nystagmus, vertigo and hearing 
loss
Unknown 
frequency and 
timing:
Fetal toxicities and teratogenic effects of vincristine (either alone or in 
combination with other antineoplastic agents) have been noted in humans. The 
toxicities include: chromosome abnormalities, malformation, pancytopenia, and 
low birth weight. It is unknown whether the drug is excreted in breast milk.
Formulation and stability: Vincristine is supplied in 1 mL and 2 mL vials in which each 
mL contains vincristine sulfate 1 mg (1.08 µmol), mannitol 100 mg, SWFI; acetic acid 
and sodium acetate are added for pH control. The pH of vincristine sulfate injection, USP 
ranges from 3.5 to 5.5. This product is a sterile, preservative free solution. Store 
refrigerated at 2˚-8˚C or 36˚-46˚F. Protect from light and retain in carton until time of 
use. Do not mix with any IV solutions other than those containing dextrose or saline.
Guidelines for administration: See Treatment and Dose Modifications sections of protocol.
The World Health Organization, the Institute of Safe Medicine Practices (United States) 
and the Safety and Quality Council (Australia) all support the use of minibag rather than 
syringe for the infusion of vincristine. The delivery of vincristine via either IV slow push 
or minibag is acceptable for this study. Vincristine should NOT be delivered to the 
patient at the same time with any medications intended for central nervous system 
administration. Vincristine is fatal if given intrathecally.
Injection of vincristine sulfate should be accomplished as per institutional policy. 
Vincristine sulfate must be administered via an intact, free-flowing intravenous needle or 
catheter. Care should be taken to ensure that the needle or catheter is securely within the 
vein to avoid extravasation during administration. The solution may be injected either 
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directly into a vein or into the tubing of a running intravenous infusion.
Special precautions: FOR INTRAVENOUS USE ONLY. The container or the syringe 
containing vinCRIStine must be enclosed in an overwrap bearing the statement: “Do not 
remove covering until moment of injection. For intravenous use only - Fatal if given by 
other routes.”
Supplier: Commercially available; see package insert for more detailed information.
5.15
Drug Shortages and Unavailability
In the case of drug shortages and unavailability of any agent used in this protocol, 
treating investigators are urged to consult with the PI or co-PI and use their best clinical 
judgment in optimizing therapeutic intent and ensuring patient safety in managing the 
protocol-specified therapy. 
Although these decisions may constitute “Protocol Violations,” they are unavoidable and 
made in consideration of the best interest of an individual patient. These will NOT be 
considered monitoring/audit findings if appropriately documented. Most importantly, all 
protocol deviations must be noted in the research database and the alterations in therapy 
due to the agent shortage will be captured. This should be accomplished by entering 
“dose modified” and details noted in the comments field.
6.0
TREATMENT MODIFICATIONS
6.1
Renal Dysfunction 
6.1.1
Methotrexate
Subclinical renal impairment (normal serum creatinine but decreased GFR) may be 
present in patients receiving concurrent nephrotoxic drugs (e.g. IV acyclovir) which, if 
possible, should be held during and for 20 hours after HDMTX infusions or until 
adequate MTX clearance has been documented. Consideration to delaying MTX should 
be given if a patient's serum creatinine indicates renal impairment.
6.1.2
Cytarabine doses ≥1000g/m2
If serum creatinine is > 2 mg/dL or > 2 x normal for age, perform a CrCl.  If the CrCl is 
<60 mL/min/1.73m2, then high dose cytarabine should be reduced from twice to once 
daily dosing, (50% dose reduction).42
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6.1.3
Etoposide
Dose modification for renal dysfunction
CCl or GFR (ml/min per 1.73m2)
Etoposide  Dose to Administer
> 60 ml/min per 1.73 m2
Full Dose
30-60 ml/min per 1.73 m2
50%
< 30 ml/min per 1.73 m2
omit
6.2
Hepatic Dysfunction 
Anthracyclines and vincristine dosages should be modified in patients with elevated 
direct bilirubin concentrations or other evidence of biliary obstruction.  

Direct bilirubin ≤3.0:
Full dose

Direct bilirubin 3.1-5 mg/dl:
50% dosage decrease

Direct bilirubin 5.1-6 mg/dl:
75% dosage decrease

Direct bilirubin >6 mg/dl:
Withhold dose
PEG-asparaginase may need to be withheld in patients with elevated direct bilirubin 
concentrations, especially if there is evidence of mucositis.  
HDMTX should be withheld if there is evidence of existing mucositis or if total bilirubin 
>2 mg/dl and direct bilirubin >1.4 mg/dl.
Subclinical hypertransaminasemia (SGPT >500 IU/L) is an indication to delay only high-
dose methotrexate but not other chemotherapy.
Patients with mild hepatic impairment do not require dose adjustment of bortezomib. 
Patients with moderate or severe hepatic impairment should receive bortezomib at 
modified doses as outlined below:
Direct bilirubin 
level
Bortezomib dose modification
Moderate
> 1.5x – 4x ULN
Severe
> 4x ULN
Reduce bortezomib in patients with moderate to severe elevated 
direct bilirubin levels to:

0.7 mg/m2  for patients ≥10kg and ≥12months of age or 

0.023 mg/kg for patients <10kg and/or <12months of age
If direct bilirubin levels decrease to ≤1.5x ULN consider dose 
escalation for subsequent doses based on patient tolerability to:

1 mg/m2 for patients ≥10kg and ≥12months of age or

0.033mg/kg for patients <10kg and/or <12months of age
If direct bilirubin levels normalize consider dose escalation for 
subsequent doses based on patient tolerability to:

1.3 mg/m2 for patients ≥10kg and ≥12months of age or
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Direct bilirubin 
level
Bortezomib dose modification

0.043mg/kg for patients <10kg and/or <12months of age
or if direct bilirubin levels continue to rise consider further dose 
reduction to: 

0.5 mg/m2 for patients ≥10kg and ≥12months of age or 

0.017mg/kg for patients <10kg and/or <12months of age
*No adjustment necessary for elevated SGOT (ALT).
6.3
Testicular Leukemia at Diagnosis
Overt testicular leukemia occurs in 2% of boys at diagnosis, generally in infants or 
adolescents with hyperleukocytosis. Ultrasonogram should be performed to differentiate 
testicular leukemia from hydrocele and to measure the testicular volume. Overt testicular 
leukemia at diagnosis per se is not an indication for testicular irradiation, as many 
patients can be successfully treated with chemotherapy, including high-dose 
methotrexate. Ultrasonogram should again be performed upon completion of remission 
induction. If testicular size is still abnormally enlarged, the sonogram should be repeated 
after consolidation treatment with high-dose methotrexate and mercaptopurine. 
Persistently enlarged testes after consolidation treatment will be biopsied. Testicular 
irradiation (24 Gy) will be administered in the rare patients with positive biopsies, after 
consultation with a radiation oncologist. 
6.4
Vincristine Neurotoxicity
The maximum single dose of vincristine must not exceed 2 mg. Mild vincristine toxicities 
(jaw pain, constipation, and decreased deep tendon reflexes) are anticipated. Loss of 
voice due to vocal cord paralysis may be a complication of vincristine toxicity but it must 
be differentiated from pharyngitis or Candida infection of the cord. 
6.4.1
Dose Modifications for Toxicity: PLEASE USE ―BALIS SCALE FOR 
GRADING NEUROPATHY (See text box below) 

Severe neuropathic pain (Grade 3 or greater):  Hold dose(s). When symptoms 
subside, resume at 50% previous calculated dose (maximum dose: 1 mg), then 
escalate to full dose as tolerated. NOTE: neuropathic pain can be not only severe but 
difficult to treat. However, because vincristine is an important component of curative 
therapy and the majority of neuropathies are ultimately reversible, vincristine therapy 
may be given at full dose at investigator discretion. Severe peripheral neuropathies, 
with or without a positive family history might suggest the need for a molecular 
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diagnostic evaluation to rule out Charcot Marie Tooth Disease (CMT), Type 1A or 
Hereditary neuropathy. Drugs such as gabapentin may be of value. 

Vocal cord paralysis: Hold dose(s). When symptoms subside, resume at 50% 
previous calculated dose (maximum dose: 1 mg), then escalate to full dose as 
tolerated. See above for comment on CMT. 

Foot drop, paresis: Should be Grade 3 to consider holding or decreasing dose. These 
toxicities are largely reversible but over months to years. Accordingly, holding doses 
of vincristine and/or lowering the dose may not result in rapid resolution of symptoms 
and may compromise cure. See above for comment on CMT. Physical therapy may 
be beneficial to maintain range of motion and provide AFO‘s and other forms of 
support. Drugs such as gabapentin may be of value. 

Jaw pain: Treat with analgesics; do not modify vincristine dose.

Hyperbilirubinemia-see section 6.2

Constipation or ileus (≥ Grade 3) or typhlitis: Hold dose(s); institute aggressive 
regimen to treat constipation if present. When symptoms abate resume at 50% of 
calculated dose (maximum dose: 1 mg) and escalate to full dose as tolerated. 

Extravasation: Discontinue the IV administration of the drug and institute appropriate 
measures to prevent further extravasation and damage according to institutional practice 
6.4.2
Modified (Balis) Pediatric Scale of Peripheral Neuropathies 
Peripheral Motor Neuropathy: 

Grade 1: Subjective weakness, but no deficits detected on neurological exam, 
other than abnormal deep tendon reflexes. 

Grade 2: Weakness that alters fine motor skills (buttoning shirt, coloring, 
writing or drawing, using eating utensils) or gait without abrogating ability to 
perform these tasks. 

Grade 3: Unable to perform fine motor tasks (buttoning shirt, coloring, writing 
or drawing, using eating utensils) or unable to ambulate without assistance. 

Grade 4: Paralysis. 
Peripheral Sensory Neuropathy: 

Grade 1: Paresthesias, pain, or numbness that do not require treatment or 
interfere with extremity function. 

Grade 2: Paresthesias, pain, or numbness that are controlled by non-narcotic 
medications (without causing loss of function), or alteration of fine motor skills 
(buttoning shirt, writing or drawing, using eating utensils) or gait, without 
abrogating ability to perform these tasks.

Grade 3: Paresthesias or pain that are controlled by narcotics, or interfere with 
extremity function (gait, fine motor skills as outlined above), or quality of life 
(loss of sleep, ability to perform normal activities severely impaired). 

Grade 4: Complete loss of sensation, or pain that is not controlled by narcotics. 
Motor Neuropathy in Infants:  Please see comments in section 6.7.
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6.5
Cytarabine Neurotoxicity
Discontinue cytarabine for > Grade 3 CTCAE v 4 nervous system disorders. The most 
common nervous system disorder is an acute cerebellar syndrome that may manifest itself 
as ataxia, nystagmus, dysarthria, or dysmetria. However, seizures and encephalopathy 
have also occurred following therapy with high dose cytarabine.
6.6
Methotrexate Neurotoxicity
Infants that experience a seizure following IT MHA or high dose methotrexate should be 
started on levetiracetam for seizure control and continue on this medication until one 
month following the last dose of intrathecal. If the seizure occurred following IT MHA, 
all subsequent IT MHA should be followed by leucovorin rescue regardless of phase or 
ANC. If the patient has further seizures following IT MHA while on levetiracetam with 
leucovorin rescue, the methotrexate should be removed from the intrathecals and the 
patient should receive IT HA for all subsequent doses. Patients who experience a seizure 
secondary to high dose methotrexate should be started and maintained on levetiracetam 
as described above. The subsequent courses of high dose methotrexate should be given at 
1g/m2. If the patient experiences another seizure on the lower dose of methotrexate, then 
the remaining courses of high dose methotrexate may be omitted and the patient can 
proceed directly to reinduction once they meet WBC, ANC, and platelet criteria.  
6.7
Mitoxantrone Cardiac Toxicity
Do not give MITOX if there is significant evidence of cardiac disease by echocardiogram 
or MUGA (shortening fraction <28% or ejection fraction <55%). Do not re-start if held 
for left ventricular shortening dysfunction that is not associated with a microbiologically 
proven bacteremia or sepsis. If the left ventricular shortening dysfunction occurred in the 
setting of microbiologically proven bacteremia or sepsis, then MITOX may be 
reinstituted at the treating clinician’s discretion once the shortening fraction has returned 
to ≥28% or ejection fraction is ≥55%.
6.8
Bortezomib Neurotoxicity
Peripheral neuropathy will be closely monitored during each block of treatment and 
toxicities graded. A complete neurological exam should be documented prior to the start 
of therapy. Neuropathy is often difficult to diagnose in infants. Symptoms may include 
hypotonia, delayed motor development, areflexia, and/or foot deformities. Facial 
weakness and tongue fasciculations may be present.  
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As a reference, timing of developmental reflexes are indicated in the table below.
Reflex 
Stimulation 
Response 
Duration 
Babinski 
Sole of foot stroked 
Fans out toes and twists 
foot in 
Disappears at nine 
months to a year 
Blinking 
Flash of light or puff of air Closes eyes 
Permanent 
Grasping 
Palms touched 
Grasps tightly 
Weakens at three 
months; disappears at a 
year 
Moro 
Sudden move; loud noise 
Startles; throws out 
arms and legs and then 
pulls them toward body 
Disappears at three to 
four months 
Rooting 
Cheek stroked or side of 
mouth touched 
Turns toward source, 
opens mouth and sucks 
Disappears at three to 
four months 
Stepping 
Infant held upright with 
feet touching ground 
Moves feet as if to walk 
Disappears at three to 
four months 
Sucking 
Mouth touched by object 
Sucks on object 
Disappears at three to 
four months 
Swimming Placed face down in water 
Makes coordinated 
swimming movements 
Disappears at six to 
seven months 
Tonic 
neck 
Placed on back 
Makes fists and turns 
head to the right 
Disappears at two 
months 
Neuropathy grading should be based on the maximum toxicity occurring during the 
previous block. All dose modifications should be based on the worst preceding toxicity. 
Bortezomib dose will be decreased for sensory peripheral neuropathy per Section 6.7.1.
6.8.1
Dose Modifications for Bortezomib-Related Neuropathic Pain and/or Peripheral 
Sensory Neuropathy
Severity of sensory peripheral neuropathy
Bortezomib modification
Grades 1-3 with no pain
Same dose as previous
Grade 1 with pain or Grade 2
Initiate gabapentin at 15 mg/kg/day divided 
into three doses43.
Grade 3 with pain
Hold bortezomib treatment until symptoms 
have resolved to ≤ Grade 1. Do not make up 
missed doses. When toxicity resolves, re-
initiate bortezomib at:

 1 mg/m2/dose subQ for patients ≥10kg 
and ≥12months of age and

0.033mg/kg/dose subQ for patients 
<10kg and/or <12 mo of age.
Grade 4
Discontinue bortezomib
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Patients experiencing any grade of peripheral neuropathy should receive all subsequent 
doses of bortezomib subcutaneously due to the lower incidence of neuropathic side 
effects with this alternative dosing route.44
If Grade 3 sensory peripheral neuropathy with pain persists for >2 weeks, bortezomib 
should be discontinued.
Patients experiencing Grade 4 sensory peripheral neuropathy will discontinue treatment. 
If Grade 2 or 3 sensory neuropathy with pain recurs despite bortezomib dose reduction to 
1 mg/m2, the patient should discontinue protocol treatment.
Patients whose sensory peripheral neuropathy resolves to ≤ Grade 1 or baseline within 2 
weeks can receive bortezomib in subsequent at 1 mg/m2/dose or 0.033mg/kg/dose subQ.
6.9
Venous Thromboembolism 
Patients who develop cerebral or other venous thrombosis will receive low molecular 
weight heparin throughout treatment with asparaginase (during Reinduction). Acute 
management of thrombosis will be managed as per individual institutional guidelines; 
questions should be referred to the PI or co-PI. Also see section 6.10.
6.10
Avascular Necrosis of Bone 
MRI exams will be interpreted by the radiologist. If there is evidence of epiphyseal or 
metaphyseal hip lesions, knee epiphyseal or metaphyseal lesions, or lesions of talus 
consistent with avascular necrosis of the bone, the patient will be referred to the 
orthopedic surgeon, who will evaluate symptoms, and will assess the severity and 
estimated risk of progression. Physical therapy, activity modifications, and surgical 
procedures will be recommended as needed. Patients with hip epiphyseal lesions or talus 
lesions affecting > 30% of weight-bearing area will have an X-ray of the affected area, 
and will be assessed at higher risk for progression. Symptomatic patients with such 
findings will likely have their dexamethasone stopped, especially if they are past 
reinduction in therapy. Asymptomatic patients with such findings will likely have their 
dexamethasone dose halved, especially if they are past reinduction in therapy. Any 
patients with X-ray findings of AVN are candidates for dexamethasone modification, 
regardless of symptoms. All modifications (or lack thereof) of dosage will be recorded in 
the research database. Patients with progression of any lesions or with worsening 
symptoms will be re-evaluated by imaging and, if appropriate, by additional orthopedic 
follow-up. If the dexamethasone is discontinued, the, first choice will be to replace each 
week’s dosing with one dose of methotrexate (40 mg/m2), if tolerated.  
6.11
PEG-Asparaginase Dose Modifications
Patients with allergic reactions or intolerance to PEG-asparaginase subsequently will be 
given Erwinia L-asparaginase intramuscularly or intravenously over 30-60 minutes 
duration. Each dose of PEG will be replaced by Erwinia at 25,000 units/m2/dose three 
times weekly  for 6 doses for each planned PEGaspargase dose. Native E. coli 
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asparaginase can also be given when clinically indicated, but this should be discussed and 
approved by the PI or co-PI. Patients who are intolerant to all asparaginase formulations 
can have asparaginase held.

Coagulopathy 
o
If symptomatic, hold asparaginase until symptoms resolve, then resume with 
the next scheduled dose. Consider factor replacement (FFP, cryoprecipitate, 
factor VIIa). Do not withhold dose for abnormal laboratory findings without 
clinical symptoms. 
o
Thrombosis: Withhold asparaginase until resolved, and treat with appropriate 
antithrombotic therapy, as indicated. Upon resolution of symptoms consider 
resuming asparaginase, while continuing LMWH or antithrombotic therapy. 
Do not withhold dose for abnormal laboratory findings without clinical 
correlate. For significant thrombosis, not line related, consider evaluation for 
inherited predisposition to thrombosis.
o
CNS Events (bleed, thrombosis or infarction): Hold asparaginase. Treat with 
FFP, factors or anticoagulation as appropriate. Resume at full dose when all 
symptoms have resolved (and evidence of recanalization in case of thrombosis 
by CT/MRI). Consider evaluation for inherited predisposition to thrombosis

Hyperbilirubinemia: see section 6.2. 

Hyperglycemia: Do not modify dose. Treat hyperglycemia as medically  indicated.

Hyperlipidemia: Do not modify dose. 

Ketoacidosis: Hold asparaginase until blood glucose can be regulated with insulin.
6.12
Dexamethasone Dose Modifications

Hypertension: Dose should not be reduced. Sodium restriction and anti-
hypertensives should be employed in an effort to control hypertension. Avoid 
calcium channel blockers due to their potential prohemorrhagic effect. 

Hyperglycemia: Dose should not be reduced for hyperglycemia. Rather, insulin 
therapy should be employed to control the blood glucose level.

Pancreatitis: Do not modify dose for asymptomatic elevations of amylase and/or 
lipase. Contact the PI or co-PI to discuss the management if there is a possibility 
that the pancreatitis is due to Dexamethasone.

Osteonecrosis (ON): Do not modify corticosteroid therapy for osteonecrosis (also 
referred to as avascular necrosis) during Reinduction and Reintensification. Omit 
Maintenance steroid for osteonecrosis Grade 2 or greater. Consider resuming 
steroid after 6 months if joint symptoms have resolved and if MRI findings have 
significantly improved or normalized. 

Varicella: Steroids should be held during active infection except during Induction, 
Reinduction and Reintensification. Do not hold during incubation period 
following exposure.

Inability to use oral doses: Substitute the IV preparation mg for mg. 

Severe infection: Do not hold or discontinue steroids during Induction, 
Reinduction, and Reintensification without serious consideration, as this is a 
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critical period in the treatment of ALL. Later one may consider holding steroid 
until patient achieves cardiovascular stability, except for ―stress doses.

Severe psychosis: Dexamethasone dose may be reduced by 50% for severe 
psychosis. If symptoms persist, switch to prednisone.
6.13
Management of Pancreatitis
Acute hemorrhagic pancreatitis is a contraindication to continue asparaginase treatment. 
In the case of mild to moderate pancreatitis, asparaginase should be held until symptoms 
and signs subside, and amylase and lipase levels return to normal and then resumed. Any 
patients with abdominal pain suspected of pancreatitis should have serum amylase and 
lipase measured as well as an abdominal sonogram or CT scan done.  In the case of 
severe pancreatitis (i.e. abdominal pain of 72 hours or more, amylase level three times or 
more of the upper limit of normal, and sonographic or CT scan evidence of pancreatitis), 
asparaginase may be discontinued permanently when the possibility of glucocorticoid- or 
mercaptopurine-induced pancreatitis is excluded. In cases with mild to moderate 
pancreatitis (abdominal pain less than 72 hours and amylase and lipase level less than 
three times the upper limit of normal), asparaginase should be held and resumed once 
symptoms and signs subsided.  Call the PI or co-PI to discuss the management if the 
patient is asymptomatic (without abdominal pain) and has only elevated amylase or lipase 
levels. Consideration should also be given to dexamethasone- or mercaptopurine- related 
pancreatitis. Contact the PI or co-PI to discuss the management if there is a possibility 
that the pancreatitis is due to either of these two drugs.  
7.0
CONTINGENCY PLANS FOR REFRACTORY DISEASE OR RELAPSE
7.1
Increasing MRD During Consolidation
Patients that achieve complete remission following induction (<5% leukemic blasts in 
bone marrow) but have detectable disease by MRD that fails to decrease during 
consolidation may abort methotrexate courses and proceed directly to reinduction 
provided they are clinically stable.  These patients should be considered for referral to 
transplant in first remission.  
7.2
Induction Failures
Patients who do not attain complete remission (≥5% leukemic blasts in bone marrow) 
after remission induction, consolidation, and reinduction treatment will be removed from 
the protocol.  Those with >0.01% leukemic blasts after consolidation therapy are 
candidates for allogeneic hematopoietic stem cell transplantation.
7.3
Hematologic Relapse
Patients with ≥25% lymphoblasts in the marrow aspirate will be removed from protocol.
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7.4
Extramedullary Relapse
Patients with any form of extramedullary relapse (testes, ovarian, etc.) except that of CNS 
will become eligible for relapse protocols.  Patients with overt CNS relapse (i.e. ≥5 
WBC/ul of CSF with blasts confirmed by TdT staining) will be removed from protocol.  
Patients with <5 WBC/ul of CSF with detectable blasts confirmed by TdT staining that 
remain in hematologic remission, will remain on study and receive twice weekly 
intrathecals until they have two negative taps or receive a total of 6 doses (whichever 
comes first) in addition to the systemic chemotherapy that is due as per the protocol.  
This will be followed by intrathecals every 4 weeks until the completion of 
chemotherapy.
8.0
REQUIRED EVALUATIONS, TESTS, AND OBSERVATIONS
8.1
Pre-Study Evaluations
All entry/eligibility studies must be performed within 1 week prior to entry onto the trial.

Complete history and physical exam with careful notation and assessment of clinical 
signs relevant to leukemia

CBC w/differential

Chemistry profile: glucose, electrolytes, BUN, creatinine, LDH, uric acid, bilirubin, AST, 
ALT, calcium, phosphorous, magnesium, total protein and albumin 

Coagulation screen (PT, PTT)

Urinalysis

Thyroid function tests (free T4, T4, TSH)

Cholesterol/lipid screen

Total IgG level

25-OH Vitamin D level 

Chest X-ray

Lumbar puncture with CSF examination (cell count with differential of cytospin 
preparation

Bone marrow evaluation: morphology, cytochemistry, immunophenotyping, 
cytogenetics, molecular diagnosis, MRD studies

Tumor: Next Generation Sequencing studies

Cardiac echocardiogram or MUGA

Baseline electrocardiogram (EKG)

Peripheral blood and bone marrow for biological studies (see tables under Section 8.2)

HLA typing – recommended as per institutional practice
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8.2
Evaluations During Therapy
Test/Evaluation
Induction
Consolidation
Reinduction
Reintensification Maintenance
Physical Exam
Q3-7 days
Weekly
Q3-7 days
Q3-7 days
Q28 days
CBC w/Diff1
Weekly, or 
as 
indicated
Weekly
As indicated
As indicated
Q28 days
Electrolytes, 
BUN, Cr1
As 
indicated
Weekly
As indicated
As indicated
Q28 days
Uric Acid, LDH, 
Phos, Ca, Mg1
As 
indicated
Before each 
HDMTX
As indicated
As indicated
As indicated
Serum glucose, 
urinalysis
As 
indicated
As indicated
As indicated
As indicated
As indicated
Bilirubin, AST, 
ALT, Total 
Protein, Albumin
As 
indicated
Weekly
As indicated
As indicated
Q28 days
Total IgG Level2
---
Day 1
Day 1
Day 1
Q28 days
25-OH vitamin D 
level2
---
Day 1
As indicated
As indicated
End of 
Therapy
Chest x-ray
As 
indicated
Day 1 in cases 
w/mediastinal 
mass at 
diagnosis
As indicated
As indicated
As indicated
CSF Studies
(cell count with 
differential of 
cytospin 
preparation)
With ea IT
With ea IT
With ea IT
With ea IT 
With ea IT
Bone 
marrow/MRD3
(See table below)
Day 22
Day 1 
(± 15, 29, 43)
Day 1
Day 1
End of 
Therapy
PB biology 
studies3
Day 1, 22
Day1
(+ 15, 29, 43)
Germline DNA2
---
PBL Day 1
---
---
---
MTX levels
As 
indicated
ea HDMTX
As indicated
As indicated
As indicated
ECHO or 
MUGA4
As 
indicated
---
Day 1
---
---
EKG4
As 
indicated
---
Day 1
---
---
1During Induction, it is critical to monitor chemistries frequently due to tumor lysis.  At a minimum, they should be 
checked daily until values are stable and within normal limits for 48-72 hours.  Patients with high tumor burden may 
need tumor lysis labs as frequently as every 4-6 hours.  Contact the study chair if there are questions or concerns.
2Level may be drawn following count recovery prior to day 1 
3Please see tables on the next page for allowances of alternate time sample draws
4ECHO and EKG may be done anytime following completion of consolidation chemotherapy prior to administration 
of mitoxantrone
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Bone Marrow Samples required for clinical MRD studies (10ml heparin)
Phase
Induction
Consolidation1
Reinduct1
Reinten1
Mtn.
Time 
point
Day11,2
Day223
Day 11
Day154
Day294
Day434
Day11
Day11
End of 
Therapy
Patients
All
All
All
MRD>0.01% 
Consol Day1
MRD>0.01% 
Consol Day15
MRD>0.01% 
Consol Day29
All
MRD>0.01%
Reinduct Day1
All
Bone Marrow Samples for Biologic Studies
Sample
Induction
Consolidation1
Reinduct1
Reinten1
Maint
Relapse
Time 
point
Day11,2
Day223
Day 11
Day154
Day294
Day432
Day11
Day11
End of 
Therapy
Tumor 
NGS5
4 ml 
heparin
---
---
---
---
---
---
---
---
5 ml 
heparin
Drug 
Studies5
4 ml 
heparin
---
---
---
---
---
---
---
---
5 ml 
heparin
MRD 
NGS5
---
5 ml 
heparin
5 ml 
heparin
5 ml 
heparin
5 ml 
heparin
5 ml 
heparin
5 ml 
heparin
5 ml 
heparin
5 ml heparin
---
1Bone marrow specimens should be obtained prior to initiation of therapy and upon count recovery prior to 
chemotherapy at these time points and are not required to be drawn on the exact days specified in the table.    
2If the patient is unable to undergo a bone marrow aspirate, the aspirate is unsuccessful, or insufficient bone marrow 
was obtained for all studies may substitute peripheral blood sample or tumor cells obtained by leukapheresis for 
Day1 specimens.
3If the patient is not clinically stable to undergo a procedure on day 22 or this day falls on a weekend/holiday, may 
delay obtaining this specimen so long as it is obtained prior to initiation of day 22 chemotherapy. 
4Specimens should coincide with LPIT and HD-MTX courses, therefore if this is delayed for clinical or scheduling 
purposes the bone marrow will also be delayed.  
5Only if patient is having a bone marrow done for clinical purposes (see above table).
Peripheral Blood Samples for Biologic Studies
1Peripheral blood specimens should be obtained upon count recovery prior to chemotherapy at these time points 
and are not required to be drawn on the exact days specified in the table.    
2Day 1 of maintenance cycles 1, 5, 10, and 15
31ml may be drawn in either lithium heparin or sodium heparin.  If no cell save tubes are available all 3 ml can be 
sent in the heparin tube.
4Blood should be drawn in EDTA and transferred to fixative tubes provided to sites – fill fixative tube with blood 
ONLY TO THE BLACK LINE  The addition of blood from the EDTA to the fixative tube must be accurate; if the 
ratio is off the assay is no longer valid.  The amount of blood added to the line is roughly 2ml, due to small volume 
inaccuracies when drawing blood, 2.5 ml should be drawn to prevent having insufficient amounts to transfer to the 
fixative.
Induction
Consol
Reind
Reinten
Maint
EOT
Sample
PreTx
6hr
24hr
Day4
Day18
Day11
Day11
Day11
Day 11,2
NFkB/
Proteasome3
2ml cell save
1ml heparin
2ml cell save
1ml heparin
2ml cell save
1ml heparin
---
---
---
---
---
---
---
Histone 
Analysis4
2.5ml  
---
2.5 ml  
2.5ml  
Immune 
Repertoire
1ml  heparin
---
---
---
---
---
2ml  
heparin
2ml  
heparin
2ml  
heparin
2ml  
heparin
Germline 
DNA
---
---
---
---
---
5ml  
heparin
---
---
---
---
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Total peripheral blood samples during Induction:

≥10kg:  17.5 ml over 7 weeks = ~1.75 ml /kg over 7 weeks

<10kg:  17.5 ml over 7 weeks = ~3 ml /kg over 7 weeks for the average infant (6kg)
For patients in which all induction samples cannot be drawn due to size or other clinical 
reason, peripheral blood research samples should be prioritized as follows: 
1.  Histone analysis
2.  NFKB/Proteasome analysis - cell save tubes should be prioritized over heparin tubes 
3.  Immune repertoire
8.3
Long-Term Follow-up Evaluations
It is recommended that patients will be followed every 4 months for 1 year, every 6 
months for 1 year, and then yearly until the patient is in remission for 10 years.  Once a 
patient has been in remission 5 years or more, they may be referred for long term follow 
up per institutional guidelines. During the visit, CBC with differential and other 
laboratory studies as clinically indicated should be obtained. Patients will be considered 
off therapy 30 days after the last treatment is taken. Adverse events will not be reported 
while patient is off-therapy unless they are deemed related to therapy by the site PI.
9.0
EVALUATION CRITERIA
9.1
Response Criteria

Complete remission: M1 marrow status with restoration of normal hematopoiesis 
as defined by Platelets >75,000/mm3 and ANC>750/mm3 

Induction failure: ≥5% leukemic blasts in marrow after 42 days of remission 
induction treatment

Bone marrow relapse: ≥25% leukemic blasts in marrow

CNS relapse: ≥5 WBC/ul of CSF with definite blasts confirmed by TdT staining 
on cytospin preparation.  

Testicular relapse: Isolated testicular relapse must be confirmed pathologically; in 
the event of bone marrow relapse, combined testicular relapse can be based on 
testicular enlargement (documented by sonogram) without biopsy. 
9.2
Toxicity Evaluation Criteria
This study will utilize the CTCAE Version 4.0 for toxicity and performance reporting. A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP home page 
(http://ctep.info.nih.gov). Additionally, the toxicities are to be reported on the appropriate 
data collection forms.
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10.0
SUPPORTIVE CARE
10.1
Fever at Diagnosis
All patients with fever at diagnosis will be admitted for broad spectrum parenteral 
antibiotic treatment until an infectious etiology can be excluded.
10.2
Metabolic Derangements
It is important to prevent or treat hyperuricemia and hyperphosphatemia with secondary 
hypocalcemia resulting from spontaneous or chemotherapy-induced leukemic cell lysis. 
Patients with large leukemic cell burden should receive hydration and oral phosphate 
binder.
Patients with large leukemic cell burden with or without hyperuricemia (e.g. WBC 
≥100/mm3, uric acid ≥6.5 mg/dl may be treated with rasburicase if they have no history 
of G6PD deficiency. For patients not at high risk of hyperuricemia, hydration, 
allopurinol, and judicious use of alkalinization (keeping urine pH between 6.5 and 7.4) 
may be sufficient.
10.3
Hyperleukocytosis
For patients with extreme hyperleukocytosis (e.g. WBC ≥ 300/mm3), leukapheresis or 
exchange transfusion may be considered. Aggressive hydration and management of tumor 
lysis syndrome should be immediately implemented. Platelets should be transfused at 
counts below 20,000/mm3 to prevent CNS bleed, or in the presence of any active mucosal 
or visceral bleeds. A platelet transfusion does not increase the blood viscosity 
significantly. Red blood cell transfusions are not indicated in a hemodynamically stable 
child, as it adversely affects the blood viscosity. In the case of severe anemia, with 
impending congestive cardiac failure, leukapheresis or exchange transfusion are better 
options. If coagulopathy is present, it should be corrected by transfusion of 10-15ml/kg of 
fresh frozen plasma.
In patients with hyperleukocytosis who are not stable for bone marrow procedures, all 
diagnostic tests should be submitted with peripheral blood specimens.
10.4
Skin Breakdown
Infants are at high risk for skin breakdown in the diaper region during times of 
neutropenia such as Induction and Reinduction, as well as during Consolidation 
following courses of high dose methotrexate. Additional factors that contribute include 
increased stooling secondary to infections, antibiotics, or chemotherapy. It is very 
important to protect the skin of the diaper area and minimize breakdown beginning at 
diagnosis and continuing throughout therapy. Consistency and frequent diaper changes 
are two key factors that help prevent skin breakdown. It is recommended that at diagnosis 
for patients with intact skin +/- erythema, a thick layer of butt balm is applied with each 
diaper change. To make butt balm, mix equal parts of Desitin®, Aquaphor®, and 
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Nystatin. When changing the diaper, stool and old paste should be removed gently. 
Aggressive scrubbing will increase the chance of breakdown. Mineral oil and a cotton 
ball can help gently remove paste that is mixed with stool. Allow skin to air dry before 
applying new layer of butt balm. For patients that develop skin breakdown, they have 
failed butt balm and we recommend trying a product such as Sensi-Care which is able to 
adhere to weepy, denuded skin and protect it from further breakdown.
10.5
Avascular Necrosis of Bone
Osteonecrosis of the bone, a known complication of treatment with corticosteroids, is 
extremely rare in infants. Any patient diagnosed with osteonecrosis will be referred to 
orthopedics. Any patient who develops symptoms of joint pain should have an MRI 
performed to rule out osteonecrosis or progression of this complication. For patients who 
require surgical intervention, treatment will vary based on degree of progression, e.g. 
observation, core decompression, bone grafting and resurfacing hemiarthroplasty.
10.6
Pancytopenias
Patients with prolonged (>3 weeks) unexplained anemia (hemoglobin <7g/dl) or 
neutropenia (ANC<300/mm3) during remission should be evaluated for B19 parvovirus 
infection or hemolysis or toxicity from non-chemotherapeutic agents (e.g. TMP/SMZ).  
For patients with neutropenia secondary to TMP/SMZ, intravenous pentamidine every 
four weeks may be substituted for PCP prophylaxis.
10.7
Nutritional Supplementation
Nutritional or vitamin therapies should not result in patients receiving more than the 
RDA for folic acid with dietary and supplement intake, to prevent interference with the 
effectiveness of methotrexate.
Evidence suggests that patients with hematologic malignancy and low 25-
hydroxyvitamin D [25(OH)D] levels at diagnosis have worse outcomes.45-47 The 
25(OH)D level of infants is dependent on the 25(OH)D level of the mother during 
pregnancy. As vitamin D deficiency is epidemic in the US due to lifestyle and diet, all 
patients will have a 25(OH)D level measured at diagnosis. Patients with levels <30 
ng/mL at diagnosis will be supplemented with 400 units D3 daily. All patients should 
have a repeat level drawn at the end of induction and those with normal levels at 
diagnosis but low levels following induction therapy should start supplementation. For all 
infants receiving supplementation, periodic repeat levels should be drawn as indicated to 
verify correction of the deficiency.
10.8
Drug Interactions
Because concurrent use of enzyme inducing anticonvulsants (e.g. phenytoin, phenobarbital, 
and carbamazepine) with antileukemic therapy has recently been associated with inferior 
EFS, every effort should be made to avoid these agents, as well as rifampin which also 
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induces many drug metabolizing enzymes. Keppra does not induce hepatic drug 
metabolizing enzymes and may be a suitable alternative anticonvulsant.
Azole antifungals (fluconazole, itraconazole, voriconazole, and ketoconazole) and the 
macrolide group of antibiotics (e.g. erythromycin, rifampin, and Zithromax) may have 
potent inhibitory effects on drug-metabolizing enzymes, and the doses of some 
antileukemic drugs (e.g. vincristine, anthracyclines, steroids, etoposide, bortezomib) may 
need to be reduced in some patients on chronic azole antifungals or antibiotics. During 
induction and reinduction, micafungin will be given at treatment doses due to the high 
risk of fungal infections. If a patient develops a fungal infection requiring an azole, 
monitor side effects of vincristine and bortezomib closely, and implement dose 
reductions as delineated in section 6.0. Consult the study PI if long-term use of these 
interacting drugs is unavoidable.
Penicillins interfere with tubular excretion of methotrexate, and it is recommended that 
an alternative non-penicillin antibiotic be used. Conversely, methotrexate clearance has 
been demonstrated not to be affected by TMP/SMZ and so this prophylactic medication 
does not need to be held during methotrexate administration.
10.9
RSV Prophylaxis
All infants less than 1 year of age should receive RSV prophylaxis between October and 
April.  
Those patients greater than one year of age should prophylaxis until they have completed 
reinduction (or Reintensification if applicable) as patients are at high risk for RSV 
pneumonia during times of neutropenia. RSV prophylaxis is not required during 
maintenance for patients greater than one year of age.
10.10 Mandatory Prophylactic Antibiotics During Periods of Prolonged Neutropenia
Infants with ALL are severely immunocompromised due to their immature immune 
systems, the presence of leukemia, and exposure to chemotherapeutic agents. Patients 
may developed serious fungal infections while treated on this protocol including non-
albicans Candida. It is mandatory that all patients  receive anti-fungal coverage using 
either the echinocandin class (e.g. caspofungin or micafungin) or an amphotericin agent 
during Induction, Reinduction, and Reintensification (if applicable). The doses used 
should be in the treatment range for the particular agent more so than prophylactic as that 
is when colonization and infection may occur on this study with patients at high risk for 
fungal infection. Recommended treatment doses are as follows: micafungin 4mg/kg/dose 
daily; caspofungin 25mg/m2/dose daily for infants less than 3 months of age; caspofungin 
70mg/m2/dose day 1 followed by 50mg/m2/dose daily for infants 3 months of age or 
greater (may increase to 70mg/m2/dose daily if necessary); Ambisome 5mg/kg/dose 
daily. Azole antifungal agents (i.e. fluconazole, itraconazole, voriconazole) given 
concurrently with bortezomib may increase risk of neurotoxicity. Caution is advised if 
azole antifungals are used.
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In addition to fungal coverage, prophylactic bacterial coverage with cefepime during 
times of neutropenia is required. Patients unable to receive cefepime due to drug 
shortage, allergy, or other cause should receive an alternative antibiotic with similar 
bacterial coverage. Coverage should be broadened as indicated following episodes of 
fever or development of symptoms consistent with a localized infection. Examples 
include additional gram negative coverage for patients with evidence of colitis or 
hypotension and vancomycin in patients with mucositis. Patients that continue to have 
fever on broad spectrum antibiotics with no source should be evaluated for fungal 
infections. Please contact the study PI for any questions or concerns. 
For patients discharged following induction, reinduction, or Reintensification courses that 
have ANC >200 but less than 500, fungal prophylaxis may be discontinued and 
monotherapy bacterial prophylaxis with oral levofloxacin is acceptable until ANC≥500. 
TMP/SMZ for PJP prophylaxis should continue. 
11.0
CRITERIA FOR OFF STUDY AND OFF TREATMENT
11.1
Off-Study Criteria

Death

Lost to follow-up

Request of the patient/parent

Found to be ineligible (e.g. incorrect diagnosis)

Discretion of the Study PI, such as the following 
o
The researcher decides that continuing in the study would be harmful 
o
A treatment is needed that is not allowed on this study
o
The participant misses so many appointments that the data cannot be used 
in the study
o
New information is learned that a better treatment is available, or that the 
study is not in the participant’s best interest
Follow up will stop at the time the patient is off study. The follow up time of an 
off-study patient is censored at this point, and no outcome data beyond the off-
study time will be used in analyses.
11.2
Off-Therapy Criteria

Research participants who fail to achieve morphological complete remission 
after treatment according to the contingency plan

Any relapse as defined in section 7.0

Second malignancy

Development of unacceptable toxicity during treatment (with concurrence of 
the PI or co-PI)

Refusal of therapy

Investigator decides continued protocol treatment is no longer in patient’s best 
interest
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
Completion of all protocol-prescribed treatment

Patients referred to transplant or CAR T cells will be considered off therapy 
the day they begin lymphodepleting chemotherapy in preparation of CAR T 
cell administration or are admitted for their stem cell transplant, prior to the 
initiation of the conditioning regimen.
12.0
SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS
12.1
Reporting Adverse Experiences and Deaths to the IRB
Only “unanticipated problems involving risks to participants or others” referred to 
hereafter as “unanticipated problems” are required to be reported to the IRB promptly, 
but in no event later than 10 working days after the investigator first learns of the 
unanticipated problem. Regardless of whether the event is internal or external (for 
example, an IND safety report by the sponsor pursuant to 21 CFR 312.32), only adverse 
events that constitute unanticipated problems are reportable to the IRB.  As further 
described in the definition of unanticipated problem, this includes any event that in the 
PI’s opinion was:

Unexpected (in terms of nature, severity, or frequency) given (1) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document, as well as other 
relevant information available about the research; (2) the observed rate of 
occurrence (compared to a credible baseline for comparison); and (3) the 
characteristics of the subject population being studied; and

Related or possibly related to participation in the research; and

Serious; or if not serious suggests that the research places subjects or others at a 
greater risk of harm (including physical, psychological, economic, or social harm) 
than was previously known or recognized. 
Unrelated, expected deaths do not require reporting to the IRB if they occur > 30 days 
after last dose of protocol treatment.  Though death is “serious”, the event must meet the 
other two requirements of “related or possibly related” and “unexpected/unanticipated” to 
be considered reportable.
Deaths meeting reporting requirements are to be reported immediately to the IRB and 
FDA, but in no event later than 48 hours after the investigator first learns of the death.  
This includes all deaths on treatment, regardless of cause.  Unexpected deaths related or 
possibly related to participation in the research will also be reported to the DSMB.
The following definitions apply with respect to reporting adverse experiences: 
Serious Adverse Event (SAE): Any adverse event temporally associated with the 
subject’s participation in research that meets any of the following criteria:

results in death;
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
is life-threatening (places the subject at immediate risk of death from the event as 
it occurred);

requires inpatient hospitalization or prolongation of existing hospitalization;

results in a persistent or significant disability/incapacity;

results in a congenital anomaly/birth defect; or

any other adverse event that, based upon appropriate medical judgment, may 
jeopardize the subject’s health and may require medical or surgical intervention to 
prevent one of the other outcomes listed in this definition (examples of such 
events include:  any substantial disruption of the ability to conduct normal life 
functions, allergic bronchospasm requiring intensive treatment in the emergency 
room or at home, blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse), a 
congenital anomaly/birth defect, secondary or concurrent cancer, medication 
overdose, or is any medical event which requires treatment to prevent any of the 
medical outcomes previously listed.  
Unexpected Adverse Event (UAE): 

Any adverse event for which the specificity or severity is not consistent with the 
protocol-related documents, including the applicable investigator brochure, IRB 
approved consent form, Investigational New Drug (IND) or Investigational Device 
Exemption (IDE) application, or other relevant sources of information, such as 
product labeling and package inserts; or if it does appear in such documents, an 
event in which the specificity, severity or duration is not consistent with the risk 
information included therein; or 

The observed rate of occurrence is a clinically significant increase in the expected 
rate (based on a credible baseline rate for comparison); or 

The occurrence is not consistent with the expected natural progression of any 
underlying disease, disorder, or condition of the subject(s) experiencing the adverse 
event and the subject’s predisposing risk factor profile for the adverse event. 
Internal Events: Events experienced by a research participant enrolled at a site under the 
jurisdiction of St. Jude IRB for either multicenter or single-center research projects.
External Events: Events experienced by participants enrolled at a site external to the 
jurisdiction of the St. Jude Institutional Review Board (IRB).
Unanticipated Problem Involving Risks to Subjects or Others: An unanticipated 
problem involving risks to subjects or others is an event which was not expected to occur, 
and which increases the degree of risk posed to research participants.  
Such events, in general, meet all of the following criteria: 

unexpected; 

related or possibly related to participation in the research; and 
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
suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. An unanticipated problem involving risk to subjects or 
others may exist even when actual harm does not occur to any participant. 
Consistent with FDA and OHRP guidance on reporting unanticipated problems and 
adverse events to IRBs, the St. Jude IRB does not require the submission of external 
events, for example IND safety reports, nor is a summary of such events/reports required; 
however, if an event giving rise to an IND safety or other external event report constitutes 
an “unanticipated problem involving risks to subjects or others” it must be reported in 
accordance with this policy. In general, to be reportable external events need to have 
implications for the conduct of the study (for example, requiring a significant and usually 
safety-related change in the protocol and/or informed consent form).
Although some adverse events will qualify as unanticipated problems involving risks to 
subjects or others, some will not; and there may be other unanticipated problems that go 
beyond the definitions of serious and/or unexpected adverse events.  
Examples of unanticipated problems involving risks to subjects or others include:

Improperly staging a participant’s tumor resulting in the participant being 
assigned to an incorrect arm of the research study;

The theft of a research computer containing confidential subject information 
(breach of confidentiality); and 

The contamination of a study drug. Unanticipated problems generally will warrant 
consideration of substantive changes in the research protocol or informed consent 
process/document or other corrective actions in order to protect the safety, 
welfare, or rights of subjects or others. 
This is an investigator-initiated study. The principal investigator, Tanja Gruber, and St. 
Jude are conducting the study and acting as the sponsor. Therefore, the legal/ethical 
obligations of the principal investigator include both those of a sponsor and those of an 
investigator.
12.2
Reporting to Regulatory Affairs Office and FDA
All treatment-related deaths and any unanticipated fatal or unanticipated life-threatening 
event judged by the PI to be at least possibly due to the study treatment, will be reported 
to the FDA by telephone or fax as soon as possible but no later than seven calendar days 
after notification of the event and followed by a written safety report as complete as 
possible within eight additional calendar days (i.e. full report 15 calendar days total after 
notification of event).
Unanticipated, non-fatal and non-life-threatening adverse events that occur in on-study 
patients and that are considered due to or possibly due to the investigational agent, will be 
reported to the FDA by written safety report as soon as possible but no later than 15 
calendar days of the notification of the occurrence of the event. Expected SAEs, even 
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unexpected fatal SAEs, considered by the PI to be not related to the study, will be 
reported to the FDA in the Annual Review Report along with non-serious AEs.  All FDA 
correspondence and reporting will be conducted through the St. Jude Office of 
Regulatory Affairs.
Copies of all correspondence to the St. Jude IRB, including SAE reports, are provided to 
the St. Jude Regulatory Affairs office by the St. Jude study team.  FDA-related 
correspondence and reporting will be conducted through the Regulatory Affairs office.
12.3
Recording Adverse Events and Serious Adverse Events
Adverse events (AEs) will be evaluated and documented by the clinical staff and 
investigators throughout inpatient hospitalizations and each outpatient visit. CRAs are 
responsible for reviewing documentation related to AEs and entering directly into CRIS 
protocol-specific database for all adverse events grade 3 or higher. Peripheral neuropathy 
and infectious complications will be captured if Grade 2 or higher. The data to be 
recorded are 1) the event description, 2) the NCI CTCAE v4.0 code and grade, 3) the 
onset date, 4) the resolution date (or ongoing if it has not resolved at time of off study), 4) 
action taken for event, 5) patient outcome 6) relationship of AE to protocol 
treatment/interventions, 7) if AE was expected or unexpected, and 8) comments, if 
applicable. AEs that are classified as serious, unexpected, and at least possibly related 
will be notated as such in the database as “SAEs”. These events will be reported 
expeditiously to the St. Jude IRB within the timeframes as described above.  
Cumulative summary of Grade 2 peripheral neuropathy, Grade 2 infectious complications 
and all Grades 3-5 events will be reported as part of the progress reports to IRB at the 
time of continuing review. Specific data entry instructions for AEs and other protocol-
related data will be documented in protocol-specific data entry guidelines, which will be 
developed and maintained by study team and clinical research informatics.
The study team will meet regularly to discuss AEs (and other study progress as required 
by institutional DSMP). The PI will review Adverse Event reports generated from the 
research database, and corrections will be made if applicable. Once the information is 
final the PI will sign and date reports, to acknowledge his/her review and approval of the 
AE as entered in the research database.
12.4
Process for Reporting AEs Between St. Jude and Collaborating Sites 
Adverse events from collaborating sites will also be reviewed by the PI and discussed in 
study team meetings as described above. SAE reports from collaborating sites for AEs 
that are serious, unexpected, and at least possibly related to protocol treatment or 
interventions will be reported to site IRB and the St. Jude IRB within the reporting 
requirements described above. The PI will determine if this is an event that will need to 
be reported expeditiously to all participating sites, considering the following criteria:

Is the AE serious, unexpected, and related or possibly related to participation in 
the research?
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
Is the AE expected, but occurring at a significantly higher frequency or severity 
than expected?

Is this an AE that is unexpected (regardless of severity that may alter the IRB’s 
analysis of the risk versus potential benefit of the research and, as a result, 
warrant consideration of substantive changes in the research protocol or informed 
consent process/document?
With the submission of the “Reportable Event” in St. Jude iRIS (Integrated Research 
Information System) application, the PI will indicate if all sites should be notified to 
report to their IRBs, and if the protocol and/or consent should be amended (consent will 
be amended if event is information that should be communicated to currently enrolled 
subjects). Generally, only events that warrant an amendment to the protocol and/or 
consent will be reported expeditiously to all sites. However, any event may be reported 
expeditiously to all sites at the discretion of the PI. A cumulative summary of Grade 2 
peripheral neuropathy and infectious complications, all Grade 3-5 AEs, and 
expected/unrelated deaths that occur more than 30 days after protocol treatment will be 
reported to all sites with study progress report at the time of continuing review. 
For collaborating sites: Serious AND unexpected events are to be reported to the St. Jude 
PI (Dr. Tanja Gruber) within 48-72 hours via fax or email.  
All treatment-related deaths and unexpected deaths must be reported to the St. 
Jude PI at 
or phone call to Dr. Gruber within 24 hours 
of the event.  A written report must follow.  
The study team should be copied on all correspondence regarding the event.  
Sent report to:
Tanja A. Gruber, MD PhD
Pediatrics Hematology, Oncology, Stem Cell Transplant and Regenerative 
Medicine
Lucile Packard Children's Hospital, Stanford
Palo Alto, CA
Email: 
 or
Email:  
 
12.5
Data and Safety Monitoring Board 
This study has been referred to the St. Jude Data and Safety Monitoring Board (DSMB) 
for regular monitoring and will be sent to the DSMB upon approval by the St. Jude CT-
SRC and IRB. The DSMB is charged with advising the Director and other senior leaders 
of St. Jude Children’s Research Hospital (SJCRH) on the safety of clinical protocols 
being conducted by SJCRH investigators and on their continuing scientific validity. Refer 
to the DSMB Charge and Criteria for Protocol Referral for more information regarding 
DSMB review.
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13.0
DATA COLLECTION, STUDY MONITORING, AND CONFIDENTIALITY
13.1
Data Collection
Electronic case report forms (e-CRFs) will be completed by the clinical trials staff from 
the Cancer Center Comprehensive Center, Hematological Malignancies Program. Data 
will be entered from record directly into a secure CRIS database, developed and 
maintained by St. Jude Clinical Research Informatics. 
Data Management will be supervised by the Director of Clinical Trials Management, and 
Manager of Clinical Research Operations for the Hematological Malignancies Program, 
working with Dr. Gruber or her designee. All protocol-specific data and all grade 2 
peripheral neuropathy and infectious complications and grade 3-5 adverse events will be 
recorded by the clinical research associates into the CRIS database weekly during 
induction and reinduction as AE during these phases comprise DLTs. AEs will be 
recorded by the clinical research associates into the CRIS database within 2-4 weeks of 
completion of consolidation and Reintensification, and monthly during maintenance. All 
questions will be directed to the attending physician and/or PI and reviewed at regularly-
scheduled working meetings. The attending physicians (or their designees) are 
responsible for keeping up-to-date roadmaps in the patient’s primary SJCRH medical 
chart.
Regular (at least monthly) summaries of toxicity and protocol events will be generated 
for the PI and the department of Biostatistics to review.
13.2
Data Collection Instructions for Collaborating Sites
Collaborating sites will collect data by using eCRFs via remote electronic data entry. All 
protocol-specific data and all grade 2 peripheral neuropathy and infectious complications 
and grade 3-5 adverse events will be recorded by the clinical research associates into the 
CRIS database weekly during induction and reinduction as AE during these phases 
comprise DLTs. AEs will be recorded by the clinical research associates into the CRIS 
database within 2-4 weeks of completion of Consolidation and Reintensification, and 
monthly during Maintenance.
13.3
Study Monitoring
Monitoring of this protocol is considered to be in the high-risk 3 category (HR-3). The 
study specific Monitoring Plan is a separate document from this protocol. The study team 
will meet at appropriate intervals to review case histories or quality summaries on 
participants. Highlights of the protocol monitoring plan are below:
The Clinical Research Monitor will assess protocol and regulatory compliance as well as 
the accuracy and completeness of all data points for the first two participants then 15% of 
study enrollees every six months. Accrual will be tracked continuously for studies that 
have strata.   All SAE reports will be monitored for type, grade, attribution, duration, 
timeliness and appropriateness on all study participants semi-annually.
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The monitor will also verify 100% of all data points on the first two participants and on 
15% of cases thereafter. Protocol compliance monitoring will include participant status, 
eligibility, the informed consent process, demographics, staging, study objectives, 
subgroup assignment, treatments, evaluations, responses, participant protocol status, off-
study, and off-therapy criteria. The Monitor will generate a formal report which is shared 
with the Principal Investigator (PI), study team and the Internal Monitoring Committee 
(IMC). Monitoring may be conducted more frequently if deemed necessary by 
administration, the Institutional Review Board (IRB), or the IMC.
Continuing reviews by the IRB and CT-SRC will occur at least annually. In addition, 
SAE reports in iRIS are reviewed in a timely manner by the IRB/OHSP.
Source document verification of eligibility for all SJCRH cases will be performed within 
two weeks of completion of enrollment. This will include verification of appropriate 
documentation of consent. Monitoring of timeliness of serious adverse event reporting 
will be done as events are reported in iRIS. St. Jude affiliates and collaborating study 
sites will be monitored on-site by a representative of St. Jude at intervals specified in the 
Data and Safety Monitoring Plan.
13.4
Confidentiality
Study numbers will be used in place of an identifier such as a medical record number. No 
research participant names will be recorded on the data collection forms. The list 
containing the study number and the medical record number will be maintained in a 
locked file and will be destroyed after all data have been analyzed. The medical records 
of study participants may be reviewed by the St. Jude IRB, FDA, and St. Jude clinical 
research monitors.
14.0
STATISTICAL CONSIDERATIONS
14.1
Primary Objective
The primary objective is to determine the tolerability of incorporating bortezomib and 
Vorinostat into an ALL chemotherapy backbone for newly diagnosed infants with ALL.
Accrual: In this multi-institution collaborative trial, we expect to enroll 50 evaluable 
patients in 7 years for the tolerability study. To achieve 50 evaluable patients’ global 
enrollment will increase from 50 patients to 60 patients with revision 5.1.
14.1.1 Dose Escalation Phase
Vorinostat, initially at 100mg/m2/day will be administered on days 1-4, 8-11, and 15-18 
and escalated based on tolerability. A classical 3-on-3 dose escalation will be done as a 
run-in phase.  Three patients will be enrolled sequentially at the 100mg/m2/day level.  At 
any of the first two dose levels (100mg/m2 or 150mg/m2), if no dose limiting toxicity 
(DLT) is observed then we will move on to the next higher does level; if there is 1 DLT 
then we will enroll 3 more patients at the same dose level, if there is no more than 1/6 
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DLTs we will then move to the next higher dose level, otherwise deem the current dose 
level too toxic and use the dosage at one level lower as the maximum tolerated dose 
(MTD). If at any dose level 2 or more DLTs occur, we will deem the current dose level 
too toxic and use the dosage at one level lower as the MTD. If the 100mg/m2 level is 
deemed intolerable (2/3 or 2/6 DLTs) then we move to dose level -1. If we escalate the 
dose to the highest dose level at 180mg/m2 and it is tolerated (0/3 or 1/6 DLT), then this 
dosage will be used for the remaining patients as the MTD. Patients that are part of the 
dose escalation cohort will receive the same vorinostat dosing for induction and 
reinduction.  
Dose Level
Vorinostat Dosing
-1
75mg/m2/day
1*
100mg/m2/day
2
150mg/m2/day
3
180mg/m2/day
*starting dose level
Definitions of Dose-Limiting Toxicities (DLT)
Toxicities will be graded according the CTEP Common Terminology Criteria for 
Adverse Events (CTCAE) version 4.0. DLT is based on non-hematologic toxicities that 
occur during induction (planned for 42 days). All three subjects in a cohort must 
complete the DLT monitoring phase before accrual may resume during the dose 
escalation phase. Please note elective intubation for procedures and as a precaution in 
infants with hyperleukocytosis will not be considered a DLT.
Non-Hematologic DLT

Any Grade 5 event, unless the event is clearly and incontrovertibly due to extraneous 
causes or disease progression

Any Grade 4 event , unless the event is clearly and incontrovertibly due to extraneous 
causes or disease progression with the exception of the following:
o
Grade 4 infection or fever
o
Grade 4 elevation in hepatic transaminases, alkaline phosphatase, GGT, 
bilirubin, amylase, lipase, and triglycerides
o
Grade 4 electrolyte disturbances that resolve to < grade 3 within 24 hours
o
Grade 4 electrolyte disturbances due to tumor lysis
o
Grade 4 hyperglycemia or hypoglycemia that resolve to < grade 3 within 24 hours
o
Grade 4 intracranial hemorrhage secondary to hyperleukocytosis
o
Grade 4 pulmonary leukostasis syndrome
o
Grade 4 acute kidney injury due to tumor lysis 
o
Grade 4 seizures secondary to intrathecal chemotherapy
o
Grade 4 leukoencephalopathy secondary to intrathecal chemotherapy
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14.1.2 Dose Expansion Phase
Based on the dose escalation phase, the MTD will be administered to the remaining 
patients for further evaluation of tolerability and response. Tolerability during the dose 
expansion phase will be defined as completing induction and reinduction blocks with no 
dose limiting toxicities as defined in section 14.1.1. A maximum of 50 evaluable patients 
will be enrolled. As a safety precaution, enrollment to the study will be suspended 
intermittently to prevent more than 10 patients being treated simultaneously with 
induction and/or re-induction therapy. 
Prior experience suggests that the induction/re-induction TRM rate with the current 
treatment approach is approximately 5% for patients older than 90 days and 10% for 
younger patients. For this design, a proportion of 10% or less of patients experiencing a 
dose limiting toxicity will be considered as clinically tolerable and used as a monitoring 
benchmark.  
Monitoring will be performed according to the following group-sequential rule. At each 
stage the null hypothesis H0: proportion (intolerable) ≤10% is tested against a one-sided 
alternative H1: proportion (intolerable)>10%. The boundary values are generated based 
on one-sample, one-sided Z test for a Binomial proportion at the 0.2 overall significance 
level. If the true proportion of intolerable patients is 20%, this monitoring rule has the 
power of 0.876 and expected sample size 30 to stop the trial. 
Table 7.  Monitoring of Intolerability
Interim Sample Size
Suspend if # Intolerable patients ≥
Z value
10
4
2.639
20
4
1.735
30
5
1.370
40
6
1.167
50
7
1.035
This design is generated by EAST6.0 with the following specific parameters: superiority 
experiment, total sample size 50, 5 equally spaced looks, alternative TRM (π1) =20%, 
“spending functions” for boundary family, Lan-DeMets function with O’brien-Feleming 
parameters, overall type-I error probability=0.20.
This monitoring rule is not prescriptive -- the final decision about halting or continuing 
the study will rest with the Data and Safety Monitoring Board (DSMB). 
The final analyses will also include calculating point estimates and 95% confidence 
intervals for the rates of TRM and other severe (CTCAE Grade 4) toxicities during 
Induction and Reinduction. The confidence interval for the TRM rate will be computed 
using the method adjusting for multiple interim looks48.
In addition, we will separately monitor the frequency of grade 5 events, grade 4 sepsis, 
grade 4 hemorrhage, and grade 4 hepatic toxicity across all patients. The stopping 
boundaries for these specific toxicities are detailed in the table below and are based on 
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the frequency of these events in the TACL T2005-003 study which most closely 
resembles the treatment combination given to patients on TINI during induction and 
reinduction. Grade 4 seizures and leukoencephalopathy will also be monitored across all 
patients due to the use of methotrexate for CNS control in all phases of treatment. We 
consider a frequency of 10% or less (seizures and leukoencephalopathy combined) to be 
clinically tolerable. Therefore, the stopping boundaries included in Table 8 for these 
events are equivalent to the boundaries listed in Table 7 for DLTs. Grade 4 and 5 events 
that are clearly and incontrovertibly due to extraneous causes or disease progression will 
be excluded from these stopping boundaries.
Table 8.  Monitoring of Specific Toxicities
Toxicity
#patients
Suspend if # of patients with 
monitored toxicities ≥
Grade 5 event (death)
5
1
10
2
15
3
20
4
30
5
40
6
50
7
Grade 4 sepsis
5
3
10
6
15
8
20
10
30
15
40
20
50
25
Grade 4 hemorrhage
5
2
10
3
15
5
20
6
30
9
40
12
50
15
Grade 4 hepatic toxicity
5
3
10
6
15
8
20
10
30
15
40
20
50
25
Grade 4 seizure or leukoencephalopathy
10
4
20
4
30
5
40
6
50
7
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14.2
Statistical Analyses and Power for the Secondary Objectives
To estimate the event-free survival and overall survival of infants with ALL who are treated 
with bortezomib and vorinostat in combination with an ALL chemotherapy backbone.
Event-free survival (EFS) and overall survival (OS) functions will be estimated by the 
Kaplan-Meier estimator. For EFS, relapse and second malignancies will be considered as 
failures in addition to death in complete remission. The time to EFS will be set to 0 for 
patients who fail to achieve complete remission. EFS and OS probabilities at years 3, 5, 10 
will be estimated with 95% confidence intervals. 
We will monitor the possible worsened 4-year EFS starting at the 5th adverse event, and for 
every 5th adverse event as defined in the EFS calculation we shall calculate the 95% upper 
confidence bound of the 4-year EFS; if this bound is below 19% for MLLr younger than 3 
month old, 44% for MLLr 3 month or older, or 75% for no MLL rearrangement patients, 
we will suspend enrollment and investigate.
The fourth amendment allows patients that are MRD positive at the end of consolidation to 
receive CART.  Based on current enrollment and MRD data for patients on study, there 
will be likely less than 5 patients who receive CAR-T. If there are 10 or more patients that 
receive CAR-T, we will secondarily estimate the EFS and OS at years 3, 5 and 10, in the 
respective sub-cohorts of patients who did and/or did not receive CAR-T cell therapy, 
using point estimates and the 95% confidence interval.
To measure minimal residual disease (MRD) positivity using both flow cytometry and PCR.
MRD status and levels at the end of each therapy block will be summarized by descriptive 
statistics such as proportion (percentage) of MRD positive patients, mean and median 
levels of MRD and standard deviation.
To compare end of induction, end of consolidation, and end of reinduction MRD levels to 
Interfant99.
The preliminary data from TOTXVI indicate that 6 out of 6 infants achieved MRD 
negative status at the end of induction, giving the Blyth-Cassella 99% lower confidence 
bound of the probability of negative MRD status as 0.46 (46%). From Figures 1b and 3 of  
Van der Velden et al.12 the point estimate of the MRD negative probability at the end of 
induction, consolidation and reinduction (corresponding to TP2, TP3 and TP4 therein 
respectively) is 0.43, 0.7, 0.89 respectively for the Interfant99 protocol, with respective 
sample size 81,60, 38. The following table shows the statistical power of the two-sample 
two-sided Z test at the 5% significance level in several scenarios. We are fully aware that 
the power is limited in several cases where the difference is small. 
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Table 8 Statistical power for the MRD comparison
Num. pts n1 
Interfant99
n2 
TINI
π1 
Interfant99
π2 
TINI
Power 
TP2 vs. end of Induction
81
50
0.43
0.9
1.00
TP2 vs. end of Induction
81
50
0.43
0.65
0.71
TP3 vs. end of Consolid.
60
50
0.7
0.95
0.96
TP3 vs. end of Consolid.
60
50
0.7
0.85
0.49
TP4 vs. end of Re-Induct.
38
50
0.89
0.99
0.48
The power was calculated using EAST6.0 with the following parameters: Asymptotic; 
nt/nc=n2/n1 (n1, n2 in the above table); Unpooled Estimate for variance.
14.3
Statistical Analyses for the Exploratory Objectives
To measure histone acetylation, ubiquitination, and methylation in leukemic blasts pre 
and post treatment with bortezomib and vorinostat
Assess NF-kB activity and proteasome inhibition pre and post treatment with bortezomib
These pre-post molecular changes will be summarized by descriptive statistics, and 
compared using the paired t test or rank-based procedures.
To assess the prognostic value of MRD by deep sequencing.
Association between MRD determined MRD levels and relapse and EFS will be modeled 
and tested by Fine-Gray and Cox hazard rate regression models.
Identify all genomic lesions by comprehensive whole genome, exome and transcriptome 
sequencing on all patients.
Population frequencies of the identified genomic lesions will be modeled as Binomial 
proportions and estimated by exact methods (e.g., Blyth-Cassela confidence intervals).
Evaluate the sensitivity of patient blasts in vitro to a panel of highly active agents 
identified by a high throughput drug screen on primary infant ALL specimens.
Responses to in vitro treatments (e.g., IC50) will be summarized by descriptive statistics, 
possibly after a proper transformation (e.g., log10) if needed.
Identify subclones in patients with detectable minimal residual disease by next generation 
deep sequencing and Determine clonal evolution of relapsed patients by next generation 
sequencing
These two objectives are in a fast-evolving area capitalizing on the maturation of the 
whole-genome sequencing technologies. We will utilize the latest and most effective 
approach to detecting subclones and modeling clonal evolution at the time of analysis. 
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Study immune repertoire diversity over the course of treatment by deep sequencing of 
lymphocyte variable regions.
The immune repertoire diversity will be estimated and described by the proportions of 
each observed variant in lymphocytes. Trajectory of each variant along time will be 
summarized and displayed graphically.
15.0
OBTAINING INFORMED CONSENT
15.1
Informed Consent Prior to Research Interventions
Initially, informed consent will be sought for obtaining extra bone marrow specimens for 
research tests, and for other procedures as necessary for standard medical care.
15.2
Consent at Enrollment 
The process of informed consent for TINI will follow institutional policy. The informed 
consent process is an ongoing one that begins at the time of diagnosis and ends after the 
completion of therapy. Informed consent should be obtained by the attending physician 
or his/her designee, in the presence of at least one non-physician witness.  Initially, 
informed consent will be sought for the acquisition of bone marrow specimens, blood 
transfusion and other procedures as necessary. After the diagnosis of leukemia is 
established, we will invite the patient to participate in the TINI protocol.  
Throughout the entire treatment period, participants and their parents receive constant 
education from health professionals at St. Jude and are encouraged to ask questions 
regarding alternatives and therapy. All families should have ready access to chaplains, 
psychologists, social workers for support, in addition to that provided by the primary 
physician and other clinicians involved in their care.
15.3
Consent When English is Not the Primary Language
When English is not the participant, parent, or legally authorized representative’s primary 
language, the Social Work department will determine the need for an interpreter. This 
information will be documented in the participant’s medical record. Either a certified 
interpreter or a telephone interpreter’s service will be used to translate the consent 
information. 
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16.0
REFERENCES
1. Pieters R, Schrappe M, De Lorenzo P, et al. A treatment protocol for infants younger than 1 
year with acute lymphoblastic leukaemia (Interfant-99): an observational study and a 
multicentre randomised trial. Lancet 2007;370:240-50.
2. Pui CH, Campana D, Pei D, et al. Treating childhood acute lymphoblastic leukemia without 
cranial irradiation. The New England journal of medicine 2009;360:2730-41.
3. Meyer C, Hofmann J, Burmeister T, et al. The MLL recombinome of acute leukemias in 
2013. Leukemia 2013.
4. Gale KB, Ford AM, Repp R, et al. Backtracking leukemia to birth: identification of 
clonotypic gene fusion sequences in neonatal blood spots. Proceedings of the National 
Academy of Sciences of the United States of America 1997;94:13950-4.
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H3K79 methylation by DOT1L. Cancer cell 2011;20:66-78.
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cells by a potent small-molecule DOT1L inhibitor. Cancer cell 2011;20:53-65.
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myeloid leukaemia. Nature 2011;478:524-8.
12. Van der Velden VH, Corral L, Valsecchi MG, et al. Prognostic significance of minimal 
residual disease in infants with acute lymphoblastic leukemia treated within the Interfant-99 
protocol. Leukemia 2009;23:1073-9.
13. Parker C, Waters R, Leighton C, et al. Effect of mitoxantrone on outcome of children with 
first relapse of acute lymphoblastic leukaemia (ALL R3): an open-label randomised trial. 
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16. Styczynski J, Gil L, Derwich K, et al. Comparison of clofarabine activity in childhood and 
adult acute leukemia: individual tumor response study. Anticancer research 2009;29:1643-50.
17. Keshelava N, Houghton PJ, Morton CL, et al. Initial testing (stage 1) of vorinostat (SAHA) 
by the pediatric preclinical testing program. Pediatric blood & cancer 2009;53:505-8.
18. Barretina J, Caponigro G, Stransky N, et al. The Cancer Cell Line Encyclopedia enables 
predictive modelling of anticancer drug sensitivity. Nature 2012;483:603-7.
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19. Szczepanek J, Pogorzala M, Konatkowska B, et al. Differential ex vivo activity of 
bortezomib in newly diagnosed paediatric acute lymphoblastic and myeloblastic leukaemia. 
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20. Boccadoro M, Morgan G, Cavenagh J. Preclinical evaluation of the proteasome inhibitor 
bortezomib in cancer therapy. Cancer cell international 2005;5:18.
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suppression programs in pro-B MLL leukemias through MLL-AF4. Cancer cell 
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human breast cancer cells relies upon proteasome-dependent monoubiquitination of histone 
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23. Zhu B, Zheng Y, Pham AD, et al. Monoubiquitination of human histone H2B: the factors 
involved and their roles in HOX gene regulation. Molecular cell 2005;20:601-11.
24. McGinty RK, Kim J, Chatterjee C, Roeder RG, Muir TW. Chemically ubiquitylated histone 
H2B stimulates hDot1L-mediated intranucleosomal methylation. Nature 2008;453:812-6.
25. Wang E, Kawaoka S, Yu M, et al. Histone H2B ubiquitin ligase RNF20 is required for MLL-
rearranged leukemia. Proceedings of the National Academy of Sciences of the United States 
of America 2013;110:3901-6.
26. Kaspers GJ, Zimmermann M, Reinhardt D, et al. Improved outcome in pediatric relapsed 
acute myeloid leukemia: results of a randomized trial on liposomal daunorubicin by the 
International BFM Study Group. Journal of clinical oncology : official journal of the 
American Society of Clinical Oncology 2013;31:599-607.
27. Dimopoulos M, Siegel DS, Lonial S, et al. Vorinostat or placebo in combination with 
bortezomib in patients with multiple myeloma (VANTAGE 088): a multicentre, randomised, 
double-blind study. The Lancet Oncology 2013;14:1129-40.
28. Robak T, Huang H, Jin J, et al. Bortezomib-based therapy for newly diagnosed mantle-cell 
lymphoma. The New England journal of medicine 2015;372:944-53.
29. Gaynon PS, Bleyer WA, Steinherz PG, et al. Modified BFM therapy for children with 
previously untreated acute lymphoblastic leukemia and unfavorable prognostic features. 
Report of Children's Cancer Study Group Study CCG-193P. The American journal of 
pediatric hematology/oncology 1988;10:42-50.
30. Ocio EM, Vilanova D, Atadja P, et al. In vitro and in vivo rationale for the triple combination 
of panobinostat (LBH589) and dexamethasone with either bortezomib or lenalidomide in 
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32. Synold TW, Relling MV, Boyett JM, et al. Blast cell methotrexate-polyglutamate 
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33. Maude SL, Laetsch TW, Buechner J, et al. Tisagenlecleucel in Children and Young Adults 
with B-Cell Lymphoblastic Leukemia. The New England journal of medicine 2018;378:439-
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34. Moricke A, Reiter A, Zimmermann M, et al. Risk-adjusted therapy of acute lymphoblastic 
leukemia can decrease treatment burden and improve survival: treatment results of 2169 
unselected pediatric and adolescent patients enrolled in the trial ALL-BFM 95. Blood 
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35. Winick NJ, Bowman WP, Kamen BA, et al. Unexpected acute neurologic toxicity in the 
treatment of children with acute lymphoblastic leukemia. Journal of the National Cancer 
Institute 1992;84:252-6.
36. Boyd SD, Marshall EL, Merker JD, et al. Measurement and clinical monitoring of human 
lymphocyte clonality by massively parallel VDJ pyrosequencing. Science translational 
medicine 2009;1:12ra23.
37. Faham M, Zheng J, Moorhead M, et al. Deep-sequencing approach for minimal residual 
disease detection in acute lymphoblastic leukemia. Blood 2012;120:5173-80.
38. Driessen EM, van Roon EH, Spijkers-Hagelstein JA, et al. Frequencies and prognostic 
impact of RAS mutations in MLL-rearranged acute lymphoblastic leukemia in infants. 
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p65 as a parameter for NF-kappaB activation: Correlation between ImageStream cytometry, 
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40. Volk A, Li J, Xin J, et al. Co-inhibition of NF-kappaB and JNK is synergistic in TNF-
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41. Hageman LL, W; Chen, Y; Kim, H; Kornegay, N; Evans, WE; Bostrom, BC; Casillas, J; 
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A; Carroll, WL; Relling, MV; Wong, FL; Bhatia, S. Impact of 6 mercaptopurine (6MP) pill-
taking habits on adherence, thioguanine nucleoside (TGN) levels and relapse risk in children 
with acute lymphoblastic leukemia (ALL):  results from a Children's Oncology Group (COG) 
study (AALL03N1).  American Society of Hematology; December 6, 2014; San Franscisco, 
CA.
42. Smith GA, Damon LE, Rugo HS, Ries CA, Linker CA. High-dose cytarabine dose 
modification reduces the incidence of neurotoxicity in patients with renal insufficiency. 
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1997;15:833-9.
43. Haig GM, Bockbrader HN, Wesche DL, et al. Single-dose gabapentin pharmacokinetics and 
safety in healthy infants and children. Journal of clinical pharmacology 2001;41:507-14.
44. Moreau P, Pylypenko H, Grosicki S, et al. Subcutaneous versus intravenous administration of 
bortezomib in patients with relapsed multiple myeloma: a randomised, phase 3, non-
inferiority study. The Lancet Oncology 2011;12:431-40.
45. Thomas X, Chelghoum Y, Fanari N, Cannas G. Serum 25-hydroxyvitamin D levels are 
associated with prognosis in hematological malignancies. Hematology 2011;16:278-83.
46. Lee HJ, Muindi JR, Tan W, et al. Low 25(OH) vitamin D3 levels are associated with adverse 
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2014;120:521-9.
47. Shanafelt TD, Drake MT, Maurer MJ, et al. Vitamin D insufficiency and prognosis in 
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48. Mehta CRB, R.; Posch, M.; Brannath, W. Repeated confidence intervals for adaptive group 
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APPENDIX I:  TREATMENT/EVALUATION CALENDARS
REMISSION INDUCTION (approximately 42 days)
1
LP, ITMHA 
LV rescue
DEX
VORINO
BORTEZ
See Section 8.1 for 
required pre-study 
tests and research 
tests (BMA and PB 
biology studies)
2
DEX
VORINO
3
DEX
VORINO
4
LP, ITMHA(*)
LV rescue
DEX
VORINO
BORTEZ
CSF studies
PB – histone 
analysis
5
PEG-ASP
6
7
8
LP, ITMHA, 
LV rescue
DEX
VORINO
BORTEZ
MITO
CSF studies
9
DEX
VORINO
MITO
10
DEX
VORINO
11
LP, ITMHA(*) 
LV rescue
DEX
VORINO
BORTEZ
CSF studies
12
13
14
15
LP, ITMHA 
LV rescue
DEX
VORINO
BORTEZ
CSF studies
16
DEX
VORINO
17
DEX
VORINO
18
DEX
VORINO
BORTEZ
PB – histone 
analysis
19
20
21
22
LP, ITMHA 
LV rescue
CYCLO
CYCLO
6MP
BMA and MRD
MRD NGS
CSF studies
23
CYCLO
CYCLO
ARA-C
6MP
24
ARA-C
6MP
25
ARA-C
6MP
26
ARA-C
6MP
27
6MP
28
6MP
29
6MP
30
ARA-C
6MP
31
ARA-C
6MP
32
ARA-C
6MP
33
ARA-C
6MP
34
6MP
35
6MP
36
37
38
39
40
41
42
1During induction, it is critical to monitor chemistries frequently due to tumor lysis. At a minimum, they should be checked daily until 
values are stable and within normal limits for 48-72 hours following Day 9 mitoxantrone. Patients with high tumor burden may need tumor 
lysis labs as frequently as every 4-6 hours. Once stable, obtain as clinically indicated. Contact the PI or co-PI if there are questions or concerns. 
Physical exam every 3-7 days; CBC w/diff weekly or as clinically indicated; Chemistries, UA as clinically indicated. *CSF studies with each 
IT treatment
Bone marrow/clinical MRD and MRD NGS Day 22. PB biology – NFKB pre-tx, 6 hr and 24 hour; histone analysis and immune 
repertoire (See section 8.2.). See Section 8.1 for Pre-study evaluations – required within 1 week prior to study entry.
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CONSOLIDATION (approximately 56 days)
1
LP, ITMHA LV 
rescue
HDMTX#1
6MP
PE, CBC, chemistries, 
IgG, vitD
CXR (med mass at dx),
CSF studies
MRD and MRD NGS
Germline DNA
PB – histone analysis
2
6MP
3
6MP
4
6MP
5
6MP
6
6MP
7
6MP
8
6MP
PE, CBC, diff
Chemistries
9
6MP
10
6MP
11
6MP
12
6MP
13
6MP
14
6MP
15
LP, ITMHA LV 
rescue
HDMTX#2
6MP
PE, CBC, diff
chemistries, CSF studies, 
BMA/MRD and MRD 
NGS**
16
6MP
17
6MP
18
6MP
19
6MP
20
6MP
21
6MP
22
6MP
PE, CBC, diff
Chemistries
23
6MP
24
6MP
25
6MP
26
6MP
27
6MP
28
6MP
29
LP, ITMHA LV 
rescue
HDMTX#3
6MP
PE, CBC, diff
Chemistries, CSF studies, 
BMA MRD and MRD 
NGS**
30
6MP
31
6MP
32
6MP
33
6MP
34
6MP
35
6MP
36
6MP
PE, CBC, diff
Chemistries
37
6MP
38
6MP
39
6MP
40
6MP
41
6MP
42
6MP
43
LP, ITMHA LV 
rescue
HDMTX#4
6MP
PE, CBC, diff
Chemistries,
CSF studies, BMA/MRD
and MRD NGS**
44
6MP
45
6MP
46
6MP
47
6MP
48
6MP
49
6MP
50
6MP
PE, CBC, diff
Chemistries
51
6MP
52
6MP
53
6MP
54
6MP
55
6MP
56
6MP
Notes: CBC w/diff weekly; electrolytes/BUN/creatinine weekly; bilirubin/AST/ALT/TP/Albumin weekly; Uric Acid/LDH/Phos/Ca/Mg 
before each HDMTX; glucose/UA as indicated. PE weekly
*IT methotrexate + hydrocortisone + cytarabine, to be given on days 1, 15, 29, and 43; IT therapy should be given on same day as 
HDMTX administration (consult PI or PK if the IT and HDMTX become separated by more than 12 hours. CSF studies with each 
IT.**Patients who are MRD positive on day 1 should have a repeat marrow on day 15 and with every HDMTX thereafter until 
they become MRD negative. Rising MRD is an indication for transplant.
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REINDUCTION
1
LP, ITMHA LV 
rescue*
MITO
DEX
BORTEZ
VORINO
PE
IgG 
CSF studies
BMA/MRD and MRD 
ECHO OR MUGA
NGS
PB – immune repertoire
2
MITO
DEX
VORINO
3
PEG-ASP
DEX
VORINO
4
DEX
BORTEZ
VORINO
5
6
7
8
DEX
BORTEZ
VORINO
9
DEX
VORINO
10
DEX
VORINO
11
DEX
BORTEZ
VORINO
12
13
14
15
LP, ITMHA(**) 
LV rescue
DEX
BORTEZ
VORINO
CSF studies if CNS3
16
DEX
VORINO
17
DEX
VORINO
18
PEG-ASP
DEX
BORTEZ
VORINO
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
PE weekly, clinical hematology and chemistry labs as indicated.
*Leucovorin rescue only in patients with prior CNS toxicities or in patients with WBC<1500/mm3 or 
ANC<500/mm3
**CNS3 patients only
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RE-INTENSIFICATION - High-Risk Patients only*
1
DEX
ARA-C
ARA-C
PE, IgG, BMA/MRD 
and MRD NGS
PB – immune 
repertoire
2
DEX
ARA-C
ARA-C
3
DEX
VP16
4
DEX
VP16
5
LP, 
ITMHA(*) 
LV rescue**
DEX
VP16
CSF studies
6
PEG-ASP
7
8
9
10
11
12
13
14
15
16
17
18
19
2-
21
22
23
24
25
26
27
28
*Patients with MRD >0.01% on day 1 of Reinduction, OR patients with increasing MRD during 
Consolidation phase.
** Leucovorin rescue only in patients with prior CNS toxicities or in patients with WBC <1500/mm3 or 
ANC <500/mm3
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MAINTENANCE
Week
Cycle
Treatment
Schedule
1
1*
LP, ITMHA 
DEX + VCR + 6MP
2
6MP + MTX
3
6MP + MTX
4
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
5
2
LP, ITMHA 
DEX + VCR + 6MP
6
6MP + MTX
7
6MP + MTX
8
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
9
3
LP, ITMHA 
DEX + VCR + 6MP
10
6MP + MTX
11
6MP + MTX
12
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
13
4
LP, ITMHA 
DEX + VCR + 6MP
14
6MP + MTX
15
6MP + MTX
16
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
17
5*
LP, ITMHA 
DEX + VCR + 6MP
18
6MP + MTX
19
6MP + MTX
20
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
21
6
LP, ITMHA 
DEX + VCR + 6MP
22
6MP + MTX
23
6MP + MTX
24
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
25
7
LP, ITMHA 
DEX + VCR + 6MP + MTX
26
6MP + MTX
27
6MP + MTX
28
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
29
8
LP, ITMHA 
DEX + VCR + 6MP
30
6MP + MTX
31
6MP + MTX
32
6MP + MTX
Day 1:  ITMHA CNS 1,2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 8, 15, 22:  MTX
33
9
LP, ITMHA(*) 
DEX + VCR + 6MP
34
6MP + MTX
35
6MP + MTX
36
6MP + MTX
Day 1: ITMHA CNS 2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 1 (CNS1**), 8, 15, 22:  MTX
Leucovorin rescue following IT MHA only in patients with prior CNS toxicities or in patients with WBC<1500/mm3 
or ANC<500/mm3. *PB for biology studies Cycles 1, 5, 10 and 15. 
**Methotrexate will be given on day 1 of cycles that do not have an intrathecal treatment. For CNS1 patients 
this is cycles 9-20, CNS2 patients cycles 12-20, and CNS3 or traumatic LP cycles 14-20.
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MAINTENANCE - continued
Week
Cycle 
Treatment
37
10*
LP, ITMHA(*) 
DEX + VCR + 6MP
38
6MP + MTX
39
6MP + MTX
40
6MP + MTX
Day 1:  ITMHA CNS 2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 1 (CNS1**), 8, 15, 22:  MTX
41
11
LP, ITMHA(*) 
DEX + VCR + 6MP
42
6MP + MTX
43
6MP + MTX
44
6MP + MTX
Day 1: ITMHA CNS 2,3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 1 (CNS1**) 8, 15, 22:  MTX
45
12
LP, ITMHA(*) 
DEX + VCR + 6MP
46
6MP + MTX
47
6MP + MTX
48
6MP + MTX
Day 1: ITMHA CNS 3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 1 (CNS1,2**), 8, 15, 22:  MTX
49
13
LP, ITMHA(*) 
DEX + VCR + 6MP
50
6MP + MTX
51
6MP + MTX
52
6MP + MTX
Day 1: ITMHA CNS 3
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 1 (CNS1,2**),8, 15, 22:  MTX
53
14
DEX + VCR + 6MP
54
6MP + MTX
55
6MP + MTX
56
6MP + MTX
Days 1-5: DEX
Day 1:  VCR
Days 1-28: 6MP
Days 1, 8, 15, 22:  MTX
57
15*
DEX + VCR + 6MP
58
6MP + MTX
59
6MP + MTX
60
6MP + MTX
Days 1-5: DEX
Day 1: VCR
Days 1-28: 6MP
Days 1, 8, 15, 22:  MTX
61
16
DEX + VCR + 6MP
62
6MP + MTX
63
6MP + MTX
64
6MP + MTX
Days 1-5: DEX
Day 1: VCR
Days 1-28: 6MP
Days 1, 8, 15, 22:  MTX
65
17
DEX + VCR + 6MP
66
6MP + MTX
67
6MP + MTX
68
6MP + MTX
Days 1-5: DEX
Day 1**: VCR
Days 1-28: 6MP
Days 1,8, 15, 22:  MTX
69
18
DEX + VCR + 6MP
70
6MP + MTX
71
6MP + MTX
72
6MP + MTX
Days 1-5: DEX
Day 1: VCR
Days 1-28: 6MP
Days 1, 8, 15, 22:  MTX
73
19
DEX + VCR + 6MP
74
6MP + MTX
75
6MP + MTX
76
6MP + MTX
Days 1-5: DEX
Day 1: VCR
Days 1-28: 6MP
Days 1, 8, 15, 22:  MTX
77
20
DEX + VCR + 6MP
78
6MP + MTX
79
6MP + MTX
80
6MP + MTX
Days 1-5: DEX
Day 1: VCR
Days 1-28: 6MP
Days 1, 8, 15, 22:  MTX
Leucovorin rescue following IT MHA only in patients with prior CNS toxicities or in patients with WBC<1500/mm3 
or ANC<500/mm3. BMA/MRD and MRD NGS at End of Therapy and at time of relapse. Tumor NGS and Drug 
Sensitivity studies at time of relapse. *Methotrexate will be given on day 1 of cycles that do not have an intrathecal 
treatment. For CNS1 patients this is cycles 9-20, CNS2 patients cycles 12-20, and CNS3 or traumatic LP cycles 14-20.
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APPENDIX II:  TARGETED KINASE INHIBITORS AND INHIBITORS OF 
EPIGENETIC MARKS
Bendamustine
BEZ-235 (PI3K/MTOR dual inhibitor)
Bortezomib
CAL-101 (PI3Ki)
Clofarabine
Cytarabine
Daunorubicin
Decitabine
Dexamethasone
Doxorubicin
EPZ-5676 (DOT1Li)
Etoposide
JQ1 (BRDi)
L-Asparaginase
Mercaptopurine
Methotrexate
Methylprednisolone
Mitoxantrone
MLN4924
Panobinostat
PD-325901 (MEKi)
Prednisolone
Quizartinib (class III receptor TKI)
Sorafenib (TKI)
Thioguanine
Torin1 (mTORi)
Vincristine
Vinorelbine
Vorinostat
St. Jude Children's Research Hospital
IRB NUMBER: Pro00005777
IRB APPROVAL DATE: 11/11/2021

TINI
Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
APPENDIX III:  VORINOSTAT COMPOUNDING
***Use compounding equipment designated for hazardous drugs and wear gloves and mask while preparing***
Product Description
Recipe
References
Items Needed
Preparation Instructions
References
Name: Vorinostat
Strength: 50 mg/ml
Dosage Form:  
Suspension Route:  PO
Stability: expires 28 days 
after preparation
Packaging:  package in 
tight light-resistant 
*GLASS* bottles
Storage:  Room 
Temperature
#20 Vorinostat 
100 mg 
capsules
20ml Ora-Plus
20ml Ora-
Sweet
1. Place 20ml of Ora-Plus (Paddock Labs 
brand) in glass bottle.
2. Place contents of 20 vorinostat 100mg 
capsules in same bottle and shake to 
dispense.  Note:  shaking could take 
upwards of 3 minutes.
3. Add 20ml of Ora-Sweet (Paddock Labs 
brand) and shake to dispense.
REF:  unpublished information 
from CTEP pediatric clinical 
trials provided by Merck.
Ref:  Reviewed date: 04/2011
Date Updated:  04/2009
***Please use a Biological Safety Cabinet***
Manufacturer
Initials
Date
Control 
number
Exp. 
Date
Total Qty 
Prepared
Name
Manufacturer 
NDC
Lot No.
Exp Date Qty
Prep
Check
Final 
Check
Vorinostat 
100 mg 
capsules
Ora-Plus
Ora-Sweet
Vorinostat 
100 mg 
capsules
Ora-Plus
Ora-Sweet
Vorinostat 
100 mg 
capsules
Ora-Plus
Ora-Sweet
Vorinostat 
100 mg 
capsules
Ora-Plus
Ora-Sweet
Vorinostat 
100 mg 
capsules
Ora-Plus
Ora-Sweet
Vorinostat 
100 mg 
capsules
Ora-Plus
Ora-Sweet
Smaller volumes may be prepared to avoid wasting capsules.
St. Jude Children's Research Hospital
IRB NUMBER: Pro00005777
IRB APPROVAL DATE: 11/11/2021

TINI
Revision 5.1, dated 10-21-2021
Protocol document date: 10-21-2021
APPENDIX IV:  TESTS/EVALUATIONS FOR CLINICAL CARE AND FOR RESEARCH
Clinical care

All drugs/agents (FDA approved or FDA-approved/off-label)

History and physical exams

CBC w/diff

Chemistry profile

Coagulation screen

Urinalysis

Lipid screen

Thyroid function tests

Total IgG level

25-OH Vitamin D level

Chest X-ray

Lumbar puncture with CSF examination

Bone marrow: morphology cytochemistry, immunophenotyping, cytogenetics, DNA 
index molecular diagnosis and MRD studies

Echocardiogram or MUGA

Electrocardiogram (EKG)

Methotrexate levels
Research

Tumor next generation sequencing

Drug sensitivity studies

MRD next generation sequencing

Peripheral blood for biologic studies (NFĸB/proteasome, histone analysis, immune 
repertoire)

Germline DNA
St. Jude Children's Research Hospital
IRB NUMBER: Pro00005777
IRB APPROVAL DATE: 11/11/2021