Rituximab, Rasburicase, and Combination Chemotherapy in Treating Young Patients With Newly Diagnosed Advanced B-Cell Leukemia or Lymphoma
Condition: Childhood Burkitt Lymphoma; Childhood Diffuse Large Cell Lymphoma; Childhood Immunoblastic Large Cell Lymphoma; Stage I Childhood Large Cell Lymphoma; Stage I Childhood Small Noncleaved Cell Lymphoma; Stage II Childhood Large Cell Lymphoma; Stage II Childhood Small Noncleaved Cell Lymphoma; Stage III Childhood Large Cell Lymphoma; Stage III Childhood Small Noncleaved Cell Lymphoma; Stage IV Childhood Large Cell Lymphoma; Stage IV Childhood Small Noncleaved Cell Lymphoma; Untreated Childhood Acute Lymphoblastic Leukemia
MeSH terms: Burkitt Lymphoma; Lymphoma; Leukemia; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Lymphoma, Non-Hodgkin; Lymphoma, Large B-Cell, Diffuse; Lymphoma, Large-Cell, Immunoblastic; Plasmablastic Lymphoma; Leukemia, B-Cell; Leukemia, Lymphocytic, Chronic, B-Cell
Study type: Interventional
Phase: Phase 2

Summary: 
      Phase II trial to study the effectiveness of combining rituximab and rasburicase with
      combination chemotherapy in treating young patients who have newly diagnosed advanced B-cell
      leukemia or lymphoma. Monoclonal antibodies such as rituximab can locate cancer cells and
      either kill them or deliver cancer-killing substances to them without harming normal cells.
      Drugs used in chemotherapy work in different ways to stop cancer cells from dividing so they
      stop growing or die. Combining more than one drug with rituximab may kill more cancer cells.
      Chemoprotective drugs such as rasburicase may protect kidney cells from the side effects of
      chemotherapy.
    

Detailed description: 
      OBJECTIVES:

      I. Determine the toxicity of the addition of rituximab to induction chemotherapy comprising
      vincristine, methylprednisolone, methotrexate, leucovorin calcium, cyclophosphamide, and
      doxorubicin (COPADM) [COMRAP] and to consolidation chemotherapy in children with newly
      diagnosed FAB prognostic group B or group C leukemia or lymphoma treated with LMB/FAB
      therapy.

      II. Determine the toxicity of the addition of rasburicase to the reduction phase comprising
      cyclophosphamide, vincristine, prednisone or methylprednisolone, methotrexate, and leucovorin
      calcium (COP-R) in these patients.

      III. Determine the incidence of tumor lysis syndrome, renal complications, and the use of
      assisted renal support (i.e., dialysis or hemofiltration) during the COP-R reduction phase
      and the first induction phase of COPADM or COMRAP in these patients.

      IV. Determine the response rate of patients treated with COMRAP incorporated into LMB/FAB
      therapy.

      V. Assess minimal residual disease in patients before and during COMRAP therapy incorporated
      into LMB/FAB therapy.

      OUTLINE: This is a multicenter study. Patients are stratified according to FAB prognostic
      group (B vs C) and treated by group classification.

      FAB GROUP B

      TREATMENT I (first 6 patients):

      REDUCTION THERAPY: Patients receive the COP-R regimen comprising cyclophosphamide IV over 15
      minutes, vincristine IV, and methotrexate and hydrocortisone intrathecally (IT) on day 0;
      rasburicase* IV over 30 minutes every 12 hours on days 0 and 1 and then once daily on days
      2-4 (patients exhibiting hyperuricemia and clinical suspicion of B-cell non-Hodgkin's
      lymphoma or B-cell acute lymphocytic leukemia also receive rasburicase on days -3, -2, and
      -1); leucovorin calcium IV or orally every 12 hours on days 1 and 3; and prednisone (PRED) or
      methylprednisolone (MePRDL) IV (or orally) on days 0-6. Patients too critical to proceed may
      receive another course of reduction therapy.

      NOTE: *Patients with G6PD deficiency do not receive rasburicase during reduction therapy.

      INDUCTION THERAPY: Patients with less than 20% tumor reduction follow the group C induction
      phase (described below). Patients with at least 20% tumor reduction receive 1 course of the
      COPADM regimen: vincristine IV and methotrexate IV over 4 hours on day 0; PRED or MePRDL IV
      (or orally) on days 0-7; leucovorin calcium IV or orally every 6 hours for 12 doses on days
      1-3; doxorubicin IV over 30-60 minutes on day 1; cyclophosphamide IV over 15 minutes every 12
      hours on days 1-3; methotrexate IT and hydrocortisone IT on days 1 and 5; and filgrastim
      (G-CSF) subcutaneously (SC) beginning on day 6 and continuing until blood counts recover.

      Patients receive the second part of induction therapy when peripheral blood counts have
      recovered but no fewer than 16 days after the first part of induction therapy. Patients
      receive 1 course of the COMRAP regimen comprising rituximab IV on days -2 and 0 with COPADM
      as in the first part of induction therapy.

      CONSOLIDATION THERAPY: Patients receive the CYM-RM regimen comprising rituximab IV and
      methotrexate IV over 4 hours on day 0; leucovorin calcium IV or orally every 6 hours for 12
      doses on days 1-3; cytarabine IV over 24 hours daily on days 1-5; hydrocortisone IT on days 1
      and 6; methotrexate IT on day 1; and cytarabine IT on day 6.

      After full recovery from consolidation therapy, patients with any residual masses undergo
      surgical excision or biopsy. Patients with histology positive for tumor (even if completely
      resected) proceed to Group C consolidation therapy (described below). Patients with histology
      negative for tumor proceed to Group B maintenance therapy.

      MAINTENANCE THERAPY: Patients receive the COPADM regimen comprising vincristine IV and
      methotrexate IV over 4 hours on day 0; PRED or MePRDL IV (or orally) on days 0-7; doxorubicin
      IV over 30-60 minutes, and cyclophosphamide IV over 30 minutes on days 1 and 2; methotrexate
      IT and hydrocortisone IT on day 1; and leucovorin calcium IV or orally every 6 hours on days
      1-3 (12 doses).

      TREATMENT II (44 patients):

      REDUCTION THERAPY: Patients receive the COP-R regimen as in treatment I.

      INDUCTION THERAPY: Patients receive 2 courses of the COMRAP regimen as in the second
      induction of treatment I.

      CONSOLIDATION THERAPY: Patients receive the CYM-RM regimen as in treatment I.

      MAINTENANCE THERAPY: Patients receive the COPADM regimen as in treatment I.

      FAB GROUP C:

      TREATMENT I (first 3 patients):

      REDUCTION THERAPY: Patients receive the COP-R regimen as in group B treatment I, with the
      addition of triple intrathecal therapy (TIT) comprising methotrexate, hydrocortisone, and
      cytarabine on days 0, 2, and 4.

      INDUCTION THERAPY: Patients receive 2 courses of the COPADM regimen as in group B treatment
      I, with the addition of TIT on days 1, 3, and 5. Patients in group C who have biopsy-proven
      disease after induction therapy are off protocol therapy and treated at the discretion of the
      investigator.

      CONSOLIDATION THERAPY:

      CNS-POSITIVE DISEASE: Patients receive 2 courses of the CYVE-RM regimen comprising rituximab
      IV and methotrexate and hydrocortisone IT on day 0; cytarabine IV over 12 hours on days 0-4;
      high-dose cytarabine IV over 3 hours and etoposide IV over 2 hours on days 1-4; and G-CSF SC
      on days 6-20. During the first course, patients also receive HD-MTX IV over 4 hours on day
      17; TIT on day 18; and leucovorin calcium IV or orally every 6 hours on days 18-21 (12
      doses).

      CNS-NEGATIVE DISEASE: Patients receive the CYVE-RM regimen without intrathecal therapy,
      HD-MTX, or leucovorin calcium.

      After full recovery from consolidation therapy, patients with any residual masses undergo
      surgical excision or biopsy. Patients who do not achieve complete remission after
      consolidation therapy are considered treatment failures.

      MAINTENANCE THERAPY (each course lasts 28 days):

      COURSE M1: Patients receive vincristine IV and high-dose methotrexate IV over 4 hours on day
      0; PRED or MePRDL IV (or orally) on days 0-7; doxorubicin IV over 30-60 minutes and TIT on
      day 1; cyclophosphamide IV over 30 minutes on days 1 and 2; and leucovorin calcium IV or
      orally every 6 hours on days 1-4 (12 doses).

      COURSE M2: Patients receive etoposide IV over 90 minutes on days 0-2 and cytarabine SC every
      12 hours on days 0-4.

      COURSE M3: Patients receive vincristine IV on day 0; cyclophosphamide IV over 30 minutes on
      days 0 and 1; PRED or MePRDL IV (or orally) twice daily on days 0-7; and doxorubicin IV over
      30-60 minutes on day 0 (after first dose of cyclophosphamide).

      COURSE M4: Patients receive etoposide and cytarabine as in course M2.

      TREATMENT II (37 patients):

      REDUCTION THERAPY: Patients receive 2 courses of the COP-R regimen as in group C treatment I.

      INDUCTION THERAPY: Patients receive the COMRAP regimen comprising rituximab IV, vincristine
      IV, and HD-MTX IV over 4 hours on day 0; PRED or MePRDL IV (or orally) on days 0-7;
      leucovorin calcium IV or orally and cyclophosphamide IV over 15 minutes on days 1-3;
      doxorubicin IV over 30-60 minutes on day 1; TIT on days 1, 3, and 5; and G-CSF SC on days
      6-20.

      CONSOLIDATION THERAPY: CNS-positive disease: Patients receive the CYVE-RM regimen plus HD-MTX
      as in group C treatment I. Patients then receive CYVE-RM for a second course.

      CNS-NEGATIVE DISEASE: Patients receive CYVE-RM regimen as in group C treatment I.

      MAINTENANCE THERAPY: Patients receive maintenance therapy as in group C treatment I.

      Patients are followed every 3-6 months for 1 year and then every 6 months for up to 5 years
    

Intervention name(s): doxorubicin hydrochloride; cyclophosphamide; methotrexate; rasburicase; leucovorin calcium; prednisone; methylprednisolone; filgrastim; rituximab; cytarabine; etoposide; vincristine sulfate; hydrocortisone sodium succinate; laboratory biomarker analysis
Intervention type(s): Drug; Drug; Drug; Drug; Drug; Drug; Drug; Biological; Biological; Drug; Drug; Drug; Drug; Other
Intervention description(s): Given IV, IT, or orally; Given IV; Given IV or IT; Given IV; Given IV or orally; Given IV or orally; Given IV or orally; Given subcutaneously; Given IV; Given IT; Given IV; Given IV; Given IT; Correlative studies
Other intervention name(s): ADM; ADR; Adria; Adriamycin PFS; Adriamycin RDF; CPM; CTX; Cytoxan; Endoxan; Endoxana; amethopterin; Folex; methylaminopterin; Mexate; MTX; Elitek; NK-631; recombinant urate oxidase; CF; CFR; LV; DeCortin; Deltra; Depo-Medrol; Medrol; MePRDL; Solu-Medrol; Wyacort; G-CSF; Neupogen; IDEC-C2B8; IDEC-C2B8 monoclonal antibody; Mabthera; MOAB IDEC-C2B8; Rituxan; ARA-C; arabinofuranosylcytosine; arabinosylcytosine; Cytosar-U; cytosine arabinoside; EPEG; VP-16; VP-16-213; leurocristine sulfate; VCR; Vincasar PFS; Sodium hydrocortisone succinate; Solu-Cortef; Solu-Glyc
Intervention MeSH terms: Leucovorin; Cytarabine; Prednisone; Methylprednisolone; Methylprednisolone Acetate; Methylprednisolone Hemisuccinate; Prednisolone; Prednisolone acetate; Hydrocortisone; Hydrocortisone 17-butyrate 21-propionate; Hydrocortisone acetate; Hydrocortisone hemisuccinate; Cyclophosphamide; Rituximab; Doxorubicin; Liposomal doxorubicin; Methotrexate; Etoposide; Vincristine; Etoposide phosphate; Rasburicase; Prednisolone hemisuccinate; Prednisolone phosphate; Levoleucovorin
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment