Combination Chemotherapy in Treating Young Patients With Newly Diagnosed Acute Lymphoblastic Leukemia
Condition: Acute Lymphoblastic Leukemia; Childhood B Acute Lymphoblastic Leukemia
MeSH terms: Leukemia; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Leukemia, Lymphoid
Study type: Interventional
Phase: Phase 3

Summary: 
      This randomized phase III trial is studying different combination chemotherapy regimens and
      comparing how well they work in treating patients with newly diagnosed acute lymphoblastic
      leukemia. Drugs used in chemotherapy work in different ways to stop the growth of cancer
      cells, either by killing the cells or by stopping them from dividing. Giving more than one
      drug (combination chemotherapy) may kill more cancer cells.
    

Detailed description: 
      PRIMARY OBJECTIVES:

      I. To determine whether the substitution of three intensified phases of post-Induction
      treatment for standard phases will improve the event free survival (EFS) of children with
      SR-average acute lymphoblastic leukemia (ALL).

      II. Determine whether the substitution of intensified Consolidation for standard
      Consolidation will improve the EFS of children with SR-average ALL.

      III. To determine whether the addition of four doses of percutaneous endoscopic gastrostomy
      (PEG) asparaginase, given once every three weeks during Consolidation and Interim Maintenance
      phases, will improve the EFS for children with SR-low ALL.

      SECONDARY OBJECTIVES:

      I. Identify potentially modifiable factors associated with impaired health related quality of
      life (HRQOL) at different periods of therapy in the patients who are SR-average enrolled on
      the standard risk ALL study.

      II. Determine the critical time periods when future intervention studies to mitigate adverse
      HRQOL outcomes should occur.

      III. Correlate day 29 minimal residual disease (MRD) with EFS and overall survival (OS) of
      patients treated with these regimens.

      IV. Correlate early marrow response with day 29 MRD status. V. To improve outcome by
      identifying additional high risk patients by Day 29 MRD for treatment with fully augmented
      Berlin-Frankfurt-Munster (BFM).

      VI. To examine the relative contributions of genetic factors and early treatment response to
      outcome by comparing the outcome of patients with and without TEL-AML1 fusion or triple
      trisomy and low levels of MRD at end Induction who are treated with identical therapy on the
      standard arms of the SR-low and SR-average trials.

      OUTLINE: This is a 2-part, partially randomized, multicenter study. Patients are stratified
      according to early response to study induction therapy (rapid early response [standard risk
      (SR)-low or SR-average acute lymphoblastic leukemia (ALL)] vs slow early response [SR-high
      ALL]). After completion of induction therapy but before proceeding to part II therapy,
      patients are assigned to 1 of 3 groups based on stratification.

      PART I:

      INDUCTION THERAPY: All patients receive cytarabine intrathecally (IT) on day 1; vincristine
      IV on days 1, 8, 15, and 22; dexamethasone IV or orally (PO) twice daily (BID) on days 1-28;
      pegaspargase intramuscularly (IM) (may give IV over 1 to 2 hours) on day 4, 5, or 6; and
      methotrexate IT on days 8 and 29 (and days 15 and 22 for patients with CNS3 disease).
      Patients with Down syndrome (DS) receive leucovorin calcium PO at 48 and 60 hours after each
      dose of methotrexate IT. Patients are assessed for response on day 29. Patients with M1 bone
      marrow AND minimal residual disease (MRD) < 0.1% OR MRD >= 0.1% and < 1% proceed to therapy
      in part II. Patients with M2 bone marrow OR M1 bone marrow AND MRD >= 1% proceed to extended
      induction therapy. Patients with M3 bone marrow are removed from the study.

      EXTENDED INDUCTION THERAPY: Patients receive dexamethasone IV or PO BID on days 1-14;
      vincristine IV on days 1 and 8; pegaspargase IM on day 4, 5, or 6; and daunorubicin
      hydrochloride IV over 15 minutes to 2 hours on day 1. Patients with M1 bone marrow and MRD <
      1% after extended induction therapy proceed to therapy in part II. Patients with M2 or M3
      bone marrow after extended induction therapy are removed from the study.

      PART II:

      GROUP 1 (SR-low ALL): Patients are randomized to 1 of 2 treatment arms.

      ARM I:

      STANDARD CONSOLIDATION THERAPY: Patients receive vincristine IV on day 1; mercaptopurine PO
      on days 1-28; and methotrexate IT on days 1, 8, and 15. Patients with Down syndrome (DS)
      receive leucovorin calcium (PO) at 48 and 60 hours after each dose of methotrexate IT.

      STANDARD INTERIM MAINTENANCE THERAPY: Patients receive vincristine IV on days 1 and 29;
      dexamethasone IV or PO BID on days 1-5 and 29-33; mercaptopurine PO on days 1-50;
      methotrexate PO on days 1, 8, 15, 22, 29, 36, 43, and 50; and methotrexate IT on day 29.
      Patients with DS receive leucovorin calcium PO at 48 and 60 hours after each dose of
      methotrexate IT.

      STANDARD DELAYED INTENSIFICATION (DI) THERAPY: Patients receive vincristine IV on days 1, 8,
      and 15; dexamethasone IV or PO BID on days 1-21; doxorubicin hydrochloride IV over 15 minutes
      to 2 hours on days 1, 8, and 15; pegaspargase IM on day 4, 5, or 6; cyclophosphamide IV over
      30 minutes on day 29; cytarabine IV or subcutaneously (SC) on days 29-32 and 36-39;
      thioguanine PO on days 29-42; and methotrexate IT on days 1 and 29. Patients with DS receive
      dexamethasone IV or PO BID on days 1-7 and 15-21 and leucovorin calcium PO at 48 and 60 hours
      after each dose of methotrexate IT.

      ARM II:

      EXPERIMENTAL CONSOLIDATION THERAPY: Patients receive vincristine, mercaptopurine,
      methotrexate, and leucovorin calcium as in arm I and pegaspargase IM on days 1 and 22.

      EXPERIMENTAL INTERIM MAINTENANCE THERAPY: Patients receive vincristine, dexamethasone,
      mercaptopurine, methotrexate PO, and methotrexate IT as in arm I and pegaspargase IM on days
      15 and 36.Standard DI therapy: Patients receive standard DI therapy as in arm I.

      GROUP 2 (SR-average ALL): Patients are randomized to 1 of 4 treatment arms.

      ARM I: Patients receive standard consolidation therapy, standard interim maintenance therapy,
      and standard DI therapy as in group 1, arm I.

      ARM II:

      STANDARD CONSOLIDATION THERAPY: Patients receive standard consolidation therapy as in group
      1, arm I. Augmented interim maintenance therapy: Patients receive vincristine IV and
      methotrexate IV on days 1, 11, 21, 31, and 41; pegaspargase IM on days 2 and 22; and
      methotrexate IT on days 1 and 31. Patients with DS receive leucovorin calcium PO at 48 and 60
      hours after each dose of methotrexate IT. Augmented DI therapy: Patients receive vincristine
      IV on days 1, 8, 15, 43, and 50; dexamethasone IV or PO BID on days 1-21; doxorubicin
      hydrochloride IV over 15 minutes to 2 hours on days 1, 8, and 15; pegaspargase IM on day 4,
      5, or 6 AND day 43; cyclophosphamide IV over 30 minutes on day 29; cytarabine IV or SC on
      days 29-32 and 36-39; thioguanine PO on days 29-42; and methotrexate IT on days 1, 29, and
      36. Patients with DS receive dexamethasone on days 1-7 and 15-21 and leucovorin calcium PO at
      48 and 60 hours after each dose of methotrexate IT.

      ARM III:

      INTENSIFIED CONSOLIDATION THERAPY: Patients receive cyclophosphamide IV over 30 minutes on
      days 1 and 29; cytarabine IV or SC on days 1-4, 8-11, 29-32, and 36-39; mercaptopurine PO on
      days 1-14 and 29-42; vincristine IV on days 15, 22, 43, and 50; pegaspargase IM on days 15
      and 43; and methotrexate IT on days 1, 8, 15*, and 22*. Patients with DS receive leucovorin
      calcium PO at 48 and 60 hours after each dose of methotrexate IT*.

      NOTE: *Patients with CNS3 disease at diagnosis do not receive methotrexate on days 15 and 22
      or leucovorin calcium.

      STANDARD INTERIM MAINTENANCE THERAPY: Patients receive standard interim maintenance therapy
      as in group 1, arm I.

      STANDARD DI THERAPY: Patients receive standard DI therapy as in group 1, arm I.

      ARM IV:

      INTENSIFIED CONSOLIDATION THERAPY: Patients receive intensified consolidation therapy as in
      group 2, arm III.

      AUGMENTED INTERIM MAINTENANCE THERAPY: Patients receive augmented interim maintenance therapy
      as in group 2, arm II.

      AUGMENTED DI THERAPY: Patients receive augmented DI therapy as in group 2, arm II.

      GROUP 3 (SR-high ALL): Patients receive the following therapy: Intensified consolidation
      therapy: Patients receive intensified consolidation therapy as in group 2, arm III.

      AUGMENTED INTERIM MAINTENANCE* THERAPY: Patients receive augmented interim maintenance
      therapy as in group 2, arm II. Treatment repeats every 56 days for 2 courses.

      NOTE: *As of Amendment #7, all SR-High patients currently receiving AIM 1 therapy should
      complete this phase of therapy and proceed to ADI 1 therapy as originally planned including
      Capizzi methotrexate during AIM 1. Upon completion of ADI 1, patients should receive a second
      Interim Maintenance phase with high-dose methotrexate (IM HD) rather than Capizzi
      methotrexate. Patients should then proceed to ADI 2 and then Maintenance.

      AUGMENTED DI* THERAPY: Patients receive augmented DI therapy as in group 2, arm II. Treatment
      repeats every 56 days for 2 courses**.

      NOTE: *As of Amendment #7, all SR-High patients currently receiving ADI 1 therapy should
      complete this phase of therapy as originally planned. Upon completion of ADI 1, patients
      should receive a second Interim Maintenance phase with IM HD. Patients should then proceed to
      ADI 2 and then Maintenance.

      NOTE: **Patients with CNS3 disease at diagnosis also undergo cranial radiotherapy on days
      29-33 and 36-40 during course 2 only; these patients do not receive methotrexate on day 36,
      thioguanine, or leucovorin calcium.

      MAINTENANCE THERAPY: All patients receive vincristine IV on days 1, 29, and 57; oral
      dexamethasone twice daily on days 1-5, 29-33, and 57-61; oral methotrexate on days 8, 15, 22,
      29, 36, 43, 50, 57, 64, 71, and 78; oral mercaptopurine on days 1-84; and methotrexate IT* on
      day 1. Courses repeat every 84 days for a total of 2 years from the start of interim
      maintenance therapy for female patients and 3 years from the start of interim maintenance
      therapy for male patients.

      NOTE: *SR-High or CNS3 patients should receive up to a maximum of 23 intrathecal treatments
      for females and 26 intrathecal treatments for males.

      After the completion of study treatment, patients are followed every 1-2 months for 2 years,
      every 3 months for 1 year, and then every 6-12 months for 2 years.
    

Intervention name(s): 3-Dimensional Conformal Radiation Therapy; Cyclophosphamide; Cytarabine; Dexamethasone; Doxorubicin Hydrochloride; Leucovorin Calcium; Mercaptopurine; Methotrexate; Pegaspargase; Thioguanine; Vincristine Sulfate
Intervention type(s): Radiation; Drug; Drug; Drug; Drug; Drug; Drug; Drug; Drug; Drug; Drug
Intervention description(s): Some patients undergo cranial radiotherapy; Given IV; Given IV or SC; Given IV or PO; Given IV or IT; Given PO; Given PO; Given IM or IT; Given IM; Given PO; Given IV
Other intervention name(s): 3-dimensional radiation therapy; 3D Conformal; 3D CONFORMAL RADIATION THERAPY; 3D CRT; 3D-CRT; Conformal Therapy; Radiation Conformal Therapy; Radiation, 3D Conformal; (-)-Cyclophosphamide; 2H-1,3,2-Oxazaphosphorine, 2-[bis(2-chloroethyl)amino]tetrahydro-, 2-oxide, monohydrate; Carloxan; Ciclofosfamida; Ciclofosfamide; Cicloxal; Clafen; Claphene; CP monohydrate; CTX; CYCLO-cell; Cycloblastin; Cycloblastine; Cyclophospham; Cyclophosphamid monohydrate; Cyclophosphamide Monohydrate; Cyclophosphamidum; Cyclophosphan; Cyclophosphane; Cyclophosphanum; Cyclostin; Cyclostine; Cytophosphan; Cytophosphane; Cytoxan; Fosfaseron; Genoxal; Genuxal; Ledoxina; Mitoxan; Neosar; Revimmune; Syklofosfamid; WR- 138719; .beta.-Cytosine arabinoside; 1-.beta.-D-Arabinofuranosyl-4-amino-2(1H)pyrimidinone; 1-.beta.-D-Arabinofuranosylcytosine; 1-Beta-D-arabinofuranosyl-4-amino-2(1H)pyrimidinone; 1-Beta-D-arabinofuranosylcytosine; 1.beta.-D-Arabinofuranosylcytosine; 2(1H)-Pyrimidinone, 4-Amino-1-beta-D-arabinofuranosyl-; 2(1H)-Pyrimidinone, 4-amino-1.beta.-D-arabinofuranosyl-; Alexan; Ara-C; ARA-cell; Arabine; Arabinofuranosylcytosine; Arabinosylcytosine; Aracytidine; Aracytin; Aracytine; Beta-Cytosine Arabinoside; CHX-3311; Cytarabinum; Cytarbel; Cytosar; Cytosine Arabinoside; Cytosine-.beta.-arabinoside; Cytosine-beta-arabinoside; Erpalfa; Starasid; Tarabine PFS; U 19920; U-19920; Udicil; WR-28453; Aacidexam; Adexone; Aknichthol Dexa; Alba-Dex; Alin; Alin Depot; Alin Oftalmico; Amplidermis; Anemul mono; Auricularum; Auxiloson; Baycadron; Baycuten; Baycuten N; Cortidexason; Cortisumman; Decacort; Decadrol; Decadron; Decadron DP; Decalix; Decameth; Decasone R.p.; Dectancyl; Dekacort; Deltafluorene; Deronil; Desamethasone; Desameton; Dexa-Mamallet; Dexa-Rhinosan; Dexa-Scheroson; Dexa-sine; Dexacortal; Dexacortin; Dexafarma; Dexafluorene; Dexalocal; Dexamecortin; Dexameth; Dexamethasone Intensol; Dexamethasonum; Dexamonozon; Dexapos; Dexinoral; Dexone; Dinormon; Dxevo; Fluorodelta; Fortecortin; Gammacorten; Hexadecadrol; Hexadrol; Lokalison-F; Loverine; Methylfluorprednisolone; Millicorten; Mymethasone; Orgadrone; Spersadex; TaperDex; Visumetazone; ZoDex; 5,12-Naphthacenedione, 10-[(3-amino-2,3,6-trideoxy-alpha-L-lyxo-hexopyranosyl)oxy]-7,8, 9,10-tetrahydro-6,8,11-trihydroxy-8-(hydroxyacetyl)-1-methoxy-, hydrochloride, (8S-cis)- (9CI); ADM; Adriacin; Adriamycin; Adriamycin Hydrochloride; Adriamycin PFS; Adriamycin RDF; ADRIAMYCIN, HYDROCHLORIDE; Adriamycine; Adriblastina; Adriblastine; Adrimedac; Chloridrato de Doxorrubicina; DOX; DOXO-CELL; Doxolem; Doxorubicin HCl; Doxorubicin.HCl; Doxorubin; Farmiblastina; FI 106; FI-106; hydroxydaunorubicin; Rubex; Adinepar; Calcifolin; Calcium (6S)-Folinate; Calcium Folinate; Calcium Leucovorin; Calfolex; Calinat; Cehafolin; Citofolin; Citrec; Citrovorum Factor; Cromatonbic Folinico; Dalisol; Disintox; Divical; Ecofol; Emovis; Factor, Citrovorum; Flynoken A; Folaren; Folaxin; FOLI-cell; Foliben; Folidan; Folidar; Folinac; Folinate Calcium; folinic acid; Folinic Acid Calcium Salt Pentahydrate; Folinoral; Folinvit; Foliplus; Folix; Imo; Lederfolat; Lederfolin; Leucosar; leucovorin; Rescufolin; Rescuvolin; Tonofolin; Wellcovorin; 3H-Purine-6-thiol; 6 MP; 6 Thiohypoxanthine; 6 Thiopurine; 6-Mercaptopurine; 6-Mercaptopurine Monohydrate; 6-MP; 6-Purinethiol; 6-Thiopurine; 6-Thioxopurine; 6H-Purine-6-thione, 1,7-dihydro- (9CI); 7-Mercapto-1,3,4,6-tetrazaindene; Alti-Mercaptopurine; Azathiopurine; Bw 57-323H; Flocofil; Ismipur; Leukerin; Leupurin; Mercaleukim; Mercaleukin; Mercaptina; Mercaptopurinum; Mercapurin; Mern; NCI-C04886; Puri-Nethol; Purimethol; Purine, 6-mercapto-; Purine-6-thiol (8CI); Purine-6-thiol, monohydrate; Purinethiol; Purinethol; U-4748; WR-2785; Abitrexate; Alpha-Methopterin; Amethopterin; Brimexate; CL 14377; CL-14377; Emtexate; Emthexat; Emthexate; Farmitrexat; Fauldexato; Folex; Folex PFS; Lantarel; Ledertrexate; Lumexon; Maxtrex; Medsatrexate; Metex; Methoblastin; Methotrexate LPF; Methotrexate Methylaminopterin; Methotrexatum; Metotrexato; Metrotex; Mexate; Mexate-AQ; MTX; Novatrex; Rheumatrex; Texate; Tremetex; Trexeron; Trixilem; WR-19039; L-Asparaginase with Polyethylene Glycol; Oncaspar; Oncaspar-IV; PEG-Asparaginase; PEG-L-Asparaginase; PEG-L-Asparaginase (Enzon - Kyowa Hakko); PEGLA; Polyethylene Glycol L-Asparaginase; Polyethylene Glycol-L-Asparaginase; 2-Amino 6MP; 2-Amino-1,7-dihydro-6H-purine-6-thione; 2-Amino-6-mercaptopurine; 2-Amino-6-purinethiol; 2-Aminopurin-6-thiol; 2-Aminopurine-6(1H)-thione; 2-Aminopurine-6-thiol; 2-Aminopurine-6-thiol Hemihydrate; 2-Mercapto-6-aminopurine; 6-Amino-2-mercaptopurine; 6-Mercapto-2-aminopurine; 6-Mercaptoguanine; 6-TG; 6H-Purine-6-thione, 2-amino-1,7-dihydro- (9CI); BW 5071; Lanvis; Tabloid; Thioguanine Hemihydrate; Thioguanine Hydrate; Tioguanin; Tioguanine; Wellcome U3B; WR-1141; X 27; Kyocristine; Leurocristine Sulfate; Leurocristine, sulfate; Oncovin; Vincasar; Vincosid; Vincrex; Vincristine, sulfate
Intervention MeSH terms: Calcium, Dietary; Leucovorin; Folic Acid; Cytarabine; Dexamethasone; Dexamethasone acetate; Cyclophosphamide; Doxorubicin; Liposomal doxorubicin; Methotrexate; Vincristine; Asparaginase; Mercaptopurine; Pegaspargase; Thioguanine; BB 1101; Calcium; 2-Aminopurine; Levoleucovorin
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment