Low-Dose or High-Dose Vincristine and Combination Chemotherapy in Treating Young Patients With Relapsed B-Cell Acute Lymphoblastic Leukemia
Condition: B-cell Childhood Acute Lymphoblastic Leukemia; L1 Childhood Acute Lymphoblastic Leukemia; L2 Childhood Acute Lymphoblastic Leukemia; Intermediate Risk Recurrent Childhood 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 low-dose vincristine to see how well it works
      compared with high-dose vincristine when given together with different combination
      chemotherapy regimens in treating young patients with intermediate-risk relapsed B-cell 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) and giving the drugs in different ways and different
      doses may kill more cancer cells..
    

Detailed description: 
      PRIMARY OBJECTIVES:

      I. Determine the efficacy of an intensive chemotherapy regimen (based on POG-9412) for
      pediatric patients with intermediate-risk relapsed B-precursor acute lymphoblastic leukemia.

      SECONDARY OBJECTIVES:

      I. To determine levels of minimal residual disease (MRD) present at the end of the first &
      third blocks of Induction and determine if higher MRD levels at these times identify patients
      at higher risk of relapse who might be candidates for alternative therapies in future trials.

      II. To determine whether common polymorphisms in candidate genes are associated with the
      frequency of vincristine adverse effects (peripheral neuropathy, syndrome of inappropriate
      antidiuretic hormone secretion [SIADH], or constipation) and with anti-leukemic response
      (level of end-Induction MRD).

      III. Compare, descriptively, the outcomes of patients treated with combination chemotherapy
      vs those treated with matched sibling-related donor hematopoietic stem cell transplantation
      (for those with eligible donors).

      IV. To use deoxyribonucleic acid (DNA) arrays to characterize patterns of gene expression
      that predict treatment failure, and to compare gene expression profiles at the time of
      relapse with those at initial diagnosis to gain an understanding of the pathways that may be
      involved in disease resistance.

      OUTLINE: This is a multicenter, randomized study. Patients are randomized to 1 of 2 treatment
      regimens (randomization closed as of 09/2010).

      INDUCTION THERAPY 1 (WEEKS 1-5):

      Regimen A: Patients receive low-dose vincristine intravenously (IV) on days 1, 8, 15, and 22;
      prednisone orally (PO) 3 times daily (TID) on days 1-28; doxorubicin hydrochloride IV over 15
      minutes on day 1; pegaspargase intramuscularly (IM) on days 2, 8, 15, and 22; cytarabine
      intrathecally (IT) on day 1; and methotrexate IT* on days 15 and 29.

      Regimen B: (closed to accrual as of 09/2010)***: Patients receive high-dose vincristine IV on
      days 1, 8, 15, and 22 and prednisone, doxorubicin hydrochloride, pegaspargase, cytarabine,
      and methotrexate* as in Regimen A.

      NOTE: *Central nervous system (CNS)-positive patients do not receive methotrexate IT. In both
      arms, CNS-positive patients receive intrathecal triple therapy (ITT) comprising methotrexate
      IT, hydrocortisone IT, and cytarabine IT on days 1, 8, 15, 22, and 29. CNS-positive patients
      not achieving remission after induction therapy 1 receive one additional dose of ITT on day
      36. Patients in both arms then proceed to induction therapy 2**.

      NOTE: **Patients who are CNS-positive at relapse receive induction therapy 3 BEFORE induction
      therapy 2.

      NOTE: ***Patients already enrolled on Regimen B are crossover to Regimen A.

      INDUCTION THERAPY 2 (WEEKS 6-10 or 7-11): Once blood counts recover, all patients receive
      etoposide phosphate IV over = 1 hour and cyclophosphamide IV over 1 hour on days 1-5;
      high-dose methotrexate IV continuously over 24 hours on day 22; leucovorin calcium IV or PO
      beginning 42 hours after start of high-dose methotrexate and continuing every 6 hours for at
      least 3 doses; and methotrexate IT* on days 1 and 22. Patients also receive filgrastim
      (G-CSF) IV or subcutaneously (SC) beginning on day 6 and continuing until blood counts
      recover.

      NOTE: *CNS-positive patients do not receive methotrexate IT. CNS-positive patients receive
      ITT on days 1 and 22. Patients with testicular-relapse with persistent testicular disease at
      the end of induction therapy 1 undergo testicular radiotherapy once daily (QD), 5 days a
      week, for 12 days during induction therapy 2**.

      NOTE: **Radiotherapy should be completed before beginning high-dose methotrexate (week 9)
      chemotherapy.

      All patients then proceed to induction therapy 3.

      INDUCTION THERAPY 3 (WEEKS 11-15 or 12-16): All patients receive high-dose cytarabine IV over
      3 hours on days 1, 2, 8, and 9, and asparaginase IM on days 2 and 9. Patients also receive
      G-CSF IV or SC beginning on day 10 and continuing until blood counts recover. Patients with a
      suitable HLA-matched related donor are removed from study and proceed to stem cell
      transplantation. Patients without a suitable HLA-matched related donor proceed to
      intensification therapy 1 (as per their randomized regimen in induction therapy 1).

      INTENSIFICATION THERAPY 1 (WEEKS 16-27 or 17-28):

      Regimen A: Patients receive low-dose vincristine IV and high-dose methotrexate IV
      continuously over 24 hours on day 1; leucovorin calcium IV or orally beginning 42 hours after
      start of high-dose methotrexate and continuing every 6 hours for at least 3 doses; oral
      mercaptopurine once daily on days 2-6; etoposide phosphate IV over ≥ 1 hour and
      cyclophosphamide IV over 1 hour on day 8; and methotrexate IT* on day 15. Treatment repeats
      every 21 days for 4 courses (with the exception of IT methotrexate which repeats for only 3
      courses).

      Regimen B: Patients receive high-dose vincristine IV on day 1 and high-dose methotrexate,
      leucovorin calcium, mercaptopurine, etoposide phosphate, cyclophosphamide, and methotrexate
      IT* as in Regimen A. (closed to accrual as of 09/2010)

      NOTE: *CNS-positive patients do not receive methotrexate IT. CNS-positive patients receive
      ITT on day 15. ITT repeats every 3 weeks for 3 courses.

      NOTE: ** Patients already enrolled on Regimen B are crossover to Regimen A.

      Patients in both regimens then proceed to reinduction therapy (as per their randomized
      regimen in induction therapy 1).

      REINDUCTION THERAPY (WEEKS 28-32 or 29-33):

      Regimen A: Patients receive low-dose vincristine IV and doxorubicin hydrochloride IV over 15
      minutes on days 1, 8, and 15, oral dexamethasone twice daily on days 1-7 and 15-21,
      pegaspargase IM on days 2 and 15, and methotrexate IT* on days 1 and 28.

      Regimen B: Patients receive high-dose vincristine IV on days 1, 8, and 15 and doxorubicin
      hydrochloride, dexamethasone, pegaspargase, and methotrexate IT* as in Regimen A. (closed to
      accrual as of 09/2010)

      NOTE: *CNS-positive patients do not receive methotrexate IT. CNS-positive patients receive
      ITT on days 1 and 28.

      NOTE: ** Patients already enrolled on Regimen B are crossover to Regimen A. Patients in both
      regimens then proceed to intensification therapy 2 (as per their randomized regimen in
      induction therapy 1).

      INTENSIFICATION THERAPY 2 (WEEKS 33-56 or 34-57):

      Regimen A: Once blood counts recover, patients receive high-dose cytarabine IV over 3 hours
      on days 1 and 2; pegaspargase IM on day 2; low-dose vincristine IV on days 22 and 29;
      high-dose methotrexate IV on day 22; leucovorin calcium IV or orally beginning 42 hours after
      start of high-dose methotrexate and continuing every 6 hours for at least 3 doses; oral
      mercaptopurine once daily on days 23-27; etoposide phosphate IV over ≥ 1 hour and
      cyclophosphamide IV over 1 hour on day 29; and methotrexate IT* on day 36. Patients also
      receive G-CSF IV or SC beginning on day 3 and continuing until blood counts recover.
      Treatment repeats every 42 days for 4 courses (with the exception of IT methotrexate which
      only repeats for 3 courses).

      Regimen B: Patients receive high-dose cytarabine, high-dose methotrexate, leucovorin calcium,
      pegaspargase, mercaptopurine, etoposide phosphate, cyclophosphamide, methotrexate IT*, and
      G-CSF as in Regimen A. Patients also receive high-dose vincristine IV on days 22 and 29.

      NOTE: *CNS-positive patients do not receive methotrexate IT. CNS-positive patients receive
      ITT on day 36. Treatment repeats every 6 weeks for 3 courses.

      Patients in both regimens then proceed to maintenance therapy (as per their randomized
      regimen in induction therapy 1).

      MAINTENANCE THERAPY (week 57-106 or 58-107):

      Regimen A: Patients receive methotrexate IT on day 1* and then PO on days 8, 15, 22, 29, and
      36; mercaptopurine PO QD on days 1-42; dexamethasone PO twice daily (BID) on days 1-5; and
      low-dose vincristine IV and cyclophosphamide IV over 1 hour on days 43, 50, 57, and 64.
      Treatment repeats every 70 days for 5 courses.

      Regimen B: Patients receive methotrexate*, mercaptopurine, dexamethasone, and
      cyclophosphamide as in Regimen A. Patients also receive high-dose vincristine IV on days 43,
      50, 57, and 64.

      NOTE: *CNS-positive patients receive methotrexate IT on day 1, instead of oral methotrexate.

      Beginning in week 1 of the first maintenance therapy course, patients with CNS relapse
      undergo cranial radiotherapy QD, 5 days a week, for 10 days. Patients with CNS relapse do not
      receive any IT therapy during maintenance therapy.

      After completion of study therapy, patients are followed periodically for 5 years.
    

Intervention name(s): vincristine sulfate; prednisone; doxorubicin hydrochloride; pegaspargase; cytarabine; methotrexate; dexamethasone; etoposide; cyclophosphamide; leucovorin calcium; filgrastim; asparaginase; mercaptopurine
Intervention type(s): Drug; Drug; Drug; Drug; Drug; Drug; Drug; Drug; Drug; Drug; Biological; Drug; Drug
Intervention description(s): Given IV; Given PO; Given IV; Given IM; Given IT or IV; Given IT or IV; Given PO; Given IV; Given IV; Given IV or PO; Given IV or SC; Given IM; Given PO
Other intervention name(s): leurocristine sulfate; VCR; Vincasar PFS; DeCortin; Deltra; ADM; ADR; Adria; Adriamycin PFS; Adriamycin RDF; L-asparaginase with polyethylene glycol; Oncaspar; PEG-ASP; PEG-L-asparaginase; ARA-C; arabinofuranosylcytosine; arabinosylcytosine; Cytosar-U; cytosine arabinoside; amethopterin; Folex; methylaminopterin; Mexate; MTX; Aeroseb-Dex; Decaderm; Decadron; DM; DXM; EPEG; VP-16; VP-16-213; CPM; CTX; Cytoxan; Endoxan; Endoxana; CF; CFR; LV; G-CSF; Neupogen; ASNase; Colaspase; Crasnitin; Elspar; L-ASP; 6-mercaptopurine; 6-MP; Leukerin; MP
Intervention MeSH terms: Leucovorin; Cytarabine; Dexamethasone; Prednisone; Cyclophosphamide; Doxorubicin; Liposomal doxorubicin; Methotrexate; Etoposide; Vincristine; Etoposide phosphate; Asparaginase; Mercaptopurine; Pegaspargase; Levoleucovorin
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment